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Table of Contents

Letter to the Editor

The Cochrane Collaboration’s Complementary Medicine Field and traditional medicines of the Middle East

Eric Manheimer,PhD1, 2

Pages: 4

Original Articles

The Burden of climate-related conditions among laborers at Al-Razi Health Centre, Bahrain

Adel Salman Al-Sayyad,*, ** Randah R. Hamadeh*

Pages: 5-8
  • Abstract
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  • Background: The negative effects of climate change on human health and well-being are widely documented in recent literature. The poorest countries, and the most vulnerable and marginalized individuals, experience the worst consequences from climate change. Laborers are more prone to climate-related conditions (CRC) as they are considered one of the under-privileged populations with low salaries and unfortunate living and working conditions.
    Objectives: To measure the burden of CRC on health services in the main laborers’ clinic in the Kingdom of Bahrain.
    Methods: A cross-sectional study of expatriate workers who attended Al-Razi Health Centre (ARHC) during the study period. A convenience sample was selected and a specific questionnaire was designed for the purpose of this study. The variables included in the questionnaire were age, gender, nationality, occupation, work setting, diagnosis including CRC, medications prescribed and length of sick leave given. CRC were identified and grouped by a panel of experts in line with the published literature.
    Results: Out of a total number of 3,715 visits during the study period, CRC visits represented 1,111 with a proportion of 29.9%. The majority (70%) of the CRC patients were working solely outdoors. Infectious diseases were the most common (62.9%) CRC followed by heat-related diseases (16.5%).
    Conclusion: CRC have a significant burden on the health services at ARHC. CRC appear not to be significantly associated with age, nationality or place of work of laborers.

    Keywords: climate; weather; laborers; outdoor jobs; Bahrain

Screening for adolescent depression: a study conducted in a primary care center in Bahrain

Shereen Hussain1*, Reham A. Al Garf2

Pages: 8-13
  • Abstract
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  • Background: Depression is the second most common chronic disorder seen by physicians in primary care, where an average of 12% of patients might present with major depression. Depressed patients are more likely to see a primary care physician than a specialist for both initial diagnosis and treatment.
    Methods: As part of the celebration for the Gulf Youth Day in October 2012, fifty-five students were invited to Naim Health Centre. The patient health questionnaire was distributed to them to screen for mental disorders. The students were given instructions on how to complete the questionnaire and the participating clinicians scored the responses and summarized the results.
    Results: Nine students had major depressive disorders and fifteen students had other depressive disorders. Seven of the students with major depressive illness had suicidal ideation compared to nine out of the fifteen students with other depressive illnesses. In addition, seven of the students who tested negatively for depressive illness, still had suicidal ideation.
    Conclusion: It is critically important that primary care practitioners are able to correctly identify patients suffering from depression. Screening is a very effective first step in the detection, diagnosis, and treatment of depression in primary care. However, the skillful clinical interview which incorporates verbal communication and good interpretation of non-verbal clues is crucial and indispensable for effective and reliable diagnosis.

    Keywords: Depression, Adolescents, Primary care, Screening, Self-reporting questionnaire

Prevalence of depression in diabetics attending primary healthcare centers in the Eastern Province of Saudi Arabia

Nazieha A. Al-Muzien,* Latifa S. Al-Sowielem**

Pages: 14-18
  • Abstract
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  • Background: The prevalence of diabetes in Saudi Arabia ranks as one of the highest in the world. Many studies have found depression to be higher in diabetics than in the general population thus increasing costs and incidence of complications. To the best of our knowledge, no study has addressed the issue of depression in diabetics in Saudi Arabia.
    Objectives: To assess the prevalence of depression and its associated factors in adult Saudi diabetics attending primary healthcare centers in the Qatif area.
    Method: A cross-sectional study conducted in Qatif primary healthcare centers from January to February 2011. Nine centers were selected by stratified sampling. Systematic sampling of adult Saudi diabetics attending those centers was done and the selected patients were interviewed and asked to complete a two-page questionnaire, which included an Arabic version of PHQ9 depression questionnaire. Files of the interviewed patients were reviewed to assess the level of diabetes control.
    Results: A total of 325 patients participated in the study. Prevalence of depression was found to be 14.5%. The prevalence of major depressive disorder was 6.2% and other depressive disorders were 8.3%. The presence of complications, co-morbidities and, in male patients, older age were found to be risk factors for depression in diabetics. The level of control was better in non-depressed patients while compliance with treatment had no relation with depression.
    Conclusion: Depression is an important prevalent co-morbidity in diabetic patients. Screening for depressions an important part of comprehensive diabetic care. Further studies of depression in diabetics in Saudi Arabia are recommended.

    Keywords: Qatif primary health care; depression; diabetes mellitus; PHQ-9

Epidemiology of tuberculosis in Bahrain: analysis of surveillance data, 2000-2006

Jaleela S. Jawad,* Adel Salman AlSayyad,* Kubra S. Nasser*

Pages: 19-23
  • Abstract
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  • Background: In 1996 Bahrain and other members of the Gulf Cooperation Council (GCC) formulated a tuberculosis elimination initiative. The objective of this initiative was to decrease the incidence of smear-positive pulmonary tuberculosis to 1 per 100,000 by 2010.
    Objective: To describe the trend of tuberculosis incidence rates and the characteristics of tuberculosis cases in Bahrain.
    Methods: A retrospective descriptive study of surveillance data of all TB cases diagnosed in Bahrain between January 2000 and December 2006, collected from Salmaniya Medical Complex, Ministry of Health, and medical records. Additional sources were accessed for tuberculosis records. Data were entered, validated and analyzed using SPSS-16 statistical package. Frequencies and cross tabulations were generated. Categorical variables were tested using the Chi Square test.
    Results: Over the seven-year study period, 1,584 tuberculosis cases were diagnosed in Bahrain. There was a slight rise in the overall incidence of tuberculosis among both Bahrainis and non-Bahrainis with little or no downward trend; however, this remained low among Bahrainis, ranging from 12.5 to 16.8 per 100,000 per year. The incidence was higher among non-Bahrainis ranging from 47.4 to 75 per 100,000. Asians were the commonest non-Bahraini nationality with tuberculosis. The incidence of pulmonary tuberculosis was higher than extra-pulmonary tuberculosis in both Bahrainis and non-Bahrainis with male predominance in both groups. Among Bahrainis, the most affected were those over 65 years of age.
    Conclusion: Despite the rising incidence of TB in Bahrain, migrant workers were the major contributors to this increase. TB incidence among Bahrainis was low.

    Keywords: tuberculosis; incidence; rate; surveillance; TB; expatriate workers

Effect of age and gender on corrected QT interval in healthy adults

Yasir M. Khaleel,* Baybeen K. Al-Selevany,* Muzahim F. Mahmood**

Pages: 24-28
  • Abstract
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  • Background: In spite of the clinical importance of accurate measurement of QT and corrected QT intervals during electrocardiographic interpretation, there appears to be some considerable difficulty in its precise measurement and in the determining of the upper accepted value for each gender. In addition to gender, QT intervals can also be affected by age and racial factors.
    Objectives: To evaluate the impact of age on corrected QT interval in healthy adults according to gender.
    Methods: Electrocardiograms from 563 apparently healthy adults (386 male and 177 female) aged 18-40 years were obtained using Cardios PC based ECG machine; 12-lead ECGs were recorded and corrected QT interval was measured by computer and reviewed manually in leads II, V2, V3, V5 and V6. The correction of QT interval was based on Bazett’s  formula. The mean QTc was calculated for the whole study sample and then for each gender separately; the mean QTc was compared between genders and in different age groups. Linear regression lines of QTc versus age were drawn in each gender separately.
    Results: The mean ±SD of QTc (414.95 ±24.94) in the study sample was within normal range although close to upper limits. Subjects with prolonged QTc (>430 ms) represented about 24% of the total. The mean QTc in females was significantly longer than males (p=0.001), prolonged QTc was also significantly more frequent in females (p=0.001). There was a significant increase in the mean QTc with increasing age in the study sample (p=0.001), and a significant increase in the frequency of reported prolonged QTc with the older age group (p=0.018). Linear regression lines of QTc versus age in each gender separately have shown that females have longer QTc than males; the difference was more noticeable in younger females and decreased with increasing age.
    Conclusions: QTc interval is both age and gender dependent, so it is worth using linear regression lines drawn according to age and gender in the determination of its normal value.

    Keywords: corrected QT interval; healthy adults; age; gender

Prevalence of anemia among nine-month-old infants attending primary care in Bahrain

Manal Al-Alawi,* Nadia Sarhan,*

Pages: 29-32
  • Abstract
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  • Background: Anemia in children is a frequent problem. Worldwide, it affects 25% of the population ranging from 64.6% in Africa to 3.4% in North America. Iron deficiency is the main cause of anemia. Even though  studies indicate that the percentage of anemia among preschool children is decreasing in Bahrain, it is still considered high and needs immediate intervention.
    Objective: To estimate the prevalence of anemia among nine-month-old infants attending child screening services in local health centers during the month of July 2012, and to examine the correlation between hemoglobinopathies and anemia in mothers during pregnancy and anemia in infants.
    Methods: This was a descriptive, retrospective study. The records of 1,378 nine-month-old infants attending mother and child care for child screening services in all local health centers during July 2012 were studied.
    Results: 1,230 infants (89.3%) had hemoglobin level test done. 498 cases (40.5%) were anemic, mainly of the mild type; 208 anemic children (41.8%) had no hemoglobinopathies, 140 (28.1%) had hemoglobinopathies and 150 (30.1%) were not tested for hemoglobinopathies. The commonest type of hemoglobinopathy was alpha-thalassemia, 91 (18.5%), followed by sickle cell trait, 58 (11.6%). 224 of the mothers of anemic infants (45%) had no anemia and 218 (43.8%) were anemic. Overall, 338 mothers with anemic infants (76.4%) had no hemoglobinopathies.
    Conclusion: Anemia among infants is decreasing in the Kingdom of Bahrain generally and decreasing with age specifically but it is still considered a severe public health problem. Most of the cases of anemia among nine-month-old children are due to iron deficiency anemia and one-fifth of the cases are hemoglobinopathies. It is recommended that iron drops be supplied as daily dietary supplementation at weaning and to be continued for one year for those with negative sickle cell disease and thalassemia test at birth.

    Keywords: prevalence of anemia; child screening services; hemoglobinopathies; Bahrain

Prevalence and associated risk factors for the development of albuminuria in patients with type 2 diabetes at NCDEG Jordan

Zainab Abbas Al Hasan

Pages: 33-41
  • Abstract
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  • Objective: To investigate the prevalence of albuminuria (microalbuminuria and macroalbuminuria) in patients with type 2 diabetes mellitus (DM) attending the National Center of Diabetes, Endocrinology, and Genetics (NCDEG) in Jordan. The second objective of the study was to determine if there is any association between albuminuria (microalbuminuria and macroalbuminuria) and a number of independent variables, including glycemic control, hypertension, duration of diabetes mellitus, serum lipids, body mass index, smoking, age, gender and the presence of retinopathy.
    Methods: A cross-sectional study was carried out at the National Center for Diabetes, Endocrinology, and Genetics (NCDEG), Jordan. A total of 869 diabetic patients aged 30 years and above with type 2 diabetes mellitus who attended the clinic from 1st September 2007 through 10th January 2008 were included. At least two out of three random morning spot urine samples were collected in a three-month period to determine the urinary albumin-creatinine ratio (ACR). Microalbuminuria is defined as an ACR of 30-299 mg/g and macroalbuminuria is defined as an ACR >300 mg/g according to the definition proposed by the American Diabetes Association (ADA). Socio-demographic, clinical, and laboratory data were obtained from the medical records of patients. Statistical analysis was carried out using the Statistical Package for the Social Sciences (SPSS, version 11.5).
    Results: Out of the 880 patients recruited, 5 (0.6%) were excluded due to the presence of urinary tract infections and 6 (0.7%) for the presence of congestive heart failure, leaving 869 patients for evaluation. There were 56.0% male and44% female. The mean age and duration of diabetes were 57.8 years and 9.5 years, respectively. Approximately 62% were being managed by oral hypoglycemic agents alone, 4.3% by insulin alone, 31.7% were on a combination of oral hypoglycemic agents and insulin and slightly less than 2% were on dietary measures alone. The mean value for HbA1c was 7.71%. The overall prevalence of  albuminuria among participants was found to be 34.6%; microalbuminuria (29.3%) and macroalbuminuria (5.3%). Multivariate logistic regression analysis identified HbA1c, SBP, DBP and the presence of retinopathy as independent risk factors for microalbuminuria and SBP. Male gender and presence of retinopathy were identified as independent risk factors for macroalbuminuria.
    Conclusion: Albuminuria is highly prevalent among Jordanians with type 2 diabetes. This calls for early and universal screening of urinary albumin. There is also an urgent need for measures that target tight glycemic and optimal blood pressure control and the use of renin-angiotensin system blockade.

    Keywords: diabetes mellitus; microalbuminuria; macroalbuminuria; Jordan

Short communications/brief reports

Statement on mouth cancer diagnosis and prevention

Crispian Scully

Pages: 48-49

Selenium supplementation for Hashimoto’s thyroiditis

Esther J. van Zuuren

Pages: 53-54

Preterm birth: Understanding a mother’s experience

Sana Haji*

Pages: 56-58

Review Articles

A Bibliometric analysis of articles indexed in PubMed, 1988-2012, with Bahrain as first author affiliation

Bruce M Manzer

Pages: 50-53

Inappropriate use of antibiotics in dentistry

Anirudha Agnihotry,* Jassim Hassan Al-Langawi,** Ankur Khanna, ***

Pages: 55-56

Case Reports

Giant cell hepatitis and Coomb’s positive autoimmune hemolytic anemia: a case report and literature review

Hasan M. Isa,* Lina F. Al Ali,** Afaf M. Mohamed,*** Rawia M. Hamad,****

Pages: 42-46
  • Abstract
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  • Giant cell hepatitis (GCH) with autoimmune hemolytic anemia (AIHA) is a rare disease occurring early in childhood. The exact cause of this illness is unknown and is assumed to be an autoimmune disorder. This disease often has a fatal outcome due to poor response to immunosuppression. In this paper, we report an 11-month-old male infant who presented initially with Coomb’s positive autoimmune hemolytic anemia followed by histology-proven GCH and rapid progression to fulminant hepatic failure and death within two months from the onset of the disease despite aggressive immunosuppression. In addition, we review the available literature about the clinical presentation, diagnosis and therapeutic options of this rare disease. 

    Keywords: giant cell hepatitis; autoimmune hemolytic anemia

Necrotizing scleritis following pterygium surgery

Nada Al-Yousuf,*

Pages: 46-48
  • Abstract
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  • A case report of a 52-year-old Bahraini male who underwent pterygium surgery with amniotic membrane transplant without adjunctive therapy of mitomycin C or beta irradiation. Post operatively, he developed necrotizing scleritis at the site of pterygium surgery. He underwent conjunctival graft on the scleritis. One week post operatively, the conjunctival graft melted and the scleritis persisted. Subsequently, he had scleral patch graft on the scleral defect overlayed by a conjunctival autograft. His post-operative course was uneventful. This case shows that scleral melt can happen post pterygium surgery with amniotic membrane transplant. This complication is well documented following the use of adjunctive therapy such as mitomycin C or beta irradiation. It has also been reported following pterygium surgery with the bare scleral technique. To our knowledge this is the first reported case of necrotizing scleritis without adjunctive treatment and with amniotic membrane transplant. Ophthalmic surgeons should take this complication into consideration before any pterygium surgery.

    Keywords: pterygium, necrotizing scleritis, scleral melt, scleral graft