Qatar Medical Journal - Volume 2000, Issue 2

Ibn Zuhr, known in the West as Avenzoar, was one of the greatest physicians, clini-cians and parasitologists of the Middle Ages. Some historians of science have declared him as the greatest of the Muslim phy-sicians since Al Razi (Rhazes) of Baghdad. Some of his con-temporaries called him the greatest physician since Galen.

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.

Advances in molecular genetics have now established that Cystic Fibrosis (CF) is due to DNA variations which modify the sequence, structure, function and/or expression of the CF transmembrane conductance regulator (CFTR) gene. To date over 885 such variations have been described. However, worldwide 65% of all CFTR gene mutations are a result of the DF508 mutation.

Al Razi was the first physician in history to describe in detail the symptoms and signs of smallpox and measles based upon clinical examination. He was the first to dis-tinguish between the two diseases by what is called now ’the differential diagnosis'in “The Book on Smallpox and Measles”. A manuscript of this book is kept now in Lieden University, Netherlands (manuscript #656) and a micro-film copy is in our institute at Aleppo. This book of four-teen chapters was twice translated into Latin in the 18^th century. The third chapter on the symptoms suggesting the exacerbation of smallpox and measles is considered the most important The aim of this study is to reveal the im-portance of this book in the history of Islamic medicine.

Erectile dysfunction (ED) is a common problem in males. About half of all men over 40 years of age suffer from some degree of ED and in half of them the dysfunction is moderate or complete. More than 90% of men with ED do not seek treatment either because they are not comfortable with the subject or because, until very recently, the effective treatments available were invasive. Recent publicity about male sexual health and the availability, for the first time, of an oral medication which is specific and effective in the management of ED have made male patients more vocal about their sexual problems, especially to their doctors. These developments have also made doctors more aware of the magnitude of this problem.

In order to compare one-stage versus multiple-stage pull-through for Hirschsprung disease (HD) and comment on transanal pull-through without laparotomy, we reviewed 35 patients operated on for HD in the last six years. Ages ranged from 1 week to 14 years with 16 patients presenting neonatally. Sixteen patients had multiple-stage and 19 single-stage pull-through. Twenty-one patients had the Swenson procedure, five the Duhamel, seven the Soave pull-through and two the Lister Martin procedure for total colonic aganglionosis.

We conclude that the one stage pull-through is effec-tive, saves the patient multiple operations, recurring costs and long hospital stays, and also saves both the patient and family the psychological trauma of colostomy.

This was a retrospective study analyzing surgical treat-ment of rigid, non-teratologic talipes equinovarus (club foot deformity) in Qatar in the ten year period from 1990 to 1999. Treatment started early (as soon as the patient was referred, usually during the first two - three weeks of de-livery) with serial manipulation and adhesive strapping or plaster of paris casting. When clinically indicated, soft tis-sue release was performed.

One hundred and twenty one feet were operated upon in Hamad General Hospital during that period. (73 patients, 46 male, 27 female). Postero-medial release was done in 73 feet; Achilles tendon lengthening in eight feet; posterior release in 32 feet. Most primary soft tissue procedures were performed between two and ten months of age. Primary bony procedures were done for eight feet with late presentation.

Posterior release alone resulted in a higher rate of secondary procedures (53%), whereas postero-medial release resulted in only 22%. Therefore we recommend postero-medial release whenever in doubt about the adequacy of posterior release.

Fifty-six needle liver biopsies from 28 patients with viral hepatitis B (15 cases) and hepatitis C (13 cases) treated with Interferon alpha for a minimum of six months were studied with the aim of determining the role of MGP-positive lymphoid cell infiltrates in the response to treatment with interferon. Besides assessing the MGP-positive cells, the following parameters were assessed and graded: (i) Inflammation in and around the portal tracts, (ii) fibrosis, nodularity and cirrhosis, (iii) piece-meal necrosis (inter-face hepatitis), (iv) lobular activity, (v) stainable iron. Sec-tions were stained with H&E, PAS, PASD, Perl, Masson Trichrome and MGP (Methyl Green Pyronin). All the parameters were graded 1 to 3 except stainable iron which was noted as present or absent.

Fourteen patients (50%) demonstrated histological evidence of a response to treatment. Seven of these showed a very pronounced response with the post treatment liver bi-opsies returning almost to normal. Five of the seven, 27.8% of all MGP stained cases and 71% of all brisk responses, contained ten or more MGP-positive lymphoid cells in the portal tracts.

In contrast, the non-responsive and worsened cases con-tained less than five MGP-positive cells as well as a pre-dominantly small mature lymphocytic infiltrate in the por-tal tracts.

Severity of piece-meal necrosis, lobular activity, portal tract inflammation, the presence or absence of stainable iron, were not of predictive value in the response of viral hepatitis to treatment with interferon alpha.

It appears that MGP-positive lymphoid cells, most prob-ably immune competent activated lymphoid cells, have a positive influence on, and are of predictive value for, the response to treatment of viral hepatitis B and C with inter-feron alpha.

A prospective study of 34 Type 2 diabetic patients was carried out to determine the effect of Ramadan fasting on the lipid profiles; serum cholesterol, triglycerides, HDLcholesterol, LDL-cholesterol, Apo A-1, Apo B, Lp (a), and HbAjc. The comparison analysis of the pre-fasting with fasting and post-fasting samples did not reveal any statistically significant changes in the value of the lipid profiles. In the biochemical profile there was a slight change in the serum albumin but otherwise there was no change in the other biochemical values. The study was conducted in the Outpatient Department at Hamad Medical Corporation from November 1999 to February 2000.

There is great concern about the risks inflicted by intubation of patients with a potential instability of the cervical spine, as in trauma cases and in patients scheduled for elective cervical spine surgery. Some of these patients may have neurological manifestations of cord compression and limited neck movement, which can range from severe to mild. Intubation requires flexion and extension of the head and neck “Sniffing Position” to achieve optimum visualization of the vocal cords. In our institute the care given to ensure the stability of the cervical spine during intubation is either by Manual In-Line Axial Stabilization (MIAS) or by the use of Intubating-Laryngeal Mask Airway (LMA) or Bullard Laryngoscope or awke intubationin the operating theatre. All of these techniques put a minimal burden on the cervical spine and reduce the chances of neurological deficits or aggravation of an existing one. In this study we relate our experience with the Bullard Laryngoscope in these cases.

Four hundred and thirty three patients with various types of fractures of facial bones were studied and analysed together with statistics related to the etiology, site, age and sex. Sixty per cent of the cases were below 30 years of age. The male to female ratio was 5.5:1.

Sixty four per cent had fracture of the mandible alone, with fracture of the body of the mandible accounting for a quarter of the total number of cases. Only twenty per cent had fractures of the middle third of the face.

Injuries from road traffic accidents were the major causes of fractures in 258 patients (59.6%), followed by fights in 99 cases (22.9%) and falls in 69 cases (16%).

Between September 1996 and May 1999 twenty six pa-tients with a pancreatic mass were studied. In 24 patients (92.3%) the masses could be detected by ultrasound but were not detectable in the other two cases. In the 24 pa-tients percutaneous FN AC under u/s guidance produced only one complication.

The accuracy of this test in diagnosing pancreatic ma-lignant tumours was 90.4%. Laparotomy was not neces-sary in three cases with advanced pancreatic carcinoma (11.5%) and the material aspirated was not suitable for di-agnosis in three cases. No benign lesions were found and so it was not possible to estimate the reliability of FN AC in their diagnosis.

In order to study the specificity and the sensitivity of a locally produced scoring system to differentiate between septic arthritis and transient synovitis at initial presentation, the records of 33 cases of irritable hip, 24 males and nine females, in the Pediatric departments of King Hussein Medical Center and Prince Rashid Military Hospital, Jordan, were reviewed retrospectively. Septic arthritis was diagnosed in nine patients all of whom scored nine or above; none were missed with false low scores. The sensitivity and specificity for this local scoring system were calculated to be 100% and 91.66% respectively. The positive predictive value was 81.81%.

Conclusion: There is a significant overlap in the temperature; erythrocyte sedimentation rate and WBC count in children with toxic synovitis and septic arthritis of the hip. We found our local scoring system useful in predicting the patients at high or moderate risk of septic arthritis thus avoiding unnecessary invasive investigations and unjustified prolonged admissions and antimicrobial treatment.

This prospective study was carried out in Basrah ma-ternity hospital (Basrah-Iraq) during the eight months of Dec.1997-Aug.1998 to study the obstetrical performance and outcome of pregnancy in 20 (>90kg) obese patients compared to 20 non-obese controls.

The incidence of obesity in their infants was also com-pared. There was no significant increase in the incidence of urinary tract infection, diabetes, caesarean section and forceps delivery.

There was a significantly increased incidence of hyper-tensive disorders of pregnancy (P < 0.01 odds ratio 0.33), and also inadequate weight gain (P < 0.01).

Apgar scores and perinatal mortality were not signifi-cantly different in the two groups.

Forty five patients with liver cirrhosis were compared with 60 other chronically ill patients in an attempt to evaluate the use of leading symptoms, leading signs, laboratory tests and various combinations of the three, in the accurate diagnosis of liver cirrhosis. It was found that a combination of leading symptoms and leading signs gave a high sensitivity rate but with an increased likelihood of false positives which needed to be mitigated by certain laboratory tests. It is recommended that the prevalence of the disease within the community is also taken into account when interpreting results.

Purpose: To assess the local experience with the percutaneous fluoroscopic gastrostomy (PG) with regard to indications, outcome, limitations and complications of the procedure.

Method: Retrospective analysis of 33 patients in whom PG was requested and performed over a period of 6 years.

Results: All 33 patients had successful catheter placement. Six patients had their catheters advanced to the jejunum (transgastric jejunostomy). Two patients had PG after failed endoscopic gastrostomy (EG). No major complications were encountered within the first 30 days. Minor complications were noted in seven patients (21%). Three patients (9%) had local infection at the stoma. The other four patients (12%) had catheter occlusion (use-related complications) that required catheter change. Longterm follow-up in eight patients showed a pericatheter leak at the stoma in three patients that was managed by change and step-up in the feeding catheter; French size. There was no 30-day mortality.

Conclusion: The results indicate that PG is a safe and effective method for enteral feeding. It is useful for short and long-term feeding. Failed EG can be considered an indication for PG.

Between November 1998 and May 1999 a prospective study for HCV antibodies was conducted on 200 patients (113 males and 87 females), with B-thalassemia major and sickle cell-thalassemia, who were attending the thalassemia center at Basrah Maternity and Children Hospital. Their ages ranged from 1-18 years with a mean age of 9 years.

Nineteen patients (9.5%) were found to have antibodies in comparison to only one (0.5%) amongst the 200 children of a control group. The risk of exposure to HCV was higher than for HBs antigen and HIV amongst the same patients.

Anti-HCV seropositivity was significantly higher amongst patients with B-thalassemia major than patients with sickle cell-thalassemia and patients older than 10 years.

The study showed also that anti-HCV seropositivity was directly related to the frequency of blood transfusion and there were significant elevations of serum bilirubin and aminotransferase levels amongst seropositive thalassemic patients compared to seronegative patients.

Difficult intubation has an incidence of 1.5-8.5%. Failed intubation occurs in 0.13-0.3% of general anaesthetics and it has been found that 30% of the mortality attributed to anaesthesia is related to difficulties in the management of the airway(1). Many techniques and instruments have been advocated in the management of difficult airways; one of these being the Bullard laryngoscope (BL). We report the management of two cases of difficult airway due to limited mouth opening using the Bullard laryngoscope.

A 15-year-old girl sustained a jelly fish sting to her left hand and subsequently developed acute vascular insuffi-ciency of the left index and middle fingers with a threat of distal gangrene.

Jelly fish venoms are complex mixtures of polypeptides and enzymes pathogenic to man by means of their anti-genic properties. Fatal reactions can be caused by hy-persensitivity of the toxins on the heart, respiratory center or kidneys. Local or generalized skin eruption, exagger-ated local oedema, local fat atrophy and pigmentary changes are also features of the jelly fish sting. A direct neurotoxic effect of the jelly fish venom on big nerves as radial, median and ulnar nerve palsies has been reported by Peel.

A Qatari boy presented at birth with muscular weakness and was diagnosed as a case of Walker Warburg syndrome (WWS) on the basis of muscular dystrophy, eye abnormalities and brain anomalies. This is believed to be the first case of WWS reported from the Arab countries. Other similar muscular dystrophies associated with brain anomalies are described and discussed.

Report of a rare occurrence of koro-like symptoms as a part of transient post-ictal schizophrenia-like psychosis in a Jordanian patient The etiology is reviewed in relation to the literature.

Hypolalemic periodic paralysis is an uncommon complication of thyrotoxicosis. It usually affects men of Oriental origin and presents with acute and profound muscle weakness especially of the lower extremities. We report a 46 year old man from Kuwait with sudden paralysis of both legs. Physical examination showed signs of thyrotoxicosis and laboratory tests revealed severe hypokalemia, very low serum thyroid-stimulating hormone and very high free thyroxin. The motor deficit regressed within 8 hours of 80 mmol ofKCI infusion. Awareness of such a problem is essential to avoid life threatening cardiac arrhythmia. Once recognized the treatment is simple and the prognosis is excellent.