Iraqi Postgraduate Medical Journal

BACKGROUND:
Brain metastasis represents a significant source of morbidity and mortality in patients with systemic cancer, In adults, cerebral metastasis are by far the most common intracranial tumors, and their incidence is rising because of increased cancer survival.
GKRS has arguably been the most important advancement in the management of metastatic brain tumors since the 1980s.
PATIENTS AND METHODS:
This is a prospective study of 50 patients of brain metastasis treated with (GKRS) between January 2017 and January 2019. A group of 14 males and 36 females with mean age was 59.1 years, 34 patient were <65 years old and 16 patients were >65 years old.
Patients status assessed according Karnofsky Performance Score (KPS), 4 % were >70 KPS and 96% were <70 KPS. The lung cancer was the primary lesion in 56% of patients, breast was 32%, and Skin Melanoma 8% and unknown origin 4%.
80% of the patients had previous treatment: surgery and chemotherapy (22%), chemotherapy (20%), surgery (16%), surgery, chemotherapy and DXT (10%), surgery, chemotherapy and WBRT (8%) WBRT (2%) and DXT (2%), while absent in 20%.
Brain MRI with contrast follow up was done in 6 months, and after 12 months
RESULTS:
After 12 months of follow up the mean of tumor volume after (GKRS) decrease from 6.2cm3 to 3.4cm3 , The mean KPS improve from (61) to (75) , Local tumor recurrence was (16%) and edma was seen in (20%) ,The Age of patients > 65, KPS < 70, patients with previous treatment surgery, chemotherapy and WBRT had poor prognosis ,The mortality was seen in (20%) half of them related to neurological death and the other to primary tumor.
CONCLUSION:
The Gamma knife radiosurgery is effective and safe treatment modality of secondary brain metastasis and is effective in increasing survival rate and Karnofsky performance scale in addition to reduction of the tumor size of patients with brain metastasis.

BACKGROUND:
Diabetes Mellitus is a complex chronic illness that has increased significantly around the world and is expected to affect 628 million in 2045. Undiagnosed type 2 diabetes may affect 24% - 62% of the people with diabetes; while the prevalence of prediabetes is estimated to be 470 million cases by 2030.
AIM OF STUDY:
To find the percentage of undiagnosed diabetes and prediabetes in a slice of people aged ≥ 45years, and relate it with age, gender, central obesity, hypertension, and family history of diabetes.
METHODS:
A cross sectional study that included 712 healthy individuals living in Baghdad who accepted to take part in this study and fulfilling the inclusion and exclusion criteria.
RESULTS:
From total 712 healthy participants, 373 (52.4%) screened negative for diabetes, 178 (25.0%) screened positive for diabetes and 161 (22.6%) had impaired fasting glucose. There was significant relation with central obesity, family history for diabetes and hypertension.
CONCLUSION:
It was concluded thatscreening for type 2 diabetes and prediabetes is reasonable, both conditions are common in people living in Baghdad and should be considered especially in people aged ≥45 years and those who are obese, have hypertension, and have a positive family history for diabetes.

BACKGROUND:
Anorectal surgery includes pilonidal sinus, hemorrhoidectomy, anal fissure, and anal fistula operations. Various surgical and anesthetic techniques have been used to increase the level of patients perioperative analgesia and decrease the length of stay in the hospital.
AIM OF STUDY:
To compare the effectiveness of saddle block and caudal block during anorectal surgery on patients' perioperative hemodynamic values, onset of sensory and motor block, mobility and frequency of analgesia given post op.
PATIENTS AND METHODS:
80 patients underwent anorectal surgery were randomly allocated into 2 equallygroups, caudal block was applied to the 1st group 40pt. and saddle block was applied to the 2nd group 40 patients .Onset of Sensory and motor block was recorded. Heart rate, systolic arterial pressure, diastolic arterial pressure and oxygen saturation were measured every 3 minutes until the end of the operation. In postoperative period the frequency of rescue analgesic drugs given and duration of staying in hospital were recorded.
RESULTS:
In both groups, there were no changes in hemodynamic profile. No motor block was detected in group B but noted in group A. Onset of sensory nerve block in group B was more rapid than in group A and duration of post operative analgesia was shorter than that in group A. Early discharge from hospital was associated with group B in comparison with group A.
CONCLUSION:
Saddle block provides rapid-onset of sensory block, zero motor block, early ambulation and early hospital discharge in comparison to caudal block which was slower in onset with mild to moderate motor block and associated with increase time of staying in hospital.

BACKGROUND:
Complementary feeding is a process starting when breast/formula milk alone is no longer sufficient to meet the nutritional requirements of infants, and therefore other foods and liquids are needed, along with breast/formula milk.
AIM OF THE STUDY:
To determine the type and time of initial complementary feeding practiced by mothers in Kut City and its relation with some associated factors.
METHODS:
A descriptive primary health center-based study conducted on 500 mothers attending 29 primary health care centers in Al-Kut City for the period of 4 months extended between 1st of April to 31st of July 2017. Data were collected using a structured questionnaire by direct interview.
RESULTS:
The majority of children received food made from carbohydrates (Rice & Rice water, Porridge, Potato’s, Broths, and Biscuits) and Cerelac in percentage of 33.8 and 33.6 respectively. The majority of the complementary feeding was started at 6th month (49.6%).
CONCLUSION:
The majority of infants who attend primary health centers in Al-Kut city received cereal-based food and Cerelac as their first complementary food.

BACKGROUND:
Idiopathic intracranial hypertension (IIH) is a neurological disorder that requires the use of lumboperitoneal (LP) shunt which is the procedure of choice for most surgeons.
AIM OF THE STUDY:
To assess the benefits of using a programmable LP shunt in the treatment of IIH, and how to reach the optimal final performance level with minimal shunt-related complications.
PATIENTS AND METHODS:
A prospective single-center study of 30 patients diagnosed with IIH, treated with adjustable LP shunt in the neurosurgical department at the teaching Martyr Ghazi Al-Hariri Hospital for Specialized Surgery for a period extending from August 30th, 2017 till November 21st, 2018.
RESULTS:
Among the included patients in the study (30 patients), the female:male ratio was 9:1 with an age range of 17-50 years. Most of the cases (40%) were presented with BMI more than 35. The opening pressure was within the range of 280-585 mmH2O. For the final performance level (P/L), 67% ended up with P/L 1.5 and 27% ended up with P/L 2.0. The outcome recorded as headache improvement 97% and visual improvement 85%. The complications were CSF collection 10%, infection 3%, and the need for shunt revision 7%.
CONCLUSION:
Using the adjustable Medtronic Strata NSC valve has the possibility of avoiding shunt-related complications with better outcomes.

BACKGROUND:
Breast cancer has become a major threat to female health in Iraq, with a cancer-related mortality rate of (23%). Despite advances in early diagnosis, treatment, and biomarker identification of breast cancer, it carries a high risk of recurrence, about 20-30% and substantially worse overall survival.
AIM:
To evaluate the role of dynamic contrast enhanced magnetic resonance imaging in differentiation between benign postoperative changes and recurrent malignant tumors in postoperative patient with breast cancer.
PATIENTS AND METHODS:
Cross-sectional prospective study was performed at MRI unit of Al-Imamein Al-Kadhimein Medical city in Baghdad/ Iraq within the period from January 2019 to January 2020. The study included 29 female patients with 42 detected lesions suspected as local recurrent.All women were recruited for dynamic contrast enhanced (DCE-MRI).
RESULTS:
The mean age of 29 patients were 50.58±10.01 years (range 21-66 years). of the 42 detected lesions 22 proved histopathologically as local recurrence (17 were invasive ductal carcinoma, 2 were ductal carcinoma insitu and 3 were invasive lobular carcinoma), the remaining 20 were benign postoperative lesions (8 were fibrosis, 5 were granulation tissue, 5 were fat necrosis, 2 were seroma and 1 was diffuse skin thickening and edema). DCE-MRI study show to have a sensitivity of 95.5%, a specificity of 90%, Positive Predictive Value of 91.3% Negative Predictive Value of 94.7% and an accuracy of 92.86% in differentiation between benign postoperative changes and recurrent malignant tumors.
CONCLUSION:
DCE-MRI is a valuable tool in evaluation of postoperative breast as it has high sensitivity and specificity in differentiation between benign postoperative changes and recurrent malignant tumor.

BACKGROUND:
The validation of the non-invasive radiological tools to replace invasive procedures like Endoscopic retrograde cholangiopancreatography (ERCP)for diagnosis of biliary obstructive disease become essential in modern medical practice. Magnetic resonance cholangiopancreatography (MRCP) is best alternative for ERCP regarding diagnostic aspects.
AIM OF STUDY:
To assess the diagnostic accuracy of MRCP and transabdominal US in identifying the cause of biliary dilatation in correlation with Endoscopic retrograde cholangiopancreatography as the gold standard.
METHODS:
A prospective cross sectional analytic study that involved 64 patients with obstructive jaundice. Abdominal US and MRCP were performed and the cause of obstruction were recorded and correlated with a subsequent ERCP results which were considered as the gold standard. Accuracy, sensitivity, specificity, positive and negative predictive values and P value were calculated for each test.
RESULTS:
Choledocholithiasis was the commonest cause of biliary obstruction (45%). The detection rate for MRCP was 96.6% and for ultrasound was 41.4% regarding CBD stones. The diagnostic performance of MRCP for malignant pathologies was (‎91.7%‎) sensitivity,100% specificity, 91.7% accuracy with significant level for detection (P value <0.001).While trans-abdominal ultrasound had lower diagnostic parameters for malignancy detection with 75% sensitivity, 66.7% specifity, 41.6% accuracy and P value (0.228).
CONCLUSION:
MRCP is a non-invasive technique that can detect level and cause of biliary obstruction with high diagnostic performance especially in choledocolithiasis and malignancies. MRCP can replace the invasive ERCP as a diagnostic tool in most cases. Also if no cause was identified in MRCP, ERCP can be avoided in most cases

BACKGROUND:
Willingness to donate blood is affected by many factors such as availability of blood banks and their accessibility to the public, awareness regarding blood donation and knowledge about blood donation.
AIMS:
To evaluate the (Knowledge, attitude and practice) in a sample of subjects toward blood donation. To determine motivators and barriers that influence blood donation and to study the influence of some demographic character with the means of the KAP scores.
METHODS:
A descriptive cross sectional study was conducted in the National Centre for Blood Donation in Baghdad, data collection was carried out from 1st of March to 31st of May 2019, on a sample of four hundred participants.
RESULTS:
This study results demonstrated higher rate of male participants by 87%, , better knowledge among females (p= 0.001), females also got better attitude than males (p= 0.001).
CONCLUSION:
The most reported motives for blood donation was that they knew it's good for their health and because they liked to help others. The most reported barriers were that they weren't approached to donate and fear of the medical errors.

BACKGROUND
Because a difficult intubation may occur unexpectedly, airway examination is the most critical component of anesthetic practice. Prior to surgery, all of the patients' airway parameters were examined. Parameters included age, body mass index, neck circumference, head movement, mouth opening space, mandibular length, sternomental and thyromental distance, dental deformities, as well as a history of medical, surgical, and difficult intubation were all taken into consideration with thyroid related factors (tracheal deviation and retrosternal goiter).In respect to the preoperative parameters, all patients were categorized intraoperative, using the Cormack and Lehane laryngoscopic View. Clinical data from each test was collected, and analyzed to establish its relevance, positive predictive value, and negative predictive value.
AIM OF THIS STUDY:
The effectiveness of airway characteristics in predicting difficult intubation was compared in a prospective research to enhance airway management especially in those with difficult intubation to prevent post operative morbidity and mortality airways complication.
METHODS:
From January 1 to June 30, 2021, a cross-sectional study was conducted on 72 patients their age range between 25-70 years old both genders .They were admitted to the Baghdad Medical City Teaching Hospital for a variety of elective procedures. The patients were collected and examined preoperatively involving the age, gender, weight and length with special evaluation of upper airway assessment including neck movement is assessed by extending the head at the atlanto-occipital joint and performing the cervical flexion-rotation test manually.
RESULT:
The findings revealed a 13.9 percent incidence of problematic intubation among the 72 patients studied. Higher prevalence of difficult intubation noticed significantly among patients with past medical history (44.4%) , patients with abnormal dentation (36.4%) also Prevalence of difficult intubation was increasing with aging to reach (30% )in patients aged ≥ 50 years. Difficult neck movement before surgery was significantly associated with difficult intubation (P= 0.001). In this study, means of mouth opening and sternomental distance were significantly (P < 0.05) lower in patients with difficult intubation than those with easy intubation. No statistically significant correlation (P ≥ 0.05) % between Cormack-Lehane grading system and any of the other characteristic.
CONCLUSION:
In this study we discovered that patients with a positive past medical history like history of diabetes mellitus and those with abnormal dentation are highly significant preoperative Intubation difficulty predictors. The risk of difficult intubation also increases in patients over the age of 50, difficult neck movement, and in patients with limited mouth opening, as well as short sternomental distance.

BACKGROUND:
Helicobacter pylori represents one of the most common pathogen worldwide. Infection with it can cause medical problem and establishe as etiologic factor in the development of gastritis, So the accurate detection is important for proper patient management.
OBJECTIVE:
This study was conducted to assess the detection of H pylori by Hematoxylin & Eosin, special stain (Modified Giemsa stain) and immune stain in gastritis biopsies and to assess the sensitivity and specificity of each method use in detection.
MATERIAL AND METHODS:
A retrospective and prospective (case series) study, from October 2019 to October 2020, 100 gastric biopsies with gastritis referred to histopathology department, in AL-Khansaa Teaching Hospital and some private labs in Mosul city, were examined.
All biopsy specimens examined histologically to assess H. pyloriinfection, by Hematoxylin & Eosin , modified Giemsa and immunohistochemical stains.
RESULTS:
Patients age range 17 to 78 years with a mean+­­- SD of 44.5+6.11 years. H. pylori positive with H&E /MGS in 79% of cases, while with IHC in 88% of cases. The sensitivity and specificity of the H&E /MGS comparing with the IHC stain were 90% and 100% respectively.
CONCLUSION:
We have concluded from this research that H& E is a reliable way to detect H. Pylori infection. As well as we recommend the usage of IHC in special cases.

BACKGROUND:
Complete Rockall risk score uses clinical criteria and endoscopy to identify patients at risk of adverse outcomes after acute upper gastrointestinal haemorrhage.
AIM:
To Identify patients at risk of adverse outcome following acute upper gastrointestinal bleeding.
METHODS:
An observational descriptive hospital-based study conducted on about 65 patients with acute upper gastrointestinal bleeding. Data from history, physical examination and oesophagogastroduodenoscopy were collected and entered into a Complete Rockall score.
RESULTS:
65 cases were identified (43 men and 22 women; mean age 50.1 years). Patients considered to be at low risk of adverse outcomes were 25(38%), while patients considered to be at high risk of adverse outcome were 40(62%).
CONCLUSIONS:
The majority of the patients who were admitted to hospital with upper gastrointestinal bleeding are of high risk group and of male gender.

BACKGROUND:
Hypotension is the most common complication after spinal anesthesia for patients undergoing cesarean section. Prevention and treatment of post-spinal hypotension has been frequently investigated.
AIM OF STUDY:
Our study aimed to compare the effect of prophylactic infusion of combined ephedrine and phenylephrine, ephedrine, or phenylephrine alone in prevention of maternal hypotension after cesarean section.
PATIENTS AND METHODS:
90 pregnant women that underwent elective cesarean delivery under spinal anesthesia were included and divided into: group A received an infusion of combined ephedrine and phenylephrine; group B received ephedrine infusion, and group C received phenylephrine infusion. Maternal parameters were recorded.
RESULTS:
There was an insignificant difference in demographic data among the groups. The maternal MAP shows no statistically significant difference, but the combined group shows less hypotensive episodes and less maternal side effects.
CONCLUSION:
Prophylactic infusion of ephedrine and phenylephrine combination can effectively decrease spinal anaesthesia related hypotension without any significant side effect.

BACKGROUND:
Renal masses have different histologic types and subtypes, aggressiveness and metastatic potential, depending on there changes in angiogenesis
OBJECTIVE:
Is to evaluate the role of multiphasic contrast enhanced CT scan in prediction histopathology of renal masses.
PATIENTS AND METHODS:
In this prospective study, 50 patients with renal mass were diagnosed by abdominal ultrasound underwent multiphasic contrast enhanced computed tomography prior to surgical treatment,CT parameters at each phase of contrast study and histopathology results were correlated.
RESULTS:
In this study( 26 female and 24 male with mean age of 55.1 ± 10.1) were evaluated, clear renal cell carcinoma was documented in 35 patients(70%), papillary renal cell carcinoma in 5 patients(10%), Wilm´s tumors in 3 patients(6%), chromophobe renal cell carcinoma in2patients(4%), angiomyolipoma in 2 patients(4%),while collecting duct renal cell carcinoma , lymphoma, and tubulocystic renal cell carcinoma were found in only one patient for each one. The correlation of mean mass density with the histopathological types revealed no statistically significant difference in noncontrast phase. Significant difference (P<0.001) was noted in the mean enhancement of mass between the types of RCC during corticomedullary phase, however it is insignificantly different than angiomyolipoma AML (P>0.05). clear cell RCC show maximum enhancement (152H.U at corticomedullary phase ) with rapid wash out while papillary subtype show delayed progressive enhancement with delayed wash out with relatively low level of peak enhancement (69H.U at nephrogenic phase ) AML and chromophobe RCC with other subtypes show moderately rising enhancement with presence of plateau and evidence of delayed washout. From the remaining renal masses that were hypovascular with slow pattern of enhancement during dynamic examination one in old patient proved to be lymphoma and other in pediatric age proved histologically as Wilms tumor.
CONCLUSION:
Muliphasic contrast enhanced CT is reliable modality to differentiate clear cell cancer from other subtype by maximum enhancement and rapid wash out at corticomedullary phase while papillary subtype show delay progressive enhancement with delayed wash out

BACKGROUND:
Dorsal reconstruction and augmentation for a saddle nose or generalized under projecting nose (familial ) require some type of grafting that increase the volume, raise the radix , raise the entire dorsum ,camouflage the osseocartilaginous junction or any irregularity along the dorsum, diced cartilage graft wrapped with fascia lata used to achieve that .
AIM OF THE STUDY :
The purpose of the study was to assess the aesthetic and functional outcome of dorsal augmentation by diced cartilage graft wrapped with fascia lata.
PATIENTS AND METHODS:
Between July 2018 and May 2019. 7 patients included ,4 females and 3 males ,their age ranged between 20 to 37 years ,5 were primary and 2 secondary case rhinoplasty,2 operated by closed approach , 3 open approach and 2 of the them the graft placed by intercartilaginous incision. Subjective evaluation was done by clinical and photographic assessment during postoperative follow up period 3-12 months.
RESULTS:
All the patients were satisfied with the postoperative results. with improvement of aesthetic shape and respiratory function .
CONCLUSION:
Diced cartilage graft wrapped with fascia lata is an effective technique for nasal dorsal augmentation.

Coronavirus disease-2019 (COVID-19) has affected countries around the world. The introduction of COVID-19 vaccines has proved the most effective weapon in the fight against the disease.
The massive vaccination campaign against COVID-19 pandemic started in 2020 lead to significant decrease in the number of symptomatic infected patients and a decline in the mortality related to COVID-19 infection. However, with the vaccination of billions of people, data on vaccine-induced adverse reactions are also emerging.
Here we report a 50 year old woman who manifested a papule-pustular rash within 24hours of receiving the second dose of pfizerBioNTech COVID19 vaccine. We report this case to raise awareness regarding various cutaneous manifestations associated with COVID-19 vaccination.

The systemic acute respiratory syndrome Coronavirus 2 (SARS-COV2) has rapidly and mercilessly spread around the globe causing the Coronavirus 2019 (COVID-19) pandemic.
Patients with chronic disease have been found to have the greatest morbidity and mortality rates, and those with chronic liver disease (CLD) with or without cirrhosis were no exception.