Temporomandibular joint disorders in patients with skeletal discrepancies

Chapter I: Literature review on the Temporomandibular joint (TMJ) and Temporomandibular disorders (TMD) Chapter II: Systematic review of TMD in orthognathic patients This review was conducted to investigate the prevalence of temporomandibular joint dysfunction (TMD) in orthognathic patients and to determine the effect of the surgical intervention on the status of the temporomandibular joint (TMJ). A methodological process was applied for study selection, data management and quality assessment and meta-analyses were conducted where appropriate. This review identified 53 papers for inclusion and there was heterogeneity in the diagnosis and classification of TMD between the studies. Patients undergoing orthognathic treatment for the correction of dentofacial deformity and suffering from TMD appeared more likely to see an improvement in their signs and symptoms than deterioration, particularly with respect to pain related symptoms. This information should be given to prospective patients during the consent process, but it should be stressed that no guarantees can be made. Chapter III: TMD in orthognathic patients and a control group with no skeletal discrepancies Sixty eight orthognathic patients and 72 control subjects (with no anterior-posterior, vertical or transverse discrepancies) were recruited for this section of the PhD. Self-reported symptoms and clinical signs of TMD were recorded and compared between the two groups. A significant difference in TMD prevalence was observed between the controls (27.8%) and patients (44.1%), with the patients being more susceptible to TMD. However, although orthognathic patients appear more likely to suffer from TMD, whether treatment improves their TMJ condition is highly questionable. This issue should be highlighted in any informed consent process. Chapter IV: A longitudinal study of TMD in orthognathic patients Twenty orthognathic patients were followed longitudinally throughout treatment to establish whether TMD signs and symptoms altered during the course of treatment. Although no significant differences were found when comparing the pre-treatment (T1) findings with those prior to surgery (T2), sufficient individual changes in TMD signs and symptoms were observed to question the suitability of the "prior to surgery" time point as a baseline for comparisons in future studies. When comparing pre (T1) and post-treatment (T3) TMD changes, no significant differences were observed. This study supports the theory that TMD is a dynamic condition and signs and symptoms are likely to fluctuate throughout treatment. However, the small sample size in this study was clearly a limiting factor. Chapter V: TMJ information course: Comparison of the instructional efficacy of an internet-based TMJ tutorial with a traditional face-to-face seminar A TMJ tutorial was developed on a virtual learning environment (VLE) to enable students to enhance their examination and diagnostic skills and a randomised cross-over trial was then conducted. Thirty postgraduate students were recruited as participants and the success of this mode of teaching was compared with a conventional face-to-face seminar. This study found that both modes of teaching were equally effective in delivering information to students but teaching the topic twice enhanced the retention of knowledge. In addition the students reported positive perceptions of VLE learning and the feedback for this mode of teaching was comparable with traditional methods of teaching

Systemic Lupus Erythematosus with Severe Nephritis That Mimicked Henoch-Schoenlein Purpura

Introduction: Systemic lupus erythematosus (SLE) belongs to a family of related autoimmune rheumatic disorders that are capable of affecting multiple organs, and they are all associated with a variety of autoantibodies. Henoch Schoenlein purpura (HSP) is a sort of systemic vasculitis that is not associated with auto-antibodies and can affect different organs including the kidneys. Case report: A 12 year-old girl presented with abdominal pain, low grade fever, swollen and tender feet and left hand, skin rash on the lower extremities, and high blood pressure. Initial laboratory tests revealed severe proteinuria, microscopic hematuria and low C3 level. Renal biopsy showed diffuse proliferative glomerulonephritis with IgA, fibrinogen and C3 deposits. The case was accordingly diagnosed as HSP with severe IgA nephropathy. Treatment was started with mycophenolate mofetil (MMF) and pulse methylprednisolone followed by prednisolone. The patient improved and treatment was discontinued after 5.5 months. One month after withdrawal of her medications, the patient presented again with serositis and recurrent proteinuria. Both antinuclear antibodies (ANA) and anti dsDNA were positive. At this point she was diagnosed to have SLE disease and immunosuppressive treatment was restarted. Following this, symptoms disappeared, proteinuria regressed and anti-dsDNA titer dropped. Conclusion: This case presented with features of HSP and was later-on diagnosed to have SLE. This kind of clinical overlapping has not been reported in the literature to the best of our knowledge.Keywords: Henoch-Schoenlein Purpura; Nephritis; Systemic Lupus Erythematosu

Cryptographic Schemes based on Elliptic Curve Pairings

This thesis introduces the concept of certificateless public key cryptography (CLPKC). Elliptic curve pairings are then used to make concrete CL-PKC schemes and are also used to make other efficient key agreement protocols. CL-PKC can be viewed as a model for the use of public key cryptography that is intermediate between traditional certificated PKC and ID-PKC. This is because, in contrast to traditional public key cryptographic systems, CL-PKC does not require the use of certificates to guarantee the authenticity of public keys. It does rely on the use of a trusted authority (TA) who is in possession of a master key. In this respect, CL-PKC is similar to identity-based public key cryptography (ID-PKC). On the other hand, CL-PKC does not suffer from the key escrow property that is inherent in ID-PKC. Applications for the new infrastructure are discussed. We exemplify how CL-PKC schemes can be constructed by constructing several certificateless public key encryption schemes and modifying other existing ID based schemes. The lack of certificates and the desire to prove the schemes secure in the presence of an adversary who has access to the master key or has the ability to replace public keys, requires the careful development of new security models. We prove that some of our schemes are secure, provided that the Bilinear Diffie-Hellman Problem is hard. We then examine Joux’s protocol, which is a one round, tripartite key agreement protocol that is more bandwidth-efficient than any previous three-party key agreement protocol, however, Joux’s protocol is insecure, suffering from a simple man-in-the-middle attack. We show how to make Joux’s protocol secure, presenting several tripartite, authenticated key agreement protocols that still require only one round of communication. The security properties of the new protocols are studied. Applications for the protocols are also discussed

Utilization Pattern of Vancomycin in a University Teaching Hospital in Oman: Comparison with International Guidelines

Purpose: To assess the prescribing and utilization pattern of vancomycin in Sultan Qaboos University Hospital (SQUH) in Oman.Methods: A retrospective study that included in-patients at SQUH who had used vancomycin from January 1 2009 to December 31 2009 was conducted to determine the utilization patterns of the drug vis a vis to the Hospital Infection Control Practices Advisory Committee (HICPAC) guidelines and the North American Therapeutic Drug Monitoring Consensus (NATDMC) recommendations. Information regarding patient characteristics and vancomycin therapy were obtained from patients’ medical records.Statistical analyses were performed using descriptive statistics.Results: Out of 478 prescriptions for 365 patients, 79.1 % were considered inappropriate, based on HICPAC guidelines. This was mainly due to the continuous use of vancomycin following negative microbiological cultures for â-lactam-resistant Gram-positive microorganisms. Vancomycin wasprescribed mostly for treatment of sepsis (27.1 %), followed by prophylaxis against various clinical conditions (20.8 %). Therapeutic drug monitoring (TDM) practices at SQUH did not comply with NATDMC recommendations on the use of trough concentration in the specified range as a guide for monitoring of therapy.Conclusion: Irrational use of vancomycin was recorded in this study. The need for a restrictive policy and a revision of the current TDM in the setting are recommended..Keywords: Vancomycin, Drug utilization, Therapeutic drug monitoring, Infectio

Comparative analysis of maternal and neonatal outcomes between elective and emergency caesarean section at a single tertiary hospital: a retrospective COHORT study

Background: Caesarean section rates have been increasing worldwide despite it’s known complications. The aim of this study was to determine maternal and neonatal complications related to caesarean section at Sultan Qaboos University Hospital (SQUH) and to compare the outcomes between emergency and elective caesarean sections. Methods: This retrospective cohort study was conducted in the department of obstetrics and gynecology at SQUH from 1st January 2016 to 31st December 2016. This comparative study involved 300 women who underwent caesarean section, 150 in elective caesarean section group and 150 in emergency caesarean section group. Results: The mean maternal age was 29.66 (±4.96) and 33.22 (±4.63) years in the elective and emergency caesarean section groups respectively (p=001). The main risk factor for both the groups was maternal diabetes and the most common indication was previous caesarean section. Hypotension related anesthetic complication was noted more in elective caesarean section (15.3%) than in emergency caesarean section group (4.0%) with p value=0.002. Post-partum fever was seen in 12.0% of women in emergency group as compared to 4% in elective group (p=0.019). Anemia was observed in 79.2% and 65.3% in emergency and elective groups respectively (p=0.011). Respiratory distress syndrome and transient tachypnea of the newborn were the main neonatal complications in both groups. Conclusions: There was no significant difference between emergency and elective caesarean section related maternal and neonatal complications except for transient intraoperative hypotension, maternal postoperative febrile morbidity and anemia. Future prospective studies including larger sample size and multiple centers is recommended.

Paediatric Restrictive Cardiomyopathy - Diagnosis and Challenges: A report of two cases

Restrictive cardiomyopathy is one of the rarest forms of cardiomyopathies in pediatric patients characterized by impaired myocardial relaxation or compliance with restricted ventricular filling, leading to a reduced diastolic volume with a preserved systolic function. We report two cases – a 5-year-old boy who presented with abdominal distension and palpitation with family history of similar complaints but no definite genetic diagnosis as yet, and a 5-year-old girl who presented with chronic cough and shortness of breath. Both cases were diagnosed in Sultan Qaboos University Hospital in 2019 and are managed supportively with regular outpatient follow-up. This is the first series of reported cases of pediatric restrictive cardiomyopathy from Oman. Keywords: restrictive cardiomyopathy, cardiomyopathy in children, heart failure in children

Managing the Adverse Events Associated with the Combination Pembrolizumab and Lenvatinib Therapy in Endometrial Cancer

Endometrial cancer (EC) is the most common gynecological cancer. The combination of lenvatinib plus pembrolizumab has exhibited efficacy as the second line treatment for advanced EC, with a significant benefit in terms of progression free survival (PFS) and overall survival (OS), but the adverse effects (AE) profile is complex. AEs associated with the treatment may represent a limitation to this combination. Here, we report the case of a 38-year-old lady diagnosed with stage IV EC elsewhere, whose disease progressed after the first line of treatment, and was referred to our center in 2021. We treated her with the combination of lenvatinib and pembrolizumab. During the course of the treatment. she developed hand- foot syndrome (HFS) grade III, and hypothyroidism grade II. The AEs were managed with supportive medications, dose interruptions, dose reductions, and multidisciplinary care, which allowed us to continue the treatment. The patient achieved a good partial response, and an ongoing PFS of more than 12 months. Keywords: cancer, endometrial, lenvatinib, pembrolizumab, adverse drug events, hand foot syndrome, hypothyroidism, Oman

Impact of work from home on work-life balance: Mediating effects of work-family conflict and work motivation

In the aftermath of the recent pandemic, organizations around the world had the opportunity to assess the benefits and drawbacks of allowing the bulk of their employees to work from home (WFH). As a result, many organizations realize that by using technology, it is possible to shift a significant percentage of their workforce to permanently function from any location without being physically present at a designated workplace. Although the economic benefits for organizations that allow WFH seem to be clear, how factors related to perceptions of employees such as their work motivation (WM) and their work-life balance (WLB) caused by blurred boundaries between work and family at home are not clearly understood. Therefore, the primary goal of this study is to determine how WFH impacts WLB through the possible mediating effects of work-family conflict (WFC) and WM. A cross-sectional survey instrument was developed using Likert type measurement scales that were adopted from top-tier journals. The data was collected through convenient sampling from 249 managerial and non-managerial employees in Omani business organizations. The relationships were tested through structural equation modeling. The results indicate that WFH increases WFC and WM, while the relationship between WFH and WLB is mediated by WFC, but not by WM. The findings of this study have implications for both theory and practice

Influence of Organisational-Level Factors on Delayed Door-to-Balloon Time among Patients with ST-Elevation Myocardial Infarction

Objective: To estimate the door-to-balloon (DTB) time and determine the organisational-level factors that influence delayed DTB times among patients with ST-elevation myocardial infarction in the Sultanate of Oman. Methods: A cross-sectional retrospective study was conducted. All patients who presented to the emergency department at two public hospitals and underwent primary percutaneous interventions during the period of two years were included. Results: The sample included 426 patients. The median door-to-balloon time was 142 minutes. The result of bivariate logistic regression showed that patients who presented to the emergency department with atypical symptoms were three times more likely to have a delayed DTB time compared with patients presenting with typical symptoms (OR = 3.003, 95% CI: 1.409–6.400, p = .004). In addition, patients who presented during off-hours were two times more likely to have a delayed DTB time compared with patients who presented during regular working hours (OR = 2.291, 95% CI: 1.284–4.087, p = .005). Conclusion: To meet the door-to-balloon time recommendation, it is important to ensure that there is adequate staffing during both regular and irregular working hours. Results from this study can be used as a baseline for future studies and inform strategies for improving the quality of care. Keywords: Acute Myocardial Infarction; Clinical Management; Door-to-balloon Time; Emergency Care Systems; Staffing and Scheduling; Oman

Estimated Glomerular Filtration Rate (eGFR): A Serum Creatinine-Based Test for the Detection of Chronic Kidney Disease and its Impact on Clinical Practice

Abstract Chronic kidney disease (CKD) is an important epidemic and public health problem that is associated with a significant risk for vascular disease and early cardiovascular mortality as well as progression of kidney disease. Currently it is classified into five stages based on the glomerular filtration rate (GFR) as recommended by many professional guidelines. Radiolabelled methods for measuring GFR are accurate but not practical and can be used only on a very limited scale while the traditional methods require timed urine collection with its drawback of inaccuracy, cumbersomeness and inconvenience for the patients. However, the development of formula-based calculation of estimated GFR (eGFR) has offered a very practical and easy approach for converting serum creatinine value into GFR result taking into consideration patient's age, sex, ethnicity and weight (depending on equation type). The commonly used equations include Cockraft and Gault (1976), Modification of Diet in Renal Disease (MDRD) (1999) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) (2009). It is the implementation of these equations particularly the MDRD that has raised the medical awareness in the diagnosis and management of CKD and its adoption by many guidelines in North America and Europe. The impact and pitfalls of each of these equations in the screening, diagnosis and management of patients with CKD are presented and discussed in this review