Keywords : KEYWORDS

Permanent Pacemaker Implantation in Ibn - Al Nafees Hospital; Indications and Early Complications

Iraqi Postgraduate Medical Journal, 2019, Volume 18, Issue 3, Pages 211-217

A pacemakers is a small device that is placed in the chest to help control abnormal heart rhythms
and prevent bradycardia.
To evaluate the practice of permanent pacemaker implantation including indications and early
This is a retrospective study in 90 patients over 2.5 years (from June 2013 to January 2016).
The case sheets of patients were studied carefully including history, clinical examination, ECG
findings, echocardiographic Study and cardiac catheterization. In addition, the reports of the first
follow up visit around two weeks after implantation were studied.
The females (61.2%) more than males, syncope (44.4%) and dizziness (33.3%) were the most
common presentations, most of patients (87 patients) represented in class I indication for pacemaker
implantation, CHB (72.2%) was the most common ECG finding, the most common causes of heart
block were unspecified (55%) and post MI (27.7%), the most common pacing mode was VVI mode
(43.3%). The complications of pacemaker implantation were 11.1% and the infections represent
3.1%, In older age group and in diabetic patients the infection incidence increased. The indication of
temporary pacemaker prior to permanent pacemaker implantation was (22.2%), and post-acute MI
and hemodynamically unstable patients were the most common causes (8 patients) and (7 patients)
respectively .
implantation of permanent pacemaker is a save and could be life saving in significant bradycardia,
and complete heart block was the most common cause of pacemaker implantation

The Value of Free Thyroid Hormones and Aspartate Aminotransferase in Vaginal Washing Fluid for Detection of Preterm Pre-Labor Rupture of Membrane

Iraqi Postgraduate Medical Journal, 2019, Volume 18, Issue 1, Pages 52-58

Preterm pre-labor rupture of membrane occurs in about 2% of all pregnancies. The most frequent
consequences of preterm pre-labor rupture of membrane is preterm delivery, sepsis and pulmonary
hypoplasia. The correct diagnosis of preterm pre-labor rupture of membrane is crucial and successful
management will be based upon it.
To determine whether measurement of vaginal washing fluid aspartate aminotransferase(AST) ,
free triiodothyronine (free T3) and thyroxin(free T4) were useful tests for the diagnosis of preterm
pre-labor rupture of membrane.
STUDY DESIGN: A case - control study.
SETTING: :This study was conducted at department of Obstetrics and Gynecology of AL-Yarmouk
teaching Hospital and National center for Diabetes
It included hundred pregnant women with a gestational age ranging between 24 - 36+6 weeks. They
were divided into two groups, the study group which included fifty pregnant women presented with
preterm pre-labor rupture of membrane and the control group which includes fifty pregnant women
without any complaint, matched for gestational age. All women underwent sterile speculum vaginal
examination. Free triiodothyronine and free thyroxin levels were measured by using Enzyme immune
assay method, and aspartate aminotransferase level was measured by using colorimetric method, in
vaginal washing fluid.
Vaginal washing fluid free T3, free T4 and AST levels were significantly higher in the study group
(1.15), (0.071), (4.9) respectively compared with the control group (0.93), (0.048), (4.5) respectively.
Vaginal washing fluid free T4 having the largest area under the curve on receiver operating
characteristic curve (ROC) analysis (P<0.001). ROC curve analysis showed that free T3 validity
results in predicting preterm pre labor rupture of membrane among pregnant women were (cut-off
1.07pg/ml, sensitivity 88%, specificity 76% and accuracy 82%), free T4 validity results were (cutoff
0.055pg/ml, sensitivity 84%, specificity 80% and accuracy 82%) and AST validity results
were (cut-off 4.9IU/L, sensitivity 52%, specificity 80% and accuracy 66%).
Measurement of aspartate aminotransferase free triiodothyronine , and thyroxin in vaginal washing
fluid of suspected and diagnosed patient presented with preterm pre labor rupture of membrane
found to be a useful markers for the diagnosis of preterm pre labor rupture of membrane.

Management of Traumatic Hemothorax a Retrospective Study of 165 Cases in AL-Jamhoori Teaching Hospital in Mosul

Iraqi Postgraduate Medical Journal, 2019, Volume 18, Issue 1, Pages 30-36

Traumatic hemothorax is one of the most common thoracic injuries in the world. There are a lot of
debates about the best method of management because of the possible risk of death and
development of subsequent complications.
The objective of this study is to decide the best type of management of traumatic hemothorax
(thoracostomy tube drainage versus thoracotomy) for life saving and prevention of subsequent
complications such as trapped lung with fibrothorax, and empyema.
This is a retrospective study of 165 consecutive patients with traumatic hemothorax admitted to
Al-Jamhoori teaching hospital in Mosul from 1st January 2010 to 1st January 2012. The parameters
that were used in this study were sex, age group, mechanism of injury, hemodynamic state at time
of according to volume of blood in the drainage bottle into5 groups. The patients were also
classified into 4 groups depending on their hemodynamic state at time of presentation.
Thoracostomy tube drainage was done in the majority of cases as the mainstay of treatment, in
minority of cases it was followed by thoracotomy for those with massive hemothorax, severe
hypovolemic shock, associated thoracic injuries, or those with complications.
Traumatic hemothorax should be treated initially by thoracostomy tube drainage except in very
urgent cases, and the decision for thoracotomy should be based on the hemodynamic state, the
volume of drained blood and the presence of associated thoracic injuries. A good initial care and
proper drainage of collected intrathoracic blood reduces the development of late complications and
the subsequent need for thoracotomy.

Results of Minimal Dosage Propranolol in the Management of Infantile Haemangioma

Iraqi Postgraduate Medical Journal, 2019, Volume 18, Issue 1, Pages 10-17

Infantile haemangioma one of the most common tumour of new borns , a safe and effective treatment
options are under ongoing research .
The authors show the effectiveness and safety of low dose propranolol as a method for infantile
haemangioma treatment .
In this study twenty- four patients with infantile haemangioma in different anatomical locations were
treated with oral propranolol and the result were assessed in a retrospective analysis of the results
patients were kept on 0.25 mg/kg/day for one month , then on 0.5mg/kg/day in 2 divided doses for
another one month , in the third month the dose will be increased to 1 mg/kg/day in 2 divided doses ,
then the propranolol were given in a maintenance dose ranging between 1-1.5 mg/kg/day in 2 divided
doses according to the clinical response .The duration of treatment ranging from 6-18 months as a
small dose increasing over a long time .
We had achieved excellent result in most of our patients, with reduction of size and fade of color of
hemangioma within 1 month from the initiation of treatment, when we stop the treatment no relapses
were noticed during our follow up period after finishing the course.
Propranolol is one of the safest and most effective treatment options for the infantile haemangioma
even in low dose, with lower relapse rates and minimal consecutive side effects and drawbacks.

Beta-2-Microglobulin as a Marker in Patients with Thyroid Cancer

Iraqi Postgraduate Medical Journal, 2019, Volume 18, Issue 1, Pages 18-22

Thyroid cancer is consider the most common of the endocrine system malignancies, also it
represents less than 1% of all tumors in human. Beta-2-microglobulin protein (β2M) is a low
molecular weight polypeptide (11800 Dalton), it is found on the surface of cells which contains
nucleus except red blood cells. It is a small subunit and the light chain of major histocompatibility
complex class I ( MHC- 1) also known as human leukocyte antigen (HLA) in human.
Aim of study:
Detection of the possibility of using Beta-2-Microglobulin protein as a marker for thyroid cancer.
A total of 49 patients with thyroid cancer, their mean age 37.77±13.84 years ranged (18-76 years)
were included in this study and healthy age-matched control group were 32 healthy donors, their
mean age 38.12±12.29 years ranged (19- 69 years) collected from healthy volunteers. Serum
creatinine level was determined by automated clinical chemistry analyzer. In addition to Beta-2-
Microglobulin protein was determined by Enzyme-linked Immunosorbent Assay technique.
The results of serum creatinine level showed a normal level of serum creatinine for all subjects
(healthy control and patients) except 14 patients with thyroid cancer who had a level of serum
creatinine out of normal range were excluded. Also the results showed significant increase (p=
0.0000001) in mean value of serum β2M protein in patients with thyroid cancer (group B)
compared to healthy control (group A). Also the results showed no significant correlation between
β2M protein and age (r= 0.153 , p-value 0.379). Also no significant correlation between β2M
protein and BMI (r= -0.092, p-value 0.598). Moreover, receiver operating characteristics ROC
showed β2M level excellent predictor in the diagnosis of thyroid cancer (area under the curve
AUC= 0.970 p<0.001).
A level of serum β2M is elevated in thyroid cancer and can be used as a marker for thyroid cancer
and an assistant in the diagnosis of this disease.

Evaluation of the Outcomes of Rhomboidal Flap "Limberg Flap” Repair Procedure for Sacroccocygeal Pilonidal Sinus Disease in Baghdad Teaching Hospital

Iraqi Postgraduate Medical Journal, 2019, Volume 18, Issue 1, Pages 62-67

Saccrococygeal Pilonidal sinus is a common surgical condition and its management is still
debatable, as many surgical techniques were developed aiming to improve outcome, better patient
satisfaction, and most importantly to prevent recurrence. Rhomboidal flap procedure "limberg flap"
is very safe and effective method for pilonidal sinus treatment due to its low complication rate
specially recurrence hence in this study we address the role of limberg flap procedure in
management of pilonidal sinus and how its complications are.
To analyze the outcome of "Limberg" Rhomboidal flap, in managing sacrococcygeal Pilonidal
sinus as a novel, with a potentially less complication and recurrence rate surgical procedure.
This is a prospective study on 44 patients suffered from sacroccocygeal pilonidal sinus, 36 patients
with primary disease and 8 patients had recurrent or previously managed pilonidal sinus collected
randomly in the 5th floor surgical department in Baghdad teaching hospital from June 1st 2014 to
December 10th 2015. All underwent rhomboidal flap procedure .there was no exclusion criteria,
data collected included demographic distribution, primary or recurrent pilonidal sinus, wound
complications, and recurrence. The minimum follow up period was 1 year after surgery.
44 patients had undergone this procedure most of them were males (41 patients), and
(3 patients) were females, youngest patient was a 16-year old and oldest one was 41-year old. Mean
agewas26. 1years±5.6SD, 5 patients (11.4%) had a previous formal surgical repair of pilonidal
sinus, 3 patients (6,8%) had a previous drainage of pilonidal abscess. The mean duration of the
disease is 10.9 months±6.9 SD.Our finding revealed that 3(6.8%) patients developed seroma ,
2(4,5%)patients had wound infection that all responded to conservative treatment. Other suspected
complications including flap necrosis, wound dehiscence and hematoma were not reported with any
of our patients.
Rhomboid flap is very safe and effective method for treatment of pilonidal sinus disease due to its
low complication rates especially recurrence of pilonidal disease, it also offers a good patient
satisfaction, although this procedure takes a longer operating time than the classical methods but it
is easy to be learned and practiced with efficiency .

Bacteriological Diagnosis of Febrile Neutropenia in Oncology Teaching Hospital

Iraqi Postgraduate Medical Journal, 2019, Volume 18, Issue 1, Pages 37-42

Fever may be the only indication of a severe infection, it occurs in about (10 -50%) of patients
with solid malignancy during chemotherapy-induced neutropenia.
To determine the common pathogens causing febrile neutropenia and their susceptibility to
antibiotics in patients with solid malignancies in oncology teaching hospital.
50 patients with solid malignancy were enrolled in this cross sectional study. Blood culture and
sensitivity test were investigated for them. Other sample cultures were investigated according to
system involvement.
Blood culture was positive in 18% of patients. Gram negative bacteria were predominant
(81.81%). Among which E.coli being the most common (33.33%). E.coli was the isolate in the
only 2 (4%) positive Urine culture.
The most frequently effective antibiotic for Gram negative infections was Amikacin followed by
Imipenem compared to Ciprofloxacin, Tetracycline and Aztreonam for Gram positive ones.
Gram negative bacteria were the most bacteria isolated in the studied patients.

Evaluation of Predisposing Risk Factors for Gallstone Formation Following Bariatric Surgery

Iraqi Postgraduate Medical Journal, 2018, Volume 17, Issue 4, Pages 335-339

The risk factors for development of gallstones have been studied extensively in the general
population. They are different when it comes to patients who underwent bariatric operations.
Obesity and rapid weight loss induced by weight-reducing surgery are well recognized for the
development of gallbladder stones. There is no standard policy whether to perform prophylactic
cholecystectomy at the time of the bariatric operation or to give postoperative treatment to decrease
the risk.
The aim of the study is to evaluate the predictors of gallstone formation post-Bariatric surgery and
associated risk factors. The implication behind it will help decide how to follow up postoperatively
and whom are at increased risk to develop cholelithasis.
This prospective study was performed on 100 patients who underwent weight-reducing operations
at Al-Imamain Al-Kadimiyen Teaching Hospital. They were followed for 12 months
postoperatively. Ultrasonography examination was done for those who developed symptoms
suggestive of gallstone formation.
Twenty percent of them were found to have gallstones. Of the the parameters enrolled in the study
(age, gender, type of surgery, preoperative body mass index, percentage of excess body weight
loss), only the factor of the percentage of excess weight loss was the most significant of predicting
development of gallstone post-bariatric procedures (p value = 0.002). The preoperative BMI, age,
gender and type of operation were found were not found to be statistically significant in terms of its
relationship with gallstone formation.
Concomitant cholecystectomy along with the bariatric procedure is not recommended. Surveillance
by ultrasonography for those with excess weight loss more than 25% of their original weight is
advised for 1 year postoperatively.

Trends of Neonatal Mortality and Factors Related with Neonatal Mortality Among Neonates admitted to the Neonatal Care Unit of Fatima Al Zahraa Hospital in Baghdad During 2017

Iraqi Postgraduate Medical Journal, 2018, Volume 17, Issue 4, Pages 348-354

The neonatal mortality rate is a key outcome indicator for newborn care and directly reflects
prenatal, natal, and postnatal care. Early neonatal deaths are more closely associated with
pregnancy related factors and maternal health, whereas late neonatal deaths are associated
more with factors in the newborn`s environment.
To find out the neonatal mortality rate and to identify the factors related with neonatal
mortality among neonates admitted in the Aseptic Neonatal Care Unit of Fatema AL Zahraa
A cross - sectional hospital-based study was done depending on data collected from records of
the Aseptic Neonatal Care Unit (ANCU) of Fatema AL Zahraa Hospital in Baghdad, to find
out the number of deaths within the neonatal period (0-28 days) that was conducted from 1st of
Jan 2017 to 31st of Dec 2017. Data was also, collected from Obstetrical Ward to determine the
number of live births for the same period. The data was collected by using special form
including; the number of deaths in neonatal period, cause of death, neonatal gender, gestational
age, birth weight, mother`s age, educational level, history of congenital anomaly in previous
pregnancy , antenatal care, parity, consanguinity, type of delivery, pregnancy outcome, total
number of live births, and history of medical disease during pregnancy .
The Neonatal Mortality Rate (NMR) was 14.37 per 1000 live birth. NMR was very high
among low-birth-weight preterm infants, (50%) of mothers completed the primary school,
(71.89 %) of mothers had positive history for Consanguinity,15% of mothers had positive
history of congenital anomaly in previous pregnancy,(70.41%) of mothers were in the (20-35
years) age group. Normal vaginal delivery (NVD) in (63.01%) of cases. The most common
cause of neonatal deaths in the preterm delivery was respiratory distress syndrome (RDS), and
in the full term delivery was asphyxia.
The neonatal mortality rate was 14.37 per 1000 live birth. The maternal and neonatal
demographic data that were related with increased NMR were prematurity, lack of antenatal
care, multipara mother, repeated CS, mother`s hypertension, and consanguineous marriage.

Recurrent Pneumonia in Children at a Tertiary–Pediatric Hospital in Baghdad

Iraqi Postgraduate Medical Journal, 2018, Volume 17, Issue 4, Pages 377-383

There are many children suffering from Recurrent Pneumonia (RP). Children with RP may present a
difficult diagnostic challenge.
This study was performed to evaluate the frequency levels and underlying causes of RP in Children
Welfare Teaching Hospital (CWTH)/Medical City/Baghdad.
In this prospective hospital-based cross-sectional study, 107 children admitted with RP in CWTH in
the period from March to July 2014. Children were included in this study if they had at least 2 times
pneumonia per year or three ever in life proved by radiographic confirmation during hospital
admission. Children were classified according to underlying diseases associated with Pneumonia.
Based on the clinical features and the results of the investigations, the underlying disease could be
identified in 92/107 (86%) children. Aspiration pneumonia was diagnosed in 25 (23.4%) children,
followed by congenital heart disease (CHD) in 22(20.6%) children, Asthma in 21 (19.6%), these three
diseases were the most frequent with a relatively small difference between them. TB was reported in
9 (9.3%) children, Cystic fibrosis (CF) in 9(8.3%), Fibrosing alveolitis and immune deficiency were
found in 2 (1.9%) children for each and the least frequent disease was congenital cystic adenomatoid
malformation (CCAM) in one (0.9%) child. On the other hand, 15 (14%) children were reported with
unknown diagnosis at the time of data collection.
Most children with RP had an underlying disease for each, which was demonstrated. Aspiration
syndrome, CHD, and asthma were the most common underlying diseases that result in RP in children.
Early diagnosis is essential to ensure optimal treatment and to minimize irreversible lung damage.

The Value of C-Reactive Protein Concentration in the Blood in Early Diagnosis of Neonatal Sepsis

Iraqi Postgraduate Medical Journal, 2018, Volume 17, Issue 4, Pages 373-376

Neonatal sepsis refers to systemic infections which include septicemia, pneumonia, arthritis,
osteomyelitis and urinary tract infection.
Infections are important cause of neonatal and infant morbidity and mortality as many as 2% of
fetuses are infected in utero also is responsible for 30-50% of total neonatal deaths.
To evaluate the role of C- reactive protein concentration in early diagnosis of neonatal sepsis
and to determine the duration and follow up of treatment.
A cross sectional study was performed in the neonatal intensive care unit (N.I.C.U) at Ibn
Al-Balady hospital in Baghdad governorate. One hundred sixty five neonates less than 30 days
with birth weigh more than 1500 gram suspected clinically to have neonatal sepsis and blood
was drawn for C-reactive protein and blood culture. Also blood was drawn for complete blood
count including WBC and differential count which was of little or no value in the diagnosis.
C- reactive protein was sensitive (62%) (by immunometric test) a method for early diagnosis
and for treatment and follow up of neonatal sepsis.
C- reactive protein was good predictor and sensitive (62%) for diagnosis of neonatal sepsis and
could detect the duration of antibiotic therapy. Hematological profile was not significant in
diagnosis of neonatal sepsis.

Molecular and Serologic Detection of HLA-B27 among Ankylosing Spondylitis Patients with Some Clinical Correlations

Iraqi Postgraduate Medical Journal, 2018, Volume 17, Issue 3, Pages 261-270

HLA-B27 can effect clinical presentation and course of ankylosing spondylitis. Different detection techniques of HLA-B27 are available with variable sensitivities and specificities.
To compare serologic and molecular diagnostic techniques of detecting HLA-B27 status and to correlate it with some clinical variables among ankylosing spondylitis patients.
A cross-sectional study was conducted on 83 Iraqi patients with ankylosing spondylitis. Clinical and laboratory evaluations were reported. HLA-B27 status was determined in all patients by real-time PCR using HLA-B27 RealFast™ kit; ELISA method was used as well to detect soluble serum HLA-B27 antigens using Human Leukocyte Antigen® kit.
The mean age of patients ± SD was (38.4±9.8) years. Male to female ratio was 9:1. Disease onset occurred <30 years in 78% of cases. All (100%) cases had lower back pain, 44 (54%) patients had enthesitis, 14 (16.9%) had peripheral arthritis, 12 (14.5%) had eye involvement, while cardiovascular disease and psoriasis were present in one patient (1.2%) each. HLA-B27 was detected in 55 (66.3%) patients by real-time PCR. The disease onset was earlier and disease duration was longer in HLA-B27-positive patients (p-value<0.05 for both). Uveitis was significantly associated with HLA-B27 positivity (p=0.032). HLA-B27 positive cases by ELISA test were 32 (38.6%) patients. Comparing HLA-B27 gene detection by real-time PCR with sHLA-B27 detection by ELISA revealed that the sensitivity of ELISA was 38.18%, specificity was 60.71% and positive predictive value (PPV) was 61.8%.
HLA-B27 typing by microlymphocytotoxicity (MLCT) test from initial old serologic typing was available for a subgroup of 28 (33.7%) cases. Comparison of ELISA and MLCT results with real-time PCR in this subgroup of 28 cases revealed that ELISA method showed a sensitivity of 60.6%, specificity of 72.72% and PPV of 86.95%, while MLCT showed a sensitivity of 68.96%, specificity of 80%, and PPV of 90.9%
Real-time PCR detection of HLA-B27 status is superior to serological techniques (ELISA and MLCT) as the latter two yielded high false results, with MLCT being relatively better than ELISA.

Efficacy of Rotavirus Vaccination in Prevention of Hospital Admission of Gastroenteritis among Children Under Two Years of Age

Iraqi Postgraduate Medical Journal, 2018, Volume 17, Issue 3, Pages 225-231

Rotavirus is the most common cause of acute gastroenteritis in children.
To find out the efficasy of rotavirus vaccine in prevention or reduce the number of cases and hospital admission of gastroenteritis among children under two years of age.
A cross-sectional study was conducted in Central Teaching Hospital of Pediatric in Baghdad,from the first of February to 31st of May 2016,on a total of(524) child under two years of age, grouped into two groups,first group(260)vaccinated with rotavirus vaccine,second group(264)non-vaccinated.
According to development of gastroenteritis and vaccination state of rotavirus vaccine,the acute gastroenteritis in non-vaccinated group was more compared with vaccinated group,192out of264(72.8 %)and128 out of 260(49.2%) respectively,and this association statistically significant.The number of cases that is admitted to hospital is48(37.5%)in vaccinated group with acute gastroenteritis which is significantly lower as compared to148(77.1%)in non-vaccinated group with acute gastroenteritis.This study showed that males and females were found to be equally affected of gastroenteritis.
Rotavirus vaccine have reduced the number of cases and hospital admission of gastroenteritis among children under two years of age in Central Teaching Hospital of Pediatric in Baghdad.

The Role of Some CT Criteria‎ in the Diagnosis of Solitary ‎Pulmonary Cavitary Lesion

Iraqi Postgraduate Medical Journal, 2018, Volume 17, Issue 3, Pages 249-254

The term cavity is a gas-filled space that appears on imaging as ‎an area of low attenuation surrounded by a variously thickened wall within a pulmonary consolidation, mass, or nodule. ‎Multidetector computed tomography (CT) of the chest is the current technique ‎of choice for evaluating lung cavities.‎
To assess the role of some computed tomography criteria in ‎differentiating benign ‎from malignant solitary cavitary lung lesion.‎
This was a cross sectional study done in the Computed Tomography ‎unit of Al-Immamain Al-‎Kadhmain Medical city in Baghdad, Iraq between ‎October, ‎‎2016 and June, 2017. All patients presented with solitary pulmonary cavitary lesions ‎‎detected by chest x-ray referred for different reasons. ‎‎Examination of ‎the chest was ‎performed by multi-detector CT (Somatom definition edge, SIEMENS ‎‎medical system, Germany (256 slices)) with 2 sets of CT examination one ‎before and another ‎after giving IV nonionic iodinated contrast ‎medium (Ultravist 370 mg /ml), 1.5 ml/kg Body ‎weight. ‎The final diagnosis was obtained depending on the sputum ‎culture for AFB, ‎bronchoscopy and biopsy, bronchoscopy and brush ‎cytology and true cut biopsy. ‎
The study included 50 patients with solitary pulmonary ‎cavitary lesions, 54% were male and 46% were females. Final diagnosis was 80% diagnosed as ‎benign and 20% as malignant lesions. Enhancement was ‎significant among 20% of studied patients. The common associated CT scan ‎features were pleural effusion (24%), consolidation (12%), consolidation and tree ‎in Bud (10%), pleural effusion and mediastinal lymph nodes (8%), tree in bud ‎‎(10%), mediastinal lymph node and consolidation (8%), ground glass opacification, ‎honeycombing and tree in bud (6%), pleural effusion and tree in bud (4%), fibrosis ‎‎(2%) and encysted hydro-pneumothorax (2%). There was a highly significant association of significant enhancement and ‎ Pleural effusion ‎ with malignant solitary cavitary lesions (p<0.001 and p=0.003‎). A highly significant ‎association was observed between increased mean thickness of lesion and ‎malignant solitary cavitary lesion (p<0.001) ‎
The common computerized tomography characteristics of malignant solitary ‎pulmonary cavitary lesions were significant enhancement, pleural effusion and ‎increased diameter and thickness of pulmonary cavities.‎

The Role of Intralesional Bleomycin in the Management of Cutaneous Infantile Hemangioma

Iraqi Postgraduate Medical Journal, 2018, Volume 17, Issue 3, Pages 204-210

Infantile hemangioma, although often small after birth, it tends to follow a proliferative phase in which the growth may be rapid and unpredictable. Besides, its involution often takes many years to happen causing psychological problems and embarrassment to the parents as well as their child.
To evaluate the efficacy of intralesional bleomycin in the management of infantile cutaneous hemangiomas and to assess the possible side effects and complications of this treatment modality.
A prospective study done in Iraq over the period from October 2014 to December 2015, were 28 patients with cutaneous infantile hemangiomas had been treated by intralesional bleomycin injection, 0.25-0.5 unit/kg/dose, administered subcutaneously. The enrolled patients were divided depending on lesion size at time of presentation into two groups; those with hemangiomas less than 12 cm2 and others with lesions greater than 12 cm2. The lesions were measured serially and monitored with photos for follow up and documentation. Side effects were also recorded. Lesion’s response was graded into five grades according to the final size after treatment.
The mean age of the studied patients was 13.5±11.2 months (3 months to 4 years). The mean number of injections given was 3.7±0.7(3 to 5), and the mean total dose administered was 3.8±1.5 units/patient(2.5 to 9). Complete involution (>90% reduction in the size of the hemangioma) was recorded in 9(32.1%) children. Twelve (42.9%) children were reported to achieve 75-90% reduction in the size of the hemangioma. In 6(21.4%) children, there was a 50-75% reduction in the size of the lesion, and only 1 patient had <25% reduction in the size of the lesion. The mean follow up period was 5.8±2.1 months (3 to 10 months).Hyperpigmentation was the most common complication and was reported in 11(42.3%)patients.
Intralesional bleomycin is an effective option in the treatment of cutaneous infantile hemangioma

Assessment of Sigma Metric Results of Serum Parameters of Liver and Kidney Function Tested by Automated Chemistry Analyzer in Medical City Hospital

Iraqi Postgraduate Medical Journal, 2018, Volume 17, Issue 3, Pages 307-314

A major goal of quality assurance is the minimization of error rates in order to augment patient safety, six sigma or sigma metrics were used to assess the analytical quality of automated clinical chemistry, six sigma metrics is used in combination with total allowable error, method imprecision and bias. The goal is to achieve the highest possible sigma scale within the acceptable limits of total allowable error.
For assessment of sigma metrics results of serum parameters of liver and kidney function test tested by automated chemistry analyzer in Medical City Hospital.
In the current study, internal quality control (IQC) and external quality assessment (EQA) data were analyzed for the period from May 2017 to July 2017 using chemistry auto analyzer (Siemens Dimension RxL Max) at the Teaching Laboratories of the Medical City Hospital. Mean, standard deviation, coefficient of variation %, bias %, total error and sigma metrics were calculated for serum urea, creatinine, total serum bilirubin(TSB), alkaline phosphatase (ALP), aspartate aminotransferase(AST) and alanine aminotransferase (ALT).
Excellent sigma values (≥6) were elicited for TSB (14) and AST (7.7), Satisfactory sigma values (≥3) were elicited for ALT (6) and ALP (4.6), while serum urea and creatinine performed poorly (2.5), (2.8) respectively on the sigma scale.
Total serum bilirubin was the best performer on six sigma scale, for AST, ALT and ALP the sigma results was accepted. While serum urea and creatinine had poor performance, so there is need for improvement of their methods which should be controlled with greater attention to ensure quality.

Unstable Angina Risk Factors and Influence of Age and Gender in relation to In-Hospital Outcome

Iraqi Postgraduate Medical Journal, 2018, Volume 17, Issue 3, Pages 285-290

Unstable angina (UA) is a type of acute coronary syndrome. It has been recognized as a distinct syndrome intermediate between stable exertional angina and myocardial infarction. It includes many types according to the onset, duration, intensity and frequency of pain.
The objective of this study to estimate the frequency of risk factors of ischemic heart disease, influence of age and gender, also to predict the in-hospital outcome.
One hundred patients with unstable angina of all ages and both gender were enrolled in a cross-sectional study from October 2010 – June 2011 who were admitted to coronary care unit of Baghdad Teaching Hospital / Medical City.
Descriptive analyses were performed to assess the relationship between unstable angina and risk factors and influence of age and gender and in-hospital outcome.
This study showed a highest incidence of unstable angina among males and females in the age of 50-54years.Hypertension was the major risk factor (58%) while, smoking (48%), diabetes (38%), family history of ischemic heart disease (35%), hypercholesterolemia (34%) and obesity (22%).There were significant differences between both gender with unstable angina and the following risk factors: hypertension, smoking, hypercholesterolemia and obesity. There were 22% of patients with persistent chest pain who developed non- fatal acute myocardial infarction and 6% died in the hospital.
The following risk factors; hypertension, smoking, diabetes, family history of ischemic heart disease, hypercholesterolemia and obesity play an important role in occurrence of unstable angina and prognosis. The incidence of UA was higher among ages of (50 -54) years of both gender. Persistence of chest pain at rest was greatly associated with unfavorable outcome.

Radical Antegrade Modular Pancreato-Splenectomy (RAMPS) Procedure with Celiac Trunk Resection Case Report

Iraqi Postgraduate Medical Journal, 2015, Volume 14, Issue 4, Pages 281-286

Carcinoma of the body and tail of the pancreas considered one of the most challenging tumors due its retroperitoneal location and neighboring major blood vessels. Therefore, it is often presents at an advanced stage and is deemed unresectable in the majority of patients.The traditional approach of left-to-right Pancreato-Splenectomy is associated with a high positive tangential margin rate, is not based on the described lymph node drainage of the organ, and is associated with high recurrence rate.In 2003, Strasberg SM described a novel approach for resection of this part of the pancreas called Radical Antegrade Modular Pancreato-Splenectomy (RAMPS)which was introduced to obtain a higher rate of negative tangential margins and a higher lymph node count.This is a case report of pancreatic tumor with celiac trunk invasion treated by the new RAMPS procedure with celiac trunk resection. Patient discharged home on fifth postoperative day,follow up reveals recurrence free survival one year later.

Illustrated Correlation of Brain C.T. Scan Findings in Clinical Assessment of Spontaneous Intracerebral Haematoma in Patients with Positive Risk Factors

Iraqi Postgraduate Medical Journal, 2015, Volume 14, Issue 4, Pages 270-275

Spontaneous intracerebral hemorrhage (SICH) is defined as non-traumatic bleeding into the parenchyma of the brain that may extend into the . head computed tomography scan is the standard diagnostic tool
Find out the most important risk factor for SICH.and Illustrate the correlation between the sites of hemorrhage detected by CT scan images and patients presentations.
A prospective study between May 2010 and May 2012; this study was done in the CT unit in AL- Imamain Kadhimmain medical city, Baghdad, The study included 224 consecutive patients with the diagnosis of primary SICH.All the patients had primary spontaneous intracerebral hemorrhage clinically diagnosed plus CT findings that showed evidence of intra-cerebral hemorrhage. Statistical analysis was done using SPSS 15.
This study included 224 patients, 128males and 96 females. Forty two patients lie in the age group of 50-59 years, 66 between 60-69 years, 48 between 70-79 years, 52 patients are seventy years old and older and only 16 are below fifty years of age. Regarding the site of bleeding 160 patients (71.4%) had bleeding in deep seated areas of the brain and 64 patients (28.6%) had bleeding in a superficial location. Regarding the deep seated hemorrhage basal ganglia was in 96 (42.8%) of the patients, followed by Thalamus in 48 (21.4%), and cerebellum in 16 (7.2%) of the patients. In the superficial sites of hemorrhage parietal lobe was in 40 patients (17.8%), then parieto-occipital hemorrhage was in 16 (7.2%) patients and 8 patients (3.6%) had temporal lobe hemorrhage. Hypertension was the most common risk factors, found in 75% of patients, followed by antigcoagulant use in 57.2% of patients. A history of diabetes mellitus was positive in 39.3% of the patients, 39.3% of them were smokers, and 25% patients had no history of any risk factors. A statistically significant difference between deep & superficial bleeding is seen in correlation with hypertension and smoking (P value is 0.00001 and 0.002 respectively) The focal neurological signs, found in 66 patients, facial palsy in 48 patients, loss of consciousness in 40 patients, 32 patients had both focal neurological signs and loss of consciousness as a presentation, 22 of them presented with speech difficulty, 8patients presented with ataxia and 8 with dementia. Significant relationship was found between the site of hemorrhage and patients’ presentation (P value 0.001). 120patients had intra-ventricular extension of hemorrhage in their CT films, 120 patients had pressure effect of the hemorrhage, and 104 were complicated by edema.
Males are more affected than females by spontaneous intra-cerebral hemorrhage which tends to occur more commonly in a deep seated area of the brain.Hypertension is the most important risk factor. There is great correlation between patients’ presentations and the site of hemorrhage. Patients 50 years and older are more liable for spontaneous intra-cerebral hemorrhage.

Management of Patients with Ampullary and Periampullary Tumors in Gastro-Entrology and Hepatology Teaching Hospital

Iraqi Postgraduate Medical Journal, 2015, Volume 14, Issue 4, Pages 454-461

Ampullary and periampullary tumors are composed of a group of malignant and benign neoplasms arising in the region of the ampulla of Vater and are a major problem to the patients and surgeons and their management remains a big challenge.
Study the age, sex distribution, presentation and management of patients with ampullary and periampullary tumors in Iraq and compare it with other world reports
prospective study of 50 patients with ampullary and periampullary tumors carried out in GIT hospital (tertiary center) from January 2013 to March 2015 ,risk factors ,age ,sex ,clinical presentation ,images study ,diagnosis and modality of treatments whether curative or palliative are studied.
29 (58%) were males and 21 (42%) were females , about the age distribution the mean age was 45 ,about the residency they were mainly from Baghdad in (40%) ,the presenting symptom was obstructive jaundice in 43 (86%) ,duration of illness (range from 1-2 months) with the mean period 45 days , abdominal ultrasound study reveal distended Gallbladders in 76 % , dilated CBD in 82% ,dilated pancreatic duct in 56% , Hepatomegaly in 42% , dilated intrahepatic billiary tree in 64% , and liver secondary in 10% .resection surgery was done in 50% ,palliative surgery in 12% and endoscopic palliation in 38%
Ampullary and periampullary tumors are relatively common. The mean age is 45 years, lower than the western studies. Sex: male are affected 1.4 times more than female with male: female ratio = 1.38 . Abdominal ultrasound is very informative but EUS,CT scan and MRI, MRCP is the cornerstone for the diagnosis, Normal looking papilla does not rule out occult ampullary tumor.

The Outcome of Combined Conchal Excision, Concho-Scaphal Sutures and Concho-Mastoid Sutures Techniques for Treatment of Prominent Ears

Iraqi Postgraduate Medical Journal, 2015, Volume 14, Issue 4, Pages 480-486

Prominent ear is one of the most common congenital deformities of the head and neck region. It can affect the aesthetics and psychosocial aspects of patients. There are over 170 techniques described in the literatures, but many do not adequately address the specific problem and can prove unstable. Technique selection in otoplasty should be done only after careful analysis of the abnormal anatomy responsible for the protruding ear deformity.
To evaluate the outcome of combined conchal excision, concho-scaphal sutures, and concho-mastoid sutures techniques for treatment of prominent ear.
A retrospective study was performed on 38 patients, from February 2009 to September 2014. All patients who had prominent ear were included in this study, except those who had constricted ear and secondary otoplasty. A combined method of conchal excision, concho-scaphal suture, and concho-mastoid suture technique was used for correction of prominent ear. The follow-up period was 6 –19 months (mean, 14 months). Data were entered and analyzed using the statistical package for social sciences SPSS version (18).
In 38 patients who underwent otoplasty for prominent ear (24 were males and 14 were female), this technique of combined method used for all patients who had underdevelopment of antihelix and conchal hypertrophy. This technique allowed for correction of prominent ears to achieve a natural appearance. It achieved good to excellent symmetry in 95% of the patients and a low rate of complications. There were no major complication like skin necrosis or infection, but one patient develops small hematoma, another patient develops suture granuloma and extrusion and one patient had mild telephone deformity.
This Technique is simple, versatile and applicable to all age groups, as well as its easy, safe and less recurrence rate with fewer complications and excellent long-term aesthetic outcomes.

Uremic Pruritus in Haemodialysis Patients; Prevalence, Severity and Possible Associations

Iraqi Postgraduate Medical Journal, 2015, Volume 14, Issue 4, Pages 548-554

Uremic pruritus is a common distressing complication of end stage renal disease and it is a common problem in dialysis patients. It causes serious discomfort and skin damage, negatively affects the quality of life.
To determine the prevalence, severity of pruritus and possible association with the laboratory parameters in patients with chronic renal disease on haemodialysis.
One hundred and three patients on chronic haemodialysis were included in this study. Fasting blood sugar, urea, creatinine, albumin, alkaline phosphatase, parathyroid hormone, sodium, potassium, chloride, calcium, phosphorus, calcium × phosphorus product, were determined.
Of the 103 patients included in the study the, 79 patients (76.7%) had pruritus of whom, 27 (34.1%) had mild pruritus, 30 (37.9%) had moderate and 22 (27.8%) had severe pruritus. No significant association (p ˃ 0.05) was found between pruritus and each of sex, age, frequency and duration of haemodialysis. There was a significant association (p ˂ 0.05) between duration of haemodialysis and pruritus onset. No significant difference (p ˃ 0.05) in the FBS, urea, creatinine, albumin, parathyroid hormone, alkaline phosphatase, sodium, potassium, chloride, calcium, phosphorus, calcium phosphorus product, average among patients who had no pruritus, mild, moderate and severe pruritus. A significant positive correlation (p ˂ 0.05) was found between severity of pruritus in pruritic patients and age.
WE CONCLUDED THAT there was a significant association between duration of haemodialysis and pruritus onset more over the age had a significant positive correlation with the severity of pruritus in pruritic patients.

Vitamin D Status in Hemodailysis Patients, A Single Center Study

Iraqi Postgraduate Medical Journal, 2015, Volume 14, Issue 4, Pages 499-505

Vitamin D deficiency and insufficiency are common in patients with End Stage Renal Disease(ESRD). Vitamin D has been found to have beneficial effects on bone, cardiovascular and immune functions. There are little data about vitamin D levels in Iraqi patients on hemodalysis..
This study was conducted to determine the vitamin D status of Iraqi patients with ESRD on hemodialysis.
This study is a cross sectional study conducted at The Dialysis Center/ Baghdad Teaching Hospital . An eighty four patients with End Stage Renal Disease (ESRD) on regular Hemodialysis (HD) enrolled in the study from January to February 2013.
The basic data of the patients had been obtained (age ,weight ,duration on HD (months), infection with HCV, drugs doses for calcium and alphacalcidol . Blood samples were collected at the start of the HD session from the vascular access for calcium, phosphorus, albumin, cholesterol, uric acid and Vitamin 25(OH) D3 blood levels. These samples were sent for analysis to the Teaching Laboratories at Medical City.
Patients were considered as vitamin D3 insufficient if the levels were between 10 and 30 ng/ml , deficient if the levels were less than 10 ng/ml and sufficient if it was ˃30 ng/ml
We assess the correlation between vitamin D3 level and other variables tested in the study.
The mean age of the patients was 49.8 ± 13.2 years, of these, 40 (47.6٪) were females and 44 (52.4٪) were males. Fifty five (65(٪ patients were infected with hepatitis C virus and 29(35٪)were not . the median dose of calcium carbonate was 1086.1 ± 400 mg per day, The median dose of alphacalcidol was1.9 ± 1.1 mcg /week. Mean weight was 68.8 ± 17.5 kg. Median duration of HD was 24.8 ± 20.8 months (range 2–72 months).The patients were on twice a week (6-8 hours/week) HD sessions.
Mean of serum albumin, corrected calcium, phosphorus, Uric acid cholesterol were 3.0 ± 0.8 g/dl., 8.6 ± 1.4 mg/dl, 3.9 ± 1.4 mg/dl , 6.1 ± 2.4 mg/dl, 149.9 ± 39.2 mg/dl respectively .
Mean vitamin 25(OH) D3 level was 33.02 ± 7.2 ng/ml. 60(71.4٪) patients were vitamin D3 sufficient, 23(27.4٪) patients were vitamin D3 insufficient and only one (1.2٪) patient was vitamin D3 deficient.
There was a significant correlation between vitamin 25(OH)D3 levels and albumin , duration of HD, virology status while there was no correlation between weight, sex ,age , activity, calcium, cholesterol, uric acid , phosphorus ,dose of alphacalcidol or calcium carbonate and vitamin 25(OH)D3 level .
The vitamin D insufficiency found in about one quarter of patients on hemodialysis while deficiency found only in 1.2% of patients and more than two third of patients had sufficient vitamin D3. There was a significant correlation between vitamin 25(OH)D3 levels and albumin , duration of HD, virology status.