IRAQI JOURNAL OF MEDICAL SCIENCES

The gold standard method for nerve reconstruction involve the use of autologous graft, however, major drawbacks included limited availability, donor-site morbidities and requirement of multiple surgeries. Researchers worldwide had aimed to produce alternative tissue-engineered synthetic nerve conduits, but development had been slow, with only four FDA (US Food and Drug Administration) approved conduits for human subjects in the past 50 years of research. This slow progress may potentially be related to the lack of standardized guideline for nerve conduit testing. This review aims to summarize the methodologies used in the testing of nerve conduits in vivo and in vitro. The review demonstrated a lack of consensus and consistency in the study methodologies, including various measures of functional assessment, over 8 different types of animal species, 17 peripheral nerves and varied gap lengths ranging between 1 mm and 90 mm. In vitro models demonstrate more consistencies in testing models, but have been discarded in recent years for functional nerve testing, and had been employed for preliminary testing in nerve toxicity and compatibility instead. This study emphasizes the urgent need for a more standardized approach for in vivo testing, and the need to re-utilize in vitro studies for functional testing purposes.

Background:Proximal isovelocity surface area method and mitral regurgitatant jet estimation (with its ratio to left atrium) are reliable methods for estimation of mitral regurgitation severity aiding in management strategy, precluding the use of other invasive procedures for assessment (e.g. left ventricular angiography).
Objective:To study the usefulness of proximal isovelocity surface area and regurgitant jet size (with its ratio to left atrium) to determine the severity of mitral regurgitation in comparison with left ventricle angiography.
Methods:Forty patients with mitral regurgitation planned to do left ventriculography to assess mitral regurgitation severity were studied. Estimation of mitral regurgitatant jet (and its ratio to left atrium) by color tracing of maximal jet area and estimation of effective regurgitant orifice, regurgitant volume and regurgitant fraction by proximal isovelocity surface area method were reported within 24-48 hours after angiography.
Results:The effective regurgitant orifice, regurgitant volume and regurgitant fraction in correlation with angiographic grades were 46.67±27.mm2 (P < 0.0001); 55.3 5±27.67 ml (P < 0.0001) and 57.41±20.63 % (P < 0.0001) respectively. The thresholds for severe mitral regurgitation (grade 4) were 60 mL, 52%, and 42.5 mm2 for regurgitant volume, regurgitant fraction, and effective regurgitant orifice, respectively. Significant correlation (P = 0.021) of mean mitral regurgitant/left atrium ratio with the corresponding angiographic grade in central mitral regurgitation, while no significant correlation (P = 0.799) was found in eccentric mitral regurgitation.
Conclusion:Proximal convergence method and estimation of mitral regurgitant size (ratio to left atrium) by color tracing of maximal jet area (in central jet) allows accurate estimation of the mitral regurgitation severity.
Keywords:Proximal isovelocity surface area method, effective regurgitant orifice, mitral regurgitant volume

Background:Ureteric stone is quite common; management involve medical and surgical intervention. Surgically the uretroscope is the most commonly used instrument.
Objectives:This study was done to demonstrate the safety and efficacy to fragment and remove ureteral calculi with an ureteroscope using Holmium laser and render patients stone free with a single procedure without the need for ureteral stenting.
Methods:One hundred and twelve patients aged between 4 to 63 years, who proved to have ureteric stones regardless the size or location of those stones, where subjected to ureteroscopy procedure under spinal or general anesthesia, and Holmium laser was used to fragment the stones.
Results:The majority (92.86%) of those patients was stone free with single session, no stent was left.
Conclusion:The stone can be disintegrated and achieving stone free state in single session and no stent was needed.
Key words:Laser, Holmium, ureteroscope, stent, stone

Background:The incidence of ophthalmologic abnormalities among the deaf children is high, compared with the hearing population of the same age.
Objective:The main objective of this study was to determine the ophthalmologic abnormalities among the students attending deaf and dumb's school in Aden city (Yemen).
Methods:This was a cross sectional descriptive study carried out from October 2012 to March 2013 in a school for the deaf and dumb in Aden (Yemen). All students who consented to participate in the study, were enrolled and subjected to a detailed ophthalmic examination, including visual acuity (VA), ocular motility, slit-lamp and fundus examination conducted by a qualified ophthalmologists.
Results:A total of 138 deaf students (90 males, 48 females with a male to female ratio of (2:1) were included in this study. A high proportion of the students (92; 66.6%) were in the age group >14 years. Normal eye examination was found in (51; 36.9%), ocular abnormalities found in (87; 63.1%), with some students having multiple abnormalities. Refractive errors comprised the leading abnormality in 41.3%, retinal pigment epithelium patches was found in 10.9% and Warrdenburg syndrome in 5.8%. Twelve eyes 4.4% exhibited VA < 6/18).
Conclusion:Ocular abnormalities in deaf students are remarkably high which indicate the importance of early ophthalmologic examination in order to facilitate adequate integration of the deaf student as a useful and productive member in the society.
Key words:Deafness, ocular abnormalities, refractory errors; visual impairment, Yemen.

Background:Guillain Barré syndrome (GBS) is an acute post infective autoimmune polyradiculo-neuropathy; it is the commonest polyneuropathy causing respiratory failure. A lot of studies suggested certain GBS clinical and preclinical features anticipate and predicate the neuromuscular respiratory failure and can accurately assess the progression to mechanical ventilation; bulbar muscles involvement, severity of weakness of upper and lower limbs, bilateral facial muscles involvement and autonomic nervous system involvement were the main features associated with progression to mechanical ventilation.
Objectives:To assess demographic, clinical and para clinical features and their relation with the progression of GBS to respiratory failure.
Methods:Clinical and paraclinical predictors of impending respiratory involvement and requirement for mechanical ventilation were studied in 40 GBS patients aged 12-57 years (28 males and 12 females).
Results:Ten (6 female/4 male) patients (25%) were admitted to the intensive care unit and received mechanical ventilation. Younger age, female gender and rapid disease progression in first 3 days were associated with respiratory involvement and subsequent ventilation. Bulbar weakness, bilateral facial palsy, poor digit counting (<10/1 breath) were the strongest indicators of impending respiratory failure. In combination they were found in 90% of ventilated patients. Dense weakness (power grade ≤2), weak neck flexion and axonal electromyography also showed significant risk for mechanical ventilation. Other parameters (autonomic dysfunction, antecedent gastrointestinal and respiratory illness, earlier upper limbs weakness and pain) showed no statistical significance in our study
Conclusion:Respiratory failure in the course of GBS can to some extent, predicted depending on clinical information. Respiratory failure was associated with younger age, female gender, rapid progressive weakness, bulbar weakness. Facial weakness. Dense weakness, weak neck flexion, poor digit count and axonal neuropathy.
Keywords:Guillain Barre syndrome, respiratory failure, bulbar weakness, mechanical ventilation.

Background:Erectile dysfunction is the inability to attain or maintain an erection sufficient for satisfactory sexual performance. There is a very high prevalence among dialysis patients. Many factors play a role including the disease itself and dialysis.
Objective:To identify the rate of erectile dysfunction in uremic patient undergoing haemodialysis and to find the association between the erectile dysfunction and many confounding factors.
Methods:All male patients of end stage renal disease were kept on maintenance haemodialysis therapy. Patients were divided into two groups according to the International index of erectile function-5, first group with erectile dysfunction with score of 21 and less, the second group without erectile dysfunction with score of 22 and more.
Results:The percentage of erectile dysfunction in the study sample was (84.9%). Factors responsible for erectile dysfunction are diabetes mellitus (73.3%), increasing age (75.5%) of patients, high predialysis urea level (82.2%), smoking, hepatitis B and C virus infection, systolic blood pressure, albumin, creatinine, haemoglobin and the duration of dialysis are not related.
Conclusion:Majority of the patients with end stage renal disease on maintenance haemodialysis have higher rate of erectile dysfunction. Major factors responsible for erectile dysfunction are diabetes mellitus, increasing age and high predialysis urea.
Keywords:Haemodialysis, erectile dysfunction, International index of erectile function-5.

Background:Pedicular screw fixation surgery for thoracolumber disorders is well established surgical method to treat instability due to different etiologies due to trauma, infection, tumor as well as spondylopathic deformity.
Objective:To evaluate surgical modalities in the treatment of lumbothoracic disorders.
Methods:Prospective study of 30 patients 6 lower dorsal trauma, 2 treated by screw and 4 by decompressive laminectomy and bone graft using rib, 4 spondylolesthsis treated by screw and 8 cases by decompessive laminectomy and fusion, 4 spondylosis treated using screw and 8 treated only decompressive and foraminotomy .
Result: Spinal fusion using pedicle screws has become popular worldwide in treating a variety of disorders of the spine. Treatment of thoracolumbar fracture with pedicle screws at injury level is easy and worthy. Compared to the lumbar region, the insertion of thoracic pedicle screws remains a challenge, despite of modern technology and computer assistance especially in the upper thoracic spine, where misplacement rates of up to 40% CT-navigation leading to the conclusion that pedicle screw instrumentation in the middle and upper thoracic area should be carried out with the help of navigation only. The availability of an intraoperative CT seems to be of particular importance. An accurate assessment of screw positions becomes hereby possible without any significant time delay and with utmost accuracy.
Conclusions:Transpedicular fixation of thoracolumbar and lumbar spine fractures has become a frequently used technique. Transpedicular screw fixation provides the greatest stability in the unstable spine.
Keyword:Pedicle screw, accuracy, lower dorsal trauma, hydatid spine

Background:Misoprostol, a synthetic prostaglandin analogue, has become the leading mean for terminating the pregnancy. It is not clear, however, whether misoprostol is a safe abortifacient after thirteen weeks gestation in women who have a uterine scar from a previous lower segment caesarean delivery.
Objective:To evaluate the efficacy and maternal side effects of misoprostol used vaginally for second trimester termination in women with a single previous lower segment caesarean delivery.
Method: Sixty participants with a history of previous one lower segment caesarean delivery underwent pregnancy termination for missed abortion or lethal fetal anomaly between 14-28 weeks gestation using intra vaginal misoprostol. The dose of which was 400 microgram up to 20 weeks gestation and 200 microgram thereafter, repeated every 4 hours with a 12 hours nightly rest from misoprostol application up to a maximum of 72 hours. Women having termination for similar reasons but lacking a history of cesarean section served as a control group.
Results:Abortion rate was 96.66% in the study group and 95% in the control group. The mean induction to abortion interval was 21.81±9.51 for the study group and 22.21±8.52 for the control group with no significant difference between the two groups. No cases of uterine rupture occurred in either groups.
Conclusion:Inducing abortion with lower misoprostol doses appear to be safe and effective throughout the second trimester in women with a single previous lower segment cesarean delivery.
Keywords:Second trimester, Misoprostol, Termination of pregnancy

Background:Recent evidence has demonstrated the complex function of adipose tissue and gastric cells as an endocrine organ through release of hormones into the blood stream and involved in physiological activities of the body; of them is ghrelin. The consequences of insulin resistance manifest at many levels and in many metabolic processes, producing a cluster of homeostatic abnormalities referred to what is called metabolic syndrome.
Objectives:To evaluate and compare the possible effects of using metformin or glimepiride on serum concentrations of ghrelin, leptin and insulin resistance in obese type 2 diabetic patients in Basra, Iraq.
Methods:Forty type 2 diabetic obese patients and twenty healthy subjects were studied. The patients were divided into 2 groups (each of 20 patients); group 1 on glimepiride therapy while group 2 on metformin treatment. Blood samples were taken after at least 8 hours fasting for measurement of serum glucose, leptin, ghrelin and insulin.
Results:Ghrelin levels were significantly lower in the two patient groups with greater significant reduction in metformin group. The highest serum insulin concentration and insulin resistance levels were clearly reported in glimepiride treated group as compared to control and metformin treated group. Leptin levels show no significant differences in all studied groups.
Conclusion:Metformin treatment associated significantly with improved insulin sensitivity; insulin resistance associated significantly with decreases ghrelin concentration. Ghrelin is negatively correlated with leptin and obesity while positively correlate with insulin resistance. Our data support the role of body weight as the major determinant of circulating leptin levels.
Keywords:Diabetes mellitus, obesity, ghrelin, metformin, leptin.

Background:Staphylococcus aureus is a ubiquitous bacterium that is generating increasingly bad press coverage due to its propensity to adopt a pathogenic lifestyle in hospital and community settings. Lipases catalyze both the hydrolysis and synthesis of triacylglycerols. Many of these enzymes are characterized by stability at high temperatures and in organic solvents.
Objective:Purification of the enzyme by using the conventional methods and characterization of lipase.
Methods:Purification included: extraction of the enzyme, the precipitation of the enzyme by ammonium sulphate, dialysis, ionic exchange chromatography by using DEAE-Cellulose (Diethylaminoethyl-Cellulose), and gel filtration by using Sephacryl S-200. Equal amounts of purified lipase solution were mixed with PBS (Phosphate buffer sodium) solutions of different pH (4,5,... until 10) and incubated in a water bath at 37 oC for 30 minutes, then the lipase activity was estimated. The purified lipase was incubated at different degrees of temperature (5, 15, ...until 85 oC) for 30 minutes. The molecular weight was determined by gel filtration chromatography.
Results:The results revealed that the crude enzyme solution had a total protein concentration of 21.3 mg/ml and an enzyme activity of 257 µmole/ml. The lipase was precipitated by ammonium sulphate with 50-75%. Then the protein concentration was 4.7 mg/ml while the enzyme activity was 812 µmole/ml. Revealed that the protein concentration was 2.3 mg/ml and enzyme activity was 1020 µmole/ml. This revealed that the protein concentration was 0.9 mg/ml and the enzyme activity was 1669 µmole/ml.
Conclusion:Lipase was purified to a considerable homogeneity and the characterization experiments revealed that the enzyme showed considerable heat stability and was optimally active at alkaline pH.
Key words:Lipase, ion exchange chromatography, gel filtration chromatography, molecular weight.

Background:Studying some of fertility-related hormones is of major benefit to identify the causative factors and to search for an appropriate treatment. Anti-müllerian hormone regarded as quantitative markers for ovarian reserve. Basal follicular stimulating hormone provides a picture of how well the hypothalamic-pituitary-gonadal axis is functioning and is the most commonly used tests for predicting success in intracytoplasmic sperm injection (ICSI) treatment.
Objective:To evaluate the level of serum and follicular fluid antimüllerian hormone, serum follicular stimulating hormone and antral follicle count and its relation to ICSI outcome in infertile patients.
Methods:Seventy four infertile women were selected randomly from those attending the Fertility Centre, Al-Sader Teaching Hospital, Al-Najaf /Iraq. Ultrasound was performed for antral follicle count and their measurement at cycle day 2. Hormonal analysis is done for serum follicular stimulating hormone at cycle day 2 and for serum and follicle fluid antimüllerian hormone at day of ovum pickup.
Result: The fertilization rate was positively correlated with follicular fluid antimüllerian hormone (r = 0.303; P = 0.048) but not with serum follicular stimulating hormone, serum antimüllerian hormone and antral follicle count.
Conclusion:Follicular fluid antimüllerian hormone level was positively correlated with fertilization rate, while serum antimüllerian hormone level does not affect the fertilization rate in ICSI cycle. The basal follicular stimulating hormone level do not relate to fertilization rate, and the same thing regarding antral follicle count.
Keywords:Anti-müllerian hormone, follicular stimulating hormone, antral follicle count, intracytoplasmic sperm injection.

Background:Accurate and sensitive detection of bladder cancer is important to diagnose this deadly disease at an early stage, estimate prognosis, prediction the response to treatment and for monitoring the recurrence. In past few years, laboratory diagnosis and surveillance of urinary bladder cancer have improved significantly. Although, urine cytology remains the gold standard test, many new urinary biochemical markers have been identified.
Objectives:To evaluate the value of fibronectin in serum and urine to detect bladder cancer in different grades and stages.
Methods:Thirty five patients diagnosed as bladder cancer with mean age 61.94±11.66 years and thirty five aged-matched healthy volunteers as control group were included in this study. Serum and urinary fibronectin were measured by ELISA technique.
Results:The mean±SEM serum and urine levels of fibronectin in patients with bladder cancer (33.11±1.90 µg/ml; 33.08±1.12 ng/ml respectively) were significantly higher than the levels in control group (8.57±1.10 µg/ml; 7.58±1.00 ng/ml, respectively). When using a serum fibronectin concentration of 25.65 µg/ml as a cutoff value for the diagnosis of bladder cancer, sensitivity was 71.4%, specificity 100%, the positive predictive value was 100% and the negative predictive value 77.78%, and the sensitivity and specificity of urine fibronectin were (94.3%, 97.1% respectively); when using a urine fibronectin concentration of 20.00 ng/ml as a cutoff value for the diagnosis of bladder cancer. The positive predictive value was 97.05%, and the negative predictive value was 94.44%.
Conclusion:The measurement of fibronectin level in serum and urine is useful in discriminating bladder cancer patients from normal subjects.
Key words:Serum and urinary Fibronectin, Bladder cancer.

Background:Omentin-1 is fat deposition-specific adipokine that is highly and selectively expressed in visceral adipose tissue. Low circulating levels of Omentin-1 have been associated with endothelial dysfunction and cardiovascular disease. Abnormalities of lipid metabolism associated with subclinical and overt hypothyroidisms patients, low Omentin-1 level can affect risk factors for cardiovascular disease.
Objective:To determine the differences in the levels of Omentin-1 in middle age women with subclinical and overt hypothyroidisms and correlate its level with parameters which considered risk factor for cardiovascular disease.
Methods:Ninety middle age women divided into three groups as follows: group I consisted of 30 healthy women as a control subject, group II comprised 30 women with subclinical hypothyroidisms, group III include 30 women with overt hypothyroidisms, serum of Omentin-1, high sensitive c-reactive protein and lipid profile levels were evaluated in patients and control groups.
Results:Serum omentin-1 levels were significant decreased in patients with subclinical and overt hypothyroidisms compared with control group. Significant negative correlation between omentin-1 and thyroid-stimulating hormone, high sensitive c-reactive protein, total cholesterol, atherogenic index in patients was found. Significant positive correlation was observed between Omentin-1 and high-density lipoprotein in the patients.
Conclusion:we conclude that serum Omentin-1 levels were decrease in middle age women with hypothyroidism and its correlate with altering lipid profile, high levels of atherogenic index and high sensitive c-reactive protein, all of these conditions is correlated with cardiovascular disease, so Omentin-1 in hypothyroidism patients is a risk factor for cardiovascular disease, our suggestion that possible follow up serum lipid profile and omentin-1 monthly for middle age women to prevent cardiovascular disease.
Keywords:Omentin-1, lipid profile, hypothyroidism disease

Background:There is an increasing interest in measuring quality of life in clinical settings and in clinical trials. None of the commonly used quality of life (QOL) instrument had been validated for use postnatally.
Objectives:To assess the psychometric properties of the 26-item of World Health Organization Quality of Life –BREF WHOQOL-BREF among women following childbirth and to identify women with postnatal depression by using Edinburgh Postnatal Depression Scale EPDS.
Methods:Cross sectional study was carried out during the period from the 1st of December 2013 to 31st March 2014 in Baghdad, Iraq. A total number of 558 women were asked within first 48 hours after delivery to complete a questionnaire form which contains three elements (maternal socio-demographic and obstetrical variables, the WHOQOL-BREF which was developed by the WHO and EPDS).
Result: The study showed that the prevalence of postnatal depressive symptoms among 558 mothers was 33.5%. Most pregnant women included in study had fair QOL scores on all domains at late pregnancy. Thus, the study concluded that women who experienced medical diseases such as hypertension, diabetes and other diseases had a lower HRQOL at late pregnancy than those who were apparently healthy. Also, woman with newborns complications' (respiratory distress, low birth weight and other complications) had been experienced significant declines in psychological health.
Conclusion:The WHOQOL-BREF is well-accepted instrument in this sample and may be used in postnatal clinical settings or for assessing intervention effects in research studies.
Key words:Quality of life, postnatal depression, adverse pregnancy outcome.

Background:Methicillin-resistant Staphylococcus aureus is a major cause of serious nosocomial infections and it is very important to have a reliable test to detect these bacteria. mecA encodes the penicillin binding protein 2a, which is associated with staphylococcal methicillin resistance.
Objective:The study was to determine the frequency of methicillin-resistant Staphylococcus aureus in different specimens from Iraqi patients and to genetically characterize and type the samples of methicillin- resistant Staphylococcus aureus through the detection of mec A gene.
Methods:Sixty clinical isolates of Staphylococcus aureus were submitted to DNA extraction. Genomic DNA was submitted to conventional polymerase chain reaction assays, employing MR1-MR2 primers (primer set). The results were compared to the cefoxitin disks agar diffusion method.
Results :Fifty seven of the sixty isolates showed positive results for mecA amplification while three isolates (5%) showed negative results for mecA gene.
Conclusion:Good correlation between the mecA gene detection by PCR and the cefoxitin disk diffusion methods was obtained.
Key words:mecA gene, Staphylococcus aureus, methicillin resistance Staphylococcus aureus

Coccidioidomycosis is caused by the dimorphic fungi of the genus Coccidioides (C. immitis and C. posadasii), which are endemic in desert regions of the southwestern United States, and Central and South America. Meningitis is the most lethal complication of coccidioidomycosis and thus is crucial to recognize. A 64 years old diabetic patient suffering from meningitis was studied. Cerebrospinal fluid (CSF) sample was collected by lumber puncture technique under aseptic conditions from female patients who admitted to Baghdad City hospital, conventional methods included cell count and differentiation, biochemical analysis, staining and culturing of CSF sample was applied. CSF smear with lactophenol cotton blue, revealed a typical picture of Coccidioidis spp. This is the first case reported in Iraq. In conclusion, fungal meningitis should be included as one of the most causes in chronic meningitis in Iraq.