Qatar Medical Journal - Volume 2008, Issue 1

“ Al Tabari was the teacher of the distinguished physician Zakariya Al Razi (Rhazes). Ali Ibn Rabban Al Tabari was born in 838 CE. He was also known as Abu Al Hasan. Al Tabari is most famous for his worldrenowned medical treatise “Firdous Al Hikmat”. Besides the medical science, he was also an accomplished Philosopher, Mathematician, and Astronomer. He died in 870 CE.

A 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.

It is clear that poverty cannot be defined solely in terms of lack of income. A person, a family, even a nation is not deemed poor only because of low economic resources. Little or no access to health services, lack of access to safe water and adequate nutrition, illiteracy or low educational level and a distorted perception of rights and needs are also essential components of poverty

A prospective study of dissociative disorders was compared with a study 20 years before. During the study period all new dissociative outpatients of King Fahd Hospital of the University, Al Khobar, Saudi Arabia were included. In accordance with the concept of decreasing incidence of dissociative disorders over the years, there was a significant decrease in the frequency of dissociative disorders between the two studies. Fits and dyspnea significantly dominated the clinical presentation, while other symptoms were rare. The dominant age was below 30 and the female-male ratio was 3.2:1, similar to that reported worldwide. Dissociative disorder seems to breed true over the years but the pattern remains unique to the ambient culture.

Group B Streptococcus infection (GBS) has emerged as a serious disease, infecting 18,000 people in the United States annually including life-threatening illness in about 8,000 newly-born infants. To evaluate the efficiency of the current universal screening strategy for the management of GBS carriers a retrospective analysis was made of the records of 1,620 pregnant women in Qatar, 550 of whom were found to be carriers. These latter were then used as a group to be compared with 450 uninfected pregnant women in terms of nationality, parity, age, treatment, and outcome. Young and nullipara pregnant women had a high incidence of GBS but there was no significant effect on birth mortality and morbidity regardless of whether or not they received treatment with antibiotics. It is suggested that the cost of screening for GBS at the 35 th week of gestation cannot be justified.

To study the effectiveness of a regimen of repeated doses of vaginal misoprostol in the management of first trimester missed abortion, one hundred andfour pregnant women with first trimester non-viable pregnancies were treated with an initial dose of800 g of vaginal misoprostol followed after four hours by further doses of400 ! g fourhourly for a maximum of three doses. The complete expulsion rate was 85.6%. Fifty of the 104 (48.1%) women underwent surgical evacuation. In 14 (135%) women, gestational products were obtained and confirmed by histopathological examination. In 36 (34.6%) there were minimal or no products obtained and these were considered to be complete miscarriages. The cervical os was found open in all (135%) the incomplete miscarriages. Severe abdominal pain was experienced by 10.6% of the patients and excessive vaginal bleeding occurred in 135% of them. A fall in hemoglobin of more than one gramldl occurred in 5.8% of the women and another 5.8% of them had fever > 38°C. The stay in hospital was two days for 87 (83.7%) women and three days for 15 (14.4%) women. One (1%) woman stayed four days and another stayed less than one day. None of the women had any complications. This study demonstrated the efficacy and safety of vaginal misoprostol as a medical treatment for first trimester non-viable pregnancies using an initial dose of 800 g, followed after four hours by further doses of 400 ! g four-hourly for a maximum of three doses. This management also provided adequate cervical dilatation for surgical evacuation when complete expulsion did not occur.

The incidence and pattern of breast diseases are well studied in the West and to a lesser extent in neighboring Arab countries but rarely in the State of Qatar. In an attempt to delineate the spectrum of breast diseases of women living in Qatar, records were reviewed and analyzed of breast lesions from 1336 women received by the Department of Laboratory Medicine and Pathology, Hamad Hospital, from 1992 until May 2002. This enabled comparisons with data from other countries in the region and with western countries. Fibroadenoma was the most common lesion encountered (34%), followed by infiltrating ductal carcinoma (22.7%), Fibrocystic changes (15.2%), and Mastitis and Abscess (8.8%). The mean age for infiltrating ductal carcinoma was 45.4 years compared to 54 years in Western countries. Statistical results were similar to neighboring Arab countries but different from Western countries (i.e. early presentation of carcinoma, and more cases attributed to lactation and pregnancy probably related to the high fertility amongst women in Qatar). The spectrum of breast diseases in Qatar shows little difference compared to neighboring Arab countries but differs from western countries in that, although breast carcinoma is the most common carcinoma affecting women residing in Qatar, its incidence is far less than in the west and it is most prevalent in a younger age group.

Necrotizing fasciitis, a devastating progressive destructive infection of subcutaneous tissue and fascia, is a surgical emergency with a high mortality and morbidity. To analyze the location of necrotizing fasciitis, mode of presentation, microbiological characteristics, comorbid conditions, morbidty and mortality, records were reviewed retrospectively of all ninety-five patients admitted with necrotizing fasciitis to the surgical intensive care unit of Hamad General Hospital between January 1995 and February 2005. Fifteen patients died (15.1%). All patients had leucocytosis and fever on admission with a mean SOFA score varying from 8 to 10.3 according to the type of necrotizing fasciitis involved (Type 1 or 2) and the regions affected. All received aggressive fluid replacement therapy and all underwent debridement at least twice. The most common comorbid condition was Diabetes mellitus. Type 1 necrotizing fasciitis was common in gluteal, cervical and perineal regions; Type 2 was common in chest, axilla, leg and foot regions. Necrotizing fasciitis of the chest, axilla and gluteal regions had the highest mortality while necrotizing fasciitis of the perineum and genitalia had the lowest mortality.

To study the effect of intrapartum antibiotics on neonatal mortality and morbidity for infants with cultureproven neonatal sepsis the records were reviewed of all live born infants with culture positive neonatal septicemia admitted to the Neonatal Intensive Care Unit (NICU), Women's Hospital, Qatar between January 1st 2004 and April 30th 2005. Of 113 infants with culture-proven septicemia, 59 had received intrapartum antibiotics. Using univariate analysis, infants whose mothers had received intrapartum antibiotics were less likely to survive the septic episode (OR 0.09,95% CL 0.11-0.75, p = 0.009) and more likely to have severe septicemia (OR 4.38, 95% CI 1.74-11.02, p = 0.01) but gestational age adjusted estimates of survival and severe sepsis showed no difference between study and comparison groups. Being retrospective the study had certain limitations in variables but there is no clear evidence that intrapartum use of antibiotics plays a direct role in increasing mortality in septicemic infants.

A retrospective review of genito-urinary tumors examined histopathologically in Qatar during the period 1998-2004 showed bladder cancer to be the most common followed by prostate, renal, testicularrenal pelvis and urethral tumours in order of decreasing prevalence. The apparent increasing annual prevalence of some tumors is discussed and the findings are compared with those reported from neighbouring countries and in literature from the West.

The elevation of reperfusion therapy for acute STsegment elevation myocardial infarction are time-related and there are decreasing benefits with increasing delays to therapy. To determine whether the time interval between a patient's arrival at the emergency department of Hamad General Hospital, Qatar and initiation of thrombolytic therapy in the coronary care unit (door-to-needle time) is within the 30 minutes recommended by American College of Cardiology!American Heart Association guidelines, the medical records were reviewed of 213 patients with STsegment elevation myocardial infarction who were admitted through the Emergency Department to receive thrombolysis in the Coronary Care Unit in the twelve months May 2006-April 2007. Medians were calculated for door-to-needle and painto-needle times and intermediate points. The median painto-needle and pain-to-door times were 211 and 143 minutes respectively, both increasing significantly with the age of the patient and were shorter in men than in women. The median door-to-needle time was 60 minutes with 11.7% of the sample having a door-to-needle time within the recommended 30 minutes. It is concluded that the need for transferring such patients from the emergency department to the coronary care unit of the hospital before the administration of thrombolysis incurs inevitable delays that can be minimized by administering thrombolysis in the emergency department.

Dementia is characterized by progressive deterioration of cognitive functions. It places a burden on caregivers and on society,and has been established as one of the major challenges of the present time. A retrospective study of 350 home care patients in Qatar found 50 with dementia for which it assessed various risk factors, co-morbities and the psychosocial burden on the care givers. It was found that the two major types of dementia, Alzheimer's disease and Vascular dementia had equal occurrence amongst home care patients in Qatar, with hypertension and atherosclerosis being the major contributing factors; a family history of dementia played only a minor role. Depression was the main co-morbidity in the patients. The care givers, mostly female, showed no significant psychosocial burden.

Ascites is a common important feature of chronic liver disease and to determine the extent, causes, clinical presentation and nature of cirrhotic ascites in Qatar a descriptive, prospective study was made of 48 males and 14 females with cirrhotic ascites and a mean age of 562 “12.6 years admitted to the Medical Department, Hamad General Hospital between January 2004 and January 2005. Twenty six were Qatari, the remainder being of various nationalities. The most common cause of cirrhotic ascites was chronic alcoholism, found in 29 (46.8%) patients. Uncomplicated liver cirrhosis was found in 40 (64.5%) patients, complicated liver cirrhosis in 22 (35.5%) patients. At admission, encephalopathy, GI bleeding, and fever were found to be significantly associated with complicated cirrhotic ascites. Results of the study suggest that cirrhotic ascites is common in the State of Qatar with the most common causes being chronic alcoholism followed by chronic viral hepatitis C and B. It is suggested that efforts are needed to prevent and treat these two conditions.

To determine the frequency of endoscopic esophageal candidiasis and to compare the results with histopathological findings while assessing the relationship between Positive oral swabs and stool examinations for Candida and esophageal candidiasis, a study was conducted on 778 patients in Iraq-Baghdad lAlyarmuk Teaching Hospital, Department of Medicine, from January 1999 to December 2000. The major presenting symptom was hematamesis. During upper GI endoscopy 22 (2.8%) had lesions suggestive of esophageal candidiasis but this could be confirmed histopathologically in only fourteen. Oral candidiasis was found in 10 of the 22 patients (45.4%); stool examinations for Monilia were positive in only two (9%) who also gave positive oral swabs. Twenty control Patients gave negative oral swabs and only three (15%) Positive stools.

Rhinosporidiosis is a chronic granulomatous inflammatory disease characterised by polypoid lesions of the mucus membranes. The disease is endemic in India but very rare in the Middle East. We report the clinical presentation, management, and histopathology of the first case of rhinosporidiosis in Qatar and review the literature.

In what appears to be the first case of Adult T-cell Leukemia|Lymphoma (ATLL) reported in Qatar and Middle Eastern Arab countries, a 39-year-old lady presented first with Pneumocystis carinii pneumonia and hypercalcaemia and later showed the full picture of ATLL, splenomegaly leukocytosis, skin rash, and bone marrow infiltrations. She responded well to chemotherapy, with complete remission after four cycles of combination chemotherapy but the prognosis of patients with ATLL is poor. Although patients may respond initially to treatment with combination chemotherapy regimens devised for advanced, aggressive Non-Hodgkin's Lymphoma (NHL), relapses are common with a median survival of eight months and a four-year survival of 12 percent.

Mesenteric Panniculitis (MP) is a rare benign inflammatory condition of the adipose tissue of the mesentery often diagnosed during multidetector CT studies of the abdomen. Two cases of MP are reported with a brief discussion of the differential diagnosis, the association with other conditions and a review of the literature

Anaplastic myeloma is a rare aggressive disease that is resistant to most chemotherapeutic agents and radiotherapy. It develops usually after a diagnosis of classical multiple myeloma and is associated with at least one extramedullary plasmacytoma site. We report a case of this rare disease in a patient who had no previous illness and presented to us with more than one extramedullary plasmacytoma site: a mass in the right anterior chest wall, a swollen scrotum and multiple nodular skin lesions mainly in the legs.

Spinal epidural angiolipomatosis (SEA) is a rare benign neoplasm of adipose tissue with a prominent vascular component. Classified as either idiopathic or secondary to chronic steroid therapy it accounts for 0.14% of all spinal axis tumours. The clinical and radiological features and treatment of a case in a 24-year-old male are described and discussed together with a review of the literature and previous reports.

We present, as a rare manifestation of miliary TB, a case of tuberculous tenosynovitis, preceding by two weeks onset of tuberculous meningitis. A gradual progressive onset of a painless swelling of the right forearm was followed by high-grade fever, headache and neck pain. A suspected diagnosis of tuberculous meningitis based upon analysis of cerebrospinal fluid (CSF) was confirmed later by positive CSF polymerase chain reaction (PCR) for mycobacterium tuberculosis. Although the patient had a positive Mantoux test of 20 mm, there was no evidence of pulmonary TB and a negative CSF smear for acid fast bacilli but a positive smear from a fine needle aspirate of the swelling of the right forearm. The antituberculous therapy led to a successful outcome.

Inflammatory myopathies are heterogeneous groups of immune mediated myopathies that present as pure form or in association with other auto-immune diseases or malignancy. There are three major subsets: dermatomyositis, polymyositis and sporadic inclusion body myositis. This review highlights our understanding of these disorders, their clinical aspects, diagnosis, pathogenesis and treatment. The idiopathic inflammatory myopathies occurring alone or in association with auto-immune disease and lor cancer have an overlapping clinical presentation with an overall incidence of 3.0 to 7.8 per million and a prevalence from 10 to 60 per million. Because of the variability in epidemiological studies, the interpretation of these results cannot be conclusive. Recent evidence indicates that polymyositis is over diagnosed and many reported cases are likely to be some other disorders. Decreasing the incidence of true polymyositis is due to reliance not only on clinical criteria but also on immunopathological changes in muscle biopsies. Polymyositis and inclusion body myositis occur primarily in adults, whereas dermatomyositis occurs in adults and children between five and fifteen years of age. Sporadic inclusion body myositis affects almost exclusively men over the age of 50 years.

Young lady referee from women's hospital to Medical Intensive Care Unit because of abdominal pain, fever (Temperature 39°C) and hypotension. She was pregnant 20 weeks on top of intrauterine device (IUD) and was evaluated as intrauterine fetal death. The diagnosis was septic shock due to intra-abdominal infection. Looking for the source of infection, CT abdomen and pelvis was done (Figs. 1 and 2).

A 28- year old male from Nepal presented with history of fever, right-sided chest pain for the last four weeks. During admission some investigations were carried out.

Objective: To review the incidence of ruptured uteri at the Women's Hospital, Hamad Medical Corporation (HMC) and to analyze the causative factors of uterine rupture with the view to its prevention and to highlight the management approach taken to preserve the patient's reproductive potential.

Background: We aimed to investigate whether the addition of nonsteroidal anti-inflammatory drugs or spinal manipulative therapy, or both, would result in faster recovery for patients with acute low back pain receiving recommended first-line care.