Vol 20, No 1 (2016)

Background and objective: Imbalance in the distribution of health workforce might result in inequities in health services delivery. The aim of this study was to assess the distribution of doctors’ workforce in Erbil governorate and identify the possible reasons for rapid turnover of doctors.      

Methods: This descriptive cross-sectional study included all the 962 doctors working in the health facilities of Erbil governorate. A questionnaire was used to collect data that included 40 questions divided into four broad sections of identification information, socio-demographic characteristics, information on professional characteristics and factors influencing employment process in rural areas.   

Results: There were 5.1 doctors per 10,000 populations. Most of the doctors were deployed in urban areas (83.6%). Most doctors were working in hospitals (74.2%) and 23.3% in primary health centers. Specialists constituted the largest categories of doctors (33.5%) and general practitioners the smallest (6.7%). Doctors’ willingness to stay at the current workplace was significantly associated with being married, having opportunities to select workplace, working in private clinics and having the workplace inside Erbil.      

Conclusion: The density of doctors per 10,000 populations in Erbil governorate is below the regional and international average, with a remarkable urban-rural imbalance in numerical, geographical and institutional terms.

Background and objective: Wear and tear of joint cartilage is regarded as one of the main causes of osteoarthritis hence recurrent minor traumas due to some of lifelong daily activities can correlate with the development of osteoarthritis especially in weight bearing large joints. This study was designed to evaluate the association between 10 specified lifelong daily activities with knee and hip osteoarthritis. Methods: A cross-sectional study was carried out in the outpatient clinic of Rizgary Teaching Hospital over a period of six months starting from November 2009. The study sample constituted 101 subjects with knee and/or hip osteoarthritis and 100 subjects of normal joints. Subjects fulfilling the inclusion criteria underwent clinical evaluation and radiology of their knee and hip joints. Differences between comparable subdivisions of the studied subjects in relation to the duration of each of the 10 specified lifelong daily activities was tested by the Chi-square test concerning the association of each daily activity with knee and hip osteoarthritis. Results: Five of the 10 specified lifelong daily activities showed association with knee osteoarthritis, and these were; squatting, sitting on the floor, knee bending and crossed leg sitting postures, cycling, and less time sitting on chair or sofa. The same applied for osteoarthritis of hip except for cycling. Conclusion: Lifestyle has an important role in the pathogenesis of knee and hip osteoarthritis.

Background and objective: The purpose of this study was to evaluate the torque insertion for drill and non drill techniques of two commercially available miniscrews. Methods: Eighty mini screws (forty Dentos miniscrews/Korea and forty 3M miniscrews/USA), having the same length and diameter, were divided into two groups for each type. Two techniques, non-drill and drill, were used. In drill techniques, manufacturer recommended drill was used. Two bovine tibias were obtained. The first technique used pre drill hole, which was made in the bone using the recommended bur (1.0 diameter). The mini-screw was placed at 9 mm manually, then the remaining 1 mm was inserted through digital torque meter. The same procedure was repeated but without a pilot hole. Results: 3M miniscerws gave high torque insertion in two techniques. Conclusion: The shape, thread design and tip geometry of miniscerw play an important role in the torque insertion.

Background and objective: Anatomy education is a principal subject within international medical and scientific curricula. Evidence based literature suggests that cadaver dissection is highly effective in establishing and retaining anatomy concepts. This study aimed to examine the perceptions of medical students about socio-cognitive aspects of dissection of human body in the Department of Anatomy at the College of Medicine, Hawler Medical University, Erbil. More specifically, the study tried to find out perceptions and level of satisfaction of medical students with engagement factors that improve positive satisfaction in learning. Methods: This is a descriptive cross-sectional study that included 169 first year medical students in the College of Medicine, Hawler Medical University. A self-administered questionnaire was distributed to the medical students during their practical anatomy sessions in the Department of Anatomy. Results: More than half of the students (55%) felt normal on their first exposure to dissection. Almost around half of the students (48.6%) had increased value for fellow humans following cadaveric training. More than 95% of them thought that improvement is needed in the cadaveric training. About 40% of the respondents had a good adaptation to cadaveric training. Conclusion: The traditional dissection laboratory must remain the center for teaching and learning anatomy. It is necessary to examine the curriculum and the mode of teaching. Factors that improve positive perceptions and in learning, like helpful environment and adequate dissection instructors should be thoroughly engaged in the training of our future doctors.

Background and objective: Chronic periodontitis is a multifactorial inflammatory disease characterized by destruction of tooth supporting tissues. Tumor necrosis factor-α, a key inflammatory cytokine, plays an important role in periodontal destruction. This study aimed to analyze the effect of non-surgical periodontal treatment on tumor necrosis factor-α levels in serum of patient with chronic periodontitis (with and without using chlorhexidine 0.2% mouthwash). Methods: A total of 44 patients with moderate to severe localized chronic periodontitis were divided into: Group I (n=22) without using of chlorhexidine mouthwash and Group II (n=22) with 0.2% chlorhexidine mouthwash. Serum samples collected from each subjects at baseline and four weeks after scaling and root planning treatment were quantified for tumor necrosis factor-α levels using ELISA technique. Results: The mean concentration of TNF-α were significantly reduced one month after treatment in sera of patients with chronic periodontitis for group I when compared to its mean concentration before treatment (P <0.05), while in group II a highly significant reduction after one month treatment (P <0.001) was observed. Conclusion: The effect of non-surgical periodontal therapy with chlorohexidine mouth wash showed more reduction in the levels of serum tumor necrosis factor-α.

Background and objective: The use of chemical irrigants solution in root canal therapy is capable of altering the proportion of organic and inorganic components of root canals. The structural properties of dentin may be changed such as permeability, solubility and microhardness. The aim of this study was to evaluate the effects of root canal irrigants on the microhardness of root canal by using three types of irrigant solutions with different concentration and normal saline used as control group. Methods: Root halves were prepared by longitudinal splitting of the roots of 56 freshly extracted caries free maxillary second premolars and embedded in autopolymerizing acrylic resin, leaving the dentin surface exposed. The root halves were randomly divided to seven groups composed of 16 samples each and treated for five minutes with one of the following irrigants: normal saline (control group), 0.2 % chlorhexidin, 2% chlorhexidin, 2.5% sodium hypochlorite, 5.25%, 5% Ethylene dimetha tetra hydrate EDTA and 17% EDTA. After surface treatment, the dentin microhardness of the root samples were recorded at the mid-root level by using a vicker microhardness tester. The data were statistically analyzed by using one-way analysis of variance, followed by Duncans test with a significant difference test at P ≤0.05. Results: EDTA, sodium hypochlorite, and 2% chlorhexidin significantly decreased the microhardness of root dentin compared with controls (P <0.05), while 0.2% chlorhexidin had no significant effect on the microhardness of root dentin. Conclusion: The irrigant solutions affect the microhardness of the samples except 0.2%.

Background and objective: Depression is a common comorbid mental condition in schizophrenia. This study aimed at estimating both the rate and demographic correlates of depression among patients with schizophrenia in Erbil, Kurdistan Region. Methods: Three hundred patients with schizophrenia were assessed for the possible existence of comorbid depression. Diagnosis of schizophrenia was confirmed by Mini International Neuropsychiatric Interview. Each participant, however, was assessed by Calgary Depression Scale for Schizophrenia for possible concurrent depressive disorder. Results: Of 300 patients with schizophrenia, 101 (33.7%) had concurrent depression as well. When all demographic variables considered, altogether, through logistic regression analysis, none of them discriminated, significantly, depressed from non-depressed patients with schizophrenia. Conclusion: Depressive disorders are frequently experienced by patients with schizophrenia. Psychiatrists are in charge to pay greater attention to this, life-threatening, mental disorder whenever they come across patients diagnosed as schizophrenia.

Background and objective: Impaired wound healing is a major complication of diabetes mellitus. This study was carried out to determine the healing process of oral mucosa in diabetic rats and the role of systemic tumor necrosis factor alpha inhibitor (infliximab). Methods: Thirty eight male rats were divided into two groups, the normoglycemic group (11 rats), and diabetic group (27 rats) that were rendered diabetic by alloxan injection. Two months later, wound was created in the lateral side of the tongue for both groups. The diabetic group was then subdivided into two subgroups, 14 rats received 5mg/kg infliximab subcutaneous injection at the day of wound creation while the other 13 rats received saline injection. After 7 days, biopsies of the tongue were collected and subjected to histological and histochemical procedure. Results: Histological examinations showed delayed healing in the diabetic group with persistence of epithelial discontinuity, large amount of granulation tissue and destruction of the underlying muscle fibers. In the subgroup injected with infliximab, reepitheliazation of the wound was demonstrated with well arranged underlying collagen fibers. Using PAS stain, diabetic group revealed a dramatically high amount of PAS positive precipitants in the lamina properia, especially in the wall of the blood vessels, while with infliximab injection, the PAS+ve precipitants were more prominent than normoglycemic group but less than diabetic group without infliximab. Conclusion: These findings suggest that infliximab accelerated mucosal wound healing in the diabetic rats with the formation of well organized connective tissue.

Background and objective: Health behaviors and risk behaviors are often related to the community in a more complex pattern of behaviors associated with lifestyles. Risk behaviors include drinking alcohol, physical fighting, smoking, sexual intercourse and drug abuse. This study aimed to assess the rates of some health risk behaviors among male students of secondary schools in Erbil city and to find out associated factors with those risk behaviors. Methods: A cross-sectional study was used. A self-administer questionnaire was used to collected data from December 17th, 2012 to July 17th, 2013 in 12 male secondary schools. 500 students were chosen randomly out of 11343 males' secondary school students. Results: Smoking was the most common risk behavior among the students (41.7%), followed by physical fighting (33.3%), sexual intercourse (15.5%), alcohol drinking (6.6%), and the lowest risk behaviors comes from drug abuse (2.7%). There was significant association between age and drug abuse which was more common among those ≥21 years than those of younger age groups. Conclusion: The highest health risk behavior among all male students in secondary schools in Erbil city was cigarette smoking. There was statistically significant association between age and drug abuse.

Background and objective: Abnormal uterine bleeding due to endometrial abnormalities is a common diagnostic challenge facing the radiologist and referring gynecologist. This study was aimed to compare the diagnostic performance of transvaginal ultrasound, transabdominal ultrasound and diagnostic curettage in the detection of endometrial pathologies in symptomatic women. Methods: A prospective comparison study of transvaginal ultrasound, transabdominal ultrasound and diagnostic curettage was conducted for evaluation of endometrial pathology in Maternity Teaching Hospital, Erbil city,Kurdistan region of Iraq, from September13th, 2013 to September14th, 2014. The study included 100 women presenting with abnormal uterine bleeding.Ultrasound findings were compared with histopathological results. The statistical package for the social sciences (version 17) was used for data entry and analysis. Results: The mean age (± SD) of sample size was 47 ±8.57 years. The mean parity was 5.17 ± 2.71. The highest percentages of women were in age group 40-59 years (73%). Of the total sample, more than half (52%) had regular cycles, 25% had irregular cycles and 23% were in menopausal state. In more than half of cases the indication for ultrasounds was for menorrhagia, followed by postmenapousal and intermenstrual bleeding (23% and 21%, respectively). Of 98 women (2 women were excluded from analysis), 19% had atrophic endometrium and 67% had endometrial hyperplasia in histopathological finding. Transvaginal ultrasound sensitivity and specificity were 100% and 92.9%, respectively while transabdominal ultrasound sensitivity and specificity were 92.8% and 65%, respectively. Conclusion: Transvaginal ultrasound scanning is an excellent tool for the determination of whether further investigation with histopathological examination of endometrial biopsy is necessary or not for women presented with abnormal uterine bleeding.

Five cases of rare and interesting foreign bodies are reported. Their presentation, difficulties in diagnosis, management and possible complications are discussed. These cases were seen in Al-Ain Hospital, ENT Department, UAE. All were diagnosed and managed by the author of this paper at variable dates. The aim of this publication is to report on rare inhaled foreign bodies, which is not seen often and to report on the difficulty in diagnoses of certain foreign bodies. It is advisable that rigid bronchoscopy be performed under general anaesthesia for all cases of highly suspicious for aspirated foreign bodies, for cases with chronic long lasting cough and in children with wheezy chest of unclear causes who do not response to medical therapy.

Background and objective: Bone integration around orthodontic implant is a matter of concern for their stability. This study was conducted to estimate calcium and phosphorous level in after insertion of orthodontic implant. Methods: Twenty five white mature male rabbits, classified into 5 groups: one control and four experimental, with five rabbits for each group were used. Fifty orthodontic implants were used, 2 micro-implant for each tibia. Four different natural products extract were used in this study that included Curcumin 15mg/kg, Nigella Sativa oil 0.25 ml/kg, Cissus Quadrangularis 500mg/kg and Virgin Coconut oil 1 ml/kg. Each product was given to certain experimental group started from the day of implant insertion for four weeks healing period. The biochemistry evaluation was conducted involving calcium and phosphorus level in serum. Results: Significant difference in serum calcium levels were detected between Curcumin, Nigella Sativa oil from side and control group on the other side. Conclusion: Systemic Curcumin and Nigella sativa oil may be used for possibly enhancing bone response around orthodontic implant as reflected by lower serum calcium level as compared to control group.

Background and objective: The micro aerophilic flagellated protozoan parasite, Giardia lamblia, is the most common intestinal pathogen infecting human and a major diarrheal disease found throughout the world. It can cause acute or chronic diarrhea contributing to nutritional status, growth, and intellectual function. This prospective study evaluated the association between giardiasis and blood minerals disorders in Hawler city. Methods: The present study was carried out at the College of Medicine, Hawler Medical University, via collaborating study between the Department of Biochemistry and the Department of Microbiology. The study was carried out on 50 patients with giardiasis and 65 age and sex matched healthy controls. Examination of fecal samples for detection of Giardia cyst and/or trophozoite was carried out using the direct wet smear, while serum zinc, iron and copper levels were measured for both groups spectrophotometrically using commercial diagnostics kits. Results: The levels of serum zinc and iron in patients infected with Giardia lamblia were significantly lower (P <0.01) compared to normal healthy control, while the differences in the level of serum copper was significantly higher (P <0.01). Conclusion: : In the frame of this work we delineate that Giardia lamblia infection had a significant effect on serum trace elements reflected by, significant decrease in serum zinc and iron levels, whereas the level of copper increased too in a statistically significant manner.

Background and objective: Local professional norms, experiences in tainting, and individual provider preference may lead to wide practice variation in rate and practice of episiotomy by midwives. The aim of this study was to find out the midwives' perspectives regarding practicing of episiotomy in three main cities of Kurdistan region/Iraq. Methods: A cross-sectional, descriptive study was conducted on 53 midwives working in delivery room in three maternity teaching hospitals in the three biggest cities of Kurdistan Region of Iraq. A questionnaire was constructed for the purpose of the study and data were collected by interview with midwives. F test and Chi-square test were used for analyzing the data. Results: The majority (88.7%) of midwives thought that the rate of episiotomy were high in their hospitals that were attributed to five factors; maternal (77.35%), fetal (39.62%), midwives (37.73%), obstetricians (30.18%) and hospital policy and health system (20.75%). The opinion of midwives regarding how to decrease the rate of episiotomy included improving midwifery care during delivery (77.35%), reforming health system (60.37%), reforming hospital policy (50.94%) and improving maternal care during pregnancy (26.41%). Conclusion: Taking into consideration the midwives' perspectives and views regarding episiotomy and providing training courses may help in decreasing the rate of episiotomy and its practice in correct way in Kurdistan's maternity hospitals.

Background and objective: Pleomorphic adenoma is the most common benign tumor of the salivary gland. It shows a remarkable degree of morphological diversity. Immunohistochemical Ki67 expression is used to predict the proliferative potential of the growth. The aim of this study was to evaluate the expression of the proliferation marker Ki-67 in benign mixed salivary gland tumors. Methods: Fifty five paraffin embedded tissue blocks were included in the study. After histopathological reassessment of hematoxylin and eosin stained section for each block, an immunohistochemical staining was performed using anti-Ki67 protein. Results: From total number of 55 cases, 58.1% of patients were in group aged ≤ 40 years. The male to female ratio was 1.037:1. The parotid gland was the most affected (56.37%) gland. The mean duration of lesions before treatment was 17.96 months and the mean size of tumors was 3.76 cm. Histologically, cell-rich subtype constituted 54.54%, followed by stroma-rich (34.55%), and only 10.91% of cases were classic. Ki67 expression was positive in 18.18% predominantly in epithelial variant with a weak score in nine cases (16.36%). Six of positive cases were in parotid gland and two cases in the submandibular gland. Only one case was in minor salivary gland. Moderate Ki67 expression score was seen in one epithelial variant case (14.28 %) associated with parotid gland. Conclusion: Immunohistochemical expression of Ki-67 in pleomorphic adenoma was characterized by low proliferative rate and predominantly seen in epithelial tumor variants.

Background and objective: Acne vulgaris is a chronic inflammatory disease of the pilosebaceous units, characterized by comedones, papules, pustules and nodules. Acne affects primarily the face, neck, upper trunk. Acne typically begins at puberty and it is often the first sign of increased sex hormone production. In all women with acne the possibility of hyperandrogenic state should be considered. The aim of this study was to determine the relationship between abnormal testosterone level and other virilising signs in young females with acne vulgaris. Methods: This case-control study was carried out from April 2013 to January 2014 in the consultation Department of Dermatology and Venereology at Rizgary Teaching Hospital in Erbil city. Sixty females were considered group A (case group with acne) and 60 females were considered as group B ( control group) without acne. Results: The mean±SD serum testosterone level was significantly higher among patients with acne compared to the control group (0.51 ng/ml ± 0.27 compared to 0.31 ng/ml ± 0.12, P ˂0.05). Irregular cycle was found in 28 cases (46.6%). Conclusion: The study showed presence of a significant association between serum testosterone level and acne vulgaris in female patients.

Background and objective: Reconstruction of post burn scalp alopecia using tissue expansion represents, nowadays, the standard method of treatment for this pathology. Tissue expansion is a straightforward technique, providing large skin flaps whose color and texture matches the area to be reconstructed, achieving optimal final aesthetic result. The aim of this study was to evaluate the results and complications of using tissue expansion for post burn scalp alopecia reconstruction. Methods: Thirty four patients having post burn scalp alopecia were treated with scalp tissue expansion, using forty tissue expanders at Rizgary Teaching Hospital in Erbil from February 2009 to December 2014. The age group ranged from 7-35 years and the mean age of the patients was 16 years. Statistical package for the social sciences (version 18) was used for data entry and analysis. Results: Complete reconstruction of post burn alopecia was achieved in 82.35% of the total patients with either a single or multiple sessions of expansions. The remaining 17.65% were benefited from reduction in the percentage of scar and recreation of anterior hair line. The size of scalp alopecia ranged between 4x7cm-11x20cm. Major complications occurred in 3 cases (8.8%), in which the expansion process was interrupted with removal of expander, while minor complications happened in 4 cases (11.76%), which did not interrupt the expansion. Conclusion: The use of tissue expansion for reconstruction of post burn alopecia is a useful and safe technique, since it is the only procedure that allows the development of normal hair bearing tissue to cover the areas of alopecia

Background and objective: Various methods have been described for management of first trimester incomplete miscarriage. The active methods include surgical methods that are highly effective but are associated with anesthetics and surgical risks. Medical methods by Misoprostol had been shown to be effective, acceptable and widely used treatment for incomplete miscarriage. The aim of this study was to compare the efficacy, patients' acceptability and the side effects of sublingual administration of single dose of 400mcg with single dose of 600mcg of misoprostol in the treatment of first trimester incomplete miscarriage. Methods: This study was conducted from April 1st, 2011 to February 1st, 2012 in the Maternity Teaching Hospital in Erbil city, Kurdistan region, Iraq. The study included 120 patients with incomplete miscarriage at a gestational age ≤12 weeks. They randomly received either single dose of 400mcg or 600mcg of misoprostol sublingually. Patients returned for follow-up and re-evaluation of abortion status after 7 days. Patients with a continuous incomplete miscarriage underwent surgical evacuation. Results: The success rate in the first and second group was 90% and 91.7%, respectively, while patients' acceptability in the first and second group was 96.7% and 95%, respectively with no difference between both groups. Gastrointestinal side effects like nausea and diarrhea were more in the second group. Conclusion: Single dose of 400 mcg of sublingual misoprostol is preferred on 600mcg of sublingual misoprostol regarding the development of side effects.