Lifestyle Changes among ACS Survivors in Arabian Gulf Countries (Gulf COAST Registry).

BACKGROUND: We described lifestyle changes one year after acute coronary syndrome (ACS) among patients in Arabian Gulf countries. METHODOLOGY: Data of patients admitted to 29 hospitals in 4 countries with the diagnosis of ACS were analysed from Gulf citizens with ACS events (Gulf COAST) registry. A total of 3565 ACS patients recruited in the Gulf COAST registry had a one-year follow up available. There was a significant correlation between return to work and the age of patient (p < .001). At one-year post ACS, the majority were performing their usual activities (93%), but only 39% were exercising. Smoking cessation was successful in 60% of patients and most non-quitters tried or considered quitting (18 and 21% of the total population of smokers, respectively). Sexual activity was reported from 2290 male patients at one-year follow up. The majority reported performing sexual activity (66%) with no fear of sexual intercourse (57%). RESULTS AND CONCLUSION: At one year after an ACS, the majority of our patients returned to their work, sexual activity and other usual activity. Clearly, improvement is needed when it comes to smoking cessation and exercise.

Impact of Digoxin on Mortality in Patients With Atrial Fibrillation Stratified by Heart Failure: Findings From Gulf Survey of Atrial Fibrillation Events in the Middle East.

OBJECTIVE: The use of digoxin in patients having atrial fibrillation (AF) with or without heart failure (HF) is not without controversy. The aim of this study was to examine the impact of digoxin therapy on mortality stratified by HF. METHODS: Gulf Survey of Atrial Fibrillation Events was a prospective, multinational, observational registry of consecutive patients with AF recruited from the emergency department of 23 hospitals in 6 countries in the Middle East. Patients were recruited between October 2009 and June 2010 and followed up for 1 year after enrollment. Analyses were performed using univariate and multivariate statistical techniques. RESULTS: The study included a total of 1962 patients with AF, with an overall mean age of 56 ± 16 years, and 52% (n = 1026) were males. At hospital discharge, digoxin was prescribed in 36% (n = 709) of the patients, whereas HF was present in 27% (n = 528) of the cohort. A total of 225 (12.1%) patients died during the 12-month follow-up period after discharge (5.3% [n = 104] were lost to follow-up). Patients with HF were consistently associated with higher mortality at 1 month (5.1% vs 2.1%; P < .001), 6 months (17.2% vs 5.0%; P < 0.001), and 12 months (24.3% vs 7.6%; P < .001) when compared to those without HF. When stratified by HF, digoxin therapy was associated with significantly higher mortality in those without HF at 6 months (8.7% vs 3.7%; adjusted odds ratio (aOR), 5.07; P < .001) and 12 months (12.3% vs 6.0%; aOR, 4.22; P < .001) but not in those with HF (6 months: 18.6% vs 14.7%; aOR, 1.62; P = .177 and 12 months: 25.4% vs 22.4%; aOR, 1.37; P = .317). CONCLUSIONS: In patients with AF and HF, digoxin did not offer any survival advantages. However, in those without HF, digoxin therapy was, in fact, associated with significantly higher long-term mortality.

Orbitofacial neurofibromatosis: clinical characteristics and treatment outcome.

PURPOSE: To report clinical observations and surgical management in a large series of patients with orbitofacial neurofibromatosis type 1 (OFNF). PATIENTS AND METHODS: Patients were identified and medical records reviewed for demographic data, ophthalmologic examinations, surgical interventions, and procedure outcome to create a retrospective, non-comparative case series of patients with OFNF seen at one medical centre over a 23-year period. RESULTS: Sixty patients with OFNF (31 females and 29 males; mean age, 14 years) were followed for an average of 5.7 years. Presenting signs and symptoms included eyelid swelling in all patients, ptosis in 56 (93.3%), proptosis in 34 (56.6%), dystopia or strabismus in 30 (50%), and decreased visual acuity in 50 (83.3%). Surgical intervention included ptosis repair in 54 (90%; mean 1.6 surgical procedures), facial and orbital tumour debulking in 54 (90%; mean 2.3 surgeries), and canthoplasty in 28 (46.6%) patients. Eleven patients required enucleation or exenteration of a blind eye. CONCLUSION: Patients with OFNF often require multiple procedures to preserve vision, prevent additional disfigurement, and achieve cosmetic rehabilitation. Patients need regular ophthalmological monitoring given the potential for progressive visual and cosmetic consequences.

Association of low heart rate variability with atherosclerotic cardiovascular disease in hemodialysis patients.

OBJECTIVE: The aim of this study was to investigate the left-ventricular (LV) mass-adjusted association between low heart rate variability (HRV) and atherosclerotic cardiovascular disease (ASCVD) among hemodialysis patients in Kuwait. SUBJECTS AND METHODS: One hundred and eight patients were enrolled in the study. HRV time domain measures were obtained by 48-hour Holter monitoring, including the standard deviation of all R-wave-to-R-wave (RR) intervals (SDNN), standard deviation of all 5-min averaged intervals (SDANN), HRV triangular index (HRV-TI), percent of adjacent RR intervals differing by >50 ms (pNN50), and root mean square of sums of squares of all differences (rMSSD). Left ventricular ejection fraction (LVEF) and LV mass index (LVMI) were measured by M-mode echocardiography. Comorbidity was assessed using medical record review. Prevalent ASCVD was defined as coronary artery, cerebrovascular, or peripheral vascular disease. RESULTS: Prevalence of ASCVD, LV hypertrophy, and LVEF <40% were 56, 59, and 10%, respectively. The SDANN was negatively associated with ASCVD (-20 ms; p = 0.003), LV systolic dysfunction (-20 ms; p = 0.001), elevated LVMI (-20 ms; p = 0.002), hypertension (-34 ms; p = 0.01), and diabetes (-20 ms; p = 0.001). After adjustment for hypertension and LVMI using logistic regression, ASCVD was associated with the lowest quartile of SDANN (OR = 4.3, p = 0.009), HRV-TI (OR = 3.3, p = 0.03), and SDNN (OR = 2.3, p = 0.10). These associations persisted after adjusting for LVEF. CONCLUSION: In dialysis patients, low HRV indices were strongly associated with prevalent ASCVD, independent of LVMI and LVEF. The interrelationships among HRV, diabetes, hypertension, and LVMI should be addressed in studies of HRV and ASCVD.

Inpatient preseptal cellulitis: experience from a tertiary eye care centre.

OBJECTIVE: To describe causes of preseptal cellulitis (PSC) and outcome of treatment in patients admitted to a tertiary eye-care centre. METHODS: A 15-year (January 1991 to December 2005) review of inpatients with clinical signs and symptoms or radiological evidence suggestive of PSC was conducted. Patients with infection anterior to the orbital septum which is characterised by acute onset of eyelid oedema, tenderness, erythema, warmth and chemosis were included in the study. RESULTS: Among the 104 patients (male:female 64:40) fulfilling the diagnostic criteria for PSC, acute dacryocystitis (ADC) was the most common predisposing cause in 32.6% patients, followed by sinusitis/upper-respiratory infection (URI) in 28.8% and trauma/recent surgery in 27.8% patients. Fifty-per cent required surgical intervention including dacryocystorhinostomy/probing/stenting in 74% and abscess/chalazian drainage in 28.8%. In 38.5% of the patients who had surgical intervention, microbiological investigations were carried out, cultures were positive in 90%. Most common micro-organisms recovered included Staphylococcus and Streptococcus species followed by Haemophilus influenzae and Klebsiella pneumonia. Blood cultures were positive in two of the 34 patients in whom blood was drawn. Most patients responded to systemic antibiotics with resolution of PSC. Seven patients developed late complications which included subacute lid abscesses, eyelid necrosis and cicatricial ectropion. CONCLUSIONS: Sinusitis/URI, ADC and recent history of trauma/surgery were the most common cause of PSC in admitted patients. Although most patients responded to systemic antibiotics, surgical intervention was necessary in some patients to prevent associated complications.

Optic nerve avulsion from door-handle trauma in children.

AIM: To report severe visual loss caused by optic nerve avulsion (ONA) in children with door-handle trauma. METHODS: Clinical records at a tertiary eye care hospital, of 14 children who sustained severe visual loss as a result of door-handle injuries, were reviewed. The data were analysed for location, presenting symptoms and signs, diagnostic studies, intervention, and the cause of visual loss. RESULTS: There were 11 males and three females with an average age of 8 years and an average height of 125 cm. The place of trauma was home in 11 and school in three children. Presenting visual acuity (VA) was light perception (LP) in five patients and no light perception (NLP) in nine. All the 14 children had evidence of ONA and four patients had ruptured eye globes that required initial repair. The diagnosis of ONA was made clinically or by imaging studies and confirmed histopathologically in eyes that were enucleated. Average follow up was 28.8 months (range 4 months to 8 years). Final VA was LP in one patient and NLP in 13 patients, eight eyes required enucleation for painful blind eye or to achieve optimal cosmesis. CONCLUSION: ONA was the common cause of visual loss in children who sustained ocular trauma caused by door-handles.

Differential distribution of risk factors and outcome of acute coronary syndrome in Kuwait: three years' experience.

OBJECTIVE: To compare the distribution of risk factors and clinical outcome of acute coronary syndrome (ACS) between Kuwaiti and other Arab men living in Kuwait. SUBJECTS AND METHODS: The data for this study was collected from the computerized database at the Mubarak Al-Kabeer Hospital, Kuwait and the 1997-2000 census data for the State of Kuwait. 1,329 Arab men (666 Kuwaitis and 663 other Arabs) older than 25 years who were admitted between September 1997 and August 2000 with a diagnosis of ACS were included in the study. RESULTS: The rate of admission for the entire patient population was twofold higher for Kuwaiti (1.68/1,000) than other Arab men (0.72/1,000), (p < 0.001); the mean age of the Kuwaiti men was 56.7 +/- 11.9 years and other Arab men 53.0 +/- 10.5 years (p < 0.001). The prevalence of hypertension, diabetes, smoking and hypercholesterolemia for Kuwaiti men was 35.9, 56.9, 51.7 and 36.2%, respectively; the corresponding prevalence for other Arab men was 28.8, 42.7, 68.2 and 32.0%, the difference in the prevalence except for hypercholesterolemia was significant (p < 0.001). In Kuwaiti men younger than 55 years of age, the prevalence of hypertension, diabetes mellitus, smoking and hypercholesterolemia was 26.6, 49.5, 68.6 and 43.3%, respectively; the corresponding values for other Arab men was 22.3, 36.2, 77.7 and 43.3%; the difference in prevalence except for hypertension was significant (p < 0.001). The in-hospital mortality for the whole study was 6.2% (Kuwaiti) and 2.3% (other Arab men; p < 0.001); while that for men younger than 55 years was 2.7% (Kuwaiti) and 0.8% (other Arab men; p < 0.05). CONCLUSION: The rate of admission for the entire patient population with a diagnosis of ACS was twofold higher for Kuwaiti than other Arab men. Among all patients and also those less than 55 years, the prevalence of diabetes mellitus was consistently higher among Kuwaiti than other Arab men thereby probably leading to the higher admission rate and in-hospital mortality.

Thrombolytic therapy in acute myocardial infarction: practice pattern at an Arab Middle Eastern centre.

OBJECTIVES: We studied the use of thrombolytic treatment at a major hospital in Kuwait. There were three aims to our study. First, to document the rates of use and shortfall of thrombolytic therapy. Secondly, to identify the reasons for the shortfall. Thirdly, to study the influence of age and gender on the shortfall. METHODS AND RESULTS: We retrospectively examined the use of thrombolytic treatment in 983 consecutive patients with the diagnosis of acute myocardial infarction (AMI) during a three-year period, from June 1994 to May 1997. The term "shortfall" refers to the number of patients who were eligible for thrombolytic treatment but did not receive it. Patients were relatively young (59% were < 55 years old). There was a high prevalence of diabetes (39%). We identified 669 patients who were eligible to receive thrombolytic therapy (68% of the total AMI population). Of the eligible population, 625 patients (93.4%) received thrombolytic therapy while 44 patients did not (a shortfall of 6.6% among the eligible population). The reasons for the shortfall were: unknown reasons, retinopathy, and others. The shortfall was higher in women than in men (13% vs. 6%, respectively; p=0.02). The shortfall was higher in older patients than in younger patients (18% vs. 5%, respectively; p=0.0002). CONCLUSIONS: Our thrombolysis rate is one of the highest, and the shortfall is one of the lowest reported rates in the literature. Many eligible women and older patients are not receiving thrombolytic therapy. Changes to thrombolytic therapy use should be implemented to avoid unnecessary shortfall and potential gender and age bias.

Differences in thrombolytic treatment and in-hospital mortality between women and men after acute myocardial infarction.

There is evidence for gender differences in the treatment and outcome of acute myocardial infarction (AMI). However, little data exist about these differences in patients from the Arab Middle East. Therefore, we studied the influence of patient gender on the presentation, the use of thrombolytic therapy, and in-hospital mortality after AMI in Kuwaiti nationals. This is a retrospective study of all consecutive Kuwaiti patients admitted to the coronary care unit of a university hospital with the diagnosis of AMI between June 1994 and May 1997. A total of 89 women and 267 men were included. Women were older than men and had significantly higher rates of diabetes (72% vs 46%), hypertension (58% vs 33%) and hypercholesterolemia (80% vs 53%). Women were less likely to receive thrombolytic therapy (40% vs 62%, p=0.001). Fewer women were eligible for thrombolytic therapy (50% vs 66%, p<0.05). Of those who were eligible for thrombolysis there was no sex difference in receiving such treatment. The in-hospital mortality among women younger than 70 years was 2.5 times higher than among men in the same age group, while there was no difference in mortality between women and men aged 70 years and older. We conclude that women and men with AMI have different clinical characteristics and outcomes following AMI. There was no gender bias for the use of thrombolytic therapy. The higher in-hospital mortality in younger women, i.e. less than 70 years, compared to younger men, indicates that younger women with AMI should be considered as a high-risk group.

Bilateral orbital hemorrhage in a newborn.

PURPOSE: To report a case of severe bilateral proptosis resulting from orbital hemorrhage in a newborn and to discuss the differential diagnoses and management. METHOD: Case report of a 13-day-old male infant with bilateral proptosis since birth. The proptosis was monitored with clinical examinations and computed tomography as well as magnetic resonance imaging (MRI) scans, and it was managed with antibiotic ointment and patching. The MRI scans demonstrated bilateral subperiosteal orbital hemorrhage. RESULTS: Proptosis decreased, and there was successful, complete recovery without untoward sequelae in 14 days; follow-up indicated no late complications at age 1 year. CONCLUSION: Spontaneous orbital hemorrhage, unilateral or bilateral, is uncommon in an otherwise healthy newborn without apparent history of birth trauma. Magnetic resonance imaging scans are helpful in making the diagnosis of subperiosteal hemorrhage, and conservative management is advised.

Thrombolytic therapy in acute myocardial infarction: Experience at a university hospital in Kuwait.

BACKGROUND: There is conclusive evidence from large clinical trials that thrombolytic therapy reduces mortality and morbidity in acute myocardial infarction (AMI). However, only a small proportion of patients receive thrombolytic treatment. Estimates have varied from 20%-50% in North America and Europe. Data from the Arab Middle East is sparse. The purpose of our study was to determine the use of thrombolytic therapy in our hospital. METHODS: We conducted a retrospective analysis of 343 patients (358 incidents of AMI), who were either discharged from or died at the coronary care unit of the Mubarak Al-Kabeer Hospital during the one-year period between June 1994 and May 1995. RESULTS: Our patients were relatively younger (63% were 7lt;55 years) and had a much higher prevalence (44%) of diabetes compared to European patients. We observed a high rate (62%) of thrombolysis and a lesser shortfall (8%) when compared to that reported for European patients. The main reason for withholding thrombolytic therapy was non-diagnostic electrocardiogram (ECG) on initial presentation. Women were less likely to be thrombolyzed than men (38% vs. 66%, P=0.0001). Older patients (aged >65 years) were also less likely to be thrombolyzed than younger patients (42% vs. 66%; P=0.0006). CONCLUSION: We conclude that the use of thrombolytic therapy in this university hospital in Kuwait is appropriate. However, as observed in other reports as well, the underutilization of thrombolytic therapy in women and the elderly needs to be addressed in future studies.