Qatar Medical Journal - Volume 2020, Issue 1

Purpose: This study aimed to determine the epidemiological features of herpes zoster (HZ) in Qatar. Methods: This study was a retrospective review of all reported HZ cases received by the surveillance unit at the Ministry of Public Health, between January 2012 and December 2017. Results: A total of 2815 cases were reported during the study period. The mean incidence of HZ was estimated to be 19/100,000 population, which increased from 9.8/100,000 in 2012 to 36.2/100,000 in 2017. The ratio of male/female was about 4:1. HZ incidence overall was found to be highest in those aged ≥ 50 years. According to nationality, the mean incidence of HZ was estimated to be 79/100,000 among Qataris and 101/100,000 among expatriates. Additionally, more HZ cases were notified during the hot months. Conclusion: Such epidemiological data will contribute to the baseline information, which is necessary for effective preventive and control measures to be implemented in the country.

Background: Obesity has always been considered a criterion of difficult airway management, and many authors have tackled this subject. We are presenting our experience in airway management in obese patients undergoing bariatric surgery in Qatar and comparing the results with previous studies. Objective: The primary objective of this study was to explore the relationship between difficult mask ventilation and difficult intubation. The secondary objective was to identify other factors that may play a role in either difficulty such as gender, associated comorbidities, and the skill and experience of anesthetists. Design: This study was a prospective observational cohort study. Sample: A total of 401 patients were selected for various elective bariatric surgery in Hamad General Hospital, including 130 males and 271 females with an average body mass index(BMI) of 46.03 kg m^− 2. Results: We used Pearson Chi-Square and Yates corrected Chi-square statistical tests in our statistical analysis. Neck circumference had a p value of 0.001 in both genders. The male gender had a p value of 0.052 and 0.012 in mask ventilation and difficult intubation, respectively. The Mallampati score had a p value of 0.56 and 0.006 in mask ventilation and intubation, respectively. In general, neck circumference, Mallampati score, gender, obstructive sleep apnea, and diabetes mellitus had greater negative effects on airway management than BMI alone. Conclusion: It was hard to intubate 25% of patients who had difficult mask ventilation (DMV). All DMV and 20 out of 23 of difficult intubation patients were in the high BMI group ( ≥ 40). Neck circumference, Mallampati score, and male gender were major independent factors; however, other factors, such as obstructive sleep apnea, and diabetes mellitus, should be kept in mind as additional risks.

Road traffic injuries are the leading cause of death in Qatar but their epidemiology in children has not been fully described. This paper will describe the epidemiology of pediatric road traffic injuries (pRTIs) in Qatar, in order to understand the relationships among risk factors, mechanisms of injury, use of safety equipment, and according to child developmental stages.

The primary sample for this study was drawn from all pRTIs (0–18 years) from January 2010 to December 2012—motor vehicle occupants, passengers and drivers, pedestrians, cyclists, motorcyclists, and all-terrain vehicle (ATV) drivers and passengers—seen at the trauma registry of the Hamad Trauma Center, the national Level I Trauma Referral Center of Qatar.

During those two years, the Trauma Center attended to 4864 patients, 443 (9.1%) of whom were pRTIs, 83% were male, and 71% were non-Qatari. Only 1.2% of injured passengers and drivers were restrained. All fatalities were passengers or drivers; the overall mortality rate was 3.4%. The motor vehicle crash (MVC) mortality rate was 6.2%, with the longest mean length of hospital stay 10.5 days and highest Intensive Care Unit (ICU) admission rate 35.7%. Older adolescents (15–18 years) comprised 56.4% of total MVC mortality. One-in-four (25%) pedestrian victims was Qatari. They had the lowest mean Injury Severity Score (9.6); 73% were nine years or younger. ATV victims had a 27% ICU admission rate; 48.4% were 10–14 years old. Older adolescents made up only 17% of the pediatric population of Qatar, yet 40% of pRTI victims and 80% of pRTI deaths. Forty-two percent of injured older adolescents were drivers, with half (21%) of those underage.

There are clear and distinct age and mechanism-specific patterns of pRTIs among children in Qatar that must be used to guide road safety policy and program formulation for underage pedestrians and drivers. Proven interventions that increase seatbelt and child restraint use and graduated driver licensing must be considered.

Background: Computed tomography (CT) features of cystic fibrosis (CF) lung disease can be objectively quantified using current CT scoring systems to assess the extent and severity of the disease. The aims of this study were to calculate the Santamaria CT scores in adult patients with CF with the predominant CFTR I1234V genotype, determine its reliability, and correlate these parameters with lung function, microbial colonization, compliance to treatment, and exacerbations. Methodology: This retrospective observational study was conducted on adult patients with CF who were regularly followed up in the adult CF service at Qatar via CT scans that were taken not during an acute exacerbation. CT scans were scored using the Santamaria scoring system. Corresponding spirometry, microbiological data of sputum culture, and relevant clinical data were correlated with individual CT scores. Results: Only 23 of the 31 patients underwent CT when not in an acute exacerbation and were included in the study analysis. A total of 20 (87%) patients had the I1234V genotype. There was good agreement between the two radiologists on the Santamaria CT scores with an intraclass correlation coefficient (ICC) value of 0.991. Bronchiectasis was the most consistent finding, followed by interlobular and intralobular septal thickening. Patients with poor lung function and frequent exacerbations had significantly higher CT scores (p = 0.015). The CT scores of patients colonized with Pseudomonas aeruginosa were higher but nonsignificant (p = 0.20). The mean CT scores were significantly higher in patients who were noncompliant to regular treatment than in those who were compliant (p = 0.012). Conclusion: Santamaria CT scores comprise a reliable scoring system for adult patients with CF and can be used to determine the extent and severity of lung disease. P. aeruginosa colonization causes more structural lung damage than other common colonizing organisms. Noncompliance to treatment has a significant impact on the increasing severity of CF lung disease.

Background: A single organ and tissue donor can serve and save eight-fold lives, but availability of organ donors is scarce, posing a grim situation for end-stage organ failure worldwide. Knowledge, attitudes, behaviors, and beliefs toward organ donation can help policymakers develop strategies to address the challenges facing organ donation and transplantation in Qatar. Aim: To assess sociodemographic characteristics, knowledge, attitudes, beliefs and intentions regarding organ donation in the household population of Qatar. Methods: A prospective observational household survey was conducted between October and November 2016 in Qatar using a validated questionnaire. One thousand forty-four individuals aged 18 and older residing in eight municipalities in the country were enrolled in the survey. Results: Average age was 38 ± 11 years. There were 27.4% Qatari citizens and 72.6% nonQatari residents in the survey. 48.9% of the total (1044) were males. Knowledge [46% (95% C.I.: 45% − 47%)], attitude [70% (95% C.I.: 66%–74%)], behavioral beliefs [42% (95% C.I.: 39%–50%)], normative beliefs [29% (95% C.I.: 28%–30%)], control beliefs [–27% (95% C.I.: − 24% to − 30%)] and intentions towards organ donation [29% (95% C.I.: 27%–31%)] were observed in the study. Factor analyses were able to explain 70%, 72%, 70%, and 74% variations in knowledge, attitude, beliefs, and intentions domains respectively showing adequacy of construct of the domains for organ donation. Conclusion: Most of the survey participants showed good attitude but less intention towards organ donation.

Background: The American College of Physicians’ (ACP) Internal Medicine In-Training Examination (IM-ITE) is designed to evaluate the cognitive knowledge of residents to aid them and program directors in evaluating the training experience. Objective: To determine the impact of the curriculum reform accompanied by the Accreditation Council for Graduate Medical Education (ACGME)-I alignment and accreditation on the internal medicine residency program (IMRP) using residents’ performance in the ACP's ITE from 2008 to 2016, and where the IMRP stands in comparison to all ACGME and ACGME-I accredited programs. Methods: This is a descriptive study conducted at a hospital-based IMRP in Doha, Qatar from 2008 to 2016. The study population is 1052 residents at all levels of training in IMRP. The ACP-generated ITE results of all the United States and ACGME-I accredited programs were compared with IM-ITE results in Qatar. These results were expressed in the total program average and the ranking percentile. Results: There is a progressive improvement in resident performance in Qatar as shown by the rise in total average program score from 52% in 2008 to 72% in 2016 and the sharp rise in percentile rank from 3rd percentile in 2008 to 93rd percentile in 2016 with a dramatic increase during the period 2013 to 2014 (from 32nd percentile to 73rd percentile), which represents the period of ACGME-I accreditation. None of the factors (ethnicity, USMLE or year of residency) were statistically significant with a p value >0.05 and standard coefficient ( − 0.017–0.495). There was negligible correlation between the USMLE test scores with the residents’ ITE scores with a p value = 0.023 and a Pearson correlation r = 0.097. Conclusion: The initial ACGME-I alignment followed by the accreditation, together with whole curriculum redesign to a structured, competency-based program starting from 2008, has led to an improvement in the ITE scores in the IMRP. This was further evidenced by the lack of change in the residency entry selection criteria.

Objectives: One of the endpoints for assessing the emergency department (ED) performance is the left-without-being-seen (LWBS) proportion. This study aimed to evaluate the impact of increasing proportions of on-duty emergency medicine (EM) trainees on LWBS rates in clinical shifts. Methods: The study was conducted at an urban-academic-ED (annual census: 452,757) over a period of one year. We employed multivariate linear regression (p < 0.05) defining significance to identify and adjust for multiple LWBS influencers related to patient care. Results: After analyzing over 1098 shifts, the median LWBS rate was 8.9% (interquartile range 5.3% to 13.5%). The increasing number of EM trainees in the ED did not adversely impact the LWBS; the opposite was noted. In univariate analysis, the increasing proportion of on-duty EM trainee physicians was significantly (p < 0.001) associated with a decrease in the LWBS rates. The multivariate model adjusted for the statistically significant and confounding LWBS influencers, with an absolute increase of 1% in trainees’ proportion of overall on-duty physician coverage, was associated with an absolute decrease of 2.1% in LWBS rates (95% confidence interval 0.43% to 3.8%, p = 0.014). Conclusions: At the study site, there was a statistically and operationally significant improvement in LWBS associated with partial replacement of board-certified specialist-grade EM physicians with EM residents and fellow trainees.

Urosepsis contributes significantly to the epidemiology of sepsis. Urosepsis can be classified as community acquired or hospital acquired, depending upon the origin of infection acquisition: either from the community or from a healthcare facility. A great deal of literature is available about nosocomial urosepsis, but the literature regarding community-acquired urosepsis (CAUs) is limited, and studies are underpowered. The aim of our study was to determine the epidemiology, bacteriology, severity, and outcome of CAUs. Methods and Patients: All patients admitted from the emergency department to the surgical intensive care unit (SICU) with urosepsis over a period of 10 years were identified and included retrospectively from the SICU registry. The study was retrospective. Data were entered into the SPSS program version 23, and groups were compared by using chi-square and t-tests. Results were considered statistically significant at p ≤ 0.05. Results: During the study period, 302 patients with CAUs were admitted to the SICU. The common etiology was obstructive uropathy (60%). The Local Arab population outnumbered the non-Arab population (164/54.3%), and there were equal numbers of patients of both genders. Diabetes mellitus and hypertension together were the common comorbidities. Seventy-five percent of patients had acute kidney injury (AKI). Thirty-eight percent of patients had percutaneous nephrostomy, and 24.8% of patients underwent endoscopic stent insertion to relieve the obstruction. Ninety-three percent of patients were admitted with septic shock, and 71.5% had bacteremia. The common bacteria (36.1%) was extended-spectrum beta-lactamase-(ESBL)-producing bacteria, with a predominance of Escherichia coli (31.5%). Fifty-four percent of patients required a change of antibiotics to carbapenem. Eighty-two percent of patients had acute respiratory distress syndrome (ARDS). Patients with bacteremia had a statistically significant AKI, ARDS, and septic shock (p < 0.001). Male patients had a significantly higher incidence of oliguria, intubation, and ARDS (p < 0.05). Eight patients died of urosepsis during the study period, giving a mortality rate of 2.6%. Conclusion: In our patients, obstruction of urine flow was the most common cause of CAUs. Our urosepsis patients had a higher bacteremia rate, which led to higher incidences of organ dysfunction and septic shock. ESBL bacteria were a frequent cause of urosepsis, requiring a change of the initial antibiotic to carbapenem. Male patients had a significantly higher rate of organ dysfunction. Mortality in our urosepsis patients was lower than mentioned in the literature.

Background: The development of multi-antibiotic resistant bacteria, especially Gram-negative bacteria which are the major cause of hospital-acquired infections worldwide, had been increasing. Escherichia coli and Klebsiella sp. had become more resistant to different classes of antibiotics, and the treatment of infections caused by these bacteria had developed into a challenge in both developed and developing countries. This study had determined the multi-antibiotic resistance (MAR) patterns of Escherichia coli and Klebsiella sp. isolated from clinical inpatient and outpatient samples. Method: The present study had used 50 E. coli and 48 Klebsiella sp. isolates. Antibiotic susceptibility test had been carried out by using disk diffusion method, and the interpretation of results of the zones of inhibition had accorded with Clinical Laboratory Standards Institute (CLSI). The antibiotics used had included the following: streptomycin, ciprofloxacin, erythromycin, nitrofurantoin, amikacin, gentamicin, ofloxacin, cefepime, oxacillin, colistin sulfate, cefotaxime, ceftazidime, pefloxacine, and cloxacillin. Results:E. coli and K. pneumoniae had shown high-resistance patterns. E. coli had exhibited high resistance against cloxacillin (96%), oxacillin (96%), erythromycin (88%), and most especially streptomycin (98%). Similarly, K. pneumoniae had presented a high resistance to streptomycin (88%), cloxacillin (92%), oxacillin (92%), and colistin (92%). E. coli had presented the highest multidrug resistance with a MAR index of 1.00. A total of 17 E. coli isolates had shown resistance to the 14 antibiotics tested. Conclusion:E. coli and Klebsiella sp. in clinical isolates in outpatients and inpatients in Ibadan, Western Nigeria had demonstrated high antimicrobial resistance. Thus, such condition should be considered a major public health concern, and measures must be taken to establish the sources and drivers of this problem.

Background: We aimed to assess the management and outcome of occult pneumothorax and to determine the factors associated with failure of observational management in patients with blunt chest trauma (BCT). Methods: Patients with BCT were retrospectively identified from the trauma database over 4 years. Data were analyzed and compared on the basis of initial management (conservative vs. tube thoracostomy). Results: Across the study period, 1928 patients were admitted with BCT, of which 150 (7.8%) patients were found to have occult pneumothorax. The mean patient age was 32.8 ± 13.7 years, and the majority were male (86.7%). Positive-pressure ventilation (PPV) was required in 32 patients, and bilateral occult pneumothorax was seen in 25 patients. In 85.3% (n = 128) of cases, occult pneumothorax was managed conservatively, whereas 14.7% (n = 22) underwent tube thoracostomy. Five patients had failed observational treatment requiring delayed tube thoracostomy. Pneumonia was reported in 12.8% of cases. Compared with those who were treated conservatively, patients who underwent tube thoracostomy had thicker pneumothoraxes and a higher rate of lung contusion, rib fracture, pneumonia, prolonged ventilatory days, and prolonged hospital length of stay. Overall mortality was 4.0%. The deceased had more polytrauma and were treated conservatively without a chest tube. Patients who failed conservative management had a higher frequency of lung contusion, greater pneumothorax thickness, higher Injury Severity Scores (ISS), and required more PPV. Conclusions: Occult pneumothorax is not uncommon in BCT and can be successfully managed conservatively with a close clinical follow-up. Intervention should be limited to patients who have an increase in size of the pneumothorax on follow-up or become symptomatic under observation. Patients who fail conservative management may have a greater pneumothorax thickness and higher ISS. However, large prospective studies are warranted to support these findings and to establish the institutional guidelines for the management of occult pneumothorax.

Malignant melanoma (melanoma) is a tumor of melanocytes that usually presents as cutaneous lesions. While melanoma can infrequently appear as a primary tumor elsewhere in the body, it is extremely rare in the urethra and even rarer as amelanotic malignant melanoma. We report the case of a 66-year-old male who presented with painless gross hematuria and lower urinary tract obstructive symptoms in the recent 2 weeks prior to his visit to our clinic. History and physical examination, including external genital examination, abdominopelvic sonography, and urine culture, were not conclusive. Cystourethroscopy revealed a creamy pink fragile mass located in the anterior proximal urethra that extended to the mid portion. Pathological examination of this lesion confirmed the diagnosis of amelanotic malignant melanoma using immunohistochemistry. Radical cystourethrectomy with ileal conduit was subsequently conducted. Although this tumor is extremely rare, urologists and pathologists should consider malignant melanoma as a diagnosis in patients with urethral tumor because of the likelihood of early metastasis and, consequently, poor prognosis. Complete surgical removal of the tumor and use of effective therapies can improve outcomes in these patients.

Duplication of vas deferens is an anomaly that is generally encountered during inguinal hernia repair, orchiopexy, radical prostatectomy, varicocelectomy, and vasectomy. The estimated rate of this anomaly in the United States is 0.01%. This anomaly may predispose to iatrogenic vas deferens injury during inguinal hernia repair. Embryological point of view suggests that the duplication of the mesonephric duct system could result in duplicated vas deferens. Failure to recognize this anomaly may lead to injury, obstruction, or spermatic granuloma. Furthermore, it is important to identify duplicated vas deferens during vasectomy to avoid failure of the procedure. Identification of duplicated vas deferens is important during inguinal hernia surgery, vasectomy, and varicocelectomy. Herein, we report a case of duplicated vas deferens during open indirect inguinal hernia repair.

Background: The retrosternal goiter (RSG) is a slow-growing mass often benign in nature; thyroidectomy remains the preferred standard curative treatment. This study aimed to explore the local experience of RSG with respect to the clinical presentation, classifications, management, and outcomes. Method: A retrospective chart review was conducted to include all cases diagnosed with RSG and underwent thyroidectomy between January 1998 and December 2013. Results: A total of 1210 patients underwent thyroidectomy; of which 30 (2.5%) patients were diagnosed to have RSG. The commonly reported symptoms were dyspnea (40%), pain and discomfort (30%), dysphagia (26.7%), and hoarseness (20%). Thirteen patients (43.3%) were completely asymptomatic. The fine-needle aspiration cytology was performed in 22 (73.3%) patients, of whom the majority was benign (77.3%). The grading classification showed that grade 1 is the most frequent (73.3%). Total bilateral thyroidectomy was the most prevailing procedure in 57% cases followed by partial thyroidectomy. All patients underwent retrosternal thyroidectomy through a cervical incision except for one case. Postoperative histopathology showed frequent benign multinodular goiter (83.3%), followed by papillary thyroid cancer (10%) and thyroiditis (6.7%). The most common complication after thyroidectomy was tracheomalacia (13.4%), transient hypocalcemia (10%), and hypoparathyroidism (6.7%). There was no intraoperative or perioperative mortality. Conclusion: RSG is a rare entity often presented with pressure symptoms, mostly involving anterior mediastinum and had a challenging surgical procedure. A large multicenter study is needed to include more cases in order to have a consensus on the definition and classification system for such important clinical goiter presentation.

Background: Increased interarm systolic blood pressure difference (IASBPD) is one of the major predictors of cardiovascular disease. An IASBPD of >10 mmHg is of clinical significance. However, studies have reported a high number of patients visiting the emergency department (ED) with high IASBPD and varying correlation of IASBPD to age, ethnic background, and comorbidities such as hypertension and diabetes. Objective: The CALIBRATE study aimed to measure the IABPDs in the multiethnic patient population presenting to the ED in Qatar and to assess the distribution of IASBPD in this population. Methods: In a sitting position, two consecutive blood pressure (BP) measurements were recorded from the right and left arms for each participant using a calibrated automated machine and appropriate cuff sizes. The data were recorded using predefined data fields, including patient demographics, past medical, and social and family history. The continuous variables were reported as mean or median based on the distribution of data. The data were analyzed using Stata MP 14.0. Results: A total of 1800 patients, with a mean age of 34 (10) years, were prospectively recruited from the ED. The median absolute systolic BP difference (ΔSBP) between the right and left arms was 6 (3–10) mmHg, and it was the same for the first (ΔSBP1) and the second readings (ΔSBP2). The absolute average of ΔSBP1 and ΔSBP2 was 7 (4–10) mmHg. The difference in systolic BP difference (SBP) of < 20 mmHg for interarm blood pressure was seen in the 95th percentile of the population. No meaningful association could be detected between the IABPD and the study variables such as age, demographics, regions of interest, and risk factors. Conclusion: In population presenting to the ED, the IASBPD of at least 20 mmHg reached at the 95th percentile, validating the known significant difference. The utility of SBP difference can be improved further by taking the average of two individual readings.

Background: Low serum vitamin D levels are reported constantly among females living in the Arabian Gulf countries, presumably due to their lifestyle, which limits direct sun exposure. Because Vitamin D deficiency has been implicated in a wide range of ailments, healthy females with the deficiency might be at risk for developing many health problems. Thus, the aim was to assess lifestyle risk factors for vitamin D deficiency in healthy women in Kuwait. Methods: A total of 104, disease-free, premenopausal women were recruited for assessment of their serum 25OHD and intact PTH levels. Physical examination, blood withdrawal and interviewer-administered questionnaires were used to collect the relevant data. Associations were detected statistically using nonparametric tests and logistic regression was used to identify risk factors for vitamin D deficiency. Results: Vitamin D deficiency ( < 25 nmol/L) occurred in 84.6%, and hyperparathyroidism ( ≥ 6.9 pmol/L) occurred in 25% of women, among which all were vitamin D deficient. Significant risk factors of vitamin D deficiency were nondaily milk intake (OR:25, CI%:4.2–147), no fish intake (OR:5, CI%:1–22.8), and no weekend sun exposure (OR:8.2, CI%:1.28–52.6). Having PTH ≥ 6 pmol/L was also associated with a higher likelihood of having vitamin D deficiency. Conclusion: Vitamin D deficiency is very common in disease-free, premenopausal Kuwaiti women and can be avoided by improving food consumption and obtaining more sun exposure.

Anti-glomerular basement membrane (anti-GBM) disease occurs in fewer than two cases per million population. Patients usually present with features of rapidly progressive glomerulonephritis (RPGN) with or without pulmonary involvement. Anti-GBM disease is classically diagnosed by both demonstrating GBM linear immunofluorescence staining on kidney biopsy and detecting anti-GBM antibodies in serum. More than 90% of patients with anti-GBM disease either become dialysis-dependent or die if left untreated.

Here, we report a 37-year-old man who presented with bilateral lower limb edema, hypertension, acute kidney injury (creatinine of 212 μmol/L), microscopic hematuria, and nephrotic range proteinuria (15 g/day). His kidney biopsy showed diffuse crescentic membranoproliferative glomerulonephritis and bright linear staining of GBM by immunoglobulin G consistent with anti-GBM disease; however, serum anti-GBM antibodies were negative. The patient was diagnosed with atypical anti-GBM disease and treated aggressively with intravenous pulse steroids, plasmapheresis, oral cyclophosphamide, and oral prednisolone with significant improvement in kidney function and proteinuria.

Atypical anti-GBM disease should be considered in patients presenting with RPGN, even in the absence of serum anti-GBM antibodies. Early diagnosis and aggressive treatment in such cases are warranted to prevent irreversible kidney damage as the course of the disease might not be as benign as previously thought.

Huntington's Disease (HD) is an autosomal dominant neurodegenerative disorder with a progressive decline in cognitive, motor, and psychological function. Chorea tends to be the most common associated movement disorder, although other variants of several abnormal movements are also seen. Adult-onset HD is the most common subtype. Juvenile Huntington's disease (JHD) accounts for 5%–10% of all HD cases and presents as a rapidly progressive disorder with a multitude of characteristics. We report on a 9-year-old male with JHD who presented with refractory epilepsy. His EEG findings, seizure type, and antiepileptic drug usage are discussed with a brief review of the currently available relevant literature. The currently reported case sheds light on antiepileptic drugs that proved effective in our patient and the importance of screening for JHD when a child presents with seizures that are difficult to control.

Background: Spontaneous subarachnoid hemorrhage (SAH) is one of the significant etiologies for stroke. SAH causes higher morbidity and mortality with loss of productivity, resulting in increased disease burden. Only few studies in Qatar have reported on SAH, and the epidemiological features of SAH and aneurysmal SAH (aSAH) have not been comprehensively studied before in Qatar. Our study aimed to describe the epidemiological profile of patients with SAH and aSAH in the State of Qatar.

Methods: We reviewed the medical records of all patients with SAH and/or ruptured aneurysm who were consecutively admitted to Hamad General Hospital (600-bed tertiary care facility) from January 1, 2007 to December 31, 2016. We performed a quantitative analysis of demographics, clinical characteristics, diagnostic findings, interventions, and overall mortality. We used SPSS version 18 for data entry. We used chi-square and student t tests to compare the groups. We considered p < 0.05 as statistically significant.

Results: The study included 323 patients with aneurysmal and non-aneurysmal SAH. The mean age at presentation was 47.4 ± 12.2 years. Men comprised 68.7% of the cases. Further, 86.6% of the patients presented with acute-onset headache. Additionally, 217 patients had 1 aneurysm, and 32 patients had multiple aneurysms. Anterior communicating artery aneurysm has been found to be the most common aneurysm. Non-aneurysmal SAH occurred in 74 patients (22.9%), with male predominance. Moreover, 23.7% and 52.6% of the patients underwent microsurgical clipping and coiling of the aneurysm, respectively. The overall mortality in World Federation of Neurosurgeon Score (WFNS) grades 1 and 2 SAH was lesser than that in higher grades (28.6% vs 71.4%). Of 323 patients, 69 died within 1 month post-ictus, accounting for an overall mortality rate of 21.2% in our study.

Conclusions: The annual incidence of aneurysmal SAH in Qatar has been increasing. Men had a higher incidence of aSAH. Internal carotid aneurysms have been found to be more common in Qatari women, which may have a genetic basis. Lower WFNS grades of aSAH have been associated with better prognosis. The overall mortality associated with aSAH in Qatar has declined over the last 3 years.

Objectives: This study aimed to investigate electronic medical record (EMR) implementation in a busy urban academic emergency department (ED) and to determine the frequency, duration, and predictors of EMR downtime episodes.

Materials and Methods: This study retrospectively analyzed data collected real time by the EMR and by the operations group at the study ED from May 2016 to December 2017. The study center has used the First Net Millennium EMR (Cerner Corporation, Kansas City, Missouri, USA). The ED operations data have been downloaded weekly from the EMR and transferred to the analytics software Stata (version 15MP, StataCorp, College Station, Texas, USA).

Results: During the study period, 12 episodes of EMRD occurred, with a total of 58 hours and a mean of 4.8 ± 2.7 hours. The occurrence of EMRD event has not been associated with on-duty physician coverage levels (p = 0.831), month (p = 0.850), or clinical shift (morning, evening, or night shift) (p = 0.423). However, EMRD occurrence has been statistically significantly associated with weekdays (p = 0.020).

Discussion: In a real-world implementation of EMR in a busy ED, EMRD episodes averaging approximately 5 hours occurred at unpredictable intervals, with a frequency that remained unchanged over the first 20 months of the EMR deployment.

Conclusion: The study could define downtime characteristics at the study center. The EMRD episodes have been associated with inaccuracies in hourly census reporting, with a rebound phenomenon of over-reporting in the first hour or two after restoration of EMR operations.