Qatar Medical Journal - Volume 2005, Issue 2

The manuscript on the cover page has a story. Back in the early 1970's in the medical school, an eminent professor of physiology arrived to give us “the Circulation”. We were proudly amazed to see his first slide, which he displayed for over 10 minutes for everybody to see. It was in arabic handwriting.

“And this is the right one of the two Cavities of the heart. If blood was to be “purified” in these cavities, it must pass to the left cavity where the “soul” is generated, but there are no passages between the two cavities. The mass of the heart here is dull and has no visible apertures, as some people wrongly thought. In fact, there are no invisible openings suitable for the passage of blood, either as Galen wrongly thought. The cavities of the heart in this region are sealed and its mass is thick. Therefore, if is necessary that blood to be “purified” it has to pass through the “ARTERIAL VEIN” to the lungs where it penetrates into its mass, mixes with air, and the better part of it is “purified”. It then passes into the “VENOUS ARTERY” to reach the left cavity of the heart.”

It is five years now since the last European resuscitation guidelines were published(1). The science of resuscitation has been enriched with further significant scientific evidence that has led to new evidence-based guidelines. These guidelines were released in November 2005 and published in the international Journal of Resuscitation, November 2005(2).

Hepatitis C virus (HCV) is emerging as a public health issue in most counties worldwide. The prevalence of HCV infection varies among different geographical areas from 0.5% to 40% with an overall global prevalence of 3%. The WHO estimates that around 170 million people are chronically infected with HCV world wide. Hepatitis CV infection causes a slowly progressive liver disease in over 60% of infected individuals culminating into cirrhosis and ultimately leading to liver failure and hepatocellular carcinoma (HCC). Chronic liver disease due to HCV infection is now the leading indication for livertransplantation both in Europe and the USA. Although the incidence of acute hepatitis C has decreased over the last decade, the number of individuals with HCV-related liver disease continues to rise and is projected to peak around year 2015. As such HCV infection imposes a significant burden on the already exhausted health resources, particularly in the developing counties where the infection is endemic and its incidence is increasing.

This article presents the available data on Ximelagatran, a novel oral direct thrombin inhibitor and explores its therapeutic potential Recent large clinical trials have evaluated the efficacy and safety of this anticoagulant compared to the standard anticoagulation therapy with warfarin and heparins in several thrombotic disorders. These trials provide strong evidence for the efficacy and safety of ximelagatran in the following clinical indications; the prevention of venous thromboembolism after knee or hip replacement, the treatment of deep venous thrombosis, and prevention of stroke in patients with atrial fibrillation. Further evaluation of this promising oral anticoagulant is warranted in other thrombotic cardiovascular disorders requiring chronic oral anticoagulation therapy such as in patients with prosthetic heart valves, intracardiac thrombi, dilated cardiomyopathy, after myocardial infarction and post percutaneous coronary interventions.

Malaria is one of the most widespread infections globally and is undoubtedly responsible for the majority of all cases of transfusion-transmitted disease in the world. Qatar is free from endemic malaria. However; cases are seen with the large expatriate work force imported from malarious areas. These constitute a significant percent of the blood donors’ pool (34%). Over a 27-month period, among 5845 volunteers tested for malaria, 21 were deferred (0.36%) showing positive result when screened by the Giemsastained thick smear technique, with 2 undiagnosed cases that led to transfusion-transmitted malaria. Since then and for the last 21 months, the Falciparum-Spot immunofluorescence (IF) test was implemented in an attempt to ensure accurate screening. Among 6367 donors tested, 274 (4.3%) were deferred. Careful questioning about donor travel history, expansion of deferral policy and the use of a more sensitive screening test have all resulted in increasing layers of safety where no transfusion-transmitted malaria was reported in the last 21 months. These measures were necessary to regain the trust of the public in the safety and stewardship of the blood supply.

To evaluate the results of the treatment of Retinopathy of Prematurity (ROP) patients in Qatar a retrospective analysis was made of 43 infants treated between January 1999 and December 2002 initially with indirect laser transpupillary photocoagulation. Cryotherapy was used only on those needing re-treatment. A favorable outcome overall was obtained in 40 cases (90%) after ten received re-treatment. The statistical interpretation, complicating factors and outcomes are discussed. It is concluded that the results of threshold ROP treatment in Qatar are encouraging.

We report on our first 20 patients treated with hybrid lower lumbar stabilization, in which one or more segments were treated with caged interbody fusion by PLIF technique and one or more adjacent segments were stabilized using GRAF instrumentation.

The indications for interbody fusion included spondylolysis; previous failed disc surgery, and primary discopathy with positive discography and/or active modic signal on MRI.

The indication for flexible stabilization of adjacent segments was for disc degeneration on MRI scanning with or without evidence of posterior annular tear.

This was a prospective study with clinical evaluation using VAS pain scales and Oswestry disability score. All patients were reviewed by an independent consultant radiologist to assess integrity of the implant after two years and underwent CT scanning to assess progression of the caged fusion. There were no instances of failed fusion in this group and no cases of implant failure.

This is retrospective study of breast cancer in Qatar during period 1999-2002, using cancer registry data. A total 214patients were diagnosed with breast cancer; with incidence of5/10,000 ofpopulation per year; accounting for l3.3%of new cancer cases and 29.9%of all female cancer. Male breast cancer is rare accounting for 3.2% of total number. Qatari patients were 23%and non-Qatari patients were 36.2%. The disease more common in ages between 46-55years old accounting for 64%of total breast cancer; patients usually presented beyond or equal to stage II and with distant metastasis in 7% of cases, patients commonly present with invasive ductal carcinoma and histological grade 2and 3, it has been noticed that were decrease in incidence of stage III and IV and increase in stage I and II which reflect improvement in patient awareness of this problem.

A prospective consecutive observational study over a period of six months was conducted in the pediatric surgical theatre of Hamad General Hospital, Qatar; on infants aged one day to one year who required general anesthesia with or without regional anesthesia. It was found that neonates (aged 1-29 days) had difficulty in maintaining a stable body temperature despite various methods of promoting warmth. Infants (aged 1-12 months) undergoing major surgery were more exposed to hypothermia than those in minor surgery. Causes of hypothermia were multifactorial

Summer shade temperatures in the State of Qatar are commonly above 40 °C making heat stroke a big problem in unacclimatized outside immigrant workers. Seven males were admitted with heatstroke to the ICU, Hamad General Hospital between 4th July and 24th August 2004. Presenting signs varied but included coma, abnormal behavior; aggression, mental confusion, fits, hypovolemic shock and respiratory failure, metabolic acidosis, hypokalemia, hyponatremia, elevated serum enzymes and sinus tachycardia. All developed renal insufficiency but none died and there appeared to be no residual brain or organ damage. This has been taken as a measure of the effectiveness of the treatment and management in the ICU. It is emphasized that heat stroke is a medical emergency that can result in major organ failure and death and that early recognition and correct treatment are crucial

A retrospective study was conducted on the records of 44 women who had received tension-free vaginal tape as a primary or secondary procedure for the treatment of stress urinary incontinence. Intra-operative complications were uncommon, operative time and hospital stays were short and late postoperative complications were few. 36(81.8%) women became dry, six cases (13.6%) are satisfied and two patients (4.5%) are still complaining of stress incontinence. The tension free vaginal tape procedure appeared to be an effective, minimally invasive method for treating female stress urinary incontinence

Two cases are reported and discussed of osteoid osteoma in the spines of two children, presenting as nocturnal low back pain irrelevant to any position or activity. Plain radiographs of the lumbosacral spine, Technetium-99 bone scan and computerized tomography (CT) were used to locate and verify the lesions. Both were then excised by open surgery and confirmed by a post-operative CT scan. A review of all the known and updated modalities of diagnosis and treatment is presented and it is emphasized that this uncommon lesion should be considered in the differential diagnosis of back pain in children.

A 35-year-old man developed obstructive jaundice ten months after laparoscopic cholecystectomy. Endoscopic retrograde cholangiography extracted a foreign body from the common bile duct. Histopathological examination revealed that the extracted foreign body was the remnant of vicryl endoloop with calcification around. Since laparoscopic surgery has become a very common procedure, endoclips and endoloops are used more frequently. It is emphasized that careful surveillance and strict follow-up are necessary to avoid similar complications.

Hemolytic uraemic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP) are described as acute syndromes with multisystem abnormalities and pentad of thrombocytopenia, microangiopathic hemolysis, neurological symptoms, renal impairment and fever. Both diseases were believed to form a continuum of the same disease, but recently it was found, that they were having a different pathophysiology, as TTP patients have a deficiency in von wilbrand factor (vWF) cleavage protease. When renal involvement is severe with little or no neurological manifestation, this microangiopathy is termed as haemolytic-uraemic syndrome. If the hemolytic uraemic syndrome is not associated with diarrhoea, it is called Dnegative or atypical HUS. This subdivision is of etiological and prognostic importance. TTP-HUS is associated with high maternal and fetal morbidity and mortality. Treatment of these syndromes differs from syndrome of hemolysis with elevated liver enzymes (HE LLP syndrome) and acute fatty liver of pregnancy hence accurate diagnosis is important for optimal therapy. Plasma transfusion and plasmapheresis have revolutionized management of TTP and HUS by increasing survival 80% to 90%. Here we are reporting a case of D-negative hemolytic uraemic syndrome associated with pregnancy causing intrauterine fetal death. Diagnosis made on clinical and hematological findings, successfully treated by plasmapheresis with residual maternal renal impairment. We are presenting this case, as it is rare disorder associated with high mortality and morbidity, to increase awareness about disease, its diagnosis and management.

A 17 year old Qatari female of Arab descent with cysticfibrosis (CF) carrying pathogenic mutation I1234V had severe respiratory disease associated with chronic Pseudomonas aeruginosa broncho-pulmonary infection with recurrent episodes of mild hemoptysis. Despite regular courses of intravenous anti-pseudomonal antibiotics, she continued to deteriorate over six months and died. It is suggested that the presence of Stenotrophomonas maltophilia was an important factor in this casey which illustrates the need for continuing vigilance in considering the acquisition of resistant organisms in such patients on long-term antibiotic therapy.

Muscle and peripheral nerve disorders are important complications in intravenous heroin abusers. Rhabdomyolysis and acute lumbosacral plexopathy are important in the differential diagnosis of patients developing muscle weakness in an intensive care unit after intravenous overdoses of heroin. A 25-year-old man developed rhabdomyolysis with neuromuscular involvement, and consistent clinical and electrodiagnostic features of lumbar plexus neuropathy after an intravenous injection of heroin. The improvement occured slowly, over months, in spite of intensive physiotherapy.