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   Table of Contents - Current issue
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January-March 2019
Volume 16 | Issue 1
Page Nos. 1-86

Online since Monday, March 18, 2019

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ORIGINAL ARTICLES  

The association between serum zinc levels and insulin resistance among polycystic ovary syndrome patients in Duhok City, Kurdistan Region, Iraq p. 1
Lashkar Abdullah Jasem, Dhia Mustafa Sulaiman
DOI:10.4103/MJBL.MJBL_97_18  
Background: Polycystic ovary syndrome (PCOS) is a relatively common endocrine and metabolic problem. Patients with PCOS are known to have a higher incidence of insulin resistance. The homeostasis model assessment (HOMA) is an indirect, rapid, accurate, and cost-effective method of assessing insulin resistance based on patient's fasting plasma insulin and glucose concentrations. Several studies have reported a significant correlation between HOMA and the traditional hyperinsulinemic-euglycemic clamp method. Zinc deficiency promotes insulin resistance, and that zinc supplementation can prevent or, at least, alleviate insulin resistance in selected patient populations. Objective: The current study primarily aims at defining the association between insulin resistance and zinc deficiency among both PCOS and selected controls. It also looks at certain risk factors associated with obesity among the study population in Duhok City, Kurdistan Region, Iraq. Materials and Methods: The current case–control study was performed at Azadi Teaching Hospital/Gynecological Outpatient Clinic in Duhok City/Kurdistan Region/Iraq. The study included 80 women (40 cases with PCOS and 40 controls of healthy women). Results: There was no age difference between both groups (Mean = 26.77 years, standard deviation [SD] = 6.42 years for PCOS cases versus mean and SD of 27.57 years and 6.45 years, respectively; P= 0.48). Likewise, there was no difference in the serum zinc levels between cases and controls. However, patients with PCOS had significantly higher Body mass index and HOMA scores compared to the controls (P = 0.005 and 0.007, respectively). Conclusion: Higher serum zinc levels are independently associated with lower HOMA. Patients with PCOS had significantly higher insulin resistance when compared to the controls of similar age and zinc level.
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Prevalence of symptomatic urinary tract infections and asymptomatic bacteriuria in Iraqi pregnant women of Babylon Governorate Highly accessed article p. 5
Najlaa Abass Al-Mamoryi, Abdulrazzaq Salman Al-Salman
DOI:10.4103/MJBL.MJBL_82_18  
Background: Urinary tract infections (UTIs) are the most common infections among pregnant women. It can be lead to poor maternal and perinatal outcomes. Objective: The objective of the study is to determine the prevalence rate of symptomatic UTIs and asymptomatic bacteriuria of pregnant women in the Babylon Governorate and to determine its association with sociodemographic, obstetrical, and other factors. Materials and Methods: Cross-sectional study between March 2018 and June 2018 involves examining 300 pregnant women at primary health centers; Maternity and Pediatrics Hospital of Hilla city, with and without symptoms of UTI were employed for this study. Midstream urine samples were taken, and general urine examination was performed. Results: The results of this study revealed that the overall prevalence of UTI among pregnant was 64.6% which include (symptomatic bacteriuria 8.0%, asymptomatic bacteriuria 6.3%, and UTI 50.3%). The higher rate of UTI was found in lower age, multiparous women, and during the second trimester. Factors such as socioeconomic status, history of UTI, dysuria, and positive laboratory results were found to be significantly associated with UTI. Conclusion: UTI is still the common health problem in pregnant women especially during their second trimester. Urinalyses are essential for all pregnant women during the antenatal period. The screening will be assisted to early detection and treatment of asymptomatic bacteriuria which prevent complication for mother and baby.
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Knowledge, attitudes, and practice of complementary and alternative medicine among diabetic patients p. 13
Esraa Kadhum Mehdi, Hadeel Fadhil Farhood
DOI:10.4103/MJBL.MJBL_83_18  
Background: Complementary and alternative medicine (CAM) is defined as a group of various medical and healthcare systems, practices, and products that are not generally considered part of conventional western medicine. Objective: This study was carried out to estimate the prevalence of CAM use among diabetic patients and to assess knowledge, attitudes, and practice of CAM among diabetic patients. Materials and Methods: This is a hospital-based cross-sectional study done at diabetic center of Merjan teaching hospital on 200 patients. Results: This study estimated that the prevalence of CAM use among diabetic patients at Babylon province was 48.5%; the most common type of CAM used by diabetic patients was Herbal products (24.7%), while nutritional supplements and spiritual healing together used by (18.6%)of (CAM) users, herbal products and nutritional supplements together at rate of (14.4%) and (40.2%) use the 3 types of CAM modalities together. The most common type of Herbal products used by diabetic patients were Garlic which used at (16.9%), while Lemon used by (19.1%) of Diabetic patients, Cinnamon (Darcin) (10.2%), Fenugreek (Helba) (8.8%), (7.3%) bitter gum, and (18.3%) were a mixture of herbs, (7.3%) black seed. (62%)of Subjects had good knowledge about (CAM),(28%) had fair knowledge and (10%) poor knowledge. (66%) of (CAM )users had negative attitudes toward (CAM) and (34%) had positive attitude. Conclusion: Our study estimated the prevalence of CAM use among diabetic patients, revealed good knowledge of the diabetic patients and negative attitudes of CAM users, and showed five significant associations with score of knowledge and attitudes (age, educational level, residence, family history of DM, and follow-up visits), which was consistent with some studies in other eastern and western countries.
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Evaluation of the effect of dapagliflozin on atherosclerosis progression by interfering with inflammatory and oxidative stress pathways in rabbits p. 20
Hajir Karim Abd-Ulhussein, Fadhil Abdul-Jabbar Rizij
DOI:10.4103/MJBL.MJBL_104_18  
Background: Atherosclerosis is a very common disease in which fat deposition in the inner layers of arteries leading to plaques formation. Dapagliflozin is one of a new class of drugs known as the sodium-glucose cotransporter-2 inhibitors, responsible for lowering of the blood glucose level, and enhancing urinary glucose excretion. Dapagliflozin may lower blood glucose levels and at the same time prevent cardiovascular diseases. Objective: The objective of this study was to assess the effect of dapagliflozin on atherosclerosis through interfering with inflammatory and oxidative pathways. Materials and Methods: Eighteen local domestic male rabbits were used in this study. The rabbits were randomly divided into three groups: Group I rabbits fed normal chow diet for 12 weeks; Group II rabbits fed with 0.5% cholesterol-enriched diet; and Group III rabbits fed with 0.5% cholesterol-enriched diet together with dapagliflozin (1 mg/kg once daily). Blood samples were collected before the study (zero time) and every 4 weeks for the measurement of serum total cholesterol, triglycerides (TGs), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), very LDL-C (VLDL-C), tumor necrosis factor alpha (TNF-α), and endothelin-1 (ET-1). Results: Dapagliflozin treatment showed insignificant elevation in total cholesterol and LDL-C, significant decrease VLDL-C and TG, and significant elevation of HDL-C level (P < 0.05) compared with the induced untreated group. It was insignificantly decreased inflammatory markers (TNF-α and ET-1), increased aortic total antioxidant capacity, and significantly reduced aortic intima thickness compared with induced untreated group. Dapagliflozin, by slightly interfering with inflammatory and oxidative pathways, may show beneficial effects on atherosclerosis and can attenuate the atherosclerotic lesion formation. Conclusion: Dapagliflozin may have a beneficial effect on atherosclerosis by slightly interfering with inflammatory and oxidative pathways and can reduce the atherosclerotic lesion formation; however, our study needs further clinical studies to be carried out on large population.
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Evaluation of the quality of maternal health services in primary health-care centers by using service provision Assessment p. 25
Wedyan Ibrahim Ismael, Hadeel Fadhil Farhood
DOI:10.4103/MJBL.MJBL_85_18  
Background: The Service Provision Assessment (SPA) survey is a nationwide facility-based survey that measures the ability of health facilities to provide quality preventive, diagnostic, and treatment services for key maternal and child health and HIV/AIDS programs. Objective: The study was designed to assess some aspects of expressed maternal health services provided at ten primary health-care (PHC) centers in Babylon province, Iraq, using interviews with health service providers and clients and observations of provider–client consultations to obtain information on the capacity of facilities to provide quality services, and the existence of functioning systems to support quality services. Materials and Methods: A cross-sectional study was done in ten Babylon PHC centers from March to August 2018. The study included 165 pregnant women. The questionnaire included sociodemographic factors (age, residence, employment, parity, and education) and data related to Service Provision Assessment questionnaire which include a facility inventory, client exit interviews, and antenatal care (ANC) observation and consultation. Results: The mean age of pregnant women attending ANC was 25.29 ± 5.48, 66.1% came from urban areas, the majority were not employed (83%), their educational level was secondary (38.8%), and 57% were multipara. The findings showed that the majority (89.1%) of patients think that health facility services were good. A sizeable majority (83.0%) of women were satisfied regarding health services including availability of medicines at the facility (91.5%), cleanliness of the facility (100%), privacy (93.9%), charging or payment of fees for services received (0.6%), and discussion of problems related to the pregnancy (93.3%). Conclusion: This study showed a high level of satisfaction with the quality of maternal health services among antenatal attendees and highlighted the need to support interventions that increase the uptake of formal maternal health-care services.
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Evaluation of serum level of soluble lectin-like oxidized low-density lipoprotein receptor-1 and its relationship with severity of preeclampsia and birth weight p. 31
Hiba Ghassan Rajab, Mohammed A.M Ali, Hala Abdulqader Al-Moayad
DOI:10.4103/MJBL.MJBL_121_18  
Background: Lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1) is one of the pattern recognition receptors that plays a critical role in vascular diseases and host immune response, LOX-1 can induce endothelial dysfunction through pathways implicated with oxidative stress and inflammation that ends with vascular lesions. Objective: The objective of the study is to evaluate the serum level of soluble LOX-1 (sLOX-1) in preeclampsia (PE) and normal pregnancy to study its relationship with the severity of PE and birth weight. Materials and Methods: A total of 56 patients with PE were allocated to the study together with 28 healthy pregnant women as normal controls. PE patients divided into 28 mild and 28 severe PE. Levels of serum sLOX-1 were measured by sandwich enzyme-linked immunosorbent assay technique. Results: Results showed a significant increase in the serum sLOX-1 in preeclamptic patients (P < 0.01) compared to normal controls. The significance increased in serum levels of sLOX-1, was noted in mild (P = 0.001) and severe patients (P = 0.001), compared to normal controls. There was a significant decrease in fetal birth weight in severe PE as compared to mild and control groups which was correlated with sLOX-1, furthermore, logistic regression of the variables for the presence of low birth weight <2.5 kg. Conclusion: High level of serum sLOX-1 is associated with the occurrence and severity of PE, which provides additional information for predicting of PE and preventing its complications and for better understanding pathogenesis of PE and the results highlight the involvement of innate immunity molecules and inflammation in pathogenesis of PE through binding to apoptotic cells and angiogenic process.
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Study the relation between internet usage and the occurrence of depression among Kirkuk technical students p. 36
Wafa Mahmood Jasim
DOI:10.4103/MJBL.MJBL_77_18  
Background: Internet is regarded as one of the most indispensable parts in our life, and majority of young and adolescent people interested in the usage of it, but in some cases, these uses are become out of the control which later on lead to a condition called internet addiction in which it will be the predominant life activity. Objective: A descriptive cross-sectional study was conducted on Kirkuk Technical Institute students from January 1, 2017, to May 30, 2017 to study, if there is any relation between the occurrence of depression and internet usage. Materials and Methods: The total number of students included in the study was 550 from different scientific departments after distributing a special questionnaire form prepared for that purpose, and face-to-face interview was conducted after receiving the written consent from them. Results: The study results show that 60.8% of technical study students and 47.3% of students from administrative departments used internet daily, while 46.0% of students of health department used it weekly. In addition to that 72.1% and 67.8% male students from technical and administrative departments used internet daily, while female students from all departments (technical, administrative, and health) used the internet monthly; in addition to that 53.1% of students from administrative departments have a depressive attempts which affects daily activity and work in comparison to 18.5% of students from technical departments. Conclusion: The study concluded that the time spent for internet was about 7–9 h/daily with the presence of a suggestive depressive symptom which affects daily activity and work. Recommendations: The study recommended that further advanced educational programs about the main adverse effects of the internet and the main possible ways to control its usage.
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Cytogenetic effects of gestogens on women with threatened miscarriage in Duhok Province, Kurdistan Region, Iraq p. 41
Hayat S Ahmed, Dian J Salih, Iman Yousif Abdulmalek, Asaad A Alasady
DOI:10.4103/MJBL.MJBL_109_18  
Background: Gestogens have been recommended to have a place in the prevention of threatened miscarriage and spontaneous pregnancy loss during the first 3 months of pregnancy. Certain studies consider that this steroid hormone has genotoxic effect because they directly involved in the change of DNA structure. Objectives: This study aims to investigate the cytogenetic effects of gestogens on peripheral blood lymphocytes of pregnant women, by damaged cells and chromosomal aberrations, as well as evaluate the models for hormonal therapy in vivo. Materials and Methods: Blood sample from 30 women with threatened miscarriage, who received gestogen therapy in the first 3 months, Were taken. Cytogenetic analyses and karyotyping were performed for Each patient Before and after therapy. Results: The numerical chromosomal aberrations which found in blood lymphocytes of women before taking gestogens were 44,XX and 48,XX. The same result was observed after taking gestogens. The percentage levels of structural chromosomal aberrations were ring chromosome (2.06%), chromatid breaks (12.47%), chromatid gaps (1.65%), dicentric (0.55%), acentric chromosome (4.02%), and interchange chromosome (12.5%). Whereas, the abnormalities after treatment with gestogens were ring chromosome (5.31%), chromatid breaks (42.19%), chromatid gaps (20.86%), dicentric (7.50%), acentric chromosome (17.75%), and interchange chromosome (43.97%). Conclusion: Gestogens as hormonal substitute therapy do not induce numerical chromosomal aberrations but have a significant increase of structural chromosomal aberrations Gestogens have genotoxic effects on human lymphocyte chromosomes at wide range of concentrations. So the potential benefits and side effects of it must be weighed up against the deleterious effects.
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Correlation of bilirubin and alkaline phosphatase in infantile patients with cholestasis p. 47
Mostafa M Al-Bassam, Hassan H Al-Saeed, Hala Sameh Arif
DOI:10.4103/MJBL.MJBL_122_18  
Background: Early and successful individualized management of infantile cholestasis depends on the time of diagnosis. Objective: The objective of the study is to assess the clinical value of serum total bilirubin, direct bilirubin, and alkaline phosphatase in children with cholestasis. Materials and Methods: Sixty patients with diseases and 25 healthy controls distributed into three groups – total/direct bilirubin, and alkaline phosphatase were measured for all case and control studies by enzyme-linked immunosorbent assay. Results: The results showed serum total, direct bilirubin, and alkaline phosphatase have a highly significantly elevated in intra- and extra-hepatic cholestasis groups when compared with control (P < 0.001). There was a significantly elevated serum total and direct bilirubin when compared the extrahepatic cholestatic group with intrahepatic cholestatic group (P = 0.002 and 0.017), and there was no statistical difference between the intrahepatic cholestatic patients and extrahepatic cholestatic group when serum alkaline phosphatase measured (P = 0.610). Conclusion: From these findings, it was concluded that the level of direct bilirubin in sera of extrahepatic cholestasis group when compared with intrahepatic cholestasis group is elevated, serum total bilirubin, and alkaline phosphatase levels are good markers in determining the poor prognosis of cholestasis disease.
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Effect of Vitamin D deficiency on pulmonary function test in a normal population p. 51
Hemin Khalid Saber, Hamanejm Faraj Jaff, Media Qader Hasan
DOI:10.4103/MJBL.MJBL_75_18  
Background: During the past years, the role of Vitamin D on wide biologic processes has received the attractiveness. Moreover, the role of Vitamin D in the prevention and treatment of respiratory infections has already been confirmed. Objective: In the present study, the pulmonary functions, including forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1) ratio, and FEV1/FVC ratio were compared between healthy individuals with and without Vitamin D deficiency. Materials and Methods: In the current case–control study, the pulmonary functions of healthy individuals with normal Vitamin D (control = 51) and with Vitamin D deficiency (cases = 57) were compared through statistical analysis. The individuals recruited in the study were screened from the outpatient clinic of medicine department of a public hospital purposively. The Vitamin D level <50 nmol/L was considered deficient. The reference values of pulmonary functions were considered as follows: FVC between 80% and 120% as normal and <80% as reduced; FEV1 ≥75 as normal and <75 as reduced; FEV1/FVC between 80% and 120% as normal. Results: The present study showed that individuals with normal level of Vitamin D (control) and those with deficient level of Vitamin D (case) were comparable in age (39.09 vs. 41.33 years; P= 0.393), and body mass index (27.48 vs. 28.39; P= 0.475), respectively. In addition, both case and control groups were similar in FVC (93.98 vs. 93.12; P= 0.653), FEV1 (90.88 vs. 89.39L; P= 0.752), and FEV1/FVC (95.94 vs. 95.01%; P= 0.777) respectively. Conclusion: The study did not show a significant difference in baseline characteristics and of those spirometry functions (FVC, FEV1, and FEV1/FVC) between the healthy individuals with normal and deficient Vitamin D levels.
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Bacterial infections in patients with appendicitis in Hilla City, Iraq p. 55
Mohammed Salih Al-Janabi, Shihab Ahmed Al-Janabi, Ali Mohammed Al-Mahdawi
DOI:10.4103/MJBL.MJBL_4_19  
Background: Appendicitis is an inflammation of the appendix, which along the tube of tissue extends from the large intestine. The study suggested that the appendix may have some role in gut immunity. Objective: The objective of this study was to investigate the bacterial infection in patients with appendicitis and study the distribution of appendicitis with sex and age groups in addition to clinical signs. Materials and Methods: The study was done on 78 patients ranged from 5 to 65 years (47 males and 31 females) who were attended to Hilla Teaching Hospital in Babylon province and diagnosed as acute appendicitis by surgeons; all specimens were sent to the bacteriology laboratory in Stuart's transport medium. The swab was cultured on different type of culture media to identification of bacteria. Results: From 78 samples, only 51 (65.3%) were positive to bacterial culture whereas 27 (34.6%) showed no growth of bacteria. The rate of infection was 33% in males and 18% in females. Results also found that Escherichia coli was predominant with 50.9% followed by Streptococcus pneumoniae(21.5%), Pseudomonas aeruginosa(13.7%), and Klebsiella pneumoniae (9.8%), while Staphylococcus aureus has shown a lowest isolation rate. Results revealed that 3.9% of clinical signs and symptoms of appendicitis were dominated right iliac fossa pain in 35.5% and fever in 26.9% of patients. Conclusion: From this study, we can conclude that there was a relation between bacterial infections and E. coli which was predominant and it was recorded that the infection in males was more than in females in patients with appendicitis.
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Parental knowledge and practice regarding febrile seizure in their children p. 58
Noor Faisal Shibeeb, Yahya Abdul Shaheed Altufaily
DOI:10.4103/MJBL.MJBL_89_18  
Background: Febrile seizure (FS) is a benign convulsive disorder in under 5-year-old children, but at the same time, it is an alarming event in the lives of both child and parents. Lack of parent's knowledge about the nature of FS and how they should deal with it can lead to poor management. Objectives: To assess the knowledge and practice of parents regarding FS in their children and to assess the association of knowledge and practice of parents with certain socio-demographic characteristics. Materials and Methods: A cross-sectional study was performed on 100 parents of children with FS attending emergency department in Babylon Teaching Hospital for Pediatrics and Gynecology and AL-Noor Hospital for Pediatrics during a period of 5 months (from March 1 to August 1, 2018). A questionnaire was administered to parents which included items regarding family characteristics, characteristics of FS, their knowledge, and their first-aid practices with FS. Results: Regarding maternal age and paternal age, they ranged between 15–43 and 20–50 years, respectively. More than half of them live in urban areas, and concerning educational level of mothers, 70% were either illiterate or had a primary level of education. Majority of FS children were presented with first attack who represent a percentage of about 69%. About half of the respondents have good level of knowledge. Fifty-two percent of them considered that FS is equivalent to epilepsy, 69% stated that it is a life-threatening event, and 80% knew that it occurs during febrile occasions. Only 25% of parents took their children to doctor during attack of fit without first aids. Conclusions: Parents' knowledge regarding FS was significantly associated with higher maternal education, urban residence, and mother age. A higher level of practices was shown to have a significant association with increasing in the number of episodes experienced by parents and advancing in maternal age.
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Assessment of the quality of life of Iraqi children with juvenile idiopathic arthritis: A single-center study p. 65
Wafaa Eskander Naser
DOI:10.4103/MJBL.MJBL_115_18  
Background: Even with the rapid advancement in the treatment of juvenile idiopathic arthritis (JIA), most affected children still suffer from remarkable degree of discomfort and reduced functional capacity. As such, many instruments have been invented to evaluate the quality of life (QoL) in those patients. Objective: This study aimed to assess the QoL in children with JIA using Children Health Assessment Questionnaire (CHAQ) instrument. Materials and Methods: This is a case–control study including 52 children with JIA who were attending Basrah Center for Disables Rehabilitation/Basrah, Iraq. Other age- and gender-matched children free from any systemic connective tissue diseases were also enrolled to represent the control group. One parent of each child (cases and control) was asked to read and fill an Arabic-translated version of the original CHAQ. Data were extracted from the questionnaire and subjected for statistical analysis. Results: Four types of JIA have been recognized which were oligoarthritis, polyarticular arthritis, systemic arthritis, and enthesitis-related arthritis which represented 48.08%, 36.54%, 9.62%, and 5.77%, respectively. Analysis of CHAQ data revealed a worse life quality in patients compared to controls. Six CHAQ domains (arising, walking, hygiene, activities, disability, and pain) attained significantly higher scores in patients (0.73 ± 0.61, 0.76 ± 0.52, 0.5 ± 0.29, 1.12 ± 0.6, 0.67 ± 0.41, and 0.83 ± 0.53, respectively) than in controls (0, 0, 0, 0.32 ± 0.26, 0.24 ± 0.21, and 0, respectively). Conclusion: CHAQ is a feasible and a reliable instrument to evaluate Iraqi children with arthritis. Treated children with JIA of different types had a worse QoL compared with the unaffected children.
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Biochemical significance of ecto-5'-nucleotidase, xanthine oxidase, and glutathione S-transferase determinations in sera of cigarette and water pipe young men smokers p. 70
Rana M Hameed, Wesen Adel Mehdi, Atheer Awad Mehde
DOI:10.4103/MJBL.MJBL_2_19  
Background: Apparently, young people begin smoking for different reasons. for instance, increase the pressure of peers, family attitudes that condone smoking, stress relief, using some drugs or it could be based on many other reasons. Currently, smoking has been involved as a main responsible for approximately 30% of all cancer deaths in developed countries. Materials and Methods: The evaluation was to examine the extent of adverse effects of cigarettes and water pipe (WP) smokers on biochemical characteristics in healthy young men smokers. Results: The results were shown a significant increase of the measured hematological parameters (white blood cells, hemoglobin, and platelet counts) associated to WP smoker group. Part of kidney performance was examined under both smoking conditions, and compared to control group, only blood urea levels of WP smoker group were indicated a significant increase (P < 0.05). On the other hand, the results demonstrated that 5'-nucleotidase and xanthine oxidase activities were higher in both smoker groups as compared to nonsmoker group, while glutathione S-transferase was shown a lower activity in WP smokers. Conclusion: Based on these results, it can be concluded that both types of smoking have influenced many endogenous factors which decreased the cellular protection against free radical attacks and that were obvious through the variability of the measured biological factors under smoking conditions compared to nonsmoking group which easily could be result in a list of diseases usually linked to smoking.
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CASE REPORTS Top

New surgical technique to restore facial bone loss and deformities by new modified proplast implant p. 77
Sabah Hassan Husain
DOI:10.4103/MJBL.MJBL_110_18  
Bone and skin grafts are the most common grafts used in oral surgery. The graft may be autogenic, isogenic, allogeneic, and xenograft. This new surgical technique is to encourage bone ingrowth through the and replacement of the Proplast by bone. Combination of the Problast with biocompatible materials by painting the Problast with this mixture encourages bone ingrowth through its porosity which is extra porous (70%–90%) by volume. This case report describes a patient with zygomatic bone loss treated by this new surgical technique.
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Intravenous Immunoglobulin Therapy in Postpoliomyelitis Syndrome p. 79
Saad Kazim Karim
DOI:10.4103/MJBL.MJBL_116_18  
Postpoliomyelitis syndrome is a new neurological disorder seen in individuals who survive remote poliomyelitis. An adequate diagnosis is important for treatment and prognosis. The diagnosis of postpoliomyelitis syndrome might be difficult as the diagnosis mostly depends on the patient's subjective description of the symptoms. The diagnostic criteria primarily depend on new and progressive muscle weakness, muscle fatigue, general fatigue, and pain in the absence of other disorders which may be similar to this syndrome. Furthermore, the postpoliomyelitis syndrome patients have reached an age when concomitant diseases are common. The possible etiology is that this entity of paralysis can be exploited by slowly progressive distal neuronal degeneration. Interestingly, this patient had primary upper limb polio paralysis and then new slowly progressive asymmetrical, muscle weakness in the contralateral lower limb. Few clinical trials using human intravenous immunoglobulin (IVIG) and pyridostigmine gave controversy about a specific treatment. In this case, we tried an IVIG therapy, but the weakness was progressively worsening and there was more atrophy in the muscle bulk of the affected muscle group. However, supportive treatment is also important to be planned. The aim of this case report is to describe the complexity of the diagnosis and treatment of such cases of the postpoliomyelitis syndrome in comparison to relevant literature.
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LETTERS TO EDITOR Top

Global elimination of viral hepatitis: Challenges and encouraging factors p. 82
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/MJBL.MJBL_111_18  
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Weak relation between increase of lipid levels and blood sugar levels in diabetic patients p. 83
Abdulameer Jasim Mohammed
DOI:10.4103/MJBL.MJBL_108_18  
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Role of graduated nurses in neonatal intensive care unit in Iraq p. 85
Sally Saad Bash, Jawad K.A Al-Diwan, Eman A AI-Kaseer
DOI:10.4103/MJBL.MJBL_105_18  
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