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1.  Criteria for Diagnosis of Familial Hypercholesterolemia: A Comprehensive Analysis of the Different Guidelines, Appraising their Suitability in the Omani Arab Population 
Oman Medical Journal  2014;29(2):85-91.
Subjects with Familial hypercholesterolemia are at increased risk for cardiac events such as premature myocardial infarction and early death from coronary heart disease, especially in patients with severe forms of the disease if left unattended. Therefore, there is an ardent need for the early diagnosis followed by aggressive therapeutic intervention and lifestyle modification. Three groups have developed clinical diagnostic tools for Familial hypercholesterolemia: the US MedPed Program, the Simon Broome Register Group in the United Kingdom, and the Dutch Lipid Clinic Network. In this article, the individual criteria are reviewed with particular emphasis on their advantage(s) and disadvantage(s), and in turn assess their suitability in diagnosing Familial hypercholesterolemia in the Omani Arab population. A brief insight into the process of "Cascade Screening" is also provided, this is a procedure that we are in the process of establishing in Oman.
PMCID: PMC3976735  PMID: 24715932
Familial hypercholesterolemia; Simon-Broome Criteria; Cascade-Screening; Dutch Criteria; US-Medped Criteria; Omani Arab Population
2.  Rationale, Design, Methodology and Hospital Characteristics of the First Gulf Acute Heart Failure Registry (Gulf CARE) 
There is paucity of data on heart failure (HF) in the Gulf Middle East. The present paper describes the rationale, design, methodology and hospital characteristics of the first Gulf acute heart failure registry (Gulf CARE).
Materials and Methods:
Gulf CARE is a prospective, multicenter, multinational registry of patients >18 year of age admitted with diagnosis of acute HF (AHF). The data collected included demographics, clinical characteristics, etiology, precipitating factors, management and outcomes of patients admitted with AHF. In addition, data about hospital readmission rates, procedures and mortality at 3 months and 1-year follow-up were recorded. Hospital characteristics and care provider details were collected. Data were entered in a dedicated website using an electronic case record form.
A total of 5005 consecutive patients were enrolled from February 14, 2012 to November 13, 2012. Forty-seven hospitals in 7 Gulf States (Oman, Saudi Arabia, Yemen, Kuwait, United Gulf Emirates, Qatar and Bahrain) participated in the project. The majority of hospitals were community hospitals (46%; 22/47) followed by non-University teaching (32%; 15/47 and University hospitals (17%). Most of the hospitals had intensive or coronary care unit facilities (93%; 44/47) with 59% (28/47) having catheterization laboratory facilities. However, only 29% (14/47) had a dedicated HF clinic facility. Most patients (71%) were cared for by a cardiologist.
Gulf CARE is the first prospective registry of AHF in the Middle East, intending to provide a unique insight into the demographics, etiology, management and outcomes of AHF in the Middle East. HF management in the Middle East is predominantly provided by cardiologists. The data obtained from this registry will help the local clinicians to identify the deficiencies in HF management as well as provide a platform to implement evidence based preventive and treatment strategies to reduce the burden of HF in this region.
PMCID: PMC4062990  PMID: 24949181
Acute heart failure; gulf; heart failure; middle east
3.  Validation of the Arabic Version of the Epworth Sleepiness Scale in Oman 
Oman Medical Journal  2013;28(6):454-456.
The Epworth sleepiness scale is a self-administered eight-item questionnaire that was developed as a tool to measure subjective sleepiness in adults. The validity of the Epworth sleepiness scale has been validated and tested in different populations and ethnic groups. However, it has yet to be validated or tested in an Omani or other Arabic speaking population. Thus, the aim of this study is to test the validity and reproducibility of the Epworth sleepiness scale in an Omani population.
Subjects were recruited from the general population and were asked to participate in the study. The study enrolled 97 Omani volunteers and was conducted between May and October 2008. An Arabic version of the original English questionnaire was used. The study was approved by the Research and Ethics committee of the institution. Lin’s concordance correlation coefficient along with Bland-Altman plots were used to test the agreement between the Arabic and English versions of the Epworth sleepiness scale.
The study included a total of 37 males (38%) and 60 females (62%) with age ranging between 18-75 years. Concordance correlation results revealed a substantial concordance (RhoC) of 0.914, but one that does not approach 1 (95% CI: 0.881, 0.947). This results from both lack of perfect correlation (Pearson’s r=0.914) and bias (C_b = 1.000). The Bland and Altman’s limits-of-agreement measured at 0.000 (95% CI: -2.684, 2.684), indicating insignificant average departure from agreement between the two versions of the Epworth sleepiness scale.
The results indicate agreement between the two versions of ESS (English and the Arabic).
PMCID: PMC3815862  PMID: 24223253
Sleepiness; Arabic ESS; Bland Altman
4.  Clinical and Demographic Profile of Attendees at Baghdad’s Walk-in Psychiatric Clinic 
Oman Medical Journal  2013;28(5):365-370.
Few studies have examined clinical and demographic profile of attendees of a walk-in psychiatric clinic in countries ravaged by wars. The aim of this study is to quantify the characteristics of attendees of an open walk-in psychiatric clinic in a general hospital in Baghdad and the suburb towns of Iraq in the year 2010.
As part of a retrospective survey, information on specific variables (socio-demographic background, clinical characteristics and attendance rate) were sought from medical records in the year 2010 (January to December).
Despite the shortcomings expected from a country coming out of the ravage of war, the survey included 2,979 attendees (1,864 [63%] males and 1,115 [37%] females) of a walk-in psychiatric clinic who fulfilled the inclusion criteria. The profile of attendees indicated that a majority of the cohort was self-referred with a predominance of employed males, aged 19 to 49 years, residing in Baghdad City. Depression and psychosis were the most common diagnosis given.
The observed patterns are discussed within the available literature relevant to consultation liaison psychiatry, and specific to situations in Iraq and Arab/Islamic cultural patterning.
PMCID: PMC3769131  PMID: 24044067
Retrospective survey; Socio-demographic; Referral; Statistical Manual of Mental Disorders; Iraq
5.  Prevalence of Celiac Disease in Omani Children with Type 1 Diabetes Mellitus: A Cross Sectional Study 
Oman Medical Journal  2013;28(4):260-263.
Published studies on the prevalence of celiac disease in type 1 diabetes mellitus from the Arab World are scant. We aim to report the prevalence of celiac disease in Omani children with type 1 diabetes mellitus.
Children with type 1 diabetes mellitus were prospectively screened for celiac disease, at Sultan Qaboos University Hospital, Muscat, Oman over a period of one year (June 2011 - May 2012). Serum anti tissue transglutaminase IgA, endomysial IgA antibodies and total IgA were measured for screening of celiac disease. Children with positive anti-tissue transglutaminase and/or endomysial IgA antibodies underwent endoscopy.
A total of 103 children with type 1 diabetes mellitus were initially included. Ten patients were lost to follow up. Ninety-three patients aged 2-17 years underwent screening for celiac disease. Sixteen patients had positive anti-tissue transglutaminase (17%). Fourteen patients underwent endoscopy with duodenal biopsies, while two were lost to follow-up. Five patients with positive anti-tissue transglutaminase had intestinal biopsy proven celiac disease. The prevalence of celiac disease is 5.5% in our cohort of children and adolescents with type 1 diabetes mellitus.
The prevalence of celiac disease in Omani children and adolescents with type 1 diabetes mellitus is similar to the World’s reported prevalence, but is less than that reported for Middle Eastern Arab children. To our knowledge, this is the first reported study on the prevalence of celiac disease in Omani children with type 1 diabetes mellitus.
PMCID: PMC3725250  PMID: 23904919
Celiac Disease; Type 1 Diabetes Mellitus; Anti-tissue transglutaminase; Oman
6.  Road Traffic Fatalities in Oman from 1995 to 2009: Evidence from Police Reports 
Fatalities from road traffic crashes (RTCs) are a public health challenge for low- and middle-income countries, especially those experiencing epidemiological transition. This paper aims to describe demographics and trend analysis of fatalities of RTCs in Oman from 1995 to 2009.
The RTC data from 1995 to 2009 were obtained from the published reports of the Royal Oman Police (ROP). Data were extracted on the distribution of deaths by age, sex, nationality, mode of travel (driver, passenger, pedestrians), and type of vehicle (four- vs. two-wheelers). Trend analyses were carried out using the Chi-square for the percentages of deaths and linear regression for rates.
A total of 9,616 deaths from RTCs were reported from 1995 to 2009. Of 9,616 fatalities, 4,666 (48.5%) were aged 26-50 years, 7,927 (82.4%) were males, 7,215 (75.0%) were Omanis, and 2,278 (23.8%) were pedestrians. Overall, mortality increased by around 50% from 479 deaths during 1995 to 953 deaths during 2009. There was a significant increase in the proportion of deaths (P < 0.05) and death rates (P < 0.05) among individuals aged 26-50 years, males, Omani nationals, and drivers. The number and rate of RTC fatalities due to overspeeding was also increased (P < 0.05).
Fatalities due to RTCs in Oman are increasing, especially among those aged 26-50 years, males, drivers, and Omani nationals with overspeeding as a major cause of road traffic fatalities. There is a need for more research in understanding the risk-taking behaviors of young drivers, and sociocultural factors, especially among Omani nationals to target interventions.
PMCID: PMC3733033  PMID: 23930183
Fatalities; injuries; national police data; Oman; road traffic crashes
7.  Geographical Clustering of Juvenile Onset Systemic Lupus Erythematosus within the Sultanate of Oman 
Oman Medical Journal  2013;28(3):199-203.
While SLE is found worldwide, there is diversity in clinical presentation of the disease according to geographical variations. The aim of this study is to describe geographical distributions of childhood onset SLE within Oman to identify geographical clustering and to compare the demographic, clinical, and immunological characteristics of this cluster against the rest of Oman.
We retrospectively reviewed the hospital charts of 104 consecutive children with childhood onset SLE who were seen in pediatric rheumatology centers in the Sultanate of Oman over a 15-year period between 1995 and 2010.
Geographical clustering of childhood onset SLE was identified in Sharqiya region, which constituted 41% (n=43) of all cases in Oman. This cohort of patients had characteristic disease features which consisted of significantly more boys affected with SLE compared to the rest of the country (42% versus 15%; p=0.002). These children also tended to be younger (10.3 versus 16.5 years; p=0.001), diagnosed at an earlier age (6.4 versus 9.4 years; p<0.001) with a stronger family history of SLE (58% versus 33%; p=0.010). These children also had increased incidence of mucocutanous changes (81% versus 62%; p=0.036) and decreased hematological abnormalities (30% versus 51%; p=0.036).
We identified geographical clustering of childhood onset SLE to Sharqiya region in Oman which is associated with unique demographical and clinical features. Whether increased prevalence of disease in this region is due to geographical, environmental, ethnic or genetic factors is yet to be determined. However, it is likely to be interplay of known and other unrecognized factors.
PMCID: PMC3679612  PMID: 23772287
SLE; Oman; Lupus; Demography
8.  Reasons for Consultation among Patients attending Primary Healthcare Centres in Oman 
Pathways to care or care-seeking, which translate into healthcare utilisation, have been investigated in many parts of the world, but there is a dearth of studies in the Arabian Gulf. The aim of this study was to examine the characteristics of attendees at primary healthcare centres in northern Oman and their reasons for visiting.
Face-to-face interviews were conducted with 676 participants attending 12 primary healthcare centres between June and July 2006. The catchment area was selected to represent the population structure in Oman. The 12-item questionnaire was read to every fifth eligible patient entering each healthcare centre for a routine appointment. Analyses were conducted using univariate statistics.
About a third (n = 200; 29.6%) of the participants had a history of chronic illness; 231 (34%) were on regular medications; 211 (31%) were taking part in health education programmes; 130 (19%) were open to complementary medicine. The majority of the participants mentioned physician’s advice (n = 570; 84%) as the strongest reason for seeking consultation. Conversely, physician’s advice was strongly related to particular demographic factors.
This observational study identified some characteristics and reasons for visiting healthcare facilities in northern Oman. These are discussed within the context of prevailing sociocultural factors. The implications for the prevention and detection of ill health in Oman are also discussed.
PMCID: PMC3706114  PMID: 23862030
Patient Acceptance of Healthcare; Attitude to Health; Community Health Centers; Physician-Patient Relations; Oman
9.  Mutation in the PCSK9 Gene in Omani Arab Subjects with Autosomal Dominant Hypercholesterolemia and its Effect on PCSK9 Protein Structure 
Oman Medical Journal  2013;28(1):48-52.
Proprotein convertase subtilisin/kexin type (PCSK9) is a crucial protein in LDL cholesterol (LDL-C) metabolism by virtue of its pivotal role in the degradation of the LDL receptor. Mutations in the PCSK9 gene have previously been found to segregate with autosomal dominant familial hypercholesterolemia (ADFH). In this study, DNA sequencing of the 12 exons of the PCSK9 gene has been performed for two patients with a clinical diagnosis of familial hypercholesterolemia where mutation in the LDL-receptor gene hasn't been excluded. One missense mutation was detected in the exon 9 PCSK9 gene in the two ADFH patients. The patients were found to be heterozygote for Ile474Val (SNP rs562556). Using an array of in silico tools, we have investigated the effect of the above mutation on different structural levels of the PCSK9 protein. Although, the mutation has already been reported in the literature for other populations, to the best of our knowledge this is the first report of a mutation in the PCSK9 gene from the Arab population, including the Omani population.
PMCID: PMC3562979  PMID: 23386946
Mutation; Autosomal dominant hypercholesterolemia; PCSK9 protien
10.  Clinical Profile and Mortality of ST-Segment Elevation Myocardial Infarction Patients Receiving Thrombolytic Therapy in the Middle East 
Little is known about thrombolytic therapy patterns in patients with ST-elevation myocardial infarction (STEMI) in the Middle East. The objective of this study was to evaluate the clinical profile and mortality of STEMI patients who arrived in hospital within 12 hours from pain onset and received thrombolytic therapy.
Patients and Methods:
This was a prospective, multinational, multi-centre, observational survey of consecutive acute coronary syndrome patients admitted to 65 hospitals in six Middle Eastern countries during the period between October 2008 and June 2009, as part of Gulf RACE-II (Registry of Acute Coronary Events). Analyses were performed using univariate statistics.
Out of 2,465 STEMI patients, 66% (n = 1,586) were thrombolysed with namely: streptokinase (43%), reteplase (44%), tenecteplase (10%), and alteplase (3%). 22.7% received no reperfusion. Median age of the study cohort was 50 (45-59) years with majority being males (91%). The overall median symptom onset-to-presentation and door-to-needle times were 165 (95- 272) minutes and 38 (24-60) minutes, respectively. Generally, patients presenting with higher GRACE risk scores were treated with newer thrombolytic agents (reteplase and tenecteplase) (P < 0.001). The use of newer thrombolytic agents was associated with a significantly lower mortality at both 1-month (0.8% vs. 1.7% vs. 4.2%; P = 0.014) and 1-year (0% vs. 1.7% vs. 3.4%; P = 0.044) compared to streptokinase use.
Majority of STEMI patients from the Middle East were thrombolysed with streptokinase and reteplase in equal numbers. Nearly one-fifth of patients did not receive any reperfusion therapy. There was inappropriately long symptom-onset to hospital presentation as well as door-to-needle times. Use of newer thrombolytic agents in high risk patients was appropriate. Newer thrombolytic agents were associated with significantly lower mortality at 1-month and 1-year compared to the older agent, streptokinase.
PMCID: PMC3424777  PMID: 22919446
Acute coronary syndrome; GRACE score; Middle East; mortality; reteplase; STEMI; streptokinase; tenecteplase; thrombolytic therapy
11.  Extent of Subclinical Pulmonary Involvement in Childhood Onset Systemic Lupus Erythematosus in the Sultanate of Oman 
Oman Medical Journal  2012;27(1):36-39.
The aim of this study was to investigate the frequency of pulmonary function abnormalities in clinically asymptomatic children with Systemic Lupus Erythematosus and to determine the relationship of these abnormalities to clinical, laboratory, and immunological parameters as well as to disease activity.
Forty-two children with childhood onset Systemic Lupus Erythematosus were included in this study. Demographic, clinical, laboratory and immunological parameters, as well as disease activity were assessed. Pulmonary function tests (PFT) were performed routinely to screen for subclinical lung disease.
Out of the 42 children, 19% (n=8) had clinical evidence of pulmonary involvement. The patients with no clinical evidence of pulmonary involvement (n=34) represent the study cohort. From our cohort of patients with no clinical evidence of pulmonary involvement 79% (n=27) had PFT abnormality; including 62% (n=21) had reduced FVC, 71% (n=24) had reduced FEV1, and 67% (n=12) had reduced DLCO. Similarly, 56% (n=15) had a restrictive PFT pattern, and 2.6% (n=2) had an obstructive PFT pattern, while 33% (n=7) had an isolated impairment of diffusion capacity. Due to small sample size; it was not possible to find a statistically significant difference between the cohort of asymptomatic SLE patients with abnormal PFT findings (n=27) and those with normal PFT findings (n=7) in terms of clinical, laboratory, immunological or disease activity index score.
Subclinical lung disease, as demonstrated by abnormal PFT in patients with normal radiographs, may be common but should be interpreted with caution as an early sign of lung disease. Although PFT studies do not correlate well with pulmonary symptoms in patients with childhood onset SLE, they nevertheless provide objective quantification of the type and severity of the functional lesions.
PMCID: PMC3282137  PMID: 22359723
Systemic lupus erythematosus; Pulmonary; Prevalence; Oman
12.  Weekend Versus Weekday, Morning Versus Evening Admission in Relationship to Mortality in Acute Coronary Syndrome Patients in 6 Middle Eastern Countries: Results from Gulf Race 2 Registry 
We used prospective cohort data of patients with acute coronary syndrome (ACS) to compare their management on weekdays/mornings with weekends/nights, and the possible impact of this on 1-month and 1-year mortality. Analyses were evaluated using univariate and multivariate statistics. Of the 4,616 patients admitted to hospitals with ACS, 76% were on weekdays. There were no significant differences in 1-month (odds ratio (OR), 0.88; 95% CI: 0.68-1.14) and 1-year mortality (OR, 0.88; 95% CI: 0.70-1.10), respectively, between weekday and weekend admissions. Similarly, there were no significant differences in 1-month (OR, 0.92; 95% CI: 0.73-1.15) and 1-year mortality (OR, 0.98; 95% CI: 0.80-1.20), respectively, between nights and day admissions. In conclusion, apart from lower utilization of angiography (P < .001) at weekends, there were largely no significant discrepancies in the management and care of patients admitted with ACS on weekdays and during morning hours compared with patients admitted on weekends and night hours, and the overall 30-day and 1-year mortality was similar between both the cohorts.
PMCID: PMC3447162  PMID: 23002404
Acute coronary syndrome; Weekend; Weekday; Mortality; Admission.
13.  Control of Risk Factors for Cardiovascular Disease Among Adults with Previously Diagnosed Type 2 Diabetes Mellitus: A Descriptive Study from a Middle Eastern Arab Population 
Despite the high burden of type 2 diabetes mellitus (T2DM) in Oman, there are scarce data from a nationally representative sample on the level of glycaemia and other cardiovascular (CVD) risk factor control.
To estimate the proportion of patients with T2DM at goal for glycaemia and CVD risk factors using the National Diabetes Guidelines (NDG) and the American Diabetes Association (ADA) clinical care guidelines; and to assess the quality of selected services provided to patients with T2DM.
A sample of 2,551 patients (47% men) aged ≥20 years with T2DM treated at primary health care centers was selected. Patient characteristics, medical history and treatment were collected from case notes, Diabetes Registers and computer frameworks including the use of the last 3 laboratory investigations results and blood pressure (BP) readings recorded in 2007.
The overall mean age of the cohort was 54±13 years with an average median duration of diabetes of 4 (range 2 to 6) years. Over 80% of patients were overweight or obese (body mass index (BMI) of ≥25 Kg/m2). Sixty-nine percent were on oral anti-diabetic medication, 52% on anti-hypertensives and 40% on lipid lowering drugs. Thirty percent of patients were at goal for glycosylated haemoglobin level (<7%), 26% for BP (systolic/diastolic <130/80 mmHg), 55% for total cholesterol (<5.2 mmol/l), 4.5% for low-density lipoprotein cholesterol (<1.8 mmol/l), 52% for high-density lipoprotein cholesterol (>1 mmol/l for men, >1.3 mmol/l for women), and 61% for triglycerides (<1.7 mmol/l). Over 37% had micro-albuminuria and 5% had diabetic nephropathy.
Control of hyperglycaemia and other CVD risk factor appears to be suboptimal in Omani patients with T2DM and need to be addressed in the triad of patient, physician and health system.
PMCID: PMC3496907  PMID: 23166566
Diabetes mellitus; glycosylated hemoglobin Alc; blood pressure; low-density lipoprotein cholesterol; high-density lipoprotein cholesterol; triglycerides; Oman.
14.  Assessment of Perceived Health Status in Hypertensive and Diabetes Mellitus Patients at Primary Health Centers in Oman 
This study aimed to assess the impact of diabetes mellitus and hypertension as well as other demographic and clinical characteristics on perceived health status in primary health centers in Oman.
In a cross-sectional retrospective study, 450 patients (aged ≥ 18 years) seen at six primary health centers in Wilayat A’ Seeb in the Muscat region, Oman, were selected. Perceived health status of the physical (PSCC) and mental (MSCC) components of quality-of-life were assessed using the 12-item short form health survey (SF-12). The analyses were performed using univariate statistical techniques.
The mean age of the participants was 54 ± 12 years and they were mostly female (62%). The presence of both diabetes mellitus and hypertension was associated with lower physical scores compared to those with diabetes alone (p = 0.001) but only marginally lower than those with hypertension alone (p = 0.066). No significant differences were found across the disease groups in mental scores (P = 0.578). Age was negatively correlated (p < 0.001) but male gender (P < 0.001), married (p < 0.001), literate (p < 0.001) and higher income (p = 0.002) were all associated with higher physical scores. Moreover, longer disease duration was associated with lower physical scores (p < 0.001). With regards to the mental status, male (p = 0.005), marriage (P = 0.017) and higher income (p < 0.001) were associated with higher mental scores. Polypharmacy was associated with lower physical (p < 0.001) and mental (p = 0.005) scores.
The presence of both diseases was associated with lower physical scores of perceived health status. Health status was also affected by various demographic and clinical characteristics. However, the results should be interpreted in light of the study's limitations.
PMCID: PMC3237269  PMID: 22174966
Perceived health status; Hypertension; Diabetes mellitus; Primary health centers; Oman
15.  Acute Coronary Syndrome in Oman 
Acute coronary syndrome (ACS) is the most common cause of cardiovascular mortality and morbidity in Western countries. International guidelines for diagnosis and treatment have been developed based on randomised clinical trials. However, data from international registries report a lack of association between guideline recommendations and actual clinical practice. Similarly, the Gulf Heart Association initiated a registry called Gulf Registry of Acute Coronary Events (Gulf RACE). This registry was developed to determine the characteristics and management of ACS in the Gulf countries including Oman. Here, we report on the results of the various Gulf RACE registry studies from Oman and compare our results with the main Gulf RACE data as well as other international registries.
PMCID: PMC3210042  PMID: 22087374
Acute coronary syndrome; Oman
16.  Accuracy of ultrasound-guided fine-needle aspiration cytology for diagnosis of carcinoma in patients with multinodular goiter 
Fine-needle aspiration (FNA) is a useful method for evaluating multinodular goiter; however, its role is still controversial. The aim of this study was to assess the utility of ultrasound-guided thyroid FNA in detecting malignancy in patients with multinodular goiter in Oman.
Materials and Methods:
This was a retrospective study where all patients with multinodular goiter seen at the Sultan Qaboos University Hospital endocrinology clinic in Oman in 2005 were evaluated. The thyroid FNA results were grouped into either malignancy (positive result) or others (negative result). They were compared to those of final histopathological examination in order to calculate the value of the test in diagnosing malignancy. Analyses were evaluated using descriptive statistics.
A total of 272 patients were included in the study. The mean age was 39΁13 years with an age range from 5 to 85 years. The majority of the patients were females (n=236; 87%). The results of thyroid FNA revealed that 6% (n=15) of the patients had malignancies while histopathological results showed that the proportion of subjects with malignancies was 18% (n=49). Out of the 15 cases identified to have malignances by thyroid FNA, only 53% (n=8) of the subjects were confirmed to have malignancy by biopsy. Overall, the results of the tests were poor, revealing a sensitivity of 16%, specificity of 97% and a diagnostic accuracy of 82%, with a positive predictive value of 53% and a negative predictive value of 84%.
Thyroid FNA is not a useful test in differentiating multinodular goiter from malignancy, as more than 80% of the malignancies go unnoticed.
PMCID: PMC3169873  PMID: 21966650
Fine-needle aspiration; malignancy; multinodular goiter
17.  Complementary and Alternative Medicine Use among Adults with Diabetes in Muscat Region, Oman 
The use of complementary and alternative medicine (CAM) for diabetes mellitus is becoming increasingly popular; however, little is known about the prevalence of CAM use in patients with diabetes mellitus in Oman. The objectives of this study were to estimate the prevalence of use of CAM among diabetic patients in Muscat region, Oman, and to determine the types of CAM used as well as to identify the demographic features influencing the use of CAM.
The study was performed from May to August 2009 on diabetic patients from 4 health centres in Muscat region. A total of 146 patients were interviewed. Information was obtained on demographics, and the prevalence and pattern of use of CAM.
Sixty two (42%) of the participants used CAM for the treatment of diabetes. Thirty (48%) were satisfied about its use and 27 (43%) intend to use it again. The only types of CAM used by participants in this study were herbs (n = 49, 79%), and/or food supplements (n = 7, 11%). Family and friends (n = 47/62, 76%) and/or traditional healers (n = 19, 31%) were the main source of information on CAM in the treatment of diabetes. There was no significant correlation between demographic characteristics and the use of CAM for diabetes.
CAM is used widely for diabetes in Muscat region, Oman. Patients have strong faith in CAM in terms of effectiveness. Doctors should recognise this and be prepared to talk more freely with patients about its use and potential side effects.
PMCID: PMC3074680  PMID: 21509210
Complementary medicine; Alternative medicine; Complementary and alternative medicine (CAM); Diabetes mellitus (DM); Oman
18.  Relationship Between Admitting Nonfasting Blood Glucose and In-Hospital Mortality Stratified by Diabetes Mellitus Among Acute Coronary Syndrome Patients in Oman 
Background and Objectives:
Hyperglycemia in patients admitted for acute coronary syndrome (ACS) is associated with increased in-hospital mortality. We evaluated the relationship between admitting (nonfasting) blood glucose and in-hospital mortality in patients with and without diabetes mellitus (DM) presenting with ACS in Oman.
Patients and Methods:
Data were analyzed from 1551 consecutive patients admitted to 15 hospitals throughout Oman, with the final diagnosis of ACS during May 8, 2006 to June 6, 2006 and January 29, 2007 to June 29, 2007, as part of Gulf Registry of Acute Coronary Events. Admitting blood glucose was divided into four groups, namely, euglycemia (≤7 mmol/l), mild hyperglycemia (>7-<9 mmol/l), moderate hyperglycemia (≥9-<11 - mmol/l), and severe hyperglycemia (≥11 mmol/l).
Of all, 38% (n = 584) and 62% (n = 967) of the patients were documented with and without a history of DM, respectively. Nondiabetic patients with severe hyperglycemia were associated with significantly higher in-hospital mortality compared with those with euglycemia (13.1 vs 1.52%; P<0.001), mild hyperglycemia (13.1 vs 3.62%; P = 0.003), and even moderate hyperglycemia (13.1 vs 4.17%; P = 0.034). Even after multivariate adjustment, severe hyperglycemia was still associated with higher in-hospital mortality when compared with both euglycemia (odds ratio [OR], 6.3; P<0.001) and mild hyperglycemia (OR, 3.43; P = 0.011). No significant relationship was noted between admitting blood glucose and in-hospital mortality among diabetic ACS patients even after multivariable adjustment (all P values >0.05).
Admission hyperglycemia is common in ACS patients from Oman and is associated with higher in-hospital mortality among those patients with previously unreported DM.
PMCID: PMC3123510  PMID: 21731803
Acute coronary syndrome; admission hyperglycemia; diabetes mellitus; hyperglycemia; in-hospital mortality
19.  Prevalence, Predictors, and Impact of Low High-Density Lipoprotein Cholesterol on in-Hospital Outcomes Among Acute Coronary Syndrome Patients in the Middle East 
To estimate the prevalence, predictors, and impact of low high-density lipoprotein cholesterol (HDL-C) on in-hospital outcomes among acute coronary syndrome (ACS) patients in the Middle East.
Data were collected prospectively from 6,266 consecutive patients admitted with a diagnosis of ACS and enrolled in the Gulf Registry of Acute Coronary Events (Gulf RACE). A low HDL-C was defined as a level <40 mg/Dl (1.0 mmol/L) for males and <50 mg/dL (1.3 mmol/L) for females. Analyses were performed using univariate and multivariate statistical techniques.
The overall mean age of the cohort was 56±12 years and majority were males (77%). The overall prevalence of low HDL-C was 62%. During in-hospital stay and at discharge, the majority were on statin therapy (83%) while 10% were on other cholesterol lowering agents. After adjustment of demographic and clinical characteristics, the predictors for low HDL-C were higher body mass index (BMI), prior myocardial infarction (MI), diabetes mellitus, smoking and impaired renal function. Multivariable adjustment revealed that low HDL-C was associated with higher in-hospital mortality (odds ratio (OR), 1.54; 95% CI: 1.06-2.24; p=0.022) and cardiogenic shock (OR, 1.61; 95% CI: 1.20-2.14; p=0.001).
ACS patients in the Middle East have a high prevalence of low HDL-C. Higher BMI, prior MI, diabetes mellitus, smoking, and impaired renal function were predictors of low HDL-C. Significantly higher in-hospital mortality and cardiogenic shock were associated with low HDL-C in men but not in women.
PMCID: PMC3178900  PMID: 21966331
High density lipoprotein cholesterol; low density lipoprotein cholesterol; triglycerides; acute coronary syndrome; myocardial infarction; gender; Middle East.
20.  Comparison of the Demographics, Semen Parameters and Hormone Profiles in Men with Primary and Secondary Infertility 
The objectives of this study were to compare the demographics, semen parameters and hormone profiles in men with primary and secondary infertility.
The study was designed as a retrospective analysis of data collected from men attending a combined infertility clinic (seen together by urologist and gynaecologist) from January 2005 to December 2008 at Sultan Qaboos University Hospital, a tertiary care hospital in Oman. Ninety-eight consecutive male patients with one or more abnormalities in semen analysis were referred to the combined infertility clinic. A complete physical examination was carried out by a urologist followed by hormone evaluation of follicle stimulating hormone (FSH), luteinizing hormone (LH), testosterone (T) and prolactin (PRL).
The semen parameters and the sex hormone evaluation were not significantly different between the men with primary and secondary infertility. The men with primary infertility were younger than the men with secondary infertility. A total of 24% of the men in the primary group and 16% in the secondary group were azoospermic with normal gonadotropin values in 9 men and 1 man in the primary and secondary group respectively.
Azoospermia was more common in the primary infertile group and, based on gonadotropin levels, obstructive causes seemed more prevalent in the primary group compared to secondary group.
PMCID: PMC3074745  PMID: 21509255
Male infertility; Primary infertility; Secondary infertility; Varicocele; Sex Hormones; Semen parameters; Oman
21.  Gender-related differences in the presentation, management, and outcomes among patients with acute coronary syndrome from Oman 
To assess gender-related differences in the presentation, management, and in-hospital outcomes among acute coronary syndrome (ACS) patients from Oman.
Data were analyzed from 1579 consecutive ACS patients from Oman during May 8, 2006 to June 6, 2006 and January 29, 2007 to June 29, 2007, as part of Gulf RACE (Registry of Acute Coronary Events). Analyses were conducted using univariate and multivariate statistical techniques.
In this study, 608 (39%) patients were women with mean age 62 ± 12 vs. 57 ± 13 years (p < 0.001). More women were seen in the older age groups (age <55 years: 25% vs. 43%, 55–74 years: 60% vs. 49% and >75 years: 15% vs. 8%; p < 0.001). Women had higher frequencies of diabetes, hypertension, hyperlipidemia, obesity, angina, and aspirin use, but less history of smoking. Women were significantly less likely to have ischemic chest pain, ST-elevation myocardial infarction (STEMI), non-STEMI and were more likely to have dyspnea, unstable angina, ST depression and left bundle branch block. Both groups received ACS medications and cardiac catheterization equally; however, women received anticoagulants (88% vs. 79%; p < 0.001), angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) (70% vs. 65%; p = 0.050) more and clopidogrel less (20% vs. 29%; p < 0.001). Women experienced more recurrent ischemia and heart failure but with similar in-hospital mortality (4.6% vs. 4.3%) even after adjusting for age (p = 0.500).
Women admitted with ACS were older than men, had more risk factors, presented differently with no difference in hospital mortality. This is similar to Gulf RACE study except for mortality. Women received anticoagulants/ACEIs /ARBs more but were under-treated with clopidogrel.
PMCID: PMC3727510  PMID: 23960630
Gender-related differences; Women; Acute coronary syndrome; Oman
22.  Acute Coronary Syndrome in Young Adults from Oman: Results from the Gulf Registry of Acute Coronary Events 
To assess the prevalence, risk factors, presenting features, and in-hospital outcomes of acute coronary syndrome (ACS) patients ≤40 years of age from Oman.
Data were analyzed from 1579 consecutive ACS patients from Oman during May, 2006 to June, 2007, as part of Gulf RACE (Registry of Acute Coronary Events). ACS patients ≤40 years of age were compared with patients >40 years of age.
A total of 121 (7.6%) patients were ≤40 years of age with mean age of 36 ± 4 vs. 61 ± 11 years in young and old adults, respectively (P<0.001). More men were seen in the younger age group (81 vs. 60%; P<0.001). Among all the coronary risk factors, young patients had more history of smoking (47 vs. 15%; P<0.001), obesity (72 vs. 58%; P = 0.009), and family history of coronary artery disease (CAD) (16 vs. 7%; P = 0.001). Both groups received aspirin, statins, thrombolytic therapy, and anticoagulants equally; however, younger patients received clopidogrel, glycoprotein IIb/IIIa inhibitors, β-blockers, and in-hospital coronary angiogram more. Younger patients experienced less heart failure (6 vs. 27%; P<0.001) and in-hospital mortality, especially among STEMI patients (0 vs. 10%; P = 0.037).
Young ACS patients from Oman have different risk profile. They were treated more aggressively and their outcome was better, which is similar to other populations. However, smoking, along with obesity and family history of CAD were strong risk factors in the young Omani ACS patients. There is a need for prevention programmes to control smoking and obesity epidemic by targeting young adults in the population.
PMCID: PMC3089825  PMID: 21577375
Acute coronary syndrome; Oman; smoking; young adults
23.  Safety of Simvastatin and Goal Attainment for Low-Density Lipoprotein Cholesterol in Sultan Qaboos University Hospital 
Oman Medical Journal  2010;25(4):264-268.
Despite the scientific evidence of reducing cardiac events with HMG Co-A reductase inhibitors (statins) therapy in both primary and secondary preventions, these therapies continue to be underutilized in patients receiving convictional care. Simvastatin, a HMG Co-A inhibitor agent, is the most commonly used statin in Sultan Qaboos University Hospital. The aim of this study is to review the safety and the effectiveness of achieving LDL-C targets with Simvastatin according to the NCEP-ATP3 guidelines in patients with different cardiovascular risk categories at Sultan Qaboos University Hospital.
A retrospective chart review was conducted for 160 patients. Patients were identified by outpatient prescriptions provided by pharmacy department from April 2008 to May 2008.
98% of the patients were prescribed simvastatin 20 mg and only 2% received 40 mg. The mean age of patients was 57 years +/- 12. While 49% of the patients were male and 45% had diabetes mellitus, 50% had cardiovascular disease, 2.5% were smokers, 67% were hypertensive, and 3% had positive family history of coronary artery disease. 75% of patients were classified as high risk, 7% moderate risk and 18% low risk for coronary artery disease. Among all lipid profiles, only LDL-C was changed from baseline with simvastatin treatment in all patients (3.60±1.03 to 3.25±1.34 mmol/L). LDL-C level at baseline was higher in the high risk group (4.11±1.06 mmol/L) compared to low and moderate risk groups (3.68±0.89, 3.42±1.15) respectively. Achievement of LDL-C goals was achieved in only 43% for high risk, 50% in moderate risk, and 90% in low risk patients. There was no significant increase in liver enzymes and creatinine kinase.
This study identified that more than half of the high risk patients were not at the target LDL-C goals which place them at a continuous risk of coronary heart disease. More appropriate lipid lowering therapy using more potent statins or combination therapy should be optimized to improve achievement of LDL-C goals according to ATP-III guidelines.
PMCID: PMC3191659  PMID: 22043355
24.  Diagnostic Value of Electrocardiographic T Wave Inversion in Lead aVL in Diagnosing Coronary Artery Disease in Patients with Chronic Stable Angina 
Oman Medical Journal  2010;25(2):124-127.
The clinical value of T wave inversion in lead aVL in diagnosing coronary artery disease (CAD) remains unclear. This study aims to investigate the correlation between aVL T wave inversion and CAD in patients with chronic stable angina.
Electrocardiograms (ECGs) of 257 consecutive patients undergoing coronary angiography were analyzed. All patients had chronic stable angina. All patients with secondary T wave inversion had been excluded (66 patients). The remaining 191 patients constituted the study population. Detailed ECG interpretation and coronary angiographic findings were conducted by experienced cardiologists.
T wave inversion in aVL was identified in 89 ECGs (46.8%) with definite ischemic Q-ST-T changes in different leads in 97 ECGs (50.8%). Stand alone aVL T wave inversion was found in 27 ECGs (14.1%) while ischemic changes in other leads with normal aVL were identified in 36 ECGs (18.8%). The incidence of CAD was 86.3%. Single, two- and multi-vessel CAD were found in 38.8%, 28.5% and 32.7% of cases respectively. The prevalence of left main, left anterior descending, left circumflex and right coronary arteries were 4.7%, 61.2%, 29.3% and 44.5%, respectively. T wave inversion in aVL was found to be the only ECG variable significantly predicting mid segment left anterior descending artery (LAD) lesions (Odds Ratio 2.93, 95% Confidence Interval 1.59-5.37, p=0.001).
This study provides new information relating to T wave inversion in lead aVL to mid segment LAD lesions. Implication of this simple finding may help in bedside diagnosis of CAD typically mid LAD lesions. However, further studies are needed to corroborate this finding.
PMCID: PMC3215494  PMID: 22125714
25.  Relatives’ Advice and Health Care-Seeking Behaviour in Oman 
It has been well established that pathways to care are considerably modified by local, social and psychological characteristics as well as the doctor-patient relationship. Scant attention has been paid to the role of family advice in care-seeking. In Omani society, traditional family values and a collective mindset are the norm rather than the exception. This paper examines how family advice affects the trajectory of care seeking.
During 2006–2007, data was collected through face-to-face interviews among a randomised sample of patients seeking medical consultation in various primary health care centres in the northern region of Oman. This study enrolled a total of 493 patients. The association between the advice of family members as a reason to seek health care and other predictors was analysed using multivariable logistic regression.
The data suggest that the advice of family members in care-seeking is strongly associated with gender, education, history of chronic illness, previous exposure to traditional medicine, and health education, as well as the history of immunisation.
These findings suggest that the advice of family members remains a strong catalyst for care-seeking in Oman. The psychosocial factors affecting care-seeking leading to underutilisation of services or otherwise are discussed.
PMCID: PMC3074806  PMID: 21509309
Care-seeking behavior; Relatives’ advice; Clinical population; Oman; Arab/Islamic

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