Vol 25, No 2 (2021)

Background and objective: The knowledge of autism spectrum disorder among physicians and medical students is limited. This study aimed to find out the level of knowledge, attitudes, and practices of primary health care physicians, junior doctors, and 6^th year medical college students in Duhok province, Iraqi Kurdistan toward autism spectrum disorder.

Methods: A cross-sectional study was carried out from September 10^th until October 30^th, 2016. A self-administered questionnaire was used for data collection. Two hundred and two questionnaires were completed by the three participants’ groups. Data analysis was carried out using the statistical analysis system (SAS, version 9.4).

Results: Of the 202 participants, 24.8% were sixth year medical students, others were junior doctors (35.6%) and primary health care physicians (39.6%). Of them, 51.5% were females and 48.5% were males. High percentages (90.1% and 91.1%) of respondents heard and knew about autism spectrum disorder, respectively. They showed poor information on identification and management. Primary health care physicians had more knowledge on the genetic basis of autism (P <0.001) and behavioral therapy for autism (P = 0.016). No significant differences in knowledge was found between both gender groups except that female participants had limited knowledge on its genetic basis (P = 0.007). 

Conclusion: Although primary health care physicians, rotators, and medical students generally heard about autism spectrum disorder, they had limited knowledge of its diagnosis and management. It is recommended to introduce autistic disorders lectures to the medical college curriculum and training of physicians by experienced professionals.

Background and objective: The gold standard for the treatment of chronic anal fissure is lateral internal sphincterotomy. Botulinum toxin injection provides temporary alleviation of sphincter spasm and allows the fissure to heal. This study aimed to compare the outcomes of lateral internal sphincterotomy and botulinum toxin injection treatments in patients with uncomplicated chronic anal fissure.

Methods: A prospective comparative study was carried out at the surgical unit of Erbil teaching hospital, Erbil, Kurdistan Region of Iraq, from January 2017 to February 2018. Fifty-five patients were enrolled in this study. Five patients were excluded, and the remaining 50 patients were equally divided into two groups. Group A was managed with lateral internal sphincterotomy and group B with botulinum toxin. Postoperative pain relief, bleeding, fissure healing, incontinence, and relapse after six weeks and three months of follow-up were compared.

Results: One month after treatment, 12% of the lateral internal sphincterotomy group had bleeding, while none of the botulinum toxin group (P = 0.234). Two patients (8%) of the lateral internal sphincterotomy group had pain while one (4%) of the botulinum toxin group (P >0.999).Three months after treatment, 4% of the lateral internal sphincterotomy group had bleeding, while none of the botulinum toxin group (P >0.999). None of the lateral internal sphincterotomy group had pain while one (4%) of the botulinum toxin group (P >0.999). Regarding healing, 96% of the lateral internal sphincterotomy group healed, while 92% in the botulinum toxin group (P >0.999).

Conclusion: The outcome of lateral internal sphincterotomy and botulinum toxin were nearly the same, but lateral internal sphincterotomy required hospitalization, period off work, and risk of anesthesia. These risks were absent in botulinum toxin injection.

Background and objective: Rectal bleeding is a common symptom that has many patterns, but none of them are accurately diagnostic. One newly noticed pattern can be diagnostic, namely, the squirting pattern, for which this study was conducted.

Methods: The study was conducted between Jan 2013 and Jun 2018, including 132 patients who presented with a squirting pattern of rectal bleeding, which is thought to be due to hemorrhoids. All these patients underwent clinical evaluation and anoscopy, and the majority (n=94) underwent colonoscopy.

Results: At the time of clinical examination, 23 patients showed actively bleeding hemorrhoids. Fifteen patients were not convinced to undergo colonoscopy. The rest (n=94) who had no visible active bleeding at the time of examination underwent a colonoscopy to exclude other possible rectal or colonic pathology. All the 94 colonoscopies were negative for other bleeding sources. Two patients showed single benign non bleeding polyps, which were excised and biopsied.

Conclusion: This study highlights a pattern of rectal bleeding that is not described before and proved it is a reliable diagnostic pattern for hemorrhoids. It also showed that colonoscopy is not needed in patients below 40 years complaining of squirting rectal bleeding unless indicated for some other reason. This decision is to be made very carefully.

Background and objective: In view of the known health hazards of X-ray radiation, this study focuses on the outlined effect of prolonged accidental or work-related Röntgenray exposure to hematological parameters such as red blood cells (RBCs), white blood cells (WBCs), platelets count as well as serum malondialdehyde (MDA) and glutathione in X-ray technicians.

Methods: In this cross-sectional study with a comparison group, blood samples were collected over six months period from X-ray technician assistants across Rizgary teaching hospital, maternity teaching hospital, Nanakaly hospital, Erbil teaching hospital, Ashty hospital, Hundreen hospital, and Harem hospital. A convenience sample was chosen for collecting subjects exposed to X-ray at the radiology department in the hospitals mentioned above. The results were analyzed and compared with a second control group of healthy unexposed individuals.

Results: It was determined that prolonged Röntgenray exposure could lead to an increase in the amount of oxidative stress as denoted by the decrease in the levels of reduced glutathione in the plasma of our test subjects.

Conclusion: Although there were changes in the mean levels of plasma RBC, WBC, platelets, and malondialdehyde, the differences of these parameters between the two groups were not significant statistically. However, there was a significant reduction in glutathione levels in plasma samples of the subjects, indicating elevated oxidative stress levels within the body.

Background and objective: Vaginal bleeding is a common complication in pregnancy and is associated with poor perinatal outcomes. This study aimed to determine the efficacy of tranexamic acid in stopping vaginal bleeding during pregnancy and improving perinatal outcomes.

Methods: A prospective clinical trial was conducted on 137 pregnant women with vaginal bleeding of unknown causes in the second and third trimesters of pregnancy who were admitted to Maternity Teaching Hospital, Erbil city, Kurdistan region, Iraq from February 2016 to November 2019. Tranexamic acid was administered to one group and normal supportive care to another group in a sequential manner. The Mann–Whitney test was used to compare the mean rank of the times of admission. Factors that were significantly associated with stoppage of bleeding were entered into a binary logistic regression model.

Results: Bleeding was stopped in 90% of women who received tranexamic acid. There was a significant difference in low Apgar score, the rate of low birth weight, and the rate of unfavorable perinatal outcome in the supportive care group than that in the tranexamic acid group. Predictors for not stopping bleeding were supportive care management compared with tranexamic acid (odds ratio (OR) = 13.38; 95% confidence interval (CI) = 3.60–49.67), and 21–32 weeks gestation compared with ≥ 37 weeks (OR = 6.52; 95% CI = 1.66–25.63).

Conclusion: Tranexamic acid in second and third trimesters bleeding is effective for rapidly arresting bleeding with a favorable neonatal outcome.

Background and objective: Colorectal cancer is a heterogeneous malignancy characterized by a wide range of genetic and epigenetic alterations. Clusterin is a heterodimeric glycoprotein widely expressed in a variety of tissues and secreted in many body fluids. Increased clusterin expression has been reported in the normal colonic mucosa, benign polyps, and colorectal carcinoma. This study aimed to detect the frequency of the clusterin immunoexpression in colorectal carcinoma and determine its association with some clinicopathological parameters.

Methods: Sixty formalin-fixed paraffin-embedded sections of colorectal adenocarcinoma were obtained and randomly selected from the histopathology laboratory at Rizgary Teaching Hospital and some private histopathology laboratories in Erbil city over two years between December 2016 and December 2018. All patients had been diagnosed to have primary colorectal adenocarcinoma and had undergone surgery. The clinicopathological characteristics of the tumors were revised, and the specimens were analyzed immunohistochemically using anticlusterin mouse monoclonal antibody.

Results: Twenty eight cases (46.6%) were labeled as clusterin positive, while 32 cases (53.4%) were negative for clusterin expression. Clusterin expression was significantly associated with the tumor type (Non-mucinous) (P = 0.01) and tumor grade (well to moderately differentiated) (P = 0.03). At the same time, no significant association was found between clusterin immunoexpression and other clinicopathological characteristics like age, gender, tumor site, and tumor stage.

Conclusion: Our study indicated that clusterin is overexpressed in some colorectal carcinomas and is significantly associated with histological type and grade. These results suggest that clusterin may play a role in colorectal carcinogenesis. Further studies are required to understand the possible mechanism of clusterin association with carcinogenesis and cancer progression.

Background and objective: Laparoscopic appendectomy entered a controversial dilemma for choosing a perfect approach for appendectomy. Evaluation studies may resolve this controversy. This study aimed to evaluate laparoscopic appendectomy proficiency depending on anatomy and pathology.

Methods: A total of 148 cases managed by laparoscopic appendectomy were studied from 2014 to 2015.These cases were diagnosed clinically and by investigations. Parameters studied were operation duration, conversion rate, complications, associated pathology, rehabilitation, and histopathology.

Results: By laparoscopy, the anatomical position of the appendix was easily recognized in 83.78%of cases, while the position of 16.22 %of cases was difficult because of the hidden appendix by adhesions, complications, and technical causes. The operation duration ranged between 34 and 60 minutes. Associated pathologies were demonstrated in 8% of cases. Regarding discharge from the hospital, 30% were on the same day, 50% on the first postoperative day, and 20% on the second postoperative day. Postoperative complications were 3% due to pelvic hematoma, port site infection, and bleeding. Postoperative pain was experienced in 3% of cases. The conversion rate was 4.7%. Rehabilitation was within 8-10 days.

Conclusions: Laparoscopic appendectomy is safe and suitable for various anatomical positions of the inflamed appendix, suspicious, hidden, and in the presence of other pathologies with a properly placed port can play diagnostic and therapeutic roles. Significant superiority of laparoscopic appendectomy was observed in this study for the management of acute appendicitis and its pathological consequences. The conversion rate was 4.7% due to other pathologies.

Background and objective: Urolithiasis is prevalent in both developed and developing countries, which is attributed to changes in lifestyles. Management of ureteric stones is highly dependent on their characteristics such as volume, size, and density which can be determined based on the images obtained from CT scan. The present study was carried out to examine the association between the final outcomes of the stones and different stone parameters specified by CT scan.

Methods: The present prospective cross-sectional study consisted of 100 patients who had been referred to the Radiology Department of Rizgary and Erbil Teaching Hospitals in Erbil, Kurdistan Region, Iraq, over six months in 2019 to undergo abdominal CT scan with clinical suspicion of ureteric stones. All patients underwent non-contrast MDCT scan, and the CT images were evaluated for the presence of ureteric stone, site of the stone, side, diameter in three planes, volume, and density. The outcome of the stone was correlated with each above variables.

Results: Ureteric stones were more prevalent among the young and middle age group (25-64 years) with an approximate male-to-female ratio of 3.34:1. There were significant associations between stone outcomes (i.e. spontaneous passage or need for intervention) and the stone characteristics including volume (P <0.001), density (P <0.001)site (upper, mid and lower ureter) (P = 0.02), anteroposterior diameter (P <0.001), transverse diameter (P = 0.006), and superior inferior diameter (P <0.001).

Conclusion: Upon the significant correlation between the spontaneous passage of ureteric stones and their characteristics (i.e., volume, density, site, anteroposterior diameter, transverse diameter, and superior inferior diameter), it is highly recommended that all patients with urolithiasis undergo CT scan examination in order to make the proper decision regarding stone management.

Background and objective: Bradyarrhythmias are one of the many causes of syncope, pre-syncope, and dizzy spells. Missing the diagnosis of bradyarrhythmias, an underlying etiology of those symptoms, may lead to serious complications and even mortality. This study aimed to set a standard case definition of bradyarrhythmias, which will improve patient survival.

Methods: Patients presented with partial or total loss of consciousness, who were misdiagnosed as other non-arrhythmic etiologies and later diagnosed as bradyarrhythmia, were included in this study. Diagnosis of bradyarrhythmias was reached by either 12 leads electrocardiography, Holter monitor, or electrophysiological study.

Results: A total of 150 patients who fulfilled the definition of missed diagnosis of bradyarrhythmias were included. A total of 100 males and 50 females were collected over 10 years. The pre arrhythmic over-diagnosis included transient ischemic attacks in 35 patients, vertebrobasilar insufficiency in 40 patients, vertigo in 30 patients, and other nonspecific diagnoses in 45 patients. The final diagnosis of bradyarrhythmias was reached by electrocardiogram only in 45, Holter recording in 75, and electrophysiological study in 30. All the diagnosed cases of bradyarrhythmias received permanent pacemaker therapy.

Conclusion: Misdiagnosis of bradyarrhythmias in patients presenting with syncope is not uncommon in clinical practice in Iraq, which may have a bad impact on patients' morbidity and mortality. Understanding the causative factors for the missed diagnosis can help set up an educational program to minimize this problem.

Background and objective: Smoking is a risk factor for major non-communicable diseases and is an important cause of preventable death. Smoking cessation is a challenge for both the smoker and the health care provider. This study aimed to assess the role of obligatory banning of smoking in 2014 - 2016 on the smoking habits of a group of men in Mosul city.

Methods: A convenience sample of 500 male smokers, aged 18 years and above who were living in Mosul on June 10, 2014 (the day of Mosul invasion by the Islamic State in Iraq and Sham, ISIS) and stayed living in the city for three years after that, were included in the study. The study design was cross-sectional, and data were collected by direct interview.

Results: One fifth (100 persons) of the participants quit smoking (without medications) during banning. More than one third (36%) of them quit due to the high price of cigarettes. Unfortunately, the majority (75%) returned back to smoking after the liberation of Mosul. The factors found to be significantly associated with the high rate of quitting included short duration of smoking(<9 years) before the banning period (P = 0.006), trial of quitting smoking before banning (P = 0.001), history of light smoking (P = 0.003), and smoking among second degree relatives, compared with the first degree relatives (P = 0.025).

Conclusion: The rate of cessation was relatively low compared with the possible punishments by the ISIS. Smoking cessation is still a challenge to public health practitioners, as many factors play a role.

Background and objective: Antacids are basic substances that can neutralize hydrochloric acid and reduce gastric acidity. They are over the counter drugs used to treat dyspepsia. The most commonly used antacids are sodium bicarbonate, magnesium hydroxide, aluminum hydroxide, and calcium carbonate. This study aimed to evaluate the effectiveness of antacids that are commonly used in Erbil city by finding their acid-neutralizing capacity.

Methods: The method for acid-neutralizing capacity was adapted from pharmacopeia. The samples were prepared by dissolving the antacid in an excess amount of hydrochloric acid, then neutralizing the excess acid with sodium hydroxide solution by doing back titration. The number of milliequivalents that are neutralized by the antacid is the acid-neutralizing capacity of the antacid.

Results: Rennie® chewable tablet showed the highest acid-neutralizing capacity, followed by AntacidAwa and Maalux® plus. The lowest acid-neutralizing capacity was for the suspensions Gaviscon® and Enoxon®.

Conclusion: Acid-neutralizing capacity is an easy and quick method to evaluate the efficacy of antacids. Different combinations of salts and concentrations can affect the acid-neutralizing capacity of the antacid. The higher the neutralizing effect of the antacid, the more effective the antacid is.

Background and objective: Exclusive breastfeeding is recommended for all newborns to gain optimal physical and neurodevelopmental growth. Despite all its advantages, prolonged breastfeeding alone without weaning places the child at risk of iron deficiency and iron deficiency anemia, which is the commonest micronutrient deficiency worldwide among infants. We investigated the effect of early weaning on the iron status of infants. 

Methods: We selected 100 infants; all of them were six months old. Fifty of them were exclusively breastfed for four months and started weaning between four to six months while continued to breastfeed till the age of six months (early-weaning group). Another 50 infants were exclusively breastfed for six months without starting weaning (no-weaning group). Then we investigated both groups at the age of six months for both iron and hematological studies. 

Results: In the present study, both study groups shared some similarities. In both groups, females accounted for more than half of the cases, the majority of the infants were residing in the urban areas, and most of the infants were delivered by cesarean section. The final result of the iron study and hematological parameters in the no-weaning group was significantly lower as compared to the early-weaning group. Both serum ferritin and serum iron were 7.42 ng/ml and 25.66 µg/dl, respectively, in the no-weaning group and were 23.94 ng/ml and 46.98 µg/dl respectively in the early-weaning group. Hemoglobin level was 10.84 gm/dl in the no-weaning group compared to 11.54 gm/dl in the early-weaning group.

Conclusion: We concluded that early weaning had a great role in the prevention of both iron deficiency and iron deficiency anemia in exclusively breastfed infants.