Al-Kindy College Medical Journal

Lifestyle Medicine is the application of evidence-based lifestyle approaches for the prevention, treatment, and even the reversal of lifestyle-related chronic diseases such as diabetes, hypertension, heart disease, obesity, polycystic ovarian diseases, dementia, arthritis, and cancers

Technological advances have yielded new molecular biology-based methods for the diagnosis of infectious diseases. The newest and most powerful molecular diagnostic tests are available at regional and national reference laboratories, as well as at specialized centers that are certified to conduct metagenomic testing. Metagenomic assays utilize advances in DNA extraction technology, DNA sequence library construction, high throughput DNA sequencing and automated data analysis to identify millions of individual strands of DNA extracted from clinical samples. At present, metagenomic assays are only possible at a small number of special research, academic and commercial laboratories. Continued research in human and pathogen genomic organization and host-pathogen interactions, represent important future goals that will maximize the information obtained from metagenomic assays. To illustrate the power and limitations of metagenomics, we report on a previously healthy 27 year old woman with work related exposure to ill animals, and who developed a rapidly progressive, severe diffuse interstitial pneumonitis that ultimately ended in the need for a double lung transplant. Metagenomic testing on DNA extracted from pleural fluid and nasopharyngeal swabs demonstrated the presence of expected normal bacterial flora along with some unexpected herpesvirus and non-HIV retroviral elements integrated into the patients DNA. Although no specific pathogen was ultimately identified to explain this patient’s severe disease, the sample preparation and data analysis methods detailed herein illustrate the powerful benefits and limitations of metagenomic testing.

Checkpoint inhibitors are a type of immune therapy used to treat different types of cancers. These drugs block different checkpoint proteins, for example, CTLA-4, PD-1, and PD-L1 inhibitors.

They block proteins that stop the immune system from attacking the cancer cells. Checkpoints are also described as a type of monoclonal antibody that antagonizes binding between B7 to CTLA-4 and PD-L1 to PD-1.

Immune checkpoint inhibitors are used to treat BARCA mutated triple-negative breast cancer (TNBCS) in patients who do not respond to chemotherapy, and also in the treatment of highly mutated and solid tumors such as brain tumors, liver, and pancreatic cancers.

Immune checkpoint inhibitors exhibit an effect on solid tumors by suppressing CTLA-4, PD-1, and PDL-1. Anti-PD-1 is less toxic than anti-CTLA-4.

For melanoma Brain metastasis immune checkpoint therapy is more effective and Combination therapy has great efficacy and less toxicity which improves overall survival rather than individual therapy

liver cancer as hepatocellular carcinoma and cholangiocarcinoma used treatment with Genetics based therapy while using alternative immune checkpoint ligands, co-inhibitory (eg. LAG-3) or decreased t-cell infiltration causing therapy failure.

Clinical studies for pancreatic cancer have not been completed yet and treating PDA needs more research as immune checkpoint inhibitors is a new treatment against PDA. A new potent class of nivolumab, pembrolizumab, and ipilimumab have been FDA approved.

For mutated tumors, Combination therapy between checkpoint inhibitors and chemotherapy has great efficacy and improves the city of life and overall survival, rather than individual therapy when using radiation or chemotherapy alone.

Background: The COVID-19 pandemic has an immense effect not only on the social and economic lives of people but also on the surgical lives of surgeons, residents, nursing staff, and patients as well as ground level staff. Amidst this COVID pandemic, emergency surgeries were being done but at a decreased rate, whereas elective cases depended on the will of hospitals, surgeons, and patients. Study aims to promulgate a "Neo–Surgical Check Box" by amalgamating the WHO surgical checklist and the results obtained from the questionnaires.

Subjects and Methods: After receiving ethical clearance from the Institute Ethical Committee, an online questionnaire with 50 questions divided into three sections was distributed to 235 surgeons in Uttar Pradesh.

Results:Two hundred and eight surgeons had responded, out of which 154 were male and 54 were female. Only 41.4% (86) were actually conducting the surgery. The emergency surgery rate was 60.3%, whereas 18.6% of elective surgeries were done, 11.8% of surgeries were avoided, and the rate of minimal access surgery was 9.3%.

Conclusion: The "Neo-Surgical Check Box" will not only increase the number of surgeries per day but also provide protection to the healthcare workers while handling not only COVID-positive patients but also any airborne communicable diseases.

Background: Lowering the amount of iodinated contrast material and tube voltage may increase pulmonary artery opacification and thrombus identification without compromising picture quality.

Objectives: To explore the efficiency of using lower tube voltage and a lower contrast medium dose for conducting computed tomography for pulmonary angiography (CTPA) aiming to increase its accuracy in detecting pulmonary thromboembolism (PTE).

Subjects and Methods:100 patients scheduled for CTPA with a preoperative diagnosis of PTE were grouped into two: group A, (50 patients) got 1 mL/kg at 120 kV and group B, (50 patients) received 0.5 mL/kg at 80 kV.The technique of bolus tracking was implemented.Values of midpoint of multiple pulmonary artery divisions were used to assess attenuation.Significant values are those that exceed 300 Hounsfield units (HU). The dosage of radiation received by the patient, defined as the effective dose, was compared between groups.

Results: Total mean attenuationdata for the pulmonary arteries have shown to be substantially greater in group-B compared to group-A (39110.4HU vs. 335.97.9HU, P=0.001). Moreover, total dose length product (DLP) values were substantially lower in group-B (934.9 mGy.cm vs. 384.443 mGy.cm, P=0.001). While effective dose values have shown to be significantly lower in group-B (2.90.3 mSv vs. 13.21.8 mSv, P 0.001).

Conclusion: Low-kilovoltage technique and low quantity of iodinated contrast are useful in conducting (CTPA) with high accuracy in detection of pulmonary thromboembolism.

Background: Diabetes mellitus is a chronic disease with an increasing prevalence worldwide and characterized by an increase in oxidative stress and inflammation. The most important factor that is responsible for oxidative stress and production of reactive oxygen species (ROS) is hyperglycemia. The major targets of ROS are proteins. The most common and widely used biomarker of severe oxidative protein damage is protein carbonyl content.

The study was designed to assess the serum level of protein carbonyl as a marker of protein oxidation in patients with type 2 diabetes mellitus and to evaluate the effect of age, body weight, waist circumference, diabetic control and disease duration on the level of protein carbonyl.

Subjects and Methods: This is a case-control study that included 91 patients with type 2 diabetes mellitus Eighty-five non-diabetic apparently healthy subjects matched for both age and sex with cases were enrolled as controls. Fasting blood samples were collected after an overnight fasting to measure protein carbonyl, fasting blood sugar, lipid profile, and glycated hemoglobin.

Results: The level of serum protein carbonyl was significantly higher in diabetic patients than in controls and positively correlated with glycated hemoglobin, age of participant and disease duration as well as with body mass index and waist circumference.

Conclusion: Diabetes mellitus is associated with an increase in protein oxidation in term of increase in the level of serum protein carbonyl with significant association in those who had poor glycemic control, obesity, higher age, and prolonged disease duration suggest that the carbonyl content of protein may be useful in evaluating the disease progression. Significant positive correlation of protein carbonyl together with waist circumference suggest that individual with central obesity are more susceptible to protein oxidation.

Background: The COVID-19 infection is a more recent pandemic disease all over the world and studying the pulmonary findings on survivors of this disease has lately commenced.

Objective: We aimed to estimate the cumulative percentage of whole radiological resolution after 3 months from recovery and to define the residual chest CT findings and exploring the relevant affecting factors.

Subjects and Methods: Patients who had been previously diagnosed with COVID-19 pneumonia confirmed by RT-PCR test and had radiological evidence of pulmonary involvement by Chest CT during the acute illness were included in the present study. The radiological data of chest CT scan of all patients were collected and analyzed after recovery (confirmed by negative RT- PCR) three months after their initial diagnosis of having COVID 19 pneumonia.

Results: A total of 40 patients who had a second CT scans were assessed; there were 27 (67.5%) male and 13 (32.5%) female, with a mean age of 40.3 years old. The collective percentage of whole radiological resolution was 65% (26 patients). Patients >40 years old showed a significantly lower cumulative percentage of complete radiological resolution than patients ≤40 years old at the 3 months follow-up. The predominant patterns of abnormalities observed at discharge were ground-glass opacity (GGO), fibrous stripe and reticular opacities.

Conclusion: Lung findings in COVID-19 pneumonia patients can be resolved completely during medium-term follow up with no sequelae. The older age and co-morbidities are the main significant risk factors for residual radiological findings of COVID-19 disease.

Background: Bacteriocin is a peptidic toxin has many advantages to bacteria in their ecological niche and has strong antibacterial activity. Objective: The aim of this study was to evaluation of bacteriocin using Streptococcus sanguinis isolated from human dental caries.

Subjects and Methods: Thirty five streptococcus isolates were diagnosed and tested for their production of bacteriocin, and then the optimal conditions for production of bacteriocin were determined. After that, the purification of bacteriocin was made partially by ammonium sulfate at 95% saturation levels, followed by and gel filtration chromatography using Sephadex G-50 column. Finally, physical characteristics were also studied and determined the bacteriocin stability.

Results: Among all streptococcal isolates, the S. sanguinis SH3 isolate with batter antimicrobial activity was selected, and used in further experiments. The optimum conditions for bacteriocin production were in Todd Hewitt broth (THB) supplemented with 1% glucose at 37°C for 24h under anaerobic conditions and inoculum size of (1.2 ˟ 109CFU/ml) and pH 7, where the inhibition zone diameter reached to 29 mm against Enterococcus faecalis. The purified bacteriocin had high inhibitory activity against S. pneumoniae, S. pyogenes, E. faecalis, E. faecium and Leuconostoc mesenteroides. Streptocin SH3 keeps its effectiveness within the pH range 3-10, and temperature until 80ºC for 20 min.

Conclusion: Bacteriocin produced from S. sanguinis has high activity against many pathogens and has high stability over wide ranges of temperature and pH, which makes it a good alternative in the medical and food preservation fields

Background: Malaria remains a leading cause of mortality in sub-Saharan Africa (including Sudan). C-reactive protein (CRP) is useful as a marker of severity in malaria. African studies have shown that serum CRP levels correlate with parasite burden and complications in malaria, especially falciparum. However, there are no data on CRP levels in Sudanese malaria patients.

This study aims to evaluate the association between CRP levels with comorbidities, species, and complications of severe malaria

Subjects and Methods: A cross-sectional study enrolled 65 severe malaria patients at Khartoum state hospitals during the period from April to June2021. Manifestations of severe malaria were defined according to WHO criteria. Data regarding demographics, presenting symptoms & signs, laboratory investigations, complications, length of hospital stay and outcomes were collected. CRP was classified as elevated when the measured level was >10 mg/l.

Results: Among 65 patients, 33(50.8%) were females and 32(49.2%) were males, and mean age was 48±21 years. The main manifestation of severe malaria diagnosis criteria was anemia in 26(40%) patients. Most of the patients had density 1+ (n=53; 81.5%) and were infected by P. falciparum (n=61; 93.8%). The overall case fatality rate for malaria was 8% (n=15 patients). The mean of CRP was 72±57 mg/L and 84% (n=55) of patients had elevated levels above 10 mg/L (ranged from 10-100 mg/L in 52%, and above 100 mg/L in 32%). The elevated CRP levels were significantly DM (P= 0.048), high malaria parasite density in blood film (P= 0.001), P. falciparum (P= 0.33), presence of complications (P= 0.001) and death (P= 0.003)

Conclusion: Elevated CRP levels were found in a considerable proportion of severe malaria patients. CRP is an effective biomarker in assessing malaria severity and poor prognosis in term of complications development and mortality.

Background: The prevalence of thyroid nodules rise with age and different data available about the risks of thyroid surgery in old age people. In general, old age could be a predictor of perioperative mortality and morbidity. The aim of this study is to prove if there is increased risk accompanying thyroidectomy in elderly patients.

Subjects and Methods: Prospective study of one surgeon of study sample undergoing thyroid surgery at Al-Kindy teaching hospital and Saint Raphael hospital .This study was including two groups; group (A) involved patients 65 years and older, group (B) involved patients below 65 years old who were subjected to thyroidectomy. Taking in consideration histopathology results, indications of surgery (compressive symptoms, suspicious or confirmed malignancy, toxic goiter and recurrent goiter) and complications (including rates of temporary and permanent hypocalcaemia, temporary and permanent RLN paralysis, postoperative hematoma, wound infection and seroma), in addition to the risk of perioperative mortality.

Results: There were 574 patients below 65 years and 127 elderly patients (>=65 years) who underwent thyroidectomy between January 2015 and December of 2018. There were no deaths in either group; no one had bilateral RLN paralysis. Old age patients had a lower frequency of complications in comparison to the younger counterparts, including transient hypocalcaemia (3.1% vs 14.8%, respectively) and temporary RLN injury (0% vs 0.69%, respectively), in addition to permanent RLN injury (0% vs 0.34%, respectively).

Conclusions: Thyroidectomy in elderly is safe as compared to younger patients regarding perioperative complications

Background: Corn Syrup is food syrup higher of carbohydrate, depending on grade. The study aimed to assess efficiency of Corn syrup as cytological fixative.

Subjects and methods: This was laboratory based study, it has been conducted at Elrazi University included apparently 30 healthy students have been involved in this study.

Results: Out of 30 smears fixed with 95% alcohol, 76.7% (n=23) shows excellent nuclear stain, 23.3% (n= 7) shows good nuclear stain. 70% (n=21) show excellent cytoplasmic stain, 26.7% (n=8) shows good cytoplasmic stain, 3.3% (n=1) shows poor cytoplasmuc stain.

Out of 30 smears fixed with corn solution, 60% (n=18) shows excellent nuclear stain, 40% (n=12) good nuclear stain, 3.3 % (n=1) shows excellent cytoplasmic stain, 83.3% (n=25) shows good cytoplasmic stain, 13.3% (n=4) shows bad cytoplasmic stain.

Conclusion: Study concluded that Corn syrup can be used as cytological fixative alternatively to 95% ethyl alcohol.

Background: Primary Health care (PHC) is unanimous to be the cornerstone of a person-centered health system. While the adoption of a well-function, two-way, and organized referral system is the mainstay in the development of an efficient healthcare delivery system.

Objective: To Assess the practice & opinion of doctors in the hospitals toward the referral system. to determine the doctors in the hospital\\'s commitment to referral system instructions and guidelines.

Subjects and Methods: A cross-sectional study with analytic elements was conducted in nine Iraqi governorates. Eight doctors from each health directorate, resulting in a total of 72 doctors using a specially designed questionnaire. Statistical analysis was done by using SPSS, the P≤0.05 was considered statistically significant.

Results: of the total 72 physicians, 31(43.1%) aged 40-49years, 48(66.7%) were males, and 58(80.6%) were specialists., 58 doctors (80.6%) had no coordination with the PHC-doctors, the same percentage considered the current referral system is ineffective. PHC patients-crowded, doctors-shortage were the causes of inadequately filling PHC-part of the referral form. And PHC-hospital doctors-coordination had a significant association with their age, gender, and their thinking about adequate filling.

Conclusion: despite the importance of the referral system, half of the doctors disagreed about the current referral system’s effectiveness; & most of them had no coordination with the PHC-doctors. PHC crowded/doctors’ shortage the main causes of inadequate filling PHC part of referral-form.

Background: Most primary hypothyroidism patients also experience inefficiency and irregularity. It is possible to understand the significance of myo-inositol in treating the thyroid gland by relating it to the synthesis of thyroid hormones. Study aimed to estimate serum of inositol 1,4,5-triphosphate (IP3) in primary hypothyroidism disorder and through that level it can shed light on whether it is accused of inactivity of the thyroid gland and at the same time open the doors for the use as a treatment.

Subject and Methods: The study was taken from the analytical cross-sectional design.120 subjects were divided into three groups, the first group included 40 healthy subjects, the second group included 25 patients with subclinical hypothyroidism, and the last group had 55 patients with primary hypothyroidism. with the subjects chosen from a teaching laboratory in the medical city. thyroid hormones and serum TSH was determined using Enzyme Immunoassay by Tosoh instrument assay, while serum inositol 1,4,5-triphosphate (IP3) using (ELISA) system.

Results: primary hypothyroidism patients showed a significant (p≤0.05) decrease level of serum IP3 when compared with healthy subjects. There is significant positive correlation with serum inositol 1,4,5 triphosphate (IP3) and each triiodothyronine S.T3 (r = 0.581, p ≤0.05), thyroxine S.T4 (r = 0.597, p ≤0.05), and significant negative correlation thyroid-stimulating hormone S.TSH (r=-0.820, p≤0.05), in primary hypothyroidism Patients.

Conclusions: inositol 1,4,5 triphosphate (IP3) deficiency in primary hypothyroidism disorder may be a cause of it happening, at the same time may be useful in its treatment even if it was not studied adequately in the study, but through its effect on a thyroid hormone.

Background: Iron homeostasis is crucial to many physiological functions in the human body, such as cellular activity, erythropoiesis, and the innate immune response. Iron deficiency anemia may occur from obesity's ability to disturb iron homeostasis. Obesity may be seen as a pre-inflammatory condition with mild, ongoing systemic inflammation. Additionally, an increase in hepcidin levels by chronic inflammation causes iron insufficiency in obese people. For this reason, this current experiment is designed to investigate the iron profile and some hematological and inflammatory parameters in obese adults in the Kurdistan region-Iraq.

Subjects and Methods: The cross-sectional study was designed within the context of a medium private laboratory with participants being common people involved, 200 adults participated in this study and were allocated into two groups according to BMI (control group (BMI ≤ 29.9): N=100 and obese group (BMI >30): N=100). Oxygen saturation (SpO2) and pulse rate were assessed. Blood sera (once) was obtained for iron profiles (s. Iron, Ferritin, Hepcidin) and inflammatory levels (c-reactive protein (CRP), interleukin 6 (IL-6)).

Results: Our findings highlighted that all inflammatory markers increased significantly in the obese groups in both sexes and a positive correlation with BMI and a significant decrease in iron in the obese group.

Conclusions: This research reveals that hepcidin levels in obese adult people contribute to the development of iron deficiency anemia due to increased inflammation.

Background: Melanin pigmentation of the gingiva appears in all ethnicities. Excessive pigmentation is an esthetic concern that has increased awareness about depigmentation procedures. This epidemiological study aims to find the correlation between skin color and gingival pigmentation in Sulaimani Governorate, Kurdistan/Iraq.

Subjects and Methods: A total of 820 apparently healthy and non-smokers, including 338 males and 482 females with healthy gingiva, aged between (18-40 years old) were enrolled in this study. Clinical examination on the participants’ gingivae was performed to assess color, and the distribution of pigmentations. Afterward the of participants skin color were visually examined and divided into six groups according to the Fitzpatrick scale.

Results: Skin color of (53%) of our participants was medium to light brown. Most of the pigmentations were observed in the attached gingiva and interdental papilla (26.83%) and least being in the marginal gingiva and interdental papilla (9.27%). A statistically significant correlation was found between the participants’ skin color, and the intensity of their gingival pigmentations

Conclusion: Darker-skinned subjects haveeavieringival pigmentation compared toair-skinned people in Sulaimani Governorate, Kurdistan/ Iraq. The intensity of gingival pigmentation increases with age with the highest rate of gingival pigmentation was in the upper and lower second premolar to premolar area.

The multisystem inflammatory syndrome in children (MIS-C) considers a post-infectious immunological response to coronavirus illness (COVID-19) that was originally identified in the United Kingdom and later identified in other countries. A previously healthy 3-month-old boy was admitted to hospital context with -5-day history of fever, gastrointestinal symptoms [diarrhea, vomiting of normal gastric contents], hypoactivity, and poor oral intake, but so far no history of covid-19 active disease. The infant was dehydrated, with macular non-blanching skin rash everywhere over his body and widespread non-pitting edema. With supportive measures, methylprednisolone and IV immunoglobulin, the child improved, with his fever, skin rash, and laboratory tests returning to normal. On the seventh day of hospitalization, he was discharged. This is identified as the youngest reported case of MIS-C since the beginning of the COVID-19 pandemic

A 20 year-old male was admitted with a history of recurrent palpitations from 5 years. Baseline ECG revealed premature ventricular contractions (PVCs) with delta waves. Stress ECG showed short non-sustained Ventricular tachycardia (VT). Echocardiography showed moderate dilation of the left ventricle with mild reduced systolic function and Ejection fraction was estimated to be 42%. Right ventricle was mildly dilated and hypokinetic. Both atria were mildly dilated. The patient referred to CVC for EP study with possible ablation. The ablation of the focus led to complete suppression of the ectopy. Post-procedure ECG and echocardiography showed normalized rhythm and systolic function.

Congenital toxoplasmosis (CT) and congenital rubella (CR) infections are well-known causes potentially leading to devastating consequences. This report aims to address the prevalence of each of these infections among suspected infants in a pediatric hospital in Baghdad.

The study sample includes 120 blood samples of suspected infants consulting Al-Alwyia pediatric teaching hospital over one year. This report represents an extension of a previous article published in Al-Kindy College Medical Journal KCMJ about cytomegalovirus infection (CMV). Using the enzyme-linked immunosorbent assay (ELISA) method, the results show that 5.8% and 5% were positive for specific IgM antibodies for rubella and toxoplasmosis respectively. Results also show that CMV is more common than CT and CR.

Although results reported one case of co-existence of IgM antibodies for both CMV and rubella, there was a significant association of negative CMV IgG and IgM results with positive rubella results; and negative rubella results with CMV IgG and IgM results.

Conclusions: This short brief addressed the prevalence of CT and CR in Baghdad. A novel finding identified in this brief is the association of the prevalence of CR active infection with negative past and negative recent CMV infections, and the association of prevalence of CMV active and past infections with negative CR infection

Recommendations: The study recommends increased awareness, early diagnosis and treatment for congenital infection, and consolidation of coverage of the rubella vaccine for children and girls at premarital age.