Qatar Medical Journal - Volume 2011, Issue 1

The development of efficient hospitals was an outstanding contribution of Islamic Medicine.

Islamic hospitals were sites of medical education from their establishment in the 900s CE. The most famous hospitals, including those in Baghdad, Damascus and Cairo, contained lecture rooms, pharmacies and libraries. As important as reading and mastering texts was to instruction in the Islamic tradition, many students received practical training in hospitals. Some even observed patients at the bedside.

Qatar Medical Journal is the official periodical of the medical community in Qatar.

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.

Diabetes is a public health problem and optimal glycemic control requires diligent daily self-management to reduce morbidity and mortality associated with diabetes and its complications. By means of a carefully designed questionnaire, 215 patients with Type 2 diabetes who were admitted to the Emergency Department at Hamad General Hospital during the period from 1 May 2008 to 31 August 2008 were selected randomly and interviewed to determine their attitudes and behaviors influencing effective glycemic control and the extent to which they were helped by education and advice from care providers. The mean ± SD of both the total diabetes attitudes with subscales, and the self-care behaviors were measured in addition to the mean ± SD of both hemoglobin A1 c, and the number of admissions to the emergency department over the preceding six months. Participants reported the highest performance following a specific diet which had the highest significant negative correlation (r = -0.181, p = 0.009) with hemoglobin A1c as compared with the other self-care behaviors. The study emphasized the importance of improving the attitude of Type∼2 diabetics and their self-care behaviors because of the association with Emergency Department Admission and Glycemic Control. An appropriate educational approach and follow-up taking into account individual patient characteristics, needs to be implemented.

Falling is the primary cause of accidental death in those aged 65 years and above. To determine the prevalence and risk factors for falls among the elderly in Qatar a cross-sectional study was made to 355 elderly persons attending 12 of the Primary Health Centers in Qatar. A questionnaire elicited socio-demographic data, and histories of falls in the previous 1 2 months, chronic disease, medication, and functional disabilities affecting daily life. One hundred and nineteen (34%) had fallen in the previous 12 months, half of it happened more than once, mostly inside the house, although most (87.6%) were still independent with little effect upon daily activities; women fell more than men; Qataris more than non-Qataris; there were significantly more falls in married and illiterate persons. Living alone was not a significant factor but those using walking aids and/ or not exercising were at significant risk. Some chronic diseases were significant, others not, and some medications showed a significant relationship. Environmental risk factors did not appear to be significant. This study makes some recommendations to reduce the frequency of falls in elderly persons. An extensive bibliography is appended. Key words: Elderly, Falls, PHC

Abstract Objective: The aim of our study was to determine the related clinical factors affecting the outcome of occlusion treatment for Strabismic Amblyopia in Qatari children.

Design: This is a retrospective descriptive study.

Subjects and Methods: The study included 38 Qatari children with strabismic amblyopia who were treated with occlusion therapy. The survey was conducted among the Qatari children below 12 years of age during a 10 year period from 1992-2002. During this study period, 23 girls and 15 boys were treated for strabismic amblyopia.

Results: A total of 38 Qatari children were treated during the 10 year period. Of these children, 39.5% were males and 60.5% females. After the treatment, it is found that their final visual acuity improved. 73.7% achieved 6/9 or more and 26.3% achieved less than 6/9. The initial visual acuity, the presence of anisometropia and compliance were found to be related to the outcome of amblyopia treatment. The age at the start of treatment was found unrelated to the outcome. It was further discovered that most vision loss from amblyopia can be reversed with the correct intervention.

Conclusion: The results of the present study indicated that the main factors affecting the treatment of strabismic amblyopia are initial visual acuity, presence of anisometropia and compliance.

To investigate coitus during menstruation as a possible predisposing factor for endometriosis 78 patients were asked about their coital habitus during menstruation and subsequently were examined by ultrasound transabdominally, transvaginally or both, before laparoscopy or surgery. MR! was used in six patients only. There was a statistically significant relationship between endometriosis and coital practice during menstruation. The incidence of endometriosis in patients with history of coitus in menses was 66% while the incidence was 34 % in patients with no such history. It is concluded that coitus during menses could be a predisposing factor for endometriosis.

To analyze the short term visual acuity and anatomic response after a single dose of off-label intravitreal injection of bevacizumab in diffuse diabetic macular edema (DME) not responding to conventionallaser photocoagulation.

Patients arid Methods: Prospective analysis of consecutive case series of 45 eyes of 38 patients with refractory diffuse DME who had one intra-vitreal injection of 1.25 mg of bevacizumab (Avastin) and followed up for 3 months. All patients passed at least six months since their last laser treatment before inclusion in the study. Patients underwent best corrected visual acuity determination, intraocular pressure measurement, stereoscopic biomicroscopy of the macula and measurement of the retinal thickness by optical coherence tomography (OCT) at base line and follow up visits.

Results: At 1 month post-injection, visual acuity improved by 1 line in 7 eyes, unchanged from the preinjection levels in 24 eyes and deteriorated in 14 eyes. At 3 months post injection, visual acuity improved in 18 eyes, it remained unchanged in 13 eyes and deteriorated in 14 eyes. The mean logMAR visual acuities were 0.60 (SD ± 0.34), 0.64 (SD ± 0.31) and 0.61 (SD ± 0.32) at pre-injection, at 1 month post-injection and at 3 months post-injection respectively; but this mean decrease in vision was statistically not significant (P value = 0.099). The foveal thickness on optical coherence tomography had decreased in 27 eyes and it increased in 18 eyes at 1 month post-injection. At 3 months following injection, foveal thickness was reduced in 34 eyes, but was increased in 11 eyes. The mean foveal thicknesses were 444.95 u (SD ± 127.36), 394.95 u (SD ± 138.03) and 378.32 u (SD ± 11 2.01) at pre-injection, 1 month post-injection and 3 months post-injection respectively. This decrease in the foveal thickness was statistically significant (P value <  0.001).

Conclusions: Intravitreal bevacizumab is effective in patients with diffuse DME which is refractory to treatment with conventional macular laser photocoagulation. Key words: bevacizumab, intravitreal, diffuse diabetic macular edema

Introduction: Diabetes mellitus is a chronic illness that requires continuous medical care. Patient health education and self-management aim to prevent acute complications and to reduce the risk of long-term complications. Care of diabetic patients is a complex process and requires many issues beyond glycemic control. This study is conducted to assess quality of care of diabetic patients in the diabetic clinic at Al Wakra Healthcare Center and to determine some factors that may affect the quality of this care.

Methodology: This is a descriptive, cross-sectional study. The target population was all diabetic patients (Type 2) that meet the inclusion criteria and registered at the center. Two checklists assessed the structure of diabetic care; the first checklist is for the essential items of care (thirteen items) and the second one is for the less essential items (ten items). The indicators of the process of diabetic care was assessed by a scoring system that depends on ten items for standard diabetic care by the primary care physicians in the past year. Assessment of the outcome was done according to an international quality assurance protocol and it includes: the degree of diabetic control, obesity, smoking among the diabetic patients and control of blood pressure. We added HbA1c to this list. Another questionnaire was designed to determine factors that may affect quality of diabetic care-related to patient's knowledge and attitude and it is divided into 4 sections: personal data, patient knowledge about diabetes, patient attitude toward care and clinical and biochemical assessments. A pilot study was carried out to test the questionnaires. Epi-info. Six statistical package was used for data entry and statistical analysis. Chi square or Fisher exact tests were used to test the significance, and P value <  0.05 was considered significant.

Results: The study showed that diabetic care at Primary Healthcare Centers (PHC) in Qatar represented by Al Wakra Primary Healthcare Center is better when compared to the care in other studies in different countries. 86.7% of physicians show that most of the structure items are good to fair except for the absence of chiropodist and identification cards for diabetic patients. Assessment of the process of care showed that there is good to fair recording in 91.75% of cases; foot examination is not recorded in most of cases; and fundus examination is not recorded in 31.7%. The outcome indicators showed that patient knowledge about diabetes is poor in 35% of cases, uncontrolled FBS in 75.6% of cases, uncontrolled HbA1 c in 57.8%; obesity in 63.5% and control of blood pressure is not achieved in 49% of cases.

Conclusion: Diabetic Clinic at Al Wakra Primary Healthcare Center provides good care for diabetic patients in terms of structure, process and outcome; however, more efforts are needed for refining these services.

To study the value of a mid-thigh graft as an alternative in the provision of long-term vascular access in patients requiring hemodialysis 11 patients (9 females, 2 males) aged 27-71 (mean 48 years) with unsuitable arm veins underwent surgery between February 2001 and January 2004 to create an arteriovenous fistula (AVF) between the superficial femoral artery (SFA) and superficial femoral vein (SFV). There were no deaths due to the procedure, no limb losses, no technical failures and all fistulae matured satisfactorily. Complications included two cases of thrombosis (surgically thrombectomised at 15 and 24 months post-operatively), one case of graft infection at three years post-operatively (treated by graft excision), and one graft failure at five years post-operatively (replaced with a second graft at the same site). After three years 10 grafts were functional and being used for dialysis. It was concluded that a mid-thigh graft is a suitable durable procedure in patients where creation of vascular access at the upper limbs is not feasible. Adequate clinical and radiological surveillance is imperative.

Ten patients with back pain and sciatica were selected according to certain inclusion criteria for a study to assess the efficacy of the Anti TNF agent Adalimumab in the treatment of refractory sciatica pain induced by a lumbar disc prolapse in patients who failed to improve following lumbar epidural steroid or disc surgery. Each was given a subcutaneous injection of 40mg Adalimumab repeated after two weeks. Patients were assessed regularly on weeks 0, 2, 4 and 8 employing the Visual Analogue Score (VAS) for leg pain and back pain and the Straight Leg Raising (SLR) test. The median improvement of the leg pain VAS was 55. Median improvements of back pain VAS was 37. Median improvement of the SLR was 45. The study demonstrated the beneficial effect of adalimumab therapy in reducing the back and leg pain associated with sciatica in this difficult to treat group of patients. The improvement of leg pain was more significant than that of back pain. The response was better in patients with symptoms of shorter duration and with less SLR restriction at base line.

To assess the efficacy and the tolerability of TAC (docetaxel, doxorubicin, and cyclophosphamide) protocol in early breast cancer patients with node positive in the adjuvant treatment 64 patients (median age 46 years) with early node positive breast cancer were studied from October 2003 to May 2009 according to certain inclusion criteria. They received TAC protocol chemotherapy; Disease free survival (DFS), Overall Survival (OS) and toxicity profile were assessed. All except one received six cycles of chemotherapy according to TAC protocol. Median follows-up was 60 months. Disease free (DFS) and Overall Survival (OS) were 77% and 87% respectively. The chemotherapy was well tolerated and the toxicity profile was better in comparison to previously published studies. It is concluded that TAC protocol in the adjuvant treatment of early breast cancer is effective and well-tolerated as evident by the toxicity profile provided the G-CSF is started as primary prophylaxis from the first cycle.

Mitochondrial disease with myopathy is a rare progressive disease which affects more than one system of the body. It can be diagnosed only by muscle biopsy showing ragged red fiber cells (RRFs) that requires special (trichrome) staining, often not available in routine histopathology laboratories. There is no specific treatment or cure for the condition. A case, confirmed by biopsy, is reported in a 42-year-old Qatari female suffering from previously undiagnosed chronic progressive weakness and possibly related hyperthyroidism. Muscle weakness, deafness, muscle biopsy Hyperthyroidism

Hereditary Benign Intraepithelial Dyskeratosis (HBID) is a rare autosomal dominant recurring disorder of the oral and ocular mucosa first described in 1960 among Haliwa Native American Indians in North Carolina. A few cases have been reported also in other parts of the United States, South America and Europe. This report describes a case with clinical and histopathological features of HBID.

Multiple Neurofibromatosis (NF) is a disease of great interest because of the familial nature of the disease, the complexity of its morphology, the progressive character of its course and the numerous complications that may develop during its evolution. The authors present a late presentation of a genital NF type 1 affecting the penis and the right lower limb of a young adult.

Thoracic ectopic kidney is a rare congenital anomaly that is often missed. We report a case of diaphragmatic hernia associated with a left thoracic ectopic kidney and bowel herniation into the left hemithorax. Radiological studies including chest radiology and computed tomography confirmed the diagnosis.

Adult-onset-still's disease is systemic inflammatory disorder of unknown origin, several reports have suggested a triggering infection in Adult-onset- still's disease, we describe a case of uncommon presentation of ASD associated with cytomegalovirus infection. A 25 year-old male was admitted to our hospital complaining of high fever. The physical examination showed Right basal crepitation, with pericardial rub. Although several antibiotics were administered, the spiking high fever was not alleviated. Two weeks after admission a macular rash appeared, and a high concentration of serum ferritin was observed. At this point, Still's disease was suspected. During the prescribed course of prednisolone, hepatic enzymes gradually increased accompanied by a positive test for cytomegalovirus (CMV) antigen. The symptoms disappeared after administration of gancyclovir and steroid. In this report, we attempt to portray the relation between the pathogenesis of adultonset Still's disease and the presence of CMV antigen.

The “all fours” maneuver for managing shoulder dystocia appears to be a rapid, safe and effective technique in women in labor with this problem. We report a case of shoulder dystocia managed successfully with complete vaginal delivery and no injury to mother and newborn after using the “all fours” maneuver. A brief literature review includes descriptions of other maneuvers for the problem of shoulder dystocia.