Mustansiriya Medical Journal

Aim of the study: Is to evaluate factors most correlated to homeostatic model analysis (HOMA-IR) and to construct a formula which can predict HOMA from the cheaper biochemical, biophysical and hormonal risk factors.
Study design; case control
Methods: A total of 34 patients with polycystic ovarian syndrome were recruited from infertility clinic in Al-Yarmuok teaching hospital. From the epidemiological characteristics the following were recorded: BMI, waist to hip ratio, menstrual cycle, hirsutism which was scored by modified Ferriman Gallwey system and the mean ovarian volume from measuring both ovaries while from the hormonal and biochemical variables, luteinizing hormone and follicle stimulating hormone, total testosterone and lipid profile were measured for each patient. For each group of variables stepwise regression followed by best subset regression were implemented to isolate the factors most correlated with HOMA. Coefficient of Mallows (Cp) was used to sort out the single most predictive variable.
Results: Coefficient of Mallows (Cp) was the smallest for BMI among the demographic and clinical characteristics hence the most correlated to HOMA-IR while from the hormonal and biochemical characteristics, high density lipoprotein was the factor most correlated to HOMA-IR as assessed by Coefficient of Mallows (Cp). Accordingly a formula which predicts HOMA-IR directly from BMI and HDL was designed through which HOMA can be estimated easily through the constructed table from the formula. In addition, its percentile can be accessed from an associated table to measure insulin resistance severity.
Conclusion: HOMA was shown in this study to be best correlated with BMI and HDL and from those factors predictive formula was constructed which can predict HOMA-IR and its percentile directly. However extreme caution is called when such formula is used in clinical practice as its validity is neither established nor such tables were constructed before, and not until their validity is established by further studies we advise extreme caution in interpreting results.

Aim: To determine the efficacy of 1% clotrimazole eye drops suspension for treating fungal keratitis as monotherapy or sequentially with topical amphotercin-B.
Method:This therapeutic trial was conducted in Ibn Al-Haetham Teaching Eye Hospital/Baghdad between February 2008 and July 2009. The patients with culture proven fungal keratitis were divided into two groups, first group (presented between February 2008 and May 2008) were treated initially with 1% clotrimazole eye suspension. Second group (presented between May 2008 and July 2009) were treated sequentially with 0.1% amphotercin-B eye drops (induction phase) for 2-3 weeks, then switched to 1% clotrimazole eye suspension (maintenance phase). The results in the sequential group were compared with a previous study of using 0.1% amphotercin-B eye drops as monotherapy for treating fungal keratitis.
Results: Thirty-two patients with culture proven fungal keratitis were enrolled in this study. Eight cases treated initially with clotrimazole suspension, only two of them had favorable response. While 24 patients treated sequentially and 20 of them had favorable response. Comparing the sequential therapy with a previous study used 0.1% amphotercin eye drops as monotherapy, showed that mean time for therapy was not significantly different in non-severe cases (4.1/4 weeks), while it was shorter in severe cases (9.5/12 weeks).
Conclusion: Use of clotrimazole eye drops as monotherapy is not effective in treating fungal keratitis. While Sequential therapy of using topical amphotercin-B during induction phase followed by 1% clotrimazole suspension as clearance, or maintenance phase is an effective and cheaper therapy for treating fungal keratitis.

Background: hyperprolactinemia is a disorder which may be represented clinically by one or more of the following: galactorrhea ,infertility , oligmenorrhea , amenorrhea, luteal phase defect and hirsutisim, lisuride drug was recently used vaginaly in the treatment of hyperprolactinemia to decrease the side effects by it's use orally .
Patients & Methods: An interventional study conducted over a period of one year from October 2011 to October 2012 , in Al-Yarmok Teaching Hospital ,50 patients presented with one or more of the following symptoms, abnormal menstrual cycle(amenorrhea,oligmenorrhea), infertility(unovulatory), galactorrhea. All the 50 patients with elevated prolactin level were received lisuride (dopergin) 0.2 mg vaginally at bed time and continued for 12 weeks ,serum prolactin was measured at 8,12 weeks with monitoring of ovulation by serial U/S.
Results: The study include fifty patients with mean age was 27.2years ±SD7.01 ,and there mean weight was 62.1kg ±SD9.08
All 50 patients had elevated serum prolactin level with mean 66.1ng/ml ±SD 15.5,at the end of the treatment the range of serum prolactin level between 6-17ng/ml ± SD2.9 , which was significantly lower than pre treatment level P =0.0001 At the end of the treatment 86% achieved regular cycle , Ovulation occur in significant number of patients p value < 0.01, (37.5%) of them get pregnancy .less side effect compared to oral lisurid
Conclusion: Vaginal lisurid is an effective drug used for the treatment of hyperprolactinemia to avoid the discontinuation of the drug because of it's side effect, when given orally.

Background: click stimuli auditory brainstem response (ABR) test is commonly used in the audiology centers for confirmation of hearing loss as well as hearing threshold estimation for hearing aid fitting in children.
Aim: To compare hearing threshold evaluation by behavioral pure tone audiometry with that by click stimuli auditory brainstem response audiometry.
Patients & Methods: The study includes 82 children with bilateral hearing loss and no ABR or behavioral responses (164 ears), ranged in ages between 1 and 8 years. These children were referred for hearing threshold estimation as a pre requisite of hearing aid fitting. 16 children (32 ears), aged 4 years and greater, which forms about 20 % of cases were selected for comparison of the results of pure tone audiograms with their auditory brainstem response results, because by the age of 4 years and greater, the pure tone audiometry with headphones can be measured reliably.
Results: The mean age of auditory brainstem response testing was 2.81 years (SD 1.56) and most of the children`s hearing is diagnosed in the 2nd, 3rd and 4th year of age with percentages of 38, 18 and 24 respectively, males (48) more than females (34). Whereas the mean age of ABR for those 4 years and greater is 2.9 (SD 1.3) and ranged in ages between 1.5 and 6 years. The mean age of pure tone audiogram tests was 5.4 (SD 1.1), and ranged between 4 and 8 years. The pure tone audiograms of the 31 ears with no click ABR responses revealed a wide range of dynamic hearing in the frequencies 250, 500, 1000, 2000, 4000, and 8000 Hz with figures of 40-100 (mean 65), 50-100 (mean 75), 70-115 (mean80), 75-120 (mean100), 75-120 (mean105), and 80-120(mean110) respectively.
Conclusion: the study indicated that the Clicks stimuli auditory brainstem response is not a good predictor of behavioral hearing threshold in children, and there is great delay in the age of hearing loss estimation and that will results in delay and inappropriate hearing aid fitting and its consequences on speech development. This raises more attention to be paid on proper behavioral testing, and reliance more on battery of tests by combining click stimuli ABR with other frequency specific tests such as tone pips auditory brainstem response and auditory steady state response for hearing aid fitting and confirmation of hearing loss, and the use of single hearing test for assessing children`s hearing should be discouraged.

Background: The tympanic membrane is an important component of sound conduction system, as an ear trauma may lead to its rupture, so non healed perforation will results in impairment of its function.
Aims: To evaluate the factors those have influence on the spontaneous healing of the traumatic tympanic membrane perforations, and their relation, with various types of ear trauma.
Patients and methods: A descriptive study of 62 patients attended the Otolaryngology Department / Al-Yarmouk Teaching Hospital in Baghdad, from September 1st 2012 to September 1st 2013, with recent ear trauma, resulted in rupture of their tympanic membrane. The diagnosis was made by history of the ear trauma and otoscopy. The frequency of spontaneous healing was assessed by regular follow up, by the author.
Results: The most common type of the ear trauma was blast injury in 43.5%; and the most affected age group was 20-29 years 40.3%. In all types of ear trauma, male were mainly affected, except in slap injury. The smallest size perforation was 51.5%, and it is found in 93.8% of slap trauma. The most common site was posterior perforation 50%, and it is found in all types of ear trauma. The incidence of the spontaneous healing was 81.81%, and the highest frequency of healing was found in slap injury 100% as well as in small size tympanic membrane perforation was 94.1%.
Conclusions: The frequency of the spontaneous healing of traumatic tympanic membrane perforation is high, and the factors that affect its healing include the types of the ear trauma, the size of perforation, and the ear infection. The maximum incidence of spontaneous healing is found in slap trauma, in small sized perforation, and in the absence of ear infection.

Background: Health information systems in most countries are inadequate in providing the needed management support and the current health information systems are therefore widely seen as management obstacles rather than as tools, the current study is an attempt to assess the behavioral and organizational determinants of Health information system performance in Iraq.
Methods: A cross-sectional study was conducted with a total of 189 respondents selected from six Iraqi governorates were interviewed. The Organizational and Behavioral Assessment Tool was used to measure the behavioral and organizational determinant of Health information system performance, it is one of the PRISM package tools that are used to assess the Health information system performance.
Results: The overall mean confidence for Health information system tasks was 69.41%, while for tasks competence, it was 37.1% and that of motivation level was 43.4%. The total score of promoting a culture of information was 63.96% with department provide reward for a good work revealed a total percent of 56.83%.
Conclusion: It can be concluded that overall mean confidence for Health information system tasks is generally high compared to a low competency level for Health information system tasks, with a negative motivation feeling among respondents.

Background: Compound femoral shaft fracture (open fracture) are unsuitable to be treated by internal fixation primarily, in these situation external fixation is the treatment of choice.
Aim of the study: The aim of this method (fixation of compound femoral shaft fractures using external fixators in knee flexion position) is to have a good range of knee movements immediately, post operation and later on, in comparism to classical method (external fixation in knee extension).
Methods: The role of external fixation in the management of compound femoral shaft fractures is reviewed based on a study of 40 patients with compound femoral shaft fractures managed by an A O external fixator in extended knee position ( 20 patients during the period from 2003 – 2005 ) and knee flexion position ( 20 patients during the period from 2006 – 2009 ).
Results: Results showed that those patients with fixation in knee flexion position have much better range of knee joint movements compared with those with knee extension position at time of fixation , without any significant differences in the of fracture healing between the 2 groups.
Conclusion: External fixation of femoral fractures in knee flexion position give good range of knee motion in early and late follow up over fixation in knee extension.

Background: The association of altered lipid profile in essential hypertension is well documented.. The pathophysiology of the underlying mechanism is unknown. Disorder of lipoprotein metabolism may contribute to endothelial dysfunction. Oxidative stress and decreased antioxidant defense enhance free radical-mediated membrane lipid peroxidation and possibly vascular endothelial damage
Objective: To assess the relationship between lipid level and lipid peroxidase with occurrence of hypertension in pregnant women in their third trimester of pregnancy.
Study design: Case control study.
Patient and Method: A total of one hundred twenty five pregnant women in their third trimester of pregnancy were enrolled in this study. Fifty normotensive pregnant women, thirty pregnant women with pregnancy induce hypertension (PIH), thirty pregnant women with preeclampsia and fifteen pregnant women with eclampsia. The four group were comparable for maternal age, body mass index and gestational age. Blood samples were taken for measurement of serum lipid and lipid peroxidase from the four groups and correlate with occurrence of pregnancy induce hypertension, preeclampsia and eclampsia.
Result: There was a significant and direct correlation between occurrence of preeclampsia and total cholesterol in comparison to the control group .There was a significant and direct correlation between preeclampsia and triglyceride, high density lipoprotein, low density lipoprotein /cholesterol level. There was a significant correlation between malondialdehyde level and preeclampsia in comparison to the control group. Also there is recognized relation between the malondialdehyde level and eclampsia.
Conclusion: abnormal lipid metabolism may play a role in the development of preeclampsia and eclampsia, can be used as a measure for early prediction of this disorder.

Background: The humoral immune response of the Camelidae is unique as these animals are the only known mammals that seem to possess functional homodimeric heavy-chain antibodies besides the classical heteromeric antibodies composed of heavy (H) and light (L) chains.
Objective: to assess the ability of camel IgGs to react much better to the tumor associated antigen (TAA) than human IgGs and independently from the haplotype-restriction of the TAA complexes with MHC molecules.
Materials and methods: The immunization of carcinoembryonic antigen (CEA) of two adult camels was carried out in the private farm at Sharjah – UAE for five weeks and then the specimens were collected and transferred to the central laboratory of the Sharjah University. The project was extended from April 2008 to April 2009. The specimens were fractionated by chromatography then were evaluated by using Elisa technique.
Results: The results of CEA immunization of adult camel and its calf was determined by using indirect ELISA test. The ELISA readings showed positive response with camelid serum, urine, milk and calf serum. Negative results showed with pre-immunized serum from camel and its calf and from blocking buffer.
Conclusions: This work succeeded in formulating TAA-specific highly reactive camelid IgG that are able to recognize only the cancerous cells and sparing the normal cells. These TAA-specific antibodies bound tightly to TAA antigens as well as to control carcino-embryonic antigen (CEA).

Background: Intra-articular injections have been used for many years to treat painful joint disorders, especially by means of injecting crystalline suspensions of long-duration corticosteroids. Viscosupplementation, which is a relatively new intervention, consists of injection of exogenous hyaluronic acid into joints in order to treat osteoarthritis of knee joint.
Patients and Methods: A prospective cohort study was conducted in a private orthopedic clinic in Baghdad from March 2013 to the end of September 2014, where it enrolled a total of fifty six (56) patients of middle ages, ranging from 39 to 64 years, classified as either grade II or III according to Kellgren and Lawrence radiographic criteria. Intra-articular injection of two drugs (a long acting steroid drug, then hyaluronic acid) were given locally in one or both knee joints with one week apart. To evaluate the effect of therapy, current study group patients were assessed by Visual Analogue Scale (VAS) after 1 week, and after 4-8 weeks from the beginning of the therapeutic trial.
Results: more than two-third of cases were women (a ratio of 2.1:1), with age group of 50- 59 years old. No statistical correlation was found between Visual analogue scale (VAS) and radiographic grading (i.e. Kellgren and Lawrence radiographic criteria). Significant statistical difference (P<0.05) was shown in patients receiving intra-articular corticosteroids after week \"1\" of therapy, and a slightly better effect after adding hyaluronic acid on week \"4\" regarding the VAS scale of pain for radiographic grade II patients. Radiographic grade III patients showed a significant statistical correlation in VAS after week (4) of therapy for both moderate and severe classes.
Conclusion: Intra-articular injections of both corticosteroids and hyaluronic acid with one week apart appear to give clinical improvement better than using Intra-articular injection of hyaluronic acid alone.

Background: Microalbuminuria is a well-known indicator of poor renal outcomes in patients with type 2 diabetes that leads to diabetic nephropathy (DN), but there are many proinflammatary markers that are elevated during injury to the nephrons which lead to chronic kidney disease, one of those is interleukin - 18 (IL-18).
Objective: To confirm the role of serum IL-18 as a novel predictor before DN onset.
Patients and Methods: The microalbuminuria levels were measured by immunoturbidimetric method, serum IL-18 levels were measured by ELIZA sandwich method, both serum and urine creatinine levels were measured by colorimetric method and hemoglobin A1c (HbA1c) levels were measured by ion exchange - high performance liquid chromatography (HPLC) in 90 individuals, 20 individuals apparently healthy (group I), 40 diabetic patients without microalbuminuria (urinary albumin to creatinine ratio (UACR) ˂ 30 mg/g) (group II) and 30 diabetic with microalbuminuria (UACR 30 -300) (group III).
Results: The mean of serum IL-18 in group I, II and III was 189.30 pg/ml ± 3.269 S.E., 220.83 pg/ml ± 0.900 S.E. and 246.67 pg/ml ± 22.341 S.E. respectively. The difference between group I and II, group I and III, and group II and III was significant (P=0.000 for all). The mean of UACR in group I, II and III was 4.25 mg/g ± 2.359 S.E., 4.20 mg/g ± 1.518 S.E. and 34.17 mg/g ± 0.629 S.E. respectively. The difference between group I and II was not significant (P=1. 000) but between group I and III, and group II and III were significant (P=0. 000 for both). The mean of serum creatinine in group I, II and III was 0.885 mg/dl ± 0.0302 S.E., 0.883 mg/dl ± 0.0240 S.E. and 0.933 mg/dl ± 0.0237 S.E. respectively. The difference between group I and II, group I and III, and group II and III was not significant (P=0.998, 0.331 and 0.145 respectively). The mean of hemoglobin A1c (HbA1c) in group I, II and III was 5.9 % ± 0.0211 S.E., 7.7 % ± 0.0445 S.E. and 8.135 % ± 0.0519 S.E. respectively. The difference between group I and II, group I and III, and group II and III was significant (P=0.000 for all). The correlation between urinary albumin to creatinine ratio (UACR) and IL-18 in group III was significant (r=0.983 with P=0.000). The correlation between hemoglobin A1c and IL-18 was significant (r=0.641 with P=0.000) in group II. The correlation between serum creatinine and IL-18 in group III was not significant (r=0.041 with P=0.830).
Conclusion: while the increased IL-18 levels were positively correlated with both HbA1c and UACR that leads to the progression of the diabetic nephropathy and it can be one of the cytokines which opens the possibility of its application in clinical treatment in the future.

Background: Thrombocytopenia is a common hematological problem in neonatal care units. Neonatal thrombocytopenia has been defined as platelet count less than 150x109 /L, regardless of gestational age.
Objectives: To determine the frequency and assess the severity of neonatal thrombocytopenia in preterms, and the maternal and neonatal conditions as risk factors.
Patients and methods: A cross sectional study was carried out in the neonatal care unit of Child Central Teaching Hospital/ Baghdad, over a period of six months (30th of June to 31st of December 2013). Study group included only preterms who had thrombocytopenia. Data of neonates was collected by direct interviewing of the mothers or other family members, clinical assessment and examination and relevant investigations were done.
Results: The frequency of preterm neonatal thrombocytopenia was 95 (13.04%), out of 728 neonates admitted to neonatal care unit. Male to female ratio was 1.37:1, male gender was significantly associated with prematurity and mild to moderate severity thrombocytopenia (P 0.016, P 0.019). Prematurity was significantly associated with late onset neonatal thrombocytopenia (P 0.035). Late-onset thrombocytopenia, and 32- <37 wk gestational age group were significantly associated with mild to moderate severity thrombocytopenia group (P 0.008, and 0.004 respectively). Sepsis was a frequently associated risk factor in thrombocytopenic preterms, and found in 70 (73.68%) cases of preterm thrombocytopenia (with only 8 cases were culture positive and 62 cases were clinical based diagnosis). Also birth asphyxia, respiratory distress syndrome, and Rh incompatibility were significantly associated with thrombocytopenic prematures (P 0.026, 0.001, 0.008 and 0.036 respectively). Birth asphyxia, respiratory distress syndrome, sepsis and Rh incompatibility were significantly associated with moderate to severe thrombocytopenia (P 0.001, 0.001, 0.003 and 0.011 respectively). There was no significant difference between the presence of maternal disease and gestational age to the severity of neonatal thrombocytopenia (P 0.458, 0.698 respectively).
Conclusions: Preterm thrombocytopenia is relatively common in neonatal care units. Sepsis, respiratory distress syndrome and birth asphyxia were significant neonatal risk factors of thrombocytopenia at lower gestational age preterms. Most episodes were late onset with mild or moderate severity.

Seventy inflammatory bowel disease (IBD) patients (35 ulcerative colitis; UC and 35 Crohn\'s disease; CD) and 20 controls were investigated for serum level of adenosine deaminase (ADA) and neutrophil-lymphocyte and monocyte-lymphocyte ratios. The results revealed that the mean of ADA was significantly increased in UC and CD patients (46.72 ± 8.99 and 41.17 ± 5.95 ng/ml, respectively) compared to controls (20.85 ± 2.79 ng/ml), but it was also significantly higher in UC patients than in CD patients. The neutrophil-lymphocyte ratio mean was also significantly increased UC patients (5.83 ± 3.10) as compared to CD patients (3.79 ± 2.02) or controls (1.66 ± 0.22). The ratio was also significantly increased in CD patients compared to controls. A similar pattern was also observed in monocyte-lymphocyte ratio. In conclusion ADA may have a role in the pathogenesis of IBD, especially UC, and consequently the peripheral immune cells might have been affected.

Spinal muscular atrophy (SMA) is a rare genetic neurodegenerative disease characterized by degeneration of spinal cord lower motor neurons, which results in atrophy of skeletal muscles, hypotonia and muscle weakness. Patients with type IV SMA often have onset of weakness at adulthood.
Anesthetic management is often difficult in these patients as a result of muscle weakness and hypersensitivity to neuromuscular blocking agents also succinylcholine induced hyperkalemia, postoperative intensive care unit admission and long hospital stay.
Laparoscopic surgery is normally performed under general anesthesia, but regional techniques have been found beneficial, usually in the management of patients with major medical problems. The goals for anesthetic management of these patients include satisfactory anesthesia during surgery, excellent postoperative analgesia with minimal compromise of respiratory function without exacerbation of neurologic signs and symptoms.
We describe a 37-year-old male patient with type IV SMA scheduled for laparoscopic cholecystectomy. We decided to use an epidural technique to avoid muscle relaxants, tracheal intubation and to evaluate the efficacy and feasibility of thoracic epidural anesthesia for laparoscopic cholecystectomy, so that it can be used later as Anesthetic technique in patients when general anesthesia is not feasible. After operation, there was no exacerbation of neurologic signs and symptoms or development of respiratory complications neither a need for intensive care unit admission.

Background:Preeclampsia is a complication of pregnancy constituting a major cause of both maternal and fetal morbidity and mortality. Pregnancy is a hypercoagulable state with changes in procoagulant, anticoagulant, and fibrinolytic systems. In preeclampsia, there is a shift in the haemostatic balance towards a pro-thrombotic state, together with changes in endothelial function. It is a state of enhanced coagulation as evidenced by an increased amount of clotting factors in maternal circulation.
Aim of the study:•To study the changes in FXII:C activity in pregnant women suffering from severe preeclampsia, and compared with healthy normotensive pregnant women.
•To correlate its level with the severity of preeclampsia.
Patients and Methods: Thirty five pregnant women in the third trimester of pregnancy with severe preeclampsia were collected from the Department of Obstetrics and Gynaecology in AL-Yarmouk Teaching Hospital from July to October 2010. Their age range is 18-41 years. The criteria for severe preeclampsia included sustained blood pressure of 160/110 mmHg or higher with persistent proteinuria of 2+ or greater on urine dipstick. A total of thirty five healthy pregnant women who were not in labour, their age and gestational age matched with the patients and normotensive throughout gestation were included as a control group. Blood samples were taken from both groups. Four ml of citrated plasma was isolated for PTT, and FXII:C assay [by parallel line bioassay of coagulation factors].
Results: There was significant difference in mean PTT between patients with severe preeclampsia (27.17±4.11) and control group (31.40±4.53). (P value < 0.0001).There was significant difference in mean FXII:C between patients with severe preeclampsia (173.29±8.82) and control group (131.85±9.78). (P value < 0.0001).
Conclusions: Factor XII:C was significantly increased in patients with severe preeclampsia than control group and show significant direct linear correlation with the severity of preeclampsia. Activated Partial Thromboplastin Time was significantly shorter in patients with severe preeclampsia than control group.