IRAQI JOURNAL OF MEDICAL SCIENCES

Quality in healthcare is imperative and not optional. To deliver continuous process improvement, the focus must be on the patient from start to finish, as often the patient’s experience of receiving care is the product of the process as in doctor consultation setting. Value healthcare can be formulated as an equation: quality divided by cost. Sometimes to do less is to achieve more, as beyond the point of optimal healthcare, adverse effects will outweigh perceived benefits. Patient safety is proportional to process quality; hence the overarching importance of focusing on quality. However, costs must always be harnessed to ensure we achieve optimality of healthcare delivery.

Keywords:Change management, errors, events reporting, frontline staff, harm events, healthcare delivery, information flow, leadership, near misses, patient safety, quality care, risk management, process improvement, system data.
Citation: Alani A. Delivering Quality Care and Patient Safety – A New Paradigm. Iraqi JMS. 2017; Vol. 15(3): 214-219. doi: 10.22578/IJMS.15.3.1

Background: The diagnosis of mechanical intestinal obstruction is sometimes very challenging especially in the absence of previous abdominal surgery or obstructed hernia and there are limited studies comparing or evaluating the usefulness of plain abdominal x-ray, ultrasonography, and computerized tomography (CT) in intestinal obstruction.
Objective: To compare the efficacy of plain abdominal x-ray, ultrasound and CT in the diagnosis of intestinal obstruction. Also, to assess ultrasound value and usefulness in pregnant women and critically bed ridden patients with intestinal obstruction.
Methods: In this prospective study with signs and symptoms of mechanical intestinal obstruction, a total of sixty two patients were investigated by plain x-ray, ultrasound, CT scan and the findings were compared with reference to the presence or absence of obstruction, the level, site, cause and strangulation of bowel for a period of eight years (2009-2016). The final diagnosis was obtained by surgery and only those with proved intestinal obstruction per-operative were included in the study.
Results: Out of the sixty two patients (41 males and 21 females) included with an age incidence (22-65 yr), 58 had mechanical intestinal obstruction (50 had small bowel obstruction and 8 had large bowel obstruction), of the remaining 4 patients; 2 had mesenteric vascular occlusion and 2 had pseudo-obstruction. The level and site of obstruction was correctly predicted in 91.9% on CT, in 82% on ultrasound and 90.3% on plain film. CT was the best 85.4% to both, ultrasound 24% and plain film 8% in determining the cause of obstruction. Regarding strangulation of bowel, CT was superior while plain film was the least informative with the ultrasound in between.
Conclusion: CT is the best tool for the diagnosis, strangulation of the bowel and detecting cause of intestinal obstruction and recommended to be the investigation of choice in equivocal cases. Ultrasound is the best and sole investigation in pregnant women and critically bed ridden patients especially in early cases.
Keywords: Intestinal obstruction, plain abdominal x-ray, ultrasound, CT scan.
Citation: Salih NK. Value of plain abdominal radiograph, ultrasound and computerized tomography in the diagnosis of intestinal obstruction. Iraqi JMS. 2017; Vol. 15(3): 227-233. doi: 10.22578/IJMS.15.3.3

Background: Polycystic ovary syndrome (PCOS) is the most common cause of chronic anovulation and hyperandrogenism in young women. This syndrome is characterized by an increase in the number of small antral follicles that are between 5-8 mm in size. Antemüllerian hormone (AMH) is secreted mostly by this type of follicle and when it is much too high, the production of a healthy egg every cycle can be halted as it works by reducing the receptors of the ovary to follicle stimulating hormone (FSH).
Objective: To compare the AMH level between women presented with PCOS with its level in normal ovulatory infertile women and to determine its correlation with the clinical, hormonal and ultrasonographic parameters in both groups.
Methods: This is a prospective cross-sectional study done at Um-Albaneen Infertility Center in Al-Imamein Al-Kadhimein Medical City from march 2015 to January 2016. One hundred infertile women were recruited in this study, 50 women with PCOS and 50 women have other factors of infertility apart from PCOS and ovulatory dysfunction. Sera were taken from all the participants at day (2-3) of menstrual cycle and were investigated for AMH, FSH, luteinizing hormone (LH), androstenedione, testosterone and estradiol (E2) levels. The number of early antral follicles (2-9 mm in diameter) was estimated by transvaginal ultrasound scanning.
Results: Level was significantly higher in PCOS women (42.6±23.8) compared to the normal ovulatory infertile women (16±7.5), P-value <0.001. There was positive correlation between AMH and LH, testosterone, androstenedione, number of antral follicles (antral follicle count) and ovarian volume. However, the correlation was negative with age, body mass index, estradiol, and FSH.
Conclusion: AMH strongly correlated with testosterone level and the number of small antral follicles in PCOS women, so it can be considered as a good diagnostic marker for PCOS.
Keywords: Antimullerian hormone, PCOS.
Citation: Almoayad HA, Abdulrasul EA. Jumaa NA. Comparison of antimullerian hormone level between women with polycystic ovary syndrome and normal ovulatory infertile women of reproductive age. Iraqi JMS. 2017; Vol. 15(3): 234-241. doi: 10.22578/IJMS.15.3.4

Background: The tight junctional complexes had been demonstrated in hepatocytes and in both epithelium and endothelium. In multicellular organisms, cell-cell adhesion is critical for development and morphogenesis.
Objective: To investigate the spatiotemporal organization of the immunohistochemical markers anti ZO-1 and anti Pan-cadherin during the prenatal development of the mice liver and to correlate the expression of these markers with histogenesis during hepatocyte maturation and biliary network formation.
Methods: Forty eight (48) pregnant mice were scarified at subsequent gestational days from day 14 till the first day of postnatal life. Paraffin blocks and sections of the liver extracted from the embryos obtained from these pregnant mice and from neonates at the first postnatal day of life were prepared. The sections were stained using the anti ZO-1 and anti Pan-cadherin immunohistochemical markers.
Results: The sequential steps of anti ZO-1 indirect immunofluorescence reactivity in the developing liver tissue showed chronological variability, during days 14, 15, and 16; positive cell surface labeling was weaker adjacent to the blood vessels. The next step includes anti ZO-1 reactivity in late prenatal and postnatal liver tissue showing marked uniform reactivity. The sequential steps were also demonstrated in the anti Pan-cadherin immunohistochemical reactivity. The reactivity of the liver tissue during days 14, 15, and 16 showed disregarded cell surface labeling that increased markedly in later prenatal and postnatal periods.
Conclusion: The initial stages in the development include the undifferentiated specification the hepatic lineage characterized by regional establishment of zonula occludens in the developing liver cells and paucity in the development of the zona adherens complexes. The later stages showed histological and functional maturation reflected by anti ZO-1 and anti Pan-cadherin reactivity that represent a requirement for the physiological functions in the entire liver tissue.
Keywords: Embryo, mice, Zo-1, Pan-cadherin, immunhistochemistry.
Citation: Ali NFM, Mubarak HJ. Indirect immunofluorescence expression of ZO-1 and Pan-cadherin during maturation of hepatocytes and biliary network formation in mice. Iraqi JMS. 2017; Vol. 15(3): 242-249. doi: 10.22578/IJMS.15.3.5

Background:Intussusception is the most common cause of intestinal obstruction in infants and young children.
Objective:To review the clinical, epidemiological, management pattern and outcome of intussusception.
Methods:A retrospective descriptive review of 47 patients who were diagnosed and managed for intussusception during the period from January 2012 to October 2014 in Al-Ramadi Teaching Hospital for Maternity and Children. Data were collected from the Pediatric Surgery Unit records, which include demographic characteristics of the patients, history of preceding gastroenteritis or respiratory infection, clinical signs and symptoms, imaging studies, type of management, operative finding, outcome and mortality. Data were analyzed by Epi Info7TM, using chi-square to obtain p value which regarded significant when it was < 0.05.
Results:Records of 47 patients were reviewed; (68.4%) were under one year of age. Peak incidence between 6-12 months of age (55.3%). Male: female ratio was 2.35:1. 27 patients (57.4%) were from rural area, peak seasonal incidence occurred in summer and winter, 41 patients (87.2%) presented with abdominal pain, a palpable abdominal mass was detected in 24 patients (51%), red currant jelly stool reported in (74.5%). Ultrasonography were done for 39 patients and showed an abdominal mass suggestive intussusception (as a target sign or pseudo kidney mass) in 34 patients (87.1%). (95.7%) of patients treated by surgical reduction, while only two patient reduced by hydrostatic enema, Meckle's diverticulum were the commonest pathological lead point (44.4%). No intussusception- associated death was recorded.
Conclusion:Colicky abdominal pain was the most presenting symptoms and red currant stool was a significant sign especially in children ≤ 12 months. Majority of cases presented after 24 hours were from rural area, seasonal peaks occurred in summer and winter months and surgery remain the mode of management.
Keywords:Intussusception, clinical, epidemiological, management pattern and outcome.
Citation:Al-Ani MMM, Ghani SH, Maklef OK. Evaluation of intussusception in children: our experience in 47 cases. Iraqi JMS. 2017; Vol. 15(3): 250-261. doi: 10.22578/IJMS.15.3.6

Background:A variety of benign soft tissue swellings can be found arising from oral mucosa, most of which are inflammatory hyperplasia and granuloma. Surgical diode lasers have been used in oral surgical procedures with beneficial and undoubted operative advantages and a better quality of the outpatient operation compared with electro- and coldblade techniques.
Objective:To assess the effectiveness of diode laser 810 nm in the removal of pyogenic granuloma of oral cavity in repetitive pulsed mode.
Methods:This study was conducted at the consultation clinic of the Maxillofacial Surgery Department in the Al-Imamein Al-Kadhiemein Medical City on 35 patients who suffered from oral pyogenic granuloma. The period of the study was from January 2013 to January 2015. The laser used in this study was diode laser 810 nm in repetitive pulsed mode. The maximum power was 5-8 watts. The pulse duration was 0.2-0.4 second and 0.2-0.4 second pulse interval. Excisional biopsies were sent for Histopathological study. Clinical examination was done and had included presence of swelling, infection, disturbance of function, pain and bleeding.
Results:Patients with pyogenic granuloma were treated efficiently with repetitive mode of diode laser 810 nm. Minimal to moderate swelling, no disturbance of function, no infection and mild pain were observed postoperatively, no bleeding was seen neither intraoperatively nor postoperatively.
Conclusion:Repetitive pulsed mode of diode laser 810 nm is efficient and safe in removal of pyogenic granuloma of oral cavity.
Keywords:Diode laser, oral pyogenic granuloma
Citation:Al-Alawi AS. The effectiveness of Diode Laser 810 nm in the removal of oral pyogenic granuloma in repetitive pulsed mode. Iraqi JMS. 2017; Vol. 15(3): 262-267. doi: 10.22578/IJMS.15.3.7

Background:Diabetes is the 2nd commonest medical complication of pregnancy after hypertension. Infants of diabetic mothers are those infants born to a mother who suffers from diabetes mellitus, but the term refers especially to infants born to a mother who has persistently elevated blood sugar during pregnancy.
Objective:To study the complications in infants of diabetic mothers and the difference in the complications between infants of gestational and pre-gestational diabetic mothers.
Methods:A cross sectional observational study carried out on (100) neonates of diabetic mothers that delivered in Al-Imamein Al-Kadhimein Medical City; the data was collected between 1st of September 2015 to 1st of December 2015. Maternal history was taken about type of diabetes and babies were divided into 2 groups; 1st group was infants of pregestational diabetic mothers and 2nd group was infants of gestational diabetic mothers. Thorough physical examination of these infants at birth at the neonatal care unit was done. Laboratory investigations included blood sugar, serum calcium, hematocrit, total serum bilirubin and echocardiograph was done in all babies but chest x-ray, abdominal ultrasound, brain ultrasound and electrocardiogram were done whenever indicated.
Results:The 1st group (36 cases) 36% of infants was product of mothers having pregestational diabetes and the 2nd group (64 cases) 64% infants of gestational diabetic mothers. Mothers were delivered by cesarean section in 69%. Mothers were primigravida in 31%. Female 59% to male ratio 1.4:1. Hypoglycemia at birth was documented in 39% of cases, was nearly equal in both groups (20%, 19%) respectively. Hypocalcemia in 18%, was more in infants of pregestational diabetic mothers (11% and 7%) respectively. Respiratory complications were the most prominent complications 41 % nearly equal in both groups (22% and 19%) respectively. Macrosomia seen in 23%, more in infants of gestational diabetic mothers (7% and 16%) respectively. Forty % of infants of both group have been discharged in the first 24 hours.
Conclusion:The respiratory complications were the most prominent followed by hypoglycemia that occurred mainly to infants of pregestational diabetic mothers. There are statistical differences in infants of pregestational diabetic mothers regarding hypoglycemia, hypocalcemia and respiratory complications. Macrosomia is more in infants of gestational diabetic mothers.
Keywords:Neonate, infants, gestational, pregestational diabetes.
Citation:Kadhum DE, Abbas SS, Khalaf DK. The neonatal outcome in infant born to gestational and pre-gestational diabetic mothers. Iraqi JMS. 2017; Vol. 15(3): 268-274. doi: 10.22578/IJMS.15.3.8

Background:Laser light is widely used for a wide range of medical applications. He-Ne laser application in medicine as in any type of laser is based on the interaction of laser light with the biological system.
Objective:To show the effect of helium-neon (He-Ne) laser (632.8 nm) irradiation on human lymphocyte blood cells and their DNA.
Methods:This study involved 72 blood samples, taken from apparently healthy volunteers. The samples were divided into two groups; the 1st group consisted of 27 samples were processed only for lymphocyte blood cells separation, while the 2nd group, which consisted of 45 samples were employed to evaluate the influence of He-Ne laser irradiation on the extracted DNA from the lymphocyte blood cells.
Results:At the used doses of He-Ne laser (18, 35, 52.5, and 69 J/m²), a significant difference was found (P < 0.05) in survival percentage of lymphocyte cells (99.8, 99.74, 99.68, and 99.59) in comparison with those cells untreated with He-Ne laser irradiation. Immediately after He-Ne laser irradiation alone, the following doses (18, 35, and 69 J/m²) were applied on the extracted DNA, the DNA demonstrated a significant damaging where the fraction of DNA survival percentage was (88.6, 87.7, 86.1) respectively, with significant difference (P < 0.05) between the DNA survival before and after He-Ne laser irradiation.
Conclusion:The percentage of lymphocytes survival is decreasing with increasing dose of He-Ne laser and longer exposure time where time exposure (2.5, 5, 7.5, and 10 s). He-Ne laser irradiation causes a significant degree of DNA damaging independent on the irradiation doses.
Keywords:Lymphocyte cells, He-Ne laser irradiation, DNA.
Citation:Abdullah SS, Taha JH, Ahmed MH. Effect of Helium-Neon Laser on the Lymphocyte Cells and their DNA. Iraqi JMS. 2017; Vol. 15(3): 275-282. doi: 10.22578/IJMS.15.3.9

Background:Hypospadias describes a urethral opening proximal to the normal position at the glandular tip (anywhere on the ventral surface) and it is considered the most common penile anomaly. There are many surgical modalities for reconstruction but with different success. The goal of modern hypospadias repair is to achieve functionally as well as cosmetically normal looking glans, meatus and phallus. Snodgrass urethroplasty was introduced in 1974 with more reliable creation of a normal appearing meatus.
Objective:To see the short-term results of tubularized incised plate urethroplasty as described by Snodgrass in mid and distal penile hypospadias.
Methods:This is a prospective study for evaluation of fifty male children with age ranged from one to ten years with penile hypospadias (distal and mid shaft) were included in this study over a period from January 2008 to January 2016 in our pediatric surgical center.
Results:The majority were between 2-4 years. Meatal stenosis (12%) and urethrocutaneous fistula (6%) were the most common complications encountered in this study. Inguinal hernia (8%) and undescended testis (10%) were the most common associated congenital anomalies with hypospadias.
Conclusion:Snodgrass urethroplasty is simple, single stage operation in the management of mid and distal penile hypospadias with good cosmetic and functional results.
Keywords:Hypospadias, Snodgrass technique, meatal stenosis, urethrocutaneous fistula.
Citation:Zain AZ. Snodgrass urethroplasty for mid and distal penile hypospadias. Iraqi JMS. 2017; Vol. 15(3): 283-287. doi: 10.22578/IJMS.15.3.10

Background:Post-operative biliary leakage in patients with liver hydatid diseases is still a major problem especially after conservative surgery. Radiologic and intraoperative findings may not be helpful to detect occult biliary communications in asymptomatic patients.
Objective:To identify the risk factors to predict occult cystobiliary communications (CBC) preoperatively to avoid development of biliary leakage after surgery.
Methods:This prospective study conducted at the Gastroenterlogy and Hepatology Teaching Hospital in Medical City, Baghdad from the 1st of December 2013 to the 29th of March 2016. Clinical assessment, laboratory tests and imaging studies were under taken for 85 patients with uncomplicated liver hydatid cysts. Endocystectomy and or partial pericystectomy were undertaken. Post-operative follow up and management of biliary leakage for those with cysto-biliary communication not detected intra operatively. Data were analyzed to predict risk factors for occult CBC.
Results:Of the 85 patients, 64 patients had no evidence of CBC neither intra nor postoperative, while the remaining 24 patients had an occult CBC, that have been discovered during operation or evident in the following days. Significant clinical predictors of communication were cyst size ≥ 10 cm, elevated total serum bilirubin (TSB) and gamma glutamyl transferase (GGT) (P < 0.001). Other findings were associated more with patients having CBC than those without, including high white blood cell count (WBC), alkaline phospatase (ALP), aspartate transaminase (AST) and alanine transaminase (ALT) levels. Nine of 13 patients who developed post-operative bile leak stopped spontaneously, the other 4 patients mandate endoscopic retrograde cholangiopancreatgraphy (ERCP) to close their fistulas.
Conclusion:Awareness about the risk factors for CBC can predict preoperative diagnosis of occult CBC. Endoscopic biliary interventions should be considered as a part of complementary treatment of those cases with refractory CBC and to be discussed in patients’s consent preoperatively.
Keywords:Liver hydatid cyst, cystobiliary communication, biliary leakage.
Citation:Abdul Hassan BA. The identification of risk factors that predict occult cystobiliary communication in liver hydatid cysts. Iraqi JMS. 2017; Vol. 15(3): 288-296. doi: 10.22578/IJMS.15.3.11

Background:Inflammation was one of the most important events in the biology of obesity; the obese subjects were recognized recently as characterized by low-grade chronic inflammation. It was thought that the mild inflammation associated with obesity, and particularly the production of inflammatory adipocytokines like interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α), was important in the etiology of the diseases associated with obesity. In particular, insulin resistance (IR) and type 2 diabetes mellitus (T2DM).
Objective:To investigate whether IL-6 and TNF-α play an important role in the etiology of IR and T2DM.
Methods:This study enrolled 70 T2DM patients randomly assigned into two subgroups, 35 non-obese (body mass index (BMI) < 30) diabetic group 1 and 35 obese (BMI ≥ 30) diabetic group 2 with another 50 healthy control volunteers, divided into two subgroups, 25 non-obese (BMI < 30) control group 1 and 25 obese (BMI ≥ 30) control group 2. Levels of IL-6, TNF-α, fasting glucose, fasting insulin, HbA1c, homeostasis model assessment of IR (HOMA-IR), homeostasis model assessment of β-cell function (HOMA-B%) were examined.
Results:The serum concentration of IL-6 of obese and non-obese diabetic patients was significantly (p < 0.05) lower as compared with obese and non-obese controls in contrast to the serum concentration of TNF-α, which was significantly (p < 0.05) higher in non-obese diabetic patients in comparison to non-obese controls. No significant correlation was observed for the levels of IL-6 and TNF-α with BMI of study population
Conclusion:The proposed link between serum inflammatory cytokines (IL-6 and TNF-α) and T2DM was more related to insulin sensitivity, insulin secretion and/or glycemic control than to adiposity. Therefore, the inflammatory cytokines may play an important role in the etiology of IR and T2DM.
Keywords:IL-6, TNF-α, type 2 diabetes mellitus, obesity, insulin resistance.
Citation:Qasim QA, Fareed YY, Hassan JK. Evaluation of inflammatory state in diabetic patients by measuring of interleukin-6 and tumor necrosis factor-α in obese and non-obese type 2 diabetes mellitus patients as compared with control subjects. Iraqi JMS. 2017; Vol. 15(3): 297-304. doi: 10.22578/IJMS.15.3.12

Background:Tonsillopharyngitis among children considered as a major public health problem in the community, because of post-streptococcal complications, cost, time consuming diagnostic tests and un-necessary antibiotics.
Objective:To determine the validity of Rapid Antigen Detection Test (RADT) in the diagnosis of streptococcal tonsillopharyngitis in comparison with clinical and bacterial culture method.
Methods:Throat swabs were taken from 214 children with tonsillopharyngitis in Baghdad from 20th November 2015 to 30th May 2016. Tonsillopharyngitis diagnosed by clinical, culture on blood agar and RADT.
Results:S. pyogenes were recovered from 116 (54.2%) cases. S. pyogenes infection alone or with overgrowth of other bacteria is associated with recommendation for tonsillectomy, and indices for MCIsaac clinical prediction for Streptococcal pharyngitis. RADT detection of S. pyogenes revealed 83.62% sensitivity and 95.92% specificity. MCIsaac clinical prediction 89.66% sensitivity and 44.9% specificity. The combined MCIsaac-RADT algorithm had increased sensitivity with an increased point of score and specificity found to be inversely associated with points of score.
Conclusion:For routine work, this study supports clinical screening with MCIsaac score for all children with tonsillopharyngitis and subsequent testing by Strep A RADT to facilitate the decision for antibiotic use.
Keywords:Rapid antigen detection, streptococcus pyogenes, tonsillopharyngitis
Citation:Hadi ZH, Ghazi HF, Abdulla MM. Impact of rapid antigen detection tests in the diagnosis of streptococcal tonsillopharyngitis in children. Iraqi JMS. 2017; Vol. 15(3): 305-313. doi: 10.22578/IJMS.15.3.13

Background:Acinetobacter baumannii (A. baumanii) has recently emerged as a major pathogen causing nosocomial infections in patients admitted to intensive care units with a surprisingly rapid acquisition of antibiotic resistance.
Objective:To study the rate of occurrence of A. baumanii isolated from different clinical specimens and to study the rate of occurrence of multidrug resistance especially NDM-1 and qnrA genes.
Methods:A total of sixty-two (62) clinical isolates of A. baumanii were tested against 14 antibiotics by disc diffusion method. Minimum inhibitory concentration was determined by agar dilution method for resistant isolates. Polymerase chain reaction (PCR) was performed to detect bla NDM-1 and qnrA genes.
Results:All Acinetobacter isolates were complete resistant to Colistin and Tigacycline (100%), while high rate of resistance was to Aztronem (93.54%), Cefotaxime, (91.93%), Ceftriaxone (88.70%) and Meropinem (80.64%). Moderate - to- low rate of resistance was to Ceftazidime (77.41%), Cefepim (75.80%), Peperacillin and Ciprofloxacin (74.19%), Gentamicin (69.35%), Levofloxacin (64.51%), Amikacin (61.29%) and Impenim (50%). The highest minimum inhibitory concentration value 128 μg/mL was to Cefotaxime, Tigacycline and Colistin. While the lowest value 8 μg/mL was to Gentamicin, Imipenem, Ciprofloxacin and Levofloxacin. The PCR results showed that 50% of Metallo beta lactamase producers A. baumannii was carried bla NDM-1 gene in chromsomal DNA and 24 (48%) of Flouroquinolone resistance A. baumannii harbored qnrA gene in chromsomal DNA while the prevalence of qnrA gene was (60.6%) in plasmid DNA.
Conclusion:There is a high prevalence of multidrug resistant A. baumannii in different samples from Baghdad with the high prevalence of bla NDM-1 and qnrA genes among this bacterium.
Keywords:Acinetobacter baumannii, bla NDM-1, qnrA- gene, MDR
Citation:Mshachal MA, Abdulrahman TR, Khudair MS, Hassan JS. Molecular detection of multidrug resistant Acinetobacter baumannii from different clinical samples. Iraqi JMS. 2017; Vol. 15(3): 314-323. doi: 10.22578/IJMS.15.3.14