Background:The aim of this study was to investigate the effect of Ramadan fasting (RF) on markers of endothelial function and metabolic parameters in patients with type 2 diabetes mellitus (T2DM) and healthy controls. Methods:This cohort study involved 305 subjects: 167 T2DM and 138 healthy volunteers subjects. The following parameters were evaluated: body mass index (BMI), diet inflammatory index (DII), serum glucose and lipid profile and high-sensitivity C-reactive protein (hs-CRP) during three separate visits, before Ramadan (baseline), the last week of Ramadan, and during the last week of the month following Ramadan. In each visit, reactive hyperaemia index (RHI) in all participants was assessed. In diabetic patients, serum homocyteine (Hcys) was mesured at baseline and during RF. The primary endpoint was change in RHI, a validated and non-invasive measure of endothelial function. The secondary end point was change in clinical, metabolic parameters, and Hcys. Analyses used non-parametric tests and multivariable regression with multiple imputation. Results:RF significantly decreased RHI [-0.2 UI (95% CI -0.3 to -0.09); p < 0.001] and increased serum homocysteine [1.2 µmol/L (95% CI 0.7-1.8); p < 0.001] in T2DM compared to baseline levels.RF did not significantly change RHI in healthy volunteers. A significant increase in blood glucose (p < 0.001) and LDL cholesterol (p = 0.003) was observed during Ramadan compared to baseline, whereas HDL cholesterol, DII, and BMI decreased. Among healthy volunteers, similar changes in metabolic parameters were observed, with hs-CRP increasing during Ramadan compared to baseline (p = 0.01). Conclusion:RF seems to be associated with unfavorable effects on endothelial function in diabetic patients but not in healthy subjects. RHI testing could help identifying diabetic patients who should not observe RF or should be closely monitored during fasting.

OBJECTIVES:The aim of this trial was to assess the effects of olive leaf extract (OLE) on blood pressure (BP) control in patients treated for hypertension. METHODS:This is multicenter randomized, double-blind, placebo-controlled trial including 621 participants who were randomly assigned to receive either oral OLE ( n  = 307) or placebo ( n  = 314). The primary outcome was the change in 24-h SBP and DBP from baseline to week-12. Secondary outcomes included the change in BP load (BPL), BP variability (BPV), metabolic parameters, C-reactive protein (CRP), and body weight. RESULTS:OLE significantly reduced 24-h SBP compared to baseline and placebo group [respectively -6.4 mmHg (95% confidence interval, 95% CI -10 to -2.1) and -1.5 mmHg (95% CI -3.9 to 0.51); P  < 0.01]. In OLE group, systolic BPL decreased from 53.9% at baseline to 42.2% at 12-week ( P  = 0.03); in placebo group, it did not change significantly ( P  = 0.55). Diastolic BPL decreased from 30.7 to 21.2% ( P  = 0.03) in OLE group and did not change significantly in placebo group ( P  = 0.12). In OLE group, systolic BPV did not change significantly between baseline and week-12 [+2%; P  = 0.23] while diastolic BPV significantly decreased [-13.3%; P  = 0.04]. In placebo group, BPV did not change significantly at week-12 compared to baseline. OLE was associated with improvement in lipid profile and a significant reduction in blood glucose, triglycerides, CRP, and body weight. No significant adverse events were reported. CONCLUSION:OLE can decrease 24-h BP, BPL, and diastolic BPV with improvement of lipid profile, systemic inflammation, and body weight in hypertensive patients.

IMPORTANCE:Post traumatic pain remains poorly managed in emergency departments. OBJECTIVE:This study aims to evaluate the effectiveness and tolerability of a phytotherapeutic topical gel (Douloff) compared to oral paracetamol for acute pain resulting from minor limb soft tissue injuries. DESIGN AND SETTING:A prospective, multicenter, randomized, double-blind study conducted over 13 months in three EDs. PARTICIPANTS AND INTERVENTION:Patients aged 18 years and older, with minor limb soft tissue injuries, were randomized into Douloff (n = 765) and paracetamol (n = 750) groups. MAIN OUTCOME AND MEASURES:The primary outcome was the pain resolution rate [reduction of at least 50% of pain intensity, measured by the numeric rating scale (NRS) on active motion at day-7compared to NRS at discharge]. Secondary outcomes included time to pain resolution, rescue analgesia, patient satisfaction, and adverse events. RESULTS:The groups were comparable in terms of baseline characteristics. On day-7, resolution of pain was observed in 641 patients (83.7%) in Douloff group versus 535 patients (71.3%) in paracetamol group (OR 1.27; 95% CI 1.015-1.6; P = 0.02). Median time to reach pain resolution was 4.5 ± 2.9 days in Douloff group compared with 5.6 ± 3.3 days in paracetamol group (P < 0.001). Patients in Douloff group required less rescue analgesics (48.2%) compared to paracetamol group (59.1%) (-10.9%, 95% CI -15.89 to -5.9; P < 0.001). No major adverse events were observed in either group, and 89.4% of patients in Douloff group were satisfied, compared to 92.5% in the paracetamol group (P < 0.001). CONCLUSIONS:Douloff, a topical herbal paste, is superior to oral paracetamol in the management of acute pain related to soft tissue injuries. RELEVANCE:Douloff can be considered as an alternative to conventional analgesics. CLINICAL TRIAL REGISTRATION:The enrollment began from December 2022. The study has been registered in clinicaltrials.gov under the study number NCT05647681.

STUDY OBJECTIVE:To compare the efficacy and safety of subcutaneous versus intranasal ketamine in controlling pain following acute musculoskeletal trauma. METHODS:We conducted a randomized, double-blinded, double-dummy prospective study, including adult participants aged 18 to 65 years, presenting to the emergency department (ED) for acute musculoskeletal trauma with moderate to severe pain. Participants were randomly assigned to receive either 20 mg subcutaneous or intranasal ketamine. Our primary outcome was the reduction in the numerical rating scale (NRS) at 30 minutes, with additional measures at 5, 10, 15, 60, 90, and 120 minutes. Other secondary outcomes were the percentage of patients with a NRS score of less than 3 at the end of the protocol, adverse events, and the need for additional pain medications. RESULTS:We enrolled 599 patients in the subcutaneous group and 595 in the intranasal group. At 30 minutes, the mean NRS decrease from baseline was -3.70 (1.88) in the subcutaneous group and -4.42 (2.15) in the intranasal group, yielding a mean difference of -0.72 (95% confidence interval -0.95 to -0.48). Although statistically significant, this difference, as well as those observed at all other time points, remained below the 1.3 NRS threshold for clinical importance. There was no difference in secondary outcomes except more minor adverse events in the subcutaneous group. CONCLUSION:For patients presenting to the ED with acute musculoskeletal trauma, we found no clinically important differences in pain reduction between ketamine 20 mg, subcutaneous and ketamine 20 mg, intranasal.

Objective. IgG4-related disease is a fibro-inflammatory multisystemic condition with lesions mimicking tumors. Involvement of the hypophysis is rare and the first case of IgG4-related hypophysitis was described in 2004. Typically, it is revealed by sellar mass effects, hypopituitarism, and diabetes insipidus. In the present paper, we report a case of IgG4-related hypophysitis revealed by submandibular sialadenitis. Case Report. The subject was a 52-year-old patient presented with swelling of the submandibular gland. His complaints were decreased libido, anorexia, and weight loss for three months. Hormonal assessment found mild hyperprolactinemia, hypogonadotropic hypogonadism, and central hypothyroidism. Pituitary magnetic resonance imaging showed heterogeneous enlargement of the pituitary gland with diffuse gadolinium enhancement. The submandibular gland biopsy revealed submandibular sialadenitis with positive immunohistochemistry to IgG4. Diagnosis of IgG4-related hypophysitis was made based on Leporati criteria 2 and 3. Glucocorticoid therapy was prescribed for this patient, but without improvement of the pituitary function. In fact, the effectiveness of steroid therapy on the pituitary swelling is proven and already represents the fifth diagnostic criterion of Leporati. However, the improvement of the pituitary functions is uncertain. Conclusion. The present case illustrates an atypical presentation of IgG4-related hypophysitis without tumor syndrome or diabetes insipidus. Continuous monitoring of the pituitary function is needed during the long-term follow up given that improvement of the hormonal deficiencies is uncertain.

Introduction and importance: Primary (isolated) splenic hydatid cyst is rare and accounts for less than 2 % of hydatid patients, even in endemic regions. Diagnosis of splenic hydatid cyst can be challenging due to the rarity of the condition and its nonspecific symptoms. Surgery is the mainstay of treatment. This case report discusses management options for such a rare condition. Case presentation: We present a 33-year-old female patient with abdominal pain for six months and splenomegaly. Ultrasonography and CT scan showed a giant splenic cyst with clear walls and multi-vesicular contents suggestive of a hydatid cyst. There was no involvement of the liver or other organs. Indirect hemagglutination was positive for Echinococcus. Through a left subcostal incision total splenectomy was performed. The patient was discharged from hospital on the sixth postoperative day. No local recurrence was detected during postoperative follow up. Case discussion: Primary splenic hydatid disease is rare. It may be detected incidentally or present with nonspecific complaints. If untreated, a splenic hydatid cyst can lead to various potentially severe complications, including cyst rupture and secondary infection. Standard treatment is open total or partial splenectomy: preservation surgery should always be considered, to avoid post splenectomy infection, especially in young patients. Conclusion: Primary splenic hydatid cyst is rare even in endemic areas. Symptoms may be non-specific. Standard treatment is open total or partial splenectomy.

The Horoscope trial aimed to assess the efficacy of home blood pressure (BP) telemonitoring (TLM) in controlling BP reduction in hypertensive patients compared with usual care. This is a multi-center, prospective randomized, parallel-group trial comparing TLM with usual care during a period of 6 months in patients with hypertension. We included 525 patients randomly assigned in a 1-1 ratio to telemonitoring (TLM group; n = 260) or usual care (control group; n = 265). After 6 months of follow up, mean values of 24-h systolic and diastolic blood pressure decreased in both TLM and control groups. The mean decrease was significantly greater in the TLM group vs control group (-3.29 mmHg Vs -1.19; p = 0.009) and (-2.9 mmHg Vs, -0.07; p = 0.002) for systolic and diastolic blood pressure, respectively. This study shows that TLM results in significant BP reduction compared to usual care in a Tunisian population of patients with hypertension. Our findings highlight the importance of integrating telemedicine in the management of hypertensive patients; it has the potential to improve the quality of the delivered care and to prevent cardiovascular consequences of uncontrolled BP.

Background Even though anti-neutrophil cytoplasmic antibodies (ANCA) are frequently linked to ANCA associated vasculitis (AAV), it's important to understand that other illnesses, including lung diseases, can also manifest as ANCA positivity. Finding the incriminated pathology might be difficult. Aim To report four ANCA-associated cases with a diagnosis problem. Methods Four patients were recruited from the allergo-pneumology department of the Fattouma Bourguiba University Hospital of Monastir, Tunisia, over two years (2020-2022). Indirect immunofluorescence technique on neutrophil cells (Euroimmun, Germany) was used for ANCA screening with a positivity limit of 1/20. ANCA typing was carried out by a line-blot technique (Euroimmun, Germany). Results This case series reports four cases (age range: 41-67 years, sex ratio: 0.3) that presented with pulmonary manifestations associated with ANCA positivity. Two patients had perinuclear ANCA with anti-myeloperoxidase on typing, and two cases had cytoplasmic ANCA with one case of anti-leukocyte proteinase 3 on typing. Final diagnoses were pulmonary tuberculosis (case 1), systemic lupus erythematosus (case 2), bronchiolitis obliterans organizing pneumonia (case 3), and pulmonary aspergillosis with AAV (case 4). Conclusion A panel of diagnoses may be evoked in front of positive ANCA, making the diagnosis difficult to determine and requiring multidisciplinary interactions, with imaging and histological investigations having a crucial role in guiding the final decision.

Otosclerosis is a primary osteodystrophy of the otic capsule that causes stapedo-vestibular ankylosis. Its diagnosis is suspected on the basis of clinical and audiometric elements, basically in the presence of conductive hearing loss with a normal eardrum. The CT-scan is an essential examination for the preoperative evaluation of otosclerosis. The aim of our study was to evaluate the use of CT-scanning in predicting the functional outcome of otosclerosis surgery by correlating postoperative audiometric results and preoperative CT findings. We conducted a retrospective study at the ENT Department in association with the Medical Imaging Department of our hospital, over a period of 8 years, from January 2014 to December 2022 and involving 90 patients (104 ears). The average age of our patients was 40 years with extremes ranging from 22 to 61 years. We noted a sex ratio of 0.38. The preoperative CT-scan showed signs of otosclerosis in 87

Ureteropelvic junction obstruction (UPJO) is a pathological condition characterized by obstruction of the junction between the renal pelvis and ureter, often resulting in dilatation of the renal collecting system. Aberrant accessory vessels or early branching of the inferior pole vessels are the most common causes of extrinsic UPJO. The inferior mesenteric artery has not been reported as a common cause of UPJO. Here, we report the case of a 7-year-old patient with UPJO and an anomalous inferior mesenteric artery. The patient was initially diagnosed with congenital uropathy during the evaluation for primary enuresis.

OBJECTIVE:Renal colic (RC) is a common urologic emergency often leading to significant pain and recurrent hospital visits. This study aimed to compare the efficacy and safety of piroxicam versus paracetamol in preventing pain recurrence and hospital readmission in patients treated for RC and discharged from the emergency department (ED). METHODS:A prospective, randomized, single-blind trial was conducted in four EDs. Eligible adults with RC were randomized to receive oral piroxicam, paracetamol, or placebo for 5 days post-ED discharge. Primary outcomes included pain recurrence and ED readmission within 7 days. Secondary outcomes included time to recurrence and treatment-related side effects. RESULTS:Of 1383 enrolled patients, no significant differences were observed among the groups regarding baseline characteristics. Pain recurrence rates within 7 days were 29% (95% confidence interval [CI] 24.9%-33.2%) for piroxicam, 30.3% (95% CI 26.1%-34.5%) for paracetamol, and 30.8% (95% CI 26.6%-35.0%) for placebo, with no significant between-group differences (p = 0.84). Among patients experiencing recurrence, the majority encounter it within the initial 2 days following their discharge (86% in the piroxicam group, 84.1% in the paracetamol group, and 86% in the placebo group, respectively). ED readmission rates were similar across groups: 20.8% (95% CI 17.1%-24.5%) in the piroxicam group, 23.8% (95% CI 19.9%-27.7%) in the paracetamol group, and 22.9% (95% CI 19.1%-26.8%) in the placebo group (p = 0.52). The piroxicam group reported significantly higher adverse effects compared to others. CONCLUSIONS:Piroxicam and paracetamol did not demonstrate efficacy in preventing pain recurrence or ED readmission within the first week following RC treatment.

Introduction: As little is known about the prognostic value of CT scan findings at onset in patients presenting with sarcoidosis, we aimed to identify factors independently associated with radiological remission of pulmonary involvement in systemic sarcoidosis on CT scan findings. Methods: We conducted a retrospective descriptive and analytic study of patients with biopsy-proven systemic sarcoidosis. We compared patients on radiological remission (group 1) to those on stabilization or progression (group 2). Multivariate analysis of variables significantly associated with radiological remission in univariate analysis was performed using binary logistic regression. Results: Out of 65 records of systemic sarcoidosis, 43 were analyzed. 18.6% were male and 81.6% were female, with a sex ratio of 0.22 and a mean age at diagnosis of 47.2 +/- 13.6 years. We found atypical lesions in CT scan findings in 16 patients (37.2%). Comparative pulmonary CT scan findings at admission and at 12-month follow-up revealed 13 patients (30.2%) in remission (group 1) and 30 patients in radiological stabilization or progression (group 2). On multivariate analysis, lymphopenia, calcifications, and typical CT scan findings at presentation were predictive factors of remission of pulmonary involvement in systemic sarcoidosis (aOR = 27.57; 95% CI = 2.67-284.63; p = 0.005), (37.2; 95% CI = 2.08-663.89; p = 0.014), and (47.1; 95% CI = 1.79-1238.5; p = 0.021), respectively. Conclusion: In patients with symptomatic systemic sarcoidosis with no lymphopenia at onset, calcifications, or typical CT scan findings at presentation, we suggest a close follow-up as well as an intensive treatment.

Introduction-Aim: The third cycle of medical studies (TCMS) lasts 3 years for the specialty of family medicine (FM) in Tunisia. The members of the FM committee of the Faculty of Medicine of Monastir (FMM) aimed to detail the learning objectives (LO) of residents in FM. METHOD:We used the Delphi method in 2 rounds including a group of experts called FM Learning Objectives Writing Group (FMLOWG) at the FMM. The FMLOWG included 74 university hospital physicians and FM internship supervisors. These members actively participated in the 10 meetings held during the month of March 2022. Three points were discussed: the identification of LOs; the development of training titles and the proposal of the teaching methods to be adopted. The writing was subdivided into 5 domains of LO: transversal, public health, typical population and by system. RESULTS:We identified 1359 LOs for FM residency, for which 552 were LOs per system (40.5%). The learning included 618 training session titles. Residents will have an academic training day every 3 weeks during 9 months for each TCMS year. CONCLUSION:A detailed, MF-specific consensus has been developed by majority of medical specialties. It will be a learning base for learners, a reference for supervisors and TCMS teachers.

Liver hydatid cyst fistulized in the abdominal wall is rare. The clinical symptoms were often misleading. It often poses a problem of seat diagnosis rather than a problem of its hydatid nature despite the great contribution of modern imagery. We reported this uncommon case to highlight the difficulties of preoperative diagnosis and a better operative approach. 46-year-old men consulted for right flank pain. The clinical exam revealed a right flank subcutaneous mass. An abdominal CT scan showed multicystic lesions on the right flank. The MRI showed multiple cystic lesions on the right flank with several endophytic and exophytic daughter cysts. The patient was operated on. A wide excision was adopted to remove all the cystic lesions. The postoperative follow-up was uneventful. Abdominal subcutaneous hydatid cysts cause a diagnostic problem and the treatment is controversial. Surgery remains the only curative treatment. It avoids the risk of complications such the fistula, infection, and rupture.

Hughes-Stovin Syndrome is a systematic disorder generally revealed by deep venous thrombosis (DVT) and pulmonary artery (PA) aneurysms. Its pathogenesis is still unclear and there are no previously established diagnostic criteria or treatment guidelines. It is usually associated with Behçet disease. The aim of this study was to further enlighten this entity as it is often misdiagnosed. We report a case series of five patients with this rare pathology with a systematic literature review of all the previously reported cases.

Cor triatriatum is an extremely rare cardiac congenital malformation characterized by subdivision of the left atrium into two chambers. This division is due to the presence of an abnormal fibromuscular membrane interrupted by one or more openings that communicate the two chambers. The size and number of those orifices is variable, affecting the age of onset of symptoms and their severity. Our case describes the fortuitous discovery of this pathology in a young adult in her forties, following the finding of atrial fibrillation during a preoperative assessment of a strangulated hernia. The cardiac ultrasound allowed in our case to invoke the diagnosis, confirmed thereafter with an angioscanner. Surgical resection was not required in our patient who was put on medical treatment involving a beta-blocker to reduce atrial fibrillation and an anticoagulant treatment to decrease the thromboembolic risk, with a good clinical evolution. It seems therefore interesting to consider this uncommon pathology which may be latent for a long time, manifesting after some physiological or pathological situations.

The COVID-19 management in kidney transplant recipients is very challenging because of their immunosuppression, comorbidity, and susceptibility to a diversity of viral pathogens such as the cytomegalovirus. Herein, we report the successful management of co-infection cytomegalovirus and COVID-19 in two kidney transplant recipients and discuss the challenge of establishing the diagnosis as well as the management of this co-infection. Further scientific research is necessary to find this relationship and its clinical significance. Ganciclovir therapy was given to our two patients with subsequent clinical recovery. The efficacy of this drug for 2019-nCoV infection needs to be appraised by clinical trials.

Calcinosis is defined as a biomineralization occurring in soft tissues leading to ectopic calcification. Isolated and localised calcification in a muscle is rare, and it is called calcinosis circumscripta in opposition to calcinosis universalis wich is seen in juvenile dermatomyositis and polymyositis. According to laboratory findings and clinical history, calcinosis circumscripta can be metastatic, dystrophic or idiopathic. Masseter muscle is rarely involved. Pre-operative diagnosis of masseter idiopathic calcinosis is a challenge because of many differential diagnosis. Here, we report a case of 22 years old women presented with swelling over left middle third of her face. Clinical history, morphologic and laboratory examinations helped considering such a rare diagnosis.

Since asymptomatic infections as “covert transmitter”, and some patients can progress rapidly in the short term, it is essential to pay attention to the diagnosis and surveillance of asymptomatic patients with SARS-COV2 infection. CT scan has great value in screening and detecting patients with COVID-19 pneumonia, especially in the highly suspected or probable asymptomatic cases with negative RT-PCR for SARS-COV2. This study aimed to detect incidentally COVID-19 pneumonia on medical imaging for patients consulting for other reasons.