Objectives: Major depressive disorder (MDD) stands as the primary contributor to disability worldwide. Identifying optimal treatment regimens for patients with MDD using advanced statistical techniques may help improve patient outcomes and reduce the number of hospitalizations. Methods: In a group of patients with MDD from north-western Iran, we compared treatments including work therapy (WT), WT plus electroconvulsive therapy (WT + ECT), WT plus family therapy (WT + FT), and other psychotherapeutic methods (PT). We also estimated the optimal treatment rule and identified essential variables in a loss-based framework using a penalized regression method. Results: The participants were 377 MDD patients of whom 198 (52.5%) received WT alone, 95 (25.2%) received WT + ECT, and 61 (16.2%) were given WT + FT. The remaining 23 (6.1%) patients were treated with PT. A comparison of the treatments revealed that a history of emotional problems was the important variable to consider when selecting WT + ECT, WT + FT, or PT, while patient education level and history of emotional problems were both important for WT + ECT. Applying the above optimal treatment rules is likely to reduce patients' hospital stay days. Conclusions: For patients with MDD, history of emotional problems and education level were the two most important variables for estimating the optimal treatment rules, including personalizing medications. Incorporating important variables into treatment regimens is likely to improve treatment outcomes and decrease the number of hospitalizations.

Keywords:Personalized Medicine; Optimal Treatment Rule; Decision Making; Psychotherapy; Variable Selection; Penalized Regression; Iran.

Objectives: Hemoglobin Constant Spring (Hb CS) is one of the most common non-deletion types of alpha (α) thalassemia in Southeast Asia. The nature of this abnormal globin gene is unstable, labile, and present in minute amounts in the peripheral blood, leading to underdiagnosis. This study aimed to determine the prevalence of Hb CS among the Kelantan population in Malaysia, compare the levels of Hb CS detected by capillary electrophoresis (CE) among three groups of Hb CS (heterozygous, homozygous, and compound heterozygous), and evaluate the efficacy of CE and high-performance liquid chromatography (HPLC) in detecting Hb CS. Methods: A cross-sectional study was conducted using data collected from secondary school students in Kelantan from 2017 to 2018 who participated in a thalassemia screening program conducted by the Ministry of Health, Malaysia. Hb analysis was performed using an automated CE system (CAPILLARYS 2 Flex-Piercing System Sebia) and HPLC (VARIANT II, Bio-rad Laboratories). DNA analysis was used multiplex polymerase chain reaction and multiplex amplification refractory mutation system to detect deletion and non-deletion α-thalassemia. Results: Termination codon CS mutation was confirmed among 376 (99.5%) samples with a peak value in zone 2 of CE. Heterozygous Hb CS was the most common type, detected in 344 samples (91.5%), followed by compound heterozygous Hb CS in 31 samples (8.2%) and one sample (0.3%) of homozygous Hb CS. Conclusions: The diagnosis of Hb CS is most accurately achieved by combining CE and HPLC methods, with confirmation by DNA molecular study, although the latter is more expensive.

Keywords:Hemoglobin Constant Spring; alpha-Thalassemia;  Electrophoresis, Capillary;  Multiplex Polymerase Chain Reaction;  Malaysia.

Objectives: We sought to estimate the impact of central precocious puberty (CPP) on psychosocial aspects in the cohort of children and to assess whether these aspects changed after treatment with gonadotropin-releasing hormone (GnRH) analogues. Methods: A case-control study enrolled 30 CPP children and 30 normal controls. The CPP group was assessed with emphasis on anthropometric measurements (Tanner staging for pubertal changes). The hormonal profile included gonadotropins, estradiol or testosterone, and GnRH stimulation test. The instruments used for neuropsychological assessment included the Arabic version of the pediatric quality of life inventory TM 4.0, the Child Behavior Checklist (CBCL), and IQ testing. Results: The mean study group age was 5.1 ± 2.3 years compared to 5.2 ± 2.2 years in the control group; 29 patients and 29 controls (96.7%) were females. CPP children had significantly lower scores than controls in health-related quality of life (QoL) domains except school functioning without significant changes in CBCL scores and cognitive function. There was a statistically significant improvement in these scores after they were treated with GnRH analogues for a year. Conclusions: There are significant aberrations in CPP children’s QoL with no effect on behavior or cognition. After treatment with GnRH analogues for a year, QoL and CBCL T-scores showed a significant improvement.

Keywords:Child; Puberty, Precocious; Quality of Life; Gonadotropins.

Objectives: Hemoglobin (Hb) level and its relation to rheumatoid arthritis (RA) is multifactorial. The primary aim of this study was to examine the association between Hb levels and disease activity in patients with RA. Methods: This retrospective study obtained data from adult RA patients with Hb reports from the Kuwait Registry for Rheumatic Diseases. Patients were recruited from four public hospitals in Kuwait between February 2013 and February 2022. The cohort was stratified into two groups: Hb ≤ 110 g/L and Hb > 110 g/L. Demographic, treatment, clinical, and laboratory characteristics were used to compare the two Hb groups. Multivariate and univariate statistical analyses were used to analyze the data. Results: The total number of patients visited (Nv) was 11 393 and consecutive patients with RA diagnoses and Hb data (Np) were 1584. Both Nv and Np were included in the study. Of these, 72.5% (n = 8260) had high Hb levels and 27.5% (n = 3133) had low Hb levels. The average age of the cohort was 55.9 ± 12.5 years. Logistic regression analysis revealed that a greater number of non-Kuwaiti patients had anemia than Kuwaiti patients [adjusted odds ratio (aOR) = 1.34, 95% CI: 1.16–1.56; p < 0.001). Patients who received biologic treatment were more likely to be non-anemic [aOR = 1.33, 95% CI: 1.23–1.45; p < 0.001). Additionally, the study demonstrated that patients with anemia had greater odds of acquiring Disease Activity Score -28 joint count (DAS-28) ≥ 3.2 versus DAS-28 < 3.2 [aOR = 0.74, 95% CI: 0.61–0.90; p = 0.002]. Conclusions: Lower Hb levels in RA are an independent predictor of disease activity.

Keywords:Arthritis, Rheumatoid; Anemia; Hemoglobins; Biological Products; Kuwait.

Objectives: There is a dearth of research in Oman regarding public knowledge and attitudes regarding the triage protocols for prioritizing patients for emergency care. This study aimed to investigate this at the emergency department (ED) of a tertiary referral hospital in Muscat, Oman. Methods: This cross-sectional study was conducted from September to November 2019. Adult Omanis visiting the hospital’s outpatient clinics or the ED during this period were selected using a consecutive convenience sampling strategy. A self-administered questionnaire was designed and used to assess the participants’ knowledge and attitudes regarding the triage process used in the ED. Results: A total of 572 Omani adults participated in the survey (response rate: 77.3%). The majority were female (56.8%). Most participants were educated to high school or bachelor’s degree level (74.7%). Overall, less than half of the sample (41.8%) demonstrated adequate knowledge of proper ED utilization, with male participants (p = 0.005) and those with a history of previous ED visits (p = 0.001) demonstrating significantly better knowledge than their respective counterparts. Knowledge of the factors used to make triaging decisions ranged from 28.5% (patient’s medical history) to 67.3% (vital signs). Most participants agreed that the triage system helped to prioritize emergency cases (84.8%), improved the quality of ED care (80.9%), and reduced overcrowding (76.2%). Although 59.1% still preferred to visit the ED for non-emergent indications to receive same-day care, 48.4% stated they would accept redirection to a primary health center if requested. Conclusions: This study's findings revealed the necessity of increasing awareness of appropriate indications for ED visits in Oman, as well as specific factors used in the ED triage process. This would help to ensure appropriate health resource utilization, avoid ED overcrowding and lengthy wait times, and increase overall levels of patient satisfaction and confidence in the healthcare system.

Keywords:Emergency Medical Services; Triage; Health Knowledge, Attitudes, Practice; Health Resources; Resource Allocation; Quality Improvement; Oman.

Objectives: Inactive hepatitis B carriers constitute a considerable proportion of chronic hepatitis B virus (HBV)-infected patients. Understanding the clinical features of this often overlooked population is essential to inform patient management strategies. Our study aimed to describe the sociodemographic and clinical features of inactive HBV carriers presenting to a tertiary center in Muscat, Oman. Methods: We conducted a retrospective, descriptive study among 375 adult Omani patients with inactive HBV infections presenting to the Sultan Qaboos University Hospital between January 2017 and December 2018. Relevant data were collected from electronic patient records. Liver fibrosis status was determined using two-dimensional shear-wave elastography. Results: A total of 200 patients met the study inclusion criteria and were included in the analysis. Of these, 53.0% were male, and the mean age was 45.0 ± 9.3 years. Most (77.5%) were aged 32–50 years and were therefore born before 1990, the year of initiation of the national HBV vaccination program. A family history of HBV infection was reported in 29.0%, while 25.0% were obese. Severe fibrosis and cirrhosis were observed in 16.0% and 3.0% of the cohort, respectively. Conclusions: A large number of inactive Omani HBV carriers were born before the implementation of the national HBV vaccination program in Oman, and just under one-third had a family history of HBV infection. Notably, despite being considered inactive carriers, 19.0% displayed radiological features of severe fibrosis or cirrhosis. Screening for high-risk inactive HBV infection is essential to ensure early management and improved patient outcomes.

Keywords:Hepatitis B virus; Obesity; Elasticity Imaging Techniques; Liver Fibrosis; Oman.

Objectives: Antibiotic resistance in clinical isolates is often correlated to poor disease management or prolonged hospitalization. The study aimed to determine the prevalence of multidrug-resistant (MDR) Salmonella isolates in clinical samples collected from Dhaka, Bangladesh. Methods: We investigated 150 clinical samples for the presence of Salmonella. The Salmonella isolates were tested against 12 antibiotics categorizable into three groups based on action mechanism and nine classes based on chemical structure. The susceptibility patterns were analyzed using the Kirby-Bauer disk diffusion method on Mueller Hinton agar. The isolates were classified as MDR and extensively drug-resistant based on their resistance patterns against different antibiotics. Results: We used 100 Salmonella isolates for this study. The highest prevalence of resistance was observed against penicillin G (96.0%), cefuroxime (75.0%), and clindamycin (71.0%). The isolates exhibited 33.0% and 43.0% resistance against imipenem and meropenem, respectively. Almost all (98.0%) isolates showed MDR. A quarter of the isolates (23.0%) were resistant to five classes of antibiotics and 18.0% to six classes of antibiotics. Moreover, 20.0% of isolates exhibited extensive drug resistance. Among the cell wall synthesis inhibitors, the highest resistance was observed against penicillin G (31.0%). Resistance rates were in the range 20–30% against protein synthesis inhibitors, clindamycin (29.0%), tetracycline (21.0%), and chloramphenicol (21.0%). Among the Salmonella isolates, 90.0% showed multiple antibiotic resistance index scores of ≥ 0.3, while 65.0% scored ≥ 0.5. The carbapenem group accounted for the maximum sensitivity (62.0%), followed by 60.0% each for gentamicin and norfloxacin. Conclusions: The high prevalence of MDR Salmonella isolates in clinical samples from Bangladesh indicates a serious threat to public health. Our findings emphasize the urgent need to control MDR through promoting responsible use of suitable antibiotics and public awareness of the dangers of antibiotic misuse, increasing testing facilities, and promoting genetic research.

Keywords:Multiple Antibiotic Resistance Salmonella; Extensive Drug Resistance; Bangladesh.

Objectives: The management for chronic suppurative otitis media is tympanoplasty. The aim of the surgery is to prevent recurrent ear discharge and improve hearing. Several influencing factors are presumed to affect the outcome of tympanoplasty; however, their effect is considered controversial. No study in Oman evaluates the success rate of this surgery. Therefore, this study aimed to evaluate the anatomical and functional outcome of type 1 tympanoplasty in Al Nahdha Hospital, Oman, from 2010 to 2020. In addition, we sought to assess various factors that might have influenced the outcome and add our experience to the literature. Methods: We conducted a retrospective study that included all patients who had undergone type 1 tympanoplasty in Al Nahdha Hospital. The demographic data for patients were collected, in addition to the preoperative findings, pre- and postoperative air-bone gap (ABG) in a pure tone audiometry, the surgical approaches, and the type of grafts used. The success rate was defined as intact tympanic membrane six months after the surgery, and hearing improvement success was assessed by closure of ABG closure of 10 dB or more. Results: The total number of patients was 345, 40.6% were male, and 59.4% were female. The graft success rate was 84.3%. The average preoperative ABG was 26.1 ± 9.5, and the average postoperative ABG was 14.4 ± 9.3 with a gain of 11.7. This was statistically significant with a p-value of < 0.001. Hearing improvement (≥ 10 dB gain in ABG) was seen in 201 (67.0%) patients. There was no statistically significant difference in the hearing improvement and graft success rate when compared with influencing factors, including age, gender, perforation size, and surgical approach. However, there was a statistically significant difference between the types of graft used, where cartilage graft showed better hearing improvement than temporalis fascia graft. Conclusions: The graft success rate of type 1 tympanoplasty in Al Nahdha Hospital was 84.3%, and closure of ABG was 11.7. The percentage of patients who had improvement in ABG closure of ≥ 10 dB was 67.0%. These results are comparable with the results of other published studies. Factors that are presumed to influence the outcome of type 1 tympanoplasty were not statistically significant, which is consistent with other studies. Cartilage graft was found to give a better closure of ABG, which was statistically significant. We recommend that further studies be conducted within a more extended follow-up period and address more factors to achieve a better insight pertaining to the outcome of type 1 tympanoplasty.

Keywords: Tympanoplasty; Otitis Media, Suppurative; Hearing Loss, Conductive; Oman.

Objectives: To investigate the incidence and associated risk factors of adverse events following COVID-19 vaccination in patients with inflammatory and non-inflammatory rheumatic and musculoskeletal diseases (I-RMD and NI-RMD, respectively). Methods: The Egyptian College of Rheumatology COVID-19 Study Group investigated physician-reported data (ECR-VaXurvey3) of RMD patients vaccinated against COVID-19 from December 2021 to June 2022, including their demographics, vaccination type, RMD diagnosis, treatments, post-vaccine flares, and other adverse events. The control group consisted of healthy, vaccinated individuals. Results: The ECR-VaXurvey3 included 890 vaccinated RMD patients, predominantly women (73.3%) with a mean age of 44.4 ± 12.1 years, and 172 controls. The RMD group comprised 816 (91.7%) with I-RMD and 74 (8.3%) with NI-RMD. The frequency of adverse events was comparable between the RMD and control groups. In RMD patients, injection site pain (59.9%) was the most reported adverse event. Post-vaccination COVID-19 infections and disease flares were reported in 2.9% and 12.1% of I-RMD patients and in 8.1% and 9.5% of NI-RMD patients (p = 0.018 and p = 0.497, respectively). The severity of prior COVID-19 infection (odds ratio (OR) = 2.4, 95% CI: 1.0–5.8; p = 0.040) and azathioprine use (OR = 2.6, 95% CI: 1.1–5.9; p = 0.024) were associated with higher post-vaccine adverse events, while biologic use was associated with fewer adverse events (OR = 0.5, 95% CI: 0.3–0.8; p = 0.010). Conclusions: Adverse events following COVID-19 vaccinations in patients with RMD are comparable to controls.

Keywords:COVID-19 Vaccine; Rheumatic and Musculoskeletal Disease; Adverse Effect; Safety; Risk Factors; Egypt.

Hyperthyroidism-related liver disease is an uncommon cause of jaundice in children. There is scarce data on its clinical and histological features and management. We report the case of a five-year-old girl with thyrotoxicosis associated with hepatitis, which was managed solely and successfully with carbimazole and propranolol.

Keywords:Hyperthyroidism; Jaundice; Pediatrics; Autoimmune Hepatitis; Carbimazole; Oman.

Brown-Séquard Syndrome (BSS) in children is a rare but serious neurological condition that can develop following damage to one-half of the spinal cord due to odontoid synchondrosis fracture. We report a case of a two-year-old girl who presented with difficulty moving her neck, gait abnormalities, and right-side weakness. She had a history of a fall from bed three months earlier. Computed tomography scan and magnetic resonance imaging revealed an incomplete fracture of C2 vertebra, resulting in focal kyphosis and posterior impingement over the craniocervical junction along with significant cord thinning. Considering the patient’s age and the incomplete nature of the fracture, a conservative approach was taken, and the patient underwent immobilization in a cervical collar for an extended period, followed by physiotherapy.

Keywords:Odontoid fracture; Synchondrosis; Brown-Sequard Syndrome; Pediatrics; Pakistan.

Biotin is sometimes administered in mega doses to children to treat certain inborn errors of metabolism. We report the case of a one-week-old newborn who was started on a ‘mitochondrial cocktail’ that contained a high dose of biotin. On day seven of life, his thyroid function test showed a biochemical picture of primary hyperthyroidism, which was not clinically evident. The suspicion of immunoassay interference with thyroid function test was confirmed when another lab, using a different immunoassay, gave normal results. If the biochemical profile does not match the clinical picture, it is reasonable to doubt the test result and think of assay interference.

Keywords:Biotin; Hyperthyroidism, Immunoassay; Newborns; Thyroid Function Tests; Oman.

Ischemic priapism is a male urologic emergency. Most cases have been linked to genetic conditions such as sickle cell disease and (much more rarely) glucose-6-phosphate dehydrogenase deficiency, and the use of certain drugs. Here, we report the case of a 34-year-old male who was a known case of the recurrent ischemic type of priapism, which was relieved by penile aspiration. Genetic investigation revealed that the patient had glucose-6-phosphate dehydrogenase.

Keywords: Priapism; Glucose-6-Phosphate Dehydrogenase Deficiency; Ischemic; Oman.

Myiasis is the term referring to an infestation of dipterous larvae in the living body tissue, where they feed on the tissue and cause infection. It is typically found in individuals living in unhygienic conditions, with foul-smelling odor emanating from neglected wounds or body discharge, which attract flies to lay their eggs in the affected area. Myiasis can cause life-threatening complications if maggots invade vital organs, resulting in sepsis, hemorrhage, and organ dysfunction. The mainstay of treatment includes mechanical removal of the maggots, wound debridement, daily wound dressing, and administration of antibiotics for concurrent bacterial infections. Recently, we encountered a patient who presented with bleeding and foul-smelling discharge from a tracheostomy wound, which was found to be infested with maggots.

Keywords:Maggot Infestations; Tracheostomy; Wound Infection.

Hypocalcemia, deafness, and renal syndrome, also known as Barakat syndrome, is an autosomal dominant genetic condition characterized by hypocalcemia, sensorineural hearing loss, and renal dysplasia. Papilledema, which refers to optic disc swelling due to increased intracranial pressure caused by hypocalcaemia, has been reported in the literature. However, optic disc edema secondary to hypocalcemia-induced optic neuropathy with normal intracranial pressure is rare. In this case report, we present a rare case of hypocalcemia, deafness, and renal syndrome, possibly the first diagnosed based on the presence of hypocalcemia-induced optic disc edema. We suggest that patients with optic disc edema referred for further neurological investigations should have their serum calcium levels analyzed, as early diagnosis and correction of hypocalcemia may improve the signs and symptoms of optic nerve disease.

Keywords:Optic Nerve Diseases; Hypoparathyroidism; Hypocalcaemia; Barakat syndrome.