Objectives: In 2017, the World Health Organization (WHO) published a list of global priority pathogens (GPP) – 12 species of bacteria with critical, high, and medium antibiotic resistance (AR). In this review, our goal was to quantify published reports of AR in this group of pathogens using the Medline-PubMed databases. We also sought to quantify, compare and rank the top five reported AR pathogens globally, regionally and for Bahrain, and describe the evidence from Bahrain for the purpose of infection prevention and control, and to help research and development. Methods: We conducted a bibliometric, retrospective, descriptive review to search the Medline-PubMed database for reports specific to the WHO GPP list published up to 19 April 2017. Results: Our search revealed 42 136 documents with an increase in the last five years. Globally, there were more high tier pathogen documents (33 640) than critical (6405) and medium (2091). Methicillin-resistant Staphylococcus aureus (MRSA) was the highest reported, followed by extended-spectrum beta-lactamases (ESBL) resistant Enterobacteriaceae and vancomycin-resistant Enterococcus faecium. Nine out of the 12 pathogens were gram-negative. MRSA was the topmost documented pathogen globally and in the Gulf Cooperation Council (GCC) region zone of classification, whereas ESBL resistant Enterobacteriaceae ranked the top in Bahrain. There were two critical tier pathogens in the global, GCC region, and Bahrain. We found 14 articles from Bahrain, four articles on ESBL resistant Enterobacteriaceae, three on MRSA, two on carbapenem-resistant Acinetobacter baumannii, and five on different pathogens. Conclusions: Our findings suggest the need for a comprehensive, multipronged policy response particularly at the time when the antibiotic pipeline is nearly empty. We recommend thoughtful, integrated infection prevention and control strategies to address the immediate and long-term threats of AR in Bahrain and the GCC.

Objectives: We sought to develop and implement a Maternity Dashboard to improve the quality of health care at the ground level. Methods: We conducted a prospective, descriptive cross-sectional study, involving patients with high-risk pregnancies who had been referred to Nizwa Hospital, Oman. The selection of quality indicators was based on the prototype of clinical outcomes from the Royal College of Obstetricians and Gynecologists. The Maternity Dashboard team adapted local parameters and used preselected general parameters, based on clinical observations, to develop the dashboard. Results: The issues posing a threat to Nizwa Hospital in becoming a world-class healthcare facility were: overbooked outpatient department, insufficient staff, and more junior doctors compared to senior doctors and consultants. Additionally, being pioneers, naturally, the dashboard development team faced difficulties while handling adverse situations. More time, guidance, and standardization of quality indicators are desirable. Conclusions: Following the approval for a Maternity Dashboard in Nizwa Hospital, the data compiled in an Excel sheet are transmitted manually every month for display on the dashboard in the delivery suite. It is intended to make data collected and dissemination completely automated in the future with the help of the Al-Shifa Healthcare Information System. Expansion of the idea of a Maternity Dashboard to other hospitals and specialties at the regional and tertiary level of the health care system in Oman and a comparison of the standard of health care provided between hospitals based on similar quality indicators would be the next milestone.

Objectives: We sought to assess the prevalence of gestational trophoblastic diseases (GTD) among pregnant women at Sultan Qaboos University Hospital (SQUH) and compare our results with the international studies. We also sought to determine the risk factors, histological features, sonographic findings, and outcomes in women with GTD. Methods: We conducted a retrospective cohort study of all women diagnosed with GTD and followed at SQUH between November 2007 and October 2015. We collected data on maternal demographics, risk factors, sonographic features, histological diagnosis, follow-up period, and chemotherapy treatment from the hospital information system. Results: Sixty-four women with GTD were included in the study with a mean age of 31.0±7.5 years, mean gravidity 4.0, and parity 2.0. The prevalence of GTD was 0.3% (one in 386 births), and the most common risk factors were increased maternal age and multiparity. A partial hydatidiform mole was diagnosed in 54.7%, complete hydatidiform mole in 43.8%, and invasive mole in 1.6% of women. Eleven percent of women required chemotherapy. Typical ultrasound features for partial molar pregnancy were present in 54.7% of our sample, while snowstorm appearance was seen in 89.3% of those with complete mole. Negative beta-human chorionic gonadotropin was achieved 70 days after diagnosis in 41 women. Conclusions: The awareness of the risks and complications of GTD among physicians with close follow-up is paramount. There is a need to establish a national registry of GTD cases in Oman.

Objectives: Medical professionals are exposed to many job stressors everyday, which can lead to psychological disturbances as well as burnout syndrome. We sought to assess the level of burnout among primary care physicians (PCPs) in Oman and explore risk factors for its development. Methods: We conducted a cross-sectional, analytical study among a random cluster sample of 190 PCP working in Muscat, Oman. Indices of burnout (emotional exhaustion (EE), depersonalization (DP) and personal accomplishment (PA)) were noted using the Maslach Burnout Inventory-Human Services Survey (MBI-HSS). We also used a questionnaire to obtain sociodemographic and job characteristics data. We used a binary logistic regression model and both unadjusted and adjusted odds ratios for statistical analysis. Results: The prevalence of burnout in all three dimensions was 6.3%. High levels of MBI-HSS subscales were reported on EE, DP and PA with 17.8%, 38.2%, and 21.5%, respectively. Logistic regression analysis revealed that working over 40 hours per week was the most important risk factor for burnout among PCPs. Conclusions: A total of 6.3% of PCPs working in urban areas in Oman suffered burnout. Long working hours was strongly associated with high occupational burnout. Solutions to eliminate or decrease the rate of burnout involve institutional changes, primarily respecting weekly working hours, and in more severe cases psychotherapy help is very important.

Objectives: Catheterization of urinary bladder during surgery frequently leads to agitation of the patient in the recovery room, especially in those patients who remain catheterized after gaining consciousness. We hypothesized that administration of a combination of ketamine-haloperidol (KH) before urinary catheterization would reduce the incidence of catheter-related bladder discomfort (CRBD) while reducing some adverse effects of ketamine in the postoperative period. Methods: A total of 119 male patients who underwent lumbar spinal stenosis surgery were randomized into three groups. The KH group consisted of 39 patients who received KH just before urinary catheterization. The second arm of the study including 40 patients who received pethidine-haloperidol (PH). The control (C) group consisted of 40 patients who received normal saline as a placebo. We sought to determine the incidence and severity of CRBD at arrival in recovery and one, six, and 24 hours after. Results: The incidence of CRBD upon arrival in the recovery room was 17.9% in the KH group, and 52.5% and 55% in the PH and C groups, respectively. The incidence of CRBD was significantly lower in the KH group at arrival in the recovery room. The severity of CRBD was lower in the KH group at one and six hours of surgery (p < 0.007). There was no significant difference 24 hours after surgery. Conclusions: Intravenous administration of KH before urinary catheterization effectively decreases the incidence and severity of postoperative CRBD while reducing adverse effects attributed to ketamine.

Objectives: Standard interviews are used by most residency programs to assess non-cognitive skills, but variability in the interviewer’s skills, interviewer bias, and context specificity limit reliability. We sought to investigate the consistency and satisfactoriness of the multiple mini-interview (MMI) model for resident selection into an otorhinolaryngology head and neck surgery residency program. Methods: This pilot study was done in an independent academic residency training center for 15 applicants, in seven eight-minute MMI stations with eight raters for the 2015–2016 academic year. The raters included the chief resident and education committee chairman in one of the stations. Candidates were assessed on two items: medical knowledge (two standardized case scenarios) and behavioral knowledge (personality and attitude, professionalism, communication, enthusiasm to the specialty, and English proficiency). Results: Of 15 candidates, 10 (66.7%) were female and five (33.3%) were male; five were recommended for selection, and five were kept on the waiting list. The reliability, intraclass correlation coefficient (ICC), of the scores obtained from seven items of MMI was 0.36 (95% confidence interval (CI): -0.31–0.75; p = 0.110). However, the ICC of the medical interview was 0.54 (95% CI: 0.45–0.84; p = 0.090). The correlation between behavioral items score and MMI total score was r = 0.135 (p = 0.150). Conclusions: The interview evaluation/survey form given to candidates and interviewers has shown that MMI is a fair and effective tool to evaluate non-cognitive traits. Both candidates and interviewers prefer MMI to standard interviews. The MMI process for residency interviews can generate reliable interview results using only seven stations and is acceptable and preferred over standard interview modalities by residency program applicants and faculty members.

Objectives: Cancer stem cells are involved in radioresistant cancers. Transcription factors Sry-related HMG box (SOX2) and octamer binding transcription factor 4 (OCT4) can confer pluripotent cell characteristics and self-renewal ability and are involved in carcinogenesis, metastasis, tumor recurrence, and resistance to therapy. Apoptosis, DNA repair, and telomerase factors also contribute to radioresistance. We sought to identify the role of SOX2 and OCT4 as cancer stem cell markers and their effects on apoptosis (via caspase 3), DNA repair (Chk1) and telomerase (hTERT) in conferring resistance to radiotherapy. Methods: We conducted a case-control study of 40 patients with stage IIIB cervical squamous cell carcinoma who completed radiation therapy at Cipto Mangunkusumo Hospital, Jakarta, Indonesia. The patients were classified according to their treatment response as having exhibited a complete or incomplete response. Clinical follow-up and Pap smears were performed between six and 12 months after therapy for those with a good initial response to determine the final response to therapy. Immunohistochemistry was used to analyze SOX2, OCT4, caspase-3, Chk1, and hTERT expression in paraffin sections of the initial biopsy. Results: Strong expression of SOX2 (p = 0.011, p = 0.001) and OCT4 (p < 0.001, p < 0.001) was significantly associated with both an incomplete initial and final therapy response, respectively. Multivariate analysis showed that SOX2 and OCT4 expression levels were the strongest markers of an incomplete response to radiotherapy (odds ratio (OR) = 5.12, p = 0.034, and OR = 17.03, p = 0.004, respectively). Conclusions: Strong expression of SOX2 and OCT4 may be a good indicator of incomplete radiotherapy outcome in patients with stage IIIB cervical cancer.

Objectives: Tenofovir disoproxil fumarate (TDF) has been reported to cause nephrotoxicity necessitating cessation in some patients. No information is available on the nephrotoxic effect of TDF in Omani or regional patients with HIV infection. We sought to determine the prevalence of the nephrotoxic effects of TDF in our cohort of Omani patients with HIV and investigate the nephrotoxic effects of other cofactors. Methods: We conducted an observational cohort study on 83 Omani patients currently on TDF-containing antiretroviral therapy. Renal dysfunction was monitored by measuring the serum creatinine estimated glomerular function rate (eGFR), urinary protein creatinine ratio (uPCR), and fractional excretion of phosphate (FEPi). Fisher’s exact test was used to determine any additional nephrotoxic effects of cofactors. Results: The median values for the duration of TDF use, patient age, and body mass index (BMI) at the time of the study were 178 weeks (range = 3–554), 42 years (range = 21–80), and 27 (range = 17.4–42.7), respectively. The median initial CD4 count and viral load were 205 × 106/L (range = 3–1745) and 37 250 copies/mL (range = undetectable–9 523 428), respectively. FEPi was high in two (2.4%) patients, moderate in 26 (31.3%), and low in 55 (66.3%) patients. uPCR was high in 10 (12.0%) patients, moderate in 28 (33.7%), and low in 45 (54.2%) patients. No cofactors added to the nephrotoxicity except hypertension (p = 0.045). Conclusions: Better definitions for TDF-associated toxicity are needed. uPCR is not a very good indicator of TDF-associated tubular dysfunction. Omani patients with HIV on TDF have a 4% prevalence of renal toxicity, but a study with a larger number of patients is required to explore this observation further. Cofactors like duration of TDF use, age, BMI, gender, diabetes mellitus, and use of protease inhibitors did not have an impact on the severity of FEPi and uPCR.

Objectives: Estradiol (E2) plays an important role in the pathophysiology of ovarian hyperstimulation syndrome (OHSS). This study aimed to evaluate the effect of fenugreek seed aqueous (FSA) extract on serum E2 levels in a rat model of OHSS. Methods: A total of 34 female Sprague Dawley rats, aged 18 days old, weighing 40 to 45 g, were randomly divided into negative control, positive control, and treatment groups. A daily dose of 1500 mg/kg per body weight of FSA extract was administrated orally to rats in the treatment group for 13 days. On day eight of the study, OHSS was induced in both positive control and treated groups by subcutaneous injection of pregnant mare’s serum gonadotropin 50 IU for four consecutive days, followed by human chorionic gonadotropin 25 IU on the fifth day. The effect of FSA extract was evaluated by measuring the concentration of serum E2 using the enzyme-linked immunosorbent assay. Results: FSA extract reduced serum E2 level significantly in the treated OHSS model (p-value < 0.050) compared to the positive control group. Conclusions: The finding has important implications on the development of female infertility adjuvant drugs for safe assisted reproduction technology cycles in terms of OHSS prevention.

Chloral hydrate (CH) poisoning is not commonly seen in the emergency department. CH is a commonly prescribed sedative agent for various day care procedures despite its toxic profile even when other safe sedative medications are available. We report a case of CH poisoning that manifested with neurotoxicity followed by cardiotoxicity leading to cardiac arrest. With a high index of suspicion and proper management, our patient was discharged with normal neurological outcome. In this case report, we discuss CH poisoning and toxicity with highlights on specific intervention including β-blockers. CH induced arrhythmias have been reported to be refractory to the standard antiarrhythmic medications and respond well to β-blockers.

Pallister-Killian mosaic syndrome (PKS) is a rare sporadic condition with multiple congenital anomalies and intellectual deficits caused by mosaic tissue-limited tetrasomy of the short arm of chromosome 12 (12p). The clinical features are highly variable, ranging from mild to severe. Diagnosis is usually missed because of the low level of mosaicism in peripheral lymphocytes. We present a case of an Omani newborn with PKS with severe clinical presentation and multisystem involvement that lead to postnatal death. Karyotype and fluorescent in situ hybridization studies confirmed the presence of chromosome 12p duplication. This is the first case of PKS reported in the literature from Oman and the Arab world.

Scrub typhus is a potentially fatal rickettsial infection caused by Orientia tsutsugamushi. It is an obligate intracellular Gram-negative bacterium transmitted by the bite of infected chigger larva. The disease is distributed from Asia to the Pacific islands, and this region is known as the Tsutsugamushi Triangle. A 28-year-old man was admitted to the Royal Hospital with a four-day history of fever, headache, rigors, anorexia, and a nonspecific macular rash. Clinical presentation, laboratory results as well as epidemiological data indicated that this might be a case of scrub typhus. Additional serology tests confirmed the presumed diagnosis, and the patient was successfully treated with empirical therapy. Untreated scrub typhus has high mortality and early diagnosis and adequate treatment can prevent the potentially fatal outcome of the disease.

Isolated septal myocardial infarction is an uncommon condition with diagnostic difficulty due to small infarction size and anatomical variations. We report a case of isolated septal myocardial infarction, in which the diagnosis was confirmed not by electrocardiographic, echocardiographic, or angiographic findings, but by nuclear imaging. A 46-year-old man with chest discomfort exhibited ST-segment elevations in leads V1 and V2, and borderline abnormalities of the septal wall motion on echocardiography. Emergency coronary angiography demonstrated delayed flow in the second septal branch of the left anterior descending coronary artery. Intravascular ultrasound showed plaque in the proximal portion of the septal branch without evidence of plaque rupture. No balloon angioplasty or stent implantation was required because the flow delay in the septal branch disappeared after the intravascular ultrasound procedure. Myocardial perfusion-metabolism mismatch, as assessed by resting thallium-201 and iodine-123-beta-methyl-p-iodophenyl-pentadecanoic acid, was seen in the mid-septal region.

Objectives: There is a high interest in the early diagnosis of hypothyroidism in preterm newborns for preventing any intellectual disability. Our study sought to determine the incidence of abnormal thyroid-stimulating hormone (TSH) between three and six days old and in weeks two, six, 10, and 12 after birth to evaluate the validity of repeating the test in premature infants. Methods: We conducted a retrospective review of 320 886 live births in Fars province, Southwestern Iran, from March 2014 to October 2017. TSH levels in premature infants were measured by heel prick test, and the data was collected from the central newborn screening center of Fars province. Results: The number of premature newborns was 15 381, and the prevalence of hypothyroidism was 2.3%. Among 355 premature newborns with high TSH, 31.3% was detected in three to six days of life, 43.9% in the second week, 14.4% in the sixth week, 9.9% in the tenth week, and 0.6% in the twelfth week as hypothyroidism. Conclusions: Our results showed that thyroid screening of preterm infants needs retesting in two, six, and 10 weeks after to detect cases in newborns who would not otherwise be identified.