Pregnancy in Patients with the Fontan Operation.

Improved survival rates for patients with a Fontan circulation has allowed more women with this complex cardiac physiology to contemplate pregnancy. However, pregnancy in women with a Fontan circulation is associated with a high risk of adverse maternal and fetal outcomes, high rates of miscarriage and preterm delivery. Factors associated with a successful pregnancy outcome are: younger age, normal body weight, absence of significant functional limitation, no Fontan-related complications, and well-functioning single ventricle physiology. Appropriate care with timely preconception counselling and regular, frequent clinical reviews by a multidisciplinary team based at a tertiary centre, improves the chance of a successful pregnancy. Empowerment of patients with education on their specific congenital cardiac condition and its projected trajectory, helps them make informed choices regarding their health, reproductive choices and assists them to achieve their life goals.

Users' attitudes to an electronic medical record system and its correlates: a multivariate analysis.

Implementation of an electronic medical record (EMR) system increases efficiency of health services, quality of care and patient satisfaction. Successful implementation depends on many factors, one of which is how users respond to the new system. We studied medical receptionists' appraisal of the newly implemented EMR system in primary healthcare centres in Kuwait. Four hundred receptionists were selected randomly from different healthcare centres and asked to complete a user interaction satisfaction questionnaire relating to their experience of the new system. The response rate was 80.5%. A large majority of the respondents considered the system to be flexible (83%), easy (89%), and satisfying (81%). However, more than one third of the respondents (36%) found the system inadequate. Bivariate and multivariate analyses found age, typing ability, ease of data entry and computer error as significant correlates with overall user response. These findings relating to users' reactions to various aspects of the EMR should assist policymakers to recognise the causes of dissatisfaction with the EMR among medical receptionists at health centre clinics that may adversely affect its successful implementation and regular use, as well as the quality of care provided by the clinics. In addition, the findings provide information to assist the development of guidelines for future implementation of the EMR system at the secondary healthcare level.

Job satisfaction of nurses with multicultural backgrounds: a questionnaire survey in Kuwait.

BACKGROUND: Nurses working in Ministry of Health hospitals in Kuwait come from 35 countries, and only 12% of them are Kuwaitis. This study explores factors that influence the job satisfaction of nurses of multicultural background working in five general hospitals in Kuwait. OBJECTIVES: This study aims to identify factors related to the job satisfaction of nurses and the effect of selected background characteristics (e.g., age, gender, nationality, educational qualification, marital status, monthly salary, experience in other countries, and years of experience) on the global satisfaction scale by using the McCloskey-Mueller Satisfaction Scale. METHODS: A stratified random sample size of 500 subjects was selected, and a questionnaire was distributed among them. Four hundred thirty-six completed questionnaires were returned, resulting in a response rate of 87.2%. RESULTS: Factor analysis identified five factors: satisfaction with (a) professional opportunities; (b) praise and recognition; (c) scheduling of duty; (d) control and responsibility, and (e) extrinsic rewards. These together explained 59.5% of the total variance. Nurses were found to be dissatisfied with two of five factors: professional opportunities and extrinsic rewards. Nurses were satisfied with the remaining three factors, although levels of satisfaction were not very high. The relationship of job satisfaction with nationality and marital status was positive and significant. However, a higher level of educational qualification showed an inverse relationship with job satisfaction. CONCLUSIONS: Two issues identified here concerned aspects of nurses' professional development and extrinsic rewards, which have to be addressed as prerequisites to any improvement in the quality of nursing care in Kuwait. Based on our findings, we recommend a concerted action in developing a strategy to improve various aspects of nurses' professional development and extrinsic rewards. This will have a positive impact on the quality of health care of the Kuwaiti population.

Vascularised bone grafting in the management of scaphoid non-union - a review of 34 cases.

We reviewed the outcomes of 34 patients who had undergone vascularised bone grafting for a chronic scaphoid non-union. Mean age was 27 years (range 16-46 years). The dominant hand was involved in 17 cases. Eleven patients were smokers. In 18 cases the fracture involved the proximal and in 16 cases the middle third of the scaphoid. In 26 patients the proximal scaphoid fragment was deemed avascular. Sixteen patients had previously undergone scaphoid fixation and non-vascularised bone grafting. At a follow-up of 1 to 3 years (mean 1.6 years), 15 of the 34 scaphoid non-unions had united. Injury to the dominant hand and duration of the non-union significantly increased the risk of failure. Persistent non-union was more common in proximal third fractures and in the presence of an avascular proximal pole but these findings did not reach statistical significance.

Prevalence of viral markers among first-time Arab blood donors in Kuwait.

BACKGROUND: The aim of this study was to assess the effect of blood donation modes on the prevalence of viral markers among Arab first-time blood donors in Kuwait. STUDY DESIGN AND METHODS: Donor ethnic background was classified as Kuwaiti nationals and non-Kuwaiti Arabs. A total of 26,874 donors were screened in 2002 for the following viral markers: hepatitis C virus antibody (anti-HCV), hepatitis B surface antigen (HBsAg), anti-hepatitis B core antigen (HBc), human immunodeficiency virus-1 and -2 antibody (anti-HIV-1 and -2), HIV p24, and human T lymphotropic virus-I and -II antibody (anti-HTLVI/II). All samples positive for the presence of anti-HBc were tested for anti-HBs. Among these donors, 12,798 were first-time donors of which 74 percent were replacement and 26 percent were volunteers. RESULTS: The prevalence of HCV among replacement donors was significantly higher than the volunteer group. The difference between the two modes of blood donations, however, was not significant for HBsAg. The prevalence of anti-HCV among Kuwaiti national and non-Kuwaiti Arab first-time donors was 0.8 and 5.4 percent, respectively, whereas the prevalence of HBsAg was 1.1 and 3.5 percent, respectively, with the difference being significant at a p level of <0.0001. The difference observed for prevalence of anti-HBc among Kuwaiti national and non-Kuwaiti Arab donors (17 and 33.3%, respectively) was significant (p < 0.0001). Among first-time donors, 13.7 percent were positive for the presence of anti-HBs, indicating that 13.7 percent of the total Arab donor population might have had a previous infection and possible immunity to hepatitis B virus (HBV). CONCLUSION: A high prevalence of HBV and HCV was found among non-Kuwaiti Arab donors. The prevalence of anti-HCV was only significantly higher among replacement versus volunteer first-time donors. Therefore, there is a need to develop a strategic plan that incorporates the diverse background of the blood donors living in Kuwait.

Determinants of job satisfaction among nurses in Kuwait.

OBJECTIVE: Job satisfaction among nurses working in five general hospitals in Kuwait was analysed using a global scale based on the McClosky Mueller Satisfaction Scale (MMSS) in relation to selected background characteristics (eg age, gender, nationality, educational qualification, monthly salary and the departments in which they worked. DESIGN: The questionnaire was distributed to 500 nurses using a stratified random sample. The response rate was 87.2%. RESULTS: Age, nationality and the department worked in had a positive significant relationship with job satisfaction. However, a higher level of educational qualification and previous work experience in other countries showed an inverse relationship with job satisfaction. CONCLUSION: Based on our findings, we recommend that expatriate staff should be provided with an understanding of cultural differences and how to cope with them. Special attention should be paid to the norms regarding interaction among males and females and social interaction among professionals from the opposite gender. Intensive courses in the languages to be used in the care provision process should be provided to impart requisite language competency.

RBC alloimmunization and autoimmunization among transfusion-dependent Arab thalassemia patients.

BACKGROUND: Thalassemia major is a common hemoglobinopathy in the Arabian Gulf region. However, limited data are available on the frequency of RBC alloimmunization and autoimmunization in transfusion-dependent Arab thalassemia patients. STUDY DESIGN AND METHODS: A total of 190 thalassemia major patients were classified as Kuwaiti Arab and non-Kuwaiti Arab. Pretransfusion investigation records were reviewed for the presence of RBC alloantibody and autoantibody, and the age at which RBC alloantibody was developed. RESULTS: Fifty-seven (30%) patients developed RBC alloantibodies. The most common clinically significant alloantibodies were directed against antigens in the Kell and Rh systems. Anti-K developed in 41 (72%) patients followed by anti-E in 26 (45.6%). RBC autoantibodies developed in 21 (11%) patients with and without underlying RBC alloantibodies. Sixty-six (49.6%) RBC alloantibodies developed between the ages of 2 and 10 years. CONCLUSION: Several factors might have contributed to the high alloimmunization and autoimmunization rate observed in this study, including the heterogeneity of the population living in Kuwait, lack of better-matched donors for those patients, and the use of poststorage leukodepleted blood. It is recommended that thalassemia patients receive blood matched for Rh and Kell antigens and prestorage leukodepleted RBCs.

Glucose-stimulated preproinsulin gene expression and nuclear trans-location of pancreatic duodenum homeobox-1 require activation of phosphatidylinositol 3-kinase but not p38 MAPK/SAPK2.

Exposure of islet beta-cells to elevated glucose concentrations (30 versus 3 mm) prompts enhanced preproinsulin (PPI) gene transcription and the trans-location to the nucleoplasm of pancreatic duodenum homeobox-1 (PDX-1; Rafiq, I., Kennedy, H., and Rutter, G. A. (1998) J. Biol. Chem. 273, 23241-23247). Here, we show that in MIN6 beta-cells, over-expression of p110.CAAX, a constitutively active form of phosphatidylinositol 3-kinase (PI3K) mimicked the activatory effects of glucose on PPI promoter activity, whereas Deltap85, a dominant negative form of the p85 subunit lacking the p110-binding domain, and the PI3K inhibitor LY 294002, blocked these effects. Similarly, glucose-stimulated nuclear trans-location of endogenous PDX-1 was blocked by Deltap85 expression, and wortmannin or LY 294002 blocked the trans-location from the nuclear membrane to the nucleoplasm of epitope-tagged PDX-1.c-myc. By contrast, SB 203580, an inhibitor of stress-activated protein kinase-2 (SAPK2)/p38 MAP kinase, had no effect on any of the above parameters, and PPI promoter activity and PDX-1.c-myc localization were unaffected by over-expression of the upstream kinase MKK6 (MAP kinase kinase-6) or wild-type p38/SAPK2, respectively. Furthermore, no change in the activity of extracted p38/SAPK2 could be detected after incubation of cells at either 3 or 30 mm glucose. These data suggest that stimulation of PI3K is necessary and sufficient for the effects of glucose on PPI gene transcription, acting via a downstream signaling pathway that does not involve p38/SAPK2.

Glucose enhances insulin promoter activity in MIN6 beta-cells independently of changes in intracellular Ca2+ concentration and insulin secretion.

Recent studies have suggested that glucose may activate insulin gene transcription through increases in intracellular Ca(2+) concentration, possibly acting via the release of stored insulin. We have investigated this question by dynamic photon-counting imaging of insulin- and c-fos-promoter-firefly luciferase reporter construct activity. Normalized to constitutive viral promoter activity, insulin promoter activity in MIN6 beta-cells was increased 1.6-fold after incubation at 30 mM compared with 3 mM glucose, but was unaltered at either glucose concentration by the presence of insulin (100 nM) or the Ca(2+) channel inhibitor, verapamil (100 microM). Increases in intracellular [Ca(2+)] achieved by plasma membrane depolarization with KCl failed to enhance either insulin or c-fos promoter activity in MIN6 cells, but increased c-fos promoter activity 5-fold in AtT20 cells. Together, these results demonstrate that glucose can exert a direct effect on insulin promoter activity in islet beta-cells, via a signalling pathway which does not require increases in intracellular [Ca(2+)] nor insulin release and insulin receptor activation.

Glucose-dependent translocation of insulin promoter factor-1 (IPF-1) between the nuclear periphery and the nucleoplasm of single MIN6 beta-cells.

Using laser-scanning confocal microscopy, we have monitored glucose-induced changes in the subcellular localization of insulin promoter factor-1 (IPF-1) labeled with a c-myc epitope tag. This construct trans-activated the insulin promoter in single living MIN6-beta-cells as assessed by luciferase-based promoter analysis. IPF-1.c-myc expression also enhanced the response of the insulin promoter to elevations in extracellular glucose concentration. In the majority (148/235, 63%) of cells maintained at low (3 mM) extracellular glucose concentration, IPF-1.c-myc immunoreactivity was confined to the nuclear periphery. Incubation of cells at stimulatory (30 mM) glucose concentrations caused a rapid redistribution of the chimera to the nucleoplasm (775/958, 81% of cells). By contrast, the irrelevant transcription factor c-Fos, tagged with either c-myc or as a chimera with luciferase, was localized exclusively to the nucleoplasm irrespective of the glucose concentration. Furthermore, IPF-1 extended with the bulky (27 kDa) enhanced green fluorescent protein (EGFP) group was confined largely to the nucleoplasm at all glucose concentrations tested and did not support trans-activation of the insulin promoter by glucose. Movement of endogenous IPF-1 from the nuclear periphery to the nucleoplasm may therefore increase the trans-activational capacity of this factor in native beta-cells exposed to high extracellular glucose concentrations.

Upstream stimulatory factor-2 (USF2) activity is required for glucose stimulation of L-pyruvate kinase promoter activity in single living islet beta-cells.

Elevated glucose concentrations stimulate L-pyruvate kinase (L-PK) gene transcription in liver and islet beta-cells. A glucose response element termed the L4 box (two noncanonical E-boxes located -165 and -154 base pairs upstream of the transcriptional start point) has previously been defined within the proximal promoter region of the gene. However, the identity of the transacting factor(s) which binds to this site remains unclear. We have used photon counting digital imaging of firefly luciferase activity to monitor promoter activity continuously in single living islet beta and derived INS-1 cells, and to analyze the molecular basis of the regulation by glucose. L-PK promoter activity, normalized to cytomegalovirus promoter activity using the distinct Renilla reniformis luciferase, was >/=6-fold higher in cells cultured at 16 mM glucose or above compared with cells cultured at 3 mM glucose. Microinjection of antibodies against the ubiquitous transcription factor USF2 inhibited L-PK promoter activity in beta- and INS-1 cells incubated at 30 mM glucose by 71-87%. Anti-USF2 antibodies had a much smaller effect on promoter activity in INS-1 cells cultured at 3 mM glucose, and on the activity of a modified promoter construct lacking an L4 box. These data support the view that glucose enhances L-PK gene transcription in beta-cells by modifying the transactivational capacity of USF2 bound to the upstream L4 box.