Analysis and prediction of nutritional outcome of patients with pediatric inflammatory bowel disease from Bahrain.

BACKGROUND: Inflammatory bowel disease (IBD) is a chronic gastrointestinal disease that causes anorexia, malabsorption, and increased energy requirements. Childhood IBD can significantly impact nutritional status and future health. OBJECTIVE: This study aimed to analyze the nutritional status of patients with pediatric IBD at presentation and during follow-up and to identify predictors of nutritional outcome. METHODS: This retrospective cohort study reviewed the medical records of children diagnosed with IBD in the Pediatric Department, Salmaniya Medical Complex, Bahrain, 1984 - 2023. Demographic data, clinical characteristics, and anthropometric data were collected. World Health Organization growth standards were used to interpret nutritional status. RESULTS: Of the 165 patients, 99 (60%) had anthropometric data at presentation, and 130 (78.8%) had follow-up data. Most patients were males (64.6%) and had Crohn's disease (CD) (56.2%), while 43.8% had ulcerative colitis (UC). The median age at presentation was 10.9 years and the mean follow-up duration was 12.6 years. At presentation, 53.5% of the patients were malnourished, that decreased to 46.9% on follow-up. Thinness was reduced from 27.3% at presentation to 12.1% at follow-up (p = 0.003). There was an increased tendency to normal weight on follow-up (59.6%) compared to time of presentation (46.5%), p = 0.035. Overweightness showed a non-significant increase from 26.3% at presentation to 28.3% at follow-up (p = 0.791). Children with IBD were more likely to become obese when they grow up to adulthood (2.3% versus 20.5%, respectively, p < 0.001). Weight-for-age, and height-for-age at presentation were higher among CD compared to UC, but body mass index (BMI) at follow-up was higher among UC patients (p < 0.05). Thinness at follow up was associated with very early-onset disease (p = 0.02), lower weight and BMI at presentation (p < 0.001 each), younger age at follow-up (p = 0.002), pediatric age group (p = 0.023), lower hematocrit (p = 0.017), and higher C-reactive protein (p = 0.007). Overweight at follow up was associated with increased weight and BMI at presentation (p < 0.001 each), longer disease duration (p = 0.005), older age (p = 0.002), and azathioprine intake (p = 0.026). Considering follow-up duration, univariate analysis exhibited that Bahraini nationality, post-diagnosis disease duration, age at follow-up, occurrence of diarrhea, height, and BMI at presentation were factors that decreased liability to abnormal nutritional status, while CD, history of weight loss, perianal disease, and skin rash, and intake of prednisolone expressed increased liability of abnormal nutritional status (p < 0.05). CONCLUSION: Pediatric IBD is associated with a high incidence of malnutrition. Thinness is more prominent at presentation, while overweight is higher on follow-up. Multiple risk factors aggravating abnormal nutritional status were highlighted. Accordingly, nutritional counseling should be prioritized in a multidisciplinary approach.

Pediatric and adult liver transplantation in Bahrain: The experiences in a country with no available liver transplant facilities.

BACKGROUND: Liver transplantation (LT) is a life-saving procedure for patients with end-stage liver disease and has become the standard and most effective treatment method for these patients. There are many indications for LT that vary between countries and settings. The outcome of LT depends on the available facilities and surgical expertise, as well as the types of liver graft donors available. AIM: To assess the clinical characteristics of patients from Bahrain who underwent LT overseas, and analyze factors affecting their survival. METHODS: In this retrospective cohort study, we reviewed the medical records and overseas committee registry information of all pediatric and adult patients who were sent overseas to undergo LT by the Pediatric and Medical Departments of Salmaniya Medical Complex and Bahrain Defence Force Hospital via the Overseas Treatment Office, Ministry of Health, Kingdom of Bahrain, between 1997 and 2023. Demo graphic data, LT indication, donor-recipient relationship, overseas LT center, graft type, post-LT medications, and LT complications, were collected. Outcomes measured included the overall and 5-year LT survival rate. Fisher's exact, Pearson χ2, and Mann-Whitney U tests were used to compare the pediatric and the adults' group in terms of clinical characteristics, donor-recipient relationship, medication, complications, and outcome. Survival analysis was estimated via the Kaplan-Meier's method. Univariate and multivariate analyses were used to detect predictors of survival. RESULTS: Of the 208 eligible patients, 170 (81.7%) were sent overseas to undergo LT while 38 (18.3%) remained on the waiting list. Of the 170 patients, 167 (80.3%) underwent LT and were included in the study. The majority of the patients were Bahraini (91.0%), and most were males (57.5%). One-hundred-and-twenty (71.8%) were adults and 47 (28.3%) were children. The median age at transplant was 50.0 [interquartile range (IQR): 14.9-58.4] years. The main indication for pediatric LT was biliary atresia (31.9%), while that of adult LT was hepatitis C-related cirrhosis (35.0%). Six (3.6%) patients required re-transplantation. Most patients received a living-related liver graft (82%). Pediatric patients received more living and related grafts than adults (P = 0.038 and P = 0.041, respectively), while adult patients received more cadaveric and unrelated grafts. Most patients required long-term immunosuppressive therapy after LT (94.7%), of which tacrolimus was the most prescribed (84.0%), followed by prednisolone (50.7%), which was prescribed more frequently for pediatric patients (P = 0.001). Most patients developed complications (62.4%) with infectious episodes being the most common (38.9%), followed by biliary stricture (19.5%). Tonsilitis and sepsis (n = 12, 8.1% for each) were the most frequent infections. Pediatric patients experienced higher rates of infection, rejection, and early poor graft function than adult patients (P < 0.001, P = 0.003, and P = 0.025, respectively). The median follow-up time was 6.5 (IQR: 2.6-10.6) years. The overall survival rate was 84.4%, the 5-year survival rate, 86.2%, and the mortality rate, 15.6%. Younger patients had significantly better odds of survival (P = 0.019) and patients who survived had significantly longer follow-up periods (P < 0.001). CONCLUSION: Patients with end-stage liver disease in Bahrain shared characteristics with those from other countries. Since LT facilities are not available, an overseas LT has offered them great hope.

Presence of SARS-CoV-2 virus in wastewater in the Kingdom of Bahrain during the COVID-19 pandemic.

Background: Several countries, including Bahrain, used wastewater surveillance for disease activity monitoring. This study aimed to determine the presence of SARS-CoV-2 in untreated wastewater and to correlate it with the disease spread. Methods: A retrospective review was conducted for all wastewater samples tested for SARS-CoV-2 in public health laboratories from November 2020 to October 2022. Samples were collected weekly between February and October 2022 from different areas across Bahrain. Real-time polymerase chain reaction was used to test for the presence of SARS-CoV-2 in wastewater, and the results were correlated with the number of COVID-19 cases in the same area. Results: Of 387 wastewater samples, 103 (26.6%) samples tested positive for SARS-CoV-2. In late 2020, of 42 samples collected initially, four (9.5%) samples tested positive for SARS-CoV-2 in the four locations that hosted COVID-19 isolation facilities. Between February and October 2022, 345 specimens of wastewater were tested, and 99 (28.7%) were positive. The highest detection rate was in February, June, and July (60%, 45%, and 43%, respectively), which corresponded to COVID-19 peaks during 2022, and the lowest detection rate was in August and September (11% and 0%, respectively), corresponding to the low number of COVID-19 cases. Conclusion: The detection rate of SARS-CoV-2 in wastewater samples from Bahrain was high and was significantly correlated with the number of reported COVID-19 cases. Wastewater surveillance can aid the existing surveillance system in monitoring SARS-CoV-2 spread.

Super-spreading social events for COVID-19 transmission: evidence from the investigation of six early clusters in Bahrain.

Introduction: This study aimed to characterize six early clusters of COVID-19 and derive key transmission parameters from confirmed cases that were traced between April and June 2020 in Bahrain. Methods: Pairs of "infector-infectee" allowed us to map the clusters and estimate the incubation period serial interval as the secondary attack rate. The chi-squared test, with a p-value computed using the Monte Carlo test, measured associations between categorical variables. Statistical analysis was performed using R software and the "data.tree, tidyverse" libraries. Results: From 9 April to 27 June 2020, we investigated 596 individuals suspected of COVID-19, of whom 127 positive cases were confirmed by PCR and linked in six clusters. The mean age was 30.34 years (S.D. = 17.84 years). The male-to-female ratio was 0.87 (276/318), and most of the contacts were of Bahraini citizenship (511/591 = 86.5%). Exposure occurred within the family in 74.3% (411/553), and 18.9% of clusters' cases were symptomatic (23/122 = 18.9%). Mapped clusters and generations increased after 24 May 2020, corresponding to "Aid El-Fitr." The mean incubation period was 4 days, and the mean serial interval ranged from 3 to 3.31 days. The secondary attack rate was 0.21 (95% C.I.) = [0.17-0.24]. Conclusion: COVID-19 transmission was amplified due to the high number of families mixing during "Aid El Fitr" and "Ramadhan," generating important clusters. Estimated serial intervals and incubation periods support asymptomatic transmission.

Assessing indicators and clinical differences between functional and organic childhood constipation: a retrospective study in pediatric gastroenterology clinics.

BACKGROUND: Chronic constipation is common among children worldwide. Constipation includes functional constipation (FC) and organic constipation (OC). The early recognition of the causes of childhood constipation and its subsequent complications is important. PURPOSE: This study aimed to evaluate the prevalence and causes of childhood constipation and compare the clinical characteristics, treatment, and outcomes of children with FC versus OC to identify the predictive factors. METHODS: This retrospective cross-sectional study analyzed children with FC or OC diagnosed in pediatric gastroenterology clinics, Salmaniya Medical Complex, Bahrain, 2017-2021. The Rome IV criteria were used to define FC. RESULTS: A total of 7,287 gastroenterology appointments were attended by 4,346 children during the study period. Of the 639 children (14.7%) with constipation, 616 (96.4%) were included in the study. Most patients had FC (n=511, 83%), whereas 17% (n=105) had OC. FC was more common in females than in males. Children with OC were younger (P<0.001) and had lower body weights (P<0.001), more stunted growth (P<0.001), and more associated diseases (P= 0.037) than those with FC. Enuresis was the most associated disease (n=21, 3.4%). Organic causes included neurological, allergic, endocrine, gastrointestinal, and genetic diseases. Allergies to cow milk protein were the most common (n=35, 5.7%). The presence of mucus in the stool was more common in OC than in FC (P=0.041), but no other symptoms or physical findings differed. A total of 587 patients (95.3%) received medication, among which lactulose was commonly prescribed (n=395, 64.1%). There were no intergroup differences in nationality, sex, body mass index, seasonal variation, laxative type, or treatment response. A good response was observed in 114 patients (90.5%). CONCLUSION: Chronic constipation represented a significant proportion of outpatient gastroenterology visits. FC was the most common type. Young children with a low body weight, stunted growth, mucus in the stool, or associated diseases should be assessed for an underlying organic cause.

Factors associated with poor outcomes in patients with severe acute respiratory infections in Bahrain.

Background: Severe acute respiratory tract infection (SARI) is a major global health threat. This study aimed to examine risk factors associated with poor outcomes in patients with SARI. Methods: All patients who met World Health Organization's (WHO) SARI case definition and were admitted to Salmaniya Medical Complex from January 2018 to December 2021 were included. Epidemiological and virological data were obtained and analyzed. Results: Of 1159 patients with SARI included, 731 (63.1%) patients were below 50 years, and 357 (30.8%) tested positive for viral pathogens. The most prevalent virus was Flu-A (n = 134, 37.5%), SARS-CoV2 (n = 118, 33%), RSV (n = 51, 14.3%), Flu B (n = 49,13.7%), other viruses (n = 3, 0.8%), and combined infection (n = 2, 0.6%). Six hundred fifty-eight (56.8%) patients had comorbidities, mainly diabetes (n = 284, 43%) and heart disease (n = 217, 33%). 183 (16%) patients were admitted to ICU, 110 (9%) needed mechanical ventilation, and 80 (7%) patients died.The odds of ICU admission were higher for patients with hematological (OR 5.9, 95% CI 3.1-11.1) and lung diseases (OR 2.7, 95% CI 1.6-4.6). The odds of mechanical ventilation were higher among patients with lung disease (OR 3.1, 95% 1.7-5.5). The mortality odds were higher among patients above 50 (OR 2.4, 95% CI 1.4-4.1) and chronic kidney disease (OR 2.5, 95% CI 1.1-5.2). Conclusions: Being 50 years or above or having kidney, lung, or heart diseases was associated with worse SARI outcomes. Efforts and actions in developing better strategies to vaccinate individuals at high risk and early diagnosis and treatment should help in reducing the burden of SARI.

The Prevalence of Iron and Vitamin D Deficiencies in Pediatric Patients With Inflammatory Bowel Disease in Bahrain.

Introduction Inflammatory bowel diseases (IBD) are chronic diseases that can affect nutrient absorption leading to micronutrient deficiencies and biochemical abnormalities.This study aimed to assess certain serum micronutrients and nutritionally related biochemical markers levels in patients with pediatric IBD and to compare the actual levels and the prevalence of micronutrients deficiencies and biochemical abnormalities between patients with Crohn's disease (CD) and those with ulcerative colitis (UC). Methods A retrospective cross-sectional study reviewing medical records of patients with IBD was conducted in the pediatric department, Salmaniya medical complex, Bahrain, from 1 January 1984 to 31 December 2021. Demographic data and laboratory results related to micronutrients and biochemical markers including full blood count, total protein, albumin, globulin, iron, ferritin, folic acid, vitamin B12, calcium, phosphorous, magnesium, and vitamin D levels were collected upon presentation before starting the treatment. Nutritional deficiencies were compared based on sex, nationality, type of IBD, age at presentation, disease duration, weight at diagnosis, and inflammatory markers levels including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Results Of 157 patients with pediatric IBD, 117 (74.5%) were included. Sixty-six (56.4%) patients were males. Sixty-six (56.4%) had CD and 51 (43.6%) had UC. No patient had indeterminant colitis. The mean age at presentation was 10.8±3.8 years. Most patients had one or more micronutrient deficiencies (n=110, 94%). Anemia was a common finding (n=79/116, 68.1%), with iron deficiency anemia (IDA) being predominant. Low iron levels were noted in 64/77 (83.1%) patients with a median of 5.0 (2.0-9.3) µmol/L (normal range, 11.6-31.3); isolated iron deficiency (ID) in 11/18 (61.1%) and IDA in 53/59 (89.8%) patients. Vitamin D deficiency was the second most common (n=45/61, 73.8%). Serum albumin, ferritin, calcium, phosphorous, and magnesium were deficient in 29.2%, 27.8%, 31.7%, 12.5%, and 10%, respectively. One patient had vitamin B12 deficiency while none had folate deficiency. Patients with CD had significantly lower serum iron (5.4±5.6 versus 8.1±6.09 µmol//L, p=0.02) and lower serum protein (71.7±8.7 versus 75.4±9.9 g/L, p=0.043) but higher serum ferritin (45 (19-110.2) versus 21.3 (10.3-51.2) µg/L, p=0.046) compared to those with UC. Elevated ESR was noted in 62/105 (59.1%) patients while high CRP was found in 67/104 (64.4%). Patients with low iron had higher ESR (28 (17-47) versus 14 (10-33) mm/h, p=0.028) and higher CRP (13.3 (1.6-42) versus 1.8 (0.9-4.6) mg/L, p=0.019) levels compared to those with normal levels. Conclusion Patients with pediatric IBD are at risk of multiple micronutrient deficiencies and biochemical abnormalities. Iron and vitamin D deficiencies are the most frequent. Patients with CD are more prone to have lower serum iron and protein levels than those with UC. ID was associated with elevated inflammatory markers.

Safety and efficacy of COVID-19 prime-boost vaccinations: Homologous BBIBP-CorV versus heterologous BNT162b2 boosters in BBIBP-CorV-primed individuals.

BACKGROUND: Booster vaccine doses against SARS-CoV-2 have been advocated to address evidence of waning immunity, breakthrough infection, and the emergence of immune-evasive variants. A heterologous prime-boost vaccine strategy may offer advantages over a homologous approach, but the safety and efficacy of this approach with the mRNA vaccine BNT162b2 (BNT: Pfizer) and inactivated BBIBP-CorV (BBIBT: Sinopharm) vaccines have not been studied. METHODS: We conducted a non-randomized, non-blinded phase II observational community trial acrossBahrain, investigating the reactogenic and immunogenic responseof participants who had previously received two doses of BBIBP, followed by a third booster dose of either BBIBP (homologous booster) or BNT (heterologous booster). Immunogenicity through serological statuswas determined at baseline and on the following 8thweek. Reactogenicity data (safety and adverse events) were collected throughout study period, in addition to participant-led electronic journaling. RESULTS: 305 participants (152 BBIBP and 153 BNT booster) were enrolled in the study,with 246 (127 BBIBP and 119 BNT booster) included in the final analysis. There was a significant increase in anti-SARS-CoV-2 antibody levels post booster administration in both groups; however, the heterologous BNT arm demonstrated a significantly larger mean increase in the level of spike (S) antigen-specific antibodies (32.7-fold increase versus 2.6, p < 0.0001) and sVNT neutralising antibodies (3.4-fold increase versus 1.8, p < 0.0001), whereas the homologous arm demonstrated a significant increase in the levels of nucleocapsid (N) antigen-specific antibodies (3.8-fold increase versus none). Non-serious adverse events (injection site pain, fever, and fatigue) were more commonly reported in the heterologous arm, but no serious adverse events occurred. CONCLUSION: Heterologous prime-boost vaccination with the mRNA BNT162b2 (Pfizer) vaccine in those who had received two doses of inactivated virus BBIBP-CorV (Sinopharm) vaccine demonstrated a more robust immune response against SARS-CoV-2 than the homologous BBIBP booster and appears safe and well tolerated. Clinical Trial Registry Number (ClinicalTrials.gov): NCT04993560.

Demographic and Viral-Genetic Analyses of COVID-19 Severity in Bahrain Identify Local Risk Factors and a Protective Effect of Polymerase Mutations.

A multitude of demographic, health, and genetic factors are associated with the risk of developing severe COVID-19 following infection by the SARS-CoV-2. There is a need to perform studies across human societies and to investigate the full spectrum of genetic variation of the virus. Using data from 869 COVID-19 patients in Bahrain between March 2020 and March 2021, we analyzed paired viral sequencing and non-genetic host data to understand host and viral determinants of severe COVID-19. We estimated the effects of demographic variables specific to the Bahrain population and found that the impact of health factors are largely consistent with other populations. To extend beyond the common variants of concern in the Spike protein analyzed by previous studies, we used a viral burden approach and detected a protective effect of low-frequency missense viral mutations in the RNA-dependent RNA polymerase (Pol) gene on disease severity. Our results contribute to the survey of severe COVID-19 in diverse populations and highlight the benefits of studying rare viral mutations.

Linear Growth Impairment in Patients With Pediatric Inflammatory Bowel Disease.

Introduction Linear growth impairment (LGI) is one of the complications of pediatric inflammatory bowel disease (IBD). This study aimed to assess the linear growth of patients with pediatric IBD and to detect the frequency and the possible risk factors of LGI. Methods A retrospective cross-sectional review of medical records of patients with pediatric IBD was conducted in the pediatrics department, Salmaniya Medical Complex, Bahrain, from 1984 to 2019. Demographic and anthropometric data were gathered. World Health Organization (WHO) standards and references were used to define LGI. According to WHO, stunting and severe stunting were defined as length/height for age of <-2 standard deviations and <-3 standard deviations from age and sex-specific reference means, respectively. To determine the possible risk factors for LGI, stunted patients were compared with normal height patients in regard to demographic data, clinical presentations, and treatment used. Results Out of 130 patients with pediatric IBD, 88 (67.7%) had anthropometric data available. Fifty-five (62.5%) were males. Forty-seven (53.4%) had Crohn's disease and 41 (46.6%) had ulcerative colitis. The mean age at presentation was 10.7±3.8 years. The median age at the time of growth measurement was 14.2 (interquartile range=12.1-24.4) years. Fifteen (17%) patients were stunted, and seven (46.7%) of those stunted patients were severely stunted. Weight at presentation was lower in stunted patients (21.6±5.9 kilograms) compared to normal height patients (31±13.4 kilogram) (p=0.048). Sex, delivery type, birth weight, height at presentation, age at presentation, age at growth measurements, IBD type, disease duration, presence of extraintestinal manifestations, and prednisolone and biologic therapy use were not significant factors of stunting. Conclusion Patients with pediatric IBD have a high prevalence of LGI compared to the general population. Low weight at disease presentation is the only significant risk factor for LGI. This might indicate that IBD as a disease by itself is having the main negative impact on linear growth.

Prevalence of Non-alcoholic Fatty Liver Disease among Patients with Diabetes Mellitus Attending Primary Health Care Centers in Bahrain.

Objectives: To identify the prevalence of non-alcoholic fatty liver disease (NAFLD) among patients with type 2 diabetes mellitus (T2DM) in Bahrain and to assess the risk factors for the same. Methods: This retrospective cross-sectional study investigated a random sample of patients who were treated for T2DM during 2018 at non-communicable disease clinics in primary health centers in Bahrain. Cases of 382 patients who underwent abdominal ultrasonography were selected for the study. The collected patients' data were statistically analyzed. Prevalence of NAFLD among T2DM patients and the possible risk factors were assessed. Results: The mean age of the study population (N = 382) was 59.0±12.0 years. The majority (61.5%) were women. Hypertension (57.9%) was the most prevalent associated condition. Most patients were either overweight (30.5%) or obese (58.3%). Fatty liver was found in 68.1% patients based on ultrasound imaging. Elevated alanine aminotransferase was found in 75 (21.0%) out of 357 (93.5%) patients who were tested for the same. The significant risk factors identified for fatty liver were female (p = 0.013), high body mass index (BMI) (p < 0.001), high waist circumference (p = 0.011), and high triglyceride levels (p = 0.043). Binary logistic regression identified BMI as an independent risk factor for fatty liver (p = 0.005). Conclusions: The prevalence of NAFLD among patients with T2DM in Bahrain is high, and comparable to the levels reported in other studies. Female and high BMI, waist circumference, and triglyceride level are risk factors for NAFLD, while BMI is an independent risk factor.

Efficacy and Safety of Endoscopic Esophageal Dilatation in Pediatric Patients with Esophageal Strictures.

MATERIALS AND METHODS: In this retrospective cross-sectional single center study, records of patients with esophageal strictures presented to the pediatric department, Salmaniya Medical Complex, Bahrain, in the period between 1995 and 2019 were reviewed. Demographic data, indications of endoscopic dilatations, the procedure success rate, and possible complications were assessed. RESULTS: Forty-six children were found to have esophageal strictures. Twenty-five (54.3%) patients were males. Most patients presented during infancy (86.5%, 32/37 patients). Twenty-six (56.5%) patients required 88 dilatation sessions, while the remaining 20 (43.5%) patients did not require dilatations. The median number of dilatation sessions per patient was three (interquartile range = 2-5). Savary-Gilliard bougienages were the main dilators used (80.8%, 21/26 patients). Anastomotic stricture (post esophageal atresia/tracheoesophageal fistula repair) was the main cause of esophageal strictures and was found in 35 (76.1%) patients. Patients with nonanastomotic strictures had more frequent dilatations compared to those with anastomotic strictures (P = 0.007). The procedure success rate was 98.8%. Yet, it was operator dependent (P = 0.047). Complete response to dilatation was found in 18 (69.2%) patients, satisfactory in seven (26.9%), and an inadequate response in one (3.9%). Those with satisfactory responses still require ongoing dilatations based on their symptoms and radiological and endoscopic findings. No perforation or mortality was reported. Patients with dilatations had more recurrent hospitalization (P < 0.0001), more dysphagia (P = 0.001), but shorter hospital stay (P = 0.046) compared to those without dilatations. Surgical intervention was required in one patient with caustic strictures. The median follow-up period was six years (interquartile range = 2.25-9.0). CONCLUSIONS: Endoscopic esophageal dilatation in children with esophageal strictures is effective and safe. Yet, it was operator dependent. Nonanastomotic strictures require more dilatations compared to anastomotic strictures. Findings of this study are comparable to those reported worldwide.

Celiac disease in children: Increasing prevalence and changing clinical presentations.

BACKGROUND: Celiac disease (CD) is a chronic autoimmune enteropathy. It results from genetic predisposition and exposure to gluten-containing food. The prevalence and presentation of CD vary among populations. PURPOSE: This study aimed to describe the prevalence and clinical characteristics of CD in children in Bahrain. METHODS: We retrospectively reviewed the medical records of children diagnosed with CD in the pediatric department, Salmaniya Medical Complex, Bahrain, in 1988-2018. Their clinical, biochemical, serological, and histopathological findings were documented. Adherence to the recommended gluten-free diet (GFD) was assessed. RESULTS: Of 86 patients with CD, 67 were included. The CD prevalence was 0.02%. A significant increase in prevalence in the last decade was observed (P<0.0001). Thirty-eight patients (56.7%) were males. The median (interquartile range) age at presentation was 4.45 (1.5-7.3) years. A family history of CD was positive in 13 out of 43 patients (30.2%). Pallor and failure to thrive were the most common presentations. The most frequent associated disease was iron-deficiency anemia in 23 patients (69.7%). Positive serology was found in 32 of 45 patients (71.1%). Marsh-Oberhuber type III was found in 16 of 35 patients (45.7%). Seropositive patients were significantly older (P=0.025) and had more severe duodenal histology (P=0.002). Adherence to GFD was poor in 27 patients (64.3%). CONCLUSION: This study revealed a significant increase in CD prevalence over the last decade. Atypical presentations were frequent. Most patients had poor adherence to GFD.

Vitamin D deficiency in healthy children in Bahrain: do gender and age matter?

BACKGROUND: Vitamin D deficiency is a global health problem in children. The vitamin D status of children and adolescents has not been evaluated in Bahrain. AIMS: This cross-sectional study aimed to determine the prevalence of vitamin D deficiency in healthy children in Bahrain and to investigate the relationship between vitamin D level and age and sex. METHODS: Medical records of children aged 1 month to 16 years who attended a vitamin D screening campaign at Al Kindi Specialized Hospital, Bahrain between September and October 2016 were reviewed. Data on sex and age were recorded and vitamin D level was measured as serum 25-hydroxyvitamin D [25(OH)D]. Children were grouped as: vitamin D sufficient [25(OH)D ≥ 75 nmol/L], vitamin D insufficient (51-74 nmol/L) and vitamin D deficient (≤ 50 nmol/L). RESULTS: A total of 531 children were included in the study, 50.8% of whom were boys. Most of the children (93.4%) had low vitamin D levels; 78.3% were vitamin D deficient and 15.1% vitamin D insufficient. Only 6.6% were vitamin D sufficient. A significantly greater proportion of girls were vitamin D deficient than boys (P < 0.001). More primary-school children and adolescents were vitamin D deficient than preschool children (P < 0.001). A negative correlation was found between vitamin D level and age (r = -0.467; P < 0.001). Regression analysis showed that vitamin D level decreased by -2.164 nmol/L for each year of age. CONCLUSION: Vitamin D deficiency is a problem among healthy children in Bahrain. Public health policies or interventions are suggested to improve vitamin D status in Bahrain, especially for school-aged children.

Pediatric Crohn's Disease in Bahrain.

OBJECTIVES: Our study aimed to report the epidemiology, clinical presentations, diagnostic and therapeutic approaches, and outcomes of Crohn's disease (CD) in pediatric patients in Bahrain. METHODS: We conducted a retrospective review of the medical records of patients with CD diagnosed in the pediatric department, Salmaniya Medical Complex, Bahrain, between 1984 and 2017. We used the data to calculate the annual incidence and cumulative prevalence. Data about gender, nationality, clinical presentation, age at presentation and diagnosis, duration of illness, consanguinity, family history, contact with smokers, and comorbidities were gathered. Results of hematological, biochemical, and serological tests were also collected. All radiological, endoscopic, and histopathological findings were reviewed. Data about medical therapy, relapse episodes, hospital admissions, complications, and outcomes were collected. RESULTS: Of 108 pediatric patients diagnosed with inflammatory bowel disease (IBD), 51 (47.2%) patients had CD. The annual incidence was 1 in 100 000 per year (range = 0-5 patients/year) with significant rise on comparing the three decades (p = 0.0001). Prevalence was 9.32 patients per 100 000 pediatric populations. Thirty-four patients (66.7%) were males, and the median age was 18.5 years (range = 6.4-35.0). Common clinical presentations were recurrent abdominal pain and weight loss. Family history of IBD was found in 10 patients. One patient had positive antineutrophil cytoplasmic antibody. The terminal ileum was involved in 68.1%, colon in 63.8%, and perianal area in 17.0% patients. Biological therapy was used in five patients. Surgical intervention was required in six patients. The mean follow-up period was 9.2±5.6 years. CONCLUSIONS: The clinical characteristics of our population are comparable to that reported in neighboring countries and worldwide.

Neonatal indirect hyperbilirubinemia and glucose-6-phosphate dehydrogenase deficiency.

PURPOSE: This study aimed to determine the prevalence of glucose-6-phosphate dehydrogenase (G6PD) deficiency among infants with neonatal indirect hyperbilirubinemia (NIH); compare G6PD-deficient and G6PD-normal patients regarding hyperbilirubinemia and need for exchange transfusions (ET); and assess risk factors for ET and kernicterus. METHODS: This is a case-control retrospective study. Medical records of NIH patients admitted to the Pediatric Department, Salmaniya Medical Complex, Bahrain, between January 2007 and June 2010 were reviewed. Data on sex, age at presentation, hospitalization duration, need for ET, hemoglobin (Hb) level, reticulocyte count, direct Coombs test, serum total and indirect bilirubin levels, thyroid function, blood and urine cultures, G6PD status, and blood groups were collected and compared between the G6PD-deficent and G6PD-normal patients. RESULTS: Of 1,159 NIH patients admitted, 1,129 were included, of whom 646 (57%) were male. Among 1,046 patients tested, 442 (42%) were G6PD deficient, 49 (4%) needed ET, and 11 (1%) had suspected Kernicterus. The G6PD-deficient patients were mainly male (P<0.0001), and had lower Hb levels (P<0.0001) and higher maximum bilirubin levels (P=0.001). More G6PD-deficient patients needed ET (P<0.0001). G6PD deficiency (P=0.006), lower Hb level (P=0.002), lower hematocrit count (P=0.02), higher bilirubin level (P<0.0001), higher maximal bilirubin level (P<0.0001), and positive blood culture result (P<0.0001) were significant risk factors for ET. Maximal bilirubin level was a significant risk factor for kernicterus (P=0.021) and independently related to ET (P=0.03). CONCLUSION: G6PD deficiency is an important risk factor for severe NIH. In G6PD-deficent neonates, management of NIH should be hastened to avoid irreversible neurological complications.

Intestinal lymphangiectasia in children. A favorable response to dietary modifications.

Intestinal lymphangiectasia (IL) is a rare disease characterized by dilatation of intestinal lymphatics. It can be classified as primary or secondary according to the underlying etiology. The clinical presentations of IL are pitting edema, chylous ascites, pleural effusion, acute appendicitis, diarrhea, lymphocytopenia, malabsorption, and intestinal obstruction. The diagnosis is made by intestinal endoscopy and biopsies. Dietary modification is the mainstay in the management of IL with a variable response. Here we report 2 patients with IL in Bahrain who showed positive response to dietary modification.

Growth assessment and risk factors of malnutrition in children with cystic fibrosis.

OBJECTIVES: To evaluate the nutritional status, to screen for the presence of malnutrition, and to study the possible risk factors associated with malnutrition in patients with cystic fibrosis (CF). METHODS: A retrospective cross-sectional review of medical records of all diagnosed CF patients in the Pediatric Department, Salmaniya Medical Complex, Manama, Kingdom of Bahrain, between January 1984 and May 2015 was conducted. Demographic and anthropometric data were collected from records of last visit to CF clinic. Nutritional status and risk factors of malnutrition were assessed. RESULTS: All records of 109 CF patients were reviewed. Forty-seven pediatric patients were included in the study. All included patients were on pancreatic enzyme replacement and 42 (89%) received high-calorie supplementation. Growth failure was noted in 34 (72%) patients, 19 (56%) were wasted and stunted, 8 (23.5%) were wasted only, and 7 (20.5%) were stunted. Low birth weight (p=0.032), and the presence of gastroesophageal reflux disease (GERD) (p=0.039) were the significant risk factors for malnutrition. CONCLUSIONS: Most CF patients in Bahrain (72%) are malnourished. Low birth weight and the presence of GERD are risk factors.

Effect of pediatric liver transplantation on renal function.

The aim of this review is to define the incidence of renal dysfunction among pediatric liver transplant (LT) survivors, to identify the associated risk factors and to outline the therapeutic options. Renal dysfunction is a common problem after pediatric LT. The measured glomerular filtration rate is considered the "gold-standard" for assessment of renal function. Renal dysfunction in pediatric LT recipients is multifactorial. Renal-sparing immunosuppressive strategies are essential to reverse renal dysfunction and to prevent end-stage renal disease.