Qatar Medical Journal - Volume 2002, Issue 1

We have received many requests from colleagues in Qatar and abroad to re-publish the biographies of the Muslim physicians and scientists who contributed to the development of science and medicine as we know it today.

Ibn Sina, also called Ave Sina, was a Muslim Physician bom in 980 in Bukhara, at the periphery of the Muslim em-pire. He was a philosopher, astronomer and poet.

Al Razi known as “Rhazes” was a Muslim physician and philo-sopher born in Rayy near Tehran. He studied chemistry first then medicine.

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.

June 2000 heralded the first draft of the human genome and with it a tremendous amount of public attention to this monumental achievement Amidst the excitement regarding the potential impact on clinical medicine and anticipating uthe development of rational strategies for minimizing or preventing disease phenotypes altogether” there has also arisen concern about the ethical use of this new technology as well as a healthy dose of skepticism about its ultimate application to clinical care. Clearly, as technology continues to elucidate new genes and theirfunction, both in normal development and pathology, questions and concerns about practical applications of this information will continue to arise. The goal of this article is to review the impact of the discoveries of Human Genome Project (HGP) on the practice of genetic counselling and clinical care as well as to discuss the potential ethical dilemmas, which may arise.

The International Guidelines 2000 Conference on Cardiop-ulmonary Resuscitation and Emergency Cardiovascular Care was the world's first international conference to produce evi-dence-based international resuscitation guidelines.

Herein, we summarize the changes in these guidelines as it applies to Adult Basic Life Support (BLS). This interpretation is basically similar to that of the European Resuscitation Coun-cil (ERC). The changes have been incorporated into the cur-riculum of our Advanced Life Support (ALS) provider courses and the new 2001 ERC ALS manual.

The prevalence of Hepatitis A, B and C infection was assessed in sixty children with Down's syndrome (DS) and compared with sixty children with normal mentality by screening for HBsAg, HBeAg, anti-HBe, anti-HBc, anti-HBs and anti-HCVand HAV-Ig. Both groups had received three doses of recombinant DNA hepatitis vaccine at 0,1 and 6 months of age.

None of the children in either group were found to have any hepatitis viral antiginaemia, hepatitis marker or to have chronic viral hepatitis.

Hepatitis B vaccine protective efficacy which was es-tablished by the presence of anti-HBs >10 mil], was sig-nificantly lower in the DS than the control group (28.3% Vs 85%,p < 0.001).

None of the children in the DS group, after the age of seven years, had protective anti-HBs level as compared to 79% of the children in the control group.

Booster doses are not recommended for normal chil-dren even if they lose their antibody to HBV vaccine be-cause of the presence of immune memory. However, in children with DS, because of their immune deficiency, low vaccination response, and their predisposition to chronic hepatitis infection especially at school age, we recommend booster HBV vaccination for them at school entry.

Occupational stressors associated with compromised job satisfaction amongst general practitioners (e.g. time constraints, burdensome patient loads and interruptions in personal life) have been found to adversely affect the quality of primary health care services.

A cross-sectional survey of 128 physicians in 22 pri-mary health care centers in Qatar used a self-administered questionnaire on factors associated with job satisfaction. Most physicians reported time pressures attributable to large patient loads that appeared to affect the quality of work and personal life. Younger and female physicians reported frustration at not having time to read about new research and advances.

Methods of addressing these problems, such as an appointment system, were favorably received by most physicians. Strategies to reduce occupational stress on most of the physicians may involve allowing them greater control over their work environment and providing time for Continuing Medical Education and postgraduate studies. This, in turn, should lead to improved primary health care.

To correlate standard tuberculin skin test (TST) results in children diagnosed with active tuberculosis (TB), data was collected retrospectively from the tuberculosis treatment unit, State of Qatar, during the period 1992 to 1996. Sixtysix patients with confirmed tuberculosis included 42 (64%) with pulmonary TB, 24 (36%) with extra-pulmonary TB, 34 Qatar nationals (52%) and 36 females (55%). Mean TST was 13.5 mm ± 9.8mm. TST was negative in 18 (27%), 5-10 mm in three (5%), 10-15 mm in eight (12%) and 15mm or more in 37 (56%) patients. Lower false negative (reaction less than 10mm) was found in five (18%) of the older children (10 to 14 years).

It is concluded that, since one-third of the children with confirmed active tuberculosis had a false negative TST, clinical judgement remains the essential determinant. However, TST remains a potent aide for epidemiological and diagnostic purposes and periodic assessment of this is highly recommended.

Adult-onset StilVs disease remains a clinical diagnosis and a diagnosis of exclusion: its prompt recognition will avoid unnecessary diagnostic procedures and delay in ini-tiating therapy.

The clinical and laboratory features and treatment of 16 patients with Adult-onset StilVs Disease (AOSD) at Hamad General Hospital (HGH) were studied and com-pared with 62 patients of G. Pouchot.

Eight patients were female (50%), ten (62.5%) hadpoly-arthritis and rash, fourteen (87%) had fever > 39°C. Leu-kocytosis, thrombocytosis and hyperferritinemia were present in most of the patients.

Tracheostomy is a procedure commonly undertaken in critically ill patients since it has several advantages over prolonged translaryngeal intubation. For critically ill patients bedside tra-cheostomy can be performed by a percutaneous approach using either an incisional or a dilatational techniques. The major advantages of bedside percutaneous dilatational tracheostomy are that it is easy to perform, more rapid and less expensive.

Purpose: To describe the pattern of both types of pri-mary glaucoma in Qatari adult patients and to outline the main problem related to its management.

Material and Methods: A random sample of Qatari patients with primary glaucoma either open angle or angle closure glaucoma in whom the diagnosis was made after the age of 30 years was studied over the last 2 years (1997-1998) by standard questionnaire as regards their personal and medical profile, and assessed ophthalmologically both subjectively and objectively.

Results: 195 patients were studied, of whom 29.7% had angle closure glaucoma. Early presentation was clearly shown in both type of glaucoma. Legal blindness was present in significant proportion of patients.

Comment: Glaucoma in Qatari patients presents at an early age, with substantial loss of visual function at presentation. Poor compliance is an obstacle for manage-ment in both types of glaucomas. The need for an educa-tional campaign and a program for early detection is highly advised.

Xanthogranulomatous cholecystitis is a severe inflammatory process, which gives rise to dense adhesions that complicate cholecystectomy. Four cases of significant injuries to the main biliary passages and surrounding structures are discussed. We suggest greater caution in the dissection of the gall bladder; a lower threshold for early conversion, examining frozen sections in suspicious cases and accurate preoperative diagnosis whenever possible.

Qatar is a small country with a population of around 580,000. Over a period of 14 months a study was conducted on 520 infant hips to compare the results of ultra sound scanning of 260 high risk” babies; half of them (130) scanned before and the others scanned after increasing public awareness of the possible serious consequences of swaddling on neonate hips. Before this public awareness, of 130 babies scanned in a six months period 26 showed a form of acetabular dysplasia (20%), eighteen mild, four moderate and four severe. Two months after the public was made aware that swaddling could cause harmful effects on infants’ hips, 130 babies were scanned in a six months period. The number of babies with hip dysplasia was reduced to eight (6%), six mild, one moderate and another had severe acetabular dysplasia.

Fifty eight patients between the ages of six months and five years were studied in a randomized double-blind trial to determine whether dexamethasone has a role in the outpatient management of patients with acute viral croup of moderate severity. For various reasons, twelve were excluded from the final results. In the 46 patients who completed the study (32 males, 14 females) the only significant differences detected between the treatment groups were that the duration ofrhinorrhea was longer in the dexamethasone group compared with placebo (median 2,5 days vs 1,5 day) and the pre-discharge croup score was higher in the dexamethasone group compared with placebo (2 vs 0).

Conclusion: The use of dexamethasone in the outpatient management of viral croup is associated with a reduction in the severity of illness within 24 hours of treatment. Patients with viral croup of moderate severity should be considered candidates for the use of dexamethasone before discharge from the paediatric emergency clinic.

One hundred and one interns who completed internship during the year 2000 were surveyed by questionnaire to study the factors, manifestations and management strategies of stresses affecting them. Factors considered included personal and family, work and working conditions, training and interpersonal matters.

Approximately one out of three interns reported significant stress from not having enough time for family, insecurity about future and career; long working hours, frequent duties, lack of encouragement and supervision, lack of feedback, no one caring, and discriminations in gender and evaluations. Marriage did not seem to add significant stress during training.

It is concluded that medical internship is a stressful training period and it is suggested that support groups or advisory committees are needed to help and counsel interns about professional stress and provide psychological assistance when necessary.

We report a case of hepatocellular carcinoma in a forty five year old man with Hepatitis C virus and liver cirrhosis. He presented with headache, double vision and leftsided facial numbness. MRI and a CT scan of his head revealed metastasis at the base of the skull

Spontaneous rupture of the spleen is a rare complication of Plasmodium vivax malaria which may be under diagnosed. Recently we encountered such a case in an expatriate a few days after arriving from his country. The presentation was of fever; abdominal pain and vomiting. Computed tomographic scan and ultrasound were not helpful in making an initial diagnosis but the development of hypotension and a significant drop in hemoglobin later pointed to the diagnosis. The rupture was sufficiently severe to necessitate splenectomy. The case is described, treatment options are discussed and pertinent literature is reviewed.

Opsoclonus myoclonus syndrome (OMS) is a very rare syndrome which presents with ataxia, opsoclonus and myoclonus. We report the combined treatment of immunoglobulins and prednisolone compared to prednisolone alone in two patients. The diagnosis was based on the clinical findings. Work up for neuroblastoma was negative in both patients. Prednisolone treatment in the first patient was associated with slow response, relapses and toxic side effects. Immunoglobulins combined with prednisolone in the second patient were effective with neither relapse nor drug side effect. The clinical findings, differential diagnosis and the management are discussed. It appears that combined therapy with prednisolone and immunoglobulin gives better results. To the best of our knowledge this is first paper from the Middle East reporting this syndrome.

Intermittently draining cutaneous sinus tracts in the area of the face and neck may be caused by chronic dental infection. Diagnosis of the causes may be challenging but is the key to successful therapy. A case of cutaneous facial sinus tract related to a mandibular molar is presented. Non-surgical endodontic treatment was performed. Healing was rapid and uneventful

Electrocution is a well known cause of cardiac arrest, mostly secondary to ventricular fibrillation. Acute myocardial infarction has been reported in a few cases although the pathogenesis is not clear. We report two cases of acute myocardial infarction after electrocution, both confirmed by electrocardiography and markedly elevated cardiac enzymes. Echocardiography showed cardiac damage evidenced by hypokinesia.

Enchinococus granulosus is endemic in many parts of the world where sheep and cattle are raised with the help of dogs. Dogs are the principal host and sheep are the most common intermediate host, Dogs acquire the infestation by ingesting hydatid scolices from infected sheep organs. The parasite develops into a tapeworm in the dog intestine and tapeworm eggs are then excreted in dog feces and transmitted to humans via the fecal-oral route. Ingested eggs develop into hydatid cysts in the intermediate host to complete the life cycle of the parasite. The patient in this study lived next to a sheep ranch

The overall incidence of lymphoma during pregnancy has not been established accurately. Hodgkin's disease is the fourth most frequently diagnosed cancer in pregnancy (1 in 1000 to 1 in 6000 pregnancies). In contrast, the incidence of non-Hodgkin lymphoma during pregnancy is rare, with fewer than one hundred cases reported(2). A case of small intestinal lymphoma in association with pregnancy is presented, with emphasis on the major clinical issues involved in the approach to the management of such cases.

This study aimed to investigate the effect of oral pilocarpine (OP) in reducing the incidence of chemotherapy-induced oral mucositis. Thirty two adult patients completed a total of 82 courses of chemotherapy in which either OP or placebo was given pro-phylactically in a double-blind cross-over design to prevent mucositis. Mucositis was documented in 20 out of 41 courses in which patients were given placebo, whereas mucositis was documented in only six out of 41 courses when patients were given OP (P<0.005). OP treatment was found to significantly reduce the mucositis score when assessed by the method of Donnelly and colleagues (Donnelly JP, Muus P, Schatttenberg A, De Witte T, Horrevorts A, De Pauw BE. Bone Marrow Transplant 1992, 9, 409–413). Using this score, all patients scored a total of 52 when they were given the placebo versus eleven when they were treated with OP (P<0.001). A similar reduction in mucositis score was noticed using the World Health Organization (WHO) mucositis score; the total patient score was 25 for the placebo-treated group versus 6 for the OP group (PcO.OOl). We therefore conclude that oral pilocarpine is highly effective in the prevention of oral mucositis when given prophylactically to adult patients receiving a variety of cancer chemotherapy regimens

Background: The analgesics used for pediatric tonsillectomy may be associated with side-effects such as sedation, respiratory depression and vomiting (opiods) or increased bleeding [non-steroidal anti inflammatory drugs (NSAIDs)]. In our institution, we employ a combination of paracetamol, NSAID and opioid, although there is no published evidence of analgesic benefits from adding NSAIDs to paracetamol in children.