Khalid Al-Rasadi,¹ Khalid Al-Waili,¹ Hilal Ali Al-Sabti,² Ali Al-Hinai,³ Khamis Al-Hashmi,³ Ibrahim Al-Zakwani,⁴ and Yajnavalka Banerjee^1*

Abstract

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.

Keywords: Familial hypercholesterolemia; Simon-Broome Criteria; Cascade-Screening; Dutch Criteria; US-Medped Criteria; Omani Arab Population.

Prevalence and Molecular Analysis of Occult Hepatitis B Virus Infection Isolated in a Sample of Cryptogenic Cirrhosis Patients in Iran

Fatemeh Akhavan Anvari,¹ Seyed Moayyed Alavian,² Mehdi Norouzi,¹ Mostafa Mahabadi,² and Seyed Mohammad Jazayeri¹*

Abstract

Objectives: The aims of this study are to investigate the prevalence of occult hepatitis B virus infection among patients with cryptogenic cirrhosis and to analyze the relationship between surface protein variability and occult hepatitis B virus infection, which may be related to the pathogenesis of occult hepatitis B virus infection in cryptogenic cirrhosis. Occult hepatitis B virus infection is a well-recognized clinical entity characterized by the detection of hepatitis B virus DNA in serum and/or liver in the absence of detectable hepatitis B virus surface antigen, with or without any serological markers of a past infection.

Methods: Sera from patients with cryptogenic chronic liver disease were tested for hepatitis B virus DNA using both real-time and nested PCR. In the detected hepatitis B virus DNA samples, the surface gene was analyzed for mutations.

Results: Hepatitis B virus DNA was detected in 38% of patients, all of whom had a viral load below 10,000 copies/mL. All hepatitis B virus belonged to genotype D. There were no significant associations between occult hepatitis B virus infection status and age, gender, ALT/AST levels, viral load or serologic markers of previous hepatitis B virus infection. There were 14 mutations found in 5 patients; 6 were in the major hydrophilic region, of which 4 were Y134F assigning for the "a" determinant region. All patients who acquired Y134F contained S207R (within HLA-A2-restricted CTL epitope) as a combination.

Conclusion: Hepatitis B virus surface antigen variants may arise as a result of natural selection to evade the immune surveillance of the infected host, and subsequently may go undetected by conventional hepatitis B virus surface antigen screening tests. Etiological diagnosis of cryptogenic cirrhosis is significantly underestimated with current serology testing methods alone.

Keywords: Cryptogenic cirrhosis; HBV surface protein mutations; Occult hepatitis B infection; Iran.

Shahrzad Aghaamoo,¹ Azra Azmoodeh,² Fardin Yousefshahi,³ Katayon Berjis,² Farahnazsadat Ahmady,⁴ Kamran Qods,⁵ and Majid Mirmohammadkhani^6*

Abstract

Objective: Because of high psychological burden and considerable costs of in-vitro fertilization, it is greatly important to identify all factors that may influence its results. In this study, general anesthesia and spinal analgesia used for oocyte retrieval were compared in terms of success in treating infertility among couples who had undergone in-vitro fertilization at an infertility center in Tehran, Iran.

Methods: This cohort study that was based on analysis of patient records at Mirza Kochak Khan Hospital, Tehran University of Medical Sciences, in 2008-2009. In this study, the status of chemical pregnancy among those who experienced general anesthesia or spinal anesthesia for in-vitro fertilization for the first time were compared, and the possible effects of clinical and laboratory factors using logistic regression models were considered.

Results: Considering the number of transferred embryos, underlying cause of infertility and fetus grade, it was found that practicing spinal anesthesia is significantly related to increased chance of chemical pregnancy (adjusted Odds Ratio=2.07; 95% CI: 1.02,4.20; p=0.043).

Conclusion: According to analysis of recorded data in an infertility treatment center in Iran, it is recommended to use spinal anesthesia instead of general anesthesia for oocyte retrieval to achieve successful in-vitro fertilization outcome. This can be studied and investigated further via a proper multicentric study in the country.

Keywords: In-vitro fertilization; General anesthesia; Spinal analgesia; Cohort; Iran.

Mojgan Mamani,¹ Mohammad Mahdi Majzoobi,² Sahar Mousavi Ghahfarokhi,³ Farzaneh Esna-Ashari,⁴ and Fariba Keramat^1*

Abstract

Objectives: Tuberculosis is one of the oldest infections known to affect humans. The aim of the study was to assess the quality of life including physiological, general health perception and social role functioning among patients with tuberculosis in Hamadan, Western Iran.

Methods: A cross sectional analytical study was conducted between December 2009 and March 2011, the quality of life scores of 64 tuberculosis cases were measured by SF-36 questionnaire before treatment, after the initial phase and at the end of treatment and were compared with those of 120 controls. The association of the quality of life with age, type of tuberculosis, sputum smear, duration of disease, and the stage of treatment were assessed among the patients.

Results: Before treatment, all scores of tuberculosis patients were lower than those of the controls (p<0.05). The patients’ score increased significantly after two months of treatment (p=0.01), but the difference was not significant between two and six months after treatment (p=0.07). The lowest score in tuberculosis patients was related to physical functioning and energy (45 ± 42, 44 ± 24, respectively).

Conclusion: According to the results, tuberculosis patients still have a low quality of life in spite of receiving new care strategies. Therefore, enhancement in quality of life may improve adherence to anti-tuberculosis treatment, functioning and well-being of patients with tuberculosis.

Nisrin Anfinan,¹ Nadine Alghunaim,¹ Abdulaziz Boker,² Amro Hussain,¹ Ahmad Almarstani,¹ Hussain Basalamah,¹ Hesham Sait,¹ Rawan Arif,¹ and Khalid Sait^3*

Abstract

Objective: To identify patients’ attitudes, preferences and comfort levels regarding the presence and involvement of medical students during consultations and examinations.

Methods: A cross-sectional descriptive study was conducted from September 2011 to December 2011 at King Abdulaziz University Hospital in Jeddah, Saudi Arabia. Participants were randomly selected from the outpatient and inpatient clinics at the Department of Obstetrics and Gynecology and the Emergency Department, provided they were admitted for obstetric or gynecology-related conditions. Data were collected using a structured questionnaire, and data analysis was performed using the Statistical Package for Social Sciences.

Results: Of the 327 patients who were recruited, 272 (83%) were elective patients who were seen at the outpatient and inpatient clinics of the Department of Obstetrics and Gynecology (group I). The other 55 (16.8%) were seen at the Emergency Department or the Labor and Delivery Ward (group II). One hundred seventy-nine participants (160 [58.8%] in group I and 19 [34.5%] in group II) reported positive attitudes about the presence of female medical students during consultations. Fewer participants (115 [42.3%] were in group I and 17 [30.9%] in group II) reported positive attitudes regarding the presence of male medical students during consultations (p=0.095). The gender of the medical student was the primary factor that influenced patients’ decision to accept or decline medical student involvement. No significant associations were observed between patients’ attitudes and perceptions toward medical students and the patients' age, educational level, nationality or the gender of the consultant.

Conclusion: Obstetrics and Gynecology patients are typically accepting of female medical student involvement during examinations. Student gender is the primary factor that influences patient attitudes regarding student involvement during physical examinations.

Rashid Al-Abri,¹* Deepa Bhargava,¹ Wameedh Al-Bassam,¹ Yahya Al-Badaai,¹ and Sukhpal Sawhney²

Abstract

Objective: Anatomic structural variations of the paranasal sinuses have a practical significance during surgical procedures conducted on the sinuses by otolaryngologists. This study aims to evaluate the prevalence of clinically significant anatomical variations of the paranasal sinuses.

Methods: A prospective analysis of 435 computed tomography (CT) examinations of adult Omani patients was conducted to determine the prevalence of clinically significant anatomical variations of the paranasal sinuses. A total of 360 CT scans were included from January 2009 to January 2010.

Results: The findings showed abnormal Agger nasi cells in 49% of cases (95% CI: 44-54%), concha bullosa in 49% (95% CI: 44-54%), Haller cells in 24% (95% CI: 18-31%), asymmetry in anterior ethmoidal roof 32% (CI: 29-37%), Onodi cells in 8% (CI: 5%-10%). The type of skull base were as follows; Type 1 was 30% (n=107; 95% CI: 25-35%), Type 2 was 34% (n=123; 95% CI: 29-39), and Type 3 was 36% (n=130; 95% CI: 31-41%). Many other surgically significant anatomical variations in small numbers (1-3) were incidentally identified.

Conclusion: Knowledge of the presence of anatomical variations of the sinuses has a clinical significance as it minimizes the potential for surgical complications. There is an ethnical difference in the prevalence of anatomical variations. Further studies of anatomical variations with clinical disease correlations are needed.

Keywords: Anatomical Variations Paranasal sinuses; Haller cell; Onodi cell.

Apurva Srivastava,¹ Balraj Mittal,² Jai Prakash,³ Varun Shanker Narain,⁴ S.M. Natu,⁵ and Neena Srivastava^1*

Abstract

Objective: Genetic variants of the melanocortin-4 receptor gene (MC4R), agouti related protein (AGRP) and proopiomelanocortin (POMC) are reported to be associated with obesity. Therefore, the aim of this study is to examine MC4R rs17782313, MC4R rs17700633, AGRP rs3412352 and POMCrs1042571 for any association with obesity in North Indian subjects.

Methods: The variants were investigated for association in 300 individuals with BMI ≥30 kg/m² and 300 healthy non-obese individuals BMI <30 kg/m². The genotyping were analyzed by Taqman probes. The statistical analysis was performed by the SPSS software, ver.19 and p≤0.05 was considered statistically significant.

Results: The genotypes of MC4R rs17782313 and POMC rs1042571 were significantly associated with obesity (C), (p=0.02; OR=1.7 and p=0.01; OR=1.6, respectively); however, MC4Rrs17700633 (p=0.001; OR=0.55) was associated with low risk. In addition, AGRPrs3412352 (p=0.93; OR=0.96) showed no association with obesity (BMI ≥30 kg/m²) in North Indian subjects.

Conclusion: This study provides the report about the significant association of MC4R (rs17782313) and POMC (rs1042571) with morbid obesity (BMI ≥30 kg/m²), but MC4R (rs17700633) and AGRP (rs34123523) did not show any association with obesity in the studied North Indian population.

Keywords: Obesity; Genetic variants; Genotype; Phenotype; MC4R; AGRP; POMC.

Saif Al-Yaarubi,¹ Irfan Ullah,^1* Sharef Waadallah Sharef,² Azza Al Shidhani,¹ Shaima Al Hanai,³ Rabaa Al Kalbani,³ and Shamsa Al Jamoodi³

Abstract

Objectives: To describe the demographic characteristics and clinical presentation of Omani children with type 1 diabetes mellitus at Sultan Qaboos University Hospital, Muscat, Oman.

Methods: A retrospective analysis of all children with type 1 diabetes mellitus attending the Pediatric Endocrine Unit at Sultan Qaboos University Hospital, Oman from June 2006 to May 2013.

Results: One hundred and forty-four patients were included in the study. The mean±SD of age at diagnosis was 6.7 ± 3.7 years. The median duration of symptoms was 10 days (IQR; 5-14). The most commonly reported presenting symptoms were polyuria (94%), polydipsia (82%), and weight loss (59%). Diabetic ketoacidosis at initial presentation was diagnosed in 31% of the patients. Different insulin regimens were prescribed: multiple daily injections in 109 (76%) patients, twice daily insulin regimen in 23 (16%) patients, and insulin pump therapy in 12 (8%) patients. Family history of type 1 diabetes mellitus was present in 31 (22%) patients. There were no significant differences in presenting complaints (polyuria, p=0.182; polydipsia, p=0.848), duration of symptoms (p=0.331), reported weight loss (p=0.753), or diabetic ketoacidosis at presentation (p=0.608) between patients with and without family history of type 1 diabetes mellitus.

Conclusion: Polyuria, polydipsia and weight loss are the most common presenting symptoms. Family history of type 1 diabetes mellitus is highly prevalent among the studied patients. Diabetic ketoacidosis was found to be less common in Oman compared to other diabetes centers in the Middle East.

Mohsen Taghizadeh,¹ Mansooreh Samimi,² Zohreh Tabassi,² Zahra Heidarzadeh,¹ and Zatollah Asemi^1*

Abstract

Objective: Micronutrient deficiency during pregnancy is associated with several complications. This study was designed to determine the effects of received multivitamin-mineral vs. multivitamin supplements on maternal, newborns' biochemical indicators, and birth size.

Methods: This double-blind randomized-controlled clinical trial was conducted among 48 Iranian pregnant women, primigravida, aged 18-35 years old in their second and third trimester from December 2011 to September 2012. Subjects were randomly assigned to receive either the multivitamin-mineral (n=24) or multivitamin supplements (n=24) for 20 weeks. Fasting blood samples were taken at baseline and after a 20-week intervention of pregnant women as well as umbilical cord blood of the babies immediately after delivery to measure serum calcium, vitamin D, iron, magnesium, zinc and biomarkers of oxidative stress including plasma total antioxidant capacity and total glutathione.

Results: Multivitamin-mineral compared to multivitamin supplementation resulted in a significant increase in maternal serum calcium (0.5 vs. -0.1 mg/dL, p=0.04) and magnesium levels (0.1 vs. -0.2 mg/dL, p<0.001). Furthermore, mean plasma total glutathione levels (1791 ± 566 vs. 1434 ± 622 µmol/l, p=0.04) of the newborns whose mothers received multivitamin-mineral were higher than those whose mothers received multivitamin supplements.

Conclusions: Overall, multivitamin-mineral compared to multivitamin supplementation for 20 weeks during pregnancy resulted in a significant increase in maternal serum calcium and magnesium levels as well as a significant elevation of newborn plasma total glutathione levels.

Sadia Masood,* Sara Sajid, Asif Jafferani, Saadia Tabassum, and Sobia Ansar

Abstract

Autoimmune diseases are known to have association with each other but it is very rare to see multiple autoimmune diseases in one patient. The combination of at least three autoimmune diseases in the same patient is referred to as multiple autoimmune syndrome. The case we are reporting features multiple autoimmune syndrome with five different conditions. The patient had type 1 diabetes mellitus, autoimmune hemolytic anemia, systemic lupus erythematosus, vitiligo, and psoriasis. Psoriasis has rarely been reported previously under the spectrum of autoimmune syndrome.

Although the relationship of autoimmune conditions with each other has been explored in the past, this case adds yet another dimension to the unique evolution of autoimmune pathologies. The patient presented with a combination of five autoimmune diseases, which makes it consistent type three multiple autoimmune syndromes with the addition of psoriasis. The current case is unique in this aspect that the combination of these five autoimmune disorders has never been reported in the past.

Keywords: Autoimmune syndrome; Vitiligo; Psoriasis; Hemolytic anemia; Diabetes; Systemic lupus erythematosus.

Pushpa Dahiya and Ranjita Bains*

Abstract

The term fetus papyraceus is used to describe a mummified fetus associated with multiple gestations where one fetus dies and is flattened between the membranes of living fetus and uterine wall. Though the maternal and fetal complications in affected cases can be severe, we report of two cases of fetus papyraceus managed conservatively without any complications. Successful outcome is related to careful monitoring during pregnancy.

Keywords: Twin pregnancy; Intra-uterine death; Term gestation.

Kowthar S. Hassan,¹ Arwa Z. Al-Riyami,² Mohamed Al-Huneini,² Khalil Al-Farsi,² and Murtadha Al-Khabori^2*

Abstract

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an X-linked genetic disorder characterized by low levels of the G6PD enzyme. It is present worldwide but with more prevalence in the Middle East and the Mediterranean areas. We report a case of severe hemolysis due to G6PD deficiency manifesting as methemoglobinemia in a 70 year old Omani male never known to have any previous hemolytic episodes or previously diagnosed of G6PD deficiency.

Keywords: G6PD deficiency; Hemolysis; Methemoglobinemia.

Palankezhe Sashidharan,¹* Apoorva Matele,² Usha Matele,² Nowfel Al Felahi,¹ and Khalid F. Kassem³

Abstract

Advances in the identification of gastrointestinal stromal tumors, its molecular and immunohiostochemical basis, and its management have been a watershed in the treatment of gastrointestinal tumors. This paradigm shift occurred over the last two decades and gastrointestinal stromal tumors have now come to be understood as rare gastrointestinal tract tumors with predictable behavior and outcome, replacing the older terminologies like leiomyoma, schwannoma or leiomyosarcoma. This report presents a case of gastric gastrointestinal stromal tumor operated recently in a 47-year-old female patient and the outcome, as well as literature review of the pathological identification, sites of origin, and factors predicting its behavior, prognosis and treatment.

Keywords: Gastrointestinal stromal tumor; Identification; Risk stratification; Management.

Ali Güleç,^1* Harun Kütahya,² Nazım Karalezli,³ Burkay Kacira,³ and M. Ali Acar⁴

Abstract

Angiosarcomas are malignant tumors, which originate from the vessel endothelium and resemble the vessel structure. Stewart-Treves syndrome is an angiosarcoma which in general, develops in female patients after mastectomy and axillary lymph node dissection and is associated with chronic lymphedema. The prognosis of this rare complication is very poor. We present the case of a 52-year-old female who had undergone mastectomy due to breast cancer and 13 years later required shoulder disarticulation due to Stewart-Treves syndrome. 

Keywords: Angiosarcoma; Lymphedema; Stewart-Treves syndrome.

Mohammad Taghi Imani,¹ Ali Akbar Mohammadi,^2* and Seyed Morteza Seyed Jafari¹

Abstract

Electrical burn occurs when a current passes through the body, interfering with the function of internal organs or sometimes burning tissue. Four major mechanisms of electricity-induced injuries are presently known. In this case report, a 29-year-old farmer sustained electrical trauma to extremities from a high voltage transformer, followed by a major, deep burn wound on upper lateral aspect of his left arm, and a deep burn wound over the left medial ankle. After a few months, the patient developed left arm fracture with complete separation of two segments, and plantar wound with purulent discharge accompanied by complete destruction of the head of 4^th metatarsal bone which was in favor of chronic osteomyelitis. In this case, passage of the high voltage current and direct trauma could destroy metaphyseal, medullary and periosteal blood supply. Patients with high voltage electrical-induced bone injuries who underwent reconstructive surgery seem to be susceptible to osteonecrosis and pathologic fractures; therefor, these patients should be under close follow-up and periodic radiologic evaluations may be recommended.

Keywords: Burn; Electrical injury; Spontaneous fracture. 

Sanjay Meena,¹ Nilesh Barwar,¹* Tusshar Gupta,¹ and Buddhadev Chowdhury¹

Abstract

 A 25-year-old male presented with complaints of abdominal pain for the past two months. He was prescribed Buscopan and omeprazole by a general surgeon. It was only when patient started complaining of backache that he was referred to an orthopedic surgeon. On examination of spine, there was tenderness at the upper dorsal spine. A diagnosis of Pott’s disease affecting the upper dorsal spine was made. Magnetic resonance imaging (MRI) confirmed the vertebral changes and showed subligamentous spread of paravertebral masses from D2 to D7. This case illustrates the unusual form in which spine tuberculosis can present. High index of suspicion is necessary for early diagnosis and prompt management. General surgeons should be aware of this atypical presentation of Pott’s disease.

Keywords: Tuberculosis; Spine; Pott’s spine; Abdominal pain.

Yahya Sulaiman Marhoon AL-Alawi,¹ Arif Ali Kolethekkat,^2* PAM Saparamadu,³ and Yahya Al Badaai⁴

Abstract

Intraoral schwannoma is a rare entity. Tongue has been reported as the most common oral site. Those involving salivary glands are unusual and parotid gland is the usual site. Literature search revealed only one case of schwannoma involving the sublingual gland. Hence, this is a presentation of another case of sublingual gland schwannoma with a review of literature, in a young female of 21 years old.

Keywords: Schwannoma; Mouth; Sublingual gland; Case report.

Vishal Gupta,^1* Mridula Mittal,² and Vishal Sharma³

Abstract

Objective: Malaria is today one of the major causes of human suffering, both in terms of increasing morbidity/mortality and stunting intellectual/ economic growth. In a developing country like India, it has devastating socioeconomic consequences. The present study was therefore carried out to study the epidemiology of malaria in Amritsar district.

Methods: Diagnosed cases of Malaria reported from 1^st January to 31^st December 2009 in the erstwhile District of Amritsar were collected from the District Epidemiologist of Amritsar and Taran Taaran and studied. A total of 314 patients were studied. Data was assessed, systematically compiled and statistically analyzed.

Results: Most (84%) of the malaria patients in our study were less than 45 years of age. Male patients (57%) outnumbered females (43%). The majority of patients with malaria (98%) were from rural areas and 68.5% of the studied patients belonged to upper lower socioeconomical class according to Kuppuswamy socioeconomic status scale. The majority (83%) of patients took treatment from Registered Medical Practitioners/quacks. Out of the total patients, only 14% used mosquito nets, 13% used repellents, and 7% had wire gauze doors in their homes

Conclusion: The people living in rural areas were found to be more vulnerable to malaria. The disease was found to be more prevalent among the lower socio economic strata and young population leading to considerable adverse effect on health and economy. Our study aims to stress the estimation of the true burden of malaria.

Keywords: Epidemiology; Amritsar; Malaria; India.