Qatar Medical Journal - Volume 2015, Issue 1

A 22-year-old booked primigravida underwent lower segment caesarean section for breech presentation. She developed signs and symptoms of wound infection by the fourth postoperative day. This was initially managed with antibiotics and wound dressing, but debridement was later undertaken after consulting surgeons. This resulted in an alarming worsening of the wound with sudden and fast increase in its size along with systemic symptoms. Wound biopsy established the diagnosis of pyoderma gangrenosum. The patient's management included oral medication with prednisolone, cyclosporin and dapsone and wound care. There was a dramatic response to this treatment. The wound completely healed by the eighth postoperative month. The oral medications were tapered off slowly and stopped by that time.

Anti-N-methyl-D-aspartate-receptor (NMDA-R) encephalitis is a new autoimmune, often paraneoplastic disorder that presents with complex neuropsychiatric symptoms. It was first described in 2007 by Dalmau et al. Our patient presented with headache, behavioral changes and then seizures with hallucinations. She was initially misdiagnosed to have schizophrenia and was prescribed antipsychotics. She deteriorated and developed further seizures with hypoventilation and choreoathetosis. Her blood investigations were positive for mycoplasma IGM. Her CSF studies showed high white cell counts, predominantly lymphocytes, and high anti-NMDA-R titre. Her brain MRI scans showed high T2 and FLAIR intensities in the grey and white matter of the left cerebellar hemisphere suggestive of acute disseminated encephalomyelitis. She responded to treatment with antibiotics, multiple antiepileptics, steroids and needed five sessions of plasmapheresis. There was no underlying malignancy on repeated scanning of the abdomen. She needed around one year for full recovery with intensive rehabilitation. The objective of this paper was to highlight the occurrence of this fairly new, challenging, easily missed, not-so-rare form of encephalitis often occurring in the absence of fever.

Introduction: Despite the large number of caregivers suffering from various psychiatric disorders, research on psychological symptoms among caregivers of hospitalized patients is lacking in Saudi populations. Objectives: The objective of this study is to determine the prevalence of depression, anxiety and stress among caregivers of hospitalized Saudi patients. Methods: A cross-sectional study of depression, anxiety and stress among caregivers of hospitalized patients was conducted. Arabic speaking caregivers (n = 353) between the ages of 14 and 80 years were included in the study. The Depression Anxiety Stress Scales (DASS-21) test (Arabic version) was used to measure the three psychological symptoms. Results: The study has shown high rates of depression, anxiety and stress among caregivers (72.8%, 76.5%, and 61.5%, respectively). Depression was found to be associated with long-term hospital stay (81.4% vs. 69.3%; p-value = 0.021) and family caregivers (75.4% vs. 46.9%, p-value = 0.001). Anxiety was found to be associated with family caregivers (78.8% vs. 53.1%; p-value = 0.001). The three psychological symptoms were higher among those with an age above 20 years old (p-value < 0.05). Multivariate logistic models show the risk of the psychological symptoms increased with low-income, higher education, immediate relation to the patient, and older caregivers. Conclusions: The findings suggest that the prevalence of depression, anxiety and stress symptoms were very common among caregivers. The results showed that approximately 8 out of 10 caregivers suffer from at least one psychiatric disorder. Older, low socioeconomic status, and well-educated caregivers were identified as being at higher risk of developing psychiatric symptoms.

Patient perceived perceptions of psychosocial support are increasingly important to understanding appropriate holistic patient-centred care. Information is scarce regarding the attitudes of female cancer patients in Arab and Muslim populations. This study was undertaken in the State of Qatar among female cancer patients. The aim of this study was to investigate what extent women undergoing cancer treatment in the State of Qatar view the importance of psychosocial support? Another aim of this study was to determine which demographic indicators, if any, may predict for certain preferences in support. The authors hypothesized that a majority of female cancer patients will perceive psychosocial support as an important aspect. This study used English and Arabic questionnaires to glean data from female cancer patients attending clinics at the National Centre for Cancer Care and Research in Doha, Qatar. For the purpose of this study, psychosocial support was defined under four categories: 1) family support, 2) religious/spiritual support, 3) support groups 4) physician referred support. Results showed that 88% of female respondents rated psychosocial support categories as important. There was no significance between patient demographics and specific preferences for the support categories in the study. This study may provide some areas for future research that may shape guidelines for improving holistic patient care and in assisting the Supreme Health Council in meeting its targets for the Qatar National Cancer strategy, which states that cancer treatment should be patient-centred focusing on both medical and psychosocial needs of patients.

Foreign bodies in the liver, although rare, have been described previously in the literature. While more common in children, adults may also swallow foreign bodies that can reach the liver by penetrating the stomach, duodenum or colon. We describe the case of a young lady who accidentally swallowed a needle, which was later found in the liver by abdominal X-ray and computed tomography (CT). It was removed intact by laparoscopy. A foreign body in the liver is a rare occurrence. Radiology is important in diagnosis through modalities including plain X-ray, ultrasonography and abdominal CT. Removal can be achieved by laparotomy or laparoscopy.

Acute angle closure glaucoma is an ophthalmic emergency and can lead to blindness if left untreated. Several types of drugs have the potential to precipitate acute angle closure glaucoma. These include adrenergic, cholinergic and anticholinergic, antidepressants, anticoagulants and sulfa-based agents. This article provides a basic overview of the risk factors and pathophysiologic mechanisms involved in angle closure glaucoma and focuses on drug-induced angle closure glaucoma for the non-ophthalmologist. A PubMed search limited to the English language was conducted to find relevant literature for the purpose of this article. Most attacks occur in subjects unaware that they are at risk due to innately narrow iridocorneal angles. Clinicians should always review medications in patients presenting with symptoms of acute angle closure glaucoma. The aim of this article is to bring this ophthalmic condition to the attention of clinicians, particularly those outside the field of ophthalmology who commonly prescribe these medications or see these patients prior to referring to ophthalmologists.

Foreign body ingestion is a common presentation in the emergency room and most cases are without any major symptoms, or go unnoticed and later cause severe complications that can potentially threaten patient life. We report a case of multiple migrated metallic foreign bodies in the right kidney presenting as right renal colic and gross haematuria one year after its accidental ingestion, treated successfully with retrograde percutaneous nephrostomy.

Nontuberculous mycobacterial infection in an immunocompetent young patient complicated with empyema and pneumothorax is rarely reported. A 36-year-old man presented to the emergency department with a history of worsening dyspnea and pleuritic chest pain. The patient had unstable vital signs on presentation, and was referred to the resuscitation area on a monitored bed. The patient had a chest x-ray (CXR) performed on a prior occasion at a primary health clinic, revealing pneumothorax and some fluid at the left costophrenic angle. On arrival at the hospital, bedside ultrasound was performed which confirmed the diagnosis of pneumothorax. His vital signs were pulse 153, BP 88/62, RR 50 breaths per minute and his oxygen saturation on air was 92%. Tension pneumothorax was diagnosed based on clinical presentation and given vital signs. It was managed immediately with needle decompression followed by chest tube insertion. The patient improved dramatically after needle decompression with stabilization of vital signs. A CXR was repeated post-needle decompression which showed an incompletely resolved pneumothorax with an increase in the size of the effusion. Iatrogenic haemothorax was a possible explanation for this increase in effusion size. Chest tube was successfully inserted in the fourth intercostal space just anterior to the midaxillary line under full aseptic precautions. The chest tube drained 1.4 liters of blood, which on analysis showed a low pH and elevated adenosine deaminase level. Two out of three sputum samples sent from the medical ward were positive for mycobacteria other than tuberculosis as confirmed on culture. The patient's symptoms improved with percutaneous tube drainage of hemopneumothorax and antituberculous medications.

Background: Organic acidemias (OA) are a group of heterogeneous metabolic inherited disorders characterized by the accumulation of organic acids in body fluids and tissues. These are rare disorders and infrequently reported worldwide. In Syria, there is a lack of information regarding these disorders. Objective: Our hospital-based study aimed to describe the pattern of clinical and demographic presenting features of organic acidemias among Syrian children and to shed light on the diagnostic experience of organic acidemias in the Children's Hospital of Damascus through a five year period. Material and methods: We conducted a retrospective cohort study by reviewing the medical records of OA patients in the Children's Hospital of Damascus between 2008 and 2012. All cases were investigated by metabolic work up, including the acylcarnitine profile performed by tandem mass spectrometry (MS/MS) and quantitative urine organic acid analysis performed by gas chromatography mass spectrometry (GC-MS). Results: A total of 70 OA confirmed cases were included in the study. There were 46 males and 31 females. Twenty-seven cases were diagnosed after the first year of life. Methylmalonic acidemia was the most frequent disorder (57.1%). There were relatively high rates of family history of unexplained death and OA confirmed cases (50%), consanguinity (74.2%) and mortality (21.4%). The most frequent symptoms were apnea or respiratory distress (65.7%) and vomiting (40%). Conclusion: The lack of specific confirmatory diagnostic tests being performed and the high mortality and consanguinity rates among OA patients suggests high incidence of OA in Syria. Further studies are needed to determine the actual incidence of OA and the cost-effectiveness of applying a governmental mandatory newborn screening program.

Background: Iraq is consistently exposed to large-scale traumatic events such as successive wars since 1980 to the present day, economic sanctions, sustained organized violence, and terrorism. These unsafe circumstances have negatively impacted the psychosocial status of the Iraqi community. Objective: To study the prevalence of witnessing or exposure to various types of violence, and its association with mental health problems in a sample of Iraqi men. Methods: This is a cross-sectional study that was conducted from April to September 2014. The target population were men from different age groups that were collected through a convenience sampling technique from two large cities; Baghdad (the capital city) and Mosul (the second largest city in Iraq). The source of data was from different institutions, colleges and lay people. The data collection process was done using the Self-Reporting Questionnaire 20 which is recommended by the World Health Organization for screening psychiatric disturbances. Results: A total of 480 Iraqi males agreed to participate in the study. The main type of violence reported was witnessing violence (55.4%), followed by exposure of friends or relatives to violence (51.4%), and witnessing or exposure to sexual assault was least reported (3.8%). The most frequent feeling recorded was of worry (72.9%), getting easily upset (65.4%), suffering from headaches (62.7%) and lethargy (59.4%). Severe psychological changes were evident in 68.5% of men, while moderate changes were present in 31.5%. Analysis of the feelings and behavioral changes in relation to the participants' history of exposure to violence revealed a significant association with witnessing shooting or stabbings, displacement, friends or relatives' exposure to violence, and viewing corpses. Conclusion: There is a high prevalence among Iraqi men of exposure to, or witnessing violence that showed an association with their mental condition, which, if proved causally, may be a leading cause for future devastating effects on their health, wellbeing and quality of life.

Background: Congenital adrenal hyperplasia (CAH) is one of the most common inherited metabolic disorders. 21-hydroxylase deficiency is responsible for the majority of cases (90-95%) and considered the most common cause of genital ambiguity. There are no statistics concerning the prevalence of this disorder in Syria, although the high rate of consanguineous marriages indicates a possible high prevalence. Objectives: This study aims to collect baseline information about CAH in Syria to evaluate the potential need of a screening program. Subjects and Methods: All medical records of inpatients who had CAH as a final or presumptive diagnosis at the Children's Hospital of Damascus between 2008–2012, or were diagnosed elsewhere and then admitted at the hospital for the first time within the same period, were retrospectively reviewed and divided into two groups: confirmed and suspected cases. Results: Eighty-nine cases were confirmed, 25 were still suspected. Of the 89 confirmed cases: 20 (22.5%) were males, 66 (74.1%) were females, and 3 were ambiguous. Sixty-one patients (68.5%) were of the salt wasting type and 28 (31.5%) were of the simple virilizing type. The mortality rate was 6.7%. Thirty-two females were assigned as males at birth. Seventeen cases (19.1%) underwent previous hospitalization. 69.7% of patients were not diagnosed during the first month of life. Of the 25 suspected cases: 12 were males, 8 were females and 5 were ambiguous. Confirmatory tests had not been performed because of death in 7 patients (28%) and early discharge upon parental request in another 7 patients (28%). Conclusion: A mandatory screening program for CAH in Syria seems necessary due to the obvious lack of awareness, delayed diagnosis and high expected prevalence. However, further efforts are needed to confirm the effectiveness of such a program in the Syrian society.