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      Sultan Qaboos University Medical Journal, a refereed multidisciplinary journal, publishes original articles three times per annum in print and on line with free public access to full text articles. Its aims are to: (1) be a leading regional medium of biomedical and allied scientific communication that will be recognized and accepted internationally; (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. Its niche is as a forum for the exchange of medical knowledge and research within Oman, the Gulf region and the Middle East/Asia encompassing clinical and basic science research and other medically relevant disciplines.

      Current Issue: December 2009 - Vol. 9, No. 3

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      Current Issue: Sultan Qaboos University Medical Journal
      December 2009 - Vol. 9, No. 3
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      Evaluation Tools in Postgraduate Medical Education : Do we need “Made in Oman” tools? (Editorial)
      Lamk Al-Lamki and Al-Neela Lamki
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      Influenza A (H1N1) 2009 : To vaccinate or not to vaccinate? (Editorial)
      Ali A Al-Jabri and Sidgi S Hasson
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      The Need to Teach Cognitive-Behavioural Therapy (Editorial)
      Gilbert Pinard
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      Cardiac Markers in the Early Diagnosis and Management of Patients with Acute Coronary Syndrome (Review)
      Hafidh A Al-Hadi and Keith A Fox
      ABSTRACT: Chest pain is a non-specific complaint and is the most frequent reason for patients seeking urgent medical attention. A small group of these patients will have acute coronary syndromes (ACS). The current diagnostic and triage systems based on clinical history and electrocardiograms are insufficient. They may result in some of these patients being misdiagnosed and being admitted to the wrong units or receiving inappropriate care, treatment and investigations. In some patients, the diagnosis is delayed resulting in the late administration (or no administration) of essential early treatment. A few patients with ACS may be inadvertently discharged from the emergency department leading to serious health and legal implications. These systems also result in the unnecessary admission of a substantial number of patients without ACS. The triage and management of patients with chest pain can be considerably improved by implementation of serial cardiac markers testing that can identify ACS in the very early stages of presentation. This review article will discuss the currently available markers of myocardial damage such as creatine kinase (CK), creatine kinase muscle and brain (CK-MB) (mass and activity), CK-MB isoforms, heart-type fatty acid-binding protein, myoglobin, cardiac troponin T, and cardiac troponin I.

      Keywords: Cardiac markers; Acute coronary syndromes; ACS; Acute myocardial infarction; AMI; Non-ST elevation myocardial infarction; NSTEMI; Chest pain.
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      Challenges of Childhood Uveitis (Review)
      Reem Abdwani
      ABSTRACT: Chronic uveitis is a rare, but potentially sight-threatening disease. The most common cause of chronic non-infectious uveitis is “idiopathic uveitis”. However, some systemic diseases are associated with chronic uveitis in children and are discussed. Chronic uveitis merits special consideration in children. The unique differences in children are highlighted with special consideration for the diagnostic and therapeutic challenges encountered in their management. While corticosteroids remain the mainstay of initial therapy, a wide range of immunosuppressive agents have been used with variable success. The role of immonomodulatory agents such as methotrexate, cyclosproin and some of the new biologic agents such as etanecept, infliximab, adalimumab are reviewed. Successful outcomes may be achieved with appropriate immunosuppressant therapy when given early in the disease, although clinical trials are required to define the true efficacy of this strategy.

      Keywords: Uveitis; Treatment
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      The Struggle Against Pandemic Influenza A (H1N1) 2009 (Special Contribution)
      Abdullah Balkhair
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      The Trend to Seek a Second Opinion Abroad amongst Cancer Patients in Oman : Challenges and opportunities (Sounding Board)
      Ikram A Burney
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      Relatives’ Advice and Health Care-Seeking Behaviour in Oman (Orginal Study)
      Ahmed Al-Mandhari, Samir Al-Adawi, Ibrahim Al-Zakwani, Mohammed Al-Shafaee and Liyam Eloul
      ABSTRACT: Objectives: It has been well established that pathways to care are considerably modified by local, social and psychological characteristics as well as the doctor-patient relationship. Scant attention has been paid to the role of family advice in care-seeking. In Omani society, traditional family values and a collective mindset are the norm rather than the exception. This paper examines how family advice affects the trajectory of care seeking. Methodology: During 2006-2007, data was collected through face-to-face interviews among a randomised sample of patients seeking medical consultation in various primary health care centres in the northern region of Oman. This study enrolled a total of 493 patients. The association between the advice of family members as a reason to seek health care and other predictors was analysed using multivariable logistic regression. Results: The data suggest that the advice of family members in care-seeking is strongly associated with gender, education, history of chronic illness, previous exposure to traditional medicine, and health education, as well as the history of immunisation. Conclusion: These findings suggest that the advice of family members remains a strong catalyst for care-seeking in Oman. The psychosocial factors affecting care-seeking leading to underutilisation of services or otherwise are discussed.

      Keywords: Care-seeking behavior; Relatives’ advice; Clinical population; Oman; Arab/Islamic.
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      Comparative Study of the Radial and Femoral Artery Approaches for Diagnostic Coronary Angiography (Orginal Study)
      *Mansour Sallam, Hafidh Al-Hadi, S Rathinasekar and Sunil Chandy
      ABSTRACT: Objectives: Femoral artery access is the standard approach for coronary procedures; however, the radial approach has gained sound recognition as an alternative to femoral access. We present our early experience with the transradial approach. Methods: A prospective, non-randomised study of 221 candidates for diagnostic coronary angiography was carried out at Sultan Qaboos University Hospital, Oman between December 2008 and April 2009. The patients had their procedure performed from radial or femoral access according to operator discretion and the results were compared. Femoral and radial groups included 116 and 105 patients respectively. Results: Radial access was associated with a significantly higher rate of procedural failure (17.1%) versus 0% in femoral group (p = 0.001). There were no local vascular complications in the radial group as opposed to 12.1% in the femoral group (p < 0.01). Hospital length of stay was significantly reduced in the radial group (4.06 versus 23.5 hours, p < 0.01). Total procedure time was longer in the radial group (23.7 ±13.7 min versus 20.1 ±7.4 min, p < 0.001), but radiation exposure was similar in both groups. There was a trend for a higher risk of major adverse cardiac events noticed in the femoral group; however, it did not reach statistical significance. Conclusion: The transradial approach for coronary angiography is associated with significantly reduced local vascular complications and shorter hospital stays. The femoral approach is the standard access site for coronary angiography; however, interventional cardiologists should acquire experience in the radial approach as an alternative in specific situations.

      Keywords: Coronary angiography; Radial; Femoral; Local vascular complications; Crossover, bleeding; Hospital stay.
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      Minor Oral Surgery Procedures in Patients Taking Warfarin : A 5-year retrospective study at Sultan Qaboos University Hospital, Sultanate of Oman (Orginal Study)
      Abdulaziz A Bakathir
      ABSTRACT: Objectives: Minor oral surgery (MOS) procedures in warfarinised patients carry the risk of post-operative bleeding. The aim of this study was to conduct a retrospective analysis and to describe the profile of warfarinised patients who underwent MOS procedures at Sultan Qaboos University Hospital. Methods: A retrospective study of 124 warfarinised patients (41 men and 83 women), who had a pre-operative international normalised ratio (INR) of ≤ 3.5 and underwent different MOS procedures under local anaesthesia, without discontinuation of their warfarin therapy, was carried out over a 5-year period from January 2004 to December 2008. Results: Ninety (72.6%) patients had simple dental extractions, 26 (21%) surgical extractions, 6 (4.8%) soft tissue biopsies and 2 (1.6%) had apicectomies with cyst enucleations. Local measures were applied in all patients, which included the use of oxidizing regenerated cellulose haemostatic agent (Surgicel) and suturing. A total of eight patients (6.5%), five who had surgical extractions and three who had simple extractions, bled enough post-operatively to require a return to hospital. All cases of post-operative bleeding were managed conservatively by repacking the bleeding site with haemostatic agent and re-suturing without the need for hospital admission. Conclusion: Minor oral surgery procedures can be safely conducted in warfarinised patients without interruption of warfarin regimen when the pre-operative INR is ≤ 3.5 and appropriate local haemostatic measures are used.

      Keywords: Warfarin; Tooth extraction; Oral surgery; Postoperative haemorrhage; Complications.
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      Patients’ Views of Interpersonal Continuity of Care in Four Primary Health Care Centres of Urban Oman (Orginal Study)
      Mohammed Al-Azri M and Shyam S Ganguly
      ABSTRACT: Objectives: Interpersonal continuity of care (consulting the same physician) is widely regarded as a core value of primary care and a crucial component of quality of care. Nonetheless, interpersonal continuity as experienced by patients remains a neglected topic in Arab countries including Oman. The aim of this study was to explore how patients view interpersonal continuity of care in the primary care setting in Oman. Methods: Four primary health centres (PHCs) were selected from two urban cities in Oman. In the period June to August 2008, adult patients were surveyed by questionnaire at their PHC while waiting to see their primary care physicians (PCPs). Results: We interviewed 319 (71%) of enrolled participants. Their ages ranged from 18-70 years. The majority of patients (223 - 70%) thought interpersonal continuity was very important for them; 232 (73%) patients felt that they obtained better care with interpersonal continuity. 225 (71%) patients preferred interpersonal continuity if they had personal, family or social problems. Nonetheless, compared to male patients, female patients had less chance to maintain interpersonal continuity (p = 0.018). Interpersonal continuity increased as the number of consultations increased (p = 0.030). Preference for interpersonal continuity was associated with increasing age (p = 0.020) and with the presence of chronic illnesses (p = 0.001). Patients with chronic illnesses, who reported more preference for interpersonal continuity, were also found to be more compliant with medications and committed to carrying out recommended advice compared to patients without such illnesses (p = 0.027). Conclusion: Omani patients perceived interpersonal continuity as an important aspect of primary care. Health planners should note patients’ preference for interpersonal continuity and take visible measures to support it. A larger study is needed to survey more of the PHCs of Oman.

      Keywords: Interpersonal continuity; Primary care; Oman.
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      Factors Contributing to the Spread of Odontogenic Infections : A prospective pilot study (Orginal Study)
      Abdulaziz A Bakathir, Khursheed F Moos, Ashraf F Ayoub and Jeremy Bagg
      ABSTRACT: Objectives: Spreading odontogenic infections (SOI) are the commonest type of serious infections encountered in the orofacial region. A prospective multi-centre study was conducted in the West of Scotland to investigate the contributing role of social, systemic and microbial factors in the pathogenesis of SOI. Methods: Twenty-five patients with severe odontogenic infections were recruited over a period of six months. At admission, clinical assessment included temperature rise, haematological and biochemical investigations. Demographic data, social and past medical histories were obtained. Microbiology samples were collected to identify causative microorganisms and the clinical management of each infection was recorded. Results: Most infections were associated with teeth or roots. Eighty percent of the patients were tobacco smokers and 72% came from deprived areas. Five patients were intravenous drug users, four admitted chronic alcohol abuse, six had underlying systemic disorders and two were at high risk of malnutrition. A raised C-reactive protein at admission was a useful indicator of the severity of infection. Inappropriate prior antibiotic treatment in the absence of surgical drainage was common. Microbiology results showed a predominance of strict anaerobes, notably anaerobic streptococci, Prevotella and Fusobacterium species. Conclusion: SOIs remain surprisingly common and our present pilot study showed a particular association with social deprivation and tobacco smoking. Further elucidation of the role of malnutrition in SOI would be of interest. Molecular characterisation of the microflora associated with SOI may help to highlight whether bacterial factors play a role in converting a localised dentoalveolar abscess into a serious, spreading odontogenic infection.

      Key words: Dental focal infection; Anaerobic bacteria; Complications.
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      Screening of Five Common Beta Thalassemia Mutations in the Pakistani Population : A basis for prenatal diagnosis (Orginal Study)
      Muhammad Usman, Moinuddin Moinuddin, Rubina Ghani and Sadia Usman
      ABSTRACT: Objectives: Thalassemia is one of the most common autosomal single-gene disorder worldwide. The highest prevalence of the disease is in the “thalassemia belt” which includes the Mediterranean region, parts of the Middle East, the Indian subcontinent, the southern parts of the Far East, Pakistan and South-East Asia. This study aimed to detect the common molecular abnormalities of the beta thalassemia syndrome in Pakistan. Methods: The study was conducted at the Institute of Hematology, Baqai Medical University, Karachi, Pakistan from August 2004 to November 2007. Blood samples of patients with beta thalassemia major (n = 400) were collected from hospital transfusion centres and diagnostic laboratories in different districts of Karachi representing five major ethnic groups including Punjabi, Pathan, Sindhi, Baluchi and Urdu speaking. All the samples were analysed for five common mutations by using the polymerase chain reaction technique ARMS (amplification of refractory mutation system). Results: The data revealed five common mutations including IVS 1-5(GC), Fr 41/42(-CTTT), Fr 8/9 (+G), IVS 1-1 and Del 619. These accounted for 90% of the total beta thalassemia genes in Pakistan. The IVS 1-5(GC) was found to be the most common beta thalassemia gene in the Pakistani population with a frequency of 44.4% present in all major ethnic groups. Conclusion: The results of this study will be helpful in the establishment of a large scale prenatal diagnosis programme in Pakistan.

      Keywords: Beta thalassemia; Mutations; Pakistani population; Prenatal diagnosis.
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      Serum Level of Heart-Type Fatty Acid-Binding Protein in Patients with Chronic Renal Failure (Brief Communication)
      Hafidh A Al-Hadi, Brent William and Keith A Fox
      ABSTRACT: Objectives: Heart-type fatty acid binding-protein (H-FABP) has been reported to be a potential novel biochemical marker for the early diagnosis of acute myocardial infarction (AMI). The effect of kidney diseases on the renal handling of H-FABP has not yet been fully evaluated. The aim of this study was to compare the effect of renal failure on the level of H-FABP and cardiac troponin (cTnT) concentrations. Methods: The study population was a small group of 16 patients with renal failure (6 females, 10 males aged 30-70 years) on routine regular haemodialysis or peritoneal dialysis. Results: The mean ±SD of serum urea and creatinine concentration in this group of patients was 19 ±9.6 mmol/L and 531.3 ±231.2 mmol/L respectively. H-FABP was increased in all 16 patients (81 ±53.3μg/L). The cTnT was increased ≥ 0.1μg/L in 8 patients (50%), ≥ 0.2μg/L in 5 patients (31.3%), and ≥ 0.3μg/L in 1 patient (6%). Conclusion: The diagnostic efficiency of H-FABP and cTnT for the diagnosis of AMI in the presence of renal failure may be limited and such patients may have high levels even in the absence of AMI.

      Keywords: Heart-type fatty acid-binding protein; Cardiac troponin T; Renal failure.
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      Leiomyomatosis Peritonealis Disseminata with Features of Carcinomatosis on Laparoscopy : A case report (Case Report)
      Ayman Al-Talib, Abdul R Al-Farsi and Gerald Stanimir
      ABSTRACT: Leiomyomatosis peritonealis disseminata (LPD), also known as diffuse peritoneal leiomyomatosis, is a rare disease characterised by subperitoneal proliferation of benign nodules mainly composed of benign smooth muscle cells, macroscopically mimicking peritoneal carcinomatosis. We report a 43 year-old woman who presented with menorrhagia, pelvic pressure and pain. Ultrasound of the pelvis showed uterine fibroids and an ovarian cyst. She was scheduled to have a laparoscopic hysterectomy and left salpingo-oophorectomy for symptomatic relief. A picture of carcinomatosis was seen on laparoscopy so multiple biopsies were taken and the patient was referred to the gynaecological oncology team. Definitive surgery was performed and final pathology was consistent with LPD with no evidence of malignancy. No hormone replacement therapy was offered after surgery. Macroscopically, LPD has features of malignancy; it usually pursues a benign course. To review current management of LPD and the risk of malignant transformation, we conducted a search in Medline, EMBASE, and the Cochrane Database of systematic reviews using the keywords: leiomyomatosis peritonealis disseminata, management and malignant transformation. LPD is a diagnostic challenge. Although rare, malignant transformation can occur since hormones play an important role in the pathogenesis of LPD, following surgery, patients should be followed carefully if they are on hormone replacement as these tumours could re-grow and cause symptoms or transform to malignancy.

      Keywords: Leiomyomatosis Peritonealis Disseminata; Peritoneal carcinomatosis; Malignant transformation; Case repor
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      A Case of Amiodarone-Induced Thyrotoxicosis : A diagnostic and therapeutic dilemma (Case Report)
      Sudheer Ahamed PS and Abe Mathew
      ABSTRACT: Amiodarone is an iodine rich agent widely used for the treatment of ventricular arrhythmias, paroxysmal supraventricular tachycardia, atrial fibrillation and flutter. However 14-18% of patients treated with amiodarone develop overt thyroid dysfunction in the form of either amiodarone-induced thyrotoxicosis (AIT) or amiodaroneinduced hypothyroidism (AIH). Two different types of AIT have been recognised and designated as Type 1 and Type 2. Distinguishing between the two is often difficult, but necessary for instituting appropriate treatment. We report a case of a 56 year-old male patient who was started on amiodarone for atrial fibrillation and then developed AIT. The challenges in the diagnosis and management of these patients are discussed.

      Keywords: Amiodarone; Thyroid; Thyrotoxicosis; Apathetic hyperthyroidism; Arrhythmias; Case Report.
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      A Case of Disseminated Tuberculosis with Adrenal Insufficiency (Case Report)
      Ali Al-Mamari, Abdullah Balkhair, Arunodaya Gujjar, Fatma Ben Abid, Ahmed Al-Farqani, Aisha Al-Hamadani and Rajeev Jain
      ABSTRACT: We present the case of a 37 year-old female who had disseminated tuberculosis (TB) with bilateral adrenal involvement resulting in primary adrenal failure (Addison’s disease) with refractory hyponatraemia and possible extrapontine ‘myelinolysis’. Laboratory results were remarkable for adrenal insufficiency. A Mantoux reaction was positive with evidence of pulmonary miliary TB. The magnetic resonance imaging scan showed all the characteristic changes of adrenal TB.


      Key words:
      TB; Adrenal; Insufficiency; Granuloma; Case report, Oman.
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      Papillary Carcinoma of theThyroid Presenting Primarily as Cervical Lymphadenopathy : An approach to management (Case Report)
      Norman O Machado, Pradeep J Chopra and Aisha Al Hamdani
      ABSTRACT: Papillary carcinoma of thyroid usually presents as a palpable thyroid mass. This could be associated with pain, hoarseness, stridor or dysphagia. Rarely, it presents solely as cervical lympadenopthy in the presence of an otherwise grossly normal thyroid gland. This could pose management problems. We report here a middle-aged lady who presented with cervical lymphadenopathy which on fine needle aspiration cytology was confirmed as metastatic papillary thyroid carcinoma. The thyroid gland was, however, normal on clinical examination and radiological investigations. Neck exploration confirmed a grossly normal thyroid gland; however, the cervical lymph node was found to invade the internal jugular vein. She underwent a total thyroidectomy and unilateral functional block dissection with resection of the involved segment of the internal jugular vein. Histopathology confirmed metastasis in the lymph node and a 2mm sized microcarcinoma in the resected thyroid gland. A radioactive iodine scan in the postoperative period revealed no other metastasis. The patient was prescribed lifelong thyroxine. She is on regular follow-up and 4 years following surgery continues to do well.

      Key words: Thyroidectomy; Carcinoma of thyroid; Lymphatic metastasis; Case report; Oman.
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      Surgical Technique for Retroperitoneoscopic Nephrectomy : A case report (Case Report)
      Shahid Aquil, Joseph K. Mathew, Krishna Prasad V, Khalid Rehman, Omar W Sharef, Ghalib Al Baadi
      ABSTRACT: A case of right non-functioning kidney secondary to chronic pyelonephritis is presented. The successful management through retroperitoneoscopic nephrectomy is described, emphasising the technique of this minimally invasive therapeutic option.

      Keywords: Laparoscopic surgery; Nephrectomy; Reteroperitoneal space; Surgical procedures; Pyelonephritis; Minimally invasive surgical procedures, Case report; Oman
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      Culture Negative Confoscan Positive Acanthamoeba Keratitis : A relentless course (Case Report)
      Nadia S Al Kharousi and Upender K Wali
      ABSTRACT: Acanthamoeba keratitis is a protozoal infection of the eye, mainly due to the use of non-sterile solutions, like saline for disinfecting contact lenses. We report a case where delay in the diagnosis of acanthamoeba keratitis due to inadequate laboratory investigations and clinical management led to an excruciatingly painful course of the disease. The importance of non-invasive imaging techniques of confocal microscopy in the diagnosis of acanthamoeba keratitis, in the absence of positive culture reports, is highlighted in this case.

      Key words: Acanthamoeba keratitis; Confocal microscopy; Penetrating keratoplasty; Case report; Oman.
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      Role of Magnetic Resonance Cholangiopancreatography in the Evaluation of Biliary Disease (Continuing Medical Education)
      Humoud Al-Dhuhli
      ABSTRACT: Magnetic resonace cholangiopancreatography (MRCP) was introduced in 1991, as a non-invasive method of imaging the biliary tree. Although endoscopic cholongiopancreatography (ERCP) has been the mainstay for diagnosing and treating pancreatico-biliary disease, complications such as pancreatitis, cholangitis, haemorrhage and duodenal perforation have limited its use as a routine diagnostic test. Although ERCP is still the standard of reference for imaging the pancreatico-biliary system, MRCP is the examination of choice in a setting where ERCP is difficult or impossible. It is useful in cases with severe biliary obstruction to evaluate the ducts proximal to the obstruction. MRCP has specific advantages over ERCP as it is non-invasive, cheaper, uses no radiation, requires no anaesthesia and is less operator dependent. When combined with conventional T1- and T2-weighted sequences, it allows detection of extraductal disease. The technology is still evolving to make the MRCP examination faster, sharper and with higher spatial resolution.

      Keywords: Magnetic resonance imaging; Magnetic resonace cholangiopancreatography; Cholangiography; Biliary ducts; Gallstone; Cholangiocarcinoma
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      Coronary Arteries Ectasia (Medical Image)
      Emad Al-Tamimi and Humoud Al-Dhuhli
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      Write Effectively : A quick course for busy health workers (Book Review)
      Tim Albert
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      Re: Silent Epidemic of Depression in Women in the Middle East and North Africa Region (Letters to Editor)
      Zena Al-Sharbati
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      Re: Plagiarism and Other Types of Publication Misconduct (Letters to Editor)
      Anupam Kakaria
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      4th Symposium on Patient Safety : One Aim with Shared Responsibilities (Abstracts)
      Sultan Qaboos University Hospital, Sultanate of Oman - 2nd - 4th February 2009
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