Iraqi Postgraduate Medical Journal

BACKGROUND:
Flexor tendons repair outcome depends on meticulous surgery built upon a thorough knowledge of the anatomy and biomechanics of the flexor tendon system. Direct tendon repair is the standard method with most rewarding outcome. Still at times where direct repair is impossible because of large defect or sever adhesions, extra synovial tendon graft is considered. Attachment of the distal end of the graft at the insertion of the flexor digitorum profundus into the distal phalanx has been a matter of controversy.
OBJECTIVE:
Compare between the traditional way of attaching the distal end of the graft to the stump of the flexor digitorum profundus tendon, with an alternative “extended graft“ technique that involves attaching the distal end to the distal phalanx through a pull-out suture.
PATIENTS AND METHODS:
Twenty-six patients included in this study, 21 case of injury to the flexor digitorum profundus and 5 involving the flexor pollicis longus. A mean age of patients of 29 years. All injuries presented late (more than 3 months). All cases reconstructed in Two-stage procedure of Hunter-Salisbury using silicone rod in the first stage, followed by replacement by Palmaris longus tendon graft in the second stage. Patients are divided into 2 groups ; first which included 15 case where the traditional methods used ; that is attaching the distal end of the graft to the stump of the ruptured flexor tendon, and in the second group the technique of ‘’ Extended graft ‘’, where the graft is attached by a pull-out suture to the distal phalangeal bone.
RESULTS:
Two groups of patients studied, fifteen case in the first group where the traditional method of repair used, and the ‘’extended technique’’ used in eleven case, the second group. In the first, more than 50% of DIP flexion lost, whereas in the second group, more than 90% of DIP flexion preserved.
CONCLUSION:
We concluded that using the “extended graft” technique can markedly reduce the stiffness in the distal interphalangeal joint and thereby the loss of flexion that result from the traditional method.


Keywords

Flexor digitorum profundus Palmaris longus silicon rod two-stage tendon repair

BACKGROUND:
Pneumothorax is the most common air-leak syndrome in neonatal period. It can be defined as accumulation of air between the parietal and visceral pleura.
OBJECTIVE:
To study the general characteristics, risk factors, causes, management details, and the outcomes of neonatal pneumothorax.
PATIENTS AND METHODS:
It is a prospective observational study included thirty infants at neonatal intensive care unit at Al-Yarmouk teaching hospital from 1st of October 2018 to the 30th of September 2019 and Patients were evaluated for: gender, gestational age, birth weight, Apgar score at 1&5 minutes, mode of delivery, time of pneumothorax development, localization, and the presence of lung pathology.
RESULTS:
During the study period, 1967 neonates admitted to Neonatal Intensive Care Unit, thirty infants were diagnosed. The incidence was 1.52%. This study showed that (70%) of neonates were male and (60%) had low birth weight. Respiratory distress syndrome was found in (60%). It occurs spontaneously in (23%), after invasive mechanical ventilation in 6 cases, and after noninvasive ventilation in 17 cases. Tube thoracostomy and closed underwater drainage were performed in 26 cases. Mortality rate was 43,3%.
CONCLUSION:
Pneumothorax occur more frequently with use of assisted ventilation, especially those with underlying medical illnesses, and it carries high risk mortality.

Keywords

Early Cesarean Section Neonatal Intensive Care Unit Respiratory Distress Syndrome

BACKGROUND:
Intravenous glucose fluids may be given to patients undergoing caesarean delivery to provide energy to the mother and fetus while maintain hemodynamics. Different intravenous solution loads before operation, however, may cause maternal and fetal hyperglycemia or hypoglycemia .
OBJECTIVE:
To compare the blood glucose level of the mother and the fetal after giving ringer lactate have (0, 1, and 5%) glucose to the mother before induction and completed after delivery to minimize the effect of both fasting and to mark the optimal glucose concentration for both mother and fetus.
PATIENTS AND METHODS:
Sixty pregnant women aged 18-35 years underwent elective cesarean delivery are randomly distributed into three groups. Group A received Ringer lactate with 0 % glucose (0 g), Group B received 1 % glucose (5 g), and Group C received 5 % (25 g) glucose. Once the patients were in the operating room, each group of them received an infusion of 500 ml of test solution before induction, and the administration ended after delivery.
RESULTS:
The mean maternal glucose level before the intravenous infusion was 80.21±11.32 in the study groups. After the intravenous infusion finished, maternal blood glucose levels were group A 72.3 (±5.6), group B 100.1 (±10.3), and group C 243.7 (±40.3). For neonatal capillary blood glucose levels immediately after delivery were Group A 54.7 ± 7.74, Group B 82.4 ±10.06 and Group C 184.2 ±12.89.
CONCLUSION:
Ringer lactate with 1 % glucose solution was the ideal fluid to maintain the appropriate blood glucose level in the mother and fetus and maintain maternal hemodynamics and provide power for both mother and fetus.



Keywords

glucose ringer solution blood sugar level preoperative infusion

BACKGROUND:
Inhaled corticosteroids administered in high and repeated doses which effect simultaneously with bronchodilators is a way to maintain the effect throughout the time. The acute effects of nebulized budesonide as an emergency treatment of acute asthma in children have been evaluated in few clinical studies.
OBJECTIVE:
The analysis of the early clinical impact of adding repeated doses of nebulized budesonide in the treatment of acute asthma in the emergency setting on clinical respiratory score, Peak expiratory flow rates and hospital admission after 4 hours of treatment.
PATIENTS AND METHODS:
The study was a double-blind and placebo-controlled trial from April 2017 to January 2018 in children who attended the pediatric emergency unit at Children welfare teaching hospital due to an acute attack of asthma were evaluated. Clinical respiratory score and the peak expiratory flow rates were recorded in all patients at the start of the study by a pediatrician. Both groups received three consecutive doses of nebulized salbutamol (0.15 mg/kg/dose) and one dose of intravenous dexamethasone (0.15 mg/kg). During this treatment, for patients in group A the salbutamol nebulizer was mixed with normal saline while patients in group B three doses of nebulized budesonide (1mg/dose) which were combined with the nebulized salbutamol. Four hours later clinical respiratory scores and the peak expiratory flow rates were measured once more by the same blinded pediatrician.
RESULTS:
Respiratory rate showed significant difference between budesonide and placebo groups after 4 hours from the start of nebulizer therapy (P = 0.01). While others clinical respiratory scores variables like auscultation, accessory muscle, SPO2, color showed evident improvement after 4 hours but the differences were not statistically significant for each. The mean PEFR percent in budesonide group after 4 hours was (156±78.1) and that of placebo group was (119±37.9). Although the differences in PEFR between two groups was evident, it did not reach statistical significance (P= 0.3).
CONCLUSION:
The effectiveness of nebulized budesonide in addition to systemic steroids and nebulized salbutamol in early treatment of moderate asthmatic attacks in children 2-15 years of age in emergency setting clinically provided meaningful benefits in improving the clinical respiratory scores and PEFR and decreasing admission to the ward.

Background: Ovarian cancer is the most lethal malignancy of female genital tract. Epithelial ovarian cancer comprises the majority of malignant ovarian neoplasms, response rate to platinum, taxan and bevacizumab is excellent in advance stages of disease, despite that recurrence can occur.
Aims: To estimated response rate to first line chemotherapy (platinum and taxane with bevacizumab) and progression free survival (PFS) in patients with advanced epithelial ovarian cancer (OC).
Patients and Methods: A total of 50 patients with OC were enrolled in this cross-sectional study whom received chemotherapy protocols (carboplatin ,paclitaxel and antiangiogenesis { bevacizumab} /Carboplatin) cycle and each cycle repeated every 3 weeks. A response evaluation criterion in solid tumors guidelines was used. Also comparison between primary debulking surgery (PDS) and interval debulking surgery (IDS) in progression free survival (PFS) was measured.
Results: The median baseline level of CA125 was 695 U/ml (range= 9.2-5000 U/ml) compared with 54.6 (range= 5.0-27 U/ml) after treatment (p value < 0.001). The mean ovarian mass before treatment was 6.9±2.62 cm which reduced to 2.5±2.61 cm after treatment (p= 0.001). Similarly, the frequency of lymphadenopathy and ascites decreased from 72% and 68%, respectively before treatment to 22% and 18%, respectively after treatment (p<0.05). One woman (2%) showed disease progression, 3 patients (6%) were stable, 42 patients (84%) had partial response and 4 patients (8%) had complete remission. Mean PFS time for IDS was 19.5±2.82 months, 95%CI= 13.97-25.03 compared with 8.5±2.82 months in PDS, 95%CI= 4.54-12.46 (p=0.008).
Conclusions: Platinum and taxan based with bevacizumab showed effective treatment regime for management of advanced OC and serum level of CA125 could be effectively used in monitoring the disease progression and response. Interval debulking surgery was more effective compared to primary debulking surgery and PFS was better in patient who is done IDS than in patient in PDS.

BACKGROUND:
Brain Glioma is one of the most common brain tumors that starts in the Glial cells of the brain which are the supportive tissue of the brain. Gliomas compromise about thirty percent of all brain tumors.
OBJECTIVE:
Evaluate the outcome of gamma knife radiosurgery as an effective treatment modality in the management of brain glioma.
PATIENTS AND METHODS:
A clinical retrospective study performed and conducted at Neurosciences hospital between January 2017 and November 2018. The cases conducted were 40 cases, 33 patients were undergone craniotomy prior to radiosurgery and the remaining 7 patients had radiosurgery with gamma knife as the first modality of treatment.
RESULTS:
Gamma Knife Radiosurgery has showed a good effect on tumor growth control and improving clinical outcome. In high grade glioma Gamma Knife Radiosurgery showed a good noticeable efficacy on prolongation of survival period and tumor control.
CONCLUSION:
Gamma Knife Radiosurgery gained an important role in the treatment of glioma in the last two decades in selected cases.

BACKGROUND:
and other inflammatory diseases of the anusand perianal soft tissues area cause perianal fistulas substantial morbidity.Diffusion-weighted magnetic resonance imaging (MRI) plays a great role in the evaluation of anal fistulae.
OBJECTIVE:
To evaluate the value of DWI in the examination of perianal fistula.
PATIENTS AND METHODS:
The study included 38 patients (30 males and 8 females) with clinical suspicion of perianal fistula. It was done in MRI department (3.0T) of AL-Imamain AL-Kadhimyianmedical city, Baghdad/ Iraq during the period from November 2020 to January 2021. MRI images were assessed for the presence of visible fistulas, internal openings, secondary extension, horse shoe and abscess.
RESULTS:
68.4% of the fistulas were at Lt. side and 31.6% in the Rt. Side. Intra-sphincteric was 63.2%, trans-sphincteric was 31.6% and supra-sphinctericwas 5.3%. The primary tract detection rate at T1 was 81.6%, at T2 was 92.1%. The internal opening, the detection rate in T1 was only 10.5%, at T2 was 21.1%, at T2 Fat was 81.6%, T1+contrast was 63.2%, at DWI was 89.5% and T2 Fat+DWI was 100%. (P< 0.001. The detection rates at T2 fat sat, T1+contrast, DWI and T2 fat sat+DWI were 100%, 89.5%, 86.6% and 100%, respectively, indicating a higher detection rate at T2 sequence and T2 fat sat+DWI, with highly significant differences (p<0.001). According to the detection rates reported above, the best accuracy rate in combined T2 Fat+DWI, (P< 0.001, highly significant).
CONCLUSION:
Both DWI and CE sequences have high accuracy in the diagnosis and detecting complications of PAF. The combined FS-T2W + DWI and FST2W + CE data sets have equal sensitivity and specificity, and the use of the combined FS-T2W + DWI data set can prevent unnecessary use of contrast agent and prevent both cost and contrast-related complications.

BACKGROUND:
Bleeding that occurs 12 months or more following the last menstrual period is known as postmenopausal bleeding.
OBJECTIVE:
Is to assess the frequency and pattern of uterine lesions in women with post-menopausal bleeding and to correlate the histopathological changes with clinical variable i.e. the age, associated illness, parity and ultrasonography finding.
MATERIALS AND METHODS:
A retrospective study, which include analysis of 110 cases of women presented with post-menopausal bleeding, the samples were collected from the Teaching Laboratories of Al-Imamain Al-Kadhumain, and Baghdad Medical City from January 2020 to June 2021. For each case the histopathological reports, slides and Paraffin block (if needed) were collected, in addition the clinical parameters such as age, parity, history of previous Dilatation &Curettage, diabetes mellitus and/or hypertension, and ultrasound findings such as (endometrial thickness, uterine size) were also obtained.
RESULTS:
The age range of 110 cases was (45-90 years) with a mean age of 58 years ± 6.6 years. Hypertension was the most common associated illness as it was present in (42.7%) cases. Diabetes mellitus was present in (33.6%) patients. The parity distribution was (4.5%) cases recognized as nulliparous, and (95.4%) were multiparous. The endometrial thickness obtained from ultrasonography ranged from (3-25) mm and distributed as following: 22 (20%) cases were equal to or less than 4 mm, and (80%) were more than 4mm.The most common histopathological diagnosis was endometrial hyperplasia with frequency of (28.5%) of cases and (10.9%) cases were diagnosed as carcinoma.
CONCLUSION:
The most common etiology for postmenopausal bleeding was endometrial hyperplasia. While, the lowest one was chronic endometritis. There is significant correlation between the clinical parameters with endometrial hyperplasia and malignancy.

BACKGROUND:
Around 20% of the global disease burden is attributed to neurological disorders. In developing countries, neurological disorders are the leading cause of disability among children. Unfortunately many children with these conditions also face the additional burdens of poverty, ignorance, and inadequate healthcare facilities. Most of the time, these children are not able to receive the proper care and support they need.
OBJECTIVE:
To observe the pattern of childhood neurological diseases that are encountered in the neurology outpatient clinics at a tertiary care hospital in Baghdad, Iraq.
MATERIALS AND METHODS:
This is a prospective descriptive study carried out in the neurology outpatient clinics of the central teaching hospital of pediatrics over the period from June 2022 to January 2023 The data were collected through a pre‑designed questionnaire from hand‑written registers maintained by neurology consultants and seniors at the neurology clinics.
RESULTS:
There were a total of 4325 children consulted the pediatric neurological outpatient clinic in the central teaching hospital of pediatrics in Baghdad Iraq during the 6 months of the study time, their ages range from 1 day to 14 years. The most common age group was those from 1 to 5 years old about 1641 children (37.94%). male were more common than female 2474(57.20%) of children. Nearly one-third of the patients consulted the outpatient clinic were complaining of seizure and epilepsy disorders (1537 children). The next most common neurological problem was cerebral palsy in 984 patients (22.75%). Almost 6% of outpatient clinic visitors were suffering from behavior problems.
CONCLUSION:
Knowing the spectrum of neurological diseases in neurology outpatient clinic at the tertiary care level will help to understand the neurological demands and supply in our pediatric hospitals, the results put forward that neurological and behavioral disorders are common in pediatrics and vary in range among them. The higher frequency of epilepsy and cerebral palsy suggests that priority should be given to training and anticipatory measures with early diagnosis and proper management.

BACKGROUND:
Flexor tendons repair outcome depends on meticulous surgery built upon a thorough knowledge of the anatomy and biomechanics of the flexor tendon system. Direct tendon repair is the standard method with most rewarding outcome. Still at times where direct repair is impossible because of large defect or sever adhesions, extra synovial tendon graft is considered. Attachment of the distal end of the graft at the insertion of the flexor digitorum profundus into the distal phalanx has been a matter of controversy.
OBJECTIVE:
Compare between the traditional way of attaching the distal end of the graft to the stump of the flexor digitorum profundus tendon, with an alternative “extended graft“ technique that involves attaching the distal end to the distal phalanx through a pull-out suture.
PATIENTS AND METHODS:
Twenty-six patients included in this study, 21 case of injury to the flexor digitorum profundus and 5 involving the flexor pollicis longus. A mean age of patients of 29 years. All injuries presented late (more than 3 months). All cases reconstructed in Two-stage procedure of Hunter-Salisbury using silicone rod in the first stage, followed by replacement by Palmaris longus tendon graft in the second stage. Patients are divided into 2 groups ; first which included 15 case where the traditional methods used ; that is attaching the distal end of the graft to the stump of the ruptured flexor tendon, and in the second group the technique of ‘’ Extended graft ‘’, where the graft is attached by a pull-out suture to the distal phalangeal bone.
RESULTS:
Two groups of patients studied, fifteen case in the first group where the traditional method of repair used, and the ‘’extended technique’’ used in eleven case, the second group. In the first, more than 50% of DIP flexion lost, whereas in the second group, more than 90% of DIP flexion preserved.
CONCLUSION:
We concluded that using the “extended graft” technique can markedly reduce the stiffness in the distal interphalangeal joint and thereby the loss of flexion that result from the traditional method.

BACKGROUND:
Cervical cancer develops slowly, raising the possibility of early recognition of pre-neoplastic lesions using Papanicolaou test and consequently avoiding deaths. Cervical screening system seeks to identify females who have an epithelial abnormality that could; if untreated, take the lead to the progress of cervical carcinoma. Extremely applied test for cervical carcinoma screening is cervical cytology which is effective in decreasing the occurrence of cervical cancer deaths by 70% since 1950.
OBJECTIVE:
To assess cervical pap smear from a sample of Iraqi patients according to The Bethesda System (TBS) 2014 and to study the relation of different categories of TBS with cinicopathological parameters include (patients age, clinical presentation, parity, and lower female genital tract infection).
MATERIALS AND METHOD:
A cross sectional study was conducted in the Department of Pathology/ Collage of Medicine/ Al-Nahrain University, Baghdad, Iraq (For a period from January 2021 to January 2022). Cases were collected from Medical Consultant Office/ College of Medicine/ Al- Nahrain University (For a period from May 2017 to December 2020). There were 209 patients referred at that period. The data that were analyzed for patients according to five general factors: (age of the patient, clinical presentation, parity, types of lower female genital tract infection, microscopic examination and final diagnosis according to The Bethesda System 2014).
RESULTS:
The mean age was 40 ± 9.95 years .According to The Bethesda System 2014: Negative for intraepithelial lesion or malignancy was (57 cases 27%), Atypical squamous cells of undetermined significance composed (4 cases 2%), Low grade squamous intraepithelial lesion was (96 cases 46%), High grade squamous intraepithelial lesion was (51 cases 24%), Atypical glandular of undetermined significance was (1 case 0.5%). There was significant correlation between The Bethesda System 2014 categories and age P value = 0.014. There was no correlation with clinical presentation, number of parities and types of lower genital infections, P value was (0.806, 0.277, 0.063) respectively.
CONCLUSION:
The most frequent category of The Bethesda system 2014 categories in this cross – section study was low grade squamous intraepithelial lesion (46%), High grade of cervical intraepithelial lesion is significantly associated with older age group and there was no significant association of The Bethesda System 2014 categories and clinical presentation, number of parities and types of cervico-vaginal infections.

BACKGROUND:
Obesity is an epidemic health problem and the use of intra gastric balloon emerge as a noninvasive and effective treatment option.
OBJECTIVE:
To compare the effect of intra gastric balloon and low-calorie diet on weight loss.
METHOD:
During the period (June 2019 till July 2020) 80 consecutive obese patient divided into 2 groups one treated with low calorie diet and the second with intra gastric balloon and low-calorie diet; their weight loss assessed during 1st,3rd, and 6th months interval and comparison between both group analyzed.
RESULTS:
Mean weight loss in IGB in 1st, 3rd, 6th months were 6.8, 13, 18,2 kg while low calorie diet group weight loss were 5.6, 9.8, 11,6 kg and this is statistically significant. BMI lost in the IGB was 7 kg\\m2 which is better than low calorie diet where BMI lost was 4.5 kg\\m2.
CONCLUSION:
IGB is more effective weight loss procedure than low calorie diet only.

Background: Adolescents with type 1 diabetes (T1DM) suffer from the lifestyle that is imposed on them for the purpose of controlling blood sugar within its natural limits, and the accompanying treatment with insulin injections, daily blood sugar measurement, irregular blood sugar level, and hospitalization, all of which lead to the deterioration of the mental health of adolescent.
Aim: This study aims to screen for anxiety and the degree of depression in adolescents with T1DM.
Method: The study was conducted at Al-Imam Al-Hasan Center for Endocrinology and Diabetes, Karbala, Iraq, from May 21st, 2023 to September 21st, 2023. It was a cross sectional study. using the patient health questionnaire-9 (PHQ9) questionnaire the Generalized Anxiety Disorder-7 (GAD7) questionnaire to screen for symptoms of depression and anxiety in adolescents with T1D.
Results: frequency of anxiety in the participants who had score ≥ 10 was 102(40.63%), and the frequency of depression in the participants who had score ≥ 10 was 116(46%), and 15(6%) had really committed suicide attempt.
Conclusion: Adolescents with type 1 diabetes mellitus have significant depression and anxiety symptoms. Poor diabetic control is a major predictor of these symptoms.
Key words: adolescent, anxiety, depression, GAD7 questionnaire, PHQ9 questionnaire, type 1 diabetes mellitus.

Looking inside Tracheo-Bronchial tree was a dream for a thoracic surgeon. Gustav Killian (1860 –1921), the father of bronchoscopy .He was a German laryngologist, was appointed a professor of ENT at the University of Freiburg in 1892. Gustav Killian in 1897 succeeded in removing aspirated pork bone from the bronchus of a 63-year-old farmer, under cocaine anesthesia. He used external light source, a head mirror, Esophagoscope and forceps to remove the bone.