Al-Kindy College Medical Journal

On Saturday, May 13, 2023, a glorious day was engraved in the history of Al-Kindy College Medical Journal as it is the day of indexing the journal in the Scopus Database Journals. The journal has paced a strenuous journey to make that achievement.

In the United States, the pharmaceutical industry is actively devising strategies to improve the diversity of clinical trial participants. These efforts stem from a plethora of evidence indicating that various ethnic groups respond differently to a given treatment. Thus, increasing the diversity of trial participants would not only provide more robust and representative trial data but also lead to safer and more effective therapies. Further diversifying trial participants appear straightforward, but it is a complex process requiring feedback from multiple stakeholders such as pharmaceutical sponsors, regulators, community leaders, and research sites. Therefore, the objective of this paper is to describe three viable strategies that can possibly increase the diversity of clinical trial participants: (1) Diversification of the clinical research workforce. (2) Adoption of the diversity in site assessment tool, and (3) incorporation of decentralized clinical trial technologies into clinical trial designs.

Background: Acute appendicitis is regarded as one of the most common inflammation that needs surgical intervention. Different scoring systems have been used for diagnosing of acute appendicitis. ALVARADO score is one of the most widely used score in diagnosing of acute appendicitis, but the accuracy of the latter is insufficiently low in Middle-East patients. Thus a new scoring system called RIPASA score has been designed for diagnosing of acute appendicitis in those patients. The aim of this study is to use RIPASA score and compare its result with ALVARADO score in diagnosing of acute appendicitis.

Subjects and Methods: The study includes 200 patients with symptoms and signs of acute appendicitis in Al-Kindy Teaching Hospital/Baghdad/Iraq from 1st of November 2017 to 30th of November 2018. The variables of both scoring systems are registered for each patient included in this study and all patients who are underwent appendectomy their specimens are sent for histopathology.

Results: The study includes 200 patients with suspicion of acute appendicitis. By applying both scores for each patient, then comparing the result of the two scores with the histopathology reports; RIPASA score has shown sensitivity, specificity, and diagnostic accuracy (93.6%, 74.4%, 89.5%) more than ALVARADO score (82.8%, 65.1%, 79%) respectively. The area under the receiver operating characteristic (ROC) curve of RIPASA score (0.957) is higher and significantly better than that of ALVARADO score (0.893) with P value <0.05.

Conclusions: The RIPASA score is more sensitive, more specific, and has high diagnostic accuracy than ALVARADO score.

Background: Metabolic syndrome (Mets) is partially heritable. High mobility group AT-hook1 (HMGA1), an architectural transcription factor, affects the homeostasis of glucose. The marked inter-individual differences between T2DM patients in response to oral anti-diabetic drugs have become an issue for effective prescribing and dosing. The objective of this study was designed to assess whether different SNPs of the HMGA1 gene are associated with metabolic syndrome, and clarify the effect of these variants on response to combination therapy of metformin, sitagliptin, and glimepiride used by Mets with diabetes patients.

Methods: From February until Augusts 2022, a total of 91 Iraqi participants (61 patients with metabolic syndrome and 30 controls). The diabetes patients were divided into two groups’ responders and non-responders, based on their HbA1c. Polymorphisms in HMGA1 and genotyping were identified by Sanger sequencing of genomic DNA.

Results: The high prevalence of CC and GG genotypes of rs1023028442 and rs112081775 respectively was seen in the Iraqi population. Minor allele frequency of rs1023028442 was higher among metabolic patients without diabetes with (MAF=0.08) compared to the control group with (MAF= 0%). While (MAF=0.1) of rs112081775 was seen in metabolic patients without diabetes compared to (MAF=0.02) in the control group. The non-significant difference in genotyping and allele carriage frequencies of the HMGA1 gene was seen between total metabolic syndrome patients and the control group. Based on their response to therapy non-significant difference was seen between those with wild and carrier genotypes.

Conclusions: This study suggests a lack of association of the rare HMGA1 gene variants with metabolic syndrome risk and response to oral anti-diabetic drugs.

Background: Post-partum depression (PPD) is a form of postnatal depression that affects mothers. Clinical manifestations usually appear within six months after delivery. Risk factors that influence the severity of post-partum depression are not fully known in the Iraqi population.
Objectives: We aim to evaluate the risk factors and identify potential predictors that may influence the symptom levels (severity) of post-partum depression among Iraqi women from Baghdad.
Subjects and Methods: The current study is cross-sectional, and we used the Edinburgh Postnatal Depression Scale (EPDS) and a cut-off value of 13 to differentiate patients into two those with lower symptom levels (LSL) and higher symptom levels (HSL). We also explored patients' attributes, newborn-related parameters, and socio-demographics.
Results: The total sample included almost one hundred patients (n=101), including females with lower symptom levels (EPDS<=13, 48.51%) and others with higher symptom levels (EPDS>13, 51.49%). There were two significant risk factors of PPD, including marital problems (OR=3.60, 95% CI=1.54 to 8.41, p=0.003) and perinatal mood disturbances (OR=3.23, 95% CI=1.40 to 7.46, p=0.005). The former results are congruent with our multivariable ordinal regression, while path analysis and structural modeling conveyed an additional risk factor: the personal history of depression. ROC analysis did not convey any significant difference between the two groups (LSL versus HSL) based on age. However, mothers with HSL were older than the other group (29.19±0.88 versus 27.08±0.79, p=0.099).
Conclusion: Post-partum depression with higher symptom levels is frequent among Iraqi mothers. Healthcare institutes should be vigilant concerning the underlying risk factors. Intervention requires integrating the role of social workers to understand the patient's family dynamics.

Background: obesity is a major global health problem with more than 200 million obese men and almost 300 million obese women. Melatonin is a well-known molecule for its involvement in circadian rhythm regulation and has multiple pathological actions including control of appetite, sleep wake cycle and metabolic syndrome.

Aim: to estimate the effect of melatonin supplements on obese patients on a calorie restricted diet in comparison to patients on lifestyle measures only in the form of weight loss, waist circumference and sleep quality.

Subjects and Method: one hundred patients with body mass index > 24 were collected, fifty patients were started on melatonin 5 mg with calorie restricted diet and they were compared to fifty patients who were kept on lifestyle measures. After twelve weeks, patients were re-assessed for weight, waist circumference and sleep duration and quality and the development of any side effects. Data analyzed using paired t test.

Results: patients’ group who were treated with melatonin has shown significant reduction in body weight (91.58. Vs 92.88, p value <0.0004) and waist circumference (99.36 +- 10.73 vs 101 +-10.51, p value< 0.0064). Patients treated with melatonin show improved insomnia severity index (5.47+-0.8 vs 9.08 +-3.58, p value <0.0001). 60% of patients noticed decreased appetite,35% reported daytime sleepiness and fatigue, 25% had dizziness and 20% had mild nausea.

Conclusion: Melatonin significantly reduces the body weight, waist circumference and appetite more than placebo, it has been shown to be safe supplement and helpful in patients with sleep disturbance and obesity.

Background: Osteoporosis is a systemic skeletal disorder that has an impact on general health, dental health and salivary composition. The mineralization of teeth happens simultaneously with that of the skeleton, but if mineral metabolism is disrupted, tooth failures will resemble those that affect bone tissue. Vitamin D plays a key role in bone and tooth mineralization.

Objective: to evaluate the impact of osteoporosis on teeth decay in relation to salivary vitamin D among menopause in Baghdad city.

Subjects and Methods: This study was cross sectional study. The study group consists of 45 menopausal women with osteoporotic disease as appeared in dual energy X-ray absorptiometry (DEXA) scan. The control group consists of 45 menopausal women without osteoporosis as appeared in (DEXA) scan. Dental caries was examined according to WHO (2013). Biochemical salivary analysis made for vitamin D. Statistical Analysis of the data were carried out using SPSS version 21.

Results: The percentage of dental caries occurrence was 100% among groups. Results revealed that DMFT value was higher but statistically not significant among osteoporotic women. Concerning DMFS components, the data showed that DS, MS and FS was higher among study group but statistically not significant. Salivary vitamin D is lower in study group with significant difference.

Conclusion: The caries experience was higher in osteoporotic women and missing teeth were reported to be most common in both groups. Salivary vitamin D is lower in osteoporotic group. Therefor old adult women need special oral health preventive and educational programs.

Background: Insufficient sleep due to excessive media use is linked to decrease physical activity, poor nutrition, obesity, and decreased overall health-related quality of life.

Objectives: To assess the effect of using the internet and social media on the sleep of 4th-stage secondary school students.

Subjects and Methods: Cross-sectional study with the analytic element; for 500 secondary school students, obtained by choosing two schools randomly from each of the six educational directorates, by using a structured questionnaire.

Result: Secondary school students are involved in this study (n = 500). The study reveals that the majority of students 350 (69.7 %) were aged group (16) years old, Regarding the internet, used by the majority of the 454(90.4%), and 419 (83.5%) students had a mobile phone, 206(41.1%) of them using the internet more than 150 hours per month and concerning the students sleep; Unexplained tiredness in the morning 182(36.3%) was sometimes complained from it, about Nightmares, 187(37.3%) of students sometimes having it, 276(55%) of them wake up during sleep.

Conclusion: students are using the internet more than one-fifth of their time per month, there is an association between the use of social media and short sleep duration among secondary school students that increases daytime sleepiness, unexplained tiredness in the morning, and nightmares.

Background: Interleukin-6 (IL-6) is a cytokine that has several functions, including stimulating growth and inhibiting cell death. It has the potential to operate as a biomarker for the accurate prediction of disease severity and activity, platelets-rich plasma was used in the treatment of oral lichen planus and can change the salivary IL-6 level.

Objectives: To study the clinical outcome of intralesional platelets-rich plasma in patients with oral lichen planus and to measure salivary IL-6 levels before and after the treatment with platelets-rich plasma were the aims of this study.

Subjects and Methods: In this clinical trial, for each patient a standardized case sheet was filled including demography, social, medical, and medication history. Before receiving, each patient was examined for phenotype, color, size, and site of oral lichen planus lesions. Patient's salivary samples were taken between 8 and 11 a.m. Three to four milliliters of saliva was obtained from each patient. The ELISA kit for IL-6 using sandwich-ELISA technique, to measure salivary IL-6 before and after PRP injections.

Results: Thirteen oral lichen planus patients were took part in this study, six males (46.2%) and seven females (53.8%). The patients were between 32 and 91 years of age, with a mean age of 60.2(±13.9) years. All symptomatic and most of the hyperemic ones showed improvement after PRP injections, while the size of the lesions was resistant to change. Mean salivary IL-6 was 44.27 pg/mL (±43.24) before PRP injections and (69.74±59.86 pg/mL) after PRP injections. No significant difference was found, however IL-6 was higher after PRP injections. In relation to color changes after PRP, there was a significant changes in IL-6 level compared with that before PRP injections. Similarly, a significant relation was found between IL-6 level and signs and symptoms; pain and burning sensation. No association was found in salivary IL-6 level in relation to lesion phenotype, size, and location.

Conclusion: All symptomatic OLP lesions that were treated with intralesional PRP responded very well, similarly almost all hyperemic lesions turned into normal mucosal color after completing the course of treatment. The majority of OLP lesions showed an increased salivary IL-6 levels after PRP treatment.

Background: Stress urinary incontinence is a frequent urological disease in women; it has a great influence on an individual’s wellbeing and places a significant economic strain on any health service. The placement of urodynamic diagnostic tests in the evaluation route is an important clinical research concern in this field.

Objective: to find out whether the duration of stress urinary incontinence is associated with the finding of bladder outlet obstruction in urodynamic study or not.

Subjects and Methods: A descriptive study. With enrolled female patients had symptomatic Stress urinary incontinence as their primary complain. All the included patients were assessed thoroughly by history taking and physical examination and relevant clinical tests and investigation in addition to urodynamic evaluation consisted of multi-channel urodynamics measuring abdominal, vesical and detrusor pressures simultaneously.

Results: 140 females were suffering from stress incontinence. Urodynamic study showed maximum urine flow rate (Q max) mean of (20.45±9.86) ml/second, the maximum post void volume was 500ml with 36.89ml was the mean of post void residual volume, and 90.83cm water was the mean of urethral occlusion pressure. The mean of duration have positive relationship with age category but without statically significant. Ninety-eight patients have Q max flow more than 25ml/sec with mean duration 6.04 without any statically significant (p=0.872). 37 patients were having >0 ml post void volume with mean duration more than other patients that didn’t have post void volume but without statically significant (p=0.257). All patients with urethral pressure less than 120 cm had long duration mean than others but without statically significant (p=0.335). also, no statistical significance association between mean of duration and sphincter pelvic floor electromyogram (EMG).

Conclusion: there was no catechistically significant relationship between the urodynamic findings and the duration neither of stress urinary incontinence nor between the urodynamic findings and the age of the patients.

Background: despite the rise in the incidence of renal cell carcinoma attributed to availability of medical imaging, a considerable decline in mortality is an association. Morbidity-wise, the shift from radical nephrectomy to partial nephrectomy is the trend for now. Multiple scoring systems have been introduced over the past decades to help surgeons choose between radical and partial nephrectomy. One commonly used system is the RENAL nephrometry score that was first introduced by Kutikov and Uzzo in 2009.

Objective: to evaluate the role of RENAL nephrometry scoring system in predicting the surgical technique to use to resect renal masses and associated perioperative outcomes.

Subjects and methods: between December 2018 and December 2020, we prospectively recruited 88 patients with renal masses. Nephrometry scores of all patients were calculated by an experienced radiologist and a decision then was made by blinded treating surgeons to proceed to radical or partial nephrectomy. Patients then sub-grouped into low, moderate, and high nephrometry scores, and into radical and partial nephrectomy. Pre-, intra-, and post-operative data were collected and analyzed.

Results: Eighty-three patients completed the study. Thirty-three had undergone radical nephrectomy and 50 had partial nephrectomy. Total nephrometry score differed significantly between the two groups. Mass radius and nearness to the renal hilum were the only influential components. The only complication that differed significantly among the three nephrometry groups was the estimated blood loss, being highest in the low complexity group. No significant difference was found in the total operation time, ischemia time, renal function and hospital stay. Major complications were seen only in the high complexity group.

Conclusion: Total nephrometry score, mass radius and nearness to renal hilum can be regarded as good and reproducible predictors of type of surgery required to treat renal masses. They also can predict the perioperative complication to a good extent.

Background: Worldwide gastric cancer is the fifth most common cancer with poor prognosis. In early stages, it is hard to distinguish gastric cancer from benign gastric diseases, resulting in delayed diagnosis. There is a need to develop a biomarker for differentiating between gastric cancer and benign gastric diseases. Serum cholinesterase is synthesized in liver and released into plasma, and it has an important role in oncogenesis.

Objectives: To determine the correlation between serum cholinesterase activity and gastric cancer, in comparison to benign gastric diseases.

Subjects and Methods: A case control study carried out at Medical City Directorate\ Gastroenterology, Hepatology Hospital, and at Oncology Teaching Hospital from April 2022 to September 2022. It involved 25 patients with gastric cancer and age matched 25 patients with benign gastric diseases. Serum cholinesterase activity was determined by a colorimetric method..

Results: There was a significant difference in the mean level of serum cholinesterase between gastric cancer group (5339.28 U/L±1816) and benign gastric diseases group (7516.92 U/L±2351) with (P value<0.001). Significant association between low levels of serum cholinesterase and early cancer stages and grades (P value<0.001). Serum cholinesterase showed 60% sensitivity and 80% specificity in differentiating between gastric cancer and benign gastric diseases with optimal cutoff value of 5568U\L.

Conclusions: Serum cholinesterase can be considered as a potential rapid and non-invasive biomarker for differentiating between gastric cancer and benign gastric diseases.

Background: Type 2 diabetes mellitus (T2DM) characterized by insulin resistance (IR) and progressive decline in functional beta (β) cell mass partially due to increased β cell apoptosis rate. Pancreatic stone protein /regenerating protein (PSP/reg) is produced mainly by the pancreas and elevated drastically during pancreatic disorder. Beta cells are experiencing apoptosis that stimulate the expression of PSP/reg gene in surviving neighboring cells, and that PSP/reg protein is subsequently secreted from these cells which could play a role in their regeneration.

Objectives: To analyze serum levels of PSP/reg protein in T2DM patients and evaluate its correlation with the microvascular complications of the disease.

Subjects and Methods: One hundred fifty participants (64 males, 86 females; aged 40–70 years) include T2DM patients with and without microvascular complications as well as healthy controls were enrolled in this study. Biochemical parameters like random blood glucose (RBG), glycated hemoglobin (HbA1c), lipid profile, urea and creatinine (Cr) were measured. Serum values of PSP/reg protein were measured by enzyme- linked immunosorbent assay (ELISA).

Results: Serum levels of PSP/reg protein were found significantly elevated in T2DM patients with microvascular complications compared with those of controls (p<0.001) and T2DM patients without microvascular complications (p< 0.001).PSP/reg protein is correlated with type 2 DM duration (p<0.001), RBG (p<0.001), and HbA1c (p<0.001). The area under the curve (AUC) for the presence of microvascular complications was 0.973.

Conclusion: PSP/reg protein may be used as biochemical marker to predict microvascular complications of T2DM.

Objective: This study was conducted to identify the association of HLA-DRB1/DQB1 genes with the susceptibility or resistance to type 1 diabetes mellitus (T1D) among patients between the ages of five and eighteen.

Subjects and Methods: The study included 200 Sudanese participants, ages ranging from 5 to 18. One hundred participants were healthy non-diabetic as the control group and 100 with T1D as the case group. The investigation was carried out in Khartoum state. The selection of patients with T1D was from diabetic centers and hospitals. The allele-specific-refractory mutation system-polymerase chain reaction (ARMS-PCR) technique was applied to identify the HLA gene polymorphism.

Results: There was a significant difference in genotype frequency across the groups in the current investigation (Kruskal-Wallis, p-value= 0.021). Whereas CG was not substantially different across groups (Chi-square, p-value=0.116), the CC genotype was considerably greater (46.0%) in patients (Chi-square Adjusted p-value0.001).

Conclusion: This study found that patients' genotypes and allele frequencies are significantly correlated when compared to those of healthy participants.

Background: Hypothyroidism is the most abundant thyroid disorder worldwide. For decades, levothyroxine was the main effective pharmacological treatment for hypothyroidism. A variety of factors can influence levothyroxine dose, such as genetic variations. Studying the impact of genetic polymorphisms on the administration of medications was risen remarkably. Different genetic variations were investigated that might affect levothyroxine dose requirements, especially the deiodinase enzymes. Deiodinase type 2 genetic polymorphisms’ impact on levothyroxine dose was studied in different populations.

Objective: To examine the association of the two single nucleotide polymorphism (SNP)s of deiodinase type 2 (rs225013 and rs225014) and levothyroxine dose requirements.

Subjects and Methods: A cross-sectional study was conducted at Baghdad Center for Nuclear Medicine and Radiation Therapy located in Baghdad/ Iraq, from March to June 2022. Based on levothyroxine dose, the enrolled patients were divided into two groups: low dose group < 1.7 µg/kg/day and high dose group ≥ 1.7 µg/kg. Then genotyping analysis was done for both groups of the study.

Results: The mean age of the participants was 40.35 ± 9.5 years with a mean body mass index of 30.61 ± 5.72 kg/m2. The mean levothyroxine doses in the low- and high-dose groups were 81.67 ± 30.74 µg/day and 161.67 ± 35.19 µg/day, respectively. Significant differences existed in the levels of TSH and TT4 between the study’s groups.

Conclusion: This study indicated that the differences in levothyroxine dose, TSH, TT4 and TT3 levels were not associated with the DIO2 rs225013. Similarly, the differences in TSH, TT3 and TT4 levels revealed a non-significant association with DIO2 rs225014 except for levothyroxine dose which was higher in the patients who carried the wild type allele (TT).

Background:

Multiple sclerosis is a chronic disease believed to be the result of autoimmune disorders of the central nervous system, characterised by inflammation, demyelination, and axonal transection, affecting primarily young adults. Disease modifying therapies have become widely used, and the rapid development of these drugs highlighted the need to update our knowledge on their short- and long-term safety profile.

Objective:

The study aim is to evaluate the impact of disease-modifying treatments on thyroid functions and thyroid autoantibodies with subsequent effects on the outcome of the disease.

Materials and Methods:

A retro prospective study enrolled 45 patients who were registered and diagnosed in the Multiple Sclerosis Clinic according to the revised McDonald criteria (2017). Blood samples for thyroid functions and thyroid autoantibody tests were taken before, 3 months and after 6 months from the start of disease modifying therapy. The Expanded Disability Status Scale was used to assess the severity of the disease before and after 6 months of receiving treatment.

Results:

45 patients with the mean age of 33.3 years, a standard deviation (SD) of ± 9.5 years were enrolled in this study. (64.4%) patients’ age was between 20 - 39 years.

The mean free T3 decreased significantly, while the mean anti-TPO and anti-TG increased after three months compared to its baseline level.

After six months of treatment, the mean free T4 decreased significantly, while the mean TSH increased compared to its baseline level. There were no statistically significant correlations between the baseline (EDSS) score and after 6 months of therapy.

Conclusion

Thyroid hormone dysfunction and thyroid autoimmune antibody levels that changed in response to interferon beta therapy in patients with multiple sclerosis may be temporary and not associated with poor outcomes.

Background: Myasthenia gravis is an autoimmune disease of the neuromuscular junction that results in fluctuating muscle weakness as well as significant fatigue. Disease exacerbation is a critical condition, and the predisposing factors for it need to be identified to improve preventive measures.

Objectives: Our study aims to determine the predisposing factors for myasthenia gravis exacerbations in a group of Iraqi patients.

Subjects and Methods: A total number of 30 myasthenia gravis patients were admitted to the hospital with an exacerbation of their symptoms, determined as the development of functional disability, dysphagia, or respiratory failure within one month prior to admission. Each patient was assessed by history taking, clinical examination, and investigations to determine the possible exacerbating factor.

Results: There were (56.7%) of patients with infection. Non-compliance to treatment was found in (26.7%) of patients, and medication induced exacerbation was found in (16.7%) of the patients.

Conclusion: Infection is the most common predisposing factor for disease exacerbation and is associated with an unfavorable outcome.

Congenital absence of anterior cruciate ligament is highly uncommon occurrence. It has since been documented as a standalone anatomical entity or, more frequently, in conjunction with other congenital anomalies. Surgical treatment for this patient population has only been reported in very few cases. In this article, we share our experience in managing a case of unilateral congenital deficiency of anterior cruciate ligament (ACL) in a 13 years old female patient by physeal sparing arthroscopic ACL reconstruction, using All-inside technique.

Background: Giant middle cerebral artery (MCA) aneurysms are surgically challenging lesions. Because of the complexity and variability of these aneurysms, a customized surgical technique is often needed for each case. In this article, we present a modified clip reconstruction technique of a ruptured complex giant partially thrombosed middle cerebral artery aneurysm.

Case description: The aneurysm was exposed using the pterional approach. Following proximal control, the aneurysm sac was decompressed. Then, we applied permanent clips to reconstruct the aneurysm neck. The configuration of the aneurysm mandated a tailored clipping pattern to account for residual aneurysm sac sagging beyond the confinement of the single inflow and the two outflow channels. As a result, clipping in a fanning pattern was done to obliterate the lateral extensions while retaining a smooth curvature of the reconstructed neck. This final clipping pattern mirrored the arrangement of the peacock tail feathers. The 'peacock tail’ clipping technique can be thought of as a variation of the traditional straight tandem clipping, also known as 'picket-fence,' applied to less complicated aneurysm configurations.

Conclusion: Giant MCA aneurysms may demand an adaptive clipping technique to account for the unique geometry of each aneurysm. In this paper, we described the 'peacock tail’ clipping technique for clip reconstruction of a giant complex partially thrombosed M2 MCA aneurysm as a modification of the conventional tandem clipping technique.

Ameloblastic fibroma is a rare benign tumor usually affects the first two decades of life. The neoplasm is more predominant in mandibular molar-premolar region and rarely affects the maxilla. In this report, we present a couple of Ameloblastic fibroma cases, affecting boys at their 1st decade. The lesions were presented as swellings of their maxilla, which is atypical location. Radiographic images showed well-defined radiolucency containing areas of radio-opacities and impacted teeth. Differential diagnosis was established as cystic/neoplastic conditions. The lesions were incised and histopathologically diagnosed as Ameloblastic fibroma, since they were composed of immature odontogenic mesenchymal and epithelial cells showing different characteristic features.