Iraqi Postgraduate Medical Journal

BACKGROUND:
Traditionally, most of anesthesiologists in Iraq evaluate the degree of neuromuscular blockade
during and after anesthesia using clinical criteria alone, which are inaccurate to assess adequate
recovery from neuromuscular block (NMB) which is essential for the patient to have full control of
pharyngeal and respiratory muscles. Fade cannot be detected reliably with a peripheral nerve
stimulator (PNS) at a TOF ratio > 0.4. The time gap between losses of visual fade by using a PNS
until objective TOF ratio has returned to > 0.90 can be considered “the potentially unsafe period of
recovery.”
OBJECTIVE:
To compare between assessment of subjective clinical, subjective TOF by peripheral nerve
stimulation (PNS), and objective TOF by acceleromyography (AMG) before reversal of
neuromuscular blockade
PATIENT AND METHOD:
A prospective clinical trial of one hundred females who underwent caesarian section under general
anesthesia. Standard anesthesia was conducted for all patients. Giving of neuromuscular reversal
was decided by the anesthesia care providers depending on clinical criteria, at that time, TOF
measured by 2 ways, 1st: counting the twitches visually (principal of PNS), and 2nd: the device
showing the TOF reading objectively (principal of AMG).
RESULT:
Comparisons between subjective criteria and objective AMG T4\T1 ratios revealed no statistical
significance (P > 0.05) in all comparisons (except that with the moving limb and lift the head). The
association and consistency of subjective criteria and visual PNS was insignificant differences in
all comparisons. There was wide discrepancy between objective reading and the visual PNS.
CONCLUSION:
The moving limbs and sustained lift head 5 seconds clinical criteria were correlated to TOF. Other
criteria (protruding tongue, respiratory effort, and swallowing reflex) were not correlated to TOF.
Objective AMG more sensitive to detect the fourth twitch than the subjective PNS.

BACKGROUND:
Multiple sclerosis (MS) is an autoimmune disease caused by a complex disorder that cluster many
common diseases in children and adults, leading to chronic inflammatory disease of the central nervous
system with morphological hallmarks of inflammation, demylination, axonal loss and gliosis .Factors
responsible for MS and its progression are still not fully understood, but it has been suggested that both
environmental determinants and genetic susceptibility are involved.
OBJECTIVE :
The aim of this study is to evaluate the role of inflammatory markers ;hs-CRP and IL-8 in pathogenesis
of MS and to see the correlation between them.
PATIENTS AND METHODS:
Twenty one MS Patients (7male,14 female) attending the MS Clinic at Baghdad teaching hospital,
their ages range between( 20-32) years (15) age- and sex- matched healthy control participated in the
study. Investigations included serum measurements of high sensitive C-reactive protein (hs- CRP) and
interleukin-8 in patients and control groups.
RESULTS:
The result of the present study showed significant increase in both CRP(p<0.001 ) and IL-8 (p< 0.001 )
in the serum of MS patients compared to control.
CONCLUSION:
There is evidence that neuroinflammatory process due to elevation of CRP and IL-8 has an important
role in MS .

BACKGROUND :
migraine is a recurring syndrome of headache, nausea, vomiting, and/or other symptoms of
neurological dysfunction in varying admixtures. Migraine, is one of the most common causes of
headache, afflicts approximately 15% of women and 6% of men.
OBJECTIVE:
This study was designed to determine the EEG changes in a sample of migraineurs with their relation to
its types.
PATIENTS AND METHODS:
This cross-sectional study was conducted in the department of neurology of Baghdad teaching
hospital from December 2007 to February 2008. A total of 60 migraineurs were taken, aging (10-
40) years, diagnosed according to International headache society (IHS) criteria. Patients with history
of epilepsy, head injury, brain lesion and recurrent headaches not Compatible with IHS criteria
were excluded from the study . EEG was performed, whenever possible, during headache and between
attacks of headache.
RESULTS:
Sixty Iraqi patients with migraine were evaluated. Twenty patients (33.3%) were having migraine with
aura (MWA) while 40 patients (66.7%) had migraine without aura (MWOA). Of the sixty studied
patients 15 were having electroencephalographic finding. Among patients with MWA, 8 of them have
abnormal EEG (40%), while in patients with MWOA, 7 of them have abnormal EEG (17.5%). Slow
waves were found in 10 patients (52.64%), sharp waves in 8 (42.10%), and spikes in one patient
(5.26%). It has been found that 9 patients (50%) have abnormality in occipital region, 6 of them
(33.34%) in frontal region, and 3 of them (16.66%) in temporal region.
CONCLUSION:
EEG is not useful as a diagnostic tool for migraine, as the EEG changes found in migraine are not
specific, they are infrequently associated, and there is no EEG difference between MWA and MWOA.
So, clinical criteria are the only way for diagnosis of migraine.

BACKGROUND:
Diabetes mellitus (DM) has been shown to be associated with oral manifestations and abnormalities in
the metabolism of micronutrients, especially copper, zinc, and magnesium.
OBJECTIVE:
To study the oral manifestations in type 2 diabetic patients and to estimate trace elements levels such as
copper (Cu), zinc (Zn), and magnesium (Mg) in those patients comparing to control group.
PATIENTS AND METHODS:
A total of 30 diabetic patients were studied for their oral manifestations and trace elements levels
including serum copper, zinc, and magnesium; their age range was (40-55) years and compared with 30
healthy controls.
RESULTS:
There was a significant decrease in serum Cu, Zn, and Mg in DM patients as compared with their
controls, (P < 0.05). Also, several oral complications are seen among diabetics.
CONCLUSION:
It can be concluded that several oral complications are seen in diabetic patients. The deficiency of some
essential trace metals such as Cu, Zn, and Mg may play a role in the development of diabetes.

BACKGROUND:
Diabetic nephropathy (DN) is the leading cause of CKD and end-stage renal disease (ESRD). CKD is
characterized by a progressive loss of renal function, chronic inflammation
OBJECTIVE:
To compare the relationship between the anti –DNA Abs in diabetic patients type 1 and type 2 and their
relation with chronic renal failure.
METHODE:
The ELISA methods was used to detect the presence of anti-DNA –Abs in sera of diabetic patients with
type 1 and type 2 D.M. with CRF.
RESULT:
The concentration of anti-DNA Abs. were more in type II D.M. patients with CRF than those with type I
D.M. without CRF and control group.
CONCLUSION:
The anti-DNA Abs. play an important role in the CRF in patients with long duration of D.M. type
II ,while in patients with short duration of D.M. type I , anti-DNA Abs. do not play a role.

BACKGROUND:
On June, 22nd, 2013, Communicable Disease Control Center (CDCC) in Baghdad notified on an
outbreak of Food Poisoning (FP) involving more than 100 persons attending a restaurant in Tikrit City,
Salah Al Din province on21st, June.
OBJECTIVE:
to identify source, and causative agents of the outbreak.
PATIENTS AND METHODS:
A case seeries study conducted on accessed cases in Tikrit and Sala Al Din hospitals. Information on
basic, clinical and food item consumed were collected using a questionnaire. Environmental assessment
of the restaurant using a standardized checklist and bacteriology testing of food samples, patients’ stool
specimens and different specimens from food handlers were conducted.
RESULTS:
A total of 214 persons who attended the restaurant sought medical care for acute gastroenteritis; 82
(38.3%) were admitted. Only 175 patients (including 11 affected food handlers) were accessed. Main
symptoms were diarrhea (92.5%), nausea (87.5%), and vomiting (84.5%). Apart of one death, all other
patients recovered completely. 32% of patients’ stool samples were positive for Salmonella
typhimurium, and 30% of food specimens were positive for Staphylococcus aureus, and 10% for
coliform bacteria; 13 food handlers were examined and specimens of blood, urine; and stool, and under
the finger nail swabs, were negative. Health inspection of the restaurant revealed unhygienic food
processing and poor personal hygiene of food handlers.
CONCLUSION:
Staphylococcus aureus and Salmonella typhimurium were the responsible pathogens. Contaminated
food stuff and unhygenic foodhandlers practices were the source. Strengthening the role of health
inspection, and upgrading local laboratory capacity were recommended.

BACKGROUND :
Acute myocardial infarction ( AMI ) is an important clinical condition which is associated with a
significant inflammatory changes that result in acute-phase responses. Significantly elevated
concentrations of cytokines and other acute phase reactants are the major events that accompanied
such condition. Our aim was to evaluate certain acute phase reactants : Interleukin-6 ( IL-6 ) , CReactive Protein ( CRP ) and plasma fibrinogen in patients with AMI.
OBJECTIVE:
This study was focused on the evaluation of certain acute phase reactants : Interleukin-6 ( IL-6 ) ,
C-Reactive Protein ( CRP ) and plasma fibrinogen in patients with AMI.
PATIENTS AND METHODS:
Thirty patients from Baghdad city with AMI were included between July 2011 and January 2012 : 21
males and 9 females, their ages range between 40 – 73 years. Thirty healthy subjects ( 16 males, 14
females ), age matched with patients as a comparative group were included. Both groups were
investigated for IL-6 , CRP , and plasma fibrinogen levels.
RESULTS :
IL-6 concentrations were found to be significantly higher with ( P value : 0.0001 ) –table 1- in
patients with AMI) than in control subjects. CRP concentrations were also found to be significantly
higher with ( P value : 0.0001 ) in patients with AMI than in control subjects. plasma fibrinogen level
was significantly higher with ( P value : 0.0001 ) in patients with AMI than in control subjects.
CONCLUSION :
The study revealed a significant elevation in IL-6 , CRP concentrations and plasma fibrinogen level
in patients with AMI.

BACKGROUND:
Tuberculosis control in the world today must face the challenge posed by the global spread of
Mycobacterium tuberculosis strains that are resistant to standard anti-TB drugs.
OBJECTIVE:
This study was done to identify the drug resistance to the first line antituberculosis drugs in Iraqi
Patients.
METHODS:
This prospective study conducted in National Center for Tuberculosis and Chest Diseases in Baghdad
from January 2012 to August 2012.For study the demographic characters and drug sensitivity test
(DST) in a total number of 155 case of sputum smear positive pulmonary tuberculosis (97 old and58
New) For each patient 3 consecutive sputum samples were taken for direct smear microscopy and
cultured to test drug resistance for First Line anti-TB drugs (INH, Rifampicin ,Ethambutol and
pyrazinamide).
RESULTS:
In this study we found ethambutol resistant in 20(34.5%)of samples in the new group and in 49(50.5%)
of samples in old group. On the other hand,our study showed that resistance to rifampicin in the new
group was 58.6% while in the old group was 75.3%. In regard to the INH drug resistance it seen in
72.4% of samples in new group and in 83.5% of samples in old group.This study showed that reistance
to streptomycin present in 44.8% of new group samples and in 55.7% of old group samples .The pattern
of drug resistance according to patient group show high frequency of polyresistance 82 cases in both
patient group(new and old) and low frequency in other group of resistance 14 cases,and MDR type of
resistance in total of 17 cases .
CONCLUSION:
The study showed 11%(17/155) of patients with pulmonary tuberculosis in this sample of patients had
multidrug resistance MDR tuberculosis .

BACKGROUND:
Osteoarthritis is a degenerative joint disease, occurring primarily in older persons. Although many
factors initiate this disease, progress to overt OA needs many biological substances like IL-6 and
IL-8 that reduce cartilage repair ability or like reactive species that induce cartilage destruction
through direct degradation of matrix components.
OBJECTIVE:
To shed the light on the expression of serum IL-6 and IL-8 levels, and production of serum
malondialdehyde level (marker of oxidative stress), then estimation of the correlation among serum
IL-6, IL-8 and MDA levels in patients with knee osteoarthritis.
PATIENTS AND METHODS:
This study was conducted in AL-Kadhemiya Teaching Hospital during the period from April 2011
to December 2011. The study included two groups: knee osteoarthritis( KOA) group of patients
and the control group. Each group was further sub-divided into: obese & non-obese according to
their BMIs. Sixty osteoarthritic patients aged 40-70 years were chosen depending on medical
history, clinical examination, and radiographic observations. 10 ml of blood needed for assessment
of the above makers. Thirty healthy control (age and sex-matched) were enrolled in this study.
RESULTS:
Mean serum IL-6 and IL-8 levels were significantly higher in KOA patients compared to control
group for both (P<0.001), with the highest levels seen in the obese KOA group. Mean serum MDA
level was significantly higher in patients with KOA compared with that in control (P<0.001).
Significant negative correlation was observed between serum IL-6 and IL-8 levels.
CONCLUSION:
IL-6, IL-8 & MDA have important role in the pathogenesis of KOA. Receptors of IL-6 and IL-8 on
chondrocytes could be considered as target for future therapy of any arthritic inflammation and also
to consider MDA reduction in patients with knee osteoarthritis, as part of treatment of
osteoarthritis.

BACKGROUND:
Preterm labour is a major cause of perinatal morbidity and mortality, so it is important to predict preterm
delivery using the clinical examination of the cervix and uterine contraction frequency. New markers for
the prediction of preterm birth have been developed such as transvaginal ultrasound measurement of
cervical length as this method is widely available.
OBJECTIVE:
To determine, whether transvaginal cervical length measurement predicts imminent preterm delivery
better than digital cervical length measurement in women presented with preterm labour and intact
membranes.
PATIENTS AND METHODS:
Two hundred women presented with preterm labour between 24 and 36+6 weeks of gestation were
included in this study. All women subjected for digital and transvaginal ultrasound cervical length
measurement and the outcome measures were occurrence of preterm delivery within 48 hours and within
7 days.
RESULTS:
Assessment of cervical length measurement using transvaginal ultrasound for the 200 women presented
with preterm labour with intact membrane revealed that 8 (4%) delivered within 48 hours and 16 (8%)
delivered within 7 days. According to the Bishop score, the test was positive if the Bishop score was ≥8,
or 4-7 with cervical length ≤30 mm. The cut-off value for transvaginal ultrasound cervical length
considered as 30 mm in the study group.
CONCLUSION:
Transvaginal sonographic measurement of cervical length can predict imminent preterm delivery in
women presented with preterm uterine contractions and Bishop score between 4 - 7 compared with digital
cervical length measurement.

BACKGROUND:
recognition of abnormal amniotic fluid volume before delivery may alert the clinician to situations
of potentially high prenatal risk. pregnancies complicated by extremes of amniotic fluid volume
also experiences increase maternal & neonatal morbidity.
OBJECTIVE:
To identify the incidence of fetal morbidity & mortality associated with abnormal liquor volume
compared with those having normal liquor volume at term pregnancy.
Study design: A prospective cohort study.
Setting: The study was conducted at Al-Elwiya Maternity Teaching Hospital, during the period
from Mar. 2011 to Apr. 2012.
PATIENTS AND METHODS:
Three hundred fifty one pregnant women at their term were collected for the study. The
participants were classified according to the amniotic fluid volume into 3 groups: Group 1: (244)
those with normal liquor volume (maximum vertical pocket 3-8 cm), Group 2: (63) those with
oligohydramnios ( maximum vertical pocket <3cm), Group 3: (44) pregnants having
polyhydramnios ( maximum vertical pocket > 8 cm). Multiple pregnancy, preterm, postterm
pregnancy or those with ruptured fetal membranes had been excluded. The fetal outcome of the
groups were analysed & data arranged in tables & subjected to statistical study.
RESULTS:
In oligohydramnios group, hypertensive disorders & IUGR were 17.4% & 9.52% respectively,
while in polyhydramnios women with diabetes diseases were 22.7% versus1.64% in the control
group. In oligohydramnios group, low birth weight , intrapartum complications & admission to
NICU were more significant with incidence of 9.59%, 39.6%, 46% respectively versus 0.04%,
5.33%, 11.07% for control respectively. Fetal congenital anomalies, early neonatal complications ,
macrosomia, low Apgar score& early neonatal death were more in polyhydramnios group as
follow: 18.18%, 29.25%, 15.9% , 18.18% & 9.09% respectively compared with the control which
were 0.41%, 8.6%, 5.74% respectively & there were no recorded cases of low Apgar score or
early neonatal complications in the control group.
CONCLUSION:
Largest vertical pocket less than 3cm at term is associated significantly with higher incidence of
hypertensive disorders & IUGR. It was highly significant in predicting neonatal admission (NICU
) & intrapartum complications. While when the largest vertical pocket is more than 8cm, diabetes
disease, fetal macrosomia, congenital anomalies, low Apgar score, early neonatal complications &
neonatal death are more frequently seen.

BACKGROUND:
World wide, cervical cancer is one of the most common cause of death from cancer in women,
HPV testing have a key role in primary cervical screening and the currently accepted view is that
HPV is an essential factor in the causation of the disease.
OBJECTIVE:
The objective of the study is to outline the presence of HPV infection in our community
through sample of Iraqi's women who attended Central Health Laboratories with normal
and abnormal Pap smear during the period from August 2006 to December 2008.
METHODS:
The data were collected from records of the laboratory which includes the information about
patients who were referred to the central health laboratories to do HPV test , these data includes:
age of the patients , marital state, years after marriage which represents the age of first sexual
acts , also the records includes the smoking state, Pap smear results and lastly the HPV test
results. HPV testing was done by PCR method , which initially required DNA extraction
by MICROGENO DNA from AB Analitica , then DNA Amplificaion by PCR , and
finally Electrophoresis for reading the UV light and translating it into certain molecular weight by
Molecular Weight Markers.
RESULTS:
The percentage of HPV infection was 15.65 % , the percentage of positive test was 20% among
those aged between 20-30 years old , no viruses had been detected above 50 years old . All the
cases that have been examined were married and had 15% infection rate among them . The
maximum infection rate 20% was among those who had sexual activity for 5-9 years. 91.6% of
the infected women were smokers. 5.5% of the women with negative cytological results was
infected, 26.3 % of those with ASCUS, 43.3% of those women with CIN I, 45.5% of those with
CIN II , and 57% of those with CIN III ; the highest infection rates were 100% among
patients with micro-invasive cancer.
CONCLUSION:
-High rate of HPV infection is associated with age , smoking and multiple sexual
partners(married more than once).
- High frequency of detection of oncogenic HPV infection are associated with increasing
grade of cervical lesion.

BACKGROUND:
Tonsillitis is one of the commonest infectious disease occurring in the young age group.
Tonsillectomy is generally indicated when there are frequent attacks of acute tonsillitis, usually six
attacks or more per year for two successive years. Other indications of tonsillectomy include
obstructive sleep apnea, quinsy ( usually after the second attack of quinsy) and suspicion of
malignancy
OBJECTIVE:
The aim of the present study is to: i) identify the types of bacteria in the tonsil core and to study the
sensitivity of bacterial isolates to some antibiotics. ii) estimate serum concentration of
Antistreptolysin O (ASO), C-Reactive Protein (CRP) and Epstein Barr Virus (EBV) serology in
patients subjected to tonsillectomy compared to control group. iii) study the histopathological
changes of routine tonsillectomy specimens.
METHODS:
This case series included hundred patients who underwent tonsillectomy at Al-jamhori Teaching
Hospital from January 2010 to July 2012. The main indication for surgery was recurrent attacks
of tonsillitis for two or more successive years. Core of the tonsil was studied regarding
bacteriology and sensitivity of the cultured bacteria to some antibiotics. At the same time blood
sample was obtained and analyzed for ASO, EBV and CRP. Finally the removed tonsils were
sent for histological examination.
RESULTS:
The mean age of our patients was 10.32 years with a range of 3-35 years. The study included 60
males (60%) and 40 females (40%) with a ratio of 1.5 :1. Group A beta hemolytic Streptococcus
pyogenes was the commonest isolate from tonsil core (21.4%) and was most sensitive to
azithromycin. Serological tests for ASO, CRP and EBV were positive in 24%, 22% and 20%
compared to 22%, 8% and 10% in control group respectively. CRP was significantly higher among
patients than control group. Histological examination revealed chronic non-specific tonsillitis with
reactive lymphoid hyperplasia.
CONCLUSION:
The resistance of many bacteria to penicillin and amoxicillin, and the high percentage of betalactamase secreting microbes in recurrent tonsillitis mandate the need to consider a combination of
amoxicillin and clavulanic acid or second generation cephalosporin. ASO titer is not an accepted
indication for tonsillectomy.

BACKGROUND:
Misdiagnosis of acute appendicitis is a common and crucial problem in general surgery, as the
mortality and morbidity increase from 3 – 15 folds if appendix is perforated. Graded compression
ultrasonography is one of the new diagnostic techniques that were introduced to improve the
diagnostic accuracy and consequently the clinical outcome.
OBJECTIVE:
The aim of the current study is to assess the diagnostic accuracy of ultrasound in the diagnosis of
suspected acute appendicitis.
METHODS:
One hundred-eighty patients admitted to the general surgical ward at Al Kindy Teaching Hospital
from 1 June 2009 to 82 Feb. 2010. All patients were complaining of right iliac fossa pain and
tenderness with a suspicion of acute appendicitis, a clinical assessment done for them by using
modified Alvarado score (only patients with Alvarado score 5 and below were included). All
patients were investigated by WBC count and general urine analysis. When the diagnosis of acute
appendicitis was clinically equivocal, an abdominal ultrasound performed within 4 hours of
admission. A dilated, Non- compressible appendix greater than 6 mm diameter, and edema and
asymmetry of the appendicular wall were considered positive for the diagnosis of acute appendicitis.
A normal appendix on histopathological examination with positive ultrasonographic findings was
considered false positive result.
RESULTS:
The findings according to histopathological examination shows that 160 cases were true positive
cases,14 cases were found to be true negative , 1 cases was false positive and 5 cases were false
negative cases.:
Ultrasonography yielded a sensitivity rate of 96% and specificity rate of 93%.
CONCLUSION:
Ultrasound by graded compression technique provides highly accurate, sensitive and specific test
for clinically equivocal acute appendicitis.

BACKGROUND:
Epistaxis is one of the commonest medical emergencies. It affects all age groups and both sexes.
The causes may be local or systemic. Trauma is considered to be a major etiological factor.
Various treatment protocols are utilized to control epistaxis depending upon the type, severity and
cause of bleeding.
OBJECTIVE:
To show most etiological factures that causes epistaxis and who we manage each case by different
method.
MATERIALS AND METHODS :
This descriptive study was designed to evaluate the etiology and efficacy of management of
epistaxis.210 patient underwent prospective evaluation in the otolaryngology department of Al
Diwaniyah Teaching Hospital . Standard principles where followed in the management.
RESULTS:
This study demonstrated a bimodal distribution with incidence peaks below25 years and above50
years of age. Males affected more than females (1:1.16) . Anterior nasal bleeding was noted in the
majority of patients. Anterior nasal packing was the most effective method of controlling anterior
epistaxis followed by chemical cautery. While posterior bleeding was controlled by posterior nasal
packing and anterior nasal packing. The most common cause was found to be trauma followed by
hypertension.
CONCLUSION:
Epistaxis affects all age groups and it has a bimodal age presentation, it affects both sexes equally.
Anterior nasal bleeding is more common than posterior bleeding .Epistaxis may be controlled with
chemical or electrical cautery if the bleeding point is visible. In case of failure to localize or access
a bleeding point or profuse bleeding, anterior nasal packing can effectively control majority of
epistaxis cases. Foley s catheter is a good option that can be used for posterior nasal packing.
Gelfoam may be used for controlling epistaxis in cases of bleeding disorders, when there is
mucosal ooze.