Abdulaziz Al-Mahrezi

Clinical characteristics of influenza A H1N1 versus other influenza-like illnesses amongst outpatients attending a university health center in Oman

OBJECTIVES To identify the clinical characteristics of outpatients with flu-like illnesses stratified by influenza A H1N1 status. METHODS The study was conducted at the H1N1 staff clinic of Sultan Qaboos University Hospital in Muscat, Oman. The population consisted of university students and university/hospital staff and their family members. All adult patients who presented to the H1N1 clinic with an influenza-like illness over a 4-month period (from August until the end of November 2009) were included. Real-time reverse transcriptase (rRT) PCR was used for the diagnosis of H1N1 influenza. Demographic data, clinical signs and symptoms, history of exposure to H1N1, history of recent travel, and co-morbid conditions were documented. Analyses were conducted using univariate and multivariate statistical techniques. RESULTS Out of the 2318 patients identified, 27% (n=616) were positive for H1N1 influenza. The mean temperature in the H1N1-positive group was significantly higher than in the negative group (38.3 °C vs. 37.2 °C; p<0.001). Proportions of patients who reported cough, sore throat, headache, myalgia, gastrointestinal symptoms, exposure to a confirmed case of H1N1, and a history of travel were significantly higher in the H1N1-positive group as compared to the swab-negative group. However, the multivariable logistic model identified only the following significant predictor variables of H1N1 infection: younger age, fever (≥ 37.8 °C), sore throat, myalgia, diarrhea, and exposure to a confirmed H1N1 case within the last 7 days. CONCLUSIONS This study provides useful data on the clinical characteristics of H1N1 influenza in a large outpatient population from the Middle East. Patients who tested positive for H1N1 were more likely to have fever, sore throat, diarrhea, and myalgia compared to those with other influenza-like illnesses.

An application of educational theories and principles of teaching and learning communication skills for general practitioners in oman.

This article discusses the crucial role of teaching and learning communication skills for general practitioners, based on the theory of experiential and self-directed learning. It also outlines the proposed ways and methods to teach these communication skills in this project.The patient-doctor interview or what is known as office visit in some countries and consultation in others is the cornerstone of the entire General Practice (GP) or Family Medicine. It is from this process and outcome that the reputation is gained or destroyed. The analysis of the consultation is complicated and varied but is most usefully employed to assess effecacy in terms of achieving the means that are mutually desired by patients and their carers.

Marfan Syndrome : Correct diagnosis can save lives

Marfan syndrome is a heritable disorder of the connective tissue that affects many systems of the body. However, the most serious complication in patients with Marfan syndrome is progressive enlargement of the aortic root, which may lead to aortic dissection, rupture, or aortic regurgitation. Prevention of these life threatening complications is very important in the management of this condition. A 39-year-old Omani man presented with progressive shortness of breath and eventually underwent major but successful cardiac surgery. It is very important to recognise Marfan syndrome early as preventive actions are possible if the condition is diagnosed before complications occur.

Case study: Using A continuous glucose monitoring system in A patient with diabetes and beta-thalassemia hemoglobinopathy

Optimum glycemic control is extremely important in patients with diabetes mellitus to avoid long-term complications. Glycemic control relies mainly on the use of hemoglobin A1c, which unfortunately showed inaccurate results in patients with hemoglinopathies. The authors describe a case of β-thalassemia with poorly controlled diabetes mellitus that has misleading low levels of HbA1c. The use of a continuous glucose monitoring system was useful in documenting her poor glycemic control, with prolonged periods of hyper- and hypoglycemia. Based on these results, her insulin regimen was adjusted and the blood glucose levels were greatly improved throughout and the patient was able to meet her target blood glucose range (72–140 mg/dL [4–7.8 mmol/L]) in 70% of the time.

Asthma Clinics in Primary Healthcare Centres in Oman: Do they make a difference?

Objectives This study aimed to determine the effect of newly established asthma clinics (ACs) on asthma management at primary healthcare centres (PHCs) in Oman. Methods This retrospective cross-sectional study was conducted between June 2011 and May 2012 in seven PHCs in the Seeb wilayat of Muscat, Oman. All ≥6-year-old asthmatic patients visiting these PHCs during the study period were included. Electronic medical records were reviewed to determine which clinical assessment and management components had been documented. Results A total of 452 asthmatic patients were included in the study. The mean age was 35 ± 21 years old (range: 6-95 years) and the majority (57%) were female. In total, 288 (64%) cases were managed at ACs and 164 (36%) were managed at general clinics (GCs). Significant differences were noted in the documentation of cases managed at ACs compared to those at GCs, including history-taking information regarding signs and symptoms (91% versus 19%; P <0.001), trigger factors (79% versus 16%; P <0.001) and a history of atopy (81% versus 17%; P <0.001), smoking (61% versus 7%; P <0.001), asthma exacerbations (73% versus 10%; P <0.001) or previous admissions (63% versus 10%; P <0.001). Furthermore, prescription rates of inhaled corticosteroids (72% versus 61%; P = 0.021) and short-acting β-agonists (93% versus 82%; P = 0.001) were significantly higher at ACs compared to GCs. Conclusion Overall, the findings indicated that ACs have had a positive impact on asthma management at the studied PHCs.

Towards effective pain management: Breaking the barriers

Pain is a common cause of agony and suffering affecting millions of people around the globe.1 Ibn Sina, a famous Muslim scholar known in the West as Avicenna, was one of the first scholars to give an excellent description of pain, its types, and treatments.2 He postulated that the true cause of pain was a change in the physical condition of the organ regardless of the presence or absence of an ongoing tissue injury.2 Interestingly, this ancient description of pain is consistent with our modern understanding of the pathophysiology of pain as defined by the International Association for the Study of Pain (IASP): an “unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”.3 Pain is generally classified as acute or chronic according to its duration. If pain lasts for three months or more, it is usually considered chronic pain.3 Studies indicate that almost one out of five people suffer from moderate to severe chronic pain, and that one in three are unable or less able to maintain an independent lifestyle due to pain.4 Epidemiological data from developed countries showed that up to 50% of the general population could be affected with chronic pain.1 Pain has been identified as one of the commonest reasons for patients to seek medical advice.5 Uncontrolled pain can lead to catastrophic consequences on physical, mental, social, and financial levels. In the postoperative period, serious complications such as poor wound healing, infections, cardiac ischemia, and ileus might occur due to inadequate pain management.6 This is explained by the fact that pain causes stress, which in turn results in the activation of the sympathetic system and triggers a cascade of negative effects on various body systems.6 Moreover, uncontrolled postoperative acute pain can be transformed into chronic pain if it is not managed timely and adequately.6 Mentally, patients with chronic pain commonly suffer from negative emotions, irritability, and anger.7 The impact of chronic pain on mental health is illustrated further by the evidence of a higher prevalence of psychological distress, anxiety, and depression among patients who suffer from chronic pain.8 Socially, pain leads to strain and disruption of relationships, the inability to perform routine physical activities, and a growing dependency on others. Pain has a huge economic burden since it is closely linked with disability and unemployment.9 It is estimated that the annual cost of pain is much greater than the annual costs for major chronic diseases such as heart disease, cancer, and diabetes.9 Therefore, considering all of the harmful consequences of uncontrolled pain, it would not be surprising to discover that pain is indeed associated with a significant increase in both morbidity and mortality.10,11 Despite the progress seen in the various fields of medicine, pain management still remains a challenge. These challenges include obstacles for the development of effective medications due to complex pathophysiological mechanisms, the overlap and multiplicity of pain pathways, and the common occurrence of adverse effects.12 Inadequate pain management affects 80% of the global population, and poses a serious problem in more than 150 countries.13 Specific vulnerable groups such as the elderly, pregnant and breastfeeding women, children, people with substance abuse, and the mentally ill are at greater risk for inadequate pain management.13 editorial Oman Medical Journal [2017], Vol. 32, No. 5: 357-358

Characteristics of Chronic Pain Patients Attending a Primary Health Care Center in Oman

Objectives To determine the characteristics of patients presenting with chronic pain in a primary health care setting in Oman. Methods A retrospective cross-sectional study was carried out including all patients aged ≥ 18 years who attended Sultan Qaboos University Health Center during 2010. Patients were identified to have chronic pain if they were prescribed an analgesic medication for at least three months. Patients were compared to a control group which consisted of age- and gender-matched patients with no chronic pain. Results Out of 6 609 patients, 241 (3.6%) were found to have chronic pain. The mean age of patients with chronic pain was 54.0±13.0 years. The majority of patients were female (n = 174; 72.1%), and most were Omani (n = 201; 83.4%). The prevalence of chronic pain was found to be significantly higher among females compared to males (4.5% vs. 2.5%; p < 0.001) and also among Omani nationals to non-nationals (83.4% vs. 70.1%; p < 0.001). Chronic pain was significantly associated with the following comorbidities; diabetes (33.1% vs. 20.7%; p < 0.001), obesity (35.2% vs. 26.5%; p = 0.001), and hypertension (51.0% vs. 38.5%; p = 0.002). Osteoarthritis was the most common pain condition (n = 104; 43.1%). Diclofenac was the most commonly prescribed drug (n = 168; 69.7%). Conclusions The findings of our study point towards a higher prevalence of chronic pain in Omani females. These patients were also found to have a higher prevalence of other common comorbid conditions.

Learning Disabilities: Opportunities and challenges in Oman

Learning disabilities (lds) refer to a group of heterogeneous disorders which may affect the acquisition, organisation, retention, understanding or use of verbal or nonverbal information.1 The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders introduced a new term, specific learning disorder, as a single diagnosis to describe all of these conditions.2 A specific learning disorder is defined as a neurodevelopmental disorder of biological origin which manifests in learning difficulties and problems in acquiring age-appropriate academic skills during the early school years.2 Learning difficulties can manifest in any of the following essential skills: reading, written expression or mathematical calculations. The difficulties should last for at least six months and should not be attributable to any of the following causes: intellectual disabilities, a lack of visual or auditory acuity and other mental or neurological problems.2 Additionally, these learning problems should not be the result of psychological adversity, lack of proficiency in the language of academic instruction or inadequate educational instruction.2 The learning difficulties should cause significant interference with academic/occupational performance or with activities of daily living.2 Despite what the term might suggest, individuals with LDs have only specific learning difficulties but maintain an average or above average intelligence quotient.3 The main causative factor for LDs is presumed to be neurobiological in origin, due to an as-yet-unidentified brain pathology.3,4 Additionally, both hereditary and environmental factors have been implicated.3,5 It is possible that these aetiological factors intertwine to trigger the development of LDs. Generally, LDs affect approximately 5% of school-aged children globally.6 However, some researchers have argued that that the true prevalence could be as high as 15–20%.3,7 Reportedly, 4.9% of Canadian children aged 6–15 years were found to have an LD; this prevalence varied across the age spectrum, from 1.6% among 6-year-olds to 7.2% among 10-year-olds.8 Data from public schools in the USA showed an estimated LD prevalence of 5% among school-aged children, with 2.4 million students found to have LDs.9 Dyslexia, which affects a complex range of abilities related to reading and language, represents the most common LD, as 80% of people with LDs are dyslexic.5,10,11 Other common types of LDs include dysgraphia, which affects writing abilities, dyscalculia, which affects the application of mathematical operations, and visual-spatial organisation problems.3,11 Nonverbal LDs are another type of learning difficulty whereby individuals demonstrate adequate verbal expression, vocabulary or reading skills, but have difficulties with certain nonverbal activities, such as problem-solving, visual-spatial tasks and reading body language or recognising social cues.3 The effects of LDs can persist during adulthood, as reading, writing and mathematical skills are usually essential to perform routine daily activities. Affected individuals may also face limited opportunities for employment. Furthermore, the frequent co-existence of two or more LDs within the same individual makes the picture even more complex; in the USA, 30% of students with a primary LD were also found to have a secondary disability, while 7% had two or three additional disabilities, such as speech/language impairments or emotional disturbance.9 Furthermore, other research has also shown that LDs are usually associated with other comorbidities including attention deficit hyperactivity disorder, oppositional defiant disorder, obsessive-compulsive disorder, anxiety and depression.12 An LD diagnosis should be confirmed by individually administered standardised achievement measures and comprehensive clinical assessment. In view of the difficulties in diagnosing children with LDs, a three-level diagnostic approach has been advocated.13 The first level is the behavioural level, at which the main players are the parents and the school teachers of an affected child; this is the most important step, because it is here that an appropriate intervention can be initiated and followed-up. The second level is the neuro-behavioural level, whereby learning problems are analysed using appropriate neurocognitive tests and an attempt can be made at a diagnosis. The third level refers to the neurobiological basis of LDs; specific questions about the exact cause of the LD can be addressed by performing sophisticated investigations such as genetic marker analyses, neurophysiological tests and neuroimaging.13 Searching for the neurobiological underpinning of a particular LD may potentially rule out other diagnoses or comorbidities. The mainstay of LD treatment is remedial intervention—that is, utilising behavioural and medical techniques to improve the functioning of LD-affected individuals. Remediation is usually performed by educators specialising in dealing with children with special needs or talents. The aim of remediation is to address a specific LD by providing intensive and individualised instruction and allowing the student extra time to practice certain skills. There have been calls to implement intensive empirically-based interventions and make them easily available to all children in general education.4 An integral part of remediation is the early identification of at-risk children so that timely interventions can follow suit. The role of the family physician comes to the forefront with regards to this issue—every interaction with school-aged children and their families should be exploited to determine the child’s educational progress and any early signs of an LD. Teachers are another potential avenue for early identification. In the USA, yearly reading assessments for kindergarten children have resulted in the earlier detection of LDs.4 Several longitudinal studies have shown that preschool diagnosis and early interventions have the net outcome of reducing the severity of LDs; indeed, early interventions have been shown to have a durable and lasting effect on the school performance of LD-affected children.4,14 Conversely, Shaywitz et al. observed that ‘late’ interventions bore no beneficial effects for children with persistent reading disabilities.15 Oman has witnessed a drastic improvement in its educational system during the last four decades.16 The number of schools rose from three in 1970 to 1,052 in 2008; the number of teachers similarly increased from 30 in 1970 to 41,988 in 2008.16,17 In 1998, comprehensive educational reforms were carried out to keep up with new trends in education.17 At that time, a new curriculum was implemented, focusing on practical education, real-life experiences and the acquisition of essential life-long skills. In addition, teaching methods became more student-centred and new assessment methods were introduced.17 Unfortunately, very little research has yet been published regarding LD prevalence rates in Oman or other Arab countries.18 Nevertheless, specialised education for students with LDs has received attention; the Ministry of Education (MOE) established a Special Education section in 1974 which later became a department within the MOE.17 Furthermore, the MOE adopted the concept of inclusive education to provide opportunities for all learners, regardless of differences in their learning abilities in mainstream schools.17 In 2001, the MOE initiated a pilot project to provide support to students with LDs.16 The project has since been very successful; from the first two schools in 2001, it had expanded to include 1,471 schools in 2015.17 As part of this project, a special education teacher is assigned to each participating school to identify students with LDs in grades 1–4. Subsequently, the teacher will work with these students both in the general classrooms and in individualised classes to help them overcome their learning difficulties, primarily with regards to their reading and mathematical skills.16 Although the establishment of these initiatives in Oman seems promising, there are several challenges which need to be addressed.19 There is a dearth of qualified special education teachers catering to the needs of children with special needs and talents. Training teachers in this field has been difficult; however, the availability of local postgraduate training since 2006 will hopefully provide more opportunities for training. Similarly, there are few qualified clinical psychologists and developmental paediatricians and no tertiary care centres which are adequately equipped to manage children with LDs. There are also few validated Arabic assessment and screening tools which can be used for children with suspected LDs.18 There is a need to establish an appropriate system for monitoring and evaluating current strategies to identify areas for improvement. Integration of care by different service providers, such as ministries and non-governmental agencies, is also required. Finally, efforts should be continued to increase the level of awareness of the community and to educate parents about LDs and the available services in Oman. In view of the recent progress made in the fields of genetics and neuroimaging, there is great hope that improved treatment strategies, interventions and the remedial services for individuals with LDs will be found in the near future.20,21 Moreover, prevention of LDs may be possible with a better understanding of aetiological factors at the neurobiological and social levels. This will hopefully allow us to identify children at risk of LDs prior to their manifestation.