Immunity to chickenpox among school adolescents in Lebanon and options for vaccination.

Varicella infections cause substantial morbidity and mortality in adolescents and adults. The primary infection, chickenpox, results in lifelong immunity to chickenpox. A seroprevalence study carried on adolescents 15-18 years of age attending schools in Lebanon showed 96.6% immunity to varicella. The positive predictive value for immunity to chickenpox based on history alone was 97.4%, whereas the negative predictive value was 4.5%. Coming from a bigger family was a statistically significant predictor of immunity to chickenpox. In a developing country like Lebanon the merits and limitations of implementing universal varicella vaccination is discussed in relation to seroprevalence and socioeconomic factors.

The current status of Balint groups in US family practice residencies: A 10-year follow-up study, 1990-2000.

BACKGROUND AND OBJECTIVES: In 1990, the first and, to date, only objective study of Balint groups in US family practice residencies was conducted to measure their prevalence, composition, leadership, and function. The study reported here collected similar information about Balint groups. METHODS: Surveys were sent to all 464 US family practice residency program directors, with a 1-month follow-up to nonrespondents. The survey included questions about the existence, leadership, meeting frequency, and objectives of Balint training. RESULTS: A total of 298 (64%) residencies responded. Almost half (48%) of US responding residences reported conducting Balint groups, and 40% of those residencies have more than one group. The frequency of Balint group meetings has shifted in the past 10 years. In 1990, 55% of groups met weekly; in 2000, only 15% of groups met weekly. Sixty-five percent of residencies require Balint participation. One third of Balint groups are conducted without a coleader and the number of physicians leading groups is 22%, a decrease of 10% from 10 years ago. Forty-four percent of groups are led by psychologists, an increase of 19% from 10 years ago. Respondents indicated uncertainly about whether their groups were true Balint groups or simply resident support groups. CONCLUSIONS: About half of US family practice residencies operate groups described as Balint groups. They meet less frequently then 10 years ago and are less likely to have a physician involved in group leadership. Some of the groups may actually be support groups rather than Balint groups.

Common prescriptions in ambulatory care in Lebanon.

OBJECTIVE: To describe prescribing practices of family physicians in a staff model health maintenance organization at a university health center in Lebanon and estimate costs of such practices for common diseases. METHODS: All prescriptions issued between July 1, 1997, and June 30, 1998, were prospectively collected. The diagnoses made by physicians at each encounter were recorded, and the total price of medications prescribed was calculated. The core prescribing indicators as defined by the World Health Organization and the mean annual prescription price per person for the 25 most common diagnoses were calculated. RESULTS: Prescribing occurred in 27.1% of encounters, with a mean of 1.6 medications per encounter; 17.5% of all prescriptions included an antibiotic. Generic drugs and essential drugs each accounted for 2.9% of all medications. Approximately 50% of the consultations for either respiratory or ear infections resulted in a prescription. Cervical spine syndromes and lipid metabolism disorders cost most among recorded diagnoses, with mean annual prescription prices per person of US $2016 and $1128, respectively. CONCLUSIONS: The low rate of generic and essential drug prescribing, as well as the frequency of prescribing in respiratory infections, highlight the need for initiatives to help rationalize prescribing in primary care in Lebanon. Together with the diagnostic categories incurring high cost per person, these issues can be part of physician education or treatment guideline development. These measures may aid the government in its subsidy of primary health care centers.

List of essential drugs for primary care in Lebanon.

In 1966, Lebanon had around 19,000 drug formulations registered in the Ministry of Public Health. The government decreased that number to 5400 in 1992 through numerous interventions. In 1995 and in an effort to rationalize drug prescribing, the Lebanese government organized an ad hoc committee of medical and pharmaceutical experts to review the 1992 list and create a list of essential drugs for primary care (LEDPC). This report describes the process and the studies used to update the 1992 list by the ad hoc committee.

Cancer screening for the primary care physician.

Cancer screening guidelines are developed by numerous agencies. These guidelines are often conflicting leaving the primary care physician in a difficult position. He (she) is requested to choose the best test for his or her patients taking into consideration the principles of screening, the test cost and most importantly the patient's emotional and physical well-being. Screening for some cancers, like lung cancer, has been considered of no benefit. Other cancers, like breast, colon, cervix and prostate, have been the subject of numerous recommendations: For breast cancer, clinical examination and mammography are recommended every 1-2 years for women between 50 to 70 years. For cervical cancer, PAP smear is suggested every 1-3 years and for colorectal cancer, a yearly fecal occult blood, sigmoidoscopy or colonoscopy every 5-10 years. Annual serum prostate specific antigen (PSA) and digital rectal examination screening for prostate cancer are still controversial.

Automation of practice management in a Lebanese University Health Clinic.

Interest in technology and the recognition that clinical practice analysis data is crucial for planning have stimulated the development of information management solutions at all levels in developing countries. The spectrum of such endeavors remains restrained due to the limitations in human resources skills. This paper describes an inexpensive operation for automating practice analysis in a Lebanese University Health Clinic. The system was developed in piecemeal fashion to accommodate the needs of the staff and their computer expertise. It demonstrates the impact of such automation on patient care, including missing medical records, appointment scheduling, referral rates, and repeat prescriptions.

Survey of a Bekaa community health needs.

Rural underserved areas can benefit from private and non governmental organizations in improving health delivery. Many such organizations operate in the underserved Bekaa area in Lebanon. This study aimed to assess the nature, scope, utilization and satisfaction with health services available to the population living in the vicinity of the American University of Beirut Agricultural Research and Education Center in Bekaa. A random sample from the residents of the area (475 individuals) and all physicians and representatives of health delivery institutions serving this population were interviewed. Individuals interviewed reported 3.7 health related visits/person/year, 65% vaccination rate and 34.1% labeled available services as poor. Interviewed physicians and health institution administrators identified the study area priority needs as nurses, emergency transport units and primary care centers. Systematic evaluation and priority setting of the health needs of this population are necessary and the establishment of health centers should be strongly considered.

Attitudes of the Lebanese public regarding disclosure of serious illness.

OBJECTIVES: To measure the preference regarding disclosure of a serious diagnosis, and its determinants, of the Lebanese public. DESIGN AND SETTING: Non-random sample survey of 400 persons interviewed in health care facilities in Beirut in 1995. RESULTS: Forty-two per cent of respondents generally preferred truth not to be disclosed directly to patients. Preference for disclosure was associated with younger age, better education and tendency to rapport-building with physicians. There were no meaningful associations between place of residence (urban/rural), level of religious practice, or religious affiliation, and preference for disclosure. CONCLUSIONS: Under one plausible interpretation, this survey suggests that the expectation for concealment will decrease as the advantage of knowledge in better coping with disease is understood by an increasingly better educated public, and that the Lebanese public will increasingly come to expect direct and full disclosure of serious diagnoses.

Recommendations for the school health physical examination in Lebanon.

School health developed gradually over the years; starting with efforts to keep contagion out of schools to global programs of comprehensive services. One of its components, school medicine, covers screening examinations, record maintenance, emergency care, immunization monitoring and health counseling. This paper proposes the essential health activities to be performed during a screening school examination in Lebanon. The recommendations are based on a combination of international literature review of evidence and the existence of Lebanese epidemiological reports identifying specific problems. Vaccination record review, tuberculin testing, vision, hearing, dental and skin disorders screening procedures are proposed as essential activities of the school physical examination.

Quality of diabetes care in a university health center in Lebanon.

OBJECTIVE: To assess the quality of care provided to diabetic patients by family physicians in a university health clinic, using measures of glycemic and cardiovascular risk control as well as documentation of and adherence to World Health Organization (WHO) guidelines for diabetes primary care. DESIGN: Chart review of the previous year's medical notes for all identified diabetics in the practice over 2.5 years. RESULTS: Two-hundred and four diabetic patients were identified, with an estimated prevalence of 4.1%. The majority was type II diabetics, on oral hypoglycemic agents. Glycosylated hemoglobin was documented in 39.7% of patients, fasting plasma glucose in 99%, cholesterol in 93.1%, triglycerides in 91.2% and blood pressure in 85.8%; optimal control of these indicators was noted in 28.4%, 17.8%, 34%, 29.6% and 55.4% respectively. Fifty percent of the diabetics were referred for retinal checks. Physicians documented the presence of nephropathy in 46.8% and neuropathy in 59.6%; however, they documented patient instruction on foot care, diet, exercise and diabetes self-care poorly. CONCLUSION: There is a need for interventions to improve management and documentation in diabetes care in order to achieve early detection and prevention of complications. Developing a protocol for the clinic based on standard guidelines, and the use of flow sheets may be helpful in improving these intermediate indicators of quality of care.

Purified protein derivative (PPD) conversion rate among Lebanese children in Beirut.

To determine the purified protein derivative conversion rate among Lebanese children we followed a cohort of 1236 students, ages 5-14 years, enrolled in 25 public schools in Beirut. All cases received an intradermal injection of purified protein derivative in 1992 and one year later. Test administration was done using standard techniques and results were read by the same physician 48-72 hours later. Demographic information was also obtained on the enrolled students. The majority of children identified belonged to a low socioeconomic class. The one year conversion rate was 1.4%. This underscores the urgent need for preventive programs.

Cancer truth disclosure by Lebanese doctors.

Truthful disclosure of cancer diagnosis is still uncommon in some cultures. In Lebanon, legislation is permissive of non-disclosure. Physicians choose the recourse most agreeable to them. This study's goal was to determine the proportion of Lebanese physicians who choose truthful diagnosis disclosure to cancer patients and to identify factors affecting their choice. A survey of a random sample of Lebanese physicians was conducted to determine the proportion of those who prefer truthful diagnosis disclosure to cancer patients and to identify factors affecting that choice. The survey involved 268 participants representing 10% of all physicians practicing in specialties with potential contact with cancer cases in the Greater Beirut area. It was completed by 212 (79%), of whom 47% would usually tell the patient about cancer. Disclosure preference was not associated with gender, location of medical training, rate of patient contact or teaching activities. It was associated with longer clinical practice and with specialties outside primary care. Most participants were open to changing their policies and considered the patient's desire to know, compliance with treatment and the patient's profession as a physician as most influencing in their choice of disclosure. Exploring the Lebanese public predicament regarding disclosure seems necessary.

Postpartum fever.

Postpartum fever is a common obstetric complication. It often results from endometritis but can also be caused by urinary tract infection, would infection or phlebitis. The rate of endometritis is higher among patients who have a cesarean delivery, compared with those who have a vaginal delivery. Postpartum febrile episodes in which temperatures are less than 38.4 degrees C (101.1 degrees F) often resolve without intervention, especially when they occur in the first 24 hours after delivery. Treatment options for patients whose febrile episodes do not resolve spontaneously or are higher than 38.7 degrees C (101.6 degrees F) during the first 24 hours or higher than 38.0 degrees C (100.4 degrees F) on any two of the first 10 days postpartum include administration of antibiotics with specific activity against anaerobic bacteria. Additional diagnostic modalities, such as computed tomography, ultrasonography, heparin administration and surgical exploration, should be employed when the patient fails to respond to antibiotic therapy.

Implementation and evaluation of a computer-based preventive services system.

BACKGROUND AND OBJECTIVES: Insufficient attention has been paid to the role that modern information systems can play in improving the delivery of and education about preventive services in family medicine training and practice sites. From September 1990-September 1993, the Department of Family Medicine at the Medical University of South Carolina conducted a demonstration project designed to develop, implement, and evaluate a comprehensive, computer-based preventive services delivery and educational system, based on the recommendations in the US Preventive Services Task Force (USPSTF) Report. METHODS: A computer-based patient record (CPR) system was implemented. The system had sophisticated preventive services tracking and reminder, physician, and patient education features. Twenty-nine basic USPSTF recommendations were incorporated in the system. An extensive physician education series was also implemented. A multi-method evaluation system, including patient exit surveys, physician interviews, and practice audits was used to evaluate and design improvements to the CPR and education systems. RESULTS: Although the system initially had no effect on patient perceptions about the frequency of preventive services delivery, there was reasonable concordance between patient desires and physician behavior for the discussion of preventive services (Kappa = .5 to .6). Physician acceptance of the system was good--in 1992, 30% of physicians used the preventive services reminders in most of their patient visits, and in 1993, 88% of physicians reported more frequent use. Practice audits from February 1992-July 1993 showed increased adherence with all seven counseling services, 10 of 15 screening services, and one of five immunization services. CONCLUSIONS: A CPR-based preventive services system coupled with an adaptable physician education about and delivery of preventive services. an ideal solution to improving the education about and delivery of preventive services.