Search results for: Nkwenti Mbelli Njah

Authors: Nkwenti Mbelli Njah

Abstract:

This research was motivated by a project requested by AXA on the topic of pensions payable under the workers compensation (WC) line of business. There are two types of pensions: the compulsorily recoverable and the not compulsorily recoverable. A pension is compulsorily recoverable for a victim when there is less than 30% of disability and the pension amount per year is less than six times the minimal national salary. The law defines that the mathematical provisions for compulsory recoverable pensions must be calculated by applying the following bases: mortality table TD88/90 and rate of interest 5.25% (maybe with rate of management). To manage pensions which are not compulsorily recoverable is a more complex task because technical bases are not defined by law and much more complex computations are required. In particular, companies have to predict the amount of payments discounted reflecting the mortality effect for all pensioners (this task is monitored monthly in AXA). The purpose of this research was thus to develop a stochastic model for the future mortality of the worker’s compensation pensioners of both the Portuguese market workers and AXA portfolio. Not only is past mortality modeled, also projections about future mortality are made for the general population of Portugal as well as for the two portfolios mentioned earlier. The global model was split in two parts: a stochastic model for population mortality which allows for forecasts, combined with a point estimate from a portfolio mortality model obtained through three different relational models (Cox Proportional, Brass Linear and Workgroup PLT). The one-year death probabilities for ages 0-110 for the period 2013-2113 are obtained for the general population and the portfolios. These probabilities are used to compute different life table functions as well as the not compulsorily recoverable reserves for each of the models required for the pensioners, their spouses and children under 21. The results obtained are compared with the not compulsory recoverable reserves computed using the static mortality table (TD 73/77) that is currently being used by AXA, to see the impact on this reserve if AXA adopted the dynamic tables.

Keywords: compulsorily recoverable, life table functions, relational models, worker’s compensation pensioners

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Authors: Asma Ammar, Nabiha Bouafia , Asma BenCheikh, Mohamed Mahjoub, Olfa Ezzi, Wadiaa Bannour, Radhia Helali, Mansour Njah

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Background: The objective of the present study was to identify factors associated with vaccination against Hepatitis B virus (HBV) among healthcare workers (HWs) in the University Hospital Center (UHC) Farhat Hached Sousse, Tunisia. Methods: We conducted a descriptive cross-sectional study all licensed physicians (n= 206) and a representative sample of paramedical staff (n= 372) exercising at UHC Hached Sousse (Tunisia) during two months (January and February 2014). Data were collected using a self-administered and pre-tested questionnaire, which composed by 21 questions. In order to determinate factors associated with vaccination against hepatitis B among HWs, this questionnaire was based on the Health Belief Model, one of the most classical behavior theories. Logistic regression with the stepwise method of Hosmer and Lemeshow was used to identify the determinants of the use of vaccination against HBV. Results: The response rates were 79.8%. Fifty two percent believe that HBV is frequent in our healthcare units and 60.6% consider it a severe infection. The prevalence of HWs vaccination was 39%, 95% CI [34.49%; 43.5%]. In multivariate analysis, determinants of the use of vaccination against HBV among HWs were young age (p=10-4), male gender (p = 0. 006), high or very high importance accorded to health (p = 0.035), perception membership in a risk group for HBV infection (p = 0.038) and very favorable or favorable opinion about vaccination against HVB (p=10-4). Conclusion: The results of our study should be considered in any strategy for preventing VHB infection in HWs. In the mean time, coverage with standard vaccines should be improved also by supplying complete information on the risks of VHB infection and on the safety and efficacy of vaccination.

Keywords: Hepatitis B virus, healthcare workers, prevalence, vaccination

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Authors: Ammar Asma, Bouafia Nabiha, Ghammam Rim, Ezzi Olfa, Ben Cheikh Asma, Mahjoub Mohamed, Helali Radhia, Sma Nesrine, Chouchène Imed, Boussarsar Hamadi, Njah Mansour

Abstract:

Background: Central venous catheter associated infections (CVC-AI) are among the serious hospital-acquired infections. The aims of this study are to determine the incidence of CVC-AI, and their risk factors among patients followed in a Tunisian medical intensive care unit (ICU). Materials / Methods: A prospective cohort study conducted between September 15th, 2015 and November 15th, 2016 in an 8-bed medical ICU including all patients admitted for more than 48h. CVC-AI were defined according to CDC of ATLANTA criteria. The enrollment was based on clinical and laboratory diagnosis of CVC-AI. For all subjects, age, sex, underlying diseases, SAPS II score, ICU length of stay, exposure to CVC (number of CVC placed, site of insertion and duration catheterization) were recorded. Risk factors were analyzed by conditional stepwise logistic regression. The p-value of < 0.05 was considered significant. Results: Among 192 eligible patients, 144 patients (75%) had a central venous catheter. Twenty-eight patients (19.4%) had developed CVC-AI with density rate incidence 20.02/1000 CVC-days. Among these infections, 60.7% (n=17) were systemic CVC-AI (with negative blood culture), and 35.7% (n=10) were bloodstream CVC-AI. The mean SAPS II of patients with CVC-AI was 32.76 14.48; their mean Charlson index was 1.77 1.55, their mean duration of catheterization was 15.46 10.81 days and the mean duration of one central line was 5.8+/-3.72 days. Gram-negative bacteria was determined in 53.5 % of CVC-AI (n= 15) dominated by multi-drug resistant Acinetobacter baumani (n=7). Staphylococci were isolated in 3 CVC-AI. Fourteen (50%) patients with CVC-AI died. Univariate analysis identified men (p=0.034), the referral from another hospital department (p=0.03), tobacco (p=0.006), duration of sedation (p=0.003) and the duration of catheterization (p=0), as possible risk factors of CVC-AI. Multivariate analysis showed that independent factors of CVC-AI were, male sex; OR= 5.73, IC 95% [2; 16.46], p=0.001, Ramsay score; OR= 1.57, IC 95% [1.036; 2.38], p=0.033, and duration of catheterization; OR=1.093, IC 95% [1.035; 1.15], p=0.001. Conclusion: In a monocenter cohort, CVC-AI had a high density and is associated with poor outcome. Identifying the risk factors is necessary to find solutions for this major health problem.

Keywords: central venous catheter associated infection, intensive care unit, prospective cohort studies, risk factors

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Authors: Ben Cheikh Asma, Bouafia Nabiha, Ammar Asma, Ezzi Olfa, Meddeb Khaoula, Chouchène Imed, Boussarsar Hamadi, Njah Mansour

Abstract:

Background: Hospital Acquired Infection (HAI) constitutes an important worldwide health problem. It was associated with high mortality rate in intensive care units (ICU). This study aimed to determine HAI mortality rate in Tunisian intensive care units and identify its risk factors. Methods: We conducted a prospective observational cohort study over a 12 months period (September 15th 2015 to September 15 th 2016) in the adult medical ICU of University Hospital-Farhat Hached (Sousse-Tunisia). All patients admitted in the ICU for more than 48 hours were included in the study. We used an anonymous standardized survey record form to collect data by a medical hygienist assisted by an intensivist. We adopted definitions of Center for Diseases Control and prevention of Atlanta to detect HAI, Kaplan Meier survival analysis and Cox proportional hazard regression to identify independent risk factor of HAI mortality. Results: Of 171 patients, 67 developed ICU-acquired infection (global incidence rate=39.2%). The mean age of patients was 59 ± 21.2 years and 60.8% were male. The most frequently identified infections were pulmonary acquired infection (ventilator associated pneumonia (VAP) and infected atelectasis with density rates 21.4 VAP/1000 days of mechanical ventilation and 9.4 infected atelectasis /1000 days of mechanical ventilation; respectively) and central venous catheter associated infection (CVC - AI) with density rate 28.4 CVC-AI / 1000 CVC-days). HAI mortality rate was 66.7% (n=44). The median survival was 20 days 3.36, 95% Confidential Interval [13.39 – 26.60]. Specific mortality rates according to infectious site were 65.5%, 36.4% and 4.5% respectively for VAP, CVC associated infection and infected atelectasis. In univariate analysis, a significant associations between mortality and cardiovascular history (p=0.04) tracheotomy (p=0.00), peripheral venous catheterization (p=0.04), VAP (p=0.04) and infected atelectasis (p=0.04) were detected. Independent risk factors for HAI mortality were VAP with Hazard Ratio = 3.14, 95% Confidential Interval [1.63 – 6.05] (p=0.001) and tracheotomy (Hazard Ratio=0.22, 95% Confidential Interval [0.10 – 0.44], p=0.000). Conclusions: In the present study, hospital acquired infection mortality rate was relatively high. We need to intensify the fight against these infections especially ventilator-associated pneumonia that is associated with higher risk of mortality in many studies. Thus, more effective infection control interventions were necessary in our hospital.

Keywords: hospital acquired infection, intensive care unit, mortality, risk factors

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Authors: Nabiha Bouafia, Asma Ben Cheikh, Asma Ammar, Olfa Ezzi, Mohamed Mahjoub, Khaoula Meddeb, Imed Chouchene, Hamadi Boussarsar, Mansour Njah

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Background: Hospital acquired infections (HAI) cause significant morbidity, mortality, length of stay and hospital costs, especially in the intensive care unit (ICU), because of the debilitated immune systems of their patients and exposure to invasive devices. The aims of this study were to determine the rate and the risk factors of HAI in an ICU of a university hospital in Tunisia. Materials/Methods: A prospective study was conducted in the 8-bed adult medical ICU of a University Hospital (Sousse Tunisia) during 14 months from September 15th, 2015 to November 15th, 2016. Patients admitted for more than 48h were included. Their surveillance was stopped after the discharge from ICU or death. HAIs were defined according to standard Centers for Disease Control and Prevention criteria. Risk factors were analyzed by conditional stepwise logistic regression. The p-value of < 0.05 was considered significant. Results: During the study, 192 patients had admitted for more than 48 hours. Their mean age was 59.3± 18.20 years and 57.1% were male. Acute respiratory failure was the main reason of admission (72%). The mean SAPS II score calculated at admission was 32.5 ± 14 (range: 6 - 78). The exposure to the mechanical ventilation (MV) and the central venous catheter were observed in 169 (88 %) and 144 (75 %) patients, respectively. Seventy-three patients (38.02%) developed 94 HAIs. The incidence density of HAIs was 41.53 per 1000 patient day. Mortality rate in patients with HAIs was 65.8 %( n= 48). Regarding the type of infection, Ventilator Associated Pneumoniae (VAP) and central venous catheter Associated Infections (CVC AI) were the most frequent with Incidence density: 14.88/1000 days of MV for VAP and 20.02/1000 CVC days for CVC AI. There were 5 Peripheral Venous Catheter Associated Infections, 2 urinary tract infections, and 21 other HAIs. Gram-negative bacteria were the most common germs identified in HAIs: Multidrug resistant Acinetobacter Baumanii (45%) and Klebsiella pneumoniae (10.96%) were the most frequently isolated. Univariate analysis showed that transfer from another hospital department (p= 0.001), intubation (p < 10-4), tracheostomy (p < 10-4), age (p=0.028), grade of acute respiratory failure (p=0.01), duration of sedation (p < 10-4), number of CVC (p < 10-4), length of mechanical ventilation (p < 10-4) and length of stay (p < 10-4), were associated to high risk of HAIS in ICU. Multivariate analysis reveals that independent risk factors for HAIs are: transfer from another hospital department: OR=13.44, IC 95% [3.9, 44.2], p < 10-4, duration of sedation: OR= 1.18, IC 95% [1.049, 1.325], p=0.006, high number of CVC: OR=2.78, IC 95% [1.73, 4.487], p < 10-4, and length of stay in ICU: OR= 1.14, IC 95% [1.066,1.22], p < 10-4. Conclusion: Prevention of nosocomial infections in ICUs is a priority of health care systems all around the world. Yet, their control requires an understanding of epidemiological data collected in these units.

Keywords: healthcare associated infections, incidence, intensive care unit, risk factors

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Authors: Ammar Asma, Bouafia Nabiha, Ben Cheikh Asma, Ezzi Olfa, Mahjoub Mohamed, Sma Nesrine, Chouchène Imed, Boussarsar Hamadi, Njah Mansour

Abstract:

Background: Ventilator-associated pneumonia (VAP) is currently recognized as one of the most relevant causes of morbidity and mortality among intensive care unit (ICU) patients worldwide. Identifying modifiable risk factors for VAP could be helpful for future controlled interventional studies aiming at improving prevention of VAP. The purposes of this study were to determine the incidence and risk factors for VAP in in a Tunisian medical ICU. Materials / Methods: A retrospective case-control study design based on the prospective database collected over a 14-month period from September 15th, 2015 through November 15th, 2016 in an 8-bed medical ICU. Patients under ventilation for over 48 h were included. The number of cases was estimated by Epi-info Software with the power of statistical test equal to 90 %. Each case patient was successfully matched to two controls according to the length of mechanical ventilation (MV) before VAP for cases and the total length of MV in controls. VAP in the ICU was defined according to American Thoracic Society; Infectious Diseases Society of America guidelines. Early onset or late-onset VAP were defined whether the infectious process occurred within or after 96 h of ICU admission. Patients’ risk factors, causes of admission, comorbidities and respiratory specimens collected were reviewed. Univariate and multivariate analyses were performed to determine variables associated with VAP with a p-value < 0.05. Results: During the period study, a total of 169 patients under mechanical ventilation were considered, 34 patients (20.11%) developed at least one episode of VAP in the ICU. The incidence rate for VAP was 14.88/1000 ventilation days. Among these cases, 9 (26.5 %) were early-onset VAP and 25 (73.5 %) were late-onset VAP. It was a certain diagnosis in 66.7% of cases. Tracheal aspiration was positive in 80% of cases. Multi-drug resistant Acinerobacter baumanii was the most common species detected in cases; 67.64% (n=23). The rate of mortality out of cases was 88.23% (n= 30). In univariate analysis, the patients with VAP were statistically more likely to suffer from cardiovascular diseases (p=0.035) and prolonged duration of sedation (p=0.009) and tracheostomy (p=0.001), they also had a higher number of re-intubation (p=0.017) and a longer total time of intubation (p=0.012). Multivariate analysis showed that cardiovascular diseases (OR= 4.44; 95% IC= [1.3 - 14]; p=0.016), tracheostomy (OR= 4.2; 95% IC= [1.16 -15.12]; p= 0.028) and prolonged duration of sedation (OR=1.21; 95% IC= [1.07, 1.36]; p=0.002) were independent risk factors for the development of VAP. Conclusion: VAP constitutes a therapeutic challenge in an ICU setting, therefore; strategies that effectively prevent VAP are needed. An infection control-training program intended to all professional heath care in this unit insisting on bundles and elaboration of procedures are planned to reduce effectively incidence rate of VAP.

Keywords: case control study, intensive care unit, risk factors, ventilator associated pneumonia

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Authors: Ammar Asma, Bouafia Nabiha, Dhahri Meriem, Ben Cheikh Asma, Ezzi Olfa, Chafai Rim, Njah Mansour

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Despite recent advances in treatment of the lung cancer patients, the prognosis remains poor. Information is limited regarding health related quality of life (QOL) status of advanced lung cancer patients. The purposes of this study were: to assess patient reported symptom burden, to measure their QOL, and to identify determinant factors associated with QOL. Materials/Methods: A cross sectional study of 60 patients was carried out from over the period of 03 months from February 1st to 30 April 2016. Patients were recruited in two department of health care: Pneumology department in a university hospital in Sousse and an oncology unit in a University Hospital in Kairouan. Patients with advanced stage (III and IV) of lung cancer who were hospitalized or admitted in the day hospital were recruited by convenience sampling. We used a questionnaire administrated and completed by a trained interviewer. This questionnaire is composed of three parts: demographic, clinical and therapeutic information’s, QOL measurements: based on the SF-36 questionnaire, Symptom’s burden measurement using the Lung Cancer Symptom Scale (LCSS). To assess Correlation between symptoms burden and QOL, we compared the scores of two scales two by two using the Pearson correlation. To identify factors influencing QOL in Lung cancer, a univariate statistical analysis then, a stepwise backward approach, wherein the variables with p< 0.2, were carried out to determine the association between SF-36 scores and different variables. Results: During the study period, 60 patients consented to complete symptom and quality of life questionnaires at a single point time (72% were recruited from day hospital). The majority of patients were male (88%), age ranged from 21 to 79 years with a mean of 60.5 years. Among patients, 48 (80%) were diagnosed as having non-small cell lung carcinoma (NSCLC). Approximately, 60 % (n=36) of patients were in stage IV, 25 % in stage IIIa and 15 % in stage IIIb. For symptom burden, the symptom burden index was 43.07 (Standard Deviation, 21.45). Loss of appetite and fatigue were rated as the most severe symptoms with mean scores (SD): 49.6 (25.7) and 58.2 (15.5). The average overall score of SF36 was 39.3 (SD, 15.4). The physical and emotional limitations had the lowest scores. Univariate analysis showed that factors which influence negatively QOL were: married status (p<0.03), smoking cessation after diagnosis (p<0.024), LCSS total score (p<0.001), LCSS symptom burden index (p<0.001), fatigue (p<0.001), loss of appetite (p<0.001), dyspnea (p<0.001), pain (p<0.002), and metastatic stage (p<0.01). In multivariate analysis, unemployment (p<0.014), smoking cessation after diagnosis (p<0.013), consumption of analgesic (p<0.002) and the indication of an analgesic radiotherapy (p<0.001) are revealed as independent determinants of QOL. The result of the correlation analyses between total LCSS scores and the total and individual domain SF36 scores was significant (p<0.001); the higher total LCSS score is, the poorer QOL is. Conclusion: A built in support of lung cancer patients would better control the symptoms and promote the QOL of these patients.

Keywords: quality of life, lung cancer, metastasis, symptoms burden

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Authors: Ezzi Olfa, Bouafia Nabiha, Ammar Asma, Ben Cheikh Asma, Mahjoub Mohamed, Bannour Wadiaa, Achour Bechir, Khelif Abderrahim, Njah Mansour

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Background: In hematology/oncology, health care improvement has allowed increasingly aggressive management in diagnostic and therapeutic procedures. Nevertheless, these intensified procedures have been associated with higher risk of healthcare associated infections (HAIs). We undertook this study to estimate the burden of HAIs in the cancer patients in an onco -hematology unit in a Tunisian university hospital. Materials/Methods: A prospective, observational study, based on active surveillance for a period of 06 months from Mars through September 2016, was undertaken in the department of onco-hematology in a university hospital in Tunisia. Patients, who stayed in the unit for ≥ 48 h, were followed until hospital discharge. The Centers for Disease Control and Prevention criteria (CDC) for site-specific infections were used as standard definitions for HAIs. Results: One hundred fifty patients were included in the study. The gender distribution was 33.3% for girls and 66.6% boys. They have a mean age of 23.12 years (SD = 18.36 years). The main patient’s diagnosis is: Acute Lymphoblastic Leukemia (ALL): 48.7 %( n=73). The mean length of stay was 21 days +/- 18 days. Almost 8% of patients had an implantable port (n= 12), 34.9 % (n=52) had a lumber puncture and 42.7 % (n= 64) had a medullary puncture. Chemotherapy was instituted in 88% of patients (n=132). Eighty (53.3%) patients had neutropenia at admission. The incidence rate of HAIs was 32.66 % per patient; the incidence density was 15.73 per 1000 patient-days in the unit. Mortality rate was 9.3% (n= 14), and 50% of cases of death were caused by HAIs. The most frequent episodes of infection were: infection of skin and superficial mucosa (5.3%), pulmonary aspergillosis (4.6%), Healthcare associated pneumonia (HAP) (4%), Central venous catheter associated infection (4%), digestive infection (5%), and primary bloodstream infection (2.6%). Finally, fever of unknown origin (FUO) incidence rate was 14%. In case of skin and superficial infection (n= 8), 4 episodes were documented, and organisms implicated were Escherichia.coli, Geotricum capitatum and Proteus mirabilis. For pulmonary aspergillosis, 6 cases were diagnosed clinically and radiologically, and one was proved by positive aspergillus antigen in bronchial aspiration. Only one patient died due this infection. In HAP (6 cases), four episodes were diagnosed clinically and radiologically. No bacterial etiology was established in these cases. Two patients died due to HAP. For primary bloodstream infection (4 cases), implicated germs were Enterobacter cloacae, Geotricum capitatum, klebsiella pneumoniae, and Streptococcus pneumoniae. Conclusion: This type of prospective study is an indispensable tool for internal quality control. It is necessary to evaluate preventive measures and design control guides and strategies aimed to reduce the HAI’s rate and the morbidity and mortality associated with infection in a hematology/oncology unit.

Keywords: cohort prospective studies, healthcare associated infections, hematology oncology department, incidence

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