Iraqi Postgraduate Medical Journal

BACKGROUND :
Acute renal failure (ARF) is most important condition in pediatric nephrology units with variable causes vary from place to place and peritoneal dialysis(PD) is the easy and feasible modality of treatment for acute renal failure in small and young children and hemodynamically unstable patients were other modalities not suitable for them.
OBJECTIVE:
To stady the aetiology and prognosis of the patients with acute renal that required peritoneal dialysis in ibn al balady hospital.
METHODS:
A retrospective study involved 82 patients with acute renal failure admitted to dialysis in Ibn Al-Balady hospital for a period of 32 months from August 2011 to April 2014 . Data were collected from patients records and involved clinical parameters of the patients, causes of ARF , indications of PD ,complications of PD and the outcome of PD(deaths).
RESULTS :
The study involved 82 children of whom 47(57.3%) male ,with a mean age of 13 +19.5 months . Azotemia was presented in all patients (100%) with oliguria in 60(73.2%) or unuria in 26 pateints (31.7%) , volume overlaod in 32(39%) , encephalopathy in 28 pateints (32.9%). Sepsis was the most common cause of ARF in 32 pateints (39%) while gastroentritis in 16 pateints (19.5%) , glomerulonephritis in 10 pateints (12.2%) and hemolytic uremic syndrome ( HUS) in 9 pateints (11%). Peritonitis is the commenest complication of PD represents 33(40.2%) of pateints. The overall mortality was 32.9 % mostly related to septicemia (63%) and the presence of fluid overlaod, peritonitis,encephalopathy and unuria (66.7,66.7,63 and 59.3% ) respectivly.
CONCLUSION :
Peritoneal dialysis is the preferred modality of renal replacement therapy (RRT) for children with acute renal failure( ARF) because its simple and feasible especially neonates and young infants and hemodynamically unstable patients. Septicemia and severity of ARF are contributory factors to high mortality in pediatric ARF.Early detection and referral of patients at risk is of great value for reducing mortality.

BACKGROUND :
Prompt diagnosis of ectopic pregnancy is a difficult dilemma, and reliable predictors for diagnosis and differentiation of ectopic pregnancy from early pregnancy miscarriage are needed.
OBJECTIVE:
To evaluate the diagnostic value of serum progesterone and CA-125 levels in ectopic pregnancy and early intra uterine miscarriage.
Study design: A prospective case control study
Setting: The study was carried out in the department of obstetrics and gynecology of AL-Yarmouk teaching hospital (Baghdad – Iraq) from February 2011 to February 2012
PATIENTS AND METHODS:
This study was carried out on sixty pregnant women in their first trimester. Twenty women diagnosed as unruptured ectopic pregnancy; treated by laparotomy ,twenty women diagnosed as inevitable miscarriage; treated by curettage and twenty women with healthy pregnancy of a comparable gestational age as control group; follow up of this group was done to ascertain uneventful pregnancy with no complications.
We compared the serum levels of progesterone and CA-125 in all groups at the time of presentation and 24h after surgical intervention in first and second groups.
RESULTS :
There was a significant decrease in mean post operative progesterone level in women with ectopic pregnancy and miscarriage groups with significant difference (P<0.0001). The study observed that the mean level of progesterone in women with ectopic group (6.76±3.63 ng/ml) was lower than that in miscarriage group (15.17±6.01 ng/ml) and control group (17.58±4.57 ng/ml) with significant difference (P<0.0001). This study also observed that the mean level of CA-125 in women with miscarriage group (117.07±94.30 U/ml) was higher than that in ectopic group (38.11±28.79 U/ml) and control group (30.51±16.10 U/ml) with statistically significant difference (P<0.0001).
There was a significant decrease in mean level of post operative CA-125 in women with ectopic pregnancy and miscarriage groups with significant difference (P<0.0003).
CONCLUSION:
Combined measurement of both serum progesterone and CA-125 can be sensitive predictors in diagnosis and differentiation of ectopic pregnancy from inevitable miscarriage and normal pregnancy.

BACKGROUND: : Threatened Miscarriage is vaginal bleeding occurring any time between implantation and 20 weeks gestation , with or without uterine contraction, without dilatation of cervix , and without expulsion of the products of conception Threatened miscarriage tends to be associated with a high likelihood of adverse subsequent pregnancy outcome.
Subchorionic Hematoma is described as the collections with circular or crescent-shaped ecogenity localised between the chorionic membrane and the uterine wall and it has been reported to occur with a varying incidence of 4- 48 %in pregnancies, which experienced vaginal bleeding in early stage.
OBJECTIVE:
To evaluate the association between threatened miscarriage in the presence of subchorionic hematoma in first and second trimester and adverse pregnancy outcome with regard to maternal and neonatal outcome.
PATIENTS AND METHODS:
prospective case control study(follow –up study) done at the Department of obstetrics and gynecology, Baghdad Teaching Hospital, Medical City complex, Baghdad.
60 primigravida women with threatened miscarriage in their first and second trimester were included in the study . . Thirty women had Subchorionic hematoma (SCH) (study group) were matched with thirty women without Subchorionic hematoma (control group). The demographic feature, course of pregnancy, obstetric outcome and neonatal outcome were analyzed.
RESULTS:
Analysis of data show that there is statistically significant difference between both groups regarding maternal and neonatal outcome. There is increasing rate of miscarriage (50%),(p=0.032) and preterm labour in study group ((93.3%), (p=0.046 ), when compared to control group . Regarding neonatal outcome there is increasing rate of very LBW <1.5 kg(26.7%), and LBW <2.5kg (40.0%) (p=0.029) and poor Apgar score in one minute (86.7%) (p=0.015) and five minutes in study group(53.3%)( p=0.002) when compared with control group. Also the study show that there is no statistically significant difference regarding the gestational age. at presentation as threatened miscarriage ,placental site, volume of hematoma, method of delivery and sex of the fetus.
CONCLUSION:
Women with threatened miscarriage who had Subchorionic hematoma are at increased risk for adverse maternal and neonatal outcome.

BACKGROUND:
diagnosis of early pregnancy failure (ectopic pregnancy and missed abortion) still challenging even by using of serial B-HCG and ultrasound. Serum progesterone hormone level value is regarded as one of the important diagnostic tools in the diagnosis of many obstetrical and gynecological conditions; one of these is early pregnancy failure.
OBJECTIVE:
To assess the role of serum progesterone level in early diagnosis of ectopic pregnancy and missed abortion.
PATIENTS AND METHODS:
The study is conducted at Al-Elwiyah Maternity Teaching Hospital throughout the period between (April 2010 –July 2011). Ninety women participated in the study, they are at their early weeks of gestation (6-10) weeks. Their ages were between 18-40 years. thirty of them served as a control group (normal intrauterine pregnancy) and sixty pregnant women included in the study group and subcategorized into 2 groups. thirty women with suspected sub-acute or chronic cases of ectopic pregnancy according to ultrasound and β-HCG results and 30 women served as suspected missed abortion. blood samples were taken from the three groups followed by another blood samples after two-day interval to measure of serum progesterone levels. the results were compared among the three groups at first and second readings. p-value, standard deviation and 95% confidence interval calculated and statistically analyzed.
RESULTS:
P-value of the serial measurements of serum progesterone levels in two-day interval in the three groups was statistically insignificant. while serum progesterone levels of both ectopic pregnancy and missed abortion were greatly lower than serum progesterone levels of normal intrauterine pregnancy in both first and second readings, with statistically significant
deference, P-value is
CONCLUSION:
Serum progesterone levels has a useful role in diagnosing ectopic pregnancy and missed abortion.

BACKGROUND:
The incidence of Lung cancer is increasing rapidly throughout developing countries. Lung cancer is the most commonly occurring cancer in men and the fifth in women.
OBJECTIVE:
To study the demographical and pathological profile of lung cancer among sample of Iraqi patients.
PATIENTS AND METHODS:
A retrospective descriptive study depending on review of records of diagnosed patients during 2006 - 2008.This study was conducted at the Baghdad teaching hospital, Baghdad-Iraq, during a period from 1st March 2012 to 1st January 2013.A total of 284 patients’ records all with proven lung cancer were selected retrospectively, reviewed and checked.
RESULTS:
There were 284 patients recruited in this study, the overall mean age was (62.1 ± 12.8) years and range was (18 – 100) years. Smokers were 232 (81.7%), Non-smokers were 32 (11.3 %) and Ex-smokers were 20 (7%). All cases had cough, almost (93%) chest pain, (88.4%) presented with shortness of breath..
Regarding the types of carcinoma, squamous cell carcinoma was present in 112 patients (39.4%), adenocarcinoma in 96 patients (33.8%), small cell carcinoma in 41 patients (14.5%), while large cell carcinoma in 31 patients (10.9%), and undifferentiated carcinoma was present in 4 patients (1.5%).
Regarding treatment for lung cancer among study groups, it had been noticed that 166 patients (58.5%) were subjected to chemotherapy, 115 patients (40.4%) were subjected to radiotherapy and only 3 patients (1.1%) were treated surgically.
CONCLUSION:
Lung cancer is more common among males and more frequent among those aged 50 years or more. The study demostrate that Sequamous cell carcinoma is the most common type of primary lung cancer in Iraqi patients (39.4%), adenocarcinoma is the second common type (33.8%). The five year survival was very low, only (0.4%) survive for five years after diagnosis, the majority of cases died within two years.

BACK GROUND:
Fibromyalgia is a disorder characterized by widespread musculoskeletal pain, fatigue, sleep and mood disturbances. Its etiology and treatment remain challenging. Oxidative stress may play a role in its pathogenesis.
OBJECTIVE:
The efficacy of pregabalin to that of amitriptyline on FM and the effect of treatment on oxidative status were examined.
METHODS:
123 patients fulfilling the Wolfe 2010 criteria for fibromyalgia diagnosis and assessment were randomized to receive amitriptyline (25 mg) or pregabalin (75 mg) once daily for 12 weeks. The revised fibromyalgia impact questionnaire criteria were also used. Malondialdehide and glutathaion levels were checked at the beginning and at the end of the study.
RESULTS:
Improvement in the pain was better with pregabalin than with amitriptyline (P=0.0001) at 4 weeks of treatment, but achieved comparable improvement at 8 and 12 weeks. The reduction in the somatic symptoms scale was significant for both drugs in favour of pregabalin. Sleep was improved significantly but pregabalin over amitriptyline (P=0.0001). Oxidative status was significantly improved.
CONCLUSION:
Both drugs improved the symptoms. Pregabalin was better than amitriptyline concerning SSS and sleep, but with a comparable effect on pain. Oxidative status was improved. Amitriptyline was better than pregabalin concerning patient compliance and tolerability.

BACKGROUND:
Gastric outlet obstruction is the clinical and pathophysiological consequence of any disease process that produces a mechanical impediment to gastric emptying. It classified into benign and malignant group. Distal gastric cancer form 35% of cases with malignant gastric outlet obstruction.
OBJECTIVE :
To study the causes of malignant gastric obstruction and how to treat them, in addition the application of gastric outlet obstruction score in our patient pre- and post-treatment.
PATIENT AND METHODS:
Between January-2012 to January-2014, a prospective study involves all patients with malignant gastric outlet obstruction in the surgical department in the gastrointestinal and Hepatology teaching hospital.
RESULTS:
A total of 51 cases of malignant gastric outlet obstruction were enrolled in the research, with mean age 53.21 ±14.6 years. There were 30 male patients (58.8%) with male to female ratio = 1.4:1. Non-bilious vomiting was present in (100%) of cases. antropyloric region was found in (47.1%) patients. Regarding GOOS, there were improvement in all patients (p value =0.048). Distal gastrectomy done in 19.6% of patients and gastrojujenostomy performed in 80.3% of patients. Gastric adenocarcinoma found in 15.7%, in 47.05% of patients was found to have metastatic adenocarcinoma.
CONCLUSION:
Gastric outlet obstruction poses diagnostic and therapeutic challenges to general surgeons. In recent years malignant cause become more. Gastric outlet obstruction score has a role in management of patients. Distal gastrectomy is the treatment of choice in resectable cases, while gastrojujenostomy can be used in advanced cases.

BACKGROUND:
Pilonidal sinus is a common disabling disease of young adults involving the sacro- coccygeal area, in the natal cleft , consisting of one or more, usually non-infected, midline openings, which communicate with a fibrous track lined by granulation tissue and containing hair lying loosely within the lumen. Many of the standard surgical procedures are associated with a significant risk both of delayed healing and of recurrent disease.
OBJECTIVE:
The study aimed to comparing the results of excision and packing method with those of lateral approach (Modified Bascom's procedure) in the treatment of sacro - coccygeal pilonidal sinus in regard to the hospital stay, time required for complete healing , time required to return to daily job or activity, early complications (infection, wound hematoma or seroma ) and late complications (scar and recurrence) .
METHODS :
Eighty patients were operated on electively for pilonidal sinus, (62) male, (18) female who underwent elective operations of sacro-coccygeal pilonidal sinus at AL-Karama Teaching Hospital between June 2009 - June 2014 . Two surgical procedures were carried out, excision and packing (40 patients, group A) and modified Bascom's procedure (lateral approach) (40 patients, group B)" Five patients omitted from further follow 'up, two cases related to excision and packing and three of modified Bascom's procedure .
RESULTS :
It has been found that the third decade of life is the most frequent age group at which patient presenting symptoms was discharge (61.2%) and pain (26.2%) although both present in combination in most cases' 75% and 52%) of patients had discharge and pain respectively during the presenting period . The duration of the disease was from one month to two years.
It has been concluded that there was no significant difference in the occurrence of the early complication ( infection , seroma / hematoma) 25% for group A and 37.5% group B, and recurrence rate l0.5 % for group A and 16.2% for group B , thus patients in group B provided a significantly quicker healing time { mean 49 days for group A and 28 days for group B }.
Shorter time - work { mean 47.8 days for group A and 28 days for group B } with better patient convenience (more pain free period), needs only simple oral analgesia , no patient needed hospital admission for pain control no dressing required and less risk of wound break down .
CONCLUSION :
The study had shown that modified Bascom's procedure for pilonidal sinus is safe and feasible as day-care surgery and is associated with potential cost saving.

BACKGROUND:
Intervententional Crush might end high rates of restenosis.
OBJECTIVE:
Studying immediate and late outcome of crush technique in distal left main stem lesion intervention.
PATIENTS AND METHOD:
(40) patient had crush technique intervention method for management of LMS lesions,(15) patients done as primary PCI method, while( 25) patients as elective management.
RESULTS:
A total of 40 patients with distal left main stem lesion included in our study, their age range between 45-75 years with a mean±SD of 59±4.5 years,25 were male,15 female.
One patient died in one year follow up because of noncompliance for medication.
One patient had ISR treated by drug eluted balloon. Two patients lost follow up after 2 months.
25 patients(62.5%)had more than one significant lesion,9 patients (22.5%) had low ejection fraction at time of intervention, functional MR were reported in 5 (12.5%) of patients.
All ischemic chest pain disappeared after interventional procedure.
CONCLUSION:
LMS crush technique is favorable alternative method for the management of LMS especially in patients unable to do CABG.

BACKGROUND:
Multidrug-resistant tuberculosis (MDR-TB) is caused by strains of Mycobacterium tuberculosis resistant to at least isoniazid and rifampicin, the two most effective bactericidal agents currently available for TB treatment.It has emerged as a global public health emergency . It requires treatment with combination therapy consisting of four to six medications for up to 2 years . Additionally, the treatment is generally more toxic and far more expensive than the standardized treatment regimen used to treat drug-susceptible TB . The latest estimates of the World Health Organization (WHO) arrive at 650 000 prevalent MDR-TB cases among the 12 million tuberculosis cases worldwide.
OBJECTIVE:
To identify the Characteristics of multidrug resistance tuberculosis cases attending the specialized center for chest and respiratory disease in Baghdad during the period 9th of September 2012 – 9th of December 2012.
METHODS :
A cross sectional study was done in the specialized center for chest and respiratory disease in Baghdad during the period 9th of September 2012 – 9th of December 2012.Any patient attending the specialized center for chest and respiratory disease in Baghdad during the study period diagnosed as a case of MDR TB was enrolled in this study.
RESULTS:
The sample is composed of 42 MDR-TB patients (29 male and 13 female ) , with age mean of 38.3±12.8 year . Male sex significantly dominates and exceeds two thirds of the sample (69.0%) (P < 0.05). The study find ages between 25-45 year contribute to about two thirds (62.0%) of patients, and ages between 55-65 years constitute about one fifth (19.0%) of the sample. (P < 0.05). Body habit significantly showed that half the sample (50.0%) were underweight and only 10% were overweight or obese (P < 0.05).Smoking is found in 21.4% of total sample.
The duration of taking first line antituberculosis drugs (FLD) before being labeled as MDR-TB varied from 14 to 72 months, with mean duration of 27.3±15.2 months with no significant difference in mean duration between the two sexes (P > 0.05,). Time required to diagnose these cases as MDR-TB varied from 0 to 24 months with mean time of 9.0±6.5 months. There was no significant difference in mean diagnosis time between males and females (P > 0.05). This study found that around one fifth (19.0%) of the sample have a history of default from treatment with FLD. Only one female was significant to be a case of primary MDR-TB (P > 0.05). Two cases (both were males) significantly had history of reaction to FLD treatment (P < 0.05). None of the sample had positive HIV testing.
CONCLUSION:
Most MDR patients in this study were males aged between 25-45 years .Most cases had acquired MDR TB and primary MDR-TB was rare finding in this study. Around one fifth of the sample have a history of default from treatment with FLD.

BACKGROUND:
To prevent posterior subluxation of the tibia and to improve range of motion and stair climbing
ability, total knee prosthesis was modified to the posterior stabilized (PS) one in 1978 and further
modifications followed. The Knee Society in 1989 introduced a rating score for TKA named the
Knee Society Score (KSS), it's widely used and revised in 2012.
OBJECTIVE:
To study the clinical and radiological results of PS/ TKA.
PATIENT AND METHOD:
We prospectively studied 30 patients with PS/TKA. The mean age was 63 years and mean followup was 12 months, 24 knees had osteoarthritis (OA) and 6 knees were rheumatoid (RA). All were
unstable and malaligned. The results assessed using the scoring system of Insall et al. and the KSS.
Postoperative radiological assessment performed using weight-bearing AP and supine lateral
radiographs.
RESULTS:
At last visit, 9 knees (30%) had excellent result, 18 (60%) had good result and 3 (10%) had fair
result. The mean KSS improvement was from 31 points preoperatively to 89 points
postoperatively. The mean ROM (flexion) preoperatively was 68.5o improved postoperatively to
106o. Postoperatively all knees were stable in AP direction only 4 (13.3%) had mild lateral
instability. The ideal position for femoral component within (6-10o) valgus was obtained in 24
knees (80%), it was within (0-5o) valgus in 6 knees (20%). In 93% (28 knees) the tibial component
were within 2o of varus or valgus, 6.6% (2 knees) was in greater than 2o varus. Knee function score
improved from a mean 27.5 points preoperatively to 58 points postoperatively and patients were
able to walk more than 500 meters.
CONCLUSION:
PS/TKA increases range of motion, increases joint stability and improved gait. Both OA and RA
patients responded well to its use with nearly same end results. We strongly recommend the use of
PS/TKA for primary total knee replacement.

BACKGROUND:
Breast reduction for mammary hypertrophy is a highly effective procedure with high degree of patient
satisfaction. There are many methods of breast reduction which involve removal of excess tissue with
reshaping of overlying skin while maintaining a viable nipple areolar complex.
OBJECTIVE:
The purpose of this study is to evaluate the use of the superomedial technique as an effective method
for reduction mammoplasty.
PATIENTS AND METHODS:
A total of 30 patients underwent reduction mammoplasty by utilizing superomedial pedicle technique
between 2010 and 2013. Those patients were evaluated postoperatively in terms of their aesthetic and
functional satisfaction, viability of nipple – areolar complex and nipple sensory preservation.
RESULTS:
The distance from suprasternal notch to nipple ranged 28-32cm on both breasts. The mean breast tissue
resection was less than 1000 g on both breasts, the amount of nipple transposition ranged from 8cm –
10cm. All patients were satisfied with postoperative results. All patients had viable nipple, except in
one breast who had partial nipple – areolar complex necrosis (1.6%). nipple areolar sensation was
preserved in 93.3% in the immediate postoperative period, and after 6 month all patient had preserved
nipple areolar sensation.
CONCLUSION:
The superomedial pedicle technique for reduction mammaplasty is simple and safe procedure with good
postoperative aesthetic results.

BACKGROUND:
The diagnosis of tuberculous uveitis is often presumptive, because of the difficulty in obtaining
microbiological evidence. The diagnosis has to rely on characteristic ocular findings, and possibly a
therapeutic treatment trial.
OBJECTIVE:
To illustrate the mode of presentations and management of presumed tuberculous uveitis at a referral
eye center in Iraq.
METHOD AND SUBJECTS:
This prospective case series study included patients with presumed ocular tuberculosis presented
consecutively at uveitis clinic/ Ibn Al-Haetham teaching eye hospital, from January 2007-January 2013.
Ocular tuberculosis was presumed when findings were consistent with possible intraocular tuberculosis,
intractable to steroid therapy, and no clinical or laboratory evidence for other causes of uveitis. Strongly
positive tuberculin skin test result (more than14 mm area of induration/necrosis) supported the
diagnosis, but was not a prerequisite for initiating therapy. All patients were treated with anti
tuberculosis therapy. Clinical findings and response on treatment were documented in a special follow
up cards.
RESULTS:
64 patients with presumed TB uveitis were included in this study. Mean age of the patients was 35.7
years with no significant sex predominance. Majority of patients were from urban places (79.7%).
Bilateral involvement was recorded in 62 patients. Vitritis was a universal finding, while multifocal
choroiditis was the most common fundus lesions (104 eyes; 82.5%).
All patients responded well to anti tuberculosis therapy. Systemic corticosteroids were added after few
days in 14 patients to decrease inflammatory reaction, retinal vasculitis, macular edema and macular
scaring.
CONCLUSION:
According to this study; vitritis with multifocal choroiditis is the most common mode of presentation in
patients with presumed TB uveitis. All cases responded well to anti-tuberculosis therapy, systemic
corticosteroids can be added to decrease inflammatory reaction, retinal vasculitis, macular edema and
macular scaring.

BACKGROUND:
Obesity is a complex metabolic disorder with significant health and economic consequences due to
related co- morbid conditions, including diabetes, cardiovascular disease, and certain cancers, and
increased mortality. So when body mass index increase mortality increase.
OBJECTIVE:
Asses and study the result of operations of obesity associated with malabsorption operations to
measure the body mass index more than sixty and To prove the benefit of this type of bariatric
surgery in weight loss within short period and its benefit in decreasing co-morbidity.
PATIENTS AND METHODS :
A retrospective study conducted in Baghdad Teaching Hospital and Dijla Private Hospital from
June 2011 to June 2012 where the follow-up of eleven patients admitted to surgical ward and
underwent the operation of Biliopancreatic diversion,Doudenal switch and Sleeve gastrectomy
were analyzed the enhance people with diseases and postoperative diseases and complication. All
patients were given nutritive instructions three months prior to surgery which was rich in vitamines
and low fat.
RESULTS:
from the analysis of the results we found a rapid decline in body weight as well as theBody mass
index,where in the 1st 3months BMI dropped of about 22%,after 6 months BMI dropped 39% and
dropped more than 50% after 12 months. Also this study show clear and significant improvement
in treatment of sleep problems,DM,and HPT.
CONCLUSION:
operation of this type is important for weight loss in morbidly obese patients in addition to high
and noticeable improvement in association comorbid diseases.

BACKGROUND:
Percutaneous nephrolithotomy (PCNL) mean extraction of renal calculi through nephrostomy
tracts placed percutaneously ,it was reported in the early 1970s. Percutaneous nephrolithotomy is
widely accepted, more safe and effective treatment modality and it is the procedure of choice for
removing large, complex, and/or multiple renal PCNL has lower morbidity and postoperative
patient discomfort.
OBJECTIVE:
To evaluate the initial experience of PCNL in al jumhoori teaching hospital, taking 21 patients with
renal stones of different sizes ,with it is complications.
METHODS:
Between May 2012 and July 2013 a case series study was applied in AL- Jumhori Teaching
Hospital, PCNL was used in 21 patients (Mean age was 55 years, ranging between 16-63 years, 15
men and 6 women) while only one child of 8 year old was enrolled. All cases have renal stone of
different size varied from (21mm-60 mm). Preoperative evaluation included , history, clinical
examination and routine labarotory investigation, all patients had intravenous urography( IVU),
some of them have non contrast or enhanced CT scan of urinary tract to evaluate the cortical thick
-ness of the kidney, anatomical abnormalities, stone location, burden and radiolucency of the
stone. All patients submitted to PCNL in AL-Jumhoori teach ing hospital ,under general anesthesia
in prone position, subcostal approach, using fluoroscopic guidance(c-arm.),and irrigation fluid
(0.9% N.S.) at body tempreture was used . Steps of PCNL include(1) Ureteric and urethral
catheterisation (supine)(2) Percutaneous renal access in the posterior axillary line ,guide wire must
always be in place to maintain access and to get (3) Tract dilatation .A track has been dilated and a
34 F working sheath is being advanced over a 30F metal dilator. Tracts can be dilated with either
metalic, telescopic, plastic or balloon dilators. Balloon dilatation is quicker and perhaps less
traumatic(4) Endoscopic stone fragment extraction (rigid-flexible endoscopy)(5) Post-extraction
drainage (nephrostomy, ureteric catheter or tubeless)(6) Wound dressing and care.
RESULT:
The mean age was (55 years), with a male to female ratio of 2.5:1. The stone burden varied from
21-60mm most of them were radio-opaque (85.7%). The range of operative time varied from 75-
200 minutes with a mean of 120 minutes, including cystoscopic and stenting procedure. The
duration of exposure to radiation was ranging from 1.1minutes - 4.5minutes, with a mean of 2.1
minutes. The mean ±SD value of irrigant fluid was19.00±3.98 liters ranging from 12 -25 liters. In
the present study the clearance rate was 76%, where 16 patients out of 21 had complete clearance
together with stone < 5 mm. In 5 patients (24%) ESWL sessions were needed since they were
already have staghorn calculus > 3cm or renopelvic plus multiple stones. The clearance rate for
staghorn (62%), non staghorn calculus varied between 75% - 100% .
Tow months later all patients except 2 became stone free;(one of them had multiple stone resist
ESWL and other one had duplex of pelvicalyseal system and his residual stone was located in the
upper mieoty) both of them probably need second PCNL. The range of hospital stay was 1-5 days,
with a mean of 2.2 days. Nephrostomy tube were removed on 1st, 2nd or even 3rd post operative day.
All patients had double J (DJ) placement except 3 patients who regarded as tubeless PCNL.
CONCLUSION:
With the development of new devices for renal access, lithotripsy and renal drainage systems the
procedure PCNL has become the first choice treatment modality for renal stones larger than 1.5 cm
by the urologists worldwide. To avoid complications during the procedure and to gain successful
outcomes after the procedure, proper patient selection, maintenance of available instruments,
training and experience of the surgeon are critical.

BACKGROUND:
Clopidogrel, an adenosine diphosphate receptor blocker, is widely used as an adjunctive antiplatelet
therapy in coronary disease and percutaneous coronary stenting. It appears to be a safe drug with few
occurrences of liver side-effects that usually resolved after drug withdrawal.
OBJECTIVE:
The goal of this study was to investigate whether the co-administration of atorvastatin could
aggravate the hepatic - toxicity of clopidogrel.
PATIENTS AND METHODS:
Eighty patients with coronary disease were included in this study. All patients received a dose of 75
mg/day of clopidogrel. Forty patients group A with recent treatment (˂ 3 months) of clopidogrel;
other forty patients group B with (˃ 1 year) treatment of clopidogrel. Liver function tests were
measured and studied at baseline (clopidogrel without atorvastatin) and at 2, 4, 6 weeks of
clopidogrel with atorvastatin (40 mg/day) afterwards.
RESULTS:
Liver function tests with co-therapy showed high significant elevation in mean serum total alkaline
phosphatase (P˂0.001), significant decrease (P˂ 0.05) in mean serum gamma-glutamyl transferase
,significant elevation (P˂ 0.05) in mean serum direct bilirubin and insignificant elevation (P˃0.05)
in mean serum total bilirubin , whereas the results appeared within normal range in mean serum
levels of alanine aminotransferase, aspartate aminotransferase ,glutamate dehydrogenase -1,and total
protein .
CONCLUSION:
Combination of atorvastatin and clopidogrel may induce hepatic injury cholestatic type resulting
from abnormal bile flow caused by either drugs or its metabolites.

BACKGROUND:
Assessment of left ventricular function and volumes provides valuable information in patients with
heart disease. It is also considered a prognostic marker in coronary artery disease. Two- dimensional
transthoracic echocardiography is the most widely used method for Left Ventricular function
assessment, but this modality is operator dependent and can be impaired by a poor acoustic window.
OBJECTIVE:
To validate a single tertiary center experience in Multi Detector Computed Tomography for the
evaluation of cardiac function in patients undergoing coronary CT angiography.
PATIENTS AND METHODS:
A cross sectional study, conducted at Ibn Albitar center from September 2012 till May 2013. Patients
included are those who already underwent 64-slice CT coronary angiography to evaluate known or
suspected coronary artery disease, CT coronary angiography is performed using a 64- slice Multi
Detector CT-scanner. Transthoracic Echocardiography was done by a single operator served as the
reference standard.
RESULTS:
Eighty patients (66.3% male) were included in the study, the mean age was 53.19 ± 10.6 years. The
mean Left ventricular End Diastolic Volume by Cardiac CT and Echocardiography were 125.31 ±
41.92, 126.75 ± 41.894 ml respectively, with excellent correlation (r =0.912; P< 0.001). Average Left
ventricular End Systolic Volume (LVESV) by Cardiac CT and Echocardiography were 58.08 ± 34.18,
53.74 ± 33.15 mL respectively^ With Excellent correlation coefficient (r = 0.971; P0.001), with trends
towards CT showing slightly higher values than that of Echocardiography.
Average Left ventricular Ejection Fraction was 55.40 ± 14.57% as determined by Cardiac CT,
compared to 59.26 ± 9.8% by Echocardiography, with good correlation between the two methods (r =
0.734; P=0.01), although LVEF was slightly underestimated by Cardiac CT (3.86 ± 9.9%; P0.001).
CONCLUSION:
The current study showed that (our experience in the) assessment of cardiac function by CT is
comparable to the commonly used 2D Echocardiography method. And can be used in patients already
performing coronary CT angiography, (potentially for those in whom the images from TTE are
inadequate. ^w j.

BACKGROUND:
Treatment of a number of complications that occur after abdominal trauma surgeries may require
that Urgent Abdominal Re-explorations, the life-saving and obligatory operations, are performed.
OBJECTIVE:
To evaluate the reasons and incidence of re-operations in abdominal trauma cases and their
outcomes in our centre, so that more preventable morbidity can be avoided.
METHODOLOGY:
A retrospective study of all trauma victims who sustained laparatomies and relaparatomies in the
Emergency Department of Al-Imamain Al-kadhymain Medical City, Baghdad, over a 2 years
period. A review of the case sheets of these victims has been reviewed to identify the various
circumstances of trauma cases and the detailed operative findings and definitive causes of
relaparatomies were noted.
RESULTS:
The study included 21 relaparatomy cases out of 244 laparatomy for various abdominal trauma
reasons ; 180 patients (74%) males and 64 (26%) females, with a male to female ratio of about
(3:1). The commonest causative accidents were missile inury 97pt (39%), gunshot injuries 58
(24%), road traffic accidents 43pt (18%), stab wound 32 pt(13%), and. Fall from height 14 pts
(6%) . Reoperations were performed in 21 cases Incidence (8.6%), finding in reoperation including
second look operation (which constituted 4 patients) were as the followings:
Bleeding 11 pts ( 52%), peritonitis from missed bowel injuries & anastomosis leak 5 pts (24% ),
small bowel obstruction one pt (5%), IAC(abscess) 2pt (9.5%) and prolonged ileus & peritonism 2
Pts (9.5%).
Overall mortality in the reexplored patients was 8 patients(38%). Incidence of missed injuries 24%
of reoperation and 1.6% of total trauma cases.
CONCLUSION:
many pt can be saved from repeat laparatomy by avoiding missed injuries. The main reason for
immediate reoperation is bleeding and lately is peritonitis and sepsis.

BACKGROUND :
Fine-needle aspiration (FNA) is a rapid, safe, minimally invasive, and inexpensive way of
diagnosing malignancy in women with palpable breast tumors.
This study was used the wide bore needle technique to obtain optimal results & can used instead of
core needle biopsy .
OBJECTIVE:
Fine-needle aspiration cytology is a rapid, safe, inexpensive and minimally invasive technique for
diagnosis of breast malignancy. This study was an attempt to use wide bore needle instead of core
needle biopsy to obtain optimal results.
METHOD:
Thirty five females with breast lumps underwent FNA aspiration cytology in the department of Aljamhuri Teaching Hospital in Mosul city. The study was achieved by using 19 gauged needle, part
as routine cytology and other part as tissue block. Immunohistochemical stain for ER, PR and
HER2 markers was performed on tissue blocks from 17 malignant cases.
RESULTS:
The cytology findings included 24 malignant cases (22 ductal carcinoma and 2 lobular carcinoma),
7 benign lesions and 4 suspicious cases. On the other hand, in tissue blocks the diagnosis of
malignancy was given in 28 cases, 25 ductal carcinomas and 3 lobular carcinomas. Seven benign
lesions ,6 were previously diagnosed as such by cytology and one suspicious case turned to be
benign on wide bore needle. The four cytologically suspicious cases turned to be malignant in 3
cases and benign fibrocystic changes in the fourth case. Immunohistochemical analysis including
ER, PR and HER-2 on seventeen cases of breast carcinomas. Seven out of 17 were shown
positivity for ER while 3 cases were PR positive and Her2-neu was positive in 12 cases.
CONCLUSION:
It is preferred to use wide bore needle in the diagnosis of breast lesions to obtain more tissue
material and optimal results. As well, to a certain extent the wide bore needle might substitute the
core needle biopsy for diagnosis and immunohistochemical assessment because the latter is rather
expensive and, at time is not available in our laboratories now.

BACKGROUND:
Vesical stones in children are common in developing countries. Historically, open
cystolithotomy has been the treatment of choice in the management of bladder calculi. Recently
there are different treatmrnt of vesical stones like Transurethral Holmium laser cystolithotripsy
and Percutaneous cystolithotripsy.
OBJECTIVE:
To Compare between transurethral Holmium :YAG laser cystolithotripsy and percutaneous
suprapubic cystolithotomy in the management of bladder stones in children.
PATIENTS AND METHODS :
A total of 33 children (31 boys and 2 girls) with vesical stones were treated at Urology
Department of Al-Sadder Medical City in Najaf between January 2013 and June 2014 . Mean
patient age at the time of diagnosis was 4.2 years (range 8 months to 10 years). The patients
were divided into 2 groups according to the procedure of stone removal. Group 1 (15 patients)
underwent percutanous suprapubic cystolithotomy and group 2 (18 patients) underwent
transurethral Holmium :YAG laser cystolithotripsy. Stone size ranged from 7 to 25 mm (mean
16.2mm).
RESULTS:
Operative time ranged from 10 to 25 minutes (mean 18 minutes) in percutanous suprapubic
cystolithotomy (group 1) and was ranged from 15 to 70 minutes (mean 30 minutes) in
transurethral Holmium :YAG laser cystolithotripsy (group 2). The day of catheter removal was
24 to 96 hours (mean 36 hours) in group 1, while it range 0 to 48 hours (mean 8 hours) in group
2. The hospital stay was shorter after transurethral Holmium :YAG laser compared to
percutanous suprapubic cystolithotomy (30 vs. 72 hours). No significant intraoperative or
postoperative complication was encountered except prolong urinary leak in two patients (13.3)
in group 1 and transient mild haematuria in three children (16.6%) and low grade fever in two
children (11%) in group 2. In all cases (100%) the stones were removed successfully in first
session in group 1 while one patient (5.5%) need second session due to residual small stone in
group 2.
CONCLUSION:
Transurethral Holmium :YAG laser and percutanous suprapubic cystolithotomy management of
vesical stones in children are efficient, with a low incidence of complications. Transurethral
Holmium :YAG laser offers a shorter hospital stay and urethral catheterization but longer
operative time compared to percutanous suprapubic cystolithotomy.

BACKGROUND:
Tribulus terrestris has been commonly used in folk medicine to energize, vitalize and improve sexual
function and physical performance in men and laboratory rats.
OBJECTIVE:
To study the effect of Tribulus terrestris on the number of Leydig cells.
MATERIALS AND METHODS:
Tribulus terrestris was given to mature male rats as an oral single herbal suspension in a dose of
2.0mg /1000gbody weight for 14 days to stimulate spermatogenesis. Formalin fixed paraffinembedded tissue sections were performed for histological, immunohistochemical and morphometrical
studies.
RESULTS:
Histological study revealed wider seminiferous tubules and increased spermatocytes population with
an increased sperm density inside the lumen of the tubules. Morphometrically, the diameters of
seminiferous tubules and thickness of the germinal epithelia were significantly increased in Tribulus
terrestris treated rats than that of the control group. There was no significant difference between the
number of Leydig cells in the control and experimental groups.
CONCLUSION:
The activity of Leydig cells, manifested by the increments in the diameters, thickness of germinal
epithelia and the density of the sperms inside seminiferous tubules, was increased but their number
remain unaffected in spite of using the aphrodisiac agent, Tribulus terrestris.

BACKGROUND :
Health information systems in most countries are inadequate in providing the needed management
support and the current health information systems are therefore widely seen as management
obstacles rather than as tools.
OBJECTIVE:
The current study is an attempt to assess Health information system performance in Iraq.
METHODS:
A cross-sectional study was conducted with a total of seven districts selected from six Iraqi
governorates by simple random sampling , and a total of twenty six health centers were selected
from the seven districts, also by simple random sampling. The performance Diagnostic tool was
used to measure Health information system performance, it is one of the PRISM package tools that
are used to assess the Health information system performance.
RESULTS:
The data accuracy at the facilities was 29.03%, while at the districts was 55.35%, the completeness
rate at the facility level was 96.38% and at the district level was 98.23%. For that of the timeliness,
the results revealed 70.43% timeliness at the district level; the information use for a given
feedback at the facility was 50% and at the district was 82.12% and for observed meeting records
it was 41.6% for the facility and 50% for the district level.
CONCLUSION:
Health information system has a low data quality in the form of accuracy at the facility and district
levels. The timeliness is relatively weak at the district level, while it is good in the form of
completeness at both facility and district level; on the other hand information use at the district
level was better than that of the facility level.

BACKGROUND:
Post stroke depression is a common neuropsychiatric consequence of stroke. Some studies show
that left hemisphere lesions may be associated with a higher incidence of depression. Others found
no significant correlation between lesion location and depressive alterations after stroke.
OBJECTIVE:
To determine whether post stroke depression is correlated with the site of stroke lesion and to
evaluate other determinants for the development of depression post stroke.
METHODOLOGY :
A cross sectional study was conducted at Baghdad teaching hospital on 50 patients with single
demarcated unilateral lesions was selected according to CT scan of the brain, psychiatric
assessment were performed to assess the presence of depression according to DSM-IV criteria. The
severity of functional impairment of all patients was performed on the modified Rankin scale
(mRS).
RESULTS :
The study showed that 54% of stroke patients were depressed and 46% of them had no depression.
Patients with higher functional impairment score were more likely to have depression rather than
those with lower score. No significant association had been found between depression with all
other variables including site of stroke lesion.
CONCLUSION:
There is no correlation between the sites of stroke lesion and post stroke depression in patients with
stroke.

Choledochocele is a congenital cystic dilatation
of the terminal portion of the common bile duct,
which classified as type III choledochal cyst.
We present a patient with large choledochocele
which is 6cm in diameter treated by
transduodenal excision of the cyst with
sphincteroplasty; this case report is one of the
largest reported cases of choledochocele in the
literature.
INTRODUCTION:
A choledochocele is a cystic dilation of the distal,
intramural portion of the common bile duct,
typically protruding into the descending
duodenum. It is classified as a type III
choledochal cyst according to the system
originally presented by Alonso-Lej et al. (1).
Todani and colleagues expanded this system in
1977 to include the occurrence of the
intrahepatic and the multiple cysts, and this
modified classification is now most commonly
used by clinicians. (2)
Choledochoceles are seen in about 1.5% of
congenital choledochal cysts. (3)
Different from type I choledochal cyst,
choledochocele anomaly was not generally
regarded as being associated with abnormal
arrangement of the pancreatobiliary ductal
system or biliary malignancy, but recently, there
have been some reports of patients with
choledochocele associated with biliary
malignancy, (4,5) as well such patients with high
levels of amylase in bile. The possibility of
choledochocele as a high-risk state for biliary
malignancy is gaining interest