Iraqi Postgraduate Medical Journal

BACKGROUND:
Severe acute malnutrition (SAM) affects nearly 20 million preschool-age children. Malnutrition is
a risk factor in approximately one third of deaths in children who are under 5 years of age
worldwide. Outpatient treatment of uncomplicated (SAM) is increasingly provided, using ready-touse
therapeutic foods (RUTF) & home-based management with locally homemade food.
OBJECTIVE:
To evaluate the effectiveness of Iraqi locally-prepared, home-made food in outpatient management
of moderate and SAM in children aged 6-59mo, and to assess foods complying with specific
nutritional compositions of standard ready-to-use therapeutic foods (RUTF), recommended by
WHO.
PATIENTS AND METHODS:
This is a Hospital-based cross sectional study was conducted at Fatema Al-Zahraa Hospital for
Maternity and Children in Baghdad from 1st Jan 2018 to 31st Dec 2018 in an attempt to assess
the use of locally-prepared, home-made food prepared high energy-dense food in outpatient
management of moderate acute malnutrition (MAM) and SAM in form of four recipes which were
designed in nutrition research institute, MOH. This is done by following the weight and length or
height of (76) patients with MAM or SAM every two weeks depending on WHO growth standards;
Weight-for-Length (W/L) or weight-for-height (W/H) Reference Card.
RESULTS:
The total number of patients who completed the study were 76; 31 (41%) males and 45 (59%)
females. The most common age group was 6 -12 months 51 (67.1% ) with a relatively MAM
predominance 43(56.6%) patients, over SAM 33(43.4%) patients. The recovery rate was 66 patients
(86.8%) while 10 patients (13.6%) were referred to inpatient treatment. The wt. gain was > 5 g/kg/d
in 34 (51.5%) patients and consistent with WHO recommendations. The mean duration of treatment was (5.93 ± 2.63) weeks.
CONCLUSION:
A locally homemade prepared food is highly relevant and it is good alternative and might be used as
substituent for imported RUTF in outpatient management of acute malnutrition.

BACKGROUND:
Etanercept is a tumor necrosis factor (TNF) α inhibitor that has been approved for the treatment
psoriasis.
OBJECTIVE:
Assessing the efficacy of etanercept therapy in Iraqi patients with moderate to severe psoriasis.
PATIENTS AND METHODS:
This study was a therapeutic interventional study at Medical City; center of dermatology and
venereology (Baghdad, Iraq) from January 2017 till June 2018, with 53 patients, 31 (58.49%) males
and 22 (41.51%) females, with 51 patients having moderate to severe plaque psoriasis and 2 patients
with pustular psoriasis. All patients were given 50 mg subcutaneous injection of etanercept twice
weekly for 3 months, followed by single injection of etanercept weekly for the next 9 months.
Psoriasis area and severity index calculations were done every 3 months until 1year of treatment.
RESULTS:
The baseline PASI score changed from a mean ± standard deviation of 24.28 ± 14.56 to 1.62 ± 3.11
At the end of 12 months of treatment with a significant difference (P=0.001). Regarding the
reduction in the patients' PASI score: At 3 months of treatment, (71.4%) achieved PASI 50, (48.2%)
had PASI 75, and (5.35%) had PASI 90, at the 12th month of treatment (75.4%) reached PASI 90,
(86.79%) reached PASI 75, &(94.33%) had PASI 50. Side effects were mild and tolerable.
CONCLUSION:
Etanercept is an effective therapy in treating moderate to severe psoriasis with tolerable side effects.

BACKGROUND:
Atrophic scars are commonly faced. The common feature of these scars is their bottom, which is
located below the level of the surrounding tissue. Scar revision can be a complex process that
requires a careful assessment, technical expertise, recognition of the psychosocial issues if
a satisfactory outcome is to be achieved.
OBJECTIVE:
The application of the dermal tube technique was first used by Mallucci et al. for the treatment of
atrophic tethered scars.
PATIENTS AND METHODS:
Between January 2017 to April 2018, 16 patients presented to us with atrophic tethered scars. Their
ages ranged between (4 -40) years and they included seven females and nine males. The locations of
the scars were in the face; (5) patients, in the neck; (2) patients, in the forearm; (3) patients, in
the arm; (1) patient, in the back; (1) patient, in the abdomen; (2) patients, in the buttocks;
(1) patient, and in the leg; (1) patient. The average history of scar was one and a half year. All scars
were treated surgically using dermal tube technique.
RESULTS:
Sixteen patients with tethered atrophic scars at different sites and due to different etiologies were
treated surgically with scar revision by the dermal tube technique. Patients results were evaluated
subjectively by the visual analogue scale for the post-surgical results. The average value of
the visual analogue scale was 7.8 with excellent improvement of the contour of the atrophic scar,
and a near normal skin texture with no recurrence of the deformity during the follow up period.
Three of our sixteen patients were unsatisfied with their results.
CONCLUSION:
dermal tube technique is an effective method to correct tethered atrophic scars. It is a simple and
single stage operation can be performed under local anesthesia ,with good results regarding scar
appearance and minimal recurrence of the deformity

BACKGROUND:
Elderly people develop different kinds of health problems which are known as geriatric syndromes
that have more than one cause and involve many activities of the body. The common geriatric
syndromes include urinary incontinence, falls, delirium, depression, dementia, sleep problems,
osteoporosis, weight loss and constipation.
OBJECTIVE:
The objective of this study to estimate the prevalence of common geriatric syndromes in relation to
gender and to interview the working state.
PATIENTS AND METHODS:
This study included 300 elderly patients with age range of 60 years -84years of both genders in
a cross-sectional study from March - June 2019 who visited geriatric clinic in Baghdad Teaching
Hospital / Medical City. Analytic study by SPSS was performed to assess the frequency of geriatric
syndromes and working state. The p value < 0.05 was significant.
RESULTS:
This study showed 65% were males. The most common geriatric syndromes included: Sleep
disturbance 50%, Urinary incontinence 48%, Osteoporosis 39% and fall 28%. Regarding working
state 56% was retired, 34.6% were unemployed and only 9.4% were working. Osteoporosis (4.3%)
and psychological problems (20.6%) were less in working older adults.
CONCLUSION:
The frequent geriatric syndromes are urinary incontinence, sleep disturbance, osteoporosis and falls.
More than half of patients were retired and one- third were unemployed. Osteoporosis and
psychological problems were decreased in working elderly patients.

BACKGROUND:
The first month of life is a time of increased risk of seizures; the prognosis largely depends on
etiologic factors and the duration of convulsive activity.
OBJECTIVE:
To describe the spectrum of brain magnetic resonant imaging (MRI) findings with neonatal seizures.
PATIENTS AND METHODS:
Cross – sectional study conducted in Children Welfare Teaching Hospital /Medical City Complex.
All full term neonates with a seizure were admitted to the Out -born Neonatal Care Unit or attending
the Consultation Clinic and infants admitted to Pediatrics Neurology Ward who had history of fit
during the neonatal period were included in the study (O -NCU) from January 1st to September
31st 2014.
RESULTS:
Eighty six neonates were included in the study, male: female ratio % o was 1.4:1. The mean age of
presentation was 24 days (+18SD). Two-thirds of neonates presented in the first week and mainly in
the first two days. The most common type of seizures was the subtle 15.1% within early or late
presentation and less common (3.5%) were the autonomic. About half of the patients had abnormal
Electroencephalography (EEG) study 49.1. Only 39.5% had normal MRI finding, about 60.5% had
abnormal MRI, the most frequent abnormality was metabolic 15.1% and developmental 11.6%.
The family history was positive in those who presented with seizures in first 14 days (early) in 30% ,
and more with those had metabolic etiology and no family history in case of vascular etiology.
89.5% of neonates had abnormal MRI finding in those who presented in the late period (p=0.003).

BACKGROUND:
Basel cell carcinoma is the most common locally invasive skin cancer in human. The diagnoses
depend on the clinical features and histopathological examination. Dermoscopy is a non-invasive
tool which allows better visualization of the subsurface structures. Dermoscopy can be used as an
aid in the diagnosis of basal cell carcinoma.
OBJECTIVE:
To evaluate the benefit of dermoscopy in the diagnosis of the basal cell carcinoma and describe
features of both pigmented and non-pigmented basal cell carcinoma.
PATIENTS AND METHODS:
This is a cross sectional study of twenty five patient with suspected basal cell carcinoma. It was
conducted at the Department of Dermatology, Baghdad Teaching Hospital, Baghdad, Iraq, from
April 2016 to August 2017. Twenty five patients with 25 lesions of basal cell carcinoma were
enrolled. History , clinical examination and photos were taken for each lesion, then dermoscopcial
evaluation for each lesion was done using fotofinder handyscope mounted on iphone6s with
a standardized dermoscopical image with 10x magnification and a polarized mode of light. Photos
were then evaluated and saved. Finally, the data was analyzed.
RESULTS:
According to the visualized pictures by dermoscopy the features of basal cell carcinoma included
leaf - like area in (50%) of lesions followed by multiple blue - grey nests in (50%) of lesions in
pigmented basal cell carcinoma, while ulceration in (100%), arborizing blood vessel in (83%)in nonpigmented
basal cell carcinoma. In mixed lesions shiny white to red structureless and milky pink
area in (86%), large blue - grey ovoid nest in (71%) were commonly seen. All histopathological
reports were basal cell carcinoma.
CONCLUSION:
Dermoscopy is a valuable tool for the diagnosis of basal cell carcinoma. There are specific findings
in pigmented and non-pigmented basal cell carcinoma.

BACKGROUND:
Pediatric acute liver failure (PALF) is a complex, rapidly progressive clinical syndrome that is
the final common pathway for many disparate conditions, some known and others yet to be
identified. Acute liver failure was first defined by Trey and Davidson as a potentially reversible
condition caused by severe liver damage accompanied by encephalopathy onset and in the absence of preexisting liver disease.
OBJECTIVE:
To assess the etiology, prognosis and outcome of FHF in a sample of Iraqi child patients
PATIENTS AND METHODS:
A prospective study was done on (50) patients diagnosed with acute hepatic failure admitted to
the Gastroenterology and Hepatology unit in Children Welfare Teaching Hospital during the period
from January 2015 to the December 2015. The patients referred to our center from all over Iraq,
Detailed history, clinical examination, routine biochemical parameters, and relevant tests were
carried out to all patients. Patients enrolled in this study with the age less than 16 years old with
the exception of neonate (< 1 month). The acute hepatic failure was diagnosed with prolonged PT,
PTT, elevated liver function test and the disturbance of level of consciousness.
RESULTS:
Hepatitis A was found to be the commonest cause of encephalopathy and was diagnosed in 18/50
(36.0%) of cases, 56% of cases presented with GIT bleeding, 32% of them presented with melena.
The worst outcome (100% mortality) was associated with sepsis, CMV infection, and biliary atresia,
and best outcome was associated with Wilson disease (20% mortality). The poor prognosis was
found in grade 3 and 4 of encephalopathy and 68% of child died.
CONCLUSION:
Hepatitis A is the most common cause of the FHF with high mortality rate. Bad prognosis was found
in grade 3 and 4 of encephalopathy, with GI bleeding, longer duration of illness before onset of
encephalopathy.

BACKGROUND:
Stroke in patients with non-valvular AF is a major cause for disability and increasing morbidity and
mortality, CHA2DS2-VASc is a tool for assessing the risk of stroke in these patients
OBJECTIVE:
This study was conducted to evaluate the use of CHA2DS2-VASc scoring system in a sample of Iraqi
patients with embolic stroke and non valvular atrial fibrillation
PATIENTS AND METHODS:
A cross-sectional study was done in Baghdad Teaching Hospital that enrolled 60 patients with nonvalvular
atrial fibrillation who presented with a first-time ischemic stroke. Data was collected using
a questionnaire, CHA2DS2-VASc score was calculated (excluding 2 points of stroke for all
patients), and also HAS-BLED score was calculated.
RESULTS:
In this study, there was a statistically significant association between age groups and CHA2DS2-
VASc scores, as most patients with low scores were in younger age groups and most of patients with
higher scores were in older age groups. The same association was found between sex and CHA2DS2-
VASc scores, noting that the majority of the study group were females (70.0%). The most frequent
risk factor was hypertension which was diagnosed in (85.0%) of the study group, followed by heart
failure (51.7%), and diabetes mellitus (40.0%), while the presence of vascular diseases was the least
common (26.7%). Warfarin use was recorded in only 7(11.7%) patients. There was no statistically
significant association between CHA2DS2-VASc and HAS-BLED scores.
CONCLUSION:
CHA2DS2-VASc was a valuable tool for assessing risk of embolic stroke, yet, there was a low
frequency of anticoagulation use which was not explained by HAS-BLED scores. Hypertension and
heart failure were the most common among study group, followed by diabetes mellitus.

BACKGROUND:
Total knee arthroplasty is now practiced increasingly. Arthroplasty is considered successful if
the knee is stable, painless with good range of motion.
OBJECTIVE:
To evaluate the importance of different factors that might affect the success rate of total arthroplasty
in knee osteoarthritis
PATIENTS AND METHODS:
Patients with osteoarthritic knees admitted to Basrah center of joint replacement (Basrah Teaching
Hospital) during the period from January 2017 to October 2018, for total knee replacement were
enrolled in the study. Factors that can affect post-operative range of motion were studied. These
involved factors related to patients (such as age, gender, body mass index, comorbidities, side of
diseased knee, knee functional score, and range of motion), and those related to the operative
procedure(duration of operation, use of tourniquet, size of femoral and tibial components, and
the type of polyethylene spacer). The amount of postoperative blood in the drain was also recorded.
The follow up period was for up to one year after the surgical operation.
RESULTS:
Seventy five patients were included in the study, 60 females and 15 males who constituted (80%,
20%) respectively. The mean age was (59.20±7.05 years), ranged between (45 - 71 years). The mean
BMI of the patients was (26.52 ± 2.67). The tibial size ranged from 3 to 7 with mean
(5.08±1.39).The mean pre and post-operative ROM (after one year follow up) was (110.20±20.25)
and (116.46±6.76) respectively. The functional knee score (Lysholm score) increased from
(50.40±14.67) to (79.48±9.75) post operatively. Fifty two percent of the patients were right sided
knee and 48% of them were left sided. There was no significant statistical correlation between knee
side and range of motion postoperatively. Correlation was also not significant between associated
diseases, gender and post-operative range of motion. Patients with normal BMI had better
postoperative ROM than over weight and obese patients with mean ROM (120.17±5.49,
115.0±10.28 and100.0±16.92) respectively. There was significant negative statistical correlation
between the age and the post-operative range of motion. There was a significant negative correlation
between post-operative range of motion, polyethylene spacer, and size of tibial and femoral
components used. No correlation was found between the time of operation and postoperative range
of motion; however, the latter was negatively correlated with the amount of blood in the drain.
CONCLUSION:
Postoperative range of motion after primary total knee arthroplasty in osteoarthritis of the knee
joint seems to be mostly affected by preoperative range of motion and BMI. Younger patients tend
to have a better postoperative range of motion, while larger size of the components of arthroplasty
are associated lower post-operative range of motion.

BACKGROUND:
Fever occurs in about 80% of patients with hematologic malignancy during chemotherapy-induced
neutropenia. Fever during chemotherapy-induced neutropenia may be the only indication of a severe
underlying infection.
OBJECTIVE:
To determine the common types of bacterial pathogens causing febrile neutropenia and their
susceptibility to antibiotics in patients with hematological malignancies in Baghdad Teaching
Hospital.
PATIENTS AND METHODS:
50 patients with hematological malignancies and febrile neutropenia were enrolled in this cross
sectional study. All patients were sent for CBC, GUE, blood culture and sensitivity test. Other
sample cultures were sent on indication
RESULTS:
AML (42%) was the most common malignancy .Blood culture was positive in (24%).
The most common bacteria isolated by blood culture was Staphylococcal aureus (41.67%), gram
positive bacteria were predominant in hematological malignancy (62.5%), positive sputum culture
was obtained in 4(8%) of patients.
The most frequently effective antibiotic was Imipenem for gram positive infections, and Amikacin,
Imipenem and Piperacillin/Tazobactum for Gram negative infections.
CONCLUSION:
Gram positive bacteria were the most common bacteria with Staphylococcal aureus as the most
common bacterial pathogen isolates in blood culture and streptococcal pneumonia in sputum culture,
Imipenem was most commonly effective antibiotic.

BACKGROUND:
Melasma is a common pigmentation disorder where there is increase in melanin stores in the
epidermis, dermis or both. There are many topical therapies for these disorders, salicylic acid and
lactic acid had been used for treatment of melasma as peeling agents.
OBJECTIVE:
To evaluate the efficacy and safety of 30% salicylic acid in comparison with 88% lactic acid in
treatment of melasma in a split face study.
PATIENTS AND METHODS:
Twenty six patients with melasma participated. 24 (93.3%) were women, and 2 (7.7%) were men.
All patients had therapy-resistant melasma for 1 year. Full clinical examination including Wood’s
light examination was done to all patients. The severity of melasma was assessed by MASI
(Melasma Area Severity Index). 88% lactic acid was used on the left half of the face while 30%
salicylic acid was applied to the right half. The peeling sessions were done every 2 weeks for 3
months. Follow-up was carried out for 3 months after the last session.
RESULTS:
Eighteen patients completed the study, their ages ranged from 24 to 47 years with a mean ± SD of
38.22±5.36 years. According to Fitzpatrick’s classification 14 (77.7%) patients had skin type IV; 3
(16.6%) patients had skin type III and one (5.5%) patients had skin type V. After 3 months, the
percent reduction to lactic acid and salicylic acid were 50% and 44.7% respectively with statically
significant value (P value = 0.0001). Mild stinging sensation and transient erythema were reported.
Most patients maintained improvement 3 months after cessation of therapy. However, there were no
statically significant differences (P value = 0.4106) between the two modalities.
CONCLUSION:
Both peeling agents were effective in treating melasma with no important side effects.

BACKGROUND:
Bronchial asthma is a chronic inflammatory disease of the respiratory tract constituting a serious
public health problem all over the world. The most common trigger in childhood asthma is viral
URTIs. Studies have shown that viruses are associated with 80 to 85% of asthma exacerbations in
school-age children in the community including, rhinovirus, enterovirus, human metapneumovirus,
echovirus, RSV and others. (1,2)
OBJECTIVE:
To study the prevalence of RSV infection in the acute asthmatic flare-ups in children 2-15 years
of age.
PATIENTS AND METHODS:
A prospective, age and sex-matched case-control study, examined 90 children aged 2-15 years; 50 of
them were asthmatics and 40 were non-asthmatics visited the outpatient clinic in the period from
July to Dec. 2013. Children who had 3 or more attacks of wheezing LRTI diagnosed by
a pediatrician as cases of asthma and showed a definite response to bronchodilator therapy were
included in the asthmatic group. Parents and patients were interviewed and a well-structured
questionnaire that solicited to their demographical and clinical characteristics was used. Blood
samples were taken from all cases and controls and sent for ELISA test for anti-RSV IgM, IgG and
IgA antibodies.
RESULTS:
There was no significant association between each of the RSV immunoglobulins detected and
asthma flare-up between asthmatics and controls. There were no significant associations between
each of residence, maternal smoking and history of fever and RSV infection between asthmatics and
controls.
CONCLUSION:
There is a minor role in RSV infection as a triggering factor in asthma flare-ups in children aged
2-15 years.