Annals of the College of Medicine Mosul

ABSTRACT
Background: Assessment of patient’s fitness prior to major surgery is mandatory because co-morbidities predispose to postoperative complications; however the ability of pulmonary function tests to predict postoperative cardiopulmonary complications is still poorly defined.
Objective: to examine the role of preoperative measurements of cardiopulmonary exercise testing and other lung function tests in predicting postoperative outcomes in patients undergoing major upper gastrointestinal surgery (stomach, oesophagus, small intestine, gall bladder and pancreas surgery).
Patients and methods: A 193 patients who had major upper gastrointestinal surgery’ age, sex and smoking status were recorded and they underwent a range of tests including body mass index, flow-volume curve spirometry, blood gas analysis, transfer factor for carbon monoxide (TLCO) and CPET at the Pulmonary Function Laboratory of Glasgow Royal Infirmary between August 2008 and December 2011. Post-operative morbidity and mortality was analysed for all patients who underwent major surgery.
Results: Comparisons between patients that did or did not have post operative pulmonary complications showed significant differences in anaerobic threshold as % predicted maximum oxygen consumption during exercise (VO2; p0.05), length of high dependency care stay (p0.001), length of ward stay (p<0.01) and length of hospital stay (p0.001). There were significant differences between those patients with and without operative anastomotic leak in body mass index (BMI; p0.05), length of high dependency care stay (p0.001), length of ward stay (6 vs.15, respectively; p0.001), length of hospital stay (14 vs. 28, respectively; p0.001) and duration between date of surgery and date of commencing postoperative chemotherapy (p≤0.01).
Conclusion: CPET and in particular anaerobic threshold % maximum predicted is useful in predicting the likelihood of the development of pulmonary complications in patients undergoing upper gastrointestinal surgery.

ABSTRACT
Context: Physicians experience a conflict of interest related to appropriate interaction to the current industries\\' practices of gifts provision as a marketing strategy.
Aim of the study: The study aims to explore physicians\\' insight about dealing with drug promotion activities of pharmaceutical industries.
Subjects and methods: A cross- sectional study design was conducted in the College of Medicine /University of Mosul during the academic year 2018-2019. Medical faculty staffs in the College of Medicine/ University of Mosul in the clinical departments including department of: (Medicine, Surgery, Pediatrics and Obstetrics and Gynecology). In addition to academic physicians in non-clinical departments who have privet clinic who agreed to participate were involved. A modified standardized questionnaire form was used.
Results: From 71 participant physicians 61 (85.92%) had no previous teaching regarding ethical principles of interaction with drug representatives. Forty percent of the participants had personal friendship with a medical representative; meanwhile 63.38% had previous dealing with pharmaceutical companies. Only 16.9% of participants trust the information that delivered from drug companies. More than one fifth of participants supposed that gift provision from drug companies will influence drug prescription manners. Physicians considered drug sample appropriate gift to be accepted followed by conference registration fees, textbooks and travel to conference.
Conclusion and recommendations: Considerable proportion of academic Physicians at College of Medicine /University of Mosul had interaction with pharmaceutical company representatives. Academic physicians\\' responses attempted to minimize gifts provision on their professional behavior. However, pharmaceutical promotional activities should be monitored and controlled through physicians\\' self- regulation and legislations.

ABSTRACT
Background: Self-reported questionnaires have become popular measures in assessing disability in patients with low back pain (LBP). Roland-Morris Questionnaire (RMQ) is one of the internationally accepted, self-reporting questionnaire which demonstrates good psychometric properties.
Objectives: The present study intended to evaluate a face to face interview applying Arabic version of the RMQ, and comparing it with a modified version of RMQ (RMQV), and whether the purely subjective RMQ scores correlate with symptoms and signs which have predictive or prognostic values.
Design: case-series study
Methods and materials: Case-series study conducted on seventy-two patients with chronic LBP at Ibn-Sina Teaching Hospital in Mosul city. Physical examination at rheumatology outpatient clinic performed for every patient, and the patients are allowed to answer the questions of RMQ through a direct investigator-patient Arabic conversation. The disability measured by the RMQ subdivided into: mild (0-8), moderate (9-16) and severe (17-24). An individualized literature review performed for clinical features which have predictive or prognostic values in LBP, and including these features in the clinical evaluation of patients in the current study.
Results: The results showed that the Arabic conversational RMQ have acceptable reliability and RMQV have excellent reliability (Cronbach’s alpha values=0.72 and 0.94 respectively). There was a significant direct correlation between these two questionnaires (r=0.861; p-value<0.001). However, we found a significant difference between them (p-value<0.01). The scores of the RMQ and RMQV correlate moderately with a score of the predictive features (r=0.503; p-value < 0.01 and 0.530; p-value<0.01 respectively).
Conclusion: The study found that the modified version (RMQV) has higher reliability than the original one. Also, the RMQV showed a better correlation with the narrow-angle straight leg raising test, and its mild and moderate subgroups have significant differences regarding the duration and pain intensity of the current episode of LBP. Other measured properties look similar between the two questionnaires.

ABSTRACT
Objectives: To assess the diagnostic value of endoscopical findings compared to histopathological diagnosis, to delineate the relative frequency and pattern of different types of gastritis and their association with H. pylori and intestinal metaplasia in our locality, and to compare the results of this study with those of others.
Methods: In a cross sectional study 150 selected patients with different upper gastrointestinal symptoms have been examined at endoscopy units in Ibn-Sina teaching hospital and Al-Jamhori teaching hospital in Mosul city, from the first of June 2013 to the first of March 2014, all were assessed endoscopically and biopsies from both antral and body mucosa were taken for histopathological examination.
Results: This study has revealed gastritis histopathologically in 96.6% of cases, and the agreement between endoscopical and histophathological diagnosis was 88%. The chronic superficial gastritis represented the highest relative frequency in this histopathologically diagnosed gastritis, where it was seen in 61.3% of the cases and it’s relative frequency decreased with advance age, while chronic atrophic gastritis was diagnosed in 30% of the cases and it’s relative frequency increased with advanced age, while gastric atrophy wasn’t detected in any case. Acute gastritis was detected in only 5.3% of the cases.
Helicobacter pylori was detected in 67% of cases. A significant association was detected between chronic gastritis and Helicobacter pylori infection, and its frequency decreased with increased severity of glandular atrophy. Follicular gastritis was diagnosed in 51% of chronic atrophic gastritis and 91.3% of them were Helicobacter pylori positive cases. By the use of the special stain AB/PAS pH (2.5), intestinal metaplasia has been diagnosed in 23% of cases and it’s relative frequency increased with advanced age.
Conclusion: There is a high rate of concordance (88%) between endoscopical findings and histopathological diagnosis of gastritis. Among gastritis chronic variety was the commonest. H. pylori had a significant association with chronic gastritis (chronic superficial gastritis and chronic atrophic gastritis). Intestinal metaplasia has been detected mainly in chronic atrophic gastritis and its frequency increased with advanced age.

ABSTRACT
Background: Many patients present to otorhinologists daily complaining of headache due to rhinosinusitis which generally has a specific findings. Nonetheless, isolated sphenoiditis is a rare type of sinusitis, but associated with more serious complications due to its contiguity with vital intracranial structures, and is usually associated with non-specific findings that may be missed as a cause of headache.
Objectives: To highlight cases with headache due to isolated sphenoiditis that present with non-specific signs and symptoms of sinusitis, and to discuss the best methods of diagnosis and treatment to avoid serious complications.
Patients and methods: A case series study of 27 patients (21 males, 8 females) aged between 18-32 years-old (mean age 25 years old), were evaluated during the period between June 2015 and December 2017 in the author's private clinic at PAR Hospital, Erbil, Iraq. Those patients were misdiagnosed as cases of primary headache (migraine or tension-type headache). The diagnosis of isolated sphenoiditis in those patients was based on clinical findings, nasal endoscopy and it was proved by computerized tomography scan.
Results: The study was performed on adult patients, half of them were between 24-28 years-old, with a male to female ratio of 7:3. Headache was the presenting symptom with minimal expression of other symptoms of sinusitis, i.e.; nasal obstruction in 10 patients (37%), postnasal discharge in 5 patients (18.5%), visual symptoms in 3 patients (11%) and sneezing and itching in 6 patients (22%). Nasal endoscopic findings were negative in 5 patients (18.5%), while septal deviation was noted in 14 patients (52%), concha bullosa in 1 patient (3.7%), postnasal discharge in 5 patients (18.5) and granular pharyngitis in 10 patients (37%). Computerized tomography scanning of the paranasal sinuses was performed for all patients and proved the diagnosis of isolated sphenoiditis. Headache was relieved by medical treatment in 22 patients (81.5%). Five patients (18.5%) required surgical treatment.
Conclusion: Although it is uncommon, isolated sphenoiditis must be suspected in patients with headache. It is a potentially dangerous disorder due to the contiguity of the sinus with vital neuro-vascular structures. Therefore, ENT specialists must be alert of this rare condition and radiological examination of paranasal sinuses should always be performed in prolonged and intractable cases of headache. Computerized tomography scan is the best tool in diagnosis and follow up of such cases.

ABSTRACT
Background: In the field of gastro-oesophageal cancer, the effect of chemotherapy treatment on patients’ cardiopulmonary fitness as well as on the incidence of post-operative cardiopulmonary complications remains controversial.
Objectives: To examine the effect of chemotherapy on cardiopulmonary fitness. Further, to examine the association between cardiopulmonary exercise testing and other measurements on outcomes in patients with gastro-oesophageal cancer undergoing neo-adjuvant chemotherapy. And to compare post chemotherapy cardiopulmonary exercise testing with surgical outcome.
Patients and methods: Forty-one patients with gastroesophageal cancer who underwent chemotherapy were referred to the Pulmonary Function Laboratory, Respiratory Medicine, Glasgow Royal Infirmary during the period August 2008 to December 2011. 35 of these patients underwent both pre- and post-chemotherapy pulmonary function testing and 31 of these 35 patients had their chemotherapy followed by surgery.
A further 6 patients underwent chemotherapy followed by pulmonary function testing and surgery but without pre-chemotherapy testing
Results: There were significant differences between the pre- and post-chemotherapy results in arterial PCO2 (p0.01), t hemoglobin (p0.001) and heart rate at anaerobic threshold as a % of maximum predicted heart rate (p0.05). There were significant differences between those patients without post-operative complications and those with post-operative complications, in length of high dependency care stay (p0.01), length of ward stay (p0.05) and length of hospital stay (p0.001)
Conclusion: the results of the present study show that there was no significant change in cardiopulmonary fitness in patients with gastro-oesophageal cancer who underwent chemotherapy apart from correctable side effect such as anaemia. In addition, CPET parameters, pulmonary function tests and other related factors did not predict an increase in the risk of post-operative complications. There was, however, a relationship between deprivation and an increased risk of postoperative complications

ABSTRACT
Objectives: To study the effect of commonly used first line antihypertensive drugs valsartan and amlodipine on insulin resistance parameters in hypertensive patients free from type 2 diabetes mellitus.
Patients and methods: In a prospective, randomized study, 32 non-diabetic patients with mild to moderate hypertension attending private clinics in Mosul city were recruited. The patients were randomized into two treatment groups to receive either amlodipine in the dose range of 5-10 mg daily or valsartan in the dose range of 80-160 mg daily. At baseline and 8 weeks of treatment fasting serum glucose (FSG), fasting serum insulin (FSI), homeostasis model assessment for insulin resistance (HOMA-IR), mean systolic and diastolic blood pressures levels were determined.
Results: Intragroup comparison showed that after 8 week treatment with amlodipine and valsartan, SBP, DBP, FSI and HOMA-IR for both groups were significantly decreased in comparison with baseline data while FSG where non significantly decreased. Valsartan reduce SBP, FSG, FSI and HOMA-IR more than amlodipine but this reduction was not statistically significant.
Conclusion: This study showed that the antihypertensive drugs amlodipine and valsartan have favorable effects on insulin resistance mediated by decreasing HOMA-IR in non-diabetic hypertensive patients. Also, this study illustrated that valsartan seems to have a more potent effect of lowering HOMA-IR than amlodipine in the standard dose

ABSTRACT
Aim of study: The aim of this work is to detect the toxic effects of tramadol on the microscopic structure of the kidneys of adult male albino rats, and the possible protective role of vitamin C against these toxic effects.
Method: Thirty adult albino rats are used in this study. The animals were divided into three equal groups: Group A (control group): Animals were injected daily with normal saline for 4 weeks. Group B (Tramadol treated group) (TGI): Animals were injected daily with tramadol in a dose of 50mg/kg b.wt for 4 weeks. Group C (group treated with tramadol+vitamin C) (TGII): Animals were injected with vitamin C in a dose 100mg/Kg/b.wt half hour prior to tramadol injection in the same dose as in group B for 4 weeks. The injection was given intraperitoneally for all animals. At the end of the experiments, the rats were anaesthetized by ether, then killed. After that kidneys removed, fixed in formaldehyde and processed for microscopic examination.
Result: Tramadol causes shrinkage of renal glomeruli with widening of bowman\'s space. Renal tubules showed hydropic degeneration and vacuolization of their epithelial cells. Infiltration of mononuclear cells along with Hyaline cast is seen within the degenerated tubules. Giving vitamin C prior to tramadol injection results in improvement in the microscopical structure of kidney mainly in glomeruli and tubules.
Conclusion: Using tramadol caused damage to renal glomeruli and tubules in renal cortex. The addition of vitamin C partially improved the histological structure of kidney.

ABSTRACT
Background: Irritable Bowel Syndrome (IBS) is the most common disorder seen in gastroenterology practice. It is also a large component of primary care practices.
Aim: To determine the association between anxiety and depression and Irritable bowel syndrome.
Methods: A case – control study design was adopted to achieve the aim of the present study. This study was conducted in Mosul city and sample was taken from the inward and outward patient department of Al-Zahrawi, Ibn-Seena teaching hospitals and Al-Salaam general hospital. The actual period of data collection has been extended between (20th of December 2006 – 31st of July 2007). A total of 150 cases diagnosed to have IBS by Rome II criteria. Another 150 control group was diagnosed as Rome II negative of apparently healthy individuals which were relatives of patients other than IBS matched according to age (+ 5 years) and sex with cases. A specially designed questionnaire form has been used to help in diagnosing IBS cases according to Rome II criteria. To assess anxiety in cases and controls, ICD- 10 checklist was used and its variables have been planned to be assessed as risk factors and For the diagnosis of depression the international diagnostic checklist for ICD – 10 ( IDCL) has been used.
A questionnaire form filling is through direct interviewing with cases and controls. Chi – square test for contingency tables was used to test for the presence or absence of statistical association or differences between cases and controls, Z – test for the differences between two proportions was used. During statistical analysis P – value of <0.05 was considered significant.
Results: present study shows that the majority of cases (93.3%) were below 55 years. Female to male ratio among cases was 1.9:1. The majority of cases had a mild symptom. Anxiety was found to be a significant risk factor in the development of IBS, this study showed that 64.8% were females with anxiety in comparison to 35.2% males and this study showed that those with depression had a very highly significant risk to develop IBS (OR=4.50) and those with both anxiety and depression have 5 times risk to develop IBS in comparison to those with anxiety or depression or none (OR=5.21, P<0.001).
Conclusion: In this study, IBS patients appeared to have a significant association with anxiety, depression and these factors maybe played a causative role in the development of IBS.

ABSTRACT
Background: The straight leg raising test (SLR) is widely used to evaluate patients with sciatica. The SLR was evaluated in many previous studies; however, there is no agreement about the characterization of the test.
Objective: To investigate the patterns of pain on passive SLR in patients with sciatica and to evaluate the effects of various maneuvers on this test.
Study design: Case series study.
Setting: Rheumatology division, Ibn Sinna Teaching Hospital, Mosul, IRAQ.
Methodology: Seventy patients with unilateral sciatica for less than 2 years duration, there ages are between 20 to 50 years, were studied. A detailed history was obtained from the patients and they were subjected to full physical examination for their current problem. The SLR was performed, the angle of elevation was recorded and the effect of ankle dorsiflexion and maximal neck flexion was evaluated. After that, the SLR repeated but with lumbar flexion, the angle of the SLR was also recorded. Then crossed SLR was performed.
Results: SLR was positive in 91.4% of cases. Ankle augmentation was positive in 95.3% of cases, while neck flexion increased pain in 28.1% only. Cross SLR test was positive in 17.1% of cases. Increased SLR angle by contralateral hip flexion was seen in 81.3% of cases; mean SLR angle with the contralateral hip extension was 47.8±12.4 degree, while contralateral hip flexion increased the mean SLR angle to 58.9±16.9 degree. The patterns of pain induced by SLR were: low back pain only in 50% of cases, leg pain only in 42.1% of cases, low back and leg pain in 7.9% only.
Conclusion: The patterns of pain that were induced by passive SLR were: low back pain only, leg pain only, low back and leg pain. This could bear relation to the position of the prolapsed disc.
The use of sensitizing maneuvers (ankle dorsiflexion, neck flexion) increases pain in patients with sciatica with positive SLR test, so we recommend the conduction of these maneuvers in patients with positive SLR. Measurement of SLR was influenced by the position of the contralateral hip (flexed Vs. extended).

ABSTRACT
Background: The World Health Organization (WHO) build up guidelines for the integrated management of childhood illnesses (IMCI) in the health facilities to improve the recognition and the individual management of the common reasons of death among children under the age of five. The approach used in outpatient clinical settings with restricted diagnostic and therapeutic tools.
Aim of study: To assess the impact of implementation of IMCI strategy, in reducing an inappropriate prescription of antibiotics and raising vaccination coverage.
Patients and methods: A cross-sectional study design was arranged, where 395 child with age from two months up to below 5 years old attending Al Hadbaa PHCC from 1st of January to 31st of March 2014 suffering from one or more of the following respiratory infection, diarrheal diseases, throat infections, ear infections and fever. The children assessed separately by two clinics, \"A\" non-adopting IMCI and \"B\" adopting IMCI guidelines, the Mc-Nemar test was applied and differences were evaluated.
Results: The attendant children are 239 males and 156 females complaining from fever (39.1%), throat problems (21.4%), ear problems (12.6%), cough (11.6%), diarrhea (11.1%) and pneumonia (4.2%). The overall use of antibiotics is 66.1% in clinic \"A\" and 21.0% in clinic \"B\" with p-value 0.000. Regarding the immunization, the outcomes appear to have very high significant difference 54.1% in \"A\" and 75.7% in \"B\".
Conclusion: The classification-approach to the sick child using IMCI guidelines has clear effect on decreasing an inappropriate use of antibiotics and raising number of vaccinated children, which justifying the adaptation of this strategy.

ABSTRACT
Background: Colorectal cancer has increased in the last decades, which constitutes about 10% of cancer mortality. It becomes the second and third most common cancer in women and men respectively.
Objective: To explore the factors for colorectal cancer in Iraq including age, gender, family history, diabetes, smoking, serum carcinembryonic antigen (CEA) as a predictor factor, stages of cancer, bowl habit, and symptoms.
Patients and methods: This study was conducted in surgical unit at Alkathymia Teaching Hospital, Baghdad and in Al-Jammhory Teaching Hospital, Mosul, during the period from Feb-1999 to June-2016. This is a case series study for 956 patients with colorectal cancer. The data gathered included: age, gender, family history, diabetes and smoking, serum CEA, stages of the disease, bowl habit and symptoms. Data are presented as mean and percentage, and were analyzed by using Chi square goodness of fit test. p values ≤ 0.05 were considered significant.
Results: Colorectal cancer patients with ages between 25-50 years were significantly (p≤0.01) higher than the patients with > 50 years or <25 years. Male patients (57.9%) were significantly (p≤0.01) higher than female patients (42.1 %). The rate of patients with family history was 39.4% of the total patients. Diabetic and smoking patients presented 28.7% and 37.9%, respectively. Patients with serum CEA > 5 ng/mL presented the high percentage (83.6%) and they were highly significant (p ≤ 0.001) than patients with serum CEA less than 5. Stage 2 (48.2%) was significantly (p≤0.01) higher than stage 1 (16.6%), 3 (20.6%) and 4 (14.5%), respectively. For bowl habit, constipation presented 75.8% was significantly higher than diarrhea (14.5%). In addition, symptoms of bleeding per rectum (71.1%) were significantly higher than symptoms of pain (28.2%).
Conclusion: Colorectal cancer is significant disease in Iraq. Middle age patients presented the highest percentage. Education of patients about bowl habit and symptoms of colorectal cancer should be applied especially constipation and bleeding per rectum.

ABSTRACT
Background: Gall stones are one of the commonest biliary diseases. Interest in the formation and clinical management of the disease dates back to ancient times. Gall stones continue to be one of the major health problems in the world today, although the exact number of patients is unknown, because there are no signs and symptoms related to the disease when there are no complications. The majority of the patients are diagnosed incidentally. However, some patients come with acute complication of gall stones. Gall stones are classified into; cholesterol gall stones, pigment gall stones, and mixed gall stones. However, all stones even pure cholesterol gall stones usually contain bilirubin (conjugated and unconjugated bilirubin) and cholesterol.
Aim: To determine the changes in glycosylation gap and glycation profile and the relation of this change to the changes in age and BMI on the measured parameters.
Patients and methods: Serum samples were collected from 40 individuals included in this work. They are divided into 2 groups. The first group included 20 apparently healthy individuals (10 males and 10 females). The second group included 20 individuals (5 males and 15 females) with Gall stone diagnosed in out-patient Clinic at Al-Jamhoory General Hospital and Neinawa private Hospital. Gall stone patients with metabolic diseases, infections and other inflammatory diseases were excluded.
Results: The study demonstrated a significant elevation in serum glucose, mean blood glucose, serum fructosamin, measured and predicated HbAc1 in GS patients in comparison with controls. Regarding the relation between age and measured parameters, the study showed a non-significant correlation between age and measured parameters in the control group, while in GS group there were a significant correlation (r = 0.05) between ages and predicted HbAc1 and BMI (p ≤ 0.03). Regarding the relation between BMI and measured parameters, the study showed a significant correlation between measured parameters and BMI in GS individuals, while in control group only serum glucose and MBG in control group (r = 0.01) (p ≤ 0.01) with MBI.
Conclusion: The study shows that there is a significant change in glycosylation gap and glycation profile in gall stone patients

ABSTRACT
A fifty four years old lady presented with severe generalized bone pain, having history of multiple fractures for the last two years, biochemical tests proved to be primary hyperparathyroidism and parathyroid adenoma localized with ultrasonography. Parathyroidectomy was carried out under local anesthesia, and the patient improved dramatically after surgery