Qatar Medical Journal - Volume 2008, Issue 2

“Abul Abbas Ahmad Ibn Muhammad Ibn Kathir A1 Farghani, a Muslim Scientist who was one of the most prominent astronomers and philosophers of the 9th Century. Born in Farghana, Transoxiana (now part of Uzbekistan) he moved to Egypt where he eventually died.

Papers considered for publication in Qatar Medical Journal are those reporting original work, review articles and case reports that are particularly

We read with interest reports in Al Jazeera News(1) and Reuters News(2) of a new tuberculosis vaccine trial in South Africa and are pleased to learn that the Phase IIMVA85 A trial will begin shortly in the Western Cape, South Africa. The vaccine was developed by researchers at Oxford University and it works in tandem with BCG and acts as a booster to the older vaccine. Previous tests have already shown it produces a very high immune response but the key is to show it actually prevents disease. This vaccine passed Phase I clinical trials (Table 1) in Britain(3), and Africa (Gambia)(4), and is now starting Phase II clinical trials in Cape Town, South Africa(5). Although it is the first subunit TB vaccine that has entered clinical practice, it is NOT the first TB vaccine in clinical trials nor is it the first vaccine in Africa. This is the Second Vaccine in clinical trials and Second TB Vaccine in clinical trials in Africa(6). The MVA85A vaccine has just entered the Phase II clinical trials while an inactivated whole cell mycobacterial vaccine completed two Phase II clinical trials, one in Europe(7) (Finland) and the other in Africa(8) (Zambia) and also completed Phase III clinical trial in HIV+ve patients BCG primed in Africa(9).

To determine whether morbid obesity increased morbidity in abdominoplasty 200 mostly female patients (100 patients morbidly obese and 100 overweight and obese) were studied but showed no statistically significant difference in the complication rate between the two categories nor between them and the international rate of complication of dermolipectomy in non-obese patients although co-morbid diseases did increase the risk of complications. It is concluded that morbid obesity should not preclude abdominoplasty, that patients do benefit, especially obese patients who are unable to lose weight following dieting or even gastric banding. surgery.

In a prospective study at the Surgical Specialty HospitalMedical City Teaching Hospital, Baghdad30 immunocompromised patients with oral candidiasis (thrush) of the tongue were treated with diode laser irradiation, antifungal antibiotics or ordinary light irradiation as a placebo. A fungicidal effect was achieved in those treated by irradiation with 805 nm wavelength semiconductor diode laser using a power of 1W and continuous working mode for 3 minutes for 5 consecutive days, and also in those treated with antimycotics but the laser treatment was shorter (5 days) compared to the antimycotic treatment (10-21 days) and was used successfully in a renal transplant patient without interference with the drug regimen. It is concluded that light from a low power laser may be valuable in the treatment of oral candidiasis, especially in immunocompromised patients where the rate of recurrence is high and development of resistant strains is a possibility.

To evaluate invasive (biopsy related) tests and noninvasive (serological) tests in the diagnosis of H.pylori, ninety-two adults (54 male, 38 female) presenting with dyspepsia were studied after classification into two groups on the basis of endoscopical diagnosis; 46 patients with erosive diseases (gastroduodenal ulcers or gastroduodenal erosions) and 46patients with non-erosive diseases (gastritis or gastroduodenitis). Sera were testedfor anti-H.pylori IgG and IgM by an immunochromatography card test and ELISA respectively. Three antral biopsies were taken for biopsy urease test (BUT), bacterial culture and histological examination. Stool samples were obtained from only 30 dyspeptic cases for H.pylori antigen detection (HpSA) by an ELISA method.

H. pylori was detected in 81 of 92 cases; these were positive by one or more of the gold standard tests (culture, histology and biopsy-urease test). Histological examination yielded the highest frequency of microorganism detection (71.7%), followed by BUT (68.5%) and then bacterial culture (26.1%). In erosive disorders the BUT gave the highest frequency ofpositivity (78.3%),followed by histological examination (67.4%), and then bacterial culture (41.3%) but in non-erosive disorders histological examination gave the highest positive results (76.1%) followed by BUT (58.7%) and bacterial culture (10.9%). The overall sensitivities of BUT, histology and bacterial culture of H.pylori were 77.8%, 81.5% and 29.6% respectively. Serologically the anti-H.pylori IgG test yielded the highest frequency of positive results (80.4%), followed by HpSA test (66.7%) and the least positive was anti-H.pylori IgM test (65.2%). In the light of the gold standard tests used (biopsy-related tests), the validity of anti-H.pylori IgG test, anti-H.pylori IgM test and HpSA test were determined; the sensitivities being 79%, 65.4% and 75% respectively and their specificities were 9.1%, 36.4% and 66.7% respectively. The positive and negative predictive values, the positive and negative likelihood ratios of serological tests were also evaluated.

Conclusion: The most sensitive invasive test (biopsy related) and noninvasive (serological) tests were histological examination and IgG immunochromatography card tests respectively.

Thumb hypoplasia and aplasia are disabling congenital deformities and in the more severe cases (Grades IV and V) the only possibility is pollicisation Some Grade III hypoplasia cases are more severe with absence of the trapezio-metacarpal joint and most of the first metacarpal These cases are best treated by amputation and pollicisation. The authors describe in detail pollicisation of the index and its pitfalls.

Hepatitis C is a major and increasing health problem in Egypt. To assess the awareness, knowledge, and attitudes of the general public towards Hepatitis C a KAP crosssectional study was conducted in Port Said between May and November 2005 on 395 randomly selected individuals over 18 years of age. A structured questionnaire collected data for the assessment ofpersonal characteristics, general knowledge about Hepatitis C, awareness about Hepatitis C transmission and ways of its prevention, and the society's attitudes towards Hepatitis C. Approximately 95% of the study population had heard about Hepatitis C but only half were certain that it was a public health problem. Many had incorrect perceptions about transmission, prevention and vaccination. There is an obvious need for public education in which government and health educators can play an important and effective role.

A prospective! descriptive! non-comparative pilot study was used to evaluate the efficacy of intravitreal injection of triamcinolone acetonide (TA) for the treatment of patients with refractory diabetic macular edema that had not responded to laser treatment. Forty eyes of 35 patients with visual acuity (VA) < 6/12 were infected with TA 4 mgl 0.1 cc under topical anesthesia. Results were assessed and analyzed using changes in visual acuity (VA), retinal thickness (RT) and macular volume measured by optical coherence tomography (OCT). In 62.85 % of cases the VA improved by more than two Snellen's lines, the initial VA (mean! log MAR) being 0.67 changing to 0.31 after six months (p = 0.008). RT improved in all patients, having the most remarkable improvement in the Macular Volume, with a decrease of 2.7 mm3 at the end of the study (p = 0.009). Both improvement ofVA and RT were more marked during the early follow-up. The most common complication was ocular hypertension (OHT) in 22.5 % of eyes, all of which responded to medical antiglaucoma treatment. Intravitreal injection ofTA looks to be a useful option for the treatment of refractory diabetic macular edema.

Objectives: To describe the clinical features of prolactin-producing pituitary adenoma (prolactinoma) in adult patients.

Methods: In a prospective hospital-based study, adult patients with prolactinoma presenting to the National Center for Neurological diseases and the National Center for cancer in Khartoum, Sudan were enrolled in the period from January 2001 to February 2005. The diagnosis was based on finding a pituitary adenoma on cranial MRI and an associated elevated blood prolactin level above 200 pig/L. The size of the adenoma was classified as either microadenoma ( < 10 mm without sellar enlargement or extrasellar extension) ormacroadema (>10 mm). The hormone profile done on each patient included blood level of prolactinand other pituitary trophic hormones, free triiodothyronine and free thyroxine hormones.

Results: Sixteen (14 females and 2 males) were identified as having a prolactinoma. The female to male ratio was 7:1. Their mean age was 24 ± 5.1 years. The prolactinoma was macroadenoma in 9 cases and microademoma in 7. Galactorrhea, amenorrhea and infertility (primary or secondary) were the commonest presenting symptom followed by headache. Affection of the visual pathway, either as bitemporal hemianopia (41.2%) or optic atrophy (11.8%), was the major neurological deficit. The mean prolactin level in macroadenoma was 2053 ± 442.6 jig/L and in microadenoma was 853.6 ± 77.8 jig/L.

Conclusions: Our prolactinoma patients, when reaching the appropriate medical attention, are more likely having an expanded macroadeoma that is compromising the visual pathway. Early recognition and referral to specialized clinics is necessary and that should have a favorable prognostic implication.

To assess the effect of an insulin pump on the glycemic control as well as the body mass index (BMI) of children with type 1 diabetes mellitus (DM1), 23 patients under the age of 18 years were monitored for one year or more. HbAlc concentration decreased from 9.36+/- 2.02% to 8.54+/-1.149%. The BMI increased significantly from 17.12+/- 2.236 to 20.4+1- 2.93. No hypoglycemia was reported in any of the patients after using the pump. Three incidences of diabetic-ketoacidosis (DKA) were reported due to two pump malfunctions and one patient error. All except two wanted to continue with the pump because of the desirable flexibility of their lifestyle including activity and meal times.

The internal concealment of highly profitable illicit drugs such as cocaine and heroin, by means of body packing is an important means of international drug trafficking. This phenomenon is apparently uncommon in Qatar, with only one reported case thus far. Here, we present a case of body packer who was transiting Doha and was found to be carrying 90 internalized packets of heroin. Regardless of whether this is another isolated case or an emerging phenomenon in Qatar, awareness of medical and surgical complication that can arise in these individuals is of importance to practicing physicians.

Background of the Study: The clinical experience that there is a great variability in the ease of performing lumbar microdiscectomy, in particular while instructing the trainee surgeons.

Objective: To determine the role of the pre operative symptoms, it is duration and the radiological findings on influencing the procedure of lumbar microdiscectomy for a single lumbar disc prolapse.

Method: A prospective study of 82 patients with a single level lumbar disc prolapse included the analysis and correlation of clinical and radiological factors: age, sex, height, weight, type of physical work, presenting symptoms and their duration, the level and status of the disc prolapse - to the intra-operative findings of epidural vein dilatation, degree of fibrosis, and the duration of operation. The data were subjected to detailed analysis by using the statistical package of Social Science (SPSS/PC) Release 10.

Results: Thirty two percent of patients had significantlydilated epidural veins; their presence was influenced by the predominance of low back pain and the duration of symptoms. A third (34%) of patients had appreciable fibrosis at the surgical site, again influenced by low back pain, duration of symptoms and radiological findings of obstruction and bony abnormalities. In 37% of the patients the blood loss was in excess of 100 ml seen in patients with a profile similar to those with significant fibrosis. The procedure of microdiscectomy lasted longer than 120 minutes in 34% of patients whose predominant symptom was low back pain with prolonged duration of symptoms and abnormal x-ray findings.

Conclusion: The patient's preoperative clinical presentation and the radiological appearance of the prolapsed disc can affect significantly the microsurgical procedure. The short history of illness with more pronounced leg pain in the absence of bony abnormalities would favor easier operation; while Lumbar microdiscectomy is expected to be a difficult procedure in patients with low back pain as predominant symptom lasting for longer than 12 months and in whom the disc prolapsed is central or who showed additional bony abnormalities.

Arterio-venous hemangiomas (also called vascular malformations) are uncommon lesions in general and very rarely reported as solitary lung tumors with no evidence of fistula formation or clinical evidence of shunting. We report the case of a 49 year old Indian male who presented to our institution with a right hilar lung mass which was histologically proven to be a classical arteriovenous hemangioma (vascular malformation). The patient did not have clinical or radiological evidence of fistula or shunts formation.

A 34-year-old male presented with a pulsatile lesion of the left external ear. Previous attempts at excision had resulted in uncontrollable bleeding. This time, under general anesthesia and a hypotensive technique, the lesion was approached distally and anteriorly through the conchal cartilage, the feeder vessels were ligated and the lesion was removed successfully with no resultant deformity to the external ear

Thiamine-responsive megaloblastic anemia (TRMA) is a rare autosomal recessive disorder including megaloblastic anemia, thrombocytopaenia, diabetes mellitus and progressive sensorineural deafness. We report cases of two infants, aged respectively four and five months, hospitalized for diabetic-acido-ketosis requiring insulin therapy. Laboratory tests revealed megaloblasic anemia, thrombocytopenia and normal thiamine-levels. Neurosensorial investigations showed bilateral deafness and ophthalmic involvements. Treatment with oral thiamine normalized hematological parameters and ameliorated diabetes.

A 46-year-old female presented with a 20-day history of right pleuritic chest pain and progressive shortness of breath. She was found to have a right pleural based malignancy initially thought to be a malignant mesothelioma but staining with the mesothelioma tumor markers calretinin, HBME-1 and CK5/6, was negative. Some epithelial markers were positive and microscopically it was consistent with a poorly differentiated large-cell carcinoma. The case was diagnosed as a pseudomesotheliomatous lung carcinoma of poorly differentiated large-cell type.

Cysticercosis is the most common heliminth infection of the human central nervous system Epilepsy is the most common presentation and occurs in 50-85% of patients. Psychiatric manifestations in a form of depressive disorders, cognitive decline and psychosis have been reported frequently(2). A19-year-old Nepalese male presented with severe headache, seizures, fears and anxiety for one week. A CT scan of the brain showed small calcified lesion in the right deep temporal white matter without perifocal edema. This was considered suggestive of a healed inflammatory granuloma-neurocysticercus cyst. Treatment with a combination of albendazole dexamethazone, ranitidine, phenytoin, lorazepam and hydroxyzine resulted in a rapid recovery.

Papillon-Lefevre syndrome (PLS), first described in 1924, is a rare autosomal recessive disorder characterized by early onset palmoplanter hyperkeratosis and severe generalized destructive periodontitis leading to premature loss of both primary and permanent dentitions. PLS usually manifest itself between the ages of six months to four years, coinciding with the eruption of primary teeth. The proband becomes completely edentulous by the age of 15.

Hypotension and bradycardia after application of suction to a subgaleal drain, or stimulus inside or outside the skull, have been reported in the medical literature. The commonly reported occurrence is stimulation of the Trigeminal nerve along its distribution and is the main factor that sets off the whole reflex arc through the Vagus nerve ending in a series of serious hemodynamic changes that institute severe bradycardia, asystole and severe hypotension. Another less common but possible patho logy caused by a suction drain is Pseudo-Hypoxic Brain Swelling (PHBS). We report a case of transient cardiac arrest after the application of theatre suction to a subgaleal drain at the closure of an uneventful craniotomy and discuss the possibilities as well as review the literature.

The pathway of extravasated urine from the retroperitoenum to the ipsilateral and contralateral pleural cavity in cases of urinothorax has been of debate in the literature. We present a proposed route for the extravasated urine pathway from the retroperitoenum to both pleural cavities based on radiological evidence.

A patient who needed surgery for a strangulated obstruction of small bowel was found to have a pair of artery forceps in the peritoneal cavity following surgery for repair of an abdominal wall hernia twelve months before. The six-inch metallic forceps fractured easily on initial manipulation directly after retrieval. This case demonstrates the easy retention of a small surgical instrument in the abdomen, with the rare and serious complication of bowel strangulation, and the sequel of corrosion of a metallic foreign body in a human.

Several electrophysiological tests have been used to diagnose focal ulnar nerve entrapment at the elbow, including evidence of focal motor slowing at the elbow, mixed ulnar nerve potentials across the elbow and comparing the results to the contralateral side; here I am trying to diagnose focal ulnar nerve neuropathy comparing the latencies of the median and ulnar nerves across the elbow.

52 year old Indian female patient with no significant past medical history presented with a skin lesion started since three weeks associated with fever for three days CBC showed pancytopenia investigations (bone marrow) revealed a very severe Aplastic anemia.

The dentofacial structures are some of the most frequently injured parts of the body by traumatic injuries which can occur as a result of sports, motor vehicle accidents or altercations. Injuries can range from minor dental injuries to facial lacerations to fracture of one or more of the facial bones.

Background: Ecological and observational studies suggest that low Vitamin D status could be associated with higher mortality from life-threatening conditions including cancer, cardiovascular disease, and diabetes mellitus that account for 60% to 70% of total mortality in high-income countries. We examined the risk of dying from any cause in subjects who participated in randomized trials testing the impact of Vitamin D supplementation (ergocalciferol (Vitamin D2) or cholecalciferol (Vitamin D3) on any health condition.