Shigella flexneri is the most common cause of shigellosis in developing countries. Up to now, 23 serotypes of S. flexneri have been reported. Different serotypes result from the addition of acetyl, glucosyl, or phosphatidylethanolamine groups on the O-antigen backbone and horizontal transfer of mentioned groups can lead to serotype conversion among S. flexneri strains. Serotype conversion causes either a circulation of pre-existing serotypes or is responsible for the emergence of new serotypes. Serotype conversion plays a pivotal role in the protection and evasion of S. flexneri from the host immune response. Furthermore, spreading any new serotype can provide evolutionary advantages. Hence, information about S. flexneri O-antigen structure, serotype conversion, and serotyping methods can be helpful to understand the disease that attributes distinct serotypes in order to apply control or prevention methods in accordance with predominant serotypes over the course of time. Thus, the scope of this review is to give an overview of the serotype structures, factors involved in O-antigen modification, molecular analysis, and epidemiological evidence for the benefits of serotype conversion for S. flexneri serotypes. We are also providing a review of the typing methods.

Keywords:Shigella flexneri; O-Antigens; Serotype; Molecular Evolution; Molecular Typing.

Objectives: Dyslipidemia is an important risk factor for cardiovascular disease. In developed countries, only 50% of patients with chronic illness adhere to their long-term therapy. This article aimed to review the factors affecting adherence to lipid-lowering drugs (LLDs). Methods: The searched articles were selected based on the available keywords in the title and abstract with the publication restricted between January 2010 and September 2020. Articles generated from the databases must fulfill both inclusion and exclusion criteria in the present systematic review. Our initial search retrieved 221 literature reviews. After excluding articles with irrelevant topics, a total of 23 articles were chosen for this current review. Results: The factors were classified based on three main factors: patient-related, medication-related, and healthcare workers-related factors. For patient-related factors, gender, age, number of family members, education level, post-hospitalization, comorbidities and cardiovascular disease risk, follow-up status, occupation, socio-economy, insurance, perception, ethnicity, and health plan were among the factors affecting adherence to LLDs. As for medication-related factors, timing, polypharmacy, duration of treatment, generic medication, intensity of medication, side effects, initiating dose, packaging, drug dosing, and type of drugs were revealed as contributing factors. In the light of healthcare workers, related factors shown were counseling, medication optimization, type of provider, and location of the hospital. Conclusions: Recommendations to improve adherence include educating patients on the disease itself and the importance of the treatment, modification of the dosing, timing and type of LLDs, and effective consultations by healthcare workers. Further studies need to be done in Malaysia as there is inadequate research on this topic.

Keywords:Risk Factors; Adherence, Drug; Compliance; Lipids; Drugs.

Objectives: Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most common enzymopathy worldwide. The fluorescent spot test (FST) is the conventional method for screening neonates for G6PD. However, it has limitations and quantitative assays such as the CareStart Biosensor 1 are being increasingly recommended. This study aimed to compare FST and CareStart Bioensor 1 in their ability to detect G6PD levels in neonates. Methods: This cross-sectional study involved 455 neonates between June and December 2020. Two milliliters of cord blood were analyzed with CareStart Biosensor 1 and dried cord blood spots with FST. Data was recorded and statistically analyzed. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated to determine the performance of FST at specific G6PD cut-off values; Cohen’s kappa analysis assessed the agreement between the two methods. Results: The sensitivity of FST at 30% cut-off G6PD activity level was 91.0%, (95% CI: 57.0–100) and specificity of 97.0% (95% CI: 95.0–98.0). At 60% cut-off, the FST sensitivity sharply declined to 29.0% (95% CI: 19.0–40.0) with a specificity of 100% (95% CI: 98.0–100). The overall prevalence of G6PD deficiency was 5.1% as measured by FST and 17.8% by Biosensor 1 (p < 0.001). Conclusions: In this study, FST missed a significant proportion of cases of intermediate G6PD levels. FST also misclassified several G6PD intermediate individuals as normal, rendering them susceptible to oxidative stress. Biosensor 1 reported a significantly higher prevalence of G6PD deficiency.

Keywords:G6PD Deficiency; Quantitative Assay; Prevalence; Sensitivity; Specificity.

Objectives: The recommended treatment for COVID-19 includes antiviral drugs, corticosteroids, immunomodulatory drugs, low molecular weight heparin, as well as antibiotics. Although COVID-19 is a viral disease, many studies indicate that antibiotics are prescribed frequently, mainly to treat suspected bacterial coinfection. At the same time, the prevalence of bacterial coinfections during COVID-19 is rather low indicating the significant antibiotic overuse in these patients. It is well known that this can trigger antibiotic bacterial resistance, and once it emerges the reversal of resistance is a complex and long-lasting process. The aims of this study were to estimate the prevalence of bacterial coinfections during the COVID-19 and to analyze the antibiotic treatment justification during this pandemic in Oman. Methods: This retrospective analysis was conducted using the Royal Hospital COVID-19 Registry Database. The study analyzed demographic and clinical characteristics, as well as laboratory parameters and antibiotic treatment of hospitalized patients. Results: During the study period, 584 patients were enrolled in the analysis. Coinfection was rare as it was confirmed in 0.9% of patients. Superinfections were present in 15.2% of patients. Gram-negative bacteria were isolated in 95 (69.9%) samples, gram-positive bacteria in 25 (18.4%) samples, while Candida spp. was found in 16 (11.8%) samples. On admission, empirical antibiotic treatment was started in 543 (93.0%) patients. Conclusions: During COVID-19, coinfections are rarely seen and the overuse of antibiotics is not justified. The incidence of superinfections is the same as in other patients in healthcare settings caused by the same resistant microorganisms, which implies the use of even more.

Keywords:COVID-19; Antimicrobial Stewardship; Oman.

Objectives: Diabetes mellitus (DM) and tuberculosis (TB) are global public health concerns and leading causes of mortality and morbidity worldwide. Coinfection is known to complicate TB control and outcomes. However, there is no national study regarding the prevalence of DM among TB patients in Oman. The objective of the current study was to assess the prevalence of DM and its associated factors among TB patients in Muscat, Oman. Methods: We conducted an analytical cross-sectional study using secondary data from the electronic system of the Ministry of Health (Al-Shifa 3+). It includes all adult TB patients in Muscat, from 2017–2020. Sociodemographic data, clinical characteristics, and comorbidities of TB patients were collected. SPSS with 95% CI and p-value ≤ 0.05 was used for statistical analysis. Results: Of 426 TB cases, the prevalence of DM was 27.0%. The associated factors of DM were age group 40–54 years (odds ratio (OR) = 9.08, 95% CI: 4.16–19.84) and ≥ 55 years (OR = 11.35, 95% CI: 5.19–24.82), male (OR = 2.35, 95% CI: 1.45–3.81), being married (OR = 13.18, 95% CI: 4.72–36.84), being employed (OR = 2.30, 95% CI: 1.19–4.47), and Bangladeshi (OR = 7.08, 95% CI: 2.50–20.12) or Indian (OR = 6.14, 95% CI: 2.40–15.70) nationality. The absence of Bacillus Calmette–Guérin scar (OR = 2.06, 95% CI: 1.19–3.56), death (OR = 7.08, 95% CI: 1.26–7.82), and cured after TB treatment (OR = 3.02, 95% CI 1.71–5.31) showed significant association. Also, smoking (OR = 2.93, 95% CI: 1.81–4.76), drinking alcohol (OR = 1.79, 95% CI: 1.10–2.91), hypertension (OR = 10.45, 95% CI: 5.29–20.64), heart disease (OR = 8.50, 95% CI: 1.69–42.77), and renal disease (OR = 4.84, 95% CI: 1.71–13.64) contributed to the study’s comorbidities. Old age (adjusted OR = 2.30, 95% CI: 1.72–3.06) and hypertension (adjusted OR = 5.21, 95% CI: 2.28–11.87) were found to be predictors of DM among TB patients. Conclusions: The prevalence of DM among TB patients in Muscat is high. Integrated systematic bidirectional TB-DM screening is needed. Furthermore, special attention is required for associated factors when managing these comorbidities.

Keywords:Diabetes Mellitus; Tuberculosis; Oman.

Objectives: To assess the adherence to clinical practice guidelines (CPGs) and explore the barriers to their implementation among primary care physicians (PCPs) in Bahrain. Methods: A cross-sectional study was conducted using an online survey among physicians working in 20 randomly selected public sector primary health centers in Bahrain. Private-sector physicians and family medicine residents were excluded. Outcome measures were assessing the extent of adherence to CPGs, describing the results in association with work roles, gender, level of formal training, and years of working experience, and investigating the barriers to adhering to CPGs. Results: The subjects were 149 PCPs (consultants, specialists, and general practitioners) working in government primary health centers. The vast majority (98.0%) reported that they implemented CPGs in their daily practice. The most commonly cited reason (79.2%) for implementation was that the CPGs were evidence-based. The most implemented guidelines pertained to diabetes (91.3%), hypertension (81.2%), and hyperlipidemia (69.8%). The least implemented ones were screening of women (38.9%) and postnatal care (45.6%). The level of formal medical training was associated with the implementation of CPGs on preventive care, antenatal and postnatal care, and children and women screening (p < 0.05). Hypertension and bronchial asthma guidelines were implemented more by male physicians (p < 0.05) while female physicians were more adherent to CPGs on antenatal and postnatal care, and women and child screening (p < 0.05). The main barrier reported by the physicians was that they wished to know more about CPGs before applying them (mean ± SD = 3.8 ± 0.9). The perception that managers or directors are non-cooperative towards the application of CPGs was associated with years of experience (p = 0.008) and the position of the physician (p = 0.028). General practitioners were more likely to consider non-cooperation from patients as a barrier (p = 0.025). Conclusions: Most PCPs in Bahrain are adherent to CPGs in their daily practice and encounter minimal barriers. Identifying and resolving barriers can help develop unified and standardized guidelines that promote better consistency in patient management, minimize medical errors, and conserve resources.

Keywords:Family Physicians; Guideline Adherence; Implementation; Barriers; Bahrain.

Objectives: Gout is a treatable disease. A complication of untreated or poorly-controlled gout is tophi formation. We conducted this study to investigate the associated factors of tophaceous gout among patients who attended 20 primary care clinics in Selangor, an urbanized state in Malaysia. Methods: We conducted a cross-sectional study from July to October 2019 that included all patients with gout who attended the clinics. Data on clinical demographics and laboratory results were collected. Comparison between tophaceous and non-tophaceous groups was performed using descriptive analysis. Results: A total of 421 patients with gout were involved in this study, 83 (19.7%) patients had visible tophi and were categorized into the tophaceous group, while the other 338 (80.3%) patients were categorized into the non-tophaceous group. The majority of patients were male with a mean age of 57.6±12.8 years. Three factors found to be significantly associated with tophaceous gout were age at symptom onset [tophaceous (45.6±13.3 years) vs. non-tophaceous (49.7±13.9 years), p = 0.026], mean disease duration of gout [tophaceous (105.2±92.6 months) vs. non-tophaceous (77.6±88.6 months), p = 0.013], and baseline serum uric acid level [tophaceous (622.3±129.1 µmol/L) vs. non-tophaceous (582.6±102.3 µmol/L), p = 0.021]. Conclusions: Tophaceous gout is associated with longer disease duration, higher baseline serum uric acid level, and younger age at symptoms onset. Hence, early initiation of urate-lowering therapy with a treat-to-target approach is crucial to prevent tophi formation.

Keywords:Gout; Uric Acid; Primary Care.

Objectives: The Rajan’s heart failure (R-hf) score was proposed to aid risk stratification in heart failure patients. The aim of this study was to validate R-hf risk score in patients with acute decompensated heart failure. Methods: R-hf risk score is derived from the product estimated glomerular filtration rate (mL/min), left ventricular ejection fraction (%), and hemoglobin levels (g/dL) divided by N-terminal pro-brain natriuretic peptide (pg/mL). This was a multinational, multicenter, prospective registry of heart failure from seven countries in the Middle East. Univariable and multivariable logistic regression was applied. Results: A total of 776 patients (mean age = 62.0±14.0 years, 62.4% males; mean left ventricular ejection fraction = 33.0±14.0%) were included. Of these, 459 (59.1%) presented with acute decompensated chronic heart failure. The R-hf risk score group (≤ 5) was marginally associated with a higher risk of all-cause cumulative mortality at three months (adjusted odds ratio (aOR) = 4.28; 95% CI: 0.90–20.30; p = 0.067) and significantly at 12 months (aOR = 3.84; 95% CI: 1.23–12.00; p = 0.021) when compared to those with the highest R score group (≥ 50). Conclusions: Lower R-hf risk scores are associated with increased risk of all-cause cumulative mortality at three and 12 months.

Keywords:Heart Failure; Chronic Kidney Diseases; Ventricular Dysfunction, Left; Mortality; Arabia.

Objectives: To evaluate the effect of COVID-19 severity on maternal, perinatal, and neonatal outcomes in pregnant women infected with SARS-CoV-2. We also aimed to assess the effect of medical comorbidities on the severity of COVID-19. Methods: A retrospective cohort study was conducted on women who became infected with SARS-CoV-2 during pregnancy and delivered at Sultan Qaboos University Hospital, Oman, from 1 March 2020 to 31 December 2021. Results: A total of 118 pregnant women with COVID-19 and their 118 newborns were included in the study. Mean maternal age was 32.0 years, with 60.2% of women infected in the third trimester. The majority of the participants had mild symptoms. Eleven (9.3%) women had moderate infection needing inpatient care. Six (5.1%) with severe infection were admitted to intensive care unit. The chronic diseases among the participants were hypothyroidism, obesity, sickle cell disease, epilepsy, and diabetes. The mean gestational age at delivery was 37.0 weeks with 20.9% of women delivering by cesarean section out of whom 37.5% had moderate-to-severe COVID-19. The most common complications associated with COVID-19 severity were preterm labor (p = 0.002), preeclampsia (p = 0.002), and intrauterine fetal death (p = 0.089). Of the total 118 newborns, 111 were singletons and six were twins. One fetus died and three singletons were lost to miscarriage. Placental histopathology conducted in 64 patients had no COVID-specific findings in most cases. Conclusions: Most pregnant women with COVID-19 infections had mild symptoms. The majority of women with moderate-to-severe infection were admitted for COVID-19 pneumonia. There was no direct effect of COVID-19 severity in neonatal outcomes or placental histopathology changes.

Keywords:COVID-19; Pregnancy; Neonate; Perinatal; Severity; Oman.

Objectives: To detect the level of ergonomic awareness related to work-related musculoskeletal disorders among 200 staff nurses in a tertiary hospital. The additional objective was to study the relationship of such awareness with the prevalence of these disorders. Methods: A group of 25–45-year-old staff nurses and a body mass index of ≤ 30 kg/m2, with at least one year working experience were randomly selected from different wards of the Royal Hospital, Muscat. The study excluded nurses who were on leave and those who had sustained traffic accidents or sports injuries in the preceding year. Cornell Musculoskeletal Discomfort Questionnaire (CMDQ) was used to measure the work-related musculoskeletal disorders experienced by the nurses. A second questionnaire was administered to measure their ergonomic awareness. The data was statistically analyzed. Correlations were established by Spearman’s rank correlation coefficient (ρ). Results: The participants were 200 staff nurses (male = 30 male, female = 170). Analysis of the ergonomics awareness construct indicated ‘agreement’ as an overall response with a mean of 3.2±0.6, indicating fair ergonomic awareness. For CMDQ, 50.3% reported discomfort in the low back region, 15.0% in the neck, and 6.9% in the right lower leg. The left wrist, left forearm, and right upper arm had the least reported discomfort (< 1.0%). The correlation between ergonomic awareness and working ability was weakly positive, yet statistically significant (ρ = 0.210; p = 0.003). Correlations were not statistically significant between ergonomic awareness and discomfort (ρ = -0.031; p = 0.664) and between ergonomic awareness and total frequency (ρ = 0.109; p = 0.123). Conclusions: There is a strong need to develop practical ergonomic awareness among nursing staff for a sustainable and safe work environment.

Keywords:Ergonomics; Musculoskeletal Disorders; Nurses; Oman.

Objectives: Inflammatory pathways play a significant role in atherosclerosis that leads to acute coronary syndrome (ACS). The initial stages of atherosclerosis are often asymptomatic; when atherosclerotic plaques become unstable it leads to ACS. Therefore, early detection, diagnosis, and treatment of atherosclerosis must be sought. These circumstances underpin the need for diagnostic values of inflammatory markers, warranting their routine clinical application to develop anti-atherosclerotic therapeutic approaches. The aim of this case-control observational study was to evaluate the plasma levels of interleukin (IL)-6, IL-18, IL-1β, and IL-10. Methods: The research was conducted at Hasan Sadikin Hospital from September to December 2021. Patients were recruited based on the typical clinical history of ACS (non-ST-elevation myocardial infarction, ST-elevation myocardial infarction, and unstable angina) and electrocardiographic and cardiac enzyme data. Healthy subjects having no more than one cardiovascular disease risk factor at admission were included. A total of 43 subjects were included in the study, of which 23 subjects were patients diagnosed with ACS and 20 were healthy controls. Results: The results showed that the mean plasma levels of IL-6 (298.6±432.9 pg/mL) in ACS patients were significantly higher than the mean concentration of IL-6 (33.7±96.6 pg/mL) in the control group (p < 0.05). Similarly, the mean plasma level of IL-18 (181.4±81.4 pg/mL) in ACS patients was significantly higher compared to the mean concentration (125.0±29.8 pg/mL) in the control group (p < 0.05), suggesting that both IL-6 and IL-18 were associated with ACS. However, there is no statistically significant difference between IL-1β and IL-10 levels. A Pearson’s correlation analysis showed that a positive correlation exists between IL-6 and IL-18. Conclusions: Both IL-6 and IL-18 are associated with ACS.

Keywords:Biomarkers; Inflammation; Atherosclerosis; Acute Coronary Syndrome; Interleukin-6.

Pilomatrixoma is a rare benign skin adnexal tumor arising from the hair follicles. Its occurrence in the male breast is extremely uncommon with very few cases reported worldwide. Pilomatrixoma may masquerade as a malignant tumor due to the presence of foci of calcification. We present a case of a 51-year-old man with a six-month history of a firm-to-hard mass in his right breast. The mammographic and sonographic features were suggestive of skin-related lesions. The lesion was excised. Histopathology confirmed the diagnosis of pilomatrixoma.

Keywords:Pilomatrixoma; Breast Tumors; Oman.

The use of immunosuppressive agents has recently been raised during the COVID-19 pandemic to manage the COVID-19-induced systemic inflammatory response and improve mortality. This widespread use of steroids and other immunomodulators for severe COVID-19 diseases might pose a potential risk of reactivation of latent diseases and the emergence of opportunistic infections such as strongyloidiasis. We report a case of strongyloidiasis with cholestasis in a middle-aged man; who was otherwise healthy and had no history of recent travel, developed three weeks after a prolonged course of steroids for the management of severe COVID-19 pneumonia. The patient was managed with a combination of albendazole and ivermectin. A high index of suspicion of strongyloidiasis in symptomatic patients post immunosuppressant therapy for severe COVID-19 is required to prevent unfavorable outcomes. In selected high-risk patients, post prolonged steroid therapy for COVID-19 pneumonia screening for strongyloidiasis and ivermectin empirical treatment might be considered even in non-endemic areas.

Keywords: Strongyloides ; COVID-19; Steroids; Ivermectin.

Distal renal tubular acidosis (RTA) is a common cause of renal stones and nephrocalcinosis in children. Distal RTA can be either acquired or congenital because of a genetic defect. Tuberous sclerosis complex is an autosomal dominant inherited neurocutaneous syndrome with variable renal involvement. We describe a case of a six-year-old boy with tuberous sclerosis complex who developed distal RTA and renal stones.

Keywords:Tuberous Sclerosis Complex; Urinary Stones; Distal Renal Tubular Acidosis; Oman.

Traumatic pulmonary pseudocyst is a rare type of parenchymal injury, estimated to occur in 0.1% of all chest traumas. We report a rare case of traumatic pulmonary pseudocyst in a seven-year-old boy who presented with a chest injury from a traffic accident. He had a scapula fracture, multiple abrasions on his body, and decreased respiratory sounds in the left hemithorax. His Glasgow Coma Scale score was 15. Chest X-ray suggested a 3 × 3.5 cm cavitary lesion. Computed tomography scan revealed a pulmonary pseudocyst in addition to parenchymal contusion and pneumothorax. A Velpeau bandage was applied to the scapula fracture. After five days of in-hospital observation without any thoracic intervention, the patient was discharged free of complications.

Keywords:Chest Injuries; Child; Traffic Accidents; Trauma; Turkey.

Congenital cholesteatoma is a rare lesion resulting from failed involution of epidermoid rest cells, which take part in the formation of the mucosa of the middle ear cleft during embryonic development. We report the first case report of a large congenital hypotympanic cholesteatoma with extension to the jugular foramen and carotid canal, in a 13-year-old girl, which was excised successfully by endoscopic-assisted hypotympanotomy infra-cochlear approach.

Keywords:Cholesteatoma; Middle Ear; Endoscopy.

The coexistence of both mucinous adenocarcinoma and carcinoid tumor within an ovarian mature cystic teratoma is extremely rare. We report a case of an 18-year-old Omani woman with a left ovarian cyst. After laparotomy with left salpingo-oophorectomy, omentectomy, and peritoneal washings, the excised cyst had the typical morphology of mature cystic teratoma with grade I mucinous adenocarcinoma and a focus of carcinoid tumor.

Keywords:Teratoma; Dermoid; Carcinoid; Adenocarcinoma; Germ Cells; Oman.