Ahmed A. Jaradat

Effectiveness of mobile phone short message service on diabetes mellitus management; the SMS-DM study.

OBJECTIVE To test the feasibility of short message service (SMS) usage between the clinic visits and to evaluate its effect on glycemic control in uncontrolled type 2 Diabetes Mellitus (DM) subjects. RESEARCH DESIGN AND METHODS 34 cases with type 2 Diabetes were followed after fulfilling the inclusion criteria. The interventional group (n=12) had the same conventional approach of the control group but had two mobile numbers (physician and diabetic educator) provided for the SMS support until their next visit in 3 months. Both groups of age, BMI and the pre-study A1c were comparable. RESULTS Both groups had a significant reduction in their A1c compared to their baseline visit. However, the interventional group had significantly greater reduction in A1c (p=0.001), 1.16% lower than controls. The service was highly satisfactory to the group. CONCLUSION The results indicate effectiveness in lowering A1c and acceptance by the patients. Further research and large-scale studies are needed.

Frequency of palmaris longus absence and its association with other anatomical variations in the Egyptian population.

The palmaris longus (PL) is one of the most variable muscles in the human body. Racial differences in its variation have been documented. Several studies have attempted to correlate PL absence with other anatomical variations. This study was conducted to determine the prevalence of absence of PL, correlate it with gender and body side and to determine its association with other anatomical variations in the Egyptian population. The presence of PL was clinically determined in 386 Egyptians using the standard technique. All subjects were examined for the presence of the flexor digitorum superficialis (FDS) to the fifth finger. Allens test was done to assess the completeness of the superficial palmar arch (SPA). The overall prevalence of absence of the PL in Egyptian subjects was 50.8%. There was no significant difference in PL absence with regard to the body side but a significant difference was seen as regards gender and when bilateral absence of PL was compared to its unilateral absence. Absence of FDS tendon to the fifth finger was seen in 1.3% subjects. There was no association between the absence of the FDS tendon to the fifth finger and either presence or absence of PL and also between the absence of PL and the incompleteness of SPA in both genders. In conclusion, the prevalence of absence of PL in the Egyptian population represents one of the highest rates of absence to be reported for this muscle, which is significantly different from that in other ethnic groups. Clin. Anat. 26:572–577, 2013.

Incidence of gestational diabetes mellitus in Bahrain from 2002 to 2010.

To determine the incidence and trends of gestational diabetes mellitus (GDM) in Bahrain from 2002 to 2010, and to investigate 2 possible risk factors within the affected population.

Predictors of abnormal bone mass density in adult patients with homozygous sickle-cell disease.

Background Adult patients with sickle-cell disease (SCD) often have multiple bone compactions causing tissue hypoxia and osteonecrosis. The impact on bone abnormalities lesion detected by bone mass density is not well defined. Aim The study is a cross sectional, perspective was designed to assess the prevalence of abnormal BMD in adult Bahraini patients with SCD and to assess the predictive risk of different metabolic variables such as serum level of vitamin D3, testosterone, and parathyroid hormone in addition to lactate dehydrogenase (LDH), hemoglobin (Hb), and reticulocyte count for the development of abnormal bone density on dual X-ray absorptiometry (DXA) scan. Method The study was conducted over the period of12 months from first of January 2012 to end of December 2012. All patients were evaluated clinically for severity of SCD and abnormal bone mass density (BMD) using DXA scan. Blood samples were withdrawn for measuring the serum level of vitamin D3, testosterone, and parathyroid hormone in addition to Hb, LDH, and reticulocyte count. Multiple logistic regression analysis was used to assess risk prediction of different variables for the development of abnormal BMD on DXA with T-score ≤–2.5 standard deviation (SD). Results The study included Bahraini patients with SCD (n = 55, age 29.24 ± 9.47 years, male 60% and female 40%) compared with an age-matched healthy control group (n = 55, age 28.82 ± 8.64 years, with 62% male and 38% female). Of the 55 patients with SCD compared with the control group, there were 33 (58%) patients with low BMD and 2 (3%) in the control. Among the 33 patients with SCD and with low BMD, there were 20 (36%) with osteoporosis (T-score of ≤–2.5 SD) and 13 (24%) with osteopenia (T-score of <–1 to −2.5 SD). The most affected site of low BMD was lumbar spine (55%), followed by the radius (30%) and neck of the femur (15%). SCD patients with osteoporosis compared with the healthy subjects had significantly lower body surface area (BSA, m2) of 1.4 ± 0.3 vs. 1.63 ± 0.5 BMI, low level of vitamin D3 of 21.11 ± 6.95 ng/mL vs. 46.2 ± 15.19 (P < 0.001), lower testosterone level of 1.34 ± 0.54 vs. 2.18 ± 0.56 ng/mL (P < 0.001), higher reticulocyte count (P < 0.001), and higher LDH level (P < 0.001). The low serum level of vitamin D3 (<20 ng/mL) and low testosterone of <0.9 ng/mL had risk prediction (odds ratio) of 1.14 and 1.2, respectively, for abnormal BMD in SCD. In the risk prediction of other variables of parathormone (PTH), LDH, and reticulocyte, were not significant. Conclusion The prevalence of abnormal bone mass density (BMD) is high (60%) in Bahraini patients with SCD. There is significant low serum level of vitamin D3 and low testosterone hormone in those with very low bone mass density (BMD) (osteoporosis and T-score <–2.5). The low serum level of vitamin D3 (<20 ng/mL) and low testosterone of <0.9 ng/mL had risk prediction (odds ratio) of 1.14 and 1.2, respectively, for abnormal BMD in SCD.

Thrombomodulin gene proximal promoter polymorphisms in premature acute coronary syndrome patients in Bahrain.

Thrombomodulin is expressed on endothelial cells and monocytes (mTM) where it has an anticoagulant function. Enzymatic cleavage from the cell surface produces soluble thrombomodulin (sTM) in plasma. Abnormal levels of sTM and mutations in the thrombomodulin gene (THBD) are linked to cardiovascular disease. The aim of this study was to investigate THBD proximal promoter mutations and levels of sTM and mTM in men presenting with premature acute coronary syndrome (ACS). This prospective cross-sectional study included 100 adult men with premature ACS (age <55 years) and 60 healthy age-matched controls. Plasma sTM was assayed by ELISA. mTM expression was assessed by flow cytometry with CD141 antibody. The −33 G/A polymorphism was identified by PCR-restriction fragment length polymorphism analysis and the THBD proximal promoter region was sequenced. Significantly lower sTM (P < 0.001) and higher mTM (P < 0.001) were seen in ACS patients. Heterozygous THBD promoter polymorphisms −33 G/A and −9/−10 GG/AT were found in eight patients and five control individuals. In patients and control individuals, allele frequencies of A were 0.02 and 0.025, and that of AT were 0.025 and 0.017, respectively. There were no significant associations of these polymorphisms with ACS, sTM levels or mTM expression. THBD polymorphisms −33 G/A and −9/−10 GG/AT are present in low frequency in our patient population, and are more frequent in the South Asians as compared to the Arabs. The frequency of −33 G/A is lower, whereas that of −9/−10 GG/AT is higher than that reported in the Orientals. The presence of THBD proximal promoter polymorphisms do not explain variations in levels of sTM and mTM in this patient population.

Pain frequency, severity and QT dispersion in adult patients with sickle cell anemia: correlation with inflammatory markers.

Background Inflammatory markers are increased during vaso-occlusive crisis (VOC) in adult patients with sickle cell anemia (SCA), but this is not clear in clinical steady state. Aim The present study aims to establish the frequency and intensity of bone pain episodes in adult patients with SCA in clinical steady state and to determine the correlation between different inflammatory markers, other variables including QT dispersion (QTd) and pain frequency and intensity in SCA. Patients and methods Patients were classified into two groups: group 1, those with more than three hospital admissions in the last 6 months, and group 2, those with no hospital admission. Pearson correlation between variables such as body mass index (BMI), level of tumor necrosis factor (TNF-α), interleukin-1 (IL-1), C-reactive protein (CRP), hemoglobin (Hb), reticulocyte count, white blood cell count (WBC), ferritin, lactate dehydrogenase (LDH), parathormone (PTH), vitamin D3 (25-OH cholecalciferol) and bone pain frequency with severity was evaluated. Results Forty-six patients were enrolled in this study with a mean age of 18.47±5.78 years, with 23 patients in each group. Vitamin D3 and Hb were lower (17.04±5.77 vs 37.59±4.83 ng/L, P<0.01 and 7.96±0.3 vs 8.44±0.27 g/dL, P<0.01, respectively); the inflammatory markers showed significantly higher level of TNF-α, IL-1 and CRP (56.52±5.43 pg/ml, 44.17±4.54 pg/ml and 3.20±0.72 mg/L, respectively, P<0.05); WBC, LDH and reticulocyte count were also significantly higher and the QTd was higher (45.0±2.22 vs 41.55±0.8 ms, P<0.05) in group 1 when compared with group 2. Pearson correlation coefficient showed significant positive correlation between serum level of TNF-α and bone pain frequency (r=0.414, P<0.005) and serum level of IL-1 (r=0.39, P<0.008). Conclusion There is a strong positive correlation between TNF-α, IL-1 and WBC and bone pain frequency in steady state in adult patients with SCA. CRP and low hemoglobin had weak positive correlation. QTd was significantly longer in patients who had hospitalizations with VOC.

Risk Stratification and in Hospital Morality in Patients Presenting with Acute Coronary Syndrome (ACS) in Bahrain

Background: Risk factors and short-term mortality in patients presented with Acute Coronary Syndrome (ACS) in Bahrain has not been evaluated before. Aim: In this prospective observational study, we aim to determine the clinical risk profiles of patients with ACS in Bahrain and describe the incidence, pattern of presentation and predictors of in-hospital clinical outcomes after admission. Methods: Patients with ACS were prospectively enrolled over a 12 month period. The rate of incidence of risk factors in patients was compared with 635 non-cardiac patient admissions that matched for age and gender. Multiple logistic regression analysis was used to predict poor outcomes in patients with ACS. The variables were ages >65 years, body mass index (BMI) >28 kg/m2, GRACE (Global Registry of Acute Coronary Events) score >170, history of diabetes mellitus (DM), systolic hypertension >180 mmHg, level of creatinine >160 μmol/l and Heart Rate (HR) on admission >90 bpm, serum troponin rise and ST segment elevation on the ECG. Results: Patients with ACS (n=635) were enrolled consecutively. Mean age was 61.3 ± 13.2 years, with 417 (65.6%) male. Mean age for patients with ST-segment elevation myocardial infarction (STEMI, n=156) compared with non-STEMI (NSTEMI, n=158) and unstable angina (UA, n=321) was 56.5± 12.8 vs 62.5±14.0 years respectively. In-hospital mortality was 5.1%, 3.1% and 2.5% for patients with STEMI, NSTEMI, and UA, respectively. In STEMI patients, thrombolytic therapy was performed in 88 (56.5%) patients and 68 (43.5%) had primary coronary angioplasty (PCI). The predictive value of different clinical variables for in-hospital mortality and cardiac events in the study were: 2.8 for GRACE score >170, 3.1 for DM, 2.2 for SBP >180 mmHg, 1.4 for age >65 years, 1.8 for BMI >28, 1.7 for creatinine >160 μmol/L, 2.1 for HR >90 bpm, 2.2 for positive serum troponin and 2.3 for ST elevation. Conclusion: Patients with STEMI compared with NSTEMI and UA were of younger age. There was higher in-hospital mortality in STEMI compared with NSTEMI and UA patients. The most significant predictors of death or cardiac events on admission in ACS were DM, GRACE Score >170, systolic hypertension >180 mmHg, positive serum troponin and HR >90 bpm.

Item Analysis of Multiple Choice Questions at the Department of Paediatrics, Arabian Gulf University, Manama, Bahrain

Objectives The current study aimed to carry out a post-validation item analysis of multiple choice questions (MCQs) in medical examinations in order to evaluate correlations between item difficulty, item discrimination and distraction effectiveness so as to determine whether questions should be included, modified or discarded. In addition, the optimal number of options per MCQ was analysed. Methods This cross-sectional study was performed in the Department of Paediatrics, Arabian Gulf University, Manama, Bahrain. A total of 800 MCQs and 4,000 distractors were analysed between November 2013 and June 2016. Results The mean difficulty index ranged from 36.70-73.14%. The mean discrimination index ranged from 0.20-0.34. The mean distractor efficiency ranged from 66.50-90.00%. Of the items, 48.4%, 35.3%, 11.4%, 3.9% and 1.1% had zero, one, two, three and four nonfunctional distractors (NFDs), respectively. Using three or four rather than five options in each MCQ resulted in 95% or 83.6% of items having zero NFDs, respectively. The distractor efficiency was 91.87%, 85.83% and 64.13% for difficult, acceptable and easy items, respectively (P <0.005). Distractor efficiency was 83.33%, 83.24% and 77.56% for items with excellent, acceptable and poor discrimination, respectively (P <0.005). The average Kuder-Richardson formula 20 reliability coefficient was 0.76. Conclusion A considerable number of the MCQ items were within acceptable ranges. However, some items needed to be discarded or revised. Using three or four rather than five options in MCQs is recommended to reduce the number of NFDs and improve the overall quality of the examination.

Circulating matrix metalloproteinases and their tissue inhibitors as markers for ethnic variation in pelvic floor tissue integrity

The purpose of the present study was to measure the plasma levels of matrix metalloproteinases (MMP)-2 and -9 and their tissue inhibitors (TIMP)-1 and -2, as surrogate biomarkers for pelvic floor tissue integrity in young, healthy multi-ethnic women. This was hoped to elucidate ethnic vulnerability to support-related pelvic floor dysfunctions. The plasma levels of MMP-2 and -9 and TIMP-1 and -2 were measured by sandwich ELISA in nulliparous, young (18-29 years) women volunteers (n=85) from five ethnic groups [n=17/group; Bahrainis, other Arabs, Filipinos, Indians/Pakistanis and Caucasians (Italians)] and compared with levels in Italians as the reference group. It was identified that the levels of plasma MMP-2 were significantly higher in Italians than in Bahrainis (P<0.001) and Filipinos (P<0.001), but significantly lower than in Indians/Pakistanis (P=0.013); whereas, the levels of plasma MMP-9 were significantly higher in Italians than in Bahrainis (P=0.009) and Indians/Pakistanis (P<0.015). The levels of plasma TIMP-2 were significantly lower in Italians than in Indians/Pakistanis (P=0.003), but the levels of plasma TIMP-1 were significantly higher in Italians than in all other groups (P<0.05) excluding Bahrainis. Although MMP-2 correlated negatively with TIMP-2 and MMP-9 correlated positively with TIMP-1, both correlations were not significant (r=0.071, P=0.533 and r=0.197, P=0.8, respectively). In all ethnic groups, MMP-9 level correlated positively with BMI (r=0.26, P=0.02), and TIMP-2 level with age (r=0.23, P=0.045). Overall, the trends for higher levels of MMP-2 and -9 and lower levels of TIMP-2 in the plasma of Caucasian women may indicate a greater tendency for collagenolysis and weaker connective tissue with increased risk of developing pelvic floor dysfunctions, and thus may potentially serve as biomarkers for pelvic floor tissue integrity.

Hormonal and echocardiographic abnormalities in adult patients with sickle-cell anemia in Bahrain

Background Adrenal, thyroid, and parathyroid gland hormonal changes are recognized in children with homozygous (HbSS) sickle-cell anemia (SCA), but are not clear in adult patients with SCA. Aim To assess the metabolic and endocrine abnormalities in adult patients with SCA and evaluate left ventricular (LV) systolic and diastolic functions compared with patients with no SCA and further study the relationship between serum levels of cortisol, free thyroxine (T4), and testosterone with serum ferritin. Materials and methods The study was conducted on 82 patients with adult HbSS SCA compared with a sex- and age-matched control group. The serum levels of cortisol, parathyroid hormone (PTH), testosterone, thyroid-stimulating hormone (TSH), and free T4 were compared. Blood levels of hemoglobin, reticulocyte count, lactate dehydrogenase (LDH), calcium, alkaline phosphatase (ALP), vitamin D3, and ferritin were also compared. Pulsed Doppler echo was performed to evaluate the LV mass, wall thickness, and cavity dimensions with diastolic filling velocities of early (E) and atria (A) waves. Biometric data were analyzed as mean ± standard deviation between the two groups. Multiple regression analysis was performed between serum levels of ferritin as independent variable and testosterone, cortisol, and thyroid hormones. Results A total of 82 adult patients with HbSS SCA were enrolled who had a mean age of 21±5.7 years, with 51 males (62%). Patients with SCA compared with the control group had significantly lower hemoglobin, body mass index, cortisol, vitamin D3, testosterone, and T4. Furthermore, there were significantly high levels of reticulocyte count, PTH, TSH, ferritin, LDH, ALP, and uric acid. The incidence of subclinical hypothyroidism and adrenal insufficiency was 7% and 4.8%, respectively, with hypogonadism 9.8% and vitamin D3 deficiency 61%. There were inverse relationships between ferritin as independent variable and serum levels of testosterone, T4, and cortisol, with regression coefficients of −0.49 (P<0.001), −0.33 (P<0.001), and −0.11 (P<0.92), respectively. Conclusion Patients with adult SCA had a high prevalence of in vivo hypoadrenialism (4.8%), hypogonadism (9.8%), and hypothyroidism (7%). There were significant inverse relationships between serum ferritin as independent variable and cortisol, testosterone, and T4. Pulsed Doppler echocardiography showed increased LV mass, with a restrictive LV diastolic pattern suggestive of diastolic dysfunction.