Eastern Mediterranean Health Journal [2011; Vol.17, Issue 8]

Contents V olum e 17 N um ber 8 A ugust 2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Volume 17 / No. 8 August / Août 2011 8 ددع / شرع عباسلا دلجلما سطسغأ / بآ Letter from the Editor ..............................................................................................................................................................637 Research articles Comparison of maternity care quality in teaching and non-teaching hospitals in Khorram Abad, Islamic Republic of Iran ............................................................................................................................................ 638 Outcome of vaginal birth after caesarean section in women with one previous section and spontaneous onset of labour ...........................................................................................................................................................................646 Reasons for cancellation of elective operations at a major teaching referral hospital in Jordan ..................................651 Determining and prioritizing competencies in the undergraduate internal medicine curriculum in Saudi Arabia .........................................................................................................................................................................................................656 Evaluation of prophylactic antibiotic administration at the surgical ward of a major referral hospital, Islamic Republic of Iran .......................................................................................................................................................................................663 Peginterferon alfa-2b and ribavirin therapy in Kuwaiti patients with chronic hepatitis C virus infection ................669 Cross-reaction of antigen preparations from adult and larval stages of the parasite Setaria equina with sera from infected humans with Wuchereria bancrofti ........................................................................................................................679 Bone mineral density in Egyptian adolescents and adults with short stature: results of a national survey .............687 Physical activity profile of students in Mansoura University, Egypt ..............................................................................................694 Reviews Medical education in Saudi Arabia: a review of recent developments and future challenges .....................................703 Aetiological factors of constipation in the elderly, with emphasis on functional causes .................................................708 Report Using surveillance data for action: lessons learnt from the second generation HIV/AIDS surveillance project in Pakistan ..................................................................................................................................................................................................712 Short communication Road rage behaviour and experiences of rickshaw drivers in Rawalpindi, Pakistan ...........................................................719 Case report Two cases of Vibrio cholerae non-O1/non-O139 septicaemia with favourable outcome in Lebanon .......................722 August 1–7 marks World Breastfeeding Week, which aims to promote breastfeeding and improve the well-being of babies. Of the estimated 1.1 million deaths which occur among children under 5 years of age in our Region annually, 13% could be prevented through higher rates of exclusive breastfeeding, representing one of the most cost-effective interventions to reduce neonatal and child mortality. Furthermore, breastfeeding contributes to a lifetime of good health. Adults who were breastfed as babies often have lower blood pressure, lower cholesterol, and lower rates of overweight, obesity and type-2 diabetes. Cover 17-8.indd 1 8/8/2011 10:11:16 AM طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم ةيميلقلإا ةنجللا ءاضعأ نادلبلا ةيملاسلإا ناريإ ةيروهجم . ةيبيللا ةيبرعلا ةييرهمالجا . سنوت . نيرحبلا . ناتسكاب . ةدحتلما ةيبرعلا تاراملإا . ناتسناغفأ . ندرلأا صرم . نانبل . تيوكلا . رطق . ينطسلف . نماُع . قارعلا . لاموصلا . نادوسلا . تيوبيج . ةينميلا ةيروهملجا . ةيروسلا ةيبرعلا ةيروهملجا ةيدوعسلا ةيبرعلا ةكلملما . برغلما Subscriptions and Distribution Enquiries regarding subscriptions and distribution of the print edition of EMHJ should be addressed to: Printing and Marketing of Publications at: email: pam@emro.who.int; tel: (+202) 2276 5000; fax: (+202) 2670 2492 or 2670 2494 Permissions Requests for permission to reproduce or translate articles, whether for sale or non-commercial distribution should be addressed to EMHJ at: emhj@emro.who.int Members of the WHO Regional Committee for the Eastern Mediterranean Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon Libyan Arab Jamahiriya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia Sudan . Syrian Arab Republic . Tunisia . United Arab Emirates . Republic of Yemen Membres du Comité régional de l’OMS pour la Méditerranée orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran Iraq . Jamahiriya arabe libyenne . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar République arabe syrienne . Somalie . Soudan . Tunisie . République du Yémen Correspondence Editor-in-chief EMHJ WHO Regional Office for the Eastern Mediterranean P.O. Box 7608 Nasr City, Cairo 11371 Egypt Tel: (+202) 2276 5000 Fax: (+202) 2670 2492/(+202) 2670 2494 Email: khayat@emro.who.int/emhj@emro.who.int EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con‑ cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col‑ laborating Centres and individuals within and outside the Region. LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser‑vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico‑sanitaire, aux ONG, Centres collabora‑ teurs de l’OMS et personnes concernés au sein et hors de la Région. EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line) and the ExtraMed‑Full text on CD‑ROM, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), CAB International, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). ©World Health Organization 2011 All rights reserved Disclaimer The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication. ISSN 1020‑3397 Cover designed by Diana Tawadros Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخا فى ةديدلجا تاردابلماو تاسايسلا لك لىإ ةهجوم ىهو .طسوتلما قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ يرغو ثاحبلأا جئاتنو زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا تايلكلاو ،ةيحصلا نهلما ءاضعأ .هجراخو ميلقلإا فى ةحصلاب ينمتهلما دارفلأاو ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما طسوتلما قشرل ةيحصلا ةلجلما Cover 17-8.indd 2 8/8/2011 10:11:18 AM Contents La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Vol. 17 No. 8 8 ددع شرع عباسلا دلجلما•  2011  • Letter from the Editor .............................................................................................................................................................................................................................................................................................................................. 637 Research articles Comparison of maternity care quality in teaching and non-teaching hospitals in Khorram Abad, Islamic Republic of Iran S.M. Moosavisadat, M. Lamyian, S. Parsai and E. Hajizadeh .....................................................................................................................................................................................................................................638 Outcome of vaginal birth after caesarean section in women with one previous section and spontaneous onset of labour K.A. Frass and A.H. Al Harazi .........................................................................................................................................................................................................................................................................................................646 Reasons for cancellation of elective operations at a major teaching referral hospital in Jordan M. Mesmar, N.J. Shatnawi, I. Faori and Y.S. Khader ..........................................................................................................................................................................................................................................................651 Determining and prioritizing competencies in the undergraduate internal medicine curriculum in Saudi Arabia H. Almoallim ................................................................................................................................................................................................................................................................................................................................................656 Evaluation of prophylactic antibiotic administration at the surgical ward of a major referral hospital, Islamic Republic of Iran G. Vessal, S. Namazi, M.A. Davarpanah and F. Foroughinia .......................................................................................................................................................................................................................................663 Peginterferon alfa-2b and ribavirin therapy in Kuwaiti patients with chronic hepatitis C virus infection S.A. Al-Enzi, W.A. Ismail, S.A. Alsurayei and A.E. Ismail ...............................................................................................................................................................................................................................................669 Cross-reaction of antigen preparations from adult and larval stages of the parasite Setaria equina with sera from infected humans with Wuchereria bancrofti M.M. Bahgat, A.H. Saad, G.A. El-Shahawi, A.M. Gad, R .M. Ramzy, A. Ruppel and M. Abdel-Latif ...........................................................................................................................................679 Bone mineral density in Egyptian adolescents and adults with short stature: results of a national survey S.A. Ibrahim, M.A. Samy, M.K. Matter and A.O.L. Saleh ............................................................................................................................................................................................................................................687 Physical activity profile of students in Mansoura University, Egypt A-H. El-Gilany, K. Badawi, G. El-Khawaga and N. Awadalla ....................................................................................................................................................................................................................................694 Reviews Medical education in Saudi Arabia: a review of recent developments and future challenges A. Telmesani, R .G. Zaini and H.O. Ghazi ..................................................................................................................................................................................................................................................................................703 Aetiological factors of constipation in the elderly, with emphasis on functional causes A.A. Amir ........................................................................................................................................................................................................................................................................................................................................................708 Report Using surveillance data for action: lessons learnt from the second generation HIV/AIDS surveillance project in Pakistan F. Emmanuel, A. Adrien, U. Athar, M. Imran, T. Reza and J. Blanchard ...............................................................................................................................................................................................................712 Short communication Road rage behaviour and experiences of rickshaw drivers in Rawalpindi, Pakistan M.A. Shaikh, I.A. Shaikh and Z. Siddiqui .................................................................................................................................................................................................................................................................................719 Case report Two cases of Vibrio cholerae non-O1/non-O139 septicaemia with favourable outcome in Lebanon R. Feghali and S.M. Adib ......................................................................................................................................................................................................................................................................................................................722 Book 17-8.indb 3 8/9/2011 2:04:35 PM M. Haytham Khayat MD, PhD, FRSPH, Editor-in-chief Ahmed Ezzat Abdou BSc, DPH, PhD, Executive Editor Editorial Board Mohammad Abdur Rab MBBS, DTM&H, MPH&TM, PhD Naeema Al Gasseer MSc, PhD Mohamed M. Ali BSc, MSc, PhD, DTMH Abdulla S. Assaedi MBBS, MPH Mounir Farag MD, DGS, DEmS, DPH Abdul Ghaffar MD, MPH, MHA, PhD Malekafzali Hossein MK, MPH, PhD Jaouad Mahjour MD, MPH Mamunur Rahman Malik MBBS, Dip (Health Economics), MSc, MPhil Kassem Sara MD International Advisory Panel Dr S. Aboulazm. Professor of Orthodontics. Egypt Dr Abdul Rahman Al-Awadi BSc, MD, MPH, Honorary FRCM, Ireland Dr Law, Korea, Honorary FRCS & P, Glasgow, FRCP, Edinbugh. Kuwait Dr Fariba Al-Darazi RN, MSc, PhD. Bahrain Dr M. Al-Nozha, MD, FRCP, FACC, FESC. Professor of Medicine and Consultant Cardiologist. Saudi Arabia Dr Ala’din Alwan MD, FRCP, FFPHM. Iraq Dr F. Azizi. Professor of Internal Medicine and Endocrinology. Islamic Republic of Iran Dr K. Bagchi BSc, MD, PhD. India Professor K. Dawson BA, MD, PhD, FRCP, FRACP, FRCPCH, DObst, RCOG. New Zealand Professor Kaussay Dellagi MD. Tunisia Dr R. Dybkaer MD. Denmark Dr M. Aziz El-Matri. Professor of Medicine. Tunisia Professor F. El-Sabban BSc, MS, PhD. United States of America Dr A.H. El-Shaarawi MSc (Stat), PhD (Stat). Canada Professor N. Fikri-Benbrahim PhD (Pub health) (SocSci). Morocco Professor A.T. Florence BSc (Pharm), PhD, DSc, FRSC, FRPharmS, FRSE. United Kingdom Professor Cheherezade M.K. Ghazi BS (Nursing), MS (Nursing), DPH, MPA. Egypt Professor M.A. Ghoneim MD, MD (Hons). Egypt Dr J.A. Hashmi DTM&H, FRCP. Pakistan Professor J. Jervell MD, PhD. Norway Professor G.J. Johnson MA, MD, BChir, FRCS (C), FRCOphth, DCEH. United Kingdom Dr M. Kassas. Emeritus Professor of Plant Ecology. Egypt Professor M.M. Legnain MBBS, MRCOG, FRCOG. Libyan Arab Jamahiriya Professor El-Sheikh Mahgoub DipBact, PhD, MD, FRCPath. Sudan Professor A.M.A. Mandil MSc (Paediatr), MPH, DrPH. Egypt Professor A.B. Miller MB, FRCP. Canada Professor S.S. Najjar MD. Lebanon Dr Abubaker A. Qirbi BSc, MD (Edin), FRCPC (Can), FRCP FRCPath (UK). Republic of Yemen Professor O.S.E. Rasslan MD, PhD. Egypt Professor W.A. Reinké MBA, PhD. United States of America Professor I.A. Sallam, MD, Dip High Surgery Cairo, Honorary FRCS, PhD (Glasgow), LRCP, MRCS, FRCS (London), ECFMG. Egypt Dr C.Th.S. Sibinga FRCP (Edin), FRCPath. The Netherlands Mr Taoufik Zeribi Eng BSc, MSc. Tunisia Editors Fiona Curlet, Eva Abdin, Alison Bichard, Guy Penet Graphics Suhaib Al Asbahi, Hany Mahrous, Diana Tawadros Administration Nadia Abu-Saleh, Yasmine El Sakhawy Book 17-8.indb 4 8/9/2011 2:04:37 PM طسوتلما قشرل ةيحصلا ةلجلما شرع عباسلا دلجلما نماثلا ددعلا 637 ررحلما نم ةلاسر Letter from the Editor The benefits of breastfeeding for most newborns and infants cannot be overstated. Not only does breast milk provide the ideal nutrients for a baby, it is readily available and affordable. Moreover, breastfeeding is beneficial to mothers; it helps them lose excess weight gained in pregnancy and reduces the risk of breast and ovarian cancer. Many women, however, experience initial dif- ficulties with breastfeeding and so need help and encouragement to start and persevere. Therefore, the World Breastfeeding Week is held annually from 1 to 7 August to promote breastfeeding and improve the well-being of babies around the world. For babies born in hospital, promotion of and help with breastfeeding is part of the maternity care that should be provided and is an indicator of the quality of care. In this issue, we include a paper on the quality of maternity care in a government teaching versus a government non-teaching hospital in Islamic Republic of Iran. The study found that the quality of the care received, as rated by moth- ers, was better in the non-teaching hospital, including instruction on breastfeeding. There are implications for medical education; doctors, nurses and other health professionals receive their clinical training in teaching hospitals and it is important that good prac- tices are evident in these settings and reinforce the theory learned. Two papers about medical education in Saudi Arabia are published in the current issue, one determining and prioritizing competencies in the internal medicine curriculum and the other reviewing medical education in the country. Beyond the usual health care responsibilities, health care workers may be faced with exceptional challenges if disasters (whether natu- ral or man-made) or emergency situations occur. They, together with other humanitarian workers, are called upon lend assistance to alleviate the suffering of people caught in the turmoil. Our Region has experienced and continues to experience numerous complex and large-scale emergencies, some very long-running and some only recently arisen. To deal with these has required the expertise and dedication of countless humanitarian workers over many years. On 19 August the World Health Organization and other international bodies celebrate World Humanitarian Day to highlight the crucial tasks performed by humanitarian workers and remember aid workers who have been killed or injured while performing their vital work. ،بسحف عيضرلل ةيلاثلما تايذغلما رّفوي لا يدثلا نبلف . َىص ُحت لاو ُّد َىع ُـح ت داكت لا يدثلا نم ةعاضرلا نم عّضرلاو نادلولا لىع دوعت يتلا ة َّملجا عفانلما نإ ءانثأ ُحهَىنْبستكا يذلا دئازلا نزولا نم صلختلا لىع نهدعاسي وهف ؛كلذك تاهملأل ةدئاف وذ يدثلا نم عاضرلإا نإ مث .فلكم يرغو ةلوهسب حاتم هنإ لب نجتيح كلذلو ،يدثلا نم عاضرلإا ءدب في بعاصم نفداصي تاهملأا نم ًايرثك نأ لىع .ضيبلما ناطسرو يدثلا ناطسرب ةباصلإا راطتخا صلقيو ،لملحا سطسغأ/بآ رهش نم لولأا عوبسلأا في يلماعلا ةعاضرلا عوبسأب ًايونس ىفت ُحيح ،ببسلا اذلهو .هيلع ةرباثلماو عاضرلإا في عوشرلل عيجشتلاو ةدعاسلما لىإ .لماعلا ءاجرأ عيجم في عّضرلا ةافاعم ىوتسمب ءاقترلااو ،يدثلا نم ةعاضرلا زيزعتل هذه ةدوج لىع ًاشرؤمو ،اهميدقت متحتي يتلا ةموملأا ةياعر نم ًاءزج تايفشتسلما في نيدولولما لافطلأل اهيلع ةدعاسلماو يدثلا نم ةعاضرلا زيزعت ُّد َىع ُحيو ةيروهجم في يميلعت يرغ يموكح ىفشتسمب ًان َىراقم يميلعت يموكح ىفشتسم في ةموملأا ةياعر ةدوج لوح ةيملع ةقرو ،ددعلا اذه في انْج َىردأ دقو .ةياعرلا ةصالخا تاهيجوتلا كلذ في ماب ،تاهملأا يأر بسحب يميلعتلا يرغ ىفشتسلما في ةمدقلما ةياعرلا ةدوج قّوفت نع ةساردلا تفشك دقو .ةيملاسلإا ناريإ ،ةيميلعتلا تايفشتسلما في )يكينيلكلإا( يريسرلا بيردتلل ينيحصلا ينلماعلاو ينضرملماو ءابطلأا يقلتو ؛يبطلا ميلعتلل رود كانهو .يدثلا نم ةعاضرلاب ةكلملما في يـبطلا ميلعتلا نع ينتيملع ينتقرو ددعلا اذه في شرننو .ةسوردلما تايرظنلا ززعتل عقاولما كلت في ةحضاو نوكت نأ نم ةديلجا تاسرماملل َّد ُحبلا ذإ .ةكلملما في يـبطلا ميلعتلا مّيقت ةيناثلاو ،ينطابلا بطلل يميلعتلا جهنلما في اتهايولوأو تاءافكلا ددت ةدحاو ،ةيدوعسلا ةيبرعلا تلااح ءانثأ فيو ،ناسنلإا عنص نم يه يتلا كلت وأ ةيعيبطلا ثراوكلا ءانثأ في ةيئانثتسا تايدت نوهجاوي ام ًايرثك ةيحصلا ةياعرلا في ينلماعلا نإف ،دعبو في ينلماعلا رئاس بناجب ،ةيحصلا ةياعرلا في ينلماعلا ءلاؤه نم ُحبَىلْط ُحي ام ًايرثكو .ةيحصلا ةياعرلل ةداتعلما تايلوؤسلما ى َّدعتت دق تايّدت يهو ،ئراوطلا ةغلاب فقاوم هجاوي لازامو انميلقإ هجاو دقو .تابارطضلاا هذه نثا َىرَىب في اوعقو نيذلا كئلوأ ةاناعم نم فيفختلل نوعلا دي ميدقت ،ةيناسنلإا تادعاسلما لئاه ددع نم ًاصلاخإو ًةبرخ فقاولما هذه عم لماعتلا بلطت دقو .روهظلا ُحثيدح اهضعبو ،ديعب دمأ ذنم رمتسم اهضعب ،عساو قاطن لىع ئراوطو ،ديقعتلا .ةديدع يننسل ةيناسنلإا تادعاسلما في ينلماعلا نم ماهلما كلت لىع ءوضلا زيكترل ةيناسنلإا تادعاسملل يلماعلا مويلاب ةيلودلا تائيلها رئاسو ةيلماعلا ةحصلا ةمظنم لفتت سطسغأ/بآ نم شرع عساتلا فيو مهمايق ءانثأ اوبيصأ وأ مهفتح اوقل نيذلا ةيناسنلإا تادعاسلما في ينلماعلا كئلوأ ىركذ ءايحلإو ،ةيناسنلإا تادعاسلما في نولماعلا ابه علطضي يتلا ما َىسِلجا .ةيويلحا متهابجاوب Book 17-8.indb 637 8/9/2011 2:04:37 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 638 Comparison of maternity care quality in teaching and non-teaching hospitals in Khorram Abad, Islamic Republic of Iran S.M. Moosavisadat,1 M. Lamyian,1 S. Parsai 2 and E. Hajizadeh 3 ABSTRACT The objective of this study was to compare the quality of maternity care in 2 types of government-run hospital in the town of Khorram Abad, Islamic Republic of Iran in 2009: a university-linked teaching and a social security organization non-teaching hospital. A sample of 264 women hospitalized in the delivery and postpartum wards was selected. Data collection was done using interviews with mothers and observation checklists based on Iranian government criteria. The quality of maternity care in the non-teaching hospital was higher than the teaching hospital in terms of facilities, processes of maternal and newborn care and outcomes (mother’s satisfaction). In the teaching hospital, the quality of the physical space, the educational level and training of health care personnel and monitoring and evaluation of care quality needed improvement. In both hospitals, meeting women’s expectations about the degree of privacy could lead to an increase in the quality of maternity services. 1Department of Midwifery; 3Department of Biostatistics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Islamic Republic of Iran (Correspondence to M. Lamyian: Lamyianm@yahoo.com). 2Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran. Received: 16/11/09; accepted: 10/01/10 ةيملاسلإا ناريإ ةيروهجم في دابأ م َّرُخ في يميلعت يرغ ىفشتسمو يميلعت ىفشتسم ينب ةموملأا ةياعر ةدوج ةنراقم هداز يجاح ميهاربإ ،ياسراب نسوس ،نايعيلم رون يم ،تاداسلا يوسوم ةموصعم ةديس ناريإ ةيروهجم في دابأ م َّر ُحخ ةدلب في ةموكلحا اهمريدت تايفشتسلما نم ينعون في ةموملأا ةياعر ةدوج ةنراقم ةساردلا هذه نم ضرغلا ناك :ةصلالخا نم ةنّيع تيرتخا دقو .يعماتجلاا نماضلا ةمظنلم يميلعت يرغ ىفشتسم نياثلاو ،يعمالجا ميلعتلاب طبترم ىفشتسم :اهمدحأ 2009 ماع في ةيملاسلإا ةظحلامو تاهملأا عم تلاباقم ءارجإ قيرط نع تايطعلما عجم َّمت دقو .ةدلاولا دعب ام حانجو ةدلاولا حانج في ينيفشتسلما في نلخدُحأ ةأرما 264 نم يميلعتلا ىفشتسلما في اهنم لىعأ يميلعتلا يرغ ىفشتسلما في ةموملأا ةياعر ةدوج تناكو .ةيناريلإا ةيموكلحا يرياعلما لىإ ًادانتسا ةيدقفتلا مئاوقلا نم ُّلك ناك دقف ،يميلعتلا ىفشتسلما في امأ .)تاهملأا ءاضرب اهنع ًاّبرعم( اهجئاتن ثيح نمو ،نادلِولاو تاهملأا ةياعر تايرمجو ،قفارلما ثيح ينيفشتسلما لاك فيو .ينست لىإ ةجاحب ةياعرلا مييقتو دصرو ،ةيحصلا ةياعرلا في ينلماعلل بيردتلاو ميلعتلا ىوتسم ةدوجو ،ةحاتلما ةحاسلما ةدوج .ةموملأا تامدخ ةدوج ةدايز ةيصوصلخا ةجرد ثيح نم ءاسنلا تاعقوت ةيبلتل نكمي Comparaison de la qualité des soins maternels dans un hôpital universitaire et un hôpital non universitaire de la ville de Khorramābād (République islamique d’Iran) RÉSUMÉ L’objectif de la présente étude était de comparer la qualité des soins maternels dans deux types d’établissements de soins gérés par le secteur public dans la ville de Khorramābād (République islamique d’Iran) en 2009 : un centre hospitalier universitaire et un hôpital non universitaire affilié à la sécurité sociale. Un échantillon de 264 femmes hospitalisées dans les salles d’accouchement puis dans les services de soins postnatals a été sélectionné. Les données ont été collectées au moyen d’entretiens avec les mères et de grilles d’observation fondées sur les critères du gouvernement iranien. Comparée aux soins maternels prodigués au sein de l’hôpital universitaire, la qualité des soins était supérieure dans l’hôpital non universitaire en termes de locaux, de protocoles de soins à la mère et au nouveau-né et de résultats (satisfaction de la mère). Au sein de l’hôpital universitaire, les caractéristiques des salles, le niveau d’études et de formation du personnel soignant, le suivi et l’évaluation de la qualité des soins devaient être améliorés. Dans les deux hôpitaux, la réalisation des attentes des mères concernant le degré d’intimité pourrait entraîner une augmentation de la qualité des services de soins maternels. Book 17-8.indb 638 8/9/2011 2:04:37 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 639 Introduction Worldwide  an  estimated  515 000  women die of complications of preg- nancy and childbirth every year, a rate of over 1400 maternal deaths each day [1].  At least 7 million women who survive childbirth suffer serious health prob- lems, and a  further 50 million women  suffer adverse health consequences after childbirth. The overwhelming major- ity of these deaths and complications occur in developing countries [1]. Ma- ternal mortality is the main factor that substantially lowers the life expectancy of women [2] and  it  is  a basic human  right that pregnancy be made safe for all women [3]. Improving the quality at maternity care services is an effective strategy to reduce  maternal  mortality  [4]. The  World Health Organization (WHO) emphasizes the importance of evaluat- ing the structure, process and outcome of health services to improve the quality of care [5]. Structure refers to the overall  ability of a midwifery service to provide care and includes such elements as office space, equipment, staff and documenta- tion. Process refers to the way in which care is provided. Outcome indicators examine the results of care in terms of patient satisfaction, clinical outcomes, appropriate use of technology and re- sources and access to care [6,7]. Quality  improvement involves using the data to modify the process of providing care in order to improve the outcomes. Many studies in developed and de- veloping countries have assessed the quality of maternity care  [8–15]. De- spite the utmost importance of mater- nity care in reducing maternal mortality, there have been few published studies about the quality of these services in the Islamic Republic of Iran. The qual- ity of care in different types of hospital is a matter of discussion. The present study in the town of Khorram Abad, the capital city of Lorestan province, there- fore aimed to compare the structure, process and outcome of maternity care in 2  types of government-run hospital:  a teaching (university) hospital and a non-teaching (social security organiza- tion) hospital. The quality standards used were based on those of the Iranian Ministry of Health and Medical Educa- tion (MOHME). Methods Sample This was a descriptive-analytical study using multistage sampling and was car- ried out over a 3-month period in 2009  (March to May). In the first stage, hos- pitals in Khorram Abad were selected from 2 categories of  government-run  hospital: teaching hospitals (under the supervision of Lorestan University of Medical Sciences) and non-teaching hospitals (under the supervision of the social security organization of Lorestan). In the second stage, the only teaching hospital with a maternity ward (Asalian hospital) and the only non-teaching hospital with a maternity ward (Khor- ram Abad social security hospital) were selected. In each hospital 2  samples of 132  women were randomly selected: 66 from the delivery ward (where women stay from the beginning of regular uterine contractions until complete dilatation of the cervix) and 66 from the postpartum ward (where mothers are transferred an hour after childbirth until discharge). The women were se- lected randomly from normal women (women with no known medical or surgical history) who had been hospital- ized for at least 6 hours in the delivery ward and from normal women who had stayed at least 6 hours after childbirth in the postpartum ward. Data collection The tool used to assess the quality of processes (e.g. clinical examinations, fetal heart monitoring, training given to mothers) and outcome (mother’s satisfaction) was part of a package prepared by  the MOHME in 2003  to  assess safe motherhood programmes and future needs in the Islamic Republic of Iran [16]. The original questionnaire  was  separated  into  2  questionnaires,  1 for the delivery ward and 1 for the postpartum ward. The questionnaire was used to interview the women about the care they received and their satisfac- tion with the care. The questionnaire had been previously tested in a pilot study and subsequently modified in 2004 when it was retested and finalized  after assessment by an internal review board, an external review board, pilot testing and assessment by an expert panel. According to the author of the standards, Cronbach alpha was 0.81 for  the questions about the care process and 0.55  for  the  satisfaction questions  (Cronbach alpha > 0.45 was defined as  acceptable). To assess the structure of the wards (physical  space and equipment), 2 ob- servation checklists, 1 for the delivery ward  [15]  and  1  for  the  postpartum  ward [13], were completed by  the  re- searcher. Data about personnel, such as education level, were obtained from the Information and Statistics section of the maternity ward. Ethical issues This study was approved by the uni- versity research ethics committee. The women were informed that all data col- lected would remain confidential and anonymous. Interviews were conducted only after explaining the objectives of study and obtaining the mothers’ consent. The interviewer had rigorous training about the questionnaire, inter- viewing skills and research ethics. Data analysis For each criterion of the quality of processes and satisfaction with care, the number of positive answers was summed (“don’t know” answers were considered as missing data) and a percentage was calculated for the sample of women. For the quality of structure, each item Book 17-8.indb 639 8/9/2011 2:04:37 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 640 was  scored 1 (present) or 0 (absent),  then the percentage was calculated for each field separately (physical space and equipment). The percentages were averaged to give the overall percentage in each field (structure, process and out- come). Percentage scores, both overall and on individual items, were compared against the MOHME standards which defined scores < 60% as unfavourable  quality, 60%–80% as acceptable quality  and > 80% as excellent quality [17]. The data were analysed using descriptive and analytical statistics including Kolmogorov–Smirnov,  in- dependent  t-test, Mann–Whitney, chi- squared and Fisher exact test in SPSS, version 17 software. Results Delivery ward Study samples: general characteristics For the delivery ward samples there were no significant differences between the women in the teaching and non- teaching hospitals in terms of age [mean  age 25.8  (SD 7.0)  and 26.8  (SD 5.1)  years  respectively] (t = 0.94, P = 0.34),  occupation (98.5% and 89.4% respec- tively were housewives) (χ2  =  4.50,  Fisher exact P  =  0.09)  or  number  of  pregnancies (53.0% and 54.5% respec- tively were primigravidas) (χ2 = 3.78, P = 0.15). However, women in the teaching  hospital had a significantly lower level of education (15.2% and 3.0% respectively  were illiterate, 25.8% and 15.1% had 1–5  years of schooling, 30.3% and 7.6% had  6–8 years of  schooling, 9.1% and 9.1%  had 9–11 years of schooling, 16.7% and  47.0% had diploma and 3.0% and 18.2%  had academic education) (χ2 = 32.81, P < 0.001). Structure of delivery care The quality of physical space in the delivery ward of the teaching hospital was  found  to be unfavourable (41.6%  compatibility with the standard) while in the non-teaching hospital it was ex- cellent (91.6% compatibility) and  this  difference was significant (χ2 = 56.19, P  <  0.001). The quality  of  necessary  ward equipment in both types of hos- pital was excellent (100.0% and 97.2%  compatibility respectively) (χ2 = 2.83, P = 0.09). The overall structure quality of  the delivery ward was acceptable in the teaching hospital (70.8% compatibility)  and excellent in the non-teaching hos- pital (94.4% compatibility), a significant  difference (χ2 = 19.37, P < 0.001). The ratio of the number of person- nel in the maternity ward to the average number of vaginal deliveries in a month was 1:11 and 1:15 in the teaching and non-teaching hospitals respectively. The educational level of the care personnel was significantly lower in teaching than non-teaching hospitals;  29.1%  in  the  teaching hospital had only an associate level of  education  and 70.8% a bach- elor’s degree while in the non-teaching hospital 93.3% had a bachelor’s degree  and 6.6% a master’s degree (χ2 = 6.59, Fisher exact P = 0.01). Process of delivery care In both hospitals the quality of delivery care was unfavourable for the items con- cerning measuring body temperature and observance of privacy/covering for women in labour, but was excellent for fetal heart sound monitoring and vaginal examination (Table 1). Meas- urement of blood pressure and body temperature was significantly more often done in the non-teaching than teaching hospitals (P < 0.001). Overall,  the quality of processes of delivery care in the teaching hospital was unfavorable (50.5% compatibility with the standard)  but was acceptable in the non-teaching hospital (70.6% compatibility), a signifi- cant difference between the hospitals (P < 0.001) (Table 1). Outcome of delivery care (maternal satisfac- tion) Women’s satisfaction with the items about observance of privacy/covering during examinations (P  =  0.04)  and  hygiene of the service provider environ- ment (P = 0.02) were significantly better  in non-teaching hospitals. In general, the level of women’s satisfaction with delivery care in the teaching and non- teaching hospitals was acceptable in Table 1 Standards of delivery care processes in teaching and non-teaching hospitals (women’s reports) Process item Teaching hospital (n = 66) Non-teaching hospital (n = 66) χ2-value P-value No. of positive answers % No. of positive answers % Monitoring of fetal heart sounds 66 100.0 66 100.0 – – Measuring blood pressure 30 48.4 64 97.0 40.72 < 0.001 Measuring body temperature 2 3.0 37 56.1 44.58 < 0.001 Vaginal examination 66 100.0 66 100.0 – – Observance of privacy & covering during examination 1 1.5 0 0.0 1.00a 1.00 Overall standard – 50.5 – 70.6 8.45 < 0.001 aFisher exact test. Book 17-8.indb 640 8/9/2011 2:04:38 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 641 both hospitals (61.0% and 73.8% com- patibility with the standard respectively) (P = 0.051) (Table 2) Postpartum ward Study sample general characteristics The mean age of women in the post- partum ward was similar in the teaching and non-teaching hospitals  [25.5 (SD  6.7)  and 27.0  (SD 6.0)  years  respec- tively] (t = 1.32, P = 0.18). The propor- tions who were housewives (98.5% and  92.4% respectively) and primigravidas  (48.5% and 42.4%  respectively) were  not significantly different (χ2  =  4.07,  Fisher exact P = 0.11 and χ2 = 1.49, P =  0.47  respectively). Women  in  the  teaching hospital were significantly less well educated than in the non-teaching hospital  (21.2%  and 0%  respectively  were illiterate, 31.8% and 22.7% had 1–5  years of schooling, 28.8% and 19.7% had  6–8 years of  schooling, 4.5% and 7.6%  had 9–11 years of schooling, 12.1% and  39.4% had diploma and 1.5% and 10.6%  had academic education) (χ2 = 33.05,  Fisher exact P < 0.001). The birth weight of most of the new- borns were in the range of 2500–4000  g (93.9%  in  the  teaching hospital  and  92.4% in the non-teaching hospital) (χ2 = 2.98, Fisher exact P = 0.52). Structure of postpartum care The quality of physical space in the post- partum ward of the teaching hospital was unfavourable (44.4% compatibility with  the standard) while in the non-teaching hospital  it  was  acceptable  (66.6%  compatibility), a difference which was significant (χ2 = 9.97, P < 0.001). The  quality of necessary equipment in the ward was excellent in both hospitals (85.1%  and  92.5%  compatibility  in  teaching and non-teaching hospitals respectively) (χ2 = 2.75, P = 0.10). Al- though the overall quality of structure in the postpartum ward was acceptable in both hospitals, it was significantly better in  the  non-teaching  hospital  (64.7%  and 79.5% compatibility  respectively) (χ2 = 5.45, P = 0.02). In both hospitals the care personnel of the delivery and postpartum wards (vaginal deliveries) were the same. Therefore, we did not analyse the edu- cational status of care personnel in the postpartum ward. Process of maternal postpartum care Table 3 shows the quality of proc- esses of postpartum care. The scores for items about instructing mothers about postnatal danger signs and about fam- ily planning were unfavourable in both hospitals. However, for all other items the quality of maternal postpartum care was excellent in the non-teaching hospital and either unfavourable or ac- ceptable in the teaching hospital. These differences were significant for all the in- dicators: examination of the uterus and uterus massage (P < 0.001),  checking  haemorrhage (P  < 0.001), measuring  blood pressure (P < 0.001) and body  temperature (P < 0.001), questioning  about urination (P < 0.001),  teaching  hygiene issues (P < 0.001) and teaching  about danger signs (P  =  0.04). The  overall level of maternal postpartum care was significantly better in the non-teaching hospitals  (44.8% versus  84.5% compatibility with the standard) (P < 0.001) (Table 3). Process of newborn care Table 4 shows that the items concern- ing teaching mothers about general care of the newborn and danger signs in newborns and in using vitamin supplements for the newborn scored unfavourably in both hospitals. The items for instructing mothers about breastfeeding and of the umbilicus and arranging the next appointment for the newborn check-up were all rated excellent in the non-teaching hospitals, and were significantly better compared with the teaching hospital (all items P  <  0.001).  Teaching  about  general  aspects of newborn care was done sig- nificantly better in the teaching hospital (P = 0.01). Overall, the quality of proc- ess of newborn care was unfavourable in both the teaching and non-teaching hospitals  (39.9% and 56.3% compat- ibility with the standard respectively) (P = 0.02). Outcome of postpartum care (maternal satisfaction) Mother’s satisfaction with the man- ners of service providers (P  < 0.001),  privacy/covering during examination (P < 0.01) and the hygienic conditions  of the service provider environment (P < 0.001) was significantly higher  in  the non-teaching hospital (Table 5). Table 2 Satisfaction with care in the delivery ward in teaching and non-teaching hospitals (women’s reports) Satisfaction item Teaching hospital (n = 66) Non-teaching hospital (n = 66) χ2-value P-value No. satisfied % No. satisfied % Manner of service providers 45 68.2 49 74.2 0.59 0.44 Waiting time for receiving services 47 71.2 56 84.8 3.58 0.058 Observance of privacy & covering during examination 19 28.8 30 45.5 3.92 0.04 Hygienic conditions of the ward 50 75.8 59 89.4 5.28 0.02 Overall standard – 61.0 – 73.8 3.72 0.051 Book 17-8.indb 641 8/9/2011 2:04:38 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 642 The overall satisfaction with postpar- tum care was rated acceptable in the teaching hospital (65.5% compatibility  with the standard) and excellent in the non-teaching hospital (84.6% compat- ibility with the standard) (P < 0.001). Time of initiation of breastfeeding There was no significant different between the hospitals in the time of initiation of breastfeeding; 59.1% and  57.6% of  the women  in  the  teaching  and non-teaching hospitals respec- tively began breastfeeding within half an hour  after  giving birth,  22.7% and  25.8% between 0.5–1 hours and 12.1%  and 15.2% > 1 hour  after giving birth (6.1%  and  1.5%  of  the  women  did  not lactate in the postpartum ward) (P = 0.59) (Table 6). Discussion The demographic characteristics of the samples of women were similar in the  2 hospitals,  except  for  education  level which was significantly lower in the teaching hospital. This can be explained by the different areas of residence and types of insurance of the people going to each hospital. Most people going to the teaching hospital were residents of villages and had rural insurance which has been  in operation  since 2005 and  allows patients to be referred within the health services. Most of those going to the non-teaching hospital were urban residents with social security organiza- tion insurance. Table 3 Standard of postpartum care processes in teaching and non-teaching hospitals (women’s reports) Process item Teaching hospital (n = 66) Non-teaching hospital (n = 66) χ2-value P-value No. of positive answers % No. of positive answers % Abdominal examination of uterus & uterus massage if needed 51 77.3 66 100.0 16.92 < 0.001 Checking presence & amount of haemorrhage 48 72.7 65 98.5 17.76 < 0.001 Measuring blood pressure 31 47.0 66 100.0 47.62 < 0.001 Measuring body temperature 0 0.0 64 97.0 124.23 < 0.001 Questioning about urination 27 40.9 66 100.0 55.35 < 0.001 Training in hazard signs after delivery 12 18.2 22 33.8 4.18 0.04 Teaching hygiene issues 46 69.7 64 97.0 17.67 < 0.001 Training in family planning 22 33.3 33 50.0 3.77 0.052 Overall standard – 44.8 – 84.5 34.48 < 0.001 Table 4 Postpartum training of mothers about care of the newborn in teaching and non-teaching hospitals (women’s reports) Process item Teaching hospial (n = 66) Non-teaching hospital (n = 66) χ2-value P-value No. of positive answers % No. of positive answers % Training mother about newborn danger signs 7 10.6 13 19.7 2.12 0.14 Teaching mother about breastfeeding methods 48 73.8 66 100.0 19.83 < 0.001 Instructing mother about vitamin supplements for the newborn 20 30.7 19 28.8 0.06 0.80 Instructing mother about how to take care of the umbilicus 15 22.7 58 87.9 56.66 < 0.001 Teaching mother about general newborn care 10 15.2 2 3.0 5.86 0.01 Arranging next appointment for newborn check-up 57 86.4 65 98.5 6.92 < 0.001 Overall standard – 39.9 – 56.3 5.38 0.02 Book 17-8.indb 642 8/9/2011 2:04:38 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 643 Our findings about the structure of care in the delivery and postpartum wards showed that although the avail- ability of necessary equipment was judged to be excellent against the MO- HME standard, numerous deficiencies were observed in the teaching hospital concerning physical space (e.g. space, temperature, ventilation, isolated room for infectious delivery). Another study in the Islamic Republic of Iran also showed that shortages in the standards of physical space were greater than the limitations of necessary equipment in the delivery wards of hospitals [15]. Re- sults of a study in India revealed that dif- ferences between women’s experience of the hospital environment (the bed, sheets, food, toilets and so on) varied significantly between the public and the private sectors. Women’s experience of the human and physical resources was uniformly better at private than public  facilities [11]. The results of  the  public and the private sectors in the above study were similar to those of the teaching and non-teaching hospitals in our study. We found that 50.5% and 70.6% of  the process of delivery care items were compatible with the standard in the teaching and non-teaching hospitals respectively. In the study in Kordestan, Islamic Republic of Iran midwifery care was 71.4% compatible with the desired  standard in the first stage of labour [15]  and this agrees with the findings of our study in the non-teaching hospital. A study in Uganda showed that many midwives provided poor quality delivery care [8] which agrees with our findings  for delivery care in the teaching hospi- tal. In our study, the following factors which affect the quality of the process of delivery care needed to be improved: observance of privacy and covering during examination and measuring body temperature in both hospitals and measuring blood pressure in the teach- ing hospital. Our findings were different from a study in Kordestan in which the unsatisfactory domains were emotional support for the woman and control of uterine contractions [15]. Hulton et al.’s  study in India found that 77% of women  had their blood pressure taken and 70%  had the fetal heart rate listened to at private hospitals  compared with 61%  and 55% at public hospitals [11]. In our  study the items for control of fetal heart sounds (100%  in both hospitals)  and  measuring blood pressure (97.0% in the  non-teaching hospital) were performed better. While these studies were similar to our study in some respects, neither used MOHME standards which may explain the differences. Our findings suggest that improve- ments are needed in the quality of care process in the postpartum ward con- cerning training mothers about hazard signs after delivery, family planning, general newborn care, newborn dan- ger signs and vitamin supplements for the newborn (in both hospitals) and concerning measuring blood pressure and body temperature of the mother, questioning about urination and in- structing mothers in how to take care of the umbilicus (in the teaching hospital). Simbar et al. in Kordestan demonstrated that postpartum care was poor for 82%  of women and the quality of care was unfavourable for control of vital signs, Table 5 Satisfaction with care in the postpartum ward teaching and non-teaching hospitals (women’s reports) Satisfaction item Teaching hospital (n = 66) Non-teaching hospital (n = 66) χ2-value P-value No. satisfied % No. satisfied % Manner of service providers 50 75.8 63 95.5 10.39 < 0.001 Observance of privacy & covering during examination 29 43.9 42 64.6 5.64 0.01 Hygienic conditions of the ward 50 76.9 62 93.9 7.64 < 0.001 Overall standard 65.5 84.6 9.74 < 0.001 Table 6 Interval between delivery and first breastfeeding of the newborn in the teaching and non-teaching hospitals (women’s reports) Time of initiation of breastfeeding (hours) Teaching hospital (n = 66) Non-teaching hospital (n = 66) Total (n = 130) No. % No. % No. % < 0.5 39 59.1 38 57.6 77 58.3 0.5–1 15 22.7 17 25.8 32 24.2 > 1 8 12.1 10 15.2 18 13.6 Did not lactate 4 6.1 1 1.5 5 3.8 χ 2 = 2.04, P = 0.59 Fisher exact test. Book 17-8.indb 643 8/9/2011 2:04:38 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 644 References Advancing safe motherhood through human rights. 1. Geneva, World Health Organization, 2001: Chapter 1 (WHO/RHR/01.5; http://whqlibdoc.who.int/hq/2001/WHO_RHR_01.5.pdf, accessed 3 July 2011). Garg BS, Chhabra S, Zothanzami SM. 2. Safe motherhood: social, economic, and medical determinants of maternal mortality. Women and health learning package. Karachi, Pakistan, The Network: Towards Unity for Health, 2006. training about breastfeeding, advising caution when leaving bed, psycho- logical care, urinary system assessment, training about perineum care, uterus as- sessment, digestive system assessment, training before discharge, training about care of the infant, perineum assessment and breast  examination  [13]. Our  re- sults agree with the above study in some areas. In another study in Zahedan, Is- lamic Republic of Iran, postpartum care quality  in hospitals was weak  in 98.6%  of cases [14]. Our findings showed the mother’s satisfaction with delivery care was 61.0%  and  73.8%  in  the  teaching  and  non- teaching hospitals respectively. In the study by Simbar et al. the mean satisfac- tion with delivery care was 81.7% [15],  which is higher than our results. In our study, satisfaction with postpartum care was 65.5% and 84.6%  in  the  teaching  and non-teaching hospitals respectively. The most unsatisfactory aspect of ma- ternity care was the item “observance of privacy and covering during examina- tion” in both hospitals. The study by Simbar et al. showed that mothers were satisfied with the care provided in all do- mains in the postpartum ward, and that the main source of dissatisfaction was caused by personnel behaviour towards their  visitors  in  the  hospital  [13].  In  Stahl’s study in Germany, overall satis- faction with maternity care in hospitals was high; clinical expertise, emotional support and successful communication were the key indicators for quality in postnatal maternity care as viewed by women [18]. In a study in Karachi, Pakistan patients’ level of satisfaction increased from 34.4% to 82.0% over a period of 1  year when sharing of results and capac- ity-building workshops were arranged to sensitize the hospital staff to work towards improving patients’ satisfaction [19]. After identifying the main reasons  for dissatisfaction in our study, we can resolve the problem by putting screens around beds and sensitizing personnel to observation of privacy and covering of the patients. Having a private and covered environment for examinations is a right for all women. WHO has  recommended 10 steps  to successful breast-feeding in which step 4 is “help mothers initiate breast- feeding within a half-hour of birth” [20].  Our findings showed nearly 60% of the  women in the postpartum ward of both hospitals began breastfeeding within half an hour after giving birth. Every woman has the right to health care during pregnancy and childbirth [21]. Our findings  about  the number  of antenatal routine visits indicated that the majority of all women in the delivery and postpartum wards of both teaching and  non-teaching  hospitals  (81.3%)  had suitable number of antenatal rou- tine visits based on the standard of the Iranian MOHME (at least 7 antenatal visits) [16]. A positive aspect of our study is that it measured the quality of services in different aspects—structure, process and outcome. Nevertheless the study has some limitations. One is concerned with MOHME’s quality evaluation tool for the care process, which is based on minimum standards and it would be better in future studies to evaluate care against excellent standards. Another limitation is concerned with the method of collecting quality of care process data by interviews with mothers, since it is possible that women’s responses to the interviewer were biased. Thus obser- vations of care provision rather than interviews with clients are suggested for future studies. Conclusion Our results found that the quality of provision of maternity care was higher in the non-teaching hospital com- pared with the teaching hospital for all the fields of structure, process and outcome. Several reasons can be sug- gested for this, including the poorer physical space, lower educational level of care personnel and lower educational level of clients in the teaching hospi- tal. Another factor which needs to be investigated is whether assignment of duties to students may be detrimental to good performance in the teaching hospital. In the non-teaching hospital, more attention should be paid to pro- viding training to the mother. Screening beds and sensitizing staff to the need to observe the privacy of women could im- prove clients’ level of satisfaction in both types of hospital. Finally, to improve the quality of maternity services, we recom- mend gaining a true understanding of the clients’ expectations and ensuring that all required resources for realization of standards are available, that staff have adequate education and that processes of monitoring and evaluation are in place. Acknowledgements We would like to acknowledge the sup- port of Tarbiat Modares University. We are also grateful for the help and continu- ous assistance of the research deputy of the Medical Faculty, the Social Security Organization of Lorestan and Lorestan University of Medical Sciences. Book 17-8.indb 644 8/9/2011 2:04:39 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 645 Kwast BE. Quality of care in reproductive health programmes: 3. monitoring and evaluation of quality improvement. Midwifery, 1998, 14:199–206. Macassa G. 4. Maternal mortality and quality of maternity care (implications for Pakistan) [Masters of Health Promotion thesis]. Stockholm, Karolinska Institute, 2005. Mother–baby package: Implementing safe motherhood in coun-5. tries. Geneva, World Health Organization, 1996. Ament L. Quality management activities in the obstetric triage 6. setting. Journal of Nurse-Midwifery, 1999, 44:592–599. Quality management in midwifery care. Position statement7. . American College of Nurse-Midwives [online factsheet] (www. midwife.org/siteFiles/position/Quality_Management_05.pdf, accessed 15 June 2011). Kaye D. Quality of midwifery care in Soroti District, Uganda. 8. East African Medical Journal, 2000, 77:558–61. Mngadi PT et al. Quality of maternity care for adolescent moth-9. ers in Mbabane, Swaziland. International Nursing Review, 2002, 49:38–46. Melkamu Y et al. Assessment of quality of post abortion care 10. in government hospitals in Addis Ababa, Ethiopia. Ethiopian Medical Journal, 2005, 43:137–49. Hulton LA et al. Applying a framework for assessing the qual-11. ity of maternal health services in urban India. Social Science & Medicine, 2007, 64:2083–2095. Fenwick J et al. Western Australian women’s perceptions of the 12. style and quality of midwifery postnatal care in hospital and at home. Women and Birth, 2009, 23:10–21. Simbar M et al. Assessment of quality of care in postpartum 13. wards of Shaheed Beheshti Medical Science university hospi- tals, 2004. Italian Journal of Public Health, 2005, 2:148. Khazaeian S. 14. Assessment of quality of postpartum care in Za- hedan hospitals [Master of Science thesis]. Islamic Republic of Iran, Shaheed Beheshti University of Medical Sciences, 2007. Simbar M et al. Assessment of quality of midwifery care in deliv-15. ery and delivery wards of selected Kordestan Medical Science University hospitals. International Journal of Health Care Quality Assurance, 2009, 22(3):266–277. Heydarzadeh A, Azemikhah A. [16. New system of evaluation of reproductive health programs]. Tehran, Ministry of Health and Medical Education of Iran, Deputy of Health, Family and Popu- lation Office, 2003 [in Farsi]. Azemi-Khah A, Heydarzadeh A. [17. New system of monitoring of reproductive health services]. Tehran, Ministry of Health and Medical Education of Iran, Deputy of Health, Family and Popu- lation Office, 2003 [in Farsi]. Stahl K. Wie zufrieden sind Frauen mit ihrer Geburtsklinik [How 18. satisfied are women with maternity care in hospital]? Zeitschrift fur Geburtshilfe und Neonatologie, 2009, 213:7–11. Shaikh BT et al. Using SERVQUAL for assessing and improving 19. patient satisfaction at a rural health facility in Pakistan. Eastern Mediterranean Health Journal, 2008, 14: 447–456. Ten steps to successful breastfeeding20. . United Nations Children’s Fund [online factsheet]. (http://www.unicef.org/newsline/ tenstps.htm, accesses 15 June 2011). Facts for life: safe motherhood21. . United Nations Children’s Fund [onoine factsheet] (http://www.factsforlifeglobal.org/02/7. html, accessed 15 June 2011). Book 17-8.indb 645 8/9/2011 2:04:39 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 646 Outcome of vaginal birth after caesarean section in women with one previous section and spontaneous onset of labour K.A. Frass 1 and A.H. Al Harazi 1 ABSTRACT The data about the safety of vaginal birth after caesarean section are conflicting. This study in a referral hospital in Sana’a, Yemen investigated the outcome of vaginal birth after caesarean section in 357 women who had one prior caesarean section and were admitted to hospital at term with spontaneous onset of labour. A control group (n = 155) was matched from women without previous caesarean section. The success rate of vaginal birth after caesarean section was 311/357 (87.1%). The mean duration of the first and second stages of labour were not significantly different in the study group (146.2 and 30.7 min respectively) compared with the control group (146.7 and 29.8 min). There were infrequent complications; only 1 woman (0.3%) had ruptured uterus and 3 women (1.0%) suffered uterine dehiscence. There was 1 stillbirth after the uterine rupture but no maternal deaths. 1Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Sana’a, Sana’a, Yemen (Correspondence to K.A. Frass: kaimafrass@ hotmail.com). Received: 30/09/09; accepted: 05/01/10 ًايئاقلت نهدنع ضاخلما أدبو ةدحاو ةيصريق نله ْتَيرجُأ ءاسن في ،ةيصريقلل ةيلاتلا ةيلبهلما ةدلاولا جئاتن يزارلحا نسح نحمرلا دبع ،صارف للها دبع ةمئاق في ةلاحإ ىفشتسم في ةساردلا هذه ناثحابلا ىرجأ دقو .ةيصريقلا ةحارلجاب ةقباس ةدلاول ةيلاتلا ةيلبهلما ةدلاولل ةملاسلا تايطعم براضتت :ةصلالخا ىفشتسلما لىإ نلخدأو ،ةدحاو ةيصريق َىنْي َىرجأ نأ قَىب َىس ةأرما 357 ىدل ةيصريق ةحارلج ةيلاتلا ةيلبهلما ةدلاولا جئاتن ايصقتساف ،نميلا في ءاعنص ةنيدم غلب دقو .لبق نم ةيصريقلاب ندلي لم ءاسن نم )155 نهددع( دهاوشلا نم ةعوممج ناثحابلا راتخا دقو .ًايئاقلت أدب ضامخ فيو ةدلاولا ناوأ ماتم في ةساردلا ةعوممج في ةدلاولا نم ةيناثلاو لىولأا ينتلحرلما تيدم طسوتم ناكو .)%87.1( 311/357 ةيصريق ٍةحارلج ةيلاتلا ةيلبهلما ةدلاولا حاجن لدعم ،ر َىكذُحت تافعاضم ْف َىداصُحت لمو .)ةقيقد 29.8و ةقيقد 146.7( دهاوشلا ةعوممج في ماهنع ًايئاصحإ هب ُّدَىتْع ُحي ًافلاتخا افلتيخ لمو ،ةقيقد 30.7و ةقيقد 146.2 قزتم دعب )ًاتيم َىِدل ُحو ديلو( دحاو صلامإ لىإ ةفاضلإاب .محرلا ر ُّزفت نم َْىينناع ءاسن ثلاثو ،محرلا في قزمتب تبيصأ )%0.3( ةدحاو ةأرما لاإ مهللا .تاهملأا ينب تايفو ةَّيأ دت لمو .محرلا Résultats de l’accouchement par voie basse après déclenchement spontané du travail chez des femmes ayant eu une première césarienne RÉSUMÉ Les données concernant la sécurité d’un accouchement par voie basse après une première césarienne sont discordantes. La présente étude réalisée dans un hôpital de recours à Sanaa (Yémen) a consisté à analyser les résultats des accouchements par voie basse de 357 femmes ayant eu une première césarienne et admises à l’hôpital à terme après le déclenchement spontané du travail. Un groupe témoin de femmes (n = 155) n’ayant jamais eu de césarienne a été apparié. Le taux de réussite d’un accouchement par voie basse après une première césarienne était de 87,1 % (311 sur 357). La durée moyenne de la première et deuxième phases du travail n’était pas très différente entre le groupe de l’étude (146,2 et 30,7 minutes respectivement) et le groupe témoin (146,7 et 29,8 minutes). Les complications étaient rares ; seule une femme (0,3 %) a souffert d’une rupture utérine et trois femmes (1,0 %) ont présenté une déhiscence utérine. Une mortinaissance a été observée après une rupture utérine mais aucun décès maternel n’a été déploré. Book 17-8.indb 646 8/9/2011 2:04:39 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 647 Introduction Trial of labour for vaginal birth after caesarean section (VBAC) is a well- established standard practice of care [1]. The success  rates  for VBAC range  between 60%–80% after one previous  lower segment caesarean incision [2,3].  Factors associated with successful vagi- nal birth in a trial of labour include age < 40 years, prior history of vaginal birth,  any indication for previous caesarean section except failure to progress in the first birth, cervical effacement greater than 75% on  admission,  and  cervical  dilatation 4 cm or more on admission [1]. However, not every woman with a  previous caesarean scar is a candidate for VBAC as the trial could likely result in major maternal as well as fetal com- plications. The risks of a failed trial, including uterine rupture, hysterectomy and long- term urinary incontinence, have been reported previously  [2]. Nevertheless,  the dictum “once a caesarean, always a caesarean” began changing approxi- mately 30 years ago as  improvements  in obstetric care made a trial of labour after a previous caesarean delivery safer for both the mother and the infant [4]. It  has been replaced by “once a caesarean, always  a  hospital  delivery”  [5]. Trial  of delivery after one prior caesarean section is therefore considered a key method of reducing the overall caesar- ean section rate. The existing data, however, about which route of delivery is most ap- propriate and safe for these women— VBAC or elective repeat caesarean delivery—are complex and conflicting [6]. Although neither  route  is  risk-free,  the crucial issue is to ensure better ma- ternal and perinatal outcomes. In a trial of VBAC, the main adverse outcome is uterine rupture. Deciding when to attempt VBAC is a major decision and should be based on careful selection of patients after thorough counselling, estimation of patient’s risk of uterine rupture and strict adherence to the most recent guidelines for managing labour in units where there are facilities for immediate access to surgery if compli- cations arise. The purpose of this study in Yemen was to test the outcome of VBAC trial in women with one prior lower transverse caesarean and sponta- neous onset of labour. Methods Sample and setting This prospective controlled clinical study was carried out at Al-Thawra gen- eral hospital, Sana’a over a 1-year period (1 January to 31 December 2008). The  criteria for selection of women to un- dergo trail of VBAC in this hospital are similar to the American Congress of Ob- stetricians and Gynecologists (ACOG) guidelines  [4]. However,  induction of  labour using prostaglandins is totally avoided and oxytocin for augmentation of labour is occasionally given in small doses and under careful observation. For this study, we selected women who had only one previous caesarean section and were considered candidates for trail of VBAC. We further selected the women to include only those who were at term (defined as 37 completed weeks up to 40 weeks), determined by  the last menstrual period and/or first trimester ultrasonography, and who had spontaneous onset of labour (defined as cervical dilatation of > 4 cm, with regular uterine contractions of 3+ per 10 min  lasting 40 s or more). Those who did not  have spontaneous onset of labour, did not reach term or had other obstetric or medical indications for caesarean section were excluded from the study. There were no post-date pregnancies noted in this study. During the study period there were 636 women who had undergone previ- ous caesarean section. Out of them, 357 women (65.1%) fulfilled our criteria and  were included in the study. A matched control group of 158 women without previous uterine incision was selected. They were matched for age, parity, ges- tational age, birth weight, Apgar score, use of oxytocin and mode of delivery. Three cases in the control group devel- oped intrapartum fetal distress and were restored to the operating theatre for abdominal delivery, leaving 155 control women who completed the study. Informed consent for participation in the study was taken from each par- ticipant and hospital ethical committee clearance was obtained. Data collection Every participant received a thorough history, clinical and obstetric exami- nation. The data retrieved included: maternal age, parity, gestational age, in- dications for previous caesarean section, circumstances surrounding the previ- ous delivery, type of uterine incision, interval since the previous caesarean and previous vaginal delivery before or after the caesarean section. We always assess pelvic adequacy using digital pelvimetry. During the trial of labour, the senior physician responsible for the labour room was informed about the case. An intravenous line was established and maintained and intravenous infusion of 5% dextrose in water was given. At least  1 unit of blood was typed and cross- matched for each woman. For those women in both groups who presented early in the first stage (cervical dilata- tion > 4 but < 7 cm) the partogram was established and the fetal and maternal conditions were assessed and plotted regularly. For the other women, fetal cardiac activity, maternal vital signs and uterine contractions were assessed eve- ry 30 min  in the first stage and 15 min  in the second stage. The uterine scar was  assessed  every 30 min by noting  maternal tachycardia, scar tenderness, fetal tachycardia, haematuria, vaginal bleeding and loss of the presenting part on vaginal examination. The progress of labour was assessed by abdominal and/ or vaginal examination 4 hourly in the first stage and more frequently in the Book 17-8.indb 647 8/9/2011 2:04:39 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 648 second stage or when membranes were ruptured or bleeding ensued. This moni- toring was continued throughout the trial of labour. Our policy to augment women with oxytocin during VBAC attempt is to infuse oxytocin 2.5 units in 500 mL of  dextrose (or normal saline) at 10 drops/ min  (2.5 mIU/min)  and  increase  the  infusion rate by 10 drops/min every 30  min until a good uterine contractions pat- tern is established. All the women in our study responded to the first dose without further increment. All women had cardi- otocography monitoring. Pain relief was given on the form of intramuscular injec- tion of tramadol hydrochloride. Epidural analgesia was not available. The outcome measures were the du- ration of first and second stage of labour, intrapartum complications, Apgar score, birth weight, postpartum haemorrhage, uterine separation, need for blood trans- fusion and length of hospital stay. Statistical analysis Data were analysed using Stata, ver- sion  10. The  data were  presented  as  mean and standard deviation (SD) and percentages when appropriate. Differ- ences in means were tested by Student t-test. Chi-squared tests were used to compare frequencies. Fisher exact test was used when appropriate. Statistical significance was taken as P value < 0.05. Results In the study group, 311 out of 357 women were delivered vaginally, giving a VBAC success  rate of 87.1%. The re- maining 46 women (12.9%) were deliv- ered by repeat caesarean section, mainly due to intrapartum fetal distress. Of the women who successfully delivered vaginally, 224 (72.0%) were admitted  during the first stage of labour and 67 women  (22.0%)  in  the  second  stage  versus  122  (78.7%)  and  33  (21.3%)  respectively in the control group. There were no significant differences between the study group and control group in terms of age, parity, gestational age or obstetric and medical history (Table 1) (P > 0.5). Oxytocin was used to augment la- bour in 31 cases (10.0%) (Table 1) but  there was no uterine rupture recorded in these cases. Overall there were 3 cases (1.0%) of uterine dehiscence and 1 case  Table 1 Maternal characteristics and outcome measures for the case group of women with trial of vaginal birth after caesarean section and the control group Variable Case group (n = 311) Control group (n = 155) P-valuea Mean SD Mean SD Age (years) 23.3 5.3 23.1 8.7 NS Parity 2.9 1.0 2.8 1.2 NS Gestational age (weeks) 38.4 3.1 38.7 0.5 NS No. % No. % Oxytocin < 0.001 No 280 90.0 74 47.7 Yes 31 10.0 81 52.3 Birth weight (g) NS ≤ 2500 63 20.3 21 13.5 > 2500–3500 239 76.8 123 79.4 > 3500 9 2.9 11 7.1 Apgar score NS < 6 18 5.8 7 4.5 6–8 161 51.8 78 50.3 > 8 131 42.1 70 45.2 Postpartum complications NS Dehiscence 3 1.0 0 0.0 Uterine rupture 1 0.3 0 0.0 Blood transfusion 2 0.6 0 0.0 Length of hospital stay (hours) NSb 2 287 92.3 148 95.5 > 2–4 17 5.5 0 0.0 > 4 7 2.3 7 4.5 aχ 2 test; bFisher exact test. SD = standard deviation; NS = not significant. Book 17-8.indb 648 8/9/2011 2:04:40 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 649 (0.3%) of uterine  rupture  among  the  VBAC group. There were no maternal deaths and only 1 stillbirth after the case of uterine rupture. There was no signifi- cant difference between the groups in Apgar  scores; 5.8% of neonates  in  the  VBAC trial group had Apgar score < 6 compared with 4.5%  in  the  control  group (P > 0.05). We found 9 neonates  (2.9%) weighed > 3500 g but < 4000 g  in the VBAC group. The mean duration of the first and second stages of labour in the study group were 146.2 (SD 74.9) and 30.7  (SD 6.3) min respectively (Table 2). In  the control group the mean duration of the first and second stages of labour were 146.7 (SD 68.7) and 29.8 (SD 7.4) min  respectively. These differences were not statistically significant (P > 0.5). There were 67 women (21.5%)  in  the study group who had already experi- enced at least one vaginal delivery after their first caesarean section; 63 deliv- ered vaginally, giving a VBAC success rate of 94.0%. The mean duration of the  first and second stages of labour in these women were 110.5 (SD 63.3) and 16.1  (SD 4.6) min respectively. Discussion Al-Thawra general hospital is the big- gest public hospital in Yemen. It is a university-affiliated tertiary care level facility. The labour ward in the hospital accepts both booked and unbooked pregnant women and many com- plicated and mismanaged cases are referred to us. The majority of women referred suf- fer various complications in their first delivery with caesarean section, such as obstructed labour, neglected trans- verse lie with hand prolapse, obstetric haemorrhage, prolonged rupture of membranes (> 24 hours), infection, fe- tal distress and prolonged labour. These women had been refereed directly from a local primary health unit in rural areas, often unbooked, or they had been mis- managed by untrained birth attendants and were given high doses of oxytocin at home. In these situations, they are often managed in hospital by primary caesar- ean section. In subsequent pregnancies, these women may seek early booking and special management both antena- tally and in labour and delivery. These women are often very young and poorly educated. When they come again to the hospital with one previous lower segment transverse caesarean section, a trial of VBAC is offered, depending on the selection criteria, after proper counselling and assessment. During the study period the rate of caesarean section in the hospital was 17.1% for all 12 069 deliveries. The suc- cess rate of VBAC trial was 87.1%. It  is  comparable to other similar studies. For example, Flamm et al. demonstrated that patients presenting with dilation ≥ 4 cm had an 86% success rate of VBAC [1,7].  Although a high success rates indicates a better maternal outcome [7], these rates  often apply to a selected population [8] and  the overall outcome measures  should include certain other delivery- related perinatal complications, such as hypoxic ischaemic encephalopathy. The mean duration of the first and second stages of labour were similar in both groups, which indicates that the previous caesarean section did not prolong labour in the next pregnancy. This result is consistent with other study findings [9].  Oxytocin was used to augment la- bour in 10.0% of women and there were  no cases of uterine rupture recorded in these women. No significant association has been reported between exposure to oxytocin and the risk of uterine rupture [1]. However, the relationship between  oxytocin and uterine rupture is dose- dependent, and the ACOG has warned that excessive use of oxytocin raises the risk of uterine rupture [4]. For women who had already had a vaginal delivery after their first caesar- ean section the VBAC success rate was 94.0% and the duration of the first and  second stages of labour was shorter than for women who had their first VBAC. These findings are consistent with most studies reviewed [10] and may encour- age patients and obstetricians to choose VBAC trial with more confidence when other risk factors are excluded. Uterine rupture is the most likely complication related to VBAC trial. Most studies report the incidence of uterine rupture as between 0.5%–1% in  women with one prior transverse lower segment caesarean section [11]. How- ever, the incidence is higher when the previous incision is classical, when there has been more one previous caesarean section, with induction of labour or with shorter  interpregnancy  intervals [4].  In  Table 2 Duration of first and second stages of labour for the case group of women with trial of vaginal birth after caesarean section and the control group Stage of labour Case group (n = 311) Control group (n = 155) P-valuea No. Mean (SD) duration (min) No. Mean (SD) duration (min) 1st stage 224 146.2 (74.9) 122 146.7 (68.7) NS 2nd stage 67 30.7 (6.3) 33 29.8 (7.4) aχ 2 test. SD = standard deviation; NS = not significant. Book 17-8.indb 649 8/9/2011 2:04:40 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 650 our study, 3 cases (1.0%) were compli- cated by uterine dehiscence and 1 case (0.3%)  suffered uterine  rupture. The  latter case was discovered intrapartum when the woman developed sudden acute lower abdominal pain, tenderness and fetal distress. Immediate caesarean section was performed and complete rupture was found along with the dead baby. The mother was managed by hys- terectomy. All 3 cases whose delivery was complicated by uterine dehiscence were discovered postpartum during exploration of the uterus and managed by rent repair. It is useful to note that in the rupture case that we found no clear obstetric, medical or social factors that could be linked to uterine rupture. However, other risk factors may have been present and additional studies are required to investigate cases of uterine rupture. The perinatal outcomes in our study showed 1 stillbirth (0.3%) in the VBAC  group after the case of uterine rupture. However, 5.8% of neonates had Apger  score < 6  compared with 4.5%  in  the  control group, a difference which was not statistically significant. Our find- ings reinforce similar previous studies suggesting that vaginal delivery after one caesarean section is safe as regards neonatal outcomes [12]. We  found  9  neonates  (2.9%)  weighed more than 3500 g but < 4000 g.  This finding shows that the estimation of fetal weight at term is relatively inaccurate whether done clinically or radiologically. Moreover, since the exact birth weight is only known after the delivery has oc- curred, this could limit the usefulness of birth weight as a predictor in clinical decision-making. Thus, birth weight may only be helpful when other predictors collectively are taken into consideration. Nevertheless, it implies that a women with one prior caesarean section and estimated  fetal weight of > 3500 g but  < 4000 g can be strongly encouraged to  undergo VBAC attempt [11]. There were no maternal deaths in either group. However, our results are based on data from a single setting for those women presenting to the hospital with previous one previous caesarean section and may not be generalizable to other locations. Conclusion On the basis of these results, we con- clude that for selected cases with one prior lower segment caesarean section who present in spontaneous active labour, a trial of vaginal delivery may have a high success  rate (> 85%) with  no increased risk of maternal and fetal morbidity or mortality. The duration of labour for these women was similar to normal deliveries. Our findings may en- courage obstetricians to tolerate VBAC and raise the threshold for recommend- ing caesarean section if low-risk patients are carefully selected. References Flamm BL, Geiger AM. Vaginal birth after cesarean delivery: 1. an admission scoring system. Obstetrics and Gynecology, 1997, 90:907–910. McMahon MJ et al. Comparison of a trial of labor with an elec-2. tive second Cesarean section. New England Journal of Medi- cine, 1996, 335:689–695. Avery MD, Carr CA, Burkhardt P. Vaginal birth after cesarean 3. section: a pilot study of outcome in women receiving mid- wifery care. Journal of Midwifery and Women’s Health, 2004, 49:113–117. American College of Obstetricians and Gynecologists. ACOG 4. practice bulletin no. 54. Vaginal birth after previous cesarean delivery. Obstetrics and Gynecology, 2004, 104:203–212. Dodd J, Crowther CA. VBAC: a survey of practice in Australia 5. and New Zealand. Australian and New Zealand Journal of Ob- stetrics and Gynaecology, 2003, 43:226–231. Gordan CS. Delivery after cesarean section, In: Studd J, ed. 6. Progress in obstetrics and gynaecology. Volume 17. Edinburgh, Churchill Livingstone, 2006:245–263. Aaron BC. Vaginal birth after cesarean delivery. 7. Medscape reference [online article] (http://emedicine.medscape.com/ article/272187-overview, accessed 28 May 2011). Vaginal birth after previous cesarean delivery. Number 5, July 8. 1999 (replaces practice bulletin number 2, October 1998). Clinical management guidelines for obstetrician–gynecolo- gists. American College of Obstetricians and Gynecologists. International Journal of Gynaecology and Obstetrics, 1999, 66(2):197–204. Tripathi JB, Doshi HU. Pattern of cervical dilatation in women 9. with a previous cesarean section. Journal of Obstetrics and Gynecology of India, 2005, 55(2):125–127. Handler I, Bujold E. Effect of prior vaginal delivery or prior 10. VBAC on obstetric outcomes in women undergoing trial of labor. Obstetrics and Gynecology, 2004, 104:273–277. George AM et al. Maternal complications with vaginal birth 11. after cesarean section: A multicenter study. American Journal of Obstetrics and Gynecology, 2005, 193:1656–1662. Colm O’H. VBAC outcome associated with standardized intra-12. partum protocol after one previous cesarean. American Journal of Obstetrics and Gynecology, 2005, 193:546. Book 17-8.indb 650 8/9/2011 2:04:40 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 651 Reasons for cancellation of elective operations at a major teaching referral hospital in Jordan M. Mesmar,1 N.J. Shatnawi,2 I. Faori 3 and Y.S. Khader 4 ABSTRACT Cancellation of elective scheduled operations leads to an inefficient use of operating room time and a waste of resources. This prospective records-based study aimed to determine the rate of and reasons for cancellations of scheduled elective surgical operations in a major teaching referral hospital in Jordan. Over a period of 12 months, cancellation was recorded in 382 (3.6%) of 10 485 scheduled elective surgical operations. Day unit cancellations accounted for 27.5% and inpatient cancellations for 72.5%. Patient-related reasons, administrative and medical reasons accounted for 31.4%, 30.4% and 38.2% of all cancelled operations respectively. The most common patient-related reason for cancellation was patient non-attendance. The most common administrative reason for cancellations was unavailability of hospital admission beds. Although the cancellation rate was low in comparison with the reported rates worldwide, reductions might be achieved by adopting some important interventions, especially better bed utilization. 1Department of Orthopaedic Surgery; 2Department of Surgery; 3Department of Nursing; 4Department of Public Health, Faculty of Medicine, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan (Correspondence to Y.S. Khader: yousef.k@excite.com). Received: 20/12/09; accepted: 28/01/10 ندرلأا في ةلاحلإل سييئر يعجرم يميلعت ىفشتسم في ةيرايتخلاا تايلمعلا ءاغلإ بابسأ ضرخ حلاص فسوي ،يروعاف ميهاربإ ،يوانطش فاون ،رماسم دممح .دراوملل رادهإو تايلمعلا فرغ مادختسا ةءافك في صقن لىإ يدؤي اهدعوم ديدت ىرج يتلا ةيرايتخلاا ةيحارلجا تايلمعلا ءاغلإ نإ :ةصلالخا في اه ُحت َىل َىوْد َىج تَّتم يتلا ةيرايتخلاا ةيحارلجا تايلمعلا ءاغلإ بابسأو تلا َّدعم ديدت لىإ تلاجسلا لىع ةزكترلما ةيقابتسلاا ةساردلا هذه فدتهو ةيرايتخا ةيحارج ةيلمع 10485 ينب نم )%3.6( ًءاغلإ 382 ل ِّج ُحس ،ًارهش شرع ْيَىنثا تدتما ةبقح ىدم لى َىع َىف .ندرلأا في ةلاحلإل يربك يميلعت ىفشتسم ةقلعتم بابسلأ ءاغللإا لكشو .%72.5 ىفشتسلما في ينلجاعلما ضىرملل تاءاغللإاو ،%27.5 ةيراهنلا ةدحولا في تاءاغللإا تغلب دقو .اه ُحت َىل َىوْد َىج تَّتم ًاعويش ضىرلماب ةقلعتم ةحارلجا ءاغلإ بابسأ رثكأ ناكو .ةاغللما تايلمعلا لممج نم %38.2 ةيبط بابسلأو ،%30.4 ةيرادإ بابسلأو ،%31.4 ضىرلماب نم َّلقأ ناك تاحارلجا ءاغلإ ل َّدعم نأ عمو .ىفشتسلما في ة َّسرأ رفوت مدع وه ةيلمعلا ءاغللإ ًاعويش ةيرادلإا بابسلأا رثكأو .ضيرلما روضح مدع وه .ىفشتسلما ة َّسرأ نم ةدافتسلاا ينست ماَّيسلاو ةمالها تلاخدتلا ضعب دماتعا قيرط نع لدعلما اذه ضْف َىخ نكمي هنأ لاإ ،ةيلماعلا تلا َّدعلما Motifs d’annulation des interventions chirurgicales programmées dans un grand centre hospitalier universitaire de recours en Jordanie RÉSUMÉ L’annulation d’interventions chirurgicales programmées conduit à une utilisation inefficace des plages opératoires disponibles et au gaspillage des ressources. La présente étude prospective, fondée sur des dossiers de patients, visait à déterminer le taux d’annulation des interventions chirurgicales programmées dans un grand centre hospitalier universitaire de recours en Jordanie, et les motifs de ces annulations. Sur une période de douze mois, 382 interventions programmées sur 10 485 (soit 3,6 % d’entre elles) ont été annulées. Les annulations concernaient pour 27,5 % d’entre elles des soins ambulatoires, et 72,5 % d’entre elles une intervention avec hospitalisation. Les motifs liés aux patients, les raisons administratives et les causes médicales représentaient respectivement 31,4 %, 30,4 % et 38,2 % de l’ensemble des annulations. L’absence du patient était le motif le plus fréquent des annulations liées à ces derniers. La raison administrative la plus courante était le manque de lits. Même si le taux d’annulation est faible par rapport aux autres taux dans le monde, il pourrait encore diminuer grâce à l’adoption de mesures importantes telles qu’une meilleure utilisation des lits. Book 17-8.indb 651 8/9/2011 2:04:40 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 652 Introduction Considerable resources are invested in maintaining a well-functioning op- erating theatre. Cancellation of elec- tive scheduled operations leads to an inefficient use of operating room time and  a waste  of  resources  [1–3]. The  disruptions which cancellations cre- ate to patients, their families and the medical teams are high. Cancellation is a major problem in most hospitals. The incidence and reasons of cancellation differ from one hospital to another, with rates varying from 10% to 40% [4,5]. In a comprehensive quality improve- ment programme the rate of surgical cancellation is one of the quality indica- tors for operative theatres. The reasons for cancellations can be patient-related, administrative or medical. For each of these reasons, different interventions can be implemented to reduce cancella- tions to the minimum. The commonest reasons for cancellation of elective sur- gical procedures reported in previous studies included lack of theatre time [6],  non-availability of recovery room beds and patients failing to attend [7]. This study was conducted to deter- mine the rate and reasons for cancel- lations of scheduled elective surgical operations in a major teaching referral hospital in Jordan. Identifying the avoid- able reasons would help to implement interventions to improve the efficiency of operating room services. Methods A prospective survey was conducted in King Abdullah University hospital between August 2005 and July 2006 to  identify cancelled day-case and inpatient elective operations. This is the main teaching and tertiary referral hospital in  the north of  Jordan with 650 beds,  20 operating theatres and a 16 bed day- care surgery unit. Operating schedules are submitted to the operative suite for each working day at 15.00 the previous  day. Any additional elective operations after that time have to be approved by the senior consultant of anaesthesia. Emergency operations are booked as they appeared on the emergency board located in the theatre reception area and there is an assigned operative theatre for emergency cases. Life-saving emergency cases can be carried out by interruptions of any of the theatres according to the state of urgency. Operative cancellations were de- fined as those cases that were booked in the operative list (schedule) and did not have the planned surgery on the intend- ed date. All cancellations of scheduled elective operations of patients who did not attend for admission to the hospital or were not admitted because of bed unavailability were included. Patients who died before the time of their sched- uled surgery were excluded. Cancellations of elective scheduled operations in the period from August 2005  to  July  2006  were  reviewed  prospectively. All cancellations were recorded in a predesigned form which included information about the age of the patient, hospital identification number, date of cancellation, type of op- eration, the surgeon and the anaesthet- ist, any associated medical problems and the presumed reasons for cancella- tions for inpatients and day care surgery unit. For each cancelled operation, the form was filled by the senior registered nurse in charge of the operative suite and signed by the consultant of anaes- thesia in charge. The medical records of cancelled cases were reviewed in order to identify associated medical condi- tions, preoperative anaesthetic evalua- tions and recommended management plans to improve the preoperative sta- tus of patients with associated chronic medical problems. Patients who did not attend were contacted by the thea- tre secretary to establish the reason for non-attendance. Cancellation reasons were classified by the authors into 3 major categories: patient-related, administrative-related and medical-related. Frequencies and percentages were reported to describe the data. Data were analysed using SPSS, version 15. Results Over a period of 12 months, 10 485 elec- tive surgical operations were scheduled. A  total  of  10 103  elective operations  were performed on the planned date. Cancellation was recorded in 382 cases  (3.6%) (215  for admitted patients and  167 for non-admitted patients). Day unit cancellations accounted for 27.5%  of all cancelled operations and inpatient cancellations for 72.5%. Table 1 shows the reasons for can- cellation according to the location of admissions. Patient-related, administra- tive-related and medical-related reasons accounted for 31.4%, 30.4% and 38.2%  of the cancelled operations respectively. The most common patient-related reason for cancellation was patient non- attendance which accounted for 23.0%  of all cancellations. Patients’ request for cancellation accounted  for 5.8% of  all cancellations. The most common administrative reason for cancellations was unavailability of hospital admission beds which accounted  for 20.7% of all  cancellations. Acute medical illnesses were the most common medical rea- sons for cancellations. Table 2 shows  the number of can- cellations according to surgical spe- cialty, nature and location of admission. Cancellations among patients admitted for ophthalmic surgery accounted for 20.9% of all cancellations, while general  surgical cancellations were 21.5% of all  cancelled cases. Discussion Surgical cancellation is defined as a scheduled surgery which is not done at the intended date. Narrow or wide Book 17-8.indb 652 8/9/2011 2:04:41 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 653 definitions are adopted by different hospitals. Narrowly defined cancel- lations include admitted scheduled operations which are not performed on  the  intended date  [8]. This  study  reported all reasons for cancellations including patient-, administrative- and medical-related reasons. The rate of cancellation  in  this  study  was  3.6%.  Hospitals that define cancellation nar- rowly have reported a rate of less than 10% [8,9], while hospitals  that defined  cancellations of all types have reported a rate as high as 24% [10–14]. Another source of variation in the reported rates of cancellations is the approach to data collection, whether it is prospective or  retrospective [15].  In  this study, data on cancellation were col- lected prospectively; therefore, under- reporting of cancellations is expected to be minimal. The low cancellation rate at this hospital might be related to the monitoring of cancellation as a Table 1 Reasons for cancellation of elective operations at a major teaching referral hospital in Jordan according to location of admissions Reason Inpatients Day unit Total (n = 382) No. No. No. % Patient-related reasons 56 64 120 31.4 Patient failed to attend 30 58 88 23.0 Patient request 19 3 22 5.8 Patient not fasting 7 3 10 2.6 Administrative-related reasons 98 18 116 30.4 No bed available 68 11 79 20.7 Overloaded schedule 14 6 20 5.2 Lack of staff 7 1 8 2.1 Lack of equipment 6 0 6 1.6 No blood available 3 0 3 0.8 Medical-related reasons 122 24 146 38.2 Upper respiratory tract infection 35 14 49 12.8 High blood pressure 39 3 42 11.0 Unfit because of other medical conditions 22 1 23 6.0 Acute illness 7 1 8 2.1 Change of treatment plan 9 3 12 3.1 Abnormal laboratory results 7 0 7 1.8 Patient taking aspirin 3 2 5 1.3 Table 2 Number of cancellations of elective operations at a major teaching referral hospital in Jordan according to surgical specialties, nature and location of admission Specialty Total Scheduled admitted patients Scheduled non-admitted patients Inpatients Day unit Inpatients Day unit No. % No. No. No. No. General surgery 82 21.5 35 7 23 17 Ophthalmology 80 20.9 43 7 17 13 Orthopaedic surgery 69 18.1 33 5 16 15 Urology 62 16.2 24 8 17 13 ENT surgery 45 11.8 18 6 13 8 Neurosurgery 20 5.2 13 2 4 1 Gynaecology 12 3.1 6 1 4 1 Plastic surgery 8 2.1 4 0 3 1 Maxillofacial 4 1.0 3 0 1 0 Total 382 100.0 179 36 98 69 ENT = ear, nose and throat. Book 17-8.indb 653 8/9/2011 2:04:41 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 654 quality indicator in the hospital quality improvement programme. For a multi-dimensional problem such as surgical cancellations, it is im- portant to address major reasons that result in cancellations. Medical-related reasons contributed  to 38.2% of can- cellations. Among the medical reasons, acute medical illness contributed the most, with acute upper respiratory tract infection as the most common reason. These cancellations are considered unavoidable; no one would wish to risk the patient’s life for an elective sur- gery. However, cancellation of elective operation for acute upper respiratory tract infections is controversial. There is debate that uncomplicated cases of upper respiratory tract infection can safely be anesthetized without in- creasing postoperative complications [16–19]. Elevated blood pressure as a cause for cancellations contributed  to 11.0%  of all cancelled operations. Long- standing hypertension may be associ- ated with perioperative cardiovascular complications  [20] and perioperative  cardiac death  [21]. Preoperative  ele- vated blood pressure on the other hand was not found to be associated with major perioperative cardiac complica- tions  [20,22]. However, patients with  arterial  blood pressure of > 210/120  mmHg (stage 4) present a real risk of periopertive complication and death. The uncertainty of the highest safe blood pressure for anaesthesia results in variations in practice [23]. Perioperative  blood pressure elevations might be due to the stress and fear of operations. Ade- quate preoperative explanation through proper channels of communication with the patients might minimize the contribution of these factors. Patients with chronic illnesses are at higher risk if they are subjected to the trauma of sur- gery and general anaesthesia’ however, these patients require preoperative op- timization of their medical status. Most patients in this study labelled as unfit for general anaesthesia had their operation performed on a later date. Furthermore, most of them were inpatient cases. This finding might indicate some degree of suboptimal preoperative hospital care for these patients. Administrative-related reasons ac- counted  for 30.4% of all  cancellations,  with unavailability of admission beds being the most common reason. All administrative reasons were basically a result of communication problems, which are avoidable Administrative reasons accounted for 45% of all cancel- lations  in  some  studies  [10,12]. Such  problems can be solved by improving the management of patient beds. In conclusion, although our cancel- lation rate was low in comparison with the reported rates worldwide, a major reduction in the cancellation rate could be achieved by adopting a few impor- tant interventions, such as creating a bed utilization manager position in the hospital. An aesthetic protocol defin- ing the parameters which will render patients as unfit for elective surgery needs to be communicated to surgical specialties and consultants in medical and paediatric departments. References Robb WB et al. Are elective surgical operations cancelled due 1. to increasing medical admissions? Irish Journal of Medical Sci- ence, 2004, 173:129–132. Tait AR et al. Cancellation of pediatric outpatient surgery: 2. economic and emotional implications for patients and their families. Journal of Clinical Anesthesia, 1997, 9:213–219. Ivarsson B et al. Patient reactions to cancelled or postponed 3. heart operations. Journal of Nursing Management, 2002, 10:75–81. Rai M, Pandit JJ. Day of surgery cancellation after nurse-led 4. preassessment in an elective surgical centre: the first 2 years. Anaesthesia, 2003, 58:692–699. Schofield WN et al. Cancellation of operations on the day of 5. intended surgery at a major Australian referred hospital. Medi- cal Journal of Australia, 2005, 182:612–615. Pandit JJ, Carey A. Estimating the duration of common elec-6. tive operations: implications for operating list management. Anesthesia, 2006, 61:768–776. Audit Commission. 7. Operating theatres. Review of national find- ings. London, Her Majesty’s Stationery Office, 2003. Fischer SP. Development and effectiveness of an anesthesia 8. preoperative evaluation clinic in a teaching hospital. Anesthe- siology, 1996, 85:196–206. Frost EA. Outpatient evaluation: a new role for the anesthesi-9. ologist. Anesthesia and Analgesia, 1976, 55:307–310. Hand R, Levin P, Stanziola A. The causes of cancelled elective 10. surgery. Quality Assurance and Utilization Review, 1990, 5:2–6. Lacqua MJ, Evans JT. Cancelled elective surgery: an evaluation. 11. American Surgeon, 1994, 60:809–811. Livingstone JI et al. Role of pre-admission clinics in a general 12. surgical unit: a 6-month audit. Annals of the Royal College of Surgeons of England, 1993, 75:211–212. Basu S et al. Impact of questionnaires and telephone screening 13. on attendance for ambulatory surgery. Annals of the Royal Col- lege of Surgeons of England, 2001, 83:329–331. Kerridge R et al. The perioperative system: a new approach 14. to managing elective surgery. Anaesthesia and Intensive Care, 1995, 23:591–596. Pollard JB, Olson L. Early outpatient preoperative anesthesia 15. assessment: does it help to reduce operating room cancella- tions? Anesthesia and Analgesia, 1999, 89:502–505. Tait AR, Knight PR. The effects of general anesthesia on upper 16. respiratory tract infections in children. Anesthesiology, 1987, 67:930–935. Levy L et al. Upper respiratory tract infections and general 17. anaesthesia in children. Peri-operative complications and oxygen saturation. Anaesthesia, 1992, 47:678–682. Tait AR, Knight PR. Intraoperative respiratory complications 18. in patients with upper respiratory tract infections. Canadian Journal of Anaesthesia, 1987, 34:300–303. Book 17-8.indb 654 8/9/2011 2:04:41 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 655 Rolf N, Coté CJ. Frequency and severity of desaturation events 19. during general anesthesia in children with and without up- per respiratory infections. Journal of Clinical Anesthesia, 1992, 4:200–203. Howell SJ et al. Risk factors for cardiovascular death after elec-20. tive surgery under general anaesthesia. British Journal of Anaes- thesia, 1998, 80:14–19. Goldman L, Caldera DL. Risks of general anesthesia and elec-21. tive operation in the hypertensive patient. Anesthesiology, 1979, 50:285–292. Howell SJ et al. Hypertension, admission blood pressure 22. and perioperative cardiovascular risk. Anaesthesia, 1996, 51:1000–1004. Dix P, Howell S. Survey of cancellation rate of hypertensive 23. patients undergoing anaesthesia and elective surgery. British Journal of Anaesthesia, 2001, 86:789–793. Management effectiveness initiatives The management of health care is a pivotal factor in the delivery of effective health service with growing recognition of the key role that non-clinical activities play in the way that health care is delivered. Management effectiveness is crucial in all health care settings: hospitals, primary health care clinics, mobile units, laboratories and pharmacies. The WHO’s Regional Office for the Eastern Mediterranean (EMRO) works in partnership with ministries of health of the Region to strengthen the way in which health care facilities and professionals are managed. The ultimate aim is to improve their functioning by working towards greater effectiveness, efficiency, quality and coverage of services, which will lead to better health outcomes. The main aspects of EMRO’s work within the field of health management involve providing technical assistance and support to countries in the Region to: Assess the performance of health services• Improve the delivery of health care services through capacity-building• Strengthen district health systems as the viable decentralized entity of the health care delivery system• Enhance the different lines of accountability and communication between levels of care• Improve the credibility of health services• Develop a strategy to find the best balance of public-private mix.• Book 17-8.indb 655 8/9/2011 2:04:41 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 656 Determining and prioritizing competencies in the undergraduate internal medicine curriculum in Saudi Arabia H. Almoallim 1 ABSTRACT To determine knowledge and skills competencies in internal medicine for the undergraduate curriculum in Saudi Arabia, competencies were identified based on group work utilizing common textbooks. The Delphi Technique was used as a consensus method to determine and prioritize competencies in internal medicine. A group of 20 clinicians rated the identified competencies from 0–3 (0: no need to know, 1: interesting to know, 2: should know and 3: must know). After formulating the results, a second Delphi round was conducted with 5 experts in internal medicine. A total of 1513 knowledge competencies and 189 skills competencies were determined and prioritized. The competencies corresponded to the 12 systems in internal medicine. All competencies rated 2.2–3.0 were produced separately and considered core competencies for the undergraduate internal medicine curriculum. Determining and prioritizing competencies should influence the curriculum reform process. 1Department of Medicine, Medical College, Umm Alqura University, Mecca, Saudi Arabia (Correspondence to H. Almoallim: hanialmoallim@hotmail.com). Received: 15/01/09; accepted: 25/02/10 ةيدوعسلا ةيبرعلا ةكلملما في ينطابلا بطلل يعمالجا يميلعتلا جهنلما في اتهاَّيولوأ مييقتو تاءافكلا ديدتح ملعلما نياه ةيبرعلا ةكلملما في ينطابلا بطلل يعمالجا يميلعتلا جهنلما في ينطابلا بطلا في تاراهلماو فراعلما تاءافك ديدت لىإ ثحابلا فده :ةصلالخا اهيلع ًاقفَّتم ةقيرط اهرابتعاب Delphi يفلد ةقيرط تمدختساو .ةعئاشلا ةيعجرلما بتكلا مادختسابو يعاجم لمع لىإ ًادانتسا كلذو ،ةيدوعسلا حواترت تاجردب اهديدت ىرج يتلا تاءافكلا بيوبتب ًابيبط نيشرع نم ةعوممج تماق دقو .اتهايولوأ ديدتو ينطابلا بطلا في تاءافكلا ديدحتل دبلا ينعت :3 ،اهتفرعم يغبني هنأ ينعت :2 ،اهيلع فرعتلا هابتنلال يرثلما نم نأ ينعت :1 ،اهتفرعلم ةجاح لا نأ ينعت :0( تاجرد ثلاث ينبو رفصلا ينب 1513 ه ُحل َىم ْ ُحمج ام ديدت ىرج دقو .ينطابلا بطلا في ءابرخ ةسخم اهيف كراش يفلد ةقيرطب ىرخأ ةلوج تيرجأ ،جئاتنلا ةغايص دعبو .)اهتفرعم نم تاءافكلا عيجم ُحزْر َىف مت مث .ينطابلا بطلا في ةموظنم ةشرع يتنثا تاءافكلا هذه لباقتو .اتهايولوأ ْت َىد ِّد ُحح ماك تاراهم ةءافك 189و فراعم ةءافك ينيعتو تاءافكلل ديدحتلا اذه لثم نأ ىفيخ لاو .ينطابلا بطلل يعمالجا يميلعتلا جهنملل ةيرومح تاءافك ْت َىِبر ُحتعاو 3.0-2.2 اهتجرد تغلب يتلا .يميلعتلا جهنلما حلاصإ ةيلمع لىع هرثأ هل نوكي نأ يغبني اتهايولوأ Détermination et classement par ordre de priorité des compétences dans le programme de médecine interne de premier cycle en Arabie Saoudite RÉSUMÉ Pour déterminer les compétences théoriques et pratiques en médecine interne dans le programme de premier cycle en Arabie saoudite, un travail de groupe a été réalisé sur des manuels communs. La méthode Delphi a été utilisée en tant que méthode d’obtention d’un consensus pour déterminer les compétences utiles en médecine interne et les classer par ordre de priorité. Un groupe de 20 cliniciens a attribué une note allant de 0 à 3 aux compétences identifiées (0 : connaissance inutile, 1 : connaissance intéressante, 2 : connaissance utile, 3 : connaissance indispensable). Après la formulation des résultats, une deuxième vague de consultation selon la méthode Delphi a été menée auprès de cinq experts en médecine interne. Au total, 1513 compétences théoriques et 189 compétences pratiques ont été identifiées puis classées par ordre de priorité. Les compétences correspondaient aux douze systèmes de médecine interne. Toutes les compétences notées de 2,2 à 3,0 ont été présentées séparément et considérées comme des compétences clés pour le programme de médecine interne de premier cycle. La détermination des compétences et leur classement par ordre de priorité devraient influer sur le processus de réforme du programme. Book 17-8.indb 656 8/9/2011 2:04:42 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 657 Introduction One of the current trends in curricu- lum planning is to base it on outcomes [1]. These outcomes should be clearly defined in the form of competencies. Curriculum designers should know pre- cisely what they want from medical stu- dents in terms of knowledge, attitudes and skills competencies. Otherwise, teaching may miss certain competen- cies important for the practising physi- cian; on the other hand, it may focus on unnecessary or less important compe- tencies. The epidemiology of diseases differs between countries and common diseases locally in Saudi Arabia such as dengue fever and tuberculosis may not be well addressed in standard textbooks. Therefore, curriculum designers are re- quired to consider such differences. The Delphi Technique a research approach is employed to develop con- sensus amongst a heterogeneous popu- lation. It is “a method for systematic collection and aggregation of informal judgment from a group of experts on specific questions and issues” [2]. The Delphi Technique utilizes iterative multistage processes; 2 or more rounds  are conducted using a questionnaire survey. Each round uses information gathered during previous rounds to con- verge toward a consensus of the group’s opinions. It is valued for its probability in avoiding drawbacks often associated with group dynamics in structured and unstructured direct interactions. The technique has many advantages over other group decision-making methods because it allows participants’ anonym- ity while preventing the possible bias of dominating the consensus development by a powerful individual in face-to-face meetings. It facilitates ownership and increases acceptance of the generated consensus. In addition, the study’s sta- tistical group response allows qualitative data to be transformed into quantitative data; and it overcomes the geographical limitation of the participation of a wide range of experts and stakeholders [3]. The primary objective of this study was to determine and prioritize knowl- edge and skills competencies in under- graduate internal medicine curriculum in Saudi Arabia. Methods Delphi The Delphi Technique is considered one of the most useful techniques in identifying competencies in medical education [3,4] A rigorous stepwise approach for use of the technique was followed in this research in conjunction with several guidelines and recommen- dations (Figure 1) [5]. Prior to application of the Delphi Technique, a list of all internal medicine competencies was developed. This was done using  a  team of  29  volunteers,  final-year medical students and interns from Umm Alqura University Medical College, Mecca. Team members were divided  into 12 groups corresponding  to the 12 systems in internal medicine.  Each group was asked to write up all internal medicine competencies cor- responding to their assigned system. Knowledge and skills competencies were identified based on standard med- ical textbooks [6,7]. All groups received detailed instructions on “how to write competencies” and “how to choose the observable verbs that describe precisely the cognitive function to be achieved by each objective” (Figure 1). To unify the work and style, the author reviewed all the competencies for each system and modifications were introduced where needed, e.g. any knowledge competency felt to be a skill was moved to the skills competencies section of that system and vice versa. Written competencies were then reviewed by a panel of 12 experts and any missing  competencies added. The second stage was the application of iteration 2 of the  Delphi Technique. This was aimed at developing a consensus on the core competencies essential for undergradu- ate medical students. Figure 1 Steps followed in identifying and rating the competencies based on the Delphi Technique Second Delphi Determining competencies First Delphi Core competencies ratings ≥ 2.2 All competencies ratings 0—3 Book 17-8.indb 657 8/9/2011 2:04:42 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 658 In the first Delphi round, a booklet containing all competencies of all sys- tems was sent with an instruction letter to a total of 30 participants. Participants  were asked to rate each competency as 0, 1, 2,  and 3 corresponding  to: no  need to know the subject, good and interesting to know, should know and must know the subject respectively. If the judgment of the rater was between 2  levels,  the  following numbers were  assigned 0.5, 1.5  and 2.5  respectively.  A period of 2 months was allowed  to  return the booklet. After collecting all data, the weighted response for each competency was calculated following a standard method [8]. The second round of Delphi was con- ducted with a list of all competencies with the weighted responses. This was sent to 6 experts in internal medicine. The same instructions and system of rating was followed, and the booklets were returned after 2 months. The final weighted  re- sponses were then calculated. Rating and analysis of data The following technique was used to analyse the ratings of each competency and the combined responses of all par- ticipants. First, the 4 levels of ratings were assigned; to obtain a weighted response for each competency, the number of responses in each level was multiplied by the assigned number, and then the products were added together and di- vided by the total number of responses, which gives a mean score for each com- petency (0.0–3.0). This  technique has  been described previously [8]. Using this method, all knowledge and skills competencies in internal medicine were ranked and the relative importance for each competency in the curriculum was determined. Participants In the first stage of developing the list of all competencies, 29 medical  students and  interns who graduated from the medi- cal college of Umm Alqura University volunteered to help with this project. Written competencies were re- viewed by a group of 12 consultants in  internal medicine. All were trained in North America and have been involved in teaching undergraduate medical student and residents in Umm Alqura University. In the first Delphi round, a group of 30 clinicians who had different  levels of  experience and different specializations were invited to participate; they included faculty staff, internship directors, practis- ing general internists, senior medical resi- dents and interns (Table 1). Participants were selected to represent all medical colleges in Saudi Arabia. The practising general internists were from 5 major edu- cational hospitals in 5 different cities. All of the non-internists selected (an obste- trician, a surgeon, a family physician and a paediatrician) were full professors in their institutions, with an academic qualifica- tion in medical education. In the second Delphi round, a total of 6 experts in internal medicine were involved (Table 1). These experts rep- resent 5 different medical colleges in Saudi Arabia and all had wide clinical and educational experience in under- graduate medical education. Results For the first Delphi survey, 20 out of the  30 participants  completed  the  survey  booklet, a response rate of 66.6%. Only  1 expert general practitioner out of 3 in our region responded to this round. For the second survey, 5 out of 6 participants completed the booklet, a response rate of 83.3%.  Table 1 Composition of groups in the two Delphi rounds Category Clinicians (No.) Experts (No.) Expert 4 5 Internist 6 0 Resident 3 0 Intern 3 0 Non-internist 4 0 Total 20 5 20 out of 30 completed the first round and 5 out of 6 completed the second round. Table 2 Number of knowledge and skills competencies for all systems. Internal medicine systems Competency Knowledge Skills Allergic and immunologic disorders 48 0 Cardiovascular diseases 135 27 Dermatologic disorders 49 7 Endocrine and metabolic diseases 236 33 Gastrointestinal diseases 224 20 Hematologic diseases 75 11 Infectious diseases 85 13 Neurologic disorders 150 11 Oncologic diseases 140 0 Pulmonary diseases 117 31 Renal, fluid and electrolyte disorders 136 16 Rheumatologic diseases 119 20 Total 1514 189 Book 17-8.indb 658 8/9/2011 2:04:42 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 659 Internal medicine systems were organized alphabetically: allergic and immunologic disorders, cardiovascular disorders, dermatologic disorders, endo- crine diseases, gastrointestinal diseases, haematologic diseases, infectious diseas- es, neurologic disorders, oncologic disor- ders, pulmonary diseases, renal diseases and rheumatologic diseases. The compe- tencies for each system were organized under  2 major  categories  knowledge  competencies and skills competencies, with disease subheadings as outlined in the textbook (Table 2). A total of 1703  competencies were identified for the 12  systems, of which 1514 were knowledge competencies and 189 skills competen- cies (All of these competencies were produced in a booklet format at the end of the study; this is available by direct request from the author). All competencies in knowledge and skills with weighted  response of ≥ 2.2  were considered core competencies. Table 3 shows an example of the core skills competencies for cardiovascular disorders. Table 4 shows the weighted respons- es of  the 12 knowledge competencies  determined for congestive heart failure (CHF) based on experts’ ratings in the second Delphi survey. Prioritization is apparent in this example as the results clearly reflect the level of importance of  this disease,  11 out 12 knowledge  competencies were  rated > 2  (should  know the subject) and 7 out of these 12 were actually  rated > 2.5, close  to 3  (must know the subject). The mean weighted responses for all disease subheadings for all systems were calculated. This is to give further prioritization and relative importance of diseases within each system. The mean weighted responses for knowledge competencies for all cardiovascular disorders are shown in Table 5. The number of determined competencies for each disease has also been counted (full package for all mean weighted re- sponses of all disease subheadings for all systems is available through direct request from the author. The correlation coefficient for all results comparing clinicians’ group rat- ings in the first Delphi to experts’ rat- ings  in  the second Delphi was 0.90  for  knowledge competencies and 0.70  for  skills competencies. Discussion Determining competencies is an es- sential component to the success of any educational programme. A strict methodology was followed in this comprehensive study to determine and prioritize knowledge and skills com- petencies for the undergraduate cur- riculum in internal medicine in Saudi Arabia. It is hoped that this effort will Table 3 Core skills competencies (rated ≥ 2.2–3.0) for cardiovascular disorders Cardiovascular disease (skills competencies) Expert rating To formulate a comprehensive history from patients with cardiovascular diseases 3.00 To apply knowledge about presenting symptoms of cardiovascular system (chest pain, dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, palpitations, nocturia, oedema, anorexia, syncope, pre-syncope, dizziness, intermittent claudication, fatigue) in obtaining history from patient 3.00 To demonstrate competency in performing a comprehensive cardiovascular examination starting with proper positioning of the patient to the general appearance then by examining the hands, the face, the trachea, the chest and the pericardium 2.80 To demonstrate competency in eliciting physical signs of CHF 2.80 To demonstrate on CXR most of the findings associated with CHF 2.60 To identify based on ECG interpretations ischaemic changes consistent with acute coronary syndrome 2.50 To demonstrate competency skills in examining patient with mi and be familiar with Killip classification 2.40 To identify based on ECG interpretations ischemic changes consistent with mi 2.70 To demonstrate competency in eliciting signs of aortic stenosis 2.30 To demonstrate competency in eliciting signs of mitral stenosis 2.70 To demonstrate competency in eliciting signs of aortic regurgitation 2.70 To demonstrate competency in eliciting signs of mitral regurgitation 2.60 To identify the ECG changes seen in pericarditis and pericardial effusion 2.20 To demonstrate competency in eliciting signs of pericardial diseases 2.40 To demonstrate on CXR changes consistent with pericardial effusion 2.20 To demonstrate competency in eliciting signs of deep venous thrombosis 2.70 To demonstrate competency in measuring the blood pressure 3.00 To demonstrate competency in examining patients with hypertension 2.40 Separate tables for all skills competencies, including core skills, for all systems are available from the author upon request. CHF = congestive heart failure; CXR = chest X-ray; ECG = electrocardiogram. Book 17-8.indb 659 8/9/2011 2:04:42 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 660 direct medical educators in developing competency-based curricula with more focus on essential and must-know competencies. There is an extensive effort in medical education literature addressing reforming and construct- ing new curricula, not only for internal medicine core clerkship [9,10], but also other specialties [11]. The type of methodology followed in this study is unique in medical education literature [12]. One of the advantages of develop- ing a core list of should know and must know competencies is to help in design- ing a national guide for internal medicine teaching in medical colleges in Saudi Arabia. It would also help in designing a clerkship curriculum in internal medicine based on the specified competencies that augment and serve as a continuum of what had been taught in the under- graduate curriculum. It was reported in a different health system than Saudi Arabia that the use of a national guide is associated with improved ability to meet clerkship accreditation criteria, im- proved performance of students on the clerkship exam and increased clerkship time devoted to ambulatory care [12]. There is no published national guideline for minimal acceptable competencies of a medical graduate in Saudi Arabia [13]. This effort of developing a comprehen- sive guide and follow its implementation on the national level should result in the rapid adoption by medical colleges, with subsequent improvement in the quality of medical education [11]. One of the applications of the result of this study is to properly design as- sessment methods. Competency-based assessment measures what doctors can do in controlled representations of pro- fessional practice [14]. Competencies (knowledge or skills) drawn from this research can be used as the compe- tencies that should be fulfilled and/ or demonstrated by candidates dur- ing examinations, including objective- structured oral examination. Rethans et al. proposed that all assessments under examination-like settings should be referred to as competence-based assessments, whereas assessments in Table 4 Knowledge competencies (rated 0.0–3.0) for congestive heart failure (CHF) Cardiovascular disease (knowledge competencies) Expert rating To define congestive heart failure 2.90 To classify congestive heart failure based on etiological abnormalities, systolic dysfunction and diastolic dysfunction 2.80 To describe pathophysiological mechanisms for CHF 2.40 To describe some terminology for CHF (high-output failure, left-sided heart failure, right-sided heart failure) 2.80 To describe clinical features of congestive heart failure 3.00 To construct approach to diagnosis of CHF based on etiology, symptoms and investigation (ECG, echo, cardiac catheterization) 2.50 To construct approach to therapy for CHF 2.60 To outline therapy of systolic dysfunction 2.20 To outline therapy of diastolic dysfunction 2.30 To prescribe therapy of pulmonary oedema 2.80 To discuss mechanism of action, indications and side effects of different drugs used in CHF 2.10 To discuss the neurohumoral hypothesis of heart failure and its application in management 1.63 All knowledge competencies for all diseases are available from the author upon request. ECG = electrocardiogram. Table 5 Mean weighted response of all disease subheadings of cardiovascular diseases Knowledge competency Expert rating (mean weighted response) Total Congestive heart failure 2.50 12 Cardiac arrhythmias 2.09 18 Ischemic heart disease 2.30 29 Valvular heart disease 2.15 25 Cardiomyopathy 1.81 12 Pericardial disease 2.35 11 Congenital heart disease in adult 1.75 6 Venous thrombosis 2.71 7 Cardiovascular syncope 1.78 5 Hypertension 2.53 10 Total – 135 Tables like this for all systems are available from the author upon request. Book 17-8.indb 660 8/9/2011 2:04:43 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 661 actual practice should be referred to as performance-based assessments [14]. The mean weighted responses for cardiovascular diseases may help plan- ners in organizing curriculum content based on this rating and in blue-printing cardiovascular-related assessments. The high ratings of competencies for CHF (knowledge: out of 12, 11 rated > 2 and  7  rated > 2.5) may direct  curriculum  planners to use these competencies as outcomes while designing and im- plementing courses and educational interventions. It also means that CHF must be considered while planning cur- riculum content and while designing as- sessment methods in internal medicine courses. The same rationale can be used when addressing the weighted responses for other competencies for all diseases in all systems outlined in this study. There are significant sets of compe- tencies in each system addressing issues taught in basic sciences in the classical curricular designs as in our college. The findings of this study should assist the redesigning of curriculum content for many basic sciences in our college. In outcome-based education, clear identifi- cation of competencies in all disciplines will prevent the flow of unnecessary information that has no relevance to the graduating doctors. This will also minimize the redundancy and overlap of information across disciplines. How- ever, this should be conducted through a careful curriculum planning process. Expert internists with subspecialty qualification from 4 different cities in Saudi Arabia with extensive academic experience were included in the first and second Delphi rounds. It has been suggested that a minimum figure of 20  or  so would  be  appropriate  for  a  medical discipline [4]. To provide rep- resentative information, some studies have  employed  over  60  participants  [15] while others have involved as few as 15 participants [16]. Obviously the larger the sample size, the greater the generation of data, which in turn influ- ences the amount of data analysis to be undertaken [5]. The aim was  to  include around 30  participants in the first round of Delphi in this study, however, only 20 clinicians  participated. They included clinicians from different specialties who all were experts in their fields with qualifications in medical education. Interns who fin- ished their internal medicine rotations were included as well: they are newly encountering the professional life of a doctor where they can judge the ap- plicability of what they have been taught and what they have experienced in the rotation. Internal medicine residents with different levels of training were also included as they are considering internal medicine as a career. Their views would likely be influenced by the relative relevancy of diseases, based on their experience. General internists with different subspecialties were included to enrich the outcome of this round with their generalist and subspecialist views. There were some limitations to this study. The results cannot be generalized to different societies with different disease epidemiology. Any application of the find- ings should consider the local epidemiol- ogy of diseases. The findings are not time sensitive as they should go for revision after a specified period of time (deter- mined by the curriculum planners). Issues that were not addressed in this research work were principles of curriculum plan- ning, teaching methods that should be employed to achieve these competencies, time for inpatient versus outpatient train- ing for medical students, communication skills, ethics and attitudes. Competencies in knowledge and skills for internal medicine have been determined and prioritized. This study would greatly influence the cur- riculum reform process that has been adopted by many medical colleges in the region. It should direct curriculum planners to organize curriculum con- tents, to base teaching on important competencies and to design valid assessment methods. It should help designing a national guide for internal medicine teaching in medical colleges in Saudi Arabia. Acknowledgements Experts: Riyadh Alsolymani, Moham- mad Alqasimi, Mansour Aljenadi, Emad Koshak, Abdulsalam Noorwali. Lina Bissar, Samar Badreddine, Saed Alghamdi, Albager Mohammad, Abdulhaleem Gasim, Atef Gabbani, Atef Alzahrani, Asim Alsaedi, Amal Abdulwahab, Ayman Abdo, Nashwa Bannani, Abdulwahab Altelmisani, Taymor Khattab, Kamran Hamed, Samer Sabban, Emad Khojah, Hussam Alem, Fahad Musally, Emad Azhari, Moafaq Kalantan, Riyadh Alleheibi, Ammar Saati, Ismail Alghamdi, Adeeb Albulkhi, Khalid Alghamdi, Turki Ba- faraj, Sultan Alwajeeh, Waleed Hafiz, Mohammad Aloofi, Norah Alshehri, Norah Alzahrani, Ghadah Noh, Hanan Alharthi, Rabab Buoghdadi, Leena Alwafi, Heba Alqurashi, Eman Alqahtani, NorAlhuda, Nashwa Ban- nani, Nuha Hemesh, Safaa Alsanoosi, Marwa Ameen, Nuha Filfilan and Shuaa Basloom Special thanks to: Salwa Aldahlawi for revising the manuscript and Tay- mor Khattab and Rania Zaini for advice given during research. References Shumway JM, Harden RM. AMEE Guide No. 25: the as-1. sessment of learning outcomes for the competent and reflective physician. Medical Teacher, 2003, 25(6):569– 584. Reid N. The Delphi Technique: it’s contribution to the 2. evaluation of professional practice. In: Ellis R, ed. Profes- sional competence and quality assurance in the caring profes- sions. New York, Chapman Hall, 1988. Book 17-8.indb 661 8/9/2011 2:04:43 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 662 De Villiers MR, de Villiers PJ, Kent AP. The Delphi technique 3. in health sciences education research. Medical Teacher, 2005, 27(7):639–643. Dunn WR, Hamilton DD, Harden RM. Techniques of identify-4. ing competencies needed of doctors. Medical Teacher, 1985, 7(1):15–25. Hasson F, Keeney S, McKenna H. Research guidelines for the 5. Delphi survey technique. Journal of Advanced Nursing, 2000, 32(4):1008–1015. Myers AR. 6. NMS Medicine. Philadelphia, Lippincott Williams & Wilkins, 2005. Talley NJ, O’Connor S. 7. Clinical examination: a systematic guide to physical diagnosis. Oxford, Wiley–Blackwell, 2005. Lawrence PF et al. Determining the content of a surgical curricu-8. lum. Surgery, 1983, 94(2):309–317. Goroll AH et al. Reforming the core clerkship in internal medicine: 9. the SGIM/CDIM project. Society of General Internal Medicine/ Clerkship Directors in Internal Medicine. Annals of Internal Medi- cine, 2001, 134(1):30–37. Bass EB et al. National survey of Clerkship Directors in Internal 10. Medicine on the competencies that should be addressed in the medicine core clerkship. American Journal of Medicine, 1997, 102(6):564–571. Olson AL et al. A national general pediatric clerkship cur-11. riculum: the process of development and implementation. Pediatrics, 2000, 106(1 Pt 2):216–222. Jablonover R.S. et al. Evaluation of a national curriculum 12. reform effort for the medicine core clerkship. Journal of General Internal Medicine, 2000, 15(7):484–491. Bajammal S et al. The need for national medical licens-13. ing examination in Saudi Arabia. BMC Medical Education, 2008. 8(1):53. Rethans JJ et al. The relationship between competence and 14. performance: implications for assessing practice perform- ance. Medical Education, 2002. 36(10):901–909. Alexander J, Kroposki M. Outcomes for community health 15. nursing practice. Journal of Nursing Administration, 1999. 29(5):49–56. Fiander M, Burns T. Essential components of schizophrenia 16. care: a Delphi approach. Acta Psychiatrica Scandinavica, 1998, 98(5):400–405. Transformative scale up of health professional education: an effort to increase the numbers of health professionals and to strengthen their impact on population health At the request of its Member States and partners, the World Health Organization (WHO) is developing policy guidelines to assist countries, development partners and other stakeholders in efforts to expand the health workforce and improve the alignment between the education of health workers and population health needs. The first set of guidelines in this process will recommend the transformative scale up of health professional education and aims to increase the quantity, quality and relevance of health professionals to strengthen their impact on population health. The information brochure Transformative scale up of health professional education: an effort to increase the numbers of health professionals and to strengthen their impact on population health provides a background and overview of WHO’s efforts to provide guidance on the transformative scale up of health professional education. Further information about this and other WHO publications is available at: http://www.who.int/publications/en/ Book 17-8.indb 662 8/9/2011 2:04:43 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 663 Evaluation of prophylactic antibiotic administration at the surgical ward of a major referral hospital, Islamic Republic of Iran G. Vessal,1 S. Namazi,1 M.A. Davarpanah 2 and F. Foroughinia 1 ABSTRACT We evaluated the appropriateness of antibiotic prophylaxis administered before surgery at a major referral hospital in Shiraz, against the American Society of Hospital Pharmacists (ASHP) guidelines. Data on surgical procedure, choice of antibiotic and administration were gathered for all surgeries performed on hospitalized patients during 15 days in March 2010. Of 155 patients included in the analysis, 98% received prophylactic antibiotic before surgery; according to ASHP guidelines, prophylaxis was needed in only 106 (68.4%). Of these 106, only 8 patients received the correct antibiotic regimen. The commonest regimens administered were cefazolin + gentamicin (47.6%), cefazolin (20.5%) and cefuroxime (8.5%). Antibiotic prophylaxis was continued in 83% of cases, while this was necessary in only 37%. In only 1 surgical procedure were all evaluated parameters correct. 1Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran (Correspondence to G. Vessal: gvessal@yahoo.com; gvessal@sums.ac.ir). 2Department of Internal Medicine, Nemazi Hospital and Shiraz HIV/AIDS Research Center, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran. Received: 22/11/09; accepted: 11/01/10 ةيملاسلإا ناريإ ةيروهجم في ىبركلا ةلاحلإا تايفشتسم دحأ في ةيحارج ةعاق في يويح داضلم يئاقولا ءاطعلإا مييقت اين يغورف هنازرف ،هانَىبر َىواد ليع دممح ،يزمان اه ُحس ،لاصو لازغ ةنيدم في ىبركلا ةلاحلإا تايفشتسم دحأ في ةحارلجا لبق ةيويلحا تاداضملل يئاقولا ءاطعلإا ةم َىءلا ُحم ىدلم ًماييقت نوثحابلا ىرجأ دق :ةصلالخا تاداضلما رايتخاو ،ةيحارلجا تاءارجلإا لوح تايطعلما ع ْ َىجم متو .تايفشتسلما ةلدايصل ةيكيرملأا ةيعمجلل ةيداشرلإا لئلادلل ًاقفو كلذو ،زايرش دقو .2010 سرام/راذآ رهش في ًاموي شرع ةسخم ىدم لىع ىفشتسلما في ين َىلجاع ُحم ضىرم لىع تيرجأ يتلا تاحارلجا عيجم نم اهئاطعإو ةيويلحا ةيعمجلل ةيداشرلإا لئلادلا لىع ًءانب هنأب ًمالع ؛ةحارلجا لبق ةيئاقّتا ةيويح تاداضم او َّقلت دق ،ليلحتلا في اوجردُحأ ًاضيرم 155 لصأ نم %98 نأ َّينبت ةينماث ىقلت ،ضىرم 106 ـلا ءلاؤه ينب نمو .)%68.4( تلااح 106 في لاإ ةياقولا هذه لىإ ةجاح كانه نكي لم ،تايفشتسلما ةلدايصل ةيكيرملأا ه َىدحو ينلوزافيسلاو ،)%47.6( ينسيماتنلجا عم ينلوزافيسلا وه ًاعويش ةيجلاعلا مظنلا رثكأ ناكو .يويلحا داضلماب حيحصلا يجلاعلا ماظنلا طقف نم %37 في لاإ ًايروضر كلذ نكي لم ينح في ،تلاالحا نم %83 في يئاقتلاا يويلحا داضلما ءاطعإ لىع َىربو ُحث دقو .)%8.5( ميسكورويفيسلاو ،)%20.5( .طقف دحاو يحارج ءارجإ في ةحيحص اهمييقت ىرج يتلا تاتباثتلما عيجم تناكو .بسحف تلاالحا Évaluation de l’administration prophylactique d’antibiotiques au service de chirurgie d’un grand hôpital de recours en République islamique d’Iran RÉSUMÉ Nous avons évalué l’opportunité de l’administration d’antibiotiques prophylactiques avant une intervention chirurgicale dans un grand hôpital de recours à Chiraz, conformément aux directives de l’American Society of Health-System Pharmacists [Société américaine des pharmaciens du système de soins de santé]. Les données sur l’acte chirurgical, le choix des antibiotiques et leur administration ont été collectées pour toutes les interventions chirurgicales réalisées chez des patients hospitalisés pendant 15 jours en mars 2010. Sur 155 patients, 98 % d’entre eux ont reçu une antibiothérapie prophylactique préopératoire ; selon les directives de l’American Society of Health-System Pharmacists, la prophylaxie se justifiait chez seulement 106 patients (soit 68,4 % d’entre eux). Parmi ces 106 cas, seulement huit ont reçu un traitement antibiotique adapté. La céfazoline associée à la gentamicine (47,6 %), la céfazoline (20,5 %) et la céfuroxime (8,5 %) étaient les traitements les plus fréquemment administrés. La prophylaxie antibiotique a été poursuivie dans 83 % des cas, alors que cela ne s’avérait nécessaire que pour 37 % d’entre eux. Une seule intervention chirurgicale réunissait tous les paramètres corrects, selon notre évaluation. Book 17-8.indb 663 8/9/2011 2:04:43 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 664 Introduction Antibiotic prophylaxis has been rou- tinely used  for more  than 25 years  to  prevent postoperative infectious com- plications  [1]. Appropriately  admin- istered antibiotic prophylaxis before surgery reduces the incidence of surgical site infection. However, inappropriate prescribing and excessive use of antimi- crobials increase antibiotic resistance as well as adverse drug events and costs [2]. Multidisciplinary development of  evidence-based prophylaxis guidelines incorporating local microbiology and resistance patterns can improve anti- microbial use [3]. Very often surgeons  do not comply with short courses of prophylactic antibiotics before surgery or they use broad-spectrum antibiotics [2]. Increasing health-care costs have led hospitals to review procedures to adjust their budgets. At the same time, concerns about antimicrobial resist- ance have pressured infection control specialists to decrease antimicrobial usage. In order to develop a guideline for surgical prophylaxis at our hospital, a major referral hospital in the south of the Islamic Republic of Iran, we col- lected data on the performance of our current perioperative practices for anti- microbial prophylaxis. Antibiotic pro- phylactic regimens administered before surgical procedures were evaluated and compared with guidelines of the Ameri- can Society of Hospital Pharmacists (ASHP), which are the most complete guidelines available and internationally recognized [4]. Methods A data collection form was designed by a clinical pharmacist, and approved by the Pharmacy & Therapeutics Commit- tee of the Nemazi Hospital in Shiraz. The form included items regarding patient demographics, type of surgical procedure, drug history, drug allergy, choice of antibiotic regimen, dose, time of administration, and number of doses (pre-, intra-, and post-operatively). A panel of experts assessed whether the data collection form measured what it was intended to measure, and if it was comprehensive enough to collect all the information needed to address the purpose and goals of the study. We then did a pilot test for 20 patients and made  appropriate changes based on expert opinion. The form was filled out prospectively by 6 pharmacists interns for all surgical procedures performed during a 15-day period (March 2008) on hospitalized  patients. Retrospective follow-up was performed by 2 clinical pharmacists and  an infectious diseases specialist, to the day of discharge, using patient files. To avoid difficulties in distinguish- ing prolonged prophylaxis from post- operative infection treatment, surgeries that were in the contaminated or dirty category as well as those patients who received therapeutic antibiotic before surgery or those with signs and symp- toms of infection after surgery were excluded from the study. These are the categories that need therapeutic an- tibiotic administration as per ASHP guidelines. The contaminated category included: any penetrated trauma (< 4 hours old), major technique break or major spillage from the gastrointestinal tract and any acute non-purulent inflam- mation; the “dirty” category included: any penetrated trauma (> 4 hours old), purulent inflammation or abscess (ac- tive infectious process) or preoperative perforation of viscera. The compliance of prophylactic antibiotic administration was assessed against the published guidelines of ASHP  [4]. The  following  6  aspects  of antimicrobial prophylaxis were as- sessed: indication: appropriate decision-• making regarding use or non-use of antimicrobial prophylaxis, choice: antibiotic choice for patients • with and without allergy, dose,• timing of dose: at a fixed time before • incision (within 60 minutes prior  to  skin incision), repeated dosing during procedure,• duration of use.• Extra costs due to incorrect or over- use of antibiotics were calculated as: cost of incorrect usage –cost of correct  usage. The cost of incorrect antibiotic(s) use was calculated as: cost of a single vial × number of vials administered incor- rectly, while the cost of correct antibi- otic use as: cost of a single vial × correct number of vials needed. All data were analysed using SPSS, version 12. Frequencies  and percent- ages were calculated. Results A total of 166 surgeries performed on hospitalized patients were evaluated during  the 15-day period; 92.8% were  elective while  7.2% were  emergency  operations.  Just over 60% (101) of  the  patients were male. The mean age and standard deviation (SD) of the patients was 39.2 (SD 22.6) years (range 0–84  years). Cardiothoracic, gastrointestinal, genitourinary, neurosurgical and or- thopaedic procedures were the most frequent surgeries performed, account- ing  for  18.7%,  17.5%,  16.9%,  13.9%,  and 11.4% of  the surgeries  respectively  (Table 1). Patients who received therapeutic antibiotic (n = 11) before surgery, were excluded from the analysis. This included operations classified as “contaminated” or “dirty”. Therefore further analysis was performed on 155 operations. Table 2 shows  that  in  the majority  of the surgeries included in the analysis [106 (68.4%)],  the prophylactic  anti- biotics administered were necessary according to the ASHP guidelines. Book 17-8.indb 664 8/9/2011 2:04:43 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 665 However,  in almost 30% of  the surger- ies, a prophylactic antibiotic was given, although it was not required according to the guideline. The prophylactic antibiotics admin- istered  in  152  patients  are  shown  in  Table 3. A combination of cefazolin and gentamicin was administered preop- eratively in 93.5% of the cardiothoracic  procedures, 70.0% of the genitourinary,  95.5% of  the neurosurgical,  and 53.3%  of orthopaedic procedures. The choice of antibiotic was consist- ent with ASHP guidelines  in 8 (7.5%)  procedures that required prophylactic antibiotics. Regardless of the choice of antibiotic,  timing was  correct  in 76%  of  the 106 operations.  In 4 operations  the antibiotic was repeated during the procedure, but only 1 required a repeat dose according to the ASHP guidelines. Prophylactic antibiotic was continued in 88 patients after their surgery; how- ever continuation was needed in only 40 of these patients. Table 4 shows the frequency of cor- rect prophylactic antibiotic administra- tion in the 106 operations that required  a prophylactic antibiotic. The average extra cost per patient due to misuse of antibiotics was 92 528  (SD 133 650)  rials, which  is  approxi- mately equal to US$ 9. The total extra cost due to misuse of antibiotics during the 15-day period was 15 267 170 rials  (US$ 1471). Discussion The present study demonstrates that, disappointingly, adherence to the ASHP guidelines for antimicrobial prophylaxis in our hospital is far from optimal. Only 0.9% of  surgical  procedures  adhered  to all antibiotic prophylaxis guideline parameters. These results are consist- ent with those of similar studies in Canada, Nicaragua, Islamic Republic of Iran and Jordan, where rates of com- plete adherence to practice guidelines were 5%  [5],  0.7%  [6],  0.3%  [7],  and  zero  [8]  respectively.  Other  studies  however have reported higher rates of adherence to antimicrobial prophy- laxis guidelines. Gorecki et al. (United States of America), van Kasteren et al. (the Netherlands), Lallemand et al. (France), and Voit et al. (United States of America) reported adherence rates of 26%, 28%, 41% and approximately  50% in their studies [9–12]. It is worth  mentioning that adherence in all of the previously mentioned studies, except the ones performed by Al-Momaney et  al.  (Jordan)  [8]  and Askarian et  al.  (Iran)  [7]  was  compared with  local  rather than international guidelines. The higher adherence in studies that used local  guidelines  (7%–50%)  suggests  that adherence to these guidelines may be easier to achieve than adherence to international guidelines. Appropriate decision-making re- garding use or non-use of prophylactic antibiotics, choice of antibiotic and duration of prophylactic antibiotic use were 3 parameters with the least adher- ence to the standard guidelines in the present study. Prophylactic antibiotics were administered in 98% of the proce- dures, while only 68% of  the surgeries  required them according to the guide- lines. This suggests that surgeons in our country are aware of the value of antibiotics in preventing surgical site in- fections, but as in some other countries [13,14], overuse of antibiotics  is com- mon. In contrast, under-use has been reported in a study from a developed country [15]. The choice of antibiotic complied with  guidelines  in  only  7.5%  of  the  surgical procedures in this study. This low rate is disappointing, particularly as selection of the appropriate antibi- otic for prophylaxis was much higher in  the United States of America (95%  appropriate)  [15]  and  Brazil  (75%)  [16]. However,  it  is  similar  to  India  (12%) [17] and higher  than  reported  in Jordan (1.7% of the procedures) [8].  The high rate of inappropriate choice of Table 1 Type of surgeries performed during the 15-day period in Nemazi Hospital, Shiraz, Islamic Republic of Iran (n = 166) Type of surgery No. % Cardiothoracic 31 18.7 Gastrointestinal 29 17.5 Genitourinary 28 16.9 Neurosurgical 23 13.9 Orthopaedic 19 11.4 Head & neck 9 5.4 Vascular 8 4.8 Obstetric/gynaecologic 1 0.6 Othersa 18 10.8 aInguinal hernia, umbilical hernia, tissue expansion, skin graft, excision of scar tissue, portal catheter, adrenalectomy, chest wall mass, herniorrhaphy, tissue expander removal and splenectomy. Table 2 Evaluation of prophylactic antibiotic indication before surgery in Nemazi Hospital, Shiraz, Islamic Republic of Iran (n = 155a) Prophylactic antibiotic: No % Required and administered 106 68.4 Not required and not administered 3 1.9 Required but not administered 0 0.0 Not required but administered 46 29.7 aPatients who received therapeutic antibiotic (n = 11) before surgery were excluded from the analysis. Book 17-8.indb 665 8/9/2011 2:04:44 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 666 prophylactic antibiotic and unnecessary continuation in our study may be due to the unavailability of a unit-based clinical pharmacist to assist physicians in cor- rect choice of medications according to guidelines. Another reason may be because medical residents are not as fully trained on medication choices as they are on diagnosing diseases and performing procedures. Our study was performed in a university teaching hospital, and medical faculty members (attending physicians) attempt to allow their trainees to practice independently. A significant proportion of the antibiot- ics used in this study were prescribed by the resident in charge. Another reason for wrong choices and dosing of pro- phylactic antibiotics may be the lack of medication protocols and treatment guidelines. Every faculty has his/her own treatment algorithm but there is no consensus guideline available on the ward for trainees to refer to. Th e A S H P r e c o m m e n d s prophylaxis with cefazolin as a single agent for most procedures. However, in the present study a combination of aminoglycoside with cefazolin was the most common regimen used, while the use of third generation cephalosporins were also not uncommon. Third gener- ation cephalosporins, aminoglycosides and fluoroquinolones should not be used for surgical site infection prophy- laxis because of less activity against staphylococci infections compared to cefazolin, emergence of resistance, and high  cost  [18,19]. The  combination  of cefazolin and gentamicin was used most commonly in cardiothoracic, genitourinary and neurosurgical op- erations. This antibiotic combination may be used in situations when certain Gram-negative bacteria not responsive to cefazolin are involved in addition to Gram-positive bacteria such as sta- phylococci. However, Gram-negative bacteria involved in the above surgeries are mostly enteric Gram-negative bacilli [20] and cefazolin alone can cover these  pathogens [21];  thus  there  is no need  for this combination. In the present study antibiotics were continued in 88 of the procedures that required prophylactic antibiotics, how- ever continuation was not necessary in 55% of  these surgeries. Similarly  in  the  study performed by Al-Momany et al. in  Jordan  [8],  the duration of  antibi- otic prophylaxis was longer than rec- ommended  in 58.9% of patients. This  has been reported by other researchers [7,14,17,22]. According to international  guidelines, a single dose of antibiotic is enough for most surgical procedures. Prolonged antibiotic prophylaxis is not only of no benefit but also potentially harmful to patients due to toxicity, risk of super-infection and the risk of induc- ing more bacterial resistance [16,23]. The timing of administration of pro- phylactic antibiotics is important and this was correct in 76.5% (81 of 106 that  required prophylaxis) of the surgeries performed. This is similar to the studies Table 3 Prophylactic antibiotic regimens used in operations performed in Nemazi Hospital, Shiraz, Islamic Republic of Iran (n = 152) Type of surgery Antibiotic regimen administered No. Cardiothoracic Cefazolin + gentamicin 29 Cefuroxime 1 Ceftriaxone + clindamycin 1 Gastrointestinal Ceftriaxone + metronidazole 6 Cefuroxime 6 Cefazolin 4 Ceftriaxone 3 Ceftizoxime + metronidazole 2 Cefuroxime + cefazolin 1 Ampicilline + gentamicin 1 Metronidazole 1 Head & neck Cefuroxime 4 Cefazolin 3 Ampicilline + gentamicin 1 Ceftizoxime 1 Obstetric/gynaecologic Cefazolin 1 Orthopaedic Cefazolin + gentamicin 8 Cefazolin 3 Cefuroxime + cefazolin 2 Ceftriaxone 1 Ampicillin + gentamicin 1 Vascular Cefazolin 3 Cefazolin + gentamicin 2 Ceftriaxone 1 Cefuroxime 1 Genitourinary Cefazolin + gentamicin 19 Cefazolin 8 Ampicillin + gentamicin 1 Neurosurgery Cefazolin + gentamicin 21 Ampicillin + gentamicin 1 Other Cefazolin 12 Cefuroxime 2 Ceftizoxime + metronidazole 1 Book 17-8.indb 666 8/9/2011 2:04:44 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 667 of Paradiso-Hardy et al. in Canada [24]  and Lallemand et al. in France [10], who  showed the timing of administration was correct  in 72% and 61.4% of cases  respectively. Appropriate timing was much higher in the study performed in  Jordan  (99.1%)  [8],  and  lower  in  studies performed in the Netherlands (50%) [11] and Nicaragua (22%) [6].  Large-scale observational studies have shown that the rate of surgical site in- fections decreased by more  than 50%  in patients given appropriately timed antibiotic prophylaxis [25–28]. In addi- tion, appropriate antibiotic timing can decrease overall hospitalization costs [29]. The  relatively  high  rate  of  cor- rect timing of antibiotic administration may be explained by the fact that any time within 0–60 minutes before  skin  incision is considered appropriate for all types of surgeries according to ASHP guidelines. Therefore, this parameter is less prone to error compared with other parameters, such as antibiotic choice, dose and duration of administration. In this study non-adherence to prac- tice guidelines resulted in almost US$ 10 extra cost per patient or US$ 1527  extra cost for the 15-day period of the study, due to over-use of antibiotics. Some patients were kept in hospital to administer intravenous antibiotics as continuation of prophylactic therapy that was not actually necessary. It should be noted that only the extra cost of the drug itself was calculated; costs would have been much higher if extra days of hospitalization and medical equipment needed to administer intravenous anti- biotics were also taken into account. To put these extra costs into a so- cioeconomic perspective, the minimum salary of a worker in Shiraz at the time of  the  study was US$ 400 per month.  Al-Ghamdi et al. in Saudi Arabia re- ported a minimum government cost of US$ 565 603 annually  for misuse of  antibiotics  [13]. According  to  surveys  performed in Belgium [30] and Turkey  [31], adherence to guidelines decreased  extra costs due to inappropriate use of antibiotic prophylaxis. In another study it  was  shown  that  reducing  24-hour  prophylaxis to a single dose, reduces costs without increasing infection rates and results in a potential monthly saving of US$ 2 000 [2]. We were not able to collect all data prospectively due to the fact that there was no clinical pharmacist in charge in the surgical ward. Although prospective data collection is more accurate because some information may not be found in patients’ charts, we were able to extract all the information we needed from the charts. Care was taken to read all the notes and laboratory reports and make sure that the patient did not have any signs or symptoms of a true infection. Patients with these signs or symptoms were excluded from the study as the antibiotic administration would then be for therapeutic treatment rather than prophylactic purposes. Although ASHP recommendations were used as rational and evidenced- based international guidelines, ASHP recommendations may not in fact be practical in our patients and setting or for the situation in the Islamic Re- public of Iran. This is because different countries and institutions may have different microbial flora, resistance patterns, antibiotic availability, rate of post-operative surgical site infection, and operation room sterility. It is sound practice therefore for each centre to have its own guidelines, although the dif- ference between the guidelines would not be expected to be significant. Thus developing a local hospital guideline may be more appropriate. Our study shows that there is an urgent need to develop such guidelines for surgical prophylaxis in our hospital. The guide- lines should include type of surgery, the optimal time of antibiotic administra- tion, choice of antibiotic and an alterna- tive, address intra-operative re-dosing and duration of use. They should also be based on hospital-specific bacterial epidemiology patterns, the best evidence derived from the literature. The support and collaboration of hospital adminis- trators and medical staff of such guide- lines is essential for their development, implementation and maintenance. Table 4 Antibiotic administration in surgeries that required prophylaxis (n = 106) Antibiotic administration No. % Correct choice of antibiotic 8 7.5 Correct choice + correct dose 8 7.5 Correct choice + correct dose + correct time 2 1.9 Correct choice + correct dose + correct continuation 1 0.9 Correct choice + correct dose +correct time + correct continuation 1 0.9 References Garey KW et al. Timing of vancomycin prophylaxis for cardiac 1. surgery patients and the risk of surgical site infections. Journal of Antimicrobial Chemotherapy, 2006, 58:645–650. Fonseca SN et al. Implementing 1-dose antibiotic prophylaxis 2. for prevention of surgical site infection. Archives of Surgery (Chi- cago, Ill.), 2006, 141:1109–1113, discussion 1114. Allerberger F et al. Optimization of antibiotic use in hospitals–3. antimicrobial stewardship and the EU project ABS interna- tional. Chemotherapy, 2008, 54:260–267. Best Practices for Hospital and Health-System Pharmacy. Position 4. and guidance documents of ASHP. Bethesda, MD, American Society of Health-System Pharmacists, 2005–2006. Book 17-8.indb 667 8/9/2011 2:04:44 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 668 Wasey N, Baughan J, de Gara CJ. Prophylaxis in elective color-5. ectal surgery: the cost of ignoring the evidence. Canadian Journal of Surgery, 2003, 46:279–284. van Disseldorp J et al. Application of guidelines on preop-6. erative antibiotic prophylaxis in León, Nicaragua. Netherlands Journal of Medicine, 2006, 64:411–416. Askarian M et al. Adherence to American Society of Health-7. System Pharmacists surgical antibiotic prophylaxis guidelines in Iran. Infection Control and Hospital Epidemiology, 2006, 27:876–878. Al-Momany NH et al. Adherence to international antimicrobial 8. prophylaxis guidelines in cardiac surgery: a Jordanian study demonstrates need for quality improvement. Journal of Man- aged Care Pharmacy, 2009, 15:262–271. Gorecki P et al. Antibiotic administration in patients undergo-9. ing common surgical procedures in a community teaching hospital: the chaos continues. World Journal of Surgery, 1999, 23:429–432, discussion 433. Lallemand S et al. Non-observance of guidelines for surgical 10. antimicrobial prophylaxis and surgical-site infections. Phar- macy World & Science, 2002, 24:95–99. van Kasteren ME et al. Adherence to local hospital guidelines 11. for surgical antimicrobial prophylaxis: a multicentre audit in Dutch hospitals. Journal of Antimicrobial Chemotherapy, 2003, 51:1389–1396. Voit SB et al. Electronic surveillance system for monitoring sur-12. gical antimicrobial prophylaxis. Pediatrics, 2005, 116:1317–1322. Al-Ghamdi S, Gedebou M, Bilal NE. Nosocomial infections and 13. misuse of antibiotics in a provincial community hospital, Saudi Arabia. Journal of Hospital Infection, 2002, 50:115–121. Hu S, Liu X, Peng Y. Assessment of antibiotic prescription in 14. hospitalised patients at a Chinese university hospital. Journal of Infection, 2003, 46:161–163. Vaisbrud V et al. Surveillance of antimicrobial prophylaxis for 15. surgical procedures. Infection Control and Hospital Epidemiol- ogy, 1999, 20:610–613. Heineck I, Ferreira MB, Schenkel EP. Prescribing practice for 16. antibiotic prophylaxis for 3 commonly performed surgeries in a teaching hospital in Brazil. American Journal of Infection Control, 1999, 27:296–300. Thomas M et al. Monitoring of antibiotic use in a primary and 17. tertiary care hospital. Journal of Clinical Epidemiology, 1996, 49:251–254. Silver A et al.; The Antibiotic Prophylaxis Study Group. Time-18. liness and use of antibiotic prophylaxis in selected inpa- tient surgical procedures. American Journal of Surgery, 1996, 171:548–552. Martin C, Pourriat JL. Quality of perioperative antibiotic admin-19. istration by French anaesthetists. Journal of Hospital Infection, 1998, 40:47–53. Antimicrobial prophylaxis for surgical procedures. In: Koda-20. Kimble MA et al., eds. Applied Therapeutics: The clinical use of drugs, 9th ed. Philadelphia, PA, Lippincott Williams & Wilkins, 2009. Principles of infectious diseases. In: Koda-Kimble MA et al., 21. eds. Applied Therapeutics: The clinical use of drugs, 9th ed. Phila- delphia, PA, Lippincott Williams & Wilkins, 2009. Hosoglu S et al. Audit of quality of perioperative antimicrobial 22. prophylaxis. Pharmacy World & Science, 2009, 31:14–17. Harbarth S et al. Prolonged antibiotic prophylaxis after car-23. diovascular surgery and its effect on surgical site infections and antimicrobial resistance. Circulation, 2000, 101:2916–2921. Paradiso-Hardy FL et al. A national survey of antimicrobial 24. prophylaxis in adult cardiac surgery across Canada. Canadian Journal of Infectious Diseases & Medical Microbiology, 2002, 13:21–27. Burke JP. Maximizing appropriate antibiotic prophylaxis for 25. surgical patients: an update from LDS Hospital, Salt Lake City. Clinical Infectious Diseases, 2001, 33 Suppl 2;S78–S83. Carlès M et al. Improvement of surgical antibiotic prophylaxis: 26. a prospective evaluation of personalized antibiotic kits. Journal of Hospital Infection, 2006, 62:372–375 Gyssens IC et al. Optimizing the timing of antimicrobial proph-27. ylaxis in surgery: an intervention study. Journal of Antimicrobial Chemotherapy, 1996, 38:301–308. Van Kasteren ME et al. Quality improvement of surgical proph-28. ylaxis in Dutch hospitals: evaluation of a multi-site intervention by time series analysis. Journal of Antimicrobial Chemotherapy, 2005, 56:1094–1102. Garey KW et al. Economic benefit of appropriate timing of 29. vancomycin prophylaxis in patients undergoing cardiovascular surgery. Pharmacotherapy, 2008, 28:699–706. Sasse A et al. Surgical prophylaxis in Belgian hospitals: estimate 30. of costs and potential savings. Journal of Antimicrobial Chemo- therapy, 1998, 41:267–272. Yalcin AN et al. Increased costs due to inappropriate surgical 31. antibiotic prophylaxis in a university hospital. Journal of Hospi- tal Infection, 2002, 52:228–229. Book 17-8.indb 668 8/9/2011 2:04:45 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 669 Peginterferon alfa-2b and ribavirin therapy in Kuwaiti patients with chronic hepatitis C virus infection S.A. Al-Enzi,1 W.A. Ismail,2 S.A. Alsurayei 1 and A.E. Ismail 2 ABSTRACT Few studies have been conducted in the Eastern Mediterranean region on chronic hepatitis C virus (HCV) infection with reference to genotypes. We investigated the response to standard combination therapy (pegylated interferon/ribavirin) of different genotypes of HCV in Kuwaiti patients and factors that could be associated with sustained virological response (SVR). The records of all Kuwaiti patients treated for chronic HCV between January 2003 and May 2009 were retrospectively identified and reviewed. Of 108 patients studied, 27.8% were infected with genotype 1, 25.0% with genotype 3 and 47.2% with genotype 4. Overall, 64.8% of patients achieved SVR, 25.9%, were non-responders and 9.3% were relapsers. Baseline viral load and alanine aminotransferase level in addition to early virological response to pegylated interferon-based therapy may serve as a decision tool for clinicians to identify patients who are unlikely to achieve SVR. 1Department of Medicine, Farwaniya Hospital, Ministry of Health, Kuwait. 2Department of Medicine, Faculty of Medicine, University of Zagazig, Zagazig, Egypt (Correspondence to W.A. Ismail: waleed.fattah@yahoo.com). Received: 15/11/09; accepted: 11/01/10 سي سويرفلاب نمزلما دبكلا باهتلا ىودعب ينباصلما ينيتيوكلا ضىرلما في نييرفابيرلاو نويرفترنيغيبلاب جلاعلا ليعماسإ ديسلا ليع ،عيسرلا نحمرلا دبع رقص ،ليعماسإ حاتفلا دبع ديلو ،يزنعلا لىع حلاص دقو .ينيلجا طمنلا عم سي سويرفلاب نمزلما دبكلا باهتلا ىودعب ينباصلما لوح طسوتلما قشر ميلقإ في ْتَىيرجُحأ يتلا تاساردلا يه ٌةليلق :ةصلالخا باهتلا سويرفل ةينيلجا طمانلأا فلتخلم نويرفترنلاا تلايجيبو نييرفابيرلاب ةيرايعلما ةيجلاعلا ةفيلوتلل ينيتيوكلا ضىرلما ةباجتسا نوثحابلا صقتسا ضىرلما تلاجس ةعجارمو ديدحتل ةيداعتسا ةسارد ْتَىيرجُحأو .ةميدتسلما ةيسويرفلا ةباجتسلااب ةلص اله نوكي نأ نكمي يتلا لماوعلاو سي دبكلا ضىرم 108 لصأ نمو .2009 ويام/رايأ ىتح 2003 رياني/لوأ نوناك نم ة َّدلما في سي سويرفلاب نمزلما دبكلا باهتلا نم اولجوع نيذلا ينيتيوكلا ضىرلما ّلياجمإ نم %64.8 ققح دقو .4 ينيلجا طمنلاب %47.2و ،3 ينيلجا طمنلاب %25.0و ،1 ينيلجا طمنلاب ينباصم مهنم %27.8 ناك ،مهتسارد تَّتم سيويرفلا لْمِلحا نأ لىع ةساردلا تّلد دقو .سْكُحن ةلاح في %9.3 ناك مانيب ،%25.9 ةباجتسا ّيأ اودْب ُحي لم ْن َىم ةبسن تناكو ،ةميدتسم ةيسويرف ًةباجتسا ةديفم ةليسو لِّثتم نأ نكمي نويرفترنلإا تلايجيب اه ُحساسأ ةلجاعلم ةركبلما ةيسويرفلا ةباجتسلاا لىإ ةفاضلإاب يننلالأا ينمأ ةلقان ىوتسمو يدعاقلا .ةميدتسم ةيسويرف ًةباجتسا مهقيقت مدع ح َّج َىر ُحي نيذلا ضىرلما لوح تارارقلا ذاتخا في ءابطلأل Traitement par peginterféron alfa-2b et ribavirine chez des patients koweïtiens atteints d’infection chronique par le virus de l’hépatite C RÉSUMÉ Peu d’études ont été conduites dans la région de la Méditerranée orientale sur l’infection chronique par le virus de l’hépatite C rapportée aux différents génotypes. Nous avons étudié la réponse à une association médicamenteuse classique (interféron pégylé/ribavirine), de différents génotypes du virus de l’hépatite C chez des patients koweïtiens, et les facteurs qui pourraient être associés à une réponse virologique prolongée. Les dossiers de tous les patients koweïtiens traités pour une infection par le virus de l’hépatite C entre janvier 2003 et mai 2009 ont été recherchés et examinés. Parmi 108 patients étudiés sur dossier, 27,8 % d’entre eux étaient infectés par le génotype 1, 25,0 % par le génotype 3, et 47,2 % par le génotype 4. Globalement, 64,8 % des patients ont présenté une réponse virologique prolongée, 25,9 % étaient non-répondeurs et 9,3 % ont rechuté. La charge virale de référence et le taux d’alanine aminotransférase, associés à une réponse virologique précoce au traitement à base d’interféron pégylé sont des critères qui pourraient servir d’aide à la décision pour les cliniciens afin d’identifier les patients qui ne sont pas susceptibles de présenter une réponse virologique prolongée. Book 17-8.indb 669 8/9/2011 2:04:45 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 670 Introduction Chronic hepatitis C virus (HCV) in- fection affects about 3% of  the world’s  population [1]. In the Eastern Mediter- ranean region, with a population of 446 million, the World Health Organization estimates of the prevalence of HCV infection  range  from 1.0%–4.6%, with  21.3 million people  infected with  the  disease  [2]. Up  to 85% of  these  indi- viduals develop chronic HCV infection, which can progress to cirrhosis, end- stage liver disease and hepatocellular carcinoma  [3]. The  standard  of  care  for the treatment of chronic HCV is a combination therapy with pegylated interferon and  ribavirin  [4]. Pegylated  interferon (PEG-INF) is a synthetic variant of interferon-α, a naturally oc- curring cytokine whose endogenous role is to activate the innate immune re- sponse. Ribavirin (RBV) is a nucleoside analogue that is thought to act through a combination of modalities [5,6]. This  combination therapy, however, shows significantly different response rates for the various HCV genotypes. There are 6 major HCV genotypes, numbered  from 1  to 6. Genotype 2  is  the most responsive, with a sustained virological response (SVR) rate greater than  80%  [7,8]. The most  prevalent  genotype worldwide, genotype 1, is the least responsive. Various studies have reported SVR  in 42%–46% of patients  infected by HCV genotype 1 and 60%  in patients infected by HCV genotype 4 [9–13]. HCV genotypes have been  associated with specific geographical areas. In developed countries, genotype determination has formed a part of the management of patients with HCV infection. The epidemiology of HCV has been shown to be changing rapidly in many countries due to population movement and different lifestyles [14]. Various factors have been associated with response to treatment of chronic hepatitis C including viral factors, such as viral genotype, pretreatment viral load and early virological response (EVR), individual patient characteristics, such as age, sex, liver fibrosis and body mass index, and  interferon regimen [6,9,15– 17].  Nevertheless,  few  studies  have  been conducted in the Eastern Medi- terranean region on chronic HCV with reference to genotypes [18]. In Kuwait,  although there is some data recording the prevalence of HCV genotypes [19]  studies have been only conducted to assess the efficacy of combined therapy on HCV genotype 4 [20–22]. The aim of the present study was to investigate the response to treatment with standard combination therapy of the different genotypes of HCV in Ku- waiti patients and factors that could be associated with SVR. Methods Setting and design The study design was a retrospective records-based study in Farwaniya hospital, which has 1000 beds  and  is  one of 5 general government hospitals which provide secondary health care in Kuwait. The study was conducted after approval from the ethical com- mittee of the Ministry of Health. The study population was recruited from the records of the hepatology outpatient clinic, where evaluation and treatment of patients with suspected HCV were applied by the treating physicians ac- cording to the standard protocol of the hospital. According to this protocol, pa- tients should be investigated for serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Also, Anti-HCV antibody should be assessed by a second-generation enzyme-linked immunosorbent assay. HCV-RNA is detected by polymerase chain reaction (PCR) using Cobas Amplicor HCV monitor, version 2.0 (Roche Diagnos- tics), and is confirmed as compensated liver disease by clinical, biochemical and imaging findings. The HCV genotype is determined using a line-probe assay (INNO-LiPA HCV, Innogenetics). Liver biopsy is done when indicated. The protocol includes treatment of all patients by PEG-INF α-2b (PegIn- tron, Schering-Plough) 1.5mg/kg body weight weekly plus RBV (Rebetol, Schering-Plough)  800  mg/day  for  body weight < 65 kg; 1000 mg/day for  body weight between 65–85 kg;  and  1200 mg/day for body weight > 85 kg.  Patients with genotype 3 disease receive treatment  for 24 weeks while patients  with genotype 1 or 4 disease receive treatment for 48 weeks. All patients are evaluated by their treating physician during office visits with blood tests at regular intervals during treatment and followed up for 24 weeks after cessation  of therapy. Patients The records of all native Kuwaiti pa- tients treated for chronic HCV between January 2003 and May 2009 were  ret- rospectively identified and reviewed. In- clusion criteria included adult, Kuwaiti patients aged ≥ 18 years, with elevated ALT at  least 2 times the upper  limit of  normal on at  least 2 occasions, detect- able anti-HCV antibody status, detect- able HCV-RNA, and demonstration of compensated liver disease by clinical, biochemical and imaging findings. Viral load was considered high if HCV-RNA ≥ 600 000 IU/ mL and low if < 600 000  IU/mL. Patients were excluded from the study if they had other liver diseases, such as hepatitis A, hepatitis B, schis- tosomiasis, autoimmune hepatitis, alcoholic liver disease, drug induced hepatitis, decompensated liver disease or other comorbid conditions such as coinfection with HIV, neoplastic disease, severe cardiac or pulmonary disease, unstable thyroid dysfunction, psychiat- ric disorder, organ transplant, therapy with immunomodulatory agents, neu- tropenia  (< 1500 neutrophils/mm3), anaemia  (haemoglobin  <  12g/dL),  thrombocytopenia (< 90 000 platelets/ mm3), creatinine concentration > 1.5 Book 17-8.indb 670 8/9/2011 2:04:45 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 671 times the upper limit of normal, serum α-fetoprotein  concentration > 25 ng/ mL, pregnancy or breastfeeding. Of 127 patient  records  reviewed,  19 were excluded for different causes and so 108 patients fulfilled the inclu- sion criteria. Patients were classified into 2 groups according  to  the SVR.  The first group was patients without SVR (cases) who were those with non-response, those who relapsed after end-of-treatment response (ETR) and those for whom treat- ment was discontinued either due safety reasons (presence of a treat- ment-related adverse event requiring withdrawal from therapy) or non- safety reasons (refusal of treatment or non-cooperation from the patient). The second group was patients who had SVR (controls). Data collection Other data for the study were re- corded on a special data collection form. These included personal char- acteristics [age,  sex, body mass  index  (BMI) and source of  infection] and  clinical information (antiviral therapy, response to treatment and adverse events) in addition to laboratory in- vestigations (HCV genotype, viral load, ALT and AST levels, complete blood picture and thyroid function tests). Assessment of efficacy EVR was defined as a 2-log10 drop  in HCV  viral  load  by week  12  as  compared to baseline values. Treat- ment was stopped if there was no EVR or if HCV-RNA was detected at week 24 by PCR. ETR was defined  as an undetectable HCV viral load at the end of the treatment course. SVR was defined as an undetectable HCV viral load 6 months after the end of treatment and was considered the primary outcome. All patients who dropped out due to adverse side-effects were considered as non- responders. Statistical analysis Simple descriptive statistics were used [median with interquartile range (IQR)  for quantitative variables and number with percentage  for  categorical ones].  Analysis was initially carried out based on a series of univariate comparisons. In order to control simultaneously for possible confounding effects of the variables, multiple logistic regression was used for the final analysis. In the univariate analysis the chi-squared test was used to detect the association be- tween SVR and explanatory variables. In multiple logistic regression analysis, the association between exposure and outcome was expressed in terms of odds ratio (OR) and  their 95% confidence  intervals (CI). All the explanatory variables in- cluded in the logistic model were categorized  into 2 or more  levels:  sex  (male,  female); age at diagnosis (< 30,  30–39, > 40 years); BMI group (nor- mal, underweight, overweight/obese); mode of infection (medical, personal, unknown); genotype (1, 3, 4); viral load (low, high); ALT times normal level: (2–2.49, 2.5–2.99, > 3); AST times nor- mal level (2–2.49, 2.5–2.99, > 3); EVR  (no, yes). Analysis was performed using SPSS, version 11.0. Results General characteristics of patients Of  108  studied  patients  with  HCV  infection,  30  (27.8%)  patients  were  infected with genotype 1, 27 (25.0%)  with genotype 3 and 51 (47.2%) with  genotype 4. A total of 58 patients were male (53.7%). The median age was 39  (IQR 14.5) years. About half of patients had normal BMI (48.1%) and 39.8%  were overweight or obese. The mode of infection was due to blood transfu- sion or a medical procedure  in 25.1%  of cases or to occupational exposure or contact in 11.1% (unknown in 64.8% of  patients). Virological response Overall 70 patients (64.8%) had SVR,  28  patients  were  non-responders  (25.9%) and 10 patients were relapsers  (9.3%). The corresponding figures were  46.7%, 40.0% and 13.3% in genotype 1,  81.5%, 11.1% and 7.4%  in genotype 3,  and 66.7%, 25.5% and 7.8% in genotype  4. No significant difference could be detected among different genotypes in terms of the final outcome (χ2 = 8.04, P = 0.09) (Table 1). As shown in Figure 1, in genotype 1, 18 patients had EVR. A single patient dropped out and 17 had ETR. Of them, 3 patients were relapsed and 14 patients had SVR (77.8% among EVR). In genotype 3, 24 patients had EVR.  All of  them had ETR. Of  them, 2 pa- tients were relapsers and 22 patients had  SVR (91.7% among EVR). In genotype 4, 41 patients had EVR. Three patients dropped out and 38 had ETR. Of them, 4 patients were relapsers and 34 patients had SVR (82.9% among  EVR). Biochemical response Overall, the median level of ALT dropped significantly from 130 to 33  IU/L (74.6% decrease) and AST from  94 to 43 IU/L (54.3% decrease) after  72 weeks. Analysing the genotypes 1,  3 and 4 separately also showed that the levels of both enzymes dropped significantly  after  72 weeks  (Table  2). Factors associated with SVR A total of 70 HCV patients with SVR  were compared with 38 patients with- out SVR. Male sex, age < 30 years and  normal BMI were more frequent in the SVR group; however, none of these personal factors reached statistical sig- nificance (Table 3). Analysing the clinical factors, geno- type 3 and 4 were significantly associ- ated with SVR (31.4% versus 13.2%,  P = 0.02). SVR was  significantly more  likely in patients with low baseline viral Book 17-8.indb 671 8/9/2011 2:04:45 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 672 load (54.3% versus 13.2%) (P < 0.001),  lower levels of baseline ALT and AST (P = 0.02, P < 0.001  respectively) and  EVR (95.4% versus 42.1%) (P < 0.001)  (Table 4). Results of multivariate logistic re- gression analysis revealed that HCV patients with high baseline viral load were more liable to be non-responders (OR = 5.2, 95% CI: 3.4–17.3), as were  those with higher levels of baseline ALT (≥ 3 times normal level) versus 2.5 times normal level) (OR = 6.8, 95%  CI: 4.1–11.6). Patients who had EVR  were less liable to be non-responders (OR = 0.2, 95% CI: 0.1–0.3) (Table  5). Safety and tolerability As shown in Table 6, overall the most common adverse events of therapy were flu-like symptoms (50.0%), pruri- tus (25.9%), anaemia (16.7%),  fatigue  (16.7%) and depression (15.7%). The  corresponding figures for each geno- type are also shown in Table 6. In  genotype  1,  3  patients  (10%)  were withdrawn from treatment; 2 patients  due  to  severe pruritus  (at  weeks 11 and 12) and 1 patient who  developed febrile neutropenia at week 8 which was adequately treated. The dose of PEG-INF was reduced in 1 patient due to neutropenia, and RBV dose adjustments were necessary  in 2  patients due to anaemia. Among genotype 3, PEG-INF was reduced per protocol in 1 patient due to neutropenia. Among genotype 4, therapy was discontinued  in 2 patients (3.9%) due  to a severe depressive state at week 16 and 6 patients needed antidepressant medication to continue the therapy. The dose of PEG-INF was reduced as per the protocol in 5 patients due to neutropenia or thrombocytopenia. The dose of RBV was reduced per protocol in 7 patients due to anaemia. There were no unusual adverse events reported during this study and no growth factors were used. None of patients devel- oped decompensation and no deaths were reported during therapy or follow-up. Table 1 Final outcome of patients with hepatitis C virus infection by genotype Outcome Genotype 1 Genotype 3 Genotype 4 Total No. % No. % No. % No. % Sustained virological response 14 46.7 22 81.5 34 66.7 70 64.8 Non-response 12 40.0 3 11.1 13 25.5 28 25.9 Relapse 4 13.3 2 7.4 4 7.8 10 9.3 Total 30 100.0 27 100.0 51 100.0 108 100.0 Figure 1 Virological response of patients with hepatitis C virus infection by genotype SVR = sustained virological response; ETR = early virological response; ETR = end-of-treatment response Genotype 3 27 patients Genotype 4 51 patients 18 patients with EVR 24 patients with EVR 41 patients with EVR 17 patients with ETR 24 patients with ETR 38 patients with ETR 3 patients relapsed + 14 patients had SVR (77.0%) 2 patients relapsed + 22 patients had SVR (91.7%) 4 patients relapsed + 34 patients had SVR (82.9%) Genotype 1 30 patients Book 17-8.indb 672 8/9/2011 2:04:46 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 673 Discussion Patients chronically infected with HCV require significantly different durations of therapy and achieve substantially different SVR rates to therapy de- pending on the HCV genotypes with which  they  are  infected  [23]. To our  knowledge, this is the first report from Kuwait to assess the efficacy and safety of the standard combination therapy in chronic HCV infection and predictors of SVR to combined therapy in different genotypes. Our study showed a predominance of  genotype  4  (47.9%)  followed by  genotype 1 (27.3%) and genotype 3  (24.6%)  in  the study population.  In a  previous study that was conducted in Kuwait, Pacsa et al found, within the typable HCV, a comparable preva- lence of genotype-4 (38%) and gen- otype-1 (27%) with a  relatively  lower  prevalence of HCV genotype-3 (9%)  in Kuwaiti nationals [19]. The increase  in the frequency of HCV genotype-3 in the present study may be attributed to the increase in the migrant popula- tion density from genotype-3 areas such as Pakistan, Bangladesh and Iran in Kuwait and this may have an im- pact on the molecular epidemiology of HCV [24,25]. The variation may  also be attributed to a certain degree to HCV accumulated mutation. In Table 2 Biochemical response to standard therapy by genotype of HCV Reading Genotype 1 Genotype 3 Genotype 4 Overall Median (IQR) Median (IQR) Median (IQR) Median (IQR) ALT level (IU/L) Baseline 159 (95) 85 (76) 136 (94) 130 (95) 72 weeks 36 (52) 0 (0) 45 (52) 33 (48) z-test 4.74 4.54 6.19 8.98 P-value < 0.001 < 0.001 < 0.001 < 0.001 AST level (IU/L) Baseline 84 (33) 96 (40) 102 (48) 94 (43) 72 weeks 33 (39) 0 (0) 45 (51) 34 (45) z-test 4.77 4.54 5.61 8.79 P-value < 0.001 < 0.001 < 0.001 < 0.001 IQR = interquartile range; ALT = alanine aminotransferase; AST = aspartate aminotransferase. Table 3 Personal characteristics of HCV patients with and without sustained virological response Variable Sustained virological response Statistical significance No (n = 38) Yes (n = 70) No. % No. % χ2 test P-value Sex Male 18 47.4 40 57.1 0.95 0.33 Female 20 52.6 30 42.9 Age (years) < 30 4 10.5 15 21.4 2.46 0.92 30–39 16 42.1 22 31.4 ≥ 40 18 47.4 33 47.1 BMI group Normal 14 36.8 38 54.3 17.09 0.06 Underweight 8 21.1 5 7.1 Overweight/obese 27 42.1 27 28.6 Mode of infection Medical 11 28.9 15 21.4 2.39 0.30 Personal 2 5.3 10 14.3 Unknown 25 65.8 45 64.3 BMI = body mass index. Book 17-8.indb 673 8/9/2011 2:04:46 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 674 a recent study in Saudi Arabia, it was found  that  55.6%  of HCV  patients  had genotype 4, 12.3% had genotype  2 or 3 and 21.8% had genotype 1 [18].  This is in strong contrast to the situa- tion  in Egypt, where more  than 90%  of chronic HCV cases are caused by genotype 4 [26]. The current study revealed an over- all SVR rate of 64.8% among patients  with HCV after combined therapy of PEG-INF/RBV. The rate of SVR was 46.7%  in  genotype 1,  81.5%  in  geno- type 3, and 66.7% in genotype 4. This is  in accordance with the rates found by Al-Ashgar et al.  in Saudi patients  [18].  However, the rate of SVR in our study was higher regarding genotype 3. To a certain degree, our rates of SVR are higher than those found in some other previous  studies  [12,13,27–29]. This  may be due different population char- acteristics and the impact of different inclusion and exclusion criteria in other studies. For example, patients with liver diseases were excluded from the cur- rent study. Most of those patients, if included, would be expected to add to the non-response group, thereby de- creasing the rates of SVR [21]. Another  study conducted in Kuwait and another one in France showed that patients with severe fibrosis were less likely to respond than other patients  [21,30]. Also,  the  relatively young median age in the cur- rent study may enhance their response [18,31]. In accordance with our results,  others have reported that Asian patients with chronic HCV achieve higher rates of SVR compared with non-Asian pa- tients, particularly those with genotype Table 4 Baseline clinical characteristics of HCV patients with and without sustained virological response Variable Sustained virological response Statistical significance No (n = 38) Yes (n = 70) No. % No. % χ2 test P-value Genotype 1 16 42.1 14 20.0 7.70 0.02 2 5 13.2 22 31.4 3 17 44.7 34 48.6 Viral load (PCR) Low 5 13.2 38 54.3 17.39 < 0.001 High 33 86.8 32 45.7 ALT (× normal level) 2–2.49 7 18.4 30 42.9 8.36 0.02 2.5–2.99 13 34.2 23 32.9 > 3 18 47.4 17 24.3 AST (× normal level) 2–2.49 19 50.0 44 63.8 23.24 < 0.001 2.5–2.99 11 28.9 21 30.4 ≥ 3 8 21.1 4 5.8 Early virological response No 22 57.9 3 4.3 39.79 < 0.001 Yes 16 42.1 66 95.4 PCR = polymerase chain reaction; ALT = alanine aminotransferase; AST = aspartate aminotransferase. Table 5 Factors associated with sustained virological response: results of multivariate logistic regression analysis Variable OR (95% CI) Viral load Low 1a High 5.2 (3.4–17.3) Early virological response No 1a Yes 0.2 (0.1–0.3) Baseline ALT level (× normal level) 2–2.49 1a 2.5–2.99 3.9 (0.9–7.3) ≥ 3 6.8 (4.1–11.6) aReference category. OR = odds ratio; CI = confidence interval; ALT = alanine aminotransferase. Book 17-8.indb 674 8/9/2011 2:04:46 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 675 1  infection  [32,33].  In  addition,  few  patients in the current study dropped out and the need for dose reduction was limited. Many researchers have tried to find the possible predictive factors for SVR. Since the composition of patient sam- ples are diverse in different studies, the results are unlikely be consistent, but ev- idence has shown that HCV genotype, low viral load and combination therapy are the most important factors. Because the factors related to PEG-IFN treat- ment interact, it is difficult to use one factor to predict the effect of therapy in chronic HCV infection [31,34].  In our analysis of patient factors, sex, age at diagnosis, BMI and mode of infection were not independent predic- tors of SVR, either in univariate or in logistic regression analyses. However, higher SVR rates were found in males, younger patients and those with nor- mal BMI. This confirms the results of previous  studies  [18,31].  Regarding  the mode  of  infection,  24.1%  of  our  patients had a documented history of blood transfusion or medical exposure and 64.8% had an unknown source of  infection. This is consistent with studies among Saudi patients [2,35]. This may  be due to a similar pattern of commu- nity-based infection sources. Xie et al. found that the ETR, female sex, younger age and genotype were predictors of SVR. However, age and sex were not statistically correlated with SVR in the logistic model  [31].  In  contrast, Gad  et al. reported an association with bet- ter response in males in the univariate analysis but not in the multiple regres- sion analysis. However, their study was only on genotype 4 [29]. Within virologic factors, we studied HCV genotype, baseline viral load, ALT and AST levels and EVR. In the univari- ate analysis, all these factors had a signifi- cant impact on SVR. After adjustment for confounding factors in the logistic model, only baseline viral load, ALT level and EVR remained significant in- dependent predictors of SVR. There currently exists no systematic explanation for these genotype-specific differences  in clinical outcome [6,36].  It is likely that genotype-specific clinical response rates are the result of a com- bination of host and viral  factors  [23].  Humans are the only known natural hosts for HCV, a virus that is estimated to be hundreds of years old [37]. This  lengthy relationship may have allowed HCV to accumulate adaptive muta- tions that confer increasing resistance to the human immune system. It has been hypothesized that genotype-specific clinical response rates to interferon- based therapies are a reflection of HCV evolutionary adaptations to the human system [23]. The  results of  this  study  indicate that PEG-INF and weight- based RBV therapy was associated with a higher SVR rate among genotype 3 compared with genotype 1 and geno- type  4  patients  (81.5%  versus  46.7%  and 66.7% respectively). Although this  difference did not reaching statistical significance, we think that cases of genotype 4 HCV display intermediate sensitivity to treatment, as it they are more susceptible to treatment than the Table 6 Side effects encountered during therapy for hepatitis C virus infection by genotype Side-effects Genotype 1 Genotype 3 Genotype 4 Overall No. % No. % No. % No. % Flue-like 12 40.0 16 59.3 26 51.0 54 50.0 Itching/rash/pruritus 9 30.0 5 18.5 14 27.5 28 25.9 Anaemia 2 6.7 4 14.8 12 23.5 18 16.7 Fatigue 4 13.3 7 25.9 7 13.7 18 16.7 Depression 7 23.3 4 14.8 6 11.8 17 15.7 Weight loss 3 10.0 7 25.9 7 13.7 17 15.7 Hair loss 7 23.3 0 0.0 5 9.8 12 11.1 Anorexia 9 30.0 2 7.4 1 2.0 12 11.1 Insomnia 5 16.7 0 0.0 6 11.6 11 10.2 Leucopenia 3 10.0 2 7.4 5 9.8 10 9.3 Arthralgia/myalgia 0 0.0 2 7.4 4 7.9 6 5.5 Nausea 2 6.7 0 0.0 3 5.9 5 4.6 Pyrexia 2 6.7 0 0.0 3 5.9 5 4.6 Thrombocytopenia 0 0.0 0 0.0 4 7.8 4 3.7 Diarrhoea 1 3.3 1 3.7 0 0.0 2 1.9 Thyroid disorders 1 3.3 0 0.0 4 7.9 5 4.6 Anxiety 0 0.0 0 0.0 1 0.2 1 0.9 Book 17-8.indb 675 8/9/2011 2:04:47 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 676 difficult-to-treat genotype 1 and display more inherent resistance to treatment than the genotype 3 variant. This is in accordance with other reports [21,38]. Viral kinetic measurements made early in the course of therapy have been used to identify patients unlikely to achieve SVR [39]. In the current study,  it was found that HCV patients with high baseline viral load were less liable to achieve SVR (86.8% of patients who  did not achieve SVR had high baseline HCV-RNA levels as compared with 45.7%  in  SVR  group). This  percent- age indicates the importance of this factor on the SVR rate and these data confirm previous studies [40,41]. Shea  et al. found that low pre-treatment vi- ral  load, genotypes 2/3 and EVR were  predictors of SVR in univariate analysis. However, in multiple analysis, only pre- treatment viral load and EVR remained as significant predictor factors [41]. This  contrasts with was found by Al-Ashgar et al. in Saudi patients [18] and Kuboki  et al. in Japanese patients [32]. The dif- ference may be attributed to the fact that viral load fluctuates and a single reading may not reflect the actual viral load at the time of treatment if it is as- sessed at varying intervals from the date of start of treatment [15]. In the current study, a higher level of baseline ALT was found to be a predictor of non-response. In a recent study conducted in Saudi Arabia, HCV patients who achieved SVR and those who relapsed had similar ALT levels at all  times of  therapy, except at week 72,  when those who relapsed after ETR had significantly higher ALT levels in the univariate analysis but not in the multivariate analysis [18]. Al-Shagar et  al. reported that baseline level of AST and not ALT had a significant effect on SVR [42]. The same was  found by  Borgia et al. in Italy [43]. This difference  could be due the known correlation between these enzymes and other pos- sible confounding effects. In the current study, EVR was found to be a protective factor for non- sustained response. Previous studies have confirmed that the presence of EVR at week 12 can accurately  iden- tify patients unlikely to achieve SVR [40,44]. Consequently,  the week  12  “decision point” has become widely adopted in clinical practice, with treat- ment goals reviewed for those patients failing  to achieve EVR after 12 weeks  [3]. However, Kuboki et al.  found that  83% of patients without EVR at week  12 failed to achieve SVR and all patients  without a virological response at week 24  failed  to attain SVR. He  suggested  that  the week 12 decision point may  not apply to the Japanese population of HCV patients, and that cessation of treatment should not be considered before week 24 [32]. EVR may predict the likelihood of attaining SVR and therefore may be an earlier positive predictor of response to combination  therapy [45,46]. Such  a policy has obvious benefits in terms of costs and reductions in side-effects [41]. Data  from  large  registration  tri- als  showed  that 95% of patients with  detectable HCV-RNA at week 24 of  treatment  failed  to achieve SVR [47].  Moreover, patients who failed to achieve EVR had a negligible chance of  achieving SVR [40,44].  Shea  et  al.  recommended that EVR, with main- tenance of full-dose HCV therapy, will identify a cohort for whom 24 weeks of  treatment will successfully achieve the primary outcome [41]. Withdrawal of patients due to ad- verse events was low in the present study (3.9%  overall).  Dose  reduction  was  indicated  in 12.6% of patients. Adverse  events were typical of those previously reported  for  PEG-INF  therapy  [32]  or even lower than those reported in some other studies [6,10,18]. The safety  profile of the combination therapy was generally similar to that reported in other studies [18,39]. We acknowledge some limitations to our study. As we relied on patient records, the data obtained might be affected by the quality of recording. As in any retrospective study, the results could be subject to bias. Nevertheless, the results are consistent with those from cohort studies. Also, due to the retrospective nature of the study, base- line liver biopsy was not performed in the majority of cases, so we could not investigate its role as a predictor of SVR. As all of the study subjects had abnor- mal aminotransferase levels, we could not assess the response of the patients with normal liver enzymes. Due the relatively small sample size, generaliza- tion of the results should be cautious. However, only native Kuwaiti patients, who constituted an ethnically homog- enous population, were included in the study. Also, the management protocol for HCV that was adopted in the se- lected hospital was the same therapy applied in all government hospitals. Conclusions Although the dominant genotype in native Kuwaiti patients with chronic HCV infection is 4, other genotypes, especially type 1 and 3, occur fre- quently. The responsiveness of HCV genotype 4 to standard therapy was intermediate between HCV genotype 1 and genotype 3. The treatment was well tolerated by most of the patients. Data about baseline viral load and ALT level in addition to EVR may serve as a decision tools for clinicians to iden- tify patients who are unlikely to achieve SVR on PEG-INF-based therapy and to consider discontinuation of treat- ment in those patients, alleviating them of the side-effects and cost of additional therapy. Acknowledgements We are grateful to the help of Dr Medhat K. El-Shazly, Department of Medical Statistics, Medical Research Institute, University of Alexandria, Egypt. Book 17-8.indb 676 8/9/2011 2:04:47 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 677 References World Health Organization. Global surveillance and control of 1. hepatitis C. Report of a WHO Consultation organized in col- laboration with the Viral Hepatitis Prevention Board, Antwerp, Belgium. Journal of Viral Hepatitis, 1999, 6:35–47. Akbar HO. Hepatitis C virus infection in Saudi Arabia. 2. Saudi Journal of Gastroenterology, 2004, 10:127–131. Strader DB et al. American Association for the Study of Liver 3. Diseases practice guideline: diagnosis, management, and treatment of hepatitis C. Hepatology, 2004, 39:1147–1171. National Institutes of Health Consensus Development Confer-4. ence Statement June 10–12, 2002. Management of hepatitis C: 2002. Hepatology, 2002, 36(Suppl. 1):S3–20. Hofmann WP et al. Ribavirin mode of action in chronic hepa-5. titis C: from clinical use back to molecular mechanisms. Liver International, 2008, 28:1332–1343. Feld JJ, Hoofnagle JH. Mechanism of action of interferon and rib-6. avirin in treatment of hepatitis C. Nature, 2005, 436:967–972. Shiffman ML et al. Peginterferon alfa-2a and ribavirin for 16 7. or 24 weeks in HCV genotype 2 or 3. New England Journal of Medicine, 2007, 357:124–134. Yu MI et al. A randomized study of peginterferon and ribavirin 8. for 16 weeks in patients with genotype 2 chronic hepatitis C. Gut, 2007, 56:553–559. Seuzem S. Heterogenous virologic response rates to inter-9. feron-based therapy in patients with chronic hepatitis C: who responds less well? Annals of Internal Medicine, 2004, 140:370–381. Manns MP et al. Peginterferon a-2b plus ribavirin compared with 10. interferon alfa-2b plus ribavirin for initial treatment of chronic hepatitis C: a randomized trial. Lancet, 2001, 358:958–965. Hadziyannis SJ et al. Peginterferon alpha 2a and ribavirin com-11. bination therapy in chronic hepatitis C: a randomized study of treatment duration and ribavirin dose. Annals of Internal Medicine, 2004, 140:346–355. Kamal SM et al. Peginterferon alpha-2b and ribavirin therapy in 12. chronic hepatitis C genotype 4: impact of treatment duration and viral kinetics on sustained virological response. Gut, 2005, 54:858–866. Males S et al. Serum alpha-fetoprotein (AFP) level predicts 13. treatment outcome in chronic hepatitis C. Antiviral Therapy, 2007, 12:797–803. Osoba AO. Hepatitis C virus genotypes in Saudi Arabia. 14. Saudi Medical Journal, 2002, 23:7–12. Hu KQ, Vierling JK, Redeker AG. Viral host and interferon 15. related factors modulating the effect of interferon therapy for hepatitis C virus infection. Journal of Viral Hepatitis, 2001, 8:1–18. Bressler BL et al. High body mass index is an independent risk 16. factor for non response to antiviral treatment in chronic hepa- titis C. Hepatology, 2003, 38:557–559. Distante S et al. Raised serum ferritin predicts non-response 17. to interferon and ribavirin treatment in patients with chronic hepatitis C infection. Liver, 2002, 22:269–275. Al-Ashgar H et al. Sustained virologic response to peginter-18. feron alfa-2a and ribavirin in 335 patients with chronic hepa- titis C: A tertiary care center experience. Saudi J Gastro, 2008, 14:58–65. Pacsa AS et al. Genotypes of hepatitis C virus in Kuwait. 19. Medi- cal Principles and Practice, 2001, 10:55–57. Varghese R et al. Treatment of chronic hepatitis C genotype 4 20. with peginterferon alpha-2a plus ribavirin. Hepato-Gastroen- terology, 2009, 56:218–22. Hasan F et al. Pegylated interferon alfa-2b plus ribavirin for the 21. treatment of chronic hepatitis C genotype 4. American Journal of Gastroenterology, 2004, 99:1733–1737. Koshy A et al. Treatment of hepatitis C virus genotype 4-related 22. cirrhosis: ribavirin and interferon combination compared with interferon alone. Journal of Clinical Gastroenterology, 2002, 35:82–85. Pang PS, Planet PJ, Dlenn JS. The evolution of the major hepa-23. titis C genotypes correlates with clinical response to interferon therapy. PloS One, 2009, 4:e6579. Mumtaz K et al. Distribution of hepatitis C genotypes and its 24. response to treatment in Pakistani patients. Saudi Medical Journal, 2008, 29:1671–1673. Zali MR et al. Hepatitis C virus genotypes in the Islamic Repub-25. lic of Iran: a preliminary study. Eastern Mediterranean Health Journal, 2000, 6:372–377. Ray SC et al. Genetic epidemiology of hepatitis C virus through-26. out Egypt. Journal of Infectious Diseases, 2000, 182:698–707. Cross TGS, Antoniades CG, Harrison PM. Current and future 27. management of chronic hepatitis C infection. Postgraduate Medical Journal, 2008, 84:172–176. Leung NW. Management of viral hepatitis C. 28. Journal of Gastro- enterology and Hepatology, 2002, 17(Suppl.):S146–S154. Gad RR et al. Predictors of a sustained virological response 29. in patients with genotype 4 chronic hepatitis C. Liver Interna- tional, 2008, 28:1112–1119. Roulot D et al. Epidemiological characteristics and response to 30. peginterferon plus ribavirin treatment of hepatitis C virus gen- otype 4 infection. Journal of Viral Hepatitis, 2007, 14:460–467. Xie Y et al. Predictive factors for sustained response to inter-31. feron treatment in patients with chronic hepatitis C: a rand- omized, open, and multi-center controlled trial. Hepatobiliary and Pancreatic Diseases International, 2005, 4:213–219. Kuboki M et al. Peginterferon a-2a (40 KD) plus ribvirin for the 32. treatment of chronic hepatitis C in Japanese patients. Journal of Gastroenterology and Hepatology, 2007, 22:645–652. Dev AT et al. Southeast Asian patients with chronic hepatitis 33. C: the impact of novel genotypes and race on treatment out- come. Hepatology, 2002, 36:1259–1265. Orito E. HCV genotype as a predictor of response to interferon 34. therapy in patients with chronic hepatitis C. Japanese Journal of Clinical Medicine, 2001, 59:1356–1362. Shobokshi OA, Serebour FE, Skakni LI. Hepatitis C genotypes/35. subtypes among chronic hepatitis patients in Saudi Arabia. Saudi Medical Journal, 2003, 24:S87–S91. Chisari FV. Unscrambling hepatitis C virus-host interaction. 36. Nature, 2005, 436:930–932. Bybus OG et al. Genetic history of hepatitis C virus in East Asia. 37. Journal of Virology, 2009, 83:1071–1082. Kamal S. Improving outcome in patients with hepatitis C vi-38. rus genotype 4. American Journal of Gastroenterology, 2007, 102:2582–2588. Di Bisceglie AM et al. Early virologic response after peginter-39. feron alpha-2a plus ribavirin or peginterferon alpha-2b plus ribavirin treatment in patients with chronic hepatitis C. Journal of Viral Hepatitis, 2007, 14:721–729. Fried MW et al. Peginterferon a-2a plus ribavirin for chronic 40. hepatitis C virus infection. New England Journal of Medicine, 2002, 347:975–982. Shea DO et al. Role of rapid virological response in prediction 41. of sustained virological response to Peg-IFN plus ribavirin in Book 17-8.indb 677 8/9/2011 2:04:47 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 678 HCV/HIV co-infected individuals. Journal of Viral Hepatitis, 2008, 15:482–449. Al-Shgar H et al. Predictors of sustained virological response to 42. a 48-week course of pegylated interferon alfa-2a and ribavirin in patients infected with hepatitis C virus genotype 4. Annals of Saudi Medicine, 2009, 29:4–14. Borgia G et al. Homocysteine levels and sustained virological 43. response to pegylated-interferon a2b plus ribavirin therapy for chronic hepatitis C: a retrospective study. Liver International, 2009, 29:248–252. Davis GL et al. Early virologic response to treatment with 44. peginterferon alfa-2b plus ribavirin in patients with chronic hepatitis C. Hepatology (Baltimore, Md.), 2003, 38:645–652. Ferenci P et al. Predicting sustained virological response in 45. chronic hepatitis C patients treated with peginterferon alfa-2b (40KD)/ribavirin. Journal of Hepatology, 2005, 43:425–433. Ferenci P. Predicting the therapeutic response in patients with 46. chronic hepatitis C: the role of viral kinetic studies. Journal of Antimicrobial Chemotherapy, 2004, 53:15–18. McHutchison JG et al. predicting response to initial therapy 47. with interferon plus ribavirin in chronic hepatitis C using serum HCV RNA results during therapy. Journal of Viral Hepatitis, 2001, 8:414–420. Hepatitis C No vaccine exists to prevent hepatitis C virus (HCV) infection, unlike those for hepatitis A and B virus. The risk of infection can be reduced by avoiding: unnecessary and unsafe injections; unsafe blood products; unsafe sharps waste collection and disposal; use of illicit drugs and sharing of injection equipment; unprotected sex with HCV- infected persons; sharing of sharp personal items that may be contaminated with infected blood; tattoos, piercings and acupuncture performed with contaminated equipment. If a person is infected with HCV, they should: receive education and counselling on options for care and treatement; be immunized with hepatitis A and B vaccine, to prevent co-infection from these hepatitis viruses, to protect their liver; get early and appropriate medical management including antiviral therapy if appropriate; and get regular monitoring for early diagnosis of liver disease. Interferon and ribaviron-based therapy has been the mainstay of HCV treatment. Unfortunately, interferon is not widely available globally, is not always well tolerated, some genotypes respond better than others, and many people who take it do not finish their treatment. Fortunately, scientific advances and intense research and development have led to the development of many new oral antiviral drugs for HCV infection. The future seems to hold great promise for HCV specific oral drugs that will be more effective and better tolerated. Much still needs to be done to ensure that these advances lead to greater access and treatment globally. Source: WHO Fact sheet No. 164, June 2011 http://www.who.int/mediacentre/factsheets/fs164/en/index.html Book 17-8.indb 678 8/9/2011 2:04:48 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 679 Cross-reaction of antigen preparations from adult and larval stages of the parasite Setaria equina with sera from infected humans with Wuchereria bancrofti M.M. Bahgat,1 A.H. Saad,2 G.A. El-Shahawi,3 A.M. Gad,4 R.M. Ramzy,5 A. Ruppel 6 and M. Abdel-Latif 3 ABSTRACT Crude antigenic preparations from Setaria equina were used in ELISA and Western blotting to examine cross- reaction with human sera from areas endemic for bancroftian filariasis. Sera from normal subjects from non-endemic areas were included as negative controls. Cross-reaction was found between S. equina antigens and antibodies in the sera of Wuchereria bancrofti-infected patients, with the highest levels observed between sera of chronic infected patients and Setaria spp. crude female worm surface antigen (CFSWA). In the absence of active transmission of Setaria spp. infection, CFWSA is useful to detect chronic W. bancrofti infection before patients become symptomatic, particularly when chronic patients are known to be amicrofilaraemic. In the presence of active S. equina infection, antigens from the adult and microfilaraemic stages showed the highest degree of cross-reaction with human sera. 1Department of Therapeutic Chemistry and Infectious Diseases and Immunology Laboratory, Centre of Excellence for Advanced Sciences, National Research Centre, Dokki, Cairo, Egypt (Correspondence to M. Bahgat: mbahgatriad@yahoo.com). 2Department of Zoology, Faculty of Science, University of Cairo, Cairo, Egypt. 3Department of Zoology, Faculty of Science, University of Beni-Suef, Beni-Suef, Egypt. 4 Department of Entomology, Ain Shams University, Cairo, Egypt. 5National Nutrition Institute, General Organization for Teaching Hospitals and Institutes, Cairo, Egypt. 6Department of Tropical Hygiene and Public Health, University of Heidelberg, Heidelberg, Germany. Received: 08/12/09; accepted: 25/11/09 ينباصم سانأ لاصمأ عم ةيليلخا ةنابْلَلها لييفطل ةَّيق ََيرلاو ةغلابلا لحارلما نم ة َّدَمَتسم ةَّيدضتسم تاضرحتسلم بلاصتلما لعافتلا ةيتفوركنبلا ةيرَخُفلاب ديس دوممح ،لبور سايردنأ ،يزمر دممح اضر ،داج دممح لداع ،يواهشلا معنلما دبع لاجم ،يفنح نيدلا دعس ميكلحا دبع ،ضاير تجبه دوممح فيطللا دبع ءارجلإ ،نترسيو ةخاطل رابتخاو ،ELISA ميزنلإاب طبترلما يعانلما زتملما رابتخا في ةَّيليلخا ةَىنابْل َىلها نم ماخ ةَّيدضتسم تاضرحتسم نوثحابلا مدختسا :ةصلالخا في ينيعيبط دارفأ نم ةذوخأم لاصمأ ةساردلا في تجردُحأو .ةيتفوركنبلا تايرلايفلا ءادب ةنوطوم قطانم نم ةذوخألما ةيشربلا لاصملأا عم بلاصتلما لعافتلا ضىرلما لاصمأ في ةدوجولما دادضلأا ينبو ةيليلخا ةنابللها تادضتسم ينب ًابلاصتم ًلاعافت نوثحابلا فشتكا دقو .ةيبلس دهاوش اهفصوب ةنوطوم يرغ قطانم .ةنابْل َىلها ةدودلا عاونأ ىثنلأ مالخا يحطسلا دضتسلما ينبو ةنمزم ًةباصإ ينباصلما ضىرلما لاصمأ ينب تايوتسلما لىعأ تدهوشو ،ةيتفوركنبلا ةير َىخ ُحفلاب ينباصلما ءادب ةنمزلما ىودعلا نع فشكلا في ًاديفم نوكيس ىثنلأا ةنابْل َىلها عاونلأ مالخا يحطسلا دضتسلما نإف ،ةنابْل َىلها عاونأب ىودعلل طشنلا لاقتنلاا بايغ فيو طشنلا لاقتنلاا دوجو في امأ .تايرلايفوركلما نم ًةيلاخ يننمزلما ضىرلما ءامد نوكت امدنع مايسلاو ،ضىرلما لىع ضارعلأا روهظ لبق ةيتفوركنبلا تايرلايفلا .ةيشربلا لاصملأا عم بلاصتلما لعافتلا نم ةجرد لىعأ ترهظأ تايرلايفوركلما نمو ةغلابلا لحارلما نم ة َّدمتسلما تاّدضتسلما نإف ،ةيليلخا ةنابْل َىلهاب ىودعلل Réaction croisée entre des préparations d’antigènes provenant du parasite Setaria equina aux stades larvaire et adulte et les sérums de personnes infestées par Wuchereria bancrofti RÉSUMÉ Des préparations d’antigènes bruts de Setaria equina ont été utilisées dans le cadre des méthodes ELISA et transfert Western afin d’étudier la réaction croisée avec des sérums humains en provenance de zones endémiques pour la filariose de Bancroft. Des sérums prélevés chez des sujets normaux vivants dans des zones non endémiques ont été inclus en tant que témoins négatifs. Une réaction croisée a été observée entre les antigènes S. equina et les anticorps des sérums prélevés chez des patients infestés par Wuchereria bancrofti, les taux les plus élevés ayant été observés dans le cas de la réaction croisée entre les sérums des patients chroniquement infestés et l’antigène de surface brut de ver femelle Setaria spp. En l’absence de transmission active de l’infestation par Setaria spp., l’antigène de surface brut de ver femelle Setaria spp. est utile pour détecter une infestation chronique à W. bancrofti avant l’apparition des symptômes, notamment lorsqu’une amicrofilarémie a été diagnostiquée chez des patients chroniquement infestés. En présence d’une infestation active à S. equina, la plus forte réaction croisée a été observée entre les antigènes provenant des stades adultes et microfilarémiques et des sérums humains. Book 17-8.indb 679 8/9/2011 2:04:48 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 680 Introduction Adult Setaria equina is a filarial parasite commonly found floating free within the peritoneal cavity of equines in all parts of  the world [1].  In most cases,  S. equina are considered nonpatho- genic in their natural hosts. However, serious pathogenic effects can occur when such a parasite is found in unu- sual habitats such as the ocular globe or central nervous system [2]. World- wide, several surveys have revealed a high incidence of the parasite both in  equines  and  in  its  vectors  [3–6],  where its morphology was previously described using both light and electron microscopes [7,8]. Cross-reaction has previously re- ported been between the antigens of S. equina, S. cervi and S. digitata adult worms and sera from humans infected with Wuchereria bancrofti (round- worms), the parasites that cause lym- phatic  filariasis  [9–12].  In  addition,  cross-reactivity of crude adult worms of the animal filarial parasites Diro- filaria immitis, Brugia pahangi  [13,14]  and the larval stages of Dir. immitis [13]  with antibodies in the sera of humans residing in endemic areas for human filariasis was found. In Egypt, antigens derived from Dipetalonema evansi, Litomosoides carinii and Dir. immitis were also found to be cross-reactive [15–20]. Many previous reports have docu- mented the existence of zoonotic filarial infections, such as Dirofilaria  spp [21– 25], Onchocerca spp [26], and Brugia spp [27,28]. Also, infections by both Dir. im- mitis and W. bancrofti were observed in both Aedes polynesiensis and Ae. samoanus mosquitoes in Samoa [29]. Thus, if the  serodiagnostic methods used for detec- tion of human filariasis are based on common antigens between animal and human filarial parasites, this may lead to false conclusions, e.g. predictions about a resurgence of human filariasis in a set- ting where animal filariasis is endemic. These cross-reactive antigens among human and animal filarial parasites need to be identified. The probability of S. equina transmission to humans, either by W. bancrofti vector species or by oth- ers, is not yet known. The focus of previous studies was to identify antigens from available filarial parasites including those in animals in order to diagnose W. bancrofti infection [11,30]. However the possibility of hu- man infection with those parasites and subsequent misdiagnosis has received little attention. In this study, we exam- ined the extent of cross-reaction among antigens prepared from different stages of S. equina with well-characterized sera collected from human subjects infected with W. bancrofti. Methods Collection of parasite stages Horses and donkeys (n = 367) of dif- ferent ages and sexes with suspected filarial infections were examined after slaughtering  from  August  2004  to  February 2008  in Beni-Suef governo- rate. Adult S. equina of both sexes were collected in peritoneal fluid, washed 3 times with cold phosphate buffered saline  (PBS)  containing  100 U/mL  penicillin and 100 µg/mL streptomycin  and frozen at –85 °C. Microfilariae were  collected in vitro, either on spontaneous release  from  female worms [31] or by  mechanical disruption of worm uteri in Tyrode solution, followed by isolation of microfilariae using Percoll gradient centrifugation [32]. Antigen preparation The following were prepared: soluble fe- male and male S. equina antigens (SFWA and SMWA) [33], crude female worm  surface antigen (CFSWA) [10] and fe- male worm excretory-secretory antigen (FWESA)  [31]. Microfilarial  antigen  (MFA) was prepared by homogeniza- tion in coating buffer for enzyme-linked immunosorbent  assay  (ELISA)  [34]  or electrophoresis sample buffer for Western blotting [35]. Human sera Human blood samples were collected from areas endemic for W. bancrofti in Egypt: 19 samples were from amicro- filaraemic chronic patients who had apparent symptoms of lymphoedema and  elephantiasis;  20  samples  were  from microfilaraemic individuals who had not developed any symptoms of the  disease;  20  samples  were  from  endemic normal subjects who were defined as individuals residing in an endemic setting but had never devel- oped microfilaraemia or symptoms, although their sera may have parasite antigens or antiparasite antibodies; and 11 sera samples were collected from nonendemic normal individuals who had no history of the disease and had never been in an area endemic for ban- croftian filariasis. Blood samples were centrifuged at 12 000 g,  sera were col- lected, aliquoted and  frozen at –85 °C  until use. ELISA The assay was carried out in U-shaped polyvinyl microtitre plates (Alto) [36].  Briefly, plates were coated with SFWA, SMWA, CFWSA, FWESA or MFA antigens  in  coating  buffer  (100  µL/ well; 3 h at room temperature) with the optimum antigen concentrations (0.2,  0.1, 0.5, 0.03, 0.11, 0.05 and 0.03 µg pro- tein/well respectively, based on results obtained from preliminary block titra- tion experiments). Plates were washed and blocked (1 h at 37 °C).  Individual  human sera from chronic infected, microfilaraemic, endemic normal and nonendemic normal subjects were diluted and loaded to the plate wells in duplicates (100 µL/well) and  incu- bated for 2 h at 37 °C. Antibody binding  was detected using diluted (1:20 000)  peroxidase-conjugated goat antihu- man IgG (Jackson Immuno Research Laboratories; Dianova). Visualization of  the antigen–antibody  reaction was  Book 17-8.indb 680 8/9/2011 2:04:48 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 681 detected using the substrate O-phe- nylenediamine (Sigma) and changes in optical density (OD) were recorded at λmax 490 nm using a multi-well plate  reader (Sunrise, Tecan). Positive reac- tions were those with ODs above the respective cutoff values, which were de- termined by the mean IgG reactivities in control sera against each antigen used plus 2 standard deviations. Electrophoresis and immunoblotting analysis Protein profiles of different antigenic preparations from S. equina were analysed by sodium dodecyl sulfate polyacryla- mide gel electrophoresis (SDS-PAGE) [37]  through  4%  stacking  and  12%  resolving gels (55 × 85 × 1 mm) under reducing conditions. Low and high molecular weight markers ranging from 14.5 to 97 kDa and 45 to 200 kDa (Bio- Rad Laboratories) were included on the same gels. Following electrophoresis, gels were Coomassie stained or electro- phoretically  transferred  [38]  from  the  gel to nitrocellulose sheets (BA85, pore size 0.45 µm; Schleicher  and Schüll).  Based on their reactivities in ELISA, the sera from chronic, microfilaraemic and endemic normal subjects were classi- fied into highly, moderately and weakly reactive groups. Pools for such groups as well as that of nonendemic normal sera were used at dilution 1:150 in PBS-0.3%  Tween. Incubation and washing condi- tions have been described previously [39]. The immunodetection was carried  out with peroxidase-conjugated goat antibodies  to  human  IgG  (1:10 000;  Bio-Rad Laboratories). Visualization of antigen–antibody binding on the ni- trocellulose strips was carried out by de- veloping the strips with the substrate 3, 3-diaminobenzidine substrate (Sigma). Statistical analysis The data were analysed using Student t- test and Pearson correlation coefficient. All statistical analyses were carried out using the Practistat statistical program (Ashcroft-Pereira). Results Electrophoresis of crude parasite antigen The Coomassie staining profile of the SFWA, SMWA, CFWSA, FWESA and MFA antigens resolved by SDS-PAGE are presented in Figure 1. The results showed clear differences in protein pat- terns among these antigens. FWESA did not show any stained bands. IgG detection by ELISA The results showed that the highest prevalences of IgG antibodies against all antigen preparations were recorded among amicrofilaraemic chronic infect- ed patients (Table 1). SFWA showed generally higher sensitivity in detecting IgG than SMWA. For both antigenic preparations, the IgG positive reactions were in the order: chronic > microfila- raemic > endemic normal subjects. All sera of chronic infected patients were uniformly IgG positive to CFWSA, while sera of both microfilaraemic and endemic normal subjects showed less reactivity. None of the microfilaraemic or endemic normal sera were IgG posi- tive for MFA, while few of the sera from chronic patients were IgG-positive. Detection of immunonogenic peptides by Western blotting Sera from chronic infected patients that were classified as highly reactive in the ELISA  (OD ≥ 0.38)  strongly  recog- nized immunogenic bands at 93.3 kDa in SFWA, 100.5 kDa  in FWESA and  24 kDa in MFA (Figure 2). Moderately  reactive sera from chronic patients (OD ≥ 0.26)  recognized  an  immunogenic  band at 27.8 kDa  in CFSWA. Weakly  reactive sera from chronic patients (OD ≥ 0.15) recognized immunogenic  bands at 17 and 60 kDa in SFWA and  MFA respectively. All chronic patients’ sera recognized immunogenic bands at 33.6 kDa in SFWA and 200 kDa in both  CFSWA and FWESA. Highly reactive sera from micro- filaraemic asymptomatic subjects (OD ≥ 0.34)  strongly  recognized  immuno- genic bands at 33.6 kDa in SFWA and 66.2 kDa  in SMWA. Weakly  reactive  (OD ≥ 0.16) microfilaraemic sera  rec- ognized  immunogenic bands  at  81.0  kDa in SFWA. All sera from both the chronic patients and microfilaraemic Figure 1 Coomassie staining profile of SDS-12.5% PAGE resolved soluble female worm antigen (lane 1), soluble male worm antigen (lane 2), crude female worm surface antigen (lane 3), female worm extracted–secretory antigen (lane 4) and microfilarial antigen (lane 5) under reducing conditions in comparison to low (left) and high (right) molecular weight markers Book 17-8.indb 681 8/9/2011 2:04:49 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 682 subjects recognized antigenic bands at 200 kDa in both CFWSA and FWESA,  while only the highly reactive sera from endemic normal subjects recognized the same band in CFWSA. The highly reactive endemic normal sera (OD ≥ 0.44) recognized a common  immunogenic band at 81.0 kDa in SFWA  and SMWA and also 33.6, 45.0 and 66.2  kDa  in SMWA (Figure 2). Only highly  and moderately reactive endemic normal patients’ sera (OD ≥ 0.23) recognized a  200.0 kDa band in CFWSA, while both  highly reactive microfilaraemic subjects’ and endemic normal patients’ sera shared recognition of the 81 kDa immunogenic band in SMWA. Discussion In this study, we attempted to determine the extent of cross-reactivity of antigens derived from animal filarial parasites such as S. equina with sera from humans infected with W. bancrofti. This could help us to predict the influence of hu- man infection with the parasite infective stages on the sensitivities of W. bancrofti diagnostic tests [40].  Comparing the efficiency of dif- ferent tests in the serodiagnosis of bancroftian filariasis has shown that the ELISA method is simple and sen- sitive  [41].  In  the present  study,  sera  from symptomatic chronic patients and asymptomatic microfilaraemic subjects did not show any IgM reactivity against the prepared crude antigens in compari- son with the sera from normal subjects who had never been in an endemic area (data not shown). However, the reactiv- ity of IgG in the same sera was obvious when compared with the sera from non- endemic normal subjects. It is notewor- thy that IgM was previously considered as having a higher reactivity over IgG for detection of active filarial infection using Dir. immitis  soluble antigen [19].  Accordingly, the present study focused on monitoring IgG reactivity in human sera using both ELISA and Western blotting. In ELISA, the observed higher positive IgG reactivity against all the antigenic preparations for human sera from chronic patients in comparison with other human sera might be attrib- uted to worm death in chronic patients, which could expose these patients to more antigenic determinants released from dead worms. This hypothesis was previously used to explain the higher humoral reactivity of symptomatic pa- tients to the detergent-extracted antigen rather  than  the soluble one [42]. Gen- erally, the presence of microfilariae in blood is immunosuppressive for anti- body production [43,44]. We observed a higher IgG positiv- ity among microfilaraemic patients to the crude female (CFWSA) than male S. equina worm antigens (CMWSA), which could be explained by exposure of such patients to cross-reactive W. bancrofti female epitopes rather than male ones. The IgG reactivity in the sera of some asymptomatic non- microfilaraemic human individuals (the endemic normals), was positive to all an- tigenic preparations from S. equina adult worms. This may be due to the pres- ence of cryptic adult worm infections or ultra-low levels of microfilaraemia in those individuals that did not allow detection of infection by conventional parasitological examination [45,46]. It was not surprising that all sera from chronic patients were cross- reactive with S. equina CFWSA, as was previously reported in a study in India focusing on S. digitata  [10]. The  cross-reaction of IgG antibodies in W. bancrofti-infected human sera with Dir. immitis and Dip. evansi sonicated mi- crofilarial antigens has been previously reported  [15,47].  In  our  study,  only  Table 1 Prevalence of IgG antibodies in human sera against different antigen preparations for Setaria equine Antigen preparation Cut-off value Human sera from: Amicrofilaraemic chronic patients (n = 19) Microfilaraemic patients (n = 20) Endemic normal subjects (n = 20) IgG prevalence (%) P-valuea IgG prevalence (%) P-valuea IgG prevalence (%) P-valuea Soluble S. equina female antigen 0.29 73.7 < 0.001 55.0 < 0.01 15.0 NS Soluble S. equina male antigen 0.42 47.4 < 0.020 20.0 NS 5.0 NS Crude female worm surface antigen 0.14 100.0 < 0.001 60.0 < 0.01 40.0 < 0.05 Female worm excretory– secretory antigen 0.23 36.8 NS 10.0 NS 50.0 NS Microfilarial antigen 0.64 31.5 < 0.020 0.0 < 0.01 0.0 < 0.001 aStudent t-test. NS = not significant. Book 17-8.indb 682 8/9/2011 2:04:49 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 683 31.5% of  chronic  patients’  sera were  IgG positive against the sonicated mi- crofilarial antigen of S. equina (MFA), while all microfilaraemic and endemic normal sera were uniformly negative. Whether this cross-reactivity between MFA and chronic patients’ sera is re- lated to cross-reactive antigens from dead worms or amicrofilaremia remains unknown. The possibility that this is re- lated to the immune clearance of blood microfilariae (amicrofilaraemia) is not inconsistent with previous immunolog- ical studies showing that many patients with chronic lymphatic obstruction are amicrofilaraemic because they are no longer infected with filarial parasites [48,49].  In addition,  endemic normal  individuals who are amicrofilaraemic were IgG negative. It is noteworthy that microscopic examination after sonica- tion revealed that the outer sheath of the majority of microfilariae was completely shed, while few microfilariae were cut (data not shown). The microfilariae sheath might represent a source of cross-reactive carbohydrate antigens with worms that result in reactivity of microfilariae antigen with IgG in some chronic patients’  sera  [50]. Recently,  anti-sheath antibodies were found to play a role in clearance of microfilarae- mia and circulating filarial antigen in W. bancrofti  infections [51]. The cross- reactivity of some endemic normal sera with the antigens derived from adult worms rather than with the microfilarial antigen supports our interpretation that those individuals may have had adult worm cryptic or unisexual infections [45,46]. It was previously suggested that the excretory–secretory antigens of Setaria spp. are formed in the uterus during embryonic development and released during hatching [52]. Using FWESA as  the antigen in ELISA, IgG reactivity was higher among sera from chronic patients than microfilaraemic individuals. The presence of free antigens released by the parasite as well as antigen–antibody  complexes in the host’s circulation sys- tem suggests that the antibody titre did not reach a level to completely neutralize these antigens [53]. This might allow us  to conclude that lower IgG reactivity in microfilaraemic sera may be related to the existence of cross-reactive antigens in the form of immune complexes with most of IgG antibodies, while immune clearance of those antigens from the sera of chronic patients results in higher IgG reactivity [48,54]. Immunoblotting has been used previously for analysing the antigenic proteins of filarial as well as other Figure 2 Western blots showing immunogenic bands of prepared antigens recognized by high (lane 1), moderate (lane 2) and weak (lane 3) IgG reactivity in human sera (CP = chronic amicrofilaraemic patients, MFA = microfilaraemic asymptomatic subjects, EN = normal subjects from endemic area, NEN = normal controls from nonendemic area). Both low (left) and high (right) molecular weight markers were included CP MF EN NEN FWESA CP MF EN NEN MFA CP MF EN NEN SMWA kDa kDa CP MF EN NEN CFSWA kDa CP MF EN NEN SFWA kDa kDa kDa1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 1 2 3 97.4 66.2 45 31 21.5 14.4 17 93.3 33.6 81 200 66.2 45 97.4 66.2 45 31 21.5 14.4 81 66.2 45 33.6 200 116.25 66.2 45 97.4 66.2 45 31 21.5 14.4 27.8 200 200 97.4 66.2 45 97.4 66.2 45 31 21.5 100.5 200 200 200 kDa kDa 116.25 66.2 45 200 116 66.2 45 60 24 97.4 66.2 45 31 21.5 kDa kDa Book 17-8.indb 683 8/9/2011 2:04:51 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 684 References Coleman SU, Klei TR, French DD. Prevalence of 1. Setaria equina (Nematode: Onchocercidae) in southeastern Louisiana hors- es. Journal of Parasitology, 1985, 71:512–513. Hillyer L, Coles G, Randle R. 2. Setaria equina in the UK. Veterinary Record, 2001, 149:464. LeBrun RA, Dziem GM. Natural incidence of 3. Setaria equina (Nematoda: Filarioidea) from Aedes canadensis (Diptera: Culi- cidae) in North America. Journal of Medical Entomology, 1984, 21:472–473. Oge S et al. Setaria equina infection of Turkish equines: esti-4. mates of prevalence based on necropsy and the detection of microfilaraemia. Annals of Tropical Medicine and Parasitology, 2003, 97:403–409. Hornok S et al. Prevalence of 5. Setaria equina microfilaraemia in horses in Hungary. Veterinary Research, 2007, 161:814–816. Marzok MA, Desouky AR. Ocular infection of donkeys (6. Equus asinus) with Setaria equina. Tropical Animal Health and Produc- tion, 2009, 41:859–863. Shoho C, Uni S. Scanning electron microscopy (SEM) of some 7. Setaria species (Filarioidea, Nematoda). Zeitschrift fur Para- sitenkunde (Berlin, Germany), 1977, 53:93–104. Li ZX, Yu LR. Morphological studies on the larval stages of three 8. species of Setaria and Dirofilaria repens. Southeast Asian Jour- nal of Tropical Medicine and Public Health, 1990, 21:95–102. Camargo M et al. [Heterologous antigen in the immunologi-9. cal diagnosis of wucheriasis: Setaria equina extract used in the immunoenzymatic reaction—ELISA ] Antígeno heterólogo no diagnóstico imunológico da wuchereriose: extrato de Setaria equina utilizado na reação imunoenzimática—ELISA. Memorias do Instituto Oswaldo Cruz, 1982, 77:385–388. parasites and its superiority over other immunochemical techniques has been discussed  [55–58]. Using  this  technique, the antigens that are cross- reactive with different human sera could have been identified by their molecular weights. In our study, a com- mon recognition of a protein band at 81 kDa in the SFWA and SMWA by sera from both microfilaraemic and endemic normal individuals may be due to the cryptic infections present in some endemic normal individuals. Similarly, a common recognition of a protein band at 33.6 kDa in SFWA in chronic patients’ and microfilaraemic sera may be a consequence of a long- lasting antibody response present in chronic patients’ sera to antigen re- leased from the female adult worm during its life. Positive IgG reactivity in chronic patients (100%) against the  CFWSA of S. equina by ELISA cor- responded to recognition of a 27.8 kDa  band by chronic patients’ sera. The controversy between the results of a previous study [10] and ours using in- fected human sera against CSFWA in immunoblotting may be due to either the different source of collected hu- man sera or species-specific reactions. Recognition of 2 protein bands at 24  and 60 kDa in MFA by both highly and  weakly IgG reactive chronic patients’ sera respectively could be associated with amicrofilaraemia. Those antigens can be further evaluated as protective antigens against microfilaraemia in animal models. A previous study indi- cated that IgG antibodies from mice immunized with an extract of B. malayi microfilariae could identify antigens at 25 and 60 kDa [59]. The researchers  further demonstrated that antibody titres of amicrofilaraemic human sera to 25 kDa were higher  than  those of  microfilaraemic ones. A common recognition of 200 kDa  in FWESA by microfilaraemic and chronic patients’ sera identifies cross-re- active epitope(s) between S. equina and W. bancrofti that can lead to misdiagno- sis using the immunochromatographic card test. The same molecular weight was identified in W. bancrofti patient sera using rabbit polyclonal antibodies raised against  excretory–secretory  antigen  of Dir. immitis  adult worms  [48]. The  immune recognition of this molecular weight antigen in both S. equina CSFWA and FWESA by W. bancrofti-infected human sera was in concordance with the recognition of the same molecular weight antigen  in excretory–secretory  and surface preparations from B. malayi female worm by homologous infected human  sera  [60]. Recently,  the  same  molecular weight glycoprotein was also identified in excretory–secretory prepa- rations of S. digitata, suggesting that it may secreted through the surface pores of male and female adult worms [61]. In conclusion, our study demon- strated cross-reaction between S. equina antigens and antibodies in the sera of W. bancrofti-infected patients, with the highest levels observed between the chronic patients’ sera and Setaria spp. CFWSA. In the absence of active trans- mission of Setaria spp. infection, such CFWSA can be useful to detect chronic W. bancrofti infection before patients become symptomatic, particularly when chronic patients are known to be amicrofilaraemic. The results suggest that in the presence of active S. equina infection it is important to avoid us- ing antigens from both the adult and microfilaraemic stages as these showed the highest degree of cross-reaction with human sera, and that improved diagnostic tests should be developed for bancroftian filariasis. The capacity of the mosquitoes present in the Egyptian habitats to transmit Setaria spp. or any other animal filarial parasites that might cross-react with W. bancrofti has to be addressed. Acknowledgements We are grateful to the General Depart- ment of Malaria, Filariasis and Leishma- niasis Control at the Ministry of Health and Population for their cooperation in collecting the sera from chronic pa- tients. Book 17-8.indb 684 8/9/2011 2:04:51 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 685 Theodore JG, Kaliraj P. Isolation, purification and characteriza-10. tion of surface antigens of the bovine filarial parasite Setaria digitata for the immunodiagnosis of bancroftian filariasis. Jour- nal of Helminthology, 1990, 64:105–114. Kaushal NA et al. Isolation of an antigen fraction from 11. Setaria cervi adults having potential for immunodiagnosis of human filariasis. Immunological Investigations, 2009, 38:749–761. Rathaur S et al. 12. Setaria cervi dual specific phosphatase: charac- terization and its effect on eosinophil degranulation. Parasitol- ogy, 2009, 136:895–904. Desowitz RS, Una SR. The detection of antibodies in human 13. and animal filariases by counterimmunoelectrophoresis with Dirofilaria immitis antigens. Journal of Helminthology, 1976, 50:53–57. Maizels RM et al. Specificity of surface molecules of adult 14. Bru- gia parasites: cross-reactivity with antibody from Wuchereria, Onchocerca and other human filarial infections. Tropical Medi- cine and Parasitology, 1985, 36:233–237. Rifaat MA et al. Preliminary evaluation of 15. Dipetalonema evansi antigen in diagnosis of filariasis in Egypt by immunofluores- cence antibody test. Journal of the Egyptian Society of Parasitol- ogy, 1982, 12:319–325. El-Ganayani GA, el-Shazely AM, Abdel-Magied SA. Evaluation 16. of ELISA and IHAT in immunodiagnosis of bancroftian filariasis using delipidized L. carinii antigen. Journal of the Egyptian Soci- ety of Parasitology, 1988, 18:111–117. El-Ganayni GA et al. Diagnosis of bancroftian filariasis by 17. detection of circulating antigens by counterimmunoelectro- phoresis. Journal of the Egyptian Society of Parasitology, 1988, 18:503–507. El-Ganayni GA. Evaluation of two different antigens in immuno-18. diagnosis of bancroftian filariasis using ELISA and IHAT. Journal of the Egyptian Society of Parasitology, 1992, 22:107–113. Ata AH et al. Antifilarial IgM versus IgG antibody determi-19. nation in the diagnosis of Wuchereria bancrofti infection in Egyptians. Journal of the Egyptian Society of Parasitology, 1993, 23:277–288. El Serougi AO et al. Evaluation of the IgG4 in Egyptian ban-20. croftian filariasis. Journal of the Egyptian Society of Parasitology, 2000, 30:59–67. Vakalis NC, Himonas CA. Human and canine dirofilariasis in 21. Greece. Parassitologia, 1997, 39:389–391. Petrocheilou V et al. Microfilaremia from a 22. Dirofilaria-like par- asite in Greece. Case report. Acta Pathologica, Microbiologica et Immunologica Scandinavica, 1998, 106:315–318. Walther M, Muller R. Diagnosis of human filariases (except on-23. chocerciasis). Advances in Parasitology, 2003, 53:149–193. Sabu L, Devada K, Subramanian H. Dirofilariosis in dogs and 24. humans in Kerala. Indian Journal of Medical Research, 2005, 121:691–693. Kokta V. Zoonotic deep cutaneous filariasis—three pediatric 25. cases from Québec, Canada. Pediatric Dermatology, 2008, 25:230–232. Ishii Y et al. Seasonal and diurnal biting activities and zoonotic 26. filarial infections of two Simulium species (Diptera: Simuliidae) in northern Thailand. Parasite (Paris, France), 2008, 15:121–129. Eberhard ML et al. Zoonotic 27. Brugia infection in western Michi- gan. American Journal of Surgical Pathology, 1993, 17:1058– 1061. Elenitoba-Johnson KS et al. Zoonotic Brugian lymphadenitis. 28. An unusual case with florid monocytoid B-cell proliferation. American Journal of Clinical Pathology, 1996, 105:384–387. Chambers EW et al. Xenomonitoring of 29. Wuchereria ban- crofti and Dirofilaria immitis infections in mosquitoes from American Samoa: trapping considerations and a compari- son of polymerase chain reaction assays with dissection. American Journal of Tropical Medicine and Hygiene, 2009, 80:774–781. Bal MS et al. Transplacental transfer of filarial antigens from 30. Wuchereria bancrofti-infected mothers to their offspring. Para- sitology, 2009, 23:1–5. Thilagavathy AH, Prabha B, Raj RK. Excretory secretory antigens 31. of filarial parasite Setaria digitata. Indian Journal of Experimental Biology, 1990, 28:291–292. Medina-De la Garza CE, Brattig NW, Tischendorf FW. Rapid 32. method for the purification of viable microfilariae from nod- ules of Onchocerca volvulus by Percoll gradient centrifugation. Tropical Medicine and Parasitology, 1987, 38:53–54. Michaud LA, Lammie PJ. Regulation of jird lymphocyte respon-33. siveness to fractionated antigens of Brugia pahangi. Tropical Medicine and Parasitology, 1988, 39:317–321. Van Hoegaerden M, Akué JP. Lack of evidence for transplacen-34. tal transfer of microfilarial antigens in filariasis due to Loa loa and Mansonella perstans. Tropical Medicine and Parasitology, 1986, 37:121–123. Tamashiro WK et al. 35. Dirofilaria immitis: studies on anti-mi- crofilarial immunity in Lewis rats. American Journal of Tropical Medicine and Hygiene, 1989, 40:368–376. Engvall E, Perlmann P. Enzyme-linked immunosorbent assay 36. (ELISA). Quantitative assay of immunoglobulin G. Immuno- chemistry, 1971, 8:871–874. Laemmli UK. Cleavage of structural proteins during the assem-37. bly of the head of bacteriophage T4. Nature, 1970, 227:680– 685. Towbin H, Staehelin T, Gordon J. Electrophoretic transfer of 38. proteins from polyacrylamide gels to nitrocellulose sheets: procedure and some applications. Proceedings of the Na- tional Academy of Sciences of the United States of America, 1979, 76:4350–4354. Ruppel A, Diesfeld HJ, Rother U. Immunoblot analysis of 39. Schis- tosoma mansoni antigens with sera of schistosomiasis patients: diagnostic potential of an adult schistosome polypeptide. Clinical and Experimental Immunology, 1985, 62:499–506. Orihel TC, Eberhard ML. Zoonotic filariasis. 40. Clinical Microbiol- ogy Reviews, 1998, 11:366–381. Kaliraj P, Ghirnikar SN, Harinath BC. Immunodiagnosis of 41. bancroftian filariasis: comparative efficiency of the indirect hemagglutination test, indirect fluorescent antibody test, and enzyme-linked immunosorbent assay done with Wuchereria bancrofti microfilarial antigens. American Journal of Tropical Medicine and Hygiene, 1981, 30:982–987. Lammie PJ, Eberhard ML, Lowrie RC Jr. Differential humoral 42. and cellular immunoreactivity to saline- and detergent-extract- ed filarial antigens. Transactions of the Royal Society of Tropical Medicine and Hygiene, 1990, 84:407–410. Grove DI. Immunity in filariasis: a review. 43. Papua and New Guinea Medical Journal, 1978, 21:32–42. Lammie PJ et al. Alterations in filarial antigen-specific immu-44. nologic reactivity following treatment with ivermectin and diethylcarbamazine. American Journal of Tropical Medicine and Hygiene, 1992, 46:292–295. Dreyer G et al. Amicrofilaraemic carriers of adult 45. Wuchereria bancrofti. Transactions of the Royal Society of Tropical Medicine and Hygiene, 1996, 90:288–289. Simonsen PE, Meyrowitsch DW. Bancroftian filariasis in Tan-46. zania: specific antibody responses in relation to long-term observations on microfilaremia. American Journal of Tropical Medicine and Hygiene, 1998, 59:667–672. Kaliraj P, Ghirnikar SN, Harinath BC. Indirect fluorescent 47. antibody technique using sonicated Wuchereria bancrofti mi- Book 17-8.indb 685 8/9/2011 2:04:52 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 686 crofilaria for immunodiagnosis of Bancroftian filariasis. Indian Journal of Experimental Biology, 1979, 17:332–335. Weil GJ et al. A monoclonal antibody-based enzyme im-48. munoassay for detecting parasite antigenemia in bancroftian filariasis. Journal of Infectious Diseases, 1987, 156:350–355. Ramzy RM et al. Evaluation of a monoclonal-antibody based 49. antigen assay for diagnosis of Wuchereria bancrofti infection in Egypt. American Journal of Tropical Medicine and Hygiene, 1991, 44:691–695. Ravindran B et al. Antibodies to microfilarial sheath in bancroft-50. ian filariasis—prevalence and characterization. Annals of Tropi- cal Medicine and Parasitology, 1990, 84:607–613. Simonsen PE et al. Immunoepidemiology of 51. Wuchereria ban- crofti infection in two East African communities: antibodies to the microfilarial sheath and their role in regulating host micro- filaraemia. Acta Tropica, 2008, 106:200–206. Decruse SW, Kaleysaraj R. Excretory secretory material from 52. different sites of female reproductive tissue of filarial parasite Setaria digitata. Indian Journal of Experimental Biology, 1988, 26:781–783. Sugunan VS, Raj RK. Excretory/secretory antigens from a bo-53. vine filarial parasite cross react with human antifilarial antibod- ies. Indian Journal of Experimental Biology, 1990, 28:1124–1127. Dasgupta A, Bala S, Dutta SN. Lymphatic filariasis in man: 54. demonstration of circulating antigens in Wuchereria bancrofti infection. Parasite Immunology, 1984, 6:341–348. Weiss N et al. Detection of IgE-binding 55. Onchocerca volvulus antigens after electrophoretic transfer and immuno-enzyme reaction. Acta Tropica, 1982, 39:373–377. Lucius R et al. Identification of immunogenic proteins of 56. Dip- etalonema viteae (Filarioidea) by the “Western Blotting” tech- nique. Tropical Medicine and Parasitology, 1983, 34:133–136. Lobos E, Weiss N. Immunochemical comparison between 57. worm extracts of Onchocerca volvulus from savanna and rain forest. Parasite Immunology, 1985, 7:333–347. Hussain R, Kaushal NA, Ottesen EA. Comparison of immunob-58. lot and immunoprecipitation methods for analyzing cross-re- active antibodies to filarial antigens. Journal of Immunological Methods, 1985, 84:291–301. Kazura JW, Cicirello H, Forsyth K. Differential recognition of 59. a protective filarial antigen by antibodies from humans with bancroftian filariasis. Journal of Clinical Investigation, 1986, 77:1985–1992. Kwan-Lim GE et al. Secreted antigens of filarial nematodes: 60. a survey and characterization of in vitro excreted/secreted products of adult Brugia malayi. Parasite Immunology, 1989, 11:629–654. Madathiparambil MG, Kaleysa KN, Raghavan K. A diagnosti-61. cally useful 200-kDa protein is secreted through the surface pores of the filarial parasite Setaria digitata. Parasitology Re- search, 2009, 105:1099–1104. Book 17-8.indb 686 8/9/2011 2:04:52 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 687 Bone mineral density in Egyptian adolescents and adults with short stature: results of a national survey S.A. Ibrahim,1 M.A. Samy,1 M.K. Matter 1 and A.O.L. Saleh 1 ABSTRACT Little is known about bone mass acquisition among stunted adolescents who did not achieve their growth in height. A national survey was made of bone mineral density among stunted adolescents and adults. A multistage stratified random sample of 2500 families (8476 adolescents and their parents) was selected from 6 governorates in different geographical areas of Egypt. Clinical history, anthropometry and measurement of bone mineral density using dual energy X-ray absorptiometry was done. Mean T-scores were significantly lower among both adults and adolescents with short stature compared with those of normal height. The predictors of bone status among adolescent boys were age, body mass index (BMI), height attained (z-score) and maternal T-score and for girls were BMI, age at menarche, paternal T-score and z-score. Stunted adolescents suffered from low bone mass density and low stature adults suffered a high prevalence of osteoporosis. 1National Nutrition Institute, Cairo, Egypt (Correspondence to S.A.Ibrahim: saharhammouda@yahoo.com). Received: 15/10/09; accepted: 05/01/10 ينطولا حسلما جئاتن :ينغلابلاو ينقهارلما نم ةماقلا راصقلا ينيصرلما ينب ماظعلا في نداعلما ةفاثك حلاص رمع ةزع ،رطم لماك يم ،يماس دحمأ ةسيام ،ةدوحم ميهاربإ ليع رحس ينطو ٌحسم َىيرجُحأ دقو .لوطلا ثيح نم داتعُحلما ومنلا اوققيح لم نيذلا ةماقلا راصقلا ينقهارلما في ةيمظعلا ةلتكلا لوح ليلقلا ىوس فرعُحي لا :ةصلالخا )مهئابآو ينقهارلما نم 8476( ةسرأ 2500 حئاشرلا ةددعتم ةيئاوشع ةنيع تيرتخاو .ةماقلا راصقلا ينغلابلاو ينقهارلما ينب ماظعلا في نداعلما ةفاثكل ماظعلا في نداعلما ةفاثك سايقو ،ةيشربلا تاسايقلاو ،ةيريسرلا قباوسلا عجم َّمتو .صرم في ةيفارغلجا قطانلما فلتمخ نم تاظفامح تس نم مهؤاقتنا مت راصقلا ينقهارلماو ينغلابلا ينب ًايئاصحإ هب ُّدَىتْع ُحي وحن لىع لقأ T - زارحلأا طسوتم ناكو .ةقاطلا جودزلما ةينيسلا ةعشلأا صاصتما سايق مادختساب ،BMI مسلجا ةلتك ب َىسْن َىمو ،رمعلا يه ينقهارلما نايتِفلا في اهيلع دمُحتعا يتلا ماظعلا ةلاحب تائبنلما تناكو .يماظنلا لوطلا باحصأ عم ةنراقلماب ةماقلا رمعلاو ،مسلجا ةلتك ب َىسْن َىم يه ّنهيف ماظعلا ةلاحب تائبنلما تناكف تايَىت َىفلا تاقهارُحلما امأ ،تاهملأل T - ز َىر َىلحاو ،)Z - ز َىر َىلحا( بستكلما لوطلاو ةماقلا راصقلا ينغلابلا نأ ينح في ،ماظعلا ةلتك ةفاثك ةلق نم ةماقلا راصقلا نوقهارلما نياعُحي .نْي َىدلاولا في Z - ز َىرلحاو T - ز َىر َىلحاو ،ةضاحلإا ءدب دنع .ماظعلا لخلتخ راشتنا ةدايز نم نوناعُحي Densité minérale osseuse chez des adolescents et des adultes égyptiens de petite taille : résultats d’une enquête nationale RÉSUMÉ Les connaissances sont rares en matière d’acquisition de la masse osseuse chez les adolescents souffrant d’un retard de croissance et n’ayant pas atteint leur taille cible. Une enquête nationale a été réalisée sur la densité minérale osseuse des adolescents et des adultes atteints d’un retard de croissance. Un échantillon aléatoire stratifié à plusieurs degrés de 2500 familles (8476 adolescents et leurs parents) a été sélectionné dans six gouvernorats de plusieurs zones géographiques d’Égypte. Les antécédents médicaux ont été notés, les mesures anthropométriques ont été prises et une ostéodensitométrie a été réalisée au moyen d’une absorptiométrie biénergétique aux rayons X. Les T-scores moyens étaient significativement inférieurs chez les adultes comme chez les adolescents de petite taille par rapport aux scores observés chez les personnes de taille normale. Les facteurs prédictifs du statut osseux chez les adolescents de sexe masculin étaient l’âge, l’indice de masse corporelle, la taille atteinte (Z-score) et le T-score maternel ; chez les adolescentes, les facteurs prédictifs étaient l’indice de masse corporelle, l’âge à l’apparition des premières règles, et les T-scores et Z-scores paternels. Les adolescents atteints d’un retard de croissance souffraient d’une densité minérale osseuse faible et les adultes de petite taille présentaient une forte prévalence d’ostéoporose. Book 17-8.indb 687 8/9/2011 2:04:52 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 688 Introduction Growth stunting constitutes the most common evidence of marginal mal- nutrition  throughout  the world [1].  In  Egypt, the prevalence of linear growth retardation among adolescents aged 10–18 years is estimated to be 22% [2].  Bone mineralization is an important de- velopment stage accomplished during childhood and adolescent growth. Bone mass accumulation generally parallels linear growth; thus a large percentage of total skeletal mass is achieved during the adolescent growth spurt. Failure to achieve an adequate bone mass during adolescence is a risk factor for osteoporosis [3]. Osteoporosis has long been consid- ered a health problem unique to older adults. Yet children and adolescents with chronic illness, primary bone disease, or poor nutrition are also predisposed to  impaired  skeletal health  [4]. Oste- oporosis is characterized by a decrease in the amount of normally mineralized bone, leading to bone fragility and sus- ceptibility to fracture. In addition to causing pain, osteoporotic fractures can lead to deformity, permanent disability, loss of independence and even death [5]. We have previously  reported on  the prevalence of osteoporosis among stunted children attending the stunting outpatient clinic of the Egyptian Na- tional Nutrition Institute [6]. Yet there  is no adequate information about bone density among stunted adolescents on a national level. The objective of this study was to investigate the levels of bone mineral density (BMD) among Egyptian stunted and normal height adolescents and adults. Methods The present study reports data from Egyptian adolescents and adults who were participants in the national study for assessment of BMD among Egyp- tian adults and adolescents conducted by the National Nutrition Institute in Cairo [7].  Study sites and sample The total sample included in this survey was 4002 adolescents aged 10–18 years  and 4474 of their fathers and mothers who were included for assessment of ge- netic and lifestyle factors affecting BMD. The age  range of mothers was 28–61  years  and of  fathers was 29–63 years.  Exclusion criteria included: pregnancy, all forms of motor disability and inability to stand erect, genetic syndromes, past or present endocrine disorders (other than diabetes), any known skeletal or bone deformities, chronic diseases, drug intake (e.g. corticosteroids or other hormones, antiepileptic drugs, nons- teroidal anti-inflammatories, antacids, tetracyclines, antidiuretic drugs, vitamin supplements, calcium supplements, an- ticancer drugs) or metabolic conditions that can affect BMD. Sample selection was done as follows. Cairo was selected as it is the capital and the main metropolitan area of Egypt. The other governorates were divided into 2 main strata. The first was upper  Egypt plus the Red Sea and New Valley governorates. This stratum included 10  governorates. Two governorates were randomly selected from this stratum (Red Sea and Sohag governorates). The second stratum encompassed lower Egypt in addition to North Sinai and South Sinai governorates. Three gover- norates were selected from this stratum (Sharqiya, Beheira and Dakahlia). The 2500  sample  units  were  distributed  across the 6 governorates according to their relative sizes. In the field the family lists prepared by family health centres were utilized  and 30  families daily  in  each site were randomly selected from the list. In all, families were randomly se- lected from contrasting socioeconomic standards. Sample design and size al- lowed estimations to be obtained on the national level. These estimates were obtained for rural and urban areas, males and females and for the 3 social classes. Social status was assessed according to the education and occupation of both the father and the mother. A score was given and the families were divided into 3 groups: low, middle and high. The targeted  families were  listed and 30  in  each site were selected randomly and interviewed. Data collection BMD was measured in the non-dom- inant side of the body at the calcaneal process by dual energy X-ray absorpti- ometry (DEXA) (Norland Apollo TM bone densitometry, Norland Medical System). Although the World Health Organi- zation (WHO) criteria for diagnosis of osteoporosis (T-score) were not estab- lished to be applied to children and ado- lescents, they were used in this study as a guide to differentiate between adequate level of BMD (normal: BMD < 1 SD of the young adult mean), mild reduction in BMD (osteopenia: BMD > 1– > 2.5  SD below the young adult mean) and severe reduction in BMD (osteoporo- sis: BMD ≥ 2.5 SD below  the  young  adult mean). A patient with 1 or more low-trauma fractures is considered to have osteoporosis regardless of the BMD value  [8]. The  term osteopenia  used here indicates that the adolescent was less advanced in reaching his/her peak bone mass (relative osteopenia). Very low BMD values (osteoporosis) are probably a reflection of underlying pathology but are referred to here as relative osteoporosis. Weight and standing height were taken from each subject using standard techniques [9]. Height-for-age z-score  (HAZ) was calculated and body mass index (BMI) using the computer soft- ware Anthro, version 1.01. Ethical approval for the study was obtained from both the Ministry of Heath and Population (Egypt) and the General Organization for Teaching Hospitals and Institutes. Book 17-8.indb 688 8/9/2011 2:04:53 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 689 Data processing and analysis The data of all participants were divided into 2 groups according to their heights.  Short stature was defined as HAZ < –2SD  for  adolescents,  adult height <  163.6 cm for males and < 151.8 cm for females [10]. The BMI of all adults were  classified as under, normal, overweight or obese in accordance with WHO classification for BMI for adults and percentile BMI-for-age for adolescents [11]. Data were analysed in the data man- agement and statistical unit of the Na- tional Nutrition Institute. Descriptive analysis using means, standard deviation (SD) and Student t-test was done using SPSS, version 10.0, including frequency  distribution and cross-tabulation. Means were compared using analysis of variance (ANOVA). Differences were considered significant at P < 0.05. Results Adolescents The total number of enrolled adoles- cents was 4002 (2003 boys and 1999  girls). The mean level of BMD was significantly lower among the stunted males and females compared with the normal height adolescents of the same sex. The results were the same for all age groups and among both sexes (Table 1). The mean T-scores were –1.7 (SD  0.9)  for  the  stunted adolescents  com- pared with –1.1 (SD 1.0)  for  the nor- mal height group (P < 0.001). Among  stunted boys, 31.1% had  relative oste- oporosis, 44.7% relative osteopenia and  only 24.1% had normal bone density.  Among normal height boys 14.9% had  relative osteoporosis, 45.2% relative os- teopenia while 39.9% had normal bone  density (Figure 1). Only  0.5% of  normal  height  girls  and 5.4% of  stunted girls had  relative  osteoporosis, while relative osteopenia was prevalent among 26.5% of normal  height and 54.2% of stunted girls. Nor- mal bone density was found among 73.0% of normal height and only 40.5%  of stunted adolescent girls (Figure 1). Using T-scores as the dependent variable, the predictors of bone status among adolescent boys were age, BMI, height attained (HAZ score) and ma- ternal T-score and for girls were BMI, age at menarche, paternal T-score and HAZ score (Table 2). This table shows  that the age of male adolescents was Table 1 Mean level of bone mineral density (BMD) of the normal height and stunted adolescents by age and sex Sex/age (years) Stunted Normal height No. Mean (SD) BMD (g/cm2) No. Mean (SD) BMD (g/cm2) Boys (n= 2003) 11– 41 0.451 (0.145) 284 0.513 (0.359) 12– 39 0.514 (0.020) 242 0.525 (0.315) 13– 34 0.490 (0.109) 225 0.535 (0.200) 14– 28 0.526 (0.200) 200 0.584 (0.350) 15– 21 0.529 (0.140) 186 0.600 (0.124) 16– 36 0.582 (0.126) 173 0.634 (0.134) 17– 19 0.620 (0.140) 134 0.651 (0.148) 18– 4 0.686 (0.145) 183 0.680 (0.147) Total 228 0.526 (0.127) 1775 0.586 (0.248) F = 13.436, P < 0.001 Girls (n = 1999) 11– 59 0.453 (0.289) 258 0.517 (0.377) 12– 30 0.453 (0.134) 199 0.520 (0.143) 13– 21 0.517 (0.026) 203 0.555 (0.124) 14– 24 0.556 (0.028) 217 0.598 (0.408) 15– 10 0.556 (0.028) 192 0.585 (0.131) 16– 7 0.501 (0.024) 169 0.628 (0.455) 17– 11 0.604 (0.121) 162 0.609 (0.121) 18– 6 0.524 (0.028) 431 0.610 (0.187) Total 168 0.495 (0.120) 1831 0.577 (0.265) F = 5.643, P < 0.001 SD = standard deviation. Book 17-8.indb 689 8/9/2011 2:04:53 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 690 the most influential among the tested variables. BMI was also influential and adolescents with high BMI values had higher T-scores than those with low BMI. HAZ score had an impact on BMD, so that the greater the height attained for age, the higher the T-score. Among females T-score was affected significantly by BMI, whether the girl had reached menarche or not, and HAZ score. Adults The total number of adults examined was 4474 (2028 fathers and 2446 moth- ers of the adolescents). Short stature was prevalent among 18.8%  of  adult males. Of  this  group  24.9% had osteoporosis compared with  12.9% of normal height males. Osteo- penia was prevalent among 17.3% of the  short compared with 13.3% of normal  height men (P < 0.001) (Figure 2). Among adult females, short stature was found in 13.4%. Of this group 15.3%  had osteoporosis compared with 12.2%  of normal height women. Osteopenia Normal, 39.9% Osteopenia, 45.2% Osteoporosis, 14.9% (a) Normal height boys (n = 1775) Normal, 24.1% Osteopenia, 44.7% Osteoporosis, 31.2% (b) Stunted boys (n = 228) χ 2 = 45.235, P<0.001 Normal, 73.0% Osteopenia, 26.5% Osteoporosis, 0.5% (c) Normal height girls (n = 1831) Normal, 45.0% Osteopenia, 54.2% Osteoporosis, 5.4% (d) Stunted girls (n = 168) χ2 = 104.558, P<0.001 Figure 1 Distribution of T-scores in the categories normal, osteopenia and osteoporosis (according to the World Health Organization 1998 cut-offs) among the normal height and stunted boys and girls Table 2 Predictors of bone status among the studied adolescents using T-score as the dependent variable Variable beta t-value P-value Boys (n = 2003) Age 0.41 6.66 < 0.001 BMI 0.24 3.84 < 0.001 HAZ 0.22 3.55 < 0.001 Maternal T-score 0.17 2.92 0.004 Girls (n = 1999) BMI 0.29 3.897 < 0.001 Age at menarche 0.36 4.810 < 0.001 HAZ 0.15 2.25 0.026 Paternal T-score 0.19 2.89 0.004 BMI = body mass index; HAZ = height-for-age z-score. Book 17-8.indb 690 8/9/2011 2:04:53 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 691 was prevalent among 10.4% of the short  compared  to  5.9%  of  normal  height  women (P < 0.001) (Figure 2). In both males and females adult height was significantly correlated with BMD (r  = 0.073, P  < 0.001 and  r = 0.073, P < 0.001  for males  and  fe- males respectively). The mean levels of the studied parameters among adults are presented in Table 3. There was a significant difference (P  <  0.001)  between the mean T-scores in both normal height and short stature adults (males or females). Mean value of BMD were significantly higher (P < 0.001 )  Table 3 Mean levels of the bone mineral density (BMD), T-scores and body mass index (BMI) among adults Height category Mean (SD) BMD (g/cm2) Mean (SD) T-score Mean (SD) BMI (kg/cm2) Fathers (n = 2028) Short stature 0.629 (0.121) –1.35 (1.5) 33.3 (7.3) Normal height 0.670 (0.232) –0.79 (1.3) 27.4 (4.9) F-value 10.89 52.78 3.472 P-value < 0.001 < 0.001 0.06 Mothers (n = 2446) Short stature 0.603 (0.105) –0.784 (1.48) 33.3 (7.4) Normal height 0.636 (0.234) –0.418 (1.46) 32.1 (6.3) F-value 6.045 17.626 9.840 P-value 0.014 < 0.001 < 0.001 (a) Normal height men (n = 1647) (b) Short stature men (n = 381) χ2 = 13.20, P<0.001 (c) Normal height women (n = 2118) (d) Short stature women (n = 328) χ2 = 45.999, P<0.001 Normal, 74.2% Osteopenia, 13.3% Osteoporosis, 12.6% Normal, 57.9% Osteopenia, 17.3% Osteoporosis, 24.9% Normal, 74.3% Osteopenia, 10.4% Osteoporosis, 15.3% Normal, 81.9% Osteopenia, 5.9% Osteoporosis, 12.2% Figure 2 Distribution of T-scores in the categories normal, osteopenia and osteoporosis (according to the World Health Organization 1998 cut-offs) among the normal height and short stature men and women Book 17-8.indb 691 8/9/2011 2:04:54 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 692 among normal height males, while the mean levels of BMI were significantly higher (P < 0.001 ) among short stature  females. Discussion In the past decade there has been con- siderable interest in the assessment of BMD in children. This has been driven partly by recognition of the fact that the risk of osteoporosis in adults is influenced by peak bone mass, which is largely achieved during childhood and  adolescence  [12]. Children with  chronic disease may have compro- mised bone growth and bone mineral accrual, increasing the lifetime risk of osteoporosis [13]. It has been suggested  that measurement of BMD by DEXA is influenced by bone size and therefore DEXA results need to be interpreted with caution in children who are growth retarded  [14]. The present  study  re- vealed that stunted adolescents had lower levels of bone mineralization at adolescents with an adequate height for their age. It seems unlikely that bone size is the reason for this low BMD, as  24.1%  and  40.5% of  stunted  boys  and girls had normal BMD. A previous study of stunted adolescents at the same institute found that some had normal BMD, some had osteopenia and others had osteoporosis. Age and HAZ score did not differ between the groups but serum levels of calcium and magnesium and dietary intake of fat, zinc, copper, vitamin A and folic acid were signifi- cantly lower in the stunted group with osteoporosis compared with stunted adolescents with adequate BMD [15].  Our team has also reported mild trauma fractures and repeated fractures among stunted adolescents in a previous study. We found no significant difference in BMD between short and normal height adolescents of the same BMI, and speculated that the markedly reduced BMD among the stunted group was mainly due to reduced body weight and delayed puberty associated with stunted growth [6]. We can  suggest  that both  osteoporosis and some cases of stunted growth may have the same etiology. In the present study, an independ- ent predictor of low BMD among the adolescents was high BMI. This result agrees with those of Ibrahim et al., Mat- ter  et  al.  [16]  and Henrick  [17], who  found that weight was predictive of ado- lescent BMD. HAZ was also found to be predictive of bone status. Children with idiopathic short stature were reported to have low BMD that increased after 1 year of growth hormone therapy [18]. In this study among adults there was a positive association between height and BMD. In both males and females, osteoporosis was more prevalent among those with short stature; a con- dition that clearly starts at a younger age. The clinical implications of the above findings are important. Calcium sup- plementation may be a treatment for both stunted growth and osteoporo- sis. In a previous study, height gain in stunted adolescents was found to increase significantly after calcium and multiple micronutrient supplements as compared with placebo. Those suffering from osteoporosis at the start of the trial had marked height improvement. Unfortunately, the study did not assess changes in BMD after supplementation [19]. Further  longitudinal  studies  are  required to understand the evolution of reduced BMD in young people and adults with short stature. Conclusion Stunted adolescents suffer from low BMD, and short stature adults suffer a high prevalence of osteoporosis. Os- teoporosis may be one of the remote complications of stunted growth. Acknowledgements The study was sponsored by the General Organization for Teaching Hospitals and Institutes, Ministry of Health and Population, Egypt. References The state of the world’s children 2006: excluded and invisible1. . Geneva, United Nations Children’s Fund, 2006. Final report on the national study: prevalence of obesity in Egypt2. . Cairo, Egypt National Nutrition Institute, 2004. Leonard MB, Zemel BS. current concepts in paediatric bone 3. disease. Paediatric gastroenterology and nutrition. Pediatric Clinics of North America, 2002, 49:143–173. Henwood MJ, Binkovitz L. Update on pediatric bone health. 4. Journal of the American Osteopathic Association, 2009, 109:5– 12. Broadus AE. Physiologic functions of calcium, magnesium and 5. phosphorus. In: Favus MJ, ed. Primer on the metabolic bone diseases and disorders of mineral metabolism. Washington DC, American Society of Bone and Mineral Research, 1993:41. Ibrahim SA et al. Bone mineral density and bone markers 6. among stunted Egyptian adolescents. Journal of Nutritional and Environmental Medicine, 2003, 3:93–101. National survey for determination of bone mass density among 7. adolescents and adults in Egypt. Final report. Cairo, Egypt Na- tional Nutrition Institute, 2004. Definition of osteoporosis and related terms. In: 8. Guidelines for preclinical and clinical trials in osteoporosis. Geneva, World Health Organization, 1998:5–25. Jelliffe DB. 9. The assessment of the nutritional status of the commu- nity: with special reference to field surveys in developing regions of the world. Geneva, World Health Organization, 1989. Measuring changes in nutritional status. Guidelines for assessing 10. the nutritional impact of supplementary feeding programmes Book 17-8.indb 692 8/9/2011 2:04:54 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 693 for vulnerable groups. Geneva, World Health Organization, 1983. Obesity: preventing and managing the global epidemic11. . Geneva, World Health Organization, 1997. Schoenau E et al. The bone mass concept: problems in short 12. stature. European Journal of Endocrinology, 2004, 151:S87–91. Bachrach LK. Consensus and controversy regarding oste-13. oporosis in the pediatric population. Endocrine Practice, 2007, 13:513–520. Langman CB, Levine MA, Sylvester F. 14. Osteoporosis clinical up- dates. Osteoporosis in children and adolescents. Washington DC, National Osteoporosis Foundation 2005. Ibrahim SA et al. Nutritional deficiencies as risk factors for low 15. BMD in stunted adolescents. Importance of food supplements and nutrition education. Nutrafood, 2007, 6(1):25–30. Mattar MK et al. Bone mineral density and nutrient intake 16. among stunted Egyptian adolescents. Medical Journal of Cairo University, 2003, 71(1) (Suppl.):45–51. Henrick D. 17. Bone mass in young adults—determinants and frac- ture prediction. Malmo, Sweden, Department of Orthopaedics, University of Malmo Hospital, 1997. Lanes R et al. Growth velocity, final height and bone mineral 18. metabolism of short children treated long term with growth hormone. Clinical Endocrinology, 2002, 57:725–730. Ibrahim SA et al. Could micronutrient supplementation in-19. crease the growth of stunted Egyptian children? Egyptian Jour- nal of Nutrition (Cairo), 2003, 18: 000–000. FAO and WHO call for data on vitamin and mineral recommendations The 32nd Session of the Codex Committee on Nutrition and Food for Special Dietary Uses (CCNFSDU) has  requested the Food and Agriculture Organization (FAO) and the World Health Organization (WHO) to provide the 33rd session of CCNFSDU (in November 2011) with a report of existing daily vitamin and mineral intake reference  values for apparently healthy populations of adult males (preferably aged 19–65 years) and adult females (preferably  aged 19–50 years). This information should be collected from data sources published after 1998 from recognized  authoritative scientific bodies and from FAO/WHO. To complete this request, the FAO and WHO request the submission from Member States of data regarding nutrient reference values used in their jurisdiction. The deadline for submission of the requested data is 14 August 2011. Further information about this call for data can be found at: http://www.who.int/nutrition/FAOandWHO_ callfordata_vitamin_mineral_recommendations/en/index.html Book 17-8.indb 693 8/9/2011 2:04:54 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 694 Physical activity profile of students in Mansoura University, Egypt A-H. El-Gilany,1 K. Badawi,2 G. El-Khawaga 1 and N. Awadalla 3 ABSTRACT A cross-sectional study was carried out on 1708 students from Mansoura University, Egypt, to describe the pattern of physical activity, predictors of physical inactivity and perceived barriers to and benefits of physical activity. The International Physical Activity Questionnaire (IPAQ) was used to measure physical activity. Data were analysed according to the guidelines for data processing and analysis of the IPAQ. Perceived barriers to and potential benefits of physical activity were asked for. More than 11% of students were physically inactive. On logistic regression analysis, the independent predictors of physical inactivity were high socioeconomic standard of the family (OR 2.1), female sex (OR 1.8), medical education (OR 1.8) and non-membership in sports clubs (OR 1.6). The most frequent barriers to physical activity were time limitation and lack of accessible and suitable sporting places. More than 70% of the participants stated that physical activity promotes and maintains health. 1Public Health Unit; 3Occupational Medicine Unit, Department of Community Medicine, College of Medicine; 2Students’ Hospital, Mansoura University, Mansoura, Egypt (Correspondence to A-H El-Gilany: ahgilany@gmail.com; ahgilany@hotmail.co.uk ). Received: 15/11/09; accepted: 25/02/10 صرم في ةروصنلما ةعماج ةبلطل نيدبلا طاشنلا مسترم للها ضوع ليبن ،ةجاولخا ةداغ ،يودب ةميرك ،نيلايلجا يدالها دبع تائبنلماو ،ميهدل نيدبلا طاشنلا طمن فيصوتل صرم في ةروصنلما ةعماج ةبلط نم ةينماثو ةئم عبسو فللأ ةضرعتسم ةسارد نوثحابلا ىرجأ :ةصلالخا اوماقو .نيدبلا طاشنلا سايقل IPAQ نيدبلا طاشنلل ليودلا نايبتسلاا نوثحابلا مدختسا دقو .ميهأر في نيدبلا طاشنلا ايازمو قئاوعو ،نيدبلا لوملخاب قئاوعلا نع ةبلطلا لاؤسب اوماق ماك .نيدبلا طاشنلل ليودلا نايبتسلاا في اهليلتو تايطعلما عم لماعتلل ةيداشرلإا لئلادلل ًاقفو تايطعلما ليلحتب ةلقتسلما تائبنلما تناك ،يتسجوللا ف ُّوحتلا ليلحتبو .ًايندب ًاطاشن نوسرماي اونوكي لم ةبلطلا نم %11 نم رثكأ نأ ينبتو .نيدبلا طاشنلل ةعقوتلما ايازلماو مدعو ،)OR = 1.8( يبطلا ميلعتلاو ،)OR = 1.8( يوثنلأا سنلجاو ،)OR = 2.1( ةسرلأل ةيعماتجلااو ةيداصتقلاا يرياعلما يه نيدبلا طاشنلا مادعناب يتلا ةمئلالما ةيضايرلا نكاملأا صقنو ،تقولا يه ًاد ُحرا َىوَىت نيدبلا طاشنلا قئاوع رثكأ تناكو .)OR = 1.6( ةيضايرلا ةيدنلأا ةيوضع في كاترشلاا .اهيلع ظفايحو ةحصلا ز ِّزعي نيدبلا طاشنلا نأ ينكراشلما نم %70 نم رثكأ َىر َىك َىذ دقو .اهيلإ لوصولا لهسي Profil de l’activité physique des étudiants de l’Université de Mansoura (Égypte) RÉSUMÉ Une étude transversale a été conduite auprès de 1708 étudiants de l’Université de Mansoura (Égypte) pour décrire les caractéristiques de leur pratique sportive, les obstacles et les avantages perçus en la matière et les facteurs prédictifs de l’inactivité physique. Le questionnaire international sur l’activité physique (IPAQ) a été utilisé, et les informations ont été analysées conformément aux directives sur le traitement et l’analyse des données de ce questionnaire. Les étudiants ont été interrogés sur leur perception des obstacles et avantages potentiels de la pratique d’une activité physique. Plus de 11 % des étudiants étaient physiquement inactifs. Selon une analyse de régression logistique, les facteurs prédictifs indépendants de l’inactivité physique étaient les suivants : statut socioéconomique familial élevé (O.R. 2,1), sexe féminin (O.R. 1,8), formation médicale (O.R. 1,8) et absence d’inscription dans un club de sport (O.R. 1,6). Les obstacles les plus fréquents à l’activité physique étaient les contraintes de temps et l’absence de lieux accessibles et adéquats pour la pratique d’un sport. Plus de 70 % des participants ont affirmé que l’activité physique favorisait durablement une bonne santé. Book 17-8.indb 694 8/9/2011 2:04:55 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 695 Introduction Health-enhancing physical activity is that which benefits health and func- tional capacities without harm or risk. This term includes the full range of human movement, such as competi- tive sports and exercise, active hobbies, cycling or the physical activities of daily living [1–3]. Physical activity is the key  strategy for reducing the risk of chronic diseases. Regular physical activity helps build and maintain healthy bone and muscle, reduces the risk of developing obesity, reduces feelings of depression and anxiety and promotes psychologi- cal well-being [4–8]. In his systematic review on the prev- alence of university students’ participa- tion in physical activity of 19 studies from 27 countries, not including Egypt,  Irwin concluded that more than half the university students in the United States of America (USA) and Canada were not active enough to gain health benefit [9].  Internationally  the  same was  true,  with Australian students having the highest level of sufficient activity. Other international studies concluded that the majority of university students were insufficiently physically active [10,11].  Physical activity habits during adolescence and youth are likely to be important influences on habitual physi- cal  activity  throughout adult  life  [12].  Opportunities for physical activity are largely determined by social, economic, and cultural factors as well as physi- cal environments that influence access, availability and utilization [13]. To the best of authors’ knowledge, no studies have been done to assess physical activity pattern among the Egyptian population in general and spe- cifically among university students. The objectives of this study were to assess the levels of physical activity, study predic- tors of physical inactivity, and perceived barriers to and benefits of physical activity among students at Mansoura University, Egypt. Such studies could pave the way for planning a programme for physical activity promotion among university students. Methods The study was carried out in Mansoura University, Egypt, 1 month before ex- aminations during the academic year 2007–08.  Mansoura  University  is  one of the biggest public universities in Egypt and has specialized medical centres which provide both medical and academic services. The main campus in Mansoura comprises 13 faculties; 4 faculties are located off campus. A total of 124 386 students were enrolled in all  faculties in 2007–08. Students of Mansoura University were the target population. Colleges outside the city were not included for logistic reasons. Only a few (3) students with chronic disease or disability were also excluded. This was determined as self-reported by students. Verbal approval was obtained from the authorities of each college to con- duct the survey in the setting as there is no research ethics committee at the moment in the university. After obtain- ing approval for data collection, the re- searchers introduced themselves to the students in each cluster and informed them about the aim of the study and about guarantees of anonymity and confidentiality. Students were allowed to respond in their own time and in private. Participation was entirely on voluntary basis after giving verbal con- sent. Study tool An anonymous, self-administered questionnaire was used to collect data on sociodemographic characteristics, membership in sports clubs, and physi- cal activity using an Arabic language translation of the long form of the In- ternational Physical Activity Question- naire (IPAQ) [14].  A list of potential barriers to physi- cal activity/sports participation was prepared and students required an- swering whether these are not barriers, permanent barriers or temporary barri- ers. Opinions about the potential ben- efits of physical activity and suggestions to promote physical activity among university students were also included in the questionnaire. The long form of IPAQ is used to collect data on physical activity levels among young and middle age adults (15–69 years) over the previous 7 days.  This version provides detailed informa- tion for evaluation purposes. The reli- ability and validity of the questionnaire were  tested  across  12  countries  (14  sites) in 2000. The findings suggest that  it has acceptable properties for use in many settings and in different languages, and is suitable for national population- based prevalence studies of participa- tion in physical activity [15,16]. The long form of the IPAQ ques- tionnaire was translated into Arabic separately  by  2  bilingual  translators  (first 2  authors). The 2 versions were  combined and revised and then back translated  into  English  by  the  last  2  authors. The translation was refined after back translation until agreement was obtained among the 4 translators. Seven bilingual experts (staff members of Department of Public Health, Col- lege of Medicine, Mansoura Univer- sity) examined the Arabic version of the questionnaire for content and construct validity and agreed upon it. A list of possible barriers to physical activity was developed by the authors and approved by the staff members. The questionnaire was then piloted for comprehension and ease of administration. Pilot study A pilot  study was done on 50 univer- sity students attending the University Students’ Hospital for inconsequential conditions e.g. acne, blood donation. During this pilot study the Arabic ver- sion of the IPAQ and the list of barriers Book 17-8.indb 695 8/9/2011 2:04:55 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 696 were tested and the level of physical in- activity was used to calculate the sample size for the full scale study. The Arabic version was retested on 41 of the same students who attended for follow-up after 1 week. The test–retest correlation  coefficients  ranged  from 0.73  to 0.87  for the total physical activity score and the domain-specific score and activity specific scores. Study variables The outcome variables are the total physical activity score, domain-specific scores, activity-specific scores and physical activity levels. The predictor variables were age in years, sex, college, residence (urban or rural), education and work of father and mother, and membership of sports club or participating in university sports activities. Social score and socioeco- nomic status were calculated according to Fahmy and El-Sherbini  [17], which  incorporates parent’s education and work, family income and number of persons per room within the home. Students were asked to think about all the vigorous and moderate activities that they had done in the previous 7 days. Vigorous physical activities are those that take hard physical effort and make a person breathe much harder than normal. Moderate activities refer to activities that take moderate physical effort and make a person breathe some- what harder than normal [14]. Metabolic equivalent (MET) is a unit used to estimate the metabolic cost (oxygen consumption) of physical activity. One MET equals the resting metabolic rate of approximately 1 kcal/ kg/h. MET-minutes is the rate of en- ergy expenditure expressed as METs per minute multiplied by minutes of a specific activity [18]. Sampling Sample size was calculated using Epi- Info,  version  6.02.  According  to  the  student affairs administration, the total number of registered students on the main  campus was 109 067. The pilot  study  showed  that  about 10% of  stu- dents were physically inactive. With the worst acceptable level 8.5%, the sample  needed for the study was estimated to be about 1515 students at a study power of 80% and 95% confidence  level. To  overcome the attrition due to cluster sampling, 10% was added to the sample  size giving a final sample size of 1667. A multistage, stratified, cluster sampling technique was adopted. In the first stage the university colleges were stratified into medical (medicine, pharmacy, dentistry, veterinary and nursing), other practical (engineering, agriculture, physical education) and non-practical/theoretical (education, commerce, law, arts). The sample size was distributed proportionally between these 3 categories. In the second stage, 1 college or more was selected from each group. Lastly, in each college students were stratified into the different aca- demic years. From each year a section or group (cluster) was randomly chosen. All students in the chosen clusters were included. A total of 1885 students were registered in 47 chosen clusters (40–50  students in each cluster). The response rate was  90.6%  (1708  out  of  1885).  Reasons for non-participation were ab- sence during  the  study period (3.8%),  incomplete questionnaires (3.3%) and  lack of interest in the study (2.2%).  Data analysis Using the Ainsworth et al. compendium of the average MET score for each type of  activity  [18],  the  following  values  were used for the analysis of IPAQ data: walking at work = 3.3 METs, cycling for transportation = 6.0 METs, moderate  yard work = 4.0 METs  and  vigorous  intensity in leisure = 8.0 METs [16]. Data were analysed using SPSS, version 16. Descriptive statistics were presented as mean and standard devia- tion (SD), first, second (median) and third quartiles (Q1, Q2 and Q3) of total  physical activity score, domain-specific scores and activity-specific scores as proposed by IPAQ Research Commit- tee  [16]. Physical  activity  scores  and  levels were calculated according to the guidelines for data processing and anal- ysis of the IPAQ. Continuous scores were expressed as MET-minutes per week (MET level × minutes of activity/ day × days per week) [16]. In categorical data, the Chi-squared test was used for comparison between groups. Significant factors predicting of physical inactivity on bivariate analysis were entered into multivariate logistic regression analysis to find out the inde- pendent predictors of physical inactivity. Odds ratio and 95% confidence interval  was calculated. P < 0.05 was considered  statistically significant. Results Age of participating students ranged from 17 to 25 years, with a mean of 19.6  (SD 1.6) years. About half (49.9%) were  males and 54.9% were rural residents.  Pattern of physical activity Total physical activity score, domain- specific scores and activity-specific scores were non-parametric (skewed) in distribution. The total physical activity score ranged from 0 to 32928.0 (mean  3133.0; median  2256.0) MET-min/ week. The highest median score was observed in the walking domain, while domestic and gardening activities had the lowest median score. Regarding the activity  levels, 11.3% of  students were  physically inactive, 52.0% had moderate  and 36.7% had high physical  activity  levels (Table 1). Predictors of physical inactivity In bivariate analysis, sex, grade, college, residence, participation in university sports activities, membership of sports clubs, father’s and mother’s education level, family income and socioeconomic standards were significant predictors of physical inactivity. The non-significant Book 17-8.indb 696 8/9/2011 2:04:55 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 697 independent variables were age, par- ent’s work  and  family  size  (Table 2).  The independent predictors of physical inactivity as revealed by logistic regres- sion analysis are presented in Table 3. Females were about 2 times more likely  to be physically inactive than males, also students of the college of medicine were more likely to be physically inactive (OR = 1.8), while students of physical education were the least likely to be physically  inactive  (OR = 0.1). Non- membership of sports clubs was asso- ciated with greater physical inactivity (OR = 1.6). Students of high social class families were about 2 times more likely  to be physically inactive compared to those with low/very low social class. Barriers to physical activity No barriers to physical activity were reported by 63  (3.7%)  students. The  perceived barriers reported are listed in Table 4. The commonest permanent barriers were time limitation, lack of accessible and suitable sporting places and lack of support and encouragement from others. The commonest tempo- rary barriers were not being interested in sports, time limitation, unsuitable (hot or cold) weather and feeling tired on physical activity. Benefits of and suggestions for promoting physical activity The commonest perceived benefits of physical activity were promotion and maintenance of health, improving body image and shape, improving muscle power, spending free time, weight control and psychological wellbeing (Table 5). More than two-thirds of the students suggested the provision of free playgrounds in each college to practice sports during free time to promote physical activity in the university. Discussion This  study  showed  that  11.3%  of  participants were physically inactive, much  lower  than  the 45.8% of college  students in a Saudi Arabian study [19].  Only 26.4% of university students  in a  Lebanese study were engaged in physi- cal  exercise  [20]. About one-third of  Chinese and Brazilian university stu- dents were physically  inactive [21,22].  Makrides  et  al.  [23]  reported  that  fewer than half of university students in Canada participated in exercise 3 or more times per week. A previous study in  the USA [24]  found  that only 39%  of students exercised 3 or more times per week. Another American study re- ported that 47% of college students did  not engage in vigorous physical activity and 17% were physically  inactive [25].  The National College Health Risk Be- havior Survey (NCHRBS) in the USA reported  that 42% of  college  students  participated in vigorous activity at least 3 times a week, while an additional 20%  participated  in moderate activity  [26].  Staten et al. reported that 39% and 41%  of university students were vigorously and moderately physically active  [27].  National statistics also show that in many countries at least one-quarter of all young people are deemed physically inactive  [28]. Among university  stu- dents of  23  countries  the prevalence  of inactivity in leisure time varied with cultural and economic development factors,  averaging 23% (northwestern  Europe  and USA),  30% (central  and  eastern Europe), 39% (Mediterranean),  42% (Pacific Asia), and 44% (develop- ing  countries)  [11]. This  variation  in  the level of physical inactivity between different countries is a reflection of so- cioeconomic development, technology and urbanization. Analysis of the risk factors of physi- cal inactivity using regression analysis Table 1 Descriptive statistics of physical activity scores and levels among Mansoura University students (n =1708) Physical activity & domain Min–max Median (IQR) Skewness Total physical activity score (MET-min/wk) 0–32928 2256 (91–4111) 2.77 Domain-specific score (Total MET-min/wk) At work 0–24906 594 (120.0–1491) 3.94 For transportation 0–13104 346 (132.0–738) 3.71 From domestic & gardening activities 0–6600 60 (0–488) 3.27 In leisure time 0–11016 264 (0–982) 3.1 Activity specific score (total MET-min/wk) Walking 0–13068 1023 (0–1848) 2.45 Moderate 0–16980 405 (0–1260) 3.53 Vigorous 0–23520 0 (0–840) 4.42 Physical activity level No. % Low 193 11.3 Moderate 889 52.0 High 626 36.7 IQR = inter quartile range (first–third quartiles). MET-min/wk = metabolic equivalent-minute/week. Book 17-8.indb 697 8/9/2011 2:04:56 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 698 Table 2 Bivariate analysis of predictors of physical inactivity among Mansoura University students (n = 1708) Predictor Total Physically inactive No. (%) OR (95% CI) Overall 1708 193 (11.3) Age (years) < 20 768 93 (12.1) 1.2 (0.9–1.6) 20+ 940 100 (10.6) Ref Sex Female 856 123 (14.4) 1.1 (1.4–2.6) Male 852 70 (8.2) Ref Grade Preparatory and first 319 53 (16.6) 1.0 (0.5–1.8) 2nd 714 83(11.6) 0.6 (0.4–1.1) 3rd 307 23(7.5) 0.4 (0.2–0.8) 4th 264 16(6.1) 0.3 (0.1–0.7) 5th & 6th 104 18(17.3) Ref College Medicine 331 64 (19.3) 1.5 (0.9–2.5) Engineering 282 37 (13.1) 1.0 (0.6–1.7) Physical education 247 2 (0.8) 0.1 (0.01–0.2) Education 229 11 (4.8) 0.3 (0.2–0.7) Law 211 23 (10.9) 0.8 (0.4–1.4) Arts 196 27 (13.8) 1.1 (0.6–1.9) Commerce 212 29 (13.7) Ref Residence Urban 771 111 (14.4) 1.8 (1.3–2.4) Rural 937 82 (8.8) Ref University sports activity No 1415 171 (12.1) 1.7 (1.0–2.8) Yes 293 22 (7.5) Ref Membership of sports clubs No 1223 162 (13.2) 2.2 (1.5–3.4) Yes 485 31 (6.4) Ref Father’s work Professional/employee 1131 132 (11.7) 1.0 (0.6–1.5) Farmer/manual worker 295 27 (9.2) 0.7 (0.4–1.3) Other 282 34 (12.1) Ref Father’s education < Secondary 952 134 (14.1) 1.7 (1.1–2.8) Secondary 456 33 (7.2) 0.8 (0.5–1.5) > Secondary 300 26 (8.7) Ref Mother’s work Housewife 871 101 (11.6) 1.1 (0.8–1.5) Working outside the home 837 92 (11.0) Ref Mother’s education < Secondary 736 112 (15.2) 1.6 (1.1–2.4) Secondary 598 43 (7.2) 0.7 (0.4–1.1) > Secondary 374 38 (10.2) Ref Family size < 6 persons 906 113 (12.5) 1.3 (0.9–1.8) 6+ persons 802 80 (10.0) r Family income Able to save 732 104 (14.2) 2.3 (1.2–4.7) Enough 811 78 (9.6) 1.5 (0.8–3.0) Not enough 165 11 (6.7) Ref Socioeconomic standard High 599 98 (16.4) 2.3 (1.6–3.2) Middle 396 38 (9.6) 1.2 (0.8–1.9) Low & very low 713 57( 8.0) Ref OR = odds ratio; CI = confidence interval; Ref = reference group. Book 17-8.indb 698 8/9/2011 2:04:56 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 699 revealed  that  females  were  about  2  times more likely to be physically inac- tive than males. The same finding has been reported by many studies in dif- ferent cultures and different age groups [9,11,21,29–32]. In traditional commu- nities, females face social pressures that have historically linked physical power and athleticism to maleness: femininity is not consistent with vigorous activ- ity and sport play. Cultural norms and values in Egypt are more permissive for boys and restrict females to the domes- tic domain [33].  Membership in sports clubs and coming from a family of high socioeco- nomic status were significant independ- ent predictors of the high likelihood of physical inactivity. Similar findings have been reported in the USA and Hong Kong, where daily participation of ado- lescents in school physical education classes, use of recreation centres, high maternal education, and high family in- come were all associated with high level of physical activity [22,34]. In contrast to  our findings, low socioeconomic stand- ard was related to sedentary behaviour and low levels of physical activity [35].  In the present study, medical stu- dents were about 2  times more  likely  to be physically inactive while students of physical education were less likely to be physically inactive compared to students of commerce. This is a direct reflection of the physical education practical curricula implemented in this college. There  are  2  cognitive  variables,  which account for physical activity lev- els: perceived benefits and perceived barriers. Perceived benefits can posi- tively improve participation in physical activity while, barriers can negatively influence it [36]. Only a minority of the  students in our study reported no bar- riers. Time limitation (permanent or temporary) was by far the most im- portant barrier to physical activity. The Table 3 Logistic regression analysis of independent predictors of physical inactivity among Mansoura University students (n =1708) Predictor β P OR (95%CI) Sex Female 0.6 ≤ 0.001 1.8 (1.3–2.5) Male – Ref College Medicine 0.6 0.04 1.8 (1.02–3.3) Engineering 0.1 0.8 1.1 (0.6–2.1) Physical education –2.5 0.001 0.1 (0.0–0.4) Education –0.7 0.07 0.5 (0.2–1.1) Law 0.2 0.6 1.2 (0.6–2.3) Arts 0.4 0.2 1.5 (0.8–3.0) Commerce – Ref Membership of sports clubs No 0.5 0.04 1.6 (1.0–2.5) Yes – Ref Socioeconomic standards High 0.7 ≤ 0.001 2.1 (1.4–3.1) Middle 0.2 0.4 1.2 (0.8–1.9) Low/very low – Ref Constant –2.7 Model χ2 125.3; P ≤ 0.001 Correctly predicted (%) 88.7 OR = odds ratio; CI = confidence interval; Ref = reference group. most cited temporary barriers were lack of interest in physical activity, having other important priorities and unsuitable weather. These were more or less similar to findings reported by other studies where lack of time due to busy lesson schedule, parents giving academic success priority over exercise, lack of time due to responsibilities re- lated to family and social environment, lack of available /convenient facilities, injuries, health condition, perceived lack of support from parents and peers who were concerned more about students’ academic performance than their par- ticipation in physical activity were the most cited items for physical activity barriers [30,35–37] It seem that parents  and caregivers play a key role in creat- ing a culture in the home and commu- nity that is supportive of participation in physical activity by children and young people [31]. People are more active when they can easily access key destinations such Book 17-8.indb 699 8/9/2011 2:04:57 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 700 as parks, green spaces, work places and shops. Other barriers to active living in- clude fear of crime, road safety, transport emissions and pollution; problems with access and/or lack of recreation and sports facilities; and negative attitude to physical activity and public transport [32]. In this study, the majority of stu- dents reported 1 or more benefits of physical activity, especially the promo- tion and maintenance of health. In contrast, Haase  et  al  [11]  reported  that knowledge about activity and health was disappointing, with only 40%–60% being  aware  that physical  activity was relevant to risk of heart disease. Physical activity is consistently associated with fewer symptoms of Table 4 Barriers to physical activity and sporting among Mansoura University students (n =1708) Barrier Permanent Temporary No. % No. % Time limitation 703 41.2 606 35.5 Lack of accessible and suitable sports place 606 35.5 400 23.4 Lack of safe sporting places 545 31.9 379 22.2 Lack of support and encourage from others 534 31.3 415 24.3 Lack of friends to encourage me 493 28.9 407 23.8 Have other important priorities 475 27.8 578 33.8 Lack of sports programme that suits my physical fitness 442 25.9 435 25.5 Not interested in sports 429 25.1 694 40.6 Lack of motivation 418 24.5 469 27.5 High cost 378 22.1 411 24.1 Lack of sports skills 344 20.1 388 22.7 Fear of failure in sports competition 319 18.7 462 27.0 Fear of injury 286 16.7 379 22.2 Fear of deterioration of physical illness 282 16.5 189 11.1 No person caring for my family 264 15.5 242 14.2 Feeling tired on physical activity 244 14.3 514 30.1 Ignorance about benefits of sports 241 14.1 345 20.2 Prefer to not attend to sports places 240 14.1 244 14.3 Lack or low physical power 238 13.9 481 28.2 Feeling of inability to practice sports adequately 235 13.8 486 28.5 Objection of parents 228 13.3 347 20.3 Body cannot tolerate physical activity 216 12.6 270 15.8 Previous failure in sports competition 187 10.9 427 25.0 Unsuitable (hot or cold) weather 178 10.4 525 30.7 Previous bad experience with physical sports activity 150 6.1 446 26.1 Categories are not mutually exclusive. No barriers was reported by 63 (3.7%) of students. anxiety and depression, fewer self-re- ported sleep problems, improved sleep quality and improved social well-being [31,38–40]. This  study has 2  important  fea- tures. First our findings may shed light on interventions that would promote physical activity in university students. Second, it highlights levels, barriers to and perceived benefits of physical activity in Egyptian youth for the first time. However it has some limita- tions. The study was carried out in students of single university during the academic year. The levels of physi- cal activity may differ in other youth groups and may vary during vacations and the time of examinations. Univer- sity students are better educated and may be more aware about benefits of physical activity than other young people. Only simple health beliefs were measured in this study, but many cognitive and attitudinal factors are known to correlate with physical ac- tivity, and examining a broader range of psychosocial variables may help to explain the motives behind the prac- tice of physical activity. Taking into account the significance of the college years as a transition from adolescence to adulthood, physical activity at the university should be encouraged as a preventive measure against chronic diseases and to improve quality of life through adult and eld- erly life. There is a need for clear, practi- cal guidelines for practising physical Book 17-8.indb 700 8/9/2011 2:04:57 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 701 Table 5 Perceived benefits of and suggestions to promote physical activity among Mansoura University students (n =1708) Benefit/suggestion No. % Perceived benefit No benefits 119 7.0 Promote and maintain health 1202 70.4 Improve body image and shape 953 55.8 Improve muscle power 950 55.6 Spent free times 905 53.0 Weight control/obesity prevention 898 52.6 Psychological wellbeing 864 50.8 Recreation 786 46.0 Prevent diseasesa 861 50.4 Improve mentality and intellectuality 772 45.2 Companionship with others 719 42.1 Socializing 588 34.4 Otherb 88 6.2 Suggestions to promote physical activity No suggestions 135 7.9 Free playgrounds in each college to practice sports during free time 1143 66.9 Educating students about benefits of physical activity 742 43.4 Include sports education in curricula 551 32.3 Otherc 207 12.1 Categories not mutually exclusive. ae.g. diabetes mellitus, cardiac diseases and hypertension. bFun and enjoyment (59), improve sleeping (14), self-dependence (10), relieve tension (5). cLow fees for membership in youth and university sports clubs (114), separate playground for males and females (61), sports training (10), organizing monthly sports day (6), care for sports injuries (9), more incentives for sports participation (7). References Foster C. 1. Guidelines for health-enhancing physical activity pro- motion programmes. Tampere, Finland, UKK Institute for Health Promotion Research, 2000. Riddoch C. Physical activity. In: Ewles L, ed. 2. Key topics in public health. Essential briefings on prevention nd health promotion. Edinburgh, Elsevier Churchill Livingstone, 2005:103–117. Physical activity and health in Europe: evidence for action3. . Co- penhagen, World Health Organization Regional Office for Europe, 2006. Chobanian AV et al. 7th report of the Joint National Committee 4. on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Journal of the American Medical Association, 2003, 289(19):2560–2571. Farrell SW, et al. Influences of cardiorespiratory fitness lev-5. els and other predictors of cardiovascular disease mortal- ity in men. Medicine and Science in Sports and Exercise, 1998, 30:899–905. Lee IM, Paffenbarger RSJr. Physical activity and stroke in-6. cidence: The Harvard Alumni Health Study. Stroke, 1998, 29:2049–2054. Sesso HD et al. Physical activity and breast cancer risk in the 7. College Alumni Health Study (United States). Cancer Causes and Control, 1998, 9:433–439. Physical activity and health: a report of the Surgeon General8. . Atlanta, Georgia, Centers for Disease Control and Prevention, 1996. activity in university students. Factors identified as predictors of physical in- activity should be taken into account in the design of interventions. University curricula should include the opportu- nity for all students to participate in physical activity. More research on ef- fective strategies to promote all forms of physical activity is needed. Provision of free playgrounds in each college to practise sports during free times would promote physical activity among uni- versity students. In conclusion the majority of students of Mansoura University are either moderately or highly physically active and perceive the benefits of physical activity. Despite these find- ings, there are many barriers to physi- cal activity. Overcoming these barriers together with consideration of stu- dents’ suggestions may contribute to a further increase in their level of physical activity. Book 17-8.indb 701 8/9/2011 2:04:57 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 702 Irwin JD. Prevalence of university students’ sufficient physical 9. activity: a systematic review. Perceptual and Motor Skills, 2004, 98(1):927–943. Irwin JD. The prevalence of physical activity maintenance in a 10. sample of university students: a longitudinal study. Journal of American College Health, 2007, 56(1):37–42. Haase A et al. Leisure-time physical activity in university stu-11. dents from 32 countries: associations with health beliefs, risk awareness and national economic development. Preventive Medicine, 2004, 39:182–190. Leslie E et al. University campus settings and the promotion of 12. physical activity in young adults: lessons from research in Aus- tralia and the USA. Health Education, 2001, 101(3):116–125. Ziglio E. 13. Addressing the socioeconomic determinant of healthy eating habits and physical activity levels among adolescents (Foreword). Copenhagen, World Health Organization Regional Office for Europe, 2006 (www.euro.who.int/__data/assets/ pdf_file/0005/98231/e89375.pdf, accessed 30 June 2011. International Physical Activity Questionnaire (IPAQ). Long last 7 14. days self-administered format. For use with young and middle- aged adults (15–69 years). 2002 (https://sites.google.com/site/ theipaq/, accessed 4 July 2011). Booth ML. Assessment of physical activity: an international 15. perspective. Research Quarterly for Exercise & Sport, 2000, 71(2):S114–20. IPAQ Research Committee. 16. Guidelines for data processing and analysis of the International Physical Activity Questionnaire (IPAQ). Short and long forms. Stockholm, Karolinska Institute, 2005 (http://www.ipaq.ki.se/scoring.pdf, accessed 4 July 2011). Fahmy SI, El-Sherbini AF. Determining simple parameters for 17. social classifications for health research. Bulletin of the High Institute of Public Health, 1983, 13(5):95–108. Ainsworth BE et al. Compendium of physical activities: classifi-18. cations of energy costs of human physical activities. Medicine & Science in Sports & Exercise, 1993, 25(1):71–80. Al-Hazzaa H. Physical activity patterns of college male subjects. 19. King Saud University Journal, 1990, 2:383–396. Musharrafieh U et al. Determinant of university students physi-20. cal exercise: a study from Lebanon. International Journal of Public Health, 200, 53(4):208–213. Abdullah ASM et al. Factors related to non-participation in 21. physical activity among the students in Hong Kong. Interna- tional Journal of Sports Medicine, 2005, 26(7):611–615. Fontes ACD, Vianna RPT. Prevalence and factors related to low 22. level physical activity among university students in a public university in the northeast region of Brazil . Revista Brasileira de Epidemiologia, [Online] 2009, 12(1):20–29. Makrides L et al. A cardiovascular health needs assessment 23. of university students living in residence. Canadian Journal of Public Health,1998, 89(3):171–175. Haberman S, Luffe, D. Weighing in college students’ diet and 24. exercise behaviors. Journal of American College Health, 1998, 46(4):189–191. Suminski RR et al. Physical activity among ethnically diverse 25. college students. Journal of American College Health, 2002, 51 (2):75–80. Centers for Disease Control. Youth risk behavior surveillance: 26. National College Health Risk Behavior Survey—United States, 1995. MMWR, 1997, 46(SS–6):1–54. Staten RR et al. College students’ physical activity: application 27. of an ecological perspective. American Journal of Health Stud- ies, 2005, 20(1/2):58–65 (http://findarticles.com/p/articles/ mi_m0CTG/is_1-2_20/ai_n27869280/, accessed 4 July 2011). National Youth Risk Behavior Survey 1991–2005: trends in the 28. prevalence of physical activity. Atlanta, Georgia, Centers for Dis- ease Control and Prevention, 2006. Abdel-Aty MA et al. Health related behaviors among adoles-29. cents and youth in Assiut Governorate, Upper Egypt. Bulletin of the High Institute of Public Health, 1999, 29(3):447–474. Daskapan A et al. Perceived barriers to physical activity in uni-30. versity students. Journal of Sports Science and Medicine, 2006, 5:615–20. Active Healthy Kids Canada. Older but not wiser. Canada’s 31. future at risk. Canada’s report card on physical activity for children and youth. Toronto, Canada, 2007 (http://active- healthykids.ca/ophea/activehealthykids_v2/upload/full- English-Report-Card-2007.pdf). Edwards P, Tsouros A. 32. Promoting physical activity living in ur- ban environments; the role of local governments. The solid facts. Copenhagen, World Health Organization Regional Office for Europe, 2006. Shafy HE. Leisure time and its implication. In: 33. Adolescence and state policy in Egypt, Ch VI. Cairo, Egypt, The Population Coun- cil, Regional Office for West Asia and North Africa, 1998. Behavioral risk factors survey (Main report). Commissioned by 34. surveillance and epidemiology branch centre for health pro- tection department of health. University of Hong Kong. Hong Kong, Social Science Research Centre, 2005. Al-Refaee SA, Al-Hazzaa HM. Physical activity profile of adult 35. males in Riyadh City. Saudi Medical Journal, 2001, 22(9):784– 789. Buckworth J, Dishman RK. Determinants of physical activ-36. ity; research to application. In: Rippe J, ed. Lifestyle medicine. Malden, Massachusetts, Williston Blackwell Science, 1999, 1016–1027. Gyurcsik NC et al. Copying with barriers to vigorous physical 37. activity during transition to university. Family & Community Health, 2004, 27(2):130–142. Calfas KJ, Taylor WC. Effects of physical activity on psycho-38. logical variables in adolescents. Pediatric Exercise Science, 1994, 6:406–423. Brosnahan J, et al. The relation between physical activity 39. and mental health among Hispanic and non-Hispanic white adolescents. Archives of Pediatric & Adolescent Medicine, 2004, 158(8):818–820. Food and Nutrition Board, Institute of Medicine. 40. Adequacy of evidence for physical activity. Guidelines development: work- shop summary. Washington, DC, National Academies Press, 2007 (http://www.nap.edu/catalog.php?record_id=11819, accessed 11 June 2011). Book 17-8.indb 702 8/9/2011 2:04:58 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 703 Review Medical education in Saudi Arabia: a review of recent developments and future challenges A. Telmesani,1 R.G. Zaini 1 and H.O. Ghazi 1 ABSTRACT Medical education has been changing rapidly in Saudi Arabia. Within a decade, the number of medical colleges increased from 5 medical schools with traditional disciplined-based curricula to 21 medical colleges with varied curricula ranging from the traditional to more innovative, problem-based, community- oriented programmes. The private sector has started investing in higher education generally and medical education in particular. Also other government sectors that provide advanced health services have started established new medical colleges. The expansion of quantity in medical education has been associated with a drive for greater quality assurance. Accreditation of higher education institutes began with the establishment of the National Commission for Academic Assessment and Accreditation in 2005. This review focuses on documenting developments in Saudi medical education up to 2008 and discussing the future potential and challenges facing the sector. 1Faculty of Medicine, Umm Al-Qura University, Mecca, Saudi Arabia (Correspondence to A. Telmesani: telmesan@gmail.com). Received: 30/04/09; accepted: 31/12/09 ةيلبقتسلما تايدحتلاو ةثيدلحا تاروطتلل ةعجارم :ةيدوعسلا ةيبرعلا ةكلملما في يبطلا ميلعتلا يزاغ نياه ،ينْي َىز اينار ،نياسملت باهولا دبع عبتت اهعيجم تايلك 5 نم بطلا تايلك ددع داز ،دقع نم لقأ للاخف .عيسر وحن لىع يرغتي ةيدوعسلا ةيبرعلا ةكلملما في يبطلا ميلعتلا نإ :ةصلالخا ةيعمتجلما حمابرلا لىعو ،لكاشلما لح لىع زكرت ًاراكتبإ رثكأ جهانم و ةيديلقتلا ينب حواترت ةيسارد جهانم عبتت بط ةيلك 21 لىإ يديلقتلا جهنلما مدقت ىرخأ ةيموكح تاعاطق تعشر ماك .صاخ هجوب يبطلا ميلعتلا فيو ،ماع هجوب لياعلا ميلعتلا في رماثتسلااب صالخا عاطقلا عشر دقف .هجوتلا داهشلإا أدب دقو .ةدوجلل لضفأ نماض قيقت في ةبغرب يبطلا ميلعتلا في يددعلا عسوتلا طبتراو .ةديدج ةيبط تايلك ءاشنإ في ةمدقتم ةيحص تامدخ ميلعتلا في تاروطتلا قيثوت لىع ةلاقلما هذه ز ِّكرتو .2005 ماع في يميداكلأا دماتعلااو مييقتلل ةينطولا ةنجللا سيسأت عم لياعلا ميلعتلا تاسسؤم لىع .عاطقلا اذه هجاوت يتلا ةيلبقتسلما تايدحتلاو تاناكملإا شقانتو ،2008 ماع ىتح يدوعسلا يبطلا Enseignement médical en Arabie saoudite : revue des récentes évolutions et des défis à venir RÉSUMÉ L’enseignement médical a évolué rapidement en Arabie saoudite. En l’espace d’une décennie, le nombre de facultés de médecine est passé de cinq établissements proposant un programme traditionnel reposant sur l’enseignement de disciplines, à vingt et un établissements offrant divers programmes, des plus traditionnels aux plus innovants, à base de résolution de problèmes et orientés vers la population. Le secteur privé a commencé à investir dans l’enseignement supérieur en général et dans l’enseignement médical en particulier. En outre, d’autres secteurs publics prestataires de services de santé de niveau avancé ont créé de nouvelles facultés de médecine. La prolifération de l’offre de cursus médicaux a été associée à une campagne pour une meilleure assurance qualité. L’agrément des instituts d’enseignement supérieur a débuté avec la création de la National Commission for Academic Assessment and Accreditation [Commission nationale d’évaluation académique et d’agrément] en 2005. Cette revue est axée sur les informations disponibles concernant l’évolution de l’enseignement médical saoudien jusqu’en 2008, et évoque le potentiel de ce secteur et les défis auxquels il sera confronté. Book 17-8.indb 703 8/9/2011 2:04:58 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 704 First phase of medical education in Saudi Arabia Saudi Arabia occupies the major part of the Arabian peninsula and has a popula- tion of  approximately 23 million  [1].  After the foundation of the country in 1932, health services began to advance  from a reliance on traditional medicine towards a modern health care system with health care personnel drawn mainly from neighbouring Arab coun- tries and the Indian subcontinent. Later, in a government-sponsored develop- ment plan, hundreds of Saudi Arabians with high-school diplomas were given scholarships abroad to study medicine and allied health sciences. This scheme continued until 1967 when King Saud University established the first medi- cal college in the capital city Riyadh in affiliation with the London College of Medicine.  In  1975  a  further  2 medi- cal colleges were established at King Abdul-Aziz University and King Faisal University, and in 1980 King Saud Uni- versity opened a branch college in Abha, the southern region, which later became King Khalid University. In 1996, Umm Al-Qura University established the new- est medical college for the first phase of Saudi medical education. However, the output of these 5 colleges was not suf- ficient to bridge the gap in supply and demand  for Saudi physicians.  In 2006,  Saudi Arabian nationals constituted less than 20% of  the physicians working  in  the country [1]. The first phase of medical educa- tion in Saudi Arabia lasted for over 3 decades. Within this era, the 5 former medical colleges followed the same 6-year traditional curriculum, which consisted of 3 years of basic and medi- cal science courses, 3 years of clinical training, followed by a 1-year internship. There were minor differences between colleges in the arrangement of the sub- jects and disciplines. Teacher-centred learning strategies were the dominant form of instruction. In  the early 2000s concerns about  the disadvantages of the traditional cur- riculum design began to be raised and calls for change increased among the Saudi medical community. The classic teacher-centred approach with copious lectures has limited opportunities for more effective student-centred learning opportunities. One of the limitations is overcrowding of the curriculum, with overemphasis on certain subjects and the inclusion of some less relevant sub- jects  [2–6].  In  the United Kingdom  these problems have been shown to have a negative impact on students’ aca- demic achievement and the educational environment [7,8]. The poor  teaching  environment was also highlighted in studies from medical schools in Saudi Arabia and Yemen which follow a tradi- tional didactic system [9]. A vigorous debate began among Saudi scholars about the divergence between what is expected of medi- cal graduates as new doctors and the content of Saudi medical programmes [4,5,10]. This debate  raised  concerns  among academics and medical school deans, which has stimulated a drive to reform the curriculum in most col- leges towards a more student-centred and  self-learning  approach  [11]. The  importance of evidence-based medi- cal education [12] as a  tool  in medical  programmes has also been discussed in the region [13]. Second phase of medical education in Saudi Arabia Saudi medical education has entered a new phase. The Ministry of Higher Education (MOHE) has taken steps to develop higher education in general and medical education in particular. Many new universities have been established and new medical colleges have been announced. The private sector has been invited to contribute and invest in higher education. By 2008, there were 10 new  medical colleges that were affiliated with the MOHE and 3 private medi- cal colleges were licensed. In addition, the Ministry of Health (MOH) and the National Guard established their own medical colleges—King Fahad Medical City and King Saud bin Ab- dulaziz University for Health Sciences respectively—raising to 21 the number  of medical colleges in Saudi Arabia. In 2005,  a national  accreditation agency  for higher education was established; the National Commission for Aca- demic Assessment and Accreditation (NCAAA). This second phase of medical education is witnessing a nationwide movement toward innovation in medi- cal education programmes, with a drive to excellence and recognition by in- ternational agencies and institutions. Most of the newly established medical colleges follow more innovative medi- cal programmes and have established international partnerships with elite educational institutes (Table 1). The educational strategies adopted include a more integrated curriculum, a focus on problem-based learning and the development of community-oriented and community-based learning. For example, King Saud bin Abdulaziz Uni- versity for Health Sciences (KSAU-HS) includes both graduate and undergrad- uate entry to a problem-based learning programme, while Qassim University (QU) follow a problem-based learn- ing, community-oriented programme. Older medical colleges have mostly un- dergone systematic reforms towards a hybrid, integrated, community-oriented, community-based or problem-oriented curriculum, such as at the medical col- leges at Jazan University, King Abdulaziz University and King Saud University. Other colleges continue to follow the same classic, discipline-based, teacher- centred curriculum. Book 17-8.indb 704 8/9/2011 2:04:58 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 705 In parallel with the recent expansion of the quantity of Saudi medical educa- tion, calls for establishing quality indi- cators are increasing. The experiences of the first innovative medical colleges at Qassim University and KSAU-HS need to be evaluated and studied. Some of the achievement of the KSAU-HS medical colleges is their recognition of the World Federation for Medical Education in addition to the national accreditation by the NCAAA. Another issue in medical education in Saudi Arabia, as in many countries of the Eastern Mediterranean region, is the language of instruction. Teach- ing in medical colleges is conducted in English language. The disadvantages of teaching medicine in a foreign language and the added stress this can impose on students is poorly addressed in the literature. Foreign language instruc- tion can pose a major difficulty for new medical students who have suboptimal competence in the English language. It has been shown that non-native English speakers studying medicine in English Table 1 Summary of medical schools in Saudi Arabia and their types of curriculum Name Location Launched Sector Type of curriculum King Saud University Riyadh 1967 Government Reformed in 2009 to integrated curriculum King Abdulaziz University Jeddah 1975 Government Reformed in 2006 to integrated, problem-based learning curriculum King Faisal University Dammam 1975 Government Classic discipline-based, teacher-centred programme King Khalid University Abha 1982 Government Classic discipline-based, teacher-centred programme Umm Al Qura University Makkah 1996 Government Classic discipline-based, teacher-centred programme Al Qassim University Qassim 2001 Government Problem-based learning, community-oriented curriculum Taibah University Madinah 2001 Government Classic discipline-based, teacher-centred programme King Faisal University Al Hassa 2001 Government Classic discipline-based, teacher-centred programme Jazan University Jazan 2001 Government Reformed in 2005 to integrated, community-oriented, problem- based learning curriculum King Fahd Medical City Riyadh 2004 Government Integrated, problem-based learning curriculum King Saud bin Abdulaziz University for Health Sciences Riyadh 2004 Government Integrated, problem-based learning curriculum Ibn Seena Medical Colleges Jeddah 2004 Private Hybrid, integrated curriculum Taif University Taif 2005 Government Hybrid, integrated curriculum Batterjee College for Medical Sciences and Technology Jeddah 2006 Private Integrated, problem-based learning curriculum Najran University Najran 2007 Government Classic discipline-based, teacher-centred programme Tabuk University Tabuk 2007 Government Classic discipline-based, teacher-centred programme Al Jouf University Al Jouf 2008 Government Classic discipline-based, teacher-centred programme Alfaisal University Riyadh 2008 Private Problem-based learning and community-based curriculum Al-Imam Mohammed bin Saud Islamic University Riyadh 2008 Government Integrated, problem-based learning, community-oriented curriculum Hail University Hail 2008 Government Integrated, problem-based learning curriculum King Saud bin Abdulaziz University for Health Sciences Jeddah 2008 Government Integrated, problem-based learning curriculum Book 17-8.indb 705 8/9/2011 2:04:58 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 706 have problems with medical vocabulary and practical problems due to different procedural and cultural expectations [14]. Learning medicine  through  their  native Arabic language has been ad- vocated by some senior academicians [15]. The advantages and disadvantages  of learning and teaching medicine in a non-native language and its effect on the learning process has not been thoroughly addressed to date in Saudi Arabia Admissions and students’ intake There is a high demand by high-school graduates in Saudi Arabia for medical education. So the expansion in medical programmes across the country has increased the overall intake of students to around 2500 students. The medical  education programme is mainly via un- dergraduate entry and runs for 6 years, followed by a 1-year internship. KSAU- HS has a graduate entry programme that runs for 4 years plus the 1-year internship for holders of a bachelor’s degree in applied or medical sciences. Admission to medicine programmes used to be solely according to high- school grades, in which students with the highest grades were admitted. Later, a written science examination (in English) and interview were introduced as part of the  selection process.  In 2002,  the Na- tional Centre for Assessment in Higher Education was established. The Centre is responsible for conducting a national standardized aptitude examination for high-school leavers who wish to apply to the universities for medicine. At present, admission to any medical college in the country is based on high-school grades, the national aptitude test, a summative examination in science and an interview. Some of the colleges are not using the interview because of lack of evidence of it objectivity and reliability. Medical schools are being chal- lenged to admit more students. In view of the considerable attrition rate among medical students, such an expansion increases the pressure to maintain a high number of quality, competent graduates. Calls have increased among academics to strengthen the student admissions policies and enhance the objectivity of admission interviews. Accreditation Saudi medical  schools have 2 profes- sional functions: medical education and health care. Concerning the edu- cational  role,  until  2005,  institutes of  higher education, including medical colleges, required no accreditation. In 2005,  the Council  of Higher Educa- tion approved the establishment of the NCAAA, tasked with ensuring the qual- ity of higher education in the country. It is now mandatory for every institute of higher education to be accredited by the NCAAA. The accreditation criteria are comprehensive and include all aspects of an institute, in particular teaching and learning. The accreditation period is limited to 7 years, after which the insti- tute will be revisited for re-accreditation [16]. The process of  self-evaluation  for  all the existing institutes has begun and aims to identify the strengths and weak- nesses of colleges and their teaching programmes. The Commission has also started reviewing some medical schools. While this is a step in the right direc- tion, the process itself will need to be evaluated for its impact on the quality of medical education. Concerning the professional role, the Saudi Commission for Health Specialties is an independent body involved in accreditation of postgradu- ate programmes, board examinations, professional classification and registra- tion. The Commission runs a national examination—the Saudi Licensing Examination—that national and inter- national graduates doctors are required to take for residency programmes or job placement in Saudi Arabia. The examination consists of 100 multiple- choice questions. Examination statistics are published annually by the Com- mission, including comparison tables of the scores of graduates from all the colleges. It is believed that such com- parisons should be a strong motivation for each medical college to improve the students’ scores, which will be re- flected in the Commissions statistics. It is considered as an indirect method of quality assurance and a stimulation for improvement and development among institutions. Again, the effectiveness of the examination as a quality indicator of medical graduates’ competencies has not yet been investigated. There have been proposals  for  a  2-part  national  licensing examination for all Saudi medical school graduates as well as overseas graduates: a written part for measuring the basic and clinical sci- ence and a practical part for evaluating graduates’ clinical and interpersonal skills [17]. Certainly such a scheme will  face many challenges and assessing stakeholders’ views of the issue is es- sential at this stage. In the meantime, a national survey of senior students’ and interns’ views of the national licensing examination is being carried out [Zaini  R, personal communication]. Challenges Many challenges face medical educa- tion in Saudi Arabia. The rising global demand for health practitioners in general and physicians in particular is a major challenge worldwide. The mushrooming of medical colleges in the country places tremendous pres- sure on the MOHE to provide a proper infrastructure and qualified personnel that are well trained in medical educa- tion. In addition, the expansion of the new medical colleges, if not carefully planned, might eventually raise ques- tions about quantity versus quality of medical training. Book 17-8.indb 706 8/9/2011 2:04:59 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 707 The pace of reform in Saudi medical education is slow and there are difficul- ties in its execution. Most of the reforms are directed towards the content of curricula, without defining the essen- tial skills, knowledge, behaviour and standards (outcome-based approach) that graduating physicians need. Some- time the revised curricula have not led to any obvious reforms and this raises concerns that Burton and McDonald [18]  express  in  their  paper  entitled:  “Curriculum or syllabus: which are we reforming?” In addition, learning medicine in a foreign language (English) has to be addressed. Medical colleges recruit the topmost high-school graduates, yet the attrition rate from medical school is still high. This is multifactorial, but the language of instruction seems to be an important  factor  [19]. Certainly  the  current criteria for student selection do not consider students’ proficiency of English language. An additional challenge is to provide the new colleges with adequate numbers of qualified staff. The Gulf Cooperative Council countries Committee of Deans of Medical Colleges agreed that the minimal acceptable faculty-to-student ratio is 1:7. However, some of the al- ready established colleges are facing shortages in the number of faculty, with a faculty-to-student ratio far from what these recommendations. The problem is compounded by an unfavourable fac- ulty salary scale as compared with other institutes and private hospitals, a similar situation to Malaysia [20]. Another challenge that faces all Saudi higher education institutes is maintaining and assuring quality. This is the responsibility of the recently es- tablished NCAAA, whose effectiveness and efficiency has yet to be established. Many medical educators call for an independent medical education profes- sional body to govern the health and medical colleges. On the other hand, an objective national graduation licens- ing examination is a possible means of providing a quality indicator for medical schools. Conclusion Medical education in Saudi Arabia is in a crucial phase that will chance the face of medical education in the country. Systematic planning that considers all potential challenges must be undertaken. The current phase of reform and expansion must be coupled with accreditation and quality assur- ance procedures in order to ensure that each endeavours are directed towards internationally acknowledged goals and standards. References Health statistic book for the year of 2006, Riyadh, Saudi Ara-1. bia, Ministry of Health, 2006. Al-Gindan YM, Al-Sulaiman AA, Al-Faraidy A. Undergraduate 2. curriculum reform in Saudi medical schools. Which direction to go? Saudi Medical Journal, 2000, 21:324–326. Elfaki EA. Undergraduate curriculum reform in Saudi medical 3. schools. Saudi Medical Journal, 2004, 21:324–326. Al-Shehri MY, Al-Ghamdi AS. Is there anything wrong with un-4. dergraduate medical education in Saudi Arabia? Saudi Medical Journal, 1999, 20:215–218. Shawky S, Soliman NK. Going beyond the curriculum to pro-5. mote medical education and practice in Saudi Arabia. Saudi Medical Journal, 2001, 22:477–480. Milaat WA, El-Gamal FM. Factors affecting the use and at-6. titude towards medical resources and educational methods in a Saudi medical school. Annals of Saudi Medicine, 1994, 14(3):209–214. Harden RM et al. 7. BEME guide no. 1. Best evidence medical educa- tion. Dundee, United Kingdom, Association for Medical Edu- cation in Europe, 1999. Roff S et al. Development and Validation of the Dundee Ready 8. Education Environment Measurement (DREEM). Medical Teacher, 1997, 19:295–299. Al-Hazimi A et al. Educational environment in traditional 9. and innovative medical schools: a study in four under- graduate medical schools. Education for Health, 2004, 17:192–203. Ahmed AM. Deficiencies of history taking among medical stu-10. dents. Saudi Medical Journal, 2002, 23:991–994. Khalid BA. The current status of medical education in the Gulf 11. Cooperation Council countries. Annals of Saudi Medicine, 2008, 28:83–88. Harden RM. Planning a curriculum. In: Dent J, Harden RM, 12. eds. A practical guide for medical teachers. Edinburgh, Churchill Livingston, Harcourt Publishers, 2001. AlFaris E, Abdulgader A, Alkhenizan A. Towards evidence-13. based medical education in Saudi medical schools. Annals of Saudi Medicine, 2006, 26:429–432. Frank RA. Medical communication: non-native English speak-14. ing patients and native English speaking professionals. English for Specific Purposes, 2000, 19:31–62. Sebai ZA. Why do not we teach medicine in Arabic? In:15. Pro- ceedings of the VII Saudi Medical Meeting. Dammam, Saudi Arabia, King Faisal University, 1982:74–75 [in Arabic]. Handbook 1. Standards and processes for quality assurance and 16. accreditation. Riyadh, Saudi Arabia, National Commission for Assessment and Academic Accreditation, 2005. Bajammal S et al. The need for national medical licensing exam-17. ination in Saudi Arabia. BMC Medical Education, 2008, 8:53. Burton JL, McDonald S. Curriculum or syllabus: which are we 18. reforming? Medical Teacher, 2001, 23:187–191. Al-Shammri E. [The role of Arabization of higher education 19. in the development of manpower and achievement of Sau- dization. In: Symposium of Disseminating Arabization and the Development of Translation in the Kingdom]. Riyadh, King Saud University, Translation Centre, 1998:75 [in Arabic]. Lim VK. Medical education in Malaysia. 20. Medical Teacher, 2008, 30:119–123. Book 17-8.indb 707 8/9/2011 2:04:59 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 708 Review Etiological factors of constipation in the elderly, with emphasis on functional causes A.A. Amir 1 ABSTRACT Constipation is a particularly troublesome complaint in the elderly yet it is usually considered to be a simple management issue. Therefore physicians’ lack of interest in and inadequate training about the etiology of constipation may contribute to their inability to manage the problem of constipation effectively. Constipation can become a chronic problem, refractory to management, and most likely the result of lifelong patterns of bowel and dietary habits and laxative use, along with the interaction of pathophysiological and perhaps senescent changes of gut motility. This article reviews the types and causes of constipation and the management of the problem in the elderly. 1Department of Medicine, University of Ahfad, Omdurman, Sudan (Correspondence to A.A. Amir: abdalaal.amir@yahoo.com). Received: 20/10/09; accepted: 05/01/10 ةيفيظولا بابسلأا لىع زيكترلا عم ،يننسلما ينب كاسملإل ةببسلما لماوعلا رماع لاعلا دبع يدؤيو .ةلجاعلما َىةلْه َىس ةيضق لاوحلأا بلغأ في د َىع ُحي لازام كاسملإا نأ لاإ ،يننسلما ينب ماَّيسلاو ،جاعزلإل ةيرثم ىوكش كاسملإا لِّثمي :ةصلالخا كاسملإا لّوحتي ام ًايرثكو .ةلا َّعف ًةلجاعم ةلكشلما هذه ةلجاعم لىع متهردقم مدع لىإ ،كاسملإا تايببس لوح مهبيردت ةيافك مدعو ءابطلأا مماتها صقن لماعتساو ةيئاذغلا تاداعلاو طّوغتلا ثيح نم دملأا ةليوط ةئطاخ طمانلأ ًةجيتن حجرلأا لىع كلذ نوكيو ،جلاعلا لىع ةيصعتسم ةنمزم ةلكشم لىإ كاسملإا بابسأو طمانأ ةلاقلما هذه ضرعتستو .ءاعملأا ةكرح في ةيخوخيشلا تا ُّيرغتلا مابرو ةيضرلما ةيجولويزيفلا تلاعافتلا اهيلإ فاضت ،تانيللما .يننسلما ينب ةلكشلما هذله يجلاعلا يربدتلاو Facteurs étiologiques de la constipation chez les personnes âgées en général et causes fonctionnelles en particulier RÉSUMÉ La constipation est un problème particulièrement gênant chez les personnes âgées, mais elle est en général considérée comme une simple question de prise en charge. Par conséquent, le manque d’intérêt des médecins et une formation inadaptée à l’étiologie de la constipation pourraient expliquer leur incapacité à prendre en charge efficacement ce problème de santé. La constipation peut devenir chronique et résistante à la prise en charge. Elle résulte le plus souvent d’habitudes de toute une vie en matière d’évacuation intestinale, d’alimentation et d’utilisation de laxatifs, ainsi que de modifications physiopathologiques et peut-être sénescentes de la motilité intestinale. Le présent article examine les types de constipation, leurs causes et la prise en charge de ce problème de santé chez les personnes âgées. Book 17-8.indb 708 8/9/2011 2:04:59 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 709 Introduction The world’s population is ageing. At the same time the elderly have special medical needs caused by the interac- tion of disease with the ageing proc- ess. There are few gastrointestinal disorders found exclusively in older people but the balance of diagnostic possibilities may be markedly altered for a given symptom or set of clinical findings when compared with younger patients. The elderly often postpone visiting the general practitioner and may give a confusing account of their symptoms. The physical signs may be misleading. For these reasons the rec- ognition of gastrointestinal disorders is often difficult in older people and the prognosis may be quite different from that of the younger patient. Age-related changes must not be overlooked in the differential diagnosis of gastrointestinal disorders [1]. Constipation is a particularly trou- blesome complaint in the elderly yet it is usually considered to be a simple management issue. Therefore treat- ment is frequently delegated to the least trained member of a health care team. Furthermore physicians (senior and junior) are usually not formally trained in evaluating or treating con- stipation [2].  In  reality,  constipation  remains a common, important prob- lem particularly in the elderly, and may be extremely difficult to manage. Types of constipation Organic constipation should be differ- entiated from functional constipation. Organic constipation is usually associ- ated with mechanical obstruction, such as narrowing of the intestinal lumen due to tumour, scar, adhesion and also abnormalities in the intestine (mega- colon, megasigmoid, diverticulosis) [1,2]. Functional constipation occurs  in an apparently normal anatomy of the colon [1–3]. It is subdivided into: Simple constipation (colonostasis).• Neurogenic constipation due to • dysfunction of the intramural neu- ral apparatus or vagus nerve. This is the so-called dyskinetic constipation, caused by the reflex action on the in- testinal motor function of another af- fected organ (cholecystitis, adnexitis, prostatitis) or by organic problems of the central nervous system (tumours of the brain, encephalitis, posterior spinal sclerosis). Constipation associated with inflam-• matory diseases, mainly of the large intestine. Toxic constipation occurring in exog-• enous poisoning with lead, morphine or cocaine. Constipation of endocrine etiology, • occurring in thyroid or pituitary hy- pofunction. Constipation caused by lack of physi-• cal exercise. Metabolic constipation, such as in • hypokalaemia. Psychogenic constipation.• Muscular constipation.• Causes of constipation The most common causes of consti- pation in elderly people are simple colonostasis caused by lack of physi- cal exercise; mechanical constipation; muscular constipation; neurogenic and psychogenic constipation; and meta- bolic constipation [4]. Simple constipation Two groups of causes of simple constipation (colonostasis) may be distinguished. Some causes depend entirely on the patient, while others stem mainly from unfavourable en- vironmental circumstances in which the person finds himself  [2,4]. Some  people ignore the urge to defaecate until the rectal receptors no longer react to the usual stimuli. Their stimu- lation and the urge to defaecate occur only under the effect of intra-intestinal pressure that is higher than normal at  the  time of defaecation [2].  In  the  elderly there is usually some disorder of normal motor activity of the large intestine and this leads to colonostasis. The simple causes of colonostasis in elderly people include poor dietary habits, insufficient physical activity and suppressed activity of the reflex mechanisms involved in defaecation [3]. Stretching of the rectum in a healthy person is accompanied by an urge to pass a stool. In elderly people with constipation the sensitivity of the rectal receptors to stretching is diminished. These leads to accumula- tion of copious amounts of faeces in the rectum and despite an overfilled rectum, they rarely have an urge to pass the stool and this leads to dilation of the rectum. Mechanical constipation Mechanical constipation is more com- mon in elderly people than the young. The obstruction of the lumen of the intestine can be caused by tumours, diverticulosis and prolapse of the rectal mucosa. Also the intestine may be compressed by ascites, an enlarged uterus or its adnexae or tumours of other neighbouring organs. In these cases colonostasis is caused not by organic narrowing of the intestinal lumen, but by disorders of the reflex mechanisms of evacuation mainly due to pain arising from the intestine itself or structures connected with it [2]. Muscular constipation The term muscular constipation is con- stipation mainly due to weakness of the muscles responsible for movement of the faeces and their discharge from the intestine. Defaecation is mainly achieved by contraction of the diaphragm. The functional state of the diaphragm suffers in diseases of the lungs, such as pulmo- nary emphysema, particularly in older Book 17-8.indb 709 8/9/2011 2:05:00 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 710 people. The muscles of the abdominal wall, which also play an important role in raising intra-abdominal pressure, are also often weakened in the elderly. Contraction of the muscle elevating the anus is very important in the discharge of faeces from the rectum. This muscle is often atrophied in older females who have had multiple pregnancies, and functional deficiency of this muscle is evidently among the causes of consti- pation  in  these women [1]. Atrophy  of the rectal smooth muscles is one of the main manifestations of sclero- derma  and Chagas disease  [1]. The  gastrointestinal tract is involved in the early stages of scleroderma in which the normal muscle tissue is replaced by connective tissue and this delays the movement of the faeces in the large intestine and leads to constipation. Diminished function of the muscles of the intestinal wall is also one of the causes of colonostasis in older indi- viduals [2]. Psychogenic and neurogenic constipation Psychogenic and neurogenic constipa- tion in elderly people occurs in states of depression, schizophrenia and nervous anorexia. Patients with these diseases often ignore the urge to defaecate. It is possible that these urges are notice- ably diminished under the effects of these diseases or due to the effects of the drugs used to treat them. Diseases of the lumbosacral part of the spinal cord and the cauda equina (such as in tumours or syphilis) are accompanied by severe colonostasis, and the large intestine is sharply dilated by the accumulation of faeces [4]. Metabolic constipation Constipation is encountered in some endocrine diseases. Colonostasis is often among the earliest signs of myxo- edema. The other signs of myxoedema usually appear later than constipation. Colonostasis is also often encoun- tered in elderly patients with diabetes mellitus complicated by neuropathy [1]. Constipation  in  elderly patients  with severe heart failure usually disap- pears soon after oedema is relieved. Diuretics intensify constipation in patients with congestive heart failure by causing hypokalaemia. Correction of hypokalaemia and decreasing the dose of diuretics can bring some relief of constipation but does not eliminate it completely [2]. Management of constipation The physician should enquire if the • patient is taking any drugs which have a constipating effect. Elderly patients should be encour-• aged to visit the lavatory regularly. Proper attention should be given to high gut motility periods (in the morning and after meals), by encour- aging the patient to allow adequate time in a relaxed environment for a bowel movement during these peri- ods. In some communities, especially in developing countries, the toilets are not suitable for use of elderly people with some motor weaknesses or dis- ability. Elderly patients should be advised • to drink large quantities of water, eat fibre-rich foods, especially fruits and vegetables, and take a reason- able amount of regular exercise. The patient should be advised that if he/she is taking only small amounts of solid foods, he/she can suffer constipation or small amounts of stool. The treatment here is to take sufficient food and not laxatives. The patient should be advised not to • use a laxative without a physician’s prescription. Elderly patients should be advised to avoid irritant laxatives unless these meet strict criteria for their use. Indications for this class of laxatives include severe muscle weak- ness, constipating medication that cannot be stopped and loss of rectal reflex which is seen in chronic idi- opathic constipation. A top priority for physicians in cases • of chronic constipation in the elderly is to search for an underlying cause and not to delay from carrying out invasive investigations such as endos- copy if necessary. The patient should be warned that in some cases the cause of constipation is an obstruc- tion due to a tumour. The patient should be informed also that there are different types of laxatives with different modes of action, and some of them may not be suitable for some patients. First-line treatment for chronic con-• stipation in the elderly is osmotic agents, sometimes with the addition of a local agent. Osmotic agents are non-absorbable sugars (lactulose or sorbitol) that result in an increase in water content of the stool. The rec- ommended dose of lactulose is 15– 30 mL per day but may be increased  to 60 mL  in divided doses. Blood  sugar levels in diabetics should be monitored carefully. Constipation can become a chronic problem, refractory to man- agement, and most likely is a result of lifelong patterns of bowel and dietary habits and laxative use, along with the interaction of pathophysiological and perhaps some senescent changes of gut motility. The idea that factors such as bowel habits, dietary fibre, liquids and long-term laxative use contribute to chronic constipation is not a new one and suggests that physicians’ lack of interest and inadequate training in the management of constipation may actually be contributing to their inability to manage the problem of constipation effectively. Also, because of the ready availability of laxatives, which are advertised as safe and gentle, patients are not educated in methods of maintaining good bowel habits, and dietary management of constipation [1,2]. Book 17-8.indb 710 8/9/2011 2:05:00 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 711 References Castle SC. Constipation and aging. 1. Medical Clinics of North America, 1989, 73:1497–1509. Castle S. Constipation: a pressing issue. 2. Archives of Internal Medicine, 1987, 147:1702–1704. Kallman H. Constipation in the elderly. 3. American Family Physi- cian, 1988, 27:179–184. Milne JS, Williamson J. Bowel habit in older people. 4. Gerontolo- gia Clinica, 1972, 14:56–60. Age-friendly primary health care (PHC) centres toolkit Increased longevity is not only a triumph for society but a huge challenge for health systems which need to be prepared to address the needs of older people at the community level. In general, training for health professionals includes little if any instruction about care for the elderly. However, they will increasingly spend time caring for this section of the population. The World Health Organization (WHO) maintains that all health providers should be trained on ageing issues, regardless of their specialism. Most preventative health care and early disease screening takes place in primary health care (PHC) centres within health systems. These centres play a critical role in the health of older people worldwide at the local level. Therefore, WHO developed the Age-friendly primary health care (PHC) centres toolkit that assists health care workers in the diagnosis and management of the chronic diseases that often impact people as they age. The purpose of the toolkit is to: improve the PHC response for older persons. • sensitize and educate PHC workers about the specific needs of their older clients. • provide PHC workers with a set of tools/instruments to assess older people’s health. • raise awareness among PHC workers of the accumulation of minor/major disabilities experienced by older people. • provide guidance on how to make PHC management procedures more responsive to the needs of older people. • offer direction on how to do environmental audits to test PHC centres for their age-friendliness. • These resources are intended to supplement and not to replace local and national materials and guidelines. Further information about the toolkit is available at: http://www.who.int/ageing/publications/upcoming_ publications/en/index.html Book 17-8.indb 711 8/9/2011 2:05:00 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 712 Report Using surveillance data for action: lessons learnt from the second generation HIV/AIDS surveillance project in Pakistan F. Emmanuel,1 A. Adrien,2 U. Athar,1 M. Imran,3 T. Reza 1 and J. Blanchard 1 ABSTRACT Although many countries are now collecting useful, high-quality HIV surveillance data, more efforts are put into the collection of data than into ensuring it is deployed effectively. The Canada–Pakistan HIV/ AIDS surveillance project has strengthened and expanded the existing national AIDS control programme surveillance system in Pakistan through a comprehensive estimate of the size and location of some of the most at-risk populations (sex workers and injection drug users) and annual assessments of their sociodemographic characteristics, behaviours and HIV prevalence. The country now uses second generation surveillance data at a broad level to lobby for policy change, mobilize resources, improve programming and measure the success of prevention through an integrated national effort. This article aims to share the experiences and lessons learnt in the development of a second generation surveillance system for HIV/AIDS in Pakistan. 1HIV/AIDS Surveillance Project, Agriteam Consulting Ltd, Canada, and Centre for Global Public Health, University of Manitoba, Winnipeg, Canada (Correspondence to F. Emmanuel: faran_emmanuel@yahoo.com). 2Pro-action, Partners for Health, Montreal, Canada. 3National AIDS Control Program, Islamabad, Pakistan. Received: 11/10/09; accepted: 05/01/10 هسويرَفب ىَودعلاو زديلإا ضرم د ُّصرت عوشرم نم نياثلا ليلجا نم ةدافتسم سورد :لمعلا في د ُّصترلا تايَطعُم نم ةدافتسلاا ناتسكاب في راشنلاب سميج ،اضر ةرهاط ،نارمع دممح ،رهطأ ى َىمْظ ُحع ،نايردآ سكيلأ ،ليونمايإ ناراف دوهلجا نإف ،هسوير َىفب ى َىودعلاو زديلإا ضرم د ُّصرت لامج في ةدولجا ةقئافو ةديفم تايطعم عمجب نهارلا تقولا في موقت ةيرثك ًانادلب نأ عم :ةصلالخا ضرم د ُّصترل نياتسكابلا يدنكلا عوشرملل ناك دقو .ابه ةلاعفلا ةدافتسلاا نماضل لذب ُحت يتلا دوهلجا نم يرثكب بركأ يه تايطعلما عجم في لذبت يتلا مجلح بعْوَىتس ُحم ريدقت للاخ نم ناتسكاب في زديلإا ةحفاكلم ينطولا جمانبرلا في د ُّصترلا ماظن عيسوتو زيزعت في حضاو ٌرود هسويرفب ىودعلاو زديلإا ،متهايكولسو ،ةيفارغوميدلاو ةيعماتجلاا مِتهماِسل يونسلا مييقتلاو )ًانقح تار ِّدخلما يرقاعمو ،اياغبلا( ًاراطتخا رثكأ يه يتلا تائفلا ضعب عقاومو دشحو ،تاسايسلا يريغت لىإ ةفدالها ةلملحا في عساو قاطن لىع نياثلا ليلجا نم د ُّصترلا تايطعم ًايلاح ناتسكاب مدختستو .زديلإا سويرف راشتنلاو سوردلاو تابرلخا لدابت لىإ ةلاقلما هذه فدتهو .ةلماكتم ةينطو دوهج للاخ نم كلذو ةياقولا في زرحُحأ يذلا حاجنلا سايقو ،ةمجبرلا ينستو ،دراولما .ناتسكاب في هسويرفب ىودعلاو زديلإا ضرلم د ُّصترلا ماظن نم نياثلا ليلجا ريوطت في ةدافتسلما Utilisation des données de surveillance pour l’adoption de mesures : enseignements tirés du projet de surveillance de deuxième génération du VIH/sida au Pakistan RÉSUMÉ De nombreux pays collectent des données de surveillance utiles et de haute qualité sur le VIH. Toutefois, leurs efforts sont davantage axés sur le recueil des données que sur une exploitation efficace. Le projet de surveillance du VIH/sida Canada-Pakistan a renforcé puis étendu le système de surveillance du programme national de lutte contre le sida existant au Pakistan, au moyen d’une estimation globale de la taille et de la distribution géographique de certains groupes à plus haut risque (travailleurs du sexe et consommateurs de drogues injectables) et d’évaluations annuelles de leurs caractéristiques sociodémographiques, de leurs comportements et de la prévalence du VIH. Le pays a désormais recours à des données de surveillance de deuxième génération à grande échelle pour faire pression en faveur de changements politiques, de la mobilisation de ressources, de l’amélioration des programmes et du suivi de la réussite de la prévention par une action nationale coordonnée. Le présent article vise à diffuser les données d’expérience et les enseignements tirés de l’élaboration du système de surveillance de deuxième génération du VIH/sida au Pakistan. Book 17-8.indb 712 8/9/2011 2:05:00 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 713 Introduction The concept of second generation sur- veillance (SGS) for HIV/AIDS as the “regular, systematic collection, analysis and interpretation of information for use in tracking and describing changes in the HIV/AIDS epidemic over time” was first introduced by the World Health Organization and Joint United Nations Programme on HIV/AIDS. Since then, a number of countries have tailored it to their specific needs in order to understand and describe the stages of their HIV epidemic [1–3]. Although  many countries are now collecting use- ful, high-quality data, it has been noted that more efforts are put into the col- lection of data than into ensuring it is deployed effectively [4–6]. Surveillance systems enable a country to understand the magnitude of the epidemic and monitor trends over time [7]. Surveillance is not a one- time activity, however, nor should it be a stand-alone programme. Information about trends in HIV prevalence, which populations are affected, and so on, can help a country to monitor its epidemic and also provide information about the effectiveness of prevention and control measures. Estimating the numbers and mapping the geographical location of groups at high risk of contracting and spreading HIV within a given commu- nity are fundamental to ascertaining the scale of required interventions and identifying areas where prevention ef- forts need to be focused. Behavioural data, for example, can serve as an early warning system that immediate action is needed and help in the design of ef- fective  services  and programmes  [8].  Furthermore, tracking risk behaviours over time enables the effectiveness of intervention programmes to be moni- tored [9]. These data can also be used  to strengthen the commitment of com- munities and mobilize them towards a more effective response [10,11]. This article aims to share the ex- periences and lessons learnt in the development of an SGS system for HIV/AIDS in Pakistan. In addition, we document the use of SGS data for advocacy, ensuring commitment from policy-makers and developing a national response for combating HIV/ AIDS in Pakistan. Second generation surveillance in Pakistan Apart from other interventions, sur- veillance has always remained a major focus of the national response to HIV/ AIDS in Pakistan. The surveillance systems in place largely relied on the collection, analysis and reporting of data from routinely reported diagnoses of notifiable diseases, based either on clinical or laboratory diagnoses. HIV sero surveillance, however, is of limited use in places where HIV infection is relatively uncommon among the gen- eral population. SGS for HIV/AIDS not only captures the seroprevalence trends but also the underlying risk behaviours which actually determine the course of epidemic in a given population [1]. In 2003, the Pakistan national AIDS  control programme expanded its re- sponse to the epidemic via an enhanced HIV/AIDS control programme [12].  As a part of this response, the Cana- dian International Development Agency provided assistance for the establishment of an effective national SGS system for HIV/AIDS through the Canada–Pakistan HIV/AIDS Surveil- lance Project (HASP). This was imple- mented by a consortium of Agriteam Canada Consulting Ltd, the University of Manitoba and ProAction: Partners for Community Health Inc., with tech- nical assistance from the Public Health Agency of Canada. Since 2004, HASP has  led  to  the  expansion of the surveillance and monitoring system for HIV/AIDS in Pakistan to focus on most at-risk popu- lations (MARPs). A key component of this is a comprehensive estimation of the numbers of MARPs and the HIV prevalence among subgroups, as well as describing some of their sociodemo- graphic characteristics and behaviours. This is now conducted in all major cit- ies of Pakistan on a yearly basis. The MARPs surveyed include 4 target groups: female sex workers (FSWs), male sex workers (MSWs), hijra sex workers (HSWs) and injection drug users (IDUs). HSWs are transgender individuals who form a unique type of  sex worker  in Pakistan and are of 2  major types, khusras and zananas. Since implementation of the SGS in  2004  and  after  pilot  testing  the  methods, Pakistan has conducted 3 an- nual rounds of surveillance with IDUs, MSWs and HSWs and collected data in 8 major cities  in 2005–06, which were  increased to 12 in 2006–07 and another  9  in  2007–08  [13–15].  For  FSWs 2  rounds of surveillance were conducted only in 2005–06 and 2006–07. Surveillance methods Mapping data Each year, data collection was done in 2 phases  [16]. Phase 1  consisted of  a  rapid, geographic mapping to estimate the numbers, location and typologies of the 4 MARPs (FSWs, MSWs, HSWs and IDUs) in major cities across all 4 provinces. The mapping methodology consisted of dividing the cities into geo- graphical zones and within each zone interviewing key informants to obtain information about the location and size of each risk population. The mapping data were entered into a database specifically designed for the study. To generate final estimates of each risk population, the estimate rang- es for each site and location were rolled up, first for a zone and then for the city, to produce minimum and maximum estimates. The mean of the minimum and maximum estimates was used as a single best estimate. Book 17-8.indb 713 8/9/2011 2:05:01 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 714 Behavioural and biological survey Information collected in phase 1 was verified in phase 2 with a cross-sectional  behavioural and biological survey us- ing interviews with members of all 4 target groups  [16]. The mapping data  provided sampling frames, and diverse sampling techniques were used to draw representative samples of the target populations in each city. A sample size of 400 was set  for each risk population  in every city, based on assumptions about baseline HIV prevalence, ex- pected changes in prevalence and key behavioural characteristics of the study population. Behavioural data were collected by trained interviewers using structured questionnaires that were designed in English and subsequently translated into the local language. These included questions on sociodemographic and personal characteristics, as well as a core set of risk behaviour indicators to moni- tor behaviour patterns in the key popu- lations. Informed consent was obtained prior to conducting the interviews. Biological data were gathered using the capillary dried blood-spot method, chosen for its ease of collection, stor- age, shipping and serological accuracy [17]. The  interviewers were  trained  in  dried blood-spot collection and infec- tion control processes. A debriefing session was held with the interviewees on completion of the questionnaire and blood sample, to answer any queries and provide information about HIV prevention and the services available including voluntary counselling and testing services. A total number of 9450 IDUs, 5275  MSWs and 4898 HSWs were inter- viewed during the 3 surveillance rounds of  2005–08, while  7773 FSWs were  surveyed in the 2 rounds of 2005–07. The behavioural and biological data were stored and analysed at the central data coordinating unit of the national AIDS control programme in Islamabad. Data entry was done using computer software developed for the study. The behavioural database was linked with the laboratory results by an encrypted unique identifier and unique study site code. The final analysis was done using SPSS, version 12.0. Outcomes Population size estimates and operational dynamics Results of the mapping studies con- ducted  in  the 12 cities of Pakistan are  shown in Table 1. The largest group of MARPs (54.7%) were FSWs, with an  estimated number of 79 127. Based on  information on group dynamics FSWs were categorized into various typolo- gies. The largest typology identified was home-based FSWs: sex workers who live at home with their families and are involved in covert sexual activities through contacts with pimps, madams/ aunties and/or network operators. Street-based FSWs, the second larg- est typology identified, solicit clients in public places through cruising sites or pick-up points. Kothikhana-based FSWs live in small premises/houses rented by a madam and/or a network operator and entertain clients there. The traditional brothel-based sex work- ers comprised only 1.2% of  the overall  female sex workers. In addition to these categories, a small number of FSWs (1.2%) were reported to operate as call  girls and hotel-based sex workers. Table 1 Estimated numbers of most at-risk populations derived from mapping of 12 cities in Pakistan, 2007 Most at-risk population Mean no. Range Female sex workers Total 79 127 67 258–90 996 Home-based 37 925 31 556–42 694 Kothikhana-based 16 125 15 491–20 958 Street-based 23 498 19 123–25 872 Brothel-based 950 807–1092 Other (call girls, hotel-based) 979 832–1126 Average per cruising site 5.7 3–31 Injection drug users Total 31 555 24 496–36 213 Average per site 7.5 2–12 Hijra sex workers Total 14 725 12 517–16 933 Average per cruising site 5.2 3–7 Male sex workers Total 19 320 16 422–22 218 Average per site 4.7 2–11 Book 17-8.indb 714 8/9/2011 2:05:01 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 715 IDUs formed the second largest group of MARPs (21.8%), with an es- timated number of 31 555 spread over 4199 sites. Two major types of IDUs were identified—street-based or home- based—depending on the place where the risk activity took place. MSWs comprised of  13.3% of  all  MARPs (estimated total number of 19 320).  HSWs accounted  for 10.2% of  all  MARPs (estimated total number of 14 725). HIV seroprevalence Figure 1 shows the trend of HIV infec- tion rate among all MARPs surveyed in Pakistan over 2005–08. This  shows  that the highest rate of HIV infection was among IDUs and that infection rates among IDUs have been increas- ing,  from 10.8%  in 2005  to 20.8%  in  2008. Not only has  the overall preva- lence increased, but the number of sites with relatively advanced epidemics has also expanded. All 8 cities where sur- veys were conducted  in 2008 showed  prevalence  rates  of  over  5%  among  IDUs, in comparison with 5 out of 8 cities  in 2005 and 8 out of 12 cities  in  2006–07 (data not  shown). Although  IDUs have the highest infection rates, HIV is beginning to become established in other MARPs such as HSWs, for whom the overall HIV prevalence rose to 6.4% (95% CI: 5.0%, 7.7%)  in 2008  (Figure 1). Substantial rates of infec- tion are now reported among HSWs in several cities; the highest prevalence was reported in Larkana (27.6%) whereas all  other cities had less than 5% prevalence  (data not shown). The infection rate among MSWs in 2008 was unchanged  from  2006,  i.e.  0.9%  (95% CI:  0.3%,  1.5%). Although FSWs formed the larg- est MARP in terms of numbers, only 1 FSW was found to be HIV positive in 2007, in comparison with 3 who tested  positive in 2006. Behavioural characteristics Table 2  shows  the  trends  in high-risk  sexual and injecting behaviours among MARPs in Pakistan. The average numbers of clients for all the 3 groups of sex workers remained between 2–3 cli- ents per day, with little variation across the years. Consistent condom use over the past month with paying clients was significantly improved for MSWs (from 6.8% to 24.0%, P < 0.001), HSWs (5.8%  versus  19.7%, P  <  0.001)  and  FSWs  (from 18.0%  to 23.0%). Condom use  at the last commercial sexual encounter also significantly increased among all MARPs over time. Among IDUs, risky practices have been decreasing. Sharing of needle/syringes at the last injection significantly decreased  from 47.1%  in  2005  to  17.6%  in  2008  (P  <  0.001),  along with reuse of syringes, which also declined  from 35.2%  in 2005 to 22.5%  in 2008 (P < 0.001). However, there was  evidence of IDUs having sex with FSWs in the previous 6 months. Behavioural data also suggested that the potential for the epidemic to spread among MSWs is high. The utilization of services provided by the various service delivery pro- grammes for MARPs has increased over 20.8 6.4 0.9 10.8 15.8 2.1 0.8 1.50.4 0.20.0 5.0 10.0 15.0 20.0 25.0 2005 2007 2008 IDUs HSWs MSWs FSWs % Figure 1 Emerging HIV infection rates among most at-risk populations in Pakistan, 2005–08 (IDUs = injection drug users; HSWs = hijra sex workers; MSWs = male sex workers; FSWs = female sex workers) Book 17-8.indb 715 8/9/2011 2:05:01 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 716 time. Among MSWs service utilization increased to  8.5%  in  2008  from 2.2%  in  2005, while  for  HSWs it increased from 2.5% in 2005 to 18.3% in  2008. Likewise  the utilization of  services showed  a significant  improvement for IDUs from 19% in  2005  to 51%  in 2008 (P < 0.001). However no  significant change was observed for FSWs. Utilizing the data Defining the HIV epidemic and estimating the size of MARPs The surveillance data collected over the years has highlighted the changing patterns of HIV in Pakistan. Mapping studies of MARPs have provided size estimates of each of the populations exposed within each city surveyed. Serial HIV se- roprevalence data has shown that like many other countries in south Asia, Pakistan’s HIV epidemic is concentrated among IDUs throughout the country and that infection rates among IDUs are increasing. Prevalence trends suggest that HIV is beginning to become established in other MARPs as well. Substantial levels of infection are now reported among transgender sex workers in several cities [15]. In addition to these index populations,  the estimates of prevalence for other populations at risk (sexual partners of IDUs, clients of sex work- ers) were derived from a combination of HIV data from these index groups and behavioural data that measured the level of exposure to the index group. Policy development and advocacy Once the magnitude of the HIV burden had been determined, this information was used to develop the first national HIV/AIDS policy. It highlighted the need for a coordinated, comprehensive, and multisectoral HIV prevention and control response in Pakistan. Provision of harm-reduction services to various high-risk groups at a scale necessary to halt the establishment of HIV among these groups and avoid its spread to the general population was acknowledged as a prime objective of the national response. For a long time, the existence of a sizeable commercial sex industry in Pakistan was denied by the government authorities. The mapping data was used as an advocacy tool to policy-makers and religious leaders to demonstrate the exist- ence of large concentrations of high-risk groups and the consequences of the unfolding HIV epidemic. For the first time new interventions, e.g. Ta bl e 2 Tr en ds in h ig h ri sk s ex ua l a nd in je ct in g be ha vi ou rs a m on g m os t a t- ri sk p op ul at io ns in P ak is ta n Va ri ab le Fe m al e se x w or ke rs M al e se x w or ke rs H ijr a se x w or ke rs In je ct io n dr ug u se rs 20 0 5– 0 6 20 0 6– 0 7 20 0 5– 0 6 20 0 6– 0 7 20 0 8 20 0 5– 0 6 20 0 6– 0 7 20 0 8 20 0 5– 0 6 20 0 6– 0 7 20 0 8 N o of c iti es 8 12 8 12 8 8 12 8 8 12 9 N o of in te rv ie w s 31 34 46 39 17 81 22 89 12 0 5 15 69 21 43 11 86 24 32 40 39 29 79 M ea n (S D ) n o. o f c lie nt s/ da y 4. 5 2. 6 (1. 8) 2. 3 2. 1 ( 1.5 ) 1.9 (0 .9 ) 2. 5 2. 5 (2 .1) 2. 6 (1. 9) – – – C on si st en t c on do m u se (% ) 18 .0 23 .0 6. 8 7.0 24 .0 5. 8 7.5 19 .7 – – – C on do m u se a t l as t c om m er ci al se xu al e nc ou nt er (% ) 34 .0 45 .0 24 .0 21 .0 35 .0 21 .0 19 .0 32 .0 17 .0 21 .0 31 .0 Se x w ith in je ct io n dr ug u se rs (% ) 13 .5 9. 9 10 .1 9. 5 6. 4 8. 4 6. 4 6. 3 – – – Sh ar ed n ee dl e at la st in je ct io n (% ) – – – – – – – – 47 .1 21 .9 17 .6 In je ct ed w ith u se d ne ed le (% ) – – – – – – – – 35 .2 27 .8 22 .5 In je ct io n dr ug u se rs h av in g se x w ith fe m al e se x w or ke rs in p as t 6 m on th s ( % ) – – – – – – – – 12 .6 26 .6 17 .7 C ov er ag e of p re ve nt io n pr og ra m m es (% ) 2. 1 1.9 2. 2 2. 7 8. 5 2. 5 4. 2 18 .3 19 .1 15 .6 50 .8 – = da ta n ot a pp lic ab le . SD = st an da rd d ev ia tio n. Book 17-8.indb 716 8/9/2011 2:05:02 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 717 opioid substitution therapy, were rec- ommended for inclusion in the national HIV prevention and control response. HIV prevalence trend data were used to sensitize the media and other relevant bodies to ensure their involvement in scaling-up the national response [18]. Development of an integrated national response and resource allocation SGS data provided valuable infor- mation for developing the second national HIV/AIDS strategic frame- work through which all donors and stakeholders were brought together to define a single national HIV pre- vention and control agenda and set priorities for the allocation of resources for the next 5 years. Based on the HIV scenario highlighted by the SGS data, a proposal to the Global Fund to Fight AIDS, Tuberculosis and Ma- laria was developed for round 9, clearly focussing on providing services for IDUs, who are currently the hub of HIV infection in the country. At the national level, estimates of the size of various high-risk groups have helped determine the universal access targets as well as set targets in line with the Millennium Development Goals. Various other programme proposals developed within this national HIV response have followed an evidence- based approach, allocating all available resources where the burden of infec- tion is the highest. Designing and scaling up services for MARPs Before SGS was effective in Pakistan, interventions among high-risk groups were programmed with limited knowl- edge about the numbers, typology and geographical distribution of these groups. The establishment of the SGS system as a core programme compo- nent provided context-specific epidemi- ological evidence to guide programme development and implementation at all levels. The behavioural data were used to develop standards of service delivery for each of these high-risk groups, and the biological data were used to channel resources to the groups and areas most affected by the epidemic. The data were also utilized by various organizations for developing and refining service delivery programmes to these high-risk groups. For example, SGS data collected on the use of sterile injection equipment by IDUs led to the expansion of the needle exchange programme for IDUs in Pun- jab  [19]. Likewise,  the  recognition of  high-risk anal sex among men who have sex with men led to the distribution of water-based lubricants along with con- doms by the outreach staff of various service delivery programmes. At provincial level a number of new cities were included in the programmes, based on the mapping information available from SGS. Thus, geographical data helped in planning service delivery sites, while population estimates helped to determine the number and extent of services required for appropriate coverage, programme staffing needs, service infrastructure and commodi- ties to be provided. The information on the subtypes and operational dynamics within each MARP was used to design interventions and determine modes of service delivery. For example, outreach strategies were planned differently for brothel-based FSWs than for home- based FSWs. Using data for evaluating programme success Although programme evaluation and surveillance activities overlap, they are not the same and they serve different purposes. However, we used SGS data to determine whether or not prevention and care programmes have been success- ful and are able to control and contain emerging epidemics. With SGS data, the estimates of the number of MARPs provided the denominators to make basic calculations about monitoring indicators and set baselines for key out- comes and indicators. Thus, improved levels of HIV knowledge, consistent condom use, reduction in sharing of needle/syringes, improved programme coverage and use of available services by target populations, all served as markers for programme success. The combined analysis of these datasets along with data collected by the services provides a valid assessment of the effects of service delivery programmes on the course of the epidemic. Conclusions and lessons learnt The SGS system in Pakistan has pro- vided a comprehensive response to the data needs of the country. In addition to understanding the magnitude of the epidemic and monitoring its trend, SGS data in Pakistan has been used extensively by the national and provin- cial programmes to lobby for policy change, mobilize resources, improve programming and measure the success of prevention through an integrated national response. A number of lessons have been learned from this initiative: Surveillance is not a stand-alone pro-• gramme and has to be embedded in the overall national response to HIV. Surveillance is not primarily a research • activity, but should be used to provide reliable documentation of trends in epidemic prevalence and associated risk behaviours, Mapping is an integral part of plan-• ning HIV response. Knowledge about population estimates, locations and the group dynamics of MARPs is the cornerstone of planning services for these groups, Simpler forms of analyses are useful. • An evaluation of different risk behav- iours among various subpopulations through simple descriptive analysis is very valuable for steering prevention activities. Likewise, a description of HIV prevalence levels is needed to Book 17-8.indb 717 8/9/2011 2:05:02 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 718 References Second generation Surveillance for HIV/AIDS: the next decade.1. Geneva, World Health Organization/Joint United Nations Programme on HIV/AIDS, 1999. Guidelines for Second generation HIV Surveillance2. . Geneva, World Health Organization/Joint United Nations Programme on HIV/AIDS, 2000. Meeting the behavioral data collection needs of national HIV/3. AIDS and STD programmes. Arlington, Virginia, Family Health International/IMPACT and Joint United Nations Programme on HIV/AIDS, 1998. Garcia-Calleja JM et al. A global analysis of trends in the quality 4. of HIV sero- surveillance. Sexually Transmitted Infections, 2004, 80(Suppl. 1):i25–30. Pisani E et al. HIV surveillance: a global perspective. 5. Journal of Acquired Immune Deficiency Syndromes, 2003, 32(Suppl. 1):S3–11. Lyerla R, Gouws E, Garcia-Calleja JM. The quality of sero-6. surveillance in low- and middle income countries: status and trends through 2007. Sexually Transmitted Infections, 2008, 84 (Suppl. I):i85–91. Brown T et al. Improving projections at the country level: the 7. UNAIDS Estimation and Projection Package 2005. Sexually Transmitted Infections, 2006, 82 (Suppl. 3):iii34–40. The BSS Development and Implementation Group. 8. Behavioral surveillance surveys: guidelines for repeated behavioral surveys in populations at risk of HIV. Arlington, Virginia, Family Health International, 2000. Brown T. Behavioral Surveillance: current perspectives, and its 9. role in catalyzing action. Journal of Acquired Immune Deficiency Syndromes, 2003, 32(Suppl. 1):S12–17. Garnett GP et al. Maximizing the global use of HIV surveillance 10. data through the development and sharing of analytical tools. Sexually Transmitted Infections, 2004, 80 (Suppl. I):i1–4. Thomas R et al. Second-generation HIV surveillance: better 11. data for decision-making. Bulletin of the World Health Organi- zation, 2004, 82:121–127. National AIDS Control Programme. 12. National strategic frame- work. Islamabad, Pakistan, Ministry of Health, 2002. National AIDS Control Program13. . HIV/AIDS surveillance project. Integrated biological and behavioral surveillance. Round 1 report: 2005. Islamabad, Pakistan, Ministry of Health, 2005. National AIDS Control Program14. . HIV/AIDS surveillance project. Integrated biological and behavioral surveillance. Round 2 report: 2006–07. Islamabad, Pakistan, Ministry of Health, 2007. National AIDS Control Program. 15. HIV/AIDS surveillance project. Integrated biological and behavioral surveillance. Round 3 re- port: 2008. Islamabad, Pakistan, Ministry of Health, 2008. National AIDS Control Program. 16. HIV/AIDS surveillance project. Mapping: field operations and monitoring manual. Islamabad, Pakistan, Ministry of Health, 2008. Solomon SS et al. Dried blood spots (DBS): A valuable tool 17. for HIV surveillance in developing/tropical countries. Interna- tional Journal of STD & AIDS, 2002, 13:25–28. Programme for Research and Capacity Building in Sexual and 18. Reproductive Health and HIV in Developing Countries. HIV in Pakistan: preventing a future epidemic in most-at-risk groups. London, London School of Hygiene and Tropical Medicine, 2009. Emmanuel F, Fatima M. Coverage to curb the emerging HIV 19. epidemic among Injecting drug users in Pakistan: delivering prevention services where most needed. International Journal of Drug Policy, 2008, 19 (Suppl. 1):S59-64. show where prevention efforts need to be concentrated. Finally, we have learnt that evidence • provided by surveillance data plays a strong role in advocacy. However, communication strategies should be developed to present data in a clear, effective way that is accessible to a wide audience. SGS data can be effectively used at a broad level to lobby for policy change, mobi- lize resources, improve program- ming and measure the success of prevention through an integrated national effort. Such effort needs to be continued for an improved national response to this emerging epidemic. Book 17-8.indb 718 8/9/2011 2:05:02 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عباسلا ددعلا 719 Short communication Road rage behaviour and experiences of rickshaw drivers in Rawalpindi, Pakistan M.A. Shaikh,1 I.A. Shaikh 2 and Z. Siddiqui 3 ABSTRACT A cross-sectional survey with convenience sampling was conducted among rickshaw drivers in Rawalpindi, Pakistan to study their road rage behaviour and experiences. Cumulatively 318 male drivers participated in this study. The most common forms of road rage reported were: having been shouted at; and having experienced rude gestures from other drivers (78.9% each). Least common forms of road rage reported were: threats of physical hurt or having actually been physically hurt (≤ 3% each). Rickshaw drivers with shorter driving time (≤ 10 years) had significantly more road rage experiences than those who had been driving for more than 10 years (P < 0.01). There is a need for nationally representative surveys to study road age in commercial vehicle drivers so as to improve road safety in Pakistan. 1Independent Consultant, Al Rehab, Cairo, Egypt (Correspondence to M.A. Shaikh: masoodali1@yahoo.com). 2Emergency and Humanitarian Action Unit, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. 3Public Health Physician, Cantt, Rawalpindi, Pakistan. Received: 01/01/09; accepted: 05/01/10 ناتسكاب ،يدنيبلاوار في تاشك ِّرلا يقئاس براتجو قرطلا لىع بضغلا تايكولس يقيدص راقفلا وذ ،خيش ليع داشرإ ،خيش ليع دوعسم تارْو َىس في متهايكولس لىع فوقولل ،ناتسكاب ،يدنيبلاوار في تاشك ِّرلا يقئاس نم ةبسانم تانيع مادختساب ةضرعتسم ةسارد تَىيرجأ :ةـصلالخا ينقئاسلا نم ةعذلالا تاحيملتلل ض ُّرعتلا وأ حايصلا نأ ينبتو ،ةَّيم ُحكاترلا ةساردلا هذه في روكذلا نم ًاقئاس 318 كراش دقو .قرطلا لىع بضغلا نيدبلا ىذلأل لعفلاب ض ُّرعتلا وأ نيدبلا ىذلأاب ديدهتلا ناك ينح في .)ماهنم لكش لكل %78.9( ًاعويش قرطلا لىع بضغلا لاكشأ رثكأ وه نيرخلآا 10≥( ةدايقلا في صرقأ تاترف اوضق نيذلا تاشك ِّرلا يقئاس بضغ براتج تناكو .)ماهنم لكل %3≥( ًاعويش قرطلا لىع بضغلا لاكشأ لقأ نم تاحوسم ءارجإ لىإ ةجالحا ُّسَى َىتمو .)P<0.01( ةدايقلا في تاونس 10 نم رثكأ اوضق نيذلا كئلوأ بضغ تارْو َىس نم هب ُّدَىتْع ُحي لكشب رثكأ )تاونس .ناتسكاب في قرطلا لىع ةملاسلا ينست َىةيغُحب قرطلا لىع ةيراجتلا تابكرلما يقئاس رماعأ ةسارد ةَىيْغ ُحب ينطولا ديعصلا لىع ةلثمم Comportements et expériences de rage routière chez les conducteurs de rickshaw à Rawalpindi (Pakistan) RÉSUMÉ Une étude transversale a été conduite sur un échantillon de commodité incluant des conducteurs de rickshaw à Rawalpindi (Pakistan) pour évaluer leurs comportements et expériences de rage routière. Au total, 318 conducteurs de sexe masculin ont participé à l’enquête. Les expériences les plus fréquemment rapportées de rage routière (78,9 % pour chacune d’entre elles) étaient les agressions verbales et les gestes insultants de la part d’autres conducteurs. Les formes les moins fréquemment rapportées (moins de 3 % chacune) étaient les menaces de violence physique ou les agressions physiques. Les conducteurs de rickshaw moins expérimentés (moins de 10 ans de conduite) étaient davantage victimes de rage routière que les conducteurs pratiquant le métier depuis plus de dix ans (P < 0,01). Des études représentatives au niveau national sont nécessaires pour évaluer ce phénomène chez les conducteurs de véhicules utilitaires au Pakistan afin d’améliorer la sécurité routière. Book 17-8.indb 719 8/9/2011 2:05:02 PM EMHJ  •  Vol. 17  No. 7  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 720 Introduction Road rage entails verbal abuse/threats or actual acts of physical harm by either a driver or passenger of one vehicle directed against the occupants of an- other vehicle or pedestrians, and could potentially lead to injuries or death and economically burden its victims [1].  Road  rage  has  been  associated  with psychiatric illnesses in both the perpetrators as well as the victims [2,3].  In a previous study in Islamabad, Paki- stan, among a sample of 532 university  students,  30%  reported  they had ex- perienced being shouted at, cursed or made rude gestures at while driving a vehicle  in  the past 3 months [4]. An- other study in Pakistan reported that the most common type of road rage experienced by bus drivers was some- one in another vehicle making rude gestures at them; this was reported by 156 (88.6%) bus drivers  in  Islamabad  and Rawalpindi [5].  A rickshaw is a three-wheeler motor vehicle and is a common mode of trans- port for hire in Pakistan. This study was conducted to gain insight into road rage experiences and behaviours of rickshaw drivers and the association with years of having driven rickshaw in the city of Rawalpindi. Methods A cross-sectional survey with conven- ience sampling was conducted among rickshaw drivers in Rawalpindi at various frequently visited city areas and popu- lar destinations from January to May 2008.  An  interviewer-administered,  pre-tested, structured questionnaire with close-ended questions was used. Rickshaw drivers who had been driving for at least 1 year were interviewed by a trained interviewer, after giving verbal consent. Results were analysed using STATA, version 9. The chi-squared and Fisher exact tests were used to test the difference between the drivers’ expe- rience and behaviour regarding road rage by length of time they had been driving a rickshaw (≤ 10 years versus >  10 years). Results A total of 318 male drivers were ap- proached and 303 agreed  to be  inter- viewed,  a  response  rate of 95.3%. The  mean age of the rickshaw drivers was 38.7  years  (range 20–55 years  ). On  average, rickshaw drivers had been driving a rickshaw for 10.6 years (range  1–30 years). Educational status was de- scribed by respondents as: 42 (13.9%)  with no formal education, 126 (41.6%)  with 2–5 years of  education,  and 135  (44.5%) with 6–11 years of education.  Smoking cigarettes on a regular basis was reported by 252 (83.2%) of the re- spondents. Table 1 shows the frequency of road rage behaviour and experiences of rickshaw drivers in the past 3 months. The majority of drivers had both been shouted at and experienced rude ges- tures  from  other  drivers  (78.9%  for  both), while fewer drivers said they had behaved the same themselves towards other drivers (55.8%  for  shouting and  cursing  and  46.9%  for  making  rude  gestures). Threatening physical hurt or actually physically hurt was rare wither for rickshaw drivers or other drivers. Table 2 shows the association between  road rage experiences/behaviours and length of time of rickshaw driving. Rick- shaw drivers with shorter driving time (≤ 10 years) had significantly more road  rage experiences than those who had been driving for more than 10 years (P < 0.01). Discussion The most common types of road rage experiences reported were being shouted/cursed at and having someone in another vehicle make rude gestures (78.9% of  respondents), while  fewer  admitted to having either shouted or cursed at someone in another vehicle (55.8%) or made of  rude  gestures  at  someone  in  another  vehicle  (46.9%).  Being either threatened with physical violence or having physically threatened someone in another vehicle was rare but nonetheless was reported by some respondents (< 3%). Table 1 Road rage behaviour and experiences of rickshaw drivers, Rawalpindi, Pakistan Behaviour/experience No. (%) (n = 303) In the past 3 months while I was driving: Someone in another vehicle shouted or cursed at me 239 (78.9) I shouted or cursed at someone in another vehicle 169 (55.8) Someone in another vehicle made rude gestures at me 239 (78.9) I made rude gestures at someone in another vehicle 142 (46.9) Someone in another vehicle threatened to physically hurt me 9 (3.0) I threatened to physically hurt someone in another vehicle 6 (2.0) Someone in another vehicle threatened to damage my vehicle 37 (12.2) I threatened to damage someone’s vehicle 35 (11.5) Someone in another vehicle damaged my vehicle or hurt someone in my vehicle 3 (1.0) I damaged someone’s vehicle or hurt some in another vehicle 5 (1.7) Book 17-8.indb 720 8/9/2011 2:05:02 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما عباسلا ددعلا 721 Rickshaw drives who had driven for 10 years or less were more likely to have  been offensive and also experienced the rage of others compared with driv- ers who had driven  for more  than 10  years.  Perhaps  having more  than  10  years of rickshaw driving experience bestowed better skills to navigate roads and highways and to avoid provoking adverse reactions or anger of the drivers of other vehicles or their occupants. Alternatively, younger men could have been speedier and more aggressive driv- ers and hence got involved in more such incidents. Future studies on road rage need to address these questions. The 2 previous studies conducted in  Pakistan in conjunction with the results of this study suggest that verbal expres- sion of road rage is a fairly common phenomenon. There is a need for larger, nationally representative surveys to study road age in commercial vehicle drivers so as to improve road safety in Pakistan. Table 2 Road rage behaviour and experiences of rickshaw drivers by years of having driven a rickshaw, Rawalpindi, Pakistan Behavior/experiencea Driven a rickshaw for: P-value ≤ 10 years (n = 178) > 10 years (n = 125) In the past three months while I was driving: Someone in another vehicle shouted or cursed at me Yes 164 75 <0.001 No 14 50 I shouted or cursed at someone in another vehicle Yes 133 36 <0.001 No 45 89 Someone in another vehicle made rude gestures at me Yes 151 88 0.002 No 27 37 I made rude gestures at someone in another vehicle Yes 112 30 <0.001 No 66 95 Someone in another vehicle threatened to damage my vehicle Yes 34 3 <0.001b No 144 122 I threatened to damage someone’s vehicle Yes 32 3 <0.001b No 146 122 aOnly statistically significant associations are reported. bThe Fisher exact test was used because of values < 5 in some categories. The P-values apply to pair-wise comparison between 2 groups based on years of having driven a rickshaw. References Smart RG, Mann RE. Deaths and injuries from road rage: cases 1. in Canadian newspapers. Canadian Medical Association Jour- nal, 2002, 167:761–762. Butters JE, Mann RE, Smart RG. Assessing road rage victimiza-2. tion and perpetration in the Ontario adult population: the impact of illicit drug use and psychiatric distress. Canadian Journal of Public Health, 2006, 97:96–99. Fong G, Frost D, Stansfeld S. Road rage: a psychiatric phenom-3. enon? Social Psychiatry and Psychiatric Epidemiology, 2001, 36:277–286. Shaikh IA et al. Road rage behavior: Experiences of university 4. students. Journal of the College of Physicians and Surgeons – Pa- kistan, 2005, 15:830–831. Shaikh IA, Shaikh MA, Siddiqui Z. Road rage behavior and 5. experiences of bus and wagon drivers in Islamabad and Rawalpindi. Journal of the Pakistan Medical Association, 2008, 58(4):220–221. Book 17-8.indb 721 8/9/2011 2:05:03 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 722 Case report Two cases of Vibrio cholerae non-O1/non-O139 septicaemia with favourable outcome in Lebanon R. Feghali 1 and S.M. Adib 2 1Department of Laboratory Medicine, Rafik Hariri University Hospital, Beirut, Lebanon (Correspondence to R. Feghali: rfeghali@ul.edu.lb). 2Department of Social and Family Medicine, Université Saint-Joseph, Beirut, Lebanon. Received: 6/10/09; accepted: 08/03/10 Introduction Vibrio cholerae species can be divided into 2 major groups:  cholera-causing  strains of the serogroups O1 and O139, and non-O1 V. cholerae  (NOVC) [1].  Non-O1 V. cholerae (NOVC) typically does not elaborate cholera toxin. It is also antigenically distinct from the V. cholerae O1 and O139 strains, which cause epidemic cholera in many coun- tries. Although NOVC strains are usu- ally associated with sporadic diarrhoea, some outbreaks have been reported. These strains have also been associ- ated with skin infections, cholecystitis, meningitis and septicaemia. While gastrointestinal infections caused by NOVC usually have a favourable out- come, invasive infections may be fatal [2].  Immunocompromised  patients,  particularly those with hepatic cirrhosis or haematological malignancies, are at highest risk for septicaemia with NOVC [2,3].  In  this paper, we  report  on 2  residents of Beirut who were di- agnosed with NOVC and treated in a large public facility. They are, to our knowledge, the first reported cases of severe NOVC infection in Lebanon. Background In Lebanon, laboratory-confirmed cholera is a reportable disease by law. The serotype identification, how- ever, is not required for this reporting (Epidemiological Surveillance Unit, www.public-health.gov.lb). Limited outbreaks usually associated with O139 Bengale serotype, have been histori- cally  described  throughout  the 20th  century. In 1993, an epidemic, which started in neighbouring Syria, expanded into Lebanon causing a few deaths in Tripoli and Beirut and lasting for about  3 months  [S.M. Adib,  I. Hajj,  E. Makarem. Investigation of the cholera epidemic—Lebanon, 1993, unpublished report ]. Since  then,  and as post-civil  war reconstruction efforts continued, no such large outbreaks were reported. However, cholera may still have limited niches of low endemicity, especially in Northern Lebanon, where sub-clinical cases may occur. An unknown number of summer acute diarrhoeas may ac- tually be caused by various strains of cholera, yet no systematic bacteriologi- cal surveillance has been initiated to this day in the country. Moreover, infections due to non-O1/O139 and other Vibrio species do not have to be reported to the Ministry of Public Health. Case 1 A 54-year-old man with a history of alcoholic liver cirrhosis was admitted with a 1-day history of abdominal pain, high-grade fever and fatigue. The patient had no diarrhoea. On examina- tion, the patient was conscious, looking ill, dehydrated, with a temperature of 39.4 °C,  pulse  110/min,  and  blood  pressure 110/60 mmHg. Shifting dull- ness indicating an ascitis was present on abdominal examination. Initial laboratory results were notable for a white blood cell  count of 9600/mm3 with 85% neutrophils. Liver  function  tests were abnormal. The ascitic fluid revealed a white blood cell count of 270/µL  with  90%  neutrophils,  but  the culture was negative. Blood and urine specimens were submitted for culture prior to treatment with intra- venous antibiotics and hydration. The patient received an initial regimen of ceftazidime and metronidazole to cover enteric organisms. Anaerobic and aerobic blood cul- tures were positive on BACTEC 9240® system (Becton Dickinson Microbiol- ogy Systems) after 4 days of incubation. Colonies grew on MacConkey and chocolate agars. Gram stain revealed colonies of small, curved gram-negative rods. A subsequent subculture on thiosulfate citrate bile salt (TCBS) agar showed yellow, sucrose-fermenting, oxidase-positive colonies. Using a com- mercial system (API 20 E®, bioMerieux), our microbiology laboratory identified the isolate as V. cholerae. Using an au- tomated identification system (Becton Dickinson Phoenix100®), we identified the organism as V. cholerae. Slide ag- glutination testing with polyvalent O1 antisera was negative. The specimen was sent to the Cen- tre National de Référence des Vibrions et du Choléra at the the Institut Pasteur (France) where non-toxigenic V. chol- erae non-O1/non-O139 was identified. Using a disc diffusion testing according Book 17-8.indb 722 8/9/2011 2:05:03 PM طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما نماثلا ددعلا 723 to National Committee for Clinical Laboratory Standards guidelines 2008  [4],  the organisms were  found suscep- tible to ampicillin, ceftriaxone, tetracy- cline, chloramphenicol, cephalotin and trimethoprim-sulfamethoxazole, but resistant to nalidixic acid, polymixin, ciprofloxacin and colistin. Meanwhile, fever, nausea, and ab- dominal pain resolved after 5 days in the hospital, and the patient was discharged in a good health status. Epidemiological investigation revealed no recent travel history and no exposure of skin to salted or fresh water. Additionally, the source of drinking water was bottled water, however, the patient revealed a con- sumption of fish and shrimps in the week prior to his admission. Case 2 A female infant was born at 33 weeks ges- tation after a preterm, premature rupture of the membranes at 28 weeks gestation.  The mother was admitted for chorioam- nionitis and precipitated delivery. The baby had an Apgar score of 8 at birth and was admitted to neonatal in- tensive care for prematurity. A few hours post-delivery, physical examination re- vealed a baby in distress with a tempera- ture of 37 °C, a heart rate of 143 beats/ min, a respiratory rate of 89 breaths/ min, and a blood pressure of 41/25 mm  Hg. The total white blood cell count was 22500/mm3 with 62% neutrophils, the  INR (international normalized ratio) was 3.2 with APTT (activated partial  thromboplastin time) of 89 s. The blood pH fell to 7.11 and the CO 2 to 10 mmol/L. Blood and cerebrospinal fluid (CSF) cultures were taken and the baby was intubated and started on va- sopressors (dopamine) and antibiotics (cefotaxime chloride, gentamicin and ampicillin). Two days later, the baby developed renal failure which forced the replacement of gentamicin and ce- fotaxime chloride by ciprofloxacin and imipenem/cilastin. She started having seizures and brain ultra sound revealed hydrocephalus and intraventricular haemorrhage. Meanwhile, CSF cultures revealed no growth, but isolates were recovered from the Standard Aerobic/F and Anaerobic/F blood culture bottles using the BACTEC 9240® system (Bec- ton Dickinson Microbiology Systems). Colourless, lactose-negative colonies subsequently developed on MacCo- nkey agar and grew on TCBS. Micro- scopically, the organisms were curved, Gram-negative bacilli. Biochemically, the isolates were oxidase-positive and were further identified by Api system (API 20 E®, bioMerieux), and by BD identification system (Becton Dickin- son Phoenix®) as V. cholerae. The agglu- tination test for Vibrio O1 was negative. The isolate was referred to the Centre National de Référence des Vibrions et du Choléra of the Institut Pasteur in France, where non-toxigenic V. chol- erae non-O1 non-O139 was identified. The isolate was sensitive to ampicillin, tetracycline, chloramphenicol, nalidixic acid, cephalotin, ciprofloxacin. It was re- sistant to erythromycin, trimethoprim- sulfamethoxazole and colistin. Epidemiological investigation re- vealed no illness with diarrhoea in the patient’s mother or other close contacts. During the second week post-delivery, this infant’s condition started improv- ing progressively under treatment. She gained weight, was extubated and an- tibiotics were discontinued 1 month later. She recovered completely and was discharged after 2 months of hospitali- zation. Discussion There are more  than 200 serotypes of  the bacterium V. cholera: O1 and O139 serogroups are toxin-producing and cause classical cholera with profuse, wa- tery diarrhoea. The non-O1, non-O139 serogroups are usually non-epidemic strains  reported as  sporadic cases  [5].  They can cause infections such as gastroenteritis, septicaemia, wound infection, meningitis and cholecystitis. [6–8].  Septicaemia  in  adults  occurs  mainly in patients with underlying liver cirrhosis [9,10] or other conditions as- sociated with immunodeficiency, haematological malignancies, diabetes, AIDS or lymphoma [11].  Case 1 is likely to be the first case of NOVC which caused spontane- ous peritonitis in a cirrhotic patient in Lebanon. Additionally, the infant case presented is one of only a handful of paediatric NOVC cases ever described, sometimes associated with meningitis [7,12].  Seawater seems to be the main natu- ral reservoir for non-O1 non-O139 V. cholerae since it requires trace amounts of sodium chloride for growth. How- ever, it can also grow in fresh water [13].  These organisms have been isolated from surface water in several locations around the world [14–16]. Additionally,  the association of NOVC with marine plankton has been demonstrated in the Mediterranean. However, no reports are available of isolation of NOVC from coastal waters nor of surface water con- tamination in Lebanon. Generally, the most common source of NOVC infection is consumption of contaminated raw or undercooked sea- food. Contamination can also occur due to direct invasion through abraded skin or wound [5]. In the 2 cases presented  here, the source of the infection could not be determined. In the adult case, consumption of local fish and seafood (shrimps) in the week prior to admis- sion was revealed. It was not possible, however, to obtain samples of the food items consumed. Nor was it possible to investigate the persons who shared these meals with the patient because the initial exposure occurred a while before that patient reached the hospital. No apparent source of infection could be identified in the neonatal case although the contamination probably occurred during or before delivery. The Book 17-8.indb 723 8/9/2011 2:05:03 PM EMHJ  •  Vol. 17  No. 8  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 724 mother denied any consumption of seafood or contact with seawater. At the time of delivery, the mother was free of NOVC contamination. Since the patient lives in a low socioeconomic community in the coastal area of the southern suburbs of Beirut, it seems possible that drinking water drawn from wells in the area may be contaminated by seawater backflow. To date, there are no published guidelines for antibiotic therapy of NOVC  infection [17].  In our cases,  the pattern of sensitivity to antibiotics varied only slightly, suggesting a com- mon source of contamination. Both strains were sensitive to ampicillin and cephalosporins. The first strain was resistant to ciprofloxacin and nalidixic acid, and both were resistant to col- istin. Prognosis in NOVC bacteraemia is less favourable than in isolated NOVC gastroenteritis. Two separate reviews of NOVC gastroenteritis showed a 100%  survival rate [18,19]. In contrast, NOVC  bacteraemia is a potentially fatal disease. The case-fatality in a series of 15 cases in Taiwan was 47% [2]. Another review  of 20 cases from Florida reported a 25%  case-fatality  rate [19]. Therefore,  it was  gratifying to obtain a total recovery in the 2 cases described in this report. Among infectious disease agents, Vibrio species cause a potential threat to public health. NOVC strains, which contaminate the marine environment near coastal lines, should be monitored carefully to detect a risk of outbreaks. Today, NOVC infection may be more common than toxigenic V. cholerae O1 or O139 in Lebanon. This situation may justify the addition of NOVC infections to the list of diseases with mandatory notification to the Ministry of Public Health. National surveillance for all Vibrio species would increase our knowledge of the burden and epide- miology of these potential pathogens and provide important measures for assessing the effectiveness of interven- tions to control Vibrio illness. Addition- ally, monitoring the plankton on algal blooms in the Lebanese seawater is important since NOVC survives on those blooms and can contaminate local fish and seafood. References Restrepo D et al. O1 and non O1 1. Vibrio cholerae bacteremia produced by hemolytic strains. Diagnostic Microbiology and Infectious Disease, 2006, 54:145–148. Ko W et al. Infections due to Non-O1 2. Vibrio cholerae in South- ern Taiwan: Predominance in cirrhotic patients. Clinical infec- tious disease, 1998, 27:774–780. Siegel M.I., and Roger A.I. Fatal non-O1 3. Vibrio cholerae sep- ticemia in chronic lymphocytic Leukemia. Gastroenterology, 1982, 106:300–301. Performance standards for antimicrobial disk susceptibility tests4. . Villanova, Pennsylvania, National Committee for Clinical Laboratory Standards, 2008 (NCCLS Document M100-S18). Anderson A et al. Non-O1 5. Vibrio cholerae septicemia: case report, discussion of literature and relevance to bioterror- ism. Diagnostic Microbiology and Infectious Disease, 2004, 49:295–297. West BC, Silberman R, Otterson WN. Acalculous cholecys-6. titis and septicemia caused by non-O1 Vibrio cholerae: first reported case and review of biliary infections with Vibrio cholerae. Diagnostic Microbiology and Infectious Disease, 1998, 30:187–191. Ismail EAR, Shafik MH, Al-Mutairi G. A case of non-O:1 7. Vi- brio cholerae septicemia with meningitis, cerebral abscess and unilateral hydrocephalus in a preterm baby. European Journal of Clinical Microbiology and Infectious Disease, 2001, 20:598–600. Kerketta JA et al. Non-O1 8. Vibrio cholerae septicemia and meningitis in a neonate. Indian journal of pediatrics, 2002, 69:909–910. Dhar R, Ghafoor MA, Nasralah A. Unusual non-serogroup O1 9. Vibrio cholerae Bacteremia associated with liver disease. Jour- nal of Clinical Microbiology, 1989, 27:2853–2855. Halabi M et al. 10. Vibrio cholerae non-O1 septicemia in a patient with liver cirrhosis and Bilroth- II-gastrectomy. Journal of Infec- tion, 1997, 34:83–84. Khan FY et al. Non O1 non O139 bacteremia and peritonitis 11. associated with chronic liver disease. Journal of clinical and diagnostic research, 2007, 1:296–298. Dhar R et al. 12. Vibrio cholerae [Non-O1, Non-O139] sepsis in a child with Fanconi anemia. Diagnostic Microbiology and Infec- tious Disease, 2004, 50:287–289. Stypulkowska H, Pancer K, Roszkowiak A. Two unrelated cases 13. of septicemia due to Vibrio cholerae non-O1, non-O139 in Poland, July and August 2006. Eurosurveillance Weekly Release, 2006, 11(11). Morris JG Jr. Non-O group 1 14. Vibrio cholerae: A look at the epidemiology of an occasionnal pathogen. Epidemiological Reviews, 1990, 12:179–191. Igbinosa E, Okoh A. Emerging 15. Vibrio species: an unending threat to public health in developing countries. Research in Microbiology, 2008, 159:495–506 Couzigou C et al. Non-O:1 and non-O:139 16. Vibrio cholerae septicemia and pyomyositis in an immunodeficient traveler returning from Tunisia. Travel Medicine and Infectious Disease, 2007, 5:44–46. Namdari H, Klaips C, Hughes J. A cytotoxin-producing strain 17. of Vibrio cholerae Non O1, Non O139 as a cause of cholera and bacteremia after consumption of raw clams. Journal of Clinical Microbiology, 2000, 38:3518–3519. Morris JG, Black RE. Cholera and other vibriosis in the United 18. States. New England Journal of Medicine, 1985, 312:345–350. Hlady WG, Klontz KC. The epidemiology of 19. Vibrio infections in Florida, 1981–1993. Journal of infectious Disease, 1996, 73:1176–1183. Book 17-8.indb 724 8/9/2011 2:05:04 PM طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم ةيميلقلإا ةنجللا ءاضعأ نادلبلا ةيملاسلإا ناريإ ةيروهجم . ةيبيللا ةيبرعلا ةييرهمالجا . سنوت . نيرحبلا . ناتسكاب . ةدحتلما ةيبرعلا تاراملإا . ناتسناغفأ . ندرلأا صرم . نانبل . تيوكلا . رطق . ينطسلف . نماُع . قارعلا . لاموصلا . نادوسلا . تيوبيج . ةينميلا ةيروهملجا . ةيروسلا ةيبرعلا ةيروهملجا ةيدوعسلا ةيبرعلا ةكلملما . برغلما Subscriptions and Distribution Enquiries regarding subscriptions and distribution of the print edition of EMHJ should be addressed to: Printing and Marketing of Publications at: email: pam@emro.who.int; tel: (+202) 2276 5000; fax: (+202) 2670 2492 or 2670 2494 Permissions Requests for permission to reproduce or translate articles, whether for sale or non-commercial distribution should be addressed to EMHJ at: emhj@emro.who.int Members of the WHO Regional Committee for the Eastern Mediterranean Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon Libyan Arab Jamahiriya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia Sudan . Syrian Arab Republic . Tunisia . United Arab Emirates . Republic of Yemen Membres du Comité régional de l’OMS pour la Méditerranée orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran Iraq . Jamahiriya arabe libyenne . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar République arabe syrienne . Somalie . Soudan . Tunisie . République du Yémen Correspondence Editor-in-chief EMHJ WHO Regional Office for the Eastern Mediterranean P.O. Box 7608 Nasr City, Cairo 11371 Egypt Tel: (+202) 2276 5000 Fax: (+202) 2670 2492/(+202) 2670 2494 Email: khayat@emro.who.int/emhj@emro.who.int EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con‑ cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col‑ laborating Centres and individuals within and outside the Region. LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser‑vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. 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ISSN 1020‑3397 Cover designed by Diana Tawadros Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخا فى ةديدلجا تاردابلماو تاسايسلا لك لىإ ةهجوم ىهو .طسوتلما قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ يرغو ثاحبلأا جئاتنو زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا تايلكلاو ،ةيحصلا نهلما ءاضعأ .هجراخو ميلقلإا فى ةحصلاب ينمتهلما دارفلأاو ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما طسوتلما قشرل ةيحصلا ةلجلما Cover 17-8.indd 2 8/8/2011 10:11:18 AM Contents V olum e 17 N um ber 8 A ugust 2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Volume 17 / No. 8 August / Août 2011 8 ددع / شرع عباسلا دلجلما سطسغأ / بآ Letter from the Editor ..............................................................................................................................................................637 Research articles Comparison of maternity care quality in teaching and non-teaching hospitals in Khorram Abad, Islamic Republic of Iran ............................................................................................................................................ 638 Outcome of vaginal birth after caesarean section in women with one previous section and spontaneous onset of labour ...........................................................................................................................................................................646 Reasons for cancellation of elective operations at a major teaching referral hospital in Jordan ..................................651 Determining and prioritizing competencies in the undergraduate internal medicine curriculum in Saudi Arabia .........................................................................................................................................................................................................656 Evaluation of prophylactic antibiotic administration at the surgical ward of a major referral hospital, Islamic Republic of Iran .......................................................................................................................................................................................663 Peginterferon alfa-2b and ribavirin therapy in Kuwaiti patients with chronic hepatitis C virus infection ................669 Cross-reaction of antigen preparations from adult and larval stages of the parasite Setaria equina with sera from infected humans with Wuchereria bancrofti ........................................................................................................................679 Bone mineral density in Egyptian adolescents and adults with short stature: results of a national survey .............687 Physical activity profile of students in Mansoura University, Egypt ..............................................................................................694 Reviews Medical education in Saudi Arabia: a review of recent developments and future challenges .....................................703 Aetiological factors of constipation in the elderly, with emphasis on functional causes .................................................708 Report Using surveillance data for action: lessons learnt from the second generation HIV/AIDS surveillance project in Pakistan ..................................................................................................................................................................................................712 Short communication Road rage behaviour and experiences of rickshaw drivers in Rawalpindi, Pakistan ...........................................................719 Case report Two cases of Vibrio cholerae non-O1/non-O139 septicaemia with favourable outcome in Lebanon .......................722 August 1–7 marks World Breastfeeding Week, which aims to promote breastfeeding and improve the well-being of babies. Of the estimated 1.1 million deaths which occur among children under 5 years of age in our Region annually, 13% could be prevented through higher rates of exclusive breastfeeding, representing one of the most cost-effective interventions to reduce neonatal and child mortality. Furthermore, breastfeeding contributes to a lifetime of good health. Adults who were breastfed as babies often have lower blood pressure, lower cholesterol, and lower rates of overweight, obesity and type-2 diabetes. Cover 17-8.indd 1 8/8/2011 10:11:16 AM