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.
The Role of Damage-Associated Molecular Patterns (DAMPs) in Human Diseases
Part II: DAMPs as diagnostics, prognostics and therapeutics in clinical medicine(Review) Walter G. Land
ABSTRACT: This article is the second part of a review that addresses the role of damage-associated molecular patterns (DAMPs) in human diseases by presenting examples of traumatic (systemic inflammatory response syndrome), cardiovascular (myocardial infarction), metabolic (type 2 diabetes mellitus), neurodegenerative (Alzheimer’s disease), malignant and infectious diseases. Various DAMPs are involved in the pathogenesis of all these diseases as they activate innate immune machineries including the unfolded protein response and inflammasomes. These subsequently promote sterile autoinflammation accompanied, at least in part, by subsequent adaptive autoimmune processes. This review article discusses the future role of DAMPs in routine practical medicine by highlighting the possibility of harnessing and deploying DAMPs either as biomarkers for the appropriate diagnosis and prognosis of diseases, as therapeutics in the treatment of tumours or as vaccine adjuncts for the prophylaxis of infections. In addition, this article examines the potential for developing strategies aimed at mitigating DAMPs-mediated hyperinflammatory responses, such as those seen in systemic inflammatory response syndrome associated with multiple organ failure.
Ebolavirus and Haemorrhagic Syndrome
(Review) Gerald A. Matua, Dirk M. Van der Wal and Rozzano C. Locsin
ABSTRACT: The Ebola virus is a highly virulent, single-stranded ribonucleic acid virus which affects both humans and apes and has fast become one of the world’s most feared pathogens. The virus induces acute fever and death, with haemorrhagic syndrome occurring in up to 90% of patients. The known species within the genus Ebolavirus are Bundibugyo, Sudan, Zaïre, Reston and Taï Forest. Although endemic in Africa, Ebola has caused worldwide anxiety due to media hype and concerns about its international spread, including through bioterrorism. The high fatality rate is attributed to unavailability of a standard treatment regimen or vaccine. The disease is frightening since it is characterised by rapid immune suppression and systemic inflammatory response, causing multi-organ and system failure, shock and often death. Currently, disease management is largely supportive, with containment efforts geared towards mitigating the spread of the virus. This review describes the classification, morphology, infective process, natural ecology, transmission, epidemic patterns, diagnosis, clinical features and immunology of Ebola, including management and epidemic containment strategies.
Increasing Incidence of Infants with Low Birth Weight in Oman
(Review) M. Mazharul Islam
ABSTRACT: This review article provides an overview of the levels, trends and some possible explanations for the increasing rate of low birth weight (LBW) infants in Oman. LBW data from national health surveys in Oman, and published reports from Oman’s Ministry of Health and the World Health Organization were collected and assessed between January and August 2014. Oman’s LBW rate has been increasing since the 1980s. It was approximately 4% in 1980 and had nearly doubled (8.1%) by 2000. Since then, it has shown a slow but steady rise, reaching 10% in recent times. High rates of consanguinity, premature births, number of increased pregnancies at an older maternal age and changing lifestyles are some important factors related to the increasing rate of LBW in Oman. The underlying causes of this increase need to be understood and addressed in obstetric policies and practices in order to reduce the rate of LBW in Oman.
The Burden of Asthma in Oman
(Review) Nasser Al-Busaidi, Zulfikar Habibulla, Malvika Bhatnagar, Nabil Al-Lawati and Yaqoub Al-Mahrouqi
ABSTRACT: Asthma is a common lung disease worldwide, although its prevalence varies from country to country. Oman is ranked in the intermediate range based on results from the International Study of Asthma and Allergies in Childhood. A 2009 study revealed that the majority of asthmatic patients in Oman reported both daytime and nocturnal symptoms, while 30% of adults and 52% of children reported absences from work or school due to their symptoms. Despite these findings, there is little data available on the economic burden of asthma in Oman. The only accessible information is from a 2013 study which concluded that Oman’s highest asthma-related costs were attributable to inpatient (55%) and emergency room (25%) visits, while asthma medications contributed to less than 1% of the financial toll. These results indicate a low level of asthma control in Oman, placing a large economic burden on healthcare providers. Therefore, educating asthmatic patients and their families should be prioritised in order to improve the management and related costs of this disease within Oman.
Keywords: Economic Burden of Disease; Asthma; Lung Diseases; Burden of Illness; Oman.
Heavy Vehicle Crash Characteristics in Oman
2009–2011(Special Contribution) Islam Al-Bulushi, Jason Edwards, Jeremy Davey, Kerry Armstrong, Hamed Al-Reesi and Khalid Al-Shamsi
ABSTRACT: In recent years, Oman has seen a shift in the burden of diseases towards road accidents. The main objective of this paper, therefore, is to describe key characteristics of heavy vehicle crashes in Oman and identify the key driving behaviours that influence fatality risks. Crash data from January 2009 to December 2011 were examined and it was found that, of the 22,543 traffic accidents that occurred within this timeframe, 3,114 involved heavy vehicles. While the majority of these crashes were attributed to driver behaviours, a small proportion was attributed to other factors. The results of the study indicate that there is a need for a more thorough crash investigation process in Oman. Future research should explore the reporting processes used by the Royal Oman Police, cultural influences on heavy vehicle operations in Oman and improvements to the current licensing system.
The Controversies of Hyponatraemia in Hypothyroidism
Weighing the evidence(Sounding Board) Ahmed S. Abuzaid and Nathan Birch
ABSTRACT: Hyponatraemia is a common electrolyte disturbance, with moderate (serum sodium: 125–129 mmol/L) to severe (serum sodium: ≤125 mmol/L) forms of the disease occurring in 4–15% of hospitalised patients. While it is relatively common, determining the underlying cause of this condition can be challenging and may require extensive laboratory investigations. To this end, it is important to ascertain the efficacy of laboratory tests in determining the cause of hyponatraemia. Up to 10% of patients with hypothyroidism also have hyponatraemia. Routine evaluation of thyroid function is often advocated in cases of low serum sodium. A review and discussion of the available literature is presented here to examine this recommendation.
Underlying Factors Behind the Low Prevalence of Autism Spectrum Disorders in Oman
Sociocultural perspective(Sounding Board) Allal Ouhtit, Yahya Al-Farsi, Marwan Al-Sharbati, Mostafa Waly, Ishita Gupta, Omar Al-Farsi, Maha Al-Khaduri, Mohammed Al-Shafaee and Samir Al-Adawi
ABSTRACT: Epidemiological surveys from various countries indicate an increased prevalence of autism spectrum disorders (ASD), leading researchers to debate whether there are now ‘more affected’ or ‘more detected’. The epidemiology of ASD in developing countries, such as Oman, has generally indicated a lower prevalence compared to developed countries in the West. In Oman, the prevalence is low; however, this article highlights some of the factors that could contribute to the appearance of a low ASD rate: cross-cultural variations in the presentation of distress; a lack of reliable biological markers for diagnosing ASD, and a lack of health services for children with ASD, thus limiting the number of participants in epidemiological surveys. While the defining features of ASD have yet to be established, pilot studies in Oman indicate a substantial number of children with these disorders. Therefore, it is important that these discrepancies be addressed and the need for appropriate services for this patient population in Oman be highlighted.
Predicting the Pathogenic Potential of BRCA1 and BRCA2 Gene Variants Identified in Clinical Genetic Testing
(Original Study) Clare Brookes, Stella Lai, Elaine Doherty and Donald R. Love
ABSTRACT:Objectives: Missense variants are very commonly detected when screening for mutations in the BRCA1 and BRCA2 genes. Pathogenic mutations in the BRCA1 and BRCA2 genes lead to an increased risk of developing breast, ovarian, prostate and/or pancreatic cancer. This study aimed to assess the predictive capability of in silico programmes and mutation databases in assisting diagnostic laboratories to determine the pathogenicity of sequence-detectable mutations. Methods: Between July 2011 and April 2013, an analysis was undertaken of 13 missense BRCA gene variants that had been detected in patients referred to the Genetic Health Services New Zealand (Northern Hub) for BRCA gene analysis. The analysis involved the use of 13 in silico protein prediction programmes, two in silico transcript analysis programmes and the examination of three BRCA gene databases. Results: In most of the variants, the analysis showed different in silico interpretations. This illustrates the interpretation challenges faced by diagnostic laboratories. Conclusion: Unfortunately, when using online mutation databases and carrying out in silico analyses, there is significant discordance in the classification of some missense variants in the BRCA genes. This discordance leads to complexities in interpreting and reporting these variants in a clinical context. The authors have developed a simple procedure for analysing variants; however, those of unknown significance largely remain unknown. As a consequence, the clinical value of some reports may be negligible. Keywords: Genes, BRCA1; Genes, BRCA2; HBOC Syndrome; In Silico.
Epidemiology of Diabetes Mellitus in Oman
Results from two decades of research(Original Study) Jawad A. Al-Lawati, Prashanth Panduranga, Hala A. Al-Shaikh, Magdi Morsi, Nabil Mohsin, Rajiv B. Khandekar, Hawra J. Al-Lawati and Riad A. Bayoumi
ABSTRACT:Objectives: This study aimed to describe the epidemiology of diabetes mellitus over the past two decades in Oman, particularly in terms of its prevalence and incidence. In addition, the study sought to estimate the future incidence of diabetes in Oman. Methods: Three national and three regional surveys conducted between 1991 and 2010 were analysed to obtain the age-adjusted prevalence and undiagnosed proportion of type 2 diabetes mellitus (T2DM) among Omani subjects aged ≥20 years. Diabetes mellitus registers and published studies were used to determine incidence rates of both type 1 diabetes mellitus (T1DM) and T2DM in Oman. Linear regression was used to determine trends and projections for diabetes in 2050. Results: The age-adjusted prevalence of T2DM in Oman varied from 10.4% to 21.1%, while the highest prevalence of impaired fasting glucose was found in males (35.1%). In comparison to men, higher incidence rates of T2DM were found in women (2.7 cases compared to 2.3 cases per 1,000 person-years, respectively). No significant trends were observed for the prevalence or incidence of T2DM in both genders. Undiagnosed T2DM was more common in men (range: 33–68%) than women (range: 27–53%). The results of this study show that by 2050, there will be an estimated 350,000 people with T2DM living in Oman (a 174% increase compared to estimates for 2015). Conclusion: Health authorities need to prioritise diabetes prevention and control in order to prevent or delay long-term complications and avert a potential epidemic of diabetes in Oman. Keywords: Diabetes Mellitus; Epidemiology; Incidence; Prevalence; Trends; Oman.
Incidence and Risk Factors of Parenteral Nutrition-Associated Cholestasis in Omani Neonates
Single centre experience(Original Study) Sharef W. Sharef, Siham Al-Sinani, Khalid Al-Naamani, Ibrahim Al-Zakwani, Zenaida S. Reyes, Hilal Al-Ryiami, Ashfaq A. Khan and Watfa Al-Mamari
ABSTRACT:Objectives: Parenteral nutrition-associated cholestasis (PNAC) is one of the most challenging complications of prolonged parenteral nutrition (PN) in neonates. There is a lack of research investigating its incidence in newborn infants in Oman and the Arab region. Therefore, this study aimed to assess the incidence of PNAC and its risk factors in Omani neonates. Methods: This retrospective study took place between January and April 2014. All neonates who received PN for ≥14 days during a four-year period (June 2009 to May 2013) at the neonatal intensive care unit (NICU) in Sultan Qaboos University Hospital, Muscat, Oman, were enrolled. Results: A total of 1,857 neonates were admitted to the NICU over the study period and 135 neonates (7.3%) received PN for ≥14 days. Determining the incidence of PNAC was only possible in 97 neonates; of these, 38 (39%) had PNAC. The main risk factors associated with PNAC were duration of PN, duration of enteral starvation, gastrointestinal surgeries, blood transfusions and sepsis. Neonates with PNAC had a slightly higher incidence of necrotising enterocolitis in comparison to those without PNAC. Conclusion: This study found a PNAC incidence of 39% in Omani neonates. There were several significant risk factors for PNAC in Omani neonates; however, after logistic regression analysis, only total PN duration remained statistically significant. Preventive strategies should be implemented in NICUs so as to avoid future chronic liver disease in this population. Keywords: Cholestasis; Parenteral Nutrition; Neonates; Incidence; Risk Factors; Oman.
The Association between Human Leukocyte Antigens and Hypertensive End-Stage Renal Failure among Yemeni Patients
(Original Study) Mogahid Y. Nassar, Hassan A. Al-Shamahy and Haitham A. A. Masood
ABSTRACT:Objectives: Many studies have attempted to locate a connection between various genetic factors and the pathogenesis of certain diseases. A number of these have found human leukocyte antigens (HLAs) to be the most significant genetic factors affecting the susceptibility of an individual to a certain disease. The present casecontrol study aimed to determine the connection between class I and class II HLAs and cases of hypertensive end-stage renal failure (HESRF), as contrasted with healthy controls, in Yemen. Methods: The study was carried out between March 2013 and March 2014 and included 50 HESRF patients attending the Urology & Nephrology Center at Al-Thawra University Hospital in Sana’a, Yemen, and 50 healthy controls visiting the same centre for kidney donation. Among both patients and controls, HLA class I (A, B and C) and class II (DRB1) genotypes were determined by polymerase chain reactions. Results: There was an association (odds ratio: 4.0) with HLA-A9(24) and HESRF, although this was not statistically significant. A significant protective function was found for the HLACW3 and DRB1-8 genes against the development of HESRF. Although HLA-B14 was present in some patients (0.06) and not in the controls, this difference was not statistically significant enough to conclude that HLA-B14 plays a role in the genetic predisposition for end-stage renal disease development. There was a high frequency of HLA-A2, B5, CW6, DRB1-3, DRB1-4 and DRB1-13 in both patients and controls. Conclusion: Although no HLAs were found to play a highly significant role in genetic predisposition to HESRF, certain HLA genes could be considered as protective genes against HESRF development. Keywords: Hypertension; Renal Failure, End-Stage; HLA Antigens; Case-Control Study; Yemen.
Knowledge, Beliefs and Behaviours Regarding the Adverse Effects of Medicines in an Omani Population
Cross-sectional survey(Original Study) Jimmy Jose, Beena Jimmy, Moza N. S. Al-Mamari, Thuraiya S. N. Al-Hadrami and Halima M. Al-Zadjali
ABSTRACT:Objectives: This study aimed to assess the knowledge, beliefs and behaviours of an Omani population with regards to the adverse effects of medicines. Methods: This cross-sectional survey was conducted between February and June 2012. A 17-item questionnaire was designed to assess three aspects: knowledge, beliefs and behaviours related to medicine safety. A total of 740 questionnaires were distributed in three representative governorates of Oman. Median total scores for the three sections were estimated. Associations with participants’ demographic variables and medication histories were also assessed. Results: A total of 618 participants completed the survey (response rate: 83.5%). Many participants (46.4%) believed that side-effects occurred only with high doses of medication and over 30% believed that they did not occur at all with traditional and over-the-counter medicines. The median total score was 19 (interquartile range: 6) out of a maximum of 30. Inadequate knowledge, incorrect beliefs and good behaviours were observed among the participants. There was a significant association between certain demographic parameters (age, educational qualification, history of chronic use of medicines and employment status) and median total scores. Participants reported obtaining additional information on medication safety from various sources, with doctors as the most widely used source. Conclusion: Inadequate knowledge and incorrect beliefs among this Omani population indicate a need for interventions to improve public knowledge and address misconceptions regarding medication safety. These interventions could be initiated on both an individual and public scale, with patient interactions by healthcare professionals and mass education activities targeting the larger population. Keywords: Knowledge; Beliefs; Behavior; Public Health; Drug Side Effects; Adverse Drug Reactions; Medication Adherence; Oman.
Lifestyles of Adult Omani Women
Cross-sectional study on physical activity and sedentary behaviour(Original Study) Azza Al-Habsi and Hashem Kilani
ABSTRACT:Objectives: This study aimed to investigate the lifestyles of adult Omani women with regards to physical activity (PA) levels and sedentary behaviour (SB). Methods: The study was carried out between May and June 2013 and included a total of 277 healthy women aged 18–48 years from five governorates in Oman. Total, moderate and vigorous PA levels and walking were self-reported by participants using the short form of the International Physical Activity Questionnaire. SB (total sitting time and different types of sitting time) was self-reported using the Domain-Specific Sitting Time Questionnaire on both working and non-working days. PA levels and SB were also objectively measured among 86 of the participants using an accelerometer. Results: The self-reported median ± interquartile range (IQR) total PA was 1,516 ± 3,392 metabolic equivalent of task minutes/week. The self-reported median ± IQR total sitting time was 433 ± 323 minutes/day and 470 ± 423 minutes/day for working and non-working days, respectively. Sitting at work on working days and sitting during leisure activities on non-working days formed the greatest proportion of total sitting time. Overall, accelerometer results indicated that participants spent 62% of their time involved in SB, 35% in light PA and only 3% in moderate to vigorous PA. Conclusion: Sedentary lifestyles were common among the adult Omani women studied. Lack of PA and increased SB is known to increase the risk of metabolic syndrome and obesity. The use of accelerometers to monitor PA and SB among different groups in Oman is highly recommended in order to accurately assess the lifestyle risks of this population.
Validity and Reliability of the Clinical Competency Evaluation Instrument for Use among Physiotherapy Students
Pilot study(Original Study) Zailani Muhamad, Ayiesah Ramli and Salleh Amat
ABSTRACT:Objectives: The aim of this study was to determine the content validity, internal consistency, testretest reliability and inter-rater reliability of the Clinical Competency Evaluation Instrument (CCEVI) in assessing the clinical performance of physiotherapy students. Methods: This study was carried out between June and September 2013 at University Kebangsaan Malaysia (UKM), Kuala Lumpur, Malaysia. A panel of 10 experts were identified to establish content validity by evaluating and rating each of the items used in the CCEVI with regards to their relevance in measuring students’ clinical competency. A total of 50 UKM undergraduate physiotherapy students were assessed throughout their clinical placement to determine the construct validity of these items. The instrument’s reliability was determined through a cross-sectional study involving a clinical performance assessment of 14 final-year undergraduate physiotherapy students. Results: The content validity index of the entire CCEVI was 0.91, while the proportion of agreement on the content validity indices ranged from 0.83–1.00. The CCEVI construct validity was established with factor loading of ≥0.6, while internal consistency (Cronbach’s alpha) overall was 0.97. Test-retest reliability of the CCEVI was confirmed with a Pearson’s correlation range of 0.91–0.97 and an intraclass coefficient correlation range of 0.95–0.98. Inter-rater reliability of the CCEVI domains ranged from 0.59 to 0.97 on initial and subsequent assessments. Conclusion: This pilot study confirmed the content validity of the CCEVI. It showed high internal consistency, thereby providing evidence that the CCEVI has moderate to excellent inter-rater reliability. However, additional refinement in the wording of the CCEVI items, particularly in the domains of safety and documentation, is recommended to further improve the validity and reliability of the instrument. Keywords: Clinical Competence; Physiotherapy Speciality; Validity and Reliability; Malaysia.
Heavy Metals in Seafood and Farm Produce from Uyo, Nigeria
Levels and health implications(Original Study) Orish E. Orisakwe, Herbert O. C. Mbagwu, Godwin C. Ajaezi, Ukeme W. Edet and Patrick U. Uwana
ABSTRACT:Objectives: This study aimed to obtain representative data on the levels of heavy metals in seafood and farm produce consumed by the general population in Uyo, Akwa Ibom State, Nigeria, a region known for the exploration and exploitation of crude oil. Methods: In May 2012, 25 food items, including common types of seafood, cereals, root crops and vegetables, were purchased in Uyo or collected from farmland in the region. Dried samples were ground, digested and centrifuged. Levels of heavy metals (lead, cadmium, nickel, cobalt and chromium) were analysed using an atomic absorption spectrophotometer. Average daily intake and target hazard quotients (THQ) were estimated. Results: Eight food items (millet, maize, periwinkle, crayfish, stock fish, sabina fish, bonga fish and pumpkin leaf) had THQ values over 1.0 for cadmium, indicating a potential health risk in their consumption. All other heavy metals had THQ values below 1.0, indicating insignificant health risks. The total THQ for the heavy metals ranged from 0.389 to 2.986. There were 14 items with total THQ values greater than 1.0, indicating potential health risks in their consumption. Conclusion: The regular consumption of certain types of farm produce and seafood available in Uyo, Akwa Ibom State, Nigeria, is likely adding to the body burden of heavy metals among those living in this region. Keywords: Heavy Metals; Food; Recommended Daily Intake; Risk Assessment; Food Safety Analysis; Nigeria.
Disclosure of Medical Errors in Oman
Public preferences and perceptions of current practice(Brief Communication) Mark I. K. Norrish
ABSTRACT:Objectives: This study aimed to provide insight into the preferences for and perceptions of medical error disclosure (MED) by members of the public in Oman. Methods: Between January and June 2012, an online survey was used to collect responses from 205 members of the public across five governorates of Oman. Results: A disclosure gap was revealed between the respondents’ preferences for MED and perceived current MED practices in Oman. This disclosure gap extended to both the type of error and the person most likely to disclose the error. Errors resulting in patient harm were found to have a strong influence on individuals’ perceived quality of care. In addition, full disclosure was found to be highly valued by respondents and able to mitigate for a perceived lack of care in cases where medical errors led to damages. Conclusion: The perceived disclosure gap between respondents’ MED preferences and perceptions of current MED practices in Oman needs to be addressed in order to increase public confidence in the national health care system.
Keywords: Medical Error; Disclosure; Ethics, Medical; Oman.
Measuring Secondhand Smoke in Muscat, Oman
(Brief Communication) Jawad A. Al-Lawati, Yusuf Al-Thuhli and Farrukh Qureshi
ABSTRACT:Objectives: This study aimed to measure exposure to secondhand smoke (SHS) and assess venue compliance with the municipal Law against smoking indoors in public places in Muscat, Oman. Methods: Following the selection of 30 public indoor venues within the Muscat governorate, the concentration of suspended SHS particulate matter (PM2.5) in the venues’ indoor air was measured throughout July and August 2010. Results: Almost all of the venues were found to be compliant with the smoke-free municipal, with the exception of a café that served waterpipes for smoking indoors. The concentration of PM2.5 in this venue showed an average level of 256 μg/m3 which was 64 times the level of that found in the non-smoking venues. Conclusion: Aside from one café, the majority of the assessed indoor public venues abided by the smoke-free municipal law. However, the enforcement of policies banning smoking in indoor public recreational venues should be re-examined in order to protect member of the public in Oman from exposure to SHS.
Estimates of Average Glandular Dose with Auto-modes of X-ray Exposures in Digital Breast Tomosynthesis
(Brief Communication) Izdihar Kamal, Kanaga K. Chelliah and Nawal Mustafa
ABSTRACT:Objectives: The aim of this research was to examine the average glandular dose (AGD) of radiation among different breast compositions of glandular and adipose tissue with auto-modes of exposure factor selection in digital breast tomosynthesis. Methods: This experimental study was carried out in the National Cancer Society, Kuala Lumpur, Malaysia, between February 2012 and February 2013 using a tomosynthesis digital mammography X-ray machine. The entrance surface air kerma and the half-value layer were determined using a 100H thermoluminescent dosimeter on 50% glandular and 50% adipose tissue (50/50) and 20% glandular and 80% adipose tissue (20/80) commercially available breast phantoms (Computerized Imaging Reference Systems, Inc., Norfolk, Virginia, USA) with auto-time, auto-filter and auto-kilovolt modes. Results: The lowest AGD for the 20/80 phantom with auto-time was 2.28 milliGray (mGy) for two dimension (2D) and 2.48 mGy for three dimensional (3D) images. The lowest AGD for the 50/50 phantom with auto-time was 0.97 mGy for 2D and 1.0 mGy for 3D. Conclusion: The AGD values for both phantoms were lower against a high kilovolt peak and the use of auto-filter mode was more practical for quick acquisition while limiting the probability of operator error. Keywords: Thermoluminescent Dosimetry; Breast; Mammography; Radiation Dosage.
Rare Presentation of Aggressive T/Natural Killer Lymphoproliferative Disorder in a Leukaemic Phase in an Omani Patient
(Medical Image) Arwa Z. Al-Riyami, Khalil Al-Farsi, Sahimah Al-Mamari, Ahmed Al-Farqani and Murtadha Al-Khabori