Table of Contents

Original Articles

Early outcomes of patients after on-pump coronary artery bypass grafting at Mohammed Bin Khalifa Bin Salman Al Khalifa Cardiac Center, Bahrain Defence Force Hospital in the Kingdom of Bahrain

Kristianna Verhagen-Mostafa,* Habib E. Tareif,** Zaid Arekat,*** Marwan Mostafa,***

Pages: 66-70
  • Abstract
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  • Background: Coronary artery bypass grafting (CABG) is increasingly performed on patients with acute coronary syndrome in Bahrain. Recognition of early outcomes associated with the procedure can provide members of the healthcare team with a better awareness of their occurrence, hence can impact on important decisions with respect to provision of monitoring, diagnosis, and further treatment.
    Objective: The objective of this study is to determine the early outcomes of patients who have undergone on-pump CABG at Mohammed Bin Khalifa Bin Salman Al Khalifa Cardiac Center, Bahrain Defence Force Hospital (BDF) in the Kingdom of Bahrain.
    Method: This is a retrospective medical record review of patients who have undergone on-pump CABG at BDF Hospital from January 1, 2010 to December 31, 2010. Data extraction was carried out by one investigator and cross checked.
    Results: 150 patients were included in this study, 85.3% were between 40 and 59 years of age and 70% were male. 43.3% of patients stayed in the Intensive Care Unit (ICU) for 5 days. One patient had congestive heart failure and another one had stroke. Two patients had acute renal failure. Post-op ejection fraction at 30-40% was seen in 35% of patients. Blood loss in 25% of patients was estimated at 150cc. Post-operative wound complication occurred in 3 patients, and in one this necessitated sternal debridement.
    Conclusion: On-pump coronary artery bypass grafting (CABG) is increasingly being undertaken for Bahraini men aged 40-59 years, with ejection fraction lower than normal levels who have multi-vessel disease. The relative safety of CABG was illustrated by the comparatively low mortality rate.

Prevalence of asthma and allergic diseases in children aged 6-7 in the Kingdom of Bahrain

Hind Al-Sindi,* Mazen Al-Mulla,* Amina Bu-Saibaa,* Bushra Al-Sharaf,* Jaleela S. Jawad,** Osama A. Karim,***

Pages: 71-74
  • Abstract
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  • Objective: To estimate the prevalence of asthma, rhinitis and eczema symptoms in school children aged 6-7 years.

    Design: A cross-sectional study of randomly selected primary schools for children.

    Setting: Government and private primary schools in Bahrain.

    Method: A standardized ISAAC-validated Arabic-translated questionnaire was distributed to 3,000 students aged 6-7 years in 18 primary schools which was to be completed by parents or guardians.

    Results: 1,951 questionnaires were completed. Participants included 1,094 males (56.1%) and 857 (43.9%) females. The prevalence of asthma was 10.8%, allergic rhinitis, 16.5% and eczema, 9.8%. The prevalence rates for physiciandiagnosed asthma were greater in males 13.3% than females 8.7% [CI (1.8-7.4)]. Symptoms of sneezing or blocked nose showed male gender predominance (18.3%) in comparison to females (14.2%) [CI (0.77-7.5)]. Ever diagnosed hay fever also followed the same pattern of a male predominance of 5.4% in comparison to 3.3% in females [CI (0.24-3.9)]. Female predominance was found in prevalence of itchy rash, 12.5% in comparison to males (8.5%) [CI (-6.9 to -1.2)]. 58.6% had symptoms of allergic rhinitis with a significant peak in the winter season [CI (50.9-66.3)], only 11.2%, had symptoms in the summer season [CI (6.48-16.4)].

    Conclusion: Prevalence of asthma, rhinitis and eczema symptoms found in this study were all similar to those reported in other Gulf neighboring countries; with a significant male predominance found in asthma and rhinitis, but not in atopic eczema.

Reasons for under-reporting of notifiable communicable diseases in the Kingdom of Bahrain: a health-centers based survey

Dalal Adnan Al-Hashimi,* Khaldoon Al-Roomi, ** Adel Salman Al-Sayyad, ***

Pages: 75-79
  • Abstract
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  • Background: Poor compliance by physicians with communicable diseases reporting is a worldwide phenomenon. In Bahrain, there are limited data regarding thoroughness and completeness of the current communicable diseases reporting system.

    Objective: To identify reasons for noncompliance with reporting of notifiable communicable diseases by primary health care physicians practicing in the Ministry of Health (MoH) primary health care centers.

    Methods: This is a cross-sectional study. Two hundred and forty-one self-administered questionnaires were distributed to all primary health care physicians practicing in all primary care health centers of the Ministry of Health. The questionnaires included items regarding socio-demographic and practice-related characteristics, self-reported practice related to communicable diseases reporting and reasons for noncompliance with reporting requirements.

    Results: The response rate was 93%; the mean age of the respondents was 43 ±8.36 years. The period of experience in clinical practice ranged from 1 to 35 years with a mean of 12.84 ± 7.86 years. Lack of feedback on notified cases, forgot to notify, and not sure of diagnosis were cited by more than half of the physicians as reasons for noncompliance with communicable diseases reporting.

    Conclusion: The findings suggest that there are several reasons for noncompliance with reporting requirements. Revising the current notification procedure to resolve some of the reasons is vital to enhance communicable diseases reporting in Bahrain.

    Keywords: Bahrain; communicable diseases; notification; reporting; reasons

Asthma knowledge, attitude and prescribing behavior of primary health care physicians in the Kingdom of Bahrain

Fatima Ahmed Al-Jurdabi,* Huda Al-Ebraheem**

Pages: 80-86
  • Abstract
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  • Background: Asthma is a serious public health problem, affecting people of all ages. When uncontrolled it can cause significant morbidity and mortality. Poor implementation of the guidelines is considered one of several barriers for achieving asthma control.

    Objectives: To determine the asthma knowledge, attitude and prescribing behavior of primary health care physicians in the Kingdom of Bahrain.

    Methods: A cross–sectional survey was carried out from March 2012 to March 2013 among primary health care physicians (PHC) attending asthma workshops as part of a continuing medical education program. During the study period 5 workshops were conducted which were attended by PHC physicians. A self-administered questionnaire was designed to achieve the research objective. The questionnaire was based primarily on a previous study carried out by the Chicago Asthma Surveillance Initiative (CASI) in the USA; a similar questionnaire was used in a study conducted in 2004, and permission was taken from the investigators to use it in our study. Questionnaires were distributed to the study groups at the beginning of each workshop and 192 of the 240 attending doctors completed the questionnaire, an 80% response rate.

    Results: The responders were mainly family physicians (66.7%), of whom 73.4% were following asthma guidelines. The study showed that slightly more than half of PHC physicians (56.8%) were able to assess the level of asthma control appropriately and the majority of them reported scheduling regular follow-ups for their patients. However, only 39.1% of PHC physicians were aware of the appropriate medication recommended for step 1 and only 37.3% of them reported that they provided written plans for their patients.

    Conclusion: Various aspects of GINA guidelines appear to have been integrated into clinical practice by primary care physicians in the Kingdom of Bahrain, whereas other recommandations do not seem to have been readily implemented.

    Keywords: Primary health care physicians; bronchial asthma; PHC; Kingdom of Bahrain

Attitudes of primary care physicians towards insulin initiation in people with type 2 diabetes in Bahrain

Fatima Habib*, Jameel Nasser*, Jaffer Abbas,  Zahra AlMussali*, Nahla Madan*

Pages: 87-92
  • Abstract
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  • Objective: The aim of this study is to explore the beliefs and attitudes of primary care physicians (PCP) regarding insulin initiation in people with type 2 diabetes.

    Methods: A structured, adapted questionnaire was distributed to all primary care physicians. The questionnaire consisted of 2 parts: the first part collected information on physicians’ demographic characteristics; the second part contained 30 items measuring the beliefs and attitudes of physicians regarding insulin initiation.

    Results: A total of 171 physicians out of 245 completed the questionnaire with a response rate of 70%. Most of the physicians were between 30 and 59 years of age. The majority were females (79.4%), had been in practice for >10 years and were certified family physicians seeing more than 25 diabetic patients a week. About 75% of the physicians found initiation of insulin as one of the most difficult aspects of managing patients with type 2 diabetes. The main obstacles reported by physicians were: route of administration by injection, the risk of hypoglycemia, and the patients’ level of education. However, they agreed that the benefits of insulin outweighed the risks of hypoglycemia and weight gain. Only 45% of them agreed that patients will eventually need to go on insulin regardless of how well they adhere to treatment. Moreover, 31.8% of physicians stated that increased levels of plasma insulin will increase the risk of cardiovascular events.

    Conclusion: Physicians’ concerns and lack of knowledge regarding insulin use may act as barriers to insulin initiation. This may increase the risk for a higher rate of uncontrolled diabetes and its subsequent complications.

    Keywords: insulin; family physician; Bahrain

Primary colorectal anastomosis, no preparation, no stoma needed

Khalid A. Beerdawood*, Faiez D. Alhmoud**, Atef A. Al Namoura***, Abdel Hadi S. Al Briezat****

Pages: 93-97
  • Abstract
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  • Background: Mechanical bowel preparation was regarded for a long time as a vital prerequisite for successful colorectal surgery; this is now being questioned. The distressful effect of bowel preparation, alongside the safety of primary colorectal anastomosis in emergency cases, has led to a considerable change in the surgical protocol, making primary repair and anastomosis after colon resection safer without bowel preparation, and the role of colostomy has changed from mandatory to optional.

    Aim: To assess whether colorectal surgery can be performed safely without mechanical bowel preparation or colostomy.

    Method: A series of 130 patients, who underwent elective and emergency colorectal surgery, were followed prospectively over a three-year period in Al Bashir Teaching Hospital, Amman, Jordan. The patients were randomized into two groups. In one group (preparation group) 66 elective patients were selected from the outpatient department; the bowel was prepared using Fortran’s solution. In the second group (non-preparation group), 64 patients were selected from the emergency and outpatient departments, no bowel preparation was used. Colostomy was omitted in both groups. The main outcomes regarding operative time, hospital stay, rate of postoperative wound infection, anastomotic leak and intra-abdominal abscess were compared between the two groups.

    Results: Malignancy was the most prevalent pathology in both the preparation and non-preparation groups, 75.7% and 62.5% respectively, while benign diseases were present in up to 24.2% of the preparation group and in 1.5% of the non-preparation group. Anastomosis was ileo-colic in 33.3% and 37.5%, colo-colic or colo-rectal in 66.6% and 62.5% of the preparation and non-preparation groups respectively. There was no significant statistical difference in the overall postoperative complication rates between the two groups, 16.6% in the preparation group and 14% in the non-preparation group. Postoperative wound infection, wound dehiscence, intra-abdominal abscess and anastomotic leak occurred in 9.09%, 1.5%, 1.5% and 4.5% in the preparation group, as compared to 7.8%, 3.1%, 0% and 3.1% in the non-preparation group respectively. The mortality rate was nil in both groups.

    Conclusion: Resection of colorectal pathology followed by primary anastomosis, without stoma, can be performed safely with the omission of preoperative mechanical bowel preparation.

    Keywords: colorectal surgery; primary anastomosis; mechanical bowel preparation; anastomotic leak; stoma

Non-compliance of children with ADHD to outpatient clinic appointments at the Psychiatric Hospital, Kingdom of Bahrain

Dr. Ahmed M.S. Al-Ansari* Maisa Al-Khunaizi**

Pages: 98-100
  • Abstract
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  • Introduction and Objectives: Non-adherence to clinic appointments by children with ADHD is considered a major obstacle to treatment.The aims of the study were to determine the rate of non-compliance to treatment and to identify the reasons for non attendance, as well as the characteristics of children who did not comply with clinic appointments.

    Method: A retrospective cross-sectional survey was undertaken of all children aged 18 years and under who attended the Child Psychiatric Unit, Psychiatric Hospital, Bahrain, from June 2010 until September 2011 and who were subsequently diagnosed with ADHD according to DSM-IV and Conners’ Parent and Teacher checklist (n=53).

    Results: More than 60% of the cases did not keep their clinic appointments. Their families were characterized by a higher level of education and social status compared to other parents attending the same clinic. Non-compliant children were characterized by the presence of comorbidity (53%), and were in the older age group.

    Discussion and Conclusion: The degree of compliance to outpatient clinic appointments of children with ADHD should be monitored regularly in team meetings. Problems should be analyzed and solved quickly to ensure better compliance. Education of parents and children should be an integral part of the management plan and presented to families as soon as diagnosis is reached.

    Keywords: Non–compliance; children; ADHD; Reasons; Bahrain

Identifying employees at high risk of diabetes among the medical staff of Jaber Al-Ahmed Armed Forces Hospital in Kuwait and screening them for diabetes

Muneera AlRandi,* Amal HJ Hussain,** Yousef Ahmed Al-Nesef,*** Wafa Ebrahim Alsharbati,****
Alanoud M Alobaidly,* Abdulla Abu Almelh,*

Pages: 101-104
  • Abstract
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  • Background: Diabetes mellitus is one of the top diseases leading to morbidity and mortality in Kuwait. There is often a delay in diagnosing patients with type 2 diabetes due to the long asymptomatic pre-clinical stage and complications are commonly present at diagnosis. Screening can identify diabetics and treatment can be initiated earlier to prevent complications. Screening can detect pre-diabetics who may benefit from interventions to prevent or delay progression to diabetes.

    Objectives: The aim of this study is to estimate the prevalence of risk factors for diabetes in healthy employees and screen those with high risk for diabetes.

    Method: A cross-sectional study conducted in Jaber Al-Ahmed Hospital from October to November 2012. The Finnish questionnaire for diabetes risk assessment was used to categorize participants into different risk categories for diabetes. Participants considered to be at high risk were screened for diabetes using HbA1c.

    Results: 647 employees participated in the study. 70.6% of the participants were overweight or obese; more than half had a high waist circumference and 23% were smokers. Kuwaiti employees tended to have more risk compared to non- Kuwaitis (P<0.001) with 27.6% of Kuwaitis belonging to the low risk group compared to 42.4% of the non-Kuwaitis. HbA1c testing showed that out of the 51 participants with high/very high risk, 6 (11.8%) were diabetics and 26 (51.0%) were pre-diabetics.

    Conclusion: Screening and a diabetic risk assessment for those at high risk should be part of the routine occupational health check program in the hospital.

    Keywords: diabetes; occupation; health; screening; Kuwait; risk

Short communications/brief reports

From junk science pawn to public-led trials

Amy Price*

Pages: 113-115
  • Abstract
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  • Junk scientists and unethical healthcare providers often tell the public that systematic reviewers reject real research because of bias or that universities and the FDA are paid off by the pharmaceutical industry. I was snared in this trap during my role in a spinal injury foundation after sustaining significant brain and spine injuries. I was too naïve and damaged to understand that not all doctors are ethical or that the role of the FDA is in protecting public health. As my brain started to recover I began attending classes at the Open University and I found the world of ethics, research methods and cell biology. Soon my days at the spinal organization were numbered as I pointed out errors in the protocols and discrepancies in what the participants should know. I shared that vulnerable persons need to be informed they are participants and not patients and that it was unethical to charge patients for experimental research or use them as shields against the recommendations of the FDA. The organization battled the FDA who won a permanent injunction against them. I was dismissed long before this but felt like I had blood on my hands. I decided I would become an informed healthcare provider and I proceeded to learn Evidence-Based Healthcare at the University of Oxford where I completed the Masters and went on to become a Doctor of Philosophy student to bring evidence-based healthcare and public led trials to the masses. This is my story.

    Keywords: Public-led trials; fecal implants; citizen health research; public engagement; evidence–based healthcare

Case Reports

The eye - the window to the soul of the diagnosis: CHARGE Syndrome, a case report

Amal Redha Hubail,* Jinan Harith Darwish*

Pages: 105-107
  • Abstract
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  • The modality of inheritance in CHARGE syndrome is autosomal dominant, classically triggered by mutations in the chromo-domain helicase DNA binding protein-7 (CHD7) gene. CHARGE syndrome is characterized by the variable occurrence of coloboma, heart defects, atresia of the choanae, retarded growth and development, genital hypoplasia, ear anomalies and deafness. In this report, we describe an infant with a typical phenotype characterized by severe psychomotor retardation, facial asymmetry, coloboma, cortical blindness, unilateral choanal atresia, congenital heart anomalies, genital hypoplasia, cranial nerve IX/X dysfunction and global developmental delay that was diagnosed clinically.

    Following clinical diagnosis a complete sequencing of the CHD7 gene was carried out at the Institute for Medical Diagnostics GmbH in Ingelheim, Germany. Genomic DNA was screened for mutations in the CD7 gene (OMMIM 608892) on chromosome 8q12.1 The codon exon 2-38 and the respective exon-intron boundaries were amplified by polymerase chain reaction and analysed by direct sequencing. Resulting sequence data were compared with the reference sequence NM_017880.3 No mutation in CHD7 gene was detected as a genetic cause for the clinical phenotype of the patient. The MPLA multiplex ligation-dependent probe amplification analysis showed no copy number variation in the CHD7 gene.

    This case report underscores the importance of a detailed family history and physical examination in the diagnosis of CHARGE syndrome. Additionally, it provides valuable insight into the pathogenesis and clinical presentation of the syndrome as well as highlighting the benefits of a multidisciplinary approach. With supportive nurturing care, children with CHARGE syndrome can overcome the associated disabilities and develop necessary motor skills and a life-style enhancing level of fitness.

    Keywords: CHARGE syndrome; CHARGE association; Hall-Hittner syndrome; CHD7 gene; empty sella

11β hydroxylase deficiency in children: the first case reported from Bahrain

Mansoor H. Rajab,* Abdul Raoof Almadhoob,** Hasan M. Isa ***

Pages: 108-111
  • Abstract
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  • Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder commonly caused by 21-hydroxylase deficiency. It accounts for 90-95% of cases. The second most common cause is 11β hydroxylase deficiency. We report on the first case of 11β hydroxylase deficiency in Bahrain with a review of the literature.

    Keywords: 11β hydroxylase deficiency; congenital adrenal hyperplasia (CAH)

Consideration of primary hyperparathyroidism in primary care

Basem Abbas Al Ubaidi*

Pages: 111-112
  • Abstract
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  • A sixty-seven-year-old female patient presented with symptomatic hypercalcemia as the first manifestation of primary hyperparathyroidism due to parathyroid adenoma. Initially the chronic hypercalcemia was investigated and then subsequent parathyroidectomy was done. She is doing very well six months following the surgery and the hypercalcemia has resolved completely.