Journal of the Faculty of Medicine Baghdad

Background: obesity is a common disease affecting more than 300 million adults worldwide. Laparoscopic sleeve gastrectomy (LSG) is a relatively new and effective procedure for weight loss, it is gaining acceptance among bariatric surgeons as a viable option for treating morbidly obese patients. We describe results of our experience with LSG in a community practice.
Objective: We aimed to evaluate our experience with LSG with regard to its safety and feasibility and early weight loss.
Methods: prospective study done in Baghdad Teaching Hospital between February 2011 and November 2013, of 50 consecutive morbidly obese patients and was designed to study the efficacy and safety of the sleeve gastrectomy in this group of patients.
Results: The mean preoperative weight of the patients was 113.4 (range 91.0–170.0) kg, while the mean BMI was 42.6 (range 33.0– 60.0) kg/m2. Hypertension was present in 34%; hyperlipidaemia in 32% and Diabetes mellitus in 8% of the patients. The majority of patients had two or more obesity-related comorbidities (52 %). Mean operative time was 142 minutes and duration of postoperative stay was three to nine days. At two weeks, one, three and six months post operation, the mean BMI was 38.6 kg/m2, 37.8 kg/m2, 34.5 kg/m2 and 30.8 kg/m2, the mean percentage of excess weight loss was 17.7 %, 23.3 %, 40.9 % and 56.7 %, and absolute weight loss was 8.00 kg, 11.52 kg, 18.77 kg and 26.85 kg, respectively.
Conclusion: LSG is a promising procedure for surgical treatment of obesity, with good early weight loss and low morbidity.
Keywords: sleeve gastrectomy, morbid obesity, body mass index

Background: B.A is a relatively rare obstructive condition of the bile ducts causing neonatal jaundice. The etiology is unknown but is the result of a progressive obliterative process of variable extent. If not treated, B.A is fatal within the first 2 years of life.
Objectives: The aim of this study was to analyze & discuss the impact of many patients' factors on short-term outcome of patients with B.A who underwent Kasai operation in our department.
Methods: A prospective study on 34 patients with B.A surgically managed at pediatric surgical department /Medical City during the period Nov. 2006 to Sept. 2013. The patients were followed-up for 2-3 months and the outcome were evaluated by morbidity and mortality rates according to different patients' parameters (preoperative, intraoperative and postoperative factors) .
Results: the mean age of the infants was (61.6 ± 8.1) days with a female to male ratio of 1.27:1. All the patients had type ш biliary atresia. Infants with body weight < 3.5 kg were about 10 folds more likely to die than those with body weight > 3.5 kg. Infants who passed greenish bowel motion at the 4th – 5th postoperative day were about 6 folds more likely to die p.value= 0.026. Infants with postoperative anastomotic leak were about 7 folds more likely to die than those with no leak p.value = 0.013. Strong highly significant correlation had been found among high death rate and reoperation rate (r = 0.78 and p < 0.001). of the thirty four infants, 24 (70.6%) survived, unfortunately, 10 infants (29.4%) died. the ratio of death to survive was 0.4: 1.
Conclusions: the survival with native liver following drainage surgery for biliary atresia in our center, compared favorably with other international figures. Body weight, significant impaired liver function, severe associated anomalies, anastomotic leak and re-intervention, all, greatly contribute to increase mortality rate of those infants.
Keywords: Biliary atresia BA, Kasai operation, Cholangitis, Cirrhosis.

Background: Poly cystic ovary syndrome is a common disorder in women of reproductive age, it is associated with disturbance of reproductive, endocrine and metabolic functions. The pathophysiology of PCOS appears to be multifactorial and polygenic. Leptin seems to play an important role in pathophysiology of PCOS especially in women with BMI ≥25kg/m2.
Objectives: To assess leptin level in both PCOS and healthy women and explore the relation to their body weight and body mass index.
Patient and Methods: A total of 120 women were enrolled in this study, 60 women (50%) had PCOS (study group) and the reminder 60 women (50%) were healthy women and considered as control group. BMI was calculated first. Both groups were further subdivided into two groups; BMI of ≥25kg/m2 and BMI of <25kg/m2. Pelvic U/S scan was done to confirm the diagnosis.
Hormonal profile (FSH, LH, LH/FSH, testosterone, TSH, T4 and prolactin) were measured. RBS was measured. Serum leptin level was measured in patient with PCOS and the control by Enzyme linked immunesorbant assay (ELISA) test. Correlations between leptin levels and age, Wt, Ht, BMI, and serum hormone levels (FSH, LH, testosterone and prolactin) were studied.
Results: Mean serum leptin levels were not significantly higher in patients with PCOS compared to the control group (P =0.052). Leptin levels were found to be higher significantly in the overweight subgroups both in patients with PCOS and in the control women. Leptin levels were found to be higher in over weight patients with PCOS compared to over weight control P value =0.0001. Serum leptin levels were significantly correlated with BMI in both patient with PCOS and control group (r=0.918 and r=0.846) respectively. Serum leptin concentration had a positive correlation with serum LH concentration in PCOS group (r=0.327). Leptin levels had strong positive correlation with serum LH, FSH, and testosterone in over weight PCOS subgroup women and (r=0.592, 0.609 and 0.604) respectively.
Conclusion: Leptin levels are higher in patient with PCOS compared to control groups. Leptin levels were correlated with the amount of fatty tissue not only in PCOS group but also in healthy women. Leptin play an important role in pathophysiology of PCOS of women with BMI ≥25 kg/m2.
Key word: polycystic ovary syndrome, serum leptin, body mass index.

Background: Preterm labor is the major cause of perinatal mortality and morbidity and it is a challenging obstetrical complication as treatment is marginally effective if ever and no improvement in incidence over the last 5 decades , although may causes were identified the majority are idiopathic and in this category infection seems to be involved as a causative agent
Objectives: to evaluate the association of abnormal vaginal flora diagnosed by direct Gram's staining and vaginal culture with preterm labor.
Patients, material and methods: 25 women with preterm labor compared with 25 women at full term pregnancy, high vaginal swabs for direct Gram's staining (Spiegel criteria for abnormal vaginal flora) and culture. The results were compared in both group
Results: this study showed significant association between preterm labor and abnormal vaginal flora 7 (28%) and 12 (48%) of grade II and III respectively . and a significant association between term pregnancy and normal vaginal flora 16 (64%) of grade I. Also in the presence of abnormal vaginal flora, no significant association with type of pathogenic microorganism and preterm labor as all types may be associated with PTL , and the presence of Lactobacillus spp. (normal grade I flora ) is associated with term pregnancy.
Conclusions: Gram's staining of high vaginal swab using Spiegel criteria can be useful simple test to predict preterm labor
Key words: preterm labor, vaginal flora grading, vaginal infection.

Background: spontaneous subarachnoid hemorrhage (SAH) is subtype of hemorrhagic stroke with extremely poor prognosis. It’s a medical emergency and can lead to death or severe disability even when recognized and treated at an early stage. Computed tomographic angiography (CTA) is frequently become the initial step in detecting intracranial aneurysms and planning therapeutic interventions.
Objectives: to analyze the findings of non traumatic SAH in cerebral CTA and characterization of the underlying causes, emphasizing the importance of CTA as a new advent investigation in Iraq.
Patients and methods: This cross sectional study performed on 62 patients with non-traumatic SAH who underwent CTA in Baghdad Teaching Hospital at medical city-Baghdad from August 2012–August 2013 of patients with highly clinical suspicion of SAH or those who were diagnosed by native computed tomography (CT) or magnetic resonance imaging (MRI), the sample of the study was consist of 37 males and 25 females, age of patients ranged from 1-70 years; all patients examined by CTA using 64 multi-slice CT.
Results: From 62 patients in our study, 10 patients have negative finding, 38 have aneurysm, 7 have AVM, 5 have cavernoma and 2 patients have venous angioma. 81.6 % of the aneurysms were saccular and 18.4% were fusiform in shape and mostly (89.5%) supratentorial in location and 10.5% infratentorially, which is single in 84.2% and more than one in 15.8% of patients. The most frequent types of arteriovenous malformation (AVM) were parenchymal (71.4%), from which the size 3-6 cm was most frequent (60%), while the Dural AVM identified in 28.6% of patients; from which, the size 3 cm most frequent size (66.6%) and no cases reported with mixed types.
Conclusion: CTA can provide rapid, minimally-invasive evaluation of broad spectrum of cerebrovascular disorders and CTA adequate for detecting aneurysms in symptomatic SAH patients especially when conjoined with native CT, also CTA is helpful in intervention planning.
Key words: subarachnoid hemorrhage, aneurysm, CT angiography

Background: Oxygenation during one lung ventilation (OLV) can be affected by positioning of Double lumen endobronchial tube (DLT). Mal position can occurs following intubation and moving the patient to the lateral decubitus position.
Objectives: To study the relation of hypoxemia to mal position of double lumen endo bronchial tube after patient positioning in lateral decubitus position and during one lung ventilation. The use of fiber-optic scope in detecting the mal position and correcting it is illustrated.
Methods: A study of 80 patients with ASA physical status I-II patients about to have elective thoracic operations. The intubation of the trachea was done with a left sided DLT, then checked clinically by auscultation and with use of fiber-optic scope and this done after patient positioning and during OLV. Oxygen saturation was measured by non invasive pulse oxy meter. IF oxygen saturation below 92 % (10.6kpa) 80 mmHg is detected, the DLT position must be checked and positive end expiratory pressure (PEEP), oxygen insufflations or (continuous positive airway pressure). CPAP or total lung ventilation (TLV) was tried if needed.
Result: Misplacement of DLT was found in 28 patients (35%) after patient positioning and in 24 patients (30%) during OLV. Patients who had malpostion of DLT after placing the patients in lateral decubitus position had a greater incidence of malposition of DLT in OLV (64%). The application PEEP to the dependent lung, CPAP or oxygen insufflations to the upper lung or brief periods of TLV were applied in 28 patients.
Conclusion: Patients who have mal position of DLT in lateral position had more incidence of hypoxemia and DLT mal position in OLV and mostly require intervention with use of fiber-optic bronchoscopy which is mandatory for detecting and correcting the mal position.
Keyword: Mal position tube, hypoxemia, double lumen endobronchial tube, one lung ventilation

Background: Several causes stand behind prolonged neonatal Jaundice (Jaundice that persists more than 2 weeks).
Objectives: To find out the frequency of association between Urinary tract infections (UTI) and prolonged neonatal jaundice in term infants during the first two months of life.
Patients and methods: We conducted an observational prospective study in children welfare teaching hospital, Medical City Complex, Baghdad. Fifty term infants, less than two months of age, with clinically evident jaundice that has persisted for more than 14 days of life were enrolled; UTI was confirmed by urine culture and sensitivity. Demographic features, historical characteristics, laboratory investigations, abdominal ultrasound findings recorded and analyzed for each patient.
Results: UTI was confirmed by urinary culture in 6 infants (12%). E. coli was the most common isolated microorganism. UTI was more common in female patients during the first 2 months of life (66%). Irritability was the most common associated clinical feature (83%). Conjugated bilirubin was found to be the most raised fraction among jaundiced infants with UTI. Jaundice resolved gradually upon treating UTI with proper antibiotics.
Conclusions: UTI was found in 12% of infants of less than two months of age with prolonged neonatal jaundice; urine culture should be considered as a part of the diagnostic evaluation for any infant with prolonged neonatal jaundice beyond 14 days of life with unexplained etiology.
Key words: Neonatal jaundice, Urinary tract infection (UTI), infants

Background: Attention Deficit Hyperactivity Disorder (ADHD) is a common neurobehavioral disorders in children includes pervasive inattention, over activity, and impulsivity imposing psychological and cognitive impairment.
Objectives: This study aims to examine the clinical types and the association of some maternal risk factors and developmental milestone with ADHD among a group of school-age children.
Method: 100 primary school- age children affected with ADHD of both sexes were clinically assessed by the semi-structured interview questionnaire of ADHD (SSIQ) according to (DSM-IV-TR) during April-August 2013at Ibn-Rushd Psychiatric Teaching Hospital in Baghdad results were submitted to statistical analysis.
Results: Most of the children were urban males with average age of 8 years old presented with combined type of ADHD and had a normal developmental milestone. Maternal adversities were not insignificantly associated.
Conclusion: ADHD was presented mostly in its combined form. Maternal adversities and type of labor was not significantly associated with its morbidity. The authors call for improvement child’s mental health services.
Key words: clinical, maternal risk factors, ADHD, children, Baghdad

Background: Coeliac disease is a chronic, immunologically determined form of enteropathy affecting the small intestine in genetically predisposed children and adults. It is precipitated by the ingestion of gluten-containing foods. It is also referred to as celiac sprue, gluten-sensitive enteropathy, or nontropical sprue. CD69 is a lymphoid activation antigen whose rapid expression makes it suitable for the detection of T-cell activation and for subset activation analyses.
Objective: Investigate the clinical value of using CD69 marker in diagnosis of coeliac disease.
Patients and method: A total of 40 patients (21 males & 19 females) with coeliac disease attending the Gastroenterology and Hepatology Teaching Hospital in the Medical City, during the period between February 2013 and June 2013.The control group consisted of 40 apparently healthy individuals who were not complaining of any gastro-intestinal problem. Venous blood samples were taken from each subject (fresh blood tested for detection of CD69 marker by flow cytometry).
Results: The age of coeliac disease patients in this study was ranged between (2-56) years with the mean age of (15.6 ± 13.1) years. Blood level of CD69 positive T-lymphocytes was significantly increased in cases group when compared with controls group.
Conclusion: Detection of CD69 marker is an accurate and rapid method for diagnosis of coeliac disease.
Key words: Coeliac disease, CD69.

Background: Several reports show that hypertension is a leading cause of maternal and fetal morbidity; also ABO blood group may be blamed in susceptibility to human diseases as blood-group antigens which influence the bioavailability of E-selectin, TNF-alpha and intra cellular adhesion molecule-1 (ICAM1) factors that implicated in the pathogenesis of preeclampsia.
Objective: To evaluate the possible relationship between ABO blood group and Rh with hypertension in pregnancy.
Patients and method: Case- control study is conducted in Al-Batool teaching hospital for maternity and children in Baquba city. Two hundred and twenty (220) pregnant women with hypertension and 100 normal healthy pregnant women, in specific age group are enrolled . Comparison between hypertension and ABO blood group is done. Statistical analysis is done by X ² and t- test.
Results: The results revel that mean age in hypertensive pregnant women is(30.0±6.8), while in healthy control pregnant women is (26.2±6.1) years in all ABO and Rh. blood groups. Mean weeks of gestations in hypertensive pregnant women and healthy control groups are (37.0±3.0), (35.8±6.1) respectively in all ABO and Rh blood groups. Blood group O is the highest percent (41%) in hypertensive pregnant women, (31%) in control group but it was statistically not significant p value (0.239), in control group higher percent found with blood group A (36%) comparing with blood group A in hypertensive group (33%) but also statistically not significant. Among both hypertensive pregnant women and healthy control pregnant women Rhesus positive (Rh +ve) percent is significantly higher in both hypertensive and control group (78%, 85%) respectively than Rhesus negative (Rh –ve) (22%) in hypertensive and (15%) in control, while no significant difference in the percentage of Rh+ve between the hypertensive(78%) and control group(85%) and Rh-ve in hypertensive(22%) and control(15%).
Conclusion: This study reveals no association between ABO and Rh blood group and hypertension in pregnancy.
Key words: Blood group, Hypertension, Pregnancy.

Background: Dystrophinopathies are the commonest forms of muscular dystrophy and comprise clinically recognized forms, Duchenne Muscular Dystrophy (DMD), and Becker Muscular Dystrophy (BMD). Mutations in the dystrophin gene which consist of large gene deletions (65%), duplications (5%) and point mutations (30%) are responsible for reducing the amount of functional dystrophin protein in skeletal muscle fibers. This study concentrate mainly at the spectrum of deletions in the 'distal hot spot' region of the DMD/BMD gene in Iraqi DMD/BMD patients using multiplex PCR technique
Objectives: The aim of this study was to investigate the rate, and distribution of deletions in 10 exons of Dystrophin gene in a group of Iraqi dystrophinopathy patients using the multiplex polymerase chain reaction (MPCR).
Patients materials and methods: This is a case prospective study which include 27 clinically diagnosed DMD/BMD patients and six suspected carriers in Medical city /Baghdad . A written consent was obtained from each family for going the research as well as ethical committee approval. Forty six apparently healthy individual were included as a control group. Blood samples were collected in 5-6 ml EDTA tubes by venepuncture. The DNA was extracted by using the Wizard Genomic purification kit (Promega/USA), and the quantity was estimated by UV-spectrophotometer (Cecil CE7800) . Ten exons of the dystrophin gene were examined ( 19 ,45 ,46 ,47 ,48 ,49 ,50 ,51 ,52,53) using synthesized primers with complementary sequences and set in five different multiplex PCR groups. The products of PCR amplifications were subjected to electrophoresis and visualized by The UVCI140 & 200 series (advanced CCD gel imaging system from Major Science. It consists of a CCD camera, UV transilluminator UV- light system). All done in college of medicine /Baghdad university.
Results: The rate (relative frequency) of subjects with any positive exonal deletion (among the10 selected and tested exons was significantly higher (85.2%) among patients compared to that among the suspected carriers (33.3%).The distribution of exonal deletions among patients compared to suspected carriers were statistically significant. The frequency of deletions detected in male patients (~82%) was higher than frequencies mentioned in the other studies of comparison. The control group show no deletion in all tested exons.
Conclusions: Multiplex PCR technology was utilized to demonstrate the frequency of 10 exons deletions in a limited group of Iraqi DMD/BMD patients. The overall distribution of deletion mutations in the distal ‘hot spot’ region was higher than that of DMD/BMD cases investigated elsewhere. The study also serves as a good starting point for further investigations into the genetic aspects of the Iraqi DMD/BMD population.
Keywords: Duchenne muscular dystrophy (DMD), Becker muscular dystrophy (BMD), Dystrophin gene, Multiplex PCR

Background: The coronary atherosclerosis received a great concern from the clinical aspect, but its pathological aspect is deficient in Iraq.
Objectives: To find a correlation between the type of the lesions that were grossly identified and their corresponding microscopical grades and Studying the effect of remodeling on preservation of the luminal area, 3) demonstrate the endothelial dysfunction in atherosclerosis.
Methods: fifty cases were gathered from the Medico-legal institute in Baghdad during the period from January to July 2004.The left anterior descending (LAD), left circumflex (LCX) and right coronary artery (RCA) from 50 postmortem cases were biopsied. Cryosectioning and staining with Oil-red O stain were done for twenty five specimens, then all the cases were embedded in paraffin blocks, and stained for hematoxylin and eosin (H&E) stain, Verhoff Van Gieson (VVG), twenty cases were stained with CD34 immunohistochemical marker. Cases were graded according to the American Heart Association (AHA) classification system.
Results: Seventy three per cent of grossly normal specimens were microscopically normal, while grossly flat fatty streaks correspond in 83% of cases to grade II. Raised fatty streaks were 100% grade III (intermediate lesions) and raised lesions were 100% advanced lesions (grade IV, V and VI). This study also shows that with progressive increment of plaque area, the total arterial cross-sectional area increased trying to preserve the lumen area. Endothelial dysfunction was also shown by decrease expression of CD34 immunohistochemical marker in diseased segments.
Conclusions: gross inspection of the vessel is a valuable method for detection of intermediate and advanced lesion, while the differentiation of early lesion from normal vessel needs microscopical examination. Remodeling has a great role in maintaining luminal patency in the major coronary arteries. This study also demonstrates the endothelial dysfunction overlying the atheroma in spite of endothelial integrity.
Key words: CD 34 immunohistochemical marker, coronary atherosclerosis, frozen section, postmortem study.

Background: Development of colorectal adenocarcinoma principally occurs via the adenoma- carcinoma sequence of a multiple step process of tumor progression. This results from an accumulation of genetic changes in cells of intestinal mucosa. The use of molecular biomarkers may further aid in determining the risk of changing to carcinoma.
Objectives: To evaluate the expression of Bcl-2 and Ki-67 in colorectal adenomas and correlate the observed levels with age, gender, histological type, grades of dysplasia as well as to the levels of these two markers with each other.
Materials and Methods: A retrospective stu dy of fifty colorectal biopsies were selected randomly, 40 cases were with different grades of colorectal adenomas and 10 cases with normal mucosa as a control group; covering the period from 2010 till 2012. All the cases collected from the Gastroenterology and Hepatology Teaching Hospital. The biopsies were re-examined histologically and then stained immunohistochemically for Ki-67 and Bcl-2.
Results: There was a significant correlation only between Ki-67 expression and grade of adenoma and there was a significant correlation between Ki-67 and Bcl-2 expression in adenoma. Also there was a significant correlation between age of the patients and histologic type.
Conclusions: The assay of Ki-67 and Bcl-2 is valuable in detecting the risk of early colorectal carcinogenesis in patients with colorectal adenomas. Ki-67 expression increases with progression of the grade of adenoma while BCL-2 decrease with progression of the grade.
Key words: Colorectal adenoma, Carcinomatous changes, KI-67, BCL-2, Immunohistochemical stain.

Background: In recent years, bone marrow angiogenesis was reported to be involved in the pathogenesis and progression of certain hematological malignancies like multiple myeloma, leukemias, and lymphomas. Recent studies have suggested that bone marrow angiogenesis plays an important role in the pathogenesis and prognosis of multiple myeloma.
Objectives: at the present study, bone marrow angiogenesis in multiple myeloma was examined using immunohistochemical staining for CD34, and correlated with various pathological and clinical parameters.
Patients and methods: This is a retrospective study; where by archival paraffin-embedded tissue blocks along with the clinical and hematological records of fifty-two patients with multiple myeloma and twenty controls were obtained from the Department of Hematology of the Medical City Teaching Laboratories in the period from January 2010 to January 2013. Bone marrow angiogenesis was studied by immunohistochemical staining for CD34 to identify microvessels.
Results: There was a significant association between higher angiogenesis grades and advanced clinical stage of the disease (p = 0.002), and higher plasma cell percent in the bone marrow (p = 0.03), and increasing immaturity of the plasma cell (p = 0.001), and diffuse pattern of bone marrow infiltration by plasma cells (p = 0.007).
Conclusions: Patients with increased plasma cell burden, immature plasma cell morphology, and diffuse pattern of infiltration had a higher microvessel density.
Key words: Multiple myeloma; angiogenesis; CD34

Background: Infertility is a relatively common condition. It can be attributed to factors in a female partner, a male partner, or in both partners. However, certain socio-demographic and life style factors have been linked to female infertility.
Objective: To determine the association between female infertility and selected risk factors.
Patients and Methods: This is a case – control study carried out in Basrah Governorate over a period of ten months, from 1st of January to 31st of October, 2006. Cases were married women who had no pregnancy for at least one year (infertile women), a total of 212 cases were included. The controls were married women who had babies aged less than one year (fertile women); the total number of controls was 213.
Results: the study found that the risk of infertility increases steadily with the increase in age. The risk of female infertility also increased in women with menstrual cycle disturbances (like irregular menstrual cycle length and scanty or heavy menstrual blood loss), women with previous history of abortion, women with previous caesarean section, and in women with previous history of ectopic pregnancy. Infertility was also found to be associated with obesity and with daily caffeine consumption.
Conclusion: the independent risk factors for female infertility were history of previous CS, menstrual cycle disturbance, regular daily caffeine intake and obesity.
Key words: Female infertility, risk factors, Basrah.