Vol 23, No 1 (2019)

Background and objective: Otosclerosis is a primary disease of the temporal bone that leads to stapes fixation. Hearing loss and tinnitus are the main symptoms. Treatment includes surgery, medical treatment, and sound amplification therapy alone or in combination. This study aimed to evaluate the functional outcomes of patients with clinical diagnosis of otosclerosis undergoing primary stapes surgery in Erbil city.

Methods: A retrospective descriptive study. A total of 32 patients with clinical otosclerosis underwent unilateral stapedotomy in the specialized center between September 2011 and September 2013. These included 20 females and 12 males, aged 21 to 48 years, their mean age (±SD) was 31.9 (±10.91) years.

Results: The average preoperative and postoperative air conduction threshold was 51.13 and 23.91 dB, respectively. The mean preoperative and postoperative bone conduction threshold was 21.53 and 16.21dB, respectively. The average preoperative and postoperative air-bone gap was 29.03 and 8.51 dB, respectively. All 32 ears (100%) had a residual air-bone gap <10 dB.

Conclusion: Stapes surgery showed significant functional hearing outcomes in this study. The very significant reduction in the air-bone gap is a good indicator of the success of the surgery.

Background and objective: Coxa vara was treated previously by subtrochanteric and inter-trochanteric valgus osteotomies with internal fixation. Recently; more attention was paid for achieving corrections of limb deformities and length discrepancies through less invasive means using external fixator systems including Ilizarov fixation. This study aimed to describe the performance of Ilizarov fixation technique in the surgical correction of coxa vara of different etiologies and limb lengthening.      

Methods: In this case series study, nine patients (11 hips) with coxa vara of different etiologies were treated surgically by sub-trochanteric osteotomy done percutaneously with the use of Ilizarov fixation device, in 15 months at Erbil teaching hospital. Patients between four and ten years of age with coxa vara with neck – shaft angle less than 120° or Hilgenreiner epiphyseal angle of more than 40° were included in this study.

Results: All osteotomies achieved the targeted correction in the Hilgenreiner –epiphyseal angle and the neck-shaft angle with a P value <0.001. All osteotomies healed primarily and on follow-up, no intra-operative complications developed, and no patient needed the post-operative blood transfusion. Three patients needed limb lengthening, one patient needed shelf osteotomy, and two patients had superficial pin tract infection. Four patients had postoperative knee stiffness which resolved completely. Radiological analysis revealed a maintained improvement in the Hilgenreiner-epiphyseal angle and neck-shaft angle.

Conclusion: Ilizarov technique is a safe and less invasive technique for the surgical management of coxa vara of different etiologies and limb length discrepancy.

Background and objective: Computed tomography angiography is one of the best methods for knowing the detailed anatomy of coronary arteries and can successfully detect any variation of coronary arteries. Anatomic variations of coronary arteries have not been studied among Erbil population which is mostly inhabited by Kurds. This study was conducted to compare the incidence of the anatomic variations of coronary arteries in Erbil population with international standards.

Methods: Variations of coronary arteries were retrospectively studied by using computed tomography angiography of 412 cases (214 males 198 females) with mean age 51.5 ± 13.5 years (mean ± SD) who underwent this procedure on suspicion of coronary artery disease. The main indication was chest pain in patients with low to intermediate probability of ischemic heart disease. The present study was carried out in the Department of Radiology, Surgical Specialty Hospital/Cardiac Center in Erbil city.

Results: The right coronary artery was dominant in 86.4% of cases, while the left main coronary artery was dominant in 10.92% of cases. Co-dominance was observed in 2.67% of cases, and Double Ostia of right aortic sinus was observed in 25% of cases. Long left main coronary artery was observed in 10.68 % of cases. Myocardial bridging was observed in 7.04% of cases. Other variations were also observed, and their prevalence was recorded.

Conclusion: Variations of coronary arteries among Erbil population were recorded and were near to the international standards.

Background and objective: Infertility and poor ovarian response are serious problems in our society; fortunately the in vitro fertilization and intracytoplasmic sperm injection technique dissolve many of these problems. This study aimed to assess the effect of an individualized GnRH antagonist regimen on intracytoplasmic sperm injection process especially the aptness of it in given mature reiterative oocytes, normal fertilization, and acceptably zygote cleavage which enhance pregnancy.

Methods: The population of the study consisted of 877 couples attending the in vitro fertilization-infertility center in the maternity teaching hospital and chose to undergo intracytoplasmic sperm injection after using of antagonist protocol for stimulation of women ovaries. The women ages ranged between 24 and 44 years. The collected data included a number of reiterative oocytes; fertilization, embryo grades and lastly estimates the pregnancy results

Results: A significant association (P <0.001) was found in the numbers of reiterative oocytes between the age groups of the study. A significant association (P = 0.005) was also found concerning to quality of fertilization process. The study of the zygote cleavage and blastomeres formation followed the fertilization show variable grade of embryos and analyzed data of embryo grades in this study indicate presence of significant association (P = 0.003). The rate of pregnancy showed significant association between the groups of the study with the <30 years age group have chance of pregnancy higher than other groups.

Conclusion: The antagonist protocol of ovary stimulation according to the results of this study is a qualified protocol; besides it is rapid and can be reversed. This protocol can give effective results in the intracytoplasmic sperm injection process especially for young women, and enhance the pregnancy.

Background and objective: Diabetic patients could be at increased risk of functional disability, which needs good control of blood glucose and other risk factors and the quality of life of diabetic patients especially those who had complications is remarkably lower than the quality of life of the general population. This study was conducted to assess the quality of life of diabetic patients in its different domains from the patient's perspective in Erbil city.

Methods: In this cross-sectional study, 160 diabetic patients were randomly selected from Layla Qassim diabetic health center. The WHO (WHO QOL- BREF) questionnaire was used as the main tool for data collection, which included26 questions on four domains of health-related quality of life (physical, psychological, social and environmental domains).

Results: Around 49% of the patients had checked their blood sugar regularly and had better scores in the social domain (P = 0.036). Diabetic patients of all age groups had low scores in all domains of quality of life, with the lowest mean score in the psychological domain. Females reported significantly higher scores in the environmental domain (P = 0.001). Patients with insufficient monthly family income had lower scores in the social (P = 0.001), psychological (P = 0.031) and environmental (P = 0.039) domains. There was no obvious statistical association between clinical characteristics of the patients and the quality of life domains. However, those with complications had lower scores in the psychological domain, with a higher proportion (P = 0.016) of complications in females.

Conclusion: All domains of quality of life are affected by diabetes mellitus, with no clear, consistent statistical association between clinical characteristics of the patients and the quality of life of various domains, which emphasize the need for more multidisciplinary team action for more patient`s education and self-care.

Background and objective: Type 2 diabetes mellitus is a metabolic disorder characterized by the increase in blood glucose due to insulin resistance or deficiency of insulin. The subjects are more likely to be prone to infection. So, it could be correlated with Helicobacter pylori infection, which means that gastrointestinal inflammation might be affected by uncontrolled glycemic level. This study aimed to examine the correlation of type II diabetes and infection of gastrointestinal in order to illustrate such complication of diabetes mellitus apart from others.

Methods: A total of 64 persons from Erbil city participated in this cross-sectional study. They were divided into two groups, each group involving 32 persons. The cases group included those suffering from type II diabetes and were selected by simple random sampling method. The other group included those not possessing any types of disease including diabetes mellitus. Examination of Helicobacter pylori, glycated hemoglobin (HbA1c), besides measuring blood pressure and body mass index were performed for all individual subjects in both groups. Chi-Square and unpaired t-test were used for data analysis.

Results: There was a 59% positively Helicobacter pylori in diabetes group whereas there was a 31% positively Helicobacter pylori in non-diabetes mellitus. The difference between the rates of Helicobacter pylori in both groups was statistically significant (P <0.05).

Conclusion: The prevalence of Helicobacter pylori infection in diabetics was significantly higher than the non-diabetics.

Background and objective: Communication skills are one of the important and effective skills for healthcare providers. Health provider-patient communication is a core component of the health system and has a strong impact on health user satisfaction. This study aimed to explore the level of communication skills among health workforces, and the role of the training course on communication skills improvement.

Methods: This quasi-experimental study included 571 newly graduated participants of health workforces from a Sulaimani city center. Standard tools of communication skills were used for pre- and post-test evaluation through 5 hours of training course including 25-30 participants with a total of 24 training courses. Data collection was performed by the self-administered method. Descriptive statistics and analytical statistics were used to test statistical difference and associations.

 Results: Minimum required for communication knowledge and skills are reported by the small percentage of studied participants (12.6%) at the beginning of training. Comparing the mean scores of communication skills showed a statistically significant improvement (mean difference scores is 5.9) after the intervention. Significant communication skills improvement scores have been reported among youngest age groups and physicians.

Conclusion: Well-organized training courses in communication skills can increase the health workforces' rate of communication skills. Training in communication skills should be widely included during undergraduate studying and in-service training programs.

Background and objective: Trace elements are now measured as possibly having an important role in the pathogenesis of atherosclerosis. This study aimed to investigate the serum rubidium, rhenium, cesium, and boron levels in patients with atherosclerosis as compared with the control group as well as to detect the effect of age and gender and estimate the correlation among the parameters.

Methods: This case-control study included 40 patients and 40 apparently healthy adults matched age and gender as a control group. Serum parameter levels were estimated using atomic absorption spectrophotometer.

Results: The data of the current study indicated that the levels of rubidium and boron were significantly reduced and there was a significant elevation in the serum level of rhenium while there was no statistical difference in the level of cesium in patients as compared with the control group. In addition, the effect of age and gender did not reveal any significant effect on the serum studied ultra-trace elements levels. There was a negative significant weak correlation between age and Rb (r = -0.38, P = 0.016).

Conclusion: Boron and rubidium were significantly reduced; therefore, supplementation could be important for therapy of atherosclerosis.

Background and objective: The British Pharmacopoeia contains four apparatus for testing inhalers. Two of these are the next generation impactor, and the twin glass impinge which differs in their use. The next generation impactor apparatus should ideally have at least five stages; even though the twin glass impinge has only two stages, it is still listed in the British Pharmacopoeia. The next generation impactor is more accurate, reliable and sophisticated than the twin glass impinger. This study gives a detailed comparison of the two pieces of equipment.

Methods: Carriers including mannitol, lactose monohydrate, trehalose and sucrose with active pharmaceutical ingredient; salbutamol sulphate were delivered by dry powder inhaler using the next generation impactor and twin glass impinger at a constant flow rate of 60L/min.

Results: The twin glass impinge respirable fractions of the powders were higher than the next generation impactor for each carrier. As expected, mannitol powder had the lowest percentage remaining in the capsule compared to lactose monohydrate, trehalose and sucrose had the greatest percentage remaining for both inhaler devices.

Conclusion: Even though both apparatus are important for in-vitro studies of drug delivery into the lungs using inhaler devices, the next generation impactor is better suited when a specific size range is required. The twin glass impinger is useful for simple inhaler testing, and the inclusion within the British Pharmacopoeia is justified.

Background and objective: Tonsillectomy with or without adenoidectomy is an operation done frequently in all otolaryngology departments all over the world. Many new surgical techniques found over the last few decades to decrease the morbidity of this surgery. This study aimed to compare intraoperative efficiency and postoperative recovery between coblation and bipolar electrocautery tonsillectomy.

Methods: This prospective study was carried out on 60 patients that underwent tonsillectomy over six months from 1(st) August 2014 to 31(st) January 2015 in Rizgary Teaching Hospital, Erbil city. They patients equally divided into two groups; coblation tonsillectomy (30 patients) and bipolar electrocautery tonsillectomy (30 patients). Their age ranged between 2.5-12 years. The operative time and intraoperative blood loss were recorded for each patient and compared. The parents were given a pain diary to record the level of pain each morning for ten days. Also, they were asked to report any complication like bleeding.

Results: There was no statistically significant difference in the mean operation time between the coblation group and bipolar electrocautery group (6.89 min vs. 7.83 min, P = 0.11). The mean intraoperative blood loss was statistically lower for the bipolar electrocautery group versus the coblation group (1.43 ml vs. 15.37 ml, P <0.001). There was a statistically significant difference in the daily pain scores between the two groups in which the coblation group was associated with lower mean pain score. No episodes of primary or secondary hemorrhage were recorded.

Conclusion: Bipolar electrocautery tonsillectomy offers the same operative speed, less intraoperative blood loss, more postoperative pain scores when compared with coblation tonsillectomy.

Background and objective: Collective high fertility behaviors is a term that refers to mothers who had got married during their teenage and having parity of five or more living children with less than 24 months apart. The present study aimed to estimate the prevalence of collective high fertility behaviors among mothers in Mosul city, Iraq.

Methods: A cross-sectional study was carried out using a multi-stage stratified sampling method. Inclusion criteria included mothers in child-bearing age who had at least two living children. The required data were collected by filling an especially structured questionnaire in the eligible primary health care centers over a period of ten months, from April, 1^st 2011 to the end of January 2012.

Results: Among 1302 participants, the prevalence of high fertility behaviors was 17.7% within all age groups. The prevalence was significantly higher among Muslim, low social classes (P ˂0.001), nuclear family structure (P ˂0.001), consanguineous marriage (P ˂0.001) and low educated mothers and husbands (P ˂0.001).

Conclusion: The study found that collective high fertility behaviors are prevalent among almost two out of ten mothers of all age groups in Mosul city. Thus, effective engagement of all human resources is recommended for constructing healthy fertility behaviors and confirming the non-reproductive role of women.

Background and objective: Treating children with head injuries is one of the most frequent causes of admission to the neurosurgical emergency unit in Erbil city. In many cases, the parents ask whether the presence of a skull fracture in their child indicates any association with intracranial hemorrhage. Most of the previous studies focused on the association between skull fractures and intracranial hematomas in the adult population. We conducted this study to determine if there is a statistically significant association between skull fracture and types of intracranial hemorrhage in children.

 Methods: A descriptive study was conducted between July 2015 and July 2017 at West Erbil Emergency Hospital. The study sample included children with the head injury whose brain Computerized Tomography (CT)-scan showed intracranial hemorrhage. Data collected using a questionnaire prepared by the researcher. Data were analyzed using descriptive and inferential statistical tests.

Results: A total of 201 children met the inclusion criteria; their ages ranged between 2 months and 17 years. Male to female ratio was 121:80. Highest percentages (64.7%) of children were 1-5 years old. The most common (72.63%) cause of head injury was fall from height. The most frequent (48.8%) intracranial hematoma encountered was an epidural hematoma, followed by intracerebral hematoma and subdural hematomas. There was a highly significant (P = 0.001) association between skull fractures and types of intracranial hematomas.

Conclusion: In children, skull fracture increases the incidence of intracranial hematoma. Most common intracranial hematomas in order of frequency were an epidural hematoma, intracerebral hematoma, and subdural hematoma. The most common cause of head injury was fall from height. Most patients were males between one and five years old.

Background and objective: Colorectal cancer is a multi-factorial disease process, with etiology encompassing genetic factors, environmental exposures, and inflammatory conditions of the digestive tract. This study aimed to investigate the immunohistochemical expression of CDX2 as well as clinical and histopathological parameters of patients with colorectal cancer in Erbil, Kurdistan.

Methods: A retrospective study including about 100 colorectal cancer cases in Erbil city, Kurdistan was conducted from January 2015 to January 2017. Tumor type, site, size, histological grade, lymph node status, and pathological stage with CDX2 expression were investigated.

Results: CDX2 was expressed in 86 out of 100 (86%) patients. It was more expressed (focal or diffuse staining) in nonmucinous carcinoma more than signet ring and mucinous carcinoma. Loss of CDX2 expression in colorectal cancer is associated with a high tumor grade and stage. Significant associations between CDX2 expression with both tumor type and tumor grade were observed. Although CDX2 expression was found to be reduced in proximal location (right colon) and higher stage, however, no significant associations between CDX2 expressions in colorectal cancer were detected with tumor site, nodal status, and tumor stage.

Conclusion: Reduced and loss CDX2 expression in colorectal cancer associated with high tumor grades as well as with the mucinous and signet ring cell carcinomas may reflect aggressive tumor behavior probably because of the CDX2 tumor-inhibitory properties. However, the full extent of CDX2’s antitumor effects has yet to be elucidated.

Background and objective: Congenital hypothyroidism is the most common preventable cause of mental retardation detected during early childhood. Its early diagnosis is crucial for a better outcome. Many factors are contributed to this problem including maternal, fetal and others. This study aimed to assess thyroid hormone status in relation to certain obstetrical especially mode of delivery and neonatal factors

Methods: A descriptive cross-sectional study conducted in postnatal care and delivery room (operative and vaginal) of Maternity teaching hospital in Erbil city. Ninety-two babies were included and subdivided into three groups according to their route of delivery. A thyroid stimulating hormone cut off value of 10 was selected as the upper normal level for the purpose of the study.

Results: A significant proportion of babies with cord thyroid stimulating hormone concentration more than 10 mIU/L (25 out of 92) were noticed, and this is near to many previous studies used the same cut off value. Mean of This hormone is relatively increased among newborns of the elective cesarean section while maternal total triiodothyronine and total thyroxine were higher within the elective group. Prenatal evidence of placental calcification and first born babies were associated with higher thyroid stimulating hormone levels.

Conclusion: Emergency cesarean section is less likely to be associated with elevated cord blood thyroid stimulating hormone level compared to other routes of delivery/but this is not confirmatory and recall test is recommended to exclude hypothyroidism.

Background and objective: Globally, diastematomyelia accounts for 5% of all congenital spinal cord defects. Clinically, symptoms of diastematomyelia are non-specific, can be progressive, and can become symptomatic at any age. This study was carried out to describe neurological, radiological and surgical findings of diastematomyelia cases reported in Erbil city of Iraq.

Methods: A retrospective review of diastematomyelia was carried out in three neurosurgical centers in Erbil city of Kurdistan region of Iraq between 1^st January 2003 and 1^st January 2013. Diagnosis of this anomaly was based on CT and MRI with surgical dissection in one case. In patients with contraindication for MRI and CT scan, the diagnosis was based on lumbar myelography. Surgical interventions included surgical decompression and laminectomy with timely follow-up at every six months to assess the outcomes after the surgical intervention.

Results: A total of 27 cases were included in this study with a mean age of 13 years (ranging from 1-19 years) and a female to male ratio of 2.9:1. Spinal deformities (66.7 %) were the main complaints for patients to seek medical advice. Clinically, 89 % of the patients had a huge spinal disfigurement, and 74% had a mid-line thoracic or lumbar cutaneous variation from the norm. Neurologically, 59 % of the patients had a least neurological disability. Radiologically, 96 % showed inter-pedicular separation and spina bifida, 59% scoliosis, and 55.6% boney spicule. Intra-operatively, around 63% of the cases had boney septum separating the dissected hemi-cords; 70 % of the septa located in the lumbar region. Post-operatively, none of the patients experienced decay in their neurologic status after surgery. Over the long term, two patients were slightly improved, and another two had an increased neurological deficit, one patient had better reflexes, but increasing deformity of the foot and 14 patients were unchanged. None of the patients had contamination, pseudoarthrosis, or loss of remedy amid the subsequent visit.

Conclusion: Despite the slight postoperative improvement, all patients with the established preoperative deficit still had residual neurological postoperative deficits and only a low proportion of them slightly improved.

Background and objective: Overweight and obesity are important risk factors for the development of some important chronic diseases and are, thus, considered leading risks for deaths. This study aimed to find out the prevalence of overweight and obesity with their associated risk factors in the adult population.

Methods: A household cross-sectional survey was carried out in Erbil city, Iraq from April to June 2017. The study involved 1480 adults selected through a multi-stage sampling method. A specially designed questionnaire was used to collect socio-demographic and other relevant data from the participants through direct interview. The height and weight were measured for all participants.

Results: The overall prevalence of overweight and obesity was 74.3% (33.4% overweight and 40.9% obese). There was a statistically significant association between being overweight and obese and older age groups, female gender, being married, low level of education, unemployment, not smoking, and not performing physical exercises. Following a multivariate analysis age (OR = 2.36, 95% CI = 1.60-3.49), female gender (OR = 2.17, 95% CI = 1.53-3.08), and married status (OR = 1.87, 95% CI = 1.20-2.90) were found to be statistically significant factors associated with overweight and obesity.

Conclusion: The prevalence of overweight and obesity in the adult population in Erbil city is very high. This alarming epidemic requires serious consideration of the health policymakers and public health specialists to plan effective and preventive and control measures. Health education is one way through which people's awareness of this important health issue could be raised.

Background and objective: The constant increase of Candida infection and unstopping emergence of drug resistant Candida species is a major concern. Natural medicinal products particularly those of edible plant could be a safe and effective alternative to synthetic substances. Considering their anti-microbial contents, the leave extracts of Anethemgraveolens and Apiumgraveolens have been investigated for their effects against Candida species.

Methods: Fresh leaves of Anethem and Apium were collected from Erbil province in Iraq. The leaves were dried then after grinding the ethanol extract was prepared. The radical scavenging activity of extracts was measured via DPPH inhibition activity method. Anti-Candida effect was assessed against C. albicans, C. glabrata, C. krusei, C. tropicalis, C. tamatta, C. parapsiosis, and C. guilliermondii. Standard antifungal drugs were used as control including Nystatin, Clotrimazole, Fluconazole, Ketoconazole, and Miconazole.

Results: The highest radical scavenging activity of both extracts was found at 0.2 mg/mL. Both extracts did not affect the growth inhibition of C. krusei, C. tropicalis, and C. tamatta. However, they were significantly effective to the extent of other antifungal drugs against the growth of other Candida species including C. albicans, C. glabrata, C. guillermondii, and C. parapsiosis.

Conclusion: The findings of this study suggest that both Apium and Anethem which are widespread vegetable and could have similar anti-Candia effects which can be a great alternative to the commonly used antifungal drugs.