Sultan Qaboos University Medical Journal, an internationally peer-reviewed multidisciplinary journal, is published quarterly in print and online with free access to full text articles. Its aims are: to be an internationally recognised regional medium of biomedical communication; to encourage medical research and publication in Oman, the Gulf and further afield, and to create awareness of new developments among health professionals in Oman and beyond. SQUMJ is listed in PubMed and indexed in SCOPUS, the Directory of Open Access Journals, the Al Manhal database of Arab journals and the WHO Index Medicus for the Eastern Mediterranean Region. SQUMJ DOES NOT CHARGE AUTHORS FOR SUBMISSION OR PUBLICATION.
SQUMJ is an Open Access Journal. This means that all content is freely available without charge to the user or his/her institution. Users are allowed to read, download, copy, distribute, print, search, or link to the full texts of the articles in this journal without asking prior permission from the publisher or the author. This is in accordance with the Budapest Open Access Initiative (BOAI) definition of open access.
Clinical management issues before, during and after pregnancy(Review) Ali Hassan and Zakia M. Yasawy
ABSTRACT:Myasthaenia gravis (MG) is an autoimmune neuromuscular disorder which is twice as common among women, often presenting in the second and third decades of life. Typically, the first trimester of pregnancy and first month postpartum are considered high-risk periods for MG exacerbations. During pregnancy, treatment for MG is usually individualised, thus improving its management. Plasma exchange and immunoglobulin therapies can be safely used to treat severe manifestations of the disease or myasthaenic crises. However, thymectomies are not recommended because of the delayed beneficial effects and possible risks associated with the surgery. Assisted vaginal delivery—either vacuum-assisted or with forceps—may be required during labour, although a Caesarean section under epidural anaesthesia should be reserved only for standard obstetric indications. Myasthaenic women should not be discouraged from attempting to conceive, provided that they seek comprehensive counselling and ensure that the disease is under good control before the start of the pregnancy.
ABSTRACT: Odontogenic tumours are lesions that occur solely within the oral cavity and are so named because of their origin from the odontogenic (i.e. tooth-forming) apparatus. Odontogenic tumours comprise a variety of lesions ranging from non-neoplastic tissue proliferations to benign or malignant neoplasms. However, controversies exist regarding the pathogenesis, categorisation and clinical and histological variations of these tumours. The recent 2017 World Health Organization classification of odontogenic tumours included new entities such as primordial odontogenic tumours, sclerosing odontogenic carcinomas and odontogenic carcinosarcomas, while eliminating several previously included entities like keratocystic odontogenic tumours and calcifying cystic odonogenic tumours. The aim of the present review article was to discuss controversies and recent concepts regarding odontogenic tumours so as to increase understanding of these lesions.
Keywords: Neoplasms; Oral Cavity; Odontogenic Tumors; Hamartomas; Classification; World Health Organization.
The Roles and Performance of Professional Driving Instructors in Novice Driver Education
(Review) Zulhaidi M. Jawi, Baba M. Deros, Ahmad A. A. Rashid, Mohd H. M. Isa, Azmi Awang
ABSTRACT: This review article aimed to analyse existing literature regarding the roles and performance of professional driving instructors (PDIs) in novice driver education (DE). A systematic classification scheme was adopted to analyse identified articles to determine the study context of PDIs in novice DE, the competency level of PDIs in relation to experienced and learner drivers and the contributions of PDIs to the novice driver learning process. A total of 14 original research articles were identified, with no systematic reviews or meta-analyses available. Overall, all of the articles were found to be inadequate in providing an in-depth understanding of the roles and performance of PDIs in novice DE. There is an urgent need to improve current understanding of the roles of PDIs in novice DE and to work towards an internationally recognised PDI management approach.
Keywords: Public Health Systems Research; Safety; Accident Prevention; Automobile Driving; Automobile Driver Examination.
First Cytogenetic Profile of Omani Patients with de novo Myelodysplastic Syndromes
Comparison with data from Asia, Africa, Europe and North and South America(Special Contribution) Achandira M. Udayakumar, Nagla Fawaz, Anil Pathare, Shakila Asraf, Mohammed Al-Huneini, Khalil Al-Farsi, Salam Al-Kindi, Murtadha Al-Khabouri
ABSTRACT: Clonal cytogenetic abnormalities have been reported among 30–80% of patients with myelodysplastic syndromes (MDS); however, 20–70% of patients with MDS show a normal karyotype that may nevertheless harbour a cryptic genetic alteration. Earlier reports have suggested that the distribution of specific chromosomal aberrations varies among Western and Asian countries, with geographical and ethnic differences in the frequency of specific chromosomal aberrations. This article compared the cytogenetic data of 36 adult Omani patients with MDS to previously reported data from other populations. Differences were noted between the percentages of clonal aberrations and the median age of Omani subjects at presentation in comparison to individuals of different ethnicities and from various geographical locations. To the best of the authors’ knowledge, this is the first report to describe the cytogenetic data of patients with MDS from Oman.
In Vitro Cysteine Reactivates Organophosphate Insecticide Dichlorvos-Inhibited Human Cholinesterases
(Original Study) Hamidreza Mohammadi, Jafar Jalilian, Mohammad Y. Karimi, Seyed V. Shetab-Boushehri
ABSTRACT:Objectives: Organophosphate (OP) pesticides inhibit both red blood cell (RBC) and plasma cholinesterases (ChEs). Oximes, especially pralidoxime (2-PAM), are widely used as antidotes to treat OP poisoning. In addition, N-acetylcysteine (NAC) is sometimes used as an adjuvant antidote. The current study aimed to assess the feasibility of using NAC as a single therapeutic agent for OP poisoning in comparison to in vitro 2-PAM. Methods: This study was carried out at the Razi Drug Research Center of Iran University of Medical Sciences, Tehran, Iran, between April and September 2014. A total of 22 healthy human subjects were recruited and 8 mL citrated blood samples were drawn from each subject. Dichlorvos-inhibited blood samples were separately exposed to low and high doses (final concentrations of 300 and 600 μmol.L-1, respectively) of 2-PAM, NAC and cysteine. Plasma and RBCs were then separated by centrifugation and their ChE activity was measured using spectrophotometry. Results: Although cysteine—and not NAC—increased the ChE activity of both plasma and RBCs over those of dichlorvos, it did not increase them over those of a high dose of 2-PAM. Conclusion: These results suggest that the direct reactions of 2-PAM and cysteine with dichlorvos and the reactivation of phosphorylated ChEs occurr via an associative stepwise addition-elimination process. High therapeutic blood concentrations of cysteine are needed for the elevation of ChE activity in plasma and RBCs; however, both this agent and NAC may still be effective in the reactivation of plasma and RBC ChEs.
Trends and Outcomes of Non-Small-Cell Lung Cancer in Omani Patients
Experience at a university hospital(Original Study) Muhammad Furrukh, Shiyam Kumar, Khawaja F. Zahid, Hanan S. Al-Shamly, Zainab A. Al-Jabri, Ikram A. Burney, Mansour S. Al-Moundhri
ABSTRACT:Objectives: The incidence of lung cancer in Oman has shown a gradual but definitive increase since 2002. This study aimed to evaluate the demographic and epidemiological characteristics and survival outcomes of patients with non-small-cell lung cancer (NSCLC) at a university hospital in Oman. Methods: This study was conducted from January to June 2016. A retrospective analysis was performed of consecutive patients diagnosed with NSCLC presenting to the Sultan Qaboos University Hospital (SQUH) in Muscat, Oman, between March 2000 and December 2015. Clinical features at presentation and prognostic and predictive markers were reviewed. Kaplan-Meir estimates were used to determine relapse-free survival, progression-free survival (PFS) and overall survival (OS). Results: A total of 104 patients presented to SQUH during the study period. The median age at diagnosis was 64 years. Overall, 62 patients (59.6%) had adenocarcinomas. Only 12 patients (11.5%) presented in the early stages (I or II) of the disease and the majority of patients had an Eastern Cooperative Oncology Group performance status of 1 (27.9%) or 2 (26.0%). The prevalence of epidermal growth factor receptor mutations was 27.9%. The median PFS for patients with advanced disease (stages III or IV) was five months and the median OS for all patients was seven months. After five years, 50.0%, 60.0%, 10.0% and 8.0% of patients with disease stages I, II, III and IV, respectively, were alive. Conclusion: Patients with NSCLC in Oman were found to present at an advanced stage. However, patient outcomes were similar to those reported in the USA.
Impact of Educational Activities in Reducing Pre-Analytical Laboratory Errors
A quality initiative(Original Study) Hamed Al-Ghaithi, Anil Pathare, Sahimah Al-Mamari, Rodrigo Villacrucis, Naglaa Fawaz, Salam Alkindi
ABSTRACT:Objectives: Pre-analytic errors during diagnostic laboratory investigations can lead to increased patient morbidity and mortality. This study aimed to ascertain the effect of educational nursing activities on the incidence of pre-analytical errors resulting in non-conforming blood samples. Methods: This study was conducted between January 2008 and December 2015. All specimens received at the Haematology Laboratory of the Sultan Qaboos University Hospital, Muscat, Oman, during this period were prospectively collected and analysed. Similar data from 2007 were collected retrospectively and used as a baseline for comparison. Non-conforming samples were defined as either clotted samples, haemolysed samples, use of the wrong anticoagulant, insufficient quantities of blood collected, incorrect/lack of labelling on a sample or lack of delivery of a sample in spite of a sample request. From 2008 onwards, multiple educational training activities directed at the hospital nursing staff and nursing students primarily responsible for blood collection were implemented on a regular basis. Results: After initiating corrective measures in 2008, a progressive reduction in the percentage of non-conforming samples was observed from 2009 onwards. Despite a 127.84% increase in the total number of specimens received, there was a significant reduction in non-conforming samples from 0.29% in 2007 to 0.07% in 2015, resulting in an improvement of 75.86% (P <0.050). In particular, specimen identification errors decreased by 0.056%, with a 96.55% improvement. Conclusion: Targeted educational activities directed primarily towards hospital nursing staff had a positive impact on the quality of laboratory specimens by significantly reducing pre-analytical errors.
Effectiveness of Prophylactic Cervical Cerclage in Prolonging Higher-Order Multiple Pregnancies
(Original Study) Nail Obeidat, Haifa Alchalabi, Maha Obeidat, Bahauddin Sallout, Shereen Hamadneh, Jehan Hamadneh, Yousef Khader, Zouhair Amarin
ABSTRACT:Objectives: This study aimed to assess the value of prophylactic cervical cerclage in prolonging higher-order multiple pregnancies. Methods: This retrospective study included all women with higher-order multiple pregnancies beyond 24 gestational weeks treated at the King Abdullah University Hospital in Irbid, Jordan, and King Fahad Medical City in Riyadh, Saudi Arabia, between February 2014 and January 2015. Selected maternal characteristics and obstetric outcomes were compared between women who received prophylactic cervical cerclage and those who did not. Results: A total of 146 women with higher-order multiple pregnancies were included in the study; of these, 94 (64.4%) underwent a prophylactic cervical cerclage insertion procedure and 52 (35.6%) women did not. No significant difference was found between the two groups with regards to maternal age, parity or number of fetuses. However, the mean gestational age at delivery was significantly higher for women without compared to those with prophylactic cervical cerclage (32.9 weeks versus 31.7 weeks) according to both univariate and multivariate analyses (P = 0.013 and 0.046, respectively). Additionally, 40.4% of women without and 14.9% of women with prophylactic cervical cerclage gave birth after 34 gestational weeks (P = 0.003). Conclusion: Overall, prophylactic cervical cerclage was not associated with prolongation of the pregnancy among women with higher-order multiple pregnancies in the current study.
Synoptic Versus Narrative Reporting of Prostate Biopsies at a Tertiary Healthcare Institution
Challenges, successes and expectations(Original Study) Nnamdi O. Orah, Charles C. Anunobi, Rufus W. Ojewola
ABSTRACT:Objectives: Cancer pathology reports are expected to contain all information required for patient management and disease surveillance. Moreover, reports for patients with prostate cancer have become increasingly complex with the addition of more pathological details. This study aimed to compare narrative and synoptic prostate cancer reports for core needle biopsies received at a tertiary hospital in Nigeria in order to determine which form was most complete according to international standards. Methods: This study was conducted from January 2010 to December 2015 at the Lagos University Teaching Hospital, Lagos, Nigeria. All malignant prostate cancer histopathology reports received during this period were analysed for the presence of important clinicopathological parameters, including the numbers of cores taken and those involved by the tumour, percentage of tumour involvement, Gleason score and the presence of high-grade prostatic intraepithelial neoplasms (HGPINs) and perineural and lymphovascular invasion. Results: A total of 83 reports were reviewed, of which 27 were in narrative and 56 in synoptic format. The documentation of clinicopathological characteristics in narrative reports was significantly incomplete compared to synoptic reports in recording the number of cores (33.3% versus 96.4%), number of cores involved by the tumour (11.1% versus 94.6%), percentage of cores involved by the tumour (3.7% versus 100.0%) and the presence of HGPINs (7.4% versus 100.0%) and perineural (59.3% versus 98.2%) and lymphovascular (48.1% versus 100.0%) invasion (P <0.001 each). Conclusion: Synoptic reports of malignant prostate cancer biopsies received at the Lagos University Teaching Hospital were found to contain more complete information than narrative reports.
Keywords: Pathology; Biopsy; Prostate Cancer; Prostatic Intraepithelial Neoplasia; Nigeria.
Neurology Research in Saudi Arabia
Urgent call for action(Original Study) Hussein Algahtani, Bader Shirah, Faisal Boker, Albaraa Algamdi, Abdulah Alkahtani
ABSTRACT:Objectives: Research activities in Saudi Arabia are promoted at the governmental and institutional levels. However, the output and quality of research conducted in the field of neurology has not yet been measured quantitatively. This study therefore aimed to analyse neurology-related publications from Saudi Arabia. Methods: This study was conducted in January 2016. A systematic search using the PubMed® search engine (National Library of Medicine, Bethesda, Maryland, USA) was conducted to identify all neurology-related articles published from Saudi Arabia between January 1996 and December 2015. Results: A total of 1,292 neurologyrelated publications were identified. Neurology research increased linearly with time, with most publications originating from Riyadh (67%) and the university sector (≈47%). However, most neurology-related articles were published in journals which had an impact factor of <1 (55%). Conclusion: Neurology research in Saudi Arabia has increased substantially over the last 20 years. However, as most articles were published in low-impact journals, the quality of research remains inadequate and should be improved. It is important that an official research culture be established in both governmental and private universities as well as colleges and health institutions in Saudi Arabia. The formation of clinical academic departments staffed by research experts is recommended to ensure the quality of neurology research output.
Keywords: Neurology; Research; Publications; Journal Impact Factor; Saudi Arabia.
Relationship Between Medication Adherence and Health Beliefs Among Patients with Hypertension in Oman
Pilot study(Brief Communication) Huda Al-Noumani, Jia-Rong Wu, Debra Barksdale, Esra Alkhasawneh, George Knafl, Gwen Sherwood
ABSTRACT:Objectives: The prevalence of hypertension (HTN) in Oman is alarmingly high and patient adherence to antihypertensive medications is inadequate. This study aimed to assess the relationship between medication adherence and health beliefs among Omani patients with HTN. Methods: This descriptive cross-sectional pilot study was conducted in December 2015 and included 45 patients with HTN recruited from four primary health centres in Al Dakhiliyah and Muscat governorates, Oman. Medication adherence and health beliefs were assessed using the Morisky Medication Adherence Scale (MMAS), Beliefs about Medicines Questionnaire, Brief Illness Perception Questionnaire and the revised Medication Adherence Self-Efficacy Scale. Results: The mean MMAS score was 5.3 ± 2.0, with 48.9% of patients reporting high adherence. Higher self-efficacy and stronger beliefs regarding medication necessity were significantly related to adherence (P = 0.012 and 0.028, respectively). Conclusion: The findings of this pilot study emphasise the role of health beliefs with regards to Omani patients’ adherence to antihypertensive medications.
Keywords: Hypertension; Health Behavior; Medication Adherence; Self Efficacy; Oman.
Bilateral Diaphragmatic Paralysis Following Paediatric Cardiac Surgery
Experience of four cases at the Royal Hospital, Muscat, Oman(Case Series) Said A. M. Al-Hanshi and Mohammed H. R. Al-Ghafri
ABSTRACT: Bilateral diaphragmatic paralysis (BDP) is a rare complication of paediatric cardiac surgery. We report four children who developed BDP following cardiac surgery who were managed at the Royal Hospital, Muscat, Oman, between 2009 and 2014. All four children suffered severe respiratory distress soon after extubation and required re-intubation within two hours. In addition, all of the children underwent a tracheostomy as an interim method for ventilation. The four children were successfully weaned from positive pressure ventilation following the functional recovery of at least one side of the diaphragm.
Secondary Adrenal Insufficiency Due to the Co-Administration of Ritonavir and Inhaled Fluticasone Propionate
Case report(Case Report) Ali Al-Maqbali, Bina Kamble, Salim Al-Qassabi, Ali Elgalib
ABSTRACT: Ritonavir is a powerful inhibitor of the cytochrome P450 3A4 (CYP3A4) isoenzyme. It is used as a pharmaceutical enhancer in the management of HIV-positive patients. However, when co-administered with other drugs that are metabolised via the CYP3A4 pathway, ritonavir can potentially cause serious drug-drug interactions. Inhaled fluticasone propionate, which is used to treat asthma and chronic obstructive airway disease, is particularly prone to such interactions due to its physiological attributes. We report a HIV-positive 48-year-old male patient who presented to Al Nahdha Hospital, Muscat, Oman, in 2012 with weight loss, generalised weakness and fatigue and diagnosed with secondary adrenal insufficiency as a result of concomitant ritonavir and inhaled fluticasone.
Keywords: Human Immunodeficiency Virus; Ritonavir; Fluticasone; Drug Interactions; Adrenal Insufficiency; Case Report; Oman.
Use of a Minimally Invasive Cardiac Output Monitor to Optimise Haemodynamics in a Patient with Mitral Valve Disease Undergoing Cerebrovascular Surgery
(Case Report) Ali M. Al-Mashani, Niranjan D. Waje, Neeraj Salhotra, Samaresh Das, Neelam Suri, Rashid A. Al-Sheheimi, Nilay Chatterjee
ABSTRACT: Patients with mitral valve disease undergoing cerebrovascular surgery face increased inherent risks due to their associated cardiac comorbidities. As such, the anaesthetic management of such patients is distinctly challenging. Simultaneous consideration of both the cerebrovascular and underlying cardiac conditions determines key anaesthetic issues, as fluids and vasopressors or inotropes need to be titrated according to haemodynamic variables in order to optimise cerebral blood flow without compromising cardiac function. We report a 45-yearold female patient with mild mitral stenosis and moderate-to-severe mitral regurgitation who presented to the Khoula Hospital, Muscat, Oman, in 2016 following a ruptured anterior communicating artery aneurysm requiring urgent surgical intervention. As highlighted in this case, the VolumeView EV1000™ (Edwards Lifesciences, Irvine, California, USA) system is a minimially invasive haemodynamic monitor that can help immensely in the perioperative management of such patients.
Transposition of the Great Arteries and Coarctation of the Aorta in an Infant Presenting with Bronchiolitis
An incidental finding(Case Report) Khaloud S. Al-Mukhaini and Ala M. Mohamed
ABSTRACT: The transposition of the great arteries (TGA) is a complex congenital heart disease which usually presents as cyanosis in neonates with limited mixing between the systemic and pulmonary circulatory systems. A delayed diagnosis of TGA can lead to ventricular failure. We report a six-week-old infant who was admitted to the paediatric Intensive Care Unit of the Royal Hospital, Muscat, Oman, in 2016 for bronchiolitis. During admission, she was incidentally diagnosed with TGA and coarctation of the aorta. Postnatal screening, including the use of pulse oximetry, plays a significant role in avoiding a late diagnosis of TGA; however, this screening tool is not widely used in Oman. Moreover, the common practice of applying a pulse oximetry probe only to the foot may have been limited in the current case due to the reverse differential saturation between the upper and lower limbs caused by this particular combination of lesions.
Keywords: Transposition of Great Arteries; Cyanosis; Neonatal Screening; Pulse Oximetry; Case Report; Oman.
Anomalous Origin of the Right Coronary Artery from the Left Coronary Sinus
Case report(Case Report) Ziyab K. Sarfaraz, Mohammad S. Siddiqi, Adil H. Al-Kindi, Tarek Alameddine
ABSTRACT: The anomalous origin of the right coronary artery from the left coronary sinus is a rare congenital disorder and can often result in sudden death upon initial presentation. We report a 19-year-old male patient who was referred to the Sultan Qaboos University Hospital, Muscat, Oman, in 2015 with multiple episodes of exertional angina. He was diagnosed as having an anomalous right coronary artery arising from the left coronary sinus following an intraoperative transesophageal echocardiogram. An unroofing ostioplasty of the anomalous right coronary artery was successful. Details of the surgical management of this anomaly are discussed.
Segmental Spinal Muscular Atrophy Localised to the Lower Limbs
First case from Oman(Case Report) Roshan Koul, Amna Al-Futaisi, Khalid Al-Thihli, Zandre Bruwer, Patrick Scott
ABSTRACT: Spinal muscular atrophy (SMA) is a genetic lower motor neuron disease. It usually involves all of the skeletal muscles innervated by the anterior horn cells of the spinal cord. In rare cases, there is also localised involvement of the spinal cord. We report a 10-year-old boy who presented to the Sultan Qaboos University Hospital, Muscat, Oman, in 2015 with muscle weakness restricted to the lower limbs. The presence of a homozygous deletion within the survival of motor neuron 1 gene confirmed the diagnosis of SMA. To the best of the authors’ knowledge, this is the first report of an Omani patient with segmental SMA involving only the lower limbs. Treatment for this rare and relatively benign form of SMA is symptomatic and includes physiotherapy. Keywords: Spinal Muscular Atrophies of Childhood; Spinal Muscular Atrophy, Segmental; Muscle Weakness; Pes Cavus; Case Report; Oman.
Bacille Calmette-Guérin Vaccine-Induced Tuberculous Hip Osteomyelitis in an Infant
Case report(Case Report) Mohammed S. Al-Azri, Jazel Manarang, Yaqoub Al-Mufargi
ABSTRACT: To this day, tuberculosis (TB) continues to pose a significant global health burden. The World Health Organization’s Expanded Programme on Immunization (EPI) recommends the bacille Calmette-Guérin (BCG) vaccine for infants to protect against the haematogenous spread of primary TB and other more severe types of TB infection. We report an eight-month-old boy who presented to the Armed Forces Hospital, Muscat, Oman, in 2015 with a one-month history of intermittent fever associated with a limited range of motion in the right hip area. He was up-to-date with his EPI vaccinations and had no history of exposure to individuals with TB infections. He was initially treated for bacterial septic arthritis; however, a GeneXpert TB assay revealed the presence of Mycobacterium tuberculosis, BCG strain. To the best of the authors’ knowledge, this is the first documented case from Oman of a child with TB hip osteomyelitis due to a BCG vaccination.
Unusual Case of an Intracranial Aneurysm Misdiagnosed as Focal Basal Meningitis
(Medical Image) Philips G. Michael, Rakesh M. Jamkhandikar, Imran K. Memon, Tahra Al-Saadi, Said Al-Aghbari, Majed Al-Muqaimi, Misbahuddin Ansari, Ahmed Al-Shamakhi, Asifa Ahmad