Issue 1

Subdural Effusion in Bacterial Meningitis Experience in Children Welfare Teaching Hospital

Mahjoob N. Al-Naddawi; Hula Raoof abdul Rasool; Nameer Mahdi

Iraqi Postgraduate Medical Journal, 2013, Volume 12, Issue 1, Pages 1-10

Subdural effusions occur in (10 - 33 %) of children with acute bacterial meningitis. Usually occur bilateral over frontoparietal region, although localized collections can develop over occipital region. Effusions are most common when meningitis results from H.influenzae .(45% of all effusions).
To find out the incidence , age distribution and type of bacteria involved in occurrence of subdural effusion in bacterial meningitis, to know the risk factors that might associated with subdural effusion .
from march 2010 – feb.2011 a Prospective study was done on 50 patients diagnosed and treated as meningitis, information's obtained from patients include (patient name, date of birth, sex, residency, duration of illness before admission, clinical presentation, and if antibiotics used prior to admission. Diagnostic inclusion criteria clinical and laboratory based. daily follow up of them .Brain CT was done to all of patients with meningitis after 7 days of treatment to roll out subdural effusion because some of the patients were asymptomatic.
The study shows that incidence of subdural effusion in bacterial meningitis was (22.0%).It is most commonly occur in children below the age of (1) year, there was no significant difference between male and female . Regarding CSF analysis, there were no specific findings that indicate presence of subdural effusion. The majority of the patients show no growth of bacteria on CSF culture, blood culture and gram stain, the others show equal growth of (streptococcus pneumonia, H.influenzae and N.meningitidis). Regarding outcome the majority of the patients discharged well, only one patient had focal deficit and one patient died.
There were no significant risk factors associated with development of subdural effusion. The majority of patients was discharged without any intervention and required follow up only. It's important for physician to maintain a high index of suspicion for diagnosis of subdural effusion .It is important to follow-up patients with meningitis by imaging study, because majority of patients with subdural effusion are asymptomatic.

Hemolytic Uremic Syndrome Epidemiological and Clinical Facts

Najla Ibrahiem Ayoub; Ahmed Hameed Mohammed; Jinan Soaod Orabi; Asaad Abdullah Abbas

Iraqi Postgraduate Medical Journal, 2013, Volume 12, Issue 1, Pages 11-17

ABSTRACT: BACKGROUND: Hemolytic uremic syndrome is the most common cause of acute renal failure in children and has high mortality rate. OBJECTIVE: To study the epidemiology, clinical course, management, complications and the important risk factors that affect the outcome of the patients with hemolytic uremic syndrome. PATIENTS AND METHOD: In this retrospective study we collect fifty two patients who were admitted to the Child´s Central Teaching Hospital from the period 1st of Jan. 2005 till 30th May 2008. The data collected from the case records includes: name, sex, age, season, presence of diarrhea, jaundice, family history of HUS, complications, associated clinical features such as: pallor, edema, rash, hypertension, hepatosplenomegaly, and coarse of the disease. Also Laboratory. Findings as Haemlglobin (Hb), Packet Cell Volume (PCV)%, White Blood Cell (WBC), Red Blood Cell (RBC) morphology, platelets counts, blood urea and serum creatinine; and managements were included in the study. RESULTS: Of total 52 , there were 21 (40.4%) cases below 2 years, the males account 33 (63.46%) from the total. There were seasonal and annual increments. Eighty four percent had diarrheal prodrome, and 1.91% had familial history of HUS. All patients had pallor and acute renal failure. The mean of the hemoglobin was 8.6 gm/dl, WBC count mean was 18 × 109/L, platelets mean was 35 × 109/L, blood urea mean was 180 mg/dl, and the mean of serum creatinine was 3.8 mg/dl. The GIT complications was the commonest 23 (44.23%) followed by CNS complication 16 (30.7%), hypertension was present in 25%. During acute phase of disease 12 (23.07%) patients died. CONCLUSION: HUS affect mainly age between 3 months and 4 years. There was seasonal variation with peak at wormer months.There were statistically significance correlation between high risk patients and age group below 2 years, CNS complication, and non diarrheal prodrome.

Evaluation of Congenital Hydrocephalus Association With Aqueduct Stenosis in Mosul Pediatric Patients

Zhraa Abd-Al Kader Taboo

Iraqi Postgraduate Medical Journal, 2013, Volume 12, Issue 1, Pages 18-25

Congenital hydrocephaly is one of the most common central nervous system anomalies. This
generally refers to a condition that exists prenatally and excludes other neural tube defects ; this
condition usually develops by the twentieth week of gestation , and defect can occur either alone,
in association with spina bifida, or as part of a greater syndrome, such as Dandy-Walker Syndrome.
There are various types or classifications of congenital hydrocephaly. Aqueductal stenosis is a type
of hydrocephaly that results from narrowing of the aqueduct of Sylvius, an opening connecting the
third and fourth ventricles in the brain.
There are few studies evaluating the incidence of aqueduct stenosis out of hydrocephalus patient in
pediatric population, in Mosul city ,therefore, this topic was considered in present study .
The study was conducted in Ebn Sena Teaching Hospital, Department of Neurosurgery and
Radiology in Iraq Mosul city, as a retrospective study for 250 cases collected between October
2007 and 31 December 2008, and prospective for 250 patients are studied between June 2009 and
January 2011. Spiral computed tomography of the brain was performed for all patients. five
hundred patients were analyzed by spiral computed tomography.
During the analyses the peak age incidence of congenital hydrocephalus association with aqueduct
stenosis was below 2 years old (39%). The male to female ratio was (1.3:1). The incidence of
aqueduct stenosis was (63.9%) out of congenital hydrocephalus and (16.6%)out of acquired cases.
In this series the non-communicating type of hydrocephalus was forming about (65.6%) and the
communicating type forming about (16.2%), the lest type is compensatory (10.4%).
The most common cause of hydrocephalus was congenital in origin (56%), and it was mostly due
to congenital aqueduct stenosis (63.9%).

Etiology & Prognostic Factors of Fulminant Hepatic Failure In Children (A Hospital –Based Study)

Sawsan I. Al-Azzawi; Mohammad F. Ibraheem; Rasha Kasim Mohammad

Iraqi Postgraduate Medical Journal, 2013, Volume 12, Issue 1, Pages 26-31

Fulminant hepatic failure (FHF) is one of the most challenging pediatric emergencies encountered in clinical practice and encompasses a pattern of clinical symptoms and pathophysiological responses associated with the rapid arrest of normal hepatic function. Major differences exist in etiology of FHF between western & eastern countries.
To study etiologies, prognostic factors and the outcome of Fulminant Hepatic Failure in a sample of Iraqi children.
A prospective study was done on (31) patients with (FHF) admitted to the Gastroenterology and Hepatology unit in Children Welfare Teaching Hospital (During the period from January 2010- January 2011). The patients referred to our center from all over Iraq.The diagnosis of FHF was based on the presence of biochemical evidence of acute liver injury (elevated plasma transaminases), associated with PT > 15 seconds, not corrected by vitamin K, in the presence of clinical hepatic encephalopathy, or PT > 20 seconds with or without clinical hepatic encephalopathy in a patient previously healthy or have well compensated liver disease. Detailed history, clinical examination, routine biochemical parameters, and relevant diagnostic test carried out to all patients.
During the study period, (31) patients admitted with the diagnosis of FHF. Eighteen males (58.1%) and 13 females (41.9%), the most common affected age group was toddlers. The mean age of the study population was (2.93± 1.06).The most common etiology was viral in 15(48.3%) cases. {10(32.2%) had HAV}, 3(18%) had HBV, and 2(6.5%) had HEV} viruses, 2(6.5%) had CMV & 1(3.2%) had herpes virus hepatitis. Two (6.5%) had Galactosemia, 2(6.5%) had Wilson's disease and 2(6.5%) had autoimmune hepatitis. Etiology could not be established in 5(16.1%) of cases .Twenty patients died with death rate of (64.5%).
The study indicates that Hepatitis A was the most common cause of FHF with high mortality rate. Those who died were younger, suffered GI bleeding, a higher grade of encephalopathy, longer duration of illness before onset of encephalopathy, prothrombin time > 41seconds, had higher bilirubin & lower SGPT, lower albumin, & lower blood sugar.

Risk Factors and Common Causes of Death Due to Measles in AL-Kadhimiyia Teaching Hospital.2009

Lamia Abdul Karim; Abdul-KaremJasemAlbahadle; Ali Kadhim Al-Husainawi

Iraqi Postgraduate Medical Journal, 2013, Volume 12, Issue 1, Pages 32-39

Remains a common disease in many parts of the world. According to the World Health Organization (WHO), more than 20 million people worldwide are affected by measles each year. It is the leading cause of vaccine-preventable deaths among young children.
To find out the epidemiological criteria of died patients because of measles& the main causes of death.
Prospective study carried out in the pediatric ward of Al-Kadmyia Teaching Hospital between the 1st of January to the 1st of May 2009,the total number of measles cases admitted were 894 , the number of died cases in the same period due to measles were 52 case , the age of the studied sample (1month- 10 years).
The data collected through a data sheet asked to the parents of the patient including the age ,sex, body weight, feeding history, history of contact, vaccination history , maternal vaccination status and her educational level.
All the patients examined systematically and investigated and followed up till discharged or unfortunately died
The age of the died cases mostly in the 1st2years(27 case), there is male(31) , female(21) died cases.
The mortality occur more in under weight cases27 , the died cases were either on mixed feeding 17cases, bottle feeding 10, solid feeding 25 cases.
All the died cases had history of contact with measles., there were 49 cases non-vaccinated, the vaccination status of the mothers were 38 mother were not vaccinated. The educational level of the mothers were 29 illitrate,15 primary and 8 secondary school.
The most common causes of death :16 encephalitis, 36 pneumonia.
The death occurs more in infants and toddlers than in other age groups, more in males,underweight, and the non-vaccinated than in the vaccinated patients.
Death is more common among children belong to non-vaccinated, illiterate mothers.
Pneumonia is the most frequent complication of measles and encephalitis is the most lethal complication.

Growth Pattern and Sexual Maturation Rate in β-Thalassemia Major Patients from Thalassemia Center Erbil

Nazar Baker; Abdulkader Alnakashabandi; Azhar H. Alsaqy; Abbas Alrabaty

Iraqi Postgraduate Medical Journal, 2013, Volume 12, Issue 1, Pages 40-44

ABSTRACT: BACKGROUND: Thalassemia is genetic disorder in globin chain production, or it refers to a group of blood disease characterized by decrease synthesis of one of two types of poly peptide chain ( α or ß ) that form a normal adult human hemoglobin molecule ( Hb A- α2 ß2 ) resulting in decrease filling of red cell with hemoglobin and anemia .Growth retardation can occur as a complication of thalassemia as early as the 1st or 2nd year of life but these abnormalities are more prominent after the 6 – 8 years of life . OBJECTIVE: The main objective of the present study was to evaluate the relationship of growth failure and sexual maturity rate (SMR) in children with β-thalassemia major in comparison with controls. MATERIAL AND METHOD : In this case-control study, the growth parameters ( height ,weight ,and sexual maturation ) and S.ferritin of 38 patients aged 8-16 years (24 males 14 females) with β-thalassemia major who were attending thalassemia center in Erbil city Iraqi Kurdistan were compared with those of 38 healthy controls of the same age and gender. RESULTS: Underweight and short stature were found in 23 (61%), 30(79%) of patient group and 3(8%), 3(8%) of control group, the mean age of menarche for female patients was 12.31±2.3 and for control female 11.12±1.31years, The SMR were delayed in 37(97.5%) of patients and in 2 (5.5%) of controls. the level of serum ferritin had no significant relationship with delayed SMR. CONCLUSION: Growth failure (underweight and short stature) and delay SMR significantly occur in thalassemia patients compared to controls, and such growth retardation was more likely to occur after 10 years of duration of the disease

The Human Seroprevalence of Echinococcus Granulosus in Sulaimani Governorate

Mohammed Omer Mohammed

Iraqi Postgraduate Medical Journal, 2013, Volume 12, Issue 1, Pages 45-50

Hydatidosis is one of the major zoonotic diseases that cause considerable economic losses and public
health problems worldwide. This study was conducted in order to determine the seropositive aspect of
hydatid disease among people in Sulaimani.
To determine the Seroprevalence of hydatid disease among people in Sulaimani and it’s relation with
age, Gender, occupation and education level.
Two areas of Sulaimani governorate (the Sulaimani city center and Saedsadq as a rural area) were
investigated from April to October 2007. In Sulaimani 372 subjects, 248 were females and 124 were
males. In Saedsadq 164 subjects, 78 female and 86 males were randomly collected.
A Seroepidimiological survey was conducted by using two methods; a- enzyme-linked immunosorbent
assay (ELISA), and b- Indirect Haemagglutination (IHA) test to detect anti Echinococcus granulosus
antibody. There were no significant differences between the Seropositivity by the two tests (P > 0.05).
The Seropositivity in Saedsadq was (3.7%) higher than in Sulaimani (2.4%). The Seropositivity in
females (2.8%, 6.4%) was higher than in male (1.6%, 1.2%) both in Sulaimani and Saedsadq
There was no statistically significant difference between different age groups.
There were no significant differences (P> 0.01) between the seropositive cases and different
occupations in both areas.
Our results implied that the prevalence of Cystic Echinococcosis (CE) had significant relationship with
the level of education. Among 15 infected persons in Sulaimani and Saedsadq 9(60%) were illiterate.
Seropositivity for hydatid disease was significantly higher in Saedsadq (3.7%) than Sulaimani city
(2.4%), also it was significantly higher among female, housewife, and illiterate persons.

The Role of Repaglinide in the Management of Type 2 Diabetes Mellitus

Abbas M Rahmah; Majid R Al-Zaidee; Roaa abbas

Iraqi Postgraduate Medical Journal, 2013, Volume 12, Issue 1, Pages 51-56

Repaglinide belongs to the meglitinide class of blood glucose-lowering drugs.
Repaglinide lowers blood glucose by stimulating the release of insulin from the pancreas.
It achieves this by closing ATP-dependent potassium channels in the membrane of the
beta cells. This depolarizes the beta cells, opening the cells' calcium channels, and the
resulting calcium influx induces insulin secretion.
To evaluate the effect of repaglinide as a monotherapy or in combination with metformin on
controlling the fasting plasma glucose, postprandial plasma glucose, HBA1C, and body weight in
61 patients with type 2 diabetes mellitus, (DM).
During the period between February 2005 and October 2005, the effects of repaglinide
has been reviewed in 61 patients with uncontrolled Type 2 diabetes mellitus (T2DM),
they are divided into two groups depending on their previous treatment , the 1st group
included 43 of them were on metformin while the remaining 18 patients were on diet
only. Weight, HBA1c, FPG and PPG were checked after 3 and 6 months.
It has been found that six months after using Repaglinide in combination with metformin or as a
monotherapy cause significant reduction in HBA1c, from 9.8 to 8.1% (P < 0.01) in 1st group, and
from 7.9 to 6.7%, (P < 0.01) in 2nd group and a significant reduction of FPG from 214.0 mg/dl to
148.5 mg/dl (P < 0.01) in 1st group and from 170.7 mg/dl to 130 mg/dl (P < 0.01) in 2nd group.
While the PPG shows a decrement from 255.6 mg/dl to 178.8 mg/dl, (P < 0.01) in 1st group and
from 248.3 mg/dl to166.1 mg/dl (P < 0.01) in 2nd group. There’s no significant weight gain thus
mean weight rose from 84.4 Kg to 84.6 Kg, (P > 0.2) in 1st group and from 75.1 kg to 76.1 kg (P >
0.2) in 2nd group .
Repaglinide when used as monotherapy or in combination with metformin improve
overall glycemic control and significantly reduced HBA1c but have no significant
change in body weight

LDL Particles Size Index and Lipid Peroxidation in Type 2 Diabetic Male Patients

Kismat M.Turki; Hind Sh.Ahmed; Perry H.Saifullah

Iraqi Postgraduate Medical Journal, 2013, Volume 12, Issue 1, Pages 57-61

Diabetes mellitus is a heterogeneous condition reflecting different metabolic disorders accompanied by a variety of complications. In DM, there is a change in oxidative stress (elevation in free radical generation with increase lipid peroxidation and derived oxidized products, and serum lipid profile abnormalities.
Several free radical species are normally produced in the body to perform specific functions. Increased free radicals in diabetes may cause the pathogenesis of atherosclerosis, and the degenerative disorders. In the present study, the oxidative stress in type 2 diabetic male patients was evaluated by estimating the lipid peroxidation. Malondialdehyde (MDA) is one of the major aldehyde derived from lipid peroxidation.
Serum MDA, Oxidized HDL (ox.HDL), and lipid profile were measured after 12 hr fasting in 30 diabetic patients, their age range was (40-55) years and compared with 30 healthy controls. RESULTS:
Serum MDA and ox.HDL were significantly increased in the diabetic group (P<0.05). All patients had significant elevation in serum levels of glycated hemoglobin (HbA1c), total cholesterol (TC), triglyceride (TG), low density lipoprotein cholesterol (LDL-C), and LDL particles size index (TG/HDL-C ratio).
This may be due to different glycemic control in these patients. There was a significant positive correlation between serum MDA and LDLs size index, while serum MDA was negatively correlated with serum HDL-C in diabetic patients. Our results indicate that oxidative stress status increases during type 2 diabetes mellitus in parallel to glucose and lipid changes

The Relationship between Diabetic Retinopathy and Metabolic Syndrome in Type 2 Diabetes Mellitu

Ikhlas Khalid Hammed

Iraqi Postgraduate Medical Journal, 2013, Volume 12, Issue 1, Pages 62-68

Diabetic retinopathy (DR) is the leading cause of blindness in both the developing and developed countries.The “metabolic syndrome” (MetS) is the clustering of abdominal obesity, insulin resistance, dyslipidemia, and elevated blood pressure and is associated with other comorbiditiesincluding the prothrombotic, and proinflammatory state, MetSis clearly associated with macrovascular complications, but its association with microvascular disease as retinopathy is unclear.
To find out the possible association between DR and MetS.
Four hundred thirty one diabetic patients fulfilling the inclusion criteria were selected for this study The metabolic syndrome was definedfollowing the national cholesterol education program-Adult. treatment panel III guidelines.the ophthalmologic examinations wereperformedbyophthalmologiststoconfirmorexcluderetinopathy.Height,weight,waist circumference and blood pressure were obtained from all participants. Fasting venous blood samples were collected from all the subjects, HbA1c was estimated by high performance liquid chromatography,the serum wasused for analyzing Fasting Blood Glucose (FBG), Total cholesterol (TC), HDL-cholesterol (HDL-C) andTriglycerides (TG).
Statisticalanalysis of data was performed using statistically package for social science (SPSS) version 17.0
The DR prevalence differedsignificantlybetween diabetics with and without metabolic syndrome (20.8% vs. 6.08%)the prevalence of metabolic syndrome in the whole studied sample was 72.6 %. Diabetics with DR hadsignificantlylonger duration of diabetes, had wider WC,higherFBG,higher HbA1c,higher systolic BP,are more likelyto be female,older, have a higher prevalence of MetS, and nonsignificant lower HDL-C and TG.Patients with concomitant MetSand DR hadsignificantly higher FBG, HbA1C, SBP, TG, WC and lower HDL than diabetics with MetS but without DR.theprevalence of DR increased as the numbers of metabolic syndrome components increased.
Diabetic subjects with metabolic syndrome are at higher risk to develop retinopathy. The prevalence of DR increased as the numbers of metabolic syndrome components increased

Effect of Trigonella Foenum-Graecum L. (Fenugreek) on Liver Enzymes in Ischemia-Reperfusion Injury

Mustafa Taha Mohammed

Iraqi Postgraduate Medical Journal, 2013, Volume 12, Issue 1, Pages 69-74

Hepatic ischemia-reperfusion (I/R) injury may occur in a variety of clinical set¬tings and this remains a significant problem. Oxygen free radi¬cals, produced on reperfusion have been shown to play a major role in hepatic I/R injury. Various therapeutic effects have been described for Trigonella. Additionally, it has been presented that Trigonella has protective effect against ischemia reperfusion injury to various organs. Therefore, it seems possible that the administration of Trigonella might protect the liver against the ischemia reperfusion injury.
To determine whether Trigonella foenum-graecum L. (Fenugreek) prevents hepatic ischemia-reperfusion injury to the liver.
Thirty-six rats were divided into three groups as, (Group 1) control group, (Group 2)I/R group and (Group3) Trigonella foenum-graecum L. (Fenugreek) treatment group. All rats underwent hepatic ischemia for 60 min followed by 60 min period of reperfusion. Rats were internal infused with only 0.9% saline solution in group 2. Rats in group 3 received hydro alcoholic - extracted Trigonella foenum-graecum L. (Fenugreek) (500 mg/kg)internal, before isch¬emia and before reperfusion. Blood samples were harvested from the rats, and then the rats were sacrificed. Serum aspartate aminotransfera¬se (AST), alanine aminotransferase (ALT), and lactate dehydrogenase (LDH) levels were determined.
The levels of liver enzymes in group 3 were significantly lower than those in the group 2.
Our results suggest that Trigonella foenum-graecum L. (Fenugreek) treatment protects the rat liver against hepatic ischemia-reperfusion injury

Pulmonary Function Test in Cement Workers in Iraq

Haider Noori Dawood; Abdul Razak Makki Abd Lrazak; Adnan Majeed Muhasen

Iraqi Postgraduate Medical Journal, 2013, Volume 12, Issue 1, Pages 85-89

Exposure to cement dust has long been associated with the prevalence of respiratory symptoms and decline in pulmonary function.
This study assessed the effect of exposure to cement dust on lung function in cement factory workers in Iraq , by measuring Forced Vital Capacity (FVC), Forced Expiratory Volume in the first second (FEV1), FEV1/FVC ratio and Forced Expiratory Flow 50% (FEF50%).
180 workers enrolled in the study , 171 , are male (93.44%) and only 12 are female(6.56%). and 100 workers controls (non exposed) were selected.The age of the subjects ranged between 20-50 years. Both groups were smokers and non smokers, had no chronic pulmonary diseases or symptoms during the time of study. Spirometeric study was used to measure FEV1, FVC, FEV1/FVC ratio and FEF50% .
Statistically, significant reduction in FEV1 and the FEV1/FVC ratio were found in exposed workers when compared to control. Lung
function indices were found to be not affected with increasing duration ofexposure to cement dust nor with smoking.
Exposure to Portland cement dust may result in reduction in the pulmonary function and may lead to respiratory diseases.Implementing measures to control dust and providing adequate personal respiratory protective equipment for the production workers are highly recommended

Effectiveness of Combination Therapy with Thalidomide and Dexamethasone in Patients with Myeloma

Abdul Hamimeed Abdul Majeed AL-Kassir; Bassam Francis Metti; Alaadin Sahham Naji; Yaseen Mohydeen Taher

Iraqi Postgraduate Medical Journal, 2013, Volume 12, Issue 1, Pages 90-95

Thalidomide is the first in the class of drugs as an immune modulatory drugs (IMiDs). In vitro data suggest that the drug and its metabolites may inhibit angiogenesis, in addition it may modulate adhesion molecules of myeloma cells and their surrounding stroma,.The combination of thalidomide plus dexamethasone is a feasible and active regimen in the treatment of multiple myeloma as It emerge an oral alternative to infusional chemotherapy with vincristine, doxorubicin ,dexamethasone currently used as pretransplantation induction therapy for myeloma.
To assess the efficacy ,response rate and safety using the combination of thalidomide-dexamehasone as front line therapy and in relapsed , refractory cases of myeloma
Between February 2008 up to January 2010, thirty five cases of multiple myeloma received a combination of Thalidomide and Dexamethasone for 4 cycles. Those patients had been followed and evaluated at National Centre of Hematology.All cases of myeloma were staged at diagnosis according to Durie – Salmon Staging system. Response based on criteria by Chronic Leukemia and Myeloma Task force ( EBMT criteria ) as complete response (CR), good partial response(GPR) and no response(NR) .
After 4 cycles of therapy , 6(17%) patients achieved complete response,22( 62.9%) patients achieved good partial response, 3(8.6%) patients with minimal response and 4 ( 11.4% ) patients fail responded to treatment .Of those who failed treatment, three patients died two of them with heart failure and one with multi organ failure. Concerning the toxicity , The most common side effect was related to neurotoxcity in form of peripheral neuropathy and thromboembolic disease. Otherwise most of the remaining side effects were rated as mild to moderate
Thal-Dex is an effective myeloma treatment in terms of response , easy to use as outpatient clinic and avoid complications related to line access or cardiac toxicity that related to other treatments.

Penetrating Carotid Artery Injuries

Abdul Salam Y Taha

Iraqi Postgraduate Medical Journal, 2013, Volume 12, Issue 1, Pages 96-103

Penetrating carotid artery injuries (PCAI) in civil time are infrequent, yet they present significant diagnostic and therapeutic challenges and can be associated with significant morbidity and mortality. Proper resuscitation and urgent exploration is necessary for actively bleeding patients.
The aim of this paper is to present our humble experience in management of such injuries with literature review.
Herein, we present 5 cases of penetrating carotid artery injuries managed in Sulaimania and Basrah from January 1996 to 30th of November 2009.
All patients were young males. Three injuries were located in zone III and 2 in zone II. Four patients presented hours to days after the injury while the fifth presented after few months. Angiography was done in 2 patients with a false aneurysm of internal carotid artery (ICA). All 3 patients with ICA injuries were managed by ligation due to profuse bleeding and poor access. The 2 patients with common carotid artery (CCA) injuries in zone II had an end to end repair. All 5 patients have survived without significant neurological deficits.
Penetrating carotid artery injuries in zone II usually do not require preoperative angiography unlike those in zone I and III. Repair is always desired. It is a straightforward operation for zone II injuries but really challenging for zone III due to poor access. Certain zone III injuries may be just observed or treated by endovascular stenting when facilities permit. Ligation of ICA carries a high risk of stroke; however, young people with well developed circle of Willis may tolerate it well

Medico-Legal Study of Fatal Stab Wounds in Baghdad

Muataz A. Al- Qazzaz

Iraqi Postgraduate Medical Journal, 2013, Volume 12, Issue 1, Pages 104-110

Even with the advent of more modern injury types,sharp force injuries and fatalities have been reported to be the most common crimes of violence in several countries, predominantly in those where access to firearms is restricted.Death due to sharp force violence is the most common cause of homicidal deaths in Sweden and in many other countries in Europe, Africa and Asia.
1-To estimate the percentage of sharp wound fatalities from the total number of all injuries referred to the medico-legal institute and the percentage of fatal stab wounds type.
2-To study the stab wounds according to age, sex, scene of injury, number, edge type, length and depth of each wound ,presence of other wound types, anatomical regions affected and organs injured
A medico-legal descriptive study conducted on 41 autopsies during 6 months period .
Cases were studied according to their age, sex, scene of incident , number and type of stab wounds , presence of other types of wounds , suggestive manner of injury , anatomical regions affected and organs injured . Blood sample was taken for alcohol detection then complete classical autopsy was done .
Sharp force injuries were occupying the 8th class of major injuries. Males were 3 times than females . The mean age was 33.4±13.8 years. Indoor and outdoor scenes of incident were almost equal in number with few unknown scenes. Most of victims were with stab wounds type only having single sharp edge wound. Homicidal manner of death was seen in all cases while defense stab wounds were seen in only 7 cases.
The mean length of all stab wounds in all cases was 2.98 + 0.64 cm ranging from 0.5 cm to 8 cm and the mean depth of stab wounds was 9.75+ 4.07 cm. ranging from 1 to 20 cm. Chest was the commonest anatomical region affected and the heart was the commonest organ injured . Alcohol had no role in causation of stab wounds in this study.
Stab wounds are uncommon in Baghdad. Adult males were usually the victims. Homicidal manner was the only manner of death . Knives were the usual weapon used.
It was difficult to determine the exact dimensions of the weapons in most cases because of variability of wounds measurements. Anatomical regions and organs injured revealed their homicidal manner.

Foreign Bodies in the Urinary Bladder: 10 Year Experience in Al-Ramadi Teaching Hospital

Niema Hamad Al-Heeti; Ehab Jasim Mohammad; Waleed Nassar Jaffal; Yahia Hameed Majeed

Iraqi Postgraduate Medical Journal, 2013, Volume 12, Issue 1, Pages 111-119

A wide range of objects have been inserted into the urinary bladder posing a challenge to urologists for diagnosis and management. Although it is not a fatal disease but can lead to serious complications.
To study the presentation, causes, diagnosis and treatment of urinary bladder foreign bodies.
From May 2001 to December 2011, 21 patients had been treated for intravesical foreign bodies at Al Ramadi teaching hospital , Anbar governorate / west of Iraq. All of the patients had underwent ultrasonography of the urinary tract , plain abdominal radiography and cystoscopy. The patient’s records were reviewed retrospectively and their clinical data were analyzed.
A total of 21 patients with mean age of 39.2 years with male: female ratio (1:2.5). The most common presentation was recurrent urinary tract infection. Frequency, dysuria, Hematuria, difficulty with micturition, and urinary retention were the other complaints at presentation. The most common cause is iatrogenic (42.9%) followed by self insertion (33.3%), migration from outside the bladder (14.3%) and external trauma (9.5%). Definitive diagnosis of vesical foreign body was achieved by ultrasonography only in (9.5%), by plain abdominal radiography only in (28.6%),by both in (14.3%) of patients and cystoscopy was needed to establish the diagnosis in (47.6%), of them 5 cases had been erroneously reported to be bladder calculi. Intravesical foreign bodies had been removed endoscopically in 19 (90.5%) patients, and in the remaining 2 (9.5%), by open surgery. No significant complications were recorded postoperatively.
Urinary bladder foreign bodies are not uncommon and should be suspected in patients presenting with chronic lower urinary tract complains. The incidence of iatrogenic foreign bodies in the urinary bladder is increasing. Radiological evaluation and cystoscopy are necessary to confirm the presence of foreign bodies and to determine the size, number, and nature of foreign bodies. Most urinary bladder foreign bodies can be removed by endoscopic and minimally invasive techniques without the need for open surgery

Efficacy of Holmium: Yag Laser in Ureteric Stone Fragmentation

Qais Abdul; Rahman Thamer; Ziad H. Abd

Iraqi Postgraduate Medical Journal, 2013, Volume 12, Issue 1, Pages 120-127

Urolithiasis is a common presenting condition in urologic daily practice, 20% are ureteral stones. The most commonly performed procedures were shock wave lithotripsy (SWL) and ureteroscopy using holmium: YAG laser that can fragment all types of calculi.
Here we provide our experience with the use of holmium: YAG laser in the treatment of ureteric stones as fragmentation rather than complete vaporization aiming to decrease the operative time and subsequent complications.
In this prospective study, 54 patients with ureteric stones were treated using Holmium:YAG laser as an intracorporeal lithotripter in Fallujah general hospital between November 2009 and July 2011, using a 9.5 Fr. storz-semirigid ureteroscope. Stones were diagnosed by excretory urography, or spiral computerized tomography. We estimated the time of operation starting from the onset of application of laser on stone till complete clearance or termination of the procedure. Stone forceps retrieval of stone fragments was done. Double J ureteric stent was placed in complicated cases only. Postoperatively all patients were followed up with plain radiography and renal ultrasonography.
Fifty four patients with ureteric stone were included, their ages range from 19 to 60 years. Complete clearance of the stones was achieved in 38 cases (70.4%). The intraoperative complication was reported in 17 (31.5%) as upward stone migration in 6 cases (11.1%), ureteric perforation only once (1.9%) and bleeding in 10 cases (18.5%). Postoperative complications were infection in 59.3%, urinoma in 1.9% and hematuria in 13%. Complete clearance was 75%, 64.7% and 66.6% in distal, mid and proximal ureter respectively. Stones with sizes less than 1cm, 1-2cm and those with multiple stone the clearance were 81.4%, 65.2% and 25% respectively. The operative time was less in distal stones and in stone size <1cm. Intraoperative complications were higher with longer operative time, while perforation only occurred once when the operative time prolonged >30 min. Postoperative complications were higher with longer operative times, while urinoma complicating perforation occurred in one case when the operative time were more than 30 minutes
Our clinical results, especially with respect to complication rates and outcome, advocate the trial of fragmentation with stone retrieval rather complete vaporization to shorten the operative time and subsequent complications

Genetic Treatment of Urological Diseases; are We Ready? (Review Article)

Ausama Saadi Abdul Muhsin

Iraqi Postgraduate Medical Journal, 2013, Volume 12, Issue 1, Pages 128-136


There is an increasing interest in the role of genetics in many urological diseases and malfunctions. The door was opened for early diagnosis, application of genetically based armamentarium to prevent, treat or modify the clinical course as well as prediction of the prognosis of such abnormalities.
Many urologists share the idea that the use of a genetic tool to diagnose or treat their patients still has a long time before coming into a real clinical and surgical practice.
The purpose of this article is to briefly and simply review gene therapy, epigenetic therapy and stem cell therapy principles and prospects in the management of various urological disorders and to encourage standard urology centers' authorities in the Middle East countries to develop, share and improve their national experience which can serve genetic counseling and possible therapeutic management of their own patients to cope with the international revolution in this field

Safety of Elective Laparoscopic Cholecystectomy in the Hands of Postgraduate Trainees

Haitham. H. Al-Najafi; Muthanna A.Al-Sharbaty; Adil M. Al- Ibadi

Iraqi Postgraduate Medical Journal, 2013, Volume 12, Issue 1, Pages 137-145

From the start of era of laparoscopic surgery the debate starts regarding the best time for laparoscopic training and in most developed countries the training is part of residency program nowadays; the safety of surgeons performing laparoscopic cholecystectomy assessed by results of surgery in addition to different scoring systems( like GOALS and Thomas R Eubanks).
The purpose of this study is to evaluate the safety of elective laparoscopic cholecystectomy done by postgraduate trainees under supervision and the introduction of proper training program of laparoscopic surgery in postgraduate residency programs in Iraq. The safety of the procedure performed was determined using The Global Operative Assessment of Laparoscopic Skills (GOALS) and Thomas R. Eubank scoring systems which were designed for evaluation of resident and surgeon in training laparoscopic performance .
This prospective study includes 200 consecutive cases underwent laparoscopic cholecystectomy for symptomatic cholelithiasis, conducted in AL-Jumhoori Teaching Hospital in Mosul city - Iraq during the period from (October 2010 to October 2011). These laparoscopic cholecystectomies were performed by(5th&4th year) postgraduate trainees under supervision of senior laparoscopic surgeons.
Among 200 cases, there were 45 (22.5 %) males and 155 (77.5 %) females. The age of patients ranged from 18-65 years. All cases were done by 4th and 5th post graduate trainees with minimal complications. The results and observations were made for the operating time, difficulty in dissection, open conversion rate and early complications, The mean operating time was 40 minutes. The open conversion was 3%. and gut injury was 0.5% with no mortality.
laparoscopic cholecystectomy can be performed safely by resident postgraduate trainees according to the outcome data , "Global Operative Assessment of Laparoscopic Skills" (GOALS) and Thomas R Eubanks scoring system and this proves the effectiveness of the suggested training program

The Association of Smoking with the Extra-Articular Manifestations in Rheumatoid Arthritis Patients

Mohammed Hadi Al-Osami; Ali Abdul Majid Allawi; Tahir Hussein Al-Saadawi

Iraqi Postgraduate Medical Journal, 2013, Volume 12, Issue 1, Pages 146-152

Rheumatoid Arthritis (RA) is a chronic systemic autoimmune inflammatory disease that affect all ethnic groups throughout the world, the main characteristic symptom is persistent synovitis of diarthroidal joints often symmetrical resulting in pain, stiffness, and limitation of movement. Smoking is the most established environmental risk factor for development, severity,and extra-articular manifestation of RA..
To assess the association between smoking and appearance of extra-articular manifestation.
A cross sectional study was conducted on 244 patients with RA meeting the American College of Rheumatology Criteria for the classification of RA. Patients data were obtained via face - to- face interview performed by rheumatologist. RA disease-related data, such as disease duration, drug use (all anti-rheumatic drugs , glucocorticoid use and NSAID's), history of smoking which is classified into current smoker, former Smoker ( patient discontinue smoking for at least three months ), and never smoker , also number of cigarette per day were also recorded.Extra-articular manifestation of RA were assessed in all patient by thorough physical examination, and the patient send for appropriate investigation to confirm the diagnosis.
Among 244 patients with RA, 76.2% were women and 23.8% were men, the females were significantly predominate the study samples (P<0.001). The mean (SD) age are 46.9 ± 11.4, the age varies with smoking history (P=0.043). It is significant to find that two third of patients (69.3%) not have smoking history (P<0.001) because majority of patients were female.Smoking is significantly increase rheumatoid factor positivity (P=0.013), Smoking is significantly associated with rheumatoid nodules (P<0.001), secondary Sjögren syndrome (P<0.001), and eye involvement (P=0.002), while there is no significant association with other extra-articular manifestations..
There is significant association between smoking and RA extra-articular manifestations

Detection of H.pylori in a Group of Iraqi Patients with Colonic Cancer (Histological and Molecular Study)

Khalid A. Al-Khazraji; Sinan S. Farhan; Fadhil A. Al-Khafaji; Huda M. Al-Khateeb; Haider A. Al-Zubaidi; Zahraa Q. Al-Kassam

Iraqi Postgraduate Medical Journal, 2013, Volume 12, Issue 1, Pages 153-159

H. pylori is a one of the gastrointestinal organism which infects more than half the population of the world. H.pylori had been recognized as a class I human carcinogen by the International Agency for Research on Cancer. Recently H. pylori were detected in the mucosa of normal colon. Certain studies suggested a possible relationship between CagA (Cytotoxin Associated Gene A) positive H.pylori and Colonic Cancer while other studies did not find causal relationship between CagA positive H.pylori and Colonic Cancer.
We studied and isolated H.pylori from at or near by the site of lesion of Colonic Cancer and it is found to assess a possible relationship between CagA positive H.pylori and Colonic Cancer.
Study involved 30 patients of colonoscopically and Histopathologicaly determined Colonic Cancer (CC group) compared with patients with normal colon (n=90) as a control group (NC group). Patients divided into <20 years age group, 20-40 years age group and >40 years age group. Endoscopic specimens were tested for Biopsy Urease Test (BUT) and Hematoxylin & Eosin (H&E) method for detection of H. pylori also the detection of CagA mRNA using In Situ Hybridization technique with a biotin labeled probe.
There was 66.7% H.pylori positive in patients with Colonic Cancer (by BUT) and 60% by (H&E) compared to 33.3% (by BUT) and 26.7% (H&E) in patients with normal colon (Control). A comparison between NC&CC groups regarding H.pylori infection using H&E method revealed significant difference (P=0.001).Using In Situ Hybridization technique, there was 66.7% CagA positive H.pylori in CC group in correspondence to 25% in NC group. CagA positive H.pylori infection between CC and NC groups revealed significant difference (P=0.008)
H.pylori detected at or near by the site of lesion of Colonic Cancer. In addition it was found that there is a statistical relationship between CagA positive H.pylori infection and Colonic Cancer which suggested a possible role of CagA positive H.pylori in Colonic Cancer.

Adult Wilms' Tumour with Intracaval Extension: A Case Report

Hayder Mahdi AL-Aridy

Iraqi Postgraduate Medical Journal, 2013, Volume 12, Issue 1, Pages 160-163


Wilms' tumors (WT) most commonly occur between the ages of 2 and 5 years and are the second most common abdominal tumor in children, secondary to neuroblastomas(1).
It accounts for approximately 5–6% of the neoplasms in children and is rare in the adult population(2). Less than 3% of all the reported Wilms' tumor cases occur in adults. The overall survival of 83% has been recently reported with the use of primary nephrectomy followed by adjuvant combination chemotherapy(3).
Up to 4% of patients with WT have tumor thrombus involving the vena cava, and the incidence of cardiac involvement is about 0.8% to 1%(4,5). In adults, tumor extension into the vena cava and the right side of the heart is extremely rare.

Hypocalcemic Tetany in a 10 Year Old Girl

Mustafa Kamil AbdUlmajeed Alqaysi

Iraqi Postgraduate Medical Journal, 2013, Volume 12, Issue 1, Pages 164-165

Autoimmune hypoparathyroidism is rare in
children. We present a 10 year old girl who presented with hypocalcaemic tetany due to autoimmune hypoparathyroidism.
The term hypoparathyrodism refers to a group of disorders in which the relative or absolute deficiecy of PTH leads to hypocalcemia and hyperphosphatemia. common cause of hypoparathyrodism are surgical removal of parathyroid glands,radiation,drugs such as alcohol,malignancy,autoimmune disorders and genetic mutations.(1)Autimmune hypoparathyrodism may occur alone or in association with additional features , including mucocutaneous candidiasis and adrenal insufficiency, as acomponent of the autoimmune polyglandular syndrome type 1(APS).(2) We report a10 year’s old girl with isolated autoimmune hypoparathyrodism

The Value of Admission Glucose and Glycosylated Hemoglobin in Patients with acute Coronary Syndrome

Manal Khudhur Abdul Razzaq; Jawad Ibrahim Rasheed; Haider Shaheed Mohmmad

Iraqi Postgraduate Medical Journal, 2013, Volume 12, Issue 1, Pages 75-84

In nondiabetic patients, elevated admission glucose level is a strong predictor of short-term adverse outcome in patients with acute coronary syndrome. Admission glucose may be affected by meals, the circadian cycle, and also the stress response. Glycated hemoglobin A1c is a convenient marker of long-term glucose regulation. However, the prognostic value of diabetic control assessed by HbA1c level in patients with acute coronary syndrome (ACS) is still undefined.
To determine the association between (admission glucose and HbA1c) and short term outcome in patients not known to be diabetics presented with ACS.
This observational study included 50 consecutive patients without known diabetes mellitus admitted to the coronary care unit with ACS. Patients were sub-divided into three groups: patients with unstable angina (UA, n = 10), those with ST segment elevation myocardial Infarction (STEMI, n = 18) and those with non ST segment elevation myocardial infarction (NSTEMI, n = 22). Patients were stratified according to their HbA1c into three groups: Group 1: <6.5
(12, 24%), group 2: 6.5- 8.5 (22, 44%) and group 3: > 8.5 (16, 32%). Both glucose and HbA1c were measured on admission. The diagnosis of ‘‘undiagnosed DM’’ was made if patients presented with fasting glucose >7.0 mmol/L or random glucose >11.1 mmol/L together with an admission HbA1c >6.5% according to the latest ADA recommendations. Main outcome measure was left ventricular (LV) systolic function which was assessed by ejection fraction (EF); and the set point was 50%. Data were analyzed separately using multiple regression analysis.
The mean age of patients was 60.6 ± 6.33 years and 74% were males. Of total, 42% were smokers, 68% were hypertensive, 48% had hyperlipidemia and BMI ≥ 30 in 22%. Eighteen percent of patients were diagnosed as new cases of DM. Mean admission glucose was higher in patients with EF< 50% compared to those with EF> 50% with statistically significant difference (P< 0.05). There was a linear correlation between EF% and HbA1c in all types of presentation. 95.5% of patients in group 2 and 100% of patients in group 3 showed EF<50% with statistically significant difference (P< 0.05).
HbA1c on admission is a powerful predictor of LV systolic dysfunction as a major adverse event of acute coronary syndrome in patients not known to be diabetics. Measurement of HbA1c levels may improve risk assessment in those patients when presenting with ACS