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Objectives: This study aimed to retrospectively review imaging findings and the outcomes of uterine artery embolisation (UAE) in symptomatic uterine vascular anomalies (UVA). Methods: This study included a total of 15 patients with acquired UVA admitted to the Aga Khan University Hospital in Karachi, Pakistan, from 2010 to 2020. These patients were evaluated using ultrasound, computed tomography and magnetic resonance imaging, either alone or in combination. All patients had a history of dilatation and curettage or uterine instrumentation and underwent angiography and embolisation of the uterine arteries. The primary outcome post embolisation was assessed clinically and/or in combination with ultrasound. Post-procedure pregnancies were also recorded. Results: Non-invasive imaging was abnormal in all patients; however, this pre-intervention imaging was unable to accurately classify the type of vascular anomaly, except in the case of a pseudoaneurysm. Conventional angiography showed uterine artery hyperaemia in six patients, arteriovenous malformation in seven patients and pseudoaneurysm in two patients. The technical success rate was 100% and no repeat embolisation was needed. The follow-up ultrasound in 12 patients revealed a resolution of the abnormal findings, while the remaining three were found to be normal on clinical follow-up. Seven patients (46.7%) had a normal pregnancy 15.7 months after the procedure (range: 4–28 months). Conclusions: UAE is a safe and effective management option for intractable severe bleeding in patients with UVA post instrumentation and it was found that the procedure does not impair future pregnancy. Keywords: Uterine Artery Embolization; Pseudoaneurysm; Arteriovenous Malformation; Ultrasonography; X-Ray Computed Tomography; Magnetic Resonance Imaging; Pakistan.

Objectives: This study aimed to assess the effectiveness of the new traffic law enforcement regulations (TLERs) on the incidence and severity of maxillofacial injuries in Oman, as road traffic accidents (RTAs) are the main cause of facial injuries in Oman. Methods: A retrospective longitudinal analytic study was conducted at three tertiary care hospitals in Muscat, Oman. All patients with RTA-related maxillofacial injuries during a five-year period from January 2005 to December 2009 (before the new TLERs) and the five-year period from January 2015 to December 2019 (after the new TLERs) were included in the study. Results: A total of 1,127 patients were included in the study. Of these, 646 (57.3%) patients sustained RTA-related maxillofacial injuries before the implementation of the new TLERs compared to 481 (42.7%) after the introduction of TLERs. No significant gender-based difference was found between the two study periods. The incidence of injury before the implementation of the new TLERs was 22.7 per 100,000 population, which then reduced significantly to 11 per 100,000 after the TLERs were implemented. Overall, the mean facial injury severity score reduced significantly, from 3.2 to 2.3, after the implementation of the new TLERs. Conclusions: The findings of this study indicate that the newly introduced TLERs have resulted in a reduction in the incidence and severity of RTA-related maxillofacial injuries. Continuous improvement and reinforcement of TLERs will further help reduce the burden of these injuries to society in general and health services in particular.Keywords: Law Enforcement; Traffic Accidents; Maxillofacial Injuries; Injury Severity Score; Oman.

Objectives: This study aimed to identify the main barriers that prevent patients with diabetes mellitus from accepting insulin therapy. Methods: This cross-sectional study was conducted from May to December 2019. Convenience sampling was used to recruit participants from three diabetes clinics in Muscat, Oman. Eligible participants were interviewed in person based on a pre-prepared questionnaire. The questionnaire, which was administered in Arabic, includes demographic data and 19 specific items on barriers to insulin therapy. Results: A total of 201 participants (response rate: 93%) were enrolled in the study. The most common barriers were as follows: concern of frequent blood glucose checking (36.3%), long-term injections (33.8%), side-effects of insulin (29.9%) and weight gain (29.4%). Needle phobia was considered a barrier by only 9% of the participants. Overall, 125 (62.2%) participants were willing to initiate insulin therapy despite the presence of these barriers and only 20 (10%) of them were influenced by these barriers to such a degree that they rejected the insulin therapy. Conclusion: The majority of participants had no identifiable reasons to stop them from accepting insulin therapy. Effective strategies should be developed to address each of the main barriers to improve acceptance and adherence to insulin therapy.Keywords: Diabetes Mellitus; Insulin; Treatment Refusal; Needles; Phobic Disorders; Hypoglycemia; Weight Gain; Oman.

Chronic recurrent multifocal osteomyelitis (CRMO) is an auto-inflammatory disease characterisedby sterile bone lesions. We report a case of a seven-year-old female patient who presented at a university hospitalin 2010 and 2018 with CRMO. While the most promising results have been observed in patients under treatment with bisphosphonates (BPs), the initial decision to treat the current patient with a dose of zoledronic acid every six months was recalled as the patient developed tonic-clonic seizures immediately following the second dose BP administration. Following recall, the patient maintained a prompt response at follow-up and her disease remained controlled with non-steroidal anti-inflammatory drugs. The current case report speculates a possible relationship between BP use and a possible seizure threshold reduction, thereby emphasising the need for closer monitoring when BPs are used.Keywords: Chronic Recurrent Multifocal Osteomyelitis; Bisphosphonate; Tonic-clonic seizure; Case Report; Tunisia.

Objectives: Remission is the ultimate purpose of treatment in rheumatoid arthritis (RA). However, even when the most stringent composite scores are used, structural damages can occur; hence, ultrasonography (US) appears to be the best way to assess real remission. This study aimed to investigate the validity of different RA remission scores using US as a reference. Methods: An analytic diagnostic study, of 30 RA patients in remission (according to the Disease Activity Score in 28 Joints [DAS28]) and a control group with active RA, was conducted between January and October 2018 at Mongi Slim Hospital in Tunis, Tunisia. Among them, patients in remission were identified according to their Simple Disease Activity Index (SDAI), Clinical Disease Activity Index (CDAI) and the Boolean American College of Rheumatology/European League against Rheumatism activity index (ACR/EULAR) remission scores. The validity of each activity score for remission was calculated by considering the absence of power Doppler (PD) signals as a gold standard. Results: All patients were in remission according to the DAS28, with an average score of 2.03 (1.1–2.6). US examination showed PD signals in 57% of patients. A total of 26 patients were in remission according to the CDAI; a Doppler signal was detected in 58% of those cases. SDAI remission was accomplished in 19 patients, with PD activity in 53% of cases. Of the 14 patients in remission according to the Boolean ACR/EULAR criteria, synovial hyper-vascularisation was found in 64%. Considering true remission as the absence of PD signals, the most sensitive and specific score was the DAS28 (93% and 68%, respectively). Conclusion: Considering remission in RA as the absence of vascularised synovitis, the DAS28 is the most sensitive and most specific score.Keywords: Rheumatoid Arthritis; Ultrasonography; Doppler; Reproducibility of Results; Tunisia.

Wilms’ tumour (nephroblastoma) is the most common abdominal malignancy in children. Extrarenal Wilms' tumour is rare, with limited reports in the literature. We report a two year-old girl who presented to a tertiary care hospital in Muscat, Oman, in 2019 with an abdominal mass. The patient was diagnosed with unilateral ovarian Wilms’ tumour (initially diagnosed by closed biopsy and confirmed later by histopathology study of the excised tumour). This report highlights the unusual location and presentation of Wilms' tumour and presents the medical challenge in both the initial clinical impression and pathological diagnosis. Furthermore, this report details the therapeutic plan and shows the good outcome achieved by using the classic renal Wilms’ tumour therapy protocols.Keywords: Wilms' Tumor; Ovary; Pediatrics; Case Report; Oman.

Objectives: This study aimed to assess parents’ awareness of and perspectives on childhood refractive errors in Saudi Arabia. Methods: This cross-sectional study was conducted between October and November 2020 in public schools across different regions of Saudi Arabia. Data were collected using an online questionnaire that assessed parents’ knowledge and perceptions of childhood refractive errors and spectacle wear. Results: A total of 358 parents from different regions of Saudi Arabia completed the questionnaire and were obtained in this study (response rate: 85%). Approximately one third (38.3%) of the parents reported that they had never heard of refractive errors and one-third (33.8%) mentioned that uncorrected refractive errors did not lead to visual impairment. The majority (74.0%) cited using eyeglasses as an effective way to manage childhood refractive errors. Two-thirds (63.7%) stated that they did not receive any information about paediatric eye care. Better knowledge was associated with a higher educational level, female gender and older age (P <0.001, P = 0.008 and P = 0.024, respectively). Regarding parents’ perspective on spectacle wear, 13.7% felt that using eyeglasses affected their children’s chances of learning. However, 82.7% supposed that eyeglasses did not affect their children’s employment opportunities. Almost a quarter of the sample (22.1%) thought that using eyeglasses would decrease the eye’s power, resulting in childhood visual impairment. Conclusion: The level of awareness and perceptions regarding childhood refractive errors and spectacle wear was low among parents. Therefore, a policy is needed to improve the awareness and perception of the key stakeholders in this issue, including parents and teachers.Keywords: Visual Impairment; Spectacles; Parents; Attitudes; Refractive Error; Myopia; Psychological Effect; Vision Care; Eyeglasses.

Objectives: This study aimed to explore undergraduate nursing students’ perception and attitude towards the Objective Structured Clinical Examination (OSCE). Methods: This cross-sectional descriptive study was conducted between April–May 2020 among undergraduate nursing students at the College of Nursing at Sultan Qaboos University, Muscat, Oman. Two self-administered questionnaires were utilised to obtain data on students’ perception and attitude towards OSCE. Students’ feedback on OSCE was collected using open-ended questions about OSCE strengths, weaknesses and recommendations for improvement. Survey responses were based on a five-point ordinal scale, ranging from strongly disagree to strongly agree. Students’ feedback on OSCE was analysed as descriptive data by identifying the common themes and categorising them in groups. Results: A total of 160 students completed the study questionnaires. Most did not find the atmosphere of OSCE to be pleasant (66.3%) and preferred more modes of practical examination (40.6%). Moreover, 64.4% believed the time limitation to be inadequate. The data depict that 33.1% of the examinees deemed the OSCE more stressful than the full practical examination. In addition, a few students confirmed that the OSCE improved their communication skills and confidence in nursing skills. Conclusion: The findings of this study appear alarming in regard to students’ perception regarding the overall process and validity of OSCE as an assessment method. Nursing educators must consider further evaluation and improvement of the OSCE in order to improve students’ acceptance and appreciation of OSCE as an important form of clinical learning and assessment. Keywords: Clinical Competence; Nursing Education; Baccalaureate; Evaluation; Attitude; Nursing Students; Practical Nursing; Oman.

Spontaneous rupture of a metastatic liver tumour is rarely documented in the literature when compared to hepatocellular carcinoma and other liver lesions, especially from a lung primary. We report a case of ruptured liver metastasis from an adenocarcinoma of the lung mimicking ruptured liver abscess, challenging the clinical diagnosis. A 42-year-female patient presented to a tertiary care institute in 2020 with complaints of abdominal pain, breathlessness and fever. On examination, the patient was tachypnoeic with a right hypochondriac mass. A contrast-enhanced computed tomography of abdomen and thorax revealed an ill-defined heterogeneously enhancing lesion in the liver with a communicating subcapsular collection and hypo-enhancing lesions in the left lobe and heterogeneously enhancing lesion in the left lung. Adenocarcinoma of the lung with hepatic metastasis was confirmed with a core needle biopsy. The patient was managed conservatively with intravenous antibiotics, intercostal drainage tube and gefitinib. However, despite best efforts, the patient succumbed to the disease. Keywords: Metastasis; Spontaneous Rupture; Hepatocellular Carcinoma; Thyroid Transcription Factor; Liver Abscess; Case Report; India.

Ameloblastoma and adenomatoid odontogenic tumors are the most common odontogenic neoplasms. However, hybrid variant of the two lesions, Adenoid Ameloblastoma with dentinoid is extremely rare. The lesion comprises of characteristic histopathological features of Ameloblastoma and Adenomatoid odontogenic tumor and also shares certain clinical characteristics with either of the entities. Adenoid Ameloblastoma with dentinoid may be considered at the more aggressive end of spectrum of benign odontogenic neoplasms. Owing to the frequent tendency of lesion to be underdiagnosed, careful histopathological screening of submitted biopsies is warranted. With the increase in number of reported cases in the recent years, it is likely to be included as a separate entity in the upcoming WHO classification. The present systematic review aims at collectively presenting the demographic, clinical, radiographic and histopathological features, treatment performed along with its outcome for all the cases of Adenoid Ameloblastoma with dentinoid reported in scientific literature till date.
 Keywords: Hybrid Odontogenic Tumor; Adenomatoid Odontogenic Tumor; Adenoameloblastoma; dentinoameloblastoma; Immunohistochemistry

Objectives: Less than a quarter of Omani infants < 6 months are exclusively breastfed. Therefore, this study aimed to examine individual barriers and supports to exclusive breastfeeding and identify potential policy and programmatic interventions in Oman. Methods: A cross-sectional Barrier Analysis was carried out among a purposive sample of Omani women - 45 “Doers” (who exclusively breastfed their infants) and 52 “Non-Doers” (who do not) – who were selected and interviewed by trained enumerators in health clinics in various parts of the country. A barrier analysis tool, adapted for the Omani context, covered 12 common determinants of behavior adoption using open-ended questions regarding participants’ perceptions about exclusive breastfeeding including positive and negative consequences, self-efficacy and social norms. Qualitative analysis involved coding and tabulating as well as thematic analysis. Results: Mothers report that motivation for exclusive breastfeeding include the perception that it leads to healthier children, is easy, readily available and therefore convenient and that mothers report an elevated level of family support for breastfeeding. Barriers included perceived milk insufficiency and mother’s employment. Conclusion: To achieve the 2025 exclusive breastfeeding target of 50%, public health action should focus on emphasizing the benefits and convenience of exclusive breastfeeding and building women’s confidence in their ability to produce sufficient milk. These efforts will require increasing the knowledge and skills of community and health care workers and establishing monitoring mechanisms. Expanding paid maternity leave and supportive workplace policies are necessary to encourage working women to exclusively breastfeed.
 Keywords: Breastfeeding, Breastfeeding barriers, Breastfeeding support, Exclusive breastfeeding, Nutrition policy, Oman, Health Promotion.

Pakistan has a burn mortality rate of 6.5%, with a considerable percentage of survivors suffering from long-term complications due to lack of rehabilitation. The aim of this review is to outline the important physiological and psychological after-effects of burn injuries. Relevant articles were included by conducting a comprehensive search between 20th March and 25th May 2020.  Psychological complications of burns include depression, post-traumatic stress disorder, anxiety, sleep disturbance, phobias, guilt, suicidal thoughts, and personality changes. Physiological complications include scarring, contractures, pain, muscle wasting, and hypothermia. Other complications include infections. The review revealed a scarcity of literature regarding the prevalence and impact of long-term complications in post-burn patients. Our findings include a lack of rehabilitative services and high rate of post-burn complications in Pakistan. Rehabilitation of burn patients should be a continuation of active treatment and should begin from the day of admission, to reduce the morbidity and improve the quality of life of burn patients.
 Keywords: Burns; physiology; psychology; rehabilitation; quality of life.

Domestic violence (DV) against infertile women is an important health concern, which affect their well-being. This systematic review and meta-analysis investigated the prevalence of DV against infertile women. The study was done based on the preferred reporting items for systematic reviews and meta-analysis (PRISMA) on international electronic databases. Inclusion criteria were cross-sectional studies published in English and Persian journals, which investigated the prevalence of DV against infertile women up to May 2020. Out of 634 studies, 26 cross-sectional studies were systematically reviewed, from which 16 studies were included in the meta-analysis. Violence varied widely in infertile women, from 14.987 to 88.918%. The results of meta-analysis showed that the prevalence of violence was equal to 47.163% (95% CI 34.660 to 59.850%). Psychological and emotional violence was the most common types of violence. Considering high rate of DV, policymakers are recommended to address the problem by providing supportive cares including educational and counseling services.
 Keywords: Women's Infertility, Violence, Domestic Violence, Intimate Partner Violence

Objectives: This study aimed to identify the prevalence of clinically significant depression among adult Omani patients with type 2 diabetes mellitus (T2DM) and explore potential associations with sociodemographic and clinical variables in this population. Methods: This descriptive cross-sectional study was conducted between August 2018 and September 2019 and included 427 Omani T2DM patients from 12 randomly selected government health centres in Muscat, Oman. An Arabic version of the validated Patient Health Questionnaire-9 was administered to the participants via face-to-face interviews to determine the prevalence of depression. Results: A total of 111 T2DM patients (response rate: 100%) had depression (26%). The presence of a personal history of depression was the only variable significantly associated with depression (P <0.001). Other sociodemographic and clinical factors including age, gender, duration of diabetes, glycated haemoglobin level, mode of diabetes treatment or the presence of diabetes-related complications such as cardiac complications, renal impairment, retinopathy, neuropathy and erectile dysfunction, were not associated with depression, (P >0.050 each). Conclusion: This study revealed a high prevalence of depression among urban Omani adults with T2DM and a personal history of depression, which was found to be significantly associated with depression. Therefore, early screening for depressive symptoms is necessary to improve the quality of life of diabetic patients in this region. Keywords: Depression; Type 2 Diabetes Mellitus; Prevalence; Public Health; Primary Healthcare; Oman.