Pure tubular carcinoma of the breast: a case series

BACKGROUND

Pure tubular breast carcinoma is a rare and well-differentiated tumor with high survival and low local recurrence rate. Our study aims to determine the clinical, radiological, appropriate management, and prognosis of this carcinoma.

MATERIALS AND METHODS

A review of Salah Azaiez institute registry from 2004 to 2019 was performed including seven cases of PTC of the breast.

RESULTS

Clinical-pathologic features and outcomes were analyzed. The median follow-up was 3 years. In our study, we found that the cohort presented more frequently with pT1 disease and pN0 disease. Conservative surgery was more frequently indicated (five cases). All patients had hormone-receptor positivity and Human Epidermal growth factor Receptor 2 (HER2) negativity. The majority of tumors had a molecular profile luminal A and a low-grade SBR. In one case we found axillary lymph node metastasis. Adjuvant radiotherapy was indicated in all cases of breast conservation and in only one case of radical surgery. One patient received chemotherapy. The mean follow-up was 4 years. We did not find any local or distant recurrence in our study.

CONCLUSION

PTC showed an excellent prognosis with a low SBR grade, a molecular profile luminal A, and a low incidence of recurrence.

Association of HLA-G 3'UTR polymorphisms and haplotypes with colorectal cancer susceptibility and prognosis

Human leukocyte antigen (HLA)-G has been considered as an immune modulator in several types of cancers. Its genetic polymorphisms may potentially affect the risk of developing colorectal cancer (CRC). The overall purpose of this study was to analyze the implication of HLA-G 3'untranslated region (3'UTR) polymorphisms particularly 14 pb insertion/deletion (Ins/Del; rs371194629) and + 3142C/G (rs1063320) in CRC susceptibility and progression. A comparative analysis between patients (N = 233) and controls (N = 241) demonstrated that Del allele (Odds Ratios (OR) = 1.41, 95% CI = 1.091-1.819, p = 0.008), the homozygous Del/Del genotype (OR = 1.80, 95% CI = 1.205-2.664, p = 0.003) and the codominant C/G genotype (OR = 1.59, 95% CI = 1.106-2.272, p = 0.013) were associated to CRC risk. As expected, the DelG haplotype was associated with CRC susceptibility (OR = 1.47, 95% CI = 1.068-2.012, p = 0.018). Assessment of patients' survival by Kaplan-Meier analysis indicated that the Del allele and the homozygous Del/Del genotype were associated with reduced event free survival (EFS) (Respectively, p = 0.009 and p = 0.05). Interestingly, the Del allele and the homozygous Del/Del genotype have been revealed as independent prognostic factors for poor EFS in patients with CRC. Additionally, haplotypes analysis revealed that DelG haplotype was linked with significant increase in CRC risk (log-rank; EFS: p = 0.02). Inversely, the InsC haplotype was associated with a significant reduced CRC risk (log-rank; Overall survival (OS): p < 10^-6; EFS: p = 0.01). Multivariate Cox regression analysis revealed that the InsC haplotype was independently associated with significantly longer EFS (p = 0.021, HR = 0.636, 95% CI = 0.433-0.935). These findings support the implication of HLA-G polymorphisms in the CRC susceptibility suggesting HLA-G as a potent prognostic and predictive indicator for CRC. Insight into mechanisms underlying HLA-G polymorphisms could allow for the development of targeted care for CRC patients according to their genetic profile.

Predictive negative value of the COVID-19 rapid antigen test

Background

Testing is a crucial tool in the pandemic response to identify and confirm COVID-19 in those who are symptomatic. The aim of the present study was to assess the negative predictive value (NPV) of COVID-19 Rapid Antigen Testing (RAT) according to the symptoms, test timing in relation to symptom onset and characteristics of the person.

Methods

We performed a prospective cohort study of patients attended the COVID-19 testing center at the university hospital of Monastir, between 23 November 2020 and 19 April 2021. In the first time we performed the COVID19 RAT. In the second time, if this result was negative we performed the reverse transcription polymerase chain reaction (rRT-PCR). The NPV was conducted with SPSS software, version 21.0. A logistic binary regression was performed to determine factors affected the NPV of COVID-19 RAT. A p value of &lt; 0.05 was considered statistically significant.

Results

A total of 855 tests were performed, of which 807 were RAT and 467 rRT-PCR. Positive RAT test was found in 336 cases (39%). False negative RAT was noted in 87 cases (10.2%). The NPV of RAT was 83.6%. The NPV ranged between 80% and 88% for the following symptoms: fever, cough, myalgia, dyspnea, dizziness, asthenia, headache, myalgia, odynophagia, flu_rhume. It varied from 64.2 to 77.8 for Ageusia, Anosmia, Arthralgia, chest pain, thrill, digestive signs. The NPV was equivalent according to age and gender. The NPV varied from 80 to 100% if the test was applied between the first and the 5th day for the onset of symptoms. Beyond this duration, it decreased to 50%. A long period of symptom onset (&gt;5 days) increased significantly the risk of false negative RAT (OR = 2.57 IC95%: [1.38-4.82], p = 0.003).

Conclusions

Many factors may affect the performance of COVID-19 Rapid Antigen Testing (RAT). In fact, negative RAT should be completed by a rRT-PCR according to the the type of symptoms and the time from illness onset.

Key messages

False negative RAT rate was high. Many factors must be taken into account in interpreting the RAT, in particular the type of symptoms and the time from illness onset.

The association between face mask use and SARS-CoV-2 RNA viral clearance: A cohort study in Tunisia

Background

The outbreak of coronavirus disease (COVID-19) continues to constitute an international public health concern. Scientific evidence showed that community mask wearing is an effective nonpharmacologic intervention to reduce the spread of this infection. However, few data are available about the effect of face masking on the duration of the disease. We aimed to study the association between recovery time among a Tunisian cohort of COVID-19 confirmed patients and mask wearing.

Methods

A prospective cohort study was conducted from March to July 2020 including patients with COVID-19 admitted to the Tunisian national containment center. Data were collected via phone call interview. Kaplan-Meir Methods and Cox proportional hazards regression models were, respectively, used to study the association between recovery time and face masks use.

Results

Among the 264 patients included, the median duration of viral clearance was 20 days (interquartile range (IQR 17-32days)). The median time to RNA viral conversion was 18 days (IQR 16-21 days) when using masks versus 23 days (IQR17-36 days) without wearing masks. Face masks use was significantly associated with an accelerated RNA clearance of SARS-CoV-2 (HR 2.006, 95% CI 1.247-3.228) (p = 0.004).

Conclusions

With the emergence of new variants, it is important to adopt widespread mask wearing to avoid SARS-CoV-2 infection and accelerate RNA negative conversion, until effective levels of vaccination are achieved nationally.

Key messages

Face masking was associated with accelerated RNA clearance of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Promoting community mask wearing during COVID-19 pandemic is crucial.

Rabies surveillance in the central region of Tunisia: A 15-year observational study

Background

Rabies remains a major public health threat in many parts of the world and is responsible for an estimated 55,000 human deaths annually. In Tunisia, the National Rabies Control Program was initiated in 1982 based on dog's annual vaccination campaign. The aim of our study was to describe the epidemiological profile and management of rabies exposure in the Monastir governorate, Tunisia.

Methods

We included in our study all cases of animal aggression reported between 2004 and 2018 in the Monastir governorate. The source of the data was the directorate of primary health care in Monastir.

Results

A total of 27,277 bites were reported with an annual average of 1,817 cases per year. Most of victims were in the 5-14 age group (25%, n = 6,902). The culprit animal was the dog in 64% of cases followed by rats and cats. Only 42% of attacking dogs were vaccinated. A significant increase in dog bites was noted from 2004 to 2018 (β = 16.5; p = &lt;10-3). The number of bites increased significantly (β = 23.2; p = &lt;10-3) by vaccinated dogs and decreased significantly by unvaccinated dogs (β = -12; p = &lt;10-3). During our study period, a total of 146 cases of animal rabies was confirmed. Only one case of human rabies was reported, the aggressor animal was a cat and post-exposure prophylaxis was not received.

Conclusions

In Tunisia, human exposure to rabies by a dog has been on the rise. Future interventions should focus on mass dog vaccination campaigns and contraception in order to eliminate this disease.

Key messages

A significant increase in dog bites was noted from 2004 to 2018. It is crucial to reinforce appropriate preventive strategies, such as mass dog vaccination programs.

Viral shedding in asymptomatic versus symptomatic patients with COVID-19

Background

An outbreak of coronavirus disease 2019 (COVID-19) is becoming a public health emergency. Data are limited on the association between a prolonged viral shedding in patients with COVID-19 and having symptoms. We aimed to study the association between the presence of symptoms and recovery time of COVID-19 confirmed patients.

Methods

We conducted a prospective cohort study of COVID-19 patients admitted to the designated national COVID-19 center in Monastir, Tunisia from March to July 2020. Kaplan-Meier survival curve and Cox proportional hazards regression models were used to assess viral shedding in asymptomatic versus symptomatic patients with COVID-19.

Results

Among the 264 patients included in the study, symptoms such as anosmia, dry cough, and fatigue were reported by 34.4% (n = 75) of cases. The median time to RNA viral conversion was 24 days (IQR 18-36 days) for symptomatic patients versus 20 days (IQR 16-30 days) for asymptomatic patients. Having symptoms was significantly associated with a prolonged viral shedding (HR 0.600, 95% CI 0.401-0.897) (p = 0.013).

Conclusions

Our findings revealed that having symptoms delayed viral clearance among COVID-19 patients. Therefore, symptomatology should be taken into consideration in isolation strategy for infected patients.

Key messages

Having symptoms was associated with a delay in SARS-CoV-2 RNA clearance.

The presence of symptoms should be taken into consideration for patient’s isolation strategy.

Health system saturation in managing COVID-19 patients in Monastir, Tunisia

Background

COVID-19 emerged in late 2019 and quickly became a serious public health problem worldwide. This study aimed to determine the average length of stay, occupancy bed rate and bed turnover rate for COVID-19 patients in Monastir university hospital between the 1st October 2020 and 28th february 2021.

Methods

This is a cross-sectional study that enrolled all hospitalizations for COVID19 in Monastir University hospital, the unique third level healthcare in this region, between the 1st October 2020 and 28th february 2021. The following indicators: the average length of stay, the occupancy bed rate and the bed turnover rate were calculated during the study period.

Results

We included 762 hospitalizations for COVID-19 during the study period. The average age of our population was 64,22 years (standard deviation= 14,17). Male predominance was noted with sex ratio=1,63. The median length of stay was significantly longer in the intensive care unit (ICU) than in the other departments (11 (7;16) days, versus 7(2;14) days), p = 0.008. The average number of beds available for COVID-19 patients during the study period was 13 in the ICU and 65 in the other wards. The bed turnover rate and the bed occupancy rate per month were respectively 2,66 patient/bed/month and 96,26% in the ICU versus 1,74 patient/bed/month and 62,26% in the other wards. The occupancy bed rate in the ICU exceeded the 100% during the outbreak of January and February 2021 (129,72% and 120,66% respectively).

Conclusions

Despite the efforts by the health services and social isolation measures in Tunisia, this study highlighted the saturation of our health system with an overload in intensive care units.

Key messages

Length of stay for patients with Covid-19 was significantly the longest in ICU. The occupancy bed rate, exceeding 100% in ICU, highlighted the health system collapse in managing COVID-19 patients.

Spirometry feedback as a motivational tool for tobacco cessation

Background

Tobacco use remains a major public health problem especially in developing countries and emerging economies. The evidence about the effect of spirometry on smoking cessation is still controversial. The aim of this study was to determine whether a spirometry and lung age announcement were a motivator for smoking cessation.

Methods

We conducted a randomized controlled trial among patients who attended the smoking cessation clinic (SCC) at Fattouma Bourguiba University Hospital in Monastir, from June 2017 to February 2020. Participants were assigned into two groups, a control arm receiving standard program and intervention arm receiving standard program and lung age announcement. The primary outcome was the smoking cessation rates after one year of follow-up between the intervention arm and the control arm.

Results

A total of 500 patients were recruited and randomized with 250 patients in each group. At one-year endpoint, a total of 456 patients were reachable for assessment, 236 in control group and 220 in spirometry group. The loss rate was equal to 8.8% (54/500). Six months smoking rate was 78 (33.1%) in control group and 106 (48.0%) in intervention group (p = 0.002). One-year smoking cessation rate was higher in the intervention group than the control group (25.5% versus 16.5%), with a considerable statistical significance (p = 0.019). Spirometric lung age was significantly higher at paired comparison with chronologic age (58.81vs 46.54; p&lt;.001); the mean difference was 10.24 years but with considerable inter-individual variability.

Conclusions

Smoking cessation is still a challenging procedure with a high risk of relapse. This study is an additional evidence for spirometry and lung age announcement as motivators for cessation.

Key messages

Spirometry increased the motivation of smoking cessation. The equipment of smoking cessation centers by spirometry may contribute on tobacco control.

Comparison of SARS-CoV-2 RNA clearance between elderly and young patients with COVID-19

Background

The SARS-CoV-2 outbreak in 2020 caused a highly transmissible disease with a significant impact on the elderly. Understanding viral clearance duration of COVID-19 is important to tailor prevention strategies to this vulnerable category. We aimed to investigate the SARS-CoV-2 infection duration and associated factors to prolonged viral clearance among elderly people comparatively to young people.

Methods

We conducted a cohort study of asymptomatic and mild forms of COVID-19 patients admitted to the designated national COVID-19 center in Monastir, Tunisia. Patients included in the study were divided into two cohorts: (elderly group: ≥ 60 years old) and (young group: < 60 years old) and were followed up to their RNA viral conversion. Stratified cox regression was performed to determine associated factors with prolonged viral SARS-CoV-2 RNA clearance in elderly subgroups.

Results

The study included a total of 289 patients with asymptomatic and mild forms of COVID-19. The median term of viral shedding was 20 days (IQR; 16 - 32 days) for the young group, and 21 days (IQR; 17 - 33 days) for the elderly group. The stratified cox regression showed that Age ≥ 60 was an associated factor to prolonged viral shedding in male sex (HR (Hazard Ratio): 1.91; 95% CI: 1.19 - 3.07) and patients with comorbidities (HR:1.68; 95% CI: 1.02 - 2.75) especially diabetics (HR: 2.06; 95% CI: 1.01 - 4.21).

Conclusions

This study, focused on the factors associated with a prolonged duration of viral RNA clearance in elderly with COVID-19. These Potential factors will help planners to chalk out effective strategies among this vulnerable category.

Key messages

Old age is associated with a prolonged duration of viral RNA clearance in specific subgroups.

Identifying these subgroups is important to know how prioritize preventive strategies in elderly.

Smoking cessation adherence:recurrent cardiovascular events after five years of first manifestation

Background

Smoking is an established risk factor for cardiovascular events, such as myocardial infarction, stroke and cardiovascular death. Although the harmful effects of smoking on health are widely known. Smoking is highly addictive and cessation can be extremely difficult, even after a life-threatening vascular event.

Objective

The present study aimed to assess the relation between smoking status and risk of recurrent Cardiovascular events 5 years after the first hospitalization for acute coronary syndrome.

Methods

A cross sectional study was conducted in the Smoking Cessation Service at University Hospital of Monastir, Tunisia during February 2020. The smoking status and recurrent cardiovascular events were assessed 5 years after the first hospitalization for acute coronary syndrome by phone call among patients attended the tobacco cessation consultation. The statistical analysis was conducted with SPSS software, version 21.0. A p value of &lt; 0.05 was considered statistically significant.

Results

A total of 112 patients were included in our study. All participants were male and the mean age was 56 ±10 years. Most patients (67%) had a high level of nicotine dependence. The rate of smoking abstinence declined from 35.7% at one year to 21.1% at 5 years. During the study period, 4 patients died(3.5%) and 17 (15.17%) had a recurrent cardiovascular event. The recurrent cardiovascular event occurred more in smoking patients but the difference was not significant.

Conclusions

Smoking cessation after a first cardiovascular event should be a key objective for both patients and physicians to reduce the risk for recurrent vascular events. More efforts are needed to maintain smoking cessation in patients at very high cardiovascular risk.

Key messages

Smoking cessation consultation can increase adherence to smoking cessation and helps in reducing the excess risk of recurrent cardiovascular events. Smoking is highly addictive and cessation can be extremely difficult, even after a life-threatening vascular event.

Impact of Haemophilus influenza immunization on hospitalized acute respiratory infections

Background

Immunization is the most cost-effective measure to combat communicable diseases in childhood. Haemophilus influenza (Hib) vaccine was included in the Tunisian expanded program of immunization for the first time in 2002 (Hib Vaccine monovalent) and is currently combined with the pneumococcal vaccine(Hib vaccine pentavalent combination) since April 2019. We aimed to assess impact of Hib vaccine on Respiratory Infection(RI) admissions in children aged up to 3 years.

Methods

It was a cohort study from January 1, 2002 to December 31, 2013. All Respiratory Infection (RI) admissions in children aged up to 3 years in the university hospital of Monastir(Tunisia) were enrolled.

Results

Admissions for RI represented 17.6% (CI95%: 17.3-18.1) of all communicable diseases hospitalizations (n = 6 061/34 289). The median age was 22 years (IQR: 3-52). Admission for Pneumonia with Streptococcus Pneumoniae (SP) increased significantly during study period (b = 25.9 (p &lt; 0.0001)) especially in children up to 5 years old (b = 10.6) and in elderly (b = 6.0). Among children up to 3 years old, the Crude incidence rate per 100,000 for Hib pneumonia admission were 11.6 in Non-Vaccinated Cohort (NVC), 10.6 in Vaccinated Cohort (VC) by protocol 1 (Hib Vaccine monovalent) and 0.80 in VC by protocol 2 (Hib vaccine pentavalent combination).The relative risk reduction was 99% for protocol 2 (p &lt; 0.001).

Conclusions

Admissions for RI in a tertiary level hospital were common with an increasing trend. The Hib immunization program, in particular the second protocol (pentavalent combination), has had a positive impact on the reduction of related acute diseases.

Key messages

The Hib immunization program, has had a positive impact on the reduction of related acute diseases. The “Hib vaccine pentavalent combination “is more efficient than “Hib Vaccine monovalent”.

Intraabdominal and ganglionic desmoplastic small round cell tumor: a case series

Introduction

Desmoplastic small round cell tumor is a rare malignancy with poor prognosis, affecting young male patients. It frequently presents as a large abdominal mass with widespread peritoneal involvement at diagnosis. In late stages, metastases may be present.

Aim

We retrospectively reviewed patient characteristics, presenting symptoms, tumor pathology, treatment, and outcome of four patients with desmoplastic small round cell tumor at our institution.

Cases presentation

The first three cases reported are 32-, 17-, and 30-year-old North African males with intraabdominal desmoplastic small round cell tumor treated by surgery, chemotherapy, and radiation therapy with different follow-ups. The final case is a 16-year-old North African male with ganglionic desmoplastic small round cell tumor but no evidence of a tissue mass. He underwent two lines of chemotherapy with no response. The patient was lost after 2 years of follow-up. In all cases, desmoplastic small round cell tumor was confirmed by presence of t(11,22) (p13,q12) translocation.

Conclusion

Treatment of desmoplastic small round cell tumor is based on multidisciplinary therapy. Despite high-dose chemotherapy, extensive surgical resection, and radiotherapy, desmoplastic small round cell tumor remains lethal.

Extra-pulmonary tuberculosis incidence, trends and predictions in Monastir, Tunisia (2000-2030)

Background

Tuberculosis (TB) is global public health problem and up to 25% of TB cases present extrapulmonary involvement. The incidence of extrapulmonary tuberculosis (EPTB) is increased worldwide. Our study aimed to give an update on the epidemiology, current trends of EPTB from 2000 to 2017 and to predict future trajectories of EPTB up to 2030 in Monastir, Tunisia.

Methods

We performed an observational study from 2000 to 2017. Data were collected by the regional direction of primary health care. Incidence was estimated by the crude incidence rate (CIR). Poisson regression model was used to calculate the slope 'b' in order to describe trends and was performed to estimate incidence projection for 2030. Data were verified and analyzed using IBM SPSS Statistics version 22.0 software.

Results

During 18 years, 997 cases of TB were declared in Monastir. Almost 51% (n = 509) were EPTB. Sex ratio was 1.68. The main EPTB forms were lymph nodes in 234 (23.5%) cases, followed by pleural TB in 35 (3.5%) cases and bone and joints in 31 (3.1%) cases. CIR was 5.62/100,000 inhabitants (inh) for EPTB with a highest incidence in patients aged 60 years and above. A positive trend was showed for EPTB with a (b = 0.05; p &lt; 0.0001) especially for lymph node localization. Up to 2030, EPTB would be increasing with an estimated incidence rate of 9.11/100,000 inh. Regarding lymph node TB, cases may continue to rise with an estimated incidence rate of 7.96 /100,000 inh.

Conclusions

Despite the availability of a treatment and knowledge on prevention measures, EPTB remains a public health problem. Thus, investigating and identifying patients at higher risk is needed in order to improve its management.

Key messages

Updated epidemiology is important for healthcare experts to improve planning policies attributed to EPTB. Our results are a tool for decision-makers to assess the efficiency of TB control programs.

Trends in cardiovascular disease in the region of Monastir (Tunisia) over 12 years

Background

Cardiovascular diseases (CVDs) are the major cause of morbidity and mortality worldwide. However, CVD prevalence trends is still weakly documented in Tunisia. The objective of this study is to examine trends in the prevalence of CVDs in the Monastir region between 2002 and 2013.

Methods

Data were collected from the regional register of hospital morbidity. The register refers to the WHO International Classification of Diseases, 10th revision (ICD-10). Data were verified and analyzed using IBM SPSS Statistics version 22.0 software. Linear regression was used to calculate the slope 'b' of the least-squares line to estimate admission trends for each CVD category according to sex and age group. A p-value of 5% was considered statically significant.

Results

From 2002 to 2013, cardiovascular diseases accounted for 21,240 hospital admission in the region of Monastir, representing more than a quarter (28.7%; CI 95%: 28.1-29.3%) of all Non Communicable Disease admissions in adults. Males represented 55.9%. The median age at admission was 64 years (IQR 54-71 years). The CVD crude prevalence rate (CPR) was 3.60 /1,000 inh. The age-standardised CVD rate (ASR) was 4.56 per 1000 PY and it was higher in men than in women (5.41 vs. 3.72, respectively, p &lt; 0.001). CVD prevalence rate increased over time (b = 17.78; p&lt;.001). This increase was significant in men (b = 33.69; p &lt; 0.001) and in age groups over 40-years-old (b = 15.30; p &lt; 0.001). However, it declined significantly in women (b= -16.32; p &lt; 0.001). Coronary heart diseases (CHD) were the most prevalent CVD categories (47.7%).

Conclusions

Hospital admissions for CVD increased over the study period, in particular in men and in age groups over 40-years-old. CHDs were the prevalent disease. A comprehensive prevention strategies focused on lifestyle habits such as unhealthy diets, physical inactivity and tobacco consumption are greatly recommended to improve this prevalence trends.

Key messages

Over a 12-year period, CVD prevalence increased in men but not in women at the university hospital of Monastir. A comprehensive prevention strategies focused on lifestyle habits such as unhealthy diets, physical inactivity and tobacco consumption are greatly recommended to improve this prevalence trends.

Epidemiological aspects of human exposure cases to rabies by in the central west region of Tunisia

Introduction

Rabies is a major public health problem in several countries in the South and East of the Mediterranean and in the Middle East. The objectives of this study were to describe the epidemiological profile of human exposures to rabies by a dog, as well as the profile of aggressive dogs during a period of 15 years in a region in the central west region of Tunisia.

Methods

We have included all cases of human exposure to a dog, reported between 2004 and 2018 in the Kasserine area. The source of the data was the directorate of primary health care in Kasserine.

Results

A total of 41,850 human exposure cases to a dog have been reported over the fifteen year study period with an annual average of 1937.5 cases. Among them, 29,062 cases (69.4%) were attacked by a bite. The crude incidence of dog bite cases was 441 per 100,000 population. The vaccination status of attacking dogs was unknown in 15.4% of the cases (n = 6423). Among all attacking dogs with a known vaccination status (n = 35427), 45.2% were vaccinated (n = 16017) and 54.7% (n = 19392) were unvaccinated. A significant increase in human exposure cases to dogs was noted from 2004 to 2018 (β = 11.7, p = &lt;10-3). The number of exposures by an unknown dog or a known unvaccinated dog increased significantly (β = 28.02; p = &lt;10-3 and b = 69.9, p = &lt;10-3; respectively). However, the number of cases attacked by a known vaccinated dog decreased significantly (β = -86.4, p = &lt;10-3). During the study period, five cases of human rabies were identified in the study area.

Conclusions

In Tunisia, human exposure to rabies by a dog has been on the rise. It could be linked to the period of popular and political movement that the country is going through.

Key messages

In this study, human exposures cases to rabies by unvaccinated dog is significantly increasing. It is crucial to strengthen appropriate preventive measures, such as mass vaccination and dog castration programs.

Bladder cancer incidence and predictions: Observational Study (Monastir, Tunisia: (2002-2030)

Background

Bladder cancer is a highly prevalent disease and is associated with substantial morbidity, mortality if not treated optimally. We aimed to describe bladder cancer incidence and trends from 2002 to 2013 and to estimate predictions up to 2030.

Methods

We performed an observational study from 2002 to 2013. Incidence was estimated by the crude incidence rate (CIR) and standardized incidence rate (SIR). Poisson regression model was used to calculate the slope 'b' in order to describe trends and was performed to estimate incidence projection for 2030. Data were verified and analyzed using IBM SPSS Statistics version 22.0 software.

Results

A total of 1024 cases of bladder cancer was declared from 2002 to 2013 predominately among males with a rate of 90.4%. CIR was 16.79/100,000 inhabitants (inh) and SIR was 21.38/100,000 inh. By gender, SIR was 41.3/100,000 inh and 7.73/100,000 inh for males and females respectively. During our study period a significant positive trend was noted with a (b = 0.042, p &lt; 10-4). In 2030, the predicted incidence rate would increase to 28.4/100,000 inh.

Conclusions

The findings have highlighted the positive trend and the increased predicted incidence of bladder cancer in 2030. Thus, developing primary prevention strategies is crucial.

Key messages

Our results are important for health-care professionals to improve planning policies related to bladder cancer. Identifying associated factors is crucial to guide preventive strategies measures.

Prostate cancer incidence and predictions: Observational Study (Monastir, Tunisia: 2002-2030)

Introduction

Cancer is an eminent public health issue in the developing countries. The risk factors incriminated in cancer higher incidence are multiple such as the growing population rates, increasing tobacco consumption, the changes of diet and lifestyle. In Tunisia, there are three population-based cancer registries at the present time providing data on cancer incidence and survival. According to the data published by WHO International Agency for Research on Cancer (IACR) (GLOBOCAN 2018), prostate cancer in Tunisia ranks fifth among cancers with almost 819 new cases per year. The aim of this study was to we report trends in the cancer incidence during the span of time between 2002 and 2013 from the population-based cancer registry of the centre of Tunisia, and to predict the future number of cancer cases by 2030.

Methods

The cancer incidence data were collected from the Center cancer registries from 2003 to 2012.The data were stratified by cancer site, sex and age. We used SPSS software in order to calculate the crude incidence rates and age-standardized incidence rates. SPSS software was used in order to estimate the future number of cancer cases by 2030.

Results

A total of 725 cases of prostate cancer were enregistrated. The mean age of patients was 71.6 ±10.61years. The crude incidence rates were estimated 23.537. The standardized incidence rate was 33.92. A significant positive trend was noted with a b = 0133 and p &lt; 10-3. 1033 new cases are predicted by 2030

Conclusions

The data of the cancer register of the center shows that the incidence of cancer is rising, and it is consistent with the National cancer intelligence, but some cancer incidence showed slightly higher, such as thyroid cancer and prostate cancer. In order to face this alarming situation, many preventive steps should be done such as strengthening early screening and diagnosis of cancer, improving clinical research in order to better control the risks factors.

Key messages

Prediction of the future number of cancer cases is of great interest to society. Prostate cancer in Tunisia ranks fifth among cancers.

Lifestyle habits among a sample of middle school adolescents in Tunisia

Introduction

Adolescent health is a major global concern today. In fact, adolescence is the period of life where different risky behaviors can take hold and is therefore the best prevention phase to guarantee healthy lifestule in adulthood. We aimed to assess the lifestyle of middle school adolescents and to highlight the main behaviors such as the eating habits, the physical activity and the personal hygiene.

Methods

We carried out a cross sectional study among a sample of adolescents from December 2017 to January 2018 and we involved two middle school schools in the region of Monastir in Tunisia. The questionnaire GSHS (the Global school-based student health survey) was used.

Results

In total, 802 participants were enrolled with a mean age of 13.6 ±1.9 years, ranged from 11 to 16 years old. Females represented 51.9% of the study population. More than one third of the students (36%) reported rarely or never eating breakfast with a significant difference in girls more than in boys (62.8% vs 37.2%, p &lt; 10-3). Almost half of students (46.2%) reported drinking sugary sodas at least once a day and 86.3% of them reported consuming fast food more than two times per week. In addition, 59.4% of middle school students reported eating fruit more than twice a day and 24.3% eating vegetables at least three times a day. Regarding physical activity, our results showed that 24.4% of middle school students were physically active (1 hour minimum during the day) every day for the last 7 days, boys more than girls (56.5% vs 43.5%, p = 0.02). In addition, 39.7% of students declared they sit at least three hours a day. As for personal hygiene, our study found that 9.3% of students never, or rarely, washed or brushed their teeth; boys more than girls (69.3% vs 30.7%, p = &lt;0.001).

Conclusions

Our results provide additional evidence on the need to combat sedentary lifestyle and encourage healthy nutrition and physical activity among adolescents.

Key messages

Understanding the health needs and concerns of young people contribute to implement effective health programs. Interventions in young people should act on various aspects of the lifestyle to ensure an optimal effect.

Gastric cancer incidence and predictions: Observational Study (Monastir, Tunisia: 2002-2030)

Introduction

Gastric cancer is a major health burden worldwide. Based on GLOBOCAN 2018 data, stomach cancer is the fifth most common neoplasm and the third most deadly cancer, with an estimated 783,000 deaths in 2018. Unfortunately, only a few countries have set up extensive programs of early screening. In Tunisia the gastric cancer ranks among the ten most frequent cancers with more than 637 new cases per year. The aim of this study was to we report trends in the gastric cancer incidence during the span of time between 2002 and 2013 from the population-based cancer registry of the centre of Tunisia, and to predict the future number of cancer cases by 2030.

Methods

The cancer incidence data were collected from the cancer register of the Tunisian Center from 2003 to 2012.The data were stratified by cancer site, sex and age. We used SPSS software in order to calculate the crude incidence rates and standardized incidence rates. SPSS software was used in order to estimate the future number of cancer cases by 2030.

Results

During our study period, 326 cases of gastric cancer were observed. 53.1% of our patients were male with a sex ratio male to female 1.13.The crude incidence rates were 5.71 for male patients and 5.43 for females. The standardized incidence rates were 7.22 and 6.3 respectively for male and female patients. A stable trend was observed. Only 28 cases of gastric cancer are predicted by 2030.

Conclusions

Over the recent, there has been a slight decrease in gastric cancer rates. Many preventive steps should be encouraged in order to maintain this decreasing trend such as changing dietary habits by encouraging the consumption of fresh fruit and vegetables, as well as decreasing the use of tobacco and salt.

Key messages

Gastric cancer is a major health burden worldwide, only a few countries have set up extensive programs of early screening. Changingdietary habits by encouraging the consumption of fresh fruit and vegetables, as well as decreasing the use of tobacco and salt.

Food diversification: a retrospective survey over fifteen years in Monastir Tunisia

Introduction

Diversification is the transition phase between exclusive breastfeeding and adult-style feeding, taken independently by the child. Breast milk covers the nutritional needs of infants during the first months of life. With a view to prevention, in particular allergy and optimization of nutritional intake, food diversification is ideally undertaken between the 4th and 6th month. The age at which food is introduced can naturally vary depending on family cultural traditions. The objective of this work is to research the factors associated with the conduct of food diversification.

Methods

A cross-sectional study was conducted in the governorate of Monastir, including mothers consulting 6 dispensaries for the monitoring of their children. the collected data concerned their medical history, the course of pregnancy, breastfeeding and the age of food diversification. The relationships between the various diversification risk factors were analyzed using SPSS software.

Results

In total,1906 infants were included in our study. The delivery method was vaginal in 81.1% of cases, cesarean section in 17.7% and forceps in 1.1% of cases. The average of birth weight was 3338 ± 522.7 grams. The duration of breastfeeding was in average 3.65 months with extremes ranging from zero days to 24 months. The mean age of food diversification was 4.31 months with extremes ranging from 0 days to 24 months. The first food introduced was fruits, then vegetables. The family dish was introduced on average at the age of 10.28 months. There was no significant difference between mode of delivery, birth weight and age of food diversification.

Conclusions

Information efforts on infant feeding are necessary by focusing on simple messages must be used. This advice must be adapted to the child's family (place in the siblings, eating habits and resources) and to the child himself (taste, appetite).

Key messages

Information efforts on infant feeding are necessary by focusing on simple messages must be used The first food introduced was fruits, then vegetables.

Factors associated with diabetic foot among type 2 diabetes in the region of Monastir (Tunisia)

Background

The diabetic foot (DF) has actually a high rate of disability leading to impaired quality of life and even mortality. Glycemic control among Tunisian adults with diabetes mellitus remains poor. However the relationship between glycemic control and foot complication have not been clearly established. The aim of the present study was to assess the relationship between diabetic foot lesions and glycemic control and the diabetic duration in the people with DT2.

Methods

A cross-sectional survey was conducted in five Primary Health care Centers (PHC) in the region of Monastir (Tunisia) from March 2016 to April 2017. Data were collected using interviewer administered structured questionnaire. Validated questionnaire was used to assess diabetic foot diseases.nA multivariate logistic regression analysis was conducted to assess the relationship between glycemic control, diabetic duration and the DF lesions. A p-value of &lt; 0.05 was considered statistically significant.

Results

In total 383 patients were recruited, of whom 258 (67.9%) were men. The mean age of participants was 60.7±11.3. Poor glycemic control (HbA1c ≥ 7.0%) increased the risk of abnormal patellar reflex (aOR=7.07; CI95% 1.65-30.1; p = 0.03) and calf claudication (aOR=7.07; CI95% 1.65-30.1). The long duration of diabetes (10 years and more) was a significant factor associated with an abnormal Achill reflex (aOR=2.31; CI95% 1.12-4.76; p = 0.02), a needle-stick perceptual disorder(aOR=2.08; CI95% 1.14-3.78; p = 0.01), a vibration sensibility perceptual disorder (aOR=2.02; CI95% 1.01-4.08; p = 0.04), a negative monofilament test (aOR=2.69; CI95% 1.04-5.16; p = 0.003), an absent dorsalis pedis artery pulsation(aOR=2.35; CI95% 1.09-5.05;p=0.02) and an absent posterior tibial artery pulsation (aOR=3.06; CI95% 1.28-7.28; p = 0.01).

Conclusions

This study identified that disease duration and poor glycemic control are significant risk factors related to DF development in the current T2DM population.

Key messages

Disease duration and poor glycemic control are significant risk factors related to DF development in the T2DM population in the region of Monastir. Prevention programs should be focused on patient education about modifiable risk factors in particular glycemic control and adequate and regular foot care.

Pulmonary tuberculosis incidence, trends and predictions in Monastir, Tunisia (2000-2030)

Background

Tuberculosis (TB) continues to be one of the infectious diseases with the highest morbidity worldwide. The lung is the most commonly involved organ, but lesions can occur in other body systems. This study aimed to describe incidence and trends of pulmonary tuberculosis (PTB) over a period of 18 years in Monastir and to estimate predictions for 2030.

Methods

We carried out an observational study from 2000 to 2017. Data were collected by the regional direction of primary health care. Incidence was estimated by the crude incidence rate (CIR) and the age standardized rate (ASR). Poisson regression model was used to calculate the slope 'b' in order to describe trends and was performed to estimate incidence projection for 2030. Data were verified and analyzed using IBM SPSS Statistics version 22.0 software.

Results

A total of 997 patients were recorded with 486 cases of PTB (48.95%). Sex ratio was 2.85. The median age was 40.5 [IQR 28-56] years old. PTB ASR was 5.71/100,000 inhabitants (inh). CIR was the highest among the eldest cohort aged more than 60 years (12.65/100,000 inh) and the lowest among youth aged less than 19 years (1.01/100,000 inh). We established a negative trend of PTB over 18 years (b= -0.032; p &lt; 10-4) in all age cohorts. PTB would be decreasing by 2030 with an estimate incidence rate of 1.83/100,000 inh.

Conclusions

The decline of PTB may be a sign of TB control program effectiveness in Monastir. Thus, the challenges for the future are to maintain PTB towards decreasing.

Key messages

Our study highlighted the impact of TB control strategies in Tunisia. Our findings play a key role in estimating whether the WHO’s End TB strategy targets can be achieved by 2030.

Burden of cardiovascular diseases in the region of Monastir (Tunisia)

Background

Cardiovascular disease (CVD) is the leading cause of death in Tunisia. The aim of this study was to analyze CVD burden from 2002 to 2013 in the region of Monastir.

Methods

Using the Global Burden of Disease methodology, cardiovascular disease mortality and disability-adjusted life years (DALYs) were analyzed by age group and sex for all admissions at the university hospital of Monastir, using standardized approaches for data processing and statistical modeling. Data were retrieved from the regional register of hospital morbidity in Monastir and were analyzed from January 2002 to December 2013.

Results

CVDs caused 519 in-hospital deaths during the study period, accounting for 43.3 % (CI 95%: 40.6-46.1%) of all in-hospital non-communicable diseases-related mortality (n = 1197). The crude mortality rate of CVDs was 8.81 per 100,000 inh. The highest rate was recorded among patients aged ≥ 60 years-old. The age-standardized mortality rate was 11/100,000 PY (14 in men and 8 in women). CVD DALY per 100,000 was 176.4 (199.4 in men and 152.7 in women). The highest CVD DALY was in the age groupe of 60 years and older (929.7/100,000). The leading causes of DALYs for both sexes are coronary heart diseases and stroke with DALY rate of 112.6 and 47.4 per 100,000 inh, respectively.

Conclusions

The CVD burden was heavy in the study population, in particular in the elderly and in men. Prevention and control of modifiable risk factors should be taken actively to improve health for Tunisian adults.

Key messages

CVD burden was heavy in the region of Monastir. More efforts are needed to improve cardiovascular health in Tunisian adults.

Being bullied and associated factors among middle school students in the region of Monastir, Tunisia

Introduction

The phenomenon of bullying among adolescents is a worldwide issue. The trend of this behavior is increasing in developed countries as well as in developing countries, with the creation of new forms such as cyberbullying. This study aimed to determine the prevalence of being bullied and to analyze the association between being bullied and some individual and familial factors.

Methods

This is a cross-sectional study conducted in two middle schools belonging to the region of Monastir in Tunisia in December 2017 and January 2018. The Global School-based Student Health Survey (GSHS) was administered for students. All present students from the two recruited schools were included.

Results

A total of 802 students were enrolled in the study. Just under half of the study group (44.0%) reported having been bullied in the past month with 95% CI [40.66%-47.57%]. The predominant type of bullying was being made fun of with sexual jokes, comments or gestures (9.1%), followed by being kicked, pushed, shoved or locked indoors (3.6%). In multivariate analysis, physical fight was an independent associated factor with being bullied (OR [CI]95%: 2.04[1,77-3,25]), p = 0.001. Lonely students had nearly 3.38 higher risk of undergoing bullying (OR [CI]95%: 3.38 [2.05-5.57]), p = 0.001). In addition, being worried was also an independent factor associated with being bullied (OR [CI]95%: 2,23 [1,45-3,43]), p = 0.001.

Conclusions

Our results support an association between existing mental health problems and bullying. Additional studies are needed to understand the factors associated with school bullying and to

Key messages

In this study, the prevalence of bullying was relatively high. Program education in schools should focus on life skills education in order to develop the self-confidence and the self-esteem of students.

Smoking abstinence 1 year after acute coronary syndrome in Tunisian adults

Background

In Tunisia, coronary heart disease(CHD) is the first cause of mortality, accounting one third (33.23%) of total deaths in 2017. Although smoking cessation is the most effective CHD prevention strategy, quitting smoking is difficult and two thirds of patients return to smoking within 1 year of their acute coronary syndrome (ACS). The present study aimed to evaluate the smoking cessation rate and to assess predictors of smoking abstinence in patients with ACS, one year after hospital discharge.

Methods

A prospective cohort study was conducted in the Cardiology Department and Smoking Cessation Service at University Hospital of Monastir, Tunisia from January 2015 to December 2017. During their hospitalization, all patients in the sample received individual therapeutic education including a motivational interview. The follow-up were carried out by clinic visits every two weeks. Logistic regression analysis was used to evaluate the independent predictors of smoking abstinence. The statistical analysis was conducted with SPSS software, version 21.0. A p value of &lt; 0.05 was considered statistically significant.

Results

A total of 288 smoking patients were included in our study. All participants were male and the mean age was 55 ± 11 years. More than half (55.4%) of patients had a high level of nicotine dependence. Successful smoking cessation rate was 35.7 % [95% confidence interval (CI): 29.4-42.5%]. Independent predictors of smoking abstinence were: therapeutic adherence (odds ratio(OR): 13.8, p &lt; 0.001), the level of nicotinic dependence (OR: 0.26, p = 0.02), the length of stay in the ICU (OR: 8.31, p = 0.001) and diabetic status (OR: 4.54, p = 0.01).

Conclusions

This study for smoking cessation highlights the importance to generalize our protocol for all Tunisian patient with cardiovascular risk.

Key messages

Smoking cessation is the most effective coronary heart disease prevention strategy. More efforts are required to improve smoking cessation in patients with cardiovascular risk.

Occupational exposures to blood and body fluids among health care workers in Tunisia

Background

Occupational exposures to blood and body fluid are among the most frequent occupational accidents in healthcare. They put healthcare workers (HCWs) at high risk of transmission of many blood borne pathogens mainly hepatitis B virus (HBV), hepatitis C virus HCV and HIV. The aim of this study was to determine the prevalence of occupational exposures to blood and body fluids and its associated factors among HCWs at the university hospital of Monastir (Tunisia) in 2017.

Methods

An exhaustive cross-sectional study was conducted from 01 June 2017 to 31 August 2017 at the university hospital in Monastir Governorate (Tunisia). An anonymous self-administered questionnaire was used to collect data on demographic characteristics, self-reported exposures and their circumstances. We performed a multivariate analysis to determine the associated factors to these occupational exposures.

Results

A total of 1493 HCWs (34.6% nurses 22% technicians and 21.6% doctors) were included corresponding to a response rate of 74%. The median age of the participants was of 36 years (IQR: 31- 46 years). The sex ratio was of 0.36. Responders from medical and surgical departments represented respectively 40.5% and 39%. Among interviewed HCWs, 56.7% reported having at least one exposure to blood or body fluid with 35.4% of them exposed twice or more. Almost half (48.3%) of the respondents had a history of needle stick injury and 32.1% had a history of blood or body fluid splash into the face.The multivariate analysis showed that doctors had the highest risk of exposure comparing to other HCWs with (AOR = 12.425; 95% CI: 05.310 - 29.075) and participants working at surgical departments were at higher risk of exposure than those at others departments (AOR=7.440; 95% CI: 4.461 - 12.408).

Conclusions

Health occupational exposures to blood and body fluids are a serious problem at the university hospital of Monastir. Preventive measures should be strengthened to alleviate this problem.

Key messages

Doctors had the highest risk of exposure to blood and body fluids comparing to other HCWs at the university hospital of Monastir. Preventive measures should be strengthened to alleviate this problem.

Expression analysis of immune-regulatory molecules HLA-G, HLA-E and IDO in endometrial cancer

HLA-G has been widely implicated in advanced cancers through different pathways of immunosuppression allowing tumor escape. Contrarily, HLA-E has a controversial role in the tumor escape from the immune system. IDO catabolic enzyme is known to be up-regulated in many tumors types allowing their immune escape. Based on these considerations, we investigated the expression of HLA-G, HLA-E and IDO molecules in endometrial cancer (EC) and their association with prognostic clinicopathologic parameters. Their expression were checked in tumoral and adjacent endometrial tissues. Both HLA-G and IDO immunostaining were significantly increased in EC tissues compared to normal residual endometrial glands (Mann Whitney U-test, p = 0.0001 and p = 0,020 respectively). However, HLA-E was highly expressed in tumoral tissues as well as in normal residual endometrial glands (respectively, 100% and 81.8%). Increased HLA-G expression levels were observed in high histological grade (grade 3), and in the non-endometrioid type 2 EC. Unexpectedly, patients with IDO Low expression had significantly impaired overall survival compared to patients with IDO High (log-rank p = 0.021). Conversely, HLA-E low expression was associated to an improved overall survival EC (log-rank p = 0.004). We concluded that, HLA-G and IDO are highly expressed in EC compared to adjacent normal endometrial tissues, that might be interesting for the EC outcome.

Multiple cutaneous metastasis of synchronous urothelial carcinoma of the bladder and the renal pelvis: a case report

INTRODUCTION

Cutaneous metastatic disease arising from urinary tract carcinoma is rare and associated with a poor prognosis. We report a case of metastatic disease occurring in a patient treated for synchronous urothelial tumor of the bladder and left renal pelvis.

CASE PRESENTATION

A 61-year-old Caucasian man was treated for a synchronous urothelial tumor of the bladder and left renal pelvis. He had an en bloc radical cystectomy and left ureteronehprectomy associated with a cutaneous transileal urinary diversion and lymph node dissection. He was scheduled for chemotherapy but was lost to follow-up. He consulted 1 year later with growing skin tumors that were confirmed to be metastatic disease, and he was referred to the oncology department for palliative chemotherapy.

CONCLUSION

Cutaneous metastatic disease is a rare entity with poor prognosis. The main treatment remains chemotherapy; however, single-site metastasis should be considered for metastasectomy.

Adrenal gland hemangioma: A rare case of the incidentaloma: Case report

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Adrenal gland hemangioma is an extremely rare benign vascular tumor.

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It is frequently discovered as incidental radiological findings in abdominal imaging performed for various reasons.

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The preoperative diagnosis is very difficult, generally CT and MR imaging are useful for the diagnosis of hemangioma.

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In front of an adrenal mass discovered incidentally there are several factors to consider: the tumor size, its secreting character or not, imaging data suggestive of malignancy and complications.

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These factors help in determining which incidental adrenal masses should be excised.

Bakground

Adrenal glands hemangiomas are rare, benign and non-functional tumors. They are often discovered as incidentalomas either during imaging or autopsies. Nearly 70 cases were reported in the literature.

Case report

We report a case of a non-functional adrenal hemangioma (AH) that was incidentally found on abdominal ultra sonography (US) during the routine control of diabetes of a 58 year-old man. Imaging with US and Computed tomography (CT) showed an heterogeneous and partially calcified 6 cm tumor of the right adrenal gland. The mass was surgically excised and the histological examination concluded to an adrenal haemangioma.

Conclusion

Although rare, AH should be included in the differential diagnosis of the adrenal neoplasmas.