Primary Hydatid Cyst of the Adrenal Gland: A Case Report and a Review of the Literature

Introduction: In North Africa which is an endemic region for Hydatid Cyst, Tunisia is considered as an endemic country. The liver and lungs are common locations for Hydatid Cysts, whereas the Adrenal Glands are unusual and rare locations.

Presentation of case: Here is a report of primary Hydatid Cyst in a 55-year old patient, with left hypochondrium pain as chief complain. No remarkable findings were revealed by physical examination and blood analysis showed normal range. Hydatid serology was negative. The diagnosis of Hydatid Cyst was suspected based on CT Scan results which showed a well-circumscribed, non-enhanced, multi-cystic, 12 cm mass with scattered calcifications located in the left adrenal gland. Therefore, the patient underwent an open surgery with resection of the protruding dome of the cyst as it was attached to the renal pedicle, the pancreatic tail, the spleen and the jejunum. The final pathological examination of the specimen led to a Hydatid Cyst.

Discussion: Throughout an extensive literature review that we have made, we have analyzed 54 reported cases, with their clinical presentations, biological exams, radiological features and surgical managements. The treatment should be surgical and has to be as conservative as possible. The prevention of the parasite transmission has to be the cornerstone of the disease management.

Conclusion: The hydatid cyst of the adrenal gland remains a rare diagnosis that has to be evoked in case of an adrenal gland cyst, especially in an endemic country.

Epidemiology of surgical valvular heart diseases in a north african tertiary referral hospital

Introduction
The etiology of valvular heart disease (VHD) has changed dramatically in the last five decades. In the western world, the significant reduction of acute rheumatic fever and its sequelae, and the recognition of non-rheumatic causes of VHD induced the metamorphosis in the etiology of valvular disorders. The aim of this study was to assess the epidemiological profile of the patients undergoing valvular surgery in a north African center of cardiology.

Methods
A retrospective study involving the 246 last patients hospitalized in our department and proposed for valvular surgery from January 2012 to December 2017.

Results
The mean age was 57 years. One hundred twenty-one patients were male (49%). Before surgery mean LVEF is 60% ± 13. Ten percent of the patients were operated with (left ventricular dysfunction LVEF ≤ 40%). Arterial hypertension, diabetes mellitus and smoking are respectively present in 29, 7%, 21, 8% and 27, 7% of the patients. A history of rheumatic fever was present in 60, 8% of rheumatic valvular disease. The rheumatic etiology was the most important (50,5%). A preoperative coronary angiography was performed in 63,4% of the patients and coronary artery disease was associated to the valvular heart disease in 14,9%. Mitral valve replacement, aortic-valve replacement and double valve replacement were respectively performed in 38,7%, 35,4% and 18,7% of the cases. Bioprothesis were implanted in 5,29% of the cases. One eighth of the patients underwent coronary artery bypass graft in addition to the valvular surgery. In 16,8% of the cases it was a redo surgery.

Conclusion
Contemporary epidemiological data show a rise of the degenerative etiology and associated coronary artery disease. Surgery offers good results for patients with significant valvular heart disease. Valve replacement and repair are the main surgical options. Older patients and redo procedures are increasingly frequent.

The Psychology of Patients Infected with COVID 19 in Tunisia during the Treatment Period

The COVID-19 still causes anxiety and apprehension among many patients today, which can lead to a refusal of care or difficult
working conditions. It, therefore, appears prerequisite to set up conditioning and relaxation methods for patients and caregivers to
optimize care and working conditions. In this regard, we assess the psychological levels of patients in their forties to detect the factors in order to facilitate the treatment.

Global Unmet Needs in Cardiac Surgery.

More than 6 billion people live outside industrialized countries and have insufficient access to cardiac surgery. Given the recently confirmed high prevailing mortality for rheumatic heart disease in many of these countries together with increasing numbers of patients needing interventions for lifestyle diseases due to an accelerating epidemiological transition, a significant need for cardiac surgery could be assumed. Yet, need estimates were largely based on extrapolated screening studies while true service levels remained unknown. A multi-author effort representing 16 high-, middle-, and low-income countries was undertaken to narrow the need assessment for cardiac surgery including rheumatic and lifestyle cardiac diseases as well as congenital heart disease on the basis of existing data deduction. Actual levels of cardiac surgery were determined in each of these countries on the basis of questionnaires, national databases, or annual reports of national societies. Need estimates range from 200 operations per million in low-income countries that are nonendemic for rheumatic heart disease to >1,000 operations per million in high-income countries representing the end of the epidemiological transition. Actually provided levels of cardiac surgery range from 0.5 per million in the assessed low- and lower-middle income countries (average 107 ± 113 per million; representing a population of 1.6 billion) to 500 in the upper-middle-income countries (average 270 ± 163 per million representing a population of 1.9 billion). By combining need estimates with the assessment of de facto provided levels of cardiac surgery, it emerged that a significant degree of underdelivery of often lifesaving open heart surgery does not only prevail in low-income countries but is also disturbingly high in middle-income countries.

Intravenous lidocaine as adjuvant to general anesthesia in renal surgery.

The role of intraoperative intravenous lidocaine infusion has been previously evaluated for pain relief, inflammatory response, and post-operative recovery, particularly in abdominal surgery. The present study is a randomized double-blinded trial in which we evaluated whether IV lidocaine infusion reduces isoflurane requirement, intraoperative remifentanil consumption and time to post-operative recovery in non-laparoscopic renal surgery. Sixty patients scheduled to undergo elective non-laparoscopic renal surgery under general anesthesia were enrolled to receive either systemic lidocaine infusion (group L: bolus 1.5 mg/kg followed by a continuous infusion at the rate of 2 mg/kg/hr until skin closure) or normal saline (0.9% NaCl solution) (Group C). The depth of anesthesia was monitored using the Bispectral Index Scale (BIS), which is based on measurement of the patient’s cerebral electrical activity. Primary outcome of the study was End-tidal of isoflurane concentration (Et-Iso) at BIS values of 40-60. Secondary outcomes include remifentanil consumption during the operation and time to extubation. Et-Iso was significantly lower in group L than in group C (0.63% ± 0.10% vs 0.92% ± 0.11%, p < 10-3). Mean remifentanil consumption of was significantly lower in group L than in group C (0.13 ± 0.04 µg/kg/min vs 0.18 ± 0.04 µg/kg/min, p < 10-3). Thus, IV lidocaine infusion permits a reduction of 31% in isoflurane concentration requirement and 27% in the intraoperative remifentanil need. In addition, recovery from anesthesia and extubation time was shorter in group L (5.8 ± 1.8 min vs 7.9 ± 2.0 min, p < 10-3). By reducing significantly isoflurane and remifentanil requirements during renal surgery, intravenous lidocaine could provide effective strategy to limit volatile agent and intraoperative opioids consumption especially in low and middle income countries.