Al-Kindy College Medical Journal

Plentiful of healthcare practice is based on a disease/treatment approach rather than a prevention one. That is, the predominant focus is on treating existing symptoms and conditions that bring the patient to healthcare setting. There is no doubt about the significance of this approach for acute conditions, but there is some question whether this is the most efficient and effective way of distributing healthcare for increasing number of diseases and limited resources.

The evidences from everywhere have showed the profound cost benefit of prevention in healthcare practice. Healthy community, therefore, is the ultimate aim in any health services planning. The priority of care giver is shifted now to promote health and prevent disease in any stage (susceptible, subclinical, clinical and recovery/disability) before death, and in all situations, as health status cannot remain constant for an individual, family, community or country over a period of time.

Background: Listeria monocytogenes, a member of the genus Listeria, is widely distributed in agricultural environments, such as soil, manure and water. The genus of Listeria bacteria is about 15-17 species. It is a pathogenic bacterium that can cause a rare but dangerous infection called listeriosis.

Objectives: Studying the rate of salads contaminated with Listeria bacteria. and Listeria monocytogenes according to International, Arabic and Iraqi specifications and finding the correlation between commitments of restaurants to standard health conditions with contamination with these bacteria

Methods: The study included 152 samples of salads taken from 39 restaurants chosen randomly and of different levels and places in Baghdad from the period between 1/9/2014 to 20/1/2015. The laboratory tests were carried out on samples based on internationally approved methods in addition to methods of the International Standards Organization.

Results: The study revealed that 23 samples (15.13%) from the 152 samples taken from the restaurants were contaminated with Listeria species. of these, 3 (2%) were contaminated with Listeria monocytogenes and 20 (13.2%) were contaminated with other types of different and non-pathogenic Listeria as follows; (Listeria welshimeri, Listeria seeligeri, Listeria ivanovii, Listeria grayi, Listeria innocua) with the following prevalence (7(4.6%), 6(3.9%), 3(2%), 3(2%), 1 (0.7%) respectively).

Conclusions: Contamination of salads taken from restaurants with Listeria bacteria is not uncommon. This indicates that routine examination is necessary and should be added to the Iraqi standard for salads.

Background: Breast cancer is the first one among Iraqi females. Most of them present later for diagnosis. Early detection center in tertiary hospital practice uses FNAB for early diagnosis. Publications on accuracy of this detection are scarce.

Objective: To test the accuracy of FNAB in breast lump diagnosis.

Methods: Diagnostic test accuracy study, on 204 women with breast lump, attending the oncology department in 2017.

Results: Fine-needle aspiration biopsy diagnosis of histologically malignant cases were, malignant in 89 (87.3%), suspicious of malignancy in 5 (4.9%), and benign in 4 (3.9%). Complete sensitivity was 87.3%, and specificity was 100%, with 12.7% false negative results and no false positive cases. The accuracy was 94%.

Background: Breast lump is one of the most common prevalent complaint of patients attending breast clinics.

Objective: To determine if there is any change in the pattern of common breast, diseases presenting as breast lumps between pregnant and non-pregnant women among patients attending Al-Elwiya Breast Clinic.

Methods: This is a cross – sectional study, with convent's patient sampling setting in AL-Elwiya Breast Cancer Early Detection Clinic from 1st Feb. to 1st May 2018, we collected data from patients with breast lumps including the age groups, pregnancy status, parity status, previous breast diseases, hormonal drugs, menstrual cycle, breast feeding. Breast lump was examined, sonography and needle biopsy, and histopathology.

Results: This study involves 306 married patients, fibro adenoma was the commonest pathology in the age group 20-29 year-old (29.9%) followed by Aberration of Normal Development and Involution which was found mainly in 30-39-year-old age group (36.1%). Carcinoma found mainly in the >40-year-old age group (10.3%).

Aberration of Normal Development and Involution was the main pathology in non-pregnant patients (36.1%), in pregnant patients fibro adenoma is the commonest (35.7%).

Conclusion: The majority of breast lumps are benign. In pregnant women, fibro adenoma is the commonest, while in non-pregnant women, Aberration of Normal Development and Involution is the main cause of breast lumps

Background: Radioactive iodine-131 therapy is highly effective in treating patients with hyperthyroidism. An ablative dose is preferred by a number of endocrinologists, and, a fixed dose protocol seems to be better than a calculated dose in real practice.

Objective: To check for hypothyroidism in hyperthyroid patients one year after RAI therapy, comparing between the results of high ablative versus usual dosages of RAI-131.

Methods: This study included 174 hyperthyroid patients, 101 males and 73 females, divided into 2 groups, the first consisted of 162 patients given a usual fixed dose of RAI while the second consisted of 12 patients given a high fixed ablative dose of RAI. The study lasted about 2 years from August 2000 till July 2002 in the Specialized Centre for Endocrinology & Diabetes, Baghdad.

Results: Out of 162 patients in the first group, 11 patients (6.8%), developed hypothyroidism compared to 4 patients out of 12 (33.3% ) in the second group ( p < 0.05).

Conclusion: A high ablative dose RAI has a better outcome regarding hypothyroidism than a usual dose, although, endocrinologists have different opinions regarding this issue.

Background: Diabetes mellitus (DM) is a significant cause of visual impairment; many diabetics do not have regular eye examinations, although it is known that early diagnosis and reduces the risk of blindness. There were many barriers that prevent diabetics from attending eye clinics.

Objectives: To assess knowledge, and practice about ocular complications among diabetic patients and to determine barriers preventing the diabetic patients annual visual checking

Methods: A cross-sectional study involving the interview was conducted among 300 diabetic patients attending out patient in Ibn Al Haitham Teaching Ophthalmology Hospital between November 2017 and June 2018.

Results: The vast majority of patients (95%) believe that; diabetes could affect their eyes. 67% have their eyes checked up after being diagnosed with diabetes, of which only 33% they examined their eyes if vision got poor. Majority of patients believe that; controlling their blood sugar levels can help preserve their vision (84%). 72% of the total has good knowledge of DM effect on the eye. 55% of patients obtained their knowledge from the doctor and only 2% having obtained this knowledge from Television. Unfortunately only 3% of them check their vision annually 37 % they don’t know treatments available for diabetic retinopathy.

Conclusion: Diabetic patients’ knowledge of ocular manifestations and the practice of diabetic patients towards eye examination were low, thus required to improve practice towards eye care to prevent visual impairment.

Background : To assess the actual practice of breast self-examination (BSE), as an early detection tool for breast cancer, among a sample of patients affected with breast cancer in Iraq.Methods: A random sample of 200 female patients with breast cancer was analyzed to evaluate the extent of their actual practice of breast self-examination before the diagnosis of the disease. The examined variables included the age of the patients, marital status, education, occupation, smoking habit, family history of cancer, frequency of gravidity, parity and abortions. Results: The age of patients ranged from (24-70) years with a mean age of 48 years. The highest frequency of the examined sample (24%) was noted in the age group (50-54) years. The majority of the patients (89%) were married, 33% had university degree and 57% were employed. While 46% of the patients had a family history of cancer, in 33.5% the breast was involved. Only 5.5% of the total number of patients had practiced BSE regularly before the diagnosis of breast cancer, 57.5% had carried out the procedure randomly while 37% did not perform BSE at all during their lives. The study illustrated that the level of education, occupation and family history of cancer had significant roles in the practice of BSE. Conclusions: The findings of this study emphasize the urgent need for promoting screening in our society through strengthening practical policy decisions to raise the level of public awareness among the Iraqi women towards the adoption of simple approaches for early detection of breast cancer.

Background: Painful elbow joint over the lateral epicondyle especially with resisted wrist extension are common signs of lateral epicondyle tendinopathy, also called tennis elbow.

Objective: To evaluate the clinical outcome of local platelet rich plasma (PRP) injection in patients with chronic tennis elbow compared with a steroid (Depomedrol 40 mg) injection.

Methods: A total of 88 patients with chronic tennis elbow were treated at Al-Kindy Teaching Hospital and private clinics. All patients had chronic pain for about 24 weeks or more and had failed first line treatment. The patients dividing into two groups, Group A injected with PRP (n = 44), and group B injected with depomedrol 40 mg (n = 44). A good clinical result was demarcated as 25% or more progress on the visual analog scale for pain. All patients followed for 6 months in both group for clinical successful result.

Results: At three months (n = 44), in group A reported a perfection of 58.2% in their pain scores while 49.3% in the group B (N = 44). At 6 months follow up, the group A informed a perfection of 74.3% in their pain scores while 58.4 % in the group B. The local elbow tenderness recording at three months was 37.4% in the group A, while in the group B was 48.4%. At six months, 16.1% versus 30.2% recounted major elbow tenderness (P = .009) in groups (A and B) respectively.

The clinical improvement rates at three months revealed no changes between both groups while it showed more significant clinically changes in group A ( 87.1%) than in group B (70.1 %) with P value = 0.008 after six months follow up.

Conclusion: No important changes were found at 3 months in both groups, but at 6months, clinical significant perfections in patients treated with PRP group (group A

Background: Imaging has a critical role in the diagnosis and evaluation of cardiac diseases, beginning with chest radiography and fluoro-scopy and progressing to coronary angio-graphy, echocardiography, nuclear medicine and recently multidetector computed tomo-graphy (MDCT) as well as magnetic resonance (MR) imaging

Objective: To highlight the role of Multi-detector CT in the evaluation of coronary artery disease and its importance of being noninvasive diagnostic technique.

Methods: A cross sectional study for 20 patients. Patients were asked to fast 6 hours prior to the examination and the patients with heart rates above 65 beats per minute were given cardio-selective beta-blocker and for heart rate above 75 (up to 85) beat/min, the best systole phase was used for reconstructing our images

Results: for Evaluation of native coronary arteries, the CTCA showed significant lesions (occlusion or >60 % stenosis) in the native arteries of 13 patients and insignificant lesions in 7 patients.

Evaluation of CABG (8 arterial grafts); for (LIMA) graft, 83% were patented, and 17% were narrowed and 100 % of (radial graft) were patent. For Venous Grafts the study included 10 venous grafts; 70 % were patent, 20% were narrowed and 10 % were totally occluded.

Conclusion: The multi-slice CTCA is now a clinically reliable noninvasive tool that allows the evaluation of the native coronary arteries, the bypass grafts, coronary stents.

Background: Endometriosis is defined as the presence or growth of ectopic endometrial tissue outside their usual site ( the uterus). It is a common condition in women. It may occur in the ovaries, fallopian tubes, vagina and rarely, endometriosis may occur in the abdomen and lungs. Endometriosis is common among women of reproductive age. It is either primary or secondary. The triad of diagnosis is a pain with menstruation, cesarean scar and a mass in the scar. Methods: A report a series of 65 patients in the period from 1st Jan 2013 to 31st Dec 2017. The study was performed in Al-Kindi Teaching Hospital and a private hospital. The mean age was 35 years (range 20-45).All patients were treated surgically i.e. excision of the tumor and old surgical scar in the lower abdomen.

Result: mean age was 35 years (range 20-45). Thirty patients (46.15%) were housewives while 35(53.84%) were officers. The interesting finding is that 52 patients had the mass in the left side, 10 in the middle and only 3 in the right side of the scar respectively.

Conclusion: Our study demonstrated a lateral asymmetry in the location of scar endometriosis i.e. mostly on the left side. The prevalence on left side of scar can be added to the triad of diagnosis mentioned above I.e. cyclical pain, cesarean scar and mass mostly in left side of the scar.

Background: Treatment of invasive prolactinoma, which has several characteristics including invasive growth into cavernous sinuses and formation of giant adenomas compressing adjacent neural structures, resulting in neurological dysfunction, has been very challenging. There are relatively few reports available describing long-term treatment outcome.

Aims of the study: In this study we evaluate the results of cabergoline administration as initial treatment during 4 years follow up period.

Methods: We prospectively categorized 36 patients into four groups according to the results of 3 months of cabergoline treatment: group 1, tumor volume reduction (TVR) ˃25% with normalized serum prolactin (NP) (n = 24); group 2, TVR˃25% without NP (n = 4); group 3, TVR ˂25% with NP (n = 5); and group 4, TVR ˂25% without NP (n = 3).

Results: During follow-up, 22 patients (91.7%) in group 1 achieved TVR˃50% with NP. Three patients (75%) in group 2 achieved TVR˃50% with NP after treatment for 8 months. In group 3, four patients (80.0%) continued medication because of improvement of symptoms and achieved additional TVR(18.8–46.4%). Surgery was performed on five patients (one in group 2, one in group 3, and three in group 4), and complete resection was achieved in four (80.0%). Overall, 25 (69.4%) of the 36 patients treated with cabergoline had complete response and 6 (16.7%) had partial response but did not require surgery. Thus, the overall response rate was 86%,with only five patients (14%) requiring surgical debulking. NP was not achieved by surgery alone in all cases, even after total resection of tumor.

Conclusion: Patients who achieve TVR˃25%with NP with 3 months of cabergoline administration had a high possibility of showing good long term response (TVR˃50% with NP) to cabergoline. A higher dose of dopamine agonist (DA) should be considered for patients who achieve TVR˃25% without NP.

Background: Otitis media with effusion is characterized by accumulation of fluid in the middle ear in absence of acute inflammation and it is the most common cause of acquired hearing loss in children, and may negatively affect language development failure of medical treatment of middle ear effusion frequently require myringotomy and tympanostomy tube insertion.

Objectives: To determine tympanostomy tube complications of tube in children with chronic otitis media with effusion who were treated with Shah Grommet tube insertion.

Methods: The Medical records of 162 ears of 87 children (52 male and 35 female) were reviewed respectively, the patients ages were between 3 to 16 years old (mean age =8.11 years), patient were followed for 6-66 months (mean 23.3) after tympanostomy tube insertion. Tube extrusion time was also reviewed in all patients, and the indication for surgery was chronic middle ear effusion.

Results: Otorrhea accured in nine ears (5.6%), granulation tissue was seen in 2 ears (1.2%), myringosclerosis in (34.6%) persistent perfor-ation (5.6%), atrophy (23.5%) retraction (16.7%) and medial displacement 1.2% the average extrusion time was 8.5 month ( ± 4.6).

Conclusions: complications of tympanostomy tube insertion are common and the most common are otorrhea myringosclerosis, atrophy but they are generally insignificant consequently in majority of these complications there is no need for management.

Background: Ulcerative colitis is a chronic inflammatory condition characterized by relapsing and remitting episodes of inflammation limited to the mucosal layer of the colon.Loop ileostomy might be helpful in the management of the disease.

Objective: To evaluate the role of loop ileostomy in the management of ulcerative colitis.

Methods: Between Januarys 2008 and January 2018, patients with fulminant ulcerative colitis resistant to medical therapy had been referred to our surgical unit and were included in our study. Assessment of the patients’ medical status (serum electrolytes, total serum protein, complete blood count, erythrocyte sedimentation rate, general stool exam,and abdominal ultrasound and x-rays) and psychological statuswere done and then preoperative status correction followed by defunctioning loop ileostomy operated upon them and followed postoperatively in hospital for the response fortwo weeks of hospitalization.

Results: Twenty patients were included in the study, two patients died postoperatively due to comorbidities and pulmonary embolism. Eighteen of twenty patients had a gradual improvement clinically (mucus diarrhea with/without blood, weight gain, fever, psychological and edema) and in hematological and biochemicalvalues (complete blood count, serum albumin protein, erythrocyte sedimentation rate and electrolytes) within two weeks.

Conclusion: Defunctioning loop ileostomy is a simple,less morbidprocedure if compared to other medical treatments which can change the complication features of fulminant ulcerative colitis towards either continue in medical therapy or towards definitive curative surgery and cost effective as it decrease the need for expensive medications.

Background: Postoperative nausea and vomiting (PONV) are one of the most common complaints following laparoscopic cholecystectomy.

Objective: This study was designed to compare the effects of dexamethasone, metoclopramide, and their combination on preventing PONV in patients undergoing laparoscopic cholecystectomy.

Methods: A total of 135 patients enrolled in the study. American Society of Anesthesiologists (ASA) physical status I and II patients were included in this randomized, double blind, placebo-controlled study. Patients were randomly assigned to group A administered 8mg iv dexamethasone, group B received metoclopramide 10 mg, group C received combination of 8mg dexamethasone and 10 mg metoclopramide and group D received 10 cc normal saline.The incidence of PONV, mean visual analog pain scores, request for analgesia, side effects , and well-being score were recorded during the first 24 h postoperatively.

Results: Total incidence of PONV during 24 hr was 24% in the dexamethasone group (group A), 47% in the metoclopramide group (group B), 15% in the dexamethasone plus metoclopramide group (group C) and 61% in the placebo group (group D).

None of the dexamethasone plus metoclopramide group patients required other antiemetic (B6 ample iv.), as compared with one patient in dexamethasone group, three patients in the metoclopramide group and five patients in the placebo group. Pain scores, the time to the first request for analgesia, and side effects were similar across the study groups.

Conclusions: Dexamethasone and the combination of dexamethasone plus metoclopramide were more effective in preventing PONV than metoclopramide and placebo.

Background: laparoscopic cholecystectomy (LC) is getting popularity for the treating of symptomatic gall bladder disease; conversion from laparoscopic to open cholecystectomy (OC) is also common.

Objective : To find out the prevalence of causes, risk factors of conversion from LC to OC among patient suffering from gall bladder disease, and to explore the most common causes of conversion from laparoscopic to open cholecystectomy.

Methods: This prospective study was conducted in the department of general surgery at Alkindy teaching hospital from first of January 2016 to the end of December 2017 .Nine hundred twenty patient were included. Patient age, gender, history of previous abdominal scar, common bile duct stone, ERCP, duration of symptom was included in our study.

Results: Seven hundreds twenty –seven patients 74.48% were females and 191 26.52% were males. The mean age of patient presented with gall bladder disease was 40.43 years. Thirty –eight patients were converted to open cholecystectomy. The most common cause of conversation was dense adhesions 42.1% - followed by bleeding 30.1%. Other common causes of conversion were biliary anomalous anatomy 10.5%, common bile injury 5%, visceral injury and technical failure 7%.

Conclusion: The main perioperative cause for OC was dense adhesion around gall bladder and the male gender, increasing age, history of common bile duct stone removed by previous ERCP, history of previous surgery, are independent risk factors of difficult laparoscopic cholecystectomy.

Background: Congenital cardiac defects have a wide spectrum of severity in infants. About 30-40% of patients with congenital cardiac defects will be symptomatic in the 1st year of life, while the diagnosis was established in 60% of patients by the 1st month of age.

Objectives: To identify the occurrence of specific types of CHD among hospitalized patients and to evaluate of growth of patients by different congenital heart lesions.

Methods: A retrospective study, done on ninety-six patients (51 male and 45 female) with congenital heart disease (CHD) admitted to central teaching hospital of pediatrics, Baghdad from 1st September 2009 to 30th of August 2010.

Results: The most common congenital heart diseases (CHD) were ventricular septal defect (VSD), tetralogy of Fallot (TOF), patent ductus arteriosus (PDA), transposition of great arteries (TGA), pulmonary Stenosis( PS), and Atrial septal defect (ASD).The most common modes of presentation were respiratory infection and heart failure in acyanotic patients and cyanosis in cyanotic groups. The study showed that only patent ductus arteriosus and atrial septal defects were more common in female while all other lesions were equal male to female ratio or slightly more common in male. The effect of acyanotic congenital heart disease on growth (Wt) is more common than cyanotic congenital heart disease.

Conclusions: VSD is the most common type of congenital heart disease and the most common cause of morbidity, while ASD is the least common cause of morbidity in patients with congenital heart disease. The most common modes of presentation of patients with CHD are respiratory infection and heart failure in acyanotic CHD while cyanosis is the most common presentation in cyanotic group.

Background: Patient satisfaction is of increasing importance and widely recognized as an important indicator of quality of the medical care. There was no homogeneous definition of patient satisfaction, since satisfaction concerns different aspects of care or settings, as well as care given by various professions.

Objective: The objective of this study is to assess the patients’ level of satisfaction with diabetes care and to identify the underlying factors influencing it.

Methods: This cross-sectional study had been conducted in the Specialized Center for Diabetes and Endocrinology in Baghdad Al- Rusafa 2018. Where150 type two diabetic patients attending their follow-up were requested to fill the questionnaire. The questionnaire identified patients, doctors, and practice related factors. For statistical analysis of the data, SPSS Version 24 was used, and the Chi-square statistical test was applied, A p-value less than 0.05 was considered statistically significant.

Results: The study showed that the overall level of satisfaction was 79.3%. There was a statistically significant association between age group, gender, profession, educational level and marital status where P value 0.001 for all variables.

Conclusion: It was concluded from the study that patients’ satisfaction was high. Majority of the diabetic patients were satisfied with health services, the level of satisfaction increases with age, female gender, and married patients, but it decreases with a high level of education and profession. High level of dissatisfaction seen on treatment services

Thyroid hemiagenesis (THA) is a rare congenital anomaly in which one lobe of thyroid gland fails to develop during embryological stage. Agenesis may be unilateral, total or isthmic. Left thyroid lobe is more commonly involved than right lobe in hemiagenesis. Agenesis of the isthmus was seen in 50% of cases. Left sided hemiagenesis is more common than right sided hemiagenesis with a Left to right ratio of 4:1. Clinically patients can be euthyroid, hypothyroid or hyperthyroid. Often it is diagnosed as an incidental finding during ultrasonography (USG) study of neck, which can easily diagnose this condition.

Actual incidence of THA is unknown; most cases are diagnosed in patients admitted for thyroid scan or thyroid surgery because of suspicion of other thyroid abnormalities. This explains high frequency of association of hemiagenesis with other thyroid abnormalities such as multinodular goiter, adenoma, hyperthyroidism, hypothyroidism, chronic thyroiditis, and carcinoma.

Khaladkar, et al. emphasized that surgeon when planning a thyroidectomy must be aware of rare anatomical variations because such anomalies are not noticed in the differential diagnosis, investigations and treatment.

We report a rare case of 46 years old female patient who presented with nontoxic nodular goiter and intraoperatively we found a right sided multinodular goiter including the isthmus with complete absence of the left thyroid lobe with ipsilateral inferior parathyroid adenoma which is according to the available studies is the sixth case recorded worldwide till now.

Background: Radiologic evaluation of breast lesions is being achieved through several imaging modalities. Mammography has an established role in breast cancer screening and diagnosis. Still however, it shows some limitations particulary in dense breast.

Methods : Magnetic resonance imaging is an attractive tool for the diagnosis of breast tumors1 and the use of magnetic resonance imaging of the breast is rapidly increasing as this technique becomes more widely available.1 As an adjunct to mammography and ultrasound, MRI can be a valuable addition to the work-up of a breast abnormality. MRI has the advantages of providing a three-dimensional view of the breast, performing with high sensitivity in dense breast tissue and using non-ionizing radiation.2

Results : Recent advances in MRI have shown the potential in bridging the gap between sensitivity and specificity. Methods based on differences in physiological, cellular and biochemical characteristics of malignant, benign and normal tissues were developed to monitor changes in diffusion. Among these techniques is diffusion- weighted MRI (DWI).3

Diffusion-weighted magnetic resonance imaging detects Brownian motion of water protons, thus reflecting the biologic character of tissue. The apparent diffusion coefficient (ADC) is used to quantify the Brownian motion4-5

Conclusion :The use of DWI for breast tumors has recently been considered in clinical application, and many studies have shown lower ADC values for breast cancer compared to normal breast tissue or benign tumors 3.