Eastern Mediterranean Health Journal [2007; Vol.13, Issue 4]

Eastern La Revue de Santé Mediterranean de la Méditerranée Health Journal orientale   Letter from the Editor .................................................................................................................................................748 Research articles Long-term immunity to hepatitis B among a sample of fully vaccinated children in Cairo, Egypt F.A. Shaaban, A.I. Hassanin, S.M. Samy, S.I. Salama and Z.N. Said ............................................................. .......750 Epidemiology of tuberculosis among Afghan immigrants in Fars province, southern Islamic Republic of Iran M.R. Kadivar, R. Ghaneh-Shirazi, F. Khavandegaran and M. Karimi ..................................................................758 Exudative pleural effusion: effectiveness of pleural uid analysis and pleural biopsy B. Heidari, K. Bijani, M. Eissazadeh and P. Heidari.............................................................................................765 Prévalence de la syphilis et de l’infection à VIH dans une population carcérale féminine au Maroc K. El Ghrari, Z. Terrab, H. Benchikhi, H. Lakhdar, I. Jroundi et M. Bennani ......................................................774 Screening for -thalassaemia carriers in Egypt: signicance of the osmotic fragility test A. El-Beshlawy, N. Kaddah, A. Moustafa, G. Mouktar and I.Youssry ...................................................................780 Bleeding duodenal ulcer in patients admitted to Erbil City Hospital, Iraq: 1996–2004 A.M. Zangana.........................................................................................................................................................787 Prevalence and risk factors of gallstone disease in a high altitude Saudi population S.A. Abu-Eshy, A.A. Mahfouz, A. Badr, M.N. El Gamal, M.Y. Al-Shehri, M.I. Salati and M.E. Rabie ..................794 Diabetes mellitus: the leading cause of haemodialysis in Jordan S. Abdallah, A.T. Ahmad, A. Batieha and K. Ajlouni .............................................................................................803 Abnormal Cambridge low-contrast grating sensitivity results associated with diabetic retinopathy as a potential screening tool M. Abrishami, J. Heravian, A. Derakhshan, M. Mousavi, T. Banaee, R.Daneshvar and H.O. Moghaddam .......810 Environmental risk factors for refractive error among Egyptian schoolchildren A. Saad and B.M. El-Bayoumy ...............................................................................................................................819 Effects of hatha yoga on well-being in healthy adults in Shiraz, Islamic Republic of Iran Ne. Hadi and Na. Hadi ..........................................................................................................................................829 Prevalence and risk factors of low-birth-weight infants in Zahedan, Islamic Republic of Iran M. Roudbari, M. Yaghmaei and M Soheili .............................................................................................................838 Growth of infants in relation to type of feeding in Jahrom, Islamic Republic of Iran F. Emamghorashi and S.T. Heydari .............................................................................................. .........................846 ويلوي/زومت ،٤ ددعلا ،رشع ثلاثلا دلجلماسطسغأ/بآ Intravaginal prostaglandin-E2 for cervical priming and induction of labour M.I. Al-Taani ..........................................................................................................................................................855 Number, maturity and phagocytic activity of neutrophils in the three trimesters of pregnancy S.S. Pramanik, T. Pramanik, S.C. Mondal and R. Chanda ....................................................................................862 Corrections. 1. Visceral leishmaniasis control in Thi Qar Governorate, Iraq, 2003. 2. Unconditional compensation: reducing the costs of disagreement about compensation for research subjects ..................867 Pattern of congenital malformations in consanguineous versus nonconsanguineous marriages in Kashan, Islamic Republic of Iran Z. Mosayebi and A.H. Movahedian........................................................................................................................868 Hyaluronic acid versus albumin in human embryo transfer medium I.M. Mahani and R. Davar .....................................................................................................................................876 Birth interval: perceptions and practices among urban-based Saudi Arabian women P. Rasheed and B.K. Al-Dabal .................................................................................................. .............................881 Safe injection practice among health-care workers in Gharbiya Governorate, Egypt N.A. Ismail, A.M. Aboul Ftouh, W.H. El-Shoubary and H. Mahaba .....................................................................893 Attitudes des enseignants à l’égard du tabagisme A. Ben Abdelaziz, Z. Amira, K. Gaha, H. Thabet, I. Soltane, A. Ghedira et R. Gaha ...........................................907 Prevalence and predictors of smokeless tobacco use among high-school males in Karachi, Pakistan S. Rozi and S. Akhtar ..............................................................................................................................................916 Students’ satisfaction with their health and social care educational programmes: qualitative ndings from the UK W. El Ansari, T. Davis and D. Pearson ..................................................................................................................925 Do free-of-charge public health services impede cost recovery policies in Khartoum state, Sudan? K. Habbani, W. Groot and I. Jelovac .....................................................................................................................939 Report Age and sex suicide rates in the Eastern Mediterranean Region based on global burden of disease estimates for 2000 M. Rezaeian ............................................................................................................................................................953 Short communications Hepatitis B surface antigen, hepatitis C and HIV antibodies in a low-risk blood donor group, Nigeria D.Z. Egah, E.B. Banwat, E.S. Audu, D. Iya, B.M. Mandong, A.A. Anele and N.E. Gomwalk ...............................961 Students’ attitudes and practices towards drug and alcohol use at Tabriz University of Medical Sciences A.R Jodati, S.K Shakurie, M. Nazari and M.B.Raue ............................................................................................967 Case reports Spontaneous ruptured and intact bilateral tubal ectopic pregnancy G.A. Al-Quraan, M.I. Al-Taani, B.M. Nusair, A. El-Masri, M.R. Arafat and M.M. Khateeb ..............................972 Floating–Harbor syndrome in a Kuwaiti patient: a case report and literature review L. Bastaki, M.M.H. El-Nabi, A.S. Azab, S.A. Gouda, A.M. Al-Wadaani and K.K. Naguib ....................................975 Letter to the Editor ..................................................................................................................................... 980 Guidelines for authors ................................................................................................................................ 982 WHO sales and discount policy ................................................................................................................. 988   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  Plagiarism, from the verb plagiarize, defined in the Concise Oxford Dic- tionary as “take and use (the thoughts, writings, inventions, etc., of another person) as one’s own”, is a hot issue in scientific publishing these days, and has provoked much recent discussion via journal articles, editorials and newsgroups. Entering the word “plagiarism” into a PubMed search gener- ates 505 hits, 121 published between January 2005 and May 2007. There are 3 basic types, and in most cases there is intent to deceive: to deceive colleagues, to deceive readers, to deceive employers, to deceive funding bodies. The most serious form is the outright copying of research work. Duplicate publication, or self-plagiarism, is another form where the intention to deceive is the main purpose, either to boost the author’s reputation or for the purposes of gaining promotion or a position. Appropriating portions of text (sentences or paragraphs) without citing sources is probably the commonest type of plagiarism encoun- tered in scientific reporting. In some cases this is due to carelessness in keeping records of sources; in others it is downright laziness. When the author is a non-native speaker, lifting whole tracts of text is often seen as an easy solution to the problem of producing a suitable Introduction or Discussion for a research paper. What does this mean to the original author whose paper is then de- nied citation? In a milieu where “number of times cited” is considered an indication of the importance of a study, not only words, but also reputation have been stolen. What does it mean for the author who copies text? It can also lead to loss of reputation: generally, those reading a paper work in the same field and will read as much as possible in that field. Coming across tracts that seem familiar and recognizing that they have been plagiarized will cast doubt on the originality of the rest of the paper, and consequently other research by the same authors. It also involves violation of copyright: most journal publishers, including the World Health Organization, own the copyright to the papers they publish. The result of plagiarism, distortion of the scientific record, is not a trivial matter. In biomedical research, especially, this can have serious implications for patients in that it can boost the evidence for or against a particular medical treatment/intervention. For this reason, journals and editors have a responsibility to eliminate all forms of plagiarism.   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                           ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  Hepatitis B virus (HBV) infection is the most prevalent chronic infectious disease and is widespread throughout the world; it is estimated that globally more than 400 million people are infected with the virus [1]. The global prevalence of HBV varies widely from low (< 2% as in Western Eu- rope, North America and Japan) to high (> 8% as in Africa, South-east Asia and China) [2]. Egypt is considered to be a region of intermediate prevalence for HBV infection with a reported figure of 4.5% [3]. The most important epidemiologic factor affecting the chronic carrier rate is age of infection. The earlier in life an infection occurs, the higher the probability that this infection will result in chronic carriage; 90% of infants, 25%–50% of children 1–5 years and > 5% of adults who acquire the infection become chronic carriers [4]. Neonatal HBV vaccination is the most effective measure for prevention of HBV infection in countries with intermediate to high levels of HBV endemicity [5]. Two types of HBV inactivated vaccines are available, plasma-derived vaccine and re- combinant DNA vaccine [6]. A compulsory vaccination programme against hepatitis B infection among infants was started in Egypt in 1992 using a yeast recombinant DNA vaccine (10 µg) and with a schedule of 2, 4 and 6 months in age [7]. Seroprotec- tion is assured when hepatitis B surface antibody (HBsAb) levels are 10 IU/L [8,9] but more needs to be learned about the duration of protection and indication for booster doses [10]. The aim of the present study was to as- sess the long-term immunity to hepatitis B among Egyptian children vaccinated under the compulsory vaccination programme 6–12 years after receiving the vaccine, and to determine the factors associated with immunity.  This was a cross-sectional study of children attending the health insurance clinic, for a period of 6 months (October 2003–March 2004). The health insurance clinic is one of the paediatric clinics of the General Insti- tute of Health Insurance of the Ministry of Health and Population. The children were attending the clinic seeking medical advice for illnesses such as anaemia, headache, visual problems and school accidents. Ap- proval was taken from the General Institute of Health Insurance in order to allow the researchers to conduct the study and to col- lect blood samples from the children. For younger children attending the clinic, their parents were informed about the aim of the study and their consent for their children to be included in the study was taken. For older children both the parents and the child provided consent. All children consecutively attending the Health Insurance Clinic over the study period and fulfilling the inclusion criteria were included in the study. The inclusion criteria were: age 6–12 years and having re- ceived the full course of hepatitis B vaccine as recorded on the back of the child’s birth certificate. Thus 242 children (116 males and 126 females) were recruited. A questionnaire was designed and ad- ministered to the parents or caretakers of the children to collect demographic data (age, sex and socioeconomic status) and history of hepatitis B vaccination in infancy. Socio- economic status was determined according to Fahmy and Sherbiny [11]. The children’s height and weight were measured at the time of enrolment to determine body mass index (BMI). Anthropometric measure- ments were converted to standard deviation (SD) scores using the National Center for Health Statistics/Centers for Disease Con- trol and Prevention (NCHS/CDC) standards [12]. Nutritional status was assessed by    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما height-for-age Z score (HAZ) and weight for-age Z score (WAZ). Children, whose WAZ or HAZ scores were below –2 SD from the median of the reference population were classified as underweight or stunted respectively. Blood was drawn aseptical ly by venepuncture and serum was separated by centrifugation and stored at –70 C. The samples were thawed for the quantita- tive determination of antibody to HBV by competitive enzyme-linked immunosorb- ent assay (DiaPro, Milan, Italy). Antibody levels were determined quantitatively by means of a standard curve calibrated against the World Health Organization reference preparation. Data were analysed using SPSS, version 9. Descriptive analysis (mean and SD) were performed in order to compare between groups. As the data are not normally dis- tributed, the Mann–Whitney test was used to compare differences between 2 means and the Kruskal–Wallis test was used to compare between more than 2 means. The chi-squared test was performed to com- pare proportions between 2 categorical variables. To detect the relation between age and antibody titre, a correlation test was used. Multivariate logistic analysis was also carried out to define the independent predic- tor variables significantly associated with hepatitis B virus seroprotection. Backward Wald analysis was used with > 0.1 remov- ing criteria.  The seroprevalence of HBsAb by titre is shown in Figure 1. Of the 242 children stud- ied, 60.7% had HBsAb titres of < 10 IU/L (no protection) and only 9.9% of them had titres > 100 IU/L. Table 1 shows distribu- tion of the children according to protection status and mean level of HBsAb and age and sex. The percentage of children with a titre < 10 IU/L increased with age but the increase was not significant and there was no significant difference between males and females. However, the mean antibody levels decreased significantly with increas- ing age. Furthermore there was a significant negative correlation between current age and HBsAb levels (r = –0.31, P = 0.041) (Figure 2). Although the seroprotection level ( 10 IU/L) of HBsAb increased gradually with increase in the socioeconomic status, it was not statistically significant (P = 0.09) (Table 2). As regards anthropometric meas- urements, there was a significantly higher proportion of children with non-protective levels of HBsAb (< 10 IU/L) with WAZ > –2 SD (62.1%, P = 0.042). On the other hand, no significant differences were found between the levels of HBsAb and HAZ score and BMI. By multiple logistic analysis, age and WAZ score were found to be the significant     ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما variables for prediction of HBsAb level < 10 IU/L. For every 1 year increase in age there was a 23% increased risk of becoming non-immune after HBV vaccination. In children with WAZ score > –2 SD, the risk of having non-protective levels of HBsAb was 8 times higher compared to those –2 SD (Table 3).                                                                                        ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  Children vaccinated against hepatitis B may show serological evidence of break-through infections, particularly if the level of HBsAb induced by the vaccine is low [9]. In the present study, the overall seroprotec- tion 6–12 years after immunization was low (39.3%) and only 9.9% of the children had titres > 100 IU/L. Compared to other stud- ies performed on children within the same age range, considerably greater proportions of children had protective HBsAb levels: ranging from 81.6% to 95% as reported by Yu, Cheung and Keefe, Floreani et al., and Lin et al. [9,8,13], and 71.4% to 77% as re- ported by Al-Faleh et al., Poovarawan et al. and Mariano et al. [14–16]. With extension of the age range up to 15 years Ni et al. and Bonanni et al. reported HBsAb seropositiv- ity levels among 75.8% and 79% of their subjects respectively [17,18]. On the other hand other studies have reported values similar to our rate of 60.7% with non-protective HBsAb levels. Lu et al. found that 62.6% of the 15-year-olds in their study had non-protective HBsAb levels after primary neonatal immunization with plasma-derived hepatitis B vaccines. Accordingly they recommended one or more booster immunizations [10]. In the United States of America, Petersen et al. reported that HBsAb disappeared by 5 years of age in most of the studied children who                                                                                                                                          ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما had been vaccinated with hepatitis B vac- cine from birth [19]. In our study, the seroprotection level ( 10 IU/L) was 47.6% 6–7 years after vaccination. Similarly low proportions of children with seroprotective antibody levels (41% at 5 years and 39% at 9 years) were re- ported by Williams et al. [20]. On the other hand, higher rates were reported by Chen et al. in China (65.95%), Garcia et al. in Spain (75%) and Reda et al. in Egypt (67%) 5 years after vaccination [4,21,22]. In the older age group, Mariano et al., [16] found that 74% of children aged 10–11 years had protective antibody levels compared to 26.9% in our study. In Taiwan, the percent- age of children with seroprotective levels of HBsAb gradually decreased from 71.1% at age 7 years to 37.4% at age 12 years [23]. In our study there was no significant difference in the frequency of HB seropro- tection between males and females. This is in agreement with some studies [24,25], while others have found that male sex is a predictor of non-response [9]. By multivariate analysis we found age and WAZ to be the only significant predic- tors of HBsAb level < 10 IU/L. In children with WAZ score > –2 SD, the risk of having a non-protective level of HBsAb was 8 times higher than those with a WAZ score –2 SD. Although several investigators have reported a strong inverse relation between BMI and final HBsAb titre in children, we did not find such correlation [9,25,26]. Yu, Cheung and Keefe reported that the predictors of non-protective levels of HBsAb were: increasing age, male gen- der and obesity [9]. Seroprotection rates and geometric mean titres have been reported to decrease significantly with increasing age possibly reflecting waning HBsAb levels over time [27,28]. The low level of HBsAb reported in our study and the diversity of results in the different studies can be attributed to several factors. First, the type of vaccine, whether it is a plasma-derived or yeast-derived vac- cine could play a role. Da Villa et al. [29] found that the DNA recombinant vaccine gave a higher titre (97.6%) than the plasma- derived vaccine (80.4%), while Floreani et al. [8] recorded a slightly higher titre with plasma-derived vaccine than with yeast- derived vaccine (87.8% and 81.6% respec- tively). Second, the schedule of immuniza- tion may also play a role in determining HBsAb level. Da Villa et al. [30] found that a higher level of protective HBsAb was achieved when the vaccine doses were ad- ministered after the third month of life rather than in the first 3 months, while Williams et al. [20] found that persistence of protective levels for a longer period occurred when the vaccine doses were administered soon after birth. According to the Viral Hepatitis Prevention Board, the 2 schedules most widely used for the hepatitis B vaccine are 0, 1, 6 months and 0, 1, 2, 12 months, both of which have been shown to be equally effective and can control perinatal infec- tion [31]. Increasing the time between the 1st and 2nd doses and 2nd and 3rd doses appears to increase antibody levels [25]. This is in agreement with the findings of previous studies performed in Egypt and accordingly they recommended a new vac- cination schedule with an increased interval between the 2nd and 3rd dose [32,33]. The third factor is the dose of the vaccine. Zuck- erman et al. suggested that increasing the dosage of the vaccine leads to significantly higher levels of HBsAb [34]. In conclusion, more than half of the studied children had non-protective levels of HBsAb and this puts them at risk of infection. The failure to achieve satisfac- tory seroprotection levels by the national immunization programme reflects the need to re-evaluate the current hepatitis B vac-    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما cination strategy in Egypt. Further studies are needed to explain whether this low sero- protective level is due to waning immunity with time or due to an initial low response. A booster dose is suggested for maintaining a high seroprotective level.                                                                                                                                                                                                                               ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                                                                                                                      ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                       ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  Since 1980, the world has experienced 3 major epidemics of tuberculosis (TB). One reason for this may be an increase in population movements from endemic to non-endemic areas. Studies in developed countries have shown that two thirds of TB cases were among racial and ethnic minorities [1]. The incidence of pulmonary TB among migrants from high-incidence countries remains high for at least a decade after immigration [2], perhaps due to reacti- vation of old infections and transmission of infections after immigration. Migrants also suffer disproportionately from poverty and malnutrition which are important factors in vulnerability to TB. The increase in morbidity and mortal- ity of TB in high-burden countries has become a major health problem in the East- ern Mediterranean Region. In 2002, the number of affected patients per annum in the Region was reported to be 630 000, with 136 000 annual deaths. Among them, 43% were from Pakistan, 12% from Afghanistan and 6% from the Islamic Republic of Iran [3]. In the latest World Health Organiza- tion (WHO) report, the incidence of TB in Afghanistan was estimated to be 314 per 100 000 population [3]. In the past decade, poor progress has been noticed in implementing the WHO recommended treatment strategy— directly observed treatment, short-course (DOTS)—in the 22 high-burden countries [3]. Afghanistan, Pakistan, India, Brazil and South Africa are among the countries still facing challenges in implementation and expansion of DOTS [4]. In Afghanistan, the situation has worsened due to cessation of disease control activities during the war. Compliance of patients with DOTS and ac- cess to treatment have become very difficult and TB is still considered a major public health problem both inside Afghanistan and in neighbouring countries such as Pakistan and the Islamic Republic of Iran [5]. In previous studies in the Islamic Republic of Iran during 1992 to 1994, the incidence of TB was 86 per 100 000 among Afghan migrants, who formed 4% of the total popu- lation of Fars province [6]. In spite of the rise in the Afghan population in 1995 and 1996 (to 13% of the total Iranian popula- tion) [7], no further study was made on the incidence of TB. However, in 1998, 17% of TB patients were Afghan, an incidence of 38 per 100 000, which was lower than the expected rate [8]. In 2000, a census, the Foreign Citizen’s Identification Programme, was carried out in Fars province, and the number of non- Iranians was determined to be 154 620 (149 654 Afghan) out of a population of 3.5 million. Due to the high incidence of TB in Afghanistan and high rate of illegal migra- tion to the Islamic Republic of Iran and especially to Fars province, we conducted this study to evaluate the epidemiology of TB in Afghans in southern Islamic Republic of Iran.  In a descriptive epidemiological study, from April 2000 to April 2002, all new Afghan patients registered to receive care for TB at the public health centres of Shiraz Univer- sity of Medical Sciences were entered into our study. The information source for the Afghan population was the Foreign Citizen Identification Programme in Fars province which identified illegal immigrants for se- curity reasons. The patients were invited for interview by trained assessors using a stand- ardized tool. Information was recorded in a questionnaire that covered demographic data, type of TB, method of diagnosis, X- ray data, clinical signs and symptoms, start of symptoms, history of TB medication,    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما previous contact with the disease and dates of referral. Every patient underwent chest X-ray by a skilled radiographer and the diagnosis of TB was confirmed by clinical evaluations, and sputum smears (Ziehl–Nielsen acid- fast stain) and culture were performed by a laboratory technologist. The data were statistically analysed by SPSS, version 11.0, and Microsoft Excel software. Cross tabulation, chi-squared test, Student t-test, one-way analysis of variance, and one-way Kolmogorov–Smirnov tests were used for statistical analysis and P < 0.05 was considered significant.  Among 1026 new cases of TB at the pub- lic health centres of Shiraz University of Medical Sciences, 371 (36.2%) were among patients of Afghan nationality. More than half of the Afghan patients (56.1%, n = 208) were males; 213 (57.5%) were married and 158 (42.5%) were single; 308 (83.0%) lived in urban areas and 63 (17.0%) in rural areas of the province. The mean (standard deviation) age of the patients was 27.6 (3.1) years. Table 1 shows new cases of TB among Afghans in different years in relation to age. The greatest proportion of cases (30.7%) were aged 15–24 years and two-thirds of cases (66.8%) were aged 15–44 years. Table 2 shows the new cases in relation to place of residence. The total number of cases decreased between 2000 and 2002 while the majority of cases were in Shiraz, the capital of Fars province and Larestan. The numbers of new cases were 144, 132 and 95 in years 2000, 2001 and 2002 respec- tively. Using population data from the year 2000, the incidence of TB among Afghan immigrants in Fars province was estimated at 96.2%, 88.2% and 63.5% in years 2000, 2001 and 2002. Table 2 also shows that the number of TB cases among Afghans in Fars province were lower than the expected rate for Afghanistan residents of 314 per 100 000 according to WHO [3]. Pulmonary TB was more common than extrapulmonary TB: 74.9% of cases versus 25.1%. Of the 278 new cases of pulmonary TB, 157 (56.5%) cases were sputum smear-                                                                                                                                               ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما positive and 121 (43.5%) were sputum smear-negative. Of the 93 cases of extra- pulmonary TB, the most common type was lymphoid TB (n = 25, 26.9%) (Table 3). The rates of extrapulmonary TB decreased over the 3 years 2000, 2001 and 2002 (30%, 24% and 19% respectively), and correspondingly the rate of pulmonary TB increased over 2000–02. In year 2000, pulmonary TB was signifi- cantly more common in males than females, while extrapulmonary TB was significantly higher in females (P = 0.002). These results were similar for years 2001 (P = 0.031) as well as the total for years 2000–02 (P = 0.001).  In this study the average incidence of TB in Afghan immigrants of Fars province over the 3 years was 82.6 per 100 000 popula- tion. According to Ministry of Health data, the incidence of TB among the Iranian pop- ulation of Fars Province from 2000 02 was 5.2 per 100 000, 16 times less than among Afghans [3].                                                                                                                                                                                                    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما The incidence of TB in this group ap- peared to decrease from 93.4 per 100 000 in year 2000 to 61.4 per 100 000 in year 2002. In view of an expected incidence of 314 per 100 000 population in Fars province based on WHO data [3], the low incidence rate may be explained by deficiencies in case-finding or by the return of Afghans to their home country. In Afghanistan there is inadequate case-finding in the health sys- tem, insufficient personnel, poor education of the community, low levels of cooperation with national TB programmes and involve- ment of the private sector without sufficient education about TB control programmes in the treatment of patients [5]. However, the total rate of case-finding among Afghans in Fars province was much higher than programmes performed in Afghanistan [3]. The difference in case-finding in various cities of Fars province may be due to differ- ent distributions of Afghans in these cities. In 2001, for example, a rate of 972.1 per 100 000 Afghans in Firouz-Abaad may be explained by a low Afghan population with a large number of patients. The correspond- ing rate in Shiraz was 63.9 per 100 000 where the Afghan population of the city is much larger. Two thirds of patients were aged 15 to 44 years. Similarly, the Iranian Centre for Disease Control reported that the age of most TB cases was above 15 years in other parts of the Islamic Republic of Iran [9]. WHO reports from Afghanistan found that most male TB patients were older than 25 years and the incidence rate increased with age [3]. However, in females, most TB pa- tients were between 25 and 55 years old and after 55 years, the incidence decreased [3]. As the age–sex distribution of the Afghan population was unavailable, an age–sex                                                                                                                                                                                     ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما comparison between Afghan immigrants in the Islamic Republic of Iran and Afghani- stan was not possible. In our study, smear-positive lung TB was more common in male Afghans (56%) than females (44%). In Afghanistan, the situation appears to be the reverse, with three quarters of smear-positive TB pa- tients being female [5]. This is unlikely to be due to a greater incidence of TB in women, but is probably due to cultural and economic factors. Men in Afghanistan usually control the household income, and therefore when they become ill, they tend to refer themselves to the private sector, where they believe a higher standard of treatment is provided. Unfortunately, since private centres do not report their cases, a lower incidence of TB is reported among men [5]. However, most Afghans who migrate to Islamic Republic of Iran are men who come to search for a job and leave their families in Afghanistan. Additionally, in Fars prov- ince, public health services are responsible for the treatment of these patients, and they provide more accurate data through regular reporting systems. Pulmonary TB in Afghans, in both fe- males and males, was more prevalent than extrapulmonary TB: 74.9% versus 25.1%. In all years, pulmonary TB was signifi- cantly more common in males than females, while extrapulmonary TB was significantly higher in females. However, during the 3 years of our study, the average proportion of pulmonary TB cases that were smear- positive was 56.5% which is lower than the expected rate (70%) [3]. This rate var- ied between 61.0% and 64.5% in all other parts of Islamic Republic of Iran [7–9]. The high rate of smear-negative pulmonary TB compared with smear-positive pulmonary cases (43.5% versus 56.5%) was likely due to delays in diagnosis and treatment of patients, which results in the progression of the disease to later stages with complica- tions and pulmonary manifestations [2]. The percentage of extrapulmonary TB was 30%, 24% and 19% in the years 2000, 2001 and 2002, respectively. However, the expected rate was 15% [10]. The cause of this high rate, which was also observed in Afghanistan [5], may be due to a weaker system of case-finding of pulmonary TB patients. Lymph node TB was observed more often than other types. This finding was similar to other reports in other parts of the world [1,4,5,11]. In conclusion, since age–sex distribution and accurate number of Afghans resident in Islamic Republic of Iran were not avail- able, the incidence in relation to age and sex could not be compared with data from Afghanistan. Therefore, we recommend the collection of data about the Afghan popula- tion in terms of age and sex separately, in order to help accurate calculation of the incidence of disease. Additionally, because new cases of TB were reported even in children below age 14 years, case-finding in these years is recommended. Finally, we recommend organizing specific health cen- tres for Afghan immigrants in south Shiraz, the area in which most Afghan immigrants live. Employing Afghan personnel at Shiraz health centres could improve case-finding and earlier diagnosis of TB patients.  We would like to thank the Office of Vice- Chancellor for Research of Shiraz Universi- ty of Medical Sciences for financial support and Dr Davood Mehrabani, the Centre for Development of Clinical Research of Nemazi hospital for editorial assistance.    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                         ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                  100 43 33 7054 33 7099 91    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  Pleural effusion (PE) is a common problem in internal medicine practice. In cases with transudate PE, the diagnosis is usually made without any difficulties but exudative PE requires careful differential diagnosis that includes tuberculosis (TB) and metastatic cancers, which are often found to be the cause in a large number of patients [1–3]. Disease in any organ can cause exuda- tive PE through a variety of mechanisms including infection, malignancy, immuno- logic response, lymphatic abnormality and noninfectious inflammation [4]. In many areas of the world, TB is the most common cause of exudative PE [5–7], but in regions with a low prevalence rate of TB, and also in patients aged over 60 years, malignant diseases should be considered the most probable cause, although in older patients a reactivation of previous TB may also present as exudative PE [8–10]. Despite the development of new di- agnostic methods, closed pleural biopsy and pleural fluid analysis remain the most common ways of establishing a diagnosis of tuberculous PE or malignant PE [10–12]. However the value of these procedures is limited in establishing the cause of PE that results from either malignant or nonma- lignant diseases. Although thoracoscopic biopsy and lavage has increased the diag- nostic rate, the cause for many patients with exudative PE remains unknown or obscure. In these patients, detection of a treatable cause is very important. Even in patients with a known malignancy, accurate diag- nosis of the cause of PE is essential, as the treatment and prognosis may vary. Since TB and malignancy are among the most frequent causes of PE, in particular exudative PE, in most parts of the world previous studies have focused on the di- agnosis of TB or malignancy [5,6,9–12]. Although the value of pleural fluid analysis and pleural biopsy in diagnosis of malignant or tuberculous PE has been shown in several studies [10–12], their diagnostic perform- ance for identification of TB or malignancy in patients with the exudative type of PE has not been studied or compared yet. The aim of the current study was to assess the effectiveness of pleural fluid analysis and pleural biopsy and the efficacy of combining both procedures in the diag- nosis of TB and malignancy in patients with exudative PE.  This study was carried out on 100 consecu- tive patients with PE admitted to the pulmo- nary division of Shaheed Beheshti Hospital in Babol, Islamic Republic of Iran between 1997 and 2001. Etiological diagnosis of exudative PE was confirmed according to appropri- ate clinical and/or laboratory findings or criteria. All patients were given a clini- cal examination, chest radiograph, blood chemistry and thoracentesis. Pleural biopsy with Abrams needle was performed in all patients except those with an obvious clini- cal diagnosis of congestive heart failure or bacterial pneumonia. Pleural fluid analysis was performed for protein concentration, lactic dehydrogenase (LDH), cultures, as well as cytologic study for tumour cells. Bacteriological examination of pleural fluid as well as examination for acid-fast bacilli (AFB) were also performed. Diagnosis of exudative PE was confirmed according to pleural fluid protein and LDH level, and the size of the effusion was determined on the basis of chest radiographs [13]. Other diagnostic methods such as bron- choscopy and bronchoalveolar lavage were done as clinically indicated. Bronchoalveo-   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما lar lavage fluids were examined for AFB by smears and culture, as well as for tumour cells. In patients with bloody sputum or those suspected for TB, 3 samples of stained sputum smears as well as 3 sputum samples for cultures were taken and sent to the TB ward of Babol health centre for examination of AFB. Standard tuberculin skin test was also performed for all patients. Definitive diagnosis of TB was con- firmed by identification of AFB from the cultures of the pleural fluid, bronchoalveo- lar lavage fluid, or from the pleural biopsy samples by direct examination. Presence of granulomas with caseous necrosis in biopsy specimens was confirmative of TB if clini- cal and radiological findings of TB were also available. Diagnosis of malignant PE was con- firmed by identification of tumour cells from the pleural fluid or pleural tissue sam- ples. Diagnosis of malignant mesothelioma was confirmed on the basis of histologic examination of pleural biopsy specimens, diffuse thickening of pleura on CT scan- ning, and bloody pleural fluid, defined as 100 000 red blood cells/mm3 of pleural fluid and exclusion of metastatic disease. The sensitivity of diagnostic tests was calculated as the proportion of diseased individuals with positive test results, i.e. diseased with positive test divided by all diseased. The gold standard for diagnosis of tuberculous PE and malignant PE was demonstration of AFB from body fluids and tumour cells from tissue biopsy samples respectively.  The mean age of patients was 57 years (standard deviation 17 years) (range 12–82 years); 62% were males and 72% were aged over 50 years.  PE was right-sided in 51% of cases, left- sided in 44% and bilateral in 5% of pa- tients. Malignant diseases accounted for 41% and TB for 33% of the 100 cases of exuda- tive PE; 2 patients (2%) had coexistence of TB and malignancy and were analysed with the malignant group. Para-pneumonia effu- sions were found in only 6% of cases. Other reasons were: congestive heart failure, 3%; complication of coronary bypass surgery, 2%; rheumatoid arthritis, 2%; systemic lu- pus erythaematosus, 1%; chronic renal fail- ure, 1%; acute cholecystitis, 1%; unknown etiology, 8%. Large pleural effusions were found in 24% of patients, moderate in 58%, and mild effusions in 18%. In 15% of cases, the pleural fluid was bloody. The majority of cases of malignant PE were due to metastatic cancers (95%). In this study the origins of primary cancers were determined in only 39% of patients, which included lung cancer (22%), breast cancer (7%), gastric carcinoma (5%) and lymphoma (5%). Malignant mesothelioma was diagnosed in only 2 patients.   The characteristics and the presenting fea- tures of tuberculous PE and malignant PE are summarized in Table 1. The most common presenting features of exudative PE for tuber- culous and malignant pleurisy respectively were: dyspnoea (82%, 72%), cough (82%, 65%) and pleuritic chest pain (64%, 49%). The presenting features of non-TB and non-malignant effusions were pleuritic chest pain, cough and dyspnoea in 71%, 54% and 38% of patients respectively. In 8% of patients the causes of exudative PE were not determined over a mean follow-up period of 3 months.    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                Pleural biopsy was the most sensitive di- agnostic measure for tuberculous PE with a sensitivity of 70%, whereas pleural fluid analysis was positive in only 33% of patients with tuberculous PE (Table 2). The sensitiv- ity of pleural fluid analysis and pleural biopsy for diagnosis of malignant PE was 70% and 53.5% respectively, whereas the diagnostic sensitivity of both pleural biopsy and pleural fluid analysis in patients with tuberculous and malignant PE was 97% and 91% respectively. The results of alveolar lavage testing are presented in Table 3. Sputum smears and cultures were not helpful for diagnosis of tuberculous PE and tuberculin skin test was positive in only 25% of patients with TB. In patients with malignant PE who had cytology-negative pleural fluid, pleural biopsy was positive in 9 out of 13 pa- tients (70%). In the remaining 4 cytology- negative cases 3 patients were diagnosed by bronchial biopsy and 1 patient by lymph node biopsy. In 14 cases of malignant PE, both pleural biopsy and pleural fluid analy- sis were positive. Patients with malignant PE were older, with higher frequency of large and bloody pleural effusions as well as higher frequency of right-sided effusions than patients with tuberculous PE. In conclusion, pleural fluid analysis was more sensitive for diagnosis of malignant   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما PE than tuberculous PE, whereas pleural biopsy was more sensitive for diagnosis of tuberculous PE. Combined pleural fluid analysis and pleural biopsy were positive in 97% and 91% of cases with tuberculous PE and malignant PE respectively.   Characteristics of the malignant and non- malignant pleural fluids are shown in Table 3. In malignant PE the mean pleural fluid protein concentration was significantly higher but the mean pleural fluid LDH level was significantly lower than in non-malig- nant effusions (P < 0.02 for both).  This study examined the effectiveness of pleural fluid analysis and pleural biopsy in diagnosis and differentiation of TB and ma- lignancy in 100 hospitalized patients with exudative PE. The results revealed that ma- lignancy was the leading cause of exudative                                                                                                                              ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما PE in this group of patients in Babol (43%), while TB accounted for only 33% of cases. Furthermore, these findings indicate that despite the development of new diagnostic procedures, pleural fluid analysis and pleu- ral biopsy, and in particular combinations of both procedures, remain valuable diagnos- tic methods for establishing the etiology and differentiating tuberculous PE from malig- nant PE in patients with exudative PE. The causes of exudative PE vary accord- ing to geographic region as well as the study population. Several factors including, age, smoking habits, exposure to environmental factors or occupational risk factors may increase the risk of malignancies, whereas crowding, poverty and malnutrition are as- sociated with increased risk of TB. Our study contrasts with 2 epidemiologi- cal studies from TB-endemic areas, where TB was the most common cause of exuda- tive PE (43.7% and 44.1% of patients), whereas malignant diseases accounted for 32.1% and 29.6 % of patients respectively [5,6]. However, in 2 other studies from TB-endemic areas, malignant diseases were more frequent than TB [9,10]. In another study of patients with exudative or tran- sudative pleural effusions in the Islamic Republic of Iran, malignant diseases were more frequent than TB [8]. In this study we have investigated a cohort of patients with exudative PE who underwent diagnostic thoracentesis. The majority of these patients were referred from other health centres for further investigation because of persistent PE. The population of this study did not include all cases of PE because several cases of tuberculous PE or malignant PE with obvious clinical and radiological findings who did not require further diagnostic measures were not re- ferred. Therefore, the present study entailed only inpatients, mostly with longstanding and probably advanced disease. The study population of the present study differs from the epidemiological-based study population regarding patient selection. The low prevalence of parapneumonia effusions and congestive heart failure in this study was also due to exclusion of patients with obvious clinical findings of pneumonia and congestive heart failure who did not require diagnostic pleural fluid analysis and pleural biopsy. However, in this study, the causes of exudative PE were undetermined in 8% of patients after follow-up for a mean period of 3 months; this value is lower than that reported by Zabokis et al. [9]. We obtained a yield of 70% for pleu- ral biopsy in diagnosis of tuberculous PE and 54% for malignant PE. The diagnostic yield of pleural fluid analysis was 33% for tuberculous PE and 70% for malignant PE. The yields of either pleural fluid analysis or pleural biopsy or both for diagnosis of tuberculous PE and malignant PE were 97% and 91% respectively. The etiological diagnosis in 93% of the entire population was established by performance of pleural fluid analysis and pleural biopsy. The diagnostic yields of pleural biopsy and pleural fluid analysis for diagnosis of tuberculous PE and malignant PE vary ac- cording to published studies [9–12,14–18]. Salazar-Lezama et al. found pleural biopsy to be the most effective method in diagnosis of pathology in 87% of cases with tubercu- lous PE [16], whereas in another study of patients with tuberculous PE the diagnostic yield of pleural biopsy was 47.4% which was lower than our study [17]. In a study by Christopher et al. the diagnostic yield of pleural biopsy was 75% in tuberculous PE and 71% in patients with malignant PE [11]. Mohamed et al. obtained a diagnostic yield of 60% in tuberculous PE and 50% in ma- lignant PE, but the yields for thoracoscopic biopsy were 93% and 94% respectively [10]. In a study by Jain et al. the diagnostic   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما yields of visceral pleural biopsy in tuber- culous PE and malignant PE were 69.7% and 81.3%, and parietal pleural biopsy were 42.3% and 31.3% respectively [18]. The proportion of patients with ma- lignant PE who had positive pleural fluid analysis in these studies ranged from 62% to 76% [9,10,12] and the positivity rate of pleural fluid cultures in patients with tuberculous PE ranged from 7.9% to 73% [12,14–17,19]. Chen et al. compared the diagnostic value of echo-guided pleural biopsy with that of pleural fluid analysis in patients with malignant PE [12]. They obtained a diag- nostic yield of 55% with pleural biopsy and 64% with pleural fluid analysis. Combining both methods increased the diagnostic rate to 88% in patients with malignant PE, which compares with 91% for our study. In another study of patients with malignant PE, the di- agnostic yields of lavage cytologic analysis and fluid cytologic analysis were 84% and 62% respectively whereas the diagnostic yield of combined thoracoscopy and lavage cytologic analysis was 96% [10]. In addition to the present study, several previous studies have shown a higher sensi- tivity of pleural fluid analysis than pleural biopsy in the diagnosis of malignant PE and superiority of pleural biopsy in diagnosis of tuberculous PE [19–24]. The diagnostic yields of combined pleu- ral fluid analysis and pleural biopsy in 3 previous studies for diagnosing malignant PE ranged from 64.7% to 94% and for diagnosis of tuberculous PE ranged 86% to 93% [20–22]. Furthermore in this study, 9 out of 13 (70%) cytology-negative pleural fluid sam- ples were diagnosed as having malignant PE by pleural biopsy. In a study by Prakash et al. [20] the diagnostic sensitivity of pleu- ral biopsy in cytology-negative malignancy was 7.1%. In the current study, the yields of pleural fluid analysis for diagnosis of malig- nant PE and pleural biopsy for diagnosis of TB, in particular the sensitivity of combined pleural fluid analysis and pleural biopsy, was higher. This may be due to advanced cases of malignant disease with extensive involvement of the parietal pleura. In this study tuberculin skin test, sputum smears and cultures were not helpful for diagnosis of TB. However, the low positive rate of these tests was also reported in previ- ous studies [12,15,17,25]. With regard to the clinical data presented here, large, bloody and right-sided PE with a high protein concentration favours the diagnosis of malignant PE rather than TB. In summary, the findings of the present study in confirmation with previous studies indicate that TB and malignancy are the most probable causes of exudative PE. Additionally, these results confirm that, despite the development of new diagnos- tic procedures, pleural fluid analysis and pleural biopsy remain the best diagnostic methods for evaluation of PE, as well as for determining the etiology in patients with exudative PE.                           ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                                                                                               ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                            World Health Assembly resolution on TB On 23 May 2007, the 60th World Health Assembly passed a resolu- tion urging WHO Member States to develop and implement long-term plans for TB prevention and control aimed at accelerating progress towards halving TB deaths and prevalence by 2015, through the full implementation of the Global Plan to Stop TB, 2006–2015. WHO is requested to strengthen its support to countries affected by TB, in par- ticular those heavily affected by Multidrug-Resistant TB (MDR-TB) and Extensively Drug-Resistant TB (XDR-TB), as well as TB/HIV. Member States are also urged, where warranted, to declare TB an emergency. The Global Plan to Stop TB 2006–2015 is a comprehensive assess- ment of the action and resources needed to implement the Stop TB strategy and make an impact on the global TB burden. The plan can be downloaded in Arabic, English, French and Spanish from the homep- age. Actions for Life, a flash film about the Global Plan can be accessed on the same page, URL http://www.stoptb.org/globalplan/    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                             ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  La fréquence des infections sexuellement transmissibles (IST) est en augmentation dans le monde, notamment dans les pays en développement où la situation est particu- lièrement préoccupante. En tant que popula- tion à risque, la population carcérale semble contenir une prévalence encore plus élevée d’IST. De nombreuses études se sont pen- chées sur l’évaluation de la prévalence des IST au niveau des centres d’incarcération, sur les facteurs de risque de transmission de ces infections et sur les moyens de lutter contre la propagation des IST en milieu carcéral. Aucune étude dans notre pays ne s’était intéressée auparavant à la situation des IST dans nos prisons. Le but de notre étude était d’évaluer la prévalence de la syphilis et de l’infection à VIH dans une prison pour fem- mes à Casablanca et d’étudier les facteurs de risque de transmission de ces deux IST dans cette population.  Nous avons mené cette étude au cours d’une action médicale organisée par une associa- tion bénévole « AMANE », qui a financé les prélèvements. Cette association natio- nale a été créée en 2001 et a pour but de promouvoir le développement durable mé- dical et environnemental des populations rurales, surtout dans les régions enclavées du Maroc. L’association mène également des actions dans des milieux clos. Cette action a été menée en avril 2004 à la prison Oukacha de Casablanca, section femmes. Elle avait pour but de prodiguer des soins à toutes les femmes qui présentaient des plaintes physiques. Une équipe de médecins de différentes spécialités a eu l’autorisation du ministère de l’Intérieur de soigner toutes les prisonnières. Nous avons interrogé et examiné toutes les femmes présentes ce jour-là. Une fiche de consentement éclairé a été signée par toutes les femmes désirant faire partie de l’étude. Sur une fiche pré- établie étaient notés les caractéristiques socio-économiques (niveau d’étude, statut matrimonial, revenu mensuel), les antécé- dents, le comportement sexuel (nombre de partenaires, prostitution, pratiques sexuel- les), les habitudes toxiques et les données de l’examen clinique (recherche de chancre, d’adénopathies, de leucorrhées et de lésions cutanées). La confidentialité a été assurée par l’anonymat des fiches et l’isolement des femmes au cours de l’interrogatoire. Des prélèvements ont été effectués chez les fem- mes ayant consenti à faire partie de l’étude pour les tests sérologiques TPHA (Trepo- nema Pallidum Haemagglutination As- say [essai d’hémagglutination passive pour le sérodiagnostic de la syphilis]), VDRL (Venereal Disease Research Laboratory) (dosage quantitatif) et VIH type ELISA avec confirmation au Western Blot en cas de positivité. Les patientes qui présentaient des sérologies positives ont été adressées aux services concernés pour prise en charge thérapeutique. Une étude uni- puis multivariée a été faite afin de déterminer les facteurs de ris- que de transmission de la syphilis et du VIH dans la population étudiée. Les variables quantitatives ont été exprimées en moyenne plus ou moins écart type, les valeurs qualita- tives en %. Pour l’analyse univariée, le test du 2 a été utilisé pour les valeurs en %, et le test t de Student pour les moyennes. Le seuil de signification a été fixé à 0,05. Seules les variables statistiquement significatives en analyse univariée ont été introduites dans le modèle de régression logistique de l’analyse multivariée. Les odds ratio ont été calculés avec leurs intervalles de confiance à 95 % pour mesurer le risque d’infection par la syphilis et le VIH dans la population    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما étudiée en fonction des facteurs étudiés supposés à risque.  Sur les 300 femmes présentes ce jour, 217 ont consenti à faire partie de l’étude. La moyenne d’âge était de 32,0 ans (E.T. 12), avec des extrêmes allant de 13 à 70 ans. La durée moyenne d’incarcération était de 22,8 mois avec une moyenne de 1,2 incar- cération (1 à 5) (Tableau 1) ; 31 % étaient mariées, 30 % célibataires, 27 % séparées et 11 % veuves. L’utilisation de préser- vatifs a été retrouvée dans 9 % des cas. L’homosexualité n’a jamais été avouée. Le taux de toxicomanie intraveineuse était de 1,8 % et le nombre moyen de partenaires de 5,17 (allant de 0 à 50). Un antécédent connu de syphilis était retrouvé dans 6 % des cas et aucun cas de séropositivité VIH n’était connu. Cinquante et une femmes, soit 23 %, avaient une sérologie syphilitique positive. Le TPHA était positif dans tous ces cas et le VDRL dans 80 % des cas. Quand le profil sérologique correspon- dait à une syphilis récente, des injections d’extencilline ont été prescrites. En cas de syphilis ancienne, un examen ophtalmo- logique et cardio-vasculaire ainsi qu’une ponction lombaire ont été pratiqués. Tous étaient négatifs, concluant dans tous les cas à une syphilis latente. Chez 4 femmes, la sérologie VIH type ELISA était positive, confirmée au Western Blot. Chez les prisonnières qui avaient une sérologie TPHA positive, nous avons noté un âge de premier rapport plus jeune, un nombre de partenaires plus élevé, une ori- gine rurale moins fréquente et un taux de prostitution avouée très élevé, de l’ordre de 40 % (Tableau 2). Parmi ces femmes, 23 % étaient sous traitement psychiatrique. Parmi les 4 femmes séropositives au VIH, 3 avaient une sérologie syphilitique également positive. Cependant leur nombre était faible, ne permettant pas de conclure à des facteurs de risque statistiquement signi- ficatifs. Pour les prisonnières non infectées, le statut familial mariée ou veuve était plus fréquent et le niveau d’instruction plus élevé. Une analyse multivariée a trouvé que le statut « mariée » était protecteur de la syphilis avec un odds ratio de 0,75 (intervalle de confiance [IC] à 95 % : 0,57 - 0,97). Par ailleurs, le nombre de partenaires élevé représentait un facteur de risque de syphilis, avec un odds ratio de 2 (IC 95 % : 1,2 - 3,51).                                                            ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  Il est connu que les populations carcérales sont confrontées à des problèmes sanitaires spécifiques, notamment la fréquence de la toxicomanie, des infections à transmission sanguine ou sexuelle, la marginalité sociale et la faible médicalisation [1]. Ainsi l’ab- sence de programme de prévention, de dia- gnostic et de traitement précoces dans notre contexte entraîne une augmentation des maladies générales et des IST en particulier. Nous notons une prévalence très élevée de la syphilis dans la prison étudiée, de l’ordre de 23 %, alors qu’elle variait de 3,2 à 5,7 % dans des prisons en Australie [2], au Brésil [3] et aux États-Unis [4] (Tableau 3). En ce qui concerne le VIH, la prévalence re- trouvée était faible, de l’ordre de 2 %, alors qu’elle atteignait 12,4 % dans une unité de détention pour homosexuels à Los Angeles [5] et 14,5 % dans une prison pour femmes au Brésil [3] (Tableau 4). Nous ne disposons pas de chiffre d’inci- dence précis de la syphilis au Maroc. Pour ce, nous avons consulté les bulletins épidé- miologiques du ministère de la Santé pu- blique [6]. Nous retrouvons une prévalence de 5,6 % sur une population consultant aux centres de santé pour des douleurs pelvien- nes [7]. Concernant la prévalence du VIH, elle reste faible dans les populations non à risque, contrairement aux professionnelles du sexe chez qui la prévalence était de 2,30 % (rejoignant la prévalence retrouvée dans la prison étudiée) [6]. Des études me- nées aux États-Unis ont montré que le VIH était cinq fois plus fréquent en prison que dans la population générale [8]. Les facteurs de risque de transmission le plus souvent retrouvés dans les prisons sont les relations homosexuelles, les drogues intraveineuses                                                           ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما et les tatouages et piercing qui sont souvent associés [8,9]. Dans notre série, nous ne retrouvons pas de facteurs inhérents à la prison puisque nous retrouvons en premier lieu la prostitution, suivie du nombre de partenaires élevé et du niveau d’instruction bas. De nombreux tabous ressentis au cours des entretiens ne nous permettent pas de nous prononcer sur l’utilisation des drogues et sur l’homosexualité à l’intérieur de l’institution.  Les infections sexuellement transmissi- bles représentent un problème de santé                                  publique en prison. Nous avons trouvé un taux très élevé de syphilis dans la prison étudiée compatible avec les mouvements d’incidence de la syphilis retrouvés dans les pays en développement et dans certaines populations défavorisées aux États-Unis. Le taux de VIH reste faible, comme c’est le cas dans la population générale, puisqu’il y a 1550 cas cumulés d’infection à VIH déclarés au Maroc depuis 1986. Des études multicentriques sont nécessaires pour éva- luer l’étendue des IST au Maroc et proposer des stratégies de prévention spécialement en milieu carcéral.                                                                                      ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                        Health in prisons—a WHO guide to the essentials in prison health Based on the experience of many countries in the WHO European Re- gion and the advice of experts, this guide outlines some of the steps prison systems should take to reduce the public health risks from compulsory detention in often unhealthy situations, to care for prison- ers in need and to promote the health of prisoners and prison staff. This requires that everyone working in prisons understands how im- prisonment affects health, what prisoners health needs are and how evidence-based health services can be provided for everyone needing treatment, care and prevention in prison. Other essential elements are being aware of and accepting internation- ally recommended standards for prison health; providing professional care with the same adherence to professional ethics as in other health services; and, while seeing individual needs as the central feature of the care provided, promoting a whole-prison approach to care and promoting the health and well-being of people in custody. This publication is available from WHO Press, Geneva, or via the web- site at: http://www.who.int/bookorders/index.htm    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  Thalassaemia syndromes are the most com- mon single-gene disorder worldwide: about 3% of the world population (150 million) carries the -thalassaemia genes [1]. In Egypt, -thalassaemia is the most common genetically-determined, chronic, haemolytic anaemia. The actual number of patients surviving to date is not, however, available [2]. The economic and social cost of the disease is high owing to the patient’s life- long need for monthly blood transfusions and treatment with iron chelating agent. If there is no concomitant reduction in the number of new thalassaemia major births, there will be a cumulative increase in numbers requiring treatment [3]. Screening programmes for detection of -thalassaemia trait, together with prenatal diagnosis and elective abortion of homozygous fetuses, allow couples at risk to avoid having a ho- mozygous thalassemic child [4]. Screening for -thalassaemia is diffi- cult, mainly because of heterogeneity of -thalassaemia and the absence of a single pathognomonic finding to cover all variants. Despite these difficulties, many attempts have been made to establish screening tests and to aid in the differentiation of various forms of microcytic anaemia, especially the most common, iron deficiency anaemia [1]. In some areas the birth of homozygotic infants has fallen dramatically [5]. The most reliable methods for diagnosis of thalassaemia trait include quantitative determination of haemoglobin A2 (HbA2), haemoglobin F (HbF), globin chain syn- thetic ratios and DNA studies for specific mutations. These methods are accurate but too expensive for initial mass screening [6]. Since thalassaemia is almost invariably associated with microcytosis and significant hypochromia, determination of red cell index has been used as a preliminary indica- tion of thalassaemia trait [7]. In Egypt, no definite national screening programme has yet been developed for detection of -thalassaemia carriers [8]. The aim of our study was to deter- mine the carrier rate of -thalassaemia in Egypt, and to determine the most economic and accurate test for a mass screening programme.  This study was carried out during the period September 2004–April 2005. The partici- pants comprised 1000 school-age children from different geographical areas, 40% from Upper Egypt and 60% from Lower Egypt. The children were randomly selected from healthy siblings of patients at the new Cairo University Children’s Hospital as well as children who were attending the surgical department of the hospital for mi- nor procedures. This hospital is the largest referral hospital in the country; patients are referred from all areas of Egypt. The partici- pants had no signs or symptoms suggesting haematological disease and no family his- tory of any haematological disease. Mean age was 10 (standard deviation 3) years. Informed consent was obtained from the children’s guardians for all participants. There were no refusals to participate. One hundred -thalassaemia carriers, who were parents of known -thalassaemia patients, were enrolled in Group 4 as con- trols. They were randomly selected while visiting the haematology clinic of the new Cairo University Children’s Hospital for follow-up appointments with their children (thalassaemia patients). This hospital is the biggest referral centre for haematological diseases in Egypt. There were no refusals to participate.    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Blood samples (5 mL) were taken from all participants and tested at the clinical pathology laboratory in the new Cairo Uni- versity Children’s Hospital. A 1 mL aliquot of venous blood was mixed with 1.2 mg EDTA to do a complete blood count for all participants using an electronic Coulter counter (Sysmex KX-21N) and to assess haemoglobin, haematocrit, mean corpuscu- lar volume (MCV) and mean corpuscular haemoglobin (MCH). For participants whose results indicated microcytosis, i.e. MCV < 80 fL [9] and/or hypochromia, i.e. MCH < 27 pg [9], a sec- ond 6 mL venous blood sample was taken. The sample was split into 2 test tubes and the following tests were carried out im- mediately. • Tests for iron status • serum iron level by automated ana- lyser (Beckman Coulter Synchron CX9 PRO); normal range 70–200 µg/dL • total iron-binding capacity (TIBC) by automated analyser; normal range 250–435 µg/dL • transferrin saturation (TS = serum iron/TIBC × 100); normal range 20%–45%. • Tests for -thalassaemia carrier detec- tion • HbA2%, the gold standard test used in this study, by microcolumn chro- matography (Helena Beta-Thal HbA2 Quik Column, cut-off 3.5%) [10]. • haemoglobin F (HbF%) by cellulose acetate electrophoresis at pH 8.4 (cut- off 1.0%) [10] • one-tube red cell osmotic fragility test with 0.36% buffered saline solution [11]. To perform the osmotic fragility tests 0.3 mL of whole blood was added to 9 mL 0.36% buffered saline. Each tube was mixed well by inverting 5 times. After 10 minutes, the tube was inspected visually in a propri- etary test tube holder with a striped back- ground. If the stripes were clearly visible, indicating complete lysis, the test was read as negative. If turbidity caused the lines to be blurred, the test was considered positive. Equivocal results were those in which there was a very fine cloudiness in the tube and the edges of the lines were slightly blurred. All equivocal or definite positive results were regarded as positive, indicating the need for further investigation. The numerical data were presented as mean and standard deviation. The Student t-test (unpaired-t) was used to compare between groups of numerical data. P-value < 0.05 was considered statistically signifi- cant. Diagnostic properties such as sensitiv- ity, specificity and predictive value were used for data analysis [12].  The complete blood count testing of the 1000 children we screened revealed that 412 (41.2%) showed microcytosis (MCV < 80 fL). These participants were divided into groups according to their HbA2 level, HbF level and iron status. • Group 1, the -thalassaemia carrier group, had high levels of HbA2 (> 3.6%) and normal levels of the iron parameters studied. Three (3.3%) had high HbF lev- els (Table 1). This group comprised 90 children (9%). • Group 2, the indeterminate group, com- prised 12 children (1.2%) with border- line levels of HbA2 (range 3.3%–3.5%), low transferrin saturation and low serum iron, but with normal TIBC (Table 1). • Group 3, the iron deficiency group, com- prised 310 children (31.0%) with normal levels of HbA2 (range 1.3%–2.4%), low   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                     µ                µ                                                                               ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما transferrin saturation, low serum iron and normal to high TIBC (Table 1). • We also included 100 obligatory carri- ers, Group 4, as controls. They had high levels of HbA2 (> 3.6%) and normal levels of iron parameters (Table 1). High HbF levels were found in 2 cases only. The rate for positive osmotic fragil- ity test was highest, 83.3%, for Group 2, closely followed by Group 1 and Group 4, both > 80%. The lowest rate, 63.9%, was for Group 3, the iron deficiency group (Table 1). There were no major differences between Group 1, the -thalassaemia carrier group, and Group 4, the obligatory carrier group, in any of the tests. Both groups showed microcytosis (MCV < 80 fL), hypochromia (MCH < 27 pg), high HbA2 (> 3.6%) and normal iron parameters (Table 1). There was a significant correlation be- tween degree of anaemia (Hb level) and degree of microcytosis in Group 1, the -thalassaemia carrier group (P < 0.01; r = 0.7) and in Group 4, the obligatory carrier group (P < 0.001; r = 0.3). In Group 3, the iron deficiency group, and Group 2, MCV was significantly corre- lated with Hb level (P < 0.01 and < 0.0001 respectively; r = 0.7 and 0.9 respectively). The MCV in these 2 groups was signifi- cantly correlated with the degree of iron deficiency. In Group 2, the MCV was statistically significantly correlated with serum iron and transferrin saturation (P < 0.002 and < 0.001 respectively; r = 0.8 for both); the correlation was also sig- nificant in Group 3 (P < 0.0001 for both; r = 0.6 for both). For the one-tube osmotic fragility test for detection of -thalassaemia carriers, sensitivity was 87.0%, specificity 34.1%, positive predictive value 47.2%, negative predictive value 82.3% and overall ac- curacy 53.0%.  In this study, microcytosis was significantly correlated with the degree of anaemia in the screened -thalassaemia carrier group but correlation between the MCV and iron parameters was not statistically significant. In the iron deficiency group, microcytosis was significantly correlated with the degree of anaemia as well as the degree of iron deficiency. It has previously been reported that microcytosis and hypochromia in tha- lassaemia trait may be greater than expected for the mild degree of anaemia, but in iron deficiency cases, microcytosis was related to the degree of anaemia [13]. Our 412 cases with microcytosis were subdivided into 3 groups according to their HbA2 levels. Group 1 had high HbA2, 3.9%–6.0%; Group 2 had borderline HbA2, 3.3%–3.5%; Group 3 had low to normal HbA2, 1.3%–2.4%. In previous reports, many researchers considered HbA2 levels 3.8%–8.0% indicative of -thalassaemia trait and 3.3%–3.8 % as borderline, requir- ing further assessment [14]. These values were in accordance with the HbA2 levels of our obligatory carriers, Group 4. In our study, elevated HbF was detected in 3.3% of cases in Group 1. This is consid- erably fewer than the 30%–50% of cases with high HbF (> 1.0%) that have been reported previously [9]. It was, however, in keeping with the levels in the obligatory carriers in Group 4, where 2% only had elevated HbF levels. Iron parameters were normal in the 2 carrier groups, but abnormal levels were found in the other 2 groups. Normal serum iron levels range from 70 µg/dL to 200 µg/ dL. Low levels are seen in iron deficiency states, and high levels are found in ineffec- tive erythropoiesis and iron overload. The TIBC has a normal range of 250–435 µg/ dL, mean 320 µg/dL, and it is raised in iron deficiency [15].   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما In our study, transferrin saturation was used as an index of iron status, and values < 16% were taken as an indicator of iron deficiency, as seen in Group 2 and Group 3. Many other researchers have reported that transferrin saturation < 16% constitutes good evidence of iron deficiency only in conjunction with low MCV [9–15]. In Group 2, iron deficiency was indicat- ed by the different index of iron status and borderline HbA2. It has been reported that such concordance results in reduction of HbA2 synthesis, and the HbA2 value may be reduced to borderline or even normal levels in -thalassaemia trait, depending on the severity of the anaemia [16]. The osmotic fragility test was positive in 81.1% of the carrier group and 63.9% of the iron deficiency group. This is lower than that reported in a previous study, 96% in a thalassaemia carrier group and 80% in an iron deficiency group [11]. In our study the one-tube osmotic fragil- ity test showed limitations as a screening test for -thalassaemia. This has been reported in other studies. The test is potentially use- ful although it cannot replace automated red cell indices, and specificity would clearly be much worse in a population where iron deficiency is common [17]. On the other hand previous reports have found the one- tube osmotic fragility test could be used as an effective preliminary screening for identifying thalassaemia carriers [7,18]. Our study verified a high prevalence of iron deficiency status among the screened sample. This has been reported in other studies, iron deficiency remains the most common cause of microcytic anaemia worldwide [19]. In conclusion, the -thalassaemia car- rier rate in Egypt is not less than 9%, and 1.2% of those we tested would require fur- ther evaluation. The combination of MCV, HbA2 level by column chromatography and transferrin saturation seems useful for a tha- lassaemia screening programme in Egypt. The osmotic fragility test has limited value in our population, where iron deficiency is prevalent.                                                                                                                   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                        ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  Duodenal ulcer disease is the common- est cause of severe upper gastrointestinal bleeding, accounting for 30%–70% of total cases [1–3]. Duodenal ulcer bleeding is 4 times commoner than gastric ulcer bleed- ing and is usually posterior and involves erosion in a branch of the gastroduodenal artery [1,4–6] Significant bleeding occurs in 10% to 15% of all duodenal ulcer patients [6–8], and significant intervention is required in up to 20% of these patients. The elderly are more likely to bleed persistently because atherosclerotic vessels contract less, and surgery may be necessary in a higher pro- portion of patients over 60 years old. Retrospective studies have shown that haematemesis and melaena which follow bleeding duodenal ulcer account for more than 30% of admissions with upper gastroin- testinal haemorrhage [1,2,9], and bleeding duodenal ulcer is a significant cause of death in hospital, with a mortality of 5%–7% [3]. To improve results emergency measures should be undertaken [8,10,11]. Previous retrospective analyses in our region have shown a relatively high mortal- ity of about 15% for bleeding duodenal ulcer [12]. This finding prompted the es- tablishment in 1999 of a separate haemate- mesis and melaena unit in our hospital where patients are managed according to a defined protocol depending on the cause of bleeding. The aim of this study was to review the medical treatment and medical outcome of cases with upper intestinal bleeding admit- ted to Erbil City hospital from the Emer- gency Department over a 9-year period, 1996–2004.  The medical records of all patients with upper intestinal bleeding admitted to Erbil City hospital from the Emergency Depart- ment over a 9-year period, 1996–2004 were reviewed and the following data extracted: cause of bleeding, procedures undergone, clinical symptoms, management, outcome and follow up. Patients with other serious conditions which may lead to bleeding or affect the treatment of duodenal ulcer, such as human immunodeficiency virus infection, uncontrolled diabetes mellitus, uncontrolled hypertension, decompensated liver disease, renal failure, ischaemic heart disease, autoimmune disorders, and patients under anticoagulant therapy were excluded from this study. The hospital management policy speci- fied immediate resuscitation and endoscopy within 24 hours of admission. The indica- tion for blood transfusion was shock and/or haemoglobin < 10 g/dL. During the first 2 years of the study, some patients had subse- quent barium meal examination after acute bleeding attacks if the endoscopy results were suspicious for some reason or other. However after this, barium meal examina- tion was only performed in patients who could not undergo endoscopic examination. In addition, endoscopy was used to collect biopsy specimens from gastric mucosa in all the cases for isolation of Helicobacter pylori. Since the eradication of H. pylori decreases the risk of recurrent duodenal ulcer and may prevent recurrent bleeding, a combination of amoxicillin metronidazole and clarithromycin for 4 weeks was admin- istered to all patients positive for H. pylori infection as part of the standard hospital procedure.   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما After 12–24 hours had passed and the bleeding had clearly stopped, a patient who felt hungry was allowed oral feeding. Twice- daily haematocrit readings were taken as a check on slow continued blood loss.   A total of 740 patients presented to the Emergency Department of Erbil City hospi- tal with upper gastrointestinal bleeding over the 9 years of 1996 to 2004. All patients were admitted to the hospital under the care of the surgeon on call and the emergency surgical team. Table 1 shows the causes of bleeding in the patients presenting to the Emergency Department. Bleeding duode- nal ulcer was the commonest diagnosis, 556 (75.1%) patients. Of these, 532 pa- tients (95.7%) (312 males and 220 females) [mean age 44, standard deviation (SD) 15 years] were first-time admissions, while 24 patients were re-admissions (4.3%). Table 2 shows the treatment given to the bleeding duodenal ulcer patients, both for first- and second-time admissions. Of the 556 admissions with bleeding duodenal ulcer, 318 received conservative medical therapy while surgery was performed on 238 patients. Of the 24 patients readmitted on a second occasion, 10 underwent surgery, while 14 were again treated conservatively, either because of associated disease (car- diac or respiratory disease) or because they refused surgery. About 5% of the patients suffering from bleeding duodenal ulcer required emergency surgery. On admission, 170 (30.6%) patients were in shock and 328 (59.0%) had a hae- moglobin of 10 g/dL (Table 3). Of the 556 patients with bleeding duodenal ulcer, 242 (43.5%) received more than 5 units of blood. Endoscopy was the diagnostic method most often used (91.4% of our cases) (Table 3). There were 26 deaths over the study period (4.7%); 20 occurred in patients who underwent emergency surgery, whilst 6 died in the group that was treated medically (1 following endoscopic perforation). There were associated lesions in the upper gastrointestinal tract of 54 patients with bleeding duodenal ulcer during en- doscopy, but those were not the source of major bleeding. Of the 54, 15 patients had acute gastric erosions, 4 had small varices, 6 had chronic benign gastric ulcer, 19 had oesophagitis, 9 had hiatus hernia and 1 patient had a prepyloric ulcer.  In order to evaluate trends, comparison was made between the 3 consecutive 3- year periods of study (Table 4). During 1996–98, there were 168 admissions with duodenal ulcer and 12 deaths (7.1%). For 1999–2001, there were 202 admissions and 10 deaths (5.0%). For 2002–04, there were 186 admissions and 4 deaths (2.2%). The operative mortality was 10 of 76 operations (13.2%) for the first 3-year period, 8 of 100 operations (8.0%) for the second 3-year pe-                                      ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما riod and 2 of 64 operations (3.1%) for final 3 years of the study. In the medically treated patients there were 2 deaths in each 3-year period. There was no change in the frequency of shock on admission. The endoscopic diagnostic rate rose from 76.2% in the first period of study, to 100% in the last period with the introduc- tion of new generations of endoscopes.   A total of 318 patients were admitted and treated medically, 32 of these were re-bleed and 20 of these were again treated conserva- tively (Table 5). The mean age of this group of patients was 55 (SD 15) years. In 106/318 (33.3%) of these patients there was a past history of upper gastrointestinal bleeding. Of the medically treated patients, 6 died in hospital. There were 92 patients lost to follow-up in this group, giving a follow- up rate of 71.1% for a mean period of 2.5 years. Fifty (50) patients subsequently under- went elective surgery for duodenal ulcer, usually for symptoms not controlled by medical management.   Of the 556 patients diagnosed with bleeding duodenal ulcer, 238 (42.8%) patients were treated by surgery (elective or emergency) (Table 6). The mean age of these patients was 56.5 (SD 10) years. Three types of sur- gical procedure were undertaken: vagotomy and pyloroplasty, vagotomy and antrec- tomy, and oversewing. Of 204 patients treated by vagotomy and pyloroplasty, 6 had a recurrent ulcer. There were 20 deaths, giving an op- erative mortality of 8.4%. The overall death rate in those undergoing vagotomy and py- loroplasty (5%) was lower than those under- going vagotomy and antrectomy (23.5%). On follow-up, 12 patients died more than 3 months after discharge; 8 deaths were due to diseases unrelated to duodenal ulcer and in 4 cases the cause of death was unknown; 12 patients were lost to follow-up. Overall, 85% of the patients with surgical interven-                                                               ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما tions had satisfactory outcome from their operation. The main complications of operative treatment were late post-operative bleeding in 18 patients (7.5%), leakage in 3 (1.3%), sepsis in 6 (2.5%), early dumping syndrome in 12 (5.0%), and late dumping syndrome in 15 (6.3%).  Most patients in this study with bleeding peptic ulcer were successfully managed by medical means alone and initial therapeutic effects usually halted the bleeding. H2- blockers and proton pump inhibitors de- creased the risk of bleeding but had limited effect on active bleeding. In cases of re-bleeding the death rate was about 30%. A policy implemented in 1999 of early surgery for those who re-bled improved this figure. Patients who were over age 60 years, who presented with hae- matemesis, who were actively bleeding at the time of endoscopy, or whose admission                                                                                                                          ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما haemoglobin was < 8 g/dL had a high risk of re-bleeding. Most cases of re-bleeding occurred within 2 days of the time the first episode had stopped.  Duodenal ulcer disease is the common- est cause of severe upper gastrointestinal bleeding, accounting for 30%–50% of total cases [1–3]. The mortality rate is high due mainly to recurrent or persistent bleeding, surgical complications, or other underly- ing diseases [3,8]. Approximately 20% of patients with duodenal ulcer will experience a bleeding episode, and this complication is responsible for about 40% of deaths from peptic ulcer [11,13]. In this study, the overall mortality was almost 5%. Patients over 50 years of age and those in shock were most likely to have a poor outcome. The study suggests that with a planned approach to the prob- lem, mortality can be reduced and supports the concept of early endoscopy and an active surgical approach. Early surgery, particularly in patients over 50 years of age, is supported by the experience of other stud- ies which noted a significant relationship between mortality and further haemorrhage in hospital inpatients of over 60 years of age or with coincidental disease [14,15]. During the three 3-year periods the mor- tality fell from 7.1% during the first 3 years to 2.2% in the final 3 years. During the last year of the study there were no deaths with 90 admissions. Admission to a special- ist unit, early endoscopic diagnosis and a combined medical/surgical approach were possibly responsible for the lower mortality. There are occasional patients with advanced disease (cancer, cardiac or respiratory dis- ease) or very old age for whom no treatment is desirable. This was the cause of 4 of 6 deaths in the medically treated group. The type of surgery performed was de- pendent upon the circumstances. Partial gastrectomy was performed when vagoto- my might have been difficult, such as when varices were present, or when there was marked obesity or an enlarged left lobe of the liver [10,14]. Vagotomy + pyloroplasty and oversewing were the most effective surgical treatments as is generally recom- mended, especially in the aged [16–18]. Despite the rapid developments in en- doscopic and surgical techniques over the study period, we had to use the same lines of treatment throughout the 9 years of the study because of the sanctions imposed by the United Nations on Iraq after the Gulf war. These circumstances pushed Iraq back considerably in progress in all areas, includ- ing the medical services. Despite this, we did succeed in lowering the mortality rate over the 9-year period, both overall and for surgically-treated patients.  We would like to express our gratitude to the Emergency Department hospital admin- istration for their help with data collection and to the surgeons in the surgical unit for their kind permission to report the cases and the patient follow-up information.                        ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                                                           ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                      ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  Asir region (population 1 200 000) is lo- cated in the southwest of Saudi Arabia covering an area of more than 80 000 km2. The region extends from the high moun- tains of Sarawat (with an altitude of 3200 m above sea level) to the Red Sea, and lies a few kilometers from the northern border of neighbouring Yemen. The region is divided into 15 health districts. Primary health care services in Abha health district are provided through a widespread network of 36 urban and rural primary health care centres, pro- viding services to 129 465 people. Each pri- mary health care centre has a well-defined catchment area and population. Gallstone disease is a major cause of morbidity, and sometimes mortality, throughout the world. About 320 chole- cystectomies are performed every year in Asir Central Hospital, an affiliated teaching hospital with 550 beds. This only reflects the magnitude of symptomatic gallstone disease in our region. However, in other reports, more than 70% of individuals had asymptomatic gallstone disease [1,2]. The change in lifestyle among Saudis in recent years may suggest that the condition is of increasing health importance. The prevalence of gallstone disease has been little studied on a community basis in Saudi Arabia. Therefore, we decided to study the prevalence of gallstone disease and related risk factors in Abha region at a community level.   The minimum sample size required for the study was calculated to be 264 cases, with an anticipated population proportion of 20%, and with an absolute precision of 5% at 95% confidence interval [3]. To avoid loss of cases, a total of 300 cases was planned to be collected. They were selected using a cluster sampling technique from the catchment areas of the 36 primary health care centres in Abha region. To ensure equal involvement of adult males and females in the study, couples were regarded as the study unit. Through house-to-house survey, couples were contacted and asked to attend their local primary health care centre.  At the primary health care centre couples were interviewed using a structured obser- vation and interview questionnaires to col- lect data about sociodemographic factors, habits, past history of right hypochondrial pain, pancreatitis or any other diseases, and family history of diseases, especially gall- stone disease. History of pancreatitis was obtained by reviewing case records (based on feedback of results of prior referral to hospital, serum amylase and lipase results and/or positive findings on ultrasonogra- phy) [4]. Blood pressure was measured at least twice, in a controlled environment, after at least 3 to 5 min of rest in the seated position. The subject was asked to sit exposing his/ her arm then using a sphygmomanometer and stethoscope the systolic pressure was recorded when the first Korotkoff sound appeared while the diastolic pressure was recorded when the sound disappeared in Korotkoff phase V. The average of 2 read- ings was recorded. WHO definitions were used as the cut-off for hypertension: systolic blood pressure > 140 mmHg and/or diasto- lic blood pressure > 90 mmHg [5]. Height was measured to the nearest 0.1 cm using measuring tape and weight was measured using a standardized measur- ing scale to the nearest 0.1 kg. Body mass index (BMI) was calculated and overweight was defined as BMI 25 kg/m2 [6].   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Upper abdominal ultrasonography ex- amination was performed on each person for detection of gallstone disease. Ultrason- ography remains the method of choice for the diagnosis of gallstone disease, offering a number of advantages: it is non-invasive, there is no ionizing radiation, it is relatively inexpensive and adjacent organs can also be assessed. It also has a high sensitivity (97%), specificity (93.6%) and diagnostic accuracy (93.0%) [7]. Ultrasonography provides better results than computerized tomography and similar results to those of perioral cholecystography in determining the number and diameter of the stones. The sensitivity of ultrasonography in diagnosing gallbladder stones is comparable to magnetic resonance cholangiography (97.7%) [7].  Data were coded, validated and analysed using SPSS PC + software package, version 13. Univariate analysis methods were used at the 5% level of significance. Multivari- ate logistic regression analysis was used to identify potential risk factors. Kappa statis- tics were calculated to measure agreement between symptoms and ultrasonography findings. To study the reliability and validity of symptoms (as mentioned by respondents) and ultrasonography findings in detecting gallstone disease, stepwise discriminant analysis was used.  A total of 291 persons (response rate 97%) were included in the present study (143 males and 148 females). Age range was 25–85 years with a mean of 44.3 [standard deviation (SD) = 10.2] years and a median of 43.0 years. The mean age of males [48.6 years (SD = 10.3)] was significantly higher than that of females [40.3 years (SD = 8.4)] (t = 7.529, P < 0.05). A total of 34 cases had positive findings of gallstone disease by ultrasound (4 cases had already had cholecystectomy and 30 had gallstones). There were 6 males and 28 females. The overall prevalence of gallstone disease was 11.7% [95% confidence interval (CI): 8.4–15.7]. The prevalence in males and females was 4.2% (95% CI: 1.7–8.5) and 19.9% (95% CI: 13.2–25.8) respectively. Among positive gallstone cases, a single stone was found in 19 cases (63.3%), and thick-walled gallbladders were found in 5 cases (16.7%). Furthermore, 26 cases (86.7%) with stones were newly discov- ered, of which 16 (61.5%) had one or more symptoms suggestive of gallstone disease, and only 10 (38.5%) were asymptomatic. Table 1 shows the agreement of symp- toms with ultrasonography findings. Right hypochondrial pain was found to be sig- nificantly associated with positive ultra- sonography findings for gallstone disease ( = 0.148, P = 0.002). The results of discriminant analysis of symptoms reported by respondents are shown in Table 2. Only right hypochon- drial pain was significantly associated with gallstone disease (a low value of Wilks , canonical correlation and P < 0.05). This symptom had a high sensitivity and specifi- city of more than 70% in detecting gallstone disease. In univariate analysis, gallstone disease was common among females, illiterate pa- tients, smokers and those aged > 40 years. It was also common among people having a past history of pancreatis and family history of gallstone disease. Using logistic regression multivariate analysis (Table 3), it was clear that people with a past history of pancreatitis were 11 times more likely to have gallstone disease (adjusted OR = 11.5; 95% CI: 7.1–15.5) than people with no history of pancreatitis. Similarly, the following factors were also   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما identified as significant risk factors for gallstone disease: female sex (adjusted OR = 4.2; 95% CI: 1.3–13.6) and family his- tory of gallbladder stones (adjusted OR = 3.4; 95% CI: 1.3–8.7). On the other hand, age, education, blood pressure, smoking, coffee intake, overweight, diabetes, number of pregnancies and use of contraceptives among females were not significant.  Cholecystectomy is one of the most common operations performed in general surgical units throughout Saudi Arabia. It comprises about 47% of major and 23% of total gen- eral surgical operations in our hospital in Abha city and 15%–50% of all laparoto- mies in 2 different studies from Medina city [1,8]. These data give the impression that gallstone disease is common among Saudi Arabians. However, apart from a few scattered reports on gallstone disease from different parts of Saudi Arabia [1,8–12], the prevalence of gallstone disease at the country level has not been determined yet. Whereas the prevalence of gallstone dis- ease in our series was 11.7%, it was 4.4% in a study group of 1604 pregnant women from Al Kharj Military Hospital [11]. In other parts of the world, varying figures were given for the prevalence of gallstones,                                                                                               ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما ranging from 4% to more than 20% (Tunisia 4.1%, Islamic Republic of Iran 4.7%, Bang- ladesh 5.4%, Peru 10.7%, Germany 7.8%, New Zealand 20.8% and United States of America 10%–15%) [13–19]. It is known that the pathogenesis of gallstone disease is related to imbalance                                                                                                                                                                           ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما in the metabolic and dynamic process of cholesterol and bile acids. This can be di- rectly influenced by genetic, hormonal and metabolic factors. Although the association between gallstone disease and “fat, fer- tile, female and forty” has been observed and taught for a long time, it has a limited support in formal epidemiological studies [10]. It has been known that female sex, race, obesity, diabetes mellitus, ageing, cirrhosis, type IV hyperlipidaemia, parity, oral contraceptive use, smoking, and family history of gallstone disease are risk factors for gallstone formation [1,2,11,12,20–28]. In our study, only female sex and family history of gallstone and/or past history of pancreatitis were found to be significant risk factors. These findings agree with the findings in other national reports, although some of them added other risk factors in- cluding obesity, BMI > 30 kg/m2 and parity [1,9–12]. This inconsistency could be at- tributed to the environmental and genetic differences among different societies. Few studies have sought to describe the prevalence of gallstones in high altitude communities. Moro et al., in their study of gallstone disease in high altitude Peru- vian rural populations (> 3000 m above sea level), reported that high altitude was not a positive risk factor for gallstone disease [16]. On the other hand, Spathis et al. [29] reported high rates of gallstones among high altitude villagers of Ladakh, India. They attributed this rate to slow intestinal transit time that can lead to constipation, in- creased bilirubin absorption and higher bile concentrations in the gallbladder [16,29]. In addition, increased blood cell formation and hence increased haemolysis may increase levels of bilirubin pigments with an in- creased risk of pigment gallstones [30]. Our region is one of the highest altitude regions in the Middle East (> 3000 m above sea level). This may be one of the etiological factors contributing to the high prevalence in our area, but it is difficult to draw firm conclusions without a comparative study between high and low altitude areas in this regard. In contrast to similar reports from Amer- ica and Europe, where more than two thirds of gallstones were asymptomatic [19,23], more than 60% of our cases had symp- toms. The low prevalence of symptomatic gallstones in cross-sectional surveys from the industrialized countries is probably due to rapid diagnosis and treatment [31]. Controversies exist about the management of asymptomatic gallstones, particularly in the era of laparoscopic surgery [32–35]. Nearly 10% of individuals with asympto- matic gallstones may develop symptoms or complications requiring treatment within 5 years [36]. We found that female sex, history of right hypochondrium pain, family history of gallstone disease, and/or past history of pancreatitis, were significantly associ- ated with gallstone disease and this agrees with other reports [9,37]. It has also been reported that acute pancreatitis seen in Asir region is predominantly biliary and more frequent in females [38]. Although gallstone disease has compli- cations, the treatment (cholecystectomy) has its own risks as well. Complications of gallstone disease range from simple recur- rent biliary colic to severe, life-threatening ascending cholangitis and/or pancreatitis. Carcinoma of the gallbladder had been postulated to be intimately associated with long-standing gallstone disease, particu- larly when large or numerous cholesterol gallstones are present and in elderly female patients [39,40]. Furthermore, gallstone disease is thought to be a risk factor for pancreaticobiliary cancer, particularly in patients with choledocholithiasis [41].   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Most decision analysis studies do not favour prophylactic cholecystectomy for asymptomatic cholelithiasis. Nonetheless, many studies have listed certain criteria for carrying out elective cholecystectomy in asymptomatic patients, including: life expectancy > 20 years, calculi > 3 cm in diameter, particularly in individuals in geo- graphical regions with a high prevalence of gallbladder cancer or calculi < 3 mm, chronically obliterated cystic duct, non- functioning gallbladder and calcified (por- celain) gallbladder. This, in turn, has given rise to a great deal of controversy regarding the optimal management of asymptomatic or “silent” gallstones. While cholecystectomy is the undisputed gold standard treatment for symptomatic gallstones, the natural history of silent gallstones is not known well enough to recommend a definitive therapeutic strategy for such patients. The treatment options for asymptomatic or silent gallstones range from no treatment to selec- tive cholecystectomy in the at-risk group to elective cholecystectomy in all patients. There are a large number of proponents for each of these options so each merits careful consideration [42]. In conclusion, gallstone disease is prev- alent in the community of Asir region of Saudi Arabia (11.7%). Primary health care physicians in the region should pay more at- tention to patients with right hypochondrial pain, especially if they are women, with family history of gallstone disease and/or having a past history of pancreatitis. They should be referred for upper abdominal ultrasonography for screening and early de- tection of gallstone disease. We would like to emphasize that a fundamental knowledge of gallstone disease and its complications is essential for clinicians. Thus, high-risk groups might be identified and a realistic approach for prophylaxis for any reversible risk factors could then be offered.  The authors would like to express their thanks and appreciation to the administra- tion of Abha Private Hospital for their coop- eration in doing all ultrasound scanning for the study group free of charge. We are also indebted to Dr Abdulla Al-Sharif, previ- ous Director General of Asir Directorate of Health Affairs, for his cooperation and sup- port during the field activities of the study, and to our colleagues in the primary health care centres.                                                                               ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                                                                                               ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                            ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                           20031711 29.2 57.512.3 45.4–17.1    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  End-stage renal disease (ESRD) is a growing problem worldwide and renal replacement therapy is exerting an increasing pressure on health systems [1]. The situation is par- ticularly serious in developing countries where health resources are limited. ESRD is defined as a glomerular filtration rate < 15 mL/minute/1.73 m2. Studies from many countries showed that the incidence of ESRD has increased [2–4]. In Jordan for example, the number of patients on haemo- dialysis has at least doubled over the past 5 years [5], posing a serious challenge to the already strained health care resources. The increasing trend of diabetes mellitus (DM) is believed to be a major contributing factor for the observed increase in the incidence of ESRD. The prevalence of DM has been increasing on a worldwide scale [6,7]. In Jordan, the reported prevalence of DM is 13.4% for people over 25 years of age [8]. Furthermore, different reports indicate that about half the patients with type 2 DM are undetected [9,10]. Key factors for the observed increase in DM include demographic changes, increase in the size of highly susceptible popula- tions, such as the elderly, and sociocultural developments that breed a more sedentary population and expose the people to added environmental risk factors for this disease. At present, DM is the leading cause of ESRD in many countries [4,11–14]. In the Eastern Mediterranean Region, data from Bahrain [15], Oman [16] and Saudi Arabia [17] showed that DM is the cause of ESRD in 30%, 14.5% and 60% of patients respec- tively. A study from the Czech Republic showed that diabetic nephropathy affects 4%–8% of diabetic patients attending diabe- tes clinics [18]. One study from the United States reported that diabetic nephropathy occurs in a high percentage (20%–40%) of all diabetic patients [19]. Another study from the United States showed that the inci- dence of ESRD attributed to DM has grown at the rate of 9% annually since 1992 [11]. Once a patient has ESRD, renal replace- ment therapy by dialysis (haemodialysis or peritoneal dialysis) or renal transplantation should be applied. Diabetic patients with ESRD are at higher risk of morbidity and mortality because of the presence of other complications of DM, such as atheroscle- rotic diseases, neuropathy and increased susceptibility to infections [7,20]. Diabetic nephropathy could be reduced and its pro- gression to ESRD significantly delayed with better overall management of the un- derlying DM [20,21]. Although data on the prevalence of diabetes mellitus are available in Jordan, little is known about the status of control of the disease and its associated complica- tions, including ESRD. The only available study was conducted in 1992 and reported that diabetes was the cause of ESRD in 10.5% of patients on haemodialysis [22]. The purpose of the present study is to report on the role of diabetes as a cause of ESRD necessitating haemodialysis in Jordan, and to determine some of the significant dif- ferences between diabetic and nondiabetic patients on haemodialysis as regards age, sex, duration on haemodialysis, family his- tory of DM, history of renal transplantation and rate of hospital admissions.  As the government reimburses the costs of all haemodialysis services in Jordan, it was possible to ascertain all the patients on haemodialysis in the country. Approval to conduct this study was obtained from all the concerned health sectors in Jordan, namely, the Ministry of Health, the Royal Medical Services and the private sector. We collect- ed data on all patients (n = 1711) who were   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما on haemodialysis at the time of the survey (1 September to 31 October 2003) in all haemodialysis units in Jordan (56 units). Each patient was personally interviewed in the haemodialysis unit using a structured questionnaire prepared by the investigators (nephrologists and epidemiologists). The questionnaire collected comprehensive data on a wide range of issues related to haemo- dialysis. Relevant data for the present study included sociodemographic variables such as age and sex, family history of DM and renal transplantation, in addition to date of starting haemodialysis, duration of haemo- dialysis and history of hospital admission. The objectives of the study and question- naire were fully explained to the haemodi- alysis personnel who were responsible for data collection and background information about the study and its objectives were pro- vided to all patients. Haemodialysis units provide this treatment in 1 to 3 shifts daily according to the number of haemodialysis machines and patients in each unit. The cause of ESRD was provided by the attend- ing physician. Epi-Info 2002 software was used for data entry and analysis. The distribution of patients by relevant variables was ob- tained. Diabetic and nondiabetic patients were compared according to a number of relevant variables. The chi-squared test was used to assess the statistical significance of observed differences in proportions while the independent t-test was used to assess the statistical significance of the differences in continuous variables.   At the time of the survey (1 September 2003 to 31 October 2003), a total of 1711 patients on haemodialysis were identified in Jor- dan. The leading cause of ESRD was DM (29.2% of cases), followed by hypertension (18.4%) and glomerulonephritis (12.3%); the cause was unknown in 21.4% of patients (Table 1). In patients who were initiated on haemodialysis in 2002 (n = 329), DM was responsible for 33.4% and in patients who were initiated on haemodialysis in                                                                                        ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما 2003 (n = 411), DM was responsible for an even higher proportion (44.0%) (Table 1). Hypertension and glomerulonephritis kept their second and third ranks, respectively, in both years. It is noteworthy that hyperten- sion was an associated condition in 63.0% of diabetic patients, and ischaemic heart disease in 22.4% of this population.  More males were on haemodialysis in Jordan (n = 957) than females (n = 754) resulting in a male to female ratio of 1.3:1 approxi- mately. Comparison between diabetic and nondiabetic patients showed that 61.1% of diabetic patients were males compared with 53.8% of nondiabetics (Table 2). The age of diabetic patients ranged from 11 to 88 years with a mean age of 57.5 years [stand- ard deviation (SD) 12.3], while the age of nondiabetics ranged from 5 to 86 years with a mean age of 45.4 years (SD 17.1). More than half of the diabetic patients were 60 years of age (51.3%) compared with only 25.8% of nondiabetics.  Duration on haemodialysis was signifi- cantly shorter in diabetic patients [mean 25 months (SD 25.3), median 17 months] com-                                                                                                                                                 ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما pared with nondiabetics [mean 50 months, (SD 48.8), median 34 months] (P < 0.001). Among all diabetic patients, 38.3% were on haemodialysis < 1 year compared with 20.9% of nondiabetics (Table 2). Only 1% of the diabetic patients were on haemodi- alysis for > 10 years compared with 10% of non-diabetics.  As shown in Table 2, and as expected, a significantly higher proportion of diabetics had a positive family history of DM in first- degree relatives (56.5%) as compared with nondiabetics (28.8%) (P < 0.001).  The frequency of previous renal transplants among diabetics was 1.4% compared to 8.5% among nondiabetics (P < 0.001), indi- cating that diabetic patients are less likely to undergo renal transplantation.  Admission to hospital during the year prior to the study was significantly more common in diabetic (57.8%) than in nondiabetic pa- tients (42.3%) (P < 0.001) (Table 4).  As shown previously in several countries of the world [10,11,15,16], this study con- firms that DM is the leading cause of ESRD among patients on haemodialysis in Jordan. ESRD attributed to DM has increased sig- nificantly over the years. In Jordan, DM was the cause of ESRD in 10.5% of patients on haemodialysis in 1992 [22] and was the cause of 29% of such cases in 2003. The observation that DM accounted for an even higher proportion of patients who started haemodialysis in 2002 and 2003 (33% and 44% respectively), could indicate that DM has been increasing as a cause of ESRD requiring haemodialysis. This could be attributed, at least partially, to the fact that diabetic patients have a higher overall mortality and spend less time on haemodi- alysis before they succumb to any of the several complications of DM. It is true that the prognosis of patients who have diabetes and are on renal replacement therapy has improved, but survival remains worse than that of nondiabetic patients. A study pub- lished in 1997 showed that the 5-year sur- vival of diabetic patients on haemodialysis was 30% compared with 60% in nondiabet- ics [23]. Consistent with these figures, the current study suggests a worse survival for diabetics as reflected by the shorter period on haemodialysis among diabetic patients. Our data suggest a preferential access of males to haemodialysis services. This is evident by the higher number of males on haemodialysis, for which we have no plausible explanation. The abundance of males in the diabetic group as compared to the nondiabetic group (P < 0.006) could be related to a restricted access of women to haemodialysis services if they also have diabetes or other comorbidities. In the present study, diabetic patients on haemodialysis were less likely to have had renal transplantation, which may relate to the fact that patients in this group are older, and tend to have comorbid conditions and, therefore, were denied this form of intervention. The association of DM and a positive family history of DM is not surprising, and has been reported by studies in sev- eral countries including Kuwait and Mexico [24–26]. In conclusion, the study showed that DM is the leading cause of ESRD in Jordan and suggests that its role is on the increase. The study also suggests a poorer survival of diabetics on haemodialysis compared to nondiabetics. The high personal, social    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما and financial costs of managing ESRD and the other complications associated with diabetic nephropathy make a powerful case for the need for better detection and better control of patients with DM.                                                                                                                                                                                                                                  ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                    Guidelines for the prevention, management and care of diabetes mellitus Diabetes mellitus is one of the most common noncommunicable diseases worldwide. In the WHO Eastern Mediterranean Region there has been a rapid increase in the incidence of the disease, and it is now the fourth leading cause of death. The increasing prevalence, the emergence of complications as a cause of early morbidity and mortal- ity, and the enormous burden on health care systems make diabetes a priority health concern. These guidelines provide up-to-date, reliable and balanced information for the prevention and care of diabetes melli- tus in the Region. The information is evidence-based and clearly stated to facilitate the use of the guidelines in daily practice. The guidelines are intended to benefit physicians at primary, secondary and tertiary levels, general practitioners, internists and family medicine specialists, clinical dietitians and nurses as well as policy-makers at ministries of health. They provide the information necessary for decision-making by health care providers and patients themselves about disease manage- ment in the most commonly encountered situations. Guidelines for the prevention, management and care of diabetes mel- litus, EMRO Technical Publication Series, No. 32, available at: http:// www.emro.who.int/dsaf/dsa664.pdf    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                           80 154grating 27.1 9.0   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  Diabetes mellitus and its complications have confronted the developing as well as the industrialized world as a major public health problem. Despite being the leading cause of blindness in Americans between 20 and 64 years, the ocular complications of diabetes are preventable and treatable in the early stages of the disease [1–3]. Screen- ing and monitoring programmes are agreed to be the most effective future means of minimizing the complications associated with diabetes mellitus. Besides the social benefits of living more years with adequate visual performance, there is a substantial cost saving by early detection of significant retinopathy using effective screening and monitoring methods [4–7]. Thus, a reliable, quick and inexpensive test for detection of early dysfunction is of vital importance to primary and shared care programmes. Visual acuity charts only measure the high frequency component of the contrast sensitivity function and are markedly af- fected by small amounts of defocus [8]. Loss of low-frequency contrast sensitivity has been reported to reduce the ability to recognize faces and background images. It may also affect recognition of pos- tures and movement [9]. Therefore, the contrast sensitivity function curve gives additional information about a subject’s visual relationship to the environment and provides a more comprehensive description of visual performance than visual acuity alone. Visual acuity can be normal in some ocular diseases, including optic neuritis and glaucoma, where contrast sensitivity can be significantly decreased [10,11]. There is still controversy about the effec- tiveness of contrast sensitivity as a screen- ing tool for diabetic retinopathy [12–17]. The present study investigated the use of Cambridge low-contrast grating as a po- tential screening tool for early detection of diabetic retinopathy by non-ophthalmolo- gists, focusing on changes of low-contrast sensitivity in different stages of diabetic retinopathy.  This was a cross-sectional study of 95 pa- tients with diabetes, referred to the oph- thalmology clinic of Imam Reza General Hospital, Mashhad, Islamic Republic of Iran between May 2003 and August 2003. The study protocol was reviewed and approved by the ethics committee of the Research As- sembly of Mashhad University of Medical Sciences. The exclusion criteria were: significant ocular diseases beside diabetic retinopathy, including cataract, glaucoma, and optic nerve diseases, amblyopia, macular dis- eases, history of previous ocular surgery or photocoagulation and systemic diseases other than diabetes. After initial evalua- tions, 15 patients were excluded. Thus a total number of 154 eyes of 80 patients were evaluated. For each patient, a questionnaire was completed about the type and duration of diabetes, mode of control and last blood glucose level, checked in the past month. Objective refraction was done with a Topcon RM-A6500 autorefractometer and refined with manual retinoscopy (Hein HSR2) and axis refinement (Jackson cross- cylinder). Afterwards, the best corrected visual acuity was determined on a subjec- tive basis. The visual acuity was checked with an illiterate E-chart. With the best correction of the refractive error, the con- trast sensitivity was evaluated with a Cam- bridge low-contrast grating system. The test was done under a standard luminance of 100 cd/m2, as described previously [18].    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما The chart luminance was regularly checked using a spot photometer. The visual acuity and contrast sensitivity were checked inde- pendently by an examiner who was blind to the results of other tests. Finally, slit-lamp evaluation of the anterior segment was used to exclude significant anterior segment pathology and narrowness of angle. Indirect ophthalmoscopy (fully-dilated) and non- contact slit lamp funduscopy were done by the same ophthalmologist. As described by the Early Treatment Diabetic Retinopathy Study [19] the pa- tients were classified as having no diabetic retinopathy, mild, moderate, severe, or very severe non-proliferative diabetic retinopa- thy (NPDR), early proliferative diabetic retinopathy (PDR), high-risk characteristic PDR (HRC-PDR), and/or clinically signifi- cant macular enema (CSME); the latter 2 were among the exclusion criteria. Considering P < 0.05 significant, Pear- son chi-squared, Student t-test and analysis of variance were used in analysing the rela- tionships. A regression analysis was done to describe the correlation between visual acuity and Cambridge low-contrast grating measurements. SPSS, version 11.5 was used for all statistical calculations.  The patients’ characteristics are presented in Table 1. There was a statistically significant difference in the age of patients (P = 0.031) and duration of diabetes (P < 0.0001) for patients with and without diabetic retinopa- thy. Sex was not a significant determinant for diabetic retinopathy (P < 0.50). Abnormal contrast sensitivity was ob- served in 27.1% of eyes with diabetic retin- opathy, compared with 9.0% in unaffected eyes. The mean contrast sensitivity in the diabetic retinopathy group was 217.60 cps compared with a mean of 309.30 cps in the group without diabetic retinopathy (Tables 2 and 3). There was a statistically signifi- cant correlation between the presence of diabetic retinopathy and poor contrast sen- sitivity (P < 0.01). The contrast sensitivity deteriorated with more advanced diabetic                                                         ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما retinopathy (Table 4), but this was not sta- tistically significant (P = 0.349, analysis of variance). However, there was a significant correlation between the duration of diabetes and the level of contrast sensitivity (Pearson r = –0.216, P = 0.007) (Figure 1). There was a statistically significant cor- relation between the decrease in visual acuity and contrast sensitivity in eyes with diabetic retinopathy (P = 0.049) (Figure 2).  After 20 years, almost 99% of patients with type 1 diabetes and 60% with type 2 diabetes will have some degree of diabetic retinopathy [19]. Beside the duration of disease, the age at onset is another impor- tant determinant of diabetic retinopathy: diabetic retinopathy is much more common in juvenile onset diabetes and this has major socioeconomic consequences. In one study, 86% of blindness in patients with a lower age of diabetes onset (age < 30 years) was attributable to diabetic retinopathy [20]. Prevention and interruption of this process depends on early detection and effective screening methods. The success of any screening test obvi- ously depends upon its ability to differenti- ate patients with the problem in question from other patients [21]. Regarding diabetic retinopathy, the ability of tests to differenti- ate those known to have diabetes mellitus but no retinopathy and those diabetes pa- tients who have already developed diabetic retinopathy is of particular interest [16]. There is a marked controversy about the loss of contrast sensitivity in diabetes patients without retinopathy and the spatial frequencies at which losses occur in the presence of retinopathy. Early studies, such as that by Arden and Jacobson, used photo- graphic plates to measure contrast sensitiv- ity in diabetes patients with background diabetic retinopathy and another group with no retinopathy [22]. They found abnormal contrast sensitivity between normal and diabetes patients with background retinopa-                                                                         ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما thy, but there was no difference in contrast sensitivity between normal and diabetes patients without background retinopathy. Ghafour et al., using a similar method, also found that diabetes patients with back- ground retinopathy had abnormal contrast sensitivity [23]. Unlike Arden and Jacob- son, however, they reported that diabetes patients without retinopathy had abnormal contrast sensitivity at mid-frequencies. Hyvarinen et al. measured individual contrast sensitivity functions in 19 patients with diabetes with different degrees of dia- betic retinopathy [24]. They reported that patients with 20/20 acuity and background retinopathy showed abnormalities in con-                                              ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما trast sensitivity. They also suggested that contrast sensitivity fluctuates with blood sugar levels in diabetes, becoming reduced in the presence of hypoglycaemia. Sokol et al. measured contrast sensitiv- ity in type 1 and 2 diabetes patients with minimal or no diabetic retinopathy [25]. They found that type 2 diabetes patients with no retinopathy had abnormal contrast sensitivity at high spatial frequencies, while those with background diabetic retinopathy demonstrated abnormal contrast sensitiv- ity at all tested spatial frequencies. Several authors found a significant loss of contrast sensitivity in early diabetic retinopathy groups at mid-to-high spatial frequencies using the Vistech VCTS chart [14,26,27]. Low-to-medium spatial frequency changes have also been reported to occur and it has been suggested that visual acuity measures alone may therefore be unreliable as a clini- cal indicator of loss of visual function [28]. To the best of our knowledge, this is the first study using Cambridge low-contrast grating in diabetic patients. We found a sta- tistically significant difference in low spa- tial frequency contrast sensitivity between diabetics with and without retinopathy. This means that Cambridge low-frequency grating may be a potential screening tool for early retinopathic changes in diabetic patients. There are a number of hypotheses about the potential causes of diminished contrast sensitivity in diabetic patients. Regan and Neima have reported a correlation between ischaemia of the parafoveal arcade using intravenous fluorescein angiograms and abnormal letter chart results [12]. This sug- gests that the pathophysiology responsible for contrast sensitivity loss in diabetes is due to functional loss of retinal ganglion cell dendrites, secondary to retinal ischae- mia. Another factor, which may explain the etiology of reduced contrast sensitivity in diabetic eyes, is the diameter and extent of the foveal avascular zone [1]. Arend et al. found that the diameters of the foveal avas- cular zone and the perifoveal intercapillary area are significantly correlated with con-     ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما trast sensitivity at mid-spatial frequencies [29]. Bresnick et al. revealed that the area of the foveal avascular zone in diabetics with non-proliferative diabetic retinopathy is significantly larger than healthy non- diabetic controls [30]. When the dimension of the foveal avascular zone progresses to greater than 1000 µm, visual acuity is usu- ally diminished. This degree of destruction of the parafoveal capillary net is usually confined to cases of proliferative retin- opathy. However, functional correlation of contrast sensitivity and foveal avascular zone extent is difficult because the diameter of the foveal avascular zone of a normal eye can vary considerably (350–750 µm) [31], and one cannot predict with accuracy the potential contrast sensitivity based solely on the appearance of the foveal avascular zone. The rate of retinal blood flow may also affect the degree of contrast sensitivity loss. Several investigators have demonstrated enhanced retinal blood flow rates in diabe- tes patients with background retinopathy [32–37]. It is suggested that the diminished con- trast sensitivity in diabetic patients is par- tially reversible by breathing oxygen, and is therefore probably the result of retinal hypoxia [38]. However, an improvement of contrast sensitivity does not occur after pan-retinal photocoagulation treatment, which implies that the reduction of contrast sensitivity is irreversible [17].  We found a significant diminution in contrast sensitivity in patients with early diabetic retinopathy compared with those without diabetic retinopathy. There was also a progressive deterioration of con- trast sensitivity in more advanced stages of diabetic retinopathy. The findings are con- trary to a number of previous studies, which found no statistically significant difference between diabetics without retinopathy and those with background retinopathy. This may be due to the use of a more sensitive tool in evaluation of contrast sensitivity in current study. It has been shown that the decrease in contrast sensitivity is more re- markable in low spatial frequencies. Hence, the Cambridge low frequency grating is a potential tool for the screening of early stag- es in diabetic retinopathy. However, larger, prospective studies will be needed to further investigate the sensitivity and specificity of the test as a screening tool.  We are indebted to the Research Assembly of the Mashhad University of Medical Sci- ences for its financial support of the project. Our sincerest thanks go to Ms Sherafat Javaheri for participation in performing the contrast sensitivity tests. We are also grate- ful to Dr H. Esmaili for his assistance in statistical analysis.                                                  ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                                                                                           ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                  ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                         129271512    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  Refractive error (RE) is the cause of a sig- nificant proportion of visual impairment and blindness. Most prominently, myopia and other refractive errors appear to be increas- ing worldwide [1], and have been grouped among the leading causes of blindness and vision impairment in the world [2,3]. RE is believed to result from a combination of genetic and environmental factors [4,5]. Control of RE and low vision are one of the priorities of the global initiative for controlling blindness. A survey conducted among 5839 Egyptian schoolchildren aged 7–15 years found that the prevalence of RE (visual acuity 6/12) was 22.1% [6]. The objective of the present study was to evaluate preventable environmental risk factors for RE among these schoolchildren in Egypt, under the World Health Organiza- tion (WHO) programme “Vision 2020” [7]. The mission of Vision 2020 is to eliminate the main causes of avoidable blindness by the year 2020 by bringing together govern- ments and non-governmental agencies.  The present study was a cross-sectional descriptive study, conducted during the school year 2003–04 in 12 urban govern- ment schools: 4 primary schools, 4 male preparatory schools and 4 female prepara- tory schools. The schools were chosen us- ing multistage random sampling technique from 4 different educational divisions in Cairo governorate. The sites were selected to have different environmental character- istics, population activities and pollution sources: • El-Waiely: mixed area (residential, industrial and heavy traffic) in north- eastern Cairo governorate. • Mataria: industrial and residential area in north of Cairo governorate. • Roxy: residential area with heavy traffic density in north of Cairo governorate. • Nozha: new residential area with low traffic density in east of Cairo governo- rate. All students in the schools were included in the study (5839 students). A total of 1292 students were diagnosed with RE by paral- lel visual screening [6]. The students ranged in age from 7 to 15 years and came from different socioeconomic status families. All the students were given a structured questionnaire that covered personal, medi- cal, social and environmental data. Per- sonal data included age, sex, school level (primary/secondary) and residential area. Environmental data sought were about the residential area and the sources of pollution based on the previously published methods [8]. We asked children about the source of residential pollution near their houses: bread ovens, refuse burning, heavy traffic, workshops for manufacturing ceramic tiles or carpenters. Moreover, we asked the child about the cooking fuel used and if their mothers frequently used pesticides. The medical questionnaire included ocu- lar manifestations of eyestrain and previous ophthalmic problems. We asked children if they had suffered from redness of the eyes, head pains (headache) or difficulty reading the blackboard at school. The questionnaire about ocular manifestations of eyestrain and previous ophthalmic problems was re- viewed with the school file of the children, to see if there had been any referral to an ophthalmologist, and what was the medical cause. The questionnaire also asked about fam- ily history of consanguinity and family history of RE. Children were asked if their parents were from the same family or from   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما different families and if there was anyone else in the family wearing glasses. Socioeconomic status was divided into 3 levels according to the education and oc- cupation of the parents: high level (highly educated and occupation reasonable for their educational level), middle level (high or secondary educated and occupation be- low their education level) and low level (illiterate and occupation not permanent). The questionnaire also asked how much near-work the child currently practised in hours per day, such as reading, writing and watching television. One social worker from each school was trained by the authors to complete the structured questionnaire according to the available data, either from the students or from their parents. To ensure the accuracy of the data, the questionnaires were filled by the social workers with each child, and the authors revised them in a pilot check.  Data were collected from the selected schools with the same protocol and forms. The data were analysed using SPSS, version 7.5. Pearson chi-squared test was used for univariate analysis. The variables found to be significantly associated with RE were entered into logistic regression with crude odds ratio (OR) and adjusted for sex differ- ences calculated to establish the statistically significant factors. Differences were con- sidered significant at P < 0.05.  The prevalence of RE was significantly higher among the students from a heavy traffic residential area (Roxy) compared with the other residential areas (P < 0.0001) (Figure 1). The prevalence of RE was significantly higher among the students aged 12 years (20.7%) compared to those with age < 12 years (15.5%) (P < 0.0001) (Figure 2). The prevalence of RE was significantly correlated with the student’s age (r = 0.9, P < 0.0001). The prevalence of RE was significantly higher among the female students (21.4%) compared with males (13.6%) (P < 0.05) and among students of high and low so- cioeconomic status compared with those of middle status (P < 0.001 and P < 0.005 respectively) (Figure 3). The prevalence of RE was significantly higher among students with positive fam- ily history of RE (80%) compared with no family history (P < 0.0001). Figure 4 shows that 80.9% of the positive family history was parents with RE (38.9% fathers, 32.0% mothers and 10.0% both parents). History       ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما of consanguinity had no significant effect on the prevalence of RE (P > 0.05). Past history of ocular problems was found in 24% of the students with RE, in the form of symptoms of eyestrain (redness of the eyes, headache, difficulty reading the blackboard or recorded comments in the medical file of the child about referral to ophthalmologist, and the cause of referral). The prevalence of RE was significantly higher among preparatory school students (20.6%) compared with primary students (11.3%) (P < 0.0001). Figure 5 shows that the prevalence of RE and low vision was significantly higher among students exposed to near-work for 5 hours/day (23.4%) compared with those exposed for < 5 hours/day (17.1%) (P < 0.0001). There was a significant positive correlation be- tween the prevalence of RE and the hours of near-work (r = 0.8, P < 0.0001). Logistic regression showed that accord- ing to the level of significance, socioeco- nomic status, school level, sex, near-work and family history of RE were the inde- pendent significant variables associated with the prevalence of RE (Table 1). Age and living in an area with many sources of environmental pollution were not signifi- cantly associated with RE. After adjustment of significantly associated environmental       ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما risk factors to sex differences, logistic re- gression found that school level became the most important risk factor, followed by hours of near-work per day, socioeconomic status and positive family history of RE.  There is strong evidence for rapid, environ- mentally induced change in the prevalence of RE associated with increased education        ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما and urbanization [9]. The effect of geo- graphical distribution was considered a risk factor for RE both for young and old age groups [10]. The screened students in this study were from different residential areas with different environmental conditions. El-Waiely residential sector in Cairo is a heavily populated commercial sector, with many small factories and workshops con- centrated in this area, beside 3 secondary lead smelters, which emit large quantities of pollutants into the atmosphere, including lead [11]. The second selected residential area was Mataria, an industrial residential area with middle traffic density. Most of the industries in this location had low irritating emissions. The concentrations of irritant gases such as SO2 in Roxy Square (the third selected site) were found to exceed the per- missible WHO limits for high traffic density areas [12]. Nozha, the fourth selected area, is a new residential area with low traffic density and without industrial activities. The prevalence of RE was significantly higher among students living in a heavy traffic residential area (Roxy area) com- pared to those from mixed, industrial, and low traffic areas. However, logistic regres- sion showed that living in an area with many sources of environmental pollution was not significantly associated with the prevalence of RE. Changes in prevalence of RE with age are noteworthy. In Taiwan, 2 studies of schoolchildren aged 6 to 18 years showed a prevalence of RE more than 80% by age 18 years [1]. The present study showed that the prevalence of RE was significantly higher among students aged 12–15 years compared with those below 12 years. Moreover, the prevalence of RE was significantly corre- lated with the age of the screened students. But the association of age and the preva- lence of RE might be explained by other environmental confounders, such as higher school level and greater hours of near-work per day. Logistic regression found that there was no significant association between prevalence of RE and age.                                                                            ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما In the present study, the prevalence of RE was significantly higher among female students compared to males, and logistic regression revealed significant association of sex with RE. This finding is similar to other studies [13–15], and contrary to the Baltimore Eye Survey that found no sex difference [16]. Wong et al. attributed the significant elevation of the prevalence of RE among females to the fact that women’s eyes have a shorter axial length and shal- lower anterior chamber depth than those of men, and hence a higher probability of being hyperopic [12]. Few population-based studies have in- vestigated the role of socioeconomic factors in the development of visual impairment [17,18]. In the present study, a U-shaped relation was found between the socioeco- nomic status of the students and the preva- lence of RE, suggesting that those with higher and lower socioeconomic status were more likely to have RE than those of middle status. The reasons for this are not clear, although it could be related to increases in the hours of near-work per day. Students of high socioeconomic status may spend a longer time watching television and playing computer games, while those from low socioeconomic status spend longer studying their lessons in badly illuminated, crowded rooms. The idea that the way in which we use our eyes early in life can af- fect ocular growth and RE is gaining scien- tific credence. It has been hypothesized that prolonged reading or the retinal blur of pro- longed near-work leads to the development of myopia [3]. Logistic regression of the present data revealed that socioeconomic status was found to be the most important environmental factor that might affect an in- dividual’s risk of developing RE. However, after adjustment for sex differences, school level (primary or preparatory) and hours of near-work were more important than socio- economic status. There is no doubt that RE is inherited, since the relation between RE in parents and siblings showed stronger correlations than would be expected by chance [19], and myopic parents are much more likely than non-myopic parents to have myopic children [20]. The study of Zadnik et al.—a thorough longitudinal prospective study into RE in parents and children—showed that children with myopic parents, although not yet myopic themselves, tended to have longer eyes than children with non-myopic parents, resulting in a predisposition to be- coming myopic later in life [21]. A small proportion of myopia is clearly familial, with defined chromosomal localizations, and in some cases causal genetic mutations [9]. In Egypt, a screening programme in Tanta city found a positive family history of RE in 63.1% of RE cases [22]. The present study revealed that family history of RE was recorded in 80% of the students with RE. However, the significant effect of the other environmental factors must not be ne- glected as only 26.3% of the students with RE were of consanguineus parents. Wu and Edwards also showed that having myopic parents increased the odds ratio for having a myopic child, showing a genetic influence [5]. But they also found that the odds ratio of having myopia increased in offspring of non-myopic parents, suggesting an environ- mental influence. Logistic regression in the present study showed that family history of RE increased the odds of having students with RE even after adjustment for sex. Myopia may be associated with other conditions including congenital ptosis, vitreal, retinal haemorrhages, and inflam- matory keratitis [3]. The present study how- ever revealed that few cases of RE had a    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما past history of ocular problems, in the form of symptoms of eyestrain. There is no doubt that extended near- work appears to be the major risk factor for RE. Cross-sectional studies have also found a positive association between myopia and near-work activity such as reading and writ- ing [23]. Since 1988, Mahmoud et al. also found that the incidence of RE was 55% in workers using computers in their work for long periods [24]. Mutti et al. concluded that heredity was the most important factor associated with juvenile myopia, but there was no evidence that children inherit a myopigenic environment or a susceptibility to the effects of near-work from their par- ents [20]. The risk factor analysis in Saw et al.’s study revealed strong associations with education and factors related to education such as tuition lessons in primary school [25]. They also found that educational level and educational stream were positively related to myopia. Prolonged near-work was thought to lead to progressive myopia through the direct physical effect of pro- longed near-work, but according to current theory prolonged near-work leads to myo- pia via the blurred retinal image that occurs during near focus [3]. This retinal blur initiates a biochemical process in the retina to stimulate biochemical and structural changes in the sclera and choroid that lead to axial elongation [26]. Thus, the long school days of reading and writing, hours of home study and watching television could explain the patterns of RE among the students in the present study. The prevalence of RE was significantly higher among preparatory school students than among primary students. This could be attributed to the higher degrees of edu- cational attainment and cumulative amount of near-work. A significant correlation of prevalence of RE and hours of near-work per day was confirmed in the present study. Previous studies showed that the correlation between level of academic achievement and the prevalence and progress of RE is strong [14,23,27]. Further myopiogenic stimuli such as prolonged reading or occupations that require extensive near-work may lead to mild myopia later in life [3]. In the present study according to logistic regression analysis, high and low socio- economic status, school level, sex, hours of near-work per day and family history of RE were the environmental factors most closely associated with the prevalence of RE. Ana- tomically, female’s eyes tend to have RE more often than those of males [14,15]. So, after adjustment for the sex difference to overcome anatomical variation and to detect the preventable risk factors, the main environmental risk factors associated with the prevalence of RE became school level, near-work, socioeconomic status and fam- ily history of RE. The main recommendation of this study is to control for environmental risk fac- tors through early detection of cases of RE, especially among students with a fam- ily history and high levels of academic achievement. Proper management is needed for students with RE, including correction of visual acuity and controlling hours of near-work per day to minimize the progress of the condition.                          ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                                                                                                            ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                        2020VISION : The Right to Sight? “VISION 2020: The Right to Sight” is a global initiative to eliminate avoidable blindness. The programme is a partnership between the World Health Organization and the International Agency for Prevention of Blindness, a large umbrella organization for eye-care professional groups and nongovernmental organizations involved in eye-care. The aim of VISION 2020 is to eliminate avoidable blindness by the year 2020. Attainment of this aim implies the development of a sustain- able comprehensive health-care system to ensure the best possible vision for all people and thereby improve quality of life. A CD, “Developing an action plan to prevent blindness at national, pro- vincial and district level: version 2” has been produced. The content can be browsed on the Internet in English, French and Spanish, or downloaded in Arabic, English, French and Spanish. Links to the down- loads can be found at: http://www.who.int/blindness/publications/en/. A free copy of the CD can be requested from whopbd@who.int.   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                 SF-36107 446334 7    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  Complementary and alternative medicine (CAM) is a group of diverse medical and health care systems, therapies and products that are not presently considered to be part of conventional medicine. The American public’s use of CAM increased substan- tially during the 1990s. In 2004, 62% of American adults had used CAM. Yoga is one of the most common methods used as a mind–body therapy [1]. Yoga is a Sanskrit word which means “the unity of body and mind”. It is a com- bination of breathing exercises, physical postures, and meditation, and has been practised in eastern traditional medicine for over 5000 years. In the philosophical doctrine of yoga, hatha yoga is the physical training part, combining postural exercise (asana), voluntary control of breathing (pranayama) and relaxation and meditation (shavasana) [1,2]. Although yoga is historically a spiritual discipline, it has also been used clinically and for therapeutic intervention. The number of publications on its clinical application has greatly increased over the past 3 decades [3]. In the literature there are more than 800 articles that indicate extended studies on the benefits of yoga: almost all focus on spe- cific medical problems such as the efficacy of yoga in randomized, controlled clinical trails on a wide variety of conditions such as multiple sclerosis [4], bronchial asthma [5], irritable bowel syndrome [6], lymphoma [7], mild depression [8], and osteoarthritis [9]. There have also been reviews on the effect of hatha yoga on musculoskeletal and cardiopulmonary function [10], reha- bilitation after myocardial infarction [11] and menopausal symptoms [12]. The ef- fectiveness of yoga has also been studied for HIV/AIDS [13], cancer patients [14,15], mood in psychiatric inpatients [16] and dia- betes [17]. The effect of the yoga lifestyle on reducing risk factors of cardiovascular and ischaemic heart disease have also been investigated [18,19]. Even though there have been numerous studies on yoga and disease, there have been few in healthy adults. In the Islamic Repub- lic of Iran, no study, either in people with a medical condition or in healthy people, is available. We therefore carried out this be- fore and after comparison study in healthy volunteers in Shiraz with the purpose of determining the effects of the practice of yoga on well-being.  Participants for the study group were re- cruited via general advertising in local, wide-circulation newspapers by the Yoga Society, which is the only formal centre for mind–body training in Shiraz. Healthy vol- unteers having no medical or psychological problems who were interested in practising yoga attended the new training courses. After explanation of the study, 112 people agreed to participate. There were no refus- als to participate. Participants were asked to enrol in the course and complete a questionnaire pre- pared using the Farsi version of the SF-36 questionnaire [20], for which validity and reliability were already confirmed [21]. Questions were scored 1–5 (poor–excellent condition). The study questionnaire was in 2 parts, the first collected demographic data (age, sex and level of education) and the sec- ond asked participants to assess quality of life and well-being according to the SF-36 health assessment instrument [20,22]. This questionnaire measures 8 domains of health-related quality of life and con- tains 2 summary measures (physical health and mental health), each divided into 4 scales. The scoring of the physical com-   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما ponent summary is divided into: physical functioning, role-physical, bodily pain and general health. The scoring of the mental component summary is divided into: vital- ity, social functioning, role-emotional and mental health [20]. For the yoga training courses, the 112 participants were divided into men’s and women’s sections each having 3 classes of about 20 individuals. The study was carried out in the Yoga Society at Shiraz University. The study groups were trained in hatha yoga by 2 instructors (1 man and 1 woman) for 6 months. Each class consisted of 10 minutes breathing exercises (pranayama), 15 min- utes slow suppleness, 50 minutes yoga posi- tions (asana) and 15–20 minutes meditation and relaxation (shavasana and yoga nidra). The questionnaires were completed again by participants at the end of the course. Scoring was the same as above. Data were analysed using a paired t-test, one-way analysis of variance and SPSS, version 10. P < 0.05 was considered statisti- cally significant.  A total of 112 healthy individuals volun- teered to attend the yoga classes and 107 of them (44 men and 63 women) cooperated until the end of the study and submitted the questionnaire before and after the courses (mean attendance rate 95.5%). The maximum age was 55 years and the minimum 18 years, mean 33.0 (standard deviation 7.0) years (data was missing for 3 participants). Out of 106 individuals who had men- tioned their education (data missing for 1), 16 (15.1%) had not completed high school, 53 (50%) had high school diploma and 37 (34.9%) had university education. We found improvement in all 8 compo- nents of the SF-36 after practising yoga for 6 months and the difference was statistically significant (P < 0.001) (Table 1) and also in the summary scores for both mental and physical components. Comparing the results by sex, the only statistically significant difference was for physical functioning (Table 2). Improve- ment in role-emotional and vitality were more marked in the females, but the differ- ence was not statistically significant. To assess whether there was any differ- ence between younger and older partici- pants, we divided them into 4 age groups: < 25 years, 26 (24.3%) participants; 25–34 years, 43 (40.2%) participants; 35–44 years, 27 (25.2%) participants; and > 44 years, 16 (14.9%) participants. Most frequent age group was 25–34 years. When compar- ing by age group, there was a statistically significant difference in general health, bodily pain and mental components before and after practising yoga. For the other items, the differences were not statistically significant (Table 3). The only item where the difference was statistically significant according to educa- tion level was mental health scale (Table 4).  Although there have been many studies about the efficacy of yoga, almost all have been about a specific disease or condition. We found only 1 study similar to ours eval- uating the effect of yoga on well-being in healthy people. Lee examined health before and after yoga as a mind–body training us- ing the SF-36 questionnaire. Improvement was reported in all domains, particularly mental health [22]. Other studies have indicated the changes which occurred after yoga practice: the posi-    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما tive effects of yoga on depression, anxiety, mood, stress-related disorders and chronic insomnia have been documented [23,24]. Practising pranayama, the breathing technique of yoga, has been shown to have a positive effect on pulmonary function. In one study on 60 healthy young females, sig- nificant increase was demonstrated in forced vital capacity, forced expiratory volume in 1 section and peak expiratory flow rate [25]. Cardiac function in normal young volun- teers has been studied in a randomized con- trolled trial in 24 schoolchildren, which was designed to determine whether pranayama had any effect on ventricular performance by measuring systolic time intervals and cardiac autonomic function tests. After 3 months training, parasympathetic ac- tivity increased and sympathetic activity decreased [26,27]. A study on 30 healthy young men also demonstrated improve- ment in oxidative status and the antioxidant pathological processes [28]. Furthermore, observation of pranayama indicated that this breathing technique induces dramatic shifts in all homodynamic variables and the authors have postulated that this effect may                                                                                                                                                                ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما be the basis for the purported yogic health claim [29]. Shavasana, the relaxation part of yoga practices, has been shown to enhance the ability to withstand stress [30,31]. Changes in brain waves and blood serum cortisol during yoga exercise have been studied and increase in alpha waves and decrease in cortisol level reported [32]. In vivo evi- dence has been provided for regulation of                                                                                                                                                                                                                                                          ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما conscious states at a synaptic level by yoga nidra meditation [33]. A study on the effects of hatha yoga practice on cardio-respiratory performance, psychological profile and melatonin secre- tion after 3 months showed improvement in these profiles and increase in plasma me- latonin, indicating that yoga could be used as a psychophysiologic stimulus to increase endogenous secretion of melatonin, which in turn might be responsible for improved sense of well-being [34]. The state of the mind and that of the body are intimately related. If the mind is relaxed the muscles in the body will also be relaxed. Stress produces a state of physical and mental tension. Yoga physical postures and breathing exercises improve muscle strength, flexibility, blood circulation and oxygen uptake, as well as hormone func- tion, In addition the relaxation induced by meditation helps to stabilize the autonomic nervous system with a tendency towards parasympathetic dominance. The physi- ological benefits which follow help the yoga practitioner become more resilient to stressful conditions [35]. These results might be the explana- tion for our own findings, i.e. significant improvement in all health indicators after yoga practice. In this study most changes occurred in the domain of general physical and general mental health. Although no statistically significant difference was ap- parent between males and females except in physical functioning, the improvements for role emotional and vitality were more marked in females. This would need further investigation to determine the nature of the association. The findings according to age show significant difference of improvement in body pain, general health and total physical health and we found more effectiveness                                                                                                                                     ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما among older participants. This may be be- cause older people by and large have more background physical problems. There was no significant improvement in health-related well-being by level of edu- cation. This is in accord with the findings of Lee after 3 months mind–body practices [22]. The limitations of this study include the fact that our study group was healthy adult volunteers who were interested in yoga, and they were probably of relatively high socio- economic status. In addition, there was no control group. Improvement in well-being in this study may have been a result of the social contact concomitant to attending classes, especially for the vitality component for females, who often have fewer opportunities for social activities than men. Overall, according to our findings and those of a number of other studies, it ap- pears that the prevention mechanism of yoga acts at 3 levels, and increases the compatibility of psychological, neurologi- cal, immunological and recognition systems in humans [1–3]. The authors conclude from this quasi- experimental trial that quality of life, which is a result of well-being related to physical, emotional, mental health and social func- tioning, can be improved by the practice of yoga as a set of physical, spiritual, psycho- logical and social intervention methods, and recommend a randomized controlled trial.  We would like to express our sincere thanks to Fars Province Yoga Society, es- pecially Mr Nazar-Aghaii, director of the society and instructor, and also to the Vice- Chancellor for Research of Shiraz Univer- sity of Medical Sciences for their helpful support in conducting this study.                                                                                                                        ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                                                                             ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                    Conference announcement & call for papers: 1st Emirates Hellenic Medical Conference & Exhibition, Al Jinan Medical Center & Greek Medical Society Joint Meeting, 6–8 December 2007, Crowne Plaza Hotel, Dubai, United Arab Emirates We invite submission of relevant original abstracts for either oral or poster presentation. The deadline for the receipt of abstracts is Sep- tember 15, 2007. Sessions that will be offered this year include: • infectious diseases • respiratory diseases • nephrology • genetics • chronic CNS and mental disorders • biomedical technology • haematology oncology • transplantation The conference will also feature a technical exhibition that explores the expanding boundaries of science. More information can be found on the conference website at: http://www.infomedweb.com/ourevents/EHMC/index.htmEHMC/index    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                     ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  According to the World Health Organiza- tion (WHO) definition, infants with birth weight less than 2500 g are low birth weight (LBW) [1]. There are almost 23 million LBW infants from 121 millions births in a year, a high proportion of which are in developing countries [2]. Birth weight is an important indication of health status of the infant and the principal factor that deter- mines the infant’s survival and physical and mental growth in the future [2,3]. LBW is one of the most important factors in infant mortality, as mortality of LBW babies is 40 times more than the normal-weight babies [2]. There have been a number of previous studies on LBW in the Islamic Republic of Iran. In a study in Hamadan, twin birth, mother’s education and job, and mater- nal disease were important risk factors for LBW, but miscarriage and the number of deliveries were not [4]. In a similar study in Bushehr port, the risk of LBW in mothers aged < 19 years was almost twice that of mothers aged 19–35 years [5]. Low edu- cational status and not attending prenatal health care were other significant risk fac- tors for LBW. In another study in Babol it was reported that sex, mother’s age, parity 1 or 5+, twin birth and gestational age < 37 weeks were risk factors [6]. Elsewhere in the world, it has been shown that smoking during pregnancy and not attending prenatal care were the most important risk factors of LBW in Argentina [7]. In Japan, the risk factors were smoking, parity and history of LBW [8]. In research in Brazil it was reported that smoking dur- ing pregnancy increased the risk of LBW by 50-fold and no prenatal care increased the risk 3-fold [9]. As the prevalence of LBW is one of the most important health indices and as the prevalence of LBW is a function of social status and lifestyle, it is important to know the prevalence and risk factors for LBW in different areas [2]. The aim of this study was to determine the prevalence of LBW and some of its risk factors in maternity hos- pitals in Zahedan city in south-east Islamic Republic of Iran, the capital city of Sistan and Baluchistan province. It was hoped that the results of this study would help to inform the health authorities about the local risk factors for LBW in order to introduce programmes to reduce its prevalence.  In a cross-sectional study, a sample of 1109 infants born over a 6-month period in spring and summer 2004 in the 3 maternity hos- pitals of Zahedan city were chosen using stratified random sampling. The data were collected by measuring the infants’ birth weights and also from an interview with their mothers. The interview data included: infant’s sex, mother’s age mother’s educational level and occupation, mother’s ethnic group (Sistani, Balouch, Afghan or other), parity, attendance at pre- natal care during pregnancy, history of mis- carriage, time interval from previous birth, twin or singleton birth, history of cigarette and opium smoking during pregnancy and use of ferrous sulfate and other supplements (multivitamins, folic acid, calcium) during pregnancy. The mothers were also asked whether they had suffered any of the fol- lowing diseases during this pregnancy: ma- ternal infection, chronic vascular disease, pre-eclampsia, chronic renal insufficiency, sickle-cell anaemia, collagen vascular dis- ease or cyanotic heart disease. To establish the relation of LBW with the risk factors, a chi-squared test was applied. Also, the odd ratios (OR) of the risk factors    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما of LBW were found using a multivariate logistic regression. Using the coefficients of the model, the ORs were estimated with their 95% confidence intervals (CI).  There were 131 infants with LBW, an over- all prevalence of LBW in Zahadan hospitals of 11.8% (95% CI: 9.9%–13.7%). There was no difference in prevalence between boys and girls (11.1% versus 12.6%) (P < 0.42). Table 1 shows the frequency of normal and LBW infants by the selected maternal variables. The rate of LBW in infants of women employed outside the home and housewives was 6.6% and 12.4% respec- tively, but this was not significant. By eth- nic group, the highest rate of LBW infants was for Balouch mothers (14.9%). The prevalence of LBW in mothers with no education was 16.9% and this reduced with increasing level of education to 5.4% (P < 0.008). The prevalence of LBW in mothers aged < 19 years was 16.0% and it reduced significantly with increasing age of mothers to 8.9% in women aged 25–34 years (P < 0.046).  Overall, 217 (19.6%) mothers had a history of miscarriage and the prevalence of LBW for these mothers was 7.8%, but for moth- ers with no history of miscarriage, it was 12.8%. The prevalence of LBW was 13.5% in mothers with < 3 years interval from the previous birth, significantly more than those with 3 years birth interval (9.3%) (P < 0.03). The LBW in twin births (65.4%) was significantly greater than singleton births (9.3%) (P < 0.001). Only 15 (0.1%) of women reported smoking cigarettes or opium. While the prevalence of LBW for mothers with a history of smoking was greater than for the non-smokers (20.0% versus 11.3%) this was not statistically significant. The rate of LBW among women who did not use fer- rous sulfate during pregnancy was signifi- cantly higher than those who used ferrous sulfate (18.6% versus 8.1%) (P = 0.0001). The prevalence of LBW in mothers not using supplements such as multivitamins, folic acid or calcium during pregnancy was also significantly greater. The mothers who attended regular prenatal health care had fewer LBW babies than the mothers with irregular or no prenatal health care (9.4% versus 27.8%). The prevalence of LBW for women with maternal disease was greater than the women without disease (23.5% versus 10.2%, P < 0.001).  Table 2 shows the multivariate logistic regression analysis. The significant risk fac- tors for LBW were birth interval < 3 years (OR 1.71, 95% CI: 1.11–2.64), twin birth (OR 18.81, 95% CI: 9.97– 35.48), no use of ferrous sulfate (OR 1.92, 95% CI: 1.16– 3.18) and presence of maternal disease (OR 2.03, 95% CI: 1.22–3.40). All other factors were not significant.  According to WHO statistics, the rate of LBW is 17% in the whole world (6% in industrialized countries and 21% in devel- oping countries). The rate in the Eastern Mediterranean Region is 11% and in the Islamic Republic of Iran 10% [10]. The prevalence of LBW in our study in Za- hedan city maternity hospitals was 11.8%. The prevalence in other Iranian cities was 8.1% in Hamadan [11], 6.3% in Gorgan [12], 9.9% in Jiroft [13], 6.2% in Babol [6], 4.2% in Tehran [14] and 9.6% in Bushehr port [5]. Although improvements have been   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                                                                                      ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                           ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما made in the prevalence of LBW in Zahedan within the last decade of the 20th century, the prevalence of LBW still needs to be reduced. The results of the study using a mul- tivariate logistic regression revealed that only birth interval (< 3 years), twin birth, no use of ferrous sulfate and maternal disease significantly increased the risk of LBW. The finding about short birth interval is similar to another study in the Islamic Republic of Iran in 5 maternity hospitals of Yazd [15]. The study showed that a birth interval of < 12 months is a major risk factor for LBW. Also, a study in Tehran found that birth interval had a close relation to LBW [16]. Twin birth was also an important risk factor for LBW in other studies in Hamadan [4] and Babol [6] and elsewhere in the Islamic Republic of Iran [13,15]. We also found that no use of ferrous sulfate in pregnancy was associated with LBW. In many studies, not using ferrous sulfate was a risk factor for LBW but in some it was not. In a study on Chinese pregnant women, the level of ferritin was measured in all women before delivery. It was shown that for women with iron defi- ciency the mean weight of their infants was 242 g less, and the risk of LBW was signifi- cantly greater among women with moder- ate anaemia compared with those without anaemia (OR = 6.5, P = 0.009) [17]. In a study in the United States, pregnant women randomly received either ferrous sulfate (case) or placebo (control) until 28 weeks of gestation. The rates of LBW infants in case and control groups were 4% and 17% respectively (P = 0.003) [18]. However, in a study in Zimbabwe on pregnant women with gestational age of 22 to 35 weeks, the mean birth weight of the case group infants was higher than the control infants but there was no difference in LBW incidence [19]. The presence of maternal diseases in- creased the risk of LBW by 2-fold in our study. Hypertension, pre-eclampsia, urinary tract infection (UTI), malnutrition and fetal infections (rubella, cytomegalovirus, toxo- plasmosis, tuberculosis and herpes simplex) are some of the most important risk factors for LBW. Hypertension causes blood vessel ste- nosis in some pregnant women and results in LBW in infants. The effect of hyper- tension on birth weight was investigated in studies in Yazd [15] and Isfahan [20]. Pre-eclampsia is another risk factor for LBW [15]. Pregnant women are usually well-monitored during pregnancy for their own health as well as the health of the fetus. During this period, regular prenatal visits in the Islamic Republic of Iran are made by the community health workers (behvarz). Normally, monthly visits are made in the first 6 months of pregnancy, increasing to 2 visits in months 7 and 8, and 4 visits in the last month of pregnancy to check for hypertension and any adverse effects. Maternal UTI has also been shown to be a risk for LBW in pregnant women in the Islamic Republic of Iran [15]. Normally, physicians ask for a urine test during preg- nancy in order to check for UTI. Therefore, prenatal care for detection of UTI is very important and necessary in pregnancy. Fetal infection is also important. The effects on the embryo of bacteriuria, intrauterine infection and other infections may result not only in restriction of weight in newborns, but may also lead to future complications for the infants [21–23]. Malnutrition is a major problem causing LBW in newborns, especially in develop- ing countries. Pregnant women who are undernourished are at greater risk of LBW [24,25]. Health centres can assess possible maternal malnutrition during prenatal care    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما and provide advice for the nutrition of preg- nant women. In the majority of studies worldwide, mothers smoking during pregnancy is one of the most important risk factors for LBW [4,8,9]. This was not shown in the present study. However, the prevalence of smoking (cigarettes and opium) might be underesti- mated as Iranian women may be reluctant to reveal their smoking habits in an interview. In general, LBW is a population health problem, so it is essential to provide the nec- essary facilities for prenatal health care. The role of health managers in health planning and educational programmes is important. Health authorities worldwide have begun to taken action on this and it is possible to see the results in the decreasing prevalence of LBW in the world. At the same time, it is necessary to screen pregnant mothers for the important risk factors of LBW, such as low birth interval, maternal disease, twin pregnancies and non-use of ferrous sulfate, to provide them with prenatal health care facilities. To do this job, skilled staff and managers are needed in the health centres, together with sufficient facilities and plan- ning programmes. For further research on LBW in this country, it is recommended that other fac- tors be considered, such as delivery outside hospital, gestational age, maternal age, maternal height and lack of weight gain in second trimester of pregnancy.  We would like to thank Dr Mokhtari from the Department of Gynecology and Dr Ki- ani from Department of Public Health for their invaluable suggestions and advice throughout the work.                                                                                                           ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                                                                              ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  Normal growth needs appropriate nutrition. In the first months of birth, breastfeeding is without doubt the most important feeding method which has value both immuno- logically and psychologically, in addition to providing adequate nutrition. Breastfeeding has familial, social and infantile significance [1–5]. In the first year, especially the first 6 months, when infants have rapid growth, regular anthropometric measurements are appropriate for growth monitoring [3]. Many studies have shown differ- ences in the growth pattern of breast- and bottle-fed infants. Breastfed infants had ideal growth before 3 months of age, but from 4 to 6 months, weight gain for age is slower, especially in developing countries [1–4,6]. In countries with children living in favourable conditions and fed according to World Health Organization (WHO) recom- mendations, there was also a deviation from standard growth curves [7]. Therefore, it has been recommended that new growth charts be designed for breastfed infants [8,9]. Because of weaning protocols in different countries, genetic differences and different types of complementary foods, it has also been suggested that local charts should be developed for growth monitoring in infants for each region and for breast- and bottle-fed infants [10]. The aim of the present study was to compare growth patterns of breastfed and bottle-fed infants in Jahrom city, Islamic Republic of Iran and to compare these patterns with the National Center for Health Statistics (NCHS) growth charts [11].  This was a prospective study of children born in Jahrom conducted from April 2001 to December 2002. The children were at- tending Jahrom health centres for routine health care. Inclusion criteria were: birth weight > 2500 g, gestational age at birth 37–42 weeks, and absence of any con- genital anomalies. The height and weight of these infants were recorded 18 times from 1 month to 2 years of age by trained person- nel (every month up to 1 year and every 2 months up to 2 years of age). The children’s length was measured in a prone position before walking and then in a standing posi- tion. Weight was measured with a precision of 10 g and height with a precision of 1 cm. The ages of children were recorded at each attendance at the centre. The infants were divided to 3 groups based on feeding type: exclusively breastfed, exclusively bottle-fed and both breast- and bottle-fed (combined). Infants who were breastfed for the first 4 months of age with only vitamin drops given additionally were defined as exclusively breastfed [12]. Types and time of complementary food introduc- tion were recorded at each visit. Based on social and local habits and guidelines of health centres, complementary foods usu- ally included beans, vegetables, meat, eggs and fruit juice. In order to estimate the children’s weight and height percentiles based on age, the Healy, Rasbash, Yang (HRY) non- parametric method was used [13]. Percen- tiles related to age in the HRY method were evaluated and then a multiphase pattern was used to smooth the percentiles. This is a non-parametric method and there is no need to assume normal distribution of the data. Smooth and non-smooth quantiles were evaluated according to age using GRO- STAT software [14]. SPSS, version 11.5 was used for statistical analysis and t-test and ANOVA were computed. P < 0.05 was considered significant.    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  Our study included 597 children (391 boys and 206 girls) aged 0–2 years. Of these, 404 were exclusively breastfed, 46 were bottle-fed and 92 were both breast- and bottle-fed. Maternal and neonatal charac- teristics are shown in Table 1 according to the 3 groups. Table 2 shows the mean weight of the infants by age and type of feeding. Up to 2 months of age, there was no significant difference in the mean weights between the 3 groups; however exclusively breastfed infants had a statistically significant greater weight gain than the 2 other groups from 3 to 10 months of age. Table 3 shows the mean height of the infants according to age and type of feeding. Up to 3 months of age, there was no statisti- cally significant difference in mean heights between the 3 groups; however breastfed infants were taller than the other 2 groups from 4 to 18 months of age although this was not always statistically significant. Af- ter 18 months the 2 other groups of infants were taller but this was not significant. Figures 1–4 show the comparison of weight and height between the 3 groups in the present study and NCHS data by sex. Figures 1 and 2 show a favourable weight gain in the first months in comparison with NCHS measurements, but over time the weight gain in our sample slowed and the mean weight fell below that of the NCHS data. While the mean height of our sample after 1–2 months was lower than the NCHS data, the heights followed a similar curve over time.  Many studies have been conducted about the relation between growth and types of feeding in infants. Kramer and co-workers in Canada in 2004 confirmed the growth- accelerating effects of formula and oth- er milks (versus breast milk) on weight and length gain throughout infancy, with a dose–response gradient and the largest associations observed at 3 to 6 months of age [15]. The study of Baker and colleagues in America in 2004 showed                                     ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما infant weight gain was associated with ma- ternal prepregnancy body mass index and with an interaction between the duration of breastfeeding and the timing of the intro- duction of complementary foods [16]. They believed that short duration of breastfeeding and earlier introduction of complementary food were associated with additional weight gain during infancy [16]. Other factors such as the time of initiation of breastfeeding and duration of exclusive breastfeeding have been reported to have important roles in the improvement of infant growth [17,18]. Our study also shows significantly better growth in breastfed infants than bottle-fed and com- bined feeding infants especially in the first few months of birth. The difference became less after the introduction of complemen- tary foods. Some studies have shown earlier introduction of complementary food results in better growth, but other studies have confirmed the adequacy of exclusive breast- feeding until 6 months of age with no need for complementary foods [16,19–21]. The difference of growth patterns be- tween the 3 groups in our study is similar                                                                                                                                         ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                   to other studies [22,23]. One study showed a slower growth rate in breastfed infants that was not compensated until 2 years of age [22]. Because of these differences, Yoneyama in Japan recommended the de- velopment of special growth curves for breastfed infants [23]. Comparison between the present study and NCHS data showed that breastfed in- fants had good growth until 6 months of age. What is clear from the study is that breastfed infants thrive very well compared to bottled-fed and combined feeding infants. This reinforces the need to promote breast- feeding and encourage mothers to initiate and continue breastfeeding their infants. Maternal education about the benefits of breastfeeding and familial and government support are recommended to achieve this.   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما        ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما       ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                                                                                                                           ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                     Child-related Millennium Development Goals (MDGs) Of direct relevance to the work that the Child and Adolescent Health and Development unit of the World Health Organization Regional Of- fice for the Eastern Mediterranean (EMRO) is pursuing in the Region is Goal 4 “Reduce child mortality”, for which the target set is “Reduce by two-thirds, between 1990 and 2015, the under-5 mortality rate”. For this target, 3 indicators have been selected to help track progress: • under-five mortality rate, • infant mortality rate, • proportion of 1-year-old children immunized against measles. Other targets of key importance to the work of EMRO in the Region are: Target 2 “Halve between 1990 and 2015 the proportion of people who suffer from hunger”, and Target 8 “Have halted by 2015 and be- gun to reverse the incidence of malaria and other major diseases”.   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  Labour induction has become common- place in modern obstetrics and is indicated in medical, obstetric and fetal conditions in which prolongation of pregnancy would jeopardize maternal and fetal well-being and in which there are no contraindications to the use of labour induction methods. The process of cervical ripening is believed to be controlled by certain hormones, in particular prostaglandin E2 (PGE2), that play a role in triggering uterine contractile activity [1]. The use of prostaglandins for cervical ripening and induction of labour administered by any route has been reported to improve the rate of vaginal delivery, and decrease the rate of caesarean section and instrument deliveries [2,3]. Because pregnancies indicated for in- duction are at higher risk of perinatal mor- bidity and mortality, this creates a stressful environment for women and physicians alike. A pregnancy requiring induction of labour is a decision dilemma between fac- ing the problems of an unfavourable cervix at induction and those of increased perinatal complications if it is decided to let the pregnancy continue. PGE2 has been shown to be safe and efficacious in promoting pre- induction cervical ripening and in initiating labour [4,5]. Induction of labour is a common pro- cedure in our unit. The total number of deliveries conducted in our hospital during the study period (12 months) was 5069. The caesarean section rate was 16.4%, while the rate of assisted vaginal deliveries was 1.9%. The total number of inductions of labour was 1059 (20.9%) and 436 were induced using vaginal PGE2. This study assessed the efficacy, safety and outcome of vaginal PGE2 pessary for the ripening of the cervix and induction of labour in this group of women, comparing multiparas and nulliparas.  This prospective study took place between September 2003 and August 2004 at Prince Rashed Ben Al-Hassan Military Hospi- tal, Irbid, Jordan. A total of 436 pregnant women were recruited for the study who had a clinically unfavourable cervix and in- dications for labour induction. Patients were considered eligible if they had a singleton pregnancy, vertex presentation, intact mem- branes, and Bishop score 5. Women with ruptured membranes, contraindications for vaginal birth, previous caesarean section and unexplained antepartum haemorrhage were excluded. Upon admission for induction, the es- timated date of confinement was reviewed based on reliable menstrual history obtained at early antenatal booking when early gesta- tion was calculated from the last menstrual period. This was confirmed by sonograms from the 1st and 2nd trimester, before 20 weeks gestational age. Full physical and pelvic examination was performed for all the women together with a nonstress test and sonogram (to evaluate amniotic fluid). Intravenous access was obtained and base- line laboratory tests were done. A dino- prostone 3-mg vaginal pessary was inserted in the posterior vaginal fornix. This was repeated after 6 hours if the signs of labour were not detected. Amniotomy was performed within 1–2 hours of the diagnosis of labour (or as soon as clinically feasible), unless membranes spontaneously ruptured. Labour progress was monitored by pelvic examination every 2 hours. Labour abnormalities were de- fined by Friedman’s criteria [6]. In this case, oxytocin augmentation was started (with Syntocinon) and administered in the manner outlined by Seitchik and Castillo [7]. This was stopped in cases of uterine hyperstimulation or changes suggestive of fetal hypoxia. Continuous fetal heart rate   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما monitoring during labour was performed in each parturient. Fetal distress was defined as the occurrence of fetal heart rate abnor- malities that require the attending physician to complete the delivery either by assisted vaginal or abdominal delivery. The pres- ence of meconium was noted either at the time of amniotomy or subsequently during labour. Every infant was given immediate suctioning of the oropharynx at the time of delivery.  Student t-test was used for continuous data, while for categorical data, the Fisher exact test or chi-squared test was used where ap- propriate. Significance was considered as P < 0.05.  Of the 436 women induced with PGE2, 235 were nulliparas and 201 multiparas. Maternal age ranged between 17 and 36 years for nulliparas and 23 and 45 years for multiparas. Gestational age ranged between 29 and 42 weeks for nullipara and 30 and 42 weeks for multiparas. Table 1 presents the indications for induction. Postdates, pre-eclampsia, dia- betes and presumed macrosomia were the most frequent indications in both groups. These were significantly higher (P = 0.001), whereas suspected intrauterine growth re- striction, oligohydramnios and non-reassur- ing cardiotocography were not significant. Table 2 shows the outcomes of labour and delivery. Overall 42% of the wom- en needed oxytocin for augmentation of labour. The need for labour augmenta- tion was significantly higher in nulliparas (47%) compared with multiparas (35%) (P = 0.001). The interval from the initiation of oxytocin to delivery was statistically significantly shorter in multiparas (mean 13.5 hours, SD 1.8 hours) compared with nulliparas (mean 15.5 hours, SD 2.4 hours). Of the nulliparas 67% delivered within 16                                                                           ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما hours after oxytocin compared with 73% of multiparas (P = 0.001). For women in both groups (93%) who delivered within 24 hours of starting induc- tion no more than 2 3 mg PGE2 vaginal tablets were needed to achieve a clinically feasible cervix for amniotomy. Women who took more than 24 hours from induction to delivery needed 4 3 mg PGE2 tablets. There was no statistical significant differ- ence between the proportion of multiparas and nulliparas who took > 24 hours from induction to delivery. Intrapartum compli- cations showed no statistical significant differences between the groups. Forceps delivery showed a statistically significant difference in nulliparas (3%) compared with multiparas (1%) (P = 0.001). Vaginal delivery was achieved in 86% of the whole study group. There was no statistically sig- nificant difference in the caesarean section rate between the groups, but descent arrest as a cause of caesarean delivery was sig-                                                                                                                                                                                 ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما nificantly more common among multiparas (3.5%) than nulliparas (2%) (P = 0.007). Table 3 presents the fetal outcomes of the study groups. There were no statistically significant differences in the rate of peri- natal deaths between the groups. The main causes of death were: respiratory distress, birth asphyxia and congenital anomaly. These causes could not be attributed to the use of intravaginal prostaglandin E2. Five-minute Apgar score < 6 (P = 0.008), meconium presence at delivery (P = 0.001) and admission to neonatal intensive care unit (P = 0.001) were all significantly higher in nulliparas than in multiparas. Birth weight was significantly higher among multiparas than nulliparas (P < 0.0001).  This study demonstrates that the use of intravaginal PGE2 for cervical ripening as well as labour induction in nulliparas and multiparas is safe and effective. This was demonstrated by the high delivery rate be- fore 24 hours (93%), and the low need of oxytocin for labour augmentation (42%). Also there were no serious maternal or neonatal side-effects attributable to the use of PGE2. The percentage of multiparas who de- livered within 16 hours after initiation of PGE2 (73%) was significantly higher than nulliparas (67%). The overall vaginal deliv- ery rate of 86% in our study is comparable with that previously reported by Hassan [8]. This finding would eliminate the option of elective caesarean delivery in women who require delivery regardless of the Bishop score. This study revealed a short induction-to-delivery interval of 93% with- in 24 hours (the great majority delivered in less than 16 hours). This would indicate a short first stage of labour from an increased uterine activity. This is in agreement with the findings of Egarter et al. [9]. The use of oxytocin for labour augmen- tation was low in our study (used in 47% of primiparas and 35% of multiparas). This is in contrast to the report of Casey et al. [10] who used vaginal prostaglandins even in the presence of a ripe cervix and oxytocin was used in 75% of primiparas and 40% of multiparas in their study group. The use of PGE2 for induction of labour appeared to be effective in achieving cervical ripening, initiation of labour and optimal type of delivery; this corresponds to that reported by D’Aniello et al. [11].                                                ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Intrapartum complications showed no statistically significant differences between the groups. Although the most dangerous complication of induction of labour by PGE2 is rupture of the uterus, this was seen most commonly where there is a previous lower segment scar. There were no cases of rupture of the uterus in our patients. This corresponds to other reports by MacKenzie et al. [12] and Al-Bar et al. [13] which re- corded no rupture of uterine scar following PGE2 induction, and disagrees with Ram- sey et al. [14] and Raskin et al. [15] who reported uterine rupture in women receiving PGE2 for labour induction. Furthermore, the results of the current study revealed no statistically significant differences in peri- natal mortality between the groups. So there were no apparently serious maternal or fetal complications. This corresponds with the findings of Ben-Haroush et al. [16]. This study agrees with other reports [13,17,18] regarding the use and safety of PGE2 vaginal tablets for labour induction, which showed a significant improvement in cervical favourability within 24 hours re- sulting in an increase in successful vaginal delivery rates in 24 hours and no increase in operative delivery rates. In the view of these findings, cervical priming as well as labour induction using intravaginal PGE2 is safe and effective and produces no harm attributable to the method.                                                                                                                                   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                 Emergency Preparedness and Humanitarian Action 1st Regional Training of Trainers on Logistics Supply System A total of 25 pharmacists, logisticians, supply officers, warehouse managers, emergency coordinators and IT experts were trained from 23 to 26 April 2007 in Amman, Jordan in the “Logistics Supply Sys- tem”, WHO/UN software which enhances efficiency and transparency of management of humanitarian supplies. Participants came from the Islamic Republic of Iran, Iraq, Jordan, Leba- non, Sudan, Syria, and the West Bank and Gaza and from different or- ganizations: the United Nations Relief and Works Agency for Palestine Refugees in the Near East, the World Food Programme, the Ministry of Health and WHO. The training is part of a larger programme aiming to implement the system in several countries in the Region and to ensure it is always used immediately after a natural disaster or crisis occurs for the man- agement of incoming donations.    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                            neutrophils band trimesters   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  Specific immunity decreases during preg- nancy [1], and this is marked by a fall in IgG in the 2nd and 3rd trimesters [2]. There is a marked decrease in the number of helper T-lymphocytes between the 14th and 28th weeks, resulting in impairment in maternal immunity [3]. As specific immunity de- creases in pregnancy, non-specific immu- nity, mediated by neutrophils and migratory phagocytes, plays an important role in the body’s defences. The phagocytic cells use primitive, non-specific recognition systems which allow them to bind to a variety of microbial products. These cells are respon- sible for innate immune responses and are the first line of defence against infection [4]. Neutrophils are involved in the body’s defence against microorganisms, especially against pyogenic bacterial infections [5]. It has been shown that the phagocytic activity of neutrophils increases in preg- nancy [2,6] but how it alters during each trimester has not been clearly determined. One study demonstrated that the phagocytic activity of neutrophils was greater in the 2nd trimester in comparison with non-preg- nant women of reproductive age [1]. On the other hand, another study reported that the phagocytic activity of neutrophils was simi- lar in women in the 1st and 2nd trimesters of pregnancy and non-pregnant women, but significantly decreased during the 3rd tri- mester [7]. It is also clear from the existing literature that the numbers of Fc and C3b receptors on the neutrophil surface increase significantly in the 3rd trimester compared with levels in non-pregnant women of reproductive age, indicating that the neu- trophils have a greater capacity for attach- ment to microorganisms, and thus have increased phagocytic activity [8]. These contradictory reports prompted our interest in studying what exactly hap- pens with regard to neutrophil status in the different trimesters of pregnancy. This study was therefore designed to explore the vari- ation in number, maturity and phagocytic activity of neutrophils in the 3 trimesters of pregnancy.  The study was carried out over a period of about 1 year starting February 2003. We approached pregnant women (aged 20–35 years) in different trimesters who were at- tending the outpatient department of J.B. Roy State Ayurvedic Hospital, Kolkata, India for routine antenatal check-up and invited them to participate in the study. Women who had any bacterial or viral infection, cold, fever, chest congestion, stomach upset or loose bowel motions were excluded. Only a few of the women refused to participate as they were apprehensive. A sample of venous blood was drawn into a heparinized syringe from each partici- pant and transferred to the laboratory of the Department of Physiology at Vidyasagar College for Women in Kolkata for testing. Total leukocyte count was estimated manu- ally using a haemocytometer [9]. Absolute neutrophil count was calculated as fol- lows: absolute value (neutrophils/mm3) = total leukocyte count (cells/mm3) × relative value (%) obtained from the differential count [10]. A blood smear was stained with Leish- man stain and was examined to determine the differential count and the proportion of band forms among the neutrophilic leu- kocytes. Neutrophils which had no distinct fine filament (length but no breadth) con- necting the nuclear lobes were considered band forms [10,11], young immature forms of neutrophils [11]. Band neutrophils were counted per 100 neutrophils. The phagocytic activity of the neu- trophils was studied by noting phagocytosis    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما [12]. Heat-killed Candida albicans was added to a leukocyte suspension obtained from the buffy coat of 0.5 mL heparinized blood. The mixture was incubated at 37 °C for 15 minutes then centrifuged. Smears were made of the precipitate and stained by Leishman stain. Intracellular C. albicans cells stain intensely and can be identified and counted inside the neutrophils under oil immersion. The number of neutrophils positive for C. albicans ingestion per 100 neutrophils gives the phagocytic index and the total number of C. albicans cells counted per 100 positive cells divided by 100 gives the avidity index [13]. Healthy volunteers, students and staff of the same age group (having no infection: bacterial, viral or parasitic) of Vidyasagar College for Women, Kolkata and J.B. Roy Ayurvedic College, Kolkata, served as non- pregnant controls. Informed consent was given. Blood samples were taken and tested in the same way as for the women in the test group. All the parameters derived from both groups of women were compared and ana- lysed by Student t-test.  The mean total leukocyte count increased in pregnancy. Mean absolute neutrophil count, which was 3054/mm3 blood in non- pregnant women, increased throughout pregnancy and was 4518/mm3 blood in the 3rd trimester. The proportion of young neu- trophils also increased with the advance- ment of pregnancy, 29% in non-pregnant women compared with 57% in women the in the 2nd and 3rd trimesters. Avidity index gradually increased from 2.03 in non- pregnant women to 2.56 in women in the 3rd trimester. For all parameters except phagocytic index in the 1st trimester, the increases were statistically significant (Table 1).  When stimulated by oestrogen, the adrenal cortex produces increasing levels of total and free plasma cortisol and other corticos- teroids from the 12th week of pregnancy to term [14]. Glucocorticoid increases the total                                                           ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما number of leukocytes and the neutrophil count, and decreases the lymphocyte count by decreasing lymphocyte mitotic activ- ity [15–17]. In our study also it was noted that, with the advancement of pregnancy, lymphocyte count decreased whereas there was a significant rise in the number of neu- trophils. Moderate leukocytosis of up to 15 × 109 cells/L is common during pregnancy [18], with a peak about 8 weeks before parturi- tion, i.e. in the 3rd trimester [19]. The cause of leukocytosis is neutrophilia, which may be a result of increased cortisol level during pregnancy as corticosteroids produce a de- layed but sustained rise in blood neutrophil count. It may also be due to promotion of the release of neutrophils from the bone mar- row under the influence of corticosteroids, which accounts for neutrophil leukocytosis [20]. In our study, the number of leukocytes and neutrophils increased with the advance- ment of pregnancy, corroborating the find- ings of previous researchers [21–23]. Clinically, it is recognized that an in- crease in younger forms (band cells, meta- myelocytes, etc.) suggests increased release of young neutrophils from the bone marrow [24]. We observed an increase in the number of band cells among the neutrophils with the advancement of pregnancy, which is con- sistent with the findings of previous studies [23,24]. Tsakonas et al. also reported a significant decrease in lobularity index in pregnancy compared to controls (indicating the production of immature neutrophils dur- ing pregnancy) but mean lobularity index did not change significantly with gestation [25]. In our study, we found greater produc- tion of band (immature) neutrophils with the advancement of pregnancy. These are younger forms which contain more my- eloperoxidase [10]. The myeloperoxidase system is the most competent bactericidal system present in neutrophils. The number of younger neutrophils increased in the 2nd and 3rd trimesters, indicating that bacteri- cidal activities of neutrophils may be greater in women in the last 2 trimesters compared to non-pregnant women and those in the 1st trimester. The phagocytic activity of neutrophils, indicated by phagocytic index and avid- ity index, increased in the 2nd and 3rd trimesters. Previous studies also showed an increase in the activity of neutrophils in pregnancy [2,6], but in which trimester and to what extent had not been demonstrated. The phagocytic activity of neutrophils is increased with stress, when glucocorticoid levels are high [13]. In our study, the in- creased levels of corticosteroids in the 2nd and 3rd trimesters may mediate increased activity of neutrophils. It has also been reported that human chorionic gonadotrophin has a stimulatory effect on the phagocytic activity of neu- trophils [8]. This placental hormone is se- creted in large amounts during the first few weeks of pregnancy, after which it declines slowly, reaching a nadir of approximately 20 000 IU/L serum at approximately 120 days gestation that persists until delivery [26]. The increased phagocytic activity of neutrophils in the 2nd and 3rd trimesters may be a result of the synergistic action of human chorionic gonadotrophin and cortisol present in higher concentrations at that time. It is likely that the nonspecific immunity offered by increased numbers of neutrophils and increased phagocytic activity may com- pensate in part for the weakened specific immunity of pregnant women. Although our study gives an indication of the number, maturity and phagocytic activity of neutrophils in the 3 trimesters of pregnancy, the bactericidal activity in each trimester is yet to be determined.    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  We are thankful to Dr Srikanta Pandit, De- partment of Kayachikitsa, J.B. Roy State Ayurvedic Hospital for his kind cooperation and help.                                                                                                                                                                                                                               ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                  2003Visceral leishmaniasis control in Thi Qar Governorate, Iraq, K. Jassim, R. Maktoof, H. Ali, B. Bodosan and K. Campbell. Eastern Mediterranean Health Journal 2006 12 , , Vol. Supplement 2, pages S230– S237. The name of the fourth author was spelled incorrectly and should read: B. Budosan. Unconditional compensation: reducing the costs of disagreement about compensation for research subjects D. Wikler, N. Sofaer, A. Jafarey, R.P Lei and X. Zhang. Eastern Mediterranean Health Journal 2007 13 1, , Vol. , No. , pages 6–16. The order of the authors was incorrect and should read: N. Sofaer,1 A. Jafarey,2 R.P Lei,3 X. Zhang4 and D. Wikler5. The author afliation should thus read: 1Program in Ethics and Health, Harvard University, Boston, Massachusetts, United States of America. 2Centre of Biomedical Ethics and Culture, Sindh Institute of Urology & Transplantation, Karachi, Pakistan. 3Centre for Bioethics and Department of Philosophy, Central China University of Science and Technology, Wuhan, China. 4Centre for Bioethics, Peking Union Medical College, Beijing, China. 5Department of Population and International Health, Harvard School of Public Health, Harvard University, Boston, Massachusetts, United States of America (Correspondence to D. Wikler: wikler@hsph.harvard.edu).    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                  ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  Congenital malformations are a major cause of perinatal and neonatal death [1], both in developed and developing countries [2]. These malformations have multifactorial etiologies and 40% of cases are idiopathic [3], but there is an impression that they are more prevalent in populations with consan- guineous marriages [4]. Epidemiologic surveys of congenital malformations in various part of the world and among different ethnic groups with widely varying marital habits, socioeco- nomic status and environment not only help in understanding the frequency of malfor- mations in specific areas but also contribute to the general knowledge about the pre- disposing factors and different patterns of congenital malformations. There may be regional variations in the rate and pattern of congenital malformations or these could vary over time. Previous studies in the Islamic Republic of Iran were conducted in 1979 and 1986 [5,6]. To our knowledge there is no recent study in our country to explore the pattern and prevalence of con- genital malformation. Therefore we carried out a pilot study with the goals of finding out the pattern and prevalence of congeni- tal malformation and its relationship with consanguineous marriage in Kashan city, Isfahan Province, Islamic Republic of Iran, where the population is predominantly Muslim, with a relatively high rate of con- sanguineous marriages.  In this prospective hospital-based study all the babies born alive during a 1-year period (May 2001 to May 2002) in Shabihkhani ma- ternity hospital were investigated. Kashan has a population of about 380 000 and 4000 4200 deliveries take place annually in this region. This teaching hospital has a rate of more than 3000 deliveries annu- ally and both high-risk and normal obstetric cases are treated. For each birth we recorded the follow- ing: gestational age, sex, maternal age and parity, type of delivery, perinatal care, ob- stetric history for any disease or medication during the recent pregnancy, consanguinity of parents and history of congenital mal- formations in the siblings. For genetic and racial homogenicity the study was confined to infants whose parents were Iranian na- tionality. Babies whose mothers had medi- cal problems (e.g. diabetes) or a history of drug use in pregnancy were excluded. All the neonates had a thorough physical examination at birth and in the first 24 hours of life by a paediatric resident and/or an attending paediatrician or neonatologist in the nursery to detect any congenital malfor- mations and in doubtful cases the consult- ant neonatologist gave the final diagnosis. For further clarification, echocardiography, X-ray, cranial and abdominal ultrasonogra- phy, computed axial tomography and other relevant investigations were performed on all infants with congenital malformations. All the infants were followed up for a period of 2 months by a neonatologist. No autopsy examinations were performed on any in- fants who died. To classify the malformations we used the International classification of diseases, 9th revision, clinical modification (ICD- 9-CM). All major and minor abnormali- ties were recorded. A major congenital malformation was defined as any condition of prenatal origin which is potentially life- threatening or if not corrected would impair the child’s development or well-being. Mal- formations were classed as minor when they affected non-vital organs, had little or no functional effect and did not cause distress in the neonatal period.    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما The data were analysed using Fisher’s exact test and the chi-squared test.  During the study period 3529 neonates (3471 singletons and 29 sets of twins) were investigated. Of these neonates, 109 (3.09%, 30.9/1000 live births) had congenital mal- formations. Some of the malformations, especially the cardiovascular ones, were discovered during the 2-month follow-up period and were included. The rate of consanguineous marriage among the neonates was 21.8% (768/3529) and nonconsanguineous marriage was 78.2% (2761/3529). Among the consanguineous group, 54 (7.0%) births had congenital anomalies, of which 39 (72.2%) were in first-cousin marriages and 15 (27.8%) were in second- cousin or more distant relatives. Congenital malformations in the nonconsanguineous group were 55 (2.0%). Therefore congenital malformations were 3.5 times more com- mon in consanguineous versus nonconsan- guineous marriages (P < 0.0001) (Table 1). Malformations in the consanguineous group were significantly more common in offspring of first-cousin marriages than second-cousin or more distant relative mar- riages (P < 0.0001). Out of 109 anomalies diagnosed 57.8% were classed as major and 42.2% minor, both of which were more common in the consanguineous group. Table 2 shows the frequency of these malformations by anatomical system. The genitourinary system was the most com- monly affected, involving 32.1% of the 109 malformations (9.92/1000 live births). Among this group the most frequent lesions were undescended testis, hypospadias and hydrocoele, representing 15.6%, 11.0% and 3.7% of the malformations respectively. The musculoskeletal system defects came second in frequency in 22.0% (6.80/1000 live births). Metatarsus adductus (5.5%), congenital hip dislocation (4.6%) and club foot (2.8%) were the most prominent le- sions. There were 16 (14.7%) infants with congenital heart disease (4.53/1000 live births). The most common anomalies were ventricular septal defect, tetralogy of Fallot and endocardial cushion defect (4.7%, 1.9% and 1.8% respectively). A total of 9 infants (8.3%) with con- genital malformations died in the neonatal period: 2 out of 6 with central nervous system (CNS) defects, 1 out of 16 with cardiovascular system defects and 6 with multiple defects. The death rate was high-                                                                   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                                                  ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما est (6/13, 46.2%) in infants with multiple malformations. Miscarriages and stillbirths in previous pregnancies were 1.5 and 2.3 times more common in consanguineous than noncon- sanguineous groups respectively. Of the 109 congenital malformations 74 cases (67.9%) were male and 35 (32.1%) female (ratio 2.1:1). These included 2 infants with ambiguous genitalia who were proven by chromosomal study to be 1 male and 1 female. Regarding birth weights there were no significant differences between offspring of consanguineous versus non- consanguineous marriages. The mean birth weight in the consanguineous group was 3370 g (SD 463) and 3211 g (SD 469) in the nonconsanguineous group. A total of 5 cases (9.3%) with congenital malformations in the consanguineous group had a history of affected siblings (2 of which had the same anomaly and the other 3 a different kind) (P < 0.0035) (Table 3). There was no history of malformations in siblings of affected neonates in the non- consanguineous group. Only 7 siblings of 2706 nonconsanguineous marriages who themselves did not have any malformation had a history of congenital anomalies.  Although this study was a hospital-based survey, the majority of deliveries in Kashan take place in this hospital and the data can be taken as a good reflection of the congenital malformations in the area. The prevalence of different congenital malfor- mations in neonates varies from one country to another, which might be due to racial and environmental factors or differences in survey methods. In the present study the prevalence of congenital malformation (30.9/1000) is consistent with reports from Atlanta, United States (31/1000 live births) [7] and Giza, Egypt (31.6/1000) [8], close to results from a hospital in Tehran, Islamic Republic of Iran (35/1000) [5] and Al-Hasa, Saudi Ara- bia (33.4/1000) [9] and higher than other studies in Spain (20.23/1000) [10] and India (27.2/1000) [11] but lower than the 3.8% and 4.7% reported from Copenhagen, Den-                                                      ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما mark [12] and British Colombia, Canada [4] respectively. In our study the frequency of congeni- tal malformations was 7.0% in offspring of consanguineous marriages, which was higher than the study from southern Islamic Republic of Iran (4.0%) but in offspring of nonconsanguineous parents was close to this study (2.0% versus 1.7%) [6]. Abdul- razzaq et al. found consanguinity was an important factor in the causation of specific illnesses in offspring such as malignancies, congenital abnormalities, mental retarda- tion and physical handicap [13]. In the present study, among 54 congeni- tal malformations in the consanguineous group, 72.2% were in first cousins and 27.8% in second cousins or more distant relatives. In Al-Jama’s study [14] 33.2% of malformed infants were in the consanguine- ous group, 74% were from first-cousin and 26% were from second-cousin or more dis- tant relatives marriages. These are similar to our findings. In our study the genitourinary tract, musculoskeletal and cardiovascular systems were the most commonly affected sites, in descending order of frequency. Other surveys revealed different results. Studies from eastern Saudi Arabia showed the most affected systems were the CNS, musculo- skeletal [3] and renal [14]. Other studies from Saudi Arabia [3], the United Arab Emirates [15] and Hungary [16] showed the alimentary tract, CNS and cardiovas- cular were the most affected systems. The cardiovascular, musculoskeletal and CNS malformations were most common in a study from Saudi Arabia [17]. There may be a genetic predisposition to certain mal- formations. Moreover, the lower incidence of some defects in our study may be due to geographic differences, under-diagnosis or the small sample size. Birth defect mortality in our study was close to a study from Libya [18] (8.3% ver- sus 7.5%) but lower than Egypt (14.7%) [8]. The highest death rate in patients with mul-                                                                        ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما tiple malformations confirmed that these anomalies were incompatible with life. Our study showed higher rates of mis- carriage and stillbirth in previous pregnan- cies in the consanguineous marriage group. In 2 studies in the Gulf region there were no significant differences in rates of abor- tion, stillbirth and neonatal death between consanguineous and nonconsanguineous marriages [13,19]. In Jordan [20] and Tur- key [21] studies mentioning abortion did not show any significant difference between consanguineous and nonconsanguineous groups but there was a higher rate of still- births and infant mortality in the consan- guineous group. Although in some studies sex was not found to be associated with congenital mal- formations [8,14,22], in our study congeni- tal malformations were more common in the male sex (male to female ratio 2.1:1), which concurs with the findings of Lary and Paulozzi [23] and Riley et al. [24]. We found no significant difference in birth weight among the infants from con- sanguineous versus nonconsanguineous marriages. Our finding is compatible with the study in Saudi Arabia which revealed a lower mean birth weight of the offspring of consanguineous couples that was not statis- tically significant [25] and no association was found between parental consanguin- ity and prematurity or low birth weight in a study of Arab women in Jerusalem [26]. Another study showed the mean birth weight of the offspring was significantly lower and the variance in birth weight was slightly larger for first-cousin marriages than nonconsanguineous marriages [27]. Our study showed that a history of con- genital anomalies, whether the same or a different condition, was more common in siblings of consanguineous versus non- consanguineous marriages. In a study from Egypt 8.42% of malformed infants had a history of affected relatives of the same or different condition [8]. According to our study we recommend that all neonates, especially offspring of consanguineous marriages, should be thoroughly examined and investigated for congenital malformations. Premarital coun- selling, especially on the subject of parental consanguinity, is advised.                                                                                                     ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                                                                                              ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                  IVF A30 B30 A81.8B71.4   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  From the early beginnings of in vitro fertili- zation (IVF) it has been recognized that the culture media supplemented with proteins have a direct role in osmoregulation. Pro- teins also serve as a source of energy and as reservoirs for the release of hormones, vitamins and minerals [1]. Because of its characteristic high abundance in the female reproductive tract, albumin has traditionally served as the main macromolecule in most culture media used for in vitro growth of human embryos [2]. In addition, albumin confers on the culture medium the useful physical properties of lubrication and vis- cosity, thus promoting ease of handling the embryo and preventing its adherence to the culture dish [3]. Because the use of blood-derived al- bumin can cause both biological variation and the possibility of disease transmission, several macromolecules, such as polyvinyl- pyrolidone, polyvinyl alcohol and hyaluron- ic acid have been suggested as alternatives [4]. Although the potential of polyvinyl- pyrolidone and polyvinyl alcohol mac- romolecules to promote efficient embryo development in vitro is still questionable [5,6], hyaluronic acid effectively supports mouse and human embryo development and also their growth [7,8]. Hyaluronic acid is a naturally exist- ing macromolecule related to the gly- cosaminoglycans family extra-cellular matrix and it is a linear polysaccharide [9]. It has been observed that both human [10] and bovine [11] embryos possess a surface receptor for hyaluronic acid that can be detected throughout their development up to the blastocyst stage. Research on bovine embryos suggests that the use of hyaluronic acid in the culture medium can increase the rate of bovine blastocyst and embryo development in IVF programmes [12]. Fur- thermore, hyaluronic acid, when added to sperm preparation media, increases sperm motility and improves retention of sperm motility in long-term incubation of both fresh and cryopreserved, thawed human spermatozoa [13] Because there have been relatively few human studies with hyaluronic acid and be- cause we have not made use of this medium before in our department, we aimed to com- pare the IVF implantation and pregnancy rate by using hyaluronic acid and albumin as transfer medium.  The study design is a prospective double- blind study performed from September 2003 to January 2004. As the embryos were grown at the embryonic laboratory, the doc- tors and women were unaware which me- dium had been used. It was conducted at the Research and Clinical Centre for Infertility in Yazd, Islamic Republic of Iran and was approved by the local ethics committee. The study included 60 women undergo- ing IVF who were divided into Group A (whose embryos were transferred to a me- dium supplemented with hyaluronic acid) and a control Group B (whose embryos were transferred to a medium containing albumin).  The indication for IVF in groups A and B was because of male factors (n = 17, n = 18), tubal factors (n = 9, n = 7) and poly- cystic ovary syndrome (n = 4, n = 5) respec- tively. Ovary stimulation was carried out for all women by a desensitizing protocol using GnRH-agonist (Suprefact D-65926, Hoechst AG, Germany). To suppress pi- tuitary function, women were treated with Suprefact 0.5 mg/day given subcutaneously    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما for 14 days from the mid-luteal phase of the preceding cycle (day 20–22). As all women were ovulatory, they experienced menses with Suprefact treatment. After pituitary down regulation was confirmed by the ab- sence of any ovarian follicle of > 10 mm in size, women underwent gonadotropin stimulation. Induction of ovulation with human menopausal gonadotropin (HMG) (Menop- ur, Ferring, Germany) was started given in- tramuscularly in a dosage of 3 ampoules per day (215 UI of HMG) from day 2 for 7–12 days depending on the woman’s response. The women were followed by vaginal sonography and monitoring of serum estra- diol (E2) level. When serum E2 level was > 2000 pmol/L and at least 2 follicles were > 17 mm in diameter, 10 000 units of human chorionic gonadotropin (Organon, Holland) were administered intramuscularly. Trans- vaginal oocyte retrieval was performed 34–36 hours after hCG administration un- der transvaginal ultrasound guidance. The retrieved oocytes were then fertilized (in G-fert + albumin 10% for 36–40 hours) according to sperm quality either by con- ventional IVF (n = 10) or intracytoplasmic sperm injection (n = 20) in each group.   Sixty (60) women were recruited on the day of embryo transfer and signed an informed consent and be included. The inclusion cri- teria were: age 35 years or younger, having at least 3 embryos suitable for transfer, and having no previous IVF embryo transfer cy- cle. The women were randomly divided into 2 groups. In group A (30 women), embryos were transferred to a medium supplemented with 0.5 mL/mL of hyaluronic acid (Em- bryoGlue®, Vitrolife, Sweden) for 10 min- utes before intrauterine transfer took place. In group B, that served as a control group (30 women), embryos were transferred as routinely done, to a medium containing albumin 20% (Bayer Corporation, United States) for 10 minutes. All embryo transfers were performed using a Labotect catheter (Labotect GmbH, Germany) on day 3 after oocyte retrieval. The luteal phase was supported by pro- gesterone in oil (Progestan, Nowr pharme- Neth, Tehran, Islamic Republic of Iran), 100 mg daily administered intramuscularly. Patients were tested for serum -hCG assay 14 days after embryo transfer. If the pregnancy test was positive, women were followed with serial ultrasounds to deter- mine fetal viability. Clinical pregnancy was defined as the presence of a gestational sac on transvaginal ultrasound. Luteal phase support was continued until 10 weeks gesta- tion.  Clinical results of the embryo transfer cy- cles were compared between the 2 groups. Data are presented as mean and standard deviation (SD). The results were analysed using the chi-squared test, Fisher exact test and ANOVA. P-value < 0.05 was consid- ered significant.  Table 1 shows some characteristics of the 2 study groups. Mean age (SD) was 27.5 (4.26) years for group A and was 28.60 (3.68) years for group B. Mean duration of infertility was 7.24 (3.68) years for group A and 6.93 (3.60) years for group B. Mean embryo transfer was 2.68 (0.66) for group A and 2.70 (0.79) for group B (Table 1). In group A, 85 embryos were transferred resulting in 11 pregnancies and in group B, 98 embryos were transferred resulting in 7 pregnancies. The implantation rate was   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما 36.7% in group A and 23.3% in group B, however this difference was not statisti- cally significant (P = 0.26) (Table 2). All pregnancies were singleton. The abortion rate was higher in group B (28.6% versus 18.2%), but this was not statistically signifi- cant (P 1) (Table 2).  This study shows that hyaluronic acid can successfully replace albumin as a human embryo transfer medium resulting in com- parable high pregnancy and implantation rates. A study in 2000 showed that the em- bryos, which were developed in media supplemented with hyaluronic acid, had equivalent rates of blastocyst development and equivalent cell numbers compared to embryos cultured with albumin. In addition, the implantation and pregnancy rate were similar in the 2 groups [8]. Our results are similar to another study conducted in 2003 which suggested that the clinical pregnancy, implantation and ongoing pregnancy rates were higher with hyaluronic acid transfer medium compared with albumin transfer medium [1]. In an- other study a significant increase in both implantation and fetal development rates were reported when hyaluronic acid was the only macromolecule in the transfer medium of mouse embryos in comparison to transfer media that were combined with bovine serum albumin and hyaluronic acid [14]. The use of hyaluronic acid in the transfer medium may offer several advantages in the implantation process, such as a sig- nificant increase in both implantation and fetal development rates. Concern has been expressed about the immediate or late ex- pulsion of embryos after their transfer to the uterine cavity [15]. However, our experi- ence, as well as that of other researchers [1,12,14], suggests that the implantation and pregnancy rates were higher in the hy- aluronic acid treatment group. We conclude, therefore, that hyaluronic acid medium can successfully replace albumin medium.                                                                                    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                                   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                       ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  Children born too close together have long been associated with an increased risk of adverse health outcomes, including infant, child and maternal mortality. Research has shown that inter-pregnancy interval is an in- dependent risk factor for pre-term delivery and neonatal death [1]. Short birth intervals (< 2 years) may lead to maternal depletion syndrome, milk diminution and competi- tion between siblings close in age for food and other resources [2]. Analysis of data on more than one million pregnancies in Latin America showed that short birth in- tervals were independently associated with increased risk of perinatal outcomes [3]. In India a comprehensive study of infant and child mortality based on National Family Health Survey data found that a previous birth interval of less than 24 months in- creased child mortality by about 67% [4]. A longitudinal analysis of 3370 births to women living in 70 villages of Bangladesh showed that if women delayed a subsequent birth by about 2 years, child survival im- proved at all ages up to 5 years. Moreover, a child born after a short birth interval (< 2 years) was 3 times more likely to suffer from malnutrition, even at age 3 years, than a child born after 2 years [5]. Evidence has consistently shown that a birth interval of 2 years improves the chances of survival of infants and children. However, new research suggests that a period of 3–5 years is the optimum birth interval, and saves more lives than a 2 years interval. Analysis of data from the Demographic and Health Survey (DHS) has shown that compared with an interval of 24–29 months, a birth interval of 36–41 months was associated with 26%, 43% and 51% reduction in deaths in neonatal, infant and under 5-year-olds respectively, as well as a 28% reduction in stunting and a 29% reduction in underweight [2]. In Bangladesh, Egypt, Indonesia and Peru, perinatal mortality rates for children born at < 24 months interval were 70, 44, 47 and 36 respectively per 1000 births. At 36 months interval, the rates for the same countries were 44, 18, 16 and 19 [2]. Evidence on maternal health has been provided by research conducted on over a million pregnancies in 19 countries by the Latin American Center for Perinatology and Human Development. It was observed that spacing births beyond 2 years (27–32 months) improved maternal health in terms of less likelihood of developing toxaemia, anaemia and third trimester bleeding as well as 2.5 times less risk of maternal mor- tality compared to birth intervals of 9–14 months. Intervals longer than 69 months were associated with increased risk of ma- ternal death (10%), third trimester bleeding (10%), eclampsia (80%) and post-partum haemorrhage (90%) [6]. Worldwide, many women have birth intervals shorter than 3 years. Data based on population reports from 55 countries showed that 26% of women gave birth < 2 years after a previous birth and 31% of the birth intervals were 2–3 years [2]. The largest proportion of women with birth intervals < 3 years were reported from the developing countries of the Middle East region, such as Jordan and Yemen, as well as from Turkmenistan in Central Asia. It is believed that birth intervals are shorter in these countries because many women prefer to have births in close succession and then use contraceptives for limiting rather than spacing births [7]. There is a paucity of information on birth interval in Saudi Arabia. Among the few studies published, Madani et al. examined lactational amenorrhoea and birth interval among Saudi Arabian women from Taif in 1994. The lack of adequate information on   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما breastfeeding and birth interval was noted [8]. A 1999 study reported on mean birth interval and the factors influencing it among rural women [9]. Another study focused on the physical and mental development of urban schoolchildren aged 9–10 years from Al-Khobar in relation to birth interval [10]. Not only is there a lack of data on birth interval in this region, little is known about the perception of Saudi Arabian women regarding optimum birth spacing or their awareness of the advantages and disad- vantages of long and short birth intervals. Such information would help in developing strategies to promote adequate birth spacing among the local population. Hence, we carried out this study to de- termine perception of birth spacing among a group of Saudi Arabian women, actual birth intervals of children born to these women during the 10 years prior to the study, so- ciodemographic factors influencing birth interval and use of birth spacing methods.  We carried out a cross-sectional study on Saudi Arabian women who attended prima- ry health care centres in Al-Khobar during March 2003. The clients of these National Health Service centres in the urban area of Al-Khobar are predominantly Saudi Ara- bian and a largely socioeconomically ho- mogenous group, belonging to the middle and lower social class. Sample size was based on an estimated 56 110 married Saudi women in the repro- ductive age group (15–45 years) registered at the primary health care centres in Al- Khobar. With an expected frequency of 50% of Saudi women having fair knowl- edge and a worst acceptable rate of 45%, the minimum sample size was estimated as 357 at 95% confidence interval using Epi-Info, version 6. Of a total of 9 primary health cen- tres, 3 centres having the largest catchment areas were selected for the study. All mar- ried women in the age group 15–50 years who had given birth to 2 children during the 10 years prior to the study were asked to participate in the research. The response rate was close to 95%. A slightly higher number (436) than the estimated sample size was recruited in a 2-week period. Data on birth interval were collected using a specially designed, pre-tested ques- tionnaire. Information was elicited from the women by a group of trained interviewers. Birth interval was defined as the time period between 2 consecutive births. Data were obtained on sociodemographic profile, per- ception of ideal birth interval and reasons for their choice. The participants were then asked specifically about their awareness of certain known benefits [2,10] related to an adequate birth interval, e.g. regarding height, weight, intelligence and school per- formance of children, better maternal health and lower risk of infant/perinatal mortality and morbidity. Information was obtained from each woman on the birth intervals of all her children born during the 10 years prior to the study; data was not limited to the last 2 births. Information on births beyond 10 years prior to the study were not consid- ered because the age range of the study population was wide (15–50 years) and older women who would have given birth 2–3 decades ago could have had shorter birth intervals than the current trend of child spacing adopted by younger women. Women were also asked about the methods of child spacing they currently used, or had used in the previous 10 years. At the end of the interview each woman was given information verbally by the trained interviewer regarding the advan- tages of longer birth interval. Immediately thereafter, in the same session, she was    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما asked whether she would space her future births adequately. Data were analysed using SPSS, version 8. Distributions and bivariate analysis of data were done. Mean birth interval for all children born during the 10 years prior to the study was estimated for each woman. The mean value per woman was computed for the population mean birth interval. The chi-squared test of significance was done where appropriate. The Pearson correlation was used. Kappa value was calculated to measure agreement between the preferred and actual birth intervals. Predictors of birth interval were determined by the multiple linear regression analysis. Prior to multiple regression analysis, the multicolinearity test was done to determine the interrelationship between the valid and significant sociode- mographic (independent) variables related to the women. Colinearity was measured by the “tolerance” value (1 – R2), which indicated the proportion of variance in a variable that was not accounted for by the other independent variables. A tolerance value of 0.7 for each independent variable was considered the criterion for inclusion in the multiple linear regression model. P < 0.05 was considered significant.  Of the 436 multiparous women recruited for the study, 66 (15.1%) were 25 years of age, 255 (58.5%) were 26–35 years, 109 (25.0%) were 36 years and 6 (1.4%) gave no response. Mean age was 32 years [stand- ard deviation (SD) 6.27]. Most of the par- ticipants (75.7%) were not employed. The majority of those employed were profes- sionals (79.2%); the others were either work- ing as secretaries/administrators (2.3%) or doing unskilled jobs (1.8%). Almost half the women (48.8%) had completed high school or college education; the rest had either studied up to primary/intermediate level (31.7%) or were illiterate/not formally schooled (19.5%). Corresponding figures for husband’s education level were 57.1%, 30.3% and 10.6% respectively. In response to the question on ideal birth interval, 12 (2.8%) women stated that they had no preference, 22 (5.2%) preferred < 2 years, 123 (28.2%) preferred 2 years, 159 (36.5%) 3 years, and 120 (27.5%) > 3 years. Of the 22 women who stated they preferred a shorter ( 2 years) birth interval, 16 were educated to less than high school level (Ta- ble 1). Among those who had high school or college education, 97.1% preferred a longer interval ( 2 years) (P < 0.05). A slightly larger proportion of the women who were employed (98.1%) favoured a longer ( 2 years) birth interval compared to the homemakers (93.7%); the results were, however, not statistically significant (P = 0.08) (Table 1). Reasons given for preferring a short birth interval (< 2 years) included: hus- band’s wish (50.0%), easier to take care of children in quick succession (31.8%), desire to complete family quickly (31.8%) and dictates of religion (18.2%). Reasons given for preferring a longer birth interval included: good physical growth of children (38.7%), good health of children (43.0%) and better maternal health (58.1%). Very few women (5.6%) mentioned more intelligent children or less risk of perinatal/neonatal mortality and morbidity (2.8%). Fifteen (5.3%) women stated dictates of religion as a reason for their choice. All the participants were then asked specifically about their awareness of certain known benefits of adequate birth interval [2,10]. A sizable proportion of the respond- ents were not aware that longer birth inter- val ( 2 years) could lead to improvement in the child’s height (60.1%), weight (45.8%),   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما intelligence (50.7%) and school perform- ance (41.5%) as well as lowering the risk of infant and perinatal mortality and morbidity (47.3%). The majority (88.5%), however, perceived that long birth intervals would decrease the risk of maternal mortality and morbidity. The women in the study sample were instructed individually about these specific physical and mental health advantages of longer birth intervals ( 2years) at the end of the interview. They were then asked in the same session about their intention regarding spacing of future births. It was encouraging to note that among 405 women who were planning future pregnancies, 81.5% were positively inclined towards adequate birth spacing. Higher level of edu- cation contributed favourably to a positive attitude (P < 0.05) (Table 2). When asked whether they would try to convince their husbands if they disagreed with a longer birth interval, 90% of the women responded in the affirmative. More than half the women (53.4%) be- lieved that the older child in a pair of siblings born with a short birth interval (< 2 years) was more likely to have a health risk while 17.2% believed that the younger sibling would be more affected; 74 (17.1%) women                                                                                                                 ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما felt that both children in a pair would be at a health disadvantage and 30 (6.9%) felt neither child would be affected. The mean birth interval of children born to women in the study population within the 10 years prior to the study was 33.5 (SD 17.8) months, range 9–120 months. About a quarter (26.0%) of the women had actual mean birth interval of < 2 years. Very few women in this study (5.3%) had mean birth interval of > 5 years (Table 3). More women who were educated up to high school/col- lege level (37.7%) had actual mean birth interval ranging from 3 to 5 years compared with those who had less education (29.0%) but the difference was not statistically sig- nificant (P = 0.09) (Table 3). Short birth interval (< 2 years) was also more common among women whose husband’s education level was less than high school (31.8%) (P = 0.15). Employment status was significantly related to birth interval. The optimum birth interval of 3–5 years was more frequently observed among women who were em- ployed (171, 39.2%) than among home- makers (143, 32.7%) (P < 0.05). Type of employment did not affect birth interval. Short birth interval (< 2 years) was more common in younger women ( 25 years), whereas the longer birth intervals were more common in women of older age groups (P < 0.05) (Table 3). Nearly two-thirds of the participants (63.9%) believed that a birth interval of 3 years was desirable, however, 21.2% of these had an actual mean birth interval of < 2 years and 53.2% had an actual mean birth interval of < 3 years (Table 4). The measure of agreement estimated by the Kappa test for preferred and actual birth interval (“no preference” category was removed from                                                                                                                                                                    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما the analysis) was statistically significant (P < 0.001), level of agreement 46.1%. During the 10 years prior to the study, 90.8% of the respondents had used 1 methods for birth spacing, the most popular being oral contraceptive pills (65.1%) fol- lowed by the intrauterine device (24.5%), breastfeeding (20.6%), rhythm method (9.6%), condom (7.1%), coitus interruptus (6.0%) and contraceptive hormone injec- tions (0.9%). The non-users of birth spacing methods (9.2%) included a greater propor- tion of the illiterate or non-schooled women (15.5%) compared to those with some school education (7.7%) (P < 0.05). The multicolinearity test was done for the independent sociodemographic valid and significant variables related to the women. The tolerance values (1 – R2) ob- served for women’s age, occupational status and education level were 0.97, 0.81 and 0.79 respectively, indicating little relation- ship between them. These factors were thus included in the model of the multiple linear regression analysis to examine their effect on birth interval. After controlling for education level of the women, 2 factors, age of the woman and occupational status, were significant positive predictors of increasing birth interval (P < 0.05) (Table 5).  Over the years, evidence has consistently shown that a birth interval of 2 years gives infants and children through 5 years a better chance of survival. This health message has                                                                                       ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما been present for decades, and most mothers studied have reported that a birth interval of 2 years is best [2]. Not only is this concept valid in industrialized societies but it is also prevalent in traditional communities. A sur- vey investigating family planning practices/ beliefs among traditional healers in Ibadan (Nigeria) reported that their preferred child spacing period was 2–3 years [11]. Muslim communities have been guided by the di- vine script of the Quran in which 3 verses in 3 different suras have indicated indirectly the optimum birth interval period by speci- fying a suggested time of 24 months for breastfeeding and the period of pregnancy and suckling to range from 24 to 30 months (Holy Quran 2:233; 31:14; 46:15). This would mean that a minimum birth interval ranging of 2.5–3.0 years is adequate. It was therefore not surprising that a large propor- tion of the mothers (63.9%) in this study from a predominantly Islamic background also believed that a gap of > 2 years be- tween births was a desirable norm. Higher education level is usually linked to better health awareness and longer birth intervals [2,9,12]. In accordance to our expectations, significantly more women in this study with higher education level preferred a longer birth interval ( 2 years) than those with less education. The stresses of work outside the home usually motivate employed women to postpone pregnancy and adopt a longer birth interval, a finding which was observed in this study as well as reported from other countries of the world [2]. “Husband’s wish” was an important factor in the choice of Saudi Arabian wom- en who preferred the short birth interval (< 2 years). Other studies from this region [13,14] and South Asia [15] have reported the role of husbands in taking the final decisions regarding issues related to family planning and child spacing. In a study con- ducted in Jordan, almost half the husbands of the study population reported that fam- ily planning issues should not be discussed with wives [13]. Researchers therefore rec- ommend that interventional strategies on fertility issues need to be targeted towards husbands in this region [13,14]. Close to half the women in this study lacked awareness about the known ben- efits of longer birth intervals and adequate child spacing. Studies from the Middle East and other areas have observed an as- sociation between longer birth interval and better physical growth of children [16–19] (S.M.N. Haque, D. Morley, unpublished report, 1996). There is also evidence that children with malnutrition, delayed teeth- ing and rickets have significantly shorter birth intervals than children without these problems [18]. The United States Agency for International Development has reported that 3-year birth intervals or longer are linked with the lowest risk of stunting and being underweight among children under 5 years [2]. Not only are there advantages of better physical growth, but a few studies conduct- ed in Singapore [19], Bangladesh (S.M.N. Haque, D. Morley, unpublished report, 1996) and Saudi Arabia [10] have noted the influence of short and long birth intervals on mental development of children. The Singapore study found that children (9 years old) born after a short birth interval suffered as regards perceptive and vocabulary ability [19]. In Bangladesh, children (9–10 years old) born after a long birth interval (> 41 months) were brighter than average, more intelligent, heavier and had a bigger mid upper arm circumference than children born after a short birth interval (< 25 months) (S.M.N. Haque, D. Morley, unpublished report, 1996). Bella et al. in Saudi Arabia showed that birth interval increases were associated with more intelligent children (9–10 years old) and better school perform-   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما ance [10]. All 3 studies showed that vari- ables of mental (intellectual) development were better correlated with birth interval than those for physical development. Infor- mation needs to be given to parents about the full range of biosocial benefits, espe- cially regarding intellectual development of children born with adequate spacing. This knowledge could reinforce their belief in longer birth interval and could be a strong incentive for adopting an adequate child spacing period. More than 50% of the women in our study considered the older child of a pair of siblings born within a short birth interval to be at greater health disadvantage than the younger. Only 17% of women thought that both children would be equally at risk. Very few studies have been done to compare the difference in the health risks to children with short preceding and short succeeding birth intervals. One study showed that a preceding short birth interval was more important, i.e. the younger child’s physical and mental development was more likely to be affected than that of the older child [19]. Another study measuring similar outcome parameters found that while both siblings in a pair were adversely affected, the older was more at risk [10]. The conclusion therefore is that short birth intervals are a health disadvantage to both siblings in a pair, and mothers need to be educated accordingly. Based on analyses of 55 countries, me- dian birth interval in developing countries was about 32 months [3]. Mean birth in- terval of 33.5 months in our study is close to this figure as well as to 31.2 months observed in a 1999 study from a rural area of Saudi Arabia [9]. However it is higher than the mean child spacing period of 26.8 [8] and 26.2 [10] months found for births of Saudi Arabian children born more than a decade ago. This difference is possibly due to a changing secular trend of increasing birth intervals that are occurring in most countries of the world [7]. One of the pos- sible reasons suggested for this change is the greater motivation of women in recent times to postpone births due to expanding opportunities for their education and em- ployment, a situation which is also relevant to Saudi Arabia. Moreover with the expansion and easy accessibility of health services in Saudi Arabia over the past two and a half decades, a focus on the health of mothers and chil- dren has gained momentum in the region. Though exclusive breastfeeding and dura- tion of breastfeeding is on the decline in Saudi Arabia [20] especially in urban areas and among the younger population, contra- ceptives are easily available in the market and are used commonly [9]. We also found contraceptive use to be popular and this may well be a factor explaining the large proportion of women (73.9%) having birth intervals of 2 years. New studies have reported that 3–5-year birth intervals were even more beneficial than 2 years. Researchers at the Demo- graphic and Health Survey programme, after assessing outcomes of 430 000 pregnancies from 18 countries in 4 regions, found that children born 3–4 years after a previous birth were 2.5 times more likely to survive to age 5 than children born less than 2 years apart [2]. Only one third of the women in this study reported optimum birth intervals of 3–5 years and this calls for public health attention. Recent research has also shown that waiting too long between pregnancies, i.e. 6 years increases the risk of having a stillbirth regardless of previous pregnancy outcome [21]. Further, Huttly et al. showed disadvantages in relation to birth weight, perinatal mortality and infant mortality in urban Brazilian children born after a birth interval of > 71 months [22]. It was encour- aging to note that birth intervals beyond 5    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما years were not common (5.5%) among the women in our study. In line with other studies [2,23,24], our research showed that optimum birth in- tervals of 3–5 years were more common among those with higher levels of educa- tion, though not statistically significantly, as well as among women who were employed, indicating greater awareness of and stronger motivation for health issues among these sub-groups. Optimum birth intervals were also significantly more frequent among the older women of this study. Other reports from this region [9] and South Asia [25] have also reported longer birth intervals among older women. We agree with Al- Nahedh that prolonged breastfeeding in the older age group of Saudi Arabian women and attainment of preferred family size by many of them could be possible reasons for this finding [9]. About a quarter of the women of this study had mean birth interval of < 2 years and 35.1% had waited between 2–3 years. This is similar to the reported average for 55 countries according to a 2002 report [2]. Moreover, many women desire longer birth intervals ( 3years), but more than half of the non-first births occur less than 36 months after the previous birth in develop- ing countries [2]. Not only are these women unable to achieve their reproductive goals, but they fall short of the 3–5 years intervals that new evidence suggests are healthiest. In Kenya, median birth interval was 35 months compared with preferred birth interval of 49.1 months [2]. Our findings also showed that the agreement between the preferred and actual birth intervals was < 50%, indicating a weak relationship. Although two thirds of the women preferred a spacing period of 3 years, more than half had birth intervals that fell short of 3 years. However it was encour- aging to note that the intention of women after having the specific health advantages of longer birth intervals explained to them, was positive for adequate spacing of births in future and their resolve to convince their husbands if they disagreed. Among the variety of contraceptives used, oral hormonal pills for women were the most popular, a finding also reported by researchers from this region [12] and other areas [26]. On the other hand, use of the condom was not common. This supports the results from other Arab [13,14] and developing countries [15,27] where males generally show a resistance to the use of condom. We suggest that education on birth interval and contraceptives should also be targeted toward men making them aware of a shared responsibility on the issue of child spacing. Breastfeeding is associated with a delay in the return of ovulation after birth and hence is an important factor in increasing birth intervals. However, the impact of breastfeeding on fertility is particularly great in populations that have extremely long periods of exclusive breastfeeding and little contraceptive use [28,29]. This relationship should be examined in a future investigation. The findings of the current research cannot be generalized to all Saudi Arabian women since the study was not community based, but conducted among users of the primary health centres of an urban area. From the evidence available in recent years (2002), children are healthier at birth and more likely to survive with a birth spacing period of 3–5 years [2]. In the lo- cal region, though birth intervals beyond 2 years are largely favoured, women need to be informed about new research find- ings on health advantages related to the optimum birth interval of 3–5 years. It is therefore essential that health programmes convey this message to parents and future parents. We agree with the Hopkins report   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما that child spacing is a matter of choice and that couples need to make spacing decisions based on personal preferences and situation, as well as on accurate information [2]. The message of optimum birth interval has to reach the people, and the responsibility for this rests with those involved in the health care of the community.                                                                                                                                                                                                                   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                            ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                   110025 278 41 47.55 13.266.211.3    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  Injections are among the most frequently used medical procedures, with an estimated 12 billion injections administered each year worldwide [1]. Injections have been used effectively for many years in preventive and curative healthcare [2]. Unsafe injection practices throughout the world result in millions of infections, which may lead to serious disease and death. Scientists estimate that unsafe injections may cause about 8–16 million hepatitis B virus infections, 2.3–4.7 million hepatitis C virus infections, and 80 000–160 000 HIV infections each year worldwide [3]. The estimated risk of infection from bloodborne pathogens following a single needle stick from an infected source-patient is 30% for hepatitis B, 3% for hepatitis C and 0.3% for HIV [4]. The probability of the source of the blood being HBsAg positive (hepatitis B surface antigen) is 1–3 per 1000 in the general population and 5%–15% in high-risk groups. The Centers for Disease Control and Prevention have estimated that there are 12 000 health-care workers infected with hepatitis B virus [4]. They have also estimated that of 61 929 adults employed in health-care settings, 3182 had AIDS [5]. In Cairo University Hospital, Egypt the overall carrier rate for hepatitis B virus among health-care workers is about 28% [6]. Approximately 13% of the Egyptian population is infected with hepatitis C vi- rus, leading to a high burden of chronic liver disease, cirrhosis and liver cancer, as well as mortality resulting from these diseases [7]. The proportion of new cases of hepatitis C that were attributable to unsafe injections exceeded 40% in 1996. This may have been related to the use of improperly sterilized needles that were used to treat schistosomiasis [8]. As a consequence of these unsafe injections, a large reservoir of chronic infection was established that still drives hepatitis C transmission in Egypt today [7]. Although most injections given in the world are done following safe clinical prac- tices, poor injection practices continue to transmit viral hepatitis and other infections on a large scale in many countries. Appro- priate measures can and must be taken to avoid this route of transmission of disease [7]. This study was conducted from 2003 to 2004 to assess safe injection practice among health-care workers in an Egyptian governorate, and to identify the obstacles to and requirements for applying safe injection practices.  A cross-sectional, observational study was conducted in Gharbiya Governorate, a gov- ernorate in the north of Egypt, which is divided into 8 districts and includes a total of 272 health-care facilities. Multi-stage random sampling was used to obtain a representative sample of these health-care facilities. First, 2 health districts, Tanta and Bassiun, were selected randomly. Within these, at least 25% of each type of health- care facility was selected randomly (hos- pital and primary health care centre). Thus the total sample included 25 health-care facilities; 7 hospitals and 18 primary health care centres. Data were collected using a combination of interview and structured observations. • A standardized questionnaire was used to interview the deputy director of the facility to obtain general information about the facility, administrative proce-   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما dures and availability of supplies needed for safe injection. • An observational checklist was designed to evaluate injection practices and waste management, based on World Health Or- ganization (WHO) definitions [9]. This included observations of the availability of supplies and equipment needed for safe injection practice and also of injec- tions administered during the visit and of waste management activities. At least 10 injections were observed in different injection settings in each selected facil- ity and were compared with the WHO definition of safe injections to verify their safety. All departments in the facil- ity where injections were provided to patients were visited (e.g. emergency room, operating theatre, family plan- ning unit, laboratories, dentistry facili- ties, renal dialysis room and vaccination room). • A standardized questionnaire was used to interview all health-care workers available on the days of the visit about prescription of injections, giving injec- tions, exposure to needle-stick injuries, hepatitis B vaccination status and safe injection training. These data collection tools were pilot- tested to ensure that they were suitable for the local circumstances. This was conducted in a limited number of health-care facilities adjacent to the selected sites prior to the actual study fieldwork.  Double data entry into a computerized data- base was used to ensure accuracy. Epi-Info, version 6.04b software was used for data entry, validation and analysis. The chi- squared test was used for statistical analysis Suitable statistical tests were used and the significance level was set at P < 0.05.  The total number of health-care facilities studied was 25 (7 hospitals and 18 primary health care centres): 10 were in urban set- tings and 15 in rural settings.   Routine immunization for children was ad- ministered in 20 health-care facilities. The reported total number of the health-care workers in the facilities was 2776. Table 1 shows that most of the health-care facilities studied lacked many procedures and policies important for safe injection practices. There was no statistically signifi- cant difference between different types of health-care facilities in this regard. Table 2 shows that in most of the health- care facilities, there was a lack of most of the supplies needed for safe injection prac- tices. Heavy-duty gloves were not available in any of the facilities. The shortage was greatest for plastic sharps containers, fol- lowed by disposable needles and syringes for therapeutic injections. There was no shortage of disposable needles and syringes for immunization injections. There was no statistically significant difference between the different health-care facilities.  Assessment of injection practices A total of 278 injections were observed in all the health-care facilities. Figures 1–3 show that the safe injection practices most commonly carried out were the use of dis- posable syringes and needles, followed by the use of new injection syringes for each injection, the use of new reconstitution syringes for each reconstitution, avoidance of touching the needle before use and the use of recommended diluents. On the other hand, the safe injection practices that were    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما least often carried out included safe disposal of syringes, proper needle manipulation be- fore disposal, safe disposal of needles and the presence of a preparation area dedicated to giving injections away from contamina- tion. Immunization injections and injections given by nurses were safer than therapeutic injections and injections given by physi- cians in most of the injection practices and the difference was statistically significant. Assessment of injection areas Table 3 shows that the areas (rooms) dedi- cated to injections often did not conform with safe injection practices. The areas where immunization injections were given were generally better than the areas for therapeutic injections. For example, in the latter, it was more likely to observe the presence of sharps in open containers and the presence of pierced, overflowing and/or open waste containers. Also, urban health- care facilities generally had more suitable areas for safe injections practice than rural facilities. Waste management in the studied health- care facilities Table 4 shows that there was a lack of many proper waste management activities and this varied with health-care facility. The commonest final waste disposal method was burning on the street near the facility. There was no statistically significant differ- ence between urban and rural health-care facilities as regards waste management activities, but removal of waste by com- munity refuse collectors was more likely to be used to dispose of waste in urban health- care facilities. There was no statistically significant difference between hospitals or primary health care centres as regards waste management activities.   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما     ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  We interviewed 1100 health-care workers representing about 40% of all health-care workers in the studied health-care facilities (n = 2776). Table 5 shows that females health-care workers were more likely to experience needle-stick injuries than males. Health- care workers who graduated from nursing school or who had lower levels of education were more likely to experience needle-stick injuries than those who had graduated from medical or nursing institutes or higher lev- els of education. Health-care workers who give injections were more likely to experi- ence needle-stick injuries than those who do not give injections. These differences were statistically significant. Table 6 shows that the reuse of used sy- ringes was reported by 13.2% of all health- care workers and there was no significant difference between those who had received training in injection control practices and those who had not. However, health-care workers who had received training were less likely to have had a needle-stick in-                                                           ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                jury than those who had not (P < 0.05). Two-hand recapping of needles was the commonest cause of such injuries. Hand- washing was the commonest reported action taken by health-care workers who suffered a needle-stick injury while one-third reported that they did not do anything at all after exposure. Only a small proportion reported that they took a vaccination against hepatitis B virus infection as soon as possible after the injury. Unsafe handling practices of needles prior to disposal (e.g. two-hand recapping, needle flexing and needle breaking) were more frequent among all health-care work- ers than safe handling practices, e.g. noth- ing done to the needle at all prior to its final disposal and one -hand recapping (scoop technique), and there was no significant difference between those who had received training and those who had not. However, health-care workers who had received training on safe injection practices within training on infection control practices were more likely to have been vaccinated against hepatitis B virus infection whether by at least 1 dose or by the full course compared to those who had not attended any training.    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                                                                                 In this study, data were collected using a combination of interviews and structured observations. In this way we attempted to minimize reporting bias and the Hawthorne effect (observer-induced changes in prac- tices) [9].   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  Ensuring availability of safe injection equip- ment and supplies is considered one of the main requirements for improvement of safe injection practices. The results of our study revealed that the Ministry of Health and Population distributes the supplies but some supplies are supported and funded by a spe- cific health programme, e.g. disposable nee- dles and syringes for routine immunization of children and women in the child-bearing period are provided through the Expand- ed Programme on Immunization and the family planning programme respectively. Therefore theses supplies are more likely to be available all of the time in immunization centres compared to therapeutic centres.  Most of the observed health-care work- ers used disposable needles and syringes for injection and used new syringes and needles for each injection. However, there were many cases where the recommended diluents were not used and a new needle for each reconstitution was not used. These findings are consistent with the results of Sophie et al., who reported that observation of injections conducted in Mongolia health- care facilities showed that needles were left in the septum of the multi-dose medication vials to be reused in the subsequent recon- stitutions [10]. In our study, two-hand recapping of needles before disposal, which exposes the health-care worker to the risk of needle- stick injury, was a common practice. This practice was also common among nurses in Mongolia [10]. Adherence to safe injection practices and the appropriateness of the injection areas were significantly better for immuni- zation injections than therapeutic injections. Simonsen et al. also reported that childhood immunization injections were safer than curative injections [11]. The immuniza- tion process constitutes a major priority for the Ministry of Health and Population and many national and international or- ganizations and agencies, such as WHO and UNICEF, and as a result more training, funding, supervision and supplies are avail- able for immunization. Of concern, we found 13.2% of the health-care workers interviewed who give injections reported that they had used sy- ringes and needles that had been used be- fore for giving injections to others. This is a very hazardous practice for the injection provider, the recipient and the community. The reuse of syringes and needles for differ- ent patients was not reported at all by nurses in Romania, while 4% of them reported the reuse of syringes and needles on the same patient in an emergency [12]. In Indonesia, the observed reuse of syringes and needles in 5 health centres in several regions was re- ported to be more than 50% of the injections [13]. Also, in 2 countries in sub-Saharan Africa, it was reported that 15%–60% of health-care centres reused syringes and needles [11]. Reports from the Dominican Republic showed that disposable syringes and needles were used multiple times in more than 50% of injections [11]. However, Sophie et al. reported that the observed injection providers consistently used newly opened syringes and needles for all injec- tions in Mongolia [10].  Our study showed that syringes were not disposed of safely at all and most needles were not segregated before their final dis- posal, nor were proper waste containers used. Collection of used syringes and nee- dles in safety boxes was also not reported in Kenya, Ethiopia, Zambia, Uganda and Tanzania [14].    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما We found that most waste management activities were unsafe as in most of the health-care facilities sharps were found lying around and not disposed of within proper containers in waste storage areas. These areas were also not secure enough to prevent the access of lay persons. The pres- ence of used syringes and needles in health- care facilities in Senegal and Cote d’Ivoire was reported in 10% and 70% of these facilities [14]. However, in Mongolia, no dirty or used sharps were observed around any of the studied health-care facilities at all [10]. In our study, this may be due to the methods of final waste disposal. In Mon- golia, all health-care facilities followed a national regulation recommending burning waste at an open site, in a drum or in a stove under supervision [10]. Waste incineration was reported in only a small proportion of the health-care facilities in our study. Incineration of used syringes was used for final waste disposal in many East African countries such as Kenya, Ethiopia, Rwanda and Zambia while it was not reported in Uganda and Tanzania [14]. There was no significant difference between immunization centres and non- immunization centres as regard waste man- agement activities, but incineration of waste on-site in the facility was more likely to be used in non-immunization centres probably because all non-immunization centres were hospitals where incinerators are more com- monly found.  Health-care workers who use or may be exposed to needles are at increased risk of needle-stick injuries. Such injuries can lead to serious or fatal infections with blood- borne pathogens such as hepatitis B virus, hepatitis C virus, or human immunodefi- ciency virus [4]. In our study, 66.2% of the interviewed health-care workers reported that they had experienced at least 1 needle-stick injury during their working life. The mean re- ported number of needle-stick injuries per health-care worker in the 3 months prior to the study was 1.3. In Mongolia, 67.8% of health-care workers reported that they had experienced at least 1 needle-stick injury in the previous12 months [10]. In Senegal and Cote d’Ivoire 70% of staff members of health-care facilities reported needle-stick injuries in the previous 6 months [14]. In developing countries, there is a lack of awareness and training of health-care workers regarding proper needle manipula- tion, prevention of needle-stick injuries and their harmful effects. Also, there is lack of supplies needed for protection of health- care workers and prevention of injury such as heavy utility gloves for waste collection, puncture- and liquid-proof sharps contain- ers and safety boxes. The commonest reported cause of needle-stick injuries among the health-care workers interviewed was during two-hand recapping of needles followed by during waste collection and then while needle flexing. Unsafe needle handling prior to disposal was also common. Past studies of needle-stick injuries revealed that 10% to 25% of injuries occurred during two hand recapping of needles [4]. Furthermore, after needle-stick injury, health-care workers who were injured did not deal properly with their injuries. In our study, only 11.3% of the health- care workers and 11.6% of the health-care workers who give injections reported that they had completed the full course of hepa- titis immunization. Sophie et al. reported that none of the health-care workers who give injections in their study in Mongolia was vaccinated against hepatitis B [10].   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما   In our study, there was a lack of training of all interviewed health-care workers on different practices related to safe injection. In Romania, 91% of health-care workers had attended at least 1 training session on universal precautions for infection control, including safe injection practices [12]. Health-care workers who attended at least 1 training course on infection control practices or its related fields were less likely to experience needle-stick injuries and more likely to be vaccinated against hepatitis B, whether with 1 dose or with the full course, compared to those who had not attended any training course. At the same time there was no significant difference between these groups as regards the cause of needle-stick injuries, their action after injury, needle- handling methods before disposal and the needle disposal methods.  The results of our study indicate that injec- tion practices within all health-care facili- ties are not as good as they should be and as such can contribute to the spread of in- fection. All the health care facilities lacked adequate activities to promote and ensure safe injection practice, such as written poli- cies and procedures, overseeing activities, etc. Clearly there is a need to address the situation and implement strategies to bring about improvement. The reasons for the inadequacy of safe injection practice may be a lack of supplies, such as disposable sy- ringes and needles and safe disposal boxes, and/or a lack of awareness of the staff of safe injection practices and their importance for control of infection, both to themselves, to the recipients of injections and also to waste disposal staff. Certainly only a very small proportion of the staff had received any training in infection control practices. Although the practices of the trained staff were better in certain areas, in others their practices were similar to those who had not received any training. This suggests that these training courses were not suf- ficient to increase the health-care workers’ awareness and change their attitudes, be- haviours and practices. This also suggests that the implementation of proper infection control practices needs not only specific training courses, but also strict regulations, supervision and even application of specific rewards and punishments schemes. It may additionally suggest that in some cases a lack of appropriate supplies made it difficult to apply safe injection practices.  • Infection control policies and guidelines including safe injection practices and hospital waste management activities should be present in all health-care fa- cilities. • Training programmes on infection con- trol, including safe injections practices, should be provided to all health-care workers. • Hepatitis B vaccination coverage should be increased to cover all health-care workers. • Adequate supplies for safe injection practices need to be made available.    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                                       ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                              ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  À l’aube du troisième millénaire, l’épidémie mondiale des maladies liées au tabac conti- nue à s’aggraver. En effet, le tabagisme est l’une des principales causes évitables de dé- cès dans le monde. L’Organisation mondia- le de la Santé lui attribue près de 4 millions de décès par an, chiffre qui pourrait attein- dre 8,4 millions d’ici 2020 dont 70 % se produiront dans les pays en développement [1-3]. La Tunisie, actuellement en phase de transition épidémiologique dominée par les maladies chroniques, connaît une extension du phénomène tabagique chez l’adulte de sexe masculin, atteignant 61,4 % [4]. Les adolescents, population cible de l’industrie du tabac, constituent certainement l’élément essentiel qui permet de prédire l’évolution du tabagisme et par conséquent des risques qui lui sont attribués. Étant donné l’importance chez l’adolescent du facteur « identification à un modèle » dans l’acquisition de l’habitude tabagique [5], l’enseignant représente pour le jeune le modèle par excellence [6]. Ainsi le corps enseignant constitue la pièce maîtresse dans la lutte contre le tabagisme. En effet, l’enseignant peut sen- sibiliser l’enfant, dès le jeune âge, aux critères sur lesquels se fonde une société saine, performante et non tabagique. Les programmes de lutte antitabac ont négligé l’éducation pour la santé des enseignants dont les comportements tabagiques dans les établissements scolaires représenteraient un obstacle majeur au succès de la promotion d’une école sans tabac et d’une génération libre de l’intoxication tabagique. Face à une telle constatation, il est important de réagir vigoureusement et de façon coordonnée. Pour cela, il est néces- saire d’évaluer le profil tabagique des enseignants. En Tunisie, quelques études ont été consacrées au tabagisme [7-10] mais aucune n’a intéressé les enseignants. Une telle étude pourrait contribuer à plani- fier une éducation sanitaire spécifique aux caractéristiques socioprofessionnelles et éducatives du corps enseignant. Pour ce faire, nous avons mené une enquête parmi les enseignants d’une région semi-urbaine (Kalaa Kebira) dont les objectifs étaient de décrire les connaissances et les attitudes des enseignants vis-à-vis de la consommation tabagique.  Il s’agissait d’une étude descriptive, trans- versale et exhaustive, qui a intéressé les enseignants exerçant dans la commune de Kalaa Kebira (région semi-urbaine de la ville de Sousse) en Tunisie. La population étudiée était composée des enseignants des dix écoles primaires et des trois lycées étatiques de la commune de Kalaa Kebira. L’effectif total était de 402 enseignants (241 instituteurs et 161 professeurs). Les données ont été collectées à l’aide d’un questionnaire pré-codé, rédigé en arabe et comportant 38 questions pour les fumeurs et 23 questions pour les non-fumeurs. Les principales sections de ce questionnaire étaient les caractéristiques de la population (âge, sexe, état civil), le comportement ta- bagique et les connaissancesattitudes. Le comportement tabagique englobait les ha- bitudes tabagiques, la variété et la quantité du tabac consommé, les signes fonctionnels respiratoires et la dépendance tabagique évaluée par le test de Fagerström [11]. On a cons idéré comme « non- fumeur » toute personne qui ne fumait pas au moment de l’enquête. Cette catégorie a été divisée en « ex-fumeur » (personne ayant fumé quotidiennement pendant au   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما moins six mois et qui ne fumait plus au moment de l’enquête) et en « autre non- fumeur » (personne qui n’a jamais fumé ou qui a fumé pendant une période suf- fisamment courte : moins de six mois). L’information à l’égard du tabagisme a été évaluée par un score, englobant 8 items pondérés à un point chacun. L’enseignant a été jugé « bien informé » s’il avait un score supérieur ou égal à 6, « assez bien informé » si ce score était égal à 5 ou 4 et « mal informé » si ce dernier était inférieur ou égal à 3. De même, nous avons procédé à l’évaluation de l’engagement des ensei- gnants dans la lutte antitabac par un score qui englobait 9 questions pondérées cha- cune à un point. L’enseignant a été jugé « en faveur de la lutte antitabac » si son score était supérieur ou égal à 4 et « indifférent » dans les autres cas. L’enquête a été menée pendant trois mois dans les 13 établissements scolaires par un médecin stagiaire interne. Le questionnaire a été distribué pendant l’intercours dans la salle des enseignants. Les données ont été saisies et traitées sur le logiciel « Systat ». En plus des statistiques descriptives (fréquence, moyenne), l’association entre les variables qualificatives a été testée par le test de 2 avec un seuil de signification de 5 %.    Ont participé à notre étude 358 enseignants (192 hommes et 166 femmes), soit un taux de participation de 89 %. La répartition des enseignants selon l’âge et le sexe est présentée au Tableau 1. L’âge moyen de la population étudiée était de 35,7 ans (E.T. 7,90) [39,7 ans (E.T. 7,75) pour les hommes et 31,2 ans (E.T. 5,21) pour les femmes]. Sept enseignants interrogés sur dix avaient un âge inférieur à 40 ans.   La prévalence globale de l’habitude taba- gique chez les enseignants de la commune de Kalaa Kebira était de 29,3 %. La préva- lence du tabagisme était significativement plus élevée chez les hommes que chez les femmes (51,6 % versus 3,6 % ; p < 0,0001 ). La prévalence du tabagisme passait de 23 % chez les instituteurs à 40 % chez les professeurs. Cependant cette différence n’a pas été retrouvée en faisant l’analyse stra- tifiée, séparément dans les deux sexes. En effet, la majorité des enseignants étaient des instituteurs et la majorité des instituteurs étaient des femmes non fumeuses. Parmi                                                     ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما les professeurs littéraires, 39 % étaient des fumeurs alors que ce taux était de 28 % chez leurs collègues scientifiques. Cette différen- ce n’est pas statistiquement significative. Selon le test de Fagerström, 78,7 % des fumeurs étaient dépendants à la nicotine.   Les tableaux 2 et 3 illustrent les connais- sances, attitudes et comportements des en- seignants à propos du tabagisme. Il ressort que 42,4 % des enseignants étaient mal informés à propos du tabagisme et seule- ment 4 % étaient jugés « bien informés ». Les ex-fumeurs étaient plus informés sur le tabac que les fumeurs. Les conséquences du tabagisme sur la femme enceinte étaient méconnues par un enseignant sur sept. Les deux sujets les plus connus par eux étaient les maladies liées au tabac et les consé- quences du tabagisme passif (Tableau 2). L’étude de l’engagement des enseignants dans la lutte antitabac a montré que 22 % d’entre eux restaient indifférents à cette politique. Les deux moyens de lutte anti- tabac les plus acceptés par les enseignants étaient la limitation de l’usage du tabac dans les lieux publics et l’interdiction de la publicité du tabac (Tableau 3). Parmi eux, 75,2 % des enseignants fumeurs consom- maient le tabac devant leurs élèves. Glo- balement, les femmes et les non-fumeurs étaient plus favorables à l’application des différentes stratégies de lutte antitabac.  Le début de plus en plus précoce de l’acqui- sition de l’habitude tabagique, qui annule tous les efforts pour lutter contre le taba- gisme, est suffisamment effrayant pour que la prévention chez les jeunes soit prioritaire à toute autre action préventive. Étant donné qu’il est extrêmement difficile d’amener les adultes à cesser de fumer, il faut agir dès l’enfance avant que les jeunes aient com- mencé, d’où la place privilégiée des leaders d’opinion. En effet, dans le domaine de la lutte contre le tabagisme, certains groupes sociaux ont un rôle très important à jouer. Au niveau individuel, la famille a été défi- nie comme un facteur important [5,12-14] pour la promotion d’un environnement non tabagique favorable à la santé des enfants. Au niveau collectif, les enseignants [6,15] comme les médecins [8,16], par l’exemple qu’ils seraient, devraient être engagés en première ligne contre le tabagisme. Une salle de professeurs enfumée dans les éta- blissements scolaires n’aurait pas plus de valeur qu’un médecin qui fumerait pendant sa consultation. Les enseignants des écoles primaires, des collèges et des lycées ont un rôle considérable à jouer dans la lutte anti- tabac auprès des enfants et des adolescents à condition, d’une part, d’être préalablement formés sur les effets du tabac sur la santé et d’autre part, sensibilisés aux moyens de lutte antitabac appropriés aux jeunes. Or, le point de départ de la conception d’une stratégie de lutte antitabac en milieu sco- laire axée sur les enseignants est l’étude de l’épidémiologie du tabagisme auprès de ce corps professionnel influent. L’« éducation pour la santé » de ce groupe faciliterait le succès des programmes antitabac en milieu scolaire [17,18]. Les résultats de cette étude, dont le taux de participation a été assez élevé (89 %), reposaient sur la validité des données re- cueillies par auto-questionnaire anonyme. Cependant, cette méthode donnerait des chiffres de prévalence relativement sous- estimés, vu la subjectivité incontournable des répondants et l’éventuel biais de désira- bilité sociale. En effet, cette pression sociale aurait été introduite dans notre enquête   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما comme un biais agissant essentiellement en diminuant la proportion des femmes ensei- gnantes ayant avoué leur tabagisme. Notre étude montre que 29,3 % des enseignants ont consommé du tabac. À l’échelle nationale, ce chiffre ne diffère pas de celui des adultes tunisiens. En effet, la prévalence du tabagisme en Tunisie était de 30,4 % d’après une récente étude menée par la Société tunisienne d’Épidémiologie et de Médecine préventive auprès d’un échantil- lon de la population générale [1]. Le tabagisme est encore un phénomène masculin. La prévalence avouée du taba- gisme chez les femmes enseignantes a été seulement de 3,6 % (contre 51,6 % chez les hommes). Cependant, étant donné que les enseignantes ayant participé à notre enquête avaient une moyenne d’âge de 31 ans, on devrait s’alarmer de la situation dans l’avenir, avec l’arrivée des nouvelles cohortes d’enseignantes fumeuses dans les prochaines générations. Une étude réalisée parmi les enseignants des écoles primaires de Nairobi a montré presque les mêmes fréquences : 50 % pour les hommes et 3 % pour les femmes [19]. Une autre étude japonaise menée auprès du personnel en- seignant des jardins d’enfants, des écoles primaires et secondaires de la ville de Mie a montré des fréquences respectives de 44,7 % chez le sexe masculin et de 3,1 % chez le sexe féminin [20]. Par contre, une enquête conduite auprès des ensei- gnants de la ville de Kolkata a montré des fréquences plus élevées de 73,9 % pour les hommes et 13,9 % pour les femmes [21]. L’acte de fumer, venant de la femme, a tou- jours suscité des positions critiques, voire moralisatrices, bien que le tabagisme soit devenu plus répandu et plus « public » avec le travail de la femme hors du foyer. Globalement, la prévalence tabagique est moins élevée chez les enseignants que chez les médecins et que dans la popula- tion générale. Aux États-Unis [16,22], en Belgique [11] et dans la quasi-totalité des pays de la Communauté européenne [23] ainsi que dans la commune de Kalaa Ke- bira [24], les enseignants semblent être un meilleur exemple en matière de promotion du comportement non tabagique que les médecins. L’Angleterre, où les médecins fument moins que les enseignants, est la seule exception [25,26]. Vu son rôle d’information dans la so- ciété, l’enseignant doit non seulement ne pas fumer pour donner l’exemple, mais aus- si avoir assez de connaissances concernant les méfaits de la cigarette. Il est heureux de constater que presque la totalité des ensei- gnants (soit 95 %) pensent que le tabac est dangereux pour la santé, mais la prévalence tabagique élevée parmi eux nous rappelle une vérité exprimée par plusieurs auteurs : les modifications du tabagisme relèvent plus de l’irrationnel et de l’inconscient que d’une conduite cohérente et raisonnée. Les enseignants fumeurs sont plus hos- tiles que les non-fumeurs quant à la majora- tion des prix des produits tabagiques et l’interdiction totale de la vente du tabac. Les deux moyens de lutte antitabac les plus acceptés par les enseignants ont été, d’une part, la limitation de l’usage du tabac dans les lieux publics fermés et d’autre part, l’interdiction de la publicité pour le tabac. Ainsi, les enseignants de la commune de Kalaa Kebira semblent être sensibilisés au problème du tabagisme, mais cette sen- sibilisation ne se traduit guère dans leurs habitudes. Une étude faite dans les écoles secondaires de Malaysia [27] a conclu que les moyens audiovisuels étaient les plus accessibles comme source d’information et de sensibilisation en matière de lutte contre le tabac. L’étude a amené à promouvoir les campagnes antitabac aux écoles et à intro- duire cette préoccupation dans les thèmes des circulaires des enseignants.    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Cette étude a révélé un paradoxe im- portant : la dissociation entre le discours des enseignants à propos du tabac dans les classes et leur usage dans les éta- blissements scolaires. Ce phénomène a été aussi rapporté récemment par une étude au Burkina Faso où des enseignants avaient déclaré fumer pendant les cours (12 %), offrir des cigarettes à leurs élèves (15 %) et même leur en demander (19 %) [28]. Or, plusieurs travaux ont montré l’influence de ces pratiques tabagiques des enseignants sur la vulnérabilité des élèves à l’acquisition précoce du comportement tabagique [29]. D’une manière générale, les enseignants de notre commune sont très proches, quant à leur tabagisme, de la situation de la popula- tion générale. Il s’agit d’une constatation un peu décevante car l’enseignant, mieux averti que quiconque, tenu par son entou- rage pour un guide ou un modèle, ne l’est pas encore.                                                                                                                                                                                    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                              ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                            ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  About 5 million people worldwide die an- nually from tobacco-related disease [1]. Tobacco kills more people each year around the world than AIDS, drug abuse, road traffic accidents, murders and suicide com- bined [2]. In Pakistan, about 34% of males and 13% of females use tobacco in different forms [3]. Currently, the major forms of tobacco that are in use in South Asian coun- tries including Pakistan are betel quid (pan) with tobacco, gutka (special tobacco formu- lation), packaged chewing tobacco products and bidis. Gutka is a new, sweetened form of smokeless tobacco, legally sold packaged in bright foil that is raising major health concerns. Betel quid with tobacco consists of 4 main ingredients: tobacco, areca nuts and slaked lime wrapped in betel leaf. Snuff is powder tobacco that is inhaled through the nasal passages or taken orally. People share the common belief that smokeless tobacco (chewable tobacco or snuff) is not harmful to health [4]. How- ever, scientific evidence shows that use of smokeless tobacco is just as addictive and harmful as smoked tobacco [5]. Chewed tobacco is a well-established risk factor for oral cancer [6,7]. The pattern of tobacco use varies ac- cording to social status and age. Tobacco use primarily begins in early adolescence, typically by age 16 years; first use mostly occurs before the time of high-school grad- uation [8,9]. Recent research indicates that smoking among adolescents is rising and age of initiation is becoming younger [10]. The use of chewable tobacco and snuff has been increasing among adolescents [11]. Smokeless tobacco is easier to hide and use than smoke products, especially in the restricted environment of schools. Tobacco use among peer groups, friends, siblings and parents is a powerful influence for initiation of various forms of tobacco use in adolescence [12–14]. Furthermore, daily smokeless tobacco users were more likely to start using cigarettes, marijuana and alcohol than were others [15,16]. Therefore, it is imperative to assess the magnitude of smokeless tobacco use and characterize this population so as to design necessary interventions to control the problem. The objectives of this study were to estimate the use of and identify the factors associated with smokeless tobacco among high-school adolescent boys in Karachi, Pakistan.  A cross-sectional study was conducted from January 2003 to May 2003 in schools of 3 areas of Karachi, the largest city of Paki- stan, with representation of people from all ethnic, social and economic groups [17]. There are 79 registered public and private schools [18]. The study only covered male adolescents as tobacco use among adoles- cent females in our culture is not common or socially acceptable; it is mostly used by older women, particularly those in the labour force. Two-stage cluster sampling stratified on school type was employed to select schools and students. Each school was treated as a cluster: 33 out of 79 schools were selected randomly proportionate to the number of each school type (17 public and 16 pri- vate) [10]. Of the students present on the day of our visit, an average of 25 students from each public school and 20 students from each private school were selected systematically on the basis of their seating arrangement. We interviewed 772 male secondary school (6th–10th grade) students aged 10–16 years. We used a structured questionnaire   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما which was initially designed in English and translated into Urdu and pre-tested. Field staff were trained in interview techniques and the purpose of the study. Data were collected about sociodemo- graphic characteristics (age, sex, education and employment status), cigarette smoking, use of smokeless tobacco (gutka, snuff, niswar) and use of other chewed products (pan without tobacco, areca nut) by the student and his family members. Students were also asked if during the past 30 days or 6 months they had seen/heard tobacco pro- motion or anti-tobacco advertisements on television, radio or in magazines. To preserve respondents’ privacy, the questionnaire was administered by trained data collectors in a separate room from the classroom. Permission was taken from Nazim district education officer and appropriate school authorities to conduct a research study in the schools of their region. Verbal consent was taken from the participants and they were assured about the confidentiality of the data.  To assess the prevalence of cigarette smok- ing and smokeless tobacco, pan and areca nut use, means and standard error (SE) for continuous variables and proportions for categorical variables were calculated. Crude odds ratios (OR) and their 95% confidence interval (CI) were calculated by univariate logistic regression. Those variables with P 0.25 or those of biological and/or social importance were selected for multiple lo- gistic regression analysis [19]. All plausible interactions were evaluated for inclusion in the multivariate model. Adjusted OR and their 95% CI were obtained from the final multiple logistic regression model. All the analysis was performed with SPSS, version 11.5.  A total of 772 male students were inter- viewed: 427 (55.3%) from government and 345 (44.7%) from private schools. The mean age of students was 14.8 (SE 0.1) years. In all public and private schools of the 3 se- lected towns, the main languages spoken by students were Sindhi (39.6%) and Urdu (20.6%). Table 1 shows the sociodemo- graphic characteristics of the respondents. The majority of mothers of the adolescents (65.2%) had no formal education and only 6.5% were in paid employment. The prevalence of smokeless tobacco use was 16.1% (95% CI: 13.5%–18.9%) and cigarette smoking was 13.7% (95% CI: 11.3%–16.2%). The mean age of starting cigarette smoking was 13.1 years (SE 0.2) and smokeless tobacco was 11.5 years (SE 0.1) (Table 1). Some of the students (18.0%) reported spending 500 rupees or more per month on buying areca nut and gutka. In addition 12.6% and 47.2% of students were using pan and areca nut respectively. The mean age of smokeless tobacco us- ers was 15.2 years (SE 1.2) compared with 14.8 years (SE 1.3) for non-users. Univari- ate analysis showed that smokeless tobacco use among the adolescents was significantly associated with age, type of school, area of residence, parents’ education and father’s occupation, with users more likely to be younger, attending government schools, living in Gadap, with less well-educated parents (P 0.025) (Table 2). Smokeless tobacco use was also associ- ated with spending leisure time outside the home, use of pan without tobacco, use of areca nut, smoking cigarettes, seeing to- bacco promotion advertisements, not seeing anti-tobacco promotion advertisements and   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما tobacco use by one or more family member (P 0.025) (Table 2). The final multiple logistic regression model showed that school type (adjusted OR = 6.3; 95% CI: 3.2–12.6), smoking (adjusted OR = 3.2; 95% CI: 1.9–5.4), not seeing anti-tobacco advertisements on television and radio (adjusted OR = 1.5; 95% CI: 1.0–2.4), family history of tobacco use (adjusted OR = 3.9; 95% CI: 2.2–6.8), use of betel quid (adjusted OR = 2.9; 95% CI: 1.7–5.0) and use of areca nut (adjusted OR = 3.2; 95% CI: 1.9–5.1) were signifi- cantly associated with smokeless tobacco                                                                                                                                                                use among high school adolescents (Table 3).  The prevalence of use of smokeless tobacco products was higher than cigarettes among high-school students (16.1% versus 13.7%) and the age at starting smokeless tobacco was also lower than for cigarettes (mean 11.5 years versus 13.1 years). Several fac- tors may contribute to the use of smokeless tobacco: it is easy to obtain, is more socially         ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                                                                                                                                                       ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما and culturally acceptable than cigarettes and easier to use than smoked products, especially in the school environment where smoking restrictions are enforced. Parental sanctions are also not very high for the use of smokeless tobacco because of the convic- tion of many people that smokeless tobacco, betel quid and areca nut pose a lower health risk than cigarettes [4]. This study is based on the self-reported status of the respondents’ smokeless tobac- co use. To maintain confidentiality students were not asked about their class or name. Another limitation of the study was that we could not make any biomedical validations of self-reported tobacco use. Use of smokeless tobacco was higher among government school students com- pared to private school students (OR = 6.3); this may have been due to better educational activities and more stringent measures to restrict tobacco use in private schools. Those adolescents who reported that at least one family member (parent, siblings and other members) use any tobacco prod- ucts were also more likely to use smokeless tobacco (OR = 3.9), presumably because they have easy access to these products.                                                                                                                                            ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما A strong association between cigarette smoking and use of smokeless tobacco was observed in this study (OR = 3.2). Also, a strong association between adolescents’ smokeless tobacco use and use of pan with- out tobacco and areca nut (OR = 2.9 and 3.2) confirms those of other studies con- ducted elsewhere [15,16]. One reason is the availability of all these products from the same sources. Furthermore, once a person starts using tobacco in any form he/she is likely to become nicotine-addicted. Smokeless tobacco, such as gutka, con- tains nicotine and therefore the health conse- quences may be similar to those of cigarette smoking, including coronary artery and peripheral vascular disease, hypertension, fatal morbidity and mortality [20]. There is a need to provide community-based edu- cational programmes in which the adverse health consequences of tobacco are ad- dressed. However, even chewing products without tobacco has risks; traditional pan has been implicated as a major etiological factor for oral submucous fibrosis [7]. As 12.6% of the students were using pan and 47.2% areca nut, it suggests that adolescents are putting themselves at risk of associ- ated diseases. There is a need for awareness programmes about the deleterious effects of betel quid and areca nut, even without tobacco. In the absence of any restriction by school authorities or parents and because of easy and widespread availability of tobacco products to all ages, adolescents are spend- ing substantial amounts on purchasing these products even when they need stationery or books for school. The average amount spent on areca nut and gutka was 500 rupees or more per month (about US$ 8). Tobacco use usually starts in early adolescence [8]. Informal discussion during our interviews suggested that many of the youth who smoked reported that they want to stop but were unable to do so. We also found a significant association with adolescent tobacco use and not seeing anti-tobacco promotional advertisements on television and radio (OR = 1.5). Tobacco advertisements are designed to encourage young people to take up smoking [21] since advertisements have been shown to have a strong influence on teenagers [22]. Based on the results of this study, we recommend that tobacco promotional ad- vertisements be banned in Pakistan. More efforts are needed to reduce easy access to any form of tobacco, betel quid and areca nut by young people. There is also a need to increase taxation of tobacco products because price is recognized as a major de- terminant of cigarette consumption [23,24]. Monitoring is necessary to assess the ef- fectiveness of intervention programmes to control the increasing use of smoked and smokeless tobacco, betel quid and areca nut or any form of chewable tobacco among adolescents.  We are thankful to the University Research Council, Aga Khan University for funding support of this study. We are indebted to the District Officer of Education, City District Government of Karachi and Town Munici- pal Administration of Malir, Bin-Qasim and Gadap towns for their support in conducting the survey. We acknowledge all selected government and private schools for their participation. We are greatly indebted to Dr Zahid Ahmed Butt (World Health Organi- zation, Campaign and Social Mobilization Cell, Islamabad) and Mr. Iqbal Azam (As- sistant Professor, Community Health Sci- ences, Aga Khan University) for providing valuable guidance and support.   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                                                                                        ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                       029Tobacco-free Mecca and Medina (WHO-EM/TFI/ /E) In 2002, the Ministry of Health of Saudi Arabia adopted a new and radi- cal policy approach to strengthening tobacco control through religion. It launched an initiative to make the two holiest cities in Islam, Mecca and Medina, not just smoke-free but literally tobacco-free. The ratio- nale and experiences of the Saudi government in regulating tobacco use in Mecca and Medina are examined in this report. This document can be obtained from Distribution and Sales, World Health Organization, Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr City, Cairo 11371, Egypt (email: DSA@emro.who.int). It can also be accessed at: http://www.emro.who.int/tfi/wntd2007/pdf/ tobacco_free_mecca_medina.pdf   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                          66 123    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  In the United Kingdom, the responsibility for both academic and practice-based health and social care education now rests with the higher education sector and universities [1]. Such developments have brought about significant changes in the organization and content of educational programmes [2], along with the recognition of the need to enhance and monitor the quality of learning and teaching. Quality education in health and social care is a complex subject and has traditionally been assessed by student evaluations that include a variety of factors [3]. These factors comprise the learning environment that involves interconnected components such as teaching methods and assessment, course structure, curriculum and teacher effectiveness. For instance, the way a module is delivered, its content and theoretical level, as well as the detail of administration and other factors all have an impact on students’ evaluations. Prepar- ing health and social care students to deal with the complex aspects of future health care systems requires cultivating independ- ence and critical thinking [4]. This raises important questions as regards students’ satisfaction with their education and how their professional preparation will be under- taken. Hence a range of factors collectively interplay to shape a satisfying learning and teaching experience. These include the module characteristics, organization, planning, workload, content, relevance, the theory–practice balance, lecture and seminar delivery, class size in terms of stu- dent numbers and accommodation, module teams, support systems and mechanisms, and university resources [5–13]. This paper is part of a study to assess the satisfaction of health and social care students with their educational programme which used an 18-item questionnaire to examine the factors affecting student sat- isfaction [14,15]. The paper focuses on the responses of students who provided open comments on their educational experience at the end of the questionnaire. The specific aims were to: • Assess whether the demographic and educational profiles as well as the satis- faction and achieved grades of students who volunteered to comment were differ- ent from those who did not comment. • Assess whether the participants who commented originated from a particular cluster of achieved grades. • Explore the different themes and factors of the learning and teaching encounter that may affect student satisfaction with their educational experience.  A questionnaire was used to survey the students. Details of the subjects, setting and questionnaire are detailed elsewhere [14,15]. An open “comments” section was included at the end of the survey question- naire where students commented on any as- pect of the teaching and learning experience that they wished. This section, which is the focus of this paper, explored qualitatively the facets of the educational process, and was employed to expand on issues critical to the effectiveness of students’ learning. Open-ended questions permit the partici- pants to respond in their own words, use their own frame of reference, and express private thoughts and feelings [16]. After permission from the module coordinators, the open-ended “comments” section of the questionnaire was administered at the end of a teaching session (by the author to stu- dents who wished to participate). This investigation used a “case study” approach [17] of students’ experience of   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما learning and teaching. Whereas, the case study is singular, it has subsections (e.g. course organization and general satisfac- tion; module organisation and planning; module characteristics; lecture and seminar delivery; module teams) which comprise complex domains. Holistic case study calls for the examination of these complexities [18]. The comments were analysed using the constant comparative method [19]. Tran- scripts of students’ comments were initially read through and indexed to form provi- sional headings, which were confirmed or rejected in subsequent readings. Categories were developed and applied to all comments until theoretical saturation was achieved. There was no attempt to impute meaning or impose pre-formed categories, hence pre- venting any preconceived ideas held by the researcher from obscuring the respondents’ meanings. As the comments were analysed, themes emerged from these categories. The theme of educational satisfaction and ef- fectiveness was followed through the whole data set. The study captured the respondents’ own words, as their descriptive immediacy means they are seldom forgotten. The objectivity or neutrality of the data (confirmability) was accomplished by compiling an audit trail for the inquiry: a collection of materials and documentation, raw data, and data reduction, analysis and reconstruction products. An educational expert at the institution examined the data in the manner of an independent financial auditor. The trustworthiness of the data and the meanings attached to them were observed and were judged worthy of confi- dence. The generalizability of the data, the extent to which findings can be transferred to other groups, was attained by providing a description of the setting, subjects and context where the study was conducted, hence providing information for judging the external validity of the enquiry [20].  Out of the 460 survey participants, 66 stu- dents (14.3%) commented. The first 2 aims of the study were to assess the generalizability of the results to the wider student population at the institu- tion. Table 1 shows the demographic and educational characteristics of students who did and did not comment. There were no significant group differences as regards their gender, level of disability, academic level or the nature of modules. In relation to the groups’ entry qualifications, there were insufficient numbers to be able to judge confidently whether there were any dif- ferences. The findings also suggested that being a part-time student aged < 21 years of “non-white” ethnicity was associated with commenting, while being on a Bachelor of Arts degree was less associated with com- menting. Participants who commented were slightly (but not significantly) more satisfied as regards 60% of the survey’s satisfaction items (data not presented). Those who com- mented had a slightly higher mean grade (1.05% higher) than those who did not, but the difference was not significant. Hence commenting did not indicate dissatisfaction or substandard student performance on the module assessment. Table 1 also shows the relation between the students’ performance and the prob- ability of commenting, by computing the percentages of students from each grade bracket who commented. Nearly equal per- centages of students from the various grade brackets volunteered to comment. Although the highest percentage (18.8%) of students who commented were those who failed    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                            ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما their modules, the differences were not significant. Hence, the qualitative narratives quoted below are from a sample of students with module performance scores represent- ing the whole continuum. The emerging categories and themes are shown in Table 2. The students’ comments are presented below, organized into the different categories that emerged from the analysis. In order to indicate that the com- ments came from different students, a semi- colon separates the comments every time a different student’s views are reported. The term “module” is used below to indicate a specific unit of under- and postgraduate study (e.g. epidemiology module or re- search methods module). Each programme of study is composed of a specific number of modules that are required to be success- fully completed by the students.   Students made judgements about the ef- fectiveness of the course organization and module arrangements. Participants praised the invested effort, while others raised some                                              ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Helpful to have all the reading list handed out, thanks. But some informants felt the need for more continuity, timely module materials, and a better use of some sessions: There seemed to be a lack of continuity; Mod- ule could have been organized differently; Would have liked the reading list earlier; Would have been useful if the seminar groups could have done a session each week on a section of the research proposal.  As regards workload intensity and time frames: Work load and intensity was much higher than expected; A lot of work to do in such a short time made it very difficult; A large amount of extra study is needed out- side the lectures; The intensity and volume of work is at times very difficult to cope with; Course work was very time-consum- ing and left little revision time; Quite a large number of topics covered, makes it difficult to remember everything.  Most participants reported that the modules were stimulating and informative, resulting in high levels of learning: Found it [mod- ule] challenging; Module was very inter- esting; Module team presented interesting information; Module is very intellectually stimulating; Lectures and seminars were informative; Module has been very stimu- lating, resulted in high levels of learning and new interest.                                                                ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Students also reported positively on the relevance of the material: Module was of huge relevance to my future career, was very interesting and thought provoking; Enjoyed especially the practical elements of it, as they relate to practical work you were doing in the hospital at the same time. However, time constraints meant that overloaded modules, short time frames and long sessions were concerns, especially for part-time students with full-time jobs who attend the university in the evening: Unfor- tunately with 4 modules to contend with this term, would have liked more time to spend on the actual academic work; The time we had for the module is not enough to take all the information in as much as I would like to; Six [pm] to 9 [pm] is a long day. Some respondents reported that there was a theory–practice gap which needed to be avoided: More lectures need to be devoted to practising practical techniques more with more clinical reasoning; Practi- cal group work [is] insufficient. Conversely, some students found their modules useful to their clinical practice: The things learnt are useful to clinical practice on a practical [level] rather than theory/academically challenging.  Informants perceived the teaching on their programmes to be of a high standard: Mod- ule delivered in clear and precise manner; Module was well taught; Module was well run; Have really enjoyed the lectures and group seminars; Quality of teaching was excellent. Although providing students with hand- outs and reading material is helpful, the amount, timing and circulation method of the material might require consideration: Very useful to be given the readings, would have been useful to have had this prior to week 1 or ready for students to collect in one batch; Too many articles given out which seemed to distract from the lectures and assignment; Appreciated the informative and useful handouts but distribution was difficult and availability variable, caused some alarm at the time. Participants gave mixed messages re- garding the actual lectures and seminars: Time given by the seminar leader was good; Many of the lectures were unhelpful and boring; The seminar delivery was bril- liant; Seminars useful, [but] never sure which articles were to be discussed; Did not find seminar sessions useful; Did not enjoy practical sessions. Some students felt that the group size and accommodation might benefit from adjustment: If the groups had been smaller this may have been easier; I personally felt the group was very large and therefore was difficult to interact; The only suggestion I could make would be for smaller groups; Rooms too small for group.  Participants praised the interpersonal skills and other characteristics of the module teams: A wonderful course led by passion- ate and enthusiastic tutors; Excellent mod- ule leader; Staff were friendly; Staff friendly and approachable. They also applauded their professional competence: The module team were well prepared; Excellent teaching styles adopted by lecturers; The module team was knowl- edgeable and skilled; The module [had] good staff; Very good visiting lecturers; Outside speakers were not always as good.  The appropriateness of assessment methods was questioned: Don’t know if the amount of learning can [be] clearly expressed through the assignment, whether marked assign- ment is a fair way to judge learning.    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما But it would seem assessment guidelines and module information can inadvertently send conflicting messages: Different groups within the same module were given differ- ent guidelines from tutors, this will cause problems; Might help to incorporate the assessment strategy information from the [assignment] guide into the handbook or reduce the diversity of the key principles. Time constraints were another factor: Due to constraints in time in submitting the assignment, knowledge may not have been sufficiently developed; the pressure of completing the written assessment by the deadline, with the other modules, detracted from the learning experience; Would have helped to have longer period to develop the assignment; ordering [references] takes 2 weeks, considering the term is only 8 weeks, have only 3–4 weeks to prepare and write essay. In spite of these challenges, some re- spondents reported good support systems and mechanisms: Students are offered sup- port; Good support from staff and students; The level of educational and personal sup- port is outstanding. While others indicated poor facilitation and communication: The assignment was difficult and relied strongly on the lecture notes and reading lists; Would have liked more input on the assignment, perhaps with opportunity to go through my drafts, al- though with lots of students this is difficult. Hence some informants indicated that more tutorial support would have been ap- preciated: Felt a bit lost and unsupported, I did not know who to appeal to for reas- surance and guidance; Would have been useful to have some feedback on what we had begun to write; All work done on my own back; They just threw you into the deep end really and did not help you; I do not feel we were guided through the assignment enough; Would be useful to have more help from lecturers.  Adequate library support of reading re- sources and materials emerged as a criti- cal issue for the students: Main complaint about module was that it was difficult to find articles for essay; Problem was lack of appropriate journal articles required for essay [assessment]; Articles needed for written assignment were hard to obtain, recommended course text was also difficult to obtain; Only problem is lack of litera- ture/journals for the essay. For instance, some books and periodi- cals were only for short loan, and access to a well-stocked nearby library was not feasible due to lack of a contractual agree- ment: Library books difficult to get hold of. I tended to use my local hospital library; One very important book was only available in short-term loans for 24 hours, with 70 people on module, not adequate; there was not enough journal resources made readily available, e.g. no access to [nearby] library which is available to other health care students; we are not allowed to use [nearby] library which had implications on amount of literature we can draw upon and reflect for our essay assignment.  Quality has become a key issue everywhere: within the World Health Organization [21], in the National Health Service [22], in the caring professions [23], and in higher edu- cation [24,25]. Further, teaching today is treated as a technology [26], with repeated calls for it to be “evidenced based” [27]. This focus on quality that is evidence based as well as the relevance of the teaching programmes [28] and the required improve- ments in quality performance [29] have col- lectively contributed to the monitoring of students’ satisfaction of their learning as a critical source of course evaluation [30].   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما The first aim of the study was to assess whether the demographic and educational profiles of students who volunteered to comment were different from those who did not comment. To that extent commenting was not related to a wide range of students’ demographic and educational characteris- tics [except being a part-time, traditionally- aged student (< 21 years) or of “non-white” ethnicity]. The first aim was also to assess whether the satisfaction and achieved grades of stu- dents who commented were higher or lower than those who chose not to comment. The findings suggested that commenting was not associated with low satisfaction or low achievement in terms of the grades the students accomplished in their final assign- ments. The second aim of the study was to assess whether the participants who com- mented originated from a particular cluster of achieved grades. In this regard, com- ments did not come mainly from respond- ents within a certain grade bracket. The third aim of the study was to ex- plore collectively how a range of factors of the learning and teaching experience affect student satisfaction. The results of the current study are in agreement with those of Kinsella et al., who reported that a majority of UK student nurses felt that their course could have been better organized [31]. Educators might need strategies to accommodate the changes in educational objectives, processes and contents [32]. Students embark on their first term without knowing what to expect [33]. Only after at- tending are they able to judge their modules. For instance, other researchers [31] have reported that students rated 30% of their nursing modules between fair and good, whereas the rest achieved lower ratings. Hence, anticipatory anxiety and stress [34] are not uncommon for nursing students, with the possible consequences of decrease in morale and performance [35]. Similarly, exhaustive training [36] is a problem in health and social care education and an unnecessarily high academic level is some- times a concern [37]. Intensive workloads do little to encourage learning, and rather, educational systems need to emphasise the learning of skills, how to learn and relearn, and how to apply new knowledge in the workplace. To foster competencies, a course must adapt to the influx of new knowledge and to the service needs [38–40]. For instance, Kinsella et al. [31] found that that only half their sample of student nurses found the lectures interesting. As regards relevance, learning is motivated when practice prob- lems are identified, or if the knowledge is of use in task performance. Effective courses must focus on delivering relevant knowl- edge, demonstrate fitness for purpose [41], and relate learning to the practice areas. However, “fitness-for-academic-award” and “fitness-for-professional-purpose” re- main uneasy bedfellows [1]. Thus, the ex- tent to which nursing courses are related to the students’ requirements remains a major consideration [16]. Different learning styles and approaches [42] have an impact on time and may act as barriers to reflective practice development [43]. Health professionals with limited clini- cal skills could be the result of nursing schools being assimilated into higher edu- cation. The lack of clinical contact [34] may indicate that the educational ideals and practice realities need reconciliation [1]. As the findings of this study suggest, situating theory in practice is important [44], and an expertly taught course whose syllabus has little clinical relevance is unlikely to im- prove care [38]. Students are caught in the centre of the theory–practice divide [10], as the move of nursing programmes to higher    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما education has led to learning occurring in 2 separate institutions [45]. As regards lecture and seminar deliv- ery, this study concurs with the finding that student nurses perceive teaching and learning on their programmes to be of a high standard [46]. For instance, providing student handouts is helpful [47] but there is no single best time to distribute them [48]. Such aspects can cause student dissatisfac- tion, where the amount, timing and circula- tion method of material need consideration [49]. Other factors include group size and accommodation. These are also important factors: group dynamics may influence resistance to shared learning and commit- ment [50], but group processes encourage critical thinking, promote reflective practice and change behaviour and attitude [51]. As dominant members could block other students [50], small tutorial groups better allow students to reflect and meaningfully relate theory to practice. In connection with the module teams, this study is in agreement with Smith [52], who reported that faculty configuration influences the shape and content of nursing curricula. The teaching skills necessitated in a clinical area or classroom are different, and various skill requirements of nurse teachers are necessary [53]. Openness to and positive interpersonal relationships with students are important characteris- tics of teacher effectiveness. Conveying knowledge, intellectual excitement and professional competence [54] are similarly critical qualities of an effective teacher. Nurse teachers need to be knowledgeable, experts in the field, credible and clinically and academically competent. As regards course work and assess- ment, changes in education might require abandoning traditional student evaluation tools [32]. This investigation casts doubt on whether learning can be adequately assessed through the methods currently employed. For instance, in agreement with another study [38], the implementation of guidelines sometimes varies. Inadvertently, assignment guides and module informa- tion can send conflicting messages and participants might feel they had not been given sufficient information on what is expected from them [31]. Further, there is scant literature on nurse teacher’s profes- sional training needs in relation to their tutorial functions, in spite of its apparent importance in maintaining student morale and in achieving academic standards [55]. This study showed that some respondents reported good support systems, but some felt there was poor facilitation and com- munication between teacher and student. This study found that more tutorial support would have been appreciated. In connection with university resources, although educational reforms have led to a greater amount of classroom learning, this needs to be paralleled by adequate library support of reading resources and materials. Library and information services may some- times be an afterthought, and consequently books and periodicals might be unavailable to support learning needs [56]. In this study, students complained that some books and periodicals were only for short loan and access to a nearby library was not feasible due to lack of a contractual agreement. This is in agreement with Bird and Roberts [57], who highlighted the value of library and information services, and their role in the facilitating student learning. Whereas teaching departments may be able to do little in preventing students’ social problems, educators should address student satisfaction when it stems from poor course organization, mismanagement or lack of support. Research is needed to learn more about what makes an effectively organized course. How can modules be   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما stimulating and relevant to a diverse student population of different ages, ethnicities, ex- periences and learning needs? The findings of this study suggest that there is room for improvement in the health and social care education programmes to increase student satisfaction. But such information will have an impact on the development of qual- ity education only if it is acted upon. The university where the study was conducted holds student satisfaction as important to the organization, and the findings of this study have been reported to the institution in order to formulate and implement strate- gies that address student satisfaction and guide lecturers to enhancing the quality of learning and teaching.  The author would like to thank all those at the institution where the study was con- ducted: the faculty and staff, and the health and social care students who generously contributed information about the modules. Special thanks go to Julie Poulton of the Systems Unit for data retrieval and linkage.                                                                                                                                                                                           ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                                                                       ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                                                                                                     ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                           Climate and health: the effects of climate change on health To a large extent, public health depends on safe drinking water, suf- ficient food, secure shelter, and good social conditions. A changing climate is likely to affect all of these. Overall, the health effects are likely to be overwhelmingly negative, particularly in the poorest com- munities. The effects include increasing frequency of heatwaves and more variable precipitation patterns (likely to compromise the supply of fresh water, increasing risks of water-borne disease). Rising sea levels increase the risk of coastal flooding, and may neces- sitate population displacement: over half the world’s population lives within 60 km of the sea. Two of the most vulnerable regions are the Nile delta in Egypt and the Ganges–Brahmaputra delta in Bangladesh. Climate change is likely to increase the transmission seasons of im- portant vector-borne diseases such as malaria and leishmaniasis, and to alter their geographic range, potentially bringing them to regions which lack either population immunity or a strong public health infra- structure. A WHO quantitative assessment, taking into account a subset of the possible health impacts, concluded that the effects of the changes in climate since the mid-1970s may have caused over 150 000 deaths in 2000. It also concluded that these impacts are likely to increase in the future. http://www.who.int/mediacentre/factsheets/fs266/en/index.html   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                    2001    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما   Both before and during colonial rule, peo- ple in sub-Saharan countries paid most of the costs of health services themselves (because of the lack of published literature available about Sudan and the similarity of conditions in sub-Saharan Africa, the au- thors support this study using background from the experiences of other developing countries). Sudan, like other developing countries, has problems resulting from inap- propriate allocation of available resources, an inefficient public health service deliv- ery system, a heavily constrained private sector and poorly developed health insur- ance schemes [1]. The policy tool chosen to reduce the effects of these problems is often the expansion of the cost recovery policies in the public sector. These policies are expected to support the sustainability of the health financing system by increasing the revenues of the public system [2–4]. They are expected to help in targeting pub- lic sector subsidies for the poor [5]. They also allow the government to reallocate tax-financed expenditures from curative services to public health activities that have a broader beneficiary base [3]. They are also expected to reduce the private sector’s price disadvantage relative to the government sector and to encourage the expansion of the health insurance schemes, especially for the informal sector [6]. The political risks of imposing new fees by establishing a cost recovery system or enforcing the existing one are extremely high. They are possibly higher than raising taxes, because they are tied to a valued social service. In Sudan, the issue of the cost recovery policies at public health facilities is politically charged. There is, however, very little information on the effects of user fees, a similar situation to that in Ethiopia [2]. There is no information regarding what people are paying for health services or what they might be willing to pay for public health services. In the absence of such in- formation, speculation and ideology tend to monopolize the political debate and make it far too general to be of much use in setting policy [2,6].   In 1996, 2 years after the declaration of the national health insurance policy and before it could harvest the benefits, the govern- ment decided to provide free-of-charge health services at emergency departments. This step was taken under the pressure of the expansion of poverty and the politi- cal situation after the increase in the price for petroleum. Furthermore, to favour the poor, the president of Sudan decided in 2000 to offer free-of-charge public health services at the third class inpatient wards [7] (free treatment in the inpatient wards had not at the time been adopted.). This was a response to the requests made by medi- cal professionals during the Medical Oath ceremony. These 2 steps were taken without any preparation nor were they supported by results from scientific studies or technical opinion. The move was entirely based on the assumption that the beneficiaries of free-of-charge public health services would be the poor. The health financing planners, however, claimed that the poor would not be the real beneficiaries of the free-of-charge public health services [2–4,8,9]. They also claimed that any free-of-charge public health servic- es would impede the cost recovery policies and lead to huge losses of medical sup- plies. The exploitation of free-of-charge pub- lic health services by high-income earners is well known and is considered by some to be   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما one of the main disadvantages of these poli- cies. Heller argued that “these mechanisms favour the less sick (who can wait longer) and higher income clients (who have the contacts)” [10]. Free service provision does not imply free access or consumption and one should consider time and transport costs that discriminate against the poor and rural residents [2,4,5,8,9]. Ofosu-Amaah also writes that “the reality in much of Africa is that attempts at the provision of free health care have resulted in inadequate or non- existent services, especially for the poor and most vulnerable” [11]. On the other hand the depletion of the available medical supplies is seen as one of the great disadvantages of the free-of- charge policy. A rapid assessment study conducted in the 3 big hospitals in the capi- tal to evaluate free public health services at the emergency departments showed that > 50% of medical materials, especially intravenous fluids, are lost [12]. The huge loss of resources may be aggravated by the ill-defined referral system in Sudan and the misuse of emergency facilities. A similar type of problem was expressed by a health post staff member in Nepal, “In the past, people used to drop into the health post whenever they were passing by to pick up medicines for future use. After the introduc- tion of charges, this custom completely died out and no one demands medicines until he/she is really sick” [13]. The misuse and siphoning off of medical supplies has been observed to be practised by health workers as well. Owing to the low salaries and high inflation rates, they sold the free-of-charge supplies [14].  In this survey, we investigated impediments to cost recovery on health care use in Khar- toum state, Sudan. A logistic regression model was used for this purpose. We aimed to describe, and provide a broad study of, the effects of free-of-charge public health services on the cost recovery policies. At- tention was focused on investigating the characteristics of the people who are likely to receive free-of-charge public health serv- ices.   This study was carried out 5 years after the implementation of a free-of-charge public health services policy at the emergency departments and before the adoption of the new policy of free-of-charge health care at the inpatient wards. Data were collected through interviews based on an adapted questionnaire in Arabic (we used questionnaires from the experi- ences of a number of developing countries to construct a questionnaire in English and then translated it into Arabic; it was not a direct translation of a specific single ques- tionnaire). The questionnaire was tested in a pilot study. After correction and modifica- tion the questionnaire was retested. The survey was conducted during the 2 months March 2001–April 2001 in Sudan. The team was composed of a supervisor, coordinator, 3 assistants, a statistician, 40 data collectors, 2 data entry workers, a secretary and a driver. They conducted the survey after 3 weeks of training for the data collectors and after some pretests (the data collectors were students and gradu- ates from Elahfad University for Women, Omdurman, Sudan). The team was centred in central Khartoum, and joined the re- search department at the Ajaweed Society, a nongovernmental organization concerned with counselling. The society has a bilateral collaboration with the Khartoum Centre for Psychiatry and Counselling.    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما The samples were selected by a multi- stage sampling procedure. First, a simple random selection of the 3 provinces of Khartoum state (each province has > 30 localities) was made. Each of these prov- inces was divided into central, peripheral and rural and 15 neighbourhoods in each area were randomly selected. One house in each neighbourhood was randomly selected as a starting point, then every 4th house till the required number was reached. The total number of households contacted was limited to 460 owing to financial restric- tions and the capacity of the SPSS package in analysis and generalization of results [15]. There were no refusals to participate. For the purpose of similarity and to increase the internal consistency of the sample we excluded 10 questionnaires to ensure that there were 150 questionnaires from each province. The overall response rate was 100%, which indicates high reliability. The survey targeted heads of house- holds, or someone representing them (the nearest relative). The survey collected data on the respondents’ socioeconomic status and on their use of health services. The sociodemographic data included age, sex, tribe, religion, place of birth, education, occupation, and place of work of the head of the household, and number of people in the household. We used 2 categories with regard to wealth: income (monthly income, occupation and other income) and expendi- ture. In developing countries, the reliability of using monthly income as an indicator for estimation of the wealth is dubious. Monthly expenditure is sometimes used instead of monthly income for reasons of reliability [16]. The inconsistency between income and expenditure in lower income countries induced some researchers to ask questions about durable consumer goods such as refrigerators, cars, other income and house/property [17,18]. This study also adopted this approach. To get an impression about health sta- tus, respondents were asked to indicate the number of episodes of sickness and visits to health facilities during the previous 3 months for the head of the household and for any member of the family (in the pre-test phase the time period used was 3 weeks, but as we suspected there was some exag- geration, we changed it to 3 months and we received the same answers). To examine payments for health care, respondents were asked whether they had paid anything for health and whether they had bought drugs for themselves or for any members of their household during the previous 3 months.  Cultural bias in the sample Because of transportation and security con- straints, the survey was conducted during daylight and thus most of the respondents were women (62.9%). Even when a Suda- nese woman is the actual head of the house- hold, she always introduces her husband as the head. So, the sex variable is culturally biased. Also family size has a measurement error due to a cultural bias: many Suda- nese families believe in the evil eye, and are reluctant to give the true number for family size. After the evaluation of the pre- test, some modifications were made to the question on family size in order to improve the response quality. Where the number of cases was small, a process of merging categories was done for the variables age, family size, education, occupation and dis- ease type [19]. Model building strategy To avoid bias, some variables were elimi- nated as a first step in the model-building strategy, e.g. tribe and religion. The selec- tion of variables in the model was done by univariate analysis of each variable using cross-tabulation, chi squared, t-test, corre-   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما lation and the ordinary least squares (OLS) method. Table 1 presents the results of the OLS models as the last step of the univariate selection analysis. After completion of the univariate analysis, selection for the multi- variate model was done: any variable with test significance < 0.05 was a candidate. Following the fit of the multivariate model, the importance of each variable included in the model was verified by a Wald statistic and a comparison of each estimated coef- ficient from the model containing only that variable [20]. Only the variables “family size 7–10”, “occupation merchant” (small traders and owners of small businesses), “other income”, “always or sometimes have dependents”, “own a house”, “sometimes pay school fees”, “got sick twice in the last 3 months”, “always paid for treatment” and “always paid for drugs during the last 3 months” were eligible to enter the logistic regression model (Table 1). A model with only the significant vari- ables of the OLS estimations proved to be a poor model without variables such as “mer- chant” and “has other income”. To obtain a model with more explanatory power, direct and the stepwise procedures were used. Compared to the OLS results in Table 1, the full model of the direct procedure method included some significant variables such as “merchant”, “other income”, “disease type”, and “bought drugs during the last 3 months”. The full model fit better than the OLS model. In the stepwise procedure method, back- ward logistic regression was done and the last step showed that the variables “mer- chant”, “own a house” and “paid for treat- ment during the previous 3 months” were candidates for the final model. A series of additions and removals together with interactions and combination of variables resulted in 8 partial models. The models of the stepwise procedure have the advantage over the OLS results model in that some of the important variables are retained in the analysis. Goodness of fit For all models, the proportion predicted cor- rectly was > 85%. The omnibus test and the significance of the chi squared distribution showed the improvement in the explana- tory power of the models. McFadden’s R2 for all models ranged between 0.2 and 0.4. This is considered satisfactory [20]. The Hosmer and Lemeshow tests for all models showed a distribution of 8 degrees of free- dom for chi squared for the different steps, with significance > 0.05. This indicates that the models are an adequate fit to the data. The likelihood ratios for all partial models except partial model-7 gave chi squared less than the critical value, indicating that the full model was an improvement. The exception, partial model-7, included the important variables; chi-squared for the likelihood ratio was greater than the critical value. This model included 2 interaction variables: “other income/have a car” and “family size 6–10/sometimes paid for treat- ment during the last 3 months”. The first interaction variable helped differentiate between the well-off and the poor regarding the variable “other income”, and the second was important for the significance of the model. Based on this and the other goodness of fit criteria, partial model-7 was the preferred model. The dependent variable in the model was “receives free-of-charge public health services”; the independent variables were the sociodemographic variables in Table 2. Method of analysis Because of the dichotomous nature of the dependent variable, a logistic regression model was used for the statistical analy- sis. The dependent variable, whether the    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                                                                                                               ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما respondent received free-of-charge public health services, was given the value 1 if the response was “yes” and 0 otherwise. However, since the linear probability model was heteroscedastic and may predict prob- abilities beyond the 0, 1 range [21], a logis- tic regression model was used to determine the factors which influenced the dependent variable.    The description of the sociodemographic variables in the sample is presented in Table 2. Almost 80% of the respondents were in the age group 31–40 years, the productive age. The family size range indicates that Sudanese society is composed of extended families. The relatively high level for university education is only true for Khartoum and other big cities. In Sudan as a whole, the literacy rate is 40% for males and 15% for females [22]. Monthly income for 86.0% of respond- ents was 50 000 Sudanese dinars (DS) (US$ 1 = DS 267, April 2001) (Table 2). Questions about car ownership and house ownership were asked to differenti- ate socioeconomic status, assuming that people who had a car and owned a house were of higher socioeconomic status. The high percentage (70.4%) of house owner- ship indicated that house ownership was not a strong indicator of wealth. The payment for dependents (for 55.6% of respondents) and of school fees (78.9% of respondents) indicated additional expenditure for some families. Family size was also an indicator of family expenses. The vast majority of heads of house- holds had paid for treatment (86.2%) or paid for drugs (90.0%) in the 3 months previous to the study.  The selected model provided the best fit for the data. The proportion correctly pre- dicted was 87.9%. McFadden’s R2 was 0.291, which is satisfactory. The likelihood ratio showed the selected model to be an improvement over the full model given that chi squared was lower than the criti- cal value. The Hosmer and Lemeshow test chisquared was 4.11, distributed with 8 degrees of freedom (P = 0.847).                                                             ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                                                                                                                                              ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما The variables “merchant”, “other in- come”, “always have dependents”, “some- times have dependents”, “own a house”, and “2 visits to health service unit during the last 3 months” were statistically sig- nificant (Table 3). In addition, 2 interaction variables were relevant, i.e. “other income/ have a car” and “family size 1–6/sometimes                                                                                                                                                                                                                                 ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما paid for treatment last 3 months”. Although the variable “pays for school fees” was not significant, it was important for the signifi- cance of the model (goodness of fit). The odds ratio for the head of household having other income indicates that this group was almost 3 times more likely to re- ceive free-of-charge public health services than those who did not have other income. The relatively small confidence intervals indicate that the sample mean must be close to the true mean. Both the intervals are > 1, which indicates that the relationship between “has other income” and “receives free-of-charge public health services” found in this sample is true for the whole popula- tion. The odds ratio for receiving free-of- charge public health services for heads of households who visited a health service unit twice during the previous 3 months was 4.67. Both confidence intervals were > 1, indicating that the relationship is true for the whole population. Although the upper limit of the confidence intervals was a little high (18.62), the odds ratio (exp B) was relatively small (4.67) so the sample mean must be close to the true mean, and a good representation of the whole population. Although the variables “merchant”, “other income/have a car”, “own a house” and “family size 1–6/sometimes paid for treatment in the last 3 months” were sta- tistically significant, the odds ratios were < 1, indicating that these respondents were less likely to receive free-of-charge public health services.  Overall, 13.8% of the participants used pub- lic health services free of charge. Together with the positive results for logistic regres- sion analysis, this indicates that both the rich and the poor benefit from the free-of- charge health services. The negative odds ratios in the logistic regression analysis findings show that the merchant who owns a house, has other income and has a car is less likely to receive free-of-charge public health services. This indicates that there is no direct impediment to the cost recovery policies nor is there exploitation by the well-off. The relatively high percentage of mer- chants and the free work category (34.4%) indicate the migration to the business sec- tor. These wages cover a small proportion of family expenses (about one quarter) [23]. Having other income and ownership of a car also give an indication of the socio- economic status of the family. The raising of other income in particular is an example of the family’s way of coping with the income–expenditure gap. Other income is generally considered in studies in developing countries as a coping approach or an adjustment method that people pursue to engineer possible available alternatives to balance the income–expenditure gap and handle possible difficult situations. Strategies to generate other income include: group solidarity strategies, which include increasing the number of income earners (e.g. work of women and children); external support mechanisms (e.g. transfers and remittance of migrants); income diversifica- tion strategies (e.g. involvement in second- ary activities besides the main occupation such as doctors working in the public and private sectors at the same time); and new forms of asset utilization (e.g. turning pri- vate cars into taxis) [23]. To differentiate between poor and rich people, a new variable “has other income/ has a car” was used on the assumption that “has a car” is an indicator of wealth. The single variable “has other income” had a positive odds ratio, which indicates that both the poor and the well-off use the free-   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما of-charge public health services. The odds ratio for “has other income/has a car” was negative, indicating that the well-off were less likely to receive free-of-charge public health services. The high proportion of respondents who paid for treatment (86.2%) or bought drugs (90.0%) during the previous 3 months is an indicator of the high demand for health services. The unexpected significance of “always paid for treatment” and “always paid for drugs” during the previous 3 months is an indication of the existence of under-the-counter payments for health care services. The response to questions on the number of episodes of sickness and frequency of visits to health service units for treatment during the previous 3 months along with the frequency of internal diseases (49.8%) con- firmed this high demand for health services. The frequency of internal diseases shows that Sudan still suffers from the old com- municable diseases such as malaria and that noncommunicable diseases such as diabetes and high blood pressure are on the increase. Results from the same survey show that malaria is on the top of the morbidity list followed by diabetes and hypertension. The frequency of visits to health service units is an indication of the demand for care of the household during the past 3 months. The debate over the price and income elas- ticity of the demand for medical care under- lies in part government efforts to continue and establish the cost recovery policies. On the other hand, it alerts the government to the negative impact of the cost recovery policies on utilization of health services, especially for the poor. A health demand study has shown that acute medical care is relatively insensitive to its cash price [24]. Recently, one study found that fees may adversely affect utilization by low income groups [25]. A 2001 Sudanese study dem- onstrated that if all types of medical care compensation are considered, cash outlays for private medicine (including traditional healers, drugs, etc.) tend to represent a large proportion of total health expenditures by people of low socioeconomic status in developing countries. This insensitivity to price suggests that the government can continue to establish cost recovery policies that favour the poor [12]. The variable “has dependents” is one of the strongest indicators of extra household expenditure in developing countries. This puts a burden on the head of household. The high dependency indicator in Sudan (93.5%) is due to poor economic status, which forces the government not to fulfil the basic human rights of housing, health care, education and opportunities for work. The extended family structure of the society together with the well-established kinship institution aggravates this problem. The vast majority of the population lives below the absolute poverty line. Women and chil- dren account for 45% of the population [24]. Responsibility towards parents and siblings weighs heavily on the head of household. The high dependency rate continues to have a negative impact on the household budget. More study is needed to explore this area and to find scientific guidelines for effective solutions. Although the poor do benefit from the free-of-charge policy, many points still need to be considered. The absence of a referral system raises the question whether all those using the free-of-charge services are emergency cases. How can we make the well-off pay for their emergency needs? How can we stop the huge losses in medical supplies?    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما   The group most likely to receive free-of- charge public health services were those who had other income and had dependents. Given their high demand for health serv- ices and given that this group is likely to be the target population for free-of-charge health services, the cost recovery policies in Sudan are not likely to be threatened by exploitation by the well-off. Therefore, the government can continue to offer free-of- charge public health services at emergency departments along with effective measures to prevent misuse. One of the top priorities facing health planners in Sudan is to establish a health referral system. To do this, the government needs to improve the quality of services at the health centres by keeping the revenues within these institutions. The retention of the revenue at the local level, as a supple- ment to public health care financing, would facilitate and improve the quality of services at the local level and keep the system viable [2,5,8,26]. Implementing free-of-charge public health services in Sudan was a political decision taken without technical studies and support. There is a need for a better un- derstanding of the packages of policies that meet the multiple objectives that politicians and the community pursue. If the govern- ment insists on executing the new free-of- charge policy at public health services in the class C wards (3rd class), this may need careful and scientific handling. The government needs to assess the limits of cost recovery policies under a variety of geographical, socioeconomic and service delivery settings. Research is needed on service costs to facilitate rate settings. The involvement of the community in the management process would enhance the importance of cost recovery policies as an effective community financing tool and would encourage the community to foster these policies [5,24]. In Sudan it seems to be very difficult to establish a full cost recovery policy. On the other hand, it is also difficult to provide to- tally free-of-charge public health services. So, if user fees are a deterrent to utilization by the poor, improving access by approach- es such as subsidies, waivers, and a sliding fee system could be potential corrective measures. The administrative feasibility of these systems would, however, need to be considered. Without proper management, it will be very difficult to effectively implement the cost recovery policies for measures aimed at protecting the poor, payment collection and revenue allocation.                                                                   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                                                                 ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                        List of Medical Journals in the Eastern Mediterranean Region As part of a continuing effort to enhance access to health and bio- medical journals in the WHO Eastern Mediterranean Region and to make them more visible on the Internet, the Eastern Mediterranean Association of Medical Editors (EMAME) publishes the “EMR Journals Information Directory”. The directory includes 385 health and bio- medical journals published in the Region and indexed in the IMEMR database on a regular basis. The Directory includes the basic bibliographic information for each journal: title, publisher, start date, ISSN, subject, country of publica- tion, frequency, abstract, etc. A cross link has been established to between each journal and its articles indexed in IMEMR as well as with the EMR Union Catalogue for Health Sciences Journals. The “EMR Journals Information Directory” can be accessed at: http:// www.emro.who.int/emrjorlist. There are also 162 online journals published in the Region, available at: http://www.emro.who.int/EMRJorList/Online.aspx.   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                     ,                 ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  In the year 2000, suicide was estimated to be the 25th leading cause of death in the countries of the Eastern Mediterranean Region (EMR) of the World Health Or- ganization (WHO), but was ranked 7th in the European Region, 8th in the Western Pacific Region and 16th in the South-East Asia Region [1]. On the face of it, suicide may not be considered as one the most ur- gent health problems in the EMR. However, the aggregate figures may hide variations among different groups [2]. Therefore, it is useful to reanalyse the patterns of suicide in order to assess which groups are at high- est risk and to apply effective measures, if needed, to address this [3]. In the year 2000, the EMR consisted of 22 countries (Afghanistan, Bahrain, Cyprus, Djibouti, Egypt, Iraq, Islamic Republic of Iran, Jordan, Kuwait, Lebanon, Libyan Arab Jamahiriya, Morocco, Oman, Pakistan, Qatar, Saudi Arabia, Somalia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates and Yemen) [1]. Countries in this Region were divided into high income (US$ 9636 or more) and low- and middle-income (US$ 9635 or less) based on their 1996 estimates of gross national product per capita. Using this classification, only 4 countries—Cyprus, Ku- wait, Qatar and United Arab Emirates—were classified as high income and the remaining countries were classified as low- or middle- income [1]. The aim of this paper was to report the estimated rates of suicide by age and sex in the year 2000 within EMR countries, ad- justed for the income level of the countries.  This report used data based on the Interna- tional classification of diseases, 9th revi- sion (ICD9) codes E950–E959 (suicides) [4], which were collected by the WHO global burden of disease project for 2000, version 1 [5]. The aggregated results for WHO regions were published in the World report on violence and health [1]. In the present study estimated rates of suicidal deaths were plotted for different sex and age groups (5–14, 15–29, 30–44, 45–59, 60+ years). A similar procedure was applied to compare suicide deaths as a proportion of all deaths due to injury. In order to have a better picture, all data were plotted without and with adjustment for the country’s level of income.  Plotting the suicide rates by age showed that in the age groups 5–14 and 15–29 years the rates of suicide were slightly higher in females compared with males (Figure 1). The peak age for suicides among females was 15–29 years (8.6 per 100 000). After this, the rates for women fell in age groups 30–44 and 45–59 years, with a rise again at 60+ years. For males, the suicide rate rose continuously with age, peaking at 60+ years (10.8 per 100 000). Plotting the same rates adjusted for the level of income of the countries showed a similar pattern for the low- and middle- income countries (Figure 2). However, patterns of suicide in the high-income countries were different. Females in these countries had the lowest rates of suicide in all age groups (range from 0.1 to 3.5 per 100 000), lower than women in low-/ middle-income countries (range 2.0 to 8.6 per 100 000). Males in the high-income countries had a lower suicide rate (range 0.4 to 7.3 per 100 000) compared to males in low- and middle-income countries (range 0.8 to 10.8 per 100 000).   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما        ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما When suicide deaths were calculated as a proportion of all deaths due to injury, the proportion of such deaths was substantially higher in females than males in all ages groups except 60+ years (Figure 3). The difference was most marked in age group 15–29 years, when suicides comprised 20.0% of all deaths due to injury in females and only 8.6% for males. When adjusted for level of a country’s income, a similar pat- tern was seen for all countries. For females in low- and middle-income countries, the rates of suicide as a proportion of all deaths by injury were the highest, while for males in high-income countries they were the low- est (Figure 4).  The WHO global burden of disease project for 2000 has been based on an extensive analysis of mortality data and also statisti- cal modelling, systematic reviews of health service data and epidemiological studies [5] and seems to produce reasonable estimates of suicide rates. However, suicide data are the end-product of a chain of informants, including family members, police, doctors and coroners, and any of them, for a vari- ety of reasons, may be unwilling to record the death as suicide. Therefore, we need to bear in mind the possibility of underestima- tion of true suicide rates in the population, especially in places where cultural and/or religious attitudes condemn suicide [1]. The countries of the EMR have cer- tain common factors including religion which justify grouping them together as a Region. The Region is the cradle of many religions—Islam, Christianity, Judaism and Zoroastrianism—but Islam is the religion of about 90% of the people [6]. This could to some extent explain why the recorded suicide mortality rate as a whole in EMR is lower than the other Regions. The Qur’an states that no one should kill him/herself,     ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما because God has been merciful to him/her. This commandment is believed to play a role in the low rates of suicide recorded among Muslim communities [7]. However, looking at the estimated sui- cide rates for different age and sex groups revealed interesting patterns: females in the age group 15–29 years and males in the age group 60+ years were at highest risk in terms of committing suicide. Furthermore, the high proportion of suicide deaths in all female age groups, especially 15–29 years, uncovers another interesting pattern. It seems that by looking at the most important risk factors for suicide it would be possible to explain these patterns to some extent. One of the strongest risk factors for suicide is mental disorders [8], and in a meta-analysis it has been shown that most types of mental disorder increase the suicide risk between 5-fold and 15-fold [9]. For instance, depression is the most impor- tant mood disorder that is strongly associ- ated with suicide [10], especially for young women and elderly people; in a recent study the prevalence of major depressive episodes in the year 2000 for the EMR were estimated to be 1872 and 2748 per 100 000 males and females, respectively; clearly both figures are higher than the world average [11]. Marriage usually has a protective ef- fect against suicide [12,13], which might illustrate the fact that those people who may be prone to suicide are more likely to be single or to have been divorced or wid- owed [13]. However, marriage might not be protective in all cultures, especially for young women. For instance, higher rates of suicide and deliberate self-harm have been reported among married women in Pakistan       ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما in comparison to both married men and single women [14,15]. This may be because social, economic and legal discrimination creates psychological stress that leads these women to commit suicide or deliberately harm themselves [14]. More research is needed in order to reveal the true nature of suicides among young women in the EMR and to find out to what extent marriage and/or other risk factors such as oppression, women’s empowerment and secondary role in a patriarchal society could explain this high suicide rate. Suicide rates are also directly associated with recent discharge from hospital [16,17], substance misuse [18,19] and deliberate self- harm [20]. It also seems that people in lower socioeconomic groups experience a greater risk of suicide [21] and the reasons for this could be as a result of poverty, unemploy- ment or job insecurity [22]. Moreover, there are several published studies which have shown that there are ecological associations between suicide rates in different areas and indices of deprivation or social fragmenta- tion [23–30]. The magnitude of these risk factors could be very high for the EMR if we realize that, as in many developing countries, the cultural backgrounds of the people of the Region are rapidly and in- evitably changing. This has resulted in fast and usually unplanned urbanization and the emergence of suburban slums, especially in large cities. Widespread unemployment usually accompanies this condition, which in turn may create young people who are prone to develop depression and behaviour problems [6]. To sum up, it seems that these find- ings justify paying more attention to the ways of preventing suicide among high risk groups, especially in low- and middle- income countries. For prevention of suicide, there are at least 2 important routes for countries within this Region. First, it will be important for each country to develop national programmes for mental health in order to meet the mental health needs of the people, especially young women and elderly people. Although countries of the Region have made significant progress over the past 2 decades in developing such national programmes, more efforts will be needed for integrating the mental health components into primary health care [31]. Secondly, countries within this Region, especially low- and middle-income ones, urgently need to tackle poverty, reduce un- employment and job insecurity and provide social support for high-risk groups. Finally, it should be added that since the enhanced information about suicide mortal- ity can come from systematic surveillance programmes [32], a national or regional database of suicide could help countries of the EMR to have a better understanding of patterns of suicide in order to adopt the most appropriate preventive plan.                          ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                                                            ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                        Eradication of poliomyelitis in the EMR Rapid and significant progress towards the eradication of poliomyelitis is continuing in all countries of the Eastern Mediterranean Region. The number of cases decreased regularly to a minimum in 2002, in the light of a well developed and efficiently performing surveillance sys- tem. Poliovirus transmission had been interrupted in 15 countries of the Region for more than 3 years. Three countries, Somalia, Sudan and Yemen, were re-infected by virus originating from West Africa dur- ing 2004-2006.                                                                    Source: http://www.emro.who.int/polio/   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                 258 1839 15.14.3 2.722.1 0.4 0.4    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  Human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV) are a burden to healthcare de- livery systems. Currently about 40 million people worldwide are living with HIV/AIDS [1]. The Nigerian Federal Ministry of Health 2003 sentinel survey recorded a prevalence of HIV/AIDS of 6.3% in Jos and 5.1% in Nigeria overall [2]. Worldwide there are 350 million chronic carriers of HBV [3]. The prevalence ranges from 1% in some developed countries to 15% in developing countries [4]. Approxi- mately 18 million Nigerians are chronic carriers [5]. About 3% of the world’s population has been infected with HCV and over 170 million people are chronic carriers [6]. HCV prevalence in developing countries has been reported to be 1%–2% [6]. HCV antibody prevalence among blood donors in Egypt ranged from 6% to 38% with a mean of 15% [7]. Although every year millions of lives are saved through blood transfusions, blood transfusion remains a major route of trans- mission of these viruses (HBV, HCV and HIV). Each year up to 4 million blood donations worldwide are not tested for HIV or HBV and only a small proportion of donated blood is tested for HCV [8]. This is particularly true in developing countries where there is widespread transfusion of blood without screening. For instance, it has been documented that no more than 10% of the countries in Africa routinely screen donated blood for HBV or HCV [8,9]. This, together with the fact that these viruses largely have the same mode of transmission and risk factors [10–12] and other short- comings (e.g. technical and clerical errors), contributes to the transmission of these viral agents by transfusion [10]. Key to the procurement of safe blood is the recruitment and retention of voluntary unpaid blood donors [9]; unfortunately, the World Health Organization and UNAIDS estimate that only 10% of countries in Af- rica receive 100% of their blood donations from voluntary donors [9]. Given this, a mathematical model developed supports the selection of donors from population groups that are at low risk for HIV infec- tion [13]. This will significantly reduce the frequency of window-period donations, thereby minimizing the residual risk of viral transmission. There is an increasing need to encourage blood donation by donors that fulfil the criteria for safe blood donation and nowhere is this need greater than in developing countries. These criteria include donation by unpaid, voluntary, responsible, young, healthy, adult, non-pregnant, low-risk and fully counselled donors [8,14]. In Jos, there is a group of young healthy clergymen-in-training who formed a chari- table blood donor group that frequently offers blood donation free to save the lives of those in need of such services. They are considered a low-risk group by virtue of their chosen profession and thus they fulfil the criteria for safe blood donation. The purpose of this prospective study, therefore, was to document the seroprevalence of HIV, HBV surface antigen (HBsAg) and HCV in this group of young clergymen with a view to making recommendations that would improve the safety of blood transfusion.   This prospective study was carried out at Jos University Teaching Hospital in Jos, Nigeria. The study population consisted of 286 clergymen-in-training who formed a charitable blood donor group and were con-   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما sidered low risk. They came from different parts of the country to undertake their cleri- cal studies in Jos. The criteria for inclusion in the study were: voluntary participation, age not less than 18 years, free of any illness at the time of recruitment, no past medical history of yellowness of the eye, and no history suggestive of infection with any of the 3 viral agents in question. Of the 286 eligi- ble clergymen-in-training, 28 declined to participate and thus 258 were included in the study. After counselling and giving informed consent, each participant was assigned a numerical code so as to maintain confidenti- ality. The only data about these participants that was allowed for documentation were their ages. Ethical clearance for the study was obtained from the hospital ethical com- mittee.  After counseling, 4–5 mL of venous blood was collected from each participant asepti- cally by venepuncture from the cubital fossa into clean plastic containers (Z-10 tubes) using a standard procedure. The blood was allowed to clot and centrifuged (Chris Craft centrifuge, model 6065, serial No. 12314) at 3000 rpm for 5 minutes to separate the serum. The sera so extracted were stored in cryovials at –20 °C until tested. A rapid enzyme immunoassay was used for HIV screening (Genie HIV1/HIV2 kit. Samofi Diagnostics Pasteur, La Coquette) and the results read using a microplate reader (Elx 800 universal microplate read- er, Biot-Tek Instruments Inc., Highland Park, United Sates of America. Serial No. 139065). Confirmation was made by West- ern blot for samples found positive. HBsAg screening was done by spot test (Biotec Laboratories Ltd., Middlesex, United Kingdom). A rocker was used to rock the sample to enhance proper mix- ing for agglutination to occur. Testing for antibodies to HCV was done using an ELI- SA method (Diagnostic Automation Inc., United Sates of America). Post-test counseling was offered to all the participants and the results were fully explained to them; those who were positive were offered medical assistance through the hospital. However, all of them preferred to seek medical assistance privately.  Data was analysed using Epi-Info, version 3.3.  A total of 258 clergymen-in-training aged between 18 and 39 years were tested for HBsAg and antibodies to HIV and HCV. The age distribution and prevalence of HBsAg and antibodies to HIV and HCV are shown in the Table 1. Table 1 also shows that 39 (15.1%) of the 258 subjects were positive for HBsAg, 11 (4.3%) for HCV infection and 7 (2.7%) for HIV infection. Table 1 shows that 22.1% of the participants were infected with at least 1 of the viruses. The highest infection (30.0%) with at least 1 of the viruses was recorded in the age group 30–39 years, followed by age groups 20–29 years (25.7%) and < 19 years (14.1%) (Ta- ble 1). Co-infection was seen as follows: 0.4% (1/258) for HIV and HBsAg; 0.4% (1/258) for HCV and HBsAg; and 0% (0/258) for HIV and HCV.  This study was carried out to document the seroprevalence of HIV, HBsAg and HCV in a group of young Nigerian clergymen-in-    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما training who had formed themselves into a charitable blood donor group. We wanted to examine the safety of heterologous blood transfusion by donors that fulfil the criteria for safe blood transfusion. Out of the 258 clergymen that were tested, 39 (15.1%) were positive for HBsAg, 11 (4.3%) for HCV infection and 7 (2.7%) had HIV infec- tion. Although the HIV prevalence of 2.7% recorded in this study is similar to previous findings in blood donors in Jos [15], it is lower than the Federal Ministry of Health sentinel survey of 6.3% [2] and the National seroprevalence rate of 5.1% [2]. These dif- ferences with our survey may be due to the differences in sample population and size; our study included only males, while the national survey included both sexes, had a larger sample size and included groups with different sociocultural practices. The HBsAg seroprevalence of 15.1% is similar to reports from other developing countries [4]. A higher prevalence (26%) was recorded in Benin [16]. However a lower figure of 7% was previously reported among blood donors in Ife [17]. Our data confirm the endemicity of hepatitis B infec- tion in Nigeria, and show that it is a problem that appears to be growing. The 4.3% prevalence of HCV recorded in this study is lower than the 6% recorded in previous work in blood donors in Jos [18] and reports from Egypt [6], but is higher than the 1%–2% reported for other devel- oping countries [6]. Hepatitis C infection is clearly a problem in Nigeria as in other developing countries. In all 22.1% of the participants were infected with at least 1 of the 3 viruses. HIV and HBV co-infection had a prevalence of 0.4% in our series, which is lower than the 28.7% previously reported in Jos among HIV patients [5]. This contrasts with the re- port from Benin city, Nigeria where no co- infection with these viruses was observed [18]. There is evidence to suggest that HBV can infect lymphocytes and produce a pro- tein X that is capable of activating HIV-1 replication in-vitro [5]. Overall, the prevalence rates of 2.7%, 15.1% and 4.3% for HIV, HBsAg and HCV respectively are high, especially when this population group would be characterized as low risk, which is alarming given that this group regularly donates blood. And even with blood screening, the possible transmis- sion of these viruses by blood transfusion as a result of the collection of blood during the so-called viraemic window period, before infection can be detected by laboratory testing, has been documented [19]. Further- more, we used HBsAg as the only marker for HBV infection in our methods, but about                                                                    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما 10% of occult HBV infection has been detected by use of polymerase chain reac- tion [20] and 10%–20% of all individuals with HBV have antibodies to the hepatitis B core antigen as the only marker for this infection [20]. Thus polymerase chain reac- tion and hepatitis B core antigen are more sensitive than the serological methods used in our study and so our results may be an underestimate of the infection rate among our study group. HIV, HBV and HCV share similar rates of transmission and risk factors [10–12]. This could account for the high rates record- ed in this population. The law in Nigeria permits blood donation only by adults, 18 years of age and above. The finding in this study, that the age group of 30–39 years had the highest prevalence of the 3 viruses is critical, since they come from such a pre- sumably low-risk, responsible, population as this one. It also calls into question keep- ing the donor age at 18 years in the present circumstances. In Zimbabwe, following the lowering, through legislation, of the mini- mum age of blood donation from 18 to 16 years, there was a tremendous improvement in the low-risk donor base [9]. Although screening of donated blood is mandatory and essential for identification of infected donations as a standard practice, especially when sophisticated equipment like polymerase chain reaction is used [20], it is not a panacea for safe blood donations [10]. The availability of a safe blood supply is critical for both medical progress and na- tional security [21]. Given that even an ap- parently low-risk group had relatively high infection rates for HIV, HBV and HCV, and thus could pass on these infections through blood donation, we advocate an autologous blood transfusion programme. This ensures that patients are carefully selected to receive their own blood, which is risk-free [22]. Above all, transfusion of blood and blood products should be given only when abso- lutely necessary [8,14].  We are grateful to the Senate of the Univer- sity of Jos for providing the grant for this study. We also extend our appreciation to the staff of the Medical Microbiology De- partment for their assistance.                                                                        ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                     ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                      173 32 166 62169 169    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  Drug and alcohol abuse among university students is a major cause for concern. Use of illegal substances may be associated with a deterioration in personal and social life, especially in the case of addictive drugs such as heroin when users often become in- volved in illegal activities to acquire money to purchase the drug [1]. Drug and alcohol use also disrupts other students who are not themselves users; one study in North America showed that 60.5% of college stu- dents had their study or sleep interrupted by others who drink alcohol, 53.6% had taken care of a drunken student, 29.3% had been insulted or humiliated, 18.6% had had a se- rious argument or quarrel, 13.6% had prop- erty damaged and 9.5% had been pushed, hit or assaulted [2]. According to Gilksman [3], although the number of times per week that students drink is not particularly high, the amount they drink at one time is a sig- nificant concern. Heavy or “binge” drinking for this age group could result in broken re- lationships, academic difficulties, accidents (related to driving and otherwise) and legal and administrative problems, which could affect the student’s future. Although much research has been con- ducted in North America and Europe [2–6] there has been little research on drug and al- cohol use in the Islamic Republic of Iran. A survey in 2001 showed that 24% of Iranian university students had used narcotics at some time in their lives [7]. Another study reported that 22.3% of secondary-school students had abused drugs [8]. An explora- tory study of Shiraz University students’ attitudes towards drug use (cigarettes, al- cohol, opium, heroin and cannabis) showed that about 52% had smoked cigarettes, 25% had tried alcohol, 21% opium and 12% can- nabis, and 1 student had used heroin [9]. In the Islamic Republic of Iran young people who use alcohol or other illegal substances may become involved in illegal activities and come to the attention of the legal authorities. The present survey was undertaken to encourage other universities and guidance centres in the country to obtain better information about drug and alcohol use for planning preventive programmes. The study examined attitudes and practices towards alcohol and illicit drug use among university students living in a dormitory at Tabriz University of Medical Sciences.  This exploratory descriptive study in 2001 was carried out among students of Tabriz University of Medical Sciences, Golestan, who were living in a single-sex male dor- mitory. Questionnaires were distributed to stu- dents living in the dormitory. The question- naire used a number of multiple-choice questions in order to reduce the answering time, to elicit more objective responses and to preserve confidentiality. The ques- tionnaire asked for information on age, residency (how long they had lived in the dormitory) and what substances they had used in the 6 months prior to the survey (cigarettes, alcohol, opium, heroin or canna- bis). The survey also asked about academic and social activities, the influence of drug users on other students and their opinion about addicts. Regardless of whether they used substances or not, the participants were asked about problems in the dormitory environment. Students were given clear instructions about the goals of the research and how to complete the questionnaire. To encourage them to answer more openly, they did not write their name or any symbols showing their identity and they were assured about the responses being kept confidential.   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما The data were expressed as descriptive frequencies and percentages.  Out of 220 questionnaires distributed, 173 (79%) were returned completed. The mean age of participants was 21.3 years. Most students were 18–20 years old (30%) or 20–22 years old (30%), although there were older students aged 22–24 years (21%) and 24+ years (18%). Students were asked their views about the dormitory environment. Many students were bothered by other students’ behaviour in the dormitory: 27 (16%) were bothered by other students drinking alcohol, 6 (4%) by their using drugs and 33 (20%) by smok- ing. Some also complained about noise (67, 36%) and general dirtiness (45, 26%). The results for tobacco, alcohol and drug use shows that 117 participants (68%) reported that they had not drunk alcohol or used illicit drugs in the last 6 months, whereas 56 students (32%) had tried alcohol or other drugs at least once in this period (Table 1). The most commonly used was alcohol (16% of students), followed by cannabis (6%), opium (6%) and heroin (2%). Sixteen students (9%) reported they were drinking large amounts of alcohol on each occasion and 16 (9%) were abusing other illicit drugs, with 2 abusing drugs by injection. Of the students who were us- ing substances, 42% became familiar with substance use before entering the university and 58% after entering. Some of the students (32, 19%) reported daily cigarette smoking but most (141, 82%) were non-smokers (i.e. not daily smokers). When students were asked their opinions about drug users, 44 (25%) believed that they were sick (i.e. had a physical problem), 97 (56%) that they had mental problems (i.e. a psychological disorder such as de- pression, anxiety, antisocial behaviour), 18 (10%) that they were guilty (i.e. should be punished by the government) and 11 (6%) that they were guiltless (i.e. society should solve their problems).  The results of this analysis of students’ use of cigarettes, alcohol and other psychoac- tive drugs shows wide variations in compar- ison with other surveys. Our research relied on self-reported answers about socially unacceptable and illegal behaviours, so the validity and reliability can be questioned. However, efforts were made to assure stu- dents about confidentiality, and multiple choice questions were used in order to obtain valid responses. We also cannot generalize the findings of this research for all students, as the students were a group living in a dormitory and were not randomly selected from all students in the university. In our study nearly one third of respond- ents (32%) had tried addictive substances (cigarettes, opium, cannabis, heroin) in the previous 6 months. On the other hand, a study previously conducted in the Islamic Republic of Iran reported that 24% of stu- dents had used at least 1 illicit drug at least once in their life and 75% had never used drugs [7].                           ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما Alcohol may cause more problems on college campuses in Northern America and Europe than other substances. Our research revealed that 16% of male students living on campus in Tabriz had used alcohol in the previous 6 months and 9% said they were abusing alcohol. Ghanizadeh reported from Shiraz University in the Islamic Republic of Iran that 25% of 213 students had tried alcohol at least once in their life [9]. A study by the Centre for Addiction and Mental Health in Canada showed that out of 7800 undergraduate students in 16 universities across Canada, 62.8% reported 5 or more drinks on a single occasion at least once since the beginning of the college year [3]. Students in university residences were most likely to report having 5 or more and 8 or more drinks per occasion at least once since September. Studies show that about 43% of all students report drinking in a high-risk manner at some point in their college career [6]. Surveys at colleges and universities across the United States of America indicate the percentage of students who used vari- ous other drugs within the previous year: marijuana (32.3%), amphetamines (6.5%) and hallucinogens (7.5%) [2]. In our research only 6% of students had used cannabis in the previous 6 months. Ghanizadeh reported that 12% of Shiraz students had tried cannabis and 5% had used cannabis in the 6 months before the survey [9]. The Canadian study showed that 47.0% of students reported using can- nabis at some point in their lives and 28.7% had used cannabis during the previous 12 months [3]. Our study also showed 6% of students used opium in the last 6 months. These figures are lower than from Shiraz in 2001 where 21% of students had used opium ever and 10% in the last 6 months [9]. However, slightly more of our students in Tabriz (2%) had used heroin in the last 6 months com- pared with only 1 student in Shiraz who had ever tried heroin and none who had used it recently [7]. Also, in accordance with the previous study, of those who had used drugs before, 29% had used opium, 10% heroin and 54% hashish [7]. On the other hand, according to a study of student drug use by Singh et al. in Punjab, India, 7 out of 10 undergraduate students had used drugs in the past [10]. This is higher than the current study and other studies in the Islamic Republic of Iran [7,9]. A total of 2.3% of Canadian students reported using at least 1 of 5 illicit drugs by injection dur- ing their lifetime (2600 students from 7800 participants) compared with just 1% of students (n = 2) in our study who reported abusing injecting drugs [3]. In the Canadian study, 12.1% of students reported daily cigarette smoking and 10.4% reported occasional smoking [3], compared with our study where 19% of male students reported daily cigarette smoking. In our study 50% of participants said they were smokers. Ghanizadeh reported from Shiraz that 52% had ever smoked cigarettes, 27% in the previous 6 months [9]. As far as we know, there are few reports of university students’ patterns of illicit drug use in the Islamic Republic of Iran, so more research is needed to understand patterns of student drug use inside our country. Recent research confirms that college campuses continue to have alcohol and other drug use problems. Students in Canada living on- campus or off-campus without their family reported higher rates of cannabis use during the previous 12 months (35.8% and 31.2% versus 24.7%) than students living with their family [3]. Our results suggest that efforts are need- ed to create a more positive campus culture regarding alcohol and illicit drug use in   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما the Islamic Republic of Iran. This could be achieved by emphasizing the importance of academic study, creating a more stress-free environment for students, facilitating a wid- er range of social and recreational activities, setting up alcohol and drug awareness and counselling programmes, and notifying parents when students engage in serious or repeated violations of alcohol laws or other drug policies.  The authors are grateful to all the staff who cooperated with this research.                                                                                                                              ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما         A 35-year-old Iraqi woman (gravida 7, para 5 + 1 abortion) was admitted to the Jordanian field hospital in Fallujah, Iraq in January 2004 with a history of 8 weeks amenorrhoea; intermittent vaginal bleeding and mild lower abdominal pain of 4 weeks duration; and a positive urine pregnancy test on the day of admission. She had been married for 13 years. Her menstrual history was not relevant. There was no past history of contraception use or previous abdomino- pelvic surgery. General examination revealed maternal tachycardia (pulse 110 per minute), hypo- tension (systolic/diastolic blood pressure 90/60 mmHg) and pallor. Her abdomen was tender on palpation with positive rebound and guarding. On pelvic examination, there was mild spotting, the cervical os was closed and the cervix tender on transverse motion. The uterus was bulky; there was fullness in all the fornices with tenderness; and the adnexae were difficult to palpate. Haema- tological examination showed: white cell count 8 × 109 cells/L, haemoglobin 8.5 g/dL and haematocrit 25%. Pelvic ultrasound examination showed bulky uterus, homog- enous texture and mild thick endometrium with smooth outline. A moderate amount of fluid collection was present in the pouch of Douglas. Emergency exploratory laparotomy re- vealed haemoperitoneum of approximately 800 mL. There was a ruptured fimbrial ectopic pregnancy with active bleeding on the right side. The left tube showed an intact ectopic pregnancy 2 cm × 2 cm in the amp- ullary region that was bleeding and forming an organized haematoma at the fimbrial end (Figure 1). In view of these findings, right salp- ingectomy and left salpingostomy with cautery were carried out with removal of the product of conception. The patient re- ceived 2 units of type O Rh positive blood. Postoperative follow-up was uneventful and the patient was discharged on the 5th day post-operation. Two weeks after surgery the beta subu- nit of human chorionic gonadotrophin was zero. Histopathological examination of the specimens, excised right ruptured tube and the product of conception extracted from the left tube, confirmed the diagnosis. It revealed tubal tissues with decidua and chorionic villi on the right ruptured tube. Inflamed decidua with chorionic villi, but no tubal tissues, were seen on the specimen from the left side.   ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما  Spontaneous bilateral ectopic pregnancy is rare, therefore preoperative diagnosis is un- common. The frequency of bilateral ectopic pregnancy has been estimated at 1/200 000 uterine pregnancies and 1/725–1/1580 ec- topic pregnancies. [1]. In the past 20 years a 3-fold increase in the incidence has been observed. [2] Heterotopic as well as bi- lateral tubal ectopic pregnancies are seen after the introduction of assisted reproduc- tive treatment [3,4,5,6]. The occurrence of spontaneous bilateral ectopic pregnancy is, however, exceedingly rare [1,7,8]. We report a very rare case of spontaneous ruptured and intact bilateral ectopic preg- nancy involving the ampullary segments. This case met the findings for simultaneous tubal pregnancy by the presence of either embryos of similar age or chorionic villi in both fallopian tubes at the time of surgery [9,10]. Ultrasonography in our case failed to make such a diagnosis and this is in agreement with other reports, i.e the use of ultrasound is not necessary to make a diag- nosis in bilateral ectopic pregnancy [8,11]. Therefore, diagnosis of ectopic pregnancy continues to be an important challenge fac- ing emergency physicians. Our findings in this case are similar to those of Kansaria, Chauhan and Mayadeo, who reported a right ruptured fimbrial ec- topic and left chronic ruptured tubal ectopic pregnancy [12]. Surgical management to preserve the left tube was by excision of the haematoma along with a thin rim of the tube; haemostasis was achieved by under-running the salpingostomy incision. In the case we describe here, only linear salpingostomy using cautery for haemostasis was done and there was no need to suture the site of incision. In both cases right salpingectomy was performed. Careful attention should be directed to follow-up tests. A serial measurement of serum concentrations of human chori- onic gonadotrophin is necessary to rule out the risk of persistent trophoblast. Since no single postoperative concentration of hu- man chorionic gonadotrophin is prognostic, follow-up until complete resolution is nec- essary [13]. Further medical treatment with methotrexate or surgery in symptomatic patients may be necessary if human chori- onic gonadotrophin levels do not decline or persist. Since the woman’s future ability to re- produce may be adversely affected, we would argue the necessity of carefully examining both adnexae at the time of exploratory laparotomy undertaken for sus- picion of ectopic pregnancy, as proposed by others [10,14,15].      ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                                                         ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما            Floating–Harbor syndrome is a rare genetic disorder that was named by Robinson et al. in 1988 [1] from the first 2 identified patients seen at Boston Floating Hospital and Harbor General Hospital in California [2,3]. The main characteristic features of the syndrome are distinct facial features delay in using expressive language, short stature and delayed bone age [4–7]. The incidence of Floating–Harbor syndrome is unknown. To our knowledge, 29 cases have been identified in the literature [3,8,9]. Most of the reported cases were of female sex and the male:female sex ratio is 7:22. Here we report the first case of Floating–Harbor syn- drome in Kuwait. The clinical picture and spectrum of the disease are discussed along with a review of the literature  A Kuwaiti female child, aged 8.5 years, was the product of the 4th pregnancy to nonconsanguineous phenotypically normal parents. At birth, the parental age was 27 and 37 years for mother and father respec- tively. The proband was referred to Kuwait Genetic Centre at the age of 5 days because of intrauterine growth retardation. Pedigree study revealed that she has 3 phenotypically normal elder siblings (2 sisters and 1 brother). One of her sisters was found to have mosaic Turner syndrome. The mother’s preconception and 1st and 2nd trimester histories were irrelevant and the pregnancy was completed at term by spontaneous vaginal delivery and cephalic presentation. Apgar scores were 8 and 9, at 1 and 5 minutes respectively. Examination at birth revealed weight 2.15 kg, length 48 cm and occipito-frontal circumference 30.5 cm. No significant specific craniofacial dysmorphia could be detected at that time and chromosomal study was arranged to exclude the presence of any mosaicism. Follow-up at the age 2 years 3 months revealed: weight 9 kg, length 78 cm, and occipito-frontal circumference 42 cm. All measurements were below the 3rd centile. She had a triangular face, microcephaly, bulging and narrow forehead, broad and prominent nasal bridge, wide columella, mild synophrys, deep-set eyes, short philtrum, thin upper lip, broad mouth, posterior rotat- ed ears (Figure 1), short neck, low posterior hairline, small hands, bilateral clinodactyly    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما of the 5th finger, bilateral shortening of the 4th and 5th fingers, bilateral shortening of the 4th and 5th toes, and bilateral partial cutaneous syndactyly between the 2nd and 3rd toes (Figure 2). There was delayed speech. At the age of 5 years 10 months she had height 105 cm, weight 12 kg, and occipito-frontal circumference 41 cm. All measurements were below the third centile for age. Several investigations were carried out. Calcium, phosphorus, alkaline phosphatase, magnesium, blood glucose, ToRCH as- say [Toxoplasma gondii, rubella togavi- rus, cytomegalovirus, and herpes simplex virus types 1 and 2], immunoglobulin electrophoresis, amino acid chromatogra- phy, organic acids assay, thyroid function and echocardiography were normal. IgA- antigliadin was negative. Growth hormone (GH) provocation test by clonidine revealed low baseline GH levels at 0 and 30 minutes. Normal response was observed after 60, 90 and 120 minutes (0.39, 0.36, 31.4, 19.0 and 14.1 mIU/L at 0, 30, 60, 90 and 120 minutes respectively) (normal range for females 0.4–26.7 mIU/L). Chromosomal study using peripheral blood and trypsin G banding was normal for both this child and her parents. Developmental assessment at 14 months of age showed a maturity level of 6–7 months. IQ assessment at 4 years 7 months was 62 (mild mental retardation) and the language skill was severely affected. EEG showed low basic activity, low voltage in all stages of vigilance and a focus of spikes with phase reversal in the right centropa- rietal region showing a focally abnormal           ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما record. Computerized tomography of the head and magnetic resonance imaging were normal. Skeletal survey showed shortening of the 4th and 5th metacarpal bones bilaterally and minimal shortening of the 4th metatar- sal bones.  In the present case, most of the cardinal features of Floating–Harbor syndrome were present: triangular face, deep-set eyes, long eyelashes, broad nasal bridge, wide colu- mella, short smooth philtrum thin upper lip, posterior rotated ears, low hairline, short stature and microcephaly. Gross deficits in verbal expression and perception (i.e. patient cannot understand and respond to what she hears), speech language problem, high-pitched voice and delayed bone age were present [1,7,10–12]. Trigonocephaly, atrial septal defects, supernumerary upper incisor, lateral asymmetry of the body and coeliac disease, which have been described infrequently, were missing in this case [4–7,9,11–14]. Trigonocephaly, described rarely, was considered an important cranio- facial manifestation and has to be added to the cardinal features of Floating–Harbor syndrome [7]. The neuropsychological deficits record- ed in this case are similar to what has been reported previously: mild mental retarda- tion, constructive apraxia and comprehen- sive and expressive language impairment [4]. The use of sign language has greatly helped some parents. In addition, speech therapy has helped when the children are over 3 years old. Unfortunately it was not successful in this case. GH deficiency and its role in the man- agement of Floating–Harbor syndrome had been discussed previously [15,16]. However, its level was low to normal with adequate response in this girl. Cannavo et al. reported an affected female child with Floating–Harbor syndrome and impairment of GH responsiveness to administration of oral 150 g clonidine and oral 4 mg dexamethasone [15]. Moreover, low mean GH levels (1.75 ng/mL) (normal value > 3.0 ng/mL) have been reported with successful treatment achieved by GH therapy [16]. The clinical diagnosis of Floating– Harbor syndrome may be unreliable or over- lap with other dysmorphic syndromes such as velocardiofacial syndrome (Shprintzen syndrome), trichorhinophalangeal syn- drome and De Lange syndrome [17–19].                                                ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما In velocardiofacial syndrome, the distin- guishing characteristics are: prominent nose with squared-off nasal tip, notched ala nasi, significant cardiac anomalies, long tapering fingers, cerebral and ocular abnormalities. Both trichorhinophalangeal and Floating– Harbor syndrome are multiple congenital anomaly syndromes with involvement of craniofacial and skeletal structures. The main clinical features of trichorhinophalan- geal syndrome are short stature, mid-facial dysmorphism, sparse hair, speech delay and genitourinary abnormalities [17,20,21]. Both autosomal dominant forms (types I, II, III) and recessive forms exist, associated with mutations in trichorhinophalangeal I, a zinc-transcription factor located at 8q24. The clinical basis of differentiation is: the shape of the nose, digital anomalies, sparse hair and long philtrum, which were missing in our case. The clinical overlap between De Lange syndrome and Floating–Harbor syndrome can be excluded by the presence of short philtrum, speech developmental delay, triangular face, lack of motor delay and absence of the De Lange phenotype at birth. All reported cases of Floating–Harbor syndrome have been sporadic. Very few familial case have been reported in the literature, although affecting siblings of both sexes have been reported and other authors have reported Floating–Harbor syn- drome in a mother and her daughter [9,22,23]. Recently Penaloza et al. reported a boy who had the clinical features of Floating–Harbor syndrome and coeliac disease [9]. His mother showed minor phenotypical features of Floating–Harbor syndrome, suggesting an autosomal dominant mode of inheritance [9,24]. In conclusion, Floating–Harbor syn- drome is a very rare dysmorphic/mental retardation syndrome affecting both sexes but more frequent among the female sex. Most of the reported cases occur sporadi- cally, but a few familial cases have been re- ported, raising the possibility of autosomal dominant mode of inheritance.                                                                                                    ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما                                                                                                                                                                                                                        ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما    Sir The Iranian Blood Transfusion Organization was established in May 1974 with a mis- sion to ensure effective and safe transfusion therapy throughout the country. We report here on the blood supply status in the Islamic Republic of Iran during the 12-month period 21 March 2001–20 March 2002. A total of 1 582 622 applicant blood do- nors were registered in 28 provinces through- out the country. After taking their medical history, 221 301 (14.0%) were rejected. The most common reasons were high/low blood pressure (24.1%), taking medication (12.2%) and having a cold/sore throat (5.2%). After completing the application form and reading the information in the blood transfusion booklet, 6.2% of the applicants refused to donate blood (self-deferral). Table 1 shows the number of blood donations in each province during the year under study. It is recognized that volunteer donors provide the safest blood supply [1]; none of the donors received remuneration. Of a total of 1 361 365 donations, 108 950 (8.0%) were from family/replacement do- nors and 1 252 415 (92.0%) from voluntary donors. This is much higher than the < 40% of blood donations [2] from voluntary, non-remunerated blood donors reported for countries with a low and medium hu- man development index (HDI) [a meas- ure of development derived from 3 basic components of human development: life expectancy at birth; adult literacy rate plus school enrolment ratio; and per capita gross domestic product (GDP)] [3]. Table 2 shows the number of blood components prepared from whole blood                                                                  ٢٠٠٧ ،٤ ددعلا ،رشع ثلاثلا دلجلما ،ةيلماعلا ةحصلا ةمظنم ،طسوتلما قرشل ةيحصلا ةلجلما for the period 21 March 2001–20 March 2002. Effective clinical transfusion practice requires that whole blood be separated into its components. In the Islamic Republic of Iran, < 10% of blood is transfused as whole blood. The availability and use of blood components is limited in many low and medium HDI countries: the use of whole blood is around 10 times higher in these countries compared to high HDI countries, e.g. > 90% is transfused as whole blood in Bangladesh, Democratic People’s Republic of Korea, India and Nepal [2]. Globally, the blood donation rate per 1000 population is almost 20 times (41–50 units) higher in developed countries (high HDI) than in countries with a low HDI (0–                                                10 units) [2]. In comparison, in the Islamic Republic of Iran, the blood donation rate per 1000 population is almost 21 units. M.M. Shooshtari Research Centre, Iranian Blood Transfusion Organization, Tehran, Islamic Republic of Iran (shooshtari@ibto.ir). A.A. Pourfathollah Haematology & Blood Bank Department, Tarbiat Modares University, Tehran, Islamic Republic of Iran.