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Hypertension is a significant predictor for cardiovascular diseases and is the most important preventable or modifiable cause of morbidity and mortality from these diseases. Undiagnosed cases of hypertension and poor control are important factors in controlling hypertension worldwide, including Oman.The aim of this study was to identify the important risk factors and predictors of the state of unawareness of the presence of hypertension, as well as the risk factors for poor control of blood pressure, among hypertensive patients.Data from Oman World Health Survey (OWHS), 2008, were used in this study. The OWHS adopted a multistage stratified cluster sampling to select study participants. An interview questionnaire was used to collect data related to risk factors. Other parameters included blood pressure, anthropometric and biochemical measurements.The prevalence of hypertension in Oman was estimated to be 41.5%. Of those who were hypertensive, three-quarters of them (75.7%) were unaware of being hypertensive and 65.5% of them had inadequately controlled hypertension. Male sex, higher wealth, and paying fewer visits to health facilities were found associated with high proportions of unawareness and high proportion of uncontrolled hypertension.The study highlights high levels of unawareness of being hypertensive and high proportion of uncontrolled hypertension in Oman that need to be considered when developing health policies and strategies. Intersectorial collaborative and innovative strategies that focus on improving awareness, detection, and control of hypertension should be considered, especially with attention to young adults and men.

There is an increasing burden of obesity and obesity-related noncommunicable diseases in Gulf Cooperation Council countries, including Oman. This descriptive, epidemiological study assessed physical activity among 2977 Omani adults using a population-based household survey in 2008. Overall, 54.2% of men and 41.6% of women were physically active; the rate was higher in younger cohorts and varied significantly by region of residence. Physical activity related to the transportation (walking and cycling) domain was higher than in the leisure or work domains. Unmarried men aged 30-39 years were twice as likely to be physically active (OR 2.25) and unmarried women aged 40+ years were half as likely to be active (OR 0.58) than their married counterparts. Young women not working were less active (OR 0.18) than working women. Higher education was significantly associated with leisure activity for men aged 30+ years and women aged 40+ years. Further research to understand regional variations and to identify culturally appropriate strategies to promote physical activity is required.الوبائيات الوصفية للنشاط البدني لدى البالغين العمانيين: المسح الصحي العالمي لعُمان في عام 2008.روث مابري، مجدي مرسي، جواد أحمد اللواتي، نيفيل أُوين.هناك تزايد في عبء السمنة والأمراض غر السارية المرتبطة بالسمنة في بلدان مجلس التعاون الخليجي؛ با فيها سلطنة عان. وقد قيَّمت هذه الدراسة الوبائية الوصفية النشاط البدني لدى 2977 بالغاً عمانياً باستخدام مسح أسَي سكاني في عام 2008. فكان - بالإجمال - %54.2 من الرجال و %41.6 من النساء نشيطين بدنياً، وكان المعدل أعى لدى الفئات الأصغر سناً، وشديد التباين باختاف منطقة الإقامة. وكان النشاط البدني المرتبط بمجال المواصات (المي وركوب الدراجات) أعى من النشاط الذي يبذل في مجالات الترفيه أو العمل. وكان النشاط البدني لدى الرجال غر المتزوجن ممن هم بأعار 39-30 عاماً ضعف نشاط نظرائهم المتزوجن (OR=2.25) ، ولدى النساء غر المتزوجات اللواتي تجاوزن ال 40 سنة نصف نشاط نظيراتهن المتزوجات (OR=0.58). وكانت الشابات اللواتي لا يعملن أقل نشاطاً (OR=0.18) من النساء العامات. وكان هناك ارتباط كبر بن التعليم العالي وبن النشاط الترفيهي لدى الرجال الذين تزيد أعمارهم عن 30 سنة والنساء اللواتي تجاوزن ال 40 سنة. هناك حاجة إلى مزيد من البحوث لفهم التباينات الإقليمية ولتحديد اسراتيجيات ملائمة ثقافياً لتعزيز النشاط البدني.Épidémiologie descriptive de l’activité physique chez des adultes omanais : enquête de 2008 à Oman dans le cadre de l'enquête sur la santé dans le monde.Le fardeau de l’obésité et des maladies non transmissibles liées à l’obésité est en augmentation dans les pays du Conseil de Coopération du Golfe, notamment à Oman. La présente étude épidémiologique descriptive a évalué l’activité physique de 2977 adultes omanais à l’aide d’une enquête de population auprès des ménages en 2008. Globalement, 54,2 % des hommes et 41,6 % des femmes avaient une activité physique ; le taux était supérieur dans les cohortes plus jeunes et variait significativement en fonction de la région de résidence. L’activité physique liée aux déplacements (marche et vélo) était plus fréquente que l’activité physique professionnelle ou de loisir. Les hommes célibataires entre 30 et 39 ans étaient deux fois plus susceptibles d’être physiquement actifs (OR 2,25) alors que les femmes célibataires âgées de plus de 40 ans étaient deux fois moins actives (OR 0,58) que les femmes mariées. Les femmes jeunes sans emploi étaient moins actives physiquement (OR 0,18) que les femmes occupant un emploi. Un niveau d’études supérieur était nettement associé à une activité physique de loisir chez les hommes de plus de 30 ans et les femmes de plus de 40 ans. Des recherches plus approfondies pour comprendre les variations régionales et identifier des stratégies culturellement appropriées visant à promouvoir l’activité physique sont nécessaires.

Lung cancer is the most common cancer in the world, with an estimated number of 1.3 million new cases as of 2002. This is the first report from the countries that comprise the Gulf Cooperation Council (GCC).All the primary lung cancer cases registered in the Gulf Center for Cancer Registration during 1998 to 2001 were used to calculate the age-standardized incidence rate (ASR) per 100,000 person-years by the direct standardization method.Overall, there were 1607 (1261 males, 346 females) primary lung cancer cases registered during this period with the male to female ratio of 3.6:1. The highest ASR was in Bahrain (34.3 for males, 12.1 for females) followed by Qatar (18.5 for males, 5.5 for females) and Kuwait (13.8 for males, 4.0 for females); the lowest rate was in Saudi Arabia (4.8 for males, 1.3 for females). The mean age at diagnosis for males ranged from 68.7 years in Bahrain to 59.2 years in Oman. For females it ranged from 68.2 years in Bahrain to 58.0 years in Oman. Squamous cell carcinoma in males (except in Qatar) and adenocarcinoma in females were the predominant histological type.Cancer of the lung is one of the common cancers among males in all the GCC countries and ranks second among Bahraini females. Adenocarcinomas were more common in women than men.

Aims To determine the prevalence of diabetes mellitus and impairedfasting glucose by age, gender, and by region and compare resultswith the 1991 survey; and estimate previously undiagnosed diabetesmellitus in the Omani population. Methods Cross-sectional survey containing a probability random sample of5838 Omani adults aged ≥ 20 years. Diabetesand impaired fasting glucose (IFG) were assessed by fasting venous plasmaglucose using 1999 World Health Organization's diagnosticcriteria (normoglycaemia 25 kg/m2. Conclusions The prevalence of diabetes is high in Oman and has increasedover the past decade. The high rate of abnormal fasting glucosetogether with high rates of overweight and obesity in the population makeit likely that diabetes will continue to be a major health problem inOman. Primary prevention programmes are urgently needed to counteract majorrisk factors that promote the development of diabetes. Diabet. Med. 19, 954–957 (2002)

Background: Recent reports have suggested that there are gender differences in the presentation of young adults with acute coronary syndromes (ACS). How these differences may affect ACS outcomes remains unclear, however. The aim of the current study was to examine the prognostic impact of gender in young adults with ACS in a multicenter multinational ACS registry from the Middle East. Methods: For a period of 9 months in 2008 to 2009, 7,930 consecutive patients with ACS were enrolled from 65 hospitals in 6 Middle East countries. A cohort of 3933 patients in the age group 55 years and younger were selected of whom 552 were women (14%). Gender differences in presentation and clinical features were examined. Multivariate analysis of in-hospital and one year mortality was also performed. Results: The mean age for women was 46 years and for men 48 years. Women had significantly higher rates of diabetes mellitus (50.4% vs. 30.7%), hypertension (57.4% vs. 34.5%), obesity (32% vs. 17%), dyslipidemia (37.5% vs. 26%) and renal impairment (4.1% vs. 1.2%) whereas men were more likely to be smokers (72.4% vs. 14%) [all P Conclusions: Our study shows that female gender independently and significantly increases the risk of immediate and long term mortality in young patients with ACS.

OBJECTIVES: It is well recognized that cardiac autonomic neuropathy associated with diabetes mellitus (DM) can cause silent myocardial ischemia, however there is limited research examining how the cardiac symptoms reported by patients with DM presenting with acute coronary syndromes (ACS) can affect the immediate and long term outcomes. The aim of the current study was to examine the prognostic impact of lack of chest pain symptoms in DM patients presenting with ACS and enrolled in a multicenter multinational ACS registry from the Middle East. METHODS: For a period of 9 months in 2008 to 2009, 7,930 consecutive patients with ACS were enrolled from 65 hospitals in 6 Middle East countries. A cohort of 3135 patients with DM were selected of whom 2686 (85.7%) presented with chest pain while 449 patients (14.3%) had no chest pain. Clinical features and outcomes were examined and compared among the two groups. RESULTS: Diabetic patients without chest pain were 5 years older and had significantly higher rates of hypertension (76.1% vs. 63.2%), prior myocardial infarction (35.9% vs. 24.3%), chronic kidney disease (CKD) (17.1% vs. 5.9%) and had significantly higher GRACE risk scores (55.3% vs. 21.4%) at presentation compared to patients with chest pain [All P CONCLUSIONS: DM patients with ACS presenting without chest pain are at an increased risk of immediate and long term mortality. Understanding the factors associated with atypical presentations of ACS in patients with DM may help in the earlier detection and more appropriate management of these high risk patients.

The Oman Renal Transplantation Program was established in 1988 as a joint venture between Sultan Qaboos University and the Ministry of Health. It began with both living related donor (LRD) and deceased donor (DD) transplants. Over the next nine years, while the LRD programme progressed relatively well, there were only thirteen DD transplants. Two of the DD kidneys were obtained from overseas via an active collaboration with the Euro-transplant organisation, and one DD kidney was obtained from Saudi Arabia within the Gulf Cooperative Council exchange programme. The rest of the DD kidneys were obtained in Oman. The Omani DD programme, although it was a pioneering effort in the Gulf region at the time, was not entirely sustainable. In this paper we focus on the challenges we encountered. Among the major challenges was the absence of resources to establish a dedicated DD programme and particularly the failure to develop a cadre of dedicated transplant coordinators. Background

Objectives: This study aimed to investigate trends in the estimated 10-year risk for developing cardiovascular disease (CVD) among adults with diagnosed diabetes in Oman. In addition, the effect of hypothetical risk reductions in this population was examined. Methods: Data from 1,077 Omani adults aged ≥40 years with diagnosed diabetes were collected and analysed from three national surveys conducted in 1991, 2000 and 2008 across all regions of Oman. The estimated 10-year CVD risk and hypothetical risk reductions were calculated using risk prediction algorithms from the Systematic COronary Risk Evaluation (SCORE), Diabetes Epidemiology Collaborative Analysis of Diagnostic Criteria in Europe (DECODE) and World Health Organization/International Society of Hypertension (WHO/ISH) risk tools. Results: Between 1991 and 2008, the estimated 10-year risk of CVD increased significantly in the total sample and among both genders, regardless of the risk prediction algorithm that was used. Hypothetical risk reduction models for three scenarios (eliminating smoking, controlling systolic blood pressure and reducing total cholesterol) identified that reducing systolic blood pressure to ≤130 mmHg would lead to the largest reduction in the 10-year risk of CVD in subjects with diabetes. Conclusion: The estimated 10-year risk for CVD among adults with diabetes increased significantly between 1991 and 2008 in Oman. Focused public health initiatives, involving recognised interventions to address behavioural and biological risks, should be a national priority. Improvements in the quality of care for diabetic patients, both at the individual and the healthcare system level, are required.

The main aim of this study is to assess the inflammatory markers in type 2 diabetes mellitus (T2DM) by measuring some cytokines concentrations and lymphocytes subset and correlate them with other laboratory investigations. Fifty-seven patients with type-2 diabetes and 30 healthy volunteers were enrolled in this study. Data for the C-reactive protein (CRP), haemoglobin, HbA1c, and autoantibody levels were obtained from the patients files. The cytokine concentrations were measured in patient’s serum using commercially available ELISA assays. Lymphocytes subsets were measured by flow cytometric methods. The levels of IL-1β, IL-6, IL-15, and TNF-α were found to be decreased in T2DM patients, whereas the levels of IL-10, IFN-γ, and caspase-1 were increased, compared to normal controls. T2DM patients with hypertension show significantly decreased levels of IL-1β and caspase-1 compared to patients without hypertension. No significant differences in lymphocytes subset between cases and normal control were observed. Significant correlations were found between HbA1c and IL-6; body mass index (BMI) was significantly correlated with CRP, TNF-α, and phosphate; the weight (Wt) was associated with CRP and IFN-γ. In conclusion, an alteration in the function of the immune system was observed in T2DM patient.

Background Stroke is a potential complication of acute coronary syndrome (ACS). The aim of this study was to identify the prevalence, risk factors predisposing to stroke, in-hospital and 1-year mortality among patients presenting with ACS in the Middle East. Methods For a period of 9 months in 2008 to 2009, 7,930 consecutive ACS patients were enrolled from 65 hospitals in 6 Middle East countries. Results The prevalence of in-hospital stroke following ACS was 0.70%. Most cases were ST segment elevation MI-related (STEMI) and ischemic stroke in nature. Patients with in-hospital stroke were 5 years older than patients without stroke and were more likely to have hypertension (66% vs. 47.6%, P = 0.001). There were no differences between the two groups in regards to gender, other cardiovascular risk factors, or prior cardiovascular disease. Patients with stroke were more likely to present with atypical symptoms, advanced Killip class and less likely to be treated with evidence-based therapies. Independent predictors of stroke were hypertension, advanced killip class, ACS type –STEMI and cardiogenic shock. Stroke was associated with increased risk of in-hospital (39.3% vs. 4.3%) and one-year mortality (52% vs. 12.3%). Conclusion There is low incidence of in-hospital stroke in Middle-Eastern patients presenting with ACS but with very high in-hospital and one-year mortality rates. Stroke patients were less likely to be appropriately treated with evidence-based therapy. Future work should be focused on reducing the risk and improving the outcome of this devastating complication.

We appreciate the insightful comments in the 3 accompanying letters regarding our recent article.1 The letters highlight important issues with regard to khat and acute cardiac events. In the first letter, we thank Drs Aleryani and Al-akwa for suggesting potentially additional mechanisms whereby khat chewing has cardiovascular effects in addition to those already described in our article, which are coronary artery vasoconstriction, elevation in blood pressure, and possibly hypercoagulable state. The authors suggest khat-induced oxidative stress and apoptosis as well as pesticide exposure of khat before it is “freshly” chewed as possibly contributing to these detrimental effects. Although to date there is lack of definitive data linking pesticides exposure to acute coronary syndrome risk, we concur with the authors that further studies evaluating the various aspects of khat use and its cardiovascular effects are urgently needed. We also concur with the authors that although Cathinone, the main active substance in khat, is very similar to amphetamine; however, it is not identical to it. The term “herbal or natural amphetamine” we used for khat was first introduced in the literature by Kalix et al2 in 1991, to highlight its similarity to amphetamine. In the second letter, we appreciate Dr Burrilo-Putze's description of the clinical impact of khat use in Europe. Indeed, cardiovascular complications of khat use have been reported in Europe and more recently in Australia,3; …

Aim The authors evaluated the prevalence and effect of the various tobacco use modalities among patients presenting with acute coronary syndrome (ACS) and compared them with non-tobacco and ex-tobacco users. Methods An analysis of the 2nd Gulf Registry of Acute Coronary Events conducted between October 2008 and June 2009 and which included 7930 consecutive patients hospitalised with ACS was made. Patients initially were divided into non-tobacco users, ex-tobacco users and current tobacco users. Subanalysis according to the tobacco modality used was subsequently made: cigarette, waterpipe or smokeless tobacco users. Results Overall, 2834 (36%) patients were current tobacco users, 306 (3.9%) patients were waterpipe smokers and 240 patients (3%) were oral tobacco users. When compared with non-tobacco and ex-tobacco users, overall current tobacco users were younger, more likely to be male subjects and less likely to have diabetes mellitus, hypertension and dyslipidaemia. Mortality rate (p=0.001) and overall cardiovascular events (p=0.001) were lower among current tobacco users when compared with the other two groups. After adjustment for baseline variables, tobacco use was not an independent predictor of adverse events. Subset analysis demonstrates oral tobacco users and waterpipe smokers were older and more likely to be women when compared with cigarette smokers. Among the various tobacco groups, inhospital mortality rates were significantly higher among the waterpipe smokers when compared with the other two groups. Conclusions Clinical characteristics and outcomes of ACS patients depend on the tobacco modality used. Further studies are required to evaluate the impact of emerging tobacco use modalities on patients with coronary artery disease.

OBJECTIVE: To evaluate the impact of evidence-based cardiac medications (EBMs) on 1-month and 1-year mortality among discharged acute coronary syndrome (ACS) patients in the Middle East. METHODS: Data were analyzed from 7,567 consecutive ACS patients admitted to 66 hospitals in 6 Middle Eastern countries enrolled in the Gulf RACE II in October 2008 to June 2009. Individual EBMs or concurrent use of the EBM combination consists of an anti-platelet therapy, angiotensin-converting enzyme inhibitor (ACEI) (or angiotensin II receptor blocker (ARB)), β-blocker, and a statin at discharge, were evaluated. Analyses were performed using univariate and multivariate statistical techniques. RESULTS: The mean age of the cohort was 56 +/- 12 years with 79% being males. 65% of the patients received the concurrent EBM combination at discharge. Aspirin, clopidogrel, statins, b-blockers and ACEIs/ARBs use was 96%, 71%, 95%, 82% and 81%, respectively. 70% of the patients were prescribed both aspirin and clopidogrel concurrently at discharge. Adjusting for demographic, clinical, revascularization, and country characteristics, the multivariable logistic regression models demonstrated no differences in mortality at both 1-month (3.0 vs. 3.6%; p = 0.828) and 1-year (3.5 vs. 3.5%; p = 0.976) between the concurrent EBM combination users and non-users. CONCLUSION: The majority of the ACS patients in the Middle East were prescribed the guideline recommended EBM combination at discharge. However, potential still remains for further optimization of management. Further studies are required to examine the long term effect of concurrent use of the EBM combination on mortality in the region.

The aim of this study was to evaluate the impact of admission anemia on in-hospital, one-month, and one-year mortality in patients from the Middle East with acute coronary syndrome (ACS).Data were analyzed from 7922 consecutive patients admitted to hospitals throughout six Middle-Eastern countries with the final diagnosis of ACS, as part of Gulf RACE II (Registry of Acute Coronary Events II). Anemia at admission was defined according to the World Health Organization definition (13 g/dL in men and12 g/dL in women). Analyses were conducted using univariate and multivariate statistical techniques.The median age of the cohort was 56 (48-65) years, with the majority being male (79%). Anemia at admission was present in 2241 patients (28%). Patients with anemia were more likely to have in-hospital complications including heart failure, recurrent ischemia, re-infarction, cardiogenic shock, stroke, and major bleed. Even after adjustment, anemia was still associated with mortality at in-hospital (odds ratio [OR]=1.71, 95% confidence interval [CI], 1.34-2.17; P0.001), at one-month (OR=1.34, 95% CI, 1.06-1.71; P=0.016), and at one-year (OR=1.22, 95% CI, 1.01-1.49; P=0.049) post-admission with ACS.Admission anemia in patients with ACS from six Middle-Eastern countries was strongly associated with mortality at in-hospital, one-month, and at one-year. Hence, admission anemia must be considered in the initial risk assessment of ACS patients along with other risk scores.

Background & hypothesis: Data on the clinical characteristics and outcome of patients presenting with acute coronary syndrome (ACS) according to their marital status is not clear. Methods: A total of 5334 patients presenting with ACS in 65 hospitals in 6 Middle East countries in the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2) were studied according to their marital status (5024 married, 100 single, and 210 widowed patients). Result: When compared to married patients, widowed patients were older and more likely to be female. Widowed patients were more likely to have diabetes mellitus, hypertension, history of heart failure, and peripheral vascular disease and were less likely to be tobacco users when compared to the other groups. Widowed patients were also more likely to present with atypical symptoms and have advanced Killip class. Widowed patients were more likely to present with non-ST-elevation myocardial infarction (NSTEMI) when compared to the other 2 groups. Widowed patients were more likely to have heart failure (P = 0.001), cardiogenic shock (P = 0.001), and major bleeding (P = 0.002) when compared to the other groups. No statistically significant difference was observed in regard to duration of hospital stay, door to needle time in STEMI patients, or cardiac arrhythmias between the various groups. Widowed patients had higher in-hospital, 30-day, and 1-year mortality rates (P = 0.001). Marital status was an independent predictor for in-hospital mortality. Conclusion: Widowed marital status was associated with worse cardiovascular risk profile, and worse in-hospital and 1-year outcome. Future work should be focused on whether the provision of psychosocial support will result in improved outcomes among this high-risk group. Clin. Cardiol. 2011 DOI: 10.1002/clc.22034 Gulf RACE is a Gulf Heart Association (GHA) project and was financially supported by the GHA, Sanofi Aventis, and the College of Medicine Research Center at King Khalid University Hospital, King Saud University, and Riyadh, Saudi Arabia. The authors have no other funding, financial relationships, or conflicts of interest to disclose.

Background— The khat plant is a stimulant similar to amphetamine and is thought to induce coronary artery spasm. Khat is widely chewed by individuals originating from the Horn of Africa and the Arabian Peninsula. The aim of this study was to evaluate the clinical characteristics and outcome of khat chewers presenting with acute coronary syndrome. Methods and Results— From October 1, 2008, through June, 30, 2009, 7399 consecutive patients with acute coronary syndrome were enrolled in the Second Gulf Registry of Acute Coronary Events (Gulf RACE-2). Nineteen percent of patients were khat chewers; 81% were not. Khat chewers were older, more often male, and less likely to have cardiovascular risk factors. Khat chewers were less likely to have a history of coronary artery disease and more likely to present late and to have higher heart rate and advanced Killip class on admission. Khat chewers were more likely to present with ST-segment–elevation myocardial infarction. Overall, khat chewers had higher risk of death, recurrent myocardial ischemia, cardiogenic shock, ventricular arrhythmia, and stroke compared with non–khat chewers. After adjustment for baseline variability, khat chewing was found to be an independent risk factor of death and for recurrent ischemia, heart failure, and stroke. Conclusions— Our data confirm earlier observations of worse in-hospital outcome among acute coronary syndrome patients who chew khat. This worse outcome persists up to 1 year from the index event. This observational report underscores the importance of improving education concerning the cardiovascular risks of khat chewing.

BACKGROUND AND OBJECTIVES: Limited data are available on patients with acute coronary syndromes (ACS) and their long-term outcomes in the Arabian Gulf countries. We evaluated the clinical features, management, in-hospital, and long-term outcomes in such a population. DESIGN AND SETTING: A 9-month prospective, multicenter study conducted in 65 hospitals from 6 countries that also included 30 day and 1-year mortality follow-up. PATIENTS AND METHODS: ACS patients included those with ST-elevation myocardial infarction (STEMI) and non–ST-elevation acute coronary syndrome (NSTEACS), including non-STEMI and unstable angina. The registry collected the data prospectively. RESULTS: Between October 2008 and June 2009, 7930 patients were enrolled. The mean age [standard deviation (SD)], 56 (17) years; 78.8% men; 71.2% Gulf citizens; 50.1% with central obesity; and 45.6% with STEMI. A history of diabetes mellitus was present in 39.5%, hypertension in 47.2%, and hyperlipidemia in 32.7%, and 35.7% were current smokers. The median time from symptom onset to hospital arrival for STEMI patients was 178 minutes (interquartile range, 210 minutes); 22.3% had primary percutaneous coronary intervention (PCI) and 65.7% thrombolytic therapy, with 34% receiving therapy within 30 minutes of arrival. Evidence-based medication rates upon hospital discharge were 68% to 95%. The in-hospital PCI was done in 21% and the coronary artery bypass graft surgery in 2.9%. The in-hospital mortality was 4.6%, at 30 days the mortality was 7.2%, and at 1 year after hospital discharge the mortality was 9.4%; 1-year mortality was higher in STEMI (11.5%) than in NSTEACS patients (7.7%; P

Background : Many patients with diabetes do not present for eye examinations, foregoing the recommended management for diabetic eye care. Proactive steps are being taken in Oman to retrieve defaulters (patients who do not present or no-show) with Sight Threatening Diabetic Retinopathy (STDR). We present the outcomes of the defaulter retrieval system in five regions of Oman in 2009. Materials and Methods : Ophthalmologists examine eyes periodically, family physicians focus on primary prevention of Diabetic Retinopathy (DR) and medical retina specialists manage DR in Oman. A person with proliferative stage of DR (PDR) and/or Diabetic Macular Edema (DME) in either eye is considered as STDR and is registered at regional hospitals. The eye care staff identify the defaulters and the hospital staff help them retrieve the defaulters. The reminder of reappointment is sent using the text messages on telephone. The glycemic control of STDR cases was also noted in Nizwa Hospital. Results : We registered 654 STDR cases, of which 494 (75%) were defaulters. Lack of awareness, transport, absence of a decision maker, and fear of laser treatment were the main causes for defaulting. We successfully retrieved 328 (66.4%) defaulters. The retrieval rates among male and female patients were 51.2% and 82%, respectively. The retrieval varied by region. In Nizwa hospital, 114 of 131 STDR cases (85%) had poor glycemic control. Conclusion : Defaulter retrieval system could help healthcare providers to identify and motivate patients with STDR towards better compliance. Primary prevention measures among STDR cases were poor and need further focus.

We assessed the prevalence, predictors, and in-hospital and long-term outcomes of conservative medical management for patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) compared with percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG). This prospective study conducted from October 2008 to June 2009 in 65 hospitals from 6 Arabian Gulf countries included 30-day and 1-year mortality follow-up for 3661 patients. Compared with conservative management group (2859 patients; 78.1%), the PCI group (638; 17.4%) had significantly better unadjusted and adjusted in-hospital (odds ratio [OR]: 0.40, 95% confidence interval [CI]: 0.17-0.97), 30-day (OR: 0.44, 95% CI: 0.24-0.76) and 1-year (OR: 0.58, 95% CI: 0.40-0.87) mortality rates. Comparison with the CABG group (164; 4.5%) yielded similar results with inclusion of patients scheduled for CABG after hospital discharge. Independent predictors of conservative medical management were mainly country of residence and history of prior CABG.

We evaluated the relationship between admission white blood cell (WBC) count and in-hospital outcomes in acute coronary syndrome (ACS) patients from the Middle East. Data were analyzed from 7806 consecutive patients with ACS who were divided into 4 groups (G) according to their WBC count (×109/L; G1

Transplantation from deceased donors is still scarce in Oman, mainly due to family refusal. We conducted a survey to learn the attitudes of the Omani population regarding transplantation. Subjects and Methods Among 500 individuals who were distributed, a questionnaire 304 responded including 247 (81%) Omani and 57 (19%) foreign residents. There were 213 (70%) male respondents of the 304 subjects, 256 individuals (84%) were between 18 and 50 years of age, and 270 (89%) had at least a high school education. Results Thirty-eight percent and 32% of Omani individuals had a family member or a friend with kidney disease or a renal transplantation, respectively. Only 42% of respondents knew that renal transplantation is performed in Oman. It was encouraging to note that 65% of Omanis knew that commercial transplantations are against Islamic and international standards. Sixty-four percent of the respondents stated that they would donate a kidney to a relative with renal failure. Nevertheless, only 49% knew that donation after death is permitted by Islam; 42% respondents would accept a kidney from a deceased person. Only 35% would donate a kidney or an organ after death. We concluded that the awareness of the Omani people toward donation after death is low, with a great need for public education and awareness programs, particularly for high school and university students.

BACKGROUND AND OBJECTIVES: Oman provides comprehensive care for the detection and management of diabetes during pregnancy with the goal of reducing or eliminating adverse outcomes for mothers and newborns. We assessed the outcome of pregnancies complicated with diabetes as compared to healthy controls. SUBJECTS AND METHODS: A 1-year retrospective review of registry records was conducted on pregnant women with gestational diabetes mellitus (GDM) and pre-gestational diabetes mellitus (PGDM). Of the 5394 women registered, 225 had GDM and 56 had PGDM. Fourteen cases of GDM and 2 cases of PGDM were excluded. For each patient recruited, the next healthy control of the same age and parity was selected. RESULTS: Nearly 80% of diabetic women achieved good glycemic control (hemoglobin A1c

We assessed the use and determinants of cardiac catheterization during index admissions, among patients with acute coronary syndrome (ACS) in the Middle East. Data were analyzed from 8150 consecutive ACS patients enrolled prospectively. The overall rate of cardiac catheterization was 20%. Major predictors of cardiac catheterization were university hospitals, hospitals with catheterization facilities, physician type, and Gulf citizenship. High-risk patients were catheterized less compared to low-risk patients; odds ratio (OR) 0.44, 95% confidence interval (CI): 0.33-0.60, P < .001 and OR 0.68, 95% CI: 0.48-0.98, P = .037 for patients with non-ST-elevation ACS and ST-elevation myocardial infarction, respectively. The use of cardiac catheterization in patients with ACS from Middle East is low. It is related more to hospital characteristics than to baseline risks. There is a need to explore ways to increase overall rate of in-hospital cardiac catheterization in the region and direct it to patients who would benefit most.

Objectives: To study the short-term mortality from ST-segment elevation myocardial infarction (STEMI) in the Arabian Gulf region of the Middle East, and to examine whether these geographically and culturally related countries had similar or different outcomes. Subjects and Methods: The Gulf Registry of Acute Coronary Events recruited consecutive acute coronary syndrome patients from six Middle Eastern countries over a 5-month period. Results: Of 6,706 patients recruited, 2,626 (39%) had STEMI, and a total of 165 patients died in hospital, with a crude mortality rate of 6.3%. However, mortality rates varied geographically between 10% in Yemen, 9.6% in Oman and 3.3% in the other countries. The unadjusted odds ratio of mortality for Yemen was 3.2 (95% CI: 2.2–4.7), and 3.1 (95% CI: 1.9–4.8) for Oman, compared to other Gulf countries. Even after adjusting for age and gender, the mortality remained significantly higher, almost double, in Oman and Yemen compared to other countries. This could be understood in the light of significant differences in a number of practice pattern variables such as reperfusion therapy, timely presentation and use of evidence-based medications. Conclusion: We found significant variability in STEMI mortality among Gulf Arab countries and identified areas requiring further efforts to reduce excess mortality in the region.

Objectives ― To identify the characteristics, management and hospital outcomes of acute coronary syndrome (ACS) patients in the Gulf region of the Middle East. Methods and results ― Overall, 8176 consecutive patients with the final diagnosis of ACS were recruited in 6 months, from 64 hospitals in 6 countries. The mean age of patients was 56 years. At presentation, 40% of patients had diabetes and 38% were current smokers. Of 2268 patients eligible for reperfusion, 183 (8%) underwent primary percutaneous coronary intervention, 1856 (82%) received thrombolytic therapy and 219 patients (10%) did not receive any reperfusion. The median door-to-needle time was 45 minutes. The majority of patients received aspirin (96%), beta-blockers (77%), angiotensin-converting enzyme inhibitors (77%) and statins (83%) at discharge. Less than I in 5 patients received coronary angiography (19%). Low-risk patients were more likely to undergo coronary angiography than high-risk patients (odds ratio 1.35, 95% confidence interval 1.15 to 1.58, P

This article examines differences and similarities in adolescent tobacco use among Member States of the Health Ministers' Council for the Gulf Cooperation Council (HMC/GCC) using Global Youth Tobacco Survey (GYTS) data.Nationally representative samples of students in grades associated with ages 13-15 in Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, United Arab Emirates, and Yemen. Schools were selected proportional to enrollment size, classes were randomly selected within participating schools, and all students in selected classes were eligible to participate.GYTS results confirmed that boys are significantly more likely than girls to smoke cigarettes or use shisha (water pipe). Students had higher rates of tobacco use than adults in Bahrain, Oman, and United Arab Emirates. For boys and girls, shisha use was higher than cigarette smoking in almost all countries. Susceptibility to initiate smoking among never smokers was higher than current cigarette smoking in all countries. Exposure to secondhand smoke in public places was greater than 30%, direct protobacco advertising exposure was greater than 70% on billboards and in newspapers, and more than 10% of students were influenced by indirect advertising. Finally, less than half of the students were taught in school about the dangers of tobacco use in the past year.For boys and girls, high prevalence of cigarette smoking, high prevalence of shisha use, and high susceptibility of never smokers to initiate smoking in the next year are troubling indicators for the future of chronic disease and tobacco-related mortality in the Member States of the HMC/GCC.

To identify the characteristics, treatments and hospital outcomes for patients diagnosed with acute coronary syndromes (ACS) in the Gulf area.Prospective, multinational, multicentre, observational survey of consecutive ACS patients who were admitted to 65 hospitals during May 2006.A total of 1484 ACS patients were recruited. The mean age was 55 years, and 76% were men. The final discharge diagnosis was ST-segment elevation myocardial infarction (STEMI) in 37%, non-ST-segment elevation myocardial infarction (NSTEMI) in 32%, left bundle branch block myocardial infarction (LBBB MI) in 2%, and unstable angina in 29%. Among patients with STEMI and LBBB MI, the reperfusion rate was 65%, with use of primary percutaneous coronary intervention in 7% and thrombolytic therapy in 93%. When thrombolytic therapy was used, the median door to needle time was 45 minutes, with 37% receiving it within 30 minutes of hospital presentation. During the first day of hospitalization, aspirin was administered to 94%, clopidogrel to 51%, and beta blockers to 65%. Angiotensin converting enzyme inhibitors/Angiotensin receptor blockers and statins were used in 62% and 82%, respectively. Coronary angiography during hospitalization was performed in 21%. In-hospital mortality was 3%.We were able to determine the characteristics, treatments and in-hospital outcomes of patients hospitalized with ACS in our region. There is room for improvement in using medications, reducing needle to door time and utilizing more cardiac catheterization services.

BackgroundThere are no data on optimal cut-off points to classify obesity among Omani Arabs. The existing cut-off points were obtained from studies of European populations.ObjectiveTo determine gender-specific optimal cut-off points for body mass index (BMI), waist circumference (WC) and waist-to-hip ratio (WHR) associated with elevated prevalent cardiovascular disease (CVD) risk among Omani Arabs.DesignA community-based cross-sectional study.SettingThe survey was conducted in the city of Nizwa in Oman in 2001.Subjects and methodsThe study contained a probabilistic random sample of 1421 adults aged ≥20 years. Prevalent CVD risk was defined as the presence of at least two of the following three risk factors: hyperglycaemia, hypertension and dyslipidaemia. Logistic regression and receiver-operating characteristic (ROC) curve analyses were used to determine optimal cut-off points for BMI, WC and WHR in relation to the area under the curve (AUC), sensitivity and specificity.ResultsOver 87% of Omanis had at least one CVD risk factor (38% had hyperglycaemia, 19% hypertension and 34.5% had high total cholesterol). All three indices including BMI (AUC = 0.766), WC (AUC = 0.772) and WHR (AUC = 0.767) predicted prevalent CVD risk factors equally well. The optimal cut-off points for men and women respectively were 23.2 and 26.8 kg m−2for BMI, 80.0 and 84.5 cm for WC, and 0.91 and 0.91 for WHR.ConclusionsTo identify Omani subjects of Arab ethnicity at high risk of CVD, cut-off points lower than currently recommended for BMI, WC and WHR are needed for men while higher cut-off points are suggested for women.

Diabetes mellitus (DM) is a major public health problem in Oman. We evaluated the impact of the revised diagnostic criteria for DM adopted by the American Diabetes Association (ADA) on the prevalence of diabetes and impaired glucose tolerance (IGT), and on the classification of individuals among the Omani population.We used the dataset of the National Diabetes Survey, conducted in 1991 and involving 4682 subjects who did not have any missing data on fasting and 2-hour glucose. The subjects comprised 2002 males and 2680 females aged 20 years or above. Data were analyzed using the ADA criteria (diabetes as fasting plasma glucose [FPG]or =7 mmol/L, impaired fasting glucose [IFG] as FPGor =6.1 mmol/L and7 mmol/L), and compared these with the World Health Organization (WHO) criteria (diabetes as FPGor =7.8 mmol/L and/or 2-hour post-glucose loador =11.1 mmol/L, IGT as FPG7.8 mmol/L, and 2-hour post-load 7.8-11.1 mmol/L).Applying the ADA criteria on the Omani population resulted in an overall reduction of diabetes prevalence by 2.2% (95% confidence interval [CI] 1.6% to 2.8%), and a 4.8% reduction of IGT (95% CI 3.8% to 5.8%). Over 29% of diabetics classified by the WHO criteria were reclassified as being normal or having IFG by the ADA criteria. Around 3.6% of those who were normoglycemic by the WHO criteria were classified as having diabetes or IFG by the ADA criteria. In all but one region of Oman, the prevalence of diabetes and IFG using the ADA criteria was lower compared to the prevalence using the WHO criteria. Gender, age and body mass index did not seem to pose an increased risk to the probability of being diagnosed by one criteria or the other or both together.The adoption of the ADA criteria in Oman will significantly reduce the prevalence of diabetes and IGT. In addition, the glycemic status of a substantial number of individuals will be changed from normal to either being diabetic or having IGT.

We used Oman's 1991 National Diabetes Survey data (n=4881) to develop a simple diabetes risk score for identification of individuals at high risk of having diabetes mellitus. The logistic regression model used included age, waist circumference, body mass index, family history of diabetes and hypertension status at the time of the survey for individuals aged > or =20 years. The validity of the model was assessed in another cohort (2001 Nizwa study n=1432). On applying this model to both cohorts, the area under the receiver-operating characteristic curve was 0.83 (95% confidence interval (CI) 0.82-0.84) for the 1991 cohort and 0.76 (95%CI 0.74-0.79) for the 2001 cohort. The Risk Score of >10 was depicted as the optimal cut-point to predict diabetes diagnosed by serum glucose > or =11.1 mmol/L 2-h post 75 g oral glucose load. This score had a sensitivity of 78.6 and 62.8% and specificity of 73.4 and 78.2% in the two cohorts, respectively. Test of the Thai, Dutch, Finnish and Danish diabetes risk scores showed poor performance of these models among Omani Arabs. In comparison, the self-administered diabetes risk score of Oman could identify most individuals at high risk of having type 2 diabetes in community-based settings in Oman.

BackgroundThe prevalence of type 2 diabetes in Oman is high and appears to be rising. Rising rates of diabetes and associated risk factors have been observed in populations undergoing epidemiological transition and urbanization. A previous study in Oman indicated that urban-dwellers were not significantly more likely to have diabetes. This study was undertaken to determine if a more accurate urban and rural categorization would reveal different findings.MethodsThis study included 7179 individuals aged 20 years or above who participated in a cross-sectional interviewer-administered survey in Oman including blood and anthropomorphic tests. Multiple logistic regression analyses were conducted to analyze the factors associated with diabetes, first in the whole population and then stratified according to region.ResultsThe prevalence of diabetes (fasting blood glucose ≥ 7 mmol/l) in the capital region of Muscat was 17.7% compared to 10.5% in rural areas. The prevalence of self-reported diabetes was 4.3%. Urban residence was significantly associated with diabetes (adjusted odds ratio (OR) = 1.7, 95% confidence interval (CI): 1.4–2.1), as was age (OR = 1.2, 95% CI: 1.1- 1.2), obesity (abnormal waist circumference) (OR = 1.8, 95% CI: 1.5–2.1), and systolic blood pressure (SBP) 120–139 (OR = 1.4, 95% CI:1.04–1.8), SBP 140–159 (OR = 1.9, 95% CI: 1.4–2.6), SBP ≥ 160 (OR = 1.7, 95% CI: 1.2–2.5). Stratified analyses revealed higher education was associated with reduced likelihood of diabetes in rural areas (OR = 0.6, 95% CI: 0.4–0.9).ConclusionA high prevalence of diabetes, obesity, hypertension and high cholesterol exist in the Omani population, particularly among urban-dwellers and older individuals. It is vital to continue monitoring chronic disease in Oman and to direct public health policy towards preventing an epidemic.

To describe the epidemiology of retinoblastoma (RB) in Omani children.The National Cancer Registry, hospital records, and treatment abroad registers were reviewed to identify the characteristics of Omani children diagnosed with RB between 1990 and 2002.Twenty-nine children (12 male and 17 female) were diagnosed with RB. The age-adjusted incidence was 4.04/million/year in children15 years and 8.33/million/year in children5 years. The mean age at diagnosis was 32.2 months (33.8 months for unilateral RB and 13.2 months for bilateral RB). 75% had unilateral tumors and 25% had bilateral tumors. The five-year survival rate for RB was 89%. None of the patients had a family history of RB.The incidence of RB in Oman is at par with other countries. A definite female preponderance exists in the Omani population. The proportion of unilateral RB cases is unusually high among Omani children. The five-year survival rate is almost at par with that reported in the West. Genetic studies and further longitudinal studies of surviving RB cases could further enhance the knowledge of the epidemiology of RB in Oman.

OBJECTIVE—To estimate the prevalence of the metabolic syndrome by age and sex in the Omani population as defined by the third report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III [ATP III]) of North America. RESEARCH DESIGN AND METHODS—We analyzed data from a cross-sectional survey conducted in 2001 containing a probability random sample of 1,419 Omani adults aged ≥20 years living in the city of Nizwa. The metabolic syndrome, defined by the ATP III, was defined as having three or more of the following abnormalities: waist circumference >102 cm in men and >88 cm in women, serum triglycerides ≥150 mg/dl (1.69 mmol/l), HDL cholesterol RESULTS—The age-adjusted prevalence of the metabolic syndrome was 21.0%. The crude prevalence was slightly lower (17.0%). The age-adjusted prevalence was 19.5% among men and 23.0% among women (P = 0.236). Low HDL cholesterol was the most common component (75.4%) of the metabolic syndrome among the study population followed by abdominal obesity (24.6%). Abdominal obesity was markedly higher in women (44.3%) than in men (4.7%). CONCLUSIONS—The prevalence of the metabolic syndrome in Oman is similar to that in developed countries. Future prevention and control strategies should not overlook the importance of noncommunicable disease risk factors in rapidly developing countries.

Little is known about the effect of female gender on cardiac arrhythmias in patients with acute coronary syndromes (ACS). Accordingly, we sought to assess the effect of gender on the incidence and in-hospital mortality of patients with clinically significant arrhythmias (CSA) in a multicenter

Traditionally, tricuspid valve endocarditis is uncommon in the Middle East region. However, recent global data indicate growing trends in the use of illicit drug abuse, specifically injectable heroin, in the Middle East Gulf region. The presence of many transit port services in the Middle East Gulf States has led to smuggling of substance abuse drugs in the region. The Middle East Gulf States, currently a transit market, are also becoming a growing consumer market in view of the increased substance abuse in the youth. However, there is a paucity of data with respect to the prevalence or incidence of tricuspid valve endocarditis in the region, probably due to underdiagnosis or underreporting. A high index of suspicion of tricuspid valve endocarditis is essential in patients with a history of intravenous drug abuse. This article reviews the epidemiology of illicit drug abuse in the Middle East Gulf region, as well as the diagnosis and treatment of tricuspid valve endocarditis, and calls for all physicians in the region to be vigilant while dealing with intravenous drug abuse.

Objective: Little is known about thrombolytic therapy patterns in patients with ST-elevation myocardial infarction (STEMI) in the Middle East. The objective of this study was to evaluate the clinical profile and mortality of STEMI patients who arrived in hospital within 12 hours from pain onset and received thrombolytic therapy. Patients and Methods: This was a prospective, multinational, multi-centre, observational survey of consecutive acute coronary syndrome patients admitted to 65 hospitals in six Middle Eastern countries during the period between October 2008 and June 2009, as part of Gulf RACE-II (Registry of Acute Coronary Events). Analyses were performed using univariate statistics. Results: Out of 2,465 STEMI patients, 66% (n = 1,586) were thrombolysed with namely: streptokinase (43%), reteplase (44%), tenecteplase (10%), and alteplase (3%). 22.7% received no reperfusion. Median age of the study cohort was 50 (45-59) years with majority being males (91%). The overall median symptom onset-to-presentation and door-to-needle times were 165 (95- 272) minutes and 38 (24-60) minutes, respectively. Generally, patients presenting with higher GRACE risk scores were treated with newer thrombolytic agents (reteplase and tenecteplase) (P < 0.001). The use of newer thrombolytic agents was associated with a significantly lower mortality at both 1-month (0.8% vs. 1.7% vs. 4.2%; P = 0.014) and 1-year (0% vs. 1.7% vs. 3.4%; P = 0.044) compared to streptokinase use. Conclusions: Majority of STEMI patients from the Middle East were thrombolysed with streptokinase and reteplase in equal numbers. Nearly one-fifth of patients did not receive any reperfusion therapy. There was inappropriately long symptom-onset to hospital presentation as well as door-to-needle times. Use of newer thrombolytic agents in high risk patients was appropriate. Newer thrombolytic agents were associated with significantly lower mortality at 1-month and 1-year compared to the older agent, streptokinase.