Vol 21, No 1 (2017)

Background and objective: Perforation of the maxillary sinus by a dental implant is an issue of concern by many dental implant clinicians. This study aimed to assess the success rate and consequences of dental implants emerging into the maxillary sinus.

Methods: The maxillary sinus was intentionally perforated for dental implant placement in 35 patients with reduced posterior maxillary bone height (4 mm or more). A total of 70 implants engaged bicortically and emerged into the sinus. Nineteen female and 16 male patients were involved in the study. The patients were followed up for sinus complications and dental implant success.

Results: From the total, only two implants were failed; one during gingival former placement and the other after loading by one year. No patient presented with sinusitis clinically and radiographically. Three patients developed epistaxis just on the day of surgery and became well after on.

Conclusion: Within the limits of this study, dental implant emergence into healthy maxillary sinus is considered a safe and successful procedure.

Background and objective: Oral mucositis is currently considered to be the most severe complication of anticancer therapy such as cyclophosphamide (CTX). Ascorbic acid is a well-known antioxidant, which can protect the body from damage caused by free radicals that can be generated during normal metabolism as well as through exposure to toxins and carcinogens. This study aimed to evaluate the effectiveness of ascorbic acid as a treatment for CTX induced oral mucositis. 

Methods: Forty Wister-albino rats, age about 6-8 weeks and weighing 150-200 g were used. The rats were randomly divided by simple random allocation into two groups (20 animals each). The control group was intraperitoneally injected with physiological saline and the animals were grouped randomly into two groups: Saline/Water treated group which were daily received intraperitoneal injection of distilled water, while the Saline/Ascorbic acid treated group received a daily intraperitoneal injection of ascorbic acid (12mg/kg/day). For the induction of mucositis, a single dose (300 mg/kg) of CTX was administered intraperitoneally to each animal in the study group, and the animals were grouped randomly into two groups: CTX /Water treated group which was daily received intraperitoneal injection of distilled water, while the CTX /Ascorbic acid treated group were daily received intraperitoneal injection of 12 mg/kg /day of ascorbic acid. The animals were sacrificed at day four and eight (five animals each) and the tongue was dissected from the jaw for histological and immunohistochemical analysis.

Results: Ascorbic acid decreased the severity of the induced CTX oral mucositis by a significant increase in epithelial thickness, significant decrease in damage score, and significant increase in PCNA immune expression at day four and eight respectively (P <0.05).  

Conclusion: CTX chemotherapy has a deleterious effect on the oral mucosa leading to marked morphometric and microscopic changes. Ascorbic acid can protect the oral mucosa from CTX-induced cytotoxicity, and attenuate or decrease the associated injury.  

Background and objective: Chamomile has been used as an herbal medication since ancient times and is still popular until today. This study aimed to investigate the potential anticytotoxic effect of chamomile extract on the lingual mucosa of rabbits treated with 5-fluorouracil (5-FU).

Methods: Thirty six rabbits were used in the study. For induction of tongue mucositis for the study group, 5-FU at a dose of (4 mg/kg) was administered intraperitoneally one time daily for five successive days. The control animals were intraperitoneally injected by normal saline one time daily for five successive days. The rats in each group were randomly divided into two groups: Distilled water and chamomile extract treated groups (9 animals each). A volume of distilled water equal to chamomile extract was given by gavage tube, while the other group was gavaged with chamomile extract at a dose of (100 mg/ kg) one time daily. The treatment with distilled water or the chamomile extract was continued for sixteen days and then the animals were sacrificed, and the tongues were
excised for histopathological and immunohistochemical analysis.

Results: The 5-FU/water treated group showed a significant increase in histological damage scores, decrease in the ki-67and increase in caspase -3 epithelial immune expression (P <0.05) in comparison with saline/water treated group. The 5-FU/chamomile treated group showed a significant increase in damage score, significant decrease in ki-67 immune expression and significant increase in caspase-3 immune expression (P <0.05) in comparison with 5-FU/water treated group.

Conclusion: Chamomile extract at a dose of (100 mg/ kg) one time daily for sixteen days cannot be used for the treatment of oral mucositis. It causes damage to the tissue, decreases proliferation, and increases apoptosis.

Background and objective: Bacterial resistance to conventional antibacterial agents has increased recently and this resistance results in complicated infections. Multiple protective mechanisms can evolve in mammalians to maintain the body protected from infections. Human cathelicidin antimicrobial peptide LL-37 and acidified nitrite are important components of the innate immune system that partake in preventing infections. Cathelicidin peptide LL-37 can be produced by epithelial tissues as well as by macrophages after microbial infections. This study was carried out to evaluate the antibacterial activity of LL-37 and acidified nitrite (AN) both individually and combined for their effect against the standard the strains of E.coli ATCC 25922 and S. aureus ATCC 25923.

Methods: Flat-bottom micro well plates (96 wells) were used for the determination of bacteriostatic activity. Sodium nitrite (NaNO2) and ascorbic acid (AA) were used to produce acidified nitrite (AN). The singular and combined forms of the antibacterial agents were used for evaluating the antibacterial activities of LL-37 through estimation optical density values at 480nm (OD480nm).

Results: The LL-37 peptide showed antibacterial activity against E.coli ATCC 25922 and S. aureus ATCC 25923. The antibacterial efficacy was enhanced when the peptide was tested in combination with AN (P <0.001). In contrast, the combination of LL-37 with NaNO2 and AA has an antagonistic effect (P <0.001) on its antimicrobial properties.

Conclusion: The combination of LL-37 with AN has a synergistic on the peptide’s antimicrobial effect. Therefore, LL-37 which might show little antibacterial activity when used alone can provide protection when used in combination therapy with other antimicrobial agents.

Background and objective: Retrograde ureteroscope has recently gained a broaden indication for use in from diagnostic to a variety of disorders that occur in the upper urinary tract. This study aimed to review our five years experience with ureteroscopic management for ureteral stones and to compare our rates of efficacy and safety of ureteroscopy with other centers.

Methods: Review of 736 consecutive patients who underwent ureteroscopic procedures for the treatment of upper urinary tract problems between January 2010 and January 2015 was done in Erbil, Iraq. Out of those patients, 587 patients underwent a ureteroscopic procedure for the treatment of ureteric calculi. The studied variables were patients and stones characteristics, in addition to the mean operative time and mean hospital stay, the stone-free rate, and complication rates were also calculated.

Results: The overall success rate (complete stone clearance) in 587 patients was 550 patients (93.7%). Mean operative time was 26.1 minutes and mean hospital stay was <24 hours. The overall complication rate was 12%. The intra-operative complication rate was 3.2%, the early postoperative complication rate was 8 %, and the late postoperative complication rate was 0.85%.

Conclusion: Growing skill and experience of ureteroscopy will lead to a significant increase in the success rate and reduce complications.

Background and objective: One of the fundamental aims of all medical schools is to ensure that medical graduates are prepared to start work safely as junior doctors. The transition of medical students to junior doctors has long been considered a primary practice of passage. In Iraqi Kurdistan Region, a two year internship (residency) is mandatory for medical graduates’ registration as practitioner doctors. This study aimed to determine the perceptions of Erbil intern on whether undergraduate clinical skills training adequately prepared them for internship responsibilities.

Methods: This descriptive cross-sectional analytical study included 369 interns working in the public hospitals of Erbil Governorate. A questionnaire including two sections: the first is interns’ demographic characteristics and the second is their views on clinical skills training (communication and practical). The collected data was analyzed by the statistical package for the social sciences (version 19.1).  

Results: Out of the 369 interns, 213 were filled the questionnaire. The majority of them felt that their undergraduate communication skills training were adequate in all the studied areas. However, more than half of the respondents felt that undergraduate practical skills training were inadequate in several areas. Female interns felt that training was adequate in all areas of communication and practical skills more than males with a statistical difference in female catheterization (P <0.001). Interns of <30 years old felt that they received more than adequate training in both areas of communication and practical skills than those of ≥30 years old with a significant difference in interviewing patients (P = 0.047), measuring blood pressure (P = 0.023), Pap smear (P = 0.043), and resuscitation - basic cardiopulmonary resuscitation (P = 0.001).

Conclusion: This study suggests that there are deficiencies in undergraduate practical skills training particularly in specific areas. Deficiencies presented by the interns should be considered and addressed. In-depth studies are required to identify ways to improve training.

Background and objective: Aspergillus clavatus is an opportunistic human pathogen causing invasive aspergillosis. It is an economically important species because it can grow on rotting fruit (apples) and stored food products and able to produce a variety of mycotoxins. It has only been known to reproduce mitotically. This study aimed to discover the sexual reproduction in A. clavatus.

Methods: Identifying mating-type (MAT1-1 or MAT1-2) using PCR of 20 worldwide clinical and environmental isolates, crossing isolates on oatmeal agar in darkness with plate sealing, Recombination in ascospore offspring was demonstrated using molecular markers.

Results: There were similar ratios of the two mating types (45% MAT1-1 n = 9, 55% MAT1-2 n = 11). A. clavatus possesses a functional sexual cycle with mature cleistothecia fawn to brown/yellow in color, containing heat-resistant ascospores, produced after four weeks incubation at 25˚C and 28˚C on Nescofilm- sealed oatmeal agar plates. The cleistothecia contain hyaline ascospores that have two equatorial ridges. Recombination, leading to increased genotypic variation demonstrated in the ascospore offspring using molecular markers.

Conclusion: The ability of A. clavatus to undergo sexual reproduction is highly significant in understanding the biology and evolution of the species. The presence of a sexual cycle provides an invaluable tool for classical genetic analysis and will facilitate research into the genetic basis of pathogenicity and fungicide resistance.

Background and objective: Intrauterine growth retardation remains the most frequent cause of perinatal morbidity and mortality. Doppler ultrasound has become an indispensable tool in evaluating pregnancies at risk, on the basis of the vascular resistance to blood flow. This study aimed to evaluate non-invasively the fetoplacental and uteroplacental circulations in clinically confirmed high-risk pregnancies, using Doppler parameters of some vessels to apply clinical interventions which could result in reduced prenatal morbidity and mortality and help to decide the type of delivery.

Methods: This cross-sectional study was conducted in Duhok city from June 2014 to January 2015. The study involved 100 pregnant women between 26–42 weeks of gestation with known last menstrual period and a definite clinical high-risk for intrauterine growth retardation. Various Doppler indices were performed including the resistive index, pulsatility indices of both umbilical and middle cerebral arteries, and the resistive index of the uterine artery to predict fetal health, correlated with physical and clinical outcomes, taking into consideration the variability in Doppler measurements of gestational age. Data have been described and then analyzed statistically for their correlation with gestational age.  

Results: Umbilical artery and fetal middle cerebral artery Doppler indices are correlated inversely with gestational age. Although the uterine artery has a major role in Doppler examination of high-risk pregnancies, there is only a weak correlation between maternal uterine artery Doppler index and gestational age in late pregnancy. Doppler measurement of three arteries was more conclusive and show more sensitivity than one arterial Doppler measurement in the third trimester.

Conclusion: Significant inverse correlations were found between Doppler indices of fetal middle cerebral and umbilical arteries, and gestational age, while the correlation with maternal uterine artery index was not significant with advancing gestational age.

Background and objective: Fine needle aspiration cytology with cell block preparation is widely used for preoperative confirmation of solitary lung mass and classification of the histologic types. This study aimed to highlight the importance of cell-block preparation in the diagnosis of primary malignant lung lesion by comparing cytomorphological preservation on paired cell block and conventional fine needle aspiration samples. 

Methods: During January 2012 to October 2015, a total of 100 cases with solitary lung mass were included, either visited Rizgary Teaching Hospital or Walfare private hospital. All the patients had undergone fine needle aspiration and cell block preparation under a CT-guide.

Results: The samples were evaluated by the fine needle aspirations and cell blocks preparations from primary lung lesion under a CT-guide. 74% were male, and the majority of them were in the sixth and seventh decade. Squamous cell carcinoma was the most common histologic type consisting 42% of the studied cases, followed by adenocarconima (31%), small cell carcinoma (19%) and the remaining 8% were large cell carcinomas. In the assessment of agreement of cellularity between the two methods of sample preparation, cell block served better than fine needle aspiration (P = 0.715). However, this difference was statistically non-significant. A significant relation was found for morphology which was preserved in fine needle aspiration samples better than that in cell block samples (P <0.05). In contrast, all cell block samples displayed a statistically highly significant architectural preservation compared to fine needle aspiration samples (P <0.001). The sensitivity and specificity of the present study were 98.46%, 99.2% respectively.  

Conclusion: Direct fine needle aspiration smears and cell blocks complement each other, and our results indicate that both are needed in the diagnostic work-up of patients with a primary malignant lung mass.

Background and objective: Interleukin 1 receptor antagonist (IL1RN) is an acute-phase protein that blocks the interleukin-1A and 1B receptors and thereby exerting an anti-inflammatory effect. Expression and secretion of IL1R are under the influence of the metabolic derangement. This study aimed to assess the serum levels of IL1RN in obese subjects taking into consideration its relationship to the cardio-metabolic risk factors in asymptomatic obese subjects.

Methods: This cross-sectional study was conducted in Martyr LaylaQasm Center for Diabetes Mellitus in Erbil, Iraq. A total number of 170 women were recruited and distributed into three groups according to their body mass index (BMI): Group I (normal; ≤ 24.99 kg/m²); Group II (overweight; 25-29.99 kg/m²) and Group III (obese; ≥30 kg/m²). The measurements of cardio-metabolic risk factors including the anthropometric measurements, blood pressure, lipid profiles and the score of cardiovascular events using Framingham Heart Study scoring were determined. Interleukin 1RN and high sensitive C-reactive protein (hs-CRP) were also determined.

Results: Overweight (Group II) and Obese (Group III) women had significant high values of cardio-metabolic risk factors. Group III have significant high values of hs-CRP, and IL IL-1RN levels compared with Group I and II. The serum levels of IL-1RN are increased as the body mass index is increased but is not associated with increased risk of the cardiovascular events or a proportional increased of hs-CRP. A significant correlation between serum IL-1RN levels with cardiovascular risk (%) was observed among subjects of Group II. 

Conclusion: The study concludes that serum IL-1RN levels are significantly increased withy body mass index in over-weight-obese subjects and its increment is not correlated with low-grade of inflammation assessed by measurement of hs-CRP. The clinical significant of determination of IL-1NR to predict cardiovascular events risk is marginal in overweight subjects.  

Background and objective: Primary implant stability is considered necessary for achieving and maintaining osseointegration. This experimental study aimed to evaluate the outcome of implants without primary stability, clinically and radiographically.

Methods: Two adult sheep (3-4 years of age), 70 kg in weight, were included in the study. After sedation and local anesthesia, the lateral side of the basal bone of mandible is exposed by a single long incision. The implant bed performed in the inferior border of the basal bone of mandible drilling to 5 mm in diameter and 10 mm in length. Five implants were inserted into the basal bone of mandible for each side (right and left), but the sizes of inserted implant was 3.8 mm in diameter and 10 mm in length, after 4 months the 2 sheep  were sacrificed and the universal torque ratchet was used to measure the stability of the implant by a counter torque 30 N/cm test. Cone Beam Tomography (CBCT) was used to evaluate the implants radiographically.

Results: Nineteen (from 20) implants successfully tolerated a 30 N/cm countertorque test comprising (95%). Only one implant failed to osseointegrate (5%). During the healing period, no any adverse clinical signs reported.

Conclusion: Dental implants may have a chance to osseointegrate even in the lack of primary stability.

Background and objective: Maintaining the ability to perform basic self-care activities by the older adults is fundamental to maintaining their independence and quality of life. This study aimed to assess the level of functional dependency of the residents of geriatric homes in Erbil and Sulaymaniyah cities.

Methods: This cross-sectional study involved 94 older adults living in geriatric homes in Erbil and Sulaymaniyah cities. Data was collected on the socio-demographic characteristics, clinical characteristics, social issues and daily recreation activities of the participants using a questionnaire. Nine essential activities of daily living were assessed through a three-point Likert scale of independent, requires assistance and dependent.

Results: The mean and standard deviation age of the participants was 71.88 ± 8.94 years (range 60-81 years). Around half (43.6%) of the participants had at least one dependent activity. The level of dependency was highest in shopping, climbing stairs and bathing activities. Dependency of activities of daily living was significantly (P <0.001) higher in females than males; in illiterate and those read and write than primary school graduates and secondary school and higher level graduates; in those self-employed before entering geriatric home than retired and unemployed; and in ex-smokers and non-smokers than smokers.

Conclusion: The level of independency in the different daily living activities was relatively high, which might be attributed to having a younger age group of elderly in the geriatric homes. Dependency was significantly associated with the sex, education level, employment status and smoking status of the participants.

Background and objective: Trophoblastic diseases constitute a spectrum of tumors and tumor- like conditions characterized by proliferation of pregnancy associated trophoblastic tissue of progressive malignant potential. This study aimed to assess the value of p53 protein immunoexpression in the diagnosis of hydatidiform molar pregnancy and the differential diagnosis of its subtypes (complete and partial) from abortions.

Methods: A cross-sectional study of tissue sections from 68 formalin-fixed, paraffin- embedded specimens of products of conception, including 1st trimester abortion (n=15), partial hydatidiform mole PHM (n=24), complete hydatidiform CHM (n=24) and full term placenta (n=5), all were examined at the Histopathology Department of Maternity Teaching Hospital in Erbil, Iraq during the period of Jan.2013-Jun.2013. Immunohistochemistry was performed using p53 antibody and the standard streptavidin-biotin immunoperoxidase method. The labeling index (number of positive nuclei/total number of nuclei) for villous cytotrophoblasts, syncytiotrophoblasts and stromal cells were evaluated separately. Statistical analysis was carried out by one way ANOVA and Fisher’s exact tests, statistical significance was determined at P ≤0.05.

Results: All villous trophoblastic lesions showed higher p53 immunoexpression in all villous components especially cytotrophoblasts, being the highest in complete hydatidiform mole (>50%) and partial hydatidiform mole (>20%). A statistically significant difference was found in immunoexpressins of p53 that was useful in separating abortion from complete hydatidiformmole, P <0.001, and partial hydatidiform mole, P <0.0002. It was also useful in separating between the complete hydatidiform mole and partial hydatidiform mole (P <0.001).

Conclusion: p53 immunoexpression was valuable in differentiation between molar and non molar pregnancies and between subtypes of molar pregnancies.

Background and objective: Rosa hemisphearica (Rosaceae) is highly cultivated worldwide as an ornamental plant and medicinally have an antibacterial and antioxidant effect. This study aimed to investigate clinically and histopathologically the anti-inflammatory activity of Rosa hemisphearica in psoriasis and to correlate the anti-inflammatory activity with the active constituents in the plant by the phytochemical study.

Methods: In this open-label uncontrolled pilot study, a topical preparation of R. hemisphearica stem extract was used by 20 patients suffering from psoriasis for three weeks. Three histopathological slides for each patient, one each week for three weeks was done for anti-inflammatory response evaluation. Subsequently, total phenolic content was measured followed by thin layer chromatography (TLC) and high-performance liquid chromatography (HPLC) analysis for the identification of phenolic acid content in the stem.

Results: By histopathological examination revealed that both Munro’s and Kogoj’s abscesses were gradually disappeared, the granular layer gradually restored to normal and the inflammatory cells gradually reduced in number prominently polymorph (neutrophils) and eventually histocytes disappeared. Total phenolic contents in R. hemisphearica stem extract were determined as 205.625 µg gallic acid equivalent\ each gm of the sample extract, TLC, and HPLC results showed the presence of rosmarinic acid in the stem extract. On quantitative HPLC analysis, the percentage of rosmarinic acid in the stem extract was 0.024 with a retention time (Rt) of 3.4 min. The proposed HPLC method was found to be linear, accurate and precise.

Conclusion: The organic solvent extract of R. hemisphearica stem showed a significant reduction in an inflammatory cell among psoriatic patients under study. Rosmarinic acid was identified by TLC and HPLC as important phenolic acid constituents.

Background and objective: Focal segmental glomerulosclerosis shares overlapping patterns of injury with segmental consolidation and obliteration of glomerular architecture by the accumulation of collagenous extracellular matrix or by increased cellularity or both. This study aimed to investigate the patterns of primary focal segmental glomerulosclerosis in adults in Erbil. The specific objectives of this study included determining the frequency of histological variant of Focal segmental glomerulosclerosis, defining the clinical characteristics of the primary type in general and recognizing the clinical and pathological characteristics for each variant separately.

Methods: A cross-sectional, clinico-pathologic study was conducted for 50 patients attending the Nephrology Department in Erbil Teaching Hospital between March and December 2013. This study included patients of >16 years old with biopsy-proven idiopathic focal segmental glomerulosclerosis.    

Results: A total of 50 patients were enrolled into this study. The median age of patients was 33 years, ranged from 18 to 54, 31 (62%) males and 19 (38%) females. The frequency of histopathological variants was 80% not otherwise specific focal segmental glomerulosclerosis, 14% glomerular tip lesion, and 6% cellular type. Nephrotic syndrome and hypertension were the main presenting features (92% and 68%, respectively). The mean percentage of sclerosed glomeruli was 40% and the mean interstitial fibrosis and tubular atrophy was 24%.

Conclusion: A not otherwise specific variant is a common morphological lesion in many glomerular and non-glomerular diseases, and it is just like a junk drawer of multiple glomerular alterations with this common pattern of the lesion.

Background and objective: The presence of bile-resistant Helicobacter spp. in bile and gallbladder tissues has been proposed as a cause of gallbladder disease. This study aimed to assess the histopathological events in calculus cholecystitis and investigate the presence of the DNA of Helicobacter spp. in the bile.   

Methods: Forty patients who underwent cholecystectomy for calculus cholecystitis were evaluated for the presence of Helicobacter spp. by polymerase chain reaction methods and gallbladder tissue was evaluated histopathologically. Gall bladders were fixed in formalin and subjected to histopathological investigation while bile sample was used for the extraction of DNA.

Results: The histopathological findings revealed that twenty-seven (67.5%) samples showed mild chronic inflammation, one (2.5 %) sample with acute inflammation, four (10 %) samples with acute on chronic inflammation, eight (20 %) samples have normal histological findings. The molecular investigation revealed that twenty one (52 %) samples out of the forty showed the presence of genomic DNA after being subjected to DNA extraction and that fourteen (66.7 %) samples out of the twenty one showed amplification bands of 300 bp after PCR amplification indicating the presence of Helicobacter spp. within the samples. But no sample revealed the presence of H. pylori DNA when PCR was applied.   

Conclusion: Helicobacter spp. are considered as a determining factor for the development of gall bladder inflammation. 

Background and objective: Thermal change in pulp chamber with the use of light cured adhesives is one of the contemporary concerns for orthodontists. This study aimed to evaluate intra pulpal temperature rises during bracket bonding using three different light sources.

Methods: Sixty intact-extracted mandibular premolars were divided into three groups of twenty teeth for each. Orthodontic brackets were bonded to the buccal surface of all the teeth with Transbond XT adhesive applying a constant force, first group light cured with halogen light, in second group light emitting diode was used, in third group plasma, arc light was used. The measurements were taken with a J-type thermocouple wire, placed in the center of the pulp chamber and connected to a data plugger.

Results: Statistical analysis showed that temperatures of pulp chamber change were influenced by a type of light source. The intra pulpal temperature changes for halogen was higher than a light emitting diode and both were higher than plasma arc. All the groups   revealed a significant difference between each other.

Conclusion: Orthodontic bonding with using different light source did not exceed the critical 5.5° C temperature rise that may induce a thermal change in the pulp.

Background and objective: Ammi majus belongs to family Apiaceae is an important plant used in a different country traditionally for treatment bacterial infection. This study aimed to investigate in vitro antibacterial and antibiofilm activity of Ammi majus seed extracts against six isolated Gram-positive bacteria.

Methods: The antibacterial activity of seed extracts were screened by disk diffusion and agar overlay bioautography method and their activities were further determined by minimum inhibitory and minimum bactericidal concentration. Biofilm formation was evaluated by the microtiter plate crystal violet assay. The quantity of bound bacteria was determined by measuring absorbance at (OD630 nm) using microtiter plate reader.

Results: Ethanol 80% and ethyl acetate extracts showed variable activity against all isolated bacteria while petroleum ether extract revealed resistance against studied bacteria. Streptococcus mitis showed more pronounced sensitivity against both extracts by disk diffusion (12 mm and 10 mm) and bioautography method with minimum inhibitory concentration 7.8125 mg/ml of ethanol 80% and 15.625 mg/ml for ethyl acetate extracts. Ethanol 80% and ethyl acetate extract significantly reduced biofilm formation as compared to control, showed antibiofilm activity at 0.4883-62.5 mg/ml and exhibited strongest antibiofim activity against Staphylococcus aureus.

Conclusion: Ammi majus seed extracts revealed highest antibacterial activity against Streptococcus species and strongest antibiofilm activity on Staphylococcus species.