Gulf Asthma Diagnosis and Management in Adults: Expert Review and Recommendations

The prevalence and incidence of asthma are increasing globally because of genetic and environmental influences. Prevalence of asthma in the Gulf has been reported to range from 4.7% to 32.0% and has a substantial economic burden. In this paper, we summarize current asthma management guidance for adults, present insights, and recommendations by key opinion leaders (KOLs) in the Gulf region, and key performance indicators for guiding clinical practice for asthma diagnosis, management, and treatment in the Gulf. While it is recommended that the Global Initiative for Asthma (GINA) guidelines should be followed wherever possible for the management of asthma, KOLs in the Gulf region have presented additional recommendations based on regional challenges and insights. There is a need for better diagnosis using objective testing, increased efforts in tackling the burden of comorbidities in the region, and greater provision of the necessary tools for phenotyping severe asthma. Furthermore, there is a need for greater education for physicians regarding asthma treatment, including the importance of inhaled-corticosteroid-containing controller medication. Regionally, there is also a need for specialist asthma clinics and asthma educators, which would serve to educate physicians and their patients as well as to improve the management of patients. Finally, the use of asthma registries, digital devices, and electronic templates would be of benefit in the management of asthma patients in the region.

The Prevalence of Human Bocavirus, Human Coronavirus-NL63, Human Metapneumovirus, Human Polyomavirus KI and WU in Respiratory Tract Infections in Kuwait

OBJECTIVE

The aim of this study was to investigate the prevalence of human coronavirus (HCoV)-NL63, human metapneumovirus (hMPV), human bocavirus (Boca), human polyomavirus KI (KIV) and human polyomavirus WU (WUV) in respiratory tract infections (RTI) in Kuwait.

MATERIALS AND METHODS

Respiratory samples from 735 hospitalized patients with RTI from September 2010 to April 2013 were evaluated for the presence of HCoV-NL63, hMPV, Boca, KIV and WUV using molecular assays, polymerase chain reaction (PCR) and reverse-transcription PCR.

RESULTS

Of the 735 patients, 285 (38.8%) were diagnosed with viral RTI. The distribution of respiratory viruses was hMPV: 15 (5.3%), Boca: 14 (4.9%), WUV: 10 (3.5%) and KIV: 4 (1.4%). HCoV-NL63 was not detected in any of the samples.

CONCLUSIONS

These newly discovered viruses were associated with the development of RTI in Kuwait. The rapid identification of these viral infections could aid in the control of nosocomial transmission, reduce the use of antibiotics and improve treatment and management strategies.

Transthoracic echocardiography and 6-minute walk test in Kuwaiti sickle cell disease patients

OBJECTIVE

The aim of this study was to investigate cardiac abnormalities in Kuwaiti sickle cell disease (SCD) patients using markers such as tricuspid regurgitant jet velocity (TRJV), pulmonary artery systolic pressure (PASP), and the 6-minute walk (6MW) test and correlate these findings with clinical, hematological, and biochemical parameters.

MATERIALS AND METHODS

Seventy-three patients with SCD and 70 matched controls were studied. The cardiac status was investigated using transthoracic echocardiography in 57 patients; the 6MW test was carried out in patients and controls. Complete blood counts and hemolytic parameters were assessed.

RESULTS

Reticulocytes, bilirubin, and lactate dehydrogenase were significantly higher (p < 0.0001) in patients, while hemoglobin (Hb) and haptoglobin were lower (p < 0.0001) than in controls. The mean fetal Hb among patients was 15.85 ± 8.7%. Of the 57 patients, 14 (24.5%) and 15 (26%) had mild tricuspid and mitral regurgitation, respectively. The mean ejection fraction, TRJV, and PASP were 63.9 ± 6.3%, 1.7 ± 0.5 m/s, and 23.0 ± 7.3 mm Hg, respectively. Three (5.2%) patients had mildly raised TRJV (2.6-2.97 m/s, normal range <2.5 m/s) while 8 (14%) had high PASP (mean 35.3 ± 5.1 mm Hg, normal range <30 mm Hg). Hb, hematocrit, and reticulocytes were different (p = 0.010, p = 0.006, and p = 0.011, respectively) between patients with normal and high PASP. All 3 patients who had a high TRJV had a high PASP, and 2 of these patients died during follow-up. The systolic and diastolic blood pressure, oxygen saturation before and after the 6MW test, and distance walked were lower (p = 0.006, p = 0.000, p = 0.002, p = 0.000, and p = 0.000, respectively) in patients compared to controls.

CONCLUSION

Raised PASP was common in Kuwaiti SCD patients while raised TRJV was not.

Respiratory syncytial virus and human rhinoviruses are the major causes of severe lower respiratory tract infections in Kuwait

Respiratory infections are very common in Kuwait, yet little is known about the cause of severe lower respiratory tract infections. This study was designed to investigate the viral cause of lower respiratory tract infections using sensitive molecular methods. PCR was applied to investigate 10 respiratory viruses in respiratory samples from 1,014 patients aged between 3 days to 76 years with acute lower respiratory tract infections. Of the 1,014 patients with lower respiratory tract infections, 288 (28.4%) had a viral infection. One hundred fifty‐five (53.8%) presented with bronchiolitis, 100 (43.7%) with pneumonia, and 33 (11.5%) with croup. One hundred six (36.8%) and 99 (34.4%) patients had evidence of respiratory syncytial virus and human rhinoviruses infections, respectively. Adenoviruses were detected in 44 (15.2%) patients, while influenza A virus in 21 (7.3%) patients. The majority of respiratory syncytial virus infections (84%) were among patients aged <1 year. Similarly, of the 99 patients infected by human rhinoviruses, 50 (50.5%) were also among this age group. In contrast, most of influenza A virus infections, 12 of 21 (57.1%), were among patients aged over 16 years. Parainfluenza virus‐2 and human coronaviruses were not detected in any of the patients' samples. Over the 3‐year period, most of the hospitalized patients were seen during the autumn and winter months from October through March. These data show that respiratory syncytial virus and human rhinoviruses may be the major causes of lower respiratory tract infections in children admitted to hospital in Kuwait. J. Med. Virol. 82:1462–1467, 2010. © 2010 Wiley‐Liss, Inc.

Factors responsible for asthma and rhinitis among Kuwaiti schoolchildren

OBJECTIVE

The aim of this study was to assess the prevalence of asthma among schoolchildren and to determine the level house dust mites in Kuwaiti homes and its role in asthma and rhinitis.

SUBJECTS AND METHOD

The International Study of Asthma and Allergy in Children questionnaire was distributed to schoolchildren in the age group of 5-7 years, after random sampling from all the five governorates of Kuwait. The questionnaires were completed and initiated by parents with the help of the investigator and parents. House dust was collected from the bedroom floor of 549 houses in the same geographical areas where the schoolchildren were sampled, extracted and assayed for mite Der p 1 by ELISA method.

RESULTS

The estimated prevalence of asthma was 22.4% and that of rhinitis was 23%. House dust collected from the bedroom floor was found to contain low levels of Der p 1. There was no significant difference (p = 0.969) in the level of Der p 1 between areas in Kuwait. The highest levels of Der p 1 ranged from 0.02 to 0.10 mg/g in 3.5% of the total samples examined.

CONCLUSIONS

There is a high prevalence of asthma and rhinitis among the schoolchildren in Kuwait. However, the level of dust mitogens investigated in this study was below the level of concern, thus undermining their role in increasing asthma cases in Kuwait. Therefore, further studies are needed to understand the role of other mite allergens and other factors that contribute to the increased prevalence of allergic diseases in Kuwaiti children.

A multinational study of treatment failures in asthma management

SETTING

Emergency rooms.

OBJECTIVE

To assess quality of care and its determinants for asthma patients before emergency room treatment.

DESIGN

Consecutive patients with acute severe asthma attending emergency rooms were questioned about the severity of their disease and treatment in the previous 4 weeks. Prescriptions of inhaled corticosteroids were recorded. Other outcomes included self-reported adherence to treatment and loss of work.

RESULTS

Thirteen centres in 11 countries recruited 1156 patients. Only 36% of patients with persistent asthma had been prescribed an adequate dose of inhaled corticosteroids. This percentage improved in those receiving regular care from the same doctor (OR 2.86, 95%CI 1.38-5.96), and was at least as good for the 10% of patients receiving 'private' health care (OR 3.08, 95%CI 1.69-5.62). Forty-four per cent of patients had health insurance covering some asthma medications. These patients were more likely to be receiving adequate inhaled corticosteroids (OR 1.74, 95%CI 1.17-2.58), and reported better adherence than those without insurance (OR 3.00, 95%CI 1.64-5.50). Of those on adequate inhaled corticosteroids, 18% had lost work in each of the 4 previous weeks compared with 59% among those more than one treatment step below the recommended dose.

CONCLUSIONS

Access to adequate treatment is critical for better management of asthma.

Changing prevalence of asthma and allergic diseases among Kuwaiti children. An ISAAC Study (Phase III)

OBJECTIVES

To estimate the prevalence of asthma and allergic diseases in 13- and 14-year-old schoolchildren and to compare it with previous phase I data.

SUBJECTS AND METHODS

A survey of 2,922 third and fourth grade students from randomly selected intermediate level schools across Kuwait was conducted. Supervised, self-administered, written and video questionnaires of the International Study of Asthma and Allergies in Childhood (ISAAC) was used.

RESULTS

Of the 2,922 students, 2,882 (96.3%) completed the questionnaires. The prevalence (95% CI) in the written questionnaire for wheeze ever, current wheeze (within the last 12 months) and physician diagnosis of asthma were 13.4, 7.6 and 15.6%, respectively. The prevalence (95% CI) for symptoms of allergic rhinitis (AR) ever, current symptoms of AR, and diagnosis of AR was 41.4, 27.6 and 22.2%, respectively. The prevalence (95% CI) for itchy rash ever, current itchy rash, and diagnosis of eczema was 10.6, 8.3 and 12.8%, respectively. Comparing to ISAAC phase I data (1995-1996), the prevalence of current wheeze has decreased from 16.1 to 7.6% (p < 0.001). Current symptoms of AR decreased from 30.7 to 27.6 (p = 0.008) and current itchy rash decreased from 17.5 to 10.6% (p < 0.001). However, physician diagnoses of asthma and eczema remained the same as in the previous study, but physician diagnosis of AR increased from 17.1 to 22.2% (p < 0.001).

CONCLUSION

The findings show that there is a decrease in the self-reported symptoms of allergic diseases over a 5-year period while physician diagnoses of these diseases remained the same over the same period.

Clinical presentation of sarcoidosis in a mixed population in the middle east

BACKGROUND

Regional and ethnic differences in the presentation and prognosis of sarcoidosis have been reported.

OBJECTIVES

To describe and compare the clinical characteristics of sarcoidosis among Arabs and South East Asians (SEA).

METHODS

Data on patients with sarcoidosis were collected retrospectively 1983-1995 and prospectively 1995-2003.

RESULTS

A total of 142 patients, 57% females and 80% Arabs, were identified. The age at onset shows the majority of cases (45%) among Arab males occur at 30-39 years, 60% of Arab females occur at 40-59 years and 61% of SEA males occur at 40-49 years. The most common symptoms were cough 77.5%, dyspnoea 54.2%, fever 31.0%, arthralgia 19%, uveitis 14.8%, erythema nodosum 14.8%, and lymphadenopathy 12%. The radiological stage at presentation was stage 0,2.1%, I,44.4%, II,42.3%, and III,11.3%. The frequency of either stage 0 or I was higher among SEA (62%) compared to Arabs 42.5%, p=0.05.

CONCLUSION

There is a peak of sarcoidosis among Arab males at 30-39 years, Arab females at 40-59 years and SEA males at 40-49 years. Arab patients presented more frequently with either stage II or III compared to SEA who usually present with stage 0 or I.

Long term prognosis of sarcoidosis in Arabs and Asians: predictors of good outcome

BACKGROUND

The prognosis of sarcoidosis is variable and often difficult to predict. Our aim was to identify predictors of good prognosis in Arabs and Asians with sarcoidosis.

METHODS

Data on patients with sarcoidosis followed up for at least 3 years in two major hospitals in Kuwait were collected retrospectively for the period 1983 to 1995 and prospectively from 1995.

RESULTS

Of the total 115 patients, 60% were females and 80% were Arabs. Majority, 86.9%, of the patients had either Stage I or II disease. Forty-five (43.7%) were followed up for 3 to 5 years, 43 (41.7%) for 5 to 9 and 15 (14.6%) for 10 or more years while 12 were lost to follow up. Good prognosis was seen in 53 (51%), intermediate in 33(32%) and poor in 17 (17%) patients. Two patients (1.9%) died. Good prognosis was observed in 74.4% of patients with Stage I, 40% of patients with Stage II and 16.7% with stage III disease, p = 0.001. In addition, presence of arthralgia predicted a good prognosis, p = 0.014. Hypercalcemia was noted only in patients with poor or intermediate outcome. Gender, ethnicity, and presence of erythema nodosum were not predictors of prognosis in our patients. Multivariate logistic regression analysis confirmed that early stage of the disease [OR (95 %CI), 6.1 (2.3-15.7), p = 0.001] and presence of arthralgia, [OR (95%CI), 4.5 (1.3-15.4), p = 0.02] were predictors of good prognosis.

CONCLUSION

Presence of arthralgia and early stage of the disease were the most important predictors of good prognosis. Sex, age, ethnicity and presence of erythema nodosum did not influence the prognosis.

Proficiency of pediatricians in the use of inhaled medication delivery systems for the management of asthma

OBJECTIVE

To evaluate the proficiency of pediatricians in the demonstration of the proper use of metered-dose inhalers (MDIs) and to assess their theoretical knowledge of inhalation devices used in the management of asthma.

DESIGN

Prospective cross-sectional survey.

SETTING

Two university-affiliated hospitals.

PARTICIPANTS

Seventy-one pediatricians and pediatric house staff.

INTERVENTION

Each pediatrician's technique was graded by two trained observers using a checklist of six essential steps recommended by national guidelines. Theoretical knowledge of asthma devices was evaluated by a written questionnaire.

RESULTS

Twenty (35.2%) pediatricians performed at least five steps correctly, 28 (39.4%) performed three or four steps correctly, and 18 (25.4%) performed two steps or less correctly. The most common errors were failure to start inhalation from functional residual capacity, failure to inhale slowly, and failure to wait at least 20 seconds before the next puff. Senior pediatricians were more skillful in the practical use of MDIs than were pediatric house staff (p = 0.03). The most common deficiencies in theoretical knowledge were related to estimation of the amount of medication in the canister (8.5% correct) and how valved holding chambers (VHCs) improve drug delivery to the lung (15.5% correct).

CONCLUSION

Pediatricians in Kuwait have significant deficiencies regarding the practical and theoretical aspects of MDIs and other inhalation devices.

The assessment and management of patients with acute asthma

Acute asthma is a common medical emergency that is often poorly assessed and managed. Initial evaluation should include a review of historical factors for identifying high risk patients; appropriate evaluation of the current exacerbation, including an objective assessment of airflow obstruction; and, in parallel, initiation of therapy with controlled oxygen therapy, regular bronchodilator therapy and, in most cases, systemic corticosteroids. There is no benefit in using intravenous (IV) corticosteroids--a single 50 mg oral dose is appropriate. Although there is no significant additional bronchodilator effect with the use of ipratropium bromide or IV magnesium, both modalities have been shown to reduce hospitalisations for moderate to severe exacerbations. There is no role for the routine use of IV aminophylline or beta (beta) agonists in patients presenting with acute asthma. Patients who achieve 60% of their predicted peak expiratory flow (PEF) or 1 sec forced expiratory volume (FEV1) or best can usually be safely discharged. The exacerbation should be taken as an opportunity to review how a patient responded to the particular exacerbation. Were they on appropriate anti-inflammatory therapy? Did they modify the dose of therapy early in the exacerbation? Did they have an action plan? Such deficiencies can usually be managed by facilitated referral to a specialist clinic that ideally has an asthma education programme. The need for long-term anti-inflammatory therapy can be reviewed at this time as well as the potential incremental benefit of the addition of add-on therapy, most likely the use of a long-acting beta agonist.

Significance of atypical pathogens among community-acquired pneumonia adult patients admitted to hospital in Kuwait

OBJECTIVES

The aim of this study is to determine the microbial etiology and severity of community-acquired pneumonia (CAP) in Kuwait.

SUBJECTS AND METHODS

The severity of consecutive adult CAP cases admitted to 3 hospitals over a 1-year period was classified according to the Pneumonia Outcome Research Team (PORT) severity index. The microbial etiology was determined using standard methods for bacteria and serological tests for atypical and viral pathogens.

RESULTS

The study population was 124 of the 135 admissions; 63 female, 61 male; mean age 41.3+/-18 years. The severity class distribution was: class I 31%, class II 37%, class III 17%, class IV 13%, and class V 2%. Etiological agents were identified from 44 patients (35%), with one pathogen in 31 (25%), two in 9 (7%), and three or more in 4 (3%). The most common pathogens identified were: Mycoplasma pneumoniae in 14 patients (11%), Legionella pneumophila in 10 (8%), Chlamydia pneumoniae in 8 (6%), influenza B virus in 8 (6%), influenza A virus in 5 (4%), Haemophilus influenzae in 4 (3%), Streptococcus pneumoniae in 3 (2%), Staphylococcus aureus in 3 (2%), gram-negative enterobacteria in 5 (4%), Moraxellacatarrhalis in 2 (2%), and viruses in 4 (3%). The yields from laboratory tests were 48% for paired serology, 20% from adequate sputum sample, and 3% from blood culture.

CONCLUSION

Our study shows that a large percentage of mild CAP cases are admitted to hospitals in Kuwait. Atypical pathogens have a significant role in the etiology of CAP. There is overtreatment of CAP with a combination treatment consisting mainly of third-generation chephalosporins and macrolides.

Asthma and sensitization in a community with low indoor allergen levels and low pet-keeping frequency

BACKGROUND

Little is known about causes of asthma and sensitization in desert countries.

OBJECTIVE

To investigate risk factors associated with asthma and sensitization in Kuwait.

METHODS

One hundred sixty children (9-16 years) with physician-diagnosed asthma were recruited and matched (age, sex) with 303 healthy controls. Risk factors were assessed by questionnaires, determination of sensitization status (skin tests and IgE), and home allergen exposure (mite, cat, dog, cockroach; ELISA).

RESULTS

Home allergen levels and frequency of pet ownership were very low (cat, 4.1%; dog, 1.5%). The risk of cat sensitization increased significantly among cat owners (odds ratio [OR], 3.53; 95% CI, 1.33-9.41; P = .01), and in children with reported contact with cats during the first year of life (OR, 2.60; 95% CI, 1.17-5.80; P = .019). In the multivariate analysis, maternal atopy (OR, 1.77; 95% CI, 1.13-2.75; P = .01) and cat ownership (OR, 3.32; 95% CI, 1.19-9.25; P = .02) remained significant associates of cat sensitization. Current dog ownership significantly increased the risk of sensitization to dog (OR, 6.05; 95% CI, 1.33-27.54; P = .02). In the multivariate analysis, dog ownership remained the only significant associate of dog sensitization (OR, 6.02; 95% CI, 1.30-27.96; P = .02). Sensitization to Alternaria was the strongest independent associate of the asthma group. Family history of asthma, history of whooping cough, current cat ownership, and breast-feeding <2 months were other significant and independent risk factors for asthma.

CONCLUSIONS

Pet ownership markedly increased the risk of sensitization to pets. Despite low allergen exposure, the pattern of childhood asthma in Kuwait follows that described in Western communities (strong association with sensitization).

Flexible fiberoptic bronchoscopy. Diagnostic yield

OBJECTIVE

Fiberoptic bronchoscopy is a minimally invasive procedure with a high diagnostic yield. The aim of this study was to document the usefulness of the procedure in the diagnosis of various respiratory disorders in a Middle East country.

METHODS

Data on all bronchoscopies carried out in Chest Diseases Hospital, Kuwait from January 1996 to December 1998 were retrospectively collected.

RESULTS

Out of 968 cases, only 620 (64%) patients had a full follow up. Suspected pulmonary tuberculosis (TB) (51.6%), unresolving pneumonia (16.1%), hemoptysis with a normal chest radiograph (8.4%), lung mass (7.7%) and hilar lymphadenopathy (3.2%) were the most common indications. Eleven percent of patients who underwent bronchoscopy had a normal chest radiograph, the reason being hemoptysis in 75.4%, inhalation injury in 21.8% and suspected upper airway obstruction in 2.9%. In smear negative suspected TB cases, 22.5% proved to have active disease. Acid fast bacillus was identified in bronchoalveolar lavage, either by smear or culture, in 44 (73.3%) patients with suspected pulmonary TB and in 6 (54.5%) patients with miliary shadows. An underlying cause was identified in 28 (28%) patients with unresolving pneumonia. Ninety-four percent of cases with clinical impression of bronchogenic carcinoma could be diagnosed. Transbronchial biopsy was diagnostic in 79% patients with diffuse parenchymal lung disease. No complications other than transient hypoxemia and controllable bleeding were noticed.

CONCLUSION

Generally, the indications for flexible fiberoptic bronchoscopy remained similar to elsewhere. Unlike western series, the majority of the cases were for the diagnosis of pulmonary infections especially TB.

Percutaneous multiple-site parietal pleural biopsy: description and evaluation of a new and safe technique

STUDY OBJECTIVES

(1) To describe a new percutaneous pleural biopsy technique to obtain multiple-site parietal pleural biopsy specimens in patients with pleural effusion (PE), and (2) to evaluate its effectiveness and safety compared to current techniques.

DESIGN

Prospective interventional study.

SETTING

University teaching hospital.

PATIENTS

Consecutively referred for evaluation of exudative PE.

INTERVENTION

With the patient in a semirecumbent position, a 9F sheath was inserted by the Seldinger technique into the pleural cavity on the midaxillary line under local anesthesia and fluoroscopic guidance. An 8F bioptome was introduced through it, and biopsy specimens were taken from several sites on the costal and diaphragmatic pleura. After biopsy, PE was completely evacuated, and the sheath was removed.

RESULTS

During the 2-year pilot study, we procured, on average, 14 adequate pleural specimens from each of the 28 patients (age range, 15 to 81 years) on the first attempt. Histopathologic examination revealed tuberculous pleuritis (18 patients), metastatic adenocarcinoma (1 patient), and nonspecific pleuritis (9 patients). Postprocedure, 25 patients had rapid symptomatic improvement without recurrence of PE. No major complications occurred during or after the procedure (mean follow-up period, 2 years).

CONCLUSIONS

Our new biopsy procedure can be performed easily, safely, and with increased diagnostic sensitivity and patient comfort. Unlike other biopsy techniques, it provides adequate multiple-site pleural biopsy specimens, in all cases, on the first attempt without any morbidity and mortality. It has a therapeutic potential to provide rapid symptomatic relief and treatment by pleurodesis. We recommend this procedure for patients whose conditions remain undiagnosed after undergoing needle biopsy or for those who cannot tolerate it, before considering more aggressive diagnostic interventions. This is the best alternative when thoracoscopy or thoracotomy are not available or when patients are at high risk for complications from them.

Clinical patterns of diffuse parenchymal lung disease in Kuwait: a prospective study

OBJECTIVE

To report our experience of the clinicopathological patterns of diffuse parenchymal lung disease (DPLD).

SUBJECTS AND METHODS

Over a 4-year period, 75 patients (41 males, 34 females), aged 13-76 years, who were referred to Mubarak Al-Kabeer and the Chest Diseases Hospitals, Kuwait with a diagnosis of diffuse lung disease, were included in the study. After a comprehensive history and physical examination, further investigations were done, including hematological and immunological profiles, sputum and bronchoalveolar lavage fluid examination, chest radiograph, high resolution computed tomography (HRCT), pulmonary function test and lung biopsy.

RESULTS

Of the 75 patients 60 (80%) were over 40 years of age. The duration of symptoms in 34 patients (45%) was less than 6 months and longer than 1 year in 28 (37.7%) patients. Twenty-five of the patients were cigarette smokers. The mean forced lung capacity (FVC), total lung capacity and diffusing capacity for carbon monoxide were less than 60% of the predicted values in most patients. There was a significant difference in mean FVC value between smokers and nonsmokers (p < 0.05). The HRCT findings were at an advanced stage in 65 patients, with additional honeycombing in 21 of the 65 patients. Idiopathic pulmonary fibrosis was the most common cause of DPLD, occurring in 52 patients, followed by sarcoidosis and collagen vascular diseases.

CONCLUSION

DPLD was observed predominantly in middle aged and elderly patients, due probably to increasing industrialization in the country. The role of cigarette smoking as a contributory factor remains unclear.

The seasonal variation in allergic rhinitis and its correlation with outdoor allergens in Kuwait

BACKGROUND

Allergic rhinitis (AR) is the most common allergic problem in Kuwait. Most of the patients who have either AR or asthma are referred to the Al-Rashed Allergy Center.

OBJECTIVE

To determine if there is a seasonal variation in AR in Kuwait and to correlate it with the daily pollen count.

METHODS

Information about the new patients referred to the center over a 5-year study period (1996-2000) was extracted from the center's records. The daily pollen count in Kuwait city was obtained from the Air Biology Laboratory.

RESULTS

There was a significant seasonal variation with a bimodal increase in the number of patients with AR referred to the center. The main peak in the number of patients occurred in September-October, and there was a smaller peak in April-May. The mean number +/- SD of new patients per month over the 5-year period varied from 87 +/- 32 for December to 367 +/- 104 for September. Similarly, the average daily pollen count varied from 3.7 +/- 1.0 pollens per mm3 in January to 124 +/- 92 in October. There was high correlation between the number of new AR patients and the average total pollen count (Pearson correlation, r=0.77, p<0.001), as well as with Chenopodiaceae and Amaranthaceae (weed) pollens (r=0.75, p<0.001), while there was no correlation between the number of new patients and either tree or grass pollens.

CONCLUSION

Seasonal AR occurs during two periods in Kuwait, i.e. September-October and April-May, with September-October being the main season. The rise in AR during late summer in Kuwait is mainly associated with the pollination of Chenopodiaceae species.

Safety of subcutaneous specific immunotherapy with pollen allergen extracts for respiratory allergy

BACKGROUND

Specific immunotherapy (SIT) is a well-documented treatment for respiratory allergy. However, the major risk of SIT is the development of systemic anaphylactic reactions.

OBJECTIVES

To evaluate the safety of SIT given by subcutaneous route for 3 years to patients with seasonal allergic rhinitis (AR) with or without asthma.

METHODS

A prospective open-label study of immunotherapy (Chenopodium album, Bermuda grass, or both) in 181 consecutive patients with AR with or without asthma. After an initial dose-escalation phase, a maintenance dose of 0.5 ml of 100,000 PNU/ml was administered monthly for 3 years. The occurrence and severity of systemic reaction (SR) and local reaction was recorded and graded according to the WHO position paper.

RESULTS

Of 181 patients enrolled, 57 (31%) did not complete the study (53 due to poor compliance and 4 due to systemic side effects). All 4 patients who developed SR had asthma and all the SR occurred during the dose- escalation phase. Three patients had moderate SR (grade 2), while 1 patient had severe reaction (grade 3). Three of the SR occurred within the first 20 min after injection and 1 SR occurred 2 h after injection. None of the reactions were life threatening and were managed easily. Total rhinitis symptom score decreased from 11.8 at baseline to 7.46 at the end of treatment (p<0.001). The size of the skin prick test reaction to the main sensitising allergen was reduced from 7.48 +/- 2.26 mm at baseline to 5.60 +/- 2.18 mm at the end of treatment, p<001.

CONCLUSION

If a strict protocol is used, SIT is safe in AR patients with or without mild asthma and may result in significant subjective and objective improvement.

Epidemiology of tuberculosis in Kuwait from 1965 to 1999

BACKGROUND

After several decades of continuous decline, the incidence of tuberculosis (TB) has increased over the last 10 years in several regions of the world. No reports have been published describing the epidemiology of TB in Kuwait.

OBJECTIVES

To examine the trend of TB in Kuwait from 1965 to 1999 and analyse the factors associated with this trend.

METHODS

Annual reports of the Kuwait central TB unit were examined. Tuberculosis registers recommended by the World Health Organization (WHO) and the International Union Against Tuberculosis and Lung Disease (IUATLD), which were available for the years 1998 and 1999, were also examined.

RESULTS

The notification rate of TB for the whole population has declined from 259 per 100000 in 1965 to 24/100000 in 1999. There has been a steeper decline among Kuwaiti nationals, from 355/100 000 in 1965 to 14/100000 in 1999. The average annual rate of decline in all cases of TB among Kuwaiti nationals was 11.9% from 1965 to 1976, and 11.0% from 1976 to 1989, but there was a slight rise of 4.3% per year from 1989 to 1999. The average annual rate of decline in all cases of TB among non-nationals was 6.3% from 1965 to 1976, and 8.3% from 1976 to 1989, but there was a rise of 2.3% per year from 1989 to 1999.

CONCLUSION

Tuberculosis in Kuwait declined steadily from 1965 to 1989. Since 1989 there has been a slight rise in TB incidence in Kuwait among both Kuwaiti nationals and non-nationals.