Qatar Medical Journal - Volume 2007, Issue 2

“Abul Kassim A1 Zahrawi” known in the west as “Abul Casis” was born in Cordoba in 936 AD. He made a famous name as a brilliant surgeon in the era of A1 Andalus (Muslim Spain). He wrote several books including a large reference book in the methodology of surgery, called Al Tasrif. He affirmed first of all that there is no barrier between Medicine and Surgery, i.e. between “Cutting” experience and knowledge of clinical and functional aspects of a disease. This is in contrast to medieval surgeons of his time whose job was to cut and chop parts and organs with little understanding of the disease problem they were treating. He recommended certainty of diagnosis before any intervention and developed many instruments. He critically analyzed various aspects of fractures and listed different methods of extraction and dis-location of arrow tips (a common injury in his time). His tech-niques were used for centuries. Instrument of traction for the treatment of dislocation and fractures are still displayed at the “Atger Museum”, Montpellier, France.

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.

Knowledge is the corner stone of teaching, and this is built upon by reading. The word “doctor” in Latin means, “to teach”. Hence reading comes with the difficulty of selecting the appropriate material. What to read and how to read? There are more than 65,000 medical articles published each day, and it is impossible to keep up-to-date by reading them all (which could take 40 years). So, one needs to be highly selective in reading by applying the first rule in evidence-based medicine; PICO (Population, Intervention, Comparability and Outcome of the study)

About 30 years ago bone marrow transplantation was an experimental procedure carried out as a last resort in terminally ill patients. Nowadays hematopoietic stem cell transplantation (HSCT) has become a standard procedure for many severe malignant or non-malignant disorders of the hematopoietic system. It is well known that HSCT is associated with transplant related mortality and morbidity (TRM), the risk of which in allogeneic transplantations can reach 40%; in contrast the risk is less than 5% in autologous transplantation. However; HSCT outcome has been improved significantly over the past decade both in terms of reduced TRM and reduced risk of relapse of the original disease.

Colorectal cancer (CRC) is one of the most frequent and aggressive neoplasms. It is the second leading cause of death from cancer in the United States and is a significant overall health problem. Tumor markers are substances synthesized and excreted by tumor tissues that can be detected in abnormal concentrations in serum, urine, and other body fluids. Two such markers, Carcinoembryonic antigen (CEA) and Carbohydrate antigen 19-9 (CA 19-9), are useful in the diagnosis, prognosis and management of colorectal carcinoma. This study attempted to evaluate the clinical and prognostic value of the two markers using forty patients with CRC and ten healthy persons as a control group. All patients with CRC showed highly significant increases in CEA and CA-19-9 compared to the control group (p <  0.001), and there was a highly significant increase in the level of CEA in more advanced tumor stages, (p <  0.01). Regression analysis showed a significant correlation between CEA and CA-19-9 (p <  0.05; r = 0.35) and significant increases in CEA in rectal tumors compared to those located in the colon; in males compared to females (p <  0.05); and also a highly significant increase in patients over 60 years of age (p < 0.01) but no relation between CA 19-9 level and age, sex, and site of tumor. These data suggest that serum levels of CEA and CA-19-9 can be clinically useful in the diagnosis and staging of colorectal carcinoma.

Periodontal conditions in 100 dentate adults with rheumatoid arthritis (RA) were compared with those of age and gender matched individuals without rheumatoid arthritis. The clinical parameters for periodontitis included probing pocket depths, attachment loss, gingival inflammation scores, plaque scoresand radiographic bone loss scores. The rheumatoid arthritis group had more missing teeth than the control group and a higher percentage of them had deeper pocketing and loss of periodontal attachment There were no significant differences between the two groups for gingival inflammation and bleeding. There was a tendency to adverse periodontal conditions amongst the rheumatoid arthritis patients with severe periodontal bone loss occurring more frequently than in the controls. The rheumatoid arthritis patients had more dental plaque deposits than the control group, a finding which could indicate a difference in periodontal care. It is suggested that this study provides evidence of a significant association between periodontitis and rheumatoid arthritis.

Objective: To evaluate the usefulness of non-enhanced spiral CT (NECT) and compare it with that of excretory urography (EU) in patients with acute flank pain.

Methods: Ninety five patients presenting with acute flank pain underwent both NECT and EU. Both techniques were used to determine the presence, size, and location of urinary stone, and the presence or absence of secondary signs was also evaluated. The existence of ureteral stone was confirmed by its removal or spontaneous passage during follow-up. The absence of a stone was determined on the basis of the clinical and radiological evidence.

Result: Seventy eight of the 95 patients had one or more ureteral stones and 17 had no stones. CT depicted 79 of 83 calculi in the 78 patients with a stone and no calculus in all seventeen without a stone. The sensitivity and specificity of NECT were 95% and 100%, respectively. EU disclosed 73 calculi in the 78patients with a stone and no calculus in fifteen of the seventeen without a stone, with sensitivity and specificity 89% and 88% respectively.

Conclusion: For the evaluation of patients with acute flank pain, NECT is an excellent modality with high sensitivity and specificity. In near future it may replace EU.

Objectives: The objective of the study was to determine prevalent pneumococcal serotypes causing infections in different age groups, their susceptibility to fi-lactams and macrolides and whether these serotypes are covered by the conjugated pneumococcal vaccines.

Methods: Streptococcus pneumonia strains isolated from different patients at Hamad Medical Corporation, Microbiology Laboratory between September 1999 and July 2000 were sent to Statum Serum Institute in Denmark for serotyping. The strains were tested for their susceptibility to penicillin, ceftriaxone and erythromycin by Vitek 2 machine (bioMerieux, France) at Hamad Medical Corporation, Microbiology Laboratory.

Results: Predominant serotypes in children <  2 years were: 6A, 6B, 9V, 11 A, 14,19A, 19F and 23 F, predominant serotypes in children between 2-7years were: 3, 6B, 15B, 19A, 19F and 23F, while predominant serotypes in adults were: 3, 8, 9V, 14,15B, 20 and 22F. In children less than 2 years, the 7-valent and 9-valent conjugate vaccines covered 52% of serotypes. 33% of strains were moderately resistant to penicillin, 27% showed high-level resistance to penicillin, 30% resistant to erythromycin and 2% resistant to ceftrixone.

Conclusion: The 7-valent and 9-valent vaccines offer similar coverage of serotypes in children less than 2 years while the 11-valent vaccines offers 55% coverage. This difference is not statistically significant. Resistance to penicillin was high which leaves ceftriaxone as the drug of choice for empirical treatment of invasive pneumococcal diseases.

Ectopic pregnancy is of increasing concern to gynecologists since it is a major cause of maternal mortality and morbidity in reproductive age women. It occurs when the conceptus implants in an abnormal position other than the uterus. Although the incidence of ectopic pregnancy during the 20 years studied increased five-folds, the risk of death from ectopic pregnancy declined by 90%. This decline might be related to the increase awareness of this condition that accompanied improved diagnostic technology and thus improved management and care. However, ectopic pregnancy remains the leading cause of maternal mortality in first trimenster. This study was to evaluate the management of ectopic pregnancy in the State of Qatar and the Kingdom of Bahrain in a time period from January I, 2000 to August 31, 2003. Statistical analysis showed high incidence of ectopic pregnancy with increase in age and abortion. Etiological factors including contraceptive usage, infertility treatment and previous ectopic pregnancy were shown to increases ectopic pregnancy rates. In the Kingdom of Bahrain, management of ectopic pregnancy was carried by surgical salpingectomy and Laparoctomy and to a lesser extend medical Methotrexate management was also carried on. While in the State of Qatar it was the opposite as Methotrexate was mainly used rather than the surgical treatment. It is recommended that further investigations are needed to enhance this data and to prove the benefits of medical management over the surgical management.

Objective: The purpose of this study is to evaluate the risk of foetal loss attributable to amniocentesis and to assess the experience in technique, successful fluid aspiration in amniocentesis performed in our hospital Study Design: Medical record of 123 women who underwent amniocentesis between September 1996 till March 2002 were reviewed for indication, maternal, age, nationality, maternal age, parity, nationality, gestational age at procedure, physician operator, amniotic fluid reports and pregnancy outcome.

Result: Within 30 days of amniocentesis there were tow (2.2%) foetal lossess, 91 patients (74%) for genetic amniocentesis, 32 patients (26%) Rh. Isoimmunization, 4 cases (3.2%) no fluid aspiration and in 10 patients procedure repeated one week later for successful aspiration.

Conclusion: Amniocentesis-related total pregnancy loss rate was 2.2%. Successful aspiration of clear amniotic fluid increases with amniocentesis experience.

We carried out a study on the prevalence of CA-MRSA in Abha and found a rate of 16% in an environment where nosocomial MRS A rate is 46%. We believe that the rate of CA-MRSA could be much lower if the patients had been interviewed with a view to eliminate obvious risk factors

Objectives: The aims of the study are to determine the role of anti-phospholipid autoantibodies (APLAs) among patients with stroke and/or transient ischaemic attacks (TIAs), to identify the types and effective isotype of some important APLAs which are lupus anticoagulant (LA), anticardiolipin (aCL), anti∼fi2 glycoprotein I dependent (afi2-GPI), and anti-phosphatidyl serine (aPS). Also, to find out any concomitant effect of non-APLAparameters not specific to antiphospholipid syndrome (APS).

Subjects and Methods: This study was carried out on 50 patients attending mainly the Teaching and General Hospitals in Mosul, Duhok, and Erbil Cities, Iraq during the period between 1st March 2004 and 1st March 2005. The studied cases were under 50 years of age, and had no recognizable risk factors. The activated partial thromboplastin time (APTT) was used for LA estimation and ELISA assay was used to test for IgG& IgM isotypes ofaCL, aJ32-GPI, and aPS. The ANA, RF, VDRL, CRP, and C4 complement were tested by different immuoserological methods. The thrombocytopenic (TP) status was diagnosed by estimation of platelets counts.

Results: The strokes and!or TIAs related to APS were diagnosed in 22/50 (44%) of patients and a significant correlation was reported among patients with IgG plus IgM aCL (p <  0.05), IgG afi2-GPI (p <  0.05), and IgG aPS (p <  0.05). In APLAs positive patients, raised CRP concentrations were reported in 36.4%, TP status in 22.7%, ANA in 22.7%, RF positive in 13.6%, and low C4 levels in l3.6%. Finally,the FP-VDRL test was found in 50 % of APLAs positive cases.

Conclusions: The aCL, afi2- GPI, and aPS antibodies were shown to play a significant role in the development of stroke and!or TIAs among the studied cases.

A total of 78,428 blood units collected by the Blood Donor Unit, Hamad Medical Corporation, Doha, from the multinational donors of Qatar (28,622 Qatari nationals donors and 49,806 Non-Qatari donors) in the period January 1994 to Dececember 2001 were screened for hepatitis markers. About 10,382 units (13.2%) were discarded because of positivity for one or more hepatitis markers; 769 units (0.9%) were positive for hepatitis-B surface antigen (HBsAg), 8516 units (10.9%) were positive for hepatitis-B core antibodies (HBcAb) and 1097 units (1.39%) were positive for hepatitis C (HCV) antibodies. There was no significant difference between the rate of positivity for HBcAb and HBsAg in indigenous Qataris and Non-Qataris despite a slightly higher rate ofpositivity for HCV antibodies in the Non-Qatari group. An outstanding finding was the significantly high rate of positivity for HCV antibodies in Egyptian donations (11.2%), which accounted for 31.2% of all discards for the Non-Qatari group. As the Blood Donor Unit at HMC is the only blood collection center in Qatar it is assumed that the results could be representative of the country as a whole.

Case records were reviewed retrospectively of 49 patients admitted between January 1992 and December 2002 to evaluate the epidemiologic pattern of Kawasaki disease (KD) in Qatar. Ages ranged from three months to nine years with a median of 28 months and a male/female ratio of 2.3:1. During the eleven years, the annual incidence varied from 2.5/100,000 to 20/100,000 and appears to be increasing. Most cases occurred in the cooler season (January-May) affecting predominantly males and children under five years of age with no apparent predilection for any section of the ethnically varied population.

Three adults with sickle cell disease (SCD) presented in the span of less than two years with pancytopenia, signs of Disseminated Intravascular Coagulation (DIC) and no localizing pain to suggest vaso-occlusive crisis (VOC). Bone marrow examination showed almost complete necrosis of the whole series of marrow cells, thus explaining the pancytopenia. Some necrotic leukocytes were noted also in the peripheral blood. The condition was self-limiting with marrow regeneration occurring in all three patients after transfusions of red cells and platelets.

Catheter-induced Left Main Coronary Artery (LMCA) dissection is a very uncommon but life-threatening complication of coronary intervention and requires urgent management. We report one such patient whose risk factors appear to be Coronary Artery Disease (CAD), smoking and a prior Myocardial Infarction (MI).

Although hypertension is a known complication of hydronephrosis, it is never severe enough to cause encephalopathy. Here we report a baby boy with unilateral hydronephrosis who presented with hypertensive encephalopathy and whose condition was cured by the insertion of percutaneous nephrostomy followed by pyeloplasty.

Brugada Syndrome is a distinct form of an arrhythmic disease characterized by right bundle branch block an ST segment elevation in the right pericardial leads (VI - V3) of the electrocardiogram (ECG). This syndrome is clinically important because of the high incidence of sudden death by ventricular fibrillation (VF) without any structural heart disease, and is seen especially in the Asian population including Japanese people. Recently, it has been demonstrated that Brugada Syndrome is generally linked to the mutation of the alpha subunit of the sodium channel gene, SCNSA, and the use of certain anti-arrhythmic sodium channel blockers (Class IA au IC) is the sole the Medical intervention which effectively protects patients with Brugada Syndrome from sudden cardiac death.

Lipid-lowering agents such as HMG-CoA reductase inhibitors (also known as statin drugs) are generally well tolerated. But a recognized side effect still can happen, We report a case of 47-year-old Iraqi male patient previously known hypothyroid, was not on replacement therapy, as he did not appear after his thyroid functions was checked came in with severe body pain for 10 months got worse in the last three months, started on lipostat (ten months ago) found to have myopathy as evident by high CPK which improved gradually clinically and biochemical after stopping lipostat.

We report a case of a tightly circumcised woman who bled irregularly throughout her first year of marriage but failed to conceive. The detection and management of a large but hidden cervical polyp solved her problems. We suggest that such cases, especially in immigrant women, require deeper investigation than might at first appear to be needed.

Xanthomas are localized infiltrates oftipid-containing cells found within the dermis. Cutaneous xanthomas are mostly cosmetic disorders but xanthomas can indicate the presence of an underlying generalized disturbance in lipid metabolism possibly associated with coronary artery disease. Because hyperlipidemia may present as xanthomatosis, a dermatologist might be the first to diagnose these associated lipid abnormalities, We report a 36-year-old male who presented with four classic types of xanthomas (Xanthelasma, Tuberous, Eruptive and Plane xanthomas) at the same time. Laboratory tests confirmed hypercholesterolemia and hypertriglyceridemia of dysbetalipoprotein Type III of the Fredrickson classification. The occurrence of four clinical types of xanthomas simultaneously in the same patient is rarely reported in the literature. The clinical, histopathology, laboratory investigation and management of hyperlipidemia and cutaneous lesions is fully discussed together with a review of the literature.

A 62-year-old Pakistani man presented with fever and chest pain of five-day duration. He was non-smoker and he had no history of hemoptysis, wheezing, loss of weight or exposure to tuberculosis. Other history was unremarkable. Physical examination revealed a heart rate of 116 beats/min, BP of 121/ 58 mm Hg, temperature of 38.5°C, and a room air oxygen saturation of 92 %. There was no cervical, axillary, or inguinal lymphadenopathy. Chest examination revealed bronchial breath sounds in the right middle and lower zones. Cardiac examination revealed tachycardia with no gallops or murmurs. Abdomen was nontender without hepatosplenomegaly. Extremities were free of cyanosis, edema, and clubbing. There were no skin lesions

A sixty years old patient, known case of chronic renal failure on regular hemodialysis through long term intravascular catheter was admitted with fever. Blood culture revealed staphylococcus aureus bacteremia (MSSA).

Objective: To investigate cross-sectional associations among blood pressures (BPs), arterial stiffness, and open-angle glaucoma (OAG). Methods: Study participants came from the population-based Rotterdam Study. The baseline examination phase took place after an extensive home interview from March 20, 1990, to June 17,1993, and the third phase between March 19,1997, and December 16,1999. Cases were classified into high-tension OAG (htOAG) and normal-tension OAG (ntOAG), according to an intraocular pressure greater than 21 mm Hg or 21 mm Hg or less. Pulse pressure was the difference between systolic and diastolic BP. Diastolic perfusion pressure was the difference between diastolic BP and the intraocular pressure; indicators of arterial stiffness were carotidfemoral pulse wave velocity and carotid distensibility. Associations were evaluated with logistic regression analysis, adjusted for age, sex, body mass index, smoking, diabetes mellitus, serum cholesterol level, and BPlowering treatment.

Heart failure (HF) is a major killer. Many die due to uncontrolled HF, but many die even when HF is well controlled, principally due to major ventricular arrhythmia. In Framingham study, one third of patients with HF died suddenly (SCD). While diuretics have made a major impact on the main symptoms of HF, edema and breathless, they did no change mortality. It was only with introduction of vasodilators and ACE Inhibitors that the total mortality was altered as shown by many trials like VHeFT and CONSENSUS etc. However, sudden cardiac death (SCD) remained unreduced. This is because HF is not only a syndrome of excess fluids. Hopes were transiently raised by Angiotensin-II Blockers (AT-II blockers) when ELITE-I trial showed reduced SCD as compared to ACE-Inhibitors. These hope soon vanished by ELITE -II, which confirmed that neither ACE-Inhibitors nor AT- II blocker reduced SCD. The major impact on SCD was only consistently shown with Implantable Defibrillators (ICD) that have become a cornerstone in management of selected patients at risk of SCD.