Iraqi Postgraduate Medical Journal

BACKGROUND:
Blood glucose increment during surgery is part of stress response, this increment is due to insulin dysfunction and glucose production and hyperglycemia increases complications.
OBJECTIVE:
Assess glucose level change intraoperatively and effect on recovery in non-diabetic recipients in renal transplant surgery.
PATIENTS AND METHODS:
52 patients from 1-1-2016 to 1-3-2017 In renal transplant center. all with standardized anesthetic technique, monitoring of blood glucose pre-induction and every half hour, soluble insulin start to be given for patient when blood glucose reach 200mg/dl as 1 unit for each 10 mg above 200 and recovery assessed using aldrete score.
RESULT:
There is variable increase in blood glucose among patients, 39/52 above 110 mg/dl at pre induction,1 patient was 276mg. 18/52 had 200-250 mg at least once among them,11patients reached 250-300mg,6 patients300-400 and 3reahed above400. 5 patients had delayed recovery with no significance relation to pre-induction level but significant to other readings, risk assessment showed more odd’s ratio for delayed recovery in high glucose reading and assessment of increment from pre-induction is a valid test for delayed recovery.
CONCLUSION:
Blood glucose measurement is mandatory in non-diabetic in renal transplant recipients.
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BACKGROUND:
The train-of-four (TOF) ratio should return to at least 90% to exclude potentially clinically significant postoperative residual block. The time gap between clinical recovery (subjective) until objective recovery (i.e. TOF ratio has returned to _0.90) can be considered “the potentially unsafe period of recovery
OBJECTIVE:
To determine the time difference (from giving the reversal drugs till reach TOF90% readings by acceleromyography) between patients maintained on propofol and those maintained on halothane.
PATIENTS AND METHOD:
A prospective clinical trial study100 females underwent caesarian section divided into inhalational anaesthesia group (maintained on inhalational anaesthesia-halothane) and propofol group (maintained on propofol infusion after delivery of the baby till the end of operation) then recovery is monitored using acceleromyography.
RESULT:
Times from giving reversal of the muscle relaxant till extubation and time from giving reversal till reading of TOF90% were significantly lower in propofol group than in inhalational group.
CONCLUSION:
Patients maintained on propofol was extubated earlier than those maintained on inhalational anaesthesia also needed less time to reach TOF90% i.e. inhalational anaesthesia augment muscle relaxation more than propofol.
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BACKGROUND:
Distal tibial fractures , it’s an extra-articular distal third tibial fractures that extend for 4-11 cm proximal to tibial plafond , it represent a significant challenge to most of the orthopedic surgeon because the tibial bone is subcutaneously located with poor vascularity & because of the thin & delicate soft tissue covering medially; this may lead to a big conflict on choosing the optimum fixation methods
OBJECTIVE:
To clarify why & when we use a medial plating for distal tibia, explaining the indication ,advantage-disadvantage, surgical procedure & complications.
PATIENTS AND METHOD:
This is a prospective study conducted on 20 patients with distal tibial shaft fracture (15 male and 5 female) with the mean age of 34 years range from (18 y. to 55 y). operated between the periods from January 2015 to July 2016. All were presented with closed distal tibia fractures , treated by open reduction and internal fixation using a DCP plate and screws fixed on the medial surface of the tibia.
RESULTS :
-All patients had a complete union in 4- 6 months except 2 patients (10%) with delayed union. we have 14 cases (70%) with an excellent result, 5 cases (25%) with a good result, one case (5%) end with fair result (6° varus deformity) , we had only one case with superficial infection treated properly & three cases with wound dehisces 15%, 2 patients (10%) developed a delayed union treated with bone graft .. CONCLUSION :
Open reduction & internal fixation by medial platting for distal tibia fracture using DCP plate, had a biomechanical advantage applying both compression and torsional loading force when used to stabilize varus fracture pattern of distal tibial fracture
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medial tibia plating and dynamic compression plate

BACKGROUND:
Chronic lymphocytic leukemia is a malignancy of mature B cells characterized by progressive lymphocytosis, lymphadenopathy, splenomegaly, and cytopenia. The progressive accumulation of leukemic cells is a consequence of defective apoptosis and survival signals derived from the microenvironment.
OBJECTIVE:
Is to assess the levels of interleukin-8, 2-microglobulin and lactate dehydrogenase in chronic lymphocytic leukemia patients and evaluate the prognostic value of interleukin-8 in correlation with 2-microglobulin, lactate dehydrogenase and Binet stage.
PATIENTS AND METHODS:
A case-control study enrolled 40 newly diagnosed chronic lymphocytic leukemia patients attended at Oncology Teaching Hospital, Medical City with 40 adult healthy volunteers as a control group. Interleukin-8, 2-microglobulin and lactate dehydrogenase were investigated.
RESULTS:
There were statistically significant relationships between Binet staging and each of following: plasma level of interleukin-8, serum level of 2-microglobulin and lactate dehydrogenase and (P= 0.005, 0.005 and 0.023, respectively). There were significant correlations between 2-microglobulin and both interleukin-8 and lactate dehydrogenase level (P= 0.005, both) but correlation between interleukin-8 and lactate dehydrogenase was insignificant.
CONCLUSION:
Interleukin-8 level was positively correlated with 2-microglobulin, and higher plasma levels were associated with advancing Binet stage which makes it a reliable marker for patients at late clinical stage.

BACKGROUND:
Nuchal cord is blamed for problems that are encountered during delivery and for increased risk of adverse perinatal outcome such as fetal heart decelerations and perinatal mortality.
Study design
A case-control, prospective study.
OBJECTIVE:
To compare mode of delivery, duration of labour, and fetal outcome in pregnants with and without nuchal cord.
MATERIALS AND METHODS:
One hundred and fifty full term pregnant women were enrolled in this study, half of them were with nuchal cord (diagnosed by ultrasound and confirmed during labour) served as study group, and the remaining were without nuchal cord and served as control.
Fetomaternal outcome including mode of delivery, duration of labour, presence of intrapartum fetal heart rate irregularities, presence of meconium, fetal weight, Apgar score at 1 and 5 minutes, and neonatal care unit admission were compared in the two groups and the data were arranged on questionnaire forms and subjected to analysis.
RESULTS:
Pregnancy with Nuchal cord has 2.6 folds increase in caesarean section rate than controls (21.3%) vs. (9.3%), mainly because increased fetal heart rate irregularities (3.2 folds), and prolonged second stage of labour.
Meconium staining of liquor was more frequently seen among nuchal cord group than controls. Fetal outcome was found to be associated with higher incidence of low birth weight, low Apgar score at 1 and 5 minutes and more neonatal care unit admission in pregnants with nuchal cord.
CONCLUSION: Nuchal cord is associated with adverse perinatal outcome including low apgar scores, fetal distress and increased cesarean section rate.

BACKGROUND:
Clavicle fractures are common injuries in young active individuals, the mid third of the clavicle is most commonly fractured part(80% of clavicle fracture)
OBJECTIVE:
To compare the outcomes of operative and non operative management of displaced and or comminuted closed fracture of the mid third of clavicle in young adults
PATIENTS AND METHODS:
This prospective observational study of 24 patients of fracture of the mid third of the clavicle was conducted in Alkindy teaching hospital from July 2015 to January 2017 and divided into two groups; one managed by operative treatment with plate and screws and the other by non operative sling immobilization after taking the consent and the patients were seen at 2, 4, 6 weeks,3, 6, and 9 months
RESULTS:
The mean time of functional recovery in the operative group was 3.75 weeks while in the non operative group was 8.09(P value=0.005) which is highly significant, the mean time of fracture healing(radiological union) in the operative group was 14.25 while in the non operative group was 28.72 with P value 0.005 which is statistically highly significant, there was no significant differences between the two groups in the range of movements although the adduction was better in the operative group but not significant P value=0.120, the DASH score was 11.25, 22.25 in the operative and non operative group respectively which is highly significant P value=0.005.
CONCLUSION:
Operative fixation of the clavicle results in improvement in the functional outcome, shorter time of union, lower complication rate in 9 month follow up .
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BACKGROUND:
Cerebellopontine angle is an area with extremely critical structures, therefore understanding its tumors behavior with the implications on the surgical outcome will help in reduction of the possible surgical complications, eventually improves the patients quality of life.
OBJECTIVE:
Our object is to illustrate the various aspects of clinical presentation and surgical complications with linkage to the tumor size regarding cerebellopontine angle (CPA) tumors in Iraq.
PATIENTS AND METHOD:
A prospective cohort study for thirty patients at the Surgical Specialty Hospital (Al Shaheed Ghazi Al Hariri Hospital) have been studied over a 1-year period (2014 / 2015), and followed up postoperatively for 6 months. Their mean age of was 36 years. The suboccipital retrosigmoid approach has been utilized for CPA tumors removal.
RESULTS:
The most common presentation was vertigo followed by tinnitus. There were two cases (6%) of cerebrospinal fluid leak. Facial nerve function was measured by the House Brackmann (HB) system and function further classified into three categories: excellent (HB I-II), intermediate (HB III-IV), and poor (HB V-VI) outcome following surgery, showing that all cases below 20 mm tumor size have an excellent outcome and (67%) of cases with > 20 mm tumor size shows poor outcome. One death in this study (mortality rate, 3%) was due to respiratory cessation.
CONCLUSION:
A female preponderance noticed. Significant relationship between tumor size and facial nerve postsurgical functional outcome, with the larger C.P.A. tumors yield worse outcomes. Tumor size also influences the development of CSF leak and operative morbidity and mortality.
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BACKGROUND:
Common bile duct stones may be small or large, single or multiple, the incidence increases with age. Biliary stones present almost always as low signal intensity on MR images. Therefore, the stone is identified as a round or oval- shaped "signal void" within the common bile duct (CBD), surrounded by the high signal intensity bile, CBD stone can present as sharp cutoff of a CBD at the ampulla, often with a well-marginated “meniscus” configuration, CBD stone may be associated with CBD dilatation and/or dilated intrahepatic biliary tree.
OBJECTIVE:
To evaluate MRCP signs in detecting CBD stones in patients with obstructive jaundice.
PATIENTS AND METHODS:
The study included 50 patients with jaundice suspecting to have CBD stones as a cause of their complaint ,MRCP parameters include: CBD diameter, meniscus sign ,Status of intrahepatic and extrahepatic ducts, Gall bladder status, Pancreatic duct status Statistical analyses for the results were done.
RESULTS:
MRCP diagnose choledocholithiasis in 49(98%) out of 50 patients with a sensitivity of 98%, Accuracy =98%, the specificity of MRCP in diagnosing choledocholithiasis in our study was 95%, P value= 0.001. MRCP show filling defect in 31 patients (3 of them show multiple filling defects) giving Accuracy =62%, sensitivity rate 62%, specificity rate 90%, P value= 0.0001. MRCP show meniscus sign in 18 patients giving Accuracy =36%, sensitivity rate 36%, specificity rate 95%, P value= 0.0001. MRCP show CBD dilatation in 48 patients giving Accuracy =96%, sensitivity rate 96%, specificity rate 95%, P value= 0.001.
CONCLUSION:
MRCP is a non–invasive investigation with high sensitivity, specificity, positive and negative predictive values in detection of CBD stones. Gathering well-defined radiological signs of CBD stones in MRCP allows good diagnostic accuracy. CBD dilatation is the more sensitive sign of detecting CBD stone while meniscus sign is more specific sign for detecting CBD stone in MRCP.
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BACKGROUND:
Iron deficiency could have an adverse effect on the health of pregnant women and their fetuses. In present, no marker could be considered as the ideal for the detection of Iron deficiency anemia in pregnant women. Some authors suggested that soluble transferrin receptor-ferritin index could be a promising marker for iron deficiency during third trimester of pregnancy.
OBJECTIVE:
To study the value of soluble transferrin receptor - ferritin index as a marker for iron deficiency during third trimester.
PATIENTS AND METHOD:
A cross-sectional study conducted at the Antenatal clinic in Al Zahra’a maternity and children hospital and Baquba Teaching Hospital in Diyala province /Iraq, during the period from 17th march 2016 to the end of March 2017, seventy pregnant women were included in the study. Hemoglobin, CBC, HCT, MCV, and RDW-CV were tested by using automated device. Serum Ferritin and Transferrin receptor was tested by using ELISA kit,
RESULT:
The mean age of the women was 28.3 ± 6.5 (range: 16 – 48) years . Iron deficiency anemia was reported in 32% of the studied group. Serum Iron and Ferritin were significantly lower in iron deficiency anemia group than normal group, (P<0.05). Soluble Transferrin receptor (sTfR) and sTfR- ferritin index were significantly higher in iron deficiency anemia group than the normal group (P<0.05).
CONCLUSION:
S. ferritin is excellent predictor of IDA and had higher sensitivity, specificity and accuracy rates than sTfR and sTfR-F index. Additionally, the validity parameters of sTfR-F index were higher than that of sTfR.
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BACKGROUND:
Thyroid dysfunction is well documented in patients with thalassemia major those required frequent blood transfusions.
OBJECTIVE:
To determine the prevalence of hypothyroidism among
patients suffering from B-thalassemia major and their association with treatment protocol.
PATIENTS &METHODS:
Descriptive cross sectional study conducted in Al-Ramadi maternity and children teaching hospital from 1st of January 2013 to the 1st of January 2014. Sixty patients with thalassemia major aged 2-20 years were studied.
Age ,sex ,age of 1st blood transfusion, frequency of blood transfusion per year, doses ,duration and method of chelating agent administration were recorded .Hb level ,serum ferritin concentration and thyroid function test( T4,T3,TSH) were measured.
RESULTS:
thyroid dysfunction recorded in 8(13.3%)cases,3(5%)overt hypothyroidism,5(8.3%)subclinical hypothyroidism , mean age 19±1 years. serum ferritin level, Hb level and age of first transfusion were statistically significant in patients with thyroid dysfunction while TSB and liver enzymes levels were statistically insignificant in studied cases.
CONCLUSION:
Hypothyroidism is an important problem in thalassemia major patients. Regular annual follow- up is essential for early detection and appropriate replacement therapy . the use of effective combined chelating therapy in sufficient quantities as well as regular blood transfusion may lead to prevention of hypothyroidism in beta thalassemic patients

BACKGROUND :
Aphasia is a condition of Loss or impairment of the production or comprehension of spoken or written language because of an acquired lesion of the brain. Aphasia is most often caused by stroke.
OBJECTIVE:
To assess the relationship of post-stroke aphasia types with age, sex and stroke types
PATIENTS AND METHODS:
A hospital - based cross sectional survey study conducted at Baghdad teaching hospital and Al Imamain Al kadhmain medical city between October 2014 and September 2015. One hundred patients with different types of patients with proved diagnosis of stroke by clinical and radiological assessment in young age group and old one of both genders and both left and right handed were included. Data regarding the clinical and demographic characteristics of the patients were reported including: Age, gender, handedness, stroke types, stroke side, stroke site, and aphasia types.
RESULTS:
A total of 100 patients with different types of stroke were enrolled in this study. The mean age of the studied group was 62.1 ± 13.2 (range: 37-87) years, moreover, majority of the studied group aged more than 50 years. Females were relatively the dominant than males; 55 (55%) vs. 45 (45%) respectively. Ischemic stroke was the dominant type of stroke among cases it was reported in 76 cases (76%) compared to only 24 (24%) of hemorrhagic type. Global aphasia was found in 32 stroke cases (32%), Broca´s in 17 (17%), Thalamic 17 (17%), Putaminal 11 (11%), Werneck's 11 (11%), Motor transcortical 6 (6%), Conductive and anomia 4 (4%) and the Mixed transcortical in only two cases (2%)
CONCLUSION:
Post stroke Aphasia was more frequent among stroke patients older than 50 years. Ischemic stroke was the dominant type of stroke. Global aphasia was the dominant subtypes of aphasia among the studied group followed by Broca’s. Thalamic and the other subtypes were less frequent.

BACKGROUND:
Pain after laparoscopy occurs for various reasons and a range of treatment have been suggested for the reduction in pain. There are reports that local anesthesia infiltration, removal of remaining carbon dioxide, administration of anti-inflammatory analgesia before surgery and dexamethasone are effective in post operative pain management. Recently multimodal analgesia methods, where a combination of the above methods are used, are recommended for their effectiveness.
METHOD:
Eighty patients aged 20-60 years; ASA class 1 &2;undergoing laparoscopic cholecystectomy under general anesthesia were studied and divided into two groups: Group S(n = 40) received dexamethasone 8 mg before induction ; Group N received 2ml normal saline before induction. We measure the degree of pain of both groups with VAS at 1,3,6&24 hours after surgery.
RESULTS:
VAS score of Group S were lower than that of Group N during 24 hours after laparoscopic cholecystectomy and analgesia consumption of Group S were lower than that of Group N.
CONCLUSION:
A single dose of dexamethasone (8mg) intravenously given before induction was effective in reducing postoperative pain after laparoscopic cholecystectomy with multimodal analgesia.
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BACKGROUND :
Blunt abdominal trauma (BAT) is a diagnostic challenge. The introduction of bedside ultrasound provides another diagnostic tool for the emergency physician (EP) to detect intra-abdominal injuries.
OBJECTIVE:
To assess the benefits of FAST in the evaluation of patients with blunt abdominal trauma in the emergency department of Kirkuk General Hospital in Kirkuk.
PATIENTS AND METHODS:
This was a prospective study including100 consecutive cases of blunt abdominal trauma in the emergency department of Kirkuk General Hospital in Kirkuk. The results of FAST scans were analyzed and compared with operative findings, diagnostic laparoscopy and CT scanning when the FAST was positive or followed by a period of clinical observation when the FAST was negative. Descriptive statistics, sensitivity, specificity, and predictive values were calculated.
RESULTS :
There was a 100 consecutive blunt abdominal trauma cases during 9 months period, and FAST scans were performed in these cases. The sensitivity and specificity were 92% and 93.3%, respectively. The negative predictive value was 0.97, while the overall accuracy was 93%.
CONCLUSION:
The high specificity of FAST (93.3%) makes it a good ‘rule in’ tool for BAT patients. The high negative predictive value also makes the FAST scan a useful screening tool. However, ultrasound examination is operator dependent, and FAST scan has its own limitations.
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BACKGROUND:
Rubella infection of a pregnant woman may end with serious adverse outcome depending on gestational age at time of infection. Congenital rubella infection may cause various disabilities in addition to increased risk of many diseases in future life. Vaccination in childhood is an effective method of prevention of this disease.
OBJECTIVE:
To assess susceptibility of a sample of pregnant women in Falluja city to rubella infection.
SUBJECTS AND METHODS:
From May to August 2017, 95 pregnant women attending private clinic in Falluja city were included in cross sectional study to assess rubella IgM and IgG antibodies using ELISA kits and ELFA technique respectively.
RESULTS:
None of the pregnant women found to have IgM antibodies. Rubella IgG serum level varies from 0- 400 IU/ml. Of 97 pregnant women included in this study, 23 (24.2%) were non-immune to rubella having IgG level less than 10 IU/ml. There was no significant association between age, parity or history of previous abortion with IgG level.
CONCLUSION:
Congenital rubella infection is a probable hidden health problem. Routine screening of pregnant women and vaccination of susceptible women after delivery should be applied in all health care institutions.

BACKGROUND:
Assessment of lymphadenopathy in children represents a diagnostic challenge because of the extensive differential diagnoses, including reactive and malignant conditions.
OBJECTIVE:
To determine the role of lymph node biopsy in the diagnosis of lymphadenopathy in paediatrics age group
PATIENTS AND METHODS:
A cross sectional study was carried out on 92 patients (males 56 and 36 females) with lymphadenopathy admitted to paediatric surgery unit at Children Welfare Teaching Hospital – Medical City Complex – Baghdad in the period between January 1st. 2010 to December 31st. 2016; for biopsy to reach final diagnosis.
Patients were referred from general wards, paediatrics outpatient clinic and oncology unit.
Data regarding patient name, age, gender, signs and symptoms, site of lymph nodes, size of lymph node, duration of enlargement, investigation, types of biopsy, and mode of treatment were collected and reviewed form patients files.
All patients underwent excisional biopsy and the diagnosis was confirmed by histology and through various specific investigations.
RESULTS:
Among the total 92 lymph node biopsies, the most common pathology encountered was reactive hyperplasia in 68 child (74 %) followed by malignant lymphoma (Non- Hodgkin and Hodgkin) in 15 children (16.3%), followed by tuberculosis in 3 (3.3%).The rest of the lesions include: 1 case of granulomatous lymphadenitis (1%), 2 of histiocytosis X (2%), 2 (2%) of rhabdomyosarcoma, and 1 of germ cell tumour (1%).
Common site of lymph node enlargement was cervical in (97%) of patients.
CONCLUSION:
Cervical lymphadenopathy is a common condition in the paediatric age group. In spite that most common cause of lymphadenopathy was reactive hyperplasia. Lymph node biopsy remains an important diagnostic tool in persistent lymph node enlargement and if malignancy is suspected.
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