Khalil Salameh

Socioeconomic associations of improved maternal, neonatal, and perinatal survival in Qatar

This retrospective study analyzed the temporal association between socioeconomic development indices and improved maternal, neonatal, and perinatal survival in the State of Qatar over a period of 35 years (1974–2008). We explored the association between reduction in poverty, improvement in maternal education, and perinatal health care on the one hand, and increased maternal, neonatal, and perinatal survival on the other hand. Yearly mortality data was ascertained from the perinatal and neonatal mortality registers of the Women’s Hospital and the national database in the Department of Preventive Medicine at Hamad Medical Corporation in Doha. A total of 323,014 births were recorded during the study period. During these 35 years, there was a remarkable decline (P < 0.001) in Qatar’s neonatal mortality rate from 26.27/1000 in 1974 to 4.4/1000 in 2008 and in the perinatal mortality rate from 44.4/1000 in 1974 to 10.58/1000 in 2008. Qatar’s maternal mortality rate remained zero during 1993, 1995, and then in 1998–2000. The maternal mortality rate was 11.6/100,000 in 2008. For the rest of the years it has been approximately 10/100,000. Across the study period, the reduction in poverty, increase in maternal education, and improved perinatal health care were temporally associated with a significant improvement in maternal, neonatal, and perinatal survival. The total annual births increased five-fold during the study period, with no negative impact on survival rates. Neonatal mortality rates in Qatar have reached a plateau since 2005. We also conducted a substudy to assess the association between improvements in survival rates in relation to health care investment. For this purpose, we divided the study period into two eras, ie, era A (1974–1993) during which major health care investment was in community-based, low-cost interventions, and era B (1994–2008) during which the major health care investment was in high-technology institutional interventions. Although from 1974–1993 (era A) the per capita health expenditure increased by only 19% as compared with a 137% increase in 1994–2008 (era B). The decline in neonatal and perinatal mortality rates was three times steeper during era A than in era B. The decline in neonatal and perinatal mortality rates was also significant (P < 0.001) when analyzed separately for era A and era B. We concluded that across the 35-year period covered by our study, the reduction in poverty, increased maternal education, and improved perinatal health care were temporally associated with improved maternal, neonatal, and perinatal survival in the State of Qatar. From the subanalysis of era A and era B, we concluded that low-cost, community-based interventions, on the background of socioeconomic development, have a stronger impact on maternal, neonatal, and perinatal survival as compared with high-cost institutional interventions.

Pattern of Maternal Complications and Low Birth Weight: Associated Risk Factors among Highly Endogamous Women

Objective. The objective of the study was to examine the pattern of low birth weight LBW, maternal complications, and its related factors among Arab women in Qatar. Design. This is a prospective hospital-based study. Setting. The study was carried out in Womens Hospital, Doha. Subjects and Methods. Pregnant women in their third trimester were identified in the log book of Womens Hospital and recruited into the study during first week of January 2010 to July 2011. Only 1674 (out of 2238) Arab women (74.7%) consented to participate in this study. Data on clinical and biochemistry parameters were retrieved from medical records. Follow-up data on neonatal outcome was obtained from labor room register. Results. The incidence of LBW (<2500 g) was 6.7% among Arab women during 2010 in Qatar. Distribution of gestational diabetes mellitus (GDM), antepartum hemorrhage (APH), maternal anemia, premature rupture of membrane (PROM), maternal occupation, parity, sheesha smoking, and parental consanguinity were significantly different (P < 0.05) between mothers of LBW and normal birth weight NBW (≥2500 g) babies. Multivariable logistic regression analysis revealed that previous LBW, consanguinity, parity, smoking shesha, GDM, APH, anemia, PROM, maternal occupation, and housing condition were significantly associated with LBW adjusting for gestational age. Conclusion. Maternal complications such as GDM, APH, anemia, PROM, and smoking shesha during pregnancy are significantly increasing the risk of LBW outcome. Screening and prompt treatment for maternal complications and health education for smoking cessation during routine antenatal visits will help in substantial reduction of LBW outcome.

Prevalence and risk factors for low vitamin D status among breastfeeding mother–infant dyads in an environment with abundant sunshine

Purpose Evaluation of vitamin D (vD) status and risk factors for low vD among breastfeeding mother–infant dyads in a population at high risk for vD deficiency. Subjects and methods We measured serum 25-hydroxyvitamin D (25(OH)D) and parathyroid hormone at 1 month postpartum in 60 consecutive exclusively breastfeeding Arab mother–infant dyads enrolled in a high dose vD supplementation study to prevent vD deficiency in Doha, Qatar, (latitude 25°N) during summer months. Data were collected on demography, sun exposure, and vD supplementation. Comparison with a US cohort was evaluated. vD deficiency was defined as serum 25(OH)D <50 nmol/L and severe deficiency categorized as 25(OH)D <25 nmol/L in mothers and infants. Results Mean maternal age was 29 years and 77% had college or university education. Maternal median 25(OH)D was 32.5 nmol/L and 78% were vD-deficient and 20% had 25(OH)D <25 nmol/L. Only 42% of mothers had reportedly taken vD supplements postpartum and median dietary vD intake (119 IU/day) and calcium (490 mg/day) were low. Maternal median sun index score (sun exposure [hours/week] × body surface area exposed while outdoors) was 0. Maternal 25(OH)D correlated with percent body surface area exposure while outdoors (rs=0.37, P=0.004). Infant median 25(OH)D was 20 nmol/L and 83% were deficient, while 58% had 25(OH)D <25 nmol/L. Infant 25(OH)D correlated with maternal levels (rs=0.41, P=0.001). None of the infants received vD supplement at 1 month of age and median sun index score was 0. Infant’s parathyroid hormone showed negative correlations with 25(OH)D (rs=−0.28, P=0.03). Sun exposure, vD supplementation rate, and vD status were lower in Doha than Cincinnati, US cohort. Conclusion vD deficiency is common in breastfeeding mother–infant dyads in this sunny environment and is associated with sun avoidance and low vD intake. We suggest corrective vD supplement of breastfeeding mothers and their infants, which should preferably start during pregnancy.

The national perinatal mortality rate in the State of Qatar during 2011; trends since 1990 and comparative analysis with selected high-income countries: The PEARL Study Project*

Abstract Objective: To prospectively ascertain Qatar’s national perinatal mortality rate (PMR) during 2011, compare it with recent data from selected high-income countries, and analyze trends in Qatar’s PMR between 1990 and 2011 using historical data. Study design: A national prospective cohort study. Methods: National data on live births, stillbirths, and early neonatal mortality (day 0–6) were collected from all public and private maternity units in Qatar (1st January–December 31st 2011) and compared with historical perinatal mortality data (1990–2010) ascertained from the database of maternity and neonatal units of Women’s Hospital and annual reports of Hamad Medical Corporation (HMC). For inter-country comparison, country data were extracted from the World Health Statistics published by WHO in 2011 and from the European Perinatal Health Report published by the Europeristat project in 2008. Results: A total of 20,725 births (20,583 live births plus 142 stillbirths) were recorded during the study period. Qatar’s national PMR during 2011 was 9.55 [early neonatal mortality rate (ENMR) 2.7 and stillbirth rate (SBR) 6.85], which was a significant improvement from a PMR of 13.2 in 1990 [risk ratio (RR) 0.72, 95% confidence interval 0.58–0.89, P=0.002]. This improvement in PMR was more significant in ENMR (P<0.001) than in SBR (P=0.019). The stillbirths constituted 55% of PMR in 1990, which increased to 71.72% of PMR during 2011. The RR of PMR had a significant downwards trend between 1990 and 2011 (P=0.016). Qatar’s 2011 PMR, SBR, and ENMR are comparable to those of selected high-income counties. Conclusions: Qatar’s PMR, ENMR, and SBR have significantly improved between 1990 and 2011, and are currently comparable to those of selected high-income countries. An in-depth research to assess the correlates and determinants of stillbirth and perinatal mortality in Qatar is indicated.

Improvements in birth weight-specific neonatal mortality rates in the state of Qatar between 2003 & 2010 and a comparative analysis with the Vermont Oxford Network database report of 2007: A pearl study review

Objective: The study aimed to develop a national reference on birth weight-specific neonatal survival in the State of Qatar to facilitate parental counseling. Study Design: This was a retrospective, analytic, and comparative study. Materials and Methods: The birth weight-specific neonatal mortality data for the years 2003 and 2010, collected from the admission and discharge registers of the neonatal intensive care unit, were stratified using the stratifications given in Vermont Oxford Network (VON) 2007 annual report. Category-wise birth weight-specific mortality and relative risk (RR) of death were compared between Qatar data (2003 and 2010) and VON 2007 report. Results: Qatars neonatal mortality rate (NMR) dropped from 5 of 1000 in 2003 to 4.4 of 1000 in 2010 (P=0.443) which was significant for birth weight categories 501–750 g and 751–1000 g (P=0.026 and P=0.05, respectively). Qatars NMR in 2010 was significantly lower than VONs NMR during 2007 (P<0.001) though VONs NMR was significantly lower among birth weight categories 751–1000 g and 1001–1500 g (P=0.001 and P=0.003, respectively). The RR of mortality decreased with increasing birth weight. The decline was very sharp for birth weight categories between 500 and 1500g. The RR was 25 times higher in babies with birth weight less than 750 g as compared to babies with birth weight ≥ 2550 g, both in Qatar and VON data. For birth weight categories 751–1000 g and 1001–1500 g, the RR was twice in Qatar as compared to the VON report (16.8 versus 7.8, and 5.5 versus 2.7, respectively). Conclusions: Qatars current overall and birth weight-specific NMRs are comparable with the VON report except in birth weight categories 751–1000 g and 1001–1500 g which were higher in Qatar. This needs further in-depth qualitative analysis.

Pediatric case of acute right-sided abdominal pain: diagnosis is not always appendicitis

Omental infarction (OI) is a rare cause of acute abdominal pain occurring in 0.1% of children, which is typically diagnosed during surgery for suspected appendicitis. We present the case of a 7-year-old Pakistani girl. She presented with acute, severe, progressive, right-sided abdominal pain, which was present for 12 hours before presentation. No constitutional symptoms such as fever, anorexia, nausea or vomiting were present. Clinical examination revealed an adequately growing child following the 50th centile. She had severe generalized abdominal tenderness with rebound tenderness and guarding, mainly on the right lower abdominal quadrant, with all other system examinations normal. She had mildly increased inflammatory markers, and her initial abdominal ultrasound scan result was within normal limits. She had laparoscopic surgery following a diagnosis of suspected acute appendicitis; however, an intraoperative diagnosis of OI was made. This was later confirmed by histopathology. This case report highlights the importance of including OI in the differential diagnosis list of acute abdominal pain in children, in addition to the importance of computed tomography (CT) as the gold standard tool to aid diagnosis. In the presence of typical symptoms and signs of OI, a CT scan can assist and guide the management of similar cases. This course of action is suggested for the reason that OI typically runs a self-limited course and conservative care may be the most appropriate recommended course of action. Consequently, unnecessary operations could be avoided due to the diagnosis confirmation of studying images.

Antenatal Bartter syndrome presenting with vomiting and constipation mimicking subacute intestinal obstruction in a 20-day-old neonate

Antenatal Bartter syndrome is a rare condition that can present with different clinical features. These features include early onset maternal polyhydramnios, failure to thrive, prematurity and nephrocalcinosis. We are presenting this 20-day-old girl who had an antenatal history of polyhydramnios. She developed persistent non-bilious vomiting that was associated with constipation soon after birth. She presented with failure to thrive and features suggestive of intestinal obstruction. On the initial evaluation, she was noted to have hypokalaemic, hyponatraemic metabolic alkalosis. The initial work-up was done to exclude surgical and renal causes of her presentation, and the diagnosis was confirmed by gene analysis to be type III—classic Bartter syndrome. She was closely monitored for her growth and development with the appropriate salt replacement therapy.