Annals of the College of Medicine Mosul

ABSTRACT
Background: Depression continues to be a major cause of morbidity and mortality. Depression is a common debilitating illness that can happen to anyone, at any age, and to people of any race or ethnic group. Females are more vulnerable than males; one out of four women may have depression sometime during their lifetime. Despite the wide range of people who suffer from this serious disorder and the associated high risk of death from suicide, only 20 percent are currently receiving treatment. Moreover, it is well recognized that depression greatly contributes to fatality associated with heart disease. The 1990 Global Burden of Disease Study ranked depression as the fourth leading disease burden worldwide as measured by life-years lost to disability, and it is projected to be ranked as the second leading disease burden by the year 2020. In light of these statistics, there is a clear need to address the impact of this condition and to develop new methods to adequately diagnose and treat those who suffer.
Objective: The objective of this paper is to highlight recent developments regarding treatment and care of the depressed patient.
Method: A review of recent literature on the neurobiology of depressive disorder, and its reflection on the care and treatment of the depressed patient formed the matrix for this paper.
Neurobiology of depression: Evidence from neuroscience, genetics, and clinical investigation demonstrate that depression is a disorder of the brain. Modern brain imaging technologies are revealing that in depression, neural circuits responsible for the regulation of moods, thinking, sleep, appetite, and behavior fail to function properly, and that critical neurotransmitters are perhaps out of balance. Genetics research indicates that vulnerability to depression results from the influence of multiple genes acting together with environmental factors. Studies of brain chemistry and of mechanisms of action of antidepressant medications continue to inform the development of new and better medical and psychotherapy treatments. STAR*D, a large study funded by the National Institutes for Mental Health, found that less than half of patients got completely well after a single antidepressant was taken, and although more patients got well once they were switched to another medicine, the proportion of those who got better decreased each time a person had to switch to another medication.
Treatment of depression: Recent advances in treatment have occurred for patients with mood disorders, these include: pharmacotherapy, combined psychotherapy pharmacotherapy, and novel physical therapies. The focus of new drug development reflects a shift from serotonin specificity to combine or specific noradrenergic activity. The efficacy of sequencing cognitive therapy after anti-depressant treatment in patients who were partially remitted was examined recently by Paykel and colleagues. The cumulative relapse rate was reduced significantly from 47% in the clinical management control group to 29% in the group that received 16 sessions of cognitive therapy.
Conclusion: Improved recognition, treatment, and prevention of depression are critical public health priorities. The administration of combination of treatment interventions and dual reuptake inhibitors are likely to ensure early response and prevention of relapse. Recovery of function ought to be the target of any treatment plan.

ABSTRACT
Background: Hypomagnesaemia is a common electrolyte abnormality in critically ill patients. A lot of controversy exists regarding the optimum method of measuring magnesium and the influence of hypomagnesaemia on the morbidity and mortality of these patients.
Objectives: To study the prevalence of hypomagnesaemia (measured in serum and RBCs) in critically ill patients and its impact on morbidity and mortality.
Patients and methods: Sixty five (65) critically ill patients were studied. Their total serum and erythrocyte Mg (representing intracellular Mg) were measured within 24 hours of intensive care unit (ICU) admission. The patients were followed throughout their ICU stay and assessed regarding the severity of their illness using acute physiology and chronic health evaluation II (APACHE II) score, duration of stay in the ICU and mortality rate.
Results: Serum hypomagnesaemia was present in 84.6% of patients. Only 36.9% of patients were having low erythrocyte Mg. There was a weak positive correlation between serum and erythrocytes Mg levels.
No patient with normal serum Mg died, compared with 22.2% mortality rate in patients with low serum Mg (p=0.000). No significant difference in the mortality rate was noticed between patients with normal and low erythrocyte Mg. Neither low serum nor erythrocyte Mg had been associated with more severe illness or prolonged ICU stay.
Conclusion: Hypomagnesaemia (measured as total serum Mg) is associated with excess ICU mortality, irrespective of the severity of the underlying illness. Intracellular Mg (measured as erythrocyte Mg) does not correlate with ICU morbidity and mortality, and its routine measurement may not be indicated

ABSTRACT
Objectives: This article focuses on unstable angina and non ST segment elevation myocardial infarction. The objectives are to clarify different ECG pattern, to correlate it with troponin results, and to evaluate the effects of risk factors.
Methods: Seventy patients with clinical diagnosis of acute coronary syndrome were collected from coronary care unit in Ibn Sina Teaching Hospital in Mosul, 20 patients with ST segment elevation were excluded, and ECG changes were evaluated. Forty five patients had troponin I test, and the results were compared to their ECG changes. The risk factors and their numbers were studied. Data statistically analyzed using Z- 2 proportion and Chi-square tests.
Results: Fifty patients with a mean age 57 year (SD 13.2), including 26 males and 24 females, show (in order of frequency): ST depression (44%), non-specific ECG (24%), T wave inversion (22%), and BBB (10%). Fifteen (33%) had positive troponin test, most of them were males (80%), showed significant association with T wave inversion (p value= 0.05). Specific ECG changes were associated with male gender, diabetes mellitus, hypertension, and old age (p value<0.03). Troponin positivity was associated with male sex (p value=0.003). Male gender and smoking were associated with positive troponin in significant ECG group (p value<0.04). All patients with positive troponin had at least two risk factors (p value=0.002).
Conclusion: ST segment depression was the most common ECG changes in non ST elevation acute coronary syndrome, but T wave inversion was more significantly associated with troponin positivity, which differs from previous studies. Male gender was the most critical risk factor; this was consistent with previous studies. Number of risk factor has important effect on ECG and troponin results.

ABSTRACT
Objectives: This study is performed to evaluate the immune-expression of human papillomavirus (HPV) in a series of 100 samples of squamous cell carcinoma (SCC) from different sites of the body and to correlate it with anatomical site and grade of the tumor, age and sex of the patients, grade of tumor and to compare our results with those of other studies.
Patients and methods: There were 100 patients with primary SCC from larynx, cervix, oral cavity and skin. Samples were obtained in a pro and retrospective fashion from teaching hospitals and private laboratories in Mosul. During a period of seven months from July 2009 through January 2010. Immunoexpression assay was performed using immunohistochemically (IHC).
Results: The patients' age ranged between 15 and 90 years, with a mean of 51.28 year. There were 62 males and 38 females. Only nine of the hundred cases were positive for HPV, 3 out of 45 cases of laryngeal SCC were positive (6.67%) and 22 of oral cavity SCC cases were positive (27.27%). All of the 23 cervical and the 10 skin cases were negative for HPV. HPV expression was significantly correlated with the primary anatomical site but not with the age and sex of the patients in laryngeal and oral cavity SCC.
Conclusions: 1.) HPV was expressed in nine out of 100 cases of SCC, adopting immunohistochemistry (IHC) for its detection, six of the cases were in the oral cavity and three were in the larynx with none from cervix or skin. 2.) In the positive cases the only significant correlations were with the anatomical site and in relation to grade in the larynx. 3.) Our results are low when compared to more sensitive methods for HPV detection like Polymerase Chain Reaction (PCR), Southern Blot Hybridization (SBH) and In Situ Hybridization (ISH); however this may also be attributed to the relatively small number of cases and to the possibility that our cases of SCC are not HPV related

ABSTRACT
Objective: To compare the efficacy of double-surface intensive phototherapy (DSIPT) and single-surface conventional phototherapy (SSCPT) in treatment of neonatal jaundice.
Patients and methods: This is a case control study conducted in Ibn Al Atheer Pediatric Hospital (Mosul) included 110 jaundiced neonates subjected to the newly used (DSIPT) during the period between 1st of Jan. 2011 to 30th of June 2011 compared to142 jaundiced neonates underwent phototherapy using SSCPT during the period between1st of July 2010 to 31st of December 2010. Patients with acute bilirubin encephalopathy, sepsis, meningitis and asphyxia were excluded from this study as well as those aged > 1 week. The medical files data of included infants were analyzed regarding their gestational age, body weight, sex, age, type of feeding and total serum bilirubin level (TSB) at initiation of phototherapy. Levels of TSB at intervals of approximately 6 hours during the first 24 hours of treatment, the need of exchange transfusion and duration of hospitalization were registered.
Results: Demographic characteristics apart from gestational age were similar in both groups. The initial mean serum bilirubin level had no statistically significant difference between DSIPT and the SSCPT group. DSIPT group had significantly greater TSB decline rates than SSCPT in term and preterm infants with hyperbilirubinemia. The mean percentages of TSB decline per hour was significantly higher within 6, 12, and 24 hours after starting DSIPT compared to SSCPT type. The mean percentages of TSB decline of DSIPT group within the second 12 hours after phototherapy was significantly higher and more than double the value of SSCPT type (43.45 ± 14.83 vs. 17.03 ± 14.22, p<0.001). Duration of hospitalization was significantly shorter in DSIPT subjected infants. At initial TSB level between 20- 25 mg/dl exchange transfusion was avoidable among intensively treated patients whereas it was inevitable in 86.36 % of patients in the SSCPT group. At TSB on exchange line 91.56% of infants received SSCPT type required an exchange transfusion whereas such intervention was eliminated in patients treated by DSIPT.
Conclusions: DSIPT was significantly more effective than SSCPT in treatment of neonatal hyperbilirubinemia. When initial TSB level is on and below exchange line on nomogram, exchange transfusion can be avoided with the use of DSIPT.

ABSTRACT
Context: High levels of noise in hospitals may interfere with patient care services, the doctor-patient relationship and medical education activities.
Aim: To measure the noise level and to determine the time-place patterns at Mosul Medical City Center Teaching Hospitals.
Materials and methods: Sound levels of different places inside the stated hospitals were recorded, using a Digital Sound Level Meter. A total of 80 readings were taken at different locations of hospitals. The time for each measurement was 5 minutes, repeated for three times in each location, and then the average reading was recorded. Three noise parameters were recorded in every measurement (in dBA): equivalent noise level (Leq), maximum noise level (L max) and minimum noise level (L min). Neither the staff nor the patients in the four institutions were aware of the recordings.
Indoor noise levels on weekdays (Saturday through Thursday) were compared to noise levels on weekends (Friday). Outdoor noise levels were measured near each hospital facet, too. Time-patterns of noise pollution were established by recordings at 08:00 a.m., 09:00 a.m., 11:00 a.m., and 02:00 p.m.
Results: The mean equivalent sound level was 93.44 ± 6.55 dBA, including hospitals facet. The maximum equivalent sound level was observed in the casualty department (97.80 ± 2.91 dBA) and the minimum equivalent sound level was in Ibn-Sena General Teaching Hospital (89.16 ± 6.83 dBA) (p = 0.001). During morning hours, the mean equivalent noise level (94.35 dBA) was higher than the afternoon level (90.14 dBA) (p=0.037). The mean equivalent noise levels were higher on the weekdays (94.05 dBA) than on the weekend (88.57 dBA) (p = 0.002).
Conclusion: The noise pollution in Mosul Medical City center greatly exceeded the WHO guideline level for hospitals. This study highlights the need for noise monitoring and control measures inside hospital areas.

ABSTRACT
Objectives: The aim of this study is to assess knowledge and attitudes of family physicians in Mosul city toward evidence-based medicine and to describe the major barriers to practicing evidence based medicine.
Method: A cross sectional questionnaire based survey has been adopted for this study. For the period between the 1st of June and 31st of August 2012; a self-administered questionnaire had been distributed to all 71 family physicians registered in Nineveh Health Directorate and practicing in primary health centers in Mosul city. The main outcome measures were: participants‟ attitudes toward evidence –based medicine (EBM), their knowledge about the important technical terms used in EBM and their perception of barriers to EBM practice.
Results: Sixty one family physicians participated in this study, 24 (39.3%) were males and 37 (60.7%) were females. The response rate was 85.9%. The mean age of the participants was 36.15 years. Most of the respondents had positive attitudes toward EBM: 54.1% showed welcoming attitudes towards EBM; 44.3% showed strongly welcoming attitudes towards EBM; 65.6% believed that most of their clinical practice was evidence based; 90% agreed with the concept of practicing EBM improves patients care. The participants showed deficient knowledge regarding the technical terms commonly used in EBM. Patients overload and lack of personal time were the major perceived barriers to practicing EBM (78.7% and 65.6%) respectively.
Conclusion: Although this research revealed high support among family physicians in Mosul for the practice of EBM, they showed a deficiency in knowledge about EBM.

ABSTRACT
Objective: To find the most accurate measurements for the nasolabial dimensions prediction utilizing the three dimensional technology.
Design: Cross-sectional study.
Setting: School of Dental Sciences, Universiti Sains Malaysia, Kelantan, Malaysia.
Participants: This study was conducted on 101 volunteers (16-30 years). The participants had harmonious balanced face, competent lips and no craniofacial abnormalities. Data were captured using stereophotogra- mmetry system which consists of Sony digital cameras, synchronize switch and a calibration control frame.
Main outcome measures: Eighteen facial, seven nasal and 11 labial dimensions were measured and analyzed. The stepwise multiple regression analysis was applied and the level of significance was established at p<0.05.
Results: The measurements of the combination of nasolabial dimensions were developed. The prediction rates were 90% and 96% and for the upper lip height, nose height respectively. However, the low prediction rate was recorded for the lower vermilion and lateral lip heights 17% each.
Conclusions: New measurements for nasolabial dimensions prediction with application of three dimensional imaging technology were offered. This study could provide reliable and objective reference material for plastic surgeons for the planning of the cosmetic nasal surgery. Moreover, these information could be beneficial in the post-surgical prosthesis construction

ABSTRACT
Background: Ovarian tumors are the second most common gynecological malignancy and the fourth most common cancer death in women, which is characterized by few or late symptoms, often called the silent killer. Early detection of ovarian carcinoma could be a formidable challenge and an elusive task.
Objectives: To Study sonographic features of benign and malignant ovarian cysts, to find the incidence of benign and malignant ovarian tumours and to determine the accuracy of ultrasound in differentiating benign from malignant ovarian cysts comparing with histopathology results.
Patients and methods: This was a cross sectional study. Convenient sample taken from a population consists of 65 women in reproductive age, scheduled for surgery because of ovarian cysts. They underwent preoperative ultrasound examination, done in the Radiology Department of Maternity and Rizgari Teaching Hospitals, Erbil city, North of Iraq. The mean patient age was 30.25 years ranging from 14-46 years.
Results: Out of 65 cases, 60 (92.3%) were benign, and 5 cases (7.7%) were malignant. Using sonographic morphological scoring, scores equal or more than 3 was regarded as malignant (the scoring system included wall thickness, shadowing, septa and echogenicity). The accuracy, sensitivity and specificity of ultrasound were 91%, 100% and 90% respectively.
Conclusion: Gray scale and Doppler ultrasound yield high diagnostic accuracy in discrimination between benign and malignant cysts. Benign cysts are more common than malignant cysts in female at reproductive age. Mature cystic teratoma (dermoid) is the commonest type of ovarian tumors. Cysts more than 10 cm in maximum diameter, multilocular cysts are more likely to be malignant. The presence of ascites also favors malignancy.

ABSTRACT
Objective: To evaluate the validity of clinical examination of the axilla for detection or exclusion of presence of lymph nodes and performing clinical staging, in patients with breast carcinoma, in comparison with histopathological evaluation and staging
Patients and methods: A case series study included ninety patients with breast carcinoma, done at Aljamhori Teaching Hospital in Mosul, during the period from January 2010 to June 2011. The diagnosis of breast cancer was confirmed by FNA and or excisional biopsy. The size of the tumors was measured and (T) stage was performed. The clinical evaluation of the axilla included: the presence or absence of axillary lymph nodes, the size, number, level and fixation of lymph nodes were assessed when positive; the clinical (cN) staging was recorded. All the patients underwent modified radical mastectomy with axillary clearance. The breast and axillae specimens were subjected to histopathological evaluation which included: the presence or absence of axillary lymph nodes, the size, number, level and fixation of lymph nodes were assessed when positive, the histopathological (hN) staging was recorded, which is regarded as the gold standard. The state of axillary lymph node (N), the size of the tumor (T) in relation of clinical to histopathological stages were evaluated and compared by using validity indicators, which includes the sensitivity, specificity, positive and negative predictive values and accuracy. P value was estimated using 2-way Contingency Table Analysis, with 95% Conf. Interval.
Results: The study included 90 patients with breast carcinoma, the clinical evaluation revealed 20 patients (22%) with T1, 45 (50%) T2, 18 (20%) T3 and 7 (8%) T4. Sixty one (67.7%) patients had negative axillary lymph node (N0) on physical examination, those with positive lymph nodes were 19 (21%) patient with (N1), 7 (7.7%) patients with (N2) and 3 (3.3%) patients with (N3), while the histopathological evaluation showed that 35 (39%) patients had (N0), those with positive lymph nodes were 30 (33.3%) patient with (N1), 20 (22.2%) patients with (N2) and 5 (5.5%) patients with (N3). The sensitivity, specificity and accuracy of axillary lymph node examination were 40%, 70% and 57% respectively, the P value was 0.064.
Conclusion: Clinical staging of axillary lymph node is neither sensitive nor specific, with low accuracy rate and it shouldn't be relied on for final staging in patient with breast malignancy.

ABSTRACT
Objective: To assess the feasibility and effectiveness of percutaneous needle aspiration under local anesthesia for the treatment of acute breast abscesses in the outpatient breast clinic.
Design: A retrospective study of forty three female patients with acute breast abscesses.
Setting: Breast clinic in Al Jamhoory teaching hospital in Mosul between February 2004 to February 2007.
Methods: Forty three patients with acute breast abscesses were studied. Special enquiries were made regarding lactation, symptomatology and sites of abscesses. All patients had preliminary breast ultrasound (U/S) examination. In the breast clinic, percutaneous needle aspiration of pus under local anesthesia was done followed by systemic antibiotic therapy. Repeated aspiration was carried out later when deemed necessary and follow up by (U/S) was conducted.
Results: Forty three patients aged between 16-75 years (mean 37 years) having a provisional diagnosis of acute breast abscesses. All patients presented with a palpable tender mass, of which 4 patients had retro-areolar abscesses. All patients had (U/S) of breast. Five patients were found on breast U/S to have inflammation without evidence of focal pus and they only required antibiotics. Four patients refused aspiration and underwent primary incision and drainage under general anesthesia (GA), while in two patients the abscesses were pointing and opened spontaneously before intervention, and they settled with wound toilet and antibiotics alone.
The remaining thirty two patients had their abscesses aspirated, and the treatment was successful in twenty nine patients (91%) with no complications or recurrence. The treatment failed in three patients who required subsequent incision and drainage.
Conclusions: Percutaneous needle aspiration of acute small unilocular breast abscesses after prior breast (U/S) followed by systemic broad spectrum antibiotics is successful, when the abscesses are completely drained. The use of this modality of the treatment has still not found wide application in our locality. This study is an attempt to recommend its use wherever facilities exist for its feasibility, low cost, no interruption with lactation and better cosmesis, though incision and drainage still may be necessary for definitive treatment for large or multilocular abscesses.

ABSTRACT
Objective: The purpose of this study is to compare ureteroscopy using pneumatic lithotripsy with open surgery (ureterolithotomy) in treating ureteric stones regarding the success rate, procedures time, need for post-operative analgesia, duration of hospital stay, and complications rate.
Patients and methods: A prospective study of 90 patients suffering from ureteric stones, referred to the urology center at Al- Jumhori Teaching Hospital in Mosul city between 1st of May 2010 – 31st of March 2011. Fifty patients were treated by ureteroscopy and 40 patients by ureterolithotomy. Their age and sex distribution was comparable. Results of both treatment modalities were analyzed and compared.
Results: The success rate for ureteroscopy was 90% and for ureterolithotomy was 97.5%. The procedure time was significantly shorter for ureteroscopy patients (21 minute versus 67 minute). Mean post-operative analgesia was much less for ureteroscopy (1.1 versus 9.5 analgesic injections). Ninety two percent of ureteroscopy patients were discharged at same day of operation with mean hospital stay of 1.12 days compared to 3.5 days for ureterolithotomy group. Complications were reported in 8% in ureteroscopy and 5% in ureterolithotomy group.
Conclusion: The success rate of ureteroscopic procedures using pneumatic lithotripsy is comparable to that of ureterolithotomy, but with significantly shorter procedure time, less need for post-operative analgesia, shorter hospital stay, and with no significant increase in the complications rate. These results mean early return to social life and activities, and make ureteroscopy a preferable option for treating ureteric stone when facilities and surgical skills are available.

ABSTRACT
Objectives: The aim of the present study is to evaluate the efficacy of septoplasty in relieving symptoms and problems attributed to septal deviation including: nasal obstruction, recurrent sinusitis, recurrent /or chronic pharyngitis, epistaxis and snoring.
Methods: This case series included eighty four patients with septal deviation severe enough to necessitate surgical intervention (severe nasal obstruction not relieved by medical treatment). The study was carried out at Al-Jumhori Teaching Hospital from July 2009 to Oct. 2010. All patients were suffering from nasal obstruction. Twenty seven patients had recurrent sinusitis, seven recurrent or chronic pharyngitis, five recurrent epistaxis, and snoring was found in four patients. The mean follow-up was six months with a range of 3-15 months.
Results: The mean age of our patients was 27.3 years with a range of 15-52 years. The study included 52 males (61.9%) and 32 females (38.1%) with a ratio of 1.62:1. Sixty eight patients (80.9%) reported good improvement in their nasal obstruction after surgery. Improvement in recurrent sinusitis, chronic pharyngitis, epistaxis and snoring was 55.5%, 28.5%, 80% and 25% respectively.
Conclusion: We conclude that septoplasty is indicated mainly to relieve nasal obstruction resulting from moderate to severe nasal septal deviation. Other conditions which are commonly attributed to septal deviation including recurrent sinusitis, chronic pharyngitis, epistaxis and snoring are not necessarily cured by this surgery.

ABSTRACT
Background: Humans have three different types of hair. Hair growth is a complex process that requires a rich supply of oxygen and nutrients provided by the capillaries that supply the active base of the hair.
Objective: To present abnormal growth of hair post prolong immobilization with plaster of Paris.
Material and methods: This report is a case series study carried out in Mosul teaching hospital, during the period between (30 Jan 1999 - 30 Sep 2011). The total number of patients treated for developmental dysplasia of the hip (DDH) were 213 patients treated by open reduction), immobilized by plaster of Paris for a period (8 - 16 weeks). Age ranged between (12-48 months) with mean (24.6 months). Females were 164 (77%) and 49 (23%) were males.
Results: Patients followed post operatively, abnormal hair growth at the lower limbs was noticed, and hair changes were disappeared completely within 4-6 months.
Conclusion: Hypertrichosis is transient, physicians should be aware of its benign nature as it relates to cast immobilization

ABSTRACT
Background: Osteoarthritis of knee is a common cause of pain and disability. It is becoming increasingly prevalent worldwide due to its association with an aging and obesity.
Objective: The aim of this study was to examine the associations between body mass index, gender, Islamic praying, praying in sitting position, usage of stairs, history of traumas, diabetes, hypertension, and hypothyroidism as risk factors for knee osteoarthritis in population of Mosul city.
Patients and methods: This study is a case - control design, it was conducted through the period from Jan 2010 - Jan 2011 in the orthopedic outpatient clinic of Aljumhoori Teaching Hospital in Mosul. The target population of this study consisted of 213, 71 cases (61 females, 10 males), their ages mean 51.77 years, and 142 as controls.
Results: The body mass index was higher in cases and shows highly significant difference between cases and control (p ≤ 0.000). Sex distribution in knee osteoarthritis revealed that there was significant difference between females and males as cases of osteoarthritis, (P ≤ 0.0001). Normal Islamic praying, Praying in sitting position, usage of stairs, appeared to be an associated risk factors, history of trauma was significantly higher in cases, while diabetes, hypertension, and hypothyroidism was not associated with the development of osteoarthritis of the knee.
Conclusion: Females as a gender, obesity, Islamic praying in sitting position and history of trauma to the knee are important risk factors of osteoarthritis of the knee, while diabetes, hypertension and hypothyroidism are not associated with knee osteoarthritis

ABSTRACT
Objective: To evaluate the proper technique used for management of penile torsion in pediatrics in relation to degree of torsion.
Patients and methods: From February 2008 to December 2010, 54 patients were assessed for the degree of penile torsion at pediatric surgery center at Al-Khansaa Teaching Hospital in Mosul. The angle of torsion was assessed using a digital photograph of the penis and classified into three grades, Mild with 15 - 30 degree angle of torsion, moderate with 45-90 degree angle of torsion and sever with 100-170 degree angle of torsion.
Two techniques were used for repairing the torsion, the degloving and skin realignment technique for the mild condition and dorsal dartous flap technique for the moderate and severe types. All operations were done as a day case procedure. No catheter used.
Results: Forty five patients (83%) were discovered accidentally while assessing for circumcision or other problems, 30 patients (55%) were in the first year of life, 50 patients (93%) have a counter clock wise direction of torsion (to the left) while only 4 patients (7%) have a clockwise direction (to the right). Thirty five patients (65%) classified as mild torsion, while 16 patients (29.5%) have moderate degree of torsion and only 3 patients (5.5%) severe degree. Degloving and realignment of skin were used for the mild condition in 35 patients (65%) while dorsal dartous flap technique was confined for moderate (29.5%) and both procedures used for severe type patients (5.5%).
Conclusion: Simple realignment technique during circumcision was enough to manage the mild degree, while in severe degree, dorsal dartous flap rotation seems to be more effective. There were no complications, and good cosmetic results were obtained

ABSTRACT
Atypical teratoid/rhabdoid tumor (AT/RTs) is a highly malignant nervous system tumor, occurs primarily in very young children. These tumors are distinctive, malignant neoplasms of uncertain histogenesis. They are thought to be embryonal and are usually composed of varying amounts of rhabdoid cells, small primitive neuroepithelial cells, epithelial tissue and neoplastic mesenchymal components. This is a case of AT/RT in a four years male patient who presented to the department of neurosurgery at Ibn-Sena Teaching Hospital, complaining of headache, nausea and vomiting for the last two months, progressed to visual disturbance and limbs weakness. Computerized tomography showed an ill-defined large mixed density posterior fossa tumor associated with hydrocephalus. Urgent ventriculoperitonial shunt followed by craniectomy and excision of the cerebellar tumor were performed. Histologically, according to the complex heterogeneity of cell types and tissue components, tumor was diagnosed as AT/RT and confirmed by immunohistochemical study.