Volume 18, Issue 2, Summer and Autumn 2022, Page 53-93

Reward Systems and Ultra-processed Foods.

Nour Rezaieg

Al- Anbar Medical Journal, 2022, Volume 18, Issue 2, Pages 53-55
DOI: 10.33091/amj.2022.176303

Indeed, the prehistoric period was associated with chronic malnutrition, which was a fundamental rule of human history. Because of this, natural selection favored genetic patterns that could survive in these harsh conditions by storing fat. This is because the main function of body fat is to store food reserves for the body [1]. Feeding behavior could be an interaction of a physiologic need for food with the reward system that powerfully encourages excessive eating in some people. Neuroadaptations in the reward system happens when people eat too many tasty foods. This disconnects eating behavior from caloric needs and leads to uncontrollable overeating [2]. Over time, body fat became a major issue. However, the negative effects of being overweight were not recognized in medical literature until as late as the 18th century. Then, technological advancement and economic prosperity resulted in the comfortable availability and simple cost of high-calorie foods, which are palatable to a large segment of the population [3].
     Many factors that were formed as a result of this technological development have become major contributors to the increase in the obesity epidemic, including the increased use of sugar substitutes, the addition of preservatives to foods, sugar-sweetened beverages, changing eating patterns, as well as the promotion of sedentary lifestyles [4].
     Excess calories taken in comparison to calories burned from any source result in the accumulation of these calories as body fat. Obesity may be characterized in many ways: For starters, it is a condition in which excess body fat interferes with normal activity and health. Second, the weight is more than 20% greater than the ideal height and body size. Third, a body mass index (BMI) is over 30. [5].  

Ventilator-associated Pneumonia: A Narrative Review

Hayder Alkayssi

Al- Anbar Medical Journal, 2022, Volume 18, Issue 2, Pages 56-60
DOI: 10.33091/amj.2022.176306

The difficulty of early diagnosis, the proper anti-microbial chosen, and the relatively high morbidity and mortality; make us collect the related subjects to deal with the most critical complication (ventilator-associated pneumonia) showing the major points needed for every intensivist. Ventilator-associated pneumonia is considered the most common respiratory complication (infection) in intensive care unit patients. Ventilator-associated pneumonia can be defined as a hospital-acquired infection of the lung parenchyma that occurs after 2 days of mechanical ventilation. Its incidence is about 9-25% in intubated patients for more than 2 days. We could classify ventilator-associated pneumonia as early and late; the first one happened within four days of receiving mechanical ventilation, otherwise, the late onset occurred after day four. Some patients with hospital stays before intensive care unit admission and intubation are considered to have late ventilator-associated pneumonia regardless of the period of mechanical ventilation because those patients might have had pathogens previously (nosocomial). Severe ill patients, prolonged mechanical ventilation, and failed extubation trials (recurrent intubation) lead to the development of ventilator-associated pneumonia rapidly and aggressively. Furthermore,ventilator-associated pneumonia is attributed to prolonged hospitality as well as high morbidity and mortality. We aimed in this narrative review to discuss ventilator-associated pneumonia regarding the etiology, causative agents, risk factors, strategies for early diagnosis, accurate treatment, and optimal prevention protocols.

Effect of Perineural Dextrose Injection on Myofascial Pain Syndrome

Sinan Khalil

Al- Anbar Medical Journal, 2022, Volume 18, Issue 2, Pages 61-65
DOI: 10.33091/amj.2022.176307

Background: Myofascial pain syndrome (MFPS) is defined as the motor, sensory, and autonomic signs resulting from trigger points (TrPs).
Objectives: To assess the effectiveness of the perineural injection in patients with MFPS.
Materials and methods: The study was conducted at AL Ramadi Teaching Hospital, Department of Rheumatology, Ramadi City, Iraq. The study period was from June 2019 to January 2021. A retrospective review of 100 patients with prospectively collected clinical and radiologic data was performed to evaluate the effectiveness of perineural injection on MFPS. A 3 ml of 5% dextrose solution was managed sub-cutaneous straight at the labeled chronic constrictive injury and tender spots rounding the knee. The VAS and WOMAC were calculated for each participant at the time of the presentation and 1, 3, and 6 months following treatment.
Results: The mean age of the patients was 60.93 ± 6.17 years (25-70 years). Three-quarters (75/100) of the cases were female. Seventy subjects were from the age group ≥ 40 years, while the remaining 30 cases were from the age group < 40 years.  Fifty-five cases were with right-sided involvement. Successful results were achieved in 90% of the participants. There were no statistically significant differences between the effective and not effective groups regarding the age, gender, and the involved side (P-value > 0.05). There was a reduction in the mean VAS (8.47 ± 0.77) of pain and WOMAC (78.99 ± 5.69) score at the time of presentation to 1.87 ± 1.32 for the VAS and 17.84 ± 4.66 WOMAC at 6-months post-injection period. No complications were reported in all patients apart from mild pain at the injection site.    
Conclusion: Perineural dextrose injection was successful in 90% of the patients with MFPS. This modality results in a sharp reduction of both VAS and WOMAC scores from the time of the presentation to 6-months post-treatment. We recommend using this modality because it is easy, effective, and safe.  

A Comparison of Treatment Success between Functional and Camouflage Orthodontic Treatments in cl II Malocclusion

Luay Zaidan; Nisreen Saleh

Al- Anbar Medical Journal, 2022, Volume 18, Issue 2, Pages 66-71
DOI: 10.33091/amj.2022.176308

Background: Functional and camouflage orthodontic treatments in cl II malocclusions are different treatment methods that usually used in orthodontic practice. A comparison of treatment success betweenthose treatment groups shows which treatment method is better to choose.
Objectives: This study aimed to compare functional and camouflage orthodontic treatments in patients with class II malocclusion.
Materials and methods: The sample size was from individuals who they completed treatments between February 2017 and July 2020 at the Department of Orthodontics, Faculty of Dentistry in Suleyman Demirel University, Turkey. The subjects were from 2 genders and a total number of 146 cases with an average age of 11-22 years. Peer Assessment Rating (PAR) index was used to evaluate the success of the treatment using plaster models taken from these cases before and after the treatment.
Results: In our study, orthodontic treatment results were evaluated by the PAR index in three groups as very successful, successful, and unsuccessful according to the scores of success rate (PAR%). The majority of treatments were found to be successful (67.81%), approximately a quarter of cases were very successful (26.71%), and low rate of failure (5.48%).
Conclusion: Although there were positive occlusal changes in functional and camouflage orthodontic treatment groups, patients in the functional orthodontic treatment group showed more improvement in the PAR change rate. Therefore, we recommend starting with treatment at an early age to get more benefit from the growth of patients. 

Prevalence of Helicobacter pylori Infection in Cigarette and Nargileh Smoking Males in Erbil City, Iraq

Chiman Saeed; Suhayla Shareef; Pshtiwan Majeed

Al- Anbar Medical Journal, 2022, Volume 18, Issue 2, Pages 72-76
DOI: 10.33091/amj.2022.176309

Background: Smoking is the foremost public health problem affecting the world and it has a crucial implication in causing many common diseases due to Helicobacter pylori infection which is globally distributed. Smoking is considered a critical risk factor that accelerates infection with this bacterium.
Objectives: The study's goal was to find out how common Helicobacter pylori infections were among male cigarette and nargileh smokers.
Materials and Methods: A case-control study was performed between August and December 2021in Erbil Teaching Hospital in Erbil City, Kurdistan Region, Iraq.  Blood samples were collected and used for detection of anti-Helicobacter pylori IgG Abfor 80 males who were smokers and 80 who were non-smoker.
Results; The prevalence of Helicobacter pylori positivity was 64.9% in smokers and 45.5% in nonsmokers (P-Value = 0.03). The highest percentage (54.1%) was found in the young age group (25-34) years (P-Value = 0.05), and 89.2% of Helicobacter pylori-positive individuals exhibited stomach symptoms (P-Value = 0.01). Fifty percent of Helicobacter pylori-infected individuals were nargileh smokers.  
Conclusion: The prevalence of Helicobacter pylori showed significant value in nargileh smoking males. Therefore, smoking was a key factor in the seroprevalence of Helicobacter pylori and had a substantial impact on it.

Prevalence of Dyslipidemia and Hypertension in Iraqi Adolescents with Type 1 Diabetes Mellitus

Dawood Abdoun; Riyadh Al-Rawi; Balsam Abulmajeed

Al- Anbar Medical Journal, 2022, Volume 18, Issue 2, Pages 77-81
DOI: 10.33091/amj.2022.176311

Background: Diabetes is one of the most common non-communicable diseases in the world. It is a chronic disease with multiple complications such as retinopathy, neuropathy, nephropathy, and cardiovascular disease.
Objectives: The study aimed to identify the prevalence of dyslipidemia and hypertension in type 1 diabetes mellitus (T1DM) in Iraqi adolescents.
Materials and Methods: A cross-sectional retrospective study was conducted on adolescent patients with T1DM for more than two years and aged 10-18 years old. For each participant, the age, gender, onset and duration of the DM, body mass index (BMI), blood pressure, and low-density lipoprotein (LDL) level in the blood were recorded
Results: Of 70 subjects, there were 42 (60%) girls. The duration of the DM was predominantly between 2-5 years (59%). Around half of the cases were diagnosed between 5 and 10 years. Girls had a significantly higher mean BMI than boys [21.5 kg/m2 for girls and 18.6 kg/m2 for boys (P-value 0.001)]. Seven (10%) patients were diagnosed with hypertension. LDL was high in 22 patients (31%) with the majority of them (15/22) having an LDL value of between 100-130 mg/dL. Most of the participants with a high LDL were girls (18/22) with a statistically significant gender difference (P-value = 0.018). There were significant correlations between high blood pressure and BMI (P-value = 0.004) and elevated LDL levels (P-value = 0.008). 
Conclusion: The study revealed that hypertension and dyslipidemia were seen in 10% and 31% of children with T1DM respectively. The elevated LDL and BMI were significantly higher in female patients than in males. Besides, there were significant associations between high blood pressure and BMI and elevated LDL levels. 

Giant Antrochoanal Polyp in a Six-years-old Boy: A Case Report and Literature Review

Raid Al-Ani

Al- Anbar Medical Journal, 2022, Volume 18, Issue 2, Pages 82-85
DOI: 10.33091/amj.2022.176312

Antrochoanal polyps are more prevalent in children than adults. Unilateral nasal obstruction and rhinorrhea are usually the features of unilateral antrochoanal polyps. Bilateral nasal obstruction can be a feature of antrochoanal polyp if it is large and obstruct both choanae. The giant antrochoanal polyp is rarely reported in the literature. We are reporting this scenario of giant left antrochoanal polyp in a 6-years-old boy who presented with bilateral nasal obstruction, nasal and postnasal mucopurulent discharge, hypo-nasal speech, mouth breathing, snoring, and obstructive sleep apnea syndrome. The physical examination revealed a mass seen in the oropharynx behind the uvula. Further examination by nasal endoscopy, computerized tomography, and histopathological evaluation of the excised polyp have confirmed the diagnosis of an antrochoanal polyp. Although this entity is not commonly seen in daily clinical practice, careful assessment is needed to not miss the diagnosis for early treatment to avoid unwanted complications. 

Atypical Presentation of Pelvic Abscess: A Case Report

Haitham Noaman; Ammar Fouad

Al- Anbar Medical Journal, 2022, Volume 18, Issue 2, Pages 86-89
DOI: 10.33091/amj.2022.176313

An abscess is a common disease worldwide and its diagnosis is usually straightforward. However, pelvic abscess is rarely seen in daily clinical practice. Besides, it is a challenge for the surgeon to diagnose abscesses in unusual location, including the pelvis. A 41-year-old housewife lady had a history of poorly controlled insulin-dependent diabetes mellitus with recurrent vaginitis, cervicitis, and recurrent urinary tract infection. She presented with bilateral hip joint pain and limitation in her movement, with diabetic ketoacidosis. She was admitted to the hospital for the treatment of diabetic ketoacidosis. A physical examination revealed a high-grade fever, unwell, and there is a pelvic mass. Laboratory tests showed leukocytosis and a low hemoglobin level. Ultrasonography and computerized tomography revealed a 5 × 5 pelvic mass, which was located anterior to the bladder, with a high suspicion of an abscess formation. The patient was admitted to the surgical ward and drainage of the abscess under general anesthesia with antibiotic cover was performed. The patient was discharged two weeks postoperatively with an improvement in all presenting features. Bilateral insidious hip joint pain with limitation of movement should orient the clinician to a pelvic abscess as one of the differential diagnoses of these symptoms.

Compound Odontoma Associated with Dentigerous Cyst

Tahrir Aldelaimi; Afrah A. Khalil

Al- Anbar Medical Journal, 2022, Volume 18, Issue 2, Pages 90-90
DOI: 10.33091/amj.2022.176315

A 17-year-old female presented to the Department of Oral and Maxillofacial Surgery complaining of hard expansion with pain sensation in the posterior part of the left mandible for two weeks ago. She  was healthy with an unremarkable medical history. Intra-oral examination revealed retained lower left deciduous molar (#75) with bony expansion on the left side of the mandible. Orthopantomograph (OPG) showed unerupted  third molars as well as compound odontoma associated with dentigerous cyst include the cement-enamel junction of impacted lower left second premolar leading to mechanical obstacle of eruption and in turn impaction (Panel A). Under local anesthesia, two sided flap was raised, surgical removal of impacted tooth with cyst enucleation, and curettage of the surrounding odontoma tissues (Panel B) with preservation of the inferior dental canal (Panel C). Odontomas are hamartomas that presented as complex or compound odontomas; their etiology still unknown. Compound odontoma was a malformation having more orderly arranged dental tissue pattern that was rarely associated with dentigerous cyst of impacted premolars. The early diagnosis and management of odontoma and cyst are important for both surgeon and patient to avoid the need for surgical intervention and the need for future Prosthodontic restoration of extracted teeth. At the end of six weeks, results showed complete healing and the patient retained her normal sensation with good aesthetic outcome.

Multiple Xanthoma Tuberosum

Hazim Ghazzay; Thamir kubaisi

Al- Anbar Medical Journal, 2022, Volume 18, Issue 2, Pages 91-91
DOI: 10.33091/amj.2022.176316

A 43-year-old unmarried healthy woman presented at the dermatology clinic with xanthelasma (Panel A) and asymptomatic multiple rounded, grouped, and yellow to orange colored nodules, located on the hands and feet for 16 years (Panels B and C). The lesions were 15 mm in size; and were indurated, coalesced, and gradually grown. The patient had no history of diabetes mellitus, hypertension, heart problems, or any history of thyroid disease. On the other hand, she had a family history of sudden death when her brother died at the age of 28 years after a cardiac attack. The vital signs were normal. Full blood counts were normal. Fasting blood glucose was 98 mg/dl (reference range 70 to 99 mg/dl), triglycerides 174 mg/dl (reference range < 150 mg/dl), serum total cholesterol 216 mg/dl (reference range < 200 mg/dl), low density lipoprotein 259 mg/dl (reference range < 116 mg/dl), and high density lipoprotein 29.5 mg/dl (reference range > 55 mg/dl for females). Serum uric acid, liver enzymes, and thyroid function tests were within normal limits. The patient had no evidence of ischemic heart disease or pancreatitis. Treatment started with Rosuvastatin at 40 mg/day. The diagnosis is multiple xanthoma tuberosum (MXT). It is characterized by deposition of lipid at the subcutaneous tissue, particularly on the elbows, knees, face, knuckles, and toe joints. Equal prevalence is reported in males and females. The biopsy is not performed owing to the missing of the patient. This case shed light on MXT associated with abnormal serum lipoprotein levels and a family history of sudden cardiac death. The affected subjects with MXT need long-life follow-up to catch its serious cardiovascular complications as early as possible and treated them promptly.

Occlusion of Two Coronary Arteries Simultaneously

Amjed Sheet

Al- Anbar Medical Journal, 2022, Volume 18, Issue 2, Pages 92-92
DOI: 10.33091/amj.2022.176317

A 60-year-old woman with a history of stroke and known hypertension presented to the emergency room after experiencing acute chest pain for an hour. Her blood pressure was 80/55 mmHg, and her pulse rate was 42 beats per minute. An electrocardiogram (ECG) showed first-degree cardiac block and inferior and anteroseptal leads with acute ST-elevation myocardial infarction (STEMI) (Panel A). The patient was promptly moved to the catheterization lab after receiving first care. Early distal left anterior descending (LAD) artery partial blockage with thrombus-containing lesion was found during diagnostic coronary angiography (Panel B). After a challenging engagement of the right coronary artery (RCA), it was discovered that there was a proximal complete blockage with a thrombus-containing lesion (Panel C). Unfortunately, the patient collapsed with severe bradycardia (34 beats per minute) and hypotension (systolic blood pressure = 60 mmHg), which did not react to quick intravenous fluid and atropine ampules. A temporary pacemaker was soon implanted. After the pacing was started, the patient developed ventricular fibrillation, which required cardiopulmonary resuscitation (CPR) and successive DC shocks before the pulse returned to sinus. The RCA was successfully stented quickly, followed by the stenting of the LAD lesion (Panel D and E). The patient rapidly returns to sinus rhythm with great coronary blood flow, and normal blood pressure is recorded after one hour of recovery. Two hours later, echocardiography demonstrated normal systolic function with no aberrant segmental motion. Occlusion of two coronary arteries is a critical disorder that requires immediate detection and treatment to avoid complications such as ventricular arrhythmias and cardiogenic shock. The patient was released with excellent outcomes.

Clear (Pale ) Cell Acanthoma

Abdullah Mancy

Al- Anbar Medical Journal, 2022, Volume 18, Issue 2, Pages 93-93
DOI: 10.33091/amj.2022.176318

A 36-year-old gentleman presented to the  Dermatology and Venereology outpatient clinic with a painless nodule of the volar aspect of the left forearm for six months (Panel A). On examination, there was a single, non-tender, smooth surface, and dome-shaped nodule. It was shiny with a reddish rim at its periphery. The nodule was excised completely as a treatment and for histopathological examination that shows it as a clear cell acanthoma (CCA) [panel B (H/E-4X) and C (H/E-10X)]. CCA is a rare benign cutaneous tumor of unknown cause. It is mostly presented as a painless, solitary, slowly growing, and pink-brown or red nodule that is seen mostly on the distal lower extremities of middle-aged and elderly patients. Multiple lesions and different morphologies such as polypoid, giant, atypical, pigmented, and cystic lesions can be seen. Other sites like the abdomen, areola, face, and scrotum can be affected. CCA has specific dermoscopic features in which the blood vessels are arranged in a string-like appearance, but the diagnosis is rarely done without biopsy. Histopathological examination reveals epidermal acanthosis with a psoriasiform pattern of pale keratinocytes and spongiosis in association with dilated blood vessels of the edematous dermal papillae. CCA is treated by surgery such as excision, CO2 laser, or cryosurgery. With a weekly regular follow-up of the patient for two months, the lesion was completely cured.