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Abstract: Background: The use of plasma exchange (PE) constituted an advance in the treatment of myasthenia. The objective of our study was to determine the relevance of PE in the treatment of myasthenia and to study the different complications which can be observed during PE. Patients and methods: We studied retrospectively 11 patients who have generalized myasthenia and underwent PE. We used an intermittent flow cell separator and we performed PE three times a week. Biological assessment was performed before and after PE for all patients. The exchange volume was calculated according to the patient weight, gender and the value of hematocrit. Results: Our series included six women and five men. The mean age at onset of the disease was 41.4±14.1 years (range: 18 to 68). Indication of PE was myasthenia crisis (eight cases), resistance to classic treatment (two cases) and exacerbation after thymectomy (one case). An improvement was observed rapidly in five cases and delayed in three cases. The remaining three patients did not improve. The most frequent side effects of PE were hypotension (four cases), heart arrhythmia (two cases) and hypoglycemia (one case). Three patients dead in the seven days after the first PE. Conclusion: PE represents an interesting tool to treat severe forms of myasthenia and improve prognosis. High incidence of complications in our series can be explained by the initial disease severity, the used method of PE, the existence of associated illness, and a long stay in intensive care unit. [Copyright &y& Elsevier]

Abstract: Introduction: Myotonic dystrophy type 1 (DM1) is an autosomal dominant multisystemic disease with frequent cardiac involvement that may cause sudden death. This study was performed to determine the various cardiac manifestations in DM1, their frequency and the relevance of cardiac electrophysiological study in this disease. Methods: Ten patients with DM1, five men and five women, mean age 44.3±7.8 years underwent neurological and cardiac assessments. Results: The most frequent electrocardiographic findings were conduction abnormalities, essentially by intraventricular conduction defects (eight out of ten cases) such as bundle branch or fascicular blocks. Echocardiography showed alterations in systolic left ventricular function in two cases. Invasive electrophysiology testing showed sub-hisien block in three patients, requiring cardiac pacemaker implantation. These three patients had normal duration of PR interval and normal width of QRS complex. Conclusions: We recommend that all patients with DM1 should undergo cardiac investigation to detect subclinical cardiac involvement. [Copyright &y& Elsevier]

Abstract: Behcet''s disease (BD) is a multisystemic vasculitis. Its etiopathogeny remains unknown. Vascular involvement in BD is frequent and venous thrombosis is the most common manifestation (30 % of cases). Arterial involvement is rare (2.7 to 7 %). The latter is often severe and considered as a life threatening complication. Pathogenesis of thrombosis occurring in BD remains unclear. We report a 45-year-old man, from south of Tunisia, who presented a BD with a bifocal arterial involvement: right internal carotid thrombosis and bilateral proximal thrombosis of the two pulmonary arteries. Therapeutic strategies to address this multiple arterial involvement and the pathogenesis of thrombosis raise many questions. [Copyright &y& Elsevier]

Background and Aims: The Tunisian medical student population is very heterogeneous. This heterogeneity is based among other things on temperamental differences between different students and their behavior and strategies to cope with the requirements and constraints of medical studies. We conducted this study aiming: to determine the prevalence of alcohol use in a student population at Sfax Medical School and to evaluate the factors associated with this use; to study the relationship between affective temperament and alcohol consumption among medical students., Methods: We conducted a descriptive and analytical cross-sectional study in the form of a survey between July 2018 and January 2019 among students (aged between 19 and 30) recruited from the University of Medicine of Sfax during their internship in the psychiatric department "A" at CHU HédiChaker of Sfax. We used a pre-established survey sheet based on data from the substance use and affective temperament literature in medical students that was completed by the participants after obtaining their consent and having explained the anonymity and confidentiality of the questionnaire. This sheet included a section on student sociodemographic characteristics, a second part describing the history and characteristics of alcohol consumption and the evaluation of alcohol consumption through the Alcohol Use Disorders Identification Test (AUDIT), and a third part for temperament evaluation by TIME-A, and Temperament Evaluation of Memphis Pisa Paris and San Diego Auto-questionnaire., Results: We recruited 136 students with an average age of 21.63 years (SD 2 years) and a sex ratio (H/F) of 0.66. Alcohol consumption was observed among 19.8 % of students surveyed, 19.1 % of whom were occasional consumers. The mean age of onset of alcohol consumption was 18.48 years (SD 1.76 years). All consumer students had started using alcohol with their friends. The desired effect was euphoric in 74 % of cases, sleeping for 14.8 % of them. Among consumers, the average score at AUDIT was 6.44 (SD 5.3). Among them 70.4 % had a risk-free consumption (score of 8 or less); 14.8% were at risk (score 9-12) and 11.1 % were likely alcohol dependent (score>12). The evaluation of affective temperament according to TIME-A showed that the cyclothymic and hyperthymic temperament scores were the highest among the students (respectively 5.5 and 4). The analytical study showed that alcohol dependence was significantly more common among male students (p=0.048). Alcohol use was significantly more common among students who smoke (p<0.001) and those who consume cannabis (p<0.001). The bivariate correlation showed that more students had a high score of depressive temperaments (r=0.18, p=0.032), irritable (r=0.2, P=0.018) and hyperthymic (r=0.27, p=0.001). The higher their scores on the AUDIT scale, the more alcohol-dependent they were., Conclusion: The implementation of preventive measures is an obvious emergency. In the same way, taking into account the difference in affective temperaments in this very particular population could have a grandiose importance and an interesting impact both in the screening and in the care of these students., (Copyright © 2020 L'Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Objective: The objective of our study was to estimate the prevalence of the post-partum depressive symptomatology in a sample of Tunisian women, to study associated factors and to assess its relationship to quality of life., Patients and Methods: This is a prospective study carried out in two stages: during the first week (T1), then between sixth and eighth week post-partum (T2). Depressive symptomatology and quality of life were assessed respectively by the Edinburgh Postnatal Depression Scale and the World Health Organization Quality of Life scale., Results: In the first stage, the prevalence of depressive symptomatology in the total sample (150 women) was 14.7% and was related to age above 35 years, low school level, personal psychiatric history, multiparity, caesarean delivery or forceps in the previous pregnancy and unplanned pregnancy. This prevalence was 19.8% among the 126 women reviewed in T2 and was correlated with the exaggerated sympathetic signs during pregnancy, namely perversion of taste and fatigue. Quality of life was strongly correlated with depressive symptoms in T1 and T2., Conclusion: Post-partum depressive symptoms were common in our sample and were correlated with quality of life. Therapeutic measures should be proposed for women with post-partum depressive symptoms and particularly with several risk factors in order to improve their quality of life., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Background: Several authors emphasize the close relationship between self-esteem and athletic performance; such a relationship may raise the following question: by saying "strong" or "without any physical condition", is it a fair presentation of the individual's abilities or he reveals the most fundamental aspects of his personality, such as emotional temperament?, Objectives: To evaluate self-esteem, physical self and temperamental profile in a group of sportsmen, and to look for a relationship between these variables and athletic performance., Methods: We performed a cross-sectional, descriptive and analytic study in 80 young handball players of the "senior" category. We assessed self-esteem using the Rosenberg Self Esteem Scale, physical self-using the Physical Self-Inventory (PSI), and temperamental profile using the Temperament Evaluation of Memphis, Paris and San Diego Auto-questionnaire (TEMPS-A). Athletic performance was evaluated by the team coach by means of a score ranging from 1 to 10., Results: High self-esteem was correlated to female gender (p=0.03), to an early start of physical activity (p<0.01), and certain dimensions of the physical self: perceived physical value (p=0.02), appearance (p<0.01), and the global score (p=0.01). Athletic performance was correlated to high self-esteem (p<0.01) and to two dimensions of the physical self: the global score (p=0.01) and the perceived physical value (p<0.01). Hyperthymic temperament was associated with high self-esteem (p=0.001). Good athletic performance was associated with hyperthymic (p<0.01) and cyclothymic (p<0.01) temperament. Low athletic performance was associated with depressive (p=0.04) and irritable (p=0.01) temperament., Conclusion: Our study shows the close relationship between selfesteem, temperamental profile and athletic performance. We suggest that the intervention of a psychiatrist or a psychologist aimed at improving sportsmen's' self-esteem might help to achieve better athletic performance. In this intervention, the individual temperamental profile should be taken into account.

Background: Depression is a common condition especially in the postpartum. It exposes mothers, newborns and couples for psychosocial complications., Aims: They were to estimate the prevalence of the depression in postpartum in a population of 302 Tunisian parturients and to identify its associated factors., Methods: Our study was prospective, in two stages: at the first week (T1), then between sixth and tenth week of the postpartum (T2). The study was conducted at CHU Hédi Chaker in Sfax, Tunisia. We used the Arabic version and validated the Edinburgh Postnatal Depression Scale (EPDS) for screening for postpartum depression. We used the scale MSSS. "Maternity Social Support Scale"to assess the social and family support and the Azrin scale to evaluate the satisfaction of the conjugal relationship. An epidemiologic questionnaire was used to collect the sociodemographic and clinical data., Results: At T1, 302 women were examined. At T2, 139 were reexamined (46% of the initial population). In the first stage, the prevalence of the intense postpartum blues, according to EPDS, was 19,2%. In the second stage, the prevalence of the postnatal depression was 12, 9%. Factors associated with postpartum blues intense were the low socioeconomic status (p =0, 01), a lower educational level (p = 0,017), the poor marital relationship (p =0, 04), an insufficient social support (p 0,001), the difficulty to accept pregnancy (p =0,001), the presence of psychiatric the presence of psychiatric history (p =0,001), the prematurity (p =0,001) and an ill newborn birth (p =0,001). Factors associated with the post natal depression were the low socioeconomic status (p =0,01), the poor marital relationship (p =0,034), difficulty with pregnancy (p =0,001) and the presence of psychiatric history (p =0,001)., Conclusion: Postpartum depressions are common. It seems to be the result of the interaction of several biological, psychological and social factors. This suggests the importance of screening for women having such risk factors to prevent the installation of this depression. This detection should be done early in postpartum or else in the later postnatal consultations. This allows an adequate treatment for the mothers, for the relationship mother-new born and later, for the psychological equilibrium of the child.

Introduction: Electroconvulsive therapy (ECT) is rarely practiced in Tunisia. We have tried to explain this lack of use by studying theoretical knowledge, the perception and the attitudes of health professionals towards ECT., Methods: We conducted a survey in the region of Sfax in Tunisia. It included 120 participants. The latter were divided into four groups, composed of 30 members, in order to compare them: group 1 (psychiatrists); group 2 (neurologists and anaesthetists); group 3 (psychiatric nurses); group 4 (paramedics in the neurological and anaesthesia wards). The surveyed people answered an auto-questionnaire including essentially 16 items: 11 had binary answers (true or false) related to theoretical knowledge about ECT, and five others explored the perception and attitudes concerning this therapy., Results: Concerning the items exploring theoretical knowledge, 67.5% of people were not able to answer, in conformity with the consensual scientific data, a minimum of 75% questions. The rates were significantly lower among the paramedics (P<0.001) and those who work outside the psychiatric wards (P=0.003). The answers of psychiatric caregivers were less frequently incorrect compared to those of non psychiatric ward workers. The latter more frequently thought that the psychiatrists easily resorted to ECT (P=0.003). The paramedics perceived, more frequently than doctors, the ECT as a violent therapeutic means (P=0.001), and more frequently refused to give their consent to apply ECT to a relative (P=0.044). The rate of doctors who refused to give their consent to apply ECT to a relative was statistically higher in group 2 than in group 1 (P=0.017). Doctors with higher scores in theoretical knowledge, consent more frequently to apply ECT to a member of their families (P=0.001)., Discussion: The comparison of theoretical knowledge between the two groups of doctors (group 1 versus group 2) revealed significantly more frequent incorrect answers among non-psychiatrists. The latter more frequently had erroneous ideas: that ECT was performed without anaesthesia; that it wasn't possible to apply it to pregnant women, nor to people suffering from Parkinson's disease, nor as a preventive treatment of recurrence, and that the vital risk was higher with ECT than medical treatments. Compared to the caregivers of group 3, group 4 had significantly more frequent negative attitudes toward ECT; concerning the application without anaesthesia, the lack of tolerance and the over-mortality rate related to ECT. This therapy seems to create an apprehension and a reticence among health professionals, mainly the paramedics and the non-psychiatrists. The lack of valid scientific knowledge concerning ECT allows prejudiced ideas to tarnish the image of this therapy., Conclusion: Information and training would play a primordial role in the improvement of the perception and attitudes concerning ECT, and lower the reticence towards this therapy, which in spite of its proven efficacy, always maintains a pejorative image., (Copyright © 2011 L’Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Background: Depression is the most common psychiatric disorder in chronic hemodialysis patients and is associated with mortality., Aim: To evaluate the prevalence of the depression in patients undergoing chronic hemodialysis, and to identify the correlated factors., Methods: The study population included 106 patients on chronic hemodialysis. The Hospital-Anxiety and Depression Scale was used to diagnosis depression., Results: The prevalence of the depression among the patients surveyed was 46.2%. Among 8 factors correlated with the depression at the univariate analysis, only 2 factors were still strongly correlated at the multivariate analysis: professional inactivity (OR = 6.54; p = 0.01) and anxiety (OR = 1.,5; p = 0.00)., Conclusion: According to our study, professional inactivity and/or anxiety should make looking for depression in order to optimize the management of the patients on chronic hemodialysis.

Behcet's disease (BD) is a multisystemic vasculitis. Its etiopathogeny remains unknown. Vascular involvement in BD is frequent and venous thrombosis is the most common manifestation (30% of cases). Arterial involvement is rare (2.7 to 7%). The latter is often severe and considered as a life threatening complication. Pathogenesis of thrombosis occurring in BD remains unclear. We report a 45-year-old man, from south of Tunisia, who presented a BD with a bifocal arterial involvement: right internal carotid thrombosis and bilateral proximal thrombosis of the two pulmonary arteries. Therapeutic strategies to address this multiple arterial involvement and the pathogenesis of thrombosis raise many questions., (Copyright 2010 Société nationale française de médecine interne (SNFMI). Published by Elsevier SAS. All rights reserved.)

Introduction: Myotonic dystrophy type 1 (DM1) is an autosomal dominant multisystemic disease with frequent cardiac involvement that may cause sudden death. This study was performed to determine the various cardiac manifestations in DM1, their frequency and the relevance of cardiac electrophysiological study in this disease., Methods: Ten patients with DM1, five men and five women, mean age 44.3+/-7.8 years underwent neurological and cardiac assessments., Results: The most frequent electrocardiographic findings were conduction abnormalities, essentially by intraventricular conduction defects (eight out of ten cases) such as bundle branch or fascicular blocks. Echocardiography showed alterations in systolic left ventricular function in two cases. Invasive electrophysiology testing showed sub-hisien block in three patients, requiring cardiac pacemaker implantation. These three patients had normal duration of PR interval and normal width of QRS complex., Conclusions: We recommend that all patients with DM1 should undergo cardiac investigation to detect subclinical cardiac involvement.

Background: The use of plasma exchange (PE) constituted an advance in the treatment of myasthenia. The objective of our study was to determine the relevance of PE in the treatment of myasthenia and to study the different complications which can be observed during PE., Patients and Methods: We studied retrospectively 11 patients who have generalized myasthenia and underwent PE. We used an intermittent flow cell separator and we performed PE three times a week. Biological assessment was performed before and after PE for all patients. The exchange volume was calculated according to the patient weight, gender and the value of hematocrit., Results: Our series included six women and five men. The mean age at onset of the disease was 41.4+/-14.1 years (range: 18 to 68). Indication of PE was myasthenia crisis (eight cases), resistance to classic treatment (two cases) and exacerbation after thymectomy (one case). An improvement was observed rapidly in five cases and delayed in three cases. The remaining three patients did not improve. The most frequent side effects of PE were hypotension (four cases), heart arrhythmia (two cases) and hypoglycemia (one case). Three patients dead in the seven days after the first PE., Conclusion: PE represents an interesting tool to treat severe forms of myasthenia and improve prognosis. High incidence of complications in our series can be explained by the initial disease severity, the used method of PE, the existence of associated illness, and a long stay in intensive care unit.

Familial spastic paraplegia (FSP) with severe muscular atrophy of hands and feet is exceptional. Autosomal dominant forms were initially described by Silver in 1966. We report two cases, from the same Tunisian family, presenting FSP with severe amyotrophy of the hands. A brother and his sister, aged respectively 37 and 36 years old, presented practically the same clinical picture. Their parents were cousins. The female patient was hospitalized. Both patients developed gait disorders around the age of three years. Muscular atrophy of the hands arose much later, around the age of 20 years. The neurological examination disclosed a spastic gait with distal amyotrophy, severe in the hands and moderate in the feet. Sensitivity was preserved and there was no fasciculation. The spinal cord and cerebral MRI was normal. Electromyography (EMG) showed a neurogenic pattern in the distal muscles. Stimulation of the median, ulnar and sciatica nerves was ineffective. The somatosensory evoked potentials (EP) were delayed (upper limb) or desynchronised (lower limb). The auditory and visual EP were normal. The cerebrospinal fluid contained 1 mononuclear cell/mm3 and 10 mg protein/100 ml. Abnormalities of the cranio-vertebral junction, Arnold-Chiari malformation, syringomyelia and familial juvenile amyotrophic lateral sclerosis (ALS) were excluded and the diagnosis of Silver's syndrome was evoked.

A 35 year-old heterosexual man had a six months history of cervical myelitis with progressive paraplegia, leg weakness and paresthesia of the four extremities. Spinal cord MRI showed a high T2 signal intramedullary lesion wide from the bulbo-medullary junction to D4. Post gadolinium T1 sequence revealed an enhancement in front of C3-C4 vertebrae. VIH serology was positive. Corticosteroid treatment achieved a marked improvement. In addition to vacuolar myelopathy, well-known at the advanced stages of the HIV infection (AIDS), myelitis and clinical pictures simulating multiple sclerosis were described during early stages of the infection. These inflammatory lesions of the central nervous system and sometimes of the peripheral nervous system seems to be related to the immune response dysfunction induced by the VIH.

Central nervous system involvement in systemic lupus erythematosus (SLE) is frequent and severe, however, myelopathy is rarely reported (0.8 p. 100 of SLE cases). We describe two SLE-young women. They were 21 and 37 year old, presented with acute paraplegia. CSF study showed pleocytosis and moderately elevated protein. Antinuclear, anti-DNA and anticardiolipin were positive. High dose steroids therapy induced marked improvement. The pathogenesis of myelopathy in SLE remains unclear. Anti-phospholipid antibodies may cause thrombosis and ischemic myelopathy. However, auto-antibodies directed against central nervous system constituents may be involved.