Vol 23, No 2 (2019)

Background and objective: Students of the college of medicine involve in a hard study and training for six years; which might adversely affect the student's mental health and physical condition. This study aimed to identify the prevalence of depression, anxiety, and stress among medical students, and its association with different sociodemographic variables.

Methods: A cross-sectional study was conducted among students of the College of Medicine, Hawler Medical University from April to May 2017. This study included a randomly selected sample of 288 students. The Depression, Anxiety, and Stress Scale-21 (DASS-21) questionnaire was used to collect data. The statistical package for the social sciences was used for data analysis. Pearson Chi-square and Fisher's Exact Test were used to finding the association between various variables and depression, anxiety, and stress.

Results: The prevalence of depression, anxiety, and stress among medical students were 52.1%, 62.5%, and 45.1%, respectively. Male students were found to be more depressed than female students (63.6% vs. 42.3%) with a statistically significant association (P <0.001). Anxiety and stress were not significantly associated with gender. Anxiety among students from rural areas (88.9%) was significantly (P = 0.021) higher than students from urban areas (60.7%). The association of depression, anxiety, and stress with other variables was not significant.

Conclusion: The prevalence of depression, anxiety, and stress among students was high. Male students were regarded as a risk factor for depression, while students from the rural areas were regarded at risk of anxiety.

Background and objective: Genital human papillomavirus (HPV) infection is closely linked to cancer of the cervix. The Papanicolaou-stained smear is the primary method for detection of high-risk HPV. This study aimed to identify women at risk of developing cervical precancerous lesions.

Methods: This cross-sectional study involved 75 married, non-pregnant women with anogenital warts. Sociodemographic, fertility history, and details of the anogenital wart infection were obtained from all patients through a questionnaire. Pap smear was performed for all patients, and histopathological assessment was done.

Results: The age of the patients ranged from 18 to 55 years. The mean (± SD) age of marriage was 22.2 (± 5.77) years, 12 (16%) women gave birth to a child before the age of 18 years. Filiform warts were identified in 33 (44%) patients, while the acuminate type was found in 24 (32%) patients. Flat warts were seen in nine (12%) patients. There was a significant association between the type of wart and recurrence. Severe erosive cervicitis was found in 45 (60%) smears. Moderate cervicitis was observed in 24 (32%) smears, and six (8%) had mild cervicitis. A significant association was found between duration of the genital wart and cervicitis. Twenty percent had atypical squamous cells of undetermined significance. No malignant changes and no koilocytes were identified.

Conclusion: Early marriage, unawareness of the risk of anogenital warts, and neglecting regular Pap smears are risk factors for developing cervical cancer.

Background and objective: Laparotomy is the surgical opening of the abdomen and the important way to control and treat any problem and complication along pathway site of penetrating by a bullet or shell. This study aimed to identify the patterns and the factors associated with complications of laparotomy for firearm and blast injuries in Erbil City.

Methods: This retrospective study was carried out on 125 injured patients at the Emergency Management Centre in Erbil city. Data was collected from the Statistics Department of Emergency Management Centre from 1^st January 2014 to 31^st December 2016.

Results: The mean age of the included patients was 26.2 ± 11.0. The majority of patients were young (54.4%), male (80%), lived in the Erbil center (45.6%), and the injured place was mostly in the center of Erbil (45.6%). The mean and standard deviation time needed to arrive at the hospital was 8.7 ± 39.2 hours. Most of them had a medium condition (53.6%), arrived within the first hour to the hospital (57.6%), had the first operation at the Emergency Management Centre (89.6%), did not have any other injury (64%) and had bullet injuries (88%). The post operative complications from laparotomy were significantly higher in those with poor condition at admission (P <0.001), not having the first operation at Emergency Management Centre (P = 0.003) and higher number of internal organs injured (P = 0.010). There was a significant association between postoperative complications from laparotomy with the time needed to arrive at the hospital (P = 0.028) and having associated injuries (P = 0.028).

Conclusion: Bullet injury was the most common penetrating abdominal trauma leading to one or more intra-abdominal organ injury and needing emergency laparotomy for treatment and prevention of complications. Postoperative complications from laparotomy were significantly associated with the condition of admission, the first operation of the Emergency Management Centre, the number of internal organs injured, the time needed to arrive at the hospital and presence of associated injuries.

Methods: A cross-sectional study was carried out from January to June 2016 in collaboration between the Clinical Biochemistry Department at the College of Medicine, Hawler Medical University and the Chemistry Department at the Faculty of Science and Health of Koya University. The study included 50 type 2 diabetic patients (group 1), and 50 healthy individuals (group 2).

Results: The mean value of serum gamma glutamyl transferase activity was significantly higher in type 2 diabetic patients (group 1) than that of healthy individuals (group 2) (P <0.001). The mean value of serum gamma glutamyl transferase activity in men diabetic patients was non significantly lower than women diabetic patients. The mean value of serum gamma glutamyl transferase activity in diabetic patients whose age was ≥50 years was non significantly higher than diabetic patients whose age was <50 years.

Conclusion: Based on the findings of the present study, it can be concluded that high serum gamma glutamyl transferase activity is an independent factor and has considerable potential in diagnosing and monitoring for type 2 diabetic patients.

Background and objective: The definition of an intranasal contact point is when two regions within the nasal cavity are opposing each other and resist separation following the application of a topical decongestant. A contact point should be identified by endoscopy, but some authors have used the appearance on computed tomography for the selection criteria. This study aimed to assess the role of some anatomical variations of the nose in rhinogenic contact point headache and to determine the role of surgery in the management of such headache.

Methods: This prospective (case-series) study included 30 patients from Rizgary Teaching Hospital in Erbil city, Iraq during the period of March 2015 to March 2017. All patients involved in this study were having symptoms for at least more than one year and not responding to medications.

Results: The study participants were 18 females and 12 males; their ages range between 18 and 43 years with a mean age of 26.90 years. Regarding surgical outcome, all patients underwent appropriate surgery and followed up for at least six months postoperatively. Twenty seven (90%) patients had a complete cure, three (10%) patients with ties or remaining the same and none (0%) with positive ranks.

Conclusion: The removal of contact points in patients with Rhinogenic Contact Point Headache is very effective for relieving the pain in carefully selected patients.

Background and objective: Electroencephalography is an essential component in the evaluation of patients with epilepsy. Electroencephalography provides important information about background electroencephalography and epileptiform discharges and the interictal spike or sharp waves. This study aimed to differentiate between epileptic and non-epileptic patients through electroencephalography investigation and determine its relationship with certain socio-demographic and clinical characteristics.

Methods: In this cross-sectional study included 400 cases (205 males and 195 females) with a mean age ± SD of 25 ± 14 years, referred to the private neurology clinic, Soran Medical Center between April 2013 and March 2017 for attacks of abnormal movements and or disturbed level of consciousness.

Results: Age-related prevalence of epilepsy showed a significantly higher prevalence (P = 0.001) of the disease among those who were 20 years and more. Epileptic patients showed significantly (P = 0.001) higher sharp slow waves and sharp waves, which were mainly dominated by parietal and occipital regions of the brain. Electroencephalography finding showed higher Beta rhythm followed by Alpha and Delta rhythms (73.5%, 14.3% and 9.0%, respectively), Patients with epilepsy (generalized and focal) had shown best rhythm adoption in Beta rhythm (75.2% and 70.2%, respectively), followed by Alpha rhythm (13.2% and 14.8%, respectively). Focal to bilateral (secondary generalized) and generalized motor epilepsy were the most common diagnosis among the epileptic cases (45.4% and 43.4%, respectively). The overall sensitivity of electroencephalography was 67.8%, and specificity was 63.5%.

Conclusion: The electroencephalography showed good sensitivity and specificity in diagnosing suspected epileptic patients, with interesting higher sensitivity than specificity. Not only the abnormal discharges, but the background dominating activity and the best rhythm adoption can help in the diagnosis of epilepsy.

Background and objective: Bullying (being a bully or a victim of bullying) is a common problem for children all around the world. The prevalence of bullying varies depending on the age, gender, and race of the individuals involved. This study aimed to explore the prevalence of each form of bullying among school adolescents of both genders and to measure the association of different forms of bullying with the sociodemographic characteristics.

Methods: A school-based cross-sectional study done in public schools across Erbil city of Kurdistan region of Iraq for the educational year 2016-2017. The sample was collected by multistage cluster sampling technique with a total number of 35 schools distributed through the six municipalities of Erbil. Data collection was done through a self-reported close-ended questionnaire.

Results: A total of 1070 school adolescents participated in this study. The mean age was 15.56 ±1.41 years, and males were 51.8% of the sample making male to female ratio 1:0.9. Sixty percent of the students reported being involved in bullying at least once through the last semester of the school year, 3.0% were bullies, 26.2% were both bullies and being bullied, and 31.8% were victims of bullying.

Bullying, victimization, and bully-victims were significantly higher among boys compared to girls for all forms of bullying. Significantly higher bullying prevalence was noticed among Arabs compared to Kurds and Turkmen.

Conclusion: Bullying behavior seems to be a widespread problem in schools of Erbil city.

Background and objective: Compounds having imine or azomethine (–C=N–) functional group are known as Schiff bases. Schiff bases compounds are found to be an active pharmacophore for the design and development of various bioactive lead compounds. In this study, several new Schiff base compounds have been synthesized and characterized.

Methods: Williamson ether synthesis process has been used to synthesize -alkyloxy and substituted benzyloxy of benzaldehyde. Differently substituted ether benzaldehydes used to react with 4-amino-1,5-dimethyl-2-phenyl-1,2-dihydro-3H-pyrazol-3-one in one hand and 1H-benzo[d]imidazol-2-amine on the other hand to produce Schiff base compounds.

Results: Synthesized ether derivative compounds (3a-e) were converted to new series of Schiff bases (4a-e and 5a-e) by condensation of equal molar amounts of compounds (3a-e) with different heterocyclic amines dissolved in absolute ethanol. All synthesized compounds were confirmed by (IR, ¹H-NMR, and ¹³CNMR) spectroscopy. All synthesized compounds were evaluated for antibacterial activities in vitro against Gram-positive and Gram-negative bacteria.

Conclusion: All compounds were purely synthesized, and all compounds were indicated growth inhibition against Escherichia coli, and Staphylococcus aureus, respectively with different inhibition zones staring from 13 to 33 mm.

Background and objective: Nimodipineis effective in the treatment of various cerebrovascular impairment, but its clinical potential is limited due to several undesirable characteristics such as low bioavailability which caused by first pass effect in the liver and low aqueous solubility. The main purpose of this study was to prepare nimodipine-loaded nanoliposomes for intranasal delivery and performing in-vitro studies.

Methods: The nimodipine loaded nanoliposome formula was prepared by ethanol-based proliposome method and characterized in term of particle size and size distribution, zeta potential, entrapment efficiency, and permeability studies. In addition, mucoadhesive nanoliposomes loaded nimodipine was prepared using chitosan as a mucoadhesive agent.

Results: The in-vitro studies explored particle size increased (122.48nm±0.002) for chitosan coated formulation after sonication in comparison to non-coated formulations (114.09 nm ± 0.025). Also, the zeta potential was positive for the sonicated chitosan-coated formulation (5.286 mV ±0.341) while for non-coated formulations with chitosan were found to be negative (-1.317 mV ± 0.153). The entrapment efficiency (76.033 % ± 0.094 %) and drug permeability (2.53 μg/ml in the duration of 240 min) were significant for chitosan-coated liposome compared to other formulations.

Conclusion: This study concludes that chitosan glutamate (PROTASAN^® UPG213)coatednimodipine-loaded liposomes can be considered as a promising novel formulation for an efficient intranasal delivery of nimodipine. Additionally, changes in the size of liposomes and zeta potential confirmed the existence of a coating layer on the surface of liposome pellets. Chitosan was found to significantly enhance the drug entrapment and could also be considered as a permeability enhancer.

Background and Objective: Ocular herpes is a recurrent viral infection caused by the herpes simplex virus-1. Herpes simplex virus type one HSV-1 is one of the most common ocular viruses causing subsequent inflammatory responses and corneal blindness worldwide. This study aimed to synthesize a series of novel mutual ester prodrug models to treat viral infection and subsequent inflammation at corneal tissue.

Various formulation strategies have been utilized to improve bioavailability by increasing ocular contact time and improving drug permeation. Chemical approaches, such as prodrug, directed to enhance the ocular bioavailability by improving physicochemical properties of the drug molecule, with the goal of improving drug permeation across cornea.

Methods: Steglich esterification method was to design and synthesis a library of novel mutual prodrugs to increase the bioavailability of acyclovir, owing to enhance the lipophilicity compared with acyclovir. In this study a number of non-steroidal anti-inflammatory drugs (NSAIDs) have been conjugated to acyclovir to improve corneal permeation through enhancing lipophilicity and reduce subsequent inflammation.

Results: The synthesized compounds were characterized through FTIR, ¹H-,¹³C –NMR and Mass spectral data. The partition coefficient (logP) of prodrugs were calculated and showed an increment in lipophilicity and permeability in comparison with acyclovir.

Conclusion: The strategy applied to design the novel compound hypothesized to be a novel mutual prodrug, and it may provide a higher absorption than hydrophilic parent (acyclovir) drug with concurrent anti-inflammatory activity.

Background and objective: Post-menopausal bleeding due to endometrial abnormalities is a common diagnostic challenge facing the ultrasonogists and referring gynecologists. This study aimed to detect the validity of transvaginal ultrasound to detect endometrial pathologies and its sensitivity and specificity for determining endometrial carcinoma in women with postmenopausal bleeding.

Methods: A diagnostic accuracy study of transvaginal ultrasound and diagnostic curettage was conducted for evaluation of endometrial pathology in the College of Medicine, Hawler Medical University from October2016to January 2018. The sample size included 55 women with post-menopausal vaginal bleeding. The ultrasound findings were compared with histopathological results of endometrial biopsy.

Results: Out of 55 women, 49.09% had endometrial atrophy, 29.09% had endometrial hyperplasia, 16.36% had endometrial polyp, 3.64% had endometrial carcinoma, and 1.82% had hyperplasia with atypia according to histopathological findings. The sensitivity of ultrasound in detecting cancer was 66.7%, the specificity was 100%, the positive predictive value (PV) was 100%, and the negative predictive value was 98.1%. The total agreement rate was 98.2%.

Conclusion: Transvaginal ultrasound is an excellent diagnostic tool to determine whether further investigation with histopathological examination of endometrial biopsy is necessary for postmenopausal vaginal bleeding.

Background and objective: Fluoride is used to prevent dental caries, and it has been one of the most effective and widespread agents. Fluoride level has been shown in saliva, plaque, and oral soft tissues after use of fluoridated toothpaste that persists at potentially active concentrations for hours. This study aimed to evaluate how fluoride in toothpaste intake can affect the salivary fluoride and test fluoride in tap water in the different places of Erbil city.

Methods: Forty five volunteers were examined. In the morning after overnight fasting before brushing teeth, the saliva of the subjects (healthy non-smoker adults) was taken before brushing teeth, which was a baseline. After 10 and 20 minutes of washing mouth with water (after brushing), saliva was taken and then the cotton pad was held under the tongue for 5 min. Saliva samples were frozen at -20 C^o for later analysis. Tap water samples in different places in Erbil city were analyzed.

Results: Toothpaste significantly (P = 0.002) increased salivary fluoride after brushing teeth. The fluoride concentration of tap water in Erbil city was very low at the places that use groundwater.

Conclusion: This research indicates that salivary fluoride significantly increases after brushing teeth. The fluoride concentration naturally occurring levels in the tap water in the places where the source is groundwater are not enough.

Background and objective: Rheumatoid arthritis is an autoimmune disease. This study investigated the potential value of combining cartilage oligometric matrix protein, anti-cyclic citrullinated protein, and 14-3-3 eta protein with traditional biomarkers to reduce the diagnostic gap.

Methods: This case-control study included 46 male and female patients and 42 age- and gender-matched adults as control group. The biomarkers were measured using ELISA technique.

Results: Tests for anti-cyclic citrullinated protein and cartilage oligometric matrix protein are excellent tools to diagnose rheumatoid arthritis because anti-cyclic citrullinated protein and cartilage oligometric matrix protein are associated with the highest ROC area. The validity of the test for 14-3-3 eta protein, which is a good test to predict rheumatoid arthritis, ranks second. The optimum cut-off values for high cartilage oligometric matrix protein, high anti-cyclic citrullinated protein, and high 14-3-3 eta protein were ≥0.242µg/L, ≥0.566ng/L, and ≥0.145ng/L, respectively. 14-3-3η protein, cartilage oligometric matrix  protein status as a parallel combination which is considered as a wonderful combination in classification criteria for rheumatoid arthritis. Parallel combination, both criteria two tests are positive, namely “high cartilage oligometric matrix protein (≥0.242) + high 14-3-3^η protein (≥0.145)” was associated with a perfect test, that the patients have rheumatoid arthritis (sensitivity 100%, specificity 100%,  accuracy 100%, positive predictive value at pre-test probability 50% and 90% = 100%). A positive test using this combination is 100% diagnostic and establishes a possible diagnosis of rheumatoid arthritis with 100%, while a negative test would exclude a possible diagnosis of rheumatoid arthritis with 100% confidence. 

Conclusion: Results confirmed that high serum level of cartilage oligometric matrix protein, anti-cyclic citrullinated protein, and 14-3-3 eta protein are significantly associated with increased risk for rheumatoid arthritis, demonstrating the potential value of combining these new biomarkers with traditional biomarkers to enhance diagnostic sensitivity and specificity and ultimately reduce the diagnostic gap.

Background and Objective: Antenatal care can help in preparing women for delivery in addition to raising awareness about the warning signs during pregnancy. This study aimed to assess the pattern of utilization of antenatal care services by the pregnant women in Syrian refugee camps in Erbil.

Methods: A cross-sectional study was conducted at the four Syrian refugee camps in Erbil between 1^st June 2015 and 1^st March 2016. A sample of 470 newly delivered women was included in the study. Data was collected through a specially designed questionnaire.

Results: The majority of the women (99.6%) had at least one antenatal care visit during pregnancy with 73.6% having adequate antenatal care visits. About 64% of the women visited both the public and private health sectors. A statistically significant higher proportion of employed women utilized adequate antenatal care services than the non-employed women (84% vs. 63.4%, P = 0.036). There was no statistically significant association between the mothers' age and education with the utilization of adequate antenatal care.

Conclusion: A high proportion of women in the Syrian refugee camps in Erbil received antenatal care services during the last pregnancy with a relatively important proportion of them receiving adequate care and having early initiation of antenatal care visits. Further studies are needed to examine the quality of the antenatal care services in the refugee camps and women’s satisfaction with these services.

Background and objectives: Cutaneous leishmaniasis can be classified into two different syndromes; New World and Old World. The later is acquired in Asia, Africa, the Middle East, or Europe. This study aimed to compare the effectiveness of intralesional pentostam with intralesional metronidazole in the treatment of cutaneous leishmaniasis.

Methods: An analytical observational study was carried out in the Dermatology Consultancy Department of Erbil Teaching Hospital in Erbil city from April to October 2017. A convenience sampling method was used to recruit 50 study participants who were diagnosed with having cutaneous leishmaniasis. A questionnaire was designed for data collection, and the size with the degree of in duration of the cutaneous lesions was measured. Patients received three injections of either intralesional pentostam or intralesional metronidazole on a two-weekly basis.

Results: The mean ± SD age of the participants was 32.38 ± 15.05 years. Most of the participants were male (72%). The mean diameter difference ± SD after receiving three intralesional injections on a two-weekly basis was 0.7692 ± 0.62017 cm for pentostam, compared to 0.4211 ± 0.62413 cm for metronidazole (P = 0.070).The mean difference in lesion's induration ± SD was 0.9091 ± 0.83121 for pentostam, compared to 0.6875 ± 0.70415 for metronidazole (P = 0.128).

Conclusion: Intralesional injection with metronidazole has shown some degree of cure in terms of decrease in the size and induration of the lesions. Although statistically insignificant, intralesional injection of metronidazole was less effective than intralesional injection of pentostam. Further studies are needed with a larger sample size to better understand the effectiveness of metronidazole in the treatment of cutaneous leishmaniasis.

Background and objective: Many drugs and chemical substances may induce sexual dysfunction and have a negative impact on male fertility. Lipid-lowering agents like statins and fibrates are usually recommended for cardiovascular diseases prevention. However, the combination of atorvastatin and fenofibrate is the subject of questions concerning their effect on androgenic activities in this study. This study was designed to evaluate the efficacy and toxicity of atorvastatin, fenofibrate, and their combination on sperm parameters, sexual hormones, and histopathology of the testis.

Methods: Twenty-four male rats were divided into four groups, each of six. The first group served as a control. The second, third, and fourth groups received atorvastatin, fenofibrate, and their combination, respectively. After 28 days, blood samples were collected for hormones and other parameters evaluations. Testis and epididymis were taken for histopathology studies and sperm parameters assessments.

Results: Fenofibrate showed a significant reduction in sperm viability and serum levels of luteinizing and estradiol hormones. The combination of both drugs significantly reduced the sperm count and viability in normal male rats. Both atorvastatin and its combination mildly changed the histological structures of the testis, reduced number of spermatozoa, and arrested spermatogenesis.

Conclusion: The findings from this prospective study suggested that there was no harmful effect of atorvastatin usage on conventional sperm parameters and sexual hormones.  Fenofibrate usage was not adversely associated with sperm parameters other than sperm viability. The combination of atorvastatin and fenofibrate significantly reduced the sperm count and viability. No deleterious effects of the drugs were seen on the testosterone, which was the essential hormone for all stages of spermatogenesis, sperm production, maturation, and transport.

Background and objective: Hypotensive attacks commonly occur during induction of anesthesia and can result in irreversible ischemic damages to the vital body organs. This study aimed to assess the effect of using ephedrine at low doses in controlling hemodynamic changes induced by anesthesia.

Methods: A single centered single-blinded, prospective comparative study was conducted in Erbil cardiac center in periods between January 2018 and July 2018. A total of 150 patients with left ventricular ejection fraction <40% and age younger than 80 years were included in this study. They were divided into three main groups; the 1st group was the placebo group, the 2nd group received ephedrine at a dose of 0.035mg/kg body weight, and the 3rd group received ephedrine at a dose of 0.07 mg/kg body weight. Systolic blood pressure, diastolic blood pressure, mean arterial blood pressure, and heart rate were reported in three different phases; before induction, two minutes after induction, and five minutes after induction of anesthesia.

Results: In the placebo group, induction of anesthesia by 3mcg/Kg of remifentanil significantly reduces diastolic, systolic, and mean arterial pressure with P <0.001. At two minutes after using ephedrine at the dose of 0.035 mg/kg in the induction of anesthesia significantly increases the diastolic, systolic, and mean arterial pressure with P = 0.002, <0.001, and 0.007, respectively, and at five minutes after induction with P = 0.02, 0.03, and 0.04, respectively. Using ephedrine at a dose of 0.07mg/kg induction of anesthesia was found to significantly increase the diastolic, systolic, and mean arterial pressure with P <0.001 for all the readings. The heart rate was not significantly affected by using remifentanil alone or in combination with ephedrine during induction of anesthesia.

Conclusion: Using ephedrine at different doses during induction of anesthesia with remifentanil in patients with low ejection fraction significantly prevents hypotensive attacks.

Background and objective: Ocular drug delivery research is challenging due to the presence of anatomical and physiological barriers. The ophthalmic preparation of diclofenac sodium (DC) for relieving ocular inflammation is presently available in the market only as an eye drop solution with low ocular bioavailability. The goal of our study was to prepare and evaluate an eye drop formulation, containing a nanocarrier, chondroitin sulfate (CS)-chitosan (CH)-nanoparticles (NPs) (CS/ CH-NPs) is being evaluated for improving the bioavailability of diclofenac sodium into the eye.

Methods: Formulation was developed and optimized for three different variables (chondroitin sulfate, chitosan, and initial drug concentration). The developed formula was evaluated by various in-vitro parameters such as particles' size, entrapment efficacy, zeta potential, and in vitro release profile.

Results: The particles' size, entrapment efficacy, and zeta potential of the best formulation were found to be 251.1±15.12nm, 73.2±5.3%, and 38.89±5.05mV, respectively. Furthermore, the best formulation showed a biphasic release profile, initial burst release in the first hour, followed by sustained release within 24hours.

Conclusion: Promising results of in-vitro studies indicated that CS-CH-NPs could be a potential substitute for improved ocular delivery of diclofenac sodium.