Objectives: Common variable immunodeficiency (CVID) is a heterogeneous disorder characterized by hypogammaglobulinemia and increased susceptibility to recurrent infections. Methods: We searched PubMed, Web of Science, and Scopus databases to find eligible studies from the earliest available date to January 2018 with standard keywords. Pooled estimates of the infection prevalence and the corresponding 95% confidence intervals were calculated using random-effects models. Results: We found that pneumonia (67.7%) was the most prevalent infection followed by upper respiratory tract (59.0%) and gastrointestinal infections (36.3%). Furthermore, bacterial complications (41.7%) were higher in CVID patients compared to viral (25.4%), parasitic (18.8%), or fungal (3.4%) infections. Patients with longer age at diagnosis presented with fewer disease comorbidities. There was an inverse correlation between T lymphocyte count and viral infections. Moreover, we found that immunoglobulin M (IgM) serum level was inversely correlated with hepatitis C and gastrointestinal infections, and IgG serum level was inversely correlated with infectious arthritis. Higher numbers of CD4 and CD8 T cells were associated with the lower frequencies of otitis media. CVID patients with infections had significantly lower percentages of CD3 T cells. In contrast, higher percentages of CD19 lymphocytes were found in CVID patients who had a history of infections. Conclusions: Our findings demonstrated that in addition to hypogammaglobulinemia, patients with CVID have an imbalance in the frequency of T lymphocytes, which is in parallel with the higher frequency of infectious complications.

Keywords: Common Variable Immunodeficiency; Hypogammaglobulinemia; Pneumonia; Sinusitis;
Otitis Media.

Interprofessional education (IPE) is an integral educational outlook that is necessary to make sure that the graduates of an allied health care education are able to be valuable members or leaders of collaborative healthcare practices. Literature and resources are available about various models that have been used by different institutions to integrate IPE as part of their curriculum. With the growing need for collaborative practice, the curriculum must be designed to foster competencies required for IPE. There are challenges present, but with the concerted effort of the administration, faculty, and students, the benefits of IPE can be enjoyed by the institution and eventually by patients.

Keywords: Professional Practice; Students; Curriculum.

Objectives: Tobacco smoking is a major public health concern and a leading cause of preventable death. We sought to review epidemiological studies available on the prevalence of tobacco use, the associated health effects, and interventions that have undergone evaluation concerning smoking cessation and prevention in the UAE. Methods: An electronic search of the PubMed and Scopus databases was conducted using appropriate keywords for articles published between 2007 and 2017. We included all English-language articles in addition to research articles on the UAE populations (including both citizens and expatriates). Results: Fourteen articles were included, of which 11 were cross-sectional studies, one was a cohort longitudinal study, one was quasi-experimental, and one case-control study. Our results suggest that current smoking prevalence estimates vary widely. This is the first study in the region to review the smoking prevalence, health risk, and interventions in the UAE. Conclusions: UAE Government demonstrated excellent efforts by raising the cost of smoking through taxation, mounting sustained social marketing campaigns, and ensuring that health professionals routinely advise smokers to stop smoking accompanied by behavioral and pharmacological support for cessation. Hence, future research should be more focused on evaluating the outcome and impact of current anti-smoking campaigns.

Keywords: Smoking Prevention; Smoking Cessation; Cigarette Smoking; Smokers; Prevalence; Public Health; Tobacco Products; Tobacco Smoking; United Arab Emirates.

Objectives: Diabetic foot disease causes substantial morbidity and mortality, but it can be prevented. Our study examined the frequency of diabetes-related foot problems and foot self-care practices, as reported by consecutive patients attending primary and secondary diabetes services in Muscat, Oman. Methods: A cross-sectional survey utilizing a newly developed and pre-tested questionnaire was conducted at eight primary health care centers and one polyclinic (secondary care) in A'Seeb, Muscat. A convenience sample of 353 consecutive Omanis, aged 20 years and above, diagnosed with diabetes were invited to participate in this study. We collected data on clinico-demographic characteristics, patient-reported foot complications, and foot self-care practices. Results: Of the 350 patients who agreed to participate (mean diabetes duration 7.9±7.4 years, response rate: 99.2%), 62.3% were female, 57.4% were unemployed, more than half were illiterate (52.9%), and around three-quarters (71.4%) were unsure of the type of diabetes they had. More than half (55.1%) reported having at least one or more sensory peripheral neuropathy symptoms, almost half (49.1%) reported one or more peripheral vascular disease symptoms in the previous month, and 12.5% a history of foot ulceration. Reported foot self-care practices were overall suboptimal; 54.7% did not examine the bottom of their feet each day. Conclusions: Although self-reported diabetes-related foot complications were common in this population, foot self-care practices were inadequate. These findings suggest a need for the provision of regular foot care education to patients with diabetes. Future research should explore barriers to recommended foot self-care practices.

Keywords: Amputation; Diabetes Mellitus; Surveys and Questionnaires; Diabetic Foot; Oman; Primary Health Care; Self Care; Ulcer.

Objectives: We sought to determine the overall observed three-year survival rate of women with breast cancer in Basrah, Iraq, and investigate the associated factors. Methods: Data was collected retrospectively from the Oncology Center registry in Basrah, all newly diagnosed women with breast cancer between 1 January 2013 and 31 December 2014 were included and followed-up until 31 December 2017. We used the Kaplan-Meier method to estimate the overall survival rates. Cox regression analysis was used to investigate the association between survival and prognostic factors. Results: A total of 605 women who were diagnosed with breast cancer during 2013– 2014 were included in the study, 44.1% had advanced tumor stages (stage III and IV). The overall observed three-year survival rate was 83.3%. Cox regression analysis showed that late stage (stage IV vs. stage I hazard ratio (HR) = 4.65; 95% confidence interval (CI): 3.28–7.81) and grade (poorly vs. well differentiated HR = 4.10; 95% CI: 3.01–6.82) were significantly associated with poor survival. Conclusions: The overall observed survival rate of women with breast cancer in Basrah was comparable to that reported for developing countries, but it is poorer than that of developed countries. Advanced stage and poorly differentiated tumors were significant predictors of poor survival.

Keywords: Breast Cancer; Survival Rate; Proportional Hazards Models; Iraq.

Objectives: Studies have consistently reported the health benefits of physical activity (PA) in diabetes care. Our study aimed to explore perceptions of general well-being in participants of the ‘MOVEdiabetes’ intervention aimed at increasing PA in adults with type 2 diabetes in Oman. Methods: ‘MOVEdiabetes’ is a cluster-randomized study where participants in the intervention group (IG) received PA consultations, pedometers, and WhatsApp messages versus the usual care in the control group (CG). At baseline and 12 months, perceptions on well-being were assessed using an English translated to Arabic 13-item questionnaire. Between groups differences in responses were compared using chi-squared tests. Spearman correlation analysis was utilized to explore associations between changes in responses and self-reported PA levels (metabolic equivalent of task.min/week). Results: Of the 232 participants in the ‘MOVEdiabetes’ study, 75.0% completed the study. Overall, findings indicate a positive effect of the intervention on perceived general health, sleep, mental health, pain, and responses to quality of life. For the IG and CG, significant associations were shown between changes in self-reported PA and general health (r = 0.70 and 0.36, p < 0.001), feeling calm/peaceful (r = 0.86 and 0.93, p < 0.001), energetic (r = 0.86 and 0.82, p < 0.001), and depressed (r = -0.35 and -0.30, p < 0.001). However, the Cronbach’s alpha value was 0.50, indicating insufficient internal consistency of the assessment tool. Conclusions: The intervention has a positive effect on many parameters of well-being. Further studies are needed to identify robust tools to measure associations between well-being and PA in culturally bounded Arabic speaking countries.

Keywords: Exercise; Diabetes Mellitus, Type 2; Primary Health Care; Outcome Assessment, Health Care; Oman.

Objectives: Multiple sclerosis (MS) is a chronic disease of the central nervous system. The pathogenesis of MS is best described by a multifactorial model incorporating interactions between genetic and environmental factors with the role of genetic factors increasingly taken into account. The main goal of this study was to investigate the associations of rs12487066, rs12044852, rs10735781, rs3135388, rs6897932, rs1321172, rs10492972, and rs9657904 polymorphisms with MS in the Iranian population. Methods: A total of 83 patients with MS (82.0% female and 18.0% male; mean age = 35.2±8.6 years) and 100 physically and mentally healthy subjects (81.0% female and 19.0% male; mean age = 40.4±6.4 years) were selected using convenient sampling. A 5 mL blood sample was taken from each case and control patient. We used the tetra-primer ARMS-PCR method to genotype the desired polymorphisms. The associations between polymorphisms and the disease were studied based on codominant, dominant, recessive, and overdominant models. Results: The rs10735781 polymorphism was codominantly (p = 0.029), overdominantly (p = 0.008), and dominantly (p = 0.009) associated with the disease. The rs6897932 was also found to be codominantly (p = 0.012), dominantly (p = 0.019), and recessively (p = 0.011) associated with the disease. Conclusions: We found an association between the rs10735781 and rs6897932 polymorphisms on the EVI5 and IL7RA genes, respectively, with increased MS in the Iranian population. Therefore, single nucleotide polymorphisms in the EVI5 and IL7RA genes can be considered a prognostic marker of MS.

Keywords: Polymorphism, Single Nucleotide; Genotype; Polymerase Chain Reaction; Multiple Sclerosis; Iran.

Objectives: Chronic lymphocytic leukemia (CLL) is characterized by the accumulation of apparently mature B-type lymphocytes in the lymphohematopoietic organs. Methylation in promoters of tumor suppressor genes is one of the mechanisms that causes blood malignancy. In this study, we evaluated the promoter DNA methylation status of miR-129-2 tumor suppressor gene and its association with clinical and laboratory parameters of patients with CLL. Methods: We studied the promoter DNA methylation frequency of the miR-129-2 gene in 50 patients with CLL and 50 healthy controls using methylation-specific polymerase chain reaction methods. Statistical analysis was performed using SPSS-18 software, and a p-value < 0.050 was considered statistically significant. Results: The frequency of promoter DNA methylation of the miR-129-2 gene was significantly higher in the CLL group compared with control group (38.0% vs. 0.0%, p < 0.001; χ² = 23.457). The promoter DNA methylation frequency of miR-129-2 gene was not significantly different between the two sexes (p = 0.236). A significant but weak correlation was seen between the methylated state of the miR-129-2 gene and organomegaly (p = 0.019, r = 0.330) as well as hemoglobin levels (p = 0.020, r = -0.233). However, binary logistic regression analysis indicated organomegaly as the only clinical biomarker with a statistically significant association with the hypermethylated miR-129-2 gene state (p = 0.046). Conclusions: The high frequency of promoter DNA methylation of the miR-129-2 gene in the CLL group compared to the control group, as well as its significant association with organomegaly, suggests the importance of this epigenetic biomarker in the pathogenesis and prognosis of CLL disease.

Keywords: Epigenesis, Genetic; DNA Methylation; Leukemia, Lymphocytic, Chronic, B-Cell.

Objectives: We sought to assess the complications and challenges facing the management of β-thalassemia major (β-TM) in Iraq. Methods: A total of 150 consecutive patients with β-TM who were registered at a main thalassemia center in Northern Iraq were enrolled in the study. The patients had their records reviewed, were clinically evaluated, and investigated for various complications. Results: Our patient cohort had a median age of 13 years (range: 1–35 years) and a male to female ratio of 1:1.2. Their median serum ferritin was 2762 µg/L, all were on regular transfusions, 94.7% were on chelation therapy, and 38.0% were splenectomized. Pre-transfusion hemoglobin levels were ≥ 9.0 g/dL in 38.7% of the patients. Short stature was encountered in 33.9% of those aged ≤ 20 years, and skeletal changes were noted in 50.7%. Iron overload associated complications, including hypogonadism, hypothyroidism, hypoparathyroidism, diabetes mellitus, and heart failure, were encountered in 52.8%, 7.3%, 3.3%, 3.3%, and 2.7%, respectively. Hepatitis C virus (HCV) antibodies were detectable in 35.3%, while HIV antibodies and hepatitis B surface antigen were not detectable in any. Patients with diabetes mellitus, heart failure, HCV antibodies, and hypoparathyroidism were significantly older than those without these complications. Hypogonadism was the only complication associated with significantly higher serum ferritin levels. Hypogonadism, heart failure, HCV antibodies, and diabetes were significantly more frequent among the splenectomized patients. Conclusions: The management of β-TM in this cohort of Iraqi patients is still suboptimal, and the need to ensure timely transfusions and optimize chelation, as well as a more robust iron overload assessment, should be underscored.

Keywords: beta-Thalassemia; Thalassemia; Hepatitis C Antibodies; Iraq

Objectives: Selenium and iodine are essential microelements for normal body functions. These two elements play important roles in thyroid metabolism. The potential relationship between thyroid diseases and mental disorders have been demonstrated. We aimed to investigate the relationship between selenium and iodine levels with anxiety and depression in patients with euthyroid nodular goiter (ENG). Methods: In this cross-sectional study, we enrolled 102 consecutive patients with ENG who attended the endocrine outpatient clinic between January 2018 and June 2018. We noted the patient’s demographics, thyroid ultrasound imaging, thyroid hormones, and urinary iodine concentration (UIC) results. We also obtained venous blood samples for serum selenium measurement. The same psychiatrist completed the Beck Anxiety Inventory (BAI) and Hamilton Depression Rating Scale (HDRS) for all participants. The study population was dichotomized according to the median values of selenium levels and UIC. Results: BAI and HDRS scores were significantly higher in the low selenium group than the high selenium group (p = 0.032 and p = 0.042, respectively). BAI scores were significantly higher in the low UIC group than the high UIC group (p = 0.007). Conclusions: Low selenium and UIC levels may contribute to the development of anxiety and depression, independent of thyroid functions, in patients with ENG. In these patients, selenium and iodine replacement may be useful for the prevention of anxiety and depression, especially in deficient regions.

Keywords: Euthyroid Goiter; Depression; Selenium; Iodine; Anxiety; Thyroid Diseases.

Objectives: The prevalence and appearance of sesamoid bones in the foot vary considerably among different populations and ethnic groups. We sought to evaluate the prevalence and distribution patterns of foot sesamoid bones among Omani patients referred for radiological investigation. Methods: We conducted a retrospective study among patients who had been referred for foot X-ray from January to December 2018. We used the chi-square test to determine the gender and age influence on the prevalence of sesamoid bones, and the Spearman’s correlation coefficient to assess the coincidence of specific distributions of sesamoid bones at the metatarsophalangeal (MTP) joints. Results: A total of 774 foot radiographs composed of 442 right foot radiographs and 332 left foot radiographs were reviewed for the presence of sesamoid bones at MTP and interphalangeal (IP) joints of the foot. We observed a high prevalence rate of sesamoid bones at the fifth MTP joint (13.7%), and first IP of the great toe (9.9%). There were nine distinctive patterns of sesamoid bones. The coincidence of sesamoid bones at two or more MTP joints was 14.6%, with a high prevalence rate at first and fifth MTP joints (10.3%). Moreover, the prevalence rate of sesamoid bones increased with increasing age at the fifth MTP joint. Conclusions: The prevalence of sesamoid bones in the foot is considerably high in Omani subjects and needs further prospective studies. Meanwhile, our findings could be helpful for clinicians to consider ailments of sesamoid bones during differential diagnosis in Omani patients who present with foot pain and discomfort.

Keywords: Retrospective Studies; X-Rays; Prevalence; Sesamoid Bones; Foot; Metatarsophalangeal Joint; Radiography; Pain.

Smooth muscle neoplasms of the vulva are rare, and when localized in the Bartholin’s gland, it can be mistaken as a benign lesion leading to a delay in diagnosis. We report a case of leiomyosarcoma of the Bartholin’s gland in a 63-year-old postmenopausal woman, which clinically mimicked a chronic Bartholin’s gland cyst. This case report emphasizes the importance of suspecting malignancy in any vulvar lesion in women of postmenopausal age, despite its location and asymptomatic appearance. A prompt, careful evaluation with adequate clinical judgment will help to manage such cases efficiently.

Keywords: Bartholin’s Glands; Vulvar Neoplasms; Leiomyosarcoma.

Hypoglycemia is a frequent problem in infants and children, causing a significant dilemma to reach the correct diagnosis and perform the appropriate management. Congenital hyperinsulinism is the most common cause of hypoglycemic hyperinsulinemia in infants and is due to beta-cell hyperplasia caused by genetic defects. This is a well-known genetically and clinically heterogeneous condition causing severe hypoglycemia in infants. Insulin-secreting tumors (insulinoma) are rare findings during childhood. In contrast, insulinoma is the most common form of endogenous hypoglycemic hyperinsulinemia in the adult population. Here we present a successful diagnosis and treatment of a nine-year-old Saudi child who presented for the first time with severe episodes of hypoglycemia at age seven. Critical samples at the time of hypoglycemia confirmed the associated hyperinsulinemia state. Initially, the child responded well to anti-insulin medications at small doses, but with time the disease became progressive in severity requiring a high dose of anti-insulin medications, frequent glucagon injections, and hospital admission for intravenous dextrose infusion. After two years of seeking therapy in many hospitals, the final diagnosis was confirmed to be an insulinoma, which was removed surgically, resulting in a complete cure and full recovery. Here we report the first published case of insulinoma in a young child aged < 15 years old in Saudi Arabia, their disease course, final diagnostic steps, and curative therapy. We conclude that hypoglycemia in children is challenging in terms of diagnosis and management. Although insulinoma is very rare in children, it requires significant time and effort by a pediatrician, pediatric endocrinologist, patients, and parents to reach the final diagnosis and carefully preserve the integrity of the neurological state of those children.

Keywords: Congenital Hyperinsulinism; Pediatrics; Pancreatic Neoplasm; Insulinoma; Hypoglycemia; Saudi Arabia.

Metformin is a widely used biguanide for the treatment of type 2 diabetes mellitus. Metformin-induced lactic acidosis (MALA) is a rare but potentially fatal entity in the pediatric age group, seen mainly in suicide attempts in adolescents. MALA has not yet been reported in younger patients or pediatric patients taking regular therapeutic doses. Here, we report a three-year-old female receiving therapeutic metformin who developed MALA. MALA should be suspected in patients with unexplained lactic acidosis and on regular metformin, especially in the setting of renal impairment or hypoxic events.

Keywords: Child, Preschool; Metformin; Acidosis, Lactic.

We report the case of a 35-year-old female with end-stage renal disease on hemodialysis for nine years. She was diagnosed with secondary hyperparathyroidism complicated with a brown tumor in the mandible. After medical therapy failed, she underwent total parathyroidectomy (PTX), which was complicated by severe and prolonged hypocalcemia (hungry bone syndrome). Post-surgery, she required prolonged and frequent intravenous calcium and a high dose of vitamin D resulting in frequent admission with symptomatic hypocalcemia. Her serum magnesium was noted to be in the normal range. She continued to be hypocalcemic for nearly eight months post-surgery despite the intensive treatment. Recombinant human parathyroid hormone (teriparatide) 20 mg daily resulted in normalization of calcium within two weeks. The use of parathyroid hormone proved to be an effective treatment approach in this case. Proper pre-operative preparation and subtotal PTX with an adequate dose of vitamin D and calcium supplement may have been a rational option for this case.

Keywords: Parathyroidectomy; Hypocalcemia; Teriparatide; Vitamin D; Hyperparathyroidism, Secondary; Parathyroid Hormone; Kidney Failure, Chronic; Renal Dialysis; Bone Diseases; Lupus Erythematosus, Systemic.