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   Table of Contents - Current issue
Coverpage
July-December 2019
Volume 18 | Issue 2
Page Nos. 59-108

Online since Wednesday, December 18, 2019

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REVIEW ARTICLE  

Hypoxia-inducible factors-α as a regulator for forkhead box protein M1 in pulmonary artery hypertension p. 59
Israa Burhan Raoof, Aseel Ghassan Daoud
DOI:10.4103/MJ.MJ_12_19  
Hypoxia is defined as decreased levels of oxygen in the cells, which are caused by vascular and pulmonary diseases. The catalysts of hypoxia in the physiological role are important in all living cells, whereas its metabolic dysfunction is related to many diseases. Hypoxia-inducible factors (HIFs) activity should be controlled by providing HIF modules. Forkhead box protein M1 (FOXM1) plays a crucial role in the maintenance and differentiation of airways epithelial cell lining, especially during embryonic life, where it is essential in the formation and proliferation of pulmonary vessels. FOXM1 is overexpressed in the pulmonary artery smooth muscle in response to hypoxia through the elements that are present in the promoters of FOXM1; therefore, it was used to diagnose patients with pulmonary artery hypertension.
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ORIGINAL ARTICLES Top

Gastroesophageal reflux disease questionnaire score and endoscopic findings in patients with gastroesophageal reflux disease p. 63
Sabeha Albayati, Firyad Dhari Khalaf
DOI:10.4103/MJ.MJ_8_19  
Background: Gastroesophageal reflux disease (GERD) is one of the most common conditions encountered in the in- and outpatient clinic, may present with heartburn and acid regurgitation, and it can be asymptomatic too. Furthermore, chronic recurrent cases lead to potentially preventable complications such as esophageal erosion, stricture, and even ulcers. Objective: The aim of the study is to evaluate the accuracy of history taking from patients with GERD and compare it with endoscopic findings. Patients and Methods: This study was conducted in GIT center, Department of Medicine at Al-Yarmouk Teaching Hospital from November 2017 to March 2018. One hundred patients (65 males and 35 females) referred for oesophagogastroduodenoscopy (OGD) for symptoms suggesting of GERD; the assumed indication of their referral, severity of their condition evaluated using GERD Questionnaire (GERDQ score), and their endoscopic finding were assessed depending on Los Angeles classification of erosive esophagitis. Results: A total of 100 patients were enrolled in this study, including 42 patients had erosive esophagitis and 58 had not. There was statistical significance in the GERDQ score of erosive esophagitis group (9.5 ± 1.2) and nonerosive esophagitis group (8.6 ± 1.98); P < 0.05 showing that significant correlation between the score and the occurrence of erosive esophagitis. GERDQ score and the severity of reflux esophagitis were positively correlated. Conclusion: There was correlation between GERDQ score and the severity of esophageal erosion by endoscope in patients with GERD, GERDQ a valid scoring system that scientifically correlates between clinical symptoms and history findings with the endoscopic result.
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Sinus venosus versus ostium secundum atrial septal defects: Their diagnosis and surgical outcome p. 70
Hammood Naser Mohsin, Firas Sadeq Abdul Kareem
DOI:10.4103/MJ.MJ_7_19  
Background: Diagnosis of sinus venosus atrial septal defects (ASDs) poses clinical difficulties than that of ostium secundum ASDs which may delay its diagnosis and treatment. Surgical repair of sinus venosus ASDs is more intricate in correlation with the repair of ostium secundum ASDs and conveys the risk of stenosis of the superior vena cava (SVC) or the rerouted pulmonary veins (PVs) and sinus node dysfunction (SND). Objectives: To compare diagnostic modalities and surgical outcome of sinus venosus ASDs to that of ostium secundum ASDs. Patients and Methods: Out of the total 72 patients in the age range of 1 year–46 years, 36 patients underwent surgical repair of sinus venosus ASDs and 36 patients underwent surgical repair of ostium secundum ASDs. Their data were collected and retrospectively studied from June 1, 2009, to October 1, 2016, at Ibn-Alnafees Teaching Hospital for cardiothoracic surgery in Baghdad, Iraq. We divided the patients into two groups: Group A including 36 patients who had sinus venosus ASDs and Group B including 36 patients who had ostium secundum ASDs. A comparison was made between the two groups according to preoperative variables, diagnostic modalities, intraoperative variables, and postoperative morbidity and mortality. Results: Transthoracic echocardiography (TTE) was the mainstay for the diagnosis of ASD secundum, while ASD venosus type needed more modalities for diagnosis. No operative death, postoperative bleeding, acute renal failure, SND, SVC stenosis, and PV stenosis were observed in any patient in the two groups. Residual shunt was not observed in any case in the two groups. Conclusion: TTE, transesophageal echocardiography, cardiac magnetic resonance imaging, or diagnostic catheterization may be needed for the diagnosis of sinus venosus ASD. Surgery is the mainstay of sinus venosus ASDs with low morbidity and no mortality, similar to ostium secundum ASDs.
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Detecting heart tissue injury in electrocution human cases using heart-type fatty acid-binding protein 3 p. 74
Ameen Mohammed Kathum, Nabeel Ghazi Hashim Al-Khateeb
DOI:10.4103/MJ.MJ_2_19  
Introduction: In the medicolegal daily practice, electrocution is a traumatic cause of death owing to wide use of electricity and electrical devices in different activities of modern life at home and workplaces. Electrical current passage through tissues elaborates different types of energy (the electrical, thermal, and mechanical energies) which can cause skin lesions, multiorgan damage, and even death. The severity and extent of tissue injuries depend on the current type (alternating current [AC] or direct current), its strength (amperage), voltage (low or high), frequency, tissue resistance, duration of exposure, and its pathway through the body. Microscopic examination of tissue samples from the heart may show nonspecific findings to electrocution, but sometimes none is detected by conventional hematoxylin and eosin stains (H and E). Therefore, immunohistochemical studies could help the forensic pathologists in their diagnosis, especially cases with less typical findings or obscure circumstances. Heart-type fatty acid-binding protein 3 (H-FABP3) is a small cytoplasmic protein of (15 kDa), composes of 133 amino acids, involves in active fatty acid metabolism, and transports fatty acids from the cell membrane to mitochondria for oxidation. Due to its cytoplasmic location and small molecular weight, it released from cardiac myocytes into the circulation following an ischemic episode. Objective: This study was conducted to evaluate the effect of electric current on the expression of H-FABP3 in human heart tissue autopsy samples. Methods: Human heart tissue samples were collected during the period from January 1 2016 to June 30, 2016, through autopsy of 30 medicolegal cases of electrocution as well as 30 cases of fatal head injuries which were used as control. They were examined by conventional histopathological H and E stain and immunohistochemical technique so that H-FABP3 was detected using FABP3 polyclonal antibody and demonstrated by ready to use biotin-free, one-step horseradish peroxidase polymer anti-mouse, rat, and rabbit immunoglobulin G with 3,3'-diaminobenzidine to achieve the aim of this study. Results: This study shows that electric shock was the fifth cause of traumatic death, being responsible for death of only 4.5% of cases referred to the medicolegal directorate in Baghdad during the period of study. It is almost accidental death in Iraqi society with higher incidence to be due to contact with low-voltage household AC sources with young males at the age of (15–20 years old) are being more vulnerable to fatal electrical injury than females during their early productive life (with male:female ratio = 6:1). Heart tissue ischemia is a major cause of death following electrocution, especially when victim being in contact with household low-voltage AC in the presence of transthoracic pathway to the ground and low body resistance due to skin wet which can cause death within a minute in association with mild if any electrical skin burns. Electrocution has a significant effect on H-FABP3 stain total index as it causes depletion of FABP3 total stain index with mean of 0.28 ± 0.149177SD for tissue sections of the heart muscle in the affected areas of human cases. Conclusions: Immunohistochemical heart tissue samples' examination which shows dramatic depletion in H-FABP3 total stain index in affected area(s) is of value in detecting heart tissue injury caused by electrocution during the early period after death even in the absence of grossly and microscopically visible lesion(s).
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Risk factors for postsurgical diabetic foot recurrence after minor or major lower-limb's amputation p. 85
Mustafa Usama Abdulmageed, Ali Adil Abdullah
DOI:10.4103/MJ.MJ_28_18  
Background: Many previous studies on diabetic foot focus on ulceration and amputation, but few studies took on recurrent ulcer or wound infection with several years' follow-up after amputations and studying risk factors such as peripheral arterial disease (PAD), renal disease, cardiovascular disease, and environmental factors which may play a role and explain for that disease recurrence. Aim: The aim of this study was to assess the risk of recurrence of diabetic foot disease after different level of amputations. Patients and Methods: A prospective study was conducted for 32 patients presented with diabetic foot disease. This study started from September 2011 up to December 2016. Those patients who admitted for (minor or major) amputation with risk factor diseases were studied and followed up for any recurrence. Results: Among 32 patients, 17 cases did minor amputation (53.1%), whereas 15 cases (46.9%) did major amputations. The number of patients who developed recurrence was 11 cases distributed, as 8 cases (25%) developed wound infection and other 3 cases (9.4%) developed ulceration. Seven cases of those who developed wound infection (87.5%) after amputation had PAD. All patients who complained recurrent ulceration (100%) had PAD risk factor with P = 0.0001*. Two cases (25%) of those with wound infection and also one case with ulceration had renal disease with P = 0.039*. Conclusion: PAD, renal disease, and renal failure have significant risk factors for recurrence of wound infection and ulceration after diabetic foot–limb amputation.
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Diode laser versus topical triamcinolone acetonide agent in the pain reduction of minor recurrent aphthous stomatitis p. 92
Ammar Hadi Khammas, Mohammed Radef Dawood, Salam Amer Kamil
DOI:10.4103/MJ.MJ_15_19  
Background: Recurrent aphthous stomatitis (RAS) is characterized by the painful ulcerations of the oral mucosa, which impacts on the patient swallowing, so an effective therapeutic strategy mostly addresses the pain reduction as well as ulcer healing process; however, no specific therapeutic modality has been validated as gold standard therapy yet. Objective: The objective of the study was to determine the efficacy of 810-nm diode low-level laser therapy (LLLT) and compare with the application of topical triamcinolone acetonide in Orabase agent in respect to pain threshold reduction in patients with minor RAS. Patients and Methods: Twenty patients with minor recurrent aphthous stomatitis were enrolled in the study and were randomly divided into two equal groups: Group “A” treated with 810-nm diode LLLT, with an estimated energy density of 30–37.5 J/cm2, and Group “B” treated with topical triamcinolone acetonide; a questionnaire was handed to all these patients and it was returned back after 7 days to record their pain perception threshold on the Visual Analog Scale (VAS) score on daily basis. Results: The mean VAS pain score of the laser group was 6.94 ± 0.32 initially and was decreased significantly to 2.14 ± 0.47 on day 3, with P = 0.001; while the mean VAS pain score of the triamcinolone group was 7.13 ± 0.38 initially and was decreased significantly to 2.16 ± 0.14 on day 3, with P = 0.001. However, in the intergroup comparison, the mean value of VAS pain perception threshold in the laser group (2.98 ± 0.32) was significantly lower than that of the triamcinolone group (3.40 ± 0.14) from day 1 to day 3, with P = 0.012. Conclusions: Both low-level diode laser and triamcinolone therapies showed a significant early and lasting pain threshold reduction in patients with minor RAS; however, in comparison between the two modalities, it goes more statically significant in favor of the low-level diode laser therapy up to day 3.
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Immunohistochemical evaluation of renal allograft biopsies from a sample of iraqi renal transplant recipients p. 97
Taha Yaseen Al-Azzawi, Refif Sabih Al-Shawk, Thaeer Jawad Al-Taee
DOI:10.4103/MJ.MJ_11_19  
Context: Renal transplantation is the best treatment for end-stage renal disease, although some complication may arise after transplantation including transplant rejection and infection, each of the two can occur oppositely to the other since the insufficiently suppressed immune system can still attack the graft while excessively suppressed immune system may allow latent virus to reactivate. The best way to diagnose both of the conditions is by immunohistochemical staining using monoclonal antibodies specific for BK virus and C4d. Aims: This study aims to investigate the frequency of antibody-mediated rejection (AMR) and BK virus nephropathy (BKVN) in renal allograft biopsies in Iraq. Settings and Design: The study encompassed 53 renal transplant recipients who developed signs of renal dysfunction. Subjects and Methods: Renal allograft biopsies were collected from centre of nephrology and kidney transplantation and AL-Yarmouk teaching hospital in Baghdad from January to September 2017, biopsies were embedded, sectioned, fixed on slides and stained with hematoxylin and eosin and monoclonal antibodies specific for C4d and BK virus. Statistical Analysis Used: Data were tested using Chi-square test; the analysis was conducted using the available SPSS-24 Package. Results: Samples were obtained from 38 males and 15 females in whom their mean age was 36.0 ± 13.8 years, the average time between transplantation and biopsy was 33.5 ± 22.5 months, and there was 31 donation from related donor and 22 from unrelated donor. The frequency of BKVN was 1.8% and the frequency of AMR was 52%. Conclusions: Using immunostaining of renal allograft biopsies using anti-BKV antibodies and anti-C4d help in identifying the causes of renal impairment after transplantation that otherwise remain hidden.
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LETTERS TO EDITOR Top

Ameliorating health-care delivery to the vulnerable population groups p. 103
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/MJ.MJ_4_19  
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Establishment of the climate-proof health systems in small islands p. 105
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/MJ.MJ_13_19  
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Need to invest and strengthen the primary health care globally: World Health Organization p. 107
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/MJ.MJ_10_19  
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