Gulf Asthma Diagnosis and Management in Adults: Expert Review and Recommendations.

The prevalence and incidence of asthma are increasing globally because of genetic and environmental influences. Prevalence of asthma in the Gulf has been reported to range from 4.7% to 32.0% and has a substantial economic burden. In this paper, we summarize current asthma management guidance for adults, present insights, and recommendations by key opinion leaders (KOLs) in the Gulf region, and key performance indicators for guiding clinical practice for asthma diagnosis, management, and treatment in the Gulf. While it is recommended that the Global Initiative for Asthma (GINA) guidelines should be followed wherever possible for the management of asthma, KOLs in the Gulf region have presented additional recommendations based on regional challenges and insights. There is a need for better diagnosis using objective testing, increased efforts in tackling the burden of comorbidities in the region, and greater provision of the necessary tools for phenotyping severe asthma. Furthermore, there is a need for greater education for physicians regarding asthma treatment, including the importance of inhaled-corticosteroid-containing controller medication. Regionally, there is also a need for specialist asthma clinics and asthma educators, which would serve to educate physicians and their patients as well as to improve the management of patients. Finally, the use of asthma registries, digital devices, and electronic templates would be of benefit in the management of asthma patients in the region.

A Cross-Sectional Study in Patients with Severe COPD to Assess the Perception of Symptom Variability (COPVAR) in the Middle East and Africa.

Purpose: This study was performed to assess symptom variability and its impact on morning activities in stable patients with severe COPD in the Middle East and Africa (MEA) countries. Patients and methods: Non-interventional, cross-sectional study (NCT03425760) in patients with severe COPD (GOLD 2015, C, or D categories). Symptom variability was assessed directly by interviewing the patient and using the Global Chest Symptoms Questionnaire (GCSQ). The impact on morning activities was assessed using the Capacity of Daily Living during the Morning (CDLM) and the Morning Activities and Symptoms Questionnaire (MASQ). Results: A total of 3253 patients (mean±SD age: 64.1±9.5 years, 90.3% males) were enrolled. Overall, 81.6% and 83.4% of patients reported weekly and daily symptom variability, respectively. The number of exacerbations in the previous year, smoking cessation, and COPD GOLD D were the most consistent factors associated with symptom variability. The GCSQ score was significantly higher (p<0.001) in GOLD D than in GOLD C patients at each time during the day. In GOLD D, the mean (±SD) GCSQ score was higher at night (1.6±1.2, p<0.001) and in the morning (1.5±1.0, p<0.001) than in the afternoon (1.3±0.9), suggesting daytime variability of breathlessness and chest tightness. Overall, 60.0% of GOLD D patients (versus 13.6% GOLD C, p<0.0001) had difficulty getting out of bed due to COPD. Patients with symptom variability had significantly more difficulty to get out of bed, especially patients with chest tightness variability (p<0.0001) and wheezing variability (p<0.0001). The CDLM global score was significantly lower (p<0.0001) in GOLD D than in GOLD C patients (3.5±1.1 and 4.6 ± 3.5, respectively). Daily variability in chest tightness and wheezing was also significantly associated with CDLM scores (p<0.0001). Conclusion: In MEA countries, patients with severe stable COPD reported significant daily and weekly symptom variability which affects morning activities, particularly in GOLD D patients.

Correlates of Pulmonary Function in Children with Sickle Cell Disease and Elevated Fetal Hemoglobin.

OBJECTIVE: The current study was carried out to compare pulmonary function tests (PFTs) in pediatric Kuwaiti sickle cell disease (SCD) patients to age-matched normal controls and to investigate the association of PFTs with selected clinical and laboratory parameters. Subjects andMethods: There were 38 patients with SCD and 36 controls in the study. The patients were recruited from the Pediatric Hematology Clinics of Mubarak Al-Kabeer and Al-Amiri Hospitals, Kuwait, and were studied in steady state. The controls were healthy, non-sickle cell siblings of the patients. Forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), total lung capacity, and other PFT parameters were obtained using a constant-volume, variable-pressure, body plethysmograph. Hemoglobin, fetal hemoglobin, serum bilirubin, and lactate dehydrogenase were determined using standard methods. RESULTS: The mean ages of the patients and controls were 10.5 ± 3.2 and 10.5 ± 3.5 years, respectively. The FEV1% predicted of 84.1 ± 15.4% among the patients was significantly lower than the 92.1 ± 11.8% in the controls (p = 0.003). The FVC% predicted was also significantly lower (p = 0.022) in the patients than in the controls, although the values were generally within the normal range. There was no association of FEV1 with pain phenotype, acute chest syndrome (ACS), or blood transfusions. Also, there was no significant correlation with reticulocytes, bilirubin, or lactate dehydrogenase. CONCLUSIONS: In this study, changes in PFT, especially FEV1, developed early in the SCD patients. There was no demonstrable association with frequent vaso-occlusive crisis, ACS, and other variables. Hence, there is a need for follow-up studies with serial PFTs to identify vulnerable patients, who might need intervention to prevent early mortality.

The Prevalence of Human Bocavirus, Human Coronavirus-NL63, Human Metapneumovirus, Human Polyomavirus KI and WU in Respiratory Tract Infections in Kuwait.

OBJECTIVE: The aim of this study was to investigate the prevalence of human coronavirus (HCoV)-NL63, human metapneumovirus (hMPV), human bocavirus (Boca), human polyomavirus KI (KIV) and human polyomavirus WU (WUV) in respiratory tract infections (RTI) in Kuwait. MATERIALS AND METHODS: Respiratory samples from 735 hospitalized patients with RTI from September 2010 to April 2013 were evaluated for the presence of HCoV-NL63, hMPV, Boca, KIV and WUV using molecular assays, polymerase chain reaction (PCR) and reverse-transcription PCR. RESULTS: Of the 735 patients, 285 (38.8%) were diagnosed with viral RTI. The distribution of respiratory viruses was hMPV: 15 (5.3%), Boca: 14 (4.9%), WUV: 10 (3.5%) and KIV: 4 (1.4%). HCoV-NL63 was not detected in any of the samples. CONCLUSIONS: These newly discovered viruses were associated with the development of RTI in Kuwait. The rapid identification of these viral infections could aid in the control of nosocomial transmission, reduce the use of antibiotics and improve treatment and management strategies.

Mixed viral infections circulating in hospitalized patients with respiratory tract infections in kuwait.

The aim of this study was to determine the frequency of viral mixed detection in hospitalized patients with respiratory tract infections and to evaluate the correlation between viral mixed detection and clinical severity. Hospitalized patients with respiratory tract infections (RTI) were investigated for 15 respiratory viruses by using sensitive molecular techniques. In total, 850 hospitalized patients aged between 3 days and 80 years were screened from September 2010 to April 2014. Among the 351 (47.8%) patients diagnosed with viral infections, viral mixed detection was identified in 49 patients (14%), with human rhinovirus (HRV) being the most common virus associated with viral mixed detection (7.1%), followed by adenovirus (AdV) (4%) and human coronavirus-OC43 (HCoV-OC43) (3.7%). The highest combination of viral mixed detection was identified with HRV and AdV (2%), followed by HRV and HCoV-OC43 (1.4%). Pneumonia and bronchiolitis were the most frequent reason for hospitalization with viral mixed detection (9.1%). There were statistical significance differences between mixed and single detection in patients diagnosed with bronchiolitis (P = 0.002) and pneumonia (P = 0.019). Our findings might indicate a significant association between respiratory virus mixed detection and the possibility of developing more severe LRTI such as bronchiolitis and pneumonia when compared with single detection.

The cost of asthma in Kuwait.

OBJECTIVE: To evaluate the direct costs of treating asthma in Kuwait. MATERIALS AND METHODS: Population figures were obtained from the 2005 census and projected to 2008. Treatment profiles were obtained from the Asthma Insights and Reality for the Gulf and Near East (AIRGNE) study. Asthma prevalence and unit cost estimates were based on results from a Delphi technique. These estimates were applied to the total Kuwaiti population aged 5 years and over to obtain the number of people diagnosed with asthma. The estimates from the Delphi exercise and the AIRGNE results were used to determine the number of asthma patients managed in government facilities. Direct drug costs were provided by the Ministry of Health. Treatment costs (Kuwaiti dinars, KD) were also calculated using the Delphi exercise and the AIRGNE data. RESULTS: The prevalence of asthma was estimated to be 15% of adults and 18% of children (93,923 adults; 70,158 children). Of these, 84,530 (90%) adults and 58,932 (84.0%) children were estimated to be using government healthcare facilities. Inpatient visits accounted for the largest portion of total direct costs (43%), followed by emergency room visits (29%), outpatient visits (21%) and medications (7%). The annual cost of treatment, excluding medications, was KD 29,946,776 (USD 107,076,063) for adults and KD 24,295,439 (USD 86,869,450) for children. Including medications, the total annual direct cost of asthma treatment was estimated to be over KD 58 million (USD 207 million). CONCLUSIONS: Asthma costs Kuwait a huge sum of money, though the estimates were conservative because only Kuwaiti nationals were included. Given the high medical expenditures associated with emergency room and inpatient visits, relative to lower medication costs, efforts should be focused on improving asthma control rather than reducing expenditure on procurement of medication.

High resolution computed tomography in asthma.

OBJECTIVES: High-resolution computed tomography (HRCT) can detect the structural abnormalities in asthma. This study attempts to correlate these abnormalities with clinical and pulmonary function test (PFT) data. METHODS: Consecutive stable asthma patients attending Mubarak Al Kabeer Hospital, Kuwait, were subjected to HRCT during a six month period from July 2004 to December 2004, after initial evaluation and PFT. RESULTS: Of the 28 cases, sixteen (57.1%) had moderate, 6 (21.4%) had mild and 6 (21.4%) had severe persistent asthma. Thirteen (46.4%) patients had asthma for 1 to 5 years and 12 (42.9%) were having asthma for >10 years. Bronchial wall thickening (57.1%), bronchiectasis (28.6%), mucoid impaction (17.9%), mosaic attenuation (10.7%), air trapping (78.6%) and plate like atelectasis (21.4%) were noted. Bronchial wall thickening (p=0.044) and bronchiectasis (p=0.063) were most prevalent in males. Ten (35.7%) patients exhibited mild, 9 (32.1%) had moderate and 3 (10.7%) had severe air trapping. The difference in Hounsfield units between expiratory and inspiratory slices (air trapping) when correlated with percent-predicted FEV1 in right upper (r=0.25; p=0.30), left upper (r=0.20; p=0.41), right mid (r=0.15; p=0.53), left mid (r=-0.04; p=0.60), right lower (r=0.04; p=0.86) and left lower zones (r=-0.13; p=0.58) showed no relation. The same when correlated as above with the percent predicted FEF 25-75 did not show any significant association. The presence of air trapping was compared with sex (p=0.640), nationality (p=1.000), disease duration (p=1.000) and severity of symptoms (p=0.581). CONCLUSION: Abnormal HRCT findings are common in asthma; however, air trapping when present was not related to the duration or severity of the illness or to the FEV1.

Effect of acute cold exposure on lung perfusion and tracheal smooth muscle contraction in rabbit.

Acute exposure to cold temperature can affect the respiratory system of those exposed to extreme weather and induces asthma in asthmatic patients. However, the effect on lung perfusion and the pulmonary circulation was not addressed in any previous study. The present study investigates the effects of acute cold exposure on tracheal smooth muscle and lung perfusion. New Zealand White rabbits were used in these experiments. For in vitro experiments, isolated tracheal segments were suspended in organ baths containing Krebs' solution for isometric tension recording. Tissue response to cooling from 37 to 4°C was examined. For in vivo experiments, the rabbits were kept in a cold room (4°C) for 1 h. Lung perfusion scintigraphy was performed at the end of this period. Each rabbit was injected with 74 MBq (2 mCi) technetium-99m macroaggregated ((99m)Tc MAA). Perfusion studies were done by using Gamma camera equipped with a low-energy, high-resolution, parallel-hole collimator interfaced with a computer. Static images were acquired 5 min after administration of the radiotracer. Cooling induced a rapid and reproducible contraction in the tracheal smooth muscle. Rabbits exposed to cold temperature had lesser lung perfusion than controls using radionuclide perfusion study. Our results highlight the response of tracheal muscle and pulmonary circulation to cold exposure. These results indicate that cooling induced contraction of the trachea and decreased pulmonary circulation and lung perfusion. This summation of acute cooling for tracheal smooth muscle and pulmonary circulation seems to be the reason for the severe cooling-induced contraction.

Closed percutaneous pleural biopsy. A lost art in the new era.

OBJECTIVE: To assess the association between size and number of biopsy specimens obtained by percutaneous closed pleural biopsy, with overall diagnostic yield in general, and histopathological evidence of tuberculosis pleurisy, in particular. METHODS: One hundred and forty-three patients, with a high index of clinically having tuberculous pleurisy, were referred to the respiratory division of Mubarak Al-Kabeer Hospital in Kuwait during a 9-year period (January 1999 to December 2007). All subjects with exudative lymphocytic predominant effusion underwent percutaneous closed pleural biopsy, looking for tuberculous granulomas. The clinical diagnosis and pathological characteristics (number and size of biopsy samples) were analyzed. RESULTS: Overall diagnostic yield of percutaneous closed pleural biopsy in all cases was noticed to be 52%. The larger biopsy sample size of 3 mm and more, and the higher number of specimens (> or = 4) were significantly associated with an increased diagnostic yield for tuberculous pleurisy (p=0.007 and 0.047). CONCLUSION: Obtaining 4 or more biopsy samples, and larger specimens of 3mm and more for histopathological evaluation, through percutaneous pleural biopsy, results in a better diagnostic yield for tuberculous pleurisy.

Technetium 99m-diethylene triamine penta-acetic acid aerosol clearance in the evaluation of pulmonary involvement in sickle cell disease.

BACKGROUND: Pulmonary clearance of inhaled technetium (Tc) 99m-labeled diethylene triamine penta-acetic acid (DTPA) aerosol is a sensitive non-invasive marker of alveolar permeability and patients with interstitial lung diseases show enhanced clearance. However, a previous study in adult patients with diabetes mellitus showed delayed clearance. OBJECTIVES: To investigate DTPA clearance in steady-state, otherwise healthy adult sickle cell disease (SCD) patients and correlate it with pulmonary function tests (PFTs), hematologic and clinical parameters. MATERIALS AND METHODS: The subjects were randomly selected from the Hematology Clinic of Mubarak Hospital, Kuwait. Hematologic and pulmonary function data were collected with standard methods. DTPA radio-aerosol clearance studies were performed using ultrafine nebulizer containing 35 mCi (1295 MBq) of Tc 99m-DTPA in its reservoir and t(1/2) clearance in minutes was determined. Average values for both lungs were calculated and compared with normal values for our population. RESULTS: Forty-three subjects (24 SS and 19 S-beta(0)thal) aged between 16 and 45 yr (mean of 27.1 +/- 9.7) were studied. Twenty-two subjects (51.2%) had delayed, while only 10 (23.3%) showed enhanced DTPA clearance. Patients with enhanced clearance showed better PFTs than those with normal or delayed clearance. There was significant negative correlation of DTPA clearance with forced expiratory volume in 1 s, forced vital capacity and total lung capacity and significant positive correlation with age. CONCLUSIONS: Majority of adult SCD patients have delayed DTPA clearance unlike in inflammatory lung diseases, but similar to diabetes mellitus. DTPA clearance may be a useful modality for monitoring pulmonary involvement in SCD.

Long term prognosis of sarcoidosis in Arabs and Asians: predictors of good outcome.

BACKGROUND: The prognosis of sarcoidosis is variable and often difficult to predict. Our aim was to identify predictors of good prognosis in Arabs and Asians with sarcoidosis. METHODS: Data on patients with sarcoidosis followed up for at least 3 years in two major hospitals in Kuwait were collected retrospectively for the period 1983 to 1995 and prospectively from 1995. RESULTS: Of the total 115 patients, 60% were females and 80% were Arabs. Majority, 86.9%, of the patients had either Stage I or II disease. Forty-five (43.7%) were followed up for 3 to 5 years, 43 (41.7%) for 5 to 9 and 15 (14.6%) for 10 or more years while 12 were lost to follow up. Good prognosis was seen in 53 (51%), intermediate in 33(32%) and poor in 17 (17%) patients. Two patients (1.9%) died. Good prognosis was observed in 74.4% of patients with Stage I, 40% of patients with Stage II and 16.7% with stage III disease, p = 0.001. In addition, presence of arthralgia predicted a good prognosis, p = 0.014. Hypercalcemia was noted only in patients with poor or intermediate outcome. Gender, ethnicity, and presence of erythema nodosum were not predictors of prognosis in our patients. Multivariate logistic regression analysis confirmed that early stage of the disease [OR (95 %CI), 6.1 (2.3-15.7), p = 0.001] and presence of arthralgia, [OR (95%CI), 4.5 (1.3-15.4), p = 0.02] were predictors of good prognosis. CONCLUSION: Presence of arthralgia and early stage of the disease were the most important predictors of good prognosis. Sex, age, ethnicity and presence of erythema nodosum did not influence the prognosis.

Demographic pattern and clinical characteristics of patients with smear- positive pulmonary tuberculosis in kuwait.

OBJECTIVE: The aim of this study was to document various clinical factors that are likely to be of help in the control of tuberculosis in Kuwait. SUBJECTS AND METHODS: Details of patients with sputum positive for acid-fast bacilli in the period from January 1998 to December 2000 were collected retrospectively from the case records and population statistics from government sources. The data were then tabulated and analyzed. RESULTS: Of the 526 cases, 83.5% were expatriates and 16.5% Kuwaiti; 373 (70.9%) were male. Of the expatriates, 66.7% were from Asia and the Far East, 5.7% were > or =60 years. The annual incidence was 8.34 per 100,000 population. The lowest incidence was observed in the Jahrah governorate with an overall incidence of 5 (2.0 among Kuwaitis and 6.4 among expatriates) per 100,000 population. The highest incidence overall (10.2) and among Kuwaitis (4.1) was observed in the Farwaniya governorate, while the highest incidence among expatriates was seen in the Capital governorate (13.4). Radiologically, 94 (19.5%) had minimal, 246 (51.5%) had moderately advanced and 141 (29.3%) far-advanced disease. The majority of the patients (72%) had only + status for AFB in the smear. Hypercalcemia (25.7%), hyponatremia (22.15%) and hyperglycemia (29.9%) were common in the patients. Mean serum albumin was low (28.7 +/- 5.5 g/l). Two hundred and forty-seven (47.2%) were declared cured while 116 (22.2%) completed treatment. Comparison between nationals and expatriates showed a significant difference only for age, smoking status, defaulter rate and place of residence. CONCLUSION: The lowest regional incidence was found in the Jahrah governorate. Both biochemical abnormalities and radiologically advanced presentations were common. Disease pattern and response to treatment was purely individual and did not differ with respect to nationality or race.