Kamlesh Bhargava

Prevalence of prehypertension and associated cardiovascular risk profiles among prediabetic Omani adults

BackgroundThe importance of prediabetes and prehypertension has been demonstrated in several studies especially for primary prevention of CVD. A recent community based cross-sectional study revealed that 40.9 percent Omani adults are prediabetics. This study was undertaken to estimate the prevalence of prehypertension and associated cardiovascular risk profiles in prediabetics. To best of our knowledge, this is the first report on this subject.MethodsThe study included 327 confirmed pre-diabetic Omani adults, who were analysed for their demographic, metabolic and behavioral characteristics. These characteristics were compared between the three different blood pressure groups to determine the CVD risk factors. Univariate and step-wise multiple logistic regression methods were used to carry out the analysis of the data.ResultsIn this study, the prevalence of prehypertension was 54.1 percent. Males were at higher risk of developing prehypertension as compared to females (OR = 2.30, 95% CI: 1.21, 4.38; P < 0.01). The individuals with higher BMI have two fold more risk of developing prehypertension (OR = 2.25, 95% CI: 1.26, 4.02; P < 0.01). The increased level of OGT enhanced the risk of developing prehypertension (OR = 1.26, 95% CI: 1.06, 1.50; P < 0.01).ConclusionA high prevalence of prehypertension (54.1%) exists in this study population. The major determinants of prehypertension in these prediabetic subjects were male gender, increasing dysglycemia and BMI. Appropriate intervention strategies have been suggested.

Prevalence of Metabolic Syndrome among Prediabetic Omani Adults: A Preliminary Study

BACKGROUND Metabolic syndrome is a well-established risk factor for the development of coronary artery disease (CAD). A recent cross-sectional, community-based study revealed that 36.1% of Omani adults are prediabetic as per American Diabetes Association (ADA) criteria. The objectives of this study were to determine the prevalence of metabolic syndrome and its relationship to various risk factors in a prediabetic population. METHODS Our study included 281 Omani prediabetic adults. The anthropometric, systolic, and diastolic blood pressure measurements together with lipid profile estimation were carried out. RESULTS In this study, the prevalence of metabolic syndrome was found to be 45.9%, and the gender-based distribution was 30.8% for men and 58.9% for women. The stepwise multiple logistic regression model revealed that women are at higher risk of developing metabolic syndrome. Prediabetics with a body mass index (BMI) >or= 30.0 (kg/m(2)) and abnormal waist-to-hip ratio (WHR) have a higher risk of developing metabolic syndrome with odds ratios (OR) of 20.20 and 6.38, respectively. CONCLUSION The prevalence of metabolic syndrome in this prediabetic study population was found to be higher than that of in the general population. Certain health promotion and disease prevention measures have been suggested. To the best of our knowledge, this is the first report on this subject.

Anisakiasis of the tonsils

A six-year-old Indian girl presenting with clinical features of chronic recurrent tonsillitis, had a tonsillectomy. Histopathology revealed a cross-section of an Anisakis worm in the tonsil. This report documents a new location in the human host for this rare parasite.

Non Allergic Rhinitis: Prevalence, Clinical Profile and Knowledge Gaps in Literature

OBJECTIVES Although Nasal symptoms induced by Non-allergic rhinitis| (NAR) are a cause of wide spread morbidity; the disease is trivialized. There is a lack of Epidemiological studies on the prevalence of non-allergic rhinitis. In spite of being one of the commonest conditions presenting to the General practitioner and otolaryngologists, the clinical profile, diagnosis, and management outcomes are unknown. The objectives of the study were to examine the prevalence and clinical profile of non-allergic rhinitis in Oman. Secondary objective was to identify Knowledge gaps in literature with the aim of directing future research. METHODS A cross sectional study of 610 consecutive adult patients presenting to the Ear, Nose and Throat clinic at Sultan Qaboos University Hospital is presented in this paper. The diagnosis of NAR was mainly based on step wise fashion; including a thorough clinical history and exclusion of other causes of rhinitis; all consecutive patients diagnosed with rhinitis (n=113) had a detailed history, nasal endoscopy, nasal smears, CT scans and an antihistamine response trial. The prevalence of NAR with its clinical profile was subsequently determined. Primary research articles and meta-analysis evaluated for the knowledge gap study were identified through MEDLINE search of English language literature published between 2000-2011. RESULTS A total of 610 consecutive patients were studied. The overall prevalence of rhinitis was 18.5% (n=113). The prevalence of NAR was 7.5% (n=46). Cases of allergic rhinitis (5.7%; n=35), Chronic rhinosinusitis (1.8%; n=11), and miscellaneous causes (3.4%; n=21) were excluded. Among the rhinitis population (n=113), the prevalence of NAR was 57% (n=46). The major presenting symptoms included nasal obstruction (93%; n=43), postnasal drainage (78%; n=36), and rhinorrhea (62%; n=29). For the knowledge gap study; 115 Medline titles were reviewed, four systematic reviews, and 34 research papers were reviewed. The text of two recent otolaryngology text books was also reviewed, and the main results of the study revealed the prevalence of NAR had not previously been studied in Oman. Although the recent text now clearly defines NAR, there is scant literature on the prevalence, diagnosis and management outcomes of NAR in the literature. CONCLUSION The study found that more than half of rhinitis patients suffered from NAR. There are no specific diagnostic tests for NAR; a thorough case history is the best diagnostic tool to date. A substantial knowledge gap exists in literature with relations to pathogenesis, clinical and laboratory diagnosis, as well as in reference to medical and surgical outcomes. Larger studies are required and management outcomes need to be studied.

Macular function in prediabetic and diabetic Omani adults: a microperimetric evaluation

Purpose. To assess if functional visual loss preceded structural changes or vice versa in diabetic patients by evaluating the macular function in prediabetic patients and in diabetic patients with varying grades of retinopathy and comparing the findings with those of age-matched healthy controls by means of microperimetry Methods. Retinal sensitivity, fixation pattern, and test response were evaluated in 25 prediabetic patients (50 eyes), 25 diabetic patients (50 eyes), and 25 age-related normal nondiabetic patients (50 eyes) using Nidek microperimetry. The diabetic patients were classified into 3 groups on the basis of clinical and fundus fluorescein angiographic evidence: group 1 = no clinical or angiographic evidence of retinopathy, group 2 = background retinopathy only, group 3 = with macular edema. Classification of retinopathy was based on Early Treatment Diabetic Retinopathy Study standards. Statistical analysis was conducted by Fisher exact test. Results. In diabetic patients, 20 eyes (40%) had no clinical or angiographic evidence of retinopathy, 13 eyes (26 %) had background changes, and 17 eyes (34%) had macular edema. Statistically significant difference in the fixation pattern, test response, and retinal sensitivity was noted in the diabetic and the prediabetic patients when compared to the controls. Conclusions. Significant loss of macular function in the eyes of prediabetic subjects was noted. These preliminary findings probably support the hypothesis that neurodegeneration precedes mi-croangiopathy.

Phenomenology and outcome of factitious disorders in otolaryngology clinic in Oman.

The phenomenology of factitious disorders from the Arab part of the world has been lacking in the medical literature and few reports have emerged from otolaryngology. Using an observational prospective case series study (n =19) with long-term follow-up (two to six years), the present study reports the magnitude and mode of clinical profile of factitious disorders in a tertiary care hospital in Oman, an Arab-Islamic country. The outcome was operationalized as prognosis following culturally sensitive intervention akin to confrontation technique. The present observation suggests the prevalence of factitious disorders in the otolaryngology tertiary care setting was 0.2%. Approximately 42.1% (n = 8) had hemorrhagic factitious disorders, 15.8% (n = 3) were those who feigned for multiple surgical interventions. Approximately 15.8% (n = 3) presented neurological factitious disorders while the remaining 26.3% (n = 5) clinical profile suggested minor feigned illnesses. Objective “evidence factitia” was present in 68.4% (n = 13) of the cases. On subsequent follow-up, nine patients with chronic forms became asymptomatic, three patients had fewer episodes, four patients were unchanged, and three patients were lost to follow-up. The prognosis was good in patients who did not have associated psychiatric illnesses as compared to those with psychiatric disorders. Factitious disorders are often incorrectly diagnosed, with all consequences in terms of adverse sequels. The observed good prognostic outcomes are discussed in the context of socio-cultural patterning and the factors that may shape the presentation of factitious disorders in Oman.

Frequenzgedoppelte Technologie (FDT) bei Patienten mit unkontrolliertem Diabetes mellitus

ZusammenfassungZielPatienten mit unkontrolliertem Diabetes mellitus Typ 2 wurden mit Hilfe der frequenzgedoppelten Technologie (FDT) auf frühe neurosensorische Funktionseinschränkungen untersucht.DesignProspektive vergleichende nichtrandomisierte Fallstudie.Methoden und PatientenAn jeweils einem Auge von 20 untherapierten Patienten mit aktuellen Blutzuckerwerten von > 14,5 mmol/1 (Durchschnitt 20,5 mmol/1) zum Untersuchungszeitpunkt wurde die FDT (MATRIX®, Zeiss-Humphrey) im 24-2-5-Überschwellen-Screening mit 5 Grad spatialer und 18 Grad temporaler Frequenz angewendet und mit je einem Auge von 20 alters- und geschlechtsentsprechenden gesunden Probanden verglichen. Klinisch wurde die diabetische Retinopathie nach der EDTRS-Klassifikation eingeteilt. Die statistische Analyse erfolgte mit dem „t“-Test mit unabhängigen Variablen und mit dem Fisher’s-exactTest.Ergebnisse9/20 Patientenaugen wiesen keine Retinopathie, 2/20 eine diabetische Hintergrundsretinopathie, 5/20 eine mit klinisch signifikantem Makulaödem und 4/20 eine proliferative diabetische Retinopathie auf. Bei der mittleren Testdauer zeigte sich ein signifikanter Unterschied zwischen der Patienten-Gruppe (2 min 26 s) und der Kontrollguppe (1 min 46 s) (p = 0,01, t-Test). 2 min und länger (Median 2 min 12 s) wurde bei 11/20 Patientenaugen (55%) gemessen. Ein reproduzierbarer signifikanter Gesichtsfeldverlust konnte bei 16/20 Augen verglichen mit der Kontrollgruppe (4/20) beobachtet werden (p = 0,032, Fisher’s-exact-Test). 6 dieser 16 Augen (37,5%) zeigten keinen klinischen oder angiographischen Anhalt für eine Retinopathie.SchlussfolgerungenBei Patienten mit unkontrolliertem Diabetes mellitus kann die FDT signifikante neurosensorische Funktionsverluste aufzeigen, die auch ohne Vorliegen einer Retinopathie nachgewiesen werden können.SummaryAimTo report on the evaluation of early neurosensory functional deficits in patients with uncontrolled diabetes mellitus type 2 and varying degrees of retinopathy by frequency-doubled technology (FDT).DesignProspective case-controlled study.MethodsSuprathreshold 24-2-5 screening with 5 degrees spatial and 18 degrees temporal frequency was performed in one eye each of 20 diabetic patients without treatment and blood sugar levels at > 14.5 mmol/1 (mean 20.5 mmol/1) by FDT (MATRIX®, Zeiss-Humphrey), and compared to 10 eyes of 20 individuals of an age-matched non-diabetic population. The clinical classification was done according to the ETDRS criteria. The ‘t’ test with independent variables and the Fisher’s exact test were used for statistical evaluation.Results9/20 eyes showed no retinopathy, 2/20 a background retinopathy, 5/20 a clinically significant macular edema and 4/20 a proliferative diabetic vitreoretinopathy. A statistically significant difference was noted in the mean test duration between the patient group (2 min 26 s) and the controls (1 min 46 s) (p = 0.01, by paired “t-test”). An increase in test duration of more than 2 min (median 2 min 12 s) was observed in 11/20 eyes (55%) of the patients. A significant and reproducible visual field loss was observed in 16/20 patient eyes vs. 4/20 controls (p = 0.032, Fisher’s Exact Test). 6 of these 16 eyes (37.5%) with abnormal visual fields showed no clinical or angiographic evidence of retinopathy.ConclusionIn patients with uncontrolled diabetes mellitus FDT can detect a significant loss of neurosensory function even in the absence of retinopathy.

Herabsetzung der retinalen Sensitivität bei Patienten mit unkontrolliertem Diabetes mellitus Typ 2 — eine Studie zur Mikroperimetrie der Makula

ZusammenfassungZielEvaluierung der Makulafunktion bei Patienten mit Diabetes mellitus Typ II.StudiendesignNichtrandomisierte kontrollierte Fallserie.MethodenBei 25 Patienten mit 50 Augen und nachgewiesenem Diabetes mellitus Typ II wurden das Fixationsund das Sensitivitätsmuster der Makula und die Testantwort (Latenz) mit Hilfe des Mikroperimeters MP-1 (Fa. Nidek) evaluiert und mit klinischen Befunden, aktuellen Blutzuckerwerten und fluoreszenzangiographischen Daten korreliert. Fundusveränderungen wurden anhand der ETDRS-Kriterien klassifiziert. Die Statistik erfolgte mit chi2-Tests.Ergebnisse20 Augen (40%, Grp. 1) hatten keinen Hinweis auf eine diabetische Retinopathie, 13 Augen (26%, Grp. 2) hatten eine nichtproliferative Retinopathie ohne und 17 Augen (34%, Grp. 3) eine nichtproliferative Retinopathie mit klinisch signifikantem Makulaödem. 9 Augen (36%) hatten ein seitenungleiches klinisches Bild. Abnormales unstabiles Fixationsmuster: Grp. 1: 8 (40%), Grp. 2: 7 (54%), Grp. 3: 17 (100%), reduzierte retinale Sensitivität Grp. 1: 4 (24%), Grp. 2: 8 (62%), Grp. 3:17 (85%) und verzögerte Testantwort Grp. 1: 8 (40%), Grp. 2: 4 (30%), Grp. 3: 17 (100%). Eine statistisch signifikante Anzahl von Augen (p < 0,0001) in der Studiengruppe zeigte damit unstabile Fixation, verzögerte Testantwort und subnormal retinale Sensitivät und korrelierten mit den klinischen Befunden je nach Erkrankungsstadium.SchlussfolgerungenAbnormales Fixationsmuster, reduzierte retinale Sensitivität und verzögerte Testantwort weisen auf einen stadienabhängigen Defekt der intraretinalen Ganglienzellen bei unkontrollierten hohen Blutzuckerwerten hin. Eine frühe Diagnose makulärer Komplikationen bei unkontrolliertem Diabetes kann durch die Mikroperimetrie ermöglicht werden.SummaryAimTo evaluate the macular function in patients with diabetes mellitus type II.Study designNonrandomized controlled case series.Methods25 patients (50 eyes) with diabetes mellitus Type II and 25 age-matched controls without were randomly subjected to evaluation of the fixation, retinal sensitivity and test response patterns of the macula using the Nidek Microperimeter. The findings were correlated with blood sugar levels and fluorescein angiography. Fundus changes were classified based on ETDRS criteria. Chi square test was applied for statistical analysis.Results20 eyes had no evidence of diabetic retinopathy, 13 eyes (26%) had background changes, and 17 eyes (34%) macular edema. 9 patients (36%) had an asymmetrical clinical picture. Abnormal fixation patterns: Grp. 1: 8 (40%), Grp. 2: 7 (54%), Grp. 3: 17(100%), reduced retinal sensitivity Grp. 1: 4 (24%), Grp. 2: 8 (62%), Grp. 3: 17 (85%), and delayed test response: Grp. 1: 8 (40%), Grp. 2: 4 (30%), Grp. 3: 17 (100%). A statistically significant number of eyes (p < 0.0001) in the study group showed unstable fixation, delayed test responses and subnormal retinal sensitivity correlating with the disease process.ConclusionAbnormal fixation pattern, reduced retinal sensitivity and prolonged test response indicate defective macular function and is related to the disease process in diabetics. Very early detection of diabetic macular complications in uncontrolled diabetics seems to be possible by microperimetry.

Putting Research Findings into Clinical Practice: Feasibility of integrated evidence-based care pathways in otorhinolaryngology head and neck surgery at Sultan Qaboos University Hospital, Oman

OBJECTIVES A perception exists that clinicians in Oman are reluctant to adopt evidence-based practice (EBP). This pilot study was undertaken to study the feasibility of using EBP pathways at the point of care in otorhinolaryngology head and neck surgery. The ultimate aim was to facilitate EBP with the probability of developing a new system for implementing research findings/translational research at the clinical point of care. METHODS A cross-sectional prospective questionnaire pilot survey of clinicians at Sultan Qaboos University Hospital (SQUH), Oman, a tertiary care medical centre, was undertaken. Respondents included 135 physicians and surgeons with between 3 months and 25 years of clinical experience and included personnel ranging from interns to senior consultants, in areas ranging from primary care to specialist care. RESULTS Of those polled, 90% (95% confidence interval (CI) 85-95%) either strongly agreed or agreed that evidence-based practice protocols (EBPP) could help in decision making. A total of 87.4% of participants (95% CI 81.8-93%) either strongly agreed or agreed that EBPPs can improve clinical outcomes; 91.8% of participants (95% CI 87.2-96.4%) would use and apply EBPP in day-to-day care if they were available at the point of care and embedded in the hospital information system. CONCLUSIONS The perception that clinicians at SQUH are reluctant to adopt EBP is incorrect. The introduction of EBP pathways is very feasible at the primary care level. Institutional support for embedding EBP in hospital information systems is needed as well as further outcome research to assess the improvement in quality of care.

Chronic intractable cough and silent sinusitis: role of functional endoscopic sinus surgery

Abstract Intractable chronic cough is common and challenging, but treatable. This paper presents a prospective study of adult patients who were referred for ENT diagnosis and management of chronic cough. In 61 patients a nasal cause was responsible for the cough. All patients were evaluated clinically, had nasal endoscopy, allergy skin tests, postnasal discharge culture and sensitivity and CT Scans. In 43 patients the cough was attributed to silent sinusitis (diagnosed on CT findings with minimal symptoms). The spectrum and frequency of causes found; postviral (20%), infective rhino sinusitis (18%), allergic rhino sinusitis (15%), nonallergic rhino sinusitis (9%), nasal polyps (8%) and more than one nasal diagnosis (30%). All patients received medical treatment initially; of these 12 patients with medically recalcitrant chronic sinusitis had functional endoscopic sinus surgery (FESS). The cough was attributed to postnasal drip and/or irritation of cough receptors in the sinuses. CT sinuses were crucial in diagnosis. Treatment outcome was obtained 3–6 months later; subjective outcome in patients undergoing FESS was better as compared to nonsurgical group.