full pdf of issue - Middle East Journal of Family Medicine

1819ISSN 1839-0188 August 2012 - Volume 10, Issue 7Quality of type-2 diabetics’consultations in IsmailiaCity, Egypt - page 19MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 7, ISSUE 10

FROM THE EDITORFrom the EditorThis is the seventh issue this year andrich with a number of good papers thatdeal with topics of importance to familyphysicians. A cross sectional study fromSaudi Arabia attempted to assess theprevalence of smoking among medicalstudents, their perceptions of healthprofessionals’ antismoking role and therisk of passive smoking. Overall 46.0%of all students had ever smoked and25.4% were current smokers. Currentand ever smoking prevalence wassignificantly higher among males andsenior students. The prevalence ofsmoking is high among medical studentsparticularly males. Students havefavorable attitudes but their perceptionof the risk of passive smoking on certaindiseases needs corrective intervention.A paper from Iran discussed theIntegration and Impact of EducationalMedia (Technologies) in the Teaching-Learning Process. The main goal of thisresearch is to highlight how individualeducational technology and mediaare being integrated and utilized byElementary School Teachers (EST) inTehran, Iran. A sealed questionnairecontaining 125 answers (indicators) toevaluate/test six hypotheses was sentto a sample population of 400 teachersin Tehran. The results indicate thatwhile the media knowledge of teacherswas average, the level and quality ofmedia utilization on the average wasmeaningful. However, use of moremodern technology and media suchas computers, video projectors, smartboards, and visualizers were belowaverage. Based on the results, it canbe stated that the main objectives ofthe teachers using the media were tofocus students’ attention on educationalconcepts, improve willingness andcollaboration, and to motivate audio/visual cognitive senses. A secondpaper was on technology from assessedinternet use and effects amongstgeneral practitioner in non Metro cities ofHyderabad and Secunderabad. A crosssectional survey was conducted usingquestionnaires distributed randomlyto healthcare professionals. Thisexplorative study revealedthat higher numbers of patients arebecoming internet savvy which is eveninfluencing their information seekingbehavior on medical information that isavailable. While the general practitionershave access to internet but cannot sayabout the quality of information on thewebsite, the general practitioners usuallyavoid patients recommending viewing thewebsite and extracting the information.A Comparison Study from Iraq looked atuse of Commercial Plant Essential Oilswith Ethanolic Extract of Spearmint andFenugreek Activity against Some GramPositive and Gram Negative Bacteria.The ethanolic extracts of spearmint andfenugreek were better than commercialessential oils as antibacterial agents,and the ethanolic extract of spearmintwas better than the ethanolic extractof fenugreek, while the antibacterialactivity of pomegranate oil, spearmintoil, pumpkin oil and rosemary oilwas better than other oils used in thestudy. The authors concluded that bothextracts have antibacterial activity inaddition to the pomegranate oil, and it isrecommended that care be taken whenbuying the plant product, because it willreflect negatively on human health, if it istaken from humans.A case report from Kuwait looked atcerebral venous sinus thrombosis in achild with Idiopathic nephrotic syndrome.CVST occurring in a child with steroidsensitive nephrotic syndrome isdescribed in this article. He presentedinitially with non specific symptoms ofheadache, lethargy and intermittentvomiting after 4 weeks of initiatingsteroid therapy. These were initiallyattributed to steroid therapy. Initial CTbrain and MRI of the brain were normal.He developed intermittent convergentsquint. At this time CVST was stronglysuspected and MR angiography and MRvenography was done which confirmedthe CVST. Anticoagulation therapy wasinitiated with heparin and after threeweeks changed to oral warfarin. Hemade slow but complete neurologicaland radiological recovery.A paper from Jordan looked at theapproach to febrile infants in theperipheral hospitals. Speciallydesigned medical records abstractforms were filled with data collectedfrom 200 infants (over a period of 12months) who presented with fever morethan 38.2ºc rectally to the pediatricemergency room at two peripheralhospitals in the southern part of Jordan(Princess Haya Hospital in Aqaba, andPrince Ali Hospital in Al-Karak). Therewas significant correlation noticedbetween positive Blood Cultures and/orpositive chest X-ray findings with thesymptoms of poor feeding, hypo-activity,convulsion and attacks of cyanosis. Themost important signs were abdominaldistension, irritability, respiratory distressand bulging anterior fontanel. Theauthors concluded that poor feeding,MIDDLEMIDDLE MIDDLEEASTEAST EASTJOURNALJOURNAL JOURNALOFOF FAMILY OFFAMILYFAMILYMEDICINEMEDICINE MEDICINEVOLUME• VOLUME10VOLUME 8ISSUEISSUE77, ISSUE 5 10hypo-activity, convulsion and cyanosisare considered indicators of seriousillnesses, necessitating admissionand treatment. Simple Laboratoryinvestigations are very helpful topediatricians and family doctors to spotthe serious cases, and spare manyyoung infants unnecessary admissionsto the hospital.Quality of type-2 diabetics’ consultationin Ismailia City, Egypt : A cross sectionalstudy from Egypt studied the quality ofconsultation using ‘consultation length’and how well patients ‘know the doctor’as process measures and ‘patientenablement’ as an outcome measure.The study included 310 type-2 diabeticsattending the family medicine clinic inIsmailia University hospital. The meanenablement score was 3.6±1.6 (rangefrom 1 to 7) while the mean duration ofconsultation was 10±4.2 minutes (rangefrom 5 to 20). The authors concludedthat at consultation level, enablementcorrelates best with the duration ofconsultations and how well the patientknows the doctor so we should improveour doctor-patient relationship and givemore attention to the consultation length.Interruptions of the consultation shouldbe avoided.Chief Editor:A. AbyadMD, MPH, AGSF, AFCHSEEmail: aabyad@cyberia.net.lbEthics Editor and PublisherLesley Pocockmedi+WORLD International11 Colston AvenueSherbrooke 3789AUSTRALIAPhone: +61 (3) 9005 9847Fax: +61 (3) 9012 5857Email:lesleypocock@mediworld.com.auEditorial enquiries:aabyad@cyberia.net.lbAdvertising enquiries:lesleypocock@mediworld.com.auWhile all efforts have been made to ensurethe accuracy of the information in thisjournal, opinions expressed are those ofthe authors and do not necessarily reflectthe views of The Publishers, Editor or theEditorial Board. The publishers, Editor andEditorial Board cannot be held responsiblefor errors or any consequences arisingfrom the use of information containedin this journal; or the views and opinionsexpressed.

TABLE OF CONTENTSOriginal Contribution / Clinical Investigation4 Prevalence of smoking among medical students and their perception of the risk of passive smokingand the antismoking role of health professionals in a new Medical CollegeAbdalla Abdelwahid Saeed, Abdulaziz F. Al-Kabbaa, Abdulshakur M. Abdalla,Hashim Hassan Ahmed, Ali Ahmed Mustafa12 A Comparison Study of Commercial Plant Essential Oils with Ethanolic Extract of Spearmint andFenugreek Activity against Some Gram Positive and Gram Negative BacteriaHêro Farhad Salah Akrayi19 Quality of type-2 diabetics’ consultations in Ismailia City, EgyptHassan A.E. Abdelwahid, Khalil A. KhalilMedicine and Society25 Approach to Febrile Infants in the Southern Peripheral Hospitals of the Royal Medical Services,JordanAbdallah M. GhanmaEducation and Training30 Integration and Impact of Educational Media (Technologies) in the Teaching-Learning Process:A Case Study in IranZohreh KavehCase Report39 Cerebral venous sinus thrombosis in a child with Idiopathic nephrotic syndromeAlexander SM, Al-Enezi Fahad, Victor A, Owaidha MTechnology and Family Medicine44 Assessment of Internet Use and Effects amongst General Practitioner in Non Metro Cities ofHyderabad and SecunderabadSyed Murtuza Hussain BakshiCME Quiz11 Organophosphate poisoning in a farmer(Answers: page 18)MIDDLEMIDDLEEASTEASTJOURNALJOURNALOFOFFAMILYFAMILYMEDICINEMEDICINE VOLUME• VOLUME10 ISSUE7, ISSUE710

Prevalence of smoking among medical students andtheir perception of the risk of passive smoking and theantismoking role of health professionals in a newMedical CollegeORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATIONAbdalla Abdelwahid Saeed (1)Abdulaziz F. Al-Kabbaa (2)Abdulshakur M. Abdalla (1)Hashim Hassan Ahmed (2)Ali Ahmed Mustafa (3)Correspondence:AbstractObjectives: To assess the prevalenceof smoking among medicalstudents, their perceptions ofhealth professionals antismokingrole and risk of passive smokingSubjects and Methods: Crosssectionalstudy using anonymous,self-administered questionnaireamong all students enrolled in thesecond semester of the AcademicYear 2008/2009.Results: Overall 46.0% of all studentshad ever smoked and 25.4%were current smokers. Current andever smoking prevalence was significantlyhigher among males andsenior students. No other significantdifferences according(1) Consultant, Community Medicine, Faculty of Medicine, King Fahad Medical City,King Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia(2) Consultant, Family Medicine, Faculty of Medicine, King Fahad Medical City,King Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia(3) Professor of Pharmacology & Therapeutics, Faculty of Medicine, King FahadMedical City, King Abdulaziz University for Health Sciences, Riyadh, Saudi ArabiaDr. Abdalla Abdelwahid SaeedDept of Community Medicine, KSAUHS,Faculty of Medicine, KFMCPO Box 59046, Riyadh 11525, KSATel. 009661 2889999ext. 7512Fax: 009661-2889999 ext. 8045Mobile 00966502469819Email: saeed.abdalla@gmail.com; aasaeed@kfmc.med.sato the other sociodemographicsstudied. Non smokers have morepositive perceptions concerningantismoking role of health professionalsand risk of passive smokingthan smokers, but differenceswere not significant. The highestperception score among smokerswas for the statement that “healthprofessionals should routinely advisepatients who smoke to avoidsmoking around children” For nonsmokers the highest was for thestatement “ Health professionalsshould routinely ask about theirpatients smoking habits”. Thehighest perception for both smokersand non smokers for the riskof passive smoking was for “passivesmoking and lung disease”,MIDDLEMIDDLE MIDDLEEASTEAST EASTJOURNALJOURNAL JOURNALOFOF FAMILY OFFAMILYFAMILYMEDICINEMEDICINE MEDICINEVOLUME• VOLUME10VOLUME 8ISSUEISSUE77, ISSUE 5 10while the lowest for both was for“ passive smoking and neonataldeath”. Male and first year studentsgave significantly a lowerrisk for association of passivesmoking and some diseases.Conclusion: Prevalence of smokingis high among medical students,particularly males. Studentshave favourable attitudes but theirperception of the risk of passivesmoking on certain diseases,needs corrective intervention.Key words: Smoking, prevalence,perception risk, passive smoking,medical students, Riyadh

ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATIONIntroductionThe harmful consequences ofsmoking on health have been welldocumented. Tobacco use is theleading global cause of preventablediseases. Studies have confirmedthe quantitative relationship betweensmoking and many health hazards inthe form of mortality, premature deathand serious morbidity(1-3). LeadingWorld Health authorities haveemphasized the vital importanceof participation and the positiveattitude of health professionals innational and international tobaccocontrol efforts. They encouragedphysicians to be role models andprovide their patients with regulartobacco interventions (2, 3). Thesame is expected from medicalstudents as they are expected to befuture physicians. They have to benon smokers themselves in order tobe convincingly effective. Measuringperceptions and attitudes of healthprofessionals and other sectors ofthe community towards smoking,provides valuable information inunderstanding the social acceptanceof smoking in a society(4, 5). Manynational and worldwide surveys havemonitored the smoking behaviors,beliefs, and attitudes of medicalstudents(6-14). They showed thatsmoking is a real problem amongmedical students irrespective ofthe level in which they are enrolled,educational strategies, or curriculumdesign.This study aims to estimateprevalence of tobacco use andassess the perception of medicalstudents of the role of healthprofessionals in antismokingactivities and the health risks ofpassive smoking in a new college ofmedicine in the Kingdom of SaudiArabia (KSA). It is of interest andsignificance to see whether medicalstudents in a new college of medicinewill show similar or different trendscompared to previous medicalstudents in other colleges. This newcollege was established in year 2004within King Fahad Medical City, atertiary health facility of the Ministryof Health. As from the academicyear 2009/2010 it became one of thecolleges of King Saud Bin AbdulazizUniversity for Health Sciences. It isadopting a problem-based integratedmedical curriculum. It is hoped thatthe results will help in designingand implementing comprehensivecorrective strategy if needed.Subjects and MethodsThis was a cross sectional studyconducted in June 2009 in theFaculty of Medicine at King FahadMedical City in Riyadh. All medicalstudents, enrolled in the secondsemester for the Academic Year2008/ 2009, were the populationfor this study. The study toolused was an anonymous, selfadministeredquestionnaire. Itwas based on a modified WHOquestionnaire surveying smokinghabits of health professionals andwas used previously in studyingsmoking habits of physicians andhealth students in Riyadh(15-16).The questions were grouped intocategories related to demographics,prevalence of cigarette smoking,reasons for smoking, not smoking,and for quitting attempts. Perceptionsof students towards the antismokingrole of health professionals andthe risk of passive smoking weremeasured using a Likert scale of oneto five points measuring the levelof agreement with the statements.Score five means full agreement;score 1 means full disagreementwith the statement. The higher thescore the higher and more positivethe perception. Questionnaires weredistributed during the classes by theauthors. The students were informedthat the results would be used forthe stated research purposes onlyand their participation was voluntary.No identification was required. Filledquestionnaires were collected andchecked for completeness beforebeing entered into a personalcomputer and analyzed usingthe Statistical Package for SocialSciences (SPSS) version 17.Descriptive statistics and t test, MannWhitney test and ANOVA or KruskalWallis tests were used for continuousvariables as appropriate afterchecking for normality.Pearson Chi square and FisherExact tests were used for studyingassociation of tobacco use andperception with the categoricalvariables (sociodemographics) asappropriate. Level ofsignificance was set to be < 0.05throughout the study. The numberof participants’ responses used inthe discrete statistical analysesvaried due to missing data forcertain variables and hence totalsmay vary. Reliability analysis forinternal consistency of the specificstatements was assessed usingCronbach alpha technique whichwas 0.862. Participation in the studywas totally voluntary but studentswere encouraged to participateemphasizing that informationcollected will be useful for them,college and community at large.Confidentiality was assured writtenand verbally, no identification wasrequired, and assurance was giventhat results will be used for thestated research purposes. An eversmoker was defined as someonewho attempted smoking any tobaccoproduct in the past. Ever smokerscan be currently non smokers (exsmokers)or current smokers. Anever smoker was one who hadnever smoked before. The study wasapproved by the Institute ReviewBoard (IRB) of King Fahad MedicalCity.ResultsCompleted questionnaires werereceived from 252 students out of300 students who were enrolledduring the study period givinga response rate of 84%. Malesconstituted about 72% (182) andfemales the rest (70), 28%. Ageranged from 17 to 26 years with amean of 20.74+-1.73 years (21.35+-1.57 for males and 19.19+-0.97 forfemales). About 61 % of the students(males and females) were enrolled inthe first and second year and the rest(males only) were enrolled in third,fourth and fifth years classes. Almost99% of the students were single.Overall 116 students (46.0%) wereever smokers and 64 (25.4%) werecurrent smokers. The age of initiationof smoking ranged from 8 to 23 yearswith a mean of 16.3+_3.3 years andwas significantly higher in males thanfemales (16.8+_2.8 compared to14.00+_4.4) years. Current and eversmoking prevalence was significantlyhigher among males and olderMIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 7MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 7, ISSUE 10

ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATIONTable 1: Ever smoking and current smoking habit according to Sociodemographic characteristicsstudents. There were no othersignificant differences accordingto the other sociodemographics asshown in Table 1. Table 2 showsmean scores of the students’perception of the antismoking roleof health professionals and risk ofpassive smoking according to theirsmoking status out of a maximumof 5 points. The highest perceptionscore among smokers was for thestatement that “health professionalsshould routinely advise patients whosmoke to avoid smoking aroundchildren” The highest perceptionscore among non smokers wasfor the statement that “Healthprofessionals should routinely askabout their patients’ smoking habitshealth”. The highest perceptionscore for risk of passive smokingfor both smokers and non smokerswas for “passive smoking and lungdisease” while the lowest for bothwere for “passive smoking andneonatal death”. Non smokershave more favorable perceptionsbut the differences were notstatistically significant. Tables 3 and4 show the perception of studentsof the antismoking role of healthprofessionals and the risk of passivesmoking respectively, according togender, age and class level. Therewere significant differences in theperception of risk of passive smokingand neonatal death. Females, olderstudents and fifth year studentsgave a higher risk score. Femalesalso gave a significantly higherrisk score for passive smoking andlower respiratory tract illness inchildren. Females, students aged20 21 years and fifth year studentswere significantly more in favor ofhealth professionals support forsmoke-free health facilities. Overallfemale students have significantlymore positive perception thanmales and students in first yearhave significantly less favorableperceptions than the other levels.DiscussionThe Faculty of Medicine at KingFahad Medical City adopted aproblem-based, integrated curriculumwhich promotes students’ activelearning, interpersonal skills and MIDDLE MIDDLE EAST EAST JOURNAL JOURNAL OF OF FAMILY FAMILY MEDICINE VOLUME • VOLUME 10 ISSUE 7, ISSUE 7 10

ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATIONTable 2. Perception of medical students of the antismoking role of health professionals and risk of passivesmoking - Mean (SD)problem solving abilities. Suchstudents are expected to be lessstressed and less involved in stressrelatedbehaviors like tobaccosmoking(9). The findings of thisstudy, however, showed that tobaccosmoking is highly prevalent amongthese medical students, particularlyamong males. This confirms thefindings of previous national studieswhich showed that the trend iscontinuing irrespective of theperiod of survey, type of institution,curriculum or the educationalstrategy(6-9). Similar results werereported from studies in differentcommunities worldwide(10-12).Nonsmokers showed more positiveperception than smokers in thisstudy in agreement with many otherpreviously reported studies (17-19).Most students were concerned withthe hazards posed by smoking. Theyencouraged health professionals toenquire about their clients smokinghabits and advise smokers to quit.Like other studies this appears tosend a strong message to nationallegislators to enforce appropriateregulations(12). Many studiesshowed high awareness of thehazards of smoking by medicalstudents(9, 13, 14, 20). Otherstudies, on the other hand, reporteddeficiencies and poor knowledgescores of the risks of smoking forcertain diseases including thoseof the lungs (21-23). Both the highprevalence of smoking and the lowlevel of awareness about smokingrelateddiseases revealed by thesestudies is worrying and raisesMIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 7MIDDLEMIDDLEMIDDLEEASTEASTEASTJOURNALJOURNALJOURNALOFOFOFFAMILYFAMILYFAMILYMEDICINEMEDICINEMEDICINEVOLUMEVOLUME• VOLUME88ISSUEISSUE7, ISSUE3510

ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATIONTable 3. Mean perception scores of antismoking role of health professionals according to sociodemographiccharacteristics Mean - (Standard Deviation)serious concerns. This may bedue to deficiencies in terms ofknowledge about the hazards ofsmoking in curricula of medicalschools. Expert reviews havesuggested that undergraduatemedical students should be equippedwith knowledge, and attitudes topromote smoking cessation skillsand this is needed more urgentlyin developing countries(24-26).Although progress has been madeto address the teaching of tobaccoin medical schools worldwide, moreeffort is required so that education ontobacco hazards and evidence-basedsmoking cessation is an ongoing partof the curricula of medical and otherhealth institutes(27).It is of concern that all studentsirrespective of their past or currentsmoking habits were not stronglyadvocating that “Health professionalswho smoke should advise people tostop smoking.” It is vital that all healthprofessionals, irrespective of theirsmoking habit, should enquire aboutthe smoking habits of their patientsand advise those who smoke, to quit.The perception of medical studentstowards the negative effects ofpassive smoking on neonatal healthis of concern. Passive smoking hadbeen reported to lead to high rates ofmorbidity and mortality in neonates MIDDLE MIDDLE EAST EAST JOURNAL JOURNAL OF FAMILY OF FAMILY MEDICINE MEDICINE • VOLUME VOLUME 10 ISSUE 7, ISSUE 7 10

ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATIONTable 4: Perception of the risk of passive smoking according to sociodemographic characteristics Mean -(Standard Deviation)and infants(28, 29). Therefore allthese aspects and facts have tobe emphasized in the curriculum.Teaching medical students aboutsmoking-related diseases andcessation intervention does resultin an increase in knowledge,attitudes and their future behaviouras doctors in relation to advisingsmoking patients to quit(30,31).Meanwhile, other aspects on tobaccouse control, such as legislation andtobacco tax policies, are also stronglyrecommended and should be formallyincorporated into the undergraduatemedical curriculum as the medicalmodel alone is inadequate for dealingwith the tobacco epidemic(32, 33).This study confirms what otherstudies have found; that the superiorknowledge of senior medical studentsis not associated with lower smokingprevalence. In the present study fifthyear students have a much morepositive perception of the hazard ofsmoking, but their ever and currentsmoking habits were not significantlydifferent from other levels. This mayneed further exploration.MIDDLE MIDDLE EAST EAST JOURNAL JOURNAL OF OF FAMILY FAMILY MEDICINE VOLUME • VOLUME 10 ISSUE 7, ISSUE 7 10

ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATIONConclusionIn conclusion, this study revealedthat tobacco use among medicalstudents in this new college isprevalent particularly among males,similar to the situation among pastmedical students. The situation is notrelated to seniority of students, typeof medical schools or educationalmethods. In general medicalstudents have favorable perceptionsand attitudes towards smokingand its hazards, particularly forchildren, but there is room for moreimprovement. It is recommended toinclude tobacco use hazards and antitobacco use strategies and activitiesin the curriculum with emphasis onthe role of students during and aftergraduation, in primary prevention ofsmoking and in smoking cessationactivities.Limitations:As smoking behavior amongstudents was self-reported therecould have been reporting bias.Verification of self-reported smokingbehavior could not be verifiedbiochemically.AcknowledgementsAuthors are thankful to theirrespective authorities of the Facultyof Medicine and KFMC and to thestudents for their valuable timegiven to respond and complete thequestionnaire.References1. Ezzati M, Lopez AD, Rodgers A,Vander HS, Murray CJ: Selectedmajor risk factors and global andregional burden of disease. Lancet2002, 360: 1347-60.2. World Health Organization. WHOreport on global tobacco epidemic2008: the MPower package. 2010.Geneva Switzerland.3. 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Thorax2004;7:623-3010 MIDDLEMIDDLE MIDDLEEASTEAST EASTJOURNALJOURNAL JOURNALOFOF OFFAMILYFAMILY FAMILYMEDICINE MEDICINEVOLUMEVOLUME10• VOLUME 8 ISSUEISSUE7, ISSUE 5710

ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATION27. Richmond R, Zwar N, TaylorR, Hunnisett J, Hyslop F. Teachingabout tobacco in medical schools: aworldwide study. Drug Alcohol Rev.2009;28:484-97.28. Polanska K, Hanke W, RonchettiR, Van den Hazel P, Zuurbier M,Koppe J, Bartonova A. Environmentaltobacco smoke exposure andchildren’s health. Acta Paediatrsuppl. 2006 ;95:86-92.29. Difranza J, Andrew aligne C,Weitzman M. Prenatal and postnatalenvironmental tobacco smokeexposure and children’s health.Pediatrics, 2004 ;113:1007- 1530. Richmond E , Cehoe I. Smokingbehaviour and attitudes amongAustralian medical students. MedicalEducation 1997; 31, 169-17631. Mostafa S, Shokeir N. Smokingrelatedbehaviour and attitudesamong medical students inAlexandria. J Egypt Public HealthAssoc. 2002;77:1-2832. lam A, Tse A , Yu C, GriffithsS. Prevalence of smoking andenvironmental tobacco smokeexposure, and attitudes and beliefstowards tobacco control among HongKong medical students. Public Health2009;123:42-433. Roddy E, Rubin P, Britton J.A study of smoking and smokingcessation on the curricula of UKmedical schools. Tobacco Control2004;13:74-7.CME QuizA 45 year old farmer, is brought to emergency by his wife afterexperiencing a sudden onset of profuse sweating, vomiting and feelingthat ‘his legs would not hold him up’.Ramesh’s wife informs you that during the journey he developedslurred speech and abdominal pains and the urgent desire to defecate.On examination the patient has constricted pupils and is salivating. Hispulse rate is regular at 65 beats per minute. There were generalisedrhonchi on chest auscultation.The wife brought a tin of pesticide that they were using. The label onthe tin was “Metacid” (an organophosphorous compound) and thepatient had wiped up some liquid that the farmhand had spilt earlier,without wearing gloves or overalls.QuestionIn relation to this presentation which of the following are True or False?1. “Metacid” is an organophosphorous compound with anti-cholinesteraseaction2. Anti-cholinesterase pesticides are an uncommon cause of acute poisoning3. Organophosphorous compounds readily penetrate the skin4. Clinical features vary depending on the relative effects on parasympatheticnerves, sympathetic ganglia and neuro-muscular junctions.5. Initial effects are due to parasympathetic activity6. Weakness of skeletal muscle is due to enzyme suppression at neuromuscularjunctions7. Atropine blocks parasympathetic overactivityAnswers and feedback are on page 18MIDDLE MIDDLE EAST EAST JOURNAL JOURNAL OF OF FAMILY FAMILY MEDICINE VOLUME • VOLUME 10 ISSUE 7, ISSUE 7 10 11

ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATIONA Comparison Study of Commercial Plant Essential Oilswith Ethanolic Extract of Spearmint and Fenugreek Activityagainst Some Gram Positive and Gram Negative BacteriaHêro Farhad Salah AkrayiCorrespondence:Hêro F. Salah Akrayi Instructor of Microbiology,College of Education,Scientific Departments, University of Salahaddin,Kurdistan Region, IraqEmail: hero_ferhad@yahoo.comAbstractIntroductionThe increased role of antibioticresistant pathogenic microorganismsis greatly mediated by the increasedfrequency of mutations, misuseof antibiotics and other factors.Evolving resistant microbial strainshave compromised the use of newergenerations of antibiotics. Combatingsuch a situation has been so fardependent upon the traditionaltreatment of such microbial infectionsbased on substances that kill orinhibit growth of causative pathogens[1].Objectives: screening the antibacterialactivity of plant extractsagainst bacteria and comparingthe effect of commercial essentialoils with the plant extracts onbacteria.Methods: (Klebsiella pneumoniae,Proteus spp., Pseudomonasaeruginosa, Staphylococcusaureus and Streptococcus mutans)isolates were obtained fromhuman infections, from HawleriFerkari hospital in Erbil city, IraqResults: The ethanolic extractsof spearmint and fenugreek werebetter than commercial essentialoils as antibacterial agents, andthe ethanolic extract of spearmintwas better than the ethanolic extractof fenugreek. While the antibacterialactivity of pomegranateoil, spearmint oil, pumpkin oiland rosemary oil was better thanother oils used in this study.Conclusion: Both extracts haveantibacterial activity in additionto the pomegranate oil, and it isrecommended that care be takenwhen buying the plant product,because it will reflect negativelyon human health, if it is takenfrom human.Keywords: Essential Oils,Ethanolic Extract, Antibacterial,G+, G-, Well Diffusion Technique.During the past decade, traditionalsystems of medicine have becomea topic of global importance.Current estimates suggest that,in many developing countries, alarge proportion of the populationrelies heavily on traditionalpractitioners and medicinal plantsto meet primary health care needs.Although modern medicine maybe available in these countries,herbal medicines (phytomedicines)have often maintained popularityfor historical and cultural reasons.Concurrently, many people indeveloped countries have begun toturn to alternative or complementarytherapies, including medicinalherbs [2]. Plant essential oils maybe an alternative source of naturalcompounds for pathogenic bacteriabecause they constitute a richsource of bioactive chemicals andare commonly used as fragrancesand as flavouring agents for foodadditives. Indeed, the effectivenessof the activity of essential oils withrespect to gram- and gram+ bacteriais largely documented in literature.[3]. Contrary to the synthetic drugs,antimicrobials of plant origin are notassociated with many side effectsand have an enormous therapeuticpotential to cure many infectiousdiseases. Botanists, Phytochemistsand Pharmacologists are increasinglyturning their attention to folk medicine12 MIDDLEMIDDLE MIDDLEEASTEAST EASTJOURNALJOURNAL JOURNALOFOF OFFAMILYFAMILY FAMILYMEDICINE MEDICINEVOLUMEVOLUME10• VOLUME 8 ISSUEISSUE7, ISSUE 5710

ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATIONlooking for new leads to developbetter drugs against cancer, as wellas viral and microbial infections.There are more than 35,000 plantspecies being used in varioushuman cultures around the world,for medicinal purpose. Althoughthousands of plant species havebeen tested for antimicrobialproperties, the vast majority have notbeen adequately evaluated [4].The antimicrobial activities of plantoils and extracts have formedthe basis of many applications,including raw and processed foodpreservation, pharmaceuticals,alternative medicine and naturaltherapies. Moreover, the increasinguse of plant extracts in the food,cosmetic and pharmaceuticalindustries suggests that in order tofind active compounds, a systematicstudy of medicinal plants is veryimportant [5 and 6].Rosemary (Rosmarinus officinalisL.) is a spice and medicinal herbwidely used around the world.Rosemary essential oil is also usedas an antibacterial, and antifungal,The main compounds responsiblefor the antimicrobial activity are a-pinene, bornyl acetate, camphor and1,8-cineole [7]. It is reported thatrosemary plants are rich sourcesof phenolic compounds with highantimicrobial activity against bothGram-positive and Gram-negativebacteria. A high percent of theantimicrobial activity is attributed tocarnosic acid and carnosol [8].Mint (M. spicata) has formed fromcross breeding of M. longifolia andM. rotundifolia. The leaves, herbsand essential oil of M. spicatawere used much earlier than thoseof peppermint. The essential oilsextracted from M. spicata, containingmainly carvone (50-70%) andmenthone, which have shown stronginsecticidal and mutagenic activity[9].Cumin has a broad antibioticspectrum against both grampositiveand gram negative bacteria.In particular the sensitivity ofHelicobacter pylori, Pseudomonasand others has been shown to cuminessential oil previously. Also in somereports it has been shown that theessential oil of cumin is equally ormore effective [10].Parsley is an annual herb indigenousto the Mediterranean region, butis now cultivated worldwide. Ithas erect stems and bright greenleaves. The oil contains twocomponents, apiol and myristicin,which are pharmacologically active.The plant also contains severalantimicrobial furocoumarins:psoralen, 8-methoxypsoralen, 5-methoxypsoralen, oxypeucedanin,and isopimpinellin. Parsley extractshave shown slight antibacterial andantifungal activity when tested in vitro[11].Pomegranate belongs to thepunicaceae family. It is one of theimportant horticulture fruits in theMediterranean climate. The ediblepart of the fruit contains considerablesaccharides, polyphenol andimportant minerals [12].Radish seeds were found tocontain alkaloid like coumarins,saponins, flavonoids andanthocyanins. Besides, radishseeds contain misothiocyanatethat has antimicrobial activity,antimutagenic, anticarcinogenic andantiatherosclerosis activity [13].A pumpkin used in medicalapplications, is an annual plant withyellow flowers. It has a climbingstem up to 12 m long and a fruitwith a round shape and fibrous flesh[14]. C. pepo has been known forits quality as an anti-helminthes.However, information on theantibacterial qualities of the seedsof these plants is unavailable andjustifies the need for this research[15].Henna (Lawsonia inermis Linn) is aplant which grows wild in abandonedareas. This plant is a worldwideknown cosmetic agent used to stainhair, skin and nails. However, it is notonly relevant to cosmetics. Alcoholicextracts of henna leaves showedmild antibacterial activity againstMicrococcus pyrogenes var aureusand Escherichia coli [16].Fenugreek (Trigonella Foenum-Graecum) found in nature and iscultivated in India and Pakistan, isa well known medicinal plant havingproperties of reducing blood sugarlevel, anthelmentic, antibacterial,anti-inflammatory, antipyretic, andantimicrobial. The important chemicalconstituents are saponins, coumarin,fenugreekine, nicotinic acid, phyticacid, scopoletin and trigonelline [17].Sesame belongs to the family-Pedaliaceae (Sesa-mum indicum L.)and is a very old cultivated crop andthought to have originated in Africa;sesame oil has antimicrobial activityagainst gram positive and gramnegative organisms [18 & 19].The black cumin seeds containthymoquinine that has antibacterial,diuretic, hypotensive and immunopotentiatingactivities via increasingneutrophil percentage and henceincreasing the defense mechanism ofthe body against infection [20].Eruca sativa Miller (Brassicaceae,synonym Eruca vesicaria Rocket),commonly known as “Tarmira”,“Rocket salad” or “Garden salad” isa diploid annual herbaceous plantgrowing up to 80cm. It showed thehighest antibacterial activity [21].Brassica nigra is a member of theBrassicaceae family. The seeds areglobular, black and about 1mm indiameter. It has a pungent taste andrich nutty odour. In addition to itsimportance as a food flavoring agent,the seeds of B. nigra also haveimportant medicinal uses [15].Almond (Prunus amygdalus) is amember of the Rosaceae familyand yields fruit of great commercialvalue. Phenolic compounds may beregarded as one factor contributingto quality of fruits and juice becauseof high antioxidative effects [22].This study aims to screen theantibacterial activity of plant extractsagainst bacteria and compare theeffect of commercial essential oilswith the plant extracts on bacteria.MIDDLE MIDDLE EAST EAST JOURNAL JOURNAL OF OF FAMILY FAMILY MEDICINE VOLUME • VOLUME 910 ISSUE 7, ISSUE 9 7 10 13

ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATIONMethods and MaterialsBacteria testedThe bacteria under study(Klebsiella pneumoniae, Proteusspp., Pseudomonas aeruginosa,Staphylococcus aureus andStreptococcus mutans) wereobtained from human infections fromHawlery ferkary hospital in Erbil city,Iraq. The isolates were inoculatedon nutrient agar to obtain singlecolonies. These were sub culturedon the same medium to check forthe purity of the isolated bacteria.Purified isolates were identifiedusing morphological, cultural andsome biochemical tests, as a moreaccurate method for identification.Essential OilsAll essential oils were obtained fromthe local market in Erbil city, Iraq, aslisted in Table (1).Plant ExtractionCollection and preparation of plantsamplesBoth plants (spearmint and seeds offenugreek) were obtained from themarket in Erbil city. For spearmint,the leaves were washed with tapwater, then with distilled water, thenleft for air drying until becomingcompletely dry, then both plantswere converted into powder formand stored in polyethylene bags inthe refrigerator at 4ºC for furtherprocessing.Extract preparationThe ethanolic extract of spearmintand seeds of fenugreek plantswas prepared by macerationmethod according to [23] with slightmodification, where 10 gm of plantpowder was steeped in 100mlethanol for three days then filtratedthrough eight layered muslin cloththen with filter paper (WhatmanNo.1), and centrifuged at 3000g for10 minutes; then the supernatantwas collected, and stored in a sterilebottle at 4ºC.Well diffusion techniqueScreening of antibacterial activity wasperformed by well diffusion technique[24]. The Nutrient agar (NA) plateswere seeded with 0.1 ml of theinoculums of each tested organism.The inoculums were spread evenlyover plate with a loop. A standardcork borer of 8 mm diameter wasused to cut uniform wells on thesurface of the NA and 100 µl ofessential oils or each concentrationof plant extracts was introduced inthe well. The plates were incubatedfor 24 hours at 37 ºC, and the zonesof inhibition were measured to thenearest millimeter (mm).Preparation of inoculumsTwo to three colonies from puregrowth of each tested organism weretransferred to 5 ml of nutrient broth.Broths were incubated overnight at37 ºC [25].Table 1: Plant oils14 MIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 7MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 7, ISSUE 10

ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATIONResults and DiscussionHistorically, many plants oils andextracts such as tea tree, myrrh andclove, have been used as topicalantiseptics, or have been reportedto have antimicrobial properties[26]. It is important to investigatescientifically those plants which havebeen used in traditional medicinesas potential sources of novelantimicrobial compounds [26].The antibacterial activity of oilof plants that were used in thisstudy is shown in Table (2). Theoil of pomegranate inhibited theStaphylococcus aureus, Proteus spp.and Pseudomonas aeruginosa,spearmint, pumpkin and rosemaryinhibited Staphylococcus aureus andProteus spp. and Staphylococcusaureus and Pseudomonasaeruginosa respectively, whilemustard, almond and radish inhibitedStaphylococcus aureus, but theother oils didn’t inhibit any of thebacteria under study. There are manyresearch studies that mention thatpomegranate is a strong antibacterialagent, and this may return to thepresence of phytocompounds in thephenols, tannins and flavonoids asmajor active constituents (95 percentpunicic acid; other constituents,including ellagic acid and sterols)may be responsible for theseactivities [12].Some researchers, such as [27, 28,10, 18, 19 and 29] mentioned thatparsley, seed oil of sesame, cuminand pumpkin have antibacterialactivity against G- and G+bacteria. The action mechanismof the essential oils is related totheir chemical composition andtheir antimicrobial activity is notattributable to a unique mechanismbut to a cascade of reactions in theentire bacterial cell. In fact, the actionmechanism of the essential oilsincludes: degradation of the cell wall,cytoplasmic-membrane damagingand cytoplasm coagulation, damageto membrane proteins, leakage ofcell contents, depletion of the* Values calculated as mean of triplicates.- No inhibition zone or less than 8 mm.Table 2: Antibacterial activity of essential oils of plantsMIDDLE MIDDLE EAST EAST JOURNAL JOURNAL OF OF FAMILY MEDICINE VOLUME • VOLUME 10 ISSUE 7, ISSUE 7 10 15

ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATIONprotective force motrice, sharpreduction of the intracellular ATP poolthrough a reduction of ATP synthesisand increased hydrolysis [3].The ethanolic extract of spearmintwas better than the ethanolic extractof fenugreek as an antibacterialagent, as shown in Table 3. Theantibacterial activity of spearmintreturns to the presence of carvacrolin its structure and this substanceseem to make the membranepermeable; its structure disintegratesthe external membrane of G-bacteria, releasing lipopolysaccarides(LPS) and increasing the permeabilityof the cytoplasmic membrane toATP. The presence of MgCl2 doesnot influence this action, suggestinga chelating mechanism of differentcations on the external membrane[30]. And Staphylococcus aureuswas the most susceptible organism,which was affected or inhibited byboth extracts and also by someoils under study, where [15] andother researchers also showed thatStaphylococcus aureus was moresensitive to the oil extract of C. pepoand other plant oils. While Klebsiellaspp. showed resistance to all oils andto all concentrations of both extractsexcept the concentration 75% and100% which inhibited the Klebsiella.This result agreed with the result of[6]. They also showed that Klebsiellapneumoniae was not inhibited bysome medicinal plants and thatrosemary is one of them but affectedon Staphylococcus aureus. It wasalso [25] found that the G+ wereaffected more than G-.G- strains are generally moreresistant than G+ strains in soliddiffusion tests and this trait hasbeen attributed to the externallipopolysaccharide wall thatsurrounds the peptidoglycan cell wallof the former, and which restrictsthe penetration of amphipathiccompounds [6 and 25].It is known that many essential oilskill bacteria by damaging the cellmembrane’s structure, inhibitingmembrane function [31]. In thisstudy it appeared that the ethanolicextracts were better than the plant* Values calculated as mean of triplicates.- No inhibition zone or less than 8 mm.Table 3: Antibacterial activity of Ethanolic extract of Spearmint and Fenugreek16 MIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 7MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 7, ISSUE 10

ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATIONoils and this is in contrast to the factthat generally the plant oils havethe antibacterial activity. This mayreturn to the fact that those oils usedin this study were obtained fromlocal market, were old, or the wayof storing them is not in correct, ormaybe it returns to the method ofextraction. Furthermore, some oilswith the same common name may bederived from different plant species.It is concluded that both extractshave antibacterial activity inaddition to pomegranate oil, and itis recommended that care be takenwhen buying the plant product,because it will reflect negativelyon human health, if it is taken byhumans.References1. Al-Hussaini, R. and Mahasneh,A. M. (2011). Antibacterial andAntifungal Activity of Ethanol Extractof Different Parts of MedicinalPlants in Jordan. Jordan Journal ofPharmaceutical Sciences, 4(1): 57-69.2. World Health Organization, 1999(monographs on selected medicinalplants. Vol. Geneva, Switzerland).3. Hafedh, H.; Ben Abdallah, F.;Snoussi, M.; Noumi E. and BakhroufA. (2010). Effect of Mentha longifoliaL. ssp longifolia Essential Oil onThe Morphology of Four PathogenicBacteria Visualized by Atomic ForceMicroscopy. African Journal ofMicrobiology Research, 4 (11): 1122-1127.4. Johnson, M.; Wesely, E.G.;Selvan, N. and Kavitha M.S. (2010).In Vivo and in Vitro Anti-BacterialEfficacy of Alternanthera sessilis(Linn.). International Journal ofPharma Research and Development.5. Akin, M.; Oguz, D. and Saracoglu,H. T. (2010). Antibacterial Effectsof Some Plant Extracts fromLabiatae (Lamiaceae) GrowingNaturally Around Sirnak-Silopi,Turkey. International Journalof Pharmaceutical and AppliedSciences, 1 (1):44-47.6. Bayoub, K.; Baibail, T.; Mountassif,D.; Retmane, A. and Soukri, A.(2010). Antibacterial Activities of TheCrude Ethanol Extracts of MedicinalPlants against Listeriamonocytogenes and Some OtherPathogenic Strains. African Journalof Biotechnology, 9 (27): 4251-425.7. Genena, A. K.; Hense, H., Junior,A. S.; de Souza. S. M. (2008).Rosemary (Rosmarinus officinalis)- A Study of the Composition,Antioxidant and Antimicrobial ofExtracts Obtained with SupercriticalCarbon Dioxide. Ciênc. Tecnol.Aliment, Campinas, 28(2): 463-469.8. Rožman, T. and Jeršek, B. (2009).Antimicrobial Activity of Rosemaryextracts (Rosmarinus officinalis L.)against Different Species of Listeria.Acta agriculturae Slovenica, 93 - 1,maj.9. Kizil, S.; Hasimi, N.; Tolan, V.;Kilinç, E. and Yüksel, U. (2010).Mineral Content, Essential OilComponents and Biological Activityof Two Mentha Species (M. piperitaL., M. spicata L.). Turkish Journal ofField Crops, 15(2): 148-153.10. Hosseini Jazani, N.; Zartoshti,M. and Shahabi, S. (2008).Antibacterial Effect of IranianCuminum cyminum Essential Oilon Burn Isolated of Pseudomonasaeruginosa. International Journal ofPharmacology, 1-3.11. Manderfeld, M. M.; Schafer, H.W.; Davidson, P. M. and Zottola, E.A. (1997). Isolation and Identificationof Antimicrobial Furocoumarins fromParsley. Journal of Food Protection,60: 72-77.12. Dahham, S. S.; Ali, M. N.;Tabassum, H. and Khan, M. (2010).Studies on Antibacterial andAntifungal Activity of Pomegranate(Punica granatum L.). American-Eurasian Journal of Agriculture andEnvironmental Sciences, 9 (3): 273-281.13. EL-Nattat, W.S. and EL-Kady,R.I. (2007). Effect of DifferentMedicinal Plant Seeds Residueson the Nutritional and ReproductivePerformance of Adult Male Rabbits.International Journal of Agricultureand Biology, 9 (3): 479-485.14. Winkler, C.; Wirleitner, B.;Schroecksnadel, K.; Schennach, H.and Fuchs, D. (2005). Extracts ofPumpkin (Cucurbita pepo L.) SeedsSuppress Stimulated PeripheralBlood Mononuclear Cells in vitro.American Journal of Immunology, 1(1): 6-11.15. Obi, R. K.; Nwanebu, F. C.;Ndubuisi, U. U. and Orji, N. M.(2009). Antibacterial Qualities andPhytochemical Screening of TheOils of Curcubita pepo and Brassicanigra. Journal of Medicinal PlantsResearch, 3(5): 429-432.16. Haddad, K. M. H. and Dezashibi,Z. (2007). Phenolic Compounds andAntioxidant Activity of Henna LeavesExtracts (Lawsonia Inermis). WorldJournal of Dairy & Food Sciences, 2(1): 38-41.17. Khan, F. U.; Durrani, F. R.;Sultan, A.; Khan. R. U. and Naz.S. (2009). Effect of Fenugreek(Trigonella Foenum-Graecum) SeedExtract on Visceral Organs of BroilerChicks. ARPN Journal of Agriculturaland Biological Science, 4 (1): 58-60.18. Shittu, L. A. J.; Bankole, M. A.;Ahmed, T.; Aile, K.; Akinsanya, M.A.; Bankole, M. N.; Shittu, R. K. andAshiru, O. A. (2006). Differentialantimicrobial activity of the variouscrude leaves extracts of Sesameradiatum against some commonpathogenic micro-organisms.Sciences Research and Essay, 1(3):108-111.19. Mohamed Saleem, T.S. (2011).Anti-microbial activity of sesame oil.International Journal of Researchin Phytochemistry & Pharmacology,1(1): 21-23.20. El-Tohamy, M. M.; El-Nattat, W.S. and El-kady, R. I. (2010). TheBeneficial Effects of Nigella sativa,Raphanus sativus and Eruca sativaSeed Cakes to Improve Male RabbitFertility, Immunity and Production.Journal of American Science, 6 (10):1247-1255.21. Rani, I.; Akhund, S.; Suhail M.and Abro, H. (2010). AntimicrobialPotential of Seed Extract of ErucaSativa. Pakistanian Journal ofBotany, 42(4): 2949-2953.22. Yildirim, A. N.; San, B.; Koyuncu,F. and Yildirim, F. (2010). Variabilityof Phenolics, a-Tocopherol andAmygdalin Contents of SelectedAlmond (Prunus amygdalus Batsch.)Genotypes. Journal of Food,Agriculture & Environment, 8 (1): 7 6- 7 9.23. Majeed, K. R. and Al-Shatty, S.M. H. (2002). Effect of AntimicrobialActivity of Some Plant Extracts onSome Microbial Growth.MIDDLE MIDDLE EAST EAST JOURNAL JOURNAL OF OF FAMILY MEDICINE VOLUME • VOLUME 10 ISSUE 7, ISSUE 7 10 17

ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATION24. Kivanc, M. and Kunduhoglu, B.(1997). Antimicrobial Activity of FreshPlant Juice on the Growth of Bacteriaand Yeasts. Journal of QafqazUniversity, 1: 26-53.25. Alhaj, N. A.; Shamsudin,M.N.; Zamri, H. F. and Abdullah,R. (2008). Extraction of EssentialOil from Nigella sativa UsingSupercritical Carbon Dioxide: Studyof Antibacterial Activity. AmericanJournal of Pharmacology andToxicology, 3(4): 225-228.26. Hammer, K. A.; Carson, C. F,and Riley, T. V. (1999). AntimicrobialActivity of Essential Oils and OtherPlant Extracts. Journal of AppliedMicrobiology, 86: 985-990.27. Elgayyar, M.; Draughon, F.A.; Golden, D. A. and Mount, J.R. (2001). Antimicrobial Activity ofEssential Oils from Plants againstSelected Pathogenic and SaprophyticMicroorganisms. Journal of FoodProtection, 64 (7): 1019-1024.28. Bakhiet, A. O.; Mohammed,S.D.; El Badwi, S. M.A.; AbdelGadir, W. S.; Alkhatim, A. H. andAdam, S. E. I. (2006). AntimicrobialActivity of Petroselinum sativum andCoriandrum sativum Seeds. Journalof Microbiology, 1 (4): 346-352.29. Dubey, A.; Mishra, N. and Singh,N. (2010). Antimicrobial Activityof Some Selected Vegetables.International Journal of AppliedBiology and PharmaceuticalTechnology, I: 994-999.30. Silva, NCC and FernandesJúnior, A. (2010) Biological Propertiesof Medicinal Plants: A Review ofTheir Antimicrobial Activity. Journalof Venomous Animals and ToxinsIncluding Tropical Diseases, 16: 402-413.31. Chao, S.; Young, G.; Oberg, C.and Nakaoka, K. (2008). Inhibition ofMethicillin-Resistant Staphylococcusaureus (MRSA) by Essential Oils.Journal of Flavour and Fragrance,23: 444-449.Answers and feedback to CME Quiz1.Metacid is an organophosphorous compound with anticholinesteraseaction.True2. Anti-cholinesterase pesticides are an uncommon cause of acutepoisoning.False3. Organophosphorous compounds readily penetrate the skin.True4. Clinical features vary depending on the relative effects onparasympathetic nerves, sympathetic ganglia and neuro-muscularjunctions.True5. Initial effects are due to parasympathetic activity.True6. Weakness of skeletal muscle is due to enzyme suppression atneuro-muscular junctions.True7. Atropine blocks parasympathetic overactivity.TrueFeedbackAnti-cholinesterase pesticides (organophoshates) are a most commoncause of acute poisoning in farmers.Organophosphates bind to acetyl-cholinesterase enzyme, inhibiting it andcausing symptoms of excessive cholinergic (parasympathetic) activity.The key signs of cholinergic overload are: frothy oral secretions, vomiting,abdominal pain, diarrhoea, constricted pupils, altered consciousness,bradycardia (or tachycardia) and muscle fasciculations.Organophosphates also suppress enzymes at nicotinic receptors, thusinhibiting neuromuscular transmission at nicotinic synapses – the majorcause of respiratory muscle paralysis.Initial management should focus on managing and stabilizing airway,breathing and circulation (ABC).There is a risk of contamination of health personnel, as well as ongoingabsorption for the patient. Ramesh’s clothing should be removed andwashed thoroughly, and his skin washed with soap and water. Healthworkers must wear rubber gloves whilst doing this to protect themselvesfrom contamination.There is no role here for GI decontamination as the pesticide was notingested by mouth, but absorbed through the skin.While the above measures are being taken, definitive treatment should bestarted without delay.18 MIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 7MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 7, ISSUE 10

ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATIONQuality of type-2 diabetics’ consultations in Ismailia City,EgyptHassan A.E. Abdelwahid (1)Khalil A. Khalil (2)(1) Assistant Professor in Family Medicine Department(2) Professor in Internal Medicine Department, Faculty of Medicine,Suez Canal University, Ismailia, EgyptCorrespondence:Dr. Hassan A. Abdelwahid ,MDFamily Medicine, Department of Family Medicine, Faculty of Medicine,Suez Canal University, Ismailia, EgyptTel. 002 0114 2231059Email: hassan22220000@yahoo.comAbstractBackground: Within generalpractice, work on quality andthe development of performanceindicators are importantfor practice organization andcare of continuing health problems.However, the core activityof general practice remains theconsultation.Aim: The aim of the presentwork was to study the quality ofconsultation using ‘consultationlength’ and how well patients‘know the doctor’ as processmeasures and ‘patient enablement’as an outcome measure.Methods: A cross sectionaldesign was used. The study wasconducted in Ismailia City, Egypt,from February 2009 to October2010. The study included 310type-2 diabetics attending thefamily medicine clinic in IsmailiaUniversity hospital. A pre-consultationquestionnaire was completedby all patients, to collectsocio-demographic data. Also,patients were asked how wellthey knew the doctor they weregoing to see. After the consultation,the patient completed thepatient enablement questionnaire.Doctors completed informationon the time the consultationstarted and finished (time inand time out), whether the consultationwas booked, open, andwhether a student was present.Results: The mean enablementscore was 3.6±1.6 (range from 1to 7) while the mean duration ofconsultation was 10±4.2 minutes(range from 5 to 20). Patient’sage over 60 was associated withhigh enablement and long consultations,and consultations forwomen lasted longer than thosefor men. Booked consultationswere significantly longer thanroutine consultations. Knowingthe doctor well resulted in considerablyincreased duration ofthe consultation. Interruptionsincreased, non-significantly,consultations by an average of1.4 minutes, but significantly reducedenablement. The presenceof trainees in the consultationroom did not affect the durationof the consultation but significantlyincreased the enablement.Conclusion: At consultationlevel, enablement correlates bestwith the duration of consultationsand how well the patientknows the doctor so we shouldimprove our doctor-patient relationshipand give more attentionto the consultation length. Interruptionsduring the consultationshould be avoided.Keywords: consultation, duration,enablement, diabetes,Ismailia.MIDDLE MIDDLE EAST EAST JOURNAL JOURNAL OF OF FAMILY MEDICINE VOLUME • VOLUME 10 ISSUE 7, ISSUE 7 10 19

ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATIONIntroductionThe core values of general practiceinclude holism and patientcentredness.Holism, the integrationof physical, psychological and socialcomponents of health problems inmaking diagnoses and planningmanagement, is well established asa central issue of good consultingpractice,(1) and there is goodevidence that this is promoted bylonger consultations(2-4) and bygreater continuity of care.(5-6)‘Patient-centredness’ is harder todefine. It indicates a commitmentby doctors to value the contributionof patients to deciding what iswrong with them and how theircare should be managed. Amongother things, patients place greatemphasis on being helped tounderstand the nature of theirproblems and made able to managetheir own illnesses.(7) ‘Enablement’,measured by the Patient EnablementInstrument (PEI), is an outcomemeasure which captures theseissues. (8)Finding a way of assessing whetherthe goals of holism and patientcentrednessare achieved atconsultations by doctors has proveddifficult, but it is a necessary part ofassessing quality of general practicecare across its full breadth. (9) Withingeneral practice, work on quality andthe development of performanceindicators(10-11) is in hand on issuesof practice organization, (12) careof continuing health problems, (13)and achievement of public healthtargets. (14) However, the coreactivity of general practice remainsthe consultation. Two areas of workin this discipline are particularlyrelevant to this paper: the use of timein consultations and its relation to“enablement,” an outcome measurethat seems related to, but differentfrom, satisfaction (8-9); and continuityof care. (5-6)Aim of the WorkThe aim of the present work was tostudy the quality of consultation thatreflects the core values of generalpractice. The Specific objectivesincluded the following:1. Measurement of the consultationlength of type2 diabetics2. Assessment of enablement of thediabetic patients3. Determination of the principalcorrelates associated withenablement as an outcomemeasure.Subjects and MethodsStudy Area and Study PopulationA cross sectional design was used.The study was conducted in IsmailiaCity, Egypt, from February 2009to October 2010. Ismailia City isapproximately 120 km from Cairo. Itis the capital of Ismailia Governoratethat is located along the coast ofSuez Canal, midway between PortSaid and Suez. The target populationwas type 2 diabetic patients inIsmailia City. The study populationwas type-2 diabetics attending thefamily medicine clinic in IsmailiaUniversity hospital. The followingequation, according to Holland etal., 1985, was used for sample sizecalculation: (15)N> [(1.96)2 x Sd2]/ (0.05 x M) 2N, number of cases;S.d, standard deviationM, the true value to be estimated andknown from previous worksA pilot study was conducted todetermine the mean and standarddeviation of the PEI of type-2diabetics. The pilot included 50patients. The mean of the PEI was3.58 1.6 (from the pilot study). So thesample size needs to be:N> [(1.96)2 x 1.62]/ (0.05 x 3.58) 2N> 303The study sample (n=310) wasselected randomly by systematicrandom sampling technique whereevery 3rd patient attending the clinicbetween February 2009 to May 2009was included in the study. The studywas completed in October 2010.Informed consent of the patients toparticipate in the study was one ofthe inclusion criteria. Type 1 diabeticswere excluded from the study.Description of the experimentalmanoeuvre1. Pre-consultation questionnaire:A pre-consultation questionnairewas completed by all patients,to collect socio-demographic data.Patients were asked how well theyknew the doctor they were goingto see.2. Post-consultation questionnaire:Doctors completed informationon the time the consultationstarted and finished (time in andtime out), whether the consultationwas booked, open, and whethera student was present. After theconsultation, the patient completedthe patient enablement instrumentthat included the followingitems: Able to cope with life, Ableto understand your illness, Ableto cope with your illness, Ableto keep yourself healthy, Confidentabout your health, and Able tohelp yourself. Responses of “muchbetter,” “better,” and “same or less”or “not applicable” were scored 2,1, and 0 respectively, givinga score range of 0-12. (16-17)Patients also indicated whether theconsultation was interrupted.Some help for patients who haddifficulty completing thequestionnaire was available in thewaiting room.Statistical methodsAll statistical analyses wereperformed by using the SPSSsoftware package (SPSS, 1996) (18).Measures of central tendency anddispersion, as well as, appropriatesignificance tests were appliedaccording to the types of variables.Group t-test was computed todetect the significance of differencein the age, enablement scores,and duration of the consultationbetween males and females.Multiple regression analysis wascomputed to detect the significantlinear associations between theenablement scores of type 2diabetics as dependent variableand other independent variablesthat were included in the study. Thefollowing variables were convertedto dummy variables (coded 0.0 and1.0) sex (male and female), knowthe doctor well, interruption of theconsultation, consultation type (open20 MIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 7MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 7, ISSUE 10

ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATIONand booked) and presence of studentduring the consultation.ResultsThe study included 310 type-2diabetics. The total number offemales was 201 (65%), while thatof males was 109 (35%). The meanenablement score was 3.6±1.6(range from 1 to 7) while the meanduration of consultation was 10±4.2minutes (range from 5 to 20).Table 1 illustrates that femalepatients were significantly older(55.03±6.96 years) than malepatients (55.70±5.94 years). Theconsultation of female patients wassignificantly longer than that ofthe males. On the other hand thedifferences between female and malepatients were insignificant regardingenablement.Table 2 illustrates that after theconsultation, the majority (92%)of patients were able to helpthemselves better or much betterthan before. Also, 68% of them weremore confident about their health.However, a big proportion of patientshad the same or less ability to copewith their illness (88%) and life(72%).Patient’s age over 60 wasassociated with high enablementand long consultations, andconsultations for women lastedlonger than those for men. Bookedconsultations were significantlylonger than routine consultations.Knowing the doctor well resulted inconsiderably increased duration ofthe consultation. On the other handknowing the doctor had no significanteffect on enablement. Interruptionsincreased non-significantlyconsultations by an average of 1.4minutes but significantly reducedenablement. The presence oftrainees in the consultation roomdid not affect the duration of theconsultation but significantlyincreased enablement (Table 3 - nextpage).All dependent variables included inthe model except sex were found tohave significant linear associationswith enablement. Knowing thedoctor well was found to have a highsignificant linear association withenablement when it was included inthe regression model (Table 4 - nextpage).DiscussionThe study included 310 type-2diabetics. The total number offemales was 201 (65%), whilethat of males was 109 (35%). Thefemale patients were significantlyolder (55.03±6.96 years) thanmale patients (55.70±5.94 years).The purpose of our study was tomeasure enablement and to identifyits principal correlates. After theconsultation the majority of patientswere able to help themselves betteror much better than before (92%) and68% of them were more confidentabout their health. However, a bigproportion of patients had the sameor less ability to cope with theirillness (88%) and life (72%).The differences in outcome andduration of consultation were relatedto age and sex of patients, to beingadded to clinic sessions withouthaving appointments, and to havinga consultation that was interrupted.As with any outcome measure itis hard to know whether reportedenablement reflects true enablement.The desire to please a familiardoctor and differences betweensocioeconomic factors could createartificial differences.*, mean and standard deviation in parenthesisTable 1: Distribution of the study group by age, duration of consultations and enablement scores*Table 2: Patients’ responses to consultation enablement itemsMIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 7MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 7, ISSUE 10 21

ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATIONN, number, *, significant 95% CI (confidence interval), and +, mean and standard deviation in parenthesisTable 3: The relationship between single variables and mean enablement scores and mean duration ofconsultationsTable 4: Multiple regression: the relationship between the enablement score as a dependent variable andother independent variables22 MIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 7MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 7, ISSUE 10

ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATIONIn the present study the meanduration of consultation was 10±4.2minutes (range from 5 to 20). Theseresults were partially in agreementwith many reported results whichconcluded that the mean ofconsultation time ranged between2 and 21 minutes. (19-20) Thevariation of the results of the presentand the above mentioned studiescould be explained by the differencesamong different family practicesettings regarding the flow rateand the existence of an appointedsystem that insures adequate timefor consultation. Also, the familyphysician may behave in differentways according to the nature ofsessions, as counselling sessionsmay need more time. This view wassupported by Freeman (2001). (21)In the present study the meanenablement score was 3.6±1.6(range from 1 to 7). This result isconsistent with that of Howie et al(1999)17 who reported that the meanenablement score was 4.5. Also, thepresent study illustrates that patient’sage over 60 was associated with highenablement and long consultations,and consultations for women lastedlonger than those for men. Theseresults are consistent with that ofKotic (2001) (22) who demonstratedthat patient satisfaction had apositive correlation with age, sex andeducational level.The result of the present studyconfirmed that there was a positivelinear association between durationof consultation and enablementscore (p

ORIGINAL CONTRIBUTION AND CLINICAL INVESTIGATION16. Howie JGR, Heaney DJ,Maxwell M. Measuring quality ingeneral practice. London: RoyalCollege of General Practitioners,1997(Occasional paper 75.)17. Howie JGR, Heaney DJ, MaxwellM, Walker JJ, Freeman GK, RaiH. Quality at general practiceconsultations: cross sectional survey.Br Med J 1999; 319: 738-743.18. Statistical package of socialscience, SPSS7.5. SPSS Inc., 1996.19. Deveugele M, Derese A, vanden Brink-Muinen A, Bensing J, DeMaeseneer J. Consultation lengthin general practice. Cross sectionalstudy in six European countries. BMJ2002 Aug 31: 325-472.20. Britt HM, Valenti L, MillerG. Length of general practiceconsultation in Australia. Aust. Fam.Physician, 2002 Sep: 876-880.21. Freeman G, Hjortdahl P. Whatfuture for continuity of care in generalpractice? Br Med J 1997; 314: 1870-1873.22. Kotic M, Bdak A, IvankovicD, Mastilica M, Lazic D, Babic A,Matkovic V. Patients views on theprofessional behavior of familyphysicians. Family practice, vol 18(1), oxford university press 2001: 42-47.23. Anderson SO, Matteson B,Length of consultation in generalpractice in Sweden: views of doctorsand patients. Fam. Pract. 1989 Jan.:.130 -134.24. Campbell S., Hann M, HackerJ, and Roland M.. Identifyingpredicators of high quality carein English general practice:observational study. BMJ, 2001; 323:784.24 MIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 7MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 7, ISSUE 10

MEDICINE AND SOCIET YApproach to Febrile Infants in the Southern PeripheralHospitals of the Royal Medical Services, JordanAbdallah M. GhanmaCorrespondence:Abdallah M. Ghanma, M.D.Senior specialist in Pediatrics.Royal Medical ServicesP.O. Box 855038Amman, JordanMobile phone 00962 795578777Email: farrisghanma@yahoo.comAbstractObjectives:The aim of this studywas to help pediatricians andfamily doctors to triage younginfants presenting with fever tothe Emergency department, intoserious and dischargeable patients.This will help in decreasingthe unnecessary use of potentantibiotics, the number of admissions,as well as the unnecessaryinvasive and noninvasive laboratoryinvestigations.Methods: Specially designedmedical records abstract formswere filled with data collectedfrom 200 infants (over a period of12 months) who presented withfever more than 38.2ºc rectally tothe pediatric emergency room attwo peripheral hospitals in thesouthern part of Jordan (PrincessHaya Hospital in Aqaba, andPrince Ali Hospital in Al-Karak).Full detailed medical historyand physical examination wereperformed. Laboratory tests wereperformed including CompleteBlood Count, C-reactive protein,chest X-ray, urine analysis andculture, stool analysis and culture(if diarrhea is present), in additionto Blood culture and Cerebrospinalfluid sampling in seriously illadmitted infants.All candidates were closely followedup daily over the next twodays if discharged from the emergencyroom, otherwise, they wereadmitted.The final diagnosis was correlatedwith the preliminary findingsand tests to define significanceand possibility of depending onfuture assessment of similarpatients.Results: Significant correlationwas noticed between positiveBlood Cultures and/or positivechest X-ray findings with thesymptoms of poor feeding, hypoactivity,convulsion and attacks ofcyanosis.The most important signs wereabdominal distension, irritability,respiratory distress and bulginganterior fontanel.The significant laboratory findingsthat we depended upon foradmission were:White Blood Cells count of morethan 14.000, with more than 40%Neutrophils, urine analysis withWhite Blood Cells more than6/High power field, positive C-reactive protein, and chest X-rayfindings.Conclusion: It can be concludedthat poor feeding, hypo-activity,convulsion and cyanosis are consideredindicators of serious illnesses,necessitating admissionand treatment. Simple Laboratoryinvestigations are very helpful topediatricians and family doctorsto spot the serious cases, andspare many young infants theunnecessary admissions to thehospital.Key words: Fever, CompleteBlood Count, CRP, Chest X-ray,Urine AnalysisMIDDLE MIDDLE EAST EAST JOURNAL JOURNAL OF OF FAMILY MEDICINE VOLUME • VOLUME 10 ISSUE 7, ISSUE 7 10 25

MEDICINE AND SOCIET YFever (pyrexia) is a common medicalsign characterized by an elevationof temperature above normal range,mediated by an increase of theHypothalamic head regulatory setpoint.A wide range of normal temperatureshas been found, and fever isgenerally agreed upon to be presentif:• Temperature in the anus (rectally) isat/or over 38.2ºc.• Temperature in the mouth (orally) isat/or over 37.7 ºc.• Temperature under the armpit(axillary) or in the ear (otic) is at/orover 37.2 ºc.Types of fever in children include:• Fever of short duration withlocalized signs.• Fever without localized signs.Core body temperature is normallymaintained within 1ºc in a range of37-38 ºc.Famous fever patterns are:• Remittent fever: temperatureremains above normal throughoutthe day and fluctuates more than1ºc in 24 hours (e.g.: infectiveendocarditis).• Intermittent fever: the temperatureelevation is present only for acertain period, later cycling back tonormal (e.g.: Kala azar, septicemia)• Continuous fever: temperatureremains above normal throughoutthe day and does not fluctuate morethan 1ºc in 24 hours.In addition to Hectic fever, Relapsingfever, Biphasic and Periodic fever.Fever is usually accompanied bysickness behavior, which consistsof lethargy, depression, anorexia,sleepiness, hyperalgesia andinability to concentrate. Fever is acommon symptom of many medicalconditions: Infectious diseases,various skin inflammations,immunological diseases, tissuedestruction, reaction to incompatibleblood and blood products,malignancies, metabolic diseasesand thrombo-embolic processes.What is called “fever phobia” is thename given by medical expertsto parents’ misconceptions aboutfever of their children. Among them,many patients incorrectly believethat fever is a disease rather thana medical sign, they are also afraidof harmless side effects like febrileseizures. Nelgum Erkek (1) and hiscolleagues published an article in2010 concerning the importanceof parental education about “feverin childhood”, which may positivelyaffect parental knowledge andapproach to fever. However, parentaleducation may not be completelyeffective in removing their fear in ourpopulation.MethodsThis prospective non-blind quasirandomized study was conductedat two peripheral hospitals of theRoyal Medical Services in Jordanover a period of 12 months atthe Emergency Departments andPediatric wards.The population of the study wasinfants beyond the neonatal periodand below 6 months of age, found tohave rectal temperature at/or above38.2ºc at presentation.I have chosen rectal temperaturebecause it has the most accurateresults at this age. Penning’s studyin 2011 showed that the diagnosticaccuracy of the temporal arterythermometer in detecting fever inchildren of all ages is low [2].All candidates underwent thoroughclinical examination after full historywas taken. A cascade of Laboratorytests were performed including:• Complete Blood Count andmorphology, C-reactive protein,urine analysis and culture, chestX-ray, stool analysis and culturefor those presenting with diarrhea,and for admitted cases Cerebrospinalfluid sample was taken forcytology, protein, glucose andculture as well as Blood culture.Admitted patients were those illlooking, or in the presence of oneor more of the following:• White Blood Cells above 14.000with neutrophils above 40%• Positive C-reactive protein.• Urine test analysis showingWhite Blood Cells of more than6/high power• Chest X-ray positive findings ofinfectionSpecial forms were filled with datacollected from two hundred patientswho presented to the pediatricemergency room. Simple descriptivestatistics (frequency and percentage)were used to describe the studyvariables.Results200 patients were included in thestudy over a period of 12 months,and selected from two peripheralhospitals in the southern parts ofJordan (Aqaba and Al-Karak cities);166 patients (83%) were consideredas non-serious cases; although 12of them (7%) were admitted to thepediatric ward for further evaluationor for non-medical reasons (livingfar away or very anxious parents).The other 34 patients (17%) wereconsidered as serious casesaccording to their general conditions,history and positive laboratoryfindings, and were admitted tohospital.The most common presentingsymptoms in serious cases (34patients) were as follows:24 patients (70%) had poor feeding,18 (53%) patients were hypoactive,17 patients (50%) had abdominaldistension, 15 patients (44%) haddecreased primitive reflexes, 13patients (38%) were irritable, 12patients (35%) were tachypneic andfinally 12 patients (35%) had coughand vomiting.On the other hand, within the 166mild cases, it was found that coughwas present in 28 patients (17%),diarrhea in 27 (16%) patients,xanthematous skin rash in 20patients (12%), tachypnea in another20 patients (12%), and finally coughand vomiting each of them in 10patients (6%).26 MIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 7MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 7, ISSUE 10

MEDICINE AND SOCIET YTable 1: Population of the StudyTable 2: Clinical Presentations among the Study GroupMIDDLEMIDDLE MIDDLEEASTEAST EASTJOURNALJOURNAL JOURNALOFOF OFFAMILYFAMILY FAMILYMEDICINE MEDICINEVOLUMEVOLUME10• VOLUME 8ISSUEISSUE77, ISSUE 5 10 27

MEDICINE AND SOCIET YThe most detected Signs in admittedpatients were: abdominal distensionin 17 patients (50%), irritability in 13patients (38%), decreased primitivereflexes in 10 patients (29%), Lungcrackles in 8 patients (23%) andfinally 5 patients (15%) with bulginganterior fontanelle (three of themwere found to have meningitis).Only two Blood Cultures werepositive in the “mild cases group”and both were Staphylococcusepidermidis, in comparison to10 positive blood cultures in theseriously ill admitted patients (5with streptococcus pneumonia,1 klebsiella, 1 E.coli and 2staphylococcus epidermidis(co-agulase negative) and 1stapylococcus aureus.8 cases with mild inflammatoryfindings on chest X-ray were foundin the group of mild cases; all ofthem were admitted to hospitalin comparison to six cases ofPneumonia in the other group.DiscussionWe noticed that Pediatriciansand Family doctors can reducesignificantly the number of hospitaladmissions in the young infantage group presenting with fever tothe emergency room, and withoutempiric antibiotic therapy or routinehospitalization, after performingsimple laboratory tests and goodclinical evaluation.All infants were seen each day for thenext 2 days as part of follow up, andthose with positive screening resultswere hospitalized and treated.We found significant relationshipbetween positive cultures and/orpositive Chest X-Ray and Laboratoryfindings, with the symptoms of : poorfeeding, hypoactivity, abdominaldistension, convulsions, attacks ofcyanosis, and respiratory distress.Although, management of feverwithout source is still controversial,there should be a way to selectthose infants who need admissionto hospital for further advancedinvestigations. “Martial M. Massin”found that the most common finaldiagnosis was acute febrile illness,either bacterial or viral ,and themanagement allowed the earlydiagnosis and treatment of seriousbacterial infections.(3)In a comparison between emergencyand pediatric physicians, “Vei-kenSeow” showed that admissions fortoxic cases and workup in thosewith body temperature more than39oc was higher among pediatricphysicians(4).Treatment, for children with severepneumonia, with oral antibiotics isnot recommended in young infantsadmitted to hospital especially thosewith rapid respiratory rate becauseof high percentage of treatmentfailure(5), Haider and his colleaguesat Aga Khan University(6) showedthat a short course (three days) ofantibiotic therapy is as effective asa longer treatment duration for nonseverepneumonias in children aged2-59 months.“Gray and his colleagues” atLiverpool children hospital, U.K.found that the most commonapparent life threatening eventspresenting to pediatric emergencydepartment were: convulsion, febrileconvulsion, gastro-esophageal reflux,and lower respiratory tract infectionand that all such infants should beadmitted for a period of observationand further investigations.Six cases of pneumonia werediagnosed in the serious 34(17.6%) cases admitted to hospital,compared to 16% of patients whohad radiographic pneumonia in the“Neuman” study in Boston, USA,where they also found that historyand physical examination findingscan be used to risk stratify childrenfor risk of radiological pneumonia,and that history of focal rales,duration of fever and mainly oxygensaturation below 92% are the mainpredictors of pneumonia [8].Infants with negative screeningresults and non-septic appearancewere managed without antibiotics oreither discharged and followed up asout-patients.Yamamoto and Boychuck [9] foundthat the clinical setting has an effecton the diagnosis and treatmentstrategies chosen when evaluatinga febrile child at risk for occultbacteremia with patients seen in theemergency department; and that wasthe case in our study.Three cases of meningitis werediagnosed in addition to 12positive blood cultures, 14 cases ofpneumonia, 8 cases of urinary tractinfection; all of them were treatedwith intra-venous antibiotics athospitals.Acute respiratory infection is one ofthe leading causes of morbidity andmortality in children under five yearsof age in developing countries.When hospitalization is required, theusual practice includes administeringparenteral antibiotics if a bacterialinfection is suspected. On theother hand, Rojas and Granados[10] concluded that oral therapyappears to be an effective and safealternative to parenteral antibiotics inhospitalized patients with pneumoniawho do not have any serious signsor symptoms. In a recent Spanishstudy they found that infants under3 months of age with fever withoutsource, undergoing full invasiveseptic evaluation were found tohave low prevalence of invasivebacterial infection in comparison withenterovirus infection which is mostlytrivial and self limiting and showshigh prevalence rate at this age, asshown by “Martinez” [11], and finally,it was shown that the incidence ofoccult bacteremia among highlyfebrile children is uncommon withcontinued use of pneumococcalconjugate vaccine [12].ConclusionIt can be concluded that symptomsof poor feeding, hypoactivity,cyanosis and convulsion are alwaysconsidered indicators of seriousillness, necessitating admissionand full investigation. On the otherhand, the important signs that areconsidered alarming of serious casesare: abdominal distension, irritability,tachypnea, decreased reflexes andbulging anterior fontanel. Simple28 MIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 7MIDDLE MIDDLE EAST EAST JOURNAL JOURNAL OF OF FAMILY FAMILY MEDICINE • VOLUME VOLUME 8 ISSUE 7, ISSUE 5 10

MEDICINE AND SOCIET Ylaboratory investigations are veryhelpful to pediatricians and familydoctors to spot the serious casesand spare many young infants fromunnecessary admissions to hospital.References1. Nilgun Erkek, Saliha, SalihaSenel, Murat Sahin et al. Parentsperspectives to childhood fever,comparison of cultural diversepopulation. Journal of pediatricsand child health- volume 46,issu10,pages:583-587,October 2010.2. Penning C, Van der linden, TibbelD. et al, Is the temporal arterythermometer a reliable instrument fordetecting fever in children. Journal ofclinical nur. Pages:1632-1639,June2011.3. Martial M. Massin, JessicaMontesanti, Philippe lepage.Management of fever without sourcein young children presenting to anemergency room. Acta paediatricaJournal- volume 95, issue 11,pages:1446-1450,November 2006.4. Vei-Ken Seow, Aming lin, I. yin lin,et al. Comparing different patterns formanaging febrile children in the ED.Between emergency and pediatricphysicians: impact on patientoutcome. The American Journal ofemergency medicine, volume 25,issue 9,pages:1004-1008,November2007.5. Addo-yobo E, Anh DD, El SayedHF, et al. Outpatient treatment ofchildren with severe pneumonia withoral amoxicillin in four countries.Trop. Med. International HealthJournal, pages :3156-3165 May2011.6. Haider BA, Saeed MA, BhuttaZA. Short course versus long courseantibiotic therapy for non severecommunity acquired pneumonia inchildren aged 2months-59 months7. Gray C, Davies. F, Molyneux E.Apparent Life threatening eventspresenting to the emergencydepartment. Pediatric emergencycare Journal, volume 15(3), pages:195-199,June 1999.8. Neuman MI, Monuteaux MC,Scully KJ, et al. Prediction ofPneumonia in a pediatric emergencydepartment. Pediatrics Journal,128(2) pages:246-253 August 2011.9. Yamamoto LG, Boychuk RB,Emergency department versusoffice setting and physician/ patientkinship effects in the diagnosis andtherapeutic choices of febrile childrenat risk for occult bacteremia. HawaiiMedical Journal, 56(8) pages:209-214. August 1997.10. Rojas MX., Granados C.Oral antibiotics versus parenteralantibiotics for severe pneumonia inchildren. April 2006.11. A.Martinez planas, C. Munozalmangro, C. Luaces cubells et al.Low prevalence of invasive bacterialinfection in febrile infants under3 months of age with enterovirusinfection, Clinical microbiology andinfection Journal, September 2011.12. Matthew L. Stoll, Lorry G Rubin.Incidence of occult bacteremiaamong highly febrile young childrenin the era of the PneumococcalConjugate Vaccine. Archives ofPediatrics and adolescent medicineJournal, volume 158 (7), pages:671-675, July 2004MIDDLEMIDDLE MIDDLE EASTEAST EAST JOURNALJOURNAL JOURNAL OFOF FAMILY OF FAMILY FAMILY MEDICINEMEDICINE MEDICINE VOLUME• VOLUME 10VOLUME 8 ISSUE 77, ISSUE 5 10 29

EDUCATION AND TRAININGIntegration and Impact of Educational Media(Technologies) in the Teaching-Learning Process:A Case Study in IranZohreh KavehCorrespondence:Zohreh Kaveh,Instructor at the Teacher Training University,Tehran, IranEmail: amelectronics@verizon.netAbstractTo a large extent, positive andimproving impacts of the ‘learningtechnologies’ depend uponproper, knowledgeable, and rationaluse of educational media.Learners’ diversified demandsof the twenty first century andcertain needs and requirementsof the information age emphasizemore and more use of learningtechnology to achieve andmaintain a creative and dynamiceducation/learning process.The main of goal this research isto highlight how individual educationaltechnology and mediaare being integrated and utilizedby Elementary School Teachers(EST) in Tehran, Iran. A sealedquestionnaire containing 125answers (indicators) to evaluate/test six hypotheses was sent to asample population of 400 teachersin Tehran. The nonparametrictesting procedure yielded meaningfulsingle variable Chi-square(X2).The results indicate that the mediaknowledge of teachers wasaverage, the level and quality ofmedia utilization on the averagewas meaningful. However, use ofmore modern technology andmedia such as computers, videoprojectors, smart boards, andvisualizers were below average.Based on the results, it can bestated that the main objectivesof the teachers using the mediawere to call on students’ attentionto educational concepts,improve willingness and collaboration,and to motivate audio/visualcognitive senses. Much lessattention was paid to the media’sconcept simplification role. Mostfrequently utilized media andtools by more than 50% of theteachers are: posters, maps, oralexplanation, white/black boards,plays, alphabet cards, and educationalCDs. It must be added thatthe educators confronted numerousobstacles in using technologysome of which are directlyrelated to the shortcomings ofthe educational system in general.These problems and theiradverse impacts on media utilizationare discussed separately.IntroductionHumans have always been in searchof effective ways and methods toconvey their messages to eachother. Teachers and educatorshave been among the many in thisquest to facilitate the simplicityand comprehension of contentareas. Educational technologiesare trying to accomplish thesegoals to convey the findings of thebehavioral sciences and maintaineffective, quick, and easy waysof teaching. Five revolutions ineducational technologies haveprovided a suitable climate toidentify and utilize modern media.Researchers in recent decades havemade considerable contributionsin developing remarkable methodsof teaching/learning processes.However, the extent and effectiveutilization has been limited.Recently, to bring teaching andinstructional technologies to thefore-ground and to foster theirpresence in instructional processes,some scientists have changed itsname to learning technologies andemphasized their role beyond justbeing mere tools.In this research the main goal is toanalyze and evaluate the extentto which the teachers incorporateeducational media in their teaching.Therefore, it is imperative to assessteachers’ familiarity and knowledge,lack of which creates many obstaclesand road blocks.In this research paper knowledgeand familiarity of the instructorshave been examined and reasonsfor avoiding or not using the mediahave also been identified. It isimportant that educated and qualifiedteachers possess a wide knowledgeof different media. Therefore, it isnecessary to conduct research toidentify the wide range of mediaapplications and their impact on30 MIDDLEMIDDLE MIDDLEEASTEAST EASTJOURNALJOURNAL JOURNALOFOF OFFAMILYFAMILY FAMILYMEDICINE MEDICINEVOLUME• VOLUME10VOLUME 8 ISSUEISSUE7, ISSUE 5710

EDUCATION AND TRAININGlearning capabilities to help teachersimprove their teaching.To conduct this research and toevaluate the educators’ familiarity,goals and expectations, a wide listof educational media was compiled.This research analyzes the levelsof familiarity with and use of eachlearning technique by the educatorswith the following objectives in mind.a. To evaluate the extent of use ofinstructional media by teachers ingeneral.b. To identify the objectives and goalsof the EST from media utilization.c. To measure the extent of use ofeach media by teachers.d. To find the best and effectivemethods to increase teachers’media knowledge.e. To identify obstacles impedingmedia applications.f. Recommend solutions andremedies that authorities shouldpursue to foster better planningand improve human resourcerequirements.The questions to be answered bythe sampled teachers (400) are asfollows.1. What is the best pattern and modelof media application?2. At what stage in the learningprocess is the instructional mediabeing used?3. Which media at what stage isbeing adopted?4. Which and to what extentinstructional technique is used?5. How much is your knowledgeof modern computers and internetapplications?6. Do you need special training toimprove your qualifications andknowledge of modern media?BackgroundAccording to Simon (1983, p. 88),technological innovation has anintellectual basis that attempts tocontrol, secure, and exploit thehuman physical environment byusing the known scientific rules andlaws. In other words, technologyis any scientific capability thatuses, manipulates, and adopts theaccumulated scientific findings of thepast and present. Technology canalso be defined as methodology orthe knowledge of better and moreeffective applications of humansciences. Fardanesh (1991, p. 9)claims that Webster’s definition oftechnology is as simple language ofapplication of knowledge for scientificgoals and purposes.Instructional technologies aredesigned to have empirical andpractical applications in the learningteachingprocess. Accordingto Raberd & Valiwer (1989),educational innovation is theoutcome of systematic challengesthat aim to diagnose and analyzethe educational shortcomings andto offer solutions. Wager (1997),while emphasizing expansion ofconcept of technology, believes thatthe effective educational technologyis not necessarily the hardware,but comprises all delicate steps ofconducive educational planningas well. The National Academy ofEngineering Instructional Technologyon Education states that educationalinnovations are scientific findings thatemerge from the actual classroomapplications of tools, techniques,and methods assisting the learningprocess (Dieuzeide, 1971).Importance and Necessity ofEducational TechnologyExperience shapes and moldslearning capabilities, therefore,thoughtful and achieving educatorswill attempt to provide a basis forstudents to be able to understandand retain new concepts andexperiences by drawing inferencesfrom their previous knowledge.Technology affects the learners intheir academic success in threedistinguishable ways: a) success inlearning the content area subjects; b)increase critical thinking and fosterproblem solving talents; c) preparethe human resource work force(Cradler, 2002).Historical Development ofTechnology in the WorldHuman beings have always beenin search of effective methodsto communicate with each other.After the inventions of script andlanguage and mitigating ease incommunications, the foundation forteaching/learning was laid down.Everyone could communicate his/her experience and findings andtake advantage of those of others.However, the pace of this revolutionwas rather slow and piecemeal untilthe invention of the press industry.Revolutionary steps were takenin instructional innovations alongwith emergence of educationalinstitutions that instituted thesecond revolutionary turn in schoolinstructional education. Learningprocess was analyzed by scientistsas an independent realm frompsychology and elements affectinglearning capabilities were indentified.Sidney Pressey invented a simplemachine in 1925 for the first timeto evaluate the performance ofstudents. That was the beginningpoint of mechanical teaching in thehistory (Zofen, Lotfipour, 2002, p.7). Burrhus F. Skinner, a well knownpsychologist, invented a “teachingmachine” that could teach subjectsin a simple manner and step bystep (Skinner, 1954). The thirdrevolution took place in the 1930’s(Gange, 1985, pp. 11-14). EricAshby was one of the first thinkerswho advocated the use of electronicmedia in education and visual mediawas accepted as the best substitutefor direct experimentation andexperience.With the start of the WWII, the focusof audio/visual researchers wasdiverted from educational institutionsto the United States Army. Duringthe war, most learning/teachingtools such as overhead projectorswere built for the first time and madetheir place along with slides, pilotsimulations, and language labs(Fardanesh, 1991, p. 21).Use of computers in classroomsstarted in the 1980’s and markedthe fourth revolution in educationalinnovations. A rise in teachers’confidence contributed to a wideapplication of computers. Itsintegration into the teaching/learningprocess started in 1990 andcomputers became an integral part ofclassroom settings and instructions.This contributed to a wide and dailyuse of computers by the studentsMIDDLE MIDDLE EAST EAST JOURNAL JOURNAL OF OF OF FAMILY MEDICINE VOLUME • VOLUME 108 ISSUE 7, ISSUE 7510 31

EDUCATION AND TRAINING(Zofen, Lotfipour, 2008, p. 10).Towards the end of the 1990’s andthe beginning of 2000, introduction ofinternet in the classrooms, assessinginformation and a host of databecame a reality and contributed tofaster and better learning. Onlinelearning and instruction constitutedthe fifth revolution in the world ofeducation.Emergence of instructionaltechnologies in many countriesstarted with A/V media (hardware)applications and the age of softwarefound its way with an aid frompsychology. Educational programswere designed and analyzed andefforts were made to find applicationbottlenecks and provide solutions(Fardanesh, 1991, pp.32-33). Ithas been said that educationaltechnology as a “science” owes itsdevelopment, in most parts, to thefiring of a Russian Sputnick missile.Launching this missile during theCold War shocked the Westernblock. The West began trying toeliminate the shortcomings of itsown educational systems resulting ina branch of science with the brandname of “educational technology”.The developments in hardware,software, and computers havekept pace with each other. Theintroduction of the internet in late1990s and early 2000s has givenway to amazing advancements in theteaching/learning processes.Evolution of Technology in IranDevelopment of educationaltechnologies in Iran, as well asother developing nations, has beenvery slow. Educational televisionstarted its program in 1964. Andthen in 1966 along with overhaulingthe educational system, TV startedputting on programs teachingphysics, chemistry, algebra, naturalsciences, and foreign (English)language grammar. After a few yearsof zero to no progress, becausenot too many people had accessto TVs, a mandate was issued thatlearning materials be broadcast fromboth National Radio and Televisionstations (Aliabadi, 2001, pp. 25-32). After the Revolutions of 1979,the Ministry of Education joinedthe efforts and educational videocassettes entered the schoolingsystem. In 1985, to motivate theteachers “Education of TechnologyMagazine” started its publication.In late 1980s computers wereintroduced to schools for the firsttime and by the end of the 1980s andearly 1990s ICDL certification and itsskills improving programs becamemandatory for the teachers. Pilotschools and models contributed tothe enrichment of student/teacherskills spreading computers and theirapplications to other schools.It should be noted that educationalhardware has been advancing muchfaster than software and human skillsdevelopment. Skill developmenthas always been lagging behind theintroduction of hard core educationaltechnologies due to the lack ofteacher guiding plans and motivation.Utilization of techniques contributesto overall quality of teaching as wellas learning. Therefore, knowledge ofappropriate applications foster goaloriented education.Implementing Educational(Learning) TechnologiesDevelopment of new learningsystems requires preparing anintertwined plan to direct and guidethe society in its use of learningtechnologies. The present centuryis the age of dynamic interchangeof data, information, and knowledge(Richardson & Wolf, 2003). Intranet,extranet, and internet and otherrecent innovations have contributedto this exchange (Afzalnia, 2005, p.62). However, levels and methods ofapplications require vigorous study ofsubject and teaching skills. Learningtechnologies in any educationalsystem mandate the presence ofphysical/mechanical tools, skills, andcoordination. Stoner (1996) produceda model of integrating technologyand content areas based on a workby Lorilard (1993). The model wasbased on the following elements:1) preparation,2) analysis and evaluation,3) choosing learning technology,4) integration plan and guidelines,5) execution,6) quality control and coordination,and7) execution assessment.Learning technology has a mediatingrole in the learning process.Effective learning depends uponefficient planning and proper use ofinstructional techniques. Accordingto Raber and Valiwer (1989) learninginnovation is the regular andsystemic outcome of investigationand identifying educational problemsand shortcomings. They believethat to utilize the potential skills,educational innovations rather thanbeing considered as an educationalcomplement, must be viewed asan outcome of the search process.Thus, innovations begin withrecognition of education problemsand obstacles; they must supportlearning and be applicable in differentsettings (Raees Dana, 2009, p. 13).Role of Media in Education/Learning TechnologiesMedia is the set of all tools,instruments, and objects that providea proper environment to fosterand facilitate learning to obtaininformation, technical inclination,and new skills (Shabani, 2005, p.188). According to scientific andprofessional viewpoints, educationalmedia is one of the importantsubjects of the debates on theconcepts of educational innovationswhich establish connections amongthe subject, learners, educatorsand learning environment. It plays amediating and communicating role.With this in mind, teachers must firstbe able to identify the philosophicaland psychological basis for selectingand incorporating certain media.Philosophical Basis for UsingMediaDiscussions and theories aboutlearning are in close contact withthe philosophy of communication.As such, a branch of philosophy hasbeen devoted to teaching/learningproblems. One of these discussionscircles around the philosophy andtheoretical foundations of properplanning, introduction of appropriateteaching methods, as well as takingadvantage of objective mediaexperiences. Different schools offerdifferent outlooks when it comes toteaching. But it must be emphasizedthat philosophical foundation ofeducational technologies lies with32 MIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 7MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 7, ISSUE 10

EDUCATION AND TRAININGpragmatism which has interestin applied teaching/learning thatproduces appropriate talent, skill, andbehavior in the educated (Afzalnia,2009, p. 26). Charles Sanders,William James, C. S. Peirce, andJohn Dewey, to name a few, werethe forerunners and founders of theSchool of Pragmatism. They believedthat thoughts and ideas are liketools to solve human problems anddifficulties. As long as those ideashave their positive impacts they arereal (http//: falsafe-godfather.blogfa.com).Psychological Basis for UsingMediaThere are two psychological aspectsof educational media. Discussionsabout psychology of learning througheducational media have beencentered between two issues.a) Emphasis on senses in thelearning process: Senses andperceptions of learners act ascommunicating channels (Razavi,2007, p. 32). For effective learning,the media that employs 75-88%of visual along with other sensesmust be adopted (Ahadian, 1995,pp. 65-66). This belief will entice theteachers to try and adopt differentmedia.b) Status of learning media inlearning theories: Every learningtheory is a set of principles andlearning rules that analyze andevaluate the learning process toidentify the elements that foster andimprove learning. Based on theseelements application methods andmodels for media are constructed.Some of the leading theories arebriefly explained below.1. Behaviorist Theory:These theories are based onexperimentation and claim thatexperience is the only source ofknowledge and learning is acquiredthrough experience. Thus theyemphasize direct use of media.Robert Gange (1977) has the largestimpact among those who hold thisview.2. Cognition Theory: Understandingthe cognitive potentials that lead tomeaningful behavior and learningare a byproduct of visual andbackground knowledge. FromGoshtalt’s viewpoint, media inlearning processes are those thatstudents have some prior knowledgeof through their teachers, friends,peers, relatives and some objectsthat have certain characteristics,colors, and shapes encompassingthe subject materials and sensibleenvironment of learners (Lotfi &Hosseini, 2009, p.13). Piage statesthat the learning process is basedupon the learner’s transactionswith the environment and his/herstage of growth. An infant adaptsitself to its environment throughcontacts with others, social andenvironmental conditions. Therefore,concepts and contents of subjectsare important. Piage’s theory tellsus that educational experiencesshould be built around the cognitivemakeup of the learners. For thelearning to take place smoothly andeffectively, the educational subjects,to some extent, should look familiar.To build such familiarity teachersshould have a vast knowledge ofcognitive capabilities of students(Hergenhan, Alison: Translated bySaif, 2006, p. 321). Lev Vygotsky,a pioneer in electronic educationand social-cognitive developmenttheories, believed that learningdepends on the individual’s priorknowledge of symbols and concepts(Mosheri, 2009, p. 15). He states thatlearning is a complex and reciprocalrelationship between science subject,learner, and the problem to besolved. Thus, education is to preparean environment in which the learners,by activating their prior knowledge,engage in a reciprocal exchange ofknowledge that helps and activatescognitive skills (Ertmer & Newby,1993). As such, principles that shouldhave been established to plan andcreate such environments werepreviously overlooked (Oscooee,2009).3. Learning by Observation:This approach to learning hasmany educational applications,but its use in a classroomrequires teacher’s assessment ofstudents’ attentiveness, retaining,memorization, and motivation.Television, movies, documentaries,lectures, and audio cassettes canbe used in this setting (Saif, 2003, p.52).4. Ultra-Cognition: Is theknowledge, control, and guidanceof thought. Teachers help to learnmethods of acquiring, organizing,retaining, and communicating theinformation, and, then, require thestudents to revisit their thoughts andrevise them to make the necessarycorrections. To accomplish thesemental and physical activities, theeducators need to incorporate newmedia into their teachings (http//:science dept.talif.sch.ir). Of courseteachers can also promote ultracognitiveabilities in plans to usecertain media for more talentedstudents. Techniques to maintainconnection can be adopted for thelesser talented by using Q/A strategy.5. Constructivism: the theoryemphasizes each and every studentin the learning environment and callson planners to pay more attention tothis. Reigeluth (1996) believes thatconstructivism will help us to decideon software to be integrated intocontent areas. Anchored instructionemphasizes skills and priorknowledge. It expands complex andinadequately structured problemsfor the learners to decide where andhow to use their prior knowledge.6. Theory of Dual-Dilemma: It is abranch of cognition theories that isbased on analyzing data and relyingon memories (Scott, 2003). Data andinformation are organized throughaudio/visual channels. Each channelcan analyze a certain amount ofinformation in a certain period oftime. Role of schema and cognitiveskills must be taken into account.This means that visual tools shouldbe used in planning for content areas(Dabbag, 2002). If the information ispresented in both visual and auditoryforms, it will facilitate and improvelearning. In educational movies thisis accomplished easily (Razavi,2007, p. 32). According to Gardner,methods by which both audio andvisual channels are combined aredifferent (Gardner, H. 1999, p. 25).Therefore, teachers should employMIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 7MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 7, ISSUE 10 33

EDUCATION AND TRAININGdifferent media according to thedominant cognitive skill of eachgroup. For example the studentswho have strong language aptitudeswould enjoy books, audio cassettes,and DVDs; students with strongmathematical skills would enjoycomputers; and students with strongspace search capabilities wouldbe on a fast track when it comesto solving puzzles and would showpositive attitudes towards slides,diagrams, and maps (Aghazadeh,2006, pp. 38-39).7. Brain/Learning Process Theory:The brain provides capabilitiesthrough nerve systems. Left and righthemispheres of the brain control andconduct different activities (Wolf,2008, pp. 153-55). Teachers must dotheir best to entice students to useboth sides by adopting media mostappropriate to increase emotionalattachment of students in the learningprocess (Raees Dana, 2009, p. 14).Social Settings of Media UtilizationAdvances in mass communicationsand modern technology havecontributed to dynamic learning inthe classrooms (Zofin & Lotfipour,1991, p. 28). The benefits of suchadvances have been felt both insociety and educational structure.Variety of information sources,cooperative and group learning,and independent studies are nowwidespread (Yadgharzadeh, 2007, p.36). Moreover, it must be noted thatthe availability of various media andtechnology, per se, can not insurepositive results unless attentionis paid to training and educatingqualified human resources. Preparingthe students for the 21st centuryrequires learning technology in allaspects of its meaning (Fall, 2009).Dimensions of Media UtilizationIt is necessary to acquire thefollowing capabilities.a) Skills required to construct andadopt the media by improvingteachers’ knowledge of educationalmedia and to motivate them to acceptthe use of it as a 21st century reality.b) Increase the knowledge ofeducators about the goals andbenefits of media use in its differentforms and designs. Seminars,lectures, and workshops for teachersand proper guidelines for educationplanners are steps in the rightdirection.c) Prerequisite skills to designing andapplication of media. Experts haverecommended different models ofdesigning plans for education. Oneof these models, so called, ASSURE,has been proposed by Russell. Inselecting the media, teachers mustbe aware of the benefits, impacts,and shortcomings (Amir Teimouri,2008, pp. 238-39). In most casescost is an issue (Waldse, 2005). In allpossibilities, coordination, goals to beachieved, content, teaching methods,learners’ characteristics, andreliability of the techniques must beused as a criteria and starting point(Amir Teimouri, 2008, pp. 240-43).d) Skills to design media for differentlevels of learners and audience. Atdifferent stages of planning countingfor the makeup of audience, goalsof teaching/learning, assessment,modifying, and taking advantage ofprevious works are riding principles.Altogether, balance, simplicity, roomfor discussions, unity and coloring,diagrams, pictures, maps, and simpleattachments make media designmore attractive and amusing.e) The stage of media use, probably,is the most important because it notonly keeps learners occupied butalso displays skills, readiness, andcompetency of the teacher withoutlosing the audience. Preparation,environment, and incorporatingcomplement activities and makemedia use more effective andproductive (Zofin & Lotfipour, 2004,p.53). The achieving educator willalways attempt to keep abreast ofnew techniques and innovations.Computers have played enormousroles in the mental growth of ourchildren, their education, problemsolving talents, and searching foranswers (Jilbert, 2005). Accordingto Collis (1998), today, teaching atpilot schools, virtual teaching, andeven network based teaching requirespecial skills and qualifications.Electronic and network basedinstruction has the benefits ofdiversity and active participation;attention to individual differences;changeability; and availability ofscientific and professional guidance.f) Ability to overcome obstacles andshortcomings of utilization. Whenusing the media teachers are usuallylimited with problems such as lackof knowledge and impact of media,inadequate media, limited budgetand cooperation of educationalauthorities, lack of coordinationbetween the education systems andinappropriate rules inherited fromthe old and traditional system, andimproper and inadequate teacherevaluation systems (http//: festival.rash.ir) (Magazine).ResearchResearch on educational mediastarted immediately after innovationsand their applications in educationalenvironments. The pivotalconcentration was to comparethe impact and effectiveness ofthe new techniques to that of thetraditional approach to educationand draw inferences. Any newtechnology and innovation wouldinitiate its own research and study.A study by Godfree (1967) titled“States of Audio/Visual Techniques,1961-67” was the first systemicattempt to assess the effects ofA/V innovations on learning. Hecollected information and data on2,927 schools. The resulting reportconcluded a considerable andpositive contribution of technologyin elementary schooling. The samereport indicated that the results weredifferent for higher levels of schoolingdue to diversity of content subjects.Traditional tools such as films andaudio cassettes were preferred bythe teachers. A joint study by JosephF. Kahalahan and Leonard H. Clarkindicated that teachers preferredthe traditional methods of teachingbecause the new methods demandedmore efforts and skills (Vasheghani& Frahani, 1992, p. 92). MichaelSimonson (1987) and his colleaguesconstructed a pilot research programto assess the impacts of film, slides,audio cassettes, and a control groupto evaluate the view of studentsabout handicapped students. Resultsindicated that compared to the controlgroup the other groups that wereexposed to films, slides, and audiocassettes showed positive signs ontheir view of the handicapped34 MIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 7MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 7, ISSUE 10

EDUCATION AND TRAINING(Simonson, 1983, p.36). McMahonand his partners studied theimpact of television education inhigher schooling. They concludedthat incorporation of TVs in theclassrooms improved eagerness,reciprocity, and students’ independentlearning. Hamel and Carolinvestigated and compared therole of computers and visual toolsin improving visual capabilities.They concluded that effects wereremarkably positive.In short, the role of media ineducation, in general, has beenemphasized throughout the worldespecially in the West. During thelast two decades investment andoutlays on classroom technologiesin the United States alone, haveamounted to more than $5b. Attemptshave been made to mandate mediause in the classrooms. The effect ofsuch decisions has been to increasethe willingness of the teachers andto keep in close touch with the realworld (Valdez-et.all, 2000).Learning environments that arerich in media facilities promotesocial cooperation models, betterteaching methodologies, and betterinitiatives and collaborations (Tiny &Lotfi, 2001). Syrin and Bialo (1995)after reviewing and revisiting theprevious works have emphasizedthe invaluable effects of technologyon student performance and selfesteem.Canadian universitieshave a larger share in promotionand integration of technologies intoteaching/learning processes whichenable students to expand theirinformation base, world view, andcollaboration.Research Conducted in IranStudies about media and its usein Iran are few, sporadic, anddisconnected. According to AbdulrezaSohrabi, one of the major problemslimiting use of media in Iran is lack ofteachers’ knowledge of media, andcosts and budget considerations. Asurvey by Mashaallah Vasheghaniand Ebrahimi titled “investigatingobstacles of media/technologyutilization in teaching/learning in thecity of Arak, Iran” indicated that thelack of proper environment, tools,software, and inadequate humanresources are the pressing problemsand issues (Vasheghani, 1992). In2001-2002, Khodadad Khodamoradistudied the impacts of educatingskilled and unskilled teachers onteaching English in a high school inRavansar, Kermanshah province,Iran. They concluded that althougheducational videos are of someinterest to students they cannotbe a good substitute for skilledand knowledgeable teachers(Khodamoradi, 2002). Mrs. AkramBarati studied multimedia planningand designing process and proposeda model based on constructivismphilosophy. She stated that utilizingnew technologies in the learningenvironment helped students to findtheir own shortcomings. Findings ofpsychology can be used to identifyand overcome these problems toincrease self-esteem in learners.In her model, Barati, reiteratesthe importance of environment,proper technique, role of teacher,learners’ creativity, collaboration, andmotivation (www.trandoc.ac.ir). Withthe supervision of Dr. Abbas Heri,Mehdi Mahdavi studied the planningprocess of multimedia educationsoftware and methods of using library( Mahdavi, 1997). He suggested:1) Teaching and expandinginformation on methods of textbookuse;2) Supervision of students in theirquest for effective and fruitfulresearch;3) Introduction of new technologiesas productive tools in education.The Present ResearchThe methodology of this researchpaper is analytical-descriptive. Itconcentrates on analyzing andassessing the levels of media useby the elementary school teachers(EST) and obstacles and problemsthey face (Hafeznia, 2000, p. 69).Descriptive research relies mainlyon establishing hypotheses andtesting to solicit the relationshipsbetween the raw data and variables(John Bast, 2002, p. 43). Therefore,by using the scientific theories andtheir findings, the main goal of thisresearch is to diagnose, as much aspossible, the educational purpose,problems, and solutions. This is afield research in Iran, to collect dataand information from the statisticalpopulation of all elementary teachersin Tehran, Iran (Male/Female:15,429). A random sample of 400teachers has been selected usingcluster sampling method. The levelsof education in the sample areDiploma 8.7%, Associates 56%, BS34%, and Masters 1.2%.A sealed questionnaire containingfive general questions each requiring25 answers (options) was sent toeach teacher in the sample. Onlythe answers to the first question(25 options) were calculated withthe 5 point Likert scale (group of 5at a time), and frequency of eachanswered option for the otherfour questions were assessed. Itshould be noted that designingthe questionnaire was based onaccumulated information aboutdifferent media and its utilization atdifferent stages of teaching process.The results were arranged in a matrixform. Fluency and credibility of thequestionnaire was calculated to be0.84 and 0.91, respectively. The datawere analyzed using descriptivemethodology. First the frequencydistributions and histograms,and tables of statistical indicatorswere constructed. Non-parametrichypothesis and a single variable Chi-Square (X2) analysis were performedusing SPSS and Pc+18 software. Thefollowing hypotheses were tested:H1: The rate of media applicationby the EST is below the average.The statistical descriptions for eachof 7 media groups, included in thequestionnaire, were given. Thegroups are:A) writing media;B) visual;C) auditory media;D) new media;E) boards (smart and black);F) 3 dimensional media; andG) locational.Testing X2 with 4 degrees of freedomwas meaningful for the writing mediagroup, thus H1 is not accepted.With regard to visual media resultsindicated that the teacher usedposters and films/pictures moreMIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 7MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 7, ISSUE 10 35

EDUCATION AND TRAININGfrequently above the average (92.8%and 66.6%) and overhead projectoruse was 59.3% (p

EDUCATION AND TRAININGthe media as an indispensablepart and parcel of education. Itis recommended for authors toincorporate the media and itsapplications into textbooks andexercises and make their use arequirement.3) Authorities should providestandards and criteria to be used indesigning and developing software.At the higher education institutionsan “educational major” should bedeveloped and designed to teachlearning technologies at the collegesand universities making it possiblefor the skilled and professionaltechnologists to enter the process ofinstituting the culture of scientific andappropriate media utilization.4) Research should concentrateon studying the teachers view andopinion of the media and its use.Reports of such research and theirassessments about the place,role, and usefulness of learningtechnologies can be guiding lightsin the teaching/learning process,design, and planning.BibliographyFarsi1. Ahadian,Mohammad (1995).Principles of Educational Technology,Tehran: Boshra2. Oscooei, Yasaman (2009).Planning & Designing theEducational Environments, EducationDesigning Site.3. Afzalnia, Mohammadreza (2005).Knowing the Centers and Resourcesof Learning, Tehran:Samt.4. Afzalnia, Mohammadreza (2009).Principles of Electronic Learning,Educational Technology GrowthMagazine: No. 7.5. Amir Teimouri, Mohammad Hassan(2008). Teaching/Learning Media,Tehran: Savalan.6. Aghazadeh, Moharram (2006).New Teaching Guides, Tehran: Aieez.7. Bast, John (2000). ResearchMethods in Behavioral Sciences,Translated by Pasha Sharifi &Narges Taleghani, Tehran: Roshd.8. Behrangi, Mohammadreza &Asadi, Arash (2009). IncorporatingMultimedia Software for EnglishTeaching, Teaching/Learning Journal:No. 1.9. Taghavi, Mehdi (1997).Constructing Multimedia Software forUsing Library, with the Supervisionof Abbas Heri: Doctoral Dissertation:Tehran University.10. Hafeznia, Mohmmadreza (2000).Methods of Research in HumanSciences, Tehran: Samt.11. Khodamoradi, Khodadad (2001-2002). Effect of Audio/Visual Mediaon Learning English Language, withthe Supervision of Professor HasanRasteghar and Parvin Kadivar.12. Lotfipour, Khosro & Zofen,Shahnaz (2004). Educational Mediafor Classroom, Tehran: Iran BooksPublishing Co.13. Razavi, Seyyed Abbas (2007).Theoretical Foundations ofLearning with Films and Television,Educational Technology GrowthMagazine: No. 5.14. Raoof, Ali (1999). TeachingContent of Educational Technology,Tehran: Madraseh.15. Raees Dana, Farrokh Lagha(1999) Educational Technologies,Educational Technology GrowthMagazine: No. 5.16. Raees Dana, Farrokh Lagha(2009). Eight Capabilities of theBrain, Educational TechnologyGrowth Magazine: No. 4.17. Leshin, Synthia B.; Polak, Jolin;and Reigeluth, Charles M. (2007).Teaching/Learning Skills: Methods &Techniques of Teaching, Translatedby Hashem Fardanesh, Tehran:Samt.18. Aliabadi, Khadijeh (2001).Principles of InstructionalTechnologies, Tehran: Payam-e-NoorUniversity.19. Fardanesh, Hashem (1991).Theoretical Foundations ofEducational Technologies, Tehran:Samt.20. Lotfi, Ali & Abdullahi Hosseini(2009). Connections betweenConstructivism and ElectronicInnovations, Educational TechnologyGrowth Magazine: No. 4.21. Moshiri Tafreshi, Manijeh (2009).Vygotsky and Peripheral Aspects ofGrowth, Rosh Technology: No. 5.22. Vasheghani Farahani,Mashaallah (1991). Teachers view onRoad Blocks of Utilizing InstructionalTechnologies, Arak, Iran, With theSupervision of Professor MostafaAskarian, Doctoral Dissertation:Teacher Training University, Tehran,Iran.23. Wolf, Patricia (2008). The Brainand Learning Process, Translatedby David Abolghasemi, Tehran:Madraseh.24. Hernghahan, Walson (2003).Preface to Learning Theories,Translated by Aliakbar Saif, Tehran:Dooran.25. Yadgharzadeh (2007).Communication & InformationInnovations for Improving Teaching/Learning Skills, EducationalTechnology Growth Magazine: No. 2.26. Shabani, Hasan (2005).Research & Teaching Skills: Methodsand Teaching Techniques, Tehran:Samt.English1. Collis, B. (1998). New Didactics forUniversity Education: Why & How?Computer Education:No. 3.2. Cradler, John (2002). How DoesTechnology Influence StudentLearning?3. Dieuzeide, H. (1971). EducationalTechnology: Sophisticated, Adaptedand Rational Technology, SeriesB: Opinions (No. 30). Paris:International Commission onthe Development of Education,UNESCO.4. Doherty, A (1998). The Internet:Destined to Become a PassiveSurfing Technology? EducationTechnology: No. 38.5. Ertmer, P. A., Newby, T. J.(1993). Behaviorism, Cognition,Constructivism: Comparing CriticalFeatures from an InstructionalDesign Perspective, PerformanceImprovement Quarterly: 6(4).6. Gange, E. D. (1985). TheCognitive Psychology of SchoolLearning, Boston: Little, Brown &Company.7. Gardner, H. (1999). IntelligenceReframed, New York: Basic Books.8. Pheonix Falls, August (2009),Technology and 21st CenturyClassroom.9. 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EDUCATION AND TRAININGLondon & New York: RutledgeFarmer.11. Simon, Y. R. (1983). Pursuit ofHappiness and Lust for Power inTechnological Society, C. Mitcham& R. Mackey (eds.), Philosophy andTechnology, New York: Free Press.12. Skinner, B. f. (Spring 1954).The Science of Learning and the Artof Teaching, Harvard EducationalReview: 24, pp. 86-97; TeachingMachines & Science: 128 (October24, 1978). Why We Need TeachingMachines, Harvard EducationalReview: 31 (Fall 1961).13. Valcke, M. (1999). EducationalRedesign of Courses to supportLarge Groups of University Studentsby Building Upon the Potential ofICT, In Information Technology forTeaching and Training, The Journalof the Integrated Study of ArtificialIntelligence Cognitive Science andApplied Epistemology: 16.14. Waldse, Jilbert (2005).Instructional Television’s ChangingRole in the Classroom, April 2009.15. www.falsafe-godfather.blogfa.com16. www.festival.roshd.ir (Magazine)17. www.irandoc.ac.ir18. www.rahavi.ir19. www.science-dept.talif.sch.ir-20. www.visual.merriam-webster.com38MIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 7MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 7, ISSUE 10

CASE REPORTCerebral venous sinus thrombosis in a child with Idiopathicnephrotic syndromeAlexander SMAl-Enezi FahadVictor AOwaidha MPaediatric Department,Al-Jahra Hospital, KuwaitCorrespondence:Dr Fahad H AlaneziAljahra Hospital, KuwaitTel: 96599846919Fax: 96524572123Email: fdh529@hotmail.comAbstractCerebral venous sinus thrombosis(CVST) is an uncommon complicationof Nephrotic syndrome(NS). CVST occurring in a childwith steroid sensitive nephroticsyndrome is described in thisarticle. He presented initiallywith non specific symptoms ofheadache, lethargy and intermittentvomiting after 4 weeks ofinitiating steroid therapy. Thesewere initially attributed to steroidtherapy. Initial CT brain andMRI of the brain were normal. Hedeveloped intermittent convergentsquint. At this time CVSTwas strongly suspected and MRangiography and MR venographywas done which confirmed theCVST. Anticoagulation therapywas initiated with heparin andafter three weeks changed to oralwarfarin. He made slow but completeneurological and radiologicalrecovery.Key words: Cerebral VenousSinus Thrombosis (CVST), NephroticSyndrome (NS), Anticoagulation,Magnetic ResonanceAngiography (MRA), MagneticResonance Venography (MRV).IntroductionHypercoagulable state is a well recognized complication of nephroticsyndrome [1, 2]. Clinically significant thromboembolic complication is wellknown to occur in nephrotics [3,4,5,6,7,8,9,10,11,12,13,14,15,16]. Theseare more common in adults than in children [9]. Both arterial and venousthrombosis have been seen [8, 9]. Among the venous thrombosis,renal vein thrombosis is the most common type. Cerebral venous sinusthrombosis in children with NS is a well known but rare complication [5,17]. CVST can present with non specific symptoms [18, 19]. It can alsobe missed by conventional diagnostic methods. It carries significantsequelae in the form of either neurological deficit or death in nearly halfof the cases [3]. Hence early diagnosis and initiation of anticoagulanttherapy is of critical importance. This case report describes a child withthis rare complication.Case ReportA four year old boy, a known case of idiopathic nephrotic syndrome, wasadmitted with history of headache, lethargy and intermittent vomitingof 4 days duration. He was diagnosed to have nephrotic syndrome amonth earlier and had been started on oral prednisolone (2mg/kg/day).Proteinuria had improved and he had been discharged on oral steroidsafter 1 week in the hospital. There was no history of seizures, psychosisor focal neurological deficits. His urine output was good. At the time ofadmission, physical examination revealed an alert and cooperative childwith cushingoid appearance. He was hypertensive (BP 134/90mmHg).His face was puffy, but he had no ascites or pedal oedema. Hisneurological examination was normal.Figure 1MIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 7MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 7, ISSUE 10 39

CASE REPORTFigure 2Figure 340Urine analysis revealed 2+proteinuria with no casts.Haemoglobin was 14.2 gm/L withhematocrit of 42.9. Leukocyte andplatelet count were normal. ESR was35 in the first hour. Prothrombin timeand activated partial thromboplastintime were normal. Serum fibrinogenlevel was 4 gm/L (2.2-4.6gm/L) andFDP level was 200-400 ngm/ml(normal

CASE REPORTweaned off. Facial nerve paralysisrecovered by 24 hours. Left abducentnerve paralysis took 3 weeks torecover. Repeat MRV done after 3weeks showed further recanalization.He was discharged on Warfarin after5 weeks with no neurological deficits.MRV repeated after 6 monthsshowed normal venous circulationof the brain with no evidence ofvenous sinus thrombosis or venousmalformation. (Figure 3) Warfarinwas then stopped.2 years later, the child has remainedin remission and has had no furtherneurological complaints.DiscussionHypercoagulable state leading tothrombosis is one of the seriousknown complications of NS [9,20,21].These include both arterial andvenous thrombosis [8,9]. Venousthromboembolic complicationsinclude renal vein thrombosis,femoral vein thrombosis, pulmonaryembolism and cerebral venous sinusthrombosis. [9, 12, 22]CVST is a well known but rarecomplication. This complication iswell known to occur in both childrenand adults [7, 8, 9,10,11,17,21,23].It is less common in children whencompared to adults [9]. Despite thelower incidence, thromboemboliccomplications tended to be moresevere in children [9]. This maybe linked to the more pronouncedhypoalbuminemia that is seen inchildren [9]. CVST has been reportedin children with congenital NS,Idiopathic NS, and secondary typesof NS [8,20,22].Few studies are available whichstudy the incidence of CVST inpaediatrics nephrotics. In theCanadian database for the PaediatricIschemic Stroke Registry, CVSToccurring in NS patients wasidentified in only 4 patients in thisstudy from 1992 to 2004 [17]. Theincidence of paediatric CSVT inSwitzerland was 0.558 per 100 000per year [24]. In most of the cases,CVST was reported in NS patientswho were either steroid sensitive orsteroid dependent [21]. Also, thiscomplication occurred mainly in NSpatients during their first presentationor within the first six months [21].This is similar to our case as hewas steroid responsive and hadjust completed a month since hisdiagnosis.The hypercoagulable statein NS is multifactorial [6]. It isdue to a) The deficient state ofthe anticoagulant factors likeantithrombin III, protein C and S,and plasminogen due to increasedurinary losses. b) Increasedproduction of procoagulant factorslike fibrinogen, fibrinopeptides, alpha2 antiplasmin, factors III and V. c)Increased platelet production andaggregability. The other contributingfactors include circulating immunecomplexes, anaemia, corticosteroids,diuretic therapy, hyperlipidemia,hypoalbuminemia, intravascularvolume depletion, infection,immobilization and elevatedhematocrit [6,7,12,18,20,21,23,25,26]. The estimation of antithrombinIII, protein C and S levels could notbe done in our patient. We presumethat the hypercoagulable state wasresponsible for the thrombosis inour patient. His D-dimer level wasslightly elevated. Other authors havereported the association of elevatedD-dimer levels with occurrence ofCVST [27,28,29].A high index of suspicion is neededto diagnose CVST in the early phasewhen only some personality changesmay be seen [12,18,20,21,25]. Thesechanges may be subtle like in ourpatient, with lethargy, decreasedactivity, increased sleepiness andheadache. Hypertension may beseen and fundus examination mayshow evidence of papilledema.These early manifestations ofincreased intracranial pressure mayprogress to focal signs like abducentand facial nerve palsy as was thecase in our patient [14]. Since the CTand MRI of the brain were normal,a diagnosis of benign intracranialhypertension was made at thispoint. The association of CVST withbenign intracranial hypertension hasalso been reported in literature [30].Without intervention, it will furtherprogress to seizures, paresis andcoma [20,21]. Persistence of thesymptoms made us evaluate thepatient further and perform MRVwhich was diagnostic.CT brain is the initial imagingmodality that is usually performed.Thrombi in cerebral veins can bedirectly visualized by CT. Initialand transient hyper density of thethrombus (cord sign) is followedby hypo density, intensified byperipheral contrast enhancement,producing a filling defect (emptydelta sign’) [13,31,32].These arepathognomonic for CVST. In a fewstudies, CVST has been frequentlyfound in asymptomatic patients inthe paediatric age group especiallyin young infants [33]. Whether thisindicates the limited specificityof this sign in this age group, orwhether unrecognized partialCVST secondary to dehydration isresponsible, is to be studied further[33]. Spontaneous resolution of thethrombus has been seen in somepatients with proven CVST [4,26,34].It will also show any parenchymallesion suggestive of venous infarctor bleed. CT scan may be normalin 16 -70 % of cases of CVST[17,20,31,35]. Therefore, a normalCT scan does not rule out thediagnosis of CVST [3,19,25,36,37].Role of CT venography is emergingas an effective modality for thediagnosis of CVST [20,31].MRI brain is superior to CT scanand will diagnose CVST in about 90% of the cases [32,35,37,38]. Thethrombus as well as haemorrhagescan be visualised directly by MRI[11,20,31]. MRV is the diagnosticstudy of choice for CVST[18,20,31,35]. It will show lack offlow in the thrombosed areas ofthe venous system. Conventionalangiography or digital subtractionangiography (DSA) is indicated whenMRV is negative and the clinicalsuspicion of CVST is very high[31,32].CVST most commonly involvessuperior sagittal sinus (72%) followedby lateral sinus (70%) [6,33]. In 30-40% cases, more than one sinusis involved with or without corticalvenous thrombosis [25,35]. In ourcase, the superior sagittal sinusMIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 7MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 7, ISSUE 10 41

CASE REPORTalong with the right sided sinuseswhere completely thrombosed.Anticoagulation with heparinfollowed by oral anticoagulation isthe treatment of choice for CVST[13,19,25,36]. Most of the studieshave shown good results with this[5,12,14,15,20,21,25,34,36,37]. Thisshould be continued as long as thepatient remains in the nephrotic state.Other modalities that have beenused include low molecular weightheparin, antithrombin III replacement,streptokinase, urokinase, warfarin,and surgical thromboectomy [4,14].The preferred modality will dependupon the associated findings in theindividual case and also upon theexperience of the treating centre[19]. Low molecular weight heparinis being increasingly used as it hasmany advantages like subcutaneousadministration, infrequent monitoring,good safety profile, longer plasmahalf life [12,15,19,20,29]. We usedunfractionated heparin as the initialanticoagulant in our case followedby warfarin after 3 weeks whenimprovement was seen clinically andradiologically. Warfarin was stoppedafter 6 months after completeresolution of the CVST. This is inaccordance to the guidelines ofthe American College of ChestPhysicians [19].Neurological outcome aftertreatment varies [8,17,21,24]. Earlydiagnosis results in a gratifyingoutcome [4,5,19,25,37]. Indicatorsof good cognitive outcome wereearly diagnosis, early initiation ofanti coagulant therapy, older ageof the patient, absence of brainparenchymal lesion and involvementof the lateral or sigmoid sinuses[25]. Patients with younger age,extensive thrombosis, seizures oraltered sensorium at admissionwere associated with adverseoutcome like epilepsy, neurologicaldeficits, cognitive and behaviouralabnormalities which was seenin about half of the patients[17,18,19,20,26,37]. Coma atpresentation is usually associatedwith death [3,20,25]. Early diagnosisand treatment in our case resultedin complete clinical and radiologicalrecovery.ConclusionDiagnosis of CVST should beconsidered in any child with NS whopresents with symptoms suggestiveof increased intracranial pressure orneurological symptoms and signs.CT and MRI of the brain may bediagnostic and should be the initialmodality of choice. However if theseare inconclusive, MRV should bedone.References1. Llach F. Hypercoagulability,renal vein thrombosis, and otherthrombotic complications of nephroticsyndrome. Kidney Int 1985;28(3):429-439.2. Cameron JS. Coagulation andthromboembolic complications in thenephrotic syndrome. Adv NephrolNecker Hosp 1984; 13:75-114.3. Nishi H, Abe A, Kita A, TokiT, Noda N, Tsuchihashi D, et al.Cerebral venous thrombosis in adultnephrotic syndrome due to systemicamyloidosis. Clin Nephrol 2006;65(1):61-64.4. Tullu MS, Deshmukh CT, Save SU,Bhoite BK, Bharucha BA. 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CASE REPORTTurk J Pediatr 1989; 31(1):1-18.23. Burns A, Wilson E, HarberM, Brunton C, Sweny P. Cerebralvenous sinus thrombosis in minimalchange nephrotic syndrome. NephrolDial Transplant 1995; 10 (1):30-34.24. Grunt S, Wingeier K, Wehrli E,Boltshauser E, Capone A, Fluss J, etal. Cerebral sinus venous thrombosisin Swiss children. Dev Med ChildNeurol 2010; 52: 1145-1150.25. Sebire G, Tabarki B, SaundersDE, Leroy I, Liesner R, Saint-MartinC, et al. Cerebral venous sinusthrombosis in children: risk factors,presentation, diagnosis and outcome.Brain 2005; 128 (3): 477-489.26. Barron TF, Gusnard DA,Zimmerman RA, Clancy RR .Cerebral venous thrombosis inneonates and children. PediatrNeurol 1992; 8(2):112-116.27. Kosinski CM, Mull M, SchwarzM, Koch B, Biniek R, Schläfer J,etal. Do normal D-dimer levels reliablyexclude cerebral sinus thrombosis?Stroke 2004; 35:2820-2825.28. Vatankhah B, Fürst A,Schlachetzki F. Do normal D-dimerlevels reliably exclude cerebral sinusthrombosis? A solution of problems?Stroke 2005; 36:2528-2529.29. Hussain N, Chieng SK, RickettA, Gosalakkal J. Cerebral venousthrombosis in child with nephroticsyndrome: A case report. J PediatrNeurol 2007; 5(4):327-330.30. Reul J, Weber U, Kotlarek F,Isensee C, Thron A. Cerebral veinand sinus thrombosis-an importantcause of benign intracranial pressureincrease in childhood. Klin Padiatr1997; 209(3):116-120.31. Wasay M, Azeemuddin M.Neuroimaging of cerebral venousthrombosis. J Neuroimaging 2005;15(2):118-12832. Rizzo L, Crasto SG, Rudà R,Gallo G, Tola E, Garabello D, etal. Cerebral venous thrombosis:role of CT, MRI and MRA in theemergency setting. Radiol Med 2010;115(2):313-325.33. Davies RP, Slavotinek JP.Incidence of the empty delta signin computed tomography in thepaediatric age group. AustralasRadiol 1994; 38: 17-19.34. Johnson MC, Parkerson N,Ward S, de Alarcon PA. Pediatricsinovenous thrombosis. J PediatrHematol Oncol 2003; 25 (4):312-315.35. Ramos M,Romero RR, de laPeña PPG, Uranga JR, MonsalveCM. Noninvasive diagnosis ofcerebral venous thrombosis.Radiologia. 2006;48(2):79-86.36. Bousser MG, Chiras J, BoriesJ, Castaigne P. Cerebral venousthrombosis--a review of 38 cases.Stroke 1985; 16; 199-213.37. Barnes C, Newall F, FurmedgeJ, Mackay M, Monagle P. Cerebralsinus venous thrombosis in children.J Paediatr Child Health 2004; 40: 53-55.38. Lafitte F, Boukobza M, GuichardJP, Hoeffel C, Reizine D, Ille O,et al. MRI and MRA for diagnosisand follow-up of cerebral venousthrombosis (CVT). Clin Radiol 1997;52(9):672-679.MIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 7MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 7, ISSUE 10 43

TECHNOLOGY AND FAMILY MEDICINEAssessment of Internet Use and its Effects amongst GeneralPractitionersSyed Murtuza Hussain BakshiCorrespondence:Syed Murtuza Hussain BakshiVice Principal and Associate ProfessorDeccan School of ManagementDepartment of hospital management,Owaisi Hospital and Research Center,Hyderabad, 500058Email: murtuza_in21@yahoo.com, murtuzain21@gmail.comAbstractSeveral studies have exploredthe notion that patients use theinternet for health information.In contrast the physician’s perspectiveon the evolving internetenvironment is lacking. Thepurpose of this study is to assessand correlate the extent of internetuse among general practitionersand examine its effects on clinicalpractice. The study is explorativein nature and a Cross sectionalsurvey was conducted in the nonmetro twin cities of Hyderabadand Secunderabad using questionnairesdistributed randomlyto general practitioners. Multiplechoices, dichotomous and contingencyquestions related tothe trends of internet use and itseffects on clinical practice wereframed. The responses wereextracted and analyzed. The mainoutcome measures are self reportedrates of internet use, perceivedeffects, and the role of medicalweb sites in clinical practice. Percentageswere used to summarizethe categorical responses. A totalof 100 survey respondents weretaken all being medical practitioners.This explorative study revealedthat more patients arebecoming internet savvy which iseven influencing their informationseeking behavior on the medicalinformation that is available. Whilethe general practitioners have accessto internet they have no sayabout the quality of information onthe website; the general practitionersusually avoid patients recommendingviewing the website andextracting the information.Key words: Internet, InformationTechnology, GeneralPractitioners..IntroductionThe Internet has significantlychanged information managementin developed countries throughcreating pressures to improvecommunication systems and developmore user friendly environments forinformation sharing. Now the Internetis penetrating developing countries,and it is changing informationpractices in various sectors. TheInternet is changing traditional waysof conducting information businessby establishing new sources ofinformation and new methods ofcommunication on a global basis.The Internet has an impact ondeveloping countries, including majorissues associated with electronicinformation access and delivery. Ifyou focus on the two most populouscountries in the world, China andIndia, the internet has been widelyaccepted and used in almost everysector of the industry (T. KantiSrikantaiah & Dong Xiaoying, 1981).India is the 2nd largest in terms ofsize of population 1,173,108,018and 4th in terms of internet users81,000,000 with populationpenetration of internet at 6.9 % andexpected growth of 1,520.0 % and interms of world users we account foronly 4.1 % (Internet users worldwidestatistics report 2011).The Internetrepresents a technological revolutionthat is transforming our society. Inthe healthcare industry, physicianshave been typified as slow adoptersof information technology. However,young physicians, having beenraised in a computer-prevalentsociety, may be more likely toembrace technology (Parekh et.al,2004).Increasingly numbers of individualsaround the world are turning tothe Internet for health-relatedknowledge. An increasing numberof health-related Web sites are nowbecoming available providing up-todateanswers to medical questions.In response to this information-44 MIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 7MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 7, ISSUE 10

TECHNOLOGY AND FAMILY MEDICINEseeking activity, physicians haveexpressed concern regarding accessto misinformation and patients’interpretation of available onlinecontent. Many doctors believe thatonly qualified medical professionalsmay adequately assess and interpretexternal sources of information.Defensive attitudes may arise fromthe Internet having a “levelingeffect” on access to informationand, subsequently, on the patientphysicianrelationship. Peopleare likely to redefine their desiresand intentions over time becausethey frequently are uncertain.Paradoxically, a patient’s interestin knowledge may not alwaysaccompany an interest in the medicaldecision-making process (Ben SGerber & Arnold R Eiser, 2001).According to studies of patientphysicianrelationships, althoughpatients typically express a highdegree of interest in learning abouttheir illnesses and treatment, theirpreference for actual participation intreatment decision-making is highlyvariable (J P Kassirer, 2000).The internet is increasingly beingused for healthcare delivery.Health promotion and educationinterventions have been successfullydelivered online (Sharline Martin,et.al, 2002).Healthcare users are morewilling to adopt the internetfor its many potential benefits, forexample, increased efficiencies,lower cost, easier access to mediarichinformation and knowledge andfaster decision making. Present-dayhealthcare consumers, for example,demand easy access to multi-mediainformation and in-depth knowledgein order to make informed decisions.Similarly, healthcare providersand managers are interested inreducing costs while preserving andmaintaining high quality healthcare(D. Keith McInnes, et.al, 2006).The Internet will have a profoundeffect on the practice and businessof medicine. Physicians, eagerto provide high-quality care andforced by competition to offeronline services, will introduce e-mail and patient-friendly Web sitesto improve administrative servicesand manage common medicalconditions. Patients will identifymore health information onlineand will take more responsibilityfor their care. The doctor/patientrelationship will be altered: Someaspects of electronic communicationwill enhance the bond, and otherswill threaten it. Patients will haveaccess to vast information sourcesof variable validity. Many physicianorganizations are preparing for theelectronic transformation, but mostphysicians are unprepared, andmany are resistant (Akerkar SM et.al,2005).MethodsThe present study is explorative innature. A Cross sectional surveywas conducted in the non metrotwin cities of Hyderabad andSecunderabad during the monthof January 2011 to April 2011by using questionnaires whichwere distributed to 100 generalpractitioners. The sample consistsof general practitioners with basicM.B.B.S qualification and havingat least 1 year of experience. Theentire greater Hyderabad city wasdivided into east, west, north andsouth regions and from each regionequal sample respondents wereselected. The questionnaire consistsof multiple choices, dichotomous andcontingency questions related to thetrends of internet, and its effects onclinical practice were extracted andresponses were analyzed. The mainoutcome measures are self reportedrates of internet use, perceivedeffects, and the role of medical websites in clinical practice. It is largelydescriptive and categorized as anon-experimental qualitative study.The data is analyzed by MatrixAnalysis which is in the form of flowcharts, diagrams and pictoriallyrepresentation as well as writtendescriptions.DiscussionThe Demography of the study is shown left:Figure 1: Total Number of GeneralPractitioners who were part of theResearch Sex WiseMIDDLE EAST MIDDLE JOURNAL EAST OF JOURNAL FAMILY MEDICINE OF FAMILY VOLUME MEDICINE 10 ISSUE • VOLUME 7 7, ISSUE 10 45

TECHNOLOGY AND FAMILY MEDICINEThe female general participants were basically concentrating on gynecology and Obstetrics and all the female generalPractitioners had been practicing for more than 3 years whereas the male General Practitioners were treating acuteand chronic illnesses patients and all the male general Practitioners had been carrying out their practice for more than1 year.Figure 2: The Age Group of General PractitionersThe age group showed 16 respondents were less than 30 years old, about 37 respondents were in between 31 to 40years age group, about 31 respondents were in age group of 41 to 50 and about 16 were in the age group above 51. Ithas been shown that the younger participants are more familiar with internet browsing and its features.According to Figure 3 a total of 100 General practitioners were surveyed and 95% (95 in number) of them had internetaccess and 5% didn’t have access to internet (5 in number). Those who didn’t have access to internet were of ageabove 70 and felt accessing internet is difficult.Figure 3: Numbers of General Practitioners with Access to InternetFigure 4 reveals that out of the 95 General practitioners who confirmed they have access to internet 13% (12in number) confirmed they had access to internet through Dial up telephone network about 29% (28 in number)confirmed that they have internet access through cable or broad band while 23% (22 in number) confirmed that theyhave net access through Leased lines. About 3% (2 in number) confirmed they have internet access via integratedservice digital network and lastly 33% (31 in number) confirmed they have access to internet via wireless connectivity.46 MIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 7MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 7, ISSUE 10

TECHNOLOGY AND FAMILY MEDICINEFigure 4: Type of Internet Connectivity the General Practitioners have while Accessing The InternetFigure 5 illustrates that the general practitioners who were surveyed had revealed the following results: about 23%(22 in number) of them have access to internet just from home and about 22% (21 in number) of them have accessto internet at hospital or clinic and about 55% (52 in number) of them have access to the internet both at home and inthe work place.Figure 5: Place where General Practitioners Have Access to the InternetFigure 6 focuses on do general practitioners use the internet for professional up grading in terms of clinical and newmedical knowledge and the response was about 75% (71 in number) of the respondents said they access the internetfor upgrading their domain and professional knowledge and about 25% (24 in number) of them do not use the internetfor upgrading professional knowledge.Figure 6: Do GeneralPractitioners usethe Internet forProfessional upGradingMIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 7MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 7, ISSUE 10 47

TECHNOLOGY AND FAMILY MEDICINEFigure 7 reveals that the general practitioners were asked questions regarding do they have their own website andthe response was only 7% (6 in number) have a website about their practice while 93% (89 in numbers) do not have awebsite (but out of 89) 95% were willing to have their own website and about 5% did not prefer a web presence. Theresults were surprising as the general practitioners never focused on their own web page and were willing to have theirinternet presence.Figure 7: Do GeneralPractitioners have their ownWebsite or Web PresenceFigure 8 focuses on patients bringing web based information in the form of hard copy or soft copy when it is relatedto a disease or condition. The survey revealed that about 79% (75 in number) says that patients never brought ininformation from internet and 21% (20 in number) says that patients bring hard or soft copy with them.Figure 8: Do Patients BringSoft Copy or Hard CopyMaterial in reference to theirDisease or ConditionFigure 9 was a behavioral response question on General practitioners who were surveyed. When they were asked doyou encourage patients to check and browse websites and bring information. The response was about 53% of them(50 in number) confirmed that they do not encourage the patients as the authenticity of the information on internetcannot be assured, while 47% (45 in number) of them confirmed that for general information seeking of the patient canassist.Figure 9: Do GeneralPractitioners recommendtheir Patients to Browse theInternet to know more abouttheir Disease or Condition48 MIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 7MIDDLE MIDDLE EAST JOURNAL EAST JOURNAL OF FAMILY OF FAMILY MEDICINE MEDICINE • VOLUME 97, ISSUE ISSUE 9 10

TECHNOLOGY AND FAMILY MEDICINEFigure 10 was again a behavioral response question on General practitioners who were surveyed. When the generalpractitioners were asked about obtaining a second opinion for patients the response was about 53% of them (50 innumber) answered no, while 47% (45 in number) answered yes.Figure 10: The General Practitioners Favor SecondOpinions for Patients, via the Internet, on SpecificConditions, as a Valuable Resource For PatientsFigure 11 was again a behavioral response question on General practitioners who were surveyed. When generalpractitioners were asked has at any time a patient asked you about a website or a web page through which you canseek information about 73% of them (70 in number) said no and 27% (25 in number) said yes.Figure 11: Had a Patient ever asked for the name of a WebSite for More Information on their ConditionFigure 12 was again a behavioral response question of General practitioners who were surveyed. When generalpractitioners were asked about quality of information on medical websites, about 13% (12 in number) said quality ofinformation on websites is good and about 16% (15 in number) said quality of information on website is not good andabout 72% (68 in number) said they can’t say. On further investigation it was found that ‘can’t say’ was the answerbecause the authenticity and the time line of the website may be deceptiveFigure 12:Questionsregardingthe Quality ofInformation onMedical WebsitesMIDDLE EAST JOURNAL OF FAMILY MEDICINE VOLUME 10 ISSUE 7MIDDLE EAST JOURNAL OF FAMILY MEDICINE • VOLUME 7, ISSUE 10 49

TECHNOLOGY AND FAMILY MEDICINEConclusionsThe twin cities of Hyderabad andSecunderabad are expanding in alldirections with increase in population.As the population is expanding itbrings positive and negative effects.The positive effects being growth andexpansion for general practitionerswhile the negative effects beinga new breed of internet savvypopulation. The interview of generalpractitioners reveals that the internetis influencing the information seekingbehavior of the common man. As thepatients are becoming more healthconscious, the internet is going toplay an important role with bothpositive and negative effects, as theinternet does not promise quality ofinformation. The medical terms andprocedures are difficult to understandby a common person and in relationto quality of information that isavailable, it does not guaranteeauthenticity. The general practitionersconsidered internet presence to beimportant but a lot of they do nothave their own web site but arewilling to have one.List of abbreviationsIT - Information TechnologyIS - Information SystemsISDN - Integrated service digitalnetworkAcknowledgementsI wish to acknowledge the entirepersonage who has helped me outin the study specially the ones, whohave arranged the interview with thetop management, the healthcareleaders who willingly expressedtheir opinions and facts about the ITapplications.References1. Akerkar SM, Kanitkar M, BichileLS.(2005), “Use of the Internet asa resource of health information bypatients: a clinic-based study in theIndian population”, postgraduateMedical journal. 2005 Apr-Jun;51(2):116-8.2. Ben S Gerber, MD and ArnoldR Eiser, MD (2001), The Patient-Physician Relationship in the InternetAge: Future Prospects and theResearch Agenda, the Journal ofMedical Internet Research, 3(2): e15.3. D. Keith McInnes, DeborahC. Saltman, ,Michael R. Kidd,M.D.(2006),” General Practitioners’Use Of Computers For PrescribingAnd Electronic Health Records”Medical Journal of Australia,185(2):188-914. Internet users worldwide statisticsreport viewed on 05-july-2011, http://www.internetworldstats.com/top20.htm5. J P Kassirer (2000) “patients ,physicians and the internet “, HealthAffairs, Vol 19, Issue 6, 115-1236. Parekh, Selene G ,Nazarian,David ,Lim, Charles K MD,(2004),“Adoption of Information Technologyby Resident Physicians” Volume 421- Issue - pp 107-1117. Sharline Martin, David C. Yen,Joseph K. Tan, 2002,” E-health:impacts of internet technologieson various healthcare and servicessectors” Volume 4, Numbers 1-2, 71- 868. T. Kanti Srikantaiah, DongXiaoying, (1998) “The Internet andits impact on developing countries:examples from China and India”,Asian Libraries, Vol. 7 Iss: 9, pp.199- 20950 MIDDLE MIDDLE EAST JOURNAL EAST JOURNAL OF FAMILY OF FAMILY MEDICINE MEDICINE • VOLUME 107, ISSUE 7 10

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OFFICE BASED FAMILY MEDICINEthe patients’ perception of their abilityto perform daily living activities.This is one of the perceptions whichwe tried to induct to the learnersin our educational intervention.Bakhshandeh et al. (2004) concludedthat breathing training facilitates dailyliving activities of asthmatic patientsby enhancing their physical capacitywhich itself promotes their QOL (12).Results also showed that ourintervention improved thepsychological dimension of QOL.Since participants obtainedknowledge about the disease’snature and management, their selfesteemand sense of independencymight be enhanced which itself canhelp them to “feel better”. Molassiotis(1997) noted that feeling of selfcontrol,self-assurance, and having apositive attitude toward the diseaseare important elements that affectpatients’ quality of life (13).Results showed significantimprovement in the general healthdimension of patients in interventiongroup. Mezarous (2003) stated thateducating patients with asthmahelps a 40% improvement in scoresof QOL in all dimensions (14).Moudgila et al (2000) reported theeffect of education on improvingall dimensions of QOL (15). In theresearch by Krishna et al. (2003),some information was deliveredto the control group while in theintervention group, information wasdelivered through a multimediaanimation CD as well as face to faceeducation. The results indicated thatthe method of education appliedfor the intervention group led to anincrease in knowledge about asthmaand reduction of the number ofemergency visits by physicians (16).There was no significant correlationbetween QOL and demographiccharacteristics. Similarly, Naeemiet al (2007) found no significantcorrelation between demographicvariables and QOL and anxiety (7).Only a significant direct associationwas found between educational leveland QOL in which the increase ineducational level led to an increasein QOL. Therefore, promotingeducational levels, knowledge andinformation might help improve theQOL in these patients.ConclusionFindings showed that the quality oflife in asthmatic patients receivingcomputer learning can promotetheir quality of life in physical,psychological and general healthdomains but has no effect on thesocio-economic aspect. Therefore,the research hypothesis “computerlearning improves the quality of lifeof asthmatic patients” is accepted.These findings emphasize thenecessity of effective education inmanaging asthma and improvingquality of life in asthma patients.Further investigations arerecommended for assessing theeffect of computer learning on otheraspects of asthma patients and onother chronic diseases.ACKNOWLEDGMENTSThe present study was approved andfinancially granted by the StudentResearch Center of Tehran Universityof Medical Sciences in (grantnumber: 132/754) 31 Oct 2009. Wethank hereby all participants whocooperated with us in this study.References1) Pedram Razi SH, BassampourSH, Kazemnejad A. Quality of Lifein Asthmatic Patients. Hayat 2007;13(1): 29-34 (Persian)2) Heidarnia M A, Entezari A,Mehrabi Y, Pourpak Z, Moein M.Prevalence of asthma symptom inIran: a meta-analysis. Medical journalof Shahid Beheshti university ofmedical sciences 2007; 31)3(: 217-225(Persian)3) Fazlolahi M. National AsthmaGuideline Prevention? Diagnosisand Management Protocol . Ministryof Health and Medical EducationUndersecretary for Health Center forNoncommunicable Disease ControlNational Committee on Asthma &Allergy Tehran. 2009; 2 - 4 (Persian)4) Lemanske RF, Nayak A, McAlaryM, Everhard F, Fowler-Taylor A, andGupta N. Omalizumab ImprovesAsthma-Related Quality of Lifecontent/full/110/5/e555) Clark NM, and Partridge MR.Strengthening Asthma Education toEnhance Disease Control. CHEST2002; 121 (5): 1661-69.6) Juniper EF, Wisniewski ME,Cox FM, Emmett AH, Nielsen KE,O’Byrne PM. Relationship betweenquality of life and clinical status inasthma: a factor analysis. EuropeanRespiration Journal 2004; 23: 287-291.7) Naeemi-Hosseini F, Majidi F,Ghayyumi MAA. Comparative studyof two educational methods onanxiety and quality of life in asthmapatients in Shiraz. Southern Iran.Iranian Red Crescent medical journal2007; 9(3):150-1538) Graff and Richard W, MadsenSantosh K, Benjamin D, FranciscoE, Andrew B, Peter K, et al. Internet-Enabled Interactive MultimediaAsthma Education Program: ARandomized Trial. Pediatrics2003;111; 503-510.9) Perneger TV, Sudre P, Muntner P,Uldry C, Courteheuse C, Naef A, andet al. Effect of Patient Education onSelf-Management Skills and HealthStatus in Patients with Asthma: ARandomized Trial. The AmericanJournal of Medicine 2002; 113: 7-14.10) Gibson PG, Powell H, CoughlanJ, Wilson AJ, Abramson M, HaywoodP, Bauman A, Hensley MJ, WaltersEH. Self-management education andregular practitioner review for adultswith asthma (Cochrane Review). Inthe Cochrane Library. Issue 2, 2003.Oxford Update Software. Availablefrom: http://www.update-software.com/abstracts/ab001117.htm11) Ignacio-Garc?´a J-M, Pinto-Tenorio M, Chocro´n-Giraldez MJ,Cabello-Rueda F, Gil AIL, Ignacio-Garc?´a J-M, de Ramo´n-GarridoE. Benefits at 3 yrs of an asthmaeducation programme coupled withregular reinforcement. EuropeanRespiration Journal 2002; 20: 1095-1101.12) Bakhshandeh SH, Yarndy A,Ahmadi Z. The assessment ofrespiration exercising education onquality of life in asthmatic patients.Journal of Iranian Nursing 2004;in Children with Allergic Asthma.17(38):16-24. (Persian)© medi+WORLD International 2012Pediatrics. [Internet]. (2002) [citedJanuary 8, 2011]; 110 (5). Available(References continued page 47)from: http://www.pediatrics.org/cgi/WORLD FAMILY MEDICINE / MIDDLE EAST JOURNAL OF FAMILY MEDICINE52 MIDDLE MIDDLE EAST JOURNAL EAST JOURNAL OF FAMILY OF FAMILY MEDICINE MEDICINE • VOLUME 97, ISSUE ISSUE 6 10