JML JOURNAL MEDICAL LIBANAIS Vol. 60 (1) - pp 1-62 Janvier-Mars 2012 January-March LEBANESE MEDICAL JOURNAL LMJ

VOLUME 60 N 1

January-March2012

o

Janvier-Mars

This is the second edition of the Primary Care Clinical Guide. The first edition was published in 2000 through a large collaborative effort among the Lebanese Society of Family Medicine, the Departments of Family Medicine at the American University of Beirut and Université Saint-Joseph, the Ministry of Public Health and the Lebanese Order of Physicians. “The ‘Guidelines’ were a success among generalists in Lebanon and mostly with students, residents and others.” This document summarizes essential information, easily readable, that can provide prompt critical ambulatory care information while caring for patients.

Copies available at the Lebanese Society for Family Medicine office - LOP, attn. Dr Najla Lakkis and at the Department of Family Medicine - AUBMC, tel. 01 350000 ext 3020

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JOURNAL MEDICAL LIBANAIS

 

LEBANESE MEDICAL JOURNAL

 

Publication du Comité Scientifique

 

Ordre des Médecins du Liban

 

Publication of the Scientific Committee

 

Lebanese Order of Physicians

 

Health insurance reform

 

Labor versus health perspectives

 

http://www.lebanesemedicaljournal.org/articles/60-1/editorial.pdf

 

W. AMMAR, M. AWAR

1

Facteurs de risque du pneumothorax et de l’hémorragie

 

associés à la biopsie pulmonaire

 

Une expérience unicentrique

 

http://www.lebanesemedicaljournal.org/articles/60-1/original1.pdf

 

T. SMAYRA, C. BRAIDY, L. MENASSA-MOUSSA, S. HLAIS

 

S. HADDAD-ZEBOUNI, N. AOUN

4

Tabagisme parental en début de grossesse

 

et cardiopathies congénitales

 

http://www.lebanesemedicaljournal.org/articles/60-1/original2.pdf

 

G. CHEHAB, I. EL-RASSI, A. ADHAMI, I. CHOKOR

 

F. CHATILA, W. HADDAD, Z. SALIBA

14

Incidence of piriformis tendon preservation on the dislocation rate

 

of total hip replacement following the posterior approach

 

A series of 226 cases

 

http://www.lebanesemedicaljournal.org/articles/60-1/original3.pdf

 

C.D. MOUSSALLEM, F.A. HOYEK, J.-C.F. LAHOUD

19

Acquired and genetic risk factors for deep vein thrombosis

 

of lower extremities among Lebanese patients

 

http://www.lebanesemedicaljournal.org/articles/60-1/original4.pdf

 

R. KREIDY, M. WAKED, E. STEPHAN, J. IRANI, R. CHEMALI

 

I. JUREIDINI, N. IRANI-HAKIME

24

Influence of the weight status on hip bone strength indices

 

in a group of sedentary adolescent girls

 

http://www.lebanesemedicaljournal.org/articles/60-1/original5.pdf

 

R. EL HAGE, Z. EL HAGE, E. MOUSSA, R. BADDOURA

 

D. THEUNYNCK, C. JACOB

30

Medication prescribing errors

 

Data from seven Lebanese hospitals

 

http://www.lebanesemedicaljournal.org/articles/60-1/original6.pdf

 

A. AL-HAJJE, S. AWADA, S. RACHIDI, N. BOU CHAHINE, R. AZAR

 

S. ZEIN, A.-M. HNEINE, N. DALLOUL, G. SILI, P. SALAMEH

37

Journal Médical Libanais 2012 • Volume 60 (1) I

JML

JOURNAL MEDICAL

LIBANAIS

LMJ

LEBANESE

MEDICAL JOURNAL

Publication du

Comité Scientifique

Ordre des Médecins du Liban

Publication of

the Scientific Committee

Lebanese Order of Physicians

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toute correspondance au

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Journal Médical Libanais

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Autostrade Tawita

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Mailing address Editor in Chief Lebanese Medical Journal Lebanese Order of Physicians Autostrade Tawita

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www.lebanesemedicaljournal.org Tel./Fax : +961 1 610710 ext 306

Production emo

Beyrouth

Tel. : +961 1 339870

Use of herbal medications and their perceived effects among adults

 

in the Greater Beirut area

 

http://www.lebanesemedicaljournal.org/articles/60-1/original7.pdf

 

N.M. ALAAEDDINE, S.M. ADIB, H.M. ALAWIEH, S.M. ADIBILLY

 

M.M. KHALIL, S.E. ASSAAD, M.C. KHAYAT

45

Osteomyelitis: Review of pathophysiology, diagnostic modalities

 

and therapeutic options

 

http://www.lebanesemedicaljournal.org/articles/60-1/review1.pdf

 

A.J. EID, E.F. BERBARI

51

L’enseignement médical au XIXe siècle au Moyen-Orient

 

A travers un des pionniers de la médecine libanaise

 

http://www.lebanesemedicaljournal.org/articles/60-1/history1.pdf

 

E. GÉDÉON

61

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Articles by Lebanese AuthorsIndexed in PubMed

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IIJournal Médical Libanais 2012 • Volume 60 (1)

HEALTH INSURANCE REFORM Labor versus health perspectives

http://www.lebanesemedicaljournal.org/articles/60-1/editorial.pdf Walid AMMAR1, May AWAR2

Ammar W. Health insurance reform: Labor versus health per-

spectives. J Med Liban 2012 ; 60 (1) : 1-3.

ABSTRACT : The Ministry of Labor (MOL) has sub- mitted to the Council of Ministers a social security reform plan. The Ministry of Public Health (MOPH) considers that health financing should be dealt with as part of a more comprehensive health reform plan that falls under its prerogatives. While a virulent political discussion is taking place, major stakeholders’ inputs are very limited and civil society is totally put away from the whole policy making process. The role of the media is restricted to reproducing political disputes, without meaningful substantive debate.

This paper discusses health insurance reform from labor market as well as public health perspectives, and aims at launching a serious public debate on this cru- cial issue that touches the life of every citizen.

THE SOCIAL SECURITY REFORM

AS PROPOSED BY THE MINISTER OF LABOR

What is the rationale behind this proposal?

The proposal states the distortion effect of social secu-

rity contributions on the labor market, as a major concern

to be addressed by the reform. The employer’s contribu-

tion share is regarded as a payroll tax, and the assumption

is that, removing this share would allow employers to

create more jobs, resolving thus the problem of unem-

ployment.

 

To view social contributions as penalizing employment

is a very old argument that goes back to the struggle for

social justice around the middle of the last century. It was

put forward by conservatives to curb social and welfare

policies that considered contributions as the expression of

solidarity between the employer and the employees, the

better off and the less well off as well as between the

healthy and the sick.

 

The recent “ideological” background for shifting health

financing from contributions to taxes comes from a poli-

cy paper issued by the World Bank in March 2010 [1], that

1Director General of the Ministry of Public Health; Faculty of

Health and Sciences, American University of Beirut (AUB).

2MPA, Technology Transfer Unit Manager, Office of Grants &

Contracts, AUB, Beirut, Lebanon.

 

Correspondence: Walid Ammar, MD, PhD. Ministry of Public

Health. Museum Square. Beirut. Lebanon.

Tel.: +961 1 615 728

e-mail: mphealth@cyberia.net.lb

has raised much controversies with the Ministry of Public Health at that time. However, the genuine part of the pro- posed reform is Minister Charbel Nahas’ proposal, on col- lecting additional treasury fund through taxes on real estate and capital gains. Disregarding how the generated money would be distributed among the many competing social programs, this kind of taxes would contribute to rectify the unfair fiscal policy in place.

What is particularly alarming however, is that the Na- tional Social Security Fund (NSSF) contribution exemp- tion was put on the table of the Council of Ministers for adoption, together with a proposal for salary adjustment within the framework of insane political barter.

The content, as well as the way to proceed with these proposals, raise some serious concerns:

– Removing the main NSSF source of financing i.e. employers’ share is a major amendment of the NSSF law and could not be made by a simple decision of the Council of Ministers. Moreover, this would imply a drastic change in the social security governance where there will be no more legitimacy for employers to sit on the NSSF Board.

– Replacing contributions by taxes is a major structural reform that requires active involvement of the civil society, through an open debate and a consensus build- ing process, that are not taking place.

– The current “urgent” proposals shift the emphasis from linking contributions with unemployment, to a trade- off between contributing to the social security and rais- ing salaries. Thus, the primary intention for removing contributions is diverted from enabling employers to create additional jobs to make them capable of afford- ing wage adjustment.

– Even from a labor market perspective, employers have a long list of claims to reduce production costs and enhance competitiveness and hence job creation. Abol- ishing their contributions to the NSSF was never among their listed priorities.

– The effect that would have the removal of employer share on job creation depends on two parameters. The first is the importance of unemployment where recent studies reveal a relatively low rate in Lebanon [2]. The second is the elasticity of labor demand i.e. the effect that would have employers’ exemption on the creation of new jobs. This should be examined in light of the relatively modest contributions ranging from less than 30 USD to a maximum of 70 USD per employee (the employer’s contribution to the sickness fund is 7% of the salary with a maximum deductible of 1000 USD).

Lebanese Medical Journal 2012 • Volume 60 (1) 1

FINANCING REFORM

FROM A HEALTH SYSTEM PERSPECTIVE

The ultimate goal of health financing reform is Universal Coverage. Therefore, in addition to fund generation, re- form plan should tackle health services provision and uti- lization. The World Health Report 2010 gives Lebanon as an example on how to move towards universal coverage by “improving the efficiency and quality of primary care network”. Germany was considered as an example for “injecting additional funds from general revenues in the wage-based insurance system” to meet the growing needs of an aging population [3]. Therefore, financing reform i.e. insurance reform is only a piece of the puzzle in the comprehensive systemic approach contributing to univer- sal coverage.

System related problems have cultural roots and are institutional dependents and cannot be solved by magic or by a coup d’état. System’s weaknesses and deficien- cies could only be addressed by building on system’s strengths, and by capitalizing on previous achievements. A particular attention should always be paid to preserving acquired advantages. It is, therefore, crucial to identify those strengths, advantages and achievements.

How the health coverage system is currently functioning? It is true that half of the population in Lebanon does not have formal health coverage. It is also true that those uncovered are entitled to the coverage of the MOH for hospital care and expensive treatments i.e. to what may constitute a catastrophic spending for households. This was designed to protect households from impoverishment

resulting from health spending.

The MOH does not reimburse ambulatory care. It pro- vides, however, an alternative for the poor by subsidizing a comprehensive package of Primary Health Care (PHC) services through a wide network of PHC centers. This net- work is becoming more and more credible and trusted by local communities leading to significant decrease in out- of-pocket (OOP) that households used to spend mostly on ambulatory care and medicines.

Provision and utilization data reveals that the poor are utilizing more ambulatory and hospital services than the better off, and indicates that equitable accessibility is not a major concern for the time being. As a matter of fact, over consumption of medicines and over utilization of health services are rather a problem [4].

Accreditation programs have contributed to a docu- mented improvement of the quality of health services at the hospital, as well as at the PHC level.

Working on payment mechanisms and performance assessment led to significant efficiency gains at the level of the MOH. Evidence shows that, with almost the same resources, the MOH has been covering a significantly increasing number of cases and continuously improved quality of services, over the past 10 years [5].

With regard to health outcomes, recent studies revealed great improvement in child and maternal mortality rates

reaching respectively 10 per thousand [2] and 26 per hun- dred thousand [6].

Thus, a functional Safety Net exists, sound policies are in place and progress has been noted. We should be par- ticularly careful though, that acquired advantages, from the culmination of years of work and militancy, would not be jeopardized by the reform.

Why do we need health financing reform?

Because health financing is unfair and not sustainable and because spending on health exposes households to a high risk of impoverishment [7].

Reform should rather be seen as a continuous process. Much can be and has been achieved at the technical and administrative levels provided that a vision exists and politicians do not interfere. However, when a structural reform is proposed, a clear, strong and continuous politi- cal commitment is required. Such reform needs major leg- islative amendments and civil society involvement. As a matter of fact, the recent history of the health sector in Lebanon has known a considerable progress in technical and administrative reform components, although it has witnessed failures whenever political commitment was needed [5]!! The World Health Report 2010, dedicated precisely to universal coverage, tells a success story about health system financing in Lebanon. It points out major achievements as a result of sound policies and profession- al work. It states “A series of reform has been implement- ed by the Ministry of Health to improve equity and effi- ciency […] spending as a share of GDP has fallen from 12.4% to 8.4%. Out-of-pocket spending as a share of total health spending fell from 60% to 44%, increasing the lev- els of financial risk protection” [8].

From a health system perspective, financing reform should protect people from financial risks, remove financial obstacle that may hinder the accessibility of the poor to es- sential health care, and prevent those living over the pover- ty line from impoverishment when spending on health.

Where does the money come from in the current health financing system ?

Forty-four percent of total health expenditures (THE) is disbursed directly by households at the point of getting the service; 29% of financing comes from the treasury. This represents what is paid by the MOPH, 25% of NSSF expenditures and most of other public funds disburse- ments. The remaining 27% are contributions to the social security and premiums to the private insurance, split into 16% paid by households and 11% by employers.

Hence, most of health financing (44%) comes from out-of-pocket (OOP) which is the worst payment modali- ty from equity perspective. It hinders the accessibility of the poor to necessary health services and pushes people living close to poverty under the poverty line. OOP are distributed by household income categories in the follow- ing manner: 30% come from the lower income categories earning less than 650 000 LBP monthly; 30% from the low middle income categories with a monthly income

2 Lebanese Medical Journal 2012 • Volume 60 (1)

W. AMMAR, M. AWAR – Health insurance reform in Lebanon

ranging from 650 000 to 1 200 000 LBP; and the remain- ing 40% from the better off. The latter share is mostly spent on luxury treatment such as first class hospitaliza- tions, cosmetic and plastic surgeries [9].

HOUSEHOLDS DIRECT PAYMENTS

AS SOURCE OF FINANCING

How OOP should be addressed to remove the financial obstacle facing the poor to health care, and protect people with limited resources from impoverishment?

For the poor, imposed fees and co-payment may hinder the accessibility to health services, and therefore a com- plete exemption from Primary Health Care fees and hos- pital co-payment is required. Beneficiaries of this catego- ry could be identified by Proxy Means Testing conducted by the Ministry of Social Affairs.

For the low middle income households, health spend- ings are catastrophic and may push people under the pov- erty line, hence, OOP should be reduced through waiver- ing schemes based on income. Those can be identified by Public (& NGO) providers, and “equity funds” could be created and managed by municipalities and/or the Ministry of Social Affairs.

As mentioned in the World Health Report 2010, OOP in Lebanon has been decreased during the past decade from 60% of THE in 1998, to 44% in 2005. However, 44% is still very high and should be lowered at least by half if we are to protect people from the risk of impover- ishment due to health spending. Eliminating unofficial payments imposed by hospitals (exceeding the 15% co- payment) will only have a limited impact in this regard. The main intervention would therefore consist in lowering the reliance of the poor on private ambulatory services. And the only source of money to finance alternative PHC in order to achieve this result, is that of taxation.

TAXES AS SOURCE OF FINANCING

This brings us to consider taxes as a source of funding. As this money will feed into the treasury, competing priorities exist among different social programs. The fairness of health financing depends on how equitable is the fiscal sys- tem i.e. the progressivity of taxes as well as the importance of tax avoidance and tax evasion.

In all cases, funding from treasury source has the advan- tage of being prepaid and somehow redistributive, and thus remains more equitable and less catastrophic than OOP. It is usually used to cover preventive and primary care as well as regulated hospital care, generating thus better value for money than households’ direct disbursements.

More progressive taxes are preferred from equity per- spective. Therefore, taxes on real estate and capital gains proposed by the MOL are particularly interesting. It is worth mentioning that the only indirect taxes that may be recommended are value added taxes (VAT) on unhealthy food or harmful products such as foods high in fat, salt, and sugar, tobacco, alcohol, hunting rifles and munitions.

CONTRIBUTIONS AS SOURCE OF FINANCING

Finally, what are the characteristics of contributions as a source of funding?

Contribution to Social Security is the expression of the culturally rooted value of Solidarity. In economic terms, contributions represent a progressive redistribution going from high income to low income adherents, and from low- to high-risk beneficiaries. However, the employers’ share may be considered as a payroll tax contributing to labor market distortions, reducing employment levels and pro- moting informality, and this is obviously the main concern of the Minister of Labor. However, abolishing contribu- tions means depriving the health sector from an important and equitable source of financing. This also means de- stroying a valuable efficient instrument for collecting money for health. Any reform plan should consider the cultural and historical development of the social security system that is based on the value of solidarity, and should capitalize on existing institutional capabilities.

In conclusion, the diversity of resources into OOP, taxes and contributions, is an important element for pooling suf- ficient revenues and ensuring sustainable health financ- ing. Increasing revenues from treasury source is a must, provided equitable fiscal policy is adopted and fair taxes are put in place. Minister Nahas’ proposal on real estate and capital gains taxes would rebalance, to some extent, the inequity of the fiscal system and is expected to ensure important revenues. Money from treasury source should be spent in preference to reduce OOP for equity purposes. Then, once additional funds are made available, the em- ployer’s share may be reduced if a meaningful positive effect on the labor market is reasonably expected.

Nevertheless, the main question remains: Do people have a say in the social security reform in Lebanon? How? References

1. Robalino D, Ekman B, Sayed H et al. Health Insurance in Lebanon; A framework to expand coverage by improving risk pooling and financing. The World Bank, Washington, 2010.

2. Multiple Indicators Cluster Survey, CAS 2011. www.cas. Healthgov. b/Mics3/CAS_MICS3_survey_2009.pdf

3. Systems Financing, the path to universal coverage p.xi, WHO Geneva, 2010.

4. Ammar W. Health System and Reform in Lebanon. WHO, MPH, ISBN 9953-427-57-7, Beirut. January 2003.

5. Ammar W. Health Beyond Politics. WHO, MPH, ISBN 978-9953-515-489, Beirut. January 2009.

6. World Health Statistics Report 2011, WHO. www.who.int/ whosis/whostat/2011/en/index.html

7. Ammar W, Kasparian R. What is fair in financing fair- ness? J Med Liban 2001 May-June ; 49 (3) : 126-8.

8. Health Systems Financing, the path to universal coverage p.xi, WHO Geneva, 2010.

9. Central Administration for Statistics, Ministry of Social Affairs, United Nation Development Fund. The National Survey of Household Living Conditions 2004/5.

W. AMMAR, M. AWAR – Health insurance reform in Lebanon

Lebanese Medical Journal 2012 • Volume 60 (1) 3

 

 

 

 

 

 

 

 

DE RISQUE DU

 

 

 

 

 

 

 

 

 

ET DE L’HÉMORRAGIE

FACTEURS

 

PNEUMOTHORAX

 

ASSOCIÉS À LA BIOPSIE PULMONAIRE : UNE EXPÉRIENCE UNICENTRIQUE

http://www.lebanesemedicaljournal.org/articles/60-1/original1.pdf

 

Tarek SMAYRA1, Chadi BRAIDY1, Lina MENASSA-MOUSSA1, Sani HLAIS2, Soha HADDAD-ZEBOUNI1, Noel AOUN1

Smayra T, Braidy C, Menassa-Moussa L, Hlais S, Haddad-

Smayra T, Braidy C, Menassa-Moussa L, Hlais S, Haddad-

Zebouni S, Aoun N. Facteurs de risque du pneumothorax et de

Zebouni S, Aoun N. Risk factors of pneumothorax and hemor-

l’hémorragie associés à la biopsie pulmonaire : une expérience

rhage in lung biopsy : a single institution experience. J Med

unicentrique. J Med Liban 2012 ; 60 (1) : 4-13.

Liban 2012 ; 60 (1) : 4-13.

RÉSUMÉ • OBJECTIFS : La biopsie pulmonaire trans-

 

 

 

 

ABSTRACT : OBJECTIVES : CT-guided transthoracic

thoracique est largement utilisée pour le diagnostic des

lung biopsy is widely used in pulmonary lesions diagno-

masses pulmonaires. Elle s’accompagne de complica-

sis. This technique rarely entails severe complications

tions, rarement sévères, telles que le pneumothorax ou

such as pneumothorax and pulmonary hemorrhage

l’hémorragie pulmonaire, nécessitant une bonne sélec-

which call for adequate candidates screening. The aim

tion des candidats. Notre but est d’évaluer les facteurs

of our study is to statistically assess risk factors related

de risque en corrélation avec ces deux principales com-

to these two main complications, and determine the best

plications, pour une prise en charge diagnostique opti-

diagnostic workup.

male.

MATERIALS AND METHODS : This retrospective study

MATÉRIELS ET MÉTHODES : Cette étude rétrospective

includes 110 patients who underwent CT-guided

concerne 110 patients ayant une lésion pulmonaire

transthoracic biopsy of a pulmonary lesion. Rates of

biopsiée sous scanner. Les taux de pneumothorax et

pneumothorax and pulmonary hemorrhage, as well as

d’hémorragie ainsi que leur sévérité ont été calcu-

their severity, were evaluated, and a correlation with

lés, et une corrélation avec des variables concernant

factors related to patients, lesions and biopsy technique

le patient, la lésion et la technique, est statistiquement

were statistically analyzed.

étudiée.

RESULTS : Higher rates of complications are signifi-

RÉSULTATS : Une majoration significative du risque

cantly found with multiple punctures (pneumothorax

de complication est retrouvée avec la multiplication des

risk multiplied by 7.4), longer intra-parenchymal

ponctions (pneumothorax multiplié par 7,4), la lon-

needle tract (5 and 7% higher risk of pneumothorax

gueur du trajet parenchymateux de l’aiguille (augmen-

and hemorrhage for every 1 mm increase in depth),

tation de 5 et 7% des risques de pneumothorax et

and with smaller lesions (2 and 5% lower risk respec-

d’hémorragie pour chaque millimètre traversé), et avec

tively for pneumothorax and hemorrhage for every

la diminution de la taille des lésions (baisse de 2 et 5%

1 cm increase in lesion size). The presence of an inter-

des risques de pneumothorax et d’hémorragie pour

posing rib is associated with a higher rate of hemor-

chaque augmentation de 1 cm de taille). La présence

rhage.

d’une côte entravant la biopsie paraît augmenter le taux

CONCLUSION : Transthoracic lung biopsy is a mini-

d’hémorragie.

mally invasive technique. However, the presence of

CONCLUSION : La biopsie pulmonaire transthora-

associated risk factors must lead to consider another

cique est une technique peu agressive. Cependant, la

diagnostic method.

présence de plusieurs facteurs de risque réunis doit

bonne corrélation avec les résultats de la thoracotomie [1].

faire rechercher une autre méthode diagnostique.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Au départ, lorsqu’elle a été introduite, elle se pratiquait

 

 

 

 

 

 

 

 

INTRODUCTION

sous fluoroscopie, et présentait des taux de complication

 

 

 

 

 

 

 

 

élevés [2-3]. Actuellement, avec le guidage scannogra-

La biopsie pulmonaire par voie transthoracique est

phique et la maîtrise de cette technique, on note moins de

complications. Le pneumothorax et l’hémorragie avec ou

actuellement une méthode diagnostique incontournable

sans hémoptysie sont les complications les plus fréquem-

pour la caractérisation des lésions pulmonaires en raison

ment rencontrées avec des taux variables selon la littéra-

de ses sensibilité et spécificité élevées, ainsi que de sa

ture [4-17]. Dans notre étude, 110 biopsies pulmonaires

Services de 1Radiologie, Centre hospitalier universitaire

transthoraciques sous contrôle scannographique réalisées

entre mars 2003 et octobre 2008 ont été rétrospectivement

Hôtel-Dieu de France ; 2Médecine de Famille, Faculté de

étudiées avec analyse de différentes variables concernant

Médecine, Université Saint-Joseph, Beyrouth, Liban.

le patient, la lésion biopsiée et la technique utilisée, à la

Correspondance : Docteur Tarek Smayra.

recherche d’éléments prédictifs des deux complications

e-mail : tarek_smayra@hotmail.com

principales.

4 Journal Médical Libanais 2012 • Volume 60 (1)