Vol 22, No 2 (2018)

Background and objective: A pterygium is a triangular fibrovascular subepithelial ingrowth of degenerative bulbar conjunctival tissue over the limbus onto the cornea. Excision is indicated if the pterygium approaches the visual axis, causing loss of vision from irregular astigmatism or in cases of considerable irritation. This study aimed to determine the percentage of astigmatism in patients presented with pterygium and measure the effect of size (width and height) of pterygium on a degree of astigmatism and indication of early surgery.

Methods: A hospital based cross-sectional study using non-probability convenience sampling was conducted in the ophthalmology department of Rizgary and Erbil teaching hospital in Erbil city from June 2015 to February 2016. Ninety-six eyes of eighty patients with pterygium were included in this study.

Results: The mean age ± SD of the 80 patients included in the study was 37.5 ± 9.62 years ranging from 22-58 years. There were 45 male and 35 female patients. Two-thirds of eyes (72.6%) had with-the-rule astigmatism while 12.6 % of eyes had against-the-rule astigmatism. A highly significant strong correlation was seen between a fraction of corneal area encroached by pterygium with induced astigmatism (r = 0.727, P <0.001). A highly significant strong correlation was found between the area of pterygium and corneal astigmatism in a case of severe pterygium (pterygium encroaching > 4 mm area on the cornea) (r = 0.802, P <0.001).

Conclusion: Pterygium size has a significant correlation to the amount of induced astigmatism. The correlation is stronger in the pterygia of severe degree (>4 mm) as in this group they are encroaching on the visual axis.

Background and objective: Knowing the rate and indications of the cesarean section will help to have an overview of this common type of obstetrical procedure and to plan for the high level of care management. This study aimed to find out the rate of cesarean section and to identify its indications.

Methods: A cross-sectional study was conducted at the Maternity Teaching Hospital in Erbil city of Kurdistan Region, Iraq. Data were collected during the period of 20^th of March to 30^th of December 2015 by an interview with 722 women who were admitted to the hospital and underwent cesarean section out of 11881 cesarean section done during 2015.

Results: Results showed the increasing rate of the cesarean section from 28.5% in 2010 to 35.77% in 2015. The main overall indications for cesarean section were a previous cesarean section (70.49%), cephalopelvic disproportion (35.31%) and mother’s request (14.26%).

Conclusion: Rate of cesarean section is much higher than the optimal range recommended by the World Health Organization. Finding the appropriate strategies for decreasing the rate of primary and secondary indications is essential.

Background and Objective: Antepartum hemorrhage is one of the major causes of obstetric hemorrhage and contributes to significant maternal and perinatal morbidity and mortality especially in developing countries with low resources and facilities. This study aimed to determine the incidence, to estimate maternal and perinatal outcome in relation to the types of antepartum hemorrhage, and to find out factors affecting the perinatal outcome.

Methods: This cross-sectional study was carried out from February 1^st to August 1^st, 2016, at the Maternity Teaching Hospital, Erbil city, Kurdistan region, Iraq. The study included 343 pregnant ladies presented with antepartum hemorrhage after 28 weeks gestation.

Results: The incidence of antepartum hemorrhagein our study was 2.34%. Placenta previa was the commonest type of antepartum hemorrhage 58%, followed by abruption placenta 36.7%. Placenta previa was most commonly occurred in women with previous caesarean scar (91%) and those with previous curettage (77%), while abruptio placentae was most commonly associated with preeclampsia (72.9%), previous antepartum hemorrhage (66.7%) and parity ≥ 5 (51.2%), Most cases of placenta previa (94.4%) delivered by caesarean section while this figure was 57.1% for abruption. Perinatal mortality in our study was 23.64%. Increasing birth weight and cesarean delivery were significantly associated with lower perinatal mortality.

Conclusion: Antepartum hemorrhage was associated with high maternal and perinatal mortality and morbidity. Placenta previa most commonly developed in women with previous uterine surgeries. In contrast, abruptio placentae developed mostly in grand multiparous women and those with preeclampsia. Most perinatal deaths occurred in babies with small gestational ages(<34 weeks), low birth weight babies(< 2.5 kg), and those who delivered vaginally.

Background and objective: Placental insufficiency is the primary cause of intrauterine growth restriction in normally formed fetuses and can be identified using middle cerebral artery to umbilical artery ratio Doppler velocimetry, and provide an estimate of downstream placental vascular resistance and placental blood flow. There is a strong association between reduced end-diastolic umbilical artery blood flow velocity and increased vascular resistance in umbilical placental microcirculation. Doppler ultrasound can assess the uteroplacental blood flow just before labor. This study aimed to investigate the use of the fetal cerebroumbilical ratio to predict the intrapartum fetal compromise in appropriately grown fetuses.

Methods: A comparative cross-sectional study set at Sulaimania Maternity Teaching Hospital, Sulaimania, Iraq, from January to June 2015. The study recruited 121 cases, fetal biometry and Doppler indices were measured before established labor. The intrapartum and neonatal outcome details recorded.

Results: Infants delivered by cesarean section for fetal compromise had significantly lower cerebroumbilical ratio than those born by spontaneous normal (none assisted) vaginal delivery and by cesarean section for other intrapartum causes. Infants with cerebroumbilical ratio <10^th percentile were more likely to be delivered by cesarean section for fetal compromised than those with a cerebroumbilical ratio > 10^th percentile. A cerebroumbilical ratio >90^th percentile appears protective against cesarean section for fetal compromise. Amniotic fluid index of < 5 was associated with an increased cesarean section for fetal indication.

Conclusion The cerebroumbilical ratio can identify fetuses at high risk of intrapartum fetal compromise. As a confounding variable, the amniotic fluid index was a useful tool for surveillance in prolonged pregnancy.

Background and objective: Chronic Rhinosinusitis characterized by inflammation of the mucosa of the nose and paranasal sinuses. The degree of sinonasal inflammation as measured by CT- scan or endoscopy fails to correlate with the extent of symptoms experienced by the individual patient. This study aimed to evaluate the effect of functional endoscopic sinus surgery in improving symptoms profile and quality of life for patients complaining of chronic rhinosinusitis.

Methods: A prospective clinical study extended from January 2013- January 2015 & included 30 patients above 18 years old of chronic rhinosinusitis without polyp who were treated by functional endoscopic sinus surgery. The data were collected and interpreted using Sinonasal Assessment questionnaire -11 (SNAQ-11).

Results: A total of 30 patients were included in the study; 18 patients were males (60%), and 12 patients were females (40%). Most of the patients (40%) were among the age group 25-34 years. The result shows no significant association between age and mean difference in SNAQ-11 score. The main preoperative complaint of our patients was the nasal obstruction (100% of patients), followed by nasal congestion (93.3%), and least complaint was sneezing (20%) and earache (20%). There was a statistically significant association between the patient's symptoms and SNAQ-11 score with a significant reduction in the total SNAQ-11 score after surgery.

Conclusion: Functional endoscopic sinus surgery performed for chronic rhinosinusitis cases has been associated with significant improvement in the quality of life after 12 months follow up & the best outcome was for nasal obstruction.

Background and objective: Approximately one in third of pregnant women experience discomfort, pain and or vaginal bleeding during the first trimester of pregnancy. Ultrasound is known to be a useful tool in detecting and diagnosing the viability of the fetus but it is sometimes inconclusive. In cases in which pregnant women experience symptoms of discomfort, serum progesterone may be admitted to the patient for counseling and prediction of the continuity of pregnancy. This study aimed to estimate the relation between single serum progesterone level and the viability of the fetus during the first trimester.

Method: A prospective study was carried out in Maternity teaching hospital-Erbil city to estimate the accuracy of single serum progesterone measurement for the prediction of fetal viability at the end of the first trimester. All the cases have been detected by ultrasound device that has been for women who attended the hospital and reported the feeling of discomfort, pain and bleeding early in the first trimester of pregnancy, serum progesterone level of the patients were compared between viable and nonviable fetuses.

Results: A total of 97 participants were involved in this study; 57 participants had a viable pregnancy at the end of the first trimester, and 40 participants had un-viable pregnancy that has been terminated either by spontaneous abortion or termination performed for missed abortion. The mean of serum progesterone level in viable pregnancies was (19.358 ng\ml) when compared with the non-viable pregnancies which were (11.082 ng\ml). The differences were statistically significant (P <0.001). The cut-off value (13.68ng\ml) provides the highest sensitivity and specificity.

Conclusion: A single serum progesterone measurement was regarded as a reliable test for the prediction of viable and non-viable pregnancy in women who reported to be experiencing pain and bleeding in the early trimester of pregnancy with or with inconclusive ultrasound.

Background and objectives: Estimation of fetal weight is an important component of maternity health care, especially in the management and planning of the delivery mode, and this will play a big role in newborn and maternal safety. This study has been carried out for providing more knowledge about the accuracy of fetal weight estimation by ultrasound and its correlation with actual weight after birth.

Methods: This study was performed in the Radiology Department of the Maternity Teaching Hospital in Erbil city on 407 pregnant women with singleton and in term pregnancies from May 4^th, 2015 to April 10^th, 2016. The ultrasound examination typically involved estimating fetal weight by using both Hadlock’s and Shepard’s formula, and the actual birth weight of each participant’s neonate was measured immediately after delivery by using a standardized neonatal weighing scale. This study was approved by the Research Ethics Committee of Hawler Medical University.

Results: Statistical analysis by t-test indicated that there was a significant difference between the actual birth weight and sonographic estimation of fetal weight using both formulas. The correlation between actual birth weight and sonographic estimation by Hadlock's formula was (R=0.869) while it slightly declined when Shepard’s formula was used (R=0.805). Hadlock's formula showed a better relation with actual fetal weight. This study was showed higher correlation when the time of estimation was within seven days of delivery time, and it was about (R=0.921), and when the time of estimation became more than seven days from delivery, it was showed less correlation (R=0.811).

Conclusion: Hadlock’s formula for estimation of fetal weight by ultrasound showed more accurate results, particularly within a time less than seven days from delivery date.

Background and Objective: Posttraumatic stress disorder is a psychiatric disorder that occurs in people who have experienced or witnessed a life threatening event. This study aimed to assess the prevalence and risk factors of posttraumatic stress disorder among Syrian refugees in Domiz Camp in Duhok City.

Methods: Through a cross-sectional study, 500 Syrian refugees were interviewed using the Posttraumatic Stress Disorder Checklist Civilian version (PCL-C) which was translated into the Arabic language. The sample was selected randomly. Refugees who were 20 years old and older and from both sexes were included, and those with severe medical diseases and serious psychiatric diseases (psychotic conditions and mentally retarded) were excluded. Data analysis had been done using the statistical package for the social sciences.

Results: The prevalence of posttraumatic stress disorder was 25.2% (126 cases). There was statistically significant association between the occurrence of PTSD and some variables such as female (28.7%; P = 0.003), housewife (28.5%; P = 0 .012) and nearly significant association with the positive family psychiatric history (42.9%; P = 0.057). The results showed no statistically significant association between the occurrence of posttraumatic stress disorder and other variables such as age (P = 0.106), educational level (P = 0.148), marital status (P = 0.210) and patient past psychiatric history (P = 0.164).

Conclusions: The high prevalence of posttraumatic stress disorder among the Syrian refugees (25.2%) makes it one of the most important mental health issues that should be taken into consideration. The females, housewives and those with a positive family psychiatric history are regarded among high risk groups. Early detection and better management of those groups may be of high priority.

Background and objective: Aspergillus fumigatus is the most common airborne fungal pathogen of humans. It is an opportunistic human pathogen in immunocompromised hosts. Following the recent discovery of the sexual reproductive cycle ascospores of this fungus were available and their germination was studied in the present study. This study aimed to study factors influencing germination of ascospores of A. fumigatus.

Methods: A total of 12 environmental A. fumigatus were chosen in both mating type, examined for sexual reproduction by crossing complementary mating type, following removing of cleistothecia, preparation of ascospore suspensions in 0.05% Tween 20, then heat treated to kill any remaining conidia.

Results: Ascospore germination of greater than 75% occurred at 28 °C on a wide variety of mycological media, 0.5% (ACM) was chosen for use in subsequent studies. Ascospores did not require a heat treatment prior to germination; however, heat treatment of ascospores at 75 °C for 1 hour previous to incubation enhanced germination to 89% and also served to inactivate contaminating conidia. Ascospores also exhibited a psychrotolerance following exposure at -80 °C for 96 hours. Inoculum concentration did not have a significant effect on germination rates between the range of 0.125×10⁶ to 4×10⁶ ascospores ml^-1 (P >0.05).   

Conclusion: This study demonstrated that ascospore germination of greater than 75% occurred at 28 °C on a wide variety of mycological media. Ascospores of A. fumigatus are thermotolerant also exhibited a psychrotolerance whilst at the same time retaining viable sexual ascospores, to assess percentage germination a drop of Lactophenol Cotton Blue was added.

Background and objective: Fanconi anemia is a rare inherited autosomal recessive disease characterized by chromosomal instability, progressive bone marrow failure, congenital malformations, and a high propensity of malignancies. Fanconi anemia is a genetically and phenotypically heterogeneous disorder defined by cellular hypersensitivity to DNA cross-linking agents. This study aimed to review retrospectively medical history, genetics, clinical course, blood test results, complications and social issues of Fanconi anemia patients.

Methods: All the patients with Fanconi anemia included in the study had been diagnosed between August 2008 and August 2016 in the Hevi pediatric teaching hospital, Duhok, Kurdistan-Iraq. The cases identified initially, which fulfilled clinical, peripheral blood and bone marrow examination (aspirate and biopsy) and confirmed by the cytogenic study as criteria of inherited hypoplastic anemia. Other causes of aplastic marrow were excluded.

Results: The study includes 30 Fanconi anemia cases,the median age at diagnosis was 7.5 years (range 1.5-15); At diagnosis the most blood parameters were reduced hemoglobin (63%), reduced platelets (57%) followed reduced leukocytes (53%) and 9 (30%) cases, all three peripheral blood count elements were reduced. Moderate aplastic anemiawas predominant, and common symptom (20 cases, 66.7%) washemorrhagic diathesis at presentation.Common physical abnormalities were skin pigmentation (70%), short stature (66.7%), thumb deformity (56.7%),and (53.3%) of the patients had small faces and eyes. Up to 33.3% of all Fanconi anemia patients exhibit none of the physical findings.

Conclusion: Fanconi anemia is a rare genetic disease in Duhok area;most patients were of moderate aplastic anemia, the bleeding tendency was the chief complaint of presentation.The diagnosis of Fanconi anemia in the early stage is important to select special management.

Background and objective: Medication administration errors are the most common medical errors that happen in hospital settings. This study aimed to find out the most common types of medication administration errors done by the hospital nurses and identifying factors that lead to medication administration errors.

Methods: This cross-sectional survey was conducted across Erbil teaching hospitals over a period of three months from June 2016 to September 2016. A convenience sample of 250 nurses who were working in acute, subacute, and general wards and had direct contact with the medication administration were included in this study. Data were collected using a self-reported questionnaire.

Results: According to this study the most common types of medication errors were, noticing allergy after drugs administration and administering drugs at a wrong time. The highest leading factors of medication administration errors were illegible medication orders of the physicians, lack of adequate staffing and workload. High statistical differences were found between the frequency of medication administration errors with nurses’ educational level, overall working experience, and nurses understanding language.

Conclusion: This study concluded that medication administration errors have multiple causes and types of errors are various. 

Background and objectives: The oxidative stress and inflammatory process are cooperative events involved in the development of essential hypertension. This study was as a step for elucidating the contribution of the malondialdehyde, glutathione peroxidase, interleukin -18 and lipid profile with the development of essential hypertension. This study aimed to assess whether the variation in serum malondialdehyde, glutathione peroxidase, interleukin-18 and lipid profile levels were associated with the development of essential hypertension, moreover, find out the effect of age, gender and stage on the serum focused parameters levels and finally detect the correlation coefficient.

Methods: This case-control study was performed at the College of Pharmacy, Hawler Medical University in newly diagnosed and untreated patients with essential hypertension of both genders, and 50 of the matched age–gender healthy adults as a control group in the period between 2013-2014.

Results: Patients exhibited a significant elevation in the serum malondialdehyde, glutathione peroxidase, interleukin-18 and lipid profile levels.

Conclusion: This investigation provided for the first evidence the ability of selected parameters in combination patterns as factors involved in essential hypertension pathophysiology and are regarded as markers of diagnostic significance. The demonstration of these parameters provided new insights into understanding the independence of antioxidant status and inflammatory pathways in essential hypertension development.

Background and objective: Hypertension is characterized by a persistent, progressive elevation in blood pressure. Oxidative stress and endothelial dysfunction have a role in the pathogenesis of hypertension through interaction with the elements of the renin-angiotensin system. This study aimed to examine the effects of lisinopril on mean arterial pressure and biosubstances of Kallikrein-kinin-system (bradykinin), endothelial dysfunction (nitric oxide), and oxidative stress (malondialdehyde).

Methods: A clinical trial was conducted in Erbil city from December 1^st, 2015 to August 10^th, 2016. The study included 65 patients with essential hypertension and 25 apparently healthy subjects; their ages were in between 18 and 55 years. The patients were receiving 10 mg lisinopril orally per day for six weeks as a starting dose.

Results: At hypertension diagnosis, patients were with lower bradykinin and nitric oxide levels when compared with apparently healthy subjects; however, malondialdehyde level showed no significant difference when compared with of healthy subjects. After six weeks patients treatment, comparing bradykinin, nitric oxide, and malondialdehyde mean levels with their baselines, showed that significantly increased in bradykinin and nitric oxide (P <0.01) and significantly decreased in malondialdehyde (P <0.01). On the other hand, the differences between after treatment and healthy subjects had no significant difference, except bradykinin. Eventually, during treatment, the mean arterial pressure was significantly lowered.

Conclusion: in addition to the significant lowering of blood pressure, lisinopril 10 mg daily for six weeks can significantly elevate kallikrein-kinin system and endothelial dysfunction markers, and significantly lowered in oxidative stress marker in hypertensive Kurd patients in Erbil city.

Background and objective: Desmoplastic infantile gangliogliomas are rare low grade supratentorial masses that are seen in the pediatric age group. Typically, they involve the superficial cerebral cortex and leptomeninges. Despite the large size of these lesions and some worrisome histological and radiological features, prognosis is generally favorable after gross total resection. To our knowledge, out of about one hundred cases reported worldwide, this is the first Desmoplastic infantile ganglioglioma reported in Kurdistan region-Iraq.

Case presentation: We report a case of Desmoplastic infantile ganglioglioma in a 2-month-old male infant, Computed tomography and magnetic resonance imaging revealed a supratentorial mixed cystic and solid temporal tumor. Near total surgical removal was done. Histopathology revealed features of desmoplastic infantile ganglioglioma, with marked desmoplastic component, glial and neuronal elements. Immunohistochemistry showed positive staining for glial fibrillary acidic protein with areas of synaptophysin positivity.

Conclusion: The diagnosis of Desmoplastic infantile ganglioglioma should be considered in differential diagnosis of tumors with a cystic component and an aggressive appearance.

Background and objective: Intravenous urography is a radiographic examination in which anatomic and physiologic abnormalities of the urinary tract are detected by obtaining a timed series of imaging of the abdomen and pelvis after the injection of intravenous "IV" iodinated contrast media. This study aimed to measure the diagnostic validity of ultrasound and intravenous urography in the hope of omitting unnecessary intravenous urography and to determine whether ultrasound could help to replace the intravenous urography in the diagnosis of hematuria.  

Patients and methods: A prospective hospital based study was performed from 15^th April 2015 to 15^th April 2016 on 100 patients presenting to Rizgary Teaching Hospital with hematuria, all patients underwent a real time ultrasound examination of the urinary tract followed by an intravenous urography. The diagnostic validities were recorded and compared for each modality.

Results: Ultrasound had higher sensitivity than intravenous urography for diagnosis of kidney calculi, lower ureteric calculi, and urologic neoplasms, but in calculi of the middle and upper ureter, there was no difference between ultrasound and intravenous urography.

Conclusion: Our results are in favor of using ultrasound in the initial evaluation of hematuria. However, we must choose our diagnostic tool according to the patient's condition and suspected disorders causing hematuria, as ultrasound can be safely done and hence minimizing the exposure of the patient and medical staff to excessive radiation.

Background and objective: Duodenal atresia and stenosis is considered a frequent cause of intestinal obstruction in the newborn, good prenatal work up and investigation make early diagnosis and better prognosis. This study aimed to evaluate the prenatal diagnosis, types, post-delivery management, associated anomalies, operative management and outcomes in neonates with congenital duodenal obstruction.

Methods: A prospective study including 21 infants (13 female and eight male) with congenital duodenal obstruction were treated at Rapareen Teaching Hospital in Erbil from December 2011 to December 2015.

Results: The mean age at presentation was 8.1 days (range 4 to 52 days), and the mean weight was 2.63 kilogram. Around 95% were term and 61.9% of patients delivered through cesarean section. The commonest presentation was bilious vomiting in 95.2% of cases. Associated anomalies were present in six cases in particular Down’s syndrome in five cases. Plain abdominal x-ray, ultrasound of abdomen and echocardiography done for all cases while upper gastrointestinal contrast study was done only in 5 cases. All managed operatively through laparotomy, and diamond shaped duodenoduodenostomy was the main procedure done in 17 cases, web resection in two cases, Ladd's procedure in one case and duodenojejunostomy in one case. The survival was 95.2%.

Conclusion: Congenital duodenal obstruction is a common condition facing the pediatric surgeon. Associated anomalies is the first factor influencing the outcome. The most common causes of congenital duodenal obstruction were atresia, and annular pancreas and the most important warning sign is the bile stained vomiting. Treatment should be expedient and concurrent with ongoing resuscitation.

Background and objective: The increase in the incidence of Beta-lactam resistance in Gram-negative bacteria has become a main clinical problem worldwide that limits therapeutic options. The production of extended-spectrum blactamases is the major source of resistance to newer beta-lactam antibiotics in Enterobacteriaceae. This study aimed to check the presence of extended-spectrum β-lactamase producing K. pneumoniae and E. coli and the evaluation of ESBL among those isolates.

Methods: A total of 120 E. coli and K. pneumoniae clinical isolates were obtained from Rizgary Teaching Hospital in Erbil City, Iraqi Kurdistan Region, during the first six months of 2016. All isolates were identified and checked for the production of ESBL using Vitek 2 automated system. The technique of PCR was performed for the detection of the presence of blaSHV gene from these isolates. The antibiotic resistant profiles for these isolates were also investigated.

Results: The overall proportion of ESBL-producing E. coli and K. pneumoniae isolates, 77 (76.2%) and 15 (78.9%) isolates were ESBL producers, respectively. ESBL-producing isolates were significantly more resistant than Non-ESBL-producers (P < 0.05). PCR performed on 30 ESBL positive isolates, 21(70%) isolates were of E. coli, and 9 (30%) isolates were of K.pneumoniae. The ESBL B-lactamase related SHV gene was detected only in 11 (36.6%) isolates, 6 (28.5 %) of E. coli and 5(55.5%) of K. pneumoniae isolates respectively. All isolates were susceptible to carbapenems.

Conclusion: The great diversity of ESBL and the prevalences of clinical isolates of E. coli and K. pneumoniae producing these enzymes indicate that this is an important problem in our region. The most active antimicrobial agent against isolates used in this study was carbapenem. It is, therefore strongly recommended to consider carbapenems as the drug of choice for such multi-drug resistant ESBL-producing microorganisms.

Background and objective: Head injury is a common injury seen in emergency departments. Early diagnosis and treatment may ameliorate the morbidity and mortality associated with intracranial injury. Computed tomography (CT) scan of the brain is a reliable imaging modality for identification of intracranial lesions in patients with an acute head injury. This study aimed to assess the cranial CT scan findings in patients with acute head injury, find out the main indication for requesting CT scan imaging, detect main etiologic factors and its distribution among different age groups.

Methods: This was a prospective cross-sectional study of cranial CT scan findings of 210 patients with acute head injury admitted to an emergency hospital in Hawler during three months. Numerical and graphical descriptors were used to summarize the data.

Results: The age of the studied patients ranged from 2 to 67 years with a mean± SD of 29.23±15.1 with males dominating the sample (78.6%).Road traffic accident was the main cause of injury (65.7%).The most common indication for requesting a CT scan was an altered level of consciousness and vomiting. Intracranial CT scan findings related to head injury were seen in 82% of victims of which fractures (50%) and intracranial hematomas (45.2%) were the main findings followed by combined injuries(31.8) and soft tissue injuries (31.6%).Incidental intracranial findings not related to trauma were seen in 6.2% of cases.

Conclusion: In patients with acute head injury, CT scan can be used as the initial imaging investigation as it can yield various types of head injuries and their consequences related to trauma.