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The New Iraqi Journal of Medicine
The official peer review medical journal of the Iraqi Ministry of Health
Executive Editor: Ali Hassan Al Shimari Minister of Health Editor in Chief: Aamir Jalal Al-Mosawi
Advisory Editorial Board
Nada Al Ward Hussam Abdul Kareem Hakam Abdul Muheimen Abdul Ridhah Al Rawaf
Hassan Ahmed Hassan
http://www.newiraqijm.4t.com Registered by Copernicus Index Journal Master List Copyright©Postspeciaty CME Center University Hospital in Al Kadhimiyia. Iraqi Ministry of Health 0
Iraqi Peer Review Journal
The New Iraqi Journal of Medicine
The Official Peer Review Journal Of The Iraqi Ministry of Health December 2006 Volume 2 Number 3
Instructions for Contributors
Letter to the Editor New International Association Formed to Address Global Medical Changes.
Unilateral accessory lobe and unusual isthmus of thyroid gland: a cadaver study Srijit Das, Rajesh Suri Vijay Kapu Psychiatry
The incidence of depression in rheumatoid arthritis
14-17 18-19 20
Ghazi Aboud The Socio-demographic pattern of depression in Iraq Abstract: Iraqi paper published in American Medical Journal Perspectives Health Resources Utilization and poverty reduction: An example of innovative therapeutic strategy to reduce the burden on the health system in the developing countries contributing to poverty reduction Al Mosawi AJ 1
Surgical experiences Primary repair versus colostomy in colonic injuries Adel Al Rubaee Infectious diseases SARS: A new clinical syndrome Al Mosawi AJ
The New Iraqi Journal of Medicine 2006 2(1): 3-7 http://www.webspawner.com/users/alkarkhjm/index.html
Instructions for Contributors
2006 © Postspecialty CME center in the University Hospital in Al-Kadhimiyia
Aamir Jalal Al Mosawi MD, PhD Editor in chief Head department of pediatrics University Hospital in Al Kadhymiyia Al Kadhymiyia Baghdad Iraq PO Box: 70025 E-mail: firstname.lastname@example.org
The New Iraqi Journal of Medicine welcomes the submission of unsolicited articles for publication. Our reputation for author care, quality control through the publishing process and rapid, timely publication is unrivalled. Typically, from receipt of a first draft to publication takes only 8-12 weeks allowing 2 weeks each for peer-review and revision. If you would like to propose an article or have any queries about contributing to the journal, please contact the Editorial Office (email@example.com). The New Iraqi J Med expects manuscripts to conform to the Uniform Requirements for Manuscripts Submitted to Biomedical Journals (the Vancouver style; N. Engl. J. Med. 336,309–315  www.icmje.org.The Journal will consider the publication of papers dealing with broad fields of medicine (Original aricles, case reports, and review articles).All articles must be submitted solely to The New Iraqi
Journal of Medicine and must be written entirely in English. This journal is a peer-reviewed scientific journal that publishes original articles in all fields of experimental and clinical medicine and related disciplines. The New Iraqi Journal of Medicine is currently issued 3 times per year. The new Iraqi J Med is listed by the ICMJE and Doctor Guide journal lists. The editor endorses the principles embodied in the Declaration of Helsinki RECOMMENDATION FOR CONDUCT OF CLINICAL RESEARCH and expects that all investigations involving humans will have been performed in accordance with these principles. Review process. Manuscripts are evaluated on the basis that they present new insights to the investigated topic, are likely to contribute to a research progress or change in clinical practice or in thinking about a disease. It is
understood that all authors listed on manuscript have agreed to its submission signifies that these conditions have been fulfilled Received manuscripts are first examined by the editor. Manuscripts with insufficient priority for publication are rejected promptly. Incomplete packages or manuscripts not prepared in the advised style will be sent back to authors without scientific review. The authors are notified with the reference number upon manuscript registration at the editorial office. The registered manuscripts are sent to independent experts for scientific evaluation. The evaluation process usually takes 1–3 weeks. Submitted papers are accepted for publication after a positive opinion of the independent reviewers. Conflict of interests. Authors of research articles should disclose at the time of submission any financial arrangement they may have with a company whose product figures prominently in the submitted manuscript or with a company making a competing product. Such information will be held in confidence while the paper is under review and will not influence the editorial decision, but if the article is accepted for publication, the editors will usually discuss with the authors the manner in which such information is to be communicated to the reader. Permissions. Materials taken from other sources must be accompanied by a written statement from both author and publisher giving permission to the Journal for reproduction. Obtain permission in writing from at least one author of papers still in press,
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Patient's confidentiality. Changing the details of patients in order to disguise them is a form of data alteration. However authors of clinical papers are obliged to ensure patients privacy rights. Only clinically or scientifically important data are permitted for publishing. Therefore, if it is possible to identify a patient from a case report, illustration or paper, a written consent of the patient or his/her guardian to publish their data, including photogram is necessary prior to publication. The description of race, ethnicity or culture of a study subject should occur only when it is believed to be of strong influence on the medical condition in the study. When categorizing by race, ethnicity or culture, the names should be as illustrative as possible and reflect how Theses groups were assigned. Copyright transfer. Upon acceptance, authors transfer copyright to The New Iraqi J Med. Once an article is accepted for publication, the information therein is embargoed from reporting by the media until the mail date of the issue in which the article appears. Upon acceptance all published manuscripts become the permanent property of The New Iraqi J Med, and may not be published elsewhere without written permission from the editor .Every effort is made by the editor to see that no inaccurate or misleading data, opinion or statement appears in the journal. However, they wish to make it clear that
the data and opinions appearing in the articles and advertisements herein are the responsibility of the contributor, sponsor or advertiser concerned.
CRITERIA FOR MANUSCRIPTS The journal takes under consideration for publication original articles in experimental and clinical medicine and related disciplines with the understanding that neither the manuscript nor any part of its essential substance, tables or figures has been published previously in print form or electronically and is not under consideration by any other publication or electronic medium. The Journal discourages the submission of more than one article dealing with related aspects of the same study. Each submission packet should include the statement signed by the first author that the work has not been published previously or submitted elsewhere for review and a copyright transfer. PREPARATION OF MANUSCRIPT Guidelines for submission are in accordance with: Uniform Requirements for Manuscripts Submitted to Biomedical Journals (N Eng J Med, 1997; 336: 309-15). Manuscripts should be up to 4000 words in length with a target of no more than 80 references. Article structure Original research articles, clinical studies, and case reports should be organized as follows: The manuscript
should be typewritten on a white paper of the size ISO A4 (210x297 mm). The text should be processed on the laser or inkjet printer preferably, or on a type writer; in the last case, however, the authors are requested to take care about the quality of printing tape. Text should be one spaced with 12 points typeface. Margins: 2.5 cm (1 inch) at top, bottom, right, and left. Illustrations are very helpful and for case reports are mandatory. In reviews it should be explained what information retrieval sources were used and what were the criteria in selecting the referred papers. The Editor reserves the privilege to adjust the format of the article.
The manuscript should include:
Title page should include the following Information: • Full names of all authors • Name of the department and institution in which the work was done • Affiliations of the authors • Manuscript full title • Full name, address, telephone and/or fax number of the author responsible for manuscript preparation. • E-mail address to speed up contacts with authors • Source(s) of support in the form of grants (quote the number of the grant) equipment, drugs etc. Abstract Page. Abstract in structured form not exceeding 300 words should consist of four paragraphs labeled: Background, Material (Patient) and Methods, Results, Conclusion. Each summary section should begin in a new line and briefly describe, respectively, the purpose of the study, how the investigation was performed, the most
important results and the principal conclusion that authors draw from the results. KEY WORDS (3 to 6) or short phrases should be written at the bottom of the page. Text. The text of the article should be divided to seven paragraphs labeled: Introduction, Material (Patient) and Methods, Results, Discussion, Conclusions, Acknowledgements, References. Introduction should contain scientific rationale and the aim of the study or (in case of a review) purpose of the article Material (Patient) and methods should describe clearly the selection of observational or experimental subjects (patients or laboratory animals)including controls, such as age, gender, inclusion and exclusion criteria, (the circumstances for rejection from the study should be clearly defined),randomization and masking (blinding)method. The protocol of data acquisition, procedures, investigated parameters, methods of measurements and apparatus should be described in sufficient detail to allow other scientists to reproduce the results. Name and references to the established methods should be given. References and brief description should be provided for methods that have been published but are not well known, whereas new or substantially modified methods should be described in detail. The reasons for using them should be provided along with the evaluation of their limitations. The drugs and other chemicals should be precisely identified including generic name, dose and route of administration. The statistical methods should be described in detail to enable verification of the reported results.
Results should concisely and reasonably summarize the findings. Restrict tables and figures to the number needed to explain the argument of the paper and assess its support. Do not duplicate data in graphs and tables. Give numbers of observation and report exclusions or losses to observation such as dropouts from a clinical trial. Report treatment complications. The results should be presented in a logical sequence in the text, tables and illustrations. Do not repeat in the text all the data from the tables or graphs. Emphasize only important observations. Discussion should deal only with new and/or important aspects of the study. Do not repeat in detail data or other material from the Background or the Results section. Include in the Discussion the implications of the findings and their limitations, including implications for future research. The discussion should confront the results ofother investigations especially those quoted in the text. Conclusions should be linked with the goals of the study. State new hypotheses when warranted. Include recommendations when appropriate. Unqualified statements and conclusions not completely supported by the obtained data should be avoided. Acknowledgements: List all contributors who do not meet the criteria for authorship, such as technical assistants, writing assistants or head of department who provided only general support. Financial and other material support should be disclosed and acknowledged. References must be numbered consecutively as they are cited.
References should be denoted numerically and in sequence in the text, using Arabic numerals placed in square brackets, i.e., . List references in numerical order in the Reference list References selected for publication should be chosen for their importance, accessibility, and for the „further readings opportunities they provide. References first cited in tables or figure legends must be numbered so that they will be in sequence with references cited in the text. The style of references is that of Index Medicus. List all authors when there are six or fewer; when there are seven or more, list the first three, then„et al.³ The following is a sample reference: Standard journal article *Lahita R, Kluger J, Drayer DE, Koffler D, Reidenberg MM. Antibodiestonuclear antigens in patients treated with procainamide or acetylprocainamide. NEngl J Med 1979; 301:1382-5. Book, personal author(s) Ringsven MK, Bond D. Gerontology and leadership skills for nurses. 2nd ed. Albany (NY): Delmar Publishers; 1996. Book, editor(s) as author Norman IJ, Redfern SJ, editors. Mental health care for elderly people. New York: Churchill Livingstone; 1996. Tables: Type or print out each table on a separate sheet of paper. Do not submit tables as photographs. Number tables consecutively in the order of their first citation in the text, and supply a brief title for each. Give each column a shorter abbreviated heading. Place
explanatory matter in footnotes, not in the heading. Explain in footnote. All non standard abbreviations that are used in each table. For footnotes use the following symbols, in this sequence: *, ý, §, ||, Â, **, ýý, etc.Identify statistical measures of variations such as standard deviation and standard error of the mean. Do not use internal horizontal and vertical rules. Be sure that each table is cited in the text. Figures should be numbered consecutively according to the order in which they have been first cited in the text. Define in the legend all abbreviations that are used in the figure. Review articles Each review article should concentrate on the most recent developments in the field. These articles aim to summarize and highlight recent significant advances in and ongoing challenges in the field. Authors should strive for brevity and clarity. The final structure of the review will, of course, depend on the title/focus but wherever possible, the following sections should be included. Submission Manuscript should be sent on floppy disc. Submission by e-mail is also welcome. Editor in chief: Aamir J Al -Mosawi Main Editorial office: Expansion building, first floor University Hospital in Al Kadhimiyia Al Kadhimiyia Baghdad Iraq PO Box: 70025 E-mail: firstname.lastname@example.org
The New Iraqi Journal of Medicine 2006 2 (3): 8-9
Letter to the Editor
New International Association Formed to Address Global Medical Changes
The International Association of Medical Colleges Medicine (IAOMC) has been formed to serve as the catalyst for assisting medical hospitals, Licensing Boards, and agencies around the world to effectively function in the ever accelerating inter communication and integration that is a part of the new global world. The mission of this non-stock, not for profit organization is to enhance world wide medical education by means of accreditation under uniform global standards. It is structured to interact in concert with the world’s governing regulators. At the present, Association members are medical schools whose standards are ranked by the USDOE as substantially similar to medical schools in the United States. Membership in the IAOMC is open to the 1,684 medical schools currently listed in the World Health Directory; and members of the 177 known regulatory agencies in the world. IAOMC invitations have been extended to all the world’s qualified medical schools and regulatory agencies.
The IAOMC is a global response to the issue of varying medical education standards. It will be the world’s first international medical school accreditor. In a challenge to traditional accreditation standards processes, every part of the Association process will be open and transparent. This is the first accreditation organization to end the mystery and secrecy that typically surrounds how most nations maintain medical education standards. Its public accountability will allow everyone to see exactly which schools are maintaining standards and which ones are not. Everyone can obtain a copy of the Associations reports. At a time of an ever-worsening physician shortage the Association’s member schools responded. Approximately 3,000 of their clinical students are now studying across the United States. For example, IAOMC members have more clinical students studying in New York State than the combined totals of Cornell University School of Medicine, Columbia University School of Medicine, NY State University of New York at Rochester, and State University of New York at Stony Brook. One of America’s outstanding physicians, Dr. Lynn Eckert, is the Chair of the American Association of Medical Colleges.
Bernard Ferguson President International Association of Medical Colleges E.mail:email@example.com
She will address the Association’s standards meeting at the NY Hyatt on August 12th in her capacity as the Academic Director of Harvard Medical International. Pledged to be a fully open and democratic association, every medical school in the world within the World Health Directory (1,684) will be contacted for comment. The Federation of State Medical Boards assisted by providing the list of every known regulatory agency in the world (177). They have each been invited to participate in the Association. Every Mission to the United Nations (190) has been notified to alert the medical schools and regulatory agencies in their nations. And the Regulatory Agencies were heard from. The interest is world wide, a few illustrations. After John P. Lamont, Registrar, of Ireland’s Medical Council
received notice of the standards meeting, and talked to Professor Muiris Fitzgerald, Chair of Education Committee. He has confirmed his attendance. Dorian Shillingford Chair of the Dominician Medical Board confirmed. Sheri Nichols, Alabama’s Medical Board Secretary placed the invitation on the next Board meeting agenda. Bulgaria’s UN Second Secretary Mrs. Anna Ruski will accompany Dr. Elena Piperkova from Sofia. Invitations from the Association has drawn responses from such as Syed Ziaur Rahman, MD of Jawaharlal Nehru Medical College in India to Aamir Jalal Al-Mosawi MD, PhD. Of Al Kadhimyia Teaching Hospital in Iraq to Michael Gordon from University of Toronto. All have submitted applications to serve as school on site inspectors.
The New Iraqi Journal of Medicine 2006 2(3): 10-13
Unilateral accessory lobe and unusual isthmus of thyroid gland: a cadaver study
Srijit Das, Rajesh Suri, Vijay Kapur
Background: The thyroid gland is known to exhibit various congenital malformations with regard to its lobes, isthmus and ectopic sites. Knowledge of variations in topographical anatomy of thyroid gland is essential for safe surgery and logical interpretation of scintiographs. Objective: To study the anomalous isthmus and accessory lobe of the thyroid gland. Materials and methods: The thyroid gland was studied for presence of any accessory lobe and abnormal isthmus in 40 cadavers over a period of five years. Results: We observed a single case of accessory lobe of thyroid gland with unusual isthmus. Conclusion: Although an accessory lobe of thyroid gland may not manifest clinically, its clinical and academic importance cannot be undermined. Presence of such anomalies may also be important for clinicians, radiologists and other medical professionals in day to day clinical practice. Key Words: Thyroid, accessory, isthmus, anatomy, variation, anomaly.
Normally, the thyroid gland consists of two lobes connected by an isthmus. The isthmus connects the lower parts of the two lobes of the gland and measures 1.25 cm in its vertical and horizontal dimension respectively . Conventional textbooks of anatomy describe the isthmus to be located anterior to the second and third tracheal cartilage but it may be found displaced above or below its usual level . Interestingly, the isthmus in the present case, did not display the usual dimensions. Thereby suggesting it to be a congenital anomaly. Many congenital malformations of the thyroid gland involving the lateral lobes, isthmus, pyramidal lobes, aplasia or
Correspondent author: Srijit Das, Associate Professor Department of Anatomy, Maulana Azad Medical College, New Delhi, India. Add: 190, RPS Flats, Sheikh Sarai Phase-I, New Delhi-110017, India Tel: 91-11-23239271Ext125 E-mail: firstname.lastname@example.org Rajesh Suri, Professor, Department of Anatomy, Vardhman Mahavir Medical College, New Delhi, India. Vijay Kapur Former Director Professor & HOD, Department of Anatomy, Maulana Azad Medical College, New Delhi, India.
hemiagenesis, ectopic sites of the gland have been reported [2, 3, 4, 5]. The accessory lobe of the thyroid gland has been reported to be situated at various regions and has been thought to be apparently developing from a compartmentalized portion of the primordial of the right lobe and forming a separate lobe .
Material and Method
The thyroid gland was carefully examined in forty dissected cadavers over a period of five years. An anomalous thyroid gland was detected in a 48 year male cadaver during traditional undergraduate teaching program. The observations pertaining to the morphological features of the gland were recorded and an appropriate photograph was taken.
Figure (1): Dissected specimen of thyroid gland: (1) Right lobe, (2) Left lobe, (3) Isthmus,(4) Trachea, (5) Thyroid cartilage, (6) Accessory part of the gland is shown with small arrow ( ↑ ) This accessory lobe (marked with an arrow) could be delineated from the main gland by a thin septum. The isthmus was located in front of the third and fourth tracheal cartilages. It measured 2.2 cm and 1.1 cm in its vertical and transverse dimensions respectively. The lobes of the thyroid gland displayed a tapering apex. The lobes of thyroid gland measured 2.5 and 2.2 cm as its maximum transverse dimension on the left and right sides respectively. The gland was as usual supplied by the superior and the inferior thyroid arteries. No accessory lobe was detected on the right side.
An anomalous thyroid gland on the left side, the accessory lobe was separated by a thin septum from the main gland An unusual isthmus whose vertical dimension was more than the transverse and a small unilateral accessory lobe of the gland could be referred to as a congenital anomaly. A thorough insight into normal and abnormal anatomy of thyroid gland may be important for surgical, radiological and clinical purposes. Figure. (1) shows a small accessory lobe of the gland located on the superior aspect of the thyroid gland on the left side.
The thyroid gland is known to develop from the epithelial proliferation in the floor of the pharynx between the tuberculum impar and the copula . Thereby, the thyroid gland descends anterior to the pharyngeal gut, as a bilobed diverticulum and remains connected to the tongue by the thyroglossal duct, which disappears later . In the due course of embryonic development, the gland descends in front of the hyoid bone and by seven weeks, it reaches the final position in front of the trachea, to have two lobes and a connecting isthmus . Morphological variations of the thyroid gland are generally found in the superior part of the gland . Further in the present case, we observed a gland with the maximum transverse dimension of the left side lobe being greater than that of the right lobe. The greater transverse dimension of the left lobe of thyroid gland is an evidence of asymmetry in the profile of the gland, an observation which is consistent with an earlier report . Malformations of the thyroid gland. Many of the past research have reported the common congenital anomalies to be aplasia or hemiagenesis of the gland [2, 8]. There are few reports on the anomalies of the isthmus of the thyroid gland or its peculiar dimensions although there have been reports on the absence of the isthmus of the thyroid gland . The present case was unique since it described unusual dimensions of the isthmus i.e. its vertical dimension being more than that of the width. The accessory thyroid gland is apparently thought to be developing from a compartmentalized portion of the primordium of the right lobe, thereby forming a separate lobe . Research workers have stated that small portions of the thyroid primordium separate from the diverticulum and may become associated with developing heart and septum transversarium . Thus there are possibilities of finding thyroid tissue at different places i.e. even near the heart and the diaphragm . Although every anomaly of the thyroid gland may not manifest with symptoms, awareness of its existence is important to surgeons. Admittedly, in the present case, the clinical history of the individual was not available to corroborate observations. Undoubtedly, prior knowledge about anatomical variations of the thyroid gland is important from academic as well as clinical viewpoint.
1- Standring Susan. Gray’s Anatomy. The Anatomical Basis of Clinical Practice. Elsevier Churchill Livingstone, 39th edn, Philadelphia, 2005, pp.560563. 2-Harada T, Nishikawa Y, Ito K. Aplasia of one thyroid lobe. Am J Surg.1972; 124(5):617-9. 3-Melnick JC, Stemkowski PE. Thyroid hemiagenesis (hockey stick sign): a review of the world literature and a report of four cases. J Clin Endocrinol Metab. 1981; 52 (2): 247-51. 4-Bhatnagar KP, Nettleton GS, Wagner CE. Subisthmic accessory thyroid gland in man: a case report and a review of thyroid anomalies. Clin Anat. 1997; 10
(5): 341-4. 5-Doria E, Agostoni P, Fiorentini C. Accessory thyroid tissue in the right ventricle Chest.1989; 96 (2): 424-5. 6- Sadler TW. Langman’s Medical Embryology. Williams & Wilkins, 7th edn, Maryland, 1995; pp, 329-330. 7- Larochelle D, Arcand P, Belzile M, Gagnon N-B: Ectopic thyroid tissue -a review of the literature. J Otolaryngol 1979; 8: 523-530. 8-Burman KD, Adler RA, Wartofsky L. Hemiagenesis of the thyroid gland. Am J Med.1975; 58 (1):143-6. 9-Yuksel M, Yuksel E, Kaymaz F. Failure of the isthmus lobe to fuse in the midline. Clin Anat. 1995; 8 (1): 33-5.
The New Iraqi Journal of Medicine 2006 2(3): 14-17
The incidence of depression in rheumatoid arthritis
Objective: To make a systematic survey of depressive symptoms in relation to rheumatoid arthritis (RA) as well as to determine the severity of these symptoms in comparison with other chronic medical patients. Design: Beck depression inventory, the Arabic version. Setting: Baghdad Medical City hospital. Participants: A hundred RA patients were screened. An equal number of patients with chronic medical disorders were taken as a compare group. Results: 38 patients with RA (38%) met the predetermined criteria for depression, while 33 patients (33%) with chronic medical disorders, reached these criteria. It was found that 23 patients (60.5%) with mild depression, 11 patients (28.9%) with moderated depression ad 4 patients (10.5%) with severe depression in patients with R.A. Conclusions: depression is not significantly differing in distribution among RA patients as compared with chronic medical patients. Most of the depressive cases appeared to be of mild severity and more often showed symptoms of fatigability, work retardation, sadness and less suicidal feeling. Introduction There have been many reports about depressive manifestations among chronic medical patients, depression is common among them but the diagnosis is frequently missed. Rheumatoid arthritis (RA) is a systemic disease characterized by inflammatory changes in joints and associated structures. There are also a number of extra-articular signs and symptoms . Self-reported pain intensity was more clearly related to disability and reported recent disease activity than to depression . Depression in arthritis is a reaction to loss of function, loss of self-esteem or anticipated losses in the future. The denial of illness in RA patients gives way to anger which is followed by depression any renewed flare may immediately promote anger or depression .The majority of studies that considered depressed mood in patients with RA failed to analyze the relative contribution of psychological, social and disease state variables .
Correspondent author: Ghazi Abboud Hummadi GA Al Rashad Psychiatric Hospital Baghdad, Iraq E-mail: email@example.com
Patients and Methods A total of hundred rheumatoid patients were screened. An equal number of patients with chronic medical illnesses including 25 % endocrine disorders,21 % cardiovascular disorders, 12% respiratory disorders,11% renal disorders,10% gastrointestinal disorders, 8% hematological disorders,6% malignant diseases,5% liver disorders, and 2% skin disorders were taken as compare group. Both groups were matched for age, sex and marital status. Patients included were between the ages of 20-45 years. Seventy-five patients (75%) of them were females and twenty five patients (25%) of them The RA patients who contributed to this study were attending out-patients clinic of rheumatology of Baghdad Medical City Hospital. They were diagnosed according to 1987 revised American Rheumatism Association criteria for RA.While the non-rheumatoid patients with chronic medical disease were attending outpatients clinic of general medicine in the same hospital. The instrument used for screening was Beck depression inventory (BDI). 13 clinical features were rated in detail. The Arabic version of the B.D.I. was used which is prepared by Dr. Gareeb, Azhar University, Psychiatric Department (56).The severity of depression was determined according to the degree of total scores for each patient. A score of 5 – 7 indicate mild, 8 – 15 moderate, and if 16+ severe depression [6[.The data were gathered and classified according to different variables or factors. were males.
Results: 1- Among the 100 patients with RA observed, 38 patients (38%) scored, 5 or above on B.D.I, so they met the predetermined criteria for depression, while in non-rheumatoid chronic medical patients of the 100 patients, 33 patients (33%) reached the cut-off score or above. 2- Sex variation: Among female patients with RA screened, 29 patients (38.6%) were depressed, while 9 patients (36%) were depressed among males. On the other hand, it was 25 patients (33.3%) among chronic medical female patients and 8 patients (32%) for males. 3- Severity of depression: It was found those 23 patients (60.5%) with mild depression, 11 patients (28.9%) with moderate depression and 4 patients (10.5%) with severe depression in patients with RA, while it was 18 patients (54.5%) with mild depression, 11 patients (33.3%) with moderate depression, and 4 patients (12.12%) with severe depression in patients with nonrheumatoid chronic medical disease. 4- Age: The rheumatoid patients & the compare patients were divided into 3 age groups. The distribution of depression according to these groups is shown in table 1 and 2, respectively. 5- Predominant depressive symptoms: According to the mean score of each symptom, the predominance of depressive symptoms were arranged in hierarchical order for the patients with RA.
Fatigability, pessimism, hopelessness, helplessness, were predominant, while in non-rheumatoid medical patients, work retardation, fatigability, sadness, indecisiveness, pessimism, hopelessness, & dissatisfaction were predominant. 6- Life events & psychiatric history: Recent life events were found in 14 patients (36.8%) of depressed patients with R.A. and in 11 patients (33.3%) of depressed patients with non-rheumatoid medical diseases, where as life events were found in 12 patients (19.3%) of non-depressed patients with R.A. and in 15 patients (22.3%) in medical nondepressed patients. 7- Depression and type of treatment in RA: Depression is more in rheumatoid patients who are on immunosuppressive, penicillamine, and gold therapy, and less depression in patients on steroid therapy. Table 1: Depression according to the age among patients with RA Depression No % 10 13 15 28.5 37.1 50
Discussion The above results have shown that depression is a common phenomenon among rheumatoid and other chronic medical patients. That is 38% among rheumatoid and 33% among nonrheumatoid patients. There is no significant difference in distribution of depression between the two groups. The depression is consistent with that in other studies [1, 7, 8, 9, 10]. A 15 years follow up study of 74 female patients with definite or classic RA was performed during the clinical course of the illness, 40% had depressive reaction. Depression among chronic medical diseases was found to fall with in a range of 22-50% in different studies[7,8,9,10,11]. Most of depression appeared to be of mild severity for rheumatoid and non rheumatoid medical patients which is consistent with that in other studies [7, 13]. In a rural general medical practice, the estimated prevalence of depression was 28.3% for mild & 18.3% for moderate & 8.8 % for severe depression. (. Depression increases with age & this may be related to the fact that psychological mechanisms which permitted coping with stress at an earlier age may have diminished gradually as well as chronicity of illness may play the same role.
Age (yrs) 20 – 29 30 – 39 40 -45
Total No. 35 35 30
Table 2: Depression according to the age among patients with nonrheumatoid chronic medical diseases. Depression No % 9 11 13 25.7 31.42 43.3
Age (yrs) 20 – 29 30 – 39 40 -45
Total No. 35 35 30
The predominant depressive symptoms in rheumatoid and non rheumatoid medical patients were nearly similar apart from more fatigability than work retardation in R.A., the reverse in nonrheumatoid patients. Work retardation and fatigability may reflect real incapacity and disability of patient due to physical illness. Suicidal thinking and guilty feelings were found little, and this goes with the study of Moffic and Paykel. The life events were found to have more impact in precipitation of depression in depressed patients of both groups. So patients were more likely to have other concurrent stresses and depression was not entirely a consequence of the medical state. Depression is more in Rheumatoid patients who are on immunosuppressive ,penicillamie and gold therapy ,however less depression is reported in patients on steroid therapy .This may be due to the remitting effect of steroid as well as amelioration of effect. References: 1-Silverman A J .In:Kaplan and Sadock
Rheumatoid Arthritis Comprehensive text book of psychiatry 4th ed., Williams and Wilkins, Baltimore 1985:1185. 2-Peck JR Smith TW, Ward SR , Milano R. Disability and depression in rheumatoid arthritis., USA-ARTHRITIS RHEUM, Excerpta Medica: Arthritis & Rheumatism 1989 Vol. 2611 (30):1100-1106. 3-Patridge AJ. Psychosocial aspect of the Rheumatic diseases. In:Scamach and Klippl Primer on the Rheumatic diseases 9th ed. Arthritis foundation 1988:307.
4-Newman S.P, Fitzpatrick R. Lamb R. & Shipley M (1989). The origins of depressed mood in R.A. London. W. GBR-J. RHEUMATOL 1989; 32/9 (1100-1106). Excerpta Medica. Psychiatry section 32, Vol. 6015 (296). 5-Beck AT, Bial WY, Rickels Short form of depression inventory: cross-validation. Psychological Reports 1974 ( 34 ): 1184. 6-GAREEB. G. Instruction for use of BeckInventory. Arabic-NAHDA-Library 1985. 7-Moffic H.S. & Paykel. Depression in medical in-patients. Brit. J. Psychiat 1974.( 126) 346 -53. 8-Stewart MA, Drakes I., Winokur G Depression among medically ill in-patients, Diseases of the nervous system 1965 26, 47, 9.85. 9-Starkstein S, Robinsom R. Affective disorders & cerebral vascular disease, Brit. J. Psych (154):170-182. 10-Deshpande S, Simdaram K, Wig N. (1Psychiatric disorders among medical inpatients in an Indian hospital, Brit J. Psych 1989 (154):504-509. 11-Schwab J., J. Bialow, M. Brown, J.M ,Jolzer.CE Diagnosing depression in medical in-patients, Annals of internal medicine 1967: 67, 695-707. 12-Rimon R. and Loakso R. L . Over Psychopathology in R.A. SCAND J. RHEUMATOL, 1984, 13/4; (324-328). Excerpta Medica, Psychiatry section 32 Vol. 51/9 (433). 13-Barrett J, Oxman T, Gerber P. Prevalence of depression and its correlates in a general medical practice USA-J, AFFECT, 1987 12/2 (167 – 174), Excepta Medica, Psychiatry section 32. Vol. 5619 (9451).
The New Iraqi Journal of Medicine 2005 2 (3): 18-19
The Socio-demographic pattern of depression in Iraq
Naama. Sh.Humaidi Specialist Psychiatrist Ibin Rushid Psychiatric Hospital Baghdad,Iraq
122 depressed patients, 82 (67%) females and 40(33%) males were observed at the outpatient clinic in Ibin-Rushid psychiatric hospital in Baghdad. Depression affected the middle age females, married patients more frequently. 72.2% of all the patients were between 30-49 year of age. Table (1) shows the Age and sex distribution of depression. The majority of females patients attempted suicide by nonviolent methods (medicine over-dose, poisoning while males by more violent methods (self injury, shooting). Disadvantageous family environment and recent life events were found as important factor in precipitating the illness. A female to male ratio of 2:1 in this study was attributed to hormonal and child birth influences, in addition to the facts that female are more likely to express and complain of depression than males. The married to single ratio was 5:1 for females, and 2: 1 for males. Table (2) shows the effect of the marital status on the incidence of depression. Approximately 50% of female patients experienced at least one vulnerable provoking life events, with much lower number of males experienced such events. About two thirds of the patients had not reached post primary school 18
.Low literacy level observed in this study may reflect the back ground of population in Iraq. Table (3) shows the relation between depression and level of education. Higher incidence of depression was observed in urban dwellers (84.4%).Table 4 shows the distribution of the patients between rural and urban areas. Approximately 50% of the female patients were house wife.
Table (1): Age and sex distribution of depression.
Age group 20-29 30-39 40-49 50-59 60— TOTAL Female 6 34 28 8 6 82 Male 6 16 10 6 2 40 Total 12 50 38 14 8 122 % 9.8 41.1 31.1 11.4 6.6 100%
Table (2): Depression and the marital status
Marital status Married Single Divorced Widowed Separated Total Female 40 8 16 12 6 82 Male 22 12 4 2 40 Total 62(50.8%) 20(16.4%) 20(16.4%) 12(9.8%) 8(6.6%) 122
Table (3): Depression and level of education
Educational level Illiterate Read write Primary school Post primary University higher total Female 16 12 26 18 10 82 Male 2 2 18 12 6 40 Total 18 14 44 30 16 122 % 14.7 11.5 36 24.6 13.2 100%
Table (4): The distribution of the patients between rural and urban areas. Female 69 13 Male 34 6 Total 103 19 % 84.5 15
The New Iraqi Journal of Medicine 2006 2 (3): 20
Abstract: Iraqi paper published in American Medical Journal
Letter from Baghdad: Coffin-Siris syndrome in a girl with absent kidney
American Journal of Medical Genetics Part A Volume 140A, Issue 16, Pages 1789 - 1790 Aamir Jalal Al Mosawi Head of the Department of Pediatrics, Al Kadhimiyia University Hospital, P.O. Box 70025, Al Kadhimiyia, Baghdad, Iraq.
Coffin Siris syndrome (CSS) is a rare clinical syndrome of unknown etiology, first described by Coffin GS and Siris E in 3 unrelated girls with mental retardation and absent nails and terminal phalanx of the fifth finger in 1970.The important clinical features of CSS include mental retardation, typical facial appearance(coarse facies,thick eye brows, thick lips hypertrichosis of the face), growth retardation hyperplasia or aplasia of the distal phalanges of fingers and toes especially the fifth finger. 75 cases of CSS have been reported from USA, Europe, Turkey, Japan, India, However No report in Arab patient. In this paper I am reporting the first Arab patient with CSS
with associated unilateral renal agenesis, an infrequently reported association.
The New Iraqi Journal of Medicine 2006 2(3):21-22
Health Resources Utilization and poverty reduction: An example of innovative therapeutic strategy to reduce the burden on the health system in the developing countries contributing to poverty reduction
Al Mosawi AJ
The judicious utilization of the resources available to the health system in the developing world is an integral part of the healthy system reform and may represent a contributing factor to poverty reduction in these countries. The introduction of the modern technologic advances in the management of certain chronic disorders that require life long care (e.g. end-stage renal failure) may not be possible in many countries with fragile heath care system. In some countries only adults can be provided to some extent these therapeutic technologies. Introducing a less expensive and easy available medical therapeutic advances can be both useful and rewarding. Patients with end-stage renal failure (ESRF) and glomerular filtration rates less than5% of the normal can’t sustain life in the absence of renal replacement therapy (RRT), and either dialysis or transplantation is required. RTT is widely available in industrialized countries. In developing countries they are not uniformly available, so patient's management often relies on the conservative measures and intermittent peritoneal dialysis (IPD). ESRF patients treated in such way may die from uremia and complications of IPD. Dialysis and transplantation (RRT) were originally developed to forestall death in patients with ESRF has become the standard management in the developed countries. However in many areas of the world RRT is considered extremely expensive in both manpower and money, with a maintenance cost far beyond costs contracted in other areas of the medical care. In developed countries RRT is considered the standard in the management of ESRF.RTT requires an expert team consisting of at least a nephrologist, cardiovascular surgeon, and urologist in addition to a skilled nursing staff. In areas where RRT introduced to some extent (e.g. hemodialysis and transplantation) despite the lack of effective and skilled teams, rehabilitation is commonly not satisfactory and the results are discouraging relative to costs in man power and money. Patients undergoing RRT in such areas are commonly experiencing disproportionate amount of discomfort and suffering not balanced by the added length of life achieved. On the other hand many patients particularly children don’t have any access to any form of RRT.These children will usually managed by intermittent acute peritoneal dialysis with death is the ultimate outcome. In the last few years confronted with unpalatable spectacular of the suffering of children with ESRD, a novel therapeutic strategy to provide these children with dialysis freedom and improved wellbeing has been investigated.
Aamir Jalal Al-Mosawi MD, Ph.D. Director Postspecialty CME center Al- Kadhimiyia University Hospital. Baghdad, Iraq
1-Al-Mosawi AJ.The challenge of chronic renal failure in the developing world: Possible use of acacia gum.Pediatr Nephrol 17(5):390-391(2002).(Research). www.springerlink.com 2-Al-Mosawi AJ. Acacia gum supplementation of a low- protein diet in children with end-stage renal disease. Pediatr Nephrol 19; 1156-1159 (2004).Research www.springerlink.com 3-Mosawi AJ.Continuouos renal replacement in the developing world: Is there any alternative. Therapy (London) 2006:3(2): 265-272.Research. www.futuredugs.com 4-Al-Mosawi AJ.Acacia gum therapeutic potential: possible role in the management of uremia – a new potential medicine. Therapy, March 2006, Vol. 3, No. 2, 301321. www.future-dugs.com
The New Iraqi Journal of Medicine 2005 2 (3): 23-24
Primary repair versus colostomy in colonic injuries
Adel Al Rubaee Simple colonic injuries can often be treated with primary repair. More significant right-sided injuries are often managed by resection with either an illeo-colic or colo-colic anastamosis.Left sided injuries are often treated by resection with either end colostomy or colocolic anastamosis. We believe that primary repair can safely be performed more frequently than generally accepted. 120 cases of penetrating injuries were observed over period of (3) years from March 2003 to March 2006.The patients were admitted in Balad ,Al-Noor and Al-Kadhimiyia Teaching hospitals. Most of them were caused by high velocity missiles or fragmentation missiles, some caused by low velocity missiles. Colonic injuries were detected by by general examination, rectal examination, sigmiodoscopy and abdominal X-rays. Their age ranged from 5 to 55 years. Most patients reached hospital from 1/2 hours to 3 hours after the injury. 30 patients (25%) reached hospital in shock state. In 85 cases (70.8%) the injury involved the left colon and in the remaining 35 (29.2%) the right colon In 60 cases there was single perforation ,in 20 cases (16.6%) there were two perforations and in the remaining 40 patients (33.4%) there were multiple perforations of colon. 95 patients (79.2%)had associated non- colonic intra abdominal injuries and 25 patients (20.8%) had isolated colonic injury. Associated injuries of the small bowel occurred in 45 patients(47.3%),in the liver in 15 patients(15.8%),in the ,spleen in 12 patients (12.6%),in the stomach in 9 patients(9.5%),in the kidney in 8 patients (8.4%).While vascular injuries occurred in 6 patients(6.4%). Complications including wound infection, intra abdominal abscess, and fistula occurred in 32 patients. 15 patients died (12.5%).The death in 11 patients was due to severe associated injuries. colon –related deaths occurred in 4 patients (3.3%) due to post-operative enteric fistula or leak and intra abdominal sepsis. Injuries of right colon treated by primary repair had the same morbidity as the ones in left colon treated similarly, and both patient part of colon had similar complication rates when the colostomy was performed. Shock on admission is generally considered a contra –indication to primary repair unless it is treated aggressively. Thirty five patients were treated with primary repair after debridment when necessary. Eighty five patients were treated with colostomy proximal to or at site of perforation. The incidence of
Adel Al Rubaee Specialist Surgeon University Hospital in Al Kadhimiyia Baghdad, Iraq
complications in patients treated by colostomy was higher than that one treated by primary repair ((29.4%) versus (20%).Complications occurred in 25.7% of patients with right colonic injuries, and 27% of patients with left colon injuries. The hospital stay of patients treated by primary closure was 10 days and in those treated by colostomy 14 days. Although colostomy is considered the safest method of treatment of colonic injuries, we believe that colostomy has been over used .Colostomy associated with higher incidence of wound sepsis and intra peritoneal abscess because its considered as an open source of contamination ,very close to the abdominal incision and communication with the abdominal cavity through abdominal wall exist .It is associated with longer hospital stay than after primary repair and the patient have to be subjected to the risk of another operation for closure of colostomy.
The New Iraqi Journal of Medicine 2006 2(3): 25 -32
SARS: A new clinical syndrome
Al Mosawi AJ
Background: SARS is the first major new infectious disease of this century. Severe Acute Respiratory Syndrome (SARS) was first recognized in midMarch 2003 and successfully contained in less than four months. On 5 July 2003, WHO reported that the last human chain of transmission of SARS had been broken? During this period more than 8,000 persons with probable SARS have been diagnosed; 812 patients have died. SARS is due to an infection with a novel coronavirus which was first identified by researchers in Hong Kong, the United States, and German, termed SARS-associated coronavirus (SARSCoV). The epidemic of severe atypical pneumonia which was observed in the Chinese province of Guangdong and reported internationally on February 11, 2003, was initially suspected to be linked to a newly emerging influenza virus. The etiologic agent of SARS was identified in late March 2003, when laboratories in Hong Kong, the United States, and Germany found evidence of a novel coronavirus in patients with SARS. This evidence included isolation on cell culture, demonstration by
Aamir Jalal Al-Mosawi MD, Ph.D. Director Postspecialty CME center Al- Kadhimiyia University Hospital. Baghdad, Iraq electron microscopy and demonstration of specific genomic sequences by 25
polymerase chain reaction (PCR) and by micro array test technology, as well as indirect immunofluorescent antibody test. Three weeks later, on April 16, 2003, following a meeting of the collaborating laboratories in Geneva, the WHO announced that this new coronavirus, never before seen in humans or animals, was the cause of SARS. This announcement came after research done by 13 participating laboratories from ten countries had demonstrated that the novel coronavirus met all four of Koch’s postulates necessary to prove the causation of disease: 1-The pathogen must be found in all cases of the disease. 2-It must be isolated from the host and grown in pure culture. 3-It must reproduce the original disease when introduced into a susceptible host. 4-It must be found in the experimental host so infected. Proof of the last two requirements was provided after inoculation of cynomolgus macaques (Macaca fascicular is) with Vero-cell cultured virus that had previously been isolated from a SARS case. The infection caused interstitial pneumonia resembling SARS, and the virus was isolated from the nose and throat of the monkeys, as shown by polymerase chain reaction with reverse transcription (RT-PCR) and by virus isolation. The isolated virus was
identical to that inoculated . In April
2003, a Canadian group of researchers from the Michael Smith Genome Sciences Centre in Vancouver, British Columbia, and the National Microbiology Laboratory in Winnipeg, Manitoba, were the first to complete the genome sequencing of the new coronavirus. .The genome sequence data
of SARS Co-V reveal that the novel agent does not belong to any of the known groups of coronaviruses, including two human coronaviruses, HCoV-OC43 and HCoV-229E, to which it is related. The SARS-CoV genome appears to be equidistant from those of all known coronaviruses. Morphology: Negative-stain transmission electron microscopy of patient samples and of cell culture supernatants reveals pleomorphic, enveloped coronavirus-like particles with diameters of between 60 and 130 nm.Examination of infected cells by thin-section electron microscopy shows coronavirus-like particles within cytoplasmic membrane-bound vacuoles and the cisternae of the rough endoplasmic reticulum. Extracellular particles accumulate in large clusters, and are frequently seen lining the surface of the plasma membrane . The SARS-CoV genome contains five major open reading frames (ORFs) that encode the replicase polyprotein; the spike (S), envelope (E), and membrane (M) glycoproteins; and the nucleocapsid protein (N).host. The M protein is the major component of the virion envelope. It is the major determinant of virion morphogenesis, selecting S protein for incorporation into virions during viral assembly. There is evidence that suggests that the M protein also selects the genome for incorporation into the virion.One remarkable feature about coronavirus RNA synthesis is the very high rate of RNA-RNA recombination. Detection: SARS Co-V has been detected in multiple specimens including extracts of lung and kidney tissue by virus isolation or
PCR; bronchoalveolar lavage specimens by virus isolation, electron microscopy and PCR; and sputum or upper respiratory tract swab, aspirate, or wash specimens by PCR [3, 4]. High concentrations of viral RNA of up to 100 million molecules per milliliter were found in sputum . SARS-associated coronavirus RNA was detected in nasopharyngeal aspirates by RT-PCR in 32% at initial presentation (mean 3.2 days after onset of illness) and in 68% at day14. In stool samples, viral RNA was detected in 97% of patients two weeks after the onset of illness. 42% of urine samples were positive for viral RNA . Viral RNA was also detected at extremely low concentrations in plasma during the acute phase and in feces during the late convalescent phase, suggesting that the virus may be shed in feces for prolonged periods of time .
Natural host: At present, no evidence exists to suggest that animal species play a significant role in the epidemiology of SARS outbreaks. Research teams in Hong Kong and Shenzhen detected several coronaviruses that were closely related genetically to the SARS coronavirus in animals taken from a southern Chinese market that was selling wild animals for human consumption. They found the virus in masked palm civets (Paguma larvata) as well as some other species. All six of the civets included in the study were found to harbor SARS coronavirus, which was isolated in cell culture or detected by a PCR molecular technique. Serum from these animals also inhibited the growth of SARS coronavirus isolated from humans. Vice versa, human serum from SARS patients inhibited the growth of SARS isolates from these animals. Sequencing of viruses isolated from these animals demonstrated that, with the exception of a small additional sequence, the viruses are identical to the human SARS virus [6, 7].
Transmission of SARS: The SARS coronavirus (SARS Co-V) is predominantly spread in droplets that are shed from the respiratory secretions of infected persons. Fecal or airborne transmission seems to be less frequent. There is growing evidence that a majority of patients might not effectively transmit the virus to other individuals: in Singapore, 162 individuals (81%) of all probable SARS cases had no evidence of transmission of a clinically identifiable illness to other persons . This is in accordance with results from epidemiological studies which indicate that SARS is moderately rather than highly transmissible. In some instances, however, so-called "Superspreaders" patients are able to transmit the SARS virus to a large number of individuals. Superspreaders and nosocomial amplification were the driving factors behind the early 2003 outbreaks.
The fact that the majority of new infections occurred in close contacts of patients, such as household members, healthcare workers, or other patients who were not protected with contact or respiratory precautions, indicates that the virus is predominantly spread by droplets or by direct and indirect contact [2, 8]. .The presence of virus in the stool suggests the possibility of oral-fecal transmission [4, 5]. This is reminiscent of characteristics of other coronaviruses  and feces are therefore potentially an additional route of transmission. In the Amoy Gardens outbreak, the SARS virus may have been spread through the sewage systems of the buildings. The airborne spread of SARS does not seem to be a major route of transmission. There are currently no indications that any goods, products or animals arriving from areas with SARS outbreaks pose a risk to public health
temperature for at least 1-2 days. The stability seems to be higher in stools from patients with diarrhea (the pH of which is higher than that of normal stool).In supernatants of infected cell cultures, there is only a minimal reduction in the concentration of the virus after 21 days at 4°C and -80°C. After 48 hours at room temperature, the concentration of the virus is reduced by one log only, indicating that the virus is more stable than the other known human coronaviruses under these conditions. However, heating to 56°C inactivates SARS-CoV relatively quickly. Furthermore, the agent loses its infectivity after exposure to different commonly-used disinfectants and fixatives.
There is no single test that can be used to diagnose SARS with a reasonable degree of accuracy. Diagnosis, therefore, continues to rely on the clinical examination, supported by case definitions that include a travel history. The initial symptoms of SARS are non-specific, complicating the differential diagnosis. Some features of the history, physical examination, radiological and laboratory findings, however, should alert clinicians to the possible diagnosis of SARS, even when the contact history is unreliable. These features are described below The most common symptom in SARS patients is fever with a body temperature > 38.0°C (100.4°F). Fever is therefore a main criterion in the current WHO case definition for suspected or probable SARS. However, fever may be absent during the early stages of the disease and in individuals with comorbidities who may be impaired in their ability to mount a fever.Fever is mostly associated with other symptoms including chills, rigors, headache, dizziness, malaise, and myalgia [2, 10, 11, 12, 13, 14, 15]. The frequency of these symptoms within different cohorts is shown in table 1. Thus, the initial
Stability and resistance: The virus is
stable in feces and urine at room
Sputum production, sore throat, coryza, nausea, and vomiting are less common [10, 11]. Inspiratory crackles may be heard at the base of the lung. Wheezing is generally absent. Diarrhea only seemed to be a prominent symptom in the Amoy Gardens' outbreak in Hong Kong . Within the other cohorts published to date, diarrhea was less frequent. The clinical course of SARS is highly variable, ranging from mild symptoms to a severe disease process with respiratory failure and death. Clinical deterioration combined with oxygen desaturation, requiring intensive care and ventilatory support, generally occurs 7 to 10 days after the onset of symptoms [10, 15]. In severe cases, SARS is a fulminate disease, progressing from being "comfortable" to respiratory failure requiring intubation within less than 24 hours [14, 16]. The incubation period of SARS is short. A median incubation period of six days was reported [10, 11]. However, the time from exposure to the onset of symptoms may vary considerably, ranging from 2 to 16 days .The maximum incubation period is probably 10 days [10, 13, 14].followed by the appearance of new lesions. IgG seroconversion, apparently correlating with falls in viral load, could be detected from day 10 to 15. Severe clinical worsening also occurred at this time. Some patients progressed to the third phase, characterized by ARDS necessitating ventilatory support. Radiographic abnormalities and hematologic
Imaging plays an important role in the diagnosis of SARS and monitoring of response to therapy. A predominant peripheral location, a progression pattern from unilateral focal air-space opacity to
unilateral multifocal or bilateral involvement during treatment, and lack of cavitations, lymphadenopathy, and pleural effusion are the more distinctive radiographic findings.At the onset of fever, 70-80 % of the patients have abnormal chest radiographs [5,11,19]. It should be noted that, in a substantial proportion of cases, chest radiographs may be normal during the febrile prodrome, as well as throughout the course of illness. In other cases, radiological evidence of pneumonic changes may precede the fever , particularly in individuals with comorbidities who may be impaired in their ability to mount a fever. Chest Xray findings typically begin with a small, unilateral, patchy shadowing, and progress over 1-2 days to become bilateral and generalized, with interstitial or confluent infiltrates. Air-space opacities eventually develop during the course of the disease. In patients who deteriorate clinically, the air-space opacities may increase in size, extent, and severity [10, 14]. .The initial radiographic changes may be indistinguishable from those associated with other causes of bronchopneumonia. The research group from Hong Kong suggested that chest radiographs might offer important diagnostic clues, in particular when, after approximately one week, unilateral, predominantly peripheral areas of consolidation progress to bilateral patchy consolidation, and when the extent of the lung opacities is correlated with the deterioration in respiratory function .There seems to be a predominant involvement of the peripheral-zone. Pleural effusions, cavitations, and hilar lymphadenopathy are usually absent. Respiratory symptoms and positive auscultatory findings are disproportional
mild compared with the chest radiographic findings .One large study focused on radiographic appearances and the pattern of progression .The radiographic appearance of peripheral air-space opacities is indistinguishable from other causes of atypical pneumonia, such as Mycoplasma, Chlamydia, and Legionella, and overlaps with other types of viral pneumonia. The presence of air-space opacity on chest radiographs has been helpful in the confirmation of the
diagnosis . During the course of illness, abnormal hematological values are common. Early studies have shown Lymphopenia and thrombocytopenia to be frequent in SARS patients [10, 14, 17, 18]. Progressive Lymphopenia was found in the peripheral blood of 153/157 (98 %) patients with SARS, reaching its lowest point in the second week. Lymphopenia was also shown in hemato-lymphoid organs at postmortem examination. The lymphocyte count commonly recovered in the third week, but about 30% of patients were still Lymphopenia by the fifth week of SARS. Most patients had reduced CD4 and CD8 T cell counts during the early phase of illness, with mean CD4 and CD8 T cell counts of 287 cells/µl (normal: 410 to 1590 cells/µl) and 242 cells/µl (normal: 62 to 559 cells/µl), respectively. Low CD4 and CD8 lymphocyte counts at presentation were associated with an adverse outcome in this study  Transient leucopenia was found in 64% of patients during their first week of illness. However, during the second and third week of illness, 61% developed leucocytosis. Neutrophilia (> 7.500/µl) developed in 82% of patients, possibly reflecting the wide use of corticosteroids. In total, 55% of patients developed a selflimiting thrombocytopenia, possibly caused by an immune mechanism. With the exception of 2% of patients, the degree of thrombocytopenia was mild (platelet counts
>50.000/µl), reaching a low point at the end of the first week. No patient had major bleeding or required platelet transfusion .
Virus detection Polymerase chain Reaction: SARS specific RNA can be detected in various clinical specimens such as blood, stool, respiratory secretions or body tissues by the polymerase chain reaction (PCR)[15,21]. Despite their sometimes high sensitivity, the existing PCR tests cannot rule out, with certainty, the presence of the SARS virus in patients. A valid positive PCR result indicates that there is genetic material (RNA) from the SARS-CoV in the sample. It does not mean, however, that the virus present is infectious, or that it is present in material (RNA) from the SARS-CoV in the sample. It does not mean, however, that the virus present is infectious, or that it is present in a large enough quantity to infect another person. Negative PCR results do not exclude SARS. Besides the possibility of obtaining incorrect, false-negative test results (e.g. through lack of sensitivity), specimen has been collected at a time when the virus may not have present. Virus isolation: The presence of the infectious virus can be detected by inoculating suitable cell cultures (e.g., Vero cells) with patient specimens (such as respiratory secretions, blood or stool) and propagating the virus in vitro. Once isolated, the virus must be identified as SARS-CoV using further tests. Cell culture is a very demanding test, but currently (with the exception of animal trials) the only means to show the existence of a live virus. . Positive cell culture results indicate the presence of live SARS-CoV in the sample tested. 29
Negative cell culture results do not exclude SARS. Antibody detection: Various methods provide a means for the detection of antibodies produced in response to infection with SARS-CoV. Different types of antibodies (IgM and IgG) appear and change in level during the course of infection. They can be undetectable in the early stages of infection. IgG usually remains detectable after resolution of the illness. The following test formats are being developed: Enzyme-linked immunosorbent assay (ELISA): a test which detects a mixture of IgM and IgG antibodies in the serum of SARS patients and reliably yields positive results at around day 21 after the onset of illness. Immunofluorescence assay (IFA): This requires the use of SARS-CoV-infected cells fixed on a microscope slide; patient antibodies bind to viral antigens and are in turn detected by immunofluorescentlabeled secondary antibodies against human IgG or IgM or both, using an Immunofluorescence microscope. IFA typically yields a positive result after about day 10 after the onset of illness. Positive antibody test results indicate previous infection with SARS-CoV. Seroconversion from negative to positive or a four-fold rise in the antibody titer from acute to convalescent serum indicates a recent infection. A negative antibody test result later than 21 days after the onset of illness is likely to indicate that no infection with SARSCoV has taken place.
The treatment of coronavirus-associated SARS has been evolving and so far there is no consensus on an optimal regimen. Treatment strategies for SARS were first developed on theoretical bases and from clinical observations and inferences. Prospective randomized controlled treatment trials were understandably lacking during the first epidemic of this novel disease. The mainstream therapeutic interventions for SARS involve broad-spectrum antibiotics and supportive care, as well as antiviral agents and immunomodulatory therapy. Assisted would be instituted in
respiratory failure. Anti-bacterial agents are routinely prescribed for SARS because its presenting features are non-specific and rapid laboratory tests that can reliably diagnose the SARSCoV virus in the first few days of infection are not yet available. Appropriate empirical antibiotics are thus necessary to cover against common respiratory pathogens as per national or local treatment guidelines for community-acquired or nosocomial pneumonia respiratory failure. Various antiviral agents were prescribed empirically from the outset of the epidemic and their use was continued despite lack of evidence about their effectiveness Ribavirin: a nucleoside analog, was widely chosen as an empirical therapy for SARS because of its broad-spectrum antiviral activity against many DNA and RNA viruses. It was commonly used with corticosteroids and has since become the most frequently administered antiviral agent for SARS [5, 10, 14, 22] the use of ribavirin has attracted a lot of criticism due to its unproven efficacy and undue side effects . R toxic concentrations have no direct in vitro activity against SARS30
CoV The prevalence of side effects from ribavirin is dose-related. High doses often result in more adverse effects, such as hemolytic anemia, elevated transaminase levels and bradycardia . However, lower doses of ribavirin did not result in clinically significant adverse effects Side effects have also been observed more frequently in the elderly. Corticosteroids have been the mainstay of immunomodulatory therapy for SARS. Their timely use often led to early improvement in terms of subsidence of fever, resolution of radiographic infiltrates and better oxygenation, as described in many Chinese and Hong Kong reports [10, 14,]. However, there is much skepticism and controversy about the use of corticosteroids, centering on their effectiveness, adverse immunosuppressive effects and impact on final patient outcomes. References 1- Fouchier R, Kuiken T, Schutten M, et al. Koch's postulates fulfilled for SARS virus. Nature 2003; 423: 240. 2-CDC. Update: Outbreak of Severe Acute Respiratory Syndrome Worldwide, 2003. MMWR 2003; 52:241-248. 3-Ksiazek TG, Erdman D, Goldsmith CS, et al. A Novel Coronavirus Associated with Severe Acute Respiratory Syndrome. New Eng J Med 2003, 348:1953-66. 4-Drosten C, Preiser W, Günther S, Schmitz H, Doerr HW. Severe acute respiratory syndrome: identification of the etiological agent. Trends Mol Med 2003b; 9:325-327.
5.Peiris JS, Chu CM, Cheng VC, et al. Clinical progression and viral load in a community outbreak of coronavirusassociated SARS pneumonia: a prospective study. Lancet 2003b; 361:1767-72 6. Cyranoski D, Abbott A. Virus detectives seek source of SARS in China's wild animals. Nature 2003; 423:467. 7. Enserink M. SARS in China. China's missed chance. Science 2003b; 301:294296. 8- Seto WH, Tsang D, Yung R, et al. Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS). Lancet 2003; 361: 1519–20. 9.Cho KO, Hoet AE, Loerch SC, et al. Evaluation of concurrent shedding of bovine coronavirus via the respiratory tract and enteric route in feedlot cattle. Am J Vet Res 2001; 62: 1436-41. 10.Lee N, Hui D, Wu A, et al. A Major Outbreak of Severe Acute Respiratory Syndrome in Hong Kong. N Engl J Med 2003; 348:1986-94. 11..Booth CM, Matukas LM, Tomlinson GA, et al. Clinical features and shortterm outcomes of 144 patients with SARS in the greater Toronto area. JAMA 2003; 289:28019. 12.Chan-Yeung M, Yu WC. Outbreak of severe acute respiratory syndrome in Hong Kong Special Administrative Region: case report. BMJ 2003; 326:850-2
13.Donnelly CA, Ghani AC, Leung GM, et al. Epidemiological determinants of spread of causal agent of severe acute respiratory syndrome in Hong Kong. Lancet 2003; 361:1761-6. 14.Tsang KW, Ho PL, Ooi GC, Yee WK, et al. A Cluster of Cases of Severe Acute Respiratory Syndrome in Hong Kong. N Engl J Med 2003, 348:1977-85. 15.Peiris JS, Lai ST, Poon LL, et al. Coronavirus as a possible cause of severe acute respiratory syndrome. Lancet 2003a, 361:1319-25. Published online Apr 8, 2003. 16- Fisher DA. Lim TK, Lim YT, Singh KS, Tambyah PA. A typical presentations of SARS. Lancet 2003; 361:1740 17.Poutanen SM, Low DE, Henry B, Finkelstein S, et al. Identification of Severe Acute Respiratory Syndrome in Canada. N Engl J Med 2003, 348:19952005. 18..Wong R, Wu A, To KF, et al. Hematological manifestations in patients with severe acute respiratory syndrome: retrospective analysis. BMJ 2003; 326: 1358-62 19. Wong KT, Antonio GE, Jui D, et al. Severe Acute Respiratory Syndrome: Radiographic Appearances and Pattern of Progression in 138 Patients. Published online before print May 20, 2003b. 20. Rainer TH, Cameron PA, Smith D, et al. Evaluation of WHO criteria for identifying patients with severe acute respiratory syndrome out of hospital: prospective observational study. BMJ 2003; 326: 1354-8.
21- McIntosh K. Coronaviruses. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases, 5th ed. Philadelphia: Churchill Livingstone, Inc., 2000.
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