Mustansiriya Medical Journal

Background; Insulin resistance and increased serum free testosterone
are well known to be associated with preeclampsia
Type of study; case control
Aim of the study; to compare serum levels of free testosterone among
hypertensive preeclamptic women versus control
Methods; two groups were constructed from primigravida women
taken from labor ward. Study group (N=30) were preeclamptic versus
control (n=30). For all women serum testosterone was assayed and
compared and correlated to mean arterial blood pressure and other
variables in preeclampsia
Result; serum free testosterone was significantly higher among women
with preeclampsia compared with control 5.00±0.72 versus 1.28±0.97, P
< 0.001. No Significant change was found between serum estriol levels
in both groups. Analysis of co-variants has shown that fetal gender
(Male) has no effect on maternal serum testosterone levels.
Conclusions; preeclamptic women in the third trimester have
significantly higher free testosterone serum levels than control women.
It is not clear yet whether this increase in free testosterone is related to
insulin resistance in the placenta or other factors. Further studies are required to explore the significance of increased testosterone levels in the blood with prediction of preeclampsia and assessment of its severity.

Background: Acute stroke is an abrupt non‐traumatic brain insult, caused by
either brain infarction (75%) or hemorrhage (25%).
Aim of the Study: To compare the sensitivity of Diffusion ‐ weighted imaging
(DWI) and apparent diffusion coefficient (ADC) map in detection of acute
stroke with sensitivity of conventional MRI study.
Patients &methods: Thirty ‐ eight patients (24 male and 14 female with age
range between 43‐90 years) with a clinically suggestive stroke and negative
CT‐scan, all patients referred for MRI study within 4‐40 hours [mean of 17 hrs]
of acute attack. brain MRI was performed for these patients. Starting with
conventional MRI sequences done followed by diffusion weighted in the
same study and follow up clinically afterwards. The study was conducted in
a general hospital in Baghdad from January 2012 to January 2013 .Ratios were
calculated between the apparent diffusion coefficient value of normal
appearing brain in the right & left hemispheres & between apparent diffusion
coefficient value of the ischemic area & the corresponding contralateral
region .
Results: With diffusion ‐ weighted images , 100% of the ischemic lesions
were detected, and with fluid‐attenuated inversion recovery, 73.7% were
detected, whereas with early T2‐weighted or T1‐weighted, only 52.6 % and
21% of lesions were detected , respectively , using McNemar test we found
statistically significant differences in sensitivity between Diffusion weighted
images and T1W (p and between diffusion weighted images and fluid attenuated inversion
recovery (p< 0.002) .The mean apparent diffusion coefficient of acute
ischemic lesions was 30 % lower than the apparent diffusion coefficient of
normal appearing parts of brain .( P <0.001).
Conclusions: Diffusion ‐Weighted images + apparent diffusion coefficient
map Imaging is more sensitive than conventional MRI sequences in MRI
detection of acute stroke .

Background: Disordered hemostatic mechanisms can play a role in the
pathogenesis of macrovascular complications in type 2 diabetes either by leading to hypercoagulable
state, or as circulating markers for arteriosclerosis.

Aim: To evaluate the plasma levels of fibrinogen, D‐dimer and C‐reactive protein in patients with
type 2 Diabetes mellitus (DM) and find a relation with disease duration, diabetic control and
ischaemic heart disease (IHD).

Patients and methods: Sixty adults attending the National Diabetes Center at Al‐Mustansiriya
University were randomly selected and divided into 3 groups, 20 patients each. Group 1 and 2
consisted of type 2 diabetic patients without and with history of ischemic heart disease,
respectively. Group 3 included 20 healthy controls. Blood was collected for measurement of
fibrinogen, D‐dimer, C‐reactive protein and HbA1C.

Results: Mean plasma D‐dimer and CRP but not fibrinogen were significantly higher in group 1 and 2
compared to the control group, in which they were significantly higher in group 2 than group 1.

CRP and fibrinogen but not D‐dimer levels were positively correlated with HbA1C levels in the
diabetic groups. The levels of plasma fibrinogen, D‐ dimer and CRP were significantly increased in
diabetic patients with increase in the disease duration. Only levels of CRP had a significant
relation with the history and type of ischemic heart disease.

Conclusions: Hyperglycemia, insulin resistance and chronic inflammatory stress may be the causative
factors for abnormal levels of hematological markers in type 2 DM. Their effect is augmented by the
duration of DM and
the association with IHD.

Background: Necrotizing fasciitis is a rare, progressive serious bacterial
infection of skin, subcutaneous tissue and fascia. It frequently affects the
perineum and genital areas in which local redness and edema progress
rapidly to necrosis and hemorrhagic bullae. Because of this rapid
progression, it is important to diagnose and treat necrotizing fasciitis
quickly.
Aims: To evaluate the role of early wide surgical debridement and diversion
colostomy in improving the prognosis.
Methods: A case series study was done at Al‐ Yarmouk teaching hospital,
involving all patients diagnosed with NF and treated by the authors for a
three‐year period. Those patients were assessed clinically on admission and
followed closely. All relevant demographic, clinical, biochemical and
radiological data were documented. The methods of treatment with special
emphasis on surgical debridement were recorded. The clinical outcome,
morbidity and mortality were recorded.
Results: Seventeen cases were included, 11(64.7%) male and 6(35.3 %)
female. The mean age was 51+
‐7 years and 64.7% were diabetics. The primary
sites affected were the perineum and scrotum, seen in 7 cases (41.1%). The
main presentation was excessive local pain, seen in 15cases (88.2%) and 15
patients had initial constitutional symptoms (88.2%). Blood cultures and
culture of debrided material revealed mainly group A streptococci and
proteus. Early wide debridement was done in 9 cases (52.9%) and those
patients had earlier healing and shorter stay in hospital (mean stay 20 days).
Initial local debridement was done in 6cases (35.2%) and the mean duration
of stay in hospital was 40 days. Diversion colostomy was done for 3 patients
(29.4%) and all had early healing without mortality. There were 3 deaths
(17.7%), two of them had initial local debridement.
Conclusions: Early wide surgical debridement is essential and improves
healing, shortens hospital stay and decreases mortality. Diversion
colostomy is helpful in some cases but needs further evaluation.

Background: Hydrocephalus is a notorious neurosurgical disease that
carries the adage “once a shunt always a shunt.” Most patients with
hydrocephalus are treated with ventriculo‐peritoneal (VP) shunt placement;
however, malfunction is common and is usually caused by mechanical
failure.
Aim: To evaluate the patients who were in need for shunt revision, analyzing
them according to their age, sex, and causes of their hydrocephalus, and
investigating the etiological causes for their revisions.
Patients and Methods: In a retrospective study, the records of 90 patients
who underwent their shunt revision in the Neurosurgical hospital and
neurosurgical departments of AL‐Kadhmia teaching hospital and the
hospital of surgical specialties between January 2000 till June 2002 were
analyzed peri‐operatively
Results: It was revealed that most of the revised patients were children
(their age≤10). The majority of them were shunted at first due to congenital
hydrocephalus and acquired hydrocephalus respectively. Regarding the
frequency of revision in these patients the majority were revised once and
few of them were revised for more than one time. Peri‐operatively clinical
status of shunt function was determined which showed upper end block in
27.8%, post‐operative meningitis in 13.3%. Yet, lower end block was found in
10% of the cases.
Conclusion: Shunt failure is still far too common especially in pediatric age
groups. Upper end block together with surgical errors and suboptimal
techniques plays a significant role in shunt revision.

Background: Evidence suggests that Cardiac Resynchronization Therapy
(CRT) is useful in patients with advanced heart failure (HF) & wide QRS
complexes despite optimal medical therapy
Objective: To demonstrate the beneficial effect of CRT in improving the
hemodynamic profile of patients with advanced HF despite optimal medical
therapy.
Methods: This prospective study enrolled 22 patients with advanced heart
failure (HF) who were selected from those patients who attend Ibn Al‐Bitar
center for cardiac surgery during the period from September 2010 to April
2011. All patients were subjected to thorough history taking and physical
examination and have been investigated to assess their eligibility to
CRT.ECG and Echocardiography {assessing LV systolic & diastolic functions,
septal to posterior wall motion delay (SPWMD), left ventricular volumes, left
ventricle ejection fraction (LVEF) (by biplane Simpson’s method) and mitral
regurgitation (MR)} had been done to all patients before and 1 day after CRT
device implantation. Tei index calculated before and after CRT, comparing
responders and non‐responders.
Results: Sixteen patients (72.7%) are matching the definition of the
responders. The responders have a decrease in QRS width (by 14.63%), LV
end‐diastolic diameter (by 6.35%), Tei index (by 14.85%), LV end‐systolic
volume (16.61%), and SPWMD (by 41.72%) with increase in EF (by 22.86%) in
comparison to the non‐responder.Also responders patients had higher
mean initial Tei index (1.040) in comparison to non‐responders whose their
mean initial Tei index was (0.9616).
Conclusions: CRT has been shown to improve the functional status in a
majority of patients with drug –refractory Heart failure (ischemic, or dilated
cardiomyopathy), and Wide QRS complex & resulted in decrease rate of
hospitalization in responders.

Objective: To evaluate the risk factors for late retinal detachment
occurrence after successful posterior segment intra‐ocular foreign bodies
removal.
Method: This prospective cases series study included subjects presented to
one vitro‐retinal surgeon at vitrectomy clinic/ Ibn Al‐Haetham Teaching Eye
Hospital from January 2007 to January 2012 with retained posterior segment
intra‐ocular foreign bodies. Ocular complications related to the trauma were
recorded. Extractions of foreign bodies were done through standard threeport
vitrectomy technique. Nature and sizes of the foreign bodies were
noted. Post operative occurrence of retinal detachment was recorded,
regarding possible risk factors. Follow‐up time was at least 6 months after
surgeries.
Results: 51 subjects with posterior segment intra‐ocular foreign bodies were
included. Most important mechanism of injury was shell injuries (43.1%).
Majority of foreign bodies were metallic (82.4%), with mean average size of
4.6 mm3. Ocular complications at presentation were; vitreous hemorrhage
(76.5%), lens injury (52.9%), retinal detachment (21.6%), siderosis bulbi (3.9%),
endophthalmitis (3.9%), and increased intraocular pressure (2.0%). Late
postoperative retinal detachment developed in 18 subjects (35.3%); 16 cases
(88.9%) were due to formation of proliferative vitreo‐retinopathy, while 2
cases (11.1%) occurred in eyes with siderosis bulbi. Ten cases had post
traumatic retinal detachment, and 6 of them had large foreign bodies (size
was 10 mm3 or more).
Conclusion: After successful posterior segment intra‐ocular foreign bodies’
removal late retinal detachment can occur mainly due to development of
proliferative vitreo‐retinopathy which was related to presence of post
traumatic retinal detachment and large foreign bodies.

Background: Acute cholecystitis is a common disease. The best management
in early cases is surgical, but the optimal timing for surgery remains
controversial. With advances and increased experience in laparoscopic
surgery, laparoscopic cholecystectomy is increasingly being used in the
management of acute cholecystitis.
Aims: To determine the best time to operate in acute cholecytitis (early vs.
delayed) and to compare the results of laparoscopic approach with those of
open surgery in the treatment of acute cholecystitis .
Patients and Methods: This was a prospective study done at al‐Yarmouk
teaching hospital, Baghdad from Sep. 1st 2012 to Sep. 2nd 2013. All patients
admitted with a proved diagnosis of acute cholecystitis were included. The
patients were divided into two groups, the first group had early
cholecystectomy, laparoscopic (LC) or open (OC). The second group was
treated conservatively and delayed cholecystectomy was done. Detailed
clinical, investigative and imaging data were recorded. The details of the
operative findings, procedures and early post‐operative complications, were
documented.
Results: There were 146 patients, 82.2% female and 17.8% male. The mean age
was 40±2 years. Early surgery was done for 32.8% of patients, 58.4% as a
laparoscopic procedure, and 41.6% as an open procedure. Delayed
cholecystectomy was done in 67.2% of cases. In the early group,the difficulty
was minimal in 27.2%, moderate in 39.5%, marked in 25 % and very difficult with
conversion done in 8.3%. Early complications were noticed in 4.2% in the early
LC group, and 8.3% in the early OC. For delayed LC, 8.1% had early
complications vs. 6.1% for delayed OC.
Conclusions: Early laparoscopic cholecystectomy is a safe and feasible
approach to the management of acute cholecystitis.

Background: Emphysema is chronic obstructive pulmonary disease that
result in an abnormal permanent enlargement of air spaces distal to the
terminal bronchioles. This leads to presence of increased air between the
heart and the ECG recording electrodes that may alter ECG findings in
patient with emphysema.
Aims: To evaluate the vertical P‐wave axis in the diagnosis of emphysema
and assessment of its severity.
Patients and Methods: This is a case ‐ control study conducted at Al
Yarmouk Teaching Hospital and The Medical City in Baghdad during the
period from the 1 st of February 2012 to 31 st of January 2013. A total of 100
emphysematous patients compared with other well matched 100 non
emphysematous patients as a control group.
The diagnosis of pulmonary emphysema was based on clinical history ,
physical examination , chest radiographs finding, High resolution chest CT
scan and pulmonary function test. Full history including age, sex,
occupation, history of smoking was taken and complete physical
examination was done on both groups, ECG and PFT done for all
emphysema patient and control group and P‐wave axis calculated.
Results: Demographic characteristics of emphysema patients & non
emphysema controls were comparable apart from significant association
between smoking and emphysema (P < 0.001). Our emphysematous
patients show that mean P‐wave axis were significantly (P < 0.01) higher
than that of control group. There is 86% of emphysema patient with
vertical (>60 °) P‐wave axis in comparison to 9% of control group.There is
a significant inverse correlation between P wave axis and FEV1 that
decrease in FEV1 is associated with increase in P wave axis and vice versa.
Those with FEV1 less than 50% significantly have higher P wave axis mean
Conclusions: This study revealed clearly that p‐wave axis deviation to the
right is the most characteristic ECG change that occur in emphysema.
Moreover, There is a significant inverse correlation between P wave axis
and FEV1.

Background:Acute Lymphoblastic Leukaemia (ALL) is the most common diagnosis
in childhood cancer. Cure is possible and even likely. Aims of study: To evaluate
the effectiveness of modified UKALL protocols in a setting with limited resources
and to define an event free survival of Acute Lymphoblastic Leukemia in children
aged 1 ‐15 years who were committed to finish treatment.
Methods: This is a retrospective study that reviewed 559 children with newly
diagnosed ALL between 1 and 15 years of age during the period: January 1st, 2000
to December 31st, 2009 who were committed to finish treatment protocol. All
patients were treated with regimens modified from Medical Research Council
protocol (United Kingdom Acute Lymphoblastic Leukemia‐ UKALL‐ protocols).
The Event Free Survival (EFS) was measured using Kaplan – Meier method with a
total duration of observation till December 31st 2011 (a minimum of two years post
starting treatment) and data were processed and tabulated using SPSS (Statistical
Package for the Social Sciences) .
Results:The majority of treated children (348, 62.2%) were standard risk group;
remission induction was achieved in 461(82.4%) patients. Eleven patients (1.9%)
were poor responders. Death during first 60 days from treatment was reported in
87 (15.5%) patients and death in complete remission (CR) was reported in 49 (8.7%)
patients. The major presumptive causes of death were infection/sepsis followed
by bleeding. Of 559 patients; 302(54%) remained in continuous complete remission
with a median follow up time of 52.5 months (range from 23.9 months‐ 11.6 years).
There was a significant difference in EFS between Standard Risk group (61.2%) and
High Risk group (42.2%) after induction (P=0.02) and in later phases of therapy
(P=0.0002). Increased relapse rate in high risk group was the reason behind the
difference in EFS (P=0.0004) between two groups. Relapses were documented in
110(19.6%) patients and the bone marrow (51.8%) was the main site of relapse
followed by CNS (27.2%).
Conclusion:The study showed lower ALL EFS than that of recognized cancer
centers.

Background: Growth hormone deficiency (GHD) is suspected in
subjects with short stature (SS) and reduced growth velocity in whom
other causes of poor growth have been excluded. Insulin‐like growth
factor‐1 (IGF‐1) measurements are relatively newer methods for
evaluating GHD or GH adequacy.
Objective: To study the relation between levels of leptin and IGF‐1 in the
children and adolescents in whom GHD was found.
Patients and Methods: This study was conducted during the period
from June 2013 until the end of March 2014. The patients were
attending to the National Diabetic Center/ AL‐Mustansiriya University.
Serum IGF‐1 and leptin were measured in children and adolescent with
GHD; 56 children with GHD were participated in this study their age
range was (5‐17) years, they were compared with 30 healthy children as
control group. Results:
Means BMI and basal serum levels of GH and IGF‐1 were significantly
decreased in children and adolescent with GHD when compared with
the control group. There was a significant decrease in serum level of
IGF‐1 in boys with GHD as compared to girls with GHD, while there was
no significant difference in basal GH and leptin between boys and girls
with GHD. A significant negative correlation was found between leptin
versus BMI and IGF‐1 in both gender groups, while a significant positive
correlation was found between serum IGF‐1 versus BMI and GH in
children with GHD.
Conclusions: The present results are consistent with the hypothesis
that leptin could contribute to the regulation of GH secretion and IGF‐1
concentrations.

Background: Many modalities of surgical treatment are available for painful
heel syndrome like: release of half of planter fascia, excision of spur, drilling
of calcaneum, and calcaneal osteotomy, without agreement on the most
effective one.
Aim: to evaluate the effect of calcaneal bone drilling in addition to planter
fascia release and calcaneal spur removal for patients with painful heel
syndrome.
Patients and methods: between 2007‐2011 at Al‐Yarmouk Teaching hospital,
a retrospective comparative study of (44) feet of (38) patients (M=11 and
F=27) with persistent painful heel syndrome divided into 2 groups: first group
(24) feet of (18) patients were treated by calcaneal drilling with the
traditional surgery (release of planter fascia + calcaneal spur excision), and
the second group (20) feet of (20) patients were treated with traditional
surgery only (control group). Evaluation of patient's pain and satisfaction
was based on VAS (visual analogue pain scale) system for local pressure
tenderness and rest pain.
Results: The mean pre‐operative rest pain and local pressure tenderness
were 8.38±0.99 and 8.95±1.21 for group I respectively and 8.50±0.81and
8.80±0.81for group II respectively.There was significant decrease in rest heel
pain in group I in comparison with group II after 6 months (from 4.40±0.97
for group II to 0.88±1.05 for group I), and after 2 years follow‐up (from
2.25±1.47 for group II to 0.25±0.66 for group I) with p<0.05. There was
significant decrease in local pressure tenderness in group I in comparison
with group II after 6 months follow‐up (from 5.85±1.01 for group II to
1.92±1.58 for group I), and after 2 years follow‐up (from 3.85±1.56 for group
II to 0.33±0.75 for group I) with p<0.05. Complications were post‐operative
infection (9.1%), heel paresthesia (13.6%), and persistent pain (2.3%).
Conclusions: calcaneal drilling is one of significantly effective modality of
treatment for recurrent heel pain syndrome when combined with ordinary
release of planter fascia and spur excision.

Trigeminal Neuralgia (TN) is a neuropathic, stabbing recurrent episode of
pain within the distribution of one or more branches of the trigeminalnerve
affecting the face.Trigeminal neuralgia is idiopathicin 50%of the patients
leading to focal demyelination andaberrantneuraldischarge.
Treatment must be individualized to each patient. Carbamazepine remains
the drug of choice and the first‐line treatment of TN but ineffective in 60%.
Minimally invasive interventional pain therapies and surgery are possible
options when drug therapy fails. Patients with poor surgical risk may be more
suitable for other types of interventional therapy.
A case of idiopathic trigeminal neuralgia in a 49 years old female, presented
with a 20 years history of severe lancinating intermittent pain, not relived by
oral medications. In our case we will discuss the role of radiofrequency
therapy in combination with alcohol ablation for this chronic pain and follow
up for 1 year duration.

Twenty five healthy control and forty two end stage renal disease (ESRD) patients on regular hemodialysis treatment were enrolled in this study. Blood samples Were drown immediately before and after hemodialysis, and erythrocyte glutathione peroxidase (GSH-Px), glutathione reductase (GSSG-RD) activities, as well as reduced glutathione (GSH) concentration were measured. To study the effect of a single hemodialysis session on glutathione defense system and oxidative stress, the patients were then divided into two groups according to the dialyzer type used in the session (cuprophane, n=23 patients and polysulfone, n=19 patients). GSH-Px activity, as well as GSH concentration was significantly decreased in ESRD patients as compared with controls. GSSG-RD activity was significantly elevated in ESRD patients as compared with controls. A single hemodialysis session, regardless to the type of dialyzer used, did not induce any significant effect on any of the parameters measured. Cuprophane dialyzer did not result in any significant changes among glutathione defense system parameters. Polysulfone dialyzer exerted a significant correction on glutathione system parameters. The findings conclude that the Glutathione defense system may serve as a good index for monitoring oxidative stress and dialyzers biocompatibility in ESRD patients on regular hemodialysis treatment and the use of polysulfone rather than cuprophane dialyzers in hemodialysis procedure is recommended.