Iraqi Postgraduate Medical Journal

BACKGROUND:
The use of new and faster MRI techniques with higher resolution, contrast and greater diagnostic
accuracy, make the MRI as an excellent method for evaluating articular cartilage disorders.
OBJECTIVE:
To evaluate the sensitivity and specificity of different sequences of MRI in diagnosing and grading
damage of articular cartilage of the knee joint.
PATIENTS AND METHODS:
From March 2017 to Feb. 2018 ,40 Patients (50 knees) with age ranging from (34-67 years) MRI
evaluation of the knee articular cartilage was performed using a 1.5T MRI scanner . Arthroscopic
surgery was done for them after a maximum delay of 2 months from the MRI study, Employing
the outer bridge grading system, the MRI grade 0, I, II, III and IV lesions were compared to
the arthroscopic results. The sensitivity, specificity and accuracy were evaluated for each sequence.
RESULTS:
Of the 40 patients, 22 (55%) were females and 18 (45%) were males. Of 300 joint surfaces
135(45%) grade 0 ,16(5.3%) grade I , 36(12%) grade II , 85(28%) grade III and 28(9.3%) grade IV
by arthroscopy, when comparing to MRI findings, there was good and very good Kappa values
(0.759-0.818). Chondral lesions were undergraded by MRI in (13%) and overgraded in (6.6%),
the sensitivity of MRI was ranging between (60-92%), the specificity ranging (68.7-88.8%) and
the accuracy (70-86%) .Results demonstrated poor sensitivity of MRI in detecting grade I(33.3%) &
grade II(35.8%) and better sensitivity in detecting grade III(85.5%) & grade IV(76.4%). IW-FS-FSE
sequence showed the highest sensitivity (88%) & accuracy (97%), followed by FS-PD with
a sensitivity of (85%) and accuracy (95%).
CONCLUSION:
MRI is an adequately sensitive and specific diagnostic tool for identifying the presence of articular
damage, but still not reliably described as Arthroscopy. Among the 2D and 3D GRE images the best
diagnostic evaluation of cartilage disorders was obtained by the IW-FS-FSE sequence . The PD
sequence can be used to evaluate knee cartilage, the dynamic range and the findings of subchondral
bone disorders are increased by fat suppression during imaging techniques so that it is important in
cartilage disorders interpretation.

BACKGROUND:
Catheter ablation is the most effective treatment for patients with accessory pathway-related
arrhythmias. There have been no clear recommendations on the optimal approach for left-sided
accessory pathway ablation.
OBJECTIVE:
To compare the efficacy and safety of the trans-septal approach versus the retrograde trans-aortic
approach for left sided accessory pathway ablation.
PATIENTS AND METHODS:
All patients with left-sided, accessory pathway who underwent electrophysiological procedure and
radiofrequency ablations in Ibn Albitar Cardiac center from January 2017 till February 2019 were
included (79 patients). The procedures (87 procdures) were divided according to the approach used
into the trans-septal and trans-aortic groups, and different parameters were measured and compared
between the groups.
RESULTS:
The mean age was 36.28±13.5 (range 8-67) years, male gender was slightly more predominant
(58.2%). The trans-aortic approach was pursued in 36 procedures (41.4%), while the trans-septal
approach was used in 51 procedures (58.6%).
The success rate was significantly better with the trans-septal approach (96.1%) than with the transaortic
one (66.7%) p=0.0002, other parameters that showed significant differences including the
procedure time and fluoroscopic time in favor of the trans-septal approach. While the number of
ablations, the presence of accessory pathway potential, and the time needed for successful ablation
at the target sites showed no significant difference between the two approaches. Complications were
generally low and were recorded in 3 patients (3.4%) ; 2 pericardial effusion and one deep vein
thrombosis.
CONCLUSION:
There was a higher success rate with the left-sided, accessory pathway ablation then with the transseptal
approach as compared to the traditional retrograde trans-aortic approach with similar safety
profile.

BACKGROUND:
Stroke is rapidly increasing clinical signs of focal (or global) disturbance of cerebral function that
last more than 24 hours. Magnetic Resonance Susceptibility-Weighted Imaging (MRI-SWI) is
especially helpful in the detection of calcifications and micro-hemorrhages, which are both
characterized by low signal. Thus allowing a significant improvement compared with T2* GE and
other MRI sequences.
OBJECTIVE:
Study the value of MR SWI in the early detection of hemorrhage in an acute ischemic stroke and
compare the findings of SWI with Gradient and conventional MR sequences.
PATIENTS AND METHODS:
This is a cross sectional analytic study was conducted between October 2016 to October 2017,
at the MRI and Computed tomography (CT) units at Al-Imamian Al-Kadhimyian medical city,
Baghdad, Iraq, 100 patients (64 males and 36 females) with signs and symptoms of acute stroke
within 72 hours of attack and positive findings in Diffusion-weighted magnetic resonance
imaging (DWI MRI). The ages ranged between 42 and 83 years (mean age 62.8 years old).
Exclusion Criteria: patients with evidence hemorrhagic infarction in CT, patients with stroke-like
symptoms but CT and MRI finding show findings not consistent with signs of stroke, patients with
previous intracranial surgery or trauma that distort brain anatomy, patients with history of >72
hours, or show normal DWI sequence (no restriction), patients with unstable vital signs and
the general MRI contraindication. CT was done in the emergency department, then an MRI study
was done for all patients. MRI examination was done with the following sequences: T2 Weighted
axial, Fluid attenuated inversion recovery (FLAIR) T2 coronal, T1 Weighted axial and sagittal,
Diffusion-Weighted Image (DWI) Axial, Gradient Echo 2D axial T2*, and Venous Bold (SWI) in
axial plane were done for all patients. Hemorrhagic transformation was diagnosed on the basis of
the hypo intense blooming region in the infarct area on SWI. Statistical Analysis using SPSS 16.00
Statistical significance was considered whenever the p-value was equal or less than 0.05.
RESULTS:
In CT 90 patients (90%) have abnormal CT finding consistent with ischemia, 10 patients (10%)
have normal CT, in all cases no hemorrhage nor calcification was detected. In MRI SWI 23 patients
(23%) show areas of hemorrhage. In MRI GRADIENT sequence 20 patients show areas of
hemorrhage (20%). In MRI T2 sequence 8 patients show areas of hemorrhage (8%). In MRI T1
sequence 3 patients show areas of hemorrhage (3%). SWI demonstrated 100% relative sensitivity.
CONCLUSION:
Susceptibility-Weighted Imaging (SWI) is an important and sensitive technique that permits early
and accurate detection of hemorrhagic transformations within an area of acute cerebral infarction.
SWI is more sensitive than 2D GRE T2WI, T2WI and T1WI.

BACKGROUND:
Treatment of acne scarring is always a challenge. Microneedling therapy (dermapen) or
percutaneous collagen induction is a new addition to the treatment modalities for atrophic
acne scars and has been reported to be simple and effective with fewer side effect than
other modalities.
OBJECTIVE:
To assess and compare the therapeutic response of microneedling (dermapen) in the treatment of
moderate and severe types of post-acne scar by using two different depth (2.5 mm on the right side)
and (1.5mm on the left side) and to evaluate the adverse effects of this therapy.
PATIENTS AND METHODS:
Thirty seven patients were included in the study, only 21 patients completed full treatment
course 13 males and 8 females, ages ranged from 19 to 35 years. With different types of
atrophic acne scars were subjected to three months of skin microneedling (dermapen)
treatment (six sessions at two-week intervals), by using two different lengths (2.5 mm on
the right side) and (1.5mm on the left side).
RESULTS:
Clinical evaluation of patients showed statistically significant (p-value <0.0001) overall
improvement of post-acne atrophic scars after 12 weeks (after 6 sessions). patients showed good
enhancement of scar appearance and moderate improvement in skin texture. Meanwhile, patient
satisfaction was good when compared to the baseline.
CONCLUSION:
Skin microneedling is a simple, inexpensive office modality of treatment for
the management of post-acne atrophic scars especially mild and moderate types.

BACKGROUND:
Statistical study for the first 1059 patients treated by Gamma knife radiosurgery in IRAQ, in
neuroscience hospital
OBJECTIVE:
Gamma knife surgery is a minimally invasive technique indicated for the treatment of different brain
lesions with Cobalt60
PATIENTS AND METHODS:
A retrospective study was conducted on a total of 1059 consecutive patients who underwent 1039
sessions of GKS procedures using perfexion model , at the neuroscience hospital between January
2016 and July 2017
RESULTS:
There were 568 males and 432 females. The mean age was 33.2 years , all patients were treated with
gamma knife radiosurgery. The indications included brain tumors, vascular malformations
& neuromodulation therapy for (epilepsy & trigeminal neuralgia).
CONCLUSION:
Gamma knife management is an effective, minimally invasive with minimal side effects.
Gamma Knife is indicated for the treatment of brain lesions & functional neuromodulations for pain
and epilepsy.

BACKGROUND:
Melasma is an acquired hyperpigmentation of the skin. Exacerbating factors include pregnancy, use
of oral contraceptives and sunexposure.
OBJECTIVE:
To study the effectiveness of intralesional tranexamic acid in the treatment of melasma.
PATIENTS AND METHODS:
This is an interventional single-blinded comparative outpatient study carried out at the Center
of Dermatology, Baghdad Teaching Hospital during the period from March 2017 to May 2018.
Forty patients with melasma were included in the study. The patients were divided into three
groups. Group A was treated with tranexamic acid 4mg/ml delivered by microneedling approach
at monthly interval for 3 months with topical hydroquinone 4% daily at night for 3 months. Group B
was treated with intradermal injection of 4mg/ml of tranexamic acid by using insulin syringe
monthly for 3 months with topical hydroquinone 4% daily at night. Group C was treated with
topical hydroquinone 4% daily at night for 3 months.
The severity of melasma was assessed before, during and after treatment with the melasma area and
severity index (MASI) score. Every patient was instructed to apply a broad-spectrum sunscreen
before sun exposure during the treatment period.
RESULTS:
Thirty-two patients with melasma completed the study. In group A: Eleven patients were included,
the mean age and SD was 33.81 ± 4.55 years. The MASI score before treatment was 5.31 ±1.65,
whereas after treatment it became 3.69± 1.79 (P value: 0.0001). The reduction of MASI score was
32.39%. In group B: Eleven patients were included, the mean age and SD was 39.72 ±6.27 years.
The MASI score before treatment was 4.52±1.79, whereas after treatment it became 3.50 ±1.61
(P value: 0.002). The reduction of MASI score was 20.96%. In group C: Ten patients were
included, the mean age and SD was 37.20 ± 7.55 years. The MAI score before treatment was
4.01±1.07 whereas after treatment became 3.13±0.17 (p value=0.002). The reduction in the MASI
score was 14.11. The percent reduction in the MASI score at follow up visits was significantly
higher in group A than in groups B and C ( p value= 0.026) while there were no significant
difference between group B and C.
CONCLUSION:
Tranexamic acid is an effective drug when it used with other conventional treatments of melasma,
and the microneedling approach of delivering tranexamic acid showed better response than the
other modes of drug delivery and this may be due to uniform delivery of the drug through the
microchannels.

BACKGROUND:
Leg wrapping is an effective technique and comparable to vasopressors to prevent post- spinal
anesthesia hypotension during cesarean patients
OBJECTIVE:
To evaluate the effectiveness of leg wrapping in decreasing the incidence of hypotension induced by
spinal anesthesia in cesarean section.
PATIENTS AND METHODS:
A prospective randomized clinical trial study conducted in the obstetric operating room at Baghdad
Teaching Hospital May 2018 to February 2019. It involved 60 full-term singleton pregnant
randomly allocated to one of two groups: Group A: Leg wrapped immediately before subarachnoid
block until the end of surgery and group B: Nonleg wrapped. Blood pressure and heart rate were
monitored before and at three-minute intervals for 20 minutes and then every five minutes until
the end of the the operation. Any decrease in systolic blood pressure ≥ 20-30% mmHg of
the baseline was considered hypotension, which was immediately treated by increasing the I.V fluid
infusion rate (Ringer solution) and by a bolus dose of epidrine 5mgIV.
RESULTS:
The Mean of MAP after three, six, nine, 12 and 15 minutes after induction of spinal anesthesia was
significantly higher among group A than that in group B). After six, nine, 12, 15, and 18 minutes,
five patients (16.7%) in group A needed ephedrine dose while in group B, 23 patients (76.7%) and
the mean of ephedrine dose needed was 0 versus 3.0, 0.48 versus 4.0, 1.0 versus 3.6, 0 versus 3.0
and 0 versus 2.0 mg respectively and these differences were statistically significant.
CONCLUSION:
Legs wrapping decrease vasopressors need in spinal anesthesia-induced hypotension

BACKGROUND:
The effect of laparoscopic sleeve gastrectomy (SG) on the development of
gastroesophageal reflux disease (GERD) has remained controversial. Despite the positive
effect of sleeve gastrectomy (SG) on weight loss and improvement in obesity and its
morbidities, there is concern about the development of gastro esophageal reflux after this
bariatric operation. There have been limited studies on this aspect and most of
the published studies are retrospective. Therefore, we conducted a prospective study to
assess this problem.
OBJECTIVE:
The aim of study is to assess the incidence of GERD post LSG.
PATIENTS AND METHODS:
We studied the incidence of GERD in patients who underwent LSG for the treatment of
their morbid obesity at Al Imamain Al Kadhimain Teaching hospital. A prospective review
of 48 patients undergoing LSG for morbid obesity from the 1st of October 2016 to the 1st
of October 2018 was performed. Patients were evaluated using the Spanish version of
the Carlsson-Dent questionnaire. Evaluation was done at 1, 6 months and 1 year
postoperatively. Postoperative gastric anatomy was checked by Gastrografin studies that
were routinely performed in all patients on the third postoperative day. These studies were
evaluated prospectively. Changes of each one of the reflux symptoms were assessed in
relation to the radiological pattern of the gastric sleeve.
RESULTS:
We had two groups of patients. Both of them underwent LSG by the same surgical team
and in the same technique; the only difference between them was the point of start of
devascularization and cutting of the stomach. Group 1 included 27 patients in whom the
start of devascularization and cutting of the stomach was at 4 cm from the pylorus. Group
2 included 21 patients in whom devascularization and cutting of the stomach was at 6 cm
from the pylorus of stomach. GERD occurred in 9 patients in Group 1 which represent
(33.33 %). While 1 patient from Group 2 had GERD postoperatively and they represent
(4.76%).
CONCLUSION:
LSG might increase the occurrence of GERD despite the satisfactory weight loss.
The incidence of GERD can be reduced by changing the surgical technique. Additional
studies including esophageal manometry and 24-hours pH testing are needed to obtain
better evaluation on the effect of LSG on gastroesophageal reflux disease.

BACKGROUND:
Metabolic syndrome is a constellation of risk factors of metabolic origin that are accompanied by
increased risk of cardiovascular disease and type II diabetes. These risk factors are atherogenic
dyslipidemia, elevated blood pressure, elevated plasma glucose, a prothrombotic state, and a
proinflammatory state. The two major underlying the risk factors of metabolic syndrome are obesity
and insulin resistance; exacerbating factors are physical inactivity, advancing age, and endocrine and
genetics . The condition is progressive, beginning with borderline risk factors that eventually
progress to categorical risk factors. In many patients, metabolic syndrome culminates in type II
diabetes, which further increases risk for cardiovascular disease. Hyperferritinemia has been linked
with a wide spectrum of pathologies, including diabetes, cardiovascular disease, neurodegenerative
disorders, and metabolic syndrome.
OBJECTIVE:
The association between serum ferritin and metabolic syndrome components (hypertension,
dyslipidemia, body mass index) in cohort of Iraqi patients diagnosed with type II diabetes mellitus.
PATIENTS AND METHODS:
This a case-control study that was conducted at the teaching laboratories of the Medical City
hospital . The study included 60 patients with type II diabetes mellitus and 25 healthy controls
matching in age and gender . Height , body weight, waist circumference along with systolic and
diastolic blood pressures were measured .The obtained serum samples were used to measure: serum
ferritin, total cholesterol, HDL-cholesterol, LDL-cholesterol , TG, fasting serum glucose (FSG),
hemoglobin and glycated hemoglobin A1c(Hb A1c).
RESULTS:
The results of the study showed that there were significant differences between patients and controls
in relation to the following parameters :
- Serum ferritin , FSG , Hb A1c , total cholesterol , TG and LDL were significantly higher in
patients with type II diabetes mellitus and have metabolic syndrome as compared to the control
group. However HDL was Significantly lower in HDL when compared with control group.
- There were no significant differences in hemoglobin levels in comparison to the control group.
The correlation between serum ferritin levels and the other parameters of the patients sample were
as follows:
- A significant positive association with systolic blood pressure (SBP)(r= 0.260) (p= 0.044),with
diastolic blood pressure (DBP)(r= 0.382)(p= 0.0025),with waist circumference(WC) (r= 0.269)
(p= 0.037) , with body mass index(BMI) (r=0.289)(p=0.023),with fasting serum glucose
(r = 0.27)(p = 0.035), with Hb A1c (r= 0.264) (p= 0.041),with total cholesterol TC)(r= 0.268)
(p= 0.038), with triglyceride (TG)(r= 0.279)(p= 0.030), with LDL (r= 0.022)(p= 0.045) But no
association with HDL (r= 0.184)(p= 0.153).
CONCLUSION:
The study showed that serum ferritin level could be used as a screening tool for hypertension,
diabetes mellitus , atherosclerosis ,cardiovascular diseases and metabolic syndrome.

BACKGROUND:
Ectopic pregnancy and spontaneous abortion are the two common complications seen in early
pregnancy. While spontaneous abortion is the most common complication of pregnancy, ectopic
pregnancy is the most life threatening emergency in early pregnancy.
OBJECTIVE:
To investigate the diagnostic value of serum homocysteine and CA-125 levels for early diagnosis
and differentiation for early pregnancy complications.
PATIENTS AND METHODS:
The study included 90 pregnant women, aged from 21 to 40 years old presented with a gestational
age ranging between 5-13 weeks. The patients were divided into three groups, group A included 30
cases of ectopic pregnancies, group B Included 30 cases who presented with spontaneous abortions
and group C included 30 cases who presented as normal uncomplicated pregnancies and were
followed up till their normal term deliveries and was considered as the control group. All women in
the studied groups underwent CA125 and serum homocysteine measurements by radioimmune assay
and Enzyme-linked immunosorbent assay (ELISA) respectively.
RESULTS:
Regarding group A, the majority of cases had low levels of serum homocysteine on admission (60%)
and only one case changed from low to high level after one week from surgical termination of
pregnancy. The CA125 readings were subdivided into two subdivisions: the first subdivision was the
ruptured ectopic pregnancy cases on admission and diagnosis and they were 20 out of the 30 cases
of ectopic pregnancy, half of these cases (50%) had high CA125 levels on admission and 3 patients
had returned to normal after one week from surgical termination of pregnancy, in the second
subdivision (unruptured ectopic pregnancies which were10 cases), the vast majority of patients
(90%) had normal CA125 levels on admission and all of them had returned to normal after one week
from the surgical termination of pregnancy. Regarding group B, (56.7%) of patients had high levels
of serum homocysteine on admission and none of them had returned to normal value after one week
from spontaneous or interventional completeness of the abortion, while the results of CA125 showed
that (63.3%) of patients had high levels of this tumor marker on admission and 6 cases had returned
to normal levels after one week from spontaneous or interventional completeness of the abortion.
In group C, the majority of the cases were within normal ranges of both CA125 and serum
homocysteine both at admission and one week follow up. (90% and 93.3% regarding CA125) and
(76.6% and 70% regarding serum homocysteine).
CONCLUSION:
The measurement of serum homocysteine and CA125 was found to be an effective method for early
diagnosis and differentiation between spontaneous abortion and ectopic pregnancy.

BACKGROUND:
Fulfillment is undeviatingly dictated by patient anticipations. Healthcare providers must have
a perception of the parameters needed to estimate satisfaction and the associated impact that
treatment has on Patient-Reported Outcome Measures (PROMs).
OBJECTIVE:
To present a brief overview of how patient satisfaction from lumbar disc surgery can be
anticipated utilizing the minimum Clinically Important Difference of Timed Up and Go (MCID ~
TUG) Test time as an assessment tool.
PATIENTS AND METHODS:
A planned cohort design prospective study spotting a populace of 45 females, 57 men, aged from 23
to 66 years, mean of 45 ± 8 yrs. Lumbar discectomy surgeries were performed at Private Nursing
Home Hospital, Medical City, Baghdad, Iraq, over 18 months from April 2018.
Timed Up and Go (TUG) test and the Minimum Clinically Important Difference (MCID) were used
to evaluate patients' satisfaction through the assessment of PROMs. Satisfaction was defined as
a 50% reduction of the PROMs values from the preoperative values. MCID ~TUG is the difference
between preoperative and postoperative times using a digital watch.
RESULTS:
The Male : female ratio was1.4:1; 71% workers, 59% elementary educated and 70% smokers.
Medium-low back pain (LBP), leg pain lasted 7, 5 months sequentially. Near 91% held disc space
height loss, disc level transpired at L4-L5 into 50%, L5-S1 into 47%. Mean Oswestry disability
index (ODI) reached 51.5, 19 each, pre/post-surgery. Mean Visual Analogue Score (VAS) LBP,
pre 6.1, postoperative 2. Mean leg pain VAS preoperatively, 5.4, post 1.4. Mean MCID of TUG Test
time lasted 4.9 s.
CONCLUSION:
The TUG test is a quick and easily applicable tool that reliably measures satisfaction in lumbar disc
patients.

BACKGROUND:
Infertility is an inability to conceive naturally after one year of regular unprotected intercourse for
problems in either one partner or both causing a major cost burden for both patients and health care
systems.
BJECTIVE:
To measure the proportion of different types of abnormalities of seminal fluid among infertile men
and to unravel the factors associated with such abnormalities.
PATIENTS AND METHODS:
A cross-sectional study in which a purposeful sample of 300 infertile males who attended infertility
department at Al- Imamain Al- Kadhimain Teaching Hospital and Baghdad Teaching Hospital
during the period from 1st of February to 31st of August, 2018 in Baghdad governorate-Iraq with at
least one- year infertility were included and interviewed for their demographic data and assessing
their seminal fluid parameters. Chi-square test was used to identify the significant association
between categorical variables and P-value of <0.05 was considered as statistically significant.
RESULTS:
More than 75% of the studied group have primary infertility. Abnormal morphology
(teratozoospermia) was the most common type of semen defect found in the studied infertile males
(76%). A statistically significant association was found between occupation and seminal fluid
parameters.
CONCLUSION:
The majority of infertile males have primary infertility type and teratozoospermia was the most
common type of semen defect. percentage of semen defect has increased with increased age and has
correlated to occupational exposures.

BACKGROUND:
The physiological changes associated with menopause can influence women's quality of life. Most
women report vasomotor, sexual, psychological and physical symptoms that commonly accompany
menopause, with varying degrees of severity and life disruption.
OBJECTIVE:
To assess the menopausal symptoms severity and its impact on the quality of life (QoL).
PATIENTS AND METHODS:
A cross-sectional study was conducted on a convenient sample of 426 women attending in seven
primary health care centers in Al-Rusafa health directorate of Baghdad for the period from 20th of
February to 20th of June 2017 using the MENQOL questionnaire.
RESULTS:
The common severe symptoms of women at menopause are low backache (63.6%), aching in
muscles and joints (53.8%),aches in the back of neck or head (52.6%), decrease in the sexual desire
(49.5%),dissatisfaction in personal life (46.5%),hot flushes (44.1%)and feeling tired and worn out
(43.7%).
CONCLUSION:
It can be concluded that the most severe symptoms in menopausal women were low backache in
the physical domain, decrease sexual desire in the sexual domain; dissatisfaction in personal life
in the psychosocial domain and hot flushes in the vasomotor domain. The QoL was less affected on
the sexual domain and highly affected on physical domain.