Iraqi Army·medical Journal - WordPress.com · 2012. 1. 9. · Iraqi Army :\Icdical Journal, Vol. 12 No.1 & 2 2000; Vol. 13 I\'o. & 2 2 I 001 3 water-buffalo, camels and dogs which

$Page 1: Iraqi Army·medical Journal - WordPress.com · 2012. 1. 9. · Iraqi Army :\Icdical Journal, Vol. 12 No.1 & 2 2000; Vol. 13 I\'o. & 2 2 I 001 3 water-buffalo, camels and dogs which$

Iraqi Army·medical Journal

Vol. 12 No.1 & 2 2000 Vol. 13 No.1 & 2 2001

PUBLISHED BY THE DIRECTORATE OF MEDICAL AFFAERS

Baghdad - Iraq

Iraqi Army medical Journal, Vol. 12 :\'o. I & 2 2000

Vol. 13 :'\o. 1 & 2 2001

Editor in Chief

Deputy Editor

Associate Editors

EDITORIAL BOARD

.\Iaj. General (Dr.) Galib T. Salman .. .\ / .\.c (.\Jed Hdlirhti. ) ( 'w /"{)

.\laj. General (Dr.) lliasll A.:\1-Shamma, .\J.Nc '.F ({.'1\j, FlU '.F (c;;, FlU ·.F (lj

.\Iaj. General (DL) l\lushrik i\L Hilmi, .\ !.H Ch.H .. US, FH. C.S l\Iaj. General (Dr.) Abdul Zahra Gizer Daish, .\f. H. ('h. 8., IJ.i\ Jed Hchuh.(/ondon;. Brigadier (Dr.) Tal"ik .\I. .\bdull:l. Hn.S., Hn.n .. F!J.S.l<.C.S Brigadier (Dr.) \'uman Sarhan Ali, .\!.NC. 1\ydr. n.F.\1., I J. C..\'. B1·igadier (Dr.) H.iadh .-\li \'illad, .\I H.Ch. H. n.s Brigadier (Ph a r.) .\I usa b .J .. \meeu, H.\'c. (}'hurmucT) .. \!.Sc. (.\/unc/iL·s~c·r.{ A/ Bl'igadier (Dr.) Shakir ~\L\1- .\nachi . . \J.fJ.( 'h.H. J) ('h. (Unh;././.1 .\/..\ rUnh.;

Brigadier (Dr.) I..:aydar :\L\l-ClJafabi . . \IS.c (.\led Hl·!whlrl.), .·ll!l .\hums ,C ·urm.

B1·igadier (D1·.) l\Iohammad R. .\1-ililli, /J.A!.R.IJ., FI.C '.A!.S (Hwlio drugrwsr.\).

General Editorial Secretary l\laj. General (Dr.) l\Iohammed Ali F.Al-Bayatii.

M.HCh. H. !J.C'h. rOnh.;. F !U ·.s. (!_i./)

.-\dministraiin• Secretary :\laj. General of Staff (Dr.) I las him I I. llashim . . \1.8.( 'h.H,.\J.Sc.

Financial secretary

Colonel (Dr.) Khalaf Gate Hussain .\1-:\loil:illladi;, i . . H.Hc 'h.H Fi.C .. \J.S

Colonel (Dr.) ;\lazin Kouther Abdul Latif. .'\!. H ( 'h. H

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Contents in English

Page 1- the Utility of 2-mercaptoethanol Test in Brucellosis ( 1 -8)

Azzams. Alzubaidy, Khalid Jumma Khaiel, Shakir Al-Enachi ............. .

2- Bone Graft And External Splint For Non-Union Of Carpal Scphoid. (9-12)

Tarik Kerellah AL-Asadi, Mohammed Ali Fat he! AL-Rayatti .............. .

3- Pediatric CNS Tumours in Iraq A study of 613 Cases.

Suhail N A. AI- Salam ........................................................... . (13-25)

4-Intraspinal Tumours In Iraq A Study Of248 Cases (26-34)

Suhail N A. AI- Salam ........................................................... .

5- Acute Appendicitis Incidence and Features in Relation To Anatomical (35-42) Position

Adil Karim AI- Hamdani, Ali Hassan Abdul Haddi ........................... .

6- Goitre in Iraq over the Period From 1985- 1995 ( Befor and After the (43-54) Embargo)

Husanz A. Karinz .................................................................... .

7- The Management oflarge bowel injmy (55-58)

Fatik Abdul-Salam , Ghaith Ahmed ........................................... .

8- Eight Years Review Of Malignant Thyroid Tumors (59 -70)

Adil Karim Al-Hamdani, Mehdi Abdullah Al-Sarraj .......................... .

9- Cholecystectomy Concomitant with other Intra-Abdominal Operations (71-8 1)

Mr. HusamAbd-Alkarim, Mr. HasanAhnzedHasan .. ..................... .

10- Clinical Aspect Of Chemical Analysis of Urinary Calculi (82-89)

Mowcif.Jak Abdul Baki, Ala 'a Al-Deen Al-Dabbagh .......................... .

11- Computerized Artificial- Intelligence Knowledge Cluster (90-96)

Data Analysis Applied on Diagnosis of Rheumatological Diseases

M WahhabAl-Khatib ······························································

12- Evaluation Of The Uses OfProplast In Iraq And Maxillofacial Surgety (97-105)

Ayad Abdul Khalic, Taric M Abdulla ......................................... .

13-Attention- deficit/ Hyperactivity disorder among School- children in (1 06-11 0)

Numan S, Ali, A.K Salman .................................................... .

·pa(Je I b

(I -8)

13-25)

26-34)

..}5-42)

'3-54)

-70)

il-81)

'105)

! 110)

Iraqi Army Medical Journal, Vol. 12 No.1 & 2 2000; Vol. 13 ::"\o. 1 & 2 2 001

The Utility of 2- mercaptoethanol Test in Brucellosis

(*J Dr.Azzams.Alzubaidy

r J Dr. J(Jzafid Jumma Khaiel

r J Dr. shaldr Al-enachi

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(*)C.A.B.l\1 .. D.l\I.. M. B.Ch.S., Internist, Arifroce Hospital.

< >JVI.B.Ch.B., M.Sc. (Haematology), Haematologist, Airforce Hospital

l 1D.Ch.,F.l.C.M.S.(Ot·th).M.B.Ch.B,. orthopaedic surgeon Hammad shehab militm·y Hospital

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The Utility of 2- mercaptocthanol Test in Brucellosis 2

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Abstract:

There has been an indication that human brucellosis is an endemic disease in Iraq. Jt is a chronic disease in which symptoms and signs arc nonspecific.

Brucellosis is not only a serious health problem but also a serious cconom1c one.

In this prospective study a total of ( 143) patients [ ( 65%) were males and (35%) were females with M:F 1.86: I] were found to show a reactive Rose Bengal test with a maximum incidence being ( 65.8%) between third and fourth decade of life. Blood samples were collected & then first screened for Brucella antibodies by microplate agglutination test, reactive sera were further analysed by standard tube agglutination test and 2-Mercaptocthanol tests. Only (39) patients out ofthe total (143) ie. (27.2%) were proved to have active disease.

In conclusion we advice the utility of 2-Marecaptoethanol test to discriminate between those with previous exposure to Brucella antigens who need no treatment and those with active disease in our countrv unti I more sensitive tests become more available in Iraq. Key words: Brucellosis ,Rose Bengal test, 2-Mcrcaptocthanol test.

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Introduction:

Zoonoses arc a significant health problem in many industrialized and developing countries and continued ctlort is needed to control them. As the trade in animals and the animal products and the movement of people is increasing, the risk of introduction and reintroduction of certain infectious zoonotic disease is growing( 11 .

Human brucellosis is a zoontic disease of world wide distribution. Although it has been almost eradicated in some countries, or at least its prevalence has declined. brucellosis is still an important public health problem

in other countries, especially in the Middle East (2.

31 Table ( 1 ). Brucellosis is not only a serious health problem but also a serious one. It has been estimated that the pi-c\·alcncc of brucellosis among cattle \\·as 4% goats 9.9(% while among sheep in north part of Iraq was 0.93% c71

.

There is a direct link between brucellosis in animals and man irrespective of how one enumerate cases, it is clear that bruceliosis has become endemic in the human

l · · (1-\161 7' T bl popu at1on m Iraq · · ·' 1 a c

(I). The mam brucellosis Ill

species the

causmg Eastern

Mediterranean region arc brucella melitensis and brucella abrotus infecting sheep, goats, cattalc,

Iraqi Army :\Icdical Journal, Vol. 12 No.1 & 2 2000; Vol. 13 I\'o. I & 2 2 001 3

water-buffalo, camels and dogs which provide the sources of human infection by ingestion, direct contact and accidental inoculation. Raw meat containing remnants of lymphatic tissues and blood from infected carcasses also contain viable organisms.B. melitensis often (Jives rise to amore severe b

form of infection than B.abrotus, the disease may present as acute from. The symptoms include lassitude , headache and muscular or articular pain and drenching sweats especially at night. The illness is labeled chronic when it persists or recurred over a period of six months or more. The only noteworthy abnormal sign is palpable spleen found m a minority of patients (IJ_

Some of studies on human brucellosis have been hospital -oriented, Al-Nadawi et.al. (1994) Stated that there has been nearly one case of Brucellosis for every (I 000) children admitted to Baghdad hosptitals the diagnoses in the majority of cases depends on Rose Bengal agglutination test (1.3).

(84) Patients were reviewed from the period (I 977-1984) from medical city teaching hospital with diagnosis of Brucellosis using Rose Bengal test (I 5J.

( 4) Iraqi patients with neurobrocellosis were reported by AL-Araji in Hammad Shihab Military hospital the diagnosis were based on positive Rose

Bengal test from CSF of those patients 1

I:2J. however,

seroepidmiological study were carried out in south of Iraq were out of ( 653) human sera only ( 41) showed positive Rose Bengal test, the estimated incidence of human Brucellosis was ( 6.2 7% ). Brucellosis can be acute, subacute, or a chronic disease in \vhich clinical symptoms and signs arc non-specific. Therefore diagnostic laboratory tests arc required to confirm the clinical diagnosis & to minimize the cost of investigating a case of PUO in an area endemic \Vith brucellosis. It is worldwide accepted that ELISA test Is the most significantly compared test with blood culture, therefore it is the most sensitive test in current use.More recently PCR technique is increasingly reported to be rapid, easy to perform & highly sensitive & specific , but the problem of cost & availability of· these two tests still exists in, om .. country\ i '· ~~i.

Other tests such as Rose Bengal plate test (the most \vidly used test in Iraq ) which is easy, rapid to perform, cheap highly sensitive with good specifity but has the disadvantage of remaining positive for months or even years

''I) after successful treatment '' . The 2-Mercaptoethanol test is used to investigate patients with chronic brucellosis (5) . Those who show a positive rose Bengal tests are examined with 2ME &if they show a positive titer of (I /40) or

i:

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The Utility of 2- mercaptoethanol Test in Brucellosis 4

above they are regarded to have active disease & treated accordingly.

Weak solutions of 2-Mercaptoethanol destroy the inter-chain sulphydryl bonds of gamma globulins. IgM antibodies treated in this way are destroyed while IgG antibodies are not (S).

IgM is the major agglutinating antibody formed in the first few weeks following infection with brucella organisms, there after IgG levels rise. The Rose Bengal test measures both IgM & IgG. With adequate therapy, IgG antibody levels usually become undetectable while patients with persistent brucella infection usually maintain elevated IgG antibodies (6J.

Since a substantial number of patients have elevated IgM antibodies for years after treatment, 2-Mercaptoethanol test helps to identify those who have been cured (6 J.

This study focuses on the the discrimination between those who had serological evidence of exposure to brucella and those with active disease by using 2-l\1crcaptoethanol test(2-M.E test).

Patients and Methods This prospective study (hospital based) was conducted in the period between March I 997 to feb. 2000 on (143) patients, presented with complaints suggestive of brucellosis ; where five ml of their blood were collected and blood allowed to

clot for one to two hours at room temperature. After centrifugation (1500g for 15 minutes), serum was carefully transferred to a plain tube. .

All sera were initially screened for anti-brucella antibodies by micro-plate agglutination test. The technique done as followed: l.Bring the serum tested and the antigen used to room temp. (25°C~'17 4C 0

).

2.Place (30ul) of serum on flat transparent clean glass, then add an equal volume of the antigen. 3.Mix the serum and antigen thoroughly using glass rods. 4.Move the plate vigorously in a wide circle ( 6) times clockwise followed by (6) circle anticlockwise.

5.After exactly ( 4) minutes has been elapsed, read the result (Alton P83-84, 1988) Positive .sera were_.Sltbsequently tested by standard tube agglutination with 2-Mercaptoethanol test which was prepared as following: I. 2-Mercaptoethanol (O.Imol/1). 2. NaH2P04.2H20(150m mol/1). 3. NaH2P04(150m mol/1). The PH of this solution was 7.2, kept at 2-8C.

A positive 2-Mercaptoethanol test with a titer of 1/40 and above ·is

d d . d. (18 19 70) regar e as active Is ease · ·-No blood culture or other tissue culture studies (which are 100% specific for the diagnosis of brucellosis were carried out due to the lack oflaboratory facilities).

Iraqi Army :\lcdical Journal, VoLI2 No. I & 2 2000; Vol. 13 No.1 & 2 2 001 5

Results 143 patients were found to have positive anti- brucella antibodies with a titer ranged from 1/80 to 111280. About 70% of patients have titers of 11160 and I /320. Using· 2-Mercaptoethanol test only 39 patents proved to have an active disease ( 27.2%) , Table (2).

Ninety three of sero-positive patients were males ( 65%) and only 50 (35%) were females with a M:F ratio of (1.86: 1). The age varied from 7 years to 78 years with a maxmium incidence (65.8%) between third and fourth decade of life Table (3 ).

Table (I): Number of reported cases of brucellosis in the Eastern

fvlediterranean l'egion during the period 1989- 1997.

(Eastern Mediterranean health J.vol . 4 No.2(1998 ))

~Country

i Ira q

i Jordan I I Saudi I j Arabia

Libya

Syria i

j Palestine

Egypt

Iran

I 1989

2464

628

7076 I

262 I

1691 1 398

92211

1990 1991 1992

2816 13106 14546 I

729 933 716

9025 7335 7184 I I

I I 102 I 65 135

I - I - I 768

I

551 352

250 233

72219 58222 42833

1993 1994 I 1995 1996 I

1997

- 10332 i 10332 - ! -i I

750 770 956 903 640

6985 4929 5997 6023

I I I

I i I

I I 131 - I - - -I I I I

I 1391 I 3457 I 2980 I -

I -

I

493 404 501 527 233

216 305 490

40880 25952 29888 27572 17155

i I

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The Utility of 2- mercaptoethanol Test in Brucdlosis (.

Table (2) :results of Rose Bengal test and- 2- iVlercaptoethanol test for

Brucellosis.

Titre I

Rose Bengal test 2- lVIercaptoethanol test Number o/o

I

l/80 I 33 23%, I

I i

1/160 I

58 40.6 1Yo i i

1/230 i 44 30.8 ! I

1/460 I 7 4.9o/o I 111280 I 1 0.7%,

Total I 143 1 00'% I

Number %,

1 2.6 1~1

I 6 4 I~~~

14 35.9 1~1 ----- -----~-----

7 17.9 1% ------~

2.6 1~) --39 1 OO<~<~

Table (3) : the age and sex distribution of seropositive patient's and those

with active disease.

-~--------·----Age I

Rose Bengal test I 2- 1\lercaptoethanol tcsf

I

I i (year) /1V1ale I

I Total CYo) )1\Iale I Female Female Tot"1 1 ';1 ) .. '/",

I I I

I I I ! i I I j I 1-9 12 I 1 /3(2.1%)) i 1 '0 1 1(2.6'~~>

I

I I I i I I /11 /3 / 1 4(9.8<Yo) !4

,---10-19 : 1 I I

I ! I

20-29 ! 30 /17 )47(32.9<Yo) I 1 o i6 I 16( 41 <Yo> ! I i '

/26 I I I 30-39 : 21 I 47(32.9%,) i'7 !5 /12(30 1~1) I I I i

I 40-49 i

Is I 29(20.2 1Yo) i

! 4(1 O'~J) i 21

12 i2 I

I I I I i Above 13 lo i 3(2.1'Yo) I I I I

10 I I (2.6<~1) I I I 50

-r---·------------- --·-Total I 93(65'%) I 50(35'%) : 143(lOO<YoO ; 25 : 14 : 39(27.2 (1;;) I

---~------·-------- --- -

(;

Iraqi Army :\ledical Journal, Vol. 12 :\o. 1 & 2 2000; \'ol. 13 :\o. I & 2 2 001 7

Discussion The Rose Bengal test IS the only

laboratory test available in many

laboratories in Iraq. The test has a

high sensiti\'tty and specificity but

its disadvantage is that it remains

positive for a long period after treatment.

Patients with fever and a history of

brucellosis may be misdiagnosed as

newly infested because the Rose

Bengal test remains positiye for less than one year.

'1 Mercaptoethanol test is less

sensitive than ELISA test m

detection of the disease but it is

cheaper . and can differentiate ne\v

cases from those exposed previously

to the disease which still show a

positive Rose Bengal test for a long time after treatment.

It has been estimated that the

sensitivity or complement fixation

test, 2- Mercaptoethanol and ELISA

99.5%) respectively the specificity of

complement fixation test, 2-

Mercaptoethano! and ELISA are

(79, I% , 81 A% ,86.3%) respectively (II)

The limitations of 2-Mercaptoethanol Jre mainly the biohazard of this reagent which is

carcinogenic, it takes about 2 hours

to be performed while ELISA takes

much shorter time about half an hour ill)

In our study it was found that only

J2__(27.2%) out of (143) patients

with positive Rose Bengal test, have active disease using 2l\1E test.

These figures are much more than

those reported in Saudi Arabia in

which only (2.3%) of positive Rose

B I 1 ' d' (lilJ} eng<L cases 1m c active 1sease ·

The explanation for that is in our

study we choosed patients with

symptoms and signs suggestive of

brucellosis while in Saudi Arabia the

sample was randomly selected by a

house to house

survey ( 19.2<!/u of population were

found to h<:ne a Rose Bengal test

positi\'e \Vith or\\ ithout symptoms).

Our study emphasised the fact that

brucellosis is n1ore C01111110l1 in adults with a peak between third and

fourth decades of life (65.8%) \Vith

male predominance (male /female

ratio 1 ,86/i) due to the fact that they

are more commonly exposed to

animals m the course of their

occupation. These findings are

identical with that found by Ali. et

al. 1998 1 IUJ in which male to female

ratio was ( i .9/1) while third

&fourth decades of life constituted

(54.9%) ofpatients with brucellosis,

Also in agreement with that reported

by AI-Shaarbaf et. al.l985,(50%) ( 15 '

f, , . l 3 rd j 4th o patients were 111 t 1e am

decades and also with that recorded by AL-Nadawi (UJ et.al. were male/

female ratio was ( 1.4/l ). In conclusion , we advised the utility

of 2- Mercaptoethanol test as

serological test in our conntry in

which the disease is endemic to

exclude those who have evidence of

exposure to brucella antigen who

need no treatment because it is cheap & available.

References l.Jiont FAO/vVHO committee on Brucellosis

expert

sixth

r

'i ,:~

'i

The Utility of 2- mercaptoethanol Test in Brucellosis 8

report 'VHO technical report series 740 (1989).

2.A wad R. Human Bbrucellosis in the Gaza-strip, palestine Eastern Mediterranean Health journal vol. 4 no.2 ' ( 1998).

3.Al-Mufleh Ibrahim Abdul-Karim, brucellosis in Epidemiology in Annals of Saudi no.3( 1996).

Saudi Arabia: the central region Medicine Vol. 16

4.Al-moslih moslih. I., Al-Mula zuhair M.Al- Samuraee S.S. seroepidemiological studies of bruscellosis in cases of fever of unknmvn origin in Baghdad .Iraq. Medical Journal Vol. 38, 39(1989-1990)

5.Alton, G.G. jones L.M. and piets. D.E. laboratory techniques in brucellosis and ED. Geneva WHO (1973 ).

6.Wyng J.B. smith H.L., Cecil textbook of medicine 18th

Edition.Pl676-1679. Jr. W.B. Saunders company ( 1988 ).

7. Zaidan A. R. prevalence of brLicellosis among friesian

Cattle in Iraq. The veterinarian vol. (4-5) 1994-1995.

8.Cooper C.W. prevalence of antibody to brucella in asymptomatic well individual in Saudi Arabia J. Trop. Med. Hyg. ( 1992). (Abstract). 9.Albaila S.R.epidemiology of human brucellosis in southern Saudi Arabia J.med Hyg. 1998 (185-9) 1995 (Abstract).

1 O.Ali M.,lat. Bajrany .Reddy .Raghava. Brucellosis in a rural

community Saudi medical J. 1998 Vol. 19 (298-300).

11. Alton G. G., Jones L. M., Angus R.D., Verger J. M., Techniques for

the Brucellosis laboratory. Institute Nati. De. ca Rechcrchi Agronomiqui 17, rue de I 'Univ. 75007 Paris (1988).

12.Al-Araji A. H.'{., Nouri K. A.,

Tawfik M. R., Ne- urobrucellosis A report of4 Iraqi patients J.fac .Med. Baghdad, vol. 40, No.:4 ( 199~). 13.Al-Nadawi M .. Al-Be!nlli A. A. R .. , Al-Zuhairi R.A.. childhuod Brucellosis in Baghdad J. Fac. :\led .Baghdad, vol. 36, No.3 1994. 14.AL-Zawi H.S., Lall A.Sh., A study on Brucellosis in AI- anbar government. J.Fac Med. Baghdad (vol. 36, Nol) ( 1994)

15.Al-Shaarbaf H. H., Yahya l-LI., Brucellosis in Iraq : study of K4 cases. Iraqi medical journal vul. 36 No.1 (1985).

16.Al-Adhami S.B.,Jawad A.H., seroepidemilogical study on

Brucellosis in Iraq Bulletin of endemic diseases Vol. XX XXX 1 No.4 1982.

17.Ajmal M., Naflc E.K.. AlHashimi J. M., AI-Alusi F .. serological survey of brucellosis in human population in the south of Iraq. Iraqi Med J. No.2&3 vol 24 Nov. 1978.

18.AI-Araji A., Al-Shaarbaf H., symposim on brucellosis college or med1cine -Baghdad. Nov.15 (I 099). l9.Russel Ao., Paton CM., Kaufman Af. Evaluation of the card test for diagnosis of human brucellosis J.clin. Microbial 1978:7 :454-8.

20.Young E.J., Serologic diagnosis of human brucellosis analysis of 214 cases by agglutination test and revievv of the literature. Rev. infect Dis. 1991. 13:359-72.

.-\i-

1 f .. 111

of 24

.H.,

Iraqi Army Medical Journal, Vol. 12 No. I'-~ 2 2000; Vol. 13 :'\o. I & 2 2001.. ....................... 0

Bone Graft And External Splint For Non-Union Of Carpal

Scaphoid

(*Jcor. Dr. Tarik Kerellaft AL-Asadi F!CflJS

(i)Jllaj Gr. Dr. Jlfolwmmed Ali Fat/ref AL-Bayatti, FRCS.

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Summary

Prospective study for treatment of nonunion of carpal scaphoid bone by Clearance of fracture site and impaction by cancellous bone graft from the iliac crest and stabilization by plaster of Paris ( P.O.P) thumb spica for 12 weeks. Thirty two patients, age range from 25--t2 years, vollar approach used, 95

1Ytl rate of union occurred, normal range of motion returned after 2-4 months of physiotherapy , power progressi\'ely increased to normal level. Follow up period was from 6-18 months, no residual complications encountered Internal fixation with bone graft is widely practiced by different devices with good results, with our limited resources we found P.O.P. external splint with bone graft ended in comparable good results. 5WWZli'ID%iCWRC7f W fd@!?t

(*) Hammad Shihab Hospital Baghdad- Iraq.

ci·) Hammad Shihab Hospital Baghdad- Iraq.

r

Bone Graft And External Splint For Nonunion Of Carpal Scaphoid ................................. 10

Introduction

Fractures of the carpal scaphoid is the most common fracture of the carpus bones and frequently diagnosis is delayed or missed and this may alter the prognosis of union ( 1

j. The blood supply of this bone is precarious and 35% of fractures of the proximal third may cause avascular necrosis and nonunion 11 !.

Nonunion of the scaphoid usually causes dysfunction of the wrist and hand in the early weeks and probably inevitable wrist JOmt arthritis in coming years depending on the amount of stress applied to 1 . I 7! t 1e \\T!St. -

Surgical treatment is necessary· for healing of fractures and to avoid complications. There are many modalities of treatment of nonunion and its sequel depending on the stage of disease and the life style of the patient

13!. Bone grafting is the

constructive operation first described by Matti and modified by Russe 1·1J; to lead the fracture to unite and arrest the process of degeneration and improve the condition of the hand and wrist 15

Y_ Internal fixation of the bone is added by many surgeons as the use of kirschner wires IC'X

7!. or screws like Herbert

IXJ • j d . screw · , or cannu ate compressiOn (lJJ · 1 IUJ screw· , or compressiOn staples .

prolonged periods of cast immobilization also needed to guarantee bone union, psychiatric background of the patient were also found to affect the result of treatment of nonunion 111 !.

More complex procedures were used on cases of severe avascular necrosis or cases reluctant to heal by the above mentioned methods; pronater Quadratus pedicle bone graft for old fractures

1121, scaphoid allograft also

used to compensate for the excised necrotic proximal pan of the scaphoid with promising success 1131.

Patients and methods This is a prospective study from January 1993- March 1998 ofthirty two patients vvith established symptomatic and radiologicai signs of nonunion of the carpal scaphoid, 31 males and l female, their age' ranged from 25-42 years, mean age was 34 years, fracture sites were at the junction of the proximal 1/J with the distal 2/3 of the bone, no arthritic changes were evident in any of the wrist joints. Period between initial trauma and diagnosis was 6-12 months, mean 9 months most of the cases were not diaunosed before

0

and some of them were treated as sprain of the \Vrist by volar splint for l-2 weeks. Fracture displacement \Vere less than l mm and scaphoiod lunate angle less than 45 degrees, no associated injury of other bones, one patient had ischaermc necrosis of the proximal piece. Grossly c!Jsplaced fractures and small proximal fragment fractures were excluded from the study. The volar approach used and technique of l\ilatti-Russe (

1 1 was follm.ved. The graft used was

lozenge shaped peg with small pieces of graft around the peg from iliac crest. The wound closed by two layers and below elbow thumb spica of plaster of Paris applied for 90 days. The wound inspected through a window in the splint and stiches removed after 2 weeks. No drain used. Antero posterior X-ray done post operatively. The graft usually did not show in the early days but the extent of excavation and position of the scaphoid is noted post operatively. P.O.P is changed after 2

Iraqi Army i\lcdical Journal, Vol. 12 No. I & 2 2000; Vol. I3 No. I & 2 2001. ........................ 11

months and removed by the end of the third month when X-ray is done to follo\Y the progress of healing and union of the bone, elastic bandage is applied to the wrist and gradual use of the hand was encouraged for

'-'

further 2 months after which union was checked radiologically and all activities were allowed. Twenly two patients \Vere followed for a period of one year as mean time 10 patients for 18 months. ln the two patients who did not show progressive healing the P.O.P sp1ca was extended for further 2 month, clinically they felt better and refused to have further treatment. Results Total number of patient was 32. Period of follow up was one year as mean time range 6-18 months. Union \\as evident radiologically by the end of the third month and progressed on ovel- the next 3 month m .JU patient (95%>) of the total number range of motion of the wrist and power of grip increased gradually and became almost comparable to the other side by the 6

1h post operative month, 5-7degress

loss in dorsiflextion was residual in 18 of the patients. The patients were instructed to do their own wrist exercise because of difficulty in attending physiotherapy department. T\\O patient (5%) did not shmv complete union radiologically after the 6

111 post operative month, their

local symptoms and signs were better than before surgery but they \vere not keen to have another operation of bone graft. T\o complications took place, surgical wounds healed uneventfully . without infection.

Discussion l\:onunion of the scaphiod was studied for many years and most authors agreed that bone graft with stabilization of the scaphoid is the proper treatment; with progress in technology several methods has been used namely the Herbert screw· 151 ,

Ao(ASIF) canulated screw 11'J ,

compression staple U! , K.wires 11' 1

and vascularised bone graft 1s 1 for difficult cases, these methods gave good resuits, hmvever, they demand surgery and mav need another operation to remove the device. The use of these devices did not decrease the period of cast wearing !Xi I'JJ d d' l I . 'fi . . an r 1(, not SlOW Siglll !Cant decrease in the time of healing 151,

J.D \~1ULDER and Annaklinek from the 1\ctherlands ( 1988) had 97~·o good result in 100 patients treated by \-latte Russe bone graft \vithout fixation device i..J

1 Lawreuce H.Schnerider gained 87S/o union of scaphoid using Russe procedure( I 982Y 11

')

Diego L Fernandez \-1.0, l\arau from Switzerland ( i 990) had 95Su union with use of cortical lag scre\v lag technique to fix the bone graft with short cast immobilization 1171.

Most operation of implant fixation need variable time of preoperative X-Ray screen control. Because of unavailability of different de\ ices to fix the bone and frequent lack of fluoroscopic facilities in the theatre we have used the original IV1atte-Russe technique by applying hard cancellous bone graft from iliac crest to impact the prepared fracture site and external P.O.P splint and gained equally good results compared to studies used fixtures to the bone, we admit that we selected our patient of stable

1!'1!'''

,,,

llonc Graft And External Splint For Nonunion Of Carpal Scaphoid ................................. 12

minimally displaced fractures and with large proximal piece and \Vithout degenerative changes. \Ve think in selected cases this method is good option for the merits it cany Our follow up was not prolonged ( 18 months) because of nature of doctor patient relationship in our community as the patient do not visit the clinics for academic reason and tend to disappear when satisfied with their conditions. Conclusion The use of cancellous bone graft with P.O.P splint is less demanding surgically and less costly and resulted in good results (95%) in most of our patients. \Ve recommend this treatment for non union of carpal scaphoid bone. References 1 .S. Teny canale, campells operative orthopedics, 91

h edition, vol 4, Mosby 1994. 2.Allende Bt: osteomihritis of the wrist secondary to nonunion of scaphoid, intorthop 12:201 1988. 3.Frenz cc, Frenundlich Bo, Proximal row carpectomy for open fracture dislocation of the carpus , J trauma 27:85 1987. 4.Mudlen JD: the result on 100 cases of pseudoanhrosis in the scaphoid bone treated by the matti -Russe operation, J Bone Joint surg 50-b: 110 1968. 5.Cooney wp, Oobyns JH, nonunion of scaphoid , analysis of the result from bone grafting ; J hand smy , SA: 343 1980. 6.Stark H H, Rickard Ta, Treatment of ununited fractures of the scaphoid by iliac bone graft and K. wire fixation ,J. Bone and Joint surg 71A ' 1201 1989. 7.Campra, cosio MQ : Multiple percutaneous pining of ununited

scaphoid fracture , Tech. Onhop 1:64 1986. 8.Bunker T.D, me Namee PB; the Herbert screw for scaphoid fracture; multi center study , j Bone Joint surg, 1987. 9.Rankin G Kuschnen sH , : A biomechanical · evaluation of cannulated compressive screw for use in fractures of the scaphoid , J Hand sug. 16-a: 1002 1991. lO.Korkala Ol,Antti - Poikau: Late treatment of scaphoid fractures by bone grafting and compression staple osteosynthesis ,J Hand surg 14-A:491 1989. ll.William C Kim, John \V, Shaffar , Failure of treatment of ununited fractures of the carpal scaphoid , J Bone joint surg, vol 65a no. 7 sept 1983. 12.Kawai H, Yamamoto K: Pronator Quadratus pedicled bone graft fm: old scaphoid fractures, J.Bone Joint surg, 70-13:829 1989. 13.Peter R. Carter, MD the scaphoid allograft for very proximal, necrotic nonunion scaphoid J Hand surg, vol 14 A no. I Jan 1989. 14.Gllman H, Caputo RJ comparison of short and long thumb spica casts for non displaced fractures of the carpal scaphoid .J Bone Joint surg. 71 -A : 354, 1989. 15. Trekelsen cJ. Jepsen Jm: Treatment of scaphoid fractures with removable cast, Acta onhop scand 59: 452 1988. 16. Lawrence H.schneider, M.D and PAT Aullcino, M.D Nonunionof the carpal scaphoid : the Russe procedure, J Trauma, vol 22, no 4, April 1982. 17.Diego L.Femandez, MD, Arau, Anterior bone grafting and conventional lag screw fixation to treat scaphoid non unions .J Hand surg, vol 15A , No A , No. I Jan 1990 140- 14 7.

1•-~HJi .-\rmy :\Icdical Journal, Vol. 12 No.1 & 2 2000; Vol. 13 No. I & 2 2001.. ................... 1:1

Pediatric CNS Tumours in Iraq A study of 613 Cases.

e·; Dr.SUHAJL 1VA. AL- SALAilf

:; y___ijl ~ jlib ':11 .s:. --?. jS yJI ~\ j~l r\ .J 5\ _y, 4J~ y::.c <i'YJ 5 4.:;\...,:W ~I .Jj ~

ji_;--.:J\ ""'_j ~,J_?l,JI ,_::J~ .)1 4-JL) ~~I w'Jk.JI ""'~ 5 .:i..w (1 -,- ~) ._:r ~_r-:JI

. ' ~ ~ o "\..c ~w ' ~ ~ 1 "\..c ..:r ~w1 5 1 ~ ~ •

~)-:JI i'I.J 5l 5 ~l:::...___._.JI i"\.J 5~\ l..L...c L_,. i"\.J 5~\ t-:'-·;~ ~~ ""'_j .JySiJ~ 4_::'rl j.9-?-5 .k,J

.b___:,.,J .Jr--Sill ~ ._:r ._,1:-\ ~L'j\ ~ ~LS ~ ~y.i'd\ i'I.J 5':fi 5 ~I ~5~ ~I (\ .--•) ..J.--> ~_r-:JI ~\ J~ ~ ~jSyJI ~~ ri.J 5':f~ ~La)~ ._._k_\ J ~lbS

.. I . ,,_JJ J-l-'-"

.. -_Ltl ·: ; ~~I I "I . ol " " .. \ . ·tl .t - .II , ...,_, 'I I I , , . ol . , . .':<'r-·~~ ~ (" _)_9J ~ /0 I I ~~ o-".Jr"-' L::.JG...i ( _)_9 ~ 100 ~ l!:. ~ _?ai

Summary

Six hundreds and thirteen cases of pediatric CNS tumours for the ages (0-16) y·ears were reviewed. Those were all the pediatric tumours that had been referred to the pathology departinents in Iraq dur-rng·the period 1986 through 1995: divided into two 5- years periods, 1986 through 1990 and 1991 through 1995. !vlales preponderance was noticed in most of the groups except for ependymomas, meningiomas, meningeal hemangiopericytomas, nerurofibromas and metastatic tumours. The peak incidence \Vas noticed during the age period of(6-JO) years. No significant changes were noticed in the total number, mean age, gender ratio and histological pattern in comparing the two 5-year periods.

Astrocytic tumours are the commonest pediatric CNS tumours comprised 540,/0 followed by medulloblastomas 22% craniopharyngiomas 6.20,-'S ependymomas 3.5%, oligodendroglioma 3.5% and other 10.8%. Astrocytic tumours are the commonest pediatric neuroepithelial tumors 62.8% followed by medulloblastoma 26%. About 94% of the pediatric CNS tumours were intracranial; ·of which 39% were supratentorial and 61% infratentorial. 6% of the tumours were intraspinaL

n l\I.B. ChB. l\1. Sc. F. I. C .M .Path.

1.

!i

:!

Pediatric Cns Tumours In Iraq A Study Of 613 Cases . . .1-l

Introduction The · CNS is · the second most common site for tumours in childhood. Unlike brain tumours in adults, a significant proportion of those occuning in children grmv relativity slowly and are associated with an excellent prognosis. '1 ;

Classifications of CNS tumours previously depend on classic histologic features, but important advances in immunocytochemistry , and cytogenetics have significantly altered the reliance on conventional histology12

;. i\/Ieeting on brain tumour classification have been held

. "1 at N1agara - on - the - lake (. J ,

Housten (clJ and Zurich. The latter two were sponsored by the \VHO. At the international meeting in Zurich in march 1990. A consensus was reached on a classification system of CNS tumours 15

J (table l ). Recently DNA ploidy has prognostic value in medulloblastma and glioblastoma in which tumours reassessing diploid or nearly diploid DNA contents have significantly poorer prognosis than aneuploidy. iCJ 7J I_} DNA . d . · · 10wever , m ex 1s not an independent prognostic factor in childhood glial tumours nn_ In malignant gliomas the degree of aneuploidy of the main stemline is not related to the biological behavior of the neoplasm (7J_ Proliferating nuclear antigens are important indices regarding the prognosis of gliomas Ki G7, a nuclear proliferating antigen, with its monoclonal antibody MI B-1, is important for predicting the clinical outcome in oligodendrogliomas. (lJJ

p53, a tumour supressor protein , over expression was noticed in gliomas, and may predicts the

clinical behavior of l r!()) tlem· Protooncogenes arc also important in pridicting the clinical outcome of gliomas as Netl/Erb-13:2, a protooncogene, high levels were noticed in high grade gliomas ancl low levels in low grade gliomas' 11 '-

lVIateriais and "''lethods The cases were selected by reviewing all the request forms and the histological reports of all the biopsies referred to rhe pathology departments in :-\1-Shaheed ,c\dnan teaching hospitaL Baghdad teacl1illg hospitaL Al-Rasheed military teaching hospital , Hammac! Shihab military hospital ,1\eurosurgical hospital , Central health laboratory , The institute of nuclear medicine and radiotherapy , the institute of forensic medicine Private laboratories , And to Iraqi cancer registry· center during the period 1986 through ! 995; divided into l\VO

5-year periods the first 1986 through 1990 and the second 1991 through 1995. The clinical data on the request fromy was considered 'HS

adequate. Six hundred and thineen biopsies \vere reviewed , and all the available sections \ven: examined by author. The routine staining method used is the haematoxvlin and eosin. i

121 phosphotungi;tic acid

haematoxylir1, periodic acid schif( Gordan and S\\eet's reticulin and alcian blue stains were used when needed.'

12: All the available

histological sections were examined by light microscope and the following histological features were assessed; predominant cell type, cellularity, nuclear atypia, mitoses, abnonnal mitoses, necrosis with pseudopalisacling . bizarre and giant cells , rosenthal fibers, perivascular

Iraqi Army l\Iedical Journal, Vol. 12 No. 1 & 2 2000; Vol. 13 No. 1 & 2 200 1.. ................... 1.'\

pseudorosettes , ependymal reosettes and canals, psammoma bodit"S, microcystic changes , calcifications , metaplasia, differentiation, invasion of CNS, leptomeninges and spines. All the biopsies were classified

according to the age , gender , site, and histological type finally the results ~vere compared with pervious reports and studies.

Table l

WHO classification of CNS tumours (SJ

!-Tumours of neuroepithelia! tissue i 2-Pineoblastoma

A Astrocytic tumours i 3-IVlixed Pineocytoma I pmeoblastoma i !

~--~ --·---------------;-----,-----------------~

I IEmbrynoal tumours I

!-Astrocytoma

: 2-Anaplastic astrocytoma

: 3-Glioblastorna

4- Pilocytic astrocytoma

: 5-Pleomorophic xanthoastrocytoma

i 1-l'v!edulloepitheliorna I

1 2-?\' euroblastoma

i 3-Ependymoblastoma

i 4-Retinoblastoma I

: 6-Subependymal giant cell astrocytoma I 5-Primitive neuroectodermal tumour I

; B Oligoclendroglial tumours ' : 1-0ligodendrogioma

i 2-Anaplastic oligoclendrglioma

[ a :Vledulloblastoma I

I b Cerebral or spinal PNET

/II-.\Ierve sheath tumours

i a Schwannoma : CEpendymal tumours , ~-----·-----------+f-------------------; !-Ependymoma i !-Cellular

/ 2-Anaplastic ependymoma 12-Plexiform

: 3-Myxopapillary ependymoma f 3-Melanotic ' I

i 4-Subepenclymoma I

j D.lVIixecl oligo -astrocytoma

/ l-IV1ixecl oligo - astrocytoma

I 2-Anaplastic oligo-astrocytoma

: 3-others

i E.Choroid plexus tumours

r !-Choroid plexus papilloma

i 2- Choroid olexus carcinoma I '

1 b l\ieurofibroma

/!-Circumscribed

I 2-Plexiform

i 3-Mixed neurofibroma /Shwannoma I i

1 sheath I f c.IVlalignant

I / tumour

( MPNST)

1-Epitheloid

peripheral nerve

2- MPNST with divergent mesenchymal

and /oepithelial differentiation.

Pediatric Cns Tumours In Iraq A Study Of G I 3 Cases ... . . I(>

F. Neuroepithelia! tumours of I 3-Melanotic

uncertain origin

!-Astroblastoma

2-Polar spongioblastoma

3-Giiomatosis cerebri

G.Neuronal and mixed neruonal -glial

tumours

f 1-Gangliocytoma

I I

1 ' . 1 III Tumours of menmges

i ATumours ofmeningothelial cells i

' ~

B Mesenchymal

tumour

non- meningothelial

C Primary melanocytic lesions

0-Tumours of uncertain orgioin

2-Dysplastic ganaliocytoma of IV Haematopoietic neoplasms ----, ' 1 cerebeilum.

3-Desmoplastic

ganglioglioma.

infantile V.Grem cell tumours

f 4-Dysembryoplastic I neuroepithelial ) VI-Cysts and tumour- like lesions

:tumour

1 5-Ganglioglioma

J 6-Anaplastic ganglioma

1 7-Central neurocytoma I

! 8-0ifactory neuroblastoma ! ' H Pineal tumours

VII Tumours of sellar region

/ VIII local extension from region tumours

IX Metastatic tumours

X Unclassified

~~~~---------r-----------------, l-Pineocytoma ..

Results

Six hundred and thirteen biopsies were reviewed with overall male to female ratio of 1.4: 1, and an overall

age - adjusted incidence (0- 1 6years) of 0. 72/1 00.000 children,

0.8/100.000 for males and 0.621100.000 for females.

The distribution of all pediatric

CNS tumour groups is shown in Table 2.

Army Medical Journal, Vol. 12 No.1 & 2 2000; Vol. 13 r\o. 1 & 2 20<Jl ..................... l7

Table 2

0.5 0.2

4 0.6 42 7 II 2

613 100

of all pediatric tumours ups are shown in table 3.

accordinu '=' to the histological

Table 3

gender distribution of 613 biopsies

! Female fvlale : Female 142 1.3 : I 47 i. 9 : I 12 0.75: l 7 J. 1

4 : I ,..., .) 3 : 1 ,...,

5 .) 0.6 : I 2 2: I 0 ,...,

.)

5 8 0.6 :I 2 0 1 ,...,

.) _,...,

. .)

2 2 1 0 2 2:

,..., .) ,..., .

J. J .... 1 : l 18 l. l : 7 : 0.6: l

260 1.4 : I

age distributions of all pediatric tumours are shown in table 4. peak incidence was noticed during the period ( 6- I 0) years.

Table (4)

i \

Pcdiatnc Cns Tumours In lraq A Study Of() Ll Cases. .IX

Ependymomas 5 !9 Oligodendrogliomas 0 29 38 Pineal body tumours i 0 50 50

--.

25 25 ! Choroid plexus tumours 3 7 5 r---' Schwannomas 0 ~ 1

..l'-t G6 ~----------------.-----·

T\eurofibromas 0 33 I iVJeningiomas j 0 '1 l

I ~,

..)--j

rr:-femar;giomas I 50 ( ....... ' --~~· ---------- --·-·-----------

Hemangiopericytomas 0 i 0 · 0 l 00 --·- --j-------------------·-- ··-·-·

i Haemangioblastomas 0 1 50 _ 50 Q _____ _ : Germ cell tumours 0 ; 0 1

, l 00 0 l_~on Hodgkin's lymphomas ~ 0 33 ~..,

.) _)

C:ysts 0 ,, ...:... _; 25

Pituitarv tumours () 25 (' .J ~ i-

!0 5 9

Craniopharygiomas 0 · i

\iletastatic tumours I 0

The age-adjusted gender predominance are summarized in table 5 Table 5

34 50

75

The age- adjusted gende'r perdominance of 613 biopsies of pediatric Cl\S tumours

Histological subgroup 0-2 years

prcJominancc

Male Female

3-5 yean

prcuominann.:

Mall! Female-

6-10 ~ L'ar; l 1 -lii Yl'a r.,

predominance p r\..·Jocn in a 1iU.c

FL'Ill ale -r-~-:;~i-!c_;:~~~k' I .

:Vlak r--:- . . i Astrocyttc tumuors +* + + ~--

l\lcdullobbstom~s + + -t------- -, ---'---~--- ··--,----- ·---~---, -r-

Epcndymom~s

i-. , Ultgodcndroghom~s

l\lixcd gliomas

Pmc~l bodY tumours

Choroid plexus tumours

Sclm ~nnom~s

j l\curofibromas ' t i :v1cningiom~s '

'T!cm~ngiom~s

Hcm~ngiopcncytom~s

II-bcmangiobbstom~s

i Germ cell tumours I

+

00

()

0

()

()

()

{)

()

0

=· ()

() 0

(i ()

+ +

() ()

()

()

0

() ()

() +

()

+

-{)-~---+

() +

+

-t-

-------;----

T

---------: --1) 0

-----+-------- i---------'

i --r ----t----------- --,

' -i-

() ----~--+---,----+ ---.,---------

+ +

-;- +

0 +

() () 0

+

() +

~------+--- -------------, T

r--- -~ ----~

() ------i---(-1-------.

0

-r

,- () I i -- __ ,, o; o

_i_

H ---:·

+

0

+

lJ

0

Iraqi Army l\Iedical Journal, Vol. 12 No. 1 & 2 2000; Vol. 13 ::\o. 1 & 2 2001.-........... ." ........ l ')

Non Hodgkin's () 0 .......... ~----~.----~--~.-

+ + +

lymphomas ; .__,_

(). ' !

Cysts () -1------ --t--------~----------~ --

+

I I (),

I Pituitary tumours ()

Craniopharygiomas () () -----.-~-----;·--------------. -----. ·-

+ +

---------------+----+--~----+--~--------r----·----:·· --------r------r----------·-;--------------- --() l\'letastatic tumours o + +

* -~ Predominant : -Not predominant •= equal tumours o 0 no tumours

------~~ _______ i_ ___ -- --- ____ _:__ ______ --

. The distribution of the tumours according to the site is summarized in tabk 6. Table 6

The site distribution of 613 biopsies of pediatric C::\S tumours. -------~--------

II istological type Supratentorial lnfratentoriai lntraspinal '-------------~--~ --------------"-·-------------~-------- -<

Comzlwm·st site Commonest

site site

Frontal --------:------, . -·------

Cerehl'lium 5 Thoracic '--.--------------!----~------------,----~ ------·-------- -· ------+----- -------.

. ·-·--·--------- ----·--------- i----------~

Jl)

lkmangiope ricytomas

I lannangioblastomas ()

i Germ cell tumours 100 I

;j Non-Hodgkin's lymphomas ! 100 ~

~ Cnts GO li •

. Pituitary tumours 100

Cen:bellum 0 ·---------r------,---~------·-----·--- ·------ - -···------ .

Ventricles : 2-1 , Cerelldlum , 75 Lumbosacral

Frontal 20 ; Cerebellum 0

0 t--------+------~--------- ; ___ ____j_ ___________ ·-------

' u . 0 '

50 CPA** Cenicai

Frontal Thoracic

Frontal ~----~----i--------~-- ··----------·----

] 00 · Cere!Jelluzn 0

Thalamus 0 ,------ - ____ .;_____ _____ ~----·--------

(I

Frontal () ----------,-- t· ---~ .. -·-··-----

' 0 i ' i

Cercbcllu-~~ 2t,--r----L~~~-~~ -----~ i !

Fnmtal 20 ----,-~--- t··----------

Scllar regin 0 1 0 , I '

~~~--~--~-----------+---~--~~----~----~--~--------------r-- --~-----------Craniopharyngiomas 100 Sellar regin 0 1 0

i\lctastatic tumours 82 Frontal ()

INTRACL'ANTAL 9-I'V.,

31) Frontal 1 Gl '

I

Thoracic +----t I 18 I

I --1----r-------: I I ----r---;-------------

--· r·-· ------~

Cerebellum i i ---------'----'---------~---'----- ____ ! ----·----'---~---------;

Pediatric Cns Tumours lnlraq A Study OfGl3 Cases.

* Vent : ventrical, ** CPA : Cerebellopontine angle.

Five hundred and twenty three biopsies were neuroepithelial tumours which constitute 85% of all

. .20

pediatric CNS tumours, with male to female ratio of 1.43: 1. The frequency and gender distribution of pediatric of neuroepithelial tumours are shovvn in table 7.

Table 7

The frequency and gender distribution of 523 biopsies of pediatric

nueroepithelial tumours.

Histological subgroup i Male 1 Female l\1ale · female Total 0/0

I I

1 Astrocytic tumuors 186 I 142 13. 1 328 62 8 I

!

I Medulloblastomas I . ~----------~'

89 I 47 i9. 1 136 26 I

~ I

~

Ependymomas ! 9 12 0.75. 1 2l 4 I

Oligodendrogliomas I !4 I .., 2: l 21 4 I i i

:'vlixed gliomas 4 l 4. I . ' 5 _j

Pineal body tumours .., ] 3 : 1 4 (\ 7 .) v. ,'

Choroid plexus tumours ..,

5 I 0 6. 1 8 1 5 .)

Total i 308 [ 215 143 • 1 ~'!..., 100 L

) __ )

The frequency of microscopical findings in neuroepithelial tumours are shown

in table 8.

Taole 8

The frequency of microscopical findings in neuroepithelial tumours.

l Iistologiratype I>i lll·r~._·natiation

-

~

~ I

~ i ~· !

" r /

~ '· s· I~ " :;. .5 I ;l· a. z j 'z ;::::·

! ~ I :i:

... ' --: --: l

f I §.: I ~

~

~ ~

~-I f.

-'

·~ ~ -- ~

0

--: -:; I

I ~

lOU% i -+0°/u .t0 11/o

l I

Flhni!rv 21 o;u

.\~t\lr..:\'tdina

:25u;u 100% 70 11/o

I I

100%

95 11/u ! -W 1Yu

I I I

100'% I

lUO% I 60°/o I

i)Ilocytic

astrncYlnma

,\napiasllc

o.o

62 8

.26

..f

4

(l 7 v.;

L5

100

i Army l\Icdical Journal, Vol. 12 No. 1 & 2 2000; Vol. 13 No. I & 2 2001.. ................... 21

The frequency to astrocytic tumours

hundred and twenty eight

were astrocytic tumours

according to the grades are

summarized in table 9 and I 0.

male to female ratio of 1.3: 1.

Table 9

The frequency of pediatric astrocytic tumours according to the grades

Grade I Grade II Grade Ill Grade IV l

Anaplastic astrocytoma ioblastoma 12(% 51 ~'0 '}'"">0/

L..) /0 14% 12% 61% 61% II~·o

1 I% 56% 20% 13% Table 10

The frequency of low and high grades astrocytic tumours

Gender Low Grade High Grade

Males

Females

Total

:vledulloblastomas : One hundred thirty six biopsies were medulloblastomas with male to female ratio of 1.9:1. The frequency , age distribution, gender distribution , the site distribution, and the microscopical findings are shown in tables 3,4,5,6, 7,8. Ependymomas :

(Gh-II) (GIIh-IV)

63%

7'"'0/ ; ..) /0

37%

/701 ~, :lo

Twenty one biopsies were ependymomas with male to female ratio of0.75:l. The frequency, age distribution , gender distribution, the site distribution, and the microscopical findings are shown in tables 3,4,5,6, 7,8. The distribution of the biopsies according to the grade are shown in table 11.

Table 11 The distribution of 21 pediatric ependymal tumours according to the grades. Gender Grade I I Grade II I Grade III Grade IV Males 22% r 78% I

Females 16% I . 76% 8% ~

I I

Total 20% i 75% 5% :

Pediatric Cns Tumours In Iraq A Study Of 613 Cases .. ..22

Oligodendrogliomas: Twenty one biopsies were oligodendrogliomas with male to female ratio of 2:1. The frequency, age distribution , gender distribution , the site distribution , and the

microscopical findings are shown in tables 3,4,5,6, 7,8. The distribution of the biopsies according to the grades are shown in table 12.

Table 12 The distribution of 21 biopsies of pediatric oligodendrogliomas according

to the grades. Gender Grade I Grade II Grade III Grade IV Males

Females Total

Mixed gliomas Five biopsies were mixed gliomas with male to female ratio of 4:1. The frequency , age distribution , Gender distribution, site distribution , are shown in tables 3,5,6,7.

Pineal body tumours Four biopsies were pineal body

tumours with male of female ratio 3: 1. The frequency, age distribution

gender distribution and site distribution are shown in tables 3,4,5,6,7.

Choroid plexus tumours Eight tumours were choroid plexus papillomas with male to female ratio of 0.6: 1. The frequency, age, gender , and site distribution are shown in tables 3,4,5,6, 7. Cranial and spinal nerve tumours Schwannomas Three tumours were schwannomas

with male to female ratio of 2: 1. The frequency , age, gender, and site distribution are shown in tables 3,4,5,6. Neruofibromas Three tumours were neurofibromas all are females. The frequency, age ,

78% 85% 81%

22%

14% 15%) 50/

/0

gender, and site distribution are shown in tables 3,4,5,6.

Meningeal tumours lvf eni ngiomas Thirteen tumours were meningiomas with male to female ratio: 0.6: 1. The frequency age , gender, and site distribution are shown in tables 3,4,5,6. Haemangwmas Two tumours were haemangiomas, both were males. The frequency, age, gender and site distribution are shown in tables 3,4,5,6. H emangiopericytomas Four tumours were

hemangiopericytomas with male to female ratio of 1:3. The frequency, age ,gender, and site distribution are shown in tables 3,4,5,6. Heamangioblastomas : Four tumours were haemangioblastomas with male to female ratio of 1: 1. The frequency, age ,gender, and site distribution are shown in tables 3,4,5,6.

Germ cell tumours One biopsy was a teratocarcinoma in the hypothalamus , in an eight -year boy.

!

es shown

Anny Medical Journal, Vol. 12 No. 1 & 2 2000; Vol. 13 No.1 & 2 2001.. ................... 23

iNon-Hodgkin's Lymphomas :"Three tumours were Non-Hodgkin's 'Lymphomas , oflarge cell type. The ,frequency , age , gender, and site distribution are shown in tables

cysts were seen. The frequency , age , gender , and site distribution are shown in tables 3,4,5,6.

Tumours of sellar region Pituitaty adenomas

Four tumours were pituitary The frequency, age,

gender, and site distribution are shown in tables 3,4,5,6. Craniopharyngiomas Thirty-eight biopsies were craniopharyngiomas. The frequency, age, gender, and site distribution are shown in tables

~·Ietastatic tumours Eleven tumours were metastatic tumours. The frequency , age , gender , and site distribution are shown in tables 3,4,5,6.

i Discussion CNS tumours show a

incidence rate when • compared with other studies carried ,out in Europe or USA. In a study carried out in Berlin °31 The incidence rate of pediatric CNS tumours for males and females was 3.1 and 2.59/100.000 children per year respectively, compared with 0.8 and 0.621100.000 children per year in our study. This lower incidence rate of pediatric CNS tumours in our

might be due to low

autopsy rate, deficiency of diagnostic and therapeutic facilities, deficiency of skilled neurosurgeons , poorly centralized tumour registry center and different population structure; as in our country half of the population are in the pediatric age group( 0-16) years. · About 94% of the biopsies were intracranial and 6% were intraspinal which is the same ftequency in

I 3) , Staneczck study ( · 93.6% and 6.4 for intracranial and intraspinal tumours respectively.

Astrocytic tumours They are the commonest pediatric CNS tumours in Iraq and comprised 54% of all pediatric CNS tumours compared with 37.8% (JIJ, and 40-60% in other studies (l

4 J. Most of the astrocytic tumours were infratentorial in location (58%) and pilocytic astrocytomas predominate the low grade cereberllar astrocytomas, while supratentorial tumours comprised 37% of all astrocytic tumours; compared with Crist et al study Cl

4J in which 50% of the tumours were supratentorial and 50% were infratentorial. The peak incidence for cerebellar astrocytoma was between 6-l 0 years of age which was the same in Crist et al study (I

4J . low grade astrocytoma comprised 63% of all astrocytic tumours, while high grade astrocytomas comprised 3 7% compared with 80% and 20% for low and high grade astrocytomas respecitvely. Recent studies have identified a number of factors that are associated with a survival advantage in children with high grade astrocytomas including an extent of

Pediatric Cns Tumours In Iraq A Study Of 613 Cases .. .2-t

resection more than 90% of the tumour, tumour location within cerebral hemispheres, histopathological grade 3 versus 4 , young age and the use of post operative chemotherapy in addition to inadiation therap/ 15

).

The proliferation index as assessed by MIB-1 monocolonal antibody is an important prognostic marker in children with malignant gliomas 115

)

Medulloblastomas They are the second most common pediatric CNS tumours and comprised 22% of all pediatric CNS tumours , compared with 17% in Rorke studyl 16

l and 14% in 13) staneczck study l They are

located in the cerebellum which usually present as midline mass. Glial differentiation predicts poor I. . I ( 111 c mica outcome ·.

Ependymomas They are common in children making up 3.5% in our study and 13% of pediatric CNS tumours in Beaker study l

18l and 11% in

staneczck c13l study. Most of

ependymomas were intraspinal 57% , in which myxopapillary type is the commonest type, and 24% were infratentorial and 19% were supratentorial. While in beaker study c18l they are 10% , 65% , and 25% , for intraspinal, infratentorial , and supratentorial respectively; suggesting a different pattem.

Craniopharyngiomas They are the third most common pediatric CNS tumours in our study comprising 6.2% compared with 10% in Beaker study 08l, and they

are confined to the sellar region , are histologically benign tumours.

Oligodendroglioma They comprised 3.3% in our study which seems higher than other

d. Ill i81 · d'f'C stu 1es · -· · suguestmo a 111erent ' b b

pattem. The remaining tumours constitue a low proportion of pediatric CNS tumours.

Conclusion !-Pediatric CNS tumours have a lower incidence rate when compared with western studies. 2-Astrocytic tumours are the commonest pediatric CNS tumours followed by medullobastomas and craniopharyngiomas.

Recommendations 1-Improvement of autopsy rate. 2-Improvement of Iraqi cancer registry center. 3-Improvement of diagnostic and therapeutic facilities. 4-Initiation of neuropathological center.

References 1-Gjenis F, Kilnkin L. Long - term prognosis in children with benign cerebellar astrocytoma. J Neurosurg 1978; 49: 179. 2-Rorke LB, Gilles FH, Davis RL Becker LE. Revision of the world Health organization classification of brain tumours for childhood brain tumours. Cancer 1985;56: 1869. 3-Becker LE. An apprasial of the world health organization classification of tumours of the central nervous system. Cancer 1985;56: 1858.

-term

Iraqi Army 1\lcdical Journal, Vol. 12 No. I & 2 2000; Vol. 13 No. I & 2 2001.. ................... 25

4-Beaker LE. Primitive neuroectodermal tumours. View on a working classification . In : fields WS,ed. Primmy brain tumours : A review of histologic classification. New York: Springer -Verlag , 1989:59.

5.Kleihuesp, Burger PC, and Scheithauer B\V. Histologic typing of tumours of the CNS. Geneva \VHO. 1993:1-15. 6.Zerbini C.Belber RD, Weinberg D, and et al. Prognostic factors in medulloblastoma including DNA pliody .J clin oncol 1993; 11: 16 -622.

7.Felice G,Chieco P, Lisignolo G. comparison of cytologic composition with microfluorometric DNA analysis of the glioblastoma multiforme and anaplastic astrocytoma. Cancer 1987;60:59-65. 8-Mathew P,Look T, Luo X. DNA index of glial tumours in chidren. Cancer 1996;78:881-886. 9-Kros JC , Wop WCJ, Godschalk J, Krishnadath K. Prognostic value of the proliferating -related antigen Ki 67 in oligendroglioma . Cancer 1996; 78: 1107-11 I3. 10- Tsuzuki T, Tsunodo S, Sakaki T, Konishi N, Hiasa Y, Nakamura M. alterations of retinoblastoma, p 53, pI 6 and pI 5 genes in human astrocytoma. Cancer 1996;78:287-293 . I I- Krist D, Yardon Y. Differences between phosphotyrosin accumulation and Neu/erd-B2 receptor expression in astrocytic proliferative process: Implication for glial oncogenes, Cancer 1996;78: 1272-1283.

12- Bancroft J, Stevens A. eds . Histopathological stains and their

diagnostic uses. Churchil Iivingstone. London 1975. I 3-Staneczek \V, Janish \V. Epidemiology of primmy tumours of the CNS in children and adolescents. Pathology I 994; 15( 4 ): 204-215.

14-Crist WR, Kun LE. Common solid tumours of childhood. N .Engl. JMed 1991 324:661-671. 15-Pollack IF. Campbell J\V. Ronald JI-f, Martinnea AJ, Bozik fv1E. Proliferation index as a predictor of prognosis in malignant gliomas of childhood. Cancer I 997;79:849-856.

16- Rorke LB. The cerebellar medulloblastoma relationship to neuroectodermal Neuropathological 1983 ;42: I.

and list primitive

tumours. J Exp Neurol

17-Janss AJ, Yachins AT, and silber JH. Glial differentiation predicts poor clinical outcome in primitive neuroectodermal tumour. Ann Neurol 1996;39:48l-489.P 18-Becker LE, Halliday \VC. C\S tumours of childhood. Perspect pediatric pathol 1987; 10:86.

Intraspinal Tumours In Iraq A Study Of 2-+~ Cases . 2(,

Intraspinal Tumours In Iraq A Study Of 248 Cases

(">DR. SlJHAIL N. A. AL -SALA!\1

'""""AW Tar·----~ z ,,_,..,._..,~.,·---e-w HES&W!-~"7iVTIW7Wtw-wrreew· ·r,k"'j·f··- ;t'n',;e~·m-cw>J '?~~·ww-z?crr-eif~f'Trr-·:r""···~eynt"~ to-,.t. ~..,. "· .,_-.,.-·~ry~---~' r

•• t I .-II .. 'II q ~~-- \ I ll I \' ·;II • 1 ;; .cl =· • •''\ ;; ; .••. ~ 1: . .--lJ. '--l /, ~. ~ o ·· . ~I ;>I I c /. "\..JL.::.. 1 <U..J 11 o -w.JLAJ o '"-l.l\.A "'--'-"I •j ~ J "'-?' "? ...l .• • I J..l "-" .. .T-:-......1 ..l •• ../ '-"·· -'

~ -lzi.J ~ '\ '\o ,.b ~w : '\;\ -~ ;>lc ·'-"' ~ .-:;n ,L;q ..J ~~ ~~ ~~ ~ Ji ~ \ •• I.,_,---~~"-?~··· _._ ~-~

~L.c 4..cw ~ '\ '\ 1 ,Lc ·'-"' :~liJI o \ '\ '\ 1 4..cw ''\,\ -~ ;>lc ·'-"' ~ ,-:;n J ,;;1 : ·w:;h w J! \ •" I '-' ·• _I .• \ L....-1 - ~ ~ .../ V.• J .._;,

. 1 '\ '\ 0

.:JI 1 ·11 I ,_ri;:JI ;; . ' i I -"I I ""'>' .. ~~~C. ' ~~ Oi \~J. :~ 1...?. .. __; . . _/ _) ~ I · ,n 'I · · .. I 1- ..,_, 1 o u " ~ ..::~ .-3 ~ '-'-1J -, .a.::.._...w ;>.J

_.l '...? ' ...../.·- "-:? •• i

· .. ·:L '-l\ ;;._: ,li:, -;~ ~i ',\i! ''·I ·~~ J ___,._.. ;-- JJ"" "'-v~

~J~ 4 ;),.,_.J\ 1-----::)t~Ji r\.J 5\ ~ 32~0 lc ~ fo'il '-,?~ ~~\ :"!.J5

';JI G.ii.S5

. 18% ~~ L)GJI ) , ,\j 22°·o ~I .. . .. _,/_, . . .. *'itt'·-._, . ..,-,-'"'"'~· ~-'-'r_., . ..., .. ,.,_,t · · -p ..... ·-- --,..·:::-·nr- -~-~'r<-~ • .,.,_ '-=-·····s .... ffi'"&"'i ..... ~ft'·{· -- ···· · ~--,··· -..-~,"'~ · ......... _ .. _,.., '"'-.:: ..... ·

-.;;:,.-tz··· '(

Summary

Two hundred and forty-eight biopsies of intraspinal tumours were reviewed , which \Wre all the intraspinal tumours that were referred to the pathology departments in Iraq during the period 1986 through 1995, divided uno two 5-year periods . !\o significant changes were noticed in the total number, mean age , gender ratio, or the histological patterns of all intraspinal tumours in comparing the two 5- year periods , \·leningiomas \Vere the comn1onest intraspinal tumours 32%, follm\ eel by ependymomas 22°/o, astroc.ytic tumours 18% , nerve sheath tumours l ~ ~o, secondaries 6°,0 and others S~'u. Epencly·monas -''ere the commonest primary intramedullary tumours 53%, follmvcd by asrrocytic tumours 44~/o_ and others 3~0.

!M&of" rnc - f · ·canv=y·-... · ·?c-z .. ·-.ewctt·y~-,-.. .,..-. __ .,., ___ ·-zfaetl>.

Introduction The intraspinal neoplasms a count for about 15% of all primary C\iS tumours and its sheath elements-' 11 A somewhat lesser male preponderance is round in spinal gliomas and more female preponderance is found in spinal

. . l. b II I menmll;Ionws reac 1m~ a out 4: I. · ~ '-'

ASTROC\'TIC tumours most commonly affect the thoracic or

") ;\JB. Ch. B., :\I. Sc., F. I. C. .1\1. Path.

·. ·· .--.. ~-· t· • * , -wtn 7

- ~c· s· · z r·· k?r -~,.-r nc 1-- -·-au~ --- .. 1

. d ... _ ·Yt

lower cen ico-thoracic region and are intrameclullarv tumours tcndinl!. - '-'

to arise more dorsally than ventrally and near the midline .. "\dults are much more commonly affected than children,_::;

OLIGO DE\. DROG LIAL tumours rarely affect the spinal cord: they may appear as \Yell -demarcated masses of soft. grayish-pink tissue

Iraqi Army Medical Joumal, Vol. 12 No.1 & 2 2000; Vol. 13 No.1 & 2 2001.. ................. 27

largely in the white matter . Cystic changes are common. C

2J

EPENDYfviOMAS

Show prediliction for the foUith & fifth decades of life, constituting the most common intramedullary neoplasm of adulthood C

3 J. Roughly half of all ependymomas originating at spinal levels involving the conus medullaris , filum terminale , or cauda equina ; these are typically of myxopapillary type. (-II The structure of myxopapillary variant bears ceitain resemblance at light and electron microscopic Ieveis to the conus medullaris and filum tennina1e; they show predilection for third, foUith and fifth decades of life. CSJ A recent report suggesting that childhood ependymomas harbor DNA sequences closely related, if not identical , to those of simian virus 40 (SV 40) , suggesting a possible pathogenic role .(GJ

MENINGIOMAS usually favor the thoracic region , cervical examples being uncommon and lumbar lesions are rare . l

2l They are usually dural

based , however there are rare examples of epidural, cutaneous, or even outside the neuraxis, in the mediastinum , lung or brachial plexus .c

2; Most of meningiomas are

encountered in middle adult life (7).Females are afflicted far more common than males and meningiomas frequently expressed progesterone and androgen receptors , which indicates that the growth of meningiomas is subject to hormonal influence (SJ.

Schwannomas usually present in adulthood as tumours of lumbosacral pinal extramedullaiy space , they exhibit a predilection for sensory divisions of the neuraxis , typically

involving the posterior roots . They usuaiiy assume a dumbbell configuration. Most (<J)

neurofibromas represent manifestations of type 1 (classical or peripheral von Recklinghausen's disease) transmitted in autosomal dominant fashion by a locus on

<) chromosome 17 c J

METASTATIC tumors involve the spinal cord by direct extension or by heamatogenous metastasis or seeding via CSF for primary brain tumours _ '2:

:\1aterials And 1\lethods Tl 1 t 1 ' 1e cases \Vere se1ec eu oy reviewing all the request forms a-nd histologic reports; which were all the cases that had been referred to the pathology departments 111 AI -shaheed Adnan teaching hospitaL Baghdad teaching hospital, Al -Rasheed military teaching hospital, Hammad Shihab military hospital,· Neurosurgical hospital, Central health laboratory, The institute of nuclear medicine and radiotherapy, The· institute of forensic medicine, private laboratories, and to Iraqi cancer registry center through the period of ten years : divided into two S - year periods , the first 1986 through 1990 and the second I 991 through I 995 .

Two hundred and forty- eight biopsies \Vere reviewed. All the available stained sections have been examined by the author, then the findings were compared to the report issues at that time . The routine staining method used is the haematoxylin and eosin stain_(IOJ Phosphotungistic acid haematoxylin

Gordon & Sweet's reticulin and periodic acid schiff stain were used when needed (IOJ All the available

Intraspinal Tumours In Iraq A Study Of 2-t::i Cases

sections were examined by light microscope and the following histological features were assesed ;predominant cell type , cellularity . nuclear atypia , mitoses , abnormal mitoses, necrosis with pseudopalisading , bizarre and giant cells , rosenthal fibers,perivascular pseudorosettes , ependymal rosettes and canals , psammoma bodies , microcystic changes . calcifications, metaplasia ,differentiation , invasion of cord . lepton;eninges and spines. For each nllcroscopical feature \Ve put the vvord present or absent Then the biopsies were classified into groups and graded according to the

Table

.. 2X

WHO histological criteria 11 1) Each

group of intraspinal tumours had been studied seperately to determine the overall incidence . age and gender distribution and the frequency of each microscopical change . Finally the results \Vere compared with pi·evious reports and studies. Results Two hundred and fourty eight biopsies were revie\\ed with O\ erall male to female ratio of 1: 1.25 . the frequenc) and gender distributiOn are shown m table ( 1)

The frequency and gender distribution of 248 biopsies diagnosed as intraspinal tumours for t_l1e_Qeriod 1986 through 1995

HISTOLOGICAL GROLP \1 . F i\.lF T u. /0

-<------ ---- . --,.- --t---~--

• ASTROCYTIC TUMOLRS 27 IX l 5 i -+5 !X r-OL-l GOD E\ r5IZOGL I 0\ (\S __ _

----.------------- -~--- -- ·-- -------t-- -.- -----------~--------

' 2 --~--~1 -~~-~~--~--- () ::; --------

'i-i- 22 ---··t---

' () -t

,-----

1() 2-1 i.25 1 -----~.----------:------:_:_:::c_:_::_____;_ __ ~ • EPE:--.:DY\10\lA-=-S __ _

lGAl\GLIO!\ELROMA ~~~--~~- ·----- ---------r-------- ---+----.

<I ' '-+ ~

• ~ERVE SHEATH TL\10LRS 17 I I l , . 1-/ ---- ----------------;----

• iv!ENINGIOl\!AS I 5 (J-1- "() ! .L ....

I t---~-.

I ()X . I-t~__;_~_:__

: HAMANGIOPERICYTO\!AS ·----~~-------;- ~ 7 i 2.7 : HEMANGIOMAS -r--2-~:-----;----;--·l2.5

' ENTEROGENOuS CYST " ~----'-'--'----+------+-iCHORDOMAS · METASTATIC TUMOURS

: TOT A:.:· =--L.~----~~---~~-~

Primary intraspinal :\euroepithclial Tumours: One hundred and two biopsies \Yere diagnosed, and the frequency, and

Table 2

I ()-f

() : ') :0 1 ' ,~"~~ X , .).l 0-~---()------,.

]() I -) 2 I -~-·t ---~----

2--lX llll.l _l_I_l_ .. ,_ .. -~~7--l-l25

gender distribution are shown 111

table 2.

The frequency and gender distribution of 102 biopsies diagnosed as neuroepithelial tumours for the period 1986 through 1995

-----~----~-------~~-----~---------

HISTOLOGICAL GROUP M F tv!F 1 T % ASTROCYTIC TUMOURS 27 18 1 5 I 45 44

EPE)JDYfY·JOfvlAS i 30 i 1 25 I 54 1 53 t

OLIGODENDROGLIOMS I 1·1 2 i '

~ GA~GLIONEUROMA 1 I TOTAL 58 44 1.3 I I 02 100

Iraqi Army Medical Journal, Vol. 12 No. I & 2 2000; Vol. 13 No.1 & 2 2001.. ................. 29

Astrocytic tumours

Forty-five biopsies were diagnosed :, as astrocytic tumours with male to

female ratio of 1.5:1. The overall peak incidence was in the 3rd decade the mean age was 30.7 years. S.D.l7.5 years. the median 32 years, and the range 2-65 years. There was no significant change in the total number, mean age, gender ratio, and histological patterns in comparing the two 5- years periods. Grade II is the most common type , comprised 65% of the biopsies , Grade I 6%) . Grade III 20% , Grade IV 9% Thoracic region is the most common site Low grade astrocytomas (Grade I+ Grade II) is the commonest type, comprised 71% of the biopsies while highgrade astrocytomas (Anaplastic "Grade III" +Glioblastoma "Grade IV" ) comprised 29% .

Oligodendroglioma Only two tumours were diagnosed as oligodendroglioma grade II, with mean age of 36 years and gender ratio of 1: 1 .

Ependymomas There were 54 biopsies diagnosed as ependymomas with male to female ratio 1 .25: I . The overall

k . . d . h 4th d "rd pea mc1 ence was m t e an .)

decades for males and females respectively. The mean age was 26.1 years S.D.11.9 years, the median 26 years, and the range 4-52 years. There was no significant change in the total number, mean age, gender ratio, and the histological pattern in comparing the two 5- year periods. Myxopapillary ependymomas comprised 40% of all ependymomas, with male to female

ratio of I: I, and showing predilection for filum terminale and conus medullaris regions . The mean age was 25 years, S.D.7.8 years, the median 27 years, and the range 15-40 years.

Ganglioneurorna Only one biopsy was diagnosed as ganglioneuroma in a 30- year old female.

NERVE SHEATH TUMOURS There were 34 biopsies diagnosed as Schwannomas with male to female ratio of 1: 1.2, The overall mean age was 30.8 years, S.D.15.4 years, the median 3 0 years, and the range 3-60 years.

These tumours are divided into Schwannomas and neurofibromas Schwannomas

There were 22 tumours diagnosed as Schwannomas with male to female ratio of 1: 1.2. The overall mean age was 32.2 years. S.D.14.3 years, the median 30 years, and the range 8-60 years, The peak

d . incidence was in the 3r decade. Cervical and thoracic regwns are the commonest sites. Neurofibromas There are 12 tumours diagnosed as neurofibromas with male to female ratio of 1.4: l. The mean age was 28.3 years, S.D. 16.2 years, the median 28 years, and the range 3-60 years. The peak incidence was in the 4

1h decade. Cervical region is the

commonest site.

In nerve sheath tumours no significant changes was noticed in comparing the two 5- year periods. MENINGEAL TUMOURS Meningothelial tumours There were 79 biopsies diagnosed as meningiomas with female to

Intraspinal Tumours In Iraq A Study Of 2-1-8 Cases ______________ .. -· ____ 3()

male ratio of 4:1 . The overall mean age was 46 years, S.D. 13. 7 years, the median 50 years, and the range 9-65 years . The peak incidence was in the 6th decade. There was no significant the two frequency

changes in comparing 5-year periods. The

and gender ratio of

Table 3

histological variants are shown in table 3 Psammomatous meningiomas are the commonest type and the dorsal (thoracic) region is the commonest site .

The frequency and gender ratio of the histological variants of meningiomas for the neriod 1986 through 1995

Psammomatous HISTOLOGICAL VARIANT l MALE I FEMALE l M:F I T

2 Transitional

lial

atous Total

Non-meningotheliaJ tumours Hemangiopericytomas Only two biopsies diagnosed as hemangiopericytomas, both were males with a mean age of 27.5 years. Hemangiomas There were seven biopsies diagnosed as hemangiomas. with male to fema-le ratio of 1:2.5 . The overall mean age was 3 7 years, S.D.l6.6 years, the median 42 years , and the range 9-56 years. Dorsal spines are the commonest site.

Cysts

Enterogenous cyst Only one biopsy was diagnosed as enterogenous cyst in a 45- year old male, it was intradural and in the lumbar region (L4-5). Local extentions from regional tumours Chordomas Eight biopsies were diagnosed as chordomas , with male to female

4 7

15

29 -17 -l 1 -7 -

0 I i 1 I

I 64 I 1:4 79

ratio of 3: 1 . The overall mean age was 37.5 years, S.D.21 years, th median 33.5 years, and the range 1-77 years. All the tumours were in the sacrococcygeal region . Metastatic tumours There were 5 biopsies diagnosed as metastatic tumours, with male to female ratio of 2:1. The overall mean age was 27 years, S.D. 1&.7 years, the median 25 years, and the range 1-64 years, dorsal spines \Vere the commonest site, and adenocarcinoma is the commonest type.

Discussion The intraspinal tumours comprised 15% of all CNS tumours (lJ ,while in our study they comprised 1 0%, possibly due to the variation in the pattem of CNS tumours . The frequency of intraspinal tumours in our study and slooff et al (l

2J study are summarized in table 4

Iraqi Anny Medical Journal, Vol. 12 No. 1 & 2 2000; Vol. 13 No. 1 & 2 2001.. ................. 31

Table 4 A c arison between our stu and slooff et al (12)

HISTOLOGICAL OUR STUDY SLOOFF et al study GROUP

Nerve sheath tumours 14% 29% Menin mas 32% 25.5%

Gliomas 40.4% 22% Sarcomas 0 11.9%

Vascuar tumours 3.5% 6.2% Chordomas 3. 1% 4%

appears that gliomas are the commonest intraspinal tumours in our study as co"mpared with slooff et al

112) study in which Schwannomas

are the commonest tumours, also there are differences m the frequencies of other tumours possibly due to the uninvolvement of metastatic tumours in the study

or might be a different pattem, however differences in frequencies might be due to defects in tumour registry system. Ependymomas are the commonest intraspinal intramedullmy gliomas m our study and in slooff et al {12J

study as shown m table 5.

Table 5 The frequency of intramedullary gliomas in our study and slooff et al (Il)

Study HISTOLOGICAL

GROUP OUR STUDY SLOOFF et al study

Ependymomas Astrocytic tumours

0 ligodendro gliomas Others

Astrocytic tumours They comprised 18% of all intraspinal tumours and 44% of all intramcdullaty gliomas. They show male preponderance of 1.5: 1 and are more common in the thoracic region which was also in Cooper et al 03)

study. The tumours are usually intramedullary, but extramedullmy tumours have been observed, presumably arising from heterotopic glial tissue that is occasionally found in the subarachniod space (13!

There is a good conelation between the prognosis and the grade of the

53% 63% 44% 32% 2% 1%

3% 2%

tumours. c14

J Low grade astrocytic tumours are more common than high grade astrocytic tumours in our study and slooff et al study (12).

In our study low grade astrocytic tumours comprised 71% of the tumours which are typically fibrillmy astrocytoma; which is the same finding seen in Leestma study (2

) "75%", and the remaining tumours are grade III astrocytic tumours "Anaplastic astrocytomas" showing nuclear atypia, increased cellularity ·and mitosis, and Glioblastoma "Grade IV" showing cellular pleomorphism, nuclear

Intraspinal Tumours In Iraq A Study Of 2.:1-8 Cases

atypia, mitosis, vascular proliferation and /or necrosis. Leestma (2) showed an encouraging correlation between the grade and the average survival, for grade 1 through IV being 101,44,16,12 months respectively. Oligodendrogliomas These are rare intraspinal tumours, which are intramedullmy in location and are the same findings in Slooff et al study. (12

)

Ependymomas These are the most common intramedullary spinal tumours, showing male preponderance of 1.25: 1. The peak incidence was in the 4th and 3rd decades for males and females respectively while in Epstein et al (3) study was in the fourth and fifth decades for males and females respectively and about 1/3 of the tumours occurred in patients younger than 20 years of age, compared with large Myo clinic . series reported by sonneland et al (

4) showing predilection for the

3rd' 4th ,and 5th decades and 1/5 of the patients were younger than 20 years of age; suggesting more younger patients in our study , possibly due to lower life span and a different population structure . Nerve sheath tumours Schwannomas They show predilection for 3rd

decade both in male to female comoared with 5th decade in other studies CL

2•11 l·and they show slight

female preponderance compared with male preponderance in other studies 0 ·2l .

These findings might suggest a different pattern .

.... 32

The Schwannoma's charactistic Antoni A&B structures ,nuclear palisading infilteration · by foamy macrophages and vascular hyalinization usually suffice for its recognition , and was seen in all the biopsies .

Neurofibromas They show predilection for the 4th decade of life and a male preponderance ; which are the same findings in other studies (1.2)

.Frequently they grow as dumbbell -shaped tumours , and are less defined than schwannomas . Meningeal tumours They are the commonest intraspinal tumours in our study , comprised 32% of the tumours ,compared with 25.5% in slooff et al c12l .study . They usually favor the thoracic region in our study and others (1.2) .

Females are afflicted far more common than males with female to male ratio of 4: I , which is the same in other studies( 1

.21 .Some studies

suggest a , patiicularly increased incidence in women with mammary carcmomas actually deposits

rare menmgwmas harboring metastatic

derived from breast primaries , coupled with their frequent expression of progesteron as well as androgen receptors ., and rapid enlargements of some examples during pregnancy or the luteal phase of menstrual cycle which indicate that the growth of meningiomas is under hormonal

rg· influence .. J . Notewmihy is the association of multifocal meningiomas with type 2( central) neurofibromatosis, the genetic locus for which resides on chromosome 22. Allelic loss involving this

'

i 32 Iraqi Army Medical Journal, Vol. 12 No. 1 & 2 2000; Vol. 13 No. 1 & 2 2001.. ................. 33

chromosome is a regular feature of meningiomas, suggesting that inactivation of tumour suppressor gene figure their genesis. (ISJ

The peak incidence was in the sixth decade, which is the same in other

· 'I 2) studies 1 · Psammomatous

meningiomas are the commonest spinal meningiomas and showed a much higher female preponderance reaching about 15: 1 , the reason for that is unknown . Chordomas They comprised 3. l% of all tumours, and show male preponderance of 3: 1. Metastatic tumours They comprised 6% of all the tumours, with male preponderance of2: 1 . Dorsal spines are the commonest site and adenocarcinomas are the commonest type as in other studies (I,

2l Epidural spinal cord

compression by malignant tumours is most frequently caused by carcinomas of pulmonaty, prostatic, or mammmy origin that have spread to the venebrae , neoplastic cells commonly entering the spinal canal via the bony foramina traversed by the ve11ebral veins ; in contrast intramedullary hematogenous metastasis is rare .

Conclusions l.No significant changes in the total number , mean age , gender ratio , or the histological pattern of intraspinal tumours were noticed during the teri -year period . 2.Meningiomas were the most common intraspinal tumours and ependymomas were the commonest intramedullary primaty gliomas . Recommendations I .Improvement of autopsy rate.

2.Improvement of Iraqi cancer regisny center. 3 .Improvement of diagnostic and therapeutic facilities. 4.Initiation of a neuropathological centre.

References 1. Rubinstein L .J. Tumours of the CNS . In atlas of tumour

1 1 ,.... nu · . ! pat 10 ogy , L senes , Fasc1c e 6. Washington D.C, AFIP, 1981 . 2. Leestma JE, Brain tumours . Am J Pathol 1980; 100: 243-316. 3.Epstein FJ, Farmer JP, and Freed D. : Adult intramedullmy spinal cord ependymoma . The result of surgery in 38 patients J Neurosurgery 1993; 97: 204-9 4. Mark SJ, Lochen AC,: Ependymoma A follow-up study of 10 1 cases . Cancer 1977; 40 : 907- 15 .

5. Sonneland PRL , Scheithauer BW ,and Onefrie Bfvi,: Myxopapillary ependymoma . A clinicopathologic and immunohistochemical study of 77 cases. Cancer 1985; 56: 883-93. 6. Bergsagel OJ ,Finegold MJ , Bultel JS ,Kupsky WJ and Gacea RI. :DNA sequences similar to those of Simian virus 40 in ependymomas and choroid plexus tumours of childhood . N Engl. J. Med 1992; m.

7.Kepes JJ, Meningiomas . Biology pathology and differential

diagnosis . New york 1982 . 8. Maxwell M, Galanopoules T, Neviiie -Golden J,Antoniades HN: Expression of androgen and progesteron receptors in primary human meningiomas J Neurosurgery 1993;78: 456-62. 9. Russell DS, and Rubinstein L J : Pathology of tumours of Nervous

Intraspinal Tumours In Iraq A Study Of 2-l8 Cases .

System , Ed 5 Baltimore , I 989 , Williams & \Vilkins , pp 533 -589. 10. Bancroft j, stevens A. eds. Histopathological stains and their uses Churchill Livingstone London, I 975 . 11. Kleihues P,Burger PC, Scheithauer BW .Hisopathological typing of tumours of CNS Geneva . WHO, 1993, 1-51. 12. Sloof JL, Kemohan J\V, and Macarty CS.Primary intramedullary tumours of the spinal cord and filum terminale Philadelphia W,Saunders company 1964. 13. Ceeper IS CRAIG WM ,and KERNOHAN J\V Tumours ofthe spinal cord Primary extramedullary gliomas Surg Gyenical Obstet 1951; 92: 193-190. 14. Kepelson G, Linggood RM: lnteramedullary spinal cord astrocytoma versus ·glioblastoma . The prognostic impmiance of histologic grade . Cancer 1982; 50: 732-35. 15. Vanger- apodna AM, Griseli F, Gamareli D, and et al. Correlation between cytogenetic and histopathological findings in 75 human meningiomas. Nerurosugery 1993;32:892-900. 16.Byrne TN: Spinal epidural metastasis. N Engl J Med 1992; 3 2 7: 6 14- 1 9.

. .. 3-4

. . _3-f

-------------··-----------------

Iraqi Army l\1cdical Journal, Vol. 12 No. 1 & 2 2000; Vol. 13 No. 1 & 2 2001.. ................ 35

Acute Appendicitis

Incidence and Features in Relation To Anatomical Position

t'J Dr. Adil Karim Al-Hamdani

(i) Dr. Ali Hassan Abdul Haddi

Summary

This study was done on (218) patients complaining from acute appendicitis, \vho were admitted to the surgice1l wards in Al-Rasheed Military Hospital and appendicectomy have been done to them \\ith inspection of its anatomical position before surgery.

In this study a comparison between the incidence of the different anatomical positions and their symptoms and signs and their relation to this difference and their effect on the diagnosis, and the results were identical \Vith the results in the previous studies with minor differences.

Introduction

Vermiform appendix Is the underdeveloped distal end of caecum, the tube being about 2 inches (5 em) long, both length and position are very variable and can lie in variety of positions (0•121.

a. 1t may lie behind the caecum and lower part of the ascending colon (retrocaecal or retrocolic ).

r'i M.B.Ch.B.-D.G.S.-CA.B.S.

diM. B. Cit. B.- D.G.S.- C.A.B.S.

b. It may descend over the brim of the lesser pelvis (pelvic or descending)

c. It may lie below the caecum (subcaecal ).

d. It mav lie in front of the .;

terminal part ofthe ileum and mav then be in contact with the anterior abdominal \vall.

Acute Appendicitis Incidence And Features In Relation To Anatomical Position ................. J(J

e. It may lie behind the terminal part of the ileum. The incidence of these positions was based on very large series of studies, both anatomical and surgical shows much contradiction

(') !2) and the most agreed ones was · . l. Retrocaecal 65.28% . 2.Pelvic 31.0 I%. 3.Subcaecal 2.26%. 4.Preileal 1.00%. 5. Postileal 0.40%. Still acute appendicitis is the most common cause of acute surgical

d . . f j b , (I 2 .-; I 01 con 1t1on o · t 1e a a omen · ···· ·. Most patients with acute appendicitis usually share common symptoms and signs and one ofthe causes of the deference is related to the variation in the position of the appendix which may give atypical presentation, which might be not clear enough to diagnose acute appendicitis and be treated as non

·r· bd . 1 . (1'15Io, spec I IC a omma pam .~ .. · · J •

This study tried to find the incidence of different anatomical positions of the appendix and their relation to the change in the clinical features. It is of interest to mention that we excluded hom the study cases with high caecal and I eft sided <.J

appendicitis, fonunately they were (J () I 7 ·~

rare·~-,.·~;.

In this study, we applied the classical symptoms, which are: Shifting pain, nausea with or without vomiting, anorexia, bowel changes and frequency of micturition. The signs applied in this study are:

Pointing sign, localized tenderness, muscle guarding, rebound tenderness, psoas sign, obturator sign, suprapubic tenderness, per rectal examination.Although fever is very important sign in acute appendicitis ,we did not include it in this study because it has no relation to the anatomical position of the appendix but related to the state of infection and intlammat1on of the appendix c 1 i .

Regarding the laboratory nndings which are white blood cell count and general urine examination, although they are important and routine investigations in cases of acute appendicitis but also are not related to the different anatomical positions of the appendix, so wc did not include them in this study (])

Patients and !VIethods This prospective study of (218) oatients. carried out over 2 vears l ' "

from Oct .1997 to Aug 1999.

These patients \Vere admitted and operated upon in AI -Rasheed Military Hospital as acute appendicitis. All the patients are males with mean age of 35 years ( 18-52) years.

The removed appendices were sent for histopathological study. Most of the patients were operated upon during the first 48 hours of presentation. We excluded fr-om the study patients with delayed appendicitis (abscess or mass) and patients with normal appendices.

IS)

Iraqi Anny \Icdical Journal, Vol. 12 No. 1 & 2 2000; Vol. 13 No. 1 & 2 2001.. .. _ .............. 37

For the aim of the study, we our patients into ( 4)

groups .as shown in table (I): Group ( 1) for patients with

retrocaecal appendix. Group (2) for patients with pelvic appendix. Group (3) for patients with sub and paracaecal appendix. Group ( 4) for patients with pre and postileal appendix .The classical symptoms and signs of acute appendicitis are shown in tables (2) and (3 ). Results The incidence of each anatomical group: Group (I) (retrocaecal) appeared to be the most common site (63.3%). While group (2) (pelvic) had an incidence of (20.6%) which was the second most common site. Group (3) (sub and paracaecal) (I 0.5%). Group_ (4) (post and periled) (5.5%). (Table 1 ). Table (2) shows different

symptoms of acute appendicitis and its incidence in each t,.rroup. It is clear that shifting pain was nearly absent in t,.rroup ( 4) (post or preileal) patients, the incidence of this symptom was (8.3%), while it was present in most of group ( 1) patients (81.15%). Other imporiant finding was the bowel motion changes which was toward constipation in group (1) (retrocaecal) patients and toward dian·hea in group (2) (pelvic) patients and patients with (post and preileal) appendicitis, i.e . group ( 4) .

Most patients of group (3) (sub and paracaecal) had no change in their bowel motion_ Frequency of micturition was present in (57.7%) of group (2) (pelvic) patients, while it was not noticed in patients of other groups. Other symptoms (like shifting pain, nausea and vomiting), we didn't find any significant changes to be mentioned_ Table (3 ). Clinical Signs 1. Pointing sign: present in significant number of patients of group ( 1) and (3) (91.3%) and ( 100%) respectively, while it was noticed in (16.6%) of group ( 4) (post and preileal) patients, and (28.8%) of group (2) (pelvic) patients. 2. Localized Tenderness: was found in all patients of group (3) (sub and paracaecal) patients and (66.6%) of group (1) (retrocaecal) patients . 3. Muscle guarding : the results were the same as that mentioned in the previous sign. Group ( 1) (66_6%) , group (2) (28_8°/o) group (3) (100%) and group (4) (33.3%). 4.Rebound tenderness: was present in all group (3) (sub or paracaecal ) patients and that (52.6%) of group ( 1) (retrocaecal )patients . 5. Psoas sign: was present in (76%) of group ( 1) (retrocaecal ) patients were it was negative in patients of group (4) (post or preileal )_ 6.0bturator sign: was positive in nearly half ( 49%) of group (I) (retrocaecal) patients were it was negative in patients of group (3)

Acute Appendicitis Incidence And Features In Relation To Anatomical Position ................. ]g

and ( 4) (sub and paracaecal and pre and postileal ) . 7 .Suprapubic tenderness: was present in all the patients of group (2) (pelvic) while it was negative in patients of other groups.

8. Per rectum (PR) examination: tenderness was positive (tenderness in the right rectovesical pouch) in most of group (2) (pelvic) patients

(84.4%) where tenderness was

negative in all other patients.

Table (1)

Number and relative incidence of different positions of appendix.

Group Position

Retrocaecal

2 Pelvic

3 Sub and paracaecal

4 Post and preileal

Total no.

Table (2)

No.

138

12

218

%

63.3°/o

20.64%

10.55%

- -o; ) .) /0

99.99%

Symptoms of acute appendicitis and their incidence in each group.

Symptom ! Group

I 1 2 3 4

l. Shifting pain 112 11 18 1 I

I 81 1 5°' . 1 .io 24.4% 78.2% 8.3%

2.Nausea with or

I 135

i 42 ' 21 9

i without vomiting 97.8% 93.3% 91.3% 57% I i I

3. Anorexia I 107 40 / 16 12 I i

77.5% i 88.8% I 69.5% 100% i

4. Bowel change i ! !

a- Constipation i 72 8 3 ! I I 52% 17.7% 13% I 8 '){)I l ) .-) lo

b-Diarrhoea I 18 I 23 I

0 8 ! ! i

13% i 51.1% 0% i 66.6% I I I

c- No change 48 I

14 20 ')

I i l I

.) I I

34.7% I 31.1% I

86.9% I 25%

I I

5. Frequency of I 0 26 0 I 0 I I I I

micturition I 0% I 57.7% 0% I 0% I i

! --1

Iraqi Army Medical Journal. Vol. 12 No. 1 & 2 2000; Vol. 13 No. 1 & 2 2001.. ................ 39

Table (3)

Signs of acute appendicitis and their incidence in each group.

Sign

1

1 .Pointing ·sign 126

91.3%

2. Localized 92

tenderness 66.6%

3 .Muscle guarding ! 92

66.6%

4.Reboud 72

tenderness 52.2%

5. Psoas sign 105

76%

6.0bturator sign 68

49%

7. Suprapubic 0

tenderness 0%

8.Per rectum 0

examination 0%

Discussion

Incidence: In our study, the incidence of

different anatomical positions of appendix shows that most common site was the retrocaecal;the incidence was

Group

2 3 4

13 23 2

28.8% 100% 16.6%

14 23 4

13.1% 100% 33.3%

13 23 4

28.8% 100% 33.3%

13 23 4

28.8% 100% 33.3%

32 " 0 .,/

68.8% 21.7% 0%

17 0 0

37.7% 0% 0%

45 0 0

100% 0% 0%

38 0 0

84.4% 0% oo/ /o

(6 ~ ...., 0 /) Tl d j . .J /o . 1e secon most common site was the pelvic appendix (20.6%).These results are in accordanc with the study by Peter L; Williams (!2

).

Roger Warwick mentioned regarding the incidence of the

Acute Appendicitis Incidence And Features In Relation To Anatomical Position ................. -Hi

(retrocaecal) and (pelvic) appendix (65 .2%,31.0 1 %). Out study showed higher incidence (31.0 I%) of pre and postileal appendix (5. 5%) a:1d (10.55%) for the sub and paracaecal appendix ,while previous studies showed lower incidence of these two groups (140/ /)60/\ . ;o, ___ ,o;.

Our study was in disagreement with that was mentioned by David C. Sabiston about the incidence of retrocaecal appendix which was (16%) only and ( 1 0.55%) for the sub and paracaecal appendix (2%). Clinical features: Retrocaecal appendicitis It was mentioned that because retrocaecal appendix is protected from the anterior abdominal wall, the epigastric pain remains poorly localized and the shift to the ri}2:ht lower quadrant may not occur 1'Iur We found a ditlerent picture, that was the shrfting pain occurred in (81.15%) of the patients. Mann and Russell (l) mentioned that localized tenderness and muscle guarding were often absent and the abdomina! examination is deceptively unimpressive unless one finger palpation was carried out into the flank, were tenderness is detected. So according to these results they called it (silent appendicitis). We do not at,JTee with this term (silent appendicitis ) because of the following reasons :

!.Localized tenderness and muscle guarding were not absent in patients with retrocaecal appendicitis , our study shows that these signs vvere present in nearly (66.6%) of patients with this t.ype of appendicitis . 2.These two signs still can be elicited in the anterior abdominal wall slightly lateral to Me Burney's point. 3.1f these two signs arc negative, we still can't excl ucle acute appendicitis unless vve app!_y other test like (psoas test) which vvas positive in (76%) of our patients. Regarding the symptoms, we found that many patients with retrocaecal appendicitis had the sensation of constipation and may feel the need for cathartic or an enema. This finding is in agreement with Lawrence \f./. Wa_y and I'v1ann and Russell and H I, d "' · 1 I ) I a 1 an L Jam · - . Pelvic appendicitis The symptoms in this type of appendicitis, the bmvel change was toward diarrhea in (51%) of the patients. Nausea and vomiting tend to be more prominent (93.3%) and the frequency of mictunt1on (57.7%) The pain remains poorly localized and no pain shifting in most of the patients. These results were reported by Lawrence W. Way and Mann and Russell and Hall & Clain l 1.31 .

The sign, pointing sign was present only in (28.8%) ,i.e. it was poorly localized . But all the

Iraqi Army i\Icdical Journal, Vol. 12 I\o. 1 & 2 2000; Vol. 13 \o. I & 2 2001.. ............... .-!1

patients (I 00°/o) had suprapubic tenderness mainly on the right side on deep palpation with positive per rectal examination in most of the patients (84.4%), these findings \Vere noticed and repor1ed by Mann and Russell and I . F I) d H I ft J n 1 1 !.(,1 ~ewJs . '-· an o era . v> . .

Edward H. Storer !I 11 mentioned

that \\"hen inflamed appendix hangs mto the pelvis, the abdominal clinical examination findings may be entirely absent and the diagnosis may be missed unless the rectum is examined. Also psoas sign is positive m ( 68. 8%) )of these patients. Sub and paracaecal The mam features of acute appendicitis are present in this group of patients in significant percent, but the prominent finding was that pointing sign, localized tenderness and muscle guarding and rebound tenderness were present in all the patients of this group ( 100% ), might be due to direct contact with anterior abdominal wall . The bmvel habit tends to be towards no change . Pre and postileal These are the rarest group in this

study and the important feature \vas anorexra ( 1 00%). Bov1el motion was toward diarrhea in (66.6%) .It might be due to direct irritation to the terminal ileum . Mann and Russell (I) mentioned also these results and also called this type (missed appendix) ,this was referred to postileal type of appendicitis due to poor physical signs that were associated with

this type ( 1) . This v;as noticed in our study Postileal appendicitis is a rare group, and because of its anatomical position, i.e. no direct relation with the anterior abdominal wall , the abdominal signs are very poor and there is no localization . Conclusion

I. Retrocaecal appendicitis \vas symptomatic in our study and diagnosis was confirmed bv careful and repeated abdominal examination. 2. Postileal appendicitis needs the aid of ultrasound examination for earlier diagnosis because of poor specific features and poor abdominal signs. Referenres 1.Bailev and Loves, Short Practice of Surgery, 21st. edition. ELBS. 1991, revised by Mann And Russell PP: I 195- i 214 2.David C. Sabston, The Biological Basis of Modem Surgical Practice .l5u' . edition , Edited by W.B. S3lmders, 1999. 3 .Hamilton Bailley's Demonstration

of Physical Signs in Clinical Surgery, 1 th edition . ELBS edited by Allan Clain , !986, PP: 294-300. 4. Jordan J.S., Kovalcik P.J., Schwbew Appendicitis \Vith mass .Ann surgery, 193;227,981. 5. Knight P.J Vassy L.E.: Specific Diseases Mimicking Appendicitis .Arch Surg 116: 744, !992.

6. Levvis F.R., Holcroft J W. et al: Appendicitis Review and

).:

~,·

I ·.~ -~ :fr

Acute Appendicitis Incidence And Features In Relation To Anatomical Position ................. -!2

Diagnosis and Tre·atment in cases Arch, Surg. 110:677, 1998. 7. Masters K. Levina B.A .et al : Diagnosing Appendicitis . Am . J. Surg .. 148: 768,988. 8. R.F. Rintoul , Farquhaeson's textbook of operation . Surgery , 8

1h .edition . Edited by Hancourt

Brace, 1999. 9.R.J. Last , Anatomy, Regional and Applied . i 11

. edition . The Appendix , 1984. 10. Savrin R.A., Clausen K. et al.: Chronic and Recurrent Appendicitis .Hm. 1.137: 355, 1989. l 1. Shwartz and Shires , Principles of surgery . i 11 edition . Appendix , McHill, 1999. 12. Williams and Warwick , Gray's Anatomy , The Appendix , 36111 edition, 1980.

Iraqi Army I\kdical Journal, Vol. 12 No.1 & 2 2000; Vol. 13 No.1 & 2 2001. ..................... -U

Goitre in Iraq over the Period From 1985 - 1995

(Before and After the Embargo)

(*I Mr. Husam A. Karim

;;, ,;)~ \...,\ -~J~\ ;;.c.il\-.:_,~1 _)S. ~ \~ ~J~\ ;;.c..i.]\ ~ ,) ~J ~\ \~ ~

L.....:,\ '~~ • f'WI ~ c.)J'j\ '"""--.a_;-JJ W~ ul_p '· ~.lli 4J} ~3 ~~)I j~ ~ . 2ll~ ~ ~ ;;.Jsj b.::. y19 J ,s.:ill w~

Abstract

A prospective study on 336 patients diagnosed on clinical basis and investigations as cases of goitre admitted for surgery in the University Hospital - Saddam College of Medicine and Al-Noor General Hospital -Baghdad - Iraq over the period 1985 - 1995.

There were changes in the pattern of presentation of the patients after the year 1990 regarding the age incidence, sex ratio, blood grouping and histolog1cal types and incidence of malignancy compared to those cases before the year 1990.

In this study. the goitre affected mostly both lobes, the right side and_the left side of the thyroid gland for both benign and malignant lesions. Concerning the age incidence, the mean age group mostly affected \vas l 0 years younger for the female patients presented after 1990, but the male patients \\ere slightly older.

The same applies for blood groups, the commonest blood group was (0) before the year 1990, blood group (0) and (A) after the year 1990 for both benign and malignant diseases. The least common was the blood group (AB) before and after the year 1990. Finally, in the malignant group of patients, the study revealed that there was an increased incidence in follicular carcinoma after the year 1990.

''l FRCS,Consultant surgeon, lecturer and clinical tutor, llniwrsity Hospital, Saddarn College of

Medicine, Baghdad, IRAQ.

Goitre in Iraq oya the Pl'r·iotl From I9X:S- l<J<J:S (Before and Aftl'r the Embargoj ................. H

Introduction Thyroid gland is a bilobed structure, the two lobes connected by an isthmus of variable size and a pyramidale lobe extends upwards from the isthmus usually to the left of the midline. In some patients there is a rich blood supply which comes from inferior, superior thyroid arteries and in some patients thyroidae ima artery. The venous drainage comes via superior, middle and inferior thyroid veins. From this, the blood supply is controlled by the sympathetic nerve fibres coming from superior, middle, and inferior cervical ganglia. The \veight oCthyroid gland is not more than 0.35 u/ku bodv weiuht

...__.. ...__, - ..........

11 r The size of the right lobe is

slightly larger than the left lobe (I)' in other studies they are or similar size \2) It has been found that the size is affected by many f~1ctors:

1- The size increases with age as far the le\ el of the thnoid stimulating hormone Cf.S.H) and thyroglobulin (thyroglobulin is inversely proportional \vith the age due to increased response to the thyroid stimulating hormone). 2- Body weight is directly proportional. 131 Obesity by itself is associated \\·ith increased risk f' I . ~ . I~ .:; (l l o t 1)TOICJ carcmoma, · · -. '

possibly by the mechanism of production of estrogenic steroids by adipose tissue. Recent studies showed the presence of oestrogenic receptors in some cases of goitre in addition to the

similarities of goitre 171 in addition to the similarities of LI-1, FSI l, liCG a -subunit \Vith asubunit of thyroid stimulating hormone ... Goitre I . d . . (S 'J raq IS an en em1c goitre area '- -10 I i. 12i . 1 lJ 'd . · simp e co 01 gmtre (S.C.G.) is the most common pathology and multinodular goitre is the commonest morphology. Nodular goitre according to Marine's theory arise from successive hyperplasia and involution phases following TSl-1 stimulation due to iodine deficiencv and other <roitreo~ens ..- C L

(eg LATS, local growth factors, etc) and after removal of the stimulating factors. It is generally agreed that endemic goitre is dw.: to many factors mainly environmental and host L1ctors are largely ovenvhdmed in the presence of severe iodine deficiency. Iodine prophylaxis, reduce the incidence of goitre not much below 4% · i'j and with iodination incidence of nodular goitre become ( 0.4 I I 000 / yr.) il~J

This have an implication on geographical distribution of goitre as far as iodine content ofTie:ris river is low'· 10

j and food habits~ In non endemic areas the male to female ratio was I :8 but t~dls to near unity in goitrous districts 11 s. I (J j 7) c. k. 1 I · · I oarette smo 'II1 (J 1as a ro e b b

due to its goitreogenic content of thiocyanate (IS) with antithyroid ~and T3) content of

i Army Mcdicai Jourrtal, Vol. 12 No.1 & 2 2000; Vol. 13 No.1 & 2 2001.. ................... ...1.5

xypyridine metabolite from ( 19) ceo smoke . total nodules atler external

with antithyroid (and T3) t of hydroxypyridine

from tobacco smoke

stimulation is held predispose to neoplastic change

(lO) initially take the form of

adenomas or cysts and ultimately change to malignancy. This

:hypothesis is confirmed by induction of carcinoma of thyroid by goitreogens u2

), radiation (20· 12· ,.,,,,4, d d" .. d" f2l\ LL., "-·· L. ·), an ra 10act1ve Io me ' ·;

The nodularity of the thyroid gland with associated fibrosis in the interfollicular stroma lead to redistribution of blood supply and consequently change in TSH level reaching each lobule in the gland and this result m different incidence of nodule and malignancy between the two lobes.

Studies showed that the relative risk to develop malignancy in endemic area was 1 .3 if the residency is< 20 years and 1.6 in > 20 years especially with follicular and anaplastic carcinoma (26· 7) .

Relationship between malignancy and radiation: There was significant increase in the incidence of carcinoma of the thyroid in those who have been exposed to radiation during childhood (27

,28

'29

) and it was

irradiation (30). Though it was

accepted that 20 ... 2000 rad is the carcinogenic dose and beyond that will destroy the thyroid cells without changes that lead to cancer but back scattering during exposure to high dose radiation

, I even 4000 rad (_, 1 this opportunity IS more among children (14 -35 %) than among adults (5-10~/o) c31 ).

Low dosage also proved to have this risk ,as low as 3-5 rad hom panoramic film of the lower jaw (31)

A particular attention was given to increase in the number of the thyroid cancer among children in the region near Chernobell (after 1986) (33 ).

The risk of I 131 estimated to be one fifteenth as affective as external irradiation in induction of thyroid nodule c

3o) and malignancy

especially anaplastic carcinoma (34)

The risk of carcinogenesis is further increased in those who are

f' 1 ()5) . l (j2 ){,'; young ema e - ~. Jew1s 1 · ·· ·.,

blood group A c35), obese C4.5·6J in

addition to the presence of thyroid nodule (single nodule 8% and multinodular goitre 7.5%) (33·36 J.

The risk of late development of carcinoma appears to be life long and high dose irradiatiOn in patients with a prolonged life expectancy may result m anaplastic carcinoma (5) .

estimated that the absolute risk of developing malignancy was 4.2 case /1 01\5 /rem /year or 1/3 of

Patients & JHcthods

A prospective study was done on the cases admitted to Al -Noor

Goitre in Intq over the Period From 1985- 1995 (Before and After the Embargo) .............. .. AG

hospital and the Hospital -Saddam Medicine.

University College of

The study was done on 366 cases of goitre referred for surgical intervention over the last 1 0 years, 174 (52%) were admitted in the period from 1 985 -1990, and 162 ( 48%) were admitted in the period 1991-1995. The data was collected according to the records of patients files as follows: Detailed clinical approach regarding history, complete physical examination and the results of general and specific investigations ,operative notes about the type of operation and the results of histopathological examination of the specimens .

The number of the cases is relatively low in spite of the long period (1 0 years) because we selected them in this study due to two main reasons: the first were only the ones with complete records and the second that any case without a complete record was neglected.

The aim of this study is to collect and analyze data to confirm or to exclude relation and effect of age, sex, blood group, site of the disease and the effect of environment on the presentation of thyroid diseases and especially the effect of embargo on Iraq since 1990 and the effect of aggressive bombardment on Iraq (in 1991) by the enemy.

Results Presented in graphs , it shows : I-Age incidence (Fig .1 ) : Before 1 990, the cases were mostly presented in the age period ( 40-60 )years. and after 1990 the cases \vere mostly presented in the age penod (20-40)years . Mean age before 1 990 was 3 8. 9 yr. and after 1990 was 42.9 yr .(which showed prevalence of older age groups ). (fig .I ) II-Sex Ratio (Fig .2) : M: F= 1:13.5 (12 male cases & 162 female cases before 1990 ) M:F= l: 4.8 (28 male cases & 134 female cases after 1990) III-Blood Groups (Fig .3): For benign and malignant diseases : Before 1990

Approximately equal distribution of cases with blood groups A,B Most prevalent blood group 0 The least prevalent blood t,'roups AB. Papillary carcinoma occurred m all blood groups . Follicular carcinoma occurred m blood groups A&B. Anaplastic carcinoma occurred in blood groups 0. After 1990 Approximately equal distribution of cases with blood groups A, B Most prevalent blood group 0 but for malignancy blood t,:rroups 0 & /1!.. are 1nost nre\rale11t

' ~"'!:. ' "':! ' ""h' 1

1 ne 1easr prevalent Giooa group AD

L JJ..L.J.

~

m

9

lr.a'ti ~-\nny .\Icdical Journal, Vol. 12 No. 1 & 2 2000; Vol. 13 No.1 & 2 200l ..................... A7

The same for papillary carcinoma and no records of anaplastic

. Follicular carcinoma

occuned in blood groups A &0. Medullary carcinoma occurred in blood group 0 .

After 1990

i 10-20 I 8.6 I 6 ! 2. 7 ~--------~----~----~--~ r 21-30 62 ! 3.5 , 65 · 39

• After 1990 1 Total 17-t 162

Table & Fig. (1) Age incidence

Sex Cpto 1990

I

I I

:\'o. I u;;, !

i i ' I I l\Iale i 12 6.9(~.

I Female : 162 93.1

I Male Female

After 1990

Table & Fig .(2) Sex incidence

'!. ------------,

, . Jl---------~

1 Blood

I group

I Up to 1990 I I

A 8

Up to I 990

AS 0

[I After 1990

i A I f"""\

! ;B I i

lAB

0

Total

1 58

:55

61

174

! 19.1 I

i '"'1 1 _)..:... l

I 3.4 I

j 35. 6

I

Table & Fig. (3) Blood grouping incidence

! After I 990 i '

I I ~0. % ! i i

I i 28 I 17.3

i !3-t 82.7

! After 1990

No.

44

48

10

60

162

I, O;,

.o i

/17.6 i ! /() " i - 'Y ·---

--1'----! ! 6.2 I

'"7 l I..) .I 1

t---1

'

Goitre in Iraq oyer the Puiod From 1985- 1995 (Before and After the Embargo) ................ .-+8

IV -Histological types : By comparing the periods : ( 1985 - 1990 ) and (1991 - 1995) all histological types included in this study showed that the difference in the second period was significant as follows : Simple colloid goitre decreased in frequency (P< 0.0). Adenomatous goitre increased in frequency (P<0.05 ). Toxic goitre increased (P<0.005). Papillary carcinoma showed no significantdifference . Follicular carcinoma increased (P<0.025 ). Frequency of malignancy 9.7% before 1990 and 11 . 7 % after 1990 i.e. ratio benign : malignant disease =9. 9: l changed to 7. 5 : 1 after 1990. This is not statistically significant . V- The prevalence of site at presentation: There was no difference whether benign or malignant disease but the most prevalent was bilater&l involvement in the site of the lesion before and after 1990 .In fact no recorded cases with left lobe involvement before 1990 . No relation to age on this respect that the left lobe involvement was most frequent in male. VI -I\1alignant disease: As shown in the table ( 1) , there was increase in adenoma in the

mean age of male patients than female patients. This ·was decreased after 1990 with a change in sex ratio for M: F from (1: 14.9 )ro(l:2.8 )after 1990. The most frequent age group involved from (30 - 50 ) before 1990 1wo age groups (20 - 30 ) and(50- 60). Papillary carcinoma is the most frequent type but there was a clear mcrease 111 the frequency of follicular carcinoma . Most of the patients came from Baghdad. The referral of cases was changed after 1990 due to reduction in the number of cases referred from the north of Iraq VII -Type of operations · Subtotal thyroidectomy (S.T.T.) was the most frequent mode of surgical intervention but was then predominant after I 990 (P<O . 005 ). Total thyroidectomy (T.T.) was used solely for malignant disease and the only recorded case of lobectomy was used for anaplastic carcinoma .It was done for diagnostic purposes. Total thyroidectomy increased after 1990 (P<O .025) but decreased for lobectomy (P<0.005).

....... A8

\Vas \\·ith a

: F from 990.

Iraqi Army l\ledical Journal, Vol. 12 No.1 & 2 2000; Vol. 13 No.1 & 2 200l.. ................... ..t9

Table (4) Thyroid gland lesions

Histo Types Frequency Mean Age (Yr.) Sex Ratio Male I Female (M: F) i ' , I

Simple colloid goitre !C<l990)i s 37 31.8 1 : 17.3 i (> 1990) I

Hyperplatic G.

Adenomatous G.

Thyroiditis ! L__

62.4 31.6 i (<1990) ! 4 29.5

j(>l990)j 13.6 38.6

!(<1990)1 5 ; (> 1990) 11.7 40.5 l (<1990) ; 0.6 i (> 1990) i

Table (5) Thyroid gland lesions

34.2 I : 7.3 32.5 1 : 2.5 37.4 1: 3.4 42 0:4

38.1 I : 3.2 24.5 0 : l

: Sex Ratio i Malignancy(fig.7,8) !

! Frequency ! Mean Age (Yr.) I

! types I Male Female 1 I

(M: F) \ Papillary Ca. 1 (<1990) f 8 9.5 34. 7

29 1 : 13

I !

Follicular

l\1edullary Ca.

l(>1990)l 7.4 29.5 i (<1990)! 0.6 I I

!(>1990)! 3.7 54.5 54.5 34. 4

1 : 2.7 0 ' 1

' l

1 : 4

r (<1990) 1

I (> 1990) 1 1.2 32 o : 2 Anaplastic Ca. \ ( <1990) I 0.6 - 44.5 0 : l

~----~--------~

j (> 1990) 1 All are referred to Center of Nuclear Ivledicine Discussion Iraq is an endemic area of goitre .In this study the patients were older than that reported for other endemic areas (IS,

16'

37)which may

be explained by introduction of the iodinated salt At the beginning of this study adequate iodine prophylaxis does not reduce the incidence much below

40' (13) .Yo .

In comparison to cancer registry reports the mean age for malignancy in both sexes was not changed so much for male patients over the years 1986 -1994.

Regarding the prevalence of site , the study shows that there is no remarkable relation to age but there is no involvement of left lobe at extremes of age period .The relation of age was taken into consideration to see the link with the recent studies ( 44) which shows expression of estrogen receptors -in goitre cases in 19% (5 out of 27 ) in specimens of adenoma ,neoplasm and surrounding normal thyroid tissue and curiously the male patients showed left lobe predominance over the right lobe For sex incidence in non endemic areas M: F is 1 : 8 and much lower in

Goitre in Iraq over the Period From 1985- 1995 (Before and After the Emhargo) ................. 50

goitre district CIG, 15 ) but in this '-

study \vhat appears as a rule is the female predominance after 1990 because of: l.Most goitre patient present due to cosmetic disfigurement and in this respect the females are the leaders. 2. Structural similarity between TSH -a subunit with (LH ,FSH ) -subuint and slight difference from HCG -a subunit (.iSJ

3 .Effect of estrogen hormone on estrogen receptors as far the latter present in goitre in both sexes (.3<-t)_

Relation of blood group and Rh systems: The similarity in frequency of blood group A and B in this study, this seems to be the picture of distribution of blood group in Baghdad \vhich is as follmvs: (A=29.9%) (B=27.5%) (+0=34.3%)(Rh + ve = 90.7~~) Rl 8 80 !..)();

( 1-ve = . ?o ) · '

That does not go with the studies that show higher percentage of blood group A in patients with cancer of the thyroid gland (50.2%) and low percentage of blood t.:,rroup 0 (27.8%) (.i<J) but what is worthy to mention that is in 1993 (..Jl) a study \Vas done showing that the absence of (P 1) antigen is the risk factor for euthyroid multinodular goitre and it was written 1

c14

J that chemical composition of surface glycoprotien of A,B, PI antigens are similar : PI GAl ( I_ 4) j3GA1) (1_ 4) GlcNac (1_3) Glc ---Cer

A Ca 1 N ac (1 _ 3) j3 ga I ( 1_ 4) (GlcNac (1 3) Gal (1 4) Glc

- -

---Cer

2

a---L- Fuc B Gal (I _ 3) BGal(l_4) G I cnac 9 ( l_ 3) Ga 1 ( 1_ 4) G l c ---Cer

2

a--- L---Fuc The relation of blood group A with malignancy (321 was regarded as one of the risk factors of thyroid radiation carcinogenesis and in this study there is increased frequency of cancer of the thyroid among individuals of blood group A though it vvas not significant statistically . Histological Tvpes : Hyperplastic goitre was significant (P<O .005) and of l 0 years older for male cases than before 1990. Papillary carcinoma start to appear in female patients l 0 years younger than before 1990 .The importance of this comes from the fact that papillary carcinoma is the type associated with exposure to external radiation during childhood. Follicular carcinoma shows clear increase after 1990 (P<0.025 ) and 20 years younger than that before 1990 . It is the type that is mostly encountered in endemic

'7( 7) areas l- L' .

For anaplastic reports from

carcmoma the cancer registry

II·aqi Army Medical Journal, Vol. 12 No. J & 2 2000; Vol. 13 No. 1 & 2 2001.. .................... 51

shovved evident increase in the incidence after 1990 .In other studies it is found to be associated with endemic goitre c26

) and I 131

irradiation C4

) .

From cancer registry reports it seems to be that there is evidence of increased incidence in thyroid malignancy but this is regardless of the fact that not all cases from the north were referred after the time o.J the war in 1 990. Geographical distribution: In C. R. reports Baghdad was the origin of approximately 27% of the cases before 1990. This shows the distribution of the cases in this study which was mostly from north of Baghdad which goes with the reports of high I-

131 uptake in group of

patients with non toxic goitre in (4~\

Baghdad , -;. Apart from that the increased number of cases from other provinces after 1990 was mostly due to shortage of facilities after the sanctions. Types of operations: There is tendency to do less (P<0.005) lobectomy after 1990 which can be explained by : - Difficulty in the follow up of

the patients. - Late presentation of cases of

goitre with malignant disease because of limited access to health care centers.

- To decrease rate of recurrence by attending more radical approach.

-Inavailability of medical treatment for thyrotoxicosis in cases of hyperplastic goitre (this

may explain the high rate of total thyroidectomy) and lead to significant mcrease (P<0.025) after 1990 . Series of studies of the most appropriate surgical approachc43 · 44)

most of them end m a conclusion that total thyroidectomy Is the most appropriate form of surgery and do not entail higher morbidity in relation to more conservative resection .

The debate between subtotal thyroidectomy (S.T.T.) Vs. total thyroidectomy T. T. is a balance between surgical experience, cost effectiveness and follow up facilities . Advantages of S. T. T. : l.Low incidence of laryngeal nerve mJury. 2.Low risk of hypothyroidism. Disadvantages of S. T. T. : 1. Increased rate of recurrent

disease. 2. Risk of carcinoma. 3. The possibility of the increase

in laryngral nerve lesions and permanent hypothyroidism after re- operation .

Conclusion The results of this study reveals the following : 1. Age incidence in female is 1 0

years younger than that before 1990.

2. Involvement of both sexes is approximating to closer incidence.

3 .Bilateral lobe involvement is the most common, and second m frequency comes the right lobeo

~~

-· ,.

~

Goitre in Iraq over the Period From 1985- 1995 (Before and After the Embargo) ................. 52

4.Blood group 0 is the most frequent group involved and blood t,JToup AB is the least frequent.

5. There is a clear increase of thyroid malignancy (Follicular carcinoma ) in this study and anaplastic carainoma compared to cancer registry reports especially after 1990 .

6. No t,JTeat advantage of S.T.T. over T. T. approach as surgical intervention. Future Proposals: 1- As preliminary investigation of

any case of goitre hematological tests should be done to detect presence or absence of A 1 antigen, Multinodular subgroup in addition to major blood t,JToups as this will detect the risk factors especially regarding problem of recurrence in benign and malignant diseases . Also ultrasound is used in case of unilateral goitre to exclude other lobe involvement .

2- Any study aiming to show the effect of blood group in thyroid disease or any other disease should include an account of the real distribution ofblood group in that area .

3-To study the real effect of environmental factors (e.g. the war ) further steps to be done : A-Records of autopsy finding of thyroid gland to detect occult cancer .

B- Survey of thyroid scan to see any significant increase in I - 13 i

uptake in cohort study involve control group from the north , middle , and south of Iraq . References !.Harland , W. A . Morphology of thyroid gland ~Jamaica, J. Clinic . Endocrinol , 1964; 24 , 580- 86 2. Rheil-A, et al. Pr Prevalence of goitre in Ankhen area . Ultraschall -Med . 1995 ; 16 (2) : 84 - 9 . 3.1. Clinic . Endocrine . Metabol . I 983 ; 56 ; 260 - 63 . 4. Goodman , M. T ., et al . Association of body size reproductive factor and thyroid cancer ~ Br. J. Cancer . 1992 , 66 : 1180 -4 .

5.Metriernan , A. J., Natle Cane. Instit. 1984; 73,575-8. 6.Rone , E .). Natle. Cancer Instit. 1987; 97,1-12. 7.Yane , K., et al .E>fpression of estrogen receptors in thyroid neoplasm ; Cancer .Lett. 1994 ; 84 (1) ; 59-66. 8.Al- Saleem T.,& AI -Ashbal A. Surgical pathology of thyroid gland in Iraq. Intern. Surg .. 1973 ~ 58 : 623- 24. 9.Al-Hashimi .Thyroid nodules in Iraq .Post . Med .1. 1972 ; 48: 80-82.

10.Caughy, J. E.: Epidemic goitre and iodine malnutrition in Iraq .1965 ~ Lancet I : 1032 -34 . ll.Demarchi ,M., AI -Hindawi ,et al : Prevalence and etiology of goitre in Iraq .,A. J. Nutrition . 1968 ; 22 : 1660 -68 .

h·aqi Army Medical Journal, VoL 12 No. 1 & 2 2000; Vol. 13 No. 1 & 2 2001.. .................... 53

12.Harun -Ghera, et al . Induction of thyrotropin dependent thyroid tumor by thyrotropes ;Endocrinology . I 960 ; 66: 694 -70 I .

13.Wemer, S.C. Thethyroida fundamental and clinical text 4111

edition , 480-50 I, 1978. 14.Gomez de Ia Torrie ,et al : Thyroid goitre disease m previously endemic area . A. Med . lntrna. 10 (10): 487-9, 1993. 15. Khavin , I. et al Disease of thyroid gland ; Peace Publication , Moscow , 1962. 16. Kilpatrick , R. Simple and non -toxic goitre : the thyroid gland , 288-111' 1964 . 17 .Zachar wice. F. A . Med. Clin. North Am ,52: 409 -15, 1968. 18 .Chritensen ,S, B., Ericsson, U. B., et al .: Influence of cigarette smoking on goitre , thyroglobulin and thyroid hormone levels in women ; J. Clinic . Endocrinol Metab. ,58 : 615 -18, 1984 . 19.Sepkovic. D.W. et al. Arch. Inter. Med.144 :501-3, 1984. 20.Studer ,H., et al .. Mechanism of Nenodocr Hyperplasia. Endocr . Rev. 16 (4): 411-26, 1995. 2I.Godbery , R,C. ,et al. Cancer risk, 24: 35-43, I 964. 22.Lindsay ,S. et al . Cancer research ,21 : 9-16, 1961. 23.Money , W. L. Cancer research ,25, 423-31' 1965 . 24.Nichois ,W. Arch .pathology. 80: 177-183, 1965. 25 .AI -Saadi et al

. Chromosomal changes mtra -thryroidal cells during iodene !..?::

depletion and repletion . Cane . Res.26:676-688, 1996. 26.D Avanzo -R, et a1. :History of thyroid disease and subsequent thyroid cancer risk ;Cancerepidemiol - Biomarker - Prevo. 4(3); 193-9,1995. 27.Bravemen L. E.: Consequences of thyroid radiation in children .; N . Engl .J .Med.292: 204- 205 , 1975 . 28.Pincus ,et al Thyroid abnormalities after irradiation exposure in infancy 1 Ann ,Int. Ned. 66 :1154- 1 I 64, 1967. · 29. Yung, H. S. Radiation carcinogenesis .Cancer 36: 941-45, I 975.

30.A.J.Madical sciences ,296(5) . 31.Shwartz, Principle of Surgery , 1994.

32.A.J. Epidemiology 144(8) : 728-33, 1996.

33. J.Chir. Parios130(10):391-6. 1993. 34. Oncology 41, 8- I 2, 1989. 35. Wilson .S >M. et al. An. Int. Med. 66: 1154- 1164, 1967. 36. Koh, K. B., et a1. Ca .In MNG. Br. J. Surg. 79(3) .266-7, 1992 .

37. Baily and Loves. Short Practice of Surgery, 22nd edition, and 1994.

38. Makarov ,A. D. et al ., Association of MNG and euthyroid goitre with various genetic markers. Probe!. Endocrinol .Mosk 39 (6) : 25-6, 1993.

39. Klechova, L et al .ABO, Rh. Factors in thyroid disease Vutr. Boles ,19(4), 75-9, 1980.

'•::!.

Goitre in Iraq over the Period From 1985- 1995 (Before and Aftet· the Embaq~o) ................. 5.t

40. Study of distribution of blood groups among population in Baghdad , 1991. 41. Human Physiology by Ganong, 1994. 42. Ahu- Eshy. Thyroid malignancy in MNG and solitary nodule ,JR. Coli. Surg. Edinb. 40 (5): 310-2, 1995. 43. Al- Salah, et al . Incidence of carcinoma in MNG in Saudi Arabia J. R. Coli. Surg. Edinb. 39(2) .106-8,1994. 44. Hoffbrand, Textbook of hematology, 1984. 45. Oncology, 50 (20): 132-6, 1993.

lntqi Anny Medical Joumal, Vol. 12 N()~ !§) 2000; Vol. l3 No. I & 2 2001.. ..................... 55

The lVIanagernent of large bowel injury

t*) Dr. Ivlohammed Abdul- Wahab Al-Khateed

~ 1...0 ~ 1! ;;. 'i ·.~ ."" 0 4...h..Ji.ll ;;. k:..o )11 ~L..al ."" ·, .,_jk ~ \A '1 0 ~ .( .. _q 0 ·Lu.il '-" ~·.....r- _r ~--...1 ... • ;. "-' U_../- •• '-"' ··..../- "'-?~ J

j ~L....ill ~ -?. JA-' ~ (i-:!.ll '""--.a y :ti)t:; 2l.l~ 4 ~~ ;;. G:..o)U ::;.i9u ~L..aJ ~.ll .J_)·ul ·, .lLS.Jl ~ . ~ "-'-' ~ ~.ll ~w o ..1c.Ldl .._,y '-? _r- \,_. • I •• .• _J

Summary

During the period between Jan . I 991 to Aug. 1997, 135 patients were admitted to AL-EMARAH military hospital suffering from injuries of the large bowel, 124 of these had penetrating wounds of the colon or rectum . 3 patients h~d haematoma related to the ascending colon and 8 patients had haematoma related to the descending colon .

9 patients died as a result of multiple injuries with systemic complications. There were no death among patients who had isolated large bow·el injuries.

Introduction The large bowel is the second most frequently injured organ as a result of penetrating abdominal trauma. Injuries to additional intra abdominal organs are common (75 to 80 %) which influence the management and prognosis. The aims of this study were to define surgical treatment, morbidity and mortality in large bowel injuries due to high and low velocity missiies. Patients and methods

During the period between Jan. 1991 to Aug. 1997, 135 patients (a11 males) were admitted to AL-EMARAH military hospital w·ith injuries to the large bowel, their, ages ranged fi·om 19 to 53 years with a mean of 36 years . penetrating injuries

There were 124 patients with penetrating injuries of the large bowel, ll6 caused by high velocity missiles ,6 were due to low velocity missiles and 2 were due to stabbing. With 1 I payients had penetrating abdominal injuries?? haematoma related to

.,·,F.I.C.M.S .. D.M. department of intcmal medicine. Hammad -Shahab Military Hospital Baghclacl-c

Iraq.

The Management of large bowel injury ........................ . )(,

the colon but did not encroach upon the lumen of the bowel .

Initial treatment The essentials of initial management are to prevent death and to avoid further damage, so good assessment of the patients and rapid work of life saving measures were preformed . Surgical treatment

m Table l.The exact procedure performed depend on the site and extent of injury ,the degree of peritoneal soiling and the presence or absence of other intra abdominal injuries. Table 2 shows the frequency with which organs other than the colon were damaged.

The distribution of injuries in the colon and rectum are summarized

Table I [ Distribution of penetrating large bowel injuries

[Caecum 16 : i Ascending colon 28 I 1 Transverse colon 23 I Descending colon 26 ! Sigmoid colon 19 I, i Rectum 5 l Multiple segments 7

Table 2 Associated injuries

Stomach 19 Duodenum 6 Srnall bowel 73 Liver 35 Spleen I 7 Pancreas 11 Urinary bladder 4 Diaphragm 15 Gall bladder 2

Penetrating injuries of right colon There were 44 patients with penetrating injuries and 3 patients with haematoma in the ascending colon .

cavity and \Vithout associated mJuries , primary repair \Vas done in two ·layers .

In 12 patients the mJury was limited, without faecal contamination of the peritoneal

In 13 patients \vhere the damage was more extensive and there vvere no serious associated .. mJu:ies, right hemicolectomy \vith

were

lralJi Ann~ Medical Joumal, Vol. I2 !\o. I & 2 2000; Vol. 13 !\o. I & 2 2001.. ..................... :'7

-transverse anastamosis was

In I 9 patients there were extensive damages with associated lesions. right hemicolectomv \\ ith end to

u -

side ilea -transverse anastmosis and vent -colostomy (M uirs procedure) was perfonned. In 3 patients retroperitoneal haematoma in the region of ascending colon. mobilization done but no perforation was found. Pcnctr·ating in juries of tr·ansYerse colon

In 9 patients with penetrating inJur~ of transverse colon the lesions \\ere small and treated by exteriorization of the injured segment. One patient died as a result of associated injuries

In 14 patients the injury was extensive and they \\ere treated by resection of the involved segment followed by proximal colostomy and distal mucous fistula. 3 patients died ,they had multiple seveeassociated · lllJUrieS. In 7 patients there were multiple injured segments involving the transverse colon and descending colon, they were treated by resection with proximal colostomy and distal mucous fistula. penetrating injuries of left colon

There were 45 patients with penetrating injuries to the left colon . In 16 patients the injmy was simple and treated by exteriorization of the lllJ ureci part after adequate mobilization. In26 patients the InJUIY was extensive and treated by resection of the involved segment with proximal colostomy and distal mucous fistula . 3 patients died because of extensive and seveeassociated injuries .

In 3 patients with extensive injury, resection of the involved segment followed by proximal colostomy and the distal segment closed ( 1-lartmanns procedure ). Penetrating Iniun of the Rectum

There \Vere 5 patiens with rectal injury· treated by closme of the rectal wound with defunctioning proximal colostomy and faecal evacuation by irrigation . tube drain was left in the peh·is and brought out at aseparate Stab \\OUnd !10 presacral dralllage \vas used .

One patient died as a result of multiple associated inJuries .In all patients 111 our series mid line abdominal incision was used , it is quick to perform relatively avascular and can be converted to thoraco -abdominal mcJsion if required . Drainage \Vas performed in all patients , tube drain was used and left for 2-J. to 72 hours .. \ntibiotics \Vere started immediately . Morbiclitv and mortalitv

Wound infection \\as the most common complication . it \\as developed in 18 patients ( l3 o,o l . Table 3

Infection of inlet and outlet \VOunds occurred in 9 patients 6.5 °:0 in spite of thorough debridement. 4 patients (3% ) dewloped intra -abdominal abscesses (3 sub phrenic and I pelvic ) . 2 patients ( 1.5 %>) developed f~tecal fistula .

'J patients died because of multipk sevee injuries to other organs, vvhich caused systemic f~1ilures (irreversible shock , septicemia , renal failure , ARDS The over all incidence was (6.6% ).

The Management of large bowel injury .. 5X

Table 3 Complications of I 35 patients with colo -rectal injmy

\Vound infection Infections of entrance

: Or exit wound : Jntraabdominal abscess ! Faecal fistula

Discussion Large bowel mjmy usually occurs in association with injuries to other organs than it does in isolation , vvhich has great effect on

.. i ' management and prognosis \-; . The morbidity and mm1ality are proportional to the number ,type and severitv of associated injuries and periton~al soiling •.J '. -

No single policy of management can be applied to all patients with missile injury to the large bowel (SJ_

The general rule is that a damaged colon should be exteriorized or defunctioned by proximal colostomy (J< The prevailing opnuon of American trauma surgeons favor primaty repair or resection and anastamosis of unprepared bowel , surgeons who manage few colonic injmy prefer colostomy more frequently .High velocity missile injmy was the only injury for which the majority of American surgeons (54 %) would perform defunctioning colostomy ((J) .(JJ . In our series we found that isolated injury of the right colon with minimal peritoneal soiling can be safely managed by primary repair or right hemicolectomy with ilea-transverse anastamosis . A retroperitoneal rematoma in the region of the ascending or descending colon should lead to a

--.--~---.... ' No.% i%

-·----------,

18 9

4 J

113 ~-~ i---

6.5% ~

:3% 1.5 ~/0

most careful search for any perforation of the bare areas of the colon 15

J.

After all operations for penetrating large bowel injuries ,the abdominal cavity must be thoroughly drained and it is best achieved through a separate incision in the flanks (SJ •

Antibiotic therapy must be given immediately pre and postoperatively, our policy was the use of broad - spectrum antibiotic combinations References !.Parks TG 1986. Assessment and management of the injured abdomen post grad j 62 . 2. Br . J . surg 1989 vol 76 , october 1006 -1010. 3. Surgery for victim of war (ICRC ).

4. SCHROCK T .G and CHRISTENSEN management of perforating injuries of the colon . 5. M. S . Owen -Smith high velocity missile wounds . 6.Record 6 of 15 -MED LINE® II 98 - 9/98 Surveyed opinion of American trauma surgeons in management of colon injuries.

Iraqi Anny l\Icdical Journal, Vol. 12 No. I & 2 2000; Vol. lJ No. l & 2 2001.. .................... 5')

Eight Years Review Of I\'1alignant Thyroid Tumors

(*)Dr. Adil karim AI - Hamdani

(t) Dr. Mehdi Abdullah AI - Sarraj

. ~ 1 '1 '1 J32!1 j_ri\.S 0J\ ~ '1 '1 \

'"'-"----'-'. • ·;_;L...c:. 'i .4.____: .... :....;•Ll..l·;; ..:;\:.i..J . _j ::j. :Ji y h..:.;':i\ c :: dl ~\ ~ i ~i ' ~ . ~ . -li ~

':" \;1 • • •• 6 ~....? "-;:" _ _JwJ-J '-" _,J "'::"'--" • ~~- -.T~ J ~ ~ '-•...

. JI~\ '-,?.J 4......awl 3 ~ ~~ ~~ JSlyJl ~ j.o ~~ ~ ~ .J..J.J\ ;;.WI J.b ~ (1 ~ ;\) 21~ jl ~3 ~ ~ 1 '1 \ ~ _} j\.S ul p.JI 2l\:i J>::. ~ ~.J fol J.S 3

. ~ d\ ;;.c..;J\ ·~Lb ~ Ll..a..., L.:::u w .. J '-" ...../ . . .. _,r-

:; L .\ ... · I"'.;, :--·II .• 1 • • '~·:: .11 :; -' .!1 •••• 'I . ' 1 • 'I ;; -I • • 1 ;·· ~ y-: .__, - •• - .•• , ~ ~ y> ~ ~.)~I o.l.:<..l ,_)La~ ~ ..rJ -w..ai..:>. 3 ~ ~

. -.# _;bjl v~\

(vo-i '1) ~ CJI.fo ~)-_,~\ Ll..i\.S..9 G1J2!1 j.o (o~1o)3 .)_,Sill j.o (1. i) 21~ j\.S ..J.il

L__., (1, \'~1:') '-?J. GIJ'i\ :_)~ill ~ ...::.:_j\.S 3 ~ ('1 ;\,;\o) ~ .J~ 'ii j..J.xA j\.S 3 ~

. (. ~: ~) GLJ';l\ o , • Cil\ ·'--'-' ~~ G\.Sj ~ d\ ;;.c.i.J\ _j ~ c.:'dl ·.Lb , .I\ ~'iG.. \~ ~J ._/,~ ~ • •• J >...? •• ./ '-' ~

( 01 """ ' \""- )' • • /0 I 1\\ > I

f hu j--e- :i };.J..J.l\ ;;.WI Jbr tl _Til ~\ji..9 ~ _} iJ)i.:.i..:;..\ 2.1~ jl -'--?- 3 ~I.J..J.l\ _}

• ...5 p 'i \ _)..:;LL,_J\

4 .: .. ...a 3 ~ iJ-ii.S ;;y J}·J re. o ... ~ .llc ~yJI j.o ~ V'~ ':I b~ 2.l~ j ~~ -"-?-35

· ~ 3\ r.lli.o J.b .r

Summary In this retrospective study (769) patients are collected and reviewed in (8) years period from Jan. (1992) to Dec. (1999). Those patients were referred from difTerent medical centres in Iraq to the (Institute of radiology and nuclear medicine) for further management as cases of malignant neoplasms of the thyroid. The highest number of patient recorded was during I 992,118 patient. Most of the patients vvere proved

,·, D.G.S.- C.A.B.S In The Institute OfR<ldiolog) And Nuclear Medicine In R1ghdad 11

' D.MRT In The Institute Of Radiology And Nuclear Medicine In Baghdad

Eight Years Re\ iew Of !\'lalignant Thyroid Tumors .............................................•....... 60

to have malignant neoplasms of the thyroid by histopathological study. For patients with locally advanced disease, the diagnosis was made by fine needle aspiration cytology (FNAC). There were (204) male patients (29 .52%) and (565) female patients (70.97°10) in this study, their age ranged from (13-75) years with mean age of (38.85) years, with male: female ratio of(.l :2,76), except in cases of secondary malignant tumors of the thyroid where the M: F ratio was ( I : I ) . Most commonly affected group were patients of age ranging (21-40) years and this group constitutes (38.36% ). In our study, papiliary carcinoma of the thyroid constituted the commonest form of malignant thyroid tumors (62.54%) while follicular carcinoma constituted ( 17.42~~0), Anaplastic type ( 11.96°~6) and the medullary· type \vas (7.02<%). There \\ere four patients with secondary metastasis to the thyroid gland "adenocarcinoma "and four patients with lymphoma of Hodgkin type. The presence of metastasis at the time of presentation of patients with malignant neoplasms of the thyroid gland \vere present in (34.3%)) of patients with papillary type while it was present in (29.85~;o) of patients with follicular type.

""·-' •• -- A., .. ,._ .•• .o:u· "<o~ rr-~----c--·- .,,.._- ~v-.:.1-·'-"'r-" ~'"~~~w'?'"·"rtf..:>·' . a-e"'"' -~- -. .,,., G 7- fp-'p·, ~~ . .., z~li" )"~-;< -'7>'--""a' . R gg-""'t•o" 'it·. -~a-· ·s-,.---,.,; -e&- ... -· ·-- t -;;;

Introduction Thyroid cancer is regarded as the most common endocrine mali!.!nancv (2l). It occurs in both

~ ,. male and female, ii1 any age group including children and elderly ( li.!'J.20.22i . · · but It most commonly affects women between the age 25-65 vears. Thvroicl cancer is divided-into four t;pes: !7.!'J~25 j !.Papillary. 2.Follicular. 3. Medullary. 4.Anaplastic. The pathological classification is based primarily on the cell of on!.!m land the degree of

~ ' ~

differentiation). Other rare groups include~ lymphoma,and secondary Metastasis. Three t,rroups of people are at high risk for having cancer of the thyroid in the general population ( (, ).

I. Individuals who have been exposed to low close radiation to the head and neck e. g.: for enlarg_~q~, thymus,_ adenoicL and acne. II. Familial type " medullary carcmoma dominant.

)1

as autosomal

III. Malignant lymphoma, sometimes develop in autoimmune thyroiditis .It is responsible for more deaths than any other endocrine tumors, however, the

. . ()') death rate Is decreasmg -~ . Thyroid cancer can be among either the most indolent tumors or the most a~J(~ressive «d 2~25 '

bb

Patients with papillary thyroid cancer are usually cured whereas patients with anaplastic type seldom live longer than 6 months 1 IL2l) .It had b;en reported that

I .. : for

and

Iraqi Army I\Icdical Journal, VoL 12 No. I & 2 2000; Vol. 13 No. I & 2 2001. ..................... 61

pure papillary carcmoma rs becoming more common, \vith late mortalitv rate of 2%, for follicular type 14% whiie 80-90~/o for anaplastic type l

3l_

Goitre develops and continues to enlarge in size under the influence of high basal TSH. The sustained high level of TSH result in follicular hyperplasia with concomitant change in the (DNA) of the thvroid cell with subsequent m;lignant change (IS)

It has been emphasized that a well differentiated follicular carcinoma will eventually change into anaplastic one if it is left without surgical treatment for a long period' 13

}

It is of interest to mention that neoplastic thyroid tissue showed a different response to TSH and V.l.P stimulation both basal and TSH stimulated cyclase activities increased in thyroid tumor relative to normal thyroid tissue (.U•

Thyroid tumors also showed a greater degree of TSH stimulation as compared with their basal level mostly in follicular type, V.I.P is able to simulate neoplastic thyroid tissue above basal level but less potent against than TSH. Also both . normal and TSH stimulated adenylate cyclase activity is markedly inhibited by somatostatin. Thus when stimulatory system and inhibitory system compete, the somatostatin wins for this reason, usmg long actmg somatostin analogue to treat

patients with aggressive thyroid cancer C3A,2I).

The recent evidence of increase in incidence \1

'!J its occurrence in young persons, the association with exposure to inadiation in childhood and the success of curing the differentiated tumors \Vith radioactive iodine and hormones have attracted the interest of surgeons, oncologist and endocrinologist. Patients and methods

This is a retrospective study, includes (769) patients referred to the (Institute of radiology and nuclear medicine) in Baghdad from different medical centres as having malignant neoplasms of the thyroid gland in a period of (8) years started in Jan. 1992 to Dec. 1999. These patients were referred according to the histopathological reports from government and private pathology laboratories. In the minority of cases the diagnosis was based on fine needle aspiration cytology (FNAC) only in patients with locally advanced disease or those unfit for surgery. We divided the patients for the aim of the study into four age groups: patients less than 21 years old, (21-40) years, (41-60) years, and the last group patients with an age above 60 years. It is of interest that we excluded patients with lack of enough information or patients with the diagnosis based on radiologicaL

'- ~ '

other specified laboratory

Eight Years Rniew Of Malignant Thyroid Tumon ..................................................... 62

investigations and on clinical grounds without histopathological or cytological proof. The mean age of our patients was (38.85) years, ranging from 13 to 7 5 years old. Results In this retrospective study (769) patients were examined during a period of 8 years. During these 8 years as shown in table ( 1 ), 1992 shmved the highest number ( 118) of patients with male: female ratio of (I: 3.3 7), which remained nearly the same ratio during the eight years .So malignant neoplasms of the thyroid gland in general vvere three times more common in female patients than male. Marked decrease in the recorded number was noted during 1995 and 1996 for unknoyvn reason. From the (769) patients there were (204) male (26.56200) and (565) female (70.97%) which gives M: Fratioofabout(l:2.76) for· all age- groups. Ages of the patients vvere ranged from ( 13-7 5) years with mean age of (38.9) years. ( 481) Patients had papillary type (62.54%), (354) patients were female (73 .6%) and (127) patients were males (26.4?lo) with M: F ratio of(1 :2.78). Regarding foliicular carcinoma of the th.yroid, our study showed that ( 134) patients (I 7.42%) had this type oftumor .One hundred eight (108)(80.59%) patients were females and only 26 (19.4%) males with M: F ratio of (I :4.15).

In medullary type, the total number of patients was 54 (7.02~;0), (34) patients of them were females (62.96%) \\bile (20) patients were males (37.03%) which M: F rat10 of ( l: I. 7 ). Ninety-nvo ·patients (I l. 96')'o) were proved to have (anaplastic type), 64 patients (69.56%) vvere females while 28 patients (30.43%) \\·er-e males with M: F

. f''ji'"'O) ratio o ( :~ .::o.

Rare tumors of the thyroid gland including, lymphoma and metastatic adenocarcinoma, ( 3) females had lymphoma of Hodgkin type while only one male patient had this type. Four patients had metastatic adenocarcinoma, (2 j vvere females These results are shown in table (2 ). In our study we found that the incidence and the type of the tumors were related to the age or the patients as shovvn in table (3) and table ( 4 ). '0/ e found that there was ( 65) patients (8.45%) vvith age less than (21) .years, (16) males and ( 49) female with M: F ratio of (1 :3.06 ). There was (295) patients (38.3600) between (21-40) years old, (77) of them were males and (218) \vere females with M: F ratio of ( l : 2. 83). This group constitute the most common age group affected. In the 3 rd age group ( 41-60) years old patients, the total number of patients was (249), ( 48) patients were males (23.52%) \Vhile (201) were females with M: F ratio of

total ' i 54

Iraqi Army Medical Journal, Vol. 12 No. I & 2 2000; Vol. 13 No.1 & 2 2001. ..................... G3

(1 :4.18) which was the highest ratio among all age groups. The 4th age group which includes patients over 60 years of age, the total number \Vas (160 ),( 63) males (30.88%) ,and (97) females (17.16%) with M:F ratio of (1:1.53). Table (6) showed that ( 165) patients from ( 481) patients with papillary carcinoma proved to have metastases, this . constitute newly one third of the patients (34.3%), ( 163) patients had only lymph node metastasis while ( 4) patients had extra nodal metastasis like, lung and bone. Regarding the follicular type ( 40) patients only (29.85%) from (134) patients presented with metastasis that was mostly extra nodal ( 3 7) patients, while only ( 8) patients had lymph node metastasis. From (54) patients with medullary carcinoma, (11) patients (20.37%) presented with metastasis, all of them were lymphatic metastasis, while in anaplastic type, (24) patients from total number of (92) patients had metastasis at presentation, that constitute (26.08%) ,( 16) patients had nodal metastasis ,while ( 1 0) patients had extra nodal metastasis . Discussion It is estimated that the incidence of thyroid cancer in U.S. is 40-50 cases /million population /year (lJ,22).

The death from thyroid cancer occur with an incidence of about (6) cases per million per year.

In the U.S. about 1200 people die from thyroid cancer every year 1251

In the U.K. the annual incidence of thyroid cancer is about 3. 7 per one hundred thousand of the people with ratio of ( 3) females to ( l) male and as a registered cases of death, it is responsible for 384 death /year . In Iraq, the number of cases registered during the period l 986-1988 \\as (324); and the number during 1992 -1994 was (386) as having carcinoma of the thyroid I I i!)

It Is assumed that the geographical difference in the incidence of thyroid malignancy is more likely to be caused by environmental or dietary factors l , 1 d · 1X ')· t 1an Dy race or 11ere 1ty '- '

The incidence of occuit thnoid cancer of the thyroid were reported in different studies as 1701 3~ jO/, 6/001 "O/ d ~ 1o, _). ,o, .- 1o, _)/o an 2.3% and such difference in the mcidence of occult thyroid cancer may reflect difTerent methods of study or geographical variations of thyroid pathology 12

'5

'1-usJ .11

has been reported that the incidence of thyroid cancer 111

goitre is 10% of cases collected in Iraq by AL-SALEEM and AL -ASHBAL ( 1973) 141 .In another report, they registered an incidence ranging from 1.6 - i 7°/o in surgical specimens with average of ( 60%) , while In a recent study by AL -Saleem and AL-Hadithy ,they reported the incidence of malignancy in 5. 7% of the thyroid specimens which

Eight Yean Review Of Malignant Thy1·oid Turnon .................................................... JJ.J

they studied c 1) . The difference in

sex incidence had been thought to be due to specific binding sites for estrogen that are detectable in all thyroid tissue and neoplasm arising from thyroid tissue, the incidence of high affinity intra cellular binding sites (Receptor )is much higher in neoplastic tissue such as adenoma and different carcinoma (88%) compared with non -neoplastic tissue (25%) like endemic goitre and normal thyroid tissue and medullary carcinoma of the thyroid ,the receptor content of the neoplastic tissue is also much higher than the receptor content of non neoplastic tissue ,all these will explain the high incidence in women of reproductive age and the poor prognosis in older men and suggest the strong possibility that steroid hormones influence 1 ·d · (212124) Tl t 1yro1 carcmoma ' -' 1e

mean age incidence of thyroid cancer in our study was (38.85) years with the highest incidence among patient in the age (2 1 -40) years old (38.36%) and lower incidence with a lower age . It is reported that about 6.4% of (776) pa6ents with thyroid cancer occurred in patients less than (18) years old, mostly of papillary type (90%), follicular (8%), medullary in (2% ), lymph node metastasis was present in (73%) and (250%) lung metastasis which indicate that thyroid cancer in younger patients is rather advanced at initial diagnosis and associated with high rate of surgical

complications post operatively and by pulmonary restrictive disease in relation to lung

'11' metastasis 1 )

While in our study (8.45%) of patients belonged to less than 20 years old age group with (78.64%) of papillary type, (9.23%) follicular carcinoma and (12.30%) medullary type. The vast majority of primary thyroid tumors are carcinoma'/'', these are classified histologically into differentiated and undifferentiated, \Nith the relative incidence of primary malignant growth of the thyroid as follovvs: papillary carcinoma (60% ), follicular carcinoma ( l7~lo), anaplast4ic carcinoma ( 13%), medullary carcinoma ( 60°;() ), and malignant lymphoma (4%) rc,)

There is a controversy about the incidence of different histological types of malignant thyroid neoplasms among different references, indicating that the geographical factor and the histopathological method of the differentiation play a role in these

. 'll) ")') drfferences, however 1' ·-·'. a reference mentions that papillary carcinoma constitutes 80% and follicular carcinoma 15-17%, and 30% for undifferentiated carcinoma and the same for medullary type, while other reference c2s). gives another different incidence mentioned that papillary carcinoma occurs in more than half of adult patients and accounts for 75% ofthyroid cancer in children ,while follicular

InHJi Army J\lcdical Journal, Vol. I2 l\o. I & 2 2000; Vol. 13 No. I & 2 2001.. .................... 65

carcinoma occurs in about 25% of patients with thyroid cancer and the lesion tends to occur in older age groups ,with peak incidence in the fifth decade .I'v1edullary carcinoma may make 3.5 to 11.9% of thyroid malignancies with no age difference (15

' 16),

Undifferentiated carcinomas make up to (I 0%) of malignant thyroid tumors and usually occur after the age of fifty Jn the same reference thyroid gland is regarded as a rare site for primary lymphoma and it mentions that Mikal in review of a literature indicated that ( 165) cases had been reported as a malignant lymphoma arising from reticular ceils and only 13 cases of Hodgkin's disease arismg primarily in the thyroid, while it was mentioned in another reference that lymphoma of the thyroid is almost always of non -Hodgkin's type c19l.

Secondary t,JTowths are rare in the 1 .d !6l I -" t 1yro1 · ' ot 1er re1erence

mentions (2-4%) of patients dying from malignant disease had secondary metastasis m the thyroid and from surgical specimens there was (0.05%) only which represented metastatic involvement of the thyroid, most commonly from hypernephroma, breast cancer, melanoma and b I . . r6 25) I ronc wgemc carcmoma ' ' . n Iraq, in 1986 -1988, the incidence of papillary carcinoma was (59.4%), follicular carcmoma (15 .1% ), undifferentiated carcmoma (10.6%), medullary carcmoma (5%) and other (0.6%)

while for 1992-1994 shmved that papillary carcmoma (64.7%), follicular carcmoma ( 16% ), undifferentiated carcmoma ( 13.50~0), medullary carcinoma .,,,. (I .8%) and others (0.5%)' :;J.

In the present study (62.54%) of the cases proved to be papillary carcmoma, which is different from the incidence mentioned above and Its occurrence at middle and old age groups \vhich is also in contrast to other references but nearly similar to the results given by reference (6). In our study, the incidence of follicular carcinoma is ( 17 .42%) at (I 4-60) years age group wh1ch 1s similar to the incidence mentioned by orloh clark ( 15-17%Y''J).

The incidence of anaplastic type in our study was found to be (I 1.96%) which was in disagreement with the incidence mentioned in other references because our study showed a higher incidence. The incidence of medullary type found to be (7.02%) which was in agreement with what was mentioned in references (6) and (25) with peak incidence in male patients above (60) years while in female patients, the incidence is of no much difference. Regarding the presence of nodal and extra nodal metastasis, table (6) shovved that most of the metastasis of papillary type was lymphatic which was m agreement with the fact

1 ' ' '

I

l:i!i,l. II ,:!

I

I I

Eight Years Review Of Malignant Thy1·oid Tumors ..................................................... M

mentioned by other reference r6 12 2s1 W'l .1 · c 11 . I · · · ". 11 e m 10 1cu ar type, the main way of metastasis is extra nodal which was also

. d . l c (6 7 12 19) reg1stere m t 1e re1erence · · · . In the medullary type, (11) patients (20.37%) presented with lymph node metastasis, there was no extra nodal metastasis at the time of presentation. In the anaplastic type, (24) patients (26.8%) presented with metastasis either nodal or extranodal or both which was a significant number of this type of aggressive tumor. Conclusion 1. Because a significant number of malignant thyroid tumors were recorded each year, so every

attempt should be made to identify aetiological factors, diagnose at an early stage, optimize treatment and follow up. 2. The most common age group affected is (21-40) years old with male; female ratio 1 :3. 3.The incidence of different types of thyroid malignancies was as follow: the most common type is papillary, followed by follicular then anaplastic type and the 4 th tumor was medullary type. 4.Asignificant number of patients presented with nodal and extra nodal metastasis, this indicate late presentation and late diagnosis . It is advisable to use FNAC for early detection.

Table (1) Distribution of patients with malignant thyroid neoplasm per year

according to sex Year Total No. 1992 118

1993 1 106

1994 l 102

1995 I 71 I

1996 I 74

1997 111

1998 90

1999 97 l I ;

Total 769

j

I i

I

I

i

I

Male 27

(22.88%) 23

(21.7%) 28

(27.45%) 21

(29.57%) 23

(31.08%) 33

,-- .. 2%) 22

(24.45%) 27

(27.83%) 204

(26.52%)

i i

Female 91

(77.12%) 83

(78.3%) 74

(72.55%) 50

(70.45%) 51

(68.92%) 78

(70 /

68 (75.55%)

70 (72.17%)

565 (73.47%)

! M:F ratio I.

I :3.37

1:3 6

1:2.64

] ·/ '"'8 . "- .. )

1:2.21

1:2.36

I 1:3.09

I i I :2.59 I I ! I

1:2.76

lfor

Iraqi Army 1\Icdical Journal, Vol. 12 No.1 & 2 2000; Vol. 13 No. I & 2 2001.. .................... 67

Figure (I) Annual distribution of malignant thyroid tumors.

120

100

80

1992 1993 1994 1995 1996 1997 1998 1999

Table (2) Distribution of different histopathological types of thyroid cancer

according to the sex of the patients. Type i

:Papillary

Follicular

Medullary

Anaplastic

Lymphoma

Metastatic

Total

Female Male Total i 3'i4 ! .....

i (73.6%) 108

(80.59%) 34

(62.96%) 64

(69.56%) ~

.)

(75%) 2

(50%) 565

(70.97%)

400 350 300 250 200 150 100

50 0

...... ~ ::J

c .!2 a. u

0 u.

(1l

c..

i27 ; (26.4%)

26 ( 19.4%)

20 (37.03%)

28 (30.43%)

1 (25%)

2 (50%)

204 (26.52%)

c ~ ::J '0 (1l

~

! 481 !

; (62.54%) 134

( 17.42%) 54

~7 0)0 /' { . - ?o)

92 (11,96%)

4 (0.52%)

4 (0.52%)

769 (100%)

I• Female !

u (1l .... E (/)

~ 0 .I:: c.. c.. (1l

E c <! >.

....J

M:F ratio 1:2.78

1:4.15

1: I. 7

l :2.28

1:3

1:1

1:2.76

I :: I Male

u .... (1l .... (/) (1l .... Q)

~

Figur·e (2) Distribution of different histopathological types of thyroid cancer

according to the sex of the patients .

1

Eight Years Rc, icH Of :\'lalignant Thyroid Tumors ..................................................... 68

Table (3) Distribution of male according to age.

Typ~ Papillary

20 years 21- 40 i 41 -60years > 60 -)~--: 13 61 30 23

Follicular 9 14 3 10 __ I\!Ie_~ullary 3 7

Anaplastic , -I~~~~-~1~~---~-_----~. -· ----

-~ /" , -~ ~,_.,- I

----+-: -- ·---------·------~·-··----

Metastatic - ·-_----, ----_-----. ----2----, Total 16 77 48 63

Table (4)

Distribution of female patients according to age. _ --·------______ I_n~~------~-- 20 years : 21-40 years 41::. 60 ye~T~-. __ > 60_ year~ ___ l::_<~pJilar:t 38 J 82 ---~-- 1 0~---·--- 31 ______ _

Follicular 6 21 · 58 23 ·------+----------t··-------+.

11 . Medullary 5 9 9 Anaplastic

_Lymphoma

-----·---~--~-

6 24 .., _)

Metastatic - - 2 Total ·- --~------- ·c

49 11 ~ }(\ .:... ,} -----------

Table (5) Male to female ratio according to the age. Age M : f ratio

34

97

--------

20~~-~-~_;_~--- ··----------,

> 60 .53

Table (6) Distribution of patients according to the presence of metastases at the

time of presentation. ----~-----~-~

!

Type Number Metastasis Nodal Extra nodal 1·

Papillary 481 165 163 4 """'4""'0/r' t _) . _) 0)

Follicular 134 40 8 37 -----

(29.85%) Medullary 54 1 l 11

~---'-----r-----------··---····-~---

(!0""']01) - __ ) /0 ·-

Anaplastic 92 24 I 16 10

-------(26.08%)

JratJi Army Medical Journal, Vol. 121\o. 1 & 2 2000; Vol. 13 No. 1 & 2 2001.. .................... (,9

600

500

400

300

200

100

0

481 Total number

Patients presented with metastasis

16

ppillary follicular medullary anaplastic

Figure (3) Distribution of patients according to the presence of metastases at the

time of presentation.

References

l.AI- Hadithy R, AI -Saleem T. PaThaoJogy of the thyroid gland in endemic goitre and possible relation to malignancy . University ofBaghdad 1986.

2. Al - Hashimi HIM. Thyroid nodal in Iraq . postgraduate Med. Journal I 972; 218: 80-82. 3.Allan E. Siperstein ,M.D etal. Stimulatory effect of vasoactive interestial polypeptide on human normal and neoplastic thyroid tissue. Surgery vol. 104 No.6, P. 958 -991 Dec. 1988.

4-AI- Saleem T.", and AI -Ashbal Surgical pathology of thyroid gland in Iraq.

5-Ann Me call, M.D. Harriet Jarosz, B.S., etal. The incidence of thyroid carcinoma in solitary

cold nodule and in M.N.G. Surgery vol. 100 No .6.1986. 6.Bady and loves Short practice of surgery. 20th edition I 989. 7.Blacke cady ,M.D. eta! An expanded view of riskgroup definition in differentiated thyroid carcinoma ,surgery , val. 104 No. 6, P. 94 7-953 Dec.l988.

8. Brennas MF, Macdonald JS. Cancer of the endocrine system .In De vita VT, Hehm.ans ,Rosenbergs ,cancer : principles and practice of oncology. 2110

edition philadelphia I 985 : 1179-1241.

9. Cady B. sedgwick ce, eta!. Risk factor analysis in differentiated thyroid cancer cancer 1979; 43: 810 -820.

Eight Y cars Hc,·icw Of Malignant Thyt·oid Tumors ..................................................... 70

I OJraqi Cancer Registry Centre, Institute of radiology and nuclear medicine -results of IRAQI CANCER REGISTRY . 1990 -1996. 11 .Clandia ceccarelli,M.D. etal. Thyroid cancer in children and adolescents. Surgery vol. 104 No. 6, PP I 143-1145 Dec .1988. 12. Cushieri A. Essential surgery practice .2nd ed .1988. 13.Goldfarb WB, Bigos Ts eta!. Needle biopsy in the assesment and management of hypofunctioning thyroid nodule . Am .J. surg. 1982; 143 -4I2. 14.He1io. Bisi, M.D eta!. The prevalence of unsuspected thyroid pathology in 300 sequential autopsies with special reference to the incidental carcinoma, cancer 64: 1888-1893, 1989. I5.Hiranandani LH. The thyroid .Bull Jas1ook Hosp. Res . Centre Bombany 1984; 9:2 -14. 16. J. schindel and segal. Thyroid gland cancer 25 years of surgical experienc~,- .Int~rnational surgery 65, l: 1980. 17.Lawrence W. Way .Current surgical diagnosis an treatment. 8 th edition 1988. 18. Minesh P. Mehta, M.D, paul G. Goetowsk :M.D and Timothy J. eta! Radiation induced thyroid neoplasms 1920 to 1987 A vanishing problem? Int .J. Radiation oncology Bio .phys vol. 16, P. 1471- 1475, 1989. l9.0rlok.Clark. Endocrinesurgery of the thyroid and parathyroid glands. 1985.

20.Persprogel and Hans H. strom. Thyroid cancer incidence ,mortality and histological pattern in Denmark. International Journal of pidemiology 18,4, 1989. 21 .P.K. chandhuri, M.D. and Richard pnnz · M.D. Estrogen Receptor in normal and neoplastic human thyroid tissue .Am .J. Otolaryngology I 0.322- 326 Sept 1989. 22.Raphael B. Pollock, James H. Doroshow, et al. Endocnne tumors, JEFFREY A. NORTON . 7th ed., I 999: 363 -365 . 23.Roman Riger, M.D.eta1 Hyperthyroidism and concurrent malignancies, Surgery 1989 121 -106. 24.Shukeri A. M. The solitary thyroid nodule in Iraq. British J. of clinical practice, March 196 7. 25 .Shwartz, shires, spencer. Principle of surgery. 5th edition 1989.

Iraqi Army Medical Journal, Vol. 12 No.1 & 2 2000; Vol. 13 No. I &2 2001. .................... 71

Cholecystectomy Concomitant with Other Intra-Abdominal

Operations

(*I Mr. Husmn abel- Alkarim

1t1 Mr. Hasan Ahmed Hasan

' ( •• • \' \ Y \') • (0/ \' \)' • Y.,.., • 'j • •• \ Q Q ~ • I • •• '• ! \ q 0 \'"" .~..J..l ~ I- l __r- ~ /0 ,I ._,~...)-" l l ,j ._,'7.+" 1 1 1 ~· ,ji_Y._? -\!W J , I I'

~ v i..,?.i\ .';s·; ·':11 ~~ ~ -.1...>?-i ..l.ic. :;_)_yJI (...,~ j)l....::.. 0-o 2ll:O..S 3 .-.\~1 ... ::.J~I 3

4 •icc jl ~j ~ U:....>?-1 -?1 w4L=JI ~ """'--:ayJI ~\.:, j'Y....::.. -J-oj ~ _r..:i ~ --.,~...)-"

Summary

In a prospective study 423 laparotomies were performed for various intraabdominal conditions in the period from March 1993 to June 1995- in the surgical department:.. UniVersity J-lospital- Saddam ·coTiege ·cifMedkine. 33 Patients (7 .8%) aged 27-78 years were found to have gall stones during unrelated major abdominal operations by thorough examination during the operation, 16 patients underwent concomitant cholecystectomy and 17 patients have had no surgical interference related to their gall stones.

For the first group ( 16 cases), one patient died from septicemia not related to cholecystectomy, 4 patients developed complications not related to the cholecystectomy.

In 17 patients with no concomitant cholecystectomy, only 4 patients developed symptoms of biliary tract disease within 6 months postoperativeiy.

l *.I FRCS Consultant surgeon. Lecturer and clinical tutor. UniYersity Hospit<d. Sac!cbm college or Medicine. R;ghd:Jc!. IRAQ P.O.BOX 7000.5.

· 'FRCS Consultant surgeon. Lecturer and ciiniclllutor. UniYersity Hospital. Saclcbm college of Medicine, Baghdacl. IRAQ P.O.BOX 7000.5.

Cholecystectomy Concomitant With Other Intra-Abdominal Operations ......................... 72

Another control group, 16 patients with silent gall stones cleteckd by ultrasound, only one patient developed symptoms within 6 months. The result of the study is that the concomitant cholecystecomy docs not alter the morbidity and mortality of the patients if they were well selected.

l''?irVft&·w·rznwrwt¥f:it%lWW§Bwemw ,--~rwwcser ~eewn""'51*'T""·--~~·r--:-· .. -w--o..g-- .,.,_~-.,·tw-r·"~--""b 'Pi· L···h:e±Hf ···ntd'&-~-"'k, Wr:fkh ·· .. , .... -. '-w·-~--

Introduction The natural historv of gallstones

~ '-

is still not entirely known. Carbon dating has shown that stones may require as long as 8 years to reach

. I . rll I l b maxima s1ze · ·. t ws cen estimated from epidemiological studies both autopsy and clinical investigation that gall stones are present in approximately I 5-20% of adults, an incidence that begins

> v

in childhood and seems to progress steadily with age. Gallstones are rare in children, begin to be identified in adolescence, have marked increase in incidence between age 35 and 55 years and continue to show a gradual increase after 55 years of age. The incidence of gall stones is greater in females than in. males and_,in patients with multiple pregnancies and obesity. Studies shmv 40-60 percent of all persons with gallstones are asymptomatic 12

J. Some patients do however, develop symptoms before gallstones can be identified; this is approximately 5 percent of patients 12 ). Clearly, only about 30 percent of patients with gallstones will come to

T cholecystectomy \ J The best means of examining the natural history of gallstones is to divide patients with gallstones into two categories - symptomatic and asymptomatic. Patients with

symptomatic gallstones are at high risk. of complications. 0\-cr 90 perce11t had s:vmptoms at the time of di~1gnosis subsequently developed recurrent symptoms or other complications. f\!Ioreon:r, operative mortality increased\\ ith emergency procedure or scnous complications. Today·· s most physicians accept that patients with symptomatic gallstones are candidates for cholecystectomy i r they are in reasonable health and have a life expectancy of at least 5 \·ears. Patients with asymptonwuc gallstones may \veil follow a ditlerent course. The general term applied to this category is silent ur

. II I) I asymptomatic ga stones ·· ·. Many of these stones are discovered either by ultrasound OL because they are radio- opaque, b_y plain xray film of abdomen done for some other purpose or they may be felt at laparotomy or noted at necropsy. On the course of symptomless gallstones 49 percent de\ eloped symptoms but only t\\ 0 third or these had trouble sufTicient to merit cholecystectomy. h1rther the incidence of major complications \\as 18 percent and twice as frequent in the group who had originally non-

Iraqi Army l\Icdical Journal, Vol. 12 No. I & 2 2000; Vol. l3 No. I &2 200 l. .................... 73

functioning gallbladder on cholecystography. There are certain parameters that might justify proph~ylactic cholecystectomy. Past experience has shmvn that patients vvith large stones (> 2.5 em), a calcified gallbladder, non-functioning

Patients & methods 423 laparotomies were performed for vanous intra-abdominal conditions other than operations were planned electively or urgently for biliary tract diseases in a period from March 1993 to June 1995- University HospitalSaddam College of MedicineBaghdad- Iraq. ~.- l d L...c.) cases 1la' emergency operations and 198 cases had elective operations. During these operations palpation of the gall bladders was done for the presence of stones, 33 patients were found to have gallstones their a}..{:e raug~d fi;anL27 to· 78 v L>

and they were 20 females and 13 males. Patients with biliary symptoms preoperatively or known to have gallstones were excluded from the studv -'.

An ultrasonography and/or plain x- ray of abdomen was taken as a part of the investigations.

Results 33 patients (7.8%) had stones detected in their gall bladders by palpation during laparotomies for other problems. The age and sex distribution are shown in table ( l)

oallbladder or diabetics with b

gallstones are at increasing risk of scnous complications reimed to the gallstones: elcctiv._: cholecystectomy is warranted in these subsets of patients \Vith

. ll ( l.l asymptomatic ga stones

Concomitant cho lccyskctomy was performed with the prim~1ry procedure in 16 patients, their <:gc ranged fl·om 2 7 to ()] year~, l U females and 6 males. These l () patients were followed for morbidity and mortality related to the concomitant cholecystectomy. 17 patients m whom cholecystectomy \\as not done. their a!le ran!..:cd fhm1 28 to 78

L ~·

y·ears, and they \Vcr-c ·I 0 /~males and 7 males, \\ere foilm\ed up for complications. A control group consist of ! 6 patients were found to ha\C· gallstones detected bv ultrasonogrphy for symptoms nut related ro the biliary tree aged from :12 to 63 years, l 0 JXlticnts were females and 6 patients \Vcre males, they were not submitted to operations, followed for 6 months for morbidity caused bv bilian' tract disease.

and figure (I). Most of the patients age was above 40 years and the common age group between (50-60) years. The stones detected more in females (20

Cholecystectomy Concomitant With Other Intra-Abdominal Operations ......................... 7~

patients) while 13 patients were males. The most frequent primary procedures were operations for upper gastrointestinal tract diseases and operations for duodenal ulcer were the commonest. The types of primary operations are shown in table (2). In (18) patients, the primary operations were planned for them electively and (15) patients underwent emergency procedure. Ultrasound had been taken for 5 patients and plain X-ray of the abdomen for 13 patients as a part of preoperative investigations but gall stones could not be detected. Cholecystectomy was performed with the primary procedure in 16 patients ( 48.5%). The common primary procedures were operations for duodenal ulcer. Most of the primary operations were elective in 14 patients (78.5%). Only in 2 patients (12.5%) the cholecystectomy was performed with an emergency primary procedure. The primary operations with

concomitant cholecystectomy are shown in table (3). At the end of operations, the gall bladders were incised and stones were found in all, and there were 11 with multiple stones and 5 with a single stone. Average hospitalisation period was one week. Post operative complications occurred in 4 patients (25%). One patient with urinary tract infection, two

patients with chest infection and one patient with wound infection. One patient died. Mortality rate was 6.2%. 17 patients (51.5%) were not subjected . to concomitant cholecystectomy. The primary operations are shown in table ( 4 ). Some of these operations were carried out as an emergency in 13 patients (7 6.15%) and 94 operations (23.5%) performed electively. The most common reasons for not performing cholecystectomy at the primary operations in the presence of cholelithiasis detected intra- operatively, were: !.Unstable general condition in 4 patients (23.5%). 2.Inadequate incision in 3 patients (17.6%). 3 .Presence of high risk of infection in 5 patients (29.4%). 4.No definite cause in 5 patients (29.4%). 5. The average hospitalisation period was 8 days. No biliary symptoms appeared postoperatively. Ultrasonography (1 0) days post operatively revealed presence of gall stones. Follow up of these patients monthly for 6 months, symptoms appeared in 4 patients (23.5%). The type of operations, age , sex , symptoms, time of appearance of symptoms, associated disease, postoperative fasting period and blood transfusion are shown in table (5). In 3 patients (75%) the operation performed urgently, one patient

of

Iraqi Army Medical Journal, Vol. 12 No. 1 & 2 2000; Vol. 13 No. 1 &2 2001.. ................... 75

was diabetic (25% ), 3 patients received blood transfusion (75%) and postoperative fasting ranged from 3 to 5 days. In control group which consist of 16 patients only one patient (6.2%) developed symptoms of biliary colic after 3 months follow up. There were no significant differences between patients who

developed symptoms and those who remained asymptomatic in the noncholecystectomised t,>roup. In relation the urgently done operations, effect of blood transfusion, presence of diabetes mellitus and postoperative fasting period as sho'WTI in the following table:

'-'

Symptomatic Pts. Asymptomatic Pts. 2 Chi square (X ) P value

N=4 N=l3

3 10 0.005 0.937N.S

7 0.559 0.453 N. S 2 0 194 0.659 N S

Postoperative 1

, fasti eriod 3-5 days N S 2-6 days

* NS indicates not significant Outcome of Patients not undergoing cholecystectomy

There was no significant during laparotomies without. difference regarding the number cholecystectomy and patients with of patients who developed silent gall stones diagnosed by symptoms during 6 months ultrasonongraphy (X2 = 2.15) (P follow- up between patients with value= 0.167). silent gall - stones diagnosed

I Age (years) I Females

i i

Total I I

Males

21-30 2 0 2 31-40 " 1 4 .)

41-50 5 5 10 51-60 7 5 12 61-70 1 ') 3 "-

~------------~-------------+--------------+-------------4 71-80 2 0 2 Total 20 13

,.,,.., .).)

Table (1) Age and Sex distribution of patients with incidental cholelithiasis.

Cholecystectomy Concomitant \Vith Other lntra-Ahdomimll Opcratio11s ......................... 7<•

)') ;; ~ ll. ~

c ci z

71 F

6

5

4

3t 21 1

0

t j''''''· I lbf' 'i!if lllllj B ' ._ ...

0-20 21-30 31-40 41-50 51-60 61-70 71-80

Age of the patients in years

Fig (I) Males and females distribution in patients with incidental choliiithiasis

Types of primary surgery I\' 0. --~-

I Operations on stomach and duodenum l-1-:-. 1) ' Total gasterectomy + esophagojejunostomy

2) Vagotomy+ gastrojejunostomy ;............_.~--

3) Vagotomy+ Pyloroplasty ____ -1-__

2 -1-) Closure of perforated D. U. ----r------

5) Suturing of bleeding D. U. II i Operations on small intestine 1) Operation for release of small intestinal obstruction 2) ! Repair of injury to the Ileum I I I ! Operation on large intestine 1) i Colostomy for colonic injury 2) i Colonic tumor resection-rend to end anastomosis 3) Rescection of valvulus of segmoJd colon + colostomr IV Openltions on the liver 1) f Excision of simple cyst of liver 2) I Suturing of injured liver V I Operations on the spleen 1) i Splenectomy VI i Operation on abdominal wall l) Repair of incisional hernia

VII ! Others 1) i Suturing of tear in the mesentry 2) I Appendicectomy "perforated aE_pendix" 3) I Multiple injuries in the abdomen

Table (2)

-I-I -3

l G 2 3 1

2

3 3

3

Types of primary operations in patients with incidental cholecystectomy

Iraqi Army l\Iedical Journal, Vol. 12 No. 1 & 2 2000; Vol. 13 No. 1 '"'\:2 200 I. .................... 77

I Types of primary procedure ===i- No. I i 11 ,, . . ---5~~---E-1--.--1 1

1 agotomy +gastro-JeJunostomy - 1 ect1ve

jl_ Vagotomy+ pyloroplasty ____ _j _ __i_ __ )~~S_t:ive~_: ; 3: Total gastrectomy i I 1 Elective __:

Suturing of bleeding D. U. __ ! 1 1 Emerge1_19~-' Small intestinal obstruction resection+ end to end anastomos~-:-~l·-~ E_Il"l_Ct"gCl_lCl_ Sim le cyst of the liver : 1 : Elective -,----------r------- ---

1 7 1

Incisional hernia L~--~~ct~~: J Sl Resection of colonic tumor i 2 · Elective _j

Table (3) Types of primary operations in patients with concomitant

cholecystectomy

. , Types of primary operations ~

:\o. - --+-------+---- -- ·---

1 Elective 1 i Vagotomy+ gastro-jejunostomy 2 (Closure of perforated D. U. -------_-_, __ -_2_--_=•==E_-._m_~~g~;~~l-3 i Colonic injuries colostomy --------; 3 Emergency 4 ! Small intestinal obstruction release 2 Emergencv 1

r--+----------------------------~---~--~------~-~~--4

1 Emeroencv · b . 5 ! Resection of volvulus of segmoid colon + colostomy I

6 t Splenectomy I

2 Elective

r-1_, --+; --'SCJp_I_:._e_n_i c-'---ii~1 ],_· t_I r_.,y __ +_s_J.p_l_e_n_e_c t_o_1_n_>Lv _____________ ----;---1-1

Em erg en cy 1 8 • Resection of colonic tumor -,-----~' _ Emergen£Y_ ~

9 i Repair of injury to the ileum ___ ' _l ___ • -~_m_ef"g_en~ _

I Perforated a endix ----------c----1 Emergen9' __ Suturing of tear in the mesentery 1 Emergenni - . ---,

1 Multiple abdominal injuries Emergency _j

Table(4) Types of primary operations in patients without cholecystectomy

--~-----~---~--~------·---,

Types of I Period 1

i Age in 1 Associated Post-

Blood ope rat in~

primary · Sex Symptom after · I (Yrs). 1 diseases fasting r-+---ol_lc_·~_·a_ti_o_n_-t-i ------r-------r-----------r---o--pc n1 tion ----~ -~-- ~~·io<l_ ___ ; __ usi on

transf

Release of 1

adhesion of I II

. . I sma mtestme i (emergency) i

Repair of Ped"onlted D.

2

(emerucnn) , Resection of

3 colonic tumor (elective)

Suturing of 4 bleeding D. U.

(emergency)

60 F

.t2 M

i 53 F

j

52 1\1

Cholecystitis 2 mon. Diabetes 3 days +

Biliary Colic -l mon. -l days

+--Dull ach in

I

Rt. Hypoch. + I 1 mon. S days -t-

dyspepsia I I . .

' . ------..-------------. i

Biliary colic 5 mon. 3 days + _ _J

Table (5) Patients with gall stones who developed symptoms postoperatively

Cholecystectomy Concomitant With Other Intra-Abdominal Operations ......................... 7H

Discussion Cholelithiasis may be discovered at the time of operation for another intra-abdominal conditions.

Ouriel et.al.(4) detected gall stones

in 42 of 865 patients (about 5 percent) with abdominal aortic aneurysm. String et. al.C5l and

(6' Herbest et. al. J found in separate studies that asymptomatic cholelithiasis is detected in 20-30 percent of individuals at the time of operation for an unrelated intraabdominal problem. In the present study the gall stones detected in 7.8% of individuals who unde1went laparotomy for other unrelated problem. However, some ofthese patients had preoperative investigations such as ultrasonography or plain X -ray of the abdomen but gallstones were not detected or demonstrated. l\1ost of the patients had operations for upper gastrointestinal problems. 16 patients (48.5%) underwent incidental cholecystectomy additional and subordinate to the main purpose of the operation using the initial anesthesia and incisiOn. If the patient has had previous biliary symptoms the decision to perform cholecystectomy is usually straightfonvard. However in making the decision of whether or not to perform concomitant cholecystectomy on a patient with asymptomatic cholelithiasis, the

possible increased morbidity of the procedure must be weighed against the likelihood of bililar) symptoms requiring opei"ation in the future, Schreiber et.al.'-: performed cholecystectomy on 39 patients during major abdominal operations with only one related complication. Meshevry and Glenn ( 18

) found a little increase in morbidity and mortality rates of patients undergoing chokcystcctumy

concomitant with other maJor intraabdominal procedures. Kovalcik et. alY)), likewise found that the rate of complications was only slightly increased when concomitant cholecystectomy vvas performed. Shennib et. ali 1'

1'

found no difference in outcome among patients undergoing elective colon resection and concomitant cholecystectomy, but they advised combining cholecystectomy · vvith emergent colon resection. Biggers ct. a!.( 11

'

reported no additional, morbidity when cholecystectomy \\as combined with colectomy. In our study 4 minor complications occurred which were unrelated to both procedures and could occur with any other operation, no complications directly related to cholecystectomy. Only one patient died 6.2% the cause of death was septicemia attributed to cholecystectomy. Concomitant cholecystectomy can be performed at the time of operation for other intra-

of

Iraqi Army iHcdical Journal, Vol. 12 No. 1 & 2 2000; Vol. 13 No. 1 &2 .2001. .. , ......... ~ ........ 79

abdominal condition with minimal additional morbidity if the patients are well selected as fit for prolonged time of operation and additional dissection. In this study cholecystectomy was not performed in 17 patients, 4 patients 23.5% developed biliary

. rT symptoms. Schreiber et al. · ; found 44 patients with incidental cholelithiasis and performed concomitant chloecystectomy in all but 4 of the patients. One of four patients required emergency cholecystectomy for acute cholecystitis. Ouriel et. al.C4)

detected gall stones in 42 of 865 patients with abdominal aortic aneurysm. Cholecystectomy was not performed in 11 patients. Acute cholecystitis developed in nine of these patients within 3 years of operations including immediate post-operative period in 2 patients. String(S) found that 65% of patients with asymptomatic gall stones developed symptoms following aortic reconstruction. Biliary symptoms will develop in approximately 20 percent of healthy patients with asymptomatic cholelithiasis (12

•13

).

Its not known why performance of a laparotomy alter the natural history of silent gall stones. Inflammation of the calculus gall bladder occurring postoperatively may be analogous to acute acalculus cholecystitis. The incidence of acalculus disease in patients in whom acute cholecystitis developed post

operatively had ranged from 35% to 65%( 14

'15

). The cause of inflammation remains unknown but it is thought to be due to ischemia of the gall bladder. Factors often present in the post operative patient and predisposing to the development of acute cholecysitis are hypotension, hypoxia, fasting dehydration and blood transfusion. Glenn liG) reported an association between prolonged fasting and acute cholecystistis. He proposed that in the absence of oral intake, there is no stimulus for gall bladder contraction, and stagnation and inspisation ofbile occur. In this study there was no significant difference in the range of post operative fasting penod between the group who developed symptoms in whom fasting period ranged between 3-5 days and the group who did not develop symptoms, the fasting period ranged between 2-6 days. Gefa et. al. (

17) found that biliary tract

sludge developed within nine days in five out of 12 patients following gastrectomy and post operative total parenteral nutrition.

'18) Lindberg et. al.l studied 3 of 4 patients who had developed symptoms after receiving blood during the operation or post operatively in comparison of 7 of 13 patients in whom symptoms did not appear which is of no significant difference as P value equal to 0.453.

Cholecystectomy Concomitant With Other Intra-Abdominal Operations ......................... 80

Also in comparison ofthe number of patients who developed symptoms of biliary tract in group with primary operations without cholecystectomy and patients with silent gall stones not submitted to operations P value 0.167. Conclusion l. Good percentage of silent gallstones might be detected during laparotomies for other intraabdominal procedures. 2. These gallstones are either asymptomatic or with mild symptoms masked by another diseases especially upper gastrointestinal tract diseases. 3. When faced with this situation, concomitant cholecystectomy can be performed in addition to the primary procedure if the patient can stand the prolongation of time of the added procedure. 4. Postoperative complications in patients with concomitant cholecystectomy are not significant . and are not different from other procedures if the patients are fit for it. 5. Although symptoms of biliary tract disease in the post -operative period could develop in patients with cholithiasis, it will be beneficial to avoid cholecystectomy in the high risk groups especially in emergency procedure, haemodynamic unstable patient, contaminated primary procedures, such as in injury of colon and a perforated VISCUS.

6. Routine evaluation for cholelithiasis if available before

abdominal operations to detect asymptomatic cholelithiasis especially in patient of gall stones prone age so that informed consent for cholecystectomy could be obtained. References 1. David, C. Sabiston, Jr.: Natural history of gall stones, Sabiston' s essential of surgery, W. B. Saunders Company, Philadelphia, 1987. 2. Robert, E. Hermann, MD, Cleveland, Ohio: The spectrum of biliary stone disease, American Journal of Surgery, vol. 158, Sept. 1989. 3. Frank Gleen, MD: Silent gall stones, ann. Surg. Feb. 1981. 4. Ouriel, Ricotta, J. J.; Adams, J. T.: Management of cholelithiasis

v

in patients \Nith abdominal aortic aneurysm, Ann. Surg. 1983: !98: 717-19. 5. Tring, S. T.: Cholelithiasis and aortic reconstruction. J. Vase. Sur g. 1984; 5:664-669. 6. Herbst, C. A.; Mittelstaedt, C. A.; Staab, E. V. et al.: Intra -operative ultrasonography evaluation of the gallbladder in morbidily obese patients. Ann. Surg. 1984:200:691-692. 7. Schreiber, H.; Macon, W. L.; Proier, E. J.: Incidental cholecystectomy during major abdominal surgery in the elderly. Am. J. Surg. 1978; 135: 196-198. 8. McSherry, 0. K.; Glenn, F.: Biliary tract surgery concomitant with other intraabdominal operations. Ann. Surg. 1981; 193: 169-175.

Iraqi Army Medical Journal, Vol. 12 No.1 & 2 2000; Vol. 13 No.1 &2 2001.. ................... 81

9. Kovalcik, P. J.; Burrell, M. J.; Old, M. J.: Cholecystectomy concomitant with other intraabdominal operations. Arch. Surg. 1983; 118: 1059-1062. 10. Shennib, H.; Fried, G. M.; Hampson, L. G.: Dose simultaneous cholecystectomy mcrease the risk of colonic surgery. Ann. J. Surg. 1986; 151: 266-268. 11. Biggers, 0. R.; Ready, R. L.; Beart, R. W.: Risk of additional intra-abdominal procedures at the time of colectomy, Dis Colon Rectum 1982; 25: 165-186. 12. Gracie, W. A.: Ransohoff, D. E.: The natural history of silent gallstones. The innocent gallstones is not amyth. N. Engl. J. Med. 1982; 307: 798-800. 13. McSherry, C. K.; Ferstenberg H.; Calhoun, W. F. et. al.: The natural history diagnosed gall stones disease in symptomatic and asymptomatic patients. Ann. Surg. 1985; 202: 59-63. 14. Ottinger, L. W.: Acute cholecystitis as a post-operative complication. Ann. Surg. 1976; 184: 162-165. 15. Zlv, Y.; Feigenberg, Zerm et. al.: Acute cholecystitis complicating unrelated disease. Am. J. Gastroentrol. 1987; 82: 1165-1168. 16. Glenn, F.: Acute acalculous cholecystitis. Ann. Surg. 1979; 189: 458-465. 17. Garfa, M. S.; Miselli, A. et. al.: Sludge and microlithiasis of biliary tract after total gastrectomy and postoperative

total parenteral nutrition. Surg. Gaynecol. Obstet. 1987; 165: 413-418. 18. Linberg, E. F.; Grinnan, G. L. B.; Smith, L.: Acalculus cholecystitis in Vietnam casualities, Ann. Surg. 1970; 171: 152-157.

Iraqi Army l\1cdical Journal. Vol. 12 No_ I & 2 2000: Vol. lJ "No_ I & 2 2()() I_ - K2

Clinical Aspect of Chemical Analysis of l.Jrinary Calculi A Prospective Study of 50 Cases in AI-Yarmouk Teaching

Hospital r'J Dr. iHorv{~ffak Abdul Bald

(i-; Dr. Ala'a AI-Deen Al-Dabbaglz *t'''¥--"·ww,.,_ ... ·r"'·t&5(7trr~sw~· ·n5·7 ff'f''tr ·-·~art rr-·rvrT&c· we-· ~r trw·-· tYW'-'W .. .,_, ·wr· ?i ·'·£¥ ·n;o"' ~, -·· · && -. ··icc· .>;,y· w·vnc r·tr&"" . .Yn%

\V) 3 (_;.--Sj 1'1) ~_r.JI .illL..J\ ~~ :i..:l...ai 4JL:.. (~) o. ~.1:. ~ ~iJ..l ~__r.\

. J,::..i..l \ '1 '1 o .bW 3 \ '1 '1 ~ .bW ..i!-! Lo :; __).!ill ..,~1 ..:J yo __r.ll ~~ ~ C ;';\ " "

~ _r.JI .illL......-JI ~~ ~Y' ( 1 1') 3 l,;WI ~ _r.JI .illL..JI ~~ ~Y' ( 1 V) ~L:,) ~ __;tr-b

,_,_ ·•1 '' ·· \ .. \ 'I · 1 1 1\ \ I · · · ·· ...•.. · ·· 1 'l I . ·· I ·· ,. '' Jr'------'--~ ;..;~ ,~ __r.>-l w~ , __r. ~ ~ 0.Y"'--! '-'>~ c ~ r '...,....:s.....J'

~~ ~ ..b ;.!···; L 4...:::..~\ ~~;;-\_Til _y:. • ~~ ,::. , ~~"=")WI ;J .. s: .... .-1. •. ..__,r-- \ • • ..,_;:;, .._ . '-!? __,----- ' ../ ""':? '- ; .../

·._f)~\

-:. -· .ILSJ\ ~..::.J......:::.b t o_j ·w ~LS. \.!:. ~ 4..:::.. ,..:.·; --il ~\ .';c\ ·.L ~~ dl ··.-;,';i \-~ _;r-._r· .../,• -~ ~ ~ '-'· _,/ •

'\ 'I . I . ·: . ' . . . \ ''I . I : "I .. . '."· .. \ "I .. I .. I • II ' ' -.J~y ._,~ ~ 0fo >'~ ._r ~~ ~_;G '-"~ "--!\...<...oJ ~ j\..,> ~1_)-ll ~h_91 ~

. J~ )1 ..,_j L,.., pi ~ "Ul .) ~~ --?.ill 3 J _r.JI F~ ~)W

·"·~I · ,·, .. - 1\ L.___._..:, ~ •. 11..::.. ,\1 ~ ~L..J\ ~L 4_,L:,':J\ ~ ..JL..lJ.\ ?t..JU\ ~~I ~ ~ _r-_...,~v._r ....;;- .. ~ . . . .. \.;,._ ~

' '

";!----"--" ~ .~ ~ " ~b ~L.S. ~~ .l\ ~~ ·,L ~~ "'=" ~ ':/\ ~ LoS :G o..J\ ~! wl: .......- "-?...7 •.....• _, . _r ,.,_,::. '-'. . . ...__ ' -"': '- _,-.

~~ :; ... _s . .J · 1 ~w ~L....o ,~ "-.b..., w . ~ . , _,.·, _s 4..1 ·; • 4...J • -'! ~ l, _ysll . . _r.J' · 1' • I .. . . yJI . - -· ~\ .. · '.r· ·t ""'!? ""!? ......;? • I...:.. • • \ •• __,-- ._, •• -r- ""? .. J ......:::>

.~\)\ ~~ _;y.S.::

Summary

A group of 50 patients (33 males and 17 females) who proved to have urinary calculi were studied at AI- Yarmouk Teaching Hospital in the period between February 1994 and February 1995. There were 27 patients with upper urinary tract calculi (14 renal and 13 ureteric calculi) and 23 patients vvith lO\\er urinary tract calculi ( 19 vesical and 4 urethral calculi). In 5 patients the stones had passed spontaneously per urethrum on conservative treatment, in 27 patients the calculi were removed by open surgery and in 18 patients the calculi were removed endoscopically. ·

Chemical analysis of the urinary calculi revealed that calcium oxalate calculi were the most frequent.

Struvite stones were found to occur more frequently in adult females often had staghorn configuration and linked with urinary infection. Vesical calculi were shown to predominate in men particularly in elderly patients with prostatic diseases.

The recunent calculi had similar chemical composition of the initial calculus in the same patient whose urine was sterile in the stone free period.

('l Depm1ment of lJ rology AI-Yarmouk Teaching Hospital.

r'l FICMS (llro.) Department of Urology Al-Rasheed Millitary Hospital.

lraq1 Army Medical JournaL Vol. i2 No l & 2 2UOO: VoL 13 No. l & 2 200! .............. XJ

Introduction Urolithiasis is a major problem met with in urological practice ( 11

. It affects 10 to I 2% of the population at sometime during their lives \2;. The incidence of urinary stone disease is quite variable in relation to age, sex, occupation,geographical location, season,climate, social class, dietary and fluid intake <-'J .

i'v1any calculi are an incidental finding and some calculi are passed without the patient knowing about it (---!;

The incidence of recurrent urinary calculi is significantly high. Estimates vary from 8 to 80% \5 c';,

therefore the management of urinary calculi involves not only removal of the calculus but also treatment to prevent its recurrence based on the

· · ·7 K analysis of the recovered calculi \ · · lJ. ll!i

~lany types of analysis of urinary calculi have been proposed including chemical, optical crystallography using a polarizing microscope, x- ray diffraction, infrared spectmscopy,

thennoanalytic computed tomography and pulsed dye laser <5

' 7

' 9>: The most

common and most practical type for the clinical laboratory is chemical analysis \5; , it is cheap, quick with very low percent (only 2%) error in the detection of components of

- II' calculi by this method P. ! . Other methods of analysis such as x -ray

(1) Detailed personal as well as family history .. (2) Thorough physical examination. (3) Investigations including: unne analysis, unne culture and sensitivity, complete blood cell count, blood urea, s. creatinine and electrolytes, S. calcium, phosphorus,

diffraction and infrared sepctroscopy, although more accurate than the chemical analysis, they are rather expensive and the procedure takes longer time 1111

. . '--'

Pulsed dye laser with a scanning diode array is an effective method of stone analysis. The main achanwg-:s of this technique are speed and the ability simultaneously to analyse and/or disintegrate a stone in vivo 17

)

Computed tomography is another method enabling urinary calculi to be analysed in vivo but exposes the patient to radiation '

7

'.The aim of the study In the present study \Ye report our findings in (50) patients with urolithiasis \vho underwent remov~d of the calculi by different means and identification of their composition using the chemical method. The aim of our study is to determine the most common type of stones encountered in those patients and to establish a relationship bcmeen the composition of the stones on one side and the distribution of the different kinds of stones depending on the sex, localization in the urinary tract and the method of removal or the stone on the other side. Also as an essential first step in the formulation of prophylactic measures to prevent recurrence or urolithiasis. Patients and Methods The group studied comprised (50) patients with urinary calculi presented to the urology department at AI- Y armouk teaching hospital in the period between Febmary 1994 and February 1995. The diagnosis of urolithiasis was based on:

Clinical Aspect of Chemical Analysis of Urinary Caiculi .............................................. 84

(5) Biochemical findings. (6) Site of stone. (7) anatomical and pathological findings. (8) Recurrence at different sites. (9) Type of treatment. ( 1 0) Stone analysis using the chemical method to determine its composition.

Results

Sex and age incidence Of the (50) patients studied, 33(66%) were males and 17 (34%) were females with a male to female ratio of 2: 1. Their ages ranging from 8-70 years (average 40 years). Duration of illness The duration of illness was from one day to many years. Presenting symptoms and signs The commonest presenting symptom was pain (loin, iliac fossa and suprapubic) found in 20 patients (40%), hematuria was found in 14 patients (28%), other symptoms and signs included frequency and dysuria in 16 patients (32%), retention of urine with palpable bladder in 5 patients (1 0%), recunent U. T. I in 3 patients (6%), fever in 6 patients (12%) nausea and vomiting in 5 patients (1 0%). Tenderness (loin and suprapubic) was found in 20 patients ( 40%) and enlarged prostate (by digital rectal examination) in 4 patients (12% ). Positive · family historv of stone disease was found in

" 11 (22%) of the patients.

uric acid and alkaline phosphatase, plain abdominal films, intravenous urography and abdominal ultra sound were canied out in all patients. The data were collected and then carefully studied with special emphasis on: (1) Sex and age incidence. (2) Duration of illness. (3) Presenting symptoms and signs. ( 4) Urinmy findings. Urinary Findings U.T.I was found in 26 patients (32%). The infection rate in females (58.8%) was higher than in males ( 48.4%). E. coli & Klebsiella were the organisms most commonly encountered in urine culture. Hematuria was found in 25 patients (50%) and crystalluria (uric acid and calcium oxalate crystals) in 9 patients ( 18%). The reaction of urine in the majority of cases was acidic, only in 8 patients ( 16%) the urine reaction was alkaline. Biochemical Findings All patients were found to have normal S. calcium, S. phosphorus and alkaline phosphatase values, S. uric acid was elevated in only 2 patients (4%). Parathyroid hormone study and 24 hour urine specimens for determination of calcium, phosphorus, uric acid and creatinine could not be done because they were not available in our hospital laboratories. Site of stone (table I)

Table -1- site of stones in the urinary tract.

I Number I Site of stone Total Right

I I

I Upper U.T. Kideny 9(18%) 5(10%) 14(28%) -, I Upper Ureter 1(2%) 3(6%) 4(8%) I

Iraqi Arllly lV!cdical JournaL Vol 12 i\o. 1 & 2 2000: Vol. 13 r\o 1 & 2 200!..

, Lower ureter 2(4~o) · 7( 14%) 1 9( i 8°·u) Lmver L'.T. Bladder .----~-·--~· ~-~·----~: ~- l ~(38~u_L~-=

Uretlu·a ·~~ __ _±( 8 ~~()_L __ ... c__ __ T_o_t<_:d ________ ~--------- -~~-~! _ _20ll_Q_U_!_'Ol__.

Anatomical and pathological findine.s 15 anatomical and pathological abnormalities were found including 8 cases of hydronephrosis, 5 cases of benign prostatic hyperplasia. one case of prostatic calculi and one of simple renal cyst.

Recurrent yersus primary stones Of the 50 patients with urinary calculi, 47 patients (94S~) had primary stones \\bile only 3 patients ( 6%) had recurrent stones and the recurrence \\as on the same s1de.

Treatment. Table ~2- Treatment of 50 patients with urinary calculi ----·--- ·------··-~~ ...

I\i1ethod of treatment :\umber ----~

(J.· /(J

: A- Operation performed* .. __ .....__ __ ____._ _______ ~--------· ·----~- ··-··-··~·-~ -----·-

. :\ephrectomy ' NephrolithotomY ~ ---~"'-------~----

! Pveiolithotomv 1

Ureterolithoto;ny Vesicoli thotomy _..__ ______ . Dormia extraction

5 8

--~--- ---

3

0

20

10 ---·-~--,

16 6

4 : Ureteric meatatomy <----------"------------j-----·-----i------ ..•

1 Litholapaxy 12 ' Urethral extraction ~------------------+---------

8- Spontanous passage of calculus ' 5 -------------

1 '\ !U.

To~l SO IOCJ

* Tv,o patients had more than one operation performed. from this table \\ e sec that litholapaxy was the most common operation performed fol1m\ ed by pyeloli tl1otomy. Table ~3- Presents method of remo\·al of stones according to the sex of patients.

Table (3) Sex Spontaneous Endoscopic Open surgery Total

passage surgery ~----r----'----'='-----r---- .,.___--t---------·---~~----~

_i\_·1_a_le_J ---+---4_,(~1_2_. 1_0;_0"---) --f-----14 ( 42.4%) _ _!_~( 45_:_:+ 0/o)··-~~~3_3(§~60.~) Female 1 (5.8%) 4(23.5%) 12 (70.5%) 17 (34%)

r------+-------'----'-----\-----"-----"---- ··---:-----,~----~--~-:-··- ~.

\---T~o~ta_· 1_+-___ 5 ..,_( 1_0_~_oc'_) __ _.,.._ __ I 8 ( 3 6%) _.__]_Z( 5~% )·-~- 5 0(_1 _ _9~(u; c___X_2 _=_~_0_.2_5_1--'(c.Lp_>_0_.0_5...L_)~~I_.O 15 (p> 0.05) • 2.8?} U?> 0.05) ~.:__----~--

Stone analvsis Table ~4- The results of analysis of 50 urinary calculi by chemical method

Clinical Aspect of Chemical Analysis of Urinary Calculi ............................................ .. ?\(,

I i\: Lun ber I Percent Stone type I Pure calcium oxalate 30

:----'60

I ,\;fixed calcium oxalate and uric acid ' 10 J

j Pure uric acid , 6 12 r Mixed uric acid and calcium phosphate 1 7 i

i Pure calcium phosphate --------l

4 8 ;

! Magnesium ammonium phosphate (struvite) 4 •!

8 Total 50 100

Chemical analysis ofthe recurrent urinary calculi in our study shO\\ed that thn· were similar to the initial calculi in their composition.

I 0 urethra 0 bladder L'3 ureter 1!!1 kidney

Ca.OX Ca.OXIU.A. U.A. U.AJCa.Ph. Ca.Ph. struvite Stone types

Ca . Ox . = Calcium oxalate Ca Ox. / U A - = Calcium u:-;.ai:ne & uric acid. U.A. =uric acid U.A./ Ca. Ph.= uric acid & calcium phosphate Ca.Ph. =calcium phosphate

Figure l Distribution of stone types according to their location in the urinary tract.

0 endscopic L'3 open surgery

Ca OX Ca.OXIU.A. U.A U A_/Ca.Ph Ca.Ph struvJte Stone types

Ca . Ox . =Calcium oxalate Ca Ox. I U.A.- = Calcium oxalate & uric acid. U.A. =uric acid U.A./ Ca. Ph.= uric acid & calcium phosphate Ca.Ph. = calcium phosphate

Figure 2 distribution of stone types according to the methods of stone removal.

Discussion An individual who forms calculi will usually produce more than one during the course of his life. To

prevent formation of future calculi we must know the calculus type usually formed by that patient, therefore stone analysis is extremely

Iraqi Army Medical JournaL VoL 12 No. 1 & 2 2000: VoL 13 No. I & 2 2001 .................. 87

important in planning therapy (S. I-L 15)

In our study a total of 50 urinary calculi were submitted to analysis using the chemical method. We have found that 88% of the calculi examined were of pure composition, the rest ofthe calculi (12%) were of mixed composition. Calcium oxalate was found to be the most common and frequently occunng constituent of the examined calculi accounting for 70% of all urinary calculi (60% pure and l 0% mixed). These results are similar to the results obtained by the studies reported by Prien 1968 \

14J, Prein and Fronde!, 194 7\IC';,

Sutor et. al., 197 4 c 11, \Vi lliams

1976\ 17J, Chambers et. al., 1972 118!,

Beukes et. al., 1987\ 19!, Sutor 1982

'20

J d D . t l 198" (4 ! · an av1es e . a ., .) . \Ve have found that for male patients in our study calcium oxalate stones were most frequently observed followed by uric acid and calcium phosphate stones. For female patients calcium oxalate stones were the most common followed by struvite and uric acid stones. The maJor difference observed is the increased frequency of struvite stones among ~,cvomen compared to men. This being related to higher incidence ofU.TI in women giving rise to the type of calculus which forms in alkaline medium typically the magnesium ammonium phosphate (struvite) stones. Similar findings were reported bv Prien and Fronde! 194i'

6J, Prien 1968( 14

!, Hodginson et. al., 1969(21

J, Murphy and Pyrah 1962 (22

J and Powis et. al., 1974 mJ.

In the present study the incidence of uric acid calculi was 24%; half of them were pure uric acid calculi and the remaining half were mixed

with either calcium oxalate or calcium phosphate. This finding conceming the percentage of mixed uric acid calculi is much higher than what was reported by a study made by Williams 1976(!/J who had stated that uric acid calculi are generally pure though some 20% may be associated with calcium oxalate or calcium phosphate. Patients \vith upper U.T. calculi in our study formed 54% (28% renal and 26% ureteric) of the total no. of cases studied while lmver U. T. calculi were encountered in the remaining 46% (38°/o vesical & 8~'o urethral) of the total no. From this It appears that vesical calculi were predominating in our patients and they \Vere found to occur most frequently in men particularly in elderly patients with prostatic diseaes. V/ e have seen in this study that all stones obtained by spontaneous passage were composed of calci urn oxalate when subjected to chemical analysis. This observation t(:}nd to support the observation reported in a study made by Prien I 968. In the patients with recurrent calculi in our study we have found that the chemical compositiOn of the recunent cacluli was similar to the chemical composition of the initial calculus in the same patient who gave negative history of U. T. L in the stone free periods. Also we have seen that positive family history of stone disease was more common among patients with recurrent calculi than patients with pnmary calculi. Conclusion A knowlege of the composition of urinary calculi is important because urolithiasis is a recurrent disease in

Clinical Aspect of Chemical Analysis of Lrinat·~ Calculi .............................................. !);.;

many people and preventive measures must be based on such information. Analysis of urinary calculi by chemical method rs the most common and most practical type for the ciinical laboratory. It is cheap, quick and reliable in the detection of components of calculi. Calcium oxalate rs the most frequent constituent found in urinary calculi. Stuvite calculi occur more frequently in adult females, often ha\ e staghorn aspect and are linked with urinary· infection. Vesical calculi prevail and occur most frequently in old male patients Successive stones from the same patients tend to be similar in chemical composition pro\ iding that urinary infection does not occur between stones or durino stone c formation which if occur would. alter the stone composition. Recommendation To decrease the incidence of recurrent urinary calculi as far as possibl·e~ we- adopt the following measures: 1- Complete removal of all calculi.

2- Any urologrcal condition leading to urinary stasis and infection is taken care of 3- Urine is rendered sterile after surgery for urinary calculi with appropriate urinary antibiotics during the follow up examination. Repeated urine culture studies are done and measures are taken to keep the urine sterile. 4- Chemical analysis of the stones removed or passed in the urine must be done and appropriate medical therapy instituted whenever necessary.

5- Dietetic advice is gi\·en to patients basing on the chemical composition of stones remo\ ed or passed by them. 6- Periodic and thorough folio\\ up examination is adviced. References (I) Sutor D. J ., Wooley S. E. & llling\vorth J. J. A geographical and historical survey of the composition of urinary stones Gr. J. Lrol. l 974: -1-6: 393. (2) Resnick \l L Lrinan calculi. In . .

Descision makmg in urolog~. ed Resmck \1. i.. caldamone .\ .. \. & Spirnak J. P. second edition, 1 99!: 138. Philadelphia, B. C. Decker. (3) Whitfield !-I. ~. & Hendry \\'. F. Epidemiology of stone disease. In Textbook of S?.enitourinav sun2er\

L -' L -'

eeL Whitfield H.:\. and I kndry W F. l 985: l: 604---- London. Churchill Livingstone. (4) D<n·is R. \\·. L., Gm,· J. Cl. & Davies D. R., calculi in the urinary tract. In A colour atlas of urology ed.. \\' ol fe medical atlases 1983: 129. · London. \Volfe medical publications Ltd. {5) Drach G. \\. Urinary Lithasis In Campbelrs urology. ed. \Yaish P C.. Gntes R. F., Perlmutter A. D. & Stamey T. A. 1986: 1:1126-1127 Philadelphia: Saunders. (6) Singh S. \'1., Rao D. V. \:. & Bapna B. C. Recurrent renal calculi: A study of incidence by follc.m - up examination. India J. \-led. Res 1971: 59: 1080. (7) Holden D.. \Vhitshurst C.. Rao P. I\., King T. A. and Blacklock\!. J. Identification of urinary stone composition by pulsed dye laser Br. J. Urol 1990; 65: 441-444. (8) Kuw·ahara [v1., Kageyama S., Kurosu S. and Orikasa S. Computed tomography and composition of

Iraqi Army !'vlcdical Journal. VoL 12 No. I & 2 2000: VoL 13 !\o 1 & 2 2UOJ .... S<J

renal calculi. Urological research 1984: 12:II1.

(9) Korn S., Bichler K. H., Eipper E., Henzler B. and Schreiber \'1. Methodologic comparison of the analvsis of unnarv calculi~ Roentgen

~ ~ ~

diffractometry, polarization microscopy and microscopic microchemical component analysis Lrologe- A I 993; 32:232. (I 0) Gebhardt M. and Bastian H. P. Exact stone analysis- sigificance to prophylaxis. Urolithiasis research, ed. Fleisch H., Robertson \V. G. Smith L. H. and Vahlensieck \V. 1976; 275-276. 1\'ew York and London Plenum Press. ( 11) Schneider H. J., Rugendorff E. W. and Dahlke J. Stone analysis in the doctor's office or m a specialized laboratory. Urologic research 1984; 12:94.

( 12) Spirnak J. P. and Resnick .\!1. I. Urinary stones. In Smith's general urology, ed. Tanagho E. A and I'vlcAninch J. W. Thirteenth edition, 1992: 275-286 USA. Prentice- Hall International Inc.

(13) Pak C. Y. C. The physiologic evaluation of the stone fom1er. In controversies in urology, ed. Carlton C. E. 1989: 64-65. London: Year book medical publishers, Inc. ( 14) Prien E. L. Composition and structure of urinary stone Am. J. Me d. 1968; 45: 654-671.

(I 5) Hesse A and Schneider H. J. Results of the standardization and centralization of the stone analysis

. in the German Democratic Republic. Urolithiasis ·research, ed. Fleisch H., Robertson W.G., Smith L. H. and Vahlensieck W. 1976; · 295. New York and London Plenum Press.

(16) Prien E. L. and Fronde! C. Studies m urolithiasis: The

composition of unnary calculi. J. Urol. 1947; 57: 949. ( 17) Williams R. ureteric calculi: In Blandy J. 1976:

E.. Renal and Lroloty. eel. I: 291-292.

London, Black scientific publication.

(I 8) Chambers A., Hodgkinson .·\. and Hornung G. Electron Probe analysis of small urinary tract calculi. Investigative urologv. 1972:

'-' v. 9: 377.

(19) Beukes G. J., Bruiyn H.and Vennaak \V. J. Effects of changes in epidemiological factors on rhc composition and racial distribution of renal calculi Br. J. Urol. 1987; 60: 387-92.

(20) Sutor D. J. Crystallographic analysis of urinary calculi. In Scientific foundation of urology, ed. Chisholm G. D. and \\'il!iams D. 1. Second edition. 1982; 259-26 7 London: Heinemann. (21) Hodgkinson A., Peacock \l and Nicholson M. Quantitative analysis of calcium- containing unnary calculi. In renal stone research symposiUm, ed. Hodgkinson A. and Nordin B. E. C. 1969; I 13. London; Churchill. (22) Murphy B. T and Pyrah L. \. The composition, stmcture and mechanisms of the formation of urina1y calculi Br. J. Urol. 1962: 2:129.

(23) Powis S. J. A., Black J.,

Macdougall J. A., and Clews J. \V.

Management of patients with

unnmy calculi. Br. Med. J. 1974;

l :355.

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lral(i Army :\ledical Journal, Vol. 12 No. I & 2 2000; Vol. 13 No. I & 2 2001.. ................... () 1

This programme [named DR:'vl-JUIEC:\IATOL] presents artificially· intelligent system for knowledge cluster-data valued analysis of patient's clinical data for diagnosing rheumatological diseases. The programme \\as constructed by 5thgeneration high le\el computer language T urbo-Prolog creating experts) stem shells for analysis of patient's medical data.

These shells are intendeci'to do human- like medical analysis including lex_ical scanning, parsing, abduactive and inducti\ e reasoning. To test the feasibility of this programme it was applied retrospective!~, on data collected from 93 patient's clinical information case sheets from HammadShchab I'vlilitmy Hospital. The selected data \\as based on that the patient's main clinical data of rheumatological unc:. The results was highly suppuni\e [ l 00~/o] for the programme regarding diagnosis ancLor difl\.:reiJllal dtaglllhis and even the leading medical comments the programme suggested for patient concerned.

This JJro~ramme ~ive the easiness. accuracv and speed in makin~ dia~nosis or <.._.,. '-'' -' L.- L

differential diagnosis of given set of patient's clinical data. AlthoLtgh this programme applied only· on rheumatological disease. yet the existance of intelligent shells make it easy to be applied on wider medical fields including nephrology, hematology, cardiology, neurlogy, ... etc. The message of this \Vork is that we h<l\ e to think seriously about the potentials and importance of building and dewloping advanced artificially intelligent medical computer 'Services in our country. that can be. and should be. applied in real life medical events and researches, and on solid background, \Vith every effort need to be afforded, aiming at improving the quality of patient's life and medical standards as a final goal.

I nt1·od uction The profound changes brought about by technology in the past few decades are leading to revolution in medicine, of most important are those applied by computerized medical knovvledge processing (I J. Computer programmes have major advantage compared to human that is, it saves time spent by physicians, and therefore costs ( 12

J. The value of computers in improving the quality of patient care in general practice is

. I ' recogmzed 1 · J.

Most important tools used in logical . b d . f5 1h processmg are ase on usmg o -

generation languages of Prolog which differ in the way it works in logic from the other languages like

. d 1 fl 21 1 d Bas1c an Pasca · · -. Know e ge

acquisition is a difficult vet important process in the formation of intelligent S)1Slems ' 1 3· -L '}

Programming an intelligem tools can uncover patterns in patient's medical informatics group. !(J

7· ~~-

Famous examples of these are fvlycin [For diagnosing infectious disease],ancl MEAN system12· s. ''·

7·13

.1 Clinicians confi"ont the classical problem of decision making under certam circumstances, but universal procedure by which they deal w·ith this situation, both in diagnosis and therapy, can be defined. This consist in the choice of specific course of action from available system for assessmg patient's clinical data or other available

Computeri~:ed Artificial - Intelligence Knm\ ledge Rheumatological Diseases

medical ·information including laboratory and radiological parameters (~.<J Ju. 11 !_

This programme is an artificial -intelligence medical programme used for diagnosing rheumatologtcal diseases according to patient's signs and symptoms using an AI system implemented as a shell (simulating in simple terms the cerebral cortex), to help physician in making the most likely diagnosis in minimal time and effort and with high specificity. Extra medical data knowledge can be implemented at any time by active editor. Background and theorv In this programme there are 3 available types, or levels, of analysis:- !-Straight analysis for words or symbols [ signs/ symptoms... etc]. 2-Apriori cross analysis from a given set of words or symbols. 3- Associative element cress- correlative cross analysis. The element of recursion. which uses the results of the previous analysis, does not come into play until the 3rd level of associative analvsis. It is this level of analvsis.

,1 . .I '

vvhich brings the d'ata retrieval activity into the realm of artificial intelligence, this is called cross data linking, much like our brain thinking activity. The analytic levels are independent of how it has been input or what state of order it is in, it pervade a database and find what one needs through the intelligent crossassociation algorithms within the programmes. It discards certain noise \vords like "what", ''do", "'is", ''and", etc.) and then looking for key words or specifics defined by

Cluster Dat1 Analysis Applied on Diagnosis of .'.12

those \vorcls remaining after the noise words are tossed out. The programme is only a\\ are of ·patterns regarding source file, also it cross-correlate information that will significantly increase assimilation abilities 111 gen~ral, then It start to analyze the patient's clinical presentations with the available stored data and give the clinically fitted disease entity. lhgure. i showing block sample of programming]. Clinician can use words, symbols. key\vords, groups of words, and groups of keywords, to analyze the clinical data with respect to just about any size of saved medical data knO\vled~e.

'-'

Complex or simple analysis can be done with a great speed advantage and may enhance the development of our own clinical cogniti\e functions. Disease ;'vlodels At the start of a consultation, the physician enters list of manifestaions, each of these evokes one or more nodes in the disease tree, the programme creates a [model] for each such node, consistmg of 4 lists: 1. Observed manifestations not associated with the disease. 2. Observed manifestations consistent with the disease. 3. \1anifestations not yet observed but arc always associated with the disease. 4. \t1anifestations not yet observed but which are consistent \Vith the qisease. The rationale behind this kind of processing [called partitioningl, is that the set of models being considered at any one time can be

Iraqi Army Medical Journal, Vol. 12 No.1 & 2 2000; Vol. 13 No.1 & 2 2001.. ................... 'F3

treated as mutually exclusive al temati ves. In cases where more than one disease appeared to be present, the programme still . have the power of giving altemative diagnosis and/ or differential diagnosis. Experiments using simulated patient's medical data: To demonstrate the feasibility of the algorithm when applied to real life data, set of clinical data is used, consisting of clinical presentations extracted from brand of real patients of either acute or chronic illnesses. This was applied retrospectively on patient's clinical data case sheets from Hammad- Shehab Military Hospital.

The selected data was based on that the patient's main clinical data of rheumatological one [ie .. joints pam, bizane systemic manifestations that also includes joint problems, fever .. etc]. 93 cases were selected, and were applied on the programme by just entering clinical data concemed trying to figure out the most probable diagnosis and/or differential diagnosis that may almost fit with the final specialist diagnosis with the help of available laboratory and/or X-ray findings on that patient. The results were in general highly supportive [100%] for the programme regarding diagnosis and /or differential diagnosis and even the leading medical comments the programme suggested for the patient concemed. An example is given in figure 1. Output and its relation to searching Regardless of what type of analysis used, once a point of match or

association is found, it is dealt with in the same manner. Within certain limits, the programme will try to go back to the last period and forward to the next, ignoring exclamq_tion points and question marks. This parsed out aggregate of information is presented in full on the screen. So .. the processing is: ( 1) Selectively locating an extract from a knowledge data file which represents a concept you are trying to draw inference from and dumping it into the hash file, and then:

(2) Creating a separate cross data link file which contains a concept you wish to cross- correlate against the contents in the hash file; you can then .. (3) Execute analysis which uses both these points as a reference and draws pattems of inference between the cross data file, the hash file, and the data knowledge file. This whole process comprises the ·associative element analysis, and is the analysis which appro-ximates inteiiigence, even though it is the physician who supplies the final meanmg. Conclusions The mechanics of human intelligence is generally understood to be a rather complicated affair. Thus any attempt to approximate this quality in a machine is bound to have its complexities. This programme is considered as ariificially intelligent design under which almost every medical data knowledge can be applied with minor modifications with respect to the medical item chosen. This medical programme although highly efficient regarding

Computerized Artificial - Intelligence Knowledge Cluster Data Analysis Applied on Diagnosis of Rheumatological Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................................................... IJ.t

memorization and high speed of 2. Miller R. A. Popler H. E. Jr. and data analysis with high accuracy, is Myers J. D., (Internist-1 ), an not a substitute to the real experimental computer based experience of the expert physician. diagnostic consultation, N. E. J. The final decision is still always Med. 1982; 307-, 68-76. governed by the specialist in this 3. Kowalski R. Logic for Problem field, yet this work might prove Solving, North Holland, New York. highly assistant and reminder of 1989;501-503. minor or forgotten or even major 4. Irvin Vl.: compiling predicate topics in diagnosing disease, it can logic programmes (Reports 39 and be proved to be of great use to 40), Implementing Prolog; junior physician and colleague Department of Artificial students as well. Intelligence; University of Of great importance to mention is Edinburgh, Scotland 1990. Chapter that this programme can accept any 2; 197-206. size of extra medical data to be 5. Hayes P., Mouradian G., Flexible edited/added, in free patterns of parsing, Am. J. Computational 8. edition and without limitation, for Linguistics 1989; 7: 232-242. the programme has the SHELL 6. Aikins J. S., Prototypical which will take the extra added knowledge for expert systems J. knowledge to be analyzed when- Aliificial Intelligence. 1988; 20" 63-ever wanted, this means no 210. limitations to the information that 7. Winston P. H., Artificial can be accessed. Intelligence, Addison Wesley More important to mention is that Reading, 1991; Chapter 7, 334-339. this programme [as in any miificial 8. Gomez F., Chandrasekaran B., Intelligent programmes] can be Knowledge organization and developed to accustom specialized distribution for medical diagnosis medical entities and fields. IEEE Trans. SMC- 11. 1992 34-42. The endless field of a11ificial 9. Winston P. H., Leammg by intelligent applications calls for Creatifying Transfer Frames, J. serious effort to go ahead foreword Artificial Intelligence 1989; 10: towards establishing specialized 14 7-172. medical unit for computer science, 10. Deday E., Simon J. C, that not just based on ( endusing) the Clustering analysis Digital Patterns available imported medical Recongnition, 2nd. ed. Bertin: programmes like MEDLIN, but Springer- Verlag, 1987: 467-479. even more important to have real 11. The First Conference on useful expe11 system programmed A11ificial Intelligence Applications, medical knowledge. IEEE Computer Society in

References 1. Slniliff E. Computer- based medical consultations. MYCIN. 1976; 202-205.

Corporation with American Association for A. I., Sheraton, Denever, Tech. Center J. Artificial Intelligence 1984: 107-432. 12. Bruyne M. C., Kors J. A., Hoes A. W., Kruijssen D. A.C. M.,

Iraqi Army Medical Joumal, Vol. 12 No. 1 & 2 2000; Vol. 13 No. 1 & 2 2001.. ................... 95

mDeckers J. W., Grosfeld M., Van Herpen G., Grobbee D. E., Van Bemmel J. H., Diagnostic interpretation of Electrocardiograms m Population Based Research: computer programme Reasearch Physicians, or Cardiologist?.

Fig. 1

Simplified

Joumal of clinical Epidemiology. 1997: 8, 947-952. 13. Smith N., Wilson A., Weekes A., Use of Read codes in the development of standard data set, BMJ., 1995; 311:313-315.

Block example dialogue of the physician with the program trying to find possible

diagnostic information of a patient

Computer: menu

1. differential diagnosis

2. editing medical knowledge data

3. quit the programme

enter your choice number 1-3? I

computer: enter your patient's clinical data? Enter (quit) to quit.

physician: there is symmetrical multiple joints pain with splenomegaly

computer: (-->analysis) want to see your diagnostic list now (y/n)?

physican: y

computer: leprosy . . . . . ........... +]

systemic lupus erythematosis .... + J still's disease ....... + ]

rheumatoid arithritis ....... ±]

I ....... etc ..

[long list of differential diagnosis including lymphoma .. etc].

plus comments regrading important features and hints are mentioned.

[so as we notice and unexpectedly leprosy was mentioned, although it is uncommon,

unusual and unexpected differential diagnosis yet, it in fact may cause the above

mentioned patient's compliant, so the computer response is considered as a good

reminder of odd or forgotten or unusual expectations among the differentials of the

disease entities, the remaining output is also valid according to the patient's

complains .. ]

Computer: enter more of patient's sign/ symptoms? Enter (quit) to quit.

Computerized Artificial - Intelligence Knowledge Cluster Data Analysis Applied on Diagnosis of Rheumatological Diseases . . . . . . . . . . . . . . . . . . . . . ............................................................ %

[here again the computer request extra clinical finding

if available to narrow the list of diagnostic possibilities]

physician: there is nail bed infarct

computer: continue analysis or quit c/q?

physician: continue

computer: enter your patient's clinical data? enter (quit) to quit

physician: there is fever and discoid lupus with butterfly rash

computer: (doing analysis) SLE .... [+Extra comments]

[here the programme gave only one diagnosis that fits the patient's available cl!mcal

data ..

computer: continue analysis or quit c/q?

physician: q

--------------->>back again to the main list of the programme

,,

EYaluation OfT he l~st·s Of Proplast In Oral And :\laxillofaeial Surgery •••....•.•••.•.....•....••••.••.•.••..•.•• ')7

Evaluation Of The lJses Of Prop-last ln Oral And

IVIaxillofacial Surgery 0 ;lfaj. Ayad Abdul Khalic and

m Brigadier Tarik 1lf. Abdulla

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<*l B.D.S., F.I.C.l\I.S Maxillofac Dept. Hammad Shihab Military Hospital.

,t, B.D.S., H.D.D., F.D.S.R.C.S. Chairman of Dept. of Plastic & 1\laxillofac. Surgery Ham mad

Shihah Military Hospital.

Iraqi Army Medical Journal, Vol. 12 No. I & 2 2000; Vol. 13 No.1 & 2 2001. ................... %

Summary

Eighteen patients received Proplast implants to augment their facial bony contour. This study revealed that the Proplast is a useful implant material for the restoration of facial bony contour (success rate was 88.9%) . There are some teclmical difficulties when it is inserted over areas that are convex such as the malar prominence and orbital margins in that it is difficult to eliminate the edge effect ,but this can be overcomed by proper feathering of the edges of the implant with a sharp scalpel . In this study 4 implants impregnated with blood and antibiotics, whereas 14 implants remain dry ,the unimpregnated Proplast did not affect on the prognosis of Prop last success . Sixteen implants were judged to be stable ,and 2 implants \Vere judged to be unstable ( removed ) due to infection .In the two infected cases the fixation was done by wire fixation instead of suture fixation or spontaneous fixation with an intraoral approach .Of these 16 stable implants 3 were mobile and 13 implants were immobile , and this seems to depend on the technique of Proplast insertion . We inseried the Prop last subperiosteally in I 5 cases and supraperiosteally in 3 cases . There was no discoloration of the skin in thin skin areas like the orbital margins ,nose or malar areas and this is due to the use of Prop last II vvhere it is indicated

Introduction Proplast is a material designed for tissue implantation commercially availabe through the Dow -Coming Corporation ° l .It is a gray black laminated felt of vitreous or glassy carbon <-and Teflon

(2' (Polytetrafluroethylene =PTFE) } . The vitreous carbon also called hyperpure or elemental carbon or a pyrolytic graphite, a pure molecular fonn of carbon that is pyrolytically derived from hydrocarbons such as rayon C3J_

Proplast was first prepared by Homsy in 1970 & it is invented originally in 1968 specifically for surgical implantation C

4l .It is

manufactured as a thin felt sheet which is then layered & rolled under high heat & pressure to fmm the laminated block in common clinical use.

n z· -, 'WttWEfwwemw=ntriffW

The resultant dark gray felt is laminated to from a resilient sponge with unique physical properties . 15

J

It is a microporous implant material, has a porosity of between 70 & 90 ·volume % ,and ha~ high surface energy (C>J • The actual surface area is approximately l200x apparent surface area. The I 00 -500 Jl pore

size and the 200 -400 p dendritic

interpore connection allow sufficient permeability of tissue for effective metabolic activity; tissue maturation is demonstrable to the point of osteoid or actual osseous tissue within the implant (7J The ultraporosity enabling as much as 80% of the implant volume to become tissue cs>. Until 1981 there was only one type of Proplast .In 1981 Proplast II was introduced, it is a PTFE I aluminium oxide (Which

Evaluation Of The Cscs Of Proplast In Oral And :\laxillofacial Surgery ••••••••••••••••...•••.•••.••.••••.••••.•. -99 '

substitute the vitreous carbon), therefore, the conventional Proplast was then called Proplast 1 & the new one is Proplast II, which is white, and therefore, more suitable for superficial implants .It is particularly indicated where the implant is placed under thin skin , such as the nasal bridge (9

l .Proplast II offers a number of advantages over other commonly used silico11e & polymethyl methactylate . It is light, porous, resilient, malleable & easy to shape . It can be readily sterilized after shaping. It has been found to integrate with the sunounding tissues, thereby minimizing the risk of subsequent implant migration and extrusion ° O.IL1 2l.

Materials and Methods Data was obtained by prospective study records of patients with the Prop last implant at the depariment of maxillofacial and plastic surgery in Hammad shihab Military Hospital for 9 months commencing in October 1997 till the end of June 1998. In our study the number of patients were eighteen, five patients have chin defects, four patients have zygomatic bone defect, four nasal bone defect, four patients have defective orbital bone & one patient have defective mandible. Patients with orbital bone defects divided into two groups, the first group, includes two patients with upper orbital rim defects and the second group includes two patients with defective orbital floor. For the roof a subperiosteal pocket was created to receive the implant by a traditional approach through the eyebrow. For the floor of the orbit the approach was through an infraorbital incision

with the skin crease, ·and inserting the implant subperiosteally. Patients with defective nasal bone are approached through the skin by supranasal flying bird incision (2 cases) & through inter -cartilaginous approach (2 cases ) all were inserted subperiosteally. Patients with zygomatic bone defects approached intraorally by a horizontal inc1s10n through the mucosa, slightly below the depth of the vestibule on the lip side above the canine -premolar teeth. All patients that received chin implants were approached intraorally by degloving incision, a horizontal mctston one inch long through the mucosa midway between the depth of the vestibule and the vermilion border of the lower lip. Only one patient was operated on for mandibular augmentation, this patient was a female, the others were adult males. And onlv in this case

J

the type of Proplast used was Prop last II in a form of block, and this required carving. We carved the implant with a sharp scalpel (blade number 15), also we made notches in the implant which promote tissue ingrowth by providing greater surface contact area with the bone. During carving, the material was handled with powder free gloves on a lint and dust -free surface . We also took care not to compress the Proplast as that might decrease its porosity. This proplast was used in conjunction with sagittal split of the mandible, and the augmentation done to left side by intraoral approach through the mucosa midway between the depth of the

Iraqi Army Medical Journal, Vol. 12 No.1 & 2 2000; Vol. 13 No.1 & 2 2001.. .................. !00

Results vestibule and the vermilion border of the lower lip, slightly to the left side. All the operations were done under general anesthesia, except one operation ( defective orbital roof) was done under local anestheia in the theatre .

There was a total of eighteen cases with Proplast implant insertion. Table (1) shows types of Prop last impregnation .

Table (1) Types of impregnation of the Prop last

Type of impregnation I No. I % Blood l 2 I 1 1 . I Antibiotics 2 1 1. l No impregnation 14 -.~ 8 I I.

Two implants · impregnated chin (I case ) , with dexon suture 3:0 preoperatively with blood, one for with the soft tissues . the nose and the other for orbital \Vire fixation (gauge 0.35mrn) was floor. Two other implants were used in two cases, one for the chin impregnated with antibiotic solution and the other for the zygomatic ( Ciystalline penicillin 1000000 l.U. ), implants .

one for the roof of the orbit and the Table (2) shows contour evaluation other for the nose. The remaining of the implant post operatively. A fomieen implants were good visible contour was one which unimpregnated (remain dry). was symmetrical in cases where Eight implants stabilized there had been asymmetry or a bony spontaneously , and these include defect . We included here the nose & the roof of orbit (2cases), nose chin for proper contouring. (2cases) , chin (3cases) & mandible There were ten implants evaluated as (lease). Eight implants fixed by a good contour these includes: orbit sutures which include the floor of (3cases), two for the roof & one for the orbit (2cases), both fixed with the floor , nose (2cases) , zygoma dexon suture 3:0 with the soft (2cases) & chin (3cases). tissues, nose (2cases), with silk 4:0 Eight implants evaluated as transcutaneonsly and in one case; as improved contour, these include: well as suture fixation , it was fixed Orbit ( 1 case) for the floors , nose with a T- shaped gypsona on the (2cases), zygoma (2cases) chin nose for 14 days ,zygomatic (2cases) & mandible (lease). No. implants (3 cases), with dexon implant evaluated as a worse, or no suture 3:0 with the soft tissues & change occur

Table (2) Contour evaluation

f Contour I No I % I Good

I 10

I 55.6

8 44.4 . Improved

1 No change I Worse

chiu'

Tab sa tis resuli

haluation Of Till· t·sl's Of Proplast In Ot·al And :\Iaxillofadal Stn·g<'ry •.••..••••..•.•.•••.••••••.••••.•••.•••••. 1 ()I

Table (3) shmvs colour changes of the skin overlying the implant, these are regarded either satisfactmy (no visible colour through the skin), or

unsatisfactory (visible colour through the skin). Satisf~lctory colour was I 00 %.

Table (3) Colour changes of the skin overlying the implant

,---------------------,~---------------L~~----L_ ____________ ___ Colour No. <:/o

1 Satisfactorv ' -i Unsatisf~1ctory

Stable implants were 16 (88.9%), unstable (removed) were 2 ( 11.1 %)

one chin implant and one z_ygornatic implant, ofthese sixteen stable Proplast, thirteen, implants

18 100 0 0

were immobile & 3 were mobile (2 nasal & 1 chin implant) (table 4) . l'v'lobile Proplast here means not true mobility, but shifting its position migrated but still fixed).

T~1ble (4) Stability of the Prop last.

Stability No. % : Stable 16 88.4

------------------T---------------------,-------------------~ : Unstable (removed) 2 11.1 ~Immobile 13 81.25 > ----------------~---------------------r---------------------: 1VIobile 3 18.75

There were eight ( 44.5%) palpable margins ofthe Proplast [floor of the orbit (2) . nose (2), zygoma (3) & chin (I)] (Fig. 1).

Palpable Not Palpable

There were three visible margins and five not visible margins. The visible margms were present in nasal implants (2cases) & in zygomatic implant (I case) .

visible Not Visible

Figure (1) The number of palpable and visible implants

Table (5) shows the degree of satisfaction of the Proplast good results obtained in seven implants,

satisfactory results were 9 implants and poor results were 2 implants.

Iraqi Army Medical Journal, Vol. 12 No.1 & 2 2000; Vol. 13 No.1 & 2 2001.. .................. 102

Table (5) Evaluation of the degree of satisfaction of the implant

Evaluation No. 1 % I Good 7 38.9 f Satisfactmy 9 50 1 Poor 2 1 l. 1

There were two failure cases (11.1%), one zygomatic implant, and one chin implant.

Discussion Proplast is a useful implant for the restoration of facial contour . These are some technical difficulties, when it is inserted over areas that are convex such as the malar prominence and orbital margins, in that it is difficult to eliminate the edge effect; in post -traumatic cases it seemed that slight underbuilding of the contour gave a better appearance than the reverse. vVhen it came to restore concave defects it was excellent. In seventeen cases we inserted Proplast II (white colour) and in one case we used Prop last I (dark colour ) . The cause of this large difference is due to mandatmy use of the Proplast II in thin skin areas which include the orbit, nose & zygoma, and in five cases of the chin implants we also used Proplast Il due to its preformed shape availability in our depa1iment.

Only in one case we used Proplast I (dark colour) for the mandible, this is because here we can use Proplast I due to presence of thick skin over the implant , and also we used it because we want a special thickness to get symmet1y of the face in the patient we operated on , and this is achieved by careful carving of the implant comparing it to the contralateral area until we get the desired shape and thickness.

In this study, two implants were impregnated preoperatively with blood , and this is taken from the same patient by intravenous aspiration of Sec with a needle and injected directly to the Proplast. In another two implants we impregnated them by an antibiotic solution by using vacuum pressure in a 50 cc syrings. In the remaining fourteen implants vve didn't impregnate them in any solution. Reasons for impregnating only two implants with blood is due to the thought of some investigators who suggested that preimpregnating the Proplast with blood might promote granulation tissue penetration into the sponge interstices. But this thought is intriguing and there has been no clear experimental evidence to support this concept. In addition, because Proplast does not rapidly " soak up " fluid like a sponge, blood must either be injected directly into it or forced into it by vacuum impregnation .The fonner technique may not give uniform perfusion and it may be laborious; the latter technique is cumbersome in an

· (5 I operatmg room · . If these maneuvers were shown to have no effect on the fibrous in growth and fixation, then the additional operating time and risk of contamination would constitute contraindications to such pretreatment of Proplast implant . In

EvaluatM.

EYaluation Of The {'scs Of l'roplast In Oral And :\Jaxillofadal Surgery ................................. , ........ 1 03

addition all the investigations did not confinn any advantages of pretreatment of the Proplast with blood, therefore, we chased only two implants for pretreament with blood, to be compared with the d1y implants. tSi

Only two implants were infused preoperatively with antibiotic for the thought that these measures might decrease the risk of infection, but this is not clear cut, as well as some investigators advocated no pretreatment and confinned that the dry implants were superior than others which impregnated with antibiotics or blood . For these reasons we prefened not to impregnate the Proplast in fourteen cases and to evaluate if there is any increase in infection rate due to this or any decrease in implant stability. The stability of the implant was judged both with regard to mobility on palpation and for any tendency for it to slip completely. Only two implants ( t 1.1%) had to be removed (poor stability ) because of infection

We agree with Witaker 1987 (11.3% poor stability), and agree with Epstein, 1979 (9. 9%). This ve1y small discrepancy is due to small sampling. Our results were less than that of Moos, 1979 (19.2% poor stability), the cause was due to different indications. Moos, 1979 used Proplast for augmentation of the temporal regions in cases of hypenelorism, also he used the Proplast for patients with secondary cleft lip and palate, hypoplastic maxillae and intranasal area. Infection became a significant hazard to the implant were the intraoral route was adopted, although surprising only one chin

implant, and one zygomatic implant became infected ( 11. I%) and therefore required removal. Therefore we used special measures to prevent infection, and these included preoperative scaling, and polishing, removal of any retained root, treatment of any non vital tooth by root canal filling, instruction for good oral hygiene with at least twice daily brushing, and postoperative prescription of antibiotics for at least 5 days. After beginning of the infection in the two cases, it was refractory to treatment unless the implant was removed. After it's removal within few days, the infection was subsided indicating that the cause was due to infection with the commensal oral flora and not a resistant microorganisms, and that was confinned by culture and sensitivity test. In the two infected cases the fixation was done with a wire (0.35 mm gauge) and drilling holes in the bone, this indicating the increased risk of infection when the fixation was done by wiring instead of spontaneous or suture fixation. In twelve unimpregnated Proplast there was no infection indicating that the pretreatment with antibiotics did not affect on the Proplast failure. We agree with Arem and Madden, 1976, Arem et al., 1978, and Kent et al., 1979. The Percentage of infection was I 1. 1%, we agree with Moos, 1979 (11.4%) and Epstein, 1979 (8%), this small discrepancy is due to small number of sampling. Our percentage was higher than that of kent et al., 1981(6.6%), the cause was due to different areas selected.

Iraqi Army Medical Joumal, Vol. 12 No.1 & 2 2000; Vol. 13 No. I & 2 2001 .................... 10-+

In his study he excluded nasal, orbital and mandibular inset1ions. The percentage of Mobile implants was 18.75%, this is less than that of Moos, 1979(24.07%), the cause appeared due to the technique of insering the implant . We inserted the implant supraperiosteally in only 16.6%, whereas Moos , 1979 inse1ted the implants supraperiosteally in 35.8% therefore , we agree with Moos report that the subperiosteal implants were much more stable than the extraperiosteal ones. In one case of chin implant migration occuned supenorly, this finding is consistent with the themy that posterior migration of the implant into bone is secondmy to increased mentalis muscle strain to accomplish lip closure, therefore, lip incompetence must be appreciated on initial clinical examination. In all cases the percentage of good contour obtained was 55.5%. We agree with Moos, 1979 (57.6%), the others regarded as improved. No implant evaluated as worse contour or no change occurs in our cases, this was due to proper selection of the cases and proper sized implant inserted. Satisfactory colour of the implant material was 100%, higher than that of Moos, 1979(17. 3 ), and agree with Ma- Let al., 1987. (100%) and shah et al., 1995(1 00%). The cause was due to proper usage of the Prop last II when it is indicated Proplast I is not indicated when the skin was less than 3-5 mm thickness especially in cases of malar, orbital & nasal areas, therefore; in these areas we used Proplast II which is white in colour

in contrast to Proplast l which is black in colour. Befere 1981, Prop last II was not yet invented , only Proplast I was present , therefore, Moos, 1979 used Proplast I in his study and especially used it in the orbit. nose and malar areas where the skin is thin . therefore, at the present time these areas considered a contraindication for the Proplast I .

Margin Palpability was 44.5%, this is because the difficult elimination of the edge effect of the Proplast when it is inserted over convex areas such as nl.alar prominence and orbital margins. In order to obtain proper contour in these areas we suggest proper feathering of the edges of the Prop last . The degree of satisfaction \Ve obtained was as follows: Good result (when the deformity was completely corrected to the satisfaction of both the surgeon and the patient) was 38. 9%, vvhile satisfactory results (when the defect was conected but there was dissatisfaction of either the patient or the surgeon) was 50%. In our study there was no dissatisfaction of the patients here, but the dissatisfaction was from us as follows: Two cases for the roof of the orbit due to step palpation, two nasal implants, one due to slightly lateral deviation and the other due to · the visibility of the edges, three zygomatic implants, one due to visibility of the edges and the other tvvo implants due to step palpation & finally two chin implants, one due to posterior migration and the other due to slightly oversized implant. Although these dissatisfaction occuned from us (but not a failure

II' 'I

I ,'

II'

E\'alualiou OfTh,. t"ses Of Proplast lu Oral And .\laxillofacial Surgny .......................................... 1 O.S

cases), none of the patients requested implant removal but they feel happy & said that the imlpant was a part of their body image. Poor results (when proplems arose necessitating removal of the implant) was ll.l %, due to infection. In our study we couldn't measure the degree of bone resorption under the implant because: 1. The implants are not radiopaque and it was vittually impossible to accurately assess the malar-orbital cases for resorption . 2. In case of chin implants, also the resorption must be assessed after at least 12 months, and we didn't had this period of time for follow up. Our follow up period ranging 2-3 months. In cases of chin implants mental nerve parasthesia was noted in two cases .It is due to retraction and slight oedema .In one case this was relieved after 3 days, in the other it was relieved after 9 days duration. Also we didn't face any tooth

devitalization as well as no any periodontal diseases .It is due to the placement of the implant far away from the roots ,heavy instructions for good oral hygiene. In cases of zygomatic implants insertion, infraorbital nerve anesthesia was noticed in one case which was relieved with the end of one week post operatively. It is due to retraction and hematoma fonnation. References l.Kent ,J.N.; Homsy ,A; Gross, B.D.; and Hinds, E.C. ('1972): Pilot studies of a porous implant in dentistry and oral surgety .D.Oral Surg. 30, 608-615. 2.Kent, J. N; and Westfall, R.L. (1979) Presurgical infusion of Proplast Primate facial

augmentation. J. Oral Surg. 37(9), 637-645.

3. Epstein, L.I. (1979): Clinical experiences with Proplast as an implant. Plastic and Reconstr. Surg. 63(2), 219-223. 4.Kent, J.N; Westfall, R.L.: and Carlton , D. M. (1981): Chin and Zygomaticomaxillary augmentation with Proplast : Long-term follow-up .J Oral Surg. 39(11), 912-919. 5.Arem, A.J, and Madden, J. W. ( 1976): soft tissue response to bloodimpregnated Proplast. Plastic and Reconstr. Surg. 58(5), 580-586 6.Freeman, B.S. (1982): Proplast [ letter] . Plastic -Reconstr. Surg. 69(5), 902-903. 7.Moos , K.F.; Jackson, I. T. ; Henderson, D; Gibbs, P.i\1. ( 1978-1979): The use of Proplast in oral and maxillofacial surgery . Br. D.Oral Surg. 16,187-197. 8.Shaber, E. P. ( 1987): Vertical intepositional augmentatiOn genioplasty with porous ployethylene. Int. J.Orai Max. Fac. Surg. I 6,678-681. 9.Georgiade , G.S.; Georgiade N.G.; Riefkohl, R; Barwick, W. d. ( 1992):Textbook of plastic, Max. fac. And Reconstr. Surg. (2), 93-101.

10. Homsy, CA.( 1981 ): Porous alloplastic implants . Rev. laryngol. Oto. Rhinol. Bord. 102 (1-2), 77-80. II. Westfall, R. L; Homsy, C. A; Kent, JN. (1982):A comparison of porous composite PTFE/ Graphite and PTFE/ Aluminum Oxide facial implants in primates. J. Oral. Max. fa c. S urg. 40(77), 771-77 5. 12.Shah, S; Rhatigan, M; Sampath, R; Yeoman, G; Sunderland, S; Brammer, R; and Leather barrow, B. (1995): Use of Proplast II as a subperiosteal implant for the conection of anopthalmic enophthalmos. Br. 1.0. phthalmolo. 79(9), 830, 833.

Attention dctlcit I Hyperacth·jty dhorder among School- children in Baghdad ................................ I 06

Attention deficit I Hyperactivity disorder among

School- children in Baghdad

r'J Dr. !\Iuman S. Ali

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Abstract

The concept of a disorder characterized by hyperactive behaviors arises in \Vesten societies, in America, Australia and Europe. It was Hspothesised that it is possible that some, or even all, aspects ofthe disorder are culture-bound This study· aims at tinding out the prevalence of Attention- deficit/Hyperactivity disorder ( ADHD)

<*}!\'l. R. C. Psyc.h, D .. P.l\1, D. C. ~· Co~1su~tant Ps~c~~ia~.rist. } P.O. Box 12~~5 ALD0

7

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:\I.B. Ch, B. F. I. C. l\I. S. Ps~c Consult,mt Ps.Hill,ltl 1st P. 0. Box .HJ[)_, 7- ABKAR

Form Department of Ps) chiatry, Rasheed l\Iilitary Hospital I Baghdad- Iraq.

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Ir·aqi Anny 1\kdica!Journal, Vol. 12 "\o. I~~ 2 2000; Vol. 13 \o. l & 2 2001 .................... 10-:-

among first year primary school children in Baghdad and comparing the results '' ith studies done in other parts ofthe \vorld

I 043 children (Aged 6-l 0) were invoked in the sun ey of ~DHD in eight priman schools in Baghdad and the work \Vas done during the period tl·om I 'l Oct. !908 to the 30th Apr !999, in a two-stage survey The tirst (screening) stage involved screening the total sample of children (I 043 child). using '"teacher's questionnaire" to iclemifv possible cases of ADHD among the children, and a second (assessmem} stagl: \\as clone using ·' a semi-structured parem·s questionnaire" based on the diagnostic and statistical manual of mama] disorders fourth Edition (DS!\:1 iV) criteria for diagnosis ofADHD.

The results showed that the prevalence of i-\DHD among primary school children \\as "5 95°o", and male to female ratio \Vas 2 2!.

This rate \Vas compared with prevalence rates in other pans o!'the world and the reasons for differences \vere discussed

This study indicates the presence of ADHD among school children in our countn· at a rate similar to that touncl in some western and eastern countries and attention should be drawn to the treatmem needs of those children.

Introduction Observation that some children are overactive in relation to their age and the appropriateness of the situation have il·equently been made in the psychiatric literature since at least the beginning ofthis centuryii' Epidemiological research has tested ideas about etiology and course An increasing appreciation of the heterogenesity of the problems subsumed with-in the diagnosis has led to reappraisal ofthe components ofthe disorder. Even so, cultural differences remain and the history of thinking about these behaviors in the past still shackles the ranv:e of therapeutic efforts in the

12> present· · Diagnostic criteria m the major schemes have varied, In DSrvi-III ( 1980) there was a category of attention deficit disorder (ADD), defined by the presence of inattentive and impulsive beha viou, especial 1 y seen at school Which tl1rther divided into those vvith the symptoms of motor overactivity as \Vee] (attention) deficit disorder and hyperactivity "ADDH") and those withou{'J In DSM-III-R ( 1987) the category of attention deficit with-out hyperactivity was dropped, and the resulting group renamed attention

defi cithyperacti vity disorder( ··ADDt-r' )'-:' DS:VI-1\ ( l0CJ4) has reintroduced the distinction and nO\\ has subt\ pes uf ADI--ID according ro \\ hether the predominant symptoms are inattenti\ eness. overacti \it\· Impulsi\'eness. or m1x:ed. :':!ymptomes must be pen·asi ,.e over situations''"'

The \Vorld health organization scheme has also e\ olved overtime ACD-<.J ( 1978) incfucled a condition of hyperkinetic syndrome. cletined b\ "ex:treme attend'. · 7 '

The DS!'v·I and ICD schemes appear to

be mo,·ing towards grater harmom _ [CD-I 0 and DSfvl-1\' are very similarr in the behcl\ iors that are impulsi\ e bahaviors cannot by themeseh es amount to grounds for the diagnosis. and inattentive, restlessness must also be present. Hyperkinetic disorder should resemble the mi:-.,:ed subtype of ADHD. The DSl\·1-IV definition therefore picks up a more common, and perhaps less distinctive pattern(.Ji A number of studies have e:-.,:amined the prevalence of ADI--ID in \ arious populations The patient sample used is different setting, at least I 0°io of

Attention deficit I Hyperactivity disorder among School- children in Baghdad ................................ 108

behavior problems seen in general pediatrics setting are due to ADHD, while children with ADHD make up to 50% of some child psychiatric

19' population· ) The prevalence rate may vary when DSM or ICD criteria are applied, and as expected from the definitions the prevalence is much higher when DSM criteria were used(iO) Epidemiological studies have also identified populations wih striking differences in prevalence This could be a very helpful finding the reasons for the differences could throw light on the causes of the disorder and the study of hyperactivity in low risk populations could be a good strategy for identifying

. (")\

causative agentes ,~/ Studies of attention deficit hyperactivity disorder among school children yielded variable prevalence rates, about 5%) in LSA (Lambert ct al !978 and Bosco and Robin 1980), and l 3% in UK (Gillberg C,et al 1983) r12

1.1)

Hyperactivity, in some sense, evidently exists in many cultures, it remains to be seen \vhether it always takes from, so no secure prevalence rate can be givenm because of disputes about what

• i]C\1

constnutes a case' · · Aim Of The Study The purpose ofthis study is : I to identify the prevalence rate of attentiondeficit I hyperactivity disorder among 1 '1 class primary school children in Baghdad 2 to compare the results of this other pans ofthe world on ADHD :VI ethodology A two-stage epidemiological survey was done from I '1 Oct I998 to the 30111

April 1999, the study ADHD in tlrst year school children in eight randomly chosen primary schools in Baghdad First -stage (screening stage) : -First class primary school in baghdad \vere screened, the total number of children involved in this stage was I 043 tAged 6-IO years) Tvventy - three teachers working in these school were instructed and trained in the use of teacher-questionnaire,

which is easy to apply and has been validated for research by five expert psychiatrists The questionnaire is in the form of direct-questions to the classteacher, about evidence of hyberactivity, attention deficits, or both The teachers in these eight -schools were able identify II 0 suspected cases out oftotal sample of 1043 children (prevalence rate, l 0 5%) to have the disorder. -second-stage (Assessment stage) suspected children with :\Dl-!0 recorded in the I st stage were involved in the assessment stage, and I 04 out of 110 children were assessed (s1x children left school between the nvo stages). and of their parents or ncar relative \vere invited to be seen with their children Routine physical and neurological examination \Jvas conducted by the research w excluclL: any sensory deficits or neurological disorder and a rough clinical assessment of intelligence was done to exclude cases of mental retardation as the intention was to study hyperactivity in relatively normal children free from the complications incurred by the above-listed problems A semi-structured parent questionnaire (based on the DSM-lV) American psychiatric association 1994) for diagnosis of ADHD \vas used, in addition to recording sociodemographic data The parent questionnaire was also approved by the same experts who validated teacher questionnaire Statistical :\1ethods Descriptive statistical means were applied whenever relevant throughout the study Results The sample consisted of 1043 school children from eight primary schools distributed over all areas in Baghdad

Iraqi Army \Irdical Journal, Vol. 121\o. 1 & 2 2iJOU: Vol. 13 "\o. I & 2 2tHJl. ................... ltl'.i

Table (1)

Sex and age distribution of the total sample of children involved in the

study.

(%) (%) %

2

(13.9) (1.05)

4

(0.38) l0.!9) (50.43} ___ J -~--~~~~·

23 7 G 517

(12.94) (2.20) (0.67) (0.57) (49.57)

Male mean age~ 6.39 S.D 0.55. Mean Age: 6.39.

Female mean age= 6.43 S.D 0.72 ~1:F ratio 1.01:1.

X 2 = 7.789

df=4

Tuoi< (2;

first~ Stage tS-.:rei!I:.;n6 stage;

(1045) Schcol ~..":hiltirt;n "Tots! san~ple"

Number: Male Percentage: 526

Female 517

49.57

M:P 1.01:1

Teacher Lcordc~ Ev'Jcnce of.'\DHD !\!ale

71

10.54 64.64 50:43

l!U

.,. ::V1:F Yi<tle ft!male ratic

Table (J)

Ft!rnale 3)>

35.3h

Children who were- involved in tho...• us::~es::>rncru stag,..: {No l 04) /\ge (~ sex

di!:>tribucioiJ.

i ~1\~~Year~yr--~--~--- Sex (NU.) ----~~-

Tut..ai

69 ~--~--&---1-1 _:.~~~~(~) 1--}=~~~n;I; (o/o)

lu +~_i44.2) _j__ • u(22.1) 'U-----·-·--'-7

1 • 18 1 11 · -r 29

~ ! 2 I ~ I . 17.3) 1- {1_()2)_

/-·- ___ (l.'>l I_.Jl2L ,

9 ·o---r ; i >----· ' 10

L~-f~yL-~-!---- (0~9) __

~------;- .. {0.9) _ __j .<.\lL_ -4-----

4

.. J I

Total 67 37 L____ __ __l___{§_4_.4_2) __ (3557)

. 10·l-___ __j __

Male mean age= 6.38 S.D 2.-66 Fernale mean age= 6.48 S.IJ 0.72 X 2 -= 2o~Mll df=4

Nwnber: Male Percentage: 67

64.42

Second-Stage (Assessment stage)

(I 043) school children 11TotR1 sHmnlF."

Sub--pected cases of ADHD who participated in Lhe study.

(104 children)•

Female M:F

Cases of ADHD 37 1.8:1 62

35:57 59.6 (5.9)*•

(M:F Male to Female ratio)

Male 43

69.45

%

66.33

27.89~-~

--~1 3.84

--~!

0.96

100.00

F~male

19 30.64

• Out of Lhc suspected cases of ADHD, six failed to participate because

they left school between Lhe two stage> of the study.

•• This is the prevalence rate (62 out of 1043 1 have the ADHD.

M:F iX!

M:F 2.2:1

Attention deficit I Hyperactivity disorder among School- children in Baghdad ................................ Ito

Table (5)

Sex distribution of children with ADHD (NO. 62)

~---S-e_x__ NO. 1 % !

Male 1 43 69.35 -l Female I 19 30.64 -j Total : 62 , 100.00 -- j

t...,...----..,---~__L__ L __________ : M:F ratio 2.2:1

:t'ablc (6)

Subtypes of A OJ--II) According. 1.0 DS~l IV

Sex distribution (NO. 62).

[-ADI-lD subtyp~;;- \ No. at Cases -:---i-~;tai •y-u

I ~·--~~~--1 I !'Vfale -- r· Female I

I Inattention only ! 13 ----:-- 1 __ r ~----• 25.~ __

Hyperactive only 1 10 f 7 --r------ 1 7 ' 2 7.4 I

l Combined type·-·j ·--------- 2(-:) .. ----T- 9 I 2'1 --- _, 46.1

I Total j 43 [ 19 · 62-- --+--- 100.00 '

I (%) I (69.35) I (30.64) I ---~ X 2

- 1.95

df-2

S.D ~ 1.68

Table(7)

Subtypes of ADHD according to DSh-1 IV

Age & Sex distribution (No. 62).

~-(; Total-·-: lnaitentio~-----~ ----~~}Jl~ractiv~ j _<;~~~~!~~~------]

Male female Malo fomak 1 "'_i!'}." I Fema~ --------r------8 2 s . 4 1 12 4 j Js i 58.o6

·~=, I 3 1 -!----2-----r-~i 7 I 4 t lY 30.64

__ ---L--+- ~---~ 0 i 0 1 I ! l) : 1 4 6.45

I rears I 0 I 0 I 0 I 0 f- ono ln 0

o--+-o 'o:. o i ; 0

+--0----·

-- -~------; 1.61.

~- ~~:;~ ; 13 -_L 3 , ___ 1_[_, _L 7 ~ 2ot '2___ ____ 62 __ _ lOO~-,.

M!ilc mean age= 6.46 Female n1ean age= 6.57

Table (8)

Th~ prevalence rates ot'AOHU subtype::;

(According to OSI\.1-TV) h1 lotal population s.an1ple (~u. l 043 j

~-~ ln total population cr·-.:6. i {).:!3) ADHD sub _ __:t)__:'P:__"_~ __

4 __ __

~-at-tcntio~ type

'<0.

.53 16

Hyperactive type 17 .63

Combined type !---·- 29 2.79

r----- ----Tara~~~------~----- 62 5.95

Tahlc (9)

Dirth order of .-\L)l-fT) children (No. 62).

Dom Rank

First bom.

nMiddle born

----L-ast bon"l.

Total

--+--

T _j___

No.

12

37

lJ

62

Table (10)

S--·o

19.3

StJ.6

20.9

100.00 ~

Prevalence studies of Attcntion-detic1l /Hypcractiv~ly Disord~r.

~;, Source, year : Crlte:riJ. ] Prcvale:lCC ! ':-;)

i C Ne\v Zea1and TA-nd~n et al 1987{ n·

1 ••.t ________ DSM-lli -osl\.1~-~1~ ., __ s--16.1. -l

I Pueno Ric~----- 1 Bird ct al 19ggcru)--

,-Pittsburgl~-(USA)_ ; Costdlo et al 19881 '"'

New York,(USA) i Cohen, 1981>1;-2

&7

1="'--,.,.-,.,-,..---~iario~ Canada ! Szatrn~t- al 1989dS) London-.E~and --:Esser cr al, !99-iJf:-"".,.;=-=-=-----

___ ,_l?Sl\1-lll--R i 22.___ ___ __ DS!v1--lll 1 "-c>

Lr::rly --~Baumgu~rt::t al 1995' '' ' '

I va:encia, Spain ____ j Andres-CalTasco:~fA_cot __ ul_ 1 995'·'-i Hong Kong 1 Leung, et ul 1996' "l

! I "- · study 1999----------

mir\"1--m 1-(y· - . ; D~M-lll--A_ l1 7 - --~ ,DSM-fll ~ : DSM-lll-K. I l 0.') ; DSM--IV I 17.8

-:--osl\.f:·m-R 1 l>.o 1 i rc~ o-- Ia ------r-o-:?s

OSM--lll I 6 I .

DSM--IV [8.9 ---------- -~---_·-:;

DSM-IV

Attention de1kit I HYpenctil itY l". d . ' . l Isor er among School- children in Bauh I· l ,., l ,\l ................................ l ](

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J.ll....a.l I ~I ....;? •• ••

y..ol ~ ·.'"•:JQ

FOLIC ACID AND COLO:\ CA.\CER :\ stuch of XX 7.56 '-'omen touncl that \\omen \\ho used tolic ac1d for more than IS \cars had DramaticallY decreased risk . -of colon cancer. \\hen --1-0C! meg F A \\as taken each da~ _Interestingly f\aturai folate in toocl arc not'' ell- absorbed.

COX-2 INHIBTORS These medicines '' ork as sckcti' c f\A.SA!Ds ,·crscs the class of medicines knO\\ as non steroidal anti-mfbmmaton drug. Rofeco-.;ib offers the com cnicncc of once - a day dosmg

NASAL FLUE SHOT (\'ACCI!\'E) The FDA apprO\ cd a tluc "shot'' that Is spra~ eel into the nose_ it IS called tlumist '' hich prcn:nt the flue.

ASPIRIN

The Amcncan heart Association recommends Aspirin to limit the size of the heart attack and possible heart muscle damage A lo\\ dose of Aspirin may help to pre\ ent a first attack in people \\·ho arc at risk.

PROTEASE INHIBITORS The~ hm c the prospect as combination thcrap\ tor HiV infection

ALENDRONATE "FOSAl\1AX"FOR OSTEOPOROSIS This biphosphonatc \\as featured last Year for prevention of glucocorticoid-induced ostcoporsis

. \LZHEIMER'S VACCINE The t\\ o medicines (Tacrine and Doncpczil) can help control Alzheimer's

disease The original research appc:trcd 111

J ul\ Jl)LJLl 1ssuc of ?\arure shcm cd tlur l11l.·

\ accme c.\:Citcd the 1mmunc S\stem allli kept sticky deposits called Am, loid from being deposited in brain.

ANGIOGEl\ESIS INHIBITORS FOR ATHEROSCLEROSIS Endostatin appears to cut off the blood suppl~ from tumors. lnkrcsti:rgl~ _ Olll.'

research group suggested that Endost:nm Jlllght aiso ha\ <..' a rule ll1 treatlll.~ c)r prL'\ Cl1[! ng athLTUSC !eros !S

ATHEROSCLROS!S \"ACCT\E We\ c ail heard th:tt htgli k' ~·l of "bad'' cholesterol arc harmful .'\' accinc is being tested against (cholesterol ester transf\:r protein ) '' hich 111::1y imprm c the r:1tio uf good HDL to bad LDL cholesterol. B-LYl\/1PHOCYTE ST!fVll'L\:\iT A human protem has been d1scm crcd lkti \\ orks to trigger one uf most Itlli)Urt:lllt

infection - fighting cells in the boch. Tlil. protein IS callcci B lymphocyte srimubnt or Blys. and is actually causes the body to make more of a specific kind of W B C CALCHil\I AND RECURREI\:T ADE \!OJ\ lAS Calcnim supplements \\ere stud1cd in LJ i ~ pc'Jplc and ''ere found to ha \ c kcl w a JLoderate (but significant) kmcnng of :-,sk of recurrent adenomas

< LRVICALCANCER VACCINE A \accinc discovered last year could help to kill the HPV \ irus. \\ hich can cause ccn·ical cancer. \Yhich can m oid one cause of ccn ical cancer .

CHLAMYDIA PNElJMOI\IA AND HEART ATTACK

v ..................... ~ · . '-~. · . - l)li.!l..s j 3~1 j.l.lJ\- ~ ..::.JL.:i.!l 5 ~ l)li.!l ..J:~I - A.,~l ~~ ~~

Thts bactcna . '' h1eh has been long knO\\ n to cause lung mfcction . some n:scarchcrs sa) mg it may be 1m oh cd 111 heart attack /\. study reported in THE LANCET found that pcopk '' ho had heart attacks \Ycrc also likely to be infected '' ith this organism FortunatelY the bacteria arc relative!\ cas\ - - . to kill. and 1f (like ulcers) some heart attacks arc found to be mfcctious. a simpk blood test ma\ be used to identify those at . -nsk Once the bactcna arc found. a course of right ~mubiotic(probabiy a macroildc) nEt) become a Kc\ to prcn:nting heart

attacks

FUSION INHIBITOR FOR HIY 1\,o expenmcntal drugs called T 20 and T 1249 has gi Yen fast -tr;J.ck designation by FDA The' block the abditY of HIV to

- -latch on healthY 1mmunc cells GE:\TICT THERAPY FOR CHF A most pr01msmg approach uses spcctfic gcnct1c probes to treat congest!\ c heart fadurc (Ci If) Some carl) research shO\\S prom1sc for ;1 onc-t1mc. non-surgical treatment that maY reverse CHF' Others arc exploring usc of gene therapy to reverse

h1gh cholesterol HC\l\ '\ GEN0!\1E Maw medicines todaY address the . -symptoms of a dtscase or cund1t10n (such as high blood prcsswc) rather than addressing the cause A project to map the cnt1rc group of human genes is nearing completion The map\\ ill be 90% finished in the year 2000 and completed by 2002 The potential for de\ eloping medicines that actualiy correct the underlying CAUSE of a d1seasc or condit1on IS suddenlY vcrv. ,-crv real IC-351 HYDROXYLASE) AND

VIAGRA A nC\\ medicine for impotence is in clinical trials . '' l11ch acti vatcs th.: same blood tlo\\ system as the existing medicme (Yiagra) !C-351 may have an advantage in that it may cause fe\\Cr possible side effects INSULIN INHALER Oralgcn insulin inhaler is currently in phase ill trial (the last phase before approvai) to deliver insulin b\ an inhaler instead of insulin injections.

UPOSOMES IN BREAST CA:\CER Doxorubicin IS nO\\ the drug of choice for

breast cancer. but has some s1dc effects. A nc'' drug called ERACET m the L:SA" a liposomalh enclosed form \\as recent!: found to offer the same clinical ad\ ant age

of Doxombicm ORZEL FOR COLO!\ CA:\CER Typ1cally. colon cZ1nccr has required treatment by I V route: this signif1eanth impacts the lives of cancer patients. A nC\\

medicine called UFT and orazel promises to treat certain kmds of colon cancer b\

mouth. PAIN TREATl\'lENT IMPLANT A team at Johns Hopkins Unl\ crs1ty lookmg in to actual!\ unplantmg (mscrring) a pam medicine under the skin. '' hich gi\ c a long- lastmg rcilef for up to a month For pam patlcnts '' ho h:n c problems tr) mg w remember to take a pill 1

PROSTATE CANCER VACCINE A phase III! study shm\eci that a \accinc named GVAX stabilized d1scasc 111 71 °'o of patients and ''as also safe and \\ell tolerated STAPH VACCINE Researches at Birmingham shm\ ed that a \·accmc directed agamst staphYlococcus aurcus bacteria protected rabb1ts and mice. and \\ill hope protcctmg patients at nsk m

hospitals.

TELOMERASE IN AGING ANU

CANCER \Yorks has continued on th1s nc\\ enzvmc that appears to ha\ c a role in agmg and ma\· also be apart of the cancer mystery ;\luch research needs to be done to sec

''hen th1s cnz\ me fits m

REFERNCE: (The Essential Guide To prescription Drugs 2000, Rybacki and Long, 2000).

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ThursdavNOV. 2nd, 2000

1Vorkshop No, "1" Neurostimulation and neuromodulation: Complementary therapies for voiding dysfupction in spinal cord injury. Speakers: 6

1Vorkslwp No. "2" :Management of the elderly spinal cord injured patient: How can we do better. Speakers: 7

TVorkshop No. "3" Management of spinal cord injury pain. Speakers:4

1Vorkslwp No. "4" Respiratory rhanagement m spinal cord injury. speakers:?

Workshop No. "5" Assistive technologies for independence after spinal cord injury. Speakers:6

Scientific sessions Friday Nov. 3rd 2000 Session"]" Pain in spinal cord injury

·No. of papers : 4 Session "2" Free papers No. of papers:6 Poster session "I" No. of posters : 44

Session "3" Basic and clinical research No. of papers: 4

Session "4" Free papers No. of papers : 4

Saturday Nov. 41Jz 2000

Breakfast session: instt·uctional course /clinical practice guidelines. Session "5" respiratory physiology No. Of Papers: 4. Session "6" free papers No. Of papers : 6. Poster session "2" No. of posters : 40.

Work shop: sexual dysfunction /Erectile dysfunction in the aging SCI patients and sexual dysfunction in the spinal cord injured women. {Treatment with sildenafil). Session "7" aging and SCI No. of papers: 4. Session "8" free papers No. of

papers :B. Session "9"

pervention symposim No. of papers:4.

Sundav Nov. 51ft 12000

Session (1 0) exercise physiology and clinical trials No. of papers : 8. Poster session : No. of papers :42. Workshop : Asia scale. Session II clinical trials and assistive technology No.paper :4 Session (12): free papers. No. of papers : 3. ·

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