Successful Treatment of Cirrhotic Chylous Ascites using Orlistat and Dietary Modifications: A Case Study and Literature Review.

BACKGROUND Chylous ascites (chyloperitoneum), a condition arising from lymphatic leakage in the peritoneal cavity, is rare in liver cirrhosis patients, accounting for less than 1% of cases. Treatment typically involves therapeutic paracentesis, dietary modifications, a low-fat, high-protein diet, and medium-chain triglyceride (MCT) supplementation. Orlistat, a fat absorption inhibitor, has been reported to show potential efficacy in treating chylous ascites. CASE REPORT We detail the case of a 59-year-old male patient admitted for decompensated liver disease and worsening ascites. Diagnostic paracentesis identified chylous ascites, indicated by a 3.5 mmol/L triglyceride level. Despite administering therapeutic paracentesis, dietary modifications, MCT supplementation, Spironolactone, and Terlipressin for a presumed hepatorenal syndrome, the patient's ascites remained chylous for two weeks. On administering orlistat, a significant reduction in ascites volume and chylous content was observed, with triglyceride levels dropping to 0.7 mmol/L. CONCLUSIONS Our case illustrates the potential of orlistat in managing chylous ascites in liver cirrhosis patients, marking only the second such case reported in the existing literature. It encourages further exploration of orlistat's therapeutic potential in treating chylous ascites.

An unusual case of acute kidney injury caused by obstructive uropathy revealing gastric cancer.

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.

Bilateral pulmonary emboli in an amateur kick boxer: A case report and literature review.

Increased knowledge of unusual pulmonary embolism presentations in athletes will prevent delays in the diagnosis and management.

Do the selection criteria of internal medicine residency program predict resident performance?

BACKGROUND: Well-performing physician reflects the success of the residency program in selecting the best candidates for training. This study aimed to evaluate the selection criteria, mainly the United States Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge (CK) results and applicants' status as international or locally trained applicants, used by the medical education department and the internal medicine residency program in Hamad Medical Corporation in Qatar to predict the residents' performance during their training. METHODS: A retrospective chart review was performed for three batches of graduates who started residency training in 2011, 2012, and 2013. Each group completed 4 years of training. The USMLE Step 2 CK status of the applicant, in-training exam (ITE) scores, formative evaluation scores, Arab Board written and clinical exams pass rate, and other indicators were analyzed. Statistical analysis included chi squares and independent t-test to identify associations. Multivariable analyses were conducted using logistic and linear regressions to test for adjusted associations. RESULTS: The study included 118 (81 international/37 locally trained applicants) internal medicine residents. The ITE score correlated positively with the USMLE Step 2 CK score (r = 0.621, r = 0.587, r = 0.576, r = 0.571, p < 0.001) over the 4 years of training and among the international compared with locally trained applicants (p < 0.001). The rate of passing part 1 and 2 written exam of the Arab Board was higher in international than in local applicants, whereas clinical Arab Board exam and formative evaluation were not associated with any criteria. CONCLUSIONS: Higher USMLE Step 2 CK score correlated with better performance on ITE but not with other performance indicators, whereas international applicants did better in both ITE and Arab Board written exam than local applicants. These variables may provide reasonable predictors of well-performing physicians.

Brucellar cervical epidural abscess - A rare cause of neck pain.

Brucellosis, is a zoonosis infection with a planetary distribution, caused by facultative intracellular bacteria of the genus Brucella, thus has a variable clinical presentation. Spinal epidural abscesses are a rare presentation of the disease, and may carry risk of a neurovascular compromise. Here we report a 22-year-old male with spinal brucellosis complicated by a cervical epidural abscess. The diagnosis was based on presenting symptoms and his occupation, confirmed by laboratory investigations, blood culture and magnetic resonance imaging results. Surgical drainage of abscess was performed, followed by 6 weeks of combination antibiotic therapy. The combination of the therapeutic strategies we used lead to a significant clinical improvement in this rare case.

Should We Rely on Screening Tests for Further Management Alone in Polymerase Chain Reaction Negative COVID-19 Patients? A Case Series.

Since the declaration of coronavirus disease 2019 (COVID-19) disease as a pandemic by the World Health Organization (WHO), it has been a challenge to the whole medical community. Researchers and clinicians have been trying to explain and explore its mechanism and pathophysiology to get a better understanding of this disease, as it has exhausted the healthcare resources and has impacted human life in general. Many tests have been developed including polymerase chain reaction (PCR) of the virus and rapid diagnostic testing in patients based on IgM/IgG serology. But owing to variable sensitivity and specificity of these tests, it has created a challenging situation to proceed with the further management plan. We are reporting a case series where we experienced the dilemma of diagnosing COVID-9 disease in our patients and further plan of care.

Primary Hypoparathyroidism Mimicking Ankylosing Spondylitis in a Young Man with Fahr's Syndrome: A Case Report.

Patients with chronic idiopathic hypoparathyroidism may develop neurological complications, including calcification of the basal ganglia and other areas of the brain. In Fahr's syndrome, intracranial calcification is associated with an underlying disorder such as hypo or hyperparathyroidism. We report the case of a 37-year-old gentleman, with a history of bilateral cataract surgery and seizures, who presented with a new episode of seizure and was found to have severe hypocalcemia and bilateral symmetric intracranial calcification due to previously diagnosed primary hypoparathyroidism. He had symptoms and signs mimicking ankylosing spondylitis (AS), but with negative radiological and serological findings, not fitting into the diagnosis of axial spondyloarthropathies (SpA), as per standard criteria. Patients with long-standing idiopathic hypoparathyroidism can have severe calcification of soft tissues and bones, including vertebrae and paravertebral soft tissues, causing inflammatory back pain and stiffness. It is vital to report such cases as their occurrence is rare, and physicians should be aware of the possibility while evaluating patients with inflammatory back pain. Treatment in these cases is directed towards hypocalcemia and underlying primary pathology rather than spondyloarthropathy.

Evaluation of Progress of an ACGME-International Accredited Residency Program in Qatar.

Background: The American College of Physicians' (ACP) Internal Medicine In-Training Examination (IM-ITE) is designed to evaluate the cognitive knowledge of residents to aid them and program directors in evaluating the training experience. Objective: To determine the impact of the curriculum reform accompanied by the Accreditation Council for Graduate Medical Education (ACGME)-I alignment and accreditation on the internal medicine residency program (IMRP) using residents' performance in the ACP's ITE from 2008 to 2016, and where the IMRP stands in comparison to all ACGME and ACGME-I accredited programs. Methods: This is a descriptive study conducted at a hospital-based IMRP in Doha, Qatar from 2008 to 2016. The study population is 1052 residents at all levels of training in IMRP. The ACP-generated ITE results of all the United States and ACGME-I accredited programs were compared with IM-ITE results in Qatar. These results were expressed in the total program average and the ranking percentile. Results: There is a progressive improvement in resident performance in Qatar as shown by the rise in total average program score from 52% in 2008 to 72% in 2016 and the sharp rise in percentile rank from 3rd percentile in 2008 to 93rd percentile in 2016 with a dramatic increase during the period 2013 to 2014 (from 32nd percentile to 73rd percentile), which represents the period of ACGME-I accreditation. None of the factors (ethnicity, USMLE or year of residency) were statistically significant with a p value >0.05 and standard coefficient ( - 0.017-0.495). There was negligible correlation between the USMLE test scores with the residents' ITE scores with a p value = 0.023 and a Pearson correlation r = 0.097. Conclusion: The initial ACGME-I alignment followed by the accreditation, together with whole curriculum redesign to a structured, competency-based program starting from 2008, has led to an improvement in the ITE scores in the IMRP. This was further evidenced by the lack of change in the residency entry selection criteria.

Tuberculoid Leprosy with External Jugular Vein Thrombosis: A Case Report and Literature Review.

Thrombotic disease represents a rare manifestation of leprosy. In this study, we report the case of an external jugular vein thrombosis associated with tuberculoid leprosy in a 23-year-old male patient. The patient presented with a 3-month history of painful cord-like swelling on the left side of the neck and a nearly 3-week history of skin lesions on the left cheek and right leg. Physical examination revealed cord-like, tender swelling on the left lateral aspect of the neck overlying the sternocleidomastoid muscle, and a hypopigmented, hypoaesthetic 6×7 cm lesion with an irregular margin on the left cheek. A Doppler ultrasound examination of the jugular vein showed thrombosis of the left external jugular vein. Three-dimensional reconstruction of the computed tomography scan showed the enlarged and enhanced left external jugular vein, as well as 1 of its tributaries, and the thickened skin patch. A skin punch biopsy from the left cheek lesion revealed granulomatous inflammation with occasional peri-adnexal granulomas, consistent with the clinical impression of tuberculoid leprosy. A diagnosis of leprosy with external jugular vein thrombosis was established. Anticoagulation therapy was initiated, and the patient was referred to an infectious disease clinic for treatment with anti-leprosy medications. LEARNING POINTS: Thickened cord-like neck swelling in leprosy can be vein thrombosis rather than a thickened nerve.Leprosy should be considered if a skin lesion is associated with thrombosis.The common causes of upper extremity DVT.

Isolated Bulbar Palsy: A Rare Presentation of Neurosarcoidosis.

Sarcoidosis, which is a non-caseating granulomatous chronic inflammatory disease, can affect virtually any organ system, including the central nervous system (CNS). Very rarely, patients may present solely with neurosarcoidosis. It commonly presents with unilateral or bilateral seventh nerve palsy. Rarely it can present as dangerous progressive bulbar palsy and is a diagnostic and clinical challenge. We present a case of sarcoidosis with a unique presentation of isolated bulbar palsy. A 38-year-old male presented to the emergency with a sudden onset of dysphonia followed by dysphagia for both solids and liquids for one week and 5 kg weight loss in two months. The rest of the CNS exam was unremarkable. On labs, he had hypercalcemia and suppressed parathyroid hormone (PTH) intact. Detailed radiological investigations, lab tests, and lymph node biopsy helped confirm the diagnosis of neurosarcoidosis. The patient did not respond to first-line steroid therapy and hence received intravenous immunoglobulin (IVIG) subsequently with adequate response and complete neurologic recovery, confirmed by a follow-up visit.

Severe Immune Thrombocytopenia Complicated by Intracerebral Haemorrhage Associated with Coronavirus Infection: A Case Report and Literature Review.

Immune thrombocytopenic purpura (ITP) is an autoimmune disorder that causes isolated thrombocytopenia. Many viruses have been identified as triggering the autoimmune process, including HIV, MCV, EBV, parvovirus, rubella and measles. However, ITP in association with coronavirus infection has not previously been reported. We describe the case of a healthy man who presented with severe ITP complicated by intracranial haemorrhage following upper respiratory tract infection. An infection screen revealed coronavirus infection. LEARNING POINTS: Coronavirus can cause severe immune thrombocytopenic purpura (ITP).Intracerebral haemorrhage is an uncommon presentation of ITP.Intravenous immunoglobulin and steroids are very effective treatments for severe ITP.

It is all about patients' stories: Case-based learning in residents' education.

Background: Problem-based learning (PBL) is an inquiry-based learning strategy which is learner centered and facilitates group discussion and critical thinking. Case-based learning (CBL), which is a more guided approach of PBL, enables students to learn within the context of patients and formulate their knowledge around patients' scenarios. Midweek (MW) activity is an important educational activity in the internal medicine residency program (IMRP). CBL has shown many benefits in postgraduate education. The aim of our study was to describe the implementation of a teaching resident's management of acute medical conditions encountered during their call utilizing the CBL format and to evaluate resident satisfaction with the new teaching style. Methods: This study describes the implementation of CBL in residents' education at the IMRP. CBL was introduced in five of the 10 acute medical sessions taught in the noon activity. A mixed-method study was employed using both a structured questionnaire and a focus group to compare the two methods to evaluate the residents' satisfaction and perception of knowledge acquisition. Results: The focus group discussion showed that sessions conducted in CBL format were more engaging, interactive, and resulted in better knowledge acquisition through sharing and peer-to-peer teaching than the traditional lecture format. Thirty-nine out of 83 (47%) residents ranging from PGY2 to PGY4 responded to the survey. Overall satisfaction with CBL was good. Sixty-four percent preferred it over the lecture format; 87% found that they did improve their knowledge; 84% agreed that they were excellent and more interactive. Seventy-nine percent stated that they would like to have this type of teaching in the MW activity sessions. Conclusion: Based on the present study, we conclude that incorporation of CBL resulted in more engagement, interaction, peer-to-peer education, and overall residents' satisfaction. The key elements for a successful implementation of this format are both instructors' and residents' orientation and careful selection of the case scenarios (problems) that trigger the learning process. Incorporation of various teaching strategies in residents' education is mandatory to enhance learning and create excellent educational experiences.

Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids, with Cranial and Caudal Extension.

A 23-year-old lady presented with vertigo and imbalance in walking, blurring of vision, diplopia, and headache, in addition to numbness in the lower limbs over a period of six days. On examination patient had nystagmus, ataxia, positive Romberg test, and hyperreflexia. MRI examination of the brain and spinal cord showed evidence of faint bright signal intensity foci in T2/FLAIR involving bilateral cerebral hemispheres, subcortical deep white matter, bilateral thalami, posterior pons and left brachium pontis, and basal ganglia, with small nodular enhancement that aligned along curvilinear structures; those lesions also were apparent along the spinal cord at multiple levels. The clinical and radiological features suggested CLIPPERS (chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids) syndrome. Symptoms improved dramatically with high dose oral corticosteroids. Our report addresses the radiological and clinical pattern of a case of CLIPPERS rhombencephalitis, with added superior and inferior extension to involve the brain and spinal cord, which is to emphasize the importance of raising the awareness of this disease and the combined role of radiologist and physicians for the diagnosis of this potentially treatable entity, responsive to glucocorticosteroid immunosuppression.

Tolosa-Hunt syndrome: an arcane pathology of cavernous venous sinus.

Tolosa-Hunt syndrome, an idiopathic granulomatous inflammation of the cavernous sinus, is primarily a diagnosis of exclusion. The majority of patients present with unilateral orbital pain and features suggestive of paralysis of one or more of the cranial nerves passing through the cavernous sinus and/or superior orbital fissure. MRI of the head may show unilateral enhancement of the cavernous sinus and orbital apex. Treatment is with high-dose intravenous steroids followed by tapering oral steroids. Rapid amelioration of pain within 24-48 h supports this rare diagnosis. Resolution of neuropathies may take longer. We describe a case of a young man who presented with left periorbital pain, complete ophthalmoplaegia and ptosis of the left eye. MRI showed enhancement of the left cavernous sinus and orbital apex. High dose steroids led to complete resolution of pain, while ptosis and ophthalmoplaegia improved gradually.

Brucellosis in Qatar: A retrospective cohort study.

BACKGROUND: We conducted a retrospective cohort study to evaluate the clinical manifestations, laboratory findings, complications and treatment of brucellosis in the State of Qatar. METHODS: The medical records of patients in Hamad Medical Corporation, Doha, Qatar were reviewed from January 2000 to December 2006. History, various socio-demographic features, clinical and biochemical parameters, therapeutic features, and complications were retrospectively collected from the patient database. RESULTS: Around three quarters of the study population were males. History of raw milk consumption and animal contact were seen in 41.7% and 12.5% respectively. The main presenting features of our cohort were fever, chills and sweating (93.1%, 62.5% and 58.3% respectively). Positive antibody titre (>1:160) was detected in 95.8% and positive blood culture was reported in 63.9% of the cohort. Splenomegaly was observed in 19.4%, hepatomegaly in 15.3% and lymphadenopathy in 9.7% of the cases. Approximately half of our patients were treated with a combination of doxycycline and streptomycine and nearly one quarter received doxycycline and rifampicine combination therapy. CONCLUSIONS: Brucellosis is an important public health problem worldwide. It is associated with significant morbidity and mortality. It may affect any organ system and can present with a variety of clinical features. Diagnosis of brucellosis requires serological tests with or without blood culture. Treatment with at least two antibiotics for six weeks or more appears to be effective.

Tailoring Morning Reports to an Internal Medicine Residency in Qatar.

BACKGROUND: Morning report, a case-based conference that allows learners and teachers to interact and discuss patient care, is a standard educational feature of internal residency programs, as well as some other specialties. OBJECTIVE: Our intervention was aimed at enhancing the format for morning report in our internal medicine residency program in Doha, Qatar. INTERVENTION: In July 2011, we performed a needs assessment of the 115 residents in our internal medicine residency program, using a questionnaire. Resident input was analyzed and prioritized using the percentage of residents who agreed with a given recommendation for improving morning report. We translated the input into interventions that enhanced the format and content, and improved environmental factors surrounding morning report. We resurveyed residents using the questionnaire that was used for the needs assessment. RESULTS: Key changes to the format for morning report included improving organization, adding variety to the content, enhancing case selection and the quality of presentations, and introducing patient safety and quality improvement topics into discussions. This led to a morning report format that is resident-driven, and resident-led, and that produces resident-focused learning and quality improvement activities. CONCLUSIONS: Our revised morning report format is a dynamic tool, and we will continue to tailor and modify it on an ongoing basis in response to participant feedback. We recommend a process of assessing and reassessing morning report for other programs that want to enhance resident interest and participation in clinical and safety-focused discussions.

Low vitamin d and cardiovascular risk factors in males and females from a sunny, rich country.

BACKGROUND: Low serum vitamin (vit) D levels are common even in sunny countries. We assessed the prevalence and relationship of low vit D with cardiovascular risk factors in Qatar. METHODS: Data were collected retrospectively from January 2008 and November 2009. In patients who had low vi t D (< 30 ng/ml ) , demographic and clinical profiles were analyzed and compared in males and females. RESULTS: The overall mean level of vit D among 547 patients was 14.4±11 ng/mL. Among the low vitamin D group, 56% were females (mean age 48±12) and 44% males (mean age 49.6±13). Severely low vit D levels (<10 ng/mL) were found in 231 (46%) patients with mean age of 46±12 years. Compared with females, males with low vitamin D were more likely to have diabetes mellitus (38 vs 22%, p=0.001), dyslipidemia (41 vs 29%, p=0.007), myocardial infarction (5.5 vs 1.5%, p=0.001) and angiographically documented coronary artery disease (CAD) (53 vs 17%, p=0.001). Multivariate logistic regression analysis showed that in the presence of low vit D, age and hypertension were independent predictors of CAD (OR 1.07;95% CI: 1.02-1.11) and OR 8.0; 95% CI: 1.67-39.82), respectively. CONCLUSIONS: Our study supports the widespread prevalence of low vit D in sunny regions. Low vit D is associated with 3 times increase in the rate of MI among males. Hypertension increases the risk of CAD 8 times in the presence of low vit D regardless of gender.

Humoral hypercalcemic crisis in a pregnant woman with uterine leiomyoma.

We report a case of parathyroid hormone-related protein-mediated hypercalcemic crisis in a 36-year-old pregnant woman, who was admitted to women hospital with recurrent vomiting and epigastric pain. She was diagnosed with uterine fibroid since the first month of her pregnancy, but the pregnancy had been uneventful. Serum calcium was 4.8 mmol/l, while parathyroid hormone was low. Hypercalcemia was attributed to humoral hypercalcemia associated with uterine fibroid as other causes of hypercalcemia were excluded.

Cerebral venous thrombosis as the initial presentation of Behcet's disease.

Neurological symptoms are rare manifestations of Behcet's disease. In this paper, we report cerebral venous thrombosis as the initial presentation of Behcet's disease in a 40 yearold man. Our patient presented with a six-week history of headache, progressive loss of vision in the right eye and recurrent oral ulcers. Physical examination revealed oral ulcers and posterior synechia in the right eye with loss of light perception. Fundoscopic examination showed evidence of retinal vasculitis. Magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) of the brain showed superior sagittal, left transverse, and left sigmoid sinus venous thrombosis. A diagnosis of Behcet's disease was made based on clinical criteria. Treatment with methylpredinsolone, cyclophosphamide, and azathioprine as well as anticoagulation was done with significant clinical improvement.