Annals of the College of Medicine Mosul

Objective: To assess the outcome of endoscopic transnasal dacryocystorhinostomy (DCR) as a new
approach in our center( Al-Jamhori Teaching Hospital) in treating 25 patients complaining of epiphora
and recurrent or chronic dacryocystitis, comparing our results with the reviewed literature.
Patients and Methods: Twenty-five (25)patients, with age range(from 5-55 years), underwent
endoscopic DCR in the period from March/2006- July/2007 in Al-Jamhori Teaching Hospital, Mosul.
Standard procedure was implemented using the drill and inserting temporary stents. Patients were
followed up for 6-24(average of 8.8) months to assess the outcome of surgery.
Results: There was improvement in symptoms in 18 patients with disappearance of epiphora with
72% success rate. One patient had orbital fat prolapse and 3 patients developed postoperative
adhesions. No major complication, namely severe bleeding, CSF leak or serious orbital injury
occurred. Revision surgery was done on 3 failed cases; only one patient had clinical improvement.
The total success rate after revision surgeries is 76%.
Conclusion: We conclude that endoscopic DCR, which is a new experience in Iraq, is a safe
technique in treating nasolacrimal duct obstruction with an acceptable success rate that matches
many studies.

Objective: To evaluate the overexpression of Her-2/neu in patients with breast cancer in Mosul (both
invasive and intraductal) against other prognostic parameters of mammary carcinomas, such as
histological type, grade, tumor size, patient age and number of lymph nodes involved.
Methods: This is a retrospective study conducted in the Pathology laboratory of Al-Jamhoori Teaching
Hospital and at private laboratories. A total of 36 breast cancer cases and 4 benign cases were
diagnosed and collected in a period spanning from April 2006 to April 2007. We used
Immunohistochemistry to evaluate the overexpression of Her-2/neu against the age, tumor size, type and
grade and the axillary lymph node status.
Results: The mean age of all cases was 47.5 years ranging from 28 to 72 years. Regarding the age,
Her-2 positivity was shown in 2 peaks (4th and 7th decades), while Her-2 negativity was found in older age
group (p=0.004). Overall Her-2 overexpression was in 37% of the cases; it was overexpressed in 34.5%
of invasive ductal carcinoma, in 100% of medullary carcinoma and in 100% of ductal carcinoma in situ.
Whereas no expression (0.0%) was seen in 3 cases of invasive lobular carcinoma and one case of colloid
carcinoma. Her-2 positivity was associated with large size (T2 and T3) rather than small size tumors
(p=0.015). There was a correlation between Her-2 positivity and high grade tumor [G3 in 69.2% of the
positive cases (p=0.045)]. Her-2 positivity was associated with axillary lymph node metastasis in 84.6% of
cases, but not reaching a statistical significance. The benign lesions included in this study (two
fibroadenoma, one fibrocystic disease and one duct ectasia) all showed negativity for Her-2 stain.
Conclusion: Her-2 overexpression was found in 37% of breast cancer in Mosul. Regarding age
incidence Her-2 overexpression was noted at 2 peaks 3rd and 6th decades. Large size and high grade
breast carcinomas were associated with high percentage of Her-2 positivity, and the majority of Her-2
positive cases had axillary lymph node metastases.
Key words: Breast carcinoma, Her-2/neu expression

Objective: In the medical encyclopedia ;Mastodynia, mastalgia or mammalgia are names for a
medical symptom that means - pain in the breast .This common problem seen in the west, finds little
mention in our country and our literature. The purpose of this study is to report the pattern of various
breast diseases amongst women presenting with mastalgia (breast pain) in Mosul breast clinic
emphasizing their assessment and hoping to initiate further studies on their natural profile.
Patients and methods: A retrospective study of 682 female patients with mastalgia. From the Breast
Clinic in Al Jamhoory Teaching Hospital in Mosul between Aug 2002 - March 2004. Records of six
hundred eighty two patients with breast pain with or without lumpiness utilizing Cardiff daily breast
pain chart filled by the patients were reviewed. Their mean age was about 38 years. All patients were
examined clinically and by ultrasound (probe7.5MHz). Mammography and histopathological
examination were done to those with equivocal and suspicious clinical and ultrasonographic results.
Results: Cyclical breast pain was reported in 422 patients (62%), normal breast nodularity in 154
(22%), inflammatory lesions in 40 (6%), benign breast pathology in 56 (8%), benign tumours in 6(less
than 1%) and malignant tumours in 4 (less than 1%).
Conclusions: Breast pain is a common problem in the breast clinic. This study showed that cyclical
breast pain and nodularity represent the commonest conditions followed by benign and inflammatory
lesions. Breast pain needs to be evaluated as with many other medical problems, by good history
(including breast pain chart) and examination. This to be followed by imaging (as the age implies) and
histopathological assessments. Surgeons evaluating breast pain should have more rational criteria in
using further sophisticated, expensive and invasive tests.
Key words: breast; mastalgia; profile.

Objective: To investigate general and socio-economic conditions in the development of breast cancer
in pre-menopausal women.
Methods: Between1st March 2007 to 1st. October 2007, we conducted a case-control study, on 52
pre-menopausal women proved to have breast cancer and 80 pre-menopausal women proved to be
without breast cancer were considered as controls. The questionnaire included, assessment of socio
economic factors, life events (stress, social discontinuities and geographical mobility), social context
(economic factors, social disintegration, urbanization) and social class. In addition, previous history of
surgical operation, parity, history of contraceptive pills usage, and chronic non-communicable
diseases and previous X-Rays exposure, were also obtained. Moreover, body mass index and waist
to hip ratio were obtained.
Results: Regarding Personal Characteristics; positive family history, sedentary life styles, unhealthy
dietary behavior, personality type A, and active smoking, all were found to be significantly associated
with the occurrence of breast cancer. According to Life Events; stress, social discontinuities and
geographical mobility, were also found to be related to the development of breast cancer. Regarding
Social Context, both economic factor and social disintegration were found to be highly and
significantly associated with breast cancer. According to Other Variables, the presence of one or
more of chronic non-communicable diseases in addition to previous exposure to diagnostic X-Rays
radiation, having a BMI > 25, having a WHR > 1, being in lower social classes and the previous use of
oral contraceptive pills were all found to be among the significant risk factors in the development of
breast cancer among pre-menopausal women.
Conclusion: Pre-menopausal women with positive family history, sedentary life, unhealthy dietary
behavior, personality type A, social discontinuities, active smoking, stress, social discontinuities,
geographical mobility, social disintegration, sudden change of economic status, chronic diseases,
previous X-Rays exposure, obesity, previous history of oral contraceptive pills usage and being from
lower social classes are at high risk of developing of breast cancer. This, indicates the very high
responsibility of modern doctors to bear social factors on mind in evaluating such diseases and also in
health education.

Aim: A retrospective study of 125 cases with different types of hypospadias. Evaluation of the
surgical procedure for each type to choose the suitable techniques for each problem.
Patients & methods: 125 cases of hypospadias were admitted and treated at Al-Khansa\'a Paediatric
Surgery centre in Mosul during the Period from Jan. 2005 to Feb. 2007. Their age ranged between 6
months to 12 years. All types of Hypospadias were managed using different techniques. Majority of
them were distal type. The surgical repair varies according to the type of hypospadias. Catheters
were used for different periods according to the procedure used. Hospitalization period also varied
according to the severity and techniques used.
Results: The types of hypospadias varied from glanular to penoscrotal. Glanular were 14 patients,
coronal and sub coronal were 48 patients, distal penile were 37, mid shafts were 18 patients, proximal
and peno-scrotal type were 8 patients. The types of repair used were, MAGPI in 41patients ( 33,6%),
TIP technique in 75 patients (60%), Mathiew technique in 4 patients (3,2%), and Onlay tube flab in 5
patients (4%). Associated problems found with hypospadias repair were; Circumcision in ten patients
(six coronal, three subcoronal and distal hypospadias, and only one case with proximal hypospadias).
Chordee found in eight patients. Torsion of the shaft of penis in 5 patients (four with mild degree and
only one with severe degree). Major complications such as stenosis in 18 patients, fistula in 16
patients and flap or skin necrosis in 3 patients.
Conclusions: There is no single procedure which could be used for all types of hypospadias, but the
TIP techniques can be used for a wide range of hypospadias from coronal up to penoscrotal type and
this techniques is simple, quick, single stage procedure, and it offers good functional and cosmetic
results. The presence of circumcision prior to the repair is not a problem in repairing distal
hypospadias but it could be a problem in the proximal type.
Key words: Hypospadias; Repair of hypospodias.

Objectives: 1- To identify the bacteria from the gall bladder and stool samples taken during
cholecystectomy of patients with acute, and chronic cholecystitis of calculus and acalculus types. 2-
To use serological agglutination tests for the diagnosis of typhoid and brucellosis cholecystitis.3- To
find out the antibiogram of the isolated bacteria from the different cases.
Methods: A prospective case series study was conducted at Al-Jumhori Teaching Hospital, and
Ninevah and Al-Zahrawi Private Hospitals during the period from the 1st of October 2003 to the 30th of
June 2004. A total of 150 patients undergoing cholecystectomy (134 females and 16 males)were
studied. From each patient samples were collected from the gall bladder (bile, tissue biopsy and stone
if present),blood for serological tests and stool (from 69/150 patients).
Results: Among the gall bladder samples, 101/150 (67.3%) cases showed bacterial growth, the
remaining 49 (32.7%) cases had no growth. The bacterial growth was seen among 83.3% and 64.3%
of acute and chronic cholecystitis respectively. A single agent per sample was detected in 62.4% of
the cases, whereas mixed growth was identified in the remaining 37.6%. The gram-negative bacteria
were predominant and represented 86.7% of the isolates,while gram-positive ones were 13.3%. The
most common aerobic bacteria isolated were E. coli (19.3%), while anaerobes were detected in only
5.3% of the isolates. The stool cultures showed similar microorganisms to those identified in the gall
bladder samples in 74% of cases. In acute cholecyctitis all the gram-negative bacteria were sensitive
to ciprofloxacin followed by ceftriaxone (96.5%) and gentamycin (96.5%). In chronic cholecystitis the
most effective drug was ciprofloxacin (93.7%) followed by amikacin (82.2%). In both acute and
chronic cholecystitis the least effective antibiotic was ampicillin.Typhoid cholecystitis was detected
among four cases only, while brucellosis cholecystitis was not observed.
Conclusions: The bacteria causing acute and chronic types of cholecystitis are similar and
predominantly are gram-negative bacilli. The intestinal origin of these microorganisms suggests
ascending infection from the intestine to the biliary tract. Ciprofloxacin is the most effective drug
against the isolated bacteria.
Keywords: cholecystitis, typhoid- cholecystitis, brucellosis-cholecystitis.

Aim: To review the different methods for treatment of pterygium.
Methods: A case series study conducted at private and out patients clinic of Al Jamhoury teaching
hospital in Mosul, during the period from Jan.2006-Jun.2007. Thirty-eight patients with 54 eye lesions
of pterygium were included in the study. They were treated under local anesthesia by simple surgical
excision with cauterization of the conjunctival edges to sclera by simple cautery or by wet bipolar
cautery.
Results: seven cases of recurrence were recorded in this study after 4-12 months of follow up
postoperatively, in the age group before 45 years. No significant preoperative or postoperative
complications were recorded with the exception of persistence of some cauterization marks on the
sclera,
Conclusion: The surgical excision of pterygium and cauterization of the conjunctival edges to the
sclera appear to be a simple, safe and successful method.

Aim: To study the frequency of diabetic retinopathy in a population of patients and to evaluate the
medical risk factors underlying its development.
Methods: A case series study conducted at the out patient clinic of Al Jamhoury teaching hospital
and at a private clinic in Mosul, during the period from Jan. 2005 to Dec. 2006.One hundred and
seventy patients with diabetes were randomly selected by ophthalmologist. They were referred by
physicians after they did diabetic profile by history and medical examination. The WHO definition of
diabetic retinopathy was recommended, several risk factors were searched for during the evaluation
of the patients.
Results: the prevalence of diabetic retinopathy was 32.35%, 20% in type I diabetes, and 80% in type
2 diabetes and surprisingly both of which had equal rate of retinopathy in this population. 80% did not
know about the need of regular dilated fundus examination. The mean age was 50 years old ranging
from 25-67 years, with 65% between the ages of 50-65 years old and the standard deviation was
(±10.95). Male to female ratio was 1:1.5 with equal rates of retinopathy (29.4% vs 34.3%). The
retinopathy rate was highest in the age group 50-59 years (37%). The rate of non-proliferative diabetic
retinopathy, proliferative diabetic retinopathy and diabetic maculopathy were 18.8%, 12.9% and
14.5% respectively
The rate was higher among subjects with longer duration of diabetes, higher fasting plasma glucose,
and cases with hypertension.
Conclusion: Public education is essential about the need for routine and regular dilated fundus
examination for diabetic patients in addition to glycemic control; lowering diastolic blood pressure (in
hypertensive patients) may be effective in lowering the incidence of retinopathy in compromised
patients.

Objectives: To define the aetiology, management, and outcome of upper gastro-intestinal bleeding,
and to assess the role of endoscopy in the management. Also to assess the factors to improve the
management of this problem in this region.
Patients & methods: A prospective study of 102 patients admitted to the main hospitals under the
care of the author (1999-2006). Patients were assessed, resuscitated, and investigated by the
standard methods. All were endoscoped by the author (OGD).
Fifty patients were treated surgically, by laparotomy and according to the findings; mainly under
running suturing of bleeding duodenal ulcers. Analysis of the causes, type and source of bleeding,
indications of surgery, and the role of endoscopy was done.
Results: Total number of patients was 102, ninety males (88.2%), and 12 females (11.8%). Age
range was (8-68years), with peak incidence at the fourth decade. All patients were admitted to
hospital, and received blood (2-18 units). Melena was found in 22 patients (2 1.5%). History of aspirin
and NSAID ingestion was found in 18 patients (17.6%). All patients were endoscoped during day
working hours. Causes of bleeding were: Chronic d.u. in 60 patients (58.8%) oesophageal varices in
15 patients (14.7%), and no source of bleeding could be detected in 7 patients (6.8%). Fifty patients
needed surgery (laparotomy); active bleeding vessel was the main pathology, present in 20 cases
(40%). Fifty two patients were managed successfully on conservative treatment.
Conclusion: The most common cause of upper g.i.t. bleeding in Erbil is bleeding duodenal ulcer,
followed by oesophageal varices. Gastroscopy proved to be a reliable and accurate method for
diagnosis and treatment. Lack of facilities for therapeutic endoscopy and intensive care, led to a high
percentage of surgical treatment in about 50% of patients. Improvement of health infrastructure is
essential to achieve a better care for our patients.

Objectives: To assess the effect of cotton dust
on pulmonary function tests of workers in a cotton textile factory.
Subjects and Methods: One hundred forty one male workers aged 21-60 years. Out of them 67 from
Pepsi factory considered as controls ,and 74 from cotton textile factory in Mosul ,during the period
from the 1st of January 2007 to the 30th of April 2007.The pulmonary function tests studied were :FVC
,FEVI , FEV%.PEF and FEF25-75%.
Results: Workers in cotton textile factory showed a significant reduction in the levels of FVC and of
FEV1 at age of 40-60 years as compared to control workers.
Conclusions: The results showed that cotton dust causes a significant reduction in FVC and FEVI as
age advances.

and others working in Mosul college of medicine.
Method: This cross sectional study was performed in Mosul college of medicine during the period
from March 2007-March 2008. One thousand fifty five (1055) persons of both sexes were
interviewed to Ishihara colour test which is the most often used to diagnose Red-Green colour
blindness. The participants were college students , staff members and clercks of college .
Results: Fifty four showed (5.1%) men and 0.37% women had red-green colour blindness. It was
seen that 176 persons from the total sample (1055) had refractive error; only one person (0.56%)
out of these 176 showed Red-Green colour blindness.
Conclusion: The present study showed that colour blindness is a not uncommon problem among
people and with the advance of modern life it is getting a source of difficulties and despair with
distinguishing colours, example traffic lights , work on computer , … ect. Our ambition is to carry out
more detailed studies for which the present study may open the door for more collaborative studies
with other departments specially psychological in order to lessen such problem facing coulor blind
people.

Objective: Histochemical and immunohistochemical examination of soft tissue sarcomas(STS) in
Mosul to assess the value of these techniques in verifying the primary diagnosis.
Methods: Paraffin embedded tissue blocks of 35 cases of soft tissue sarcomas collected over a
period of 20 months in Mosul, were utilized. H&E, reticulin ,and Van Gieson\'s staining techniques and
immunohistochemical marker for S-100 protein were applied to all the cases.
Results: Soft tissue sarcoma accounts for 16.4%of the total of 213 cases of benign and malignant
soft tissue neoplasms,with a mean age of 30.5 years ,and a male preponderance( Male: Female ratio
of1.7:1). The most common histologic subtypes are extraskeletal Ewing’s sarcoma(ES),
dermatofibrosarcoma protuberans(DFSP) ,and spindle cell sarcoma, not other wise specified (NOS).
The extremities are affected in 51.4% of all cases, particularly the lower limbs. The majority of soft
tissue sarcomas belong to the high grade category by applying French Federation of Cancers Centers
Sarcoma Group ( FFCCSG) and American Joint Cancer Committee (AJCC) grading schemes .Both
reticulin and Van Gieson\'s stains have been successfully depicting the growth patterns of different
subtypes. Immunoreactivity for S-100 protein was positive in two cases.
Conclusions: High quality H&E stained sections remain the best method for establishing the
diagnosis of sarcomas .Reticulin stain proved extremely helpful in subclassifying sarcomas and S
100 protein was instrumental in changing the diagnosis of sarcoma in one case.

Context: leukemia is the most common malignancy in childhood; many studies were conducted to
explore the probable protective effect of breast feeding on childhood leukemia.
The aim of the present study is to evaluate the effect of breast on the development of childhood
leukemia.
Methods: A case control design was conducted at the hematology unit;Ibn Alatheer pediatrics
hospital in Mosul city. A total of 71 children diagnosed to have acute lymphoblastic leukemia and 70
children diagnosed to have diseases other than malignancy were included in the study as cases and
controls respectively. SPSS and excel computer programs, chi squared test and Z test of two
proportions, were used in statistical analysis.
Results: The present study observed a protective association between breast feeding and the risk of
childhood leukemia (OR=0.2, P<0.05). Moreover, the study showed increased risk of leukemia among
children exposed to explosions near their residency (OR= 3.9, P<0.001).
Conclusions: Breast feeding might have a vital protective effect against childhood leukemia. On the
other hand, exposure to explosive materials might carry a high risk for developing leukemia.

Objective: To estimate the relative frequency, as well as specific pathological features of thyroiditis in
thyroidectomy specimens in Mosul.
Methods: One hundred (100) cases of histopathologically proved thyroiditis had been evaluated
between July 2001 and March 2002. Histopathological examination , serum autoantibody assay, with
thyroglobulin immuno-histochemical marker were done. In addition we utilized results of thyroid
function tests brought by many patients
Results: Hashimoto\'s thyroiditis (H.T), 31 cases, F:M ratio 30:1, median age 38 years. Eighty percent
of the cases were euthyroid. Focal lymphocytic thyroiditis (FLT) was recognized in 66 cases. It was
divided into three grades according to the intensity of the lymphocytic infiltration, all cases showed
female preponderance with F:M ratios of 9:1, 23:1 and 1:1 for grades I,II and III respectively with a
mean age of 37 years. H.T. and FLT shared positivity for serum autoantibody and the presence of
other pathological conditions of the thyroid, namely follicular adenoma, Hurthle cell(H.C.) adenoma
and papillary carcinoma. Immunohistochemical stain for thyroglobulin monoclonal antibody marker
showed strong reactivity within the atrophic follicles in H.T..The remaining three cases include
granulomatous, suppurative and Riedel\'s types of thyroiditis.
Conclusions: Thyroiditis is a common condition in Mosul with marked female preponderance, and
incidence in adulthood. The two main types encountered were H.T and FLT . Hashimoto\'s thyroiditis
invariably shows Hürthle cell metaplasia either in focal or diffuse pattern of growth, particularly the
latter. While H.C., if present, are mainly sporadic in FLT. In H.T., thyroid function is related to the type
of follicular epithelial cells and the presence or absence of plasma cells.

A 55 years old female with dedifferentiated liposarcoma is described in which the diagnosis was
unsuspected clinically and diagnosed histopathologically. The clinical and pathological features are
briefly reviewed.

A female neonate with parauretheral cyst is rarely encountered in our surgical practice and
uncommonly reported in literature. Nearly all these cases were asymptomatic.
In this paper I reported a case of symptomatic parauretheral cyst which required surgical
management with excellent results functionally and cosmetically.