Reflections on the Academic Accreditation of the MD Programme of the College of Medicine & Health Sciences, Sultan Qaboos University, Oman

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Twelve-month observational study of children with cancer in 41 countries during the COVID-19 pandemic

Introduction Childhood cancer is a leading cause of death. It is unclear whether the COVID-19 pandemic has impacted childhood cancer mortality. In this study, we aimed to establish all-cause mortality rates for childhood cancers during the COVID-19 pandemic and determine the factors associated with mortality. Methods Prospective cohort study in 109 institutions in 41 countries. Inclusion criteria: children <18 years who were newly diagnosed with or undergoing active treatment for acute lymphoblastic leukaemia, non-Hodgkin's lymphoma, Hodgkin lymphoma, retinoblastoma, Wilms tumour, glioma, osteosarcoma, Ewing sarcoma, rhabdomyosarcoma, medulloblastoma and neuroblastoma. Of 2327 cases, 2118 patients were included in the study. The primary outcome measure was all-cause mortality at 30 days, 90 days and 12 months. Results All-cause mortality was 3.4% (n=71/2084) at 30-day follow-up, 5.7% (n=113/1969) at 90-day follow-up and 13.0% (n=206/1581) at 12-month follow-up. The median time from diagnosis to multidisciplinary team (MDT) plan was longest in low-income countries (7 days, IQR 3-11). Multivariable analysis revealed several factors associated with 12-month mortality, including low-income (OR 6.99 (95% CI 2.49 to 19.68); p<0.001), lower middle income (OR 3.32 (95% CI 1.96 to 5.61); p<0.001) and upper middle income (OR 3.49 (95% CI 2.02 to 6.03); p<0.001) country status and chemotherapy (OR 0.55 (95% CI 0.36 to 0.86); p=0.008) and immunotherapy (OR 0.27 (95% CI 0.08 to 0.91); p=0.035) within 30 days from MDT plan. Multivariable analysis revealed laboratory-confirmed SARS-CoV-2 infection (OR 5.33 (95% CI 1.19 to 23.84); p=0.029) was associated with 30-day mortality. Conclusions Children with cancer are more likely to die within 30 days if infected with SARS-CoV-2. However, timely treatment reduced odds of death. This report provides crucial information to balance the benefits of providing anticancer therapy against the risks of SARS-CoV-2 infection in children with cancer

Essential Medicines at the National Level : The Global Asthma Network's Essential Asthma Medicines Survey 2014

Patients with asthma need uninterrupted supplies of affordable, quality-assured essential medicines. However, access in many low- and middle-income countries (LMICs) is limited. The World Health Organization (WHO) Non-Communicable Disease (NCD) Global Action Plan 2013-2020 sets an 80% target for essential NCD medicines' availability. Poor access is partly due to medicines not being included on the national Essential Medicines Lists (EML) and/or National Reimbursement Lists (NRL) which guide the provision of free/subsidised medicines. We aimed to determine how many countries have essential asthma medicines on their EML and NRL, which essential asthma medicines, and whether surveys might monitor progress. A cross-sectional survey in 2013-2015 of Global Asthma Network principal investigators generated 111/120 (93%) responses41 high-income countries and territories (HICs); 70 LMICs. Patients in HICs with NRL are best served (91% HICs included ICS (inhaled corticosteroids) and salbutamol). Patients in the 24 (34%) LMICs with no NRL and the 14 (30%) LMICs with an NRL, however no ICS are likely to have very poor access to affordable, quality-assured ICS. Many LMICs do not have essential asthma medicines on their EML or NRL. Technical guidance and advocacy for policy change is required. Improving access to these medicines will improve the health system's capacity to address NCDs.Peer reviewe

Pathophysiology of obstructive sleep apnoea syndrome: a review

Sleep apnoea syndrome is a common disorder and a major health hazard that affects many body systems. It is particularly associated with increased cardiovascular and cerebrovascular morbidity and mortality. Among its other manifestations include increased daytime somnolence, fatigue, depression, reduced sexual libido and endocrine dysfunction. The main risk factors are obesity, male gender, middle age and heredity. Despite being a recognised major health problem in the industrialised countries, this condition has not yet received its due importance in the developing world. This review introduces breathing disorders during sleep and discusses the pathophysiological features of obstructive sleep apnoea syndrome in the light of the currently available literature and the authors’ own clinical experience

Screening of Patients with Snoring and Obstructive Sleep Apnoea using Heart Rate Variability Indices

Objective: Snoring and obstructive sleep apnea (OSA) are common disorders. Snoring associated with excessive daytime sleepiness is the most prevalent symptoms of OSA. Heart rate variability (HRV) is altered in patients with OSA and the degree of alteration may be linked to the severity of OSA. Alterations in HRV in 24 hour tachograms have recently been used in screening OSA patients. Autonomic components causing HRV can be reliably studied using spectral analysis techniques involving fast Fourier transformation (FFT). Methods: Twenty-three subjects, 13 with severe OSA and 10 controls matched for age and body mass index, were selected from patients who had undergone polysomnography (PSG) for snoring at Sultan Qaboos University Hospital, Oman. A 24- hour electrocardiogram (ECG) Holter recording was done at home, starting at 10am. Spectral analysis of ECG from sleep Holter and PSG recordings was analysed using fast Fourier transformation (FFT). Results: The ECG RR intervals of snorers with OSA were significantly shorter than in snorers without OSA (p<0.01). The low frequency (LF) spectral densities of HRV from polysomnography and Holter were significantly higher in OSA patients than in snorers, (p< 0.0001). The power spectral density of the high frequency bands was similar in the two groups. The overnight ECG Holter accurately identified all 13 snorers with severe OSA. Conclusion: The spectral power of the LF band obtained using FFT of sleep HRV from Holter tachograms may be a useful and cost effective test in identifying snorers with severe OSA.

The alveolar-capillary membrane diffusing capacity and the pulmonary capillary blood volume in heart transplant candidates

OBJECTIVES—To determine the mechanism of impairment of pulmonary transfer factor for carbon monoxide (TL(CO)) in heart transplant candidates, as this is the most common lung function abnormality.
SETTING—Regional cardiopulmonary transplant centre.
METHODS—TL(CO) and its components (the diffusing capacity of the alveolar-capillary membrane (D(M)) and the pulmonary capillary blood volume (V(C))) were measured using the Roughton and Forster method and the single breath technique in 38 patients with severe chronic heart failure awaiting heart transplantation (mean age 51 years, range 19 to 61; mean left ventricular ejection fraction 12.8%). Results were compared with data from 26 normal subjects (mean age 47 years, range 27 to 62).
RESULTS—Mean per cent predicted TL(CO), D(M), and V(C) were significantly reduced in patients (69.9%, 81.4%, and 80.2% of predicted, respectively) compared with controls (97.7%, 100.1%, and 102.3% of predicted, respectively, p < 0.001). The relative contribution of the two components of TL(CO) in patients was similar to that of normal subjects, with each component accounting for approximately 50% of the total resistance to diffusion (1/TL(CO)).
CONCLUSIONS—TL(CO) impairment in patients with severe chronic heart failure awaiting heart transplantation results from a proportionate reduction in both D(M) and V(C), suggesting a significant disturbance of the pulmonary vascular bed.


Keywords: heart failure; diffusing capacity; pulmonary transfer factor; pulmonary capillary blood volum

Assessment of aerobic fitness and its correlates in Omani adolescents using the 20-metre shuttle run test : A Pilot Study

Objective: To assess aerobic fitness in male and female adolescents using the multistage 20-metre shuttle run test and correlate it with selected fitness variables. Method: The subjects comprised 83 girls and 64 boys aged 15-16 years, randomly selected from two segregated government schools in Muscat. After the pupils filled in a short questionnaire on their personal leisure time activities of the preceding week, their heights and weights were measured. Aerobic fitness was assessed by estimating each pupil’s minimal oxygen uptake levels (VO2max) using the multistage 20-metre shuttle running test (20-MST). Results: Boys spent more time than girls on leisure physical activities, television, computer and video games and the Internet. The estimated VO2max in both boys and girls showed high correlation with their weekly physical activities. The time spent on television and computer negatively correlated with VO2max in girls but not in boys. Girls had higher body mass index (BMI) and less VO2max compared to boys; BMI showed a negative correlation with VO2max in girls but not in boys. Conclusion: Aerobic fitness in this sample was higher in boys than in girls and was strongly influenced by weekly physical activities in both genders. The 20-MST has proved a simple and inexpensive field test for aerobic fitness that could be implemented on a wide scale. Key words: shuttle run test, aerobic fitness, leisure time activities, VO2max, adolescent, Oma

Cardiovascular regulation in the period preceding vasovagal syncope in conscious humans

To study cardiovascular control in the period leading to vasovagal syncope we monitored beat-to-beat blood pressure, heart rate (HR) and forearm blood flow in 14 patients with posturally related syncope, from supine through to tilt-induced pre-syncope. Signals of arterial blood pressure (BP) from a Finapres photoplethysmograph and an electrocardiograph (ECG) were fed into a NeuroScope system for continuous analysis. Non-invasive indices of cardiac vagal tone (CVT) and cardiac sensitivity to baroreflex (CSB) were derived on a beat-to-beat basis from these data. Brachial vascular resistance (VR) was assessed intermittently from brachial blood flow velocity (Doppler ultrasound) divided by mean arterial pressure (MAP). Patients underwent a progressive orthostatic stress test, which continued to pre-syncope and consisted of 20 min head-up tilt (HUT) at 60 deg, 10 min combined HUT and lower body suction (LBNP) at -20 mmHg followed by LBNP at -40 mmHg. Pre-syncope was defined as a fall in BP to below 80 mmHg systolic accompanied by symptoms. Baseline supine values were: MAP (means ± S.E.M.) 84.9 ± 3.2 mmHg; HR, 63.9 ± 3.2 beats min-1; CVT, 10.8 ± 2.6 (arbitrary units) and CSB, 8.2 ± 1.6 ms mmHg-1. HUT alone provoked pre-syncope in 30 % of the patients whilst the remaining 70 % required LBNP. The cardiovascular responses leading to pre-syncope can be described in four phases. Phase 1, full compensation: where VR increased by 70.9 ± 0.9 %, MAP was 89.2 ± 3.8 mmHg and HR was 74.8 ± 3.2 beats min-1 but CVT decreased to 3.5 ± 0.5 units and CSB to 2.7 ± 0.4 ms mmHg-1. Phase 2, tachycardia: a progressive increase in heart rate peaking at 104.2 ± 5.1 beats min-1. Phase 3, instability: characterised by oscillations in BP and also often in HR; CVT and CSB also decreased to their lowest levels. Phase 4, pre-syncope: characterised by sudden decreases in arterial blood pressure and heart rate associated with intensification of the symptoms of pre-syncope. This study has given a clearer picture of the cardiovascular events leading up to pre-syncope. However, the mechanisms behind what causes a fully compensated system suddenly to become unstable remain unknown