Iraqi Postgraduate Medical Journal

Breast cancer is the most common malignancy affecting the Iraqi population. As many cases are still detected in advanced stages of the disease, regular follow-up of the diagnosed and treated patients is crucial to manage therapy-related complications and limit loco-regional recurrences.
OBJECTIVE:
To report the clinicopathological features, the offered treatment options and the recurrence rates among a sample of Iraqi female patients followed up after diagnoses with breast cancer.
PATIENTS AND METHODS:
A retrospective study design was followed enrolling a sample of 154 female patients diagnosed with breast cancer at a referral center for early detection of cancer in Baghdad, Iraq during a six month period (from January to July 2019). All cases with histopathologically confirmed invasive breast carcinoma were included in the study if they had reliable valid data related to their demographic, clinical, pathological and follow up status (for at least two years).
RESULTS:
The peak age frequency for breast cancer occurred in the fifth decade of life. Family history was observed in 18.2% of patients. The most common histological type was invasive ductal carcinoma (92.9%) while 46.8% of the patients presented in advanced clinical stages (III and IV). ER and PR and HER2 were positive in 66.2%, 63.6% and 36.4% of the cases respectively. Surgery was prescribed in 95.5% of the patients; 83.8% underwent modified radical mastectomy. Chemotherapy, Radiotherapy, Hormonal and Biological therapy were received by 92.2%, 66.9%, 64.9% and 32.4%) of patients respectively. Overall, discontinuation of the treatment was observed in 8.4% while recurrence was recorded among 10.1% of the patients.
CONCLUSION:
Frequent regular follow up of patients diagnosed with breast cancer is crucial to achieve better prognosis. Continuous monitoring of the response to therapy and coordination through multidisciplinary follow-up care are essential recommendations to avoid risks of local and regional recurrences.

BACKGROUND:
Anorectal malformation is a complex spectrum of anomalies. There are different types of anorectal malformation. The distinction can usually be made on the basis of clinical data regarding the presence or absence of a visible perineal opening or passage of meconium through the vagina or urethra.
OBJECTIVE:
To assess the validity of ultrasonography in detection of the exact anomaly in male type imperforate anus, in order to help plan the proper surgical approach.
PATIENTS AND METHODS:
A prospective study carried out between December 2017 and December 2018, at pediatric surgery department in Central Teaching Hospital in Baghdad, Iraq. Nineteen patients with imperforate anus were enrolled in this study (all were males), their age ranged between 1 day and 6 months. All patients were sent for trans-perineal ultrasound and infracoccgeal ultrasound, which were performed by using a high-resolution 11 MHz linear array transducer, in which the rectal pouch-perineal distance(P-P distance), presence or absence of recto-urinary fistula along with its précised location and the relation of the blind rectal-pouch to the pubo-rectalis muscle were obtained for a proper classification of the type of imperforate anus.US findings were compared to the operative findings which were the gold standard.
RESULTS:
The rectal pouch-perineal distance(P-P) was identified using US in all patients with a mean (27.3211) mm and SD +\- (14.78631) mm. The puborectalis muscle was identified as a hypoechoic U-shaped band in all patients along with its relation to the blind rectal-pouch. There is a statistically high significant relationship between the US and the operative findings regarding the presence and precise location of the internal fistula (P-value=0.0001).US findings showed a high sensitivity of 92.8%, specificity of 100% and accuracy of 94.7%.
CONCLUSION:
U\S whether in (Transperineal \ Infracoccygeal) approach is highly accurate, it provides an excellent imaging modality with high sensitivity and specificity in the detection of the internal fistula. U\S measurements are independent of age.

BACKGROUND:
Ultrasound elastography (UE) is widely used in the diagnosis of thyroid diseases.
OBJECTIVE:
to evaluate the diagnostic utility of elastography stain ratio in the assessment of solid solitary thyroid nodules.
PATIENTS AND METHODS:
a cross-sectional study was conducted on 65 selected patients with solid solitary thyroid nodules discovered on Ultrasound (U/S) examination. The study was conducted in the U/S unit of medical college/ Al-Nahrain university and U/S unit of Al-Imamein Al-Kadhimein Medical city in Baghdad during the period from February 2018 to October 2019. U/S findings (size, shape and echogenicity of the nodules, presence of calcification, elastography findings and measurement of stain ratio), and histopathological results of the FNA.
RESULTS:
the final histopathological diagnosis of the 65 thyroid lesions revealed 46 (71%) benign and 19 (29%) malignant. Of the 19 malignant nodules; 12 were papillary carcinoma and 7 were follicular carcinoma. The mean age of the patients was 43.7 ±11.7 years (range 28 - 60) years, 50 (77%) of them were female and 15 (23%) were male, male: female ratio is 5:1. Strain ratio (SR) of Benign nodules was lower than that of malignant nodules (1.95±0.62 versus 6.11±3.4) and this difference was statistically significant (P- value <0.001. Best SR Cutoff - value was (>2.6) with a sensitivity of 100% & specificity of 86.4% (a higher value was more indicative of malignancy).
CONCLUSION:
SR in a good parameter to aid differentiating benign from malignant solitary thyroid nodule. SR is higher in malignant thyroid nodules.

BACKGROUND:
The posterior fossa is the biggest and the deepest intracranial fossa, containing the most complicated intracranial organs. Posterior fossa tumor access used to involve bone removal permanently, the first craniotomy was done in 1974 using burr holes to access CPA tumors.
OBJECTIVE:
To evaluate the postoperative complications of posterior fossa tumor surgery operated by craniotomy versus craniectomy in pediatric patients.
PATIENTS AND METHODS:
A prospective single-center study of 35 pediatric patients with posterior fossa tumors operated in the neurosurgical center in Martyr Ghazi Al-Hariri Hospital from Oct. 2017 to Oct. 2018. Patients were categorized into two groups using craniotomy or craniectomy for tumor access; these patients were followed postoperatively for 3 months and any signs or symptoms of complications were recorded (CSF leak, Pseudomeningocoele, wound dehiscence and infection).
RESULTS:
Thirty-five patients were studied, craniotomy was done for 15 patients, and craniectomy for 20 patients. The patients’ age averaged 2-16 years with a mean age of 7 years. The study included 17 male and 18 female patients with a male: female ratio of 1:1.058.
CONCLUSION:
Craniotomy resulted in less postoperative complications like Pseudomeningocoele, CSF leak, wound infection and dehiscence as well as less hospital stay than craniectomy.

BACKGROUND:
Renal masses have different histologic types and subtypes, aggressiveness and metastatic potential, depending on the changes in angiogenesis.
OBJECTIVE:
To differentiate between benign and malignant renal masses and predicate renal tumors histopathological subtypes by using non invasive methods (Doppler ultrasound and resistive index).
PATIENTS AND METHODS:
Sixty-eight patients with a renal mass prepared for surgical intervention were involved in this prospective study. Every patient was underwent Doppler ultrasonography by single operator. By gray and color Doppler ultrasound the site, location, dimensions, echogenicity and the vascularity of the renal mass were assessed. Then by spectral Doppler ultrasound specific vascular wave parameters from intra tumor vessels which include a Peak systolic velocity, end diastolic velocity and Resistive index was checked. All those patients underwent partial or radical nephrectomy and the histopathological result, were collected.
RESULTS:
It had been found that the mean RI in patients with clear RCC was 0.59 ± 0.09 and it was significantly higher than that of Wilms tumor (mean = 0.49 ± 0.05, (P. value = 0.029), and significantly higher than oncocytoma (0.42 ± 0.06) (P. value = 0.025).
Patients with malignant renal mass had significantly higher mean RI than that of benign renal mass, 0.58±0.11vs 0.42±0.06,(P-Value =0.021) . The optimal cutoff point of RI was 0.47 which gives the higher sensitivity and specificity of 88.9% and 100% respectively with an accuracy of 94.5%, (PPV) was 100% and (NPV) was 90%.
CONCLUSION:
The usage of color spectral Doppler US parameter (Resistive index) is considered as an excellent predictor to differentiate between benign and malignant renal masses, but failed to differentiate and predicate the malignant renal tumors subtypes.

BACKGROUND:
Closure of skin and soft tissue defects is a main stream procedure in the field of plastic and reconstructive surgery .Keystone perforator island flap is a curvilinear trapezoidal shape. It is essentially elliptical in shape and it is long axis adjacent and parallel to long axis of defect. We focused in this study specifically on pressure ulcer and traumatic wound as an example of chronic and difficult wounds.
OBJECTIVE:
To evaluate keystone design perforator island flap as reliable versatile method for closure of soft tissue defect.
PATIENTS AND METHODS:
In this prospective study, keystone perforator island flap applied to 11 patients , 7 of them were pressure ulcer and 4 of them with traumatic soft tissue defect.
RESULTS:
Keystone flap used in 11 patients in this study , all of patients showed complete flap survival without even minor necrosis, only one patient developed wound dehiscence ,otherwise all patients showed complete recovery without any sequalae.
CONCLUSION:
Keystone flap is reliable ,safe ,easy to perform ,cost effective flap, with low rate of flap failure and no donor site morbidity, can be used as effective method of wound closure even in chronic and unhealthy wound.

BACKGROUND:
Cholecystectomy is the defacto standard operation for cholelithiasis and there are continuous attempts to do it through a less invasive incision known as mini laparoscopic cholecystectomy (MLC).
OBJECTIVE:
The purpose of this study is to evaluate the safety and feasibility of MLC in our center.
PATIENTS AND METHODS:
This is a pilot study involving 6 selected patients for whom MLC was performed at Al-Jamhory teaching hospital after acquiring the ethical committee permission and patients’ informed consent.
RESULTS:
The study includes six patients, their average age is 27 years and their average BMI is 28kg\m2. The average operative time is 53 minutes without intra-operative complications. The post-operative pain is mild and the hospital stay is about 12 hours. All patients were satisfied with the cosmetic results.
CONCLUSION:
This study shows that MLC a safe and feasible procedure; it takes more time than LC but has mild post-operative pain and excellent cosmetic results. It can also be done as a day case surgery.

BACKGROUND:
Elder abuse or elder mistreatment is one of the most important problems encountered by the elderly. It includes harms by people the older person knows such as spouse, partner, family members, neighbor or people that older person relies on for services.
OBJECTIVE:
The aim of this study was to determine the abuse to which elder people were exposed and its relation with age, sex, marital status, economic income and education. The study increased awareness and helping families, relatives of the elderly, professionals, social workers, nurses, doctors and counselors about elder abuse.
PATIENTS AND METHODS:
The present cross- sectional study was carried out on 300 elderly patients of age range 60-84 years attending geriatric clinic Baghdad Teaching Hospital from April to August 2019 who answered face to face survey questionnaires to elicit elder abuse.
RESULTS:
This study showed that 66.2% of elderly abused patients experienced more than one type of abuse. Majority of the patients were victims of abandonment abuse (70.3%), followed by financial abuse (25.3%), emotional abuse (21%) neglected (10.3%) and physical abuse (7%). There was a significant relationship between sex, marital status, economic income and education of the elderly and being abused.
CONCLUSION:
Abuse of the elderly is an important social and public health issue. Elderly abused patients experienced more than one type of abuse. There was a significant association with gender, widow, divorced, poor economic income and low level of education.

BACKGROUND:
Hirschsprung’s disease (HD) is a congenital intestinal motility disorder with absence of ganglion cells in the colonic wall, Diagnosis of the disease is based primarily on histopathological analysis, but in this respect, there are limitations associated with standard histology and histochemistry. Calretinin immunohistochemistry (IHC) was implemented to solve the diagnostic problems of this disease as a diagnostic marker.
OBJECTIVE:
We aimed to test, identify and compare the immunostaining calretinin in the aganglionic segment of colon specimens and to assess the diagnostic importance of the process with the normoganglionic segment (control group).
PATIENTS AND METHODS:
The specimens contained 40 patients with HD histopathology and 20 others (as a control group) who were colectomied for other reasons,60 paraffin wax blocks were analyzed for full-blown bowel specimens and rectum biopsy. Sixty) paraffin wax) blocksof full bowel thickness and rectal biopsy were examined. In IHC stained slides, calretinine immunoreactivity and pattern of stain for ganglion cells( nuclear and cytoplasmic)and nerve fibers in different bowel layers were assessed.
RESULTS:
Calreinin Immunostaining was positive of ganglion cells(nuclear and cytoplasmic staining) and nerve fibers in the mucosa) lamina propria(, submucosa and muscularis propria in all specimens of control group except one case (2.5 percent), calretinin immunoexpression of ganglion cells and nerve fibers was negatively(-) ,In aganglionic segments (case group).This method had sensitivity of 97.5% and specificity of 100% for diagnosis of HD. The positive predictive value was 100% and negative predictive value was 95.2%.
CONCLUSION:
Immunohistochemistry Calretinin can be used for the diagnosis of HD as a dependable and ancillary method.

BACKGROUND:
Osteoarthritis is a low-grade systemic inflammatory and degenerative disease in which many inflammatory mediators are known to be elevated in the peripheral blood. Platelet lymphocyte ratio and neutrophil monocyte ratio are novel markers in many systemic inflammatory disorders. Studies are limited on its link with knee osteoarthritis severity.
OBJECTIVE:
To evaluate the relationship of PLR and NMR with the Knee Osteoarthritis (KOA) severity
PATIENTS AND METHODS:
A total of 200 patients with KOA were diagnosed according to the American College of Rheumatology clinical criteria 2016. Demographic and clinical characteristics data were recorded. X-ray was taken for both knee joints in standing and lateral position view. Blood samples were collected PLR and NMR were calculated.
RESULTS:
Mean age was 62.3 ± 8.7 years, female to male ratio as 1.5:1. Mean BMI was 29.2 ± 6.3 kg/m2, and knee OA duration 9.8 ± 7.8 years. Age, knee OA duration, menopausal duration, total WOMAC score and menopause were significantly correlated with increase knee OA severity (p<0,001), (p<0,001), (p<0,001), and (p=0,003) respectively while marital status was significantly inversely correlated with knee OA severity (P<0.001). Knee OA duration and total WOMAC score were the only independent predictors of knee OA severity (p<0.001), (p<0.001) respectively. PLR and NMR were not correlated with severity of KOA.
CONCLUSION:
PLR and NMR had no significant correlation with the KOA severity

BACKGROUND:
Preterm premature rupture of membranes occurring from 24-37 weeks gestation. Ferritin is an acute phase reactant as it increases during inflammation that inflammation can predispose to preterm premature rupture of membranes during pregnancy.
OBJECTIVE:
To investigate the value of serum ferritin as a marker for preterm premature rupture of membrane.
PATIENTS AND METHODS:
The study includes 150 pregnant women attending the department of Obstetrics and Gynecology with a gestational age ranging from 28+0 – 36+6 weeks. 50 of them presented with Preterm premature rupture of membrane (group A), 50 women were presented with spontaneous preterm labor (group B), and the other 50 were without any complaint (group C). Venous blood samples of five ml were collected on admission for measurement of serum ferritin level by enzyme-linked immunosorbent assay.
RESULTS:
No statistically significant differences between study groups regarding age, parity, gestational age and hemoglobin level (P ≥ 0.05). The mean of serum ferritin was significantly higher among pregnant women presented with Preterm premature rupture of the membranes than those presented with spontaneous preterm labor and healthy women (45.07 versus 26.22 and 22.83 ng/ml respectively) (P= 0.001). By receiver operating characteristic curve analysis, the cut point of serum ferritin value was 38.6 ng/ml.
CONCLUSION:
Measurement of serum ferritin level is a simple rapid and accurate test. It can be applied as a marker for preterm premature rupture of membrane.

INTRODUCTION: Cervical thymic cyst is uncommon cause of neck cysts in children, more common in boys and on the left side of the neck, congenital typemore prevalent than the rare acquired types.
CASE PRESENTATION: We report a case of three years old boy who presented with soft, mobile, non tender cystic mass on left side of the neck. The cystic nature of the lesion was detected clinically and confirmed by CT-scan and MRI .Successful surgical excision through mid line sternetomy was done. The diagnosis was established by histopathological study
CONCLUSION: Congenital cervical thymic cyst is rare condition with an excellent prognosis especially if diagnosed early followed by prompt surgical excision by a surgeon who is familiar with anatomy and embryology of the thymic cyst