Annals of the College of Medicine Mosul

ABSTRACT Objectives: Palpitations (increased or abnormal awareness of the heart beats), often caused by cardiac arrhythmia, anxiety, and non cardiac causes; also caused by non arrhythmic cardiac problems such as mitral valve prolapse (MVP), other valvuler disease, heart failure, cardiomyopathy, and congenital heart diseases (CHD). Some patients had no cause for palpitations. We aim to study the cardiac problems revealed by echocardiography in patients with palpitations, and the differences between males and females. Patients and methods: A total of 267 patients who seeked medical advice specifically for palpitations, and another 173 controls, had echocardiography evaluation, results were classified into three groups, MVP, myocardial disease, and valvular and CHD. Statistical analysis using chi- square test was applied. Results: The patients consisted of 221 (83%) females, and 46 (36%) males, aged between 14- 77 years, mean age 38 years. MVP was diagnosed in 76 (28%) patients (P value 0.019) and it was more significant in females (P value 0.046). Other valvular diseases and CHD were also considerable causes of palpitations in females (P value 0.043). Myocardial diseases were diagnosed in 62 (23%) patients, including 15 (33%) males. Conclusion: Echocardiography was normal, or minimally abnormal as in MVP in most of patients 189 (71%). MVP and other valvuler diseases and CHD were significant causes of palpitation in females, while myocardial diseases were more frequent in males. These results are consistent with previous studies.

ABSTRACT
Objectives: (1) To assess the prevalence of primary and secondary polycythaemia in our locality and
their detailed clinical and haematological parameters. (2) To determine causes of secondary
polycythaemia. (3) To establish a working formula for determining packed cell volume reduction after
a given number of blood units donated.
Methods: A prospective clinico- haematological case series study, done in Mosul teaching hospitals
and central blood bank, including seventy two patients with raised packed cell volume. The patients
were assessed by clinical evaluation, complete blood picture, coagulation tests, chemical tests, chest
x-ray, echocardiography, ultrasound, in addition to arterial O2 saturation and pulmonary function tests.
Results: The most common clinical features were headache, dizziness and plethora. The pruritus
was present only in polycythaemia vera. Thrombotic complications present more in secondary
polycythaemia. Raised packed cell volume and haemoglobin above normal value has been found in
all patients. Leucocytosis and thrombocytosis was present in 12/42 patients with polycythaemia vera.
Majority of patients with secondary polycythaemia (86.7%) have ventilatory defects. The effect of
number of blood units donated and it’s frequency (in weeks) on the degree of packed cell volume
reduction in patients treated with venesection was expressed by equations.
Conclusions: Polycythaemia vera patients were younger than those with secondary polycythaemia
and found mainly to affect males. All cases of secondary polycythaemia were due either to chronic
lung disease or congenital heart disease. We have established an equation when applied to patients
with polycythaemia can predict value of packed cell volume reduction after donating a given number
of blood units

ABSTRACT
Background: The most common reason for injuries to be missed is altered level of consciousness
due to head injury or alcohol. Other reasons include severity of injury and instability requiring
immediate operation, lack of symptoms at admission, technical problems, and low index of suspicion
by the examiner. Missed injuries can occur at any stage of the management of patients with major
trauma. Any delay in providing the necessary treatment may lead to increased morbidity and
mortality.
Objective: To find the frequency of missed intra-abdominal injuries and their mortality, to raise
suspicion of potential missed injuries in order to avoid these preventable deaths.
Methods: A retrospective study including 2978 patients with abdominal injuries out of 13201
traumatized patients in 2006. Records were reviewed for demographics, injury characteristics, and
associated injuries, missed injuries, need and indications of reoperation, morbidity and mortality.
Results: The study included 2978 trauma victims; 2195 males and 783 females, with a male to
female ratio of about 4:1.Thier age ranged from 2- 87 years, median age 39.5 and peak age of trauma
was 31 years. From 2978 patients with abdominal injuries, there were 28 deaths (1.06%), and four
missed injuries (0.134%).
Conclusion: A careful history taking, precise and repeated clinical examinations, complete diagnostic
procedures, complete surgical explorations, and proper timing of reoperation are necessary for
patients with blunt abdominal injuries, which are cornerstones in improving the quality of trauma care.

ABSTRACT
Background: Prevalence of diabetes mellitus is increasing in developed and developing countries.
Diabetes is known to strongly affect the health-related quality of life (HRQOL).
Objectives: To assess the quality of life of patients with type 2 diabetes mellitus and to determine the
clinical and sociodemographic factors that affect the quality of life of these patients.
Patients and methods: This was a case series health center based study, the data for this research
was taken from an MSc research during the data collectinon phase. A 300 patients with type 2
diabetes mellitus attending AL-Wafaa Diabetic Centre in Mosul. The world health Organizations
quality of life assessment (WHOQOL-BREEF), short version questionnaire was applied to assess
quality of life after being modified and translated to local Arabic language.
Results: The overall QOL show that most of the respondents performed fairly well on the
questionnaire used, 41% had good score, 46% had fair score and 13% had poor score. For physical
activity domain 30% had poor score, for social domain 14% had poor score, for psychological and
enviromental domains 23% had poor score.
Conclusion: This study supports previous reports that QOL of patients with diabetes mellitus was
fairly good and D.M significantly affects physical health especially in females. Further community
based cross sectional studies is recommended for measuring QOL in DM.

ABSTRACT
Objective: To measure the effects of type 1 and type 2 diabetes mellitus on the various spirometric
pulmonary function tests
Methods: This study involved 70 diabetic patients, 25 type 1 and 45 type 2 diabetes mellitus, and 45
control group. Type 1 diabetic patients included 14 males and 11 females, their ages ranging from 17-
63 years with their mean was 47.12, with SD12.83. Type 2 diabetic patients included 26 males and 19
females; their ages ranging from 19-63 years with their mean 46.67, with SD 9.50. The control group
involved 24 males and 21 females, their ages ranging from 13-68 years with their mean 38.78, with
SD13.3.
The study was conducted in Ibn Sena Teaching Hospital Medical Outpatient Clinic, Al-wafa Medical -
Center in Mosul, and Mosul University-Medical Center.
Results: There were statistically significant differences between the control group and type 1
diabetes mellitus during the measurements of FVC%, FEV1/FVC% and MMFR%, with statistically
significant reductions in their values when compared to controls. Furthermore, type 2 diabetes
mellitus has significant effects on FVC%, FEV1 and FEV1/FVC% when compared with the controls,
with statistically significant differences from the control group. There were no much differences
between them apart from the FVC% which favors type 1 diabetes mellitus over type 2 diabetes
mellitus with highly significant P-value.
Conclusion: The present study clearly indicates that both type 1 and type 2 diabetes mellitus
adversely affects the various pulmonary function tests, and the results are in accord with other
previous studies.

ABSTRACT
Objectives: 1). To determine the prevalence of ESBLs producing Klebsiella species. 2). To examine
their antibiogram profile. 3). To evaluate the association between ESBLs production and antibiotics
resistance in Klebsiella isolates.
Materials and methods: This prospective study included 116 non repeated isolates of Klebsiella
species 62 obtained from urine and 54 recovered from wounds. These bacterial isolates were reidentified and tested for antibiotic sensitivity against 19 selected antimicrobial agents. Also, these
isolates were evaluated for extended spectrum beta lactamases (ESBLs) by double disk synergy test.
Results: Extended spectrum beta lactamases were found to be produced by 16.4% of the total
studied Klebsiella isolates. Amikacin showed the lowest resistance rate (27.6%), while the highest
one was detected against cephalothin, penicillin, cloxacillin and ampicillin (98.3%). The statistical
analysis between ESBLs production and antibiotics resistance revealed a significant association only
with ceftriaxone (p<0.05), cefotaxime (p<0.001), cefixime (p<0.001), gentamicin (p<0.05) and
nitrofurantoin (p<0.05). Moreover, it was found that the strains produced ESBLs showed a higher
resistance to all the used antibiotics except for levofloxacin.
Conclusions: This study highlights the emergence of ESBLs producing strains of Klebsiella, which
endowed with extremely wide spectrum of antibiotics resistance including resistance to pencillins,
cephalosporin, aminoglycosides and fluroqunilones. This increased resistance to antimicrobial agents
may result in treatment failure.

ABSTRACT
Objectives: To assess the effect of carbamazepine (CBZ) monotherapy in male adult epileptic
patients on serum leptin, insulin levels, body mass index and oxidative stress represented by serum
malondialdehyde (MDA) in comparison to healthy controls.
Patients and methods: To achieve the aims of the current study, a case-control study design was
adopted. A total of 38 male adult patients with primary generalized epilepsy, on continuous CBZ
monotherapy, for at least six months before participation in the study, were collected over the period
from Sept. 2010 to Jan. 2011. Forty apparently healthy male volunteers without previous history of
epilepsy were recruited as controls. Fasting blood samples were taken and sera were separated and
used to measure serum levels of leptin and insulin, and MDA. Body mass index (BMI) was calculated
as weight in kilograms divided by the squared height in meters.
Results: The results of this study revealed that there was insignificant difference in BMI, serum leptin
and insulin between male epileptic adult patients and their matched control subjects. The results also
revealed that male epileptic adult patients had a significantly higher (p<0.001) serum MDA compared
to their matched control subjects.
Conclusion: Carbamazepine is a relatively low risky antiepileptic drug (AED) in terms of obesity,
while it can cause oxidative stress as reflected by an elevated serum MDA in comparison to controls.

ABSTRACT
Objective: To identify the value of clinical data in diagnosis of celiac disease (CD) in children.
Patients and methods: a prospective study was conducted in Mosul city during the period from 30th
of October 2007 to 30th of April 2011. A total of 57 patients (39 males, 18 females) aged more than 6
months on gluten containing diet presented with symptoms suggestive of (CD) were evaluated
clinically and serologically using IgA human recombinant tissue transglutaminase antibody. (IgA anti
tTG2). Multiple duodenal biopsies were performed for every patient enrolled in this study. CD cases
had been followed up 6 months after a gluten free diet (GFD) by weight measurement and the
mentioned serological testing.
Results: A total of 29 (50.9%) out of 57 symptomatic patients with mean age of 56.1 months,
demonstrated positive biopsy results for celiac disease. Failure to thrive (FTT) was noticeable in 25
(86.2%) of studied patients with celiac disease followed by anemia, abdominal distension, offensive
stool and chronic diarrhea in decreasing frequency. Catch up of weight was not achieved in 10
(43.5%) out of 23 CD patients with FTT whose (IgA anti tTG2) normalized after 6 months of GFD.
Conclusions: The diagnosis of celiac disease on the basis of clinical features alone was incorrect in
(49.1%) cases, indicating that diagnosis and lifelong GFD treatment is not justifiable relying on clinical
data. Catch up of weight cannot be relied upon as an early marker of clinical improvement in patients
with proven adherence to GFD.
The result of this study emphasizes the importance of increasing awareness of the accurate tools in
diagnosis of CD in children based on serological and biopsy evidences

ABSTRACT
Background: Physical school environment considered one of the critical points for children growth
and development. Schools are large places that present significant opportunities for getting an
accident or infection.
Objective: To assess the physical environmental health criteria of primary schools in Mosul city.
Methods: A descriptive cross sectional study design has been adopted. A sample of 25 schools has
been taken using multi-stage stratified stratum sampling technique. A special questionnaire form has
been prepared depending on WHO criteria for schools environment. A separate questionnaire form
has been filled by the investigator herself for each school.
Results: Study results revealed that 52% of the schools are near a main street, 80%of schools are
close to sources of pollution specially garbages, 20% of schools have maintained gardens, 72% of
schools have inadequate faucets, 92% of schools have inadequate toilets. Whereas only 24% of
toilets founds have good sanitary conditions. On the other hand only 20% of classrooms were found
to be appropriate, 48% of schools were having inadequate lighting and 28% have inadequate
ventilation.

ABSTRACT
Objectives: (1) to identify the opportunistic fungi from sputum and bronchial wash of patients with
lower respiratory tract (LRT) infections in immunocompromised (IC) and immunocompetent (IP)
patients, and apparently healthy controls, (2) to detect antibodies against Aspergillus species by
double immunodiffusion test (ID).
Subjects and methods: Three hundred patients suffering from LRT infections of both IC (150/300)
and IP (150/300) patients were included in the study. The clinical specimens collected were samples
of sputum (247), bronchial wash (80), and blood (300). The control group was 50 apparently healthy
individuals, from whom sputum and blood were obtained. The identification of the isolated fungi was
carried out by direct fluorescent and/or light microscopy, culture on different media, and biochemical
tests. Moreover, the serums of patients with Aspergillus isolates were tested by double ID test for the
detection of specific antibody.
Results: One hundred eighty patients showed fungal elements in their clinical specimens (60%). Two
hundred four funguses were detected, including 24 samples with 2 types of isolates. The identified
fungi were encountered from both IC (60.9%) and IP (39.1%) patients with a significant difference
between them (p< 0.001). Nine opportunistic genus-species were identified. Five were filamentous
type namely Aspergillus spp., Penicillium spp., Cladosporium spp., Fusarium spp., and Geotrichum
spp., while the other 4 were unicellular organisms including Candida spp., Saccharomyces cereviciae,
Cryptococcus neoformans, and Rhodotorula rubra. In the control group, 36% showed fungal isolates
in their sputa, and the ID test showed a positive result for antibody in only one patient with Aspergillus
isolate.
Conclusions: Many opportunistic fungi are important uncommon pathogens in LRT infections in IC
patients. The ID test is of limited value for the detection of specific antibody of Aspergillus spp.

ABSTRACT
A case of pneumocystis pneumonia was diagnosed on clinical and mycological grounds. A 35 - year -
old man was presented with severe chest infection. His medical history included lymphoma for 5
years and under treatment with cytotoxic drugs. The patient diagnosed as a case of pneumonia and
treated with antibiotics for one week but with no response. Later on, his sputum was sent for
mycological examination that revealed the cysts and trophic forms of pneumocystis jirovecii. Good
response with complete healing was achieved after 3 weeks of treatment with co-trimoxazole.
Pneumocystis pneumonia may be suspected clinically in hospitalized patients, but this is the first case
to be confirmed mycologicaly in Mosul. Good awareness of the full clinical spectrum of the disease
aided by mycological study is needed to minimize the misdiagnosis of cases