ATTITUDES OF SAUDI MEDIA


ATTITUDES OF SAUDI MEDIA TOWARDS WORLD HEALTH EVENTS

Mohammed A. Al-Zahrani, PhD*, Abdulaziz M. Al-Hudaithy, BPH†,

Hany H. Ziady, MD†

Departments of *Preventive Health and †Health Education, Ministry of Health, Riyadh, Saudi Arabia

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هدف الدراسة: تعتبر وسائل الإعلام ذات أهمية كبيرة في برامج التوعية الصحية، حيث تعتمد عليها الحملات الصحية و تعتبرها جزءا هاما في وسائلها. وكان الهدف من هذا العمل هو دراسة نمط مشاركة الصحف السعودية اليومية في مناسبتين صحيتين عالميتين  في عام1416 هـ (يوم الإيدز العالمي 1995 – يوم الصحة العالمية 1996).

طريقة الدراسة: أجريت هذه الدراسة الخلفية من خلال مراجعة ثماني صحف سعودية يومية وقد شملت الدراسة كافة النسخ الصادرة في الفترة من ثلاثة أشهر قبل إلى ثلاثة أسابيع بعد كل من المناسبتين ، وتم تحديد كل المواد الصحفية التي نشرت عن المناسبتين والحصول منها على بيانات عن نوعيتها ومواضيعها وخواصها.

نتائج الدراسة: أوضحت الدراسة أن مشاركة الصحف كانت أكبر في يوم الإيدز العالمي عنها في يوم الصحة العالمي، مما يعنى اعتبار العاملين بالصحافة أن الإيدز أكثر جاذبية للقراء عن الموضوع البيئي الخاص بيوم الصحة العالمي، وكانت معظم المواد منشورة في الصفحات الداخلية للصحف وخاصة في يوم الصحة العالمي، وهذه النتائج تتفق مع عمل سابق أوضح قلة اهتمام الصحافة السعودية بالموضوعات البيئية. وكان حوالي ثلثي المواد عن أنشطة الوزارة والجهات الأخرى وأخذت هذه المواد شكل الأخبار الصحفية بينما كانت مواد التثقيف الصحي ومشاركات القراء محدودة.

الاستنتاجات: وقد تم استنتاج أن هناك بصفة عامة عدم اهتمام من الصحف بالمواضيع الصحية وخاصة التثقيف الصحي.

الكلمات المرجعية: المناسبات الصحية – التوعية الصحية – الصحف – الإيدز – البيئة – المملكة العربية السعودية.

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Introduction: Mass media are very important in health education programmes. Health promoters rely on them to play a crucial role in their campaign.

Aim: The aim of the study was to study the patterns of contribution of the Saudi daily newspapers on two international health occasion during the year 1416H (World AIDS Day 1995 and World Health Day 1996).

Material and Methods: The study was retrospective, carried out by reviewing ei ght daily Saudi newspapers including all issues covering three months before and extending three weeks after each occasion. All newspaper materials concerning the two occasions were specified, and data obtained from them included types of materials, topics and characteristics of the paper.

Results: The study revealed that the newspapers gave more coverage to World AIDS Day  than  on  World  Health  Day. This meant that journalists considered that AIDS

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Correspondence to:

Dr. Mohammed A. Al-Zahrani, Dir. Gen. Preventive Health, P.O. Box 2903, Riyadh 11461, Saudi Arabia

was more interesting to the readers than the environmental topic of World Health Day. Most of the materials especially in World Health Day were published in the inner pages. These findings are in consonance with previous work, which showed that Saudi journalists had little interest in environmental issues. Nearly two thirds of the materials were news items about ministerial and activities of other organizations. Informative articles on health education and readers’ participation were minimal.

Conclusion: It was concluded that newspapers took not much interest on health matters especially health education.

Key Words: Health occasions, health education, newspapers, AIDS, environment, Saudi Arabia

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INTRODUCTION

One of the simplest definitions of health education, is that, it is that part of health care concerned with promoting healthy behavior.1 It depends on conveying information on health to target groups in a way that influences their behavior for the better, by inducing a change in their attitudes and practices for the achievement and maintenance of good health.1,2

    Methods used in health education vary a great deal according to circumstance. They each have their advantages and disadvantages. For the individual, counseling is the most appropriate; group health education is usually in the form of lectures, symposia, discussions, etc. Lastly, methods such as the use of the mass media are suitable for a large number of people. This utilizes the radio, television, newspapers, etc. They have the advantage of reaching a large number of people in a very short time.1,2

    The mass media can be of great help in the promotion of health, particularly in influencing public opinion. The media also bring recent developments and innovations in the health sciences to the attention of decision makers.1

    With the rapid technological advancement in communication, methods of health education have improved tremendously. A lot of interest has been generated in interactive methods. In some countries, clinics and hospitals are now beginning to provide health-oriented software and information systems on-line to patients at home and on-site in waiting room, hospital room and health education libraries.3-5 Educative video games are also used successfully in many communities. Thou gh technology is useful in many instances, there should be caution in adopting new gadgets promoted by commercial interests especially in developing countries.3-6

    However, the mass media, remain the most important channel of health education. Health promoters rely greatly, upon them, and consider them a crucial part of their campaign.7 The aim of this study was to study the contribution of the daily Saudi newspapers on two international health occasions during the year 1416H (World AIDS Day 1995 and World Health Day 1996).

MATERIAL AND METHODS

Reviewing ei ght daily Saudi newspapers namely, Al-Jazira, Al-Riyadh, Al-Madina, Al-Yom, Al-Nadwa, Al-Bilad, Okaz and Al-Shark Al-Awsat carried out this retrospective study. All issues of these daily newspapers covering a period of three months before and extending three weeks after each of the two occasions were included in the study.

    Any newspaper material concerning the two occasions was specified, cut and filed. The following data were obtained on each material using a special form designed by the authors: (1) Characteristics of material: Name of the newspaper, page on which material appeared (first, last or inside) and when the material was covered in relation to occasion (before, during or after).       (2) Topics covered: Scientific, inter-national events, activities, discoveries – research – statistics and analyses – opinions – book summaries (3) Type of material: News, article, reportage announ-cement and readers’ comments.

Data management and statistical methods:

After data on all materials were collected, they were revised and entered into an IBM compatible personal computer. After the revision of the data, frequency distributions were tabulated, and comparisons were made using X2 and Fisher Exact Test according to requirements.

    The 5% level was chosen to indicate statistical significance. EPI5 and SPSS/ PC+ software were used.8-10

RESULTS

1.  Size of coverage

As shown in Table 1, the total coverage of the two occasions amounted 139 newspaper materials, 89 (64%) of which were about World AIDS Day (WAD) and 50 (36%) about World Health Day (WHD). Jazira newspaper had the hi ghest percentage of materials (18.7%), followed by Okaz and Al-Yom (17.3% and 16.5% respectively). The least was by Al-Shark Al-Awsat (2.2.%).

    Jazira’s coverage of WHD was significantly greater than that of WAD (X2=9.08, p=0.003). However, Al-Yom published significantly more materials about WAD than WHD (X2=4.13, p=0.042). There was no statistical difference on the coverage of the two occasions by the other newspapers.

2.  Characteristics of the coverage

A.  Page of publishing

Table 2 shows that most materials were published on inner pages (81.3%), and fewer on the first or last pages (6.5% and 12.2% respectively). Significantly, more materials about WHD appeared on the inner pages than those on WAD (X2=3.89, p=0.049), and no statistical significance was found between the two occasions with regard to the first and last pages.

    Okaz was the newspaper that published the hi ghest number of materials on the first page, while Al-Bilad was the paper that published most materials on the last page (44.5% and 41.2% respectively).

B.  Time of publishing

The study showed that the newspaper campaign on WAD started 11 days before the day and continued 12 days after it, covering a period of 24 days. The campaign on WHD, however, covered a period of 51 days, starting 42 days before the day and ending 8 days after it.

    The time distribution of materials was almost similar on the two occasions for approximately one third of the material was published before, nearly one half during, and one fifth after each of the occasions. There was no statistical significance between the two occasions (Table 3) (N.B. the expression “during the occasion” was used for the special day, one day before and another after).

    Jazira published the hi ghest percentage of materials before and after the occasions (23.2% and 21.2% respectively), while Okaz had the hi ghest percentage during the two occasions (20.3%).


Table 1: Distribution of newspaper materials covering World AIDS Day and World Health Day according to newspapers and occasions

Newspaper

WAD

WHD

Total

Test of

N

%

N

%

N

%

Significance

Jazira

10

11.2

16

32.0

26

18.7

X2=9.08*; p=0.003

Riyadh

10

11.2

6

12.0

16

11.5

X2=0.02; p=0.892

Okaz

18

20.2

6

12.0

24

17.3

X2=1.52; p=0.218

Madina

7

  7.9

7

14.0

14

10.1

X2=1.33; p=0.249

Nadwa

6

  6.7

6

12.0

12

8.6

X2=1.12; p=0.289

Yom

19

21.4

4

8.0

23

16.5

X2=4.13*; p=0.042

Shark Awsat

3

3.4

0

0.0

3

2.2

†FET=0.553

Bilad

16

18.0

5

10.0

21

15.1

X2=1.59; p=0.208

Total

89

100.0

(64.0)‡

   50

100.0

(36.0)‡

139

100.0

(100)‡

*Statistically significant     †Fisher Exact Test   ‡Percentage calculated out of total of 139

Table 2: Distribution of newspaper materials covering WAD and WHD according to pages of publication and occasions

Page

WAD

WHD

Total

Test of

n

%

n

%

n

%

Significance

First

   7

   7.8

  2

4.0

  9

6.5

FET=0.489

Last

14

15.6

  3

6.0

17

12.2

X2=2.82; p=0.093

Internal

68

76.6

45

90.0

113

81.3

X2=3.89*; p=0.049

Total

89

100

50

100

139

100

Table 3: Distribution of newspaper materials covering WAD and WHD according to time of publishing and occasions

Time of

WAD

WHD

Total

X2 value

publication

n

%

n

%

n

%

Before

30

33.7

17

34.0

47

33.8

0.00 (p=0.972)

During

42

47.2

22

44.0

64

46.0

0.13 (p=0.717)

After

17

19.1

11

22.0

28

20.2

0.17 (p=0.683)

Total

89

100

50

100

139

100

Table 4: Distribution of newspaper materials covering WAD and WHD according to topics and occasions

Topics

WAD

WHD

Total

Test of

n

%

n

%

n

%

Significance

Scientific

15

16.9

  7

14.0

22

15.8

X2=0.20 (p=0.658)

Discoveries Research Statistics

17

19.1

  1

  2.0

18

12.9

X2=8.31* (p=0.004)

International events

5

5.6

  0

  0.0

5

  3.6

FET=0.159

Ministry+others activities

48

53.9

40

80.0

88

63.3

X2=9.37*, (p=0.002)

Analyses Opinions Books

4

4.5

  2

  4.0

  6

  4.4

FET=1.00

Total

89

100

50

100

139

100

Table 5: Distribution of newspaper materials covering World AIDS Day and World Health Day according to types of materials and occasions

Types

WAD

WHD

Total

Test of

n

%

n

%

n

%

Significance

News

49

55.1

33

66.0

82

59.0

X2=1.58 (p=0.208)

Articles

23

25.8

4

8.0

27

19.4

X2=6.51* (p=0.012)

Messages

0

0.0

3

6.0

3

2.2

FET=0.045*

Reportage

7

7.9

4

8.0

11

7.9

FET=1.00

Announcements

10

11.2

5

10.0

15

10.8

X2=0.05 (p=0.822)

Readers’ opinions

0

0.0

1

2.0

1

0.7

FET=0.360

Total

89

100

50

100

139

100


3.Topics of Newspaper materials

Most published materials, for both occasions (63.3%) concentrated on ministerial or the activities of other governmental organizations. This   was   more   obvious  on WHD, when the coverage constituted 80.0% of all materials published, a percentage that is significantly hi gher than that of WAD (53.9%) (Table 4) (X2=9.37, p=0.002). Jazira published the most on this topic, followed by both Okaz and Riyadh (17.1% and 15.9% respectively).

    Scientific materials constituted 15.8% of the number of materials published. There was no statistical difference between WAD and WHD (Table 4) in this regard. Again Jazira was the newspaper that led in the number of material published (36.4%), followed by Okaz (22.7%).

    Discoveries, research and statistics formed a small percentage of materials covered (12.9%). Those on AIDS published on WAD, were significantly more than those published on WHD (X2=8.31, p=0.004) (Table 4). Al-Yom was the newspaper that published the largest number of such materials (38.9%). International events formed a very small percentage (3.6%), distributed equally in five newspapers. They were totally absent on WHD. Similarly, analyses, comments and book reviews formed a minor percentage, and were present in three newspapers only. No statistical differences were found between WAD and WHD on these topics (Table 4).

4.Type of coverage

Table 5 shows that “news” was the most frequent type of materials published (about 60%). The two occasions had similar percentages (55.1% and 66.0%), with no statistical differences between them. There was not much difference among the newspapers except for Al-Shark Al-Awsat which published only one news item. Articles formed about one fifth of the materials published (19.4%). WAD articles were significantly hi gher than those of WHD (25.8% and 8.0% respectively, X2=6.51, p=0.012). Al-Bilad published the hi ghest number of these articles (22.2%). Announcements formed more than one tenth of the materials (10.8%) and the percentages on the two occasions were close to each other. There was little reportage, approximately 8.0% for both occasions. Okaz, which published more than a third (36.4%) of this, was the newspaper with the hi ghest coverage.

    There was no “messages” on WAD, but there were three on WHD forming a very small percentage (6.0%) of the total coverage. This difference was of statistical significance (Fisher Exact Test = 0.045). The three messages were found in Jazira. Finally, except for one sole comment in WHD published by Okaz, almost no readers’ comments were published on the two occasions.

DISCUSSION

World Health Organization has specified a number of health occasions to be celebrated by the whole world since these special occasions present good opportunities for health education in different communities.1 Perhaps the two occasions, which generate the greatest interest and attention in various countries, are World AIDS Day and World Health Day.

    World AIDS Day (WAD), was first celebrated in 1988, after the World Health Ministers’ Conference for Discussion of the AIDS Prevention Programme (January 1988). During that conference, the first of December of every year was designated the World Day for AIDS Control, simply known as World AIDS Day.11

    World Health Day (WHD), however, was first celebrated in 1950. The 7th of April, was the day of establishment of the World Health Organization in 1948.12

International health occasions are celebrated in various ways in different countries. In some countries, health education is carried out by means of competitions, symposia, and publication of posters etc. Other countries issue postage stamps or have mass media campaigns.13,14

    This study showed that generally speaking, newspapers gave little prominence to health subjects. This was obvious, since most of the materials concerned with the two occasions under study were found in the inner pages of the papers. However, there was more interest by the media in WAD than WHD. This was evidenced by the greater coverage and the significantly larger number of articles on WAD that were given greater prominence by being published on the front and back pages. This may be due to the difference in the nature of the two occasions. WAD has a different slogan every year, but the original topic of AIDS is the same. Consequently, its scientific materials and literature are available beforehand. The topic for the WHD, on the other hand, changes every year. This means that some effort must be made to obtain information on every new topic. The slogan for the day under study was “Healthy Cities for Better Life”. It is an important environmental topic, but journalists considered AIDS, a disease with no known cure or vaccine of more interest to readers. This agrees with the results of a previous study, which showed that Saudi newspapers and magazines exhibit little interest in environmental issues and thus do not participate much in raising public awareness on environmental issues.15-17

    In Saudi Arabia, however, statistics show that diseases, which depend on their transmission on environmental conditions, are of a hi gher priority than AIDS. Thus the newspapers/ media should give equal if not more attention and coverage to the environment than AIDS.18-20

    The period during which materials on WHD were published was longer than that of WAD (51 days and 24 days respectively), and most of the former (42 days) occurring before the occasion. This finding may be because, as stated earlier since there is a new topic for WHD every year, its slogan is specified few months prior to the date making it possible for newspapers to publish articles on the topic well before the due date. However, since the general subject of WAD doesn’t change, only its new slogan needs to be published close to the day. The distribution of the materials in terms of time was similar in both occasions; one third “before” to raise awareness, one half “during”, at the hei ght of the campaign, and one fifth “after” the event to report the events.                           Generally, newspapers allocated much space to the activities of ministries and other organizations on both occasions (63.3%).  This is similar to the distribution of the type of materials published in which news constituted nearly 60%. The news covered the activities that took place. Together with statements, by prominent personalities the sum total of these materials constituted 70%. Articles, reportage, messages and readers’ comments made up the remaining 30%. This meant that, in effect, actual health education would form a small fraction of this. Moreover, articles, which dealt mainly with health education, were largely absent.

    One may add that the distribution of material types in this study, is similar to a previous study on the coverage of environmental issues in a Saudi newspaper in which “news” constituted the main area covered (58.7%), followed by other issues in small percentages.17

    This lack of cooperation between the health sector and mass media is also evident in other countries. In some developing countries, the mass media hardly ever dealt with health education. In a series of discussion panels with mass media staff, the importance of health issues was emphasized resulting in the mobilization of the media to give prominence to health matters on these special occasions.21

    In Western countries, the mass media play a crucial role in health education. In a health education campaign for sports in Britain, which lasted several weeks, publications on the campaign in the 18 local newspapers covered 32 large pages. Radio and Television spent a total of five hours of broadcasting on the same issue. The mass media coverage was estimated to cost at a total of more than five million American dollars.22

CONCLUSION

From the results, it could be concluded that the interest of Saudi newspapers on health matters was low. They showed more interest in World AIDS Day than to World Health Day. However, most of the materials published on both occasions concentrated on activities of the ministry and other organizations. They were in the form of “news” and “announcements”. Thus, materials directed towards health education were few and readers’ comments were minimal, (less than 1%). In other words, there was hardly any participation in health occasions throu gh newspapers by the community.

RECOMMENDATIONS

It is recommended that Saudi newspapers should pay more attention to health topics. Also better rapport between the health sector and journalists should be established so that the help of the latter could be enlisted in giving priority to publish more health matters and health education. Finally, more newspaper space should be set aside for readers’ opinions on special health occasions.

REFERENCES

1.      World Health Organization. Education for Health-A manual on health education in primary health care. Alexandria: Eastern Mediterranean Regional office of WHO, 1989; 25, 216. (In Arabic)

2.     Park JE, Park K. Textbook of Preventive And Social Medicine. 12th edition. Jabalpur: Banarsidas Bhanot, 1989; 457.

3.     Lieberman DA. The Computer’s Potential Role In Health Education. Health Communication 1992; 4(3): 211-25.

4.     Gustafson DH, Bosworth K, Chewning B, Hawkins RP. Computer-based Health Promotion: Combining Technological Advances With Problem-Solving Techniques To Effect Successful Health Behavior Changes. Annual Review of Public Health 1987; 8: 387-415.

5.     Lieberman DA, Brown SJ. Designing Interactive Video Games For Children’s Health Education. In: Morgan K, Satava RM, Sieburg HB, Mattheus R, Christensen JP. Eds. Interactive Technology And the New Paradigm For Health Care. IOS Press and Ohmsha, 1995; 201-10.

6.     World Health Organization. New Approaches To Health Education In Primary Health Care. Geneva: World Health Organization, 1983; 7. (Tech. Report series 690).

7.     Gabr B. A Manual For Field Testing Of Mass Media And Materials In Health Education. Beirut: Faculty Of Health Sciences - American University in Beirut, 1987; 57. (In Arabic).

8.     Dowson - Saunders B, Trapp RG. Basic And Clinical Biostatistics. New - Jersey Prentice - Hall International Inc. 1990; 148-52.

9.     Dean AG. Epi Info version 5- a word-processing database, and statistics system for epidemiology on microcomputers. Geneva: The Programme On AIDS - WHO, 1990.

10.   Norusis MJ. SPSS/PC+ Program Manual. Chicago: SPSS Incorporation, 1986.

11.   Anonymous. What is World AIDS Day ? World AIDS Day Newsletter 1995; 2:2.

12.   Manuila A. editor. EMRO Partner In Health In The Eastern Mediterranean 1949-1989. Alexandria: APTC, 1991; 44

13.   Kamper - Jörgensen F. Postage Stamps with WHO Messages. World Health Forum 1992; 13(1): 20-2.

14.   Lamont G, Nani W. Christ With AIDS. AIDS/ STD Health Promotion Exchange 1996; 2: 6.

15.   Benenson AS ed. Control of Communicable Diseases in Man. 15th edition. Washington, DC: American Public Health Association, 1990; 1-7.

16.   Nakajima H. Editorial- World Health Day 1996 - Healthy Cities For Better Life. World Health 1996; 49 (1) :3.

17.   El-Medany IM, Mahmoud HH, Al-Roshoud RA. Assessment of the present situation of environmental awareness in Saudi journalism. In: General Secretary of Gulf Cooperation Council Countries And Riyadh Chamber of Commerce And Industry. Papers and Studies of the Symposium of “Environment And Development - Complementation Not Opposition”. 21-23 Jomada I 1413H. (15-17 November 1992) Part I. Riyadh Chamber Of Commerce And Industry, 1992.

18.   Anonymous. Acquired Immunodeficiency Syndrome (AIDS) - Data as at 30th June 1996. Weekly Epidemiological Record 1996; 71(27): 206.

19.   Anonymous. AIDS Update - Reported AIDS cases in the Eastern Mediterranean Region. EMR AIDS news 1998; 2(1): 8.

20.   Ministry of Health. Annual Health Report 1996. (1416/1417 H.) Riyadh: Al-Badia Offset Printing Press, 1996; 27-30.

21.   Abia ghona - Wardina LND, Malalaskira T. Collaboration of the efforts of mass media for health promotion. World Health Forum 1991; 10(1): 29-30. (In Arabic)

22.   Player DA. Sport For All, Health For All. World Health Forum 1986; 7(4): 374-9.



-0001-11-30

AUDIT OF DIABETIC CARE


AUDIT OF DIABETIC CARE IN A SAUDI PRIMARY CARE SETTING

Abdallah M. Mangoud, PhD (UK), Ahmed M. Mandil, Dr.P.H., Ahmed A. Bahnassy, PhD, Abdulaziz M. Al-Sebiany, MD, Nabil Y. Kurashi, FFCM (KFU)

Department of Family and Community Medicine, College of Medicine, King Faisal University, Dammam, Saudi Arabia

هدف الدراسة: قياس الرعاية المقدمة لمرضى الداء السكري المسجلين بعيادات طب الأسرة والمجتمع التابعة لجامعة الملك فيصل بالمملكة العربية السعودية

طريقة الدراسة: دراسة مقطعية شملت ملفات 45 مريضا من الذين يراجعون عيادات طب الأسرة والمجتمع جامعة الملك فيصل – الخبر – المملكة العربية السعودية بانتظام في الفترة من يونيو 1997 إلى مايو 1998 وشملت جميع المراجعين المصابين بالداء السكري البولي (النوع الثاني) خلال فترة الدراسة. النتائج والتوصيات: اتضح أن مستوى الرعاية المقدم إلى هؤلاء المرضى غير كاف وفى حاجة إلى التحسين. وأوصت الدراسة بتطبيق تدابير خاصة  للتحكم الأفضل في رعاية مرضى البول السكري ،  مع التوصية بالاهتمام بتدريب الفريق الصحي على إعطاء رعاية مركزة لهؤلاء المرضى. الكلمات المرجعية: المملكة العربية السعودية، قياس الرعاية الطبية، الداء السكري، الرعاية الأولية. 

Objective: To audit the care offered to diabetic patients attending the Family and Community Medicine Clinic (FAMCO), King Faisal University, Kingdom of Saudi Arabia (KSA).

Design: A cross-sectional study of medical records of 45 diabetic patients who regularly visited the clinic during a one-year period from June 1997 to May 1998.

Subjects: Patients who presented at the clinic because of non-insulin-dependent diabetes mellitus (type II).

Results and Conclusions: The level of care for diabetic patients was relatively inappropriate, and some important parameters were under-recorded. Specific measures to improve and promote diabetic care in FAMCO clinics need to be undertaken. These include formulating and using protocols for diabetes management and better training of health-care providers.

Key Words: Saudi Arabia, medical audit, diabetes mellitus, primary care.


 

INTRODUCTION

Diabetes mellitus is a group of metabolic diseases, characterized by hyperglycemia resulting from defects in insulin secretion, peripheral insulin action, or both. The chronic hyperglycemia of diabetes is usually associated with long-term dysfunction, which may lead to the failure of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels.1

Correspondence to:

Dr. A.M. Mangoud, P.O. Box 40107, Al-Khobar 31952, Saudi Arabia


 

increasing burden on the health care system. The reduction in mortality, morbidity and cost of such a common disease could hardly be achieved without proper healthcare and education of diabetic patients so that they can participate actively in their own care.

Diabetes is a disease prevalent in almost every part of the world, with increasing incidence of Non-Insulin Dependent Diabetes Mellitus (NIDDM).2 The disease is widely recognized as one of the leading causes of death and disability; it caused or contributed to more than 200,000 deaths in the United States.3 The actual toll may be much higher because it was not indicated on half of the death certificates of people who had had diabetes.1 In 1988, WHO estimated that there were approximately 40 million people with diabetes mellitus in developing countries, and by the year 2000 this number is expected to increase to about 65 million.2

In the Eastern Mediterranean Region (EMR), an overall prevalence of 2.3% has been reported by several surveys based on the WHO criteria.4 The prevalence in Saudi Arabia has been shown to vary from one study to another and from one area to another though an overall prevalence of 4-10% has been estimated.5,6

In the KSA, the audit of diabetic care in primary health care is becoming common, especially since the introduction of certain mandatory requirements in the Saudi Government’s chronic disease manage-ment. Clinical audit allows family physicians to ensure that their patients receive satisfactory standard of care and its attendant benefits.7,8 To date, diabetes, asthma and hypertension have proved to be the three most popular topics for audit in general practice.9

In this study, a diabetic audit was conducted in the Family & Community Medicine (FAMCO) clinic, which is the main satellite teaching clinic of King Fahd Hospital of the University, Al-Khobar, Saudi Arabia. This clinic offers services to about 10,000 people. It also offers training in Family and Community Medicine to residents, medical and nursing interns of the University. The clinic has three major units: MCH; adult family and health promotion and education unit. In these units, promotive, preventive and curative services are provided.10 The overall aim of this audit is to improve care received by patients with diabetes in the FAMCO clinic, and reduce long term morbidity.

OBJECTIVES

To audit the quality of care provided by the clinic to diabetic patients, to provide staff with data to assist in improving patient care and to identify needs for further education and training.

METHODOLOGY

Audit design and data collection instruments:

The audit was conducted in two phases: a structure audit and a file review audit and instruments for these were designed by the authors. For the structure audit, all facilities available were inspected according to a checklist modified from the Saudi Board for Family Medicine and the MOH Total Quality Manual (TQI). Special instruments for the auditing process, measures for diabetic care in the FAMCO clinic, through review of medical records, was also specially designed for the study.

Process variables were sub-divided into patient characteristics and process measures. Patient characteristics included: age, sex, nationality, occupation, education, marital status, smoking, date of diagnosis, type of diabetes, duration, family history and diabetic flow-chart. Process measures included: weight, height, Body Mass Index ( BMI), blood pressure, blood sugar (fasting/random: basic and most recent), hemoglobin AIC, fructosamine, urinalysis items, serum creatinine/lipids, foot inspection, fundoscopy/visual acuity, ECG, chest x-ray, management (health education, insulin, oral hypoglycemics, combin-ations, compliance), medications for associated conditions (e.g., hypertension, ischemic heart disease, hyerlipidemia), and referral pattern/reason.

Abstraction of medical records of diabetic patients managed in the clinic during a one-year period (June 1997-May 1998) was made to complete the questionnaire for the pre-mentioned process variables (n=45 records). Wrongly-labeled, single visits, or records before June 1997 were excluded. For each variable: the recording status as well as positive (for yes/no variables as smoking) or value (for tests or measures as blood glucose) was included in the questionnaire. American Diabetics Association (ADA) standards were used to verify the diabetic status of patients in the sample.3 King Fahd Hospital of the University (KFHU) laboratory standards were used to determine cut-off points for abnormality and interpret the values of tests collected.

An IBM compatible computer was then used to manage the collected data using SPSS, version 6.0 software. After data entry, verification was carried out to ensure completeness and accuracy. For the structure variables, the availability of each item was verified and results tabulated. For the process variables, the recording status was verified for each variable. Out of the recorded data, percentages of positive/abnormal values for each variable were then calculated, using standards described above. The necessary tabulations were then done to summarize the findings. Means, standard deviations and ranges were reported, as appropriate.

RESULTS

Table 1 reflects the demographic characteristics of the diabetic patients, as observed from their records (n=45). The review showed that there were more females (55.6%), non-Saudis (62.2%), manual laborers   (69.8%  among  recorded),   married                 (75.6%), educated (97.5% among the recorded), smokers (61.5% among the recorded), no family history (56.7%), those that  had  diabetes  flow-charts  (80%)  in  the

Table 1: Characteristics for Diabetic Mellitus (DM) patients in a PHCC Setting in Eastern Province, Saudi Arabia

Variable

No.

%

Sex

Male

20

44.4

Female

25

55.6

Nationality

Saudi

17

37.8

non-Saudi

28

62.2

Occupation

Recorded

43

95.6

Manual labourers

30

69.8

Professionals

7

16.3

Job-less

6

13.9

Marital status

Recorded

38

84.4

Single

1

2.6

Married

34

89.5

Divorced

1

2.6

Widow

2

5.3

Education

Recorded

40

88.9

Illiterate

1

2.5

Educated

39

97.5

Smoking

Recorded

26

57.8

Smoker

16

61.5

Ex-smoker

2

7.7

Non-smoker

8

30.8

Family history of DM

Recorded

30

66.7

Yes

13

43.3

No

17

56.7

DM Flow Chart

Available

36

80.0

Recorded

40

88.9

Table 2: Some process measures for DM patients in a PHCC setting in the Eastern Province, Saudi Arabia

Variable

No.

%

Type of DM

Type I (IDDM)

1

2.5

Type II (NIDDM)

39

97.5

Recorded

31

68.9

Urine Ketones

+ve

28

90.3

-ve

3

9.7

Recorded

32

71.1

Urine Glucose

+ve

9

28.1

-ve

23

71.9

Proteinuria

Recorded

21

46.7

+ve

18

85.7

-ve

3

14.3

Fundoscopy

Done

15

33.3

Once

12

80.0

Twice

2

13.3

Three times

1

6.7

Visual Acuity

Recorded

6

13.3

Normal

4

66.7

Abnormal

2

33.3

ECG

Done

17

37.8

Once

13

76.4

Twice

2

11.8

Three times

2

11.8

Chest X-ray

Done

4

8.9

Foot Inspection

Done

9

20.0

+ve

7

77.8

-ve

2

22.2

Health Education

Done

42

93.3

Referral

Recorded

14

31.1

Once

8

57.1

Twice

6

42.9

Recorded

43

95.6

Therapy

Diet only

7

16.3

Diet + OHA

34

79.1

Diet + Insulin

2

4.6

studied sample. For the status of smoking there was no recording (42%) and none (33%), for family history; there were no diabetes flow charts for 20% of the cases.

                                Table 2 shows the clinical characteristics of the patients as reflected by some examination, investigative and management procedures. Among the recorded variables, most patients (97.5%) were NIDDM or type II diabetes. Of these, 90% had ketonuria and proteinuria (86%) but with no glucosuria (72%). The results of the 3 urinalysis were not recorded in 29-53% of the charts and for most of the patients, some procedures were not performed. For example, only 20% of the 45 patients had had their feet inspected and 77.7% of these exhibited certain abnormalities. ECG and fundoscopy were done for one third of cases only (37.8 and 33.3%, respectively). About one third (31.1%) of the cases had shared case i.e., had been referred. The main mode of management of the sampled patients (79%) was diet coupled with oral hypoglycemics.

                                Table 3 provides the range, mean and standard deviation of selected demographic, anthropometric, examination and investi-gative procedures. It is to be noted that hemoglobin AIC and fructosamine estimation were not performed for any patient in our sample.

STRUCTURE CRITERIA

As shown in the list in Appendix 1, the following was noticed. All items for glucose except lancets were available. Items used for urine, neuropathy, and body mass tests were all available. However, pinhole card and mydriatic drops used for eye tests were not available.

                                With regard to administrative work on patients ,   it   was  found  that  there  were  no patient monitoring diaries, annual and educational checklists. The FAMCO clinic uses the services of the social worker of the nearby  MOH  hospital  and  has  no dieticians


 

Table 3: Some process measures for DM patients in a PHCC setting in Eastern Saudi Arabia

Variable

Done

Mean ± SD

Minimum

Maximum

No.

%

Age (years)

45

100

   48.8 ± 11.7

  25

  72

Duration (month)

40

88.9

   89.4 ± 61.8

   7

240

Weight (kg)

44

97.8

76.8 ± 18.6

  46

134

Height (m)

41

91.1

160.8 ± 9.6

142

184

Body mass index [wt(kg)/ht (m2)]

14

31.1

  28.4  ± 5.1

  20

  40

Systolic blood pressure

45

100

  31.1  ± 22.4

  90

200

Diastolic blood pressure

45

100

    82.1± 10.2

  60

100

Fasting blood sugar

34

75.6

198.7 ± 74.7

  94

370

Baseline random blood sugar

19

42.2

270.8  ± 103.6

  95

466

Most recent random blood sugar

  9

20.0

275.6 ± 74.4

170

413

Blood urea nitrogen

36

80.0

0.82 ± 0.22

       0.4

       1.4

Cholesterol

35

77.8

202.6 ± 79.4

  23

525

Triglycerides

31

68.9

136.43 ± 73.0

    1

307


 

and social workers of its own. There are no rooms specially allocated for diabetic care, nor is there a special appointment system solely for diabetics or a mini-clinic for their care. Hypoglycemic medications were only available from the pharmacy. Although the referral system included the items of referral from FAMCO to and from the hospital, as well as feedback; referred cases rarely report back to us. After this structure audit, most of the items missing were replaced.

DISCUSSION

Although there are diverse descriptions of quality-control assessments for diabetic patients, e.g., structure management of the diabetic foot according to Saint Vincent’s movement,13 there is little in available literature that describes long term changes in diabetic control of NIDDM patients. Consequently, the appreciation of the natural history of the disease is difficult. This in turn renders the assessment of the achievements of diabetic auditing in a PHC clinic arduous. Some of the problems that arose during the audit are worth discussion. The most common problems were the lack of training and oversight of medical reviewers; the use of data-collection instruments that provided little guidance to reviewers to ensure that the accurate information was obtained; and the reliance upon provider attestation in place of medical record review. Furthermore, it was found that the most frequent problems were poor data collection, inadequate or incompatible information systems, inefficiency in the monitoring of data collection and processing procedures, and insufficient oversight of vendors.9

                                In this study, we found that there were problems with follow-up and the recording of patients. Similar inadequacies in the care of diabetics have been recorded in other studies.11,12

                                Taking all auditing parameters into account, our study showed that more than half of the diabetic patients was poorly controlled. This result is much higher than another study conducted recently in Riyadh which showed and inadequate control of only 12.3% diabetic patients.12 The big difference could be attributed to the small number of the patients (45) in our study and the fact that more parameters were utilized. As observed  in other similar local studies11,12 there were more females (55.6%) in our study.

                                In general, there is a great need to emphasize the importance of recording complete information such as demographic data, smoking status and family history of diabetes to the health team. Although there is better recording for urine dipstick (ketone 69% and glucose 71%) compared to 55.9% in the Riyadh study, there is room for further improvement.

                                Visual acuity, fundoscopy and foot inspection were recorded in less than one-third of the patients under study. Therefore, the health team should be trained in these skills to help them record their findings, which will in turn help in the early detection of complications among diabetic patients.

                                The practice of having the blood pressure of all patients measured; is good and should be encouraged. HbA1C was recorded in less than one-third of the cases (16.7%). There is a need for the improvement of this since HbA1C is a sensitive parameter in detecting diabetes control status. With better management, the number of referrals (more than half) which resulted from diabetic complicat-ions might diminish.

CONCLUSION

This audit study was the first to be conducted in Family and Community Medicine clinic of King Faisal University. We realized that some important parameters were under-recorded and many diabetic patients were not appropriately managed.

RECOMMENDATION

To standardize and increase quality of care at our clinic, it is recommended that:

1. A clear and standardized policy of diabetic patient care be established as follows: formulate and use protocols for DM management; proper recording; check-list of smoking, related diseaes i.e., hypertension, family history, foot inspect-ion, fundoscopy; flowchart of laboratory results, medications, diet.

2. Provide continuous education and training of all members of the health team.

3. Provide critical health education of diabetic patients and improve their skills for self-monitoring at home (e.g. face-to-face, one-on-one basis with return demonstrations of self-monitoring, etc.).

4. Establish structure treatment and teaching program for type II DM, in accordance with published literature including the Saint Vincent’s declaration.13,14

5. An audit of the clinic be conducted every two years to provide continuous monitoring so that diabetic patient care in the clinic could be improved.

ACKNOWLEDGMENT

We would like to extend our sincere gratitude for the assistance provided by the residents of the FAMCO Department to help accomplish this work.

REFERENCES

1.     Zimmet R (editor). Diabetes - definitions and classification, The Medicine Publishing Company Ltd.  1997.

2.     Eko JM.  Diabetes mellitus.  Aspects of the worldwide epidemiology of diabetes mellitus and its long term- complications.  Amsterdam: El-Sevier, 1991.

3.     American Diabetes Association.  The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.  Diabetes Care 1998; 21-29.

4.     Alwan A. Diabetes prevention and control.  Alexandria:  WHO/EMRO, 1993.

5.     El-Hazmi M , et al. Prevalence of Diabetic Mellitus in Saudi Arabia. Saudi Medical Journal 1995; 16(4): 294-9.

6.     Al-Shammari A, Khoja T, Al-Rubeaan K. Diabetes care in primary care centers in the Riyadhregion. Huisarts En Wetenschap 1993; 36:463-6.

7.    Tunbridge FKE , Millar JP, Schofield PJ.  Diabetic care in general practice:  An approach to audit and outcome.  British Journal of General Practice 1993; 43: 291-5.

8.     Chesover D, Tudor-Miles P, Hilton S. Survey and audit of diabetic care in general practice in South London.  British Journal of General practice 1991; 41:282-5.

9.     Simon G. Diabetic care in general practice: Metaanalysis of rondomized controlled trials. British Medical Journal, 1998; 317:390-4.

10. Abdel-Aal RE , Mangoud AM.   Modeling and forecasting monthly patient  volume at a primary health care clinic using univariate time-series analysis. Computer Methods and Programs in Biomedicine  1998; 56:235-247.

11.   Al Owayyed A , Al Sheikh A , Taha S. A survey and audit of diabetic care in large family practice in Riyadh. Saudi Medical Journal 1997; 18(2):175-9.

12.   Qureshi R, Al-Owayyed A. An audit of the process of diabetic care in a large family practice in Riyadh.  Saudi Med J 1995; 16:394-7.

13. SulzerM, BergerM. Quality assessment of diabetic car in rural Australia. Diabetologia 1992; 35:429-435.

14.  Kronsbein P Jorgens V, Muhlhauser I, Scholz V, Venaus A, Berger M. Evaluation of a structured treatment and teaching program on non-insulin dependent diabetes. The Lancet 1988; II: 1407-11.


-0001-11-30

SMOKING PATTERNS


KNOWLEDGE, ATTITUDE AND SMOKING PATTERNS AMONG NURSING AND LABORATORY TECHNOLOGY STUDENTS, DAMMAM, SAUDI ARABIA

Ahmed M. Mandil, Dr.P.H.*, Ahmed A. Bahnassy, PhD*, Shadia M. Aboul-Azm, PhD†, Laila A. Bashawri, FCP‡

Departments of *Family & Community Medicine, †Nursing and ‡Medical Laboratory Technology, Collegeof Medicine, King Faisal University, Dammam, Saudi Arabia

هدف الدراسة : هدفت الدراسة إلى تقييم السلوكيات والمعلومات والاتجاهات تجاه ظاهرة التدخين ، لدى طالبات التمريض وتقنية المختبرات الطبية بكلية الطب جامعة الملك فيصل .

طريقة الدراسة: دراسة مقطعية تم اختيار 266 طالبة ( 152 من التمريض ، 114 من تقنية المختبرات الطبية ) . وطلب منهن تعبئة استبيان خاص بتقييم المعلومات والاتجاهات والسلوكيات الخاصة بظاهرة التدخين .

نتائج الدراسة: أظهرت الدراسة أن 6, 5 % من الطالبات في العينة هن مدخنات ( 6 , 6% بين طالبات التمريض ، 4, 4 % بين طالبات التقنية ) . كما أظهرت أن الاتجاهات والمعلومات الخاصة بالتدخين لديهن كانت مرضية ، عدا بعض العناصر التي بينتها الدراسة ( لا سيما بين المدخنات ) .

الاستنتاجات والتوصيات: إن برامج التوعية الصحية حول حقائق وخطر وعواقب التدخين يجب أن يبدأ تطبيقها بالمدارس الابتدائية ، مع استمراريتها فى المناهج الدراسية الخاصة بعاملي المستقبل في الحقل الصحي (بما في ذلك مناهج التمريض والتقنية) حيث يعتبرهم المجتمع دائماً نموذجاً يحتذى به .

الكلمات المرجعية : ظاهرة التدخين ، طلبة تقنية المختبرات ، التمريض ، المعلومات ، الاتجاهات ، السلوكيات ، التوعية الصحية ، جامعة الملك فيصل ، السعودية.

Objective: To study the reported practices of knowledge about and attitude towards smoking among nursing and medical laboratory technology (MLT) students, College of Medicine, King Faisal University at Dammam and Al-Khobar.

Setting: Collegeof  Medicine, Dammam and King Fahd Hospitalof the University, Al-Khobar, Saudi Arabia

Methods: A cross-sectional approach involving a sample of 266 students and interns (152 nursing and 114 MLT), which included all enrolled students in the academic year (1998/1999). A self-administered questionnaire was used to collect data covering knowledge, practice and attitude to smoking. SPSS was used for statistical analysis.

Results:The  overall  smoking  prevalence  was low (5.6%),  slightly   higher  among nursing (6.6%) versus MLT (4.4%) students. Knowledge of and attitude towards smoking was generally satisfactory in both groups, although deficient in some key areas, such as the addictive nature of smoking, some of its consequences on health, and difficulty of quitting.

Conclusion and Recommendations:The prevalence of smoking among nursing and MLT  students  is  generally low but their knowledge and attitude need improvement.

Correspondence to:

Dr. Ahmed M.A. Mandil, P.O. Box 2114, Dammam 31451, Saudi Arabia

Health education on facts, dangers and consequences of smoking should start as early as the primary school, and should continue throughout the education of future health professionals (role models for the community).

Key Words: Smoking, tobacco consumption, university students, nursing, laboratory technology, knowledge/attitudes/practice ( KAP), Saudi Arabia


 

INTRODUCTION

Smoking is still the single greatest preventable cause of premature death and disability in modern times.1 It has been estimated that one third of the world’s population, above 15 years of age, are current smokers. It is much more prevalent among males (47%) than females (12%).2 Tobacco consumption does not only pose multiple health risks (respiratory, cardiovascular, gastrointestinal, genito-urinary), but also adversely affects the lives of individuals, their families and communities, socially, economically and hence developmentally.3,4 Smoking places are the heaviest morbidity and mortality burden on people, compared to any other risk factor.1 The estimated annual death rate of about 3.5-4 million people is expected to rise to 10 millions by the 2020s - 2030s, 7 million of which will occur in developing countries.2 To compensate for the deaths, tobacco companies need to recruit 11,000 new smokers daily, especially “young adolescents”, to maintain the size of their business.5 Most smokers (78-90%) take up the habit during adolescence (10-19 years); less than 2% of them start smoking after their 22nd birthday.3,5

                                Students in the countries of Gulf Cooperation Council (GCC) have estimated that the prevalence of smoking among male secondary students ranges from 12-50%.6-11 Among GCC male medical students, the rate of prevalence was 13.6-33%, compared to only 2.3-8.6% among female medical students (12-16). Very few studies have been done among the students of the allied sciences. However, Saeed reported that smoking prevalence among students of the allied medical sciences in Riyadh from 12.4% among females to 46.8% among males;17 but was much lower (8-17.5%) among students of the secondary health institutes in Riyadh.18 While several studies have looked into the knowledge and practice of smoking among secondary school or medical students in the central and South-Western Saudi Arabia,7-9,12-14 to the best of our knowledge there has been no study of nursing or medical laboratory technology (MLT) university students in the Eastern Province. This work is aimed at exploring the patterns of smoking among nursing and MLT students and interns of King Faisal University College of Medicine to estimate the magnitude of the problem; assess their knowledge on smoking and find out their attitude towards the habit. This will help us make suitable recommendations for its control.

MATERIAL AND METHODS

This was a cross-sectional study of nursing and MLT students at King Faisal University, Dammam, Saudi Arabiain 1998/1999. All students and interns enrolled in the nursing and MLT Departments during the academic year were included in the study sample (overall n=266; with nursing n1=152 and MLT n2=114). All students were included in the study to ensure an adequate sample size.

A self-administered Arabic questionnaire, modified from the World Health Organization tools was used.19-20 The questionnaire was first tested in a pilot study of  medical students. They were therefore, not included in the current study sample. Any ambiguous questions were adjusted accordingly. The nursing and MLT students (1998/1999) were then asked to complete the questionnaire after the objectives of the study and contents of the study tool (questionnaire) had been classified by a member of the research team. The questionnaire, which had been explained to the students, included 3 groups of questions. The first elicited demographic information, such as college year, age, sex, marital status, nationality, residence, parents’ education, parents’ occupation and smoking status. The second group of questions inquired about pattern of smoking behaviour: e.g. type, duration, frequency, age/source/cause/ where the habit began. WHO definitions of current and ex-smoking status were adopted.19 The third group included questions about attitude towards smoking and smokers. After the data collection, all the information was entered into the computer and checked. Using the SPSS/PC programme it was transferred for analysis after it had been rechecked for accuracy.21 Univariate and bivariate analyses of the reviewed data were used, as appropriate. The level of significance was set at <0.05 throughout the study.

RESULTS

Tables 1 to 3 reflect the attributes of the practice of tobacco consumption in the study sample (n=266). The mean age of students and interns studied was 19.7 ±1.8 years (ranging from 16-30 years). As shown in Table 1, only 15 of them were smokers (5.6%), but the prevalence was higher among nursing students (6.6%), compared to MLT students (4.4%). Of the MLT group showed the highest prevalence of smoking was among the interns (27.3%), while the prevalence was highest among the second year students in the nursing group (13.8%).

Table 1: Prevalence of smoking comparing nursing with MLT female students and interns by specialty and school year, 1998-1999


 

School

Specialty

Year

Nursing

No. (%)

MLT

No. (%)

Total

No. (%)

First year

4 (4.8)

2 (3.3)

6 (4.2)

Second year

4 (3.8)

-

4 (8.2)

Third year

1 (4.0)

-

1 (2.7)

Fourth year

1 (11.1)

-

1 (2.7)

Interns

-

3 (27.3)

3 (2.1)

Total

10 (6.6)

5 (4.4)

15 (5.6)

Table 2: Characteristics of smokers among nursing and MLT students and interns, 1998-1999

Variable

Mean ±SD

Min.

Max.

Age (years)

19.7 ± 1.8

16

30

Age at which smoking started

17.6 ± 2.5

14

22

No. of cigarettes / day

1.9 ± 1.5

1

6

No. of shisha / day

1.8 ± 0.8

1

3

Duration of smoking (years)

1.7 ± 1.1

1

5

As shown on Table 2, the mean age at which smoking started was 17.6 ± 2.5 years (ranging from 14 - 22 years), with a mean duration of 1.7 ± 1.1 years. As shown on Table 3, most smokers (86.7%) smoked only cigarettes or shisha (water-pipe) as well the quantity, ranging from 1 - 6 cigarettes per day. Two thirds of the smokers (66.7%) have been smoking daily for the last 6 months - 5 years. Almost half the smokers (46.7%) indicated that friends or parents had been the source of the first cigarette. Curiosity (53.5%),  and  stress  (33.3%) were  the   most important reported motives for initiating the habit. Most of the smokers (66.7%) had started the habit at home.

Table 3: Distribution of smokers accord-ing to selected variables 1998-1999

Variable

No. (%)

Type of smoking

Cigarette

13 (86.7)

Shisha

6 (40.4)

Both

4 (26.7)

Duration of daily smoking

< one month

3 (20.0)

1 - < 6 months

2 (13.3)

6 - < 12 months

4 (26.7)

1 - < 5 years

6 (40.0)

Source of the first cigarette

Friends

4 (26.7)

Parents

3 (20.0)

Self

4 (26.7)

Other

4 (26.7)

Motives for smoking the first time

Curiosity

8 (53.3)

Sign for maturation

1 (6.7)

Friends initiation

1 (6.7)

Getting rid of psychological pressure

5 (33.3)

Place of smoking the first cigarette

Home

10 (66.7)

School

1 96.7)

Coffee shop

1 (6.7)

Outside home

3 (20.0)

For Tables 4 and 5, the mentioned numbers represent the percentage of students who responded with “true” to these statements (i.e., agreed to the statement, whether “true” or “false” is the correct response). Table 4 deals with a comparison between the views of MLT students and interns and nursing students on tobacco use. It also deals with those who have never smoked as against those who have. For most statements (referred to as Group A), “true” is the correct answer; except for the two (referred to as Group B “some types of cigarettes are harmless”) to which “false” is the correct response and “quitting smoking is too difficult” (74.1 - 97.7%). Except for the statement: “Smoking may lead to stomach cancer” which was wrongly responded to by more than half the participants of the study (54.1%) Group A responded to most statements correctly. Group B, generally got the two questions correct (only 13.9 - 28.9%) agreed to these false statements). There was a statistically significant difference between the nursing and MLT with regard to their percent correct responses to some statements such as: “Smoking increases the heart rate”, “smoking leads to addiction” and “Quitting smoking is too difficult”. A similar difference was observed when the response of those who had never smoked on the statement. “Most of lung cancer patients were regular smokers” were compared with those who had.

Table 5 compares the attitude of nursing and MLT students/interns; the ‘ever’ and ‘never’ smokers on statements on tobacco use. On the whole (n=266), most statements were responded to correctly, except for three statements which should have been rejected as false. The first was: “I should smoke whenever in the company of smokers”, which was wrongly agreed to by 91% of the respondents. When ‘ever’ with ‘never’ smokers were compared, a highly significant statistical difference was observed (p<0.001). The second statement: “Smoking is a personal matter. I do it in the time/place of my choice,” was wrongly agreed upon by 82.4% of respondents, but similarly when the ‘ever’ with ‘never’ smokers were compared, a highly significant statistical difference was observed (p<0.001). The third statement: “Information gained about smoking in the college is enough for to help people stop smoking”, was agreed upon by 47.8% of respondents, but a comparison of the ‘ever’ with the ‘never’ smokers, revealed a statistically significant difference (p < 0.05).

Only three statements showed a statistically significant difference when nursing and MLT students and interns were compared. These were “Physicians are not doing enough to help people stop smoking”, “If you are a smoker, will you be upset when others ask you to quit”, and “Every encounter with a


 

Table 4: A comparison of the knowledge on smoking of nursing with MLT female students and interns by specialty and smoking status, 1998-1999

Knowledge, % responding “true”

Statement

Total

Specialty

Smoking status

(n=266)

Nursing (n=152)

MLT

(n=114)

Ever

(n=15)

Never (n=251)

Passive smoking is harmful for infants

97.7

97.4

98.2

86.7

98.4*

Most of lung cancer patients were regular smokers

82.0

78.9

86.0

60.0

83.3*

Smoking increases heart beats/minute

74.1

81.6

64.0†

80.0

73.7

Some types of cigarettes are harmless

13.9

17.1

9.6

20.0

13.5

Smoking lead to addiction

79.7

73.0

88.6†

66.7

80.5

Quitting smoking is too difficult

28.9

33.6

22.8‡

26.7

29.1

Smoking may lead to stomach cancer

45.9

50.7

39.5

26.7

47.0

A large anti-smoking campaign in the university is necessary

93.6

94.1

93.0

80.0

94.4


*p = <0.05, †p = <0.001, ‡p = <0.01

Table 5: Smoking attitudes comparing nursing with MLT female students and interns by specialty and smoking status, 1998-1999

Knowledge, % responding “true”

Statement

Total

Specialty

Smoking status

(n=266)

Nursing (n=152)

MLT

(n=114)

Ever

(n=15)

Never (n=251)

I should smoke whenever I am in the company of friends who smoke

91.0

89.5

92.9

53.3

93.2*

Smoking gives me bad breath

86.1

86.8

85.1

66.6

87.3

If you are a smoker, will you be upset when others ask you to quit?

20.3

24.3

14.8†

13.3

20.7

Smoking is a personal matter. I do it at any time and/or place

82.4

83.5

80.7

40.0

84.5*

Families should prohibit their kids from smoking

94.7

96.0

93.0

86.6

95.2

Cigarettes prices should be very high

80.9

84.2

76.3

73.3

81.3

Smoking should be prohibited in public transportation

94.0

95.4

92.0

86.7

94.4

Smoking should be prohibited in public places

91.7

93.4

89.5

80.0

92.4

It is very annoying to stay beside a smoker

90.9

92.1

89.5

80.0

91.6

Most smokers would not stop even if they were asked by a physician

15.8

15.8

15.8

26.7

15.2

Physicians are not campaigning enough against smoking

64.3

71.7

54.4‡

46.7

65.1

Information gained about smoking in the college is not enough to persuade people to quit

47.8

46.7

49.1

26.0

49.5†

Every encounter with a smoking patient should be utilized to convince him/her to quit

93.6

96.7

89.4‡

100.0

93.3†

*p = <0.001, †p = <0.05, ‡p = <0.01


 

smoking patient should be utilized to convince him/her to quit”.

DISCUSSION

It has been observed that tobacco consumption in this region has escalated with the rising population, increased purchasing power, especially of the youth, campaigns by tobacco companies, and the increase in the number of girls and women who smoke. Another reason to the lack of awareness of the hazards of smoking, insufficient support and inadequate funds for campaigns against the use of tobacco.22 It is unfortunate that this habit which inevitably results in smoking-related diseases and other subsequent social and economic problems is on the increase.23 This study on female university students and interns, from the nursing and MLT departments of King Faisal University indicated an overall smoking prevalence of 5.6%. In comparison with other Saudi studies on prevalence of smoking among female students, reported by Felimban (1993) as 4.7% among King Saud University medical students;13 by Saeed et al (1993) as 8% in secondary health institutes in Riyadh,18 as high as 12.4% among allied medical sciences students in 1987 was fair.17 It should be emphasized that these figures are low in comparison with female professionals, such as Saudi female physicians (15.8%) as reported in another study by Saeed et al in 1989.24 Even though these figures, ranging from 4.7 - 15.8%, are much lower than those among male students or health professionals, they are quite alarming. Women/mothers who are to be role models for their children, are in continuous contact with their offspring, should be in good health to function efficiently and fulfil their responsibilities to their families as well as their communities. The effect of this new epidemic among women on health and socio-economic conditions if allowed to continue would indeed be disastrous.

                                According to our study the habit of smoking began between 14-22 years of age. This is quite similar to what was reported by Saeed in two studies in which he stated that 92% of female smokers among Allied Medical Sciences students formed the habit when they were less than 18 years,17 while all female smokers in secondary health institutes started between 10-20 years.18 These figures reaffirm the importance of effective health education as early as possible in life in schools and through the mass media in order to protect children, especially girls, from adopting this dangerous habit.

                                In this study  the most cited motives for the adoption of the habit of smoking were curiosity (53%) followed by relief of stress (33%). This is in agreement with the findings of Abolfotouh et al in 1998,14 where curiosity/ showing off were each mentioned by 52% of the smokers in King Saud University in Abha (currently known as King Khalid University).

                                Compared to MLT students in our study, the nurses’ knowledge about smoking and its hazards was generally more satisfactory. These results are comparable to the results of other studies on medical students done elsewhere in Saudi Arabia.12-14 The knowledge of smokers as compared to non-smokers did not yield any statistically significant difference. This was not in conformity with the report of Abolfotouh et al,14 which showed that non-smokers were more knowledgeable than smokers. The role of efforts to promote health is again emphasized here. Bridging the gap between knowledge and practice is difficult and requires intensive and collaborative effort on the part of the entire community.

Our findings were similar to those of Abolftouh et al in two studies14,25 on the attitude towards public health drives against smoking in that they were less favorable among smokers compared to non-smokers. A similar pattern was observed for statements of attitude towards time, place and company of smoking, which is again in agreement with the studies mentioned above. Differences in attitude statements between nursing and MLT students strongly reflected the background or training offered to each group. The nurses’ attitude was more inclined towards the clinical sciences and patient satisfaction  whereas MLTs focus more on laboratory technology studies.

In conclusion, an effective sound education on tobacco consumption should be incorporated into our educational system, commencing as early as the primary schools. In addition, the media engagement in this drive to control tobacco use should be intensified to reach the entire community. There should be a vigorously pursuit of this objective through curricula designed for future health professionals, including nursing and MLT departments of universities. These professionals should be able to provide sound advice to the public on the one hand (as through health promotion and education activities), as well as present themselves good role models for their communities.

REFERENCES

1.     Last J. Social and behavioral determinants of health. In: Last J. Public health and human etiology. Second edition. Stanford, Connecticut: Appleton & Lange, 1998.

2.     WHO. Growing up without tobacco. Geneva: WHO, 1998.

3.     Novotny TE, Giovino GA. Tobacco use. In: Brownson RC, Remington PL, DavisJR (editors). Chronic disease epidemiology and control. Washington DC: American Public Health Association, 1998, 117-48.

4.     Meltzer EO. Prevalence, economic and medical impact of tobacco smoking. Ann Allergy 1994; 73:381.

5.     Gezairy HA. Regional Director’s message. World No-Tobacco Day, 31 May 1998. Alexandria: WHO/ EMRO, 1998.

6.     WHO. Tobacco or health: A global status report. Geneva: WHO, 1997.

7.     Rowlands DF, Shopster PJ. Cigarette smoking amongst Saudi school boys. Saudi Med J 1987; 8:613-8.

8.     Felimban FM, Jarallah JS. Smoking habits of secondary school boys in Riyadh, Saudi Arabia. Saudi Med J 1994;15:438-42.

9.     Jarallah J, Bamgboye EA, Al-Ansary LA, Kalantan KA. Predictors of smoking among male junior secondary school students in Riyadh, Saudi Arabia. Tobacco Control 1996; 5:26-9.

10.   Ministry of Health. Extent of knowledge, attitude and practice of school students with respect to nutrition, hygiene and smoking (Arabic). Preliminary report. Muscat, Oman: General Directorate of Health, Ministry of Health, 1997.

11.   Haddad N. Smoking among secondary male students in Bahrain. Family Practice Residency Program. Ministry of Health, Bahrain, 1998.

12.   Jarallah J. Smoking habits of medical students at King Saud University, Riyadh. Saudi Med J 1992; 13:510-13.

13.   Felimban FM. The smoking practices and attitudes towards smoking of female university students in Riyadh. Saudi Med J 1993; 14:220-4.

14.   Abolfotouh M, Adel-Aziz M, Alakija W, et al. Smoking habits of King Saud University students in Abha, Saudi Arabia. Ann Saudi Med 1998; 18:212-6.

15.   Hamadeh RR. Smoking habits of medical students in Bahrain. J Smoking-related Diseases 1994; 15:189-95.

16.   Tessier JF, Freour PP, Nejjari C, et al. Smoking behaviour and attitudes of medical students towards smoking and anti-smoking campaigns: a survey in 10 African and middle-eastern countries. Tobacco Control 1992; 1:95-101.

17.   Saeed AAW. Smoking habits of students in Collegeof Allied Medical Sciences, Riyadh. J Roy Soc Health 1987; 5:187-8.

18.   Saeed AAW, Al-Johali E, Al-Shahry AH. Smoking habits of students in secondary health institutes in Riyadhcity, Saudi Arabia. J Roy Soc Health 1993; 11:132-5.

19.   WHO/Tobacco or Health Program. Guidelines for controlling and monitoring the tobacco epidemic. Geneva: WHO, 1996.

20.   WHO. Guidelines for the conduct of tobacco-smoking surveys among health professionals. Report of WHO Meeting, Winnipeg, Canada, July 7-9, 1983. Geneva: WHO, 1984.

21.   SPSS-PC (Statistical Package for Social Sciences). 444 N. Michigen Ave., Chicago, Illinois, USA, 1996.

22.   WHO. Plan of action for tobacco control in the Eastern Mediterranean Region. East Med Health J 1997; 3:168-75.

23.   Bakhotmah MA. The epidemic of smoking in Saudi Arabia. Saudi Med J 1996; 17:416-7.

24.   Saeed AAW, Taha AM, Shahri AH. Smoking habits of physicians in Riyadh, Saudi Arabia. Saudi Med J 1989; 10:508-11.

25.   Abolfotouh MA, Abdel-Aziz M, Badawi IA, Alakija W. Smoking intervention program for male secondary-school students in south-western Saudi Arabia. East Med Health J 1997; 3:90-100.


-0001-11-30

PATTERNS OF RESISTANCE


PATTERNS OF RESISTANCE TO ANTIB IOTICS AT KING FAHD HOSPITALOF THE UNIVERSITY

Mastour S. Al-Ghamdi, PhD,* Fikry El-Morsy, PhD,†Zaki H. Al-Mustafa, PhD*

Departments of *Pharmacology and †Microbiology, Collegeof Medicine, King Faisal University, Dammam, Saudi Arabia

هدف الدراسة: لوحظ مؤخرا وفي جميع أنحاء العالم ارتفاعا مطردا  في نسبة مقاومة البكتيريا لمضادات الجراثيم مما قد يؤدي إلى الفشل في علاج الأخماج أو زيادة تكاليف العلاج. لذلك فانه من الأهمية بمكان دراسة نمط مقاومة البكتيريا للأنواع  المستعملة من مضادات الجراثيم بانتظام على مستوى الإقليم أو الدولة.

طريقة الدراسة: لقد تم تحليل نمط سلوك البكتيريا التي عزلت في مستشفى الملك فهد الجامعي بالخبر على مدار سنة كاملة تجاه مضادات الجراثيم  المستعملة في المستشفى.

نتائج الدراسة: لقد تم عزل 3679 كائن جرثومي حي ينتمون إلى 35 نوعا وكانت أجناس البكتيريا العقدية هي الأكثر شيوعا (25.5 %) يليها العنقودية الذهبية (16.1 %)، الاشريكية القولونية  (12.7 %)، أجناس الزائفة (9.3 %)، و أجناس الكبسيلة (7.0 %).

لقد كان اكثر من 50 % من أجناس البكتيريا المعوية وكذلك المستديمة النزلية مقاوم لدواء الامبسلين ومركب الامكسيسلين + الكالفونيت بينما كان نحو 60 % و 38.1 % من بكتيريا الاشريكية القولونية مقاوم للدواءين السابقين على التوالي. أما بالنسبة للبكتيريا العنقودية الذهبية فقد كان نحو  98.1 % منها مقاوم للبنسلين فيما 91.1 % مقاوم لمركب الامكسيسلين + الكالفونيت و 25.5 % مقاوم للمثيسلين ولكنها بقيت حساسة لدواء الفنكوميسين.

لقد لوحظ مقاومة عالية لدواء التتراسيكلين ( 53 % من 2830) وخاصة بكتيريا المستديمة النـزلية    80.5 % ، البكتيريا العقدية 72.9 % و الاشريكية القولونية 54.5 %، كما كان هناك مقاومة عالية لمركب السلفامثيكسازول + الترايميثوبريم من قبل هذه البكتيريا وبالنسب التالية 75.5 %، 80.4 % و 48.1 % لكل منها على التوالي. لقد كانت المقاومة العامة لدواء الجنتاميسين متوسطه (26.0 % من 1567) ولكن من المهم ملاحظة ان البكتيريا السالبة بقيت حساسة لهذا الدواء. ومن الجدير ملاحظة ان نحو 24.3 % من 839 تم تحليلها لتعدد مقاومتها لمركب الامكسيسلين + الكالفونيت     ولدواء الجنتاميسين.

الاستنتاجات: إن هذه الدراسة تبين أن نمط مقاومة البكتيريا لمضادات الجراثيم عالية جدا وتنذر بالخطر وربما كان ذلك يعكس  سوء استعمال هذه المضادات في المنطقة الشرقية من المملكة العربية السعودية.

التوصيات: نوصي بان يكون لكل مستشفى سياسة خاصة تعتمد على التحليل المستمر لنمط مقاومة البكتيريا في المنطقة التي يقع بها، كما نؤكد على أهمية إنشاء مركز في كل منطقة من مناطق المملكة لمكافحة أمراض الأخماج وكذلك لحفظ وتبادل المعلومات وصياغة الاستراتيجية اللازمة لشراء وصرف واستعمال مضادات الجراثيم

الكلمات المرجعية: مضادات الجراثيم ، مقاومة مضادات الجراثيم  ، كائنات حية دقيقه ممرضه ، المملكة العربية السعودية. Correspondence to:

Dr. Mastour Al-Ghamdi, Department of Pharmacology, College of Medicine, King Faisal University, P.O. Box 2114, Dammam 31451, Saudi Arabia

Introduction and Aim: A sharp worldwide rise in bacterial resistance to antimicrobial agents in both nosocomial and community acquired pathogens has recently been observed. This may complicate treatment of infectious disease or increase the cost of its management. It is, therefore, important to regularly investigate the patterns of resistance to antimicrobial agents at both local and national levels.

Methods: The antibiograms of organisms isolated over a one-year period in King Fahd Hospitalof the University were analyzed.

Results: Of the 3679 microbial isolates of 35 types of organisms identified, the most common were Streptococcous spp (25.5%), S. aureus (16.1%), E. Coli (12.7%), Psueudomonas spp (9.3%) and Klebsiella spp (7%) High resistance rates (50%) to ampicillin and to amoxycillin + clavulanate (AMX+CLV) were encountered in Enterobacter spp., and H. influenzae while in E. coli, the resistance was higher to ampicillin (60.0%) than to AMX+CLV (38.1%). With regard to S. aureus, 98.3%, 91.1% and 25.5% of isolates were resistant to penicillin, AMX+CLV and methicillin respectively but all were sensitive to vancomycin. High resistance (53% of 2830 isolates) to tetracycline was also observed especially in H. influenzae (80.5%), Streptococcous spp (72.9%) and E. Coli (54.5%). The same organisms were also highly resistant to trimethoprim/sulphamethoxazole with rates of 75.5%, 80.4% and 48.1% respectively. Moderate resistance (26% of 1567 isolates) to gentamicin was noted but the drug remained very effective against most tested gram-negative organisms. In addition, multiple resistance to gentamicin and AMX+CLV was also detected in 24.3% of 839 isolates.

Conclusions and Recommendations: It is concluded that the alarmingly high pattern of bacterial resistance to antibiotics may reflect the extent of use of each antibiotic in the eastern provinceof Saudi Arabia. It is recommended that hospital antibiotic policies (purchasing, prescribing and dispensing) be based on, and regularly reviewed in accordance with hospital antibiogram results. A center for infectious disease control should also be established in each region of the Kingdom to disseminate information and coordinate antibiotic policies among hospitals.

Key Words: Antibiotics, resistance, pathogenic organisms, Saudi Arabia


 

INTRODUCTION

Over the last several years, the incidence of bacterial resistance to antimicrobial agents has risen sharply in both nosocomial and community acquired pathogens.1 The resistance to antibiotics may result in therapeutic failure, relapse of infections or increase in the cost of their management.2 Many factors contribute to the increase in the incidence of bacterial resistance to antibiotics, particularly, the misuse of antibiotics by physicians and the easy acquisition of antibiotics via non-physicians.3 In addition, the feeding of farm animals with subtherapeutic levels of antimicrobial agents may cause the development of resistant strains that may spread to humans.3

The mechanisms by which bacterial resistance to antibiotics arise may be natural or acquired through chromosomal mutation or transfer of plasmids between bacterial cells by conjugation, transformation and transduction.4 Resistance to individual antibiotics differs according to bacterial species and antibiotic policies adopted by different countries. One of the most important mechanisms of resistance to b-lactam antibiotics is the production of  b-lactamase enzymes. The incidence of development of strain-producing enzymes together with that of those with extended spectrum b-lactamases has been increasing rapidly.5 Most of these strains show cross-resistance to different types of antibiotics.5 Among the isolates which exhibit these characteristics are E. coli and Klebsiella spp. Resistance to the new fluoroquinolones is also increasing especially in some nosocomial pathogens such as Serratia spp., Acinetobacter spp., and methicillin-resistant S. aureus.6

Our study aimed at analyzing the antibiograms of the organisms isolated during a one-year period in the laboratories of King Fahd Hospitalof the University, Al-Khobar, in order to provide the basis for updating the current antibiotic policy in our hospital and serve as base data for future review.

METHODOLOGY

The results of all microbiological suscept-ibility tests performed at King Fahd Hospitalof the University (KFHU) were collated over a period of one year, between 1st January 1995and 31st December 1995. Organisms were isolated and identified according to standard laboratory methods.7 Each organism was tested against the recommended antimicrobial agents using single-disc antibiotic-sensitivity testing method. Susceptibility tests were performed using BBL® Sensi-Disc® antimicrobial suscept-ibility test discs (Becton Dickinson Microbiology Systems, Cockeysville, USA). The criteria for interpretation were those recommended by the National Committee for Clinical Laboratory Standards (NCCLS)8 and quality control was performed on a regular basis. Control culture of S. aureus (ATCC 25923), E. coli (ATCC 25922) and P. aeruginosa (ATCC 27853) were used and zone diameters were measured in parallel with susceptibility tests performed on clinical isolates. The zone diameters given by the control studies were compared with the standard zone diameters recommended by NCCLS. Patient’s number, type of specimen, organism detected and its antibiogram were recorded and later entered in a database for analysis using SPSS/PC software.

RESULTS

Over the one-year period, 3679 isolates of 35 types of organisms were isolated from 2484 patients (Table 1). The most frequently isolated organisms (939 – 25.5%) were streptococcus groups (552 Streptococcus B, 199 Streptococcus D, 124 Streptococcus A, 57 Streptococcus pneumoniae and 7 Viridans streptococci), S. aureus 594 (16.1%),  E. coli 469 (12.7%) and Pseudomonas spp. 342 (9.3%).

The overall resistance rate to ampicillin was 36.4%. Streptococcus groups showed the lowest resistance rate (1.6%) while the highest rates were observed with Enterobacter spp. (92.8%), H. influenzae (61.9%) and E. coli (60.2%) (Table 2). S. aureus, Enterobacter spp., H. influenzae and E. coli organisms were also highly resistant to amoxycillin + clavulanate with rates of 91.1%, 80%, 50% and 38.1% respectively (Table 3). All B. fragilis, 98.3% of S. aureus and 92% of S. epidermidis isolates were resistant to penicillin G while streptococci remained the most sensitive to the drug with a resistance rate of only 5.6% (Table 4).

The resistance rates of Pseudomonas spp., isolates to piperacillin, aztreonam, imipenem and ceftazidime were 8.5%, 16%, 12.4% and 6.8% respectively; 15.2% of 407 S. aureus and 25.7% of 74 S. epidermis isolates were resistant to cefoxitin.

Table 1:Organisms isolated from patients treated in KFHU

Organisms Detected

Frequency

%

Streptococci

939

25.5

S. aureus

594

16.1

E. coli

469

12.7

Pseudomonas spp.

342

9.3

Klebsiella spp.

258

7.0

Candida spp.

172

4.7

Enterobacter spp.

145

3.9

S. epidermidis

119

3.2

Salmonella spp.

118

3.2

H. influenzae

90

2.4

H. aegyptius

80

2.2

Serratia spp.

64

1.7

Proteus spp.

40

1.1

Acinetobacter spp.

39

1.1

Citrobacter spp.

30

0.8

B. fragilis

29

0.8

Peptococcus spp.

21

0.6

S. saprophyticus

19

0.5

M. catarrhalis

17

0.5

M. morganii

17

0.5

Shigella spp.

16

0.4

G. vaginalis

13

0.4

N. gonorrhoeae

12

0.3

Providencia spp.

9

0.2

H. pylori

7

0.2

X. maltophilia

6

0.2

B. melentesis

3

0.1

C. perfringens

2

0.1

Aspergillus spp.

2

0.1

Bacillus spp.

2

0.1

Campylobacter spp.

1

0.0

Corynebacteria spp.

1

0.0

Aeromonas sobria

1

0.0

Flavobacterium spp.

1

0.0

C. tetani

1

0.0

Total

3679

100

Table 2: Patterns of resistance to ampicillin

Microorganisms

No. of tests

No. resistant

% Resistance

E. coli

455

274

60.2

Enterobacter spp.

139

129

92.8

H. aegyptius

72

44

45.8

H. influenzae

84

52

61.9

Salmonella spp.

117

26

22.2

Streptococci

925

15

1.6

Others

315

227

72.1

Total

2107

767

36.4

Table 3: Patterns of resistance to amoxicillin + clavulanate (AMX + CLV)

Micro-organisms

No. of tests

No. Resistant

% Resistant

E. Coli

197

75

38.1

Enterobacter spp

110

88

80.0

H. aegyptius

72

33

45.8

H. influenzae

84

42

50.0

Klebsiella spp

149

36

14.5

Salmonella spp

118

  7

  5.9

S. aureus

146

133

91.1

Streptococci

412

   4

  1.0

Others

208

119

57.2

Total

1496

537

35.9

Table 4:Patterns of resistance to penicillin G

Micro-organisms

No. of tests

No. Resistant

% Resistant

B. fragilis

28

28

100

G. vaginalis

13

2

15.4

Peptococcus spp

18

2

11.1

S. aureus

517

508

98.3

S. epidermidis

100

92

92.0

Streptococci

568

32

5.6

Others

67

48

71.6

Total

1311

712

54.3

Table 5: Patterns of resistance to tetracycline

Micro-organisms

No. of tests

No. Resistant

% Resistant


 

E. Coli

418

228

54.5

Enterobacter spp

131

36

27.5

H. aegyptius

65

50

76.9

H. influenzae

82

66

80.5

Klebsiella spp

130

49

37.8

Salmonella spp

114

24

21.1

S. aureus

507

179

35.3

S. epidermidis

102

29

19.4

Streptococci

872

636

72.9

Others

409

192

46.9

Total

2830

1489

52.3


 

Table 6: Patterns of resistance to gentamicin and multiple resistance to gentamicin and amoxycillin + clavulanate

Resistance to gentamicin

Resistance to gentamicin & AMX+CLV

Micro-organisms

No. tested

No. Resistant (%)

No. tested

No. Resistant (%)

E. Coli

211

38 (18.0)

168

12 (7.10)

Enterobacter spp

120

26 (21.7)

106

20 (18.9)

H. aegyptius

71.0

  8 (11.3)

66

  3 (4.50)

H. influenzae

69.0

11 (15.9)

63

  3 (4.80)

Klebsiella spp

167

27 (16.2)

139

16 (11.5)

Pseudomanas spp

328

60 (18.3)

  6

  1 (16.7)

S. aureus

239

130 (54.4)

124

110 (88.7)

Others

321

120 (37.4)

167

  39 (23.4)

Total

1568

411 (26.2)

839

204 (24.3)


 

Table 7: Patterns of resistance to trimethoprim/sulphamethoxazole

Micro-organisms

No. of tests

No. Resistant

% Resistant

E. Coli

455

219

48.1

Enterobacter spp

143

28

19.6

H. aegyptius

69

62

89.9

H. influenzae

85

64

75.5

Klebsiella spp

248

64

25.8

Salmonella spp

115

15

13.0

S. aureus

533

111

20.8

S. epidermidis

100

26

26.0

Streptococci

929

742

80.4

Others

295

117

39.7

Total

2972

1448

48.7

Sensitivity of 2830 isolates to tetracycline is presented in Table 5. The overall resistance rate was 52.3%. In ranking order, the higher resistance rates were 80.5%, 76.9%, 72.9% and 54.5% for H. influenzae, H. aegyptius, streptococci and E. coli respectively, while S. epidermidis had the lowest rate of resistance (19.4%).

Table 6 summarizes the resistance patters of 1568 isolates to gentamicin. The highest rate of resistance (54.4%) was observed with  S. aureus and the lowest (11.3%) with H. aegyptius. In addition, a high resistance pattern to amikacin was exhibited by S. aureus, 135 (71.1%) while 33 (10%) of 331 Pseudomonas spp. and only 1 (1.1%) of 93 S. epidermidis isolates showed resistance to it. All the 146 (25.5%) methicillin resistant S. aureus isolates were sensitive to vancomycin and teicoplanin but 11.3% of them were resistant to lincomycin.

Sensitivity of 2972 isolates to trimethoprim/sulphamethoxazole is shown in Table 7. The overall resistance rate was 48.7%, the highest rate (89.9%) was observed with H. aegyptius, streptococci (80.4%), H. influenzae (75.5%), and E. coli (48.1%) while Salmonella spp. sowed the lowest resistance rate (13%).

Nalidixic acid, norfloxacin and nitrofurantoin showed high efficacy against E. coli with resistance rates as low as 15.8%, 10.5% and 7.4% respectively. Only 7 (4.3%) of 163 Klebsiella spp. and 6 (5%) of 119 Enterobacter spp. isolates were resistant to ciprofloxacin.

Amoxycillin + clavulanate and chloram-phenicol were the most effective drugs against Salmonella spp. isolates with resistance rates of 5.9% and 8.7% respectively, while resistance rates to erythromycin were relatively high in streptococci (41.5%) and S. aureus (33.9%).

DISCUSSION

The data in this study include community and nosocomial infections at King Fahd Hospitalof the University (KFHU) in the eastern provinceof Saudi Arabia. The most frequently isolated pathogens were strepto-cocci (25.5%) of which streptococcus B was the most common group, S. aureus (16.1%) and E. coli (12.7%). However, another study carried out in a general hospital in the same region9 showed that the most frequently isolated nosocomial pathogens were Pseudomonas spp., S. aureus, Klebsiella spp., and E. coli. Similar patterns of prevalence were observed in Danish, Spanish and Canadian hospitals while P. aeruginosa and methicillin resistant coagulase-negative staphylococci and S. aureus were found to be the most frequent nosocomial pathogens in some other European hospitals.10-14

The antibiograms of isolated organisms showed great variation between types of antimicrobial agents tested and types of isolates. Very low rates of resistance were observed with streptococci to all the investigated penicillins (range 1.0-5.6%), thus penicillins remain the most effective agents in the treatment of streptococcal infections which constitute 26% of all infections. In contrast, very high rates of resistance (90%) were encountered with S. aureus to both penicillin and AMX+CLV suggesting that the likely mechanism of resistance to penicillin and AMX+CLV is in the change in the target of action of penicillin and not the production of beta-lactamases since AMX+CLV contains a beta lactamase inhibitor, clavulanic acid. Similarly, enterobacter isolates in our hospital were highly resistant to both ampicillin (92.8%) and AMX+CLV (80.0%), again, suggesting that the mechanism of enterobacter resistance to beta lactam antibiotics is not via the production of b-lactamase. These results are in agreement with those of Andersen et al15 who reported that 46 enterobacter isolates showed a high resistance to both extended spectrum penicillins and third generation cephalosporins. Resistance of E. coli to ampicillin (60.2%) and AMX+CLV (38.1%), however, suggests that production of b-lactamase and extended – spectrum b-lactamase are the most likely mechanisms of resistance by these organisms. Similar findings have been reported for both E. coli and Klebsiella spp., by several investigators.5,16-18

Resistance to tetracycline (Table 5) was generally high or moderate with all isolated organisms including Haemophilus spp., streptococci, E. coli and staphylococci. However, tetracyclines are not considered among the drugs of choice for infections caused by all of these organisms. Nevertheless, our data reflects the impact of extensive use of these antibiotics in primary health clinics and as additives to animal feed in the eastern provinceof Saudi Arabia. It is well established that cross-resistance between the various tetracycline compounds is common and probably plasmid mediated. The mechanisms by which organisms acquire resistance to tetracyclines possibly involve decreased drug penetration through cell membranes, reduced binding to bacterial ribosomes or by enzymatic inactivation of the drug.19

The good activity of gentamicin against all gram-negative organisms investigated (Table 6) in our study confirms the fact that aminoglycosides are known to be mostly effective against gram negative species. The relatively low resistance rates observed with gentamicin suggest that aminoglycosides are not misused since their use is restricted mainly to hospitalized patients. Multiple resistance to both gentamicin and AMX+CLV was observed with some gram-negative organisms, such as E. coli (7.1%), Enterobacter spp., (18.9%) and Klebsiella spp., (11.5%). Such findings were previously reported by French et al18 who isolated an extended-spectrum b-lactamase producing Klebsiella strains which were resistant to aminoglycosides and both cephalosporins and b-lactam b-lactamase inhibitor combinations. Although, P. aeruginosa isolates were not investigated for the combination of aminoglycosides and extended spectrum b-lactams in our study, other investigators reported an outbreak of these organisms which were highly resistant to aminoglycosides, extended spectrum b-lactams and quinolones in a Brazilian hospital.20

Trimethoprim is a bacteriostatic agent commonly used in combination with sulphamethoxazole (Co-trimoxazole, TMP-SMX) or as a single agent to treat urinary tract infections.21-23 Our data suggest an emergence of high resistance to this drug combination especially, in E. coli and streptococci which are the main infecting agents of the urinary tract. The mechanism of acquired resistance to trimethoprim in gram negative bacteria is suggested to be plasmid – mediated alteration of the target enzyme, dihydrofolate reductase.24

In contrast to the observation of Asensi et al25 who reported an outbreak in Brazil of Salmonella agona that was resistant to ampicillin, TMP-SMX, tetracycline, chloramphenicol, cephalosporins and aminoglycosides.  Amoxycillin + clavulanate, chloramphenicol and trimethoprim were still highly effective against Salmonella spp.

The results of the investigated quinolones showed that nalidixic acid and norfloxacin had good activity against E. coli while ciprofloxacin was highly effective against enterobacteriaceae. Similar results were reported by Acar et al6 who concluded that resistance to fluoroquinolones was still rare in common pathogens in France.

In conclusion, the antibiograms of pathogenic organisms in the eastern provinceof Saudi Arabiashow alarmingly high resistance patterns especially to these essential antibiotics. This may be due to the fact that these drugs are available to patients without prescription26,27 inspite of laws which classify them as non-over-the-counter (non-OTC) drugs. However, in comparison to those published in other countries our results show a great variation owing to a number of factors, such as antibiotic policies, the extent of use of broad spectrum antibiotics, abuse of antibiotics and the absence of global standard method for performing the sensitivity test or interpreting the results.28

We, therefore, recommend that antibiogram studies of nosocomial and community pathogens should be carried out periodically on national or regional levels. The results would be of great value in optimizing treatment strategies and national drug policies as well as in measuring the success of these policies. Furthermore, the results of such studies could be used to educate policy-makers, prescribers, health care professionals, and the general public in order to reduce misuse of antibmicrobial agents.

ACKNOWLEDGMENTS

The King Abdulaziz City of Science and Technology (KACST) to whom we express our gratitude funded this work. Our sincere thanks also go to Dr. Abdulrahman Qurashi, and the technical staff at the Microbiology laboratories at King Fahd Hospitalof the University and to Mr. Hasan Isa and Mr. Abdul-Rahman Al-Fakki, Collegeof Medicinefor their assistance. We also thank Dr. E.B. Larbi for reviewing the manuscript.

REFERENCES

1.     Dever LA, Dermody TS. Mechanisms of bacterial resistance to antibiotics. Arch Intern Med 1991; 151: 886-95.

2.     Sanders CC, Sonders WE. Microbial resistance to newer generation B-lactam antibiotics. Clinical and laboratory implications. J Infect Dis 1985; 151:399-406.

3.     Boyed RF, Hoerl BG.Basic medical microbiology 4th ed. Boston( Toronto): Little Brown and Company; 1991.

4.     Livemore DM, Wood MJ. Mechanisms of bacterial resistance to antimicrobial agents. N Engl J Med 1991; 324: 601-12.

5.     Sader HS, Pfaller MA, Jones RN. Prevalence of important pathogens and the antimicrobial activity of parenteral drugs at numerous medical centers in the United States.  II study of beta-lactamases producing Enterobacter-iaceae. Diagn-Microbiol-Infect Dis 1994; 20(4):203-8.

6.     Acar JF, O’ Brien TF, Goldstein FW, Jones RN. The epidemiology of bacterial resistance to quinolones. Drugs 1993; 45 (suppl. 3): 24-8.

7.     Koneman EW, Allen SD, Janda WM, Schreckenberger BC, Winns WC. Color Atlas and Textbook  of Diagnostic Microbiology. Phladelphia: J.B. Lippincott Company; 1992.

8.     National Committee  for Clinical Laboratory Standards (NCCLS). Performance Standards for Antimicrobial Disk Susceptibility Tests. 5th ed. Approved standard M2 - A5. Villanova, Pa: National Committee  for Clinical Laboratory Standards; 1993.

9.     Elbashier AM. Five years of prospective surveillance of nosocomial infections in a Saudi Arabian general hospital. Saudi Med J 1997; 18(4): 414-7.

10.   Fomsgaard A, Hoiby N, Fris HM, Gahrn-Hansen B, Kolmos HJ, chouenborg P, Korsager B, Tvede M, Gutschik E and Bremmelgaard A. Prevalence and antibiotic sensitivity of Danish versus other European bacterial isolates from intensive care and hematology/oncology units. Eur J Clin Microbiol Infect Dis 1995; 14(4): 275-81.

11.   Vincent JL, Bihari DJ, Suter PM, Bruining HA, White J, Nicolas-Chanoin MH, Wolff M, Spencer RC, Hemmer M.  The prevalence of nosocomial infection in intensive care units in Europe. JAMA. 1995; 274(8): 639-44.

12.   Spencer RC.  Epidemiology of infection in ICUs.  Intensive Care Med  1994; 20 (suppl 4): S2-6.

13.   Vazques F, Mendoza MC, Villar MH, Perez F and Mendez FJ. Survey of bacteraemia in a Spanish hospital over a decade (1981-1990). J Hosp Infect 1994; 26(2): 111-21.

14.   Preston CA, Bruce AW and Reid G. Antibiotic resistance of urinary pathogens isolated from patients attending the Toronto Hospitalbetween 1986 and 1990. J Hosp Infect 1992; 22(2):129-35.

15.   AndersonJ, Asmar BI and Dajani AS.Increasing Enterobacter bacteremia in pediatric patients. Pediatr-Infect-Dis J 1994: 13(9): 787-92.

16.   Johnson AP, Weinbren MJ, Ayling-Smith B, Du-Bois-SK, Amyes SG, George-RC. Outbreak of infection in two UKhospitals caused by a strain of klebsiella pneumoniae resistant to cefotaxime and ceftazidime. J Hosp Infect 1992; 20(2):97-103.

17.   Meyer-KS, Urban C, EaganJA, Berger BJ and Rahal JJ. Nosocomial outbreak of klebsiella infection resistant to late-generation cephalosporins. Ann Intern Med 1993; 119(5): 353-8.

18.   French GL, Shannon Kpand Simmons N. Hospital outbreak of Klebsiella pneumoniae resistant to broad-spectrum cephalosporins and beta lactam-beta-lactamase inhibitor combinations by hyperproduction of SHV-5 beta-lactamase. J Clin Microbiol 1996; 34(2):358-63.

19.   Speer, B.S., Shoemaker, N.B and Salyers, A.A.  Bacterial resistance to tetracycline: mechanism, transfer, and clinical significance.  Clin Microbiol Rev 1992; 5:387-99.

20.   Sader-HS, Pignatari AC, Leme IL, Burattini MN, Tancresi R, Hollis RJ and Jones RN. Epidemiologic typing of multiply drug-resistant pseudomonas aeruginosa isolated from an outbreak in an intensive care unit. Diagn Microbiol Infect Dis 1993; 17(1): 13-8.

21.   Vahlensieck W Jr and Westenfelder M. Nitrofurantoin versus trimethoprim for low-dose long-term prophylaxis in patients with recurrent urinary tract infections. Int Urol  Nephrol 1992; 24 (1): 3-10.

22.   Spencer RC; Moseley DJ and Greensmith MJ. Nitrofurantoin modified release versus trimethoprim or co-trimoxazole in the treatment of uncomplicated urinary tract infections in general practice. J  Antimicrob  Chemother 1994; 33 suppl A: 121-9.

23.   Masterton RG and Bochsler JA. High-dosage co-amoxiclav in a single dose versus 7 days of co-trimoxazole as treatment of uncomplicated lower urinary tract infection in women. J Antimicrob Chemother 1995; 35(1):129-37.

24.   Houvinen, P. Trimethoprim resistance. Antimicrob Agents Chemother 1987;31:1451-6.

25.   Asensi MD, Solari CAand Hofer E. A salmonella agona outbreak in a pediatric hospital in the city of Rio de Janeiro, Brazil Mem Inst Oswaldo Cruz 1994; 89(1):1-4.

26.   Al-Freihi H, Ballal SG, Jaccarini A, Young MS, Abdul-Cader Z, El-Mouzan M. Potential for drug misuse in the eastern provinceof Saudi Arabia.  Ann Saudi Med 1987; 7:301-5.

27.   Bawazir SA. Prescribing pattern at community pharmacies in Saudi Arabia.  Int. Pharmacy J 1992; 6 (5): 222-3.

28.   World Health Organisation, Geneva.  Weekly Epidemiological Record 1997; 72 (45): 333-40.


-0001-11-30

PREDICTIVE FACTORS


PREDICTIVE FACTORS AND INCIDENCE OF COMPLICATIONS IN APPA RENTLY HEALTHY FULL TERM INFANTS OF DIABETIC MOTHERS

Hakam A. Yaseen, CES, DUN*, Suleiman S. Al-Najashi, M.MED(O/G), Ashraf A. Adel, MD*, Ahmad A. Bahnassy, PhD‡, Khalid U. Al-Umran, MD*, Abdulatif A.     Al-Faraidy, FACHARTZ*

Departments of Paediatrics, Obstetrics and Gynecology, and Family & Community Medicine, College of Medicine, King Faisal University, Saudi Arabia

هدف الدراسة: لتحديد المضاعفات التي تصيب أطفال الأم المصابة بالسكري المعافين ظاهرياً من الأمراض لدى ولادتهم وتحديد إمكانية توقيع تلك المضاعفات .      

طريقة الدراسة: أجريت الدراسة في وحدة الحضانة بمستشفى الملك فهد الجامعي واستمرت لمدة 18 شهراً. الأطفال المدرجين في الدراسة هم أطفال الأم السكرية الخاليين من الأعراض عند ولادتهم ووزن ولادتهم يساوي أو يزيد عن 2000غ. أمهات الأطفال مصبن بمرض السكري الحملى أو السريري. كل هؤلاء الأطفال لوحظوا في وحدة الحضانة لمدة لا تقل عن 48 ساعة. خلال تلك المدة، أجريت فحوص دموية لهؤلاء الأطفال تضمنت تعداد الدم ونسبة كل من الجلوكوز والبروتين والكالسيوم. مجموعة الأطفال المرضى تتضمن كل طفل من هؤلاء احتاج إلى مراقبة أو علاج بالمستشفى لمدة تزيد عن 48 ساعة من وقت ولادته.

نتائج الدراسة: مجموع الأطفال المدرجين في الدراسة كان 188 طفلاً بمعدل أوزان  3411  + 616 غ وكان معدل عمرهم الحملي 5, 38  + 2, 1 أسبوع. نسبة المضاعفات لديهم كانت كالتالي : نقص السكر  ( 31% ) ، نقص الكالسيوم ( 4% ) ، احمرار الدم ( 13% ) ، اليرقان ( 18% ) نقص الوزن ( 2% ) أما زيادة وزن الولادة فقد كان ( 30% ) إن استخدم طريقة التراجع الاحصائي ساعدت في إمكانية توقع زيادة نسبة حدوث هذه المضاعفات فقد ظهر بأن معالجة الأم بالأنسولين ، نقص التحكم بمرض السكر ، اختناق الوليد ، نقص السكر المبكر واحمرار الدم كانت شائعة في مجموعة الأطفال المرضى مع نسبة أود: 2.41 ، 2.91  9.65، 3.88، 3.74 بالترتيب .

الخلاصة : تم تحديد نسبة المضاعفات المشاهدة عند أطفال الأم السكرية الخاليين من الأعراض ظاهرياً عند ولادتهم ، وقد تم تحديد بعض العوامل المرضية التي قد تزيد من إمكانية حدوث تلك المضاعفات.

الكلمات المرجعية: أطفال الأم السكرية، المعافين، المضاعفات.

Aim:To determine the incidence of different complications of the apparently healthy full-term infants of diabetic mothers (IDMs) and whether these complications could be predicted early.

Methods: A prospective study was performed in the Nursery Unit of King Fahd Hospitalof the University in Al-Khobar over an 18-month period. Eligible neonates were those full-term IDMs who were asymptomatic at birth, with birth weight ³2000 g and whose mothers had gestational or pregestational diabetes. AUDMs were routinely observed for at least 2 days. A complete blood count, glucose, bilirubin and

Correspondence to:

Dr. Hakam Yaseen, King Fahd Hospital of the University, P.O. Box 40227, Al-Khobar 31952, Saudi Arabia

calcium serum levels were monitored. The morbidity study group included all IDMs who experienced complications requiring treatment or observation for 48 hours.

Results: One hundred and eighty eight infants with a birth-weight of 3411 ±616 g and with gestational age of 38.5 ±1.2 weeks  were enrolled  in  the study. Asymptomatic  hypoglycemia (31%) was mostly  mild and  transient. The  rate of   other  complications such as hypocalcemia (4%), polycythemia (13%), hyperbilirubinemia (18%), intrauterine growth retardation (2%) with 30% rate for large gestational age. Using a logistic regression model; maternal insulin therapy, poor diabetic control, birth asphyxia, early neonatal hypoglycemia and polycythemia were found to be highly predictive of  morbidity with an odd ratio of 2.41, 2.91, 9.65, 3.88 and 3.74 respectively.

Conclusion:Complications of apparently healthy IDMs appear to be very mild and transient. These were found to be strongly associated with specific perinatal events.

Key Words: Infant of diabetic mother, full-term, complications.


 

INTRODUCTION

It has been recognized for many years that infants of diabetic mother (IDMs) are at increased risk of perinatal morbidity. It has been estimated that IDMs account for 5% of all admissions to neonatal intensive care units.1 Disorders of fetal growth (40%), hypoglycemia (25-50%), hypocalcemia (10-20%), polycythenia (10-40%) prematurity (15%), hyper-bilirubinemia (20-25%), respiratory distress (15%), and intrapartum asphyxia (15%) are some of the clinical problems still affecting the IDMs.1-3 All these values mentioned above were calculated from a general population of IDMs including term, preterm, symptomatic, and asymptomatic neonates. Complications and postnatal care should certainly not be the same for all neonates of diabetic mothers. Some modern series suggest  that   neonatal complication rates are now so low in full term IDMs that routine admission would not be justified.4 To our knowledge, no precise data of the incidence of complications of apparently healthy full-term IDMs has been reported in the literature. A prospective study was therefore, conducted in an attempt to answer the following questions: What is the incidence of the different complications of the apparently healthy full-term IDMs? Could these complications be predicted early during the first day of life? Answers to these questions will help pediatricians to make decisions as to whether or not to routinely admit apparently healthy full-term IDMs to the special care baby unit.

METHODS

This prospective study was performed in the Nursery Unit at King Fahd Hospitalof the University, Al-Khobar over an 18-month period from January 1996 to June 1997. The study protocol was approved by the local human ethics committee. Informed parental consent was obtained prior to study entry. Eligible neonates of diabetic mothers were those full-term infants weighing ³2000 g admitted to Nursery Unit at birth. Gestational age was calculated from the last menstrual period, consistent within two weeks with the gestational age as measured by clinical assessment. All studied infants were asymptomatic at birth. Transiently and mildly hypotonic infants born with mild birth asphyxia (as defined below) were also included in this study. All the mothers of studies neonates had gestational or pregestational diabetes and were managed with both diet and insulin or with diet only. The criteria for exclusion from the study included all IDMs born with severe or moderate asphyxia, respiratory distress, sepsis or suspected sepsis, hemolytic jaundice and congenital anomalies or metabolic diseases that required admission to the Neonatal Intensive Care Unit.

Maternal Care

Perinatal data were obtained by maternal interviews and charts. Antenatal control and management of maternal diabetes had been performed in the Obstetric Department. The 100 g, 3-hour oral glucose tolerance test on venous plasma was adopted by our obstetricians as a diagnostic test for gestational diabetes.5 Once gestational diabetes was diagnosed, diet therapy was initiated as the primary way to control glucose. A fasting glucose level of more than 100 mg/dL (5.8 mmol/L) and a postprandial glucose level exceeding 120 mg/dL (6.7 mmol/L) indicated the need for insulin treatment.5

According to the weekly sugar profile (the mean of fasting, three postprandial and midnightglucose measurements) maternal diabetic control was classified into three types: tight, fair and poor control if maternal sugar profile were <120 mg/dL (6.7 mmol/L), 120-140 mg/dL (6.7-7.7 mmol/L), and 140 mg/dL (7.7 mmol/L) respectively.6

Neonatal Care

All infants of diabetic mothers were routinely observed in the Neonatal Care Unit for at least 2 days. At birth, serum glucose, complete blood count, calcium level, and blood gases were performed from blood from the umbilical cord. Requirement for resuscitation or sodium bicarbonate was noted. In the unit, early feeding was practiced. Neonatal glucose level was monitored by a glucometer (ONE TOUCH IITM, California, USA) at 1, 2, 4, 8, 16, 24, 36 and 48 hours of life. Serum glucose was monitored more frequently if hypoglycemia was detected. If the glucometer value of glucose level was less than 40 mg/dL (2.2 mool/L), serum glucose level was requested. A serum glucose concentration of less than 40 mg/dL (2.2 mmol/L) was considered as hypoglycemia.2 All infants were observed for clinical signs of hypoglycemia including: apnea, cyanosis, seizures, temperature instability, hypotonia and sweating. After the initial oral feeding, if glucose level remained abnormally low, a peripheral intravenous infusion of 2 ml/kg D10W was administered.3 A continuous infusion of D10W, 8 mg/kg/minute of glucose was usually ordered. Persistent hypoglycemia was defined as the presence of at least 2 plasma glucose values < 40 mg/dL. Serum calcium level was performed at 48 hours of life. Hypocalcemia was defined as a central hematocrit level greater than 65%. Neonatal hyperbilirubinemia was defined as a total serum bilirubin greater than 8 mg/dL (136 mmol/L) and 13 mg/dL (221 mmol/L) at 24 hours and 48 hours of life, respectively.8 Phototherapy was started whenever the indirect bilirubin level reached 13 mg/dL (221 mmol/L) during the first 48 hours of life.8 Perinatal asphyxia was defined by the presence of fetal distress before delivery (fetal heart rate, late decelerations or prolonged fetal bradycardia), and neonatal asphyxia (1-minute Apgar score £6 associated with umbilical cord blood gas showing metabolic acidosis).9 Infants were considered large for gestational age (LGA) if their birth weight was ³90th percentile and small for gestational age (SGA) when their birth weight was £10th percentile.10

The group of IDMs which experienced complications that required treatment or observation for 48 hours was defined as the “morbidity group”, the rest was defined as the “no morbidity group”.

Statistical analysis

The Chi-square test with the Fisher exact test, when appropriate, was used for nominal data. A two-tailed T-test was used for the comparison of means of continuous variables. To predict factors that increase the risk of delaying discharge for more than 48 hours, logistic regression with the forward method was used. The dependent variable was either ‘yes’ (morbidity group) or no (no-morbidity group). Data with odds ratios (OR) were used to express the magnitude of the association between the morbidity group and the independent variables such as: pregestational diabetes, insulin treatment, poor diabetic control, mode of delivery, mild perinatal asphyxia, early hypoglycemia, polycythemia, LGA and SGA. Data were analyzed using SPSS6.0 for windows. A p-value of <0.05 or a 2-tailed test was taken as statistically significant.

RESULTS

During the study period, 188 apparently healthy full-term infants of diabetic mothers  including  one set of  twins were enrolled in the study. The mean birth weight was 3411 ±616 g and the mean gestational age of 38.5 ±1.2 weeks. The maternal characteristics and outcome of all the patients are shown in Table 1. Past history of LGA, SGA or congenital malformations were found in 42 cases (22%). Parent obstetric history relating to the maternal diabetes such  as  polyhydramnios,  preeclampsia or maternal hypertension was found in 39 cases (20%). Incidence of different types of complications in apparently healthy full-term IDMs is listed in Table 2. Hypoglycemia appeared during the first 4 hours in all hypoglycemic infants. There were 8 cases of persistent hypoglycemia and only 4 infants required intravenous infusion for more than 24 hours (Table 3).In all cases, serum glucose

Table 1: Maternal characteristics and outcome


 


 

Characteristics

No.

%

Pregestational diabetes

26

14

Insulin treatment

63

33.5

Cesarean delivery

37

20

Poor diabetic control

21

11


 


 

Table 2: Morbidity of apparently healthy full-term IDM


 

Complications

No.

%

Any hypoglycemia

59

31

Persistent hypoglycemia

8

4

Hypocalcemia

8

4

Mild birth asphyxia

9

5

Polycythemia

25

13

Hyperbilirubinemia

34

18

LGA

58

30

SGA

4

2

Table 3: Causes of delay of discharge of IDM for


 

48 hours (Morbidity group)


 

Causes

No.

%

Jaundice requiring phototherapy*

28

15

Persistent hypoglycemia†

4

2

Hypocalcemia‡

7

4

Poor sucking§

4

2

Total

43

23


 

*Indirect hyperbilirubinemia 13 mg/dL during the first

  48 hrs of age

†Requiring D10W intravenous (IV) infusion for 48 hrs.

‡Calcium level <7.5 mg/dL requiring IV calcium

§Feeding with gastric tube for 48 hrs.

was normalized in the second day of life. Eight cases of hypocalcemia were discovered at 48 hours of life. Three of these cases had calcium level of 6 to 7 mg/dL and 5 cases, calcium level of 7 mg/dL and <8 mg/dL. Hypocalcemia was treated with intravenous calcium. All cases of hypocalcemia were persistent. Twenty-five patients (13%) had polycythemia; 19 of these required partial exchange transfusion because their hemotocrit exceeded 67%. From 34 patients (18%) with hyperbilirubinemia, 28 patients had been treated with phototherapy (Table 3). Delayed discharge for more than 48 hours of birth was found in a total of 43 infants (23%) (Table 3).

Table 4: Factors associated with delayed discharge of IDM (Morbidity group)


 

Variable

B

Odds ratio

p- value

Poor diabetic control

1.069

2.91

0.030

Maternal insulin therapy

0.883

2.41

0.025

Birth asphyxia

2.267

9.65

0.003

Hypoglycemia within the first 4 hours of birth

1.357

3.88

0.010

Polycythemia

1.32

3.74

0.012


 

From Logistic Regression Model


 


 

Table 4 shows the logistic beta slopes, the odds ratio, and the p-values of the five factors found by logistic regression analysis to be predictive of morbidity group of IDMs early after birth. There  was  no  significant difference between the two groups (morbidity and no-morbidity groups) in maternal age, maternal weight gain during pregnancy, maternal glucose profile and neonatal birth weight. Bilirubin level at 24 hours of age was significantly more in the morbidity group 7.5 ±2.2 mg/dL versus 5.6 ±2 mg/dL in the no-morbidity group (p=0.002). Hypocalcemia was associated with at least one of the factors listed on Table 4.

DISCUSSION

A  previous study has  shown that prematurity is the most important factor predisposing to severe neonatal complications among the general population of IDMs.11 In our study, it was found that apparently healthy full-term IDMs experienced relatively lower incidence of complications such as: hypocalcemia, polycythemia, hyperbilirubinemia, and intrauterine growth retardation than in the general population of IDMs.2,3 Although, the incidence of  hypoglycemia  was not significantly decreased in this group of infants, it seemed to be very benign and transient. Only 4% of infants had more than one reading of hypoglycemia with a total normalization of serum glucose at 24 hours after birth. This  rapid improvement  of  hypoglycemia  could be  explained by the significant increase in plasmatic glucagon of IDMs during the first 24 hours of life.12 The incidence of hypocalcemia was significantly low in our patients (4%) compared with 10% to 20% in the general population of IDMs.2 It would be even much lower (1.5%) if hypocalcemia was defined as a calcium level <  7 mg/dL (1.7 mmol/L).3 Hypocalcemia in IDMs was found to be potentiated by prematurity and asphyxia.13 The selection of our patients as a full-term IDMs could explain the low incidence of hypocalcemia. The incidence of LGA infants is approximately 8% in infants of non-diabetic women and about 26% in the general population of infants of diabetic mothers.3

                                In our study, the incidence of LGA infants was higher reaching 30%. This increased LGA incidence might be related to the exclusion of preterm infants from our study. Macrosomia is increasingly common after 37 weeks gestation, with the highest rate at 41 weeks gestation and over.14

                                The most important factor responsible for delaying discharge from the nursery was hyperbilirubinemia. A recent study found that none of 1140 newborns who had bilirubin level lower than 5 mg/dL on the first day of life subsequently developed serum bilirubin concentration of 17 mg/dL or more.15 In our patients, the mean bilirubin level at 24 hours of birth was greater in the morbidity group (7.5 mg/dL) compared with 5.6 mg/dL in the no-morbidity group, so these results are similar to those reported in a previous study.15 Using Logistic Regression model, maternal insulin therapy, poor diabetic control, birth asphyxia, early neonatal hypoglycemia within the first 4 hours of birth and polycythemia were found  to be highly predictive of morbidity in IDMs. All these factors are easy to obtain on admission or during the first hours of life. Gabbe et al16 observed a 65% incidence of neonatal morbidity among 260 women treated with insulin. It is now widely accepted that the degree of glycemic control achieved in the diabetic pregnant women significantly affected perinatal outcome.6 Hanson et al11 found that an elevated maternal glycosylated hemoglobin as an index of a poor diabetic control was associated with increased neonatal morbidity. What is important is whether it is necessary for pediatricians to routinely admit all IDMs to the special care baby unit.

                                In our opinion, the above predictors of morbidity are helpful in making decisions for the management of apparently healthy full-term IDMs. The following guidelines are therefore, suggested: At 4 hours of birth, the absence of any of the predictors shown in Table 4 would allow for a routine postnatal care and discharge from the nursery within the normal time period. Admission to the nursery might be considered, if the presence of at least one of these predictors was associated  with  bilirubin level of  5 mg/dL at 24 hours of birth. Admission policy in this group of infants should, therefore, be based on the presence or absence of predictors of morbidity, condition at birth and subsequent development of hypoglycemia and/or hyperbilirubinemia. Such a policy has obvious advantages in terms of improving cost-effectiveness and perhaps would contribute to better continuation rates of breast-feeding.

REFERENCES

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2.     Ogata E.S. Carbohydrate Homeostasis. In Avery GB, Fletcher MN, and MacDonald MG. Neonatology pathophysiology and manage-ment of the newborn. Philadelphia. JB Lippincott 1994. 4th Ed. 568-81.

3      .Cordero L and Landon  MBInfant of the diabetic mother. Clin Perinatol 1993; 20:635-47.

4.     Fraser R. Diabetes in pregnancy. Arch Dis Child 1994; 71:F224-30.

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6.     Al Najashi SS Control of gestational diabetes. International J Gynecol Obstet 1995; 49:131-5.

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8.     Fetus and Newborn Committee, Canadian Pediatric Society.  Use of phototherapy for neonatal hyperbilirubinemia. Can Med Assoc J 1986; 134:1237-45.

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10.   Brenner WE, Edelman DA, Hendricks CH.A standard of fetal growth for the United States of America. Am J Obstet Gynecol 1976; 126:555-64.

11.   Hanson U, Persson B, and Stangenberg M. Factors influencing neonatal morbidity in diabetic pregnancy. Diabetic Research 1986; 3:71-6.

12.   Kuhl C, Andersen GE, Hertel J, Molsted-Pendersen L. Metabolic events in infants of diabetic mother during firs 24 hours after birth. Acta Pediatr Scand 1982; 71:19-25.

13.   Kalhan S and Saker F. In Neonatal Perinatal Medicine. Fanaroff A and Martin R. Disorders of carbohydrates metabolism. St. LouisMosby Year Book 1997: 6th Ed, 1439-63.

14.   Neiger R. Fetal macrosomia in the diabetic patient. Clin Obstet Gynecol 1992; 35:138-50.

15.   Bhutani VK, Johnson LH and Cleplinski JA. Risk assessment of subsequent hyperbilirubinemia and phototherapy after early discharge. Presented at the American Academyof Pediatrics, San Francisco, California, Oct. 1995.

16.   Gabbe SG, Mestman JH, Freeman RK. Management and outcome of diabetes mellitus, Class B. R Am J Obstet Gynecol 1977, 129:723-32.


 


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