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This paper aims to highlight the relationship between cultural differences and the performance of non-equity alliances in the hotel sector with reference to a developing country. The paper employs an empirical investigation based on quantitative analysis. Data were gathered through questionnaires obtained from Tunisian hotels involved in 78 non-equity alliances with foreign partners. The partial least squares (PLS) technique was used to estimate the model. Results reveal that national and organizational cultural differences have a negative impact on alliance performance in this sector. The likelihood of alliance decay is then strengthened. However, national cultural differences do not moderate the relationship between organizational cultural differences and alliance performance. The corporate culture of these hotels could somehow be impervious to local culture. This paper helps fill the void of empirical evidence of the impact of both levels of culture on the performance of non-equity alliances in the hotel industry, which warrants more attention, especially in developing countries.

Background. Immune response plays a crucial role in virus clearance during COVID-19 infection and underpins vaccine efficacy. Herein, we aimed to assess the immune response during COVID-19 infection and following SARS-CoV-2 vaccination. Methods. In this retrospective study, 94 confirmed COVID-19 patients admitted to the intensive care unit were categorized into unvaccinated patients (n = 50), including 33 deceased and 17 discharged patients, and vaccinated group (n = 44) with 26 deceased and 18 discharged patients. Records of patients with severe COVID-19 admitted to the ICU between March, 2021 and March, 2022 were gathered and analyzed. Result. The assessment of immune cell counts revealed a large rise of neutrophils associated to decrease number of lymphocytes in patients with COVID-19 infection. In dead patients, we detected a significant correlation between neutrophils and inflammatory parameters such as IL-6 and CRP. Moreover, analysis of immune cell count following vaccination did not reveal any significant difference. However, the most substantial result, herein, detected is the decrease level of IL-6 in vaccinated patients as compared to unvaccinated. The reduce level of IL-6 following vaccination is observed in discharged patients as compared to deceased. Regarding the level of mortality after vaccination, we showed that all patients who received the first dose were died (46.1%, n = 12) as compared to those who have received two doses (34.6%, n = 9) and the third dose of vaccine (19.23%, n = 3) ( p = 0.0018 ). Strikingly, studying the inflammatory parameters after each vaccine dose, we revealed a significant decrease of IL-6 level after the booster dose (third dose), especially in vaccinated discharged patients. Conclusions. Neutrophils combined with IL-6 and CRP can be very useful markers to predict disease severity in patients admitted to ICU. The decrease level of IL-6 in vaccinated group pointed out the impact of vaccination to prevent inflammatory cytokine release.

Extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae have emerged as important nosocomial pathogens. Community infections by these organisms have been also reported and were associated with previous intestinal colonization. We aimed to characterize cefotaxime-resistant Enterobacteriaceae (CTX-R-En) isolated from hospitalized children in a Tunisian paediatric ward. Seventy CTX-R-En isolates were collected from 227 rectal swabs from hospitalized children in a paediatric ward. Antimicrobial susceptibility testing was determined according to the EUCAST guidelines. Isolates were characterized by polymerase chain reaction (PCR, genes encoding: ESBLs, pAmpC, carbapenemases, plasmid-mediated quinolone resistance, virulence factors in Escherichia coli and Klebsiella pneumoniae isolates, occurrence of classes 1 and 2 integrons, phylogenetic groups of E. coli isolates, ERIC-PCR and PCR-based replicon typing) and conjugal transfer experiments. In total, 65 out of 227 (28·6%) hospitalized children were colonized with CTX-M-R-En, and 70 isolates were identified. Isolates were 59 ESBL-, 7 plasmidic-AmpC (pAmpC)-, 3 ESBL+pAmpC-, and one ESBL+carbapenemase producers. The following bla genes were identified: blaCTX-M-15 (n = 54), blaCTX-M-1 (n = 5), blaCTX-M-9 (n = 2), blaCTX-M-13 (n = 1) and blaCTX-M-14 (n = 1), blaCMY-2 (n = 5), blaCMY-4 (n = 4), blaACC-1 (n = 1) and blaOXA-48 (n = 1). Our results showed that hospitalized children were colonized with various CTX-R-En-producing several beta-lactamase enzymes.

The main objective of this study was to identify carbapenem resistance mechanisms among clinical, commensal and environmental carbapenem-resistant Acinetobacter baumannii (CRAB) strains isolated in 5 Tunisian intensive care units (ICUs).CRAB isolates were recovered from different sources: clinical specimens, rectal and environmental swabs. Bacterial identification was carried out using conventional methods and susceptibility testing according to EUCAST recommendations. Evaluation of phenotypic carbapenemase production of was performed using seven different methods, and molecular detection of carbapenemase-coding genes (blaAll in all, 46 CRAB isolates were identified in clinical specimens (n = 26/26), rectal swabs (n = 17/36) and environmental swabs (n = 3/63). Most of them (n = 41/46) were clonally related and found in the different ICUs. All of the CARB isolates harbored blaThe emergence and diffusion of clonal CRAB strains inducing high mortality rates in ICUs is a major public health concern. Enhanced infection control practices and mandatory staff education are needed to control the spread of these multidrug-resistant bacteria.

Background: Caplan's syndrome, also known as rheumatoid pneumoconiosis (RP), is a rare disease associating pneumoconiosis with rheumatoid arthritis (RA). This is one of the rare cases evaluating the effect of Rituximab, which was used initially for the treatment of RA, on pneumoconiosis. Case presentation: In this case report, we described a 21-year long-standing history of pneumoconiosis and its association with RA. A 67-year-old man diagnosed with pneumoconiosis presented with morning stiffness and symmetrical polyarthritis. Laboratory investigations showed high titers of rheumatoid factor (RF) and anti-citrullinated protein antibodies. The diagnosis of RA was established and the patient was put on leflunomide. Then, he was treated with Rituximab, as he did not respond to leflunomide. The patient showed marked improvement as pain and swelling decreased. More importantly, Caplan’s nodules stabilized on chest-computed tomography. Conclusion: The use of rituximab in pneumoconiosis does not alter the evolution of the pulmonary nodules. More trials are needed to establish a treatment consensus for RP.

With the COVID-19 pandemic, health care systems are facing challenges in delivering proper patient care. Children and adolescents with juvenile idiopathic arthritis require specialized and comprehensive attention. In this context, telemedicine is an alternative that has the potential to improve access to healthcare in addition to cost savings. The objective of our study was to evaluate parents' willingness for telemedicine and factors helping to adopt this alternative in the era of COVID-19.We undertook a cross-sectional study via structured phone interviews of parents' JIA patients as well as those with no established diagnoses. We evaluated their point of view and willingness to adhere to TM.The study included 40 parents. The main reasons for favoring TM were avoiding hospitals during the pandemic (32.5%), time saving (27.5%) as well as avoiding school absenteeism (27.5%). The main reasons for preferring a live consultation were the fear of a possible discrepancy between physical and distant evaluation (47.5%) and the fear of the trivialization of the disease (38.5%). There was no association between preference for TM and a family history of COVID-19 (p = 0.704) as well as electronic devices afforded (p = 0.263). However, patients who lived away from hospital, not familiar with the concept of TM and with higher income adhered less to TM.Unlike the literature data, our study showed the low prevalence of parents willing to accept TM as a model of care. This imply an urgent need for parent and patient education to promote TM especially in pediatric rheumatology.

Learning Classifier Systems (LCSs) are a kind of evolutionary machine learning algorithms that provide highly adaptive components to deal with real world problems. They have been widely used in resolving complex problems such as decision making and classification. LCSs are flexible algorithms that are able to construct, incrementally, a set of rules and evolve them through the Evolutionary Algorithm (EA). Despite their efficiency, LCSs are not capable of handling imperfect information, which may lead to reduced performance in terms of classification accuracy. We propose a new accuracy-based Michigan-style LCS that integrates the belief function theory in the supervised classifier system. The belief function or evidence theory represents an efficient framework for treating imperfect information. The new approach shows promising results in real world classification problems.

Sarcoidosis is a systemic inflammatory granulomatous disease that can develop in almost any organ system. Rheumatologists may encounter sarcoidosis in different situations varying from arthralgia to bone involvement. While the peripheral skeleton was a frequent location, data regarding axial involvement is scarce. Most patients with vertebral involvement have a known diagnosis of intrathoracic sarcoidosis. They tend to report mechanical pain or tenderness over the involved area. Imaging modalities, particularly Magnetic Resonance Imaging (MRI), are a mainstay of axial screening. It helps exclude differential diagnoses and delineate the extent of bone involvement. Histological confirmation combined with the ap- propriate clinical and radiological presentation is the key of diagnosis. Corticosteroids remain the cornerstone of treatment. In refractory cases, methotrexate is the steroid- sparing agent of choice. Biologic therapies may be used, although the evidence base for their efficacy is bone sarcoidosis controversial.

Background and Aims: Changes in body mass composition, such as reduced lean and fat mass, can occur in a patient with rheumatic diseases. However, data about body composition in spondyloarthritis (SpA) showed conflicting results. The aim of the present study was to assess by DXA the distribution of lean and fat mass in SpA patients compared to healthy controls and to in-vestigate the association between body mass composition and disease characteristics. Methods: We conducted a cross-sectional case-control study including 50 SpA patients and 50 con-trols. Sociodemographic data, as well as disease characteristics, were assessed. Body composition measurements and biochemical and inflammatory serum markers were evaluated. Radiographic data (Bath Ankylosing Radiologic Index and the modified Stroke Ankylosing Spondylitis Spine Score) was also recorded. Results: No statistically significant correlation was found between the two groups regarding bone mineral density and body mass distribution. However, a lower weight was observed in the study group compared to the control group (p = 0.043). Male gender and younger age were associated with a higher lean mass (p = 0.05). C-reactive protein (CRP) level was positively correlated with lean mass (r = 0.38, p = 0.023). Similarly, BASFI was higher in patients with lower fat mass (r = -0.42, p = 0.024). A longer duration of NSAIDs intake was associated with a lower lean mass and a higher fat mass. However, no correlations were found between body mass composition and BASRI mSASSS scores as well as bone mineral density and calcium intake. Conclusion: Our findings suggest that younger age, male gender, and axial phenotype were associ-ated with higher lean mass.

In this paper, we develop some generalized Fredholm perturbation results for bounded linear operators acting on non-reflexive Banach spaces satisfying certain conditions. Furthermore, we investigate the stability of the generalized Schechter S-essential spectrum by means of the so-called generalized Fredholm index. This concept is introduced as a semigroup homomorphism satisfying certain properties. Some generalized Fredholm results for block operator matrices acting on a non-reflexive product of two Banach spaces are also developed.

Serine is an important precursor of various biomolecules. Here, we investigated the role of the phosphorylated pathway of serine biosynthesis in a non-vascular plant Marchantia polymorpha by analyzing knockout mutants of MpPGDH, a single gene encoding the first committed enzyme 3-phosphoglycerate dehydrogenase (PGDH), to assess functions of this pathway in relation to those of the other two pathways. Growth phenotypes of the mutants indicated that serine supply from the phosphorylated pathway in the dark was crucial for vegetative growth. Sperm formation required serine from this pathway, while egg formation did not depend on it. Knockout of MpPGDH in the maternal genome disrupted sporophyte development. When the mutants were grown in high CO2 where the photorespiratory glycolate pathway for serine biosynthesis is inhibited, thallus growth was suppressed and not fully recovered to wild-type level by exogenous serine supplement, suggesting that serine homeostasis involving both the phosphorylated and glycolate pathways was essential. Metabolome and lipidome analyses indicated that the phosphorylated pathway mainly influenced the tricarboxylic acid cycle, the amino acid and nucleotide metabolism, and lack of serine significantly perturbed lipid metabolism. Our results indicate the importance of serine from the phosphorylated pathway for sperm formation, sporophyte development, and metabolism in M. polymorpha.

Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory disorder primarily affecting children. It is characterized by a peripheral involvement of the metaphysis of long bones rather than axial involvement. Due to the scarcity of the disease, there are no guidelines regarding its management.This review aims to provide an overview of the different therapeutic alternatives and recent protocols. For this reason, first-line and second-line treatment, as well as the impact of new therapies, are discussed in depth. We conducted a search through PubMed on the different aspects of CRMO. Outcomes were categorized as first and second-line treatments.Non-steroidal anti-inflammatory drugs remain the keystone of CRMO management and are proposed as the first-line treatment. In the case of vertebral involvement, bisphosphonate should be considered, even as a first-line treatment. Several case series and retrospective studies highlight the efficacy of anti-TNF agents. Their use could be an optimal treatment choice for CRMO with comorbid immune-mediated diseases. The potentially favorable effect of interleukin-1 antagonists remains to be determined.

Actually, no data on the prevalence of plasmid colistin resistance in Tunisia are available among clinical bacteria.This study aimed to investigate the current epidemiology of colistin resistance and the spread of theA total of 836 GNB strains were inoculated on COL-R agar plates with selective screening agar for the isolation of GNB resistant to colistin. For the selected isolates,Colistin-resistance was detected in 5.02% (42/836) of the isolates and colistin-resistant isolates harboured an ESBL (This study reports the first description of the

Extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae have emerged as important nosocomial pathogens. Community infections by these organisms have been also reported and were associated with previous intestinal colonization. We aimed to characterize cefotaxime-resistant Enterobacteriaceae (CTX-R-En) isolated from hospitalized children in a Tunisian paediatric ward. Seventy CTX-R-En isolates were collected from 227 rectal swabs from hospitalized children in a paediatric ward. Antimicrobial susceptibility testing was determined according to the EUCAST guidelines. Isolates were characterized by polymerase chain reaction (PCR, genes encoding: ESBLs, pAmpC, carbapenemases, plasmid-mediated quinolone resistance, virulence factors in Escherichia coli and Klebsiella pneumoniae isolates, occurrence of classes 1 and 2 integrons, phylogenetic groups of E. coli isolates, ERIC-PCR and PCR-based replicon typing) and conjugal transfer experiments. In total, 65 out of 227 (28·6%) hospitalized children were colonized with CTX-M-R-En, and 70 isolates were identified. Isolates were 59 ESBL-, 7 plasmidic-AmpC (pAmpC)-, 3 ESBL+pAmpC-, and one ESBL+carbapenemase producers. The following bla genes were identified: bla

Brown tumours (BTs) are focal bone lesions encountered in patients with uncontrolled hyperparathyroidism (HPT). They are due to a proliferation of multinucleated giant cells in osteolytic lesions. Because of early screening of bone metabolism disorders, BTs are rare bone manifestations. More importantly, they scarcely reveal the disease. We demonstrate through these two cases reports unusual locations of BT complicating the course of HPT due to parathyroid hyperplasia.

Multiple myeloma is a neoplasm of plasma cells affecting mostly the elderly with incidence peaks between 60 and 70 years. This disease is exceedingly rare in younger people, especially in adults under 30-year-old. Non-secretory multiple myeloma accounts for 1–5% of all cases of multiple myeloma. It is also a rare condition in young adult patients, and only six cases have been reported [1]. We herein describe a rare case of non-secretory myeloma in a 22-year-old male, explaining from chest wall pain, without general manifestation. Plain radiography and CT scans revealed diffuse osteolytic lesion mimicking the Gorham disease. A bone marrow biopsy was conducted, revealing the diagnosis of myeloma.

Introduction: The Synovitis, Acne, Pustulosis, Hyperostosis, and Osteitis (SAPHO) syndrome is a rare autoinflammatory disease. The clinical presentation is heterogeneous, hence the difficulty of making the diagnosis. Aim of the work: To assess clinical, laboratory parameters and radiological features, and to detail the therapeutic options of SAPHO syndrome. Patients and methods: Patients diagnosed with SAPHO syndrome were retrospectively studied from two rheumatology centres in Tunisia. The epidemiological, clinical, radiological, and therapeutic data were collected from patients’ medical records. Results: Twenty-three patients were enrolled. The mean age was 44.7 ± 16.9 years (14–76 years). Skin involvement was found in a third of patients. Osteoarticular manifestations involved anterior chest wall damage in 56% of cases and axial skeletal lesions in 93% of patients. Ten (43%) patients had peripheral joint involvement, and one reported bone pain in the forearm. HLA-B27 was positive in a third of the patients. All patients were treated with nonsteroidal anti-inflammatory drugs (NSAIDs) with variable clinical responses. Antibiotic therapy with doxycycline was prescribed in 3 cases, with no clinical improvement. Sulfasalazine was used in 4 cases after therapeutic failure of NSAIDs. Methotrexate was prescribed in 4 cases. Tumor necrosis factor (TNF) inhibitors (Etanercept) were provided for 2 with a good clinical response, and were planned for two others. Pamidronate was given to a patient with bone involvement with pain relief and clinical improvement. Conclusion: Patients with SAPHO were relatively young. Skin lesions were not common. The involvement of the anterior chest wall and the axial skeleton was predominant.

In plants, coordinated growth is important for organ mechanical integrity because cells remain contiguous through their walls. So far, defects in inflorescence stem integrity in Arabidopsis thaliana have mainly been related to epidermal defects. Although these observations suggest a growth-limiting function at the stem cortex, deeper layers of the stem could also contribute to stem integrity. The nac secondary cell wall thickening promoting factor1 (nst1) nst3 double-mutant background is characterized by weaker vascular bundles without cracks. By screening for the cracking phenotype in this background, we identified a regulator of stem cracking, the transcription factor INDETERMINATE DOMAIN9 (IDD9). Stem cracking was not caused by vascular bundle breakage in plants that expressed a dominant repressor version of IDD9. Instead, cracking emerged from increased cell expansion in non-lignified interfascicular fiber cells that stretched the epidermis. This phenotype could be enhanced through CLAVATA3-dependent cell proliferation. Collectively, our results demonstrate that stem integrity relies on three additive mechanical components: the epidermis, which resists inner cell growth; cell proliferation in inner tissues; and growth heterogeneity associated with vascular bundle distribution in deep tissues.

Plant leaves display abundant morphological richness yet grow to characteristic sizes and shapes. Beginning with a small number of undifferentiated founder cells, leaves evolve via a complex interplay of regulatory factors that ultimately influence cell proliferation and subsequent post-mitotic cell enlargement. During their development, a sequence of key events that shape leaves is both robustly executed spatiotemporally following a genomic molecular network and flexibly tuned by a variety of environmental stimuli. Decades of work on Arabidopsis thaliana have revisited the compensatory phenomena that might reflect a general and primary size-regulatory mechanism in leaves. This review focuses on key molecular and cellular events behind the organ-wide scale regulation of compensatory mechanisms. Lastly, emerging novel mechanisms of metabolic and hormonal regulation are discussed, based on recent advances in the field that have provided insights into, among other phenomena, leaf-size regulation.

OBJECTIVES Hip involvement remains a predictor of severe juvenile idiopathic arthritis (JIA) course and carries a high risk of disability. This study aims to determine the factors of poor prognosis of hip involvement in patients with JIA and to assess the treatment response. METHODS This is a multicenter observational cohort study. Patients were selected from the JIR Cohort database. Hip involvement was defined as clinically suspected and confirmed by an imaging tool. Follow-up data were collected during 5 years. RESULTS Among the 2223 patients with JIA, 341(15%) patients had hip arthritis. Male gender, enthesitis-related arthritis, and North African origin were factors associated with hip arthritis. Hip inflammation was associated with disease activity parameters during the first year, particularly Physician Global Assessment, joint count, and inflammatory marks. Structural hip progression was associated with early onset of the disease, a longer time to diagnosis, geographic origin, and JIA subtypes. Anti-TNF therapy was found to be the only treatment able to effectively reduce structural damage progression. CONCLUSION The early onset diagnostic delay, origin, and systemic subtype of JIA predict a poor prognosis of hip arthritis in children with JIA. The use of anti-TNF was associated with a better structural prognosis.

Since 2012, few reports on the molecular epidemiology ofThis study aimed to evaluate carbapenem-resistance determinants and molecular epidemiology and to compare the carbapenemase-phenotypic detection methods of multidrug-resistantDuring a period of four years (2014 to 2017), all imipenem-ceftazidime-resistantA total of 35 isolates were recovered among patients hospitalized in different units. All strains were colistin-susceptible.All carbapenem-resistant isolates showed a high-level resistance to carbapenems. CIMTris and mCIM showed 96.15% and 46.15% sensitivity and 44.44% and 100% specificity, respectively, for detecting carbapenemase production.CIMTris is a promising approach for detecting carbapenemase activity in

OBJECTIVES The aim of this study is to compare the clinical features, disease activity and physical impairment, between enthesitis-related arthritis, adult and late-onset spondylarthritis in Tunisian patients. METHODS This study included 190 patients divided into three groups according to their age at the onset of symptoms: ERA (onset of symptoms ≤ 16 years of age), AOSpA (16

The present study highlights the influence of support and monomer properties on the performance of thin-film composite (TFC) membranes. For this purpose, a series of polyamide-cellulose acetate thin-film composite nanofiltration (TFC-NF) membranes were prepared by interfacial polymerization technique using cellulose acetate (CA) membrane as support and the monomer of cyclohexane-1,3,5 tricarbonylchloride (HTC) as an organic phase. The effect of the cellulose acetate concentration on the pore size of the membrane support was investigated using 15%, 16.5%, 18%, 19.5%, and 21.5% of cellulose acetate. m-phenylenediamine (MPD), piperazidine (PIP), and 1,3- cyclohexanebis (methylamine) (CHMA) were studied as monomers. Results displayed that PIP/HTC membrane is more hydrophilic and has more intense granular and convex structure with rougher surface compared to the other prepared membranes. The water flow and the porosity depended on the cellulose acetate concentration. The decrease in porosity complied well with permeability, contact angle, and SEM analysis. The membrane performances were evaluated for the retention of NaCl, CaCl, and NaSO retention. Comparing the NaSO rejection with CaCl and NaCl, the former is higher than the latter.

Backgrounds:Milk well- known important source of human nutrition and contain considerable amounts of macro and micronutrients and have enormous health benefit. This study was performed to determine the nutritional knowledge and health benefit knowledge of diary and dairy products consumption among medical students at Benghazi university. Methodology:This a cross section study comprised of 541 students from branches of medical faculties in which 290 female and 251 male. Data were collected by using a semi-constructed questionnaire. Data was analysis by either mean ± SD or frequencies and percentages according to the natural of data. Chi-square test was used at α< 0.05. Results:The result of present work revealed that milk was consumed by one serving a day (53%) (P< 0.05), and among types of milks, whole fat milk significantly consumed (P< 0.05). Our result also shown that dairy products were highly consumed by one serving/day. Furthermore, 65.2 % of the students drink milk with tea (P=0.000). Nutrition knowledge of milk and dairy products reported that students have good knowledge score for nutritional knowledge questions and poor knowledge scores for questions related to health benefit with exception question on oral health (P< 0.05). Even though, the nutritional status of the students reveals that they fall under normal weight categories. However there were abnormal low levels of Hb, vitamin D have been found and abnormal high levels of calcium among male students. ConclusionDairy consumption among students was relatively higher with good nutritional knowledge of dairy and dairy products consumptions and poor knowledge regarding health benefit. The result of this study suggested that nutritional education program might be in great importance of dairy and dairy product knowledge and benefit. The data of this study needed to be validated in large samples.

Background Foot deformities seem to be frequent in children with Juvenile Idiopathic Arthritis (JIA) [1,2]. These deformities can deeply affect the child’s activity and alter his quality of life. Objectives To study the association between disease activity and foot deformities in JIA patients. Methods We conducted a cross-sectional study including patients meeting the International League of Associations for Rheumatology (ILAR) 2001 criteria for JIA. For each patient, we collected the following data: age, disease duration, tender joint count (TJC), swollen joint count (SJC), Patient Global Assessment (PGA), Visual Analogic Scale (VAS), and therapeutic management. Disease activity was assessed using the Juvenile Arthritis Disease Activity score (JADAS). Foot deformities were assessed using an optical podoscope. C-reactive protein (CRP) and Erythrocyte sedimentation rate (ERS) levels were measured. Statistical analysis was performed using SPSS software. Results We included 35 patients. Forty-three percent of the patients were boys (n = 15). The mean age was 12.2 ± 3.61 years. The mean disease duration was 4.1 ± 3.29 years. The mean PGA and the mean VAS were 3.4 ± 3.02 and 3.37 ± 2.92, respectively. The mean TJC and the mean SJC were 1.48 ± 1.69 and 0.61 ± 0.77, respectively. The mean CRP and ESR were 7.51 ± 11.85 mg/l and 18.88 ± 15.53 mm, respectively. Twenty-four patients were under non-steroidal anti-inflammatory drugs (69%), 12 patients were under methotrexate (34%), and 5 patients were under TNFα inhibitor (14%). The mean JADAS was 7.58 ± 6.3. Seventeen percent of the patients had the inactive disease (n = 6). Foot deformities were found in 80% of the patients (n = 28). They were flatfoot in 40% (n = 14) and pes cavus in 46% (n = 16). These deformities were bilateral in 18 cases (51%). Hallux valgus was present in 14% of the cases (n = 5). Foot deformities were associated to a higher PGA (4.04 ± 3.01 vs 0.86 ± 1.2, p< 10–3), VAS (3.93 ± 2.94 vs 1.14 ± 1.46, p = 0.022), CRP level (8.84 ± 13.1 vs 2.79 ± 2.5 mg/l, p = 0.039), and higher JADAS (9.12 ± 6.25 vs 2.08 ± 1.93, p< 10–3). Conclusion Our study showed that foot deformities are common in JIA. Interestingly, these deformities are associated with a higher CRP level and a higher disease activity. These results suggest that an early screening of foot deformities is advisable in patients with active disease. References 1. Truckenbrodt H, Häfner R, von Altenbockum C. Functional joint analysis of the foot in juvenile chronic arthritis. Clin Exp Rheumatol. 1994; 12 Suppl 10: S91-96. 2. Gschwend N, Ivosevic-Radovanovic D. [The child’s foot in juvenile polyarthritis (cP)]. Orthopade. 1986; 15(3):212–9.

Background The pediatric Gait, Arms, Legs, and Spine (pGALS) is a practical quick musculoskeletal assessment to increase awareness of the joint disease, facilitate early recognition of joint problems, and prompt referral to specialist teams to optimize clinical outcomes. pGALS has been shown to be practical and useful, with excellent acceptability by children and their parents. Its use was limited in French-speaking countries because of the lack of the francophone version. Objectives To describe the steps of the translation of the pGALS francophone version using the Delphi approach. Methods Delphi method is the consensus-building method, providing the consensual opinion of the experts. For each translated item of the pGALS, the experts assessed the relevance using a scale ranging from 1 to 9 (not relevant-completely relevant). Then median was calculated giving for each item the position of the group: disagree (if the median < 3), equivocal (median between 4–6) and agreement (median >7). The degree of the convergence with the group was assessed to clarify this result: the group’s opinion is consensual if 70% of the responses were within the range of the median; otherwise, it’s “not consensual”. For the no consensual and no relevant item, the experts propose a comment to reformulate the sentence. Results Three native speakers were invited to translate the English form of the pGALS into the francophone language. The different propositions were mixed in a consensual way by a children’s musculoskeletal specialist. The version was validated according to the Delphi method. Six experts (pediatricians and rheumatologists) from different French-speaking countries were interviewed during 3 rounds by electronic survey individually and anonymously. After each round: the median, consensus, and comments of every item are collected and a meeting with experts was held to analyze the results. During the first meeting, we were consensual and we had an agreement on 82% of the items (28 items were validated, and 6 items were reformulated). Then the form was reformulated using the results of the preliminary rounds: opinions of the experts and their proposals during the last meeting). We were in agreement and we validated the remaining six-item during the second meeting. In the last round, we obtain a consensual version of pGALS. Conclusion Our approach contributed to the consensual translation of the francophone version of pGALS. This tool is now ready to be used as a basic clinical skill. More research is mandatory to assess its sensibility and specificity in screening musculoskeletal disorders.

Background Pediatric Rheumatology is currently gaining importance across Africa. Initiatives such as the creation of the paediatric society of the African league against rheumatism (PAFLAR) proved the efforts made to bridge the insufficiency. In the same line, training in pediatric rheumatology remains the main challenge of this orphan subspecialty. For this purpose, a post-graduate certification in Pediatric Rheumatology was created in 2021 in the Faculty of Medicine of Tunis—Tunis-El Manar University. It is the first online certification dedicated to French speakers in Africa. The certification is entitled “musculoskeletal diseases of children and adolescents”. Objective To assess the learners' perceptions and views of this certification. Methods We established an online survey targeting the participants. The questionnaire was divided into three main sections: the first section examined the participant characteristics: their specialty, the use of the Moodle platform of the Virtual University of Tunis (UVT), their previous participation in an online post-graduation course, etc.). The second section focused on platform acceptability. The third and final section evaluated the content of the course. The Likert scale was used in most questions. Results Fifteen participants responded to the survey. Among them, one is specialized in family medicine, 1 in orthopedics, 5 in pediatrics, and 8 in rheumatology. Fifty-three percent have never used the platform of the virtual university of Tunis (UVT) before, and 26.7% have never attended an online course. Most participants found the platform easy to access and easy to use with a mean Likert scale of 2.2 and 2.13, respectively. In the third section of the questionnaire, the course met the expectations of the candidates with a mean Likert scale of 2.1. Most of them found the post-test useful to their learning experience, and only two found it to be the opposite. This can be explained by the pressure that it may generate. Eighty-six percent of the candidates had an interactive experience with the educator and enjoyed the interactions and the discussions between the participants. Most participants were pleased with the seminar organization and with the number of h devoted to each seminar (mean Likert Scale = 2.1). Eighty-six percent of the participants have found that the course improved their medical practice and 93.3% confessed that they were satisfied with the online nature of the certification and did not wish it to be physical. Conclusion Overall, the post-graduate “musculoskeletal diseases of children and adolescents” course was beneficial and enriching/rewarding for the participants. Developing this training program helps to promote pediatric rheumatology in Africa and to provide children with rheumatic diseases access to healthcare.

Background Although ankle and foot involvements are common in juvenile idiopathic arthritis (JIA), they are often neglected. Hip involvement, also common in JIA, may affect these joints by creating a chronic imbalance of the musculoskeletal system. However, no studies have been published on this subject. Objective We aimed to describe ankle and foot impairment in a cohort of patients with JIA and to study the correlation between these impairments and the presence of hip arthritis. Methods A monocentric cross-sectional study was conducted including JIA patients fulfilling the 2001 ILAR criteria. Patients with congenital malformation of the ankle or foot or with any other foot impairment due to a disease other than JIA were not included. Foot examination was performed on bare feet both in supine and standing position. We completed with an analysis of footprint with a podoscope and shoes examination. Patients were divided in two groups depending on the presence or the absence of hip arthritis on pelvis X-ray, hip ultrasound or hip magnetic resonance imaging. Results We included 35 patients (M/F = 15/20). Hip arthritis was noted in 45.7%. Oligoarticular (43.8%) and enthesitis-related arthritis (25%) were the most frequent form of JIA. Functional complaints related to foot and ankle were reported in 34.3% of cases. The pain was the most frequent symptom (91%), mainly in the hindfoot and ankle (50%). Foot pain was more frequently encountered in the absence of hip arthritis (52%, vs 31.2% in presence of hip arthritis). Physical examination revealed limitation of the talocrural joint in 20% of cases and feet tenosynovitis in 14.3% of cases. Achille tendon enthesitis was found in 8.6% of patients. These abnormalities were more prevalent in the absence of hip arthritis. Half of the patients had hindfoot deviation dominated by hindfoot varus (22.9%). In the group with hip arthritis, a hallux valgus was found in 14.3%, a supraductus of the 2nd toe, and claw toe in one case each. An anomaly of the footprint was noted in 28 patients, including 11 in the group with hip involvement: 7 cases of cavus foot and 4 cases of flat foot. There were no correlations between foot or ankle anomalies with hip impairment apart from an association of flat foot with the absence of coxitis, and a leg length discrepancy more important in the group with hip arthritis. Conclusions Our study confirms the frequency of foot and ankle involvement as well as hip arthritis during JIA, hence the importance of their systematic screening even in asymptomatic children. Larger-scale studies would be necessary to evaluate with more precision the relation that there could be between hip and foot impairment.

Background Juvenile idiopathic arthritis (JIA) is chronic inflammatory arthritis of childhood that may result in persistent and disabling foot impairments. Foot disorders are common in JIA with a prevalence estimated at over 90%. Many factors can worsen foot disorders in these patients. The influence of weight on foot disorders is poorly studied. Objectives To examine associations between weight and foot disorders in patients with JIA. Methods Patients with a diagnosis of JIA, based on the International League of Associations for Rheumatology (ILAR) criteria were included. Age, gender, weight, characteristics of the disease and of foot pain were noted. A specialized podiatric examination was performed. Results Thirty-two patients were included. The mean age was 12.2 ± 2.9 [5–18]. Forty-three percent of the patients were boys (n = 14). The mean age of disease onset was 8.5 ± 3.9 [3–15]. Only one patient had a triggering factor (elbow fracture). The most common type of JIA was oligoarthritis in 12 cases, then enthesitis-related in 8 cases, polyarthritis without rheumatoid factor in 3 cases, polyarthritis with positive rheumatoid factor in 1 case, psoriatic arthritis in 3 cases, systemic arthritis in 1 case and undifferentiated arthritis in 4 cases. The mean weight was 43.5 kg [17–98]. Only 28% (n = 9) of the children had a normal weight for their age, 41% (n = 13) of them had a low weight for their age and 31% (n = 10) of them had overweight. Ten patients had foot pain: hindfoot pain in 5 patients, midfoot pain in 3 patients, and forefoot pain in 2 patients. Foot deformities were found in 78.1% of the patients (n = 27): flat foot in 39% (n = 13) of the patients and pes cavus in 39% (n = 13). There was no association between overweight and foot pain (p = 0,14) or hindfoot pain (p = 0.08). However, overweight was associated with a forefoot (p = 0.01) and midfoot (p = 0.01) pain. Overweight was not associated with foot deformities (p = 0.1). Conclusion This study showed that weight is associated with foot pain especially forefoot and midfoot pain. A healthy lifestyle and a normal weight are fundamental to preventing foot pain at an early age in patients with JIA and improving their quality of life.

Background Juvenile idiopathic arthritis (JIA) is an unusual aetiology of scoliosis in childhood. With few data in literature, the associated factors of scoliosis in JIA are still unknown. Objectives To describe the incidence and associated factors of scoliosis in children with JIA. Methods A cross-sectional study including children with JIA according to the International League of Associations for Rheumatology (ILAR). The recorded data included anthropometric measurements (weight, size, body mass index (BMI), and leg length), disease characteristics (JIA subtypes and duration), and static foot posture disorders. Regarding scoliosis, we collected clinical and radiographic findings. Results Thirty-five patients, forty-three percent of the patients were boys (n = 15). The mean age was 12.2 ± 3.61 years. The mean disease duration was 4.1 ± 3.29 years. The mean patient global assessment and the mean visual analogic scale were 3.4 ± 3.02 and 3.37 ± 2.92, respectively. The patient's distribution of JIA subtypes was oligoarticular (n = 13), enthesitis-related arthritis (n = 9), polyarticular (n = 4), undifferentiated (n = 4), psoriasis-related JIA (n = 4) and systemic-onset (n = 1). The mean CRP and ESR were 7.51 ± 11.85 mg/l and 18.88 ± 15.53 mm, respectively. The mean JADAS was 7.58 ± 6.3. Seventeen percent of the patients had an inactive disease (n = 6). Seven patients (20%) (6 females) had developed scoliosis during their disease, the spine regions of scoliosis were thoracolumbar scoliosis (n = 6) and thoracic scoliosis (n = 1). There was no specific distribution of scoliosis among JIA subtypes (p = 0.464). Most patients with scoliosis had associated leg length discrepancy (71.43% vs 28.57%, p = 0.025). Static foot posture disorders were present in most patients with scoliosis (85.71% vs 14.29%) but this difference was not significant (p = 0.673) compared with patients with no scoliosis. Weight, size and BMI were not associated with scoliosis (p = 0.955, p = 0.922, p = 0.303 respectively). Conclusion Our study shows that scoliosis is associated with leg length discrepancy. Indeed, the joint inflammation of the lower limb may explain the postural syndrome in children with JIA, with a prompt impact on the axial skeleton.

Background Juvenile idiopathic arthritis (JIA) is considered to be an autoimmune disease, which is a result of an immune reaction caused or triggered by environmental factors in a genetically susceptible individual. However, interactions between early feeding and risk Juvenile idiopathic arthritis (JIA) remains largely unexplored. Objectives To determine the impact of early alimentation on the occurrence of JIA in Tunisia. Methods We conducted a case-control study including 26 children with JIA fulfilling the international league against rheumatism (ILAR) 2010 criteria compared with a homogeneous control group of 21 children hospitalized in a paediatric orthopedic unit for traumatic reasons and healthy for any chronic inflammatory rheumatism. Parents of patients were asked after having their consent to participate. We collected the following data: Type of JIA, juvenile disease activity score (JADAS), type of feeding, total duration of breastfeeding, duration of exclusive breastfeeding and age at introduction of gluten. Patients were divided into two groups: group 1 (G1): JIA patients, group 2 (G2): control group. Data were analyzed using the SPSS statistical package. A p-value < 0.05 was considered significant. Results Forty-seven children (26 diagnosed with JIA and 21 controls) with a mean age of 10.07 years ± 4.96 were enrolled. JIA subtypes were in decreasing order of frequency: oligoarticular (45.8%), enthesitis-related arthritis (20.8%), undifferentiated JIA (12.5%), seronegative polyarticular JIA (8.3%), juvenile psoriatic arthritis (8.3%), and seropositive polyarticular JIA (4.2%). The mean JADAS was 6.966 ± 5.38. There was no significant difference between the G1 and G2 with regard to the duration of breastfeeding (12.23 ± 3.8 months vs 8.14 ± 4.1 months, p = 0.09), exclusive breastfeeding (3.8 ± 3.6 vs 4.1 ± 2.62, p = 0.40) and age at introduction of gluten (G1: 8.48 ± 5.30 months vs G2: 7.48 ± 1,2 months, p = 0.35) Conclusion Our study didn’t show any impact of early alimentation on the occurrence of JIA in Tunisia. However, more studies are necessary to conclude these issues.

Background Juvenile idiopathic arthritis (JIA) is one of the commonest rheumatic diseases in children. Hip involvement is a common problem in JIA patients and is associated with functional disability and poor outcomes. Intensive therapy is required to avoid joint replacement surgery. Little studied in the literature, the predictors of hip involvement are still unknown. Objectives Our study aims to identify the clinical, biological characteristic of patients with hip involvement and determine the associated risk factors. Methods A cross-sectional study including children with JIA according to the International League of Associations for Rheumatology (ILAR). The recorded data included sociodemographic features, disease characteristics (subtype disease, duration, and juvenile arthritis disease activity score (JADAS)) as well as treatment modalities. Regarding coxitis, we collected radiographs, ultrasound (US), and magnetic resonance imaging (MRI) of the hip when performed. Coxitis was defined by clinical (limited range of motion) and/or radiographic findings (destruction, synovitis, bone marrow oedema). Results Thirty-five patients (20 females) with a median age of 12 years (5–18) and disease duration of 3 years (0.25–15) were recruited. The patient's distribution of JIA subtypes were oligoarticular (n = 13), enthesitis-related arthritis (n = 9), polyarticular (n = 4) (negative rheumatoid factor in 3 patients), undifferentiated (n = 4), psoriatic-arthritis (n = 4) and systemic-onset (n = 1). ESR and CRP median values were 15 mm/h (0–63) and 2 mg/l(0–47) respectively. Sixteen patients were under DMARDs (Methotrexate (n = 10), biological agent (n = 3), biological agent and methotrexate (n = 2), salazopyrine (n = 1)). Sixteen patients (45.71%) developed coxitis (radiographic (n = 8), MRI (n = 5) and US findings (n = 3)) with eight (50%) presenting limited range of motion and 10 (62.5%) developing radiological evidence of hip damage. Hip involvement was associated with a longer disease duration (p = 0.051). JADAS score value of patients with coxitis was higher (Mean 8.35 vs 7.05) but not significantly (p = 0.565). Higher CRP and ESR values were found in patients with coxitis (mean 8.39 mg/l vs 6.83 mg/l, 22.29 mm/h vs 16.37 mm/h respectively) but not significantly (p = 0.718, p = 0.287 respectively). No associations were found between hip involvement and BMI (p = 0.233), age-onset (p = 0.496), JIA subtype (p = 0.509), nor sex (p = 0.767). Conclusion Our study shows that long disease duration exposes to a higher risk of hip involvement in children with JIA. Active disease and biological inflammatory syndrome could be associated risk factors. Studies with larger sample sizes are needed to draw definite causal associations.