Trends in Secondary Prevention of Coronary Heart Disease in Tunisia: Prevention of Recurrences of MI and Stroke

ObjectivesThe survival benefits achieved by prescription of antiplatelet agents, B-adrenoreceptor antagonists (beta-blockers), angiotensin II receptor blockers (ARB), and lipid lowering agents in patients surviving the myocardial infarction (MI) have been well documented in large clinical trial. Despite well-established benefits, these pharmacological agents continue to be underutilized. The main objective of this study was to evaluate the progress of cardiovascular secondary prevention practices in Tunisia.MethodsThe PREMISE (Prevention of Recurrence of Myocardial Infarction and Stroke) is a descriptive, cross-sectional study conducted in Tunisia in two phases (2002 and 2009). Seven hundred eighty two patients were recruited. The recruitment criteria were: previous MI, stable angina, unstable angina, percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass graft (CABG), stroke, transient ischemic attack (TIA) or carotid endarterectomy. This analysis is limited to coronary heart disease (CHD) patients. Five hundred hospital patients were interviewed and their medical records were reviewed: 250 in 2002 and 250 in 2009. Patients were included if they had confirmed diagnosis of MI, angina, CABG or PTCA, and if their first cardiovascular event had occurred more than one month but not later than 3 years ago. We compared the total of both patient groups, using the prevalence of Cardio-Vascular Risk Factors (CVRF) and the treatment prescribed at hospital discharge.ResultsThe proportion of patients with reported hypertension, diabetes, hypercholesterolemia and current smoker patients had decreased. Concerning pharmacological prescriptions, a significant increase was observed in prescribing statins (38.9% vs. 70.3%) and ACE inhibitors (49.3% vs. 69.9%), non pharmacological prescriptions as healthy diet or tobacco cessation had opposite trends. Adherence to treatment did not change substantially.ConclusionAlthough the use of cardioprotective drugs had increased in CHD patients, there are still gaps in secondary prevention in Tunisia. The recommended strategies of secondary prevention need to be applied more intensively in clinical practice

Use of evidence to support healthy public policy: a policy effectiveness-feasibility loop

Public policy plays a key role in improving population health and in the control of diseases, including non-communicable diseases. However, an evidence-based approach to formulating healthy public policy has been difficult to implement, partly on account of barriers that hinder integrated work between researchers and policy-makers. This paper describes a “policy effectiveness–feasibility loop” (PEFL) that brings together epidemiological modelling, local situation analysis and option appraisal to foster collaboration between researchers and policy-makers. Epidemiological modelling explores the determinants of trends in disease and the potential health benefits of modifying them. Situation analysis investigates the current conceptualization of policy, the level of policy awareness and commitment among key stakeholders, and what actually happens in practice, thereby helping to identify policy gaps. Option appraisal integrates epidemiological modelling and situation analysis to investigate the feasibility, costs and likely health benefits of various policy options. The authors illustrate how PEFL was used in a project to inform public policy for the prevention of cardiovascular diseases and diabetes in four parts of the eastern Mediterranean. They conclude that PEFL may offer a useful framework for researchers and policy-makers to successfully work together to generate evidence-based policy, and they encourage further evaluation of this approach

Analyzing Recent Coronary Heart Disease Mortality Trends in Tunisia between 1997 and 2009.

BACKGROUND: In Tunisia, Cardiovascular Diseases are the leading causes of death (30%), 70% of those are coronary heart disease (CHD) deaths and population studies have demonstrated that major risk factor levels are increasing. OBJECTIVE: To explain recent CHD trends in Tunisia between 1997 and 2009. METHODS: DATA SOURCES: Published and unpublished data were identified by extensive searches, complemented with specifically designed surveys. ANALYSIS: Data were integrated and analyzed using the previously validated IMPACT CHD policy model. Data items included: (i)number of CHD patients in specific groups (including acute coronary syndromes, congestive heart failure and chronic angina)(ii) uptake of specific medical and surgical treatments, and(iii) population trends in major cardiovascular risk factors (smoking, total cholesterol, systolic blood pressure (SBP), body mass index (BMI), diabetes and physical inactivity). RESULTS: CHD mortality rates increased by 11.8% for men and 23.8% for women, resulting in 680 additional CHD deaths in 2009 compared with the 1997 baseline, after adjusting for population change. Almost all (98%) of this rise was explained by risk factor increases, though men and women differed. A large rise in total cholesterol level in men (0.73 mmol/L) generated 440 additional deaths. In women, a fall (-0.43 mmol/L), apparently avoided about 95 deaths. For SBP a rise in men (4 mmHg) generated 270 additional deaths. In women, a 2 mmHg fall avoided 65 deaths. BMI and diabetes increased substantially resulting respectively in 105 and 75 additional deaths. Increased treatment uptake prevented about 450 deaths in 2009. The most important contributions came from secondary prevention following Acute Myocardial Infarction (AMI) (95 fewer deaths), initial AMI treatments (90), antihypertensive medications (80) and unstable angina (75). CONCLUSIONS: Recent trends in CHD mortality mainly reflected increases in major modifiable risk factors, notably SBP and cholesterol, BMI and diabetes. Current prevention strategies are mainly focused on treatments but should become more comprehensive

Les osteomes des sinus de la face

Introduction : Le but de notre travail est préciser le profil épidémio-clinique de cette pathologie, l’apport de l’imagerie dans le diagnostic, et discuter les modalités de l’exérèse chirurgicale et l’apport de la voie endoscopique.Patients et méthode : il s’agit d’une étude rétrospective de 18 patients porteurs d’ostéomes des sinus paranasaux opérés entre 1993 à 2010. Ont été exclus les patients non opérés et les malades perdus de vue.Résultats : il s’agit de 18 patients porteurs d’un ostéome symptomatique des sinus de la face, d’âge moyen 40 ans, sex ratio 0,38. La localisation la plus fréquente était le sinus frontal dans 55.5% des cas. Le traitement chirurgical était de mise pour les patients symptomatiques. La voie endonasale était indiquée dans 6 cas.la récidive a intéressé deux patients (11%) ayant un ostéome frontal et fronto-ethmoïdal. Pour le reste des malades l’évolution était favorable avec un recul moyen de 36 mois.Conclusion : L’ostéome des sinus paranasaux reste longtemps asymptomatique mais peut se compliquer par extension orbitaire ou cérébrale. L’abord endonasal a permis d’améliorer la prise en charge.Mots clés : Ostéome, sinus de la face, tomodensitométrie, chirurgie, voie endonasaleObjective : Lymph node infection is the most frequent localization of extrapulmonary tuberculosis. The treatment does not make general agreement. The aim of this study is to specify, from a review of the literature, the different ways of antimicrobial treatment and the indications of surgery.Patients and methods : il is about a retrospective study including 18 patients with paranasal sinus osteomas operated between 1993 and 2010. Were excluded unoperated and lost patients.Results : in this group of 18 patients with symptomatic sinus osteoma of the face, the mean age was 40 years, sex ratio was 0.38. the frontal sinus was the most affected, 55.5% of cases. Surgical treatment was set for symptomatic patients. The endonasal route was indicated in 6 cases. Recurrence was observed in two patients (11%) having a frontal osteoma and fronto-ethmoid. Outcomes were favorable in the remaining patients, mean follow-up was 36 months.Conclusion: Paranasal sinuses osteoma is a long asymptomatic tumor, but it may be complicated with orbital extending or stroke. Endonasal approach contributed to improve the treatment.Keyswords : Osteoma, paranasal sinus, computed tomography, surgery, endonasal approac

Otospongiose : a propos de 149 cas

Introduction : L’otospongiose est une ostéodystrophie de la capsule otique se traduisant par une surdité de transmission ou plus rarement une surdité mixte d’apparition progressive. Le but de notre travail est d’analyser les caractéristiques épidémiologiques, cliniques, paracliniques et comparer les résultats en fonction de l’âge, du stade de l’ostéodystrophie, de la technique chirurgicale et de la prothèse.Patients et méthodes : notre étude est rétrospective portant sur 124 patients (149 oreilles) colligés sur une période de 9 ans (2000-2008).Résultats : notre population a comporté 86 femmes et 38 hommes. La moyenne d’âge à l’intervention était de 39,82 ans. La surdité était bilatérale dans 61,3% des cas et unilatérale dans 38,3%. Les seuils moyens préopératoires de la conduction osseuse et aérienne étaient respectivement de 17,33 dB et 52,52 dB, le rinne moyen était de 35,19 dB. La tomodensitométrie a été réalisée chez 63 patients. On a réalisé 21 platinectomie totale, 24 platinectomie partielle et 101 platinotomie calibrée. Selon la classification de Portmann, on a trouvé une répartition sensiblement égale entre les stades II, III et IV. On a utilisé un piston téflon 6/10 mm dans 119 cas et 4/10 mm dans 27 cas. Le rinne moyen postopératoire était de 15,95 dB. a 1 an, le rinne était de 14,81 dB avec un résultat satisfaisant de 94,2%.Conclusion : Il ressort de notre travail que certains facteurs semblent prédictifs de bons résultats et qui sont : le sexe féminin, l’âge <50 ans, le stade chirurgical< stade IV, la platinotomie, et le piston 0,4 mm.Mots clés : otospongiose, conduction osseuse, conduction aérienne, platinotomie, platinectomie.Objective : Otosclerosis is a common disorder of the otic capsule characterized by the presence of a progressive conductive or rarely mixed hearing loss. The aims of this study were to analyses the epidemiologic, clinical, paraclinical characteristic and compare our results according to age, stage, surgical technique and prosthesis. Patients et méthodes : Our study is retrospective about 124 patients (149 ears) in the period of 9 years (2000-2008).Results: Our population included 86 female and 38 male patients. mean age at intervention time was 39,82 years. The hearing loss was bilateral in 61,3% of cases and unilateral in 38,3%. The bone and air conduction threshold was 17.33 dB and 52,52 dB, the air-bone gap was 35,19 dB. The CT scan was realized in 63 patients. We have realized 21stapedectomy, 24 partial stapedectomy and 101 stapedotomy. In accordance with Portmann classification, the distribution between II, III and IV stages was almost equal. We used 6/10 mm Teflon piston prosthesis in 119 cases and 4/10 mm in 27 cases. The postoperative air-bone gap was 15,95 dB. after 1 year, the air-bone gap was 14,81 dB with a satisfying results in 94,2%.Conclusion: it seems that some factors are predictive for good results like a female sex, age<50 years, stage< stage IV, platinotomy and piston 4/10 mm.Keyswords : otosclerosis, bone conduction, air conduction, stapedectomy, stapedotom

Menopause and metabolic syndrome in Tunisian women

Objectives. This study aimed to evaluate the effect of menopausal status on the risk of metabolic syndrome (MetS) in Tunisian women. Methods. We analyzed a total of 2680 women aged between 35 and 70 years. Blood pressure, anthropometric indices, fasting glucose, and lipid profile were measured. The MetS was assessed by the modified NCEP-ATPIII definition. Results. The mean values of waist circumference, blood pressure, plasma lipids, and fasting glucose were significantly higher in postmenopausal than in premenopausal women, a difference that was no longer present when adjusting for age. Except for hypertriglyceridaemia, the frequency of central obesity, hyperglycemia, high blood pressure, and high total cholesterol was significantly higher in postmenopausal than in premenopausal women. After adjusting for age, the significance persisted only for hyperglycemia. The overall prevalence of MetS was 35.9%, higher in postmenopausal (45.7% versus 25.6%) than in premenopausal women. A binary logistic regression analysis showed that menopause was independently associated with MetS (OR = 1.41, 95% CI 1.10-1.82) after adjusting for age, residence area, marital status, family history of cardiovascular disease, education level, and occupation. Conclusions. The present study provides evidence that the MetS is highly prevalent in this group of women. Menopause can be a predictor of MetS independent of age in Tunisian women

Modelling transmission and control of Mycobacterium avium subspecies paratuberculosis within Irish dairy herds with compact spring calving

Paratuberculosis is a chronic bacterial infection of the intestine in cattle caused by Mycobacterium avium subspecies paratuberculosis (Map). To better understand Map transmission in Irish dairy herds, we adapted the French stochastic individual-based epidemiological simulation model to account for seasonal herd demographics. We investigated the probability of Map persistence over time, the within-herd prevalence over time, and the relative importance of transmission pathways, and assessed the relative effectiveness of test-and-cull control strategies. We investigated the impact on model outputs of calf separation from cows (calves grazed on pasture adjacent to cows vs. were completely separated from cows) and test-and-cull. Test-and-cull scenarios consisted of highly test-positive cows culled within 13 or 4 weeks after detection, and calf born to highly test-positive cows kept vs removed. We simulated a typical Irish dairy herd with on average 82 lactating cows, 112 animals in total. Each scenario was iterated 1000 times to adjust variation caused by stochasticity. Map was introduced in the fully naive herd through the purchase of a moderately infectious primiparous cow. Infection was considered to persist when at least one infected animal remained in the herd or when Map was present in the environment. The probability of Map persistence 15 years after introduction ranged between 32.2-42.7 % when calves and cows had contact on pasture, and between 18.9-29.4 % when calves and cows were separated on pasture. The most effective control strategy was to cull highly test-positive cows within four weeks of detection (absolute 10 % lower persistence compared to scenarios without control). Removing the offspring of highly test-positive dams did not affect either Map persistence or within-herd prevalence of Map. Mean prevalence 15 years after Map introduction was highest (63.5 %) when calves and cows had contact on pasture. Mean prevalence was 15 % lower (absolute decrease) when cows were culled within 13 weeks of a high test-positive result, and 28 % lower when culled within 4 weeks. Around calving, the infection rate was high, with calves being infected in utero or via the general indoor environment (most important transmission routes). For the remainder of the year, the incidence rate was relatively low with most calves being infected on pasture when in contact with cows. Testing and culling was an effective control strategy when it was used prior to the calving period to minimize the number of highly infectious cows present when calves were born

Valeur de l’examen extemporane en pathologie thyroïdienne

OBJECTIF : Etudier la valeur de l’examen extemporané dans la pathologie thyroidienne et identifier ses limitesMATERIELS ET METHODES : Notre étude est rétrospective incluant 800 examens extemporanés réalisés sur des pièces de résectionthyroïdienne colligés dans notre service sur une période de 12 ans (2000-2011).Les résultats ont été comparés à ceux del’examen anatomopathologique définitif.RESULTATS : Les résultats étaient concordants dans 96,5%, discordants dans 3,5 %. La sensibilité de l’examen extemporané toustypes confondus était de 78 % et la spécificité de 100 %CONCLUSION : Notre étude a montré une spécificité parfaite de l’examen extemporané cependant l’interprétation difficile des lésionsthyroïdiennes d’architecture vésiculaire expliquent une sensibilité de 78 %.Mots Clés : Thyroïdectomie, examen extemporanOBJECTIVE: To assess the value of frozen-section examination in thyroid surgery and evaluate its limitationsPATIENTS AND METHODES: This retrospective study examined the results of 800 frozen-sections of thyroid specimens analysedover the 12 –year period (2000-2011). Their results were compared with definitive anatomo-pathological examinationRESULTS :Frozen-section diagnosis was concordant with subsequent histopathological examination in 96,5% ,discordant in 3,5%.The global specificity of frozen section analysis for all histological subtypes was 100 % and its sensitivity was 78 %.CONCLUSION: This study shows the good specificity of frozen section .Discordances between frozen-section and definitive diagnosiswas associated with microfllicular lesions wich explain the sensibility of 78%Key Words: Thyroid surgery, frozen section examinatio