Volume 18, Issue 4, Autumn 2019, Page 291-369


Arthroscopic Fixation of Isolated Type II Superior Labrum Anterior to Posterior (Slap) Lesions, Short-Term Results

Iraqi Postgratuate Medical Journal, 2019, Volume 18, Issue 4, Pages 291-298

ABSTRACT:
BACKGROUND:
SLAP defined as separation of superior labrum from anterior to posterior, with or without the involvement of the attachment of the biceps tendon.
OBJECTIVE:
To assess the results of arthroscopic management of type II isolated SLAP tear using suture anchors in patients below forty years of age according to the University of California Los Angeles (UCLA) rating scale.
PAT IENTS AND METHODS:
This is a prospective study conducted in the medical city directorate in Baghdad starting in October 2015 till October 2017, it included fourteen patients having dominant side type II SLAP tear, twelve males and two females, mean age was 31.8. All the tears fixed by arthroscopic suture anchor using the 2-ports technique. All patients evaluated by the (UCLA) scale preoperatively and one year after surgery.
RESULTS:
The UCLA shoulder rating scale regarding the pain relief, function and patient satisfaction showed significant improvement from 14.0±2.8 preoperatively to 31.9±1.9 one year postoperatively in all the patients with a P value < 0.0001.One patient had post-operative anterior stitch infection treated by daily dressing and antibiotic.
CONCLUSION:
Arthroscopic repair of isolated type II SALP lesions by using suture anchors fixation and by two ports technique show favorable outcomes in term of function, pain relief and satisfaction of patients below 40 years in one year follow up.
KEYWORDS SLAP lesion, shoulder arthroscopy

Frequency of Skin Cancer among Iraqi Patients Attending Dermatology Center/Medical City in Baghdad between January 2013 and December 2018

Iraqi Postgratuate Medical Journal, 2019, Volume 18, Issue 4, Pages 299-304

ABSTRACT:

BACKGROUND:
Nonmelanoma skin cancer is the most common cancer in humans especially with lighter skinned individuals and ultraviolet exposure which are the major predisposing risk factors. There are many reports of increased frequency of skin cancer among Iraqi individuals.
OBJECTIVE:
To study the frequency of skin cancer in Iraqi patients.
PATIENTS AND METHODS:
This is a retrospective study, conducted in the outpatient clinic of dermatology center at Baghdad Teaching Hospital from the beginning of January 2013 to the end of December 2018. A total of 365 biopsies proved histopathologically as malignant skin cancer were included in the study. RESULTS:
Basal cell carcinoma accounted for 37.3% (n=136), mean age was 63±13 years. Squamous cell carcinoma represented 16.2% (n=59), mean age was 61±15 years. Mycosis fungoid frequency was 15% (n=55) with a mean age of 47±16 years. Kaposi sarcoma was 10.1% (n=37), mean age 64±15 years. Cutaneous metastasis represented 7.8% (n=29) with mean age of 64±5 years. Patients with malignant melanoma were 4.3% (n=16), mean age was 50±19 years. Other less commonly skin malignancies represented 9.3% (n=33).
CONCLUSION:
The most frequent primary skin cancer is nonmelanoma skin cancer followed by mycosis fungoides, Kaposi Sarcoma and malignant melanoma, respectively. The most common origin of skin metastasis is breast carcinoma.
KEYWORDS: Skin cancer, Iraq, Metastasis

Role of Dixon MRI in Quantification of Liver Fat in Non-Alcoholic Fatty Liver Disease

Iraqi Postgratuate Medical Journal, 2019, Volume 18, Issue 4, Pages 305-312

ABSTRACT:
BACKGROUND:
Hepatic steatosis is a broad term; nonalcoholic fatty liver disease (NAFLD) is the most common type. Magnetic resonance imaging (MRI) can provide a quantitative, accessible and accurate evaluation of diffuse liver disease.
OBJECTIVE:
Study the role of MRI Dixon in quantification of hepatic fat in patients with NAFLD in correlation with (computed tomography) CT attenuation, serum alanine aminotransferase (ALT), serum aspartate aminotransferase (AST) and body mass index (BMI)
PATIENTS AND METHODS:
This cross sectional analytic prospective study was conducted from November 2016 to December 2017 at radiology department of Al-Imamein Al Kadhimein Medical City, Baghdad/ Iraq. Fifty patients were included in this study (28 females and 22 males), the study included patients with clinical and laboratory suspicion of NAFL and CT evidence of fatty liver (in unenhanced CT the liver parenchyma were less than 40 Hounsfield unit (HU), or if CT attenuation of the liver were 10 HU less than that of spleen). All patients were examined with T1 vibe Dixon sequence with breath hold. Hepatic fat fraction (HFF) was calculated from mean ROIs of water and fat images using following formula: % of HFF=F/F+W, where W and F are the signal contribution from water and fat respectively.
RESULTS:
The cases were divided into 3 groups according to the results of MRI Dixon fat fraction % as following: group A MRI Dixon fat was less than 15% (21 patients), group B between 15 -30% (13 patients) and group C more than 30% (16 patients). There was statistically significant relationship between Dixon fat fraction with CT attenuation in group A and C while no statistically significant relationship was seen in group B. There was no statistically significant relationship between Dixon fat fraction and serum ALT and AST in group A and B while statistically significant relationship between Dixon fat fraction and serum ALT was found in group C. there was statistically significant relationship between Dixon fat fraction and body mass index in all 3 groups.
CONCLUSION:
Dixon MRI was noninvasive, reliable technique in quantification of fat fraction in NAFL, Dixon MRI was more sensitive sequence for early detection of fatty liver diseases infiltration.
KEYWORDS: Dixon Magnetic resonance imaging, liver fat, fatty liver disease

Relation between Human Papilloma Virus Infection and Spontaneous Miscarriage

Iraqi Postgratuate Medical Journal, 2019, Volume 18, Issue 4, Pages 313-321

ABSTRACT:
BACKGROUND:
Approximately one in four women will have an early pregnancy failure during her lifetime. In pregnant women or in their partners, human papillomavirus infection can be considered as a risk of preterm birth, miscarriages and virus transmission to the newborn.
OBJECTIVE:
To disclose the prevalence of high risk human papillomavirus infection in women suffering from spontaneous miscarriage .
PATIENTS AND METHODS:
A case - control study included 100 pregnant women ,age (20-42 years old) ,50 full term pregnant )Gestation age 37-40 week) delivered viable full term pregnancy, and 50 pregnant women experienced spontaneous miscarriage (Gestation age 8-24week), cervical swab was done in the labor ward of Al-Yarmouk Teaching Hospital from all participants, and the samples were taken to a private lab for high risk human parvovirus detection. The study period was from 1st of March to 30th of November 2017.
RESULTS:
The overall prevalence of high risk human papillomavirus is 7%, the highest proportion of study patients with high risk human papillomavirus infection ended with miscarriage (71.4%), while in those with viable full term pregnancy were (28.6%). A number of risk factors which increased prevalence of high risk human papillomavirus hrHPV infection were detected as previous history of miscarriage, smoking, and history of oral contraceptives use.
CONCLUSIONS:
High risk human papillomavirus prevalence was higher in pregnancy with spontaneous miscarriage compared to women experience a normal full term pregnancy.
KEYWORDS: Miscarriage, high risk human papillomavirus (hrHPV), Pregnancy.

Knowledge, Attitude and Practice of Female Physicians, Dentists, and Pharmacists Regarding Complementary Feeding of Their Infants: An Online Study

Iraqi Postgratuate Medical Journal, 2019, Volume 18, Issue 4, Pages 322-328

ABSTRACT:
BACKGROUND:
The transitional period from exclusive breastfeeding to family foods, is known as complementary feeding, and it is a very vulnerable period. WHO has developed and updated the guide "Complementary feeding: Family Foods for breastfed children" that gives a clear guidance for health care workers on how to promote complementary feeding.
OBJECTIVE:
To assess the knowledge, attitude and practice of mothers from the medical staff concerning complementary feeding, and pattern of their infants feeding
SUBJECTS AND METHODS:
A cross sectional study with analytic components was carried out online through Facebook, targeting members of close group of mothers from the medical staff. The study was done in 2018.
RESULTS:
The age of mothers ranged between (23- 44) years, (45.6%) were physicians, (54.2%) of them were prim gravida. 73.2% of mothers introduce the complementary food between the age of four to six months. The total knowledge score of mothers was (68.4 ± 23.03. The total attitude score was (44.1 ± 22.8). The total practice score of mothers was (51.25 ± 18.2). (59%) received their information from the internet.
CONCLUSION:
Almost half of the participants had a good knowledge, majority of them had poor attitude and almost half had a poor practice toward their infants feeding. Internet is the major source of their information.
KEYWORDS: complementary feeding, medical professions, online(facebook) group.a

Distribution of Hematological Neoplasia Diagnosed by Bone Marrow Morphology in Adult Patients Attending Medical City Teaching Hospital

Iraqi Postgratuate Medical Journal, 2019, Volume 18, Issue 4, Pages 329-334

ABSTRACT:
BACKGROUND:
The hematological malignancies are clonal diseases that derive from a single cell in the marrow or peripheral lymphoid tissue that has undergone genetic alteration; they represent approximately 7% of all malignant diseases.
OBJECTIVE:
Assessment for the frequency of the hematological neoplasia diagnosed by bone marrow morphology in adults patients attending Medical City-Baghdad.
PAT IENTS AND METHODS:
This is a retrospective cross sectional study carried out in Teaching Laboratories of Medical City-Baghdad during the period from 1/1/2017 to 1/1/2018. All the cases of hematological neoplasia were diagnosed by the morphology of peripheral blood, bone marrow aspirate and /or biopsy were included in the study.
RESULTS:
Out of 2266 bone marrow examinations carried out in 2017 year, 570 patients (25%) were diagnosed as Hematological Neoplasia and included in the study; The frequency of HN was as follow: Acute Myeloid Leukemia:19.3% , Non-Hodgkins Lymphoma: 15.7 %, Acute Leukemia (unclassified morphologically):15.6%, Multiple Myeloma: 14%, Chronic Myeloid Leukemia:10.3%, Chronic Lymphocytic Leukemia:4.5%, Acute Lymphoblastic Leukemia: 4.4%, Myeloproliferative Neoplasia: 4.2%, Lymphoproliferative Disorders:3.3%, Primary Myelofibrosis: 2.6%, Essential Thrombocythemia: 1.9%, Hairy Cell Leukemia:1.7% ,Myelodysplastic Syndrome:1.2%, Chronic Myelomonocytic Leukemia: 0.5%, Plasma Cell Leukemia: 0.4%; 489 (86%) patients were diagnosed by bone marrow aspirates while 81(14%) patients were diagnosed by bone marrow biopsy.
CONCLUSION:
The most common hematological neoplasia was Acute Myeloid Leukemia followed by Non-Hodgkins Lymphoma while the least was Plasma Cell Leukemia. Patients with Acute Myeloid Leukemia, Acute Lymphoblastic Leukemia and Chronic Myeloid Leukemia presented at lower age than other hematological neoplasias. The majority of hematological malignancies were diagnosed by bone marrow aspirates.
KEYWORDS: Acute Myeloid Leukemia, Acute Lymphoblastic Leukemia, Chronic Lymphocytic Leukemia

Ultrasonographic Guidance versus Fluoroscopic Guidance for Renal Access in Percutaneous Nephrolithotomy (PCNL): A Comparative Study

Iraqi Postgratuate Medical Journal, 2019, Volume 18, Issue 4, Pages 335-343

ABSTRACT:
BACKGROUND:
Guiding access of percutaneous nephrolithotomy is essential in acquiring better surgical outcomes and preventing serious postoperative complications.
OBJECTIVE:
To assess the safety and efficacy of ultrasonographic guidance vs. fluoroscopic guidance for renal access in percutaneous nephrolithotomy (PCNL) focusing on the success rate of renal access, stone-free rate, operating time, duration of hospitalization, and major complications after the procedure.
PATIENTS AND METHODS:
A Prospective comparative study conducted in Shahid-Ghazi Hariri Surgical Specialties Hospital and Nursing Home Hospital in Baghdad Medical city. The duration of study was through the period from 1st of October, 2016 to 1st of October, 2018 on convenient sample of 70 patients with renal stones underwent percutaneous nephrolithotomy. The selected patients were categorized into two groups were undergoing percutaneous nephrolithotomy ;(35 patients guided with ultrasound) and (35 patients guided with fluoroscopy), they compared mainly by stone free rate, and secondarily by access time, operative time and post operative complication. S. T. O. N. E. score use to determine the charecter of the stone.
RESULTS:
For patients with low S.T.O.N.E score no difference was found regarding stone free rate between ultrasonographic guidance and fluoroscopic guidance percutaneous nephrolithotomy (p value 0.1). For patients with high S.T.O.N.E score fluoroscopic guidance percutaneous nephrolithotomy achieve higher stone free rate ( p value 0.04) . No significant difference was found between the two groups regarding hemoglobin decline, blood transfusion, operative time and hospitalization.
CONCLUSION:
Percutaneous nephrolithotomy under ultrasound guide is safe and effective as fluoroscopic guidance for patients with low S. T. O. N. E. score. Fluoroscopic guidance is more effective for patients with high S. T. O. N. E score.
KEYWORDS: Percutaneous nephrolithotomy, Ultrasonography guidance, Fluoroscopy guidance

Comparative Study between Simplified Modified Ripping, Coagulation and Pluck ( RCP Technique) of Mural Part of Ureter and Open Resection of Mural Part in Radical Nephroureteroectomy

Iraqi Postgratuate Medical Journal, 2019, Volume 18, Issue 4, Pages 344-350

ABSTRACT:
BACKGROUND:
In radical nephroureterectomy for high risk upper tract urothelial cancer UTUC, mural part of the ureter need to be removed otherwise recurrence will occur in up to 75% .
OBJECTIVE:
To compare results of modified transurethral ripping, coagulation and pluck technique with the traditional open resection of the mural part of the ureter in the radical nephroureterectomy for upper TUC.
PATIENTS AND METHODS:
Seventeen patients with high risk upper tract urothelial cancer were managed by radical nephroureteroctomy ,7 of them the mural part was removed by open resection while for 10 patients the mural part was managed by transurethral ripping by Collins knife then the meatus was closed by ball electrode coagulation before plucking of the ureter during nephroureteroctomy which was done by open method in 8 patients and by laparoscopic way in two patients.
RESULTS:
There is a statistically significant difference in the outcomes of endoscopic procedure (ripping, coagulation and plucking of mural ureter) in comparison to the results of open resection for mural part of ureter ,where the mean operative time for bladder cuff excision reduced from 75+6 to 10.5+ 2 minute ,mean total operative time reduced from 190+2 to 100 + 7 minutes ,hospital stay from 7 + 0,6 days to 4.5 + 0.6 days, and bowel recovery period reduced from 3.5 + 1 to 1.5 + 0.4 days
CONCLUSION:
Retrograde modified ripping-coagulation and pluck of mural part of the ureter in radical nephroureterectomy for high risk UTUC is rapid ,safe ,simple and applicable with all type of radical nephroureterectomy procedures, whether open or by minimal invasive procedures and it applies all means for oncological safety.
KEYWORDS: Urothelial cancer

The Association of Fibromyalgia with Adult Ankylosing Spondylitis Patients

Iraqi Postgratuate Medical Journal, 2019, Volume 18, Issue 4, Pages 351-355

ABSTRACT:

BACKGROUND:
Ankylosing Spondylitis is a chronic systemic inflammatory disorder affecting the spine and other areas of the body(joints and entheses). Fibromyalgia is a syndrome characterized by chronic( more than three months) wide spread musculoskeletal pain. Detection of fibromyalgia in patients with ankylosing spondylitis is an important aspect in the treatment of ankylosing spondylitis.
OBJECTIVE:
To determine the association of fibromyalgia with adult ankylosing spondylitis, and to evaluate the effect of coexisting fibromyalgia on the scores of disease activity and functional status.
PATIENTS AND METHODS:
A case-control study with 100 ankylosing spondylitis patients and 100 controls enrolled in the study. Ankylosing spondylitis was diagnosed with modified New York criteria. Fibromyalgia assessed by using modified 2010/ 2011 American Collage of Rheumatology criteria for the diagnosis of fibromyalgia.
RESULTS:
Fibromyalgia was found in 25% of patients with ankylosing spondylitis with female: male ratio(5.2:1), while seen in 6% of controls with female to male ratio(5.9:1). Fibromyalgia was significantly associated with increase in the disease activity index. The function index in fibromyalgia patients was significantly higher than in non-fibromyalgia patients.
CONCLUSION:
Fibromyalgia is more common in ankylosing spondylitis patients than in controls. The coexistence of fibromyalgia with ankylosing spondylitis negatively impacts the scores of ankylosing spondylitis disease activity and functional status.
KEYWORDS: Fibromyalgia, Ankylosing spondylitis.

Difficult Laparoscopic Cholecystectomy Prediction by the Use of Clinical Parameters

Iraqi Postgratuate Medical Journal, 2019, Volume 18, Issue 4, Pages 356-362

ABSTRACT:
BACKGROUND:
Laparoscopic cholecystectomy has now replaced open cholecystectomy for the treatment of gallbladder pathologies (stones, polyps) , However, Laparoscopic cholecystectomy may be considered ‘difficult’ by various problems encountered during surgery, such as difficulties in accessing the peritoneal cavity, creating a pneumoperitoneum, dissecting the calot’s triangle, extracting the gall bladder from the liver bed, or the excised gall bladder removal from the port.
OBJECTIVE:
This study was cond ucted to identify and evaluate whether preoperative clinical parameters in patient undergoing laparoscopic cholecystectomy for cholelithiasis can predict the levels of intra- operative difficulties.
PATIENTS AND METHODS:
100 patients who underwent laparoscopic cholecystectomy. All the patients were with symptomatic gallstone disease. Detailed clinical history, examination and Investigations were taken. Prospective analyses of different preoperative (patient-related) clinical parameters contributing to difficult laparoscopic cholecystectomy were performed. The study was performed in Al-Imamain Al-Kadhimain Medical City between October 2015 to October 2016.
RESULTS:
OF 100 patients with laparoscopic cholecystectomy, 33 patients (33%) developed difficulties during operation. Factors associating difficult laparoscopic cholecystectomy included; male gender, wall thickness more than 4 mm, previous upper abdominal surgery and BMI more than 35 and the most common (specific) type of intraoperative difficulties was bile leak due to gall bladder perforation and liver bed affecting 10 patients out of the 33 difficult cases (10%) from the total cases and the least difficulty was conversion to open cholecystectomy occurred in 2 patients (2%).
CONCLUSION:
The prediction of difficult laparoscopic cholecystectomy by the use of clinical parameters showed that male gender, wall thickness above 4mm, and history of previous upper abdominal surgery are statistically significant predictive factors.
Knowledge of these predictive factors preoperatively may help in improving patient safety with
involvement of experienced laparoscopic surgeon who could better anticipate intraoperative risk & technical difficulty encountered while operating on these patients.
KEYWORDS: prediction, difficult laparoscopic cholecystectomy, clinical parameters

An Observational Case Control Study of Nailfold Capillary Dermoscopy in a Sample of Iraqi Patients with Connective Tissue Diseases: A Single Center Study

Iraqi Postgratuate Medical Journal, 2019, Volume 18, Issue 4, Pages 363-369

ABSTRACT:

BACKGROUND:
Connective tissue diseases show certain characteristic morphological changes in their nailfold capillaries. Studies are limited on nailfold capilloroscopic findings using dermoscopy.
OBJECTIVE:
To describe nailfold capillary findings and patterns in patients with connective tissue diseases using dermoscopy.
PAT IENTS AND METHODS:
Demographic variables, nailfold capillary findings and patterns were examined and described using a handheld dermoscope in 40 healthy control subjects and 85 patients with connective tissue diseases including 37 scleroderma patients, 36 systemic lupus erythematosus and 12 dermatomyositis patients.
RESULTS:
Capillary disorganization, giant capillaries, capillary hemorrhage, avascular areas and ramified capillaries were significantly higher in patients than control subjects (p<0.001). Giant capillaries, hemorrhages, avascular areas, disorganized and ramified capillaries were observed significantly more in scleroderma and dermatomyositis patients than systemic lupus erythematosus patients, but no single finding differentiated scleroderma from dermatomyositis. The presence of tortuous capillaries was significantly more in systemic lupus erythematosus patients than scleroderma and dermatomyositis (p<0.001). The scleroderma-dermatomyositis pattern is observed significantly higher in patients than controls (p<0.001). The scleroderma-dermatomyositis pattern was seen significantly more in dermatomyositis and scleroderma than in patients with systemic lupus (100% and 86.5% respectively vs. 11.1%, p<0.001). The normal pattern was significantly more seen in systemic lupus than scleroderma and dermatomyosits (66.7% vs 5.4% and 0% respectively, p<0.001).
CONCLUSION:
The dermoscope is a very useful tool in detecting scleroderma- dermatomyositis pattern, allowing a confident differentiation among normal subjects and those with underlying connective tissue diseases. The scleroderma-dermatomyositis pattern is seen in scleroderma as well as in dermatomyositis but to a much lesser extent in systemic lupus erythematosus patients. Detecting a normal pattern in a patient with underlying connective tissue disease is more likely to be seen in systemic lupus erythematosus patients rather than other diagnoses.
KEYWORDS Nailfold capillaroscopy, connective tissue diseases, Raynaud’s, scleroderma, dermatomyositis, and systemic lupus erythematosus.