Qatar Medical Journal - Volume 1998, Issue 2

Papers considered for publication in Qatar Medical Journal are those reporting original work, review articles and case reports that are particularly relevant to medicine in the broad sense. Editorials and Review articles are by invitation.

The antiphospholipid syndrome (APS), first described in 1983(1), is now recognised as one of the most common acquired thrombophilia(2). The syndrome is defined by the presence of antiphospholipid antibodies (aPL) [a positive anticardiolipin antibody (aCL) assay and/or lupus anticoagulant (LA)] and a history of either arterial or venous thrombosis and/or recurrent pregnancy loss (Table 1). Some of these patients may also have other features such as mild thrombocytopenia, heart valve disease, cutaneous ulcers, and, most commonly, livedo reticularis. Pulmonary embolism, often multiple and associated with deep venous thrombosis and pulmonary hypertension are potentially life-threatening features of this syndrome.

Hyperlipidemic pancreatitis represents one of the most acute and dramatic consequences of the chylomicronemia syndrome which, if misdiagnosed, can lead to pancreatic destruction and death.

A retrospective analysis of 16 cases admitted to Hamad General Hospital since 1990 investigated the relationship between hyperlipidemia and pancreatitis.

All the patients had discrete, recurrent episodes of acute pancreatitis with typical pain, hyperamylasemia and hypertriglyceridemia. Acute pancreatitis usually occurred when the serum triglyceride levels were above 10 mmol/L. Chylomicronemia, with the serum being visibly creamy, was a constant feature of the lipoprotein pattern of the patients during these acute episodes.

It seems that chylomicronemia is the most consistent feature of hyperlipidemic pancreatitis. Most patients respond well to a low fat diet but lipid lowering agents are generally required to prevent recurrence.

We reviewed 35 cases of bronchiectasis seen at the Department of Pediatrics of Hamad Medical Corporation in the State of Qatar. The main objective was to determine the etiology and the clinical features and to evaluate their management Ages ranged from 7 months to 12 years with a mean of 63.8 months. The male to female ratio was 1.7:1 and 23 (65.9%) of the cases were diagnosed before the age of six years.

Cough was present in every case and rales in 30 (85.7%) of the cases. Dyspnea, wheezing, clubbing and failure to thrive were found less frequently. The cause of the bronchiectasis was unidentifiable in almost 50% of the cases and in the remainder it was due to childhood infection (2 cases), congenital and genetic disorders (6 cases, including 4 cases of cystic fibrosis, 1 case of ciliary dyskinesia and 1 case with congenital right middle lobe bronchus stenosis), immune defects (4 cases), airway obstruction (4 cases, including two cases of foreign body aspiration), extrinsic compression (1 case), bronchial asthma with right middle lobe syndrome (1 case) and four miscellaneous cases: Down's syndrome with A-Vcanal (1 case), persistent RLL atelectasis (2 cases), and mediastinal lymphadenopathy with persistent LLL atelectasis (1 case).

Of the various diagnostic methods available, CT was found to be the most conclusive and surpasses the other diagnostic modifies of bronchiectasis in children and should then be resorted to any clinical suspicion of the disease.

The outcome of medical treatment, (excluding 4 cases of cystic fibrosis) was that 7 cases missedfollow-up, 7 cases responded favorably, 4 cases remained unchanged, 2 cases died (one with HIV and one with Down's syndrome and congenital heart disease) and 11 cases were referred for surgery. Both medical and surgical treatments are discussed and the recommendations for surgery outlined. Address for correspond

Twenty-one patients with unstable burst fractures of the thoracolumbar spine (T12-L3) were treated with narrow DC plates and 6.5mm cancellous pedicle screws. The number of levels instrumented in all patients were only one level above and one level below the fracture. Follow-up averaged 22 months (range 12-45 months). The correction of kyphotic angle in all patients averaged 6.1 degrees at follow-up, while in patients with fractures above L2 level 1.4 degrees, and in patients with fractures below L2 level 24 degrees.

The improvement of vertebral segment height for all patients averaged 5% of normal at follow-up, while in patients with fractures above L2 level 3%, and in patients with fractures below L2 level 11% The neurologic improvement averaged 1.7 Frankel grades (range, 1-3). The fixation was stable enough to allow early mobilization and rehabilitation. There were no screw breakage of implant failure, and solid fusion was obtained in all patients.

The history of epilepsy is probably as long as human race. It is estimated that 6-7% of population suffer at least one seizure at some time in their life, between 0.5-1% of Population suffer from active epilepsy. Drug treatment even when successful is only suppressive, since none of the drugs ls curative. Surgical approach, hence is more logical as it would eliminate the cause of the seizures. In pediatric age group, the need or early surgery is even greater as frequent seizure activity interferes with neuronal migration, leading to mental retardation.

For several years only small number of patients were offered surgery, however, advances in neuroimaging studies and development of new surgical techniques have enabled Us to deal with the lesion in the eloquent areas, without any major problem.

A series is presented of 30 patients with generalized myasthenia gravis (MG) who were treated by sternal split and extended thymectomy. The mean age was 22 years, median 19 years with a female to male ratio of 2:1. The overall improvement rate was 90%; 70% achieved drug-free remission and another 20% required decreased medication. Drug-free remission was achieved in 80% female and in 50% male and in 50% on steriods and mestinon compared with 80% of those on mestinon alone. There were no deaths or significant complications. These results suggest that an aggressive surgical approach to myasthenia gravis can result in a higher percentage of drug-free remissions.

The purpose of this study was to validate Pugh's modification of the Child-Turcotte Classification (CTC) in the prediction of mortality in patients with liver cirrhosis.

A cohort of 45 cirrhotics collected in Mosul Teaching Hospitals, Iraq, was followed for five years and deaths were recorded at twelve month intervals from the individual dates of diagnosis. Cohort analysis and estimation of Relative Risk measured the strength of the association between Pugh's classes and five year mortality. Life table analysis was used to compute the probability of survival or death in each year during the 5 year period.

Results . During the five-year period of study twenty patients died. Eighteen of the total deaths (90%) occurred in class C (severe class) from which 78% of the patients died while only two (15% of the group) died in class B (Relative Risk = 5.2). None died in class A (mild class).

In the first year 20% of the cohort died (all from Class C) and the Life Table Analysis showed a high probability of death for the whole cohort. A further 24% died during the next four years..

Conclusion - Pugh's grading can confidently be used in clinical practice to categorize the chances of patient survival. Patients with cirrhosis in the severe grade have a poor chance of survival.

To discover the pattern of upper GIT (Gastro-intestinal tract) bleeding in the north of Jordan.

A retrospective study of 110 patients with upper GIT bleeding who had been admitted to the Prince Rashed Hospital between the 1st July1995 and the 31st December 1996.

The mean age was 52 years; NSAI intake was reported in 26 patients (23%); 60% of the patients had duodenal ulcers; the mortality was nine per cent.

With regard to age and endoscopic findings, the pattern of acute upper GIT bleeding showed some differences Compared to other parts of the world. Initial resuscitation is the first priority as shock is an important factor determining mortality.

By using the Silver Platten International CD-ROM version with MedSPIRS of the database Medline from 1966 to 1995 the intention of this survey was to investigate biomedical research in a developing country, Afghanistan, through collating the number and types of publications and to review the number of publications concerned with diseases of particular relevance to the country.

Six hundred and two publications were identified and their types and distribution are discussed in relation to Afghanistan and to developing countries in general and to research published from more developed regions of the World.

Two hundred patients presenting at the Emergency Department (ED) with signs and symptoms of acute asthma and requiring emergency management were studied to determine their response to repeated nebulization with B-2 agonist. This was effective in 83% while a further 14% needed the addition of intravenous hydrocortisone. The remaining 3% did not improve and were admitted.

We concluded that the assessment of the severity of asthma is easy for a primary care doctor and that B-2 agonist nebulization is an effective, safe and easily applied method of treatment.

The aim of this study is to report the indications for corneal grafting at (KHMC) during the past four years.

The study includes a review of 282 eyes that had undergone penetrating keratoplasty from January 1993 till December 1996. The age range was from 6 to 75 years and the female to male ratio was 1:1.15.

The study revealed that the indications for penetrating keratoplasty in respective order were; keratoconus, pseudophakic bullous keratopathy, rejected graft, corneal dystrophies, and corneal opacities.

It was found that keratoconus is the commonest indication for penetrating keratoplasty at KHMC, 73% of which were accompanied with vernal cattarh. Vernal catarrh poses a major challenge to ophthalmologists in the Middle East because it is common, has no satisfactory treatment, and leads to poor vision. Bullous keratopathy is the second commonest cause for penetrating keratoplasty.

Objectives and methods: In Jordan no data have been reported on the frequency and diversity of hematological abnormalities occurring in brucellosis in adults. In order to determine the hematological changes during the active course of the disease, 217 adult patients, (ages ranging from l4 to 75 years; mean 28.7 years) were studied Prospectively at the Jordan University Hospital during the Period 1987-1996. Two hundred and eleven patients who had a clinical picture suggestive of human brucellosis were admitted to the hospital for investigations.

Results: From 175 cases proved to have brucellosis, anemia was detected in 76 (43.4%) patients; leukopenia in (15.4%)patients; lymphocytosis in 87 (49.7%) patients and lymphopenia in 27 (15.4%)patients. Thrombocytopenia

was found in 13 (7.4 %) and pancytopenia inl2 (6.9 %) Patients. Patients with a brucella antibody titre (1280 were found to be more likely to develop bone marrow granulomata. Hypersplenism and hemophagocytosis appeared to play a role in producing these abnormalities of the peripheral blood. There was no significant relation between bone marrow granuloma and the above hematological abnormalities.

Conclusion: Brucellosis may be included in the differential diagnosis of patients presenting with anemia, leukopenia, thrombocytopenia and pancytopenia especially in areas such as Jordan where the disease is endemic.

A prospective study was carried out to demonstrate the bacteriology of post-traumatic bone infections with particular attention to the role of anaerobic microorganisms. Compound fracture was found to be the most common predisposing factor for infection. Seventy-seven patients were studied and a total of 155 organisms was recovered (117 aerobes and 38 anaerobes). The most frequently isolated organisms were Pseudomonas aeruginosa and Klebsiella species. Bacteroides spp and Peptostreptococcus spp were the most common anaerobes isolated from 29 patients (37.7%). In five patients, anaerobes were the only organisms isolated (6.5% of total cases). It is concluded from this study that anaerobic bacteria play a role in post-traumatic osteomyelitis and routine anaerobic culture for all cases is recommended.

Seventy eight acute hepatitis B cases, identified by the presence of HbsAg and IgM anti-HBC markers, were compared with 102 normal individuals from malaria endemic areas in Ninevah (Northern Iraq). Both groups were asked for any history of malaria. More hepatitis B cases reported malaria (70.5%) than normal individuals (odd's ratio 11) which suggests that the vector of malaria plays a role in the transmission of hepatitis B.

This study is a comparison between the allowing of free clear fluids until about two hours preoperatively and the usual preoperative fasting.

In a prospective trial the residual volume and pH of gastric content were measured in 60 patients who were put into either a study group where the intake of free fluids was allowed up to two hours preoperatively or a control group who were fasted for six hours.

There were no significant differences between the study group's residual gastric volume (RGV) (22±16) and the control group's RGV (21±14) nor the study group's pH (2.5±0.8) and the control group's pH(2.3±0.9). There were no complications of aspiration or regurgitation in either group but the patients in the study group reported less preoperative thirst.

We believe that to allow the drinking of clear fluids until two hours before an operation is safe and enhances the comfort of the patient.

Objective: To evaluate the effectiveness of intravaginal prostaglandin E2 pessaries, for the induction of labor in intrauterine fetal death.

Design: Sixty five women at 20-40 weeks gestation, with intrauterine fetal death proved by ultrasound examination and with no history of previous delivery by caesarean section, were treated with 20mgprostaglandin E2 pessaries intravaginaly. The dose was repeated 8-hourly for up to 48 hours until effective uterine contractions were obtained.

Setting: Patients with intrauterine fetal death who presented to King Hussein Medical Center in the period from 1994 to 1996.

Results: The mean time from induction to delivery was 14 hours, and only 4 patients (6%) required between 30 - 48 hours. Two patients (3%) required only 4 hours to deliver completely.

Conclusions: The use of prostaglandin E2 vaginal pessaries at a dose of 20mg every 8 hours appears to be a safe, effective, practical method for the termination of pregnancy in intrauterine fetal death.