CME in AL-QASIM


EVALUATION OF CONTINUING MEDICAL EDUCATION IN AL-QASIM, SAUDI ARABIA

Omer A. Al-Yahia, ABFM,* Mohamed M.K. Khalil, MD,* Mohamed I.Omer, FRCP,* Yasser S. Al-Ghamdi, FRCP†

*Regional Medical Education and Research Center, †Al-Qassim Health Affairs, Buraidah, Saudi Arabia

هدف الدراسة:تهدف هذه الدراسة إلى تقييم التعليم الطبي المستمر في المستشفيات بمنطقة القصيم في المملكة العربية السعودية .

طريقة الدراسة:تم عمل مسح للأطباء العاملين في مستشفيات المنطقة وقد أجري المسح على مرحلتين في بداية إنشاء إدارة التعليم الطبي في المنطقة والمرحلة الثانية بعد عام من المرحلة الأولى . وتم توزيع استمارة البحث على عينة عشوائية من الأطباء العاملين في المستشفيات .

نتائج الدارسة:وقد أظهرت النتائج أن متوسط ساعات التعليم الطبي في السنة قد زاد من 5.5 ساعة سنوياً إلى 14 ساعة (P=0.001) وأن 50% من الأطباء الذين اشتركوا في البحث طالبوا بأن يقدم التعليم الطبي بطريقة مختلفة لتشمل بصفة رئيسية الدورات التدرييبة (61%) والتدريب العملي داخل الأقسام (52%) والإكثار من المحاضرين الزائرين (45%) كما أظهرت الدراسة أن ( 47%) من الأطباء يستخدم شبكة الإنترنت.

الخلاصة :تظهر الدارسة الحاجة إلى التطوير النوعي وليس الكمي في التعليم الطبي المستمر ليشمل التدريب ذو العلاقة المباشرة بالعمل مع تشجيع استخدام شبكة الإنترنت في التعليم الطبي المستمر.

الكلمات المرجعية:التعليم الطبي المستمر، التقييم. 

Objective: To evaluate CME activities in Al-Qassim region in the Kingdom of Saudi Arabia

Methods: A study using a pre-structured questionnaire was conducted in Al-Qassim, targeting physicians working in the hospitals. The survey was conducted in two phases. The first phase was conducted at the inception of the department of professional education and the second one year later. Questionnaires were given to a sample of physicians working in the hospitals.

Results: Mean CME hours in the region increased from 5.5(±5.9) to 14.2(±19.7), p=0.0001. 50% said that the CME should be presented differently. There was a need for regular courses (61%), departmental and bedside activities (52%) and visiting speakers (45%). Only 47% of the physicians were using the Internet.

Conclusion: There is a need to shift from credit counting to a process that can yield professional development through practical courses and departmental activities. The use of the Internet in CME activities should be encouraged.

Key Words: Education, continuing, CME, professional,  evaluation.

Correspondence to:

Dr. Omer A. Al-Yahia, Regional Medical Education and Research Center, P.O. Box 2290, Buraidah, Saudi Arabia


INTRODUCTION

Continuing medical education (CME) is part of the lifelong process of learning that all doctors are involved from medical schools until retirement.1 However, CME concentrates on the update of knowledge mainly, not on skills needed in order to practice modern medicine effectively. That learning, not teaching,  is what leads doctors to change their practice has resulted in a shift in perspective.2 Accordingly, education is regarded as the facilitation of learning not instruction.

                The Department of Medical Education, a new department, was established as a responsible body to provide a framework for continuing medical education , facilitating, monitoring and evaluating activities at the regional level in the Ministry of Health (MOH). The aim of this department is to facilitate change in clinical practice through self-directed curriculum, small group interaction and organizational learning.  Since good quality CME can ensure high quality care of the population, the development of an objective systematic evaluation followed by modification of the CME events is vital for the improvement of the health care system.3 An important part of this systematic evaluation is to conduct needs assessments for medical education and to re-modify the content of CME to meet those needs.4,5 This situation analysis is an important step especially with the evolution of a new department like the department of health professions education that would collect a data base information to evaluate the progress of  work in the future, and help planners to identify their objectives more clearly. The aim of this study was to evaluate the CME activities and to assess needs among physicians working in hospitals in the Al-Qassim region, Saudi Arabia.

METHODS

This is a surveillance study, conducted in two phases, to evaluate the CME activities among physicians working in hospitals in the Al-Qassim region. The first phase was conducted in the year 1421 Hejri corresponding to year 2000 Gregorian, at the start of our work as a department of health professional education. A structured questionnaire was used to collect information from physicians working in the hospitals. This information included; (1) Identification data, (2) amount of CME hours attended in the region and outside,  (3) the attitude and suggestions regarding CME and (4) how to improve it. Fifty questionnaires were distributed to each of the five main hospitals in the region; King Fahad Specialist Hospital (KFSH) in Buraidah, Maternity and Children’s Hospital (MCH) in Buraidah, King Saud Hospital (KSH) in Uniza, Al-Rass Hospital  and Al-Mednab General hospital. The sample represents almost 50% of physicians working in the 5 main hospitals, 250/527. The questionnaires were distributed in envelopes, through the medical education coordinator in each hospital and collected two days later. Physicians were recruited at random from physicians list. After one year, the second phase, in the year 1422 Hejra, 2001 Gregorian, 30 questionnaires each containing specific questions on the number of CME hours and Internet use was distributed to a new sample, in the following hospitals: Al-Rass, KFSH, KSH, and MCH. A total of 120 physicians working in the hospitals were re-sampled using the same methods as in phase one.

                SPSS was used for data entry and analysis. T-test was used to compare quantitative data while chi-square was used to compare qualitative data. The sample was re-weighted according to the total number of physicians working in each hospital in



Table1:CME hours (mean + SD) attended in the last year by status of physicians

Place

Status

Total

Consultant

Specialist

Resident

Hospital

61.5 (± 68.56)

50.4 (± 55)

33.2 (± 39)

46.72 (± 54.6)

Region

7.24 (± 6.83)

5.79 (± 6)

      4.12 (± 4.76)

5.51 (± 5.9)

Outside region

   4.69 (± 10.89)

    1.0 (± 2.96)

       2.51 (± 9.17)

   2.31 (± 7.76)


relation to the total number of physicians in the five hospitals.

RESULTS

Phase I study: 168/250 (67%) completed questionnaires were collected. The average age of the respondent physicians was 41.9 (± 7.5) years and with an average duration of work in the region of  5.6 (± 5.2) years. The average years of work in the region was significantly higher for doctors working with MOH (6.7 years) compared to 2.9 years for doctors contracted by companies (p=0.0001). This was expected as the turnover in the companies is higher than MOH. 1.8% (3) were Saudi, 51.6% non-Saudi (Arabs), and 46.6% non-Saudi, (others).

Average CME activities attended in the last year

Although it did not reach a significant level, consultants and specialists attended a higher number of CME hours compared to residents(Table 1). It should, however, be noted that a high dispersion of the data around the means reflects a big discrepancy of CME hours attended within each group. No attempts were made to compare hospitals, as the sample was rather small (Table 1).

                Circulars and notice boards (80%) were the main methods of announcement of CME activities and it reached the physicians (87%) a few days before the activity. The main drive to attend such activities was to gain professional competence (97%) although the checking of attendance also played an important role. Lack of time (81%) was the main reason for non-attendance of CME activity.

                Seventy percent of the respondents said that the number of activities was adequate, while 26% said that the activities were few. Only 14%  of the consultants said that the activities were inadequate, compared to 35% of specialists and 25% of the residents(p=0.002).

                Sixty-five percent of physicians said that the quality was good, while 18.4% said that they were excellent, but 16.5% said that it was poor. Of the respondents, 48.7% said that the presentation of CME should be different. The following suggestions were given by the doctors for the improvement of CME activities. More than one suggestion was allowed. Thirty-five percent said that the topics should be of more practical importance and that departmental activity (16%) would be more effective than lectures given to doctors from all the different specialties. Also, many doctors (19%) suggested that eminent speakers should be invited to improve the quality of CME activities and attract more doctors to attend. According to physicians, clinical courses and clubs especially those related to their specialty, as well as life support courses were the main areas needing attention.

Internet connectivity and use

Thirty-four percent of the sample had Internet connection at the time of the first phase study. Being connected to the Internet was significantly affected by status. Fifty-three percent of the consultants compared to 36% of the specialists and 23% of the residents (p= 0.034) were connected to the Internet.

Phase II study: The response rate was 62%, as 93 physicians responded to the questionnaires. Mean age was 41.7 ( ±6.5) years with an average 7.5 (±6.5) years of work in the region. In the region, the duration of service was longest in Al-Rass hospital [9.61 years (±9.1)], as physicians were MOH employees while it was shortest in KSH [2.5 years (±1.29)], since physicians were company employees.

CME activities

There is a significant increase in the average number of CME hours gained through regional activities. CME hours gained through hospital activities fell but not significantly compared to first phase of the study.

Internet

There was a significant increase in the number of physicians who had access to Internet (34% in first phase to 47.36% in the second phase), but the main increase was in the consultant category where there was an increase from 53% in the first phase to 71% in the second phase. Consultants were more likely to have an Internet connection (71%) compared to specialists (40%) and residents (22%), p=0.003.

DISCUSSION

The high turnover of physicians is a big challenge to CME in Al-Qassim, as medical education is a cumulative process. In the four main hospitals in Al-Qassim, physicians are employed through companies. The contracts for these companies are of  three years duration only. This may explain why the average duration of work is 2.9 years for physicians employed by companies compared to 6.7 years for MOH employees (p=0001).

Table 2:Frequency distribution of variables related CME activities

Variable

No. (%)

How did they know about CME?

Circular

134 (80.0)

Notice board

133 (79.6)

Morning meeting

85 (50.4)

Word of mouth

54 (32.4)

Others

46 (27.3

When did they know about the activity?

Few days

146 (86.7)

Few hours

14 (8.2)

Just before

  6 (3.8)

After

  2 (1.3)

Why you are attending CME activities?

increase my professional competence

163 (97.1)

To accumulate credit hours

140 (83.1)

Because they are checking attendance

119 (70.9)

To pass exam

114 (67.9)

To support the speaker

73 (43.6)

I have nothing else

37 (21.9)

Others

34 (20)

How to improve CME activities?

Subject of practical importance

58 (34.8)

Guest speaker

32 (19)

Suitable time

28 (16.8)

At departmental level

26 (15.7)

Audiovisual

19 (11.2)

CME activities suggested as needed most by the physicians:

Regular courses

102 (61)

Morning meeting

89 (53)

CPR

87 (52)

Departmental cases

87 (52)

Regular clubs

86 (51)

ACLS

76 (45)

Visiting lecture

76 (45)

Critical care management

73 (43.4)

Departmental journal

73 (43.4)

Bedside teaching

72 (42.8)

                Although specialists and residents attended fewer CME activities, compared to consultants (Table 1), they felt that the available CME activities were too few. This may be explained by the fact that the system


Table 3:Comparison between CME hours and Internet connection in the first and second phase

Variables

First phase (1421H) N=127

Second phase (1422H) N=93

p-value

CME hours in hospital (Mean ±SD)

46.72 ± 54.6

37.6 ± 26.9

0.139

CME hours in the region (Mean ± SD)

5.51 ± 5.9

14.22 ± 19.77

0.0001

CME hours outside region (Mean ± SD)

2.31 ± 7.76

4.25 ± 12.0

0.149

Proportion of physicians with an Internet connection

34%

47.36%

0.04


of work gave the specialists and the residents little time to attend or made it difficult because of unsuitable timing.

                Although the trend now is to maximize the use of web-based CME,6,7 only 34% in the first phase and 47% of physicians, one year later, had internet connection (Table 3). Since only 22% of the residents had an Internet connection, any attempt to use the Internet as a channel for CME would be affected.

                A consultant is more likely to have an Internet connection (71%) and attend more CME activities (61.5 hours/year). One wonders whether it is job obligation or personal character that motivates and spurs a doctor to self-improvement and a higher status.

                Although some studies done in Saudi Arabia covered some of the challenges facing CME,8 our study revealed other challenges including high turnover of physicians, distance which prevent physicians working in remote Primary Health Care Centers from attending activities, and scarce resources. Also, one of the most important challenges of continuing medical education and continuing professional developments is the creation of a demand for career development.9 This is a life-long process, for both the need and the obligation to learn and improve oneself apply to all doctors of all ages and all hierarchical levels.

                Our study (Table 2) showed that physicians expressed the need to shift away from credit counting of theoretical lectures, to a process that can record learning that has taken place and its application in practice.10 Learning that occurs in the context of workplace is needed and is far more likely to be relevant and reinforced and lead to better practice.11 

                We recommend the use of a model of small CME groups2 in direct relation with the different specialties emphasizing practical issues and interdepartmental cooperation. Courses like Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS) (Table 2), are good models for CME which can lead not only to professional developments but also CME hours.

                As shown in Table 3, CME  activities increased significantly one year after the establishment of the Department of Health Professional Education. To improve the quality of CME and to meet the needs of professional development, the central role of Health Professional Education Department in planning, evaluating  and monitoring is mandatory. This role should not only be reflected on the quantity but also on the quality of CME in the region.

REFERENCES

1.        From CME to CPD: getting better at getting better? [editorial]. BMI 2000;320:393-4

2.        Eliasson G, Mattsson B. From teaching to learning: experience of small CME group work in general practice in Sweden. Scan J Prim  Health Care 1999;17(4):196-200

3.        Von Reis EO, Bott U, Sawicki PT. Quality and structure of continuing medical education in internal medicine using example of the chamber of physicians of the northern Rhine area. Z Arztl Fortbild Qualitatssich 1999;93(8):569-79

4.        Glazebrook R, Chater B, Graham P. Rural and remote Australian general practitioners’ educational needs in radiology. J Contin Educ Health Prof 2001;21(3):140-9

5.        Robinson BE, Barry PP, Renick N, Bergen MR, Statos GA. Physicians confidence and interest in learning more about common geriatric topics: needs assessments. J Am Geriatr Soc 2001;49(7): 963-7

6.        Basely BW, Kallail  KJ, Walling AD, Davis N, Hudson L. Maximizing the use of a web-based teaching skills curriculum for community-based volunteer faculty. J Contin Educ Health Prof 2001;21(3):158-61

7.        Carriere MF, Harvey D. Current state of distance continuing medical education in North America. J Contin Educ Health Prof 2001;21(3):150-7

8.        Al-Shehri AM, Al-Haqwi AI, Al-Ghamdi AS, Al-Turki SA. Challenges facing continuing medical education and the Saudi Council for Health Specialties. Saudi Med J 2001; 22(1):3-5

9.        Matos-Ferreira A. Continuing medical education and continuing professional developments: a credit system for monitoring and promoting excellence. BJU Int 2001;87 Suppl 2:1-12

10.     Grant J, Chambers E.The good CPD guide: a practical guide to managed CPD. London: Joint Centerfor Education in Medicine; 1999.

11.     Davis DA, Thompson MA, Oxman AD, Haynes B. Changing physicians performance: a systematic review of the effect of continuing medical education strategies. JAMA 1995;274: 700-5.


-0001-11-30

DIETARY MISCONCEPTIONS


DIETARY MISCONCEPTIONS AMONG DIABETIC PATIENTS IN MAKKA CITY, SAUDI AR ABIA

Mohammed Al-Saeedi, FFCM-KFU,* Ahmed G. Elzubier, FRCP,† Kasim M. Al-Dawood, FFCM-KFU,† Ahmed A. Bahnasi, PhD†

*Directorate of Health Affairs, Holy Makkah and † Collegeof Medicine, King Faisal University, Dammam, Saudi Arabia

هدف الدراسة:قياس معدل انتشار بعض  المفاهيم الغذائية الخاطئة لدى مرضى السكرى المسجلين بالمراكز الصحية بمدينة مكة  بالمملكة العربية السعودية.

طريقة الدراسة:تمت معاينة عينة مكونة من 1039 من مرضى السكرى المسجلين بمراكز الرعاية الصحية الأولية و ذلك عن طريق استبانة مصممة. و كان محتوى المقابلة يختص بالمفاهيم اامتعلقة بالتغذية. وقد تم حصر المفاهيم بواسطة نظام حسابى. واستخدم أختبار "كاى" لتقييم أهمية الأرتباطات بين المفاهيم و المتغيرات الديموغرافية و تلك المتعلقة بمرض السكرى.

نتائج الدراسة:كان لدى أغلبية المرضى (68.7%) معيار عالى للمفاهيم الخاطئة عن التغذية.

وأعتقد أكثر من نصف العينة بفائدة الامتناع عن السكريات وتناول المواد المرة الطعم والخبز الجاف. وكذلك كانت هنالك مفاهيم تتعلق بفائدة العسل و التمر، و بعدم تناول الوجبات الصغيرة أثناء اليوم ، والأعتقاد بأن المحليات الصناعية قد تسبب السرطان و كذلك بأن السمنة من علامات الصحة الجيدة. و كان معيار المفاهيم الخاطئة أعلى بين الذكور (ت أقل من 0.01) ، و لدى كبار السن(اكبر من 35سنة من العمر) من المرضى ( ت أقل من 0.02) و كذلك لدى المرضى غير المتعلمين (ت أقل من 0.01).

الأستنتاج:أظهرت الدراسة معدلا عاليا للمفاهيم الخاطئة ذات الأهمية بمكان. كما أشارت الدراسة للفئة المستهدفة بين مرضى السكرى الذين تتفشى بينهم هذه المفاهيم. و أظهرت كذلك الحاجة للتثقيف الصحى المتواصل لهذه الفئة وصولا للأرتقاء بمعرفتهم عن مرض السكرى.

الكلمات المرجعية:المفاهيم الخاطئة، مرض السكرى، التغذية، المملكة العربية السعودية.

Objectives:   To assess the prevalence of some dietary misconceptions among primary health care center-registered diabetic patientsin Makka City, Saudi Arabia.

Methods: A sample of 1039 primary health care center- registered diabetic patients was interviewed using a structured questionnaire on diabetic diet -related misconceptions. A scoring system was used to document the frequency of misconceptions. The relationship of the misconceptions to socio-demographic and diabetes-related variables was assessed using chi-squared tests.

Results: Most patients (68.7%) had a high diet misconception score. More than half of the sample had the misconception that carbohydrates were to be completely eliminated from the diet, and only dried bread and bitter foods were to be consumed. Data included the belief in the consumption of honey and dates; the omission of snacks; belief in the carcinogenicity of the sugar substitutes; and obesity as a sign of good  health. The  score  was  significantly  higher  among  males (p<0.01), patients

Correspondence to:

Dr. Kasim M. Al-Dawood, P.O. Box 2290, Al-Khobar 31952, Saudi Arabia

older than 35 years (p<0.02), and among patients whose level of education was low (p<0.01).

Conclusion: It is important to note that the rate of diet-related misconceptions among diabetics in Makka city is high. The study pointed to the target fraction of diabetic patients among whom these misconceptions prevailed.  There is a need for constant motivation and appropriate education at frequent intervals to encourage better knowledge of the disease so that there is compliance to treatment.  

Key Words: Misconceptions, diabetes, diet, Saudi Arabia.

INTRODUCTION

Diabetes mellitus is rapidly becoming a common condition with complications. Consequently the cost for its care is escalating. Dietary management is essential to the management of diabetes mellitus. Therefore, patients’ education about diet remains an essential part of this management.1 For various reasons, diabetic patients often do not comply with the dietary recommendations.2-4 This problem is aggravated by the common misconceptions held by different groups of people about diabetic dietary management.5 It is now recognized that patients’ education on a healthy diet and exercise is a method for the prevention of diabetes mellitus.6 Hence it is important to assess the common misconceptions among diabetic patients about diet in order to plan a good health education program. The objective of this study was to assess the prevalence of some dietary misconceptions among primary health care center-registered diabetic patientsin Makka City, Saudi Arabia.

MATERIAL AND METHODS

This cross-sectional study was carried out in Holy Makka city during the year 2000. The study population was the primary health care-registered adult diabetic subjects. A sample size of 1039 patients which represented 10% of all diabetic subjects who were registered in PHCCs (Primary Health Care Centers) in Makka city was selected. This was done by means of a two-stage, stratified, random  sampling technique with proportional allocation to choose about 10% of diabetic patients, from 9(70%) urban and 12(30%) rural PHCCs. At the first stage, simple random sampling technique was used to choose 9 urban and 12 rural PHCCs. At the second stage the sample of diabetic subjects from each chosen PHCC was also taken, using simple random sample.   

                Data were collected with a structured questionnaire which was administered to patients by pre-trained primary health care center physicians. The questionnaire included demographic information such as gender, age and nationality. Educational level was categorized as low = elementary school or below, average = high school or below, and high= university or above. It also included diabetes-related information such as family history, duration of diabetes, body mass index (calculated as the weight in kilograms divided by the square of the height in meters), continuity of care as measured by whether the patient was always seen in the same or different centers, regularity of follow up and the number of primary health care center visits made per year. Patients' recall of compliance with diet was also recorded.

                Patients were asked specifically about their belief in eight misconceptions about dietary aspects in diabetes. Those misconceptions were about the consumption of carbohydrates, bitter foods, dry bread, intake of snacks, honey and dates, the use of sugar substitutes and their opinion about obesity. The patient's responses on these aspects were scored as "1" or "0' if he/she had a misconception, or not, respectively. The sum of all scores was computed to represent a misconception score. A cut-off point of 30% chosen on the basis of the median score was used to categorize scores whereby a score equal to or less than 30% was considered low while that above 30% was considered high. This cut-off point was chosen after taking the average opinions of some experts in the field.

                Data was entered and analyzed by means of an IBM-compatible computer incorporating the Statistical Package for Social Science SPSS PC Version 10. Frequency distributions were generated and a chi-squared test was used to assess the significance of difference between categories. A p-value of 0.05 or less was considered indicative of statistical significance.

RESULTS

The total number of patients in the sample was 1039. Saudi diabetic patients formed the majority (93.7 %) compared to a small number of non-Saudis (6.3%). Males constituted (66.7 %), while females constituted (33.3 %) of the sample. The mean patient age was 54.6 ± 12.6 years. Most of the patients had a low level of education (74 %) and the majority of them (71.9%) had had diabetes for more than 5 years. Also, most of them (73.2%) had a high body mass index (higher than 25 kg/square meters). Patients who were followed up in the same center and those who stated that they were regular in their follow up were 89.0% and 83.9%, respectively. Most patients (69.8%) visited the health center more than 6 times per year. Patients who stated that they were compliant with the prescribed diet were 28.5%.

                About half of the sample had the misconception that carbohydrates were to be completely removed from the diet; bitter food items were to be consumed to neutralize hyperglycemia; that dried bread was good for diabetes; that snacks were to be avoided by diabetic patients. Other misconceptions held were that honey and dates were good food items for diabetic patients (34.3% and 17.0%, respectively). Less than 10% of the patients thought that sugar substitutes could be carcinogenic, while a quarter of them thought that obesity was a sign of good health (Table1).

Table 1:Misconceptions of diet shown by 1039 diabetic patients in Makka city during the year 2000

Misconception

Number (%)

Carbohydrates should be omitted completely from diet

543 (52.3)

Bitter foods help buffer hyperglycemia

639 (61.5)

Dried bread is good for diabetes

560 (53.9)

Snacks should not be taken by diabetic persons

495 (47.6)

Honey is good for diabetes

356 (34.3)

Eating dates is good for diabetes

177 (17.0)

Sugar substitutes are carcinogenic

89 (8.6)

Obesity is a sign of good health

266 (25.6)

                Most patients (68.7%) had a high diet misconception score. The score was significantly higher among males than females (P < 0.01), among patients older than 35 years (P < 0.02), and among patients who had a low level of education (p<0.01) (Table 2).

                Variations of the misconception score regarding family history, duration of diabetes, body mass index, continuity of care, regularity of follow up, number of visits per annum to the health center, and with compliance to diet were not statistically significant (Table 3).

Table 2:Effect of demographic variables on diet misconception score by 1039 diabetic patients in Makka city during the year 2000

Variable

High score

Low score

X2

p-value

Gender:

Males

233 (33.6)

460 (66.4)

5.309

0.01

Females

  92 (26.6)

254 (73.4)

Age:

< 35 years

     9 (18.0)

  41 (82.0)

4.327

0.02

35 years

316 (32.0)

672 (68.0)

Nationality:

Saudis

307 (31.6)

666 (68.4)

0.527

0.3

Non-Saudis

  18 (27.3)

  48 (72.7)

Education level:

Low

254 (33.4)

507 (66.6)

6.478

0.01

Average

  50 (25.8)

144 (74.2)

High

  14 (22.6)

  48 (77.4)

Table 3:Effect of diabetes-related variables on diet misconception score by 1039 diabetic patients in Makka city during the year 2000

Misconceptions

High score

Low score

X2

p-value

Family history:

Positive

174 (32.2)

366 (67.8)

0.464

0.3

Negative

151 (30.3)

348 (69.7)

Duration of Diabetes Mellitus:

Less than 5 years

  86 (29.9)

202 (70.1)

0.506

0.3

5 years and more

237 (32.2)

500 (67.8)

Body Mass Index:

High

231 (32.7)

475 (67.3)

0.151

0.4

Normal

  81 (31.4)

177 (68.6)

Continuity of care:

Follow-up in the same center

288 (31.3)

633 (68.7)

0.066

0.4

Follow-up in different centers

37 (32.5)

77 (67.5)

Follow-up regularity:

Regular

277 (31.9)

592 (68.1)

0.908

0.2

Not regular

47 (28.1)

120 (71.9)

Annual number of visits to center:

Less than 6 visits/year

  54 (31.3)

116 (68.2)

0.222

0.4

6 visits or more/year

244 (33.7)

481 (66.3)

Compliance with diet:

Compliant

103 (34.9)

192 (65.1)

2.502

0.06

Non-compliant

221 (29.9)

519 (70.1)

DISCUSSION

The subjects of this study sample were patients who were mostly past middle age, afflicted with type 2 diabetes, mostly males and with not much education.  Moreover, most of them were overweight or obese, with poorly controlled diabetes; and held many misconceptions about diabetes. They therefore, represented a target group for the proper management of diabetes mellitus, especially in respect of health education, because of the possible morbidity and mortality risk factors they were exposed to.

                The theme of health education needed in the light of the study findings, should be dietary management considering that 25.6% of the sample believed that obesity was a sign of good health, contrary to all basic information on the hazards of obesity and overweight.7 It is vital to use behavior-modifying education,8,9 to help them get rid of this misconception and correct the status of their risk factors. However, such efficacy of this education might be diminished if not carried out with the proper educator-patient communication.10

                The study also revealed some misconceptions related to the types of food eaten by diabetic subjects. A sizable proportion of the sample believed that carbohydrates should be omitted from their diet. This is a genuine misconception since carbohydrates are now known to be an essential component of diabetic diet, for 40–60 % of the diet content should be in that form to maintain adequate energy, and as far as possible, an ideal body weight. However, it is important to educate patients on how to count carbohydrates, a process that was tried successfully on a sample of patients in a recent study.12 Patients also expressed a preference for bitter foods, in the false hope that these would neutralize hyperglycemia. Of course, this is absolutely unfounded, and needs correction with the appropriate health education. Another important misconception expressed by the sample was their ignorance of the benefits of snacks in meal planning for diabetic patients. It has been shown that snacks are associated with better glucose tolerance and physical as well as psychological functioning.12 It is, therefore, necessary to correct this misconception among diabetic patients.  The study also revealed a preference for honey and to a lesser extent dates. This arises out of religion and culture since honey and dates are local products. These two items might not interfere with diabetes control as along as they were taken in moderation as part of their carbohydrate intake. Therefore, patients need to be educated on this. This study revealed the patients’ poor basic knowledge of the fundamentals of treating diabetes,  although 72% of them had had the disease for more than five years. The consequences of these misconceptions may be fatal, or at least may have a negative effect on patients’ compliance and control.13,14 In Saudi Arabia, this situation may be related to deficiencies in the structures and the process of the health education programs directed at diabetic patients, for only 33% of diabetic patients were found to have adequate health education.15 Barriers to effective health education may include such factors as low educational level,16 inaccurate culture-bound beliefs,13 time required for patient education,17 the educator’s poor knowledge  of the disease;18,19 and language16,17 or cultural barriers.17 Studies have shown that the impact of effective health education and behavioral intervention reflect on the patients’ compliance, metabolic control and knowledge about the management of the disease.20,21 The outpatient visit for diabetes mellitus should be different from other chronic and acute diseases as more time should be invested in patients’ education.22,23 The dietary management of diabetic patients has evolved from the concepts of 'simple' and 'complex' carbohydrates to that of the glycemic index, and eventually to the hypocaloric diet and carbohydrates counting. Physicians should translate these developments into practical instructions for patients and correct patients' misconceptions through well-organized health education.

                The main variables that were revealed as significantly related to the diet misconception score in this study were male gender, older age and low education. This finding identifies the population of diabetic patients at whom health education should be targeted in order to help them control this serious disease effectively.

                In this study, dietary-related misconceptions were significantly higher among males which could be explained by the variation in age, as more females were younger and better educated. However, studies have shown that knowledge is not influenced by the gender of the patient when the difference in the level of education of both genders is not significant.24 Our results support earlier findings that correct knowledge of the disease is associated with younger age groups.24 The rate of misconceptions found in this study appears to be universal to all strata of the diabetic community of the study sample, with insignificant differences among Saudi nationals and non-Saudis. Similar to our findings, studies have shown that the higher the level of education of the patient, the better the knowledge about diabetes.16 Others have, however, found that non-adherence to treatment is greater among this group of patients.25 The association between positive family history of diabetes and higher rate of misconceptions in this study, supports an earlier finding that the characteristics of the family determine the self-care practices.26 Similar to our findings, studies have shown that the rate of the misconception is not associated with the duration of the disease.24 Results of this study suggest that  misconception scores are not affected by  the number of visits to the health center per year, continuity, or regularity of care. Results reported from Saudi Arabia have shown that compliance to appointments in primary health care centers by diabetics is good in 60% and poor in 30%. Only 33% of diabetic patients had adequate health education; 27% of the patients had not had any at all.10 Elsewhere, compliance with appointment was found to be associated with good care score.13,14,20,21 It was surprising to find that the sample compliance with diet was only 28.5%. This may explain why 73.2% of the sample had high body mass index. This finding stresses the importance of compliance to diet in addition to drugs to attain a good diabetic control.2  

                In conclusion, the results of this study revealed rather importantly, that there was a high rate of diet-related misconceptions among diabetics in Makka city. The study identified the target fraction of diabetic patients among whom such misconceptions prevailed.  It is necessary to constantly motivate and give appropriate education at frequent intervals to promote better knowledge about the disease and consequent compliance to treatment.  

REFERENCES

1.        Parkin T. An audit of the theoretical basis of education during dietetic consultations with diabetic subjects. J Hum Nutr Diet 2001;14(1): 33-42.

2.        Khattab MS, Abolfotouh MA, Khan MY, Humaidi MA, Al-Kaldi YM. Compliance and control of diabetes in a family practice setting, Saudi Arabia. East MediterraneanHealth Journal 1999;5(4):755-65.

3.        Zilli F, Croci M, Tufano A, Caviepzel F. The compliance of hypocaloric diet in type 2 diabetic obese patients: a brief-term study. Eat I Weight Disord 2000;5(4):217-22.

4.        Bernal H, Woolley S, Schensul JJ, Dickinson JK. Correlates of self-efficacy in diabetes self-care among Hispanic adults with diabetes. Diabetes Educ 2000;26(4):673-80.

5.        Fisher EB, Walker EA, Bostrom A, Fischhoff B, Haire-Joshu D, Johnson SB. Behavioral Science Research in the Prevention of Diabetes: Status and Opportunities. Diabetes Care 2002;25(3): 599-606.

6.        Kao PC, Wu TJ, Ho LL, Li XJ. Current trends and new approaches in the management of diabetes mellitus. Ann Clin Lab Sci 2000;30(4): 339-45.

7.        Saw SM, Rajan U.The epidemiology of obesity: a review. Ann Acad Med Singapore1997;26(4): 489-93.

8.        Cabrera-Piveral CE, Gozalez-Perez G, Vega-Lopez G, et al. Effects of behavior-modifying education in the metabolic profile of the          type 2 diabetes mellitus patients. J Diabetes Complications 2000; 14(6):322-6.

9.        Schalch A, Ybarra J, Adler D, Deletraz M, Lehmann T, Golay A. Evaluation of a psycho-educational nutritional peogram in diabetic patients. Patient Educ Couns 2001;44(2):171-8.

10.     Shultz JA, Sprague MA, Branen LJ, Lambeth S. A comparison of views of individuals with type 2 diabetes mellitus and diabetes educators about barriers to diet and exercise. J Health Commun 2001;6(2):99-115.

11.     Bruttomesso D, Piñata A, Crazzolara D, et al. Teaching and training programme on carbohydrates counting in Type 1 diabetic patients. Diabetes Nutr Metab 2001;14(5):259-67.

12.     Benton D, Slater O, Donohoe RT. The influence of breakfast and a snack on psychological functioning. Physiol Behav 2001;74(4):559-71.

13.     Philis TA, Walker C. Improved care for diabetes in underserved populations. J Ambulatory Care Manage 2001;24:39-43.

14.     Duran VB, Rivera CB, Franco GE. Pharmacological therapy compliance in     

      diabetes. Salud Publica Mex 2001;43:233-6.

15.     Al-Khaldi YM, Khan MY. Audit of a diabetic health education program at a  large primary health care center in Asir region. Saudi Med J 2000;21: 838-42.

16.     Larsen IF. Diabetes among immigrants from non-western countries. Tidsskr Nor Laegeforen 2000; 120:2804-6.

17.     Chin MH, Cook S, Jin L, Drum ML, Harisson JF, Koppert J, etal. Barriers to providing diabetes care in community health centers. Diabetes Care         2001;24:268-74.

18.     Speight J, Bradley C. The ADKnowl : identifying knowledge deficits in the diabetes care. Diabet Med 2001;8:626-33.

19.     Muhlhauser I, Berger M. Evidence-based patient information in diabetes. Diabet Med 2000;7:  823-9.

20.     Gagliardino JJ, Etchegoyen G, Pendid LA Research Group. A model educational  program for people with type 2 diabetes: a cooperation Latin American implementation study (PENDID-LA).   Diabetes Care 2001;24: 1001-7.

21.     Matam P, Kumaraiah V, Munichoodappa C, Kumar KM, Aravind S. Behavioural  intervention in the management of compliance in young type-1 diabetics. J Assoc Physicians India 2000;48: 967-71.

22.     Yawn B, Zyzanski SJ, Goodwin MA, Golter RS, Stange KC. Is diabetes treated as an acute or chronic illness in community family practice? Diabetes Care 2001;24:1390-6.

23.     Bamgboye EA, Jarallah JS. Long-waiting outpatients : target audience for health education. Patient Educ Couns 1994; 23:49-54.

24.     Ford S, Mai F, Manson A, Rukin N, Dunne F. Diabetes knowledge-are patients getting the message? Int J Clin Pract 2000;54:535-6.

25.     Shobhana R, Begum R, Snehalatha C, Vitjay V, Ramachandran A. Patients’ adherence to diabetes treatment. J Assoc Physicians India1999; 47: 1173-5.

Fisher L, Chesla CA, Skaff MM, etal. The family and disease management in Hispanic and Europian-American patients with type 2 diabetes. Diabetes Care 2000;23:267-72.


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CLINICAL PATTERN


CLINICAL PATTERN OF ACNE VULGARIS AND ITS ASSOCIATED CONDITIONS IN THE EAS TERN PROVINCEOF KINGDOMOF SAUDI ARABIA: A HOSPITAL-BASED CLINICAL STUDY

Ali M. Al-Ameer, MD, Omar M. Al-Akloby MD

Department of Dermatology, King Fahd Hospitalof the University, Al-Khobar, Saudi Arabia

هدف الدراسة:أجريت الدراسة للتعرف على أشكال مرض حب الشباب السريرية بين المراجعين لأحدى مستشفيات المنطقة الشرقية.

طريقة الدراسة:أجريت الدراسة من خلال الفحص الإكلينيكي على مئتين من مرضى حب الشباب الذين راجعوا عيادات الأمراض الجلدية بمستشفى الملك فهد الجامعي بالخبر بالمملكة العربية السعودية  وذلك في الفترة  من أكتوبر 1999م إلى مايو 2000 م.

نتائج الدراسة:كان أكثر الأنواع شيوعا هو النوع الالتهابى وذلك بنسبة 76?  في الذكور و 79?في الاناث. وقد لوحظ أن الدسم الجلدي هو أكثر الحالات المصاحبة لمرض حب الشباب (11?) يليها قشرة الرأس (4?). بالنسبة للاناث فقد كانت زيادة حب الشباب المصاحب للدورة الشهرية بنسبة (9.8?) يليها اضطراب الدورة الشهرية بنسبة (4.1?) يليها الشعرانية (2.5 ?).

الكلمات المرجعية: حب الشباب, الدسم الجلدي, قشرة الرأس, الدورة الشهرية , الشعرانية

Objective:This study aims to review the clinical pattern of acne vulgaris cases referred to one  hospital in the Eastern Province.

Methods:Two hundred cases diagnosed in the Dermatology Department at King Fahad Hospital of the University (KFHU), Al-Khobar, Saudi Arabia were studied Results: Inflammatory acne was the predominant type observed in both males and females (76% and, 79%, respectively). Seborrhea (greasy skin) was the most frequently associated condition 22 (11%) followed by dandruff 8 (4%). The difference between males and females was not statistically significant (p-value = 0.46, 0.93, respectively). In female patients, premenstrual flare was observed in 12 (9.8%), irregular period 5 (4.1%), and hirsutism 3 (2.5%). 

Key Words: Acne vulgaris, seborrhea, dandruff, premenstrual flare, irregular period, hirsutism.

The aim of the present study was to review the clinical pattern of acne vulgaris and its associated conditions in patients diagnosed in a university hospital in the Eastern Province of Saudi Arabia. However, no similar studies, to our knowledge, have been reported from Saudi Arabia.

PATIENTS AND METHODS

A total of 200 cases of acne vulgaris (122 females and 78 males with a mean age of 14.8 and 16.3 years, respectively) diagnosed during the period of 1st October, 1999 to the end of May, 2000 were studied. King    Fahd Hospital of the University is a  referral

Correspondence to:

Dr. Ali M. Al-Ameer, P.O. Box 4609, Hofuf 31982, Saudi Arabia

tertiary care hospital for the entire Eastern Provincewith an estimated population of three million.

                Charts of patients with acne vulgaris seen during the study period were reviewed. The cases were divided into two major groups; inflammatory and non-inflammatory acne. The inflammatory lesions included papules, pustules, nodules and even pseudocysts, whereas the non-inflammatory lesions were comedones, either open (blackheads) or closed (whiteheads).1,2

                Data were entered into a compatible personal computer using statistical package for social sciences ( SPSS) version 10. Statistical analysis was performed with Chi-square test for qualitative variables, and t-test for quantitative variables. A p-value of less than 0.05 was considered as the statistical level of significance.3

RESULTS

Inflammatory acne was the predominant type observed in both males 59 (76%) and females 96 (79%) (Figure 1). The difference was statistically insignificant (p-value = 0.36).

                Among all patients papulo-pustular lesions were the commonest type of inflammatory acne 74 (52%), followed by papular 46 (32%) and nodular 17 (12%).  The least common were the isolated pustular lesions 13 (9%) (Figures 2). No significant difference between males and females was found (p-value = 0.96).

                The face was involved in all cases 200 (100%). The face alone was involved in 151 (75.5%) whereas 49 (24.5%) of the cases had both facial and trunk involvement (Table 1). There was no statistical significant difference between the two genders (p-value = 0.17).

                Seborrhea (greasy skin) was the most frequently associated condition, 22 (11%) followed by dandruff 8 (4%). The difference

Table 1: Sites of involvement in acne patients (N=200)

Distribution

No of patients (%)

Face only

151 (75.5)

Face and trunk

49 (24.5)

Total

200 (100)

between males and females was not statistically significant (p-value = 0.46 and 0.93 respectively) (Figure 3).

                In female patients, premenstrual flare was observed in 12 (9.8%), irregular periods 5 (4.1%), and hirsutism 3 (2.5%). 

DISCUSSION

Acne vulgaris is generally limited to skin areas rich in sebaceous glands.1 Non-inflammatory lesions of acne include white (closed) and black (open) comedones.1,2 The inflammatory lesions vary from small papules to pustules to large, tender, fluctuant nodules. Some of the large nodules have previously been called cysts, and the term nodulocystic has been used to describe severe cases of inflammatory acne.2

                In the present study,inflammatory acne was the predominant type. It was seen in slightly more than three quarters of acne patients. These findings are in line with those noted by Goulden et al4 in spite of the difference in the mean age of the two studies.

                All acne patients in this study had facial lesions. This finding is nearly the same as that reported by Cunliffe and Williams.5 In slightly more than three quarters of the patients, the face alone was involved. Both facial and truncal lesions were seen in approximately a quarter of the cases. These findings are in a close agreement with what was observed by Patricia and Chee-Leok.6

                In this study, seborrhea (greasy skin) was the most common associated condition occurring in almost one tenth of all cases. Several studies have indicated that seborrhea is a frequent finding in acne.5,7 Furthermore, acne patients excrete more sebum than normal subjects, and the level of secretion correlates reasonably well with the severity of the disease.8

                Dandruff was reported in 4% of the acne patients. However, like many dermatological symptoms, though not easy to assess clinically, it is probably more prevalent in patients with acne.9

                Premenstrual flare was found in 9.8% of female acne patients which is less than that reported in western studies, which is almost 70%.5,10 This might be an underestimate, since for cultural reasons, Saudi female teenagers would rather not discuss private issues like menstruation. The other possible explanation of this difference is that the files used in the research  may have insufficient information. 

                Acne vulgaris represents one of the most common chronic skin diseases and is the commonest dermatological disorder of adolescents.1,5 Since the prevalence of this condition is not known at the community level in Saudi Arabia, a cross-sectional, community-based, multi-center study is recommended.

REFERENCES

1.     Brown SK, Shalita AR. Acne vulgaris. Lancet 1998; 351: 1871-6.

2.     John SS, Diane MT. Diseases of the Sebaceous Glands. In: Fitzpatrick TB, Eisen AL, Wolff K, Freedberg IM, Austen KF. Editors. Dermatology in General Medicine. 5th ed. New York: McGraw Hill; 1999: 769-83.

3.     Wayne WD. Biostatistics: A foundation for analysis in the health sciences. 3rd ed. John Wiley & Sons Inc; 1983.

4.     Goulden V, Clark SM, Cunliffe WJ. Post-adolescent acne: a review of clinical features. Br J Dermatol 1997:136:66-70.

5.     Cunliffe W J, Cotterill JA. The Acne: clinical features, pathogenesis and treatment. Ronald Marks, editors. London: Martin Dunitz Ltd;1989: 11-75.

6.     Patricia PN, Chee-Leok G. Teatment outcome of acne vulgaris with oral isotretinoin in eighty-nine patients. Int J Dermalol 1999; 38: 213-6.

7.     Beylot C. Seborrhea and its complications. Rev Prat 1993; 43(18):2320-7.   

8.     Cunliffe WJ, Simpson NB.Disorders of the Sebaceous Glands. In: Rook, Wilkinson, Ebling, editors. Textbook of Dermatology. 6th ed. Oxford: Blackwell Scientific Publications; 1998. 1940-71.

9.     Munro AD. Acne vulgaris in a public school. Trans StJohns Hosp Dermatol Soc 1963; 49:144.

10.   Cunliffe, Cotterill. The Acnes: clinical features, pathogenesis and treatment. London: Lavenham Press; 1975.


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INCIDENCE OF HELICOBACTER


INCIDENCE OF HELICO BACTER PYLORI IN DENTAL PLAQUE OF SA UDIGASTRITIS PATIENTS

Abdel-Nasser M. Al-Refai, PhD, Sami E. Fathalla, PhD, Rambhala Nagamani, MD, Sami Al-Momen, MD

Dammam Central Hospital, Dammam, Saudi Arabia

خلفية: لقد تم التعرف على بكتيريا البوات اللولبية فى اللويحات الجرثومية مما أدى الى احتمالية أن تكون مستودع لتلك البكتيريا عند مرضى التهاب وقرح المعدة.

هدف الدراسة: دراسة العلاقة بين وجود بكتيريا البوات اللولبية فى اللويحات الجرثومية والمعدة عند مرضى التهاب المعدة وأيضا لمعرفة تأثير العناية بصحة الفم وحالة اللثة على  وجود بكتيريا البوات اللولبية فى اللويحات الجرثومية  والمعدة.

طريقة الدراسة: تم أخذ عينتين من كل مشارك فى البحث من اللويحات الجرثومية من الميزاب اللثوى أو من أعـمق جيوب لثوية حيث تم حفظ العينة الأولى فى  أنبوبة أجار يوريا كريستنسن بها 2% يوريا وتم نقلها بسرعة الى معمل البكتيريا حيث تم  تحضينها فى 37درجة مئوية وذلك لبحث امكانية وجود بكتيريا البوات اللولبية فيها بواسطة اختبار البولة السريع حيث تنتج بكتيريا البوات اللولبية كمية كبيرة من انزيم اليوريا الذى يقوم بتكسير اليوريا الى ثانى كربونات الصوديوم ونشادر وحيث أن هذه المواد قاعدية فانها تغير لون محتوى الأنبوبة من اللون الأصفر الى اللون الأحمر خلال مدة نصف ساعة الى ساعة على أكثر تقدير وسرعة التغير فى اللون يعتمد على كمية انزيم اليوريا أو بكتيريا البوات اللولبية. أما العينة الثانية فتم حفظها فى أنبوبة تحتوى على 5% أجار دم الغنم وأجار شيكولاتة ووسط انتقائى لزرع بكتيريا البوات اللولبية.

نتائج الدراسة: أظهر فحص انزيم البولة السريع فى اللويحات الجرثومية  أن 89% من المرضى كانت نتائجهم ايجابية.وكان معدل تراكم اللويحات الجرثومية معتدلا في 24% من الحالات ومتوسطا في41% بينما كان شديدا فى 35% من المرضى.أما معدل التهاب اللثة:  كان معتدلا فى 17% ومتوسطا فى 48% وشديدا فى 35% من المرضى على التوالى.ومعدل المجتمع لمرضى النسيج الحول سنى: كان معتدلا فى 50% ومتوسطا فى 23% وشديدا فى 27% من المرضى على التوالى. وأظهرت نتائج فحص انزيم البولة السريع فى المعدة ايجابية فى 87% من الحالات.كما كانت كل نتائج مزرعة بكتيريا البوات اللولبية سلبية.

ألخلاصة: ان الكشف عن وجود بكتيريا البوات اللولبية فى اللويحات الجرثومية بالفم يتيح طريقة سهلة لاختبار وجودها بالمعدة ويعطينا تصورعن احتمال اصابة المعدة مرة ثانية عن طريق الفم بعد علاجها. وكذلك يمكن استخدامها للكشف عن مدى تأثير العلاج.

الكلمات المرجعية: بكتيريا البوات اللولبية، اللويحات الجرثومية، التهاب المعدة. 

Background: Helicobacter pylori (H. pylori) was identified in dental plaque, raising the possibility of future gastritis and peptic ulceration.

Objective: This trial was to study the association between presence of H. pylori in dental plaque and in the stomachs of patients with gastritis; the effect of oral hygiene and periodontal condition on the stomach.

Correspondence to:

Dr. Abdel-Nasser M. Al-Refai, P.O. Box 4103, Dammam 31491, Saudi Arabia

Patients and Methods: Seventy-five Saudi adult dyspeptic patients, together with 60 healthy persons as control. Two samples of dental plaque were taken from gingival crevice of deepest pocket. One sample was kept in  Christensen’s urea agar and incubated for H. pylori detection by rapid urease test. The second sample was kept in 5% sheep blood agar , chocolate agar and a selective medium to culture the H. pylori.Gastric urease test was done for the same patients.

Results: (1) Plaque urease test results showed 89% positive patients. (2) Dental plaque Index:- Mild dental plaque accumulation in 24%, moderate in 41%, while severe accumulation was in 35% of the patients. (3) Gingival Index: Showed mild, moderate and severe gingivitis in 17%, 48% and 35% of patients, respectively.

(4) Community periodontal index of treatment needs ( CPITN ) : Showed gingivitis, mild periodontitis and moderate periodontitis in 50%, 23% and 27% of patients, respectively. (5)Gastric urease results: 87% of patients were positive. (6)All cultured samples results were negative.

Conclusion: The ability to detect H. pylori in dental plaque samples offers a potential for a noninvasive test for gastric infection and would lend support for oral spread of H. pylori as the princi­pal mode of transmission. However, the presence of H. pylori in dental plaque and in the stomach (in gastritis patients) could permit not only a target for therapeutic procedures but also a monitor­ing tool for the efficacy of therapy.

Key Words: Helicobacter pylori, Dental Plaque, Gastritis, Saudi patients

INTRODUCTION

Helicobacter pylori (H. pylori), a microaerophilic gram negative spiral bacteria, first isolated from a human gastric biopsy specimen in 1983, is well adapted to life in the hostile acidic environment of the stomach.1 

                The association between H. pylori and the increased risk of duodenal ulceration and antral gastritis has been well established. Hence the importance of preventing reinfection by identifying the potential natural reservoirs of H. pylori.2 The reservoir of H. pylori and its mode of transmission are unclear, a fecal-oral, oral-oral, and in developing countries a water borne route of infection have been suggested.3,4   Studies on gastritis reinfection by H. pylori from an oral reservoir  has produced conflicting reports as both supragingival and subgingival dental plaque provide an optimal microaerophilic environment required for the survival of H. pylori.2,5

                H. pylori was identified in dental plaque in 1989. Some researchers have hypothesized that dental plaque might be the reservoir for H. pylori in those patients with associated gastritis and ulceration. As techniques have improved, this bacterium has been frequently isolated in dental plaque, with some reports showing 100% correspondence between H. pylori–containing dental plaque and patients with H. pylori–associated gastritis and oral ulceration.6

                Various methods have been used to detect H. pylori in dental plaque, suggesting that dental plaque may be responsible for the transmission of the bacteria and possibly serve as a source of reinfection after eradication treatment. H. pylori has also been isolated from saliva and denture fitting surfaces.3

The aims of this study

(1) To study the association between presence of H. pylori in dental plaque, and its presence in the stomach of the patient group. (2) To know the effect of oral hygiene on the presence of H. pylori in dental plaque and stomach. (3) To determine the correlation between presence of H. pylori in dental plaque and periodontal condition.

PATIENTS AND METHODS PATIENTS

1.Patient group

Seventy-five Saudi adult patients of both gender attended the gastrointestinal (GI) clinic complaining  of dyspepsia. They were referred  to Dental clinics in Dammam Central Hospital  where a complete medical and dental history on oral hygiene was taken including the number of times the teeth are brushed, flossed, the use of miswak (chewing sticks derived from Salvadora Persica). No antibiotics were taken nor was or mouth wash  used for at least one month before the study. Clinical oral examination including periodontal charting, dental plaque index, gingival index and CPITN index were determined.

2.Control cases

Sixty apparently healthy adult persons were taken as controls. They followed the same methodology as the patients.

METHODS

1.Dental plaque samples

Two samples of dental plaque were taken from gingival crevice at deepest pocket reading and removed from the clinical site using a sterile universal curette. The tip of the curette was inserted into the depths of crevice/pocket, moved coronally while in contact with the tooth surface, to remove both sub and supragingival plaque . (a) The first dental plaque sample from each patient was immediately placed in a vial of Christensen’s urea agar containing 2% urea, kept at room temperature and transported to a microbiology laboratory. The tubes were incubated at 37°C for H. pylori detection by the commercially available rapid urease test, CP-Test (Brocades pharma spa Milano-Italia).   H. pylori produces large amounts of urease enzyme, which breaks urea into bicarbonate and ammonia. These substances are strong bases. This reaction is important for the diagnosis of H. pylori . When the urease enzyme of H. pylori is present in an inserted tissue or bacteria culture sample, the degradation of urea causes the pH rise,  and the color of reagent vial turn from yellow to red or red-violet. The speed of color change depends on the amount of enzyme or density of germs in the specimen. In most cases the color change occurring between 30 to a maximum of 60 minutes (as recommended by the manufacturer), was considered positive. This test has a sensitivity of 94% and specificity of 100%.10 To confirm this, when pure proteus (urease producing organism) culture was injected, there was no change in color for up to 24 hours (no further observation was made). (b) The second dental plaque sample from each patient was cultured, by being directly introduced into a sterile tube containing 5% sheep blood agar , chocolate agar and a selective medium, and transported to the microbiology laboratory to be incubated microaerophically at temperature of 37°C for seven days. The plates were examined for characteristic growth, identified as H. pylori by colony morphology, Gram stain and motility.

2.Gastric biopsy

All the patients underwent upper gastro-intestinal endoscopy and were found to have gastritis. At least two biopsies were taken from antrum and the body of the stomach. Each patient’s biopsies were inoculated into a vial of Christensen’s urea agar containing 2% urea , kept at room temperature and transported to the microbiology laboratory for rapid urease test as was done with the dental plaque samples.

INDICES USED IN THIS STUDY

1.Dental plaque index (PI)

Dental PI was scored according to Silness and Loe7 where: 0=no plaque in the gingival area; 1=a film of plaque adhering to the free gingival margin and adjacent area of the tooth (plaque may only be recognized by running a probe across the tooth surface); 2=moderate accumulation of soft deposits within the gingival pocket, on the gingival margin and/or adjacent tooth surface, which can be seen with the naked eye; 3=abundance of soft matter within the gingival pocket and/or on the gingival margin and adjacent tooth surface.

                To make statistical analysis applicable, we considered the following: Plaque score 0.1-1.0=mild, 1.1-2.0=moderate and 2.1-3.0=severe.

2.The gingival index 

The gingival index was scored according to Löe and Silness8 where: 0:  normal gingival; 1= mild inflammation, slight change in color, slight edema and glazing, and bleeding on probing; 2=moderate inflammation, redness, edema and glazing, and bleeding on probing; 3=severe inflammation, marked redness and edema, ulceration, and tendency for spontaneous bleeding.

                Gingivial score from 0.1-1.0 was considered mild, 1.1-2.0 as moderate and 2.1-3.0 as severe.

3.Community periodontal index of treatment needs (CPITN)9

Community periodontal index of treatment need were scored as follows: 0=healthy periodontium; 1=bleeding observed, directly or by using mouth mirror, after sensing; 2=calculus felt during probing, but the entire black area of the probe is visible; 3=pocket 4 or 5 mm (gingival margin is situated on black area of probe); 4=pocket ³6 mm (black area of probe not visible).

                These data of CPITN were used to compute a single periodontal status index value for each subject and was scored: I=gingivitis, for subjects with at least one CPITN sextant recording of (score 1 or 2); II=mild periodontitis for subjects with at least one CPITN sextant recording of (score 3); III=moderate periodontitis for subjects with at least one CPITN sextant recording of (score 4).

STATISTICAL ANALYSIS

The data were analyzed using SPSSfor Windows (Release 8.0)   statistical software. Chi-squared test was used, a significance levelwas set at a p-value of 0.05 to find statistical association:  between plaque urease and gastric urease, and between each of dental plaque urease and gastric urease and each of oral hygiene parameters, dental plaque index, gingival and periodontal indices.

RESULTS

Patient group consisted of 75 Saudi gastritis patients, 33(44%) of whom were males and 42(56%) females, aged between 21-76 years old, with a mean age of 37.23 years. Control group consisted of 60 normal adult Saudis, 30 (50%) of whom were males, and 30 (50%) females, aged 21-65 years old, with mean age of 36.37 years old. Results of all cultured samples were negative.

Table 1: Oral hygiene in patients and controls

Frequency

Brushing

No. (%)

Flossing

No. (%)

Using Miswak

No. (%)

No oral hygiene:

Patients

25 (33.3)

40 (53.3)

41 (54.7)

Controls

7 (11.7)

28 (46.7)

27 (45.0)

Once daily:

Patients

16 (21.3)

28 (37.3)

10 (13.3)

Controls

16 (26.7)

12 (20.0)

9 (15.0)

Twice daily:

Patients

23 (30.7)

7 (9.3)

  8 (10.7)

Controls

18 (30.0)

16 (26.7)

13 (21.7)

Thrice daily:

Patients

11 (14.7)

0

16 (21.3)

Controls

19 (31.7)

4 (6.6)

  8 (13.3)

Five times daily:

Patients

0

0

0

Controls

0

0

3 (5.0)

Table 2: Periodontal indices in patients and controls

Indices

Mild

No. (%)

Moderate

No. (%)

Severe

No. (%)

Mean

Standard Error

Plaque index:

Patients

18 (24.0)

31 (41.3)

26 (34.7)

2.11

8.8

Controls

20 (33.3)

25 (41.7)

15 (25.0)

1.92

9.8

Gingival index:

Patients

13 (17.3)

36 (48.0)

26 (34.7)

2.17

8.1

Controls

17 (28.3)

28 (46.7)

15 (25.0)

1.97

9.5

CPITN index:

Patients

38 (50.6)

17 (22.7)

20 (26.7)

1.76

9.8

Controls

22 (36.6)

22 (36.7)

16 (26.7)

1.90

0.1

1.Oral hygiene findings (Table 1):

a.Brushing of teeth: Twenty-five patients (33.3%) of the patient group did not use the tooth brush, while 50 patients (66.7%) did. Seven of the controls (11.7%) did not brush their teeth, while 53 (88.3%) did brush their teeth.

b.Flossing of teeth: While 40 patients (53.3%) did not floss their teeth, 35 (46.7%) flossed their teeth regularly. Twenty-eight of the controls (46.7%) did not floss their teeth, but 32(53.3%) flossed their teeth regularly.

c. Use of miswak: In the patient group, 41 (54.7%) did not use Miswak, while 34 (45.3%) did. In the control group, 27 (45.0%) persons did not use Miswak, while 33 (55.0%) did.

2.Findings of periodontal indices

                                (Table 2)

a.Dental plaque Index: In the patients, mild dental plaque accumulation was detected in 18(24%), moderate in 31 (41.3%), while severe accumulation was in 26(34.7%). On the other hand, in the controls, mild dental plaque accumulation was detected in 20(33.3%), moderate in 25(41.7%), while severe accumulation was in 15(25.0%) persons.

b.Gingival Index: In the patient group, mild gingivitis, in the form of mild inflammation, slight change in color, slight edema and glazing, and bleeding on probing was seen in 13(17.3%) patients. Moderate gingivitis manifested as moderate inflammation, redness, edema and glazing, and bleeding on probing in 36(48.0%) patients, and severe gingivitis seen as severe inflammation, marked redness and edema, ulceration, and tendency for spontaneous bleeding  in 26(34.7%) patients. In the controls, mild gingivitis was seen in 17(28.3%), moderate gingivitis in 28(46.7%), and severe gingivitis in 15(25.0%) patients.

c. Community periodontal index of treatment needs (CPITN): When calculus was probed in the patients, gingivitis was seen in 38(50.6%), while mild periodontitis Pocket 4 or 5 mm (gingival margin is situated on black area of probe) was found in 17(22.7%) patients and moderate periodontitis pocket 6 mm (black area of probe not visible)  in 20(26.7%) patients. In the control cases when calculus was probed, gingivitis was seen in 22(36.6%) while mild periodontitis in 22(36.7%) and moderate periodontitis in 16(26.7%) patients.

3.Statistical analysis results (Table 3)

Highly significant association resulted statistically for Plaque Urease / Gastric urease (chi-squared = 42.629), which correspond to (P<0.0001). No statistically significant association was seen between each of plaque urease, and gastric urease, and each of oral hygiene parameters (use of tooth brush, dental floss silk or miswak), or dental plaque, gingival and periodontal indices used in this study.

Table 3: Statistical results

Variables

X2 test

p-value

Plaque urease/gastric urease

35.747

<0.0001

Plaque urease/plaque index

0.175

NS

Plaque urease/Gingival index

3.232

NS

Plaque urease/CPITN

1.83

NS

Gastric urease/plaque index

0.001

NS

Gastric urease/gingival index

1.736

NS

Gastric urease/CPITN

0.312

NS

NS=Not significant

4.Plaque urease

Plaque urease test results showed that 67 patients (89%) were positive, and 8 (11%) negative, and for the controls, 52 cases (87%) were positive, while 8 (13%) were negative.

5.Gastric urease

Gastric urease results showed that 65 patients (87%) were positive, and 10(13%) were negative.

DISCUSSION

In 1904, Robson and Moynihan suggested that oral sepsis may play a role in the pathogenesis of gastric ulcers.11 Recently, attention has been focused on the importance of dental plaque in harboring H. pylori, and in having a role in the epidemiology of H. pylori infection. However, published works in this field give conflicting results on the incidence of H. pylori in dental plaque and its significance.3

                The results of this current limited study have shown that there was a high significant association between dental plaque urease and gastric urease. Thus, it can be suggested that dental plaque may play a role in the development of gastric H. pylori infection. This is supported by other studies in which rapid urease test for the detection of H. pylori was used. A study done by Gill et al showed that H. pyloriwas detected in the dental plaque of 82% (18/22) Indian children and 88% (15/17) of their adult family members and concluded that their observations indicate that H. pylori is present in the dental plaque of a majority of children and their family members.12 Song et al, using rapid urease test for the detection of H. pylori in dental plaque, showed that H. pylori was present in most of the patients' dental plaque.13

                In other studies using Polymerase chain reaction (PCR) for the detection of H. pylori, Kim et al detected H. pylori in dental plaque in 6.9% of the cases and declared that this rate might have been an underestimation due to the low sensitivity of the PCR method. However, the results that H. pylori was found in dental plaque and saliva, suggest that the oral cavity can be a reservoir of H. pylori.14 Also, in another study done by Oshowo et al, 7% of the patients tested were positive for H. pylori by PCR in dental plaque. They concluded that the detection of H. pyloriin dental plaque could indicate that the oral cavity may act as a reservoir for the organism. Whether H. pylori is a resident or transient oral microorganism is still unclear, although it is more likely to be transient in nature.15

                Mapstone et al16 used a nested?PCR test to detect the 16S ribosomal RNA gene of H. pylori in saliva, dental plaque, gas­tric juice, and gastric biopsy specimens from 13 his­tologically confirmed, H. pylori gastritis patients. Twelve of these patients had PCR?positive gastric as­pirates, and 5(38.5%) had PCR?positive oral speci­mens. Shimada et a117 also reported the presence of H. pylori in the oral cavity of 27 of 100 patients tested. These studies in aggregate suggest that H. pylori is present in dental plaque implicating the oral cavity as an important reservoir for H. py­lori.

                Khandaker et a110 used the ribotyping fingerprinting approach to show that paired strains from the mouth and antrum of their ulcer patients were identical. They hypothesized that dental plaque may be a reservoir for gastric reinfection by H. pylori. However, other studies have showed contradictory results. Von Recklinghausen et al, investigating H. pylori in dental plaque, were unable to cultivate H. pylori from any of the 100 dental plaque specimens from 55 dental surgery patients. Plaque material from 12 patients with moderate and severe gingivitis showed urease activity. These results contradict the hypothesis that dental plaque is a relevant reservoir of viable H. pylori cells, and that non-cultivable forms of H. pylori may survive in dental plaque.18 Cammarota et al found in a study done by PCR that H. pylori had a low prevalence (3.2%) in dental plaque, with no significant relationship between gastric mucosa and dental plaque colonization.19

                In a study done by Sahin et al to detect the presence of H. pylori in the dental plaque of 50 dyspeptic Turkish patients by polymerase chain reaction (PCR) none of the dental plaque samples, even in the 23 patients whose gastric biopsy specimens were positive proved positive. They concluded that there was no correlation between dental presentation of the microorganism and H. pylori gastritis.20

                The different results in the detection of H. pylori in dental plaque by PCR may be due to the low sensitivity of the PCR method used.14 The reduced sensitivity of detection in clinical biopsy and dental plaque sam­ples could reflect the low number of organisms in the specimens, problems in isolating DNA, or the pres­ence of inhibitors to the PCR reactions. False positive results can also be due to the contamination of specimens by PCR product. This can be a real problem since the disinfection of equipment will not render the bacterial DNA refractory to amplification with PCR.21 Hence, inorder to improve the quality of DNA templates, the use of different DNA extraction and the purification methods may be needed to enhance the sensitivity of the assay without compromising the specificity and vice versa.2 In a comparison with PCR, rapid urease test has a sensitivity of 94% and specificity of 100%.10

                In another study by Savoldi et al on 80 patients undergoing gastroscopy, an indirect immunoperoxidase test was done, employing a mixture of two monoclonal antibodies against H. pylori. No immunostained bacteria were shown in any of the examined dental plaque samples. It was concluded that H. pyloriwas not usually present in dental plaque, indicating that oral-oral transmission of the infection could be due to intermittent esophageal reflux only.22

                The result of the present study showing that H. pyloriwas not isolated by culture from any of the dental plaque samples, is in agreement with other studies.2,3,23

                Kamat et al, evaluated Dental plaque obtained from 156 patients and 92 healthy volunteers for the presence of H. pylori using rapid urease test. He found that  H. pyloriwas not isolated by culture from any dental plaque.23  Another study done by Cheng et al., showed that dental plaque from all dentate participants was negative for H. pylori culture, and concluded that dental plaque could not be implicated as the major reservoir of H. pylorifor gastric reinfection.2 Also, in a study done by Hardoet al, on sixty two patients for the presence of H. pyloriin plaque, all of the cultures of dental plaque were negative.3

                Although cultures are generally considered the gold standard for the detection of H. pylori in clinical samples, they prove to be efficient when biopsy samples from the stomach are used, the current media may be unsatisfactory when specimens harboring abundant flora, such as from the mouth and stools, or when environmental speci­mens are tested. Poor sensitivity of the culture meth­ods to date probably reflects the low number of organisms or the loss of viability during processing of dental specimens. Theoretically, interference by com­mensal microorganisms in the mouth may also play a role either by inhibiting growth in culture media or by inducing transformation of the rod?shaped H. pylori to coccoid forms.24

                The results of this study are in agreement with Hardo et al3 and Nguyen et al25 that there was no association of H. pylori in dental plaque with either dental hygiene or periodontal disease. However, Peach et al concluded that positive H. pylori status was significantly associated with increasing number of tooth surfaces with a high plaque score.26 Also, Avcu et alin a study done in Australian patients with vitamin B12-deficiency anemia, found that H. pylori positivity in dental plaque was correlated with oral hygiene indices scores.27 The same result was established in another study done by Von Recklinghausen et al.18

                Dental plaque has been implicated as a possible source of H. pylori in studies that used culture, biochemical, nucleic acid, and immunologic analyses. Variation in the sensitivities of detection by these different reported assays may reflect the methods used, technical difficulties, microbiota complexes, geographic distribution, and host response.21

CONCLUSIONS

(1) There is a correlation between the presence of H. pylori in dental plaque and the stomach as shown by plaque and gastric urease test. Failure to eliminate H. pylori from the mouth could then lead to recoloniza­tion of the stomach. (2) The ability to detect H. pylori in the dental samples offers the potential for a noninvasive test for infection and would lend support for the oral spread as the princi­pal mode of transmission. (3) Presence of H. pylori in dental plaque and in the stomach (in gastritis patients) could permit a target for therapeutic procedures as well as a monitor­ing tool for efficacy of therapy. (4) No significant association was found between plaque urease and gastric urease tests and oral hygiene parameters or the extent of periodontal destruction.

ACKNOWLEDGMENT

The authors are grateful to Dr. Ali Q. Al-Qahtani, Consultant Gastroenterologist, Dammam Central Hospital, Dammam, Saudi Arabia and Dr. Ahmad A. Bahnassy, Associate Professor, Department of Family and Community Medicine, College of Medicine, King Faisal University, Dammam, Saudi Arabia for their assistance and advice during preparation of this study.

REFERENCES

1.     Anne?Marie H, Nguyen A, Fouad A, El?Zaatari K, Graham DY. Helicobacter pylori in the oral cavity. A critical review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;76:705?9.

2.     Cheng LH, Webberley M, Evans M, Hanson N, Brown R. Helicobacter pylori in dental plaque and gastric mucosa. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:421-3.

3.     Hardo PG, Tugnait A, Hassan F, et al. Helicobacter pylori infection and dental care. Gut 1995;37:44-6.

4.     Song Q, Lange T, Spahr A, Adler G, Bode G. Characteristic distribution pattern of Helicobacter pylori in dental plaque and saliva detected with nested PCR. J Med Microbiol 2000; 49:349-53.

5.     Young KA, Allaker RP, Hardie JM. Morphological analysis of Helicobacter pylori from gastric biopsies and dental plaque by scanning electron microscopy. Oral Microbiol Immunol 2001;16:178-81.

6.     Majmudar P, Shah SM, Dhunjibhoy KR, Desai HG. Isolation of Helicobacter pylori from dental plaques in healthy volunteers. Indian J Gastroenterol 1990;9:271-2.

7.     Silness P, Löe H. Periodontal disease in pregnancy. Acta Odontol Scand 1964;22:121.

8.     Löe H, Silness J.  Periodontal disease in pregnancy. Acta Odontol Scand 1963;21:533.

9.     Ainamo J, Barnes D, Beagrie G, Cutress T, Martin J, SardoInfirri J. Development of the World Health Organization (WHO) Community periodontal index of treatment needs (CPITN). Int Dent J 1982;32:281-91.

10.   Khandekar K, Palmer KR, Eastwood MA, et al. DNA fingerprints of Helicobacter pylori from mouth and antrum of patients with chronic ulcer dyspepsia (letter).  Lancet 1993;342:751.

11.   Mayo-Robson AW, Moynihan BGA. Diseases of the stomach and their surgical treatment. 2nd ed. London: Bailliere, Tindall and Cox; 1904.

12.   Gill HH, Shankaran K, Desai HG. Helicobacter pylori in dental plaque of children and their family members. J Assoc Physicians India1994; 42:719-21.

13.   Song QS, Zheng ZT, Yu H. Helicobacter pylori in the dental plaque. J Chung Hua Nei Ko Tsa Chih 1994;33:459-61.

14.   Kim N, Lim SH, Lee KH, et al. Helicobacter pylori in dental plaque and saliva. Korean J Intern Med 2000;15:187-94.

15.   Oshowo A, Gillam D, Botha A, et al. Helicbacter pylori: The mouth, stomach, and gut axis. Ann Periodontol 1998;3:276-80.

16.   Mapstone NP, Lynch DAF, Lewis AF, et al. Identification of Helicobacter pylori DNA in the mouth and stomachs of patients with gastritis using PCR. J Clin Pathol 1993;46:540?3.

17.   Shimada T, Ogura K, Ota S, et al. Detection of Helicobacter pylori in gastric biopsies, gastric juice, saliva and feces by polymerase chain reaction. Gastroenterology 1994;106:178.

18.   Von RG, Weischer T, Ansorg RM.No cultural detection of Helicobacter pylori in dental plaque. Zentralbl Bakteriol 1994;281:102-6.

19.   Cammarota G, Tursi A, Montalto M, et al. Role of dental plaque in the transmission of Helicobacter pylori infection. J Clin Gastroenterol 1996;22:174-7.

20.   Sahin FI, Tinaz AC, Simsek IS. Detection of Helicobacter pylori in dental plaque and gastric biopsy samples of Turkish patients by PCR-RFLP. Acta Gastroenterol Belg 2001;64:150-2.

21.   Clyton CL, Kleanthous H, Coates PJ, Morgan DD, Tabaqchali S. Sensitive detection of Helicobacter pylori by using polymerase chain reaction. J Clin Microbiol 1992;30:192-200

22.   Savoldi E, Marinone MG, Negrini R, et al. Absence of Helicobacter pylori in dental plaque determined by immunoperoxidase. Helicobacter 1998;3:283-7.

23.   Kamat AH, Mehta PR, Natu AA, et al. Dental plaque: an unlikely reservoir of Helicobacter pylori.  Indian J Gastroenterol 1998;17:138-40.

24.   Jones D, Curry A. The genesis of coccal forms of Helicobacter pylori in Helicobacter pylori? gastritis and peptic ulcer. In: Malfertheiner P, Ditschuneit H, editors. Helicobacter pylori, gas­tritis and peptic ulcer. Berlin: Springer?Verlag; 1990:29?37.

25.   Nguyen AM, Engstrand L, Genta R, Graham DY, El?Zaatari FAK. Detection of Helicobacter pylori in dental plaque by re­verse transcription? polymerase chain reaction: J Clin Micro­biol 1993;31:783?7.

26.   Peach HG, Pearce DC, Farish SJ. Helicobacter pylori infection in an Australian regional city: prevalence and risk factors. Med J Aust 1997;167:310-3.

27.   Avcu N, Avcu F, Beyan C, et al. The relationship between gastric-oral Helicobacter pylori and oral hygiene in patients with vitamin B12-deficiency anemia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:166-9.


-0001-11-30

A STREPTOCOCCAL BACTERIA


A STUDY OF GROUP A STREPTOCOCCAL BACTERIA ISOLAT ION FROM CHILDREN LESS THAN 12 YEARS WITH ACUTE TONSILLITIS, PHARYNGITIS AND HEALTHY PRIMARY SCHOOL CHILDREN

Abdulwahab M.A. Telmesani, FRCPC, FAAP, Hani O. Ghazi, PhD

Faculty of Medicine and Medical Science, Umm Al-Qura University, Makkah,      Saudi Arabia

هدف الدراسة: تمت هذه الدراسة لتقييم مدى انتشار المكورات العقدية المجموعة (A)في مسحة البلعوم بين الأطفال المصابين بالتهاب اللوز أو التهاب البلعوم والأطفال الأصحاء  بنفس العمر.

طريقة الدراسة:كانت هذه دراسة مستقبلية حيث تم أخذ مسحة البلعوم من 73 طفلاً في عمر بين     1-12 سنة مصابين بالتهاب لوز والتهاب بلعوم (ألم بالبلعوم مع ارتفاع بدرجة الحرارةأعلى من 38،5 درجة) قاموا بزيارة عيادة الأطفال من تاريخ ديسمبر 1999م إلى أبريل 2000م وفي نفس هذه الفترة تم أخذ مسحة بلعوم من 465 طفل سليم من طلاب المدرسة الإبتدائية في عمر  بين 6-12 سنة وتم اختبار حساسية المكورات العقدية المجموعة (A)المعزولة عن المرضى للبنسلين ، الإيثيروميسين ، السيفاكلور.

نتائج الدراسة: في الأطفال المصابين بالتهاب اللوز والتهاب البلعوم كانت المكورات العقدية المجموعة (A)موجودة بين 29 حالة/ 73 حالة (40%). وفي أطفال المدرسة الأصحاء كانت المكورات العقدية للمجموعة (A)موجودة بين 15 حالة/ 465 حالة (3%) وكانت حساسية المكورات العقدية مجموعة (A)في الأطفال المرضى للبنسلين 14 حالة (48%) و إرثيروميسين 27  حالة (93%) وسفاكلور 28 حالة (96%).

الخلاصة: بالرغم من انتشار المكورات العقدية مجموعة (A)في الأطفال الأصحاء كان مشابهاً للدراسات العالمية إلا إنه كانت نسبتها عالية في الأطفال المصابين بالتهاب اللوز والتهاب البلعوم وكانت حساسيتها للبنسلين أقل من 50 % وأكثر من 90 %  بالنسبة للإثيروميسين والسيفاكلور ولذلك نوصي باجراء مسحة البلعوم روتينياً لكل الأطفال المصابين بالتهاب البلعوم أو التهاب اللوز ومعالجة الحاملين للمكورات العقدية مجموعة (A)بشكل مناسب منعاً لحدوث مضاعفات لاحقة.

 

الكلمات المرجعية:المكورات العقدية المجموعة (A)، التهاب اللوزتين والبلعوم، أطفال المدارس المملكة العربية السعودية.

Aim: This study was carried out to assess the prevalence of Group A Streptococcal (GAS) bacteria  in the throat specimens of children with tonsillitis and pharyngitis compared to healthy children of the same age group.

Methodology: The study was a prospective one. Throat swabs were obtained from 73 children aged 1-12 years diagnosed with acute tonsillitis and pharyngitis (sore throat and pyrexia 38.5oC) visiting a pediatric outpatient clinic between December, 1999  and  April, 2000. In the  same period  throat  swabs were  obtained  from  465

Correspondence to:

Dr. Abdulwahab MA Telmesani, Associate Professor of Pediatrics, College of Medicine, Umm Al- Qura University, P.O. Box 13069, Makkah, Saudi Arabia

healthy primary school children aged 6-12 years. GAS from patients was tested for sentivity to penicillin, erythromycin, and cefaclor.

Results: In children with tonsillitis and pharyngitis GAS was found in 29 out of 73 (40%) . In healthy school children GAS was found in 15 out of 465 (3%).In the patients group GAS was sensitive to penicillin in 14(48%), erythromycin in 27(93%), and cefaclor in 28(96%)

Conclusion: Although the prevalence of GAS among healthy children was similar to international studies, the GAS infection was high among children with acute tonsillitis and pharyngitis. Sensitivity to penicillin was less than 50% and more than 90% for erythromycin and  cefaclor. We recommend routine throat swab for children with acute tonsillitis and pharyngitis and the proper treatment of GAS positive patients to prevent further complications.

Key Words: Group A streptococcus, tonsillitis, pharyngitis, antibiotic sensitivity, healthy, school children, Saudi Arabia.

INTRODUCTION

Acute tonsillitis and pharyngitis are the most common clinical illnesses produced by group A streptococcus (GAS) bacteria. Untreated patients may develop purulent complications, including otitis media, sinusitis, peritonsillar and retropharyngeal abscesses, and cervical adenitis. The significance of streptococcal respiratory tract infection is related particularly to its acute morbidity and nonsuppurative sequelae, ie, acute rheumatic fever and acute glomerulonephritis.1 Acute rheumatic fever continues to be a health problem. Reappearance of acute rheumtaic fever in several areas serves as a reminder of the importance of continued attention to its prevention in the developed and developing countries.2 Rheumatic fever in Saudi Arabia occurs in young children and in a form more severe than in the western world.3 Group A steptococcal infection constitutes 20% to 40% of the causes of tonsillitis and pharyngitis in children.3,4 Transmission rate of GAS is approximately 35% within a family or school if the patient is untreated.5  The carrier rate of GAS is different in the developed and developing countries. Pichichero et al reported a carrier rate of 2.4% among healthy children in the United States.6 A rate of 13% was reported from India7 and  21% in Iran.8 In the gulf region, Dawson et al reported a carrier rate of 11.3% in the children in United Arab Emirates.9 There is not much literature from Saudi Arabia on the GAS carrier rate or infection. This paper serves as a pilot study of the rate of GAS infection and carrier rate among children less than 12 years old from the same neighbourhood in the city of  Makkah, Saudi Arabia.

METHODOLOGY

Throat swabs were obtained from 73 children visiting a pediatric outpatient clinic complaining of sore throat and fever of more than 38.5oC and diagnosed as tonsillitis and pharyngitis. The age range of the children was 1 to 12 years (mean age of 7 years). Similarly, swabs were obtained from 465 primary school children whose ages ranged from 6to 12 years (mean age of 9 years) who lived in the neighborhood of the clinic. The pediatrician and the nurse of the clinic took the swabs of the children attending the clinic. The swabs were put in transport media and sent immediately to the laboratory. A team of specialists and residents from the Departments of Pediatrics and Microbiology at Umm Al-Qura University-Makkah took the throat swabs from the school children. They were put in transport media, plotted and cultured immediately. The organisms were isolated and identified according to standard laboratory methods.10 The GAS cultured from patients with tonsillitis and pharyngitis was tested for sensitivity to penicillin G, erythromycin, and cefaclor.

RESULTS

Group A streptococcus bacteria was positive in 29 patients (40%) of children with tonsillitis and pharyngitis. The cultures were positive for GAS in 15 carriers (3%) out of 465 healthy school children (Table 1). GAS in the 29 children with tonsillitis and pharyngitis was sensitive to penicillin G in 14(48%), erythromycin 27(93%), and to cefaclor in 28(96%) (Table 2).

Table 1:Prevalence of GAS among children with tonsillitis, pharyngitis and healthy children.

Variable

No. of GAS positives (%)

Children with tonsillitis and pharyngitis (n=73)

29 (40)

Healthy primary school children (n=465)

      15 (3)

Table 2:GAS sensitivity to antibiotics in patients with tonsillitis and pharyngitis.

Antibiotics

Sensitivity (%)

Penicillin G

14 (48)

Erythromycin

27 (93)

Cefaclor

28 (96)

DISCUSSION

This study shows a low carrier rate of GAS in healthy Saudi children compared to studies from some developing and neighboring countries. However, the occurrence of GAS among children with tonsillitis and pharyngitis is 40%. Al-Mazrou from Saudi Arabia reported an increase in the severity and invasiveness of GAS infection.11 Resurgence of acute rheumatic fever has been reported from different parts of the world.12 The risk of invasive GAS infection in one study was estimated as 225 times higher in household contact of cases than in the general population.13 The high rate of GAS infection found in our study raises concern, specially in view of the lack of data of GAS infection and carrier rate in Saudi Arabia. A large study across the Kingdom showed a high prevalence of rheumatic fever of 0.3 per 1000 and the prevalence of chronic rheumatic heart disease of 2.8 per 1000, giving an overall rate of 3.1 per 1000 school children 6-15 years old.14 The problem is compounded by insufficient data on the sensitivity of GAS to penicillin in Saudi Arabia. Al-Ghamdi et al reported 5.6% resistance of GAS to penicillin in eastern Saudi Arabia.15 However, resistance to Penicillin has been reported as being as high as 20% while cefuroxime, clarithromycin, and azithromycin are said to provide a better response.16-18

                Resistance of more than 50% in our study is a cause for alarm. We recommend routine throat swabs for children with tonsillitis, pharyngitis and high fever and appropriate treatment of GAS positive cases. There is a need for a large-scale study in Saudi Arabiato assess the carrier rate of GAS, its sensitivity to penicillin G, and the magnitude of nonsuppurative sequelae of GAS infection.

ACKNOWLEDGMENT

We would like to extend our sincere thanks  to Dr. Nassim Khan and the team of residents for their assistance in collecting the samples of the school children.

REFERENCES

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