Journal of Emergency Medicine, Trauma and Acute Care - 5 - The 12th international scientific conference of Al-Nahrain University, November 2024

Background: Pancreatoduodenectomy (PD) is a surgical procedure used to treat diseases of the pancreatic Head, the distal common bile duct (CBD), and the duodenum, as well as trauma to the head of the pancreas. Once the pancreatic head and the duodenum are resected, the surgeon needs to reconnect the stomach, the biliary tract, and the pancreatic stump. The technique for reconstructing the biliary tract is fairly standard, represented by the anastomosis of the CBD to the jejunum, but the reconstruction of the pancreatic stump is a matter of debate. In general, two procedures can be used: pancreaticojejunostomy (PJ), which is an anastomosis between the pancreatic stump and the jejunum, and pancreaticogastrostomy (PG), which is an anastomosis between the pancreatic stump and the stomach.

Aim: The objective of this study was to compare the impact of PJ and PG on the occurrence of postoperative pancreatic fistula (POPF), morbidity, and mortality following PD.

Patients and Methods: This study took place between April 1, 2021 and April 1, 2023 at Gastroenterology and Hepatology Teaching Hospital in Baghdad Medical City. The cases in the study were designed prospectively. It is a comparison between PG and PJ after undergoing Whipple surgery. A total of 30 patients were selected and divided into two groups. The first group consisted of 16 patients who underwent PJ, while the second group consisted of 14 patients who underwent PG. The cases were prepared in the surgical consultation clinic. On the one hand, through PG, it was determined whether the texture of the pancreas was soft and the size of the main pancreatic duct (MPD) was less than 3 mm. On the other hand, through PJ, it was determined whether the texture of the pancreas was firm or hard and the size of the MPD was more than 3 mm.

Results: The age group of males and females ranged from 11 to 68 (median 57) years. There were a total of 16 males and 14 females. The ampullary tumor was present in 11 patients of the PJ group and 7 patients of the PG group. Histopathology of tumors showed adenocarcinoma in 13 patients of the PJ group and in 6 patients of the PG group. POPF occurred in 3 patients of the PJ group, type A in 1 patient and type B in 2 patients, and no POPF was observed in the PG group. Hemorrhage occurred in 1 patient of the PG group and 2 patients of the PJ group. Delayed gastric emptying occurred in 5 patients: 3 patients of the PJ group (type A) and 2 patients of the PG group. SSI (surgical site infection) occurred in 7 patients: 5 patients of the PJ and 2 patients of the PG group. Finally, mortality occurred in 3 patients of the PJ group.

Conclusion: Pancreatic intestinal anastomosis must be tailored to the surgeon's preferences and experience level, and any innovative technique that reduces the prevalence of POPF is welcome in pancreatic surgery. PG seems to be associated with less POPF, morbidity, and mortality than PJ after undergoing Whipple surgery, especially given the soft texture of the pancreas and the size of the MPD < 3 mm.

Recommendations: 1. Because our study included a limited number of samples, further prospective randomized studies with larger samples are required to confirm that PG had fewer complications. 2 Surgeons should be encouraged to use PG more frequently in the future.

Background: MRSA (methicillin-resistant Staphylococcus aureus) is a global health problem. Many people are looking for new ways to combat MRSA, for example by using bacteriophages (phages). It has been extremely challenging to isolate a sufficient quantity of lytic anti-MRSA phages. Therefore, new techniques for separating, refining, and reworking anti-MRSA phages were sought in this study.

Methods: Of 437 S. aureus isolates, nine clinical MRSA isolates were obtained from three hospitals in Baghdad, Iraq and two ATCC MRSA strains were used to separate wild anti-MRSA phages from sewage, filth, and hospital settings. The wild phage was optimized using plaque-based biokinetic methods. The resulting highly lytic and specific anti-MRSA phages were subjected to novel physico-chemical phage redesign protocols using agents to weaken the bacterial cell wall to allow phages to enter into host bacteria and acquire the specificity of the new host. Three protocols were tested using different combinations of benzethonium chloride (BZT-CH), alkaline ethanol, and chlorhexidine gluconate.

Results: Five newly redesigned, transiently stable, anti-MRSA phages were produced using the BZT-CH and ethanol–alkali methods, albeit at varying rates.

Conclusion: Although the resulting designed anti-MRSA phages are transiently stable, they represent a rare opportunity and an excellent endless source of lytic anti-MRSA phages from which a large number of permanent phage lysins can be separated and purified.

Background: A global health concern is methicillin-resistant Staphylococcus aureus (MRSA). The use of bacteriophages is one of the many novel control strategies against MRSA that are frequently sought. However, it is quite challenging to isolate enough lytic anti-MRSA phages. In order to extract, optimize, and remodel anti-MRSA phages, this study sought novel approaches.

Methods: Two ATCC MRSA strains and nine clinical MRSA isolates were used to isolate wild anti-MRSA phages from hospital settings, dirt, and sewage. The wild phages were optimized using plaque-based biokinetic techniques. Using chemicals that weakened bacterial cell walls, the resulting highly lytic and specific anti-MRSA phages were subjected to unique physicochemical phage redesign processes. This allowed the phages to enter host bacteria and acquire the specificity of the new host. Three different protocols were tested using combinations of Tween 20, lysozyme, and nisin A.

Results: Nisin A and lysozyme protocols at different rates were found to be successful in producing newly redesigned, transiently stable, anti-MRSA phages.

Conclusion: Unlike self-depleting antibiotic-based applications, phage redesign is self-fortifying. In order to address the increasing number of epidemic MRSA strains, this model could prove to be a perfect platform for developing trustworthy control and treatment strategies. Additionally, it is believed to be an infinite supply of anti-MRSA lytic phages from which several permanent phage lysins can be isolated and refined.

Background: Penetrating neck injuries (PNI) pose significant clinical challenges due to the involvement of vital structures. Timely management is crucial for favorable outcomes.

Objective: The aim of this study was to investigate the occurrence, etiological factors, intervention, and outcomes of PNI in patients treated at a tertiary center in Iraq.

Methods: A retrospective and prospective study spanning three years was conducted at Al-Immamian Al-Kadhimain Hospital. Data were collected from hospital records, and patient demographics, injury details, treatment approaches, and outcomes were analyzed.

Results: The study included 50 patients, predominantly male (86%), with a mean age of 42.5 years, in whom gunshot wounds were the leading cause of injury (44%), followed by shrapnel. The mortality rate was 8%. While survivors had a mean hospital stay of 8 days, the stay of deceased patients was significantly shorter at 2 days. Soft tissue injuries were universal, with arterial injuries being more common in deceased patients. The common carotid artery was the most commonly injured vessel among the deceased, and ligation was the predominant surgical intervention in this group. Postoperative complications, including wound infections and neurological deficits, were notable among survivors. The associated injuries to critical anatomical regions such as the head, face, and abdomen highlighted the severity and complexity of the trauma experienced.

Conclusion: In summary, penetrating neck injuries demand prompt and comprehensive management to mitigate potential complications. By integrating evidence-based diagnostic and therapeutic strategies, clinicians can improve outcomes and reduce morbidity and mortality associated with these injuries. The findings of this study highlight the importance of individualized care and the need for further research to enhance the understanding and treatment of penetrating neck injuries.

Background: The enzyme protease accounts for approximately two-thirds to one-third of all enzymes used in different industries. Protease is produced in large quantities as a crude enzyme for food industries.

Objectives: The aim of this study was to investigate the effect of UV radiation on the protease produced by Pseudomonas aeruginosa.

Methods: Of a total of 149 samples collected from various clinical cases (wounds, burns, otitis media, and urinary tract infections) in four hospitals in Baghdad for the isolation of P. aeruginosa, 90 isolates were identified as belonging to P. aeruginosa after isolation on a specific selective media, and the Vitek 2 system was later used for final identification. Thirty-six P. aeruginosa isolates were screened for protease production on a skim milk medium.

Results: This study found that most of the P. aeruginosa isolates were protease producers and the isolate p3 was the best, which had a hydrolysis zone of up to 29 mm and their specific activity was 0.134 units (U)/mg protein in the culture filtrate. Therefore, this isolate was selected to study the effect of UV light on the production of the protease enzyme. The results showed that protease was produced at high levels from mutant p3 isolates after exposure to UV irradiation for different durations (15, 25, 35, 45, 55, 65, 75, 85, and 95 seconds). The specific activity of the enzyme in a crude filtrate was 0.65 U/mg protein compared with the wild type (0.134 U/mg protein). Protease produced from the mutated isolate p3 was later purified in three purification steps: first, its precipitate with 70% ammonium sulfate, second through a DEAE-cellulose column, the specific activity of which reached 7 U/mg protein, and in the final step through a Sephadex G-200 column. The purified enzyme protease had a specific activity that gradually increased to 10.5 U/mg with an 18.23-fold purification and 84.1% enzyme recovery.

Conclusion: UV radiation was an efficient method to induce the production of protease enzymes.

Background: Obesity is a multifactorial metabolic disorder characterized by the accumulation of excess energy in adipose tissue. The risk of this disorder lies in genetic problems, intake problems, psychological disorders, lack of exercise, eating habits, and medical conditions. Weight loss attempts involving dietary changes, behavioral modifications, and exercise have been of limited benefit to most affected individuals. Weight loss operations have obviously evolved in recent years. The most commonly used and best-studied procedure is laparoscopic sleeve gastrectomy (LSG).

Aim: The aim of this study was to assess certain points of LSG (benefits and complications for patients with morbid obesity) performed in Al-Imamein Al-Kadhimein Medical City.

Patients and Methods: Data were collected in a prospective cohort study in Al-Imamein Al-Kadhimein Medical City between January 2021 and December 2022. LSG was performed for 40 patients for the treatment of obesity and included the following demographic data: body mass index (BMI, weight in kilograms divided by height in square meters (kg/m²)), hip circumference, waist circumference, total cholesterol, triglyceride, low-density lipoprotein, high-density lipoprotein, HbA1c%, and fasting blood sugar, presence of comorbidity (e.g. diabetes and hypertension), and complications following surgery. All patients were followed 3 months and 9 months postoperatively.

Results: A total of 40 obese patients underwent bariatric surgery (laparoscopic sleeve gastrectomy), there were 65% female and 35% male, their mean age was 34.30 ± 5.31 years (range:23-45 years), the mean weight of patients was 146.70 ± 21.92 kg (115- 200 kg), the mean BMI was 51.45 ± 5.65 kg/m² (37.5-63.8 kg/m²). Excess weight loss was 69% after 9 months. The improvement in comorbid diseases was significant.

Conclusion: LSG is a useful procedure for the surgical management of morbid obesity. Most people who underwent these operations experienced a reduction in complications of obesity, such as hypertension and diabetes mellitus.

Background: Self-medication puts the benefits of antibiotics at risk. This has resulted in underdeveloped countries facing an increased economic burden, treatment failures, growth of bacteria that are resistant to antibiotics, and a higher population risk of exposure to and infection by such pathogens. The aim of this study was to assess knowledge, attitudes, and practices regarding antimicrobial use and resistance among a group of final-year pharmacy students and medical students at universities in Baghdad, Iraq.

Methods: This was a descriptive cross-sectional and institution-based study conducted between September and November 2023. Knowledge, attitudes and practices regarding antibiotic use were assessed using a self-administered questionnaire.. In addition, the students were assessed on how they felt that their medical education had prepared them to become pharmacists and physicians after graduation.

Results: The total number of students was 642 (328 medicine and 314 pharmacy). The survey shows that although 94.7% of the students had good knowledge, only 65.4% of them actually practiced it. There was a significant (p < 0.05) difference in the total attitude score according to the gender of the participant. In other words, female participants had significantly higher positive attitudes than male participants. There was a significant (p < 0.05) difference in the total attitude, behavior, and practice scores according to the college type of the participants. In other words, pharmacy students had significantly higher total attitude, behavior, and practice scores than medical students.

Conclusion: The students’ level of knowledge was more than sufficient, but they need more education to improve their practice. Significant work still needs to be done to focus on improvements.

Background: Subfertility affects approximately 15% of couples globally, with unexplained infertility being a common diagnosis. Homocysteine, a sulfur-containing amino acid, has been implicated in reproductive health, but its association with unexplained infertility remains unclear.

Aim: This observational case–control study aimed to compare homocysteine levels among women with unexplained infertility and those with normal fertility.

Methods: Fifty women with unexplained infertility and fifty controls matched for age and BMI were recruited. Homocysteine levels were measured using venous blood samples collected after overnight fasting. Statistical analysis included independent t-tests, ROC (receiver operating characteristic) curve analysis, and odds ratio calculations.

Results: Women with unexplained infertility had significantly higher mean homocysteine levels compared to controls (15.05 ± 2.4 vs. 9.2 ± 2.3 μmol/L, p < 0.001). The ROC analysis showed a cutoff value of 12.3 μmol/L, with a sensitivity of 92.0% and a specificity of 99.9%. The odds ratio for unexplained infertility with homocysteine levels >12.3 μmol/L was 180.16 (p < 0.001).

Discussion: The findings are consistent with previous studies, suggesting elevated homocysteine levels as a potential biomarker for unexplained infertility. The high discriminatory power of homocysteine levels indicates its potential diagnostic utility in identifying women at risk for unexplained infertility.

Conclusion: Determination of homocysteine levels may be helpful in diagnosing unexplained infertility, providing a cost-effective biomarker to guide treatment strategies and optimize resource utilization in fertility care. Further research could explore interventions that target homocysteine levels to improve fertility outcomes in affected women.