Objectives: Streptococcus pyogenes is associated with mild to severe infections, particularly in children and young adults. Proper antimicrobial treatment of S. pyogenes infections is important to prevent post-streptococcal complications. Therefore, the purpose of this meta-analysis was to evaluate the prevalence of S. pyogenes antibiotic resistance among Iranian children. Methods: We identified all published studies up to 20 March 2019 related to S. pyogenes antibiotic resistance by searching Persian and English electronic databases. Search terms included S. pyogenes, children, and Iran. Out of 1022 publications, 12 articles were eligible and included based on the inclusion and exclusion criteria. Results: Our analysis indicated the following prevalence pattern for S. pyogenes antimicrobial resistance in Iran: 4.2% to penicillin, 38.3% to amoxicillin, 5.4% to erythromycin, 12.0% to azithromycin, 12.6% to clarithromycin, 12.4% to clindamycin, 15.3% to rifampicin, 8.1% to ceftriaxone, 17.6% to cefixime, 36.9% to ampicillin, 14.1% to vancomycin, 8.4% to chloramphenicol, 30.4% to tetracycline, 8.8% to cefotaxime, 82.8% to trimethoprim/sulfamethoxazole, 39.6% to gentamicin, 11.9% to ofloxacin, 28.3% to carbenicillin, 3.1% to ciprofloxacin, 6.1% to imipenem, 18.2% to cephalothin, 57.6% to tobramycin, 49.3% to kanamycin, 79.0% to cloxacillin, 12.9% to cephalexin, 10.7% to cefazolin, and 89.5% to amoxicillin-clavulanic acid. Conclusions: Our findings suggest penicillin (in non-allergic children) and macrolides, lincosamides, and narrow-spectrum cephalosporins (in penicillin-allergic children) as the treatments of choice in Iran.

Keywords: Streptococcus pyogenes; Drug Resistance, Bacterial; Iran.

Objectives: Self-management education (SME) is recognized globally as a tool that enables patients to achieve optimal glucose control. While factors influencing the effectiveness of self-management interventions have been studied extensively, the impact of program length on clinical endpoints of patients diagnosed with diabetes is underdeveloped. This paper synthesized information from the existing literature to understand the effect of program length on glycated hemoglobin (HbA1C) in adults with type 2 diabetes mellitus. Methods: We searched Web of Science, PubMed, Scopus, MEDLINE, EMBASE, PsychINFO, and the Cochrane Central Register of Controlled Trials to identify relevant English language publications on diabetes self-management education published between January 2000 and April 2019. Results: The review included 25 randomized controlled trials, with 64.0% reporting significant changes in HbA1C. The studies classified as long-term (lasting one year and above) were associated with the greatest number of interventions achieving statistically significant (87.5% significant vs. 12.5% non-significant) differences in changes in HbA1C between the intervention and the control subjects, recording an overall between-group HbA1C mean difference of 0.6±0.3% (range = 0.2–1.2). Conclusions: Our findings suggest that program length may change the effectiveness of educational interventions. Achieving sustained improvements in patients’ HbA1C levels will require long-term, ongoing SME, and support.

Keywords: Glycated Hemoglobin A; Blood Glucose; Diabetes Mellitus, Type 2; Self-Management; Glycemic Control; Chronic Disease.

Objectives: The use of mobile technologies and handheld computers by physicians has increased worldwide. However, there are limited studies globally regarding training physicians on the use of such devices in clinical practice. In addition, no studies have been conducted previously in Oman addressing this issue among postgraduate medical trainees and trainers. The present study explores the practice and perception of resident doctors and trainers towards the use of mobile technologies and handheld devices in healthcare settings in Oman. Methods: This cross-sectional study was conducted using a validated questionnaire disseminated via email to all residents and trainers in five major training programs of the Oman Medical Specialty Board (OMSB). The questionnaire explored three main areas; perception, usage, and perceived barriers of handheld devices. Results: Overall, 61.4% of the residents and 28.3% of the trainers responded to the questionnaire. Both types of participants agreed that the use of such devices positively affects clinical decision-making. In total, 98.8% of the participating residents and 86.7% of the trainers frequently used handheld devices. Both OMSB residents and trainers agreed that lack of time, training, and applications were the most common factors limiting the use of these devices. Participants emphasized the need for constructive training regarding the use of handheld devices as healthcare resources. Conclusions: Point-of-care devices are positively perceived and frequently used by OMSB trainees and trainers. However, constructive training on the effective usage of these devices in clinical decision-making is needed. Further future studies to evaluate the impact of using such devices in patient care should be conducted.

Keywords: Internship and Residency; Point-of-Care Systems; Cross-Sectional Studies; Clinical Decision-Making; Oman; Computers, Handheld; Training Support.

Objectives: We sought to analyze the neutrophil-to-lymphocyte ratio (NLR) as an alternative marker of neonatal sepsis. Methods: In this cross-sectional study, we undertook consecutive sampling in all inborn neonates admitted to the Neonatal Intensive Care Unit with clinical manifestations of neonatal sepsis. Neonates with congenital anomalies and referred neonates were excluded. Complete blood count, C-reactive protein (CRP), and blood culture were carried out as the septic workup examinations based on the local Clinical Practical Guidelines. NLR is obtained by dividing the absolute count of neutrophils from lymphocytes manually. A cut-off value of NLR is obtained using a receiver operating characteristic curve. Results: The median NLR value of the 104 neonates who met the inclusion and exclusion criteria was 3.63 (2.39–6.12). Neonates with NLR of 2.12 have the area under the curve of 0.630 (95% confidence interval (CI): 0.528–0.741) and 0.725 (95% CI: 0.636–0.814) when combined with CRP = 2.70 mg/dL. Neonates with NLR ≥ 2.12 in clinical neotnatal sepsis had almost double the risk of providing positive blood culture results (relative risk = 1.867, 95% CI: 1.077–3.235; p = 0.011). Conclusions: NLR, calculated from complete blood count, can be used as an alternative marker of easy and relatively inexpensive neonatal sepsis, especially in developing countries, and detection of proven neonatal sepsis to be better when combined with CRP.

Keywords: Infant, Newborn; Neonatal Sepsis; Neutrophils; Lymphocytes; Intensive Care Units, Neonatal; C-Reactive Protein.

Objectives: In 2013, the World Health Organization (WHO) recommended new criteria for diagnosing gestational diabetes mellitus (GDM). Our study aimed to compare the incidence of GDM and its complications among Omani pregnant women using the new diagnostic criteria compared to previous criteria published in 1999. Methods: This retrospective cohort study was conducted between January and December 2016 at the Bawshar Specialized Polyclinic in Muscat, Oman. A total of 613 Omani women were included in the study. Baseline maternal characteristics such as age, body mass index, parity, and socioeconomic status were recorded in addition to maternal and neonatal outcomes. Results: Based on the current diagnostic criteria, the incidence of GDM was 48.5% (n = 297); however, this dropped to 26.4% (n = 162) when applying the old criteria. Moreover, rates of maternal complications including polyhydramnios (5.6% vs. 4.6%), pregnancy-induced hypertension (3.2% vs. 1.5%), and preterm delivery (3.2% vs. 1.5%) were slightly higher among women with GDM diagnosed using the latest criteria. However, these differences were not statistically significant. Neonatal complications were also slightly more frequent among the first group, without any significant differences. Conclusions: The incidence of GDM among Omani women rose dramatically when utilizing the latest WHO diagnostic criteria, owing to a lower fasting blood glucose cut-off value. In addition, a comparison of the frequencies of maternal and neonatal complications supports the validity of the new criteria. These findings should be taken into consideration by decision-makers in Oman when planning antenatal and postnatal services.

Keywords: Diabetes, Gestational; Incidence; World Health Organization; Oman.

Objectives: As coronavirus disease (COVID-19) was pervading different parts of the world, little has been published regarding responses undertaken within primary health care (PHC) facilities in Arabian Gulf countries. This paper describes such responses from January to mid-April 2020 in PHC, including public health measures in Muscat, Oman. Methods: This is a descriptive study showing the trends of the confirmed positive cases of COVID-19 and the undertaken responses to the evolving epidemiological scenario. These responses were described utilizing the World Health Organizations’ building blocks for health care systems: Leadership and governance, Health workforce, Service delivery, Medical products and technologies, and health information management. Results: In mid-April 2020, cases of COVID-19 increased to 685 (particularly among non-nationals). As the cases were surging, the PHC responded by executing all guidelines and policies from the national medical and public health response committees and integrating innovative approaches. These included adapting comprehensive and multi-sectoral strategies, partnering with private establishments, and strengthening technology use (in tracking, testing, managing the cases, and data management). Conclusions: Facilities in the Muscat governorate, with the support from national teams, seemed to continuously scale-up their preparedness and responses to meet the epidemiological expectations in the management of COVID-19.

Keywords: COVID-19; Oman; Muscat; Public Health; Leadership; Health Workforce; Delivery of Health Care; Primary Health Care.

Objectives: Chronic kidney disease (CKD) is an independent predictor of mortality. Several creatinine-based equations are used to assess the estimated glomerular filtration rate or creatinine clearance and mortality prediction in various ethnic populations. Similarly, renal insufficiency is associated with poor prognosis of UAE nationals with cardiovascular disease (CVD) risk factors. However, the equation that best assesses prognosis among these patients is unknown. This study aimed to compare the prognostic abilities of different creatinine-based kidney function equations for predicting all-cause mortality in UAE nationals with vascular comorbidities. Methods: This retrospective observational study analyzed 1186 patients (54.0% men) with CVD risk factors. Multivariable Cox regression analysis was used to evaluate the associations of categorical renal function stages with all-cause mortality. Measures of performance in each equation assessed with respect to all-cause mortality were evaluated and compared to the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation by calculating the C-index, net reclassification index (NRI), and integrated discrimination index. Results: Over a median follow-up of 8.9 years, the cumulative incidence of all-cause mortality was 9.4% (n = 112). After multivariable adjustment, the discriminative ability for all-cause mortality was significantly higher in the body surface area-adjusted Cockcroft-Gault (BSA-CG) formula than in the CKD-EPI equation (C-indices: 0.869 vs. 0.861, respectively, p = 0.037). NRI was significantly positive and favored the BSA-CG formula (0.54; 95% confidence interval: 0.35–0.64) compared to the CKD-EPI equation. Conclusions: Our findings suggest that the BSA-CG equation may have the potential to slightly improve mortality prediction compared to the CKD-EPI equation in UAE nationals with vascular risk. Further large multicenter studies are warranted to confirm our findings.

Keywords: Cardiovascular Diseases; Chronic Renal Insufficiency; Kidney Function Tests; Mortality; United Arab Emirates.

Objectives: Acute leukemias (AL) are a heterogeneous group of hematological malignancies with the presence of 20% or more blasts in the peripheral blood or bone marrow. Malignant cells display characteristic patterns of surface antigenic expression. Aberrant phenotypes are defined as patterns of antigen expression on neoplastic cells different from the process of normal hematopoietic maturation. We sought to evaluate the occurrence of aberrant phenotypes in newly diagnosed cases of AL. Methods: The study included 100 patients in whom both bone marrow aspiration and flow cytometry were performed. Patients with blasts > 20% of all ages were included in the study. Flow cytometric analysis was done using the monoclonal antibody panel of peripheral blood/bone marrow. Results: Out of 100 cases, 53 were categorized as acute myeloid leukemia (AML), 43 as acute lymphoid leukemia (ALL), and four cases of mixed phenotypic acute leukemia (MPAL). ALL were subcategorized based on immunophenotyping into B-ALL and T-ALL, which comprised 88.4% and 11.6%, respectively, of total ALL (43.0%) cases. Cluster of differentiation 33 (CD33) and CD13 were the most commonly expressed antigens in AML, with CD7 being the most common aberrancy. CD19 was expressed in all B-ALL cases followed by cCD79a, CD10, Tdt (86.8%) with CD13 being the most common aberrancy. cCD3, CD7, and CD5 were expressed in all T-ALL cases with aberrant antigen expression in 80.0% of T-ALL cases. MPAL cases showed expression of B/myeloid antigens. Conclusions: The diagnosis and classification of leukemia rely on the simultaneous application of cytomorphology, cytochemistry, flow cytometry, cytogenetics, and molecular techniques. Flow cytometry is of great help in the diagnosis of AL, particularly in ALL for lineage assignment and in classifying MPAL. It also helps in detecting aberrant antigen expression and assisting in minimal residual disease detection.

Keywords: Immunophenotyping; Flow Cytometry; Leukemia, Myeloid, Acute; Leukemia, Lymphoid; Antigens, Surface.

Objectives: Precise and quantitative assessment of the trend of cancer burden enables policymakers and health managers to prioritize diseases and allocate resources better. This infers what caused a decrease or increase in the rate of cancer occurrence, and if it denotes timing of implementation of a control measure, it presents the impact on the disease rate. This study’s objective was to evaluate trends in child and adult cancer in Iraq from 2000 onwards. Methods: We used the registries of the Iraqi Ministry of Health that were gathered from all governorates from 2000–2016. Data were presented as incidence rates to depict the trends of different types of cancers distributed by age, gender, and governorates. Results: Breast cancer witnessed a significant increase with predominance in females. Lung cancer rate increased significantly from 4.08 to 5.60/100 000 (p = 0.038), affecting males more than females. The brain cancer trend showed a bimodal pattern (two peaks in 2004 and 2011) with no significant trend change (p = 0.788). Both genders were similarly affected. The trend of stomach and colorectal cancer showed an accelerated increase after 2007. Conclusions: Almost all cancers (particularly lung and gastrointestinal) showed constantly raising trends, especially after 2007. Only cervical and laryngeal cancer had a decreasing trend. Most cancers were predominant in males.

Keywords: Cancer; Trend; Incidence; Iraq.

Objectives: We sought to determine the estimated glomerular filtration rate (eGFR) among patients with COVID-19 and to examine its correlation with different demographic, clinical, and laboratory characteristics. Methods: This study examined patients diagnosed with COVID-19 and enrolled at Al Kuwait Hospital, Dubai, UAE. eGFR was calculated using the Modification of Diet in Renal Disease equation, 186 × (SCr mg/dL)-1.154 × (age)-0203 × 0.742 [if female] × 1.212 [if black], and compared for 250 COVID-19 cases and 153 non-COVID-19 controls. Analysis were performed using univariate statistics. Results: The overall mean age of the cohort was 47.2±14.0 years, and 54.6% (n = 220) were males. The results showed that 45.3% of COVID-19 patients had mild-severe renal impairment, as reflected in the eGFR. When compared to patients with normal eGFR, those with severe renal impairment were older (62.5 vs. 40.2 years; p < 0.001), more likely to be male (100% vs. 71.1%; p = 0.016), and have comorbidities (90.9% vs. 40.0%; p < 0.001) including diabetes mellitus (72.7% vs. 21.5%; p < 0.001) and hypertension (72.7% vs. 25.2%; p = 0.003). They were also more likely to be associated with those that had severe (36.4% vs. 25.9%; p < 0.001) and critical (63.6% vs. 16.3%; p < 0.001) COVID-19 infection as well as intensive care unit admission (72.7% vs. 16.3%; p < 0.001). Correlational analysis showed a significant association between renal function indicators and different laboratory markers, including hematological indices and different liver enzymes. Conclusions: This is the first study to examine the renal function among COVID-19 cases in the Middle East. Nearly half of COVID-19 patients had moderate to severe renal impairment. Diabetes mellitus and hypertension were the most common underlying comorbidities associated with moderate-severe renal function impairment among COVID-19 patients.

Keywords: COVID-19; Renal Insufficiency; Hypertension; Diabetes Mellitus; Glomerular Filtration Rate; Intensive Care Units; United Arab Emirates.

Objectives: Many studies have confirmed that the use of alcohol, tobacco, and cannabis is prevalent among university students. This study aimed to assess the prevalence of substance misuse among college students in Oman, identifying the most commonly used substances, and reviewing the effect of substance misuse on the students’ performance. Methods: This cross-sectional study was conducted in a higher learning institution in an urban setting in Oman from April 2018 to December 2018. A descriptive, self-administered online questionnaire, the Alcohol, Smoking, and Substance Involvement Screening Test, version 3.0 (Arabic version), adapted from the World Health Organization was sent to 12 000 students at the college. The sample size was calculated using online software (Raosoft), with a margin of error of 5% and a confidence level of 95%. Results: A total of 375 students responded (response rate = 3.1%). The overall lifetime prevalence for any substance misuse (including tobacco and alcohol) among the participants was 41.3%, with the overall prevalence without tobacco or alcohol at 29.9%. Tobacco was the most common substance used, with a prevalence of around 23.5%, followed by alcohol at 10.7%. Male students had a significantly higher rate of substance abuse, for any substance, compared to female students (p < 0.001). There was a significant correlation between tobacco use, alcohol misuse, and misuse of other substances. Most of the adverse effects attributed to substance misuse reported by the respondents in this study were social (27.7%) and health-related (25.8%) problems. The impact of substance abuse on their performance was also high (23.8%). Furthermore, 15.4% of the respondents had financial problems, and 4.7%% were struggling with legal issues. Notably, only 49.1% of the respondents perceived that substance misuse was a serious problem. Conclusions: Although college students are expected to be more aware of the negative impacts of substance misuse, this study found a high prevalence of smoking, alcohol, and other substance misuses among the group of Omani college students. Further research in this field is essential, and the results of this study have shed light on a critical problem among Omani college students. It is hoped that the findings of this study will be used and built on in future research to recognize students at risk of substance misuse from early school life, leading to early intervention, and potentially preventing the possible negative consequences.

Keywords: Universities; Prevalence; Cross-Sectional Studies; Oman; Students; Substance-Related Disorders; Tobacco Use; Drug Misuse.

The physiological actions of thyroid hormone (TH) are mediated through TH alpha and TH beta receptors. Resistance to TH (RTH) is characterized by a lack of peripheral tissues’ response to the active form of TH. TH receptor beta has been extensively studied. Mutations in this receptor were considered the main reason for TH resistance for some time up until the discovery of mutations in TH receptor alpha (TRα) that has attained more focus and interest in recent years. A 13-year-old child with classic hypothyroidism features (coarse facies, growth and developmental delay, skeletal dysplasia, generalized muscular hypertrophy, and severe constipation) associated with near-normal thyroid hormone levels, which did not support the diagnosis of hypothyroidism biochemically. Therefore, progressing with whole-exome sequencing had revealed a de novo heterozygous mutation in a gene encoding TRα that establishes a diagnosis of RTHα. This case report demonstrates a rare form of TH resistance due to mutation of TRα. It also emphasizes that THs act through distinctive receptor subtypes in different target tissues. Moreover, this report aims to raise awareness about this genetic mutation, which is thought to be more common than expected. However, due to its subtle features and insidious presentation, many cases remain undiagnosed; hence, the disorder’s exact incidence is unknown.

Keywords: Thyroid Hormone Resistance Syndrome; Receptors, Thyroid Hormone; Whole Exome Sequencing; Mutation.

Tenosynovial giant cell tumor (TGCT) is a benign soft-tissue neoplasm that rarely occurs in the craniofacial region. We report a case of a 27-year-old male who presented to our unit in September 2017 with severe temporomandibular joint (TMJ) pain and progressive limitation opening his mouth. Based on clinical and imaging examinations, a well-defined soft tissue lesion was identified within the right infratemporal fossa, causing pressure on the TMJ and the surrounding structures. The lesion was surgically excised through trans-mandibular and endoscopic approaches. Histopathology diagnosis revealed a rare chondroid subset of TGCT. At 18 months follow-up, the patient showed resolution of the jaw pain, good functional and esthetic outcomes, and no evidence of recurrence.

Keywords: Temporomandibular Joint; Giant Cell Tumor of Tendon Sheath; Soft Tissue Neoplasms; Oman.

Pheochromocytomas are tumors derived from chromaffin cells within the medulla of adrenal glands, whereas paragangliomas are tumors derived from extra-adrenal chromaffin cells of the sympathetic prevertebral and paravertebral ganglia. The growing deployment of genetic testing has shown that approximately 30% of pheochromocytoma and paraganglioma (PPGL) patients carry familial pathogenic germline mutations in known PPGL-susceptibility genes. This prompts genetic screening of their family members and leads to an increase in the detection of asymptomatic PPGLs or non-secreting tumors reported in familial cases discovered after the index patient work-up. Here, we present three case reports of affected members of a single Omani family with a history of paraganglioma and highly variable clinical presentations among the affected members. Eight out of the 16 siblings (50.0%) in the second generation of the reported family pedigree were carriers of the succinate dehydrogenase B:c.574T>C mutation, reflecting the autosomal dominant inheritance risk of paraganglioma and other associated tumors. This report highlights the complexity of managing such families and encourages further discussion regarding the management of asymptomatic PPGL-associated mutation carriers. Genetic screening has enabled the early detection of PPGLs, for which early surgical intervention can significantly impact prognosis and treatment strategies to reduce morbidity and mortality. Although PPGLs are similar tumors, they warrant distinction from each other with respect to their differences in locations, manifestations, secretory functions, genetic syndromes, and propensity to metastasize. While current guidelines are clear concerning symptomatic PPGL cases, the management of asymptomatic mutation carriers requires further elucidation.

Keywords: Renal Pheochromocytoma; Germ-Line Mutation; Chromogranin A; Paraganglioma; Adrenal Gland Neoplasms; Family Characteristics.

Spontaneous coronary artery dissection is a serious and underreported clinical entity strongly associated with fibromuscular dysplasia (FMD). The female predominance of FMD may predispose many women to coronary artery dissection or other similar vascular pathologies. We present a case of a young woman who presented with a clinical tetrad of spontaneous coronary artery dissection, cardiogenic shock requiring extracorporeal membrane oxygenation, internal carotid dissections, and subacute cerebellar infarct secondary to underlying FMD. The patient’s clinical course and vascular pathology are discussed. A review of the relevant literature of previously published similar cases, the incidence of spontaneous coronary artery dissection, and issues in the clinical management of spontaneous coronary artery dissection are also included.

Keywords: Fibromuscular Dysplasia; Shock, Cardiogenic; Coronary Artery Dissection, Spontaneous.

We present a case of a 47-year-old female with three primary malignancies. This is an unusual presentation and highlights the dilemmas in the workup and formulation of treatment plans. Genetic studies to identify mutations may help explain the pathophysiology.

Keywords: Familial Adenomatous Polyposis; Ovarian Neoplasms; Endometrial Neoplasms; Rectal Neoplasms.