Iraqi Postgraduate Medical Journal

Celiac disease is an immune-mediated enteropathy triggered by the ingestion of gluten in genetically susceptible individuals. Gluten is the major protein component of wheat, rye, and barley, the major predisposing genes are the HLA-DQ2 and DQ8 genotypes found in at least 95% of patients.

BACKGROUND:
The most effective treatment for muscle-invasive bladder cancer and non-muscle invasive bladder cancer with highest risk of progression, is Radical cystectomy and urinary diversion. This operation carries a high risk of complications of multiple types that can affect not only the urinary system but also other systems.
OBJECTIVE:
This study analyzes the early complications (within 30 days) of Radical
Cystectomy and urinary diversion, using a standardized classification system i.e. Clavien-Dindo classification system.
PATIENTS AND METHODS:
This is a combined retrospective and prospective study analyzing the early complications of RC. We review the early (30 days) post-operative period retrospectively for the previous cases and monitor this period, prospectively, for the coming cases at Al-Yarmook teaching hospital in Baghdad, Iraq from October 2017, to October 2019. We record the preoperative variables and postoperative complications in a systematic method using Clavien-Dindo classification system and the relationship between them.
RESULTS:
Twenty three patients are included in the study with a mean age 65.1 year. Urinary diversion types are cutaneous ureterostomy (9 patients) ileal conduit (10 patients) and orthotopic bladder (4patients). Most of the postoperative complications are minor (CD grade I and II) (73.3%).
The predominant grade of complications are grade II (46.4%), while the least grades are grade IVb (3.5%) and grade V (3.5%).
CONCLUSION:
Radical cystectomy and urinary diversion for urinary bladder cancer carries a high risk of complications, but fortunately, most of these complications are minor and of low grade according to Clavien-Dindo classification system. Applying this classification system in the early complications of radical cystectomy allows rapid review of complications by researchers.

Introduction: Diffuse large B-cell lymphoma (DLBCL) constitutes 30%–58% of non-Hodgkin’s lymphomas. Treatment strategies should be stratified according to age, IPI and feasibility of dose-intensified approaches. Six cycles of combination chemotherapy (R-CHOP) is the current standard.
Aim of the study: To assess the response rate and disease free survival in patients with Diffuse Large B- cell Lymphoma treated with standard therapy (R-CHOP).
Patients and methods: An ambidirectional cross-sectional study with data obtained from November 2020 till December 2021 from Baghdad Teaching hospital / Department of Hematology. A total 100 adult patients who were diagnosed with diffuse large B cell lymphoma (DLBCL) and received R-CHOP were enrolled in this study.
Results: All the patients were evaluated using PET/CT or computed tomography scans with contrast (CeCT) post R-CHOP therapy: 53% patients were in complete response, 16% patients were in partial response, 20% patients were in progressive disease, 10% patients became primarily refractory to the therapeutic regimen. There was no significant association (P= 0.887) between the response to treatment and IPI scores. There was no significant association between patients’ response to treatment and the prognostic factors of DLBCLs including age, LDH level, extra-nodal involvement and stage (P= 0.402, 0.281, 0.201, and 0.674 respectively).
Conclusion: The current study showed that R-CHOP treatment has good response rate for patients with DLBCL with 53% of the patients were with complete response rate. Evaluation of patients by using PET/CT or CeCT after R-CHOP treatment showed that IPI score and patients’ prognostic factors of DLBCLs including had no significant effect on achieving response.

Background: Gamma knife radiosurgery, a bloodless surgery used to treat a variety of intracranial pathologies and is regarded as the first line for treating trigeminal neuralgia, since it has the property of minimal invasiveness and risk.
Aim: In this report, we estimate the effect of gamma knife radiosurgery on certain inflammatory markers in patients with TN.

Materials and Methods:
29 patients underwent gamma knife radiosurgery for TN between September 2018 to March 2019. Two readings of inflammatory biomarkers were recorded, the first one just prior to GNRS while the second within one month after it.

Statistical Analysis: Statistical analysis was performed using the Microsoft Excel Statistical Package
Results: the measured data for each gender is considered separately since TN is more common among women than men. significant changes were observed regarding PDW and Lymphocytes level post radiosurgery in female group (n=19) but not in male

Conclusion: the significant decrement in PDW and lymphocyte cell percentage post radiosurgery supports the inflammatory hypothesis in trigeminal neuralgia

Results: the measured data for each gender is considered separately since TN is more common among women than men. significant changes were observed regarding PDW and Lymphocytes level post radiosurgery in female group (n=19) but not in male

Conclusion: the significant decrement in PDW and lymphocyte cell percentage post radiosurgery supports the inflammatory hypothesis in trigeminal neuralgia
Keywords
Trigeminal neuralgia, gamma knife, PDW

Background: Post-menopausal bleeding is problematic condition that occurs in old female patients. Diffusion weighted images with quantitative apparent diffusion coefficient value is considered one of the most helpful non-invasive, easiest procedures and not need contrast to differentiate malignant from benign conditions.
Aim of the study: This study aimed to detect the usefulness of diffusion-weighted magnetic resonance imaging (DWI) and(ADC)values in differentiating endometrial cancer from other benign endometrial lesions in females with thickened endometrium /endometrial mass and to detect a cut off value between benign and malignant endometrial lesions in females with PMB.
Patients and Methods: This prospective study included(60)postmenopausal female patients with thickened endometrium >6mm. All patients were examined first by ultrasound and then by MRI unit in Al Imamein AlKadhimein Medical city in Baghdad-Iraq during the period January-October 2021. T2-weighted, STIR, pre- and post-contrast vibe T1-weighted and diffusion weighted images were obtained with three b values (50-600-1000). Mean ADC values of all patients with endometrial pathologies were estimated after correlation with T2WI, DWI image study, then correlated with histopathological results.
Results: The results showed that 48(80%)of the lesions were benign, 12(20%) were endometrial cancers. The mean endometrial thickness among women with malignancy was significantly higher than those with benign lesions (40.08±18.59 vs 14.98±5.95) respectively. Subsequently, diffusion weighted image was restricted significantly to women with malignancy than those with benign lesions(100% vs. 2.1%)respectively. The mean ADC value(10–3 mm2/second) in malignant lesions was significantly lower than benign lesions(722.58±112.02 vs. 1483.408±275.03) respectively. The optimal ADC cutoff value for differentiation benign from malignant endometrial lesion was 0.8725 x10-3 downwards with 97.9% sensitivity and 100% specificity, and positive predictive value was 100%, negative predictive value was 92.30% while accuracy rate was 98.3%.
Conclusion: Quantitative ADC values differentiate between benign endometrial lesions and endometrial cancer in postmenopausal patients before interpretation with interventional managements.

Background: As early as 1960, (Gerald W. Shaftan,M.D.) advocated “observant and expectant treatment” in the management of penetrating abdominal injury rather than exploratory laparotomy. This was reinforced in 1969 by Nance and Cohn for the abdominal stab wounds (SWs) management. Since that time, selective nonoperative management (NOM) of SWs to the anterior abdomen has become more readily accepted.

objective: To assess the feasibility and safety of selective nonoperative management in penetrating abdominal injuries.
Patients & Method: prospective study was performed at Al-Imamain Al-Kadhimain Medical City over a two years from (October 2018 to October 2020) the study included patients with penetrating abdominal injuries from level of fifth intercostal space to the level of pubic symphasis. Patients with peritonitis or hemodynamic instability were selected for emergent laparotomy. Clinically conscious patients who were haemodynamically stable and had no signs of peritonitis were evaluated by CT scan with intravenous contrast.
Results: During the study, there were 143 patients with penetrating abdominal injuries , (62.22%) underwent an emergency laparotomy. (37.76%) were selected for CT scan evaluation and clinical observation. (7.69%) of them have CT-scan findings of hallow viscous injury and explored. (1.39%) failed for nonoperative management. (28.67%) had been managed nonoperatively successfully.
Conclusion: selective nonoperative management of penetrating abdominal injuries can be practiced safely with use of CT scanning.

ackground: Delivery by elective cesarean section has been risen and was found to be associated with risk of adverse neonatal outcome.
Aim of the study: To assess neonatal morbidities among term neonates delivered by elective cesarean section.
Methods: It is a prospective study conducted at neonatal intensive care unit at Al-Yarmuk teaching hospital from the 1st of June 2017 to the 1st of January 2018. Included neonates were: Term, singleton, and product of elective cesarean section. The following variables were studied: maternal age, antenatal steroid, and mode of anesthesia, indication of elective cesarean section, gestational age, neonate gender, Apgar score and birth weight, with neonatal morbidities.
Results: During the study period, (693) neonates were enrolled. Maternal steroid given to (94.5%). Repeat cesarean section represent (73.2%), and general anesthesia was used in (91.7%). Neonates were subdivided into: early term, and full-late term groups; (55.3%) were male. About a quarter were admitted, mostly with Respiratory distress. The admission associated with gestational age, male gender, and lower birth weight. Only respiratory morbidities and the use of assisted ventilation were significant for early term.
Conclusion: Elective cesarean section is found to be associated with significant neonatal morbidities, especially respiratory ones.
Keywords: Elective Cesarean Section; Neonatal Respiratory Morbidities, Neonatal Intensive Care Unit.

Background: To investigate the Outcome and complication of retrograde intrarenal surgery for renal stone below 15mm, and evaluate our experience with this type of surgeries.

Aim of the study : To evaluate our experience with flexible ureteroscope in treatment of renal stone below 15 mm and focusing on the operative time, stone free rate and possible complication .

Patient and methods : From August 2019 to December 2020 a 44 patient were selected to perform retrograde intrarenal surgery for renal stone below 15mm, using flexible ureteroscope with holmium laser.

Results : This cross sectional study show mean stone diameter 11.75±1.658 mm. mean operative time 54.66±17.089 min, while the mean lasing time 41.70 ±17.814 min, and the primary stone free rate 77.3%, Follow up done to the patient for duration of 3 months to reach a total stone free rate 88.6%, the complication rate was 18.2% sub classified with Clavien-Dindo Classification to show 7 patients (15.9%) of them were clavien grade 1, while 1 patient (2.27%) were clavien grade 2, no major complication found during the course of the study.

Conclusion: RIRS using flexible ureteroscope with holmium laser is minimally invasive surgery with both safe and effective results and with acceptable hospitalization period and lower complication rate.

Background: disc prolapse is thought to cause one-third of all back pain, in which the spongy interior matrix of an intervertebral disc in the spine is drying out compressing the thecal sac and nerve roots. Traditional discectomy involves removing a portion of an intervertebral disc. TLIF is atechnique that is used to achive disc resection, decompression and circumferential arthrodesis in the lumbar spine, it fuses the anterior and posterior sections through a posterior unilateral approach.
Aim: In this study, we aim to review cases of massive single level lumber disc prolapse treated surgically either with traditional discectomy or (TLIF) and compared their outcomes regarding pain, deficits, instability, complications, blood loss, hospitalization and cost.
Methods: study included 43 patients presented with symptomatic, single level, massive lumbar disc prolapse at different levels were designed in to 2 groups: (Group A: 23 patients were treated with open TLIF) and (Group B: 20 patients were treated traditional discectomy).
Results: The outcomes of 43 patients were assessed and followed up at 12 months postoperatively. The results was appeared to be significantly better in open TLIF than traditional discectomy in a term of both low back and radicular leg pain and mechanical instability, while significantly better in traditional discectomy than open TLIF in a term of intraoperative complications and blood loss, hospitalization stay and cost, there was no significant difference between the two types of surgery in the term of neurological deficits. The overall success rate in open TLIF was (91.3%), while (70%) in traditional discectomy.
Conclusion: Both open TLIF and traditional discectomy were effective in treatment of patients with massive single level lumber disc prolapse.

Background. Mental health special services for children and adolescents are inadequate in Iraq. Autism spectrum disorder (ASD) is increasing in prevalence worldwide with no study illustrating the incidence and prevalence of ASD in Iraq. More information is needed regarding autism in Iraq, the most presenting symptoms which cause the referral and the way of referral to the child and adolescent mental health services to improve these services and for a better outcome. Method by taking all the children with a diagnosis of ASD who visited the child and adolescent outpatient mental health center at the children welfare hospital coming from different Iraqi areas during ten months period from January to October 2020. A total of 292 children, a full psychiatric history and examination were done, and the diagnosis was made using DSM5 criteria and the use of childhood autism rating scale CARS. Information including the source of referral to the child and adolescent mental health service and the most presenting symptoms were also obtained Result boys (77.4%) were more than girls (22.6%). regarding the severity, (56.8%) were of a mild type. Speech problems were the most presenting symptom in (43.5%) of them. Being a boy or girl was significantly associated with the most presenting symptom and with the source of referral. Also, there was a significant association between age and the severity of the symptoms. Most of the referral was by the family member advice in (82.5%).Conclusion families were the most referral source to the child and adolescent mental health center. Speech problems were the most presenting symptoms which lead to referral. Psycho educational programs are needed for the health workers including the pediatricians and audiologists about the autism spectrum disorder for early detection and better outcome.

Background: The Coronavirus Disease 2019 (COVID-19), an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2), has become one of the worst pandemics in this century. COVID-19 may increase the risk of acute ischemic stroke similar to the increased risk of 3.2-fold to 7.8-fold seen within the first 3 days after other respiratory tract infections.

Aim: To have the ability of predicting risk of stroke development in COVID

19 patients by relaying on variable parameters involving clinical and inflammatory markers.

Methods and materials: A case control study conducted in Baghdad, the capital of Iraq at Baghdad teaching Hospital, in a period from March 2021 till August 2021.the study included 90 patients tested positive for COVID-19 infection.

Results: The mean age of participants was 58.2 ± 15.6 years (range 22 – 88 years old). The mean age across group A was 65.4 years which was significantly higher than group B age (p=0.0001). Regarding gender, males were representing 53% and 46% of group A and B respectively. Regarding the severity, no mild cases was observed among group A patients (p=0.001). Regarding risk factors, hypertension, DM, history of CVD, smoking, and were associated significantly with developing ischemic stroke (p<0.05). Also, developing respiratory failure was associated with development of ischemic stroke (p=0.002). Regarding inflammatory markers, D-Dimer and ferritin levels were significantly higher among group A patients in comparison to group B patients (p<0.05). While, LDH did not demonstrated significant difference between both groups (p=0.14).

Conclusion: Age, hypertention, D.M, somking, Hx of CVD, Severity of COVID-19 infection, respiratory failure and D-Dimer, ferritin levels were significantly higher among COVID patients who developed stroke. LDH did not demonstrated significant difference.

Background: Shoulder pain is one of the most common complaints encountered in Rheumatological practice and often leads to considerable disability.
Aim of the study: to assess the diagnostic value of six clinical tests for identifying pathologies in patients complaining of shoulder pain, and utilize ultrasound examination (US) as an imaging modality to confirm the clinical diagnosis.
Patients and Methods: This Cross-sectional study included 80 consecutive patients who presented with shoulder pain and at least one of the subsequent features: pain during daily activities, pain at night, neck pain, arm paresthesia, or numbness. Six clinical tests that elicit tenderness in the shoulder were performed and then ultrasonography was performed to confirm the diagnosis.
Results: A total of 80 participants were enrolled in this study. Tenderness in various parts of the shoulder to deep palpation was the most accurate test for predicting the diagnosis with a sensitivity of 100% and specificity of 14.5%. There was a significant difference between shoulder pain in the dominant and non-dominant side (p-value <0.001), and significant differences between the clinical examination results and US findings for 5 tests, except for the drop-arm test which was insignificant (p = 1.000). There were no significant differences between diabetic and non-diabetic patients regarding all the shoulder ultrasound findings (p > 0.05).
Conclusion: Although clinical tests are insufficient for diagnosis of the shoulder pathologies, the examination of the patient still plays an important role. However, Ultrasonography should be used for all patients suffering from a painful shoulder in order to confirm the diagnosis.

BACKGROUND:
Breast cancer is comments type of cancer in women, and the second leading cause of death worldwide. Mammography had been the cornerstone for breast cancer diagnosis throughout the years. Digital breast tomosynthesis had been developed as an advanced method for early diagnosing a breast lesion and found to have promising results in both screening and diagnostic measures more importantly in dense and previously treated breasts.
OBJECTIVE:
To evaluate digital breast tomosynthesis (DBT) compared to digital mammography for the detection of different breast lesions and interpretations of BIRADS IV and V scoring in different breast densities.
PATIENTS AND METHODS:
A prospective cohort conducted at Oncology teaching hospital in Medical City teaching complex in Baghdad for the period of 8 months from March 2021 to November 2021, included 101 suspicious breast lesions (BIRADS IV and V) was undergone Digital mammography and Digital Breast tomosynthesis, and diagnosis confirmed with FNA cytology and/or US guided core needle biopsy.
Statistical analysis was done using IBM SPSS software version 25, statistical comparisons were performed using the Chi-square test or fisher’s exact test. Significance was defined as a P value less than 0.05.
RESULTS:
The results obtained from the study regarding the diagnostic performance of each modality showed that higher sensitivity for DBT 100% in comparison to DM 69.2%, however the specificity for DBT was not measured because of absence of true negative cases as the result of the selection criteria, the accuracy of DBT was higher for ACR a (100% vs 72.7%) and c (54.5 vs 45.4%) than mammography, However, they were the same for ACR b, for ACR d we have only 2 cases.
Additionally, we found that change in BI-RADS scoring with BDT was 12/24 (50%) in dense breast categories (ACR c and d) while in fatty and scattered fibroglandular breasts (ACR a and b), it was 44/77 (57%).
CONCLUSION:
These findings indicate that tomosynthesis is superior to mammography in terms of sensitivity at all breast densities, but notably at greater densities. It is advantageous because, unlike mammography, which produces two-dimensional images, it eliminates obscuring breast tissue and provides a higher resolution of the internal breast structures. And this will result in a decrease in false positive results, recalls, and special mammographic views, as well as a decrease in radiation exposure and costs.

ABSTRACT:
Family medicine, recognized as a specialty in its own right, is a cornerstone for developing a community-based healthcare system, with primary care as its milestone. Training family physicians is more important than ever. The most significant regional barrier to the development of primary care systems is the insufficient number of family physicians and other primary care providers.
This paper will review the status of family medicine in Iraq and Lebanon as examples of health systems in the Middle East.

ACKGROUND:
Vascular anomalies represent a wide range of vascular pathology classified by flow velocity. Venous malformations are the most frequent kind of head and neck vascular malformation that cause functional and cosmetic disturbances. Injection sclerotherapy is the initial therapeutic choice for venous abnormalities.
AIMS OF STUDY:
To compare the effects of bleomycin foam and liquid in treatment of maxillofacial venous malformation regarding the dose, size of the lesion and number of treatment sessions.
PATIENT AND METHOD:
This study involved 20 patients (11 females, 9 males) with an age range (9- 47) years, had venous malformation in the head and neck region presented to Maxillofacial Surgical department in Alwasity hospital / Baghdad, from Jan 2021 to April 2022.
Patients were divided into two equal groups randomly. The odd number of patients (group A) were treated by bleomycin foam injection while the even number group (B) were injected by bleomycin liquid.
RESULTS:
The results showed in group (A), 6 patients were in scale 4 with an excellent response and 4 patients were in scale 3 good response . In group (B) group, 3 patients were in scale 4 excellent response, 6 patients were in scale 3 good response and one patient was in scale2 fair response.
CONCLUSION:
Bleomycin liquid and foam injections are effective sclerosing agent for vascular malformation Treatment. Bleomycin foam sclerotherapy was an effective with decrease in number of treatment sessions and less dose of bleomycin medication. Data from the present study suggested more effective treatment outcomes in female than male.