Abstract

Over the past 20 years, patient satisfaction surveys have gained increasing attention as meaningful and essential sources of information for identifying gaps and developing an effective action plan for quality improvement in healthcare organizations. However, there are very few published studies reporting of the improvements resulting from feedback information of patient satisfaction surveys, and in most cases, these studies are contradictory in their findings. This article investigates in-depth a number of research studies that critically discuss the relationship of dependent and independent influential attributes towards overall patient satisfaction in addition to its impact on the quality improvement process of healthcare organizations.

Keywords: Patient satisfaction; Quality improvement; Healthcare.

Abstract

In 2012, Oman Heart Association (OHA) published its own guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction, the aim was not to be comprehensive but rather simplified and practical in order to reduce the gap between the long comprehensive guidelines and our actual practice. However, we still feel that the busy registrars and residents need simpler and direct clinical pathways or protocol to be used in the emergency departments, coronary care units and in the wards. Clinical pathways are now one of the main tools used to manage the quality in healthcare concerning the standardization of care processes. It has been shown that their implementation reduces the variability in clinical practice and improves outcomes in acute care.

Abstract

Objectives: Hematological changes are among the most common complications encountered in malaria. This study analyzes and statistically evaluates the hematological changes as a diagnostic test for malaria in patients with acute febrile illness and whether these could guide the physician to institute specific antimalarial treatment.

Methods: The present study was an observational study, conducted from January to December 2012. A total of 723 patients presenting with acute febrile illness at our hospital were evaluated. A complete blood count and malarial parasite microscopy were performed for each patient.

Results: The findings showed that 172 out of 723 patients (24%) were diagnosed to have malaria by positive smear report. There were 121 males and 51 females with a male to female ratio of 2.3:1. Maximum number of cases were seen in the 20-30 years age group. There was a statistically significant reduction in hemoglobin (p<0.005), platelet count (p<0.001) and total leukocyte count (p<0.001) levels in patients with malaria compared to those without the disease. Likelihood ratios for a positive result of platelets (6.2) and total leukocyte count (3.4) was relevant as compared to hemoglobin (1.61) and Red cell distribution width (1.79). The negative predictive values for hemoglobin (79%), total leukocyte count (86%), platelets (94%) and Red cell distribution width (93%) were significant. Red cell distribution width values were found to be higher in patients with malaria than in patients without malaria (p<0.001).

Conclusion: This study revealed that routinely used laboratory findings such as hemoglobin, leukocytes, platelet counts and even red cell distribution width values can provide a diagnostic clue in a patient with acute febrile illness in endemic areas, thus increasing the probability of malaria and enhancing prompt initiation of treatment.

Abstract

Objectives: Stillbirth is an important public health concern and its rate indicates the sanitary development of society. The purpose of this study is to determine the trend of stillbirth rates and its risk factors in Babol.

Methods: A retrospective study was conducted based on the data of hospital charts of two major Gynecological wards in Shahid Yahyanejat and Babol clinic hospitals in Babol, Northern Iran. In the first phase, the frequencies of stillbirths and live birth deliveries were collected for the period of 1999-2008. In the second phase, a case-control study of 150 stillbirths cases and 300 live births as controls was conducted. The risk factors data included maternal age, gestational age, gravity, history of stillbirth, abortion, diabetes mellitus, preeclampsia, fetal sex, residence area, birth interval and prenatal care. The odds ratio for risk factors with 95% confidence interval for stillbirths was calculated using the logistic regression model.

Results: Stillbirth rate was reduced significantly from 10.51 in 1999 to 8.57 per 1000 deliveries in 2008 (p=0.001). A significant association was found between preterm delivery (p=0.001) and preeclampsia (p=0.01) with stillbirths. Although the proportion of stillbirths was higher among mothers with history of diabetes, abortion and maternal age of more than 35 years, the odds ratio was not statistically significant.

Conclusion: There is a relationship between stillbirth, preterm delivery and preeclampsia. Thus, we can considerably prevent stillbirths with sanitary remedial interference on these risk factors.

DOI 10.5001/omj.2014.07

Abstract

Objective: To assess the usefulness of a computed tomography scan in patients with non-localized headache.

Methods: One-hundred and forty-two patients with non-localized headache were included in a retrospective study after reviewing the medical records of 896 patients at the Radiology Department, Sultan Qaboos University Hospital. Patients with neurological deficits, head injury, previous intracranial intervention, or malignancy were excluded. Radiological findings of all patients were reviewed and results were divided into 3 groups: 1) no intracranial abnormality; 2) with clinically significant intracranial abnormality; and 3) positive without clinical significance or with extracranial abnormality. All patient history records were reviewed for a period of six months following their initial computed tomography scan to assess their clinical outcomes. The cost of computed tomography examination and patient radiation dose were calculated.

Results: Of the 142 patients, 64% were females and 36% males (7% pediatric) with an age range of 4-87 years (mean: 36.2 years). Among the patients, 70% demonstrated negative computed tomography findings (grade 1), only 4% showed clinically significant findings (grade 2), and 26% demonstrated incidental positive findings with no clinical significance (grade 3). The average cost of computed tomography head examination was approximately 60 Omani Riyal ($156). The clinically significant positive cases were fewer than expected. The average estimated radiation dose for these patients was calculated and found to be around 5 times the radiation from computed tomography of the sinuses (approximately 1.84 mSv).

Conclusion: Computed tomography head imaging in patients with non-localized headache has a low likelihood for any significant intracranial lesion. Therefore, it is essential to develop local standard operating procedures to promote better utilization of this type of imaging service.

DOI 10.5001/omj.2014.08

Abstract

Objective: To compare the efficacy of behavioral intervention program and vaginal cones on stress urinary incontinence.

Methods: In this randomized clinical trial, 60 women aged 25-65 years with stress urinary incontinence were randomly divided into two groups, those who participated in a behavioral intervention program (n=30) and those who used vaginal cones (n=30). The women in the behavioral intervention group were instructed on pelvic floor exercise and bladder control strategies. In the other group, pelvic floor exercises were performed using the vaginal cones. All participants were treated for 12 weeks and followed-up every 2 weeks. The subjective changes in severity of stress urinary incontinence were measured using a detection stress urinary incontinence severity questionnaire, leakage index, and a 3-day urinary diary. The objective changes were measured by pad test. For better evaluation of the effects, two questionnaires were used: Incontinence Quality of Life and King’s Health Questionnaire.

Results: Among the 51 women who completed the study, 25 subjects were in the vaginal cones group and 26 participated in the behavioral intervention program. The changes in leakage rate on pad test and leakage index in the behavioral intervention program group were significantly higher than in the vaginal cones group (p=0.001 and p=0.008, respectively), but the severity of stress urinary incontinence was not significantly different between the two groups (p=0.2). The changes in strength of the pelvic floor, Incontinence Quality of Life, and King’s Health Questionnaire scores showed no significant differences between the two groups after 12 weeks of intervention.

Conclusion: Vaginal cones and behavioral intervention programs are both effective methods of treatment for mild to moderate stress urinary incontinence, but the behavioral intervention program is superior to vaginal cones in terms of cost-effectiveness and side effects.

DOI 10.5001/omj.2014.09

Abstract

Objectives: The aim of this study is to investigate the effect of eicosapentaenoic acid combined with vitamin C in comparison with the pure form of eicosapentaenoic acid on the serum concentration of malondialdehyde, erythrocyte activity of superoxide dismutase, glutathione peroxidase, and the serum level of total antioxidant capacity in patients with type 2 diabetes.

Methods: Eighty one male diabetic patients, aged 33-63 years, were randomly assigned to one of 4 groups. The subjects consumed 500 mg/d pure eicosapentaenoic acid, 200 mg/d vitamin C, 500 mg eicosapentaenoic acid and 200 mg/d vitamin C or placebo depending on their groups. In fasting blood samples, superoxide dismutase and glutathione peroxidase activities were determined via the enzymatic method (Randox kit) and the serum total antioxidant capacity, malondialdehyde and vitamin C concentrations were estimated by colorimetric methods.

Results: Administration of pure eicosapentaenoic acid in diabetic patients increased superoxide dismutase by 4%, glutathione peroxidase 53%, total antioxidant capacity 36% and decreased malondialdehyde significantly by 25%. Prescription of eicosapentaenoic acid combined with vitamin C demonstrated a significant increment for superoxide dismutase activity by 3% and for glutathione peroxidase activity by 52% during the study, but no significant change was seen for total antioxidant capacity and malondialdehyde, respectively. There was a significant decrease in FBS and HbA_1c following prescription of eicosapentaenoic acid with/without vitamin C along the study, although these changes were not significant between the study groups.

Conclusion: It is concluded that prescription of eicosapentaenoic acid in the pure form reduces oxidative stress in type 2 diabetic patients; albeit, it does not alleviate hyperglycemia. Combination of vitamin C and eicosapentaenoic acid does not improve antioxidant property of eicosapentaenoic acid.

DOI 10.5001/omj.2014.10

Abstract

Objectives: Hypotestosteronemia has been reported in approximately half of type 2 diabetic men in general. This study aims to assess serum total testosterone levels in type 2 diabetics with erectile dysfunction and to correlate the degree of improvement between sildenafil citrate and testosterone levels.

Methods: A cross sectional and prospective comparative interventional study was conducted at the Diabetic Clinic of Assalam Teaching Hospital in Mosul, during the period from January 1, 2009 through to December 31, 2011. The study enrolled 120 type 2 diabetic males with erectile dysfunction who were analyzed with regard to age, duration of diabetes, duration and severity of erectile dysfunction, serum total testosteron levels and the degree of response to sildenafil citrate in terms of testosterone levels. The data were statistically analyzed using the independent two-sample Student t test, χ² test and Pearson correlation test. A p-value of <0.05 was considered statistically significant.

Results: Thirty six percent of type 2 diabetic males with erectile dysfunction were found to have low serum testosterone levels. The hypotestosteronemic and normotestosteronemic subgroups were not significantly different in terms of mean age, duration of diabetes, reduction of libido, and reduction in erectile function. The rate and the degree of improvement of erection by sildenafil in the normo-and-hypotestosteronemic respondents were not significantly different, but the degree of improvement by sildenafil was significantly correlated to testosterone levels among the hypotestosteronemic group.

Conclusion: Hypotestosteronemia was found in 36% of type 2 diabetic males with erectile dysfunction. The degree of improvement of erectile dysfunction by sildenafil was directly proportional to the serum testosterone levels among the hypotestosteronemic group. Therapeutic supplement with testosterone preparation in the hypotestosteronemic diabetics with erectile dysfunction may improve their response to sildenafil.

DOI 10.5001/omj.2014.11

Abstract

Objective: The aim of this study was to screen Omani individuals for the familial aggregation of type 2 diabetes mellitus.

Methods: A random cohort of 1182 Omani individuals visiting the Family Medicine Clinic at Sultan Qaboos University Hospital (SQUH), Muscat, Oman, for regular medical checkup, aged ≥40 years, were sampled. Patients were categorized into three groups: (1) individuals who claim not to have diabetes and had no family history of diabetes; (2) individuals who claim not to have diabetes but had family history of diabetes; (3) individuals with diabetes. Only 16% of these Omani individuals had no diabetes and no family history of diabetes. Another separate random cohort of 234 Omani type 2 diabetes mellitus patients, from the Diabetes Clinic at SQUH, were interviewed and questioned about their family history of type 2 diabetes mellitus.

Results: Ninety five percent of the patients had a family history of diabetes. Eighty percent had first degree relatives with diabetes and 46% had second degree relatives with diabetes. At least one parent with diabetes was reported among 55% of these diabetics, while maternal diabetes (55%) was found to be higher than paternal diabetes (47%). However, only 15% had both parents with diabetes. Furthermore, almost half of the 234 diabetics were having at least one of the following relatives with diabetes: brother, sister, aunt or an uncle.

Conclusion: The findings of this study confirm familial aggregation of diabetes among the Omani population. Compared to other populations, familial aggregation of type 2 diabetes mellitus among Omanis is relatively very high, and is perhaps due to the very high degree of consanguinity among Omanis. Since almost everyone seems to have a genetic predisposition to diabetes, the dramatic lifestyle changes over the past 25 years, could tip the population into an epidemic of type 2 diabetes mellitus.

Abstract

Objectives: Stage III non-small cell lung cancer (NSCLC) has a poor prognosis. Reports suggest that five-year survival after current treatment is between 14 to 24 percent. The purpose of this retrospective study was to investigate the morbidity and mortality of patients diagnosed with stage III NSCLC and treated with pneumonectomy at the University of Kentucky Medical Center in Lexington, KY.

Methods: We reviewed the medical record and tumor registry follow-up data on 100 consecutive patients who underwent pneumonectomy for lung cancer at the University of Kentucky.

Results: We identified thirty-six patients in stage III who underwent pneumonectomy. Ten patients had surgery only, eight patients received adjuvant chemotherapy, and eighteen patients received neoadjuvant therapy. There was one surgical death in this series. Mean follow-up was 2.9 years. One-, three-, and five-year survival was 66%, 38%, and 38%, respectively. Five-year survival for the group with adjuvant therapy was 60%.

Conclusion: Most lung cancer patients present with advanced disease and the prognosis remains poor. Our experience indicates resection offers an above average chance of long-term survival when supplemented with neoadjuvant and/or adjuvant therapy.

Keywords: Pneumonectomy; Non-small cell lung cancer; Resection; Lobectomy; Surgery; Chemotherapy; Neoadjuvant therapy; Survival.

DOI 10.5001/omj.2014.12

Abstract

This is the first report of congenital adrenal hyperplasia (CAH) due to combined 17α-hydroxylase/17,20 lyase deficiency in an Omani patient who was initially treated for many years as a case of hypertension. CAH is an uncommon disorder that results from a defect in steroid hormones biosynthesis in the adrenal cortex. The clinical presentation depends on the site of enzymatic mutations and the types of accumulated steroid precursors. A 22-year-old woman who was diagnosed to have hypertension since the age of 10 years who was treated with anti-hypertensive therapy was referred to the National Diabetes and Endocrine Centre, Royal Hospital, Oman. The patient also had primary amenorrhea and features of sexual infantilism. Full laboratory and radio-imaging investigations were done. Adrenal steroids, pituitary function and karyotyping study were performed and the diagnosis was confirmed by molecular mutation study. Laboratory investigations revealed adrenal steroids and pituitary hormones profile in addition to 46XY karyotype that are consistent with the diagnosis of CAH due to 17α-hydroxylase deficiency. Extensive laboratory workup revealed low levels of serum cortisol (and its precursors 17α-hydroxyprogesterone and 11-deoxycortisol), adrenal androgens (dehydroepiandrosterone sulfate and androstenedione), and estrogen (estradiol); and high levels of mineralocorticoids precursors (11-deoxycorticosterone and corticosterone) with high levels of ACTH, FSH and LH. Mutation analysis revealed CYP17A1-homozygous mutation (c.287G>A p.Arg96Gln) resulting in the complete absence of 17α-hydroxylase/17,20-lyase activity. The patient was treated with dexamethasone and ethinyl estradiol with cessation of anti-hypertensive therapy. A review of the literature was conducted to identify previous studies related to this subtype of CAH. This is the first biochemically and genetically proven case of CAH due to 17α-hydroxylase/17,20-lyase deficiency in Oman and in the Arab World described in the literature.

Keywords: Congenital adrenal hyperplasia; 17 α-hydroxylase; 17,20-lyase; Hypertension; Pseudohermaphroditism; Adrenal cortex; Oman.

DOI 10.5001/omj.2014.13

Abstract

Coronary artery fistula is an uncommon finding during angiographic exams. We report a case series of five patients with congenital coronary fistulas. The first patient was 56 years old and had a coronary fistula associated with a partial atrio ventricular defect, the second patient was 54 years old and had two fistulas originating from the right coronary artery with a severe atherosclerotic coronary disease, the third patient was 57 years old with a fistula originating from the circumflex artery associated with a rheumatic mitral stenosis, the fourth patient was 50 years old and had a fistulous communication between the right coronary artery and the right bronchial artery, and the last patient was 12 years old who had bilateral coronary fistulas draining into the right ventricle with an aneurismal dilatation of the coronary arteries. Angiographic aspects of coronary fistulas are various; management is controversial and depends on the presence of symptoms.

DOI 10.5001/omj.2014.14

Abstract

Accidental ingestion of foreign bodies is common in ENT practice. A very small number of ingested foreign bodies perforate the esophagus and even a smaller fraction of extra mucosal migration penetrates into the soft tissues of the neck. Most cases reported in the literature involve fish bones. If left untreated, they may result in life threatening complications. This case presents a patient with a metallic foreign body (metal wire) in the esophagus which migrated extraluminally into the prevertebral muscle of the neck and describes the difficulties encountered in removing the migrated foreign body. Intra-operative radiography using two metallic pointers was used to locate the exact position of the foreign body during exploration of the neck.

Keywords: Esophagus; Metallic foreign body (steel wire); Migration; Prevertebral muscles.

DOI 10.5001/omj.2014.15

Abstract

Rasmussen encephalitis is an extremely rare chronic inflammatory neurodegenerative disease affecting a single cerebral hemisphere, causing progressive neurological deterioration and intractable seizures. Imaging plays an important role in diagnosis by demonstrating focal or unihemispheric involvement and excluding other possible causes. Here, we report a case of Rasmussen encephalitis with an update on recent diagnostic criteria and emphasis on differential diagnoses which can be excluded on imaging.

DOI 10.5001/omj.2014.19

Abstract

Hepatocellular carcinoma is the most frequent type of liver malignancy. Most cases of hepatocellular carcinoma are secondary to either viral hepatitis (hepatitis B, C) or alcoholic cirrhosis. Liver cirrhosis due to any other causes is considered as a risk factor for development of hepatocellular carcinoma; however, hepatocellular carcinoma in a young patient with no cirrhosis or fibrosis is a relatively rare condition. The present case report describes a young 24-years-old male patient who presented with a two-month history of fever, right upper quadrant abdominal pain, and weight loss with no evidence of pre-existing liver disease, initially treated as liver abscess; however, a computed tomography (CT) showed numerous hepatic hypodensities with ring enhancement. Serum alpha-fetoprotein level was high (>1000 ng/L) and histopathological study confirmed the presence of primary hepatocellular carcinoma. The present case findings suggest that multifocal hepatocellular carcinoma can occur in a young patient with no apparent risk factor, and that the clinical presentation of hepatocellular carcinoma can be similar to liver abscess.

Keywords: Hepatocellular carcinoma; Liver abscess; Chronic liver disease.

DOI 10.5001/omj.2014.20

Abstract

This is a case of bilateral cavernous sinus thrombosis in a five-and-a-half-year-old boy who presented with bilateral proptosis with difficulty in swallowing and excessive salivation. Clinical features along with contrast-enhanced computed tomography and hemogram diagnosed the case as bilateral cavernous sinus thrombosis and retropharyngeal abscess with third cranial nerve palsy. The patient was treated with standard regimen successfully. Cavernous sinus thrombosis is a very rare complication of retropharyngeal abscess.

Keywords: Cavernous sinus; Retropharyngeal abscess; Thrombosis; Third nerve palsy.

DOI 10.5001/omj.2014.16

Abstract

Objective: Intelligence quotient is an indicator of one's efficacy and many factors including chronic diseases may impact upon it. This study aims to compare the IQ of children diagnosed with moderate asthma to the IQ of healthy children.

Methods: This comparative study was conducted between June 2011 and January 2012 in an Academic Referral Clinic. In this study, 114 patients aged 6 to 13 years who were diagnosed with moderate asthma were compared with 90 age and sex matched healthy patients from their families. Wechsler intelligence scale for children was used by split half method to calculate the overall IQ, verbal IQ and practical IQ. The t-test and Chi square test were used to analyze quantitative variables and qualitative variables, respectively.

Results: In this study, 204 children, 114 (56%) in the case group and 90 children (44%) in the control group participated in comparing their IQs. One hundred and fifteen (56%) were males and 89 (44%) were females. The overall IQs of asthmatic patients and healthy patients were 109 and 108, respectively; the difference was not significant (p=0.905). Furthermore, there was no significant difference in the IQ scores between males and females.

Conclusion: Although asthma is a chronic disease and causes many respiratory problems, it has no negative impact on IQ.