Mustansiriya Medical Journal

Abstract:
Background: Benign breast disease is the most common cause of breast problems. Its diagnosis is
important to differentiate it from malignant one as they differ in treatment and prognosis.
Objective: To study the prevalence of different types, their relation to age, presentation and
investigations used in diagnosis will be studied.
Methods: This is a retrospective study that had enrolled 114 female patients who were treated
surgically at Al‐Yarmouk Teaching Hospital for benign breast diseases, during the period from 1st
Jan. 2006‐30th April 2007. Data includes age, presenting symptoms, investigations and final
diagnosis.
Results: The median age was 35.39 years (range 15‐55y). Forty (35%) patients were in the 4th
decade of life. Breast lump was the main presenting symptom in 95(83.4%) patients. Investigations
carried out included; ultrasound for 65 (57%) patients. Sixty two (54.4%) patients had the
investigation of FNAC with a sensitivity and specificity of 85% and 95.1% respectively.
Mammography was done in 20 cases which gave the sensitivity of 81.8% and specificity of 88.8%.
Fibroadenoma was the most common benign pathology and affected 70(61.4%) patients.
Conclusion: Most patients with benign breast diseases were in the 4th decade. Fine needle
aspiration cytology had the highest sensitivity and specificity when taken alone. Fibroadenoma
was the commonest pathology. Patients with benign breast diseases should have excisional biopsy
or followed by according to the clinical impression of the examiner to exclude malignancy

Abstract:
Background: the symptoms of acute appendicitis (A.A.) mimic sometimes the symptoms of
ureteric colic (U.C.) due to stone leading to mistake in the diagnosis and delay in the management
hence increased mortality and morbidity.
Aim:to compare the features of differential diagnosis between the two groups and to see how
frequent cases of U.C managed and treated as A.A.
Method: prospective study of 100 patients who are proved A.A and 100 patients proved U.C were
taken to compare the features of differential diagnosis while 50 patients of histologically proved
negative appendicectomies were followed up for ureteric stone.
Result: no urinary stones in the 50 cases of negative appendicectopmies have been found when
followed up. A.A cause more often fever, localized pain in the right iliac fossa, nausea with or
without vomiting, C ‐ reactive protein (C.R.P) and white blood cell (W.B.C) count elevation more
than U.C while general urine examination (G.U.E.) revealed more red blood cells (R.B.C) and pus
cells in cases of U.C as compare with A.A.
Conclusion: misdiagnosis between A.A and U.C is a rare clinical event in our hospital. U.C causes
pain and tenderness in the flanks and revealed more R.B.C in the urine while A.A causes more
fever, leucocytosis and elevated C.R.P

Asthma is a common, chronic inflammatory, anaphylactic hypersensitivity disease .It is a world‐
wide distributed with a range extends from mild to severe fatal episodes. Fifty eight asthmatic
patients sera have been collected from Al‐Zahra\\\\\\\\\\\\\\'a consultant for asthma and allergy , during the
period between July / 2008 – September / 2008 and thirty two sample of healthy peoples as a
control group .The patients age ranged from ( 12‐45 ) years .Enzyme linked immunosorbent assay (
ELISA) has been applied estimation of interleukin – 8(IL‐8).
The results showed that highly significant differences (P < 0.0001) between asthmatic patients –
positive IL–8 and asthmatic patients – negative IL‐8. There are no significant differences between
residency (urban and rural regions) and levels of IL‐8. There is a good relation between body mass
index (BMI) and asthmatic patients (P < 0.005), but no relation between body mass index and
levels of IL‐8.

act:
Background: Asthma is associated with higher risk of adverse cardiovascular outcomes.
Hypoxemia and inflammation had been suggested to play a role and the use of inhaled
corticosteroids is possibly associated with a major effect on reduction this higher risk with
amelioration of the suggested mechanisms.
Objective: This study had been designed to assess the effect of the use of low dose inhaled
corticosteroids on the frequency of myocardial infarction in asthmatic patients, compared to the
effect of other anti‐asthmatic medications.
Methods: This study is a prospective study that included 92 asthmatic patients who had unstable
angina at the time of inclusion. The sample were randomly selected from those who had been
admitted to the coronary care unit of Al‐Yarmouk Teaching Hospital during the period between
February 2008 to February 2009, with the mean period of follow up of 8.3± 2.1 months (6 months‐
1 year). Detailed medical history had been taken and thorough physical examination was made for
all patients. The patients had been sub‐classified according to the type of the used therapy for
asthma.
Results: Twenty three male and 69 female patients had been enrolled in this study. The mean age
was 52.48 ± 9.86 and 50.36 ± 6.8 year‐old for male and female patients, respectively. After 1 year
of follow up 17 patients (18.5% of the sample) had myocardial infarction during the period of
follow up, the rest of the sample (75 patients, 81.5% of the sample) completed their period of
follow up without any evidence of having myocardial infarction. Sixty patients had been treated
with inhaled corticosteroid therapy (65.2%), while 20 patients (21.7%) and 12 patients (13%) had
been treated with inhaled B2 agonist therapy alone and inhaled B2 therapy in addition to
leukotrien receptor antagonist therapy, respectively. Nine out of the 17 patients (52.9% of those
with MI) were 40‐49 year‐old. Only 5 out of the 60 patients who had been treated with inhaled
corticosteroid therapy (29.4% of those having MI, 8.3% of those treated with inhaled
corticosteroid therapy) had myocardial infarction during their follow up. This study revealed that 5
out of 17 patients with evidence of acquiring myocardial infarction during the period of follow up
(29.4%) had at least one marker of asthma severity. Only 2 out of 18 patients with any marker of
asthma severity had used low dose inhaled corticosteroid (11.1%), while the rest of them (16
patients, 88.9% of those with any marker of severity) were using other anti‐asthmatic medications.
Conclusion: The use Low dose inhaled corticosteroid was associated with decreased frequency of
acute myocardial infarction in asthmatic patients initially diagnosed to have unstable angina in
comparison to the frequency of MI among patients treated with other anti‐asthmatic medications.
MI was more frequent among younger asthmatic patients. Having any marker of asthma severity is
associated with higher risk of having myocardial infarction. Having any marker of asthma severity
is associated with higher risk of having myocardial infarction. Use of low dose inhaled
corticosteroid is associated with less severe asthma and lower frequency of developing acute
myocardial infarction

Background:The increased incidence of high velocity missile (H.V.M.)abdominal injuries in Iraq had
been associated with an increase in the incidence of duodenal injuries.
Setting:Second and fourth surgical units at Al‐Yarmouk Teaching Hospital.
Objective:To study the pattern of duodenal injuries, evaluate the proper surgical methods of
duodenal injury management, to minimize the morbidity & mortality rates.
Patients &methods:Prospective study of forty two duodenal injury patients in 6 years period
between Jan .2003 – Dec .2008 managed surgically .For Grade 2 duodenal injury we did primary
repair with tube drainage, for grade 3; primary repair with tube duodenostomy or primary repair
with triple ostomies, or primary repair with Pyloric exclusion and gastro ‐jejunostomy.
Results:Four hundred six laparatomy for (H.V.M.)abdominal injury, of these 42 cases
(10.3%)associated with duodenal injury .80 %35 male & 20 %7 female aged between (10‐50)years
with mean age of 32 .There were no isolated duodenal injury, 43.8 %had haemorragic shock on
admission to the emergency room, 14 cases 33.3 %died perioperatively, 4 cases 9.5 %died
postoperatively due to complications, no death in patients after leaving hospital
Conclusions:Second part of the duodenum is the most common site of injury .Grade 3 duodenal
injury has high morbidity & mortality rate .Time interval between the injury & operation is more
important to decrease morbidity & mortality rate

Background:lower ureteric stones and accompanying ureteric colics represent one of the most
common medical problems faced by urologist, the treatment usually starts with conservative
therapy, however, if the stone fails to pass within 4‐6 weeks, a prompts action should be taken to
save the kidney, this usually involves one of the minimally invasive therapy options like shock
wave lithotripsy )ESWL(, of ureteroscopy .However this is not free of risk, and cost, for these
reasons, urologists now concentrate on what\\\'s called medical expulsive therapy, which means
using drugs to enhance stone passage.
Objective ::in this study we evaluated and compared three of the most commonly used drugs,
nifedipine, tamsulosin, and sildenafil citrate, for their expulsive role in lower ureteric stones.
Methods:through out the period from Feb .2008 until Nov .2009, 98 patients with lower ureteric
stones were enrolled in this study, they were thoroughly examined and investigated, then
randomized into 4 groups, the first group patients received nifedipine, the second group patients
received tamsulosin, the third group patients received sildenafil citrate, and the forth group
patients served as control .Patients followed up for one month and monitored for stone passage,
time of stone passage and number of ureteric colics experienced while on treatment .Data
collected and analyzed statistically.
Results:only patients on tamsulosin therapy showed a statistically significant improvement in
stone passage rate )81.4(%, compared to those on nifedipine)69.6(%, sildenafil citrate )57.6(%, and
control )54.5 .(%Both nifedipine and tamsulosin significantly shortened the time needed for stone
passage and reduced the number of ureteric colics, while sildenafil citrate failed to show any
beneficial effect compared to control.
Conclusions:tamsulosin may have a significant role in enhancing lower ureteric stone passage
within shorter time and with less pain, and it is superior to nifedipine, and sildenafil citrate in this
regard.

Background: H Pylori infection could be regarded as the commonest infection worldwide, it had
been suggested that H pylori infection is more frequent among diabetics.
Objective: This study had been designed to define any significant association between diabetes
and H pylori infection, to evaluate different demographic features of patients with diabetes
mellitus who have H pylori infection, assess any relation between H pylori infection and the
metabolic control of diabetes mellitus and to estimate the frequency of different
oesophagogastroduodenoscopy findings among diabetic population with H pylori infection.
Methods: This study enrolled 50 patients with diabetes mellitus and another 50 non‐diabetic
patients (as a control group). The patients attended Gastrointestinal unit at Al‐Yarmouk Teaching
Hospital Baghdad/Iraq during the period between the 1st of March2004, to the 31st of November
2004. Full history was taken and clinical examination, investigation to assess the glycemic control
and esophagogastroduodenoscopy (OGD)had been done to all of them. H pylori status had been
detected by positive Rapid Urease test and histopathology and/or ELIZA test for anti‐H pylori IgG.
Results: This study revealed that 26diabetic patients (52%) were H pylori positive, while 14 non
diabetic patients (28%) were H pylori positive which is statistically significant (X2=6.0,P=0.01).
patients aging 60 year old or more (24 patients, 48% of the sample) 18 of them had positive H
pylori status, 20 patients out of the 26patients with positive H pylori status (76.9%) had poor
glycemic control, 84.6% of those with positive H pylori status (22 out of 26 patients) had glycated
hemoglobin level of 8% and greater, 61.8% of those with positive H pylori status (16 patients)
were diabetic for more than 10 years. 61.5% of those with positive H pylori status had one or more
of the chronic diabetic complications, 12 patients had OGD finding consistent with duodenitis, all
of them were H pylori positive, OGD examination revealed 20 cases without active disease, 18 of
them had negative H pylori status.
Conclusions: This study indicates that Helicobacter pylori infection is more common in diabetic
patients. Frequency of H pylori infection is higher among elderly diabetics, those with long
standing, poorly controlled and with diabetic complications.

Background:acute poisoning is an important cause of morbidity and mortality in children all over
the world.
Objective:to find out the types of acute accidental poisoning (AAP) in children in Baghdad and
various host and environmental factors responsible.
Methods:one hundred and seventy poisoning cases and hundred controls were enrolled in a case
control study done in central teaching hospital for the period from 1st of Jan. 1998 to 30th of April
1998.
Results:kerosene poisoning was the commonest type (56.4%) followed by drugs (23.5%) then
organophosphorus insecticides (11.8%), household products (3.5%). The highest frequency was
noticed at 8.00 am‐12.00 noon followed by 12.00 noon – 4.00 pm. It has been found that there is
no significant relationship between poisoning and sex of child, mother educational level but the
followings found to be significant risk factors: age of 1‐3 years followed by 3‐5 years, urban
residence, peak time of poisoning was during mid‐morning hours and early afternoon, also order
of the child (5th) besides family size (family of 4‐7 members), mother\'s age of above 35 years, not
working mother (housewife). Also it showed a relation with recurrence of poisoning in the same
child (7.1%) or other sibling in the same family (16.5), being at home (86, 5%) and use
inappropriate method of storing and placing poisonous materials.
Conclusions and Recommendations:significant risk factors regarding younger age, larger family
size, early day time occurrence and recurrence of accidents in the same family, in addition to
improper storage places necessitate the need for earlier poison prevention education programs as
an integral part of well child visits even before child is mobile.

Background :This topic has been the subject of interest for many authors for many years, because
still there is a recurrent theme …should the nerve be explored routinely along with internal
fixation of fracture or should exploration be limited to those cases in which spontaneous recovery
has not occurred within expected time ? or when justify?
Objectives: This study is designed is to shed a light on the dilemma of management radial nerve
injury, in surgically treated patients versus conservatively treated others .
Methods : A series of
25 patients presented with any degree of radial nerve palsy
complicating140 case of closed fracture shaft humerus , were treated by surgical & conservative
method , according to certain indicators and evaluated during three years period, in two teaching
hospital in Baghdad, from 2006 to 2008. Most of patients were males 19 case & the remaining
patients were females 6 cases ,their age ranging from 3 days old baby to 45 years old & the mean
age was 25 years .Ten (10) patients treated conservatively , Fifteen (15 ) patient treated surgically
by either early exploration ( too early & late early ) or delayed exploration.
Results: The radial nerve was explore in seventeen patients from total number of study 25
patients. Eight treated by early exploration .. ( five by too early exp. within few days & three by
late early exp. within next two weeks).Nine patients treated by delayed exploration after ( 3.5~ 4 )
months post traumatic period .In the last eight patients , the radial nerve was not explored &
treated conservatively? The overall useful recovery rate from applying our policy was (84 % ).
Conclusion: Treatment of radial nerve palsy complicated closed fracture shaft humerus should be
programmed well, depending on many factors , such as severity & onset of nerve lesion and type
& site of associated fractures.

Objective: the aim of the study is to re‐emphasize the importance of open drainage in the
treatment of advanced thoracic empyema.
Methods: Fifty two patients with different types of thoracic empyema were received in advanced
state with thick pus accumulating in the pleural cavity, in the period between 1996 and 2005.
Most of
these patients were too catchexic to tolerate thoracotomy for decortication or more aggressive
treatment. We treated them by open drainage with rib resection. .
Results: Nine patients (17.41 %) died∙\\\'.while the rest of the patients survived. In 3 out of these 9
patients the death was due to the original pathology with empyema as an additional factor.
Conclusion: open drainage should not be ignored as one of the therapeutic options in treatment
of advanced thoracic empyema. It might be the best therapeutic modality in catchexic patients,
and \\\'where the facilities for more aggressive treatment are not available.

Background: Many clinical trials have indicated that lifestyle modification can delay or prevent the
progression to type 2 diabetes in people with impaired glucose tolerance test (IGT). Detection of
IGT requires a test which is inconvenient to screen for this condition in clinical practice or in the
general population. Therefore, there is a need to search for additional significant risk factors for
type 2 diabetes.
Patients &methods: Seventy two adults ≥ 40 years old (36 males and 36 females) were evaluated
in this study. They were subjects who performed a brief 75‐grams oral glucose tolerance test and
were classified as having normal glucose tolerance (NGT group; 24 subjects), impaired
glucose tolerance
(IGT group; 24 subjects), or diabetes mellitus (DM group; 24 patients).In addition to hematocrit
(PCV) and erythrocyte sedimentation rate (ESR), serum level of highly sensitive C‐reactive protein
(hsCRP) was measured. Also the serum levels of thiobarbituric acid‐reactive substances (TBARS),
iron, copper and ferric reducing ability of plasma (FRAP) were estimated in addition to erythrocyte
glutathione (Ery‐GSH) level.
Results:Both IGT group and DM group have a significantly high hsCRP mean level (2.59 ± 1.03 and
2.89 ± 0.90 respectively vs. 1.57 ± 1.40 mg /L in NGT group, P< 0.001), and a significantly
decreased FRAP level (939.2 ± 157.4 and 961.5 ± 125.1 respectively vs. 1063 ± 104.5 µmole/L in
NGT group, p< 0.01 ) as well as a significantly high TBARS and a significantly low Ery‐GSH
level in comparison with NGT group. The positive correlation between hsCRP and TBARS, although
was statistically not significant, showed a step‐wise increment from NGT, to IGT and to DM group
(r = 0.01, 0.14 and 0.23 respectively).
Conclusions:IGT is associated with a state of low‐grade inflammation and oxidative stress. Serum
levels of hsCRP as a marker of inflammation and TBARS as a marker of oxidative stress may serve
for identifying people at high risk for developing type 2 diabetes. Such people will be important
targets for programs that are designed to prevent diabetes.

Background: Tuberculosis is increasing in Iraq population since 1980s. Studies from the
surrounding countries showed that renal transplant recipients are more liable for TB infection.
Aim: To study the clinical presentation and outcome post renal transplant tuberculosis.
Patient and Methods: 412 recipients are enrolled from May 2001 till November 2008. Age,
gender, weight, waiting list duration, period between TB infection and transplant, history
rejection. Investigation as blood urea, s.creatinine, hemoglobin, ESR, blood sugar, are recorded at
time of TB diagnosis and at end of TB treatment. Diagnosis of TB depends on clinical finding
supported by bacteriological, radiological, and/or hispothological.
Results: there are 18 (4.37%) PTTB cases (12 pulmonary, six extrapulmonary) are recorded. None
of them has a history of TB, nor a radiological finding suggestive of TB at time of transplant. All
these cases are HIV –ve. Most cases have been diagnosed within the first year of transplantation.
Fever is present in 17/18 patients, mostly low grade fever. Diabetes 3/18 cases and history of
acute rejection is 6/18 patients. Mortality was 5/18 (27.77%). Acute rejection and diabetics are
strong associations. Renal impairment at time of TB diagnosis significantly associated with high
mortality.
Conclusion: PTTB is high, and pulmonary TB is also the most common type here. When it is
compared with immun‐competent TB cases, there is an increase in percentage of extra‐pulmonary
TB.

Background: Smoking is associated with increased risk and enhances progression of chronic
diabetes related complications like nephropathy and retinopathy.
Objective: This study was designed to assess the effect of smoking on the development of some
chronic diabetes related complications namely nephropathy and retinopathy.
Methods: This is a cross sectional study that enrolled 100 patients with diabetes mellitus, 50
patients were smokers and the other 50 patients were non‐smokers. The patients had been
randomly selected from those who had attended the National Diabetes Center‐Baghdad/Iraq
during the period between the 1st of January 2004, to the 1st of June 2004. All of the patients have
been asked for their history of smoking by a questionnaire form and they had been examined and
investigated to assess their glycaemic control and diagnosing any chronic diabetic complication
that might be present. Statistical analysis had been done using Chi square test and P<0.05 is
considered significant.
Results: This study revealed male to female ratio of 6:1, 66% of patients were 40‐59 year‐old, 70%
had diabetes for less than 15 years, 92% had smoked for 10 years or longer time, 60% smoked
more than 1 pack (20 cigarettes) per day, the male :female ratio ,age range of patients and
duration of diabetes in the non‐smoker group were almost identical to smoker diabetics .84% of
smoker diabetics had HbA1c level of 7.0% or more, while 64% of non‐smoker diabetics had HbA1c
>=7.0%. 88% of non‐smoker diabetics had abnormal BMI (being overweight, obese, and morbidly
obese) compared to only 62% of smoker diabetics with abnormal BMI . 50% of smoker diabetics
had positive Micral test for micro albuminuria, while only 28% of non‐smoker diabetics had
positive Micral test. 60% and 34% of smoker and non‐smoker diabetics respectively had evidence
of retinopathy in its different stages. Statistical analysis revealed significant association between
being smoker diabetic and poorer glycaemic control (P<0.05), occurrence of microalbuminurea
(P<0.05) and development of diabetic retinopathy (P<0.05).
Conclusions: This study indicated that smoking significantly enhances the development of chronic
diabetes related complications namely nephropathy and retinopathy. In order to reach strict or
near strict glycaemic control which is the corner stone in primary as well as secondary prevention
of chronic diabetes related complications, smoking cessation must be encouraged to get better
and longer life for diabetics

Background: mental retardation is a common clinical problem in pediatrics, it present during
infancy or preschool years as developmental delay.
Objectives: to determine the diagnostic yield of neuroimaging in children with mental retardation
of unknown origin.
Methods: Neuroimaging (Computerized Tomography CT scan) was performed in a total of 59
patients with developmental delay/mental retardation, in AL‐Yarmuk Teaching hospital in Baghdad
from September 2006 to June 2008 where no etiological diagnosis could be made following clinical
examination and preliminary investigations.
Results: Forty one (69%) had abnormal neuroimaging findings of which 13 (22%) were specific
abnormalities useful in arriving at etiological diagnosis. Positive outcome of neuroimaging
increased with the severity of mental retardation, presence of microcephaly and other neurologic
deficits other than MR.
Conclusions: Neuroimaging (CT scan) should be the standard clinical practice for a child with global
developmental delay where no cause is apparent after examination and relevant investigations.

Background: Anti‐tuberculous drugs can induce liver injury. Although, it is usually mild and
transient, but it can be presented in a form of markedly severe liver injury.
Objective: To assess the severity of hepatic injury that can be induced by the anti‐tuberculous
drugs and to evaluate the effect of different demographic features, duration of therapy and the
presence of any other risk factors for liver injury on the frequency of anti‐tuberculous drugs
induced hepatotoxicity.
Methods: This cross sectional study had enrolled 30 patients who were on quadruple anti
tuberculous therapy regimen (Rifampicin and Isoniazid for 6 months and Pyrazinamide with
streptomycin for the initial 2 months). They were randomly selected from those patients who had
attend the outpatient clinic or admitted in the medical wards of Al‐Yarmouk Teaching Hospital
during the period between the 1st of Feb. 2006 to the 31st of January 2007.
Results: This study had enrolled 30 patients, 7 of them were female (23.3% of the sample), and 23
were male (76.7% of the sample). Male to female ratio was 3.28:1. This study revealed that 73.3%
of those patients included in this study were older than 50 years old. 86.7% of the sample had less
than 3 folds increase in their serum alanine aminotransferase (26 patients), only 4 patients
(13.3% of the sample) had more than 3 fold increase in their serum alanine aminotransferase level
more than the upper limit of normal range. 73.3% of the sample had increased serum bilirubin
level by less than 3 times the upper limit of normal range. 46.7% of the sample (14 patients) were
underweight. 70% of the sample (16 patients) had been included in this study within the first 2
months of anti‐tuberculous therapy. 7 patients give history of regular alcohol intake (23.3% of the
sample). While 4 patients had been discovered to be hepatitis B positive (13.3% of the sample).
Jaundice was found in 9 patients (30% of the sample).
Conclusion: This study revealed that severe anti‐tuberculous drugs induced liver injury is
uncommon, increasing age is an important risk factor. It is unusual to find marked and very high
level of alanine aminotransferase and bilirubin in patients using anti‐tuberculous drugs. Being
underweight can be regarded as a factor that may increase the risk of hepatotoxicity. Most of the
cases of liver injury occur early from starting therapy. The presence of other risk factors that can
induce liver injury can increase the risk of anti‐tuberculous drug induced hepatotoxicity.