Vol 25, No 1 (2021)

Background and objective: Breastfeeding is a useful and natural source of nutrition that provides the healthiest start for an infant. Despite its nutritional benefits, breastfeeding promotes a unique and emotional connection between mother and baby. This study aimed to assess the determinants of exclusive breastfeeding within the first six months of age in Erbil City, Iraq.

Methods: A cross-sectional study was conducted in Erbil city, Iraq, from December 2017 to December 2018. A convenience sampling method was used for selecting mothers of infants aged 6-15 months. A structured interviewer administered questionnaire was used for data collection. The statistical package for the social sciences was used for data analysis and a P value of ≤0.05 was regarded as statistically significant.

Results: A total of 306 mothers with children aged between 6 and 15 months were included. The prevalence of exclusive breastfeeding was 26.5%. Around 36% of mothers had a primary school qualification, of whom 28.2% gave exclusive breastfeeding. Around 84%of the mother were housewives, of whom 28.3% had exclusive breastfeeding. Around 92% of the mothers had a birth at health facilities, of whom 26.2% gave exclusive breastfeeding. Around 50% of mothers had cesarean section deliveries, of whom 23.4% gave exclusive breastfeeding. Around 44% of the mothers mentioned that insufficient milk is the barrier to exclusive breastfeeding.

Conclusion: Exclusive breastfeeding still remains low compared to the current WHO recommendations. The most common barrier to continuing exclusive breastfeeding was the perception of insufficient milk production. Housewife mothers are more likely to breastfeed their infants exclusively, and least when the mother is a non-house wife.

Background and objective: Levator aponeurosis resection is an effective technique to correct blepharoptosis when the levator function is fair to good. This study aimed to determine the amount of levator resection in congenital blepharoptosis repair.

Methods: This is a prospective case series study conducted in Rizgary teaching hospital and private hospitals in Erbil city, Kurdistan Region, Iraq, from June 2011 to August 2019. The data of 53 patients (64 eyelids) affected by congenital blepharoptosis with poor to good levator function that underwent unilateral orbilateral levator resection blepharoptosis repair through the standard approach were included. The final outcome measures included postoperative eyelid height, contour, and symmetry.

Results: This study includes a total of 53 patients with congenital blepharoptosis (64 eyelids); 20 males and 33 females. The age of the patients ranged from 3 years to 54 years, with a mean age ± SD of 14.11 ± 10.66 years. The ptosis was right sided in 22 patients (41.5%), left sided in 20 patients (37.7%), and bilateral in 11 patients (20.8%). The study showed good patient satisfaction in 66.03% of the cases, suboptimal satisfaction in 22.64% of the cases, and poor satisfaction in 11.32% of the cases.

Conclusion: The levator resection for congenital ptosis is effective even with poor levator function and replaced in our practice the traditional fascial sling. We recommend that further studies be done on a larger number of patients to investigate the effectiveness of levator resection in patients with severe ptosis and very poor levator function.

Background and objective: The most common cancer of women worldwide is breast cancer and usually presents as a breast lump. Fine needle aspiration cytology and ultrasonography are two investigational techniques used to differentiate malignant breast lump from benign one. This study aimed to find out and compare the specificity, sensitivity, and predictive values of ultrasonography versus fine needle aspiration cytology for the diagnosis of malignant breast lump.

Methods: Patients who presented with clinically palpable breast lump at the department of Surgery, Rizgary Teaching Hospital, Erbil, from October 2014 to March 2016, were included. The age of the study participants ranged from 15 to 56 years. The highest rate (28.9%) was among the age group 35-45 years. Breast abscess, cystic breast lumps, and recurrent lumps have been excluded. The ultrasonographic evaluation was done by using 7.5 MHz probe for all patients at the department of radiology and fine needle aspiration cytology at the department of histopathology. All the patients underwent excision of the lumps, and histopathological examination was done for tissues. Specificity, sensitivity, and predictive values of ultrasonography and fine needle aspiration cytology were estimated, taking the histopathological result as the gold standard. A comparison of values was made.

Results: Ninety patients with 93 breast lumps were included in this study. Fine needle aspiration cytology reported 28 lumps as malignant lumps and 63 as benign, and two cases were indeterminate. Ultrasonography reported 27 cases as malignant, 54 as benign, and nine as indeterminate, while three breast lumps were failed to be detected. Sensitivity, specificity, positive and negative predictive values of ultrasonography and fine needle aspiration cytology in diagnosing malignant breast lump were 94.74%, 100%, 100%, 97.22%, and 90.48%, 100%, 100%, 95.24%,respectively.

Conclusion: Ultrasonography and fine needle aspiration cytology are 100% specific in diagnosing malignant breast lesions. Although ultrasonography appears more sensitive than fine needle aspiration cytology, it has a higher percentage of the indeterminate report.

Background and objective: Giardia lamblia is the intestinal flagellated protozoan parasite that infects vertebrates, including humans. Giardiasis is the major diarrheal disease found worldwide. It can be symptomatic or may be an asymptomatic carrier that led to chronic disease. This study aimed to determine the proportion of giardiasis among food handlers and evaluate the correlation between two laboratory methods for identifying the Giardia lamblia.

Methods: A total of 308 stool samples were collected from food handlers that annually attend the central laboratory in Erbil City. Wetmount microscopic examination was performed for the diagnosis of cysts and trophozoites of the Giardia parasite. Molecular analysis done for positive samples, DNA extraction performed using the QIAamp Fast DNA Stool Mini Kit (Qiagen Company, Germany). Nested PCR analysis was done targeting the Glutamate dehydrogenase gene using two sets of primers for amplification of 734bp fragment. Gel electrophoresis was performed for visualizing the amplified DNA by Ultraviolet light.

Results: The mean age of food handler participants was 29 years. Most (93.8%) of the food handlers were males, and the majority (98.6%) of the participants did not have any signs and symptoms. Four (7.4%) microscopy positive sample participants were highly educated. There was no association between educational level and positive rate by microscopy (P = 0.066). The majority of participants did not receive treatments, particularly most of the microscopic positive samples. The food handlers did not take any antiparasitic treatments 9 (3.4%) (P = 0.676). From 11 (3.6%) microscopically positive samples, 10 (90.9%) Giardia lamblia gdh gene 734 bp fragments were amplified by nested PCR.

Conclusion: Amplification of 734bp of gdh gene by the nested PCR is the most specific and sensitive method for identifying Giardia lamblia. Food handlers were important people to care about sanitation and preparing food, particularly for avoiding diseases transmitted by food.

Background and objective: Musculoskeletal injuries frequently occur in the ankle in both the athletic and general population. Ankle sprains are among the most frequent types of ankle injuries, which are conventionally diagnosed through clinical examinations. However, magnetic resonance imaging can provide a more precise diagnosis, leading to better injury management and prevention of consequent chronic complications. The present study aimed to examine the significance of magnetic resonance imaging in detecting and assessing changes that occur in ligaments and soft tissues in patients with ankle sprains.

Methods: In a prospective study, 50 patients with ankle sprain referred to Rizgary and Erbil Teaching hospitals in Erbil city, Iraqi Kurdistan Region, from March 2018 to April 2019, were included in the study. They underwent clinical evaluation and MRI (GE general electric 1.5 Tesla). Two expert radiologists analyzed the magnetic resonance imaging images, and the results were compared. The collected data were analyzed using SPSS version 23 through descriptive statistics.

Results: Most patients (64%) belonged to the age groups of 30-49 years old. Most of them (64%) were males. Most events of ankle sprain (66%) were because of sports and accidents. The clinical evaluation proved 82% of the ankle sprains. Regarding the laterality of the lesions, 60% were spotted in the right ankles and 40% in the left. According to magnetic resonance imaging results, both radiologists diagnosed that the ankle sprains included bone lesions, ligament injury, tendon injury, and effusion. There was an agreement of ≥ 96% between the two radiologists in this regard. The two radiologists were not significantly different in terms of diagnosing the ligament side. As reported by the radiologists based on the magnetic resonance imaging images, the anterior, lateral, and medial tendons were normal in most cases.

Conclusion: Magnetic resonance imaging is a vitally important tool that can be utilized reliably and accurately to diagnose and evaluate changes in ligaments and soft tissues in patients with ankle sprains.

Background and objective: Many epidemiological studies and clinical manifestation studies of multiple sclerosis have been done in Iraq. Up to our knowledge, no such observational study to the radiological feature of the multiple sclerosis lesion has been done yet in Erbil in comparison to other worldwide studies. This study aimed to assess the distribution of multiple sclerosis lesions in brain regions detected by magnetic resonance imaging among Erbil population.

Methods: This was a cross-sectional study conducted at the College of Medicine, Hawler Medical University, from April 2018 to July 2019. A review of magnetic resonance imaging scans of the brain of 120 patients was done. Special attention was directed toward identifying the variance in multiple sclerosis lesions distribution in the brain regions and their MR signal intensity characteristics.

Results: Periventricular lesions were observed in more than 90% of the study sample. The next common was juxtacortical lesions (24.8%), followed by corpus callosum lesions (16.8 %), while brain stem lesions were the least observed proportions. No significant difference was detected in the distribution of multiple sclerosis lesions among ethnicities and genders, except for basal ganglia lesions, which were significantly more common in women (P = 0.016).The magnetic resonance imaging signal intensity of the lesion was significantly variable among disease duration.

Conclusion: The T2 hyper intense lesions were most commonly seen in the periventricular region. Juxtacortical and corpus callosum lesions were also frequently observed. The proportions of the brain stem and cerebellum lesions appeared to be lower in comparison to previous studies.

Background and objective: There are many histological types of colorectal polyps. Most of these polyps are benign epithelial polyps harboring very low risks of cancerous changes. Adenomatous polyps are the most known cancer precursors. Cyclin D1 gene amplification and or overexpression occurs in many human cancers. Cyclin D1 participates potentially in the multistep process of colorectal carcinogenesis. The present study aimed to assess the clinicopathological features of colorectal polyps and evaluate the significance of immunohistochemistry expression of cyclin D1 in adenomatouse polyp as a marker for predicting malignant transformation.

Methods: A total of 180 cases of colorectal polyps were collected from Rizgary teaching Hospital and some private laboratories in Erbil, Kurdistan Region, Iraq, from January 2013 to January 2018. All cases underwent polypectomy by colonoscopy for removal of the polyp. Only cases presented with a single polyp were included. The histopathological diagnosis was revised, and the polyps were divided into four subtypes; inflammatory, hyperplastic, juvenile, and adenomas. All adenoma specimens were stained using IHC technique with cyclin D1.

Results: Out of the 180 cases, the results showed that 70(38.9%) were adenomatous polyps, 56(31.1%) were hyperplastic polyps,40(22.2%) were juvenile polyps, and 14(7.8%)were inflammatory polyps. Cyclin D1 nuclear staining was detected in 24 (34.2%) adenomas. Statistical significant relations between cyclin D1 expression with male gender and with high grade dysplasia were found.

Conclusion: Adenoma was the most common type among colorectal polyps. Cyclin D1 was shown to be aberrantly expressed in colorectal adenomas and may play a role in the early stages of adenoma carcinoma development.

Background and objective: Osteoporosis is among the top five conditions causing disability and prolonged hospital stay; however, it is still underestimated worldwide, especially in developing countries. Therefore, this study aimed to determine the knowledge, attitude, and preventive practice in Erbil city toward this global disease.

Methods: A cross-sectional study was conducted among 395 premenopausal women aged ≥25 years and ≤ 49 years old, who were recruited by simple random sampling throughout three months from the first of October to December 2015. A questionnaire was completed through a direct interview, which consisted of four parts, including questions about knowledge, attitude, practice, and demographic questions. The statistical package for the social sciences was used for data analysis.

Results: The mean age of the participants was 35 ± 8.24 years. Almost half of them did not hear about osteoporosis before. The identification of risk factors by participants was poor. Out of 395 of the participants, 92.9% had no knowledge about the diagnosis of this disease. Approximately half of the participants believed that there is no way to prevent osteoporosis. Regarding practice scoring to prevent the disease, the total score (mean) was 2.9 out of a maximum of 12, which is very low, especially among females aged 25-29 years.

Conclusion: The majority of premenopausal women in Erbil city had little knowledge of osteoporosis, however unaware of osteoporosis risk factors and poor preventive practice regarding prevention.

Background and objective: The accelerated protocol of Ponseti method was suggested to shorten the period of treatment of the conventional one for the cases of talipes equinovarus deformity. This study aimed to compare the accelerated protocol of Ponseti method in the treatment of clubfoot deformity with the conventional one.

Methods: A prospective comparative study was conducted for infants less than six months with congenital talipes equinovarus deformity. The patients were randomized to either Group 1 (casts changed every week, conventional protocol of Ponseti method) or Group 2 (twice weekly, accelerated one). Pirani score was used to assess the severity of the deformity at presentation, at time of last cast removal, and at the last follow up visit (6^th months).

Results: The patients included were 48 cases with 79 feet. Group 1 (39 clubfeet) had a mean Pirani score of 5.6 (± 1.15) at presentation, which dropped to 0.47 (± 0.41) when the last cast was removed. In Group 2 (40 clubfeet), it dropped from 5.57 (± 0.83) to 0.77 (± 0.01). The result of each treatment protocol was significant, but the difference between them was not significant. Five cases (three patients aged more than three months) of Group 2 needed eight casts to reach an acceptable position of correction. The difference between the mean number of casts applied in Group 1 (5.09) and Group 2 (5.82) was statistically not significant. However, the difference between the mean number of days spent in the cast was significant. The complications occurred in 12 out of 79 feet, with no statistically significant difference between both groups.

Conclusion: The accelerated protocol of Ponseti method for treating clubfoot deformity is as effective and as safe as the conventional one. It shortens the time required to complete the treatment program. Those who present lately (beyond the age of three months) may require an additional number of casts.

Methods: A case-control study was carried out from November 2018 to June 2019 in collaboration between the biochemistry unit at the College of Medicine and the biochemistry unit at the College of Nursing, Hawler Medical University. The study included 100 type 2 diabetic patients (group 1) and 100 healthy individuals (group 2) to evaluate the serum ceruloplasmin and zinc in both groups.

Results: The mean value of serum ceruloplasmin was significantly (P <0.001) higher in type 2 diabetic patients (55.9 ± 1.26 mg/dL) than that of healthy individuals (36.65 ± 0.71 mg/dL). The mean value of serum zinc was significantly (P <0.001) lower in type 2 diabetic patients (39.19 ± 0.46 ug/dL) compared with controls (65.27 ± 2.5 ug/dL). There was a significant positive correlation between serum ceruloplasmin and the age of diabetic patients (P <0.001). There was a significant negative correlation between serum ceruloplasmin and serum zinc of diabetic patients (P <001). There was no significant correlation between serum ceruloplasmin and body mass index of diabetic patients (P = 0.928).

Conclusion: Based on the findings of the present study, we concluded that high serum ceruloplasmin and low zinc were associated with type 2 diabetics.

Background and objective: One of the important health problems in Duhok city, Iraqi Kurdistan Region, is sickle cell disease. Blood transfusion remains a significant therapeutic intervention in patients with sickle cell disease that reduces complications related to vaso-occlusions. This study aimed to assess compliance to guidelines for the use of blood transfusionsin Duhok, Kurdistan, Iraq.

Methods: This is a cross-sectional study that included 135 patients with sickle cell disease registered at Jeen center of pediatric hematological diseases in Duhok, Kurdistan, Iraq. Between April 1^st and July 31^st, 2019, 205 medical visits of sickle cell disease were registered. Every patient was evaluated to record the clinical setting and explanations behind visiting and indications for transfusion.

Results: Of 135 patients,65.9% had sickle cell anemia (HbSS disease), 33.3% had sickle beta thalassemia, and one patient (0.7%) had Sickle/D disease. A total of 205 medical visits of sickle cell disease were registered with 84 blood transfusion decisions. The most common indicated guideline reasons for transfusion were symptomatic anemia and acute hemolytic crisis with a drop of hemoglobin >2 g/dl below steady state hemoglobin and severe painful crisis only accounted for 38.1%.

Conclusion: In this study of patients with sickle cell disease, most blood transfusions were not indicated according to the transfusion guidelines (British Committee for Standards in Haematology – BCSH, 2017).

Background and objective: Vaginal candidiasis is a common infection among pregnant women. The current study aimed to investigate the etiologic species of vaginal candidiasis and the genotypes of C. albicans isolated from vaginal samples among pregnant women in the Kurdistan region of Iraq.

Methods: Vaginal swabs were collected from pregnant women admitted to the Maternity hospital in Sulaymaniyah and Erbil cities from March 2016 to December 2018. Candida isolates were identified on CHROMagar medium, then confirmed with PCR depending on ITS region. All C. albicans isolates were confirmed using chitin synthase gene (CHS1) and subjected to genotypic analysis based on the transposable intron in 25S rDNA with using CA25S and CA-INT primers. DNA sequencing of 25S rDNA region was done by using CA and CA-INT primers.

Results: Among 340 women tested, 114 (33.53%) were positive for vaginal candidiasis. Five Candida species were identified, where they are C. albicans (56.14%), C. glabrata (24.56%), C. kefyr (11.40%), C. tropicalis (5.27%) and C. krusei (2.63%). It has been found that C. albicans significantly (P <0.01) higher than non-albicans species. The genotypes A (450 bp), B (840 bp), and C (450 and 840 bp) of C. albicans were detected. The Genotype A (54.69%) was the most prevalent, followed by Genotype B (34.38%) and Genotype C (10.94%). In regards to genetic variation, genotypes A and B were more similar compared to genotype C.

Conclusion: The current study revealed a high prevalence of vaginal candidiasis with different genotypes of C. albicans among pregnant women. Therefore, it is worth considering a vaginal swab culture with clinical symptoms during the diagnosis of vaginal candidiasis.