Qatar Medical Journal - Volume 2022, Issue 1

Background: Acute pulmonary embolism (PE) is a common and potentially life-threatening condition. This comprehensive study from a Gulf Cooperation Council (GCC) country aimed to evaluate the clinical, radiological, and outcome characteristics associated with acute PE.

Methods: This retrospective observational study analyzed data of patients with confirmed acute PE who were admitted to the largest academic tertiary center in the State of Qatar from January 1, 2014, to December 31, 2018. Data on the clinical presentation, radiologic, and echocardiographic findings, as well as outcomes were collected.

Results: A total of 436 patients were diagnosed with acute PE during the study period (male, 53%). Approximately 56% of the patients were < 50 years old at presentation, with a median age of 47 years. In approximately 69% of cases, the PE occurred outside the hospital. The main associated comorbidities were obesity (34.6%), hypertension (29.4%), and diabetes (25%). Immobilization (25.9%) and recent surgery (20.6%) were the most common risk factors. The most frequent presenting symptom was dyspnea (39.5%), and the most frequent signs were tachycardia (49.8%) and tachypnea (45%). Cardiac arrest was the initial presentation in 2.2% of cases. Chest X-ray findings were normal in 41%. On computed tomography pulmonary angiography (CTPA), 41.3% of the patients had segmental PE, 37.1% had central PE, and 64.1% had bilateral PE. The main electrocardiographic (ECG) abnormality was sinus tachycardia (98%). In patients who underwent echocardiography, right ventricular (RV) enlargement was the main echocardiographic finding (36.4%). Low-, intermediate-, and high-risk PE constituted 49.8%, 31.4%, and 18.8% of the cases, respectively. Thrombolysis was prescribed in 8.3% of the total and 24.4% of the high-risk PE cases. Complications of PE and its treatment (from admission up to 6 months post-discharge) included minor bleeding (14%), major bleeding (5%), PE recurrence (4.8%), and chronic thromboembolic pulmonary hypertension (CTEPH) (5%). A total of 15 (3.4%) patients died from PE.

Conclusions: Acute PE can manifest with complex and variable clinical and radiological syndromes. Striking findings in this study are the younger age of acute PE occurrence and the low PE-related mortality rate.

Coronavirus disease 2019 (COVID-19) has become one of the worst global pandemics in recent history. Post-COVID-19 interstitial lung disease is a significant concern in COVID-19 survivors. It is a disabling clinical condition for patients and a burden on the healthcare system. With time and subsequent waves of COVID-19 globally, the post-COVID-19 sequelae of lung diseases can be debilitating. We report cases of three patients with persistent hypoxia post-COVID-19, raising concerns for interstitial lung disease in Qatar. In this report, we shared our experience of the patient's clinical course, complications, and outcomes with post-COVID-19 sequelae of lung parenchymal disease. Patients were followed up during and after treatment until recovery or discharge from the hospital.

Background: Cardiovascular disease is the leading cause of death worldwide. Multiple risk factors, including low hemoglobin levels, have been associated with poor outcomes in patients with cardiovascular disease. However, the long-term impact of anemia on death has not been investigated in high-risk patients in the United Arab Emirates. Therefore, this study evaluated whether anemia is a significant predictor of mortality in United Arab Emirates nationals with cardiovascular disease over 10 years.

Methods: A retrospective cohort study was conducted in an adult population of United Arab Emirates nationals with a history of cardiovascular disease, recruited from a tertiary healthcare facility. Electronic medical records between April 2008 and December 2008 were reviewed, and follow-up was conducted until December 2019. The survival functions for all-cause mortality in the presence and absence of anemia were compared using univariate Kaplan–Meier analysis with a log-rank test. The association between anemia and all-cause mortality was evaluated using a multivariable Cox regression model.

Results: A total of 224 patients were included in the follow-up for 10.5 years. At baseline, 46% of the patients had anemia, with a mean Hgb level of 105.5 ± 28.0 g/L. Patients with anemia were older (68 vs. 63 years, p = 0.001) and had a higher rate of chronic kidney disease (37.5% vs. 17.5%, p = 0.001) than those without anemia. A total of 77 (34.4%) deaths were recorded by the end of the follow-up period. Risk of all-cause mortality was significantly higher in patients with anemia than in those without (hazard ratio = 2.03, 95% confidence interval = 1.22–3.40, p = 0.006). Age and chronic kidney disease were also statistically significant predictors of death (p < 0.001 and p = 0.001, respectively).

Conclusion: Anemia is an independent predictor of all-cause mortality in United Arab Emirates nationals with underlying cardiovascular disease. Early intervention and treatment for anemia may improve clinical outcomes in this population.

Takotsubo cardiomyopathy is a type of non-ischemic cardiomyopathy that usually appears after a stressful event or in a woman and is rarely seen after pacemaker implantation (PMI). Herein, we present the case of a 65-year-old man with PMI because of a 2:1 atrioventricular nodal block who had a syncopal episode later in the day of the procedure. Echocardiography showed septal and apical hypokinesis with reduced ejection fraction suggestive of takotsubo cardiomyopathy. Before PMI, echocardiography showed normal left ventricular function with no wall-motion abnormality. Coronary angiography showed no coronary artery stenosis. The patient was seen again in the clinic 1 month later, and repeat echocardiography showed improvement of ejection fraction to 55% with no wall-motion abnormality. Generally, the complication rate after PMI is very low and includes infection, hematoma, lead dislocation, or allergic reaction at the site. The clinicians must be aware of potentially rare complications that can occur after PMI, such as takotsubo cardiomyopathy.

Background: Mesotheliomas are benign masses that can arise from any body parts that contain mesothelium, such as the abdominal, pelvic, pleural, and pericardial cavities. Benign multicystic peritoneal mesothelioma is a cystic tumor that arises from peritoneal mesothelial cells. It is a rare pathological entity, as only fewer than 200 cases have been reported. Benign multicystic peritoneal mesothelioma mainly occurs in women, and it is extremely rare in men. Its diagnosis and management are often challenging.

Case presentation: This report demonstrates a case of a 61-year-old man who presented to the outpatient clinic with persistent abdominal discomfort that progressed over the years. He had visited different clinics and was referred to a gastroenterologist because of a misdiagnosis. After an extensive clinical evaluation, we failed to provide a definitive diagnosis; thus, diagnostic laparotomy for possible intra-abdominal malignancy was performed. After successful surgical resection of the lesions, the pathology was found compatible with benign multicystic peritoneal mesothelioma.

Conclusion: Given its high recurrence rates and potential malignant transformation, meticulous and detailed surgical excision of the cystic lesions is of utmost importance to avoid repeated surgeries. Long-term follow-up is recommended.

Immune-mediated necrotizing myopathy (IMNM) or necrotizing autoimmune myopathy includes a set of distinct disorders associated with marked myasthenia, myofiber necrosis, and high creatine kinase levels. Anti-3-hydroxy-3-methylglutaryl coenzyme A reductase (anti-HMGCR) and anti-signal recognition particle (anti-SRP) are the two main autoantibodies associated with IMNM. Anti-HMGCR is usually associated with statin use. However, it may also be discovered in children without previous statin exposure, suggesting the existence of a complex genetic–environmental relationship in disease pathogenesis. Anti-SRP IMNM tends to present with more severe disease distinguished by pronounced myasthenia, worse neurologic outcomes, and treatment refractoriness. Its pathogenesis is also unknown; however, preliminary data suggest an antibody–complement-mediated mechanism of muscle cell lysis. Herein, we present the case of a 63-year-old man diagnosed with anti-HMGCR- and anti-SRP-positive IMNM that was treated with multiple immunosuppressants resulting in clinical improvement.

Cardiac amyloidosis is a rare disorder caused by the myocardial deposition of abnormal fibrils. A 52-year-old man was referred to our center with clinical features of heart failure, after cardiac magnetic resonance imaging showed restrictive cardiomyopathy. Abdominal fat pad biopsy showed features of amyloidosis, and after hematological workup, he was diagnosed with Waldenstrom macroglobulinemia (WM). He was initiated on a rituximab-based chemotherapy regimen, and his cardiac function was assessed serially. Because of non-response, he was switched to a bortezomib-based regimen. Unfortunately, three days into this regimen, the patient died. WM is a rare plasma cell dyscrasia with a nonspecific presentation. It uncommonly presents with sequelae of amyloidosis–the IgM subtype of amyloid-light chain (AL) amyloidosis. Diagnostic delays are common, contributing to an already poor prognosis. Amyloidosis in WM requires urgent treatment – clonal chemotherapy, and supportive cardiac care in heart involvement. Bortezomib-based regimens are commonly recommended, with diuretics as the mainstay for cardiac treatment. However, in most advanced cases, the prognosis is poor; thus, a high degree of suspicion is necessary for early diagnosis. This case illustrates the possible presentation of cardiac amyloidosis as a rare malignancy.

Purpose: Scapular fractures are uncommon injuries that account for up to 1% of all fractures and 5% of all shoulder girdle fractures. Moreover, most of the evidence on the treatment of scapular fractures stems from case series, with paucity of comparative studies. Despite the lack of standardized criteria for the operative treatment of scapular fractures, a set of suggested radiological parameters has been recently reported. The primary aim of this study was to compare the treatment implemented for scapular fractures in comparison with standard published criteria. The secondary aim was to investigate epidemiological parameters of scapular fractures at a level 1 trauma center.

Methods: In this cross-sectional study of scapular fractures at a level 1 trauma center, data were collected between December 2012 and January 2016. Data of all scapular fractures that presented to our center were retrospectively collected through electronic medical records. Identified cases of scapular fractures were then evaluated whether surgical treatment was indicated in accordance with recent standard operative criteria. Percentages were used to express the number of cases that were operatively indicated according to the predefined criteria and the number of cases operatively treated at our institution.

Results: A total of 52 patients met the inclusion criteria of having scapular fractures documented on radiography and Computed tomography (CT). The mean age of the patients was 38.5 years, with the majority being men (92.3%). The most common mechanism of injury was a fall from a considerable height in 26% of the cases. Of the included patients, 53.8% were polytraumatized, and the most frequent concomitant traumatic injury was rib fractures (26.9%). Only 33% of intra-articular glenoid fractures with significant displacement were treated operatively. Furthermore, non-operative treatment was undertaken in indicated extra-articular scapular body and neck fractures, acromion or coracoid process fractures, or superior shoulder suspensory complex double disruptions.

Conclusion: A significant discrepancy was found between the treatments implemented at our institution and the current standard criteria for the operative treatment of scapular fractures. This study emphasizes the need to educate surgeons on scapular fractures and to treat such fractures in accordance with standard published criteria. Furthermore, scapular fractures that require surgery should be referred to a surgeon experienced in scapular fracture fixation.

Introduction: Coronavirus disease 2019 (COVID-19) has become a threat to public health. People with chronic diseases, such as diabetes, are at a greater risk of severe diseases and death upon contracting this new disease. Due to the novelty of COVID-19, no specific information is available about the degree of its mortality and risk factors among diabetic patients. Therefore, this study aims to compare diabetic and nondiabetic COVID-19 patients regarding mortality rate, the need for intensive care unit (ICU) admission, invasive and noninvasive ventilation, and the associated risk factors.

Methods: This was a cross-sectional study performed on the medical records of 650 adult COVID-19 patients (325 diabetics and 325 nondiabetics) admitted to Razi Hospital in Ahvaz from March 2020 to September 2020.

Results: The mean age of the patients was 61.3 years in the diabetic group and 52.3 years in the nondiabetic group. Men comprised 48.3% of the diabetic group and 59.7% of the nondiabetic group. Diabetic patients suffered from significantly more underlying diseases, such as ischemic heart disease (IHD), hypertension (HTN), chronic kidney disease (CKD), and acute renal failure (ARF) compared to the nondiabetic group (p < 0.0001). Also, when compared with the nondiabetic group, the diabetic group had a significantly higher mortality rate (17.5% vs. 12%; p = 0.047, respectively), more ICU admissions (35.4% vs. 27.7%; p = 0.035, respectively), and a greater need for invasive ventilation (17.5% vs. 11.4%; p = 0.026, respectively).

Conclusion: In diabetic patients, the mortality rate, need for ICU admission, and need for invasive ventilation were significantly higher than nondiabetic patients. Our logistic regression analysis in diabetic patients with COVID-19 showed that age, CKD, and ARF were the risk factors affecting mortality. In contrast, age and CKD were the risk factors affecting the rate of ICU admission, and CKD and ARF were the risk factors affecting the need for invasive ventilation.

Background and Purpose: A growing field of interest is exploration of the functional outcomes of post-coronavirus disease 2019 (COVID-19) patients with stroke after rehabilitation. The association between stroke and COVID-19 infection is still being studied. We had explored the functional gain in post-COVID-19 patients with stroke following active rehabilitation services in Qatar to understand the possible predictors of functional gain.

Methods: We had included twenty patients diagnosed with post-COVID-19 with stroke in this retrospective pilot study conducted at a Qatar rehabilitation setting. We had used preexisting data from electronic medical records. We had included the Functional Independence Measure (FIM), post-COVID-19 functional status (PCFS), Action Research Arm Test (ARAT), Functional Ambulation Category (FAC), and Borg Rating of Perceived Exertion (RPE) as outcome measures. We had used descriptive statistics to summarize the baseline characteristics. A paired t-test had been used to compare the pre and posttests of the study group at admission and discharge. Multiple regression analyses had been performed to assess the predictors of functional gain, including age, employment status, impaired side, family history, and length of stay (LOS). All the results had been presented with associated 95% confidence intervals.

Results: This study had revealed an increase in functional gain (mean FIM gain, 32.9 ± 8.9) and improvements in functional performance throughout active rehabilitation (LOS, 62.45 ± 37.61). Significant differences had been noted in all outcome measures from admission until discharge (p < 0.05). Age (β = − 0.769, p = 0.022) and impaired side (β = 0.573, p = 0.007) had significantly predicted National Institutes of Health Stroke Scale (NIHSS) scores. Age (β = − 0.764, p = 0.047) had been a major factor that significantly predicted FIM gain. LOS (β = − 0.990, p = 0.002) had predicted FAC. The mean age was 56 ± 8 years.

Conclusion: Various factors are independently associated with functional gain after rehabilitation. Our findings suggest that active rehabilitation services and immediate intervention will be required to rehabilitate post-COVID-19 patients with stroke, a vulnerable population, to achieve adequate functional improvement.

Introduction: Since the outbreak of coronavirus disease 2019 (COVID-19) in December 2019, various thrombotic complications have been frequently reported in patients with infection. Acute mesenteric ischemia (AMI) is a rare but life-threatening complication in this disease, which requires early recognition and prompt treatment.

Case presentation: We report two cases of COVID-19-related AMI. Both patients underwent emergency laparotomy for small bowel ischemia. The first patient received prompt intervention and was discharged 5 days after surgery. The second patient presented late to the hospital and succumbed 72 h after surgery.

Conclusion: These two cases highlight the importance of high suspicion, early recognition, and prompt treatment in patients with abdominal symptoms related to COVID-19.

Pleuropulmonary blastoma (PPB) is a rare malignant lung tumor in the pediatric population and occurs mainly in young children. Its clinical presentation is usually nonspecific. We report a rare occurrence of this tumor in a 15-year-old girl, who presented with symptoms mimicking respiratory tract infection and was nonresponsive to the initial treatment. Imaging investigations revealed a large solid lesion in the left hemithorax with a mass effect on the adjacent structures. Biopsy demonstrated primitive cells with blastematous appearances, and the stroma cells were positive for vimentin and desmin, consistent with PPB. Unfortunately, she died from neutropenic sepsis while undergoing chemotherapy. This report highlights the epidemiology of PPB, its imaging and histopathological features, overview of prognosis, and clinical management.

Melioidosis is a severe disease that can affect humans and animals. It is caused by Burkholderia pseudomallei, which is an environmental aerobic gram negative bacteria. Despite being endemic in Southeast Asia and Northern Australia, many cases have been reported from different regions, including the Middle East. This is the third imported case of B. pseudomallei from Oman in a 46-year-old Indian male with left knee septic arthritis in less than three weeks after arrival in Oman. He underwent open arthrotomy, and his synovial fluid culture grew a bacteria with dry, pink colonies that were oxidase positive, susceptible to amoxicillin–clavulanic, identified by API NE as B. pseudomallei, and confirmed by molecular tests. This single case report highlights the urgent need to increase molecular diagnostic capacity and improve public health surveillance while maintaining a one health tripartite approach.

Background: Polysomnography is the gold standard diagnostic method for obstructive sleep apnea syndrome, and on-time treatment can help prevent further complications of obstructive sleep apnea. However, polysomnography is associated with some difficulties for the patients and physicians, which hinder its application. This study aimed to evaluate the clinical features and polysomnography findings of patients with obstructive sleep apnea.

Methods: Data were retrospectively collected from polysomnography studies at the Sleep Laboratory of Namazi Hospital, Shiraz, Iran, from February 2013 to December 2017. Polysomnography was performed for any patients suspected of obstructive sleep apnea. The researcher reviewed the data extracted and selected the essential clinical features for the statistical analysis. The association of variables with the polysomnography findings was analyzed.

Results: Significant associations were observed between the following factors and severity of obstructive sleep apnea: older age (p = 0.01), snoring (p = 0.122), history of sleep disorders (p = 0.11), no sedatives before sleep (p = 0.039), nocturia (p = 0.001), apnea (p = 0.035), no smoking (p = 0.039), no substance abuse (p = 0.011), hypertension (p = 0.001), cardiac diseases (p = 0.025), and overweight and obesity (p < 0.001).

Conclusion: Considering the concomitant occurrence of obstructive sleep apnea with obesity, hypertension, cardiac disease, snoring, and observed apnea, polysomnography is recommended in these patients before further assessments.

Acute kidney injury is a common complication in patients with cancer. Obstructive uropathy is a rare complication of gastric cancer and occurs mainly during treatment. Moreover, obstructive uropathy is rarely complicated by acute renal injury and thus requires emergency treatment. We report a rare case of anuric acute kidney injury that was actually obstructive uropathy secondary to gastric adenocarcinoma. Based on this case and literature review, malignancy should be considered in any patient not known to have cancer who presents with acute kidney injury caused by obstructive uropathy. This presentation reflects an advanced stage of malignancy. Non-enhanced computed tomography is valuable and should be the initial imaging study for diagnosing the obstruction and its cause. Early diagnosis and relief of the obstruction are associated with better recovery of the renal function.

Background & Objectives: Splenic abscess (SA) is a rare clinical entity. There is a lack of information on SA in most Arab and Gulf countries, including Qatar. This study describes the demographics, clinical features, microbiologic etiologies, treatments, and outcomes of patients with SA at the largest tertiary medical center in Qatar over the previous six years.

Methods: This retrospective observational study was conducted at Hamad general hospital. It involved all patients of 18 years old or above who were admitted with the diagnosis of SA for the period between January 1, 2015, and December 31, 2020.

Results: We recruited 25 patients, of which 14 (56%) were males, and 11 (44%) were females. The mean age ( ±  SD) of them was 48.64 ± 19.08 years. The mean illness duration was 22.88 ± 11.88 days. Fever was the most common presenting symptom and was found in 21 (84%) cases, whereas bacteremia was the most predisposing factor found in 15 (60%) patients. The etiology of SA was bacterial in 16 cases (64%), mixed (fungal and bacterial) in one (4%), and tuberculous in one (4%), whereas the etiological agent was unidentified in seven (28%) cases. Intravenous antimicrobial therapy was administered empirically in all patients. However, seven patients (28%) received intravenous antibiotics as the only treatment modality for SA, 15 patients (60%) underwent percutaneous drainage with a pigtail catheter, and two patients underwent splenectomy. The inhospital mortality was three (12%).

Conclusions: This study showed that SA could be caused by various organisms that should be isolated to guide the choice of antimicrobial agents. An abdominal computed tomography is a good diagnostic modality, whereas computed tomography- and ultrasonography-guided percutaneous drainage were efficient therapeutic options that reduce the need for surgery.

Background: Tracheostomy is among the oldest and most common surgical procedures for critically ill patients. Over the past decade, tracheostomy practice has changed regarding its indication, timing, technique, decannulation, and follow-up procedures. A systematic assessment tool for tracheostomy could maximize the quality of care and improve patient outcomes. This study develops a tool for systematically evaluating tracheostomy-related practices, assesses its validity and reliability, and conducts pilot testing of the tool.

Methods: The questionnaire development process involved three rounds using the Delphi technique with eight experts in airway management. The experts were selected from multiple healthcare specialties and workplace backgrounds. There was a two-week interval between each discussion round. In February 2019, the questionnaire themes and statements were identified through qualitative content analysis. Subsequently, in March 2019, the developed tool was emailed to 31 heads of tracheostomy care teams at multiple national hospitals for further validity and reliability assessment.

Results: The developed tool demonstrated reliability of 0.975. Tracheostomy-related practices showed acceptable levels in all 31 assessed hospitals with areas for improvement in the long-term follow-up domain.

Conclusion: This study designed a tool for the comprehensive assessment of tracheostomy-related practices. It can be used to monitor institutional outcomes, which can reduce costs. Moreover, this tool can be employed to track the improvement or deterioration of tracheostomy-related procedures and long-term follow-up to facilitate institutional progress. In addition, this tool could be used for formative and summative assessments of tracheotomy practices at national and international levels.

Quality improvement and patient safety are cornerstones to the delivery of effective patient care. The introduction of a quality improvement curriculum for medical students and trainee physicians can have a significant effect on their understanding of the science of improvement and its role in improving the quality of healthcare delivery and patient safety. The article describes the development and implementation of a quality improvement curriculum for trainee physicians in the department of internal medicine at a tertiary care center in Qatar through online training courses, workshops, didactic activities, and trainee-led quality improvement projects.