Given the importance of influenza infections in the Eastern Mediterranean Region (EMR), we conducted a comprehensive literature review to analyze the status of influenza research in the region from 2012. Influenza research has gained more momentum recently with the emergence of H5N1 and new virus strains. Research covering epidemiological, veterinary, and basic science aspects is growing. More sequences were being generated per year, not only for diagnostic purposes but also for research. We included gray literature publications in our search and found several graduate student dissertations from Egypt, which were published on an online portal. However, the search revealed some weaknesses, mostly in the areas of study design and the lack of surveillance studies. Another weakness was the fact that the publications originated from very few countries, mainly Egypt and Iran. Although improving, influenza research in the EMR remains weak. We recommend encouraging countries in the EMR to conduct more influenza research using stronger methodologies.

Objectives: To evaluate the significance of serum chromogranin A (CgA) status in patients with and without different neuroendocrine tumors (NETs) by conducting a retrospective assessment of the diagnostic utility and limitations of CgA as a biomarker for NETs in a tertiary care hospital in Oman. Methods: We conducted a retrospective analysis of CgA requests referred to the Clinical Biochemistry Laboratory, Royal Hospital, Oman over a 24-month period (April 2012 to March 2014). During this time, 302 CgA tests for 270 patients (119 males and 151 females; age range 11–86 years and mean±standard deviation (SD) 44.0±18.0 years), were requested. Of these CgA tests, 245 tests were performed for 245 patients investigated for the diagnosis of NETs, and 57 CgA tests were performed for 25 patients with diagnosed NETs who were undergoing follow-up. Serum CgA levels were analyzed using the enzyme-linked immunosorbent assay based on a cut-off value of 22 IU/L. Results: Of the 302 CgA tests reviewed, 197 (65.2%) were within the quoted normal range; however, 105 (34.8%) had CgA > 22 IU/L. Of the 245 patients with first-line CgA, 38 patients (15.5%) had NET that included carcinoid, pheochromocytoma, pancreatic NET, adrenal adenoma, prostatic adenocarcinoma, gastrointestinal NET, medullary thyroid carcinoma, Schwannoma, lung small cell carcinoma, parathyroid adenoma, and pituitary macroadenoma. The mean±SD of CgA in these patients with NETs was 205.0±172.0 IU/L. Meanwhile, there were 45 (18.3%) patients with CgA > 22 IU/L (83.0±116.0 IU/L) who did not have NETs. The conditions/diseases included: essential hypertension, chronic kidney disease, heart failure, peptic ulcer, chronic diarrhea, use of proton pump inhibitors, and other chronic diseases (hypothyroidism, asthma, diabetes mellitus). Of the 25 patients with known NET who were followed-up, there were 57 CgA results (29 with CgA ≤ 22 IU/L and 28 with CgA > 22 IU/L). The overall clinical sensitivity of CgA in the diagnosis of NETs was 84.2%, overall specificity was 78.2%, positive predictive value was 41.5%, negative predictive value was 96.4%, and overall efficiency was 79.2%. In patients with individual NET, a good reflection in CgA was noticed in the follow-up period following surgery or therapy. Conclusions: Serum CgA is a sensitive and effective noninvasive laboratory test for the clinical detection and management of NETs. Awareness of the pitfalls of the tests in patients with non-NET conditions, particularly chronic diseases and use of certain drugs, is important to be considered during the interpretation of the CgA levels.

Objectives: Between 20 to 50% of medical imaging examinations are considered inappropriate, and unnecessary ionizing radiation exposures may lead to cancer. We hypothesized that Bahraini patients who self-present for ionizing radiation procedures are not aware of, and lack the requisite knowledge of, the inherent risks associated with their use than patients prescribed for diagnostic purposes. We attempted to examine and compare the awareness and knowledge of the associated risks of ionizing radiation in common diagnostic radiological procedures between prescribed and self-presenting patients in Bahrain. Methods: A cross-sectional survey was carried out among 416 Bahraini patients attending the radiology department of the Salmaniya Medical Complex (SMC), a secondary health care center, who had been referred by primary care physicians or self-presented to the center. Data was collected via face-to-face interviews. Results: Prescribed patients (n = 358) had a better awareness than self-presenting (n = 58) patients on all ionizing radiation awareness statements (i.e., risks, permissible levels, willingness to undergo the procedure, and preference for a clinical examination over a radiological procedure) (p < 0.050). Of the 10 knowledge statements, the prescribed patients agreed on four statements than the self-presenting patients: preventing or minimizing exposure improves health, people can prevent or minimize exposure, a lifelong health concern, and radiological procedures offer best diagnoses compared to medical tests or procedures (p < 0.050). Conclusions: Bahraini patients who reported to SMC lack awareness and knowledge on ionizing radiation. The proportion of appropriate responses to awareness and knowledge questions were paltry for self-presenting patients and deficient for the prescribed patients in the knowledge segment alone.

Objectives: This study was conducted to determine the efficacy of mindfulness-based cognitive therapy (MBCT) on psychological symptoms and quality of life (QoL) in patients with systemic lupus erythematosus (SLE). Methods: We conducted a randomized single-blind clinical trial in patients with SLE referred from the Imam Ali Clinic in Shahrekord, southwest Iran. The patients (46 in total in two groups of 23 each) were randomly assigned into the experimental and control groups. Both groups underwent routine medical care, and the experimental group underwent eight group sessions of MBCT in addition to routine care. The patient,s QoL was assessed using the General Health Questionnaire-28 and 36-Item Short Form Health Survey before, after, and six months after intervention (follow-up). Results: A significant difference was seen in psychological symptoms and QoL between MBCT and control groups immediately after the intervention and at follow-up (p ≤ 0.050). However, the difference was not significant for the physical components of QoL (p ≥ 0.050). Conclusions: MBCT contributed to decreased psychological symptoms and improved QoL in patients with SLE with a stable effect on psychological symptoms and psychological components of QoL, but an unstable effect on physical components.

Objectives: To find out the major determinants of maternal near-miss (NM)and maternal deaths (MDs) in Erbil city, Iraq, by comparative analysis of maternal NMs and MDs. Methods: We conducted a hospital-based cross-sectional study in the Maternity Teaching Hospital in Erbil city from 1 June to 31 December 2013. All MDs and NMs that occurred in the hospital during the study period were included in the study. Systematic identification of all eligible women was done. This identification included a baseline assessment of the severe pregnancy-related complications using the World Health Organization NM criteria. Results: Severe preeclampsia and postpartum hemorrhage (PPH) constituted the highest proportions of complications in women with potentially life-threatening conditions (PLTCs) (30.5% and 30.0%, respectively). The highest mortality indexes were those for ruptured uterus (16.7) and severe complications of placenta previa (14.2). Factors that were significantly associated with MD (compared to NM) were hepatic dysfunction (p = 0.046), multiple/unspecified disorders
(p = 0.003), arrival as an emergency condition by ambulance (p = 0.015), and history of previous cesarean section (p = 0.013). Conclusions: Severe preeclampsia and PPH are the main complications that lead to PLTCs. Factors found to be associated with MDs are hepatic dysfunction, multiple/unspecified disorders, arrival as an emergency condition by ambulance, and history of a previous cesarean section.

Objectives: A resurgence of pertussis or whooping cough has been observed worldwide despite broad vaccination coverage. Pertussis like illness (PLI) refers to a clinical syndrome compatible with pertussis infection but lacking laboratory confirmation or an epidemiological link to a confirmed case. Our study aimed to estimate the contribution of Bordetella pertussis infection and identifying predictors of its diagnosis in a cohort of children with PLI. Methods: Demographic and clinical information were retrospectively collected from the medical records of children < 13 years old and hospitalized for PLI in two pediatric units in Oman from 1 January 2012 to 31 December 2013. The laboratory data of all cases were reviewed and confirmed cases of pertussis were identified, analyzed, and compared with non-confirmed cases. Results: A total of 131 patients were enrolled in this study. The majority (95.4% [125/131]) were infants. Only 54.1% (71/131) of admitted children with PLI were tested for pertussis. The incidence of pertussis infection among the tested group was 16.9% (12/71) with a 95% confidence interval 8.2−25.6. Severe illness occurred in 56.4% (74/131) of patients, and six were confirmed to have pertussis. Pediatric intensive care unit admission was required for one confirmed case of pertussis and eight cases from the PLI group (three were negative for pertussis, and five were not tested). Receiver operator characteristic curve analysis revealed that a white blood cell count ≥ 23.5 × 109/L had 96.6% specificity and lymphocytes ≥ 17 × 109/L had 98.3% specificity. Conclusions: Taking into consideration that the number tested for pertussis was limited, the incidence of pertussis was 16.9% (12 out of 71 patients). Lymphocytosis can be used as a reliable predictor for the diagnosis of pertussis especially in the absence of specific confirmatory tests or until their results are available.

Objectives: Ventilator-associated tracheobronchitis (VAT) is a common cause of mortality and morbidity in patients admitted to intensive care units (ICUs). This study was conducted to evaluate the clinical course, etiology, and antimicrobial resistance of bacterial agents of VAT in ICUs in Hamedan, Iran. Methods: During a 12-month period, all patients with VAT in a medical and a surgical ICU were included. The criteria for the diagnosis of VAT were fever, mucus production, a positive culture of tracheal secretions, and the absence of lung infiltration. Clinical course, including changes in temperature and tracheal secretions, and outcomes were followed. The endotracheal aspirates were cultured on blood agar and chocolate agar, and antimicrobial susceptibility testing of isolates were performed using the disk diffusion method. Results: Of the 1 070 ICU patients, 69 (6.4%) were diagnosed with VAT. The mean interval between the patient’s intubation and the onset of symptoms was 4.7±8.5 days. The mean duration of response to treatment was 4.9±4.7 days. A total of 23 patients (33.3%) progressed to ventilator-associated pneumonia (VAP), and 38 patients (55.0%) died. The most prevalent bacterial isolates included Acinetobacter baumannii (24.6%), Pseudomonas aeruginosa (20.2%), and Enterobacter (13.0%). P. aeruginosa and Enterobacter were the most prevalent bacteria in surgical ICU, and A. baumannii  and K. pneumoniae  were the most common in the medical ICU. All A. baumannii and Citrobacter  species were multidrug-resistant (MDR). MDR pathogens were more prevalent in medical ICU compared to surgical ICU (p < 0.001). Conclusions: VAT increases the rates of progression to VAP, the need for tracheostomy, and the incidence of mortality in ICUs. Most bacterial agents of VAT are MDR. Preventive policies for VAP, including the use of ventilator care bundle, and appropriate empirical antibiotic therapy for VAT may reduce the incidence of VAP.

Objectives: Our study sought to determine the distribution of hepatitis C virus (HCV)-genotypes among patients attending two tertiary care hospitals in Benghazi and Tripoli, Libya, and correlate this with patient’s characteristics, viral load, and degree of fibrosis. Methods: We conducted a retrospective study of 286 HCV-RNA positive Libyan patients referred from different health care facilities in east and west Libya for specific HCV treatment. HCV genotyping was carried out by gene amplification. Liver histology was graded by Metavir score according to the stage of fibrosis. Results: HCV genotypes 1, 2, 3, and 4 were found in 24.1%, 10.8%, 3.4%, and 61.5% of the patients, respectively. Genotype 4 was detected more frequently in patients from east Libya (Benghazi) compared to west Libya (Tripoli) (75.9% vs. 41.6%, p = 0.245). Genotype 1 was more frequent in patients from west Libya compared to east Libya (34.1% vs. 16.8%, p = 0.657). There was a significant correlation between HCV genotype distribution and viral load. Patients with genotype 4 exhibited a higher degree of liver fibrosis (p < 0.001). Conclusions: HCV genotype 4 is the predominant genotype in Libya followed by genotype 1. However, as we go from the east to the west of the country, genotype 1 increases. Genotype 4 was associated with higher level of viremia and higher stage of liver fibrosis. It is important to note that both genotypes 1 and 4 are associated with a poor response to pegylated interferon and ribavirin combination therapy. The findings emphasize the need to develop improved strategies in Libya for the successful treatment of HCV infection with novel newly available antiviral drugs.

Objectives: The physical injuries and financial implications as a result of road accidents have serious economic, cultural, and social effects. We conducted this study to determine any changes in the trend of road-accident-related deaths in Asian and North African countries from 1990 to 2010. Methods: The current study was carried out using data from the Global Burden of Disease database. First, the process was assessed using the growth curve divided into six regions. Moreover, the classification was done based on the death rate using growth mixed modeling. Results: The road injury death trend for men had more variations than women. Classification of these countries based on mortality using the latent growth mixture model resulted in more homogeneous classes according to trend in road fatalities. Disregarding gender and sex, there were four optimal classes. The first three classes had a decreasing trend with the third class having the greatest decreasing trend. South Korea and Taiwan were in this group. Afghanistan, Indonesia, Thailand, Iran, the UAE, Saudi Arabia, and Oman lay in group 4 and had an increasing trend in road injury deaths. Conclusions: Successful interventions that developed countries have used to avoid casualties of road injuries could be used in developing countries. These include passing laws making the use of seatbelts and child seats compulsory and determining appropriate speed limits.

Parvovirus is a known culprit of transient red cell aplasia (TRCA) in children with sickle cell disease (SCD). Few reports have previously described the association between the virus and acute splenic sequestration crisis (ASSC) in the same patient. Here, we are shedding light on such a potentially serious combination by reporting two cases of siblings with SCD complicated with concurrent ASSC and TRCA and presenting a review of the relevant literature.

Tenofovir, a nucleotide analog, is one of the first-line medications recommended for the treatment of active chronic hepatitis B virus infection (CHB) and as a primary prophylaxis to prevent hepatitis B reactivation in cases of immunosuppression. We report the first case of tenofovir-induced leukocytoclastic vasculitis (LCV). A 43-year-old obese woman, who was known to have inactive CHB, was diagnosed with chronic immune thrombocytopenic purpura (ITP). She was treated with corticosteroid therapy and was put on tenofovir to prevent hepatitis B virus reactivation. A month later, she developed a skin rash, described as non-blanchable well-defined erythematous to violaceous papules and targetoid patches in her lower extremities. A skin biopsy showed features of LCV. The rash resolved completely within few days after replacing tenofovir with entecavir.

Sialolithiasis is the formation of calculi or sialoliths in the salivary gland. It is the most common benign condition of the salivary gland. Sialolithiasis can occur in all salivary glands. The submandibular gland is most commonly affected followed by the parotid gland. Calculi commonly measure less than 10 mm. Calculi of more than 15 mm are termed giant salivary gland calculi and are infrequently reported in the literature. Here, we report a case of unusually large submandibular gland calculus of 5 cm in greatest dimension which caused erosion of the oral cavity.

Stevens-Johnson syndrome (SJS) is a rare and acute life-threatening condition which is almost always precipitated by drugs. Genital mucositis in female patients may also be an important cause of long-term morbidity secondary to mucosal scarring. We present the case of a 33-year-old nulligravid woman with distal vaginal synechiae necessitating a surgical approach, which occurred after an episode of SJS. Also, we aimed to review the literature to reveal cases which required surgical management for long-term genital sequelae as well as discuss preventive measures.