IRAQI JOURNAL OF MEDICAL SCIENCES

Clinical judgment and long experiences, reading textbooks and scientific journals, in addition to conferences and personal beliefs are generally sources for physician management plan, however; errors in clinical reasoning and gaps in evidence were described since long time. For which evidence based strategy had been applied in medical practice aiming to improve the decision-making skills of individual physicians to individual patients. Evidence base medicine (EBM) is a systematic approach to clinical problem solving which make use of the best research evidence in term of clinical expertise and patient values.
Keywords: Evidence-based medicine

Background:Primary total knee arthroplasty (TKA) is technically demanding surgery, which if it is done perfectly can give excellent patient satisfaction and pain relief. Still abnormal patellar tracking is the most common complication of primary TKA (24%) and it is the most common cause of revision.
Objective:To emphasize on the effectiveness of adherence to certain surgical steps (peroperatively) and to which extent these steps can reduce the incidence of peroperative abnormal patellar tracking in primary TKA.
Methods:A prospective descriptive study was conducted in Al-Imamein Al-Kadhimein Medical City from May 2011 to December 2014; it involves 67 patients who underwent unilateral total knee replacement for different pathology and variable knee deformity. Step wise surgical procedure for primary TKA insisting on certain technique and tricks to achieve perfect TKA and finally checking the patellar tracking preoperatively using no thumb test and towel clips test.
Results: NEXGENR posterior cruciate substitution design used in 62 patients (92.5%) and condylar constrained knee in 5 patients (7.5%) and abnormal patellar tracking occurred preoperatively only in 1 patient (1.4%).
Conclusion:Strict adherence to surgical procedures keeping in mind certain factors, which should be fulfilled is essential for successful peroperative patellar tracking, while postoperative assessment required different investigation like computed tomography or dynamic radiographs to ensure this good patellar tracking and improving the outcome of primary TKA in our country.
Keywords:primary TKA, peroperative patellar tracking

Background:Coronary artery disease (CAD) is one of the most common diseases in the world. Acute coronary syndromes (ACS) represent the acute life-threatening phase of CAD. Epidemiology and management of ACS patients differ a lot between countries and there is a wide gap between guidelines and clinical practice.
Objective:To assess contemporary data on clinical characteristics and outcomes of patients with ACS in the Medical City Complex and to evaluate adherence to the guidelines’ recommended treatment.
Methods:This is a descriptive study registry, started on January 2014 to June 2014, and involved 348 patients with ACS in the Medical City Complex.
Results:The mean age of this study's population was (60.3±11.2 years), ranging between 29 to 90 years old. Most of patients were males (61%). Only 233 (67%) patients have typical angina. Symptom onset-to-admission time was delayed (≥ 12 hours) in 65% of patients. The final diagnosis was: ST elevation myocardial infarction (STEMI) in 126 (36.2%), non ST elevation myocardial infarction (NSTEMI) in 40 (11.4%), and unstable angina (UA) in 182 (52.3%) of patients. Electrocardiography was normal in 29% of patients with UA and 10% of patients with NSTEMI. Anterior territory was the most common location of ischemia (77%). Hypertension (47.9%) was the most significant risk factor followed by diabetes mellitus (41.6%) and smoking (31.8%). Reperfusion therapy for patients with STEMI was applied in 73(57%) patients: 56 (44.4%) by thrombolytic therapy, 24 (19%) by percutaneous coronary intervention (PCI) and 3 (2.3%) by emergency CABG. Overall in-hospital mortality was 7.7% (15%, 7.5% and 2.7% for STEMI, NSTEMI, and UA respectively).
Conclusion:There is lack of awareness of ischemic symptoms among our patients. There is high incidence of risk factors that can be modified by primary and secondary measures. There is underutilization of invasive management. We have a high mortality rates in patients with ACS.
Keywords:Acute coronary syndromes, registry, in-hospital outcome

Background:Oral Lichen planus (OLP) is chronic mucocutaneous disorder with or without involvement skin, of unknown etiology. Lichen planus (LP) is T-cell-mediated chronic inflammatory disease of the stratified squamous epithelium. It can affect oral mucosa, skin, esophagus, nasal mucosa, larynx, genitalia, urinary tract, hair follicles and the eyes. Latterly has been focused on presence association between OLP and hepatitis C virus (HCV) infection, but this relation is not stable, since the prevalence of this virus in patients varies depended on studies, ranging from 0% to 67.8%.
Objective:This study was established to investigate the relationship between the OLP and HCV infection in Iraq and to detect the virus by Real-time polymerase chain reaction (RT-PCR).
Methods:Blood samples were collected from 62 patients with OLP and controls to detect the HCV in those patients by using one step anti-HCV test, ELISA test and RT-PCR.
Results:The current study revealed that the early detection of HCV by one step Anti-HCV for all OLP patients was negative and by ELISA showed that four patients (12.5%) of OLP were positive for HCV. While using RT-PCR found that only one patient (3.1%) was positive for the presence of the virus.
Conclusion:There was not relationship found between OLP and HCV infection in Iraqi patients.
Keywords:Oral lichen planus, HCV, RT-PCR, ELISA

Background:Obesity has become a major worldwide health problem and therefore, the associated morbidity, mortality and both medical and economical costs are expected to increase as well. Obesity increases cardiovascular risk via risk factors such as triglycerides (TG), high LDL cholesterol, low HDL cholesterol, elevated plasma glucose and insulin concentrations.
Objective:To investigate the effect of metformin and betahistine along with lifestyle change on lipid profile in obese women in Iraq.
Methods:This study was carried out on 78 female patients with age range of 18-50 years who were allocated into three groups: Group 1: treated with oral metformin 850 mg twice daily with lifestyle change for 12 weeks. Group 2: treated with betahistine 32 mg 3 times daily with lifestyle change for 12 weeks. Group 3: treated with placebo 500 mg twice daily with lifestyle change for 12 weeks to serve as control. Complete history was taken, in addition to clinical examination to meet inclusion criteria. Serum transaminases (ALT+AST) and estimated glomerular filtration rate (GFR) were estimated at baseline to exclude hepatic or renal abnormalities.
Results:Each metformin and betahistine, along with lifestyle intervention highly significantly reduced total cholesterol level, LDL-C level, TG and VLDL level, and increased plasma level of HDL after 12 weeks in obese women with disturbed lipid profile compared to pre-treatment values, and the changes elicited by metformin and betahistine (plus lifestyle change) were highly significant compared to placebo (lifestyle change alone).
Conclusion:The results obtained in this study clearly demonstrated the beneficial effect of using metformin or betahistine to obese women with dyslipidemia and confirmed the role of pharmacotherapy in targeting the lipid metabolism changes accompanying obesity.
Keywords:Obesity, dyslipidemia, lifestyle change, betahistine, metformin

Background:Candida albicans (C. albicans) has emerged as a potentially pathogenic fungus rather than benefit mucosal commensal in patients with pulmonary diseases. Although respiratory candidiasis secondary to pulmonary tuberculosis has been reported in the past, it has gained more relevance recently due to increased use of broad spectrum antibiotics and immunosuppressive drugs.
Objective:To detect C. albicans in sputum samples from patients with pulmonary diseases using conventional and molecular methods.
Methods:One hundred sputum samples obtained from patients with pulmonary symptoms were included in this study. Sputum samples were dispensed into three specimen parts; the first one was applicated for cultured on Sabouraud dextrose agar at 37 °C for 48 hrs and then the purified colony of Candida underwent biochemical tests including API Candida strips, and germ tube. The second part was undergone direct gram stain, while the third part was applicated for DNA extraction and then molecular diagnosis with PCR technique using specific primers.
Results:Culture result revealed 43 positive samples for Candida species out of 100 samples. Among these positive samples, 23 (53.5%) were positive for C. albicans in each of culture, germ tube and API. Molecular test revealed an amplicon with 538bp fragment of phospholipase gene from the same 23 samples.
Conclusion:C. albicans is highly prevalent among patients suffering from bronchopulmonary symptoms. The molecular and conventional methods gave concomitant results as detection tools for the diagnosis of such microorganisms.
Keywords:Candida albicans, phospholipase B gene, sputum.

Background:Human cytomegalovirus (HCMV), a member of herpes virus family, is associated with different cancers in humans, including breast and colorectal cancers.
Objectives:To shed light on the possible oncogenic mechanisms exerted by HCMV on tissues at the genetic level.
Methods: HCMV was propagated in medical research council-5 (MRC-5) cell line and cytopathic effects of HCMV were checked for confirming infection. Oncogenic mechanism that exerted by HCMV was screened using high-throughput real-time qPCR microarray to investigate the mRNA expression of 983 genes in 16 gene families associated with oncogenesis in human cells.
Results :Twenty differentially expressed genes. Upregulated genes (SCGB1A1, MAP2K3, ITGB3, TGFB1, PTN, MMP2, AKT1, AKT2, BCL2L10, CKS1B, SERPINB4, CASP4, TOLLIP, BCL-2, SERPINB5) were mostly of oncogenic or oncopromoting activity, involved mainly in MAPK, PI3K/Akt, inflammation, and angiogenesis pathways while downregulated genes (STAT3, BAK1, BLM, RB1, and IGF2R) were mostly tumor suppressor, proapoptotic, and DNA damage repair genes.
Conclusion:The current study revealed that HCMV might have an oncogenic or oncomodulating activity on normal infected cells by different intracellular pathways.
Keywords: Cytomegalovirus, oncogenic viruses, mrc-5, Waffergen, SmartChip Real-Time PCR System.

Background:Sickle cell disease is hematological disease that affect the endothelial function. The hemoglobinopathy in this disease triggers erythrocyte polymerization and the sickling process leads to vascular occlusion, tissue hypoxia and subsequent reperfusion injury, thus inducing inflammation and endothelial injury.
Objective:To assess the value of brachial artery diameter measurement as a predictor of the state of endothelium in sickled individuals.
Methods:Thirty patients with sickle cell disease (15 females and 15 males) with a mean age of (27.0±8.9 yr) and 30 healthy controls (18 females and 12 males) with a mean age of (29.7±9.1 yr) participated in the study. Assessment of endothelial function done by studying physiological parameters, which included flow-mediated dilatation and endothelial-independent dilatation of the brachial artery depending on the measurement of the diameter of the blood vessel.
Results:Endothelial independent dilatation was significantly lower in sickle cell disease patients (21.71±6.96) in comparison with that of the control group (26.81±6.31) despite the findings that both base line brachial artery diameter and intima media thickness were not significantly different between both groups.
Conclusion: Brachial artery diameter assessment is a useful noninvasive predictor of endothelial dysfunction in patients with sickle cell disease. The reproducibility of the test in addition to its low cost and being free of biological hazards makes it optimum for assessing the state of the endothelium and may be used to monitor the response to treatment.
Keywords:Sickle cell disease, flow-mediated dilatation, endothelial-independent dilatation, brachial artery diameter.

Background:Obstructive jaundice poses diagnostic and therapeutic challenges to practicing physician gastroenterologist and general surgeons.
Objective:To highlight the etiological spectrum, treatment outcome of obstructive jaundice endoscopically by Endoscopic Retrograde Cholangiopancreaticography (ERCP).
Methods:It is a cross sectional case series study included 140 patients who presented with obstructive jaundice and dilated biliary system. They managed at Gastroenterology and Hepatology Center in Al-Imamein Al-kadhimein Medical City, Baghdad, Iraq from April 2012 to April 2014. All the patients were offered abdominal sonagraphy (U/S), magnetic resonance cholangiopancreaticography (MRCP) and upper endoscopy, as well as other laboratory work up, in order to prepare them for either palliative or curative treatment by the ERCP. Both success rate and complications were reported.
Results:Common bile duct (CBD) stones were confirmed in 100 patients (71.4%) (56 female and 44 male) while pancreatic-biliary tumors found in 25 patient (17.8%) (15 male and 10 female) as pancreatic tumor in 11 patients, periampulary and ampulary tumor in 5 patients and cholangiocarcinoma in 4 patients while the rest due to metastasis. Benign causes as biliary fibrosis was seen in (10.8%). The success rate of ERCP treatment was 87.2%, but complications represented 6.4%. All of them were mild and reported within 24 hours.
Conclusion: CBD stones are the predominant cause of benign cause of surgical obstructive jaundice, while the carcinoma of head of pancreas is the commonest concerning malignant causes. ERCP is very safe and effective procedure in the management.
Keywords: CBD stone, Obstructive jaundice, ERCP, gallstone.

Background:Despite the high incidence of coincident spinal degenerative changes due to the high dynamic interplay between adjacent spinal elements leading to the clinical pain syndromes, yet the diagnostic approach and therapeutic options are still diverse and often inconsistent.
Objective:To evaluate the short and long term outcome of two different surgical approaches in the treatment of lateral lumbar disc prolapse associated with spondylosis.
Methods:Twenty patients presenting with a comparable complaints of radicular low back pain falling in the age group of 40-50 who attended the outpatient clinic in Science and Technology Hospital in Sanaa from 1st January 2008 to 1st of June 2009 and who were diagnosed to have lumbar lateral disc prolapse with mild spondylotic changes in need for surgery were divided into two groups. Group A offered microdiscectomy while group B offered standard discectomy. They were followed up and evaluated both clinically and radiologically at fixed postoperative intervals (day of discharge, three months, and one year post operatively).
Results:It has been revealed that most of cases showed improvement of their presenting complaints due to the acute decompression offered to the neural tissue by either approach though was initially much higher with the minimally invasive microdiscectomy. However, the picture changed at three months interval where (30%) of patients from group A had complaints, two cases (66.6%) of the incompletely responding cases presented with new symptoms mostly due to incompletely treated spondylotic changes and 1 patient (33.3%) of the incompletely responding cases presented with persistence of symptoms due to incomplete disc removal. In contrast, only one case from group B had the persistence of symptoms, which was due to the effect of spondylosis. With further follow up at 1 year interval 40% of cases from group A had complaints mostly in form of bilateral radiating pain due to incompletely treated spondylotic changes, while only (20%) from group B had complaints either as ipsilaterally radiating pain due to incomplete disc resection or as bilaterally radiating pain due to postoperative adhesions.
Conclusion:Treatment with the first modality though has the advantages of a shorter duration of surgery, less invasion, less postoperative stay at hospital and comparable clinical response on short term follow up to that of second group, yet data at long term follow up showed that it is associated with a higher incidence of recurrence or incomplete resolve of the presenting complaint as well as evident evolving radiological complications in contrast to treatment by the second modality.
Keywords:Lateral disc prolapse, spondylosis, micro discectomy, standard discectomy.

Background: Nasal polyposis and chronic rhinosinusitis is much debated subject. Generally speaking, nasal polyposis should probably be regarded as one form of chronic inflammation in the nose and sinuses, which is indeed part of the spectrum of chronic rhinosinusitis. Nasal polyposis is the ultimate form of inflammation for unknown reasons; polyps preferentially develop in subtypes of inflammatory diseases. Allergic fungal rhinosinusitis (AFRS) is defined the consequence of immunocompetent patient whenever there is allergy to fungus.
Objective: To determine the frequency of allergic fungal rhinosinusitis among patients having nasal polyposis.
Methods: A prospective study of 60 selected patients with nasal polyposis was studied at Al-Imamein Al-Kadhimein Medical City. After thorough history and full ENT examination, all patients sent for computed tomography (CT) scan of the nose and paranasal sinuses. Patients who needed surgical treatment, the specimens were sent for histopathological analysis to identify the fungi. The diagnosis of allergic fungal sinusitis was based on analysis of clinical, radiological, and laboratory investigations.
Results: The mean age was (41.3±13.7) years; male to female ratio was (1.7:1). Both nasal obstruction 54 (90%) and nasal discharge 51 (85%) were the commonest clinical presentation. CT scans opacities were found in all 60 patients (100%). Fungal elements were detected by histopathological study in 7 (11.7%) of them.
Conclusion: Allergic fungal rhinosinusitis is a significant cause of nasal polyposis.
Keywords:Allergy, fungal infection, nasal polyposis.

Background:There is a growing interest in the potential beneficial effects of 3-hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) reductase inhibitors drugs (statins) in chronic obstructive pulmonary disease (COPD) as anti-inflammatory agent. The basis of the systemic inflammation in COPD comes from two possibilities: spill-over effect or inherent systemic-based pro-inflammatory state conferred by a genetic disposition. The inhaler-based therapy for COPD aims to reduce symptoms, improve quality of life and reduce hospitalization, but does not substantially change disease progression or reduce mortality.
Objective:To assess the efficacy and safety of statin therapy in COPD patients with evidence of inflammatory markers.
Methods:Ninety patients were included in the study, aged 40 years or more, who visit the outpatient private clinic in Babylon government, Iraq from September 2012 to April 2016. They were divided randomly for 3 groups (receiving 40 mg, 10 mg atorvastatin or placebo, respectively), in addition to their baseline treatment. Severity reassessment performed after 6 months\' duration of treatment as well as hospitalization frequency and mortality.
Results: Statin therapy showed a significant improvement in the both doses treated groups regarding the HsCRP, CAT (chronic obstructive airway disease assessment test) score and forced expiratory volume in first second after 6 months of treatment. This improvement fails to be reported significant effect on CAT score when compared to placebo group. Thus, statin treatment doesn’t show any symptomatic improvement as measured by CAT score over placebo treatment.
Conclusion:The statin treatment in patient with chronic obstructive pulmonary disease can be useful in form of improvement of hospitalization, number of exacerbations but not mortality.
Keywords: Atorvastatin, statins, COPD, high sensitive C-reactive protein.

Background:Renal biopsy is an indispensable tool for the accurate diagnosis and treatment of different forms of renal disease. Many advances have improved the utility and safety of renal biopsy procedure.
Objective:To determine the extent to which renal biopsy used and how much it affects the Iraqi nephrology practice.
Methods:A systematic review of articles published from 1990 to 2014 was carried out by searching Medline and Google scholar. We included all studies that concerned with renal biopsy as the main intervention. Eligible studies determined by predefined criteria were reviewed. Data from these studies combined and analyzed.
Results:The search yielded 55 title, of which, eleven studies met the inclusion criteria. Analysis of the 11 studies (2278 patients) that underwent 2667 renal biopsies. Ten studies centered on native renal pathology and one study focused on allograft pathology.
Conclusion:The Iraqi renal biopsy practice and pathology interpretation need to be rejuvenated by modern pathology services, data registry, and well-designed studies with clinical impact.
Keywords:Renal biopsy, Allograft, Pathology, Iraq.

Background:Human cytomegalovirus (HCMV) is the major viral etiology of congenital infection and birth defects, during current maternal infection the fetal transmission is high (30-40%) and the symptomatic neonates have diseases involving the neurologic, hematopoietic, respiratory and other organ systems, causing high mortality and long-term sequelae.
Objective:To measure the frequency of congenital and perinatal HCMV infection among symptomatic neonates and its possible burden of disease among them.
Methods:A total of one hundred ninety-eight symptomatic neonates with clinical manifestations of overt congenital infection enrolled in this study from September 2014 to March 2015. Serum samples were obtained from each subject targeted in this study. HCMV infection was defined as HCMV-IgM antibody positive by Electrochemiluminescence Immunoassay (ECLIA) techniques.
Results:The prevalence of HCMV infection among symptomatic neonates with congenital infection was 25 (12.6%). The average age of HCMV detection was 9.96 (SD 6.73) days with a median of 7 days, a minimum of 3 days and a maximum of 28 days. Jaundice was the most predominant clinical finding 14 (56%), followed in order of frequency by hepatomegaly 9 (36%) and pneumonitis 7 (28%).
Conclusion:The high prevalence of neonatal HCMV infection among neonates with symptomatic congenital infections could indicate a high rate of maternal HCMV primary or current infection among our population.
Keywords: HCMV, congenital infection, neonates, clinical finding.