Qatar Medical Journal - Volume 2009, Issue 1

Ibn Al-Thahabi Abu Mohammed Abdellah Ibn Mohammed Al-Azdi (ca. ?- 1033 CE), known also as Ibn Al-Thahabi, was an Arab physician, famous for writing the first known alphabetical encyclopedia of medicine.

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.

Oral infections are a source of bacteremic organisms that can infect damaged heart valves causing bacterial endocarditis and other forms of cardiovascular disease including stroke. This review discusses the relationship of oral infections, bacterial endocarditis and coronary artery disease, especially periodontal disease, while suggesting guidelines for best practice clinical management.

Unexplained infertility occurs in many couples of childbearing age, immune mechanisms have been postulated in this disorder for the last few decades. Circulating antibodies against spermatozoa present in serum and seminal plasma have been especially implicated. This autoimmunity against spermatozoa has been investigated in males, while the isoimmunity (in the females) has got low attention. Fifty women with unexplained infertility and twenty fertile women were involved in this case-control study. ELISA test was used to detect antisperm antibody (ASA) from cervical mucus (CM) and serum specimens of both groups of women. CM was collected at mid-cycle period and dissolved mechanically (not by bromeline). Thirty percent of infertile women have IgG-ASA in their serum and 20% have IgA-ASA in the CM, while 22% of fertile women have IgG-ASA in their serum and no fertile women have any titer of IgA-ASA in their CM specimens. Only CM-IgA-ASA of infertile women showed significant statistical correlation with cellular property of CMwhich was scored according to Insler score. It is concluded that ELISA test is more sensitive and specific than microagglutination tests for detection of serum and secreted ASA. Also, secretory IgA-ASA are more indicative and have potential role in immunological infertility as iso- immunity than IgG-ASA. Therefore, it is strongly recommended that immunological infertility should be considered as an important cause of infertility and have to gain a special interest by clinicians.

To analyze the different presentation, types of infection, predisposing factors (particularly diabetes mellitus) of necrotizing fasciitis; a rare potentially fatal rapidly progressing necrotizing infection of subcutaneous tissue and superficialfascia with secondary necrosis of overlying skin, the medical records were reviewed retrospectively of 94 patients (71 male; 23 female) admitted to the surgical intensive care unit of Hamad General Hospital, Qatar, between January 1995 and February 2005. Fifty-three patients (56.4%) were diabetic with a mean age of 55 years compared with 40.2 years in non-diabetic patients. Type 1 necrotizing fasciitis, especially of the perineal and genital regions, was more common in diabetic patients whereas type 2 necrotizing fasciitis, especially of torso and upper limbs, was more common in non-diabetic patients. Overall 63.4% of cases were type 2 necrotizing fasciitis. E.coli was the most common bacterium isolated from necrotic tissue of diabetic patients and streptococci were the most common cause of necrotizing fasciitis in non-diabetic patients. Fifteen (16%) patients died but there was no significant difference in mortality between the groups, eight (15.1%) diabetic, seven (17.1%) non-diabetic, although diabetic patients were significantly older.

To assess the possibility of pre-operative differentiation of strangulated and non-strangulated intestinal obstruction based on clinical; radiological and laboratory features without CT scan, 66 patients with acute bowel obstruction were studied prospectively. Forty-nine (74%) were male, 17 (26%) female with a wide age distribution. In 56 (85%) the small bowel was obstructed, in ten (15%) the large bowel. Adhesions were the most common cause of obstruction (36%), followed by hernias (20%), volvulus (12%), intussusception (11%), malignancies (11%) and other causes (10%). At surgery strangulation, defined as compromise of the blood supply and necessitating resection of gangrenous bowel, was found in 18 (27%) of the patients. Ten patients (15%) developed complications after surgery and ten patients died, mostly from age and cardiovascular conditions. Persistent abdominal pain, rebound tenderness, elevated temperature, leukocytosis, and air-fluid levels were considered as possible predictive factors for the pre-operative diagnosis of strangulation but it was concluded that such factors were not sufficiently reliable and early surgery was imperative to detect reversible ischemic bowel in strangulated obstruction.

Background: The currently available TNF blocking agents include ifliximab, etanercept and adalimumab. They are approved for the treatment of rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis in the United States and Europe. Also TNF blockers are used currently in other rheumatic and non-rheumatic disease.

Objective: Primary objective: To evaluate our practice of using TNF blockers in the outpatient rheumatology clinics at Hamad Medical Corporation in Qatar, to evaluate the response rate to TNF blockers, and the rate of switching from one TNF blockers to another.

Secondary objective: to assess rate of serious infection and TB.

Methods: The study involved a retrospective chart review of 82 patients in rheumatology outpatient clinic since the introduction of TNF-Blockers at Hamad Medical Corporation in 2002 till December of2005.

Results: Twenty two patients out of 82 received Infliximab (26.8%), 51 patients received etanercept (62.1%) and 22 patients received adalimumab (26.8%) including switchers and non switchers. Response rate was 82% to initial TNF blocker in RA, and almost 100% in Psoriatic arthritis and ankylosing spondylitis. Reason of switching was either due to no response or side effects. No significant serious adverse events in our cohort and no TB reactivation.

Conclusion: Our data are comparable with the international guidelines; regarding the use of TNF blockers in rheumatic disease.also they reflect the daily practice in the rheumatology outpatient clinic in Qatar.

Objectives: To investigate maternal and neonatal outcomes of pregnancies in women with different types of diabetes in Qatar. To identify factors such as age, family history of diabetes and obesity contributing to the increased risk of GD.

Design: The design of this study is retrospective.

Materials and Methods: il4 pregnant women with different types of diabetes including 143(28%) Impaired Glucose Tolerance Test (IGTT), 334(65%) Gestational Diabetes (GD), 26(5%) Insulin Dependent Diabetes Mellitus (IDDM) and 11(2%) Non Insulin Dependent Diabetes Mellitus (NIDDM) who delivered between Jan - June 2004formed the subject of this study.Data extracted from the files included maternal characteristics, fetal and maternal complications.

Result: Eight women had abortions and two had stillbirths, leaving a final dataset comprising 504 women (141 IGTT, 332 GDM, 21 IDDM and 10 NIDDM). Two hundred and eighty three (56.2%) were Qatari.53 %(n = 267) aged >30 years, 57.5 %(n = 290) had family history of diabetes, only 16.1 %(n = 81) treated by insulin.Polyhydramnios was the most common antenatal complication occurred in 15 %(n = 76). No maternal mortality.The overall Cesarean section was 6.2 %(n = 31),.Preterm delivery 5.8 %(n = 29). Macrosomia appeared in 7.3 %(n = 37) infants and congenital malformations in 2 %(n = 10) infants.

Conclusions: We observed that the risk factors for GDM found in other studies are generally valid for our population. Also we found that IDDM has a poorer outcome than NIDDM. However a future prospective study is need it to draw firm conclusions regarding the relative magnitudes of the adverse effects between the different diabetic groups

To study the outcome of various methods of endometrial ablation as a treatment of heavy vaginal bleeding, the records and post-operative histories were reviewed of 122 women with a mean age of 47 years who attended the Women's Hospital, Doha, Qatar, between January 2002 and December 2005. Post-operative amenorrhea, oligomenorrhea, or a normal flow plus a satisfied patient were considered evidence of success; a needforfurther medical or surgical intervention was consideredfailure. Fifty-eight women (47.5%) had Thermachoice Balloon Ablation with a success rate of 83%; 37 (30%) had Microwave Endometrial Ablation (MEA) with 71% success; and27 (22%) had Transcervical Resection of Endometrium (TCRE) with 74% success. Apart from the duration of the procedures there were no statistically significant differences in age, parity, pre-operative haemoglobin and platelets, presence of fibroids, pre-operative endometrial preparation by hormones, or final satisfaction level. It is concluded that Balloon Thermal Ablation, MEA and TCRE are equally effective for the treatment of abnormal vaginal bleeding.

Brucella arthritis is common in Mosul, Iraq, with peripheral arthritis being the most common presenting manifestation. A prospective analysis of 80 patients (43 female, 37 male) attending the Ibn-Sina General Teaching Hospital between October 2001 and September 2002recorded information on gender, age, residence, contactwith animals and intake of unsterilized dairy products andstudied the distribution of arthritis according to the patternof joint involvement. The knee joint was the most commonjoint affected (34%), followed by the hip joint (30%). Ofthe totaljoints involved, the arthritis was monoarticular in 563% andpausiarticular in 43.7%. It is recommended thatthe public and primary healthcare physicians are made aware of the occurrence, manifestations and importance of having correct treatment for this condition in view of its prevalence and economic implications.

To evaluate the response rate of hyperthyroidism to radioactive iodine treatment (RAI) and the mortality rate post RAI treatment in a Qatari cohort the records were analyzed retrospectively of 113 hyperthyroid Qatari patients (23 male, 90 female) treated with RAI (1-131) in the Endocrine Clinic, Hamad Medical Corporation, between 1984 and2002. 90 (79.6 %) had diffuse goiter, 14 (12.4%) multinodular goiter, 6 (5.3%) single nodular goiter and 3 (2.7 %) unknown etiology. Follow up ranged from two to ten years with free thyroxin and thyroid stimulating hormone being recorded at diagnosis; six months and one year post RAI treatment and yearly thereafter.

The incidence of hypothyroidism was 64.4% after six months post RAI treatment and 75.9% at one year. Euthyroid state was high in patients who did not receive antithyroid drugs, whereas the hypothyroid state was higher in a group with pre-treatment antithyroid medication (80% versus 62.8%). The euthyroid state was more in diffuse hyperthyroidism 22.4%, while 84.6% of multinodular goiter became hypothyroid after six months of RAI treatment. Mortality rate was not increased post RAI treatment as compared to general population.

Conclusion: The incidence of hypothyroidism was 75.9% at one-year post RAI treatment and the rate of hypothyroidism increased with the length of follow up to 10 years (86.7%). There was no linear relation in response rate to increasing doses of RAI treatment groups.

Respiratory syncytial virus (RSV) is one of the most common causes of infection of the lower respiratory tract in infants and young children. In the United States RSV is responsible for 90,000 hospitalizations and 4,500 deaths each year 1, 1. Fleming, Pannell, and Cross3 reported that the average death rate from RSV is 6.7 per 100,000 population. Infants with congenital cardiac defects are at greater risk because changes associated with congestive heart failure and cardiac defects limit the ability to compensate during viral bronchiolitis, which in turn increases morbidity and mortality associated with this viral illness4,5. The infection can cause serious illness, prolonged hospitalization, and increased post-operative complications after surgical repair for children with congenital heart malformations6’ 7 ’8. There may also be long term sequelae, proven by a number of studies linking the infection with increased risk of subsequent development of reactive airway disease9,10, 11 compromising the ability of children with congenital heart disease to return to baseline.

Laparoscopic cholecystectomy (LC) is the treatment of choice for symptomatic gall bladder disease and is one of the most frequently performed operations in Qatar. Daycare laparoscopic cholecystectomy (DCLC) was started in 2003 offering many advantages over conventional laparoscopy including reduced demand for hospital beds. DCLC has been shown to be safe in many centers worldwide but in Qatar its feasibility and safety had not been studied. During the 24 months July 2003-July 2005 fifty-six cases of DCLC were studied. Inclusion criteria were aged less than 60years, Grade 1 and 2 anesthesia risk according to American Society of Anesthesiology (ASA), living within an hour's drive of the hospital, had telephone access, living with a responsible adult, capable of reaching the hospital with or without depending on emergency medical services (EMS), able to understand discharge instructions, agreeing to participate by informed consent and the presence of symptomatic gall bladder disease. Complicated cases were excluded. The success rate of DCLC (same day discharge) was 48/56 (86%), most patients being observed in the Daycare Unit (DCU)for 6-8 hours. Pain,post-operative nausea and vomiting (PONV) were the most common causes of failure. There were no re-admissions within 30 days of surgery. Complications were minor and most patients were highly satisfied with same day discharge from the hospital. We conclude that DCLC is safe, feasible and has potential benefits for the health care system in Qatar.Surgeons performing laparoscopic cholecystectomy should recognize the advantages of DCLC and offer this approach to their patients in uncomplicated cases

An unusual case of a blunt and penetrating injury to the thumb is described. A laterally displaced epiphyses of the first metacarpal divided the digital artery and a penetrating injury in the first web space inflicted on the medial digital artery resulting in a total vascular interruption leading to gangrene and ultimate amputation. Such injuries are rare in children but proper assessment and examination could have prevented the end result.

Peripartum cardiomyopathy (PPCM) is a rare condition affecting women in late pregnancy or up to five months of the postpartum period. The signs, symptoms and treatment of PPCM are similar to that of heart failure. Early diagnosis and proper management are the cornerstones for a better outcome for these patients. We report two cases of peripartum cardiomyopathy which were treated in the surgical intensive care unit (SICU) of Hamad General Hospital, Qatar.

By means of in-vitro fertilisation and embryo transfer an epileptic married Qatari female with Kartagener's syndrome bore two sons, both of whom were haemophiliac. The nature of Kartagener's syndrome audits implications are explained and discussed.