Measuring adherence rate to quality indicators for diabetes care identified by primary health care in Bahrain.

OBJECTIVES: To measure the quality of care for patients with diabetes mellitus at the outpatient clinics from 12 general practitioners clinics (GPC) and one diabetes care clinic (DCC). METHODS: A cross-sectional study was conducted at the Al-Razi Health Center, Manama, Bahrain, and health records from January to December 2012 were reviewed. The study consisted of 120 patients from GPC, and 80 patients from DCC. Information regarding quality indicators on the management of diabetic care was gathered, which consisted of data on the adherence rate for each of the 8 processes and 4 intermediate outcomes indicators, and was then compared to the standard target. RESULTS: The average rate for the examination of measurement in GPC for diabetic retina was 0%, diabetic foot was 2%, second microalbuminuria retesting was 13%, and glycosylated hemoglobin test order (HbA1c) was 18%, and in the DCC, 87% (diabetic retina), 97% (diabetic foot), 58% (second microalbuminuria retesting), and 79% (HbA1c). The differences were statistically significant between DCC and GPC. CONCLUSION: This study has found significant differences in the adherence rate of process and clinical outcome indicators across the GPC, an area that requires further improvements. The DCC, however, highly exceeded the target in 7 indicators, while it was relatively far from the target in the other 3 indicators. The study revealed that adherence to process indicators was not associated with good intermediate outcomes. 

Hypocomplementemic Urticarial Vasculitis Syndrome in an 8-year-old Boy: A Case Report and Review of Literature.

Hypocomplementemic urticarial vasculitis syndrome is an immune complex-mediated disease of unknown etiology. The clinical course is characterized by urticaria, conjunctivitis, joint pain, and hypocomplementemia. We here report a case of a child with hypocomplementemic urticarial vasculitis syndrome that progressed to nephritis. Renal biopsy was consistent with diffuse proliferative glomerulonephritis with diffuse subendothelial immune deposits. He responded well to a combination of steroid and mofetil micofenolate.

Juvenile systemic lupus erythematosus in Bahrain. A tertiary referral center experience.

OBJECTIVE: To analyze the clinical and serological features of children with systemic lupus erythematosus (SLE) in a major referral center in Bahrain and to assess the comorbidity, its morbidity, and mortality. METHODS: We retrospectively reviewed the medical charts of children with SLE treated in the Pediatric Rheumatology Clinic at Salmaniya Medical Complex, Kingdom of Bahrain from 1998 to 2007. The ethical approval for the study was obtained from the Research Health Committee, Ministry of Health, Kingdom of Bahrain. RESULTS: Thirty-two children with SLE were identified. Thirty-one (96.8%) were Bahrainis. The mean age was 14 +/- 4 years, the mean age of disease onset was 9 +/- 4 years and the mean duration of illness was 7 +/- 5 years. The female to male ratio was 2.5:1. Twenty-five percent of the cases had relatives with SLE. Eight patients (25%) had sickle cell anemia (SCA). Systems involved were as follows: skin (93%), kidney (81%), musculoskeletal system (65%), blood (56%), gastrointestinal tract (31%), central nervous system (31%), lungs and cardiovascular system (21%). Serological tests showed: positive antinuclear antibody in 90.6%, and positive anti double-stranded DNA antibody in 65%. The morbidity rate was 21% (n=7) due to complication and 12.5% (n=4) died. CONCLUSION: Clinical and serological results were comparable with the international studies. Nephritis was the primary cause of morbidity and mortality. Coexistence of SLE with SCA was also reported in other studies and may need further investigation with genetic studies.

Diabetic nephropathy in children with type 1 diabetes mellitus in Bahrain.

OBJECTIVE: Children and adolescent patients with type 1 diabetes mellitus (T1DM) may have an increased risk of developing diabetic nephropathy (DNP). The incidence of DNP varies with glycemic control, and peaks after 15-20 years of diabetes and decline thereafter. Microalbuminuria is uncommon before puberty, and usually occurs after 5 years of diabetic duration. Once overt DNP is established, a progressive decline in the glomerular filtration rate and elevation in arterial blood pressure occurs, and it is the most important disorder leading to renal failure in adult patients with diabetes in developed countries. The purpose of this study was to screen all the children and adolescent with T1DM of 5 years duration or more for DNP. METHODS: Between April 2000 and February 2001, all patients with T1DM of more than 5 years, who were diagnosed between years 1985 to 1995 and followed by pediatricians at Salmaniya Medical Complex, Kingdom of Bahrain, were screened for DNP. Medical records were reviewed for demographical data, blood for hemoglobin A1c (HbA1c), fasting sugar and renal function test. The presence of DNP, retinopathy and neuropathy and the medications were also reviewed. DNP was diagnosed by urine microscopy, overnight urine collection for albumin to creatinine ratio, or 24-hour urine for protein, and the medications RESULTS: Diabetic nephropathy was diagnosed in 10 patients (31%), 2 with microalbuminuria (incipient nephropathy), and 8 with proteinuria (clinical nephropathy). Diabetic nephropathy was diagnosed at a mean of 10.5 years after the onset of T1DM. The mean age was 18 years for the DNP. Mean HbA1c was 11.8% for DNP and 10.2% for non-nephropathy group. All the patients with DNP were treated with an angiotensin converting enzyme inhibitor, 5 of them had hypertension. None developed renal failure or retinopathy. CONCLUSION: Microalbuminuria is uncommon before 5 years of the onset of T1DM. Screening for microalbuminuria should be performed in adolescent over 12 years of age, with diabetes of more than 5 years duration and persistent hyperglycemia (HbA1c > 11 %).

Cystinuria in arab countries.

Recent advances in molecular biology have provided new insights into the pathophysiology and genetics of cystinuria. It is expected that future development will be based on molecular and gene therapy. Until then, the therapy in cystinuric patients remains a difficult task and the goal should be the prevention of recurrences. This can be achieved by full compliance with medical regimens that result in significantly reduced urinary cystine excretion and good long-term prognosis in most patients. Such measures include urinary alkalinization with potassium citrate, modest reduction of dietary sodium and maintenance of a daily urinary volume of about three liters to prevent stone recurrence in adult cystinuric patients. The use of life-long pharmacological agents with disulfide chelators should be reserved for patients who fail the general conservative therapy. Invasive surgery should be used only minimally so as to preserve renal anatomy and function. However, repeated episodes of obstructive uropathy, frequently complicated by infection may eventually result in the need for nephrectomy, and are significantly associated with development of chronic renal failure. In the Arab World we lack properly designed epidemiological studies on renal stone-disease in general, and the cystine stones in particular. We recommend a multi-center study to determine the incidence of the disease and a molecular genetic analysis of cystinuric patients and their relatives, to determine the different mutations in our population and the types of the disease both the homozygotes and the heterozygotes.

Cystinuria in children in bahrain.

Cystinuria is a rare autosomal recessive trait with a defect in transport of cystine and other dibasic amino acids in the kidney and intestine. Renal stone formation is the only clinical presentation of cystinuria. We present herewith three cases with cystinuria. Case 1 is a 13-year-old boy known to have Bernard Soulier syndrome who presented at the age of six years with staghorn stone of the left kidney. He was treated with extracorporeal shock wave lithotripsy (ESWL) with little benefit, followed by percutaneous nephro-lithotomy (PCNL). He still gets recurrent renal stones and is being treated with high fluid intake, low sodium diet, captopril, K-citrate and D-pencillamine. Case 2 is a 10-year-old boy, brother of the first patient, who was diagnosed as cystinuria on family screening. He presented with bilateral tiny renal stones. Case 3 is a four-year-old girl who presented at the age of 1.5 years with urinary tract infection (UTI). Renal ultrasound showed left hydronephrosis and intravenous pyelography (IVP) showed bilateral ureteral stones. She underwent cystoscopy and lithiotripsy twice; currently she is on captopril, K-citrate, high fluid intake and low sodium diet. We believe this is the first report of cystinuria in children from Bahrain.