Prevalence of Nephrotoxicity in HIV Patients Treated with Tenofovir Disoproxil Fumarate: A Single-center Observational Study

Objectives: Tenofovir disoproxil fumarate (TDF) has been reported to cause nephrotoxicity necessitating cessation in some patients. No information is available on the nephrotoxic effect of TDF in Omani or regional patients with HIV infection. We sought to determine the prevalence of the nephrotoxic effects of TDF in our cohort of Omani patients with HIV and investigate the nephrotoxic effects of other cofactors. Methods: We conducted an observational cohort study on 83 Omani patients currently on TDF-containing antiretroviral therapy. Renal dysfunction was monitored by measuring the serum creatinine estimated glomerular function rate (eGFR), urinary protein creatinine ratio (uPCR), and fractional excretion of phosphate (FEPi). Fisher’s exact test was used to determine any additional nephrotoxic effects of cofactors. Results: The median values for the duration of TDF use, patient age, and body mass index (BMI) at the time of the study were 178 weeks (range = 3–554), 42 years (range = 21–80), and 27 (range = 17.4–42.7), respectively. The median initial CD4 count and viral load were 205 × 106/L (range = 3–1745) and 37 250 copies/mL (range = undetectable–9 523 428), respectively. FEPi was high in two (2.4%) patients, moderate in 26 (31.3%), and low in 55 (66.3%) patients. uPCR was high in 10 (12.0%) patients, moderate in 28 (33.7%), and low in 45 (54.2%) patients. No cofactors added to the nephrotoxicity except hypertension (p = 0.045). Conclusions: Better definitions for TDF-associated toxicity are needed. uPCR is not a very good indicator of TDF-associated tubular dysfunction. Omani patients with HIV on TDF have a 4% prevalence of renal toxicity, but a study with a larger number of patients is required to explore this observation further. Cofactors like duration of TDF use, age, BMI, gender, diabetes mellitus, and use of protease inhibitors did not have an impact on the severity of FEPi and uPCR

Complicated Subacute Bacterial Endocarditis in a Patient with Ventricular Septal Defect

Infective endocarditis (IE) is an uncommon but life-threatening infection. Despite advances in management, it still causes high morbidity and mortality. We report the case of an 8-year-old girl who presented with a prolonged fever of 2.5 months duration and a history of a small perimembranous ventricular septal defect. She was diagnosed with subacute bacterial endocarditis secondary to Streptococcus mutans. The patient developed a septic pulmonary embolism; however, with the use of appropriate antimicrobial therapy, she made an uneventful recovery. Clinicians should have a high index of suspicion for IE as the possible cause of a prolonged fever, especially in the presence of congenital heart disease (CHD). Currently, IE prophylaxis is not indicated for unrepaired acyanotic CHD. Nevertheless, with the new changes in the guidelines, more prospective studies are needed to investigate the incidence of IE in such lesions, before long-term conclusions can be drawn

Spectrum of AIDS Defining Opportunistic Infections in a Series of 77 Hospitalised HIV-infected Omani Patients

Objectives: Most of the morbidity and mortality in human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) result from opportunistic infections (OIs). Although the spectrum of OIs in HIV infected patients from developing countries has been reported, there is a paucity of data on the natural history, pattern of disease, and survival of hospitalised patients with HIV/AIDS, particularly in Arab countries. The aim of this study was to study retrospectively the spectrum and frequency of various OIs in a cohort of hospitalised HIV-infected Omani patients. Methods: Included in the study were 77 HIV-infected Omani patients admitted to a tertiary care teaching hospital in Muscat, Oman, between January 1999 and December 2008. They were diagnosed on their first admission and hence were not on highly active antiretroviral therapy (HAART) at presentation. The frequency of various clinical and laboratory findings and individual OIs were analysed. Results: In total, 45 patients (58%) had one or more AIDS-defining OIs. Pneumocystis jiroveci pneumonia (PCP) was commonest (25%), followed by cryptococcal meningitis (22%), cytomegalovirus (CMV), retinitis (17%), disseminated tuberculosis (15%), and cerebral toxoplasmosis (12.5%). Only one patient with Mycobacterium avium-intracellulare (MAI) was identified and one patient had disseminated visceral leishmaniasis. The majority of patients (77%) had CD4+ counts <200 cells/µL. Ten patients (22%) died during hospital stays, with five deaths (50%) being caused by disseminated CMV infection. Conclusion: A wide spectrum of OIs is seen in hospitalised HIV-infected patients in Oman. P. jiroveci pneumonia and cryptococcal meningitis were the commonest OIs, while disseminated CMV was the commonest cause of death. We hope these results will advance the knowledge of specialists treating HIV in Oman and the Gulf region.

Barriers and challenges in adopting Saudi telemedicine network: The perceptions of decision makers of healthcare facilities in Saudi Arabia

Summary Despite emerging evidence about the benefits of telemedicine, there are still many barriers and challenges to its adoption. Its adoption is often cited as a failed project because 75% of them are abandoned or ‘failed outright’ and this percentage increases to 90% in developing countries. The literature has clarified that there is neither one-size-fit-all framework nor best-practice solution for all ICT innovations or for all countries. Barriers and challenges in adopting and implementing one ICT innovation in a given country/organisation may not be similar – not for the same ICT innovation in another country/organisation nor for another ICT innovation in the same country/organisation. To the best of our knowledge, no comprehensive scientific study has investigated these challenges and barriers in all Healthcare Facilities (HCFs) across the Kingdom of Saudi Arabia (KSA). This research, which is undertaken based on the Saudi Telemedicine Network roadmap and in collaboration with the Saudi Ministry of Health (MOH), is aimed at identifying the principle predictive challenges and barriers in the context of the KSA, and understanding the perspective of the decision makers of each HCF type, sector, and location. Three theories are used to underpin this research: the Unified Theory of Acceptance and Use of Technology (UTAUT), the Technology–Organisation–Environment (TOE) theoretical framework, and the Evaluating Telemedicine Systems Success Model (ETSSM). This study applies a three-sequential-phase approach by using three mixed methods (i.e., literature review, interviews, and questionnaires) in order to utilise the source triangulation and the data comparison analysis technique. The findings of this study show that the top three influential barriers to adopt and implement telemedicine by the HCF decision makers are: (i) the availability of adequate sustainable financial support to implement, operate, and maintain the telemedicine system, (ii) ensuring conformity of telemedicine services with core mission, vision, needs and constraints of the HCF, and (iii) the reimbursement for telemedicine services. Abbreviations HCFs, Healthcare Facilities; STN, Saudi Telemedicine Network; KSA, Kingdom of Saudi Arabia; TOE, Technology–Organisation–Environment; UTAUT, Unified Theory of Acceptance and Use of Technology; MOH, Saudi Ministry of Health; PHCs, Primary Healthcare Centres; OTN, Ontario Telemedicine Network; CPG, Clinical Practice Guidelines; ETSSM, the Evaluating Telemedicine Systems Success Mode

Severe Pulmonary Involvement in Leptospirosis : Alternate antibiotics and systemic steroids

Pulmonary complications in leptospirosis, though common, are often unrecognized in a non-endemic area. We report here a patient with leptospirosis and severe pulmonary involvement who was treated with meropenem (1 g every 8 hours), moxifloxacin (400 mg once daily), and high doses of corticosteroids. Systemic steroids were continued for 3 months because of persistent pulmonary lesions

Chikungunya Masquerading as Acute Rheumatism in an Omani Traveler

Chikungunya is a mosquito-borne viral disease. It typically presents as an acute febrile illness associated with a varying degree of arthralgia and musculoskeletal sequelae. Cases of chikungunya have been reported from more than 40 countries in several continents. Chikungunya is often reported in travelers returning to non-endemic/epidemic countries. With increasing international travel, it is vital that clinicians in non-endemic areas are made aware of this rapidly spreading infection. Increasing international travel (for social, leisure, and business) between Oman and several chikungunya endemic countries including Pakistan may facilitate the introduction of chikungunya to Oman. We report the first imported case of chikungunya in an Omani traveler with a link to the current outbreak in Pakistan

Identification of Asymptomatic Severe Acute Respiratory Syndrome Coronavirus 2 Infections among Healthcare Workers at Sultan Qaboos University Hospital, Oman

Objectives: This study aimed to describe the incidence and features of asymptomatic COVID-19 infections among HCWs at a tertiary hospital in Oman. Methods: This cross-sectional study was conducted between August 2020 and February 2021 among HCWs with no history of COVID-19 infection using an online questionnaire to collect sociodemographic and clinical data. COVID-19 infection was diagnosed using nasopharyngeal/throat swabs, which were tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Analyses were performed using Chi-squared test, Fisher’s exact test, or univariate ordinary least squares regression, as appropriate. Results: A total of 583 HCWs participated in the study. Most were female (56.6%) and the mean age was 35 ± 8 years . Only 9.6% (95% confidence interval [CI]: 7.3–12.3%) of the HCWs were at high exposure risk as they were directly involved in the care of COVID-19-infected patients. Overall, 4.1% (95% CI: 2.7–6.1%) of the HCWs screened positive for SARS-CoV-2; of these, five (20.8%) developed symptoms within two weeks. The frequency of SARS-CoV-2 positivity among HCWs working in high, intermediate, low, and miscellaneous risk areas was 1.8% (95% CI: <0.1–9.6%), 2.6% (95% CI: <0.1–6.5%), 5.3% (95% CI: 0.3–9.3%), and 4.8% (95% CI: <0.1–69.3%), respectively. Working in high-risk areas was associated with increased compliance with various infection control strategies (P <0.001). Conclusion: There was a greater frequency of SARS-CoV-2 positivity among HCWs working in lower-risk areas, whereas HCWs who worked in high-risk areas were significantly more likely to report increased compliance with infection control strategies. Keywords: SARS-CoV-2; COVID-19 Nucleic Acid Testing; Asymptomatic Infections; Health Personnel; Occupational Exposure; Infection Control; Real-Time Polymerase Chain Reaction; Oman

Drug resistant Mycobacterium tuberculosis in Oman: resistance-conferring mutations and lineage diversity

Background The Sultanate of Oman is country a low TB-incidence, with less than seven cases per 105 population detected in 2020. Recent years have witnessed a persistence in TB cases, with sustained incidence rate among expatriates and limited reduction among Omanis. This pattern suggests transmission from the migrant population. The present study examined the genetic profile and drug resistance-conferring mutations in Mycobacterium tuberculosis collected from Omanis and expatriates to recognise possible causes of disease transmission. Methods We examined M. tuberculosis cultured positive samples, collected from Omanis (n = 1,344) and expatriates (n = 1,203) between 2009 and 2018. These isolates had a known in vitro susceptibility profile to first line anti-TB, Streptomycin (SM), Isoniazid (INH), Rifampicin (RIF), Ethambutol (EMB) and Pyrazinamide (PZA). The diversity of the isolates was assessed by spacer oligo-typing (spoligotyping). Drug resistance-conferring mutations resulted from full-length sequence of nine genes (katG, inhA, ahpc, rpoB, rpsL, rrs, embB, embC, pncA) and their phenotypic relationship were analysed. Results In total, 341/2192 (13.4%), M. tuberculosis strains showed resistance to any drug, comprising mono-resistance (MR) (242, 71%), poly-resistance (PR) (40, 11.7%) and multi-drug resistance (MDR) (59, 17.3%). The overall rate of resistance among Omanis and expatriates was similar; however, MDR and PZAR were significantly higher among Omanis, while INHR was greater among expatriates. Mutations rpsL K43R and rpoB S450L were linked to Streptomycin (SMR) and Rifampicin resistance (RIFR) respectively. Whereas, katG S315T and inhA –C15T/G–17T were associated with Isoniazid resistance (INHR). The resistance patterns (mono-resistant, poly-resistant and MDR) and drug resistance-conferring mutations were found in different spoligo-lineages. rpsL K43R, katG S315T and rpoB S450L mutations were significantly higher in Beijing strains. Conclusions Diverse drug resistant M. tuberculosis strains exist in Oman, with drug resistance-conferring mutations widespread in multiple spoligo-lineages, indicative of a large resistance reservoir. Beijing’s M. tuberculosis lineage was associated with MDR, and multiple drug resistance-conferring mutations, favouring the hypothesis of migration as a possible source of resistant lineages in Oman