Recent reports suggest that 20 million people worldwide are regularly using khat as a stimulant, even though the habit of chewing khat is known to cause serious health issues. Historical evidence suggests khat use has existed since the 13th century in Ethiopia and the southwestern Arabian regions even before the cultivation and use of coffee. In the past three decades, its availability and use spread all over the world including the United States and Europe. Most of the consumers in the Western world are immigrant groups from Eastern Africa or the Middle East. The global transport and availability of khat has been enhanced by the development of synthetic forms of its active component. The World Health Organization considers khat a drug of abuse since it causes a range of health problems. However, it remains lawful in some countries. Khat use has long been a part of Yemeni culture and is used in virtually every social occasion. The main component of khat is cathinone, which is structurally and functionally similar to amphetamine and cocaine. Several studies have demonstrated that khat chewing has unfavorable cardiovascular effects. The effect on the myocardium could be explained by its effect on the heart rate, blood pressure, its vasomotor effect on the coronary vessels, and its amphetamine–like effects. However, its direct effect on the myocardium needs further elaboration. To date, there are few articles that contribute death among khat chewers to khat-induced heart failure. Further studies are needed to address the risk factors in khat chewers that may explain khat-induced cardiotoxicity, cardiomyopathy, and heart failure.

Objectives: Optimal glycemic control is an important goal in the management of type 1 diabetes mellitus (T1DM). Although the use of multiple daily injections (MDI) is a common regimen worldwide, its use is not yet universal in many countries. Our aim was to evaluate the effects of switching from a twice daily (BID) to a MDI insulin regimen in children and adolescents with T1DM in order to revisit its benefits in the Omani population. Methods: We conducted a retrospective cohort study of children and adolescents with T1DM at Sultan Qaboos University Hospital, Muscat, Oman, between January 2007 and June 2013. Patients using the BID regimen for more than six months who were then switched to MDI were included in the analysis. We compared glycated hemoglobin levels (HbA1c) before and after the regimen change. Results: Fifty-three children were eligible for the study. Ten patients were excluded for various reasons. The remaining 43 patients were 58% male and 42% female, with a mean age of 9.4±3.7 years. There was significant decrease in the overall mean HbA1c level from baseline (10.0) compared to three months after switching to MDI (9.5); p=0.023. Nevertheless, the improvement was not significant in the subsequent follow-up visits at six and nine months. The reduction in HbA1c values was observed mainly in children five to 11 years. Conclusions: Switching from a BID to MDI insulin regimen has favorable effects on the overall control of T1DM in children and adolescents, as assessed by HbA1c levels. In addition, this regimen has been proved to be safe and well tolerated by patients.

Objectives: Our study aimed to estimate the rate of white coat hypertension (WCH) and effect, and masked hypertension in patients attending a tertiary care hospital for 24 hour ambulatory blood pressure monitoring (24-h ABPM). Methods: A total of 231 adult patients were referred to the Department of Clinical Physiology at Sultan Qaboos University Hospital, Muscat, for ABPM, between January 2010 and June 2012. The following data were gathered and analyzed: demographic data, clinic blood pressure (BP) measurements, and 24-h BP profile from ABPM. Thirty-two patients were excluded and the final analysis included 199 patients. Results: There were 105 (52.8%) women and 94 (47.2%) men studied. The mean age of patients was 46±15 years and most patients were overweight with a mean BMI of 29.6±5kg/m2. Around half of patients (53.8%) were on one or more antihypertensive medications. WCH was found in 10.6% and white coat effect was found in 16% of patients. The majority of patients (57%) with WCH were aged 40 years or above. Masked hypertension was present in 6% of patients and masked uncontrolled hypertension in 8.5% of patients. Conclusions: Our study showed that WCH and effect, and masked hypertension are common in hypertensive patients. Identifying these patients will have an impact on their management. However, the results of the study should be interpreted within the context of its limitations. Prospective randomized community and hospital-based studies should be conducted to estimate the true prevalence in the general population as well as in hypertensive patients.

Objectives: Sickness certification (SC) is common practice in primary health care with proven implications on the health system. To assess the rate of sickness certifications in the Bowsher province and describe related demographic, occupational and medical factors. Methods: Our retrospective, cross-sectional study retrieved data for all consultations, with patients aged six to 65 years old, which ended with SC. The data from four primary health care centers in the Bowsher provice were collected during 2011 using the electronic medical record system. Collected data included patient demographics, occupation, date issued, duration of sickness certification, recorded vital signs, and clinical diagnosis. Suitable rates were calculated as percentages and important differences were compared using the chi-square test. Results: The total number of consultation visits for the targeted population was 189,275. Of these 26,096 consultations resulted in SC to a total of 15,758 patients. The overall rate of SC was 13.8 per 100 consultation-years (confidence interval (CI): 13.6–14). SC rates in males were significantly higher than females (17 and 11 per 100 consultations/year, respectively). Patients aged 19–29 years old had the highest rate of SC (18.6/100 consultations/year). School students aged six to 18 years made up 28% of patients, and 24% and 22% of patients were working in the private and public sectors, respectively. No vital signs record was found for 30% of SC visits. The highest rate of SC was in October (17%) and the lowest was in August (9%). Acute respiratory infections were the most frequent diagnoses (31%) resulting in certifications. The rate of SC issued for Omanis and non-Omanis was 14 and 9 per 100 consultations per year, respectively. Conclusion: Sickness certification is a burden on primary health care in the studied health centers with approximately one in seven consultations ending with SC issued. More investigations are needed to identify determinates of high sickness absence. Robust guidelines are important to regulate the number of sickness certificates issued.

Objectives: We sought to determine the role of obesity and insulin resistance (IR) in the pathogenesis of inflammation in metabolic syndrome (MetS). Methods: Our study included 100 patients with MetS and 100 age and gender matched control patients who attended a tertiary care laboratory in Rawalpindi, Pakistan. Anthropometric data was obtained including height and weight to calculate body mass index. A record of patient’s blood pressure (BP), waist circumference (WC) and hip circumference (HC) was made. Biochemical analysis included measurements of fasting glucose, triglycerides (TG), high-density lipoprotein cholesterol (HDL-c), insulin, and high-sensitivity C reactive protein (hsCRP). IR was determined by the homeostasis mode assessment insulin resistance (HOMA-IR) method. Results: The levels of hs-CRP were found to be elevated in all patients with MetS where it correlated significantly with all its components including measures of obesity, fasting insulin and glucose levels, IR, TG and HDL-c. However, on linear regression analysis only WC, fasting insulin, and HOMA-IR remained significantly correlated with hs-CRP. Conclusion: MetS is a condition characterized by chronic low-grade inflammation, which arises because of increased abdominal adiposity and IR. Large multicenter studies are needed to gain insight into its pathogenesis and derive treatment strategies.

Objectives: We sought to assess microbial air quality and bacterial surface contamination on medical instruments and the surrounding areas among 30 ambulance runs during service. Methods: We performed a cross-sectional study of 106 air samples collected from 30 ambulances before patient services and 212 air samples collected during patient services to assess the bacterial and fungal counts at the two time points. Additionally, 226 surface swab samples were collected from medical instrument surfaces and the surrounding areas before and after ambulance runs. Groups or genus of isolated bacteria and fungi were preliminarily identified by Gram’s stain and lactophenol cotton blue. Data were analyzed using descriptive statistics, t-test, and Pearson’s correlation coefficient with a p-value of less than 0.050 considered significant. Results: The mean and standard deviation of bacterial and fungal counts at the start of ambulance runs were 318±485cfu/m3 and 522±581cfu/m3, respectively. Bacterial counts during patient services were 468±607cfu/m3 and fungal counts were 656±612cfu/m3. Mean bacterial and fungal counts during patient services were significantly higher than those at the start of ambulance runs, p=0.005 and p=0.030, respectively. For surface contamination, the overall bacterial counts before and after patient services were 0.8±0.7cfu/cm2 and 1.3±1.1cfu/cm2, respectively (p<0.001). The predominant isolated bacteria and fungi were Staphylococcus spp. and Aspergillus spp., respectively. Additionally, there was a significantly positive correlation between bacterial (r=0.3, p<0.010) and fungal counts (r=0.2, p=0.020) in air samples and bacterial counts on medical instruments and allocated areas. Conclusions: This study revealed high microbial contamination (bacterial and fungal) in ambulance air during services and higher bacterial contamination on medical instrument surfaces and allocated areas after ambulance services compared to the start of ambulance runs. Additionally, bacterial and fungal counts in ambulance air showed a significantly positive correlation with the bacterial surface contamination on medical instruments and allocated areas. Further studies should be conducted to determine the optimal intervention to reduce microbial contamination in the ambulance environment.

Objectives: To assess the response rate and duration of response in patients with chronic immune thrombocytopenia (ITP) receiving rituximab. Methods: We retrospectively analyzed 32 consecutive patients with chronic ITP who were treated in two tertiary centers in Oman. Response assessment was based on the American Society of Hematology criteria. Results: Nineteen patients (59%) had an initial response. However, six of the 19 patients lost their response leaving 13 patients with long-lasting remissions. The median age at diagnosis was 25 years (range 14–58). The median time from diagnosis to rituximab therapy was 21 months. The median follow-up after starting rituximab was 26 months. The overall cumulative response rate was 59% (complete response 44%, partial response 15%) and the median time to respond was 30 days with a response rate of 44% at four weeks. In all responders, the cumulative rate of loss of response was 32% with a median time to lose response of 54 months. Conclusions: The use of rituximab in ITP achieves high response rate and long remission duration. Our study was limited by the small sample size and further larger prospective studies are recommended.

Objectives: Vitamin D has been found to be strongly associated with many systemic disorders. There has been an augmented interest within the medical community in vitamin D, especially its deficiency, in various systemic disorders. Although the role of vitamin D deficiency in irritable bowel syndrome (IBS) has not yet been established, studies are underway to clearly establish its role in the disease. The objective of the our study was to elucidate and establish the role of vitamin D deficiency in IBS patients compared to a healthy control group. Methods: This study is a comparative case control study of vitamin D deficiency in patients with IBS diagnosed with ROME 3 criteria of classification (the third ROME foundation classification) to an age and gender matched healthy control group. The vitamin D level was measured in both cohorts for comparison and the results interpreted statistically. Sixty patients with IBS and 100 healthy individuals were included as test and control groups, respectively, in the study. The mean serum vitamin D level (nmol/L) of IBS patients was compared to the control group. Results: Vitamin D deficiency was detected in 49 patients (82%) in the IBS group and 31 patients (31%) in the control group. There was a statistically significant difference in the mean vitamin D level (p=0.025) between the IBS group and control group. Conclusions: Our study shows that vitamin D deficiency is highly prevalent in patients with IBS and these results seem to have therapeutic implications. Vitamin D supplementation could play a therapeutic role in the control of IBS.

Objectives: To analyze the safety and efficacy of bronchial artery embolization (BAE) in the management of hemoptysis. Methods: We conducted a retrospective study of 334 patients who had undergone BAE for hemoptysis from January 2007 to July 2013. Our study included 255 (76.3%) males and 79 (23.7%) females with an age range from five to 81 years old. All relevant arteries were evaluated but only those arteries that showed hypertrophy and significant blush were targeted. Polyvinyl alcohol (PVA) was used in all patients and gel foam was used in combination with PVA where there was significant shunting. Results: Mild hemoptysis was seen in 70 patients, moderate in 195 patients, and severe in 69 patients. On imaging, right side disease was seen in 101 patients, left side involvement in 59 patients, and bilateral involvement in 174 patients. Post-tubercular changes were the predominant pathology seen in 248 patients. Among 334 patients (386 procedures), 42 patients underwent the procedure twice and five patients underwent the procedure thrice. A total of 485 arteries were attempted of which 440 arteries were successfully embolized. Right intercosto-bronchial was the most common culprit artery present in 157 patients, followed by common bronchial (n=97), left bronchial (n=55), and right bronchial (n=45). We embolized a maximum of four arteries in one session. Immediate complications such as dissection and rupture occurred in only nine sessions (2.3%). Twenty-five procedures (6.5%) were repeated within two months, which were due to technical or clinical failure and 27 procedures (7%) were repeated after two months.Conclusions: BAE is a safe and effective procedure with a negligible complication rate. Our approach of targeting hypertrophied arteries was effective.

This is the first case report in Oman and the Gulf region of a 17-β-hydroxysteroid dehydrogenase type 3 (17-β-HSD3) deficiency with a novel mutation in the HSD17B3 gene that has not been previously described in the medical literature. An Omani child was diagnosed with 17-β-HSD3 deficiency and was followed up for 11 years at the Pediatric Endocrinology Clinic, Royal Hospital, Oman. He presented at the age of six weeks with ambiguous genitalia, stretched penile and bilateral undescended testes. Ultrasound showed no evidence of any uterine or ovarian structures with oval shaped solid structures in both inguinal regions that were confirmed by histology to be testicular tissues with immature seminiferous tubules only. The diagnosis was made by demonstrating low serum testosterone and high androstenedione, estrone, and androstenedione:testosterone ratio. Karyotyping confirmed 46,XY and the infant was raised as male. Testosterone injections (25mg once monthly) were given at two and six months and then three months before his surgeries at five and seven years of age when he underwent multiple operations for orchidopexy and hypospadias correction. At the age of 10 years he developed bilateral gynecomastia (stage 4). Laboratory investigations showed raised follicle-stimulating hormone, luteinizing hormone, androstenedione, and estrone with low-normal testosterone and low androstendiol glucurunide. Testosterone injections (50mg once monthly for six months) were given that resulted in significant reduction in his gynecomastia. Molecular analysis revealed a previously unreported homozygous variant in exon eight of the HSD17B3 gene (NM_000197.1:c.576G>A.Trp192*). This variant creates a premature stop codon, which is very likely to result in a truncated protein or loss of protein production. This is the first report in the medical literature of this novel HSD17B3 gene mutation. A literature review was conducted to identify the previous studies related to this disorder.

Transient neurological deficit following cervical trauma have been reported following sports injuries, and has been referred to as cervical cord neurapraxia. The so-called “whiplash injuries” following minor motor vehicle collisions usually do not produce any neurological deficit. Here we report the case of a whiplash type of injury presenting with a delayed onset neurological deficit, which was followed by rapid and complete recovery. The patient, an otherwise healthy 34-year-old male, attended the emergency department of Sultan Qaboos University Hospital following a rear-end motor vehicle collision. We present images showing degenerative disc disease causing spinal canal narrowing and mild cord compression in the patient, but no spinal instability. Differential diagnoses are also discussed.

Wolcott-Rallison syndrome (WRS) is an autosomal recessive disease, characterized by neonatal or early-onset non-autoimmune insulin-dependent diabetes. WRS, although rare, is recognized to be the most frequent cause of neonatal-onset diabetes. The majority of reported patients are from consanguineous families. Several mutations with variable expression of the syndrome are reported. Here we describe a six-year-old boy with WRS who was evaluated at Sultan Qaboos University Hospital and was found to have a novel homozygous nonsense mutation in the EIF2AK3 gene. His younger sister also had WRS but with milder expression. The mutation exhibited different clinical characteristics in the siblings proving that WRS patients phenotypic variability correlates poorly to genotype. This is the first case report of two Omani children with WRS and a report of a novel mutation.

Traumatic asphyxia, or Perthe’s syndrome, is a rare clinical syndrome characterized by cervicofacial cyanosis, petechiae, subconjunctival hemorrhage, neurological symptoms, and thoracic injury. It affects both adults and children after blunt chest traumas. The diagnosis of this condition is based mainly on the specific clinical signs, which should immediately bring to mind the severity of the trauma, the various probable types of pulmonary injuries, and the need for screening and careful assessment of other organs that might also be injured. In this report, we describe the case of a 39-year-old male who developed traumatic asphyxia after severe blunt chest trauma during his work at a construction site. The patient had multiple injuries to the chest, abdomen, head and neck, which were treated conservatively. An associated diaphragmatic injury was successfully treated by video-assisted thoracic surgery. This patient is one of five patients who were admitted to Saqr Hospital in the United Arab Emirates, diagnosed with traumatic asphyxia, and treated by mechanical ventilator, supportive measures, and fiberoptic bronchoscopy, for both diagnostic and therapeutic indications, in our unit in the period between July 2006 and June 2013. As traumatic asphyxia is a systemic injury, careful assessment of the patient and looking for other injuries is mandatory. Treatment usually involves supportive measures to the affected organs, but surgical intervention may sometimes prove to be an important part of the treatment. Bronchoscopy should be performed for diagnostic and therapeutic reasons because of the associated pulmonary and possible tracheobronchial injuries.

Snake bites are an important public health problem worldwide. Snake venom causes both systemic and local complications, which can prove fatal if not treated on time. The local effects of snake bite include tissue necrosis, edema, and compartment syndrome. Patients may also be left with permanent physical deformities due to residual sequelae of the snake bite. Compartment syndrome after a snake bite is an uncommon occurrence. The effects are more pronounced in children possibly due to the the reduced total dilution volume in children. The administration of anti-snake venom is the only specific therapy. Compartment syndrome occurs due to a vicious cycle of edema causing hypoxia and acidosis, which further increases capillary permeability and fluid extravasation. This results in a volume increase in the closed fascial compartment, which ultimately compromises circulation and causes irreversible muscle and nerve damage. Our report describes a case of upper limb compartment syndrome following a snake bite on the right wrist of a five-year-old girl who presented eight-hours after the snake bite to the emergency department of Nizwa Regional Referral Hospital. The patient received early and appropriate care but progressed to develop compartment syndrome for which she had to be taken to the operating theatre for emergency fasciotomy. All clinicians should be able to recognize the early symptoms and signs of an evolving compartment syndrome in absence of intracompartmental measuring equipment. The timely fasciotomy in our patient helped the patient achieve excellent functional results.