Volume 20, Issue 2, Spring 2021, Page 99-208

A Review on Vitamin B12 and Diabetic Neuropathy

Rana Ali Hamdi

Iraqi Postgraduate Medical Journal, 2021, Volume 20, Issue 2, Pages 99-101
DOI: 10.52573/ipmj.2020.168616

Vitamin B12, also called cobalamin, is a vitamin that is important for several biological functions. It is acted as a neurotrophic factor with an affinity for neuronal tissues and has been showing to be essential in preserving and regenerating peripheral nerves. It is important in supporting the process of myelination, participating to functional restoration. Diabetic neuropathy mentions to various types of nerve damage linked to diabetes mellitus. These conditions are microvascular complications of diabetes mellitus including small blood vessels that provide nerves. Relatively,  third, fourth, or sixth cranial nerve palsy are common conditions that may be linked with diabetic neuropathy. Interestingly, a significant correlation was found between lower vitamin B12 concentrations and possessing a positive diagnosis of diabetic neuropathy.

Clincopathological Assessment of Cases of Inflammatory Bowel Disease & Other Types of Colitis in Province of Basrah

Russul Mahmood Ali; Alaa G. Hussein

Iraqi Postgraduate Medical Journal, 2021, Volume 20, Issue 2, Pages 102-109
DOI: 10.52573/ipmj.2020.168617

Inflammatory bowel disease is group of inflammatory disorders of unknown etiology. The main members of this group are ulcerative colitis and Crohn's disease (granulomatous colitis).Histopathologic evaluation of colonoscopic mucosal biopsy remains one of the earliest modalities of investigation in patients which clinically suspected. Any biopsy underwent histopathological diagnosis should be accompanied by endoscopic findings and full clinical history.
Assessment of colonic biopsies in patients of colitis on the basis of specific histopathological criteria and correlation with clinical and endoscopic presentations.
A Retrospective and prospective study included randomly selected 102 colonic specimens from
January 2016 to June 2018.The clinicopathological parameters including (age of the patients, gender, hematochiza, diarrhea and abdominal pain) obtained from endoscopic reports and correlated with                 the histopathological parameters and sections which revised by a senior pathologist.
Out of (102) patients in this study; there were 41(40.2%) males and 61(59.8%) females. hematochiza is the main presentation in ulcerative colitis, while abdominal pain is the main presentation in Crohn's disease patients and diarrhea in those with non-specific colitis. Certain parameters can favoring                 the diagnosis of non-specific colitis over inflammatory bowel disease and another set favoring ulcerative colitis over Crohn's disease and vice-versa. This leads in shifting of diagnosis of most of endoscopic biopsies rather than resection biopsies. And there is under diagnosis of cases of non-specific colitis and Crohns disease in comparism to Ulcerative colitis.
Inflammatory bowel diseases are female predominate.Ulcerative Colitis predominate in 3rd and 4th decades of life, Crohn's disease is more in 2nd and 3rd decades while non specific colitis are more
found in old age. Correlation between clinical, endoscopic and histopathological features is essential  in the diagnosis of inflammatory bowel diseases. Accurate diagnosis of inflammatory bowel diseases depends on finding of certain histopathological features.

The Effect of Opening Injection Pressure Monitoring Device to Detect Needle Nerve Contact During Ultrasound Guided Popleatial Approach in Diabetic Patients for Below Knee Amputation

Ayad Abbas Salman; Ahmed Basim Qasim

Iraqi Postgraduate Medical Journal, 2021, Volume 20, Issue 2, Pages 110-115
DOI: 10.52573/ipmj.2020.168618

BACKGROUND:                                                                                                                                              Ultrasound-guided popliteal sciatic nerve blocks is a useful approach for below- knee surgery. Using the injection pressure monitoring device.
This study to assess the role of opening Injection Pressure monitoring device in providing and avoid nerve injury in patients who underwent, popliteal sciatic nerve block under ultrasound-guided.                                                                                      
This study involve fifty patients underwent unilateral below knee amputation were randomly assigned under ultrasound-guided popliteal sciatic nerve block and femoral nerve block have been done, with use opening Injection Pressure monitoring device and additional ultrasound guided.
RESULTS:                                      :                                                                                       
Regarding the pressure of the injections monitoring , we noticed that in this study, the highest proportion of study patients recorded needle nerve contact (44%) ,needed low pressure CONCLUSION:                                                                                                                                                There is high incidence of intraneural needle placement or needle neve  contact of nerve under ultrasound guide.                                                                                                                     

Short Segment Posterior Instrumentation with Intermediate Screw in Thoracolumbar Junction Injury: Prospective Study

Karam Fawaz Aldarzi; Walid W. Al-Rawi

Iraqi Postgraduate Medical Journal, 2021, Volume 20, Issue 2, Pages 116-127
DOI: 10.52573/ipmj.2020.168619

Thoracolumbar fractures are traditionally treated surgically by short segment fixation;
however, they may be associated with high implant failure. The insertion of an additional screw at
fracture site makes it more stable with a better clinical outcome.
The aim was to evaluate the radiological and clinical parameters of posterior short
segment fixation with intermediate screw implantation into the fractured vertebra.
We evaluated 30 patients with unstable thoracolumbar fractures, managed with short
segment posterior instrumentation with intermediate screw in the fractured vertebra; fractures
classification was done according to AOspine and TLICS systems . Eighteen male and 12 females
qualified for the study; male to female ratio was 1.5:1; average age 28.86 years. Neurological status
was classified according to the ASIA impairment scale. Pain was evaluated by VAS score. The
percentage of vertebral body collapse and segmental kyphosis were assessed by Cobb method.
Duration of follow-up lasted for 12 months.
The mean preoperative VAS score was 8.55, had significantly improved to 0.87 at final
follow up. Preoperative mean vertebral body collapse was 48.40%, which had significantly improved
to 12.85% at final follow up. Mean segmental kyphotic angle was 21.83° before surgery, final mean
segmental kyphosis was 8.63°. Fifteen patients with incomplete neurologic deficits had improvement
by at least one ASIA grade on final follow-up observation, and 2 of 4 patients with complete
neurologic deficit remained unchanged. All neurologically intact patients remained unchanged. None
of patients had implant failure.
Short segment fixation with intermediate screws in treatment of thoracolumbar junction
fracture effectively improve stability with most of patients achieve significant improvement in clinical

Nail Changes in Alopecia Areata and Their Correlation with Disease Severity

Hayder Raouf Al-Hamamy; Ghusoon Nazar Al-Ani

Iraqi Postgraduate Medical Journal, 2021, Volume 20, Issue 2, Pages 128-135
DOI: 10.52573/ipmj.2020.168620

Alopecia areata (AA) is a chronic, autoimmune, inflammatory, non-scarring type of hair loss. Significant variations in the presentation of AA have been observed, ranging from small, well-circumscribed patches of hair loss to complete absence of body and scalp hair. Nail involvement is                  a common finding in patients with alopecia areata.
Study of nail changes in alopecia areata and evaluation of the correlation between the nail changes and severity of alopecia areata
The study is an observational, cross-sectional, descriptive study that was carried out at                                         the Dermatology center, Medical City, Teaching Hospital, during the period from May 2018 to July 2019.  The severity of (AA) was measured by the Severity of the Alopecia Tool Score1 (SALT1) score, in 70 patients with different severities of AA. A new measurement tool (Nail in Alopecia Areata Severity Index, NAASI score) was applied for the evaluation of the nail changes associated with AA.
Seventy AA patients were divided into two groups, patients with nail changes, group A, which included 48 patients; 33 were males and 15 were females, the mean age was 19.19 ± 14.28 years. Group B included patients without nail changes; 22 patients; 11 were males and 11 were females,                   the mean age was 22.36 ± 11.50 years. NAASI score for patients in group A was 34 ± 31. Pitting  was the most common nail changes (38 patients), followed by trachyonychia, 15 patients. Group A was subdivided into two groups according to severity of AA. The mean NAASI score for the group with mild to moderate AA was 20 ± 23, while it was 56 ± 28 for patients with severe AA. There was positive correlation between SALT1 and NAASI scores.
The prevalence of nail changes in AA was 68.6%. They were associated with early onset and long duration of AA. Pitting was the most common changes. A new scoring system for nail changes was described. Nail changes correlated with severity of AA.

Use of Bipolar Vessel Sealing Device(Ligasure) Versus Conventional Suture Ligation in Thyroid Surgery

Muhammed Faiz Abdullah Hassan; Qahtan Adnan Mahdi

Iraqi Postgraduate Medical Journal, 2021, Volume 20, Issue 2, Pages 136-142
DOI: 10.52573/ipmj.2020.168621

Effective vessel hemostasis can be achieved by knot tying or newer techniques like ligasure as an alternative bipolar surgical diathermy system. Various diathermy techniques have been proposed to reduce intraoperative blood loss in surgery and the new electrothermal bipolar tissue sealing system (Ligasure) has been applied in various specialties of surgery.
To compare the outcome of ligasure versus conventional suture ligation in thyroid surgery.
This study was conducted in Al–Imamein Alkadhmein Medical City over 2 years period from the first of  October 2016 to the first of October 2018.A Total of 110 patients were operated upon by the same surgical Team, using ligasure in 55 and conventional suture ligation in 55 patients for hemostasis. The medical records of the patients enrolled were reviewed and compared regarding age, sex, histopathological diagnosis, types of thyroidectomy, operating time, estimated intraoperative blood loss, postoperative complications, hospital stay , postoperative pain and outcome evaluation.
There was no statistical difference between the two groups regarding age, sex and histopathological Data. The mean operating time was significantly shorter in the Ligasure group compared with the conventional group. Transient hoarseness of voice was detected in 2 patients (3.6%) of both groups. no permanent complication was seen in LVSS group but EBSLN injury (1.8%) was the only permanent complication occurred in conventional group. 
The use of LigaSure Vessel Sealing System for thyroid surgery is proved safe and effective as conventional suture ligation Technique, with the benefit of reducing intraoperative blood loss, reduced operating time, and postoperative pain severity.

Evaluation of a Modified Dome Holding Technique for Transdomal Suture in Rhinoplasty

Mustafa Khalid Khudhair; Redha Ali Taher

Iraqi Postgraduate Medical Journal, 2021, Volume 20, Issue 2, Pages 143-148
DOI: 10.52573/ipmj.2020.168622

There are multiple techniques for gaining the refinement of tip, increase projection and rotation.
This study based on A modified dome holding technique for transdomal Suture in rhinoplasty.
To evaluate the result of A modified dome holding technique for transdomal suture in rhinoplasty.
Between November 2018 and March 2020, 10 patients were subjected to aesthetic rhinoplasty in Alwasity teaching hospital. Their ages between 19-30 years “8 females versus 2 males”. Those patients were undergoing rhinoplasty with using innovative technique. Nine out of ten of our patients had thin skin and only one of them had thick skin.
Average time of operation was one hour and a half (1 hour-2 hour), our results showed that the post-operative appearance had acceptable aesthetic results in all our patients with narrow nasal tip without pinching and with adequate tip projection and rotation.
Dome stabilizing suture using this innovative method is effective way for producing narrow of nasal tip, dome symmetry, and enhancing tip rotation and projection, with good functional results.

Seasonal Variations of Lipid Profile

Noor Falih Ahmed; Azher Sebieh

Iraqi Postgraduate Medical Journal, 2021, Volume 20, Issue 2, Pages 149-154
DOI: 10.52573/ipmj.2020.168623

Cardiovascular and cerebrovascular disorders have been the most prevalent cause of death and morbidity in the world over the last decades. Seasonal differences in blood lipids have recently raised interest in this area of lipid metabolism. In the current study
To determined if changes in weather having effect on lipid profile readings
Eighty five subjects, forty males and fort five females were included with age range of (22-85) years. Two serum samples were investigated in hospital lab for lipid profile for every participant from outpatient clinic/Baghdad teaching hospital, in 12 months’ period. Other clinical data and some modifiable risk factors were also obtained.
The results showed that a significant increase in winter was shown in LDL and total cholesterol among males only (P value 0.011, and 0.012), respectively, but no changes in HDL, triglyceride and LDL/HDL were found. Systolic blood pressure was also found increased in winter significantly (P=0.008), while diastolic pressure, FBS and BMI did not change significantly.
The present study concludes that there are significant changes of lipid parameter in male sex may affect assessment of risk of cardiovascular disease.

Immunohistochemical Assessment of MGMT Expression in Human Gliomas. A Clinico-Pathological Study

Mustafa Hafudh Hamoodi; Ban J. Qasim

Iraqi Postgraduate Medical Journal, 2021, Volume 20, Issue 2, Pages 155-164
DOI: 10.52573/ipmj.2020.168624

Gliomas are the most common primary malignant brain tumors in adults. They can occur anywhere in the central nervous system but primarily occur in the brain and arise in the glial tissue. O6-alkylguanine DNA alkyl transferase is a protein (DNA repair molecule) encoded by the O6-methylguanine DNA methyltransferase (MGMT) gene in human, and are able to remove alkyl adducts from the O6 position of guanine, and the O4 position of thymine, restoring these DNA bases and preventing temozolomide induced cell death.
To assess the immunohistochemical expression of MGMT in human glioma.
This retro and prospective study included 56 tissue paraffin blocks of intracranial gliomas assigned as cases group, and 28 tissue paraffin blocks of normal brain tissue as control group. From each block, two sections were taken; one was stained with the routine hematoxylin and eosin stain, and the other was stained immunohistochemically for marker MGMT.
MGMT showed a highly significant difference in its expression between the control group and the disease group (p value<0.001). MGMT showed a highly significant relation between its expression and the age of patients with glioma (p value< 0.001). MGMT expression showed no significant correlation with other clinicopathological parameters like the histological types and gender (p value CONCLUSION:
MGMT revealed a highly significant difference inits expression in brain tumors (gliomas) compared to control groupwhich mayreflects the need in proliferating cells for greater capacity to repair O6-alkylguanineadducts before replication. Besides there was a significant correlation between age and MGMT expression which may reflect processes associated with the physical and functional maturation of the CNS during life.

Clinicopathological Evaluation of CD44 Expression as a Proliferative Marker in Prostatic Adenocarcinoma

Wurood Abdullah Imran; Hadi Muhammad Ali Almosawi; Rafid Fakhir Al Husseini

Iraqi Postgraduate Medical Journal, 2021, Volume 20, Issue 2, Pages 165-171
DOI: 10.52573/ipmj.2020.168625

Prostatic cancer is the 6th commonest cancer worldwide, and the 2nd commonest cancer among men. In Iraq, it is the fourth most common cancer and cause of cancer deaths in males.
The commonest form of prostatic cancer is adenocarcinoma (75% of patients > 65 years). Prevalence of prostate cancer rises with age and hormonal causes. Core needle biopsy is a standard technique and largely preferred for non-operative diagnosis since it permits architectural and cytological assessment.
Immunohistochemical evaluation of CD44 expression in prostatic adenocarcinoma as                                a proliferative marker and correlate it with clinicopathological parameters (age, PSA level, and tumor grade).
Prostatic specimens were obtained via different procedures (TURP, and tru-cut biopsy). Formalin fixed paraffin embedded blocks from 50 patients with prostatic adenocarcinoma, histological sections taken for hematoxylin and eosin staining to determine histopathological features, monoclonal antibody for CD44 used for immunohistochemical staining of tissue sections and CD44 expression correlated with clinicopathological parameters (age, PSA level, and tumor grade).
There was a significant inverse correlation between CD44 expression and Gleason grade score (i.e. high expression in low grade tumors), while there was no correlation between age and PSA level with CD44 expression.
CD44 expression in prostatic adenocarcinoma can be utilized as a prognostic marker as it implies less tumor aggressiveness with positive high expression which means lower grade tumor and better differentiation.

Association of Carotid Intima Media Thickness with the Severity of Coronary Artery Disease

Hafidh Jaleel Hussein; Hussein Jubair Lazim; Ameer Adnan Muhsen

Iraqi Postgraduate Medical Journal, 2021, Volume 20, Issue 2, Pages 172-177
DOI: 10.52573/ipmj.2020.168626

Nevertheless, of a number of prevention schemes, coronary artery illness continues to exist as                    the leading cause of death worldwide disease. Within this context, Intima media thickness is believed to have a key role in the atherosclerosis initiation. The development of ultrasound machines, advances in echocardiographic devices with great determination transducers facilitate total study of carotid –intima media thickness (C-IMT).                                            
To investigate the relationship of Carotid Intima Media Thickness with the severity of coronary vessels illness.                                                                                                             
Through the sections of a cross sectional multicenter diagnostic accuracy survey assessing C-IMT in a total of one hundred thirty two  patients preselected to undergo coronary angiography. For this purpose, patients' demographic data and the disease- associated risk factors were evaluated. Two dimensional transthoracic echocardiographic measurements were done. Furthermore, C-IMT measurements were obtained as it specified by the American society of echocardiography (ASE). Consequences of the study sample as all were revised according to angiographic findings.
 In the present study, a total of 132 patients, of them 72 patients were included in the CAD group while 60 patients with no CAD served as control. The most important risk factors for CAD are modifiable, while family history of CAD ( a non- modifiable risk factor) was not significant                         (P value=0.348). There was direct and significant correlation between C-IMT and severity of CAD. ROC analysis for validity of C-IMT to discriminate between multiple vessels disease and no vessel involvement is excellent (AUC= 0.961, cut point > 1.04mm, sensitivity=92.9%. specificity=86.7%). C-IMT is fair to discriminate between single vessel disease and no vessel involvement (AUC=0.738, cut point ˃ 0.84mm, sensitivity 100%), so if correlated with age, C-IMT above 0.84 is utilized as  can  be used as a detached theme to guessing of CAD.                                  
C-IMT is simple, inexpensive and reproducible parameter that is utilized to be showing aid to the presence and severity of CAD particularly earlier indications showing in great danger for sick people.                                                                 

Evaluation of Release of Wide Post Burn Contracture of Joints Using Central Axis Propeller Flap

Rabaab Abass Hasan; Hassan Salman Attai

Iraqi Postgraduate Medical Journal, 2021, Volume 20, Issue 2, Pages 178-185
DOI: 10.52573/ipmj.2020.168627

Post burn contractures of joints can produce significant impact on quality of life by interfering with the ability to perform activities of living. Varieties of techniques are available for coverage of defect following contracture release. A Central axis propeller flap a strategy that used in patient with contracture deformities. It's a reliable method of reconstruction in release of axillary, elbow and popliteal region of knee joints contractures.
To evaluate of central axis propeller flap in wide joints post burn contractures release.
Between October 2017 to May 2019 ten patients with wide joints post burn contracture, their age range between (10-45) years .A central axis (propeller) flap based on random sub dermal pedicle              of two design was used (rhomboid design for eight patients and Namaste design for two patients) by designed and elevated as a “propeller,” and then rotated by 90° to straddle the defect after contracture release.
Good functioning result in all patients indicated by good range of motion in affected joints and no serious complication, only one case of superficial epidermal sloughing was managed conservatively.
Central axis propeller flaps are reliable methods for surgical management of post burn contractures with good range of motion .However it used scary tissue, a result appearance is cosmetically acceptable for those patients, when the functions the primary concern.

Barriers for Insulin Therapy Initiation among Type 2 Diabetic Patients Attending the Specialized Center for Endocrinology and Diabetes / Baghdad 2019

Ruaa Naji Zidane; Wijdan Akram Hussein

Iraqi Postgraduate Medical Journal, 2021, Volume 20, Issue 2, Pages 186-192
DOI: 10.52573/ipmj.2020.168628

The beginning of insulin therapy is a mutual decision between the health care provider and the patient. People    with   type 2 diabetes   mellitus often   have   strongly   negative attitudes toward insulin therapy. This refusal is often   based on a range of patient concerns and misconceptions.
To determine the barriers for insulin therapy refusal among type 2 diabetic patient, and to find the association between socio-demographic characteristic and the barriers of refusal.
A cross sectional study was conducted during the period from first of March to 30th of June 2019 in the Specialized Center for Endocrinology and Diabetes in Al-Kindy Teaching Hospital in Baghdad/Al-Rusafa. .The study was conducted by using a convenient sampling method of 400 patients’ withT2DM. A questionnaire form was used to collect demographic data, and appraisal of insulin therapy measured by Insulin Treatment Appraisal Scale (ITAS).
Perceived loss of control/ life style adaptation and restriction were the first barrier to initiation of insulin therapy (70.6%), and the least barrier to start insulin was perceived lack of positive gain               (43. 1%), also there is statistically less negative appraisal scores in patients aged 45-60 years, males, higher educational levels and ‘10-12 years’ duration of illness, but no statistical difference in regards whether a family member or a friend used, or did not use insulin.
Many misconceptions about the use of insulin therapy can be corrected by working to increase patient education.

Management of Bile Leak after Laparoscopic Cholecystectomy

Ali Momtaz Bikhtiyar; Sattar Jabbar Kadhim

Iraqi Postgraduate Medical Journal, 2021, Volume 20, Issue 2, Pages 193-199
DOI: 10.52573/ipmj.2020.168629

Bile leak after laparoscopic cholecystectomy is not an uncommon complication, it’s a serious one and its management requires a lot of resources, and expertise. The evolution of laparoscopic cholecystectomy and being the standard of management had a disadvantage of slightly elevating bile leak incidence.
To identify the best way management to decrease the burden on the patient either quick healing, decrease complications and outline the complications after management modalities.
This is a prospective study describing route of management from the period January 2018- January 2019 in Al-Yarmouk Hospital and Gastrointestinal and hepatology teaching Hospital. Where 34 patients enrolled for bile leak after laparoscopic cholecystectomy. Patients were followed from their admission, investigations, determining site of leakage, choosing the method of management according to out-put grade, site. Comparing closure time and complications related to each.
The study involved 34 patients who were managed for bile leak, mean age 42.13. Females were 76.5% (26), males were 23.5% (8). ERCP and MRCP used to determine the site of leakage: cystic duct 55.9% (19), liver bed 8.8% (3) and major duct injuries: Strasberg D 32.4% (11) and Strasberg E1 2.9% (1). These sites further divided in to low-grade <300 cc/day 73.5% (25) and high-grade >300 cc/day 26.5% (9). Management was according to site and grade of leak: conservative 23.5% (8), Endoscopic Retrograde Cholangiopancreatography alone/stent 70.6% (24) and surgical reconstruction 5.9% (2).             All patients were followed for 4 months. These modalities compared to each other in terms of closure time and complications.
Some patients with bile leak can be managed using conservative measures alone. Sphincterotomy alone can be used in low grade leaks, from cystic duct. High grade, major duct injuries is best managed with sphincterotomy plus stenting to enhance healing.
Although conservative management or sphincterotomy alone decreases the complications rate but carries a disadvantage of delaying closure time.
Sphincterotomy plus stenting enhances closure time over other methods.

Sedimentation Sign Appraisal in Lumbar Spinal Stenosis

Mazin S. Mohammed Jawad

Iraqi Postgraduate Medical Journal, 2021, Volume 20, Issue 2, Pages 200-208
DOI: 10.52573/ipmj.2020.168630

Lumbar nerve roots normally sediment, due to gravity, to the dorsal part of the dural sac, which is known as negative sedimentation sign. If there is a magnetic resonance finding of nerve roots in  the ventral part of the dural sac the sedimentation sign is positive.
To evaluate the presence of the MRI finding of positive sedimentation sign in patients clinically suspected to have lumbar spinal stenosis and if this sign can be a valid tool to differentiate  symptomatic spinal canal stenosis from other causes of non-specific back pain.
A planned cohort design prospective study had conducted over a year through July 2019 at the department of neurosurgery at Medical City / Baghdad / Iraq. The study incorporates 200 patients. Those with symptomatic lumbar spine canal stenosis (n=100) show claudication with or without low back pain, leg pain, a dural sac cross-sectional area < 80 mm2, and a walking interval < 200 meters. The nonspecific low back pain group (n=100) had no leg pain, no claudication, a cross-sectional area of the dural sac >120 mm2, and a walking interval >1000 meters. The frequency of a positive sedimentation sign compared between both groups to evaluate if this sign can be a valid tool to differentiate spinal canal stenosis from other causes of back pain, intra-rater and inter-rater assessment dependability in a stochastic subsample executed.
A positive sedimentation sign recognized in 96 patients in the symptomatic lumbar spine canal stenosis group (96%; 95% Confidence Interval CI, 90%–98%), no positive sedimentation sign recognized in the nonspecific low back pain group (0%; 95% Confidence Interval CI, 0%–5%). Credibility was Kappa (ĸ) =1.0 (intra-rater) and Kappa (ĸ) =0.90 (inter-rater), in sequence.
A positive sedimentation sign is dependably seen in lumbar spine canal stenosis cases, recommending its value in clinical application.