Qatar Medical Journal - Volume 2006, Issue 1

Abu Abdullah Mohammad Ibn Musa A1 Khawarizmi, known as Father of Algebra, was born at Khawarizmi (Kheva), South of Aral Sea. Very little is known about his early life.

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

Patients with HCV-related cirrhosis are frequently seen in clinical practice when the diagnosis is established either clini-cally when signs of chronic liver disease are evident, or histo-logically when liver biopsy is performed as part of the assess-ment of patients with HCV infection. It continues to be debat-able whether cirrhotic patients should receive antiviral therapy. Those who propose treatment state that eradication of HCV is the main goal of antiviral therapy thus limiting the spread of HCV infection and stress that cirrhosis is not a permanent in-jury that cannot be reversed. Opponents of antiviral therapy in patients with cirrhosis state that such treatment produces very low virological response rates in the face of a reportedly high incidence of side effects.

The three factors responsible for the lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) are the prostate itself, the bladder and the central nervous sys-tem. The prostate is responsible for obstruction through its physi-cal mass (static component) and its smooth muscle contraction (dynamic component). The bladder and spinal cord are mainly responsible for irritative (storage) symptoms.

Arthroscopy is widely used nowadays for the diagnosis and treatment of increasing numbers of disorders of the knee, shoul-der, elbow, ankle, wrist and hip. Arthroscopy of wrist joint has also been developed as a useful diagnostic device as well as a successful surgical tool in managing disorders of the wrist joint. Wrist arthroscopy has a high diagnostic score which bough some wrist surgeons to contemplate the need for wrist arthroscopy in the majority of patients presenting with significant wrist disor-ders.

Acute pancreatitis has a variety of presentations from self-limiting abdominal pain to development of local and systemic complications resulting in sepsis, multi-organ dysfunction, extended intensive care stay and death. Very good quality of life in survivors justifies an optimal therapy in an intensive care setup. The records of 91 patients with acute pancreatitis were reviewed retrospectively. There was a significant difference (p < 0.001) between those with edematous pancreatitis and those with necrotic pancreati-tis as regards the length of ICU stay and severity scores: Ranson and SOFA (Sepsis-related Organ Failure Assess-ment). The most common cause of pancreatitis was biliary (70.3%) followed by hyperlipidemia (12.1%), post ERCP (5.5%), trauma (4.4%), idiopathic (6.6%) and in one case, ascariasis. Common associated diseases were hypertension (33%) and diabetes mellitus (25.3%). Six patients with necrotic pancreatitis died. It is concluded that acute pancreatitis treated in an in-tensive care unit has a favorable outcome and that a com-bination of Ranson and SOFA scores with CT index helps in establishing the prognosis.

Objective: To identify the risk factors for Colorectal Cancer (CRC) at King AbdulAziz University Hospital (KAUH) in the western region of Saudi Arabia.

Methods: Clinical, pathological and risk factors data of all patients with CRC managed at KAUH, over a 10 years period (1993-2002) were collected and analyzed retrospec-tively. Risk factors, were then correlated with sex and race (Saudis vs Non- Saudis).

Results: Out of 90 patients evaluated, 5 were excluded because of incomplete data. Out of 85 patients, 45 (52.9%) patients were males, 40 (47.1%) females, 33 (38.8) Saudis and 52 (61.2%) were Non-Saudis. The Majority were Asians; 81 out of 85patients (95.3%) and4African (4.7%). Comparisons between males and females revealed no dif-ference for all the following risk factors; familial causes, polyps, Inflammatory bowel disease (IBD), High fat low fiber diet, Non steroidal anti inflammatory drugs (NSAIDS) use and Obesity. Comparisons between Saudis and Non-Saudis revealed no difference in all mentioned risk factors except for familial causes which was found higher among Saudis versus Non-Saudis (15.2% vs 1.9%, P = 0.031).

Conclusions: Risk factors for CRC are present in this study population especially dietary habits and obesity. Fa-milial risk factors were higher among Saudis than Non Saudis. The relative high frequency of some risk factors calls for family screening and surveillance.

In order to determine the national incidence of adverse events following laparoscopic cholecystectomy (LC) the records were reviewed retrospectively of4861 patients who underwent LC over a period often years (1993-2003).

The most serious non-biliary complication was trocar injury of major vessels in three cases. Other non-biliary complications included duodenal perforation during dis-section of the Calot's triangle, small bowel injury while inserting the umbilical port and trocar site hernia. Adverse biliary events included common bile duct injury, common hepatic duct injury, bile leakage from the cystic duct and one instance of the migration of an endoloop into the com-mon bile duct. Conversion to open cholecystectomy was required in 109 cases.

Although LC may be associated with various adverse sequelae, these are rare and should not deter surgeons and patients.

A prospective observational study at the newly estab-lished Fetal Medicine Unit, Hamad Hospital, Qatar; evalu-ated the impact of the service on the detection rate of criti-cal congenital heart defects, patterns of referral and sub-sequent yield for structural congenital heart disease in a population with a significant proportion of high risk fac-tors.

Of 391 pregnant females examined between January 2003 and December 2004, 58 (14.8%) had fetal cardiac abnormalities of which 23 (5.8% of total referrals) had major structural malformations of the heart. Cases of fetal congenital heart disease had further evaluation us-ing real time three-dimensional echocardiography (RT3DE) which is new equipment in the paediatric cardi-ology department. All cases with cardiac defects whether minor or major had follow up fetal echocardiography. Neonatal echocardiography confirmed the diagnosis in all cases with major defects (100% specificity). False positive cases that were found to be normal post natal were 1% of the total cases referred (12% of cases with congenital mal-formation). False negative cases were 1% and all had a small ventricular septal defect (VSD) except for one Down's syndrome with a very large VSD.

Three patients needed urgent Caesarean section (CS) deliveries, one with complete heart block (HB) and two with supraventricular tachycardia (SVT). One patient traveled abroad as the fetus had left isomerism and major cardiac defects and complete HB. Fifteen newborns had to receive prostaglandin based on the fetal diagnosis before being seen by paediatric cardiologists. There was no termination of pregnancy due to major cardiac defects even in cases of HLHS.

The preliminary results of this clinic are very satisfac-tory and have affected favorably the outcome of the new-borns with congenital heart defects. It is hoped that the results of this study will encourage more referrals to the FMU.

Once daily tobramycin is convenient to use and achieves higher tissue levels that should kill Pseudomonas aeruginosa more rapidly. Small trials of OD compared with TDS aminoglycosides in CF patients have shown no dif-ference in efficacy or toxicity. No one has looked in detail at the impact on sputum microbiology. In a prospective, randomized study at Papworth Hospital, UK, we compared OD with TDS tobramycin, each plus a second anti-pseudomonal, for the treatment of acute infective exacer-bation in 15 adult cystic fibrosis patients colonized with Pseudomonas aeruginosa. Using the patients as their own control, the same individuals received the alternate treat-ment regime for the next exacerbation. We aimed to com-pare the clinical and bacteriological efficacy, toxicity>, and the effects on susceptibility of the organism among patients in both treatment groups. Isolates were identified, and the Minimum Inhibitory Concentration (MIC) of the antibi-otic in each patient was performed. Patients were assessed for clinical improvement, toxicity and the total viable count in their sputum on days 0\ 7 and 14. In both treatment groups there was a significant clinical improvement, and toxicity did not occur in either group. There was no differ-ence in clinical outcome, adverse events, or time to the next exacerbation. No difference was seen in the selection of antibiotic resistance. OD tobramycin appeared more ef-fective in reducing the number of bacteria in the group overall at day 7 and in two individuals, at day 14.

Upper respiratory tract infections (URI) are very com-mon in general practice. Although viruses cause the ma-jority of URI, many patients expect antibiotic treatment. At one Primary Health Care Center in Qatar; during October - November 2004, eleven hundred and eleven adult patients completed a short questionnaire on demographics, knowl-edge, attitudes, practices towards URI, and patient satis-faction. Four hundred and forty eight (40.3%) recognized viruses as the most common cause of URI; seven hundred and eighty-eight (70.9%) chose consulting a physician as the first line of action when contracting URI; 721 (64.9%) stated that management should be based on physician's diagnosis while 28% expected antibiotics. A majority of participants acknowledged the importance of counseling in their satisfaction but 49.6% reported dissatisfaction if antibiotics were not prescribed and 31.6% reported seek-ing antibiotics when not prescribed. Participants expect-ing antibiotics differed significantly regarding knowledge of causes of URI (p = 0.004). There was no significant dif-ference regarding factors affecting satisfaction based on antibiotic expectation. Results highlight the need for public education and counseling on etiology, course, and management of URI by physicians.

Introduction: In the absence of objective evidence, doc-tors frequently overestimate the level of their patient's ad-herence to medication and there is no published work look-ing at what factors influence the doctor's perceptions of medication adherence by hypertensive patients. Therefore, the aim of this study to determine the doctor's perceptions of adherence to antihypertensive medication and to com-pare this with their perceptions of the clinical situation and with the patient's self -reported medication adherence.

Methods: An English self reporting measure (7-item questionnaire) was adapted and translated to Arabic and used to determine the adherence to hypertensive medica-tion. Also, a 10-item questionnaire was developed to elicit the doctor's perception of adherence (taking > 80% of doses) and the treatment and overall condition. This de-scriptive study was conducted in across 2 primary health centers in Abu-Dhabi, UAE.

Results: About 40 % of them were controlled regard-ing BP and 30% of hypertensive patients were diabetics. The doctors estimated adherence to be high (taking more than 80% of doses) in 143 (71%) of patients compared with 103(52%) patients who reported high adherence by using Morisky score where, there was a statistically significant relationship between them. Of the 143 subjects perceived by their doctors as having high adherence, only 64 (45%) succeeded to achieve the target blood pressure (p <  0.001) while 55 (52%) of the adherent patients from the self-reported point of view achieved their target BP (p <  0.001). The doctor evaluation was not as good as expected for treatment effectiveness and quality of communication (57% only were evaluated as good). Only the doctor's evaluation of the seriousness of the medical situation showed a sig-nificant correlation with the self-reported adherence and this was in the opposite direction (gamma = - 0.32, p < 0.05). 71% of the adherent patients perceived by doctors were estimated to have effective treatment (p <  0.0001) while 81% of patients achieved their target BP were estimated to have effective treatment by their doctors.

Conclusion: The practical assessment of adherence and drug management would have been greatly enhanced if the results of the Arabic/English self-reporting measure had been available to the doctors in the course of routine practice.

In order to assess the prevalence ofvitamin-D deficiency in patients attending the rheumatology outpatient clinic at Hamad Medical Corporation, Qatar; 360 consecutive pa-tients (97% female) were tested for fasting levels of 25-hydroxyvitamin D, parathyroid hormone, calciumphos-phorus, albumin and alkaline phosphatase. Two hundred and three patients (56%) showed vitamin D levels below 20 ng/ml. From the results obtained it is concluded that lev-els of serum calcium, phosphorus, and alkaline phos-phatase are of limited value in predicting vitamin-D sta-tus. The difficulty of skin synthesis in heavily-robed women is discussed and it is concluded that hypovitaminosis D is frequent in such women and that routine assays of vitamin D and parathyroid hormone and vitamin D supplementa-tion would be beneficial.

A community based rehabilitation (CBR) project was initiated in Qatar on September 2001 and the CBR service was introduced at the beginning of2003. Until December 2004,189 patients with primary physical disabilities were included 49% Qatari and 51% non-Qatari nationals; 81% male, 19% female; 6% children; 94% adults, aged 37 ± 18 years. The main interventions were training for involve-ment in life situations, job site training and providing fam-ily counseling and support. Rehabilitation conferences were held for 132 individuals of whom 25% were with traumatic brain injuries (TBI), 23% with spinal cord injuries (SCI), 20% with stroke, 9% with cerebral palsy (CP), 4% with neu-romuscular dystrophy (NMD), and 19% with other physi-cal disabilities (amputee, trauma etc.). The project demonstrated that CBR could successfully evolve using available resources and that patients present-ing with favorable predictors for reintegration could ben-efit from CBR programs. It was found that health and com-munity participants involved in CBR activities were able to collaborate on common goals but there is room for im-provement in the services available for people with disabili-ties (PwD). Implementation of CBR is sustainable only if people from the community take a leading and active role and work together with the experts and with the disabled people themselves

Background: Obesity should be recognized as a primary medical condition that is progressive, chronic and relaps-ing. Simply, obesity refers to an excess of body fat or adi-posity. The aim of this study is to explore some variables of social aspect of Iraqi obese.

Methods: A cross-sectional study was conducted in four medical centers in Baghdad city from 15th October 2002 through February 2003. A sample of (400) adult obese aged (20-60)years of both sexes with inclusion and exclu-sion criteria was studied. A socio-demography data were collected by direct interview technique. Height and weight were measured, Body mass index (BMI) was calculated and subject of 30kg/m2 and more were considered as obese. Obese were classified into three classes.

Results: The peak of obesity (34%) was found at age (40-49) years. BMI distribution significantly associated with educational level of male but not of female. Marital state showed significant relationship with different classes of obesity for female but not for male. Obesity has no sig-nificant association with social relationships. The feeling of social acceptance was strongly associated with the de-gree of obesity. There was a significant difference between both sexes in their trials for dieting.

Conclusion: Both sexes of different age groups are affected with increased prevalence in middle age group. Obese have ordinary social relationship with others and a normal sexual relationship with partners. The obese con-sider obesity as being unwanted or dangerous status, still their trials to lose weight are not convincing. There are many barriers for not exercising in Iraqi obese.

Various hematological abnormalities commonly occur in active tuberculosis (TB) but thrombocytopenia is exceed-ingly rare and immune thrombocytopenic purpura (ITP) is reported in only a few cases. A 28-year-old male pre-sented with thrombocytopenia-induced epistaxis and gen-eralized purpura that did not respond to intravenous im-munoglobulin but did resolve after antituberculous treat-ment The characteristics of this rarely documented asso-ciation are reviewed.

A young male was treated for right-sided pneumonia with cloxacillin and piperacillin/tazobactam. As he was recovering from the pneumonia he developed left-sided pleuritic pain and pleural effusion. At thoracocentesis an exudative pleural effusion contained 16% eosinophils with a simultaneous 28% peripheral eosinophilia. An allergic reaction to penicllins was thought to be the cause. After withdrawal of those medications and institution of pred-nisolone a rapid resolution was seen of symptoms, signs, peripheral eosinophilia and radiological abnormalities.

In a 45-year-old female with chronic uncontrolled hy-pertension complicated by hypokalemia, laboratory and radiological findings were consistent with an aldosterone producing adenoma (APA). Diagnosis of Conn's syndrome was confirmed by histopathology. The hypokalemia re-solved and her hypertension improved after laparoscopic adrenalectomy. Discussion of the case, diagnosis and treat-ment are presented.

We report two patients with pachydermoperiostosis. Both patients presented with pain and swelling of the large joints, characteristic facial features, clubbing and enlargement of distal parts of the extremities.

Diagnostic procedures performed on patients with multiple myeloma typically reveal lytic bone lesions, osteopenia or osteoporosis, bone marrow infiltration by plasma cells as well as overproduction of immunoglobulin or light chains in the serum or urine. Skeletal manifestations are extremely variable and the unusual forms have been described extensively. Extramedullar plasma-cell tumours (plasmocytoma) are found in about 5% of newly diagnosed patients with multiple myelomas. In this paper we present eight patients with atypical forms of multiple myeloma.

Background: A consensus has emerged that angiotensin-converting-enzyme (ACE) inhibitors and angiotensin-II receptor blockers (ARBs) have specific renoprotective effects. Guidelines specify that these are the drugs of choice for the treatment of hypertension in patients with renal disease. We sought to determine to what extent this consensus is supported by the available evidence.