Mohamed Mahjoub

Healthcare-associated infections in a Tunisian university hospital: from analysis to action.

Introduction Our study was conducted, in university hospital center (UHC) Farhat Hached of Sousse (city in Tunisian center-east), within healthcare-associated infections (HAI) epidemiological surveillance (ES) program, based, among others, on HAI regular prevalence surveys. Our objectives are to resituate HAI prevalence rate and to identify their risk factors (RF) in order to adjust, in our hospital, prevention programs. Methods It is a transversal descriptive study, including all patients who had been hospitalized for at least 48 hours, measuring prevalence of HAI a “given day”, with only one passage by service. Risk factors were determined using Epiinfo 6.0, by uni-varied analysis, then, logistic regression stepwise descending for the variables whose p Results The study focused on 312 patients. Infected patients prevalence was 12.5% and that of HAI was 14.5%. Infections on peripheral venous catheter (PVC) dominated (42.2%) among all HAI identified. HAI significant RF were neutropenia (p < 10−4) for intrinsic factors, and PVC for extrinsic factors (p = 0,003). Conclusion Predominance of infections on PVC should be subject of specific prevention actions, including retro-information strategy, prospective ES, professional practices evaluation and finally training and increasing awareness of health personnel with hygiene measures. Finally, development of a patient safety culture with personnel ensures best adherence to hygiene measures and HAI prevention.

Gastric Adenocarcinomas in Central Tunisia: Evolution Specificities through Two Decades and Relation with Helicobacter pylori

Introduction: In developed countries, authors have reported variations over time in the seat and histological type of gastric adenocarcinomas, which were explained by Helicobacter pylori infection (HPI) incidence changes. In North-African countries and the Arabic world, epidemiological changes in gastric adenocarcinomas are still unknown. Our study aims to explore and to describe those changes in central Tunisia. Materials and Methods: This is a retrospective observational and descriptive study including 876 cases based on the National Central Tunisian Register of Cancers over a period of 21 years. Two groups were formed and compared (group A: 337 patients from 1995 to 2005; group B: 539 patients from 2006 to 2015). Results: HPI decreased from 32.6% in group A to 11.2% in group B (p < 0.05). Signet ring cell carcinomas increased in 2 decades from 14% in group A to 36% in group B (p < 0.05). Proximal cancers were 16.61% in group A and increased to 19.66% in group B (p = 0.3). Total gastrectomy rate was 10.4% in group A versus 23.2% in group B (p < 0.05). Conclusion: This study has shown a significant increase of signet ring cell carcinomas with a simultaneous decrease in HPI in the last decade in central Tunisia.

Retroperitoneal follicular dendritic cell sarcoma in a young woman: Diagnosis and treatment challenges

INTRODUCTION Follicular dendritic cell sarcoma (FDCS) is an uncommon tumor that usually arises in lymph nodes, especially in the cervical, mediastinal, or axillary areas, but rarely in extranodal sites. Few cases have been reported in English literature so far. The scarcity may be partially due to under-recognition of this entity. Through this case report we analyzed the difficulties of clinical and pathological diagnosis of this rare tumor with its unusual location mistaken it with gynecological cancers iliac lymph nodes metastases. We also discussed its systemic treatment options. CASE REPORT A 48-year-old woman presented with a loss of weight and epigastralgia. Computed tomography (CT) showed a mass of 5cm of diameter, located close to iliac vessels. Investigation for gynecologic cancers was negative and a partial tumor resection was performed. Pathological examination readdressed the diagnosis of FDCS. Microscopically, the tumor was composed of a proliferation of spindle to ovoid cells arranged in fascicles, whorls and storiform pattern, accompanied by sprinkling of small lymphocytes. The nuclei of the tumor cells were elongated spindled or ovoid shape with vesicular chromatin and distinct small nuclei. Immunohistochemically, the tumor cells were positive for CD21, CD23 but negative for any type of cytokeratin. Even pathological diagnosis was misleading, therapeutic management was more challenging with this unusual location particularly associated with an aggressive clinical course. Two lines of chemotherapy gave different responses. CONCLUSION Clinical and pathological diagnosis of retroperitoneal FDCS needs vigilance. Both lymphoma and sarcoma chemotherapy regimens are effective. Due to this pathologys rareness we highlighted a lack of treatment consensus and proposed options.

Case of Massive Hydatid Pulmonary Embolism Incidentally Discovered in a 56-Year-Old Woman with Posttraumatic Abdominal Pain

Hydatid pulmonary embolism rarely occurs. It arises from the rupture of a hydatid heart cyst or the opening of a visceral hydatid cyst into the venous circulation. We report a case with pulmonary hydatidosis resulting in a massive bilateral pulmonary embolism in a 56-year-old woman with history of hepatic echinococcosis. A brief overview of clinical features and radiologic findings is presented.

Réparation juridique en dommage corporel de l’insuffisance antéhypophysaire post-traumatique

Post-traumatic anterior pituitary insufficiency (PTAPI) is a rare but established disease caused by ischemic lesions after severe cranial trauma. This case study aims to highlight the criteria for imputability of PTAPI to a cranial trauma as well as the specific principles of legal redress in relation to this disease. We conducted a forensic study of a patient with diagnosed PTAPI followed up in the Division of Endocrinology and Legal Medicine at the University Hospital, Sousse (Tunisia). The patient included in the study was a 45-year old woman with no particular past medical history. (6 gynaecological procedures, 4 parities and 2 abortions) having regular menstrual cycles, without a history of hemorrhagic childbirth, who had been involved in a road accident (pedestrian got hit by a car) causing occipital trauma without initial knowledge loss. She developed hypothyroidism three years after the accident. The hormonal assessment showed the involvement of all the other axes. Neuroradiological examination objectified pituitary gland and pituitary stalk integrity. The definitive diagnosis of PTAPI was made. Medical examination (performed 4 years after the accident) concluded that PTAPI was imputable to the accident. Permanent partial disability rate according to ordinary law has been assessed at 25%. PTAPI diagnosis is made by elimination. The evaluation of physical injury should be based on residual symptoms, on therapeutic constraints and on its impact on daily and professional activity. Patients evolution under hormone replacement therapy is often favorable, however, complications may occur, hence the necessity to establish these complications in order to preserve the right of the patient to underwent new treatments.

Perceptions of a Healthcare-associated Infections Reporting System in a Tunisian University Hospital

Objective: The implementation of a healthcare-associated infections reporting system is a principal component of infection control and quality improvement policies in healthcare institutions. This study was designed to determine the perceptions of health professionals concerning implementation of a healthcare-associated infections reporting system and to analyse factors influencing these perceptions.Methods: A descriptive cross-sectional study conducted in 2012 using a predefined, pre-tested and self-administered questionnaire in 380 health professionals working in 16 different departments of Farhat Hached University Hospital, Tunisia.Results: The majority of respondents (71.8%) reported that no healthcare-associated infections surveillance procedure had been implemented in their departments. However, most respondents (93%) recognised the value of implementation of a healthcare-associated infections reporting system in order to provide them with corrective actions (77%), to support the investigation of epidemic and emerging phenomena (49%) and to share experiences about the prevalence of healthcare-associated infections and their risk factors (44%).Conclusion: Staff training and development of a regulatory framework are essential to implementation and correct functioning of a healthcare-associated infections reporting system.

Sudden Death Due to Unusual Complication of Takayasu Arteritis: An Autopsy Case

Abstract Takayasu arteritis is an uncommon inflammatory disease with usually a good prognosis. However, sometimes, the evolution can be fatal essentially by a coronary arteries involvement. We present a case of a 19-year-old woman who died suddenly from cardiogenic shock complicating an unknown Takayasu arteritis. At the autopsy, the aorta showed a significant thickening of the wall. The coronary arteries were slightly thickened and did not show any occlusion. Microscopic examination of the aorta showed an abundant granulomatous and a lymphoplasmacytic infiltrate. Microscopic sections of other internal organs showed signs of cardiac hypertrophy and an extensive edema of the lung. Death was attributed to acute heart failure complicating a supravalvular aortic stenosis secondary to unknown Takayasu arteritis. Takayasu arteritis can be life-threatening by an occlusion of the ascending aorta and its major branches, without any coronary arteries involvement.

La matério-vigilance dans un Centre Hospitalo-Universitaire du Centre-Est tunisien: enquête auprès des médecins

Introduction Pour la meilleure gestion des risques en milieu hospitalier et l’amélioration de la qualité et la sécurité de nos soins, le CHU de Sousse (Tunisie), a mis en place, suite aux recommandations de l’ANCSEP (Agence Nationale de Contrôle Sanitaire et Environnementale des Produits) un système de matério-vigilance (MV). En Tunisie l’absence d’un cadre réglementaire organisant la MV est l’obstacle majeur à l’implication des soignants à ce système. L’objectif de cette étude est de déterminer les connaissances, attitudes et pratiques des médecins du CHU quant à la mise en place du système de MV. Méthodes Etude descriptive de type CAP (connaissances, attitudes et pratiques) transversale auprès de tous les médecins titulaires exerçant au CHU de Sousse (Tunisie) qui sont utilisateurs des dispositifs médicaux (DMs) lors de leur pratique d’activité de soin. Un questionnaire auto-administré, préétabli et pré-testé a été établi. Saisie et l’analysée des données par logiciel SPSS20.0. Résultats Le taux de réponse de 51,9 % (183/95), un manque des connaissances relatif à la MV a été rapporté. Plus de la moitié des répondants ne connaissent pas le correspondant local de son établissement et l’existence d’un formulaire standardisé de signalement. Concernant les attitudes, 89,5 % notifient l’intérêt de mise en place du système de MV et 37,5 % reconnaissent que le signalement doit émaner du soignant constatant l’incident. Pour les pratiques, la majorité confirment l’absence d’une gestion organisée de la maintenance des DMs dans leurs services. 90,5 % expriment leurs souhaits de recevoir une information mais peu d’entre eux expriment leurs désirs de suivre une formation (57,9 %). Conclusion Un manque d’information et de formation dans un domaine pourtant sensible et devant être lourdement réglementé est soulevé. La promulgation de textes réglementaires est nécessaire afin de promouvoir le secteur des DMs et garantir la sécurité sanitaire du patient et de l’utilisateur.

Stratégie transfusionnelle des hémorragies graves du post-partum: étude rétrospective à propos de 47 cas

Introduction L’hémorragie du post-partum est la principale cause de morbi-mortalité maternelle dans le monde. La prise en charge est multidisciplinaire. La stratégie transfusionnelle est capitale jouant un rôle majeur dans le pronostic maternel. L’objectif de ce travail a été de déterminer le rapport PFC/CGR lors de la prise en charge des hémorragies graves du post-partum. Méthodes Une étude Etude rétrospective sur une période de 4 ans (2009-2012) a été réalisée dans un centre de maternité de référence de niveau III du centre-Est tunisien. Elle a inclut les parturientes admises pour une hémorragie sévère du post-partum définit par la nécessité d’une transfusion de plus de 04 CGR durant les 3 premières heures ou de plus de 10 CGR durant les 24 premières heures de prise en charge. Résultats Notre étude a inclut 47 parturientes. Le diagnostic de l’HPP a été fait devant un saignement vaginal dans 28 cas et suite à une césarienne dans 19 cas. En préopératoire le taux d’Hb a été de 6.3 g/dl. Le rapport transfusionnel (PFC/CGR) a été de 1/0.7. Conclusion Au cours de notre prise en charge, le rapport transfusionnel a été plus élevé que les recommandations récentes de la littérature stipulant une administration précoce et massive de PFC avec un ratio PFC/CGR compris entre 1/2 et 1/1. L’administration du fibrinogène (Fbg) et de l’acide tranexamique doit être précoce. L’emploi du facteur VII activé recombinant (rFVIIa) doit rester une solution ultime de prise en charge.INTRODUCTION Postpartum haemorrhage is the leading cause of maternal morbidity and mortality worldwide. It requires a multidisciplinary approach. Transfusion strategy is essential, playing a key role in maternal prognosis. This study aims to determine FFP/RBC ratio (plasma frais congelé/concentrés de globules rouges; fresh frozen plasma/red blood cells) during the treatment of serious postpartum haemorrhages. METHODS We conducted a retrospective study at a Maternity Referral Center (level III) in eastern Tunisia over a period of 4 years (2009-2012). All parturients admitted due to severe postpartum bleeding requiring transfusion of more than 4 Units of RBC during the first 3 hours or of more than 10 Units of RBC during the first 24 hours of treatment were included in the study. RESULTS 47 parturients were enrolled in our study. The diagnosis of PPH was made on the basis of vaginal bleeding in 28 cases and following cesarean section in 19 cases. Preoperative hemoglobin level was of 6.3 g/dl. Transfusion ratio (FFP/RBC) was 1/0.7. CONCLUSION During tratment transfusion ratio was greater than that indicated in the existing guidelines stating an early and massive administration of FFP with a FFP/RBC ratio ranging between 1/2 and 1/1. Fibrinogen (Fbg) and tranexamic acid should be administered as early as possible. The use of recombinant activated factor VII (rFVIIa) should remain the ultimate treatment option.

Patient’s safety culture among Tunisian healthcare workers: results of a cross sectional study in university hospital

Introduction Healthcare safety has become a public health priority in developed world. Development of safety culture care is fundamental pillar to any strategy for improving quality and safety care. The objective of this study is to measure level of patients’ safety culture among healthcare professionals at university hospital, center Farhat Hached Sousse (Tunisia). Methods We conducted, in 2013, a descriptive study among all licensed physicians (n= 116) and a representative sample of paramedical staff (n= 203) exercising at university hospital center Farhat Hached Sousse (Tunisia). Measuring instrument used is a valid questionnaire containing ten safety care dimensions. Data were analyzed using SPSS version 19. Results The response rates were 74.1% for physicians and 100% for paramedical staff. Overall score of different dimensions varies between 32.7% and 68.8%. Dimension having most developed score (68.8%) was perception of “Frequency and reporting adverse events”. Dimension with lowest score (32.7%) was “Management support for safety care”. Conclusion Our study has allowed us to conclude that all dimensions of patients’ safety culture need to be improved among our establishment’s professionals. Therefore, more efforts are necessary in order to develop a security culture based on confidence, learning, communication and team work and rejecting sanction, blame, criminalization and punitive reporting.