Iraqi Postgraduate Medical Journal

BACKGROUND:
Remifentanil is widely used as intraoperative analgesic. Post infusion hyperalgesia has been documented experimentally in both animal and human volunteers. Gabapentin has anti-hyperalgesic effect.
OBJECTIVE:
To evaluate the effect of single preoperative oral dose of 300 mg gabapentin in attenuation of postoperative hyperalgesia induced by remifentanil and the decrease in post-operative analgesic requirement.
PATIENT AND METHOD:
A prospective randomized clinical trial conducted in Tikrit teaching hospital/ Iraq, at 2013. It involves 60 patients who underwent appendectomy. All patients were randomly allocated into two equql groups (each of 30 patients): First controlled group (CG) didn’t pre-medicated with gabapentine and 2nd gabapentine group (GG) pre-medicated with gabapentin.
Intraoperative infusion of remifentanil was used & postoperative pain was assessed in all cases.
RESULTS:
The numerical analog scale NAS score and analgesia requirement post operatively was significantly higher in most times in the (CG) as compared with those of the (GG).
CONCLUSION:
Premedication with 300mg gabapentin orally decreased hyperalgesic effect induced by remifentanil and so decreased the pain score and the analgesic requirement postoperatively.

BACKGROUND:
β-Thalassemia is an inhereted hemoglobin disorder characterized by the absence or reduced synthesis of the β-globin chain. Several immunological defects can be found in patients with β-thalassaemia. Increased IL-8 level was documented in patients with β-thalassaemia and it is probably due to overstimulation of macrophages.
OBJECTIVE:
Evaluation of serum levels of IL-8, soluble IL-2 Receptor, and serum ferritin in the splenectomized and the non-splenectomized β-thalassemia major patients.
METHODS:
A cross sectional study was conducted on 60 patients with homozygous β-thalassemia major who were attending Al Karama Teaching hospital from May 2011 to Auguest 2011. Place of work was Al-Kadhmia and Al Karama teaching hospital. Patients were divided into two groups; thirty splenectomized, thirty non-splenectomized, and thirty healthy age and sex matched as control group.
RESULT:
The mean level of IL-8 was increased in both groups of thalassaemia with significantly higher in the splenectomized 333.06±255.50 pg/ml compare to the non-splenectomized 118.61±46.59 pg/ml and the control 38.39±9.52 pg/ml , P-value<0.05. The mean level of sIL-2R was not increased above the reference range in the control subjects, the non-splenectomized and the splenectomized, which was 732.96+28.96 pg/ml, 723.42±74.15pg/ml and 777.38±86.93pg/ml respectively .The mean serum ferritin level in the splenectomized was 2050.1 ng/ml which was significantly higher compared to the non- splenectomized 1212.2 ng/ml, P-value<0.05. There was significant correlation between IL-8 and serum ferritin, P-value<0.05 while there was no significant correlation between s IL-2R and serum ferritin, in both groups of Thalassaemia P value> 0.05.
CONCLUSION:
- β-thalassemia major patients had increased level of IL- 8 which was more prominent in splenectomized patients, while no increase in IL-2R levels in both groups of Thalassemia.
-IL-8 levels correlated with ferritin levels, while no significant correlation between IL-2R levels and ferritin levels in both groups of Thalassaemia.
- Splenectomized thalassaemic patients display higher ferritin levels compared to the non-splenectomized.
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BACKGROUND:
Epley's manoeuver can give satisfactory and long lasting relief of symptoms in patients with typical history of benign paroxysmal positional vertigo without nystagmus in Dix-Hallpike positional test.
OBJECTIVE:
To evaluate the effectiveness of Epley's manoeuver in those patients with typical history of benign paroxysmal positional vertigo without nystagmus in Dix-Hallpike positional test.
MATERIAL AND METHOD:
Ninety six patients with benign paroxysmal positional vertigo(37 of them males and 59 females).With Dix-Hallpike positional test 58 patients had nystagmus(objective benign paroxysmal positional vertigo) and 38 patients had no nystagmus (subjective benign paroxysmal positional vertigo), was carried out comparism of Epley s manoeuver in both groups.
RESULTS:
There was significant improvement of symptoms (87%) by Epley's manoeuver in patients who had benign paroxysmal positional vertigo without nystagmus.
CONCLUSION:
Epley's manoeuver can give good result in relieving of vertigo in patients with typical history of benign paroxysmal positional vertigo even if no nystagmus can be detected in Dix-Hallpike test.
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ACKGROUND:
Vitiligo is a common dermatological disease with a great psychological impact on the life of individual. Narrow band ultraviolet B phototherapy has been used successfully for the treatment of vitiligo with variable results.
OBJECTIVE:
To assess the response to NB UVB and to identify factors that could predict the response to therapy.
Patients and methods:
This study is an interventional prospective therapeutic study, had been conducted in the Department of Dermatology and Venereology - Baghdad Teaching Hospital extending from October 2013 to October 2014.
Thirty two patients with vitiligo were included in the study , the ages ranged from 8- 35 (18.84±7.86) years, 22 (68.8%) females and 10 (31.2%) males, the body surface area of vitiligo ranged from 2- 60%( 23.8 ± 16.66 ), full history and physical examination , assessment of skin phenotype , daily life quality index before and after completing the 48 sessions. Narrow band phototherapy was given twice weekly, recording of the body surface area of vitiligo was done before the treatment and every 16 sessions till the end of 48 sessions. Documentation of the first response session for every patient, calculation of the total percent of reduction , the main predictive factors and the development of any side effect had been recorded.
RESULTS:
First response session ranged from 3- 20 (10th ± 4.37) ,the response of patients according to the degree of regimentation was as the following: 3 (9.37%) patients had excellent response, 6 (18.75%) patients had good response , 14 (43.75%) patients had moderate response and 9 (28.12%) patients had poor response. The age of patients and negative hair involvement had a statistically significant correlation to the total percent of reduction. The face was the area of maximum response , The side effects were tolerable and no patient discontinued the treatment due to the side effects. Daily life quality index showed a statistically significant reduction at the end of treatment.
CONCLUSION:
Narrow band is an effective treatment for vitiligo with few side effects. Age of the patients and absence of hair involvement are favorable predictive features. The face was the area of maximum response.

BACKGROUND:
C-reactive protein (CRP) is an acute phase reactant produced primarily by hepatocytes; its production is stimulated by systemic inflammation of either infectious or noninfectious origin. The cytokines that are released during the inflammation are the main stimulants of the acute phase reactants. Interleukin-6 is the main stimulant cytokine of the synthesis of most acute-phase reactants.
OBJECTIVE:
To differentiate between infectious and malignant pleural effusions by measuring pleural fluid CRP titer.
MATERIALS AND METHODS:
This was a hospital-based cross-sectional study at Baghdad teaching hospital medical wards conducted from the 1st of November 2014 up to the 31th of august 2015.
Fifty patients with pleural effusion proved by the history, examination,
Chest imaging and pleural tapping included in this study, all proved to have
An exudative pleural effusion by the light criteria.
RESULTS:
Showing statistically significant differences in CRP titer between:-
1-Parapneumonic pleural effusion (PPE) and malignant pleural effusion (MPE)
2-TB pleural effusion (TBPE) and malignant pleural effusion (MPE).
CONCLUSION:
Pleural fluid C-reactive protein titer can be used as an aid in the differentiation between some infectious causes of pleural effusion and malignant pleural effusion as there is a statistically significant difference between the Pleural fluid C-reactive protein titer of the infectious pleural effusion and the malignant pleural effusion.
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BACKGROUND:
As an alternative to the standard of care for muscle-invasive bladder cancer, certain bladder preservations protocols should be offered to patients with significant co morbidities or for those keening intact bladder and not so compliant with cystectomy approach provided that they included in strict criteria.
OBJECTIVE:
To review the efficacy of bladder preservation therapy for muscle-invasive bladder cancer (MIBC) for selected patients by non-randomized prospective study over two years follow up period.
METHODS:
A study started from a January -2014 until October -2016, twenty eight Patients were included in combined prospective and retrospective manner; they were included within those two years. Patients were confirmed having muscle invasive disease if initial TURBT or the 2nd look TURBT specimens were showed a muscle invasive bladder cancer. All candidates included in bladder preservation strategies shared common strict inclusions criteria. Cisplatin-based chemotherapy and split- course chemo radiation therapy then was offered for all patients after radical TURBT and re assessment carried out after the 3rd cycle of chemotherapy and or 40 GY radiotherapy 3 months later, patients with response after 2nd look TUR were offered other 20 GY radiotherapy.
RESULTS:
Initial clinical response was assessed after 3 months from initial resection (after completion of 3 cycle chemotherapy). Those were subjected to preservation trial, 22(78.5 %) achieved complete response, 4(14.3%) achieved partial response, and 2(7.1%) had no response. Out of responsive group (22 patients), two patients developed recurrent pattern, one of them at first year and another one in the second year, so for over all response assessment obtained for two years there were 28 patients : Twenty patients (72%) were cancer clear, Eight patients (28%) had failed response. No mortality recorded at the study period. All recurrent cases were offered salvage radical cystectomy.
CONCLUSION:
Bladder preservation protocols in selected patients with MIBC might be an effective alternative to standard radical cystectomy with pelvic lymph nodes dissection in controlling low volume favorable invasive and high grade multifocal bladder tumors in up to 70 % of patients.
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BACKGROUND :
Parkinson’s disease (PD) is a neurodegenerative disorder of the central nervous system characterized by resting tremor, bradykinesia, cogwheel rigidity, and impairment of postural reflexes. It appears that certain environmental factors are involved.
OBJECTIVE:
The aim of the present work is to study the age, gender, residency, family history of patients with Parkinson’s disease in Kurdish population.
PATIENTS AND METHODS:
A cross sectional survey study conducted in outpatient clinic at Shar hospital, a teaching hospital in Sulaymania city, during the period between the first of October 2014 and first of February 2015. Thirty five patients diagnosed idiopathic Parkinson’s disease by a neurologist include in this study. Data was collected in outpatient in one hospital Shar teaching hospital in Sulaymania city.
RESULT:
Mean age of patients of Parkinson’s disease 65 years, disease started in male earlier than female in Kurdish population in Sulaymania. We found that 22 cases (62.9%) of total cases were male and 13 cases (37.1%) of all cases female, male was affected more than female. Male to female ratio was (1.7:1).
There was statistically significant difference between cases who were living in urban area and who were living in rural area in regarding age but no significant difference regarding to gender.
There is statistically significant difference in family history distribution in different age groups. Patients with family history positive of Parkinson’s disease affected the disease in earlier ages.
There was statistically significant difference between age groups for smoking
CONCLUSION:
Male was more affected Parkinson’s disease than female, male with earlier ages in Kurdish population. Patients living in rural area and patients with positive family history of Parkinson’s disease affected by the disease in earlier ages.

BACKGROUND:
Understanding the factors that motivate donors to donate blood will facilitate improvement in recruitment programs. Highlighting aspects of blood donation that are particularly motivating or attractive is important to both induct first-time donors and enable repeat donors to continue their donation behavior.
OBJECTIVE:
Assessment the motives for voluntary blood donation in the donors of Iraqi National Blood Bank through the study of sample of these donors.
DONORS AND METHODS:
This study conducted in the Iraqi National Blood Bank-Baghdad, in the period from November 2015 to February 2016. The persons who included in the study were voluntary donors, conveniently included in the study. A special form was prepared for each donor and a questionnaire is performed to fill the form.
RESULTS:
The study included 208 blood donors; the mean of age was 35.4 years with range of 18 to 60 years. One hundred and ninety eight (95%) donors were males while 10 (5%) females and Males: Female was 19.8:1. Forty donor (19%) donated the blood for the first time (first time donor) while 168 donors (81%) donated blood for more than one time.
The most common motive for blood donation as general, was humanity which was the motive in 89 donors (42.8%), followed by polycythemia (increased blood) which was the motive in 67 donors (32.2%), while patriotic motive was in 31 donors (14.9 %), followed by emergency motive in 14 donors (6.7%) while high blood pressure was the drive in 7 donors (3.4%).
CONCLUSION:
Most of the donors were in the forth decade of life and the majority were males. The most common motives for voluntary donation were humanity, increased blood, patriotic, emergency and high blood pressure
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BACKGROUND:
The left ventricular diastolic dysfunction (LVDD) in asymptomatic patients with polycystic ovarian syndrome (PCOS) has been documented by both pulsed wave Doppler and tissue Doppler echocardiography.
OBJECTIVE:
The aim of this study was to identify the earliest asymptomatic impairment of the left ventricular diastolic dysfunction in polycystic ovarian syndrome women.
PATIENTS AND METHODS:
This study is conducted by the Department of Physiology, College of Medicine, Al-Mustansiriya University in cooperation with the unit of Infertility and unit of Echocardiography at Al-Yarmook teaching hospital in Baghdad during the period from December 2015 to April 2017. A total number of 150 subjects were included in this study, 50 healthy subjects (control group) and 100 patients with polycystic ovarian syndrome with (mean age and standard deviation of 28.27 ± 7.27 years). Pulsed wave blood flow Doppler and tissue Doppler imaging were used for estimating left ventricular diastolic dysfunction.
RESULTS:
11% of the 100 PCOS women showed evidence of left ventricular diastolic dysfunction through impairment of mitral valve annular velocities and in the filling velocities of the left ventricle by pulsed wave Doppler, the ratio of peak early (E) filling velocity to the late (A) filling velocity (E/A ratio) was significantly lower in polycystic ovarian syndrome women with left ventricular diastolic dysfunction (0.780.17). By TDI the ratio of early (e՛) mitral annular velocity to the late (a՛) mitral annular velocity (e՛/a՛ ratio) was significantly reduced in polycystic ovarian syndrome women with the left ventricular diastolic dysfunction. Body mass index, waist circumference, waist-to-hip ratio, fasting blood sugar, fasting insulin, serum cholesterol, serum triglycerides, low density lipoprotein, very low density lipoprotein and homeostasis model assessment of insulin resistance were higher in polycystic ovarian syndrome group with left ventricular diastolic dysfunction.
CONCLUSION:
Diastolic dysfunction can develop early in patient with PCOS, and might be an early signal for cardiac involvement in this patient population.

BACKGROUND:
Pulmonary embolism is a common complication of hospitalization and contributes to 5 to 10 percent of deaths in hospitalized patients, making it one of the leading causes of preventable hospital deaths.
OBJECTIVE:
Is to evaluate patients with pulmonary embolism admitted to Ibn Alnafees Hospital, Baghdad, Iraq.
PATIENTS AND METHOD:
Cross-sectional study in one year( 2016) , We treated 52 cases of Pulmonary embolism in Ibn Alnafees Hospital in the CCU and we collected their data on admission to the hospital on different age group, gender, sign and symptoms, investigation, predisposing factors, treatments with thrombolytic therapy and the outcome of the patient. Seven patients died after admission, two of them same of day of admission.
RESULT:
In this study, the surgery was the most common risk factor for pulmonary embolism followed by deep Venus thrombosis. However, there was no obvious risk factor present in 11.5% of cases, and 28.7% of cases had have more than one risk factor.
CONCLUSION:
The surgery was the most common risk factor for pulmonary embolism followed by deep vein thrombosis. The CT pulmonary angiography is positive in vast majority of cases, so it's useful and effective diagnostic tool for pulmonary embolism.

BACKGROUND:
Transfusion-transmitted infections continue to be a threat to the safety of the blood supply, in particular the risk is high for parent rally transmitted viral hepatitis in pediatric malignancy.
OBJECTIVE:
The aim is to estimate the prevalence of hepatitis in children with malignancy, identify some variables that could affect the prevalence of hepatitis in these patients, and to have an idea about the effect of vaccination in controlling hepatitis infection.
PATIENTS AND METHODS:
A cross sectional study was done over ten months period between December 1st, 2013 to September 30th, 2014 at the Pediatric Oncology Unit in Al- Emamain Al -Kadimain Medical City, A total of (54) children between the age of [1-15] years with malignancy who were diagnosed and treated at the pediatric oncology department before 6 months and more were studied. Information regarding age, gender ,residence, hepatitis vaccine received ,number of blood transfusion ,any surgical intervention for solid tumors and lymphoma was done, history of hepatitis screen at diagnosis were taken from hospital record and pediatric oncology consultation clinic files ,re- evaluation of hepatitis screen were done through with screen for HBs Ag , Anti HCV. Among those children with malignancy, testing for HBV and HCV were done through blood samples taken from the patients and sent to lab. of the hospital.
RESULTS:
From (54) patients with malignancy, 46 patients were with hematological malignancy(85%) and 8 cases(15%) with solid malignancy, from them 8 (14.8%) cases were HBV positive and 4 (7.4%) cases with HCV positive. Most of the patient were from Baghdad 37 cases (68.5%), male to female ration(1.7:1) and also most dominant age group was from (4-9 year).The number of blood transfusion had significant positive impact on prevalence of hepatitis virus infection , and also the vaccine status had significant positive influence.
CONCLUSION: There is a low frequency of HBV &HCV infection in patients with malignancy treated in Al-Emamain Al- Kadimain Medical City with lower incidence of HCV infections than HBV.
Blood transfusions (more than 3 times) is significantly increasing the incidence of HBV infection and HBV vaccine is significantly reducing the incidence of HBV infection.

BACKGROUND :
Post Transplant Erythrocytosis (PTE) is relatively a common complication following renal transplantation, occurs in 8 to 15 percent of renal transplant recipients ,it is mainly due to adequate production of erythropoietin by the transplanted graft and elimination of bone marrow inhibitors attending the uremic symptoms.
OBJECTIVE:
This study was conducted to know the prevalence, manifestation , and risk factors of Post Transplant Erythrocytosis (PTE).
PATIENTS AND METHODS:
This is an observational retrospective study enrolled 290 patients who underwent kidney transplantation and followed up at The Nephrology and kidney transplantation Center, Medical City Baghdad , The data used in this study were collected from the patients, their medical records and from the laboratory. The follow up period was from the third months post transplant to the end of first year. These data include ( name, age, sex ,weight, etiology of chronic renal failure, duration of hemodialysis before transplantation, the use of erythropoietin stimulating agent, living kidney donor (related or unrelated), The use of basilixmab or Anti Thymocyt Globulin) at induction, the calcineurine inhibitor ( cyclosporine or tacrolimus), the occurrence of acute rejection, the type of antihypertensive used post transplant .Laboratory data include ,hemoglobin level, red blood cells packed volume, serum creatinine .
RESULT :
Twenty three patients (7.9%) had erythrocytosis post kidney tranplantation with Hemoglobin level of 17.5 g/dl (17 -17.9) and PCV of 54 % (52.1 – 54.4). Only two patients (8.7 % ) had cerebrovascular accident. From the non transplant related parameters, hypertension was significantly associated with PTE ( P Value of 0.026 ). While the others ( age , gender, weight , etiology of the ESRD and the duration of dialysis) showed no significant association. From the transplant related parameters, low serum creatinine (0.8-1.2mg/dl) showed significant association with PTE (P value <0.0001). Also both hypertension and the use of Beta blocker shows significant association (P value <0.05)
CONCLUSION:
Post transplant erythrocytosis occurs in about eight percent of kidney transplant recipient, it may be asymptomatic or complicated by thrombotic event, and it is associated with lower serum creatinine and hypertension.

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BACKGROUND:
Iron overload is a major concern in blood transfusion dependent beta-thalassemic patient and it is a major cause of cardiac dysfunction. Magnetic resonance imaging T2* has a vital role in liver and cardiac iron deposition and assessment of its severity
OBJECTIVE:
To highlight the role of MRI T2* in assessment of liver and cardiac iron deposition and assessment of other methods of liver and cardiac iron concentration estimation.
PATIENTS AND METHODS:
This cross sectional prospective study had been conducted at the MRI unit of Al-Imamain AL-Khadimain medical city, Baghdad/ Iraq, from December 2015 to December 2016. One hundred, blood transfusion dependent beta-thalassemia major patients had been examined by MRI using T2* images to assess its value which had been changed to liver iron concentration and cardiac iron concentration by using a MEDIS software program.
RESULTS:
One hundred patients (56 male and 44 female) of transfusion dependent beta-thalassemia major had been evaluated for their liver and cardiac T2*, 17 of them shows a mild LIC (liver iron concentration) and normal MIC (myocardial iron concentration), 49 patients show mild increase in both LIC and MIC, 9 show moderate LIC and mild MIC, 16 show moderate both LIC and MIC, 2 show severe LIC with mild MIC, only one shows severe LIC with moderate MIC and 6 of them show severe both LIC and MIC. There is a positive significant correlation between liver T2* and cardiac T2* (P values of 0.017), between liver T2* and LIC (P value of > 0.001), between liver T2* and MIC (P value of 0.031) and that between cardiac T2* and MIC (P value is >0.001). There is non- significant correlation between the age and frequency of blood transfusion with LIC and MIC (P value <0.05). There is also a significant negative correlation between S.ferritin and liver T2*and cardiac T2* (correlation coefficient of -0.251 and -0.397 respectively), with a (P value of 0.014 and 0.00015 respectively). There is non significant correlation between S. ferritin and the severity of LIC and MIC (P value of 0.129 and 0.792).
CONCLUSION:
Magnetic resonance imaging has a vital role as a non-invasive and reliable method in the assessment of liver and cardiac iron deposition in patients with blood transfusion dependent beta-thalassemia major. There is no correlation between S.ferritin level and the severity of LIC and MIC. Patients using Exjade show a lower LIC and MIC than those using Desferal. No correlation between age and frequency of blood transfusion with LIC and MIC in patients on regular chelation.
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BACKGROUND:
Acetabular fracture is a complex injury, it mostly results from a high-energy mechanism and mostly in young patients. whenever indicated surgical treatment is possible thought several surgical approaches with different fixation constructs. Many authors proved the important relation between the occurrence of postsurgical complications and the presence of associated hip dislocation, whereas the fracture type and operative approach did not prove to be significant in the occurrence of complications after surgery.
Recent studies focused on decreasing the rate of complications that follows the operative management.
OBJECTIVE:
To evaluate the complications of surgical treatment of isolated closed acetabular fractures including surgical site infection, iatrogenic nerve injury, heterotrophic ossification (HO), and femoral head necrosis (AVN) and to assess any relationship of these complications with fracture type, operative approach, and age of patients.
PATIENTS AND METHOD:
Thirty-one operatively managed acetabular fracture, 24 males and 7 females with a mean age of 37.2 years were studied over the period from October 2013 to June 2016 in Medical city complex / Baghdad with a minimum follow up of 6 months. Infection, AVN of femoral head, nerve injury and heterotrophic ossification were studied.
RESULT:
Significant relation between postsurgical complications and presence of hip dislocation at presentation was noticed while the fracture type and operative approach were insignificantly related to the complications.

BACKGROUND:
Coeliac disease (CD) is a chronic reversible enteropathy . Increased intraepithelial infiltrate, crypt hyperplasia, and villous atrophy are the three basic features of coeliac enteropathy.
OBJECTIVE:
The aim of this study was to evaluate the cutoff value number of intraepithelial lymphocyte count needed for the diagnosis of CD , this is supported by the use of CD3 T-cell immunohistochemical staining.
PATIENT AND METHODS:
This is a retrospective study including 25 duodenal biopsies , the cases were divided into three groups, 11 patients their biopsies show only early celiac changes supported by 9 biopsies show histological features of advanced CD, and 5 duodenal biopsies diagnosed as duodenitis.
All paraffin embedded sections were stained with H&E stain and with immunohistochemicalmarker(CD3).
RESULTS:
Mean age of all subjects was 19.5 years. Mean age of control group was 11.8 years. Mean age of patients with early changes was 21.8 years. Mean age of patients with celiac disease was 21.5years. There was no significant difference in mean age and sex among the three groups.
Mean IEL in celiac disease was 63.1, while it was 38.7 in patients with early changes. Mean IEL in control group was 11.6.
The least cutoff count of IEL/100enterocyte to segregate our sample into those with definite celiac disease and those who are free of disease was 20 IEL/100 enterocytes with 100 % specificity and 100% sensitivity.
CONCLUSION:
Mean IEL was significantly higher in celiac disease than in patients with duodenitis and those with early changes of celiac disease
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