Middle East Gulf Region Research Articles

Trends and findings of lipoprotein(a) testing and associated cardiovascular disease profiles: a large single-center study from the Middle East-Gulf region.

Lipoprotein(a) [Lp(a)] is a genetically determined risk factor for atherosclerotic cardiovascular disease (CVD). Limited data are available on Lp(a) testing from the Middle-East region. Therefore, we aim to evaluate the utilization and yield of Lp(a) testing over time and characterize CVD profiles of patients with abnormal Lp(a) tasting at a single-quaternary-care center in the United Arab Emirates. Unique Lp(a) tests conducted between 07/2017 and 10-2023 were included. Overtime trends in Lp(a) test utilization and abnormal Lp(a) [defined as Lp(a) > 125 nmol/L] test findings were described. CVD rates in patients with abnormal Lp(a) were compared to those with Lp(a) ≤ 125 nmol/L using appropriate methods. In our center, 0.95% of the patients (n = 5,677) had their Lp(a) measured, with a median level of 32 [11-82] nmol/L. Lp(a) was abnormal in 15.9% of the tests. Over the years 2018-2022, there was a 109% increase in Lp(a) testing, with concomitant up-trends in findings of abnormal Lp(a) (11.8% to 16.4%, P = 0.02). Compared to patients with Lp(a) ≤ 125 nmol/I, those with abnormal Lp(a) had higher rates of any prevalent CVD (34% vs. 25.1%, P < 0.001), CAD (25.6% vs. 17.7%, P < 0.001), HF (6.5% vs. 3.8%, P < 0.001), and stroke (7.1% vs. 4.4%, P < 0.001). Almost one in six patients tested for Lp(a) had abnormally elevated Lp(a), and CVD was prevalent in one-third of the patients who tested abnormal for Lp(a). The study highlights the growing awareness of the relevance of Lp(a) for CVD risk stratification and prevention.

Survival To Discharge Among Cardiogenic Shock Patients Supported By VA-ECMO: An Insight From The Largest VA-ECMO Experience In The Middle East-Gulf Region

Survival To Discharge Among Cardiogenic Shock Patients Supported By VA-ECMO: An Insight From The Largest VA-ECMO Experience In The Middle East-Gulf Region

1197. Pharmacist-assisted urine culture review and antimicrobial stewardship interventions in the emergency department: A study from the Middle East Gulf region

Abstract Background Urinary tract infection (UTI) is one of the most frequent reasons encountered for emergency department (ED) visits. The treatment of asymptomatic bacteriuria (ASB) is identified as one of the causes of inappropriate antimicrobial use. We designed the study to evaluate and improve the prescribing practices for UTIs in Cleveland Clinic Abu Dhabi ED. To our knowledge, this is one of the first studies in the Middle East Gulf region which evaluated the impact of pharmacist-assisted urine culture review in the ED. Methods A pre-post quasi-experimental study was conducted between September 2021 and July 2022 with a 4-month pre-intervention phase, a 3- month wash-out period, and a 4-month post-intervention phase. The pharmacist-assisted antimicrobial stewardship interventions included distinguishing between UTI and ASB, proper screening through diagnostic stewardship, and rationalizing the need to order urine cultures. The major interventions included appropriate antimicrobial therapy, dosing, frequency, and duration of therapy in compliance with the hospital guidelines. All patients with a negative urine culture, aged ≤ 18 years, or requiring inpatient admission during the same ED visit were excluded from the study. Data were analyzed using Fisher’s exact test. Results Three hundred and seventy ED patients were included in the study. Thirty percent of the urine cultures were ordered for patients without urinary signs and symptoms. Escherichia coli was the predominant urinary isolate in our study from both groups, followed by Klebsiella species and Streptococcus agalactiae. Antimicrobials were prescribed for asymptomatic bacteriuria in 5.2 % of patients in the post-intervention group and 21.8 % in the pre-intervention group (P = 0.0001). Readmission to ED for the same complaints within 30 days of the ED visit occurred in 9.8 % of patients in the post-intervention group and 13.2 % in the pre-intervention group (P = 0.3337). All study findings are presented in the tables.Table 1:Characteristics of the pre-and post-intervention groupTable 2:Treatment and outcome of the pre-and post-intervention groupTable 3:Impact of pharmacist-assisted urine culture review in the emergency department Conclusion Our study observed higher rates of appropriate culture-direct antimicrobial therapy after implementing the pharmacist-assisted urine culture review and positively impacted clinical outcomes. Additionally, there was a significant reduction in treating asymptomatic bacteriuria. Disclosures All Authors: No reported disclosures

Anticoagulation practices and complications associated with Impella® support at an advanced cardiac center in the Middle East gulf region.

Anticoagulation during Impella® support is a challenge due to its complications and inconsistent practice across the globe. This observational, retrospective chart review included all patients with Impella® support at our advanced cardiac center at a quaternary care hospital in the Middle East gulf region. The study was conducted over six years (2016-2022), a time period during which manufacturer recommendations for purge solution, anticoagulation protocols as well as Impella® place in therapy and utilization were all evolving. We aimed to evaluate the efficacy of different anticoagulation practices and association with complications and outcomes. Forty-one patients underwent Impella® during the study period, including 25 patients with support for more than 12h, and are the focus of our analysis. Cardiogenic shock (n = 25, 60.9%) was the primary indication for Impella®, followed by facilitating high-risk PCI (n = 15, 36.7%) and left ventricular afterload reduction in patients undergoing veno-arterial extracorporeal membrane oxygenation (n = 1, 2.4%). Our overall Impella® usage evolved over the years from a primary use to facilitate a high-risk PCI to the recent more common use of LV unloading in cardiogenic shock. No patients experienced device malfunction and the incidence of other complications including ischemic stroke and bleeding were comparable to those reported in the literature (12.2% and 24% respectively). The 30-day all-cause mortality of 41 patients was 53.6%. In line with the evolving recommendations and evidence, we observed an underutilization of non-heparin-based purge solutions and inconsistent management of anticoagulation in the setting of both Impella® and VA ECMO which necessitates more education and protocols.

The "obesity paradox" in patients with atrial fibrillation: Insights from the Gulf SAFE registry.

The prognostic impact of obesity on patients with atrial fibrillation (AF) remains under-evaluated and controversial. Patients with AF from the Gulf Survey of Atrial Fibrillation Events (Gulf SAFE) registry were included, who were recruited from six countries in the Middle East Gulf region and followed for 12 months. A multivariable model was established to investigate the association of obesity with clinical outcomes, including stroke or systemic embolism (SE), bleeding, admission for heart failure (HF) or AF, all-cause mortality, and a composite outcome. Restricted cubic splines were depicted to illustrate the relationship between body mass index (BMI) and outcomes. Sensitivity analysis was also conducted. A total of 1,804 patients with AF and recorded BMI entered the final analysis (mean age 56.2 ± 16.1 years, 47.0% female); 559 (31.0%) were obese (BMI over 30 kg/m2). In multivariable analysis, obesity was associated with reduced risks of stroke/systematic embolism [adjusted odds ratio (aOR) 0.40, 95% confidence interval (CI), 0.18-0.89], bleeding [aOR 0.44, 95%CI, 0.26-0.74], HF admission (aOR 0.61, 95%CI, 0.41-0.90) and the composite outcome (aOR 0.65, 95%CI, 0.50-0.84). As a continuous variable, higher BMI was associated with lower risks for stroke/SE, bleeding, HF admission, all-cause mortality, and the composite outcome as demonstrated by the accumulated incidence of events and restricted cubic splines. This "protective effect" of obesity was more prominent in some subgroups of patients. Among patients with AF, obesity and higher BMI were associated with a more favorable prognosis in the Gulf SAFE registry. The underlying mechanisms for this obesity "paradox" merit further exploration.

Abstract 14045: Implementation of High-Sensitivity Cardiac Troponin Assay in Emergency Department Increases Myocardial Infarction Diagnosis and Utilization of Invasive Cardiac Procedures: An Insight From Middle East/ Gulf Region

Introduction: Utilization of high-sensitivity cardiac troponin T (hsT) assays facilitates evaluation of patients with suspected acute coronary syndrome in emergency department (ED) by expediting clinical-decision making and disposition. While the utility of (hsT) has been previously shown, data from the Middle East/ Gulf region (MEG) are limited. We aimed to evaluate the association between hsT implementation and changes in resource use at a tertiary care center in MEG. Methods: Consecutive patients evaluated in ED using hsT (hsT era) or conventional troponin assays (pre-hsT era) were identified. Discharge diagnosis of myocardial infarction (MI), utilization of invasive and non-invasive testing (cardiac CT, perfusion imaging and stress echocardiography) during index admission was determined using ICD codes. Unadjusted rates of these outcomes in addition to in-hospital mortality were compared before and after adoption of hsT assays using appropriate tests. Results: Among 21,149 and 18,979 ED encounters before and after implementation hsT, mean patient age was 53.8 ± 18.1 and 53.3 ±17.8, (P=.09), respectively. The introduction of hsT assay was associated with a 23% increase in MI diagnosis (3.7% vs 3.0%; P&lt;.001), 13% increase in invasive angiography use (4.4% vs. 3.9%; P=.02), and a concomitant 70% reduction in use of non-invasive studies (0.02% vs. 0.07%; P=.02). Additionally, mortality during index admission was significantly higher in the hsT era (1.3% vs. 1.1%; P=.01). Conclusion: Introduction of hsT assay at a single-center in MEG increased MI diagnosis and identified patients who are at increased risk of death. Furthermore, it was associated with greater use of invasive cardiac procedures. Whether more aggressive management during index hospitalization in this population is associated with favorable long-term outcomes requires additional studies.

Patient Characteristics Of Heart Failure With Improved Ejection Fraction (HFimpEF) Following Treatment With Sacubitril/Valsartan: A Real-world Experience From The Middle East

Introduction With the contemporary role of sacubitril/valsartan (Sac-Val) in improving mortality, heart failure (HF) hospitalization, and positive remodeling, left ventricular recovery can be variable. There remains a need to understand patients who have been recently defined as heart failure with improved ejection fraction (HFimpEF). Aims In patients who have been treated with Sac-Val, we aim to describe patient characteristics in those who became HFimpEF vs. those who had persistent HFrEF in our newly established heart failure program in the Middle East-Gulf Region. Methods A total of 131 HFrEF (ejection fraction (EF) of ≤40%) patients were included in this study, who were started on Sac-Val, in addition to GDMT were followed up in our HF outpatient clinic between March 2016 to December 2019. We compared patients who had persistent HFrEF vs. those who became HFimpEF at 12 months follow-up, incorporating the latest universal definition of HFimpEF (symptomatic HF with a baseline EF ≤40% with a ≥ 10-point increase from baseline EF and a second measurement of LVEF > 40%). The comparison was made using appropriate testing methods, and a p-value <0.05 was considered statistically significant. Results After a follow-up of 12 months, 27.5% of patients became HFimpEF, while the others had persistent HFrEF (Table). Although there was no difference in baseline EF between the persistent HFrEF and HFimpEF group (27.2 ± 7.7 vs. 26.6 ± 7.8, p=0.6), patients in HFimpEF developed a significant higher EF at 12 months follow-up (48.6 ±7.2 vs. 28.7± 8.7, p<0.001). The proportions of patients with NYHA class ≥ 2 were comparable at baseline. However, patients in the HFimpEF group had a significantly lower proportion of patients with NYHA class ≥ 2 at follow-up (2.8% vs. 21%, p=0.01). Patients in the HFimpEF group were younger (50.9 ±15 vs. 59.2 ±14.3, p=0.004), tended to have lower baseline creatinine (0.86 ± 0.3 vs. 1 ± 0.4, p=0.08), and were less likely to be hypertensive (58.3% vs.79%, p=0.02), or Ischemic (25% vs. 63.2, p<0.001). Conclusion : Among patients who were treated with Sac-Val, the HFimpEF group had significantly higher EF and improved NYHA class at follow-up. Those who had persistent HFrEF were older with more cardiovascular co-morbidities. This analysis sheds light on future endeavors to better characterize HFimpEF patients. With the contemporary role of sacubitril/valsartan (Sac-Val) in improving mortality, heart failure (HF) hospitalization, and positive remodeling, left ventricular recovery can be variable. There remains a need to understand patients who have been recently defined as heart failure with improved ejection fraction (HFimpEF). In patients who have been treated with Sac-Val, we aim to describe patient characteristics in those who became HFimpEF vs. those who had persistent HFrEF in our newly established heart failure program in the Middle East-Gulf Region. A total of 131 HFrEF (ejection fraction (EF) of ≤40%) patients were included in this study, who were started on Sac-Val, in addition to GDMT were followed up in our HF outpatient clinic between March 2016 to December 2019. We compared patients who had persistent HFrEF vs. those who became HFimpEF at 12 months follow-up, incorporating the latest universal definition of HFimpEF (symptomatic HF with a baseline EF ≤40% with a ≥ 10-point increase from baseline EF and a second measurement of LVEF > 40%). The comparison was made using appropriate testing methods, and a p-value <0.05 was considered statistically significant. After a follow-up of 12 months, 27.5% of patients became HFimpEF, while the others had persistent HFrEF (Table). Although there was no difference in baseline EF between the persistent HFrEF and HFimpEF group (27.2 ± 7.7 vs. 26.6 ± 7.8, p=0.6), patients in HFimpEF developed a significant higher EF at 12 months follow-up (48.6 ±7.2 vs. 28.7± 8.7, p<0.001). The proportions of patients with NYHA class ≥ 2 were comparable at baseline. However, patients in the HFimpEF group had a significantly lower proportion of patients with NYHA class ≥ 2 at follow-up (2.8% vs. 21%, p=0.01). Patients in the HFimpEF group were younger (50.9 ±15 vs. 59.2 ±14.3, p=0.004), tended to have lower baseline creatinine (0.86 ± 0.3 vs. 1 ± 0.4, p=0.08), and were less likely to be hypertensive (58.3% vs.79%, p=0.02), or Ischemic (25% vs. 63.2, p<0.001). : Among patients who were treated with Sac-Val, the HFimpEF group had significantly higher EF and improved NYHA class at follow-up. Those who had persistent HFrEF were older with more cardiovascular co-morbidities. This analysis sheds light on future endeavors to better characterize HFimpEF patients.

Heart Failure Clinic No-show Rates And Effect On Heart Failure Hospitalizations: A Real-World Experience From The Middle East

<h3>Introduction</h3> Adherence to scheduled appointments in heart failure (HF) patients remains an important factor for optimum HF management. Recognizing patterns of adherence to appointments will provide insight and help to improve compliance in attending future HF clinics. <h3>Aim</h3> We aim to describe the frequency and characteristics of no-show appointments in relation to patient demographics and distance traveled, and evaluate the effect on HF hospitalizations in our newly established advanced HF program in the Middle East-Gulf Region. <h3>Methods</h3> A total of 230 patients who have been followed up in our HF clinic were included. Retrospective chart review was used to collect data on patients' demographics and adherence to appointments. Based on the average no-show rate, a head-to-head comparison was conducted using appropriate testing methods between those who were adherent (no-show rate ≤10%) vs. non-adherent (no-show rate >10%) patients. The comparison included the 12 months HF-admissions as well. <h3>Results</h3> A total of 1667 appointments were scheduled and confirmed. Patients did not show in 199 (11.9%) of the appointments, but attended an average of 6.5± 2 appointments during 12 months follow-up. Wednesday and Monday clinic appointments were more likely to be missed (32.6% and 24.1%, respectively). Afternoon appointments represented 57.8% of all missed appointments. Non-convenient appointment was the most documented reason for not showing (29.4%, Table.1). When comparing the adherent vs. the non-adherent group, (Table.2). Travel distance was similar in both groups. Males and smokers were more predominant in the non-adherent group (p=0.02 and p=0.02, respectively). The adherent group had a total of 35 HF hospitalizations compared to the non-adherent group who had a total of 42 HF hospitalizations (p=0.15). <h3>Conclusion</h3> This study explores important real-world data and adds to the available evidence on HF patient adherence. Highlighting key patient characteristics, including distance traveled to specialized HF programs increases our understanding and helps formulate future strategic planning to predict and reduce the impact of patient no-show rates and future HF hospitalizations.

Impact of Big 5 Personality &amp; Intelligence on Transformational Leadership Process and Managerial Performance: A Case of the Middle East Gulf Region

The objective of this study was to investigate the impact of emotional intelligence (EI) and the Big Five personality traits on the attainment of success in leadership positions within hospital administration. The researchers predicted the association between emotional intelligence (EI) and neuroticism, anticipating a negative link. Additionally, they projected a positive relationship between EI and the Big Five personality traits, specifically openness to experience, agreeableness, openness to new ideas, and extraversion. The primary objective of this study is to fill a void in the existing body of research by examining the relationship between personality, emotional intelligence (EI), and leadership effectiveness and performance. Our results indicate that the association between individual differences, leadership, and performance exist. This study did not examine the firm’s performance metrics, but the disturbances’ absorption of measurement errors in the endogenous regressors, which are independent of the exogenous, and minimize coefficient estimate biasesas as held by (Antonakakis et al., 2020). Individual predictors had a low to moderate effect on variation, but their aggregate influence accounted for 56% of transformational leadership variance and 26% of management leadership effectiveness variance. Our study supported merits consideration due to the implementation of controls such as age and managerial experience, the utilization of a longitudinal measure of effectiveness, and the mitigation of common method variance through the use of measures from different sources for predictors and criteria.

Abstract 16240: Knowledge of Clinical Presentation and Diagnostic Pathways for Cardiac Amyloidosis Among Physicians in the Middle East-Gulf Region: on Behalf of the Gulf Cardiac Amyloidosis Working Group

Background: There is a growing interest in raising awareness about amyloidosis as an under-recognized cause of heart failure and preserved ejection fraction (HFpEF). Recently, the prevalence of cardiac amyloidosis in the United States has increased, which may partly be attributed to initiatives from major professional societies aimed to improve patient identification and disease detection. Whether this has also impacted physicians’ knowledge about cardiac amyloidosis in the Middle East-Gulf region is unknown but critical to assess, as it would identify a need for dedicated regional educational activities. Methods: Physicians practicing in 5 Gulf countries (UAE, Bahrain, Qatar, Oman and Kuwait) were invited to participate in this anonymous, online survey by receiving a unique survey link by email. We assessed awareness of cardiac amyloidosis, knowledge of disease manifestations and approach to diagnosis. Responses to the survey were recorded using a 4- or 5-point Likert scale. Results: A total of 272 physicians participated in the survey. Most participating physicians were men (82%) and have been practicing cardiology (71%) for &gt;10 years (65%). Whereas 83% of responders considered themselves to be somewhat or extremely familiar with signs and symptoms of cardiac amyloidosis, only 63% would consider cardiac amyloidosis as a cause of HFpEF, 59% would consider it in patients with heart failure and orthostatic hypotension while only 39% consider cardiac amyloidosis in patients with low-flow, low-gradient severe aortic stenosis. Furthermore, cardiac MRI was found to be useful for diagnosis of cardiac amyloidosis by 92% of responders, while echocardiography, cardiac scintigraphy with bone-seeking radiotracers and biomarkers were felt to be useful by only 81%, 60% and 31% of survey participants, respectively. Conclusion: Despite perceived familiarity with cardiac amyloidosis among a group of mid-career cardiologists, there is need to raise awareness about the heterogenous manifestations of the disease and about the respective roles of testing modalities in making this diagnosis.

Thrombotic events following tocilizumab therapy in critically ill COVID-19 patients: a Fa\xe7ade for prognostic markers

BackgroundHospitals in the Middle East Gulf region have experienced an influx of COVID-19 patients to their medical wards and intensive care units. The hypercoagulability of these patients has been widely reported on a global scale. However, many of the experimental treatments used to manage the various complications of COVID-19 have not been widely studied in this context. The effect of the current treatment protocols on patients’ diagnostic and prognostic biomarkers may thus impact the validity of the algorithms adopted.Case presentationIn this case series, we report four cases of venous thromboembolism and 1 case of arterial thrombotic event, in patients treated with standard or intensified prophylactic doses of unfractionated heparin or low molecular weight heparin at our institution. Tocilizumab has been utilized as an add-on therapy to the standard of care to treat patients with SARS-CoV-2 associated acute respiratory distress syndrome, in order to dampen the hyperinflammatory response. It is imperative to be aware that this drug may be masking the inflammatory markers (e.g. IL6, CRP, fibrinogen, and ferritin), without reducing the risk of thrombotic events in this population, creating instead a façade of an improved prognostic outcome. However, the D-dimer levels remained prognostically reliable in these cases, as they were not affected by the drug and continued to be at the highest level until event occurrence.ConclusionsIn the setting of tocilizumab therapy, traditional prognostic markers of worsening infection and inflammation, and thus potential risk of acute thrombosis, should be weighed carefully as they may not be reliable for prognosis and may create a façade of an improved prognostic outcome instead. Additionally, the fact that thrombotic events continued to be observed despite decrease in inflammatory markers and the proactive anticoagulative approach adopted, raises more questions about the coagulative mechanisms at play in COVID-19, and the appropriate management strategy.

Appropriateness of the Direct Oral Anticoagulants Dosing in the Middle East Gulf Region.

Direct oral anticoagulants (DOACs) have proven efficacy to prevent cardioembolic strokes. Data are scarce about the appropriateness of DOAC dosing in the Middle East. We investigated the prevalence of inappropriate DOAC dosing in the region. A cross-sectional study was conducted at our hospital between April 2015 and February 2019 of patients receiving 1 of the 3 available DOACs. Patients with incomplete data sets, those prescribed DOACs for indications other than atrial fibrillation, on DOACs for <30 days, and dialysis patients were excluded. A total of 608 met the inclusion criteria. The mean age was 65.2 ± 13.9 years, and most were men (58.6%). The mean CHA2DS2-VASc score was 3.8 ± 2.0. There were 346 (56.9%) on apixaban, 123 (20.2%) on dabigatran, and 139 (22.9%) on rivaroxaban. The logistic regression model showed that for the 3 agents together, age, eGFR, major bleeding history, and history of prior stroke were significantly associated with the decision to inappropriately underdose (P < 0.05). Fifteen patients had an ischemic stroke after apixaban initiation (5 underdosed and 3 overdosed). Among patients with at least one follow-up encounter, major bleeding occurred in 13 patients (11.7%) with inappropriate dosing compared with 29 patients (6.0%) with appropriate dosing (P = 0.04). Ischemic stroke occurred in 11 patients (9.9%) with inappropriate dosing compared with 15 patients (3.1%) with appropriate dosing (P < 0.01). We concluded that inappropriate DOAC underdosing is common in our region, particularly with apixaban and rivaroxaban. It is associated with increased risk of stroke and bleeding. More education targeting prescribers is needed to encourage adherence to standard dosing criteria.

Establishing the first pharmacist‐led heart failure medication optimization clinic in the Middle East Gulf Region

AbstractBackgroundHeart failure (HF) patients derive a dose‐dependent clinical benefit from medications that are part of guideline‐directed medical therapy (GDMT). The widespread underdosing of these medications and the clinical implications of the lack of titration have been well documented. There is paucity of data on design and outcomes of pharmacist‐led HF clinics.AimThe aim of this study is to describe the establishment of the first pharmacist‐led HF pharmacotherapy clinic (HFPC) in the Middle East gulf region.MethodsThis is a retrospective study of patients seen by the HF pharmacotherapy clinic. We determined the percentage of patients on target doses of GDMT at baseline and at the end of follow‐up in the subgroup of patients with HF with reduced ejection fraction (HFrEF). All baseline self‐care behaviors and interventions performed were examined.ResultsThe first 100 patient referrals and 193 visits were included in this analysis for an average of 1.9 ± 1.4 visits per patient and a mean follow‐up period of 51 ± 36.1 days. Most patients (94%) had HFrEF and were referred to from the outpatient clinics (72%). Many patients (76%) had at least one inadequacy in medication adherence or self‐care behaviors at baseline, and none were on simultaneous target doses of all GDMTs. At the end of follow‐up, more patients with HFrEF were on target doses when compared with baseline (beta‐blockers 31.9% vs 40.4%, P = .032, angiotensin‐converting enzyme inhibitor/angiotensin II receptor blocker/angiotensin II receptor blocker neprilysin inhibitor 7.4% vs 25.5%, P &lt; .001, mineralocorticoid receptor antagonist 37.2% vs 39.4% P = .46, all three target GDMTs 0% vs 6.4%, P = .093). Significantly, more patients were on any dose of all three GDMTs.ConclusionsPharmacist‐led HF medication optimization clinic establishment can contribute to longitudinal medication titration, successful transition of care, and correcting noncompliance and indiscretions. Pharmacists are in an ideal position to fill gaps and help evolve the current HF care model.

P281 Factors influencing apixaban dosing in the middle east gulf region

Abstract Background Approved dose adjustment criteria for apixaban are based on the clinical trial. Adjustments require presence of 2 of 3 criteria. In the ARISTOTLE trial, 4.7% of patients met those criteria. Real world data show much higher utilization of the lower dose. Accurate statistics on the prevalence and predictors of such dosing in the Middle East Gulf region are lacking. Purpose We sought to explore the appropriateness of apixaban dosing and to predict the factors influencing physician dosing strategies at a tertiary care center in our United . Methods We performed a retrospective chart review of patients receiving apixaban for atrial fibrillation from our hospital-based outpatient pharmacy between April 1, 2015 and October 1, 2018. Patients with missing data or on apixaban for other indications were excluded. Results A total of 232 patients were included with a mean follow-up of 400 ± 271 days. The mean age was 66.0 ± 13.2 years, 45.5% female, mean weight 82.4 ± 44.7 kg, mean serum creatinine 1.0 ± 0.4 mg/dL, CHA2DS2VASc 3.7 ± 1.8, and 30.1% were on at least 1 concomitant antiplatelet drug. Seventy three patients (31.3%) received a reduced apixaban dose of 2.5 mg twice daily. Deviation from recommended criteria was seen in a total of 62 patients (26.6%), most being under-dosed (93.5%). The significant predictors of underdosing in our model were older age (risk of under-dosing increases by 7.2% for each additional year of age) and eGFR 30 to 60 mL/min/1.73 m2. Conclusion Under-dosing of apixaban is prevalent in the Middle East Gulf region. Advancing age and eGFR are the main predictors of under-dosing. More education is needed to optimize dosing of apixaban for stroke prevention in AF. Table 1 % Change in Odds Ratio Variables coef. std. error p expected min max Intercept -1.563 0.223 0.000 Age 0.069 0.022 0.002 7.2% 2.5% 12.1% eGFR (30-60 relative to &amp;gt;60) 1.583 0.625 0.011 386.9% 39.6% 1597.8% Table 1. Stepwise logistic regression model for predictors of apixaban underdosing. Adjusted for serum creatinine, weight, BMI, gender, CHADS2-VASc score, concomitant antiplatelets, and eGFR &amp;lt; 30 or &amp;gt; 60 mL/min/m2

Adapting to the COVID-19 pandemic at a quaternary care hospital in the middle East Gulf Region

Adapting to the COVID-19 pandemic at a quaternary care hospital in the middle East Gulf Region

Pax Americana and the Dissolution of Arab States: The Humanitarian Consequences (1990–2019)

This article provides an assessment of three decades of US hegemony over the Arab-majority states of the Middle East's Gulf region. Since its direct military intervention in the 1990 war over Kuwait, the US increasingly engaged itself as an architect forging the region through deployment of its neoliberal economic and financial coercion, Janus-faced support for authoritarian regimes while promoting democracy, human rights and individual freedom rhetorically, as well as repeated direct military interventions into Arab states in an effort to bring about regime change. At the base of diplomatic and public justification for the 1990–91 intervention—or the Gulf War as it became known to Americans—was the assertion that the war was defensive in nature, protecting the territorial integrity of Kuwait as well as the enshrining the norms of non-intervention and the sanctity of borders. Over the following years, however, US military forces came to be active in Iraq, Syria, Yemen and Libya with an expanded coterie of bases littered across the states of the Gulf (Saudi Arabia, Kuwait, Bahrain, Qatar, UAE and Oman). While the US and its allies had been engaged in the region's politics throughout the Cold War, from 1990 through 2019, the US escalated its role to preside over regional politics through a hub-and-spoke latticework of relations between itself and regional states. From the perspective of nearly three decades since 1990, an appraisal of this coercive relationship, focusing on the humanitarian impacts it has wrought upon the region's peoples, suggests it has failed according to these criteria. Many of the region's peoples have experienced a marked decline in their economic well-being, personal safety and health, while the state apparatuses established following the retreat of European imperialism now lie in ruin in Iraq, Libya, Syria and Yemen. The populations of these states now face a precarious future, without the protection of state institutions, against a range of predatory actors. Moreover, these actions have contributed toward the decline of US global influence, thereby encouraging further change in an environment where popular sovereignty and inputs into governance by regional peoples has been frustrated through the exercise of US power.

Multiple Sclerosis in the Emirati Population: Onset Disease Characterization by MR Imaging.

Background and Objectives Multiple Sclerosis (MS) epidemiology is on the path of globalization mainly due to changing environmental factors. The prevalence of MS is on the rise in the Middle East and Persian Gulf region. Our observations has led us to hypothesize a heavy MRI lesion load at the onset of disease in a relatively younger native population. We aimed to estimate and characterize the onset disease on MRI using McDonald's criteria while applying its terms of “Dissemination in Space (DIS) and Dissemination in Time (DIT)”. Materials and Methods Retrospective review of onset MRI studies of 181 Emirati (native) individuals. Basic demographics were captured. Only 47 patients with Clinically Definite MS (CDMS) were included who had onset diagnostic MRI available. Lesion load was quantified using the specific zones of involvement designated for DIS: (1) Periventricular (PVZ) (I), (2) Juxta-cortical (II) (3) Infra-tentorial (III) and, (4) Spinal cord (IV). PVZ was sub-classified and lesions were quantified. A single enhancing lesion was required for DIT. Results Average age of onset was about 26 years with female dominance of about 2 : 1. About 50% had all 4 zones and about 85% had at least 3 zones involved at the onset. Involvement of only 1 zone was rare. Dissemination in time (DIT) in brain and/or cord was present in approximately 50%. Each of the 4 zones were involved in at least 70% of cases. PVZ was not spared in any case with at least 3 lesions present in approx. 95% and ≥12 lesions in approx. half of the patients. Spinal cord specifically cervical cord was involved in up to 80% with typical patchy lesions. Conclusion Onset disease characterization using MRI in a young Emirati cohort showed a heavy lesion load in the brain and spinal cord at the onset, signifying cumulative disease before presentation. Disseminated disease also facilitated early diagnosis of MS. The findings have significant potential ramifications for local environmental and cultural factors, as well as disease course and disability progression.

Stakeholder’s perception of service quality: a case in Qatar

PurposeThe purpose of this paper is to investigate and report students’ perception of service quality in a university by examining the perceptual context of service quality with respect to students’ loyalty behavior, image of the university and culture/values.Design/methodology/approachA research framework is developed for quality assessment with three hypotheses. A questionnaire with 65 instruments was used for gathering the required data for the analysis. The questionnaire was sent through email to all engineering students. The analysis included descriptive statistics, reliability analysis, gap analysis and hypotheses tests. Seven dimensions of service quality were identified: the original dimensions of the SERVQUAL, namely, reliability, responsiveness, assurance, empathy and tangibles. Two additional dimensions image and culture/value were added for the research to understand perceived service quality and loyalty.FindingsThe results provide a significant positive correlation between service quality and student's loyalty. It also shows that there is statistically significant relation between the image of the institution and the perceived service quality, and culture/values of the students in the institution and perceived service quality.Research limitations/implicationsThis study used data collected from a survey in the university in a given period.Practical implicationsThe findings indicate that to provide quality education, meeting students’ needs, wants and expectations of services quality should be carefully understood and addressed. Management also needs to consider factors such as corporate image and culture/value, as they have the ability to heavily impact the type of services provided by the institution.Originality/valueThe findings presented in this paper fill the gap in the current literature by providing empirical knowledge on the quality of service assessment and customer satisfaction in the higher education context. The study is the first of its kind in Qatar’s context and provides opportunities for higher institutions to focus more on current students’ services. This can lead to an increased brand value representing one of the premier institutes of higher education in the Middle East Gulf Region.

Achieving Successful Longitudinal Titration of Evidence Based Heart Failure Medical Therapy at a Newly Established Multidisciplinary Program in the Middle East Gulf Region

Background The 2017 ACC expert consensus decision pathway for optimization of heart failure (HF) treatment emphasizes the fact that target doses of medications are associated with the best outcomes. It has been reported that a significant portion of HFrEF patients are not on optimal doses of medical therapy, and gaps exist in longitudinal medication titration. The objective of this retrospective study is to describe medical therapy after 12 months of follow up in a newly established multidisciplinary HF program in the Middle East Gulf region. Methods A retrospective outpatient chart review was conducted on HF patients after initial outpatient clinic enrollment between October 2015 and July 2017. All patients with EF ≤ 40 were included. We documented baseline and follow-up evidence based HF medications including beta blockers, RAAS inhibitors, and MRA. Results Out of 305 enrolled patients, only 186 had a 12 month follow up appointment, out of which 139 had HFrEF and were included in this analysis. At baseline, 25.2%, 13.7%, and 42.4% of patients were receiving target doses of beta-blocker, ACEI/ARB/ARNI, and MRA, respectively. Only 2.9% were on target doses of all 3 classes of evidence based therapies. At 12 months, percentage of patients on target doses significantly increased to 51.8% for beta blockers and 31.7% for ACEI/ARB/ARNI, while there was no significant change in patients on target dose MRA (36.7%). More patients (10.1%) were on target doses of all 3 evidence based therapies (table 1). A significant increase was observed in the rate of adoption of ARNI from baseline to follow-up (10.1% vs 48.9%, p Conclusion Close follow up of patients with HFrEF was associated with statistically significant increase in those on target doses of both beta blockers and ACE/ARB/ARNI and patients on simultaneous target doses of all evidence based medications. Compared to recent western outpatient registries, our study shows that the success of longitudinal titration of evidence based medications and adoption of new ones can be enhanced when patients are followed by a specialized multidisciplinary program.

A per-protocol initiation of sacubitril/valsartan in an advanced heart failure disease management programme in the Middle East Gulf Region.

AimsThe aim of this study is to evaluate the utilization and success in therapy intensification after initiation of sacubitril/valsartan using a specified protocol within an advanced heart failure and transplant programme in the Middle East Gulf Region.Methods and resultsWe studied a single‐centre, retrospective cohort in a 364‐bedded multi‐speciality hospital located in the United Arab Emirates (February 2016 to July 2017). The advanced heart failure and transplant programme formulated an institutional protocol for initiation of sacubitril/valsartan with defined criteria for switching from angiotensin‐converting enzyme inhibitor (ACEI) and angiotensin II receptor blocker (ARB). Prescribing this drug is intended for patients with heart failure with reduced ejection fraction with left ventricular ejection fraction ≤40%. We excluded patients (i) with age below 18 years or (ii) initiated on sacubitril/valsartan from an outside hospital with or without follow‐up in our outpatient clinic. We included 102 patients with an average initial dose of 78.9 ± 44.2 mg twice daily. Only 17 patients were on target doses of ACEI or ARB prior to switching to sacubitril/valsartan. Up‐titration was successful in 55 patients during the follow‐up period. In addition, 6.9% patients were hospitalized with heart failure exacerbation. In patients with elevated baseline serum potassium prior to initiating this medication, the serum potassium levels decreased post‐initiation by 0.5 ± 0.3 mmol/L (P = 0.0008).ConclusionsInitiating sacubitril/valsartan through a defined protocol selects for appropriate candidates and guides starting dose and titration. Overall, significant success can be achieved in replacing ACEI or ARB by sacubitril/valsartan in symptomatic heart failure with reduced ejection fraction patients.