Qatar Medical Journal - Volume 1997, Issue 1

Medical genetics is an exponentially progressing field. In less than a decade, the increase in our understanding of genetics, particularly Molecular genetics has exceeded that achieved over the previous 4 decades marked by Watson and Crick's specification of the double helix structure of DNA in 1953. Since then the genetic code has been deciphered, the nature of the gene was clarified and many of the intricacies of its function became overt. Genetics has a long tradition of merging clinical observation with basic laboratory investigation. This has culminated in the emergence of molecular biology in which biological processes are understood from the level of the gene through proteins that direct the development and function of the creature. Genetics is therefore playing an increasingly central role in the medical field, and no physician can remain ignorant of its fundamental principles and practice.

Gestational diabetes mellitus (GDM) is a common medical complication that can have a profound impact on the mother and infant. It is defined as Carbohydrate intolerance of variable severity with onset or first recognition during the present pregnancy. The definition applies irrespective of whether or not insulin is used for treatment or the condition persists after pregnancy. It does not exclude the possibility that unrecognized glucose intolerance may have antedated the pregnancy.

The fasting plasma glucose levels are lower in normal pregnancy than in the nonpregnant state, and this decline occurs before any rise in fasting plasma insulin levels can be detected. The fasting levels of glucose fall despite a rise in hepatic glucose production, which serves to provide the needs of the developing fetus. The rise in plasma glucose following an oral glucose load or a normal meal is exaggerated. This occurs despite an increase in insulin secretion in response to both oral and intravenous glucose and to normal meals. This indicates that insulin sensitivity declines as pregnancy progresses. The postprandial glucose and insulin levels are increased further in the pregnant woman who is obese. Although glucose tolerance deteriorates in human pregnancy, about 97 to 98% of all pregnant women retain a normal glucose tolerance and only 2 to 3% develop gestational diabetes. However, the prevalence of GDM depends upon the genetic characteristics and environment of the population under study.

Minimally invasive direct coronary artery bypass (MIDCAB) is a new approach that allows selected coronary stenoses to be bypassed through a much smaller incision, either a lateral thoracotomy or a mini-sternotomy, without the aid of cardiopulmonary bypass. Generally, the internal mammary artery is used as the bypass graft, although the gastroepiploic artery or saphenous vein may also be used. The minimally invasive approach eliminates the potential complications associated with cardiopulmonary bypass. Other benefits include decreased cost, minimal postoperative discomfort, and a shortened hospital stay. Although MIDCAB is an exciting alternative to conventional coronary bypass or angioplasty procedures, this approach is currently limited mostly to patients with isolated, proximal stenoses of the left main, left anterior descending, and right coronary arteries. MIDCAB will not be suitable for widespread use until further experience is gained and additional technical refinements introduced. In this report, we describe use of the mini-sternotomy approach to MIDCAB in a 62-year-old ma and briefly summarize our total experience at the Texas Heart Institute.

The present study describes the indications and results of 636 Percutaneous Transluminal Coronary Angioplasty (PTCA) procedures that were carried out in 596 patients. Of these, 366 (61.4 %) patients had Single Vessel Disease (SVD), 183 (30.7%) had Two Vessel Disease (2VD) and 47 (7.8%) had all Three Vessels Diseased (3VD). Dilatation of a single lesion was carried out in 564 (93.5%) patients. In another 41 (6.5%) patients, more than one vessel was dilated. The patients were predominantly male (562/596,93%) with a mean age of 46 (7.9 years. The indication for angiography was angina in 65.8% and for recent Acute Myocardial Infarction (AMI) in 34.2%. The number of procedures increased from 106 in 86-89 to 320 in 92-96 (an increase of 280%).

PTCA was carried out in the same session as the angiography in 113/596 (19%). In the remaining 81%, PTCA was planned as an elective procedure with a similar success rate (85% and 87% respectively, p=N.S). Females and Qatari patients had the highest success rates (97.6% and 90.5%) respectively.

The Left Anterior Descending (LAD) was the most frequently tackled vessel (53% of cases), Left Circumflex (LCX) in 20% and Right Coronary Artery (RCA) in 27%. For coronary stenoses, the overall success rate was 89%, being highest in the LAD (89.5%), lowest for LCX (82%) and moderate for RCA (88%). When faced with a total occlusion the overall success rate was 71% and was highest in RCA (84% success) and lowest in LCX (43%) and moderate in LAD (74%). Major complications were rare with only one mortality (1/596, 0.16%) and four emergency CABG is (4/596, 0.7%). Intracoronary stents were used as a bailout device in five patients and to obtain an optimal result in one patient. Stents were technically successful in all but one case.

In a 3-year retrospective study in Qatar (1992-1994) eleven patients, eight boys and three girls were diagnosed as having infantile spasm. The incidence was 0.36/1000 live births. Two patients had idiopathic infantile spasm and nine patients (82%) were symptomatic. A positive family history of epilepsy was found in 27% of the patients and Parental consanguinity was found in 45% of the patients. Two patients had cerebral malformation and all the patients had one or more risk factors during pregnancy and delivery-The outcome for the idiopathic group -1 out of the two was normal, and all the patients from the symptomatic group were found to be abnormal at the end of the follow-up. Seizures were controlled in six of the patients, partially controlled in four, and only one continued to have seizures in spite of treatment.

200 Platelet Concentrate (PC) bags were tested for bacterial growth on day 1 (3-5 hrs after blood collection) using segments from tubings. The same bags were retested on their expiry date (5th day) by culturing a specimen drawn from the bag by syringe.

The frequency ofpositive cultures on day 1 was not statistically significantly higher than on day 5 (p = 0.07).

This interesting finding is explained and its relation to febrile transfusion reaction (FTR) is discussed. The organisms isolated were most likely contaminants from the skin or air at the time of blood collection.

Submucous resection (SMR) of the nasal septum is a simple procedure, which was used in a study on sixty patients, forty four (73%) males and sixteen (26.7%) females. This study was carried out over four years from September 1988 in King Hussein Medical Centre and Prince Hashem Ben Al Hussein Hospital.

Ml the patients had a headache for 2-13 years as the maJor symptom. Some of them had additional symptoms SUch as nasal obstruction and snoring. Successful results were obtained in fifty six cases who were relieved of their headache after surgery. The other four cases showed no significant improvement because of allergic rhinitis.

This is a retrospective study of the effect of air pollution on Pediatric asthmatic patients in Qatar following the second Gulf war in 1991. A comparison study of four months of the same period in 1990 before the war; 1991 through the presence of air pollution and 1992 following the end of air pollution showed a significant increase of asthmatic visits to the emergency center in 1991, almost double the number of the previous year, The number decreased significantly in 1992 following the end of the air pollution.

The male to female asthmatic ratio was 2.37:1 and Qatari to non-Qatari asthmatic visit ratio was 2.1:1. The temperature fall was about 1-2 degrees centigrade during the air Pollution, and no change in humidity was noticed during the three periods studied.

Immunization therapy, for treatment of recurrent pregnancy loss (RPL), has been developed since the mid-1980's. The effect of this kind of therapy is still controversial The purpose of this retrospective, case-control study, was to evaluate the beneficial effect of immunotherapy for the treatment of patients with RPL and negative antipaternal cytotoxic antibodies. During a 3-year period (1992 to 1994), we were able to collect 25 such patients who conceived after having been immunized abroad. We compared the outcome of the pregnancies of those 25 patients with that of 41 unimmunized patients used as controls. There was no statistically significant difference between the two groups regarding maternal age, parity, number of previous abortions, gestational age, infant weight, and Apgar score at 5 minutes. The pregnancy success rate was higher in patients who were not immunized (80.5%) than in those who were immunized (56%). The difference bordered on, but did not reach, statistical significance (P=0.064). There was no significant difference whether immunization was performed before or during pregnancy or whether pregnancy occurred within 26 weeks of immunization or between 27 and 52 weeks. The only significant difference between the two groups was related to the drugs (Aspirin and progesterone) used in the antenatal period and this may explain the higher; although not significant, success rate in the control group. It is not yet clear whether immunotherapy has any substantial effect in preventing recurrent abortions. More controlled prospective studies are required to reach a final conclusion regarding this form of treatment.

Records of 57 patients with Delusional Disorder were examined retrospectively between 1990-1996 to identify patients who metDSM-III-R criteria for Delusional Disorder. Six patients were excluded from the study because they did not fulfill the diagnostic criteria. Of the remaining 51 patients, 31 patients were followed prospectively for a minimum of four clinical interviews extending over a period of 18 months. Comparisons were made between socio-demographic characteristics and types of delusion and between outcome and types of delusion. No significant difference was found in comparing the socio-demographic variables with types of delusion. But there was a significant difference when comparing types of delusion with outcome. At the last follow-up, full recovery was achieved in 27.5% , modest improvement in 25.5%, mild improvement in 5.9%, 15.7% were still deluded and 25.5% with unknown outcome because they had lost contact with the services.

A 38-year-old female patient, known to have widespread adenocarcinoma of an unknown primary, presented with galactorrhoea and amenorrhoea for a few months. The serum prolactin level was markedly elevated (more than 20-fold the upper normal limit). A pituitary C.T. Scan was normal. Other causes of marked hyperprolactinaemia were excluded.

Ectopic Prolactin production is an interesting phenomenon, only four cases having been reported worldwide(1).

The diagnosis of more cases of ectopic prolactin production may help to explain some aspects of osteoporosis and hypogonadism in patients with internal malignancy.

A case of orf affecting the ear and cheek is presented. Although this is a common viral infection in the farming community, the otolaryngologist's encounter with orf is rare. However, being a worldwide self-limiting infection, awareness of orf is important to avoid unnecessary or extensive Surgical intervention.

A case report of an 80 year old woman with squamous cell carcinoma of the bronchus presenting with the rare Paraneoplastic cutaneous sign of acquired hypertrichosis lanuginosa, and a review of the literature on acquired hypertrichosis associated with malignancy by searching the database Medline (since 1966) and hand searching the Index Medicus (1903-1965). Fifty three case reports of hypertrichosis associated with malignancy were found. Sixteen of these described an association with carcinoma of lhe bronchus. Since1970 one case report per year has been Published. It was concluded that hypertrichosis is a rare but important cutaneous sign of malignancy. Despite a large number of case reports the suspected cause, a hormone, remains to be found.

A discharging reno-cutaneous fistula was the first manifestation of xanthogranulomatous pyelonephritis in a 33 year old man. Because of the rarity of this complication of xanthogranulomatous pyelonephritis (less than 20 cases worldwide have been reported in the literature) its clinical and diagnostic aspects are discussed. The correct Preoperative diagnosis was made by computed tomography, gallium scintigraphy, ultrasonography and was confirmed by surgery and anatomopathologic examinations. The authors stress the technique of sinography with fractional administration of contrast medium while the patient was kept in a prone position for several minutes prior to the CT examination. This facilitated the demonstration of the entire fistulous track and enabled the establishment of a more precise diagnosis.

Aspirin was prescribed for 20 non-insulin dependent diabetic patients receiving one of the sulfonylureas (Glibenclamide, Gliclazide and Glipizide) with or without Metformin. The majority of the patients were on Glibenclamide and Metformin.

Aspirin slows the progression of nephropathy and retinopathy. Fasting blood sugar levels improvedfollowing the addition of aspirin to oral hypoglycemic agents (OHA) (p = 0.0057). The mean fall in F.B.S. was 3.9 mmol/L.

Glycated Hemoglobin (Hb A1C) was measured before and 3 months after giving aspirin to diabetic patients receiving one of the sulfonylurea drugs with or without Metformin. Following aspirin use the Hb A1C fell significantly (p = 0.0138). The mean fall in HbAlC was 0.81%.

A 32-year old female patient was referred to our hospital for evaluation of headache. A preliminary diagnosis of possible temporal arteritits in young patient was made in the referral letter. She had been complaining of episodes of left sided headache for the last 2 years. The headache occurred mainly in the horning; it is mild to moderate in severity, associated with feeing of fullness in the left temple. The episodes were coming at no regular time, was not related to menstruation and was not accompanied by nausea, vomiting or photophobia. It lasts for few hours and then subsides, and she noticed that the sensation of fullness also disappears. She had no history of trauma. She denied any fever, weight loss, morning stiffness, or any sinuses, ear or eye complaints. She was diagnosed at one time as migraine headache and was given treatment for that. Clinical examination at the time of headache revealed afebrile patient with normal blood pressure and pulse. The left temple showed fullness compared to the right side but there was no redness or warmth of the overlying skin. There was an ill-defined slightly raised 5 × 4cm soft swelling in the left temple. There was no palpable thrill or audible bruit. The temporal artery was pulsating without any tenderness.