Issue 3

Evaluation of Full-Thickness Skin Grafting with De-Epithelialization of the Wound Margin for Finger Defects with E xposed Tendon

Iraqi Postgraduate Medical Journal, 2020, Volume 19, Issue 3, Pages 187-193

Full-thickness skin grafts are generally considered unreliable for coverage of full-thickness finger
defects with exposed tendons, but there are some clinical reports of its use in this context. In this
study, covering the exposed tendon with FTSG with de-epithelialization of wound edges was
To evaluate the reliability of FTSG survival on an exposed tendon in full thickness finger defects.
From January 2017 to May 2018, nine patients (5 males, 4 females), with tendon-exposed defects of
12 fingers managed with FTSGs.This included marginal de-epithelialization of the normal skin
surrounding the defect, and preservation of the subdermal plexus of the central graft, and partial
excision of the dermis along the graft margin. The donor site was from mastoid, wrist or groin
Most of grafts (10 of 12 fingers) survived without significant surgical complications and achieved
satisfactory functional and aesthetic results.
In this study graft survival was good, with no additional surgical injury of the normal fingers, and
satisfactory functional and aesthetic outcomes. However, few disadvantages like depression and
graft hyperpigmentation were recorded. Therefore, FTSG is an option for treatment of full-thickness
finger defects with the exposed tendon.

New Modification of Chevron Osteotomy in the Treatment of Hallux Valgus

Iraqi Postgraduate Medical Journal, 2020, Volume 19, Issue 3, Pages 194-198

The Corless original chevron osteotomy is a 60 degree V shaped cut which had been described in
1976 to address some of the drawbacks in Mitchell's procedure, several modifications since there
had been added both to extend the indications and to improve the stability of the cheveron
osteotomy. In our study, we used the 90 degrees angle cut but kept the original Corless V shaped
osteotomy in order to retain the stability.
To evaluate the mechanical and the clinical results of these modifications.
From January 2016 until June 2018, 15 patients (16 feet) have undergone new modification of
chevron osteotomy in medical city teaching hospitals, their ages were (25-50) year, the median
age±SD was (40±8.3), 2 male (3 feet), and 13 female, the patients included in this study have
intermetatarsal angles 12-20 and hallux valgus angle 23-46 degree all of them complaining of pain
or bursitis at the bunion site or discomfort in shoe wear, and followed clinically and radiologically
for at least 1 year.
The 15 patients included in this study have completed at least 6 months of follow up, the point at
which the final assessment was done, two of them were male (3 feet )(13.3%) their ages (43,45 y)
median 44.0 ± 1.4y , and 13 female (86.7%) their age range (23-50y) the median 38.0 ± 8.7y.
Significant improvements were noted in HVA (P- value 9.7x10-12 and IMA (P-value 1.6x10₋ 10)
measurements, also similar improvement were obtained about the functional outcome represented by
the AOFAS score results (P-value 6.4 x 10-9).
Modified chevron osteotomy was useful and safe to address mild to moderately severe cases of
hallux valgus, our new modification render it more stable with a high union rate.

Effect of Saline Flush and Hand Elevation on the Onset, Time and Duration of the Action of Rocuronium

Iraqi Postgraduate Medical Journal, 2020, Volume 19, Issue 3, Pages 199-204

Nondepolarizing neuromuscular blocking drugs (NMBDs) were developed as alternatives to Succinylcholine due
to its serious side effects. Rocuronium bromide has been suggested as the drug of choice when Succinylcholine is
contraindicated. Shortening the onset time of NMBDs is important in some situations, which can be achieved by
several techniques as the priming principle.
To evaluate the effect of fluid (normal saline) flush after Rocuronium bolus on the onset and
duration of action.
Sixty patients were divided randomly into two groups; each group had 30 patients: group (A) and group (B). All
of them have undergone surgical operations under general anesthesia. Rocuronium without normal saline was
received in induction by 30 patients (Group A), while Rocuronium followed by 20 ml normal saline flush and
hand elevation were received in induction by the other 30 patients (Group B). A peripheral nerve stimulator was
used to measure a train-of-four (TOF) stimulation. The time from the disappearance of T1 until the appearance of
T3 is the duration of the action of Rocuronium.
In this study, means of time of onset were significantly higher in Group A than that in Group B
(61.12 versus 44.41 sec, P= 0.001), and duration of action was higher in Group B than that in Group
A but statistically not significant (40.87 versus 34.61 mints, P= 0.063).
A 20 ml saline flush and hand elevation immediately after administering a Rocuronium bolus of (0.6 mg/kg)
decreased the onset time but did not significantly increase the recovery phase of Rocuronium. Therefore, we
recommend to use 20 ml Normal Saline flush and hand elevation after Rocuronium injection as a safe method to
get rapid onset for intubation especially when Suxamethonium is contraindicated

Maternal Serum Placental Leucine Aminopeptidase as a Predictor of Pregnancy Outcomes

Iraqi Postgraduate Medical Journal, 2020, Volume 19, Issue 3, Pages 205-212

Placental leucine aminopeptidase is a glycoprotein, known as oxytocinase. It helps to maintain
normal pregnancy to term, also it is involved in fetal development, maintenance of homeostasis
during pregnancy, blood pressure regulation, memory retention, antigen presentation, and cancer
To evaluate the value of maternal serum placental leucine aminopeptidase levels as a predictor of
pregnancy outcomes.
Hundred pregnant women were included in the study, they were divided into four groups, 25
pregnant women with hypertensive disorder of pregnancy, 25 pregnant women with gestational
diabetes and 25 pregnant women with intrauterine fetal death at a gestational age between 28 - 41
weeks, another 25 healthy pregnant women as a control group with gestational age range 37 - 40
weeks. Serum levels of placental leucine aminopeptidase were measured using Enzyme-linked
immunosorbent assay (ELISA) method for all study groups at the time of presentation. It is a case -
control study that was conducted at AL-Yarmook Teaching Hospital, department of obstetrics and
Serum placental leucine aminopeptidase concentration significantly lower in pregnant women
presented with fetal death group was(mean ± SD)61.6 ± 15.8IU/ml compared to pregnant women
with hypertensive disorders in pregnancy, gestational diabetes mellitus and healthy pregnant women
were (83.2 ± 12.51IU/mL, 85.0 ± 13.11IU/mL and 108.9 ± 19.1IU/mL), respectively. Receiver
operating characteristic( ROC) curve analysis showed that the result of serum placental leucine
aminopeptidase level for predicting perinatal mortality among pregnant women was (optimal cut
point ≤78.98, sensitivity100%, specificity 73.3and accuracy 80.0%).
Maternal serum placental leucine aminopeptidase was low among patients with hypertensive
disorders in pregnancy, gestational diabetes mellitus and much lower among patients presented with
fetal death compared to healthy pregnant women. Low serum placental leucine aminopeptidase level
had high sensitivity and specificity for predicting perinatal mortality.

Repair of Hypospadias Fistula Using a Penile Skin Advancement Flap with Penile Dartos Interposition

Iraqi Postgraduate Medical Journal, 2020, Volume 19, Issue 3, Pages 213-219

Presence of various techniques in hypospadias repair is attributed to the relatively common
complications following those repairs which shown as an immediate and long term complication.
Urethrocutanous fistula is the commonest complication of the hypospadias repair , with a reported
incidence of 4-25%. The incidence is varying with severity of hypospadias, surgical techniques, and
experience of the operating surgeon.
To evaluate the efficacy of using a penile skin advancement flap with penile dartos Interposition to
repair hyposapadial fistula.
Between October 2017 and March 2018, eleven boys with urethrocutaneous fistula were included in
this study. Their age ranged between (3 years – 10 years ) . All were repaired with penile skin
advancement flap with dartos fascia as an interposed reinforcing layer in Al shaheed Ghazi
Al- Hariri hospital and Alwasity teaching hospital .
Most of the patients showed no recurrence of fistulae after repair during follow up period which
extended for about 6 months postoperatively. Those pati-ents had good urine stream and straight
penis on erection without any torsion or deviation. No major complications were seen in all of these
The penile skin advancement flap with interposition dartos is simple procedure which can be used
for surgical treatment of primary posthypospadias fistula of any size, site provided that there is
adequate pliable durable penile skin .

Prevalence of Exclusive Breastfeeding and Some of Its Determinants in Hilla City, 2018

Iraqi Postgraduate Medical Journal, 2020, Volume 19, Issue 3, Pages 220-225

Health organizations recommended that mothers exclusively breast feed infants for the first six
months of life. Breastfeeding is a natural food that serves as a complete source of infant nutrition
for the first six months of life. It contains all the necessary nutrients provided in a bioavailable and
easily digestible form, protecting both mothers and children against illnesses and diseases with
immunological properties. Place of delivery in many study showed positive effect of rate of
exclusive breast feeding.
The study aimed to estimate the prevalence of breastfeeding in Hilla city and the rate of delivery in
different sites and to identify relationship between exclusive breastfeeding habit and place of
This cross sectional study was conducted between the first of April and the first of July of 2018, in
which 520 mothers were included and attending vaccination unit in PHCC in Hilla city. A selfconstricted
questionnaire form was used to collect the required data. Data entry and analysis was
done by using SPSS program version 23.
The mean age of mother’s was26 ±6.1 years, the percentage of exclusive breast feeding was
49.6%,the percent of delivery in the baby friend hospital was 30.6%.Mother age, type of delivery,
who attended the delivery, and the type of feeding used by the mother in her previous infant was the
factors that contributed for practicing exclusive breastfeeding.
The prevalence of exclusive breast feeding in Hilla city is fair and agrees with the rate reported in
other parts in Iraq.

Prevalence and Risk Factors of Low Birth Weight in Al- Elwiya Maternity Teaching Hospital in Baghdad

Iraqi Postgraduate Medical Journal, 2020, Volume 19, Issue 3, Pages 226-230

Low birth weight as a public health indicator and determinant of perinatal mortality should always
be monitored. Attempts to trace possible risk factors and prevalence of low birth weight should not
be wasted.
Finding the prevalence of low birth weight in Al-Elwiya maternity teaching hospital in Baghdad in
2011 and 2012 and studying risk factors associated with a sample of low weight neonates born in
the hospital.
Prevalence of low birth weight in Al-Elwiya maternity teaching hospital in 2011 and 2012 was
obtained through reviewing data registered in the hospital′s medical statistics unit and inpatient
medical records unit, while risk factors were traced through conducting a case control comparison
by collecting 100 cases and similar number of controls using direct interview questionnaire with
the mothers who laboured in the hospital.
The calculated prevalence of low birth weight in Al Elwiya hospital was slightly higher than
the national figure, and the risk factors found statistically significant for low birth weight were;
multiparty, anaemia, urinary tract infection, chest infection, passive smoking and level of education.
While age, antepartum haemorrhage and pregnancy induced hypertension found insignificant.
Prevalence of low birth weight in the hospital is slightly higher than the national figure although
the latter was not published, all factors affecting birth weight were controllable.

The Use of Limberg Flap in the Management of Sacrococcygeal Pilonidal Sinus

Iraqi Postgraduate Medical Journal, 2020, Volume 19, Issue 3, Pages 231-238

Sacrococcygeal pilonidal sinus disease is a common condition that commonly seen in young adult
males. It is disease that have high rates of morbidity unless properly identified and treated.
To study the procedure of Limberg flap reconstruction and to evaluate the results and success of
Limberg flap reconstruction in pilonidal sinus disease management.
40 patients with pilonidal sinus disease selected randomly, rhomboid excision with Limberg flap
was done for them. Duration of operation, postoperative pain, duration of hospital stays and
postoperative complications were noted. Follow up of all patients was performed on an out-patient
Our study consists of 40 patients, 35males (87.5%) and 5 females (12.5%), with a mean age of 27.2
years range (18-36 years). The mean duration of symptoms was 2.25 months (range 1–3 months).
Mean operative time was about 42.2 minutes (range 40-45 minutes), time to return to work and
normal activities from 3 to 4 weeks. Postoperative complications occur in 4 patients in the form of
wound infection and seroma.
Limberg rhomboid flap in sacrococcygeal pilonidal sinus is useful in primary pilonidal sinus and in
recurrent cases, has been associated with lower complication rates, healing time, and recurrence
rates, and it is an easily mastered technique.

Applying P40 and TTF-1 in the Subtyping of Poorly Differentiated Non-Small Cell Lung Carcinoma in Bronchoscopic Biopsy

Iraqi Postgraduate Medical Journal, 2020, Volume 19, Issue 3, Pages 239-245

Lung cancer is the leading cause of cancer-related deaths worldwide, regardless of gender. It is
categorized into two main groups: small cell lung carcinoma (SCLC, 15% of all lung cancers) and
non-SCLC (NSCLC, 85% of all lung cancer). Increasing knowledge of the molecular pathology of
lung cancers has led to their classification into specific subtypes according to appropriate treatments
and molecular-targeted therapies.
Evaluation of the expression of P40 and TTF-1 in randomly selected samples from Iraqi patients
who have NSCLC and correlate their expression with the clinicopathological variables.
This is a retrospective study of 40 patients who were diagnosed to have NSCLC. Formalin fixed,
paraffin embedded tissue blocks.P40 and TTF-1 immunoreactivity and pattern of staining were
evaluated in immunohistochemical stained slides and correlated the results with clinicopathological
55% of the tumors were squamous cell carcinoma while 45% were adenocarcinoma. The sensitivity
and specificity of P40 for the SQC diagnosis were 100% while the sensitivity of TTF-1 for ADC
diagnosis was 88.9% and specificity was 100%.
P40 and TTF-1 can be used as a reliable minimalistic panel for accurate subtyping of NSCLC.

Classical Laparoscopic Cholecystectomy (CLC) versus Mini Laparoscopic Cholecystectomy(MLC). Is It Worthy?

Iraqi Postgraduate Medical Journal, 2020, Volume 19, Issue 3, Pages 246-251

Laparoscopic chohecystectomy is the standard operation for cholelithiasis and replaced the classical
open cholecystectomy as it has better outcome.
The purpose of this study is to make a comparison between classical laparoscopic cholecystectomy
(CLC)and Mini laparoscopic cholecystectomy (MLC).
This study was conducted in Al-Jumhoori Teaching Hospital during the period from 10th February
till 15th may 2019. It involved 30 patients with symptomatic gallstones randomly divided into
2 groups (the first group treated with CLC while the second group treated with MLC);the intra and
post operative complications were recorded for comparison.
Thirty patients involved in this study and divided randomly in two groups ;Group (A) age (average
38 years )and their BMI (average 36 kgm2) underwent CLC ,while group (B) age (average 28 years)
and their BMI (average 31kgm2). The mean operative time in CLC was 42 minute while MLC
recorded time was 51minutes. The MLC group has less post operative pain, better cosmetic results
with comparable hospital stay ,but two cases converted from MLC to CLC.
MLC can be performed safely and although it takes more time than CLC ,but has less post operative
pain and more patient satisfaction with comparable hospital stay

Sutureless Total Abdominal Hysterectomy Using Marclamp® IQ : A Prospective Cross-Sectional Study

Iraqi Postgraduate Medical Journal, 2020, Volume 19, Issue 3, Pages 252-259

Hysterectomy, the second most common surgical procedure performed in female patients, is
associated with various complications like other major surgical procedure.To reduce such
complications and shorten both ,the operating time and the intraoperative blood loss, sutureless
hysterectomy was recently practiced using novel vessel sealing devices as marClamp® IQ and
To compare the outcomes of marClamp® total abdominal hysterectomy (TAH) versus total
abdominal hysterectomies performed by LigaSure and suture ligature techniques of other studies.
A total of 47 female patients presenting with various benign and malignant uterine and malignant
ovarian diseases were suturelessly hysterectomised using marClamp® .
Main outcome measures: The primary outcome measures were: the operating time and blood loss
while the secondary outcome measures were: intraoperative and post-operative complications,
hospital stay and histopathologic results of the removed specimens.
Operating time of marClamp®: TAH only, TAH +bilateral salpingo-oopherectomy (BSO),
TAH+BSO+ infracolic omentectomy and total study group were: mean±SD = 60.91±8.31minute
(m) ,75.93±14.61m, 83.89±13.18 m and 73.94±15.11m respectively (P-value =0.001, it was
statistically significant ). The intraoperative blood losses of marClamp®: TAH only, TAH + BSO,
TAH+BSO +infracolic omentectomy and total study group were: mean±SD = 64.09±8.61 mililiter
(ml) , 85.74±17.30 ml ,103.33±20.62 ml and 84.04±20.71 ml respectively (P-value =0.000, it was
statistically significant ). Hospital stay of this study was mean±SD =2.08±0.59 day. This study had
no intraoperative complications .Its postoperative complication rate was 10.63 %. Premenopausal
simple endometerial hyperplasia with / without atypea was the most common histopathologic variety
(51%) .This study had no mortality during the follow-up period.
The use of marClamp® IQ device can reduce operating time, intraoperative blood loss,
intraoperative and postoperative complication rates and the hospital stay. Thus it is cost-effective.
It allows quick and secured hemostasis compared with the conventional suture ligature technique.

Assessment of Left Ventricular Longitudinal Function in Hypertensive Patients with Left Ventricular Hypertrophy by MAPSE

Samara Mohammad Khider; Ghalib Al-Shareefi

Iraqi Postgraduate Medical Journal, 2020, Volume 19, Issue 3, Pages 260-265

Hypertension is an important risk factor for many cardiovascular diseases worldwide. The use of MАPSE in thе assessmеnt of LV systolic dysfunction is helpful especially in cases of poor imaging quality, since good imaging quality is needed for the modern echocardiographic techniques.
Detection of early subclinical LV systolic dysfunction in hypertensive patіents with left ventricular hypertrophy (LVH) with preservеd ejectiоn fraction by MAPSE.
A comparative case-control study which took place at Al-Yаrmouk Tеaching Hospitаl in Baghdad/Iraq from October 2018 to October 2019.The study population consisted of  60 hypertensive patients with left ventriculаr hypertrophy (LVН) and  60 healthy subjects enrolled as controls.
There was a high significant reduction in mean MAPSE for hypertensive patients with LVH compared with controls (Р value = 0.0001). There was a significant reduction in mean S’ for hypertensive patients with LVH when compared with mean S’ for controls (P = 0.0001). There was a positive linear correlations between MAPSE and S’ for hypertensive patients with LVH ( r = 0.572, P = 0.001).
MAPSE can be used on daily practice for assessment of subclinical LV systolic function in hypertensive patients with left ventricular hypertrophy and select them for preventive trеatment.

Ventilation Tube Insertion: Oto-Endoscopy versus Surgical Microscopy (Comparative Study)

Omar Ali Hussein; Muhammed Dheia Ahmed

Iraqi Postgraduate Medical Journal, 2020, Volume 19, Issue 3, Pages 266-271

At the last years, oto-endoscopy have been used for ventilation tubes insertion procedure in cases of otitis media with effusion.
The purpose of the study to evaluate the endoscopic myringotomy and ventilation tube insertion as        a valid alternative of using the surgical microscope regarding: safety and time. 
This study involved (42) patients diagnosed with chronic otitis media with effusion, divided in to tow groups regarding type of procedure was performed. The first group consist of (23) patients, ventilation tube was inserted by using oto-endoscopy, while the second one involved of (19) patients operated by using Surgical microscopy.   
Patients that participate in this study were (42 patients) with otitis media with effusion. The oto-endoscopy procedure group consists of (16 patients) were males (69.56%), and  (7 patients) were females (30.43%), the group consists of 20 right ears and 23 left ears. Time varied from (2.43-11.54) minutes, mean time ± (SD) 5.55 ± 2.48 minutes. The microscopic procedure group consists of (11 patients) were males (57.89%), and (8patients) were females (42.1%), the group consists of 18 right ears and 18 left ears. Time varied from (4.21-17.02) minutes, mean time ± (SD) 10.92 ± 4.04 minutes. We found statistical significant difference observed in the average operative time between the endoscopic and the usual microscopic procedure for myringotomy and ventilation tube insertion operation at p value < 0.05. (p value 0.008). Regarding the operation related complications between the endoscopic and usual microscopic procedure for myringotomy and ventilation tube insertion there was no significant difference noticed between both operations.
We conclude that the endoscopic procedure of myringotomy and ventilation tube insertion operation is a valid alternative to surgical microscope regarding: safety and time.

Diagnostic Value of D-Dimer’s Serum Level in Patients with Cerebral Venous Thrombosis

Muthana Ismai’l Abdullah; Nameer Mohammed Taher

Iraqi Postgraduate Medical Journal, 2020, Volume 19, Issue 3, Pages 272-278

Cerebral venous thrombosis (CVT) is the presence of a blood clot in the dural venous sinuses, which drain blood from the brain. D-dimer is a specific product of the degradation of fibrin clots that can reflect the activity of coagulation and the fibrinolytic system. 
To assess the role of plasma D-dimer, as well as, the sensitivity and specificity of this assay in diagnosis of cerebral venous thrombosis.
This is a case-control study which included 50 adult patients diagnosed with CVT. Other 50 age- and sex-matched healthy subjects were enrolled in the study as control group. Demographic data were collected from each participant, while the clinical data of cases were collected separately. Blood samples were collected from each participant in sodium citrate tubes, and a ready commercial kit was used to measure plasma levels of D-dimer.  Receiver operating characteristic (ROC) curve was employed to evaluate the diagnostic value, sensitivity and specificity of D-dimer in                          the discrimination of CVT healthy controls.
Mean plasma level of d-dimer in CVT patients and controls were 536.7± 102.34 ng/mL and 318.4± 88.71 ng/mL respectively with a significant difference (p= 0.029). The sensitivity and specificity of the test at cut off value of 400 ng/mL were 0.88 and 0.86 respectively, indicating a very good discrimination value.
Measurement of D-dimer can be a reliable tool for diagnosis of CVT, especially in patients with acute and subacute disease.