Annals of the College of Medicine Mosul

Background : Basal cell carcinoma (BCC) is the most commonest malignant tumor of the skin especially fair-skinned individuals makes up roughly 70–80% of all malignant tumors. In certainty, this malignancy had a variety of many tumor sub-types, through a distinct histo-morphological appearance and biological function. Unlike other tumors, usually has an affirmative clinical course, developing slowly and just locally. Antibodies against “Ki-67 antigen” or proliferating Cell nuclear antigen (PCNA) are typically used in immunohistochemistry to detect the proliferative activity (growth fraction) of malignancies.
Aim of the study : This study aims to examine the tumor cells' proliferative status utilizing an immunohistochemistry analysis of the “Ki-67” antigen in skin biopsy specimens of different sub-type of BCCs.
Material and methods : A Case series study enrolling 35 biopsies sampled from retrospectively selected cases of cutaneous BCCs were registered in the research.
Results : Thirty five biopsy (31 Primary, 4 Recurrent)of different histological types from 35 patients (11 male, 24 female) were included. The patient’s age ranged from 36 to 75 years (with mean of 59.2 year) .In this study results showed that commonest site of involvement was the face in 71.4% of cases , and there was significant association between tumor size and the Ki67 level and grade, the study reported a non-significant association between the tumor histological subtype and Ki67 level.
Discussion : The data showed that there were a wide range of ki67 level (2 to 70%) among various histological growth subtype of basal cell carcinoma, higher proliferative index indicate more malignant potential and lower proliferative index mean less aggressive tumor. So the wide range of proliferation which had been reported in the BCC illuminate the wide spectrum of biological activity of tumor.

Background : Detection of lytic bone lesions is crucial in the workup for multiple myeloma (MM) and very often dictates the decision to start treatment. Modern imaging techniques such as MRI, PET, and CT offer superior detection of myeloma bone disease and extramedullary manifestations of plasma cell dyscrasias. Autologous stem cell transplant (ASCT) is regarded as frontline therapy in candidate patients. Recent advances in understanding of myeloma bone disease showed that the receptor activator of nuclear factor kappa-B ligand (RANKL) and osteoprotegerin (OPG) system plays a key role in this regard.
Objectives : to assess the response of bone disease in patients with multiple myeloma using whole body low dose CT (WBLD CT) scan after different modalities of treatment including autologous stem cell transplant.
Patients and method : This is a prospective cohort study in which patients with multiple myeloma had baseline WBLD CT scan with basic evaluation. They were then received induction chemotherapy with and then grouped into two groups according to the modality of consolidation (ASCT vs no ASCT).
Both groups had second WBLD CT and were compared for the osteolytic lesions concerning size and site.
Results : 20 patients were included in the study (12 males, 8 females), 8 treated with chemotherapeutic protocols (mainly bortezomib based) (group A) while 12 patients underwent ASCT during their course of treatment (group B). The improved score was found only in two patients, one in each group.
Conclusion : myeloma bone disease needs to be assessed initially and promptly prevented and treated since it increases morbidity and mortality. Using newer imaging modalities like WBLD CT, MRI, PET scan is encouraged over conventional X ray skeletal survey.

Background : The thyroid gland and its hormones participate and have a critical part in the development and function of different parts of the body like the kidney, which is the most important site of renin synthesis and release which is followed by angiotensin and aldosterone formation. As needs are; any abnormality in this gland’s function can harm the Renin-Angiotensin -Aldosterone System.
We aimed to discover the effects of using an Angiotensin Receptor Blocker (Olmesartan) on the Renin-Angiotensin-Aldosterone System (RAAS) in rats with abnormal thyroid functions.
Methods : Thirty rats were used and three groups were formed. 6 rats (First group) were the control. 12 rats (Second group) was the hypothyroid group (6 rats control, 6 rats given Olmesartan). 12 rats (the Third group) was the hyperthyroid group (6 rats control, 6 rats given Olmesartan).
L-Thyroxine and Propylthiouracil (PTU) were given orally daily for induction of hyperthyroidism and hypothyroidism respectively.
Blood pressure measurement was done on days 1 and 40th day of the study. The rats were sacrificed on day 40th of the study.
Results : In hyperthyroid rats, T4 was raised and the use of Olmesartan on these rats caused a lowering of this parameter. Renin levels increased in hyperthyroid rats treated with Olmesartan. Angiotensin I increased in hyperthyroid rats. Systolic BP increased in hyperthyroid rats and the use of Olmesartan on these rats caused a lowering of this parameter. Diastolic BP and Mean BP both increased in the hyperthyroid rats.
T3 and T4 levels dropped and TSH increased in hypothyroid and hypothyroid treated with Olmesartan rats. The level of Renin decreased in hypothyroid rats and increased in Olmesartan-treated rats. Angiotensin I decreased in hypothyroid and Olmesartan-treated hypothyroid rats. Blood Pressure components decreased in both hypothyroid and hypothyroid treated with Olmesartan rats.
Conclusions : Olmesartan was able to decrease T4 level along with Systolic BP in hyperthyroid rats. It also decreased Angiotensin I and Blood Pressure components in hypothyroid rats.

Background: Polycythemia Vera (PV) is a myeloproliferative neoplastic disorder involving uncontrolled red blood cell production resulting in elevated red blood cell (RBC) mass. There is a signaling defect leading to an abnormal response to growth factors, and the abnormal clonal line interferes with normal lineage proliferation. The Janus kinase-2 (JAK2) gene involved with intracellular signaling is mutated in 90% of cases of PV. It can occur in all age groups, but the median age of diagnosis is 60 years. Thrombosis considered as the most common cause for morbidity and mortality.
Aim of study: To review the clinical characteristics of a sample of PV patients and their current treatment in addition to assessment of frequency of development of thrombotic events while on treatment.
Patients and method: A hospital based retrospective study was conducted in the hematology outpatient's clinic from different centers in Iraq over a period of 11months (from January 2020 till November 2020). Patient's age more than 18 years old with duration of the disease more than 6 months and all of them were positive for JAKII V617F mutations were included in this study while excluding those who were negative for this mutation. The patients were divided in to low and high risk based on age and leukocyte counts and history of previous thrombosis and presence of cardiovascular risk factors. The response and resistance to treatment with hydroxyurea were evaluated according to ELN definition.
Result: Thirty patients were enrolled in this study. The median age was 60.6±11 years, ranging between 35-78 years. The mean duration of disease was 54± 5.5 months. Headache was the predominant symptom observed in 96.7%, pruritus was experienced in 63.3%.Splenomegaly was seen in 46.7% .Thrombosis at time of diagnosis happened in 13.4%of cases. The most common complication that occurred in this study group was thrombosis in 20% of patients ,16.6% progressed to myelofibrosis and 63.3% of patients were controlled by treatment.
Conclusion: The demographic and some of characteristic of Iraqi PV patients are similar to those from other countries. A good number of patients were controlled with hydroxyurea. Thrombosis is still the commonest complication in patients with PV and occurred mainly in the first 4 years since diagnosis of polycythemia Vera. Median time for development of myelofibrosis was more than 10 year.

Background : Fractional CO2 laser resurfacing in the treatment of acne scars, attempts to reduce the adverse effect of laser resurfacing by creating microscopic injury zones to the dermis with skipped interval areas.
Aim of the study : The purpose of this study is to compare the safety and efficacy of high pulse energy (70 mJ) and low pulse energy (45 mJ) of fractional CO2 laser resurfacing in the treatment of facial acne scars.
Patients and Methods : Twenty patients with moderate to severe atrophic acne scars were treated with three sessions of fractional CO2 laser resurfacing at four-week intervals with high and low energy levels applied to each side of the face separately. The severity of acne scars at baseline and after treatment was assessed using Goodman and Baron’s qualitative scar grading system. Patient satisfaction score was obtained using a quartile grading scale.
Results : The severity of acne scars on both sides was comparable to each other before the treatment (p = 0.643). At the final assessment, both sides with high and low energy levels demonstrated an excellent response (p = 0.000). However, the difference between the mean final scores of both sides was not significant (p = 0.731). The most frequently reported side effects were crustation and erythema. Crustation lasted longer on the right side (mean = 6.75 days) whereas for the left side (mean = 5.45 days). Erythema was transient and only in four cases persisted beyond a week (right side mean = 10.5 days while left side mean = 8.75 days)
Conclusions : Both high energy (70 mJ/pulse) and low energy (45 mJ/pulse) CO2 fractional laser resurfacing of acne scar results in satisfactory outcomes with no statistically significant differences. While the duration of side effects (crustation and erythema) was increased slightly with higher fluence.

Background: Ovarian cancer is third gynecologic cancer after uterine and cervical cancer . It is heterogeneous disease with different in clinical features and outcome. It is a group of many subtypes with variation in biological features that lead to differences in response to treatments, survival and recurrence rates.
Aim: This study aims to detect the frequency of histological types of primary malignant ovarian tumors and to find it\'s clinicopathological correlation.
Subject and Methods: The retrospective cross sectional study done from 1st of July 2020 to 1st August 2020 on data of forty cases of primary malignant ovarian tumors who were diagnosed during the last three years (from 2017 to 2020) in Mosul hospitals labs and private labs.
Results: Two thirds of cases 72.5% were surface epithelial tumors , followed by germ cell tumors 15% and sex cord‑stromal tumors 12.5% .The serous cystadenocarcinoma was the most common histological type in this study .About one third of the cases 30 %were seen in 51–60 years of age group, most of tumors unilateral with solid cystic in nature .The largest diameter shows in mucinous adenocarcinoma . Pelvic mass was the most presenting sign of ovarian cancer .
Conclusion: Malignant surface epithelial tumors comprises the most common type of ovarian cancer and of which serous carcinoma considered the main subtype followed by mucinous cystadenocarcinoma . Advancing age increased the possibility of malignant transformation and most of cases occur over 50 years old especially the cases of surface epithelial type , most of tumors unilateral with solid cystic in nature , pelvic mass was the most presenting sign of ovarian cancer .

Background : Primary myelofibrosis is a Philadelphia-negative myeloproliferative neoplasm(MPN) with predominant proliferation of megakaryocytes and granulocytes in the bone marrow characterized by initial proliferative phase, followed by a reactive deposition of fibrous connective tissue in the bone marrow.
Objectives : To evaluate the clinical and laboratory data in primary myellofibrosis and to correlate the genetic disorders with clinical and other laboratory parameters.
Setting : This case series study conducted at Ibn-Sina Teaching Hospital/Outpatients Hematology Department from November 2019 to April 2020.
Patients and method : Total fifteen patients with primary myelofibrosis included in this case series (retrospective and prospective) study. The records of old cases were reviewed from patients for clinical history, clinical examination, previous blood counts, bone marrow study and genetic study. For new cases clinical history and physical examinations were noted, ten mls of venous blood were aspirated from patients (new cases) by clean venipuncture and delivered into sterile EDTA and gel tubes for doing complete blood pictures, genetic study (JAK2) and biochemical tests. Data were collected and analyzed by using SPSS software version 24.
Result : The males were (60%) of patients and females were (40%) with male to female ratio was 1.5:1, their age ranged from 43-75 years with a mean of 59.3 years. The most common complains were fatigue (86.7%), fullness in the abdomen (73.3%) and constitutional symptoms (66.7-80%). All patients(100%) had splenomegaly at presentation. The total mean Hb was 8.2 g/dl with a range of 4.7-12.5 g/dl. Leukocytosis had been observed in (40%) of patients, while thrombocytosis was found in (26.6%) of patients. Compared in hematological parameters in PMF patients with JAK2 Positive and JAK2 Negative, it was found that MPV significantly increased in JAK2 positive patients with p-value 0.03 .
Conclusion : old age groups (55-64 years) were commonly affected by primary myelofibrosis and males were predominance over females. The most common complains were fatigue and constitutional symptoms, while splenomegaly was the most common clinical sign. The mean platelets volume (MPV) significantly increased in JAK2 positive patients with p-value 0.03.

Objective: The current research aims to assess the acute behavioral toxicity and brain histological changes of ceftriaxone in chicks as a biological model.
Methods: The acute IM median lethal dose (LD50) by Dexon method was obtained during the first day. The scoring of toxicity was estimated in the open-field activity and body-weight was measured. The acute toxic effects of ceftriaxone on brain tissue were recorded.
Results: The IM ceftriaxone LD50 value in chicks was 2131mg/kg. Intramuscular administration of ceftriaxone at doses of 0.532, 1.065 and 1.598 mg/kg caused signs of toxicity such as dropping of wings, eyelids closure, decreased movements and gasping. Ceftriaxone caused a statistically significant decrement in the body weight, decreased activity in the open field experiment represented by delay in movement, and decrease in the crossing lines. The brain showed histopathological changes such as congestion, bleeding and inflammatory cell infiltration. The lesion was more severe when exposed to high concentrations especially during the first 24 hours.
Conclusion: The results of the current study demonstrated that ceftriaxone caused behavioral toxic effects in addition to histological changes in the brain especially with acute administration.

Background: A portion of patients exhibit subsequent cognitive impairment, including memory deficits, after undergoing anesthesia. Despite the wide use and long history of anesthesia, the mechanisms of action that cause loss of consciousness and some of the side-effects, such as temporary amnesia, are not understood.
Methodology: A descriptive cross-sectional study was conducted among patients undergoing surgery in Sulaimani city, and involved 368 patients. Data, in form of questionnaire, have been collected between October 15, 2021 to February 15, 2022. (SPSS) Version 22 was used to analyzed the data.
Results: In this study, 185 (50.3%) were males and 183 (49%) were females, respiratory problem in the form of apnea found in (30.3%) of patients who received (propofol, fentanyl, atracurium) compared to (6.4%) of those patients who received (propofol, (ketamine and fentanyl), atracurium) this difference was significant (P-value < 0.001), (30.3%) of patients who received (propofol, fentanyl, atracurium) (5.4%) of patients who received (thiopental, fentanyl, atracurium) and p value (< 0.001). (28.7 %) of patients who received (propofol, fentanyl, atracurium) recovered late compared to (2.3 %) of patients who received (propofol, (ketamine and fentanyl), atracurium) the difference was significant (P-value < 0.001). systolic blood pressure dropped to below 120 mmhg in (64%) patients and diastolic blood pressure dropped to below 80 mmhg in (62.8%) of patients, who received (propofol, (ketamine and fentanyl), atracurium) and compared to systolic blood pressure that dropped to below 120 mmhg in (74.3%) of patients (74.3%) of patients and diastolic blood pressure dropped to below 80 mmhg in (74.3%) of patients who received (Thiopental, fentanyl, atracurium), the differences were significant (P-value < 0.001). Finally, SpO2 level of (24.3%) of patients, who received (Propofol, (ketamine and fentanyl), atracurium), dropped to below 95% while the SpO2 level of (8.2 %) of patients who received (propofol, fentanyl, atracurium), dropped to below 95% whereas the SpO2 level of (74.3%) of patients, who received (Thiopental, fentanyl, atracurium), dropped to below 95%, these differences were significant with (P-value < 0.001).
Conclusion: this study concluded that (propofol, fentanyl, atracurium) can cause respiratory problem in the form of apnea and delay recovery more than the other two sets of anesthetic drugs, while (Thiopental, fentanyl, atracurium) have effect on lowering SpO2 level more than the others sets of anesthetic drugs.

Background: Trauma to the temporalis muscle sometimes associated with the trismus that may interfere with many daily activities like eating, speech and oral hygiene maintenance, so the treatment is necessary.
Aims of study : were to evaluate the effects of local injection of steroids triamcinolone in and around the scar in the temporalis muscle to alleviate the trismus.
Materials and methods : Thirty patients presented with trauma in Al-Salam teaching hospital to the temporal region. The procedure done by using local anesthetic agent injected by dental syringe around the scar. Then 1 ml of triamcinolone acetonide injected directly in the scar area and the injection site covered by surgical dressing. Jaw stretching exercise start immediately after injection and daily basis exercises. Two injections interval about 3 weeks repeated in the scar area. The exercise done four times daily for 10 minutes and lasting for four weeks. The improvement of mouth opening checked every five days and mean taken by measuring the inter incisal distance by a ruler. The follow up period continues for 3 months after treatment.
Results : There is significant post-operative improvement of mouth opening and the range of inter incisal distance became about 2-4 cm, The patients who start treatment within first two months after trauma show significant improvement in comparison with those who start treatment after 3 months were there is a certain relapse in spite of prolong time and frequency of muscle stretching exercise.
Conclusions : Post-traumatic trismus can be treated by early management of local steroid injection along with jaw stretching exercise for masticatory muscle if started in proliferating phase of wound healing.

Background : Paper currencies are widely exchanged, and because they are exchanged from one place to another and from one person to another, they can serve as ways of transmission of multi-resistant bacterial diseases.
Objective : The aim of the study is to isolate bacterial contamination in Iraqi currency and determine their antibiotic resistance in Mosul City.
Materials and Methods : The 30 samples of paper currency were collected from five local sources from the population of the community and examined using bacterial cultivation. The developing colonies on the selective culture media were identified using the gram stain and the biochemical tests. The bacterial isolates resistance for twelve standard antibiotics were tested according to clinical and laboratory institute guidelines.
Results : out of 30 samples of collected paper currencies, 27 (90%) paper currency were contaminated with bacteria, 16 paper currency containing different mixed culture isolates. 48 bacterial isolates ,37 (77%) Gram-negative bacteria and 11 (22.91 %) Gram-positive bacteria were identified belonging to Seven bacterial species, out of 48 bacterial species isolated, the E. coli represent (11) (36.67%); Salmonella (11) (36.67%); Klebsiella (7) (23.34%), Coagulase Negative staphylococcus (7) (23.34%), Staph. aureus (4) (13.34%), Pseudomonas. aeroginosa (4) (13.34%), and Proteus. spp (4) (13.34%). All the isolated strains revealed high resistance to several antibiotics such as Bacitracin, Methicillin, Cefixime, Erythromycin, Azithromycin, while all isolated showed susceptibility of (100%) to Impenime, moderate to sensitively to Amoxiclav and Nitrofurantoin, Trimethoprim-Sulfamethoxazole,
Conclusion : The Iraqi currency notes in circulation are contaminated with several bacteria species, the majority of which are resistant to commonly used antibiotics, posing risks and public health exposures to the community and individuals handling currency notes.

Brunner's gland adenoma (BGA) is a rare benign tumor of the duodenum, it is most found during routine esophagogastroduodenoscopy (EGD).
a 52-year-old male patient presented with melena and severe anemia, EGD showed a large wide base polypoidal lesion arise from the anterior wall of duodenal bulb, biopsy taken by biopsy forceps, revealed BGA.
After patient's consent, EGD and Endolooping done aiming for ischemia and autoamputation, 2 weeks later I repeat EGD with complete loss of duodenal lesion, we report this technique for the first time to treat large BGA.

Pneumocystis Jirovecii is a unique yeast-like fungus (previously named Pneumocystis carinii). It has been demonstrated as a predominant cause of intrapulmonary and rarely extra-pulmonary infection and a significant cause of morbidity and mortality in immunocompromised patients with and without AIDS. Pneumocystis jirovecii was classified previously as protozoan endoparasite, and then reclassified as a fungus, based on nucleic acid analysis and biochemical characteristics. No successful cultural method for the organism had been preceded yet. Direct microscopic identification of the organism in biopsies or inspired materials is the method of choice for diagnosing the organism. Advanced molecular techniques offer a high sensitivity and specificity in P. Jirovecii diagnosis. Sulfa-based medicines have been shown effectiveness in P. Jirovecii infections treatment.
Aim of this review to provide an updated knowledge on the role of P. jirovecii as a human pathogen.

Background : One of the most prevalent intracellular protozoan parasites, is Toxoplasma gondii, which can infect humans as well as a variety of mammals and is the main cause of toxoplasmosis. During the acute stage, the parasite infects numerous organs, and it then selectively creates cysts in the brain, which causes many psychological disorders, including schizophrenia.
Aim of the study : This review's objective is to shed light on toxoplasmosis caused by the T. gondii parasite and its association with neurological disorders, such as schizophrenia.
Conclusion : Numerous studies indicate that T. gondii, once localized in the brain, can increase the amount of dopamine that is available for processing motivation and pleasure.
Certain alterations in the chemical messengers are employed by the connection between neurons in the brain.
It was shown that schizophrenia, depression, suicide attempts, and other neuropsychiatric disorders are all related to seropositivity for the intracellular parasite, T. gondii.

Background: Nurses play a significant part in avoiding and managing the transmission of an illness. All nurses show leadership in infection prevention control by implementing appropriate and prompt infection control measures utilizing their knowledge, skills, and judgments in all roles and settings.
Study aims: The aims of study to evaluate knowledge and attitude of nurses about infection preventive measures, and to describe relationship between socio-demographic characteristics and nurses level of knowledge and attitude.
Material and Method: A cross-sectional descriptive study design included (320) of nurses staff selected from Imam Al-Sadiq Hospital in Babil City. Sampling technique were non-probability (convenience sample). Data collection was through direct interview technique with each participant from March 2022 to July 2022. Study instrument was included socio-demographic, knowledge and attitude of nurses. Data analysis was used statistical package of social sciences (SPSS) ver. (25), which included frequency, percent and Chi-square.
Results: Almost of items related to knowledge and attitude of nurses about infection prevention measures the answer were know and always. Highly statistical significant association between items related to the knowledge and attitude of nurse's with age, gender, educational level, experience years, catch communicable disease.
Conclusion: Study concluded that knowledge of nurses were good and their attitude were not good, as well as found highly statistical significant relationship between items related to the knowledge and attitude of nurses and socio-demographic characteristics.