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Tracheal hemangioma is a very rare benign vascular tumor. Few cases of tracheal hemangioma in children are reported in the literature. Chronic cough is the main symptom of the disease; however, hemoptysis is rarely reported as a symptom of tracheal hemangioma in children. Here, we report a case of tracheal hemangioma in an eight-year-old girl admitted to our pediatric department for recurrent hemoptysis. Routine biological and radiological investigations were normal. Diagnosis was made using computed tomography and bronchoscopy. Beta-blocker therapy was not efficient. Bronchoscopic treatment by electrical excision enables complete recovery. Tracheal hemangioma should be considered a cause of recurrent hemoptysis when routine biological and radiological investigations are negative., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Sonographic approach for labour monitoring was introduced in order to improve the shortcomings of digital vaginal examination (DVE). This was a prospective study. We aimed to investigate the agreement between transperineal ultrasound (TPUS) measurements and DVE during first and second stages of labour. Patients in the first stage of labour were included. Cervical length (CL), cervical dilation (CD), cervical position (CP), foetal head descent (FHD) and foetal head rotation (FHR) were assessed by both DVE and TPUS. Agreement between two methods was examined. Eighty-five patients were included. One hundred and eighty-three paired TPUS and DVE assessments were performed. Satisfactory agreement between both methods was obtained regarding CL: systematic bias= -0.05 cm (95%CI, -0.13; 0.03), R  = 0.7, p <.0001; CD: systematic bias = 0.07 cm (95%CI, -0.08 to 0.22), R  = 0.93, p <.0001 and FHD: systematic bias = 0.83 cm (95%CI, 0.685-0.977), R  = 0.55, p <.0001. There was a low correlation for the assessment of CP (kappa = 0.24) and FHR (kappa = 0.06). DVE was inefficient in determining FHR especially during latent phase with failure and error rates of 86% and 36%, respectively. A conceptual sonopartogram covering the hole childbirth process is presented based on reliable ultrasound measurements.Impact Statement What is already known on this subject? Digital vaginal examination (DVE) is used worldwide for labour monitoring. However, it is far from perfect. Some investigators have raised concerns about the value of the Bishop score because it is a subjective measure with great intra- and inter-observer variability, affected by a physician's clinical experience. Moreover, this method is intrusive, uncomfortable and may increase the risk of infection. The sonographic approach for labour monitoring was introduced in order to improve the shortcomings of DVE. Multiple studies focussed on the reliability of the sonographic method in assessing each parameter during labour. Hassan et al. were the first to determine whether it is feasible to perform assessment in the first stage of labour based only on US, and to describe a method of recording these observations: the 'sonopartogram'. What do the results of this study add? The outcomes concluded that sonographic approach was at least as accurate as the clinical examination. Moreover, a conceptual sonopartogram covering the hole childbirth process is presented based on reliable ultrasound measurements. What are the implications of these findings for clinical practice and/or further research? Clinical relevance of this sonopartogram should be evaluated in further studies.

Microbial contamination of hematopoietic stem cells (HSC), used for autologous and allogenic transplantations, is rare but could cause serious blood stream infection in transplanted patients. These infections occur immediately, or later following the formation of biofilm on the catheter lumen. The present study describes an intermittent B. cepacia HSC contamination associated with nosocomial bacteremia: from October 2011 to April 2015, 17  B. cepacia strains were isolated in HSC bags ( n = 14) and blood cultures ( n = 3) in patients hospitalized in the National Bone Marrow Transplant Center. Two epidemiologic investigations in the National Blood Transfusion Center, allowing the isolation of three strains in hygiene samples, and four interventions in this institution were done. To identify the source of this contamination, a molecular investigation was done on 23  B. cepacia strains isolated in our center from 2007 to 2015. PFGE analysis revealed five clusters. The major cluster included 18 strains isolated from HSC bags ( n = 14), blood culture ( n = 1), and water cans and bath ( n = 3). The second cluster (B) including only two and the remaining clusters (C, D, and E) contained single strains isolated before the epidemic period. These findings confirmed that the origin of the outbreak was the contaminated water used in the water bath during the thawing step of HSC bags. Based on this result, new sterile water was used for every defrosting, but HSC bags contamination persisted. In May 2015, the water bath was replaced with a dry bath and no B. cepacia strain was isolated from that date to April 2020., Competing Interests: Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

Acalculous cholecystitis etiologies while numerous, some of them are less-known such as brucellosis. In this report, we elaborate the clinical findings, investigations and management of two female patients presenting acalculous cholecystitis in whom diagnosis of acute brucellosis was retained. Both patients had fever, asthenia and abdominal tenderness. Laboratory results showed evidence of inflammation as well as hepatic cytolysis while cholestasis was noted in one patient. In both cases, ultrasound study and CT confirmed the presence of acalculous cholecystitis. Serology (tube agglutination test) led to the diagnosis of brucellosis. Diagnosis of brucellosis-related acute cholecystitis was established in both cases based on imaging findings as well as serology without resorting to cholecystectomy. Favourable clinical response to specific antibiotic therapy further supported our diagnosis as well as our decision to avoid surgery. Although few cases have been reported, brucellosis must be considered as a cause of acalculous cholecystitis, especially in endemic countries., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

While autoimmune haemolytic anaemia (AIHA) is a well-known paraneoplastic syndrome in haematological malignancies, it has been described far less in solid tumours. We hereby report the case of a 61-year-old male patient presenting AIHA related to pancreatic cancer. Investigations excluded infectious, autoimmune and toxic causes of AIHA. CT of the abdomen highlighted the presence of hypodense, infiltrating mass of the tail of the pancreas measuring 70×37×36 mm, compatible with pancreas neoplasm. Histological examination of two associated nodular lesions of the liver showed metastasis of pancreatic adenocarcinoma. The patient was started on corticosteroid without improvement of haemoglobin. Palliative chemotherapy was initiated; this led to significant improvement in haemoglobin comforting our diagnosis. This case illustrates the rare association between AIHA and pancreatic cancer. However, such association cannot be considered before excluding other, more frequent, aetiologies., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Although not frequent, thromboembolic events occurring in patient presenting tuberculosis may be observed. Frequency of such thromboembolic events seems correlated with the severity of tuberculosis. We herein report a case of venous thrombosis revealing an asymptomatic tuberculosis. A man aged 32 years was admitted for deep and superficial vein thrombosis of the left arm. Chest CT angiography ruled out pulmonary embolism and showed a mediastinal and pulmonary heterogeneous necrotic mass at the apical segment of the left lung. Histological study of a CT scan-guided pulmonary biopsy showed signs of caseating granuloma compatible with tuberculosis. Diagnosis of venous thrombosis due to pulmonary tuberculosis with lymph nodes involvement was made. Antituberculosis treatment was initiated and required an adjustment of anticoagulant therapy. Our observation highlights the possibility of causative effect between tuberculosis and venous thrombosis., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Spontaneous right hepatic artery branch gallbladder fistula is a rare condition. Our case reported a spontaneous fistula between the right branch of the hepatic artery and the gall bladder. It constitutes a rare cause of haemobilia. In fact, the most common aetiology of haemobilia is traumatic or iatrogenic secondary to hepatobiliary surgery or interventions. Diagnosis of vascular-biliary fistula is not easy. The gallbladder endoluminal clot can mimic a mass, as in our patient. Selective arterial angiography is helpful in identifying the source of gastrointestinal haemorrhage. It can demonstrate the presence of arteriobiliary fistula. The differential diagnosis is arterial pseudoaneurysm in the vicinity of the vessel. Mini-invasive treatment of this fistula constitutes the best treatment. We here report a case of haemobilia with upper cataclysmic gastrointestinal bleeding revealing a spontaneous fistula between the right branch of the hepatic artery and the gall bladder., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Purpose: To report the annual hazard of relapse in stages II and III colorectal cancer (CRC) Tunisian patients treated with curative intent. We also aim to evaluate impact of oxaliplatine according to anatomo-clinical features., Methods: We collected data about clinico-pathological parameters of 331 CRCs. We analyzed annual hazard of recurrence (locoregional and/or distant) of the overall population and several subgroups: colon cancer vs rectal cancer and stage II vs stage III. We also analyzed impact of adjuvant oxaliplatine on recurrence within these subgroups., Results: Relapse rate was 38.1%, with a mean time to relapse of 27.6 months. We noted 23.8% local recurrence, 69.8% distant recurrence, and 6.4% both. We observed higher local relapse rate in rectal cancer (26.8 vs 3.2%) vs colon cancer (p = 0.004). Stage III had a higher metastatic relapse rate vs stage II (31.6 vs 20.8%, p = 0.043). Annual hazard of recurrence for the overall population showed two peaks: [1-2] year-interval by 10.1% and [3-4] year-interval by 11.3%. Stage III showed significantly higher and earlier recurrence hazard peak compared to stage II (16.3 vs 8.1% in [1-2] year-interval). Oxaliplatine significantly improved annual hazard of recurrence in each year-interval from year 1-4, in colon cancer and in stage III but without impact in rectal cancer and stage II., Conclusion: Extended follow-up to 4 years should be considered in Tunisian population. Impact of oxaliplatine showed same features to reported occidental series.

Purpose: The introduction and success of imatinib mesylate have become a paradigm shift in chronic myeloid leukemia (CML) treatment. However, despite its high efficiency, resistance to imatinib has emerged as a significant problem, which may in part be caused by pharmacogenetic variability. Three single-nucleotide polymorphisms (C1236T, G2677T/A, C3435T) and/or mRNA expression changes of ABCB1 gene were demonstrated to be associated with inter-individual variability of imatinib response in CML patients. In this study, we aimed to examine whether genetic variations and/or altered expression of ABCB1 gene may influence response to imatinib., Methods: Sixty nine CML Tunisian patients, undergoing imatinib therapy, were enrolled in this study. These were divided into two groups: responders and non-responders to imatinib. The relative transcript expression levels of ABCB1 gene and the distribution of allele and genotype frequency of ABCB1 SNPs were compared between these two categories of patients. Linkage disequilibrium tests and haplotypes analysis were also studied., Results: Our results showed that the mRNA expression level of ABCB1 gene did not differ significantly between the two categories of patients. In addition, results obtained from ABCB1 polymorphisms study and their correlation with imatinib response showed that the optimal response rate to imatinib did not differ significantly between C1236T, G2677T/A or C3435T genotypes. However, haplotype analysis showed that the 1236C-2677A-3435C haplotype was observed only in imatinib non-responders' patients suggesting that CAC haplotype was linked to higher risk of imatinib resistance., Conclusion: Furthermore, analyses of ABCB1 haplotypes should be taken into account to study the relationship between ABCB1 genotypes and imatinib efficacy.

Competing Interests: Competing interests: None declared.

The gold standard for cervical length (CL) assessment is transvaginal ultrasound scan (TVUS). Transperineal ultrasound scan (TPUS) is an alternative route to CL measurement, which may be more acceptable to women. The primary outcome of this study was to investigate the reliability of TPUS performed by obstetrical team on duty in case of preterm labour (PL) and to compare transperineal to transvaginal CL measurements as a reference. Secondary, we aimed to assess the predictive value of transperineal CL measurement for preterm delivery (PD). Correlation, agreement and patient's preference were assessed. Cut-off points predictive of PD were calculated using receiver-operating characteristic (ROC) curves. Sixty patients admitted with PL were included. Median CL measurements with TPUS and TVUS were 25.3 mm and 27.3 mm, respectively. Correlation was significant (R = 0.95; p  < 0.0001; [95% CI = (-0.032-0.170)]. The cut-off point was 25 mm for TPUS and 22.8 mm for TVUS. In case of PL, CL measurement with TPUS seems reliable and can be performed by the obstetric duty team.

Background: Given that handball is a mixed sports activity requiring 3 energy systems, namely aerobic, anaerobic alactic and lactic, it supposes then a cavity dilatation for the efforts involving endurance and a parietal hypertrophy for the efforts involving anaerobic work., Aim: To obtain, using the echocardiographic method, myocardic measurements from 3 groups of Tunisian handball players of different ages, in order to define the myocardic predispositions of the young players and to define the morphodynamic adaptation of the heart of the adult players so that the impact of the specialty on the operation and the morphology of the heart can be better explained., Methods: Two-dimensional and time motion (T.M.) echocardiography (using a TOSHIBA SSH 104 A) was conducted to examine the following parameters: diastolic and systolic diameters of the left ventricle, the root of the aorta, the left atrium and the right ventricle, as well as the mean velocity of the shortening of circumferential fibers, the ejection time of left ventricle, and the dimensions of the inter-ventricular septum and the posterior wall as well as the E/A ratio. The echocardiograms were performed by medical technicians and reviewed by physicians. Thirty six handball players were involved in this study. Height and weight of all players were measured before the medical test., Results: The Obtained results enable us to advance that the loads of drive and competition in handball requested the increase in the parameters of dilatation in the young players of 11-12 years to 15-16 years, whereas parameterize them of hypertrophy improved thereafter. What justifies the idea, which says that in the young players work must be based primarily on the improvement of aerobic quality requesting the dilatation of the myocardium, thereafter one can consider anaerobic work., Conclusion: The practice of handball at an early age may induce both cavity dilatation and parietal hypertrophy. The long-term consequences and significance of this marked remodeling of the athlete's heart is not known.

Background: Bone metastasis is very frequent in prostate cancer. It is a turning point that marks the severity of the disease. Before metastasis become symptomatic, treatment preventing bone events should be indicated., Aim: To evaluate the role of bisphosphonate in the treatment of bone metastases from prostate cancer., Methods: A review of literature., Results: Bisphosphonates play a very important role to prevent bone mass loss and to reduce bone complication events., Conclusion: Bisphosphonates are recommended as preventive treatment at the time of diagnosis of bone metastatic prostate cancer.

Background: Intestinal parasitosis are cosmopolitan affections, often related to the fecal peril. However urinary bilharziosis is a disease eliminated in Tunisia. As part of monitoring the emergence and re-emergence of intestinal parasitosis and urinary bilharziasis, foreign students benefit from parasitological systematic monitoring stool and urine during their enrollment to the University., Aim: To study the prevalence of various intestinal parasitosis and urinary bilharziasis among non permanent resident students in Tunisia., Methods: A retrospective survey was carried at the Laboratory of Parasitology- Mycology of Charles Nicolle Hospital of Tunis during the inscription period of 6 university years 2005-2010. 328 students profited from a parasitological examination of stool and urine., Results: 144 students (43.9%) harbored intestinal parasites. More than one parasite was detected in 69 students (47.9%). Intestinal protozoa were the majority of identified parasites (96.9%). 9.7% of identified parasites were pathogenic. Three cases (0.91%) of urinary bilharziasis were diagnosed., Conclusion: The prevalence of intestinal and urinary parasitism among the "non-permanent residents" students in Tunisia has not changed. This justifies a systematic parasitologic monitoring for students coming from areas of high endemicity of parasitosis in order to avoid the introduction of these.

Background: Determination FSH and LH at day 3 of the menstrual cycle predicts the response to stimulation., Aim: To evaluate the value of FSH and LH measurements compared with women's age in predicting qualitative and quantitative ovarian response to gonadotrophin stimulation., Methods: 305 patients underwent at least one intra cytoplasmic sperm injection (ICSI) cycle. The levels of FSH and LH at day 3 were determined in an earlier cycle. A good quantitative ovarian response was defined as ³3 oocytes retrieved and 3 embryos obtained. A good qualitative ovarian response was defined as a percentage of mature oocytes ³75% and immature ones²15% of the total number of oocytes retrieved with at least one top quality embryo obtained., Results: Receiver operating characteristic (ROC) curves were generated for FSH, LH and female age. FSH is better than female age in predicting the number of oocytes retrieved (respectively ROCAUC=0.77, p=10-3 versus ROCAUC=0.73, p=10-3) and the number of embryos obtained (ROCAUC=0.69, p=10-3 versus ROCAUC=0.66, p=10-3). LH is non predictive. None of the three tested parameters was predictive of the fertilization and pregnancy rates. An FSH cutoff was calculated and a value of 7.8mUI/ml is associated with a sensitivity of 73% and a specificity of 70% for the prediction of ovarian response to controlled stimulation., Conclusion: Basal FSH level predicts good quantitative rather than qualitative response. LH is non predictive. FSH and LH do not predict pregnancy rate. Patients having high FSH levels should not be excluded from IVF/ICSI treatment.

Background: Chronic kidney failure is associated with dyslipidemia and accelerated atherosclerosis., Aim: To study lipidic metabolism alterations in patients with chronic kidney failure on hemodialysis., Methods: The study interested 45 hemodialysis patients with a mean age of 49.04 ±15.92 years old and 45 healthy controls. A blood sample was collected from each patient and control to measure total cholesterol, triglycerides, HDL- cholesterol, LDL-cholesterol, apolipoproteins AI and B100, lipoprotein (a) and C Reactive Protein., Results: A significant increase of serum triglycerides (p= 0.002), lipoprotein (a) (p = 0.001) and C Reactive Protein (p = 0.008) was observed in patients when compared with healthy controls. A significant decrease of serum total cholesterol (p=0.01), HDLcholesterol (p<0.001), LDL-cholesterol (p=0.005) and apolipoprotein AI (p<0.001) was also observed in patients., Conclusion: Disorders of lipidic metabolism are frequent in hemodialysis patients. These alterations can lead to cardiovascular disease in uremic patients.

Background: Health human resources management is one of the important determinants of health care access equity., Aims: To analyse the trend of Tunisian medical density during 2000-2009 and to predict its situation by 2024., Methods: Current medical density was calculated using Bar Council of Physicians of Tunisia database. Medical density was calculated and analysed for the period 2000-2009 then modelled by 2024 (estimate of needs and supply)., Results: The active medical density raised by 36% during the period 2000-2009 with a higher increase for specialists. The proportion of non-active physicians rose from 4.6% to 15.2% in 2009. Increasing feminization of medical density and persistence of its regional disparities. By the year 2024, 217 physicians for 100,000 inhabitants would be required while the supply would correspond to 212/100 000 inhabitants., Conclusion: medical human resources have indeed globally improved. However, some lacks remain and adequate measures are required, based on a rational planning directed to satisfy the population needs and to allow health equity.

Background: Mental retardation is one of the most frequent major handicap, with a 1-3 % frequency in the general population, it appear a major problem of public health. The recent progress of molecular biology and cytogenetic allowed to identify new genes for non syndromic autosomal recessive mental retardation (NSAR-MR)., Aim: Genetic analysis of NSAR-MR: the GRIK2 gene (6q16.3-q21) and the TUSC3 gene (8p22)., Methods: Four Tunisian families with NSAR-MR were included in this study. Genotyping was made using polymorphic microsatellite markers and statistical analysis was validated using the Fast Link programme of the Easy linkage software (V4:00beta)., Results: Genotyping and linkage analysis excluded linkage of the GRIK2 gene and TUSC3 gene., Conclusion: Our results confirm the extreme genetic heterogeneity of NSAR-MR.

Objectives: Active cytomegalovirus infection remains a major problem for bone marrow transplant recipients. If not quickly diagnosed and treated, it can evolve into cytomegalovirus disease, which represents a life-threatening complication. In this work, we sought to evaluate the interactions between clinical complications after bone marrow transplant and factors associated with active cytomegalovirus infection., Materials and Methods: We evaluated 91 allogeneic bone marrow transplant recipients (35 female, 56 male; median age, 20 years; age range, 3-47 years) for malignant and nonmalignant hematologic diseases. Active cytomegalovirus infection was monitored using pp65 cytomegalovirus antigenemia and a semiquantitative cytomegalovirus polymerase chain reaction. Cytomegalovirus end-organ disease was defined as an association between compatible signs and symptoms (dyspnea, hypoxia, and diarrhea) and detection of cytomegalovirus (>or= 2,000 cytomegalovirus genome copies/mL) by hybrid capture assay in tissue biopsy. Variables were compared using the chi-square and Fisher exact tests. Time of death after bone marrow transplant was plotted using the Kaplan-Meier method. A Cox regression model was used for multivariate survival analysis with 95% confidence limits., Results: Sixty-four patients experienced active cytomegalovirus infection, 26 had acute graft-versus-host disease, and 11 had cytomegalovirus diseases. The overall survival rate at 4 years was 83.52%. On multivariate analyses, cytomegalovirus disease (hazard ratio = 15.9, P = .001) and age older than 18 years (hazard ratio = 8, P = .18) were the only independent negative prognostic factors for overall survival. Occurrence of acute graft-versus-host disease was increased by early active cytomegalovirus infection (P = .03) and represents a significant factor for active cytomegalovirus infection recurrence (P = .01). Viral load as quantified by antigenemia and cytomegalovirus DNA in the patients' peripheral blood leukocytes was significantly associated with clinical complications., Conclusions: Active cytomegalovirus infection interacts significantly in several ways with graft-versus-host disease and others infections. Acute graft-versus-host disease increases the chances of a poor outcome, especially of acquiring cytomegalovirus disease. Cytomegalovirus disease constitutes a significant independent risk factor for death after bone marrow transplant.

Recombinant DNA probes from a genomic Leishmania major library were screened for their potential to distinguish among Old World Leishmania taxa by Southern blot analysis. A probe, pDK10, was selected and tested on a panel of 58 Old World Leishmania strains that had already been typed isoenzymatically; these strains belong to the different species described so far and had been isolated from various hosts and vectors in 14 countries. In the present study, 45 zymodemes were represented. Using the pDK10 probe, we were able to differentiate between the different phenetic complexes. No variations in hybridization patterns were found within these complexes. In addition, there was a good concordance between identification based on DNA hybridization with the pDK10 probe and that based on isoenzyme typing. The probe has been applied in identifying Leishmania strains that were isolated in Tunisia from humans, animals, or insects. Our results show that the application of the pDK10 probe, in combination with a Pst I digestion of Leishmania DNA, could be a possible alternative to isoenzyme analysis for the identification of Leishmania strains.

Forty-two Tunisian patients suffering from Behçet's disease (23 with uveitis) were typed for HLA-DR and DQ antigens. There was a significant excess of HLA-DQw3 (p less than 0.01) but also an important deficiency of HLA-DRw6 and DQw1 (p less than 0.01). A substantial increase of HLA-DR2 (p less than 0.01) for those with uveitis, and of HLA-DR4, DR7, for the others has been recorded (p less than 0.01).