IRAQI JOURNAL OF MEDICAL SCIENCES

Background:Acute peritoneal dialysis is commonly practiced in IRAQ.
Objective:To evaluate and improve the management of peritoneal dialysis in Al-Kindi Teaching Hospital.
Methods:Six hundred and sixty nine patients underwent peritoneal dialysis during the period from January 2011 to June 2012. The mean age of patients was 54±13.9 years. Among the patients, there were 168 cases of acute renal failure, and 501 cases of chronic renal failure requiring acute dialysis.
Results:Acute peritoneal dialysis performed on patients admitted in dialysis unit of Al-Kindi Teaching Hospital was safe, a simple procedure, easily tolerated by the patient and requiring less expertise than hemodialysis and had complication rates nearly comparable to other established centers.
Complications occurred in 349 patients (52%). The most common complication was bleed¬ing in the peritoneal cavity (30%) while dialysis solution leak was the second most common complication (25%). Dialysis episodes complicated by peritonitis was (2.5%). Death rate was 15%.
Conclusion:Acute peritoneal dialysis was performed safely and effectively in Al-Kindi Teaching Hospital. Improvements are possible through closer supervision of new doctors and tighter nursing precaution.
Key Words:Acute peritoneal dialysis, outcome.

Background : High androgen levels may increase cardiovascular disease (CVD) risk in women through adverse effects on lipids, blood pressure, and glucose metabolism. Lipid abnormalitiesare often found in women with CVD.
Objective:To study the relationship between postprandial triglycerides (TG) as a risk factor for cardiac disease and the androgenic activity in postmenopausal women with CVD.
Methods:Postprandial lipid profile and sex hormone levels were measured in 30 patients with CVD and 25 postmenopausal women age and body mass Index (BMI) matched served as control group.Testosterone and sex hormone binding globulin (SHBG), Estradiol (E2), follicular stimulating hormone (FSH) and luteinizing hormone (LH) were estimated.
Results:Postprandial TG, high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C) and atherogenic index (AI) were different between the two groups (P≤0.001). The SHBG and Free Androgenic Index (FAI) were significantly higher in the CVD postmenopausal women (P≤ 0.001) while no differences in testosterone, LH, FSH, and E2 levels noticed between CVD patients and the control group. Serum testosterone levels correlated positively with the postprandial TG and the atherogenic index, and negatively with HDL-C in the CVD patients.
Conclusion:Elevation in androgenic activity could be a cause of higher elevation in postprandial serum TG which may increase the risk of CVD in women.
Key Words:postmenopausal women, cardiovascular disease, postprandial lipid profile, testosterone, sex hormone binding globulin, free androgenic index

Background:The reconstruction of facial deformity has been of paramount clinical concern for many years and one of the most difficult and challenging tasks facing the maxillofacial surgeon. The ultimate goal in the treatment is the relief of suffering, restoration of function of jaw, restoration of speech, regain of the normal looking contour and improvement in the quality of life.
Objective:To obtain more knowledge on autogenous on lay bone graft behavior in different facial defects and to evaluate the lateral and medial surgical approaches to the iliac crest.
Methods:A prospective study was conducted during the period from January 2009 to January 2012 on 20 patients with facial defects, in the orbit, zygoma, maxilla and mandible. The causes of defects were trauma, odontogenic tumors and alveolar cleft. Types of bone graft used were either block cortico-cancellous or chips cancellous bone, the block was either monocortical or bicortical bone graft.
Results:Complications associated with donor site harvesting procedure included pain 5% and gait disturbance 5%. Failure of bone graft was observed in 3 patients (15%) while the rest, 17 patients, (85%) ended with functional and esthetic successful graft. Causes of failure were due to sequestration (5%), inflammation due to osteomesh (5%) and soft tissue breakdown (5%).
Conclusion:Iliac crest graft has evolved as a safe, well accepted procedure, with relatively low morbidity that can be used for a wide variety of maxillofacial procedures.
Keywords:Iliac crest, bone graft, facial defects

Background:Immunohistochemistry seems to be important method for differentiation between papillary thyroid carcinoma which is the commonest thyroid cancer and Grave's disease which may be challenging by light microscopic features only.
Objectives:The aim of the study was to evaluate the immunohistochemical expression of CK 19 antibody that is considered a marker of malignancy in papillary thyroid carcinoma and in Grave's disease and to determine whether CK19 is effective in the discrimination between these two pathological conditions.
Methods:In this retrospective study paraffin embedded archival materials from 40 cases including 20 papillary thyroid carcinoma and 10 Grave's disease in addition to ten normal thyroid tissue were used as a control group, collected from the department of pathology of Al-Yarmook Teaching Hospital for the period between Jan 2009 to Jan 2011. The immunohistochemical expression of CK19 markers was assessed for intensity and extent of staining in semiquantative method.
Results:Sixteen of the 20 papillary carcinomas showed diffuse and intense cytoplasmic staining with CK19 (80%), 4 cases showing diffuse faint staining (20%). Seven of the 10 Grave's cases (70%) are completely negative. The remaining 3 cases showing focal weak staining with CK19 (30%). There was a significant difference in the extent of staining between papillary thyroid carcinoma and Grave's disease and there was highly significant difference in intensity of staining between them.
Conclusions:The staining features of CK19 may be helpful in the differential diagnosis between papillary carcinoma and Grave's disease with papillary carcinoma like structures. This immunoreactivity should be evaluated with histopathological findings in order to prevent over diagnosis of papillary carcinoma.
Keywords:CK19 immunohistochemical expression, papillary thyroid carcinoma, Grave's disease.

Background:N-RAS mutations are the most commonly detected molecular abnormalities in hematologic malignancies, especially in those of myeloid origin.
Objective:Current study aimed to determine the frequency of N-RAS mutation; and its influence on response to induction therapy in patients with acute myelogenous leukemia (AML) in Iraq.
Methods:Peripheral blood and bone marrow samples were taken from 58 newly diagnosed AML patients and 30 individuals with reactive bone marrow were selected as a control group. Samples screened for N-RAS gene mutations using nested PCR were followed by mutation sensitive digestion analysis (MSDA).
Results:N-RAS mutations at the time of diagnosis were found in 10/58 (17.24%) patients with AML and no mutation in control individuals. Patients with mutant N-RAS showed lower complete remission (CR) than wild type, the difference was not significant (60% vs. 72.92%, P = 0.414).
Conclusion:The current results provide clues for activation of RAS-signaling cascade in AML patients, supporting their role in molecular pathogenesis of leukemia. N-RAS mutations show no influence on CR rate in AML patients. Further studies on larger scale to define the prognostic significance of N-RAS mutations are recommended.
Keyword:AML, N-RAS mutation, MSDA, complete remission.

Background:Fissure in ano is a common painful anal problem in female patients.
Objective:To study the sociodemographic variables of female patients with fissure in ano, and to identified the characteristic of anal fissure and their treatment among those patient in Al-Imamian Al-Kadhimiyian Medical City and two private hospitals.
Methods:This is a prospective study that was carried out from May 2008 to May 2011. Two hundred fifty female patients with fissure in ano were interviewed regarding their age, marital state, address, level of education, clinical presentation and the subsequent management.
Result: The commonest age of presentation in females was between 21-30 years. 78% of them were living at the peripheral areas of north of Baghdad, and 79.6% were of low level of education (primary school or below). The prevalence was found more in women with high parity especially when their child delivery was supervised by a midwife in their location. All patient has presented with anal pain, 55% were associated with bleeding per rectum and 64.2% with constipation. The location of fissures was 51.6% anterior, 48% posterior, 0.4% lateral in position. Less than half of patients underwent a surgical treatment. 77% of them were treated by lord dilatation under anesthesia and 23% by lateral sphinecteromty.
Conclusion:Factors which had an impact on the clinical course and management of fissure in ano in female patients were found to be the social status, the level of education and the parity, therefore to prevent this illness, a cooperation between the heath services and the family health center and the government is necessary in order to overcome such a common problem.
Keywords:Fissure in ano, Female

Background:In spite of the recent advances in the endoscopic treatment of urinary stones, extracorporeal shock wave lithotripsy (ESWL) is still the treatment of choice for most renal and upper ureteric stones; however the outcome depends on multiple factors.
Objective:To investigate the effects of stone density, as measured by Hounsfield Units (HU) by non-contrasted computerized tomography (CT), stone size and stone location on ESWL treatment outcome of urinary calculi.
Methods:A prospective study that included 65 patients. Data collection and patient evaluation were performed in Al-Salam Teaching Hospital in Mosul, in the period from March 2012 to December 2012. Patients were submitted to clinical, biochemical and radiological assessments followed by ESWL treatment. Statistical analyses using chi-square, analysis of variance (ANOVA), correlation, regression were performed for statistical significance between ESWL treatment, stone fragmentation and stone density, size and location in the renal pelvicalyseal system.
Results:ESWL success rate was high (92%) for low density stones (< 500 HU). ESWL treatment outcome and stone size were inversely related. CT stone densities of 700 HU or less were almost always successfully treated by ESWL. CT stone density and stone size combined account for nearly 74% of the variation in the number of shock waves required to attain fragmentation. Stones located in lower calyceal area had less success rates.
Conclusion:Stone density measurement is helpful to predict the success of ESWL for urinary stones, stones with higher density, large size and lower location may better be managed by percutaneous nephrolithotomy or endoscopic procedures.
Key words:CT stone density, ESWL, none contrasted CT scan (NCCT).

Background:The Bethesda System (TBS) aims to simplify cervical smear report and make it more reproducible and facilitates the communication between pathologist and clinician.
Objectives:To evaluate 2001 Bethesda System of cervicovaginal smear classification in the diagnosis of different pathologies seen in women having different gynecological complaints.
Methods:A prospective study of cervicovaginal smears that obtained from 360 female patients (aged 15-75 years) attending Gynecological Consultation Clinic in Al-Imamian Al-Kadhimiyian Medical City – Baghdad- Iraq for the period from November 2011 to April 2012. Smears were stained by Pap stain to evaluate according to Bethesda system 2001.
Results:A total of 360 cases were evaluated, 317 cases (88%) had satisfactory smears for evaluation. 246 cases (68.3%) had negative cervical smears for intraepithelial neoplasia (TBS 2001). Seventy one cases (19.72%) had abnormal cervical smears (AS). Minimal cervical smear abnormalities (ASC-US, ASC-H, AGC, LSIL), includes (53) cases (74.64% of AS). HSIL (CIN- II, CIN-III, & carcinoma in situ), includes (18) cases (25.36% of AS).
Conclusion:Pap smear is a screening test, it is not a diagnostic test; positive result indicates that there may be a problem and that further diagnostic procedures must be done. The Bethesda system is of validity in providing a uniform format for cervical cytology report.
Key words:Pap smear, cervical intraepithelial Neoplasia (CIN), LSIL, HSIL, 2001 Bethesda System (TBS).

Background:Variations in the anatomy of gallbladder, bile ducts and the arteries that supply them are important to the surgeon during cholecystectomy, because failure to recognize them may lead to inadvertent iatrogenic injuries.
Objective:To evaluate the type and frequency of anatomical variations of extra hepatic biliary system encountered during cholecystectomy.
Methods:One hundred and fifty patients with gallstones underwent cholecystectomy at Baghdad Teaching Hospital. There comprised 112 females and 38 males with age range between 20-80 years. Open (33 cases) and laparoscopic (117 cases) cholecystectomies were done. Extra hepatic biliary tree was carefully dissected to study the variations in the anatomy of the gallbladder, bile ducts, and the arteries that supply them.
Results:There were only three important vascular and four important ductal anomalies while gallbladder anomalies were rare. The total numbers of the extrahepatic biliary anomalies were 81 cases (incidence 54%), and included vascular anomalies (60 cases = 40%); ductal anomalies (18 cases = 12%); gallbladder anomalies (3 cases = 2%); mostly occurred as Phrygian cap (2 cases = 1.3%). The higher incidence of anatomical abnormalities was found in females 80% (65 cases) while in males 20% (16 cases).
Conclusion:Anomalies of the vascular and ductal components of the extra hepatic biliary tree are relatively common (the former occurring much more frequently than the latter). Failure to recognize them during biliary surgery leads to iatrogenic injuries and can increase morbidity and mortality.
Key Words:Extra hepatic biliary tract; biliary anomalies, cholecystectomy.

Background:H. influenzae bacteria classified as type-able and non-type-able according to the presence or absence of capsule which is correlated with site of isolation.
Objectives:To isolate H. influenzae from different clinical samples and differentiate both capsulated (type-able) and non-capsulated (non-type-able) one by molecular detection method and to make a comparison between the two types by cultural, molecular, and clinical aspects.
Methods:A total of 220 clinical samples were aseptically taken from throat, ear, eye, sputum and CSF of patients attended three main hospitals in Hilla city, Iraq during the period from Feb. 2012 to Jun. 2012. All samples were subjected to bacterial cultivation, standard bacteriological method and molecular detection method. Other primers were used to detect the presence or absence of capsule using Bex A, Bex B, while p2 primer was used to detect non-type-able. Among capsulated one a specific primers (Hib, bex) targeting H. influenzae type b were used.
Results:29 (13.2%) out of 220 clinical samples give presumptive detection and isolation of H. influenzae, of these only 10 (34.5%) were positive using X (haemin) and V (Nad) tests. Using PCR, only 6 out of 10 (60%) were positive, out of 6 isolates only 2 (33.3%) were capsulated (type-able) and 4(66.6%) non-type-able, out of 2 capsulated 1 (50%) was type b H. influenzae.
Conclusion:Specific genetic marker should be used to detect both types. Many non-type-able H. influenzae isolates are also important cause of upper respiratory tract diseases including pharangitis, otitis media, and conjunctivitis. Using serotype specific gene targeting type b (Hib) is important among patient with meningitis and lastly separation between type-able and non-type-able according to the site of isolation.
Keyword:H. influenzae , genetic marker, serotype specific gene, Hib, Bex( A, B) P6, NTHI, X,V factors

Background:Carpal tunnel syndrome (CTS) is the most common nerve entrapment, electrodiagnostic studies are a valid and reliable means of confirming the diagnosis.
Objectives:The study aims to find a correlation between the presence of Tinel's sign and Phalen's maneuver and the degree of severity of the CTS and to compare it with severity of nerve conduction study of median nerve.
Methods:The study involves 133 patients (102 females and 31 males) with CTS, all were examined for Phalen's maneuver and Tinel's sign and median and ulnar nerves electro physiological study in Al-Yarmouk Teaching Hospital and the Neurosciences Hospital in Baghdad between January 2010 and January 2011. Their ages ranged between (19-87) years. The patients were grouped into mild, moderate and severe CTS according to modified Padua scale of CTS severity. Statistical correlation was done using one way Anova test.
Results:Positive Tinel's sign was seen in 25% and positive Phalen's maneuver in 28%, coexistent Tinel's sign and Phalen's maneuver positive at the same time were seen in 47%. Total Tinel's sign was72% and total patients who had positive Phalen's sign was 75%. Mild, moderate and severe CTS were seen in 38%, 41% and 21% out of the total number of the studied patients.
Conclusion:The study didn't find association between severity grading and provocative test, added to negative provocative tests in high percentage of patients. These results mandate the use of electrophysiological examination for the diagnosis of carpal tunnel syndrome and assessment of severity.
Keywords:Carpal tunnel syndrome, Tinel's sign, Phalen's maneuver

Background:Ovarian cancer is one of the most common causes of gynecologic neoplasm all over the world.
Objective:The objective is to shed light on the role of p53 protein and patient`s age in the pathogenesis of ovarian lesions.
Methods:Paraffin embedded blocks of 62 patients with ovarian lesions were studied. Thirty-five cases of surface epithelial ovarian tumors, (31 cases of invasive surface epithelial ovarian tumors, and 4 cases of borderline intermediate malignancy cases of neoplastic ovarian cystic lesions). In addition, eighteen cases of benign neoplastic ovarian cystic lesions and 9 cases of non- neoplastic functional one were enrolled in this study. All of cases included, were stained with p53 by immunohistochemistry.
Results:Immunohistochemistry for p53 showed that malignant cases were positive for p53 while all benign cases were negative for p53 and the borderline cases were also negative for p53. The non-neoplastic cases were negative for p53. There is a significant statistical difference in P53 expression in malignant cases compared to other groups (P < 0.001). A significant difference in mean age of malignant and border line cases in comparison with benign and non-neoplastic cases; (P < 0.001).
Conclusion:Protein p53 may play a role in the pathogenesis of malignant ovarian cancer but not in benign lesions. The age of the patient has a role as a risk factor in ovarian lesions.
Keywords:Ovarian lesion, ovarian cancer, p53, immunohistochemistry.

Background:Many mothers breastfeed their babies while they are pregnant.
Objective:To explore whether breastfeeding during pregnancy increases the risk of miscarriage and preterm births.
Methods:A case-control study conducted in Al-Mawany General Hospital through a period extended from first of September 2011 till the first of September 2012. Two hundred fifteen pregnant women who breastfed during pregnancy and two hundred eighty pregnant who weren't breastfeeding during pregnancy were studied. Demographic data, frequency of miscarriage and preterm deliveries and neonatal birth weight were compared between the two groups. Chi-Square and student t-test were used to compare the result. Significant difference was considered when P value < 0.05.
Result: The frequency of miscarriage among those who breastfed their babies during pregnancy were significantly lower than among those who didn’t breastfed during pregnancy, this was unaffected by exclusiveness of breastfeeding, however, there was statistically insignificant difference in the frequency of preterm deliveries and in the birth weight between the two groups.
Conclusions:Breastfeeding doesn't increase the risk of miscarriage or preterm births neither does it affect neonatal birth weight.
Keywords:Miscarriage, breastfeeding, preterm labour, exclusive breastfeeding, non exclusive breastfeeding

Background:Pediatric urolithiasis (UL) should not be underestimated, because it is associated with significant morbidity, particularly because stones tend to recur.
Objective:To study the demographic characteristics, clinical manifestations, metabolic disorders and some risk factors for stone formation in a group of Iraqi children.
Methods:A total of 96 children with UL comprised 66 males and 33 females with an age range 0.1-14 years were studied for the period from 1st of January 2009 to the end of December 2011.
Results:Positive family history was present in 29 patients (30.2%); all of them had metabolic disorder. Recurrence rate of stone was recorded in 41 (42.7%); of them 28 (68.3%) had metabolic disorder. The commonest clinical presentation was urinary tract infection in 40 (41.7%). Urine culture was positive in 57 (59.3%) children predominated by E.Coli in 23 (40.3%). Twenty four hour urine collection were positive for metabolic disorders in 84 patients (87.5%) and mainly hypercalciurea in 53 (63 %), hyperoxalurea in 31 (36.9%), hyperuricosurea in 23 (27.3%), and cystinurea in 15 (17.8%). Staghom calculi were detected in 6 patients (6.2%), all are associated with infection. Chemical analysis show calcium salt as major component in 22 out of 33 stones (66.6%). Predisposing risk factors for stone formation was established in 91 patients (94.8%) while no etiology could be found in 5 (5.2%). Metabolic disorders were the major risk for stone formation in 54 (56.3%), infection in 21(21.8%) and renal anomalies in 16 (16.7%).
Conclusion:Metabolic disorders were found to be the major predisposing factors to stone formation among this group of Iraqi children. Early presentation, family history of stone disease, high recurrence rate of UL, bilateral and multiple stones are all indicators for metabolic disorders which mandate complete metabolic evaluation in pediatric stone formers.
Keywords:Urolithiasis, stones, metabolic, children

Background:Several studies have demonstrated that Wilms’ tumour gene 1 (WT1) is consistently overexpressed in most forms of leukemias, and the usefulness of quantitative assessment of WT1 expression as a molecular marker for minimal residual disease (MRD). Many suggest a role of WT1 for angiogenesis in hematological malignancies, WT1 is also expressed in a large variety of tumour blood vessels, and some suggests that it might be a general marker for angiogenesis.
Objective:To assess the role of WT1 protein expression immunohistochemically in chronic myeloid leukemia (CML) and to determine whether there is a correlation between WT1 protein expression and CD31 expression as a marker of angiogenesis.
Methods:This study involved 16 cases of newly diagnosed CML. In addition, 20 age matched control cases were involved having no apparent bone marrow pathology. Immunohistochemistry was done on bone marrow biopsies using Anti-WT1 and Anti-CD31 Monoclonal antibodies.
Results:There was a significant increase in WT1 protein expression in CML cases, as well as an increase in CD31 expression; however, there was no significant correlation between WT1 expression and hematological parameters (WBC count, platelets count, PCV level, and peripheral blood blast %) and CD31 expression.
Conclusion:This study showed that WT1 is overexpressed in CML patients, while it was undetected in controls, thus we may propose that it maybe used as an auxiliary marker for the disease. WT1 expression was not found to be of prognostic significance. Moreover CD31 as a marker for angiogenesis was significantly increased in CML but did not correlate with WT1 expression.
Key words:WT1, chronic myeloid leukemia, immunohistochemistry