Bladder cancer (BC) originates mainly from the epithelial compartment of the bladder, which is defined as transitional cell carcinoma or urothelial cell carcinoma. About 70% of patients with BC will survive five years from diagnosis. Previous studies revealed that the immune system and its mediators, particularly chemokines, play a crucial role in modulating responses against BC. Chemokines, which serve as chemoattractants for leukocytes, are small proteins that can initiate inflammatory and anti-inflammatory immune responses and also are associated with many aspects of both regulation and progression of mentioned responses. Additionally, these immune mediators can interfere with the other tumor-related processes, including tumor proliferation, neovascularization, and metastases. Among these chemokines, CXC chemokines, including CXCL9, CXCL10, and CXCL11, are recognized as the main ligands of C-X-C motif chemokine receptor 3 (CXCR3) and contribute to related immune responses after therapeutic strategies for BC. Evidence suggests that the production of these chemokines can have two important implications. First, these mediators can trigger the accumulation of CD8+ T cells that can contribute to the elimination of the tumor. Secondly, the production of these chemokines by tumor tissue may trigger the migration and activation of immune cells including myeloid-derived suppressor cells and regulatory T cells, which act in favor of the tumor and its progress. Therefore, in this review, we describe the latest therapeutic approaches based on targeting this axis’s components and subsequent immune phenomenon.

Free sugars intake plays a major role in dental caries formation and other general health issues such as obesity. Therefore, interventions, which assist individuals or populations in the control of their free sugars intake, are of central importance in caries prevention strategies. There is good evidence that behavioral interventions benefit from a foundation in conceptual theories of behavior change founded on empirical data. In this review, we discuss the future application of seven theories, including six common psychological theories in predicting and developing interventions to reduce free sugars intake related to dental caries among adults. For each model, we summarize its key features and the data derived from its application in general and oral health settings and make recommendations for future research. We searched Medline, PsycINFO, Global Health, PubMed, and Embase databases to identify items dealing with dental caries, adults, sugars intake, and six psychological theories. These included the Transtheoretical Model of Change, Theory of Planned Behavior, Social Cognitive Theory, Information-Motivation-Behavioral Skills model, PRIME Theory, and Behavior Change Wheel theories. We searched literature published in the last 10 years, and priority was given to systematic reviews and randomized control trials. Although there is extensive literature on the application of the six psychological theories, there is a gap in knowledge about their effectiveness in reducing free sugars intake related to dental caries among adults. There is a need for better-designed trials of interventions based on the clear operationalization of psychological constructs to reduce sugars intake among the adult population.

Objectives: Language barriers pose challenges in terms of achieving high levels of satisfaction among medical professionals and patients, providing high- quality healthcare and maintaining patient safety. To address these challenges, many larger healthcare institutions offer interpreter services to improve healthcare access, patient satisfaction, and communication. However, these services increase the cost and duration of treatment. The purpose of this review is to investigate the impact of language barriers on healthcare and to suggest solutions to address the challenges. Methods: We identified published studies on the implications of language barriers in healthcare using two databases: PubMed and Medline. We included 14 studies that met the selection criteria. These studies were conducted in various countries, both developed and developing, though most came from the US. The 14 studies included 300 918 total participants, with participation in each study ranging from 21 to 22 353 people. Results: We found that language barriers in healthcare lead to miscommunication between the medical professional and patient, reducing both parties’ satisfaction and decreasing the quality of healthcare delivery and patient safety. In addition, the review found that interpreter services contribute indirectly to increased cost and the length of treatment visits. One study reported the implementation of online translation tools such as Google Translate and MediBabble in hospitals, which increased the satisfaction of both medical providers and patients (to 92%) and improved the quality of healthcare delivery and patient safety. Language barriers are responsible for reducing the satisfaction of medical providers and patients, as well as the quality of healthcare delivery and patient safety. Many healthcare institutions use interpreter services that increase the cost and length of treatment visits. Conclusions: The results of our review suggest that implementing online translation tools such as Google Translate and MediBabble may improve the quality of healthcare and the level of satisfaction among both medical providers and patients.

Keywords: Communication Barriers; Patient Satisfaction; Limited English Proficiency; Quality
of Health Care.

Objectives: We sought to evaluate the performance provided at a ‘See and Treat’ (ST) clinic at a tertiary hospital emergency department (ED) in Abu Dhabi, UAE, and to assess its impact on ED crowding. Methods: We conducted a retrospective electronic medical chart review and database analyses. We included patients triaged as triage level 4 (T4) and triage level 5 (T5) as per the Emergency Severity Index treated at ED in the ST clinic and other ED areas, including the off-site Urgent Care Centre (UCC) between 1 June 2016 and 30 June 2017. We analyzed a group of process and outcome measures at our ST clinic and compared them to the same measures in other areas of our ED and the co-located UCC. The process measure analyzed was the door-to-doctor time. In addition, the outcome measures analyzed were the door-to-door time, unplanned return within 72 hours, and feedback from T4 and T5 triaged patients treated at the clinic. Results: The number of patients enrolled in the study was 43 109. Of these, 11 329 (26.3%) patients were treated at the ST clinic, 6328 (14.7%) were treated at the UCC, and 25 452 (59.0%) were treated at the main ED. The door-to-doctor time was within 30 minutes for 89.0% of ST clinic patients, and 94.0% of patients experienced a door-to-door time of within two hours; 2.1% of these patients returned within 72 hours. Among these, 78.7% returned for an issue related to their first visit. However, none of the patients were admitted on their return visit. For patients presenting to UCC and other parts of our ED, we recorded a door-to-doctor time of within 30 minutes for 80.5% of patients and a door-to-door time of within two hours for 73.0% of patients. We found the difference in waiting times (i.e., door-to-doctor times between ST clinic patients and the rest of ED) to be statistically significant (p < 0.001, 95% confidence interval (CI): 0.56–0.63). However, on comparing door-to-door times, we found the difference between ST clinic patients and the rest of ED patients was not statistically significant. Conclusions: Door-to-doctor times were shorter in ST clinics compared to other parts of our ED, but there was no statistically significant difference in door-to-door times when comparing ST clinics to the rest of the ED. ST clinic patients had a lower rate of unplanned return within 72 hours, of which, none required admission on the return attendance. We believe ST clinics have a positive impact on reducing ED crowding but acknowledge they are one of the many plausible solutions attributing to optimized patient flow in the ED.

Objectives: Many scales have been developed to assess health literacy. These scales have been developed extensively in clinical populations in developed countries. Our study describes the process of development and validation of the Health Literacy Questionnaire to measure health literacy in the general Iranian population. Methods: We followed the scale development process outlined by Schwab in 1980. After a comprehensive review of the research published on Nutbeam’s definition of health literacy and its measurement, two focus groups were considered to generate a pool of items. We then assessed the face validity and content validity of the items. The final version of the questionnaire was subject to independent exploratory and confirmatory factor analysis. The internal consistency of the questionnaire was evaluated using Cronbach’s alpha. Finally, construct validity was assessed using bivariate analysis between the total scores on the scale and theoretically relevant variables. Results: The results of exploratory factor analysis revealed a three-factor 14-item structure for the scale. Confirmatory factor analysis provided a good statistical and conceptual fit for the data. The analysis of the internal consistency of the scale was satisfactory (α = 0.798). Further, health literacy was significantly associated with participants’ age, educational level, self-rated household income, smoking history, self-rated health, and self-rated health literacy. Conclusions: The results we obtained indicate that this newly constructed health literacy tool is highly valid and reliable. Prospective studies are required to evaluate the predictive validity of the scale with regard to health outcomes.

Objectives: Despite being recognized worldwide as an alternative therapy in treating various chronic diseases and pain, the mechanism of wet cupping is still not well understood. The purpose of this study was to evaluate fasting blood sugar (FBS), renal function parameters, and endothelial function changes following wet cupping in healthy individuals. Methods: We conducted a single-arm intervention study at the Clinical Lab of Community Medicine, Universiti Sains Malaysia, and included 31 healthy individuals aged between 30 and 60 years old. Wet cupping therapy was performed at five treatment points at the beginning of the study and repeated after three months. Health outcomes at baseline, one, three, and four months were assessed for FBS, renal function parameters (urea, creatinine, and uric acid), systolic blood pressure (SBP), and von Willebrand factor (vWF). Results: Forty-five percent of participants were female, and the mean age of study participants was 44.9±6.4 years. Wet cupping therapy significantly reduced FBS, serum urea, and serum creatinine at one, three, and four months compared with baseline values. Serum uric acid and SBP showed a significant reduction at one and four months compared with baseline. The vWF (a measure of endothelial function) had a 4.0% reduction at four months compared to baseline, with a mean difference of 5.3 (95% confidence interval (CI): 2.20 = 8.55; p = 0.002). Conclusions: This study provides preliminary support that repeated wet cupping therapy enhances body health status; thus, it could be an effective complementary medicine in disease prevention.

Keywords: Cupping Therapy; Blood Glucose; Fasting; von Willebrand Factor; Malaysia.

Objectives: We sought to determine the prevalence of asymptomatic bacteriuria (ASB) in patients with sickle cell disease (SCD), the susceptibility profile of its agents and their extended-spectrum β-lactamase (ESBL) production. Methods: Fifty-nine patients with SCD and 116 healthy controls were investigated. Urine samples were collected and cultured by standard techniques. We used the disc diffusion technique to determine antibiotic susceptibility. ESBL was detected by the combination disc method and detection of blaSHV, blaTEM, and blaCTX-M genes by multiplex-polymerase chain reaction. Results: The prevalence of ASB was higher among patients with SCD (8.6%) than controls (0.9%) (p = 0.016), predominantly among females. Coagulase-negative staphylococci (n = 2; 33.3%) predominated among the isolates. Other uropathogens included Stenotrophomonas maltophilia, Acinetobacter baumannii, and Enterobacter cloacae. All isolates were sensitive to meropenem but were resistant to ceftazidime, ampicillin, and tetracycline. blaSHV, blaTEM, and blaCTX-M-15 were detected in Enterobacter cloacae. Conclusions: The prevalence of ASB is high in patients with SCD predominantly among females. Rare multidrug-resistant uropathogens were implicated. We posit a need for resistance surveillance programs and antibiotic stewardship to prevent treatment failure and reduce drug resistance.

Keywords: Anemia, Sickle Cell; Bacteriuria; Anti-Bacterial Agents; Drug Resistance.

Objectives: Anabolic-androgenic steroids (AAS) have been used internationally for enhancing physical appearance and performance despite their significant side effects. We sought to identify the prevalence of AAS use and its different risk factors among gym users in Riyadh, Saudi Arabia. Methods: A cross-sectional survey was distributed among gym users across 20 gyms in Riyadh. The cluster sampling technique was used to represent the four regions of Riyadh (North, South, East, and West). Univariate and multivariate analyses were performed to identify the factors associated with AAS. Results: Out of 482 participants, 29.3% reported using AAS. The mean age of the study participants was 27.2±6.9 years, 61.0% were single, 67.1% were educated, 35.5% were government employees, and 31.1% were students. The use of AAS was more prevalent among gym members who practiced weightlifting (45.5%), were employed in the private sector (35.8%), and aged > 25 years old (53.3%). Multiple logistic regression showed that the most significant factors associated with the use of AAS among gym members were: weightlifting, using supplementary vitamins or minerals, following special diets, knowing individuals who used AAS, and being offered AAS. Conclusions: Our study provides clear evidence that the lifetime prevalence of AAS use is high among male gym members in Riyadh with modifiable risk factors. The results could help public health policymakers to take the necessary measures to alleviate the potential negative implications of AAS use at the community level.

Keywords: Steroids; Substance-Related Disorders; Weight Lifting; Doping in Sports; Saudi Arabia.

Objectives: In countries with a high prevalence of tuberculosis, such as Iran, the differentiation of malignant from non-malignant tumors is crucial. We attempted to find a reliable model in determining malignant nodes by investigating the sonographic characteristics of lymph nodes (LNs). Methods: In this prospective study, the morphologic characteristics of LNs, including size, shape, vascular pattern, echogenicity, margin, coagulation necrosis sign, calcification, and central hilar structure, which had been obtained during endobronchial ultrasound-guided transbronchial needle aspiration, were compared with the final pathology results. Results: We examined 253 LNs from 93 patients. Round shape, non-hilar vascular pattern, heterogeneous echogenicity, hyperechogenicity, distinct margin, and the existence of necrosis signs were significantly higher in malignant nodes. On the other hand, the existence of calcification, as well as the presence of central hilar structure, were highly suggestive of benign nodes (p < 0.050). Multivariate logistic regression revealed that size > 1 cm, heterogeneous echogenicity, hyperechogenicity, the existence of necrosis signs, and the lack of central hilar structure are independent predictive factors for malignancy. The accuracy of each of the aforementioned characteristics are 42.3%, 71.5%, 71.9%, 73.5%, and 65.6%, respectively. Of 74 malignant LNs, 100% had at least one of these independent factors. Conclusions: The morphological features of LNs based on endobronchial ultrasound-guided transbronchial needle aspiration can play a role in predicting malignancy.

Keywords: Pathology; Malignancy; Lymph Nodes; Endosonography; Iran.

Objectives: We sought to estimate the prevalence of depression among Oman Medical Specialty Board (OMSB) residents and determine the relationship between depression and sociodemographic characteristics. Methods: We conducted a cross-sectional survey from January to March 2017. A self-administered questionnaire was distributed to all residents enrolled under different OMSB training programs. Information was obtained on the sociodemographic characteristics. The Patient Health Questionnaire-9 (PHQ-9) was used to screen for depressive symptoms. Results: A total of 399 residents (158 males and 241 females) participated in the study. Overall, 115 residents had a PHQ-9 score of 5 or more, giving a prevalence of depression of 28.8%. Of those who were depressed, 85 (73.9%) had mild depression, 20 (17.4%) had moderate depression, and 10 (8.7%) had severe depression. There was a significant association between depression and participants’ gender (p = 0.030), level of residency (p = 0.006), sleep duration (p = 0.001), and exercise (p = 0.019). There was no significant association between depression with the other demographic characteristics such as marital status (p = 0.489), specialty (p = 0.370), smoking (p = 0.953), or drug use (p = 0.060). Conclusions: Depression is a common issue among medical residents. Health education on the harmful effects of depression needs to be addressed. Further research on the consequences of depression and its effects on quality of life and academic performance is needed.

Keywords: Cross-Sectional Studies; Prevalence; Depression; Patient Health Questionnaire; Internship and Residency; Oman.

Objectives: We sought to compare functional and cosmetic satisfaction among male and female patients undergoing open and closed septorhinoplasty within sub-groups of indications for the surgery at a tertiary care hospital in Oman. Methods: We conducted a prospective study in the ear, nose, and throat surgery department at Sultan Qaboos University Hospital from 2010 to 2015. All patients aged above 17 years, without dysmorphic pathologies, and due to be operated through open or endonasal septorhinoplasty based on the appropriate indications (functional or cosmetic or functional and cosmetic), were included in the study. Results: Out of 215 patients who underwent septorhinoplasty, 30 were lost to follow-up. One-hundred and eighty-five patients (124 males and 61 females) available for postoperative assessment had been allocated to septorhinoplasty by the endonasal approach (n = 89; 59 males and 30 females) or open approach (n = 96; 65 males and 31 females) based on their indications for surgery: functional (n = 98; 64 males and 34 females); cosmetic (n = 39; 23 males and 16 females); and both functional and cosmetic (n = 48; 37 males and 11 females). Sex-wise distribution across different age groups for the specific surgical technique based on indication for surgery did not show any significant differences within any of the respective sub-groups. Both sexes reported no significant difference in satisfaction per their scores on the functional satisfaction scale post open or endonasal intervention. However, in their cosmetic satisfaction scale scores, a significantly higher proportion of males within the functional indication for surgery subgroup (90.9%) expressed satisfaction with the open surgical approach than the 71.0% males operated by the endonasal approach (p = 0.041). Conclusions: Males undergoing septorhinoplasty for functional indications expressed significant satisfaction with the open surgical approach compared with the endonasal approach on the cosmetic satisfaction scale. This study could accrue only 185 patients during the five-year study period and hence was unable to generate any significant evidence to prove any differences in postoperative functional and cosmetic satisfaction outcomes within sub-groups based on other indications for surgery for males and females separately.

Keywords: Postoperative Period; Prospective Studies; Rhinoplasty; Oman.

Polymyalgia rheumatica (PMR) is an inflammatory condition of unknown etiology, commonly occurring in the elderly and is associated with a good prognosis. Patients usually present with pain in the neck, shoulders, and hips. The onset is often abrupt and is associated with depression and flu-like symptoms. Lung involvement in patients with PMR is unusual. Here we report a rare case of a 66-year-old man who presented with clinical features of PMR and respiratory symptoms, namely exertional dyspnea and dry cough.

Mycetoma, formerly known as Madura foot, is a chronic, localized, gradually increasing in size, granulomatous exogenous infection of the skin and subcutaneous tissue with risks of bone and visceral involvement. It is unevenly found worldwide but it is endemic in tropical and subtropical countries. Two groups of mycetoma exist with similar clinical presentation; eumycetoma due to true fungi, and actinomycetoma due to aerobic bacteria from actinomycomycetes species. Mycetoma is difficult to treat and can lead to serious sequelae including disability, deformity and even death, so early diagnosis and treatment can elicit good results. The diagnosis is made based on a clinical picture of a triad of painless tumefaction, draining sinuses and granules of the causative micro-organism along with direct microscopic examination and histological study. It is very important to distinguish between actinomycetoma and eumycetoma for selecting the therapy. Actinomycetomas generally respond well to antimicrobials compared with eumycetomas, which respond poorly and need a combination of medical and surgical therapy. Bone involvement makes treatment more difficult, keeping surgical amputation as the only choice of treatment. Despite the possibility of a cure with medical treatment alone, treatment failure may occur even with long-term therapy, which necessitates adding surgical intervention to achieve cure. We report a case of gluteal actinomycetoma in an Omani man, treated successfully by combined medical treatment and surgical excision with graft reconstruction after failure of different regimens of antimicrobials.

Tracheostomy is a common life-saving surgical procedure, which has its own short- and long-term surgical complications. Occasionally, after being in place for several years, the tube may fracture, causing a foreign body reaction in the bronchus followed by life-threatening pneumonia. We report a rare case of a 29-year-old man with a known leukodystrophy disorder whose tracheostomy tube was never changed in 14 years. He presented with signs of sepsis and respiratory distress. The management and intraoperative findings, including recommendations for tracheostomy care, were described.

Pulmonary alveolar microlithiasis (PAM) is a rare disease caused by a mutation in the SLC34A2 gene encoding the type IIb sodium phosphate cotransporter in alveolar type II cells. This results in the formation and accumulation of calcium phosphates crystals in the alveoli. Early in the disease, most patients are asymptomatic or might experience mild symptoms. However, in some patients, PAM can progress resulting in pulmonary fibrosis, cor pulmonale, and respiratory failure. We report the case of a 33-year-old Omani male who was referred to our institute with a history of fever and shortness of breath. A chest radiograph revealed bilateral dense consolidation. Chest computed tomography showed bilateral dense interlobular thickening and extensive consolidations with a lower lung predominance. Our findings were highly suggestive of PAM. The diagnosis was confirmed by bronchoalveolar lavage.

Abdominal pain is a common clinical presentation that can be caused by a variety of conditions ranging from self-limited to serious pathologies. It may be the first symptom of an occult malignancy, especially in elderly patients or in the presence of systemic manifestations such as weight loss, fever, fatigue, and anorexia. However, functional gastrointestinal disorders, vascular pathologies, renal diseases, genitourinary illnesses, and chronic infections should also be considered as possible causes of abdominal pain. We report a case of a 59-year-old female who presented to our center with a three-month history of abdominal pain and weight loss. Initial workup revealed the presence of a suspicious hepatic mass, circumferential wall thickening of the transverse colon, and pericardial effusion. Exploratory laparotomy with a surgical biopsy of the hepatic mass was performed, and the histopathologic picture was consistent with actinomycosis. The patient was treated successfully despite the initial diagnostic challenges and complicated hospital course.

Keywords: Liver; Abdominal Pain; Actinomycosis.