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.     

Vers des nouvelles perspectives d'appui à la Prévention au Système National de la Santé, en Tunisie

"Prevention", a component of primary health care since Alma Atas declaration (1978), has been a strategic axis of health policy in Tunisia for four decades. If the Tunisian Revolutionary Constitution (2014) declared in its Article 38 that "the State guarantees prevention", the regulatory texts, organizing preventive structures and its operational programs, have today become ill-suited with the global burden of disease and current scientific evidence. The analysis of current preventive practices in Tunisia, based on the "health continuum", the taxonomy of "preventive strategies" and the identification of "vulnerable populations", has shown the need to implement prevention activities. "Primordial" and "quaternary" (for the management of cardiovascular diseases and cancers), extension of the fields of health education and epidemiological surveillance, towards Therapeutic Education of Patients / Health Promotion, and health monitoring, and coverage of new groups at risk: adolescents and the elderly. Faced with the multitude of prevention structures and the fragmentation of health programs, the reform of the national preventive policy and its practices should be based on the principles of integration, relevance and efficiency, through the establishment of a National Health Protection Agency (NHPA). This ANP is called upon to launch new prevention support projects including integrated preventive medicine centers (providing periodic health examinations), hospital patient therapeutic education services and home care units. Such a reform, announcing the birth of a new generation of preventive basic health care activities in Tunisia, should be reinforced by a legal, organizational and educational basis.     

Place du Bilan Médical Périodique dans les Soins de Santé de Base en Tunisie

The objective of primary health care is to reduce mortality and morbidity. This kind of care was very efficient in communicable diseases, malnutrition and maternal and neonatal diseases; however, their impact on non communicable diseases and mental disorders control is not obvious. In Tunisia, primary health care was introduced in the early 1980s; a lot of progress were notified in particular in health of mothers and children in particular, but only slightly in non communicable diseases control and mental health promotion. Therefore, a new approach would be strongly recommended to remedy this situation. The Medical Periodic Check-up (MPC) implemented in North America would have a positive impact in the prevention and management of non communicable diseases. What would be the place of this MPC in primary health care in Tunisia? The MPC has two main objectives: the prevention of specific diseases and health promotion. However, despite its efficiency and usefulness, the MPC could be costly, especially for countries with limited resources. Current evidence suggests that the most appropriate approach would be to take periodic preventive health visits tailored to the level of risk. The frequency of visits depends on the age, sex and state of health of the individual. In conclusion, there are strong arguments in favor of the introduction of MPC in primary health care in Tunisia, especially among adults in non communicable diseases control strategy. However, it''s highly be recommended that the BMC should be oriented according to the risk levels in order to optimize resources. It is also important to educate and the public, especially women and young adults, to benefit from periodic medical and dental examinations.     

Traitement endoscopique pré opératoire dans la prise en charge de la lithiase de la voie biliaire principale associée à la lithiase vésiculaire

Background :

The combination of gallbladder stone and main biliary stone is seen in 10-25% of cases. Its management with the combination of endoscopic and surgical treatment is increasingly adopted.

Aim:

To evaluate the efficacy and safety of preoperative retrograde endoscopic retrograde cholangiopancreatography in the treatment of concomitant gallstones and common bile duct stones.

 Methods:

Retrospective study including patients with concomitant gallstones and common bile duct stones and who had preoperative endoscopic retrograde cholangiopancreatography. The rate of clearance from the main bile duct and the rate of complications were evaluated.

Results:

One hundred and twenty patients aged 57.4±2.7 years were included on average. The rate of catheterization of the main bile duct was 90%. Endoscopic retrograde cholangiopancreatography was unnecessary in 34.1%. Main bile duct clearance was obtained in 95.5% of patients who presented lithiasis during the procedure. The endoscopic treatment was efficient in 53,3% of cases Post endoscopic retrograde post cholangio-pancreatography acute panreatitis occurred in 1.6% of cases with an overall complication rate of 6.6%.

Conclusion:

Preoperative endoscopic treatment of concomitant gallstones and common bile duct stones is effective with good safety.     

Valoración y seguimiento de los pacientes con sospecha de COVID-19 en la primera ola pandémica en una zona urbana de Andalucía

ObjetivosConocer las características de la atención inicial y el seguimiento telefónico de pacientes con sospecha de COVID-19 en la primera ola de la pandemia.DiseñoObservacional retrospectivo (auditoría de historias clínicas).EmplazamientoCentro de salud urbano.ParticipantesCasos probables de SARS-CoV-2 (15/03/2020 a 15/06/2020).Mediciones principalesÁmbito de atención inicial y seguimiento telefónico (número de llamadas y duración). Variables sociodemográficas (incluyendo estructura familiar). Curso clínico (sintomatología, vulnerabilidad, pruebas, ingreso hospitalario y desenlace).ResultadosTrescientos uno pacientes (51,5 [± 17,8] años, 23% vulnerables, 17% estructura familiar no nuclear). Valoración inicial en el centro de salud (59,8%: telefónica; 25,2%: presencial). En urgencias hospitalarias (11%) presentaron síntomas similares que en atención primaria, predominan estructuras familiares no nucleares (p < 0,05; test χ²), realizando más pruebas (p < 0,05; test χ²). En domicilio (3,9%) son pacientes ancianos vulnerables (p < 0,01, test ANOVA). El seguimiento telefónico duró 17,1 [± 10,3] días con 8,2 [± 4,4] llamadas, superior si provenían de urgencias o domicilio (p < 0,03; test ANOVA). Se incrementa tras ≥ 2 consultas presenciales (OR: 4,8), la presencia de síntomas de alarma (OR: 2,3) y la edad ≥ 45 años (OR: 2,0). Se realizaron pocas pruebas de confirmación (19,3% antigénicas, 13% serologías). El 15,3% ingresos hospitalarios (todos valorados en centros de salud), con 6,3% casos severos y 2,3% exitus.ConclusiónDurante la primera ola de la pandemia, la población optó por ser atendida de forma telemática en su centro de salud. Las valoraciones iniciales en urgencias del hospital se relacionan con la falta de apoyo social, pero no con mayor gravedad clínica. El seguimiento telefónico fue aceptado por la población y permitió seleccionar a los pacientes con peor curso clínico.Palabras clave: COVID-19, Pandemias, Necesidades y demandas de servicios de salud, Atención primaria de salud, Telemedicina, Servicios médicos de urgencia     

Soutien au réseau des services de garde montréalais dans la prévention et la gestion de la COVID-19 : un service à 3 pôles

SettingFrom April 2020, in sight of child care reopening, the Direction régionale de santé publique de Montréal (DRSPM) conducted a situational analysis with its child care (CC) partners in order to learn about the challenges they envisioned in their role in preventing and managing COVID-19. The CC partners requested access to preferred public health support.InterventionThe DRSPM established a service consisting of three components: (1) telephone support available 6 to 7 days/week for CC managers facing a COVID-19 situation; (2) a regional committee combining four Montreal representatives of CC associations and one from the Ministère de la Famille; (3) prevention brigades formed by front-line health workers from the Centres intégrés universitaires de santé et de services sociaux (CIUSSS).OutcomesThis health promotion intervention (1) enabled CC services to handle the pandemic with better capability and confidence through facilitating access to accurate and positive information; (2) supported the commitment and collaboration of CC services by acting as a mediator between them and decision-makers; and (3) responded to the psychosocial needs of community members.ImplicationsThis service helped to adjust public policy and promote community resilience by raising awareness of the importance of balancing COVID-19 prevention and the collateral impacts of the pandemic.     

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.     

Caractérisation d’un cluster des cas de COVID-19 liés au variant Omicron,en Mauritanie

Objective: To describe the epidemiological and genomic profile of COVID-19 during the 4^th epidemic wave in Mauritania. Methods: This is a cross-sectional study in Mauritania, from October 1, 2021 to February 28, 2022. Were included all people in the process of travel, performing an RT-PCR, at the level of the National Research Institute in Public Health and patients who have been sampled for sequencing by teams from the Department of Strategic Information and Epidemiological Surveillance. Results: Out of 37,574 RT-PCR tests collected on March 3, 2022, during the study period, 1,465 cases were diagnosed positive for COVID-19 (3.9%), with an average age of 39±14,6 years and a sex ratio of 2.08. Of the 112 genomic sequences performed, 75 were of the Omicron variant (66.9%). The average age was 40±15 years, with extremes of 15 to 82 years and a sex ratio of 0.97. The vaccination status was assured in 67.7% of patients and the peak of the Omicron variant was reached during the first week of January 2022 Conclusion: The Omicron variant was predominant during the 4^th wave in Mauritania. As part of its response plan against COVID-19, the installation of new sequencing units inside the country and the strengthening of the training of technicians in the virology laboratory will be essential.     

Aspects médicaux, éthiques et déontologiques de la grève de la faim en milieu carcéral

Background: A hunger strike is a common form of protest in prison and is a potential cause of many types of problems, both for facility administrators and health care staff. Issues of conflict of rights and obligations involved, and how to treat people who are subject, have created major controversies. Objectives: To identify and review published studies that discuss the medical, ethical and legal considerations of managing a hunger strike in a prison setting from a physician''s perspective. Methods: A database search using "Medline" "Ovid" and "Science Direct was conducted to identify relevant publications. We included case series, guidelines and, review articles. Results: The physician must clearly inform the striker of the risks and provide clinical assessment and regular monitoring of the concerned. The role of the psychiatrist is to detect an initial mental pathology underlying or secondary to fasting and assess the capacity of the striker''s judgment. Thus, the clinician is faced with two paradoxical obligations: to assist and respect the striker''s will. In addition, medical intervention is possible if the prognosis is life-threatening even without the patient''s consent. Conclusion: The current practice of non-consensual attitude among hunger-striking seeking in detention needs a closer inquiry. Medical practitioners should be aware of their ethical and legal responsibilities, and that they should act independently of government or institutional interests.     

40 ans des Soins de Santé de Base en Tunisie d'Alma Ata à Astana. Il est temps de revitaliser la première ligne des soins

In order to readjust the national policy of Basic Health Care (SSB) to the declaration of Primary Health Care (SSP) of Astana (2018), 40 years after that of Alma Ata (1978), this paper summarizes the lessons learned from the international and national experience of PHC / SSB and presents the originator lines of the roadmap of the second version of SSB in Tunisia. WHO and Unicef have identified four lessons from PHC policy: 1. Political leadership, prioritizing primary care. 2. Sufficient funding to ensure the availability of basic services and their access by the population served. 3. Health personnel specifically trained in primary care, with decent working conditions. 4. A support strategy for the quality of care, based on financial and moral motivation. In Tunisia, the history of SSBs has memorized images of successes such as the organization of simulation sessions for the preparation of the “oral rehydration solution”, “mobile teams” of home visits, “deadlines” for monitoring vaccination and “school social action units” for multisectoral management of the problem of school backwardness. The "Think Tank" groups, having reflected on the perspectives of SSBs in Tunisia, came up with a roadmap made up of four fundamental axes. 1. Creation of a National Health Insurance Fund (CNAS), affiliated with the Ministry of Health, and promoting prevention and health promotion. 2. Focus on non-communicable diseases, both young and old. 3. Establishment of a periodic health assessment, stratified by sex and age, guiding health behaviors and "self-care" skills. 4. The development of “nursing homes”, providing continuous care, by multi-functional and multidisciplinary teams. Thus, the reform of the SSB policy of Tunisia, by referring to the Astana declaration and the cumulative national expertise, is essential to revitalize the first line of care and ensure the Tunisian population a "health for all", leaving no one behind”.     

Facteurs de sévérité chez les patients Algériens hospitalisés pour COVID-19

Introduction. Determining the profile of COVID-19 patients with low pulsed hemoglobin saturation in oxygen (SpO₂) could help clinicians identify those with a poor prognosis. Aim. To identify and to compare the clinical, biological and radiological data of Algerian patients hospitalized for COVID-19 and divided according to the SpO₂ measured at admission, at rest, and in ambient air. Methods. A prospective study was carried out on Algerian patients hospitalized for COVID-19 during the period from March 9 to April 30, 2020. The general characteristics of the patients and the clinical, biological and radiological data were determined. Results. 86 patients were included in the study [G₁: SpO₂ >95% (n=51) and G₂: SpO₂ ≤95% (n=35)]. Compared to G₁, G₂ was older (48±14 vs. 61±12 years, p=0.0001), included more patients aged ≥ 50 years (37.2 vs. 80.0%, p=0.0001), having an arterial-hypertension (21.6 vs. 45.7%, p=0.0180), a cancer (0.0 vs. 14.3%, p=0.0054), an anemia (25.6 vs. 56.3%, p=0.0069), a leukocytosis (4.7 vs. 21.9%, p=0.0236), a biological inflammatory syndrome (82.5 vs. 100%, p=0.0142), a hyper-uremia (7.0 vs. 37.5%, p=0.0185), a hyper-creatininaemia (4.7 vs. 18.8%, p=0.0356), a tissue damage (41.0 vs. 66.7%, p=0.0341), a diffuse ground-glass opacity (52.0 vs. 71.4%, p=0.0397), band condensations (30.0 vs. 54.3%, p=0.0244), a severe extension (2.0 vs. 25.7%, p=0.0008), and included fewer patients who complained from diarrhea (49.0 vs. 22.9%, p=0.0145), having a nodular ground-glass (66.0 vs. 40.0%, p=0.0177) and a slight extension (78.0 vs. 40.0%, p=0.0004). Conclusion. Criteria associated with low SpO₂ in hospitalized COVID-19 patients were advanced age, a history of arterial-hypertension and cancer, high frequencies of certain biological abnormalities or radiological signs. The diarrhea symptom, the radiological appearance of nodular ground glass, and a slight extension of the radiological lesions appear as protective elements.