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   Table of Contents - Current issue
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April-June 2020
Volume 17 | Issue 2
Page Nos. 117-231

Online since Wednesday, June 17, 2020

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REVIEW ARTICLES  

Spinal stenosis: What outcome should be expected? Review the latest evidence using the assessment of multiple systematic reviews appraisal tool (AMSTAR) p. 117
Jameel Tahseen Mehsen, Zaid Saad Madhi, Imad Saad Madhi
DOI:10.4103/MJBL.MJBL_16_20  
Lumbar spine stenosis is a degenerative osteoarthritic change. The common presentations are pain in the lower extremities, weakness, numbness, and neurogenic claudication. The management of lumbar spine stenosis is controversial. The aim of this review is to evaluate the best evidence-based management for the patients with moderate severity degenerative lumbar spine stenosis with radiculopathy. The review included the evidence-based reports relevant to lumbar spinal stenosis and their management (nonsurgical and surgical), with no restriction on patient's age or gender. The exclusion criteria were all case series, cohort, and Level V evidence. The relevant references of the systematic reviews and meta-analysis were considered. The quality of the literature was performed using the assessment of multiple systematic reviews appraisal tool. Six systematic reviews were considered in our review for further analysis. The majority of the reports showed the preferable outcome of the surgical intervention over conservative therapy regarding leg pain and disability. The complication rate from decompressive surgical intervention was estimated at 18%. Minimal invasive surgery had a preferable outcome in preventing iatrogenic spondylolisthesis. The epidural injections were effective. Calcitonin therapy had no significance. Similarly, there was no supportive evidence for physical therapy regarding the long-term outcome. The management decision depends on the severity of the stenosis through the clinical and the radiological finding to improve the outcome
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von Willebrand Disease: The diagnosis and management of this bleeding disorder p. 122
Basim A. Abd, Nawrass J Al-Salihi
DOI:10.4103/MJBL.MJBL_18_20  
von Willebrand disease (vWD) is one of the most common bleeding disorders, first described by Erik von Willebrand in the Aland Islands. It occurs as a result of decreased or abnormal von Willebrand factor (vWF), a factor that is needed in the process of blood coagulation; acting like a “glue” helping platelets to stick together and form the blood clot. The principal function of vWF is binding with other clotting factors (especially Factor VIII) that are also necessary in the clotting process. There are two main forms of this disease: the inherited and the acquired forms; each one's pathophysiology depends on the qualitative or the quantitative defects in vWF. The diagnosis of vWD depends on several factors: measurement of vWD antigen, vWF activity assay, the activity of Factor VIII, and some other additional tests. The management of this disease includes replacement therapy, nonreplacement therapy, and some other kinds of managements that include the use of fibrinolytics and topical agents.
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ORIGINAL ARTICLES Top

Evaluation of osteocalcin and reproductive hormones in men with type 2 diabetes in Misan province/Iraq p. 126
Eman Ali Al-Saidy, Zainab Abdul Jabbar Al-Ali
DOI:10.4103/MJBL.MJBL_87_19  
Background: Diabetes mellitus (DM) is a group of metabolic disorders in which there are high levels of blood sugar over a prolonged period. DM can be accompanied by numerous complications, including different organ systems for instance skeleton and reproductive system. Objectives: The aim of the present study was to determine the levels of osteocalcin (OC) and reproductive hormones in men with type 2 DM (T2DM) of Misan province from December 2018 to May 2019. Materials and Methods: The study population consists of 110 men aged 35–49 years of whom 66 type 2 diabetic and 44 healthy men; patients with T2DM were divided based on the age into three groups: the first (35–39) years, second (40–44) years, and third (45–49) years; patients with T2DM were also divided based on the body mass index into four groups: normal weight (18.5–24.9), overweight (25–29.9), obesity class I (30–34.9), and obesity class II (35–39.9) groups. Results: According to the age, the mean values of fasting blood glucose and glycosylated hemoglobin A1c (HbA1c) were significantly higher in diabetic subjects when compared with the control. OC increases significantly in the second and third groups as compared to control. Luteinizing hormone (LH) of the patients in the third group significantly increases as compared to the first group. Patients of the third group increase significantly compared to the patients in the first group. Follicle-stimulating hormone (FSH) means value no different significantly according to the age. The testosterone (TT) mean value in compare between patients group, the third increase significantly in compare with first group. Estradiol (E2) in the first group increases significantly as compared to control. Prolactin (PRL) in the first group decreases significantly compared to control. According to the BMI, the mean value of fasting blood glucose and HbA1c was significantly higher in diabetic subjects when compared to control. OC value of T2DM significantly increases in the group obesity class II and overweight. LH, TT, and FSH were not significantly significant compared with control. E2 value significant different in compare with control of obesity class I and class II. PRL decreased significantly as compared to control in normal weight group; in patients of obesity class I, the E2 value increases significantly as compared to patients of normal weight.Conclusions: This study revealed no relationship between OC and reproductive hormones and no relationship between OC and T2DM.
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Effect of estradiol on the severity of lower urinary tract symptoms in men p. 133
Ihsan Shakir Mahmood, Jamal A Al-Dohan, Murtadha M Salih Al-Musafer
DOI:10.4103/MJBL.MJBL_5_20  
Objective: The aim of this study is to investigate the relationship between estradiol (E2) level and the severity of lower urinary tract symptoms (LUTS) in men. Materials and Methods: This study involved 82 patients suffering from LUTS for >1 month, with age ranged from 36 to 85 years old who attended Basra General Hospital outpatient clinic of urological surgery seeking for management. The medical and surgical histories were taken through special questionnaire and the severity of LUTS was assessed using the international prostate symptom score (IPSS). General and urological examinations were conducted to them. Four milliliters of venous blood was drawn from each patient to measure luteinizing hormone (LH), follicle-stimulating hormone (FSH), E2, and prostate-specific antigen and the results were used to assess the presence of any association with IPSS or prostate volume. Furthermore, fasting blood sugar, blood urea, serum creatinine, and thyroid-stimulating hormone were measured to identify unknown diabetic patients and exclude those with renal failure or thyrotoxicosis. Results: The IPSS, irritative, obstructive, and bother scores were (13.9 ± 9.4), (5.6 ± 4.6), (6.6 ± 4.4), and (2.99 ± 1.91), respectively. Mean serum FSH, LH, and E2were (11.0 ± 12.6) mIU/ml, (6.26 ± 5.40) mIU/ml, and (39.9 ± 23.3) pg/ml, respectively. There were no correlations in the current study between gonadotropins and IPSS or any of its subgroups, but men with moderate-to-severe LUTS tended to have a significantly lower mean of FSH (P < 0.05). E2didnot correlate with age or prostate volume. E2showed significant associations and correlations with the IPSS, irritative, and bother scores, and these correlations persisted after adjustment for age and prostate volume. Conclusion: E2has a significant relationship with LUTS severity and may act as an independent risk factor for LUTS.
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Experience in management of penile fracture at Al-Hilla teaching hospital p. 139
Jawad Abdul-Hasan Masser, Tammoz Mezhi Mohsen, Salam Abd-Elameer Yahya
DOI:10.4103/MJBL.MJBL_10_20  
Background: Penile Fracture (PF), consider as uncommon emergency in the urological field occurring due to tear in the tunica albugina of the corpora cavernosa of the penis. Objective: This retrospective study aims to analyze the main presentation, management modalities and complications that occurred for the cases of penile fractures who are admitted to Al-Hilla teaching hospital over the last 10 years. Materials and Methods: Fifty-four patients who presented to our hospital with PF over a 10-year period from December 2006 to December 2016 were included in this study. Hospital records and data collected from all the urologists at Hilla Teaching Hospital using a direct questionnaire were evaluated for all patients with PF. All patients treated by immediate surgical exploration, hematoma evacuation and repair of the tear or tears founded. Results: Out of a total of 54 patients who are include in the study, there were 44 patients (81.48%) between 21 and 40 years old. Most of the injuries were on the left proximal side of the penis. In almost all of the cases, the patients were admitted for 2–4 days. All the patients were given intravenous antibiotics at the hospital and completed an oral course of treatment at home. Forty nine patients (90.7%) report satisfactory penile erection post operatively without pain. Rough sexual activity was the primary cause of the penile fractures in our study. Most patients presented within 4–24 h of sustaining the injury, and the rest presented within 1 day to 1 week. The injury was usually repaired immediately. Most patients reported that erectile function returned 2–7 days after surgery, while sexual intercourse returned 2 weeks after the surgery. Conclusions: Vigorous sexual intercourse is the most common etiological factor for fracture of the penis for cases included in this study. Surgical repair is associated with a low complication rate. According to the results of our study, immediate surgical repair is strongly recommended.
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Relationship between iron deficiency anemia and febrile seizures: A case–control study p. 144
Alok Khanna, Ashok Kumar, Dayanand Hota, Aarti Sharma, Manish Swami
DOI:10.4103/MJBL.MJBL_7_20  
Introduction: Febrile seizure (FS) is a common convulsive disorder of childhood, which affects approximately 2%–5% of children aged 3–60 months. The etiology of FSs is not clear. Different etiological factors have been considered previously that include familial (genetic) factors, prenatal factors, acute illness, the degree of fever, and finally, anemia. Relationship between iron deficiency anemia (IDA) and febrile convulsions in children has been seen in various studies. Our study has also reported that IDA could be a risk factor for FS and can be considered as one of the modifiable risk factors that predisposes to FSs in children. Methods: It was a case–control study. A total of 150 (75 cases and 75 controls) were included between 6 months and 6 years who presented with febrile convulsion. The controls included 75 children between the age group of 6 months and 6 years who presented with short duration of fever (<3 days) but without seizures. Diagnostic criteria for FSs were based on the AAP clinical practice guidelines. Complete blood count and serum ferritin were evaluated for all subjects. Iron deficiency was diagnosed as per the WHO criteria (hemoglobin [Hb] value <11 g%, red cell distribution width of >15%, serum ferritin value <12 ng/ml, and red blood cell indices). Results: The mean age of the study group was 27.16 ± 16.65 months, and in control group, it was 27.82 ± 15.33 months. Mean Hb was 9.64 ± 1.54 in study group and 10.05 ± 1.45 in control group, mean corpuscular volume was 72.52 ± 4.94 in cases and 75.06 ± 3.94 in control. Mean corpuscular Hb (MCH) was 25.36 in cases and 27.08 ± 1.90 in control group, MCH concentration 32.73 in cases and 34.63 in control. Mean serum ferritin in Group A was 39.54 ± 24.55 and 51.29 ± 20.26 in control group which was found to be statistically significant (P < 0.01). Conclusion: In the present study, we found high incidence of IDA in patients with FSs (48%) as compared to controls (22%). Serum ferritin level was also significantly lower in study group as compared to control group suggesting that children who had FS were more iron deficient than the controls.
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Identifying the risk factors of local recurrence of early-stage breast cancer after surgery and adjuvant treatment p. 148
Maqsad Abdul Khadim Fadheel, Ameer Kadhim Al-Humairi, Mushtaq Qahtan Mohammed
DOI:10.4103/MJBL.MJBL_12_20  
Background: Local recurrence of breast cancer after treatment remains a major challenge that affects survival and quality of life. Identifying the risk factors for locoregional recurrence (LRR) may change our strategies in the treatment of those patients to let them enjoy long survival. Aim of the Study: To identify the risk factors associated with high rate of local recurrence of early breast cancer and its impaction on time of recurrence. Materials and Methods: In this retrospective study, we evaluated 225 patients with early breast cancer (T1–2, N0–1) with a mean age of 46.178 years and a median of 45 years, who treated by surgery and adjuvant treatment (chemotherapy and/or hormonal therapy) without radiotherapy in Babylon Oncology Center from 2012 to 2014 and followed for next 5 years. We collected data to identify the risk factors; we used files from archive and follow-up program in this center. We used SPSS version 23 in our calculation; P ≤ 0.05 was considered statistically significant. Results: From a total of 225 patients, the mean age was 46.178 years and the median was 45 years; we found that 31 (13.8%) patients developed local recurrence after surgery. The median time for follow-up was 40.2 months, and the median time to recurrence was 30 months. From 31 recurred patients, 58.1% were recurred after 2 years and 41.9% recurred within 2 years and less after surgery. In univariate analyses, tumor size more than 20 mm, lymph nodes (LNs) <10 removed by surgery, positive (1–3) LNs, high-grade tumor, presence of lymphovascular invasion, extracapsular extension, and estrogen receptor (ER) negative appeared significant for local recurrence. In multivariate analyses, all significant factors did not change except number of LNs removed and ER negative. No single factor appears significant for early recurrence (2 years and less after surgery). Conclusion: Our study showed many factors can affect locoregional recurrence after initial treatment with surgery and chemotherapy with (58.1%) of cases recur after 2 years of surgery, so we recommend 1) offering a post mastectomy radiotherapy (PMRT) for those patients with significant clinical and pathological risk factors. 2) establish a close follow up program to diagnose early LRR to deal with those patient early in order to prevent more serious event that affect quality of life and patient survival.
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First 24 h' outcomes of acute coronary syndrome in Iraq p. 154
Ameen Mosa Mohammad, Bahaadin Hassan Abdulhaleem, Qayser S Habeeb
DOI:10.4103/MJBL.MJBL_15_20  
Background: In recent years, there has been a noticeable increase in the frequency of acute coronary syndrome (ACS) in Iraq. Despite the need for the data related to the subject in the area, there is a great paucity of such data that mandated the design and conduct of this study. Methods: This prospective, cross-sectional analysis was performed in the coronary care unit of tertiary Azadi Teaching Hospital in Duhok, Kurdistan, Iraq. All patients consecutively who were hospitalized for ACSs between 2015 and 2016 were included to determine the clinical presentations, short term in-hospital complications, and the first 24 h outcomes of ACSs in Duhok, Iraq. Results: The study comprised 380 (279 men and 101 women) cases with a mean age of 59.54 ± 11.50 years. The final diagnosis was ST-elevation myocardial infarction in 67.4%, non-ST-elevation myocardial infarction in 24.7%, and unstable angina in 7.9%. Al least 50% of patients arrived beyond 6 h of symptoms' onset. Participants within the age group 45–74 years constituted the main bulk of the sample (79%). Typical ischemic chest pain accounted for most of the presentations (80.3%). The most common complications were arrhythmias 44.8%, followed by heart failure 15.5%, cardiogenic shock 5.5%, and mechanical complications 3.4%. Uneventful recovery and recovery with complications constituted 74.5% and 19.7%, respectively. The first 24 h in-hospital death was 5.8%. Conclusions: Our patients presented at a relatively young age. In terms of disease presentations, we observed significant gender differences. In-hospital short-term mortality rate was comparable to neighboring nations. Older age rather than gender impact the outcomes.
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Seroprevalence of antinuclear antibodies, antibrucella antibodies, and hepatitis B surface antigen in women with recurrent abortion p. 159
Nabaz Fisal Shakir Agha
DOI:10.4103/MJBL.MJBL_96_19  
Background: Recurrent abortion is a globally common problem. Many factors play a crucial role in the pathogenesis of abortion such as antinuclear antibodies (ANA), antibrucella antibodies and hepatitis B surface antigen (HBsAg). Objectives: The study objective was to estimate the serum levels of antinuclear antibodies (ANAs), antibrucella antibodies, and hepatitis B surface antigen among recurrent aborting women. Materials and Methods: One hundred and twenty women were enrolled in this prospective case–controlled study from Maternity Hospital, Erbil City, Iraq. The study included sixty patients with a history of three and more attacks of previous abortions and sixty healthy pregnant women. All were screened for ANA-IgG, antibrucella antibodies, and hepatitis B surface antigen (HBsAg) in serum. Results: It was noted that 15/60 (25%) patients and 6/60 (10%) healthy controls were positive for ANA-IgG with a mean concentration of 6.2 ± 0.4 IU/ml in the patient group and 0.75 ± 0.325 IU/ml in the healthy controls with statistical significance at P ≤ 0.05. The distribution for ANA with antibrucella and HbsAg in patient group was as follows: 12/15 (80%) and 6/15 (46.15%), respectively, among the seropositive ANA patients with a high significance atP < 0.01 for antibrucella and a significance atP < 0.05 for HbsAg. Conclusions: ANAs constitute an important cause of recurrent mid-trimester abortion in women. Furthermore, there is growing clues of the pathogenicity of Brucella organisms and hepatitis B virus, especially as agents of adverse pregnancy.
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The association between Vitamin D level and body mass index in a sample of childbearing age women in Erbil p. 165
Parwez Jameel Hamza, Muhammed Khalid Hasan
DOI:10.4103/MJBL.MJBL_11_20  
Backgrounds: There is a high prevalence of Vitamin D deficiency worldwide, especially in developing countries, but there is wide variance with regions the prevalence of Vitamin D deficiency ranges between 30% and 90%. Objectives: The aim of this study was to explore the prevalence of Vitamin D deficiency and insufficiency and its association with body mass index (BMI) in a female childbearing sample. Methods: In this cross-sectional study, a purposive sample of female patients who were in childbearing age was invited from Erbil in Iraqi Kurdistan. The information required for the study was collected through the self-reported technique between January 20, 2019, and October 20, 2019. Results: The study showed that 51.0% of the study population was in the 27–37 years of age group. 33% and 16% of the study population were overweight and obese, respectively. Half of them did never physical activity followed by 1–2 and 3–4 times/week, 42%, and 8%, respectively. The study showed that 54.5% and 54% worked indoor and outdoor house for <30 min, 16% for between 30 and 60 min, and 2% for more than 60 min. The population was regularly exposed to the sun (23.5%), the occasionally (34.0%), and scantly (42.5%). The patients had insufficient Vitamin D (44%), followed by deficient 34%, and sufficient (22%). Population with deficient Vitamin D were more likely to be obese (43.8%) compared to overweight (28.8%), normal weight (39%), and underweight (20%), but the overall difference was not significant among BMI groups. Conclusions: The present investigation showed a high prevalence of deficient and insufficient Vitamin D in young childbearing females, especially among overweight and obese individuals.
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Assessment of biochemical parameters and study its correlation in ß-Thalassemia major patients and healthy controls in Kirkuk City, Iraq p. 172
Ismail Khalil Abd, Israa Ghassan Zainal
DOI:10.4103/MJBL.MJBL_77_19  
Background: Thalassemia is the name of a group of genetically (acquired) blood diseases, which include defects on the production of hemeprotein, and fractional or complete damage to the combination of a particular sort of simple protein chain. The defect might have an effect on the “α, γ and δ” chains or might have an effect on few combination of the “β, γ and δ” chains within the same patient. Objective: The aim of the study was to evaluate the various protein parts in the ß-thalassemia major (BTM) patients in the city of Kirkuk compared to the healthy control group. Materials and Methods: Seventy blood samples were divided into two groups – 45 patients with BTM samples; they visited Azadi Hospital/Kirkuk city and 25 samples of healthy controls as a control group. Results: The results of the correlation coefficient showed that there were significant positive correlation between total protein (TP) and albumin and albumin and albumin/globulin ratio and significant negative correlation between globulin and albumin/globulin ratio. Finally, nonsignificant positive correlation between TP and thiol, TP and globulin, TP and albumin-globulin ratio, albumin/thiol, globulin and free amino and globulin and thiol and non-significant negative correlation between TP and free amino, thiol and carbonyl, thiol and free amino, carbonyl and free amino, albumin and carbonyl, albumin and free amino, albumin and globulin, and globulin and carbonyl. Conclusion: The correlation studies between the above parameters indicated a negative relationship between TP and free amine in β-thalassemia patients. These results reinforce the importance of measuring both TP and free amine concentration to investigate their development of β-thalassemia complications. Also, measuring both thiol and free amine yields is also important for the same reason.
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Retrospective study of Hirschsprung's disease in Erbil city/Iraq during 2004–2016 p. 177
Suhel Mawlud Alnajjar, Jawhar Tahir Omer, Salah Abubakir Ali
DOI:10.4103/MJBL.MJBL_45_19  
Background: Hirschsprung's disease is caused by the failure of ganglion cells to migrate cephalocaudal through the neural crest during 4–12 weeks of gestation, causing an absence of ganglion cells in all or part of the colon. Most patients present in infancy, and the early diagnosis is important to avoid complications. With proper treatment, most patients live normal adult live. Objectives: The objective of this study is to investigate the incidence and severity of Hirschsprung's disease in our location (Erbil city/Iraq). Materials and Methods: In this prospective study, we collected 150 cases that referred to our private laboratory in Erbil city from January 2004 to December 2016. A total of 108 cases were studied grossly and histopathologically stained by H and E in addition to Phosphotungstic acid-haematoxylin stain (PTAH) special stain for ganglion cells and neural plexuses. Results: The results found that Hirschsprung's disease was more common in males than females (male gender 52% and female 48%). The majority of cases were below the age of 1 year (48% of cases). The resected segment is 21–30 cm in about 46% of cases. Regarding the narrowing segment is about 5 cm in most cases (56% of cases). Finally, the number of neural plexuses in the whole narrow segment was five neural plexuses in the majority of cases (found in 24 cases [23%]). Conclusions: Hirschsprung's disease is a common disease in this locality (Erbil city/Iraq). All constipated newborn babies should be examined to exclude HD.
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The impact of ramadan fasting on acute coronary disease events among Iraqi population p. 181
Shwan Othman Amen, Soza Tharwat Baban, Salah Hassan Yousif, Ahmed Himdad Hawez, Zana Tharwat Baban, Dlovan Mustafa Fateh Jalal
DOI:10.4103/MJBL.MJBL_4_20  
Background: Ramadan fasting is a common religious tradition practiced by several prominent faiths in the world. It is also currently regaining interest as a medical practice, both as preventive and as therapy and/or simple choice of lifestyle. Fasting brings about some changes in life style, diet, and sleeping patterns, which raises major concerns for cardiac patients. Thus, the role of Ramadan fasting in acute coronary events could be pivotal for cardiac patients. The association of fasting with acute myocardial infarction (AMI) remains to be further clarified. Objectives: The major aim of this study was to determine the prevalence of AMI and its associated risk factors among Iraqi patients during Ramadan (DR) and non-Ramadan months. Materials and Methods: A total of 154 AMI patients admitted to the Surgical Specialty Hospital–Cardiac Center, Erbil city were enrolled a month before Ramadan and DR in 2019. The serum levels of lipid profile parameters were analysed using enzymatic immunoassay analyzer. The HbA1c was measured using a fully automated glycohemoglobin analyzer. Results: The incidence of AMI was statistically significantly lower among fasted patients (29%) as compared to non-fasting patients (71%) (P < 0.05). Low-density lipoprotein-cholesterol and triglycerides statistically significantly decreased in fasted AMI patients (15.6% and 22.2%,P < 0.05) compared to nonfasting patients (31.2% and 58.7%), but not with high-density lipoprotein-cholesterol and total cholesterol. No statistically significant changes were found in hypertension and diabetes between fasted and nonfasted patients with AMI (P > 0.05). Conclusion: Ramadan fasting has a preventive effect, and it does not increase the risks of acute coronary events in Iraqi patients.
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Molecular detection of carbapenemase-producing Pseudomonas aeruginosa isolated from intensive care units of surgical specialty hospital in Erbil city p. 185
Soza Tharwat Baban
DOI:10.4103/MJBL.MJBL_24_20  
Background: The emergence and spread of carbapenem-resistant Pseudomonas aeruginosa (CRPA) is a serious cause of nosocomial infections in critically ill patients. Objectives: The aim of this study was to determine the prevalence of CRPA and carriage of class B Metallo-β-lactamase resistant genes in intensive care units (ICUs) from patients with surgical-site infection or ventilator-associated pneumonia at a Surgical Specialty Hospital in Erbil city. Materials and Methods: During 6 months' study, a total of 80 clinical samples were collected from ICUs. The identification of P. aeruginosa in clinical specimens was confirmed by polymerase chain reaction (PCR) amplification of a molecular marker–oprL gene. Antimicrobial susceptibility was performed using Vitek-identification system. Screening of carbapenemase-producer isolates was confirmed using Rapidec Carba NP test. CRPA isolates were tested for the presence of metallo-β-lactamase (MBL)-encoding genes, including: blaVIM, blaIMP, and blaNDMby using PCR. Results: A total of 50 (62.5%) P. aeruginosa isolates were identified with antibiotic resistance profile (4% pan drug resistant [PDR], 20% extensively drug resistant [XDR] and 76% multidrug resistant). Twelve (24%) isolates were CRPA positive, in which the most prevalent MBL-encoding gene was blaVIM (58.3%), blaNDM (41.7%), and blaIMP (33.3%). Conclusions: Alarmingly, high prevalence of CRPA with predominance of MBL-encoding genes was detected. The XDR and PDR resistance phenotypes have become highly prevalent for this nosocomial pathogen in ICU patients that may cause a therapeutic impasse. The MBL-encoding genes were predominant among clinical isolates of P. aeruginosa. These findings emphasize on adherence to infection prevention and control standard precautions, early detection of CRPA isolates and development of to effectively reduce the burden of carbapenem resistance.
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Opinion's assessment of female teachers regarding the risk factors affecting the reproductive health p. 194
Wafa Mahmod Jasim
DOI:10.4103/MJBL.MJBL_97_19  
Background: Reproductive health is affected both by the quality of the health-care services and the socioeconomic development level and the position of women in the society. Women's health cannot be understood unless a specific definition of health that is related to their role and position in society, specifically in the family unite. Materials and Methods: The aim was to assess the female teachers' opinions regarding the factors affecting the reproductive health in the Kirkuk Technical Institute. A cross-sectional study was done, and a randomly selected sample from 50 female teachers from different scientific departments after receiving their agreements to participate in the study which was started from November 1, 2016, to December 1, 2016. A special questionnaire form was prepared and distributed to the study sample. Results: The study results showed that 66.0% of study teachers were living inside Kirkuk city, (58.0%) from the administrative department. Nearly 42.1% teachers from the administrative department married at the age <20 years, whereas 32.2% teachers from the technical department married at the age >20 years. Conclusions: The study concluded that young age pregnancy can be prevented through the encouragement of family planning counselling.
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Correlation of serum concentration cyclin-dependent kinase 4 and cyclin-dependent kinase 6 with breast cancer in Babylon province p. 199
Dalya Shakir Al-Owaidi, Moaed E Algazally, Alaa Sadeq Alawaad
DOI:10.4103/MJBL.MJBL_22_20  
Objectives: The goal of this study to estimate the correlation between breast cancer and cyclin-dependent kinase 4 (CDK4)\CDK6 enzyme concentrations in the occurrence of breast cancer and breast cancer subtypes. Methods: A total of 80 breast cancer patients are subdivided according to molecular classification into four groups, Luminal A, Luminal B, Her2/neu enriched, and TPN and 80 healthy individuals as control were enrolled; biochemical tests and body mass index were assayed. Results: No significant differences were found between patients and control groups and no significant differences were found among breast cancer subtypes in the concentrations of CDK4 (P > 0.05). There were no significant differences found between patients and control groups and no significant difference in the CDK6 concentration among subtypes groups (P > 0.05). The correlation between age, CDK4, and CDK6 in cases and control revealed that the correlation was absent between age, CDK4, and CDK6 concentration, except a weak positive correlation was found between CDK4 and CDK6 concentrations. Conclusion: There was no significant difference in serum levels of CDK4 and serum level of CDK6 between case and control and among patient subtypes.
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Dermatological manifestations in patients with end-stage renal disease at the hemodialysis center in merjan hospital at Babylon province, Iraq p. 204
Safaa S Alwaash, Maha Abd A. Alshukri, Khalid H Al-Shibly
DOI:10.4103/MJBL.MJBL_30_20  
Background: Chronic kidney disease (CKD) refers to an irreversible deterioration in renal function which ordinarily develops over a period of years. Many cutaneous anomalies have been encountered in patients with end-stage renal disease that precedes or follows the initiation of dialysis treatment or kidney transplantation. Manifestations such as pallor, pruritus, xerosis, or even hyperpigmentation and perforating disease are commonly exhibited in such patients. Objective: The aim of this study is to estimate the prevalence of cutaneous manifestations in patients with CKD undergoing hemodialysis. Materials and Methods: A cross-sectional study involved 103 patients with CKD at the hemodialysis center of Merjan Teaching Hospital, Babylon province, Iraq. Results: Many dermatological manifestations were diagnosed in patients of this study ranging from xerosis (85%) and pallor (82%) to calcinosis cutis (1%) and perforating disease (1%). Forty percent of our patients had a 2-year history of dialysis, 50% possess between 2 and 6 years, whereas the remaining 10% were compelled to have hemodialysis for more than 6 years. Cutaneous manifestations were found in 97% of patients. Conclusions: There is a high prevalence of cutaneous changes found in patients with CKD undergoing hemodialysis.
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Outcome of response of multiple myeloma to induction treatment in kurdistan region of Iraq p. 209
Akram Mahmood Mohammed, Kawa M Hasan, Dana A Abdullah, Ameer I A. Badi, Ahmed K Yassin, Banaz M Safar, Basil K Abdulla, Rawand P Shamoon, Truska A Amin, Zeki A Mohamed, Ali I Mohammed, Diveen J Hussein, Nawsherwan S Mohammed, Rezhin N Rajab, Firiad Hiwaizi, Kanar J Karim, Abid M Hassan, Hisham A Getta, Najmaddin S H. Khoshnaw, Sana D Jalal
DOI:10.4103/MJBL.MJBL_25_20  
Background: Nowadays, the therapy of multiple myeloma (MM) has successful and hopeful outcomes. Worldwide, various treatment regimens are prescribed by clinical hematologists. Objectives: The objective was to evaluate response to induction treatment and survival of MM patients treated with various treatment regimens in the Kurdistan Region of Iraq (KRI). Materials and Methods: A total of 114 patients in the KRI were included in a retrospective study through the period of January 1, 2010, to September 31, 2019. The diagnosis of MM was confirmed using the International Myeloma Working Group (IMWG) guidelines. The treatment responses were assessed according to the IMWG response criteria. Results: Complete response among the MM patients was 35.7%, very good partial response (VGPR) was 28.7%, partial response reached 9.1%, and stable disease reached 16.5%. The Kaplan–Meier curve showed those with VGPR had better survival than the rest of the response categories. Meanwhile, there was a significant association between MM patients on bortezomib and dexamethasone treatment regimen and complete remission was noticed (P = 0.02). Conclusions: The combination therapy of bortezomib and dexamethasone is effective in achieving a better response to treatment and good survival than other therapy regimens.
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Arteriopathy by doppler ultrasound study and neuropathy by electromyography and nerve conduction study in diabetic foot p. 215
Imran Sulaiman Dawood, Sahar Abdl Hussein Jupori
DOI:10.4103/MJBL.MJBL_14_20  
Background: Diabetic foot ulcer is a common surgical problem in the surgical population. Objectives: This study evaluates some of the risk factors which are thought to play a role in the development of diabetic foot ulcer by using (color Doppler sonography, electromyography, and nerve conduction study). Materials and Methods: This was a prospective study on patients admitted to the surgical, medical, and orthopedic wards in the Almahweel General hospital in Babylon for a period from December 15, 2016, to December 15, 2018. Data were collected by history, clinical examination, investigation, and Doppler ultrasound for all patients. Results: Sixty-one patients (47 males and 14 females) were included in our study admitted to the Almahweel General Hospital in Babylon, Iraq. All patients showed different degree of peripheral arteriopathy, retinopathy, osteomyelitis, and different degree of neuropathy. Smoking increases the risk of diabetic foot. Conclusions: Smoking increases the severity of peripheral arteriopathy and neuropathy so increases the severity of diabetic foot ulcer. The severity of peripheral arteriopathy and neuropathy increased with increase the duration of diabetes mellitus. Diabetic foot ulcer is due to the coexistence of peripheral arteriopathy and neuropathy.
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Incidence of Shoulder Tip Pain in Patients with Laparoscopic Cholecystectomy p. 221
Doaa Riyadh Abd-Aljabbar, Salah Hadi Al Janaby
DOI:10.4103/MJBL.MJBL_74_19  
Background: Laparoscopic cholecystectomy (LC) is the gold standard procedure for the surgical treatment of gallbladder disease; it is associated with decrease in postoperative pain and early mobilization after surgery, but still associated with shoulder tip pain that lead to patient's distress and delayed discharge, so the provision of postoperative pain relief is of great importance. Objectives: To evaluate the effect of intraperitoneal installation of local anesthesia (bupivacaine) on reduction of the incidence of shoulder tip pain after LC and its effect on postoperative analgesia need, early mobilization, and time of hospitalization. Materials and Methods: An experimental double-blind randomized control trail study include 60 patients with elective laparoscopic cholecystectomy at the age between 18 and 60 years of both sex, randomly assigned to 30 patients in each group either Group A (not received bupivacaine) or Group B (intraperitoneal installation of bupivacaine), at the end of surgery after gallblader resection, 20 ml of 0.5% bupivacaine in 500 ml normal saline irrigate intraperitonealy. Postoperatively, the patients were assessed for shoulder tip pain using visual analog scale, the number of analgesic doses required, and time of mobilization after surgery at 1hr, 4 hr, 8hr, and 12 hr postoperatively, and time of discharge was also recorded. These information were analyzed using SPSS version 22. Results: The visual analog scale was significantly higher in Group A compared to Group B at 1st, 4th, and 8th postoperative h (P = 0.0001, 0.0001, 0.001;P < 0.05), the total number of patients require rescue analgesia was higher in Group A than Group B, the mobilization after surgery in Group B earlier than Group A and shorter hospitalization in Group B than Group A. Conclusion: Intraperitoneal instillation of bupivacaine (20 ml of 0.5%) with normal saline will significantly lower the intensity of postoperative shoulder tip pain, as well as decrease analgesic consumption, time to mobilize after surgery and time of hospitalization.
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An urgent call to improve the coronavirus disease 2019 pandemic readiness and response actions in the american region: The world health organization p. 227
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/MJBL.MJBL_23_20  
The pace of the international spread of the ongoing Corona Virus Disease-2019 (COVID-19) pandemic has become a grave cause of concern for the public health authorities. Moreover, based on the trend of the outbreak in other affected nations, the number of cases is expected to rise further in the coming days in the American region and this calls for the need to prepare health care establishments. Even though, the spread of the virus cannot be restricted by geographical boundaries, even now, a brief window of opportunity still exists for the health authorities to improve their outbreak readiness and response activities, which in turn will be crucial factors in reducing the overall caseload and saving a multiple number of human lives. In conclusion, the America region is facing an unprecedented challenge in the form of the ongoing COVID-19 pandemic and it is expected that the caseload will rise even in the future. Thus, there is an indispensable need to believe in ourselves and take every small step which can minimize or stop the transmission of the disease and this will essentially require active engagement of all the concerned sectors.
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SHORT COMMUNICATION Top

Improving measles vaccination coverage in South Sudan: The necessity to adopt a coordinated and multisectoral approach p. 229
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/MJBL.MJBL_9_20  
Measles is a life-threatening infectious disease, accounting for the deaths of more than 140,000 deaths worldwide in 2018. It is worth noting that the incidence of the disease is extremely high in the low- and middle-income nations, which are having multiple other competing public health priorities, a weak health-care delivery system, or ongoing humanitarian emergencies. South Sudan has been subjected to long-term conflicts, and with regard to measles, it has been reported that more than 4700 cases and 26 deaths have been reported in the nation since the disease outbreak began last year. Keeping this in mind and in order to avert fatal consequences and accomplish 95% vaccine coverage, the international welfare agencies have joined their hands together and initiated a vaccination drive to immunize 2.5 million children across the entire nation along with the provision of Vitamin A and deworming tablets. In conclusion, considering the fact that measles is vaccine preventable and every child deserves the right to receive the vaccine, it is high time that we take necessary steps to ensure political leadership, strengthening of health facilities, and involvement of the parents so that the planned vaccination campaign can accomplish the intended results in the conflict-affected South Sudan.
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ERRATUM Top

Erratum: Prevalence of leukocytes in type 2 diabetic patients in Erbil City p. 231

DOI:10.4103/1812-156X.287063  
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