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      Sultan Qaboos University Medical Journal is a refereed multidisciplinary journal, published quarterly print and online with free public access to full text articles. It aims to:
      1) Be a leading regional medium of biomedical and allied scientific communication that is internationally recognized. 2) Encourage and stimulate medical research and scientific publication within Oman and the Gulf area, while attracting contributions from further a field. 3) Create awareness of developments in medicine and allied fields among health professionals in and outside Oman.
      SQUMJ is listed in PubMed and indexed in both SCOPUS and the WHO Index Medicus for the Eastern Mediterranean Region.

      ISSN Print: 2075-0051X; ISSN Online: 2075-0528
      Current Issue: May 2012 - Vol. 12, No. 2
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      Current Issue: Sultan Qaboos University Medical Journal
      May 2012 - Vol. 12, No. 2
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      Deaths from Sickle Cell Disease in Intensive Care Units : Can we do better? (Editorial)
      Lamk Al-Lamki
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      A New Cellular Weapon to Kill Leukaemic B-Cells (Editorial)
      Mohamed-Rachid Boulassel
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      Vitamin D Deficiency : This clandestine endemic disease is veiled no more (Review)
      Moeness Moustafa Alshishtawy
      ABSTRACT: Recently, scientists have generated a strong body of evidence providing new information about the preventive effect of vitamin D on a broad range of disorders. This evidence suggests that vitamin D is much more than a nutrient needed for bone health; it is an essential hormone required for regulation of a large number of physiological functions. Sufficient concentration of serum 25-hydroxyvitamin D is essential for optimising human health. This article reviews the present state-of-the-art knowledge about vitamin D’s status worldwide and refers to recent articles discussing some of the general background of vitamin D, including sources, benefits, deficiencies, and dietary requirements, especially in pregnancy. They offer evidence that vitamin D deficiency could be a major public health burden in many parts of the world, mostly because of sun deprivation. The article also discusses the debate about optimal concentration of circulating serum 25-hydroxyvitamin D, and explores different views on the amount of vitamin D supplementation required to achieve and maintain this concentration.

      Keywords: Vitamin D deficiency; 25-hydroxyvitamin D; Vitamin D2 (ergocalciferol); Vitamin D3 (cholecalciferol); Sunlight; Oman.
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      Icterus Neonatorum in Near-Term and Term Infants : An overview (Review)
      Rehan Ali, Shakeel Ahmed, Maqbool Qadir and Khalil Ahmad
      ABSTRACT: Neonatal jaundice is the yellowish discoloration of the skin and/or sclerae of newborn infants caused by tissue deposition of bilirubin. Physiological jaundice is mild, unconjugated (indirect-reacting) bilirubinaemia, and affects nearly all newborns.  Physiological jaundice levels typically peak at 5 to 6 mg/dL (86 to 103 µmol/L) at 72 to 96 hours of age, and do not exceed 17 to 18 mg/dL (291–308 µmol/L). Levels may not peak until seven days of age in Asian infants, or in infants born at 35 to 37 weeks’ gestation. Higher levels of unconjugated hyperbilirubinaemia are considered pathological and occur in a variety of conditions. The clinical features and management of unconjugated hyperbilirubinaemia in healthy near-term and term infants, as well as bilirubin toxicity and the prevention of kernicterus, are reviewed here. The pathogenesis and aetiology of this disorder are discussed separately.

      Keywords: Newborn; Icterus; Hyperbilirubinaemia; Jaundice.
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      Snoring-Induced Nerve Lesions in the Upper Airway (Review)
      Rajesh P Poothrikovil and Mohammed A Al Abri
      ABSTRACT: The prevalence of habitual snoring is extremely high in the general population, and is reported to be roughly 40% in men and 20% in women. The low-frequency vibrations of snoring may cause physical trauma and, more specifically, peripheral nerve injuries, just as jobs which require workers to use vibrating tools over the course of many years result in local nerve lesions in the hands. Histopathological analysis of upper airway (UA) muscles have shown strong evidence of a varying severity of neurological lesions in groups of snoring patients. Neurophysiological assessment shows evidence of active and chronic denervation and re-innervation in the palatopharyngeal muscles of obstructive sleep apnoea (OSA) patients. Neurogenic lesions of UA muscles induced by vibration trauma impair the reflex dilation abilities of the UA, leading to an increase in the possibility of UA collapse. The neurological factors which are partly responsible for the progressive nature of OSAS warrant the necessity of early assessment in habitual snorers.

      Keywords:  Neurogenic; Obstructive sleep apnoea syndrome (OSAS); Palatopharyngeal Muscle; Snoring; Upper airway; Trauma.
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      Emerging Burden of Frail Young and Elderly Persons in Oman : For whom the bell tolls? (Sounding Board)
      Hamed Al-Sinawi, Mohammed Al-Alawi, Rehab Al-Lawati, Ahmed Al-Harrasi, Mohammed Al-Shafaee and Samir Al-Adawi
      ABSTRACT: Recent improvements in health and an increased standard of living in Oman have led to a reduction in environment-related and infectious diseases. Now the country is experiencing an epidemiological transition characterised by a baby boom, youth bulge and increasing longevity. Common wisdom would therefore suggest that Omanis will suffer less ill health. However, a survey of literature suggests that chronic non-communicable diseases are unexpectedly becoming common. This is possibly fuelled by some socio-cultural patterns specific to Oman, as well as the shortcomings of the ‘miracle’ of health and rapid modernisation. Unfortunately, such new diseases do not spare younger people; a proportion of them will need the type of care usually reserved for the elderly. In addition, due to their pervasive and refractory nature, these chronic non-communicable diseases seem impervious to the prevailing ‘cure-oriented’ health care system. This situation therefore calls for a paradigm shift: a health care system that goes beyond a traditional cure-orientation to provide care services for the chronically sick of all ages.

      Keywords:  Chronic disease; Non-communicable diseases; Transition, demographic; Disability; Burden of illness; Oman.
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      Adult Sickle Cell Disease : A Five-year Experience of Intensive Care Management in a University Hospital in Oman (Orginal Study)
      Qutaiba Amir Tawfic, Rajini Kausalya, Dhuha Al-Sajee, Jyoti Burad, Ahmed K Mohammed and Aravind Narayanan
      ABSTRACT: Objectives: Sickle cell disease (SCD) is an inherited disease caused by an abnormal type of haemoglobin. It is one of the most common genetic blood disorders in the Gulf area, including Oman. It may be associated with complications requiring intensive care unit (ICU) admission. This study investigated the causes of ICU admission for SCD patients. Methods: This was a retrospective analysis of all adult patients ≥12 years old with SCD admitted to Sultan Qaboos University Hospital (SQUH) ICU between 1st January 2005 and 31st December 2009. Results: A total number of 49 sickle cell patients were admitted 56 times to ICU. The reasons for admission were acute chest syndrome (69.6%), painful crises (16.1%), multi-organ failure (7.1%) and others (7.2%). The mortality for SCD patients in our ICU was 16.1%. The haemoglobin (Hb) and Hb S levels at time of ICU admission were studied as predictors of mortality and neither showed statistical significance by Student’s t-test. The odds ratio, with 95% confidence intervals, was used to study other six organ supportive measures as predictors of mortality. The need for inotropic support and mechanical ventilation was a good predictor of mortality. While the need for non-invasive ventilation, haemofiltration, blood transfusions and exchange transfusions were not significant predictors of mortality. Conclusion: Acute chest syndrome is the main cause of ICU admission in SCD patient. Unlike other supportive measures, the use of inotropic support and/or mechanical ventilation is an indicator of high mortality rate SCD patient.

      Keywords:  Anemia; Sickle cell; Acute chest syndrome; Oman.
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      Putting Research Findings into Clinical Practice : Feasibility of integrated evidence-based care pathways in otorhinolaryngology head and neck surgery at Sultan Qaboos University Hospital, Oman (Orginal Study)
      Deepa Bhargava, Zainab Al-Lawatia, Rashid Al-Abri and Kamlesh Bhargava
      ABSTRACT: Objectives: A perception exists that clinicians in Oman are reluctant to adopt evidence-based practice (EBP). This pilot study was undertaken to study the feasibility of using EBP pathways at the point of care in otorhinolaryngology head and neck surgery. The ultimate aim was to facilitate EBP with the probability of developing a new system for implementing research findings/translational research at the clinical point of care. Methods: A cross-sectional prospective questionnaire pilot survey of clinicians at Sultan Qaboos University Hospital (SQUH),  Oman, a tertiary care medical centre, was undertaken. Respondents included 135 physicians and surgeons with between 3 months and 25 years of clinical experience and included personnel ranging from interns to senior consultants, in areas ranging from primary care to specialist care. Results: Of those polled, 90% (95% confidence interval (CI) 85–95%) either strongly agreed or agreed that evidence-based practice protocols (EBPP) could help in decision making. A total of 87.4% of participants (95% CI 81.8–93%) either strongly agreed or agreed that EBPPs can improve clinical outcomes; 91.8% of participants (95% CI 87.2–96.4%) would use and apply EBPP in day-to-day care if they were available at the point of care and embedded in the hospital information system. Conclusions: The perception that clinicians at SQUH are reluctant to adopt EBP is incorrect. The introduction of EBP pathways is very feasible at the primary care level. Institutional support for embedding EBP in hospital information systems is needed as well as further outcome research to assess the improvement in quality of care.

      Keywords: Otorhinolaryngology; Surgery, head and neck; Evidence based practice; Clinical protocol; Clinical practice guidelines; Decision making; Oman.
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      Caesarean Myomectomy : Feasibility and safety (Orginal Study)
      Lovina SM Machado, Vaidyanathan Gowri, Nihal Al-Riyami and Lamya Al-Kharusi
      ABSTRACT: Objectives: Caesarean myomectomy has traditionally been discouraged due to fears of intractable haemorrhage and increased postoperative morbidity. However, a number of authors have recently shown that myomectomy during Caesarean section does not increase the risk of haemorrhage or postoperative morbidity. Methods: We present a series of 8 cases from Sultan Qaboos University Hospital, Oman, where myomectomy was performed during Caesarean section for large lower segment fibroids. Seven were anterior lower segment fibroids, while one was a posterior lower uterine fibroid which interfered with closure of the uterine incision. The antenatal course, perioperative management, and postoperative morbidity are discussed. Results: The average age of the women was 28.7 years and mean gestational age at delivery was 36.75 weeks. Regarding intra-operative blood loss, 1 patient lost 900 ml, 5 patients lost 1–1.5 litres, 2 lost 1.5–2 L, and 1 patient with a 10 x 12 cm fibroid lost 3.2 L. Despite the majority being large myomas (7 of the 8 patients had myomas >5 cm in size) and 50% being intramural, no hysterectomy was required. Stepwise devascularisation was necessary in one case and preoperative placement of uterine balloon catheters was necessary in another. The size of the fibroids was confirmed by histopathology. Myomectomy added 15 minutes to the operating time and 1 day to the hospital stay, but there was no significant postoperative morbidity. Neonatal outcome was good in all patients. Conclusion: In selected patients, myomectomy during Caesarean section is a safe and effective procedure at tertiary centres with experienced surgeons.

      Keywords: Caesarean section; Myomectomy; Fibroids; Pregnancy; Haemorrhage; Oman.
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      Oxidative Stress and C-Reactive Protein in Patients with Cerebrovascular Accident (Ischaemic Stroke) : The role of Ginkgo biloba extract (Orginal Study)
      Imad A-J Thanoon, Hilmy AS Abdul-Jabbar and Dhia A Taha
      ABSTRACT: Objectives: This study aimed to investigate the presence of oxidative stress and inflammation in ischaemic stroke patients by measuring malondialdehyde (MDA), total antioxidant status (TAS), and highly-sensitivity C-reactive protein (hsCRP) in the early post-ischaemic period, and to determine the role of Ginkgo biloba therapy in correcting the markers of oxidative stress and inflammation. Methods: This study was conducted at Ibn Seena Hospital, Mosul City, Iraq and included 31 cerebrovascular accident (CVA) patients and 30 healthy controls. Ischaemic stroke patients were divided into two groups: group I (n = 15) received conventional therapy; group II (n = 16) received conventional therapy with G. biloba (1500 mg/day) for 30 days. Blood samples were obtained from patients and controls before treatment and assays done of serum levels of MDA, TAS, and hsCRP. For CVA patients, a post-treatment blood sample was taken and the same parameters reassessed. Results: Compared with the controls, patients’ serum levels of MDA, and hsCRP were significantly higher (P ≤0.001) and TAS significantly lower. Group I and II patients reported a significant reduction in serum levels of MDA and hsCRP and a significant increase in serum levels of TAS, in comparison with pre-treatment levels. There was no significant difference (P = 0.19) in serum MDA levels between groups I and II, whereas, serum TAS levels were significantly higher (P ≤0.01) and hsCRP significantly lower (P ≤0.01) in group II. Conclusion: Acute stroke is associated with oxidative stress and inflammatory response in the early period. G. biloba plays a potential role in reducing oxidative damage and inflammatory response. 

      Keywords: Cerebrovascular accident; C-reactive protein; Ginkgo biloba; Ischaemia; Stroke; Malondialdehyde; Oxidative stress; Antioxidant; Iraq.
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      Psychological Health of First-Year Health Professional Students in a Medical University in the United Arab Emirates (Orginal Study)
      Kadayam G Gomathi, Soofia Ahmed and Jayadevan Sreedharan
      ABSTRACT: Objectives: The aim of this study was to assess the psychological health of first-year health professional students and to study sources of student stress. Methods: All first-year students (N = 125) of the Gulf Medical University (GMU) in Ajman, United Arab Emirates (UAE), were invited to participate in a voluntary, anonymous, self-administered, questionnaire-based survey in January 2011. Psychological health was assessed using the 12-item General Health Questionnaire. A 24-item questionnaire, with items related to academic, psychosocial and health domains was used to identify sources of stress. Pearson’s chi-squared test and the Mann-Whitney U-test were used for testing the association between psychological morbidity and sources of stress. Results: A total of 112 students (89.6%) completed the survey and the overall prevalence of psychological morbidity was found to be 33.6%. The main academic-related sources of stress were ‘frequency of exams’, ‘academic workload’, and ‘time management’. Major psychosocial stressors were ‘worries regarding future’, ‘high parental expectations’, ‘anxiety’, and ‘dealing with members of the opposite sex’. Health-related issues were ‘irregular eating habits’, ‘lack of exercise’, and ‘sleep-related problems’. Psychological morbidity was not significantly associated with any of the demographic factors studied. However, total stress scores and academics-related domain scores were significantly associated with psychological morbidity. Conclusion: Psychological morbidity was seen in one in three first-year students attending GMU. While worries regarding the future and parental expectations were sources of stress for many students, psychological morbidity was found to be significantly associated with only the total stress and the academic-related domain scores.

      Keywords: Psychological stress; Medical student; Health professions; Undergraduate medical education; United Arab Emirates.
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      Assessment Methods of an Undergraduate Psychiatry Course at a Saudi University (Orginal Study)
      Mostafa Amr and Tarek Amin
      ABSTRACT: Objectives: In Arab countries there are few studies on assessment methods in the field of psychiatry. The objective of this study was to assess the outcome of different forms of psychiatric course assessment among fifth year medical students at King Faisal University, Saudi Arabia. Methods: We examined the performance of 110 fifth-year medical students through objective structured clinical examinations (OSCE), traditional oral clinical examinations (TOCE), portfolios, multiple choice questions (MCQ), and a written examination. Results: The score ranges in TOCE, OSCE, portfolio, and MCQ were 32–50, 7–15, 5–10 and 22–45, respectively. In regression analysis, there was a significant correlation between OSCE and all forms of psychiatry examinations, except for the MCQ marks. OSCE accounted for 65.1% of the variance in total clinical marks and 31.5% of the final marks (P = 0.001), while TOCE alone accounted for 74.5% of the variance in the clinical scores. Conclusions: This study demonstrates a consistency among the students’ assessment methods used in the psychiatry course, particularly the clinical component, in an integrated manner. This information would be useful for future developments in undergraduate teaching.

      Keywords: Undergraduate medical students; Assessment; Psychiatry; Undergraduate; Saudi Arabia
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      Extra-luminal Air Fluid Level on Abdominal X-ray of a Patient with Isolated Jejunal Blow Out : Case report (Case Report)
      Khalid Munir Bhatti, Mohammed Zulfiqar Ali, Afshan Khalid, Umar Mushtaq and Mohammed Idrees Anwar
      ABSTRACT: Patients with trivial blunt abdominal trauma may present with isolated jejunal blow out (IJBO). A high index of suspicion is required as delayed presentation or delayed diagnosis may increase morbidity. Presentation with frank perforation peritonitis can be diagnosed by abdominal X-rays. We report the case of a patient who presented with features of peritonitis 10 days after being injured by a knee kick trauma. An erect abdominal X-ray showed extraluminal air-fluid levels, suggesting a hollow viscous injury which on exploration was found to be IJBO.

      Keywords: Blunt trauma; Delayed diagnosis; Intestinal perforation; Jejunum; Peritonitis; Case report; Pakistan.
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      Ovarian Hernia : A rarity (Case Report)
      Kamran A Malik, Ruqaiya M Al Shehhi, Hani Al Qadhi, Moza Al Kalbani and Abdullah Al Harthy
      ABSTRACT: Ovarian hernias are extremely rare. The prevalence of ovaries and fallopian tubes in operable inguinal hernias is only about 2.9%. We report here an unusual case of an ovary in a hernia sac in an adult female. She presented with symptoms and signs of an incarcerated left inguinal hernia. The left ovary contained a haemorrhagic cyst and, along with the left fallopian tube and broad ligament, these were found in the sac. She underwent a left ovarian cystectomy and the inguinal hernia was repaired with mesh.

      Keywords: Inguinal hernia; Ovary; Case report; Oman.
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      Unusual Presentation of Oral Squamous Cell Carcinoma in a Young Woman (Case Report)
      Diurianne CC França, Lira M Monti, Alvimar L de Castro, Ana MP Soubhia, Luiz ER Volpato, Sandra MHC Á de Aguiar and Marcelo C Goiato
      ABSTRACT: Oral squamous cell carcinoma (OSCC) is the most common oral malignant neoplasm, mainly affecting individuals over 50 years old with a history of tobacco and alcohol use. The occurrence of this oral cancer in individuals under 40 years old is unusual and, when it does occur, shows a weaker relation to those risk factors and a more aggressive clinical course. Due to the paucity of reports in this population, it is difficult to prove its increasing trend. A case of oral squamous cell carcinoma in a 39-year-old woman with no history of tobacco or alcohol use is reported. Clinical and histopathological findings, aetiology, and treatment are discussed. The increasing trend of oral squamous cell carcinoma in young women without known risk factors highlights the need for clinicians to be prepared to diagnose this lesion quickly and precisely, providing a better prognosis, chance of survival, and quality of life for the patient.

      Keywords: Carcinoma, Squamous cell; Mouth neoplasms; Risk factors; Case report; Brazil.
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      Amyand’s Hernia : Study of four cases and literature review (Case Report)
      Syed M. Ali, Kamran A. Malik and Hani Al-Qadhi
      ABSTRACT: The presence of the appendix in an inguinal hernial sac is described as Amyand’s hernia. It is a rare entity which presents mostly at the exploration of the inguinal canal. The appendix may be apparently normal or have all the features of acute appendicitis with its possible complications. We report four cases of Amyand’s hernia which were treated at Sultan Qaboos University Hospital, Oman. All patients underwent appendectomy. In three cases, the inguinal hernia were repaired with Vipro mesh while, in the remaining case, a darning repair was done with Prolene sutures.

      Keywords:  Inguinal hernia; Appendix in hernia; Acute appendicitis; Case report; Oman
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      Acquired Methemoglobinaemia (Case Report)
      Adil Al-Lawati and Nick Murch
      ABSTRACT: Acquired methemoglobinaemia is a relatively rare condition and, therefore infrequently encountered in acute medical practice. Suspicion of the condition may be triggered when the measured PaO2 is ‘out of keeping’ with the oxygen saturations that are discovered with pulse oximetry. We describe two separate cases of acquired methemoglobinaemia secondary to the recreational use of alkyl nitrites (’poppers’). The patients presented at separate times to two different teaching hospitals in London, UK. The similarity of these cases has led the authors to conclude that a raised awareness of this potentially fatal condition, and its association with a widely-available recreational drug, is necessary to ensure a correct and timely diagnosis.

      Keywords: Methaemoglobinaemia; Methylene blue; Case report; UK.
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      Lost And Found : Catastrophic En Block Embolism of a Mechanical Prosthetic Valve Thrombus after Thrombolytic Therapy (Medical Image)
      Prashanth Panduranga, Faisal Alam, Laxmi Ratnam, Matllooba Al-Zadjali and Mohammed Al-Deeb
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      Statin of Preference to Treat Dyslipidaemia in Patients with Renal Dysfunction : Cues from (SATURN) (Letter to Editor)
      Khalid Al-Waili, Tamima Al-Dughaishi, Khalid Al-Rasadi, Riad Bayoumi andYajnavalka Banerjee
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      Suture Artefacts : Explored through polarising microscope (Medical Image)
      Sonal Grover, Rashmi Naik, Jayadeva HM and Ahmed Mujib BR
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      First International Nursing Conference Oman : Innovations in Nursing Education and Practice Leading to Quality Care (Abstracts)
      Sultan Qaboos University, Oman, 28–29th November 2011
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