IRAQI JOURNAL OF MEDICAL SCIENCES

Background: In the context of the much-heralded advantages of laparoscopic surgery, it can be easy to overlook post-laparoscopy pain as a serious problem, yet as many as 80% of patients will require opioid analgesia. It is generally accepted that pain after laparoscopy is multifactorial, and the surgeon is in a unique position to influence many of the putative causes by relatively minor changes in technique.
Objective: To determine whether a drain placed in the peritoneal cavity during laparoscopy is both clinical and cost-effective method of reducing postoperative shoulder pain.
Methods: One hundred female patients were having laparoscopic cholecystectomy were divided into two groups, a control group (50 patients) where no intra-peritoneal drain was inserted and second group (50 patients) in which the patients had intra-peritoneal gas drain sited in the subhepatic area. Patients' age, weight, height, operative time, total amount of CO2 and amount of analgesia used were recorded for each patient in both groups. Shoulder pain was assessed using visual analogue score (VAS) from 1-5 scale at 4, 8, 24 & 48 hours postoperatively, where as abdominal pain was assessed at 48 hour post-operatively. pH of the abdominal fluid was assessed in the second group of patients by using pH meter 48 hours postoperatively.
Results Shoulder pain may occur in many of patients of the control group more frequent than those of the second group, where as postoperative abdominal pain was found to be greater in patients with subhepatic drain after laparoscopic cholecystectomy.
Conclusion: Low-cost drain decreased the frequency of shoulder pain and reduced the need for analgesia, but increases the abdominal pain; however it is less cost-effective than simple oral analgesia after laparoscopy.

Keywords: laparoscopic cholecystectomy, intra-abdominal drain, shoulder pain

Background: Lichen planus characterized by its violaceous color most commonly seen on the flexor surfaces of the upper extremities, the genitalia and the mucous membranes. Psoriasis is a common, chronic, relapsing, inflammatory skin disorder with a strong genetic basis. Plaque type of psoriasis is the most common. Selenium is a component of the enzyme glutathione peroxidase, and is important in protection against damage by peroxides and free radicals.
Objectives: To measure selenium level in Iraqi patients with lichen planus and in patients with psoriasis and its relation to the chronicity and the severity of both diseases.
Methods: One hundred twenty patients were included in this study, 68 males and 52 females, with ages between 18-54 years. Full history and examination, including dermatological examination, were done for all patients. The patients were divided into three groups. The first group includes lichen planus patients, the second group includes psoriasis patients and the third group was a control group study. Serum selenium level was measured for all patients by spectrophotometer.
Results Serum selenium level was decreased in 20 (50%) patients of the first group, in 32 (80%) patients of the second group and 14 (35%) of the third group. The results were of high statistical significance when compared between groups 2 & 3 but it was insignificant when compared between groups 1 & 3. Selenium level was decreased in 12 of the first group who had the disease for two years and above while it was decreased in 18 of the second group who had psoriasis for two years and above, selenium level was decreased in patients with severe and diffuse variants of both lichen planus and psoriasis.
Conclusion: Serum selenium level was decreased in both lichen planus and psoriasis but it was more significant in psoriasis and this decrease was related to both chronicity and severity.

Keywords: Selenium, Lichen planus, Psoriasis, Chronicity, Severity.

Background: Dialysis is one of the common strategies of renal replacement therapy for patients with chronic renal failure; however it harbors significant cellular changes in various body fluids.
Objective: To evaluate the cellular changes in urine samples of patients undergoing dialysis.
Methods: Seventy-two fresh midstream, spontaneously voided urine samples, they were included in the study. Early morning samples were excluded, Duration of dialysis was taken into consideration (short term and long term dialysis). Samples were centrifuged at 3000 round per minute for 15 minutes, the supernatants were decanted and the sediments were examined cytomorphologically.
Results: The gross appearance of all urine samples was neither purulent nor hemorrhagic. Microscopically there was an excessive shedding of urothelial cells in urine samples of patients undergoing dialysis compared with samples of the control group which showed evidence of normal shedding. There were no significant cytological atypia or malignancy in all urine samples. The excessive exfoliation in the absence of significant inflammation, hemorrhagic, or cytological atypia was compared with control group.
Conclusions: The study revealed that some cytological changes do occur in the urothilial cells in patients undergoing dialysis; these changes need further attention to disclose their real causes.

Key words: chronic renal failure, hemodialysis, cytomorphology, epithelial exfoliation

Background: The development of autoimmune disease involves a breakdown in the mechanisms that control T cell tolerance to self antigens, these mechanisms are many and complex, and they integrate as immunoregulation. Among the cells that might be responsible for this regulation is a specific type of T cells which has the ability to downregulate the differentiation of helper cells or antigen specific effector cells. The main subset of these suppressor T cells is the naturally occurring CD4+CD25+ regulatory T cells (n Tregs) which are the most important and they derived as a functionally mature population from the thymus.
Objective: The purpose of this study was to determine the correlation between the numbers of circulating CD4+CD25+ regulatory T cells (nTregs) and CD4+ T cells in chronic rheumatic heart disease patients.
Methods: Peripheral blood samples were taken from 48 Iraqi patients with chronic rheumatic heart disease (CRHD). Lymphocytes were isolated from the peripheral blood, nTregs and CD4+ T cells; also, cell numbers were detected by using immunofluorescence technique.
Results: In general, nTregs were found in lower numbers in the peripheral blood of CRHD patients in different study groups than in healthy control group, whereas, CD4+ T cells were found in higher numbers in some of patients than controls. Also, our results revealed that there was a significant negative correlation between naturally occurring CD4+CD25+ regulatory T cells and CD4+ T cells in all study groups.
Conclusions: Our finding confirmed that there is a significant correlation between circulating nTregs and CD4+ T cells in chronic rheumatic heart disease.

Key words: CD4+CD25+ regulatory T cells, CD4+ T cells, chronic rheumatic heart disease.

Background: Obesity may be associated with lower prostate specific antigen(PSA) values, If true, this would result in fewer obese men having an elevated PSA, fewer biopsies performed, and fewer cancers detected , consequently cancers may be missed or not detected until at a more advanced stage.
Objective: We examined the influences of age, body mass index (BMI) and waist circumference (WC) on PSA before and after adjusting for prostate volume. We also examined associations among age, body mass index, waist circumference and prostate volume (PV).
Methods: We analyzed 125 Iraqi men aged 40 to 84 years old who attained the urological outpatient clinic for BPH evaluation during 2009. Curent health status information including prostate related problems, medical interview, basic physical examination and anthropometric measurements including height, weight, BMI and waist circumference were taken for all patients. Blood tests including PSA concentration were performed after overnight fast. A radiologist performed transrectal prostate ultrasound. PSA measurements preceded routine digital examination and transrectal prostate ultrasound.
Results: The median serum PSA was significantly lower among obese subjects compared to normal BMI subjects. BMI showed a statistically significant moderately strong negative linear correlation (r = -0.5) with serum PSA. Waist circumference showed a similar pattern with a statistically significant linear correlation with serum PSA (r = -0.43); the median serum PSA was significantly lower among subjects with highest waist circumference compared to subjects in the lowest quartile of waist circumference. The median PSA was significantly higher among subjects with large prostate size compared to those with lowest quartile prostate size. The anthropometric measures were tested for association with PSA density, to adjust for the effect of prostate size on serum PSA.
Conclusion: The current data suggest that the PSA cut-points used to recommend biopsy need to be adjusted for the degree of obesity.

Keywords: body mass index, waist circumference, prostate specific antigen.

Background: Ageing and hormonal changes in menopause are factors which may play the most important role in the development of all events of this stage of women\'s life. Of importance in this respect is obesity and related events as insulin resistance, oxidative stress, dyslipidemia and consequent increase in the risk of cardiovascular disease.
Objective: To evaluate the association of dyslipidemia with the development of obesity and related events as lipid peroxidation after menopause, and to correlate the different parameters with each other.
Methods: Thirty seven premenopausal women aged (33.95±7.9 years) and 41 postmenopausal women aged (59.9±7.2 years) were involved in this study. All were normal and without a previous history of any disease or illness. Blood specimens were collected after 12 hour fast for measurement of serum lipids (total cholesterol TC, Triglycerides TG, and high density lipoprotein cholesterol HDL-C) by enzymatic spectrophotometric methods. Low density lipoprotein cholesterol (LDL-C) was estimated by calculation. The athrogenic index (AI) indicates the ratio of LDL-C to HDL-C, while sex hormones (estradiol, E2, follicle stimulating hormone, FSH and luteinizing hormone, LH) and oxidized LDL (ox-LDL) were measured by ELISA methods. All participants were subjected to anthropometric measurements including body mass Index (BMI) and waist circumference (WC).
Results:Marked significant increase in BMI and WC in the postmenopausal women as compared with the premenopausal women and was associated with a significant low E2, high serum TG, TC, LDL-C, AI and ox-LDL with low HDL-C.
Conclusion: Changes in serum levels of sex hormones at menopause may be the trigger for the development of post-menopausal obesity, dyslipidemia and elevated Ox-LDL, and that at a given age all these factors should be considered for evaluation of body fat distribution and related health risks.

Key Words: menopause, obesity, dyslipidemia, sex hormones, ox-LDL

Background: Human semen contains high concentrations of fructose, zinc (Zn) and copper (Cu) in bound and ionic forms for Zn and Cu. The presence of abnormal levels of fructose and those trace elements may affect spermatogenesis with regard to production, maturation, motility and fertilizing capacity of the spermatozoa.
Objective: To evaluate the levels of fructose, Zn and Cu in seminal plasma in different groups of male infertility and to correlate their concentrations with various sperm parameters.
Methods: The concentrations of fructose, Zn and Cu were measured in 114 semen samples from normozoospermic, oligozoospermic, astheno-zoospermic, and azoospermic men using the electrothermal-atomic absorption spectrometry for Zn and Cu determination. The concentration of fructose in seminal plasma was determined with a spectrophotometric method, using the resorcinol method.
Results: Results of the present study showed that there was an inverse relationship between fructose levels and sperm count. The mean value of seminal plasma fructose concentrations was significantly increased (p ≤ 0.001) in the three groups of infertile male subjects (azoospermia, asthenozoospermia and oligozoospermia) than in fertile males. The mean value of seminal plasma Zn concentrations was significantly decreased (p ≤ 0.001) in the three groups of infertile male subjects (azoospermia, asthenozoospermia and oligozoospermia) than in fertile males. A good correlation in a positive direction was noted between the sperm count and seminal plasma Zn concentration. There was significant decrease in seminal plasma Cu concentration between asthenozoospermia and control groups (p ≤ 0.05) and insignificant increase in oligozoospermic patients.
Conclusions: On the basis of the observations of the present study, seminal fructose, zinc and copper may contribute to fertility through their effects on various semen parameters.

Key words:Male infertility, fructose, zinc, copper.

Background: Cutaneous leishmaniasis (CL) is caused by a protozoan from the genus Leishmania that infect macrophages of many mammals including humans, their infection induces both humoral and cellular immune responses, but the balance of their expression varies with the type of the disease.
Objective: The aim of the present study is to understand the effect of antimonial compounds on some serum cytokines levels that include (IFN-γ, TNF-α, TGF-β, IL-1β, IL-6, IL-8) before, during and after treatment from CL infection.
Methods: Eighty people were included in the present study, 60 patients with CL lesions and 20 healthy individuals (control). Patients were diagnosed on the basis of clinical and parasitological criteria. All patients treated with pentostam by intralesional injection. Serum (IFN-γ, TNF-α, TGF-β, IL-1β, IL-6, IL-8) levels were determined by ELISA using a quantitative sandwich enzyme immunoassay technique.
Results: Serum levels of (TNF-α, IL-1β, IL-6, and IL-8) were significantly higher in patients group than healthy subjects (p < 0.05). INF-γ and TGF-β levels were decreased significantly during infection with CL. During therapy with pentostam, cytokines levels (IFN-γ, TNF-α, TGF-β, IL-1β, IL-6, IL-8) were significantly increased (p < 0.05). All cytokines levels returned to the normal values after three months of healing from CL lesions.
Conclusions: Cytokines plays an important role in the resolution of CL infection. Pentavalent antimonials compounds may have immuno-stimulating effects which may be responsible for its antimicrobial activities.

Key words: Cutaneous leishmaniasis, cytokines, treatment, pentostam.

Background: The Epstein -Barr virus (EBV) is the first human virus implicated in the carcinogenesis. EBV contributes to the carcinogenesis like Hodgkin's Lymphoma (HL) and Non Hodgkin’s Lymphoma (NHL).
Objective: Quantitative Competitive Polymerase Chain Reaction (QC-PCR) and ELISA was used to quantitate the EBV DNA load in blood samples of HL and NHL patients pre and post therapy.
Methods: EBV DNA extracted from blood samples of 18 HL and NHL patients pre and post therapy, 9 apparently healthy controls used to quantify the EBV DNA load. Quantitative Competitive Polymerase Chain Reaction (QC-PCR) and ELISA were used to quantify EBV DNA load. Wild EBV DNA (WT) obtained by Transformation of Escherichia coli MM 294 with Wild type (WT) DNA plasmid pGEMBamHI-K.
Results: EBV DNA load in controls was found to be 7-1.99 × 103 in HL and NHL patients, while in patients it's ranged from zero to 1.936×109 copy numbers per ml of blood. High EBV load with the range of 10715(1.071×104) to 1936421960 (1.936×109) above cut-off value was detected in 66.7% of HL and 5861(5.86×103)-50118(5.01×104) copies/ml blood in 44.5 % of NHL patients pretherapy. After chemotherapy, 60% of HL patients and 100% of HL patients with high EBV load showed significant response. Low viral load was found in 44.45% of patients. Only 55% of lymphoma patients with high EBV load, after chemotherapy 16.6% of them continue to have high EBV DNA load compared to the control group, 38.3% of the patients showed response to chemotherapy when their viral load decreased below cut off value. While 11.1 % continue to have high DNA load. One patient (5.5%) showed an elevated EBV load after completion of chemotherapy.
Conclusions: EBV DNA load estimated by Quantitative Competitive Polymerase Chain Reaction considered as valuable promising tumor biomarker in the diagnosis and monitoring of EBV related HL and NHL patients.

Key words: Quantitative Competitive Polymerase Chain Reaction (QC-PCR), Epstein-Barr virus (EBV), Viral DNA load, Hodgkin’s (HL) and non Hodgkin’s Lymphoma (NHL) Patients.

Background: Atopic dermatitis (AD) is a chronic inflammatory disease of the skin that occurs in persons of all ages but is more common in children.
Objective: To determine the effect of breast feeding on atopic dermatitis.
Methods: A descriptive study carried on pediatric patients visiting asthma and allergy center and pediatrics out patient in Tikrit Teaching Hospital from March 2007 to August 2007. This study included 100 patients with AD; 58 cases (58%) were males and 42 cases (42%) were females, they all underwent full history, clinical examination and blood sampling for total WBC count, eosinophil cells count, and total serum IgE.
Results: Statistical analysis was done by using (ANOVA, Chi-square test). There was significant association between severity of AD according to scorad index (S.I) and type of infant feeding, the mean severity score (S.S) for the breast fed (B.F) children was 21.48±4.96, while the mean S.S for the formula fed (F.F) children was 35.70±9.79, p value ≤ 0.05. There was a significant association between the hematological parameters of disease activity (total serum IgE level, eosinophil count) and type of infants feeding; the mean total serum IgE level for the B.F children was 211±178.7 IU/ml, was lower than mean total serum IgE level for F.F children (638.2±355.8 IU/ml). The mean eosinophil cells count for the B.F children (355.7±193.1) cell/μl was lower than the mean eosinophil cells count for the F.F children (654.8±236.3) cell/μl.
Conclusions: There is significant association between the type of feeding and the level of hematological parameters (IgE and eosinophil count), and that breast feeding is protective against development of severe AD.

Key words: atopic dermatitis, breast feeding, IgE, eosinophil

Background: The acute phase protein, CRP, when elevated, provides good evidence of an active tissue–damaging process. Thus; its measurement provides a simple screening test for active organic disease .Increased CRP production is a very early and sensitive response to most forms of bacterial infection..
Objective: was to ascertain whether infective exacerbations of chronic obstructive pulmonary disease (COPD) and their successful treatment correlate with corresponding changes in CRP level.
Methods: Fifty Patients (age 65 ± 6 years) diagnosed as COPD on the basis of clinical history and pulmonary function test were enrolled into the study. All those were admitted to Al-Kadhimya Teaching Hospital because of clinical exacerbations of their condition. Serum samples were obtained on admission from the patient for measurement of CRP and full blood count together with sputum sample for microbiological diagnosis (especially culture). CRP measured by semi quantitative method, the cutoff point of this test is 0.6 mg/L .So all positive values were ≥ 1.2 mg/L. All these patients with exacerbations were treated by conventional treatments. Blood samples for CRP, full blood count and forced expiratory volume in 1st second (FGV1) were repeated 4-5 days thereafter.
Results: The levels of CRP were elevated ≥ 1.2 mg/L in 27 patients who were positive for bacterial culture .The average CRP level after adequate treatment was highly decreased (p value < 0.001) .There was a significant improvement in their measured FEV1 (p value < 0.001 ) . The peak CRP level and fall in CRP were significantly correlated with both the corresponding peripheral blood smear white cell count (r=0.57, p value < 0.001) and the correlation Coefficient between CRP and FEV1 was (r= -0.45, p value < 0.001).
Conclusions: Since patients with acute exacerbations of COPD had their CRP levels elevated initially and had clinical improvement with lowering of the CRP levels after treatment, there is a strong possibility that CRP is a marker of exacerbation of COPD. We suggest that, in exacerbation of COPD, CRP estimation provides a useful and inexpensive early marker of the exacerbation and provides a useful guide to assess the efficacy of treatment.

Key words: C reactive protein, CRP, Chronic obstructive pulmonary disease with exacerbation.

Background: The lateral wall of the mastoid antrum, which offers the usual surgical approach to the tympanic cavity, is formed by the postmeatal process of the squamous part of the temporal bone. Since the suprameatal triangle covers the lateral wall of the mastoid air system, it is of importance to otologic surgeons during mastoidectomy.
Objectives: To examine the relationships of the surgical landmarks on the lateral surface of the mastoid bone with the landmarks in a deeper location. Morphometric measurements were performed between the surgical landmarks (Macewen's triangle) and the sigmoid sinus plate.
Methods: 30 dry human adult skulls were investigated. Three marks were allocated on the left and right sides of the norma lateralis of these skulls namely the tip of the mastoid process, the asterion, and the region of the suprameatal triangle (posterior border).
Results: The measurements of (D1+D2), (D1+D3) and (D2+D3) showed statistical significant differences. The correlations of D1, D2 and D3 on the right and left sides showed statistical significant differences
Conclusion: The assessment of the depth of sigmoid sinus plate may be used as a mark that possibly point toward avoidance of the bleeding possibility during mastoidectomy. The suprameatal approach eliminates the need for mastoidectomy and avoids the damage of sigmoid sinus plate. If the depth can be assessed by measuring D1 and D2 on lateral X-rays of the heads as this study prove that we can avoid the dangerous complications which occur in the normal mastoidectomy.

Keywords: Suprameatal triangle, mastoidectomy

Background: Prescription order and information on it; represent the key for reach of safe and effective medications to the patient, and the clarity of its information is important to prevent medications errors that may be lethal to the patient.
Objectives: Comparison of samples of prescriptions and their contents of physician; patient related information with standard information provided by WHO prescription writing.
Methods: A sample of prescription orders received from private clinics by community pharmacies in Al-Ashar of Basra city. The prescriptions were taken from several pharmacies randomly and about 1000 prescriptions were collected. The prescriptions represent about 40 physicians in different specialties and for a period extended from November 2009 until March 2010. The information of prescriptions were analyzed by simple statistics for calculation the percentage of adherence for WHO guideline in prescription writing.
Results: The prescription information includes; prescriber’s name, address, telephone number and signature were on 97.5%, 74.8%, 4.3% and 96.5% of prescriptions respectively. The patient’s name, age and weight were on 96.6%, 15.5% and 2.2%. No prescription contained the patient’s address and gender. The strength of medication and dose units were included in 1.7% and 1.4% of prescriptions. The prescriptions had only quantity indicated 2.4% and more than one third instructions for patient use (36.1%); the diagnosis was not included in more than two-thirds (85.2%). The prescriber’s handwriting was illegible in 16.3% of prescriptions.
Conclusions: There is severe deficiency in fitness of prescriptions written by the physician to WHO guidelines; so we recommend for administrative monitoring program for fitness of prescriptions to these guidelines and start education about this guideline for prescribers.

Key words: Prescriptions, WHO, prescriber, patient, prescriber’s name, address, telephone number, signature