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

Documentation of the management of asthma exacerbation in adults by primary health care physicians in a teaching hospital in Oman

Asthma exacerbation is a major cause of morbidity and it is usually an indication of poor control. Appropriate management and documentation of the clinical assessment of an exacerbation, its severity, contributing factors and treatment are all essential components of asthma control. The aim of this study was to assess the documentation of the management of asthma exacerbations by primary care physicians [PCPs]. A retrospective analysis was carried out on patient records from 1 May 2008 to 31 April 2009. We included all acute exacerbation episodes in asthmatic patients aged >/= 14, who received nebulized bronchodilators in the two family medicine clinics attached to Sultan Qaboos University Hospital [SQUH], Oman. A special form was designed to collect PCP's documented management. A total of 67 patients with 100 episodes were treated by 42 PCPs. Documentation of clinical assessment was low for previous admissions [2%], rescue nebulization [25%], duration of symptoms [57%], trigger factors [19%], compliance [9%], clinical signs [48%], peak flow rate [3%], and inhaler technique [5%]. The diagnosis of asthma exacerbation was documented in 77% of the episodes.Documentation of therapy was also low [3% for oxygen therapy and 24% for systemic steroids]. Documentation of post-nebulization assessment, follow-up appointment, and referral to asthma clinic were found in 37%, 23% and 11% of cases respectively. No documented evidence was found for referral to chest specialist or spirometry. Our study indicates major deficiencies in the documentation of asthma exacerbation management among PCPs. Further research is needed to identify the causes of those deficiencies. Following the standardised management protocol can be helpful

Management and control of asthma in patients attending a specialist centre in Oman

The management of asthma by specialists is likely to become more evidence-based. This study analysed the characteristics of patients reporting to a specialist clinic including demographics, dispensed medications and the level of asthma control. All consecutive stable asthmatics seen in the adult pulmonary clinics of Sultan Qaboos University Hospital, Oman, between December 2005 and November 2006 were prospectively evaluated using a structured assessment protocol. Of the 207 patients, [mean age 40.64 +/- 14.8], 72% were females. The majority, 83.1%, had moderate persistent asthma. A positive history of allergic rhinitis, eczema and a family history of asthma were obtained in 58.0%, 11.1%, and 50.7% of patients respectively. Total serum immunoglobulin E [IgE] was elevated in 66.7%. Skin testing was positive for more than 2 antigens in 52.3%, with the house dust antigen being reactive in 49%. Inhaled steroids, long-acting beta agonists [LABA], antihistamines and leukotriene receptor antagonists were prescribed in 94.2%, 85%, 54.5% and 11.6% of cases respectively. The majority [40.1%] was receiving medium dose inhaled steroids. Although asthma was controlled in 162 [78.3%], during the previous month 66 [31.9%] patients had visited the emergency department and 31 [15.0%] patients were hospitalised at least once during the previous year. Only 63 [30.4%] patients were using their inhalers correctly. Good compliance with inhaled steroids was observed in only 53 [25.6%] patients. Allergic comorbidities and a strong family history of asthma were common. Although the level of asthma control in the previous month was high, it was much lower in the long term. The concepts of short term, long term and total control of asthma need to be explored

audit of the sleep medicine service in Oman

To audit the sleep service at Sultan Qaboos University Hospital [SQUH], Muscat, Oman, and to explore deficiencies to introduce new measures of improvement. Polysomnography [PSG] reports and SQUH medical records of all patients who underwent sleep studies from January 1995 to December 2006 in the sleep laboratory at SQUH were reviewed and analyzed. Out of a total of 1042 sleep studies conducted in the specified period, 768 PSG recordings were valid for analysis. The audit showed that the Otolaryngology Department was the main referring specialty for PSG [43%]. Snoring was the main symptom for 33% of the subjects referred, but suspicion of obstructive sleep apnea was the main reason for referral [38%]. Three quarters of the patients were males who were also younger, and with lower body mass index compared to females [p=0.0001 for all]. Despite large number of patients with an apnea-hypopnea index of >15 [n=261], only 94 [36%] patients received continuous positive airway pressure titrations and treatment. The sleep medicine service in SQUH provided the basic service, and raised the awareness of the importance of this specialty. However, substantial effort is required to bring it to international standards

Regional variation in the prevalence of asthma symptoms among Omani school children: Comparisons from two nationwide cross-sectional surveys six years apart

The International Study of Asthma and Allergies in Children [ISAAC] highlighted the presence of wide variations in asthma prevalence between and within countries. The aim of this study was to determine the changes in the prevalence of asthma and its symptoms across the different regions of Oman. Two cross-sectional surveys were conducted as part of ISAAC phases I [1995] and III [2001] in two age groups [6-7 and 13-14 years] from nation-wide samples of Omani school children, with 7,067 participants in 1995 [3,893 young and 3,174 older group] and 7,879 participants in 2001 [4,126 young and 3,753 older group]. Over the period of six years, the Sharqiya [Eastern] region continued to have the highest prevalence of self-reported asthma diagnosis and all asthma symptoms in both age groups, with a significant increase in the prevalence of wheeze in the past 12 months [from 8.7% to 13.8%; p=0.002] and asthma diagnosis [from 13.8% to 17.8%; p=0.046] in the young group, and a significant increase in night cough [from 21.6% to 27.8%; p=0.039] in the older group. All other regions had lower prevalence rates in 1995 in both age groups, and showed either no significant change or a decline in one or two of the self-reported asthma symptoms. The prevalence of asthma diagnosis among wheezy children remained unchanged across all regions. In addition, asthma under-diagnosis remains a problem with only 60% of children with severe wheeze reporting asthma diagnosis in both surveys. The geographic variation in the prevalence of self-reported of asthma symptoms among Omani school children persists with further increase in the Sharqiya region. The findings also suggest under-diagnosis and/or poor recognition of asthma which had not improved over time

pattern of sensitisation to inhalant allergens in Omani patients with asthma, allergic rhinitis and rhinoconjunctivitis

Identification of relevant allergens that are prevalent in each environment which may have diagnostic and therapeutic implications in allergic diseases. This study aimed to identify the pattern of sensitisation to inhalant allergens in Omani patients with asthma, allergic rhinitis and rhinoconjunctivitis. The study was carried out during three consecutive years [2004-2006] at the allergy skin test laboratory of Sultan Qaboos University Hospital, Oman. Records of patients who had undergone an allergy skin prick test with a referring diagnosis of asthma, allergic rhinitis or rhinoconjunctivitis were reviewed. Two panels were used during the 3 years period. The frequencies of positive skin tests were analysed. Results: 689 patients were tested, 384 for the first panel and 305 for the second panel. In the first panel, the commonest positive allergens were: house dust mites [37.8%], hay dust [35.4%], feathers [33.3%], sheep wool [26.6%], mixed threshing dust [25.8%], cat fur [24.2%], cockroach [22.7%], straw dust [22.7%], horse hair [17.4%], maize [16.?%], grasses [11.5%], cotton flock [10.7%], trees [10.4%], cow hair [7.8%], Alternaria alternata [3.6%], Aspergillus Niger [3.4%], and Aspergillus fumigatus [?.3%]. In the second panel, the commonest positive allergens were also house dust mites: Dermatophagoides pteronyssinus [50.8%], Dermatophagoides farinae [47.9%]; Mesquite [Prosopis glandulosa] [35.7%], Russian thistle [Salsola kali] [34.4%], cockroach [32.1%], Bermuda grass [Cynodon dactylon] [19.7%], grass mix-five standard [18.0%], wheat cultivate [14.1%], cats [13.8%], Penicillium notatum [4.3%], Alternaria tenius [3.9%], Aspergillus Niger [3.3%], feather mix [3.0%], dog [2.6%], horse hair and dander [2.6%], and Aspergillus fumigatus [1.6%]. The pattern of sensitisation to environmental allergens in Oman seems to be similar to other reports from the Arabian Peninsula. Methods to identify and characterise environment specific allergens like a pollen survey may help in the management of patients with allergic asthma, allergic rhinitis and rhinoconjunctivitis

Atopy in Omani patients with asthma

To determine the range of serum IgE in healthy subjects and in asthmatic patients in Oman and to assess the degree of atopy in the asthmatic patients. Serum IgE and in vivo [the skin prick test] and in vitro [the ImmunoCAP test] allergen- specific IgE levels were measured in 44 patients with asthma. Control groups were 19 healthy subjects and 27 asymptomatic allergic subjects. The normal range for serum IgE in the Omani population was established at >/= 101 IU/ml. The geometric mean [and 95% confidence interval] for asthmatic patients was 468 IU/ml [323-676]. Positive results for allergen-specific IgE, defined as responses to >/= 1 allergen mix in the ImmunoCAP and to >/= 3 allergens in the skin prick test, occurred in 26/35 [74%] and in 34/44[77%] asthmatic patients respectively. Six out of 38 patients with serum IgE >/= 101 IU/ml and 2/6 with levels < 101 IU/ml gave negative and positive results respectively in the skin prick test. Overall, the degree of reactivity in the skin prick test correlated with the level of total serum IgE [r = 0.54, p < 0.001]. A similar correlation could not be established with ImmunoCAP reactivity, but sIgE levels >/= 101 IU/ml were supported by a high frequency of positive ImmunoCAP responses for the majority of allergen mixes. Total serum IgE levels should be routinely monitored in asthmatic subjects as this may give an indication of atopy where skin prick testing is not indicated. Since in a minority of patients serum IgE levels and skin prick results do not predict in the same direction, all laboratory data should be interpreted in context of clinical history

Metered dose inhaler technique among healthcare providers practising in Oman

To evaluate the correctness of metered-dose inhaler [MDI] technique in a sample of healthcare providers practicing in Oman, considering that poor inhaler technique is a common problem both in asthma patients and healthcare providers, which contributes to poor asthma control. A total of 150 healthcare providers [107 physicians, 33 nurses and 10 pharmacists] who were participants in symposia on asthma management conducted in five regions of Oman, volunteered for the study. After the participants answered a questionnaire aimed at identifying their involvement in MDI prescribing and counseling, a trained observer assessed their MDI technique using a checklist of nine steps. Of the 150 participants, 148 [99%] were involved in teaching inhaler techniques to patients, and 103 of 107 physicians [96%] had prescribed inhaled medications. However only 22 participants [15%] performed all steps correctly. Physicians performed significantly better than non-physicians [20% vs. 2%, p < 0.05] among the physicians, internists performed better [26%] than general practitioners [5%] and accident and emergency doctors [9%]. The majority of healthcare providers responsible for instructing patients on the correct MDI technique were unable to perform this technique correctly indicating the need for regular formal training programmes on inhaler techniques