Histoplasmosis is uncommon in many parts of the world, including Bangladesh, where, in recent years, cases are increasingly reported. We sought to describe the sociodemographic characteristics, clinical presentation, investigations, treatment, and outcome of histoplasmosis in Bangladesh. We conducted a retrospective data review of published literature from 1962 to 2017, containing information on histoplasmosis in and/or from Bangladesh. Unpublished, well-documented histoplasmosis cases were also included. A total of 26 male patients aged 8–75 years, with a diagnosis of histoplasmosis were included; nine were farmers, seven had diabetes, one was a renal transplant recipient, and four had HIV/AIDS. Fever (n = 20), weight loss (n = 17), anemia (n = 15), lymphadenopathy (n = 9), and hepatosplenomegaly (n = 7) were common. Eleven patients had bilateral adrenal enlargement. Diagnosis was confirmed by histo/cytopathology from skin (n = 1), oropharyngeal ulcers (n = 8), lymph nodes (n = 3), adrenal glands (n = 11), paravertebral soft tissue (n = 2), and bone marrow (n = 4). Cultures of representative samples and antibodies were detected in three and two cases, respectively. Twenty-two patients had disseminated histoplasmosis and four patients had localized oropharyngeal disease. Nine patients were prescribed anti-tuberculosis drugs empirically before establishing the diagnosis of histoplasmosis. Treatment consisted of amphotericin B and itraconazole. Six patients died in hospital, 14 patients recovered with relapse in two cases, and the outcome of the other patients could not be ascertained. Histoplasmosis is thought to be endemic in Bangladesh, but few cases are reported to date, which may be due to many asymptomatic, undiagnosed, misdiagnosed, or under-reported cases. Histoplasmosis should be considered as a differential in appropriate clinical scenarios.

Objectives: We sought to evaluate the possible correlation between serum vitamin D levels and exudative age-related macular degeneration (AMD). Methods: We conducted a cross-sectional study including 95 patients with exudative AMD and 95 healthy age- and sex-matched controls. The participants’ serum 25-hydroxyvitamin D3 (25(OH)D3) levels were measured, and the results were classified into three categories: deficient (< 20.0 ng/mL), insufficient (20.1–29.9 ng/mL), and sufficient (>30.0 ng/mL). We compared serum 25(OH)D3 levels between the two study groups and the AMD ratio between the patients with deficient serum 25(OH)D3 levels and those with levels in the sufficient and insufficient ranges. Results: The median 25(OH)D3 levels were significantly lower in patients with AMD compared to the control subjects (p = 0.042). The frequencies of patients with AMD among the vitamin D categories were statistically significant (p = 0.043). Subgroup analysis showed that the frequency of patients with AMD and deficient vitamin D levels was significantly higher than that found in the patients who had sufficient and/or insufficient ranges of vitamin D levels (55.0% vs. 36.0%, p = 0.043, respectively). Conclusions: Serum 25(OH)D3 levels may have an impact on the neovascular type of AMD. As 25(OH)D3 levels decrease, the frequency of AMD increases.

Objectives: We sought to determine the prevalence of immune-mediated skin disorders (IMDs), their oral manifestations, and the related comorbidity among Omani patients with IMDs attending the outpatient Department of Dermatology and Dental Clinic at Al Nahdha Hospital, Muscat. Methods: We conducted a retrospective study of 236 newly-diagnosed patients with IMDs who attended the outpatient clinic between September 2014 and September 2017. Data, such as age, sex, investigations, diagnosis, comorbidity, and associated oral manifestations of the affected individuals, were collected from the hospital health information system. Results: Of the 236 diagnosed cases of IMD, lichen planus substantially comprised over half of the total cases (59.7%). This was followed by relatively fewer cases of discoid lupus erythematosus (11.0%), systemic lupus erythematosus (10.2%), and erythema multiforme (8.1%). Pemphigus vulgaris and bullous pemphigus comprised only 3.0% and 4.2% of the total studied cases, respectively. The other less common disorders found in our study were toxic epidermal necrolysis (1.7%), pemphigus foliaceus (1.3%), and gestational pemphigoid (0.8%). Oral mucosal involvement was seen more commonly with lichen planus (78.7%), pemphigus vulgaris (71.4%), and erythema multiforme (75.0%), while systemic lupus erythematosus and discoid lupus erythematosus were shown to appear with more comorbidities compared to the other skin disorders studied. Conclusions: Several IMDs have considerable oral involvement. These oral manifestations of the diseases may be overlooked by other specialists leading to a delay in the diagnosis and its management. In order to circumvent this delay, the analysis and evaluation of a disease need to be done by a team comprising of a dental surgeon, dermatologist, and an oral medicine specialist.

Objectives: We sought to identify the prevalence, commonest causes, and severity of home accident injuries and their effects on children who present to the emergency department (ED) of a university-tertiary hospital in Oman. Methods: We conducted a retrospective study among children aged ≤ 18 years old who presented with home accidents to the ED between January and June 2017. A checklist for data collection was designed to include demographic data, causes and effects of home accidents, and treatment outcomes. The data was retrieved from the hospital electronic patient records. Results: A total of 1333 children presented to the ED over six months as a result of unintentional home accidents, giving a prevalence of 7.7% from all children who visited the ED. There was a significant male to female ratio of 1.7:1. The most prevalent causes for home accidents were ‘falls’ in 716 (53.7%) children, followed by ‘struck by/against-animate/inanimate mechanical force’ in 201 (15.1%) children. ‘Poisoning’ was the third major cause in 117 (8.8%) children. Severity scale showed that around 36.0% of children suffered from severe injuries and 5.4% were admitted to the hospital. Conclusions: Despite this study being a single-center study in Oman, it indicates a high prevalence and severity of unintentional home accidents among children. The study findings suggest the need for implementing strategies to raise public awareness of child safety at home and to improve the preparedness of healthcare providers in ED to deal with such accidents.

Objectives: There is substantial increase in referrals for investigations at Sultan Qaboos University Hospital (SQUH). Evaluating the quality of hospital referral notes (RNs) is necessary from diagnostic, patient, and economic perspectives. RNs for pulmonary function tests (PFTs) can be considered as representative of the array of tests performed at SQUH. Methods: This cross-sectional study evaluated the quality of RNs based on ‘completeness’ for all consecutive patients referred for PFTs at SQUH over six months. Evaluation included documentation of demographic features, RNs date, priority for investigation, referral reason, pulmonary and relevant medical and smoking history for spirometry RNs, and addition of hemoglobin level for full lung functions (Full-LuFs) tests. The proportion of complete RNs was determined and analyzed separately to study association of spirometry and full-LuFs tests with source and reasons for referral. Results: Only 644 of 683 RNs were available for analysis. Smoking history was stated in only 3.3% of all RNs; hence, it was excluded from the analysis. RNs were complete only in 12.4% of cases for spirometry and 14.4% for full-LuFs tests. RNs for patients who primarily had pulmonary disease were proportionately incomplete than those for patients with other reasons (p < 0.050). There was no significant association between incompleteness of RNs and referral hospital (SQUH vs. non-SQUH) and SQUH inpatient or outpatient status implying that the overall proportion of completeness of RNs from all concerned referral locations was similar and low in both types of RNs. Conclusions: There is a need to improve the quality of RNs at SQUH. Referring doctors must be made aware of the importance of completeness of RNs to improve test reporting, patient management and satisfaction, and reduce financial burden on hospital exchequer.

Objectives: We sought to evaluate the role of bronchoscopy-related procedures such as bronchoalveolar lavage (BAL), bronchial wash (BW), bronchial brush (B brush), transbronchial biopsy (TBB), and post-bronchoscopy sputum (PBS), alone or in combination, in the rapid diagnosis of negative sputum smear disseminated tuberculosis (TB). Methods: We performed a secondary post hoc analysis of data collected from our previous study entitled “Disseminated tuberculosis among adult patients admitted to Hamad General Hospital, Qatar: A five-year hospital-based study” with a modified objective. Results: We identified 27 patients. BAL fluid was positive for acid-fast bacilli (AFB) smear in 7/27 (25.9%) patients and were culture-positive for Myobacterium tuberculosis in 17/27 (63.0%) cases, while BW collections were smear-positive in 9/27 (33.3%) cases and culture-positive for M. tuberculosis in 18/27 (66.7%) cases. TBB showed caseating granulomas in 10/16 (62.5%) cases and one case of non-caseating granuloma (6.3%). PBS was positive for AFB in 4/8 (50.0%) patients. The combination of these procedures enabled us to diagnose disseminated TB rapidly in 22 (81.5%) cases. Conclusions: Bronchoscopy proved to be an effective method for the rapid diagnosis of disseminated TB in patients in whom sputum smear microscopy was negative.

Objectives: Coronary artery (CA) involvement is the most well known complication of Kawasaki disease (KD). Previous studies have suggested that QT dispersion has a predictive value in diagnosing cardiac ischemia, ventricular arrhythmia, and sudden cardiac death. However, limited data exits regarding the application of QT dispersion in KD. Therefore, we sought to determine whether there is a relationship between QT dispersion and CA involvement in patients with KD. Methods: We performed a cross-sectional study of all consecutive patients with KD who were followed-up at the Pediatric Rheumatology Department (Pediatrics Center of Excellence affiliated to Tehran University of Medical Sciences, Tehran, Iran) from September 2013 to November 2015. Patients who met the criteria for KD, based on the American Heart Association guideline, were enrolled in the study. We collected data regarding patients’ demographics, clinical manifestations, laboratory, and echocardiographic findings. Results: A total of 70 KD patients were identified, including 43 males (61.4%) and 27 females (38.6%). The median age of patients was 21.0 (11.0–48.0) months. We found statistically significant differences between age, gender, and platelet count among patients with and without CA involvement (p < 0.050). Median corrected QT dispersion in patients with CA involvement calculated from 12 leads in the acute phase was significantly higher compared to the non-CA involvement group (108.0 (89.5–138.5) ms vs. 63.0 (54.0–74.5) ms, respectively (p < 0.001)). Conclusions: Prolonged QT dispersion (corrected or non-corrected) during the acute and convalescence phases in patients with KD is associated with coronary involvement.

Objectives: We sought to determine the main factors related to relapse in patients with substance-related disorders (SRDs) who received methadone maintenance therapy (MMT) using decision tree (DT) analysis. Methods: We conducted a cross-sectional study of 4175 patients referred to the 45 MMT centers in Kermanshah province, west of Iran. We included all patients who were under MMT for at least one year. All information was collected through an interview by a psychologist. Descriptive statistics and univariate and multiple regression models were used in statistical analysis. The Gini index was calculated to determine the cut-off point of nodes. We used the Classification and Regression Trees algorithm to create the DT. Results: The relapse rate was 76.6% for all participants, with no significant gender differences. The DT resulted in a five-level model of significant factors affecting substance abuse relapse. These included lower cost for buying substances, lower age at first substance use, history of quitting substances without medication, frequency of substances utilization per month, and frequency of methadone therapy. Conclusions: Knowing the main factors associated with substance abuse relapse could be important for health care providers to make better decisions for improving the treatment outcomes of SRDs.

Objectives: We sought to investigate and prove the effect of hyperbaric oxygen therapy (HBOT) on T helper 17 (Th17)/regulatory T (Treg) cell polarization through changes in the expression of hypoxia-inducible factor-1 alpha (HIF-1α) in rheumatoid arthritis (RA) animal model. Methods: We used antigen and collagen-induced arthritis (ACIA) as a RA animal model. Sixteen male BALB/c models of ACIA mice were divided into two groups, the non-HBOT group as the control group and the HBOT group as the treatment group. Expression of HIF-1α, Th17 anti-cluster differentiation 196 (CD196), and Treg anti-interleukine 2 receptor β-chain cells (IL-2Rβ) in tissue from the left knee joint tissue were determined histologically. Oxidative stress and systemic inflammation were assessed by levels of superoxide dismutase (SOD), interleukin 17a (IL-17a), C-reactive protein (CRP), and rheumatoid factor (RF) using the enzyme-linked immune-sorbent assay. The degree of arthritis was assessed by clinical scoring of paw swelling and the diameter of paw swelling. Results: We found a significant decrease (p < 0.050) in the expression of HIF-1α, Th17 (CD196), IL-17a, RF levels, and the clinical scores and the diameter of paw swelling when comparing both groups. There was no significant decrease in the level of CRP in the treatment group compared to the control group. The expression of Treg (IL-2Rβ) increased significantly (p < 0.050) and the level of SOD increased but not significantly (p > 0.050) in the treatment group compared to the control group. Conclusions: HBOT has effects on the polarization of Th17 to Treg through a decrease in expression of HIF-1α in mice with ACIA. HBOT is recommended for use as a support therapy for RA in combination with drug therapy.

Objectives: We sought to estimate the mortality and morbidity in diabetic acute heart failure (AHF) patients stratified by left ventricular ejection fraction. Methods: We analyzed the data of patients with AHF from seven Middle Eastern countries (Bahrain, Oman, Yemen, Kuwait, UAE, Qatar, and Saudi Arabia) from February to November 2012, who were enrolled in a multinational registry of patients with heart failure (HF). Results: A total of 2258 AHF patients had diabetes mellitus. The mean age was 63.0±11.0 years (ranging from 18 to 99 years), and 60.3% (n = 1362) of the patients were males. The mean ejection fraction (EF) was 37.0±13.0%. HF with reduced EF (< 40%) (HFrEF) was observed in 1268 patients (56.2%), whereas 515 patients (22.8%) had mid-range (40–49%) (HFmrEF) and 475 patients (21.0%) had preserved EF (≥ 50%) (HFpEF). The overall cumulative all-cause mortalities at three- and 12-months follow-up were 11.8% (n = 266) and 20.7% (n = 467), respectively. Those with HFpEF were associated with lower three-months cumulative all-cause mortality compared to those with HFrEF (7.6% vs. 5.9%; adjusted odds ratio (aOR) = 0.54, 95% confidence interval (CI): 0.31–0.95; p = 0.031), but not significantly different when compared to those with HFmrEF (aOR = 0.86, 95% CI: 0.53–1.40; p = 0.554). There were largely no significant differences among the groups with regards to the 12-months all-cause cumulative mortality (11% vs. 11% vs. 10%; p = 0.984). There were also no significant differences in re-hospitalization rates between the three HF groups not only at three months (23% vs. 20% vs. 22%; p = 0.520), but at one-year follow-up (28% vs. 30% vs. 32%; p = 0.335). Conclusions: Three-month cumulative all-cause mortality was high in diabetic HFrEF patients when compared to those with HFpEF. However, there were no significant differences in mortality at one-year follow-up between the HF groups. There were also no significant differences in re-hospitalization rates between the HF groups not only at three months but also at one-year follow-up in the Middle East.

Objectives: We sought to investigate the epidemiology of thyroid cancer and its trends in Oman over a 20-year period. Methods: We analyzed all cases of primary thyroid cancer reported to the Oman National Cancer Registry between 1996 and 2015. Age-standardized incidence rates (ASR) were calculated using the World Standard Population. Joinpoint regression was used to assess trends and obtain annual percentage changes (APC) in incidence rates with 95% confidence intervals (95% CI) and p-values at the alpha = 0.050 level. Gender-specific APC was used to project thyroid cancer incidence rates in Oman over the next 20 years. Population attributable fraction was calculated for obesity and current non-smoking. Results: A total of 1285 cases of primary thyroid cancer cases were registered in Oman between 1996 and 2015, with a female to male ratio of 4:1. In men, the ASR was 2.0 per 100 000 while in females it was 7.6 per 100 000 (p < 0.010). Over 80.0% of thyroid tumors were of a papillary type and 19.0% follicular type. Statistically significant trends for thyroid cancer were detected in women from 2008–2015 (APC = 14.3%, 95% CI: 8.0–20.9, p < 0.010) and among both genders (APC = 16.7%, 95% CI: 4.9–29.9, p < 0.010). If current trends continue, thyroid cancer incidence will increase to 3.1, 16.6, and 11.8 per 100 000 by 2040 in men, women, and both genders, respectively. Nearly 10.0% of thyroid cancer can be prevented by controlling obesity in the Omani population. Conclusions: Oman has had moderate incidence rates of thyroid cancer with an increasing trend among women. Since projections estimate that the rates of this disease will double in women over the next 20 years, health authorities should consider providing sufficient resources to manage this condition and establish prevention programs that address obesity as part of the strategy for the prevention and control of noncommunicable diseases.

Tongue angioedema is a well-recognized side effect of angiotensin-converting enzyme inhibitor particularly during the first few months of initiation. Unilateral tongue involvement is rarely encountered. We report the case of a 78-year-old woman who presented with unilateral right side tongue angioedema, which occurred after two years of lisinopril use. She did not have any respiratory distress and her symptoms had completely resolved after twelve hours of observation. Lisinopril was discontinued and no recurrence of angioedema was reported.

Ataxia telangiectasia (A-T) is a common, genetically inherited cause of early childhood-onset ataxia that is classically characterized by progressive cerebellar malfunction, oculocutaneous telangiectasia, genome instability, and immunodeficiency. There is vast phenotype variation in patients with A-T and recently, dystonia, an extrapyramidal movement disorder. Here, we report the case of a 10-year-old girl who had experienced repeated diarrhea and mild gait ataxia since the age of two years. At age seven, ataxia and ocular telangiectasia were evident and immunoglobulin level assessment showed hyper IgM immune phenotype, thus a diagnosis of A-T was made based on clinical and laboratory findings, and she was started on intravenous immunoglobulin therapy. Generalized dystonia appeared when she was 10-years-old. Molecular analysis revealed two heterozygous mutations, c.6259delG and c.6658C>T, in the ATM gene of which one (c.6259delG) is novel. Dystonia can be part of the clinical picture in the A-T disorder and may even mask ataxia. This should be considered as a major feature mainly in variant A-T, which may occur without general ataxia and may be misdiagnosed in adults with primary dystonia.

Sarcoidosis is a systemic disease of unknown etiology affecting multiple organs and is characterized by the presence of non-caseating granulomas. It is very rare for patients with this condition to present initially with a penile lesion only. We report the case of a 63-year-old man who presented initially with an isolated single penile lesion. He subsequently developed multiple skin nodules over his right arm, chest, and trunk. The diagnosis of sarcoidosis was made based on clinical, radiological, and histopathological reports. The patient responded well to steroids.