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| ORIGINAL ARTICLE |
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| Year : 2021 | Volume
: 35
| Issue : 4 | Page : 188-196 |
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Perceived stress and its correlates among medical trainees in Oman: A single-institution study
Siham Al Shamli1, Shahad Al Omrani1, Tamadhir Al-Mahrouqi1, Moon Fai Chan2, Ola Al Salmi3, Muna Al-Saadoon4, Aishwarya Ganesh1, Samir Al-Adawi1
1 Department of Behavioural Medicine, College of Medicine and Health Sciences, Sultan Qaboos University, Al-Khoud, Muscat, Oman
2 Department of Family Medicine and Public Health, College of Medicine and Health Sciences, Sultan Qaboos University, Al-Khoud, Muscat, Oman
3 Department of Child and Adolescent Psychiatry, Al-Massara Hospital, Wilayat Al Amerat, Muscat, Ministry of Health, Muscat, Oman
4 Department of Child Health, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman
| Date of Submission | 13-Aug-2021 |
| Date of Decision | 08-Oct-2021 |
| Date of Acceptance | 09-Oct-2021 |
| Date of Web Publication | 21-Dec-2021 |
Correspondence Address:
Ph.D Samir Al-Adawi
P.O. Box 35, Al-Khoudh 123, Muscat
Oman
 Source of Support: None, Conflict of Interest: None  | 2 |
DOI: 10.4103/TPSY.TPSY_37_21
Objectives: Medical students from several parts of the world have increasingly been reported to have higher rates of stress and distress. In this study, we intended to explore the prevalence of perceived stress, disordered eating, and poor quality and pattern of sleep among medical students in the Arabian Gulf country, Oman. The related objective was to explore the relationship between sociodemographic variables and the expression of perceived stress. Methods: A cross-sectional online survey was conducted among medical students at the only national university in Oman. The outcome measures included perceived stress (Perceived Stress Scale-10), disordered eating (Eating Attitudes Test-26), and the quality and pattern of sleep (Pittsburgh Sleep Quality Index). The study survey also included sociodemographic variables and risk factors. Results: We contacted 600 students, and 253 students responded (response rate = 42.2%) with a filled study survey. We found that 51.4% (n = 130) of the sample scored in the threshold of perceived stress, 16.2% showed disordered eating, and 79.1% displayed poor quality and disrupted pattern of sleep. The total sample comprised more females (73.1%) as compared to males (26.9%) at an average age of 22.0 ± 2.0 (mean ± standard deviation) years. More than 77% (n = 196) of them were senior students (year 4th–7th), and their average body mass index (BMI) was 23.6 ± 5.9) kg/m2. Twenty-five participants had a history of psychiatric illness. Among those with psychiatric illness, 7.5% (n = 19) were on regular psychotropic medications. In multivariate analysis, perceived stress was found to be significantly correlated with age (p < 0.01), years of study (p < 0.05), and poor quality and disrupted patterns of sleep (p < 0.001). Conclusion: This study was embarked upon to examine the risk factors related to perceived stress among medical students in Oman. The rates of perceived stress, disordered eating, and poor quality and disrupted pattern of sleep were to echo international trends among medical students. The factors that were found to be related to perceived stress included age, having completed less than four years of their medical education, and poor quality and disrupted pattern of sleep. In addition to laying the groundwork for further studies, this data can be used for the prevention and mitigation of poor mental health outcomes.
Keywords: disordered eating, medical students, sleep quality, Sultan Qaboos University
How to cite this article:
Al Shamli S, Al Omrani S, Al-Mahrouqi T, Chan MF, Al Salmi O, Al-Saadoon M, Ganesh A, Al-Adawi S. Perceived stress and its correlates among medical trainees in Oman: A single-institution study. Taiwan J Psychiatry 2021;35:188-96 |
How to cite this URL:
Al Shamli S, Al Omrani S, Al-Mahrouqi T, Chan MF, Al Salmi O, Al-Saadoon M, Ganesh A, Al-Adawi S. Perceived stress and its correlates among medical trainees in Oman: A single-institution study. Taiwan J Psychiatry [serial online] 2021 [cited 2023 Mar 28];35:188-96. Available from: http://www.e-tjp.org/text.asp?2021/35/4/188/332966 |
| Introduction | |  |
Oman has been internationally lauded to have undergone rapid human development [1]. With respect to education, the literacy rate in the country has increased from 54.7% in 1990 to 93.0%, according to recent estimates [2]. Along with the vertical and horizontal growth of primary and secondary education and universally free education up to secondary schooling, the country has witnessed a parallel development of tertiary education, including medical schools [3]. But scant attention has been paid to the well-being of medical students, despite existing preliminary studies suggesting poor mental health outcomes to be common among them [4],[5],[6],[7]. Similarly, higher rates of stress and distress among medical students have been documented in different parts of the world [4],[5],[6],[7],[8].
Some studies suggested that mild levels of stress can have positive physiological effects and facilitate the learning process through improving cognitive function [9]. But prolonged and unremitting factors that lead to stress tend to be detrimental to the well-being of medical students and their education [7]. Heavy academic load and frequent examinations are frequent sources of acute and chronic stress among medical trainees [7],[10]. Other factors, such as high parental academic expectations, a lack of enough time to maintain a healthy work–life balance, and living in hostels with a lack of entertainment facilities, have been suggested to contribute to the development of poor coping mechanisms for stress among medical students [11].
Several studies have explored the antecedent factors that precipitate stress and distress among medical students. It has been found that the adjustment of sleep schedules to accommodate for the time needed to complete large workloads commonly results in poor quality and disturbed sleeping patterns among medical students. Studies in the United States of America showed that 51% of medical students suffer from sleep deprivation, which led to adverse effects on their academic performance [10],[12]. Quality and quantity of sleep have a direct influence on the integrity of cognitive functioning that is required during the learning process [13],[14],[15]. Many studies in the United States, Australia, India, and other countries showed that students with poor sleep quality have lower marks on their evaluations and are likely to have poor mental health outcomes, including disordered eating [15],[16],[17]. Large academic workloads and the associated stress among medical students increase their vulnerability to develop dysfunctional eating behaviors, which often lead to serious consequences [18],[19]. Disordered eating is one of the most common chronic health conditions among college-going students, with a prevalence ranging from 7% to 20% [20]. Disordered eating has received less attention among medical students in the Arabian Gulf countries, and unfortunately, Oman is no exception.
The association between sleep disturbances, eating disorders, and levels of stress among medical students has not been adequately explored. To fill in this gap in the literature, in this study, we intended to explore the prevalence of perceived stress and its covariates among medical students enrolled in Sultan Qaboos University (SQU) in Muscat, Oman. We also aimed to analyze the relationship between perceived stress, quality of sleep, and disordered eating. The rôles of different sociodemographic variables in the expression of perceived stress were also analyzed in this online survey.
| Methods | | |
The study setting
This was a cross-sectional study conducted among medical students attending the College of Medicine and Health Sciences in SQU from March 2020 to December 2020. The medical school came into operation in 1986. It offer M.D., bachelor of sciences (B.Sc.) health sciences, and biomedical laboratory sciences programs, plus pockets of postgraduate programs (master and doctorate) [21]. The undergraduate program has an annual intake of prospective medical students ranging from 120 to 130 students. Oman has universally free education until secondary school. To enter medical school, securing a competitive scholarship to study medicine is essential. Self-funded education is an option that is available for students who are likely to be residents rather than citizens. Completion of the M.D. program takes place over about six years. At the end of the 4th year, students are given an option to opt out and graduate with a B.Sc. degree. Being the only national university in Oman [Figure 1], SQU consists of students drawn from different parts of the country. | Figure 1: Oman (area = 309,501 km2, population = 5.107 million) is a country in the Arabian Peninsula in Western Asia between latitudes 16° and 28° N, and longitudes 52° and 60° E. Oman shares land borders with Saudi Arabia to the west, the UAE to the northwest and Yemen to the southwest. The country also shares the maritime borders with Iran and Pakistan. The coastline consists of the Indian Ocean and its derivate – the Arabian Sea in the southeast and the Gulf of Oman in the northeast. Oman has eleven administrative regions. The bulk of the population resides in the coastal region of the north of the country known as Al Batinah coast which is protruded Al Hajar Mountains. The capital, Muscat, is the largest metropolitan along the coast overlooking the Arabian Sea where the only national University, SQU is located. (Photo courtesy: modified from www.commons.wikimedia.org/wiki/ Atlas More Details_of_Oman#/media/File:Oman_in_its_region.svg). UAE, United Arab Emirates; SQU, Sultan Qaboos University.
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Study participants
All undergraduate medical students (M.D., B.Sc.) enrolled in the College of Medicine, SQU, were invited to participate. The invitations were sent through an institutional e-mailing system. Additional medical student-led distribution through e-mail listservs and social media groups was done to reach the present cohort. Electronic informed consent was obtained to ensure the protection of the participant's privacy, confidentiality, and anonymity.
The study was approved by the Ethics and Research Committee of SQU (study protocol number = SQU-EC/068/19, MREC Approval #1892, and date of approval = April 11, 2019) with the need to obtain signed informed consent from the study participants. The required permits were acquired to administer the Perceived Stress Scale (PSS)-10 to the participants.
Inclusion and exclusion criteria of study participants
All medical students from the first year to the final year of medical school were invited to participate in this survey. Students from a nonmedical background or those who were majoring in biomedical laboratory sciences, master, or Ph.D. degrees were excluded from the study. We included all medical students who signed the informed electronic consent form and provided copies of completed questionnaires. Excluded from the study were students who refused to take part in the study or did not complete the survey.
Study instruments
Sociodemographic questionnaire
The study first solicited sociodemographic information (age, gender, marital status, and socioeconomic status that was inferred from family income per month). Second, the participants were asked to state whether they were citizens or residents of Oman (Omani versus non-Omani). Third, the participants were asked to mention whether they were on a scholarship or were self-funded for the duration of the course.
For theoretical interest, since the medical education lasts for six years, the cohort was grouped into two subsections: (a) first-, second-, and third-year students and (b) fourth, fifth- and sixth-year students. The fourth was anthropomorphic measurements, particularly BMI which was calculated according to the protocol prescribed by the World Health Organization with the following breakdown: 18.5 = underweight; 18.5–24.9 = normal weight; 25.0–29.9 = obesity; 30.0–34.9 = overweight. Some relevant risk factors were also enquired about including having a history of psychiatric illness and whether they were taking psychotropic medications.
The Perceived Stress Scale-10
The PSS-10 is a 10-item self-report questionnaire used to assess stress levels [22]. It uses a five-point Likert scale (0 = never, 1 = almost never, 3 = sometimes, 3 = fairly often, 4 = very often). PSS-10 is a reverse score measure where the only positively scored items are 4, 5, 7, and 8, respectively. The total scores ranging from 0 to 40 are obtained by summing up all reported items of the scale. There are various methods of interpreting PSS-10. Some studies have endorsed the score of 0–13 to constitute “low perceived stress” 14–26 as “moderate perceived stress” and 27–40 as “high perceived stress” [23]. Others have recommended scores of around 13 as “average,” while scores of 20 or higher correspond to a high level of stress or the mean score [24]. According to Yerkes–Dodson law, some level of stress is often viewed as beneficial to performance [25]. This study used a cutoff score of 20, similar to the protocol of a study by Sathiya et al. [26]. Using this cutoff for the present sample, Tau-equivalent reliability was found to be adequate (Cronbach's alpha = 0.84).
The Eating Attitudes Test-26
The Eating Attitudes Test (EAT)-26 has been a well-established measure for quick screening of general eating behaviors that directly impact dieting, bulimia, food pre-occupations, and issues pertinent to oral control [27]. The participants were asked to indicate their level of agreement on a six-point Likert scale (“always,” “usually,” “often,” “sometimes,” “rarely,” and “never”). The score ≥ 20 denotes case-ness for disordered eating. The literature of EAT-26 exhibits cross-cultural applicability among various research samples, including among Omanis [28]. For the present sample, Tau-equivalent reliability was found to be adequate (Cronbach's alpha = 0.80).
The Pittsburgh Sleep Quality Index
The Pittsburgh Sleep Quality Index (PSQI) is a 19-item questionnaire used to assess the quality and pattern of sleep among the sample over the previous one-month period [29]. It assesses seven components of sleep – sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medications, and daytime dysfunction. Each component carries a score ranging from 0 to 3, with a score of 0 indicating no difficulty and a score of 3 indicating severe difficulty. The scores from each component are added to give a total score, also called a “global score” (ranging from 0 to 21). A total score > 5 signifies a poor quality of sleep, while that of ≤ 5 signifies the acceptable quality of sleep. For the present sample, Tau-equivalent reliability was found to be adequate (Cronbach's alpha = 0.86).
Statistical analysis
The total number of medical students registered in the College of Medicine of SQU during the academic year 2019–2020 was 700. To estimate the sample size, we used the OpenEpi® software (www.openepi.software.informer.com) to calculate the sample size. The sample size was calculated with a type-1 error of 5.0% (alpha = 0.05) and 95% level of significance, to reach a power level of 95%, with a design effect of 1. Therefore, the minimum sample size required was 249. Participants were selected through convenience sampling.
We used descriptive statistics (e.g., percentage, mean, standard deviation, and median) to explore the sociodemographic (e.g., gender, age) and clinical (e.g., sleep problems, eating disorder) profiles of the study's participants' and to identify how they may relate to the prevalence of stress, sleep disorders, and eating disorders among medical students in SQU. To identify the contributing variables associated with stress subtypes (PSS-10 score: no stress < 20m stress 20 +), the first univariate analysis was used to explore the association/difference between stress subtypes with sociodemographic and clinical variables.
We used Chi-square/Fisher's exact test/odds ratio (OR) for categorical variables and t-test for continuous variables. Next, a logistic regression model (enter method) was used, where stress subtypes were the dependent variable. The variables that showed significance in the univariate analysis were included in the model as independent variables and concurrently adjusted by each other.
We computed all the study data with the International Business Machine Statistical Package for the Social Science software version 19 for Windows (IBM SPSS Company, Armonk, New York, USA). The differences between the groups were considered significant if p-values were lesser than 0.05.
| Results | | |
[Table 1] shows the results for sociodemographic and clinical variables and their associations with each other. There were more females (73.1%) than males (26.9%) at an average age of 22.0 ± 2.0 (mean ± standard deviation [SD]) years. About 98.8% (n = 250) of them were Omani, and more than 77% (n = 196) of them were senior students (4th–6th year). Their average BMI was 23.6 ± 5.9 (mean ± SD) kg/m2. A small percentage of the cohort had a history of psychiatric illness (9.9%, n = 25) and required regular medications (7.5%, n = 19). The scores of the students obtained on the PSS-10 indicated that the rate of perceived stress was 51.4% (n = 130). On administering the EAT-26 scale to the participants, 16.2% of the sample had a score that indicated case-ness for disordered eating. The PSQI depicted that 79.1% of the sample had poor quality and disturbed patterns of sleep. | Table 1: Sociodemographic factors and clinical measurements of the study samples (N = 253)
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For theoretical interest, the present study explored the relationship between the indices of perceived stress, disordered eating, and quality and pattern of sleep. [Table 2] shows a correlation matrix. The correlation values between perceived stress on sleep quality and disordered eating levels were significant, at 0.419 (p < 0.001) and 0.246 (p < 0.001), respectively. On the other hand, no significant correlation was found between poor sleep quality and disordered eating levels. | Table 2: Correlation matrix of student's perceived stress, sleeping quality, and eating disorder levels
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[Table 3] presents the univariate and logistic regression analyses. The logistic analysis showed that demographic and clinical variables were having some risk factors for the cohort's perceived stress. The model was a good fit according to the Hosmer–Lemeshow goodness-of-fit test (χ2 = 8.456, p = 0.390), with a predicting power of 64.0% (sensitivity = 76.2%, specificity = 51.2%). Students who were significantly younger (OR = 0.926, p < 0.01) and studied at a junior level (1st–3rd year) were 2.3 times (OR = 2.322, p < 0.05) significantly more stressed compared to older and senior year students (year 4th–7th year). On the clinical side, students who had sleeping disorders were 6.1 times (OR = 6.074, p < 0.001) significantly more stressed than those without a sleeping problem. | Table 3: Univariate and logistic regression analysis on perceived stress for students in the association of sociodemographic factors and clinical measurements
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| Discussion | | |
Oman is an emerging economy that currently fulfills the criteria for the second phase of demographics in transition [30]. Societies in such phases tend to have pyramidal-like population structures which imply that there is a preponderance of the young population or “youth bulge” in its about four million strong population [31]. Safeguarding the well-being of the upcoming youth with bright futures is therefore paramount. According to longitudinal psychiatric epidemiology, most adult mental health issues and poor social outcomes originate from childhood or adolescence [32]. This resonates with Wordsworth's statement that “the child is the father of the man” [33]. Therefore, concerted efforts are needed to safeguard their well-being. While some preliminary studies on different types of predicaments faced by the Omani population in educational streams have been explored, to date, the factors associated with perceived stress among medical students have received negligible attention. Perceived stress is high among medical students as compared to the general population [34],[35]. Indeed, the professions medical students aspire for appear to be marked with poor coping mechanisms followed by high professional demands, which may consequently steer them toward developing several psychological issues, including poor mental health outcomes. This could further result in the compromise of the quality of care delivered to their patients in their respective specializations.
The cohort accrued for this study were to adequately represent the medical student population from the current single institute. The first objective of this study was to explore the prevalence of perceived stress, disordered eating, and subjectively reported sleep problems. These are discussed below in tandem.
Findings from the present study indicate that 51.4% of the sample scored case-ness for perceived stress [Table 1]. In the neighboring countries, using various instruments, the magnitude of stress and the resultant burnout have been widely documented. In Saudi Arabia, it has been reported that the stress and burnout affects about 31%–96.3% of the college-going population [36],[37],[38],[39],[40],[41],[42]. In Bahrain, Al Ubaidi et al. [43] and Sanad [44] reported that rate of stress and distress afflicts 47%–92.5% of medical students, while in Kuwait and Qatar, the reported rate ranges from 43% to 76.7% [45],[46],[47]. In Pakistan, Shah et al. reported that 30.84% of medical students in Lahore, Pakistan, exhibit the presence of perceived stress, 16.2% of them have disordered eating, and 79.1% of them have poor quality and disrupted patterns of sleep [34]. In India, Chowdhury et al. reported that 46.3% of medical students in Kolkata, India, exhibit perceived stress [48]. These studies from different parts of the world suggest that the concept of perceived stress is common among medical trainees around the world. The current study's result of 51.4% [Table 1] is in the middle range of the global trend.
Along with perceived stress, disordered eating has been reported to be rife among medical students. Various studies have emerged on body dissatisfaction and disordered eating in the Arabian Gulf population. In Qatar, Kronfol et al. [49], Al-Thani and Khaled [50], and Nasrallah et al. [51] reported that 18%–31.2% of the college-going population exhibit body dissatisfaction and disordered eating. In Kuwait, Musaiger et al. [52] and Ebrahim et al. [53] reported 32.8%–46.2% of the sample to be marked with body dissatisfaction and disordered eating. In the UAE, O'Hara et al. [54], Thomas et al. [55], Thomas et al. [56], Schulte and Thomas [57], and Radwan et al. [58] have reported a similar frequency of 20%–33% of body dissatisfaction and disordered eating. The presently observed frequency of 16.2% [Table 1] of the sample exhibiting disordered eating is lower compared to previous studies among the school-going population in Oman, where 20%–29% of the studies' participants exhibited deliberate food restriction [26]. This may stem from the fact that disordered eating and deliberate food restriction tend to peak during puberty when growth spurts are common [59]. Jahrami et al. conducted a global systematic review and meta-analysis on the prevalence of disordered eating and have reported a pooled prevalence of 10.4% [60]. Out of the various antecedents of disordered eating, including dietary changes and varying body image issues, disordered eating often develops as a maladaptive coping strategy to deal with stress. In support of the latter, various studies in the Arabian Gulf suggested that emotional eating and night-eating syndrome are common phenomena among the youth [61],[62],[63]. Overall, disordered eating has long-term adverse effects on an individual, if left untreated [64]. If the present temporal relationship between stress and eating disorders can withstand further scrutiny and is amenable to intervention, then culturally sensitive preventative measures need to be devised and be made available for medical students in Oman.
The related objective of this study was to examine the predictors of perceived stress. As shown in [Table 3], variables such as age (p < 0.01), year of medical study (p < 0.05), and having poor quality and disturbed patterns of sleep (p < 0.001) were significant when evaluating the multivariate (logistic regression) analysis. On a bright note, there were fewer cumulative effects of perceived stress reported in this study, which contrasts with the results in other similar studies [65]. In the present study [Table 3], those in the first three years of their medical training were significantly more likely to report the vagaries of stress and distress (p < 0.01) when compared to those in their senior years (≥ four years of medical education). Another dissenting view on the “cumulative stress hypothesis” is indicated in the present study, which suggests a substantial association between being younger and experiencing perceived stress. The result of the present study, therefore, does not support the view that those who are afflicted with poor coping at the beginning of their career or training are likely to have these issues persist throughout their medical education. Future studies should examine whether there are sociocultural differences in factors contributing to perceived stress as individuals grow older.
Daytime sleepiness resulting from lack of sleep or irregular sleep schedules affects about 50% of the student population [66]. A previous study in Oman reported that 99.8% of college-going students have subjective sleep problems [67]. The reported poor quality and disrupted patterns of sleep in Saudi Arabia range from 63.2% to 86.3% [41],[68]. Quality and quantity of sleep were significant in shaping poor mental outcomes among the present study's participants [Table 3]. Results from the PSQI used to assess the present sample of medical students in Oman depicted that 79.1% were having poor quality and disrupted patterns of sleep [Table 1]. In the multivariate (logistic regression) analysis [Table 2], the subjective reporting of poor quality of sleep was significantly to be associated with perceived stress (p < 0.001). This view is consistent with other similar studies where medical students and the nature of the profession were found to negatively impact the quality and quantity of sleep [69],[70]. This is an important concern that requires swift action by concerned authorities, either at the university or government levels. Studies suggested that even when experiencing stress, good quality and quantity sleep has the potential to “scavenge” residual stress in the body [71]. A review by Curcio et al. [72] suggested that student learning and academic performance are closely linked to sleep quality and quantity. Sleep stabilizes and enhances cognitive processes. Cognitive competencies such as the consolidation and encoding of memories, critical and creative thinking, and problem-solving skills are very important for higher education. This is especially true for medical education because of the need to study a substantial amount of complex factual knowledge within a short time and retain the information for a prolonged duration of time [17].
Study limitations
The readers are cautioned against over-interpreting study results because this study has four limitations:
- This is a cross-sectional study that is inherently unfit to determine cause and effect.
- The majority of the participants were female (73.1%) in this study. This is consistent with the situation on the ground where the medical profession is increasingly constituted by the female workforce [73]. To generalize the implications of the present study, the sample should comprise an equivalent number of male and female medical students.
- Some of the outcome measures used, such as the PSQI, are suboptimal for quantifying the quality and quantity of sleep compared to the “gold standard” of sleep evaluation, namely, polysomnography (sleep studies) with modern objective measures. Similarly, criticism could arise regarding the efficacy of the PSS and EAT-26. Future studies could employ objective measures that are considered to serve as the gold standard for eating disorders and stress.
- This study was designed and planned to be executed before the onset of the COVID-19 pandemic. But because of logistical factors, it was conducted during the pandemic period.
This means that the study had to rely on an online survey to collect data, thus bearing all the limitations of using online platforms for such research work [74]. Related to this point, the pandemic has caused a global rise in poor mental health outcomes among the general population and among medical students and healthcare workers in particular [75]. This would imply that the prevalence that has been noted might be “contaminated with COVID-19 factors,” such as lockdown, social isolation, and economic contradiction. Thus, the generalizability of this study could be impacted by such a confounder.
Summary
Despite the growth of medical school education in the Arabian Gulf, aspects of stress and distress such as perceived stress, disordered eating, and quality and quantity of sleep among medical students have not received their due attention. The plethora of studies have suggested that various psychosocial dysfunctions are common among medical students and their prompt recognition and mitigation are paramount. To fill the gap in the literature, this study explored the prevalence of perceived stress, poor sleep hygiene, and disordered eating among medical students in one such Arabian Gulf country, Oman. The predictors and risk factors of perceived stress were also explored. The rate of poor mental health outcomes is to be congruent to the rates that have been reported from other parts of the world. The factors heightening perceived stress included age, years in medical education, and subjective sleep deprivation. Further research is needed using more robust methodology to scrutinize the results so that culturally sensitive preventive and mitigating measures can be contemplated and implemented.
| Acknowledgment | | |
The authors thank Dina Said Khalfan Fatah for her technical support in drawing the map of Oman.
| Financial Support and Sponsorship | | |
None.
| Conflicts of Interest | | |
The author declares no conflicts of interest in writing this report.
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[Figure 1]
[Table 1], [Table 2], [Table 3]
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