Qatar Medical Journal - Volume 2019, Issue 1

Background: Hemoptysis is an alarming symptom in clinical practice. We reviewed ten years of experience with hemoptysis in a tertiary hospital in Qatar to identify hemoptysis etiologies, patient characteristics, and associated factors. Methods: Hemoptysis was defined based on severity as mild ( < 50 ml or streaks of blood), moderate (50–150 ml) and massive (>150 ml) in the 24 hours before admission. Hemodynamically unstable is considered when systolic BP  < 100 mmHg,tachycardia with HR>110/min, tachypnea with RR>22/min, or SpO2  < 92% on room air. Results: A total of 102 patients (41 females and 61 males) with 133 episodes of hemoptysis were identified in this study. Among the hemoptysis patients with co-morbidities, 19 patients had hypertension, 17 patients had cardiovascular disease, and 66 patients with other co-morbidities. COPD patients had a significant (p  <  0.02) association with hemoptysis. Chest X-ray was used in most patients and other modalities like CT scan and bronchoscopies were used less frequently. Pneumonia (12.8%), bronchiectasis (11.8%) and cardiovascular disorders (11.8%) are the primary causes of hemoptysis. Malignancy was less frequent (7.8%), and bronchogenic carcinoma was uncommon (2%). There were 24 (23.5 %) no identified causes of hemoptysis. The overall mortality was 9.8% in this study. Conclusions: Population demographics played a significant role in the severity of hemoptysis and prognosis. Most patients had benign etiologies, lower severity of hemoptysis and good prognosis. Differences in the etiology, initial severity, and prognosis of patients with hemoptysis were found significantly different when compared with those reported in previous studies.

Background: Although cesarean delivery on maternal request (CDMR) has been associated with an increase in the frequency of cesarean sections (CSs), there is a lack of studies reporting the frequency of CDMR in Saudi Arabia. This study was conducted to estimate the prevalence of and the motives for CDMR and identify its associated factors. Methods: This cross-sectional study was conducted between March and June 2017 on 364 pregnant women who planned a CS at King Abdulaziz Medical City in Riyadh. The characteristics of the women and their motives for undergoing a CS for the current pregnancy term were collected. Results: The prevalence of CDMR was found to be 13.7% (50/364) [95% confidence interval (CI): 10.370%–17.706%]. Older maternal age ( ≥ 40 years) [adjusted odds ratio (aOR) = 3.9; p = 0.019], family history of CS (aOR = 2.9; p = 0.038), non-Saudi nationality (aOR = 5.0; p = 0.050), and receiving education or medical information about the possibility of delivering by CS (aOR = 13.7; p = 0.030) were significantly associated with a higher prevalence of CDMR. As the number of previous CSs increased by one (aOR = 0.6; p = 0.011), the odds of CDMR decreased by 40%. The most common motives for demanding a CS in the absence of medical indications were avoiding labor or possible complications from vaginal birth (60%) and fear of pain on vaginal delivery (46%). Conclusions: A high prevalence of CDMR was documented at King Abdulaziz Medical City, especially among women of older maternal age, having a family history of CS, of non-Saudi nationality, and who received education or medical information about the possibility of delivering by CS. Counseling programs might be helpful for pregnant women who fear pain in vaginal delivery or have had a previous traumatic birth experience.

Background: Although acute respiratory distress syndrome (ARDS) is a common reason for admission to intensive care units, limited information is available about the epidemiological and clinical characteristics of these patients in Middle Eastern countries. Qatar is a high per capita income country with a large multinational expatriate population. Hamad General Hospital is our main tertiary referral center with the largest medical intensive care unit (MICU). Method: A retrospective cross-sectional study was conducted to extract data from the MICU registry for 101 patients aged >14 years who were admitted with ARDS from January 2015 to December 2015. Results: In 2015, a total of 101 (14.8%) of 682 patients admitted to MICU were diagnosed with ARDS. Males comprised 71.3% and females 28.7%. The mean age of the study population was 44.96 ± 17.97 years. Community-acquired bacterial and viral pneumonia were the most common reasons for ARDS. Crude mortality rate was 35%. The mean age of survivors was 42.09 ± 13.58 years compared with 50.36 ± 16.84 years of non-survivors (p = 0.008). Mortality was associated with increasing age, the Acute Physiologic Assessment and Chronic Health Evaluation II severity score, lower P/F ratio, higher Murray's score, higher PCO2, lower pH, and circulatory support with vasopressors. Preexisting comorbidities did not contribute to high mortality. No difference in mortality was noted with higher versus lower positive end expiratory pressure. The prone position was used in 8% of the cases. Twenty-seven (27%) patients had undergone salvage therapy with extracorporeal membrane oxygenation (ECMO) that resulted in a survival rate of 44%. ARDS was associated with acute renal failure requiring dialysis in 28.7% of the cases, pneumothoraces in 4%, ventilator-associated pneumonia in 7.9%, and central line-associated bloodstream infection in 2%. ARDS led to a prolonged length of stay compared with the average length of stay in MICU. Conclusion: Community-acquired bacterial and viral pneumonia were the most common causes of ARDS at our center. Critical care outcome correlated with the severity of the disease. ECMO was used as salvage therapy in our center.

Introduction: Vaccination is considered one of the most successful and cost-effective public health interventions of the 20^th century. In 2017, Qatar's Expanded Program of Immunization (EPI) provided vaccination services against a comprehensive list of 15 vaccine-preventable diseases. Objectives: To assess the performance of Qatar's national immunization system, identify possible gaps by determining the national vaccination coverage rates, and benchmark these rates against regional and global figures. Methods: The data utilized herein were retrieved from the vaccination coverage estimates generated by the World Health Organization and United Nations International Children's Emergency Fund. Relevant local, regional, and global vaccination coverage figures were manually extracted and then analyzed for six vaccines (DTP3, Pol3, MCV2, HepB, PCV3, and RotaC) in 2017. Percentages and proportions were compared using the Chi-squared test. Results: Vaccination coverage levels in Qatar have surpassed the optimal level of 90% for all vaccines. Compared with international figures, the national coverage exceeds the relevant benchmarks. For DTP3 and Pol3, Qatar achieved 97% coverage compared with 99% coverage in Jordan and 85% coverage globally. For MCV2, Qatar achieved 93% coverage compared with 99% coverage in Jordan and 67% coverage globally. For RotaC, Qatar achieved 97% coverage compared with 96% coverage in Jordan and 28% coverage globally. For HepB, Qatar achieved 97% coverage compared with 43% coverage globally. Conclusions: Compared with the international benchmarks of major vaccines, the vaccination coverage rates in Qatar are high. However, challenges for maintaining high coverage, such as cultural and language barriers, should be addressed.

Objective: To study the demographic data and histopathological specimen findings of patients who have undergone laparoscopic sleeve gastrectomy. Design: A retrospective descriptive study. Setting: Pathology and Laboratory Medicine Department, Al-Ahli Hospital, Doha, Qatar. Methods: Data of patients who underwent laparoscopic sleeve gastrectomy between January 1, 2009 and December 31, 2016 were retrospectively collected from the laboratory information system of Al-Ahli Hospital. Results: A total of 342 patients underwent laparoscopic sleeve gastrectomy. Among these patients, 294 (86%) were Qatari and 241 (70%) were female. The patient age ranged from 13 to 72 years, and most patients were in the 31–40-year age group. Histological examination of specimens showed that lymphocytic aggregates in the lamina propria were the most frequent histopathological finding (171, 50%), followed by no remarkable pathological finding (98, 28.6%). The other pathological findings were follicular gastritis, fundic gland polyps, and acute and chronic gastritis. Conclusion: Our findings clearly indicate the need for routinely performing histopathological examination of laparoscopic sleeve gastrectomy specimens. The study also highlights lymphocytic aggregates as the most common histopathological finding.

The overall rate of major bleeding in patients with atrial fibrillation receiving warfarin therapy is approximately 4%. Among these 4% patients, spontaneous retroperitoneal hemorrhage (SRH) is a rare but potentially lethal complication with a nonspecific presentation that can lead to missed or delayed diagnosis. The current literature provides little direction for diagnosis and management of such cases. Anticoagulation-related SRH is associated with a high mortality rate (approximately 20%). Despite the vague presentation, prompt diagnosis is crucial to reverse the anticoagulation and prevent further bleeding. Contrast-enhanced computed tomography (CT) of the abdomen is the imaging modality of choice in suspected cases. Patients with SRH require aggressive treatment with blood transfusions, interventional radiological procedures, percutaneous drainage or surgical evacuation of the hematoma. We report a case of warfarin-induced SRH from the renal vein in a patient who presented to our emergency department with acute, nonspecific abdominal pain and shock. We diagnosed the patient with warfarin-induced SRH on the basis of clinical suspicion and characteristic CT findings. We initially treated the patient conservatively, followed by embolization of the right renal artery during the late course of hospital stay, and he was discharged with good recovery. SRH should be considered in the differential diagnosis of abdominal pain, hypotension, and/or decreased hemoglobin levels in patients receiving anticoagulation therapy, especially in those with preexisting end-stage renal disease.

Background: Congenital hypothyroidism (CH) is a treatable thyroid hormone deficiency that causes severe mental retardation and growth deficiency if not detected and treated early. The treatment of CH is simple, inexpensive, and effective. With early detection and treatment, infants usually develop normally without mental retardation and become productive members of society. In Syria, a screening program is not available, and there is no published information about the actual incidence of CH. However, an unpublished pilot study supported by the International Atomic Energy Agency showed that the incidence of CH in Syria is more than the global incidence, indicating the importance of the application of a CH screening program in Syria. Objectives: The present study aimed to collect baseline information about CH in Syria to estimate the potential need of a screening program. Materials and methods: This retrospective study was performed at Children's University Hospital, Damascus. The study included the medical records of patients who had CH as the final diagnosis between 2008 and 2012. Some patients were diagnosed elsewhere and were then admitted to the hospital within the same period. Results: In this study, 70 cases registered as CH, 67 of them had confirmed, 40 (57.1 %) were male and 30 (42.9%) were female. Among the patients, (51.4%, n = 36) involved parental consanguinity and 6 had a family history of hypothyroidism. Additionally, 74.3% were not diagnosed during the first month of life. The signs and symptoms most commonly detected were cretinoid face (60%), pallor (44.3%), delayed neuropsychomotor development (37.1%), growth failure (36.7%), jaundice (35.7%), and hypotonia (35.7%). Conclusion: A CH screening program is necessary in Syria owing to the low specificity of the signs and symptoms of CH, which can lead to delayed diagnosis, and the presence of asymptomatic cases (subclinical hypothyroidism).

Introduction: Despite the high income level in Arabian Gulf countries, people in the region need to improve their use of child restraint systems (CRSs) to reduce the incidence of preventable injuries to child automobile passengers. Anecdotal reports have attributed the resistance to using CRSs to the expense and unavailability of the systems, prompting car seat giveaway programs. Previous studies have not assessed the adoption of CRS. This study reports the results of a rapid market survey (RMS) to understand the availability, characteristics, and affordability of CRSs in Qatar and recommend future child restraint policies and legislation. Methods: The RMS identified all retail outlets that sell CRSs in Qatar and collected standard data on each restraint system: brand, model number, age/weight limits, compliance with standards, availability, and language of the owner's manual. A previously utilized metric for child safety devices was used to measure affordability. Results: The RMS showed a sufficient number (83) and variety (five types) of car seat models at 15 retail outlets, selling at a wide price range of $14–$1,399. All the car seats complied with the European standard. Only 2% showed a manufacturing or expiry date. A user manual was available for 71% of the seats and in different languages, but only 28% appeared in Arabic. The median CRS price was equivalent to the wages for less than one day of work. Conclusion: The RMS demonstrates the availability, variety, and affordability of CRSs in Qatar. Unavailability and expense cannot be cited as barriers to use CRS, and the market is prepared for legislation requiring car seats for children in Qatar. Areas for improvement include requiring user manuals for all seats, especially in Arabic; requiring that all car seats comply with globally accepted safety standards, especially for expiry/manufacturing dates, given the harsh local climate; and encouraging further varieties of CRSs in the local market.

Rationale and objectives: We aimed to report and compare accuracy, reproducibility, and reporting confidence between thoracic dual-energy subtraction (DES) and routine posterior–anterior chest radiography (PA-CR) techniques. Materials (patients) and methods: We obtained DES (D1–D4) images from 96 patients using DES and a high-resolution dynamic flat-panel detector in combination. We compared the DES images of these patients with their PA-CR images. The maximum time interval between performing DES and PA-CR was nine weeks. Two radiologists evaluated abnormal findings on DES and PA-CR images using a three-point scale, and reporting confidence was scored using a four-point scale. The intra- and interobserver agreement values of the scores were analyzed. Further, the radiation exposure doses during PA-CR and DES acquisitions were calculated. Results: The intra- and interobserver agreement values of PA-CR and DES images were good. The reporting confidence scores for DES were generally higher than those for PA-CR. Between bone-subtracted (D3) and soft-tissue-subtracted (D4) images, the former was more successful and useful in the evaluation of bone structures, whereas the latter was better in the evaluation of consolidation and/or solitary nodules. Conclusions: DES has the potential to improve the accuracy, reproducibility, and reporting confidence of thoracic radiography. It also has the potential to provide a better diagnosis of chest pathologies using relatively low dose radiation.

Background: Preeclampsia and eclampsia are two hypertensive disorders of pregnancy that significantly contribute to higher morbidity and mortality rates. Eclampsia is the occurrence of seizures in patients with preeclampsia without any previous history of seizure disorders. The incidence and prevalence of eclampsia varies, and there is scarce literature about the prevalence and trends of eclampsia in the Arabian Gulf countries. This study aimed to identify the incidence and changing trends of eclampsia in Qatar. Patients and Methods: This retrospective study was conducted at Hamad Medical Corporation, the only tertiary heathcare center in Qatar, and included all patients admitted with eclampsia from 1979 to 2017. The demographic data, maternal age, parity, gestational age, antenatal visits, timing of seizures, mode of delivery, treatment, maternal morbidity, and mortality were recorded. The study period was divided into the initial period of 1979–1988, 1991–2009, and the recent period of 2010–2017. Data analysis was performed using chi-square tests to identify trends among the three different periods. A p value of ≤ 0.05 (two-tailed) was considered statistically significant. Results: A total of 151 patients with eclampsia were admitted with an increasing incidence of eclampsia over time. There was a statistically significant improvement in antenatal follow-up and an increase in the maternal age of patients with eclampsia (p = 0.001). The incidence of eclampsia without proteinuria increased significantly over time (p = 0.03). Postpartum eclampsia was more common (p = 0.002). Labetalol was the most frequently used antihypertensive agent (p = 0.001), and magnesium sulfate has been increasingly used as an anticonvulsant agent (p = 0.001). The rate of maternal morbidity was decreasing, and in the recent period, posterior reversible encephalopathy syndrome was becoming a common comorbidity in patients with eclampsia. Maternal mortality displayed significant improvement, reaching 0% in the recent study period (p = 0.02). Perinatal mortality likewise displayed a decreasing trend and reached 3.17% in the recent period. Conclusion: The incidence of eclampsia is increasing in Qatar. The antenatal care of patients with eclampsia has improved significantly. The medical management of patients with eclampsia has also drastically improved, leading to a significant decrease in maternal mortality and improvement in perinatal outcomes.