Qatar Medical Journal - Volume 2011, Issue 2

Abu Nasr Mohammad Ibn Al Farakh Al Farabi, known as Al Phrarabius in Europe, was born the son of a general in Wasij, a small village near Farab in Turkistan in 259 AH (870 AD). He completed his early education at Farab and Bukhara but later went to Baghdad for higher studies where he studied and worked from 901 AD to 942 AD becoming fluent in several languages and mastering various branches of knowledge and technology. He lived through the reign of six Abbasid Caliphs and was a well-respected and renowned philosopher and scientist

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

Records were reviewed of 81 cases of ruptured gravid uteri seen in the hospitals of Hamad Medical Corporation, Doha, in the 32 years 1977–2008, an overall incidence of 0.025%, although the incidence 1977–1997 was 0.01 % and that of 1998–2008 was 0.036%. Grand multiparity was a prominent cause (56.5%) in the first 21 years but less so in the later period 1998–2008 (10%) although involvement of a uterine scar from a previous caesarian section was noted more (84%) in the later period than in 1977– 1997 (43.5%). Other associated factors were the use of oxytocin or PGE2. Epidural anesthesia in the later period might have provoked abnormal fetal heart rates. The need for hysterectomy decreased from 65% to 10%. Perinatal mortality decreased slightly. Although we conclude that uterine rupture is rare (0.025%) it can be catastrophic for mother and newborn and might be prevented by multi-layer uterine hysterotomy closure, a longer interpregnancy interval following a caesarian section, and no or limited use of prostaglandins.

Objective: To evaluate the mid-term results of balloon pulmonary valvuloplasty (BPV) in children. Design: Prospective study. Settings: Pediatric Cardiology Department of Queen Alia Heart (QAHI), Jordan. Methods: One hundred and thirty-two patients with a median age of 3 years (range 1 day to 16 years), underwent (BPV) between January 1999 and January 2006. We evaluated our patients with regard to peak pressure gradient across the right ventricular outflow tract before and after BPV. Thereafter we followed them at the Outpatient Clinic regarding the peak instantaneous gradient pressure, the pulmonary valve incompetence, right ventricular function based on echocardiographic findings, and the need for repeat BPV. Results: There was significant reduction in the peak to peak gradient from 93.5 ± 32.3 mmHg to 26.1 ± 9.6 mmHg (p <  0.001). Echo-Doppler data showed that residual peak instantaneous gradient dropped from 26.1 ± 9. 6 to 19 ± 6 mmHg; (p <  0.001) on follow-up for 6 years. Mild to moderarte pulmonary valve regurgitation was noticed in 34 patients (27.8%) at one year and in 43 patients (38%) at mid term follow-up, but non had right ventricular dilatation or paradoxical interventricular septal motion. Conclusions: The results of mid-term follow up after balloon dilatation of the pulmonary valve are encouraging. The degree of pulmonary regurgitation is increasing with time. Longer term follow-up studies should be undertaken to evaluate the significance of residual pulmonary regurgitation.

Obesity is a chronic disease prevalent in both developed and developing countries and as a risk factor for several other chronic diseases it should be regarded as one of the greatest neglected public health problems with significant future implications to healthcare systems. With the aim of assessing the prevalence of overweight and obesity in patients attending Primary Health Care Centers (PHC) and identifying important causal factors a cross-sectional study using a questionnaire was made of 217 randomly selected adults >18 years attending five Qatari PHCs between February and April 2008. The overall prevalence of obesity in adult Qataris was 47.9% and prevalence of overweight was 33.6%; higher in males than females (17.9%, 15.6%), while the prevalence of obesity was higher in females (49.5% cf. 46%). Obesity was significantly higher among those on a high caloric diet, with physical inactivity and a family history of obesity (p = 0.000). Obesity increased with age, the highest prevalence being in the group above 48 years, (p = 0.0002). All the chronic diseases were significantly higher among the obese; e.g. diabetes (p = 0.02) and hypertension (p = 0.037). It is concluded that obesity is highly prevalent in the community and is caused by several social and lifestyle factors. The health authority should establish a program to prevent and control obesity, an important factor linked to the occurrence of several chronic non-communicable diseases.

Although it is a common malignancy, there is a lack of information about leukemias in Kurdish people. To evaluate the pattern of acute lymphoblastic leukemia among Kurdish children in Duhok city/ North of Iraq, and to compare it with available data from other countries, 83 cases were studied of acute lymphoblastic leukemia diagnosed by bone marrow aspiration cytology, cytochemistry and immune-phenotyping between July 2006 and August 2010.

Data recorded included age, sex, area of residence whether rural or urban, socio-economic status, the presenting features and the initial peripheral blood and bone marrow findings. Ages ranged from 7 months to 14.5 years, the peak occurrence was between one and five years and the male to female ratio was 1.7:1. Most patients were low socio-economic class (86.7%), and 68% were living in rural areas.

The most frequent presenting features were pallor (88%) and bleeding tendency (65%), and 25.2% of patients had a leukocyte count above 50,000 per cubic millimetre. L1 and L2 morphology was approximately equal (51.6% and 46.9%, respectively). The percentage of T-cell ALL was higher than the range reported in other countries. Conclusion: Acute lymphoblastic leukemia is an important health problem in Kurdistan region and its pattern differs in certain respects from that reported from different regions of the world though comparable in other aspects. The study recommends implementation of preventive, diagnostic and therapeutic strategies for leukemias in the Kurdistan region.

To investigate the possible role of circumcision in decreasing urinary tract infections in children less than five years of age the clinical and laboratory findings of 100 cases of urinary tract infection admitted to Al Khansaa Pediatrics Hospital were compared with a similar number of apparently healthy children. The results showed a strong relationship between circumcision and decreased incidence of urinary tract infections and that the risk of urinary tract infections in uncircumcised children was more than six-fold that of circumcised children of the same age.

To investigate the risk factors and characteristics of obstructive sleep apnea records were reviewed retrospectively of 88 patients at a European center (UK) during January-October 2005 and 198 patients at a Middle Eastern center (Qatar) from April 2002-April 2005. A greater percentage (83%) in the UK group had OSA (RDI-5 events/hr) compared to 55% in Qatar (p < 0.05). In both groups OSA was diagnosed more in males. Declared alcohol intake, smoking, insomnia, witnessed apnea and nocturia were associated significantly with OSA in the UK group (p < 0.05). BMI was significantly higher in the Qatar group (mean 34 kg/ m2) than the UK group (mean 31.2 kg/m2) (p < 0.05). The mean age, mean Epworth sleepiness score and associated vascular conditions were similar in both groups and hypertension was relatively common in both groups. It is concluded that obstructive sleep apnea in the West (UK) and the Middle East (Qatar) has similar risks and associations. That in the UK might arise from higher alcohol consumption and smoking of tobacco while mean BMI in Qatar is high although the exact contribution of these factors needs further evaluation.

To assess the causes of high serum ferritin (over 1000 nanogram/ml) the records were reviewed of 145 samples of blood with ferritin levels over 1000 ng/ml taken in 2004 at Hamad Medical Corporation. The most common causes of hyperferritinemia in Qatar were found to be: end-stage renal failure, thalassemia major and sickle cell disease.

The diagnosis of growth hormone deficiency (GHD) needs consideration of both clinical and biological aspects such as auxological data, GH provocative tests and active metabolites of GH including IGF-I and IGFBP-3. In children with GHD, recombinant human GH (rhGH) replacement therapy has been used worldwide with minimal serious side effects. This study aimed to report the results of an investigations for GHD, to describe the growth responses to rhGH in deficient children compared to those without GH deficiency, to evaluate the relationship between clinical and biochemical responses, and to describe the experience of diagnosis and treatment with rhGH at Hamad General Hospital, the main hospital in Qatar where most short children are referred for further investigation. The clinical records of 116 short children were reviewed retrospectively. Forty-six failed the clonidine test and 42 of these also failed the glucagon test and were confirmed with GHD. These and 16 children without GDH were treated with rhGH (25 gg/kg/ day) and were evaluated in terms of growth response, HtSDS, changes of IGF-I concentration and the relationship between these parameters. Treatment with GH of short children with GHD does produce a satisfactory growth response but the HtSDS gain was significantly higher in those with GHD compared to children without GHD. Measurement of IGF-I was found not to be a useful diagnostic test in GHD.

With the intention of assessing the neuro-imaging, clarifying the percentages of symptomatic, idiopathic and cryptogenic cases and identifying the underlying causes, records were reviewed retrospectively of 30 children with infantile spasm admitted to Hamad Medical Corporation, Doha, Qatar. Twenty-three patients were symptomatic, four idiopathic and three cryptogenic. Brain CT and MRI scans of 13 cases detected similar neuro-imaging findings in nine cases while MRI provided more information in another four cases. Three patients had normal neuro-images despite persistently abnormal EEGs. We conclude that MRI scans are superior to CT scans in detecting areas of cortical dysgenesis, disorders of neuronal migration, or disorders of myelination although more advanced studies are required for patients with persistently abnormal EEGs but normal MRIs.

There is a growing awareness that Vitamin D sufficiency is required for optimal health during all stages of life. Inadequate Vitamin D status is increasingly recognized as common problem. To assess the serum level of 25 Hydroxyvitamin D 250 HD among healthy post-menopausal Qatari women living in Doha a crosssection randomized study of 205 post-menopausal Qatari women was conducted between 1 September 2008 and 31 April 2009 at four Primary Health Care Centers. Using interviews, a questionnaire, and a 5 ml blood sample, personal data was collected plus likely risk factors for Vitamin D insufficiency. More than onethird of the women (38.0%) had severe Vitamin D deficiency, almost half (47.3%) had mild Vitamin D deficiency, only 14.6% had a normal Vitamin D level. Risk factors were inadequate exposure to the sun, the use of sun screen, complete covering of the body with clothing, low dietary Vitamin D intake and the use of Vitamin D supplements. The study indicated clearly that hypovitaminosis D is common in post-menopausal Qatari women and that efforts are required to encourage adequate exposure to sunlight and an increased intake of fortified Vitamin D to maintain normal levels.

More than 90% of malignant tumors of the larynx are squamous cell carcinomas. Extramedullary plasmacytoma is a plasma cell tumour representing less than 1 % of all head and neck malignancies and involvement of the larynx is very rare. In the larynx the supraglottis is the primary site of involvement compared to the glottic and subglottic regions. We report a case of 54-yearold Indonesian female who presented at our clinic with stridor as primary manifestation secondary to solitary extramedullar plasmacytoma involving the glottis and subglottis of the larynx. The patient underwent microlaryngoscopy, biopsy and CO² laser excision of the tumour with significant improvement of the airway and was referred for locoregional radiotherapy. We review the literature and discuss the management of this rare condition.

In our study we present two cases that have been diagnosed as stage I endometrial carcinoma where a Levonorgestrel intrauterine releasing system (LNG-IUS) referred to as Mirena was used as a primary treatment because the standard surgical treatment was deemed to carry an unacceptable risk of death. Histopathology report after therapy showed complete regression of endometrial cancer.

Chordomas are rare malignant tumors arising from embryonic remnants of notochord. The usual location is the axial skeleton, with the commonest sites being, clivus and sacrococcygeal region. Naso maxillary region is a very rare site for chordomas. We present a case of chordoma in Cranio Maxillofacial Surgery of the clivus treated with surgery and radiotherapy ten years previously, who reported with an extensive secondary lesion in the maxilla and nasal cavity. Surgical management of this case is demonstrated. The question of whether the maxillary lesion represents a metastasis or a surgical pathway recurrence is discussed. The factors such as the amount of normal tissue between the original tumor and the secondary lesion, presence or absence of recognizable lymphatic or perineural pathway of spread, presence or absence of other metastatic lesions are important in distinguishing marginal recurrences from surgical pathway recurrences. Modifications of surgical, chemotherapy(2) and radiotherapy regimens are considered in the light of the aforementioned factors.

HELLP (Hemolysis Elevated Liver Enzymes and Low Platelets) syndrome is a multi-system pregnancy associated disorder, commonly seen in patients with pre-eclampsia but can occur alone. It is significantly associated with maternal-fetal morbidity and mortality.

A triad of hemolysis elevated liver enzymes and thrombocytopenia after 24 weeks of gestation is diagnostic of this syndrome. HELLP syndrome is classified depending on simple parameters but it dictates severity of the disease. Frequently encountered complications with HELLP syndrome are hemorrhagic stroke, disseminated intravascular coagulation, pulmonary edema, acute renal failure and hepatic rapture. The aggressive supportive care of failing organs with high dose of steroids will decrease the duration of HELLP syndrome, decreases intensive care and hospital stay of these patients as well as reduction in fetal complications. HELLP syndrome is associated with significant increase in morbidity and mortality of pregnant patients; hence it is of vital importance that not only obstetrician, but acute care physicians and intensivist should be aware of this clinical entity. We report a case of Classl, normotensive postpartum HELLP syndrome complicated by pulmonary edema and acute renal failure, successfully managed in our intensive care unit.

Celiac trunk aneurysm is a rare finding. Most patients are symptomatic at the time of diagnosis but occasionally such aneurysms are detected incidentally during diagnostic imaging for other diseases. Since the anomaly was first described in 1745(1) fewer than 180 cases have been reported in the international medical literature.(2) Atherosclerotic aneurysms of the celiac artery (CAAs) comprise approximately 4–6% of all visceral aneurysms.(3–4) Early surgical intervention has reduced the rupture rate to 7% in recent years.(5) Early recognition and intervention are crucial because the operative mortality rate associated with ruptured celiac artery aneurysms is around 40%.(6) There are no absolute size criteria associated with significant rates of CAA rupture, but 2 cm appears to warrant intervention in most series.(7–8) Surgical reconstruction, surgical ligation, intraluminal embolization, thrombin injection and endovascular grafting have all been reported with success/9”11) We present a case of a 6.9 cm symptomatic celiac artery aneurysm treated successfully with endovascular stenting.