Patterns of prescription of antipsychotics in Qatar.

OBJECTIVE: Even though all guidelines recommend generally against antipsychotic polypharmacy, antipsychotic polypharmacy appears to be a very common practice across the globe. This study aimed to examine the prescription patterns of antipsychotics in Qatar, in comparison with the international guidelines, and to scrutinize the sociodemographic and clinical features associated with antipsychotic polypharmacy. METHODS: All the medical records of all the inpatients and outpatients treated by antipsychotics at the Department of Psychiatry-Hamad Medical Corporation (HMC) in Doha, Qatar (between October 2012 and April 2014) were retrospectively analyzed. We retrieved the available sociodemographic data, psychiatric features, and details on the medication history. RESULTS: Our sample consisted of 537 individuals on antipsychotics (2/3 were male; mean age 33.8±10.2 years), prescribed for a psychotic disorder in 57%, a mood disorder in 9.3%, and various other diagnoses in 33.7%. About 55.9% received one antipsychotic, 29.6% received two antipsychotics, and 14.5% received more than two antipsychotics. Polypharmacy was associated with younger age (p = 0.025), being single (p<0.001), the diagnosis of a psychotic disorder (p<0.001), and previous admissions to psychiatry (p<0.001). CONCLUSIONS: Antipsychotic polypharmacy appears to be quite common in Qatar, as it is the case in many other countries, in contrast with most international recommendations. Studies are needed to explore the reasons behind this disparity.

Acute Pancreatitis Induced by Polatuzumab-Vedotin-Piiq in Combination With Bendamustine and Rituximab for Diffuse Large B-Cell Lymphoma.

While alcohol and gallstones have been considered the most common causes of pancreatitis, we investigate two uncommon etiologies such as drug-induced and viral-induced. Pancreatitis, an inflammatory process, can lead to many complicated outcomes such as acute respiratory failure, sepsis, and death. Examining drug-induced pancreatitis poses a large challenge for physicians as majority of the data is extrapolated from case reports. This is made even more difficult for patients who are on large chemotherapeutic regimens which include multitude of drugs and various side effects. Besides patient medication regimens, other etiologies of pancreatitis must be ruled out such as viruses. We examine a case of a 48-year-old female undergoing treatment for diffuse large B-cell lymphoma with various chemotherapeutic agents and positive cultures for varicella zoster virus (VZV) presenting with diffuse epigastric abdominal pain.

Paecilomyces in an immune competent host.

Paecilomyces species was first recognized to cause human disease in 1963. It is a rare cause of invasive fungal infection, with cases sporadically reported in immunocompromised patients. Here we report the first case of pulmonary Paecilomyces in an immunocompetent patient that was successfully treated with amphotericin B and posaconazole.

Vaping-associated diffuse alveolar hemorrhage - A case report.

"Vaping" is a rapidly growing habit seen worldwide, especially amongst the younger population. Several aspects of vaping have made it more appealing than cigarettes and have lead to the conversion of many smokers. Appeal resides in the belief that it is a healthier alternative to cigarettes. It also has the ability to interchange flavors and type of oil used. The focus of advertisement for vaporized products is its use as a smoking cessation aid. Systematic reviews have failed to display evidence of harmful processes other than exposure to nicotine (Bullen et al., 2013; Burstyn, 2013) [1,2]. We report a clinical case of a woman who suffered diffuse alveolar hemorrhage correlated with e-cigarette usage due to history and negative findings of extensive rheumatologic and infectious disease workup. Her presentation, clinical course, and effective therapy are outlined here.

Paroxysmal Sympathetic Hyperactivity in a Young Male with Glioblastoma Multiforme.

Paroxysmal sympathetic hyperactivity (PSH) is a rare syndrome that is a recognized complication of severe brain injury. It is characterized by episodic hypertension, hyperthermia, tachycardia, tachypnea, diaphoresis, and specific posturing. It is prevalent in an intensive care unit (ICU) setting where high acuity illnesses can mask the symptoms of PSH. Herein, we report a case of PSH in a patient with a past medical history significant for glioblastoma multiforme (GBM) status post hemicraniectomy, radiation, and chemotherapy.

Risk Factors of Metabolic Syndrome Among Patients Receiving Antipsychotics: A Retrospective Study.

This study aimed to assess the differential effects of first-generation (FGA) and second-generation antipsychotics (SGA) on the prevalence of risk factors for metabolic syndrome among mentally ill patients in Qatar. We also wanted to check if there is proper adherence with the guidelines for prescribing antipsychotics and the monitoring of metabolic effects in this population. We collected the available retrospective data (socio-demographic, psychiatric, anthropometric, and metabolic measures) from the records of 439 patients maintained on antipsychotics. The majority were males, married, employed, having a psychotic disorder, and receiving SGA. Patients on SGA showed more obesity, higher BP, and more elevated triglycerides compared to those on FGA. The prevalence of the abnormal metabolic measures was high in this sample, but those on SGA showed a significantly higher prevalence of abnormal body mass index and BP. Obesity and hypertension were common in patients maintained on antipsychotics, especially those on SGA. Polypharmacy was common, and many metabolic measures were not monitored properly in those maintained on antipsychotics. More prospective studies with guided monitoring of the patients' clinical status and metabolic changes are needed to serve better this population of patients.

Kounis syndrome secondary to gadolinium contrast agent.

Cases of coronary artery spasm secondary to contrast agent use are rarely reported. Herein, we report the case of a 53-year-old woman who developed chest pain, dyspnea, and bradycardia and quickly become unresponsive after magnetic resonance imaging of the brain. A heart monitor showed ST elevation, and an electrocardiogram showed ST elevations in leads II, III, aVF, V3, and V4 and ST segment depression in lead I. Urgent left heart catheterization revealed no evidence of obstructive coronary artery disease or pulmonary embolism. A few days later, she was discharged from the hospital with no symptoms. A type I variant of Kounis syndrome was diagnosed.

Case report: Steroid responsive mesothelioma-related pleural effusion.

Malignant pleural mesothelioma (MPM) is an asbestos-related tumor arising in the pleural cavity. Symptoms reflect extension of disease and include shortness of breath and chest pain. Unexplained pleural effusion and pleural pain in patients exposed to asbestos should raise the suspicion of MPM. The most common radiologic presentation is ipsilateral pleural effusion with or without pleural thickening or a mass. Thoracoscopic biopsy remains the most appropriate procedure for definitive diagnosis of mesothelioma. Despite advancement in diagnostic procedures and biomolecular research, this tumor nevertheless has poor prognosis. Mesothelioma remains a diagnostic and therapeutic challenge and is likely to remain one in the years to come. Here we present the first reported case of steroid treatment responsive pleural effusion in a 72 year-old-male that initially was misdiagnosed as rheumatoid related effusion. However, Pleuroscopy with biopsy revealed mesothelioma.

Clostridium sporogenes bacteremia in an immunocompetent patient.

Of the 200 Clostridium spp. known to exist, approximately 30 have been associated with human disease. Commonly found in soil, marine sediment and mammalian intestinal tracts, these gram-positive bacilli are known to cause infections ranging from cellulitis to septicemia. Isolates that are identified by clinical microbiology laboratories include Clostridium perfrigens species in 20-40% of cases. However, when Clostridium sporogenes is identified, is rarely considered to be pathogenic. We present a case of Clostridium sporogenes bacteremia secondary to lower limb cellulitis and osteomyelitis in an immunocompetent patient.

Premenstrual dysphoric disorder in Arab women: Validation and cultural adaptation of the Arabic version of the premenstrual screening tool.

Premenstrual dysphoric disorder (PMDD) is not well-studied in Arab populations. The goal of this study was to validate the Arabic version of the Premenstrual Symptoms Screening Tool (PSST) using the DSM diagnosis of PMDD as the gold standard. The PSST was translated and culturally adapted using back translation and the approval of the original author. We recruited 194 adult women (between October 2013 and March 2014) from two primary care centers in Doha, Qatar. A psychiatrist determined the diagnosis using the semi-structured Mini International Neuropsychiatric Interview, and another rater blinded to the diagnosis finalized the Arabic PSST and administered other clinical questionnaires. The data showed that premenstrual symptoms and PMDD were observed in about 37 percent and 15 percent, respectively, of the women enrolled. The mean age of the women with PMDD according to the PSST was about 30 years, and the majority had children. The Arabic PSST showed high specificity of 95.6 percent but low sensitivity of 26.7 percent. A factor analysis of the different items in Arabic PSST showed that the Arabic PSST could detect the cases with definite PMDD and thus can be a useful tool in primary care settings as this treatable disorder is underdiagnosed in the Arab populations.

Heat sink effect on tumor ablation characteristics as observed in monopolar radiofrequency, bipolar radiofrequency, and microwave, using ex vivo calf liver model.

Thermal ablation of liver tumors near large blood vessels is affected by the cooling effect of blood flow, leading to incomplete ablation. Hence, we conducted a comparative investigation of heat sink effect in monopolar (MP) and bipolar (BP) radiofrequency ablation (RFA), and microwave (MW) ablation devices.With a perfused calf liver, the ablative performances (volume, mass, density, dimensions), with and without heat sink, were measured. Heat sink was present when the ablative tip of the probes were 8.0 mm close to a major hepatic vein and absent when >30 mm away. Temperatures (T1 and T2) on either side of the hepatic vein near the tip of the probes, heating probe temperature (T3), outlet perfusate temperature (T4), and ablation time were monitored.With or without heat sink, BP radiofrequency ablated a larger volume and mass, compared with MP RFA or MW ablation, with latter device producing the highest density of tissue ablated. MW ablation produced an ellipsoidal shape while radiofrequency devices produced spheres.Percentage heat sink effect in Bipolar radiofrequency : Mono-polar radiofrequency : Microwave was (Volume) 33:41:22; (mass) 23:56:34; (density) 9.0:26:18; and (relative elipscity) 5.8:12.9:1.3, indicating that BP and MW devices were less affected.Percentage heat sink effect on time (minutes) to reach maximum temperature (W) = 13.28:9.2:29.8; time at maximum temperature (X) is 87:66:16.66; temperature difference (Y) between the thermal probes (T3) and the temperature (T1 + T2)/2 on either side of the hepatic vessel was 100:87:20; and temperature difference between the (T1 + T2)/2 and temperature of outlet circulating solution (T4), Z was 20.33:30.23:37.5.MW and BP radiofrequencies were less affected by heat sink while MP RFA was the most affected. With a single ablation, BP radiofrequency ablated a larger volume and mass regardless of heat sink.

Effect of nonparallel placement of in-circle bipolar radiofrequency ablation probes on volume of tissue ablated with heat sink.

OBJECTIVES: Percutaneous bipolar radiofrequency ablation (RFA) is a minimally invasive technique for treating liver tumors. It is not always possible to insert the bipolar probes parallel to each other on either side of tumor, since it restricts maneuverability away from vital structures or ablate certain tumor shape. Therefore, we investigated how nonparallel placement of probes affected ablation. METHODS: Bipolar RFA in parallel and in divergent positions were submerged in tissue model (800 mL egg white) at 37°C and ablated. Temperature probes, T1 and T2 were placed 8.00 mm below the tip of the probes, T3 in between the probe coil elements and T4 and T5 at water inlet and outlet, respectively. Both models with heat sink (+HS) and without (-HS) were investigated. RESULTS: The mean ablated tissue volume, mass, density and height increased linearly with unit angle increase for -HS model. With +HS, a smaller increase in mean volume and mass, a slightly greater increase in mean density but a reduction in height of tissue was seen. The mean ablation time and duration of maximum temperature with +HS was slightly larger, compared with -HS, while -HS ablated at a slightly higher temperature. The heat sink present was minimal for probes in parallel position compared to nonparallel positions. CONCLUSION: Divergence from parallel insertion of bipolar RFA probes increased the mean volume, mass, and density of tissue ablated. However, the presence of large heat sinks may limit the application of this technique, when tumors border on larger vessels.

Radiofrequency ablation in metastatic melanoma.

Radiofrequency ablation (RFA) is a minimally invasive therapy that has, until recently, received limited attention in the management of metastatic melanoma. RFA is well described in the management of primary malignancies of the liver, however limited data are available on its application to metastatic deposits of melanoma occurring in the lung, liver, or adrenal glands. This article explores the basic principles of RFA, its safety, efficacy, and application to metastatic malignancies of the lung, liver and adrenal glands, with particular emphasis on melanoma. Previously published results are reviewed, and we report a small additional series of patients with liver and lung metastases treated in Sydney using RFA.

Peritoneal carcinomatosis from colorectal cancer and small bowel cancer treated with peritonectomy.

BACKGROUND: This study aims to assess the survival of patients who underwent peritonectomy, to assess the morbidity and mortality associated with the procedure and to review the published reports on the survival of patients with peritoneal spread of colorectal cancer (CRC). METHODS: Peritonectomy involves resection of all visible peritoneal tumour and is followed by heated intraperitoneal chemotherapy. Peritonectomy with heated intraperitoneal chemotherapy is associated with a 3-year survival of 30-50% in patients with low peritoneal cancer index (PCI) with peritoneal carcinomatosis from CRC. There are approximately 1000 patients in phase 2 studies and a large survival advantage was shown in a randomized control trial. We have carried out over 100 peritonectomy procedures. This study describes 22 patients with peritoneal spread of gastrointestinal cancer treated with peritonectomy between 1996 and March 2005. Twenty of these patients had primary colorectal cancer and two patients had primary small bowel cancer. RESULTS: Of the 22 patients who underwent peritonectomy, 8 patients are now deceased. The median follow up is now 16.1 months. At 12 months, the survival was 61.5% and at 24 months the survival was 46.1%, which are creditable results comparable with the world published reports. We found that those patients with all macroscopic residual tumour removed at the end of the procedure (completeness of cancer resection, CCR O) had improved 24-month survival compared with patients in whom there was incomplete tumour resection (53.3% survival vs 22.2%, respectively, P = 0.024). Patients with a PCI score less than 13 had better survival (P = 0.0003). CONCLUSIONS: Peritonectomy for peritoneal carcinomatosis from CRC offers patients improved survival. Our results are consistent with the published data with respect to improved survival in patients with low PCI and complete cytoreduction.