E-learning pour la Continuité de la Formation en Ophtalmologie Pendant la Pandémie COVID-19 : Degré de Satisfaction des Résidents de l'Institut Hédi Raies d'Ophtalmologie de Tunis

Introduction:

COVID-19 pandemic created great challenges for the continuity of medical education. At the Hédi Raies Institut of Ophthalmology of Tunis (HRIO), the need to ensure continuity in the teaching of ophthalmology has stimulated the development of a new e-learning resource based on clinical case studies.

Aim: 

To evaluate level of satisfaction of HRIO residents in regard to clinical case-study-based e-learning of ophthalmology.

Methods:

Cross-sectional survey including 40 ophthalmology residents doing their internship at the ROHI during the first half of 2020. Learners were tutored in e-learning via the Moodle online learning platform and using a problem-solving format based on clinical case studies describing various ophthalmologic conditions. Data collection was carried out through an online survey after four months of training, designed to assess learners'' satisfaction with the e-learning.

Results:

Mean age of participants was 29.95 ± 1.73 years. The majority had found the navigation easy, the content relevant to their training objectives, and were satisfied with the discussion forums as a method of communication. All respondents were satisfied with clinical cases presented through the platform and felt that they helped them to better understand the content. Among them, 97.5% considered that this teaching method corresponded to their training needs. There was a statically significant difference in the level of knowledge before and after e-learning teaching, taking into account the residents'' appreciation (p<0.001).

Conclusions:

This study highlights the importance of virtual learning in ophthalmology in the era of the COVID-19 pandemic. E-learning is well appreciated by ophthalmology residents, relatively easy to integrate to their training program, and reduces issues of time, patient availability and case exposure.     

Bactériémies à bactéries multirésistantes chez les greffés de cellules souches-hématopoïétiques

Background:

Bacteremia become fearsome in hematopoietic stem cell transplant (HSCT) recipients with the emergence of multidrug-resistant (MDR) strains.

Aim:

Our purpose was to investigate the prevalence of MDR bacteremia in HSCT recipients at the Tunisian National Bone Marrow Transplant Center, associated factors and attributable mortality rate.

Methods:

Our retrospective study (January 2010-December 2017) included all MDR bacteremia in the Hematology department. MDR rods were: extended spectrum beta-lactamase producing Enterobacterales (ESBL-E), P. aeruginosa and A. baumannii resistant to at least three families of antibiotics, methicillin-resistant S. aureus (MRSA) and vancomycin resistant E. faecium (VRE).

Results:

The prevalence of MDR bacteremia among HSCT recipients was 5.9% (48/816) with a stable trend over time (rs=0.18). Neutropenia, prior hospitalization, prior antibiotherapy and prior colonization with MDR pathogens were observed in 59%, 58%, 48% and 31% of cases, respectively. Imipenem was the most prescribed first-line antibiotic (50%). The attributable mortality rate was 13%. MDR bacteria (n=48) belonged to ESBL-E (60%), P. aeruginosa (19%), A. baumannii (13%), MRSA (4%) and VRE (4%). For ESBL-E and P. aeruginosa, the rates of antibiotic resistance were respectively, 17% and 44% to imipenem, 31% and 56% to amikacin and 15% and 0% to colistin. Strains of A. baumannii were susceptible only to colistin. The MRSA (n=2) were resistant to ciprofloxacin and gentamicin and susceptible to glycopeptides. The VRE (n=2) were susceptible to linezolid and tigecycline.

Conclusion:

Low prevalence of MDR bacteremia in HSCT recipients but high attributable mortality rate, requiring reinforcement of hygiene measures.     

Le chemin vers la Médecine de Famille en Tunisie. Analyse stratégique

Background:

Health system reforms in many countries have shown that the delivery of integrated primary health care services according to family medicine is the most efficient approach to achieve universal health coverage. In Tunisia, the issue is therefore the capacity of our health system to integrate a care approach based on family practice.

Aim:

To assess the preparedness to implement family medicine in our country

Methodology:

this is a qualitative study carried out over a period of 9 months during the year 2017.Based on a WHO protocol addressing the 13 pillars of family practice, our study explores health policy context, actors (using interviews with key informants at national, regional and local level) and health content.

Results:

Family practice model is a strategic priority in Tunisia. However, this political recognition suffers from a lack of operationalization, in relation with continuing medical training, registration of patients and families by doctors, referral system, minimum package of essential care/ essential drugs and quality of care monitoring as well as community involvement..

Conclusion:

Our situation analysis reveals that the delivery of integrated care based on family practice model; enforce to adopt a comprehensive and operational health policy that goes beyond the academic aspects.     

Hépatite C : Etat des lieux de la littérature Tunisienne (1991-2019)

Background:

Hepatitis C virus (HCV) is one of the leading causes of chronic liver disease and liver cancer related deaths in Tunisia.

Aim:

Perform a systematic review on viral hepatitis C in Tunisia between 1991 and 2019.

Methods:

A global search of HCV-specific documentation in Tunisia in bibliographic data search sites.

Results:

Tunisia is a low endemic country for hepatitis C with a prevalence that not exceed 1% in the general population. Several studies have focused on populations at risk of HCV contamination such as hemodialysis and polytransfused patients. The prevalence of hepatitis C is higher in these groups. In relatively small series, a clear predominance of genotype 1 and subtype 1b has been reported in Tunisia with a lower co-circulation of the other genotypes. Several polymorphisms of cytokine and chemokine genes can influence the clearance or persistence of HCV infection. Tunisian studies have focused on the efficacy of conventional dual therapy (pegylated IFN + ribavirin) by analyzing the predictive factors linked to SVR and mutations associated with resistance to viral inhibitors. No publication has discussed the effectiveness of new direct-acting antivirals in Tunisia.

Conclusion:

This review of the literature provides an update on the status of hepatitis C in Tunisia and reveals a lack of investigations on new directacting antivirals.     

Amélioration des habiletés communicationnelles en médecine à l'aide du jeu de rôle : étude auprès de 28 étudiants de deuxième cycle d'études médicales

Background:

Medical teaching is usually centred on an objective-based approach and influenced by a flexnerian approach inducing an emphasis on abilities and skills more than the know-how. The know-how is usually under taught and assessed.

Aim:

To assess the competencies in announcing bad news of students in medicine in addition to their satisfaction about the methods used which were serious games.

Methods:

Students in the third-pregraduate year of medicine who performed their externship in a Department of Pathology of a university Hopsital were included during the year 2018-2019. Seven groups including 4 externs performing a 3-week-period were included. The training started with a pre-test, which consisted in an Objective-Structured-Clinical situation with a simulated patient and a evaluator with a checklist. The students were asked to perform a serious game, then they assisted to a lecture-based learning about the rules of announce of bad news. The serious game was screened then watched by all the students. After a debriefing session, the students were asked to fulfill a post test and a questionnaire-test

Results:

Twenty-eight students were included. The mean score accounted for 6,76 +/- 2,78 over 20 for the pre-test and 13,17 +/- 1,99 over 20 for the post-test. A significant difference was observed between the pre and post test (p<0.0001). All the students expressed their satisfaction. 27 students wished to repeat the experience. All the students put emphasis on the importance of the peer and auto-evaluation phase using videos. 14 students suggested to integrate this teaching method to the curriculum of the Faculty before their internship.

Conclusion:

Inspite of some limits, this study highlighted the improvement of the students’ relational competences in addition to their satisfaction related to the use of role play in the acquisition of relational competences related to particular situation such as the announce of bad news.     

Prise en charge des diabétiques. Etude comparative de deux structures de santé contrastées

Background:

The proportion of total Tunisian with Diabetes reached 15.5% in 2016. The objective of this study was to analyze diabetic''s management in contrasted health care settings.

Methods:

Mixed methodology (quantitative and qualitative) with explanatory design was used in contrasted health care structures (a primary health center (PHC) and the National Institute of Nutrition and Food Technologies (INNTA)). Interviews with health providers and patients were than condcuted in both centers to explain quantitative findings.

Results:

Quality of care assessement was performed among 100 patients in the PHC and 96 in the hospital. Glycemic control was reached in less than 30 % of the cases in both centers. Although clinical evaluation was better in the PHC, conducting ECGs, measuring of HbA1c  and  LDL-Ch were far from being optimal. The qualitative study did supply some hypotheses explaining these gaps: treatments shortage and lack of laboratory assessments specifically pointed in PHC settings, potentially lower its attractiveness, thus compounding overcrowding and stressful working conditions in hospitals. These last points as well as poor communication and overloaded clinics in hospital were major sources of providers and patient dissatisfaction.

Conclusion:

This study made it clear that primary health care is a cornerstone in diabetes management. However, it is crucial to strengthen primary health care centers by operational technical support (laboratory equipements and quality information system) as well building capacities of health professionals in information, education and communication.     

Stratégies des pays Maghrébins dans la lutte contre le cancer

Objectives:

Describe the cancer control strategies adopted by the Maghreb countries and identify their main weaknesses.

Methods:

Data on cancer epidemiology and "Cancer plans" in the Maghreb were collected through a search in bibliographic databases, on GLOBOCAN and the sites of international and national organizations responsible for surveillance and cancer control.

Results:

In the Maghreb, cancer registries observed low population coverage (Morocco: 20%; Tunisia: 60%; Algeria: 82%) and a lack of computerization. Primary prevention strategies remains insufficient as evidenced by the high prevalence of smoking in 2018 (Tunisia: 26%; Algeria: 19%; Morocco: 14%). Screening coverage for major cancers are still low in the Maghreb; In Tunisia for example the levels observed for cervical and breast cancers are respectively 14% and 10%. Regarding cancer care, the main problem is a limited access to cancer health services,   due to poorly decentralized infrastructure and equipment (Morocco: six oncology centers; Algeria: three oncology centers; Tunisia: only one institute specializing in cancer care). Palliative care is mainly supported by civil society in the Maghreb countries.

Conclusion:

The resources dedicated to cancer control in the Maghreb are limited, explaining its poor performance. Better governance in cancer control is required, with the adoption of multisectoral approach for prevention, and the strengthening of cancer surveillance and research.     

Profil des initiatives communautaires de riposte contre la pandémie COVID-19 en Tunisie

Introduction:

Colorectal cancer (CRC) is a real public health issue in Tunisia. A screening program based on fecal immunological occult blood test, followed in case of a positive test by colonoscopy, was launched in Tunis region in 2016. We aimed to evaluate this screening program in order to make recommendations for a better implementation of this program in years to come.

Methods:

A mixed approach has been adopted with a quantitative component based on the production of indicators related to activity, monitoring and screening quality; and a qualitative component conducted through focus groups with frontline health care professionals (HCP) and individual interviews with those lost to follow-up after a positive screening test. SWOT analysis was then performed in order to assess main strengths, weaknesses, opportunities and threats of the program.

Results:

This study showed a coverage rate of 41.2% [40.5-41.8] for population consulting the first line of care, and an effective participation rate estimated at 23.1% [22.6-23.6]. Out of 5856 tests performed, 6% (n=352) were non-treatable and 6.7 % (n=390) were positive. Only 18.6% (n=72) of those tested positive had undergone colonoscopy. A total of 26 polyps, 03 cases of cancer and 04 cases of dysplasia were recorded. SWOT analysis pointed out that the variable adherence of HCP, lack of awareness of general population regarding CRC screening, the non-acceptability of colonoscopy without sedation with a problem of affordability for its realization in the private sector, and long appointments delays in public sector, were main weaknesses and of this program.

Conclusion:

This evaluation underlined certain strengths regarding the program implementation and revealed, in return, several shortcomings which certainly impair the program’s effectiveness and efficiency. The involvement of the national health insurance fund in CRC screening tests and colonoscopies reimbursement, as well as the establishment of a performance-based payment modality for HCP, constitute main key pillars to reach success and sustainability for any CCR mass screening program in Tunisia.     

ASPECTS ÉPIDEMIOLOGIQUES ET THÉRAPEUTIQUES DES FRACTURES ACETABULAIRES CHEZ LE SUJET ÂGÉ

Introduction:

Management of acetabular fracture in the elderly patients is becoming an increasingly topic of debate. Data from different parts of the world specified particularities of their patients.

Aim:

To describe patterns of these fractures in the Tunisian patients aged > 60, which can contribute to management and preventive plans.

Methods:

We performed a retrospective review from 1997 to 2016 treated at the Charles Nicolle university hospital. Information regarding demographics, co morbidities, mechanism of injury, Injury Severity Score (ISS), types and levels of injury, treatment type, and mortality were collected.

Results:

The mean age of our patients was 68,6 years (range 60–94 years). The male to female ratio was 3:85.Main causes were motor vehicle accident. Most of our patients were in good health. The associated lesions were very frequent and present in 64.7% of cases with a clear predominance of cranio-fascial trauma, with a median of the ISS score at 11. According to the Judet and Letournel classification, 18 elementary fractures and 16 complex fractures were reported with predominance of the anterior column-posterior hemitransverse fracture pattern. Posterior wall fracture in the elderly is often associated with comminution and / or marginal impaction and / or posterior dislocation of the hip. Fractures of the anterior segment are often associated with hip protrusion and / or quadrilateral plate involvement and / or the superomedial roof impaction or "Gull sign".

Conclusion:

As our population continues to age, traumatic acetabular fractures will become more prevalent. Appropriate screening strategies, treatment and prevention plans will need to be developed to improve outcomes in this devastating injury.     

Composition corporelle des patients atteints de BPCO et son impact sur la fonction respiratoire

Introduction:

Despite fat-free mass index (FFMI) is one of the strongest predictive factors of survival during chronic obstructive pulmonary disease (COPD), there is a considerable lack of information regarding body composition in Tunisian patients with COPD.   Aim: Describe the body composition of Tunisian patients followed for COPD and examine the relationship between body composition and the severity of the disease.

Methods:

Cross-sectional study of patients with stable COPD. Body composition was assessed by bioelectrical impedance analysis. Pulmonary function tests (PFT) included spirometry with plethysmography and the six-minute walking test. The severity of dyspnea was assessed by the mMRC scale.

Results:

During the study period, 104 patients with stable COPD were included (average age= 65.9 years and average FEV1= 49.3%). Fifty-four percent of patients were GOLD D stage. According to the IMM, malnutrition was identified in 20.2% of cases. Patients with low FFMI were the most symptomatic, had a more severe air flow limitation and a more severe disease. The walking distance was lower in malnourished patients. However, FFMI was not significantly associated with exercise capacity.

Conclusions:

Malnutrition is highly prevalent in COPD patients and is correlated to the severity of the disease. Thus, body composition analysis should be considered in COPD patient management.     

LE SULFATE DE MAGNESIUM : MOLECULE ADJUVANTE DANS LA PREMIERE HEURE DE PRISE EN CHARGE DE LA FIBRILLATION ATRIALE RAPIDE AUX URGENCES.

Introduction:

Rapid Atrial fibrillation (AF) is a common arrhythmia in emergency department (ED) that requires an urgent control of ventricular rate.

Aim:

To evaluate the safety and efficiency of magnesium sulfate as an adjunctive therapy in addition to usual care for rapid AF in emergency department.   

Methods:

This was a prospective, randomized, double-blind study. We included patients who presented to ED with rapid AF >110 batt/min. Group A received 3g of magnesium in 100mL of glucose solution and group B received 100 ml of glucose solution. Primary endpoint was slowing the ventricular rates to less than 110 beats/ min in the first 12 hours of management.   

Results:

One hundred and three patients were included. Fifty-three patients in group A with a mean heart rate of 146 ± 18 beats / min and fifty patients in group B with a mean heart rate of 143 ± 17 beats / min. A significantly greater number of patients slowed down their ventricular rate in group A during the first hour of management (p = 0.02). After 12 hours, mean heart rate was significantly lower in group A (p = 0.04).

Conclusion:

The use of 3 g of magnesium sulfate slowed down the ventricular rate of a larger number of patients with rapid AF in the first hour of management. Only minor adverse effects were registered.     

Diagnosis and treatment of cholelithiasis

Most patients with gallbladder stones are asymptomatic and do not require treatment. Biliary colics are the main indication for laparoscopic cholecystectomy: the treatment of choice for gallbladder stones. Dyspepsia is not an indication for treatment of gallstones. The indications for bile salt therapy and extracorporeal lithotripsy are limited. Acute cholecystitis should be treated with cholecystectomy à chaud whereas longstanding cholecystitis is preferably treated with cholecystectomy à froid. Bile duct stones are mainly treated endoscopically during endoscopic retrograde cholangiopancreatography (ERCP): pancreatitis, bleeding and perforation are the main complications. Prior to cholecystectomy, an ERCP is indicated in case of cholangitis, severe pancreatitis, persisting jaundice, bile duct stones on ultrasonography, or the combination of dilated ducts and abnormal liver function tests. After endoscopic stone removal, a cholecystectomy is indicated for patients < 50 years but a 'wait and see' policy is justified in elderly patients.     

内镜下治疗胆总管结石48例临床分析

目的：评价内镜下十二指肠乳头括约肌切开术、鼻胆管引流术治疗胆总管结石的疗效和安全性。方法：对48例胆总管结石的患者行常规内镜下逆行胰胆管造影,必要时行十二指肠乳头括约肌切开术、内镜下乳头气囊扩张术、鼻胆管引流术治疗。对其临床资料进行回顾性分析。结果：48例患者中,46例常规逆行胰胆管造影成功,成功率95．8％。另2例结石嵌顿于壶腹部行乳头开窗术取石成功;36例一次取尽结石,11例分2次取石成功,总成功率98％,1例取石失败。术后并发高淀粉酶血症10例,胆道感染4例,急性胰腺炎1例,无大出血、穿孔等严重并发症。术后平均住院6天。结论：经内镜下胆总管取石疗效好,创伤小、并发症少,术后恢复快。     

Les médecins maghrébins ont-ils besoin de renforcement de leurs capacités en investigation et contrôle des épidémies ?

Objective:

Describe the training needs of young Maghreb doctors in epidemic management.

Methods:

This is a study to quantify the need for medical training on "epidemic management". The study population was formed by residents and assistant professors of the French-speaking faculties of medicine in the Greater Maghreb, hospital-university professors, who were invited to respond to an online questionnaire. The "need" for learning a skill was defined by the perception of its importance, of its low coverage by the curricula and its poor mastery. A grid with 20 items, coded according to the Likert scale of 1 to 5 points, was specially developed for the measurement of need, retained beyond the thresholds of 45/90 points for the two dimensions "confirmation" and "investigation", 60/120 points for the "control" dimension, and 150/300 for the total sum.

Results:

A total of 121 young Maghreb doctors answered the questionnaire to assess the needs for learning epidemic management skills. The median overall scores for the chapters "importance", "coverage" and "performance" were 76, 40 and 48 respectively out of 100 points. The median scores for training «needs» were 54/90, 48/90 and 67/120 points, respectively, for the dimensions «confirmation», «investment» and «control», giving a global median score of 168 / 300.

Conclusion:

Capacity building in epidemic management is a need felt by young Maghreb doctors, partially covered by current medical school programs, and consequently altering their professional performance.     

Barreras para la normalización de la telemedicina en un sistema de salud basado en la concertación de servicios

Objective

Despite the clear political will to promote telemedicine and the large number of initiatives, the incorporation of this modality in clinical practice remains limited. The objective of this study was to identify the barriers perceived by key professionals who actively participate in the design and implementation of telemedicine in a healthcare system model based on purchasing of healthcare services using providers’ contracts.

Methods

We performed a qualitative study based on data from semi-structured interviews with 17 key informants belonging to distinct Catalan health organizations.

Results

The barriers identified were grouped in four areas: technological, organizational, human and economic. The main barriers identified were changes in the healthcare model caused by telemedicine, problems with strategic alignment, resistance to change in the (re)definition of roles, responsibilities and new skills, and lack of a business model that incorporates telemedicine in the services portfolio to ensure its sustainability.

Conclusions

In addition to suitable management of change and of the necessary strategic alignment, the definitive normalization of telemedicine in a mixed healthcare model based on purchasing of healthcare services using providers’ contracts requires a clear and stable business model that incorporates this modality in the services portfolio and allows healthcare organizations to obtain reimbursement from the payer.     

El coste de la aplicación de la Ley de Dependencia a la enfermedad de Alzheimer

Aim

To calculate the formal cost of social care for people with Alzheimer disease according to the implementation of the dependency law in Gipuzkoa (Spain).

Method

A retrospective observational study was carried out of the database of the Dependency Care Services of Gipuzkoa from 2007 to 2012, using a prevalence-based bottom-up approach.

Results

The average annual formal cost per person was €11,730. The annual population cost was €34.7 million, representing 19% of the annual expenditure corresponding to the dependency law and 29% of the total cost of Alzheimer disease.

Conclusions

Despite the implementation of the new law, most of the burden of the disease is bourne by the family.