Piloting a Culturally Adapted Arabic Structured Small-Group Education Program for Adolescents with Type 1 Diabetes

BACKGROUND

Kuwait has a high prevalence and incidence of type 1 diabetes (T1D). At present there is a need for structured educational programs (SEP) specifically tailored for Arabian youth with T1D. This SEP was locally and culturally adapted from the Kids In Control of Food (KICk-OFF) course delivered at the Dasman Diabetes Institute, Kuwait.

AIMS

To explore the psychological and social impact of a pilot SEP for Arabian youth with T1D and their mothers through exploring their respective perspectives.

METHODS

All 20 participants were interviewed using semistructured interviews individually, with a duration of approximately 30-45 min. The interviews were recorded and then transcribed verbatim. Data were analyzed using an inductive thematic approach.

RESULTS

The adolescents gained more self-confidence in managing their diabetes and their mothers were more confident in allowing their children take the lead in their diabetes self-management. Participants were empowered with adequate knowledge about the underlying pathophysiology of glucose metabolism and the nutritional and pharmacological management which made them feel in control and helped them to better cope with diabetes. It reduced diabetes-related family stress and gave them more social freedom, supporting behavioral change for a better lifestyle.

CONCLUSIONS

Attending the adapted SEP had a positive impact on adolescents with T1D and their mothers through enhancement of their knowledge and confidence, thus giving them a sense of disease control. This pilot study has proven effective in terms of enhancement of confidence in diabetes management and psychosocial factors. Therefore, there is a need for a wider implementation.

ASSESSMENT OF RADIOLOGICAL HAZARDS OF USING PETROLEUM RAW MATERIALS AND THEIR WASTE

Activity concentrations of 238U, 232Th and 40K in raw and waste petroleum materials (Egypt and Kuwait) were measured using gamma ray spectrometer. The average values of 226Ra, 232Th and 40K were 21.1 ± 3.2, 7.6 ± 1.3 and 88.4 ± 8.2 Bq kg-1 for Egyptian samples while for Kuwaiti samples, they were 25.2 ± 3.4, 6.1 ± 2.2 and 67.8 ± 6.4 Bq kg-1, respectively. All samples had activity less than the exemption level recommended by the International Atomic Energy Agency. Moreover, radiological indices of radium equivalent, external, internal, alpha and gamma indices and radiation dose as well were calculated and their values were lower than the recommended regulatory limits. Thus, radiation exposure to petroleum materials did not present a significant radiological hazard.

Divulging diazotrophic bacterial community structure in Kuwait desert ecosystems and their N2-fixation potential

Kuwait is a semi-arid region with soils that are relatively nitrogen-poor. Thus, biological nitrogen fixation is an important natural process in which N₂-fixing bacteria (diazotrophs) convert atmospheric nitrogen into plant-usable forms such as ammonium and nitrate. Currently, there is limited information on free-living and root-associated nitrogen-fixing bacteria and their potential to fix nitrogen and aid natural plant communities in the Kuwait desert. In this study, free living N₂-fixing diazotrophs were enriched and isolated from the rhizosphere soil associated with three native keystone plant species; Rhanterium epapposum, Farsetia aegyptia, and Haloxylon salicornicum. Root-associated bacteria were isolated from the root nodules of Vachellia pachyceras. The result showed that the strains were clustered in five groups represented by class: γ-proteobacteria, and α-proteobacteria; phyla: Actinobacteria being the most dominant, followed by phyla: Firmicutes, and class: β-proteobacteria. This study initially identified 50 nitrogen-fixers by16S rRNA gene sequencing, of which 78% were confirmed to be nitrogen-fixers using the acetylene reduction assay. Among the nitrogen fixers identified, the genus Rhizobium was predominant in the rhizosphere soil of R. epapposum and H. salicornicum, whereas Pseudomonas was predominant in the rhizosphere soil of F. aegyptia, The species Agrobacterium tumefaciens was mainly found to be dominant among the root nodules of V. pachyceras and followed by Cellulomonas, Bacillus, and Pseudomonas genera as root-associated bacteria. The variety of diazotrophs revealed in this study, signifying the enormous importance of free-living and root-associated bacteria in extreme conditions and suggesting potential ecological importance of diazotrophs in arid ecosystem. To our knowledge, this study is the first to use culture-based isolation, molecular identification, and evaluation of N₂-fixing ability to detail diazotroph diversity in Kuwaiti desert soils.

Responses of salinity and chlorophyll-a to extreme rainfall events in the northwest Arabian Gulf: Emphasis on Shatt Al-Arab

Recent extreme hydrological events, such as high rainfall and storms, have been linked to climate change worldwide due to their relatively uncommon trends, which are generally described as having varying frequencies and higher intensities. Similar extreme rainfall trends were observed in the northwest Arabian Gulf during the 2018-2019 season. Heavy rainfall events have triggered high discharges in the river of Shatt Al-Arab, where, prior to these events, the discharge rate has exhibited a declining trend over the past 40 years. Shatt Al-Arab provides various physical, chemical, and biological functions in the region. In this study, some recent and extensive measurements of salinity and post-processed satellite images of chlorophyll-a in the northwest Arabian Gulf were recorded to assess the response of the region to the higher discharges. The results indicated that the salinity decreased significantly during and after the rainfall events in response to the higher discharges from Shatt Al-Arab. The effects of higher discharges extended over most of Kuwait's coastline, including Kuwait Bay. The chlorophyll-a distributions doubled after the extreme events, emphasising the effects of Shatt Al-Arab. Collectively, the results indicated that the discharge from Shatt Al-Arab during the extreme event exceeded 1400 m³/s, while, in the previous seasons, it rarely exceeded 80 m³/s. The higher discharge levels of discharge would result in various changes in ecology at multiple levels due to the sudden and reversing shift in the hydro-environmental processes.

Characterisation of a novel SCCmec VI element harbouring fusC in an emerging Staphylococcus aureus strain from the Arabian Gulf region

Fusidic acid is a steroid antibiotic known since the 1960s. It is frequently used in topical preparations, i.e., ointments, for the treatment of skin and soft tissue infections caused by Staphylococcus aureus. There is an increasing number of methicillin-resistant S. aureus (MRSA) strains that harbour plasmid-borne fusB/far1 or fusC that is localised on SCC elements. In this study we examined a series of related CC30-MRSA isolates from the Arabian Gulf countries that presented with SCCmec elements and fusC, including a variant that-to the best of our knowledge-has not yet formally been described. It consisted of a class B mec complex and ccrA/B-4 genes. The fusidic acid resistance gene fusC was present, but contrary to the previously sequenced element of HDE288, it was not accompanied by tirS. This element was identified in CC30 MRSA from Kuwait, Saudi Arabia and the United Arab Emirates that usually also harbour the Panton-Valentin leukocidin (PVL) genes. It was also identified in CC8 and ST834 isolates. In addition, further CC30 MRSA strains with other SCCmec VI elements harbouring fusC were found to circulate in the Arabian Gulf region. It can be assumed that MRSA strains with SCCmec elements that include fusC have a selective advantage in both hospital and community settings warranting a review of the use of topical antibiotics and indicating the necessity of reducing over-the-counter sale of antibiotics, including fusidic acid, without prescription.

Dispatcher assisted cardiopulmonary resuscitation implementation in Kuwait: A before and after study examining the impact on outcomes of out of hospital cardiac arrest victims

Dispatcher assisted cardiopulmonary resuscitation (DACPR) by Emergency medical services has been shown to improve rates of early out of hospital cardiac arrest (OHCA) recognition and early cardiopulmonary resuscitation (CPR) for OHCA. This study measures the impact of introducing DACPR on OHCA recognition, CPR rates and on patient outcomes in a pilot region in Kuwait.EMS treated OHCA data over 10 months period (February 21-December 31, 2017) before and after the intervention was prospectively collected and analyzed.Comprehensive DACPR in the form of: a standardized dispatch protocol, 1-day training package and quality assurance and improvement measures were applied to Kuwait EMS central Dispatch unit only for pilot region. Primary outcomes: OHCA recognition rate, CPR instruction rate, and Bystander CPR rate. Secondary outcome: survival to hospital discharge.A total of 332 OHCA cases from the EMS archived data were extracted and after exclusion 176 total OHCA cases remain. After DACPR implementation OHCA recognition rate increased from 2% to 12.9% (P = .037), CPR instruction rate increased from 0% to 10.4% (P = .022); however, no significant change was noted for bystander CPR rates or prehospital return of spontaneous circulation. Also, survival to hospital discharge rate did not change significantly (0% before, and 0.8% after, P = .53)In summary, DACPR implementation had positive impacts on Kuwait EMS system operational outcomes; early OHCA recognition and CPR instruction rates in a pilot region of Kuwait. Expanding this initiative to other regions in Kuwait and coupling it with other OHCA system of care interventions are needed to improve OHCA survival rates.

A review of the valorization and management of industrial spent catalyst waste in the context of sustainable practice: The case of the State of Kuwait in parallel to European industry

Industrial solid waste management encompasses a vital part of developed and developing countries strategies alike. It manages waste generated from vital industries and governs the hazardous waste generated as a major component of integrated waste management strategies. This article reviews the practices that govern the management approaches utilized in the developed world for industrial spent catalysts. It critically assesses the current situation of waste management within the developing world region focusing on the industrial waste component, in a novel attempt to crucially develop a strategy for a way forward based on best practices and future directions with major European industries. The review also draws parallels with European countries to compare their practices with those of the State of Kuwait, which rely solely on landfilling for the management of its industrial waste. Spent catalysts recovery methods are discussed at length covering conventional methods of valuable metals and chemicals recovery (e.g., hydrometallurgical, solid-liquid and liquid-liquid extraction) as well as biological recovery methods. A major gap exists within regulations that govern the practice of managing industrial waste in Kuwait, where it is essential to start regulating industries that generate spent catalysts in-view of encouraging the establishment of valorization industries for metal and chemical recovery. This will also create a sustainable practice within state borders, and can reduce the environmental impact of landfilling such waste in Kuwait.

Biodegradation of total petroleum hydrocarbons (TPH) in highly contaminated soils by natural attenuation and bioaugmentation

Bioremediation is an emerging and sustainable technique that can either occur naturally or be enhanced by introducing nutrients or bacteria able to degrade specific contaminants. In this study, the efficiencies of natural attenuation with nutrients, and bioaugmentation with nutrients and a consortium of five exogenous bacteria, were evaluated for total petroleum hydrocarbon (TPH) degradation in five highly contaminated soils from China, and Kuwait. The bioaugmentation treatment exhibited better efficiencies than the natural attenuation, and reached 48.10% of TPH degradation with a half-life of 41.76 d. The addition of exogenous bacteria also increased the removal of TPH in the highest contaminated soil sample. The concentration of TPH in that soil was reduced from 236, 500 mg kg^-1 of dry soil to 176, 566 mg kg^-1 of dry soil in 40 d, which was equivalent to 25.4% degradation of TPH. The degradation rate (1501.8 mg kg^-1d^-1 of TPH) was higher than those reported in previous studies with a lower concentration of TPH. The bioaugmented strains could withstand high concentrations of TPH and thrive in five different types of soils. Consequently, these strains can be used to remediate soils that are heavily contaminated with petroleum hydrocarbons.

Fasting in Ramadan with type 1 diabetes: A dose adjustment for normal eating workshop in Kuwait

This pre-Ramadan workshop was aimed at educating and counselling people with type 1 diabetes, who graduated from the Dose Adjustment for Normal Eating (DAFNE) Kuwait programme, on safe fasting practices as well as determining their views on the challenges associated with fasting. The workshop also served as a pilot for a Ramadan-specific module to inform its implementation in all DAFNE programmes with the goal of meeting the needs of Muslim DAFNE graduates wishing to fast safely. A 2-day workshop (5 hours each) was conducted at DAFNE Kuwait 3 days before the start of Ramadan 2018 and all DAFNE graduates were invited to attend. The workshop consisted of group discussions about fasting-related challenges, followed by three interactive lectures and hands-on experience with popular Ramadan dishes. A qualitative approach was employed to determine the experiences of the participants with fasting by conducting three focus group discussions. The discussions were recorded via handwritten notes and analysed thematically. Seventy-two people with type 1 diabetes attended and 47 participated in the group discussions. Participants discussed their past experiences with fasting and the associated challenges, and shared practices adopted over the years. In addition, they confirmed the positive impact of DAFNE on their fasting experiences. The workshop provided a platform for people with type 1 diabetes to share their experiences with fasting and learn how to fast safely. Furthermore, it provided preliminary information that can be further explored to inform recommendations for safer fasting practices and the implementation of a specific fasting curriculum for people with type 1 diabetes.

Heterotrophic consumption may mask increasing primary production fuelled by anthropogenic nutrient loading in the northern Arabian/Persian Gulf

Monthly measurements of nitrate, nitrite, ammonium and phosphate at three stations off Kuwait during 2002-2015 revealed considerable inter-annual variability, broadly corresponding to fluctuations in the Shatt-al-Arab River discharge, but a lack of secular increasing trend. Nutrient enrichment experiments during two seasons revealed nitrate uptake, chlorophyll build-up and growth of micro-phytoplankton, even in the presence of ammonium, provided the availability of phosphate. Primary production was mostly nitrogen limited, but anthropogenic nitrogen supply may eventually make it phosphorus limited, especially in summer and in the open Gulf. Anthropogenic nutrient inputs appear to have enhanced biological productivity of the northern Gulf, but heterotrophic consumption, indicated by high respiration rates, probably prevented accumulation of phytoplankton biomass, accounting for the observed lack of chlorophyll increase over the past three decades. Consequently high total organic carbon and emerging hypoxia in the Gulf may lead to expansion/intensification of the oxygen minimum zone of the Arabian Sea.

Lack of detection of Candida nivariensis and Candida bracarensis among 440 clinical Candida glabrata sensu lato isolates in Kuwait

Occurrence of Candida nivariensis and Candida bracarensis, two species phenotypically similar to Candida glabrata sensu stricto, in human clinical samples from different geographical settings remains unknown. This study developed a low-cost multiplex PCR (mPCR) and three species-specific singleplex PCR assays. Reference strains of common Candida species were used during development and the performance of mPCR and singleplex PCR assays was evaluated with 440 clinical C. glabrata sensu lato isolates. The internal transcribed spacer (ITS) region of rDNA was also sequenced from 85 selected isolates and rDNA sequence variations were used for determining genetic relatedness among the isolates by using MEGA X software. Species-specific amplicons for C. glabrata (~360 bp), C. nivariensis (~250 bp) and C. bracarensis (~180 bp) were obtained in mPCR while no amplicon was obtained from other Candida species. The three singleplex PCR assays also yielded expected results with reference strains of Candida species. The mPCR amplified ~360 bp amplicon from all 440 C. glabrata sensu lato isolates thus identifying all clinical isolates in Kuwait as C. glabrata sensu stricto. The results of mPCR were confirmed for all 440 isolates as they yielded an amplicon only in C. glabrata sensu stricto-specific singleplex PCR assay. The rDNA sequence data identified 28 ITS haplotypes among 85 isolates with 18 isolates belonging to unique haplotypes and 67 isolates belonging to 10 cluster haplotypes. In conclusion, we have developed a simple, low-cost mPCR assay for rapid differentiation of C. glabrata sensu stricto from C. nivariensis and C. bracarensis. Our data obtained from a large collection of clinical C. glabrata sensu lato isolates show that C. nivariensis and C. bracarensis are rare pathogens in Kuwait. Considerable genetic diversity among C. glabrata sensu stricto isolates was also indicated by rDNA sequence analyses.

Sequential biowashing-biopile processes for remediation of crude oil contaminated soil in Kuwait

The application of biological processes for remediation of the aged crude oil-contaminated soil of Kuwait can be an inefficient way, thus, this study developed 20 d-sequential biowashing and biopile processes where the biowashing step uses an enrichment culture of the indigenous soil bacterial community and the biopile step includes hemoglobin-catalyzed oxidation (HCO). The residual total petroleum hydrocarbons (TPH) concentrations and CO₂ generation were measured to determine the removal efficiency, and the bacterial community changes were studied to investigate the effect of the sequential processes on the soil indigenous bacterial community. The enrichment culture grown on hemoglobin showed an increased surface activity, and this promoted desorption and emulsification of crude oil from the soil sample in the biowashing step resulting in 75% TPH removal. Potential surfactant-producing bacterial species were observed in the soil sample after biowashing. The HCO in the beginning of the biopile step removed 21% of the residual TPH, and further TPH removal was observed with a longer biopile period. Overall, the sequential biowashing and biopile processes removed 86% TPH. The results show that the developed sequential biowashing and biopile processes can be used to efficiently remediate the aged crude oil-contaminated soil of Kuwait.

Size Scaling of Contaminant Trace Metal Accumulation in the Infaunal Marine Clam Amiantis umbonella

Size scaling of the accumulation of four trace metals was examined in the infaunal clam Amiantis umbonella in Kuwait Bay. In clams of varying shell length (2.5-5 cm), soft tissue growth in A. umbonella from a contaminated site was inhibited compared with clams from a less contaminated reference site. Body burdens of all four metals were positively correlated with clam soft tissue wet weight, but for Cd, Cu, and Pb, correlations were stronger in clams from the contaminated site (r² = 0.6-0.9, p < 0.001) than the reference site (r² = 0.2-0.3, p < 0.002). Scaling factors for the accumulation of Cd, Cu, and Pb in the soft tissues of A. umbonella from both sites were not significantly different than 1, indicating that clams accumulated these metals in proportion to growth with little regulation. The scaling factor of Hg in clams from the contaminated site also was 1 but was 0.5 and 2.4 for high and low Hg accumulating subpopulations of clams from the reference site, respectively. The greater retention of Hg with respect to growth in clams from the reference site than from the contaminated site requires further investigation to determine differences in Hg bioavailability at the two sites and the form of Hg these clams accumulate.

Audit of glycemic control in patients with type 1 diabetes referred to a pediatric clinic in a specialized center in Kuwait

INTRODUCTION

Intensive glycemic control reduces the risk of microvascular and macrovascular complications. Furthermore, optimal glycemic control is essential for normal growth and development. Thus, there is a need to monitor and evaluate glycemic control in patients with type 1 diabetes (T1D). Our aim was to audit glycemic control in patients with T1D in a specialized center as per the Society of Pediatric and Adolescent Diabetes (ISPAD) Hemoglobin A1C (HbA1C) target recommendations published in 2014.

METHODS

This is a retrospective cross-sectional study reporting on glycemic control (HbA1C) of patients younger than 21 years of age and with T1D treated at Dasman Diabetes Institute (DDI) between January 2013 and December 2015.

RESULTS

A total of 470 patients with T1D (250 males and 220 females) were included. Only 53 (11.3%) patients met the ISPAD target for optimal glycemic control with HbA1C < 7.5% (58 mmol/mol). Older age was positively associated with poor glycemic control (p = 0.001) while Continuous Subcutaneous Insulin Infusion (CSII) therapy was negatively associated with poor glycemic control, adjusted Odds Ratio (OR) 0.33 (95% confidence interval (CI): 0.16-0.66) for CSII and adjusted OR 0.42 (95% CI: 0.27-0.64) for shifting to CSII (p < 0.001).

CONCLUSION

Achieving optimal glycemic control is a significant challenge for young patients with T1D. Glycemic control goals should be individualized to achieve such goals safely, realistically and with a better quality of life for patients with T1D.

The application of the maximal opposition therapy approach to an Arabic-speaking child

The aim of this study is to examine the efficacy and applicability of the maximal opposition approach to treatment of an Arabic-speaking child with a phonological disorder. A 4:2 year old Jordanian boy, born and raised in Kuwait, received phonological therapy using a maximal opposition approach with major-class distinctions, using a single-case experimental design. The child's speech production accuracy improved. Success with this one child suggests phonological contrast therapy-specifically a maximal opposition approach-could be used to treat other Arabic-speaking children who present with phonological disorders. More research is required before the most appropriate technique and treatment frequency for Arabic speaking children can be determined.

Assessment of loss of 210Po from fish and shrimp by cooking and its effect on dose estimates to humans ingesting seafood

An experimental study was conducted to assess loss of ²¹⁰Po due to cooking fresh seafood, and provide a more realistic and reliable dose estimate that humans may receive from consuming cooked seafood. Fresh fish and shrimp samples from Northern Gulf waters were grilled and boiled to simulate the effect of different cooking methods. Sixteen different species of fish were compared and significant differences in ²¹⁰Po concentration in uncooked samples were observed between species (ANOVA I, F_15,79 = 362.81, p < 0.0001). The effect of the treatment (uncooked, grilled, boiled and stock) was compared for each species and it was found that cooking led to a significant decrease in ²¹⁰Po concentration ranging from 14 to 58% compared to the uncooked samples, with no difference between grilled or boiled treatments. The effect of the cooking and shrimp treatment on ²¹⁰Po concentration was tested using ANOVA II after logarithmic transformation. Cooking led to a significant 38% reduction of ²¹⁰Po concentration as compared to uncooked treatments with no difference between grilled and boiled samples (ANOVA I: F_3,99 = 14.72, p < 0.0001). The two treatments with deveined shrimp led to a 75% decrease in ²¹⁰Po concentration as compared to all other treatments. As a consequence, cooked deveined shrimp contained an 84% lower ²¹⁰Po concentration than whole uncooked shrimp. As ²¹⁰Po is known to be the major contributor to radiation dose in humans consuming seafood, based on the results obtained, it is evident there is a need to re-examine how committed effective doses (CEDs) are best calculated for seafood consuming populations considering that most populations consume fish and shellfish cooked.

Assessment of Kuwait Health System Towards Telemedicine Readiness & Adoption: Organizational and Technical Issues

This study aims to assess the organisational readiness to predict the success of telemedicine system implementation in Kuwait. Semi-structured interviews were conducted with: (1) IT managers to assess the readiness of the technical infrastructure of Kuwait health system; and (2) policy makers to assess the organisation's ability to receive telemedicine. A set of policies and strategies were developed to demonstrate how the Kuwaiti health system could be ready for telemedicine services.

Hydro-environmental processes governing the formation of hypoxic parcels in an inverse estuarine water body: Model validation and discussion

The mechanism of fish kill events is not thoroughly understood in Kuwait Bay (KB). However, it is obvious that fish kill events have a close relationship with hypoxia due to some biogeochemical processes. Hydrodynamics controls the dissolved oxygen (DO) concentration that occurs within various spatial and temporal scales. The current study utilizes a previously validated hydrodynamic model to drive a three-dimensional water quality model for KB. The water quality model was validated using comprehensive field measurements during the summer of 2018. Reasonable model computations were achieved to represent the general patterns of the DO in KB. The model computations reproduced the formation of hypoxic water parcels. Some minor fish kill events that occurred during summer 2018 correlated well with predicted hypoxic parcels. The hydro-environmental controls over the extent of the hypoxic parcels and interplaying forces shall be addressed in a separate article by the same authors.

Assessing the knowledge, perception and practices of physicians and pharmacists towards medication reconciliation in Kuwait governmental hospitals: a cross-sectional study

OBJECTIVES

To assess the knowledge, perception and practices towards medication reconciliation (MedRec) and its related institutional policies among physicians and pharmacists in governmental hospitals in Kuwait and identifying potential obstacles that prevent the successful implementation of MedRec.

DESIGN

A descriptive, cross-sectional study.

SETTING

Six governmental hospitals across Kuwait in January-May 2017.

PARTICIPANTS

351 physicians and 214 pharmacists.

BRIEF INTERVENTION

A self-administered questionnaire distributed to the participants.

MAIN OUTCOME MEASURES

Knowledge, perception, attitudes and practices of hospital physicians and pharmacists towards MedRec, and major barriers to implementing a MedRec process in their institution/department.

RESULTS

Of the 739 questionnaires distributed, 565 were completed (351 physicians and 214 pharmacists), giving a response rate of 76.5%. Results showed that most participants were familiar with the term MedRec (n=419; 75.2%) with significantly more pharmacists compared with physicians (n=171; 81.8% vs n=248; 71.3%; p=0.005). Most participants (n=432; 80.0%) reported perceiving MedRec as a valuable process for patient safety. However, significantly more physicians compared with pharmacists were aware of a MedRec policy in their institution (n=195; 55.9% vs n=78; 37.9%; p<0.001) and routinely asked patients about their current list of medication on arrival (n=339; 96.6% vs n=129; 61.1%; p<0.001) and provided an updated list on discharge (n=281; 80.1% vs n=107; 52.0%; p<0.001). These results are supported by the findings that participants perceived physicians as providers, mainly responsible for various steps of MedRec.

CONCLUSIONS

Overall, this study showed low awareness among physicians and pharmacists of hospital policy despite MedRec being perceived as valuable. Physicians were the providers most responsible and involved in MedRec, who may be driven by the policy putting them at core of the process. The current findings could pave the way for the expansion of the existing MedRec policies and processes in Kuwait to include pharmacists and improve patient safety.

Risk of relapses during pregnancy among multiple sclerosis patients

BACKGROUND

Relapse rate in women with Multiple Sclerosis (MS) is reduced during pregnancy especially in the third trimester according to the previous studies.

OBJECTIVES

To measure the annual relapse rate (ARR) in women with MS during pregnancy.

METHODS

A retrospective study was conducted using prospectively collected data from two MS registries in Kuwait and Lebanon. Demographics, clinical characteristics including relapses, disease modifying therapies (DMTs) and their washout periods were extracted. The annual relapse rates pre and post pregnancies were compared and the relationship between relapses and prior use of different DMTs was assessed.

RESULTS

Data of 164 pregnancies (132 MS patients) was reviewed. Mean age and disease duration at the time of pregnancy confirmation were 32.4 ± 5.3 and 7.8 ± 4.7 years respectively. Most patients (91.7%; n = 121) were on DMTs in the year prior to pregnancy. The pre-pregnancy ARR was 0.10 (95% CI: 0.04 - 0.13), which increased to 0.20 (95% CI: 0.13- 0.29) during pregnancy. Most relapses occurred either during the 1^st (ARR = 0.24; 95% CI: 0.12 - 0.44) or 3^rd (ARR = 0.32; 95%CI: 0.17 - 0.53) trimesters. Fingolimod (31.8%) and natalizumab (22.7%) were the most commonly prescribed DMTs in patients who sustained relapses during pregnancy. The mean washout period was significantly longer among subjects with relapses (9.3 ± 6.6 vs. 2.5 ± 3.9; p < 0.001) than those of without relapses.

CONCLUSIONS

Relapse rate during pregnancy was higher than previous studies conducted in patients on platform therapies or untreated. Longer washout period prior to conception was associated with increased relapses especially in fingolimod and natalizumab treated patients.

Medical errors: Healthcare professionals' perspective at a tertiary hospital in Kuwait

Medical errors are of economic importance and can contribute to serious adverse events for patients. Medical errors refer to preventable events resulting from healthcare interactions, whether these events harm the patient or not. In Kuwait, there is a paucity literature detailing the causes, forms, and risks of medical errors in their state-funded healthcare facilities. This study aimed to explore medical errors, their causes and preventive strategies in a Kuwait tertiary hospital based on the perceptions and experience of a cross-section of healthcare professionals using a questionnaire with 27 open (n = 10) and closed (n = 17) questions. The recruited healthcare professionals in this study included pharmacists, nurses, physicians, dentists, radiographers, hospital administrators, surgeons, nutritionists, and physiotherapists. The collected data were analysed quantitatively using descriptive statistics. A total of 203 participants filled and completed the survey questionnaire. The frequency of medical errors in Kuwait was found to be high at 60.3% ranging from incidences of prolonged hospital stays (32.9%), adverse events and life-threatening complications (32.3%), and fatalities (20.9%). The common medical errors result from incomplete instructions, incorrect dosage, and incorrect route of administration, diagnosis errors, and labelling errors. The perceived causes of these medical errors include high workload, lack of support systems, stress, medical negligence, inadequate training, miscommunication, poor collaboration, and non-adherence to safety guidelines among the healthcare professionals.

Phase II/III Randomized Controlled Trial of Concomitant Hyperfractionated Radiotherapy plus Cetuximab (Anti-EGFR Antibody) or Chemotherapy in Locally Advanced Head and Neck Cancer

INTRODUCTION

Globally, there is marked variation in overall incidence and presentation of head and neck cancers, these cancers account for 11.5 per 100,000 population in G.C.C states. Concomitant chemotherapy and external beam radiotherapy (EBRT) is indicated in such cancers with aim of organ preservation, control and possible cure. Hyper fractionated radiotherapy with concomitant chemotherapy or cetuximab is a lesser explored option. In this study we wish to assess the tolerability and efficacy of cetuximab with altered fractionation and compare this with the chemotherapy (cisplatin).

MATERIALS AND METHODS

This is a randomized controlled study from a single institute in Kuwait. Locally advanced head and neck cancer cases excluding cancer nasopharynx are enrolled for the study. Stage III or stage IV-A cases were enrolled with histopathology squamous cell carcinoma. Patients were randomized into 2 arms. Arm A: to receive platinum-based CT i.e. cisplatin in a dose of 100 mg/m2 3-weekly or 40 mg/m2 weekly during radiation; Arm B: received cetuximab with a loading dose 400 mg/m², one week before radiation followed by weekly dose of 250 mg/m² during radiation. Radiotherapy was delivered using intensity modulated radiotherapy (IMRT) or 3D-conformal radiotherapy (CRT). The primary objective was to evaluate whether the use of cetuximab with concurrent hyperfractionated radiation regimen will have loco regional control rates (LC) and Disease-free survival (DFS) that are comparable to concurrent cisplatin in patients with LAHNC. The secondary endpoints were to compare the impact of using concurrent cetuximab vs chemotherapy regimen on Overall Survival of patients (OS) and acute and late adverse events.

RESULTS

From November 2012 to November 2017, 40 patients were randomized. The median age of was 51 years (range 27-72 years). Thirty-five patients are male and remaining was female. 14 patients have their primaries in larynx, 11 in oropharynx, 8 in oral cavity, and 5 has tumor in hypopharynx. Two patients had disease in nasal sinus or overlapping subsides. 50% has T4 lesions while 35% has T3 lesions, Nodal status was (N0-1) in 20 patients and (N2-3) in 20 patients. Overall staging showed a majority to have stage IV disease (63%). HPV was negative in 2 cases in Arm 1 and positive in 2 cases in Arm 2. 22 patients were randomly allocated in Arm A (platinum-based) while 18 were in Arm B (cetuximab). CR was achieved in 59% in arm A vs 50% in Arm B, while PR was 27.3% and 27.8% respectively. Disease progressed in 2 patients in Arm B only. Out of these 40 patients, 14 patients failed (6 and 8 in arm A and B respectively). Locoregional failure was documented in 6 (27.3%) vs 7 (38.9%) of arm A and B respectively, which was statistically not significant possibly related with lower number of cases. 2 years DFS was 56.5% vs 77.3% in cisplatin vs cetuximab arm (denoting nonsignificant increase of relapse rate in cisplatin arm). However, 2 years OS was 80.7% vs 57.3% in cisplatin and cetuximab arm respectively (p value=0.04).

CONCLUSION

Though cetuximab has lesser side effects but it is not indicated in treatment of LAHNC. Concurrent cisplatin is a trusted option for concomitant setting regardless of the HPV status and tumor location. However, in the context of cisplatin ineligible patients, cetuximab should be used only with hyper fractionation. This preliminary study could represent a good core of large international multicenter RCT.

The endoscopic treatment of pilonidal sinus disease: a short-term case-series study

BACKGROUND

Pilonidal disease (PNS) is a common inflammatory disease that can significantly impact the quality of life of the patient. Previous open techniques for the management of this condition have been unsatisfactory, with high recurrence rates reported.

OBJECTIVE

Investigate a new endoscopic procedure for the management of PNS disease.

DESIGN

Case series.

SETTING

Single hospital in Kuwait.

PATIENTS

From April 2014 to October 2017, patients with symptomatic chronic or recurrent PNS were consecutively enrolled to undergo the endoscopic pilonidal sinus treatment (EPSiT) procedure.

MAIN OUTCOME MEASURES

Control of pain, wound complications, recurrence rate over a 6-month follow up.

SAMPLE SIZE

35 patients.

RESULTS

The mean age of the patients was 22 years, with 33 (94%) males. Fourteen (40%) presented with recurrent disease and were recommended to undergo an EPSiT procedure. A single tract was used in 32 (91%) of the cases, with an average operative time of 51 mins. On follow-up 5 patients reported minimal pain judging by the need of only mild analgesics for the control of pain. No patient experienced early wound complications necessitating hospitalization. There were 2 (6%) recurrences encountered by the time of the 6-month follow-up period.

CONCLUSION

In these early results, the EPSiT procedure provided effective healing with acceptable recurrence rates and aesthetics. In addition, the procedure allows the surgeon to see the PNS, fistula tracts or any abscess cavities.

LIMITATIONS

Short follow-up period with a small number of patients CONFLICTS OF INTEREST: None.

Drug resistance-associated mutations in antiretroviral treatment-naïve and -experienced patients in Kuwait

The identification of human immunodeficiency virus (HIV) mutations leading to drug resistance enables patient-specific adaptation of the treatment regimen and predicts the risk of transmission of drug-resistant HIV. In this study, we report for the first time the prevalence in Kuwait of non-polymorphic resistance-associated mutations (RAMs) in patients under first-line antiretroviral therapy. Viral RNA was extracted from plasma samples of 64 treatment-naïve (untreated) and 64 treatment-experienced patients. The HIV-1 load was determined by real-time RT-PCR. The protease- and reverse transcriptase-encoding regions were analyzed by subtyping, and for drug resistance. The HIV-1 load at sampling in treatment-naïve patients ranged from 1.61 x 104 to 1.91 x 106 copies/ml, whereas that in treatment-experienced patients ranged from bitors (PIs) and NNRTIs. These results necessitate efforts to be made for reducing emergence of resistance-associated mutations in treated patients, and highlight the need for continuous monitoring of drug resistance patterns in Kuwait.

New National Record for Culex perexiguus from Kuwait

Mosquitoes can transmit a wide variety of viral and parasitic pathogens. Several species have recently been reported in new locations throughout the Arabian Peninsula as a result of entomological surveillance by the US military. We report a new national record for Culex perexiguus from Kuwait based on morphologic and molecular identification of captured samples. This mosquito might pose a public health threat to local populations and to military personnel as a potential vector of both Sindbis and West Nile viruses.

A geochemical analogy between the metal sources in Kuwait Bay and territorial sea water of Kuwait

The sea water serves as a source for desalination and shelter for dependent biota. To understand the sources of metal in Kuwait Bay and the open sea, samples were collected and analyzed for metals like B, Li, Sr, Hg, Pb, Ba, Fe, Zn, Mn, Be, Cd, Co, Cr, Ni, Se, V, Al, Mo, and As. The comparison of Bay and Seawater shows that most of the metals were higher in sea water. Samples were collected in two different transects in the territorial sea water (TSW), the northern, and the southern transects. The heavy metal evaluation index and degree of contamination calculated for Bay and TSW show that they are contaminated, and the degree was higher in TSW. The variation of metal concentration along the transects in TSW reflects three different behaviors; (1) few metals decrease from the shore, (2) few increases from the shore, and (3) others show no significant trend. The statistical analysis of the data shows a representation of five factors for bay water and six for TSW indicating the complexity in sources of metal in TSW. The analysis infers the metal contamination due to petroleum products, and oxidation-reduction cycles are predominant in TSW. But, tidal influence along with dustfall plays a key role in the metal contamination of bay waters. Apart from these, desalination rejects and domestic sewage effluents are common sources contributing metals to both the environment. It is also observed that the suspended sediments play a significant role in the leaching, adsorption, and distribution of metals. The extraneous process has a predominant control over the distribution of the metals in TSW than the Bay.

Attitudes of Physicians towards Different Types of Euthanasia in Kuwait

OBJECTIVE

Although in recent years the world has witnessed great advances in the medical field, much ambiguity still surrounds the issue of euthanasia and physician-assisted suicide, with increasingly favorable attitudes among physicians around the world. In our study, we aimed to assess the attitudes of physicians in Kuwait towards different types of euthanasia and examine whether physicians' frequent encounters with terminally ill patients were associated with their approval.

SUBJECTS AND METHODS

We conducted a cross- sectional study on 464 physicians employed in government hospitals (6 general and 3 specialty hospitals). A self-administered questionnaire adapted from previous studies was used.

RESULTS

Of the physicians in our study, 43.9% reported that the Ministry of Health should legalize euthanasia under certain restricted conditions. In addition, 29.1% of our population was willing to perform euthanasia. After controlling for several characteristics in logistic regression analysis, approval of passive euthanasia was significantly associated with the following 2 factors: frequent exposure to terminally ill patients (AOR = 2.45) and obtention of the basic medical degree from Asia (AOR = 4.36) or North America/Europe (AOR = 3.24) compared to Kuwait. Male gender was significantly associated with willingness to perform euthanasia. Religion was the major reason for opposing euthanasia.

CONCLUSION

The attitudes of physicians towards euthanasia are diverse, and therefore the Ministry of Health should provide guidelines for physicians dealing with situations where patients or their families request euthanasia.

Triple Negative Breast Cancer: 10-Year Survival Update of The Applied Treatment Strategy in Kuwait

BACKGROUND

Triple negative breast cancer (TNBC) is recognized as a distinct clinical and biological entity of poor outcome for almost two decades, yet its treatment strategy still needs to be better specified. The study aim is to update the 10-year survival data of our TNBC patients and to find its association with different treatment modalities.

PATIENTS AND METHODS

We updated the 10-year survival data of 359 women diagnosed with TNBC between 1999 and 2009 in the Kuwait Cancer Control Center (KCCC). The overall survival (OS), disease free survival (DFS), distant metastasis free survival (DMFS) and loco-regional recurrence free survival (LRFS) were estimated using Kaplan Meier method. Survival was correlated with different prognostic factors and treatment modalities. Statistical significance was calculated using the log-rank test and defined as p < 0.05. Cox regression is used for Multivariate analysis.

RESULTS

TNBC represented 12% of breast cancer in Kuwait with a median age of 48 years. The stage distribution was as follow: stage I, II, III, IV in 15%, 43%, 35% and 7% of patients respectively. Regarding surgery, 33% had Conservative surgery; 67% had mastectomy; 82% had axillary clearance. Chemotherapy was neoadjuvant in 25%, adjuvant in 56% and palliative in 5% of patients. Two-thirds of patients (67%) received adjuvant radiotherapy. After a median follow-up of 108 months, the 10-year OS, DFS, DMFS and LRFS were 66%, 59%, 72% and 77% respectively. The 10-year OS was 92%, 80%, 49% and 0% for Stage I, II, III and IV respectively (p =< 0.0001). OS was significantly worse with the presence of lymphovascular invasion (LVI) with p = 0.003. OS was not significantly affected by age, grade or treatment modality. In multivariate analysis, the clinical stage and LVI were still significant (P<0.0001 and 0.04 respectively).

CONCLUSION

In the absence of biological biomarkers, clinical stage and LVI seem to be the only significant prognostic factors for survival of TNBC patients in our study population. Timing of chemotherapy as well as the extent of surgery do not seem to affect the TNBC patients' outcome.

Oral Health Status of Kuwaiti Children with a History of Chronic Liver Disease

OBJECTIVE

To investigate the oral health status and dental manifestations of children with a history of chronic liver disease (CLD) compared to healthy children.

SUBJECTS AND METHODS

Twenty children (15 boys and 5 girls) with a history of CLD were compared to 20 healthy controls matched for age and gender. The clinical examination was carried out by the same dentist. Caries prevalence, using the decayed, missing, and filled primary and permanent teeth indices (dmft/DMFT), was recorded. Developmental enamel defects, plaque scores, and gingival overgrowth were also investigated.

RESULTS

No statistically significant differences were found in mean dmft scores for children with a history of CLD (4.9 ± 5.4) and for healthy individuals (3.9 ± 4.5). However, the mean DMFT score was significantly higher (p =0.025) in children with CLD (4.2 ± 4.6) compared to controls (1.7 ± 1.6). The mean decayed teeth parameter (DT) was also significantly higher in children with CLD (p =0.004). All patients with CLD exhibited enamel defects compared to only 33% in the control group (p< 0.05). A higher mean plaque index was observed in children with a history of CLD (p< 0.001). Also, a positive correlation for gingival overgrowth was noted in patients with a history of CLD (p< 0.05). Green staining was evident only in the permanent dentition of 1 child with CLD.

CONCLUSION

Children with a history of CLD exhibited a high caries prevalence, high plaque scores, and more enamel defects compared to healthy subjects. Gingival overgrowth is less prevalent among pediatric liver transplant patients on tacrolimus therapy.

Female Physicians Leading Health Care in the Arab World

BACKGROUND AND OBJECTIVES

A global trend in female leadership roles in the medical profession is on the rise, and females have been taking up leadership roles in varying and increasing levels. This study aims to identify changes in trends in the medical field in terms of gender in the last decade in Kuwait.

METHODS

A case study was conducted, in which data on leadership positions in Kuwait's government hospitals were obtained from hospital registries. Demographic data about female to male physicians were collected from statistics published by the Department of Manpower, Statistics and Planning of Kuwait's Ministry of Health. In addition, statistics on medical graduates were obtained from the Faculty of Medicine (FOM), Kuwait University (KU).

RESULTS

In general, every government hospital in Kuwait has experienced an increase in leadership roles among females; in 2008, among all leadership positions in Kuwait's general hospitals, males occupied a majority of positions (60%); whereas in 2016, the male to female ratio was 1:1. The most change in gender trends was witnessed at Mubarak Al-Kabeer Hospital, where female leaders went from 38% in 2008 to 73% in 2016. The specialties that have the highest number of females in leadership positions across all hospitals from 2008 to 2016 were nuclear medicine, radiology, and laboratory medicine. In KU's FOM, female graduates outweighed male graduates, except in 2005-2006, where females reached a minimum of 48%. The number of female physicians has also increased from its lowest of 31% of the total number of physicians in 2004-2006, to 37% in 2015.

CONCLUSION

While women make up more than half of medical graduates in Kuwait at present, significant barriers had restricted their entry into formal medical leadership roles in the past. However, it is now seen that females currently occupy more leadership positions in government hospitals in Kuwait.

Assessing HIV/AIDS Knowledge, Awareness, and Attitudes among Senior High School Students in Kuwait

OBJECTIVES

An estimated 1.8 million individuals worldwide became newly infected with human immunodeficiency virus (HIV) in 2016, which amounts to 5,000 new infections per day. This includes 160,000 children. The HIV epidemic not only affects the health of individuals but also impacts households, communities, and the development and economic growth of nations [<xref ref-type="bibr" rid="ref1">1</xref>]. The prevention and control of HIV infection and acquired immune deficiency syndrome (AIDS) are recognized as a national priority in Kuwait. This study assesses the knowledge, awareness, and attitudes about HIV/AIDS among senior high school students in Kuwait.

MATERIALS AND METHODS

A cross-sectional study was conducted in a convenience sample of 346 students in 8 randomly selected high schools in 3 governorates of Kuwait, using a questionnaire designed to measure the student's knowledge and attitude towards HIV/AIDS. The survey questionnaire was administered to the students in their classrooms.

RESULTS

This study revealed that the students were knowledgeable with regard to the nature and mode of transmission of HIV/AIDS, but they needed a more detailed understanding of the disease to prevent stigmatization and discrimination of an infected person.

CONCLUSION

This study provides a benchmark for further elaborate studies in the community to develop appropriate health education and awareness programs.

A Novel Approach to Obtain Follow-up Data on the Vital Status of Registered Cancer Patients: The Kuwait Cancer Registry Experience

OBJECTIVE

We present an approach to obtain accurate and complete data on the last known vital status, and the date of last known vital status of all Kuwaiti cancer patients. These data are essential for robust estimation of population-based cancer survival.

METHODS

Government-issued Civil ID numbers (IDs) of patients registered during 2000-2013 were obtained from the Kuwait Cancer Registry. Missing IDs were traced using the Ministry of Health's Information System or the patient's medical records. IDs were manually entered in the Public Authority of Civil Information (PACI) database to ascertain vital status for patients whose vital status was not known in the registry. To obtain the date of death for deceased patients, IDs were then manually entered and searched in the electronic archive of "Death Announcements" at the Ministry of Health's Central Records Department of Births and Deaths. Patients not found in the "Death Announcements" archive were considered alive as on 31 December 2015.

RESULTS

The traditional method to obtain data on cancer patients' vital status, restricted to patients whose death was certified as due to cancer, had captured only 62% of all patients' deaths. This new approach resolved the vital status for 98.3% of patients for whom it was previously unknown. The impact was substantial: the proportion of patients known to be dead rose from 27.9% to 45.0%, while the proportion presumed alive dropped from 72.1% to 53.7%. Only 1.3% of the patients remained lost to follow-up.

CONCLUSION

This approach substantially improved the quality and completeness of follow-up data for all Kuwaiti cancer patients. We recommend that this approach should be performed routinely in Kuwait to enable accurate estimation and monitoring of population-based survival trends.

Laparoscopy in Acute Care Surgery: Repair of Perforated Duodenal Ulcer

INTRODUCTION

The use of laparoscopic management as a first choice for the treatment of duodenal perforation is gaining ground but is not routine in many centers. In this report, we aim to report our experience with laparoscopy as the first approach for the repair of duodenal perforation.

MATERIALS AND METHODS

This is a retrospective review of patients during our initial experience with the use of laparoscopy for the treatment of duodenal perforation between 2009 and 2013.

RESULTS

A total of 100 patients underwent management of duodenal perforation. Laparoscopy was attempted initially in 76 patients (76%) and completed in 64 patients (64%). The length of hospital stay was shorter in the laparoscopic group (mean 2.6) than in the open group (mean 3.1) (p = 0.008). Complications developed in 14 patients (20%). There was a tendency towards fewer admissions to intensive care, less acute kidney injuries, and less acute respiratory distress syndrome in the laparoscopic group. In patients who underwent laparoscopic surgery, the chances of uneventful recovery were 4.3 times higher than in those patients who underwent open surgery (95% CI 1.3-13.5, p = 0.014).

CONCLUSIONS

Laparoscopy in the treatment of perforated duodenal ulcer is safe and can be utilized as a routine approach for the treatment of this pathology.

Cancer survival trends in Kuwait, 2000-2013: A population-based study

OBJECTIVE

To examine population-based cancer survival trends in Kuwait; to facilitate public assessment of cancer control.

METHODS

Data were obtained from the Kuwait Cancer Registry for Kuwaiti adults (15-99 years) and children (0-14 years) diagnosed with one of 18 common cancers during 2000-2013 and followed up to 31 December 2014. Net survival was estimated at 1, 3, and 5 years by sex. To control for background mortality, life tables of all-cause mortality in the general population were constructed by single year of age, sex, and calendar year of death ("complete" life tables). Net survival estimates were age-standardised using the International Cancer Survival Standard weights.

RESULTS

Cancers with the highest net survival throughout the 14-year period were prostate, breast (women) and rectum in adults, and lymphoma in children. Survival was lowest for liver, pancreas and lung cancer in adults, and brain tumours in children. During 2010-2013, one year survival was over 80% for cancers of the prostate, breast, rectum, cervix and colon. Five-year survival was above 80% only for prostate cancer. For children, one and five-year survival was above 80% only for acute lymphoblastic leukaemia (ALL) and lymphoma. Survival was generally higher for women than men, and declined faster in women than men between 1 and 3 years after diagnosis. Differences between boys and girls were small.

CONCLUSION

Cancer survival improved for most Kuwaiti adults and children over the 14-year period, with women generally having a more favourable prognosis than men. Continuous surveillance is required to monitor cancers for which survival did not improve, and to dissect the underlying causes for the differences in survival between Kuwait and other countries.

Simulation for Continuing Pharmacy Education: Development and Implementation of a Simulation-Based Workshop on Medicines Reconciliation for Pharmacists

INTRODUCTION

Simulation has been increasingly used to train health care professionals on clinical skills. Little is published on simulation-based education in the context of continuing pharmacy education (CPE) of pharmacists. This article describes the development implementation and evaluation of simulation-based workshop to train hospital pharmacists on medicines reconciliation in Kuwait. The study aimed to explore pharmacists' perceptions about simulation use in CPE. It also assessed the impact of the workshops on pharmacists' attitudes toward, knowledge, and comfort level to apply medicines reconciliation.

METHODS

One hundred ten pharmacists attended 11 simulation-based workshops. Data were collected using focus groups and self-administered surveys in a mixed-method research design. Focus groups were audio-recorded, transcribed verbatim, and analyzed for content. Descriptive statistics were used to report surveys' findings.

RESULTS

The workshops were well-received by pharmacists. Few pharmacists recalled previous exposure to simulation in CPE activities. Pharmacists' perceived challenges to simulation integration into their professional training were the need for good preparation/setting, qualified faculty, well-trained simulated patients, and time constrains. Participants felt that simulation enhanced their attitudes toward, knowledge, and comfort level to apply medicines reconciliation. They rated their knowledge level as having increased by 62.3% and comfort level as having increased by 37.0%. They overwhelmingly welcomed more integration of simulation in CPE activities.

DISCUSSION

A simulation-based continuing education workshop was well-received by pharmacists and enhanced their self-reported knowledge, comfort level, and preparedness to apply medicines reconciliation. Efforts are needed to expand simulation use in the development, refinement, and maintenance of clinical skills of pharmacists throughout their educational continuum including CPE.

A qualitative exploration of clozapine prescribing and monitoring practices in the Arabian Gulf countries

Clozapine is considered as the first line antipsychotic for treatment resistant schizophrenia (TRS). Worldwide reports indicate an overall underutilization of clozapine in patients experiencing TRS. This study aims to understand the prescribing practices, monitoring strategies and barriers to the use of clozapine in the Arabian Gulf (AG) region. Qualitative methodology was employed to explore mental health professionals' experience with clozapine prescribing practices. Semi-structured, individual in-depth interviews were conducted. All interviews were analyzed using a thematic approach. A total of 13 interviews were conducted with participants from six AG countries. Four major themes emerged from the analysis in relation to clozapine prescribing and monitoring practices, clozapine use guidelines, and barriers to the use of clozapine. Thematic analysis revealed a tendency to under prescribe clozapine in the AG region, which appears to be predominantly influenced by prescriber-related barriers and less likely due to the lack of a nation-wide hematological monitoring program. Future studies should explore strategies for overcoming the barriers identified.

An Atypical Case of Middle East Respiratory Syndrome in a Returning Traveler to Korea from Kuwait, 2018

We report a case of Middle East respiratory syndrome coronavirus (MERS-CoV) infection in a 61-year-old businessman returning from Kuwait. The patient arrived there on August 16, 2018, developed watery diarrhea on August 28 (day 0), and came back to Korea on September 7 (day 10) as his condition worsened. Upon arrival, he complained of diarrhea and weakness, but denied any respiratory symptoms, and he directly went to visit an emergency room. Chest radiography revealed interstitial infiltrates in the lungs, and he was immediately transferred to an isolation unit. Quantitative real-time PCR analysis of sputum samples taken on day 11 returned positive for MERS-CoV. No secondary MERS-CoV infection was identified among people who had close contact with him. This case underscores the importance of a high index of suspicion of MERS-CoV infection in any febrile patients who present after a trip to the Middle East.

Accounting for peoples' preferences in establishing new cities: A spatial model of population migration in Kuwait

Modelling of internal migration to new cities is challenging, yet necessary to ensure that these newly established urban areas will be populated and function as intended. In the State of Kuwait, there is a unique set of push and pull factors: government subsidised housing for citizens, the existence of a single urban area, and the initiation of a new and ambitious master plan for the construction of 12 new cities, which are expected to attract not only locals, but also international residents and businesses. On top of these factors, there is an unusual demographic situation, as non-citizens outnumber Kuwaiti citizens by a factor of 2.3, with these groups having widely different preferences in terms of housing. Currently, there is no plan to take these resident groups' opinions into consideration for the new cities project. Besides, the current study simulates the impacts of the involvement of residents in urban planning. Samples from resident groups (citizens and non-citizens) participated in targeted surveys and useful answers were extracted in relation to the migration likelihood, push and pull factors that may affect their decisions, spatial preferences for new cities and their opinions on segregation by nationality. Specifically, the survey results showed significant interest of residents in moving to the new cities. For citizens, the most important factors in deciding whether to move or not were proximity to their close family and housing availability, while for non-citizens the most important factor was the creation of new employment opportunities. Both survey groups agreed that existing city property prices are too high and make the prospect of moving to a new city more attractive. The responses were transferred in an Agent Based Model, and the simulations showed certain differences to the official projections for 2050 without the public responses, in regards to the geographical distribution of the most desirable suburbs. Furthermore, the simulations showed that in the new cities, nationality segregation levels are expected to drop by at least 15% compared to the 2015 levels. The findings may be utilised by the authorities to modify the master plan accordingly.

Multi-criteria decision approach for evaluation, ranking, and selection of remediation options: case of polluted groundwater, Kuwait

Freshwater groundwater resources at north Kuwait were contaminated by infiltrated oil as well as sea water that was used to fight the oil-well fires during the liberation of Kuwait in 1991. This paper investigates the feasibility of five remediation options to restore the polluted aquifers. These options include: (i) pump and treat of contaminated groundwater; (ii) cleaning the aquifer formation; (iii) construction of additional desalination plant; (iv) constructing additional storage tanks, and (v) development of artificial aquifer recharge schemes. The basis for this assessment study is to supply minimum basic drinking water to Kuwait City at a total rate of 50,000 m³/day in an emergency for up to one year based on essential basic need of 32 liters per capita per day. To compare these options, a decision matrix to select suitable remediation options using Multiple Criteria Decision Analysis (MCDA) approach is developed. The cost was given a relative weight of 20 whereas other criteria are given weight of 10. Based on these MCDA scores, it was found that option 3, namely, establishing an additional water desalination plant, is the most feasible option followed by option 5, artificial recharge of aquifers.

Using phytoremediation by decaying leaves and roots of reed (Phragmites austrates) plant uptake to treat polluted shallow groundwater in Kuwait

Phytoremediation is the use of plants and their associated microorganisms, to remove or degrade biochemically the pollutants from the soil and groundwater environment. It is an emerging technology for water/soil/agricultural remediation, which offers a low-cost flexible technique suitable for use against a number of different types of contaminants in a variety of media. This research illustrates that this technology can be used to reduce the concentration of pollutants in Kuwait shallow groundwater to improve the efficiency of irrigation for greenery purposes. The investigation of this research was carried out through using reed plants in two experiments: First in decaying reed leaves and the second in reed roots. The change in the concentration of the inflow of the polluted groundwater and the outflow of the treated irrigation water was measured in the laboratory for chemical analysis. The two experiments indicated the ability of the reed plants to reduce the concentration of salt ions (Cl, Na, K, and SO₄) by about 66-78%. Roots reduced the total dissolved solid values by 66%, the plants were capable of reducing the concentration of nitrogen compounds significantly, and fluoride was reduced by ≈ 86% while the roots removed the lithium significantly. This research illustrates that the roots of the reed plants are capable to reduce the heavy metals of Cd, Co, Zn, and Fe significantly. The reduction of Al, Cu, and Cr by the roots of the reed plants was 53%, 39%, and 89% respectively. These results provide a preliminary indication that reed plants have the capability to remove pollutants at various levels and that salinity can be reduced considerably to improve irrigation efficiency in Kuwait.

Meta-analysis of depleted uranium levels in the Middle East region

Since the first widespread use of depleted uranium in military in the 1991 Gulf War, the so-called "Gulf War Syndrome" has been a topic of ongoing debate. However, a low number of reliable scientific papers demonstrating the extent of possible contamination as well as its connection to the health status of residents and deployed veterans has been published. The authors of this study have therefore aimed to make a selection of data based on strict inclusion and exclusion criteria. With the goal of clarifying the extent of DU contamination after the Gulf Wars, previously published data regarding the levels of DU in the Middle East region were analyzed and presented in the form of a meta-analysis. In addition, the authors attempted to make a correlation between the DU levels and their possible effects on afflicted populations. According to results observed by comparing ²³⁴U/²³⁸U and ²³⁵U/²³⁸U isotopic activity ratios, as well as ²³⁵U/²³⁸U mass ratios in air, water, soil and food samples among the countries in the Middle East region, areas indicating contamination with DU were Al Doha, Manageesh and Um Al Kwaty in Kuwait, Al-Salman, Al-Nukhaib and Karbala in Iraq, Beirut in Lebanon and Sinai in Egypt. According to these data, no DU contamination was observed in Algeria, Israel, Afghanistan, Oman, Qatar, Iran, and Yemen. Due to the limited number of reliable data on the health status of afflicted populations, it was not possible to make a correlation between DU levels and health effects in the Middle East region.

Measuring the extent and nature of use of Social Networking Sites in Medical Education (SNSME) by university students: Results of a multi-center study

There is a sharp rise in the use of social networking sites (SNSs) by university students for various purposes. However, little is known about the use of SNSs for educational purposes. This study aims to determine educational use of SNSs by the medical students of two Saudi and a Kuwaiti medical school. A cross-sectional study was conducted by administering a 20-statement questionnaire to the undergraduate medical and allied health sciences students of two Saudi universities: Taibah University (TU) and Imam Abdulrahman AlFaisal University (IAFU), and one Kuwaiti university, Kuwait University (KU). The data were collected and analyzed by SPSS 20. Of a total of 1312 respondents, 1181 (90%) students used SNSs and 131 (10%) did not use SNSs for any reason. Further, only 442/1181 (37%, p < 0.00) students used SNSs for education and found these sites to be useful. As many as 357 (27%) students used SNSs for sharing education-related information once a day, 306 (23%) 3-5 times a day, and 331 (25%) once a week. A maximum of 678 (52%) used Facebook for educational purpose and most of the students, 469 (38%), used SNSs for sharing lectures. There were significant variations in responses among genders and year of schooling. The use of online social media in medical education is a rapidly evolving arena of scholarship. Low use of SNSs for sharing information and significant variations in perceptions of medical students about social media should draw attention of policy-makers for promoting awareness and educational reforms.

Atmospheric deposition fluxes of 137Cs associated with dust fallout in the northeastern Arabian Gulf

For many years, monitoring and determining the radioactivity of ¹³⁷Cs in the environment has considerable interest. This paper presents monitoring ¹³⁷Cs deposition fluxes during the period from 2009 to 2011. Dust fallout samples were collected from ten locations in Kuwait, and ¹³⁷Cs concentrations were determined using ultra low spectrometry system. The average of the annual atmospheric deposition fluxes of ¹³⁷Cs was 4.3, with an extreme value reaching 50 Bq m^-2. The monthly deposition rates of ¹³⁷Cs were attributed to seasonal increases in the spring. ¹³⁷Cs deposition fluxes showed a significant relationship with dust deposition and precipitation rates, where the correlation between the monthly dust fallout and the ¹³⁷Cs deposition fluxes and precipitation rates were approximately 0.95 and 0.81, respectively. The spatial monthly distribution of ¹³⁷Cs fluxes showed high rates in the southeastern part of Kuwait while the lowest rates were recorded along the coastlines. A strong correlation was observed between the annual ¹³⁷Cs and ⁴⁰K deposition rates considering that both radionuclides deposition were governed by similar conditions. It was concluded that long-range transport from the northwestern areas along with the effects from local dust washout and the site specify played a major role in controlling the rate of ¹³⁷Cs deposition. The estimated annual effective dose equivalent due to external and internal exposures was insignificant and can be ignored. It is worthwhile to continue investigating the source origin of ¹³⁷Cs in Kuwait to enhance understanding of the radiological hazards in the country.

Assessment of patient safety culture: a nationwide survey of community pharmacists in Kuwait

BACKGROUND

Medication errors have been the largest component of medical errors threatening patient safety worldwide. Several international health bodies advocate measuring safety culture within healthcare organizations as an effective strategy for sustainable safety improvement. To the best of our knowledge, this is the first study conducted in a Middle Eastern country at the level of community pharmacy, to examine safety culture and to evaluate the extent to which patient safety is a strategic priority.

METHODS

A descriptive cross-sectional study was conducted. The Pharmacy Survey on Patient Safety Culture (PSOPSC), developed by the Agency for Healthcare Research and Quality (AHRQ), was used to collect data. PSOPSC is a self-administered questionnaire which was previously tested for validity and reliability. The questionnaire was distributed among pharmacists who work in community pharmacies from the five governorates of Kuwait (Capital, Hawalli, Farwaniya, Jahra, and Ahmadi). The Statistical Package for Social Science (SPSS) software, version 24 was used for analysing data.

RESULTS

A total of 255 community pharmacists from the five governorates were approached to participate in the study, of whom 253 returned a completed questionnaire, with the response rate of 99%. Results from the study showed that patient safety is a strategic priority in many aspects of patient safety standards at the level of community pharmacies. This was reflected by the high positive response rate (PRR) measures demonstrated in the domains of "Teamwork" (96.8%), "Organizational Learning-Continuous Improvement" (93.2%) and "Patient Counselling" (90.9%). On the other hand, the lowest PRR was given to the "Staffing, Work Pressure, and Pace" domain which scored 49.7%.

CONCLUSIONS

Understanding community pharmacists' perspectives of patient safety culture within their organization is critical. It can help identify areas of strength and those that require improvement, which can help support decision about actions to improve patient safety. The current study showed that urgent attention should be given to the areas of weakness, mainly in the dimension of "Staffing, Work Pressure and Pace." The pharmacists pointed the need for adequate breaks between shifts and less distractible work environment to perform their jobs accurately.

in Kuwait by ISSR markers

Haloxylon salicornicum moq. Bunge ex Boiss (Rimth) is one of the native plants of Kuwait, extensively depleting through the anthropogenic activities. It is important to conserve Haloxylon community in Kuwait as it can tolerate extreme adverse conditions of drought and salinity to be potentially used in the desert and urban revegetation and greenery national programs. Therefore, a set of 16 inter simple sequence repeat (ISSR) markers were used to assess genetic diversity and population structure of 108 genotypes from six locations in Kuwait. The ISSR primers produced 195 unambiguous and reproducible bands out of which 167 bands were polymorphic (86.5%) with a mean PIC value of 0.31. The overall average values of Nei’s gene diversity (h') and Shannon’s diversity index (I) were 0.254 and 0.375, respectively. Results of AMOVA revealed high genetic variations within populations (77.8%) and low among populations (22%). The values of Fixation index (F_ST = 0.22; P = 0.0), Genetic differentiation (G_{ST =} 0.262; G’_ST = 0.327; D = 0.335 and Gene flow (N_M = 0.880) were indicative of heterozygous populations. The results of STRUCTURE and split decomposition analysis suggested that the Rimth accessions of Kuwait can be grouped into five and six subpopulations, respectively. Principal coordinate analysis (PCoA) grouped them into three clusters. The pairwise Nei’s genetic distances (D_S) among populations demonstrated a narrow range from 0.047 to 0.187 (Scale-0.0 to 1.0). The Mantel’s test revealed a weak correlation (r²- 0.188; P-0.013) between the genetic distance and geographic distances. Our results suggest that the narrowly distributed Haloxylon community in Kuwait demonstrated a high genetic diversity within the populations however the overall population structure was weak.

On the chemical nature of precipitation in a populated Middle Eastern Region (Ahvaz, Iran) with diverse sources

This study reports on the chemical composition of rainwater collected at three ground sites with varying degrees of pollution in Ahvaz, Iran, between January 2014 and February 2015. A total of 24 rainwater samples were analyzed for pH and concentrations of trace elements (Fe, Al, Pb, and Cd) and major ions (Na⁺, NH₄⁺, Ca²⁺, Mg²⁺, HCO₃^-, NO₃^-, Cl^- and SO₄^2-). Principle Component Analysis (PCA) was used to identify sources of the measured species. The equivalent concentration of the components followed the order of Ca²⁺ > SO₄^2- > HCO₃^- > NH₄⁺ > Cl^- > Na⁺ > NO₃^- > Mg²⁺. The average pH of the rainwater samples was 6, and only three events exhibited acidic conditions below a pH of 5.6. The lowest and the highest average pH values were observed in the high traffic area (5.96) and industrial area (6.54), respectively. The highest and lowest Ca²⁺ levels were observed in the industrial and high traffic areas, respectively. Na⁺, Mg²⁺, and SO₄^2- exhibited their highest and lowest concentrations in the industrial and high traffic areas, respectively. 70.36% of the total variance was due to anthropogenic species (Ca²⁺, SO₄^2-, Mg²⁺, NO₃^-, Cl^-), soil particles (Cl^-, Na⁺, and HCO₃^-), and biomass burning (NH₄⁺, pH). The results of this study show that local anthropogenic sources and Middle Eastern Dust (MED) storms affect the rainwater chemistry strongly, which the latter stems from the Arabian Peninsula, Kuwait, Iraq, and some parts of Iran.

Distribution Profiles of Melamine and Its Derivatives in Indoor Dust from 12 Countries and the Implications for Human Exposure

Melamine and its derivatives (i.e., ammeline, ammelide, and cyanuric acid) are extensively used in household products, such as furniture, dinnerware, and food utensils. Nevertheless, limited information is available on human exposures, other than dietary sources, to melamine and its derivatives. In this study, the occurrence of melamine and its derivatives was determined, for the first time, in 341 samples of indoor dust, collected from 12 countries. All of the dust samples contained target analytes, with global median concentrations of 1800, 1100, 48, and 45 ng/g for melamine, cyanuric acid, ammelide, and ammeline, respectively. The total concentrations of melamine and its derivatives varied among countries in the following decreasing order: United States (median: 17 000 ng/g) > Japan (8400) > China (8000) > South Korea (7300) > Saudi Arabia (4400) > Romania (4300) > Greece (3400) > Kuwait (2400) > Vietnam (2300) > Colombia (1300) > Pakistan (820) > India (430). Correlation analysis indicated the existence of multiple and varied sources for melamine and cyanuric acid. Estimated daily intakes of melamine via indoor dust ingestion were at least 2 orders of magnitude below the current tolerable daily intake.

The environmental Kuznets curve relationship: a case study of the Gulf Cooperation Council region

By using panel data over the 1980-2017 period and two alternative indicators of environmental pollution (carbon dioxide (CO₂) and sulfur dioxide (SO₂) emissions), this paper investigates the validity of the environmental Kuznets curve (EKC) hypothesis in the Gulf Cooperation Council (GCC) region. Using three alternative econometric estimation techniques, we find strong evidence of a long-run inverted U-shaped relationship between real GDP per capita and both environmental indicators in the GCC region. Country-level short-run analysis indicates that the EKC hypothesis holds for Bahrain, Kuwait, Qatar, Saudi Arabia, and the United Arab Emirates (UAE) when CO₂ emissions are used as a measure of environmental pollution. However, when SO₂ emissions are used as a measure of environmental pollution, the EKC hypothesis holds for Oman, Qatar, Saudi Arabia, and the UAE. The results of a recently developed panel causality test reveal one-way causality from real GDP per capita to CO₂ emissions and from real GDP per capita to SO₂ emissions.

THE SCREENING INDOOR RADON AND PRELIMINARY STUDY OF INDOOR THORON CONCENTRATION LEVELS IN KUWAIT

Indoor measurements of radon and thoron in Kuwait were conducted during the years 2015 and 2016. In this study, 65 dwellings were selected for the long-term radon-thoron survey using passive nuclear track monitors. The monitors (at least one) were used at various locations in the dwellings for 83-306 days. Some measurements were also repeated at the same locations in different seasons. This current study is a preliminary thoron survey with relatively small sample size. The results showed that the range of thoron concentration was from below the lower limit of detection to 35 Bq m-3, whereas the range of radon concentration was within 10-202 Bq m-3. Furthermore, 22% of the radon results exceeded the WHO radon reference level of 100 Bq m-3. The analysis of variance showed a correlation between indoor radon concentration and the season. However, the thoron measurements were rather limited and the values were low. In addition, the relationship was investigated between radon and thoron concentrations involving the floor levels and the type of ventilation systems used.