Despite the benefits of using virtual reality (VR) in medical education and treatment, some challenges and limitations result in the uselessness or misuse of this technology. Therefore, recognizing potential challenges related to VR might be helpful in the strategic decision-making process to implement and develop this technology in the healthcare field. Accordingly, our review aimed to determine the challenges associated with the application of VR in the field of medical education and treatment. We searched Science Direct, Google Scholar, and PubMed databases for relevant papers using a defined search query. We restricted the search to articles in English or Persian language published by the end of 2018. The main challenges of developing and using VR with educational and therapeutic objectives are categorized as general and specific. General challenges include reduced face-to-face communications, education, cost challenges, users’ attitudes, and specific challenges such as designing, safety considerations, VR side effects, evaluation, and validation of VR applications. Challenges related to VR will have different effects, thus identifying each of them helps to determine the solutions for each challenge. Also, it is suggested to develop and update laws, standards, and protocols, which play an important role in increasing the effective application of VR at the national level.

Single gene mutations have been implicated in the pathogenesis of a form of diabetes mellitus (DM) known as the maturity-onset diabetes of the young (MODY). However, there are diverse opinions on the suspect genes and pathophysiology, necessitating the need to review and communicate the genes to raise public awareness. We used the Google search engine to retrieve relevant information from reputable sources such as PubMed and Google Scholar. We identified 14 classified MODY genes as well as three new and unclassified genes linked with MODY. These genes are fundamentally embedded in the beta cells, the most common of which are HNF1A, HNF4A, HNF1B, and GCK genes. Mutations in these genes cause β-cell dysfunction, resulting in decreased insulin production and hyperglycemia. MODY genes have distinct mechanisms of action and phenotypic presentations compared with type 1 and type 2 DM and other forms of DM. Healthcare professionals are therefore advised to formulate drugs and treatment based on the causal genes rather than the current generalized treatment for all types of DM. This will increase the effectiveness of diabetes drugs and treatment and reduce the burden of the disease.

Objectives: Childhood injuries are among the most significant causes of mortality and morbidity as estimated by the World Health Organization. We sought to assess the incidence of school-related injuries in A'Dakhiliyah governorate schools, with the secondary aim of addressing common causes, risk factors, and how the school environment contributes to injuries. Methods: We conducted a prospective cohort study involving all students in A'Dakhiliyah governorate schools during the 2015–2016 academic year. Data were collected using a questionnaire that was filled out by the school nurses or social workers at school health units. Results: The incidence of school-related injuries was 2.3% per year. The majority of injured students were in grades 1–4 (63.7%) and 72.6% were boys. Improper school equipment and furniture accounted as a risk factor for 25.3% of injuries. The three most common mechanisms causing injury were falling (50.4%, n = 584), collision with an object (30.7%, n = 356), and collision with a person (18.8%, n = 218). Asphalt (59.5%, n = 295) and concrete (40.5%, n = 201) were the most common surfaces in the school environment to contribute to injuries. Conclusions: School-related injuries are not uncommon and can be prevented by improving the infrastructure of school buildings and supplying appropriate school stationary equipment for age. Our results are useful in developing a national injury prevention program aimed at enhancing safety in school environments.

Keywords: Child; Students; Incidence; Schools; Risk Factors; Accidental Falls; Oman.

Objectives: Consuming raw vegetables presents a considerable risk to the public and is the chief mode of transmission of intestinal parasites. We sought to assess the degree of parasitic contaminations on selected vegetables in the UAE. Methods: A total of 218 fresh vegetable samples were collected randomly from different farms and local supermarkets between February 2017 and January 2018. After washing and centrifugation, the sediment was examined microscopically for parasitic forms. Results: Protozoa cysts and helminths eggs were detected in 15.1% (33/218) of samples. The most detected parasites were Entamoeba complex (E. histolytica/E. dispar/E. moshkovskii) (30.3%), Entamoeba coli (18.2%), Trichuris trichiura (12.1%), Strongyloides stercoralis (12.1%), Ascaris lumbricoides egg (9.1%), Endolimax nana cyst and Enterobius vermicularis egg (6.1% each), and Giardia lamblia and Hymenolepis nana (3.0% each). We found no significant association between the vegetable type and the parasite occurrence (p > 0.050). Moreover, parasite incidence was independent of the vegetable type (p > 0.050). Conclusions: The study highlights the potential of raw produce serving as a major source of foodborne disease outbreaks and its role in the transmission of intestinal parasitic infections. Public education on the safe handling of raw vegetables is recommended.

Keywords: Intestinal Diseases, Parasitic; Parasites; Vegetables; United Arab Emirates.

Objectives: Miscarriage is a common pregnancy complication causing substantial psychiatric complications. This study was designed to investigate whether the administration of brief supportive psychotherapy (BSP) is effective on the management of women with miscarriage when conducted in the first 24 hours of hospitalization in order to prevent symptoms of anxiety, depression, and grief at four-months post-miscarriage. Methods: We conducted a randomized clinical trial on 79 women with miscarriage hospitalized in Ayatollah Rohani teaching hospital. The women were randomly assigned into two groups (39 in the experimental group and 40 in the control group). All interventions were implemented for two study groups during the first 24 hours of hospitalization in a private room in the hospital. The experimental group received a two-hour BSP. The objective outcomes were assessed using Hospital Anxiety and Depression Scale and Perinatal Grief Scale (PGS), which has three subscales (active grief, difficulty coping, and despair) and were measured before the intervention and at four-months post-miscarriage. Results: The results of pre-tests in the follow-up of the trial suggested that the participants who received BSP reported significant reductions in the mean scores of active grief (-34.2±9.7 vs. 28.1±-6.9), difficulty coping (27.1±6.4 vs. 23.3±4.3), despair (28.0±8.4 vs. 22.8±5.2), and total PGS (89.6±23.1 vs. 74.4±15.3), in contrast to participants in the control group who did not report such results. Further, the results of generalized estimating equations models revealed that brief supportive psychotherapy caused a significant decrease in the level of factors including active grief, difficulty coping, despair, total perinatal grief, anxiety symptoms, and depressive symptoms in subjects in the experimental group compared to those in the control group after miscarriage. Also, the frequency of anxiety symptoms (13.5% vs. 60.5%), depressive symptoms (32.4% vs. 71.1%), and grief symptoms (10.8% vs. 65.8%) was found to be significantly lower in the group receiving psychotherapy than in the control group at four-months follow-up. Conclusions: Administration of BSP session during the first 24 hours of hospitalization for women with miscarriage can be considered a reliable method to prevent anxiety symptoms, depression symptoms, and perinatal grief at four-months follow-up.

Keywords:Abortion, Spontaneous; Grief; Anxiety; Depression; Counseling; Psychotherapy, Brief.

Objectives: Colorectal cancer (CRC) is a common malignancy with a high rate of mortality. The dysregulation of genes involved in the Wnt/β-catenin signaling pathway is a common finding in cancers. Wnt-inhibitory factor-1 (WIF-1) suppresses the Wnt/β-catenin signaling pathway and its inactivation by genetics and epigenetic changes may cause cancer. We investigated the DNA methylation status of the WIF-1 gene in patients with CRC and its interaction with MTHFR C677T polymorphism, a known modifier of methylation reaction. Methods: We investigated 50 cancerous tissues and the adjacent non-cancerous tissue. Genomic DNA was extracted using a commercial kit and was treated by sodium bisulfite. Methylation-specific PCR was used for methylation analysis, and restriction fragment length polymorphism PCR to analyze the C677T polymorphism of the MTHFR gene. Results: The frequency of WIF1 promoter DNA methylation was significantly higher in cancerous tissue than adjacent non-cancerous tissue (52.0% vs. 8.0%; p < 0.001). WIF1 promoter DNA methylation status showed a significant association only with tumor location (p = 0.009). Carriers of TT genotype and T allele of MTHFR C677T polymorphism had a significantly higher frequency of unmethylated WIF1 gene than methylated WIF-1 gene in cancerous tissue (p = 0.025 and p = 0.001, respectively). Conclusions: Promoter DNA hypermethylation of the WIF-1 gene is a significant risk factor for CRC development, which was significantly associated with tumor location only. The significant association of TT genotype and T allele of MTHFR C677T polymorphism with unmethylated WIF-1 gene suggests a

Keywords: DNA Methylation; Colorectal Neoplasms; Polymorphism, Restriction Fragment Length; Genotype.

Objectives: Despite the fact that sleep disturbances have been associated with poor maternal and neonatal health outcomes in pregnancy, no studies have assessed excessive daytime sleepiness or the risk for sleep apnea among pregnant Saudi Arabian women. We sought to estimate the prevalence of excessive daytime sleepiness (EDS) and the high risk for sleep apnea (OSA) in a sample of pregnant Saudi women. Methods: An anonymous self-report questionnaire was completed by 517 pregnant women who attended obstetric outpatient clinics at King Abdulaziz Medical City, Riyadh, Saudi Arabia, for a routine pregnancy check. We collected demographic and clinical data for all patients and used the Berlin Questionnaire and the Epworth Sleepiness Scale to determine the primary outcomes. Results: A high risk of OSA was found in 37.1% of women (95% confidence interval (CI): 33.00%–41.50%), and EDS was found in 32.1% (95% CI: 28.10%–36.30%). The presence of both (EDS and a high risk of OSA) was found in 14.9% of women (95% CI: 11.90%–18.30%). We found increased odds of EDS in women who reported pain three times or more per week (adjusted odds ratio (aOR) = 2.59) and insomnia (aOR = 1.65). Older women (≥ 37 years) (aOR = 3.00), those who reported pain once a week (aOR = 1.99), pain twice a week (aOR = 2.75), three times or more a week (aOR = 2.57), and insomnia (aOR = 1.95) increased the odds of high risk for OSA. Conclusions: EDS and a high risk for OSA affected a large portion of the pregnant women included in the study, primarily those who reported pain and insomnia. Our study provides important information for gynecologists to help promote healthy sleep and manage the issues arising from sleep disturbances among pregnant women as part of their daily practice.

Keywords: Pregnancy; Sleep Apnea Syndromes; Pain; Sleep Apnea, Obstructive; Saudi Arabia.

Objectives: We sought to assess the relationship between respiratory distress syndrome (RDS) in neonates delivered by elective cesarean section at term gestation with and without corticosteroids cover. We also aimed to determine other neonatal complications such as sepsis, hypoglycemia, and hyperbilirubinemia. Methods: We conducted a retrospective descriptive study from January 2010 to December 2015 on all Omani women who delivered by elective cesarean section at Sultan Qaboos University Hospital between 37+0 and 38+6 weeks gestation. Results: Among 650 patients included in the study, 20.8% (n = 135) received corticosteroids antenatally and 79.2% did not. RDS was found in 16 out of 650 neonates, making the prevalence of RDS 2.5%. Higher gravidity and parity and a mean gestational age of less than 37.6 weeks, were associated with a significant risk of RDS. Administration of antenatal corticosteroids did not change the respiratory morbidity in the newborns (p = 0.340). A mean birth weight of 2.9 kg was associated with a significant risk of RDS (p = 0.043). All 16 newborns required neonatal intensive care unit admission and ventilator support. The most common ventilatory support used was continuous positive airway pressure (56.2%). The most common secondary complication in neonates diagnosed with RDS was transient tachypnea of the newborn (53.8%). Conclusions: The prevalence of RDS was low. Giving antenatal corticosteroids for patients with planned elective cesarean at term did not seem to have a beneficial effect on neonatal respiratory morbidity. Further studies with larger sample size including multiple centers is recommended.

Keywords: Infant, Newborn; Pregnancy; Cesarean Section; Respiratory Distress Syndrome, Newborn; Pregnancy Outcome; Oman.

Objectives: We sought to evaluate the effectiveness of six weeks pulmonary rehabilitation (PR) in patients with asthma-chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS). Methods: We enrolled 28 patients with ACOS. Fourteen patients were randomly allocated to the PR group, which comprised of supervised endurance training, supervised resistance training, breathing exercises, self management, and education. The other 14 patients were allocated to the control group, who were asked to continue their usual routine strategies for six weeks. All patients were assessed at baseline and after six weeks using the six minute walk test (6MWT), St George Respiratory Questionnaire (SGRQ), pulmonary function test (PFT), and Bode index (BI). Results: We saw a significant improvement in 6MWT (p = 0.001), SGRQ (p = 0.007), and BI (p < 0.001) in the PR group after six weeks compared to the control group. There was no significant difference between the groups for PFT (p = 0.182) after six weeks. Conclusions: Use of a short-term PR program in ACOS patients results in favorable changes in functional capacity, health-related quality of life, and BI. However, short-term PR was not sufficient to register changes in pulmonary function in these patients.

Keywords: Asthma-Chronic Obstructive Pulmonary Disease Overlap Syndrome; Walk Test; Self-Management; Resistance Training; Quality of Life; Breathing Exercises.

Objectives: Empathy is a core component of an efficient physician-patient relationship. Although students’ preexisting medical views may influence responses to physician-patient relationship, there is little knowledge about the psychological predictive factors of empathic perspective for physician-patient relationship. We aimed to examine whether psychological well-being, dispositional perspective, and spiritual well-being could predict the empathic perspective of medical students regarding the physician-patient relationship. Methods: In a cross-sectional study, 350 medical students of Babol University of Medical Sciences were recruited at four levels of education including basic sciences, preclinical medicine, clerkship, and internship. The students completed four questionnaires including Jefferson Scale of Empathy - student version, Brief Ryff psychological well-being, Individual Disposition, and Spiritual Well-Being. Results: The score of medical student’s perspective to clinical empathy was high (106.1±29.8, range: 20–140), but diminished with further years of education. Female students had higher empathy scores than their male counterparts. Pearson’s correlation coefficient revealed a strong positive significant relationship between student’s perspective to clinical empathy and spiritual well-being (r = 0.56), cognitive empathy (r = 0.51), and psychological well-being (r = 0.43), and tendency to egalitarianism (r = 0.37). The results of stepwise multivariate analysis regression revealed that cognitive empathy (β = 0.300), self-esteem (β = 0.133), and spiritual well-being (β = 0.388) positively predicted student’s perspective to clinical empathy regarding the physician-patient relationship. Conclusions: The results suggested that promoting empathic care in curricula of medical schools may be more effective if students’ preexisting perspectives, cognitive empathy, self-esteem, spiritual well-being, and tendency to egalitarianism are taken into account.

Keywords: Empathy; Physician-Patient Relations; Self Concept.

Objectives: We sought to describe the clinical and genetic characteristics of patients with familial hypercholesterolemia (FH) that presented to the lipid clinic at Sultan Qaboos University Hospital, Muscat, Oman. Methods: Patients who presented with high low-density lipoprotein cholesterol (LDL-C) levels (> 189.0 mg/dL or 4.9 mmol/L) were recruited to the study. FH was diagnosed according to the Dutch Lipid Clinic Network criteria. Analyses were performed using univariate statistics. Results: The study enrolled 450 patients with a mean age of 48.0±12.0 years, 56.0% (n = 252) were males and 11.3% (n = 51) were smokers. At admission, the proportion of ‘probable/definite’, ‘possible’, and ‘unlikely’ FH were 27.6% (n = 124), 70.0% (n = 315), and 2.4% (n = 11), respectively. Overall, 26.0% (n = 117) of patients had hypertension, 22.4% (n = 101) had a history of coronary artery disease, and 17.3% (n = 78) had diabetes mellitus. Those with ‘probable/definite’ FH were more likely to be prescribed high-intensity statin therapy (75.8% vs. 54.5%; p < 0.001) and statin ezetimibe combination (50.8% vs. 27.3%; p < 0.001) when compared to the ‘unlikely’ FH cohort. Additionally, those with very high atherosclerotic vascular disease (ASCVD) risk were also associated with high-intensity statin therapy (54.7% vs. 42.7%; p = 0.006) and statin ezetimibe combination (26.4% vs. 17.2%; p = 0.023). Patients with ‘probable/definite’ FH were less likely to achieve their LDL-C goal attainment compared to those with ‘unlikely’ FH (13.0% vs. 57.1%; p < 0.001). Furthermore, those with very high ASCVD risk were less likely to achieve their LDL-C goals compared to the high ASCVD risk cohort (9.6% vs. 32.0%; p < 0.001). Conclusions: FH patients are underdiagnosed, undertreated, and less likely to attain their LDL-C goals in Oman.

Keywords: Hypercholesterolemia; Acute Coronary Syndrome; Cardiovascular Abnormalities; Diabetes Mellitus; Arabs; Oman.

Type B insulin resistance syndrome (TBIRS) has not been previously reported in Arab populations. We report a case of TBIRS in an Arab patient with mixed connective tissue disease (MCTD). Investigations revealed a clinical condition marked by positive anti-insulin receptor and ribonucleoprotein antibodies. The patient presented with severe hyperglycemia, weight loss, arthralgia, and acanthosis nigricans. He was managed successfully with an intensive pulsed combination regimen of cyclophosphamide and plasmapheresis augmented with high doses of prednisolone, which normalized his blood sugar levels without insulin therapy. MCTD was controlled by hydroxychloroquine. During the course of his treatment, the patient developed diabetic ketoacidosis secondary to the gluteal abscess, leukopenia, and recurrent hypoglycemia. Here, we showed that immunosuppressive agents and plasmapheresis can induce remission of TBIRS and can be used to normalize the blood sugar levels of Arab patients with this condition.

Keywords: Insulin Resistance; Mixed Connective Tissue Disease; Arabs.

Congenital generalized lipodystrophy (Berardinelli-Seip syndrome) is an autosomal recessive condition, presenting during infancy with generalized loss of fat. We report a 30-year-old female patient with diabetes who has acromegaloid features, prominent umbilicus, prominent muscles, prominent subcutaneous veins, and gross hepatomegaly. Near-total loss of subcutaneous fat was confirmed by whole-body magnetic resonance imaging and laboratory data revealed significant hypertriglyceridemia, uncontrolled diabetes mellitus, and heavy proteinuria with stage IIIa chronic kidney disease. Her blood film revealed thrombocytosis that on further evaluation by bone marrow biopsy was confirmed to be a myeloproliferative neoplasm (MPN); essential thrombocytosis (ET). She also had skin lesions that were proven to be reactive perforating collagenosis and necrobiosis lipoidica diabeticorum. She was managed conservatively and received interferon injections with fair general condition and control of her ET. However, her kidney function deteriorated furthermore to stage V chronic kidney disease requiring regular treatment with hemodialysis. We believe this is a unique case of Berardinelli-Seip syndrome with MPN that could be a coincidental association or part of a new syndrome.

Keywords: Lipodystrophy, Congenital Generalized; Thrombocytosis.

Between 3–5% of all patients with Parkinson’s disease (PD) have onset before the age of 40 years, which is likely related to genetic causes. Parkin gene mutations are the most common mutations, which are associated with autosomal recessive early-onset PD. A 34-year-old Emirati female presented with complaints of limb and speech tremor. She had been having difficulties in initiating movement and speech during her job. These problems began two years ago and had become progressively worsened. Her medical history was significant for generalized seizures for the past three years, which was well controlled with prescription medications. She was unaware of any family members with Parkinson’s or any genetic disorders. Her examination revealed a reduction in eyelid blinking movement and hypomimia facial appearance. She had severe bilateral upper and lower extremity rigidity, which was more evident on her right side. While resting, the patient exhibited bilateral pin-rolling tremors in both of her upper extremities. Her gait was shuffling in nature with reduced arm swing and abnormal retropulsion. All of her laboratory investigations were normal. Genetic analysis revealed a homozygous 1 base pair insertion in exon 5 of PARK2 gene (c.601_602insA), resulting in a nonsense mutation causing a stop codon instead of a cysteine codon (p. Cys201X). The patient showed an excellent response to treatment. We described a case of early-onset PD in a female, who on genetic analysis, was found to have a previously undescribed homozygous mutation in the PARK2 gene.

Keywords: Codon, Terminator; Codon, Nonsense; Autosomal Recessive Parkinsonism; Parkinson’s Disease; PARK 2 protein, human.

The concomitant occurrence of tuberculous adenitis and Hodgkin lymphoma is rare, posing a diagnostic dilemma since both have similar symptoms, such as lymphadenopathy, weight loss, fever, and night sweats. We reported such a case in a 15-year-old girl who presented with fever and neck swelling and was found to have lymphadenopathy. A biopsy of the right supraclavicular lymph node showed Reed-Sternberg cells and stained positive for acid-fast bacilli and tuberculosis culture. The patient was diagnosed with tuberculous adenitis with concurrent Hodgkin lymphoma in the same lymph node. She was started on anti-tubercular medications and chemotherapy and showed clinical improvement. This case highlights the need for suspicion in order to identify these two disorders in the same patient, since missing one of them is possible and may lead to fatal complications.

Keywords: Hodgkin Disease; Tuberculosis; Lymphadenopathy.

Objectives: We sought to identify the epidemiological characteristics of the first case series of patients with COVID-19 in Oman. Methods: We included national surveillance data of patients with laboratory-confirmed COVID-19 from 24 February to 17 April 2020. Analyses were performed using descriptive and univariate statistics. Results: Of the 1304 patients studied, the mean age was 37.0±13.0 years old, 80.3% were males, and 35.8% were Omanis. The other mostly affected nationalities were Indian (29.1%), Bangladeshi (20.0%), and Pakistani (10.7%). Out of the total, 80.1% were from the Muscat governorate. Omani patients were significantly more likely to be males than females and aged between 20 and 59 years old (p < 0.001). On presentation, 95.9% cases were mild, 3.6% moderate, and 0.5% severe. The case fatality rate was 0.5%. All deaths were from Muscat governorate; four from Mutrah, one from A'Seeb, and one from Bawshar. Conclusions: This case series provides epidemiological characteristics as well as the early outcomes of patients with laboratory-confirmed COVID-19.

Keywords: COVID-19; Epidemiology; Coronavirus; Oman.