Medical education in the United Arab Emirates: Challenges and opportunities.

Medical education (ME) in the United Arab Emirates (UAE) has a relatively short history that begins with the inception of the UAE almost 50 years ago. The UAE has made great strides in widening access to ME through the rapid implementation of national agendas aimed at advancing healthcare and expanding higher education, in addition to the presence of a strong infrastructure for privatization and business development. While progress is being made at all levels of ME, complex challenges for both undergraduate and postgraduate ME remain. Going forward, issues of standardization, quality, sustainability of academic and healthcare workforces, and research must continue to be addressed.

Creating a Framework for Medical Professionalism: An Initial Consensus Statement From an Arab Nation.

Background Medical professionalism has received increased worldwide attention, yet there is limited information on the applicability and utility of established Western professionalism frameworks in non-Western nations. Objective We developed a locally derived consensus definition of medical professionalism for the United Arab Emirates (UAE), which reflects the cultural and social constructs of the UAE and the Middle East. Methods We used a purposive sample of 14 physicians working in the UAE as clinical and education leaders. This expert panel used qualitative methods, including the world café, nominal group technique, the Delphi method, and an interpretive thematic analysis to develop the consensus statement. Results The expert panel defined 9 attributes of medical professionalism. There was considerable overlap with accepted Western definitions, along with important differences in 3 aspects: (1) the primacy of social justice and societal rights; (2) the role of the physician's personal faith and spirituality in guiding professional practices; and (3) societal expectations for professional attributes of physicians that extend beyond the practice of medicine. Conclusions Professionalism is a social construct influenced by cultural and religious contexts. It is imperative that definitions of professionalism used in the education of physicians in training and in the assessment of practicing physicians be formulated locally and encompass specific competencies relevant to the local, social, and cultural context for medical practice. Our goal was to develop a secular consensus statement that encompasses culture and values relevant to professionalism for the UAE and the Arab region.

Restructuring graduate medical education to meet the health care needs of emirati citizens.

Many nations are struggling with the design, implementation, and ongoing improvement of health care systems to meet the needs of their citizens. In the United Arab Emirates, a small nation with vast wealth, the lives of average citizens have evolved from a harsh, nomadic existence to enjoyment of the comforts of modern life. Substantial progress has been made in the provision of education, housing, health, employment, and other forms of social advancement. Having covered these basic needs, the government of Abu Dhabi, United Arab Emirates, is responding to the challenge of developing a comprehensive health system to serve the needs of its citizens, including restructuring the nation's graduate medical education (GME) system. We describe how Abu Dhabi is establishing GME policies and infrastructure to develop and support a comprehensive health care system, while also being responsive to population health needs. We review recent progress in developing a systematic approach for developing GME infrastructure in this small emirate, and discuss how the process of designing a GME system to meet the needs of Emirati citizens has benefited from the experience of "Western" nations. We also examine the challenges we encountered in this process and the solutions adopted, adapted, or specifically developed to meet local needs. We conclude by highlighting how our experience "at the GME drawing board" reflects the challenges encountered by scholars, administrators, and policymakers in nations around the world as they seek to coordinate health care and GME resources to ensure care for populations.

Submaximal exercise in patients with severe obstructive sleep apnea.

PURPOSE: Several studies have used the cardiopulmonary exercise test to assess patients with obstructive sleep apnea (OSA). However, no report has investigated the use of the 6-min walk test (6MWT) in this group of patients. METHODS: We studied consecutive, newly diagnosed, OSA patients (aged >18 years). The control group was composed of matched healthy subjects with no clinical history indicative of sleep breathing disorders. The study population was divided into three groups: an OSA group, a control obese group, and a control lean group. The obese controls were gender-, age- (+/-2 years), height- (+/-5 cm), and weight- (+/-2 kg) matched to the OSA patients, while the lean controls were matched in gender, age, and height, but not weight. All patients underwent sleep study at our Sleep Disorders Center. Each subject underwent a single 6MWT within 1 week of the sleep study. RESULTS: A total of 55 patients were recruited to the OSA group (age 36.7 +/- 7.9 years, body mass index 38.7 +/- 8.6 kg/m(2), and apnea hypopnea index 66.6 +/- 34.8/h), 32 subjects to the control obese group, and 30 to the control lean group. There was no difference in distance walked (6-min walk distance (6MWD)) between the OSA group (389 +/- 70 m) and the obese group (408 +/- 66 m). In the OSA group, the 6MWD results did not correlate with patient age, apnea hypopnea index, or other polysomnographic variables. At the end of the test, heart rate, systolic and diastolic blood pressure, and dyspnea perception were significantly increased in the OSA group compared with healthy subjects. CONCLUSIONS: The 6MWT is easy to perform and well tolerated by patients with OSA. There were no correlations between the 6MWD and the severity of OSA or other polysomnographic parameters. However, patients with OSA exhibited abnormal hemodynamic responses to submaximal exercise.

Six-min walk test in a healthy adult Arab population.

BACKGROUND: The 6-min walk test (6MWT) is a submaximal exercise test used to assess functional status in patients with cardiopulmonary diseases. Regression equations have previously been published as a normal reference for 6-min walk distance (6MWD) in healthy Caucasian adults. However, a recent study showed that the normal predicted 6MWD could differ among ethnic populations. The aim of this study was: (1) to determine the normal 6MWD in a sample of healthy Saudi adults; (2) to create a regression equation for the established 6MWD; and (3) to compare the 6MWD in the present study with previously published equations. METHOD: The 6MWT was administered to 298 healthy volunteers (53% males) between the ages of 16 and 50 years. RESULT: The average 6MWD was 409+/-51 m, with longer distances walked by males (429+/-47 m) than by females (386+/-45 m) (p<0.001). The regression equation revealed that height (p<0.001) and age (p=0.034) were the most significant predictors of distance (6MWD=(2.81 x height)+(0.79 x age)-28.5). In addition, the equation explained 25% of the distance variance. All previously published equations overestimated the Saudi 6MWD by 109-340 m. CONCLUSION: Saudi populations have significantly shorter 6MWDs than those reported for other ethnic groups. Thus, the Caucasian reference value for the 6MWD should not be used in Saudi subjects, as it overestimates the distance and may interfere with the therapeutic and prognostic value of the test.

Cosleeping and its correlates in Saudi school-aged children.

BACKGROUND: There are cross-cultural variations in sleep habits among children. No previous study has assessed the prevalence of cosleeping in school-aged children in Middle Eastern countries. PURPOSE: To assess the prevalence of, and the factors associated with, cosleeping in Saudi school-aged children. METHODS: Questionnaires were distributed according to a specified sampling procedure, and parents were asked to rate each item that described their child's behavior within the previous 6 months. Cosleeping was defined as all-night sharing of a bed or room with a parent. RESULTS: Data were analyzed for 977 children (50.5% boys) with a mean age of 9.5 +/- 1.9 years and a range from 5 to 12 years. Cosleeping with parents was reported by 26% (95% CI: 23.2-28.7%) of the sample. According to a multivariate logistic regression model, a child's school level, enuresis, and nightmares were the only predictors of cosleeping. CONCLUSION: This study demonstrated that cosleeping is more common among Saudi school-aged children than has been reported for other countries. When assessing children's sleep, the practitioner should give special consideration to the child's needs, and his/her family's cultural background.

Dyspnea, pulmonary function and exercise capacity in adult Saudi patients with sickle cell disease.

OBJECTIVE: To examine pulmonary function, dyspnea and exercise capacity in adult Saudi sickle cell disease (SCD) patients. METHODS: The patients were recruited from the hematology clinic at King Khalid University Hospital in Riyadh from January to December 2005. The study involved 39 patients with stable SCD (20 women and 19 men), with a mean age of 22.7+/-7.1 years, hemoglobin level of 95.5+/-14.6 g/L and hemoglobin F level of 13.7+/-8.6%. Patients underwent pulmonary function tests (PFT) (forced expiratory volume in first second [FEV1], forced vital capacity [FVC], and diffusion capacity of carbon monoxide [DLco] data are presented as a percentage of the normal prediction), a 6-minute walk test (6MWT) and echocardiography. Dyspnea was assessed using the Borg score. The 6MWT data were compared to body mass index-matched healthy controls. RESULTS: Forty-one percent of SCD patients had mild dyspnea at rest, and this increased to 61% at the end of the 6MWT. Pulmonary function tests were abnormal in 51% (36% of patients had a restrictive pattern, 10% had isolated decrease in DLco, and 5% had a mixed restrictive-obstructive pattern). The 6MWD was shorter in SCD patients compared to the controls (368+/-67 versus 407+/-47m, p=0.005). No hematological variables correlated with outcome variables. CONCLUSION: Chronic pulmonary complications in adult Saudi SCD patients are relatively mild but common. Pulmonary function in these patients differs from that published for African-origin SCD patients. This difference may reflect a different natural history of SCD in the 2 populations.

Is serum alanine transaminase level a reliable marker of histological disease in chronic hepatitis C infection?

BACKGROUND: Approximately 20-30% of patients chronically infected with hepatitis C virus (HCV) have persistently normal alanine transaminase (PNALT) levels. These patients are described to have a mild degree of histological liver damage. We aimed to assess the histological liver changes in HCV patients with PNALT. PATIENTS AND METHODS: Sixty-five patients with HCV and PNALT (group A) underwent a liver biopsy. PNALT was defined as three or more determinations identified to be within the normal range over 6 months or longer. The demographical features and histological changes were compared with 66 consecutive patients with chronic HCV infection and elevated ALT (group B). All patients had a detectable HCV RNA. Histological disease was scored according to the METAVIR system. RESULTS: Females were more likely to have normal ALT levels (65%). The mean ALT level in Group A and B was 30 and 105 IU/L respectively. No patient in either group had normal histology. The mean necro-inflammatory scores in groups A and B (2.0+/-0.68 vs 2.09+/-0.67) and the mean fibrosis scores (2.11+/-0.87 vs 2.24+/-1.04) were not significantly different. Bridging fibrosis in groups A and B was seen in 24.6 and 37.9% patients, respectively, while cirrhosis was seen in 6.2 and 7.6% patients respectively. Hepatic steatosis in groups A and B (0.94+/-0.86 vs 1.0+/-1.02 respectively) was also not significantly different and did not show any association with the fibrosis scores across the two groups. In group A, the necro-inflammatory and fibrosis scores of patients with and without steatosis were not statistically significant. Age was the only predictor of normal ALT levels. However, increasing age did not show a significant increase in histological activity in either group beyond a certain age. CONCLUSION: This study demonstrates that ALT is a poor surrogate marker for inflammation and fibrosis in HCV patients. Given the presence of significant necro-inflammation in PNALT patients, the risk/benefit ratio justifies treatment without the need for a liver biopsy.

Six Minute Walk Test to assess functional capacity in chronic liver disease patients.

AIM: To examine the utility of Six Minute Walk Test (6MWT) in patients with chronic liver disease (CLD). METHODS: Two hundred and fifty subjects between the ages of 18 and 80 (mean 47) years performed 6MWT and the Six Minute Walk Distance (6MWD) was measured. RESULTS: The subjects were categorized into four groups. Group A (n = 45) healthy subjects (control); group B (n = 49) chronic hepatitis B patients; group C (n = 54) chronic hepatitis C patients; group D (n = 98) liver cirrhosis patients. The four groups differed in terms of 6MWDs (P < 0.001). The longest distance walked was 421 +/- 47 m by group A, then group B (390 +/- 53 m), group C (357 +/- 72 m) and group D (306 +/- 111 m). The 6MWD correlated with age (r = -0.482, P < 0.01), hemoglobin (r = 0.373, P < 0.001) and albumin (r = 0.311, P < 0.001) levels. The Child-Pugh classification was negatively correlated with the 6MWD in cirrhosis (group D) patients (r = -0.328, P < 0.01). At the end of a 12 mo follow-up period, 15 of the 98 cirrhosis patients had died from disease complications. The 6MWD for the surviving cirrhotic patients was longer than for non-survivors (317 +/- 101 vs 245 +/- 145 m, P = 0.021; 95% CI 11-132). The 6MWD was found to be an independent predictor of survival (P = 0.024). CONCLUSION: 6MWT is a useful tool for assessing physical function in CLD patients. We suggest that 6MWD may serve as a prognostic indicator in patients with liver cirrhosis.

Echocardiographic abnormalities in adolescent and adult Saudi patients with sickle cell disease.

OBJECTIVE: Cardiovascular complications in sickle cell disease (SCD) have been well documented but cardiac involvement in Saudi patients with SCD is not known. We sought to identify cardiac abnormalities by echocardiography in adolescent and adult Saudi patients with stable SCD. METHODS: Sixty-five consecutive patients with SCD followed at King Khalid University Hospital, Riyadh, were prospectively studied from January 2005 to December 2005. All patients underwent echocardiographic examination to determine chamber dimensions, left ventricular function, valvular anomalies and pulmonary artery pressure. Data were compared to normal age and gender-matched controls. Hematological data were also collected from the patients and correlated with the echocardiographic results. RESULTS: Twenty-eight males and 37 females were evaluated. The mean age of the group was 24.5+/-9.2 (range 14-44) years. The most common abnormality found was pulmonary hypertension (PH) present in 25 (38%) patients. The majority of these patients had mild PH and only 6 (9%) patients had pulmonary artery systolic pressure (PASP) more than 40 mm Hg. Older age, lower level of fetal hemoglobin and high serum ferritin were associated with increased PASP. Other abnormalities present included dilated left atrium in 17 (26%) patients, dilated right atrium 13 (20%), dilated left ventricle 10 (15%), valvular anomalies 21 (32%) and reduced ejection fraction in 4 (6%) patients. CONCLUSION: Cardiac abnormalities are found in a significant proportion of Saudi patients with SCD. Pulmonary hypertension is the most common finding while other abnormalities are less frequent.