Annals of the College of Medicine Mosul

Objective: to assess the role of clinical manifestations and radiological findings in the early recognition and diagnosis of blunt diaphragmatic rupture, with determination of the operative findings during surgical intervention.
Design: a prospective case series study.
Setting: Al-Jamhori Teaching Hospital in Mosul, during the period July 1999-June 2004.
Participants: thirty three (33) patients with blunt traumatic rupture of the diaphragm proved by surgery.
Results: three quarters of the blunt diaphragmatic rupture were caused by motor vehicle accidents, 91% of the patients had respiratory embarrassment. Only 27.2% of the patients were diagnosed by chest x-ray, the remaining 72.8% were discovered during laparotomy. The left dome of the diaphragm was ruptured in 75.8%, whereas herniation of the abdominal viscera into the chest was found in 45.8%. Concomitant intra-abdominal injury was found in 84.8% of the patients. The mortality is sharply increased when the right dome of the diaphragm is ruptured.
Conclusion: the clinical features may be masked by other chest or abdominal injuries. Chest-x ray is a reliable test to diagnose diaphragmatic rupture. The left hemi-diaphragm is more commonly injured; in addition concomitant intra- abdominal injuries are very common. A meticulous inspection of the diaphragm should be undertaken during all exploratory laparotomies for trauma.

The biological calcium hydroxyapatite was isolated and purified from local cow bones in laboratories of the University of Mosul. The chemical analysis of the product shows that the purity of the biological calcium hydroxyapatite is 99%. The biological calcium hydroxyapatite was prepared locally as bone graft substitute from cheap unlimited resource. The biological calcium hydroxyapatite was implanted around induced fracture of forearm in 4 white male rabbits. The forearm fracture united thirty days after the experiment. The biological calcium hydroxyapatite was implanted inside the medullary cavity of the femur and around fracture ends in another 4 male white rabbits. The implanted biological calcium hydroxyapatite was replaced by callus around the bone and in medullary cavity of bone without any chronic inflammatory changes or foreign body reaction. We conclude that biological calcium hydroxyapatite can be used as bone graft substitute.

Objective: ureteric injuries may be missed and present as a complication.
Design: A case series study.
Setting: Retrospective study conducted during the period from January 1998 to March 2002 in the urosurgical departments at Al-Jumhoori and Al- Salaam teaching hospitals, Mosul.
Participants: Ten cases of missed ureteric injuries were consulted for or referred to the urosurgical departments, during or after their initial surgical procedures either from the general surgical or gynecological departments.
Results: There were (6) males and (4) females; mean age was (25 years). Eighty percent of cases diagnosed post operatively. They were missed for variable duration from 24 hours to 2 months. Complications like urinary fistula, loin abscess, fever or loin pain were diagnosed. Two cases were diagnosed and managed intra operatively. The cause of injury was bullets in (50%) of cases, gynecological operations in (30%) and RTA in (20%). Lower parts of the ureter was involved more frequently (60%) specially in pelvic surgery, while the whole ureter was involved by missiles. Both sides were equally implicated. Missed or improperly treated ureteric injury carries high morbidity like hospital stay, re-exploration (70%) and loosing renal unit function. Uretero- common iliac artery fistula is a rare but serious complication reported in one of the cases.
Conclusion: Sound knowledge of pelvic anatomy, preoperative ureteric stenting, isolated uterine artery ligation, keeping the ureteric injury in mind and deliberate ureteric identification during shell injuries decrease the chance of missed ones and their sequelae.

Objective: To assess whether there is an increase in prevalence of gastro-esophageal reflux disease (GERD) in patients with chronic obstructive pulmonary disease (COPD), and the influence of reflux on the respiratory symptoms of these patients. Methods: A case control study that was conducted at the outpatient clinic of Ibn Sina Teaching Hospital in Mosul, and two private clinics, during the years 2002-2003. Sixty six patients with COPD and 50 sex- and age- matched controls were questioned about experiencing GERD symptoms, utilizing a modified questionnaire originally developed by Mayo clinic. COPD patients were asked whether they noticed an association between experiencing reflux episodes and worsening respiratory symptoms, and whether smoking a cigarette is associated with GERD symptoms. Results: COPD patients showed a significantly increased prevalence of GERD symptoms as compared with the control group (29(43.9%)vs. 11(22%), respectively), (p=0.014). COPD patients more frequently reported significant heartburn (43.9%vs. 20%; p=0.007), and regurgitation (25.8%vs. 6%; p=0.005).COPD patients who were still smoking were not statistically significant from those who have stopped smoking regarding experiencing GERD symptoms (46.7%vs. 30.8%; p=0.08). Fifty one percent (51.7%) of COPD patients noticed that their respiratory symptoms are worsened during episodes of heartburn or regurgitation. Conclusion: GER symptoms are more prevalent in patients with COPD, compared to control subjects.Keywords: COPD, gastro-oesophagael reflux disease.

Objective: (a) To describe the demographic characteristics of malignant gestational trophoblasic disease (GTD) in Mosul. (b) To evaluate the classification system that stratifies the treatment of the malignant GTD. (c) To know the incidence of malignant changes of mole to malignant GTD.
Design: retrospective clinical case series study done over a period of 5 years.
Setting: Al-Batool Maternity Teaching Hospital and Ibn Seena Teaching Hospital.
Participants: The records of a series of 17 consecutively treated patients who had been diagnosed to have malignant GTD were reviewed. The records of these 17 patients were studied for their age, parity, and mode of presentation. All patients underwent staging studies which included chest x-ray and abdominal ultrasound and were classified as good prognosis group 8 patients (47%) and poor prognosis group 9 patients (53%).
Intervention(s): The good prognosis group was treated with courses of intramuscular methotrexate (50 mg on alternative days 1,3,5,7) with folinic acid rescue (7.5 mg orally on alternative days 2,4,6,8) .The poor prognosis group was treated with methotrexate (10 mg/m2 /day) intravenously (iv), dactinomycin (0.3 mg/m2 /day) iv, and cyclophosphamide (110 mg/m2 /day) iv, for three-day course. Both courses were repeated according to patients’ response.
Results: The mean age incidence of malignant GTD was 37.2 years; the mean parity was 4.6, equally presented from rural and urban areas. The presenting symptom of malignant GTD was vaginal bleeding in 47%, cough and shortness of breath in 41.1%, cough and hemoptysis in11.7%. The blood group was O+ve in 64.7%, A+ve in 17.5%, B+ve in 11.7% and AB+ve in 5.9%. The antecedent pregnancy for malignant GTD was complete mole in 88.2 % (the entire good prognosis group), term pregnancy in 5.9% and abortion in 5.9% (both of them in the poor prognosis group). The mean duration between the antecedent pregnancy and treatment of malignant GTD was 5.7 months. Complete response rate without recurrence was 75% for the good prognosis group and 44.4% for the poor prognosis group. The mortality rate was 0% for the good prognosis group and 33.3% for the poor prognosis group giving an overall cure rate of 58.8%. Hysterectomy was needed in 2 patients (22.2%) of the poor prognosis group. The ratio of changes from complete mole to malignant GTD was about one to nine.
Conclusion: Malignant GTD usually complicated complete mole and presented as poor prognosis type in nearly half of the patients. Classification into good and poor prognosis groups is a successful way for treatment selection.

Objective: To evaluate the effectiveness of amniotic membrane as a biological dressing in the healing, relieving of pain, decreasing the possibility of infection and decreasing the discoloration and hypertrophic scars of split-thickness skin graft (SSG) donor sites.
Design: Case-control prospective study.
Setting: Burns and plastic unit (BPU), Al-Jumhoori teaching hospital , during the period from Sept.2002 to April 2004.
Participants: Sixty donor sites in 40 patients, in whom we used the thigh as a donor site for SSG, were studied.
Results: The study revealed that the time required for complete healing is less in amniotic membrane-treated group (group 1) than in traditionally-treated group (group 2). There was also less pain, less infection and more color match in group 1 than in group 2.
Conclusion: Amniotic membrane is a good and beneficial biological dressing. It hastens wound healing, protects donor sites from infection and reduces its pain.

Background: Scabies is a contagious disease. It can be easily misdiagnosed with many other dermatological conditions.
Objective: This study was designed to evaluate some laboratory methods, (e.g. IgE,NBT) which might be useful in confirming the diagnosis of scabies, and to follow up the response of the patients after treatment.
Patients and method: This study was conducted on 103 patients from Al- Zenjelli Custody (jail) in Mosul City (Iraq) over a period of 6 months (Oct. 2001 to April 2002). Blood samples from 103 scabietic patients and 40 control subjects were analysed by using various tests including total white blood cell count, eosinophil count and nitroblue tetrazolium (NBT) positive neutrophils count. Plasma total IgE levels were measured for only 70 patients and 20 control subjects by using Enzyme Linked Immunosorbent Assay (ELISA).
Results: Plasma total IgE level showed a significant raise in patients with scabies in comparison to control group. (p< 0.05)The NBT test revealed a significant raise in both treated and non-treated subjects in comparison to control group. (p<0.05) Also, the untreated patients showed a higher NBT positive neutrophils than the treated ones. Eosinophil counts were higher in patients with scabies than the control subjects in the first few postinfection days. (p<0.001) Total white blood cell counts revealed no significant variation between patients and control groups.
Conclusion: The results indicate that nitroblue tetrazolium (NBT) test was the best in comparison to other tests. It was used to study the role of phagocytosis in scabies. Its increase reflected an efficient innate immunity. This test might explain to us some immunopathological aspects of this disease and its symptoms which might help in diagnosis and follow up of patients with scabies.

Objective: To evaluate the clinico-pathological spectrum and treatment of chronic testicular pain patients. Methods: A prospective and descriptive case series study, conducted at the out-patient clinic of the department of urology at Al Jumhoury teaching hospital in Mosul, between Jan2000 and Dec 2005. The parameters analyzed include; character of the pain, onset, and duration, patient’s age, occupation, past surgical and medical history, the clinical examination, the investigations and treatment. Results: Forty five patients were studied, their age ranged from (16 – 68) years, twenty (44%) patients were under the age of 30 years, ten (22%) patients were between (31 - 45) years, and fifteen (34%) patients were above (46) years of age. The presenting symptom was chronic scrotal pain for more than three months, which is differing in its onset, duration and description. The pain was mainly at the left side, eight (18%) patients had positive clinical findings, 17(38%) patients had positive ultrasonographic pathological findings.The treatment ranged from psychological (reassurance), physical (antibiotic with chronic analgesia) to surgical intervention for those with positive lesion proved by physical examination and investigations. Conclusion: Chronic testicular pain patients remain as dilemma to the general practitioners and frustrating clinical problem for urologists.Key words: Chronic testicular pain, ultrasonography, Varicocele.

Aim: the aim of the study is to clarify the incidental intra scrotal pathological findings during evaluation of infertile males depending on the clinical examination and Doppler ultrasonic scanning. Patients and methods: A prospective case series study conducted in the radiology department of Al Batool teaching hospital from Feb. 2000 – Feb. 2003, where most of the patients referred from the infertility unit of the same hospital and evaluated by Doppler ultrasonographic scanning with (SIEMENS, SONOLINE Versa Pro, 7.5 MHz Linear array transducer) in supine and some times in erect position. Results: The data of 1660 patients analyzed to different pathologies, their ages ranged from (18-60) years with mean of 23 years. One thousand and four hundreds sixty patients (88%) were primarily infertile and two hundreds patients (12%) were secondarily infertile, seven hundreds and sixty six patients (46%) had abnormal findings on clinical and ultrasonic examinations of their genitalia, while nine hundreds and sixteen patients (54%) were normal. The distribution and the frequency of different discovered abnormalities were studied; varicocele was found in (42.7%) of the patients and followed by testicular atrophy in (33.8%).Conclusion: Varicocele and testicular atrophy are the most common causes of primary as well as secondary male infertility and the color Doppler US is superior to physical examination in evaluating patients with infertility.Key words: infertility, testicular atrophy, varicocele, color Doppler ultrasound

Objective: To analyze the intracranial complications following ventriculo-peritoneal (V-P) shunt among patients in our locality.Design: Prospective study utilizing CT scan. Participants: 140 hydrocephalus patients with V-P shunt. Setting: Computed tomography (CT) scanner Unit at Ibn Sina Teaching Hospital over a period between January 2001 and September 2003 in Mosul City .Main results: One hundred forty hydrocephalus patients with V-P shunt covering all age groups were analyzed, 93 cases (66.4%) were males and 47 cases (33.6%)were females. 37 cases (26.4%) showed impaired or malfunctioning shunt due to obstructive causes, 26 cases (18.6%) were suffering from inter ventricular collection/cyst. 20 cases (14.3%) were suffering from chronic subdural heamatomas.Conclusions: Inter ventricular collection/cyst ,and subdural heamatomas were found as frequent complications among our patients. This may be related to unavailability of programmable valves during embargo or their poor quality, together with lack of proper antibiotics and also break down of the CT scanner which led to delay in the diagnosis and follow up in the shunted patients. Key words: CT scan, post VP shunt complications.

Objectives: This study was conducted to assess the effect of carbamazepine (CBZ) and sodium valproate (VPA), as a monotherapy in epileptic patients, on thyroid function tests as assessed by serum total triiodothyronine (TT3), total thyroxine (TT4) and thyroid stimulating hormone(TSH). Subjects and methods: Sixty three epileptic patients using monotherapy were included in the study. These included 44 patients using CBZ and 19 using VPA. A control group of 47 apparently healthy individuals were also included in the study for comparison. Measurement of TSH, TT3 and TT4 was done using Gamma counter.Results: The results of this study revealed that patients on CBZ showed significantly decreased mean level of TT4 in comparison with the control group (P<0.01), while mean TT3 and TSH levels showed statistically insignificant differences from the control group (P>0.05). In the VPA group, mean TT3, TT4 and TSH values showed insignificant differences from the control group (P>0.05).Conclusion: Unlike VPA, CBZ significantly decreases level of TT4 without affecting TT3 and TSH levels. Keywords: Carbamazepine, sodium valproate, thyroid function tests.

Objective: This study was conducted to assess the effect of valsartan and captopril, each as monotherapy in hypertensive patients, on hepatic enzymes activities including alanine aminotransferase (ALT), aspartate aminotransferase (AST) and alkaline phosphatase (ALP).Patients and methods: Thirty nine hypertensive patients were included in the study, 20 of them using captopril and 19 using valsartan. Serum ALT, AST, and ALP activities were measured before and after 2 months of starting treatment.Results: Patients on captopril showed significantly increased mean level of ALT and AST (P<0.001),( although still within normal limits) while mean ALP levels showed no significant difference. In the valsartan group, mean ALT, AST and ALP values showed insignificant differences.Conclusion: In hypertensive patients with liver disease, valsartan may be more suitable than captopril for the potential influence of the latter on serum transaminase levels.Keywords: captopril, valsartan, hepatic enzymes activities.

We report here two unusual cases of a rare tumour “pseudomyxoma peritonei”. 1. Case one: A 55 -year- old female patient, with history of carcinoma of left breast presented with ascites which was proved to be due to pseudomyxoma peritonei rather than to metastases from breast cancer. 2. Case two: An 18 –year- old male patient presented with huge abdominal distention in whom a diagnosis of pseudomyxoma peritonei was confirmed; an unusual age and sex for this rare tumour.