Iraqi Postgraduate Medical Journal

Medical education is more than just providing up-to-the-minute medical knowledge and clinical practice. It is an art that involves designing a teaching program that serves the needs of the healthcare sector and community in the near future (1). Iraq is a country that has been facing numerous challenges in the healthcare sector, particularly in medical education. Proper medical education could be one of the contributing factors to improving health care in this country (2).
A combination of governmental and private universities facilitates the provision of medical education in Iraq. While both types of institutions serve an important role, public universities are more prevalent and may be found in practically every province across the country. In recent years, the number of medical schools in Iraq has increased significantly, with a total of 24 medical schools now available to aspiring healthcare professionals (3).

BACKGROUND:
Since the end of December 2019, the world has been fighting one of the most serious pandemics in human history due to coronavirus disease 2019 (COVID-19). A pandemic that makes health care workers susceptible of developing depressive, anxiety symptoms now or in the future.
OBJECTIVE:
To identify symptoms of depression, anxiety and stress among physicians managing COVID 19 patients in Iraq and to ascertain association with socio-demographic and clinical variables.
SUBJECTS AND METHODS:
A cross-sectional study (descriptive and analytical) was done from the 1st of September to the 1st of November 2020. Physicians working in different Iraqi health care institutions (general hospitals, primary health care centers and COVID 19 quarantine centers) were asked to submit an online survey.
RESULTS:
Out of the 656 physicians who were included in this study, 61.9% had stress symptoms, 27.0% had anxiety symptoms and 27.1% had depressive symptoms.
Stress related symptoms were more prevalent in younger age, females, single physicians, having less years of experience and lower academic degree, working in COVID 19 isolation wards, avoiding contact with the family and being infected with COVID 19. These factors were positively associated with developing stress symptoms. Anxiety symptoms were positively associated with married physicians and working in COVID 19 isolation wards. Depression was not significantly associated with any of the studied variables.
CONCLUSION:
COVID 19 pandemic negatively impacts the psychological status of physicians as depression, anxiety and stress symptoms were found in different levels.

BACKGROUND:
Open septorhinoplasty is one of the most challenging procedures in facial plastic surgery and consideration must be given to both facial aesthetics and nasal function.
OBJECTIVE:
To evaluate the functional and the aesthetic outcomes of alar base reduction techniques in patients of primary open septorhinoplasty.
PATIENTS AND METHOD:
A prospective, descriptive study had been conducted from the first of April 2018 to the first of April 2019 at the Center of Otolaryngology- Head and Neck surgery at Ghazy AL-Hariry Medical City Hospital, 40 patients were selected (28 females and 12 males) who underwent primary open septorhinoplasty. All patients were evaluated by questionnaire, subjective assessment, clinical examination and photo documentation both pre and post-operatively quantitatively analyzed using image J processing software for objective assessment, with follow up at first, third and sixth month post-operatively and three types of operations techniques were used to reduce the wide nasal base.
RESULTS:
Among the 40 patients, the mean ratio of inter-alar distance to inter-canthal distance changed significantly from (1.234) to (1.034), the frequency of nostrils symmetry increased from (18) patients to (33) patients, the frequency of nasal flaring decreased from 30 patients to only 7 patients, the mean width of the internal vestibular resection was 3.675 mm and the mean width of the external alar wedge resection was 4.45mm. All the patients were satisfied in varying degrees and no worsening of the functional outcomes postoperatively assessed subjectively. No cases of postoperative bleeding, infection, vestibular stenosis, keloid, hypertrophic scar formation or nasal obstruction were encountered.
CONCLUSION:
A conservative excision is preferred to a radical one because it is a simple matter to resect additional alar tissue than reconstruct a stenotic ala. Alar base reduction techniques are effective techniques for patient with wide alar base and/or alar flaring with good outcomes regarding patients’ satisfaction and without worsening of the functional outcomes. The internal vestibular floor resection that is inclined 30-45 degrees laterally together with placement of the external alar resection in the natural alar facial crease result in natural curvature of the alar rim and an inconspicuous scar.

BACKGROUND:
Assessment of bone tumors needs more than one imaging modality. Zero echo time (ZTE) MRI is a high-resolution and rapid sequence. It gives an enhanced bone contrast in MR imaging and may obviate further need for CT and its attendant ionizing radiation
OBJECTIVE:
To evaluate clinical applicability of zero time echo magnetic resonance imaging in the assessmentand evaluation of bone lesions (tumors and tumor like conditions) in comparison with CT.
PATIENTS AND METHODS:
21 patients (7 males and 14 females) were included. ZTE MRI was done for all patients included in the study. Quality assessment of bone findings was performed between ZTE and CT using a 5 point grading scale. The findings were considered significance with P < 0.05. Agreement was assessed between the raters and Weight Kappa statistics were used. Interpretation of agreement was based on published standards: 0.00–0.20Indicated slight; 0.21–0.40, fair; 0.41–0.60, moderate; 0.61–0.80, substantial; and 0.81–1, perfect agreement.
RESULTS:
In this study, 6 types of bone tumors and tumor-like lesions. The image quality between ZTE and CT imaging showed good agreement between the 2 raters (K = 0.93, K = 0.81) in the bone tumors. ZTE-MR XIII and CT had similar displays in assessment of lesion boundary, periosteal reaction, bone sclerosis, bone destructions, calcifications, and soft tissues.
CONCLUSION:
ZTE is radiation-free bone imaging and provides image contrast similar to that CT. ZTE-MR can meet the diagnostic requirements of bone assessment, but also presented better tumor boundary and extra or intraosseous soft tissue components in some cases. ZTE-MR can be used as an alternative to CT.

BACKGROUND:
Tic douloureux is a debilitating disease presented as a recurrent unilateral short- living, electric, shock -like pain, abrupt in onset and termination, limited to the distribution of one or more division of trigeminal nerve.
OBJECTIVE:
To evaluate the effectiveness of Gamma Knife® radiosurgery (GKRS) using retrogasserian approach.
PATIENTS AND METHODS:
A follow up review was conducted on twenty patients who were treated with GKRS for refractory TN at our institution Dr. Saad Al-Witry Neuroscience Hospital in Baghdad, Iraq, between December 2019 and March 2021. T.N pain score was assessed using the Barrow Neurological Institute (BNI) Pain Scale. An ideal result was counted by post-GKRS BNI score of (I–III), whereas insufficiency outcome was (IV – V) of same scale.
RESULTS:
From the entire (twenty) GKRS procedures, (85%) of patients had result with remarkable relief in their complain (BNI I-III). No noteworthy relation was found between unacceptable outcome and age, sex, side of complain, period of symptoms. Only four cases (20%) developed undesirable outcome in form of facial numbness.
CONCLUSION:
Considering the satisfactory results in our own experience, GKRS is also offered as a feasible, effective, safe initial and repeat treatment modality targeting patients who were intractable to medical treatment.

BACKGROUND:
Appendicitis is the commonest surgical emergency in pediatric patients. Although the diagnosis is mainly clinical, imaging studies can be used to enhance diagnosis. Ultrasound is widely used as a screening tool because it is readily accessible in most centers, cost effective, and radiation free, but still there is a percentage of (equivocal study), so searching for secondary inflammatory sonographic signs may enhance the diagnosis.
AIM OF STUDY:
To assess the role of secondary sonographic signs in diagnosis of acute appendicitis in pediatric patients.
PATIENTS & METHOD:
This is a prospective study involved 187 patients (121 males, 66 females) done in Baghdad Medical city/ Children Welfare Teaching Hospital /Pediatric Surgery department between November 2018 and November 2019, all presented with abdominal pain mainly at right iliac fossa, patients sent for abdominal ultrasound, complete blood count, urinalysis, and histopathological examination of surgical specimens.
RESULTS:
Secondary signs have sensitivity of 53.7%, specificity of 80.0%, PPV of 97.9%, NPV of 8.9%, and accuracy of 55.1%.
There is significant statistical difference in rate of detecting SS (p-value=0.038).
CONCLUSION:
Secondary signs have high specificity but fair or low sensitivity. Multiple secondary signs in one patient make the ultrasound more valuable in diagnosis.

BACKGROUND:
Coronaviruses are microorganisms of animal and mankind. The WHO categorized the disease as COVID-19 in February, 2020.
Various laboratory markers can support the identification and follow up of COVID-19 case. Current evidence proposes a prognostic impact of neutrophil-lymphocyte ratio (NLR) in diverse inflammatory syndromes. Hence, it is rationalized to investigate its role as a prognostic biomarker in severe COVID‐19 pneumonia.
OBJECTIVE:
The objective is to analyze the effect of NLR, D-dimer, CRP, and ferritin role in the prediction of consequence of inpatients with severe COVID-19.
METHOD OF THE STUDY:

A retrospective cross-sectional study was conducted on 96 patients aged (18-80) years whom PCR SARS-CoV-2 positive, and admitted to (Al-Sader Medical City) in Al-Najaf City, Iraq between (July to October 2020).
The absolute number of neutrophil count divided by the absolute number of lymphocyte count is measured on admission to determine the value of (NLR). Parameters like (D-dimer, C-reactive protein, and ferritin) also have been investigated in relation to outcome.

RESULT:
High (NLR) was significantly (p-value = 0.001) linked with lower oxygen concentration and worse prognosis.
CONCLUSION:
Raised (NLR) was a convenient indicator connected with unfortunate outcome in those admitted with COVID-19. High inflammatory markers, like ferritin, CRP, and D-dimer were also associated with doomed prognosis.

Background: The most frequent abnormal physical finding in the first week of life is hyperbilirubinemia, which is found in 60% of term and 80% of preterm newborns. It can be managed by phototherapy, exchange transfusions, and pharmaceuticals. Aims and Objectives: This study aimed to assess the impact of phototherapy and its duration on serum calcium levels in newborns hospitalized for neonatal jaundice. Patients and Method: A prospective cross-sectional study was conducted on 100 neonates with exaggerated physiological jaundice who had been treated with phototherapy in Baghdad over a period of 10 months. The levels of total serum bilirubin and calcium were measured before and after phototherapy, and the number of hours spent receiving phototherapy was noted. Results: The mean serum level of calcium and total bilirubin at admission was 9.43±0.67 mg/dl and 18.2±2.78 mg/dl, respectively which dropped to 8.06±1.18 mg/dl and 8.96±2.0 mg/dl, respectively at discharge with highly significant differences. Serum calcium demonstrated a positive significant correlation with birth weight (r= 0.208, p= 0.038, and a significant negative correlation with the duration of phototherapy (r= -0.492, p<0.001). Each age, gender, and mode of delivery had non-significant relationships with post-phototherapy hypocalcemia. Conclusion: Phototherapy is a significant risk factor for the occurrence of hypocalcemia, and serum calcium has a negative correlation with the duration of phototherapy and a positive correlation with birth weight.

BACKGROUND:
Fingertip injuries are among the most common injuries to upper extremities. Maintenance the functional length of the finger and reconstruction with a durable sensate coverage are among the primary goals in fingertip reconstruction. The aim of this study is to evaluate the use of Propeller digital artery perforator flap in covering traumatic fingertip defects.
PATIENTS AND METHODS:
A prospective study done between April 2019 and January 2020 for 11 patients suffering from traumatic fingertip amputations who underwent reconstruction with propeller digital artery perforator flap. The flap designed on the radial or ulnar aspect of the digit based on perforator closest to the defect which is detected intra-operatively without use of Doppler device. We cover the defect with this flap and evaluate its functional and aesthetic outcomes.
RESULT:
Patient’s age ranged between 15 - 45 years. All flaps survived completely except one flap developed partial skin necrosis. The donor site closed primarily in six of patients and covered with full thickness skin graft in five of them. Temporary venous congestion observed in five cases. Static two-point discrimination test ranged between 3-6 mm. The flaps had good sensation and contour.
CONCLUSION:
Propeller digital artery perforator flap is a reliable one stage procedure, replace tissue of similar characteristics to the original defect digital neurovascular bundle that can be used for all types of fingertip injury.

BACKGROUND:
Urothelial carcinoma is the most common histological type of bladder cancer, it accounts for 90% of bladder cancers. Annexin A6 (AnxA6) is a member of a superfamily of Ca2+dependent membrane-binding proteins.
AIM OF STUDY:
To study the expression of Annexin A6 in high grade urothelial carcinoma and cystitis using anti_Annexin A6 antibody; and to correlate the results with some clinico-pathological parameters such as age, sex, presence of necrosis, inflammation, hemorrhage and muscle invation.
MATERIAL AND METHODS:
A retrospective case control study included a total of 60 paraffin embedded samples were divided into two groups: 30 cases of high grade urothelial carcinoma and 30 cases of cystitis. The samples were collected from the archives of teaching labs of Al Yarmouk Teaching Hospital and the archives of Almustansiryah College of medicine for a period from November 2019 to November 2020.
RESULTS:
Annexin A6 was positive in 73.3% of urothelial carcinoma cases. Males were 86.3% while female were 13.6% of positive cases. Annexin A6 was positive in 40% in cystitis samples.
CONCLUSION:
Annexin A6 expression was significant in high grade urothelial carcinoma samples as compared with cystitis samples. In urothelial carcinoma samples, Annexin A6 was significantly associated with the presence of inflamation, hemorrhage, necrosis and muscle invasion, but there was no association with other clinicopathological parameters. Annexin A6 expression shows significant association in primary tumors rather than recurrent tumors.

BACKGROUND:
TCC is the most common cancer in urinary bladder, despite important advances in cancer treatment, the disease continues to become a big challenges to the clinicians due to high recurrence rate. Invasive urothelial carcinoma is characterized by alterations in cell-cycle regulatory pathways. Altered expression of the TP53 gene has been associated with TCC.
OBJECTIVE:
To evaluate the expression of p53 in urothelial bladder lesions immunohistochemically and to correlate the immunohistochemical expression of p53 with tumor grade and histological diagnosis of lesions.
MATERIALS & METHODS:
This is a retrospective study of 50 bladder biopsy in AL Shaheed Ghazi AL Hariri hospital in Baghdad (covering the period from Jan 2018 to Feb 2019). 49 were transurethral biopsy specimens and 1 was radical cystectomy. Two sections of 5μm thickness were taken from each block, the first was stained (H&E) for histological revision, the other section was stained IHC for TP53.
RESULTS:
The patient’s age was in range of 13 to 89 years with mean of 61.24 years. The highest proportion of study patients was aged > 60 years (70%).
The immunostaining of TP53 was nuclear, P53 positive in 4/10 cases (40%) of flat hyperplasia, 12/19 cases (63.2%) of low grade papillary transitional cell carcinoma and 19/21 cases (90.5%) of high grade papillary transitional cell carcinoma.
CONCLUSION:
There was statistical significant correlation between TP53 expression and urothelial bladder lesions, tumor grade and patients gender.

BACKGROUND:
The escalating need for the Internet is becoming a concern globally, various agents made the internet use addictive to all ages. Recently internet addiction is being considered as a psychiatric disorder
OBJECTIVE:
To measure high school students' prevalence of internet addiction and its association with internet activities, socio-demographic factors and academic performance.
METHODS:
A convenient sample of 526 students from 6 high schools in Baghdad. Using internet addiction test and a questionnaire to enquire about the socio-demographic factors from November 2020 till February 2021.
RESULT:
Internet addiction prevalence was 45.82%, internet addiction severity was (13.3 % mild, 23.4 % moderate and 9.1 % severe). Internet addiction prevalence was higher in Al-Rusafa district and students with chronic illness, internet addiction prevalence was lower in female students with higher academic performance using internet for browsing and studying.
CONCLUSION:
High internet addiction prevalence was associated with male high-school students with low academic performance.

BACKGROUND:
Meningiomas are the most common tumor of central nervous system with a higher prevalence in women. Clinical and epidemiological data reveal that meningiomas are hormone sensitive tumors and they have been found to express hormone receptors.
Meningiomas are common slow growing primary intracranial neoplasms attached to the dura matter and are composed of neoplastic meningiothelial cells and these tumors fall in to WHO grades I, II and III.
AIM OF STUDY:
The aim of this study is to determine the progesterone receptor status in meningiomas by using specific monoclonal antibody and to evaluate the effect of age, gender, tumor grade, location and histological types on hormone receptor status.
MATERIALS AND METHODS:
This is a retrospective study of fourty patients who were diagnosed histopathologically as meningioma.
Formalin fixed, paraffin embedded tissue blocks were collected from pathology departments of Ghazi AL Hariri teaching hospital, for the period from May 2015 to June 2020 and from neurosurgery hospital, for the period from January 2018 to December 2019.
All the clinical details including age, gender, location, histological type and pathological grade have been taken from the patients archive files.
Two sections of 5 µm were taken from each block, the first was stained with hematoxylin and eosin stain (H&E) for histological revision, the other section was stained immunohistochemically for progesterone receptor (PR).
RESULTS:
Fourty patients were studied 27(67. 5%) female and 13(32.5 %) male, age was ranging from 12-70 years with a mean of 49.47 years. Female to male ratio of 2.07:1.Cerebral site was the dominant site of lesion (60%), followed by olfactory groove, parasagittal site (10% for both of them), orbital, sphenoid site (7.5% for both of them) and spinal site (5%).
Regarding histopathological types of meningioma, meningiothelial type was the most common (32.3%), followed by Atypical (20%), Angiomatous (15%), Anaplastic, fibroblastic, psammomatous and transitional (7.5 for each of them), then Anaplastic papillary (2.5%).
In all stained slides of meningiomas, there were positivity for PR (62.5%) with different scores from +1(20%), +2(17. 5%) and +3(25%).
There is a significant statistical correlation between the grade of meningioma (p=0.003), histological types (p=0.014) and PR expression.
There is no significant statistical correlation between age, sex, location and PR expression.
CONCLUSION:
There is a significant correlation between tumor grade, histological types and PR expression and PR immunohistochemical staining is a reliable test when used to predict a low-grade meningioma.

BACKGROUND:
The intervertebral cartilage supports the human body structurally. It absorbs shock and allows movement between adjacent vertebrae1. This framework deteriorates with age, a physiological consequence of the normal aging process.
OBJECTIVE:
To assess alterations that occur between vertebrae of the spinal column from L1 to L5 and to study the changes in vertebral height, occurrence of osteophytes in the lumbar spine vertebrae as well as the prevalence of ligamentum flavum hypertrophy and other signs of degeneration according to the age and sex.
PATIENTS AND METHODS:
The cross sectional study was performed by examining (600) patients suffering from a sharp pain in the lumbar region presented at MRI units at Al-Nuiman Hospital in Baghdad and Ibn Sina teaching Hospital in Mosul .
RESULTS:
The peak age incidence was at the age range of (60-69) years for both degeneration and herniation. Below the age of 40 years, there were 46 patients (7.6%) with degeneration and 22 patients (3.6%) with herniation, while over 40 years the figures were 369 patients (61.5%) showed degeneration and 243 patients (40.5%) with herniation respectively. In addition, there are158 patients have both degeneration and hernia at same time. Out of 600 patients, 371(61.83%) of them are females and 229 (38.17%) are males. The man-to-woman ratio is 1 : 1.6. The vast majority of patients showed degeneration and herniation at L4-L5 level being 367 discs (61.1 %) and 163 patients (27.1 %) out of 600 discs located at that level respectively. Decreased height of the disc increases the potential for fundamental framework changes to the disc, bone and connective tissue.
CONCLUSION:
There is a universal impression that age and sex have an influence on the degeneration of disc of lumber spine

BACKGROUND:
Isolated sphenoid sinus disease represents a difficult to diagnose disease, generally presents with unclear symptoms. With potential serious complications, early diagnosis requires a high index of clinical suspicion and appropriate radiological imaging.
OBJECTIVE:
The study aims to evaluate clinical presentation, pathological features, radiological appearance and different surgical approaches of isolated sphenoidal sinus disease.
PATIENTS AND METHODS:
A cross-sectional study was performed at Baghdad medical city (Ghazi Hariri Hospital for Specialized Surgery/ otorhinolaryngology and Private Nursing Home Hospital) from December 2018 to December 2019, involved 23 patients with isolated sphenoid disease all patients were assessed by history, examination and investigations diagnosis made by CT scan evidence, demographic data, clinical presentation, pathological feature, radiological appearance and surgical approaches were evaluated.
RESULTS:
23 patients with isolated sphenoid sinus disease, their gender distribution was 10 male and 13 female, their mean age was 33.26 years, headache was the most common clinical presentation in 15 (65.21%) patients, CSF leak in 2(8.69%) patients, epistaxis in 1(4.34%) patient, left side facial pain in1(4.34%) patient, bilateral nasal obstruction in 1(4.34%) patient, recurrent attack of sore throat in1(4.34%) patient, loss of vision in 1(4.34%) patient and blurred vision in 1(4.34%) patient. Most common etiology of isolated sphenoid sinus disease was inflammation in 17(73.91%) patients, Neoplasm account in 3(13%) patients. Others account in 3(13%) patients. All patients underwent C.T imaging and M.R.I done to some of them, its finding was recorded. Two surgical approaches used in sphenoid sinus disease, most cases operated by direct endoscopic trans-nasal approach 86.95% in (20) patients and trans-ethmoid used in three patients 13%.
CONCLUSION:
Headache mainly retroorbital is the most common clinical presentation, inflammatory lesion mostly mucocele is the most pathological feature, isodense homogenous soft tissue opacity without bone erosion is the most common radiological appearance, transnasal approach is the most surgical approach of isolated sphenoid sinus disease.

BACKGROUND:
Renal cell carcinoma is the third most common cancer of genitourinary tract and account for approximately 2-3% of all cancer death. Conventional clear cell carcinoma comprises 75% of all renal cell carcinoma. Immunohistochemical had greatly improved the diagnostic accuracy of renal cell carcinoma.
AIM OF STUDY:
Evaluation of the expression of PAX-8 & Carbonic anhydrase IX in randomly selected samples from Iraqi patients who have RCC and correlate their expression with the clinicopathological variables.
PATIENTS &METHODS:
This is a retrospective study of 40 patients who were diagnosed to have renal cell carcinoma, CAIX & PAX-8 markers to be applied to the tumor tissue sections.
The results will be evaluated & correlated with the tumor grade, stage & other clinicopathological features.
RESULTS:
The present study showed that twenty five of cases(62.5%) were conventional clear cell RCC while fifteen of cases (37.5%) were non clear cell RCC. Five of cases (12.5%) were grade 1, twenty three of cases (57.5%) were grade 2, ten of cases (25%) were grade 3 and two of cases (5%) were grade 4. Eighteen of cases (45%) were stage I, seven of cases (17.5%) were stage II and fifteen of cases (37.5%) were stage III. The high expression of CAIX was presented in 71.0% of cases while the low expression was presented in 29.0% of cases, While the PAX-8 expression showed 22.5% of cases were score 0, 20% of cases were score 1, 25% of cases were score 2 and 32.5% of cases were score 3.
CONCLUSION:
Higher expression level of CAIX and PAX-8 in clear cell RCC than in non-clear cell type RCC so aid in differential diagnosis of RCC subtypes. PAX-8 expression was decreases with high nuclear grade while decrease CAIX levels are independently associated with advanced stage. There was no significant correlation between pax-8 &CAIX and clinicopathological variables as age and sex.