Al-Kindy College Medical Journal

Low back pain a major causes of morbidity throughout the world and it is a most debilitating condition ,and can lead to decreased physical function ,compromised quality of life, and psychological distress.

Obesity is nowadays a pandemic condition. Obese subjects are commonly characterized by musculoskeletal disorders and particularly by non-specific LBP. However, the relationship between obesity and LBP remain to date unsupported by objective measurements of mechanical behavior of spine and it is morphology in obese subjects.

Background: Different diagnostic definition and criteria have been recommended by different expert groups for the diagnosis of metabolic syndrome, however, it’s prevalence in the same population could differ depending on the definition used yielding different results. In Iraq, there is a lack of research comparing these different diagnostic definitions.

Objective: To find out the most suitable metabolic syndrome definition to be used for Iraqi people.

Methods: 320 participants were recruited for this study, 53.4% men and 46.6% women, aged between 25-85 years, visiting Baghdad Teaching Hospital, the prevalence of metabolic syndrome according to different definitions were compared and the agreement was assessed by the Kappa statistic.

Results: Metabolic syndrome was diagnosed in 37.8%, 40.6% and 46.9% participants respectively for the National Cholesterol Education Programme Adult Treatment Panel III 2005, International Diabetes Federation 2005 and the recently (2009) revised International Diabetes Federation definition. The prevalence was higher in women than in men, independent of the criteria used. The Kappa statistics suggested that the agreement between the three definitions ranged from good-to-very good,

Conclusion: Metabolic syndrome was high in this Iraqi cohort regardless of the definition used. The recently (2009) revised International Diabetes Federation definition may be more suitable in diagnosis of metabolic syndrome in Iraq.

Background: Acute appendicitis is the most common surgical abdominal emergency with a life time prevalence of 1 to 7 individuals. Because the clinical diagnosis of acute appendicitis remains a challenge to surgeons, so different aids were introduced like different scoring systems, computer aided programs, ultrasonography, computerized tomography, Magnetic resonance imaging, Gastrointestinal tract contrast studies and laparoscopy to improve the diagnostic accuracy.

Objective: To evaluate ultrasound in the diagnosis of acute appendicitis in those patients clinically diagnosed with histopathology as gold standard.

Methods: A cross sectional study carried in Al-kindy Teaching Hospital through one year duration from 1st of may2015 to1st of May 2016. All included patients were subjected to ultrasonographic examination to assess the vermiform appendix with a graded compression technique. The Ultrasonography findings were recorded as positive and negative for acute appendicitis.

All the appendices removed from the study patients were sent for histopathological study. Statistical analysis done using (SPSS) version 21, Chi-sequare test used for categorical variables and t-test was used to compare between two means. Level of significance (P value) set at ≤ 0.05.

Results: A total of 215 patients with suspected appendicitis, males 112 (52.09%) and females 103(47.9%) were included in present study. The validity results of ultrasound in comparison with histopathology findings were as following; accuracy 86.5%, sensitivity 86.5%, specificity 86.6%, positive predictive value 99.8% and negative predictive value 32.5%.

Conclusion: The ultrasonography has a good accuracy, sensitivity and specificity in diagnosing acute appendicitis

Background: Several risk managem-ent standards had been developed including the Project Management Institute, the National Institute of Standards and Technology, actuarial societies, and ISO standards.

Objective: The study aimed at evaluating risk management among managers of model and ordinary primary health care centers in Baghdad City and comparing the risk management among these centers.

Methods: A descriptive comparative design was carried throughout the present study at 55 primary health care centers; 15 model primary health care centers and 40 ordinary health care centers in Baghdad City. The study was initiated from May 25th 2017 up to January 25th 2018. Non-probability (purposive) sample of 55 managers of primary health care centers was selected of 15 model primary health care centers and 40 ordinary primary health care centers in Baghdad City. A questionnaire was constructed for the purpose of the study. The overall number of items included in the questionnaire is 20 items. Internal consistency "split-half" reliability was obtained through computation of Cronbach alpha correlation coefficient. Data were collected through the employment of the questionnaire and the interview technique as means of data collection. Data were analyzed through the application of descriptive and inferential statistical data analysis approaches.

Results: The study revealed that most of the managers of both model and ordinary primary health care centers had employed poor performance of standards of risk management of method of identifying risk (67%) (52.5%); risk management process (67%)(55%); potential risk treatments (60%)(67.5%); and cardinal rules for the practices of risk communication (60%)(50%) respectively. Conclusions: Managers of both sites unfortunately had performed the risk management standards inadequately.

Background: Insertion sequence is a short DNA sequence encode for proteins implicated in the transposition activity. Transposase catalyzes the enzymatic reaction allowing the insertion sequence to +9*lo2 move. ;qqa;.

Objective: To study the sequencing of transposase gene, tnp, IS1216V of S. aureus isolated from food and then compared with that documented in National Center for Biotechnology Information (NCBI).

Methods: Food samples of animal and plant origin were collected, and screened for presence of S. aureus, IS1216V was identified in the Tn1546-like elements in the genomes of all Staphylococcus aureus isolates.

Results: About 75% of total food samples were positive to S. aureus especially in the food of animal origin. tnp amplification showed that, 85% of isolates gave positive result. Sequencing of amplified part of IS1216V tnp of S. aureus isolates showed that, tnp gene had high identity (78-79%) with the reference strains of NCBI.

Conclusion: High percentage of local food samples were contaminated with S. aureus especially of animal origin. Most of the S. aureus isolates showed the presence of transposase gene (tnp) of IS1216V. Sequencing showed some dissimilarity between the sequence of transposase gene (tnp) of IS1216V S. aureus isolated from local foods and strains recorded in database of NCBI.

Background: Acetabular retroversion has been proposed to contribute to the development of pain and osteoarthritis of the hip. Conventional anteroposterir (AP) pelvic radiographs may represent a reliable, easily available diagnostic modality.

Objective: To obtained a reproducible technique allowing the anterior and posterior acetabular rims to be visible for assessment

Method: This is a cross-sectional study conducted from December 2015 to March 2017 targeting patients with hip pain in orthopedic clinic of Al-Kindy teaching hospital. The study sample consisted of 100 patients with hip pain who were investigated with Antroposterior pelvic plain x-ray, which was done for all patients, looking for cross-over sign, the patients with positive cross-over sign radiographs were sent for CT scan to ensure retroversion of acetabulum.

Results: Presence of a cross over sign was documented in 9 patients (9%). From these 9 patient only 8 were proved by CT scan to have retroverted acetabulum. Then the prevalence was 8%.

Conclusion: The cross-over sign is a reliable indicator for diagnosis of acetabular retroversion and the presence of a cross-over sign in a plain film should heighten awareness of the advisability of proceeding to full assessment .

Background: Early detection of subclinical left ventricular (LV) systolic dysfunction is crucial and could influence patients' prognosis by aiding the clinician to candidate patients for better management.

Objective: To detect early LV systolic dysfunction in asymptomatic patient with chronic aortic regurgitation by two dimensional speckle tracking echocardiography.

Methods: Sixty one asymptomatic patients with chronic aortic regurgitation, with no ischemic heart diseases (by coronary angiography) or conductive heart diseases, no diabetes mellitus, no hypertension, and no other valvular heart diseases (group 1) and fifty age and sex-matched healthy subjects (group 2) were enrolled into the study. Group (1) was further classified into 3 sub-groups according to 4 chosen parameters from the published guidelines of American Society of Echocardiography (ASE) into: Mild AR, Moderate AR, and Severe AR.

All patients and controls underwent echocardiographic examination including conventional echocardiography, tissue Doppler study and Two Dimensional (2-D) Speckle Tracking Echocardiography.

Results: GLS showed the highest sensitivity and specificity in detection of subtle LV systolic dysfunction in moderate AR. In moderate AR,a cut off value of > (-19.62) has sensitivity and specificity of 91.3% and 95.5% respectively, with Positive Predictive Value (PPV) and Negative Predictive Value ( NPV ) of 87.5% and 96.9% respectively, Area under curve (AUC) of 0.981. In all types of AR, GLS had higher NPV than PPV which makes it a powerful screening tool for early detection of subtle LV systolic dysfunction.

Conclusion: Global Longitudinal strain measured by 2-D speckle tracking echocardiography is an excellent tool for early detection of subtle LV systolic dysfunction in asymptomatic patients with chronic AR

Background: Plantar heel pain is a clinical syndrome characterized by pain and tenderness beneath the heel which is typically worse in the morning and improves after the first few steps in the day. It is a common and frequently disabling clinical complaint that may be caused by a broad spectrum of osseous or soft tissue disorders.

Objective: To evaluate the effectiveness of an operation of multiple drilling of calcaneum for resistant plantar heel pain syndrome.

Methods: During the period from November 2012 to August 2016, 17 patients (17heels) were enrolled in a cohort clinical study at the orthopedic unit in AL-Sheikh Zayed and Al-Wassity Hospitals.

Result: Drilling of the calcaneum is a simple procedure achieving 70.6% cure in resistant ases with few complications provided good patient selection was done.

Conclusion: Abnormalities in the intraosseous pressure within the calcaneum are a possible cause of plantar heel pain in some patients who failed to respond to conservative treatment

Background: Health education was put as one of the components of primary health care elements and was recognized as a fundamental tool to the attainment of health for all

Objective: To evaluate the Knowledge, attitude regarding health education & to find out if there is any association between the gathered data and certain variables (age, gender, educational level, occupation). Methods: A Cross-sectional study done at Al Mustansyryia Primary Health Care Center from the 1st of January to 1st of May 2016. All patients attending the Primary Health Care Centers who were above 18 years of age and willing to participate in the research (303) were included in the sample, data was collected by structured questionnaire, & then introduced into Statistical Package for the Social Sciences,V.17 for statistical analysis. Chi-square test was computed for significance of difference, and P < 0.05 was considered significant

Results: The highest group of age was (18-30) years old, (51.5%) were male, (35.3%) of participants are of high school education. The participants had good knowledge about health education. There was a significant association regarding knowledge, with ages and educational levels of participants, with no association regarding the gender and occupation. There was no association regarding attitude with these variables. Most of the of participants showed positive attitudes about health education as a practice

Conclusion: The participants had good knowledge about health education, and positive attitude.

Background: Patients who have both neurological impairment and kyphotic deformity can be treated medically, and this treatment can be achieved with anti-tuberculous drugs alone.

Objective: To evaluate conservative medical management of patients with tuberculosis of the spine (Pott disease). The prognostic significance of various clinical, radiological, and long-term follow-up findings in these patients was also evaluated.

Methods: Between January 2009 and January 2018 data were collected prospectively at The Neurosciences Hospital/ Baghdad/ Iraq in 44 patients with Pott disease in the thoracic and lumbar spine. These patients had no major neurological deficits or severe spinal deformities. The study population consisted of 21 male (48%) and 23 female (52%) patients, with a mean age of 42.1 years (range 10–70 years). The most common region of Pott disease was the thoracolumbar junction (18 cases; 41%), followed by the thoracic (16 cases; 36%) and lumbar (10 cases; 23%) regions. With the exception of two cases, all had kyphotic angles less than 30°. At presentation, 20 patients had neurological signs of spinal cord compression during clinical examination. Clinical , radiological, and laboratory investigations findings were used in all cases for diagnosis. All patients were treated with anti-tuberculous drugs, and the disease in only two (4.5%) was resistant to the regimen. The follow up period was 24 months.

Forty-two (95.4%) of the 44 patients were successfully treated with conservative medical management and attained acceptable spinal deformity angles, and none of these patients had any residual instability, radiculopathy, or neurological compromise. Only 4.5% of the patients experienced residual spine deformity (as much as a 30° kyphotic angle), which was clinically obvious but biomechanically stable.

Conclusions: Patients with Pott disease in the lumbar and thoracic regions, without neurological deficits or kyphosis, can be treated conservatively in the vast majority of cases. Indications for surgery need to be redefined given these new data.

Background: A core set of checks have been incorporated into World Health Organization (WHO) WHO surgical safety checklist. Lack of access to basic surgical care remains a major concern in low-income settings.

Objective: We use a WHO surgical safety checklist items to improve team communication and cooperation to help in reduction of morbidity and mortality of surgical procedures.

Methods: This is a prospective study involving 300 patients after applying the 19 items of the surgical safety checklist with different types of operations had been operated in the surgical theater at Al-Kindy Teaching Hospital during the period 1st of September 2016 until 1st of March 2017. We follow up the patients until 30 days after surgical intervention.

Results: After applying the 19 items of surgical safety checklist, the risk of the surgical site infection, respiratory complications, retained gauze and risk of blood loss [14% , 4.6% , 1.3% , and 2% respectively] was comparable to the results of the World Health Organization. Using the pulse oximetry in 94 % and site marked in 65.3%. In 64.6% of patients received antibiotic prophylaxis in which just 4 % developed surgical site infection [SSI], while in extended regime 36.67% there is 10% developed SSI. No mortality reported during collection of the data.

Conclusions: The surgical safety checklist is a simple method, and there is evidence for its effectiveness in reducing complications in clinical use. WHO recommends use of the checklist in all surgical operations and encourages clinicians to modify the list for different specialties and hospitals.

Background: Psoriatic arthritis is a type of arthritis that can often affect some patients who suffer from psoriasis. Approximately 40-50% of individuals with psoriatic arthritis have the HLA-B27 genotype

Objective: To investigate whether we could confirm the role of HLA-B27 alleles and psoriatic arthritis in Iraqi Arab Muslims patients.

Method: A cross sectional case control comparative study included thirty Iraqi Arab Muslims who had psoriatic arthritis that consulted the Dermatological and Rheumatological Department in AL-Kindy Teaching Hospital from November 2014 to June 2015. HLA-genotyping for HLA-B27 were assessed. A control group consisted of fifty-one healthy volunteers among the staff of Al-Kindy College of Medicine that did not have psoriatic arthritis or family history of psoriasis. HLA-B*27allele was done by using an Exicycler TM 96 Real-time Quantitative Thermal Block (Bioneer, Daejeon, Korea) and Accupower, HLA-B27 real-time PCR kit (Bioneer, Daejeon , Korea)

Results: Plaque type psoriasis is more common than other types of psoriasis (66% versus 34%). There is no association between psoriatic arthritis and HLA-B27 with p-value of 0.1197 and Odds ratio (confidence interval) of 2.9375 (0.755-11.415).

Conclusions: HLA B*27 is not associated with psoriatic arthritis in Iraqi Arab Muslims patients.

Background: World Health Organization (WHO) and United Nation International Children Fund (UNICEF) developed a strategy known as Integrated Management of Childhood Illness (IMCI); which aims to reduce less than five years children morbidity and mortality in developing countries.

Objective: To assess the completion of the IMCI format status in primary health care centers, Baghdad.

Methods: A cross sectional study with analytic element was conducted during the period from 15th of January till 15th May 2016 in selected Primary health centers in Baghdad, Iraq. The sample consists of form of child files less than 2 months and form from 2 month up to 5 years children. Classified correctively, determined follow up visits, Comparison classified of nutritional status assessment between health center and IMCI guideline.

Result: 1400 child files were collected, 1295 from child files (2months-5year), and 105 forms from child less than 2 month. In form less than 2 months (correct classified 54.29%, incorrect 45.71%), (Determined date of follow up 13.33%, not determined 86.67%).Form from (2month-5years) (57.07% correct classified, 43.93% incorrect classified), (Determined date Follow up visit 38.38%, Not determined visit 61.62%).

Conclusion: Impaired classification of nutritional status assessment

Background: Anti-vascular endothelial growth factors commonly used intravitreally for treatment of variable retinal disease worldwide, which help to regulate the upregulation of vascular endothelial growth factors due to ischemia or/and other retinal insult.

Objective: To review all cases of intravitreal bevacizumab given in the retinal unit of the Eye Specialty Private Hospital in Iraq from December 2015 to June 2016, pointing out the common indications.

Methods: A retrospective study including all cases of intravitreal injections of bevacizumab recorded at the Eye Specialty Private Hospital from December 2015 to June 2016 were retrieved. Age, sex, laterality, diagnosis and the indication for injection were recorded in the data sheet prepared for the study.. The indications for intravitreal injection of bevacizumab are classified into four groups: Group 1: Intravitreal injection for diabetic complications. Group 2: Intravitreal injection for retinal vein occlusion. Group 3: Intravitreal injection for choroidal neovascul-arization Group 4: Intravitreal injection for other retinal disease.

Results: A total of 306 patients underwent intravitreal injection of bevacizumab were enrolled in the study period. The most common indication was group 1 (intravitreal injection for diabetic complications [213 patients (69.6%)] followed by group 3 (choroidal neovascularization) [45 patients (14.7%)] and then group 2 (intravitreal injection for retinal vein occlusion) [42 patients (13.7%)] and lastly group 4 (intravitreal injection for other retinal disease) represent [6 patients (1.96%)].

Conclusion The most common indication for intravitreal bevacizumab was diabetic retino-pathy that need more care for early diagnosis and treatment of diabetic retinopathy and good screening programs to avoid complications.

Background: Hand, foot, and mouth disease is viral disease caused commonly by coxsackie virus A16 virus. It is a mild disease and children usually recover with no specific treatment within 7 to 10 days. Rarely, this illness may be associated with aseptic meningitis were patient may need hospitalization.

Objective: To determine significance of clinical features of hand, foot and mouth disease.

Methods: A cross sectional study of cases with clinical features of hand, foot and mouth disease visiting the dermatological consultation unit of Al Kindy teaching hospital. Sampling was for Zyona and Edressi Quarter patients over the period of 1st December 2017 to 30th of November 2017.

Aim: To determine significance of clinical features of hand, foot and mouth disease

Results: The mean age of patients (100 patients) was 29.99 months. Males were 65 (65%) and females were 35 (35%), (P 0.23). Tenderness of skin lesions, Malaise and decreased Appetite were the most frequent symptoms. Winter months illness was common .Cases were diagnosed two days before seeking medical help, while home contact of patients was most common place for infection transmission .Involvement of palms and soles was universal and indifferent (100%). Groin was more commonly affected (67%), (P 0.015). Fever was present in 81%.

An anal fissure which does not heal with conservative measures as sits baths and laxatives is a chronic anal fissure. Physiologically, it is the high resting tone of the internal anal sphincter that chiefly interferes with the healing process of these fissures. Until now, the gold standard treatment modality is surgery, either digital anal dilatation or lateral sphincterotomy. However, concerns have been raised about the incidence of faecal incontinence after surgery. Therefore, pharmacological means to treat chronic anal fissures have been explored. A Medline and pub med database search from 1986-2012 was conducted to perform a literature search for articles relating to the non-surgical treatment of chronic anal fissure. Pharmacological sphincterotomy using Glyceryl trinitrate , Isosorbide dinitrate or calcium channel blockers are exciting alternative treatment , that relaxes the anal sphincter and, therefore, promote healing, the drawback of such medications are headache and poor compliance. With the introduction of Botulinum toxin as mean of chemical sphincterotom, topical injection of Botulinum toxin reduces the anal hypertonia which lasts for few months, allows the fissure to heal, thus eliminating the need for surgery without incidence of incontinence. Cure rates are over 60%, and the procedure can be repeated safely. Therefore, Botulinum toxin is a reasonable first-line management of chronic anal fissure and the relapses can be managed by surgery Keywords: Non-surgical treatment of anal fissure, fissure in ano, sphicterotomy,botulinum toxin in anal fissures, glyceryl trinitrate. Chemical sphincteratomy, pharmacological sphincteratomy.