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   Table of Contents - Current issue
Coverpage
July-September 2020
Volume 17 | Issue 3
Page Nos. 233-310

Online since Wednesday, September 16, 2020

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REVIEW ARTICLES  

Multiple myeloma, the plasma cell cancer: An overview Highly accessed article p. 233
Basim A Abd, Mushtaq Q Mohammed
DOI:10.4103/MJBL.MJBL_20_20  
Multiple myeloma (MM), also known as plasma cell myeloma, is a cancer of plasma cells, a type of white blood cells that normally produce antibodies. The word myeloma is from the Greek (myelo), meaning “marrow” and (oma), meaning “tumor.” It usually occurs around the age of 60 and is more common in men than women. It is uncommon before the age of 40. Usually, no symptoms are noticed initially. As the disease progresses, bone pain, bleeding, frequent infections, and anemia may occur. The cause of this disease is unknown. Risk factors include obesity, radiation exposure, family history, and certain chemicals. The abnormal plasma cells produce abnormal antibodies, which can cause kidney problems and overly thick blood. The plasma cells can also form a mass in the bone marrow or soft tissue. When one tumor is present, it is called a plasmacytoma; more than one is called MM. MM is diagnosed based on blood or urine tests finding abnormal antibodies, bone marrow biopsy finding cancerous plasma cells, and medical imaging finding bone lesions. Another common finding is high blood calcium levels. MM is considered treatable, but generally incurable. Remissions may be brought about with steroids, chemotherapy, targeted therapy, and stem cell transplant. Radiation therapy is sometimes used to reduce pain from bone lesions.
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Ear, nose, and throat foreign bodies in pediatric age p. 238
Santosh Kumar Swain, Krishna Chandra Mallik
DOI:10.4103/MJBL.MJBL_37_20  
Ear, nose, and throat foreign bodies (FBs) in pediatric age group are one of the most common emergencies managed by otorhinolaryngologists. FB in the ear, nose, and throat may cause significant morbidity and may need costly management if not treated in time. The diagnosis of the FB is based on the history from parents or caregivers, physical examination, and imaging. Successful removal of the FB depends on the site of FB, type of the FB, availability of the instruments, and skill of the clinicians attempting for FB removal. The attempts of the FB removal from the ear, nose, and throat by untrained or inexperienced health professionals may lead to complications. It is a necessity to educate the caregivers or parents for close monitoring their children for close monitoring and avoid such FB insertion. This review article focuses on the prevalence, factors related to the FB insertion into the ear, nose, and throat in pediatric age, clinical presentations, and current management. This article will surely increase awareness among the emergency physicians, pediatricians, family physicians, and otolaryngologists for dealing with pediatric patients with FB in the ear, nose, and throat and help them to resolve this problem to a great extent.
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ORIGINAL ARTICLES Top

Vitamin B12 deficiency without anemia in the middle- and old-aged population in Sulaymaniyah City p. 244
Hisham Arif Getta
DOI:10.4103/MJBL.MJBL_71_19  
Background: In our laboratory, we received many cases of Vitamin B12 deficiency without anemia, and we observed that the deficiency is more prominent in females than males. It is well known that Vitamin B12 deficiency is usually associated with macrocytic anemia. However, the clinical importance of Vitamin B12 insufficiency without any hematological abnormality is underestimated in the Sulaymaniyah city population. Thus, the aim of this study is to assess the frequency of Vitamin B12 deficiency with normal complete blood counts (CBCs), especially in the middle- and old-aged population. Materials and Methods: Within the period from April 2018 to April 2019, the patients came to the Dr. Hisham Alrawi Private Laboratory for Vitamin B12 level estimation; the CBCs for all patients with Vitamin B12 deficiency have been collected. We selected patients with low-level Vitamin B12, which were 149 patients, aged 30 years and above. Normal serum Vitamin B12 value in our laboratory is 191–633 pg/ml according to the e411 Roche competitive-binding luminescence immunoassay system. CBC has been collected were done for all patients with Vitamin B12 deficiency by Orphee Mythic 18 Hematology Analyzer. Results: The mean of their age is 64 years, and the mean of hemoglobin (Hb) level is 12.1 g/dL, whereas the mean of Vitamin B12 level is 131.3 pg/ml. About 74 (49.6%) of them have anemia, and 75 (51.4%) are with the normal CBC parameters. The mean of the Hb in females is with the normal range (12.1 g/dL), whereas the mean of the Hb in the males is lower than the normal range (12 g/dL). Conclusions: Vitamin B12 deficiency is common in middle and old age in Sulaymaniyah city, especially in females. Thus, screening programs for B12 levels estimation for this age group are recommended to avoid expected complications.
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Modified supracondylar chevron osteotomy for correction of genu valgum deformity in constrained resources p. 247
Ashish Jaiman, Jatin Prakash, Rajesh Kumar Chopra, Siddharth Gupta
DOI:10.4103/MJBL.MJBL_40_20  
Background: Various types of corrective osteotomies of the distal femur have been described in the literature for genu valgum deformity such as lateral opening wedge, medial closing wedge, dome osteotomy, wedgeless spike osteotomy, and wedgeless “V” osteotomy. Objectives: We aimed this study to evaluate the effectiveness of our modified supracondylar chevron osteotomy in correction of deformity. Materials and Methods: It was a prospective intervention study. Thirty young adults between the ages of 13–30 years were enrolled in the study. Modified chevron osteotomy was done and fixed with medial locking plate. Patients were evaluated at 1 year of follow-up. Results: A total of 30 patients included in the study underwent surgical correction of genu valgum deformity. The average blood loss during surgery was 187 ml (range, 150–260 ml). The mean duration of hospital stay was 4.5 days (range, 3–7 days). The mean time to union of osteotomy was 14.9 weeks (range, 12–17 weeks). The mean preoperative clinical tibiofemoral angle (TFA) was 23.4° (range, 18°–28°) that improved after surgery to a mean postoperative value of 5.8° (range, 4°–7°) which was statistically significant (P < 0.001). The mean preoperative radiological TFA was 23.5° (range, 19°–28°) that improved to a mean postoperative value of 5.7° (range, 4°–7°) and that was statistically significant (P < 0.001). Conclusion: Supracondylar chevron osteotomy and internal fixation with anatomically designed medial distal femur locking plate with the modified technique of using multiple 30-cm long solid 4.3-mm drill bits and using increasing width osteotome has the advantage of avoiding C-arm use and avoiding nibbling of the medial cortex. Keeping both limbs in the surgical field and replicating the clinical TFA with the help of sterile metal goniometer is a simple, safe, cost-effective procedure with a short learning curve that can be used for correction of genu valgum deformity in adolescent and young adult patients in constrained resource setup.
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Compatibility of prescribed antibiotics to patients with pelvic inflammatory diseases with microbial sensitivity test in Duhok, Iraq p. 253
Rojan Ibrahim Said, Heja Mikdad Ahmed, Dian Jamel Salih,
DOI:10.4103/MJBL.MJBL_8_20  
Background: Pelvic inflammatory disease (PID) is a clinical syndrome that has the wide range of infections and inflammatory diseases of the upper female genital tract. Microbiological researches revealed that multiple bacteria have been identified as causative agents and several types of antibiotics are required to cover causative pathogens. The choice of an appropriate treatment mostly depended on antimicrobial sensitivity tests. Objectives: The present study aims to investigate the compatibility between the prescribed antibiotics given to patients with PIDs based on the clinical features with microbial sensitivity tests. Materials and Methods: The present study included 70 patients who attend Amedy hospital in Duhok province and screened for PIDs based on the clinical features. Due to the lack of antimicrobial-sensitivity culture tests, the patients are treated according to the standard treatment. The clinician records the clinical features of each patient with their prescribed drugs and antibiotics and takes an endocervical swab of each patient. These swabs are undergone microbial sensitivity tests for drug resistance. Results: The results revealed that 62.86% of patients were positive for the infection pathogens. There were 13 bacterial isolates of Staphylococcus aureus as the most commonly isolated organism in (29.55%) of cases followed by Candida specious (25%) and Streptococcus pyogenes (15.1%) with one case of Escherichia coli (2.27%). Seven antibiotic and antifungal drugs were the most prescribed antibiotics to patients with PIDs. Conclusions: The results of our study concluded that treating PIDs according to the standard treatment and based on clinical symptoms only is limited to coverage these diseases. Additional clinical and microbial sensitivity test are required before prescribed antibiotics or antifungal to patients with PIDs.
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Relation between maternal obesity and fetal congenital malformations p. 257
Imran Suliaman Dawood, Sahar Abdl Hussein Jupori
DOI:10.4103/MJBL.MJBL_13_20  
Background: There is evidence suggests that there is an association between maternal obesity and some congenital abnormalities. Objective: Since there is no local study has been examined the relation between maternal pregnancy obesity and overweight and fetal congenital malformations, we explored this relation in Babylon women and compared our findings with previous studies. Materials and Methods: This prospective study was carried on patients admitted to Babil Obestetric and Pediatric Teaching Hospital in Babylon city, Iraq, from April 2016 to April 2017. Data were collected by history, clinical examination, and investigations and body mass index was measured for all patients. All neonates examined by pediatrician and surgeon to detect any congenital malformations. All the mothers of case infants or control infants of age more than 35 years or <18 years were excluded from this study. Control infants are infants without any congenital malformations. All the mothers with positive tests for toxoplasmosis, cytomegalovirus, rubella, or proved to have diabetes and surgical problems were also excluded from the study. All the mothers living in an area known to have a history of radiation exposure were also excluded. The affected infants have been identified. The risks for obese and overweight women were compared with those for average-weight women. Results: Obese women (study cases) have more infants with neural tube defect, especially spina bifida and anencephaly than were average-weight women (control). Obese women were more likely to have an infant with hydrocephaly defect in compare to average-weight women. Over-weight women also have an infant with defects, such as meningocele, spina bifida, meningocele and hydrocephaly, multiple abnormalities, hydrocephaly, meningocele and anencephaly, and anencephaly. There were no significant associations between congenital malformations and underweight women. Conclusions: Our study gives an evidence that there is an association between maternal obesity and fetal congenital malformations. Maternal obesity constitutes a serious health risk for the fetus the impact of which increases with the degree of obesity.
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Causes of death among adult diabetic patients in Hawler Teaching Hospital, Erbil, Iraq p. 262
Hemin Khalid Saber, Zahir Salih Hussein, Bakhtyar Othman Omer
DOI:10.4103/MJBL.MJBL_17_20  
Background: Type 2 diabetes mellitus (T2DM) is one of the most challenging diseases of this age. T2DM is responsible for 1.5 million deaths across the world. Objectives: This study aimed to determine the causes of mortality in T2DM patients in one general hospital in Erbil city, Iraq. Materials and Methods: In this cross-sectional study, medical records of patients who attended Hawler Teaching Hospital between January 1, 2012, and December 31, 2012, were reviewed retrospectively for eligibility criteria. The patients who were diagnosed with T2DM by an internist or an endocrinologist regardless of sociodemographic characteristics were included in this study. The patients were categorized into two groups as dead and alive. The death of the patients was confirmed by reviewing the death certificate issued by the hospital. Results: The study showed that of the total 1310 patients diagnosed with T2DM, 186 (14.20%) passed away due to different factors. The study revealed that type 2 diabetic patients were aged >70 (49.47%) and 50–70 (39.24%) years followed by 35–50 (9.67%) and <35 years (1.62%). Most of the T2DM patients had a duration of >5 years (86.03%). The most common causes of mortality in T2DM patients were hypertension and its complications (50.0%) and kidney failure (25.26%). Some other causes of mortality were sepsis (6.46%), cancer (5.92%), respiratory issues (5.92%), diabetic ketoacidosis (3.22%), and some other causes (3.22%). Conclusions: The present study showed that a high percentage of the patients died due to T2DM in Erbil. In addition, the most common factor for mortality in these patients was hypertension and its compactions.
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Cigarette smoking and serum level of Vitamin D among older adults p. 267
Ismael Hasan Jawad, Hasan Alwan Baiee
DOI:10.4103/MJBL.MJBL_28_20  
Background: Vitamin D has different biological actions in the body. Vitamin D has pleiotropic effects in multiple organ systems. Vitamin D deficiency has been found to have an inverse relationship with tobacco smoking. Objective: The objective of this study was to identify the prevalence of Vitamin D level and its correlates with tobacco smoking among old adults in Al-Hilla city, Babylon Province. Methods: A cross-sectional study was conducted on a sample of old adults, both males and females, who were selected from dwellers in community of Al-Hilla city, Babylon Province, Iraq, during the period from January to August 2019. A pretested questionnaire was used for data collection adopted from previous standard national surveys and studies, and the questionnaire included information about sociodemographic characteristics and cigarette smoking habit. Results: The study included 300 participants, and most of them had either insufficiency or deficiency of Vitamin D level (84%). Tobacco cigarette smoking elders had a significantly low serum Vitamin D level (both deficiency and insufficiency) as compared to the nonsmoker group (P < 0.05). Conclusion: There was a significant inverse relationship between Vitamin D level and tobacco cigarette smoking.
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Maternal determinants of low birth weight newborns in central India p. 272
Anuradha Jain, Saurabh Piparsania, Nagesh Chandra Doharey, Anurag Mohta, Rakesh Kumar Soni
DOI:10.4103/MJBL.MJBL_36_20  
Background: Low birth weight (LBW) is a major public health concern, especially in developing countries, and is frequently related to child morbidity and mortality. Materials and Methods: About 1000 live newborns on the 1st day of birth and their mothers were studied from the Department of Obstetrics and Gynaecology and Intensive neonatal care, Department of Pediatrics, Index Medical College Hospital and Research Centre, Indore, Madhya Pradesh, between January 2016 and December 2019. Examinations of mother and newborns were carefully carried out in all cases recorded on a pretested and predesigned data capturing form. Results: The present study comprises observations made on 1000 newborns and their mothers admitted to a tertiary care teaching hospital, Indore, Madhya Pradesh. In LBW group, 145 (29%) were preterm, 347 (69.4%) term, and 8 (1.6%) post term while in LBW group 399 (79.8%) were term. The mean birth weight of preterm babies was 1860 ± 442.044 g and of term babies 2570 ± 400.72 g. This observed difference was statistically significant (t = 18.43, P < 0.001). Primipara mothers had highest number of LBW babies (39.4%) whereas second para mothers had maximal normal birth weight (NBW) babies (38.2%). Conclusion: Mothers below 20 years and above 30 years of age, primipara, poor caloric, and protein intake during pregnancy gave births to more number of LBW babies than NBW babies. In multiparas with spacing of 2 years or less, the number of LBW babies was more than NBW babies. Maternal weight and weight gain during pregnancy also found to have a definite correlation with birth weight.
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Understanding precautionary behaviors among neighbors of COVID-19-positive patients using health belief model: An analysis from available evidence p. 278
Nilanjana Ghosh, Sudip Bhattacharya, Tulshi Pramanik, Indranil Chakrabarti
DOI:10.4103/MJBL.MJBL_45_20  
Background: COVID 19 pandemic is a unique public health challenge affecting millions globally. Asymptomatic carriers are a primary concern. Prevention is the only cure. Interruption of transmission dynamics is identified and accepted as a key containment strategy to prevent community spread. Risk perceptions influence precautionary behaviors which subsequently affect adherence to lockdown and home quarantines. The presence of positive patients in locality creates panic as many contacts have to undergo testing and quarantines/isolations. Objectives: The present study assesses the perception of close contacts in the neighborhood applying the health behavior model after one of their neighbors tested positive. Materials and Methods: A mixed-method month long study was conducted among close contacts of a proven positive case. Data were elicited using online questionnaires after necessary consent and permission and analyzed accordingly. Results: The perceived stress and susceptibility were high. Risk perception was high, and health care workers were considered a potential threat to the community. Similar studies have been compared. The residential complex was declared a containment zone. Conclusion: Researchers concluded risk perceptions as high and emphasized the need for pandemic preparedness. A larger study is recommended.
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Accuracy of noncontrast chest computed tomography in COVID-19 infection: An observational and retrospective study p. 282
Zaid Hadi Hammoodi, Hasan Falah Al-Khafaji, Zeid Hamid Al-Murib, Hussain Ketab Al-Esawy, Ali Salih Baiee, Ahmed Abd-Alhaleem Al-Shimmary
DOI:10.4103/MJBL.MJBL_47_20  
Objective: During the novel coronavirus pandemic, great challenges are becoming prominent, such as early and rapid diagnoses using simple and readily available tests. Chest computed tomography (CT) scan plays a major role in the diagnosis and monitoring of the complications with high specificity. The purpose of this study is to assess the accuracy of nonenhanced chest CT scan in the diagnosis of coronavirus disease 2019 (COVID-19) disease in suspected patients. Materials and Methods: Eighty four suspected patients were included in this retrospective study from March 1, 2020, to April 1, 2020, who underwent both nonenhanced chest CT scan and real-time polymerase chain reaction (PCR) test for COVID-19 disease. Results: The total number of initial reverse transcriptase (RT)-PCR-positive results was 52 (61.9%) patients and that of negative results was 32 (38%) patients. Out of the total number of positive RT-PCR tests, only fifty (96%) patients showed positive CT findings. Of the total number of negative RT-PCR tests (32 [38%] patients), only 8 (25%) patients showed negative CT results. With RT-PCR results as the reference standard, the sensitivity, specificity, and the accuracy of chest CT in indicating the COVID-19 infection were 96.15%, 25%, and 69.04%, respectively. Ground-glass opacity (GGO) was seen in all positive CT patients (74 [100%]), mixed GGO was seen in 27 (36.4%) patients, and consolidation was seen in 36 (48.6%) patients which was subsegmental in 28 (37.8%) patients. Vascular dilatation sign was seen in 61 (82.4%) patients, crazy paving sign was seen in 31 (41.9%) patients, reverse halo signs were seen in 23 (31%) patients, and air bronchogram was seen in 39 (52.7%) patients. Conclusions: Highly characteristic and specific bilateral multifocal GGOs were reported as the classical/typical chest CT features of COVID-19 infection with high confidence rate, although it may vary in different patients' parameters and stages so that chest CT imaging has very high sensitivity (96.15%) for the diagnosis of COVID-19 in epidemic areas with high pretest probability for disease, and it is recommended to be included as a decision-making diagnostic test in suspected patients with RT-PCR-negative results.
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Diagnostic value of neutrophil lymphocyte ratio in detection of acute appendicitis p. 288
Istabraq Akram Al-Husseiny
DOI:10.4103/MJBL.MJBL_43_20  
Background: The diagnosis of acute appendicitis (AA) sometimes is illusive and the accompanying clinical and laboratory manifestations cannot be used for definitive diagnosis. Objective: This study aimed to evaluate the diagnostic value of neutrophil/lymphocyte ratio (NLR) in detection of AA. Materials and Methods: This is a cross-sectional study that included a total of 80 adult patients with AA and 62 age- and gender-matched patients with abdominal pain due to causes other than AA. Three milliliter of peripheral blood were collected from each participant. The NLR was calculated by dividing the absolute neutrophil count by the absolute lymphocyte count. Receiver operating characteristic curve was used to assess the diagnostic value of NLR in detection of AA cases. Results: Mean NLR in AA patients was 7.18 ± 2.11 compared with 2.68 ± 1.08 in patients with abdominal pain due to causes other than AA with a highly significant difference. The area under the curve was 0.916 (95%confidence interval = 0.842–0.989), P < 0.001. The sensitivity and specificity of the test at NLR = 4.45 were 90% and 83%, respectively. Conclusions: NLR is an easy, inexpensive test that can be used for AA detection. This test is more sensitive and more specific than either total white blood cell or absolute neutrophil count.
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Impact of chronic hepatitis B virus infection on bone mineral density p. 292
Istabraq A Al-Husseiny, Maysaa K Al-Malkey, Maitham A Al-Sammak, Faheema J Abo-Alhur
DOI:10.4103/MJBL.MJBL_34_20  
Background: Chronic hepatitis B virus (HBV) infection is a common health problem that has a worldwide distribution. Apart from the direct effect of the virus on the liver, there are many extrahepatic manifestations among which the probable effect on bone turnover associated with low bone mineral density (BMD). Objectives: This study aimed to determine the association between treated and untreated chronic HBV infection with BMD. Methods: This is a cross-sectional study which included a total of 48 patients with chronic HBV (28 patients treated with tenofovir-disoproxil-fumarate [TDF] antiviral drug and 20 patients have not yet started treatment). Other age- and sex-matched 30 apparently healthy individuals were recruited to represent the healthy controls. BMD was measured using dual-energy X-ray absorptiometry on the anteroposterior lumbar spine (L1–L4 spine) views, from which T-score was calculated. Liver function tests were also evaluated from serum samples. Results: Treated patients showed a lower T-score (−0.48 ± 0.72) than either healthy individuals (1.08 ± 0.84) or untreated patients (0.78 ± 0.51), with highly significant differences. In multivariate regression, only disease duration (adjusted odds ratio [OR] = 9.71, 95% confidence interval [CI] = 4.8–16.68) and TDF treatment (adjusted OR = 6.4, 95% CI = 4.18–97.05) were significantly associated with BMD. Conclusions: Prolonged use of TDF in the treatment of HBV infection can significantly reduce BMD. Moreover, BMD can also be inversely affected in long-standing HBV, regardless of treatment regimen.
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SHORT COMMUNICATION Top

COVID-19 pandemic and Ramadan: Minimizing the risk of exacerbation of disease p. 297
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/MJBL.MJBL_35_20  
Nations across the globe have taken multiple steps for the control and the effective containment of the corona virus disease-2019 (COVID-19) pandemic. Amidst the developments of the COVID-19 around the world, the holy month of Ramadan is about to begin from the latest in April month. However, from the perspective of the COVID-19 containment, this can turn out to be an important event, as it will enhance the prospects of staying in close proximity and thereby increases the chance of the transmission of the infection from one person to another. In these difficult times, it is essential to make informed decisions for organizing any religious gathering and even consider the possibility of canceling the same depending upon the level of transmission in the nation and the preparedness of the health sector. In conclusion, Ramadan is an important religious event, nevertheless amidst the ongoing COVID-19 pandemic, it is the responsibility of the national and religious leaders to take a well-informed and scientific decision to safeguard the lives of people and also not create any opportunity for the exacerbation of the disease.
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Planning and implementation of risk communication and community engagement action plan in the battle against COVID-19 pandemic p. 299
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/MJBL.MJBL_26_20  
The Corona Virus Disease-2019 (COVID-19) outbreak attained pandemic status and has created a scare among the general community and the public health authorities. Risk Communication and Community Engagement have been identified as the essential and the integral component of the national emergency preparedness and response strategy. The entire communication process should target both the vulnerable population as well as the people who act as a representative or change agent in the community. The information which is delivered to the community should be decided on the basis of the need assessment of the vulnerable population and it should not be presumed that something is quite obvious and thus there is no need to focus on it. In conclusion, risk communication and community engagement are the crucial aspects of our preparedness and response in the battle against the COVID-19 pandemic. It is extremely important to establish the risk communication mechanism in the emergency response system and then follow-it up with proper planning, implementation, monitoring and evaluation activities.
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CASE REPORT Top

Uncommon or rear disorders affecting the face due to maxilla facial trauma p. 301
Sabah Hassan Husien
DOI:10.4103/MJBL.MJBL_33_20  
The diagnosis of the uncommon and rear disorders, together with the postoperative complication of trauma affecting the face, and the treatment of such disorders are discussed. A male 22-year-old admitted to our center sustained a trauma to the right parotid region. The patient complained of unilateral weakness on (right side) of the face, dysarthria, loss of taste, the jaw deviated toward the right side on opening, unable to raise the upper right eyelid, and defect in hearing in the right ear.
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LETTERS TO EDITOR Top

COVID-19 and herbal medicine? Challenge in hand p. 303
Hassan Hussein Musa, Taha Hussein Musa, Idriss Hussein Musa
DOI:10.4103/MJBL.MJBL_38_20  
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Percutaneous biliary drainage in malignant biliary obstruction: Results of initial experience p. 305
Zaid Hadi Hammoodi
DOI:10.4103/MJBL.MJBL_96_18  
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Role and challenges of radiology in COVID-19: Our experience at a tertiary care center in India p. 308
Zohaib Hussain, Syeda Nilufar Islam
DOI:10.4103/MJBL.MJBL_41_20  
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