Iraqi Postgraduate Medical Journal

BACKGROUND:
The advantage of gamma knife radiosurgery is lack of major side effects. It is preferred over microvascular decompression in elderly patients who are poor candidates for general anesthesia or those unwilling to undergo an open neurosurgical procedure.
PATIENTS AND METHODS:
This is a comparative study conducted at Dr. Saad Alwitry Neuroscience Hospital, Gamma Knife Department. 20 patients were included in the study, divided into 2 groups in which 10 are treated with dorsal root entry zone DREZ and the another 10 treated with retrogasserian RG, starting from July 2019 to March 2020. The new target (retrogasserian zone) was targeted for the first time in Iraq, were compared to those patients treated with root entry zone as their target. The follow up time was 4 months. The DREZ target received 80 Gray in 50% isodose, while the RG target received 90 Gray in 50% isodose.
RESULTS:
The mean age is 54.3 years for DREZ and 59 years for RG, most of the treated patients are female with male to female ratio 2.2-1, pain intensity was assessed by BNI scale pre and post Gamma Knife that targeted both DREZ and RG, pain intensity with DREZ, mean improvement is 3.2. Pain is significantly improved.
Pain intensity with RG, mean improvement is 3.2, pain is significantly improved. Pain frequency was less in postGK for both the DREZ & RG with mild superiority in the RG.
CONCLUSION:
GK is considered as being both a safe and effective procedure to treat medically resistant trigeminal neuralgia. GK is the least invasive procedure in treating medically resistant trigeminal neuralgia MRTN, with the least and less serious complications. GK targets (DREZ & RG) both can achieve a good pain control with decrease in medication and improving overall life quality. RG target shows slight further reduction in pain frequency than DREZ.

BACKGROUND:
Core Needle Biopsy involves introducing large hollow needle through the skin to collect a tissue for investigation. It’s become a well-established method as the standard sampling procedure. It’s a relatively safe, minimal invasive procedure with diagnostic accuracy comparable to open surgical biopsy.
AIM OF STUDY:
Assess the accuracy and safety of core needle biopsy in diagnosis of renal and suprarenal tumors.
METHODS:
This is a prospective interventional study. Core needle biopsy was done for 42 patients; 38 patients were included. Biopsy done by activation of needle biopsy device that introduced into the tumor under ultrasound guidance and collection of sample.
RESULTS:
Wilms tumor was positive in 71.1 % (n=27), 23.6 % (n=9) were neuroblastoma and 5.3 % (n=2) were non-conclusive. Only 18.4% (n=7) developed hematuria while intra-abdominal bleeding was not observed in any patient. For Wilms tumor the sensitivity is 93.1 % and the specificity is 100 % and diagnostic accuracy is 94.7 %. The sensitivity, specificity and diagnostic accuracy for neuroblastoma are 100 %.
CONCLUSION:
It is a simple, safe and efficient method for diagnosing renal and suprarenal tumors, complications occur infrequent, and most are easily treated or self-limiting.

BACKGROUND:
Although laparoscopic cholecystectomy became the gold standard for the treatment of gallstone disease, there is some risk of surgical site infection that required prophylactic antibiotic. Prophylaxis for low risk patients is still controversial as well as whether single or multiple doses is needed.
AIM OF STUDY:
Compare between single vs. multiple dose of antibiotic prophylaxis in laparoscopic cholecystectomy in terms of post-operative infection and cost.
METHODS:
A prospective study conducted at Baghdad Teaching Hospital, from January 2017 to March 2018. 200 patients admitted for elective laparoscopic cholecystectomy randomly divided in two equal groups: single dose (SD) group was given ceftriaxone (2gm) intravenously at induction of anesthesia, and multiple doses (MD) group was given ceftriaxone (2gm) intravenously at induction of anesthesia followed by ceftriaxone (1gm) intravenously twice a day for two days postoperatively. Surgical site infection and treatment cost in two groups compared and analyzed.
RESULTS:
Postoperative infection rate was 1% in both groups; the difference was not significant (p=1). The cost was higher in MD group.
CONCLUSION:
Single dose prophylactic antibiotic administered at induction of anesthesia, is equally effective as multiple doses to prevent post-operative infection in low risk patients undergoing laparoscopic cholecystectomy and is cost effective.

BACKGROUND:
Hodgkin’s lymphoma is one of most curable lymphoid malignancy. Here we conducted in this study the outcome of frontline therapy in adult Hodgkin’s lymphoma patients.
AIM OF STUDY:
1. To evaluate the results of first line treatment with ABVD chemotherapy protocol in patients with Hodgkin’s lymphoma in this study.
2. To find predictors associated with poor outcome of first line treatment with ABVD chemotherapy protocol in patients with Hodgkin’s lymphoma in this study.
METHODS:
This is a retrospective and prospective study in which information was gathered from Baghdad hematology center involving 50 patients who were diagnosed with Hodgkin’s lymphoma from 1/1/ 2017 until mid of 2019 and treated with frontline therapy, ABVD chemotherapy protocol.
RESULTS:
The mean age of diagnosis was 29.6 ±12.12 year. Nodular sclerosis was the predominant subtypes constituted (62%) of patients. Advanced stage disease involved 86% of patients. At interim evaluation by imaging studying including either ultrasound and CT scan or Pet scan according to availability , complete remission, partial remission and progressive disease involving 58% , 26% and 16% of patients respectively. Two years progression free survival was 68.95%. There was a strong correlation between lymphocytopenia and progression free survival. In this study, univariate analysis showed that initial lymphocytopenia was poorly associated with chance of achieving complete remission at end of treatment.
CONCLUSION:
The outcome of ABVD in this study shows lymphocytopenia was poorly associated with complete remission at end of treatment of patients.

BACKGROUND:
Prostate carcinoma is one of the most common malignant tumors in men older than 50 years of age and is characterized by a highly variable clinical course. Cyclin D1 proto-oncogene is an important regulator of G1 to S phase progression in many different cell types
AIM OF STUDY:
To study the expression of cyclin D1 in prostate adenocarcinoma, and to evaluate the relationship of this protein with clinicopathological features (histological grade, perineural invasion, and preoperative PSA level).
MATERIALS AND METHODS :
This is retrospective study including 50 cases, forty cases diagnosed histopathology as prostate adenocarcinoma and 10 cases as a benign prostatic hyperplasia. These cases were collected from laboratory department of AL Shaheed Ghazi ALhariri hospital from November 2018 to May 2019. Type of biopsy is a needle core biopsy.
RESULTS:
The immunohistochemical expression of cyclin D1 was negative in benign prostatic hyperplasia, while in prostate adenocarcinoma 52.5% were positive .There was significant correlation between histological grade of prostate adenocarcinoma and immunohistochemical expression of cyclin D1 There was no association between immmunohistochemical expression of cyclin D1 in prostate adenocarcinoma with the presence of perineural invasion, and the pre –operative PSA level.
CONCLUSION:
Cyclin D1 expressed in prostate carcinoma and not in benign prostate hyperplasia.
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BACKGROUND:
Prostate carcinoma is one of the most common malignant tumors in men older than 50 years of age and is characterized by a highly variable clinical course. Cyclin D1 proto-oncogene is an important regulator of G1 to S phase progression in many different cell types
AIM OF STUDY:
To study the expression of cyclin D1 in prostate adenocarcinoma, and to evaluate the relationship of this protein with clinicopathological features (histological grade, perineural invasion, and preoperative PSA level).
MATERIALS AND METHODS :
This is retrospective study including 50 cases, forty cases diagnosed histopathology as prostate adenocarcinoma and 10 cases as a benign prostatic hyperplasia. These cases were collected from laboratory department of AL Shaheed Ghazi ALhariri hospital from November 2018 to May 2019. Type of biopsy is a needle core biopsy.
RESULTS:
The immunohistochemical expression of cyclin D1 was negative in benign prostatic hyperplasia, while in prostate adenocarcinoma 52.5% were positive .There was significant correlation between histological grade of prostate adenocarcinoma and immunohistochemical expression of cyclin D1 There was no association between immmunohistochemical expression of cyclin D1 in prostate adenocarcinoma with the presence of perineural invasion, and the pre –operative PSA level.
CONCLUSION:
Cyclin D1 expressed in prostate carcinoma and not in benign prostate hyperplasia.
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BACKGROUND:
Dermatological problems are common in patients with other medical problems, they may provide clue to the diagnosis of medical diseases.
AIM OF THE STUDY:
To study consultations from different departments of Baghdad Medical City to Baghdad Center of Dermatology and Venereology regarding frequency causes of referral and final dermatological diagnosis, and to design a typical consultation form.
PATIENTS AND METHODS:
This is a cross – sectional observation study, it was conducted at Baghdad Center of Dermatology and Venereology, Baghdad Medical City, Iraq from October 2018 to January 2020 (15 months).
All consultations from other departments of Baghdad Medical City to dermatological department were included in the study.
RESULTS:
A total number of 998 consultations out of 39540 patients attended dermatological department during the same period of study (3% from total patients that consulted the department during this period), 694 (69.5%) patients were outpatients while 304 (30.5%) patients were inpatients. The age range was from 1day to 86 years old with a median age of 26. The most common consultations were referred from pediatric department with total number 256 (25.6%) patients, rheumatology department 220 (22%) patients followed by hematological department 157 (15.7%) patients. The most common dermatological disease group that was diagnosed by dermatologists was eczematous disorders 107 (10.7%) patients, viral infections 106 (10.6%) patients followed by parasitic infestation 87 (8.7%) patients. Scabies represents the most common disease that was referred to dermatological department (8.3% of all consultations).
CONCLUSION:
Consultations were referred from 23 different departments; the most common ones were from pediatric department. Dermatological opinion helped to reach the final dermatological diagnosis among referred patients.

BACKGROUND:
Transient tachypnea of the newborn (TTN) is a condition characterized by tachypnea that develops shortly after birth but resolves within 2 to 5 days. TTN has been reported to occur more frequently in Caesarean delivery, maternal sedation, perinatal asphyxia, maternal asthma, and birth of male infants.
AIM OF THE STUDY:
To assess the risk factors for transient tachypnea of newborn in Duhok.
METHODS:
This study included 100 cases with TTN and 100 controls who are full term neonates without any respiratory problems. All participants were chosen from deliveries in Maternity Hospital in Duhok from Nov. 2018 till Nov. 2019. The diagnosis of TTN was established with clinical and radiology data and by excluding other causes of respiratory distress. Potential risk factors for TTN are selected as follows: maternal age, parity, history of infertility, pregnancy-induced hypertension, premature rupture of membranes, induction or augmentation or both of labor, mode of delivery, neonatal birth weight and Apgar score of the neonates.
RESULTS:
This study showed the risk factors that emerged to be significant in this study that included multigravida mother, pregnancy induced hypertension, birth weight <2,500grams , APGAR score<7 at 5min and delivery by Caesarean section( elective and emergency) .Other risk factors that were not significant included maternal age >35years ,maternal infertility, in vitro fertilization, maternal diabetes mellitus, maternal asthma, male gender, prolonged rupture of membrane, induction of labor and twin pregnancy.
CONCLUSION:
Low birth weight, APGAR score <7 at 5 minutes, delivery by Caesarean section, pregnancy induced hypertension in the mother and multiparty are significant predisposing factors for transient tachypnea of newborn.

BACKGROUND:
Positive people’s perception determines their interaction and provides support to persons with mental health problems in order to express their own emotional problems and seeking care while negative perception results in avoidance, discrimination, stigma, and even low access to health services.
OBJECTIVE:
To assess the perception towards people with mental health problems, among people who attend Primary Health Care centers (PHCCs) in Baghdad, and to study the association of the level of perception with certain personal attributes.
METHODOLOGY:
A cross-sectional study was conducted on a sample of Primary Health Care centers (PHCCs) in Baghdad. Five centers from each side of Baghdad City (Karkh and Rusafa).The study was conducted on 400Iraqi adults attended the selected centers, for a period of four months extended from 1stFebruary to the end of May 2019.
RESULT:
The results revealed that 56.8% of the respondents were with fair perception, 32% with good perception and only a small proportion of the respondents (11.3%) have poor perception towards mental health problems. The educational level of respondents and their occupational status were found to be significantly associated with perception of mental health problems.
CONCLUSION:
In the current study, a small proportion of the respondents have poor perception towards mental health problems, and regarding the association of perception with different demographic characteristics, the educational level and the occupational status were found to be significantly associated with perception toward mental health problems.

BACKGROUND:
Placental alpha microglobulin-1 (PAMG-1) is an important biomarker for the detection of preterm labor and premature rupture of fetal membrane, also fetal fibronectin leak observed into the vagina if a preterm delivery is likely to occur and can be measured by a screening test.
OBJECTIVE:
To compare the rapid bedside test for (placental alpha microglobulin-1) with the instrumented fetal fibronectin test for prediction of imminent spontaneous preterm delivery among women with symptoms of preterm labor.
PATIENT AND METHODS:
A prospective observational study, it included 86 pregnant women between 24 – 35 weeks of gestation with singleton pregnancy, viable fetus, intact membrane, and cervical dilatation ≤ 3 cm who attend to the labor room of the hospital complaining from signs and symptoms of spontaneous preterm labor.
Patients were tested for placental alpha microglobulin-1 with the instrumented fetal fibronectin test for prediction of imminent spontaneous preterm delivery.
RESULTS:
The positive predictive values for spontaneous preterm delivery within seven days for placental alpha microglobulin-1and fetal fibronectin were 25% (4/16) and 5.6% (2/36), respectively (P= 0.001 for placental alpha microglobulin-1 superiority), while the negative predictive values were 82.9% (58/70) and 72% (36/50) for placental alpha microglobulin-1 and fetal fibronectin, respectively (P= 0.02 for PAMG-1 superiority). The sensitivity and specificity of placental alpha microglobulin-1 were (25%, and 82.9% respectively), and of fetal fibronectin were (12.5%, and 51.4% respectively).
The PPVs for spontaneous preterm delivery within 14 days for placental alpha microglobulin-1 and fetal fibronectin were 43.8% (7/16) and 11.1% (4/36) respectively (P= 0.001 for placental alpha microglobulin-1 superiority), while the NPVs were 81.4% (57/70) and 68% (34/50) for placental alpha microglobulin-1 and FFN, respectively (P= 0.001 for placental alpha microglobulin-1 superiority). The sensitivity and specificity of placental alpha microglobulin-1 were (35%, and 86.4% respectively), and of fetal fibronectin were (20%, and 51.6% respectively).
CONCLUSION:
Placental alpha microglobulin-1 performed the same as fetal fibronectin in ruling out spontaneous preterm delivery among contemporary cohort of symptomatic women but demonstrated statistical superiority in predicting it.

BACKGROUND:
Polycystic Ovary Syndrome (PCOS) is an endocrine-metabolic disorder characterized by multiple hormonal imbalances, reflecting on a clinical presentation dominated by manifestations of hyperandrogenism and insulin resistance. Plasma homocysteine is a non-protein sulfur-containing α-amino acid plays a role in cardiovascular morbidity and mortality due to its atherogenic and prothrombotic properties.
OBJECTIVE:
To assess the association between insulin resistance and homocysteine level in women suffering from polycystic ovary syndrome.
Study design: A case control study.
Setting: Department of Obstetrics and Gynecology at Al-Elwiya Maternity Teaching Hospital during the period from 1st of March 2017 to end of April 2018.
MATERIALS AND METHOD:
One hundred women suffering from polycystic ovary syndrome and same number of healthy women were included in the study.
After assessment according to questioner form, fasting blood sugar, serum insulin and plasma homocysteine were checked to find the association among them, the insulin resistance was calculated according to the following formula “IR= Fasting Glucose X Fasting Insulin/22.5= mmol/dl”.
RESULTS:
Increase in body mass index is found to be accompanied with increase in mean fasting blood sugar (6.4±2.7 mmol/L), Insulin resistance (11.6±10.7 mmol/L) and homocystiene level (14.9±1.6 µmol/L) when compared to control group whose mean values are (4.4±0.5 mmol/L, 3.6±1.5 mmol/L and 9±1.7 µmol/L) respectively were significantly higher. A noticeable significant association between obesity and high fasting blood sugar (p0.04), high insulin resistance (p0.009) and homocysteine level (p0.001) in women suffering PCOS.
CONCLUSION:
There are significant differences found in homocysteine level and insulin resistance among women suffering from PCOS when compared to control group. A significant positive association between increased homocysteine level and insulin resistance with increased body mass index in women with PCOS.




PCOS insulin resistance homocysteine

BACKGROUND:
Hemorrhoids are quite common disease affecting the anus and may require traditional surgical treatment, but the rubber band ligation (RBL) emerged as a less invasive and effective method of treatment.
AIM:
This study was performed to assess the efficacy of rubber band ligation as an option in the treatment of hemorrhoid in comparison to classical hemorrhoidectomy using (pain, bleeding, return to daily activities and recurrence) as parameters.
METHOD:
A prospective study was conducted from January 2018 till July 2019 at Mosul teaching center, it compares the results of RBL and classical hemorrhoidectomy. It includes 100 patients having grade two and three hemorrhoid who were selected randomly and divided into 2 groups of 50 patients each (hemorrhoidectomy group and RBL group). Patients with other lesions such as fissures and fistulae were excluded from the study. All data were recorded and subsequently analyzed.
RESULTS:
From 100 patient, the 50 patient whom were treated by rubber band ligation had less pain , less bleeding, early mobilization, and more cost effective as they were treated as an outpatient basis compared to hemorrhoidectomy group; however, the recurrence rate (after less than 6 months) were much higher in RBL group compared to Hemorrhoidectomy group.
CONCLUSION:
RBL can be used effectively in the treatment of grade 2 and 3 hemorrhoid as it has less postoperative complications (less pain and less bleeding) and should be considered as first line in patients who are unfit for surgery as it is done as an outpatient basis. However, patients may need multiple sessions (more recurrence rate) especially those with multiple hemorrhoids and with grade 3 hemorrhoid.

ACKGROUND:
Skin tumors and tumor like conditions constitute an important part of the work of the dermatopathologist. The incidence, the clinical and pathological characteristics differ in different countries due to genetic and environmental factors.
AIM OF THE STUDY:
To evaluate the rates of skin tumors and tumor like conditions and to study the histopathological characteristics of 3 important malignant neoplasms (basal cell carcinoma, squamous cell carcinoma and malignant melanoma).
PATIENTS AND METHODS:
The study is a cross-sectional retrospective study. It was conducted at the Histopathology Department, Teaching Laboratories, Baghdad Medical City during the period extending from the beginning of January 2018 till the end of December 2020. It included all skin biopsies sent from different departments. It included 243(37.97%) skin tumors and tumor-like conditions from 640 skin biopsies.
RESULTS:
Females were more commonly affected than males with a female to male ratio of (1.19:1). Malignant tumors (67.48%)) were more common than benign tumors (32.51%). The most common malignant tumor was basal cell carcinoma)(16.87%), followed by direct invasion by cancer (15.64%), then squamous cell carcinoma (9.87%). The most common benign tumors were intradermal nevus (3.7%), skin tag (3.7%%)and seborrheic keratosis (3.29%).
CONCLUSION:
Skin tumors and tumor like conditions constitute an important part of the work of the dermatopathologists. Malignant neoplasms were more frequently encountered than benign neoplasms in our laboratory. Basal cell carcinoma, direct local invasion by cancer and squamous cell carcinoma were the most frequently reported.

BACKGROUND:
Cancer is the greatest cause of mortality in the world; Breast cancer claimed the lives of 2.26 million worldwide.
OBJECTIVE:
To determine the reasons for reluctance to examine the mammogram among women attending early detection clinics for breast cancer in the city of Mosul / Iraq
METHOD:
A cross-sectional study was carried out between January 2018 and December 2020. It was carried out in early detection clinics in Mosul's two major hospitals. Females who were diagnosed as breast cancer participants were included in the study.
RESULTS:
A Total of 384 women were diagnosed with breast cancer, (mean age 52.96 ±12.4 years) and the women are reluctance to examine the mammogram was 72.76 %. Reasons were unavailability of x-rays at 25.45%, fear at 20.43% and not knowing about a mammogram at 15.77%. There were 16.62%, 32.29%, and 17.18% of patients with stage-III breast cancer, 5.2%, 10.41%, 8.59% stage-II and 0.26%, 1.3%, 2.34% Stage-I who was discovered in the years 2018, 2019 and 2020 respectively. The percentage of cases with stage-IV decreased from 2% in 2018 to 1.3% in 2020.
CONCLUSION:
Unavailability of x-rays, fear and not knowing about mammography, were among the most important reasons for women reluctance to examine the mammogram. As well as the increase in the percentage of women who underwent examination in the second year of activating the early detection program for breast cancer, it was noted that the stage of the disease discovered in women gradually decreased during the research years.
There is an urgent need for more efforts to improve the early detection program for breast cancer and to classify women at risk of developing breast cancer according to risk factors.

BACKGROUND:
Alopecia areata is a common type of non-scarring hair loss. The typical clinical features are well circumscribed bald patches. Vitiligo is an acquired skin disease of progressive melanocyte loss which is clinically characterized by well-defined milky-white macules. alopecia areata and vitiligo are observed with other autoimmune diseases .among these diseases, the chance of coexistence with autoimmune thyroid diseases is high.
OBJECTIVE:
To determine whether vitiligo or alopecia areata has statistically significant association with subclinical thyroid dysfunction.
PATIENTS AND METHODS:
This case control study wascarried out on 69 vitiligo, 69 alopecia areata patients and 75 sex and age matched control. Serum samples from both patients and control were collected and assayed for triiodothyronine (T3), thyroxine (T4), thyroid stimulating hormone (TSH) then we compared the results between cases and control.
RESULTS:
Thyroid functional abnormalities were found in 18.8%, 13% of vitiligo and alopecia areata patients respectively, subclinical hypothyroidism constitutes 78%, 69% of them respectively .however when were compared with control group, there are no statistically significant differences in thyroid dysfunction between vitiligo or alopecia areata and control.
CONCLUSION:
There is no statistically significant difference in thyroid dysfunction between vitiligo or alopecia areata and control. Thyroid function test is unnecessary for alopecia areata or vitiligo patients unless the patient had signs and symptoms of thyroid disease, old age or severe clinical subtype of disease.
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BACKGROUND:
Tuberculosis is one of the most common communicable diseases world wild and continues to be a major global health problem. It causes disease among millions of people each year, and, after HIV, it ranks as the second leading cause of death from an infectious disease worldwide. TB is a public health priority in Iraq. A report published by the World Health Organization highlighted ' the value of undergraduate tuberculosis training and outlined a systematic educational plan to ensure that students are provided with the necessary knowledge, skills, and attitudes essential to the effective management of tuberculosis.
AIM OF STUDY:
To assess the level of knowledge and attitude of medical students towards tuberculosis in the College of Medicine /University of Kufa and College of Medicine /University of Babylon in Iraq .
METHOD:
A cross-sectional study was done on medical students (4th ,5th,6th stages) at College of Medicine/ University of Kufa and College of Medicine / University of Babylon in Iraq during one year. Data was entered and statistical analysis conducted using statistical package for the social sciences version 20 (SPSS).Chi square test(X2-test) used for categorical variables. P value of 0.05 or less considered statistically significant.
RESULTS:
The overall knowledge of all students(84.5%) and overall attitude (76%).There was a significant difference between male and female in regarding attitudes questions, male percent of good attitudes was (79.9%) higher than female percent(73.8%). The percent of Babylon medical students of good knowledge was (86.7%) higher than percent of good knowledge of Kufa medical students (81.9%), but there was no significant difference between both colleges.
CONCLUSION:
The overall knowledge and attitudes were high in the present study .The percent of knowledge for Babylon medical students were higher than the percent of knowledge for Kufa medical students. There was a low percent of correct answers in some aspects regarding knowledge about epidemiology, chemoprophylaxis, transmission isolation of active disease patients and treatment of tuberculosis patients with human immunodeficiency virus.