Annals of the College of Medicine Mosul

ABSTRACT
Objective: The aim of the study is to investigate medical students\\' attitudes and opinions regarding medical
ethics education.
Subjects and methods: The study was conducted in the College of Medicine, University of Mosul during the
academic year 2011-2012. A cross-sectional study design was adopted with a self-administered
questionnaire form distributed to medical students in the 5th and 6th undergraduate grades.
Results: Of 150 respondents, the majority (82%) considered medical ethics teaching for medical students an
important issue, and 69.3% agreed that medical ethics teaching would influence the attitudes and behaviors
of doctors, and improve patient-doctor relationship. However, only 40% had general interest in learning more
about medical ethics. Two thirds (64.8) of students were confident with their ability to recognize a significant
ethical problems in clinical practice. Only 36% knew how to proceed when a patient is mentally incompetent.
Conclusion: Medical students have a low positive attitude about the medical ethics teaching, and they may
not be adequately prepared to meet the challenges of clinical practice. There should be incorporation of
creative and integrated ethics curriculum to start in the first medical grade, with emphasis on ethical aspect
of daily medical practice.

ABSTRACT
Objective: To demonstrate the efficiency and safety of Harmonic scalpel in comparison with electrocautery
for gallbladder dissection and hemostasis in laparoscopic cholecystectomy.
Patients and methods: A prospective comparative, study was done at Al-Jamhori Teaching Hospital in
Mosul, during the period from 1st of January 2010 to 1st of January 2012. Three hundred and twenty patients
underwent laparoscopic cholecystectomy, the following criteria were applied for selection: they had chronic
cholecystitis, no complaint at time of operation, age between 25 to 50 years, normal body weight, with
American Score of Anesthesia (ASA) of 1 or 2, no previous upper abdominal operation, no, or well controlled
hypertension or diabetes, gall bladder wall thickness with less than 6 mm by preoperative ultrasonography
and all the patients were operated by the authors. The patients were divided into two groups according to
the instrument used for dissection of gall bladder from its bed, the first group with electrocautery and second
group with harmonic scalpel. The time needed for complete dissection and hemostasis started from
spreading of Calot’s triangle till removal of gall bladder totally from its bed, was recorded. Any intra operative
complications: bleeding, gallbladder perforation, slipped stones, or conversion were recorded.
Results: The study included 320 patients, 172 patients belonged to the first group (electrocautery) and 148
patients belonged to second group (harmonic). For the first group, the median time was 17 minutes, the
mean time was 17.7 minutes and the mode was 13 minutes, while that for second group, the median time
was 14 minutes, with a mean time of 16 minutes and a mode of 14 minutes. Intra-operative bleeding was
recorded in 34 (20%) for the first group and 17 (11%) for the second one. Gallbladder perforation was
recorded in 26 (15%) patients and slipped stone in 12 (7%) patients in the electrocautery group and 13(9%)
and 5 (3%) respectively in the harmonic group. No common bile duct injury was recorded in either group.
Conversion was needed in 4 patients (1.3%), 3 (2%) patients belonged to the first group and one (06%) to
the second group.
Conclusion: Harmonic scalpel is very safe and effective instrument for dissection of gall bladder and
hemostasis in laparoscopic cholecystectomy and can replace electrocautery for this purpose if available at
operative theater.

ABSTRACT
Background: Laparoscopic cholecystectomy (LC) has become the standard treatment of benign gallbladder
diseases. However, it has been noticed that following LC, the serum level of certain liver enzyme rises
markedly in patients who had preoperatively normal liver enzyme values.
Objectives: The study is aimed to evaluate the effect of pneumoperitoneum in LC on liver enzymes and
serum bilirubin in comparison with open cholecystectomy (OC).
Patients and methods: A prospective case control study involved 74 patients treated by LC, and, 30
patients treated by OC as a control group, during the period from October 2010 to October 2011 at the
Department of Surgery, Surgical Unit Number One, Al-Jumhori Teaching Hospital, Mosul, Iraq. Blood
samples were taken 24 hours preoperatively and 24 hours after operation for biochemical tests.
Results: There were significant increases in serum bilirubin, Aspartate aminotransferase (AST), alanine
aminotransferase (ALT), and Lactate dehydrogenase (LDH) levels in LC group postoperatively when
compared with the OC group, while there were no significant changes in serum alkaline phosphatase (ALP).
Conclusion: It has been concluded that, serum bilirubin and liver enzymes elevation could be attributed to
the negative effects of the pneumoperitoneum on the hepatic blood flow. Although these changes seem to
be of no clinical importance, care should be taken before deciding to perform LC in patients with hepatic
insufficiency.

ABSTRACT
Background: Carpal tunnel syndrome (CTS) is a common entrapment neuropathy. Local steroid injections
are used for its treatment, which is usually associated with improvement in different electrophysiologic
parameters of the median nerve. However, evidence for its efficacy has not been established in our
community.
Objective: The aim of this study is to evaluate the changes in electrophysiological parameters after local
steroid injection for mild and moderate idiopathic CTS.
Material and methods: The study is a prospective clinical trial assessing the electrophysiological
parameters following local steroid injection (Depomedrol-80 mg methylprednisolone acetate) in the treatment
of mild and moderate idiopathic CTS. The study was carried out in Mosul Teaching Hospitals during a period
from December 2010 to December 2011. The total number of patients was 54 (46 females and 8 males),
their mean age was 36.13 ± 9.32 years. Patients with idiopathic CTS were included after clinical confirmation
of diagnosis electro-physiologically at preinjection, and electro physiological evaluation repeated 1 and 6
months after local steroid injection.
Results: All electrophysiological parameters showed significant improvement (P value is < 0.05) one month
after injection except sensory nerve action potential. All median nerve electrophysiological parameters in 6
months post injection showed no significant changes except, compound motor action potential, motor nerve
conduction velocity, and sensory nerve action potential which showed significant deterioration (P value is <
0.05). All electrophysiological parameters showed significant deterioration (P value is < 0.05) in comparing
results of one month and 6 months after injection.
Conclusion: Local steroid injection for CTS provides transient improvement in electrophysiological
parameters while causes deterioration in these parameters 6 months after injection

ABSTRACT
Objectives: The aim of the present study is to evaluate the aetiology of secondary (referred) otalgia.
Patients and methods: A case series study of 79 patients clinically diagnosed as secondary otalgia,
collected from the Outpatient Department of ENT at Al-Jamhory Teaching Hospital, Mosul/IRAQ, and private
clinics, for the period from Jan. 2010 to Sept. 2011.
Results: The average age of the patients was 33.3 years with a range of 4-80 years. The peak age
incidence was in the fourth decade of life. The study included 34 male patients (43.1%) and 45 females
(56.9%) with a ratio of 1:1.3. Temporomandibular joint dysfunction was found to be the main cause of
secondary otalgia (37.9%). Pharyngitis (24%), dental pain (17.7%) and cervical spine pain (7.6%) came next
in that order.
Conclusion: Temporomandibular joint dysfunction, pharyngitis, dental problems and cervical nerve root pain
were the commonest causes of secondary otalgia. Moreover, upper aerodigestive tract malignancies should
be considered in differential diagnosis.

ABSTRACT
Objective: To determine the incidence of ocular trauma (OT) in Mosul.
Methods: Retrospective case series study of (156) patients of OT admitted to Al-Jamhori Teaching Hospital,
who were referred from emergency department to ophthalmic unit during one year from 1st Jan. till 31st Dec.
2010. Data regarding age and sex of patients, and types, causes and season of injuries were noted.
Results: About 4.4% (156 out of 3307) of patients admitted to ophthalmic unit as (OT) in one year period
and 4.3% of operations (101 out of 2335) done for OT in operative theater, 85.2% were males, and 89.1%
were 30 years and younger. Mean age was 15.8 years ± 13.2 SD, 60.3% (94/156) were open-globe injuries
and there were seasonal differences.
Conclusion: Young age males were mostly affected and open-globe injuries were the commonest types.
Also there were seasonal differences

ABSTRACT
Objective: To assess the degree of tear film stability in eyes with pingueculae and ptergia in patients from
Mosul.
Patients and methods: Case-control study from private clinic and Al-Jamhori Teaching Hospital during a
period of one year from Feb. 2009.Tear break-up time were measured in 36 eyes with pterygia, and 37 eyes
with pingueculae, compared to control group of 37 eyes.
Results: The mean tear break-up time (TBUT) was 11.1±3.6 sec. in the eyes with pingueculae & 11.4±6
sec. in the eyes with pterygium compared to 15±4.5 sec in the control group. Unstable tear film (TBUT less
than 10 secs.) was found in 17 (47.2%) eyes with pterygia, compared to 13 (35.1%) eyes with pingueculue
and 7 (18.9%) control eyes. Unstable tear film was significantly associated with eyes with pterygia.
Conclusion: Unstable tear film is associated more with pterygia than with pingueculae, other factors as
environmental and racial ones should be evaluated.

ABSTRACT
Background: Infection is one of the major problems in neonates. The diagnosis of neonatal septicemia is
difficult to establish based on the clinical criteria alone. Empirical treatment should not be delayed because
of the high mortality. Blood cultures are considered the gold standard for diagnosis of neonatal sepsis. Creactive protein (CRP) is an acute phase protein found in the blood, the levels of which rise in response to
inflammation. During the acute phase response, levels of CRP rapidly increase within 2 hours of acute insult,
reaching a peak at 48 hours.
Objective: To investigate the diagnostic value of CRP. To show the benefit of doing serial measurement of
CRP in neonatal sepsis in providing additional support for the observation and follow up of patient with
sepsis. To show the prognostic meaningful of CRP in neonatal sepsis.
Methods: A hospital-based cross sectional study design was conducted in Mosul over one year period from
the 1st of Nov. 2010 to the 30th of Oct. 2011. A total of 198 neonates aged 1-28 days who were admitted to
pediatrics wards in Al-Khansaa Teaching Hospital in Mosul during the study period under provisional
diagnosis of sepsis and had a positive C-reactive protein level >6 mg/l were included in the study. All
patients were sent for blood culture, and the final diagnosis of sepsis depended on the result of blood
culture.
Results: Male gender constituted 63.5% of patients with sepsis compared to 51% patients without sepsis.
Refusal to feed and tachypnea were the most frequent complaints in both groups (sepsis and no sepsis). All
patients at admission had high CRP while only 52% had culture-proven sepsis. After 72 hrs of admission,
CRP was still high in approximately half of the patients after receiving treatment but only 62% of them had
positive blood culture. Higher initial CRP titer constituted 40.4% of the sepsis group compared to only 23.4%
of no sepsis group, the difference was significant (p=0.009). CRP levels between 6 mg/L and 12 mg/L were
more frequently observed among no sepsis than in sepsis groups (14.4% and 37.2% respectively). In
patients with CRP ≥40 mg/L, CRP was significantly higher in patients with blood culture positive than in
patients with suspected sepsis but negative blood culture, and after 72 hours of treatment high levels of CRP
still constituted 60.6% of cases with proven sepsis compared to 46% among the suspected sepsis group but
with negative blood culture. Death rate was 5% and E. coli was the predominant micro-organism isolated.
Conclusion: Gram-negative micro-organisms are a predominant cause of neonatal sepsis in our community.
Predictive value of CRP could be enhanced by serial rather than a single measurement. A high cut off value
of CRP may be needed to diagnose neonatal sepsis.

ABSTRACT
Background and objectives: Recent advances of Invitro Fertilization (IVF) and Intracytoplasmic Sperm
Injection (ICSI) combined with the progress in sperm retrieval from testes have provided a hope for
azoospermic patients to become fathers. The aim of this study is to describe the cytological features of the
cells aspirated from testes of patients with azoospermia and to select those who have mature spermatozoa
in their aspirate for assisted fertilization.
Design and setting: A descriptive study (case series) conducted in private clinic from Jan. 2007 to Sept.
2012.
Patients and methods: Under local anasthesia Fine Needle Aspiration Cytology (FNAC) was performed on
250 patients whose sperm count was zero in at least three consecutive semen samples.
The size of the testes was measured and recorded for each case. The cytological features of the aspirated
cells were described and the patients who have mature spermatozoa were identified for assisted fertilization.
Results: Normal spermatogenesis was found in 54 patients (21.6%), complete maturation arrest at primary
spermatocytes in 95 patients (38%), complete maturation arrest at secondary spermatocytes in 32 patients
(12.8%), germ cell aplasia in 62 patients (24.8%), and atrophic testis in 7 patients (2.8%). The mean age of
the patients was 29.8 years. Regarding the greatest dimension of the testes, there was a significant
difference in the greatest dimension of atrophic testes and in testes with germ cell aplasia, from the other
groups. The procedure was well tolerated by the patients and no complications were encountered.
Conclusions: The technique can differentiate obstructive from intrinsic causes of azoospermia. It is simple,
quick, cost effective and free from complications.

ABSTRACT
Objective: The primary objective of this study is to evaluate the effect of gender on angiographic findings in
referred patients with chest pain and to study the gender-related differences in risk factors in patients with
coronary artery disease as a secondary goal.
Design: A retrospective, clinical study of 230 patients with chest pain.
Setting: Mosul Heart Center – Ibn Sina Teaching Hospital.
Patients and methods: From Sept. 1st 2011 to Jan. 31st 2012, a total of 230 (100 female, 130 male) patients
with chest pain who underwent diagnostic coronary angiography in Mosul Heart Center – Ibn Sina Teaching
Hospital were studied retrospectively. Both the whole female population and post-menopausal females as a
separate group was compared with a whole male population depending on the presence or absence of
coronary artery disease identified by coronary angiography. The main outcome of cardiovascular risk factors:
hypertension, diabetes mellitus, hypercholesterolemia, smoking and family history of coronary heart disease
were also studied in relation to the gender.
Results: The correlation between the whole female and male populations with positive coronary
angiography: 59% (59/100) vs. 89.2% (116/130) respectively, was statistically significant (p< 0.001). The
correlation between post-menopausal women and whole male population with positive coronary
angiography: 67.14% (47/70) vs. 89.2% (116/130) was also statistically significant (p< 0.05).
The mean age (yr) ± SD of whole female population with positive coronary angiography was (57.48± 8.8),
while it was (53.34± 9.0) for male population with positive coronary angiographic findings. The correlation
was statistically significant (p<0.01). The mean age (yr) ± SD of post-menopausal females with positive
results was (59:14±7.04). This was also statistically significant in comparison with main age of whole male
population (p<0.01). Hypertension and family history of ischemic heart disease were more prevalent in
females than in males with coronary heart disease, 30 (50.8%) and 41(69.4%) versus 44(37.9%) and 60
(51.7%) respectively, this was statistically significant (p< 0.05).
Conclusions: Females with chest pain who were referred for diagnostic coronary angiography had
significantly more negative angiography test than males, and the mean age of females with positive test is
significantly higher than males. Hypertension and family history of ischemic heart disease were more
prevalent in females with coronary artery disease than in males

ABSTRACT
Background: In Basrah, previous studies reported increased risk of certain cancers including leukaemia.
Two important features were reported: a rise in the incidence rate of leukaemias in children and an age shift
towards younger children. These studies were limited by the incompleteness of data they used.
Objectives: This paper is intended to present a profile of leukaemia in Basrah over the years 2005-2008.
Methods: The cases of leukaemia presented in this paper represent all cases diagnosed, treated and
registered in Basrah during the years 2005-2008. The cases were drawn from the pool of cancer registries in
various health care institutions dealing with cancer using a case series study design. All available and
verifiable cases were included in the study. Relevant incidence rates were calculated by dividing the average
annual number of cases by mid-period population for each category used.
Results: During the four – year study period, it was possible to identify 608 cases of leukaemia; 56.4% were
among males and 43.6% were among females. More than half of the cases (52.8%) were from Basrah,
26.5% were from Thi Qar, 13.6% were from Missan, and 7.1% were from other governorates. The agespecific incidence rate in Basrah showed a bimodal distribution with higher rates at extreme ages. The crude
incidence rate was 3.6 per 100000 population (3.9 per 100000 males and 3.2 per 100000 females). The age
standardized incidence rate was 4.3 per 100000 males and 3.9 per 100000 females.
Conclusion: Leukaemia is a significant malignant disease in Basrah. The figures of incidence rate point
towards an upward trend, but still comparable to the figures from other Gulf countries.

ABSTRACT
Objectives: To assess bone mineral density in β- thalassemia major (TM) patients and its relation with
gender, age, hemoglobin (Hb), calcium, ferritin, body mass index (BMI), chelation therapy, and splenectomy.
Patients and methods: Randomised cross-sectional study of 52 patients with beta thalassemia major (TM)
from Thalassemia Center in Ibn-Alatheer Teaching Hospital (32 males and 20 females) with age between 3
and 30 years scanned for bone mineral density (BMD) at lumbar spine with dual-energy X-ray
absorptiometry (DEXA) scan at DEXA unit in Ibn-Sena Teaching Hospital from September 2010 to
December 2010. The information about chelation therapy and splenectomy were obtained from the patients
with measurement of height and weight and blood samples for hemoglobin (Hb), calcium and ferritin were
taken.
Results: All 52 patients had T-score in osteoporotic range (100%), however, Z-score osteoporosis was seen
in 26 (50%) and osteopenia in 19 (36.5%). Bone density was normal in only 7 (13.4%). All patients had
elevated ferritin levels (100%), 36 (69.2%) had low body mass index (BMI) and 32 (61.5%) had low
hemoglobin (Hb) levels. Twenty six (50%) had low calcium levels and 2 (3.8%) were not using chelation
therapy. Sixteen (30.7%) had delayed puberty and the rest 36 (69.2%) were in prepubertal stage. Twelve
patients (23%) had splenectomy.
Conclusion: There is high incidence of low BMD in beta thalassemia (100% by T-score and 86.5% by Zscore) with significant association with age (P-value0.000), low BMI (P-value 0.038), low Hb (P-value 0.022),
delayed sexual maturity (P-value 0.000), and splenectomy (P-value 0.000).

ABSTRACT
Objective: To study the alterations in the expression pattern of alkaline phosphatase (ALP) in gallbladder
mucosa in cases of cholelithiasis (cholesterol type) in order to find its role as an indicator of functional
alteration in gall bladder mucosa in these cases.
Materials and methods: A prospective study was conducted over a period of 2 months started from July 1st
2010 to September 1st 2010 at the laparoscopic unit in Al-Jumhori Teaching Hospital, Mosul, Iraq, and the
Laboratory of postgraduate studies at the Department of Anatomy, Histology and Embryology, College of
Medicine, University of Mosul. Analysis of the sections which were obtained from twenty-two surgically
resected gallbladder specimens using laparoscope was done. Mean age was 50.5±2.1 years (range 21-77),
while the male:female ratio was 1:6. Clinical details were retrieved from the records. The cholecystectomy
specimens that were received were fixed in 10% formalin. The findings on gross examination were noted,
and the stones recovered from the gallbladder were analyzed by chemical examination. Multiple sections
were taken from each cholesterol stone-containing gallbladder (body, neck, and fundus) for paraffin blocks
and were examined after staining with hematoxylin and eosin (H&E). Microscopic examination was done to
assess the type of histological changes. To evaluate the enzymatic activity of alkaline phosphatase, sections
were stained using alkaline phosphatase stain (Gomori's method- Cobalt).
Results: Light microscopic examination using haematoxylin and eosin (H&E) revealed that 13 (59.09%) out
of 22 cases were diagnosed as cholerterosis, while sections obtained from 3 (13.6%) out of 22 cases
showed inflammation. Rokitansky-Aschoff sinuses were noticed in 6 (27.27%) out of 22 cases. Using
alkaline phosphatase stain (Gomori's method- Cobalt), the amount of alkaline phosphatase activity varied
considerably among the different areas in the same sections, and often among different areas of the same
layer of gallbladder, thus making the assessment difficult. However, this study showed 14 (63.63 %) out of
22 cases with moderate reaction to ALP stain in the mucosa, while 8 (36.36%) cases showed weak to
negative reaction to that stain.
Conclusion: The changes in ALP localization patterns may represent functional alterations either preceding
or running concurrently with morphological damages in gallbladder with cholesterol stones. Futural studies
will be recommended to localize ALP with different gallbladder disorders especially on ultrastructural,
immunohistochemical, and biomolecular levels.

ABSTRACT
Objectives: To use a panel of seven tumor markers for the detection and follow up of colorectal cancer. To
compare the diagnostic utility of the tumor markers with that of the standard methods. To construct ROC
curve for the purpose of the best detection of the studied cancer.
Patients and methods: Fifty two colorectal cancer patients and 30 apparently healthy individuals as a
control group were studied. They were tested for: carcinoembryonic antigen (CEA), cancer antigen 19-9,
cancer antigen 72-4 and tissue polypeptide antigen (TPA), two cytokines [interleukin-6 (IL-6)] and vascular
endothelial growth factor (VEGF)] by using ELISA. Twenty colorectal cancer patients were followed up for a
period of 3-5 months after surgical resection.
Results: There was a significant difference (p<0.001) in the diagnostic utility between cancer and control
group for all the seven tumor markers. In colorectal cancer group, a significant difference (p<0.001) in the
serum concentration of CEA, TPA, IL-6, VEGF and CRP was detected according to the stage of cancer. No
significant difference was shown for CA 19-9 and CA 72-4. Using ROC curve analysis, CEA was the best
diagnostic test. In the follow up group, a significant reduction was found for all the seven investigated
parameters.
Conclusion: CEA, CA 19-9, CA 72-4, TPA, IL-6, VEGF and CRP are of considerable diagnostic, prognostic
and follow up utility. ROC curve is used to enhance the diagnostic accuracy of the studied tumor markers

ABSTRACT
Objectives: To determine the causes of bleeding per rectum in patients undergoing flexible colorectal
endoscopy, taking in consideration the frequency of serious causes in our locality, and to compare the
results with others.
Patients and methods: A retrospective descriptive study done at Al-Salam Teaching Hospital, endoscopy
unit, Mosul, Iraq. One hundred and eighty five patients underwent flexible colorectal endoscopy between
January 2008 and December 2011 complaining of bleeding per rectum, biopsies were taken from lesions
and sent for histopathology then the findings were tabulated and recorded.
Results: One hundred and eighty five patients, with mean age of 44 years, and a male:female ratio of
2.36:1. One hundred and twenty patients (64.86%) had hemorrhoids, 10 patients (5.4%) had hemorrhoids
and fissure in ano, 20 patients (10.8%) had carcinoma, 14 patients (7.5%) with inflammatory bowel disease,
9 patients (4.8%) with non-specific proctitis and colitis, 9 patients (4.8%) had polyps, 2 patients (1.1%) with
solitary rectal ulcer, and 1 patient (0.5%) had benign tumor.
Conclusion: An appreciable number of serious lesions was found in patients with rectal bleeding especially
in those above 40 years of age.

ABSTRACT
Objective: To describe the radiological findings of active pulmonary tuberculosis (PTB) and /or tuberculous
pleural effusion (TPE) in adult males, to determine the site and extent of lesions and test the significance of
the erythrocyte sedimentation rate (ESR) in these patients.
Patients and methods: A retrospective observational study of two hundred and sixty two military male
patients with PTB and /or TPE with their age ranging from 25 to 40 years. Data were collected from the
medical records at the Mosul General Hospital (which was a military hospital prior to 2003), during the period
from July1995 to June 2002.
Results: The radiologic lesions of PTB were most commonly seen in the upper zones, (74% P-value
0.0001). TPE was more commonly involving the right side (64%). ESR value was found to be elevated in
most of the patients (84%).
Conclusion: PTB was seen mostly in the upper zones, TPE has more predilections to the right side. The
ESR is still a useful test in the diagnosis of tuberculosis.