Pediatric Malignant Pelvic Paraganglioma-A Diagnostic and Surgical Challenge

Pheochromocytoma are chromaffin cell-derived tumors that have an exceptionally high genetic predisposition. The presentation of extra-adrenal and pelvic paraganglioma (PGL) in children is uncommon. Due to the relative rarity, PGL tumors' presentation and disease behavior may vary. Genetic testing, imaging, and biochemical investigation are employed to diagnose PGL. Surgical resection with preoperative angioembolization has been practiced in alleviating the burden of torrential intraoperative bleeding.

Antimicrobial Management of Complicated Skin and Soft Tissue Infections in an Era of Emerging Multi-Drug Resistance: Perspectives from 5 Gulf Countries

The number of complicated skin and soft tissue infections (cSSTIs) in the Arabian Gulf region has risen in recent years, particularly those caused by multi-drug resistant (MDR) pathogens. The high prevalence of diabetes, obesity, and associated cardio-metabolic comorbidities in the region renders medical and surgical management of cSSTI patients with MDR infections challenging. An experienced panel of international and regional cSSTI experts (consensus group on cSSTIs) was convened to discuss clinical considerations for MDR infections from societal, antimicrobial stewardship, and cost perspectives, to develop best practice recommendations. This article discusses antibiotic therapies suitable for treating MDR cSSTIs in patients from the Gulf region and recommends that these should be tailored according to the local bacterial ecology by country and region. The article highlights the need for a comprehensive patient treatment pathway and defined roles of each of the multidisciplinary teams involved with managing patients with MDR cSSTIs. Aligned and inclusive definitions of cSSTIs for clinical and research purposes, thorough and updated epidemiological data on cSSTIs and methicillin-resistant <i>Staphylococcus aureus</i> in the region, clearcut indications of novel agents and comprehensive assessment of comparative data should be factored into decision-making are necessary.

Prevalence of risk factors of non-communicable diseases in the Sultanate of Oman: STEPS survey 2017

BACKGROUND

Non-communicable diseases (NCD) represent a major public health issue and currently cause 185.75 deaths per 100,000 population in Oman. Hence, there is a need for comprehensive, up-to-date and internationally comparable data on NCD risk factors in order to evaluate the effectiveness of ongoing public health policies and to develop further NCD prevention and control interventions. The aim of the study was to provide evidence-based, up-to-date, extensive, and reliable baseline data on the behavioural and biological risk factors of NCDs in the Sultanate of Oman.

METHODS

A cross-sectional, prospective, observational community-based survey designed to be nationally representative of the Sultanate of Oman was conducted based on the WHO STEPwise approach to Surveillance (STEPS). Multi-stage stratified random sampling according to geographical distribution selected a total of 9053 households (Omani nationals and non-Omani residents). Cluster sampling was used to randomly select equal clusters from each governorate. 823 households were randomly selected from the list of all households in all selected clusters from each governorate and one eligible adult selected from each household randomly accounting for 6582 consenting participants. The survey used demographic and behavioural information questionnaires along with physical and biochemical measurements among adults aged 18 years and above.

RESULTS

The prevalence of behavioural risk factors such as tobacco use was 9%, alcohol consumption was 2%, insufficient fruit or vegetable intake was 61%, and insufficient physical activity was 39%. The prevalence of biological risk factors such as overweight and obesity was 66%, raised blood pressure was 33%, raised blood glucose was 16%, and raised blood cholesterol was 36%. The prevalence of multiple risk factors was also determined and 95% of the population were found to have more than one risk factor. Three or more risk factors were found among 33% of population aged 18 years and above and 45% of the population aged 45 years and above.

CONCLUSION

A high prevalence of various NCD risk factors was found which needs to be addressed through health promotion, education, and policy. The findings are important to support the formulation and implementation of NCD-related policies and action plans that improve health status and prevent mortality due to NCDs in Oman.

Airway and Anaesthetic Challenges in a Child With Bronchus Suis and Superimposed Double Aortic Arch: A case report

Bronchus suis or tracheal bronchus is an accessory bronchus arising from the trachea above the carina. Double aortic arch is a congenital vascular anomaly with persistence of both left and right aortic arches beyond fetal life which can form a vascular ring compressing the major airways and may be symptomatic. We report the case of a 16-month-old girl who had recurrent episodes of respiratory distress requiring multiple hospitalisations and was diagnosed at the Sultan Qaboos University Hospital, Muscat, Oman in 2019 with a double aortic arch compressing upon a tracheal bronchus causing symptomatic emphysema of the right upper lobe. This report presents anaesthetic and airway challenges during the patient's lobectomy. A single lumen cuffed endotracheal tube was successfully used as a bronchial blocker to occlude the origin of the aberrant bronchus. The position of the tube was confirmed intraoperatively using fibreoptic bronchoscopy. Following her discharge, she continued to have recurrent episodes of respiratory distress and three months after her last appointment she succumbed to her illness. To the best of the authors' knowledge, this is the first such reported case in Oman.

Prevalence and risk factors of diabetes in a large community-based study in the Sultanate of Oman: STEPS survey 2017

BACKGROUND

Type 2 diabetes in the Gulf Cooperation Council countries, including Oman, is currently the fastest growing health crisis and is a significant cause of premature mortality and disability. There is currently insufficient up-to-date information available on prevalence of type 2 diabetes. This study aimed to assess the latest prevalence of type 2 diabetes mellitus and its associated demographic, behavioural, and clinical risk factors.

METHODS

Using the WHO STEPwise approach to chronic disease surveillance, a nationally representative population-based survey was conducted from January to April 2017 of adults aged 18 years and above. A multi-stage, stratified, geographically clustered random sampling surveyed 9053 households including Omani nationals and non-Omani residents. Univariate and multiple logistic regression analysis was performed to determine the predictors of diabetes.

RESULTS

Overall prevalence of diabetes among the population was 15.7% (95% CI: 14.0-17.5%) whereas prevalence of prediabetes was 11.8% (95% CI: 11.4-12.2%). Age, educational level, raised blood pressure, family history of diabetes, abnormal waist-to-hip ratio, and hypertriglyceridemia were found to be significantly associated with diabetes mellitus. Of the cases of diabetes mellitus, 17% were newly diagnosed and 13.2% were on medication and had an uncontrolled glucose level while 55.5% were not taking medication (although diagnosed) and had an uncontrolled blood glucose level.

CONCLUSIONS

The present study provides reliable information regarding the high prevalence of diabetes mellitus among the adult population in Oman with urgent attention needed to address this significant burden on the health system. The high proportion of uncontrolled cases warrants further research, awareness programmes, and community interventions.

PHACES Syndrome with Intestinal Hemangioma Causing Recurrent Intussusceptions: A Case Report and Literature Review of Associated Intestinal Hemangioma

PHACES syndrome comprises posterior fossa malformations, segmental hemangioma, arterial anomalies, cardiac defects, eye anomalies and less commonly, sternal cleft, or supraumbilical raphe. We report a case of PHACES syndrome associated with intestinal hemangioma causing recurrent intussusceptions. A full-term infant female presented at the age of three months with segmental distribution of telangiectatic patch with red swelling involving the right periorbital area, right forehead, and lips. After a full workup and evaluation, the diagnosis of PHACES syndrome was confirmed based on the presence of facial segmental hemangioma, hypoplastic right internal carotid artery, intracranial hemangioma, and right optic disc anomaly. At the time of workup, she developed typical symptoms of intussusception. Diagnostic laparoscopy was performed, and she was found to have hemangioma covering the whole ileal wall and a thickened circumferential hemangioma covering the mid ilium causing the lead point of the intussusception. Control of this patient’s hemangiomas was achieved by surgical resection of the thickened circumferential hemangioma covering the mid ilium along with oral propranolol. We reviewed the literature to explore the relationship between gastrointestinal (GI) hemangioma and PHACES syndrome and compared other associated extracutaneous hemangioma of the same series. We found 18 (58%) reported cases of GI hemangioma compared to other visceral hemangiomas on the same series of confirmed PHACE syndrome. All of the reported cases in this series present with anemia and GI bleeding except our patient who had intussusception. This might indicate the significant association of GI hemangioma as extracutaneous hemangioma in PHACES syndrome, emphasizing the importance of investigating 
symptomatic patients.

National survey to estimate sodium and potassium intake and knowledge attitudes and behaviours towards salt consumption of adults in the Sultanate of Oman

OBJECTIVES

To estimate population sodium and potassium intakes and explore knowledge, attitudes and behaviour (KAB) towards the use of salt in adults in the Sultanate of Oman.

DESIGN

National cross-sectional population-based survey.

SETTING

Proportional random samples, representative of Omani adults (18 years or older), were obtained from all governorates of the Sultanate of Oman.

PARTICIPANTS

Five hundred and sixty-nine (193 men, 376 women; 18 years or older) were included in the analysis (response rate 57%). Mean age was 39.4 years (SD 13.1). Participants attended a screening including demographic, anthropometric and physical measurements.

PRIMARY AND SECONDARY OUTCOME MEASURES

We assessed dietary sodium, potassium and creatinine by 24-hour urinary sodium (UNa), potassium (UK) and creatinine (UCr) excretions. We collected KAB by a questionnaire on an electronic tablet.

RESULTS

Mean UNa was 144.3 (78.8) mmol/day, equivalent to 9.0 g of salt/day and potassium excretion 52.6 (32.6) mmol/day, equivalent to 2.36 g/day, after adjusting for non-urinary losses. Men ate significantly more sodium and potassium than women. Only 22% of the sample had a salt intake below the WHO recommended target of 5 g/day and less than 10% met WHO targets for potassium excretion (>90 mmol/day). While 89.1% of those interviewed knew that consuming too much salt could cause serious health problems and only 6.9% felt they were using too much added salt, one in two participants used always or often salt, salty seasonings or salty sauces in cooking or when preparing food at home.

CONCLUSIONS

In the Sultanate of Oman, salt consumption is higher and potassium consumption lower than recommended by WHO, both in men and in women. The present data provide, for the first time, evidence to support a national programme of population salt reduction to prevent the increasing burden of cardiovascular disease in the area.

Management strategies for supply risk dependencies: empirical evidence from the gulf region

Purpose

The purpose of this study is to propose a conceptual model for managing supply risk (SR) dependencies in regional supply networks (SNs). Grounded on resource dependency theory (RDT), the research conceptualises the management of SR as buffering and bridging strategies that enable organisations to redefine their SN to cope with SR and as a three-stage transformation mechanism.

Design/methodology/approach

Four supply failure case studies from the aluminium and the oil and gas industries in the Gulf Cooperation Council (GCC) region inductively provide empirical insights for a revised conceptual framing. Within and cross case analysis on transcribed semi-structured interviews with 11 SN managers focus on the SRs and dependencies associated with the supply failures and an abstraction of risk management (RM) strategies for coping with these failures.

Findings

The analysis finds that underpinning ‘second-order’ buffering and bridging strategies from RDT are four main ‘first-order’ RM strategies: unit independency, organisational adaptation, network reconfiguration and environmental acceptance. These RM strategies are due to controllability and predictability levels that influence investment in RM and reflect the locations for implementing RM practices, i.e. the business unit, the organisation, the SN and the environment.

Originality/value

The article contributes to research through the conceptual framework of SR dependencies and unique insights on SR management within the GCC region. Practically, the research is novel in offering strategic directions for RM evaluations and investments that reflect the controllability and predictability of risk incidents. Such evaluations are potentially valuable in orchestrating regional SNs, for managing GCC companies in global supply chains, and for strategic decisions to expand or outsource to the GCC region.

A Triad of Temporomandibular Joint Ankylosis, Mandibular Retrognathia and Severe Obstructive Sleep Apnoea: Case report

The surgical management of paediatric patients with temporomandibular joint (TMJ) ankylosis, mandibular retrognathia and obstructive sleep apnoea (OSA) is challenging. We report a nine-year-old boy who presented to the Department of Oral Health, Sultan Qaboos University Hospital, Muscat, Oman, in 2016 with complaints of limited mouth opening, loud snoring and excessive daytime sleepiness. He was diagnosed with TMJ ankylosis, mandibular retrognathia and severe OSA. The patient initially underwent mandibular distraction and, subsequently, release of the TMJ ankylosis and rib graft reconstruction. The overall patient outcome was successful, with improvement in OSA-related symptoms, good facial symmetry and adequate mouth opening.

Congenital mesenteric hernia in neonates: Still a dilemma

Congenital transmesenteric hernia in neonates is a rare cause of intestinal obstruction with devastating outcomes and still remains a challenge to diagnose pre-operatively. Patients are often managed with emergency surgical exploration and may need bowel resection. We present 2 neonates with small bowel obstruction secondary to strangulated transmesenteric hernia through a congenital defect in the small bowel mesentery, which were managed successfully. We have also reviewed the literature about congenital transmesenteric hernia in neonates.

Scapular bronchogenic cyst: a case report and literature review

Bronchogenic cysts originate from abnormal budding of the tracheal diverticula during the embryological period. Inaccuracy in the process of growing of the ventral foregut will give rise to bronchogenic cyst. Scapular bronchogenic cyst is an extremely rare form of this anomaly. A three years old boy suffered for 2 years with left sided suprascapular cystic lesion which was gradually increasing in size. The swelling was 4 × 3 cm in size and non tender. The cyst was evaluated by CT scan that showed complex cystic lesion over the left scapular spine. Total excision of the cyst was done and histopathology showed cutaneous bronchogenic cyst. The proposed mechanism for such cutaneous lesion is that the accessory buds from the tracheobronchial tree/primitive foregut migrated from the thorax in an aberrant manner to lie in periscapular positions. The definitive treatment of scapular lesions is total surgical excision. The final diagnosis is based on the histopathological findings in the majority of cases.

Iatrogenic Horner syndrome after tube thoracostomy

Iatrogenic Horner syndrome is a rare complication of chest tube insertion, with little information available on this topic in the pediatric literature. We present a case of a 13-month-old boy with a left-sided pneumonia and an associated pleural effusion for which a chest tube was inserted. His respiratory and septic parameters improved, but he was noted to have ptosis, miosis, and anhydrosis of the left side. These resolved in the days after chest tube removal. Although tube thoracostomy is a common procedure in surgical practice, little is written about the potential for injury to the ipsilateral sympathetic chain. This report reviews the available literature, with an emphasis on complication avoidance.