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Risk Factors and Genotypes of Hepatitis C Virus Infection in Libyan Patients

	Libyan J Med, AOP: 080425

	Risk Factors and Genotypes of Hepatitis C Virus Infection in Libyan Patients
Original Article	Alashek WA¹ and Altagdi M²
	1 Community Medicine Department, Faculty of Medicine, Alfateh Medical University, Tripoli/ Libya. 2 Department of Infectious Diseases, Tripoli Medical Centre

ABSTRACT
Background: The prevalence and incidence of HCV infection varies geographically due to exposure to different risk factors. Identification of HCV genotype is important to defining the epidemiology of the disease. The objective of this study was to describe genotype distribution and its relation to risk factors among HCV infected patients attending virology clinic of the Department of Infectious Diseases at the Tripoli Medical Centre.Methods: The medical records of 891 Libyan chronic HCV infected patients registered and followed up from January 2003 to January 2007 were reviewed. Data gathered includes patient's age, gender, risk factors and family history of HCV infection. Statistical analysis was performed using t, x² and contingency coefficient tests.Results: The mean age was 40.22±13.09 years. Two thirds of patients were males. Normal alanine aminotransferase (ALT) at diagnosis was found in 62% of the patients. HCV RNA < 2 million copies at diagnosis was found among 54% of patients. HCV genotype 1 (G1) was the most frequent (30.9%), followed by G4 (29.2%). Genotype 2 affected 19.3% and G3 13.6%. No classification of HCV genotype was available for 2% of the patients. Many subtypes of HCV were detected with different frequencies (G1a and b, G2a, b, c and a/c, G3a and G4a and c/d). All genotypes of HCV were more common among males (P<0.001). Genotype 3 was the most frequent among male patients (88.6%). Regarding the risk factors, 33% of patients had a history of hospitalization and/or surgical procedures, and 22.7% had a history of blood transfusion. A past history of intravenous drug abuse (IVDA) was reported by 15% of the patients, and 15.9% reported a history of dental procedures. The relationship between the genotype of HCV and risk factors was statistically significant (P<0.001). No history of risky exposure was found among 10.8% of patients. Conclusion: Genotypes 1 and 4 were more predominant among HCV infected patients. Males were affected more than females and they presented themselves to the clinic at a younger age. The results of this study strongly suggest the need for implementing strict infection control measures in hospitals and dental clinics to reduce the nosocomial transmission of HCV, as well as measures to control the problem of intravenous drug users in the community.

INTRODUCTION
Hepatitis C Virus is the most frequent cause of chronic viral hepatitis in the world [1]. The prevalence and incidence of HCV infection varies geographically due to the evolution of risk factors [2]. Up to 80% of patients with acute viral hepatitis C develop chronic viral hepatitis [2]. In Libya, HCV infection has become a public health problem. A national sero-epidemiological survey showed that the prevalence of HCV antibodies in the general population was 1.2% [3].
HCV has marked genetic heterogeneity with nucleotide variability between different isolates [4,5]. Phylogenetic analysis indicates that there are at least 6 different genotypes of HCV and more than 90 subtypes [5,6]. HCV genotypes 1, 2 and 3 are distributed worldwide, whereas genotypes 4, 5 and 6 are found mainly in certain areas [6,7]. For example, genotype 4 is highly prevalent in Egypt and many central African countries [7-11]. Data on the genotype of HCV infections in Libya are scarce. One recent study from Benghazi showed that G4 was the most prevalent HCV genotype in the eastern part of the country [12].
Some studies showed that there is little difference in the severity of disease or in the outcome of patients infected with different genotypes [13]. However, the genotype of HCV does affect recommendations and counseling regarding interferon treatment [14-16]. Moreover, when using combination therapy, the recommended dose and duration of treatment depend on the genotype of the virus [17,18]. Some studies showed that patients with genotypes 2 and 3 are more likely to respond to interferon-based therapy [17,18]. On the other hand, genotyping of HCV infection is helpful in defining the epidemiology of the disease because it does not change during the course of infection [1,2].
Genotype distribution of HCV has not been described before in Tripoli. The objective of this study was to analyze the genotype distribution and its relation to risk factors among chronic HCV infected patients attending the virology clinic of the Department of Infectious Diseases at the Tripoli Medical Centre.
METHODS
This study was carried out at the Tripoli Medical Centre. The medical records of 1279 Libyan chronic HCV infected patients were reviewed. These patients had been registered and followed up at the virology clinic of the Department of Infectious Diseases, Tripoli Medical Centre, from January 2003 to January 2007. Genotyping was done only for 891 of these patients (69.7%).
Patient's age, gender and, in the initial screening, nationality were recorded. Non-Libyan patients were excluded from the study. Patients who had a history of hemodialysis were also excluded from the study. Data gathered included risk factors for HCV infection (history of blood transfusion with or without blood disease, intravenous drug abuse "IVDA", hospital admission with or without surgical intervention, dental intervention, unsafe sexual activity and/or promiscuity). Ethical approval from the Department of Infectious Diseases at the Tripoli Medical Centre was obtained.
Genotyping results of HCV were considered if they were performed by gene amplification by using the Cobas-Amplicor HCV test (Roche Diagnostics, Basel, Switzerland) [19].
Data were analyzed using SPSS version 11.5 to identify the demographic characteristics and risk factors associated with the different HCV genotypes.
The distribution of HCV genotypes, age, gender and risk factors of different groups were compared by using t, x² and contingency coefficient tests.

osocomial transmission of HCV.RESULTS
The patients’ ages ranged from 16 to 76 years with a mean of 40.22±13.09 years. The mean age of the males was 38.89±12.70 years and of the females 42.88±13.45 years. The difference was statistically significant (P<0.001).
Alanine aminotransferase (ALT) at diagnosis was normal in 62% of patients. HCV RNA < 2 million copies at diagnosis (low viral load) was found among 54% of patients. A positive family history of HCV infection was found among 3.2% of patients.
Table 2 shows that genotype 1 was the most frequent genotype, occurring in 30.9% of the

Table 1: The demographic and clinical characteristics of Libyan HCV infected patients attending the virology clinic at the Tripoli Medical Centre.

Demographic and clinical characteristics
1.	Mean age and SD in years	40.22±13.09
2.	Mean age and SD in years by gender	Males 38.89±12.70 Females 42.88±13.45 (P=0.000)
3.	Age range in years	(16-76)
4.	Normal ALT at diagnosis	62%
5.	HCV RNA < 2 million copies at diagnosis	54%
6.	Family history of HCV infection	3.2%

patients. Genotype 2 was found in 172 patients (19.3% of patients), while genotype 3 infected 166 (13.6% of patients), and genotype 4 was found in 260 (29.2% of patients). Genotypes 5 and 6 were not detected at all in those patients. No classification of HCV genotype was available for 2% of the patients.
Table 2: The distribution of HCV genotypes.

Genotype of HCV		No of patients	Percent
1.	Unclassified HCV	18	2
2.	Genotype 1	275	30.9
3.	Genotype 2	172	19.3
4.	Genotype 3	166	18.6
5.	Genotype 4	260	29.2

The four genotypes and several subtypes were observed with different frequencies (Table 3). One quarter of the patients had unclassified genotype 4. Subtypes G2b and G4c/d were uncommon. Some patients were infected by more than one subtype, e.g. 3% of patients had G2a/c and 0.9% had G4c/d.
Table (4) shows that two thirds of the patients were males. All HCV genotypes were more common among males and the difference from females was statistically significant (P<0.001). Genotype 3 was the most frequent among males (88.6%), followed by G1 (66.5%). Genotypes 2 and 3 were found among 59.9% and 56.9% of male patients, respectively. On the other hand, the most frequent HCV genotype among females was G4 (43.1%) and the least common was G3 (11.4%).
One third of the patients had a history of hospitalization and/or surgical procedures (Table 5). A history of blood transfusion was recorded among 22.7% of the patients. A history of dental procedures and IVDA was recorded amongst 15.9% and 15% of the patients, respectively. A minority of the patients (2.6%) had a history of sex with an HCV infected person and/or promiscuity. No history of any risky exposures was found among 10.8% of the patients. There was a significant relationship between the HCV genotype and risk factors for infection (P<0.001).
Table 3: The distribution of subtypes of different HCV genotypes.

Genotype/ subtype	No of patients	Percent
Unclassified HCV	18	2
G1a	72	8.1
G1b	107	12
G1 unclassified	96	10.8
G2a	22	2.5
G2b	7	0.8
G2c	18	2
G2a/c	27	3
G2 unclassified	98	11
G3a	19	2.1
G3 unclassified	147	16.4
G4a	25	2.8
G4c/d	8	0.9
G4 unclassified	227	25.5
Total	891	100

Genotypes 1 and 4 were detected more frequently among patients who had a history of blood transfusion, hospitalization, surgical procedures, sexual contact with an HCV infected person, or promiscuity. Genotype 2 was found in one third of those who had a history of dental procedures. Genotype 3 was detected among 60.4% of patients who had a history of IVDA. Genotypes G1 and G4 were predominant in patients who had a history of sex with an HCV infected person and/or promiscuity. Moreover, 35.7% of patients who had a history of hospitalization and/or surgical procedures were affected by G1 and 30.3% of them were affected by G4. Genotype 4 was detected in 39.6% of those who had no history of risky exposure.

Table 4: The distribution of HCV genotypes according to gender. For differences between males and females, X² = 50.367 and P<0.001.

Genotype of HCV	Males (%)	Females (%)	Total
Unclassified HCV	12 (66.7)	6 (33.3)	18
Genotype 1	183 (66.5)	92 (33.5)	275
Genotype 2	103 (59.9)	69 (40.1)	172
Genotype 3	147 (88.6)	19 (11.4)	166
Genotype 4	148 (56.9)	112 (43.1)	260
Total	593 (66.6)	298 (33.4)	891

Table 5: The distribution of HCV genotypes according to risk factors. For the relationship between the HCV genotype and risk factors for infection, the contingency coefficient = 0.465, P<0.001.

Risk factor	Un-classified n (%)	G1 n (%)	G2 n (%)	G3 n (%)	G4 n (%)	Total n (%)
Blood transfusion	14 (6.9)	65 (32.2)	39 (19.3)	18 (8.9)	66 (32.7)	202 (22.7)
Dental procedures	0 (0)	36 (25.4)	47 (33.1)	17 (11.9)	42 (29.6)	142 (15.9)
IVDA	0 (0)	35 (26.2)	0 (0)	81 (60.4)	18 (13.4)	134 (15)
Sexual contact with HCV infected person and/or promiscuity	0 (0)	7 (30.4)	3 (13.1)	6 (26.1)	7 (30.4)	23 (2.6)
Hospitalization and/or surgical procedures	3 (1)	105 (35.7)	63 (21.4)	34 (1.6)	89 (30.3)	294 (33)
Unknown	1 (1.1)	27 (28.1)	20 (20.8)	10 (10.4)	38 (39.6)	96 (10.8)
Total	18	275	172	166	260	891

DISCUSSION
This study shows that HCV genotypes 1 and 4 are the more frequent genotypes among Libyan patients attending the virology clinic of the Department of Infectious Diseases at the Tripoli Medical Centre. A previous study conducted in Libya had shown that HCV infection with genotype 1 was more prevalent in the western region. A study in Tunisia (which borders the west of Libya) showed that genotype 1b was the most prevalent type of HCV infection (79%) [20]. The former study [12] also showed that genotype 4 was the most prevalent genotype in the eastern region of the country (63.6%), which resembles results reported from Saudi Arabia, where G4 were the most prevalent HCV among Saudi patients (62%), as well as among Egyptian patients living in Saudi Arabia [21].
Our study shows that Libyan male patients presented at the medical centre at a younger age than females. Moreover, nearly two thirds of the patients were males, and all HCV genotypes were more frequent among males, especially G3. G3 could be more common among males because 60% of subjects with a history of IVDA had type G3, and most likely IVDA in Libya is much more common among males.
Four genotypes and several subtypes were recognized with different frequencies, but genotypes 5 and 6 were not detected at all. Infection by more than one subtype occurred in a minority of cases. Importantly, we observed that the laboratory failed to classify the HCV genotype and subtype in many patients.
We observed a statistically significant relationship between the HCV genotype and the risk factor for infection. A history of hospitalization and/or surgical procedures was reported by one third of the patients. Previous hospitalization is a known risk factor for HCV infection in some countries [22,23]. Nosocomial transmission is likely if disinfection procedures are inadequate and contaminated equipment is shared between patients [24,25]. Other common histories associated with the infection reported by the patients in our study were blood transfusion, dental procedures and IVDA. Only a few patients (2.6%) gave a history of sexual contact with an infected HCV person and/or promiscuity.
Notably, 22.7% of the patients reported a history of blood transfusion. Worldwide, blood transfusion constitutes the most commonly recognized transmission mechanism of HCV [26].
A past history of IVDA was reported by 15% of the patients, but IVDA carries an extremely high risk of HCV infection. Data from the Centres for Disease Control (CDC, Atlanta, USA) showed that from 1986 to 1988, IVDA was responsible for 42% of cases of acute hepatitis C [27]. Some studies showed that anti-HCV antibodies are present among 70 to 90% of IVDA [26].
The results of this study showed that a history of hospitalization and/or surgical procedures were more frequent among patients who had G1. A study from France had shown that genotype 1 is associated more commonly with blood transfusion [28]. Genotype 2 was not recorded among patients who had a history of IVDA, while genotype 3 was the most frequent one among those patients. A study from southeast France showed some similar results, where it was found that G3 was associated with IVDA [29]. Genotypes 2 and 4 were also common in patients who had a history of hospitalization and/or surgical procedures and blood transfusion. A positive family history of HCV infection was found only among a minority of patients. HCV RNA < 2 million copies at diagnosis (low viral load) was found in approximately half of the patients. Nearly two thirds of the patients presented to the clinic initially with normal ALT.
CONCLUSION
Genotypes 1 and 4 are predominant among patients chronically infected with HCV and attending the virology clinic at the Tripoli Medical Centre. Twice as many males as females were infected with HCV and they presented themselves to the clinic at an earlier age. The most common risk factors were a past history of hospitalization and/or surgical procedures, blood transfusion, dental procedures, and intravenous drug abuse (IVDA). The results of this study constitute a strong indicator that strict infection control measures should be implemented in hospitals and dental clinics to reduce the nosocomial transmission of HCV, and that ways to reduce the number of intravenous drug users in the community should be sought.

CORRESPONDING AUTHOR:
Alashek WA, e-mail: wiam4ash@yahoo.com

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Dental Care Utilization and Satisfaction of Residential University Students

	Libyan J Med, AOP: 080601

	Dental Care Utilization and Satisfaction of Residential University Students
Original Article	Bamise CT¹, Bada TA², Bamise FO³, Ogunbodede EO⁴
	1Department of Restorative Dentistry, 2Department of Educational Technology, Faculty of Dentistry, Obafemi Awolowo University, Ile-Ife. 3Department of Information, Archives and Library Science, University of Ibadan, Ibadan. 4Department of Preventive and Community Dentistry, Faculty of Dentistry, Obafemi Awolowo University, Ile-Ife, Nigeria

Key words: dental care, utilization, satisfaction, young adults, Nigeria

ABSTRACT

Aim: The objective of this study was to provide information on the level of utilization and satisfaction of residential university students with the dental services provided by the dental clinic of a teaching hospital. Volunteers and Material: A stratified sampling technique was used to recruit volunteers from the outpatient clinic of the Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria. Information was collected by a self-administered questionnaire composed of questions that measure the level of utilization and satisfaction with the dental services provided. Questionnaires were provided to 650 randomly chosen students residing in the University hostels. There were 39 refusals, and 6 incomplete questionnaires were discarded. This left a sample size of 605 volunteers.

Results: Forty seven students (7.8%) indicated that they visited the dental hospital within the last 12 months. Males and females utilized the dental services equally, and utilization increased with age and the number of years spent on campus. Anticipation of painful dental treatment, high dental charges, long waiting times and being too busy for a dental visit were cited as the most important impediments to seeking dental treatment. Females expressed greater satisfaction with the services. Conclusion: Dental service utilization among the students was found to be low. Oral health awareness campaigns, improving the quality of the services, and shortening the waiting time are expected to increase service utilization and satisfaction.

INTRODUCTION

Adopting a habit of visiting dentist regularly is one of the common messages in oral health education [1]. Dental care utilization is the percentage of the population who access dental services over a specified period of time. Measures of actual dental care utilization describe the percentage of the population who have seen a dentist during given periods of time [2]. A survey conducted in the United States in 1995 reported that 69% of the respondents had visited a dentist during the previous 12 months [3]. In 1997, another study reported that 75.5% of the population 25 years of age or older who had a dentist indicated that they had visited a dentist in the preceding year [4]. These reports of dental care utilization rates are higher than the 1993 numbers reported in the National Health Interview Survey [5] and the dental care utilization rates reported by Eklund and colleages [6], indicating that more Americans are visiting dentists.

A survey of the utilization of dental services among university students in Helsinki showed that during the previous 12 months 59% of the students had had a dental appointment, mostly on their own initiative [7]. Generally, the dental utilization rate was higher among females; it increased with income and educational level, and decreased with age [2,7].

Various methods have been used to assess the adequacy of patients’ utilization of health services, with patient satisfaction being considered an important indicator of the efficient utilization of health services, as it assesses an individual’s attitude to the health services received [8,9].

Dental health care providers worldwide are showing increasing concern for patients’ satisfaction with the aim of responding appropriately to their needs when seeking to improve the quality of the services. Patients’ views have been frequently used to evaluate the quality of dental care [7,10-12]. A review of patient satisfaction studies shows that the characteristics of health care delivery that influence patient satisfaction the most are accessibility [13,14], cost [11,13], attitude of staff [15,16], waiting time [17-20], waiting area environment [20-21], and physical surroundings [22].

Obafemi Awolowo University, Ile-Ife, is located in the southwestern part of Nigeria and provides residence for about nine thousand students. The outpatient unit of the Obafemi Awolowo University Teaching Hospital is located on campus and provides dental care for the University community (staff and students on campus), Ile-Ife town, and residents in the surrounding area. If the university dental clinic wants to improve utilization and satisfaction, it should carefully analyze the opinions of its consumer groups. The aim of this work is to provide information about utilization and satisfaction of residential students with the dental services provided by the outpatient clinic of the Teaching Hospital's dental department.

VOLUNTEERS AND METHODS

A multistage stratified sampling technique was used to recruit the volunteers. First, male and female hostels with similar student distributions were identified as two survey sites. A systematic random sampling method was used to select the hostel rooms from which all the occupants were to be recruited: starting with the first room, every fifth room was selected.

Information was collected by a self administered questionnaire. Volunteers were asked to provide information on age, sex and number of years on campus, indicate whether they had decayed or missing teeth, and mention previous visits for dental treatment. The respondents with dental pathologies who had not visited a dentist were asked to explain the reasons and to state whether they were willing to do so. All the respondents were to specify whether or not they were aware of the need to visit the dentist regularly.

Respondents who had visited a dentist were asked to indicate whether the last visit was within a year or more than one year. Five questions were asked about their last dental visit to explore their satisfaction with the dental facility and the services provided. A five-point rating scale (very satisfied, 5; satisfied, 4; uncertain, 3; dissatisfied, 2; very dissatisfied, 1) was used.

The data were analyzed by using SPSS statistical software (SPSS Incorp., 1999). Frequencies and proportions were calculated. Associations between discreet variables were tested by Chi square test. In all cases a p-value < 0.05 was considered significant.

RESULTS

Six hundred and fifty questionnaires were distributed. There were 39 refusals and 6 volunteers provided incomplete answers. The remaining 605 volunteers constituted the study sample.

The ages of the respondents ranged from 16 to 48 years and most of them were 21 to 25 years old. Table 1 shows that of the 605 volunteers, 307 were males and 298 were females. Ninety eight percent of the respondents (n = 592) had spent about two years on campus, and 52.9% of them (n = 320) claimed to know that dental check-up should be regular. However, only 7.8% of the respondents (24 males, 23 females) indicated that they had visited the dental hospital for treatment within the previous 12 months. There was no statistically significant difference between males and females in the utilization of the dental service (X2=0.0, d f = 1, p=0.96).

One hundred and seventy three respondents (28.6%) (79 males, 94 females) had one or more decayed teeth, and of these, 36 (20.8%) indicated unwillingness to seek treatment in the dental hospital. Missing or decayed teeth were reported by 77 volunteers (12.7%) (41 males, 36 females), and 19 of these (24.7%) were unwilling to seek treatment in the dental hospital.

Table 2 shows the frequencies of some of the reasons why respondents with dental problems were unwilling to seek treatment. There was no statistically significant difference between males and females in any of the reasons assessed. Anticipation of painful dental treatment, high dental charges, long waiting times and being too busy for a dental visit were cited as the most important barriers to seeking dental treatment.

Table 3 shows the rate of satisfaction with different aspects of quality of service. The satisfaction rate is the proportion of the respondents whose reply was either “very satisfied” or “satisfied.” Females had a higher satisfaction rate than males on each of the five aspects examined. Overall, satisfaction rate was higher among females (66.5%.) than among males (54.6%), but the difference was not statistically significant (p=0.89). Satisfaction was lowest with the length of time spent in the hospital: 26.9% for males and 44.2% for females.

Table 1: Frequency distribution of gender and number of years on campus of the respondents

Gender	Total respondents	Those who visited the hospital within 12 months	Those who did not visit	Significance of difference between genders
Male	307	24 (7.8%)	283	X²= 0.00, df=1, p=0.96
Female	298	23 (7.7%)	275
Total	605	47 (7.8%)	558
Number of years on campus
Two	311	17 (5.5%)	294	X²=5.91, df=2, p=0.05
Three	215	19 (8.8%)	196
Four years or more	66	9 (13.6%)	57
Total	592*	45 (7.6%)	547

* 13 volunteers did not give their number of years on campus.

Table 2: Reasons for unwillingness of respondents who had dental problems to seek treatment

Reasons not to seek treatment		Responses			Significance of difference between genders
Reasons not to seek treatment		Yes	No	Total	Significance of difference between genders
Anticipation of painful experience	Male	24	13	37	X²=0.46, df=1, p=0.50
	Female	33	24	57
	Total	57 (60.6%)	37	94
Anticipation of worsened esthetics	Male	13	22	35	X²=2.50, df=1, p=0.11
	Female	10	37	47
	Total	23 (28.0%)	59	82
Distance to the hospital	Male	9	22	31	X²=0.08, df=1, p=0.78
	Female	16	34	50
	Total	25 (30.9%)	56	81
Anticipation of expensive dental charges	Male	24	15	39	X²=0.01, df=1, p=0.94
	Female	34	22	56
	Total	58 (61.1%)	37	95
Attitude of staff in previous visit	Male	3	26	29	X²=0.21, df=1, p=0.65
	Female	6	37	43
	Total	9 (12.5%)	63	72
Anticipation of long waiting time	Male	24	17	42	X²=1.63, df=1, p=0.20
	Female	24	29	53
	Total	48 (51.1%)	46	94
Just too busy	Male	28	18	46	X²=0.85, df=1, p=0.36
	Female	29	27	56
	Total	57 (55.9%)	45	102
Failure of previous treatment	Male	4	27	31	X²=0.03, df=1, p=0.87
	Female	5	38	43
	Total	9 (12.2%)	65	74

Table 3: Satisfaction rate of respondents with each aspect of the quality of service. In the table “satisfied” refers to those who responded either “satisfied” or “very satisfied.”

Component	Gender	Satisfied	Not Satisfied	Uncertain	Satisfaction Rate (%)	Significance of difference between genders
Distance to the hospital	Male (n=52)	31	7	14	59.6%	X²=0.01, df=1, p=0.93
Distance to the hospital	Female (n=43)	28	6	9	65.1%	X²=0.01, df=1, p=0.93
Attitude of staff	Male (n=52)	32	11	9	61.5%	X²=0.70, df=1, p=0.40
Attitude of staff	Female (n=43)	32	7	4	74.4%	X²=0.70, df=1, p=0.40
Cost of treatment	Male (n=52)	30	14	8	57.7%	X²=0.30, df=1, p=0.59
Cost of treatment	Female (n=43)	28	10	5	65.1%	X²=0.30, df=1, p=0.59
Time spent	Male (n=52)	14	31	7	26.9%	X²=2.4, df=1, p=0.12
Time spent	Female (n=43)	19	31	3	44.2%	X²=2.4, df=1, p=0.12
Clinic environment	Male (n=52)	35	6	11	67.3%	X²=0.97, df=1, p=0.33
Clinic environment	Female (n=43)	36	3	4	83.7%	X²=0.97, df=1, p=0.33

DISCUSSION

Many studies of dental service utilization have been conducted on various consumer groups and using different dimensions i.e., doctors-patient relationships, accessibility and availability of dental services to measure patient satisfaction. This study focused on university students as a major group of users of the modern dental facility in order to provide information on utilization and measure the degree of satisfaction with the services provided. Information on this important matter is scarce in Nigeria. Therefore, this study intends to be a baseline study for dental service utilization and satisfaction among college undergraduates in Nigeria.

The authors took into consideration the target group, the time scale for the study and factors that increase compliance of the respondents; we agreed to use an instrument that is as less time-consuming as possible. This led us to using a self administered questionnaire that included the most important components of health care utilization and satisfaction.

This study shows very low (7.8%) utilization of the dental services by undergraduate students of Obafemi Awolowo University, Ile-Ife, Nigeria in contrast to the high rates in highly industrialized countries, where more than 60% of 25-year-olds and above had visited a dentist within a year [3,4]. Utilization in the Nigerian university was also lower than reported for university students in Helsinki, where 59% of the students had a dental appointment within 12 months [7].

The relationship between dental service utilization and the main demographic variables, e.g., location of residence, income, wealth, education, occupation and age, were less relevant in this study. However, our findings show that males and females utilized the dental service equally, in contrast to the higher rate of utilization by female students reported in Helsinki [7]. A gradual increase in dental service utilization was observed as the number of years in the university campus and age of the students increased, but the trend did not achieve statistical significance.

A substantial proportion of students reported dental caries, missing teeth or both. Paradoxically, despite that we observed considerable unwillingness to visit the dental hospital for treatment although it is located on the university campus. This could be attributed to inadequate awareness of the importance of dental health care among students. This is evident from the low percentage of respondents (52.9%) who knew that dental check-ups should be regular. We had expected inadequate awareness, and so we also investigated the impediments to seeking dental care. Anticipation of painful dental treatment, expensive charges, long waiting times and being too busy for a visit ranked highest among the factors causing unwillingness to seek dental treatment. Similar findings have been reported in some other parts of the world [23,24].

The respondents that claimed to have visited the hospital were relatively satisfied with most of the aspects investigated. We observed that higher levels of satisfaction were expressed by females. With one exception [25], studies reported that women generally express greater satisfaction with dental care than men [26,27]. Newsome and Wright in their review suggested that such a result could be due to their greater exposure to dental services, which would likely moderate their expectations, which in turn are more likely to be met [26]. Our experience shows that in recent times, patients especially women were more concerned about esthetic rather than functional outcomes. The establishment of the adhesive and esthetic dentistry unit in our hospital may have influenced their response.

Time spent in the dental center was the component causing most dissatisfaction. Long waiting time has been reported as an item of dissatisfaction in literature [17-20]. This has been described as a natural outcome of inadequate personnel and facilities in the face of high demand for services [17,28]. This situation exists in our dental center. As a teaching hospital that serves the host communities and the suburb, our resources are stretched to the limit.
This study does not claim to be comprehensive, as it was intended as a simple baseline study. We were concerned with drawing attention to the pattern of utilization of our teaching hospital dental center by the undergraduate students in the immediate community as a major group of users. Many other aspects of dental service utilization and seemingly important factors of dental care satisfaction were not included. We hope that further exploration would be carefully and comprehensively done in future studies.

Our major finding of low utilization of our dental services underscores the need to urgently improve oral health care awareness in the university community; primarily through postal and hand bills on oral health, oral health education brochures for new students, increasing campus activities of the dentistry students, sponsoring of oral health programs in the media, and including oral health topics in the university’s special elective courses.

Also, improving the quality of care, e.g., better pain control, use of more conservative treatment approaches, better staff-patient interaction, subsidization of charges for students, improved staffing, and availability of materials and equipment will probably be required to increase the level of utilization of our services by all users.

Finally, reducing the time spent in the dental center, i.e., at the registration desk, waiting time, consultation time, surgery time and time with the radiographer and the hygienist would go a long way towards increasing the satisfaction rate of the consumers.

CORRESPONDING AUTHOR: Bamise CT, e-mail: bamisect@yahoo.com

REFERENCES

1. Ashley FP. Role of dental health education in preventive dentistry. In Murray JJ (ed) The prevention of dental disease. Oxford: Oxford University press; 1996: 406-414.

2. Brown J, Lazar V. dental care utilization: how saturated is the patient market. J Am Dent Assoc. 1999; 130:573-580.

3. Centers for Disease Control and Prevention. Dental service Use and Dental Insurance Coverage: United States, Behavioural Risk Factor Surveillance System, 1995. MMWR weekly 1997; 46:1199-1203.

4. American Dental Association, Survey Center. 1997 Survey of consumer attitudes and behaviors regarding dental issues. Chicago: American Dental Association; 1998.

5. National Center for Health Statistics. Health: United States, 1995. Hyattsville, Maryland: Public Health Service; 1996.

6. Eklund SA, Pittman JL, Smith RC. Trends in dental care among insured Americans: 1980-1995. J Am Dent Assoc. 1997; 128:171-178.

7. Venta I, Murtomaa H, Meumrman J, Turtola L. Use of dental services by students of Helsinki University during six years. Proc Finn Dent Soc. 1992; 88:123-129.

8. Roghmann KJ, Hengst A, Zastowny TR. Satisfaction with medical care: its measurement and relation to utilization. Med Care. 1979; 17: 461-477.

9. Zastowny TR, Roghmann KJ, Hengst A. Satisfaction with medical care: replications and theoretic reevaluation. Med Care. 1983; 21:294–322.

10. Chu CH, Lo EC. Patients' satisfaction with dental services provided by a university in Hong Kong. Int Dent J. 1999; 49:53-59.

11. Butters JM, Willis DO. A comparison of patient satisfaction among current and former dental school patients. J Dent Educ. 2000; 64:409-415.

12. Melver S. An introduction to obtaining the views of the users of health services. London: King’s Fund Centre, 1992.

13. Gopalakrishna P, Munnaleneni V. Influencing satisfaction for dental services. J Health Care Mark. 1993; 13:16-22.

14. El-Guebally N et al. On evaluating patient satisfaction: methodological issues. Can J Psychiatr. 1983; 8:24-29.

15. Bockting W, Robinson B, Benner A, Scheltan K. Patient satisfaction with transgender health services. J Sex Marital Ther. 2004; 30:277-294.

16. Weiss BD, Senf JH. Patient satisfaction survey instrument for use in health maintenance organizations. Med Care. 1990; 28:434-445.

17. Mahfouz AA, Al-Sharif AI, El-Gamal MN, Kisha AH. Primary health care services utilization and satisfaction among the elderly in Asir region, Saudi Arabia. East Mediterr Health J. 2004; 10:365-371.

18. Sur H, Hayran O, Yildirim C, Mumcu G. Patient satisfaction in dental outpatient clinics in Turkey. Croa Med J. 2004; 45:651-654.

19. El Sabrawy AM, Mahamoud ME. A study of patient satisfaction with primary health care services in Saudi Arabia. J Community Health. 1993; 18:49-54.

20. Evason E, Whittington D. Patient satisfaction studies; problems and implications explored in a pilot study in Northern Ireland. Health Education J. 1991; 50:73-77.

21. Cohen G, Forbes J, Garraway M. Can different patient satisfaction methods yield consistent results? Comparison of three surveys Br Med J. 1996; 313:841-844.

22. Scott A, Smith RD. Keeping the consumer satisfied: issues in the interpretation and use of patient satisfaction surveys. Int J Qual Health Care. 1994; 6:353-359.

23. Chu CH, Yeung CY, Lo FC. Monitoring patient satisfaction with university dental services under two fee-paying systems. Community Dent Oral Epidemiol. 2001; 29:390-398.

24. King T. Tooth brushing and utilization of dental services in Fiji (1998). Pac Health Dialog. 2003; 10:23-27.

25. Skarel E, Berg E, Raadal M, Kvale G. Factors related to satisfaction with dental care among 23 year olds in Norway. Community Dent Oral Epidemiol. 2005; 33:150-157.

26. Newsome PRH, Wright GH. A review of patient satisfaction: 1. Concepts of satisfaction. Br Dent J. 1999; 186:161-170.

27. Al-Mudaf BA, Moussa MAA, Al-Terky MA, Al-Dakhil GD, El-Farargy AE, Al-Quzairi SS. Patient satisfaction with three dental specialty sciences – A centre-based study. Med Prin Pract. 2003; 12:39-43.

28. Desai P, Zachariah B, McCaw-Binns AM, White S. Patient-flow and waiting times in general medical and dental clinics in Jamaica's primary health care services. West Indian Med J. 1989; 38:153-158.

Satisfaction rate of respondents with each aspect of the quality of service. In the table “satisfied” refers to those who responded either “satisfied” or “very satisfied.”

Syncope: Evaluation and management

	Libyan J Med, AOP: 080530

	Syncope: Evaluation and management
ABC Article	Mohamed HA
	University of Saskatchewan, Regina General Hospital, Regina, SK. Canada.

Syncope is a sudden transient loss of consciousness and postural tone with spontaneous recovery. Loss of consciousness results from a reduction of blood flow to the reticular activating system located in the brain stem. Syncope is an important clinical problem which accounts for 1% of hospital admissions and 3% of emergency department visits with a reported mortality and major morbidity rate of over 7% [1]. It is often disabling, may cause injury and may be the only warning sign before sudden cardiac death. The prognosis of patients with syncope varies greatly with the underlying etiology.

Causes of Syncope
Syncope is a symptom, not a disease, and can be classified according to the underlying cause. The causes of syncope can be classified into six groups including vascular, cardiac, neurological, psychogenic, metabolic, and syncope of unknown origin. Vascular causes of syncope (Table 1) are most common, followed by cardiac causes of syncope (Table 2). The most common cause of syncope in the general population is the neurally- mediated syncope (also known as neurocardiogenic, vasovagal syncope and as “fainting”), followed by primary cardiac arrhythmias.

The causes of syncope are highly age dependent [2]. The etiology of syncope in children and young adults is most likely related to neurocardiogenic syncope, psychiatric conversion reactions, and primary arrhythmic causes such as Wolff-Parkinson-White (WPW) syndrome and long QT interval syndrome (LQTS).

In middle age, neurocardiogenic syncope remains the most frequent cause of syncope.

Common causes of syncope in elderly persons include orthostatic hypotension, postprandial hypotension, medications, aortic valve stenosis, carotid sinus hypersensitivity, and bradyarrhythmias (e.g. sick sinus syndrome, heart block).

Other forms of neurocardiogenic syncope (so-called situational syncope) related to deglutition, micturition, defecation, and cough are more common in the middle-aged or elderly patients than in young patients [3].

Metabolic causes of syncope are rare, accounting for less than 5% of syncopal episodes. The most common metabolic causes of syncope are hypoglycemia, hypoxia, and hyperventilation.

Table 1: Causes of vascular syncope

Orthostatic	Reflex-mediated
- Autonomic insufficiency. - Idiopathic. - Hypovolemia. - Drug-induced.	- Carotid sinus hypersensitivity. - Neurally mediated syncope. - Glossopharyngeal syncope. - Situational (cough, micturition). - Adenosine sensitive.

Table 2: Cardiac causes of syncope

Structural	Arrhythmogenic
Aortic valve stenosis. Aortic dissection. Atrial myxoma. Hypertrophic cardiomyopathy. Cardiac tamponade. Myocardial infarction. Pulmonary embolism. Pulmonary hypertension.	Bradyarrhythmia: - Sinus node dysfunction. - AV-block. Tachyarrhythmias: - Supraventricular arrhythmias. - Ventricular arrhythmias.

Table 3: Features of clinical history distinguishing seizures from syncope:

- Confusional state following the event (postictal state).
- Blue face (not becoming pale) during the event.
- Frothing at the mouth.
- Aching muscles.
- Feeling sleepy after the event.
- Duration of unconsciousness of more than 5 minutes.
- Tongue biting (strongly suggestive of a seizure).
- An aura before the episode.
- Horizontal eye deviation during the episode.
- Elevated BP and pulse during the episode.
- A headache following the event.
- Tonic-clonic movements (may also occur in cardiac syncope).

Pathophysiology
Neurocardiogenic syncope is caused by an abnormal or exaggerated autonomic response to various stimuli, such as standing and emotion. The mechanism is poorly understood but involves reflex mediated changes in heart rate or vascular tone, caused by stimulation of the medullary vasodepressor region of the brain stem. Stimulation of this region in the brain may occur due to activation of various receptors, such as the afferent mechanocardiac receptors (cardiac C fibers), cardiopulmonary baroreceptors, gastrointestinal or genitourinary mechano-receptors [4,5]. When a person stands, 500 to 800 ml of blood is displaced to the abdomen and lower extremities, resulting in an abrupt drop in venous return to the heart. This drop leads to a decrease in cardiac output and stimulation of aortic, carotid, and cardiopulmonary receptors, which trigger a reflex increase in sympathetic outflow. As a result, heart rate, cardiac contractility, and vascular resistance increase to maintain a stable systemic blood pressure on standing.

In patients susceptible to neurocardiogenic syncope, the reduction in ventricular preload (due to venous pooling) and increased catecholamine levels lead to a vigorously contracting volume-depleted ventricle. It has been proposed that vigorous contractions of a volume-depleted ventricle lead to activation of the cardiac C fibers (nonmyelinated fibers, found in the atria, ventricles and pulmonary artery). Stimulation of these afferent C fibers leads to a “paradoxical” withdrawal of peripheral sympathetic tone and an increase in vagal tone, which, in turn causes vasodilation and bradycardia. The ultimate clinical consequence is syncope or presyncope [1].

Cardiac arrhythmias are an important cause of neurologic symptoms. Bradyarrhythmia and tachyarrhythmia may cause syncope by disrupting blood flow to the brain.

Clinical Features
Although presentation of neurocardiogenic syncope is similar to that of other types of syncope, loss of consciousness in patients with neurocardiogenic syncope may be preceded by prodromata such as nausea, diaphoresis, lightheadedness, ringing in the ears, blurred vision, headaches, palpitations, paraesthesia, and pallor [6,7].

Key clinical features of neurocardiogenic syncope are as follow:
- It tends to be situational.
- It is often recurrent during a patient’s lifetime.
- It is often preceded by at least a few seconds of prodromal symptoms.
- It occurs when the patient is in the upright position, and is resolved and can be aborted by assuming the supine position.
- After recovery, patients with neurocardiogenic syncope often complain of a “washed out” and tired feeling.

Although neurocardiogenic syncope can be seen in any age group, it is most common in younger patients with normal cardiac function. It tends to be uncommon in patients with significant cardiac dysfunction, probably because the C fibers are affected by myocardial disease [4].

Syncope associated with high intensity physical activity is a typical presentation of hypertrophic cardiomyopathy or catecholaminergic ventricular tachycardia.

Diagnostic Evaluation of Syncope
The primary purpose of evaluating patients with syncope is to determine whether the patient is at increased risk of death. This involves identifying patients with underlying heart disease and potentially life-threatening arrhythmias.

1- History and Physical Examination:
In most patients, the cause of syncope can be determined with great accuracy from a careful history and physical examination. The history is also useful for identifying precipitating factors that may increase risk of syncope [8]. Assessment of the symptoms and the clinical setting may yield clues as to the possible cause of the syncope.

Syncope after cough, defecation, and micturition suggests situational syncope; and syncope after pain, fear, or noxious stimuli suggests neurocardiogenic syncope [5]. Carotid sinus syncope may occur with rotation or turning of the head or pressure on the carotid sinus (for example, carotid massage, shaving, tight collars or neckwear).
History of tonic-clonic seizure-like activity is associated with both cardiac and neurological causes of syncope [6].

Auras, premonitions, postictal confusion, and focal neurological signs and symptoms suggest a neurological cause of syncope (Table 3).
Episodes of neurocardiogenic syncope are typically associated with post-episode fatigue and weakness, whereas the absence of a prodrome is consistent with cardiac syncope [9].

Vertebral basilar insufficiency should be considered as the cause of syncope if syncope occurs in association with other symptoms of brainstem ischemia such as diplopia, tinnitus, focal weakness or sensory loss, vertigo or dysarthria.

A history of myocardial infarction or previously repaired congenital cardiac defect raises the possibility of ventricular arrhythmias.

It is also useful to obtain careful history from witnesses who may have been present during the episode of syncope.

A careful physical examination is extremely useful in the evaluation of syncope. Orthostatic hypotension, autonomic dysfunction, and some cardiac defects can be identified by measuring blood pressure and pulse rate in the upper and lower extremities both in supine and upright positions. Carotid bruits should raise the possibility of compromised cerebral blood flow and underlying carotid artery disease. Abnormalities of visual fields, speech, motor strength, and sensation, tremor, and gait disturbances suggest an underlying neurological disorder.

Physical examination may suggest the presence of pulmonary hypertension, left ventricular dysfunction, valvular heart disease, or other forms of structural heart disease.

2- The electrocardiogram (ECG):
The ECG provides important information about the cardiac rhythm and the atrioventricular (AV) conduction.
Specific findings that can identify the probable cause of syncope include QT prolongation (LQTS), the presence of a short PR interval and delta waves (WPW syndrome), the presence of a right bundle branch block and ST segment elevation (Brugada syndrome), evidence of an acute myocardial infarction, or inverted T waves in the right precordial leads (arrhythmogenic right ventricular dysplasia).

3- Echocardiography:
It is an excellent tool to identify underlying structural heart disease, including valvular heart disease and cardiomyopathies.

4- Exercise stress:
It should be performed in patients with unexplained syncope, especially if the episode was related to exertion. This test provides the opportunity to monitor pulse and blood pressure (BP) responses to exercise. A drop of BP or failure of BP to rise in response to exercise raises the question of severe coronary artery disease or hypertrophic obstructive cardiomyopathy.

5- Noninvasive ambulatory ECG monitoring:
It allows for the diagnosis of cardiac rhythm disturbances and the correlation of symptoms with the cardiac rhythm. The type and duration of ambulatory ECG monitoring is dictated by the frequency of symptoms. The gold standard for the diagnosis of an arrhythmic cause of syncope is ECG documentation of the rhythm disturbances at the time of symptoms.

6- Tilt table testing (TTT):
This is a useful test in establishing the diagnosis of neurocardiogenic syncope. A positive TTT (i.e. a study that reproduces the patient’s syncope) identifies a patient who is prone to neurocardiogenic syncope [4]. Nevertheless, there have been serious questions about the sensitivity, specificity and diagnostic yield of this test [11,12].

In a patient of any age with an otherwise normal evaluation who has a negative TTT, the most likely diagnosis is still neurocardiogenic syncope. In patients with a malignant episode of syncope, it may be more important to rule out other causes of syncope such as cardiac arrhythmias than it is to perform a TTT.

7- Electrophysiological testing (EPS):
It involves placement of Transvenous catheters/wires within the heart to assess sinus node function, AV conduction, and susceptibility to supraventricular and ventricular tachycardias. Invasive EP testing is indicated in syncopal patients who are found to have a previous myocardial infarction, poor left ventricular function (left ventricular ejection fraction of less than 40%), or nonsustained ventricular tachycardia.
Approximately 30% of patients with syncope referred for EPS to evaluate syncope of unknown origin have a presumptive diagnosis established. A negative EPS has generally been considered predictive of a low risk of sudden death. In patients with an otherwise normal evaluation for syncope, the yield of EPS is low (approximately 3%) and, therefore, this test is not routinely recommended [13].

8- Neurological Evaluation:
Syncope as an isolated symptom rarely has a neurological cause. Neurological causes of syncope are established in less than 5% of patients with syncope. Neurological causes of syncope should be pursued only if suggested by history or physical examination.

Seizure disorders are the most common neurological cause of episodic unresponsiveness. An electroencephalogram can confirm seizure disorders. It must be noted here that cardiac syncope can be accompanied by upward gaze deviation, asynchronous myoclonic jerks, and brief automatisms that result from global cerebral hypoperfusion and are not an indication for a neurological evaluation.

Focal neurological signs such as diplopia, limb weakness, sensory deficits, or speech difficulties are indications for a neurological evaluation. Current guidelines for the evaluation of syncope suggest that EEGs be only obtained when there is a relatively high likelihood of seizure disorder. CT and magnetic resonance imaging (MRI) should be avoided in patients with uncomplicated syncope [14].

Treatment
The approach to treatment of a patient with syncope depends largely on the diagnosis (cause) that is established. In the elderly, multiple causes of syncope frequently coexist and need to be addressed. Emphasis should be given to the impact of polypharmacy, orthostatic intolerance, autonomic dysfunction, and carotid sinus hypersensitivity, particularly in elderly patients.

1- Syncope in the patient with a normal Evaluation
Although many life-threatening clinical entities are less likely in the presence of a normal evaluation, the possibility of neurocardiogenic syncope, carotid sinus hypersensitivity, paroxysmal bradyarrhythmias and tachyarrhythmia and myriad noncardiac causes of syncope remains [3].

In the absence of underlying heart disease, syncope is not associated with excess mortality. The main risk is related to physical harm that may occur if the patient has recurrent syncope.

The mainstay of management of patients with neurocardiogenic syncope is education of the patient to avoid situations that predispose to syncope (e.g., dehydration, stress, alcohol consumption, prolonged standing, and extremely warm environments). This should also include anxiety management and coping skills, and reassuring the patient that this is a benign condition.

It has been found that the administration of beta-blockers or disopyramide is often effective in preventing neurocardiogenic syncope [15]. Although it may seem paradoxic to prescribe beta blockers for patients whose syncope is often accompanied by significant bradycardia, using beta blockers makes sense when one considers that hypersympathetic tone is necessary to engage the cardiac C fibers. Disopyramide has a strong vagolytic effect, but more importantly, it has a direct negative inotropic effect on the heart, presumably inhibiting C fiber stimulation. It is not considered first line treatment because of the risk of proarrhythmic and anticholinergic adverse effects. Midodrine, an alpha agonist, has been shown to be effective in several randomized trials.

In most patients with neurocardiogenic syncope, a fall in blood pressure precedes bradycardia; therefore, cardiac pacing is often ineffective in most patients. However, dual chamber pacing may be effective in reducing symptoms if there is a large cardioinhibitory component [7].

2- Syncope in the patient with cardiac disease:
Syncope in patients with underlying heart disease is associated with a high rate of mortality.

The appropriate treatment for patients with syncope related to advanced AV block or sick sinus syndrome is permanent pacing. The treatment of a patient with syncope related to WPW syndrome would probably involve catheter ablation of the accessory pathway.
Treatment of patients with syncope related to ventricular tachycardia and underlying ischemic cardiomyopathy would probably involve placement of an implantable cardioverter defibrillator (ICD) and/or revascularization. Implantable defibrillator therapy is also effective in high-risk patients with hypertrophic cardiomyopathy [16], nonischemic dilated cardiomyopathy, long QT syndrome [17], Brugada syndrome and in patients with arrhythmogenic right ventricular dysplasia [18]. Treatment of patients with syncope related to critical aortic valve stenosis would involve aortic valve replacement with or without coronary revascularization.

Conclusions
Syncope is an important clinical problem and is associated with considerable morbidity. Neurocardiogenic syncope is the most common cause of syncope and is generally considered a benign condition, although frequent and recurrent episodes can negatively affect quality of life. Syncope can be a precursor to sudden death, particularly in patients with underlying heart disease. Therefore, the primary purpose of the evaluation of the patient with syncope should be to determine whether the patient is at increased risk for death. This involves identifying patients with underlying heart disease and potentially life-threatening arrhythmias.

CORRESPONDING AUTHOR: Hassan A. Mohamed, e-mail: dr.hmohamed@gmail.com

REFERENCES

1. Calkins H, Zipes DP: Hypotension and syncope. Braunwald’s Heart Disease. 8th edition; 2008: 975-983.

2. Manolis AS. Evaluation of patients with syncope: focus on age-related differences. ACC Curr J Rev 1994; November/December:13–8.

3. Kapoor WN. Syncope. N Engl J Med 2000; 343:1856–62.

4. Fogoros RN. Cardiac arrhythmias, syncope and stroke. Neurologic clinics. 1993 Volume II (2):375-390.

5. Kapoor WN. Current evaluation and management of syncope. Circulation 2002; 106:1606 –9.

6. Sheldon R, Rose S, Ritchie D. Historical criteria that distinguish syncope from seizures. J Am Coll Cardiol 2002; 40:142– 8.

7. Goldschlager N, Epstein AE, Grubb BP, Olshansky B, Prystowsky E, Roberts WC, Scheinman MM. for the Practice Guidelines Subcommittee, North American Society of Pacing and Electrophysiology. Etiologic considerations in the patient with syncope and an apparently normal heart. Arch Intern Med 2003; 163:151– 62.

8. Linzer M, Yang EH, Estes NA III, Wang P, Vorperian VR, Kapoor WN. Diagnosing syncope, part 1: value of history, physical examination, and electrocardiography: Clinical Efficacy Assessment Project for the American College of Physicians. Ann Intern Med 1997;126:989 –96.

9. Calkins H, Shyr Y, Frumin H, Schork A, Morady F. The value of the clinical history in the differentiation of syncope due to ventricular tachycardia, atrioventricular block, and neurocardiogenic syncope. Am J Med 1995; 98:365–73.

10. Maron BJ. Sudden death in young athletes. N Engl J Med 2003; 349: 1064–75.

11. Garcia-Civera R, Ruiz-Granell R, Morell-Cabedo S. Selective use of diagnostic tests in patients with syncope of unknown cause. J Am Coll Cardiol 2003; 41:787–90.

12. Sarasin FP, Louis-Simonet M, Carballo D. Prospective evaluation of patients with syncope: a population-based study. Am J Med 2001; 111:177–84.

13. Fujimura O, Yee R, Klein G, Sharma A, Boahene K. The diagnostic sensitivity of electrophysiologic testing in patients with syncope caused by transient bradycardia. N Engl J Med 1989; 321:1703–7.

14. Brignole M, Alboni P,Benditt DG, Bergfeldt L, Blanc JJ, Thomsen PE, Gert van Dijk J, Fitzpatrick A, Hohnloser S, Janousek J, Kapoor W, . Task Force on Syncope. European Society of Cardiology. Guidelines on management (diagnosis and treatment) of syncope. Eur Heart J 2004 Nov; 25(22):2054-72.

15. Akhtar M, Jazayeri M, Sra J: Cardiovascular causes of syncope. Postgrad Med 90:87. 1991.

16. Maron BJ, Shen WK, Link MS. Efficacy of implantable cardioverter-defibrillators for the prevention of sudden cardiac death in patients with hypertrophic cardiomyopathy. N Engl J Med 2000; 342:365–73.

17. Zareba W, Moss AJ, Daubert JP, Hall WJ, Robinson JL, Andrews M. Implantable cardioverter-defibrillator in high-risk long QT syndrome patients. J Cardiovasc Electrophysiol 2003; 14:337– 41.

18. Corrado D, Leoni L, Link MS. Implantable cardioverter-defibrillator therapy for prevention of sudden death in patients with arrhythmogenic right ventricular cardiomyopathy/dysplasia. Circulation 2003; 108:3084–91.

Road safety: A call for action

	Libyan J Med, AOP: 080620

	Road safety: A call for action
Correspondence	By Omar AH, Ashawesh K
	Ottawa Hospital, Canada, and Walsgrave Hospital, Coventry, UK. Email: ahomar3@gmail.com

To The Editor: We would like to thank both Dr. A. Ali [1] and Dr. A. Salamat [2] for highlighting the issue of road traffic accidents in Libya.

Road traffic accidents and their consequences have become a huge burden on societies all over the world; this is especially true for Libya in recent years where it has reached epidemic proportions.
Each year over a million people are killed worldwide in road traffic accidents and about 10 million people are injured, 85% of these deaths occurring in developing countries [3]
The Global Burden of Disease study, undertaken by the World Health Organisation (WHO), Harvard University and the World Bank, showed that in 1990, traffic crashes were assessed to be the world's ninth most important health problem. The study forecasts that, by the year 2020, road crashes would move up to third place in the table of leading causes of death and disability facing the world community [4].

In Libya the picture is very grim; each year over 2000 people die as a result of road traffic accidents, and the number is steadily and surely rising. Last year alone 2138 people died on the roads in Libya (approximately 35 deaths per 100 000), which is the second highest death rate within the Arab world [5]. Compare this figure to the UK where the death rate is 5.9 per 100 000 [6]. This year, the number of road deaths in Libya is already in the hundreds. Only recently two traffic accidents occurred within weeks of each other, the first resulting in the death of 36 people and the other in 9 people, both accidents involved forms of public transport, and as with most of the accidents, these 45 deaths could have been prevented.

There is no doubt that the issue of road safety is of paramount importance in Libya, but, unfortunately, despite the tragic figures there is little tangible evidence of any measure to combat this serious issue. Policymakers in Libya have neglected the issue of road safety and its burden, barring few and far in between exceptions. This neglect is also replicated within our own medical community.

There is literally a wealth of available research and evidenced based guidance from around the world, all pointing towards implementing a scientific and systemic approach to the problem of road traffic accidents, a process which leads to marked reductions in deaths and injuries.

As an example of this, in developed countries, road traffic death rates have decreased since the 1960s because of successful interventions such as seat belt safety laws, enforcement of speed limits, anti-drunk driving law enforcement and safer design and use of roads and vehicles. For example, road traffic fatalities declined by 27 percent in the United States and by 63 percent in Canada from 1975 to 1988 [7].

There is hardly any effort expended on prevention and research, a sad fact and in keeping with a pattern known throughout the developing world.

The main reasons why death rates are so high and increasing in Libya have not been accurately studied, but one can reasonably infer from what is known the following major causes:

1- Poor enforcement of traffic safety regulations. A huge problem, the departments responsible are archaic in nature, lack of proper resources and training at all levels. The main issue in the responsible departments is, unfortunately, corruption, which could and does result in terrible consequences. Many drivers and vehicles on the roads should not be allowed to be so; this is plain to see and requires no scientific probing! Many deaths have occurred due to improper and often illegal licensing both of drivers and cars.

2-Aging and poorly designed roads. This is further aggravated by an exponential increase in the number of cars.

3- Poor trauma-related health care. Trauma and emergency care is below standard. There are enormous short falls in this area. There is a lack of trained staff in all areas of the "rescue chain", starting from the road side ending in the bedside. Trauma care is still archaic and the lack of development in this area is tragic, and like road safety, it has not shown any improvement at all.

Most of the trauma departments are run by medical staff who has not received any formal trauma or emergency training such as ATLS/ACLS. Basic trauma guidelines are not practiced nor are there the basic resources to implement them.

ATLS/ACLS would be a huge step in the right direction, but who would fund or introduce it to those departments? The scientific evidence is clear, better trained doctors will reduce morbidity and mortality of trauma patients.

Most trauma department resources are inadequate and aging and they are in need of modernising in keeping with today’s standards.

We have to be honest and forthright at pointing out the problems facing trauma care in Libya. Furthermore we need to encourage appropriate resource channelling and use for this important facet of care. Many people in health care management are either unaware and if not, are ignoring the importance of modernising and implementing evidence based practice in trauma care. This attitude- if continued- will unfortunately lead to more
suffering and loss of lives.

The responsibility to implement changes not only lies with doctors on the front lines in our hospitals in Libya, but also lies collectively with all of us wherever we may be. We have a moral and scientific responsibility to contribute to improve the situation on our roads and hospitals.

The question we all have to ask is: What can we do? The answer is that we all can do something, through raising awareness, using our scientific and managerial influence to try to encourage research and implement a modern effective evidence based approach to the issue of road safety in Libya. Dr. Ali and Dr. Salamat kindly gave excellent suggestions on what can be done, and we need to explore all of these suggestions and expand upon them but the most important thing is to implement them.

Many of our surgical and emergency care colleagues can contribute by arranging and participating in training courses, seminars and workshops on the issue of trauma care. This would be an enormous step in the right direction.

Further to this issue, we recommend to the editors of the Libyan Journal of Medicine to dedicate a full issue of the LJM to road safety in Libya and to invite contributions on this subject. This will not only encourage awareness but also stimulate much needed research and debate and hopefully a positive influence which can lead to the reduction in the number of deaths on our roads. As we all know any procrastination on dealing with this issue will sadly lead towards more death and injury.

REFERENCES

1. Abdulmajid Ahmed Ali. Road Traffic Accidents: The Number One Killer in Libya. Libyan J Med, 2007: 2(2); AOP: 070327.

2. Ahmed Salamat. Road traffic accidents in Libya: An undeclared War. Libyan J Med, AOP: 080118.

3. Jacobs G, Aeron-Thomas A, Astrop A. Estimating global road fatalities. TRL report 445. Crowthorne: TRL Limited, 2000.

4. Murray C, Lopez A. The global burden of disease. Cambridge: Harvard University Press/WHO/World Bank, 1996.

5. Libya With Second Highest Number of Road Accidents. The Tripoli Post, 2008. Available at (http://www.tripolipost.com/articledetail.asp?c=1&i=1753). Accessed on 20 June 2008.

6. Dyer O. One million people die on world's roads every year. BMJ 2004;328:851.

7. Elizabeth Kopits and Maureen Cropper, "Traffic Fatalities and Economic Growth," The World Bank, Policy Research Working Paper No. 3035 (Washington, DC: World Bank, 2003).

To cite this article: Omar AH, Ashawesh K. Road safety: A call for action. Libyan J Med, AOP: 080620