Iraqi Postgraduate Medical Journal

BACKGROUND:
Ocular toxoplasmosis is an important cause of posterior uveitis worldwide including Iraq.
OBJECTIVE:
To study the clinical manifestations of ocular toxoplasmosis at a referral center in Iraq.
PATIENTS AND METHODS:
Nine months prospective case series study was performed in the outpatient clinic at Ibn Al Haetham teaching eye hospital in Baghdad, Iraq. The diagnosis was mainly clinical supported by serological tests.
RESULTS:
In this study 20 patients were diagnosed with Ocular toxoplasmosis. Primary active, recurrent & an inactive diseases were reported in: 8 patients (40%), 7 patients (35%) & 5 patients (25%) respectively. Unilateral disease was seen in 13 patients (65%), while bilateral disease was seen in 7 patients (35%). The macula was involved in 15 eyes (55.5%). Visual acuity at presentation was: ≤ 6/36 seen in 15 eyes (55.5%). Complications –reported at a rate of (75%)- were include: High IOP, macular edema, optic disc swelling, Choroidal neovascularization & branch retinal vein oclusion.
CONCLUSION:
The commonest type of presentation of ocular toxoplasmosis seen in this study was the primary active retinitis, followed by recurrent disease. Poor visual outcome seen at the end of treatment course was mainly due to macular involvement.

BACKGROUND:
An ectopic pregnancy is defined as the implantation of a pregnancy outside the normal uterine cavity. Serum ischemia-modified albumin (IMA) and adjusted IMA appear to be significantly increased during pathological pregnancies.
AIM OF THE STUDY:
To compare the level of IMA in ectopic and normal pregnancies, thus understanding the association between oxidative stress and the incidence of ectopic pregnancy.
METHODS:
A case-control study that included 80 women; 38 of them with ectopic pregnancy, and the other 42 were healthy pregnant women. Patients with systemic diseases, a history of smoking, the use of antiinflammatory drugs and antioxidants were excluded from the study. Serum IMA was measured using enzyme-linked immunosorbent assay (ELISA) for all participants.
RESULTS:
Means of IMA and adjusted IMA in women with ectopic pregnancy were significantly higher than that in women with normal pregnancy.
CONCLUSION:
There is an association between oxidative stress and ectopic pregnancy

BACKGROUND:
Several techniques and maneuvers for surgical correction of caudal septal dislocation have been
mentioned in the literature nevertheless the subject has still bearing different opinions and preferences
on which approach to be applied.
AIM OF STUDY:
to assess different surgical approaches and techniques that are used in the management of caudal septal
dislocation.
PATIENTS AND METHOD:
A prospective, observational study was conducted on 50 patients from 10 January 2018 to August 2018
with age range from (18-39 years) who underwent nasal surgery (septoplasty, septorhinoplasty). The
study conducted in Center of Otolaryngology- Head and Neck surgery/ Sulaymaniyah Teaching
Hospital and Azmar private hospital. Preoperative assessment data were gathered & compared with
postoperative assessment data after 3-6 months follow up. The data was analyzed statistically using
SPSS version 25.
RESULTS:
patients included in the study were 64% males and 36% females, 22% went through septoplasty while
78% went through septorhinoplasty. For the techniques that used in surgical correction of the caudal
dislocation (wedge resection, batten graft and L-strut graft) the results were significant postoperatively
while for scoring technique the results were insignificant postoperatively .
CONCLUSION:
There are different techniques used in surgical correction of caudal septal dislocation with good results
and according to each patient. The use of L-strut graft technique whenever it needed especially in
severe deviation .

BACKGROUND:
Angiogenesis seems to be important for leukemogenesis and susceptibility to intensive chemotherapy, and high levels of vascular endothelial growth factor (VEGF) is detected in acute myeloid leukemia (AML) patients
AIM OF THE STUDY:
To assess the correlation of plasma VEGF level with the response to remission induction therapy in adult AML PATIENTS.
PATIENTS AND METHODS:
An analytical cross-sectional study performed on thirty adult patients with newly diagnosed AML. Plasma VEGF level measured by ELISA in all patients twice, before and after chemotherapy.
RESULTS:
The VEGF level was significantly higher in AML patients, at presentation, than control group with median level of 88.13 pg/mL and 49.26 pg/mL, respectively (P=0.002). The median VEGF level decreased after chemotherapy in patients who achieved complete remission although not statistically significant (P=0.071). Whereas the level increased significantly after treatment in patients who failed to response to induction therapy, from 66.27 pg/mL to 165.37 pg/mL (P= 0.025).
CONCLUSION:
Plasma VEGF level was high in adult AML patients at presentation and increases significantly after induction therapy in AML patients who responded poorly to treatment. However, in patients who achieved complete remission the level normalize after therapy, although statistically insignificant.

BACKGROUND:
The precision of axial length measurement has great impact on successful cataract surgery and refractive outcome besides its diagnostic role of many ophthalmic conditions. There are various methods for axial length measurement which differ in their operating principle and technology beside the difference in their advantage and limitation.
AIM OF STUDY:
To compare the axial length measurement performed with optical biometry IOLMaster 500(Carl-Zeiss Meditec,Jena, Germany) with those obtained by applanation ultrasound (A-Scan biometer AL-100) in three groups.
METHODS:
207 eyes of 104 candidates with age range (20-40 year) were included. These candidates divided into three groups according to axial length; group 1 (22 - 24 mm), group 2 (24.1 – 26 mm) and group 3 (26.1– 28 mm). Axial length was measured in three groups, firstly by optical biometry then by applanation ultrasound by the same examiner.
RESULTS:
The axial length measured by IOLMaster was longer than by applanation ultrasound in all groups. The mean differences were (0.15mm, 0.15mm and 0.2 mm) in three groups respectively, which were statistically significant p-value < 0.05. Bland-Altman plots shows there is good agreement between measurements of two devices for all groups.
CONCLUSION:
The results show optical biometry provided longer axial length than applanation ultrasound with hypermetropic shift (0.35D-0.5D) by applanation ultrasound in normal eye.

BACKGROUND:
Chronic lymphocytic leukemia (CLL) is a B‐cell neoplasm. It is the most frequent adult leukemia in European countries, comprising up to 30% of all adult leukemias with male predominance. Detection of a 17p13.1 deletion (loss of TP53) or 11q22.3 deletion (loss of ATM), by fluorescence in situ hybridization (FISH), is associated with a poorer prognosis.
OBJECTIVE:
This study aims to analyze the frequency of cytogenetics abnormalities among CLL patients.
PATIENTS, MATERIALS AND METHODS:
This study enrolled 30 adult patients presented with chronic lymphocytic leukemia visiting Baghdad teaching hospital/hematology center lab/cytogenetic unit-Baghdad /Iraq during the period extending from Mar. till Nov. 2020.The patients were diagnosed on the basis of standard clinical (Lymph node involvement and / or hepatosplenomegally), hematological and immunophenotypic criteria for diagnosis of B-CLL. Interphase FISH technique was performed on peripheral Blood samples using XL ATM/TP53 dual-color probe.
RESULTS:
We studied 30 CLL patients by I-FISH technique to detect the occurrence of cytogenetic abnormalities, eighteen (60%) had one or more cytogenetic abnormalities; Eleven (36.7%) had 17p- (including 2 with 17p- and 11q- in separate clones), Five (16.7%) had 11q-, and Two (6.7%) of patients had clonal 17p-/11q-. Twelve (40%) had neither 17p- nor 11q-. There was no statistically significant clinico pathological correlation with these cytogenetic abnormalities; p-value >0.05.
CONCLUSION:
The cytogenetic abnormalities including 17p-, 11q- and clonal 17p-/11q- among CLL patients occur within the reported figures worldwide. There was no statistically significant clinico pathological correlation with these cytogenetic abnormalities.

BACKGROUND:
Preeclampsia (PE) is a multisystem progressive disorder characterized by the new onset of hypertension and proteinuria. Women with PE have been shown to be at increased risk of venous thromboembolism (VTE).
OBJECTIVE:
To evaluate the levels of protein C and protein S among females with PE, and todetermine whether there is relationship between deficiencies of these proteins and PE severity.
SUBJECTS AND METHODS:
A total of 30 pregnant women with PE and other 30 normotensive age-matched healthy pregnant women in their third trimester of pregnancy were enrolled in this case-control study. Beside blood pressure and general physical examination of each participant, peripheral venous blood sample were tested for complete blood count (CBC) prothrombin time (PT) activated partial thromboplastin time (APTT), protein C and protein S.
RESULTS:
Out of 30 patients, there were 8 patients 26.67%) who had protein C deficiency compared to only 1 pregnant woman (3.33%) among the control group with a significant difference. Likewise, the frequency of protein S deficiency was 20% among patients, while none among controls had such deficiency. Mean plasma level of protein C and protein S in preeclmaptic women was 79.07±21.94% and 68.73±13.19%, respectively which was significantly lower than that of women with normal pregnancy (90.0± 14.96% and 78.67±10.17%, respectively). Furthermore, 50% of women suffering from protein C or protein S deficiency experienced severe PE while 95.45% and 91.67% of women with sufficient protein C and protein S, respectively displayed mild form of the disease.
CONCLUSION:
Both protein C and protein S significantly reduced in pregnant women with PE and are associated with the severity of the disease.



BACKGROUND:
Preeclampsia (PE) is a multisystem progressive disorder characterized by the new onset of hypertension and proteinuria. Women with PE have been shown to be at increased risk of venous thromboembolism (VTE).
OBJECTIVE:
To evaluate the levels of protein C and protein S among females with PE, and todetermine whether there is relationship between deficiencies of these proteins and PE severity.
SUBJECTS AND METHODS:
A total of 30 pregnant women with PE and other 30 normotensive age-matched healthy pregnant women in their third trimester of pregnancy were enrolled in this case-control study. Beside blood pressure and general physical examination of each participant, peripheral venous blood sample were tested for complete blood count (CBC) prothrombin time (PT) activated partial thromboplastin time (APTT), protein C and protein S.
RESULTS:
Out of 30 patients, there were 8 patients 26.67%) who had protein C deficiency compared to only 1 pregnant woman (3.33%) among the control group with a significant difference. Likewise, the frequency of protein S deficiency was 20% among patients, while none among controls had such deficiency. Mean plasma level of protein C and protein S in preeclmaptic women was 79.07±21.94% and 68.73±13.19%, respectively which was significantly lower than that of women with normal pregnancy (90.0± 14.96% and 78.67±10.17%, respectively). Furthermore, 50% of women suffering from protein C or protein S deficiency experienced severe PE while 95.45% and 91.67% of women with sufficient protein C and protein S, respectively displayed mild form of the disease.
CONCLUSION:
Both protein C and protein S significantly reduced in pregnant women with PE and are associated with the severity of the disease.

BACKGROUND:
Measurement of the bladder weight, bladder wall thickness and intravesical prostatic protrusion can be done by using ultrasound which is a simple, non-invasive and less complex, which may predict bladder outlet obstruction in patient with benign prostatic hyperplasia.
PATIENTS AND METHOD:
Across sectional comparative study conducted inUrology outpatient department at Ghazi al-Hariri hospital for surgery specialties during the period between the first of March 2017 till the end of July 2018, a sample of 47 men aged 50 years or older with LUTS/BPH grouped in 2 groups according to urodynamic results: patients with bladder outlet obstruction and patients patient without outlet obstruction.
RESULTS:
In this study, we observed that bladder wall thickness, bladder weight and intravesical prostate protrusion were higher in bladder outlet obstruction group as compared to non- bladder outlet obstruction group with significant accuracy, sensitivity and specificity.
CONCLUSION:
Ultrasonographic measurements of bladder wall thickness, ultrasound estimated bladder weight and intravesical prostate protrusion are good parameters for the diagnosis of symptomatic bladder outlet obstruction due to benign enlargement of the prostate and they are easy to measure, with no complications, less time consuming and cost effective.

BACKGROUND:
To evaluate the safety, efficacy and durability of Vantris injection over a period of 3 years.
PATIENTS AND METHOD:
From 2015 to 2018 we followed 40 patients {male 14, female 26} with a mean age of 4.2±3.4 years (mean ± SD) underwent endoscopic Vantris injection therapy for treatment of primary vesicoureteral prospectively by voiding cystourethrogram at 3months, 1 year and 3 years. Those 40 patients comprising 70 refluxing renal unit (RRU), were unilateral in 10 patients and bilateral in 30 patients. Those were grade II in 10 RRU, grade III in 35 RRU and grade IV in 25 RRU. The volume of injected Vantris material was 0.8ml (range 0.4-1.2 ml) per refluxing unit. The patients were followed. Ultrasound was used at 1 week, 1 month and yearly for 3 years.
RESULTS:
All patients completed 3 years follow up by voiding cystourethrogram. At 3months VCUG 1 was done and shows: 10/10 RRU of grade II, 32/35 RRU of grade III and 23/25 RRU of grade IV show complete resolution of reflux, Success rate is 92.85%. At 1year VCUG 2 was done and shows: 10/10 RRU of grade II, 32/32 of grade III and 21/23 of grade IV show complete resolution of reflux, Success rate is 96.92%. At 3years VCUG 3 was done and shows: 10/10 RRU of grade II, 32/32 of grade III and 21/21 of grade IV show complete resolution of reflux, Success rate is 100%. The overall success rate is 63/70 (90%).
CONCLUSION:
Endoscopic injection of Vantris material for treatment of vesicoureteral reflux in children is very effective, safe and durable, and can be considered as first line treatment of grade Ⅱ-Ⅳ vesicoureteral reflux.

BACKGROUND:
The facial symmetry is a specific measure of bodily symmetry and it influences judgements of aesthetic traits, therefore special attention and care must payed during orbital fracture treatment to consider every detail in the scenario of surgical reconstruction. Many materials have been used for treatment of orbital bones fractures and titanium mesh is widely used implant for this purpose therefore it worthwhile to study it.
AIM OF STUDY:
Evaluate the complications of using titanium mesh in the treatment of orbital floor fractures.
MATERIALS AND METHODS:
The study included 13 patients (11 males and 2 females) presented to Oral and Maxillofacial Surgical Department in Al-Yarmook Teaching Hospital Iraq/ Baghdad in the period from January 2018 to June 2019 with traumatic orbital floor fracture and they underwent reconstruction with titanium mesh.
RESULTS:
The results showed that the most common cause for trauma was road traffic accident (53.8%). Preoperative diplopia found in 12 patients (92.31%) followed by persistent diplopia found in only one (7.69%). Preoperative enophthalmos was (61.5%) in eight patients, six of them improved after treatment and returned to the normal condition but only two had postoperative enophthalmos with less severity.
CONCLUSION:
The reconstruction of orbital floor using titanium mesh was successful in most of the cases and the resulted was good and satisfactory aesthetic and functional results.

BACKGROUND:
Transitional cell carcinoma of the bladder is one of the most widely recognized cancers affecting the genitourinary tract and it is the second most common cancer in Iraqi male population .Cross sectional imaging studies assume a significant role in the staging of this cancer , also the prognosis of the patients with bladder carcinoma worsens with higher stage and accurate preoperative radiological staging is required to increase cancer free survival for patients submitted for radical cystectomy.
OBJECTIVE:
To compare the accuracy of computed tomography and magnetic resonance imaging for staging of muscle-invasive bladder cancer.
PATIENTS AND METHODS:
Twenty patients were included in the study hnd undergone staging for their muscle invasive bladder cancer by the use of computed tomography scan and magnetic resonance imaging at least two weeks of their last trans-urethral resection of tumour, the radiological staging was compared to the staging of the histopathological reports of the radical cystectomy of the included patients.
RESULTS:
The staging accuracy of the computed tomography was 93.8%, sensitivity 88.8%, specificity 90.2%, while magnetic resonance imaging accuracy of staging was 71.30%, sensitivity 45.8%, specificity 81.70%. Accuracy increased with advancing stage.
CONCLUSION:
It is concluded that computed tomography staging is more accurate than magnetic resonance imaging tumor staging in patients with muscle invasive bladder cancer, with comparable results in lymph node staging.

BACKGROUND:
Pituitary adenomas are common benign brain tumors which account for 15% of all primary brain tumors & 25% of benign brain tumors. It's treatment modality includes medical management and surgery either transcranial or trans-sphenoidal. In recent years, gamma knife radiosurgery has emerged as a treatment modality in the management of pituitary adenoma especially for those cases who have residual tumor and/or those who are not candidate for surgery.
PATIENT AND METHODS:
This prospective and retrospective study was conducted on 132 pituitary adenoma patients (54 males and 78 females) with a mean age of 45.6 years. Patients were of four groups, 67 with prolactinoma, 10 with somatotroph adenoma, 22 with Cushing disease (ACTH releasing), and 33 with non-functional adenoma. Before performing the gamma knife treatment, a pre-MRI examination was done to these pituitary adenoma patients, then the post-MRI examination was done after 6 months, 1 year and 1.5 year of gamma knife treatment as well as clinical evaluation by examining the type of secretion and hormonal laboratory investigation with visual field assessment.
RESULTS:
In our study, the most pituitary adenoma group treated with gamma knife was prolactinoma patients (67), with a size of treatment ranging from 2-55 mm, showing 88.05% tumor necrosis; with hormonal level normalization reaching to 82.08%. In the (10) growth hormone releasing adenoma patients, the size of treatment ranged from 5-48 mm, with (90%) tumor necrosis, and (90%) hormonal level normalization. In the (22) ACTH-releasing adenoma patients, the size treated ranged from 3-29 mm, with tumor necrosis of (86.36%), and (81.81%) hormone level normalization, whereas in the (33) non-secretory type of adenoma, the size of treatment ranged from 18-67 mm and the tumor necrosis was 93.93%.
CONCLUSION:
It can be concluded from this study that gamma knife is an effective and safe option to treat pituitary adenomas by it's low incidence of both morbidity and mortality rate; the tumor necrosis is the highest in non-secretory type when the dose was above 18 grey, but the peri-tumoral edema was found in prolactinoma when the dose of irradiation was above 22 grey.

BACKGROUND:
Amblyopia is a common cause of unilateral visual defect, affecting patients with history of strabismus, refractive errors, and those who had visual deprivation in the critical period of visual development. Amblyopia may have an effect on various levels of the visual pathway. Cells atrophy in the lateral geniculate nucleus that receives information from the affected eye, and a shift in the dominance pattern in the visual cortex have been reported. Retinal involvement in amblyopia is controversial.
SUBJECTS AND METHODS:
This is a cross sectional study carried out in Al-Shaheed Ghazi al-Hareery Teaching Hospital in Medical City at Baghdad, Iraq .Forty-two patients with unilateral amblyopia were selected, 23 males and 19 females with age range of 12-40(mean age of 25.33 years) all of these patients had one amblyopic eye and the other eye normal. OCT scan was done for both eyes of each patient and the RNFLT measured after complete ophthalmological examination ( VA, refraction, slit lamp, and funduscopic examination
RESULTS:
It has been noticed that the mean of NFLT in normal eyes was higher than that of amblyopic eyes (108.88 versus 105.05) but this difference was statistically not significant (P=0.074).
CONCLUSION:
OCT is a sensitive way to estimate RNFLT, we concluded that there is no statistically significant difference in NFLT between the amblyopic, compared to the normal eyes. Also NFLT seems not affected by: type of amblyopia, age of patients and also the severity of amblyopia as all these factors didn’t reach statistical significant.

The novel coronavirus disease, COVID-19, impose a challenge on scientists and physicians in terms of understanding the phases of viral pathogenesis and host immunopathogenesis that lead to the fatal complications of the disease. Three pillars have been thought to play essential role in determining the prognosis of COVID-19, namely the viral load of SARS-CoV-2, the count and functionality of T lymphocytes and the crossreactivity of T lymphocytes with common cold coronaviruses. Collectively, these three factors might constitute a triad governs the time-based and phase-based progression of COVID-19
patients. This review discusses the role of this triad in COVID-19 and presents the so far accumulated knowledge and research that justify the central role of this triad of factors in disease prognosis. Understanding the factors control disease progression is most important in helping physicians to treat the multi-phased host-microbe disease.