Vol 23, No 3 (2019)

Background and objective: Adherence to antihypertensive drugs is very important for controlling blood pressure and preventing its complications. This study aimed to assess the adherence level to antihypertensive drugs in adult hypertensive patients in Erbil city and examine its association with socio-demographic characteristics and access to medications.

Methods: A household survey was carried out in 20 quarters of Erbil city using a multi-stage sampling method. Adult patients known to have hypertension were identified. A questionnaire designed for this purpose was used to collect data about the socio-demographic and clinical characteristics, access to antihypertensive drugs, and adherence to drugs. 

Results: Of 373 study participants known to have hypertension, 87.9% were taking their antihypertensive treatment regularly, 5.9% were taking the treatment irregularly, while 6.2% were not taking any treatment. Around 77% of the patients were obtaining their drugs from private pharmacies, and the rest were getting them for free from the public hospitals. A statistically significant association was found between adherence to drugs, and increasing age, duration of having hypertension, and economic status.

Conclusion: The antihypertensive drug adherence among our sample was relatively good. Access to free drugs was limited. Drug adherence was significantly associated with increasing age, increased the duration of hypertension, and economic status. Similar studies need to be conducted in rural areas for comparison purposes.

Background and objectives: Punicagranatum (pomegranate) is a fruit-bearing deciduous shrub or small tree from the family Lythraceae. It has been cultivated since ancient times throughout the Mediterranean region. Different parts of it have been used for research, such as fruits, peels, and juice. This study aimed to investigate the antibacterial and anti-ulcer effect of Punicagranatum peel extract and to screen the expression of transforming growth factor β1 (TGF β1) in rat’s blood serum after stomach ulcer was induced by ethanol.

Methods: Twenty four rats were divided randomly into 4 groups; GroupI(ulcer positive group) rats were (experimental) orally administered 5 ml/kg sterilized distilled water (the vehicle). Group II (ulcer negative group) rats were orally administered 5 ml/kg of 20 mg/kg esomeprazole. Groups III and groups IV were orally administered 5 ml/kg of 250 and 500 mg/kg of Punicagranatum plant extract, respectively.

Results: Data showed an antibacterial activity of Punicagranatum peel extract against gram positive and gram negative bacteria and the best antibiotic in which both bacteria were sensitive to was norfloxacin(10 µg). Treatment with Punicagranatum peel extract and esomeprazole had protective effects on stomach gastric mucosa, which indicate an anti-ulcer effect confirmed by the high levels of TGFβ1 in serum.

Conclusion: We conclude that Punicagranatum peel extract exhibit antibacterial effect and possess a protective role against ethanol induced gastric ulcer in rats.

Background and objective: The prevalence of Streptococcus pneumoniae and resistance to antibiotics has become a public health problem in different countries of the world. This study aimed to investigate the occurrence of Streptococcus pneumoniae nasal carriage among children, and their antibiotics susceptibility profiles.

Methods: A nasal swab was obtained from 1092 healthy children aged from 6 to13 years in Erbil Parks, Kurdistan region, Iraq. The swabs were cultured on appropriate culture media to isolate Streptococcus pneumoniae and to examine their susceptibility to antibiotics. The antibiotic susceptibility testing was performed using the standard disk-diffusion method.

Results: Streptococcus pneumoniae was isolated from 224 (20.51%) of the specimens; 57.59%, and 56.25% of isolates were resistant to penicillin and ampicillin, respectively, while 3.57% and 4.46% were resistant to clarithromycin and moxifloxacin, respectively. None of the isolates had resistant to vancomycin.

Conclusion: There is a high prevalence of penicillin and another β-lactam drug resistance among isolates of Streptococcus pneumoniae from the nasal carriage of children in our region.

Background and objective: Atrioventricular nodal reentry tachycardia is the commonest type of supraventricular tachycardia referred to the electrophysiology laboratory. It constitutes about two thirds of the supraventricular tachycardia admitted to the emergency department. The mechanism of this tachycardia is reentry. This study aimed to evaluate the efficacy of radiofrequency ablation therapy in atrioventricular nodal reentry tachycardia as the first line treatment using the conventional method.

Methods: The standard technique for the electrophysiological study done to induce tachycardia. Three or four catheters were used. Atrial or ventricular programmed stimulation used to induce the tachycardia. Differentiation of the atrioventricular nodal reentry from atrial tachycardia and atrioventricular tachycardia done by ventricular entrainment. The dry ablation catheter of 4 mm tip used to modify the slow pathway. The appearance of junctional rhythm was a sign of the effective application of the radiofrequency application. The success of ablation was indicated by a failure to induce the tachycardia with repeated programmed stimulation.

Results: Seventy patients with atrioventricular nodal reentry tachycardia were selected from total supraventricular tachycardia cases of 106 patients referred to the catheter lab for radiofrequency ablation. In 85% of the cases atrial programmed stimulation were used to induce the tachycardia and ventricular programmed stimulation and in 15% of the cases. Acute success rate was seen in 68 patients (97%).

Conclusion: Catheter radiofrequency ablation is becoming technically easy, safe, and reliable as first line treatment in the majority of patients with atrioventricular reentry tachycardia.

Background and objective: Patients affected by fibular hemimelia primarily presented clinically as foot deformities and limb length discrepancies. Surgical restoration of normal limb alignment and length has been reached by using Ilizarov technique. This study aimed to determine the outcome of using Ilizarov procedure in the management of lower limb discrepancy cases in Erbil.

Methods: This study is a review of fibular hemimelia cases managed at the orthopedic department of Erbil Teaching Hospital between November 2014 and June 2018. Fibular hemimelia patients complaining from lower limb shortening of 3–11 cm were included in this study. All patients were examined pre and post application of Ilizarov procedure to determine the range of lower limb motion by using the lower extremity functional scale. Ilizarov operative technique was used for the correction of deformities and restoration of normal limb length and alignment.

Results: Eight fibular hemimelia patients, including three males, were enrolled in the study with a mean (±SD) age of 7.37 ± 4.13 years (range from 3 to 16 years). They had a mean limb shortening of 6.06 ± 2.36 cm. A wide range of residual deformities and congenital anomalies was reported among fibular hemimelia cases. A number of residual deformities and complications were associated with Ilizarov technique affecting the knee joint, proximal tibia, and ankle joint. Improvement in the lower extremity functional scale from quite a bit and moderate difficulty to a little bit of difficulty (P <0.001) between the two means of pre and postoperative lower extremity functional scale was demonstrated.

Conclusion: Ilizarov procedure is effective in improving the lower extremity function in fibular hemimelia despite the associated complications and leg length inequality.

Background and objective: The association of metabolic syndrome and subclinical hypothyroidism is a matter of debate. Both confer an increased risk for cardiovascular disease and type 2 diabetes mellitus, and previous studies showed overlap between features of both conditions. This study aimed to evaluate the association of subclinical hypothyroidism with metabolic syndrome in young women.

Methods: This case control study was conducted in the internal medicine consultation department of Rizgary Teaching Hospital Erbil, Iraq, from May 2017 to May 2018. Sixty eight consecutive women with the metabolic syndrome as per the Harmonizing definition were compared to 95 age matched women with no metabolic syndrome as a control group. Detailed history and physical examination with blood pressure and waist circumferences recorded and appropriate fasting blood samples were tested for plasma glucose, lipid profile, TSH, free T3, and free T4.

Results: Subclinical hypothyroidism was present in 10 (14.7%) of the 68 women with metabolic syndrome and four women (4.2%) of the 95 control group with a significant difference (P = 0.018). Central obesity, hypertriglyceridemia, and low levels of high density lipoprotein were present in 9 (17.3%), 9 (23.1%), and 10 (16.4%) women with subclinical hypothyroidism with a significant difference for each association (P = 0.013, 0.001 and 0.006, respectively).

Conclusion: There is a significant association between subclinical hypothyroidism and metabolic syndrome in young women.

Background and objective: Dry powder inhalation provide many promising features for drug delivery to the pulmonary system, such as localization of drug within the lungs, drug retention in the respiratory tract, and reduced systemic toxicities. This study aimed to prepare dry powders of liposomes containing salbutamol sulfate using spray drying and study the influence of carrier type and concentration on liposome size and drug entrapment following rehydration of liposomal powder.

Methods: Ethanol based proliposomes technique was used to generate liposomes containing salbutamol sulfate. Carbohydrate carriers: lactose, trehalose, sucrose, and mannitol in 1:6 or 1:10 (w/w) lipid to carrier ratio were separately incorporated into liposome formulations and dried by Büchi Mini-SprayDryerB-290. The protective effects of the sugars were investigated in terms of product yield (%), volume median diameter and size distribution of liposomes and entrapment efficiency of the drug.

Results: The product yield (%) of spray dried liposome formulations with carriers was in the following order; trehalose (94.02 ± 1.20%) > sucrose (69.91 ± 1.75%) > lactose (68.30 ± 1.14%) > mannitol (50.16±0.80%) for the 1:6 formulations. Depending on the carrier type and lipidto carrier ratio, the vesicle size of liposomes with lactose and mannitol increased significantly (P <0.0001 and P = 0.0027, respectively), while the vesicle size with trehalose and sucrose varied to a lesser extent (P >0.05) compared to the control formulations (3.6µm ±0.24). For 1:10formulation, the vesicle size with mannitol (P <0.001) and sucrose (P <0.001) increased significantly. The drug entrapment efficiency using the 1:6 formulations was 20.74±1.78% for sucrose, 35.59±2.42% for trehalose, 67.21±1.89 % for lactose, and 80.84±3.64% for mannitol.

Conclusion: Stable spray-dried liposomes were manufactured using sugars as carriers. The findings of this study have demonstrated the potential using of carbohydrate carriers to increase the physical stability of liposomes during the drying process, and trehalose can offer formulations with most desirable characteristics, while mannitol showed the least benefits.

Background and objective: Inflammatory process and genetic factors play a key role in neoplasia of colorectal cancer. Cyclooxygenase-2 is involved in a variety of important cellular functions, including cell growth and differentiation, cancer cell motility and invasion, angiogenesis, and immune functions. This study aimed to evaluate the frequency of cyclooxygenase-2 in colorectal cancer and its correlations with different clinicopathological parameters.

Methods: A study carried out in the Department of Pathology in Rizgary Teaching Hospital and private laboratories in Erbil city from May 2015 to February 2016. Eighty formalin-fixed paraffin-embedded specimens of colorectal cancers were collected. The clinicopathological data was collected by the researcher from records of known cases of colorectal carcinoma in Erbil city and was done in a private laboratory in Dohuk city.

Results: High cyclooxygenase-2 expression was represented by 63.8% of colorectal carcinoma patients, and low expression was represented by 36.2% of them. There was a significant association between the mucinous subtype of colorectal carcinoma and low cyclooxygenase-2 expression (P = 0.01). A significant association was observed between moderately differentiated carcinoma and high cyclooxygenase-2 expression (P = 0.04). A significant association was also noted between increased tumor size and high cyclooxygenase-2 expression (P = 0.03).

Conclusion: Cyclooxygenase-2 expression is more likely to be prevalent among colorectal carcinoma patients and is correlated to tumor subtypes (low in mucinous subtypes), grade (high in moderately differentiated), and tumor size (high in the big sized tumor).

Background and objective: Hypertensive disorders during pregnancy remain one of the major causes of maternal and fetal morbidity and death. Subclinical thyroid disease may play an important underlying cause of hypertension during pregnancy. This study aimed to find out the prevalence of subclinical thyroid disease in a sample of pregnant women with hypertension during labor.

Methods: A cross sectional study was performed at the Maternity Teaching Hospital, Erbil city, Kurdistan region, Iraq, from January to December 2016.Two hundred fifty women were included in this study, all with hypertension related to pregnancy (pregnancy induced hypertension, pre-eclampsia, and eclampsia). The TSH and serum free T4 levels were estimated and the participants were classified to be euthyroid, subclinical hyperthyroid, or subclinical hypothyroid. A specially designed questionnaire was used to collect data.

Results: Of the 250 women included in our study, 191 (76.4%) had TSH levels within the normal range and were considered to be euthyroid, 59 (23.4%) had TSH levels more than 4 milliunits/L meeting the criteria of sub-clinical hypothyroidism. There were no cases of subclinical hyperthyroidism (TSH level below normal).

Conclusion: Subclinical thyroid disease may be a contributory factor in the development of hypertension during pregnancy. No correlation was found between subclinical hyperthyroidism and hypertension during pregnancy.

Background and objective: Congenital anomalies of the female genital tract is a known cause for infertility and recurrent pregnancy losses. This study aimed to evaluate the pattern and prevalence of each type of congenital malformation of the reproductive tract among infertile women attending the IVF center in the Maternity Teaching Hospital in Erbil city.

Methods: A retrospective study was conducted in Center of Dr. Khawer for Infertility and IVF in the Maternity Teaching Hospital in Erbil city. Data of five years from the 1^st January 2010 to the 1^st January 2015 were collected from patient files, such as age, sex, residence, type of infertility, type of anomaly, duration of infertility, Karyotype, Intervention, Success rate of intervention, cycle, parity, history of abortions, history of preterm deliveries, and history of ectopic pregnancy.

Results: The prevalence of congenital reproductive system anomaly was 4.1% among infertile women. The sub-septate uterus was the most common type (23.24%) anomalies. No significant association was found between the types of the anomaly and the type of infertility. The genetic factor was found to has a significant role in developing such a condition. Success rate after management significantly raised to 61.1% with sub-septate uterus (91.3%) bicornuate/ partial (85.7%), and septate/ complete (72.2%).

Conclusion: One of the causative factors of female infertility is congenital anomaly. Most types have a good prognosis in achieving pregnancy after proper management.

Background and objective: The tolerance of biofilms to antibiotics results in the dissemination of resistance. Many of the recurrent urinary tract infections are assumed to be caused by biofilm producing uropathogenic isolates. This study aimed to investigate the correlation between the ability of biofilm formation and extended spectrum beta lactamase producing uropathogens.

Methods: A total of 438 urine specimens were collected from Rizgary Teaching hospital in Erbil, Iraq, from September to December 2017. Extended spectrum beta lactamase was determined using the Vitek-2 automated system and confirmed by using the combination disk diffusion test. Biofilm formation was checked using 96-well flat bottom microtiter plates.

Results: Out of the 438 urine specimens, only 37.89% (n =166) developed an infection, the most common isolate was Escherichia coli. The distribution of the bacterial species according to the patients' gender found to be significant (P = 0.014). The proportion of betalactamase producing isolates was 29% (n = 31). The strength of biofilm formation among Klebsiella species was significantly higher than in Escherichia coli (P <0.001), while a non-significant difference (P = 0.163) was observed between beta lactamase production and ability of biofilm formation. The sensitivity and specificity of VITEK-2 in the detection of extended-spectrum beta-lactamase were 79.48% and 80.95%, respectively.

Conclusion: The study revealed that Klebsiellae species were stronger biofilm producers. Beta lactamase producing isolates do not have a greater ability of biofilm formation.

Background and objective: Cadmium is a widely distributed metal in the environment that causes testicular toxicity and various tissue damage associated with hypertension. Omega-3, an essential fatty acid, has been demonstrated to be an effective antioxidant and anti-inflammatory agent. This study aimed to investigate the toxic effects of cadmium on cardiovascular and reproductive systems in male rats and examine the possible protective effects of omega-3 against cadmium-induced hypertension and testicular dysfunctions.

Methods: The rats were divided into three groups. The first group served as the control, the second group received cadmium chloride in drinking water, and the third group received cadmium chloride plus omega-3 for 28 days. Blood pressure and heart rate were estimated. Blood samples were collected; sexual hormones and other biochemical parameters were evaluated. Testes and epididymis were taken for semen analysis and histopathology.

Results: Significant adverse effects were seen in the studied parameters of the cardiovascular and reproductive systems after cadmium exposure, including hypertension, alteration in sperm parameters, weights of sex glands, and histological structures. In contrast, co-administration of omega-3 significantly reduced mean blood pressure, but improved sperm parameters and the histology of testis. No protective effect of omega-3 could be seen on male hormone and lipid profile parameters except high-density lipoprotein.

Conclusion: Exposure to cadmium induced hypertension, impaired testicular functions, and histology. Omega-3 has protective effects on vascular and testicular functions. Therefore, supplementation with omega-3 had a protective effect against cardiovascular and reproductive toxicity induced by cadmium.

Background and objective: Reports indicate that Rheum ribes has antihyperglycemic effects. This study aimed to find out the hypoglycemic effects of aqueous extract of Rheum ribes on the pancreatic tissue of diabetic male rats and compare the results of both histological and biochemical findings with that of metformin.

Methods: Thirty-two albino male rats were divided into four groups with eight animals for each group; 1^st group as normal control, 2^nd group as alloxan induced diabetics, 3^rd group as diabetic treated with Rheum ribes, and 4^th groups as diabetic treated with Metformin. The body weight and fasting blood glucose levels of all the rats were recorded at weekly intervals during the experimental period. Biochemical, histochemical, and immunohistochemical investigations were used.

Results: Diabetic rats showed a decrease in serum amylase with marked elevation in blood glucose level. Histological examination of the pancreas from diabetic rats revealed an increase in the thickness of the basement membrane of the blood vessels and capillaries in islets of Langerhans, as well as decreased activity of Beta-cells and increase the activity of Alpha and Delta cells using both Periodic Acid Schiff stain and immunohistochemistry techniques. Administration of aqueous extract of Rheum ribes caused significant and dramatic changes in most of the parameters measured in this study, including an increase in serum amylase, and lowering the level of blood glucose, in comparison to the diabetic group.

Conclusion: Daily administration of Rheum ribes significantly reduced blood glucose and caused a marked increase in the activity of Beta-cells, followed by a decrease in the activity of Alpha-cells. The results of tissue structures and serum biochemical estimation indicated that the plant extract has regeneration and repair effects.

Background and objective: Atopic dermatitis is a chronic, relapsing inflammatory disease of the skin. It is a common disease that primarily affects young children. It results from complex interactions between genetic susceptibility genes. This study aimed to assess atopic dermatitis among the affected cases, mainly in terms of age and gender distribution, and its clinical and laboratory findings.

Methods: A descriptive cross sectional study was carried out in two private clinics in Erbil city. A convenience sampling method was used to recruit 70 study participants who were clinically examined by the investigator. A questionnaire was specially designed for interviewing these patients. The diagnosis was made on the clinical ground. Patients were also sent for blood investigations and a skin swab for microscopic examination.

Results: The mean ± SD of the participants' age was 20.57 ± 17.94 years. Females constituted 68.6% of the participants. More than 64% of the patients had generalized body lesions, 54.3% had a positive family history of atopic dermatitis, and 48.5% had a history of other atopic diseases. The majority (58.3%) of those aging less than two years had face lesions while the majority (74.4%) of the patients aging more than 15 years had generalized body lesions, and this was statistically significant.

Conclusion: Atopic dermatitis affects a wide age group, and different age categories have different sites of the lesion. Family history is a prominent feature of the disease. Clinically, lichenification is more among older age groups compared to the eczematous lesion, which is more among younger age groups.

Background and objective: Tuberculosis is a major public health problem worldwide, especially in developing countries. The disease poses a massive threat to public health, causing increased morbidity and mortality. Therefore, early detection is essential to reduce the death rate and interrupt transmission. In this study, GeneXpert assay was used for the rapid identification of bacteria, and its sensitivity and specificity were compared with acid fast bacilli staining in both pulmonary and extrapulmonary clinical specimens.

Methods: A total of 115 pulmonary and extrapulmonary samples were collected and diagnosed for tuberculosis detection. Acid fastbacilli, culture, and GeneXpert methods were used for the diagnosis of tuberculosis.

Results: Out of 115 tuberculosis specimens, 70 were acid fast bacilli smear positive, while 97 samples were positive for Mycobacterium tuberculosis by GeneXpert assay. The results indicated a higher sensitivity of GeneXpert assay compared to the acid fastbacillistaining method. The sensitivity of GeneXpert was 91.6%, specificity 50%; positive and negative predictive values were 89.7% and 55.6%, respectively. No significant differences were detected between the Gene Xpert test results and the culture results (P = 0.815), and the total agreement between the tests was 84.3%.

Conclusion: We concluded that the GeneXpert test results is sensitive as culture results for both pulmonary and extrapulmonary specimens. Although culture remains the gold standard for laboratory confirmation of tuberculosis disease, GeneXpert should become standard practice for patients suspected of tuberculosis, and all clinicians and public health tuberculosis programs should have access to molecular testing for tuberculosis to shorten the time of diagnosis.

Background and objective: Colorectal carcinoma is one of the commonest cancers and the second leading cause of cancer death in Europe and North America. Despite the improved surgeries and adjuvant therapies, the prognosis of colorectal cancer remains poor, and the survival rate is unsatisfactory. Overexpression of HER2 gene has been noticed in many human cancers, and it is associated with poor prognosis. This study aimed to detect the frequency of the HER2/neu immunoexpression in colorectal carcinoma and investigate its association with the clinicopathological parameters.

Methods: A retrospective study was carried out in Rizgary teaching hospital and private laboratories in Erbil city for the period from January 2014 - December 2017. A total of 103 formalin fixed, paraffin embedded, archival tissue blocks of colectomy samples of colorectal carcinoma cases were collected. Immunostaining was done in a private laboratory (Vin Lab) in Dohuk city. Scoring of the HER2/neu immunostaining was managed according to published criteria for breast carcinoma.

Results: Fifty-five cases (53.4%) were labeled as positive for HER2/neuimmunoexpression. While 48 (46.6%) of the cases were labeled as negative. HER2/neu status was significantly associated with the tumor grade (P = 0.02), while no significant association was found between HER2/neu expression and other clinicopathological parameters.

Conclusion: HER2/neu immunoexpression was observed in 53.4% of the cases of colorectal carcinoma, and it was significantly associated with tumor grade.

Background and objective: Trauma to the chest is a life-threatening condition because the chest contains many vital organs such as the heart, multiple blood vessels, and lungs. This study aimed to identify the pattern and outcome of the war-related penetrating chest injuries at the Emergency Management Center, Erbil, during the Islamic State in Iraq and Syria conflict.

Methods: This retrospective study involved 154 chest injured victims at the Emergency Management Centre in Erbil City. Data were collected from the Statistics Department of this hospital from June 2014 to July 2017.

Results: The mean (SD) age of the victims was 25.75 ± 11.567 years. The majority of the cases were young (61%), male (85.1%), Kurds (72.1%), and injured outside Erbil governorate (40.9%). The leading cause of injury was bullet injury (74.7 %). Provision of the first aid before admission was high (87%). Most victims did not have any other injuries (66.9%). Surgical operations were performed to the majority of victims (93.5%). Most of them did not develop any complications (78.6%), with only 21.4% of the cases had some complications. The development of the complications was significantly associated with the presence of other injuries (68.6% vs. 83.5%, P = 0.034).

Conclusion: During the Islamic State in Iraq and Syria related war in Iraq, chest injury by gunshot had increased. The Emergency Management Center provides a suitable medical service that helped in reducing complications and deaths. The development of complications was significantly associated only with the presence of multiple injuries.

Background and objective: Colonoscopy, which is the visual examination of the large bowel and distal part of the small bowel, is an important diagnostic and therapeutic procedure. This study aimed to find out diagnostic findings of endoscopies in Erbil endoscopy unit and relation to important personal data including age and gender.

Methods: An observational study was carried out from July 2017 to October 2017. Colonoscopies were done for 125 patients who met the inclusion criteria.

Results: The findings of 125 colonoscopies were classified into gross and pathological findings. Colitis was found in 17 patients (13.6%), of which 10 patients (58.4%) had inflammatory bowel disease with higher incidence in females (60%). Polyps were found in 20 patients (16%) with adenomatous type being the most common pathological type (12 patients, 60%). Grossly sessile types were found in 13 patients (60%).Malignant tumors were found in eight cases (6.4%) with male predominance (62.5%). Ulcers were found in six cases (4.8%), and diverticula in five cases (4%). Normal colonoscopy was found in 46 cases (36.8%), with majority of these cases (37 cases) aged 21-41 years. Hemorrhoids were found in 23 patients (18.4%).

Conclusion: Polyps were the most common colonic mucosal pathology with male predominance and older ages, followed by colitis with a higher incidence in females. Malignancies had lesser frequencies, the majority being in male and old age people. Normal colonoscopies and hemorrhoids were the largest groups, and diverticula with ulcers were the least findings.