Iraqi Postgraduate Medical Journal

BACKGROUND:
Skin cancer is an uncontrolled skin cell growth. It most often forms on regions of the skin that are exposed to the rays of the sun. Skin cancer impacts people of all colors and races although there is a higher risk for those with fair skin who develop quick sun burns. Basal cell carcinoma, squamous cell carcinoma, and melanoma are three major types.
STUDY OBJECTIVE:
To study the outcomes of histopathological analysis of skin biopsies and their correlation with age, patient gender and frequency of the three types of skin cancer.
PATIENTS AND PROCEDURES:
A Retrospective cross sectional study was carried out in the Al-Kindy teaching hospital's clinical laboratory. In this study, surgical specimens of skin lesions that were collected from 2015 through 2018 by open biopsy of all patients were selected. Seventy cases of 39 female and 31 male patients have been reviewed.
RESULTS:
Out of 70 sample of skin biopsies, female percentage was 55.71% (no:39), while male percentage was 44.29% (no:31). The commonest type of skin cancer was basal cell carcinoma (68.6%) followed by squamous cell carcinoma (22.9%), followed by melanoma (8.6%). The peak incidence of BCC was at age 50-59 yrs. & 60-69 yrs. The peak incidence of SCC was at age 60-69 yrs. While melanoma occur in different groups of age mostly in 30-39 and 60-69 years age group. The peak incidence of BCC and SCC was at year 2016.
CONCLUSION:
Skin cancer is more in female than male and more at age 50-70 year. The commonest type of skin cancer was BCC followed by SCC followed by melanoma.

BACKGROUND:
Overactive bladder Syndrome refers to a group of lower urinary tract symptoms related to the storage of urine in the bladder. Normally the bladder fills and stores urine without discomfort or leakage. The sensation of bladder fullness gradually increases until the need to void comes to conscious awareness. In those who have overactive bladder, however, the sensation to void is altered (and generally delayed) to the extent that involuntary urination may occur. current evidence suggests that it may be associated with insulin resistance .
AIM OF STUDY:
We aimed to investigate the association of insulin resistance with overactive bladder in female patients.
PATIENT AND METHODS :
We prospectively conducted the study in our urogynecological department. Female patients aged between 30 and 76 years with or without overactive bladder syndrome OABS symptoms were enrolled. Fifty patients with OABS and fifty age-matched controls without OABS were included in the study. Fasting serum insulin and fasting blood sugar were measured. Insulin resistance value was obtained via the homeostasis model assessment of insulin resistance (HOMA-IR) calculator.
RESULTS:
There was no significant difference in the age, and mode of delivery ‎between ‎women with or ‎without overactive bladder (OAB), while BMI and parity ‎number ‎were significantly higher in OABS ‎women‎. FBS, fasting insulin (‎11.2‎‏ ‏vs‎. ‎7.9 ????U/ml‎‏)‏ ‎, HOMA-IR value (‎2.62‎‏ vs‎. ‎1.77) and insulin ‎resistance (IR) was ‎significantly higher in OABS women‎, in which 50% had IR while ‎‎12% had IR in ‎women with or without OABS.‎ In multivariate analysis insulin resistance (IR≥2.5) , age, increased BMI, higher parity, and CS ‎history were independent predictors of overactive bladder‎.
CONCLUSION:
- insulin resistance is associated with overactive bladder syndrome, and about half of the women with overactive bladder presented with insulin resistance
- Hyperinsulinemia is strongly associated with overactive bladder
- Obesity is an independent predictor of overactive bladder
- HOMA-IR equation can be used as diagnostic methods that assist in confirmation of overactive bladder diagnosis by 20 – 25% additional increase in the index of suspicion.

BACKGROUND:
Spasticity is a motor disorder characterized by a velocity-dependent increase in muscle tone with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex, as a component of the upper motor neuron syndrome.
OBJECTIVE:
To evaluate the effect of intrathecal baclofen therapy after one to five years of treatment.
PATIENTS AND METHODS:
Aretrospective questionnaire-based study was done including 20 patients operated for intrathecal baclofen pump insertion at neurosciences hospital from 1/1/2013 to 1/1/2018,
RESULTS:
According to GMFCS in C.P, only those who were grade 4 or 3 had benefit, while grade 5 patients only improved easier diapering and transfer. From 8 spinal cord injury cases, 7 had improvement, while both M.S. cases were improved, but one of them started to have tolerance four years after implantation. Eighteen out of 20 patients were satisfied from ITB therapy
One patient suffered from side effects (nausea, drowsiness) only after the test dose, and no side effects were mentioned during continuous therapy.
Two patients had drug tolerance were required to increase the dose.
CONCLUSION:
Intrathecal baclofen is a good treatment for spasticity, it can be considered safe as it caused no serious side effects, intrathecal baclofen is safer than oral baclofen because is uses a smaller dose, and it regarding tolerance, it occurs but not in every patient.

BACKGROUND:
Chronic rhinosinusitis (CRS) is an inflammatory disorder of paranasal sinuses. The computerized
tomography (CT) scan remains the common diagnostic modality for diagnosis of paranasal diseases.
AIM OF STUDY:
To evaluate the value of CT scan in the management of chronic rhinosinusitis by correlating
preoperative symptoms severity score as well as overall disease severity score of CRS depending on
radiological findings on CT scan.
PATIENTS AND METHODS:
A cross-sectional analytic study conducted in Computerized Tomography (CT) unit of Al-Emamain
Al Kadhimain Medical City in Baghdad/Iraq during the period from 1st of July to 31th of December,
2019 on sample of 100 CRS patients (58 male - 42 female). The diagnosis of CRS disease was done
by Otolaryngology Specialist depending on history and clinical examination the data were collected
from the patients directly and filled in a prepared questionnaire.
RESULTS:
There was a strong positive significant correlation between CT scan Lund Mackay (L-M) score of
CRS patients and CS score (r=0.89, p<0.001). Mean L-M score was significantly higher among CRS
patients with high risk of CS score (>40) (p<0.001). L-M CT score was higher in males (1.3:1 ) and
in extremes of age .The acceptable cut off points and the corresponding validity values for L-M
score level in prediction of high risk was 11.5 with acceptable validity results (90% sensitivity, 80%
specificity and 86% accuracy).
CONCLUSION:
The computerized tomography scans Lund Mackay score had good correlation with clinical
symptoms of chronic rhinosinusitis.

BACKGROUND:
Nail psoriasis occurs in both adults and children. Nail involvement is associated with significant physical and psychological consequences for a substantial number of patients. The prevalence of nail changes among patients with psoriasis varies between 10 and 55 percent. In most patients, nail involvement follows or is concurrent with onset of cutaneous psoriasis.
OBJECTIVE:
To evaluate nail changes in a sample of Iraqi patients with psoriasis and study their association with the disease severity.
PATIENTS AND METHODS:
The study is a clinico-epidemiological observational cross-sectional study. It was conducted at the outpatient clinic at the Center of Dermatology and Venerology/ Medical City Teaching Hospital between May 2018 and August 2019. A total of 94 patients were enrolled in this study. The severity of psoriasis was assessed using Psoriasis Activity Score Index (PASI), Body Surface Area (BSA), and Dermatology Life Quality Index (DLQI) scores whereas the severity of nail involvement was assessed by Nijmegen Nail Psoriasis Activity Index Tool (N-NAIL) and then compared against psoriasis scores. The patients were divided into two groups; patients with (group A) and without (group B) nail involvement.
RESULTS:
The study sample included 41 males (43.62%) and 53 females (56.38%). The mean age at presentation was 32.59±16.32 years. The number of patients in group A was 69 patients (73.4%). The mean ±SD for PASI score was 6.6±7.71 and the mean ±SD for DLQI score was 11.36 ±7.93.While the number of patients in group B was 25 patients (26.6%). The mean ±SD for PASI score was 4.38±3.02 and the mean ± SD for DLQI score was 8.48±4.77.There were no statistical differences between group A and group B regarding age, duration of the disease, PASI score and DLQI score. The patients in group A were subdivided into two groups: the first group included patients with mild psoriasis; 37 patients (PASI score ≤ 10) and the second group included patients with moderate to severe psoriasis; 10 patients (PASI score > 10).The patients with severe cutaneous psoriasis had more severe nail changes. In patients with mild psoriasis, the N-NAIL score was 25.62±23.96 while in patients with moderate to severe psoriasis, the N-NAIL score was 48.8±27.95 (p value =0.011). Crumbling, onycholysis and subungual hyperkeratosis were more frequent in this group. In general, pitting was the most frequently observed finding (52.13%) followed by onycholysis and crumbling.
CONCLUSION:
This is the first study of nail changes in psoriasis patients in Iraq. Nail changes were observed in 73.4% of patients with pitting as the most frequent nail finding. The patients with severe psoriasis had more severe nail changes with higher N-NAIL scores than patients with mild psoriasis.

BACKGROUND:
Clubfoot is one of the most common congenital birth defects, most occuras an isolated birth defect and are considered idiopathic. The Ponseti method of serial casting has gained widespread popularity in recent years for the treatment of idiopathic clubfoot.Non-idiopathic clubfeet are thought to be too rigid to correct by casting alone, it is often treated primarily with surgical extensiveSoft tissuereleases, and the use of Ponseti method for the treatment of non-idiopathic clubfoot has not been extensively reported.
AIM OF THE STUDY:
To study the effectiveness of Ponseti method to achieve correction in non-idiopathic clubfoot, and to follow the patient for relapses.
PATIENTS AND METHOD:
During the period from February 2013 to December 2017, 16 infants with clubfeet associated with other congenital deformities were managed by Ponseti method, and followed for a minimum of 10 months and maximum of 60 months (mean ± SD= 32.94±17.39 ). All patients were treated at medical city center in Baghdad/Iraq.
RESULTS:
16 patients with syndromic clubfoot, 9 of them diagnosed as arthrogryposis and the rest as other syndromic types. 12 of them were males(75.0%) and 4 of them were females (25.0%). 14 of cases had bilateral deformities (87.5%) and 2 unilateral deformities (12.5%).5 patients required 4- 5 casts to achieve initial correction (31.2%) and 11 patients required 6-8 (68.8%).In arthrogryposis only 55.6% of cases required 5 and more casting, while in other syndromic cases 85.7% of cases required 5 and more casting. All patients required additional minor surgical procedures. Initial Pirani score of pre casting to the right and left was (mean±SD) 4.83±0.81 and 5.03±0.85 respectively, Pirani score after removal of final cast(pre surgery) to the right and left was (mean±SD) 1.03±0.74 and 1.3±0.7 respectively (p –value ˂ 0.001).Follow-up for minimum 10 months and maximum 60 months (mean±SD/ 32.94±17.39) .Half of our patients got plantigrade, pain free, and flexible foot at last follow up with no relapse, another half of patients developed relapse at subsequent follow up. Most relapses occurred in arthrogryposis cases (66.7%),while in other syndromic cases relapses occurred in (28.6%).Two of relapsing cases(25%) treated by repeated casting, another two cases(25%) treated by repeated casting and heel cord release, and four cases (50%) treated by salvage procedure (talectomy) after failed repeated casting due to rigid and stiff feet.
CONCLUSION:
The Ponseti method is effective treatment for syndromic clubfootto achieve flexible, pain free and plantigrade foot and to minimize the extensive future surgeries.

BACKGROUND:
Ocular astigmatism is the sum of corneal astigmatism and internal astigmatism. The component of ocular astigmatism that cannot be a attributed to the anterior corneal surface is referred to as ocular residual astigmatism.
OBJECTIVE:
To evaluate the difference between ocular residual astigmatism and total ocular residual astigmatism in normal virgin eyes with refractive errors.
PATIENTS AND METHODS:
Eighty four patients ( 135 virgin eyes) with refractive errors were enrolled consecutively in this study at the Lasik clinic in Ibn Al- Haitham Teaching Eye Hospital. Measurement of astigmatism was done by
manifest refraction and corneal topography using Oculus Pentacam, and these measurements were used for calculating ocular residual astigmatism and total ocular residual astigmatism with comparison between them.
RESULTS:
The study showed a significant difference between the means of ocular residual astigmatism (-0.7416 ± 0.4341 ) and the total ocular residual astigmatism (-0.6223 ± 0.401) in with the rule astigmatism (P value < 0.001), and the means of ocular residual astigmatism (-0.8113 ± 0.38517) versus the means
of total ocular residual astigmatism (-0.6658 ± 0.3844) in against the rule astigmatism (P value <0.001).
CONCLUSION:
The ocular residual astigmatism based on the total corneal topographic astigmatism corresponds better with manifest refractive cylinder than the ocular residual astigmatism based solely on anterior corneal
topographic astigmatism .
KEY WORDS: Ocular residual astigmatism, Posterior corneal astigmatism.

ABSTRACT:
BACKGROUND:
Ocular astigmatism is the sum of corneal astigmatism and internal astigmatism. The component of ocular astigmatism that cannot be a attributed to the anterior corneal surface is referred to as ocular residual astigmatism.
OBJECTIVE:
To evaluate the difference between ocular residual astigmatism and total ocular residual astigmatism in normal virgin eyes with refractive errors.
PATIENTS AND METHODS:
Eighty four patients ( 135 virgin eyes) with refractive errors were enrolled consecutively in this study at the Lasik clinic in Ibn Al- Haitham Teaching Eye Hospital. Measurement of astigmatism was done by
manifest refraction and corneal topography using Oculus Pentacam, and these measurements were used for calculating ocular residual astigmatism and total ocular residual astigmatism with comparison between them.
RESULTS:
The study showed a significant difference between the means of ocular residual astigmatism (-0.7416 ± 0.4341 ) and the total ocular residual astigmatism (-0.6223 ± 0.401) in with the rule astigmatism (P value < 0.001), and the means of ocular residual astigmatism (-0.8113 ± 0.38517) versus the means
of total ocular residual astigmatism (-0.6658 ± 0.3844) in against the rule astigmatism (P value <0.001).
CONCLUSION:
The ocular residual astigmatism based on the total corneal topographic astigmatism corresponds better with manifest refractive cylinder than the ocular residual astigmatism based solely on anterior corneal
topographic astigmatism .

BACKGROUND:
Neonatal mortality is mainly caused by infections, birth asphyxia and pneumonia (developing nations). Determinants included socioeconomic-demographic factors, healthcare system and culture. Risk factors: low birth weight, prematurity, insufficient antenatal care, repeated caesarian deliveries. Limited neonatal deaths research in Iraq justified this study.
AIM OF THE STUDY:
Describe and plot the neonatal mortality trend during the period of 2008-2017, and finding relation with key determinants and risk factors.
METHODS:
Retrospective software and hardcopy neonatal medical records review & analysis (February-June 2019) in MOH, Central Statistical Organization, Baghdad's Health directorates, International Health Organizations, & 2-3 conveniently selected hospitals in health directorate. Records studied: Annual Statistical Reports, "Neonatal deaths Statistics Form", "Born", admission files, intensive care units' logbooks, death certificates, international organizations’ estimates & Multiple Indicator Cluster Surveys.
RESULTS:
Highest mortality rate was in West region 2015 (18.38/1000), lowest in east 2014 (3.78/1000) excluding Kurdistan; the decline during 2014-2015. Highest admission deaths: males (57.8%), cesarean deliveries (52%), extreme low birth weight (8.5%), preterm (71.2%), >31 years (20.2%). Top death cause: Respiratory distress syndrome (51.9%), & late death: sepsis (33.36%).
CONCLUSION:
Mortality rate declined to lowest in 2014, followed by a rise attributed to increased registration; highest in west 2015, lowest in east 2014. Respiratory distress & sepsis were the most common causes. Most deaths in: preterm neonates, males, extremely low birth weight, operative deliveries & >31 years maternal age.

BACKGROUND:
Almost in all types of surgical operations, patients experienced some kinds of anxiety which is reflected by a perceptible change in some vital signs. Music therapy is an emerging nonpharmacological intervention that had proven effectiveness in different medical conditions.
OBJECTIVE:
To assess the effect of music intervention on some vital signs in patients undergoing elective pelvic and lower limb surgery under spinal anesthesia.
PATIENTS AND METHODS:
A prospective randomized study was conducted including a total of 100 patients scheduled for elective pelvic and lower limb surgery under spinal anesthesia. Patients were randomly assigned into two equals groups: the intervention group, and non-music group. Spinal anesthesia was standardized to all patients. Patients in music group were given headphone set connected to CD player and listened to a soft music immediately after the induction of spinal anesthesia until the end of the operation. Patients in non-music group were given midazolam in divided doses each with 1 mg as required. Hemodynamic parameters and respiratory rate were recorded at the entrance of operating room and then 5, 10, 15, 20, 30, 40, 50 and 60-minute post anesthesia induction.
RESULTS:
During all the time period after anesthesia induction until the end of operation, there were no significant differences between intervention group and non-music group in the all included vital signs (heart rate, systolic pressure, diastolic pressure, and mean blood pressure).
CONCLUSION:
music intervention can be used as a nonpharmacological alternative midazolam to control the vital signs after spinal anesthesia.

BACKGROUND:
The choice of micro-anastomosis technique (end to end or end to side) in free flap surgeries is a critical step especially in single vessel extremity in which end to side is the preferable method. Which type of end to side (arteriotomy or arteriotomy) is another relevant point to be considered?
AIM:
This study aims to evaluate the reliability of end to side anastomosis using longitudinal slit arteriotomy.
METHODS:
(9) patients were managed with free tissue transfer using end to side anastomosis with longitudinal slit arteriotomy. (8) Patients with lower extremity defects and (1) patient with upper extremity defect. (6) Patients were managed with Latissimus dorsi flap and (3) patients were managed with ALT flap. In all cases end to side anastomosis is made using no. 11 blade to create a longitudinal slit in the recipient artery for micro-anastomosis
RESULTS:
All anastomosis remain patent and flaps survived without complications, neither re-anastomosis is required intra-operatively nor re-exploration is required post operatively
CONCLUSION:
longitudinal slit arteriotomy is easy to perform, reliable with high patency rate and can consistently be used in free tissue transfer with excellent results

BACKGROUND:
Colorectal cancer is a major cause of mortality and morbidity. The interplay between systemic inflammation and the local immune response was recognized as the seventh hallmark of cancer, and it has been demonstrated to be involved in the initiation, development, and progression of several types of malignancies. systemic immune-inflammation index, was reported as prognostic factors in some malignant tumors, including Colorectal cancer.
AIM OF STUDY:
To investigate the relationship between systemic immune-inflammation index and clinicopathological characteristics (sex, age, site of tumor, T stage, N stage, M stage, Clinical (TNM) stage, Duke stage, Grade, Lympho-Vascular Invasion and Carcino-Embryonic Antigen level) of colorectal cancer.
METHOD:
cross-sectional study was conducted, involving seventy patients with Colorectal cancer who were diagnosed by histopathological proof, to evaluate the relationship by dividing the patients into two groups depending on cut-off values: (1) those with high marker level, (2) those with low marker level.
RESULTS:
The study involved 70 patients who are 38 males and 32 females. Their mean age was 53 years. Tumor site was in 40% of them in the left colon. The majority (67.1%) of patients have no metastasis and moderately differentiated tumors, 22 of 38 patients (58%) have positive lymphovascular invasion. Only 53 patients (75%) have a recorded pretreatment Carcino-Embryonic Antigen level and the mean was 13.07 ng/ml. There was a statistically significant association between systemic immune inflammation index and T stage and presence of metastasis, thereby clinical and Duke stages, as the value of systemic immune inflammation index is higher in advanced stages. Higher values of systemic immune inflammation index were associated with higher grade and with positive lymphovascular invasion also.
CONCLUSION:
Elevated systemic immune-inflammation index is associated with higher stages and with lympho-vascular invasion of colorectal cancer. It is furtherly associated with higher grade of disease. Systemic immune inflammation index is easily accessible, and its association with poor prognostic indicators (like stage or presence of metastasis) warrant further investigation.

BACKGROUND:
Obstruction or stenosis of the lacrimal ducts, which leads to inadequate drainage of tears, may cause intermittent or constant tearing, which is termed “epiphora, radiological evaluation to the lacrimal gland are divided into anatomical (conventional dacrocystigraphy, CT dacrocystography and MR dacrocystograhy), and functional evaluation (staining test, scintigraphy and dynamic MR dacrocystography).
AIM OF STUDY:
To study the value of MRI dacrocystography in patients with clinically diagnosed epiphora.
METHODS:
A total of 36 patients who had presented to the Ophthalmology Clinic from 1st of April 2019 to 1st of October 2019 who were suspected to have obstruction of lacrimal drainage system, were evaluated with MR-DCG after instillation of 0.5% sterile water into the conjunctiva. The examination was performed at MRI department in the X-ray institute in the Medical City, then ophthalmological examination (punctum lavage test) was performed bilaterally for all enrolled patients.
RESULTS:
Obstruction of lacrimal drainage system was successfully detected in a total of 41 eyes of 36 patients undergoing examination with MR-DCG. The MR-DCG findings of 72 nasolacrimal systems were compared with the ophthalmologic professional diagnosis findings in all patients the sensitivity of MR-DCG was 90.6% for identification of nasolacrimal system obstruction when compared with the ophthalmological professional examination findings, and MR-DCG was found to detect obstruction with high accuracy and provide further information about the level of obstruction and if the obstruction in partial or complete.
CONCLUSION:
MR-DCG has a high success rate in detection of lacrimal drainage system obstructions and the level and cause of the obstruction, this method avoids both cannulation and ionizing radiation, so could be repeated if necessary, non-time consuming and avoids the side effect of contrast.

BACKGROUND:
Male factor infertility is a multifactorial condition that is observed in the infertile couples. However, a proportion of infertile men have now been shown to have defective sperm functions related to oxidative stress (OS) which is a significant pathology,
AIM OF THE STUDY:
To estimate the indicators of OS by measuring malondialdehyde (MDA) and reduced glutathione (GSHr) levels in sperms of the infertile and fertile men and to evaluate the correlations of them with sperm quality parameters.
METHODS:
The levels of MDA and GSHr were measured spectrophotometrically at The Higher Institute of Infertility Diagnosis and Assisted Reproductive Technique /Al-Nahrain University, Baghdad, Iraq, between February till August 2019.
RESULT:
It was found that the mean of MDA levels was significantly higher in spermatozoa of infertile men (P ≤ 0.0001) and mean of GSHr levels was significantly lower in spermatozoa of infertile men compared to spermatozoa of fertile controls (P ≤ 0.0001). Furthermore, there were no statistical significant correlations between MDA and GSHr with sperm quality parameters.
CONCLUSION:
Evaluation of MDA and GSHr levels in spermatozoa of the infertile men provide valuable assays for estimation of OS which help in planning treatment for male infertility.

BACKGROUND:
Diabetic Ketoacidosis (DKA) is the most serious acute Complication of type 1diabetes mellitus and the leading cause of morbidity and mortality in children. It still carries high incidence rate at time of diagnosis.
Study design: Hospital-based cross-sectional observational study conducted at Children Welfare Teaching Hospital /Medical City /Baghdad; including the admitted patients in ER.
OBJECTIVE:
To identify the frequency of ketoacidosis and associated risk factors at the onset of Type 1 Diabetes Mellitus in children and adolescents.
METHODS:
The demographic, clinical manifestation, laboratory data of 69 patients presented with DKA at the disease onset out of total 144 patients who were diagnosed as Type 1Diabetes Mellitus; during a one-year period from 1st of September 2017 to 31th of August 2018. Age distribution was categorized into three groups: 1- 5 years, <5 years, >10 years. DKA was defined as blood glucose ≥200 mg/ dl; blood PH < 7.3; associated with ketonuria and glucosuria.
RESULTS:
Of 69/144 patients (47.9%) presented with diabetic ketoacidosis at disease onset; 41 patients (59.4%) were females which was significant (P value 0.045); Mean age at diagnosis was 7.5± 3.4 years: with highest frequency (43.5%) in age group >5 years but (50%) of severe DKA patients were involved in younger age group ≤ 5 years. Family history of diabetes was found in 11 (15.9%) patients. Majority of primary caregivers had a low academic achievement just14 (20.3%) of them had higher education.
CONCLUSION:
The frequency of childhood DKA at the disease onset was still high. Girls had a higher rate of occurrence. Younger age is associated with more severe DKA. Family history of diabetes and education level of the parents did not affect the frequency of DKA.

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