Qatar Medical Journal - Volume 2010, Issue 1

Prof. Dr. Hulusi Behcet is a famous Turkish physician. He was the one who discovered the Behcet's Disease and he studied many topics on dermatology. Dr. Behcet was born on 20 February 1889 in Istanbul. He graduated from Gulhane Military Medical Academy and completed his specialization in 1914. Between 1918 and 1919, he went to Budapest and to Berlin's Charity Hospital to improve his medical knowledge. He was appointed as the head-physician at the Hasky Venereal Disease Hospital in Istanbul in 1923. Six months later, he was appointed as dermatologist to Gureba Hospital which is now a part of the Istanbul Faculty of Medicine, for which he received the title of professor in 1933. After the 1933 University Reform, he set up the department of dermatology and venereal diseases. Prof. Dr. Hulusi Behcet was the first Turkish who received the title of Professor in the Turkish academic 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.

Post-operative radiotherapy to the breast is a standard treatment for the management of breast cancer. Treatment-related skin toxicity will occur in many patients and usually develops two to three weeks into treatment and may persist for up to four weeks post therapy. Management of acute toxicity remains a challenge for oncology professionals because there is very limited evidence-based research that addresses interventions for the prevention and management of radiation skin damage. Forty breast cancer patients being treated with radiotherapy at Al Amal Hospital were evaluated for the frequency and the severity of acute skin reactions. Clinical skin evaluation was performed by the same Radiation Oncologist during weekly reviews and on the last day of treatment. Normal tissue damage was scored according to the Radiation Therapy Oncology Group side-effect scales. The most frequent acute complications were erythema and dry desquamation, although moist desquamation was a problem in high friction anatomical sites. The reactions were classified as severe (RTOG’2) in only one case. There was remarkable consistency in the assessment and documentation of patient education among nurses following the hospital's standard practice.

To assess the plasma concentration-time profile of sildenafil alone and after a single dose (400 mg) of cimetidine, with other pharmacokinetic parameters, a study was conducted at the Department of Pharmaco- logy, College of Medicine and Department of Che-mistry, College of Science, University of Mosul, from May 2008-June 2008. Twelve healthy volunteers were each given a sildenafil tablet 50 mg and blood samples were drawn at 0, 0.5,1, 2, 4, 6, 8,10 and 12 hours after administration. After a one week washout period, the same volunteers were given cimetidine 400 mg followed two hours later by sildenafil 50 mg and blood samples drawn at 0, 0.5,1,2, 4, 6, 8,10 and 12 hours after the sildenafil administration. Using high performance liquid chromatography (HPLC) for analysis, the concentration-time profile, half-life (t1 /2), area under the curve (AUC), k (elimination) were measured. Maximum plasma concentration (Cmax) and time to reach maximum plasma concentration (T max) were calculated.

Co-administration of cimetidine resulted in significantly higher plasma concentrations of sildenafil, reflected by a significant rise in AUC (p < 0.0001) and a significant increase in C max (p < 0.0001). The k (elimination) of sildenafil was significantly delayed (p < 0.0001) and the elimination half-life was prolonged (p < 0.0001).

Cimetidine through its action as an inhibitor of Cytochrome P3 A4 (the metabolic pathway of sildenafil) increases the plasma level of sildenafil as reflected by the increase in AUC, C max, 11 /2 and a significant reduction in k(elimination).

To analyze the factors influencing outcome in Traumatic Brain Injury (TBI) rehabilitation in Qatar medical records, we reviewed 50 patients with TBI who were seen between January 2004 and Sep 2007 in the Rehabilitation Unit of Rumailah Hospital (RH), Hamad Medical Corporation. Demographic and clinical variables included age at admission, length of stay in acute care (LOSa), length of stay in rehabilitation (LOSr), Rancho Level (RLA), Glasgow Coma Scale (GCS). Functional Outcomes were functional independence measure on admission (FIMa) and functional independence measure on discharge (FIMd).

There was a significant positive correlation of FIMd with FIMa and Rancho level (r = 0.69, p = 0.00 and r = 0.70, p = 0.00) respectively, where there was no correlation between FIMd and GCS score. Negative correlation was observed between FIMd and age as well as LOSa (r = − 0.47, p = 0.01) and (r = − 0.49, p = 0.00) respectively. Multivariate regression analysis was performed taking age, Rancho, FIMa, mobility, GCS and LOSa variables as independent and FIMd as the dependent variable. The model could explain 70% of variation.

It was concluded that the Rancho level of cognitive functioning, FIMa and mobility variables were the most influential factors in determining the functional outcome.

Job satisfaction of Primary Health Caregivers is critical for the improvement of health systems. A cross-sectional study was conducted by means of a questionnaire to evaluate the job satisfaction and stress in 323 Primary Health Caregivers in Qatar, of whom 176 (54%) Physicians/General Practitioners responded. Similar numbers of males (85; 48%) and females (91; 52%) replied; most were non-Qatari, aged 30–45 years, married with children. The overall job satisfaction and stress were both below average. There were no significant differences in overall job satisfaction for nationality, sex, marital status and number of children, but female Qatari health caregivers were stressed more than their counterparts. There was a negative correlation between job satisfaction and stress level (r = − 0.29, p = 0.01). Qatari physicians were less satisfied with their salaries and the variety in their work and stress was greater in Qatari Health Caregivers than Non-Qatari counterparts.

Respiratory Distress Syndrome (RDS) causes significant mortality and morbidity in babies born before 32 weeks gestation. To determine the effectiveness of antenatal steroid treatment (ANS) in reducing neonatal morbidity from respiratory distress syndrome, and patent ductus arteriosus (PDA), intra-ventricular haemorrhage (IVH), and retinopathy of prematurity (ROP) in very low birth weight infants, a retrospective case control study examined the medical records of 125 babies born before 32 weeks gestation. Divided into two groups according to whether or not antenatal corticosteroids were given, the groups did not differ in rates of RDS, IVH, PDA, or ROP but the group that did not receive ANS had a significantly higher risk of death (p < 0.05).

Traumatic brain injuries (TBI) are important public health problem resulting in short-term or permanent disability and death. To determine the extent and outcome of severe TBI amongst children in Qatar medical records were reviewed retrospectively of all cases of severe TBI in children aged 14 years or less who attended the Children Rehabilitation Unit, Hamad General Hospital, Qatar, between January 2002 to December 2008. The severity of TBI was assessed by the Glasgow Coma Scale (GCS). Of 65 children with severe TBI, most were male (73.8 %) and 91 % were older than five years of age. The leading causes of injury were road traffic accident (84.6%) and falls (10.8%). Other causes included trauma by ceiling fan blades (4.6%), sports and recreation injuries. Early sequelae included spasticity (43.1 %) and posttraumatic epilepsy (33.8%); both were significantly associated with the increased severity and need for intracranial surgery. Almost a quarter of the children had communication disorders, 17 (26.2 %) had poor cognition, 16 (24.6%) had hemiplegia and 12 (18.5 %) had abnormal behaviour. Twelve (18.5%) children died within the first month of admission to hospital. It is clear that severe TBI results in significant morbidity and mortality among children in Qatar and special efforts are needed to reduce the causes especially motor vehicle crashes and injuries. Rehabilitation programs are also needed to limit the extent of long-term complications associated with TBI.

To describe the characteristics of Pseudomonas aeruginosa (P. aeruginosa) in cystic fibrosis (CF) patients with CFTR 11234V in a large kindred family in Qatar, medical and laboratory records were reviewed of 46 patients of CF with CFTR 11234V from 25 families arising from a single large Arab kindred tribe who attended the CF clinic between May 2002 and June 2008. Thirty eight CF patients, who were negative for P. aeruginosa at first lower respiratory culture, were enrolled in the study. The diagnosis of CF was confirmed by sweat test and molecular genetic study. Trypticase soy agar with 5% sheep blood, McConkey agar, oxidative-fermentative polymyxin B-bacitracin lactose agar, Hemophilus isolation agar and mannitol salt agar were used as selective media for the isolation of important CF respiratory pathogens. The prevalence of (P. aeruginosa) in lower respiratory cultures from 46 patients was 60.9%. Twenty (52.6%) of 38 CF patients with CFTR 11 234V acquired P\ aeruginosa with no seasonal variation. Positive siblings with P. aeruginosa were found in 70% indicating cross-infection within the family. The median (range) age at first detection of P. aeruginosa was 12.5 (1–19) years. There was no significant difference between males and females in acquisition of P. aeruginosa. P\ aeruginosa of mucoid phenotype was detected in 11 (55%) of 20 with additional organisms, 5. aureusbe'mg the second isolated organism in nine (81.8%) of the 11. Conclusion: A larger prospective study in a cohort of CF patients with CFTR 11234V in the Arabian Gulf region is required to determine the risk factors for acquisition of P. aeruginosa with early aggressive antipseudomonal therapy.

Type 1 diabetes mellitus (1 DM) resulting from immunological damage to pancreatic islets (cells is the most common immune-mediated, endocrine metabolic disorder in children with evidence suggesting that type 1 DM is a T-cell-mediated autoimmune disease. About 5% of people with a major polyendocrine autoimmune syndrome develop type 1 DM. Autoimmune thyroid disease is the most frequent autoimmune disease with type 1 DM. An estimated 7% of children with type 1 DM develop Celiac disease within six years of diagnosis. To determine the prevalence of Celiac disease and thyroid disorders among children with type 1 DM, together with their first degree relatives, and to estimate the prevalence of DM among the first degree relatives of diabetic children, 300 type 1 DM children with 1950 first degree relatives were matched with 600 controls together with their 3,900 first degree relatives were screened in a case control study for autoimmune diseases (Celiac disease, thyroid disorders) and the first degree relatives of cases and controls were screened for type 1 DM. Celiac disease and thyroid disorders were insignificantly higher in cases than in controls. Similar findings were seen in 1 st degree relatives of cases compared to controls, with a significant difference in Celiac disease. Type 1DM prevalence was significantly higher in 1^st degree relatives of cases than controls. Conclusion: Target screening for Celiac disease and thyroid diseases in type 1 DM children is necessary, but screening 1st degree relatives of diabetic children for auto-immune diseases remains controversial.

A 15-year-old pale and wasted prepubertal Yemeni girl presented with carpo-pedal spasms of the limbs and drowsiness after severe bilateral thigh pain and weakness for a few days. She denied any trauma or taking medications but complained of recurrent abdominal pains and distension with occasional diarrhea. Her height = 119 cm and weight = 19.5 kg, BMI = 13.7. Her quadriceps were contracted bilaterally and there was exquisite pain on palpation of both thighs. Deeptendon reflexes were brisk all over and Chvostek sign was positive. Abdomen appeared distended with no organomegaly. Tests showed hypocalcemia, hypophosphatemia, hypomagnesemia, high PTH and low vitamin D 25-hydroxy level, hypoalbuminemia, low B12 and low RBC folate, normal ESR with normal renal and hepatic functions. Tissue transglutaminase antibody was positive but stools negative for fat. Upper gut endoscopy revealed total villus atrophy. Bone age was nine years with osteomalacia. She was diagnosed with celiac disease plus multivitamin deficiency and was treated with vitamin D3 (600, 000 U)IM, calcium carbonate, B12 100 meg IM, multivitamins, and Fe-sulfate. She was put on a gluten-free diet with increased calcium intake. Two months later, her weight had increased by 5 kg, height by 4 cm and her appetite improved markedly with disappearance of all abdominal symptoms and cramps. Adolescents with delayed puberty and short stature must be screened for celiac disease.

Acute appendicitis is the most common surgical case met in an emergency department. Immediate surgery results in the confirmation of diagnosis and control of sepsis. To determine whether the delay in operating upon patients with acute appendicitis will affect the outcome or the stage of the disease, and if the clinical parameters give an indication of the severity of the disease medical records were reviewed retrospectively of 373 appendectomized patients above 14 years of age who were diagnosed with appendicitis in the emergency department of Hamad General Hospital, State of Qatar, between June and September 2007; 341 were diagnosed as acute appendicitis. Patients were classified according to the pre-operative and histopathological findings into four grades; A1: inflamed appendix, A2: gangrenous appendix, A3: perforated appendix, A4: pus +/- mass formation. Complications increased with the duration of the pre-hospital delay. The length of stay in hospital correlated significantly with the grade of diagnosis. The presence of fever, no change in bowel habit, and rigidity correlated well with advanced pathology, the complications increasing with greater delay. We conclude that delayed appendectomy is unsafe since it is associated with an increase in pathological grading as well as increasing the morbidity and the length of stay in hospital.

Definitive airway control of penetrating laryngotracheal injury can be an extremely difficult challenge for the emergency physician. We report three serious cases of penetrating neck trauma with laryngeal injury that were managed successfully using different techniques of airway control in the Emergency Department (ED) of Hamad General Hospital during the three years from January 2006 through December 2008. Individualized assessment, identification of type of injury and familiarity with airway control techniques and the available options assure timely, safe and proper airway control in such injuries. Choice of technique in penetrating laryngotracheal injury is multifactorial and depends upon case presentation, physician preference, skill, and clinical constraints. The incidence of neck injury during this period was lower than in other reports; being 0.07 % of total trauma cases, while the incidence of penetrating neck injuries represented 17.6% of total neck injuries with no deaths. Implications Statement: Familiarity and availability of variant airway management techniques and variant surgical interventions in penetrating laryngotracheal injuries, improve outcome and reduce mortality.

Mucous cysts formation following a rhinoplasty is a rare complication and typically presents late. Only one case has been reported in our department. The cysts seem to arise from mucosal remnants left in the subcutaneous layer and must be distinguished from other complications causing post-operative swelling of the nose, such as foreign body, paraffinoma (rare nowadays) and bony or cartilaginous fragments. We describe a case of dorsal mucous cysts following rhinoplasty, provide a quick review of the relevant literature and discuss the surgical removal of this unusual lesion.

Myelopathy is an infrequently reported complication of bacterial meningitis. We report the case of 32- year old Nepali male who developed acute transverse myelopathy, confirmed by MRI, subsequent to acute bacterial meningitis.

Fat embolism occurs in all patients with long bone fractures and intra-medullary reaming of long bone but is usually asymptomatic. A few patients will have pulmonary, cerebral and dermal dysfunction; this triad is called fat embolism syndrome (FES). We report a case of FES developed after intramedullary nailing of both femurs that was successfully managed in our surgical intensive care unit (SICU).

Bismuth Iodoform Paraffin Paste (BIPP) impregnated ribbon gauze is one of the most commonly used packs after external and middle ear surgery. Allergic reaction to BIPP is rare. We report two cases of hypersensitive BIPP reaction following tympanoplasty surgery. To our knowledge no such cases have been reported previously in Qatar. We reviewed the literature and discuss the management and its prevention.

A middle-aged lady admitted with metastatic breast cancer developed acute respiratory problems with bilateral pulmonary infiltrates after five days of cytotoxic administration, as an acute adverse drug reaction to the docetaxel that resolved completely after high dosage of dexamethasone.

A nine-year old girl presented in shock preceded by fever vomiting, lower abdominal pain and rebound tenderness with signs of peritonitis. Ultrasonography supported a diagnosis of acute appendicitis confirmed later by the presence of peritoneal fluid and by histopathology. She had also the clinical picture of meningo-encephalitis with positive meningeal signs and an abnormal electroencephalogram (EEG). Cerebrospinal fluid (CSF) showed high protein, normal cell count and normal pressure. Brain CT scan and MRI were normal. The polymerase chain reaction (PCR) in the blood was highly positive for Epstein Barr virus (EBV). She improved dramatically after urgent appendectomy with supportive management. This case is unusual in presenting with a combination of acute appendicitis, peritonitis and shock associated with acute encephalitis.

Mechanical ventilation is of two types: Invasive and Non-invasive. Invasive mechanical ventilation involves endotracheal intubation and tracheostomy. This requires sedation, involves the risk of infection, has major complications and is also extremely uncomfortable for the patient. Non-invasive positive pressure ventilation (NIPPV) includes Continuous Positive Airway Pressure (CPAP) and Bi-level Positive Airway Pressure (BiPAP). NIPPV reduces the risk of infection and complications and has the added advantage of patient comfort. However, it should be noted that, for the use of NIPPV, the patient should be breathing spontaneously.

Background: The herpes zoster vaccine is effective in preventing herpes zoster and postherpetic neuralgia in immunocompetent older adults. However, its safety has not been described in depth.

A great variety of procedures have been proposed for the cure of sacrococcygeal pilonidal disease. A bilobed fasciocutaneous flap, based on the parasacral perforators, is described. This retrospective study was conducted to evaluate our experience with bilobed fasciocutanous flaps and to review current publications about flap surgery for the treatment of sacrococcygeal pilonidal sinus. Eight bilobed fasciocutanous flaps have been performed between February 2004 and September 2006. Eight males, aged 19 to 35 years (mean age: 26.2 years), presented with chronic and recurrent pilonidal disease. The duration of the disease was ranged from 2 to 6 years (mean age: 3.8 years). The sinuses were excised in a vertical, elliptical fashion and the defect closed using a bilobed fasciocutanous flap. This flap was designed using the parasacral perforators and tailored to obliterate the midline defect. Primary wound healing was achieved in all patients. Large defects after excision can easily be closed using the bilobed fasciocutaneous flap. The flap provides a tensionless wound closure. Hospitalisation is brief, and the postoperative course is comfortable. No recurrence was seen in any of the eight cases. This procedure is indicated in patients in whom wide skin resection is required, because of the tension-free skin closure in such cases. This technique enabled regional reconstruction, conserved tissues, and provided satisfactory aesthetic results. Therefore, this procedure can be considered an additional, useful tool in the treatment of pilonidal sinus.