Iraqi Postgraduate Medical Journal

BACKGROUND:
Melatonin is a pineal gland hormone with complex roles in the pathogenesis of autoimmune disorders. Immune abnormalities and disturbed endocrine secretion have been reported in patients with systemic sclerosis (SSc). A possible role of melatonin in pathogenesis of SSc patients might be present
OBJECTIVE:
To assess the predictive utility of serum melatonin in diagnosis of SSc patients.
METHODS:
A case-control study conducted at Rheumatology Unit of Baghdad Teaching Hospital-Medical City from November 2015 to April 2016 on 40 SSc patients diagnosed according to the 1980 criteria for classification of systemic sclerosis or 2013 American College of Rheumatology/European League Against Rheumatism for the classification of systemic sclerosis criteria and compared with 40 healthy controls matched in age, sex, and body mass index. Patients with overlapping other inflammatory arthritis or connective tissue disease or autoimmune diseases were excluded. Serum melatonin was measured in both groups by enzyme-linked immunosorbent assay (ELISA).
RESULTS:
Mean level of serum melatonin concentration was significantly lower in patients compared with controls (Mean ± SEM of patients was 602.9 ± 30.69 vs 782.1 ± 43.66 pg/ml for controls, p=0.001). The optimum cut-off value of serum melatonin that differentiate between patients and controls was ≤ 810.8 pg/ml (AUC=0.72, p=0.0005). Validity of serum melatonin at the optimum cutoff value showed highest level of accuracy (75%) with sensitivity 87.5% and specificity 62.5% and if the test was positive and the clinical suspicion of prestest probability was 50% then we have 70% confidence that the patient has systemic sclerosis [ Positive predictive value (PPV) at pretest 50%=70%]. However, this confidence will increase to 95.5% if the clinical suspicion of pretest probability was 90% (PPV at pretest probability 90%=95.5%). Also, if the test was negative then we can exclude the disease with 97.8% with confidence [Negative predictive value (NPV) =97.8%].
CONCLUSION:
Serum melatonin was a valid measure to diagnose SSc.

BACKGROUND:
Melasma is a major cosmetic problem affecting young people mainly females. There are many modalities of topical therapy but usually end with relapse.
OBJECTIVE:
To evaluate the efficacy and safety of 6% lactic acid cream in comparison with glycolic acid cream 6% and 12% in the treatment of melasma.
PATIENTS & METHODS:
This is a COHORT comparative therapeutic trial conducted in the Department of Dermatology-Baghdad Teaching Hospital.
Sixty patients with melasma were included in this study. They were divided into three groups; each one consisted of twenty patients. Group one treated with 6% lactic acid cream, group two with 6% glycolic acid cream, group three with 12% glycolic acid cream. Patients were evaluated clinically using wood’s light & melasma area severity index score before and after therapy. Follow up was done regularly every two weeks for two months to assess the improvement and side effects. Also patients were seen monthly for 3 months after the end of treatment to see any relapse. All patients were instructed to apply the cream once at night for two months with broad spectrum sun block SPF > 30 before sun exposure.
RESULTS:
In group one of the study using lactic acid cream 6%, 14 patients completed the study; their ages ranged from 26-42 years, with a mean 31.9 SD 4.1 years, twelve patients (86%) were females and 2 (14%) males. The result showed that the average score before treatment was 11.45  2.9 while after treatment score changed to 5.312.71; so the improvement was 6.14, this represented a (54%) decrease and was statistically significant (p value<0.0005). No important side effects were recorded during the treatment or follow up. In group two of the study using 6% glycolic acid cream, 13 patients completed the treatment; their ages ranged from 17- 40 years with a mean 27.5  SD 6.8 years, all patients (100%) were females. The result revealed the mean of score before treatment was 10.56  2.77 while after treatment score became 8.36  2.85. So the average decrease was2.2 which represented (21%) decrease and it was statistically significant (p value<0.0005). No important side effects were recorded during the treatment or follow up. While In group 3 of the study using 12% glycolic acid cream,15 patients completed the study; their ages 22 to 40 years with a mean of 31.8  SD 5.3 years. Thirteen (87%) patients were females and 2 (13%) males. The result showed that the mean before treatment was 12.54  3, 4 while after treatment score changed to 6.06  2.38. So the average decrease was 6.48; this represented 52% decrease and was statistically significant (p value <0.0005). No important side effects were recorded during the treatment or follow up. The three agents were statistically significant for the treatment of melasma and there were no significant difference between 6% lactic acid cream and 12% glycolic acid cream (p value= 0.654). But there were significant difference between 6% glycolic acid cream and the others.
CONCLUSION:
Lactic acid cream 6% is a new, non costly, alternative effective, safe agent and as effective as 12% glycolic acid cream for the treatment of melasma.

BACKGROUND:
Deep white matter ischemia (DWMI) is bilateral patchy or diffuse pattern of ischemia and demyelination in the deep white matter region of the brain. WM lesions (WMLs) increase in frequency with age and are associated with lower cognitive performance. Reported prevalence ranges from 5% to 90%, depending on study design, study population, and rating scales. Although the main pathophysiology is still under investigation, they are attributed to degenerative changes of long penetrating arteries and it has been postulated that chronic vascular diseases of the arteries and arterioles supplying these regions can play a role in the process. Deep white matter ischemia is imaged by using T2 weighted (T2W) sequences in addition to FLAIR sequences. Coronal section is used to enable precise sampling of WMLs
OBJECTIVE:
To assess 3T MRI vs. 1.5 MRI in evaluating the extent of DWMI.
PATIENTS AND METHODS:
A cross sectional study was conducted at the MRI unit of the Department of Radiology in Al-Imamain Al-Kadhimain Medical City in Baghdad. Data collection was obtained during the period starting on October 2015– June 2016. The study included 87 patients with the diagnosis of DWMI based on previous MRI data. Patients with initial MRI findings that show no evidence of DWMI as well as patients presented with trauma, migraine, epilepsy, tumor, TB and cerebral venous thrombosis were excluded. Each patient was examined by using 3T MRI, followed by a 1.5 T MRI two days later. The patient images were evaluated for 1.number of lesions, 2.size, 3.volume and 4.intensity of a selected prominent lesion.
RESULTS:
Of the 87 patients, 51 were male and 36 female. Their mean age was 59.48 ± 10.83 years. In all lobes there is a statistical significance (P < 0.0001) between 3T and 1.5T i.e. 3T platform was able to show a greater number of lesions in comparison with the 1.5T platform. It was seen with high statistic significance (P <0.0001) that one the 3T images, mean intensities, sizes, and volumes were higher across the board. The average additional number of lesions shown by 3T over 1.5T was 9.52 lesions with a standard deviation of 6.50.
CONCLUSION:
Three tesla MRI is significantly superior than1.5 tesla MRI in the number of detected lesions, determining size of a lesion, detecting lesion volume and intensity
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BACKGROUND:
Cervical squamous intraepithelial neoplasia is a premalignant condition of cervix. Human papilloma virus (HPV) infection has been associated in the development of premalignant and malignant changes in the cervix. Folate and vitamin B12 can potentially influence carcinogenesis through its effect on DNA synthesis or methylation.
OBJECTIVE:
To determine the influence of plasma folate and vitamin B12 concentrations in cervical squamous intraepithelial lesions.
PATIENTS AND METHODS:
A case-control study conducted in Baghdad Teaching Hospital from the 1stof Dec 2014 to the 31st of Dec 2015 whereas 60 patients participated in the current study and divided in two groups: cases whose pap smears showed cervical squamous intraepithelial neoplasia and controls whose pap smear was normal).
RESULTS:
Mean age of cases was 33.6±4.9 years; prevalent age group was 30-40 years (76.7%). No significant difference was observed between cases and controls regarding age (P=0.5), educational level (P =0.6) and oral contraceptive pills (P=0.4), but a significant association was found between cases and controls regarding parity and smoking (0.01 and 0.003) respectively. Moreover significant association was found between both groups of the study regarding to the folic acid deficiency (P <0.001)and vitamin B12 deficiency (P=0.01). Human Papilloma virus was higher among cases than controls but it is still not significant (p=0.2).
CONCLUSION:
There is significant association between folate and vitamin B12 deficiency, smoking and parity with the cervical squamous intraepithelial neoplasia.

BACKGROUND:
Postoperative pain is a common problem after inguinal hernia repair. Postoperative pain may delay the return to normal activity and delay hospital discharge. Various techniques have been employed to provide postoperative analgesia, by the use of regional anesthetic technique, local anesthesia or traditional analgesic technique: opiates, non-steroidal anti-inflammatory drugs (NSAIDs) or combinations.
OBJECTIVE:
To compare the postoperative pain relief provided by simple bupivacaine wound instillation and ultrasound guided inguinal hernia field block.
PATIENT AND METHOD:
A single blind, prospective, randomized controlled clinical trial for 72 male patients who were undergoing elective unilateral inguinal hernia repair. In 37 of them 10 ml of 0.5% plain bupivacaine was instilled (irrigated) into the wound by the surgeon for 1 minute. In another 35 patients, ultrasound guided field block performed using 20 ml of 0.25% plain bupivacaine at the end of surgery. Vital signs, numerical pain score and analgesia requirement were recorded at recovery (zero hour), 1st, 2nd, 4th& 8th hours postoperatively.
RESULT:
By applying null hypothesis, using the t-student test of two independent samples, pain score and request for analgesia show significant difference only at the first two hours with p-value <0.05, otherwise there was no significant differences in the following hours. For vital signs there was no significant difference for both groups
CONCLUSION:
Bupivacaine instillation is as effective as ultrasound guided field block for inguinal hernia repair pain. We recommend this technique in places where ultrasound machine is not available especially in many developing countries.

BACKGROUND:
Common bile duct stones or choledocholithiasis are present in 10% of people with gall stones disease. Patients may be asymptomatic or presented with jaundice, abdominal pain and fever. CBD stones can be single or multiple. The vast majority of common bile stones are secondary to the passage of stone from the gall bladder.
Pre-operative detection of choledocholithiasis is usually by imaging study, either abdominal ultrasonography (US) or magnetic resonance imaging (MRI).
Management of choledocholithiasis is usually done by means of endoscopic retrograde cholangio-pancreatography (ERCP), but sometimes this is not feasible for variable reasons and surgical exploration and stone extraction is needed.
There are variable methods for surgical management of choledocholithiasis, each method has its advantage and disadvantage.
OBJECTIVE:
The aim of our study is to compare these surgical methods and compare the outcome of each procedure
METHODS:
One hundred patients with CBD stones were included in the study and divided into five groups according to the choice of surgical intervention used, the outcome of each group was compared.
CONCLUSION:
There are several surgical methods to deal with CBD stones, each has its advantage and its disadvantage and there is no single best method over the other.

BACKGROUND:
Epidemiological studies had been demonstrated that subclinical cardiovascular disease in one vascular bed is associated with the presence of clinical disease in another bed; as well as subsequer cardiovascular and total mortalities. Degree of peripheral vascular disease(PVD) in the legs as measured non invasively are common in old adults without overt signs and symptoms of PVD .an ankle —arm index has been shown to be a strong predictor of total cardiovascular morbidity and mortality in those without prior history of clinical cardiovascular disease at the baseline examination.
PATIENTS AND METHODS:
A cross sectional study done in IBN AL NAFEES teaching hospital for cardiology and cardiac Surgery. from 1st of June 2015 to 30th of Feb. 2016, for different age groups and multiple different risk factors (smoking, D.M, hypertension, family history of Ischemic heart disease, previous Ischemic heart disease,, hyperlipidemia) have their ankle-arm index measured by Doppler study and reported as abnormal (<0.9)and normal (>9). Then ‘ their coronary angiographic findings were obtained and correlated to the level of Ankle Brachial Index .
RESULT:
Study showed that 18 patients with low ABI value have abnormal angiographic findings (100%) i.e. High specificity; while 28 patients with normal ABl value proved to have coronary artery disease by (39.1%) i.e. Low sensitivity; but on the other hand low ABI significant relation for both multiplicity and severity of coronary disease diagnosed by angiography (p value 0.0001) for both.
CONCLUSION:
Ankle-brachial index (ABI) index despite it is easy, quick and inexpensive bed side test for cardiovascular diseases it is of low sensitivity ;but its high specificity.

BACKGROUND:
BCC is a malignant epithelial neoplasm constitutes 70%-75% of all skin cancers .It arises from basal cells layer of the epidermis. It has a higher degree of invasive potential with an extremely rare ability for distant metastases so the mainstay treatment is surgical excision.
OBJECTIVE:
To study histological types of BCC, age and gender preference, size, anatomical location and find a correlation between various clinical and histological parameters.
MATERIALS AND METHODS:
In this retrospective study all histologically proven cases of BCC during two years period, in the period from October 2014 to February 2017 (in the pathology lab of Alwasity teaching hospital for plastic and orthopedic surgery in bagdad) were collected .The microscopic features of these tumors were carefully reviewed including histological types and surgical margin status and compared with the related clinical information.
RESULTS:
This study enrolled 76 excisional biopsies of basal cell carcinomas include 34 (44.74%) for males and 42(55.26%) for females, with mean age of 55.64 ±14.613. 63 (82.89%) were above forty years old. 72(94.73%) were located in the sun exposed areas. Regarding histological types, 64(84.21%) were mixed, 6(7.89%) were nodular, 3(3.95%) were pigmented and 3(3.95%) were superficial. According to the size of the excised tumors, those above two cm were 22(28.95%). Regarding surgical margin status, 28(36.84%) were margin positive and 48(63.16%) were margin negative. The study found that there is a significant statistical relationship between histological type and surgical margins status with P value 0.030(<0.05) .By Analyzing histological type in regard to age, gender, locations and size, the study find that there is no statistical relationship between them with P value (>0.05) , also there is no significant statistical relationship between tumor size and age ,gender , tumor location with P value (>0.05).
CONCLUSION:
Basal cell carcinoma is malignant skin tumors most commonly affects older population with a strong association to sun exposure. Commonly present with a size of two cm. and below .There is a significant associations between histological types and completeness of surgical excison highlighting the importance of histological sub typing for prognostic purposes and giving a clue to the surgeon about management decision since the clinical (macroscopic) and histological (microscopic) types of BCC are closely correlated. Otherwise there is no age, gender and location preference of various histological types and there is no significant relationship between tumor size and various clinical parameters.

BACKGROUND:
Intubation and mechanical ventilation are sometimes necessary during treatment of acute stroke. Indications include neurological deterioration, pulmonary complications, and elective intubation for procedures and surgery.
OBJECTIVE:
This study was performed at neurosciences hospital for the period 2013 - 2014 to prospectively assess the prognosis of stroke patients who require ventilation in a neurological intensive care unit and to determine factors that may influence outcome.
METHODS:
Analysis was made of 124 consecutive stroke patients,who required mechanical ventilation over a 2-year period. We determined the survival rate at 1 year after admission.
RESULTS:
The 1-year survival rate was 33.1%. Sixty-five patients (52%) died in the neurological intensive care unit. Among 17 variables analyzed, seven were found to significantly influence 2-month fatality in the univariate analysis: age greater than 65 years, atrial fibrillation, bilateral absence of pupillary light reflex, bilateral absence of corneal reflex, bilateral Babinski’s sign, infratentorial stroke, and Glasgow Coma Scale (GCS) score less than 10. Independent predictors of death at 2 months were age greater than 65 years, GCS score less than 10, and intubation performed because of coma or acute respiratory failure.
CONCLUSION:
Intubation and mechanical ventilation of severe stroke patients should be performed in a timely manner.older patients comatose on admission requiring mechanical ventilation have very poor prognosis. Fatality rate in our patients was high, but one third were still alive at 1 year after admission. Patients electively intubated in our study had a better prognosis independent from other factors, including age and GCS score.The probability of death at 2 months was more than 2.5 times greater in patients who were intubated because of neurological or respiratory deterioration than in those electively intubated for angiography or surgical intervention.

BACKGROUND:
Infection with H. pylori has been recognized as a public health problem worldwide. Studies to address the association of H. pylori infection with diabetes mellitus (DM) had yielded controversial results.
OBJECTIVE:
To figure out the association between H. pylori infection and DMtype 1 and 2 in Baquba city, Iraq .
PATIENTS AND METHODS:
This cross-sectional case control study was conducted in Baquba-Diyala province for the period from August 2015- March 2016. 82diabetic patients (67 with type 2 and 15 with type 1) and 23 healthy non-diabetic individuals were enrolled. The DM patients include 45 (54.9%) females and 37(45.1%) males. The mean age ±SD of type 2 DM patients was51.37± 10.84 years,while the mean age ±SD of patient with type 1 DMwas 23.66 ± 6.99 years. The patients were collected from the outpatient clinic of Baquba General Teaching Hospital according to the WHO definition criteria of the DM. Blood samples were collected, sera were separated and tested for the presence of anti-H. pyloriIgG antibody using the commercially available Enzyme- linked immunosorbant assay kit.Statistical analyses were done using the Statistical Package for Social Science (SPSS) Version 18, and P value < 0.05 was considered significant.
RESULTS:
The results showed that the anti- H. pylori positivity rate among patients with diabetes mellitus and controls was 35.2% and 9.5% respectively, with statistically insignificant difference (p= 0.54). The anti- H. pyloripositivity rate was slightly higher in type 2 DM than in type 1 DM (29.5 % vs 5.7 %, p=0.9).Diabetic male had insignificantly higher positivity rate compared to female ((29.5% vs26.8, p= 0.096%). Furthermore, higher positivity rate was found in the age group 30-50 years.
CONCLUSION:
The anti-H. pyloripositivity rate is insignificantly higher among diabetes mellitus patients; particularly type 2 diabetes mellitus than non-diabetic individuals in Baquba cit, Iraq .

BACKGROUND:
The liver is the second most commonly injured organ in abdominal trauma, liver injury could be caused by trauma to abdomen, lower chest and back (blunt or penetrating injury) and may be associated with high mortality and morbidity depending on the mechanism of injury and associated injuries.
OBJECTIVE:
Discuss the types and grades of liver injury, assess treatment modalities and identify morbidity and mortality caused by liver injury.
PATIENTS AND METHODS:
This is a prospective study; included 60 patients admitted with liver injury within period of 13 months from (1st.January 2015- 31 st. January 2016) in Baghdad Teaching Hospital, Only patients who underwent operative management were included in this study. They were analyzed according to their age, gender, and mechanism of injury, site of trauma, physical examination, investigations, and details of management which include operative management.
RESULTS:
In this study, most injured patients were male 54 (90%) patients and 6 (10%) patients were female. The peak incidence of age was in those between 20-29 years, 28 (46.67%) patients while the lowest incidence was in those between 50-60 years, 2 (3.33%) patients. 52 (86.67%) patients had penetrating liver injury making it the most common type of injury and 8(13.33%) patients had blunt liver injury. The patients in this study were diagnosed by clinical examination, imaging study and exploratory laparotomy.
23 (38.33%) patients had grade II liver injury making it the most commonly encountered grade of injury while 19 (31.67%) patients had grade III as second most common grade of injury. Diaphragmatic injury was the most common associated organ injury with liver injury 30 (50%) patients. Surgical options for treatment of liver injury depend on general condition of the patients and grade of liver injury; simple suturing (hepatorrhaphy) with gelfoam was the most commonly used modality of treatment. Regarding postoperative complications, wound infection was the most common postoperative complication 8 (13.33%) patients followed by respiratory complications in 6 (10%) patients, jaundice in 5 (8.33%) patients, bile leak in 3 (5%) patients ,subphrenic collection in 3 (5%) patients ,disseminated intravascular coagulopathy (DIC) had occurred in 3 (5%) patients, bleeding occurred in 2 (3.33%) patients, hemobilia occurred in 1 (1.67%) patient and liver abscess and necrosis occurred in 1 (1.67%) patient .
CONCLUSION:
The most common grades of liver injury were grade II and grade III. The mortality rate increases with increasing the evidence of vascular injury.

BACKGROUND:
Sudden infant death syndrome is a common cause of infant mortality below age of one year, and it is of unknown cause, but simple protective measures in the infant sleep practice and sleep environment can dramatically reduce its occurrence.
OBJECTIVE:
To study infants sleep environment and sleep practice in Erbil city.
METHODS:
This was an observational cross sectional study, random sample of 100 mother-infant pairs aged between 1 and 8 months were interviewed face to face using a questioner about infant sleep practice and sleep environment in relation to SIDS risk factors.
RESULTS:
In this study most Risky infant sleep practice detected were: lateral sleep position 39%,face covering 22%,bed sharing 42%,soft mattress 68%,bottle feeding 40% and smoke exposure 47%,the mothers had little knowledge about SIDS and no recommendations was given to them about safe infant sleep.
CONCLUSION:
There is a need to increase mothers' awareness about SIDS by public education by the health personnel at the neonatal care units and the primary health centers about SIDS and its risk factors and safe sleep recommendations to decrease its occurrence.

BACKGROUND:
C-reactive protein (CRP) is an acute phase reactant produced primarily by hepatocytes; its production is stimulated by systemic inflammation of either infectious or noninfectious origin. The cytokines that are released during the inflammation are the main stimulants of the acute phase reactants. Interleukin-6 is the main stimulant cytokine of the synthesis of most acute-phase reactants.
OBJECTIVE:
To differentiate between infectious and malignant pleural effusions by measuring pleural fluid CRP titer.
MATERIALS AND METHODS:
This was a hospital-based cross-sectional study at Baghdad teaching hospital medical wards conducted from the 1st of November 2014 up to the 31th of august 2015.
Fifty patients with pleural effusion proved by the history, examination,
Chest imaging and pleural tapping included in this study, all proved to have
An exudative pleural effusion by the light criteria.
RESULTS:
Showing statistically significant differences in CRP titer between:-
1-Parapneumonic pleural effusion (PPE) and malignant pleural effusion (MPE)
2-TB pleural effusion (TBPE) and malignant pleural effusion (MPE).
CONCLUSION:
Pleural fluid C-reactive protein titer can be used as an aid in the differentiation between some infectious causes of pleural effusion and malignant pleural effusion as there is a statistically significant difference between the Pleural fluid C-reactive protein titer of the infectious pleural effusion and the malignant pleural effusion.

BACKGROUND:
A variety of pulmonary resection techniques are currently available, including pneumonectomy (intrapleural, extrapleural, intrapericardial,and sleeve pneumonectomy), lobectomy and sleeve lobectomy , segmentectomy, wedge resection and non-anatomic parenchymal sparing resection.
OBJECTIVE:
To evaluate the experience with pulmonary resections at our hospital.
METHODS:
This is a retrospective study utilized medical records of 110 patients from 1st of January 2013 to the 31st December 2014. After doing the routine laboratory work and chest x-ray for all patients, they were operated under general anesthesia with double lumen endotracheal tube, for whom different types of pulmonary resections were performed for different reasons.
RESULT:
A total of 110 patients, 65 males (59.1%) and 45 females (40.9%). Lobectomy is the most common type of pulmonary resection used 62.7%.Malignant tumor is a common indication for pulmonary resection 36.3%. Trauma and hydatid cyst are a significant cause of pulmonary resection in our country. Mortality rate for pulmonary resection is 9.09%.
CONCLUSION:
Pulmonary resections are the most used surgical modalities for treatment of many pulmonary diseases. It is a safe procedure providing the proper selection of the patient and assessment regarding pulmonary function status.

BACKGROUND:
The incidence of neonatal duodenal obstruction has been variously estimated as 1 in 10000 to 1 in 40000 live births. Duodenum obstruction may also caused by annular pancreas and band of Ladd in association with malrotation.The detection of double bubble sign on plain radiograph of abdomen lead to suspicion of duodenal obstruction. Duodenoduodenostomy of different technique has been used to bypass duodenal obstruction.
OBJECTIVE:
To study congenital duodenal obstruction (atresia,annular pancreas and malrotation) and to evaluate and analyze the age presentation, x-ray findings and the operative findings in comparison with other studies, with emphases to the operative procedures suitable for each cause.
PATIENTS AND METHODS:
In this study patients were collected prospectively through the period between first of January 2010 to the end of January 2013 in pediatric surgical ward, at Al-Khansa teaching hospital in Mosul/Iraq. Erect abdominal x-ray was done for all patients to assess the radiological findings, while barium meal done selectively. Operative findings were evaluated in relation to the cause of obstruction, site, degree of proximal dilatation, presence of distal obstruction and other associated anomalies.
Surgical procedures were used according to the operative findings which were either diamond duodenoduodenostomy (DDD), side to side duodenoduodenostomy (SSDD), side to side duodenojejunostomy (SSDJ), Ladds procedure and Heinecke-Mikulicz (HM) or combined procedures.
RESULTS:
Fifty six patients were admitted to our center, 31male (55.5%) and 25 female (44.5%). Fourty five patients presented in the first 4 days of life (80%), 35 of them (60%) in the first 2 days, while 11 patients (20%) were delayed after the seven day of life, one patient aged one month proved to have fenestrated web. Vomiting was the main presenting symptoms in 50 patients (90%), and was bile stained in 42 patients (85%) and nonbile stained in 8 patients (15%). Erect abdominal x-ray show typical double bubble gases shadow sign in 39 patients (70%), Operative findings at time of exploration shows 36 atresia(67%) including 25 web(type one atresia), type 2 atresia in 8 patients and 3 patients with type 3 artesian. annular pancreas were detected in 11 patients(20%) and 7 patients(13%) with malrotaion. Diamond duodenoduodenostomy (DDD) was the procedure of choice in 38 patients (70%).
CONCLUSION:
The double bubble sign in erect abdominal X-ray is still diagnostic for cases with complete obstruction. High index of suspicious in patients with bilious vomiting is important for early referral, Diamond duodenoduodenostomy is very effective technique in most cases with very good post operative results.
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BACKGROUND:
Acute coronary syndrome (ACS) is the clinical manifestation of acutely diminished coronary arterial blood supply. The rate of increase of intraventricular pressure during isovolumetric contraction (left ventricular dP/dt) represents the rate of change of pressure during ejection.
OBJECTIVE:
The aim of this study is to evaluate the usefulness of the rate of increase of intraventricular pressure during isovolumetric contraction (dP/dt) in assessment of left ventricular function in patients with acute coronary syndrome and its relation to certain clinical and echocardiographic features.
PATIENTS AND METHODS:
The study is a cross sectional study including 50 patients with an established diagnosis of acute coronary syndrome. The study was performed in Baghdad Teaching Hospital during the period between 2/2/2013 and 5/3/2014. History was taken from all patients and recoded using a specially prepared questionnaire paper. Left ventricular internal dimensions at end diastole (LVIDd) and end systole (LVIDs) were measured using M-mode echocardiography to asses left ventricular systolic function (ejection fraction). Pulse Doppler tracing of the transmitral flow velocities and tissue Doppler image (TDI) mitral annular velocities were obtained from the apical four-chamber view to assess left ventricular diastolic function. Doppler-derived dP/dt was determined from mitral regurgitation (MR) spectral flow
RESULTS:
The study included 50 patients (31 males and 19 females, mean age of 65.26 ± 5 years). Low dP/dt values were found in 42 patients (84%). Low dP/dt values were found more in the age group (51-60 yrs) (p value < 0.05). The mean age of patients with low dP/dt (<1000) was (65.62 ± 5yrs) and that of patients with normal dP/dt (≥ 1000) was (63.38 ± 5 yrs) with no significant difference (p value > 0.05). Low dP/dt value was significantly associated with smoking and positive family history and not significantly associated with male sex, hypertension, and diabetes mellitus. No significant association was found between low dP/dt value and type of presentation of acute coronary syndrome (p value > 0.05) or ejection fraction (p value > 0.05). It was significantly associated with LV diastolic dysfunction, left atrial size, left atrial pressure, and left ventricular size (p value < 0.05).
CONCLUSION:
The use of dP/dt is useful for evaluating left ventricular function in patients with acute coronary syndrome.