Qatar Medical Journal - Volume 2025, Issue 1

Objective: This systematic review and meta-analysis examines the impact of intensive versus standard blood pressure control following post-endovascular therapy in ischemic stroke patients.

Methods: We conducted a systematic review and meta-analysis in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching PubMed, Google Scholar, and Cochrane Central databases from inception to December 2023. The outcomes evaluated included symptomatic intracerebral hemorrhage, functional independence (modified Rankin Scale (mRS) score 0–2), death or disability (mRS score 3–6), and health-related quality of life (three-level EuroQoL five-dimensional self-report questionnaire (EQ-5D-3L score). We used the standard mean difference (SMD) with a 95% confidence interval (CI) for continuous outcomes in all studies and used a random-effects model for data synthesis irrespective of heterogeneity. Heterogeneity was assessed using the I² statistics.

Results: We screened 2,000 articles and included four randomized controlled trials (3,635 patients). Intensive blood pressure control affected the health-related quality of life (EQ-5D-3L score) more than standard blood pressure (SMD = -0.22, 95% CI: -0.34 to -0.11, p = 0.0002). However, intensive blood pressure control after endovascular therapy did not significantly reduce the risk of intracerebral hemorrhage within 36 hours (risk ratio (RR) = 0.91, 95% CI: 0.70–1.19, p = 0.51). Additionally, there was an insignificant improvement in the likelihood of regaining functional independence (mRS score 0–2) at three months (RR = 0.87, 95% CI: 0.73–1.04, p = 0.12). Moreover, there was an insignificant increase in the risk of death or disability (mRS score 3–6) at 3 months with intensive blood pressure control compared to standard blood pressure control (RR = 1.18, 95% CI: 0.93–1.51, p = 0.18).

Conclusion: In summary, our findings indicate that implementing intensive blood pressure control does not lead to an increased risk of adverse outcomes such as intracranial hemorrhage within 36 hours, compromised functional independence, disability, or mortality 3 months following endovascular therapy. Despite the observed reduction in health-related quality of life reflected in the EQ-5D-3L score, the overall safety profile of intensive blood pressure control compared to standard management suggests its viability as a potential strategy for improving patient outcomes in the context of endovascular therapy.

Background: This review provides a comprehensive and current overview of the clinical outcomes associated with the use of OviTex reinforced tissue matrix (RTM) in hernia repair.

Methods: We conducted a systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Our search included research publications related to clinical outcomes involving the use of OviTex RTM in hernia repair up to August 2023. We extensively examined and extracted relevant data from databases such as Embase, PubMed, and Scopus. The meta-analysis included comparisons related to body mass index (BMI) in hernia treatment, primary abdominal wall hernias treated with OviTex, and other relevant factors. The quality of the included studies was assessed using the MINORS (Methodological Index for Non-Randomized Studies) scale. Our systematic review protocol was registered with PROSPERO (International Prospective Register of Systematic Reviews) under registration number CRD42023456009.

Results: A total of 9 observational studies involving 990 patients from three countries (USA, Netherlands, and Germany) were included in our study. Pooled results show that the risk of the OviTex group was lower than that of the comparison group (pooled risk ratio (RR) = 0.84; 95% confidence interval (CI): 0.67–1.05; Z = -1.514; p = 0.13). The prevalence rate of primary abdominal wall hernia among the included studies ranged from a minimum of 43% (95% CI: 30–58) to a maximum of 81% (95% CI: 64–91%), the risk was not significantly higher in the comparison group compared with the OviTex group (pooled RR = 1.11; 95% CI: 0.29–4.30; Z = 0.155; p = 0.877), the prevalence of laparoscopic surgery was 12% (95% CI: 6–19%), the BMI was favorable in the comparison group but was not statistically significant (mean difference = 25; 95% CI: -0.02, 0.52; p = 0.073).

Conclusion: OviTex RTM has shown promising outcomes in abdominal wall reconstruction and hernia repair. However, it is crucial to conduct further research and clinical studies to confirm these findings and unlock the capabilities of OviTex across different medical scenarios.

Background: Diabetes mellitus (DM) is a prevalent condition that requires careful management in the perioperative setting to reduce surgical risks and optimize patient outcomes. The preoperative care of diabetic patients is complex because glucose control must be balanced with minimizing hypoglycemic or hyperglycemic events during surgery. A variety of diabetic medications such as insulin, dipeptidyl-peptidase-4 inhibitors, glucagon-like peptide-1 receptor agonists, sodium–glucose cotransporter-2 inhibitors, and biguanides such as metformin present unique challenges and considerations due to their different mechanisms, benefits, and potential adverse effects. In recent years, professional organizations have developed recommendations on the perioperative management of these therapies, although there remain some variations in guidelines related to medication cessation and dosage adjustments. Standardized protocols in preoperative DM care remain a topic of interest to ensure consistent and safe practices across healthcare settings, and further collaborative research efforts could provide clarity and consensus in managing this diverse patient population.

Objective: The objective of this study was to provide an overview of guidelines and practices to support healthcare professionals in delivering improved preoperative care for diabetic patients. This initiative aims to enhance surgical outcomes and minimize the occurrence of complications.

Methods: This is a comparative review that provides a systematic comparison of the similarities and differences in the guidelines and recommendations of three professional organizations along with Hamad Medical Corporation. All guidelines were from official websites including Hamad Medical Corporation.

Conclusion: Although the reviewed guidelines for the preoperative care of diabetes patients share some similarities, there are also a number of differences due to outdated data and expert opinions, and therefore differ in practices around the world. While the key elements are agreed upon, more research and global collaboration are needed to create consistent guidelines and improve patient outcomes.

Background: Endometrial osseous metaplasia (OM) is a rare condition characterized by the transformation of endometrial tissue into bone cells. Despite its rarity, OM remains a significant contributor to infertility. Although the underlying mechanism remains debatable, an association with previous abortions and curettage has been suggested.

Case presentation: We present two cases of OM presented to the infertility clinic and discuss their similarities and discrepancies in presentation and risk factors. A transvaginal ultrasound raises suspicion about the diagnosis of OM with a hyperechoic mass and post-acoustic shadowing. An office hysteroscopy showed white, mesh-like bony sheets. Both cases underwent operative hysteroscopy to address surgical challenges, and the two cases were followed postoperatively for one year.

Discussion: A comprehensive literature review examined various aspects of OM, including diagnosis, therapeutic options, outcomes, prognosis, and follow-up. Our aim was to raise awareness of this intriguing condition by providing up-to-date knowledge and emphasizing the central role of hysteroscopy in diagnosis and treatment. Here, we present two cases with the same complaint, infertility. Moreover, although the same treatment method was used in both cases, only one achieved pregnancy. This highlights that OM is a possible underlying cause of infertility, in addition to considering other factors that contribute to the overall clinical picture.

Conclusion: OM should be considered in the evaluation of infertility despite its rarity, especially with hyperechoic lesions and acoustic shadowing on ultrasound examination. Hysteroscopy is the gold standard for diagnosis and therapeutic approaches. A complete understanding of the reasons that trigger its growth is crucial. To rule out other differential diagnosis, a holistic evaluation of the patient's history, imaging, and histopathological examination is needed.

Background: Late-onset group B streptococcus (LOGBS) sepsis is a notable cause of morbidity and mortality in preterm neonates. While the vertical transmission of group B streptococcus (GBS) during delivery is well established, the potential role of breast milk in the transmission of LOGBS is not as clearly understood. This case report examines a unique instance of preterm triplets developing LOGBS sepsis following maternal GBS mastitis, with the aim of investigating the possible association between breast milk and LOGBS infection in preterm infants.

Case presentation: A set of preterm male triplets born at 30 weeks of gestation were admitted to the neonatal intensive care unit. At two weeks of age, the infants showed clinical manifestations of LOGBS sepsis, including septicemia. Additionally, one of the triplets developed meningitis complicated by hydrocephalus, while another developed necrotizing enterocolitis (NEC). Concurrently, their mother was diagnosed with mastitis and her breast milk cultures tested positive for GBS. The triplets were treated with systemic antibiotics. However, triplet B subsequently required a ventriculoperitoneal shunt for hydrocephalus management, and triplet C underwent laparotomy for NEC treatment.

Conclusion: The occurrence of LOGBS sepsis in these preterm triplets, coupled with maternal GBS mastitis and positive breast milk cultures, raises critical questions regarding breast milk as a possible route of transmission for LOGBS. Understanding this relationship is vital for improving clinical practice, particularly in the management of recurrent infections in this vulnerable population.

Background: Influenza infections are recognized globally for their respiratory manifestations, but are less commonly associated with severe cardiovascular complications such as cardiac tamponade. The relationship between influenza infections, particularly influenza B, and cardiac complications such as myocarditis, pericarditis, and cardiac tamponade remains underexplored, particularly in immunocompetent individuals.

Case summary: We report the case of a 22-year-old immunocompetent female who presented to the emergency department with acute shortness of breath, fatigue, and dizziness due to symptoms suggestive of an influenza-like illness. Laboratory and imaging findings revealed a large circumferential pericardial effusion suggestive of cardiac tamponade. Subsequent investigations confirmed influenza B infection. The patient was managed with pericardiocentesis, oseltamivir, nonsteroidal anti-inflammatory drugs, colchicine, and supportive care, resulting in complete recovery. This case highlights the significance of considering influenza as a potential cause of acute cardiac complications and the importance of early diagnostic and therapeutic interventions to prevent morbidity and mortality.

Discussion: The occurrence of cardiac tamponade secondary to influenza B infection in a young, immunocompetent female highlights the critical need to educate healthcare providers about the potential cardiovascular complications of influenza. The mechanisms underlying influenza-associated cardiac involvement may include direct viral invasion, systemic inflammation, and immune-mediated responses.

Conclusion: This case contributes to the limited but growing body of literature on influenza-induced cardiac complications and highlights the importance of timely antiviral therapy alongside traditional management strategies for cardiac tamponade. Further research is needed to elucidate the pathophysiology of influenza-related cardiac complications and to provide guidelines for the management of such cases.

Background: Malignant syphilis is a rare form of secondary syphilis that occurs mainly in patients living with human immunodeficiency virus (HIV), with approximately 15 cases reported in the last century. We present the case of a patient treated in our institution.

Case presentation: A 25-year-old male patient presented with round lesions in the form of ulcerations with blackish crust on the plantar area and inner edge of the right foot. VDRL (venereal disease research laboratory) test and ELISA (enzyme-linked immunosorbent assay) were performed for the diagnosis of syphilis and HIV, respectively, which were positive. Subsequently, the patient was hospitalized, and ceftriaxone was indicated due to the lack of crystalline penicillin G in the hospital. Four days later, he had complete improvement of the skin lesions. The patient is currently stable and has no recurrence of skin lesions.

Discussion: Due to the lack of supplies in our unit, we chose ceftriaxone, which is used in patients with penicillin allergies. The use of this drug has shown good outcomes in different reviews.

Conclusion: Due to the use of appropriate treatment, the patient is currently stable and has no recurrence of skin lesions. Malignant syphilis should be considered as part of the differential diagnosis in patients who present with nodulo-ulcerative lesions and have a positive treponemal or non-treponemal test.

Background: Hypocalcemia is an electrolyte disorder that can be effectively corrected. However, in its severe form, it poses significant risks, including potentially fatal symptoms such as electrocardiographic changes that may lead to sudden cardiac arrest if not treated promptly.

Case presentation: We report the case of a young female patient who presented with multiple episodes of tonic posturing and altered level of consciousness. Diagnostic evaluation revealed severe hypocalcemia with hypomagnesemia, QT prolongation, and episodes of non-sustained ventricular tachycardia. The condition was managed with calcium and magnesium supplementation. Further investigations revealed a novel missense mutation in transient receptor potential melastatin 3 (TRPM3).

Discussion: Hypocalcemic seizures are rare in adults and are typically associated with severe hypocalcemia and cardiovascular instability, including ventricular dysrhythmias. The differential diagnoses in this case included primary hypoparathyroidism, Bartter syndrome type 5 (CaSR (calcium-sensing receptor) mutation), Gitelman syndrome, and claudin mutations. TRPM3 is highly expressed in kidney tissue, playing a role in the resorption of calcium and divalent ions. However, further research is needed to confirm its role in calcium homeostasis.

Conclusion: The patient was initially misdiagnosed with epilepsy for the past two years. Following a comprehensive evaluation, she was successfully treated with intravenous calcium and magnesium. On follow-up after six months, her condition showed marked improvement, characterized by better cardiac function and the absence of further seizure episodes. This case represents the first reported instance of a TRPM3 mutation affecting calcium channels, highlighting the need for further investigation into its implications for calcium metabolism.

Background: The artery of Percheron (AOP) stroke is a rare cause of bilateral thalamic strokes, which may or may not involve the midbrain. Existing literature has identified four anatomical variants of thalamic blood supply, with AOP being the IIB variant that arises as a solitary arterial trunk from either posterior communicating artery. The clinical manifestations of AOP strokes are diverse, with no specific localizing signs. Typically, patients present with symptoms such as amnesia, gaze palsy, and hypersomnolence. The predominant underlying etiology is often cardioembolic, requiring management strategies that are tailored to the source of emboli with anticoagulation/antiplatelets.

Clinical presentation: We report a case involving a 72-year-old female patient with AOP stroke characterized by a sudden loss of vision, followed by a decreased level of consciousness. Magnetic resonance imaging revealed bilateral thalamic infarcts sparing the midbrain. CTA (computed tomography angiography) revealed a filling defect at the origin of the Percheron artery arising from the left P1 segment. The patient was treated with intravenous thrombolysis. The stroke workup was unremarkable, with a normal thrombophilia workup, a transthoracic echo, and no arrhythmias detected on a prolonged Holter monitor. The patient was treated with aspirin, atorvastatin, and intensive physical and cognitive therapy. On follow-up, she regained her consciousness but exhibited residual impaired vertical eye movements and right-sided dysmetria.

Conclusions: AOP stroke is a radiological diagnosis with no specific localizing neurological signs. A high index of suspicion is essential for timely diagnosis and management, as bilateral thalamic involvement can arise from a wide range of metabolic, infectious, and other vascular etiologies that could delay optimal management.

Background: Parinaud syndrome is a rare condition that can arise as a consequence of strokes, hemorrhages, and neoplasms. Due to the debilitating after-effects of this condition, such as functional dependency, a high risk of falls, decreased mobility, and increased caregiver burden, immediate and holistic intervention is essential.

Case presentation: A 40-year-old male patient presented with Parinaud syndrome following an episode of stroke. Physical examination on admission revealed self-care dependence, limited mobility and upper limb function, limited visual fields, and reduced therapy tolerance.

Discussion: The patient was treated with belay glasses, an innovative strategy, to assess functional changes. This intervention resulted in notable improvements in overall function, contributing to greater independence in daily activities. Standardized assessments indicated improvements in self -care, mobility, and hand function. The use of belay glasses not only increased visual function but also facilitated overall functional gain.

Conclusion: Parinaud syndrome is an unusual condition that can arise following a stroke or brain trauma. This case report aimed to explore the functional gain of a patient diagnosed with Parinaud syndrome during an 8-week rehabilitation program, using a multidisciplinary approach and the application of prism glasses. Clinically significant differences were observed using belay glasses, representing an innovative intervention strategy.