Home exposure to Arabian incense (bakhour) and asthma symptoms in children: a community survey in two regions in Oman.

BACKGROUND: Incense burning has been reported to adversely affect respiratory health. The aim of this study was to explore whether exposure to bakhour contributes to the prevalence of asthma and/or triggers its symptoms in Omani children by comparing two Omani regions with different prevalence of asthma. METHODS: A randomly selected sample of 10 years old schoolchildren were surveyed using an Arabic version of ISAAC Phase II questionnaires with the addition of questions concerning the use and effect of Arabian incense on asthma symptoms. Current asthma was defined as positive response to wheeze in the past 12 months or positive response to "ever had asthma" together with a positive response to exercise wheeze or night cough in the past 12 months. Simple and multivariable logistic regression analyses were performed to estimate the effect of bakhour exposure and other variables on current asthma diagnosis and parents' response to the question: "Does exposure to bakhour affect your child breathing?" RESULTS: Of the 2441 surveyed children, 15.4% had current asthma. Bakhour use more than twice a week was three times more likely to affect child breathing compared to no bakhour use (adjusted OR 3.01; 95% CI 2.23-4.08) and this effect was 2.55 times higher in asthmatics (adjusted OR 2.55; 95% CI 1.97-3.31) compared to non-asthmatics. In addition, bakhour caused worsening of wheeze in 38% of the asthmatics, making it the fourth most common trigger factor after dust (49.2%), weather (47.6%) and respiratory tract infections (42.2%). However, there was no significant association between bakhour use and the prevalence of current asthma (adjusted OR 0.87; 95% CI 0.63-1.20). CONCLUSION: Arabian incense burning is a common trigger of wheezing among asthmatic children in Oman. However, it is not associated with the prevalence asthma.

Normal spirometric reference values for Omani adults.

International guidelines recommend the use of population-specific reference values to eliminate the well-recognized influence of ethnic variation on lung function. This study was designed to derive spirometric prediction equations for healthy Omani adults. Forced vital capacity (FVC), forced expiratory volume in one second (FEV(1)), peak expiratory flow rate (PEFR), and forced expiratory flow at 25% to 75% of FVC (FEF(25-75%)) were measured in 419 "healthy" nonsmoking Omani adults (256 men, 163 women), aged 18-65 years. Multiple linear regression analysis was performed for each spirometric parameter against age, height, and weight for men and women separately, and prediction equations for all the above parameters were derived and compared with values derived using equations published from other populations. All measured spirometric parameters increased with height and decreased with age, and they were all significantly higher in men. In contrast, FEV(1)/FVC% values decreased with height and increased with age and were higher in women. The predicted normal values of FVC and FEV(1) for our subjects using the derived equations were lower by 7-17% compared with respective Caucasian values, with smaller difference in the predicted values of PEFR, FEV(1)/FVC%, and FEF(25-75%). This report presents previously unavailable spirometric reference equations for the Omani adults. Our findings highlight the need to use reference values based on updated data derived from relevant populations.

Management and control of asthma in patients attending a specialist centre in oman.

OBJECTIVES: The management of asthma by specialists is likely to become more evidence-based. This study analysed the characteristics of patients reporting to a specialist clinic including demographics, dispensed medications and the level of asthma control. METHODS: All consecutive stable asthmatics seen in the adult pulmonary clinics of Sultan Qaboos University Hospital, Oman, between December 2005 and November 2006 were prospectively evaluated using a structured assessment protocol. RESULTS: Of the 207 patients, (mean age 40.64 ±14.8), 72% were females. The majority, 83.1%, had moderate persistent asthma. A positive history of allergic rhinitis, eczema and a family history of asthma were obtained in 58.0%, 11.1%, and 50.7% of patients respectively. Total serum immunoglobulin E (IgE) was elevated in 66.7%. Skin testing was positive for more than 2 antigens in 52.3%, with the house dust antigen being reactive in 49%. Inhaled steroids, long-acting beta agonists (LABA), antihistamines and leukotriene receptor antagonists were prescribed in 94.2%, 85%, 54.5% and 11.6% of cases respectively. The majority (40.1%) was receiving medium dose inhaled steroids. Although asthma was controlled in 162 (78.3%), during the previous month 66 (31.9%) patients had visited the emergency department and 31 (15.0%) patients were hospitalised at least once during the previous year. Only 63 (30.4%) patients were using their inhalers correctly. Good compliance with inhaled steroids was observed in only 53 (25.6%) patients. CONCLUSION: Allergic comorbidities and a strong family history of asthma were common. Although the level of asthma control in the previous month was high, it was much lower in the long term. The concepts of short term, long term and total control of asthma need to be explored.

An audit of the sleep medicine service in Oman.

OBJECTIVE: To audit the sleep service at Sultan Qaboos University Hospital (SQUH), Muscat, Oman, and to explore deficiencies to introduce new measures of improvement. METHODS: Polysomnography (PSG) reports and SQUH medical records of all patients who underwent sleep studies from January 1995 to December 2006 in the sleep laboratory at SQUH were reviewed and analyzed. RESULTS: Out of a total of 1042 sleep studies conducted in the specified period, 768 PSG recordings were valid for analysis. The audit showed that the Otolaryngology Department was the main referring specialty for PSG (43%). Snoring was the main symptom for 33% of the subjects referred, but suspicion of obstructive sleep apnea was the main reason for referral (38%). Three quarters of the patients were males who were also younger, and with lower body mass index compared to females (p=0.0001 for all). Despite large number of patients with an apnea-hypopnea index of >15 (n=261), only 94 (36%) patients received continuous positive airway pressure titrations and treatment. CONCLUSION: The sleep medicine service in SQUH provided the basic service, and raised the awareness of the importance of this specialty. However, substantial effort is required to bring it to international standards.

Trends in asthma prevalence and severity in Omani schoolchildren: comparison between ISAAC phases I and III.

BACKGROUND AND OBJECTIVE: This study evaluated changes in the prevalence of asthma symptoms and asthma severity in Omani school children over time. METHODS: Two cross-sectional surveys, in 1995 and 2001, were conducted as part of the International Study of Asthma and Allergies in Children on Omani schoolchildren in two different age groups (6-7 and 13-14 years). RESULTS: There were 7067 children surveyed in 1995 (3893 in the younger and 3174 in the older group) and 7879 in 2001 (4126 in the younger and 3753 in the older group). Over the 6 years there was a significant increase in the prevalence of current wheeze 'any wheeze during the past 12 months' (from 7.1% to 8.4%; P = 0.035) in the younger group with no significant change in asthma diagnosis (10.5% vs 10.6%) or any other asthma symptoms. In the older group, all asthma symptoms remained unchanged except speech-limiting wheeze which declined from 4.0% to 2.8% (P = 0.007). In both surveys, more than 60% of current wheezers reported severe asthma symptoms, while only 60% of these reported a diagnosis of asthma. CONCLUSION: The prevalence of both asthma and severe asthma remains high among Omani children. There is significant 'under-diagnosis' and/or 'under-treatment' of asthmatic children which requires urgent evaluation and intervention.

Regional Variation in the Prevalence of Asthma Symptoms among Omani School Children: Comparisons from Two Nationwide Cross-sectional Surveys Six Years Apart.

OBJECTIVES: The International Study of Asthma and Allergies in Children (ISAAC) highlighted the presence of wide variations in asthma prevalence between and within countries. The aim of this study was to determine the changes in the prevalence of asthma and its symptoms across the different regions of Oman. METHODS: Two cross-sectional surveys were conducted as part of ISAAC phases I (1995) and III (2001) in two age groups (6-7 and 13-14 years) from nation-wide samples of Omani school children, with 7,067 participants in 1995 (3,893 young and 3,174 older group) and 7,879 participants in 2001 (4,126 young and 3,753 older group). RESULTS: Over the period of six years, the Sharqiya (Eastern) region continued to have the highest prevalence of self-reported asthma diagnosis and all asthma symptoms in both age groups, with a significant increase in the prevalence of wheeze in the past 12 months (from 8.7% to 13.8%; p=0.002) and asthma diagnosis (from 13.8% to 17.8 %; p=0.046) in the young group, and a significant increase in night cough (from 21.6% to 27.8%; p=0.039) in the older group. All other regions had lower prevalence rates in 1995 in both age groups, and showed either no significant change or a decline in one or two of the self-reported asthma symptoms. The prevalence of asthma diagnosis among wheezy children remained unchanged across all regions. In addition, asthma under-diagnosis remains a problem with only 60% of children with severe wheeze reporting asthma diagnosis in both surveys. CONCLUSION: The geographic variation in the prevalence of self-reported of asthma symptoms among Omani school children persists with further increase in the Sharqiya region. The findings also suggest under-diagnosis and/or poor recognition of asthma which had not improved over time.

The pattern of sensitisation to inhalant allergens in omani patients with asthma, allergic rhinitis and rhinoconjunctivitis.

OBJECTIVE: Identification of relevant allergens that are prevalent in each environment which may have diagnostic and therapeutic implications in allergic diseases. This study aimed to identify the pattern of sensitisation to inhalant allergens in Omani patients with asthma, allergic rhinitis and rhinoconjunctivitis. METHODS: The study was carried out during three consecutive years (2004-2006) at the allergy skin test laboratory of Sultan Qaboos University Hospital, Oman. Records of patients who had undergone an allergy skin prick test with a referring diagnosis of asthma, allergic rhinitis or rhinoconjunctivitis were reviewed. Two panels were used during the 3 years period. The frequencies of positive skin tests were analysed. RESULTS: 689 patients were tested, 384 for the first panel and 305 for the second panel. In the first panel, the commonest positive allergens were: house dust mites (37.8%), hay dust (35.4%), feathers (33.3%), sheep wool (26.6%), mixed threshing dust (25.8%), cat fur (24.2%), cockroach (22.7%), straw dust (22.7%), horse hair (17.4%), maize (16.1%), grasses (11.5%), cotton flock (10.7%), trees (10.4%), cow hair (7.8%), Alternaria alternata (3.6%), Aspergillus Niger (3.4%), and Aspergillus fumigatus (1.3%). In the second panel, the commonest positive allergens were also house dust mites: Dermatophagoides pteronyssinus (50.8%), Dermatophagoides farinae (47.9%); Mesquite (Prosopis glandulosa) (35.7%), Russian thistle (Salsola kali) (34.4%), cockroach (32.1%), Bermuda grass (Cynodon dactylon) (19.7%), grass mix-five standard (18.0%), wheat cultivate (14.1%), cats (13.8%), Penicillium notatum (4.3%), Alternaria tenius (3.9%), Aspergillus Niger (3.3%), feather mix (3.0%), dog (2.6%), horse hair and dander (2.6%), and Aspergillus fumigatus (1.6%). CONCLUSION: The pattern of sensitisation to environmental allergens in Oman seems to be similar to other reports from the Arabian Peninsula. Methods to identify and characterise environment specific allergens like a pollen survey may help in the management of patients with allergic asthma, allergic rhinitis and rhinoconjunctivitis.

Compliance of physicians with documentation of an asthma management protocol.

BACKGROUND: Studies continue to show poor physician compliance with asthma management guidelines in clinical practice. However, standardized protocols specifically designed to be practical and user-friendly improve patient outcomes. OBJECTIVE: To determine the degree of physicians' compliance with the documentation of an asthma management protocol in a university hospital. METHODS: A simple asthma management protocol was designed and applied in our pulmonary clinic and primary care clinic for asthma. The protocol was based on the 1998 Manual for the Management of Asthma, from the Oman Ministry of Health, which follows internationally recognized guidelines. The protocol consisted of 4 sections: clinical history, peak expiratory flow (PEF) data, medication section, and simplified asthma management guidelines. RESULTS: All 30 physicians scheduled to conduct asthma clinics in the pulmonary clinic (14 physicians) and the primary care clinic (16 physicians) agreed to use the protocol. A total of 282 protocol forms were collected: 130 forms from 6 senior physicians and 152 from 24 junior physicians. Documentation of the entire clinical history was 65%, with the senior physicians scoring significantly higher documentation-completion rates (82%) for all components of the history than the junior physicians (50%). Documentation of all PEF data was poor (26%), despite high documentation of the PEF value itself (95%). There were significant differences in documentation of percent-of-predicted PEF between junior physicians in primary care clinic (70%) and other physicians (19%). Documentation of the entire medication section was only 34%. Although documentation of prescribed medicines was high (92%), compliance (48%) and inhaler technique (49%) documentation was low, with similar patterns demonstrated by all physicians. Documentation of the entire protocol by all physicians was low (9%), with junior physicians in the primary care clinic completing 28% of their forms. CONCLUSIONS: Our protocol enabled us to identify opportunities for improvement in documentation of asthma management in both the pulmonary and primary care clinics. The findings highlight the need for regular asthma education programs for all physicians, with a focus on documentation of performance skills such as monitoring of PEF and inhaler technique.

Normal spirometric reference values for Omani children and adolescents.

OBJECTIVES: Normal lung function has been shown to be population specific. The aim of this study was to derive normal reference spirometric values for Omani children and adolescents. METHODOLOGY: Forced vital capacity (FVC), forced expiratory volume in 1 s (FEV(1)), peak expiratory flow and forced mid-expiratory flow were measured in 837 healthy Omani school children aged 6-19 years. Multiple linear regression analysis was performed for each spirometric parameter against age, height and weight for boys and girls separately. RESULTS: All measured spirometric parameters increased with age and height and were significantly higher in boys than girls. Height explained the maximum variance for all parameters. After accounting for height in the prediction equations, the contribution of age and weight was minimal. The expiratory ratio (FEV(1)%FVC) was independent of age and height and its mean values (+/- standard deviation) were slightly higher in girls (91.1 +/- 6.1%) than boys (86.5 +/- 7.1%; P < 0.001). The predicted normal values of the subjects using the derived equations were between 5 and 10% lower than the respective values for subjects in Caucasian sample groups. CONCLUSION: The developed prediction equations can be used in clinical practice in Oman and can be considered for use in neighbouring Arab countries.

A relatively high prevalence and severity of asthma, allergic rhinitis and atopic eczema in schoolchildren in the Sultanate of Oman.

OBJECTIVES: Although asthma, allergic rhinitis and eczema are among the most common chronic diseases in children worldwide, there is very limited information about the burden of these conditions in Oman. The aim of this study was to determine the prevalence and severity of symptoms of asthma, allergic rhinitis and eczema in Omani schoolchildren using the International Study of Asthma and Allergies in Childhood (ISAAC) Phase I questionnaire. METHODS: An Arabic version of the ISAAC Phase I questionnaire was completed by parents of 3893 children aged 6-7 years and self-completed by 3174 children aged 13-14 years, randomly selected from a nationwide sample of public schools. RESULTS: The prevalence rates of reported diagnoses of asthma, allergic rhinitis and eczema were higher in older children (20.7%, 10.5% and 14.4% compared with 10.5%, 7.4% and 7.5%, respectively, in young children). In young children, 277 were current wheezers and of these 40.8% had sleep-disturbing wheeze at least once a week and 45.1% had speech-limiting wheeze during the past year. Similarly, 283 older children were current wheezers, and of these 30.0% had sleep-disturbing wheeze at least once a week and 37.5% had speech-limiting wheeze during the past year. Exercise-induced wheeze was higher in older children (19.2% vs 6.9%; P < 0.001). Allergic rhinitis and eczema were also associated with significant sleep disturbance and limitation of activity in both age groups. CONCLUSION: Allergic conditions in Omani schoolchildren are common and associated with significant morbidity. Further research is required to identify the local risk factors for allergy to allow better understanding and management of these conditions.

Prevalence of asthma symptoms in Omani schoolchildren.

OBJECTIVES: To determine the prevalence of asthma in Omani schoolchildren using the International Study of Asthma and Allergies in Children (ISAAC) protocols. METHOD: The ISAAC-written questionnaire was completed by a total of 7,067 Omani schoolchildren (3,893 children aged 6-7 years of which 56% were boys and 3,174 aged 13-14 years of which 51% were boys) from the 10 health regions in the country. RESULTS: The estimated mean national 12-month prevalence of any wheeze, night waking with wheeze, speech limiting wheeze and exercise wheeze were respectively 7.8%, 3.5%, 3.2% and 6.9% for the 6-7 year age group and 8.9%, 2.9%, 4.0% and 19.2% for the 13-14 year age group. Both age groups reported high prevalence of night cough (19.6% and 20.9% in the younger and the older children respectively). The prevalence of self-reported asthma diagnosis was higher in the older age group (20.7% vs. 10.5%, p<0.001). In the younger age group, the diagnosis of asthma was more common in boys (12.5% vs. 8.0%, p>0.001), but there was no significant difference between the two sexes in the older age group (22.0% of boys vs. 20.5% of girls). There was nearly three-fold difference in the prevalence of self-reported diagnosis of asthma between the regions with the highest and the lowest prevalence of asthma for both young and older children (from 5.3% and 9.5% in Musandam to 14.2% and 30.6% in South Sharqiya, respectively). CONCLUSION: The results of this first epidemiological survey of asthma in Oman indicate that asthma is common in Omani children and adolescents. Night cough is the most frequent symptom. There is also significant regional variation in prevalence of asthma symptoms and diagnosis within the country and this requires further investigation.

Metered-dose inhaler technique among healthcare providers practising in Oman.

OBJECTIVE: To evaluate the correctness of metered-dose inhaler (MDI) technique in a sample of healthcare providers practising in Oman, considering that poor inhaler technique is a common problem both in asthma patients and healthcare providers, which contributes to poor asthma control. METHOD: A total of 150 healthcare providers (107 physicians, 33 nurses and 10 pharmacists) who were participants in symposia on asthma management conducted in five regions of Oman, volunteered for the study. After the participants answered a questionnaire aimed at identifying their involvement in MDI prescribing and counselling, a trained observer assessed their MDI technique using a checklist of nine steps. RESULTS: Of the 150 participants, 148 (99%) were involved in teaching inhaler techniques to patients, and 103 of 107 physicians (96%) had prescribed inhaled medications. However only 22 participants (15%) performed all steps correctly. Physicians performed significantly better than non-physicians (20% vs. 2%, p <0.05) Among the physicians, internists performed better (26%) than general practitioners (5%) and accident and emergency doctors (9%). CONCLUSION: The majority of health-care providers responsible for instructing patients on the correct MDI technique were unable to perform this technique correctly indicating the need for regular formal training programmes on inhaler techniques.