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Iraqi Academic Scientific Journal

المجلة العراقية للاختصاصات الطبية

ISSN: 16088360
Publisher: The Iraqi Borad for Medical Specialization
Faculty:
Language: English

This journal is Open Access

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Table of content: 2017 volume:16 issue:4

Article
The Polycystic Ovary Syndrome as A Cause of Increase in Inflammatory Markers and Metabolic Risks

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Abstract

ABSTRACT: BACKGROUND: Polycystic ovary syndrome(PCOS) is one of the most common endocrine disorder affecting women in reproductive age. No single etiologic factor fully accounts for the spectrum of abnormalities in the polycystic ovary syndrome. Different changes in hormonal, metabolism and the inflammatory markers as squealy of PCOS with adverse effect on the women life. OBJECTIVE: To study the relationship between polycystic ovary syndrome and levels of C-reactive protein, human interleukin and hormonal and metabolic alteration in women with PCOS PATIENTS AND METHODS: Thirty women with Polycystic Ovary syndrome (PCOS) and other thirty women without PCOS were included. Venous blood samples were taken in early follicular phase of menstrual cycle [day 2-6] for luteinizing hormone (LH), follicle-stimulating hormone (FSH), and testosterone. Serum level of Human Interleukin 1B (IL-1B) was quantitatively determined. Blood samples were also tested for detection of CRP (C-reactive protein, in addition to levels of cholesterol, triglycerides. RESULTS: The mean cholesterol level was significantly higher in PCOS group rather than controls; (188.3 ± 7.2) vs. (168.7 ± 6.1) respectively. Mean LH level was higher in PCOS women than control (13.3 ± 2.4 IU/L) vs. (5.85 ± 1.47) IU/L, while in contrary mean FSH level was lower in PCOS cases. The mean serum testosterone in PCOS group was significantly higher than in controls, with no significant difference regarding IL-1B, but again it was significant in cases of CRP. CONCLUSION: PCOS was associated with higher levels of cholesterol, LH, and serum testosterone with lower levels of FSH. Positive C-Reactive Protein was more frequent in PCOS cases. Still serum level of Human Interleukin 1B (IL-1B) was not significantly affected by PCOS.


Article
Cytological Findings in Patients with Haematuria

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ABSTRACT: BACKGROUND: Regardless of the accessibility of more up to date and more modern methods of investigations, urinary cytology still remains the most regularly utilized non-invasive investigation for the diagnosis of cancer of the bladder. OBJECTIVE: To assess the helpfulness of urine cytology in assessment of patients with hematuria for the presence of malignancy. PATIENTS AND METHODS: A total of 1560 recently voided urine samples got at private clinics from patients with hematuria, whether gross or microscopic, over a time of three years were incorporated in the study. Physical and microscopical (cytological) examination done for all samples. RESULTS: Among these cases of hematuria incorporated in the study, 23.7% (370 cases) were found to have positive finding of atypical cells. In these cases with atypia, 48.7% (180 cases) were proved to have malignancy both with cystoscopic findings and the histopathological biopsy. The remaining cases of atypia were found to be reactive, either due to instrumentation or foreign body. In an extensive number of cases of hematuria, that is, 1190 cases (76.3%) no atypical cells were identified. CONCLUSION: Urine cytology can distinguish urothelial cells changes and high grade bladder tumor so it is a good tool particularly with coordinated effort amongst clinician and cytopathologist. Urine cytology can be utilized as an adjunct test in assessment of patients with hematuria.


Article
Quality of Life Assessment in Iraqi Patients with Acne Vulgaris and Psoriasis

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Abstract

ABSTRACT: BACKGROUND: Skin diseases may affect daily lives of individuals and their psychological and social relationships. Appropriate measurement systems are required to evaluate the impact of the disease on the quality of life. The Dermatology Life Quality Index (DLQI) is an important and commonly used dermatology specific quality of life instrument. OBJECTIVE: To assess the quality of life in 2 common dermatological disorders (acne and psoriasis) in Iraqi patients attending dermatological outpatient clinic, Baghdad Teaching Hospital. PATIENTS AND METHODS: A case series study of 400 patients with 2 dermatological diseases (acne and psoriasis); 200 patients for each disease were evaluated. Information related to socio-demographic data and disease severity were recorded and quality of life was assessed by means of the Dermatology Life Quality Index. RESULTS: The DLQI of patients with acne and psoriasis were comparable; 7.71+/-4.64 and 8.52+/-4.48 respectively. In patients with acne the DLQI was significantly affected by higher level of education P=0.002, also in unmarried patients P=0.0001. Increased disease severity also affected DLQI (P=0.003). In patients with psoriasis the only factor which was associated with a higher DLQI was female gender. CONCLUSION: Acne and psoriasis affect significantly the DLQI of patients. DLQI is a good indicator of the impact of the disease on the life of the patient.


Article
Validation of Mitral Annular Plane Systolic Excursion & end Point Septal Separation for Rapid Assessment of Left Venticular Systolic Function

Authors: Arshad Fuad Ridha
Pages: 349-356
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Abstract

LEFT VENTICULAR SYSTOLIC FUNCTION THE IRAQI POSTGRADUATE MEDICAL JOURNAL VOL. 16,NO,4. 2017 Validation of Mitral Annular Plane Systolic Excursion & end Point Septal Separation for Rapid Assessment of Left Venticular Systolic Function Arshad Fuad Ridha INTRODUCTION: Mitral annular plane systolic excursion (MAPSE) also known as mitral ring displacement & mitral annulus excursion (MAE), is obtained from M mode & it assesses LV longitudinal function (1,2,3). It can be get easily (5,6,7) even for the junior doctor (7) and in patients with poor acoustic windows (3). It has been suggested as a surrogate measurement for LVEF in cardiac patients (6,8). MAPSE may be reduced with increasing age & in patients with atrial fibrillation, myocardial infarction & heart failure(9,10,11) and to be more sensitive than Al Mustansiriyha Medical College. conventional echocardiographic markers in detecting abnormalities in LV systolic function at an early stage (2,12). MAPSE is known to be prognostic for major cardiac events and mortality in patients with cardiovascular disease (9,13,14,15). Measurement of MAPSE MAPSE can be measured using the M mode from the lateral & septal walls of the apical 4 chambers views & from the anterior & inferior walls of the apical 2 chambers views. The best is to obtain it from the lateral & septal walls. Generally, the lateral MAPSE values are higher than that of septal walls. (16) ABSTRACT: BACKGROUND: Assessment of LV systolic function is sometimes difficult because of obesity, chest wall deformities or in critically ill patients. We try to evaluate alternative methods for rapid assessment of LV systolic function. OBJECTIVE: In this study we try to evaluate mitral annular plane systolic excursion (MAPSE) ( Since LV longitudinal shortening reflected by MAPSE is a sensitive marker of LV systolic function.) & E-point septal separation (EPSS) for rapid assessment of LV systolic function & as alternative way to assess ejection fraction (EF). METHODS: This is an observational case-control study enrolling 143 patients, 73 patients with LV dysfunction & 70 persons with normal LV function served as a control group. LV EF (Left ventricle ejection fraction), MAPSE & EPSS all are measured for patients & the control groups. P-value ≤0.05 is considered as a statistically significant. RESULTS: A 73 patients with LV dysfunction & 70 patients with normal LV function (taken as a control) were enrolled in this study. There are significant LV dilatation, a decrease in LVEF, decrease in MAPSE & increase in EPSS in patients group in comparison with control groups, & all are statistically significant (P-value=0.0001).MAPSE less than 7 mm & EPSS more than 7 mm had a sensitivity of 34.24 % & 97.26% respectively & a specificity of 100% & 85.71% respectively. CONCLUSION: Both MAPSE & EPSS parameters are simple, easy to obtained & require no time especially in patients with poor acoustic window. An average MAPSE of less than 7 mm & EPSS of more than 7 mm can be used as a surrogate of LV systolic dysfunction with acceptable sensitivity & specificity. KEY WORD: MAPSE, EPSS, LV function. THE IRAQI POSTGRADUATE MEDICAL JOURNAL VOL. 16,NO,4. 2017 349 LEFT VENTICULAR SYSTOLIC FUNCTION THE IRAQI POSTGRADUATE MEDICAL JOURNAL VOL. 16,NO,4. 2017 & during measurement always make the cursor parallel to the LV walls. The excursion in M mode should be measured from the lowest point to the highest point i.e. from end diastole to end systole. (Fig. 1). The post-systolic motion towards the apex during the isovolumetric relaxation period, which is sometimes linked with ischaemia, fibrosis, or pressure overload,(17) should not be included in the measurement. Figure 1 The average normal value of MAPSE derived from previous studies for the four annular regions (septal, anterior, lateral, and posterior) ranged between 12 and 15 mm (18, 9) and a value of MAPSE <8 mm was associated with a depressed LV EF (<50%)(18) . A mean value for MAPSE of ≥10 mm was linked with preserved EF (≥55%) (1, 20). In addition, a mean value for MAPSE of <7 mm could be used to detect an EF <30% in dilated cardiomyopathy patients with severe congestive heart failure (9). One important thing is that the association between MAPSE & EF is only true in case of a normal or dilated LV (20, 21), but this association is not applicable in case of left ventricular hypertrophy (LVH) (22). This is because the LV longitudinal function represented by MAPSE is impaired in case of LVH while radial function represented by EF will remain normal or even increased (23). The same is also true with increasing age in which MAPSE is impaired while the EF remain normal or even increased.(24,25) EPPS, Surrogate markers of LV systolic function: EPSS refers to the distance between the anterior leaflet of the mitral valve and the interventricular septum during early diastole. This is easiest to measure using M-mode echocardiogram, and the measurement is taken when the anterior mitral leaflet is at its closest to the septum (Figure 2). Figure 2 During diastole, the tip of the anterior MV leaflet move toward the septum & during M mode this is represented by E point as seen in fig. 2. The distance between E point & the septum is called E point septal separation (EPSS) & it does not only assess LV dilatation & function but it has a strong negative correlation with EF i.e. the higher the distance the lower the EF (26,27). Normally, the EPSS is no more than 6mm. The distance increases with worsening left ventricular 350 LEFT VENTICULAR SYSTOLIC FUNCTION THE IRAQI POSTGRADUATE MEDICAL JOURNAL VOL. 16,NO,4. 2017 systolic function, and an EPSS >7mm is a sensitive marker for severely impaired systolic function. METHODS: Study design: This was an observational case-control study evaluating the relationship of MAPSE & EPSS to LVEF in patients with LV dysfunction & in healthy population who attended the Echocardiogram department in Al-Yarmouk hospital for any indication. Subjects: 73 patients with LV dysfunction as documented by an LVEF < 54 % in females or LVEF < 52% in males were enrolled during the period from 21ST of April 2016 to 25th of March 2017. A 70 healthy individuals as documented by an LVEF ≥ 54 % in females & LVEF ≥ 52% in males were enrolled as a control during the period of 21st of April 2017 to 20th of April 2017. Exclusion: 1. Patients with valvular cardiomyopathy (valve leading to LV dysfunction). 2. Patients with left ventricular hypertrophy. Measures: All echocardiographic examination were completed using S4 probe 2.5 Mhz phased-array. Comprehensive transthoracic echocardiogram was performed with Vivid E9 echocardiography system (GE). After taking a consent, we asked about past medical history, current or past occupation, smoking status & presence or absence of ischemic heart disease. By echocardiogram, we measure LV size (left ventricular internal diameter diastolic) (LVIDD), LVEF, EPSS & MAPSE. Two-dimensional imaging examination was performed in the standard fashion in parasternal long- & short-axis views & apical 4-& 2- chamber views. LVEF were calculated using cubed formula i.e. Teichholz methods. Excursion of mitral annulus was measured using M mode from the apical 4 chambers view with beam positioned to the lateral walls. The amount of excursion was measured in mm. In M mode the longitudinal motion of MV annulus was recorded against time giving the appearance of a sine wave. The depth of the sine wave occurred in end diastole while the height occurred in end systole. Measurement of depth to height represent MAPSE Regarding measurement of EPSS, an M-mode from parasternal long axis view was taken at the level of mitral valve leaflet tips. Measurement was taken in early diastole (in mm), & EPSS was defined as the shortest distance from the E-point of mitral valve (the tip of the anterior mitral valve leaflet) to the ventricular septum. Statistical analysis: Data were coded & analyzed using the SPSS package program, version 24.0 (SPSS Inc, Chicago, IL, USA) & excel 2013 programs. Qualitative data were presented using the frequency & its related percentage, while quantitative data were presented using the mean & standard deviation. Continuous variables were compared between the two groups using student’s t-test, while categorical variables were compared using Pearson Chi-square test. One-way analysis of variance (ANOVA) was used to compare three or more groups. A P-value of < 0.05 was chosen as the level of significance. RESULTS: A 73 patients with LV dysfunction classified according to their EF (EF ≤ 54 % in females & ≤ 52 % in males ) & 70 patients with normal LV function (EF > 54 in females & > 52 in males ) (taken as a control) were enrolled in this study. There were 47 (64.38 %) males & 26 (35.62%) females in patients group, & 31 (44.28%) males & 39 (55.72 %) females in the control groups. The mean age was 58.9 ±12.4 year of the patients group, the range was 6-77 years & the mean age of the control group was 45.8 ± 13.5 year, range 19-75 year. The rest of clinical data is demonstrated in table 1. 351 LEFT VENTICULAR SYSTOLIC FUNCTION THE IRAQI POSTGRADUATE MEDICAL JOURNAL VOL. 16,NO,4. 2017 Table 1: Demographic & clinical data of patients with LV dysfunction & control groups. Patients Controls P-value Number 73 70 Age “Mean±SD (Range)” 58.9±12.4 (6-77) 45.8±13.5 (19-75) 0.0001* Males 47 31 0.016# Females 26 39 Hypertension 36 26 0.142 Diabetes 33 12 0.0001# IHD 33 8 0.0001# Smoking 11 16 0.053 *Significant using Students-t-test for two independent means at 0.05 level # Significant using Pearson Chi-square test at 0.05 level. Table 2 shows the echocardiographic parameters of patients & control groups, there are significant LV dilatation, a decrease in LVEF, decrease in MAPSE & increase in EPSS in patients group in comparison with control groups, & all are statistically significant (P-value=0.0001). Table 2: Echocardiographic findings in patients with LV dysfunction & control groups. Mean Patients Control P-value LV size (mm) 62.5±9.5 (41-90) 50.3±5.4 (40-68) 0.0001* EF (%) 36.3±8.5 (17-53) 70.9±6.3 (57-83) 0.0001* MAPSE (mm) 8.4±3.1 (4.2-17) 15.1±2.5 (11.3-22.1) 0.0001* EPSS (mm) 16.3±5.9 (6-35)) 4.0±2.5 (0-11.3) 0.0001* *Significant using Students-t-test for two independent means at 0.05 level Table 3 shows the echocardiographic parameters between males & females patients, there are significant LV dilatation, decrease in LVEF & decrease in MAPSE in male patients in comparison to the females (P-values: 0.001, 0.002, 0.001 respectively. While there is no statistically significant deference between males & females regarding EPSS. Table 3: Comparison of echocardiographic findings between males & females patients. Mean Male patients Female patients P-value LV size (mm) 65.3±9.7 (41-90) 57.6±6.9 (44-70) 0.001* EF (%) 34.1±7.9 (17-52) 40.4±8.2 (25-53) 0.002* MAPSE (mm) 7.9±2.8 (4.2-17) 9.3±3.3 (5-16) 0.001* EPSS (mm) 17.9±5.9 (6-35) 13.3±4.8 (6.8-22.7) 0.070 *Significant using Students-t-test for two independent means at 0.05 level Table 4: Comparison of echocardiographic findings between ischemic & non-ischemic LV systolic dysfunction. Table 4 shows the echocardiographic parameters between ischemic & non-ischemic LV dysfunction patients. LV dilatation, LVEF & MAPSE all showed a non-statistically significant difference, while EPSS is significantly increased in non-ischemic patients in comparison to the ischemic ones (P-value: 0.045) Ischemic Non-ischemic P-value LV size (mm) 61.6±8.4 (41-49) 67.0±12.9 (51-90) 0.061 EF (%) 36.6±8.2 (17-52) 35.2±10.3 (21-53) 0.587 MAPSE (mm) 8.4±2.9 (4.2-17) 8.5±3.7 (4.2-14.2) 0.919 EPSS (mm) 15.6±5.4 (6-27) 19.3±7.4 (8.3-35) 0.045* *Significant using Students-t-test for two independent means at 0.05 level 352 LEFT VENTICULAR SYSTOLIC FUNCTION THE IRAQI POSTGRADUATE MEDICAL JOURNAL VOL. 16,NO,4. 2017 Table 5 shows a statistically significant relation between MAPSE & LVEF in patients with LV dysfunction (LVD) (P-value: 0.0001) Table 5: The relation between MAPSE & EF in patients with LV dysfunction. MAPSE (mm) No. EF (%) (Mean) P-Value ≥10 24 40.2±6.4 (29-53) 0.0001* 9.9-8 borderline 17 40.0±8.0 (28-52) <8 LVD 7 37.9±7.5 (28-47) <7 Severe LVD 25 29.7±7.2 (17-51) *Significant using ANOVA test at 0.05 level Table 6 shows a non-statistically significant relation between EPSS & LVEF in patients with LV dysfunction (LVD) (P-value: 0.380) Table 6: The relation between EPSS & EF in patients with LV dysfunction (LVD). EPSS (mm) No. EF (%) (Mean) P-Value ≥7 71 36.1±8.4 (17-53) 0.380 <7 2 45.5±9.2 (39-52) *Significant using Students-t-test for two independent means at 0.05 level Table 7: The sensitivity and specificity of different echocardiographic parameters for diagnosing LVD. Diagnosis of LVD by EF(Male <=52; Female <=54) LVD (n=73) Control (n=70) MAPSE Severe LVD (<7) 25 - LVD (<8) 7 - Borderline (10-8) 17 - Normal (≥10) 24 70 EPSS LVD (=>7) 71 10 Normal (< 7 mm) 2 60 EPSS: Sensitivity=71/(71+2) x 100=97.26%; False negative=2.74%; Positive predictive value=71/ (71+10) x 100=87.65% Specificity =60/(10+60) X 100= 85.71%; False positive=14.29%; Negative predictive value=60/ (60+2) x 100= 96.77% Accuracy rate= (71+60)/143 x 100= 91.61% MAPSE: 1. For MAPSE less than 8 for the detection of LV dysfunction Sensitivity = (25+7)/73 x 100= 43.84%; False negative %=56.16%; Positive predictive value =32/32x100=100% Specificity =70/70 X 100= 100%; False positive %=0%; Negative predictive value =70/ (24+17+70) x 100= 63.06% Accuracy rate= (7+25+70)/143 x 100= 71.33% 2. For MAPSE less than 7 for the detection of LV dysfunction Sensitivity = 25/73 x 100= 34.24%; False negative %=65.76%; Positive predictive value =25/25 x100=100% Specificity =70/70 X 100= 100%; False positive %=0%; Negative predictive value =70/ (24+17+7+70) x 100= 59.23% Accuracy rate= (25+70)/143 x 100= 66.43% DISCUSSION: Assessment of LV systolic function & obtaining LV EF is sometimes difficult because of obesity, chest wall deformities, and poor window or in critically ill patients. So we have to look for other parameters, compare these parameters with EF & trying to know their sensitivity & specificity. Longitudinal shorting of the left ventricle is a sensitive marker reflecting heart function & can be obtained by measuring MAPSE. Measurement of MAPSE doesn’t require high imaging quality nor highly specialized personnel. 353 LEFT VENTICULAR SYSTOLIC FUNCTION THE IRAQI POSTGRADUATE MEDICAL JOURNAL VOL. 16,NO,4. 2017 Although MAPSE & EF are strongly positively related, they are not completely related. MAPSE is more likely to assess longitudinal function of the LV i.e. subendocardial fibers & is more sensitive to subtle LV function changes while EF is more likely to assess radial LV function i.e.subepicardial (circumferential) fibers .(29) i.e. the longitudinal function could be impaired while the radial function can be preserved or even increased. The other method for assessment of left ventricular function is by measuring the distance between anterior MV leaflet & ventricular septum in diastole (EPSS) which can roughly assess LV EF. In diastole, the anterior MV leaflet should approach or even touch the septum. In LVD, the dilated LV with increased preload will pull valve away from the septum. It is easy to obtain, fast as it is a simple linear m-mode measurement obtained from parasternal long axis view. The current study showed that there are significant LV dilatation, a decrease in LVEF, decrease in MAPSE & increase in EPSS in patients group in comparison with control groups, & all are statistically significant (P-value=0.0001), Matos et al. (7) reported that the average systolic excursion of the mitral annulus correlated excellently with LVEF. Previous studies also stated that chronic heart failure patients showed a significant reduction of MAPSE, and there was a good correlation between MAPSE and EF (9). Qin et al (30) have shown that MAPSE measurement correlate well with other techniques for LV functional assessment including 3D echocardiogram & cardiac MRI imaging. Also, Tsang et al (31) studied the correlation of MAPSE, as derived from speckle-tracking echocardiography, with MRI-derived LVEF. They found a very strong correlation using this alternative MAPSE technique, suggesting a strong relation between MAPSE & LVEF. The current study showed that there are significant LV dilatation, decrease in LVEF & decrease in MAPSE in male patients in comparison to the females (P-values: 0.001, 0.002, 0.001 respectively). While there is no statistically significant deference between males & females regarding EPSS. The explanation is that women’s hearts are typically smaller than men’s, this could account (at least partially) for the observed differences between men and women. Matos et al (7) showed that although average MAPSE values did not differ significantly between men and women, EFs did (P-values 0.33 & < 0.001 respectively). For a given MAPSE value, the correlating EF was higher for women than for men. No other study to date has been published that evaluated gender specifically as a factor that affects the correlation between MAPSE and EF. The current study showed that LV dilatation, LVEF & MAPSE all showed a non-statistically significant difference between ischemic & non-ischemic (dilated cardiomyopathy) LV systolic dysfunction, while EPSS is statistically significant in non-ischemic (dilated cardiomyopathy) patients in comparison to the ischemic ones (P-value: 0.045). The explanation is that the LV takes on a more spherical geometry in dilated cardiomyopathy than ischemic LV systolic dysfunction & with progressive dilatation, the minor axis increases disproportionally, & the ratio of long to minor axis decreases i.e. sphericity index less than 1.5:1 implies marked pathological remodeling. There is no published data to date comparing MAPSE & EPSS between ischemic LV dysfunction & dilated cardiomyopathy. In this current study there is strong relation between MAPSE & EF (measured by M-mode), P-value:0.0001.In Walaa et al (32) study they found a significant positive correlation between average MAPSE & EF measured by M-mode (p<0.001), EF measured by Simpson’s rule (p<0.001), & EF measured by visual inspection (p<0.001). Our study failed to find a relation between EPSS & EF measured by M-mode (P value: 0.38).While in Conor et al study (33) they found that a prediction of LVEF from linear regression equation using EPSS measurement could theoretically be used to generate to generate a quantitative prediction of LVEF, while in Abdalla Elghaha et al (34) study they found that Correlation coefficient revealed to be very strong between Mitral EPSS measured by CMR & LVEF (r= -0.92; 95% Confidence interval for r= -0.95 to -0.87) with high significant level (P<0.0001). The current study showed that a MAPSE less than 8 had a sensitivity of 43.84%, a specificity of 100% & accuracy rate of 71.33% for the detection of LV systolic dysfunction & a MAPSE less than 7 had a sensitivity of 34.24%, a specificity of 100% & accuracy rate of 66.43% for the detection of severe LV systolic dysfunction. While in Walaa et al (32) study showed that an average MAPSE cutoff value of less than or equal to 5 provided the best balanced sensitivity (67.1%) and specificity (76.5%) to predict EF < 30%. A cutoff value of less than or equal to 3.9 could determine EF < 30% in 100% of the patients. Matos et al.(7) study stated that a MAPSE cutoff point of <6 served as an appropriate 354 LEFT VENTICULAR SYSTOLIC FUNCTION THE IRAQI POSTGRADUATE MEDICAL JOURNAL VOL. 16,NO,4. 2017 cutoff point to predict severely depressed EF less than or equal to 30%. Elnoamany et al.[5] demonstrated that a MAPSE value of <7 mm had 92% sensitivity and 67% specificity for the detection of severe left ventricular dysfunction. Alam et al.(9) demonstrated that a mean MAPSE < 7 mm could detect an EF < 30% with sensitivity of 92% and specificity of 67% in patients with dilated cardiomyopathy with severe congestive heart failure. Our study showed that EPSS ≥7 had a sensitivity of 97.26%, a specificity of 85.71% & accuracy rate of 91.61% for the detection of LV systolic dysfunction. In Conor et al (33) study they found that an EPSS greater than 7 may be used to predict patients with severely reduced LVEF. In another study, EPSS of 7 mm would determine severe left ventricular dysfunction (EF <30%) with 100% sensitivity. Study limitation: 1. This is a small observational case-control study, a large randomized multicenter study for extended period is required 2. Inclusion of diastolic function assessment 3. Inclusion of patients with Valve diseases 4. 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Assessment of mitral valve E pointseptal separation as an index of left ventricular performance in subjects with acute and previous myocardial infarction. Am J Cardiol 1978;41:836–45. 27. Engle SJ, Disessa T, Perloff J, Isabel-Jones J, Leighton J, Gross K, et al. Mitral valve E point to ventricular septal separation in infants and children. Am J Cardiol 1983;52:1084–7. 28. Emilsson K, Wandt B: The relation between ejection fraction and mitral annulus motion before and after direct-current electrical cardioversion. Clin Physiol 2000;20:218–24. 29. Emilsson K, Wandt B: The relation between mitral annulus motion and ejection fraction changes with age and heart size. Clin Physiol 2000;20:38–43. 30. QinQin J,Shiota T, Tsujino H. al.e. Mitral annular motion as a surrogate for left ventricular ejection fraction: real-time three-dimentional echocardiography & magnetic resonance imaging studies. Eur j Echocardiogr 2004;5:407-15. 31. Tsang W, Ahmad H, Patel A. al. e. Rapid estimation of left ventricular function using echocardiographic speckle tracking of mitral annular displacement. J Am Soc Echocadiogr 2010;23:511-15. 32. Walaa A, Alaa M, Mohamed Nabil. Mitral annular plane systolic excursion-derived ejection fraction: A simple & valid tool in adult males with left ventricular systolic dysfunction. Echocardiography 2016;33:179–84. 33. Conor J. McKaigney, Mori J. Krantz, Cherie L. La Rocque et al. E-point septal separation: a bedside tool for emergency physician assessment of left ventricular ejection fraction. j.ajem.2014.01.045 34. Abdalla Elagha, Anthon Fuisz. Mitral valve E-Point to Septal Separation (EPSS) measurement by cardiac magnetic resonance Imaging as a quantitative surrogate of Left Ventricular Ejection Fraction (LVEF). J Cardiovasc Magn Reson. 2012;14(Suppl 1):154. 356 LEFT VENTICULAR SYSTOLIC FUNCTION THE IRAQI POSTGRADUATE MEDICAL JOURNAL VOL. 16,NO,4. 2017

Keywords

KEY WORD: MAPSE --- EPSS --- LV function.


Article
Electrophysiological Patterns of Guillain Barre Syndrome in Iraqi Children...A Hospital Based Study

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ABSTRACT: BACKGROUND: Guillain-Barre syndrome (GBS) is an acute idiopathic progressive ascending weakness and considered the most common cause of acute flaccid paralysis in healthy infants and children. It is now known to be a heterogeneous syndrome with several variant forms. In addition to the demyelinating form, which is the most common type, axonal forms of GBS are now well recognized. OBJECTIVE: To estimate frequency, demographics, clinical characteristics and complications of GBS subtypes from nerve conductive study (NCS) and electromyography (EMG) in patients were admitted to Children Welfare Teaching Hospital. PATIENTS& METHODS: Fifty three children with GBS admitted to Children Welfare Teaching Hospital Medical City-Baghdad from January 2009 till August 2010 was enrolled in this study. Clinical data were obtained; electrophysiological studies (NCS, EMG) were performed to determine GBS subtypes. RESULT: Out of 53 children studied, eleven patients (20.6%) were diagnosed as axonal subtype and 42 (79.4%) were of demyelinating subtype. Axonal subtype was more frequent in rural than urban (8/11 patients 72.7% and 3/11 patients 27.3% respectively), where as demyelinating subtype was more frequent in urban residency compared to rural area (33/42 patients 78.6% and 9/42 patients 21.4% respectively) with a P value=0.0025. Although gastroenteritis was higher in axonal subtype (3/11 patients 27.3%) compared to only (5/42 patients, 11.9%) in demyelinating subtype, it did not reach the statistical significant. History of upper respiratory tract infection was reported more in demyelinating compared to axonal subtype (25/42 patients 59.6% and 3/11 patients 27.7% respectively). Cranial nerve involvement was found in 8 patients (72.7%) of the axonal subtype while it was found in 24 patients (57.1%) of demyelinating subtype. Respiratory failure was reported as complication in 4 patients (36.4%) of axonal subtype, compared to 7 patients (16.7%) of demyelinating subtype. Ventilator support was recorded in 3 patients (27.3%) of axonal, compared to only 1 patient (2.4%) in demyelinating subtype (p value=0.024). CONCLUSION: The demyelinating subtype was the predominant type of GBS followed by the axonal. Gastroenteritis was the predominant recorded antecedent event in axonal subtype and more frequent in rural residency. Cranial nerves involvement was reported more frequently in axonal subtype and has been a significant factor for future assisted ventilation. .

Keywords

KEYWORD: gbs --- demyelinating --- axonal --- children


Article
Progression of Keratoconus after Corneal Collagen Cross-Linking Procedure

Authors: Najah Kadhum Mohammad
Pages: 362-368
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ABSTRACT: BACKGROUND: Keratoconus is a non-inflammatory, usually bilateral disorder, that leads toabnormal thinning and steepening of the cornea duo to progressive corneal instability. OBJECTIVE: To estimate the progression of keratoconus after cross linking during 1 year duration. PATIENTS AND METHODS: This study is a prospective study carried out to estimate the progression of keratoconus after cross linking. It was conducted in Dar Al Salam eye hospital, Lasik center, Baghdad city, fromMarch, 2011 to the December, 2016. All patients with keratoconus included in this study were referred from private clinic.The surgery was done in Dar Al Salam hospital by one consultant ophthalmologist. The researcher followed up the keratoconus eyes for 1 year. RESULTS: Two hundred sixty six eyes of one hundred seventy two patients were completed follow up after Collagen cross-linking using UVA light and riboflavin. Mean age of patients was 18 ± 10 years and female to male ratio was nearly 2:1. Postoperatively, VA was unchanged in 206 eyes,improved in 50 eyes, and deteriorated in 10 eyes. No significant differences were observed in means of autorefraction, simulated keratometry and central corneal thickness postoperatively for all eyes (p > 0.05). CONCLUSION: Cross linking is a minimally invasive procedure. This method can halt or reduce keratoconus progression. KEY WORDS: keratoconus and cross linking.


Article
Comparison of Efficacy & Safety of Levetiracetam Versus Topiramate in Treatment of Epilepsy

Authors: Sarwer Jamal Al- Bajalan
Pages: 377-384
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ABSTRACT: BACKGROUND: More than 14 antiepileptic drugs (AEDs) have been licensed for use in epilepsy over the last 20 years. Levetiracetam (LEV) & topiramate (TPM) are two of the most commonly prescribed new AEDs. The comparison between different AEDs is a crucial issue for decision making in epileptology. OBJECTIVE: To compare the efficacy & safety of LEV vs. TPM as monotherapy or add-on therapy in focal onset or generalised epilepsy. METHODS: The study carried on 75 epileptic patients (45 on LEV vs 30 on TPM). Data were taken regarding age, gender, type, dosage & duration of treatment, type & frequency of seizures six months before & after therapy, & drug-related adverse reactions (ARs). For data analysis each therapy group is divided into mono or add-on therapy. Further subdivision into generalised or focal seizure was done. Efficacy was assessed as a percentage of reduction of monthly seizure frequency after LEV or TPM initiation compared to baseline. RESULTS: In the total samples; although LEV was better than TPM in overall seizure control, the difference was not significant (p-value = 0.1). Seizure freedom was 57.8% with LEV vs. 43.8% with TPM. Reduction ≥50% was achieved in 100% LEV vs. 90% TPM patients. Both showed high efficacy in generalised & focal seizures in both add on & monotherapy groups. In the subgroup analysis of monotherapy; LEV showed a higher rate of seizure freedom (83.3%) vs. 55.6% with TPM for treatment of generalised seizure. While for focal seizure, LEV showed 100% responder rate vs. 50% for TPM. Despite the above observations none of the two AEDs showed significant superiority over the other. Both were equally effective in paediatric & adult patients in high & low doses. Drug ARs were less frequent with LEV than TPM although both of them had reasonable safety profile. CONCLUSION: The efficacies of LEV & TPM were almost equal in treating focal or generalised seizures as mono or add-on therapy. Both were equally effective in adults & paediatric patients, in high & low doses. The safety profile of LEV was more favourable than TPM.


Article
Effect of Simultaneous Cystocele Repair on Transobturator Tape Outcome in Female Patients with Pure Stress Urinary Incontinence

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ABSTRACT: BACKGROUND: Today; mid urethral slings are the first option for surgical treatment of stress urinary incontinence (SUI) due to high success rates and minimally invasive characteristics of the procedure. Concomitant prolapse surgery does not appear to have an effect on treatment outcomes according to previous studies predominantly evaluating tension-free vaginal tape (TVT) procedures. OBJECTIVE: To evaluate the efficacy of cystocele repair performed simultaneously with trans obturator tape (TOT) on the outcome of operation in patients with stress urinary incontinence (SUI) and pelvis organ prolapse (POP). PATIENTS AND METHODS: The data of patients who had SUI and cystocele were evaluated prospectively and Patients who underwent only TOT were classified as group 1 and the patients who underwent TOT simultaneously with cystocele repair (grades 1&2) were classified as group 2. The age, number of normal deliveries, number of pad used per day, cystocele grade, and duration of operation, pre- op International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) and postoperative complications were evaluated. RESULTS: It was observed that there was no significant difference between groups 1 and group 2 in terms of preoperative International Consultation on Incontinence Questionnaire-Short Form scores (16.08±0.32 and 16.71±0.31, respectively). It was observed that the postoperative ICIQ-SF scores decreased markedly in both groups (2.31±0.69 and 4.42±1.21, respectively, p=0.003). CONCLUSION: Cystocele repair performed simultaneously with TOT in patients with mild to moderate (grade 1&grade2) cystocele did not provide additional improvement on TOT alone in regard to treatment of SUI.


Article
Extensive Versus Traditional Phototherapy in Treatment of Neonatal Jaundice

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ABSTRACT: BACKGROUND: Neonatal jaundice affects more than 60% of neonates. Phototherapy is the main treatment, and its effectiveness is directly related to the duration of exposure, exposed surface area of the infant, and intensity of light used for phototherapy. OBJECTIVE: To determine the role of extensive phototherapy in the treatment of neonatal jaundice and to compare efficacy of extensive phototherapy with traditional phototherapy. PATIENTS AND METHODS: Over a period of one month occupying throughout April 2017, 100 cases of neonatal jaundice whom either term or preterm, near term (≥ 35 weeks of gestational age), visited Al-Elwiya Pediatrics Teaching Hospital were collected from day zero age, precisely from 1st hour till 240 hours of age. Half of them were put on traditional phototherapy and other half were on extensive phototherapy depending on clinical grounds and their total serum bilirubin levels according to American Academy of Pediatrics guidelines, where a cutline total serum bilirubin (TSB) level of 20-25 mg/ dl was used to identify a phototherapy type. RESULTS: Percentage of improvement in neonates whose treatment included extensive (intensive) phototherapy was 72% compared to 40% for traditional phototherapy, with full term neonates` relative risk (1.9) was higher than preterm (near term babies) (1.7), also males` relative risk (1.84) was higher than females` (1.78), but no significant difference was seen regarding both (gestational age and sex). Breast fed, bottle fed, and mixed fed newborns were improved better in extensive than traditional phototherapy (87.50% vs 41.20%, 55% vs 36.36%, 78.57% vs 45.45%, respectively). Extensive phototherapy was more frequently associated with lethargy as a side effect (12% vs 10%). CONCLUSION: Extensive phototherapy was more effective in treating neonatal hyperbilirubinemia (significant p value= 0.0012), but with a slightly higher percentage of lethargy as a side effect (12% vs 10%). KEY WORDS: neonatal jaundice, traditional phototherapy, extensive phototherapy.


Article
The Role of Strain Elastography in Differentiation Between Metastatic and Benign Axillary Lymph Nodes in Patients with Breast Cancer

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ABSTRACT: BACKGROUND: Elastography is a promising diagnostic tool that is increasingly used by radiologists to increase the sensitivity and specificity of conventional ultrasound in a wide range of disease processes. One of its major uses was to differentiate between benign and malignant lesions. OBJECTIVE: Is to investigate the value of elastography in assessing lymph nodes in the patients with breast carcinoma. PATIENTS AND METHODS: This single center prospective cross sectional study involved forty-nine (49) women with breast cancer and the total of sixty (60) lymph nodes (LNs) that were suspicions to be metastatic. The study was carried out at Al-Imamain Al- Kadhimain Medical city/the breast clinic, from January 2016 through October 2016. Ultrasound examination included conventional B-mode, power Doppler and elastography at same session. The results were compared with tissue diagnosis of biopsy specimens and fine needle aspiration cytology. RESULT: Our final result included 60 LNs, 33 reactive and 27 metastatic. The Mean of B-mode score of lymph nodes involved by metastasis was higher than that of reactive lymph nodes, 3.26 ±0.98 versus 1.00 ±1.12, and the difference was highly significant (P<0.001). While the mean for strain elasticity score of lymph nodes involved by metastasis was higher than that of reactive lymph nodes, 3.89 ±0.70 versus 1.85 ±0.76, and the difference was highly significant (P<0.001). The Mean strain ratio of lymph nodes involved by metastasis was higher than that of reactive lymph nodes, 5.04 ±1.96 versus 1.7 ±0.87, and the difference was highly significant (P<0.001). Overall sensitivity and specificity of B mode US was 81.5% and 90.9% respectively, sonographic elastography sensitivity and specificity 77.8% and 100.0% respectively, while the sensitivity of combined B mode and elastographic ultrasonography increase to 96.3%. CONCLUSION: The present study showed that combined ultrasound B-mode and elastography added significantly to the sensitivity of ultrasound differentiation among benign lymph nodes and those which are involved by malignant metastasis.


Article
Attitude Towards Mentally Ill People Among University Students in Baghdad

Authors: Mushtaq Talib Hashism
Pages: 408-411
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ABSTRACT: BACK GROUND: Recent literature show a high prevalence of stigma in Iraq toward mental illness, discrimination towards people suffering from mental illness is still common in Iraqi society and this can negatively affects the attitudes of university students to ward patients with mental illness and till now the publications of stigma among youth is scarce. OBJECTIVE: To estimate the prevalence of stigma against mental illness among university students. SUBJECTS & METHODS: A total of 405 university students from different governorates in Iraq. They were randomly selected from colleges of Engineering, Arts, Education and Science. Stigma was measured by community attitude toward mental illness questionnaire (CAMI) scale. CAMI consists of four subscale: authoritarianism (oppressive attitude), benevolence (sympathetic attitude), social restrictiveness (belief that mentally ill patients are threat to society) and community mental ideology (CMH1) (community oriented care for mentally ill patients. RESULTS: The age of participants in the study sample was 21.3 ± 2.5 year giving male: female ratio of 0.58:1. Students from Baghdad were 370 (91.1%), and 154 (38.0%) were living in houses of > 2 crowding index. Stigma was clearly noticed in 307 (75.8%) students. Three hundred ten (76.5%) were Authoritarians, 23 (5.7%) were benevolent, social restrictiveness was noticed in 298 (73.5%) and negative CAMI was seen in 320 (79.0%). Out of males, in the study (77.9%) and out of females 191 (74.6%), are showed stigma toward mentally ill patients, no significant role in developing stigma between sex and educational stages (p=0.4 for both). Both those with crowding index > 2 and ≤ 2 have no significant effect on stigma (p=0.2). CONCLUSION: High prevalence of stigma was noticed among university students.


Article
Seasonal Variation in Spontaneous Intracerebral Hemorrhage in Iraq

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ABSTRACT: BACKGROUND: Spontaneous intracerebral hemorrhage is the deadliest and most disabling type of stroke. Spontaneous ICH is defined as intraparenchymal bleeding in the absence of trauma or surgery. Seasonal effect on incidence of intracerebral hemorrhage had Longley been studied with unrewarding, and conflicting results. OBJECTIVE: To determine whether different seasons of the year had a relationship with the rate of primary intracerebral hemorrhage,and some of the factors that may contribute for this relationship PATIENTS AND METHODS: A total of 315 patients diagnosed as a case of primary intracerebral hemorrhage attending AL-Imamain Medical City were taken between December 2009 and December 2011. Females were 112(35.6%) and males were 203(64.4%) aged between 18 and 93 years old with mean age group of 59.298±13.7616. The diagnosis was based on history, clinical examination and non-contrast Computed Tomography scan of brain. RESULTS: Of the 315 patients, the highest rate of cases during December being 13.7% and the lowest during February and October being 4.1% and 4.8% respectively. Intracerebral hemorrhage rate among age group less than 55 years old being 42(34.71%) of 121 patients during summer. There was a significant relationship between winter season and intracerebral hemorrhage incidence among diabetic patients being 29(34.52%) of total 84 diabetic patients. 74(93.67%) of 79 patients presented during winter season had a large sized hemorrhage. CONCLUSION: The highest rate of intracerebral hemorrhage during December There was a seasonal variation in patient’s age, incidence among diabetic patients and size of hemorrhage.


Article
Knowledge, Attitudes, and Practices of Parents of Asthmatic Children in an Asthma Clinic in Baghdad

Authors: Nadia Aziz Nasir
Pages: 419-426
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ABSTRACT: BACKGROUND: Asthma is becoming increasingly prevalent among children in Iraq. Poor parent knowledge and attitudes often contribute to inappropriate management practices. OBJECTIVE: The study aimed to document the knowledge, attitudes, and practices (KAP) of parents of children with asthma and analyze how knowledge and attitudes relate to practices. The second objective was to study the effect of educational interventions with parents of asthmatic children on the future use of asthma controller medications and control status. SUBJECTS AND METHODS: A cross-sectional survey of knowledge, attitudes, and practices and educational intervention was conducted on 130 parents of children with asthma attending an asthma clinic in Baghdad. KAP scores were divided according to (Bloom’s cut off point 60-80%), and control scores were measured according to Global Initiative for Asthma (GINA) guidelines. RESULTS: There were 36 (27.7%) male participants and 94 (72.3%) females. The knowledge scores were high level in 83.1%, moderate level in 13.8% and low level in 3.1%.The attitudes scores were moderate level in 43.1% and low level in 56.9%, and the practices scores were moderate level in 9.2% and low level in 90.8%. One fifth of participants adhered to corticosteroid inhalers. There was no significant association between knowledge score and practice, and there was a significant association between attitudes score and practice. Use of controllers increased and asthma control scores increased significantly after the educational intervention CONCLUSION: Negative attitudes towards steroids use especially inhalational preparations played an important role and resulted in the unsuitable practice of asthma control. Educational intervention may increase the use of asthma controllers and asthma control scores.

Keywords

KEYWORDS: parents --- KAP --- asthma --- children --- baghdad


Article
Cytological Findings in Cervical Smear in Al-Anbar Governorate

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ABSTRACT: BACKGROUND: Cervical cancer is the 3rd most common cancer in women globally. There is variation in incidence & mortality between developing & developed countries is attributed to the national screening programs in the developed countries to detect cervical changes in addition to human papilloma virus vaccination. Human papillomavirus (HPV) is well known as a direct cause of cervical cancer. OBJECTIVE: This study designed to detect the percentage of cervical changes in Al-Anbar governorate. Study design: A cross-sectional study for detection of abnormal cervical smears. Study setting: Private clinic of gynecology & obstetric governorate & private laboratory of histopathology & cytology in al-Anbar. PATIENTS AND METHODS: A prospective study was carried out from January 2012 - July 2014, 450 patients were included in this study diagnosed at private laboratory in Al-Anbar govrnorate. Bethesda system was used to assess these Pap smears. Patients were analyzed for clinical data with special focusing on the age and the chief complaint. Pap smears were prepared from patients presenting with complaints like abnormal vaginal discharge, post-coital bleeding, irregular vaginal bleeding and dyspareunia. RESULTS : Among total of 450 patients , commonest age group at time of presentation was between 40-49 years (172 pateints). Most of the patients were presented with vaginal discharge include one hundred eighty eight patients (188) (41.8%). Others were presented with vaginal discharge include one hundred eighty eight patients (188) (41.8%) , others presented with vaginal bleeding, post coital bleeding & dyspareunia . The results of cervical smears were classified into non specific inflammation ( 150 cases) ( 33.3 %) , and abnormal pap smear results ( 300 cases). The results of abnormal pap smear include ASC-US (40 cases) (8.9 %) , LSIL (99 cases) (22 %) , HSIL (45 cases) (10%) , squamous cell carcinoma (25 cases) (5.5%) , AGC (21 cases), adenocarcinoma ( 0 case) & koliocytosis (70 cases) (15.6 % ). CONCLUSION: Regular cervical Pap smear is highly advisable to recognize premalignant cervical changes in sexually active female. HPV play a major role in development of cervical cancer. Cervical cytology is a simple, safe and effective test to detect premalignant and malignant lesions of cervix at an early stage, so help the clinicians in management of the patients.


Article
Establishing the Superiority of Topical Diltiazem Over Compound Cream in the Treatment of Chronic Anal Fissure: A Prospective Analytical Study

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ABSTRACT: BACKGROUND: Anal fissure is an elliptical ulcer in the anal canal extending from the dentate line to the anal verge; chronic anal fissure is a common problem across the world treated largely by surgical methods. The treatment for chronic anal fissure (CAF) has undergone a transformation in recent years from surgical to medical as the common goal is reducing the internal anal sphincter spasm. OBJECTIVE: To assess the efficacy of topical treatment with 2% diltiazem gel (DTZ) in patient with chronic anal fissure versus combination cream. MATERIAL AND METHODS: Consecutive 400 adult male patients with symptomatic chronic anal fissure attending the surgery clinic were enrolled in the study form February 2014- July 2016, 200 patients were treated with topical application of 2% DTZ cream, other 200 patients were treated with combination cream. Patients were followed up for 6 month at regular intervals for symptomatic relief and healing of fissure. RESULT &CONCLUSION: In our study diltiazem 2% gel was more effective than combination cream in the treatment of chronic anal fissure. .


Article
Single Stage Posterior Sagittal Anorectoplasty in Patients with Imperforated Anus and Recto Vestibular Fistula

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ABSTRACT: BACKGROUND: Malformations of the anorectum include a series of congenital lesions, ranging from a slight malposition of the anus to complex anomalies of the hindgut and urogenital organs.An anorectal malformation (AMR) occurs in one out of every 4000 to 5000 newborns and is slightly more common in males. There is no specific cause of AMR has been described. The most frequent defect in males is imperforate anus with a recto urethral fistula while in females is a recto vestibular fistula. Imperforate anus without a fistula is unusual defect, occurring in about 5% of the entire group of malformations, and is associated with Down syndrome. OBJECTIVE: This prospective study was undertaken to evaluate the safety and feasibility of primary anorectoplasty without a protective colostomy using the posterior sagittal anorectoplasty (PSARP) technique in patients having vestibular fistulae, its complications, results, and outcome. METHODS: From January 2012 to November 2014, 20 patients with imperforate anus and vestibular fistulae subjected to single-stage surgical correction at Children Welfare Teaching Hospital in Medical City in Baghdad were followed prospectively for six months; their ages were range from 2 days -2 months. Routine blood investigations such as hemoglobin, blood sugar, renal function tests, serum electrolytes, blood group and Rh in addition to blood preparation was done. X-ray for the chest and pelvic spine with abdominal ultrasound and echocardiography also done to rule out any associated congenital anomalies. Patients who had undergone a staged repair were excluded from the study. All patients were assessed for complications including stenosis, infection, prolapse, excoriation, dehiscence and constipation. RESULTS: Anal stenosis (10%), mucosal prolapse (10%), superficial wound infection (10%), wound dehiscence (5%), constipation (5%) and excoriation (5%). Mortality was nil. Apart from one patient who needed re-do operation with protective colostomy, all patients with complications were successfully managed by local wound care, antibiotics, laxatives, enema, anal dilatation, and dietary changes. CONCLUSION: Single stage anoplasty without protective colostomy can be done safely and effectively as 3 stages operation in patients with imperforate anus and recto vestibular fistula in selected patients with less burdens on the baby and family.

Table of content: volume:16 issue:4