The epidemiology and outcome of childhood tuberculous meningitis. The Pelonomi Hospital experience

A prospective study was undertaken to determine the epidemiology and outcome of tuberculous meningitis in children admitted to hospital in Bloemfontein, OFS. Over a 5-year period 75 patients were studied, and 78% of them were less than 5 years of age. The largest group of patients came from rural areas. The annual incidence in the 0-14-year-old group for the City of Bloemfontein was estimated at 3,6/100,000. Most patients were in an advanced stage of illness at the start of therapy and the mortality rate was 18%. Of those patients who survived, 26% had severe neurological sequelae. The incidence of tuberculous meningitis can be decreased by improving primary health care facilities in certain areas of the OFS.     

Management of fracture of the penis in Qatar.

We present 21 patients with fracture of the penis treated between July 1982 and July 1990. Eighteen patients were treated surgically, with good functional and morphological recovery; 3 refused surgery, 1 of whom had penile deformity and pain on erection. The literature is reviewed with respect to the necessity of different diagnostic and therapeutic options.     

Varicocele among infertile men in Qatar

Objective of this retrospective study was to assess the presence and clinical grade of varicocele among Qatari and non‐Qatari men evaluated for infertility. Diagnosis of varicocele was performed clinically and confirmed via colour Doppler ultrasonography. A total of 455 infertile male patients (mean age 36.3 ± 7.6 years) were divided into either Qatari (n = 91, mean age 37.3 ± 9.1 years) or non‐Qatari (n = 364, mean age 36.0 ± 7.1 years) groups. Among all patients, 43.1% (n = 196) were confirmed to have varicocele, of which 40 were Qatari and 156 non‐Qatari. Among all patients, 171 (37.6%) presented with left‐sided varicocele and 25 (5.5%) with bilateral varicocele. Of the 196 patients with varicocele, grade I was given to 40 (20.4%), grade II to 68 (34.7%) and grade III to 88 (44.9%). Grade II and III varicocele were seen significantly more frequently than grade I among all patients and non‐Qatari patients (p < .05). Grade II varicocele was seen more frequently than grades I or III among Qatari patients, but difference was not significant. Grade III was seen significantly more frequently than grade I among patients with secondary infertility (p < .05). Varicocele is an important health issue in Qatar among both Qatari and non‐Qatari men.     

Renal transplantation: seventeen years of follow-up in Qatar

Among 432 patients receiving renal transplants (RT) between 1986 and 2002, 238 were Qatari nationals and 194, expatriates of mixed nationalities. Since 1986 when we started a local transplant program, 70 cases were performed at our center and 362 abroad. Diabetic nephropathy was the most common cause of end-stage renal disease among Qatar and chronic glomerulonephritis among expatriate patients. New-onset diabetes was reported after the transplant operation in 7.3% of the cases. Recipient age ranged from 14 to 75 years with the mean of 48.5 years among diabetics and 34.5 years among nondiabetics. Acute rejection occurred in 19.2% with chronic allograft nephropathy in 16.2% of cases. Two-year survival rates at our center versus the abroad units were 98% and 97% for patients and 85.7% and 82.5% for grafts respectively. The mortality was mainly related to myocardial infarction, which occurred significantly more often among diabetics. Other causes of mortality, such as sepsis, hepatic failure, and cytomegalovirus infection, did not differ significantly between diabetic and nondiabetic patients. The donor source at our center was living related (78.6%), cadaver (18.5%), and living unrelated (2.9%) as compared to 29.3%, 6.6%, and 64.1% of those performed abroad, respectively. The 5-year survivals among living-unrelated allografts performed abroad was 45.2% compared to 64.3% in living-related and cadaveric donors. Despite the disappointing results, the existing shortage of local kidney donors persuades our patients to go abroad for living- unrelated transplants. Educational programs and incentives are recommended to increase the supply of cadaver organs.     

Acute Renal Failure in the State of Qatar: Presentation and Outcome

Despite major improvements in health care, acute renal failure is still one of the main prognostic factors in terms of patient mortality and long-term morbidity. This cohort prospective study to evaluate the patterns and outcomes of renal failure in Qatar was performed between January and June 2005. Of the 213 patients followed prospectively from referral to the end of their hospitalization, 66.7% were males and 33.3% females. Their overall mean age was 60 years; the majority were referred from critical care units. Comorbidity was present in 87% of all patients. Volume depletion, hypotension, and sepsis were the main predisposing factors for renal failure. Eighty three patients (39%) needed renal replacement treatment and 130 (61%) were treated conservatively. The majority of critical care patients needed dialysis. Overall mortality was 23.9%, 7% needed chronic dialysis, and 69.1% were discharged with normal or mild renal impairment. This study showed that acute renal failure was a major factor affecting patient mortality in Qatar. Early treatment of predisposing factors may improve overall patient outcomes.     

Abdominal trauma due to road traffic accidents in Qatar

OBJECTIVES: To measure the incidence and severity of abdominal trauma due to road traffic accidents (RTA) in Qatar. PATIENT AND METHODS: Retrospective analysis of all patients admitted with documented abdominal trauma to the only acute General Hospital in the state of Qatar in the period 1991-1995. RESULTS: In the 5-year period, 3744 patients were admitted following an RTA. Of these, 667 (17.8%) were admitted to the surgical intensive care unit (SICU) and 84 patients had abdominal injuries, constituting 0.45% of total number and 12.6% of patients admitted to SICU. Twenty-one (25%) of patients with abdominal trauma died. However, only nine patients died from the abdominal injury. Eight patients died due to hepatic injury and one patient due to splenic injury.     

Nosocomial meningitis in the adult]

Cerebrospinal fluid (CSF) has anti-infectious defense abilities similar to those of the serum of a neutropenic patient. A septic inoculation as in case of nosocomial meningitis (NM), results rapidly in microbial proliferation with major alterations to the blood brain barrier, cerebral oedema and loss of autoregulation of the cerebral blood flow. Arterial hypotension during NM may induce focal or global cerebral ischaemia. The incidence of NM is increasing, staphylococci and Gram negative bacilli being the most frequent pathological agents. Clinical symptoms are not specific in this postoperative and post-traumatic context. In this context, the analysis of pleocytosis and the increased protein content of CSF is disturbing. Numerous clinical conditions may cause NM. Among them, NM from spinal puncture is an important issue for anaesthetists, while combined epidural and spinal anaesthesia carry the highest risks. Cutaneous contamination plays a major role. Half of the post-operative infections after neurosurgery are due to NM, and CSF leakage, iterative operations and surgery in contaminated conditions are the main risk factors. Antibioprophylaxis for postoperative NM is validated for clean and clean-contaminated surgery. Some consider that only procedures of more than two hours require this prophylaxis. Prophylaxis is targeted on staphylococci. Other preventive measures (drainage of less than 24 h, head shaving and prevention of CSF leakage) are of major importance. Antibiotherapy should be guided by the same considerations as for community acquired meningitis, associated with specific issues in the surgical context (presence of foreign material and CSF blockage).     

Improving the outcome of tuberculous meningitis in childhood

Two groups of 28 children with tuberculous meningitis (TBM) and hydrocephalus were matched for age and stage of the disease and treated with appropriate antituberculosis therapy. The patients in one group were subjected to ventriculoperitoneal or lumboperitoneal cerebrospinal fluid shunting procedures. The results of treatment were assessed in both groups. The outcome in the group of patients subjected to shunting was clearly superior to that in the group in which shunting was not carried out. The hydrocephalus associated with TBM is associated with a significant mortality and morbidity if the obstruction to cerebrospinal fluid flow is not relieved.     

Meta-analysis in epidemiology

Meta-analysis is the structured and systematic qualitative and quantitative integration of the results of several independent studies (i.e. the epidemiology of results). As in any epidemiological study, a meta-analysis needs to start with clearly stated aims and objectives. Attention needs to be paid to selection bias in selecting the study population (all publications on the topic). An initial qualitative assessment (conducted blinded to results) categorises projects on the basis of their methods, as unacceptable (dropped from later analysis) and acceptable or good. Further analysis could be conducted by stratifying or weighting independent studies according to preset quality criteria. The quantitative assessment involves deriving a pooled measure of outcome (usually the relative or attributable risk). Tests for heterogeneity are required before pooling. By pooling the results from many settings using different methods, the ability to generalise them in terms of their public health relevance is increased.     

Chloride levels in meningitis

The blood/cerebrospinal fluid bromide ratio is sensitive and specific in the diagnosis of tuberculous meningitis (TBM). Blood/CSF chloride (Cl-) ratios were not found to be useful in differentiating between TBM and viral and acute bacterial meningitis in 59 black children. In a study of 148 children with bacterial or viral meningitis or TBM, the majority (112) had CSF Cl- levels below the lower limit of normal. Accordingly, CSF and blood Cl- levels and the blood/CSF Cl- ratio were not found to be useful in differentiating between TBM, acute bacterial meningitis and viral meningitis.     

Primary tuberculosis of the breast in Qatar: ten year experience and review of the literature.

OBJECTIVE: To present our experience of isolated tuberculosis of the breast, 1988-98. DESIGN: Retrospective study of case notes and radiographs. SETTING: Hamad General Hospital, Qatar. SUBJECTS: 13 multiparous women with tuberculosis of the breast. MAIN OUTCOME MEASURES: Objective confirmation of diagnosis and adequacy of treatment. RESULTS: We found an overall incidence of histologically confirmed tuberculosis to be 0.4%/year. All patients presented with a lump, 2 had nipple discharge and one had a palpable axillary node on the same side. 7 were treated by excision biopsy, 3 by incision and drainage, and 3 had fine needle aspiration (FNA) as their only procedure. All diagnoses were confirmed histologically. 2 patients developed recurrences during treatment but these were successfully treated. CONCLUSION: Although the incidence of the disease is low, the diagnosis should be suspected in young multiparous women with a breast lump in whom malignancy has been excluded. The minimum of surgical intervention (incision or excision biopsy) together with antituberculous drugs seems to be the most successful treatment.     

Effectiveness of surgical parathyroidectomy for secondary hyperparathyroidism in renal dialysis patients in Qatar

Pharmacologic interventions designed to control hyperparathyroidism (HPT) in uremic patients have limitations and potentially serious adverse clinical consequences. Hence, one still has to resort to surgical parathyroidectomy (PTX) in a considerable number of dialysis patients. The aim of the present study was to illustrate our experience with 26 renal dialysis patients who underwent surgical PTX. The main indications for PTX included iPTH > 1000 pg/mL associated with severe osteitis fibrosa, debilitating pruritus, marked soft tissue calcification, or hypercalcemia with hyperphosphatemia, which sometimes complicated vitamin D therapy. All patients were resistant to more conservative measures, including control of serum phosphate, attention to oral intake and dialysate calcium levels, and oral/intravenous administration of active vitamin-D-pulse therapy. Ultrasound and technetium 99-sestamibi scan were used to image the thyroid and the parathyroid glands. Total PTX with autotransplantation was performed in 23 patients; subtotal PTX was performed in 3 patients. Histology of frozen sections taken intraoperatively showed nodular changes in 14 and diffuse hyperplasia in 12 cases. During the 2-year follow-up period significant reductions in parathyroid hormone, alkaline phospatase blood levels, skeletal changes, and soft tissue calcifications were observed. Pruritis improved in half the cases. Some improvement in hemoglobin and hematocrit was also noticed. The complication rate after PTX was low. Transient postoperative hypocalcemia requiring intensification of calcium and vitamin D therapy was seen in cases with high preoperative alkaline phosphatase levels. Recurrence was observed in two cases. Hypoparathyroidism was not recorded. We conclude that surgical reduction of parathyroid mass is a safe and effective treatment for symptomatic disease not suppressible by pharmacologic means.     

Post-traumatic meningitis in children

A retrospective survey over a 66-month period of children admitted with head injury who subsequently developed meningitis within the same period yielded six cases (five boys, one girl), giving an incidence of 0.38 per cent. Two of the six died, and four survived with no sequelae. Four cases occurred within the first week. One patient, who had received prophylactic antibiotics, developed Escherichia coli meningitis after 14 days and one had meningitis 2 years after the head injury. The most common organism was pneumococcus (four cases). Three patients had periorbital haematomas and none had cerebrospinal fluid leakage. Increasing drowsiness and fever were the most consistent features. Radiography of the skull was of little use in demonstrating fracture of the base of the skull. Two of the four surviving patients had craniotomy with successful dural repair.     

Tuberculous meningitis in children

Opinion statement