full pdf of issue - Middle East Journal of Family Medicine

ISSN 148-4196 September 2008 - Volume 6, Issue 7Chief Editor:Abdulrazak AbyadMD, MPH, AGSF, AFCHSEEmail: aabyad@cyberia.net.lbAssistant to the Editor:Ms Rima KhatibEmail: Rima@amc-lb.comReporter and Photographer:Dr Manzoor Butt,Email: manzor60@yahoo.comEthics Editor and Publisher:Ms Lesley Pocockmedi+WORLD International572 Burwood Road,Hawthorn, Vic Australia 3122Phone: +61 (3) 9819 1224:Fax: +61 (3) 9819 3269Email: lesleypocock@mediworld.com.auEditorial enquiries:aabyad@cyberia.net.lbAdvertising enquiries:lesleypocock@mediworld.com.auWhile all efforts have been made toensure the accuracy of the informationin this journal, opinionsexpressed are those of the authorsand do not necessarily reflect theviews of The Publishers, Editor orthe Editorial Board. The publishers,Editor and Editorial Board cannotbe held responsible for errors or anyconsequences arising from the use ofinformation contained in this journal;or the views and opinions expressed.Publication of any advertisementsdoes not constitute any endorsementby the Publishers and Editorsof the productadvertised.The contents of this journal arecopyright. Apart from any fair dealingfor purposes of private study, research,criticism or review, as permittedunder the Australian CopyrightAct, no part of this program may bereproduced without the permissionof the publisher.2 EditorialAbdul AbyadOriginal Contribution / Clinical Investigation3 The prevalence of metabolic Syndrome among type 2Saudi diabetic patientDr. Almoutaz Alkhier Ahmed8 The Distribution of Intestinal Parasites among Turkish Children Livingin a Rural AreaAsisst. Prof. Dr. Gulnaz CULHAMedicine and Society12 Strategies to improve status of family physicians:A perspective from an international collaborationWaris Qidwai, Tawfik A M Khoja, Victor Inem, Salman Rawaf, William E CayleyJr, Bader A. Almustafa, A. Abyad, Hakan YamanEducation and Training20 Job Satisfaction and Stress level of Primary Health Caregivers at PrimaryHealth Centers in Qatar.Jamila Hassan, Alkhalaf, Rajvir Singh, Maryam Malalah, Ezz Aldinal JakClinical Research and Methods24 Cerebral Palsy in Iranian Children:Farin Soleimani (M.D, Pediatrician), Sahel Hemmati (M.D, Psychiatrist), NasrinAmiri (M.D, Child Physiatrist)29 Pathophysiology of MigraineM. Bashir AbiadCase Report31 The Etiology and patterns of maxillofacial injuries at a militaryhospital in JordanMuntaha Y.Jerius MDOffice Based Family Medicine34 Efficacy of Mitomycin C in Pterygium ManagementMohammad Droos, MDMODEL AND SYSTEM OF PRIMARY CARE36 Marriage Migration Associated with Distance in Bangladesh: An Applicationof Polynomial ModelMd. Rafiqul Islam

FROM THE EDITORFrom the EditorAbdulrazak AbyadMD, MPH, AGSF, AFCHS(Chief Editor)Editorial office:Abyad Medical Center &Middle East Longevity InstituteAzmi Street, Abdo CenterPO BOX 618Tripoli, LebanonP + (961) 6 443684F + (961) 6 443685E aabyad@cyberia.net.lbW www.amc-lb.comIn this issue, an internationalcollaboration, with authors from7 countries looks at strategies toimprove the status of family physicians.Proposed strategies fall under thefollowing headings:1. Family medicine as the foundationfor health care systems;2. Promoting broad based scope forfamily practice;3. Promoting Family medicineresearch and scholarship.Further discussions relate tostrengthening of undergraduate andpost graduate education in FamilyPractice and promotion of quality infamily medicine with particular referenceto policy and services provision.A population based cross sectionalstudy paper from Qatar looked at JobSatisfaction and Stress level of PrimaryHealth Caregivers at Primary HealthCenters in Qatar. 323 questionnaireswere distributed to all the physicians/General Practitioners (GPs) workingin Primary Health Care Centers inQatar. Out of 323, only 176 (54%)responded. The authors concludedthat job satisfaction of primary healthcaregivers is critical for improvementof health systems. The results of ourstudy showed that Qatari physicianswere less satisfied with the rate ofpay and the amount of variety in work.Stress was found more in Qatari HealthCaregivers than Non-Qatari.A cross sectional study from SaudiArabia looked at the prevalence ofmetabolic Syndrome among type2 Saudi diabetic patients. The aimof the paper was to determine theprevalence of the syndrome amongtype 2 diabetic patients attending thediabetic center at Gurayat GeneralHospital. The population of the studywas patients with type 2 diabeteswith specific characters. Only 530patients were eligible to enter thestudy. Four criteria for diagnosing thesyndrome were defined (Fasting BloodGlucose >150mh/dl, Blood Pressure>140/90mmHg or taking drugs, obesityif BMI>30, dyslipidaemia if S.triglyceride> 150mg/dl and HDL

ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATIONThe Prevalence of Metabolic Syndrome Among Type 2Saudi Diabetic Patients: A particular View in GurayatProvinceABSTRACTIntroduction: the metabolic syndromeis one of the great challengesfacing physicians dealing with diabetesmellitus. The presence of thesyndrome increases the direct andindirect cost of care due to cardiovasculardisorders. The early surveillanceof the components of the syndromeand early intervention, willstopthe occurrence of the syndrome.Objectives: to determine the prevalenceof the syndrome among thediabetic patients with type 2 attendingthe diabetic center at GurayatGeneral Hospital and to determinethe commonest components amongthose patients.Methods: a randomized cross sectionalstudy was designed to detectthe magnitude of the syndrome. Thepopulation of the study was patientswith type 2 diabetes, with specificcharacters. Only 530 patients wereeligible to enter the study. Two hundredand sixty five (265) diabeticpatients (118 male and 147 female)were selected by randomized simplesystemic method. Four criteria for diagnosingthe syndrome were defined(Fasting Blood Glucose >150mh/dl,Blood Pressure >140/90mmHg ortaking drugs, obesity if BMI>30, dyslipidaemiaif S.triglyceride > 150mg/dland HDL

ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATIONof France estimates the prevalenceof metabolic syndrome was 23% inmales and 12% in females (11) . Ourresult was found to be higher thanthe result done by the view publishedstudies done in Saudi Arabia, butlower than the result of the lonelystudy done at the national level byAl-Nozha et al. In 2005 Al-Nozhaet al in his national survey for riskfactors for coronary disease foundthat the prevalence of the metabolicsyndrome was increased significantlyamong the Saudi population. It was39.3%, higher among females (42%)than among male (37.2%). Also Al-Nozha pointed to the increase in theprevalence of the syndrome amongurban dwellers in comparison to ruralpopulations (44.1% vs 35.6%) (17) .Interestingly our study highlights thehigh prevalence of low S.HDL-cholamong those with metabolic syndromethan those without the syndrome (Pvalue150MFBMI>30MFBP>140/80mmHgMFNon-Metabolic syndrome66.34% (N=205)58%58.9%57.2%37%35.7%39%37%35.7%39%Metabolic syndrome22.64% (N=60)100%100%100%81%82%81%36%18%65.2%MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6

ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATIONS-TG >160mg/Dl 49%48%M49.4%47.8%F50%48.6%HDL-chol30 47.5%N=126M 44.9%F 49.6%BP>140/80 37%N=99M 41.5%F 30%HDL-chol160mg/dL 49.7%N=131M 49.1%F 49.6%FBG>150mg/dL 67.5%N=179M 66.9%F 68.2%Figure 1: The overall percentage of the metabolic syndrome risk factors among all participantsFigure 2: Prevalence of metabolic syndrome componentsamong male patientsFigure 3: Prevalence of metabolic syndrome componentsamong female patientsMIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6

ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATIONFigure 4: Prevalence of metabolic syndrome in different countriesMIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6

The Distribution of Intestinal Parasites among TurkishChildren Living in a Rural AreaKey words: childhood, intestinal parasites, prevalence, personal hygiene, socioeconomicalstatus.ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATIONABSTRACTBackground: The aim of this studywas to determine the prevalence ofintestinal parasites in children and toevaluate its association with socioeconomicand environmental factors.Asisst. Prof. Dr. Gulnaz CULHACorrespondence to:Methods: Stool samples and cellulosetape slides of children between Deparment of ParasitologyMustafa Kemal University School of Medicine,1-16 years of ages living in a rural Antakya/HATAY TURKEYarea in Antakya were investigated.Phone:+90 326 2148661Fax:+90 326 2148214Stool samples were examined bye-mail: gulnazculha@yahoo.comusing the direct wet mount, iodinemethod, and sedimentation techniques.Results: One hundred and ninentynine(51.3%) of the 388 children in-Introductioncluded in the study were male, andIntestinal parasitosis is still anthe mean age was 6,8±3,4 yearsimportant public health problem(minimum 1, maximum 16). Most ofin underdeveloped or developingthe families (87.4 %) were from thecountries. 1 Incidence of intestinallowest socio-economical level andparasitosis is affected by variousalmost all of the mothers (96.4%)factors, such as personal hygiene,were housewivfes. One hundreddietary habits, education level ofand fifty-three (39.4%) stool specimensand 114 (29.4%) cellulosethe community, socioeconomicconditions, climate and environmentaltape slides were considered asfactors. Also non-hygienic livingpositive. The most frequently detectedparasites were Enterobiusconditions give rise to parasiticinfections in children 2 . Intestinalvermicularis (29.4%), Blastocystisparasites are more frequentlyhominis (19.8%), Giardia intestinalisencountered during childhood, since(16.5%). No statistical significancehygenic habits have not been fullywas observed in relation to intestinaldeveloped 3,4 .parasites detected in tape slides and The World Health Organizationstool samples and; gender (p=0,906 estimates that more than one billionand p=0,751), maternal occupation people of the world’s population(p=0,075 and p=0,410), paternal occupation(p=0,355 and p=0,354), transmitted helminths and 450 millionis chronically infected with soil-conditions of the residence [i.e havinga garden (p=0,185 and p=0,733) the majority being children 5 ,6 . Non-are ill as a result of these infections,and stable (p=0,523 and p=0,851), hygienic living conditions give risewater supply (p=0,675 and p=0,218), to parasitic infections in children. Settinghaving pets or animals (p=0,856 and These infections are regarded asp=0,429), having a separate room for serious public health problems, aseach sibling (p=0,927 and p=0,079)] they cause iron deficiency anemia,and, having symptoms indicating growth retardation in children andintestinal parasites (p=0,126 and other physical and mental healthp=0,611).problems. 7Conclusion: High prevalences ofPrevious studies at variousintestinal parasites in children livinginstitutions in Turkey revealed highin lower socioeconomic conditionsprevalances of intestinal parasiticshowed that parasitosis remains toinfections among the followingbe a public health problem in Antakya.populations: 6-16 years old (10.8%),12-16 years old (48.0%), 7-15 years MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6Asisst. Prof. Dr. Gulnaz Culha, Department of Parasitology, Mustafa Kemal UniversitySchool of MedicineAsisst. Prof. Dr. Cahit Ozer, Deparment of Family Medicine, Mustafa Kemal UniversitySchool of Medicineold (55.1%), and(88.0%) 8,9 .6-12 years oldHatay province is in anunderdeveloped region of southernTurkey. A number of studies indicatethat G. intestinalis and E. vermiculariswere endemic in children 10,11 . But thereis no study revealing associationbetween intestinal parasitic infectionsand sociodemographic factors.In this study we aimed to investigateintestinal parasitic infectionsamong children between 1-16years of ages, and relation with thesociodemographic, environmentalfactors, behavioral habits andcomplaints in a small village nearto Antakya, where the sanitaryconditions are very poor, and most ofthe children studied reside near poolsof sewerage.MethodsThis study was performed in ruralareas of Antakya, which is located insouthern Anatolia. Antakya is a bigcity with a population of 140 thousandand has a mild climate whereby astemperature arises to about 35-40C degrees in summer days. Sanitaryconditions are insufficient in largeparts of the city. We randomly selecteda village representing a rural area ofthe city. We calculated the samplesize as 369 (CI: 95%, predicted

10 MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATIONintestinal parasites detected in stoolsamples (p=0.769), E. vermiculariswere significantly more prevalent inelder children.countries has created, in urbanslums and shanty towns, sanitaryconditions which may be as favorablefor transmission of some intestinalfactors, behavioral habits and alsorelated complaints. 145 students(31.8%) were infected with one ormore intestinal parasites. 29 (6.4%)parasites as those found in most poor of the students were infected withInfections with intestinal parasitesand remote, rural areasand malnutrition are common in.more than one parasite, 26 (5.7%)with two parasites and 3 (0.7%)developing countries and with the Okyay et al 8 collected 456 stoolwith three parasites. The result ofexception of hookworm; intestinal specimens from 7-14 year oldthis study revealed that the threeparasites affect mostly children 17 . schoolchildren from Aydın to identifymost common parasites wereThe accelerated and unplanned an association between sociodemographicand environmentalE.vermicularis, G.intestinalis, andgrowth of many cities in developingTable 1 Intestinal parasites, socioeconomic factors, and related symptomsFeatures Cellulose tape slide Stool specimenn (%) p n (%) pGender 0.906 0.751Male 59 (29.6) 80 (40.2)Female 55 (29.1) 73 (38.6)Family Income 0.421 0.048Very low 102 (30.1) 140Low 12 (24.5) 13Maternal occupation 0.075 0.410Worker 1 (7.1) 7 (50.0)Unemployed 113 146 (39.0)Paternal occupation 0.355 0.354Worker 106 (30.5) 137 (39.4)Food 4 (23.5) 9 (52.9)Unemployed 4 (17.4) 7 (30.4)Sleeping outside 0.064 0.538Yes 6 (54.5) 3 (27.3)No 108 (28.7) 149 (39.4)House with a garden 0.185 0.733Yes 95 (28.2) 134 (39.5)No 19 (37.3) 19 (37.3)Having a separate room 0.927 0.079Yes 43 (29.7) 49 (33.1)No 71 (29.2) 104 (42.8)Stable around the residence 0.523 0.851Yes 80 (31.8) 110 (39.1)No 34 (28.5) 43 (40.2)Water supply 0.675 0.218Tap 113 (29.6) 149 (39.0)Well 1 (16.7) 4 (66.7)Keeping animals (domestic or pet) 0.856 0.429Yes 31 (28.7) 46 (42.5)No 83 (29.6) 107 (38.2)Enuresis 0.344 0.799Yes 34 (27.4) 48 (38.7)No 78 (32.2) 97 (40.1)Diarrhea 0.253 0.377Yes 10 (22.2) 15 (33.3)No 104 (30.5) 137 (40.2)Symptoms 0.126 0.611Yes 51 (33.8) 62 (41.1)No 62 (26.5) 90 (38.5)E.coli. They also found that intestinalparasite prevalence was higher inÇeliksöz and colleagues reportedthat E.vermicularis were positive inintestinal parasites in a total of 1820schoool children in three primaryrural areas, in children with less than 15.6% of participants with cellophane schools between 7-14 years ofprimary school educated mothers, in slides and Taenia spp eggs were age. The prevalance of helminthicchildren who use hands for washing positive in 1.6% of participants in infections were 77.1% of thethe anal area after defecation, andin children who seldom or never usea study comprising 2,200 schoolchildren in 6 schools in Sivas 19 .schoolchildren in shanty towns, 53.2%in apartment districts and 53.1% intoilet paper.rural areas. They found that AscarisUlukanlıgil et al 15 investigatedlumbricoides was the most prevalant

ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATIONspecies and that was followed byTrichuris trichura, Hymenolepis nanaand Taenia species in three schools.Sanitation surveys indicated that thetap water was limited in shantytownschools, in shantytowns and ruralareas, whereas the school in theapartment area was well sanitised.In our study we found that 153(39.4%) stool specimens and 114(29.4%) cellulose tape slides werepositive. The most frequentlyobserved parasites were Enterobiusvermicularis (29.4%), Blastocystishominis (19.8%), Giardia intestinalis(16.5%).In the present study no relation wasobserved between water supply andparasites identified. Thus we thinkthat parasites were transmitted eitherdirectly through the contaminationof soil and food by faeces, orindirectly poor living conditions.We investigated the relationshipbetween sociodemographic data andenvironmental factors. No relationwas identified between the presenceof intestinal parasites and gender,maternal and, paternal occupation,housing conditions, keeping animals,and parasite related symptoms. Verylow family income was found to be arisk factor for having parasites. As amatter of fact all the participants werefrom a low socio-economical status,but we dichotomised the group aslow and very low income according toTable 2 Parasites according to age groupstheir reports.We have so many limitations. Weselect a low socio-economical groupof patients from a rural area of ourregion. Their living conditions arealmost homogenous. The study grouprepresents their socio-economicalclass but homogenity of theparticipants may lead low statisticalsignificance between the risk factorpreviously reported. Our study mayactually have underestimated thetrue prevalence of parasitic infectionsbecause we carried out the study in arelatively small sample and observedone stool sample and a tape slide.To our knowledge the present studyis the only study in Hatay regionabout intestinal parasites in children.Thus the present study will provideinformation about prevalence ofintestinal parasites in children living inlower socioeconomic conditions, riskfactors and alert health authorities tothe matter. In conclusion, parasiticinfections remain a serious healthproblem in our region.References1.2.3.Ulukanligil M, Seyrek A. Anthropometric status, anaemiaand intestinal helminthic infections in shantytownand apartment schoolchildren in the Sanliurfa provinceof Turkey. Eur J Clin Nutr. 2004;58(7):1056-61.Ardebili HE, Kamali P, Pouranssari Z, KomarizadehZakai HA. Intestinal parasitic infections among primaryschool children in Jeddah, Saudi Arabia. J Egypt SocParasitol. 2004;34(3):783-90.Saksirisampant W, Nuchprayoon S, Wiwanitkit V,Yenthakam S, Ampavasiri A. Intestinal parasitic infestationsamong children in an orphanage in Pathum4.5.6.7.8.9.Thani province. J Med Assoc Thai. 2003 ;86 Suppl 2:S263-70.Nematian J, Nematian E, Gholamrezanezhad A, AsgariAA. Prevalence of intestinal parasitic infections andtheir relation with socio-economic factors and hygienichabits in Tehran primary school students. Acta Trop.2004 ;92(3):179-86.WHO: Control of Tropical Diseases. Geneva 1998WHO. Bench aids for diagnosis of intestinal parasites.World Health Organization, Geneva. 1994Ulukanligil M, Seyrek A. Demographic and socio-economicfactors affecting the physical development,haemoglobin and parasitic infection status of schoolchildrenin Sanliurfa province, Turkey. Public Health.2004;118(2):151-8.Okyay P, Ertug S, Gultekin B, Onen O, Beser E. Intestinalparasites prevalence and related factors in schoolchildren, a western city sample--Turkey. BMC PublicHealth. 2004 22;4:64.Özçelik S, Değerli S. 1998: Giardiasis in Turkey (Turkish).Acta Parasitologica Turcica 22(3):292-298.10. Çulha G, Canpolat A, Gülbol G. The Prevalance ofIntestinal Parasites in Four Different Special DaytimeNursing Homes and day-Centers in Antakya (Turkish).Acta Parasitologica Turcica. 2005; 29(2):120-122.11. Çulha G. Investigation of the prevalence of Enterobiusvermicularis in Children in Orphanages in Hatay (Turkish).Acta Parasitologica Turcica; 28(4):221-22312. Giacometti A, Cirioni O, Antonicelli L, D’ Amatto G,Silvestri C, Del Prete MS, Scalise G. Prevalence ofintestinal parasites among individuals with allergic skindiseases. J Parasitol. 2003 ;89(3):490-2.13. Reinthaler FF, Linck G, Klem G, Mascher F, Sixl W. Intestinalparasites in children with diarrhea in El Salvador.Geogr Med. 1988;18:175-80.14. Kaur R, Rawat D, Kakkar M, Uppal B, Sharma VK.Intestinal parasites in children with diarrhea in Delhi,India. Southeast Asian J Trop Med Public Health.2002;33(4):725-9.15. Ulukanligil M, Seyrek A. Demographic and parasitic infectionstatus of schoolchildren and sanitary conditionsof schools in Sanliurfa, Turkey. BMC Public Health.2003;3:29.16. Ahmed AK, Malik B, Shaheen B, Yasmeen G, Dar JB,Mona AK, Gulab S, Ayub M. Frequency of intestinal parasiticinfestation in children of 5-12 years of age in Abbottabad.J Ayub Med Coll Abbottabad. 2003;15(2):28-30.17. Muniz PT, Ferreıra MU, Ferreıra CS CondeWL,Monteıro CA. Intestinal parasitic infections in young childrenin Sao Paulo, Brazil: prevalences, temporal trendsand associations with physical growth. Ann Trop MedParasitol. 2002;96(5):503-12.18. Astal Z. Epidemiological survey of the prevalence ofparasites among children in Khan Younis governorate,Palestine. Parasitol Res. 2004;94(6):449-51.19. Celiksoz A, Acioz M, Degerli S, Alim A, Aygan C.Egg positive rate of Enterobius vermicularis andTaenia spp. by cellophane tape method in primaryschool children in Sivas, Turkey. Korean J Parasitol.2005;43(2):61-4.ParasitesInfantn=22Toddlern=166School Childn=163Adolescentn=37E. vermicularis 2 37 60 15 114 (29.4)B.hominis 6 31 32 8 77 (19.8)G.intestinalis 1 25 34 4 64 (16.5)E.coli 10 9 4 23 (5.9)D.dentriticum * 1 3 3 1 8 (2.1)E.hystolytica 3 3 1 7 (1.8)H.nana 3 3 6 (1.5)A.lumbricoides 1 1 2 (0.5)C.mesnili 1 1 (0.3)I butchii 1 1 (0.3)Total 9 76 87 18 189 (47.7)Stool Specimen positive 8 63 70 12 153 (39.4)* False positiveTotaln (%)MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6 11

MEDICINE AND SOCIET Ytravel time to, and longer waitingtime at these hospitals, patients aredeprived of the personal attention andthe more frequent follow-up visits thatcould be provided by a local facility.Current health care systems oftenfail to recognize the value of familyphysician care and fail to support ahealth care model based on primarycare. The resulting inadequacies inrecognition of family medicine bythe general public and by medicalinstitutions, accompanied by lack ofadequate reimbursement for familyphysicians, have demonstratedthe need to debate, identify andimplement strategies to improve thestatus of family physicians in globalhealth care systems.Objectives:1.2.To look at strategies that canensure a proper place for familydoctors in health systems andhealth care development.To share knowledge andexperiences on how to promotequality and excellence in familymedicine issues in policy andservices provision.MethodologyThis paper is a collaborative effortat international level, based on aneffort by an interested group offamily doctors, who looked at thestrategies required to ensure familydoctors get their proper position inthe health care delivery system. Thiseffort involved write-up based onextensive literature search by all theparticipating authors.The lead author collected all theobservations and put together adraft manuscript for publicationconsideration. The draft was reviewedby all authors prior to submission offinal paper for publication.Proposed StrategiesA strategy based on an approachthat focuses at different levels issuggested.Family medicine as the foundationfor health care systemsWe should foster developmentof systems that integrate familymedicine into a foundational rolein health care systems around theworld. Appropriate primary care isassociated with improvements inall-cause mortality, heart diseasemortality, stroke mortality, infantmortality, low birth weight, and lifeexpectancy. Furthermore, patientsreporting better primary careexperiences are likely to report betterhealth 3 . Specific characteristics ofprimary care associated with improvedhealth include: first-contact care,longitudinal care, comprehensivecare, co-ordination of care, familycenteredcare, and a communityorientation 5 .The practice of medicine is toimpart safe, effective, efficient, timely,patient-centered, and reasonablecare. This can be achieved bystrengthening primary care. In mostcountries, majority receive formalmedical care in primary care, andit is in the setting most episodes ofillness are treated. Clinical decisionsmade on first encounter influencecorrect use of health care resources.Effort to improve the knowledge basein primary care will lead to bettermedical care.Family medicine and primary careare not identical concepts. Familyphysicians in different countries workwith other primary care professionalsin a variety of arrangements. Familymedicine has to be the backbone andthe foundation of new health caresystem. A health care system that willput the human value ahead of healtheconomics and cost effectiveness.Family physicians work in thecommunities for the common good.As the trainers of the next generationof family physicians, we need to startput together the groundwork of abetter health care system.Implementing the characteristicsof primary care will vary around theworld, depending on factors such ashealth-care financing, the relationshipbetween publicly supported andprivately funded health care, and themedical infrastructure. In Uganda,traditional healers, nurses, andnon-residency trained physiciansall provide “primary care” due to thelow doctor-patient ratio, with moretrained family physicians functioningas medical superintendents or clinicalsupervisors. In Turkey, inline with theneed of the hour, “socialized” primaryhealth care is converted to familypractice-based health system 6 . Familymedicine has the potential to offera higher level of primary, generalistcare in collaboration with front-lineprofessionals, but further challengesremain 7 . We need development ofstate-funded primary care, withemphasis on health promotion at thelocal level in coordination with publichealth and primary care servicesand accessibility of care for thedisadvantaged 8 .Family medicine has the opportunityto engage with partners and policymakers to guide development ofchronic care systems, at the sametime emphasizing the centrality ofthe patient’s journey for individualpatients, and working to collaboratewith the multiple health-care systemsa chronically ill patient may interactwith 19 . The family physicians need totake the lead in collaborating with othermedical and non-medical partners inthe development of community healthpartnerships 10 .The world population is gettingolder and the burden will be higherin developing countries for examplein India, China. Lack of infrastructurefor care of chronic conditions andthe care of elderly will be a seriouschallenge. Initiatives of WHO andWONCA (SIG Elderly Care) canaddress this issue.The methods for developing familymedicinebased systems will varyfrom place to place. Nevertheless,opportunities exist for advocatingpolicy change and engaging inlocal initiatives. It will lead to furtherintegration of family medicine intothe local health care system asthe foundational source of primaryhealth care. Such integration shouldhelp improve the status of familymedicine both through measurableimprovements in health-careoutcomes and cost efficiency, andthrough demonstration that familymedicine can and does providethe longitudinal, patient-centered,comprehensive care that patientsseek when they ask “who is mydoctor?Promoting broad based scope ofpracticeMIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6 13

Family medicine has conventionallyincluded a very broad-based training.Although individual family physiciansoften tend to narrow the scope of theirpractice over the years, they beginequipped for a wide range of practicepossibilities. These “pluripotent stemcell 11 . of the medical profession maylater be found staffing emergencyrooms, serving as hospitalists, andpracticing occupational medicine, aswell as in the outpatient clinic. Familymedicine is becoming a basis forglobal health activities, where a broadscope of clinical skills and knowledgeare imperative. We need a cleardefinition of our specialty. Are we to be“full-spectrum” physicians, or are weto be chronic disease specialists? Orperhaps family medicine is destinedto be a discipline divided into twosubspecialties: Comprehensivists andOutpatientists (acute; Hospitalists)? 12Comprehensiveness has beendistorted for family physicians withincreases in specialization. Canadianfamily physicians, for example, arebecoming less likely to deliver babies,give anesthetics, provide care inemergency departments and nursinghomes, or make house calls 13 . Otherchanges have expanded the roleof the family physician, such as therecent recognition of the importanceof primary care in provision of mentalhealth in Bosnia 14 .The environment in which familymedicine is practiced can have agreat effect on specifics of clinicaland organizational practice. Manylocal drivers for these differencesinvolve not only economics and socialgeography but also the wider politicalcontext. Differences in health carefunding can result in an additionalvariation. As an example, Americanfamily physicians are much less likelythan their Canadian counterpartsto provide psychotherapy or formalcounseling for their patients. Thedifference is in part due to training, butAmerican physicians are also heavilyinfluenced by major restrictions toreimbursement for this service bytheir insurance companies. Familyphysicians who find themselves insituations in which financial structuresprovide a disincentive to practicingpreventive medicine may find itdifficult to fulfill this core role.14MEDICINE AND SOCIET YThe methods of family medicineare also changing in response tothe ongoing explosion in medicalknowledge. Fortunately, thisunprecedented growth has beenaccompanied by huge improvementsin access to that knowledge throughtechnologies, such as the Internet,and through the availability ofcareful systematic reviews, suchas those provided by the CochraneCollaboration. As a result, it hasactually become easier for a properlytrained family physician to accessthe latest evidence and to apply it topatient care.The wide variation in the scopeof family physician practice leads toconfusion over the nature of familymedicine on the part of the public,physicians in other specialties, andpolicy makers. Additionally, physiciansof other specialties may feel that anarrower scope of practice or lack ofprocedural care by family physiciansimplies a lower level of training, skill,or expertise.One USA family medicine residencysurveyed graduates from 1998 to2004 regarding their current scopeof practice. By 2004 there was asignificant decline in the percent ofgraduates practicing hospital care(71 to 56%), obstetrics (40 to 23%),or emergency care (25 to 13%) 15 . Incontrast, family physicians practicing inrural areas tend to maintain a broaderscope of practice, and provide a morediverse range of procedural care aswell 16 . An additional challenge to thescope of family medicine practicein some countries is a policy-drivendemand for an increasing populationhealth role for the family physician.While health promotion may seem anintuitive extension of continuity care,there is also concern that this mergingof disciplines obscures the primaryfocus in family medicine on personcenteredcare and inappropriatelyintroduces policy imperatives into theclinical relationship 17 .Research has called into questionthe assumptions behind somemotivations for family physicians toreduce their scope of practice. Onestudy has questioned the assumptionthat maternity care causes an unduedrain on personal time, and suggeststhat failure to provide maternity careMIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6may in fact adversely affect practicerevenue and viability 18 . Another studyfound that hospitalist care actuallydoes not provide any cost savingscompared to family physician carefor managing patients with commoninpatient diagnoses 19 . In many ruralareas the family physician commonlyprovides care for diagnoses thatmay be managed by specialistsin urban centers. Thus, trainingfamily physicians for a broad scopeof practice is essential to supportthe needs of rural or underservedareas 20 .One response to the tensionsin family medicine over scope-ofpracticeissues was the Future ofFamily Medicine (FFM) project in theUSA. A central FFM recommendationwas the development of a “NewModel” of practice emphasizing a“Basket of Services” to be offered byfamily physicians including: healthcare for children and adults, healthpromotion and disease prevention,acute and chronic care, maternitycare, and hospital care 2 . While theFFM recommendations providemore of a conceptual model thanan agenda for change or specialtyre-organization, this project is oneexample of a country-level effortby family physicians to define theirspecialty and specify a vision for acomprehensive scope of practice.In order to help increase thestature of family physicians, it willbe important to work to define theplace of family medicine as a primarycare field within health care systems,and to develop a consensus on theappropriate scope of practice thatis both general enough to apply tofamily medicine world-wide, yet alsosensitive to local contexts, systemsand needs. An international FFM typeproject, conducted by an organizationsuch as WONCA, could help establishan international consensus as to thecore scope of practice essential tofamily medicine.Family medicine research andscholarshipFamily medicine’s fundamentalbase of knowledge and skills drawson a long tradition of general practice“wisdom and pragmatic knowledge.”Stange, Miller and McWhinney have

MEDICINE AND SOCIET Yconceptually described the “knowledgebase of family practice” as anintegration of inner and outer realitieswith both individual and collectiveknowledge 21 . Family medicine is notjust about managing straightforwardmanifestations of common diseases.Rather, family medicine dependson understanding both health anddisease, an understanding of how tomanage uncertainty and an ability todeal with individuals both on their ownand as parts of larger family or socialsystems. Furthermore, in rural areasand in developing nations, familyphysicians may need to be competentat providing first-line emergency careand surgical services 22 .Family medicine research goesbeyond the basic and clinical scienceaspects of disease to include researchinto health services and healthsystems, and also research intomedical education and professionaldevelopment. In order for an effectivefamily medicine research enterprise tobe established in a given country, anacademic home for family medicineis necessary, as is collaboration withother disciplines and explicit efforts tolink or translate the results of researchdirectly to clinical practice 23 .Strategies to help establish familymedicine research include both “topdown”efforts to establish familymedicine training programs andacademic departments, and “bottomup”efforts to include front-line familyphysicians in research endeavors5, 23 .Practice-Based Research Networks(PBRNs) provide a way to meaningfullyconnect front-line family physicianswith primary care researchers.PBRNs allow research into the careof unselected primary care patientstypical of family medicine 24 . PBRNsalso create an avenue for includingcommunity members into familymedicine research, thus fosteringengagement of the surrounding socialsystems in further understanding thenature of family medicine 25 , and theycan allow for networking amongstfamily physicians to identify questionsof relevance to front-line care that arein need of exploring.The variety within the disciplineoffers both an opportunity anda challenge for family medicineresearch. Family medicine researchfacilitates the correct operation ofhealth care systems and securesaccess to health care on the basis ofindividuals’ needs in a framework ofequity of access for all persons.A need exists to promote awarenessamong health care funders, planners,and publishers, of the current input offamily medicine research and of itspotential to ameliorate health. In orderpublicize family medicine researchin the medical research community;family medicine research must bemore widely disseminated.Wonca, as an international bodyof family medicine can play a majorrole in promoting and highlighting thescholarly activities of family doctors.Research achievements in familymedicine should be displayed to policymakers, health (insurance) authorities,and academic leaders in a systematicway. Practice systems should bedeveloped to provide surveillancereports on illness and diseases thathave the greatest impact on thepopulation’s health and wellness in thecommunity. A clearinghouse shouldbe organized to provide a centralrepository of knowledge about familymedicine research expertise, training,and mentoring. National researchinstitutes and university departmentsof family medicine with a researchmission should be developed.Practice-based research networksshould be developed around the world.Family medicine research journals,conferences, and Web sites should bestrengthened to disseminate researchfindings internationally, and their usecoordinated. Improved representationof family medicine research journalsin databases, such as Index Medicus,should be pursued. Funding ofinternational collaborative research infamily medicine should be facilitated.International ethical guidelines, with aninternational ethical review process,should be developed in particular forparticipatory (action) research, whereresearchers work in partnership withcommunities. When implementingthese recommendations, the specificneeds and implications for developingcountries should be addressed.Despite the lack of a research traditionin family practice, there has been agrowing consensus among familymedicine educators that researchtraining is an important componentof residency training curriculum.There are several elements that helpimplementing a successful researchprogram including support of theprogram director, dedicated timefor research, faculty involvement,access to research professionals, andopportunities for presenting papers atscientific meetings.Family medicine scholarshipcan improve the stature of familyphysicians in three ways:1.2.3.Enhance the generalist knowledgebase of family medicine,Develop appropriate generalistresearch methods and practices,such as PBRNs, andDefine and advance family medicinescholarship in order to promote theinstitutional academic standingof family medicine departmentsand individual family physicianscholars.Undergraduate Medical EducationIn its 1993 document ‘Tomorrow’sDoctors’, the UK General MedicalCouncil emphasized an importanteducational paradigm shift askingmedical schools to ensure studentsacquire knowledge and solidunderstanding of:1. Health and its promotion,2. Disease and its prevention, and3. Management, in the context of thewhole individual and his or herplace in the family and society 26 .It underpinned the need to learnin biomedical, psychological andsocial contexts, based on firmepidemiological foundations in allmedical schools.Today, key questions remain.How many hours of family medicine(general practice) should be includedin the curriculum? And in whatcontent? Who will be responsible forthe teaching? And finally, what arethe settings for delivering the principalteachings of general practice (familymedicine)?Health centre and family medicinesurgeries provide excellentopportunities for medical studentsto learn and develop skills in clinicalproblem solving, simply because of thefrequency with which patients presentMIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6 15

with undifferentiated problems acrossthe entire spectrum of disease 27 .As a consequence, studentslearn to make cautious diagnosticassumptions and have to approachpresenting problems with an openmind. This provides students withrepeated opportunities to integrateand apply knowledge and skillslearned from basic, behavioural andclinical sciences in a discriminatingway 27,28 . Medical students can alsogain unique insights into the trueprevalence and nature of diseasethrough the exposure to the clinicalepidemiology of the community 29 .Family medicine / general practice isalso the context in which anticipatoryand continuing care, and the socialand psychological aspects of illnessand disease, can be best observedand understood 27 .Generally speaking, hospitalsprovide medical students with the bestlearning opportunities to recogniseand manage serious conditions.However, this provides them witha misleading picture of society’smedical and health problems sincethey are mainly exposed to a highlyselected population. In the hospitalcontext students are often exposedto a restricted bio-medical modelwhich principally views the body as amachine, disease as a consequenceof breakdown of the machine andthe doctor’s task as repairer of themachine 27,30 . Furthermore, with moresub-specialisation and increasedthroughput in hospital care, itssuitability for teaching medicalstudents about the society’s healthproblems and the whole spectrumof illnesses is questionable. Thereis plenty of convincing researchevidence that the basic clinical skillscan be taught as effectively or evenbetter, in family practice than in ahospital setting 31,32 .The key question which must beaddressed for any health systemwhich would like to introduce familymedicine education and training(both under and post graduate): Dowe have the infrastructure in primarycare services in the health systemto introduce the curriculum forexample?16MEDICINE AND SOCIET YPostgraduate Training in FamilyMedicineSupervised by the PostgraduateMedical Education and Training Board(PMETB) the UK curriculum for postgraduate general practice (familymedicine) training is based on 3 yearsof vocational training. In line will allmedical, surgical and public healthspecialties, the training contributes toachieving the highest standards andquality of learning. The curriculum isdesigned to address the wide-rangingknowledge, competences, clinicaland professional attitudes consideredappropriate for a doctor intending toundertake practice in modern healthsystems 33 . The GMC publicationGood Medical Practice and the UKRoyal College of General Practitionersdocument Good medical practicefor General Practitioners provided aframework against which doctors canjudge their own performance and bywhich they can also be judged 34,35 .However, entering the vocationaltraining scheme (VTS) for generalpractice in the UK is part and parcelof wider programme of undergraduatemedical education, foundation schooland postgraduate higher medicaltraining, under Modernizing MedicalCareer (MMC) 30 . In this programme,all junior doctors who are startingtheir first year after medical school(previously known as the preregistrationhouse officer year) willhave to demonstrate explicitly thatthey are competent in a number ofareas including communication andconsultation skills, patient safetyand team working, as well as themore traditional clinical skills. Thetwo-year Foundation Programmewill give trainees exposure to arange of career placements acrossa broad spectrum of specialties. Alltrainees will also have access toan educational supervisor, as wellas a clinical supervisor for eachplacement. The programme has asits focus patient safety; progressionthrough the programme is basedon the achievement of competence,rather than time served. At the heartof this new training programme isquality of medical care. By makingthe continuous development of skillsand knowledge central to trainingand by making explicit the standardsMIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6of competence those doctors reachbefore they progress, the FoundationProgramme will improve patientsafety as well as medical careers36.Figure 1 sketches the new trainingprogramme for all specialties(medical, surgical, public health,general practice) in the UK under thenew MMC programme.Reinventing Graduate Educationand Preparing a New Generation ofLeadersGraduate students are emergingscholars and professionals whosecuriosity, open minds, and freshperspectives will launch new waysof thinking and problem solving. Ifwe adopt a spirit of experimentation,collaboration, and an unwaveringcommitment to push the frontiersof knowledge, the practice of familymedicine will prosper worldwide.As the issues facing the delivery ofhealth care services become morecomplicated, their solutions must alsobe multifaceted. Leaders in familymedicine must be able to approachproblems from multiple dimensionsand leverage the expertise of peoplein different fields to forge effectiveand sustainable answers. Problemsolving and innovation are necessarilybecoming more multidisciplinary intoday’s complex world.Family Medicine program needto incorporate a clear leadershipcurriculum into graduate educationprograms to help students developthe practical skills they will needto contribute to and transform theirfields, their organizations, and theworld.Promotion of quality in familymedicineIssues in policy and servicesprovisionMany health care challenges inthe 21st century will place a greatdemand on primary care, which canserve its purpose only if it is of highquality and evidence based. Familymedicine research can contribute tomany areas of primary care, rangingfrom early diagnosis to equitablehealth care 37,38 .

MEDICINE AND SOCIET YNew Rules for the 21st CenturyHealth Care System could besummarized as the following 37 :••••••••••Care is based on continuoushealing relationships.Care is customized according topatient needs and values.The patient is the source ofcontrol.Knowledge is shared andinformation flows freely.Decision making is evidencebased.Safety is a system property.Transparency is necessary.Needs are anticipated.Waste is continuously decreased.Cooperation among clinicians is apriority.Family physicians and their healthprofessional colleagues must assumeresponsibility for the constantassessment and improvement oftheir care. Working together onbehalf of patients requires teamworkthat occurs within a complex set ofrelationships and services. It requiresskillful management with appropriateauthority and collaboration as well asa mindset of vigilance and continuousprocess improvement 39 .Emphasis on quality and safetySystems is considered as one ofthe important characteristics of thenew model of family medicine, andis fully described as: “Systems arein place for the ongoing assessmentof performance and outcomes andfor implementation of appropriatechanges to enhance quality andsafety 38 .Quality Improvement (QI) is apractical approach to systems orprocess change. A growing body ofliterature shows how QI principlescan help create much-neededimprovements in a variety of healthcare situations.The goal of “rapid cycle qualityimprovement” is to allow teams to1.2.3.identify what they want toaccomplishdevelop a measure for evaluatingchange, anddetermine a change or an actionthat a QI team believes will resultin an improvemen t40 .Quality Improvement in FamilyPracticeA new recipe is presented, splittingquality improvement into 4 levels. TheQ1 level corresponds to the everydayprocesses that guide our daily workflow. Q2 corresponds to commonlythought of outcome measures. Q3relates to the executive functionsthat permit seasoned clinicians todraw generalizations about care forindividual patients by synthesizinglarge amounts of data. Finally Q4reflects more population-basedquality improvement activities.Each of these levels requires adifferent approach for improvementactivities. Each must be seen inthe context of an expanded “qualitycompass” and in the paradigm of theQI cycle. Finally, a practical applicationof how this could be instituted at aFamily Practice residency is given 41 .So, Practices will document qualityand safety through ongoing analysesof practice patient care data. 36Patient feedbacks will be solicited toensure that the practice is meetingpatients’ expectations, satisfying theirneeds for access to the practice, andresponding to the needs of increasinglydiverse populations. Each practice willdevelop and use a structured, recurringadministrative mechanism to examinethe measurements of the practice andthe patients under its care. Practicestaff, along with representativepatients, will be included in thesequality improvement processes. A highpriority will be on taking steps to ensurepatients’ safety within the practice,including the use of electronic data anddecision support systems 42 .GP and FM practices that useelectronic medical records and receiveregular performance reports canimprove their adherence to clinicalpractice guidelines. But, on the otherside, no intervention to improve dataquality has been put to rigorous enoughtests. We still lack empirical knowledgeas to how improvement can be broughtabout 43 .A roadmap for quality improvementin physician offices (PracticeManagement)Population-based medicine targetsinterventions at discrete subpopulationsof patients within the medical practiceand anticipates needed servicesaccording to evidence-based guidelinesusing quality measures to track resultsand make adjustments.Physicians integrate caremanagement into their routine clinicalcare by using these guidelines andquality measures to assess patients’needs, create care plans and coordinateand monitor services for their patients.In order to meet the need for betterchronic care management successfully,a medical practice will need to progressthrough nine discrete steps 44 .1.2.3.4.5.6.Define the subpopulation of patientsin need of care management.Choose a physician performancemeasurement set of qualitymeasures.Use a clinical information systemto track quality measures.Establish patient goals for qualityimprovement.Analyze the current workflowprocesses to identify areas forimprovement.Implement a change in the workflowprocess.7. Measure and analyze results 38 .8.Repetitively implement workflowchanges and measure results untilgoals are reached.9. Sustain the improvements.Promotion of QualityAs the number of physicians whoenter residency training in familypractice gradually increases, so doesthe need to evaluate the effect of theirtraining and postgraduate educationon the quality of care in their practices.Quality of care provided by familyphysicians can be measured usingadministrative data.A group from the European WorkingParty on Quality in Family Practice(EQuiP), working with over 20European colleges of primary care,has assessed what, in their view,is needed to improve the quality ofcare at the interface between generalpractice and specialists. Experiencesand ideas from a wide range of peoplewere gathered through focused groupdiscussions. From these it was clearthat, for real improvement at theinterface of care, changes are neededMIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6 17

in the system of care and in the waysthat doctors view their roles and theirperformance. All providers of careneed to be able to see the care systemfrom the patients’ perspective if theyare to help their patients make senseof and benefit from an increasinglycomplex system. Cooperationbetween general practitioners andspecialists might be improved. Thisincludes strategic perspectives andboth targets for improvement andmethods for teaching, training anddevelopment that are all independentof country and health care system. The10 targets for development identifiedby the group are: leadership, initialshared care approaches, task division,mutual guidelines, patient perspective,informatics, education, team building,quality monitoring systems, and costeffectiveness. Working towards thesetargets could provide an effectiveapproach to improving the cooperationbetween the interfaces of care. Gettingeffective leadership is a necessaryfirst step as implementation of such astrategy will involve significant change.Responsibility lies primarily with themedical profession.MEDICINE AND SOCIET YConclusionsReferences1.2.3.4.5.6.7.18A multiprong approch involvingefforts in promotion of family medicinein areas of education, research, andservice with particular emphasis ondelivery of high quality in all areasis proposed as a strategy to improvethe status of family doctors.Phillips WR, Haynes DG. The domain of familypractice: scope, role, and function. Fam Med. 2001;33(4):273-7.Martin JC, Avant RF, Bowman MA, Bucholtz JR,Dickinson JR, Evans KL, Green LA, Et al. TheFuture of Family Medicine: a collaborative projectof the family medicine community.Ann Fam Med.2004; 2 Suppl 1:S3-32.Starfield B, Shi L, Macinko J. Contribution of primarycare to health systems and health. Milbank Q2005; 83 (3):457-502.Yaman H.Training in family medicine: the currentstate in Turkey. Education for Primary Care, Volume13, Number 3, 1 July 2002 , pp. 394-397.Roth LM, Neale AV, Kennedy K, DeHaven MJ. Insightsfrom practice-based researchers to developfamily medicine faculty as scholars. Fam Med.2007; 39(7):504-9.Günes ED, Yaman H. Transition from “Socialized”Primary Health Care to Family Practice in Turkey.Journal of Continuing Education in the Health Professions2008; 28(2): 106-112.Ssenyonga R, Seremba E. Family medicine’s role inhealth care systems in Sub-Saharan Africa: Ugandaas an example. Fam Med. 2007; 39(9):623-6.8. Lee A, Kiyu A, Milman HM, Jimenez J. Improvinghealth and building human capital through an effectiveprimary care system. J Urban Health. 2007;84(3 Suppl):i75-85.9. Martin CM. Chronic disease and illness care: addingprinciples of family medicine to address ongoinghealth system redesign. Can Fam Physician.2007;53(12):2086-91.10. Glasser M, Holt N, Hall K, Mueller B, Norem J, PickeringJ, Brown K, Peters K. Meeting the needs ofrural populations through interdisciplinary partnerships.Fam Community Health. 2003; 26(3):230-45.11. McWhinney IR. A Textbook of Family Medicine.New York, NY: Oxford University Press; 1997.12. Olesen F, Dickinson J, Hjortdahl P. General practice- time for a new definition. BMJ. 2000;320:354-357.13. Chan BT. The declining comprehensiveness of primarycare. CMAJ. 2002; 166:429-434.14. Ceric I, Loga S, Sinanovic O, et al. Reconstructionof mental health services in Bosnia and Herzegovina.Med Arh. 2001;55(1 Suppl 1):5-23.15. Ringdahl E, Delzell JE Jr, Kruse RL. Changing practicepatterns of family medicine graduates: a comparisonof alumni surveys from 1998 to 2004. J AmBoard Fam Med. 2006; 19(4):404-12.16. Curran V, Rourke J. The role of medical educationin the recruitment and retention of rural physicians.Med Teach. 2004; 26(3):265-72.17. Buetow S, Docherty B. The seduction of generalpractice and illegitimate birth of an expanded rolein population health care. J Eval Clin Pract. 2005;11(4):397-404.18. Rodney WM, Hardison D, Rodney-Arnold K, Mc-Kenzie L. Impact of deliveries on the office practiceof family medicine. J Natl Med Assoc. 2006 ;98(10):1685-90.19. Lindenauer PK, Rothberg MB, Pekow PS, KenwoodC, Benjamin EM, Auerbach AD. Outcomes of careby hospitalists, general internists, and family physicians.N Engl J Med. 2007; 357(25):2589-600.20. Bell RA, Quandt SA, Arcury TA, Snively BM, StaffordJM, Smith SL, Skelly AH. Primary and specialtymedical care among ethnically diverse, older ruraladults with type 2 diabetes: the ELDER DiabetesStudy. J Rural Health. 2005 ; 21(3):198-205.21. Stange KC, Miller WL, McWhinney I. Developingthe knowledge base of family practice. Fam Med.2001 ;33(4):286-97.22. Downing R. African Family Medicine. J Am BoardFam Med 2008 21: 169-170.23. Beasley JW, Starfield B, van Weel C, Rosser WW,Haq CL. Global health and primary care research. JAm Board Fam Med. 2007; 20(6):518-26.24. van Weel C, de Grauw W. Family practices registrationnetworks contributed to primary care research.J Clin Epidemiol. 2006;59(8):779-83.25. Westfall JM, VanVorst RF, Main DS, Herbert C.Community-based participatory research in practice-basedresearch networks. Ann Fam Med.2006;4(1):8-14.26. General Medical Council. Tomorrow’s Doctors. London:GMC, 199327. Dowrick C. Mackenzie Report: New century, NewChallenges. A report from the Heads of Departmentsof General Practice and Primary Care in themedical schools of the United Kingdom. SAPC,Oxford, 2002. [Online] assessed on June 30, 2008.http://www.kcl.ac.uk/depsta/medicine/gppc/umet/Outline0506.pdf28. Fraser R. Undergraduate medical education:present state and future needs. BMJ1991;303:41-3.29. Rawaf S. Public Health Functions and Infrastructuresin the MENA/ME Region. In Public Healthin the Middle East and North Africa. Washington:World Bank, 2004, Chapter 2, Pp25-41.30. Engel G. The needs of new medical model: a challengeto biomedicine. Science 1977;196:129-36.31. Murray E, Jinks V, Modell M. Community-basedmedical education: feasibility and costs. MedicalEducation 1995; 29:66-71.32. Johnston B, Boohan M. Basic clinical skills: don’tleave teaching to the teaching hospitals. MedicalEducation 200; 34:692-9.MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 633. www.pmetb.org.uk34. General Medical Council. Good Medical Practice.London: GMC, 1998.35. General Practitioners Committee of the MBA &the Royal College of General Practitioners. GoodMedical Practice for General Practitioners. London:RCGP, 2002.36. http://www.dh.gov.uk/en/AdvanceSearchResult/index.htm?searchTerms=MMC37. Future of Family Medicine. Annals of Family Medicine.www.annfammed.org Vol. 2 (Supplement 1):S3. 1 March/April 2004.38. Cindy L.K.LamCi. the 21st country. The age of familymedicine research? Ann Fam Med 2004 May,2(supple 2): s50-s45.39. QI- Data Management, statistics of Quality Improvement.Family Medicine Digital Resources.11/13/2006. www.fmdrl.org/index.cfm.40. About: Quality improvement. Wisconsin initiative topromote healthy lifestyles 10/28/2007. www.wiphl.com.41. Stephen Elgert, MD Quality Improvement in FamilyPractice: A Recipe for Change American Journal ofMedical Quality, Vol. 19, No. 2, 83-87 (2004) DOI:10.1177/106286060401900206.42. Brouwer HJ, Bindels PJE, Van Weert HC. Dataquality improvement in general practice. FamilyPractice 2006; 23: 529-536.43. Steven Ornstein, MD; et.al. A Multimethod QualityImprovement Intervention To Improve PreventiveCardiovascular Care . Annals of internal medicine.5 October 2004 | Volume 141 Issue 7 | Pages 523-532.44. A roadmap for quality improvement in physician offices.(practice management) 3/22/2008. http://goliath.ecnext.com/coms2/gi_0199-6985477/A-roadmap-for-quality-improvement.html

MEDICINE AND SOCIET YFigure 1: Medical Career, UK 2007.MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6 19

Job Satisfaction and Stress level of Primary HealthCaregivers at Primary Health Centers in QatarJamila Hassan Alkhalaf, Rajvir Singh, Maryam Malalah and Ezz Aldinal JakDepartment of PHC and Medical Research Centre, Hamad Medical Corporation (HMC), Doha, Qatar.Key words: Health Caregivers, Jobsatisfaction, Stress.ABSTRACTObjective: Our aim was to evaluate theextent of job satisfaction and stress ofPrimary Health Care givers in Qatar.Subject and Methods: A populationbased cross sectional study was conductedin July 2007. 323 questionnaires weredistributed to all the physicians/GeneralPractitioners (GPs) working in PrimaryHealth Care Centers in Qatar. Out of 323,only 176 (54%) responded. Data on socio-demographiccharacteristics and jobsatisfaction and stress were collected onself-administered English forms developedby Warr-Cook Wall (5).Results: Out of 176 participants 85 (48%)were nale and 91 (52%) were female.Most were non-Qatari of age between30-45 years and married withchildren.The overall job satisfaction and stresswere below average. There were no significantdifferences in overall job satisfactionfor nationality, sex, marital statusand number of children whereas femaleQatari Health Caregivers were found tobe more stressed than their counterparts.There was negative correlation betweenjob satisfaction and stress (r =-0.29,p=0.01).Conclusion: Job satisfaction of primaryhealth caregivers is critical for improvementof health systems. The results of ourstudy showed that Qatari physicians wereless satisfied with the rate of pay and theamount of variety in work. Stress wasmore in Qatari Health Caregivers thanNon-Qatari.20EDUCATION AND TRAININGIntroductionPrimary Health Caregivers areresponsible for providing medicalcare to the larger extent of the Qatarpopulation. They play a pivotal role inmedical care and medical care couldbe improved by facilitating them inworking conditions, improving rate ofpay and other peripheral facilities atwork. The World Health Organization(WHO) has also recognized theimportance of Primary HealthCaregivers in 1978 in Alma AtaDeclaration (1) .Ibrahim S Al-Eisa (2) published astudy on job satisfaction of PrimaryHealth Care (PHC) Physicians atCapital Region Kuwait in 2005. Theauthors concluded that attentionshould be given to income, varietyin work and practice conditions inorder to improve overall Physiciansatisfaction.Al Mari S.A. (3) in 2002 from Qatarsuggested improving job satisfaction ofPHC Physicians by giving incentives,reducing workloads and providingvocational training for improving thequality of PHC services.Khalid A Kalantan (4) publisheda similar study in 1999 on factorsinfluencing job satisfaction amongPHC Physicians in Riyadh suggestedto provide vocational training, adequateincentives as well as administrativesupport to PHC Physicians.Although, few studies are publishedin Qatar on job satisfaction forPhysicians working in PHCs in past,and giveing no clues to improve jobsatisfaction of PHCs Physicians,recent changes in incentives andother facilities in PHCs are warrantedto look into this matter again.Our aim is to determine jobsatisfaction and stress levels ofPrimary Health Center Physiciansand GPs in Qatar.MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6Materials and MethodA total of 323 questionnaires were sentto all primary health care physiciansof 24 Primary Health Centers in thestate of Qatar. Out of a total only 176(54%) Care Givers responded. Thequestionnaire was adopted from Warr-Cook Wall (5) specially designed forjob satisfaction and stress level incaregivers. The data were collectedon demographic, job satisfaction andstress characteristics during July2007. Responses were collected onsatisfied, not satisfied and cannot tellor cannot say, for job satisfaction andstress characteristics. Variables, age,gender, religion, nationality, maritalstatus, specialty, number of yearsworking in primary health care andnumber of households were collectedfor demographic characteristics of theparticipants.Job satisfaction and stress scoreswere calculated for each participantin the study. One value wasassigned for satisfaction or agree,0 for cannot tell or cannot say, and-1 for no satisfaction or disagree forquantification of the given responsesby the participants on job satisfactionand stress simultaneously. All theitems were added for each individualand divided by total numbers ofitems for respective scores on jobsatisfaction and stress.Frequency distribution withpercentage for categorical variablesand mean and standard deviations forcontinuous variables were calculated.Student t test and One-Way ANOVAwith post-hoc analysis by Bonefirroniwere applied to see significantdifferences in continuous variables(Job satisfaction and stress scores)between and among categories forcategorical variables. Chi-square testswere applied to see the associationbetween categorical variables. Twotailedprobability 0.05 has beenconsidered as a statistical significance

CLINICAL RESEARCH AND METHODSlevel. SPSS 14.0 statistical packagehas been used for the analysis.ResultsA total of 176 questionnaires werecollected from Physicians andGeneral Practitioners from all thePrimary Health Centers. Most wereof 30-45 years of age. There was 1:1ratio of male to female. There were80% non-Qataris in the study. More orless all the participants were marriedand had 5 or more children. Therewere 119 (68%) participants from theGeneral Practitioner community and49 (27.8%) from Physicians whereas8 (4.5) participants didnot mentiontheir discipline. The distribution ofdemographic data has been describedin Table 1.Table 2 described the distribution ofjob satisfaction items. More than 75%of participants from both specialtieswere satisfied with physical workingconditions, colleagues and fellowworkers and working hours. 60-70% satisfaction was for freedomto choose own method of work,variety of jobs and job satisfactionof today in comparison to the past.Below average satisfaction was forrate of pay whereas above averagesatisfaction was for two shifts atwork and appointment system insubspecialty.Table 3 described the stress level atwork in Primary Health Centers forPhysicians and General Practitioners.87.5% were of the opinion thatthere was increased demand frompatients and 80% agreed there wasinsufficient time to do justice withpatients during consultations. 104(59%) participants were of the opinionthey were interrupted by emergencycases during consultation. Out of 176,103 (58.5%) were of the opinion thatthet were not getting sufficient timeto update themselves. There was nodisturbance of family life for 52% ofparticipants in the study.Overall job satisfaction score wasbelow average in the study withmean level 0.36± 0.39. There was nostatistical difference in job satisfactionscore for all the demographicvariables included. The results havebeen displayed in Table 4.Stress level at work was also of thesame level with mean 0.38±0.42.The study suggested that therewas more stress in females thanmales (p =0.001) and more stress inQatari participants than non-Qatariparticipants (p=0.02). Qatari femaleproportion was higher than theQatari males in Health Caregivers(Chi-square= 16.7, p=0.00). Otherdemographic and professionalvariables like age, specialty, numbersof years working in practice andnumber of households in the studydid not have a statistical differenceat stress level. The results have beenshown in Table 5.DiscussionMost of the Caregivers in PHCs werenon-Qatari; a similar proportion wasdescribed in a previous study done in2002 (3) . It may be due to the demandof PHCs services or Qatari CareGivers may have an inferior sotiationin comparison to other specialties.Our data showed a significantnegative association betweenderived job satisfaction score andstress score. The study showed morestress in Qatari Health Care Giversthan non-Qataris in PHCs. It may bedue to more female Qataris workingin PHCs than males. Qatari HealthCaregivers might have householdjobs at home. Our study also showedmore job satisfaction compared topast experience in PHCs Caregivers.It may be due to increases in salary,increases in numbers of doctors, andother facilities in PHCs.More thrust is warranted to updateithe medical education system, asCaregivers are not able to updatethemselves with new developmentsin their fields due to workload.C.L. Cooper (6) , Bonnie Sibbald (7) ,and Barbara (9) showed that jobsatisfaction has increased whereasBruce E. Landon (8) demonstratedjob satisfaction did not changedramatically.Similar results have been describedand suggested regarding demographicand professional variables in studies(1),(2),(4).CONLCUSIONOur study showed that job satisfactionand stress are both are belowaverage. More facilities, incentivesand suitable working conditionsshould be provided to increase jobsatisfaction and to reduce stress.Further, it suggested a large studyon job satisfaction, stress and mentalhealth be undertaken to generalizethe results in the region.References1.2.3.4.5.6.7.8.9.World Health Organization (WHO). Alma Ata 1978Primary Health care. Geneva: WHO, 1978.Ibrahim S Al-Eisa, Manal S Al-Mutar and Huda Kal-Abduljalil. Job Satisfaction of Primary Health CarePhysicians at Capit Health Region, Kuwait. MiddleEast Journal of family medicine 2005, Vol. 3(3): 1-5.Al Mari S.A., Al Taweel A.A. and Elgar F. FactorsInfluencing Job Satisfaction among Primary HealthCare Physicians in Qatar. Qatar Medical Journal2002, Vol.11 (1):15-18.Khalid A. Kalantan, Ahmed A, Al Taweel and HamzaAbdul Ghani: Factors Influencing Job satisfactionamong Primary Healthcare (PHC) Physiciansin Riyadh, Saudi Arabia. Special Communication1999: 1-4.Warr P, Cook J and Wall T. Scales for measurementof some work attitudes and of Psychological Wellbeing.J Occupat Psychol 1979 52: 129-148.C.L. Cooper, U. Rout and B. Faragher. Mentalhealth, job satisfaction, and job stress among generalpractitioners. BMJ 1989, 298(6670):366-370.Bonnie Sibbald, Ian Enzer, Cary Cooper, Usha Routand Valerie Sutherland. GP job satisfaction in 1987,1990 and 1998: lesions for the future. Family Practice2000, Vol. 17(5): 364-371.Bruce E. Landon, James Reschovsky and DavidBlumenthal. Changes in career satisfaction amongprimary care and specialist physicians, 1997-2001.JAMA 2003, 289: 442-449.Barbara Ulmer and Mark Harris. Australian GPs aresatisfied with their job: even more so in rural areas.Family Practice 2002 Vol. 19(3):300-303MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6 21

EDUCATION AND TRAININGTable 1:Distribution of Demographic and Professional VariablesVariable Category N (%)Age30 years11 (6.3)30-45 years 97 (55.1)45 years67 (38.1)No response 01 (0.6)SexMale85 (48.3)Female91 (51.7)ReligionMuslim167 (94.9)Non Muslim 09 (5.1)Nationality Qatari32 (18.2)Non Qatari 144 (81.8)Marital status Single07 (4.0)Married168 (95.5)Widow01 (0.6)SpecialtyFamily Physician 49 (27.8)GP119 (67.6)No-response 08 (4.5)Years in practice 5 years40 (22.7)5-10 Years 61 (34.7)10 years74 (42.0)No-response 01 (0.6)Number of house 575 (42.6)holds in family 5-1089 (50.6)108 (4.5)No-response 04(2.3)Table 2: Distributions of Job Satisfaction According to ProfessionalVariablesVariable Category N (%)Q.1 Satisfaction with Not Satisfactory 31 (17.7)the physical working Cannot say5 (2.9)conditionsSatisfactory139 (79.4)No-response01 (0.6)Q.2 Satisfaction with the Not Satisfactory 50 (28.7)freedom to choose your Cannot say7 (4.0)own method of working Satisfactory117 (67.2)No-response02 (1.1)Q.3 Satisfaction with Not Satisfactory 8 (4.5)your colleagues & fellow Cannot say9 (5.1)workersSatisfactory159 (90.3)Q.4 Satisfaction with Not Satisfactory 78 (44.3 )your rate of payCannot say25 (14.2)Satisfactory73 (41.5)Q.5 Satisfaction with Not Satisfactory 13 (7.4)your hours of work Cannot say5 (2.9)Satisfactory157 (89.9)No-response01 (0.6)Q.6 Satisfaction with the Not Satisfactory 68 (39.1)two shifts at work Cannot say10 (5.7)Satisfactory96 (55.2)No-response02 (1.1)Q.7 Satisfaction with The Not Satisfactory 100 (58.8)incentives you get for Cannot say21 (12.4)your good work. Satisfactory49 (28.8)No-response06 (3.4)Q.8 Satisfaction with Not Satisfactory 45 (25.6)amount of variety in Cannot say22 (12.5)your job.Satisfactory109 (61.9)Q.9 Satisfaction with Not Satisfactory 55(31.8)the appointment system Cannot say24 (13.9)in subspecialty clinic in Satisfactory94 (54.3)decreasing the problem No-response03 (1.7)of patients load.Q.10 Compared with a Not Satisfactory 27 (15.5)year ago how you would Cannot say24 (13.8)describe your overall job Satisfactory123 (70.7)satisfaction today. No-response02 (1.1)Table 3: Distribution of Stress According to Professional VariablesVariable Category N (%)Q.1 Increased demands Disagree12 (6.8)from patientsCannot tell04 (2.3)Agree154 (87.5)No-response06 (3.4)22Q.2 Insufficient time todo justice &preventivemedicine during consultationsQ.3 Interruptions byemergency cases duringconsultations.Q.4 Disturbance of familylife by GP workingQ.5 There’s insufficienttime to update your selfDisagreeCannot tellAgreeNo-responseDisagreeCannot tellAgreeNo-responseDisagreeCannot tellAgreeNo-responseDisagreeCannot tellAgreeNo-responseMIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 626 (14.8)05 (2.8)140 (79.5)05 (2.8)45 (25.6)20 (11.4)104 (59.1)07 (4.0)92 (52.3)26 (14.8)51 (29.0)07 (4.0)61 (35.7)07 (4.1)103 (60.2)05 (2.8)Table 4: Mean levels and Comparison of Characteristics ofVariables According to Job Satisfaction Score.Variable Category N, Mean, SD P valueAge 3030-4545GenderReligionNationalitySpecialtyNumber of years workingin practiceMaleFemaleNumber of households 55-1010MuslimNon MuslimQatariNon QatariFamily physicianGP5 years5_10 years10 years10, 0.34±0.3991, 0.36±0.461, 0.37±0.3878, 0.38±0.3685, 0.34±0.42154, 0.35±0.4609, 0.47±0.3829, 0.33±0.45134, 0.37±0.3946, 0.33±0.43110, 0.39±0.3836, 0.38±0.3958, 0.34±0.3968, 0.36±0.4169, 0.43±0.3383, 0.32±0.4307, 0.33±0.290.970.480.410.700.440.890.22Table 5: Comparison of Different Characteristics of VariablesAccording to Stress Score.Variable Category N, Mean, SD P valueAgeGenderReligionNationalitySpecialtyNumber of years workingin practice30 Yrs30-45 Yrs45 YrsMaleFemaleNumber of households < 55-1010MuslimNon MuslimQatariNon QatariFamily physicianGP< 5 years5-10 years10 years10,0.40±0.3892, 0.37±0.4463, 0.38±+0.4280, 0.26±6.4687, 0.48±0.37158 , 0.38±0.4309, 0.29±0.2831 , 0.54±0.39136 , 0.34±0.4307, 0.38± 0.50112 , 0.38 ±0.4039 , 0.48 ±0.4560 , 0.31±0.4367 , 0.39±0.4168 , 0.35±0.4587 , 0.38±0.4108, 0.58±0.330.960.010.530.020.900.150.36

CLINICAL RESEARCH AND METHODSMIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6 23

CLINICAL RESEARCH AND METHODSCerebral Palsy in Iranian Children: Etiology, types andassociated disordersimproved maternal and childcareABSTRACTparticularly in the ante and perinatalperiods may reduce the incidence ofObjectives and Background: CerebralPalsy (CP) is a non-progressiveCP in this environment.encephalopathy that may be accompaniedby speech, auditory or visualFarin Soleimani (M.D, Pediatrician)Sahel Hemmati (M.D, Psychiatrist)abnormalities; seizure or learningNasrin Amiri (M.D, Child Physiatrist)disorder, and mental retardation. CPUniversity of Social Welfare and Rehabilitation Sciencesoccurs as a result of injury in eachPediatric Neurorehabilitation and Developmental Disorder Research Centerphase of brain growth and usuallyAsghar Dadkhah, PhD. (Associate professor)the motor pathways are involved. WeUniversity of Social Welfare and Rehabilitation Sciences, Tehran, Irandecided to investigate this problem,because there is limited study on CPCorespodence to:(with respect to etiology, types andDr Asghar Dadkhahassociated disorders) in Iran.University of Social Welfare and Rehabilitation Sciences,Method: A descriptive-analyticalEvin, Kudakyar Ave., 19834 Tehran, Iranstudy was carried out to investigateEmail: fsoleimani@uswr.ac.irthe etiology, types and associateddisorders. Iranian children with CP,Key words: Cerebral palsy, perinatal factors, birth asphyxia, low birth weight.between one and six years of age,were studied over a two year periodand were selected from children presentingto the referral neuro-developmentalservices of university rehabilitationclinics in the northern andIntroductioneastern districts of the health centers Cerebral palsy, a persistent, nonprogressivedisorder of movement andof Tehran province with an estimatedpopulation of 20 million inhabitants,posture which occurs during a periodand evaluated at 3 monthly intervalsfor two years during 2004-2006.of cerebral growth and developmentResults: 112 children with CP were (infancy and childhood)(1,2) remainsseen during the study period. The a globally common cause of pediatric hypoglycemia,main symptoms were delay milestones(91.1%), inability to walk inde-advances in neonatal intensive caremorbidity despite the technologicalpendently (52.7%), delayed speech and improved maternal care over(41.1%) and seizures (30.4%). The the last two decades(3,4). All of themain neurological features werechildren with CP suffer from a kind ofmotor weakness (63.4%), spasticity(55.4%), language dysfunctionbrain damage and this usually involves(33%), loss of head control (23.2%)motor pathways. More than 100 yearsand mental retardation (8.5%). Cranialcomputerized tomography abnor-Little’s classic paper linking abnormalhave elapsed since the publication ofmalities were mainly cerebral atrophy parturition, difficult labor, premature(18.8%). MRI abnormalities (18.7%) birth, and asphyxia neonatorum withwere mainly cerebral atrophy, demyelinationand ventriculomegaly. The pathogenesis of cerebral birth injuriesa “spastic rigidity of the limbs(2), theresults showed that the perinatal factorswere the most frequent causesis far from completely understood.This is not because of lack ofof CP among which asphyxia waspresent in 52 (46.4%), and includedinterest. The evolution and ultimate Concomitantlow birth weight and very low birth neurologic picture of cerebral palsyweight with 51(45.4%), pre-term deliverieswith 42 (37.5%), and neonatal papers. Today it is known that mosthas been recorded in innumerableseizure in 28 (25%) which were the of the high risk pregnancies will havemost outstanding factors. Spastic normal children. Indeed, many ofhemiplegic CP was recorded as the the patients with CP have had extramost frequent type (36.6%).CNS anomalies, which have been ledConclusions: The main factors identifiedwere birth asphyxia, pre-termto increased risk of asphyxia duringdelivery, low birth weight (especiallydelivery.VLBW). Our findings suggest that24MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6The etiologies of CP can be groupedinto three categories: Prenatal(genetic, intrauterine infections),Perinatal (asphyxia, LBW, birthtrauma), Postnatal (hemolytic diseaseof neonate that leads to kernicterous,metabolic derangements likehypocalcaemia,hypoxia, and inborn errors ofmetabolism, CNS infections such asmeningitis and encephalitis)(5,6).Different types of CP can be groupedaccording to physiologic, topographicand functional capability. In this studydifferent types of CP were groupedaccording to physiologic, spastic andnon-spastic (hypotonic and atonic,attetoid or dyskinetic and mixed), andtopographic (hemiplegia, diplegia,quadriplegia, monoplegia, triplegiaparaplegia, double hemiplegia)parameters.disturbances,which are observed in this studyare: communication and learningdifficulties, epilepsy, mentalretardation, speech, auditory,swallowing and visual disorders(7-8).The reported prevalence of CPranges from 1.5 - 2.5 per 1,000live births, and a higher ratein thelowest birth weight groups has been

CLINICAL RESEARCH AND METHODSattributed more to the increasednumber of survivors as a result ofimproved care in itself(9,10). Theneed for resuscitation and presenceof congenital abnormalities were alsoidentified as risk factors for CP(11).More recent studies showed thatthe Apgar score equal or lower than3 in the 5th minute of birth in manyobserved infants did not lead toCP; but the study of Apgar scorein minutes 10th and 20th of birth isimportant(5). In another study it wasdefined that in more than 50% ofpatients, asphyxia was not the solereason of CP and a concomitantetiology also existed. It should bementioned that in considering theetiology of CP the percent of asphyxiais not absolute and it is in conjunctionwith other factors such as LBW,prematurity, respiratory distresssyndrome(RDS), NICU admission >3days and environmental stresses andprocedures(12).According to the WHO report 2006, in Iran “ perinatal factors “ are thefourth common cause of mortality inall ages, and cause 10 years of lifelost (YLL), which is the third mostcommon cause for lost years in thecountry (after ischemic heart diseaseand road traffic accidents)(13).According to the same report until2004, the under 5 - mortality rate inIran was 38 per 1000 live births, 63percent of which was due to neonatalmortality which in comparison to 43percent in the regional averageEastern Mediterranean countries, isa significant figure. The same sourcehas reported that among all etiologiesfor neonatal mortality in Iran, pretermbirth (31%, in comparison to 22%in the Eastern Mediterraneanarea), congenital anomalies (15%in comparison to 9% in the EasternMediterranean area with high childand adult mortality), birth asphyxia(22%), and severe infections (22%)are the most common(13).One can conclude that congenitalanomalies aside, the three othermost common etiologies of neonatalmortality in Iran are somehow relatedto the perinatal period, and thus under5 mortality, which as said before ismainly due to neonatal causes andoccurs mainly in the neonatal period,is also strongly related to perinatalfactors.When considering years of life lostin Iran, one can also presume thatchildhood long-term morbidities andhandicaps may be significantly relatedto the perinatal period as well(13).One report supporting thispresumption suggests that indeveloping countries, amongall etiologies of cerebral palsy,prematurity and intrauterine growthrate restriction (40 -50%) and birthasphyxia or birth trauma (25-30%)are the most common causes(14).In order to prevent neurodevelopmentaldisorders, one of themost effective strategies universally,is early intervention following earlydetection of the most subtle andearliest signs of neuro-developmentaldisorders. Thus the early signs andsymptoms for primary physiciansis very important for referral for thesecond level of assessment whichis performed by experts and withprofessional tests.On the other hand, cerebral palsyis a common cause of disability inIranian children. Because there hasnot been any research about themost frequent etiologies and kindsof CP and its associated disorders,this research has been done tospecify the most frequent causes forbetter management and preventionfor reducing incidence in Iran anddeveloping countries such as Iran.Since prevention is superior totreatment especially for disease suchas CP, the importance of this researchwill be noted.Materials and MethodThis study was carried out inthe years 2004-2006, on 112 oneto six-year old children, who werereferred from different health-carecenters in the northern and easterndistricts of Tehran to the child neurodevelopmentservice at the UniversityRehabilitation Clinic in the easternand northern Tehran provinces ofIran and were evaluated at 3-monthlyintervals for at least two years.The reason for choosing thenorthern and eastern districts waseasier geographical accessibility tothis center for the referred childrenand their families. The gender andsocio - economic status were thesame of Tehran province, the capitalcity of Iran, with 20 million inhabitants,(all coming from the same districts inTehran city).In order to detect etiology, aquestionnaire was completed for eachchild, including the prenatal, perinatal,neonatal and infantile medical history,with the aid of the mother and thechild’s medical and health records.At the initial assessment, informationon their demographic characteristics,clinical data including the durationof gestation and labor, place andmethod of delivery, number of fetusesand outcome, birth weight, maternalpast and current medical and socialhistories, complications duringpregnancy and labor was collected.In addition, information on stillbirths,abnormal children, ante partumhemorrhage, and exposure to drugs,exanthemata, and febrile illnesssevere enough to warrant admissionto the hospital in the mother duringthe current pregnancy, was alsoobtained.Baseline investigations includedcomplete blood count, serumelectrolytes, renal, thyroid and liverfunction tests. Organic acid screen,TORCH study, serum lactate andpyruvate, electroencephalography(EEG) and cranial computerized axialtomography (CT) or MRI, visual andhearing evaluation were obtainedon clinical suspicion and were notperformed in any of the children.Information on intrauterine growthand details of monitoring of fetalgrowth for any of the children wasalso not available.The questionnaire had beenpreviously evaluated for contentvalidity and pilot studies had beencarried out.The diagnosis of CP was reachedusing predefined criteria for thestudy. CP was defined as a chronicdisability characterized clinically bynon progressive aberrant control ofmovement that appears early in lifeand is not caused by a recognizedprogressive disease or identifiedetiology such as encephalitis orMIDDLE EAST JOURNAL OF FAMILY MEDICINE •VOLUME 6, ISSUE 6 25

CLINICAL RESEARCH AND METHODSmeningitis.pediatrician,pediatrician,Results26These patients were groupedaccording to physical examinationand standard protocols.For study of concomitantdisorders a group of developmentalneuro-rehabilitationophthalmologist,pediatric neurologist and psychiatristwas used. Assessment of severity ofmotor, mental retardation, speech andswallowing disorders, was carried outby a professional rehabilitation teamincluding occupational and physicaltherapist, speech and languagepathologist and special psychologist.In this study, the term perinatalrestricts itself to the period extendingfrom the onset of labor to the end ofthe first week of postnatal life.The collected data was verified andentered into a standard database fileand analyzed using the statisticalpackage for social sciences.During the study period, 112 CPpatients (53 males, 59 females) aged12 to 72 months were seen with anoverall male: female ratio of 0.89: 1.The mean age +standard deviation(SD) for males was 33.3 ±35.2 monthsand females 24.8±22.5 months. Themean head circumference + SDfor males was 45.30 + 3.5 cm andfemales 43.93 + 3.7 cm. Microcephaly(head circumference

CLINICAL RESEARCH AND METHODSwere perinatal etiologies, of which29% were asphyxia, 24.5% wereprematurity and 13% were LBW(19).The other studies report that,different types of CPs are as follows:Hemiplegic (25-40%), diplegic (10-23%), mixed (9-22%), quadriplegic(9-43%), extra pyramidal (9-22%)which is similar to our study(1,6), butin another study in Iran, frequencyof different types of CP were spasticdiplegic, mixed spastic quadriplegic,extra pyramidal and hemiplegic(19).In our study it was observed that97.3% of patients were deliveredin hospital and 46.4% had birthasphyxia with persistent low Apgarscore, 25% neonatal seizure and5.4% ASMF, that is according to therecent studies that indicate the role ofintrapartum events and CP(20). Thus,maternal factors during pregnancyand labor appear to play a major rolein the etiopathogenesis of CP in ourpatients.The clinical characteristics of our112 CP children are similar to thosereported in other studies(21-23). Ourfindings of low birth weight (45.4%),prematurity (37.1%), (8.8% with

CLINICAL RESEARCH AND METHODS2. Menkes JH, Sarnat HB: Child Neurology, Philadelphia,Lippincot Williams & Wilkins, 2006, 7th ed. bddeathdalyestimates.xls.25. Pharoah POD, Platt MJ, Cooke T. The changing13. http://www.who.int/entity/healthinfo/statistics/bodg-Behav Pediatr 2001 ; 22 : 11-18.3. Badawi N, Watson L, Petterson B, Blair E, Slee J, 14. Hermansen MC. Perinatal causes of cerebral palsy. panorama of cerebral palsy. Arch Dis Child 1996;Haan E et al. What constitutes cerebral palsy? Dev Clin Perinatol 33: 2006.75: F169-F173.Med Child Neurol 1998; 40: 520-527.15. Moster D, Lie RT, Irgens LM, et al. The association 26. Hack M et al. Effect of very low-birth-weight and4. # Arpino C, Curatolo P, Stazi MA, Pellegri A, VlahovD. Differing risk factors for cerebral palsy in the palsy: a population-based study in term infants. J age. N Engl J Med 1991;325:231-237.of Apgar score with subsequent death and cerebral subnormal head size on cognitive abilities at schoolpresence of mental retardation and epilepsy. J Child Pediatr 2001;138:798-803.27. Piecuch RE, et al. Outcome of extremely low-birthweightinfants (500 to 999 grams) over a 12-yearsNeurol 1999;14:151-155.16. Nelson KB, Ellenberg JH. Antecedents of cerebral5. # Volpe JJ: Hypoxic-ischemic encephalopathy: clinicalaspects. In Volpe JJ (ed): Neurology of the New-1986;315-86.28. Hach M, et al. School-age outcomes in childrenpalsy: multivariate analysis of risk. N Engl J Med. period. Pediatrics 1997;100:633-639.born, 4rd ed. Philadelphia, WB Saunders,2001,pp 17. Stanley FJ, Blair E: Why have we failed reduce with birth weights under 750 g. N Engl J med314-369.the frequency of cerebral palsy? Western AustralianResearch Institute for Children Health - Prin-29. Kolawole TM, Patel PJ, Mahdi AH. Computed tomo-1994;331:753-753.6. McMillan J, Deangelis CD, Feigin RD, et al, Oski’sPediatrics, 3nd ed, Philadelphia, Lippincitt Williams cess Margaret Hospital Subiaco. Med J Austria. graphic (CT) scans in cerebral palsy (CP). Pediatr& Wilkins, 1999, pp 756 - 840.1991;6:623-26.Radiol 1989; 20: 23-27.7. Rudolph AM, Huffman JIE, Rudolph CD: Pediatrics, 18. Robertson CMT, Finer NN. Long-term follow-up of 30. Al-Sulaiman A. Electroencephalographic finding inUSA, INC, 1996, pp. 87 - 195.term neonates with perinatal asphyxia. Clin Perinatol1993;20:483-500.funct Neurol 2001; 16; 325-328.children with cerebral palsy; a study of 151 patients.8. Day RE: Psychomotor and Intellectual DevelopmentIn: Campbell AGM, Mc Intosh N(ed), FORFAR 19. Sajedi F, Togha M, Karimzadeh P. A survey of 200 31. Zafeiriou DI, Kontopoulos EE, Tsikoulas I. Characteristicsand prognosis of epilepsy in children with& ARNEIL textbook of Pediatrics,5th ed, New York , cases of cerebral palsy in welfare and rehabilitationChurchill, 1998, pp 349 - 381.centers of Tehran. Saudi J Disabil 2003;9(1):1-7. cerebral palsy. J Child Neurol 1999; 14: 289-294.9. Botos M, Granato G, Gloachin C, Puato ML. Prevalenceof cerebral palsy in north-east Italy from 1965 tion between acute intrapartum events and cerebral NL: Language abilities following prematurity, periv-20. MacLennan A. A template for defining a causal rela-32. Feldman HM, Janosky JE, Scher MS and Warchamto 1989. Dev Med Child Neurol 1999; 41: 26-39. palsy: international consensus statement. BMJ entricular brain injury, and CP. Journal- Common-10. Liu JM, Li S, Lin Q, Li Z . Cerebral palsy in China. Int 1999; 319: 1054-1059.Disorder. 1994;27(2):71-90.J Epidemiol.1999; 28(5): 949-54.21. Kuban KCK, Leviton A. Cerebral palsy. N Engl J 33. Lespargot A, Langevin MF, Muller S, GuillemontS: Swallowing disturbances associated with11. Dite GS, Reddihough DS, Bessell C, Brennecke S, Med 1994; 330: 188-195.Sheedy M. Antenatal and perinatal antecedents of 22. Rosenbloom L. Diagnosis and management of cerebralpalsy. Arch Dis Child 1995; 72: 350-354.1993;35(4):298-304.drooling in CP children: Dev Med Child Neurol.moderate and severe spastic cerebral palsy. Aust NZ J Obstet Gynaecol 1998; 38: 377-383.23. Al-Sulaiman A, Bademosi OF, Ismail HM et al. 34. Schenk-Rootlieb AJF, van Nieuwenhuzen O, van12. Vohr BR, Cashore WJ, Bigsby R: Stresses and Interventionsin the Neonatal Intensive Care unit In: 2003;8(1):26-29.alence of cerebral visual disturbances in childrenCerebral palsy in Saudi children. Neurosciences der Graaf Y, Wittebol-Post D, Willense J. The prev-Levine MD, Carey WB, M.D, Crocker AC: Developmental-Behavioral Pediatrics, 3rd Edition, 1999,W. , academic progress , behavior and self concept at 473-480.24. Rickards AL , Kelly EA, Doyle LW , et al . Cognition with cerebral palsy. Dev Med Child Neurol 1992; 4:B.Saunders Company.14 years of very low birth weight children . J DevTable 1: Frequency of major symptoms and signs in Iranian Table 2: Frequency of main associated factors in Iranian childrenaged 1-6 years with cerebral palsy (N=112)children aged 1-6 years with cerebral palsy (N=112)FrequencyEtiologyMale N=53 Female N=59 Total N(%)Male Female TotalPrenatal & Intra uterineN=53 N=59 N (%)Small for Gestational Age 221638 (33.9)Presenting symptomsIntra Partum Hemorrhage 4610 (8.9)Delayed Milestones 5052 102(91.1)PROM9817 (15.2)Inability to Walk 3128 59 ( 52.7)Multiple pregnancy7411 (9.8)Delayed speech 2125 46 ( 41.1)Breech presentation134 (3.6)Seizure1816 34 (30.4)Preeclampsia314(3.6)Poor head control 1214 26 ( 23.3)Intra Uterine Infection (TORCH) 358(7.1)Physical signsStructural Uterine Abnormality 123(2.7)Motor Weakness 3041 71(63.4)Using Drug5510(8.9)Spasticity3131 62(55.4)Infertility Treatment459(8)Microcephaly2020 40(35.7)Repeated Abortion91019(17)Speech disorders 1720 37(33)Sensory disorder 1011 21(18.8)Perinatal & Early postnatalStrabismus10818(16.1)onsetHearing Loss549(8.9)Low Birth Weight262551 (45.4)Mental Retardation 538(8)Neonatal seizure111728 (25)Preterm delivery251742 (37.5)Depressed Apgar score 252752 (46.4)Table 3: Types of Cerebral Palsy in 112 Iranian childrenNICU Admission > 3 days 252247 (42)Meconium-stained Amniotic 246(5.4)TYPEFrequencyfluidN PercentProlong Labor022(1.8)spastic Hemiplegia 41 36.6Diplegia 35 31.3Postnatal onsetSevere hyperbilirubinemia 246(5.3)Quadriplegia 14 12.5Pneumonia type II13821(18.8)non-spastic Hypotonic & Atonic 15 12.5Metabolic Disorder121022(19.6)Attetoid or Dyskinetic 5 4.5Infantile Seizures141226(22.3)Mix 2 1.8Total 112 100Table 4: Frequency of birth weight of 112 Iranian cerebralpalsy children.Birth Weight FrequencyN Percent> 4000 gm 2 1.82500-4000 gm 59 52.81500-2500 gm 36 32.1

CLINICAL RESEARCH AND METHODSPathophysiology of MigraineABSTRACTMigraine is a neurovascular disordercharacterized by a unilateral mild orsevere headache lasting from a fewhours to as long as three days. It hasbeen recently shown in many studiesthat this disorder has a firm andcomplicated genetic background thatexposes individuals to a higher susceptibilityto migraine attacks. Oldtheories used to focus on the vascularchanges and the subsequentblood flow alterations in the brain toexplain the different symptoms occurringduring migraines. New theorieson the other hand are sheddingmore light on the involvement of thenervous system in the brain, primarilythe trigeminal nerve in the brainstem, considering it the primarycause for the initiation of migraineattacks. Changes in blood vessels inthe brain are believed to be an epiphenomenononly.In this article, the pathophysiology ofa migraine attack is explained on thebasis of the unified theory that triesto integrate all the available scientificdata about migraine.M. Bashir Abiad, BS BiologyPathophysiology ofmigraine:Migraine is best defined as achronic disorder of the centralnervous system. It is characterizedby a series of events beginningwith the abnormal over-excitementof certain nerve cells in the brain.These neurons release a pool ofchemicals that stimulate the brain’sblood vessels to swell (vasodilation),and create an inflammatory reactionin the affected area. As a result,the person suffers from a severeand pulsating unilateral headache,accompanied by nausea, vomiting,visual and auditory problems, tinglingof the face and extremities, as well asfatigue, drowsiness and yawning [1] .Migraine attacks may be triggeredby many different factors, includinghormonal changes (observedin menstrual cycles, with oralcontraception or estrogen replacementtherapy, which explains why nearly74% of migraine sufferers in theUnited States are females [2] ). Othertriggers involve dietary factors (likechocolate; alcohol; cheese; yoghurt;fermented, decayed or marinatedmeat and anything that may containtyramine, a monoamine which isproduced by the decarboxylation oftyrosine during fermentation or decayand that causes the release of storedmonoamines (dopamine, epinephrineor norepinephrine) [3] . Changes in sleeppatterns, emotional disturbances(like excitement, fear, anxiety, anger,and stress), allergic reactions, andenvironmental factors (like weatherchanges, bright light, loud noise,certain odors and perfumes) mayalso trigger migraine attacks [4] . Eachperson, with his/her unique geneticbackground, is at a certain thresholdof neuronal excitability in his/herbrain. In fact, specific allele mutationshave been recently discovered to beinvolved in exposing the individualto higher risks to migraine attacks:four different missense mutations inthe α 1Asubunit of the P/Q – type ofvoltage-gated Ca 2+ on chromosome19 affect the release of serotonin,a vasoconstrictor, in midbrain [5][6][7] .ATP1A2 gene, found on chromosome1q23, is also linked to migraineattacks. This gene codes for theα 2subunit of the Na + /K + ATPase [8] .Moreover, the dopamine D2 receptorgene is found to be responsible alsofor increasing the susceptibility tomigraine recurrence [9] .When exposed to the migrainetriggers listed above, the ones withlow threshold (i.e. higher susceptibilityto migraine attacks) will experience ashort wave of neural depolarizationin the brain due to the initial releaseof potassium and glutamate in theoccipital lobe and then propagatethroughout the whole cortex at aspeed ranging between 3 and 6 mm/min. This wave is followed by a longerone of neural depression known ascortical spreading depression, orsimply CSD [1] . These consecutivealterations in the neural activity in thebrain stimulate the vasoconstrictionof specific blood vessels in thebrainstem. If the decrease in the bloodflow goes below a critical value, thedifferent symptoms observed duringthe aura phase (e.g. blurred vision,weakness, tingling or numbness ofthe face and extremities) may beinitiated [10] .It should be noted that one thirdonly of migraine sufferers passthrough the aura symptoms. The resttwo third, despite the electrical wavedisturbances, have what we callmigraine without aura because thedecrease in blood flow in their brainis not so critical [11] . Some studieshave shown that the disruption of thenormal electric status of the brainmight affect the performance of thehypothalamus causing the differentprodromal signs observed severalhours (or even days) before themigraine, like mood disturbances,food cravings, drowsiness, thirst, andyawning [12] .MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6 29

CLINICAL RESEARCH AND METHODSOnce the CSD is terminated,the brain cells synthesize manyvasodilators but most importantlynitric oxide (NO), which diffusesto the cortical area and stimulatesthe peripheral blood vessels at themeninges to swell. These vessels arehighly innervated by the peripheraltrigeminal nerves; also know as thetrigeminal afferents. Once the stretchreceptors found in the walls of themeningeal vessels are activatedupon the dilation of these vessels, thetrigeminal afferents will send specificsensory input to the trigeminal nucleusin the brain stem [13] . In a pseudo-reflexpathway, motor trigeminal nervesrelease at their axonal terminals manyneurotransmitters and neuropeptidesnear the dilated vessels. The mostimportant chemicals are substanceP, which is mainly responsible formediating the pain impulses to theappropriate nociceptors in the brain,and neurokinin A which promotesprotein extravasations from theblood plasma to the neighboringtissue. Both of the latter, with theneuropeptide calcitonin gene-relatedpeptide (CGRP) induce vasodilationof more peripheral arteries, worseningthe pain. Other chemicals like thevasoactive intestinal peptide (VIP),nitric oxide (NO), serotonin (5-HT),and dopamine (D) are also involved.This pool of chemicals will cause alocal inflammatory reaction, termedsterile neurogenic perivascularinflammation [13] .It is suggested as well that thethalamus plays an important role indirectly stimulating the cortical painareas situated in higher centersof the CNS, which produce painof the headache [11] . Note also thatseveral aminergic brain stem nucleiare directly involved in the migraineattack. Dorsal Raphe nucleus forinstance is involved in changing thelevels of serotonin in the brain [12] .This neurotransmitter is crucial formood control, pain sensation, sexualbehavior, sleep, as well as dilationand constriction of the blood vessels,which might trigger a migraine [14] .Locus Ceruleus causes changes inepinephrine level, which explains theactivation of the sympathetic nervoussystem in the body during or arounda migraine attack. This activity in theintestine causes nausea, vomiting,30and diarrhea. Sympathetic activityalso delays emptying of the stomachinto the small intestine and therebyprevents oral medications fromentering the intestine and beingabsorbed. The impaired absorption oforal medications is a common reasonfor the ineffectiveness of medicationstaken to treat migraine headaches.The increased sympathetic activityalso decreases the circulation ofblood, and this leads to pallor of theskin as well as cold hands and feet.The sensitivity to light and soundas well as blurred vision are alsoconsequences for the increasedsympathetic activity [15] .Till now, the complete phenomenonof migraine initiation was not wellunderstood. In fact more research andstudies are required in order to revealthe whole pathway triggering thisdisorder. Once this stage is reached,the “perfect” treatment for migrainewould be easily synthesized.Results1. 1. Migraine. Microsoft® Student 2008 [DVD]. Redmond,WA: Microsoft Corporation, 2007.2. 2. Sahai, S. (2007, April, 27). Pathophysiology andTreatment of Migraine and Related Headache.emedicine, Retrieved August 20, 2008, from http://www.emedicine.com/neuro/TOPIC517.HTM3. 3. Trigeminal nerve. In Medical Dictionary Online[Web]. Retrieved August 20, 2008, fromhttp://www.online-medical-dictionary.org/omd.asp?q=trigeminal+nerve4. 4. Migraine. (2006). In MedlinePlus [Web]. U.S.:Retrieved August 20, 2008, from http://www.nlm.nih.gov/medlineplus/ency/article/000709.htm5. 5. Ophoff RA, Terwindt GM, Vergouwe GM, et al.Familial hemiplegic migraine and episodic ataxiatype-2 are caused by mutations in the Ca2+ channelgene CACNL1A4. Cell.1996;87:543-552.6. 6. May A, Ophoff, RA, Terwindt GM, et al. Familialhemiplegic migraine locus on chromosome 19p13is involved in common forms of migraine with andwithout aura. Hum Genet. 1995;96(5):604-608.7. 7. Nyholt DR, Lea RA, Goadsby PJ, et al. Familialtypical migraine: linkage to chromosome 19p13and evidence for genetic heterogeneity. Neurology.1998;50:1428-1432.8. 8. De Fusco M, Marconi R, Silvestri L, et al. Haploinsufficiencyof ATP1A2 encoding the Na+/K+ pumpalpha2 subunit associated with familial hemiplegicmigraine type 2. Nat Genet. 2003;33(2):192-196.9. 9. Peroutka SJ, Wilhoit T, Jones K. Clinical susceptibilityto migraine with aura is modified by dopamineD2 receptor (DRD2) NcoI alleles. Neurology.1997;49:201-206.10. 10. Warner, J. (2008). Migraine Headaches WithAura Magnifies Risk of Heart Disease and Stroke inWomen. In WebMD [Web]. USA: Retrieved August20, 2008, from http://www.webmd.com/heart-disease/news/20080730/womens-migraines-mult11. 11. Retrieved August 23, 2008, from Migraine Associationof Ireland Web site: http://www.migraine.ie/index.cfm/loc/3-5-2.htm12. 12. Migraine. (2001). In Merckmedicus [Web]. USA:Merck & Co.. Retrieved August 20, 2008, fromhttp://www.merckmedicus.com/pp/us/hcp/diseasemodules/migraine/path13. 13. Boyd, J. Pathophysiology of Migraine and ra-MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6tionale for a targeted approach of prevention. RetrievedAugust 23, 2008, from Migraine preventionWeb site: http://www.migraineprevention.com/14. 14. Alexander Mauskop; Fox, Barry (2001). WhatYour Doctor May Not Tell You About(TM): Migraines: The Breakthrough Program That Can Help EndYour Pain (What Your Doctor May Not Tell YouAbout...(Paperback)). New York: Warner Books.ISBN 0-446-67826-0.15. 15. Dennis, L. Migraine Headache. Retrieved August20, 2008, from MedicineNet Web site: http://www.medicinenet.com/migraine_headache/article.htm

CASE REPORTSThe Etiology and Patterns of Maxillofacial Injuries At AMilitary Hospital in JordanABSTRACTObjective: To describe the cases ofmaxillofacial injuries that attendedthe Emergency Department at QueenAlia Military Hospital.Methods: A descriptive study of 85cases representing patients withmaxillofacial injuries who attendedthe emergency department at QueenAlia military hospital during a 3year period (January 2002 till January2005) were analyzed in relationto age, gender, cause of injury andneed for referral to other specialtiesfor better management.Results: Out of the total 85 casesthat were reviewed, there were 65(76.4%) males and 20 (23.6%) females.The mean age of the patientswas (24.5) and their age range wasbetween (3-50) years. The majorityof the maxillofacial injuries weredue to car accidents 69 (81.17%).Regarding the need for referral, 14(16.4%) cases had associated serioushead and eye injuries, thereforethey were referred to Neurosurgeryand Ophthalmology Departments.The majority of cases 71 (83.6%) hadmaxillary and mandibular fractures,which required referral to the departmentof maxillofacial surgery.Conclusion: The number of documentedcases of maxillofacial injuriesduring the study period may reflectunder-reporting of the problem.This may necessitate the need for anobligatory special form to be used atthe Emergency Department to overcomethis problem.Keywords: Oral Injuries, Maxillofacialinjuries, Mandibular fracture.Muntaha Y.Jerius MDKing Hussain Medical centerOut patient DepartmentRoyal Medical ServicesAmman-JordanCorrespondence to:Muntaha Y.JeriusP.O.Box 921004Amman 11192JordanE-mail: dr.muntaha@hotmail.comIntroductionMaxillofacial trauma is presented inAccident and Emergency Departmentof the hospital either as isolated injuryor part of multiple injuries to the head,neck, chest and abdomen (1) . Theetiology of these injuries is variablefrom one country to another and evenwithin the same country dependingon prevailing socioeconomic culturaland environmental factors (2) . Theseinjuries not only affect the functionof the patient but also cause seriouspsychological, physical and cosmeticdisabilities. Most of our patients wereinvolved in road traffic accidents (2) ,while in developed countries like theUnited Kingdom it was found thatviolence is the commonest causeof maxillofacial injuries, while caraccident injuries were declining,maybe because of improvement incar design and safety equipment andrapid management of the patients (5) .Epidemiologically, studies ofmaxillofacial trauma have classicallyshown that young adults are the mainvictims (3,4,5) . The aim of this study wasto investigate the incidence, etiology,management, age and sex distributionof maxillofacial injuries.Materials and MethodsThis descriptive study wasconducted at Emergency Departmentat Queen Alia Military Hospital duringa 3year period from January 2002till January 2005. The data werecollected by reviewing 85 medicalrecords representing patients withmaxillofacial injuries who attendedthe Emergency department at thatperiod, analyzed in relation to age,sex, cause of injury and need forreferral to other specialties for bettermanagement. The managementstarted with (ATLS) AdvancedTrauma Life Support including themaintenance of airway control ofbleeding, antibiotic coverage andhead elevation. Regular mouthwashwas advised. In all cases plain x-rays and CT scan were obtainedwhen possible. Patients who neededsurgical intervention were referredfor admission to be managedaccordingly.ResultsOut of the total 85 cases that werereviewed, there were 65 (76.4%)males and 20 (23.5%) females.More than 90% were between theage of 5 years and 35 years, meanage was (24.5). 69 cases (81%) weredue to car accidents and the restwere either due to quarrels or othertypes of trauma as seen in Table 1and Table 2.Regarding the need for referral, 14(16.4%) cases wereassociated withserious head and eye injuries; thereforethey were referred to neurosurgeryand ophthalmology departments, andthe rest were referred to the oral andmaxillofacial surgery department forfurther management.MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6 31

The mandible was the most commonsite of injury in about 69% followedby maxilla which represents 14% ofthe cases, then the other bones asshown in Table 3.DiscussionMaxillofacial injury is injury to thefacial soft tissues, facial bones andassociated specialized soft tissuewithin the head and neck as a resultof wounding or external violence.Regarding the etiology of maxillofacialinjuries, in this descriptive study roadtraffic accidents were the cause of81% of the injuries which agreeswith other studies done by S.shahidHussain (1) and Ansari MH (8) andcomparable to two other studiesdone in Jordan by Qudah MA et aland Jasser K (7,11) . In contrast, studiesin developed countries reportedthat violence is the main cause ofmaxillofacial injuries which was foundby Ogundar BO et al, Laski R et aland BuchananJ et al (3,4,6) , as well asin the UK, as reported by Tefler M etal (13) . Males were involved more thanfemales, which can be justified by thefact that men are working outdoorsmore than women, especially in thissociety. Some results about malepredominance were reported in otherstudies in Pakistan and Jordan aswell as in developed countries (3,4,13) .The pattern of maxillofacial injuryvaries with the severity of trauma.The most common bone to be injuredis the mandible, in about 69% of thecases, maybe because it is the mostprominent bone in the face, comparedwith the middle third of the face. Thiswas followed by the maxilla in 14%of the cases. These observationsare parallel to those of other studies.Another study in Jordan reported75% of the cases as mandibularinjury (11) so as in Ansari MH studywho recorded 52% of the injuriesare in the mandible (8) . The severity ofinjury varies from simple soft tissuelaceration to more complicatedfractures of the maxillofacial bones.Some patients have associated otherinjuries so they need to be treated byactive participation by neurosurgeonor ophthalmologist or orthopedicsurgeon (1,9) .Young people were the main32CASE REPORTSvictims in this study comparedwith other studies maybe becausethey are the most active age groupphysically (2,3,9,10,12) .The oral and maxillofacial surgeonis an essential part of comprehensiveAccident and Emergency Services inthe management of these injuries, bothprimary and secondary. In the moresevere injuries, the OMF Surgeonworks in close collaboration withmany other specialists, in particularneurosurgical and ophthalmologiccolleagues. Most of the patients inour study had associated injuriestreated concomitantly. Facial woundsand lacerations were closed primarily;bone injuries like mandible andzygomatic arch fractures were treatedby reduction, fixation and elevationaccordingly. Patients having anelement of head injury were observedand treated by the neurosurgeon.an intra-oral approach was used toprevent facial scarring.ConclusionThe number of documented cases ofmaxillofacial injuries during the studyperiod may reflect under-reporting.This may necessitate the need foran obligatory special form to be usedat the Emergency Department toovercome this problem.Maxillofacial injuries may causeserious cosmetic and functionaldeformities; patients with theseinjuries are candidates for a numberof operations. We conclude that earlyintervention including reduction,stabilization of fractures as well asbone or cartilage grafting will reducethe time of healing and number ofsurgeries done.The oral and maxillofacial surgeonis an essential part of comprehensiveAccident and Emergency Servicesin the management of these injuries,both primary and secondary.References1.2.3.S.Hussain SS, Ahmad M, Khan MI et al.Maxillofacialtrauma: current practice in management at Pakistan.J Ayub Med coll Abbottobad 2003 Aprjun;15(2):8-11.Malara P, Malara B,Drugacz J. Characteristics ofMaxillofacial injuries resulting from accidents .Headface Med .2006 Aug 28;2:27.Ogundare BO, Bonnick A, Bayley N.Pattern of man-MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6dibular fractures in an Urban trauma center; J oralMaxillofac.surg. 2003 jun ; 61(6):713-8.4. Laski R, Ziccardi VB, Broder HL et al.Facial trauma:A recurrent disease?... J oral Maxillofac.surg. 2004jun; 62(6):685-8.5. Wood EB , Freer TJ. Incidence and etiology of facialinjuries resulting from motor vehicle accidents…Australian Dental Journal 2001;46(4):284-288.6. Buchanan J, Colquhoun A,Fried lander L etal.Maxillofacial fractures at waikato Hospital,NewZealand:1989 to 2000 NZ Med J.2005 jun 24;118(1217);U 1529.7. Quadah MA,Al-khateeb T, Bataineh AB et al. Mandibularfractures in Jordanians ; a comparative studybetween young and adult patients.J Craniomaxillofacsurg. 2005 Apr; 33(2):103-6.8. Ansari MH. Maxillofacial fractures in Hamedanprovince,Iran…J Craniomaxillofacial surg.2004Feb; 32(1):28-34.9. Roy Chowburg SK, Suresh Menon P. Etiology andmanagement of zygomatico maxillary complex fracturein the Armed forces. MJAFI 2005;61:238-240.10. Bader E Al-Mahmeed ,Ibrahim M. Al yassin,RagaiEl Mostehy et al . The etiology and patterns of maxillofacialfractures in children in kuwait ,The SaudiDental Journal Vol 6 no.3 sep 1994.11. Jasser K Maaita. Maxillofacial fractures. Journal atthe Royal Medical services vol.9 no.1 jun 2002.12. Derek G, Martin M , Leslie S et al. Head injuries andassociated maxillofacial injuries. The New ZealandMedical Journal vol.117 no.1201 ISSN 11758716.13. Tefler M, Jones M, Shepherd P. Trends in etiology ofmaxillofacial fractures in the United kingdom (1997-1998) Br.J oral & maxillofac surg 1991;29:250-255.

CASE REPORTSTable 1: Etiology of maxillofacial injuries in relation to age groups.Age(years) Car accidents Violence Falls Sports Total3-9 11 0 3 0 1410-19 13 0 3 0 1620-29 24 3 1 3 3130-49 21 2 0 1 24Total 69 5 7 4 85Table 2: Number and percentage of cases related to etiology.Etiology Number of patients %Car accidents 69 81%Violence 5 6%Falls 7 8%Sports 4 5%Table 3: Site of fracture of maxillofacial bones.Site of Injury Number of patients % of patientsMandible 59 69.4%Zygomatic arch 8 9.4%Maxilla 12 14%Orbit 2 2.3%Temperoparietal 2 2.3%Frontal 2 2.3%Total 85 99.7%MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6 33

Efficacy of Mitomycin C in Pterygium ManagementOFFICE BASED FAMILY MEDICINEABSTRACT34Aims: To determine the efficacy andsafety of using Mitomycin C in themanagement of Pterygium.Methods: A retrospective study of 37eyes (30 patients), with the mean ageof 43 years (30 -55 yesar) attendingthe ophthalmology clinic. 17 eyes(17 patients) were treated by usingMitomycin C; 14 eyes had primarypterygia and 3 eyes had recurrentpterygia. 20 eyes (13 patients) weretreated without use of Mitomycin C;15 eyes had primary pterygia and 5eyes had recurrent pterygia. All eyesreceived the same medications postoperatively.Results: In the Mitomycin C treatedeyes we noted that only 2 eyes(11.7%) had recurrent pterygia, after14 months follow-up, but the recurrencein the non-Mitomycin groupwere higher than that of Mitomycingroup 9 eyes (45%) after the sameperiod of follow-up. Also we notedthat the healing of conjunctiva wasdelayed when we use Mitomycin C incomparison to the other group; whichis a known side effect of MitomycinC.Conclusion: From these results weconclude that the use of MitomycinC in the management of Pterygiumis effective in decreasing the recurrenceof pterygia after excision. Soit is a simple, safe and successfully\procedure that we recommended inall pterygium management.Mohammad Droos, MD (Oph)Correspondence to:Ophthalmology Department, Royal medical services,Amman, JordanTel: 00962-777265101E-mail: droos75@hotmail.comIntroductionA pterygium is an abnormal (noncancerousgrowth of the conjunctiva)a triangular fibrovascular subepithelialingrowth of degenerative bulbarconjunctival tissue over the limbalonto the cornea (1) . The conjunctivais a thin membrane lining the insideof the eyelid and part of the eyeball(located between the sclera, or the“white of the eye” which surroundsthe eyeball).Excessive growth of the conjunctivaleads to a pterygium, which appearsas a fleshy spot; pterygia are nearlyalways preceded and accompaniedby pingueculae (2) .The exact cause of pterygium isunknown. The most common factorsthat contribute to pterygium include:••••••Excessive exposure to sunlightSex: MaleIncreasing ageWorking outdoorsExcessive exposure to harshenvironmental conditions such asdust, dirt, heat, wind, dryness, andsmoke.Excessive exposure to allergenssuch as industrial solvents andchemicals.The symptoms of pterygia includethe following: redness, irritation,tearing, foreign body sensation,dryness, sometime blurring of visionespecially when it causes cornealastigmatism (11) .Management of pterygium can bedivided into:Observation• Periodic eye examination, usuallywhen the pterygium causes no orminimal symptoms• If symptoms increase, additionaltreatments may include:• Medications: prescriptionMIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6antibiotics to prevent infection;corticosteroids to reduceinflammation; ocular lubricants.• Radiation therapy to stoppterygium cells from reforming (7) .• Mitomycin C to aid in healing andto prevent recurrence (8) .SurgeryIndications for pterygium excisioninclude (12) : persistent discomfort,vision distortion, and restricted ocularmotility. Microsurgical excision of apterygium aims to achieve a normal,topographically smooth ocularsurface (3) .Mitomycin (mitomycin C; MMC)is an antibiotic isolated fromStreptomyces caespitosus. The drugis a bioreductive alkylating agentthat undergoes metabolic reductiveactivation, and has various oxygentension-dependent cytotoxic effectson cells, including the cross-linking ofDNA. It is widely used systemically forthe treatment of malignancies, and hasgained popularity as topical adjunctivetherapy in ocular and adnexal surgeryover the past 2 decades (6) , its use hasbeen described in the managementof ocular surface neoplasias (4) ,conjunctival malignant melanomaand primary acquired melanosiswith atypia (5) , and in conjunctivalintraepithelial neoplasia (10) .Complications of topical MitomycinC have been described in theliterature include the following: scleralnecrosis and thinning, perforation,endophthalmitis, endothelialdecompensation, glaucoma, iritis (9) .Materials and MethodsA retrospective study of 37 eyes(30 patients), with the mean age of43 years (30 -55 years) attending theophthalmology clinic.

OFFICE BASED FAMILY MEDICINEWe divided the patients into twomain groups; in the first group weused Mitomycin C, in the second weexcise the pterygium.17 eyes (17 patients) were treatedby using Mitomycin C; 14 eyes hadprimary pterygia and 3 eyes withrecurrent pterygia. 20 eyes (13patients) were treated without useof Mitomycin C; 15 eyes had primarypterygia and 5 eyes had recurrentpterygia. All eyes received the samemedications postoperatively.The examination included:• Visual Acuity-a test to measure theability to see and read the smallestletters on an eye chart (by usingTopcon chart projector (visiontesterVT-SE; Topcon Co, Japan) with Eletters at a distance of 6 meters.• Slit Lamp Examination - a brightlight with magnification used toview the eye.• Photo Documentation -Photography to record the degreeof growth of a pterygium.The cornea and conjunctiva wereexamined by using binocular slitlamp microscope with magnification,and we chose the patient that hadpterygium indicated for surgicalexcision (one that caused one ofthese; visual impairment, persistentdiscomfort, and restriction of ocularmotility).We excluded from this study;pingueculae, simple pterygia thatcauses no or minimal symptoms.In this study we applied 0.4 mg/mlMitomycin C intraoperatively for 3minutes following pterygium excision.Table 1: Recurrent rate in Mitomycin GroupPre-op.PrimaryRecurrentResultsOf the 37 eyes (30 patients)Mitomycin C treated eyes (17 eyes) we noted that only 2 eyes (11.7%)had recurrent pterygia, after 14months follow-up (see Table 1) , butthe recurrence in the non-Mitomycingroup (20 eyes) was higher thanthat of the Mitomycin group 9 eyes(45%) after the same period of followup(see Table 2) . Also we notedthat the healing of conjunctiva wasdelayed when we use Mitomycin C incomparison to the other group; whichis a known side effect of Mitomycin C;and it is not a significant complicationbecause we use it in a minimal dosefor a short period of time.The postoperative recurrentpterygia in the Mitomycin groupwere not from the primary pterygia ,but only from the recurrent pterygia(preoperative). The recurrent pterygiain the non-Mitomycin group were fromboth primary and recurrent pterygia.DiscussionPterygium is a common disorderaffecting conjunctiva and corneaespecially in hot and dry environmentalareas. It is insignificant when it issimple and not causing discomfortto the patient and dies not needaggressive management exceptobservation and some medicationssuch as antibiotics to prevent theinfections, corticosteroids to reduceinflammation; and ocular lubricants.Pterygium is significant when itcauses patient discomfort (persistent),visual impairment, and restriction ofocular motility; these are indicationsfor excision of pterygium which canbe either excision alone or excisionPost-op.PrimaryMales 9 2 0 1Females 5 1 0 1Total 14 3 0 2Recurrence rate 2 eyes (11.7%)Recurrentwith using adjunctive therapy such asMitomycin C, 5 fluorouracil , etcThe former studyhad a highrecurrence rate which is annoying forthe patient, in opposition to the latter.In this study we use Mitomycin Cintra-operatively with the excision ,and we follow up these patients, withgood results; recurrence of pterygiawas decreased and with minimalcomplications. From these resultswe recommend to use Mitomycin Cin pterygium management becauseit is a simple, safe and successfulprocedure.References1. Jack J. kanski, Jay Menon. Clinical Ophthalmology,a systemic approach, fifth ed. 2003;82-3.2. Thomas J, Lirsegang, Jacksonville, Florida.American Academy of Ophthalmology. 2002; section8:339-341.3. Thomas J, Lirsegang, Jacksonville, Florida.American Academy of Ophthalmology. 2002; section8:394-396.4. E G Kemp, A N Harnett, and S Chatterjee. Preoperativetopical and intraoperative local mitomycin Cadjuvant therapy in the management of ocular surfaceneoplasias, Br J Ophthalmol. 2002 January;86(1): 31-34.5. Demirci H, McCormick SA, Finger PT. Topical mitomycinchemotherapy for conjunctival malignantmelanoma and primary acquired melanosis withatypia. Arch Ophthalmol 2000;118:885-91.6. Abraham, Lekha M.; Selva, Dinesh; Casson, Robert;Leibovitch, Igal. Mitomycin: Clinical Applicationsin Ophthalmic Practice. Drugs, Volume 66, Number3, 2006 , pp. 321-340(20).7. Parida DK; Agarwal S; Rath GK, The role of radiotherapyin the management of Pterygium.The IndianPractitioner. 1999 Jul; 52(7): 466-8.8. Anduze AL. Pterygium surgery with mitomycin-C:ten-year results. Ophthalmic Surg Lasers. 2001 Jul-Aug;32(4):341-5.9. Tsai YY, Lin JM, Shy JD. Acute scleral thinning afterpterygium excision with intraoperative mitomycin C.Cornea. 2002;21:227-229.10. Rozenman Y, Frucht-Pery J. Treatment of conjunctivalintraepithelial neoplasia with topical drops ofmitomycin C. Cornea 2000;19:1-6.11. Kampitak K.The effect of pterygium on cornealastigmatism. J Med Assoc Thai. 2003 Jan;86(1):16-23.12. Assia E. Surgical management of pterygium. IsrMed Assoc J. 2002 Dec;4(12):1138-9.Table 2: Recurrence rate in Non-Mitomycin GroupPre-op.PrimaryRecurrentPost-op.PrimaryMales 10 3 2 3Females 5 2 1 3Total 15 5 3 6Recurrence rate 9 eyes (45%)RecurrentMIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6 35

Marriage Migration Associated with Distance inBangladesh: An Application of Polynomial ModelMODEL AND SYSTEM OF PRIMARY CAREABSTRACT36In this study an effort has been madeto fit mathematical model to marriagemigration associated with distanceof Comilla district in Bangladesh.For this, data have been taken fromYadava, Soni and Sabina (2002) butthe data is also available in Hosain(2000). It is to be noted that Hossain(2000) applied pareto exponentialmodel (Morril and Pitts, 1967). Yadava,Soni and Sabina (2002) alsoapplied exponenial distribution to thesame data and they showed that exponentialdistribution provided goodapproximation. In this study an attempthas been given attention toshow that the polynomial model isalso applicable to the same data set.It is found that marriage migration associatedwith distance follows polynomialmodel. To verify the stabilityof the model, cross validity predictionpower is employed to the model.Keywords and Phrases: Marriagemigration Mathematical modelingPolynomial Variance explained (R 2 )Cross validity prediction power(CVPP) F-test.Md. Rafiqul Islam, Associate ProfessorCorrespondence to:Dept. of Population Science and Human Resource Development, Rajshahi University,Bangladesh.E-mail: rafique_pops@yahoo.comIntroductionIt is to be mentioned here thatmathematical modeling in PopulationStudies especially in Demography(Fertility, Mortality, Migration) inBangladesh have been workedvery limited scale. In the era ofglobalization, mathematical modelsare very realistic and sophisticatedmechanisms to express data inMathematics. Mathematical modelsare of great useful to demographers inrealizing the process in differentiatingamong various variables to find outthe functional relationships and theirdynamic behaviors among variousdemographic phenomena. Finally,model is important for predictionpurposes Mathematical models indemography are mainly two groups:stochastic and deterministic.Deterministic model has only beendiscussed in the present study.Deterministic models are used todescribe the functional relationshipbetween variables that take definitevalues. Traditionally, one candraw graphs of the demographicparameters but very few of us knowin the context of Bangladesh whichmodels are more appropriate for theparameters.Islam and Ali (2004) found thatage specific fertility rates (ASFRs)follows slightly modified biquadraticpolynomial model where as forwardand backward cumulative ASFRsfollow quadratic and cubic polynomialmodel, respectively in the ruralcommunity of Bangladesh. To observethe distribution or pattern of marriagemigration associated with distance inBangladesh, India and other countriesof the world a number of models havebeen fitted to the data set (Libbee andSopher, 1975; Morril and Pitts, 1967;MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6Perry, 1969a and 1969b; Samuel,1994; Sharma, 1984; Yadava et. al.1988). Hossain gave an atention tobuild up the model of Sharma (1984)and Yadava et. al (1988).But these models did not supplygood fit and then Hossain used thePareto-Exponential model proposedby Morril and Pitts (1967) to presentthe marriage migration related todistance for his data of Bangladesh.Although Pareto-Exponential modelsupplied better approximation than themodels of Sharma (1984) and Yadavaet. al. (1988) but not significantly fit tothe utilised data set. It is to be notedthat proposed models of Sharma(1984) and Yadava et. al (1988) aresuitable for Hinda community in India.For this, Yadava et. al. (2002) triedto show that exponential distributionprovides a better fit to the distributionof marriage migration associated withdistance than pareto-Exponentialfunction as applied by Hossain (2000).Also Yadava et. al (2002) comparedwith pareto-exponential functinapplied by Yadava et. al (1998).In this study an effort has beengiven attention to build mathematicalmodel to total marriage migrationassociated with distance, that is,the same data aggregate which wasalready used by Yadava et. al. (2002).For this purpose, a polynomial modelis chosen to applied here. A briefdiscussion about polynomial model isgiven below:A general expression of the formy = f(x)=a 0+a 1x+a 2x 2 +a 3x 3 +...+a nx n(a n0) (Waerden, 1948)where a 0is the constant term; a iisthe coefficient of x i (i =1, 2, 3, ..., n)but a 1, a 2,..., an are also constants butthese belong to a field (field meansa nonempty set in which group for

MODEL AND SYSTEM OF PRIMARY CAREaddition, group for multiplication andleft as well as right distributive lawhold) and n is the positive integer,is called a polynomial of degreen and the symbol x is called anindeterminate.An effort has been made here tofind out what types of models aremore appropriate to total marriagemigration by distance in Comilla ofBangladesh. Thus, the fundamentalobjectives of this study are brieflymentioned below:i) to build up mathematical modelsto total marriage migration by distanceandii) to apply cross-validity predictionpower (CVPP), , to the model toverify how much the model is valid ornot.Data and MethodologySources of DataThe data on total marriage migrationassociated with distance of Comilladistrict in Bangladesh have beentaken from Yadava et. al. (2002). Thisdata was also available in Hossain(2000) and prohibited in Table 1.Mathematical Model FittingUsing the scattered plot of marriagemigration associated with distance ofBangladesh (Fig. 1), it is observedthat marriage migration can be fittedby polynomial model with respect todistance. Therefore, an nth degreepolynomial model is considered andthe form of the model is(Gupta and Kapoor, 1997)where, x is distance; y is marriagemigration; is the constant; is thecoefficient of (i =1, 2, 3, ..., n) and u isthe stochastic error term of the model.Here a suitable n has been selectedfor which the error sum of square isminimum.The software STATISTICA wasused to fit the mathematical model.Checking Model ValidationTo check how much the model isstable, the cross validity predictionpower(CVPP),, is applied. Here,where, n is the number of cases, k= the number of regressors in themodel and the cross-validated R isthe correlation between observed and(1-Rpredicted values of the dependent2 );variable (Stevens, 1996). Theshrinkage of the model is the absolutevalue of the difference of and R 2 . Thestability of R 2 of this model is equal to1- shrinkage.F-testTo verify the measure of the overallsignificance of the fitted model aswell as the significance of R 2 , the F-test is employed to this model. Theformula for F-test in mathematics isas follows:where k is the number of parametersto be estimated, n is the number ofcases and R 2 is the coefficient ofdetermination in the model (Gujarati,1998).Applicationof the modeland resultsThe polynomial model is assumedfor marriage migration due to distancein Comilla of Bangladesh and thefitted equation isy = 1025.557 - 169.5126x +9.613215x 2 - 0.182286x 3t-stats- (105.562) (-47.561) (27.80423)(-19.2117)p-value- (0.000) (0.000) (0.00001)(0.0000)providing R 2 =0.999714324 and= 0.998875. This is the polynomialof degree three i.e. cubic polynomial.From this statistics we see that thefitted model is highly cross-validatedand its shrinkage is 0.000839.These imply that the fitted model is99.8875% stable. Moreover, all theparameters of the fitted model arealso highly statistically significant with99.9714324% of variance explained.Moreover, the stability of R 2 of thismodel is also more than 99%.In this study the calculated valueof F-test is 4665.96, that is, largequantity which means that the fittedmodel is overall highly significant at1% level of significance. Therefore,from these statistics we see that thefitted model and corresponding R2are highly statistically significance.As a result, the model is good fit.Thereafter, the prediction is dine andthe predicted values of the model arealso demonstrated in the last.ConclusionIn this paper it is found that thirddegree polynomial model is fittedto the distribution of marriagemigration associated with distanceof Muslim community in Bangladesh.The results show that this model isalso applicable or suitable even ifHossain fitted pareto exponentialmodel and Yadava et. al. showedthat exponeutial distribution providedbetter approximation than Hossain.Hence it is concluded that the patternof marriage migration due to distancefollow 3rd degree polynomial model.ReferencesGujarati, Damodar N. (1998). BasicEconometric, Third Edition, McGrawHill, Inc., New York.Gupta, S. C. & Kapoor, V. K. (1997).Fundamentals of MathematicalStatistics, Ninth Extensively RevisedEdition, Sultan Chand & Sons,Educational Publishers, New Delhi.Hossain, M.Z. (2000). SomeDemographic Models and theirApplications with Special Referenceto Bangladesh. An Unpublished Ph.D. Thesis in Statistics, Banaras HinduUniversity, Varanasi, India.Islam, Md. Rafiqul & Ali, M. Korban.MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6 37

MODEL AND SYSTEM OF PRIMARY CARE(2004). Mathematical Modeling of Perry, P. (1969b). Working classAge Specific Fertility Rates and Isolation and Mobility in RuralStudy the Reproductivity in the Rural Dorset 1837-1936: A Study ofArea of Bangladesh During 1980- Marriage Distance, Trans. Inst. Brit.1998, Pakistan Journal of Statistics, Geographers, 47, 121-140.Pakistan Vol. 20(3), Page-381-394.Samuel, M.J. (1994). PatternsLibbee, M.J. and Sopher, D. E. of Female Migration, In Maithili(1975). Marriage and Migration in Vishwanathan (eds). Women andRural India. in Kosinski, L.A. and Society, IV, Printwell, Jaipur, India.Prothero, R.M. (eds.) People onSharma, L. (1984). A Study of thethe Move: Studies on International,Pattern of Out-migration from RuralMigration, London: Methuen andAreas. Unpublished Ph. D. Thesis inCompany.Statistics, Banaras Hindu University.Morril, R. L. and Pitts, F.R. (1967). India.Marriage, Migration and the MeanStevens, J. (1996). AppliedInformation Field. Annals, AssociationMultivariate Statistics for the Socialof American Geographers, 57, 401-Sciences, Third Edition, Lawrence22.Erlbaum Associates, Inc., Publishers,Perry, P. (1969a). Marriage Distance New Jersey.Relationsship in North Otago 1975-Waerden, B.L.Van Der. (1948).1914. New Zealand’s Geographers,Modern Algebra, Vol. 1, ICK Ungar25(1), 36-43.Table 1 Distribution of Marriage Migration Associated with Distance of Comilla in BangladeshDistanceNumber ofPredicted Values(in miles) Migrants0-3 792 792.30303-6 442 440.80746-9 219 218.05419-12 87 94.513012-15 48 40.653715-18 29 26.945918-21 18 23.859321-24 4 1.8636038Fig. 1 Observed and Fitted Marriage Migration Associated with Distance of Comilla in BangladeshMIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 6, ISSUE 6Publishing Co. New York.Yadavs, K.N.S., Srivastava, Soniand Islam, Sabina. (2002). Distributionof Distance Associated with MarriageMigration, International Journal ofStatistical Sciences, Vol. 1, Dept.of Statistics, University of Rajshahi,Bangladesh, Page 49-54.Yadavs, K.N.S., Hossain, M.Z andIslam, Sabina (1998). Distributionof Distance Associated withMarriage Migration in Rural Areas ofBangladesh. The Bangladesh Journalof Scientific Research, 16(2), 201-207.Yadava. K.N. S. Raju, K.N.M.and Yadava, G.S. (1988). On theDistribution of Distance Associatedwith Marriage Migration in RuralAreas of Uttar Pradesh. India. RuralDemography, XV (1), 7-18.

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