Content Iraqi Peer Review Journal The New Iraqi Journal of Medicine The Official Peer Review Journal Of The Iraqi Ministry of Health March 2006 Volume 2 Number 1 Content 1-2 Instructions for Contributors 3-7 Editorial The Practice of evidence based medicine 8-10 Aamir Jalal Al Mosawi Anatomy Double extensor pollicis longus muscle and its clinical significance 11-14 Srijit Das, Associate Professor Rajesh Suri ,Professor Vijay Kapu Risk factors associated with wound dehiscence 15-19 Dhiaa T.Al-Anbaky General surgery Literature Abstracts of Iraqi Research published in International medical journal: Acacia gum supplementation of a low-protein diet in children with end 20 -stage renal disease Experience with refractory vitamin D-resistant rickets and non- 17α alkyl testosterone derivative anabolic agent 1
Transcript
Content Iraqi Peer Review Journal
The New Iraqi Journal of
Medicine The Official Peer Review Journal Of
The Iraqi Ministry of Health
March 2006 Volume 2 Number 1
Content 1-2 Instructions for Contributors 3-7
Editorial
The Practice of evidence based medicine 8-10 Aamir Jalal Al Mosawi
AnatomyDouble extensor pollicis longus muscle and its clinical significance 11-14 Srijit Das, Associate ProfessorRajesh Suri ,Professor Vijay Kapu Risk factors associated with wound dehiscence 15-19 Dhiaa T.Al-Anbaky General surgeryLiterature Abstracts of Iraqi Research published in International medical journal: Acacia gum supplementation of a low-protein diet in children with end 20 -stage renal disease Experience with refractory vitamin D-resistant rickets and non- 17α alkyl testosterone derivative anabolic agent
1
OrthopedicsEvaluation of new reduction technique for acute anterior shoulder 22-26 dislocation. Hamza N Aboud
NephrologyThe Etiology of chronic renal failure in a sample of Iraqi patients: 27-30 Lower incidence of diabetes and hypertension related renal failure. Aamir Jalal Al Mosawi PsychiatryThe phantom limb 31-34Ali Rzuki Ghazi Aboud Mohammad Rzuki Practical ExperienceSilk granuloma at gastrointestinal anastomosis stoma. 35-36EditorialSilk granuloma:Editorial commentary. 37-38
This journal is a peer-reviewed scientific journal that publishes original articles in all fields of experimental and clinical medicine and related disciplines. The New Iraqi Journal of Medicine is currently issued 3 times per year. The new Iraqi J Med is listed by the ICMJE and Doctor Guide journal lists. The editor endorses the principles embodied in the Declaration of Helsinki RECOMMENDATION FOR CONDUCT OF CLINICAL RESEARCH and expects that all investigations involving humans will have been performed in accordance with these principles. Review process. Manuscripts are evaluated on the basis that they present new insights to the investigated topic, are likely to contribute to a research progress or change in clinical practice or in thinking about a disease. It is understood that all authors listed on manuscript have agreed to its submission. The signature of the corresponding author on the letter of
submission signifies that these conditions have been fulfilledReceived manuscripts are first examined by the editor. Manuscripts with insufficient priority for publication are rejected promptly. Incomplete packages or manuscripts not prepared in the advised style will be sent back to authors without scientific review. The authors are notified with the reference number upon manuscript registration at the editorial office. The registered manuscripts are sent to independent experts for scientific evaluation. The evaluation process usually takes 1–3 weeks. Submitted papers are accepted for publication after a positive opinion of the independent reviewers. Conflict of interests. Authors of research articles should disclose at the time of submission any financial arrangement they may have with a company whose product figures prominently in the submitted manuscript or with a company making a competing product. Such information will be held in confidence while the paper is under review and will not influence the editorial decision, but if the article is accepted for publication, the editors will usually discuss with the authors the manner in which such information is to be communicated to the reader. Permissions. Materials taken from other sources must be accompanied by a written statement from both author and publisher giving permission to the Journal for reproduction. Obtain permission in writing from at least one author of papers still in press, unpublished data, and personal communications. Patient's confidentiality. Changing the details of patients in order to disguise
them is a form of data alteration. However authors of clinical papers are obliged to ensure patients privacy rights. Only clinically or scientifically important data are permitted for publishing. Therefore, if it is possible to identify a patient from a case report, illustration or paper, A written consent of the patient or his/her guardian to publish their data, including photogram is necessary prior to publication. The description of race, ethnicity or culture of a study subject should occur only when it is believed to be of strong influence on the medical condition in the study. When categorizing by race, ethnicity or culture, the names should be as illustrative as possible and reflect how Theses groups were assigned. Copyright transfer. Upon acceptance, authors transfer copyright to The New Iraqi J Med. Once an article is accepted for publication, the information therein is embargoed from reporting by the media until the mail date of the issue in which the article appears. Upon acceptance all published manuscripts become the permanent property of The New Iraqi J Med, and may not be published elsewhere without written permission from the editor .Every effort is made by the editor to see that no inaccurate or misleading data, opinion or statement appears in the journal. However, they wish to make it clear that the data and opinions appearing in the articles and advertisements herein are the responsibility of the contributor, sponsor or advertiser concerned.
4
CRITERIA FOR MANUSCRIPTS The journal takes under consideration for publication original articles in experimental and clinical medicine and related disciplines with the understanding that neither the manuscript nor any part of its essential substance, tables or figures has been published previously in print form or electronically and is not under consideration by any other publication or electronic medium. The Journal discourages the submission of more than one article dealing with related aspects of the same study. Each submission packet should include the statement signed by the first author that the work has not been published previously or submitted elsewhere for review and a copyright transfer. PREPARATION OF MANUSCRIPT Guidelines for submission are in accordance with: Uniform Requirements for Manuscripts Submitted to Biomedical Journals (N Eng J Med, 1997; 336: 309-15). Manuscripts should be up to 4000 words in length with a target of no more than 80 references. Article structure Original research articles, clinical studies, and case reports should be organized as follows: The manuscript should be typewritten on a white paper of the size ISO A4 (210x297 mm). The text should be processed on the laser or inkjet printer preferably, or on a type writer; in the last case, however, the authors are requested to take care about the quality of printing tape. Text should be one spaced with 12 points typeface.
Margins: 2.5 cm (1 inch) at top, bottom, right, and left. Illustrations are very helpful and for case reports are mandatory. In reviews it should be explained what information retrieval sources were used and what were the criteria in selecting the referred papers. The Editor reserves the privilege to adjust the format of the article. The manuscript should include: Title page should include the following Information: • Full names of all authors • Name of the department and institution in which the work was done • Affiliations of the authors • Manuscript full title • Full name, address, telephone and/or fax number of the author responsible for manuscript preparation. • E-mail address to speed up contacts with authors • Source(s) of support in the form of grants (quote the number of the grant) equipment, drugs etc. Abstract Page. Abstract in structured form not exceeding 300 words should consist of four paragraphs labeled: Background, Material (Patient) and Methods, Results, Conclusion. Each summary section should begin in a new line and briefly describe, respectively, the purpose of the study, how the investigation was performed, the most important results and the principal conclusion that authors draw from the results. KEY WORDS (3 to 6) or short phrases should be written at the bottom of the page.
5
Text. The text of the article should be divided to seven paragraphs labeled: Introduction, Material (Patient) and Methods, Results, Discussion, Conclusions, Acknowledgements, References. Introduction should contain scientific rationale and the aim of the study or (in case of a review) purpose of the article Material (Patient) and methods should describe clearly the selection of observational or experimental subjects (patients or laboratory animals)including controls, such as age, gender, inclusion and exclusion criteria, (the circumstances for rejection from the study should be clearly defined),randomization and masking (blinding)method. The protocol of data acquisition, procedures, investigated parameters, methods of measurements and apparatus should be described in sufficient detail to allow other scientists to reproduce the results. Name and references to the established methods should be given. References and brief description should be provided for methods that have been published but are not well known, whereas new or substantially modified methods should be described in detail. The reasons for using them should be provided along with the evaluation of their limitations. The drugs and other chemicals should be precisely identified including generic name, dose and route of administration. The statistical methods should be described in detail to enable verification of the reported results. Results should concisely and reasonably summarize the findings. Restrict tables and figures to the number needed to explain the argument of the paper and assess its support. Do not duplicate data
in graphs and tables. Give numbers of observation and report exclusions or losses to observation such as dropouts from a clinical trial. Report treatment complications. The results should be presented in a logical sequence in the text, tables and illustrations. Do not repeat in the text all the data from the tables or graphs. Emphasize only important observations. Discussion should deal only with new and/or important aspects of the study. Do not repeat in detail data or other material from the Background or the Results section. Include in the Discussion the implications of the findings and their limitations, including implications for future research. The discussion should confront the results ofother investigations especially those quoted in the text. Conclusions should be linked with the goals of the study. State new hypotheses when warranted. Include recommendations when appropriate. Unqualified statements and conclusions not completely supported by the obtained data should be avoided. Acknowledgements. List all contributors who do not meet the criteria for authorship, such as technical assistants, writing assistants or head of department who provided only general support. Financial and other material support should be disclosed and acknowledged. References must be numbered consecutively as they are cited. References should be denoted numerically and in sequence in the text, using Arabic numerals placed in square brackets, i.e., [12]. List references in numerical order in the Reference list References selected for publication should be chosen for their importance,
6
accessibility, and for the „further readings opportunities they provide. References first cited in tables or figure legends must be numbered so that they will be in sequence with references cited in the text. The style of references is that of Index Medicus. List all authors when there are six or fewer; when there are seven or more, list the first three, then„et al.³ The following is a sample reference: Standard journal article *Lahita R, Kluger J, Drayer DE, Koffler D, Reidenberg MM. Antibodiestonuclear antigens in patients treated with procainamide or acetylprocainamide. N Engl J Med 1979; 301:1382-5. Book, personal author(s) Ringsven MK, Bond D. Gerontology and leadership skills for nurses. 2nd ed. Albany (NY): Delmar Publishers; 1996. Book, editor(s) as author Norman IJ, Redfern SJ, editors. Mental health care for elderly people. New York: Churchill Livingstone; 1996. Tables. Type or print out each table on a separate sheet of paper. Do not submit tables as photographs. Number tables consecutively in the order of their first citation in the text, and supply a brief title for each. Give each column a shorter abbreviated heading.Placeexplanatory matter in footnotes, not in the heading. Explain in footnote. All non standard abbreviations that are used in each table. For footnotes use the following symbols, in this sequence: *, ý, §, ||, Â, **, ýý, etc.Identify statistical measures of variations such as standard deviation and standard error of the mean. Do not use
internal horizontal and vertical rules. Be sure that each table is cited in the text. Figures should be numbered consecutively according to the order in which they have been first cited in the text. Define in the legend all abbreviations that are used in the figure. Review articles Each review article should concentrate on the most recent developments in the field. These articles aim to summarize and highlight recent significant advances in and ongoing challenges in the field. Authors should strive for brevity and clarity. The final structure of the review will, of course, depend on the title/focus but wherever possible, the following sections should be included. Submission Manuscript should be sent on floppy disc. Submission by e-mail is also welcome. Editor in chief: Aamir J Al -Mosawi Main Editorial office: Expansion building, first floor University Hospital in Al Kadhimiyia Al Kadhimiyia Baghdad Iraq PO Box: 70025 E-mail: [email protected]
The New Iraqi Journal of Medicine 2006 2(1): 8- 10 Editorial The practice of evidence based medicine Aamir Jalal Al –Mosawi MD, PhD. Head department of pediatrics University Hospital in Al Kadhymiyia Al Kadhimiyia Baghdad Iraq PO Box: 70025 E-mail: [email protected] Evidence-based medicine (EBM) has been defined as ‘the integration of clinical information obtained from a patient, with the best evidence available from clinical research and experience and the application of this knowledge to the prevention, diagnosis or management of disease [1, 2]. In fact EBM was defined for the first time by David Sackett as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient”. Therefore basis of evidence based care involves the integration of the best research evidence with clinical expertise and patient values.EBM has roots going back to nineteenth century. A major factor for the recently broadened interest has been the information explosion that increased dramatically in the last decade. Every few years the literature doubles in size, now there are more than 100,000 scientific and medical journals. Dr. Sydney Burwell 1956 (Dean, Harvard Medical School.) said "Half of what you are taught as medical students will in 10
years have been shown to be wrong. And the trouble is none of your teachers know which half.” So although the concept of practicing medicine based on sound evidence is not new, it has become more formalized with additional recent refinements that have enabled physicians to approach medical problems and evaluate medical literature with greater consistency and to deal with massive amounts of medical information via a qualitative approach. EBM has originally been developed to aid the busy clinicians to provide the best health-care for their patients. It requires new skills of the physician, including efficient literature searching, and the application of rules of evidence in evaluating the literature. Traditionally there are four basic steps described in this approach. The first is to frame a clinically relevant question and to focus it in a way which can be answered. This is not as trivial a step as it may at first appear. The key elements of a well framed question include a description of: the patient or population; the intervention or exposure; the comparison
8
intervention or exposure (if relevant); and the clinical outcome(s) of interest. Such an approach can be applied whether the issue is one of diagnosis, prognosis or therapy. Having defined the question, the second step is to undertake a comprehensive review of the best available clinical evidence. This is likely to involve searching electronic databases (e.g. Medline, EMBASE, CINAHL and The Cochrane Library). The development of search strategies for these databases often involves expertise of information scientists who can adjust the search strategy to maximize finding all relevant studies (which increases sensitivity), but at the expense of identifying many irrelevant articles (decrease specificity).Having retrieved all potentially relevant articles which address the question, the third step is to critically appraise them. Tools have been developed to appraise studies evaluating diagnostic tests, prognostic markers, treatments, adverse effects and systematic overviews. There are many different study designs which may address this type of question. A hierarchy of such study designs has been developed with the most rigorous at the top and the least rigorous at the bottom. The primary research study, which is considered to be the gold standard in assessing treatments, is the randomized controlled trial. The key element in this design is that the allocation of patients to the treatment group or to the comparison group is done randomly, and thus the observed differences between the treatment and the comparison group(s) will be due to the experimental treatment alone rather than to biases which may be introduced by patient characteristics, physician preferences, etc. However, even given this robust study design, the
methodological quality of randomized controlled trials may be subject to biases in other ways and these can be evaluated appropriately by checklists. Evidence-based medicine proponents endorse the importance of clinical expertise, which uses narrative skills to integrate the information provided by the clinical method. In practicing evidence based medicine, clinicians integrate this information with that provided by sound clinical research. When tensions arise in this approach, it is usually because the narrative/intuitive paradigm has been discarded and decision making is predicated on the ‘evidence’ alone. Systematic reviews are the result of rigorous research, using methodology which is designed to reduce bias. As such they can provide reliable summaries of evidence. This methodology has been most comprehensively developed for systematic reviews of randomized controlled trials, but is being developed for other study designs. By searching databases of systematic reviews, such as those contained within the Cochrane Library, the clinician can obtain high quality evidence rapidly and reliably and enhance his/her clinical practice. The fourth step, which is to apply the evidence in clinical practice, is the point at which clinical expertise and patient values are integrated with the best available external evidence. To do this, the clinician needs to ask two questions concerning the evidence that s/he has appraised. The first is ‘is this evidence sufficiently robust for me to be confident in its application?’ and the second is ‘is this study applicable to the patient (or population) about whose care I am deciding?
9
Practitioners of evidence-based medicine have long argued that it should not be conducted from ivory towers, by individuals who have little patient contact. If it is to be applicable it needs to be practiced by all clinicians, not least because the questions or question posed need
…………………………………………. ……………………………… References
to be relevant to routine practice. However, as will be apparent from the brief description above, the second and third steps of this approach can be very laborious. One of the most attractive and reliable of these tools is the development systematic reviews. As will be seen from the systematic review is now regarded by many as the most rigorous study design for providing information about treatments. The term systematic or scientific review is used to distinguish them from more traditional or narrative type reviews of topic areas conducted by experts in the field. Most manuals written for evidence based practitioners do not consider textbooks to be a valuable source of information. In the relevant section in their textbook Evidence-based Medicine state ‘we begin with textbooks only to dismiss them’ later stating ‘while we may find some useful information in text books about the path physiology of clinical problems it is best not use them for establishing the cause, diagnosis, prognosis, prevention or treatment of a disorder’. Part of the problem is that the material published in textbooks is written some time (often some years) before the book is published. Thus textbooks rapidly become out of date. Publishers have realized this and are trying to address this with strategies such as providing regular electronic updates more frequently than the published paper editions.
1- Moyer V, Elliott E. Preface. In: MoyerV, Elliott E, Davis R, et al, eds. Evidence based pediatrics and child health. London:BMJ Books; 2000. 2-Sackett DL, Richardson WS, RosenbergW, et al. Evidence-based medicine: how to practice and teach EBM. London: Churchill Livingstone; 2000. The
10
The New Iraqi Journal of Medicine 2006 2(1):11-14 Anatomy Double extensor pollicis longus muscle and its clinical significance Srijit Das, Associate Professor Department of Anatomy, Maulana Azad Medical College 190 RPS Flats, Sheikh Sarai Phase-I. New Delhi-110017 India Tel: 91-11-9811974702 E-mail: [email protected]. Rajesh Suri ,Professor Department of Anatomy, Vardhman Mahavir Medical College New Delhi, India. Vijay Kapur, Former Director Professor & HOD Department of Anatomy, Maulana Azad Medical College, New Delhi, India Abstract Background: The Extensor Pollicis Longus (EPL) is an important muscle producing the extension of the thumb. There are few reports on double EPL muscle in literature. The present study reports the presence of double EPL muscle with its morphological description and also highlights its clinical significance. Materials and Methods: We dissected 50 upper limbs in the department of anatomy to observe the variations of the extensor muscles of the forearm. The anomaly of double EPL was studied in detail and appropriate photograph was taken. Results: Double EPL muscle was observed in a left upper limb of a 37 year old male cadaver. The two muscles had its origin from the posterior surface of the shaft of the ulna and interosseous membrane and displayed a common insertion into the base of distal phalanx of the thumb.
Conclusion: The presence of double EPL muscle may be important for academic purpose and clinical studies considering the fact that EPL tendon is used for tendon transfer. The prior knowledge of such anomalies may be important during Surgeries for hand trauma. Key Words: Extensor Pollicis Longus, double, accessory, tendon, anomaly, variations, abnormalities. Introduction The EPL muscle has been known to exhibit variations. Interestingly, the incidence of the variations of the extensor tendons has been found to be less common on the radial side than on the ulnar side [1]. There are some reports on the presence of double EPL muscle [2,3]. Variations of EPL may be in the form of an individual muscle belly
11
which may completely separate from the common extensor tendons having a proper tendinous insertion [4]. It is often necessary to be aware of the anatomical
variations of the extensor tendons while performing tendon transfer and treating traumatized hand [5]. A
previous research study had described accessory EPL tendon in a patient which resulted in wrist pain [6].Considering the fact that an incidence of 26% cases having double EPL tendons have been reported, the clinical importance of this anomaly cannot be neglected [7]. A previous research report had described an accessory EPL located between the normal EPL and the Extensor Indicis Proprius muscle [8]. The anatomical knowledge of such anomalous muscle may be important for surgeons. The present study describes in detail a case of double EPL muscle and discusses its clinical significance Awareness of the normal and abnormal topographical anatomy of the extensor muscles of the hand may be important during tendoplasty, tendon transfer operations and during decompression for the treatment of de Quervain’s tenosynovitis. Materials and Methods Fifty upper limbs from formalin fixed cadavers in the Anatomy dissection hall were taken for the study. The extensor compartment of the forearm was dissected. The tendons of these muscles were displayed and studied in detail. Any anomalies were looked for and appropriate photograph was taken (Fig.1). Results Double EPL muscle was observed in the left upper limb of a 37 year old male cadaver. There were two muscle bellies of EPL (marked as ‘a’ & ‘b’ in Fig.1).
One originated from the posterior surface of the shaft of ulna and the other from interosseous membrane. These two slender muscle bellies became tendinous, about 4 cm proximal to the wrist. The two tendons traversed deep to the extensor retinaculum and were found to unite at the dorsum of proximal phalanx of the thumb to be inserted into the distal phalanx. Discussion Standard anatomy textbooks do not mention in detail the incidence of anomalies of EPL especially double EPL muscle. There are reports of supplementary extensor tendons of the hand [2, 9, 10, 11].It may be an individual muscle belly separated from the common extensor tendons having an additional insertion as an additional tendon [4]. Interestingly, the anomalies of the extensor tendons have been found more on the radial side compared to the ulnar side [1]. In the present study also, the anomaly involves the EPL muscle which is on the radial side of the forearm. The variations of extensor tendons of the thumb have been reported while performing operations and cadaver dissections [12]. On extensive review of literature we encountered two cases of double EPL tendon [2, 3]. There are also reports of abnormal origin and insertion of extensors of the thumb [13, 14, 15]. In the present case, the muscle originated as two separate bellies, traversed deep to the extensor retinaculum to be inserted as a single tendon into the base of the distal phalanx. Additional extensor of the thumb, having their own origin,
12
insertion and separate belly is an extremely rare entity[16]. Such anomalous muscles may be incidental finding during cadaver dissection or
operations. The anomalous course of EPL muscle has been reported to be associated with pain [17]. The presence of double EPL could be
developmental in origin. It has been suggested that an accessory long extensor tendon to the thumb may be regarded as a primitive remnant [1]. A previous researcher had stated that phylogenetically the accessory EPL in human beings can be traced to primates [18]. The explanation for such anomalies may be related to a shift of the deep extensor sheet of muscle to the radial side as seen in rhesus monkeys and baboons [1]. Conclusion The presence of two tendons of EPL could be physiological advantage in case of injury to one. It has been documented earlier that rupture of the EPL may be associated with chronic tenosynovitis caused be repetitive activity [19]. The awareness of the variations of the extensor tendons is important while decompressing the compartment for de Quervain’s tenosynovitis [10]. We as anatomists opine that awareness of anomalous extensor muscles of the hand may be important for surgeons while carrying out reconstructive procedures in the hand region. Acknowledgement: The authors express their sincere thanks to Dr. Aamir Al Mosawi Honorable Editor, The New Iraqi Journal of Medicine for the excellent support. References 1-Straus WL: The phylogeny of the human forearm extensors Human Biol 1941; 13: 23-50.
2-Mc Gregor AL: A contribution to the morphology of the thumb. J Anat 1926;60: 266- 269. 3- Wood J: On some variations in human mycology. Proc R Soc London 1867; 15 : 518- 546. 4- Jones BV: An anomalous extensor indicis muscle. J Bone Joint Surg 1959 ;41B: 763-765. 5-von Schroeder HP, Botte MJ : Anatomy of the extensor tendons of the fingers: variations and multiplicity. J Hand Surg [Am]. 1995; 20: 27-34. 6-Beatty JD, Remedios D, McCullough CJ : An accessory extensor tendon of the thumb as a cause of dorsal wrist pain. J Hand Surg [Br]. 2000; 25: 110-1. 7-Yoshida Y : Anatomical study on the extensor digitorum profundus muscle in the Japanese. Okajimas Folia Anat Jpn.1990; 66: 339-53. 8-Cohen BE, Haber JL : Supernumerary extensor tendon to the thumb: a case report.Ann Plast Surg. 1996; 36: 105-7. 9-Aydinlioglu A, Tosun N, Keles P,Akpinar F, Diyarbakirli S : Variations of abductor pollicis longus and extensor pollicis brevis muscles: surgicalsignificance.Kaibogaku Zasshi. 1998; 73: 19-23 10-.Gonzalez MH, Sohlberg R, BrownA, Weinzweig N : The first dorsal extensor
13
compartment: an anatomic study. J Hand Surg [Am]. 1995; 20: 657-60. 11-Schenk R: Variations on the extensor tendons of the fingers: surgical ignificance.J Bone Joint Surg [Am] 1964; 46:103–110. 12-Martinez R, Omer GE Jr : Bilateral subluxation of the base of the thumb secondary to an unusual abductor pollicis longus insertion: a case report. J Hand Surg [Am]. 1985; 10: 396-9. 13- Cauldwell EW, Anson BJ, and R.R.Wright : The extensor indicis Proprius muscle. A study of 263 consecutive specimens. Q. Bull. Northwestern Univ.Med. School 1943; 17: 267-279. 14- Macalister A: Note on muscular anomalies in human anatomy. Proceedings of the Royal Irish Academy 1866 ; 9 : 444-467. 15- Stein AH: Variations of the tendons of insertion of the abductor pollicis longus and the extensor pollicis brevis.Anat Rec. 1951 ;110 : 49-55. 16-Abu-Hijleh MF : Extensor pollicis tertius: an additional extensor muscle to the thumb. Plast Reconstr Surg. 1993;92: 340-3.Orthop Relat Res 1997; 345 :171-173.
17-Nishijo K, Kotani H, Miki T, Senzoku F, Ueo T : Unusual course of the extensor pollicis longus tendon associated with tenosynovitis, presenting as de Quervain disease--acase report. Acta Orthop Scand. 2000; 71 : 426-8. 18-Papaloizos MY: Accessory extensor ollicis longus. Scand J Plast Reconstr Surg Hand Surg. 2004; 38: 310-3. 19- Adler Louis, Blazar Philip ,Lee ong : Acute Attenuation of the Extensor Pollicis Longus Tendon: A Case Report.Clin
Figure (1): Photograph of dissected specimen showing two muscle bellies of Extensor Pollicis Longus arrows (a) and (b).
14
The New Iraqi Journal of Medicine 2006 2(1): 15-19 General Surgery Risk factors associated with wound dehiscence Dhiaa T.Al Anbaky Specialist surgeon Al Kadhimiyia Teaching hospital Baghdad, Iraq
Abstract: Background: The incidence of wound dehiscence continues to be around 0.3- 10% despite the progress in the preoperative care during the last few decades. Wound dehiscence after abdominal surgery continues to be a challenging problem, which considerably prolongs hospital stay and is associated with significant mortality rate. The aim of this paper is to study the various risk factors that lead to wound dehiscence and the method to minimize it. Patients and Methods: During 3 years period from April 1996 to April 1999 thirty patients (17 males and 13 females) developed wound dehiscence of all abdominalwall layers after abdominal surgery at Al-Kadhymiyia Teaching Hospital. Their age ranged from 2 months to 90 years. The patients who did not have a disruption of all layers of the abdominal wall were excluding from the study. The cases were studied to identify the preoperative, operative, and postoperative risk factors, related to wound dehiscence. The results of the patients were compared with control group (30 patients, of similar sex, age, and operative indication who had operation during the same period).
Results: Wound dehiscence occurred on average 8 days postoperatively (range 3-14). The primary diagnosis in both groups included malignancy (biliary, pancreatic, and urinary), acute abdomen (intestinal obstruction, acute appendicitis, intestinal perforation, acute pancreatitis, mesenteric vascular ischemia), obstructive uropathy, biliary disorders, and miscellaneous disorders (liver rupture, colonic ileus, pelvic abscess).The main preoperative risk factors associated with wound dehiscence were Hypoprotieneimia, anemia, and chronic lung disorders, while emergency surgical procedure was the main operative risk factor. The number of patients in the dehiscence group increased significantly when the number of risk factors increased. Key words: Wound dehiscence-Risk factors-Abdominal surgery. Introduction: The incidence of wound dehiscence (The post operative separation of the abdominal musculoaponeurotic layers, which occurs within days and require intervention during the same hospital
15
stay) continues to be around 0.3-10% in various reports despite progress made in preoperative care during the last few decades. Wound dehiscence after abdominal surgery continues to be a challenging problem ,which considerably prolongs hospital stay and is associated with mortality rate of 36% in 20 reviews of wound dehiscence published before1940, and 18% in a review of 34 studies from 1950 to 1984 and dehiscence associated mortality rate dose not appear to be declining [1,2,3,4,5,6].The aim of this paper is to study the various risk factors associated with wound dehiscence and the methods to minimize. Patients and Methods During 3 years period from April 1996 to April 1999 thirty patients (17 males and 13 females) developed wound dehiscence of all abdominal wall layers after abdominal surgery at Al-Kadhymiyia Teaching Hospital. Their age ranged from 2 months to 90 years. The patients who did not have a disruption of all layers of the abdominal wall were excluding from the study. The cases were studied to identify the preoperative, operative, and postoperative risk factors, related to wound dehiscence. The cases were analyzed with complete review of the hospital stay, laboratory results, operative notes and bacteriological culture results. The patients nutritional status on admission was deter mined, the patients were considered malnourished if they had serum albumin level of 35 g/l and weight loss of >5 kg during the past 6 months. Obesity was defined as a body mass index (BMI)>27kg/squre meter. Jaundiced patients had a serum bilirubin level >50 mmol/l (normal 2-20 mmol/l)
and clinical jaundice .Anemia was defined as a hemoglobin value of <11g/l.The presence of peritonitis was confirmed by clinical examination and purulent exudates of the abdomen .Systemic infection was diagnosed by fever and rigor .Local wound infection was considered to be present if there was clinical signs of infection and positive bacteriological examination[6].The preoperative risk factors, the underlying diseases, the factors which increases intra abdominal pressure postoperatively and post operative mortality were recorded .The information obtained from records and by direct contact with the patients. The results of the patients were compared with control group (30 patients, of similar sex, age, and operative indication who had operation during the same period. The statistically significance of these variables were determined using chi square analysis (contingency table method), fisher exact test, and standard t test .The 95% confidence interval (CI) was used to assess the significance of the difference between the groups < 0.5 was considered significance. Results: Wound dehiscence occurred on average of 8 days postoperatively (range 3-14).The primary diagnosis in both groups included malignancy (biliary, pancreatic, and urinary),acute abdomen (intestinal obstruction, acute appendicitis, intestinal perforation, acute pancreatitis, mesenteric vascular ischemia), obstructive uropathy, biliary disorders, and miscellaneous disorders (liver rupture, colonic ileus, pelvic abscess).Table (1) shows the distribution of the primary diagnosis in both groups.
16
Table (1): shows the distribution of the primary diagnosis in both groups. Dehiscence Group (DG), Control group(CG). Primary diagnosis DG CG Malignancy(biliary, pancreatic, and urinary)
Biliary disorders 5 8 All 30 dehiscence are treated surgically and the ruptured anterior abdominal wall fascia was closed with either absorbable suture continuously in 18 patients or interruptedly in 12 patients using additional non absorbable nylon suture in 30 patients, polyglycolic acid in 11 patients polyglactin in 19 patients for facial reclosure. Three patients died (10%) within 30 days in our hospital two of them due to renal failure ,the third one due to cardiac stand still and another 3 patients (10%) died within 90 days after discharge, and their exact cause of death couldn’t be determined. Preoperative risk factors: There were 15 patients (50%) with preoperative hypoalbuminemia in the dehiscence group compared with only 10 patients (30%) in the control group (table 2) and this was significantly different (p=0.0005).Anemia was recorded in 8
out of 30 patients (26%)in the dehiscence group and 4 out of 30 patients (13.2%) in the control group(p=0.0035).Patients considered to be malnourished prior to surgery were more common in the dehiscence group 5 out of 30 (16.1%) than the control group 3out of 30 (10%); p=0.0316, as were also the patients chronic lung disease 12 out of 30 (40%)verses 4 out of 30(13.2%),respectively(p=0.026). Operative risk factors: Patients undergoing emergency operative procedure were more common in dehiscence group 22 out of 30 (70%) than in control group (10 out of 30 (30%) ;(p=0.0423). In the dehiscence group ,18 patients underwent continuous closure (polyglycolic 14 ,polyglactin 4 and 12 interrupted closures (polyglycolic 10,ppolyglactin 2) of the anterior abdominal wall where as in the control group ,the anterior fascias of 14 patients were closed with continuous sutures (polyglycolic 12 ,polyglactin 2) and that of 16 patients with interrupted sutures (polyglycolic 14,polyglactin 2)no significant difference found. The number of patients in the dehiscence group increased significantly when the number of risk factors increased from 0 to 5 (p=0.0001(Figure).In patients with 4 or 5 risk factors (8 out 11) and (11 out of 12), respectively, developed wound dehiscence. When the patients had 3,2,1, or 0 risk factors ,( 5 out of 9),(3 out of 12 ),(2 out of 13),and (1 out 3)had wound disruption respectively. Postoperative risk factors that increase intra abdominal pressure were present significantly more often in the dehiscence group.
17
The mean hospital stay in the dehiscence group was (25+_10 days), which was significantly longer than control group (11+_5 days; p=0.0001).The 30 days mortality rate in the dehiscence and control group was (10%) and (0%), respectively and 90 days mortality rate was (10%) and (3.3%) respectively. Table (2):Distribution of risk Factors between the two groups Preoperative risk factors
Sepsis 14 10 Closure in layers Continuous 18 14 Interrupted 12 16 Discussion In this study, no significant difference Could be demonstrated between the use of different types of sutures material Separate closure of the abdominal layers at the primary surgery did not influence the rate of wound dehiscence significantly. This result agrees with the result of Pollock study of randomized trial of mass versus layered closure, in 282 incisions found no difference in
dehiscence =0.7% versus 1.5%, respectively [7]. Figure (1) Number of patients at risk
Wound dehiscence is more likely to occur in elderly patients than in younger age group, this is may be due to wound disruption occurred with less force [8].The male to female ratio in this study is similar to previous reports1.2:1.0. [9]. Malignancy is also a significant prognostic factor which agrees with other studies [10,11, 12], this is due to cancer induced cachexia. Hypoprotieneimia and malnourished patients showed a preponderance of wound dehiscence, a finding that suggests Hypoprotieneimia is a very strong risk factor, which similar to Makola study [13] and this is probably due to limited supply of aminoacid required for synthesis of collagen. Emergency surgery, showed a preponderance of wound dehiscence, which quite similar to other studies like Makola study [13,14].Chronic lung
18
disease and postoperative pulmonary complication are important systemic factors that may increase intra abdominal pressure through coughing during the early postoperative period [15]. Acknowledgement: The author of this paper is very grateful for the editor Dr Al Mosawi for his help in the editing of this paper rendering it suitable for publication. References: 1-Bruce A, wound dehiscence .Surgery clinic of North America 1997; 77:529- 530. 2-Bowen A, Postoperative wound disruption and evisceratioin:An analysis of thirty-four cases with review of the literature .Am J Surg 1990; 47:3. 3-Poole GV.Mechanical factors in abdominal wound closure: the prevention of facial dehiscence .Surgery 1985; 97:631- 639. 4-Madesn G,Fischer L,Wara P .Burst abdomen: clinical features and factors influencing mortality .Dan Bull 1992;39:183. 5-Greenberg AG,Saik RPM,Peskin GW. Wound dehiscence :pathophysiology and prevention .Arch Surg 1979;114:143. 6-.Arnaud JP,Humbert W,Eloy MR,etal:Effect of obstructive jaundice on wound healing .Am J Surg 1981;141:593. 7-Pollock AV,Greenal MJ ,Evans M.Singlelayer mass closure of major laparotomies by continuous suturing .J Rsoc Med 1979;7:889. 8-Kenkin TP.The Burst abdominal wound:
mechanical approach Br J Surg 63:873 876,1976. 9-Larsen PN ,Nielsen K,Schulz A ,etal. Closure of the abdominal fascia after clean contaminated laparotomy .Acta Chir Scand 1989; 115:461-464. 10-Rubio PA ,Closure of abdominal wound ,with continuous non absorbable experience in 1,694 cases .Int Surg 1991; 76:159-160. 11-Thompson WD,Ravidan IS ,FrankIL:effect of Hypoprotieneimia on wound disruption. Arch Surg 193836:500. 12-Lawerence WT,Norton JA,Harvey AK,etal:wound healing in sarcoma –bearing rats :tumor effects on cutaneous and deep wounds.J.Surg Oncol 1987;35:7. 13- Makola JT, Riviniemi,Juvonen T ,et al .Factors influencing wound dehiscence after midline laparrotomies .Am j Surg 1995;170:387 . 14-Goodson WH III,Lindenfield SM,O.H.machi RS,et al:Chronic ureamia causes poor wound healing .Surg Forum1982;33:54. 15-Hogstrom H,Hagland U.Postoperative decrease in suture holding capacity in laparotomy wound and anesthesia .Acta Chir Scand 1985; 151:533-535
19
The New Iraqi Journal of Medicine 2006 2(1): 20 Literature Abstract Literature Abstract of Iraqi Research published in International Medical journal Acacia gum supplementation of a low-protein diet in children with end-stage renal disease.
Aamir Jalal Al-Mosawi MD,PhD. Department of Pediatrics, University Hospital Al-Kadhymiyia, Article: Pediatric Nephrology Publisher: Springer-Verlag GmbH ISSN: 0931-041X (Paper) 1432-198X (Online) DOI: 10.1007/s00467-004-1562-5 Issue: Volume 19, Number 10
Date: October 2004 Pages: 1156 – 1159 .
Abstract Patients with end-stage renal disease (ESRD) die in the absence of renal replacement therapy (RRT). In developing countries RRT is not uniformly available and treatment often relies on conservative management and intermittent peritoneal dialysis (IPD). This study investigates the possibility of using acacia gum supplementation to improve the quality of life and provide children with ESRD with a dialysis-free period. Three patients referred to our hospital with ESRD during a 3-month period were enrolled in a therapeutic trial to investigate the efficacy of acacia gum (1 g/kg per day in divided doses) as a complementary conservative measure aimed at improving the quality of life. Inclusion criteria included a pre-dialysis creatinine clearance of <5 ml/min, current dietary restrictions and supplementation, at least one
dialysis session to control uremic symptoms, absence of life-threatening complications, and sufficient motivation to ensure compliance with the study protocol. One patient complied with the protocol for only 10 days and died after 6 months, despite IPD. Two patients completed the study. Both reported improved well-being. Neither became acidotic or uremic, and neither required dialysis during the study period. Both patients maintained urinary creatinine and urea levels not previously achieved without dialysis. In conclusion, dietary supplementation with acacia gum may be an alternative to renal replacement therapy to improve the quality of life and reduce or eliminate the need for dialysis in children with ESRD in some developing countries.
Background: Renal tubular disorders may be associated vitamin D-resistant rickets, dwarfism and deformities. Treatment is non-specific and directed towards correcting acidosis, hypokalemia, hypophosphatemia and vitamin D resistance. The response to therapy depends on the severity of the disorder, and sometimes bone changes persist with the development of skeletal deformities. Patients & methods: From June 2000 to 2001, 4 patients with renal tubular disorder associated with vitamin D-resistant rickets and deformities despite previous therapies, were observed. Of these patients, 3 have hereditary (autosomal recessive) proximal renal tubular acidosis affecting siblings with perfectly normal parents and grandparents, including two sisters, and one patient has X-linked dominant hypophosphatemic rickets. All of them have at least one sibling who died affected by the same disorder. Two boys, each with proximal
renal tubular acidosis and X-linked dominant hypophosphatemic rickets were enrolled in a clinical study investigating the possibility of adding nandrolone to their conventional therapies to promote healing of rickets, provided both were males and having markedly delayed bone age together with close monitoring of bone age and careful observation for any sign of virilization. The boy with X-linked dominant hypophosphatemic rickets (Figure-1) aged 18 months at enrollment, continued to have severe active rickets with the development of kyphosis despite 5 months of combined therapy with 1-alfacalcidol and phosphate supplementation. He received seven doses of nandrolone decanoate (12.5 mg) every 4 to 5 weeks. The boy with proximal renal tubular acidosis was aged 7 years at the time of addition of nandrolone to the conventional therapies of alfacalcidol, alkali and potassium supplementation. He also demonstrated severe active rickets and worsening of his bowing deformities. He received ten injections of nandrolone (25 mg) every 2 weeks. Nutritional support was provided for both and their skeletal age was monitored biweekly. Results: The novel addition of nandrolone resulted in a perfect radiological healing of rickets and growth acceleration without the occurrence of unwanted effects or advancement of bone age. The two sisters didn’t show any clinical or radiological improvement in their rickets and one of them died within 6 months of referral. Conclusion: The judicious use of nandrolone in carefully selected patients with refractory vitamin D-resistant rickets and significant delay of bone age was associated with a beneficial effect on healing of rickets and growth without any obvious adverse effect. This beneficial effect has to be confirmed by additional trials in the future.
21
T The New Iraqi Journal of Medicine 2006 2(1): 22-26 Orthopedics he Iraqi Journal of Medicine (2005) 2(1): 22-26 Orthopedics Evaluation of new reduction technique for acute anterior shoulder dislocation. Hamza N Aboud, MD, PhD. Head of Orthopedic Department Al-KadymeiaTeaching Hospital Baghdad, Iraq E-mail: [email protected] Abstract Background: Traumatic shoulder dislocation is relatively common serious injury in sports activities, because of its inherent anatomy and biomechanics, shoulder joint is one of the most unstable and frequently dislocated joints in body, accounting for nearly 50% of all dislocations. Therefore dislocated shoulder should reduced as quickly and a gentleas possible to prevent further soft tissue damage and to maintain its normal stability by simple, harmless method of reduction. The aim of this study was to evaluate efficacy of new simple and gentle method of reduction technique for anterior shoulder dislocation. Patients and Methods: Seventeen Patients(15 men, 2 women) , their age ranging from (18 – 55) years old with traumatic anterior shoulder dislocation whom were treated by a new abduction horizontal-adduction technique, in outpatient clinic and emergency department in Al Karkh general hospital in Baghdad , over 6 months period during the year 2001.From these 17 patients, 13 patients have primary dislocations , 3 have recurrent dislocations and one patient have old neglected dislocation.
Results: 16 patients (94%) have successful reduction from the first trial by using this abduction - horizontal adduction technique, without using any anesthesia or assistance. Only one patient had reduction under general anesthesia because his dislocations associated with fracture of both greater and the lesser tuberosity, in addition to muscular body and complained from sever pain and anxiety. The follow up period of those patients for about one and half year showed no immediate complications such as (neurovascular injuries, additional fractures, nor recurrent dislocation, was reported after reduction. Keywords: Shoulder- Dislocation reduction–New technique. Introduction Traumatic shoulder dislocation is relatively common serious injury in sports activities [1], because of its inherent anatomy and biomechanics, shoulder joint is one of the most unstable and frequently dislocated joints in body, accounting for nearly 50% of all
dislocations [2].Therefore dislocated shoulder should reduced as quickly and a gentle as possible to prevent further soft tissue damage and to maintain its normal stability by simple, harmless method of reduction. Shoulder (glenohumeral) joint has small bony articulation, and glenoid fossa is a flattened dishlike structure, with only one fourth of the large humeral head articulate with glenoid at any given position[3] The small , flat glenoid bony area, does not provide inherent stability for humeral head as the acetabulum does for the hip. But the glenoid deepened further more about 50% by presence of glenoid labrum which increase the humeral head contact to about 75%. The shoulder joint can perform greater freedom of movement with a considerable loss of stabilization. Patients and Methods Seventeen Patients (15 men , 2 women) ,their age ranging from (18 – 55) years old with traumatic anterior shoulder dislocation whom were treated by abduction – horizontal adduction technique, in outpatient clinic and emergency department in Al Karkh general hospital in Baghdad , over 6 months period during the year 2001.From these 17 patients, 13 patients have primary dislocations, 3 have recurrent dislocations and one patient have old neglected dislocation. Dislocation was diagnosed clinically and radiologically before reduction. Each patient was placed in supine position on examining table to start reduction by reassurance of patient and to make him relaxed as much as possible without
any medication. With the physician standing on the side of the dislocation, holding the wrist of dislocated shoulder by one hand to start gently and slowly abduction of extended upper extremity, till reach 90 0 of abduction, avoiding as possible patient discomfort during abduction, the patients felt some what anxious about this maneuver, but they didn’t experience severe pain. Now at 90 0 abduction , with the same physician’s hand gentle axial traction with horizontal adduction applied to extended upper extremity of patient while the thumb of other hand placed against humeral head to check reduction plus applying some pressure to assist reduction till reduction done, which often complete with this step in about 450 of horizontal adduction. , lastly the arm was brought down to the side for checking joint mobility and then immobilized with sling and swathe. Figure (1). Results: 16 patients (94%) have successful reduction from the first trial by using this abduction – horizontal adduction technique, without using any anesthesia or assistance. Only one patient had reduction under general anesthesia because his dislocation associated with fracture of both greater and the lesser tuberosity, in addition to muscular body and complained from severs pain and anxiety. The follow up period of those patients for about one and half year showed no immediate complications such as (neurovascular injuries, additional fractures, nor recurrent dislocation).
23
.
24
Discussion Analysis of reduction mechanism: at 60º abduction of affected upper extremity, scapula was slightly rotated compared with starting position and with continued upward elevation up to 90º abduction, scapula will shift more anteriorly with superior rotation along thoracic wall. With horizontal adduction, scapula reach maximum shifting anteriorly and rotating superiorly leading the humeral head to be externally rotated and then reduce at this point .The anatomy of the shoulder joint reveal three kinds of structures and factors which can play role in shoulder joint stability such as, capsular ligaments and four muscle groups in addition to scapular mobility and other factors [1, 3].From biceps tubercle at superior rim of glenoid and passes distally in the biciptal groove, guides the dislocated humeral head moves in direction of glenoid fossa during final stages of reduction. So the long head of biceps tendon seems to have important role in this reduction technique along with the musculotendinosus units of rotator cuff and scapular shifting and rotation. Milch H reported [4] that the complete overhead abduction is the only position in which a simple force, exerted along the axis of humerus is directed to overcome each and all muscle action at the same time, so the overhead position aligns the shoulder musculature and minimizes muscle spasm, there by increasing comfort and facilitating reduction. Recently , many authors have described numerous techniques to reduce a dislocated shoulder because the old methods of reduction such as Hippocratic technique or kocher
leverage technique , although they are still effective but frequently fails in muscular and obese patients and some times produced iatrogenic humeral neck fractures in elderly patients and may injure other soft tissue such as anterior capsule , glenoid labrum and neurovascular structures which may lead to further complications and shoulder instability[5,6,7,8,] By comparing the results of Hiromoto. et al[9] who reported 91% success rate (41 from 45 dislocations) reduced successfully, with our results with 94% success rate (16 from 17 dislocations reduced successfully).This new reduction technique can give good results when used properly. Further more most methods required general anesthesia and assistant , while this method of reduction , maintain or provide simple maneuver without using assistance or analgesia minimizes further soft tissue damage and can be easily done in obese or muscular patients. References 1-Williams JGD. A Colour Atlas of Injury in sport (Wolfe medical publications, London 1980). 2-Simonest WT, Melton, LJ ІІІ, Cofield RH, Ilstrup DM.Incidence of anterior shoulder dislocation in Olmstead County, Minnesota, Clin .Orthop. 1984,186: 186. 3-Anderson D,Zvirbulis R,Ciullo I .Scapular manipulation for reduction of anterior shoulder dislocations. Clin Orthop.1982; 164: 181 -183.
25
4-Milch H.Treatment of dislocation of the shoulder .Surgery 1938 ; 3 : 732-740. 5-Beattie TF, Steedman DI, McGowant A , Robertson CE. A comparison of the Milch and Kocher techniques for acute dislocation of the shoulder. Injury,1986: 17: 349-352. 6- Oni OOA: Irreducible acute anterior dislocation of the shoulder due to a loose fragment from an associated fracture of the greater tuberosity, Injury1983, 15: 138. 7-Seadge H., OrmG .Acute irreducible
anterior dislocation of the shoulder, J.Trauma 1982; 22: 330. 8-Rosson.CR. Pierce DS, Clark JG Voluntary dislocation of the shoulder. Journal of Bone and Joint surgery 1973, 55A, 445-460. 9-Hiromoto Ito, Akinori Takayama, Yasumasa Shirai, M. Abduction-and Horizontal-Adduction Technique for Reduction of Acute Anterior shoulder dislocations; A simple technique evaluated with radiographs. Am Journal Orthopedic 2001; 201-204.
26
The New Iraqi Journal of Medicine 2006 2(1): 27-30 Nephrology The Etiology of chronic renal failure in a sample of Iraqi patients: Lower incidence of diabetes and hypertension related renal failure. Aamir Jalal Al Mosawi MD,PhD. Consultant of pediatrics and nephrology University Hospital in Al Kadhymiyia PO Box 70025 Baghdad Iraq E-mail: [email protected] Abstract Background: Chronic renal failure (CRF) is a pathophysiologic process with multiple etiologies, resulting in the inexorable attrition of nephron number and function, and frequently leading to end-stage renal disease (ESRD).The etiology of renal failure may vary according to the country of origin and little is known about the etiology of chronic renal failure (CRF) in Iraq because of the lack of central reporting agency. The aim of this study is to determine the etiology of CRF in a sample of Iraqi patients. Patient and Methods: From 2001 to October 2005 50 patients, 33 males (66%) and 17 females (34%), with chronic renal failure were referred to a single consultant (of pediatrics and nephrology). Their ages ranged from 6 months to 81 years (Mean: 28.5). Results: The 3 most common causes are different with chronic GN accounts for 28%, hereditary nephropathies and genetic syndromes (20%), and congenital abnormalities (16%). Conclusion: The causes of CRF in Iraqi patients differ markedly from the causes in the western societies with markedly
lower incidence of diabetes and hypertension related renal failure. Keywords: Chronic renal failure-Iraqi-Patients. Introduction Chronic renal failure (CRF) is a pathophysiologic process with multiple etiologies, resulting in the inexorable attrition of nephron number and function, and frequently leading to end-stage renal disease (ESRD).the incidence and prevalence of ESRD has increased during the last decade in many areas of the world Whereas glomerulonephritis was the leading cause of CRF in the past, diabetic and hypertensive nephropathy are now much more frequent underlying etiologies in adult patients in Western societies[1,2,3,4].The etiology of renal failure may vary according to the country of origin and little is known about the etiology of chronic renal failure (CRF) in Iraq because of the lack of central reporting agency[5]. The aim of this study is to determine the etiology of CRF in a sample of Iraqi patients.
Patient and Methods From 2001 to October 2005 50 patients, 33 males(66%) and 17 females(34%) , with chronic renal failure were referred to a single consultant (of pediatrics and nephrology). The patients were observed at the University hospital in Al Kadhymiyia an Al Mosawi private clinic at Al Kadhymiyia. The male to female ratio was 1.94. Patients came mainly from 5 provinces of Iraq including Baghdad,Al Anbar,kirkuk,AlBasraha,andAlNasiriyia. Their ages ranged from 6 months to 81 years (Mean 28.5). Six (12%) patients were under the age of 5 years, 13 patients(26%) their age ranged from 5 to 15 years, 11 patients(22%) their age ranged from 16 to 30 years, 9 patients(18%) their age ranged from 31 to 50 years,11 patients(22%) were above 50 years. Figure (1) shows age distribution of patients with CRF.
0
5
10
15
Age distribution ofpatients w ith CRF
Under 5 years
5-15 years
16-30 years
30-50years
51-81 years
Figure (1): Age distribution of patients with CRF Results There were 14 patients with chronic glomerulonephritis (GN).A presumptive diagnosis of GN was made by the presence of albuminuria/or hematuria
(+granular casts).Three of them each has biopsy proven focal segmental glomerulosclersis(FSGS),Membranoproliferative GN(MPGN),and rapidly progressive GN(RPGN) respectively. Two of them have SLE and GN, and they didn’t underwent renal biopsy. Ten patients have CRF caused by hereditary nephropathies and genetic syndromes including 3 patients with nephronophthisis,3 patients with nephropathic cystinosis,2 patients with adult polycystic kidney disease, and 3 patients each with polycystic disease of kidneys and liver, primary oxalosis,and oculo-cerebro-renal syndrome. Four patients have CRF caused by renal stone disease. Eight patients have CRF caused by congenital abnormalities including single kidney and unilateral hypoplasia, ectopic hypoplastic kidney with infection or obstruction, and neurogenic bladder. Two patients have reflux nephropathy. One patient has diabetic nephropathy and one patient has bladder cancer. The cause of CRF was undetermined in 10 patients. Table (1) summarizes the etiology of CRF in this sample of Iraqi patients. 21 patients didn’t underwent dialysis before referral,26 patients were treated with IPD, and 4 patients were on regular or intermittent HD including one patient initially treated by IPD.One patient was observed after failure his transplanted kidney ,in whom transplantation was proceeded by IPD.One patient was transplanted few weeks after referral ,but died about one month after transplantation. The patients were followed for variable periods, and it was not possible to follow many patients for a long time. During this period of
28
observation 11 patients died from uremia. mainly because of a lack of proper facilities of renal replacement therapies. Table (1):The etiology of CRF in a sample of Iraqi patients. Chronic GN 14(28%)Non specific SLE FSGS MPGN RPGN
Congenital abnormalities: single kidney and unilateral hypoplasia, ectopic hypoplastic kidney with infection or obstruction, and neurogenic bladder.
8(16%)
Undetermined 10(20%)Renal stone disease 4 (8%) Reflux nephropathy. 2 (4%) Diabetic Nephropathy 1 (2%) Bladder cancer 1(2%) Discussion CRF is a major health issue in various parts of the world. There has been a dramatic increase in the incidence of ESRD as well as a shift in the relative incidence of etiologies of CRD during the past two decades in many areas of
the world. Whereas glomerulonephritis was the leading cause of CRF in the past, diabetic and hypertensive nephropathy are now much more frequent underlying etiologies. This may be a consequence of more effective prevention and treatment of glomerulonephritis or of diminished mortality from other causes among individuals with diabetes and hypertension.[1,2,3,4]. The 3 most common causes of ESRF are diabetes related ESRF (42.3%),hypertension (25.8%),and GN (10.8%).In this sample of Iraqi patients, the 3 most common causes are different with chronic GN accounts for 28%, hereditary nephropathies and genetic syndromes (20%),and congenital abnormalities (16%). CRF was commoner in females in this sample. However this observation was similar to the observation in other countries[1,2]. Conclusion: The causes of CRF in Iraqi patients differ markedly from the causes in the western societies with markedly lower incidence of diabetes and hypertension related renal failure. Reference 1-U.S.Renal Data System,USRDS 1998 Annual Data Report. National Institute of Health. National Institute of diabetes and digestive and kidney diseases,Bethesda,MD,April 1998. 2-16-US renal Data system:USRDS 2004 Annual Data Report. The National Institute of Health. National Institute of diabetes and digestive and kidney diseases,Bethesda,MD,2004.Available at
29
:http://www.usrds.org.accessedApril27 2005. 3-Whelton PK The evolving epidemic of cardiovascular and renal diseases: a worldwide challenge.Curr Opin Nephrol Hypertens 1995; 4:215-217.
4-Port FK.End-stage renal disease: Magnitude of the problem, prognosis of future trends and possible solutions. Kidney Int 1995; 48:S3-S6. 5-AL-Mosawi AJ. The etiology of chronic renal failure in 54 Iraqi children. Pediatr Nephrol 2002; 17: 463-464.
30
The New Iraqi Journal of Medicine 2006 2(1):31-34 Psychiatry The phantom limb Ali Rzuki Ghazi Aboud Mohammad Rzuki Psychiatrist Psychiatrist Orthopedics,Assistant Prof Al-Yarmok Hospital Al-Rashad Hospital Al Koofa Medical College Baghdad,Iraq Baghdad,Iraq Al Najaf ,Iraq Abstract Background: Phantom limb (PL) is the subjective sensation that an amputated limb is still present and sometimes referred to as stump hallucination, but often , they are very painful, resulting in another condition called phantom pain. The aim of this study is to study the clinical experience with phantom limb and to evaluate the value of medical and psychological treatment. Patients and methods: 163 amputated patients were selected randomly at Baghdad Handicapped Centers, Al-Rasheed Military hospital, and Middle Euphrates Handicapped Centers and Al Najef General Hospital. 134 (82%) were males and 29 (18%) were. Females Their age ranged from 15 to 68 years. Demographic, social and clinical data were collected by medical personal through a clinical interview. Results: 91% of the amputees were in the lower limb and the majority. 45% of amputations were below knee, 27% were above knee and 20% were through the ankle joint. 66% of amputations were caused by war injuries, 22% were caused by accident and 12%were caused by disease.119 patients (73%) have phantom limb phenomena (PLP) since the amputation and 18 patients (11%) developed it after a while. 84% of our sample suffered from PLP.. The duration of PLP varies from few days up to 5 years.
Key words: amputation-phantom limb Introduction Phantom limb (PL) is the subjective sensation that an amputated limb is still present and sometimes referred to as stump hallucination, but often, they are very painful, resulting in another condition called phantom pain .A painful phantom may persist indefinitely and cause much distress. The French surgeon Ambriose Pare first coined the term phantom limb in the sixteenth century, later Silas Weir Mitchell ( American neurologist) described phantom pains during the Civil War 1872.[1,2]When a condition or an accident occurs that causes a limb to be severed or to be removed surgically, there is a good chance of phantom sensation and pain. Sensation from an amputated limb can manifest themselves in many different ways such as sensation of touch. Sometimes an amputee is able to feel their arm resting on a table, their fingers able to feel the texture of the table or they can feel the absent limb in movement possibly reaching for a glass. Associated complaints of tingling, prickling and shooting pains have been reported. Some patients experience a pain they had previous to the amputation, such as an in growing toenail.
31
The pain is not usually constant [3]It is widely accepted that over 90% of all patients have some sensation after surgery or accident [4].The actual pain and sensation has to deal with the thalamus and the memory of feeling the limb from the past. Eighty percent of all amputated patients experience phantom pain or a sensation.[5] Sherman etal have reported that amputees reluctant to divulge their complaints of phantom limb pain for fear of being labeled insane [6].When a person's limb gets amputated, the severed nerves in the stump grow into nodules called neuromas. Early physicians believed that the neuromas fired randomly, sending signal, to the spinal cord to the thalamus and then to the somatosensory cortex, eventually causing the phantom limb sensations including the phantom pain. Drugs have been tried in PL include Beta blockers,CNS serotonin agonists, the tricyclic antidepressants and Calcitonin[4].Melzack reported that neurosurgical treatment of the dorsal column stimulation procedure” in which electrodes are implanted surgically in the spinal cord may work for a while ,but pain often returns"[7]. Patients and methods: 163 amputated patients were selected randomly at Baghdad Handicapped Centers, Al-Rasheed Military hospital, and Middle Euphrates Handicapped Centers. and Al Najef General Hospital. 134 (82%) were males and 29 (18%) were. Females Their age ranged from 15 to 68 years.
Demographic, social and clinical data were collected by medical personal through a clinical interview.141 patients (87%) were married, the other 22 (13. %) were single. Results: 73 patients (45%) have below knee amputation,44 patients (27%) have above knee amputation .32 patients (20%) have through ankle amputation,4 patients (2%) have above elbow.4 patients (2%) have below elbow amputation, and 6 (4%) have other types of amputation. Figure (1).In 107 patients (66%) the amputation were caused by war injury. in 36 patients (22%) caused by accident, and in20 patients (12%) caused by disease. Figure (2 )shows the causes of amputation.137patients (84%) got phantom limb phenomena, 119 of them since the amputation while 18 patients got it after a while.The duration of the phantom limb phenomena ranged from few days to more than 5 years. Table ( 2) shows the onset of the delayed PLP.
Table (1): The duration of PLP No. of patients Duration 90 Less than 1 year 36 1 - 5 years 5 More than 1 year 6 Intermittent Total 137
32
Figure (1): Types of Amputation Type of amputation
Table( 2) shows the onset of the delayed PLP. No. of patients Onset 5 After 1 - 6 months 9 After 1 year 4 More than 1 year TOTAL 18 108 patients asked a general practitioner for treatment of their condition with 22 patient of them consulted psychiatrist later. Table (3) shows the response to treatment.
Table (3): Response to treatment Treatment provided by
No. of patients Response
General practitioner
27 Complete resolution
49 Partial improvement
32(Total 108) No benefit Psychiatrist 2 Complete
resolution 15 Partial
improvement 5 No benefit TOTAL 22 Discussion In this series the majorities (66%) of amputees were caused by war injuries because our country was involved in successive wars since 1980 till now, while other causes of amputees were accidental in 22% and 12% were caused by disease process. The incidence of PLP among amputated patients in this series was 84%, However the previously reported incidence was inconsistent and ranging from 0.5 to97% [4, 5].The relatively high percentage above reflect that our Iraqi patients feel no fear or shame about having PLP because it is not considered as stigma (being labeled as insane),and this type of compliant was acceptable socially. So they differ from
33
other people who reluctant to divulge their complaint. [5]. References: 1-http://www .library.ucla.edu/ libraries /biomed/his/painexhibit/pane14.htm. 2-http://dubinserver. colorado.edu/mos /os good3.htm. 3.-http://www.webdiner.com. 4-Kamen, Leonard: Chapis.Gregory. Prosthetics: phantom limb sensation and phantom pain. Physical Medicine and Rehabilitation: state of the Art Reviews,Vol 8,1994:54%-88. 5-http://www. bbsonline. Org/documents /a/00/00/12/50/bbs0000 1250-00/phantom Paper.htm.
6-Sherman,RA.Published treatments of phantom limb pain. Am J of physical Medicine.Vol 59,(5),1980:232-243.
7-Melzack ,Ronald. phantom limbs .Scientific American, April 1992:pf 20-126.
34
The New Iraqi Journal of Medicine 2006 2(1): 35 -36 Practical experiences Silk granuloma at gastrointestinal anastomosis stoma.
Abdul Redah AL-Rawaf Consultant surgeon. Depatment of surgery University Hospital in Al Kadhymiyia
Abstract Silk granuloma has been reported as benign complication seen after surgery. Suture granuloma can occur many months or years after the primary surgical procedure. The most common suture causing tissue irritation and subsequent granuloma is probably the silk (non-absorbable suture ) especially braided one. The diagnosis in cases of granuloma occurring at gastrointestinal anastomosis stoma is generally made at endoscopic examination. The aim of this paper is to report the cases of stitch granuloma observed at upper gastrointestinal endoscoy. From January 1987 to October 1987 100 patients were referred for upper gastrointestinal endoscoy for various reasons. Silk granuloma at gastric side of gastrointestinal anastomosis stoma for duodenal ulcer operation were found in 7 patients (7%).All of the patients were treated by removal of silk by endoscopic forceps. Keywords: Stitch-Silk granuloma-postoperative-anastomosis-endoscoy. Introduction
Silk granuloma has been reported as benign complication seen after surgery. Suture granuloma can occur many months or years after the primary surgical procedure. The
most common suture causing tissue irritation and subsequent granuloma is probably the silk (non-absorbable suture ) especially braided one. The granuloma presents as a chronic intermittent indolent infection commonly known as stitch abscess. The diagnosis in cases of granuloma occurring at gastrointestinal anastomosis stoma is generally made at endoscopic examination . Monofilament and recently manufactured absorbable suture has been associated with a lower risk of infection. Curative treatment is removal of the infected suture material (silk) by endoscopic biopsy forceps [1,2,3,4].
Patient and Methods
From January 1987 to October 1987 100 patients were referred to us at the University Hospital in Al Kadhymiyia for upper gastrointestinal endoscoy for various reasons.
Results Silk granuloma at gastric side of gastrointestinal anastomosis stoma for duodenal ulcer operation were found in 7 patients (7%),they were located at gastric site of the stoma with evidence of ulceration and easy bleeding glaucomatous area. All of the patients were treated by removal of silk by endoscopic forceps
35
Discussion
Most of the surgeons in Iraq are treat duodenal ulcer when necessary by vagotomy and drainage operation (pyloplasty or gastro-jejunostomy). In both these types two layers anastomosis are applied, the inner absorbable and outré non- absorbable (silk) sutures, both of continuous layers. The outer silk layer form non-elastic ring like band around the anastomosed stoma. By time and with action of peristaltic movement, this band pushed from the outer sero-muscular layer toward inner sub-epithelial layer, with it's irritating effect and tissue reaction forming granuloma. Therefore intra abdominal contamination with foreign material should be minimized. Silk granuloma can occur in the bronchial stump after lung resection, in the lung parenchyma after segmentectomy or as a paravesical mass or abscess after inguinal hernia repair .The use of synthetic absorbable sutures especially those with delayed absorbable monofilament sutures such as polydioxanon (PDS), Maxon ( polyglyconate), ,polycolic sutures( Dexon), polyglatid sutures(vicryl), poliglecapron monofilament( Monocryl) ,and poliglecapron braided sutures ( panacryl) could possibly lower the incidence of stitch granuloma as they elicit lower tissue reaction and lower affinity for bacteria as well as fair knot security than natural absorption [1,2,3,4].
References
1-Lynch TH, Waymont B, Beacock CJ, Wallace DM: Paravesical suture granuloma: a problem following herniorrhaphy. J Urol 1992; 147(2):460-2.
3-Brunsvold MA, Reding ME, Kornman KS: Infected suture granuloma: a case report. Int J Oral Maxillofac Implant 1991; 6(2):215-7.
4- Wada,H. Kubota, M. Taketa,H. Miura etal.Comparison Of The Mechanical Properties Of PolyglycolideTrimethylene Carbonate ( Maxone) And Polydioxanone Sutures (Pds2) Used For Flexor Tendon Repair And Active Mobilization A. Japan J of Hand Surg 2002 (British & European ) 27B:4:329-332.
36
The New Iraqi Journal of Medicine 2006 2(1):37-38 Editorial Silk granuloma:Editorial commentary. Aamir Jalal Al Mosawi MD,PhD. Consultant physician Editor in chief, The N Iraqi J Med University Hospital in Al Kadhymiyia In this issue of The New Iraqi journal of Medicine,Dr Al Rawaf reported his endoscopic experience with stitch (silk granuloma) at gastrointestinal anastomosis stoma following duodenal ulcer operations.Dr Al Rawaf was too late in his decision to publish the observation he made during the years 1986 and 1987.However,I have made clear that the policy of this journal is to publish papers that could add something to the body of the available literature. Searching the PubMed for stitch granuloma,suture granuloma,and silk granuloma it was possible to find only 14 relevant papers [1,2,3,4,5,6,7,8,9,10,11,12,13,14]published during over 30 years period. Stitch granuloma have been reported following pediatric herniotomy[1,2], after thyroid surgery[3],and colorectal surgery [4,5,6],and following radical retropubic prostatectomy, and after an appendectomy [14]. The observation of Dr Al Rawaf that stitch granuloma associated mostly with the use of silk agrees with report of Kronborg O.who suggested that the use of polyglycolic acid (Dexon) instead of silk for fascial closure of abdominal incisions would reduce the rate of granulomas without an accompanying increase in rate of wound dehiscences. The two sutures were evaluated in a triple blind, randomized
trial, using the paired sample principle in patients subjected to elective gastrointestinal surgery. One gram of Pentrexyl powder was applied to the subfascial space in all the patients and the wounds were examined 10 days, 1 and 3 months after the operations. The trial was terminated when a closed sequential analysis had shown a significantly higher rate of dehiscences after closure with silk (12/163) than after closure with polyglycolic acid (1/163). Seven patients had granulomas after silk and one after polyglycolic acid at that time. Postoperative wound infections occurred in 7 patients after silk and 8 after polyglycolic acid. Kronborg O concluded that the use of polyglycolic acid (Dexon) nearly eliminates the risk of suture-granulomas, without increasing the risk of wound dehiscences; on the contrary, the rate of dehiscences was lower after polyglycolic acid[4]. In one retrospective 10-year study of herniotomies performed by a pediatric surgical service. Twenty children developed stitch granulomas following herniotomy. In all cases, silk sutures had been used in the repair. Masses appeared 1-10 years following surgery and were demonstrated by preoperative US in 17 patients, by CT alone in 1 patient and by both CT and US in 2 patients [2].To my
knowledge this is the first paper reporting the occurrence of silk granuloma at gastrointestinal anastomosis stoma following duodenal ulcer operations. References 1-Nagar H, Kessler A, Graif M. The role of ultrasound in the diagnosis of stitch granlomas following paediatric herniotomy. Pediatr Radiol. 1999 Nov;29(11):803-6. 2-Nagar H. Stitch granulomas following inguinal herniotomy: a 10-year review. J Pediatr Surg. 1993 Nov;28(11):1505-7.
4- Kronborg O. Polyglycolic acid (Dexon) versus silk for fascial closure of abdominal incisions. Acta Chir Scand. 1976;142(1):9-12.
5-Sanders I, Woesner ME. "Stitch" granuloma: a consideration in the differential diagnosis of the intramural gastric tumor. Case report. Am J Gastroenterol. 1972 Jun;57(6):558-62.
6-Belleza NA, Lowman RM. Suture granuloma of the stomach following total colectomy.Radiology. 1978 Apr;127(1):84.
7-Baba K, Nagao K, Matsuda M, Nishimura R, etal. An operative case of suture-granuloma which resulted from an intra-pulmonary treatment 10 years ago and manifested hemoptysis]
Kyobu Geka. 1996 Nov;49(12):1048-51. Japanese
8-Carroll KM, Sairam K, Olliff SP, Wallace DM. Case report: paravesical suture granuloma resembling bladder carcinoma on CT scanning. Br J Radiol. 1996 May;69(821):476-8.
9-Brunsvold MA, Reding ME, Kornman KS. Infected suture granuloma: a case report. Int J Oral Maxillofac Implants. 1991 Summer;6(2):215-7.
11-Muzafer M. Silk granuloma.Br J Clin Pract. 1985 Sep;39(9):367-8.
12-Manor A, Kaffe I. Unusual foreign body reaction to a braided silk suture: a case report. J Periodontol. 1982 Feb;53(2):86-8.
13-Marcus VA, Roy I, Sullivan JD, Sutton JR. Necrobiotic palisading suture granulomas involving bone and joint: report of two cases. Am J Surg Pathol. 1997 May;21(5):563-5.
14-A case of suture granuloma occurring 25 years after an appendectomy. J Dermatol. 2003 Aug;30(8):634-6. Ichimiya M, Hamamoto Y, Muto M.
