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Introduction Poisoning is a major public health issue and a leading cause of admission to the emergency department (ED) worldwide. There is paucity of data describing epidemiology, outcomes, and cost of acute poisoning. Up-to-date information about poisoning pattern is imperative for accurate diagnosis and effective management. This study therefore investigates the epidemiology, poison pattern and associated cost of acute poisoning in Qatar. Method A retrospective review of electronic health records of 397 patients admitted due to poisoning at the ED from January 2015 - December 2019. Demographic characteristics, incidence, clinical characteristics, cause of exposure, outcomes, and cost associated with acute poisoning were included. Frequency and percentages were calculated for categorical variable and mean and SD for continuous variables, relation between sociodemographic characters and poisoning profile was assessed using Chi-square. P-value less than 0.5 was considered statistically significant. A micro-costing approach using the cost of each resource was applied for the cost calculations. Result The incidence of acute poisoning was found to be 178 patients per 100,000 patients. Females (56%), and children below 14 years (44.3%) accounted for the largest proportion. The majority of the exposures were accidental and therapeutic agents (64.2%) were the most common toxic agents. The mean length of stay in the hospital was found to be 1.84 ± 0.81 and most patients (76.6) were discharged within the first 8 hours of the ED admission. A statistically significant difference was found between age groups and type of toxins (χ2 = 23.3, p < 0.001), cause and route of exposure (χ2 = 42.2, p < 0.001) and length of stay (χ2 = 113.16, p < 0.001). Admission to intensive care units had the highest cost expenditure (USD 326,008) while general wards accounted for the least (USD 57,709). Conclusion The study demonstrates unintentional poisoning due to pharmacological agents was common among infants and children. The findings of this study will assist in the development of educational and preventative programs to minimise the exposure to toxic agents. Further studies exploring the impact of medical toxicology services, potential risk factors and post discharge monitoring of poisoning are highly warranted.

Background In line with global trends, cancer incidence and mortality may have decreased for specific types of cancer in Qatar. However, the cancer-related burden on patients, healthcare systems, and the economy is expected to expand; thus, cancer remains a significant public healthcare issue in Qatar. Qatar’s free access to cancer care represents a considerable economic burden. Ensuring the best utilization of financial resources in the healthcare sector is important to provide unified and fair access to cancer care for all patients. Experts from the Qatar Oncology Health Economics Expert Panel (Q-OHEP) aimed to establish a consistent and robust base for evaluating oncology/hematology medications; involve patients’ insights to accelerate access to cutting-edge medications; increase the value of cancer care; and reach a consensus for using cost-effective strategies and efficient methodologies in cancer treatment. Methods The Q-OHEP convened on 30 November 2021 for a 3-hour meeting to discuss cancer management, therapeutics, and health economics in Qatar, focusing on four domains: (1) regulatory, (2) procurement, (3) treatment, and (4) patients. Discussions, guided by a moderator, focused on a list of suggested open-ended questions. Results Some of the salient recommendations included the development of a formal, fast-track, preliminary approval pathway for drugs needed by patients with severe disease or in critical condition; and encouraging and promoting the conduct of local clinical trials and real-world observational studies using existing registry data. The Q-OHEP also recommended implementing a forecast system using treatment center data based on the supply/demand of formulary oncology drugs to detect treatment patterns, estimate needs, expedite procurement, and prevent shortages/delays. Furthermore, the panel discussed the needs to define value concerning cancer treatment in Qatar, implement value-based models for reimbursement decision-making such as health technology assessment and multiple-criteria decision analysis, and promote patient education and involvement/feedback in developing and implementing cancer management guidelines. Conclusion Herein, we summarize the first Q-OHEP consensus recommendations, which aim to provide a solid basis for evaluating, registering, and approving new cancer medications to accelerate patient access to novel cancer treatments in Qatar; promote/facilitate the adoption and collection of patient-reported outcomes; and implement value-based cancer care in Qatar.

Background Routine utilization of evidence-based clinical practice guidelines (CPGs) is an effective strategy to optimize patient care and reduce practice variation. Healthcare professionals’ failure to adhere to CPGs introduces risks to both patients and the sustainability of healthcare systems. The integration of theory to investigate adherence provides greater insight into the often complex reasons for suboptimal behaviors. Aim To determine the coverage of literature surrounding the use of theory in studies of CPG adherence, report the key findings and identify the knowledge gaps. Method In April 2021, three bibliographic databases were searched for studies published since January 2010, adopting theory to investigate health professionals’ adherence to CPGs. Two reviewers independently screened the articles for eligibility and charted the data. A narrative approach to synthesis was employed. Results The review includes 12 articles. Studies were limited to primarily investigations of physicians, quantitative designs, single disease states and few countries. The use of behavioral theories facilitated pooling of data of barriers and facilitators of adherence. The domains and constructs of a number of the reported theories are captured within the Theoretical Domains Framework (TDF); the most common barriers aligned with the TDF domain of environmental context and resources, fewer studies reported facilitators. Conclusion There is emerging use of behavioral theories investigating physicians’ adherence to CPGs. Although limited in number, these studies present specific insight into common barriers and facilitators, thus providing valuable evidence for refining existing and future implementation strategies. Similar investigations of other health professionals are warranted.

Background Studies have highlighted advancing clinical pharmacy practice in Qatar. Objective To explore pharmacists’ aspirations and readiness to implement pharmacist prescribing. Setting Hamad Medical Corporation (HMC), the main provider of secondary and tertiary care.Method A sequential explanatory mixed-methods design. Questionnaire items were derived from the Consolidated Framework of Implementation Research (CFIR), in domains of: awareness/support; readiness; implementation; and facilitators and barriers. Following piloting, all pharmacists (n=554) were invited to participate. Questionnaire data were analysed using descriptive and inferential statistics with principal component analysis (PCA) of attitudinal items. Focus groups were recorded, transcribed and analysed using the Framework Approach. Main outcome measure Aspirations and readiness to implement pharmacist prescribing. Results The response rate was 62.8% (n=348), with respondents highly supportive of implementation in Qatar (median 4, scale 0-5, extremely supportive). The majority (64.9%, n=226) considered themselves ready, particularly those more senior (pConclusion HMC pharmacists largely aspire, and consider themselves ready, to be prescribers with inpatient and outpatient settings most ready. CFIR domains and constructs identified as facilitators and barriers should be focus for implementation.

The introduction of new disease-modifying therapies (DMTs) for remitting-relapsing multiple sclerosis (RRMS) has considerably transformed the landscape of therapeutic opportunities for this chronic disabling disease. Unlike injectable drugs, oral DMTs promote patient satisfaction and increase therapeutic adherence.This article reviews the salient features about the mode of action, efficacy, safety, and tolerability profile of approved oral DMTs in RRMS, and reviews their place in clinical algorithms in the Middle East and North Africa (MENA) region. A systematic review was conducted using a comprehensive search of MEDLINE, PubMed, Cochrane Database of Systematic Reviews (period January 1, 1995-January 31, 2018). Additional searches of the American Academy of Neurology and European Committee for Treatment and Research in Multiple Sclerosis abstracts from 2012-2017 were performed, in addition to searches of the Food and Drug Administration and European Medicines Agency websites, to obtain relevant safety information on these DMTs.Four oral DMTs: fingolimod, teriflunomide, dimethyl fumarate, and cladribine have been approved by the regulatory agencies. Based on the number needed to treat (NNT), the potential role of these DMTs in the management of active and highly active or rapidly evolving RRMS is assessed. Finally, the place of the oral DMTs in clinical algorithms in the MENA region is reviewed.

The introduction of disease-modifying therapies (DMTs) - with varying degrees of efficacy for reducing annual relapse rate and disability progression - has considerably transformed the therapeutic landscape of relapsing-remitting multiple sclerosis (RRMS). We aim to develop rational evidence-based treatment recommendations and algorithms for the management of clinically isolated syndrome (CIS) and RRMS that conform to the healthcare system in a fast-developing economic country such as Qatar.We conducted a systematic review using a comprehensive search of MEDLINE, PubMed, and Cochrane Database of Systematic Reviews (1 January 1990 through 30 September 2016). Additional searches of the American Academy of Neurology and European Committee for Treatment and Research in Multiple Sclerosis abstracts from 2012 through 2016 were performed, in addition to searches of the Food and Drug Administration and European Medicines Agency websites to obtain relevant safety information on these DMTs.For each of the DMTs, the mode of action, efficacy, safety and tolerability are briefly discussed. To facilitate the interpretation, the efficacy data of the pivotal phase III trials are expressed by their most clinically useful measure of therapeutic efficacy, the number needed to treat (NNT). In addition, an overview of head-to-head trials in RRMS is provided as well as a summary of the several different RRMS management strategies (lateral switching, escalation, induction, maintenance and combination therapy) and the potential role of each DMT. Finally, algorithms were developed for CIS, active and highly active or rapidly evolving RRMS and subsequent breakthrough disease or suboptimal treatment response while on DMTs. The benefit-to-risk profiles of the DMTs, taking into account patient preference, allowed the provision of rational and safe patient-tailored treatment algorithms.Recommendations and algorithms for the management of CIS and RRMS have been developed relevant to the healthcare system of this fast-developing economic country.

Objective To evaluate the impact of a multi-approach strategy to improve the appropriate usage of acid suppressive medication (ASM) in medical inpatients and compare it with the baseline data from 2007. Setting Five general medicine wards in a 600-bed teaching hospital in Doha, Qatar. Method A prospective evaluation of the usage of ASM 1 year after a multi-approach strategy. This consisted of four main interventions: audit and feedback method (including awareness lectures to all medical and pharmacy staff), implementation of a usage guideline for medical inpatients, circulating a logarithmic chart on the proper usage of ASM for medical inpatients from admission through to discharge and participation of clinical pharmacists in the multidisciplinary rounds. All medical patients admitted from May through June 2009 were evaluated. Data about the usage of ASM were collected upon and during admission, at discharge and at the next follow-up visit. Justified indications for its usage were based on the approved product information and on evidence-based literature recommendations. Data were compared with the findings of the baseline clinical audit done 2 years earlier. Main outcome measure The usage of ASM in justified and non-justified indications upon and during admission, at discharge and at the next follow up visit. Results A total of 414 patients were admitted during the study period, 208 patients (50%) received ASM compared to 53% in 2007 (206 patients out of 389). Seventy-four patients (36%) were using ASM upon admission compared to 48 patients (23%) in the 2007 clinical audit. Inappropriate ASM use decreased with 51% during admission (66 to 32%, P

Objective: The aim of this hospital-based study is to get an insight into the efficacy and tolerability of antiepileptic drugs (AED) in Omani epileptic patients. Patients and methods: All Omani patients (aged 14 years and above) suffering from epileptic seizures for at least 2 years and followed-up by board-certified neurologists in Sultan Qaboos University Hospital (SQUH) were evaluated. The treatment retention rate since first visit at SQUH and over the last 2 years was used as primary efficacy measure of AED therapy. Change in seizure-frequency and side effect profiles were also assessed. Results: In this population of 203 confirmed epileptic patients, generalized tonic-clonic (40%) and partial seizures (39%) were most commonly observed, idiopathic/cryptogenic origin (81%) being the most frequent encountered origin. Sixty one percent of the patients were controlled with an AED in monotherapy and overall 34% of patients could be successfully maintained on monotherapy during the whole follow-up period at SQUH (median 6 years). The treatment retention rates for carbamazepine (CBZ) at a daily dose of 400–600 mg, sodium valproate (VPA) at a daily dose of 500–1000 mg, and phenytoin (PHT) at a daily dose of 300 mg, in monotherapy over the total follow-up period was 51, 50, and 21%, respectively. In contrast, over the last 2 years these rates were highest for VPA (91%) followed by CBZ (83%) and PHT (73%). Adverse drug reactions were recorded in 67% of patients, and were most commonly encountered with VPA. Conclusions: Despite a higher adverse effect profile for VPA, long-term treatment with CBZ and VPA appeared to be equally effective in terms of treatment retention rates and seizure control. © 2005 Elsevier B.V. All rights reserved.

Apomorphine, a short-acting dopamine D1 and D2 receptor agonist, was the first dopamine receptor agonist used to treat Parkinson's disease. Subcutaneous apomorphine is currently used for the management of sudden, unexpected and refractory levodopa-induced 'off' states in fluctuating Parkinson's disease either as intermittent rescue injections or continuous infusions. Other indications include the challenge test for determining the dopaminergic responsiveness and finding the appropriate dose of the drug in intermittent subcutaneous administration. Except for a rapid on- and offset of the antiparkinsonian response with subcutaneous apomorphine, the magnitude and pattern of the motor response to single dose of subcutaneously administered apomorphine is qualitatively comparable to that of oral levodopa. Seventy-five percent of patients achieve a clinically significant improvement with a dose of apomorphine 4mg. The efficacy of intermittent subcutaneous apomorphine injections as an add-on to levodopa therapy in advanced Parkinson's disease was explored in one short-term, randomised, double-blind, placebo-controlled trial, one short-term and six long-term, open-label, uncontrolled studies, including a total of 195 patients. These studies provide evidence that this mode of administration was successful in aborting 'off' periods and improving Parkinson's disease motor scores, but tended to increase dyskinesias. No levodopa-sparing effect was observed. Eleven long-term, open-label, uncontrolled studies, including a total of 233 patients evaluated the efficacy of continuous subcutaneous apomorphine infusions in monotherapy or as an add-on to levodopa therapy in advanced Parkinson's disease. These studies proved that subcutaneous apomorphine infusions are successful in aborting 'off' periods, reducing dyskinesias and improving Parkinson's disease motor scores with the added benefit of a substantial levodopa-sparing effect. The apomorphine challenge test has at least 80% overall predictive ability to clinically diagnose Parkinson's disease across the different stages of the disease and parkinsonian syndromes. Similarly, those data also indicate that the apomorphine challenge test has a >80% ability to predict dopaminergic responsiveness across all stages of Parkinson's disease. Adverse events are usually mild and consist predominantly of cutaneous reactions and neuropsychiatric adverse effects. The incidence of adverse effects is higher in patients receiving continuous infusion than in those receiving intermittent pulsatile administration. Based on the results of these studies it is recommended that subcutaneous apomorphine either as intermittent injections or continuous infusions should be offered to any suitable Parkinson's disease patient who has difficulties in his/her management with conventional therapy. Low-dose levodopa therapy in combination with waking-day hours subcutaneous apomorphine infusion would probably be the most efficient treatment. Continuous subcutaneous apomorphine infusions should be evaluated before more invasive measures or neurosurgical interventions are contemplated.

Remifentanil is an opioid analgesic frequently used in intensive care patients because of its rapid onset of action, potency, and ultra-short duration. If an excessive dose is given, it leads to rapid, short lasting, potentially life-threatening side effects such as apnea, bradycadia, hypotension, and rigidity, following rapid peak serum levels. We report a 36-year-old woman developing apnea with bradycardia and hypotension, following an infusion in the central venous catheter lumen that had been used for remifentanil till tracheal extubation. The patient was immediately ventilated with bag-valve-mask and improved within 8 minutes. She became fully awake, heart rate and blood pressure returned to normal, and oxygen saturation improved to 100%. Acute care physicians, intensivists, anesthesiologists, and critical care nurses should be aware of this clinical problem in order prevent it as much as possible and to initiate immediate resuscitative measures.

The health care system in Oman is characterized by its rapid development and free medical services for all its nationals although traditional medicine still plays a major role in daily life. Epidemiological data on poisoning are scanty.To determine the annual rate of poisoning-related AccidentEmergency Department visits at Sultan Qaboos University Hospital in Oman and to evaluate, in both children and adults, the etiologic and demographic characteristics of poisoning cases. The poisoning pattern is contrasted to that of other countries.A prospective observational study included all symptomatic and asymptomatic poisoning-related AccidentEmergency Department visits over 4 years (1996-1999). Data were recorded on a specifically designed poison reporting form.Two hundred and four poisoning-related AccidentEmergency Department visits were recorded corresponding to an average annual rate of 1.8/1000 AccidentEmergency Department visits. Therapeutic agents were most commonly involved (50% of all cases). Accidental poisoning in toddlers was most commonly caused by drugs. Intentional poisoning in adults involved mainly therapeutic agents (50%), particularly analgesics, followed by industrial and environmental agents (25%). Animal poisoning (14%) was most commonly encountered in adult males. Traditional remedies constituted 7% of all poisoning cases. A total of 148 patients (73%) were admitted for 1 to 175 days.Compared to studies performed in urban hospitals in other countries, (1) the annual rate of poisoning-related AccidentEmergency Department visits was substantially lower, (2) psychoactive drugs were less frequently incriminated in intentional ingestions, and (3) we found a significantly higher frequency of poisoning by animals and traditional remedies than reported by urban hospitals in other Middle Eastern countries. The limitations of our study (AccidentEmergency Department-based data collection in an urban hospital) do not permit extrapolation to the rest of the country.

Case Report: A 21-year-old man who had sniffed toluene since the age of 13 presented with a 4-year history of progressive cerebellar dysfunction and visual deterioration. The patient's condition did not improve despite 5 months of abstinence. Magnetic resonance imaging revealed cerebral atrophy and hypointensity signals in the white matter and bilaterally in the globus pallidus, thalamus, red nucleus, and substantia nigra. Amantadine hydrochloride therapy (100 mg/d, then 200 mg/d) resulted in dramatic improvement of his cerebellar and visual symptoms.

The European Union has thoroughly reformed its pharmacovigilance legislation in July 2012. Despite the changes, underreporting of adverse drug reactions remains a concern. This underreporting seems to be partially associated with incorrect customs and beliefs by healthcare professionals. Therefore, strengthening teaching and training in drug safety monitoring and reporting are essential. Sustained campaigns and education on pharmacovigilance are key elements to enhance its performance and effectiveness. In general, all healthcare professionals as well as patients should be more sensitized and empowered to contribute to pharmacovigilance programmes in order to improve drug safety.

Neurogenic stunned myocardium (NSM) is a well-known complication of subarachnoidal hemorrhage, but has been reported rarely in association with other central nervous system disorders. A case of NSM is described in a patient with hemorrhagic brain contusion associated with cerebral edema. An 18-year-old man was admitted with severe cranial trauma following a car roll-over. Six days after admission, he developed findings suggestive for NSM. The troponin T and creatine kinase-MB level were elevated and echocardiogram showed apical and inferoposterior hypokinesis and diffuse left ventricular akinesis with severely reduced ejection fraction (18%). Invasive measurements confirmed low cardiac output. His cardiac function resolved completely within 6 days after decompressive craniotomy. This case supports the presumed unifying role of the increased intracranial pressure, probably triggering a vigorous sympathetic outflow hyperactivity leading to NSM.

Background: Pneumocephalus is the presence of air in the cranial cavity. When this intracranial air causes increased intracranial pressure and leads to neurological deterioration, it is known as tension pneumocephalus (TP). TP can be a major life-threatening postoperative complication, especially after evacuation of chronic subdural hematoma. We report a case of TP after evacuation of chronic subdural hematoma and review the literature. Case Description: A 70-year-old man developed right-sided weakness after being admitted with minor head trauma a few weeks earlier. He was found to have a chronic subdural hematoma and underwent burr-hole evacuation. On day 3, he suddenly deteriorated and needed intubation and ventilation. Computerized tomography (CT) of the brain showed typical Mount Fuji's sign due to TP. Immediately, 20-30 mL of air was aspirated from the intracranial fossa, and a catheter drain was inserted. The patient became fully awake after few hours and was extubated successfully. The drain was removed on day 5, and he was transferred to the ward before being discharged home. Conclusion: TP after evacuation of a chronic subdural hematoma is a neurosurgical emergency and needs immediate resuscitation and therapy; hence it is of vital importance that all acute-care physicians, intensivists and neurosurgeons be aware of this clinical emergency.

To report the occurrence of abdominal compartment syndrome (ACS) due to infection with Clostridium difficile.Case report.Trauma intensive care unit (TICU) of Hamad General Hospital, a teaching hospital in Doha, Qatar.A 36-year-old man involved in a motor vehicle accident had severe traumatic brain injury and received ceftriaxone. On day 7, he developed severe abdominal distension and diarrhoea followed by paralytic ileus with oliguria, hyperkalaemia, and intra-abdominal hypertension. The patient's stool sample was positive for C. difficile toxin A and B MEASUREMENTS AND RESULTS: An ACS was diagnosed. The patient was successfully treated in the TICU by stopping the offending antibiotic and starting metronidazole plus neostigmine as a prokinetic agent. The fluid status was guided by pulse-induced continuous cardiac output, and frusemide was added to the treatment. With this aggressive management the abdominal pressure decreased and the renal function improved, with full recovery of renal function by day 21. Unfortunately the patient's Glasgow coma score (GCS) deteriorated, so percutaneous tracheostomy was performed. He was transferred to the neurosurgical ward on day 35. A week later he was shifted to the rehabilitation unit for further management.C. difficile colitis can cause intra-abdominal hypertension (IAH) and ACS. Rapid diagnosis, early aggressive supportive care, metronidazole and prokinetics are necessary to lower the morbidity and mortality of C. difficile colitis associated with IAH and ACS.

Background: Correct administration of oral medicines in patients with swallowing problems and feeding tubes remains a challenge. Objective: To improve drug administration in patients with swallowing problems and feeding tubes in a 1600 bed tertiary referral center in the State of Qatar. Methods: A questionnaire was used to evaluate the knowledge and practice of nursing staff from 6 different intensive care units (ICU). Questions assessed the respondents' knowledge of the purpose of controlled-release (CR) preparations, codes used for CR medication, the consequences of crushing these preparations, and their interactions with enteral feeds and feeding tubes. Based on the results of the questionnaire, a 2 day training program was conducted for a core group of 34 staff nurses from all units (ICU and non-ICU) and 3 nursing instructors. Following the principle of “training the trainers,” the core group and the nursing instructors would widen the scope of education by running programs in the future. Lecture sessions for pharmacy staff and a monitoring tool to evaluate the practice were also developed. Results: Overall knowledge of CR codes increased from 0% to 40%, correct crushing of solid preparations from 35% to 90%, and knowledge of possible interactions with the enteral feed or feeding tubes from 51% to 88%. Correct administration of medication in patients with feeding tubes improved from 32% to 83%. The quality and value of the 2 day training course received a mean score of 96%. Conclusions: While most nurses were aware of the purpose of CR formulations, little was known about the different codes used by drug companies and the consequences of crushing these preparations. Interactions with enteral feeds and feeding tubes were mostly overlooked. A 2 day training course followed by continuous in-service training, a lecture to pharmacy staff, and provision of supportive educational material greatly improved the overall medicine administration process in patients with swallowing problems and feeding tubes.

The primary objectives were to evaluate the current usage of anti-microbial agents in the Medical Intensive Care Unit (MICU) of Hamad Medical Corporation (HMC) in Doha, State of Qatar and to correlate this with: a) the infectious disease pattern, b) the isolated microorganisms and their sensitivity pattern, and, importantly, c) the patient's clinical outcome. A secondary objective was to evaluate the influence of the use of steroid therapy on the development of fungal infections.A prospective study covering a 2-month period from February through April 2004, including all patients admitted to the MICU for a minimum of 48 hours, and receiving a systemic antibiotic.From the 71 eligible patients admitted, 54 (76%) were treated for presumed or proven infections and received antibiotics, corresponding with 280 (89%) of the 313 patient days. Respiratory infections accounted for 57%. A total of 159 antibiotics (134 intravenously and 25 orally) were administered to the 54 patients during their stay in the MICU, corresponding with an average of almost 3 antibiotics per patient. Ceftriaxone was prescribed in 31 patients (57%) as initial therapy. Throughout the study period, a total of 385 microbiology samples for culturing were taken, corresponding with almost one sample per patient per day. Fifty-two percent of patients had a microbiologically proven infection (MPI): 18% with community-acquired pneumonia (CAP), 18% ventilated-acquired pneumonia (VAP), and 11% with hospital-acquired pneumonia (HAP). In the group of bacterial MPI, sensitivity pattern resulted in change in empirical antibiotic therapy in 12 of 23 patients (52%). In the group of patients with non-MPI, antibiotherapy was changed in 5 of the 26 patients (19%). Yeast infections developed in 13 of 30 (43%) patients receiving steroids (with 3 out of 9 patients (33%) receiving steroids for severe sepsis, and septic shock) compared to 5 of 24 (21%) patients receiving no steroids.This study highlights the urgent need for updated empiric and treatment guidelines as well as the monitoring of the antibiotic usage.

A 42-year-old pregnant woman (26 weeks of gestation, G(4)P(0+3)) presented at the emergency department with a two-hour history of dizziness, blurred vision and repeated vomiting. These symptoms started during the use of an undiluted insecticide liquid (diazinon 60 EC) while cleaning a small non-aired bathroom. After clinical and laboratory confirmation for organophosphate poisoning (plasma pseudocholinesterase levels 161 U/l), treatment with atropine and pralidoxime was started. She recovered within 7 days and delivered a healthy baby 12 weeks later (Apgar score 9 and 10) by elective cesarean section. The child showed no signs or symptoms of organophospate, atropine or pralidoxime exposure.

"Man-in-the-barrel" syndrome has been rarely described following osmotic myelinolysis. We report a case of a 45-year-old woman admitted with septicemia and severe hyponatremia. She presented with a "man-in-the-barrel" syndrome which developed more than 10 days after rapid correction of the hyponatremia. There was radiological evidence of central pontine and extrapontine myelinolysis. Three days after completing a course of intravenous immunoglobulin therapy (0.4 g/kg body weight/day for 5 days) there was considerable improvement (Expanded Disability Status Scale score improved 30%). This case, reported for its peculiar mode of development, unusual presentation and challenging therapeutic response to intravenous immunoglobulin, highlights the enigmatic and unpredictable aspects of osmotic myelinolysis.

Objectives: To describe the pharmaceutical use, health care resource utilisation patterns, and annual direct medical cost of epilepsy as well as determining the impact of various demographic and clinical characteristics on total costs of epilepsy in Oman. Methods: Medical and pharmacy data were collected for 6 months on all patients aged ≥13 years attending the Sultan Qaboos University Hospital. Unit pharmacy and medical costs were retrieved for each patient, and multiple linear regression was utilised to analyse the impact of various demographic and clinical characteristics on total cost. Results: A total of 486 patients were seen over the study period. Annual direct medical costs of epilepsy amounted to US$1426. In-patient care, the antiepileptic drug (AED) lamotrigine and specialist visits, respectively, were the first, second and third most significant predictors of total cost. Age was associated positively, and was the most significant predictor of total costs among demographic and clinical parameters. Conclusions: This analysis, the first economic study of epilepsy in Oman, could assist in health care allocation of scarce resources and in pharmacoeconomic analysis of AEDs. Besides in-patient admission, our findings demonstrate that the newer drugs are significant predictors of total cost, and hence any incremental benefits derived from them must be rigorously assessed for their cost-effectiveness.

Apomorphine and certain ergot alkaloids (bromocriptine, lisuride and pergolide) have been available for several decades; for the last few years, they were joined by newer dopamine agonists (cabergoline, pramipexole and ropinirole) most of them are non-ergolines. Each of these dopamine agonists has its own pharmacological characteristics and occupies a place in the pharmacotherapy of Parkinsons disease. In this evidence-based review, emphasis is put on the clinical efficacy of dopamine agonists in early and advanced Parkinsons disease, and where possible comparative evidence regarding their efficacy and safety is provided. In addition, their clinical pharmacokinetics, adverse effect profiles and most relevant interactions will be summarized.

Summary Purpose: To get an insight into the type and aetiology of epileptic seizures; to describe the drug utilization pattern of anti-epileptic drugs (AEDs) for the treatment of various forms of epileptic seizures in this tertiary referral centre in Oman; and to compare our drug utilization pattern with that from other countries. In addition, the tolerability of AEDs and the use of therapeutic drug monitoring (TDM) were evaluated. Methods: In a 6-month study, all epileptic patients aged 14 and above who were prescribed an AED were considered for analysis. Demographic data, type and aetiology of epileptic seizures, AED data, tests performed and adverse drug reaction (ADR) data were collected. Results: A total of 1039 prescriptions originated from 488 epileptic patients. The age ranged from 14 to 77 years (median, 24 years). Generalized tonic–clonic seizures (51%) of idiopathic/cryptogenic origin (83%) were the most common type and aetiology of epileptic seizures, respectively. An average of 1·34 AEDs per patient was prescribed with 78% of patients being on monotherapy. Sodium valproate (49%) was the most frequently prescribed AED, followed by carbamazepine (44%), phenytoin (12%) and lamotrigine (11%). Ten patients suffered an ADR and phenobarbital followed by carbamazepine were most commonly the subject of TDM. Conclusions: Unlike the results in most other studies, generalized seizures represented the majority of epileptic seizures. The selection of the AEDs corresponded well with their known efficacy profiles for specific epileptic seizure types. Monotherapy was the type of therapy most frequently used, and sodium valproate and carbamazepine were the most commonly used AEDs.

Current research in Parkinson’s disease (PD) focuses on symptomatic therapy and neuroprotective interventions. Drugs that have been used for symptomatic therapy are levodopa, usually combined with a peripheral decarboxylase inhibitor, synthetic dopamine receptor agonists, centrally-acting antimuscarinic drugs, amantadine, monoamine oxidase-B (MAO-B) inhibitors and catechol-O-methyltransferase (COMT) inhibitors. Drugs for which there is at least some evidence for neuroprotective effect are certain dopamine agonists, amantadine and MAO-B inhibitors (selegiline). Levodopa remains the most effective drug for the treatment of PD. Several factors contribute to the complex clinical pharmacokinetics of levodopa: erratic absorption, short half-life, peripheral O-methylation and facilitated transport across the blood-brain barrier. In patients with response fluctuations to levodopa, the concentration-effect curve becomes steeper and shifts to the right compared with patients with stable response. Pharmacokinetic-pharmacodynamic modelling can affect decisions regarding therapeutic strategies. The dopamine agonists include ergot derivatives (bromocriptine, pergolide, lisuride and cabergoline), non-ergoline derivatives (pramipexole, ropinirole and piribedil) and apomorphine. Most dopamine agonists have their specific pharmacological profile. They are used in monotherapy and as an adjunct to levodopa in early and advanced PD. Few pharmacokinetic and pharmacodynamic data are available regarding centrally acting antimuscarinic drugs. They are characterised by rapid absorption after oral intake, large volume of distribution and low clearance relative to hepatic blood flow, with extensive metabolism. The mechanism of action of amantadine remains elusive. It is well absorbed and widely distributed. Since elimination is primarily by renal clearance, accumulation of the drug can occur in patients with renal dysfunction and dosage reduction must be envisaged. The COMT inhibitors entacapone and tolcapone dose-dependently inhibit the formation of the major metabolite of levodopa, 3-O-methyldopa, and improve the bioavailability and reduce the clearance of levodopa without significantly affecting its absorption. They are useful adjuncts to levodopa in patients with end-of-dose fluctuations. The MAO-B inhibitor selegiline may have a dual effect: reducing the catabolism of dopamine and limiting the formation of neurotoxic free radicals. The pharmacokinetics of selegiline are highly variable; it has low bioavailability and large volume of distribution. The oral clearance is many-fold higher than the hepatic blood flow and the drug is extensively metabolised into several metabolites, some of them being active. Despite the introduction of several new drugs to the antiparkinsonian armamentarium, no single best treatment exists for an individual patient with PD. Particularly in the advanced stage of the disease, treatment should be individually tailored.

This study on primary chronic daily headache was based on the 1996 proposed revision of the diagnostic criteria of the International Headache Society (IHS). To investigate the relative frequency, clinical characteristics, and associated features of primary chronic daily headache in Omani patients, 171 patients visiting the Neurology Clinic at Sultan Qaboos University Hospital were evaluated. Forty-five percent was diagnosed as suffering from primary chronic daily headache (female to male ratio, 1.7:1). Sixty-two percent suffered from transformed migraine and 34% from chronic tension-type headache. The average age across sexes was 32.3 +/- 12.3 years. A dull heavy feeling in the head was reported by 58% of patients and was associated in less than one third with associated features characteristic of migraine. All headache types shared the same trigger factors. All patients were taking medication, predominantly analgesics, at the time of their first visit. We concluded that primary chronic daily headache is very common with the relative frequency of transformed migraine being similar to that found in Mediterranean studies. Also in Oman, chronic use/overuse of analgesics and nonsteroidal anti-inflammatory drugs is a problem that coexists with primary chronic daily headache. Finally, the proposed revised IHS criteria are highly recommended as a standard classification system for this type of headache.

Sterile neurogenic inflammation within cephalic tissue, involving vasodilation and plasma protein extravasation, has been proposed as a pathophysiological mechanism in acute migraine. The action of 5-hydroxytryptamine (5-HT1B/1D) agonists--so-called triptans--on receptors located in meningeal arteries (5-HT1B) and trigeminovascular fiber endings (5-HT1D) has an inhibitory effect on this neurogenic inflammation. Recently, a series of second-generation 5-HT1B/1D agonists (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, and zolmitriptan) have been developed and are reviewed in this article. Their in vitro pharmacological properties, pharmacokinetics, clinical efficacy, drug interactions, and adverse effects are evaluated and compared to the golden standard in the treatment of acute migraine, sumatriptan.

The pharmacologic management of migraine has traditionally focused on two approaches: symptomatic treatment and prophylactic therapy. The objective of symptomatic treatment is to reduce the intensity and duration of pain with its attendant symptoms and to optimize the patient's ability to function normally. The efficacy of most abortive antimigrainous drugs in probably related to their inhibitory effects on neurogenic inflammation mediated through serotoninergic control mechanisms. A variety of treatment strategies provide effective treatment for most attacks of moderate to severe migraine when utilizing one or a combination of the following classes of drugs: simple analgesics, nonsteroidal anti-inflammatory drugs, antiemetics, narcotic analgesics, ergot derivatives, and serotonin1-agonists. The choice of medication for an acute attack depends on factors such as the severity of the attack, the presence or absence of vomiting, time from onset of pain to peak pain level, rate of bioavailability of the drug, comorbid medical conditions, and the side effect profile of the drug. The major objective of prophylactic therapy is the reduction of frequency, duration, and intensity of attacks. Beta-blocking drugs without intrinsic sympathomimetic activity (such as propranolol), amitriptyline, flunarizine, serotonin antagonists (such as methysergide) and nonsteroidal anti-inflammatory drugs (such as naproxen) are the five main classes of drugs or agents that may be used as prophylactics.

Despite their potentially disastrous side effects, topical mercury salts can still be found as ingredients in some over-the-counter preparations or local remedies.Peripheral polyneuropathy as a result of chronic ammoniated mercury poisoning was studied and followed over 2 years. A 36-year-old man developed peripheral polyneuropathy following chronic perianal use of an ammoniated mercury ointment. Highly elevated blood and urine mercury levels were found. Sural nerve biopsy showed mixed axonal degeneration-demyelination. There was progressive improvement of his symptoms over 2 years but neurophysiological examination revealed incomplete recovery.The availability of safer drugs should result in a complete ban of these dangerous compounds.

Gallstone disease is one of the most common problems affecting the digestive tract. Symptomatic patients are advised to undergo laparoscopic cholecystectomy (LC), which is considered the gold standard of care in these patients. LC has clear advantages over traditional surgery such as a shorter hospital stay, an earlier return to work and better patient satisfaction. Despite LC being a common surgical procedure, it is not totally free from complications. These include cardiorespiratory problems, biliary leakage, peritonitis, hemorrhage and superior mesenteric artery (SMA) occlusion. We report an unusual and fatal complication of LC, being SMA thrombosis complicated by multiple intra-abdominal collections, abdominal compartment syndrome, multiorgan failure and septic shock.

Dialysis disequilibrium syndrome (DDS) is a central nervous system disorder, which occurs during hemodialysis (HD) or within 24 h following the first HD. DDS commonly occurs in patients suffering from end-stage renal failure undergoing HD for the first time. In a critically ill patient suffering from severe sepsis or septic shock, the combined effects of post-HD brain edema and changes in the brain due to septic encephalopathy, may become amplified leading to DDS. Here we report 2 cases with acute renal failure (ARF), undergoing HD for more than a week and being ventilated and who developed DDS. DDS might have contributed to the sudden deterioration and death in these septic patients. The first case was a 31-year-old male, involved in a motor vehicle accident and had a severe abdominal injury. Underwent laparotomy and hemostasis was achieved. On day 4, the patient developed hemorrhagic shock associated with ARF, which prompted daily HD. On day 8, he went into septic shock. On day 16, 1 h after his daily HD, he became unresponsive and his pupils became dilated and fixed and he expired 2 days later. The second case was a young male who suffered severe abdominal and chest injury after a fall from a height. He developed ARF on day 3 and required HD. On day 9, he had septic shock. Three days later, during his daily HD, he became unconscious and his pupils were not reacting to light and the patient died on day 12. Conclusion: In patients with severe sepsis/septic shock, DDS may occur even after repeated sessions of HD. The acute care physicians, intensivists, and nephrologists should be aware of the risks of DDS.

We read with interest the article by Miyagi et al 1 and comment on the medical treatment of toluene induced tremor. Microdialysis experiments in rats have shown that inhalation of toluene increases extracellular γ-aminobutyric acid (GABA) concentrations within the cerebellar cortex2 which probably explains why GABA agonists including benzodiazepines (for example, clonazepam) are not very effective in toluene induced tremor and ataxia. Rat experiments also showed a 50% reduction in …

The efficacy of 5-hydroxytryptamine 1B/1D (5-HT 1B/1D) agonists is related to their inhibitory effects on neurogenic inflammation, mediated through serotoninergic control mechanisms. Recently, a series of oral second generation 5-HT 1B/1D agonists (eletriptan, naratriptan, rizatriptan and zolmitriptan) have been developed and are reviewed in this paper. Their in vitro and in vivo pharmacological properties, clinical efficacy, drug interactions, and adverse effects are evaluated and compared to the gold standard in the treatment of acute migraine, sumatriptan.

It was our purpose to perform a geographical analysis for the number of biomedical and clinical research publications from the six countries of the Gulf Cooperation Council over the past decade (1990-1999).Medline was searched with the aid of the Internet provider PubMed. By using the advanced search option, entries were based on the country name for each of the Gulf Cooperation Council countries and the time period considered.The number of Medline-listed biomedical research papers published in the Gulf Cooperation Council countries over the last 10 years totaled 6,960 and increased by 14% over the past decade. The Kingdom of Saudi Arabia followed by Kuwait was by far the most prolific and accounted for 67 and 16% of publications. The research output from the United Arab Emirates and Oman grew steadily over the past decade, while it appeared to plateau for both Bahrain and Qatar.Taking into account that Gulf Cooperation Council countries have a relatively short history of research, the data show that the Gulf Cooperation Council countries are very prolific in terms of Medline-indexed biomedical research publications.

Treatment of migraine has traditionally been divided into managing acute attacks and prophylactic treatment. Treatment of acute migraine has been the subject of many research papers and review articles in recent literature partly at the cost of prophylactic treatment, which is the focus of this review. The objective of prophylactic therapy is to reduce frequency, duration and severity of attacks in addition to optimize the patient`s ability to function normally. Preventive therapy is usually undertaken in patients who have more than two migraine episodes per month or when less frequent have severely disabling headaches resistant to usual treatment. Beta-blocking drugs without intrinsic sympathomimetic activity (e.g. propranolol) are usually the first drugs of choice followed by tricyclic antidepressant agents (e.g. amitriptyline), non-steroidal anti-inflammatory drugs (e.g. naproxen), calcium antagonists (e.g. flunarizine) or valproate. The use of serotonin antagonists (e.g. methysergide) is limited because of their potential serious side effects. Migraine refractory to standard prophylactic therapy is very often the result of overuse of abortive antimigraine drugs. The choice of medication clearly depends on the patient`s profile (age, co-morbid medical conditions) and the contraindication and side effect profile of the drug.