Validation of the Arabic version of the early inflammatory arthritis detection tool.

OBJECTIVE: To evaluate the reliability and validity of the Arabic version of the Early Inflammatory Arthritis Questionnaire (EIAQ-A), a detection tool for screening for early inflammatory arthritis (EIA) in Arabic-speaking populations. SUBJECTS AND METHODS: A cross-sectional study was conducted among 30 consecutive participants (21 female and 9 male) attending the Internal Medicine Outpatient Clinic at Mubarak Al-Kabeer Hospital. They completed the self-administered EIAQ-A twice within a 2-week period. Their disease activity was evaluated during the visits based on clinical and laboratory variables. Cross-cultural adaptation was performed using forward and backward translations of the original questionnaire. Test-retest reliability of the EIAQ-A was evaluated using the measure of agreement, kappa (κ), between the response of participants in the two interviews. Internal consistency of the EIAQ-A was measured using the Kudar-Richardson-20 coefficient (KR-20), a binary response equivalent to Cronbach's α. External construct validity was assessed by Spearman's rank correlation coefficient (rs) between the score of EIAQ-A and both clinical and laboratory variables of disease activity. RESULTS: The test-retest reliability for EIAQ-A was good (κ = 0.558) for the overall score and between 0.841 and 0.368 for the subscale scores. Internal consistency had an acceptable value of KR-20 = 0.869. The construct validity for EIAQ-A was high for all disease activity variables tested, rs was between 0.727 (swollen joint count) and 0.896 (visual analog scale pain score). CONCLUSION: The EIAQ-A was a reliable and valid tool for population screening for EIA. Its use may accelerate the early detection of EIA in Arabic-speaking communities.

The dentist workforce in Kuwait to the year 2020.

AIM: To project the future demand for dentists in Kuwait for the years 2007 to 2020 based on the period 1994 to 2006. The study addresses the supply of and demand for dentists in Kuwait in the light of emerging variables such as increasing population, economic growth, changes in dental care, education strategies, and changes in demographics of dentists. BASIC RESEARCH DESIGN: Population projections for the years 2007 to 2020 were derived using the average annual natural increase rate of the 1994-2006 populations. The future demand for dentists for the years 2007 to 2020 was projected using the average dentist to population ratios of the years 1994-2006. RESULTS: The average annual growth rate of indigenous Kuwaiti dentists during the period 1994-2006 was 5.58% compared to 31.9% for non-native expatriot dentists. There is a gap between the numbers of native and foreign dentists. In 2006, native dentists constituted 44.4% of the dental workforce in Kuwait, this is likely to affect the quality of provided dental care owing to language, religious and sociocultural barriers between foreign dentists and patients. The disparity between the total number of dentists needed and the number of native dentists is expected to decline from 54.41% in 2007 to 24.67% in 2020. CONCLUSIONS: The supply of native dentists is likely to remain insufficient to meet the projected demand until the year 2020. The supply of indigenous dentists should be increased through improvement in recruitment and retention of Kuwaiti national dentists and dental students.

The level and determinants of diabetes knowledge in Kuwaiti adults with type 2 diabetes.

AIM: To investigate the level of diabetes knowledge in a population with type 2 diabetes (T2D) and a high prevalence of illiteracy, to identify the main gaps in the knowledge and to study the determinants of the knowledge score. METHODS: This cross-sectional survey involved 24 diabetes clinics and Kuwaiti adults with T2D (n=5114), and used the Michigan Diabetes Knowledge Test. RESULTS: The participants' mean age (+/-S.D.) was 55.6+/-10.4 years; 68.2% were women, 45.0% were illiterate, 52.2% reported a family income equivalent to 1200 to 2400 euros per month and only 28.6% performed glucose monitoring. Mean+/-S.D. HbA(1c) was 8.76+/-2.3%. Their mean score for the total knowledge test was 58.9%. Knowledge deficits were apparent in the questions related to diet and self-care. Participants who were older, and with lower educational levels, limited family income, negative family history of diabetes or were smokers had significantly lower knowledge scores. The scores were also lower in those who had shorter disease duration and fewer complications, were taking insulin, had less frequent insulin injections, performed less glucose monitoring and had lower HbA(1c) levels. Education, family income, glucose monitoring and presence of complications were independent determinants of the knowledge score. CONCLUSION: Knowledge of diabetes in a T2D population with a high prevalence of illiteracy was poor. Limited family income and lack of self-care are other predictors of knowledge deficits. Efforts need to be focused on educational programmes with strategies to assist T2D patients of limited education and income to manage their disease more effectively.

The nursing workforce in Kuwait to the year 2020.

BACKGROUND: The study addresses the supply and demand for nurses in Kuwait in the light of emerging variables such as increasing population, economic growth, changes in healthcare strategies and expansion of healthcare facilities. OBJECTIVE: To project the future demand for nurses in Kuwait for the years 2007-2020 based on the period 1994-2006. METHODS: Population projections were derived using the average annual natural increase rate of the 1994-2006 populations. The future demand for nurses was projected using the average nurse to population ratios for the years 1994-2006. FINDINGS: The number of Kuwaiti indigenous nurses is declining at an average decrement rate of 3.3% per annum. There is a gap between the numbers of native and migrant nurses, which will be wider with time. In 2006, native nurses constituted only 6.6% of the nursing workforce; this affects the quality of provided health care owing to language, religions and socio-cultural barriers between foreign nurses and patients. CONCLUSIONS: The supply of indigenous nurses in Kuwait should be increased in order to deliver effective nursing care with shared culture and language in the modern healthcare system of Kuwait. This can be achieved through an improvement in recruitment and retention of indigenous nurses and nursing students.

Factors associated with type 1 diabetes in Kuwaiti children.

Type 1 diabetes is a common chronic disease in childhood, and the outcome of environmental, genetic and immunologic interactions. The aim was to study the social and metabolic characteristics (lipids, lipoproteins, apolipoproteins, lipoprotein a (Lpa) and total sialic acid) and predisposing factors in 6-18-year-old Kuwaiti children with type 1 diabetes. This pair-matched case-control study included 348 type 1 diabetic children (131 males, 217 females) matched by age and gender to 348 non-diabetic controls. Diabetic children were identified, according to the WHO and the American Diabetes Association criteria, at 182 randomly selected schools. Social and metabolic characteristics were adversely affected in diabetic children compared to their controls. The logistic regression analysis showed that the predisposing factors: family history of type 1 and type 2 diabetes and thyroid disease, were significant associated factors with type 1 diabetes after adjusting for demographic and social variables. The significant correlations of Lpa and total sialic acid with glycated haemoglobin, lipoproteins and apolipoproteins partially explain reporting them as possible markers for coronary heart disease. There are adverse metabolic changes in children with type 1 diabetes. As these changes are associated with early onset atherogenesis, metabolic markers need to be measured and possibly corrected at an early stage in children with diabetes.

Social and psychological characteristics of Kuwaiti children and adolescents with type 1 diabetes.

Type 1 diabetes mellitus is a chronic disease that may have an impact on children's psychosocial adjustment. This study aimed to investigate the psychosocial characteristics of Kuwaiti children with type 1 diabetes as compared to healthy children without diabetes, and assess the impact of glycaemic control on psychosocial variables. A total of 349 school children aged 6-18 years with type 1 diabetes, and 409 children without diabetes having comparable age, gender, and social class were included in the study. Data were obtained by interviewing children and parents using a questionnaire. Psychological distress was measured by the Hopkins symptoms checklist-25 scale including anxiety and depression. Glycaemic control was assessed by glycosylated haemoglobin, HbA(IC) level. Glycaemic control was considered 'good to excellent' at HbA(IC)<8.0%, 'fair' at HbA(IC) 8.1 to 10.0%, and 'poor' at HbA(IC)>10.0%. Median scores of anxiety, depression, and total distress were significantly higher in children with diabetes indicating worse psychological adjustment. There was also significant difference between children with diabetes and those without diabetes in social aspects and school absence days. There was significant positive correlation between HbA(IC) concentration and scores of the psychological functioning indices. Children with poor glycaemic control had worse psychological adjustment. After controlling the variance accounted by gender and age, stepwise multiple regression analysis showed that girls, older children, children in need of emotional support, and those with higher HbA(IC) were at higher risk for psychological maladjustment. These variables explained 47.9% of the variation in total distress. In conclusion, the study supported our hypotheses. Children with diabetes had worse psychological adjustment, and distress was related to glycaemic control. Since psychological distress increases the risk for future complications due to its relation with glycaemic control, longitudinal studies are recommended to identify children with diabetes having distress at an early stage when preventive interventions are effective.

Lipoprotein(a) and other cardiovascular metabolic risk factors in Kuwaiti children with type-1 diabetes.

BACKGROUND/AIMS: Lipoprotein(a) synthesis and catabolism could be influenced by insulin or by diabetes metabolic complications in patients with type-1 diabetes. The aim of the study was to investigate the relation of plasma lipoprotein(a) concentrations with metabolic cardiovascular risk factors in Kuwaiti children with uncomplicated type-1 diabetes. METHODS: This case-control study included 115 (44 males and 71 females) diabetic children aged 6-18 years matched by age and sex to 115 non-diabetic children as controls. RESULTS: There was no significant difference between the mean lipoprotein(a) concentrations in type-1 diabetic children (27.34 mg/dl) and their controls (22.80 mg/dl). Total cholesterol, apolipoprotein A1 and B levels were significantly higher in diabetic children than controls. In diabetic children, significant correlations were found between lipoprotein(a) levels and glycated hemoglobin (r = 0.249, p = 0.011), total cholesterol (r = 0.208, p = 0.025), and apolipoprotein B (r = 0.349, p < 0.001). The proportion of diabetic children with lipoprotein(a) >30 mg/dl was significantly higher in those having poor glycemic control (glycated hemoglobin >9.0%, p = 0.013), raised total cholesterol (p = 0.033), or with a family history of cardiovascular disease (p = 0.006). CONCLUSION: Plasma lipoprotein(a) levels were not elevated in young type-1 diabetic children compared to non-diabetic controls; however, lipoprotein(a) levels were significantly higher in diabetic children with poor glycemic control. Moreover, there were significant correlations between lipoprotein(a) and the metabolic cardiovascular risk factors total cholesterol, atherogenic index, apolipoprotein B and apolipoprotein B/A1 ratio.

Angiotensin-converting enzyme gene polymorphism and lipid profiles in Kuwaiti children with type 1 diabetes.

METHODS: We studied angiotensin-converting enzyme (ACE) gene polymorphism and lipid profiles in Kuwaiti children with uncomplicated type 1 diabetes. A total of 125 children with type 1 diabetes were matched in a case-control study on age and gender to 125 non-diabetic children as controls. Serum lipids (total cholesterol, TC; high-density lipoprotein cholesterol, HDL; low-density lipoprotein cholesterol, LDL-c; triglycerides, TG; apolipoprotein A1 and B, apo A1 and B; lipoprotein(a), Lp(a)); and glycated hemoglobin, HbA1c were evaluated according to ACE genotypes. RESULTS: Genotype distributions were found to be similar in cases [ACE insertion/insertion (II) 9.6%, ACE insertion/deletion (ID) 38.4%, ACE deletion/deletion (DD) 52.0%], and controls (II 8.8%, ID 43.2%, DD 48.0%), and were characterized by higher frequencies of DD, ID, and lower frequencies of II. Diabetic children with DD genotype showed significantly higher levels of TC (p < 0.01), HDL (p < 0.001), and apo A1 (p < 0.001) than controls. There was a higher proportion of diabetic children with family history of cardiovascular disease (CVD) in the DD genotype group (51.9%) than those with II genotype group (11.1%) (p < 0.001). Also, there was a significant increase in the frequency of diabetic children with Lp(a) > 30 mg/dL in children with a family history of CVD (p = 0.008). Lp(a) levels were correlated with HbA1c in the diabetic group (r = 0.239, p = 0.019), but when patients with poor glycemic control (HbA1c > 9%) were excluded, the significant correlation disappeared (r = 0.127, p = 0.381). After adjusting confounding between variables, the logistic regression analysis showed that the two significantly related variables with the rise in Lp(a) were increasing TC level and poor glycemic control. CONCLUSIONS: In children with type 1 diabetes, the role of ACE polymorphism as a probable contributor to CVD seems to be partially mediated through other factors such as poor glycemic control, TC, and Lp(a) level. A longitudinal study is recommended with a larger number of patients in each ACE genotype group in order to assess such associations.

Prevalence of endometrial proliferation in pipelle biopsies in tamoxifen-treated postmenopausal women with breast cancer in Kuwait.

OBJECTIVE: To determine the prevalence of pathologic changes in the endometrium of tamoxifen-treated asymptomatic postmenopausal patients with breast cancer. SUBJECTS AND METHODS: Fifty postmenopausal asymptomatic breast cancer patients with positive estrogen receptor status were treated with 20 mg of tamoxifen daily for a period of 5-60 months. The control group consisted of 30 asymptomatic postmenopausal breast cancer patients who were negative for estrogen receptor and therefore did not receive tamoxifen. Endometrial biopsies were performed using Pipelle endometrial suction curette at least 5 months after the study began. The endometrium was classified as atrophic (negative finding) and proliferative or hyperplastic (positive findings). The study and control groups were compared for demographic characteristics, risk factors for endometrial cancer, histological findings and the duration of tamoxifen treatment. RESULTS: A significantly greater prevalence of endometrial abnormalities existed among the tamoxifen-treated than control patients (76 vs. 33%, p < 0.001). The abnormal endometrial changes were further demarcated in both groups into proliferative (54 vs. 26.7%, p = 0.02) and hyperplastic (22 vs. 6.6%, p = NS). In the study group, 63.6% of hyperplastic endometrium was simple hyperplasia and 36.4% was complex/no atypia hyperplasia, while in the control group all the cases were simple hyperplasia. No endometrial cancer was detected in either group. In addition, there was a positive association between the duration of tamoxifen exposure (<1 year vs. >/=1 year) and the endometrial abnormalities (46.6 vs. 88.6%, p = 0.003; proliferative 57.1 vs. 74.1%, p = 0.015; hyperplastic 42.8 vs. 25.8%, p = NS). CONCLUSION: The adjuvant use of tamoxifen is associated with significant time-dependent abnormal endometrial changes among patients with cancer of the breast.

Further evidence for the rising incidence of childhood Type 1 diabetes in Kuwait.

AIMS: To provide age-gender standardized incidence rate, temporal trend and seasonal variation of Type 1 diabetes in Kuwaiti children aged < or = 14 years. METHODS: Data were prospectively collected over a period of 6 years (1992-1997) according to the DiaMond Project protocol using the capture-recapture method of ascertainment. RESULTS: Data ascertainment varied between 90% and 96%. The incidence rate of Type 1 diabetes was 20.1 per 100,000 children 0-14 years (95% confidence interval (CI) 18.0-22.1); age-standardized incidence rate 20.9 (95% CI 18.8-23.0). The incidence rate among boys, 21.1 per 100,000 (95% CI 18.1-24.1) was slightly higher than that among girls, 19.0 per 100,000 (95% CI 16.1-21.8). The age-standardized incidence rate was 21.9 (95% CI 18.9-24.8) in boys, and 19.9 (95 CI 17.1-22.8) in girls. Incidence rates increased with age in both sexes (boys chi(2) for linear trend = 13.5, P < 0.001; and for girls chi(2) = 27.8, P < 0.0001). There was a significant trend towards increase in overall incidence during the 6-year period (chi(2) = 6.210, P = 0.013), and in age group 5-9 (chi(2) = 10.8, P = 0.001). Seasonality was demonstrated overall, in boys and girls (P < 0.001). CONCLUSION: The incidence of Type 1 diabetes in Kuwait is high compared with the neighbouring Arab countries, and it appears to be increasing as in many European populations.

Estimation of age-specific reference intervals for skewed data.

OBJECTIVES: To compare Cole's LMS method with Wright and Royston's Exponential-Normal (EN) method for estimating reference intervals and generating smooth centile curves for the body mass index (weight in kg/height in meters squared) measurements of children aged 6 to 13 years. METHODS: In the LMS method, the parameters L (the power needed to normalize the data), M (median) and S (coefficient of variation) are modeled as smoothed fits of maximum likelihood estimates. In the Exponential-Normal method, the three parameters mean, standard deviation and skewness are estimated separately using multiple regression techniques. RESULTS: The centiles generated by the LMS and EN methods are close in most of the age groups. The 2.5th and 97.5th quantiles of the interval of the differences between the loss function scores of the LMS and EN methods calculated by bootstrap was found to include zero, indicating that the difference in loss function scores of the two methods is random and not systematic. CONCLUSIONS: The two methods are simple to use and generate comparable centile curves.

Performance of students in the final examination in paediatrics: importance of the "short cases".

AIMS: To determine which component of the final examination in paediatrics at Kuwait University best predicted the final outcome. METHODS: The performance of 356 medical students in the short cases, the long case, multiple choice questions (MCQs), and the essay components of the final examination in paediatrics at Kuwait University was correlated with the final grade, and the mean difference between each component and the final score calculated. RESULTS: The correlation was highest for the short cases, followed by MCQs, the long case, and essays. The mean difference between the final score and that of short cases was not significant, but was highly significant for the other components. CONCLUSION: Results show that performance in the short cases component of the final examination in paediatrics is a better discriminator of competence than that in the long case.