Ministry of Higher Education and Scientific Research University of Kirkuk - College of Medicine
ISSN: 2308 - 6270
Journal of Kirkuk Medical College
Vol. 1 No. 2 December 2013 [email protected] 009647481463575
JKMC Journal of Kirkuk Medical College Published by Medical College, Kirkuk University, Kirkuk, Iraq Vol. 1, No. 2, Dec. 2013 ISSN: 2308-6270
Editorial Board
Editor in chief: Prof. Ayla Khedher Ghalib Kahya FIBMS Deputy in chief: Asst. Prof. Zeyad Mohammed Sadiq FIBMS Secretary: Lect. Raad Hassan Najim FIBMS, MRCP Editorial Board: Prof. Mohammed Mustafa Mohammed PhD Asst. Prof. Luay Shihab Ahmed FIBMS, FRCS Asst. Prof. Saadoun Dawood Ahmed FIBMS Asst. Prof. Dhaher Hameed Bra FIBMS Advisory board: Prof. Hikmat Abdul-Rassul Hatim FRCS Prof. Hama Najim Aljaf FRCP
Prof. Najimeldeen Karim MD Prof. Faris Baker Alsawaf MRCP
Prof. Ali Mohammed Jawad CABM Prof. Noorhan Shakir Mahao FIBMS
Prof. Mosa Mahmood Marbut PhD Prof. Budoor Abdulkadir Alraheem MRCpath
Prof. Tahir Abdulla Hawrami CABS Prof. Mohammed Sharif Abdulla MRCP
Prof. Tariq Alhadeethi PhD
Secretary Officer: Hussein Farooq Shareef Journal of Kirkuk Medical College (JKMC)
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The Journal of Kirkuk Medical College is a biannual journal published by the college of medicine of Kirkuk University. The journal welcomes contributions from readers in Iraq and outside Iraq. The contributions will be reviewed by the editorial board and evaluated by selected reviewers in appropriate specialties.
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Vol. 1, No. 2, 2013
Journal of Kirkuk Medical College (JKMC)
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Vol. 1, No. 2, 2013
Journal of Kirkuk Medical College
No. Paper Title Page 1 Detection of Trichomonas Vaginalis among Females Attending Private 1 Gynaecological Clinics in Kirkuk Province Using Different Laboratory Methods Yahya J. Salman Esraa A. Mohammed 2 Hypospadias Fistula Repair; Should A Stent be Left? 9 Ali A. Ali 3 Urinary Tract Infection among Diabetic Women in Kirkuk City 14 Dilshad S. Mohammed 4 The Effect of Plaster Immobilization on the Proprioception of the Limb 23 Adnan A. Faraj Mohammad H. Elanbari 5 Deferoxamine vs. Deferasirox in the Treatment of Thalassemia Major with Iron 30 Overload: Retrospective Study in Thalassemia Center, Kirkuk, Iraq Jamal Q. Weli Mohammed S. Mohammed 6 Maternal Serum Creatine Kinase and Single Serum Progesterone Measurement 37 as Predictors of Ectopic Pregnancy Aseel G. Rifat Maha M. Al-Bayati Abdul Wahab R. Hamad 7 Development of Chronic Conjunctival Swelling in Association with Congenital 48 Lymphedema Abdulhameed A. Hassan Brian Campolattaro Francine Beli 8 Evaluation of the Employment of Four Laboratory Diagnostic Methods in 52 Detecting of Giardia Lamblia among Children in Kirkuk City Yahya J. Salman Maha I. Mussttafa 9 Management of Missile Injuries of the Knee 61 Adnan A. Faraj 10 An Epidemiological Study of Irritable Bowel Syndrome among Students of 68 Medical and Nursing Colleges in Kirkuk University Dilshad S. Mohammed Amanj M. Salih Mohammed M. Mohammed 11 Correlation of Handedness with High Cerebral Function 74 Osama H. Othman Mohammed M. Mohammed Summer S. Abdulhussain 12 Knowledge of Women Attending Two Primary Health Care Centers/ Sulaimany 81 City/ Iraq Regarding Breast Cancer Bushra M. Ali
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Detection of Trichomonas vaginalis among females attending private Yahya Jirjees Salman gynaecological clinics in Kirkuk Province using different laboratory methods.
Detection of Trichomonas vaginalis among Females Attending Private Gynaecological Clinics in Kirkuk Province Using Different Laboratory Methods. Yahya Jirjees Salman, Esraa Abdul Kareem Department of Microbiology, Department of Obstetrics and Gynecology (College of Medicine/ Kirkuk University). Abstract: Background: Trichomonas vaginalis infection is a common sexually transmitted protozoal infection and is associated with several adverse health outcomes, such as preterm birth, delivery of a low–birth weight infant, and facilitation of sexual transmission of human immunodeficiency virus. The annual incidence rate in Iraq has been estimated range between 1.33% to 34%. However; there are no data on the prevalence of trichomoniasis among all reproductive-age women. Patients and methods: Total of 161 women from 15- 61 years who participated in the study form 1st October 2011 to 30th September 2012 with collection of vaginal swab specimens after taking consent from each patient. The vaginal fluids extracted from these swabs were evaluated for the presence of Trichomonas vaginalis using direct wet mount preparations, staining, and cultivation on special culture media. Results: Over all, 33 (20.49%) of 161 women were positive for trichomoniasis with 98.12 % of specificity and 100% of accuracy of wet mount preparations technique for parasite detection. Compared to culture methods that show low sensitivity and specificity P< 0.05 .Women aging from 50 years and above and those aging from 20 to 30 years revealed high rate of trichomoniais than other age groups P<0.05. Relationships between Trichomonas vaginalis distribution and color of vaginal discharges, pH, signs, symptoms, residency of women, occupation, height and body weight were statistically significant, greenish vaginal discharge with pH ranging from 4 to 6 reveal more trichomoniaisis mostly associated with high dominancy of burning sensation and vaginal itches, P < 0.05. While thin and short women from urban area and officers, their vaginal discharges examination show high frequency of trichomoniasis in contrast to other women, P<0.05 . Trichomonas coexists were recognized with high rates of Gardnerella vaginalis and Candida albicans in vaginal discharges especially among women aging from 20 to 30 years, P < 0.05. Conclusions: Under clinical examination women with abnormal vaginal discharges, burning sensation and genital itches should be checked for trichomoniasis using high sensitive and specific tests: direct wet amount preparations and fixed slide stained with giemsa stain, in addition to measuring the pH of the vaginal fluid and performing germ tube and whiff test for detecting vaginal thrush and bacterial vaginosis caused by Candida albicans and Gardnerella vaginal respectively. Key words: Trichomonas, Gardnerella, Candida, Discharge, Sensitivity.
Introduction: Trichomonas vaginalis is a flagellated cervicitis and urethritis in male (1). It is protozoan parasite that causes vaginal predominantly spread via unprotected infections in women, including vaginitis, intercourse with an infected partner.
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Detection of Trichomonas vaginalis among females attending private Yahya Jirjees Salman gynaecological clinics in Kirkuk Province using different laboratory methods.
Potential outcome of this STD in private gynecological clinics of Kirkuk females include pelvic inflammatory province suffering from abnormal disease, ectopic pregnancy, preterm vaginal discharge, itching, dysuria and labor, and predisposing agent for dyspareunia, their age ranges from 15 acquitting human immunodeficiency years to above than 61 years, for each virus (HIV) (2). Investigators have woman complete information were reported epidemiologic associations arranged in a special questionnaire. between trichomonas infection and Body indices such as height and weight subsequent cervical neoplasia and were determined by using metric scale carcinoma (3). Between (10-50%) of and sensitive electrical balance women are asymptomatic, amongst the respectively. After clinical examination, reminder were the commonest two high vaginal swabs were taken from symptoms involving vaginal discharge, each woman, by passing bivalve vaginal vulval itching, dysuria and offensive speculum without using antiseptic odor, a strawberry cervix is visible by lotions. Directly each swab was soaked naked eye in (2%) of cases and in more inside the second cover of swab women on colposcopy (4). Direct containing transport medium, then the observation of a wet smear from swabs were transported using ice pack posterior cervix reveal (40-80%) of box as it was recommended for sample cases whereas culture of organism will collection and preservation till correctly diagnose 95% of cases. processing. Then the first swab was Trichomonas vaginalis trophozoites are preceded for checking (odor, color of sometimes reported on cervical discharge), gram staining, pH cytology, the sensitivity being (60-80%) determination and cultivation for but false positive rate is about (30%), bacterial isolations. While the second for this reason if cervical smear is swab was used for trichomonas suggestive of trichomonal infection, it is cultivation using modified trichomonas worth to confirm the diagnosis by the media (purchased from high media above two methods (5). Other options for company-India) and brain heart broth detecting the parasite include serological supplemented with L-cysteine and tests such as. ELISA, IFA and non- arginine, antimicrobial such as serological test involving parasite Penicillin G (million unit/ml), genome amplification by using Streptomycin (500 000 units/ml) and polymerase chain reaction PCR (6) .This Nystatin (10 mg/100 ml) were added for study aims are to assess the relationship each screw sterile vial before specimen between trichomonal infection in soaking. Culture vials were incubated women and age, laboratory methods anaerobically using anaerobic candle jar usage, body indices, color of vaginal at 35°C, each vial was examined daily discharge, pH of discharge, women for one week before being considered occupations and residency in addition to negative. Statistical analysis using Chi- coexisting with other microorganisms. square and t-student test were applied for determination of variances among Patients and Methods: variable parameters within the study, P- From 1st of October 2011 to 30th of value 0.05 is considered to be September 2012, cross sectional study significant. was carried on 161 women attending
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Detection of Trichomonas vaginalis among females attending private Yahya Jirjees Salman gynaecological clinics in Kirkuk Province using different laboratory methods.
Results: were recorded in samples of short The rate of Trichomoniasis was stature below 155 cm and thin (below (20.49%). According to women age's 55 kg) women. (P value <0.05). higher rate (28.57 %) was found among Table five shows the rate of trichomonal women aging from 51 to 60 years, while infection in relation to residency of low rate (15 %) was recorded among women enrolled in the study, high rate women aging from 41 to 50 years, as (25 %) of trichomonas trophozoites shown in table 1. were recorded in vaginal discharges Table two clarifies the role of laboratory from the center of Kirkuk stains, solutions and cultivation on province(urban area) compare to 12.28 special protozoa media. High rate was % in samples of women from rural area. found by using wet preparation of (0.85 According to women occupations, the %) NaCl followed by (14.9%) and following rates were obtained (66.66 (11.18 %) by using vital stain and %), (24.32%) and (18.18%) in Giemsa stain respectively. While culture adolescent, officers and housewives method reveal low rates of parasite respectively. (P value<0.001), P growth (3.72%) and (1.24%) using value<0.05). modified trichomonas media and The causative agents for vaginal enriched brain heart broth. Wet discharge other than trichomonas was preparation of normal saline exert high Gardnerella vaginalis that recorded in rate of accuracy, specificity and high rate (34%) among women aging sensitivity compared to other from 21 to 30 years while it was not preparations and culturing methods. recorded in specimens of women aging Table three shows that high rates of from 51 to 60 years and those aging 61 trichomonal infection were recorded years and above , (P<0.05). with greenish discharge, pH ranged Fungal thrushes caused by the yeast from 4 to 6 and patients suffering from Candida albicans also seen in some burning sensation, itching and back vaginal discharges as pure or inform of pains the rates were (40 %), (77.78 %), co-exist with trichomonas in the present (62.79%), (62.26%) and (57.17%) study, table 7 reveal high rate of respectively. candidiasis among women aging from With regard to body design (body height 21 to 30 years, while low rate (7.69 %) and weight) in relation to trichomonal was recorded in samples of patients infection table four shows that high rates aging from 11 to 20 years, P <0.05. (22.22%), (31.03%) of trichomonas
Table (1): The distribution of Trichomonas vaginalis among women is according to age. Age Total No. % No. of Positive % of positive Chi2 values groups/years Examined 15---20 33 20.49 6 18.18 0.043 21--- 30 50 31.05 12 24.00 0.51 31--- 40 47 29.19 9 19.14 0.088 41 --- 50 20 12.42 3 15.00 10.04 51--- 60 7 4.34 2 28.57 32.64 * ≥ 61 y 4 2.28 1 25 20.34 Total 161 100 33 20.49 *P<0.05
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Detection of Trichomonas vaginalis among females attending private Yahya Jirjees Salman gynaecological clinics in Kirkuk Province using different laboratory methods.
Table (2): Frequency of Trichomonas vaginalis trophozoites according to lab.stains and cultures, and efficacy of lab.tests for detecting trichomoniasis. Parasitological stains and solutions Culture media
0.85 % NaCl Giemsa Vital stain Modified T.V Enriched stain brain heart No. of Positive cases 33 18 24 6 2 % of positive cases 20.49 11.18 14.90 3.72 1.24 Efficacy of tests Sensitivity % 79.51 54.54 37.5 10.34 3.12 Specificity % 100.00 86.33 76.30 20.76 20.12 Accuracy 98.17 82.29 89.94 74.88 71.55 Total number examined=161 Number positive =33 samples.
Table (3): Distribution of Trichomonas vaginalis according to colour, pH of vaginal discharge and the dominant signs and symptoms. Colour of Total No. No. (%) of pH of vaginal discharge in infected cases Chi2 disgharge exam infected cases. 3-4 4-6 6-8 Values Colorless 24 0 0 0 0 0 0 0.0 White 46 6 (13.04%) 1(16.66%) 4(66.68%) 1(16.16%) 2.42 Green 40 16 (40%)* 2(12.5%) 12(75%) 2(12.5%) 1.0 Yellow 31 9 (29.03%) 1(11.11%) 7(77.78%) 1(11.11%) 4.07 Blood 20 2 (9.52%) 0 0 2(100%) 0 0 5.49 Total 161 33 (20.49%) 4(12.12%) 26(78.78%) 3(9.09%) P<0.05 Signs and symptoms Back Itching Dysuria Burning sensation Sweating Fever pain Frequent No. 28 53 15 43 16 12 Tricomonas +ve 16 33 3 27 5 5 (%) of positive 57.17 62.26 20 62.79 31.25 41.66
Table (4): Trichomonas vaginals distribution according to body length and mass. Body Body height (Cm) Body weight (Kg) parameters Results Tall Moderate Short Total Thin Moderate Obese Total No.Exam. 22 94 45 161 58 73 30 161 Percentage 13.66 58.38 27.96 100 36.02 45.34 18.64 100 No.+ve 4 19 10 33 18 9 6 33 Percentage +ve. 18.18 20.21 22.22* 20.49 31.03** 12.32 20 20.49 Tall is above than 165 cm. Moderate=155-165 cm short= below 155cm Thin= below 55kg Moderate= 56 to70 Kg Obese= above than 70 kg. *, ** P<0.05 Chi 2 *=1.27 **=0.909
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Detection of Trichomonas vaginalis among females attending private Yahya Jirjees Salman gynaecological clinics in Kirkuk Province using different laboratory methods.
Table (5): Frequency of trichomoniasis in relation to women residency. Total No. t-values Residency (%) No. of infected women % Examined P<0.01 Urban 104 64.59 26 25.00 2.36 * Rural 57 35.41 7 12.28 1.9 Total 161 100.0 33 20.49 2.29 Occupations No. Exam % No. of infected women % House wives 121 75.15 ** 22 18.18 Officer 37 22.98 9 24.32 Adolescent 3 1.87 2 66.66 Total 161 100 33 100 *P<0.01 and **P<0.05.
Table (6): Frequency of Gardnerella vaginalis among women according to age. Age Total number Percentages No. Positive Percentages Chi2 values group/years exam % +ve +ve 15---- 20 33 20.49 6 18.18 0.26 21---- 30 50 31.05 17 34.00 8.90 * 31---- 40 47 29.19 6 12.76 2.91 * * 41----50 20 12.42 4 20.00 0.17 51----60 7 4.34 0 0.00 0.00 ≥ 61 4 2.28 0 0.00 0.00 161 100 33 20.49 *, **P<0.05
Table (7): Frequency of Candida albicans among women according to age. Age Total No. No. Positive Percentages percentages Chi2 values groups/years Exam. +ve +ve 15 --- 20 26 16.14 2 7.69 1.077 21 --- 30 57 35.40 15 26.31 1.157 * 31--- 40 46 28.57 10 21.73 0.606 41 --- 50 21 13.04 4 14.28 0.28 51--- 60 7 4.34 1 14.29 0.27 ≥ 61 4 2.28 1 25.00 1.002 Total 161 100 33 20.49 *P<0.05
Discussion: The best way for assessing the efficacy rates recorded by using parasite of any laboratory method should be cultivation in artificial media especially characterized by high rate of sensitivity, brain heart infusion media. From the specificity and accuracy(10), so obtaining results of current study it is obvious that high rate of trichomonaisis in the the all rate of trichomoniasis is high present study by using wet preparation when it was compared to (8.5%), and Giemsa staining procedures are (10.2%), (16.5%) recorded in Kirkuk good guidelines and provident to city by Ali B M, Sulayiman M E, and determination of trichomonaisis among Kadir M A(5,13). Controversy to women in this study. In contrast to low (61.25%) recorded by Karyaghdi T K in
Journal of Kirkuk Medical College 5 Vol. 1, No. 2, 2013
Detection of Trichomonas vaginalis among females attending private Yahya Jirjees Salman gynaecological clinics in Kirkuk Province using different laboratory methods. the same province (14) .The rate of to use of contraception by them as a step trichmoniasis in our study (20.49%) was for reducing the conception rate, also higher than (1.33%), (7.5%), (13.0 %) some females enrolled the study were and (19.6 %) recorded in Tikrit, Mosul, adolescent (18.88%) might be due to Basra and Baghdad respectively by Al- hormonal changes because they were Somaeyday E G, Kharofa W A, Mahdi not adult. Trichomonas vaginalis co- N K, and Alkaysi A A respectively infection with Gardnerella vaginalis (15,16,17). and Candida albicans among women Trichomonaisis rate in Turkey and USA aging from 21 to 30 years mostly related were (40.3 %), (46.9 %) are not in to factorial agents such as vaginal agreement with the rate of present study, douching that reduce normal flora and Suay A, Mete O, Yayla M et al and enhance growth of Gardnerella Shuter J, Bell D and Graham vaginalis, none programmed checking D.Variances in trichomonasis rates can of the intra-uterine device, abuse of be explained by different causes such as antibiotics which increases the differences in size of the study, age propagation of Candida albicans in groups, type of the laboratory methods addition to an frequent sexual activity and hygienic condition and sanitation in by woman or their husband. The result the study community (19,20). High rate of was agreed with that recorded in Kirkuk trichomoniais among old age women and in India by Griebeler M L and may be explained by high rate of Silvina L, Thulker J, Kriplani A and atrophic vaginitis in this age group, Agrawstudyal N respectively(7,22). High while high incidence among women rate of trichomoniasis finding in aging from 21 to 30 years may be greenish vaginal discharges and pH attributed to an excess sexual activity or range from 4 to 6 can be related to to hormonal changes due to usage of scientific fact that this parasite prefer contraception(9). To evaluate role of and survive in pH ranging from 4 to 6 body indices such as body height and (7,23). Regarding more dominancy signs weight, the high rate of trichomonas and symptoms burning sensation and frequency among short stature and thin itching in the present study can be weight compare to other design of interpreted by the parasite colonization women can be explained by heavy in the vagina, surface trichomonad infection of trichomoniasis and other protein and movement by the aid of microorganisms such as Gardnerella anterior four flagella, in addition to vaginalis and Candida albicans which axostyle that extend outside of the increases the period of illness definitely parasite causing irritation of the lining that influence immune system that tissue of the vagina and evoking mast becomes weak. Statistical significant cells for secretion the chemo-tactic relationships between trichomonas substances which had role in increasing frequency among women from urban the IgE level mostly ended by pruritus, area and among house wives in the erosions and sever genital itches(5). present study against with that recorded in Kirkuk by Ali B M and that recorded Conclusions: in Al-Najaf by Al-Zubaidy K GH(5,21). Under clinical examination women with High occurrence of trichomoniasis abnormal vaginal discharges, burning among officer women may be attributed sensation and genital itches should be checked for trichomoniasis using high Journal of Kirkuk Medical College 6 Vol. 1, No. 2, 2013
Detection of Trichomonas vaginalis among females attending private Yahya Jirjees Salman gynaecological clinics in Kirkuk Province using different laboratory methods. sensitive and specific tests: direct wet performing germ tube and whiff test for amount preparations and fixed slide detecting vaginal thrush and bacterial stained with Giemsa stain an addition to vaginosis caused by Candida albicans adjusting the pH of the vagina and and Gardnerella vaginal respectively.
References: [1]. Moodley P, Wilkinson D, Connolly C, peripheral laboratories .Regional office Moodley J, Sturm AW. Trichomonas Alexandria Egypt 1995.1-7. vaginalisis associated with pelvic [11]. Taher J H. Epidemiological and inflammatory disease in women infected biological viability in clinical isolates of with human immunodeficiency virus. Clin Trichomonas vaginalis among women in Infect Dis 2002; 34: 519-522. Najaf/Iraq during 1999 to 2008.Kerbala [2]. Kissinger P, Amedee A, Clark RA, Journal of Pharmaceutical Sciences. Dumestre J, Theall KP, Myers L, Hagensee [12]. Sulayiman M E.Epidemiological ME, Farley TA, Martin DH. Trichomonas study of Trichomonas vaginalis and some vaginalis treatment reduces vaginal HIV-1 associated bacteria and effects of some shedding. Sex Transm Dis 2009; 36: 11-16. herbal extracts on the parasite in-vitro in [3]. Viikki M, Pukkala E, Nieminen P, Kirkuk city.M.Sc.thesis.College of Hakama M. Gynaecological infections as Sci.Tikrit Univ.2008. risk determinants of subsequent cervical [13]. Kadir M A;Salehy A and Hammad neoplasia. ActaOncol 2000; 39: 71-75. EE. Studies on Trichomonas vaginalis in [4]. Abdulazeez, A, Alo E, Livingstone R. Erbil Teaching Hospital. Epidemiology of urinogenital 1988.J.Fac.Med.Baghdad; 83-88. trichomoniasisin a north-eastern State, [14]. Karyaghdi T K. The efficacy of Nigeria. The Internet J Parasitic Dis 2007; 2 laboratory methods in detecting protozoan (2). parasites among people in Kirkuk Province. [5]. Ali B M. Relationship between M.Sc.thesis. College Sci .Kirkuk University Trichomonas vaginalis and other genital 2013. infectious agents among women in Kirkuk [15]. Al-Somaeyday E G. Prevalence of and Tikritcities.M.Sc.thesis,College of Trichomonas vaginalis among women in Sci.Tikrit Unev.2008. Tikrit city and the effect of some herbal [6]. Jamali R, Zareikar R, Kazemi A, extract on the. parasite. M, Yousefee S, Ghazanchaei A, Estakhri Sc.thesis.Coll.Educ.girl.Tikrit. University Rasoul, Asgharzadeh M. Diagnosis of 2006.. Trichomonas vaginalis infection using PCR [16]. Kharofa W A.an epidemiological method compared to culture and wet mount study and cultivation of microscopy. Int Med J 2006; 5. Trichomonasvaginalis in Mosul city..M.Sc. [7]. Griebeler ML and Silvina L. Self- thesis.Coll.Sci.Mosul Univ 1999. reported versus measured height and weight [17]. Mahdi N K; gany Z H and Sharief M. in hispanic and non-hispanic menopausal risk factor for vaginal trichomoniasis women. J Women’s Health (Larchmt). 2011 among women in Basra.Iraqi Med. Health April; 20(4): 599–604. J.2001;7(6): 918-924. [8]. World Health Organization. Basic [18]. Alkaysi A A .The incidence of laboratory procedures in medical Trichomonas vaginalis among female with bacteriology.1st edit. Geneva .2003:37-39. vaginal discharge.. M.Sc. thesis, Coll. Med [9]. World Health Organization. Basic .Baghdad Univ 1994. laboratory procedures in clinical [19]. Suay A; Mete O; Yayla M and Elei S. bacteriology.1st edit.Geneva.1991:52-58. Relationship between trichomoniasis and [10]. World Health Organization.basic of menstruation T.Protozol J.1995; 19(3):334- quality assurance for laboratories and 339. (Abstract in English).
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Detection of Trichomonas vaginalis among females attending private gynaecological clinics in Kirkuk Province using different laboratory methods. Yahya Jirjees Salman
[20]. Shuter J, Bell D and Graham D. Rates test in syndromic approach of abnormal and risk factors of Trichomoniasis among vaginal discharge. Indian J Med Res. 2010 pregnant women in New York City. Mar; 131:445-8 Sex.Trans.Dis.1998; 25: 303-307. [23]. Sobel J D, NyirjesyP ,Kessary H and [21]. Al-Zubaidy K GH. Sexually Ferris D G. Use of the VS-sense swab in transmitted diseases among women with diagnosing vulvo-vaginitis. J Women’s abnormal vaginal discharges in Al-Najaf Health (Larchmt) . 2009 Sep; 18 (9):1467- Province. 2001. M.Sc. thesis [24]. Sweet R L and Gibbs r S. Infectious Coll.Med.Kufa Univ. disease of the female genital tract.4th .edit. [22]. Thulkar J; Kriplani A and Lippincott, Williams and Agrawstudyal N. Utility of pH test & Whiff Wilkins.2004.USA:57-100.
Journal of Kirkuk Medical College 8 Vol. 1, No. 2, 2013
Hypospadias fistula repair; should a stent be left? Ali Adwal Ali
Hypospadias Fistula Repair; Should a Stent be Left?
Ali Adwal Ali Department of Surgery, College of Medicine, University of Kirkuk
Abstract: Objectives: to evaluate the role of stenting in a children undergoing fistula repair, as a stent free fistula repair has been successful without prolonged discomfort. Patients and methods: The study included all Hypospadias repaired patients with fistula formation; both primary surgery and fistula repair surgery done by one surgeon, between July 2005 and September 2011, patients were prospetively randomized at the end of surgery to either leaving a stent (folyes catheter) for one week or no stent at all. The study included 74 patients (40 stented and 34 not stented). Median age of patients was 6 years, range (4-7) years. For the stented group, the stent placed in the bladder for continuous bladder drainage. Results: The median range follow up was 8 months (6-12) months. Voiding was painful in the first week, in 5(12.5%) and 13(38%) of the stented and unstented patients respectively, none of the stented patients developed urinary retention, compared with 7(20.5%) patients in the unstented group. Although the re-operation rate was 0% for the stented group, while it was 20.5% for unstented group, the difference was statistically not significant (p> 0.05). Conclusions: The use of stent in Hypospadias urethrocutaneous fistula repair is advantageous, it eliminates the risk of urinary retention and extravasations, reducing the overall patient discomfort adding to that, lower re-operation rate. Key Words: Urethrocutaneous fistula, Hypospadias, Catheter.
Introduction: Hypospadias has been recognized as a The most common complication after surgically treatable malformation for Hypospadias repair is urethrocutaneous nearly two millennia. Physicians of both fistula with a reported incidence of (12.1 the Hellenic (Heliodorus and Antyllus) % - 50%) (8, 9). and Roman worlds (Celsus and Galen) Many techniques have been described described the condition as well as its for correction of urethrocutaneous possible surgical remedies (1, 2, 3). fistula. Where enough intact penile skin Needless to say, surgical techniques is available, simple closure of a fistula is have evolved with time. The most used. Skin flaps are used for repairing significant recent advance in this fistulas that are too large for simple evolution occurred in 1994 with closure, provided that the local skin is Snodgrass description of the tabularized pliable and adequate (10). incised plate urethroplasty (TIP) Snodgrass (11), in his initial description technique (4). Since the initial for Hypospadias repair used a silicon description in cases with distal catheter for 10 days. Significant Hypospadias, TIP urethroplasty has now morbidity has been associated with been applied with notable success to urethral stent including infection, both proximal and reoperative bladder spasm. Furthermore, indwelling Hypospadias repair surgeries (5,6,7). catheter require a special care to avoid Journal of Kirkuk Medical College 9 Vol. 1, No. 2, 2013
Hypospadias fistula repair; should a stent be left? Ali Adwal Ali accidental forcible slippage or urinary bag. In the unstented group the inadvertent pressure on the urethra (12), bladder was emptied and the catheter in contrast , repair with no bladder was removed at the end of the surgical drainage is associated with total procedure, allowing the patient to void ambulation and short hospital stay(13). spontaneously. Penile block with 0.25% Nevertheless, a stent free repair may bupivacaine instead of caudal analgesia compromise the comfort and increase was used in all patients, to avoid drug the incidence of urinary retention after induced urinary retention. Rectal surgery (14, 15, 16). Disagreement on the acetaminophen was given as post- need for urethral stent in reparative operative analgesia. surgery remains and there use continues The early evaluation includes to be dictated according to the surgeons’ observation for bleeding, infection, and preference (17,18).Steckler and Zaontz bladder instability, accidental forcible reported excellent results with a stent slippage of the stent, painful voiding free repair (13). urinary retention and extravasations. Patients were then examined weekly in Patients and Methods: the first month then monthly in the first The study included all Hypospadias 3 months and when necessary thereafter. urethrocutaneous fistula patients For both groups most of the fistulae between July 2005- September 2011, were located in proximal shaft and mid who underwent surgery in Azadi shaft regions (44 patients) of total 74 teaching hospital/ Kirkuk. patients (table 1), (table 2). The surgical technique for small fistulae (<2 mm) was excision of fistula Results: tract; inverted epithelial continuous 6-0 The median range of the age of the vicryl suturing, 2nd layer interrupted patients was 6 (4-7) years; the post- suturing of fascia with 6-0 vicryl and operative complications in both groups last layer of skin suturing with are given in (table 3). interrupted 6-0 vicryl suture; all layers Regarding the stented group, 3 patients must be sutured water tight. While the developed bladder instability during the surgical technique for large fistulae (>2 first 48 hours of surgery and mm) was releasing of the epithelial disappeared with hot sponges and pain margins and suturing without tension control. None of the stented patients with 6-0 continuous vicryl suture, fascia developed urinary retention or flap from one side of the fistula sutured extravasations of urine, while unstented with interrupted 6-0 vicryl as a 2nd layer, group had both urinary retention in 7 while skin rotation flap from opposite patients, extravasation in 6 patients and side sutured with interrupted 6-0 vicryl bladder instability in 1 patient only. as a third layer, all layers of suturing Patients with urinary retention and/or must be water tight. extravasations were managed by Patients were randomized at the end of urethral catheterization, without the study in to 2 groups, stented 40 anesthesia, for 2-5 days and no children and unstented 34 children. In cystostomy were required. From 13 the stented group a soft plastic urethral patients who required urethral catheter of suitable size (Foleys catheterization, 7 of them developed catheter) was passed in to the bladder fistula; the correlation between fistula for one week, catheter connected to formation and urethral manipulation was Journal of Kirkuk Medical College 10 Vol. 1, No. 2, 2013
Hypospadias fistula repair; should a stent be left? Ali Adwal Ali statistically significant (p<0.001). 2 patients and on the 3rd day in 2 Urinary retention is defined as full patients , no retention or extravasations bladder on physical examination was diagnosed after the 3rd day of associated with pain. Urinary retention surgery. Although the reoperation rate was diagnosed the night after surgery was nil in the stented group; while it (few hours post operatively) in one was 20.5% for the unstented group, the patient; and on the first day (within 24 difference was statistically not hours) in remaining 6 patients. significant (p> 0.05). Urinary extravasations was noted on the first day in one patient, on the 2nd day in
Table (1): Site of fistula in stented group Site number % Penoscrotal 4 10% Proximal penile 8 20% Mid penile 21 52.5% Distal penile 7 17.5%
Table (2): Site of fistula in unstented group Site number % Penoscrotal 7 20.5% Proximal penile 14 41.1% Mid penile 9 26.4% Distal penile 4 11.7%
Table (3): Post-operative complications Bladder spasm Urinary retention extravasation Stented group 3 (7.5%) 0 0 Unstented group 1 (2.9%) 7 (20.5%) 6 (17.6%)
Table (4): Relation of postoperative urethral manipulation and fistula formation. Urethral manipulation Fistula formation Stented patients 0% 0% Unstented patients 13(38.2%) 7(20.5%)
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Hypospadias fistula repair; should a stent be left? Ali Adwal Ali
Discussion: Rabinwtz(19) used an unstented cystostomy was not required, this could Hypospadias repair in 59 boys, be attributed to good lubrication thus achieving excellent functional results preventing the formation of the false with few complications. Buson et al (18) passage by the catheter , in contrast ,The evaluated the surgical outcome of only catheter discomfort in the series stented and unstented Hypospadias was bladder instability; in 3 patients in repair in 102 patients, overall of 65 stented group (7.5%). There was no patients in whom stent was used, three infection, migration or forcible catheter (4.6%) had complications, in contrast to slippage. a complication rate of 18.9% in the Stecker et al (13) evaluated the unstented unstented group. fistula repair in babies; catheterization Hakim et al (17) in a multi-center study was not used and was not necessary. reported excellent results in (97%) of The lack of a stent was not associated 339 fistula repaired patients the results with any urinary retention. Buson et al were not affected by urethral (18) reported a (19%) retention rate in catheterization. Minevich et al (20) unstented fistula repair. reported a single institution of 201 The use of the stent in fistula repair stented fistula repair, the total significantly eliminates the risk of reoperation rate was minimal (1.5%) urinary retention, extravasations and and compared favorably with unstented subsequent urethral manipulation, the repairs .The authors thought that urethral last has been regarded as a potential stenting decreased the risk of fistula cause of fistula formation (18). In the formation while adding only minimal present study there was a significant morbidity. correlation between urethral Controversy remains about the manipulation for urinary retention and indication for urethral stents in fistula or extravasations, and fistula formation, repair. of the 13 patient who required urethral The present results indicate that, catheterization 7 developed although fistula repair can be done urethrocutaneous fistula (table 4). without stent, the complication rate is lower when a stent is left indwelling for Conclusions: 1 week. The overall reoperation rate The overall incidence of discomfort (9.4%) was higher than that in other including bladder spasms dysuria, published series of repaired fistula, but retention, extravasations and subsequent this partly explained by the high urethrocutaneous fistula were (20.5%) reoperation rate in unstented significantly lower in the stented than group. the unstented patients so the use of a Early complications were significantly stent in hypospadias urethrocutaneous more common in unstented patients, fistula repair is advantageous. nearly half of unstented patients References: developed dysuria and catheterization [1]. J.Lascaratos, A. Kostakopoulos, and G. was required in (38.2%) of patients Louras, “penile surgical techniques because of retention and or described by Oribasius (4th century CE),” extravasations. Catheterization was BJU international, 1999: vol, 84, no. 1, pp. possible in these patients and 16-19,
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Hypospadias fistula repair; should a stent be left? Ali Adwal Ali
[2]. E. D. Smith,”The history of [12]. J.G.Borer, S.B. Bauer,C.A. Peters, et Hypospadias”,Pediatric Surgery al,” tabularized incised plate urethroplasty, International, 1997: vol. 12, no. 2-3, pp. 81- expanded use in primary and repeat surgery 85. for Hypospadias”, J Urology, 2001: vol.5, [3]. J. C. Routh, J. J. Wolpert, Tunneled pp.165-181. tunica vaginalis flap for recurrent [13]. R.E. Stecker, M.R. Zaontz, “ stent free urethrocutaneous fistulae. Advances in Thiersch- Duplay Hypospadias repair with urology, 2008: vol. 52, no. 3-5. the Snodgrass modification”, J.Urology, [4]. W. Snodgrass, “Tubularized incised 1997: vol 158, pp.1178-1180. plate urethroplasty for distal Hypospadias”, [14]. W.Snodgrass, M. Koyle, G.Manzoni, The Journal of Urology, 1994: vol. 151, no. et al, “Tubularized incised plate 2, pp.464- 465. Hypospadias repair. Results of multicenter [5]. W. Snodgrass, M. Koyle, “Tubularized experience.” J.Urology, 1996: vol.156, incised plate Hypospadias repair for pp.839-841. proximal Hypospadias” the journal of [15]. W.Snodgrass,” Tubularized incised urology, 1998: vol. 159, no. 6, pp. 2129- plate urethroplasty for distal Hypospadias”, 2131. J Urology, 1994: vol.151, pp. 464-465. [6]. J. G. Borer, C. A. Peters, et al., [16]. R.A. Wheeler, P.S.Malone, D.M. “Tubularized incised plate urethroplasty: Griffiths, D.M.Burge,” The Mathieu expanded use in primary and repeat surgery operation. Is a urethral stent mandatory?” for Hypospadias,” the journal of urology, Br,J.Urology, 1993: vol.71,pp. 492-493. 2001: vol.165, no. 2, pp. 581-585. [17]. S.P.Hakim, A.Merguerian, [7]. W. T. Snodgrass and A. Lorenzo,” R.Rrabinowitz, et al,” Outcome analysis of tabularized incised plate urethroplasty for the modified Mathieu Hypospadias repair: Hypospadias reoperation, ”BJU comparison of stented and unstented International, 2002: vol.89, no.1, pp 98- repairs”, J Urology, 1996: vol. 156, pp. 100. 836-838. [8]. A. Soni, S. Sheoran, “repair of large [18]. H.Boson, D.Smiley, Y.Reinberg, et urethrocutaneous fistula with dartos based al” Distalhypospadias repair without stent: flip flap: Astudy of 23 cases,” Indian J. is it better?” JUrology, 1994: vol.151, P.S., 2006: vol, 40, no.1, pp.34-38. pp.836-838. [9]. G. Yehudain, B. Hirshowitz,” closure of urethral fistula by transverse Y-V [19]. R.Rrabinowitz,”outpatient catheterless advancement flap,” BJU, 1984: vol.56, no. modified Mathieu Hypospadias repair”, 5, pp. 312-314. JUrology, 1987: vol.138, pp.1074-1076, [10]. F. Richter, PA. Pinto,M.K. Hanna,” [20] E.Minevich, B.R.Pecha, J.Wachsman, Management of recurrent urethral fistulas et al,”Mathieu Hypospadias repair: after Hypospadias repair”,Urology.2003: experience in 202 patients”, JUrology, vol,51, no.3, pp.448-451. 1999: vol. 162, pp.2141-2142. [11]. W.T. Snoodgrass,M.T. Nguyen, “Current technique of tabularized incised plate Hypospadias repair”. Urology 2002: vol. 60, pp.157-162.
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Urinary tract infection among diabetic women in Kirkuk city Dilshad Sabir Mohammed
Urinary Tract Infection among Diabetic Women in Kirkuk City
Dilshad Sabir Mohammed Department of Medicine/ College of Medicine/ Kirkuk University
Abstract:
Background: Urinary tract infection (UTI) is the most common of all bacterial infections in diabetes mellitus; it affects persons throughout their life spans. The term UTI encompasses a variety of clinical entities ranging from asymptomatic bacteriuria to cystitis, prostatitis and pyelonephritis. Patients and methods: In the present study, 200 diabetic women,100 of them were at active age group(AAG) their ages range from (25-35)years with mean age of 31 years. Another 100 women were post-menopausal (PM) their ages range from (55-75) years with mean age of 64 years. Two hundred non diabetic women were taken as control group and were divided into 100 at AAG and 100 PM. The patients and control groups were attendant of Kirkuk general hospital. Results: UTI was found to be present in 28 out of 100 cases of AAG diabetic women (p value =0.02) while it presents in 25 out of 100 PM diabetic women (p value =0.04). Also this study shows that 13 out of 25 PM diabetic women received insulin for treatment while 7 out of 25 PM diabetic women received oral antidiabetic drugs, and only 5 out of 25 PM diabetic women didn't receive any treatment (p value=0.03). The present findings shows that 14 out of 28 AAG diabetic women received insulin for treatment, while 8 out of 28 of them received oral antidiabetic drugs and only 6 out of 28 AAG diabetic women didn't receive any treatment (p value =0.043) Conclusion: The prevalence of UTI is higher among diabetic patient compared to non- diabetic patient regardless of age .Diabetes treated with insulin is related to substantial increases in the risk of UTI among both age groups included in the present study. Keywords: UTI, Diabetic, Bacteriuria.
Introduction: Diabetes and its attendant acute and virtually more prone in diabetic patients. chronic complications continue to carry On a population basis, diabetic women, a major health problem worldwide (1). depending on age, are 6–24 times more There is evidence that diabetics are likely than non-diabetic women to be more prone to skin and chest infection admitted for acute pyelonephritis, and than non-diabetic (2). There is also view diabetic men are 3.4–17 times more that urinary tract infections (UTI) are likely than their non-diabetic more common in diabetic patients counterparts to be admitted for the same (3).Urinary tract infection is an important condition(5). clinical problem for people with Despite the frequency and importance of diabetes. this problem, it has received relatively This observation is most apparent in the little attention, and many important increased severity of infection that may scientific and clinical questions remain occur in diabetic patients (4).Serious unanswered. complications of UTI, such as In hospitalized diabetic patient, emphysematous cystitis, pyelonephritis particularly those with multiple organ
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Urinary tract infection among diabetic women in Kirkuk city Dilshad Sabir Mohammed complication the incidence of infection insulin to keep blood glucose levels and true pyelonephritis also appear to be normal, often because the body does increased, partly because of poor not respond well to the insulin. Many bladder function and partly because of people with type 2 diabetes are urinary catheterization. Other clinical asymptomatic, although it is a serious conditions that causing obstruction in condition. Type 2 diabetes is urinary flow or incomplete voiding also becoming more common due to the predispose diabetic patient to infection. growing number of older population In addition, impaired cytokine secretion was increasing obesity, and failure to may contribute to asymptomatic exercise. (6). bacteriuria in diabetic women Gestational diabetes is high blood Urinary tract infection accounts for glucose that develops at any time considerable morbidity among adult during pregnancy in a person who women, Diabetes causes several does not have diabetes. abnormalities of the host defense system Over the years, evidence from many that might result in a higher risk of epidemiological studies have suggested certain infections, including UTI .These that asymptomatic bacteriuria (ASB) include immunologic impairments, such and symptomatic UTIs occur more as impaired migration, intracellular commonly in women with diabetes than killing, phagocytosis, and chemotaxis of in those without diabetes(8). Most of polymorphonuclear leukocytes and these studies, however, were not abnormal T lymphocyte function in prospective cohort designs and are thus diabetic patients and neuropathic subject to multiple biases complications, such as impaired bladder characteristically associated with case- emptying (6). control, retrospective, or cross-sectional In addition, a higher glucose studies. Further, the majority of the data concentration in the urine may create a has been collected in patients with type culture medium for pathogenic 2 diabetes and in women; therefore, data microorganisms. Other important regarding these relationships in type unanswered questions include the 1diabetes and in men are less available. association between glycemic control Recent studies have focused on the risk and the role of asymptomatic relationship of ASB to diabetes (9-11). In bacteriuria as a precursor to UTI in women without diabetes, ASB is diabetic women (7). relatively uncommon and increases risk There are three types of diabetes: of UTI but does not lead to serious (12) Type 1 diabetes is usually diagnosed sequale . Diabetic women have a (2- in childhood. The body makes little or 3) folds higher prevalence of ASB and no insulin, and daily injections of are at risk for developing more serious insulin are required to sustain life. consequences (9, 10). Women with type 2 Without proper daily management, diabetes and are ASB have an increased medical emergencies can arise. risk for development of a symptomatic (13) Type 2 diabetes is far more common UTI , and women with type 1 than type 1 and makes up 90% or diabetes are at an increased risk for more of all cases of diabetes. It usually pyelonephritis and subsequent occurs in adulthood. Here, the impairment of renal function (11). pancreas does not make enough
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Urinary tract infection among diabetic women in Kirkuk city Dilshad Sabir Mohammed
Patients and Methods: control only 7 (7%) show positive urine culture also the table demonstrate that Patients group: among 100 postmenopausal diabetic This case –control study was carried out women 25 (25%) of urine sample gave in outpatient clinic of Kirkuk general positive result while from 100 hospital from March 2005 to September postmenopausal non diabetic normal 2005. The study includes 200 women control only 9 (9%) gave positive divided into 2 groups, first group results. includes 100 diabetic active age group, (Table 2) summarizes the numbers and their ages range from (25-35) years and percentages of positive urine cultures the second group includes100 diabetic among both treated and non-treated postmenopausal women, their ages diabetic postmenopausal and active age range from (55-75) years. The entire group women. patients included in the study have been According to the types of treatment proved to be diabetic by clinical received by the diabetic women which examination and laboratory was either oral antidiabetic agents, investigations. insulin or the patient doesn't receive any Patient's clinical history was treatment seven (28%) of positive urine investigated by Medical specialist. cultures were postmenopausal diabetic Microscopic and culture methods were women whom they received oral done for patients urine samples and antidiabetic agents while 13 (52%) 0f antibiotic sensitivity test were done for positive urine cultures were the isolated microorganisms, the postmenopausal diabetic women microorganisms were identified received insulin and 5 (20%) 0f positive (14) according to Mackie and McCartney , urine cultures were postmenopausal and antimicrobial susceptibility test was diabetic women whom they didn't (15) done according to Bauer et al, . receive any treatment. Among active age diabetic women 8 Control group: (28.57%) of positive urine cultures were Two hundred non-diabetic women were they received oral antidiabetic drugs, 14 chosen as a healthy control, 100 women (50%) of positive urine cultures were of them were at active age and the other they received insulin while only 100 were postmenopausal women, 6(21.42%) of positive urine cultures Isolation, identification and antibiotic were didn't received any treatment. sensitivity of the microorganisms were (Table 3) shows the type of done for their urine samples as with that microorganisms isolated from positive of patients group. urine cultures of postmenopausal Results: diabetic and non-diabetic women. (Table 1) summarizes the number and Escherichia coli were the most percentages of the positive urine microorganisms isolated among diabetic cultures among both active age group and control group followed by and postmenopausal diabetic women klebsiellaspp, staph.aureas and proteus and their related normal control. From spp. respectively. 100 active age group diabetic women 28 (Table 4) demonstrates microorganisms (28%) show positive urine culture while isolated from positive urine cultures of from 100 active age group non diabetic (treated and non-treated) active age
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Urinary tract infection among diabetic women in Kirkuk city Dilshad Sabir Mohammed
group diabetic and non-diabetic women. and control group followed respectively Escherichia coli is the most by klebssiella spp., staph. aureas, microorganism isolated among diabetic pseudomonas spp. and proteus spp.
Table (1): The percentages of positive urine cultures among both patient and control groups. positive urine cultures among positive urine cultures among Age groups P value diabetic patients no. of cases=200 control group no. of cases=200 Post-menopausal 25 (25%) 9 (9%) 0.04 group Active age group 28 (28%) 7 (7%) 0.02
Table (2): The No. of positive urine cultures among both treated and non-treated diabetic women. positive urine cultures positive urine positive urine Diabetic women among diabetic cultures among cultures among P groups women treated with diabetic women diabetic women not value antidiabetic drugs treated with insulin receiving treatment Post-menopausal 7 (28%) 13 (52%) 5 (20%) 0.03 diabetic Active age group 8 (28.57%) 14 (50%) 6 (21.42%) 0.043 diabetic
Table (3): Microorganisms isolated from positive urine cultures of (treated and non-treated) postmenopausal diabetic and non-diabetic group of women. Type of treatment used by post- Type of microorganisms isolated from positive urine cultures menopausal diabetic women with positive urine cultures E .coli Klebsiella spp. Staph. aureas Proteus spp. Hypoglycemic agents 6 (85.7%) 0 1 (14.2%) 0 Insulin 9 (69.2%) 2 (15.3%) 2 (15.3%) 0 Non treated group 4 (80%) 0 1 (20%) 0 Control group 7 (77.77%) 1 (11.11%) 0 1 (11.11%) P value 0.7 0.26 0.9 0.9
Table (4): Microorganisms isolated from positive urine cultures of (treated and non-treated) active age group diabetic and non-diabetic group of women. Types of treatments used by Microorganisms isolated from positive urine cultures active age diabetic women Klebssiella Pseudomonas Proteus E .coli Staph. aureas with positive urine cultures. spp. spp. spp. Hypoglycemic agents 5 (62.5%) 0 2 (25%) 0 1 (12.5%) Insulin 8 (57.1%) 3 (21.4%) 1 (7.1%) 1 (7.1%) 1 (7.1%) Non treated group 4 (66.6%) 1 (16.6%) 1 (16.6%) 0 0 Control group 4 (57.14%) 0 1 (14.28%) 0 2 (28.57%) P value 0.6 0.26 0.27 0.9 0.3
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Urinary tract infection among diabetic women in Kirkuk city Dilshad Sabir Mohammed
Table (5): AST of microorganisms isolated from urine cultures of active age group diabetic women. No. of susceptible isolates to antibiotics
AMC
CRO
CTX
SXT
AM GM
CIP
AK Microorganisms CX
No .of E
isolates
E.coli 17 15 14 14 1 9 9 6 5 4 6 Klebssiella spp. 4 2 2 3 0 1 2 1 1 1 1 Staph.aureas 4 0 1 0 0 3 4 1 1 2 3 P roteus spp. 2 0 1 1 0 0 2 2 1 1 2 Pseudomonas aerogenosa 1 0 0 0 0 1 1 1 1 1 1 AM = Ampicillin AMC = Augmentin CX = Cloxacillin E = Erythromycin G = Gentamicin AK = Amikacin CTX = Cefotaxime CIP = Ciprofloxacin CRO = Ceftriaxone SXT = Trimethoprim + Sulfamethaxazole
Table (6): AST of microorganisms isolated from urine cultures of active age non diabetic women. No. of susceptible isolates to antibiotics
AMC
CRO
CTX
Microorganisms SXT
AM GM
CIP
AK No. of CX
E
isolates
E. coli 4 2 3 3 1 4 3 2 1 3 2 Proteus spp. 2 1 1 1 0 1 2 1 1 1 1 Staph. aureas 1 1 1 1 0 1 1 1 1 0 1
Table (7): AST of microorganisms isolated from urine cultures of post-menopausal diabetic women. No. of susceptible isolates to antibiotics
AMC
CRO
CTX Microorganisms SXT
AM GM
CIP
AK
CX
No .of E
isolates
E. coli 19 16 81 81 3 11 7 5 5 3 6 Klebssiellaspp 2 1 1 2 0 1 1 1 1 1 1 Staph. aureas 4 0 1 0 0 3 4 1 1 2 3
Table (8): AST of microorganisms isolated from urine cultures of post-menopausal non- diabetic women.
No. of susceptible isolates to antibiotics
AMC
CRO
CTX
SXT
AM GM
CIP AK Microorganisms CX Hypoglycemic
No. of E
agents
isolates
E.coli 7 6 6 6 1 4 5 3 5 3 3 Insulin Klebssiella spp. 1 1 1 1 0 1 1 1 1 1 1
Proteus spp. 1 0 0 0 0 1 1 0 0 1 1 Non treated
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Urinary tract infection among diabetic women in Kirkuk city Dilshad Sabir Mohammed group Discussion: negative bacilli because of its proximity Urinary tract infection (UTI) is the most to the anus, and also sexual intercourse common bacterial infection. Acute causes the introduction of bacteria to the Control group uncomplicated UTI occurs in young bladder. So sexually active persons had women with normal genitourinary tracts more significant symptomatic UTI and and, while frequently distressing, is finally due to the absence of prostatic seldom associated with significant secretion which contain bactericidal P value morbidity. Acute pyelonephritis occurs properties. in the same group of women but is a It is noteworthy to notice from (table 1) more serious illness. Complicated UTI that the prevalence of UTI is higher occurs in individuals with functional or among diabetic women compared to structural abnormalities of the non-diabetic patient regardless of age. In genitourinary tract. It may be either both age groups of the present study symptomatic or asymptomatic and may concerning UTI significant difference present with a wide spectrum of clinical was obvious between PM diabetic and illness. The most severe manifestations non-diabetic women and between AAG occur in individuals with trauma or diabetic and non-diabetic women (p- obstruction of the genitourinary tract. value=0.04, 0.02 respectively). Selected groups, including pregnant This results agrees with Balasion et women, diabetic patients, and the al(1997), Kayima et al(1996) Zhanel et elderly, have some unique al(1995) and Epoke et al (2000) (20, 21, 22, characteristics relevant to UTI that may 23). The explanation of these results may require different approaches to be due to: management (16). 1. The presence of significant amount of In the vast majority of UTIs, bacteria glucose in diabetic urine which serves as gain access to the bladder via the favorable media for growth of bacteria urethra. Ascent of bacteria from the (25). bladder may follow and is probably the 2. A change in bacterial adhesion to the pathway for most renal parenchymal uroepithelium partly as a result of infections. The factors that predispose to abnormal intracellular calcium periurethral colonization with gram metabolism which lead to decrease in negative bacilli remain poorly tam horsfall protein which usually understood but probably include adhere to the bacteria and prevent alteration of normal perineal flora by attachment to the uroepithelium is antibiotics, other genital infection such involved in the pathogenesis of UTI. in as by use of contraceptives especially diabetic patients (25). diaphragms and spermicides, small no. 3. Also abnormal intracellular calcium of periurethral bacteria probably gain metabolism which lead to granulocytes entry to the bladder frequently, a dysfunction which promotes attachment process that facilitated in some cases by of bacteria to uroepithelium causing urethral massage during intercourse (17, more infection (25). 18, 19). The higher prevalence of UTI 4. Finally it was found that diabetic among females could be due to, women had a higher mean post void Presence of short urethra in females; the residual bladder volume, an indicator of female urethra appears to be particularly bladder dysfunction and possibly prone to colonization with colonic gram autonomic neuropathy (25).
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Urinary tract infection among diabetic women in Kirkuk city Dilshad Sabir Mohammed
While it is disagreement with one study microorganisms among UTI of diabetic (Lindsay et al 2000) (24), which showed and non-diabetic individuals. that the prevalence of UTI in diabetic The present findings are in agreement outpatient women was no significantly with other studies that demonstrate that higher than in non-diabetic women E. coli was the most frequent outpatient or healthy control (p-value microorganisms isolated from diabetic =0.07) (23). The explanation of these and non-diabetic women (Geerlings SE results may be due to: et al 2002) (27). Significant association was found Although diabetic persons may be more between insulin treated diabetic women susceptible to infection by opportunistic and the prevalence of UTI regardless of microorganisms, it was found that most age as demonstrated in (table 2). Among of their infections were due to typical postmenopausal diabetic treated women uropathogens, which suggest that 13 out of 25 positive urine cultures were diabetes facilitates the same route of treated with insulin while only 7 out of infection as that for UTI in non-diabetic 25 positive urine cultures were PM persons (i.e., ascending infection from women treated with oral antidiabetic urethra). drugs and only 5 out of 25+ve urine cultures from PM diabetic women didn't Conclusion: receive any treatment (p value =0.03) 1. The prevalence of UTI is higher Regarding AAG diabetic women among diabetic patients compared with treated with insulin 14 out of 28 gave non-diabetic patient regardless of age. positive urine cultures and8 out of 28 2. Diabetes treated with insulin is were from AAG treated with oral related to substantial increases in the antidiabetic drugs and only 6 positive risks of UTI among both age groups urine cultures out of 28 from women included in the present study. didn't receive any treatment (p 3. Escherichia coli. Was the most value=0.04). common microorganism that causes UTI These present findings are in agreement in both diabetic and non-diabetic of with other studies demonstrates by different age groups of women. (Turner et al 1999) who stated that 4. UTI should be considered as a women taking insulin were mainly at complication of diabetes in both age higher risk of UTI, possibly because of groups of women included in the present more severe diabetes since the use of study. insulin considered to be a marker for 5. Diabetic women should be screened disease severity (26). for UTI and asymptomatic bacteriuria In present study, and as shown in (table and should be treated to prevent 3) and (table 4), E. coli was the most complications, such as chronic microorganisms isolated among diabetic pyelonephritis, renal scarring and and non-diabetic women. Regardless of chronic renal failure. age, followed respectively by klebssiella References: spp., Staph aureaus, proteus spp. [1].The diabetic control and complications Pseudomonas spp. No significant trial research group. The effect of intensive difference was demonstrated in the treatment of diabetes on the development present study concerning types of and progression of long term complications in IDDM.NE.JM 2000:329.
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Urinary tract infection among diabetic women in Kirkuk city Dilshad Sabir Mohammed
[2]. Moy CS, ed.:vital statistics.American [12].Hooton TM, Scholes D, Stapleton AE, diabetic association,New york.2001:43. Roberts PL, Winter C, Gupta K, Samadpour [3]. Joshi N, Caputo GM, Weitekamp MR, M, Stamm WE: A prospective study of Karckmen AW: Infections in patients with asymptomatic bacteriuria in sexually active diabetes. N Engl J Med: 1999:341:1906- young women. N Engl J Med: 2000: 1912. 343:992–997. [4]. Patterson JE, Andriole VT: Bacterial [13].Geerlings SE, Stolk RP, Camps MJ, urinary tract infections in diabetes. Infect Netten PM, Collet TJ, Hoepelman AI: Risk Dis Clin North Am: 1997: 11:735–750. factors for symptomatic urinary tract [5]. Nicolle LE, Friesen D, Harding GKM, infection in women with diabetes. Diabetes Roos LL: Hospitalization for acute Care: 2000:23:1737–1741. pyelonephritisin Manitoba Canada, during [14]. Mackie TJ,McCartney JE .Practical the period from 1989 to 1992: impact of Medical Microbiology.14thedition.long man diabetes,pregnancy, and aboriginal origin. Singapore Publishers 1996. Clin Infect Dis: 1996:22:1051–1056. [15]. Bauer AW.Antibiotic susceptibility [6]. Geerlings SE, Stolk RP, Camps MJL, testing by astandarized single disc Netten PM, Hoekstra JBL, Bouter KP, method.Am J clinpathol 1996; 44:493-496. BravenboerB, Collet JT, Jansz AR, [16]. Hooton TM, Scholes D, Hughes JP, et Hoepleman AIM: Asymptomatic al. A prospective study of risk factors for bacteriuria might be considereda diabetic asymptomatic urinary tract infection in complication in women with diabetes. young women. N Engl J Med. 1996; Diabetes Care: 2000:23:744–749. 335:468-474. [7]. Zhanel GG, Nicolle LE, Harding GKM, [17]. Nicolle LE. A practical guide to the and the Manitoba Diabetic Urinary management of complicated urinary tract Infection Study Group: Prevalence of infections. Drugs. 1997; 53:583-592. asymptomatic bacteriuria and associated [18]. Nicolle LE. Asymptomatic bacteriuria host factors inwomen with diabetes in the elderly. Infect Dis Clin North Am. mellitus. Clin InfectDis: 1995:21:316–322. 1997; 11:647-662. [8]. Stapleton A: Urinary tract infections in [19]. Zhanel GG, Nicolle LE, Harding patients with diabetes. Am J Med: 2002: GKM, for the Manitoba Diabetic Urinary 113 (Suppl. 1A):80S–84S. Infection Study Group. Prevalence of [9]. Zhanel GG, Nicolle LE, Harding GK: asymptomatic bacteriuria in women with Prevalence of asymptomatic bacteriuria and diabetes mellitus. ClinInfect Dis. 1995; associated host factors in women with 21:316-322. diabetes mellitus: the Manitoba Diabetic [20]. Balasion. D; Van-Kessek-KG; Van- Urinary Infection Study Group. Clin Infect KatsRenano-HJ;Collet-TJ;Hopelman- Dis: 1995: 21:316–322. Al,Granulocyte function in women with [10]. Geerlings SE, Stolk RP, Camps MJ, diabetes and asymptomatic bacteriuria, Netten PM, Hoekstra JB, Bouter PK, Diabetes care 1997;20930:392-5. Braveboer B, Collet TJ, Jansz AR, [21]. Kayima-TK; Otieno-LS; Twahir-A; Hoepelman AM: Asymptomatic bacteriuria Njene-E Asymptomatic Bacteriuria among can be considered a diabetic complication diabetics attending Kenyatta National in women with diabetes mellitus. AdvExp Hospital, East.Afr.Med.J.1996; 37(8). Med Biol: 2000: 485:309–314. [22]. Zhanel-GG; Nicolle-LE.Harding- [11].Geerlings SE, Stolk RP, Camps MJ, GK.Prevelance of asymptomatic bacteriuria Netten PM, Collet JT, Schneeberger PM, and associated host factors in women with Hoepelman AI: Consequences of diabetes mellitus, asymptomatic bacteriuria in women with Clinic.Infect.Dis.1995:21(2):316-22 diabetes mellitus. Arch Intern Med: 2001: [23]. .Epoke,C.O.Odigue.GOCAnganwn 161:1421–1427. and AAO Prevalence of significant
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Urinary tract infection among diabetic women in Kirkuk city Dilshad Sabir Mohammed bacteriuria in diabetic patients in Calbar, Neigeria Diabetic Internation,2000, Vol 10 No.1,p.16-17. [24]. Lindsay E. Nicolle,M.D,New Eng.J.Med.2000,vol.(343)No.(14),p.1037- 1039. [25]. Hosking DJ, Bennett T, Hampton JR. Diabetic autonomic neuropathy. Diabetes Care 1978; 27:1043–54. [26]. Turner RC, Cull CA, Frighi V, et al. Glycemic control with diet, sulfonylurea, metformin, or insulin in patients with type 2 diabetes mellitus: progressive requirement for multiple therapies (UKPDS 49). UK Prospective Diabetes Study (UKPDS) Group. JAMA 1999; 281:2005–12. [27]. Geerlings SE, Meiland R, Hoepelman AI. Pathogenesis of bacteriuria in women with diabetes mellitus. Int J Antimicrob Agents 2002; 19:539–45.
Journal of Kirkuk Medical College 22 Vol. 1, No. 2, 2013
The effect of plaster immobilisation on Adnan Abdulmajeed Farag the proprioception of the limb
The Effect of Plaster Immobilisation on the Proprioception of the Limb
Adnan Abdulmajeed Faraj, Mohammad Hasson Elanbari Department of Surgery / College of Medicine/ Kirkuk University Department of Orthopaedic/ Airedale NHS Foundation Hospital/ UK Abstract:
Background: It is difficult to establish the effect cast immobilisation has upon a patient and whether or not it causes a significant detriment to the proprioceptive mechanisms within the body. An observational pilot study on random group of patients collected from the fracture clinic. Patients and methods: Twenty two male and sixteen female fracture clinic patients from Airedale general hospital were included within this study, with ages spanning from six to eighty years old. A comparison between patients drinking alcohol and patients not drinking, were made. Also the effect of age was analyzed. A subjective analysis using a questionnaire and an objective examination on modalities of light touch, vibration and position sense, to investigate any variation in proprioceptive awareness. Results: Highlighted a correlation between time in cast and sensorimotor deficit especially in patients above the age of 50 years. An increased time lead to an increased deficit with an eleven week duration following Achilles tendon rupture being the most significant. The results also indicated the profound negative effect of alcohol consumption on the proprioception of the patient, regardless of quantity. Conclusion: Individuals who are known to consume alcohol are suggested to receive assistance with their proprioceptive function by means of physiotherapy and limb movement re-training prior to driving. Individuals who have Achilles rupture should be subjected to clinical review three months post-cast-removal prior to returning to drive. Key words: Immobilisation, Cast, Proprioception, Recovery.
Introduction: The intended result of any fracture originating from an environment which treatment is to; bring about healing of inherently lead to awareness, in a the affected limb, to restore full ranges relative viewpoint, of the body at rest of movement, to restore full power in and at motion. This is connected greatly motion and cause no detriment to to the dynamic position sense (DPS) of proprioceptive ability, it is recognized the limb. The focus of DPS is that of that prolonging the duration can lead to maximising input from sensory a rise in complications. individuals can receptors at different locations within experience swelling of the affected limb, the body, the subsequent central with pain and muscle atrophy following processing of such information and the cast being removed. (1,2) finally contributing towards the Proprioceptive acuity can be defined as knowledge of angular positioning and of the ability of an individual to detect the velocity of any limb. (2,3,4,5) positioning of their limbs in order to respond to their own surroundings. It describes the collective sensations
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The effect of plaster immobilisation on Adnan Abdulmajeed Farag the proprioception of the limb
Aim of the study: assessment of various key modalities The objective of the current study is to thought to contribute towards the overall assess the factors contributing to placement of the limb was done. This alteration in the proprioception. included testing aspects such as sensation, vibration change and Patient and Methods: proprioceptive acuity. Patients attending the fracture clinic at The details of the process are as follows: AGH, in twelve week duration from the 1st of June 2009, were included within Sensation: assessed through this study. A review was conducted post checking the light touch modality of cast removal and assessments were each dermatome on the limb and made accordingly from here. comparing it to that of the unaffected Those patients who fit the criteria of limb. having a fracture requiring cast Vibration: changes were noted by immobilisation, and having the cast placing a tuning fork on a distal bony removed recently (within two weeks) landmark, whilst in motion, and the were included within the study. No patient was asked to remark on when selection criteria for gender were the vibration had ceased with no required however extremes of age (<5 visual stimulus. and >85) were not included to reduce Gross proprioceptive assessment: inaccuracy (Figure 1, 2). conducted by moving the limb in A comparison was made between either an upward or conversely a patients not drinking alcohol (12), and downward direction and asking the those who are moderate alcohol patient to comment on the direction consumer (5), the remaining of the of movement without looking. patients, were social drinkers. Symmetrical positioning: assessed In total, (57.9%) (22/38) subjects were by moving one limb into a certain male and (42.1%) (16/38) subjects were position and angulations and asking female, with ages spanning from six to the patient to place their other limb eighty years of age. Informed consent in the same place with no visual was obtained regarding the observations input. prior to any questioning or examinations Position reproducibility: the patient being carried out. Fractures were not was asked to reproduce a specific restricted to the lower limb and any position of a limb actively, after fracture involving cast immobilisation having the limb placed in this was included within the audit. position passively and with eyes open Process: If appropriate, muscle wasting was After the consultation with the clinician, taken by measuring the largest information was collected regarding the circumference of the affected limb patients’ other medical issues and any and comparing it to that of the problems encountered with their unaffected limb. affected limb. This revolved around a structured proforma set by the Results: orthopaedic department at AGH. The results were collated for each of the A brief physical assessment was proprioceptive modalities under subsequently carried out whereby an investigation a numerical figure was
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The effect of plaster immobilisation on Adnan Abdulmajeed Farag the proprioception of the limb given for each finding observed. This proprioceptive rankings as a measure. was formed by assigning the number 1 All but one patient in the “alcoholic to mild, 2 to moderate and then 3 to group” had greater deficits observed severe clinical deficit. than any of the “nonalcoholic group”. The correlation between the time It can be said that the least deficit duration in cast and the increasing patient within the “alcoholic group” can problems with regards to sensorimotor be equated symptomatically to the and proprioceptive issues; There is a patient with the highest deficiency in the distinct upward increase to the trend and “non-alcoholic group” (Figure 3). This as the time duration increases so does graph has been constructed to attempt to the problems encountered by all patients highlight any possible connection placed in cast (Figure 1). between increasing age and There was a difference between patients proprioceptive deficit following a who suffered from a fracture and drank fracture. The span of ages within the alcohol to patients who suffered from study does not show a direct correlation fractures but did not drink alcohol towards increasing age. This seems to (Figure 2). The values are quantified show an even distribution to the using collective sensorimotor and population group.
Figure (1): graph showing the general upward trend in sensorimotor problems when increasing the time in cast.
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The effect of plaster immobilisation on Adnan Abdulmajeed Farag the proprioception of the limb
Graph to show alcoholic vs. non alcoholic Sensorimotor deficits
6
5 4 3 2
1
Sensorimotor Problems 0 Alcohol Consumed No Alcohol
Figure (2): graphs showing the relatively greater number of sensorimotor problems encountered with fracture patients who drink alcohol (n=5) as compared those who do not (n=13). Each bar represents a fracture patient included within the study.
Figure (3): a graph to show any connection between increasing age and increasing proprioceptive deficit. All patients with deficit are shown (n=12).
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The effect of plaster immobilisation on Adnan Abdulmajeed Farag the proprioception of the limb
Discussion: The outset of this audit was to observe Follak 2004(9) observed that bone the proprioceptive and sensorimotor healing is affected with endocrine changes, if any, following cast removal. conditions such as diabetes. Rayyan The literature states that prolonged 2009(10) showed that if the problem is duration of cast immobilisation is well controlled that the effect on bone indicative of a proprioceptive deficit. healing would not be sufficient enough However, the effect to which this is to cause a problem. In this study, one associated with time or any other individual was a diabetic however his compounding factors has not been blood sugars were under control. His described to its entirety. overall deficit in proprioception was The results obtained highlighted quite relatively not as great as those with clearly that the longer the period of cast alcoholic tendencies. immobilisation, the larger the potential problem of proprioceptive deficit was to Limitations: arise. This corresponds greatly to the Any limitations that were observed were literature as numerous aforementioned restricted at every possible eventuality sources refer to conclusions which can however with regret there were still be held as reasoning for this. some present. If in the future a follow Hassan et al 2001, Bartley 1982, up to this study is conducted the Skinner 1985(6,7,8), described three following points should be addressed or themes of eventualities resulting from rectified. cast placement. Firstly that co- The angle reproduction test was used ordination can be expected to be because it is described in the literature affected cast removal. Secondly, that to be one of the few processes that can muscle atrophy is present also following assess the perception of joint position the duration of immobilisation. Lastly, directly. It was not feasible for this further literature suggests that muscle study to brace every patient in order to afferents are being seen as increasingly accurately quantify the differences seen important in the processes involved between the attempts. It was done on within collecting and relaying sensory visual assessment only and therefore information prior to surmounting a was categorized and ranked accordingly motor response. Logically when taking from here. into account these three poignant Muscle wasting was assessed in the factors, it is inevitable that the duration form of measuring the largest of cast immobilisation would cause a circumference of the affected limb and deficit in proprioception or sensorimotor comparing it to that of the unaffected capacity to some degree. The extent to limb. Ideally this should be done prior which the differences were seen varied to, or at injury, in order to see the quite considerably however, possibly differences before and after the cast due to the other factors being assessed. being put into place. An example of this would be the Muscle spindle assessment would patients who did not take in any alcohol contribute greatly towards the who subsequently did not suffer from specificity and reliability of the results, the same symptoms as those patients without the use of expensive tools this who did.
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The effect of plaster immobilisation on Adnan Abdulmajeed Farag the proprioception of the limb was not possible when conducting this suggested that the patients who drink audit. any amount of alcohol should observe a Conclusions: This audit aimed to establish whether or further duration of caution prior to not the impact of a cast and returning to the road (up to six weeks), immobilisation was sufficient enough to whereas the patients of Achilles tendon affect proprioception clinically. After rupture should be reviewed clinically for conducting the study we can be proprioceptive acuity prior to any confident in stating that an effect is thoughts of attempting to drive. This present clinically however it can be review should, unless otherwise short lived depending on the individual. indicated, be set at three months The largest conclusion to be stated is following complete cast removal. that of an effect that alcohol has upon Acknowledgement: both joint healing and proprioception. I would like to thank all of the All individuals who reported drinking orthopaedic staff at Airedale General alcohol during the healing process found Hospital for their help, support and themselves to be affected to a greater understanding throughout the testing degree than their counterparts who did period, without which none of this could not drink any alcohol at all. To further have been possible. this point, the problems encountered were by all consumers of alcohol and References: was not restricted to what is considered [1]. Moseley M, Kathryn M R, Marion H, to be an excessive drinker. Robert D H “Effectiveness of joint The patient who had an eleven week immobilisation after cast immobilisation for ankle fracture: a protocol for a randomised cast placed as treatment for their controlled trial”. BMC 2006; 7: 46-49 Achilles tendon rupture had a [2]. Vandenborne K, Elliott MA, Walter considerable proprioceptive deficit. The GA, Abdus S, Okereke E, Shaffer, M, patient had no other known co- Tahernia D, Esterhai JL “Longitudinal morbidities or detrimental social study of skeletal muscle adaptations during activities, indicating time as the immobilisation and rehabilitation” 1998; prevalent factor. 21:1006-1012. [3]. Spanos S, Brunswic B, Billis E “The Recommendation: effect of taping on the proprioception of the With regards to a clinically applicable ankle in a non-weight bearing position, aspect, it can be suggested that amongst injured athletes”. 2008; 18: 25–33. [4]. Swinkles A, Ward CD, Bagust J “Bed- individuals who are prone to a drink or rest and Plaster of Paris Leg Cylinders Do have an alcohol problem should be they alter knee joint proprioception” 1995; recommended some form of training or 10: 626-631 physiotherapy to re-introduce a level of [5]. Digby M, Holloway G Webb J “A normality to their daily proprioceptive study of function after tibia1 cast bracing”. functions prior to resuming normal life. 1982; 14: 432-439. This can also be suggested for patients [6]. Hassan B, Mockett S, Doherty M with Achilles rupture however to a “Static postural sway, proprioception, and greater degree as the deficit was so maximal voluntary quadriceps contraction substantial. With regards to in patients with knee osteoarthritis and recommendations for driving it can be normal control subjects”. 2001; 60: 612– 618.
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The effect of plaster immobilisation on Adnan Abdulmajeed Farag the proprioception of the limb
[7]. Bartley HS “the second childhood of defect size in spontaneously diabetic Proprioception”, perceptual and motor BB/OK rats”.2004; 34: 144– 152. skills 1982; 55: 446-49. [10]. Rayyan A. Kayal , Alblowi J, [8]. Skinner, H B. Banadt. M Dand Cook.S McKenzie E, Krothapalli N, Silkman L, D “Age related decline in Proprioception”. Gerstenfeld L, Thomas A, Graves DT 1984; 184, 4, 206-211. “Diabetes causes the accelerated loss of [9]. Follak N, Ingrid Klo¨ting, Eduard W, cartilage during fracture repair which is Harry M Histomorphometric “evaluation of reversed by insulin treatment”. 2009; 44 the influence of the diabetic metabolic state 357–363 on bone defect healing depending on the
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Deferoxamine vs. Deferasirox in the treatment of thalassemia major with iron Jamal Qasim Weli overload: retrospective study in Thalassemia Center, Kirkuk, Iraq.
Deferoxamine vs. Deferasirox in the Treatment of Thalassemia Major with Iron Overload: Retrospective Study in Thalassemia Center, Kirkuk, Iraq.
Jamal Qasim Weli, Mohammed Saleem Mohammed Azadi Teaching Hospital, Kirkuk, Iraq Abstract:
Background: Iron overload is a major problem in patients with Thalassemia major. An effective and safe iron chelator protocol with high compliance rate plays an important role deciding the best treatment option in these patients. This study was done to assess the efficacy and safety of both Deferoxamine and Deferasirox in Thalassemia major patients in Kirkuk province, Iraq. Patients and methods: In this retrospective study we have included serum ferritin records of 280 Thalassemia major patients treated with two types of iron chelating therapy at Thalassemia center, Azadi teaching Hospital, Kirkuk province, Iraq. The study started since March 2012 till December 2012 and they were categorized in to two groups; First group Thalassemia major patients who had been treated with subcutaneous (SC infusion) Deferoxamine, while second group had been treated with oral Deferasirox (Exjade) with serum ferritin records of both base line and 9 month later had been compared. Most patients with relatively high serum ferritin had been treated with SC Deferoxamine. As a secondary end point, side effect profile had been analyzed in the two studied groups. Results: 173 Thalassemia major patients (mean age 11 year) treated with oral Deferasirox (Exjade) had mean decrease in their serum ferritin after 9 month was 840 ng/ml while the mean decrease in the 107 patients (mean age=17 year) treated with SC infusion Deferoxamine was (1527 ng/ml) with very significant difference between the two studied groups and (p-value = 0.0005). Abdominal cramp, nausea and vomiting, skin rash were more with oral Desferosix (Exjade) than SC Deferoxamine treated patients [52 (30%), 62 (35%), 13 (7%) versus 23 (21%), 11 (10%), 0 (0%) consecutively]. Renal impairment especially elevation of serum Creatinine to a degree requiring dose modification were found in 15 patients treated with oral Deferasirox (Exjade) while it has not been noticed in patients treated with Deferoxamine. Conclusion: In spite of less side effects and more compliance of Thalassemia Major Patients treated with Deferasirox than Deferoxamine; Deferoxamine still is more effective treatment modality than Deferasirox in decreasing serum ferritin level.
Keywords: Thalassemia Major, Deferoxamine, Deferasirox, Serum ferritin, Kirkuk, Iraq.
Introduction: Iron chelating therapies are indicated in that are available parenteral hematology to decrease the effect of Deferoxamine (Desferal) and oral iron overload on the morbidity and Deferasirox (Exjade) have got great mortality of common hematologic benefit in decreasing the risk of cardiac problems like Thalassemia, problems, congestive heart failure, myelodysplastic syndrome and sickle endocrinopathies, hepatic fibrosis and cell anemia (1). The two iron chelators death, but still these drugs have got their
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Deferoxamine vs. Deferasirox in the treatment of thalassemia major with iron Jamal Qasim Weli overload: retrospective study in Thalassemia Center, Kirkuk, Iraq. controversies regarding tolerability and long term effectiveness, most patients side effect profile (1, 2) . now make use of Deferasirox because of the ease of oral administration (3). Patients and methods: Deferasirox is also preferred for Using SPSS 17 independent t test in this prophylactic or maintenance therapy (4). comparative study, we analyzed the data Deferoxamine, which has been proved of (280) Thalassemia major patients to reverse iron-induced heart disease treated with two types of iron chelating and increase long-term survival, may be therapy at Thalassemia center, Azadi indicated if Deferasirox is ineffective in Teaching Hospital, Kirkuk province, a particular patient, and it may be Iraq since March 2012 till December favored for severe iron overload, 2012. Patients were categorized into two especially with cardiac involvement (5). groups; First group Thalassemia major Measuring serum ferritin alone as an patients had been treated with indicator for iron burden had some subcutaneous Deferoxamine (40 disadvantages as an indirect measure for mg/kg/day) 5 days per week infusion iron burden and not reflecting accurately over 10-12 hours daily using an infusion the iron status in organs like liver and pump, while second group had been heart e, also serum ferritin levels treated with oral Desferosix (Exjade) fluctuate in their response to [30mg/kg/day which is reduced to 20 inflammation, abnormal liver function mg /kg/day when needed]. In this study and ascorbate deficiency. Now a day, Deferasirox oral chelating therapy was many new advanced techniques had used for patients serum ferritin levels been adopted for more accurate less than 4000 ng\ml, while patients estimation of Iron burden in with relatively high serum ferritin had Thalassemia major patients like liver been treated with subcutaneous biopsy, liver MRI, cardiac MRI T2*. In Deferoxamine. spite of that, serum ferritin seems to Age categorization into three groups have some advantages like being including those who are less than 5 inexpensive, easy to done, positively years old, between 5-10 years old and correlate with morbidity and mortality those who are older than 10 years old and still it is adopted in many with comparison in between the two Thalassemia centers as a useful mode of groups of patients on Iron chelating monitoring iron chelating therapy (6, 7, 8). therapy was. Furthermore, side effects decreased over 9 month to a mean of between the two groups had been (840 ng/ml).The second group of analyzed including abdominal pain, Thalassemia major patients (n=107) had asthenia, skin rash, conjunctivitis, been treated with subcutaneous nausea and vomiting, dyspepsia and Deferoxamine (mean age of 17 year) others like headache. with male to female ratio (1:1.31), and mean base line serum ferritin of 5670 Results: ng/ml decreased to 1527 ng/ml after (173) Thalassemia major patients treated treatment with the subcutaneous with Exjade have a (mean age of 11 Deferoxamine (Figure 1). Crossover years) at the start of the study with male from one iron chelating therapy to to female ratio (1:1.16) and mean another has been allowed and 21 baseline serum ferritin of 2680 ng/ml patients treated with subcutaneous which had Despite the lack of data on
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Deferoxamine vs. Deferasirox in the treatment of thalassemia major with iron Jamal Qasim Weli overload: retrospective study in Thalassemia Center, Kirkuk, Iraq.
Deferoxamine had changed to Exjade ferritin following iron chelating therapy, while 5 patients had changed their shows significant difference between the therapy to Deferoxamine. two group and p-value = 0.0005, which By comparing the two populations of is very significant. (Table1). patients in three age groups sub Side effects have been recorded in the categorization we can see that most of two studied group concentrating on those who are on Deferoxamine are abdominal cramp, nausea and vomiting, more than 10 years old age; while the skin rash, asthenia, allergic rest are in the age group of (5-10 years conjunctivitis, dyspepsia and even the old) and none of the patients is less than effect of both drugs on the renal 5 years old age. While those function test. Abdominal cramp, nausea Thalassemia major patients who are on and vomiting, skin rash were more in Exjade have got similar distribution in Exjade than Deferoxamine treated three age categories as seen in (figure patients (30%, 35%, 7% versus 21%, 2). Male to female ratio shows slight 10%, 0% consecutively).Fifteen patients female predominance in both Exjade treated with Exjade had an increase in and Deferoxamine (Desferal) as shown their serum creatinine to limits requiring in (figure 3). dose modification while there was no Using independent two sample t-test and renal impairment in patients treated with comparing the two mean decrease serum subcutaneous Deferoxamine, (table 2).
Thalassemia major treated in thalassemia unit
N=280
Thalassemia major treated Thalassemia major treated with Deferasirox with Deferoxamine N=173(62%) male = 80 , N=107(38%) male = 46, female =93 female =61
Patients changed their Patients changed their iron chelating therapy to iron chelating therapy to Deferoxamine Deferasirox
N=21 N=5
Patients remaining on Patients remaining on Deferasirox Deferoxamine N=189 N=91
Figure (1): Censor diagram for thalassemia major patients treated with two types of Iron chelating agent over 9 month.
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Deferoxamine vs. Deferasirox in the treatment of thalassemia major with iron Jamal Qasim Weli overload: retrospective study in Thalassemia Center, Kirkuk, Iraq.
80 70 60 50 40 Iron chelating drug EXJADE 30 20 Iron chelating drug Desferal 10 0 LESS THAN 5 Yrs 5-10yrs MORE THAN 10yrs AGE
Figure (2): Comparison between Deferasirox (Exjade) and Deferoxamine (Desferal) in three categories of age group.
100 80 60 Iron chelating therapy EXJADE 40 Iron chelating therapy Desferal 20 0 male female sex
Figure (3): Sex differences in both Deferasirox (Exjade) and Deferoxamine (Desferal) Group.
Table (1): Statistics for the mean difference in the serum ferritin after treatment with Iron chelating therapy. No. of Mean difference in Standard Standard Iron Chelating therapy P value patients Serum ferritin Deviation error Mean Deferasirox 173 840.5723 1036.40 78.79 0.0005 Deferoxamine 107 1527.5294 681.62 67.49
Table (2): Difference in the side effect profile between the patients treated with Deferasirox (Exjade) and Deferoxamine (Desferal). Side effect type Oral Exjade n=168 SC* Deferoxamine n=86 Abdominal cramp 52 (30%) 23 (21%) Skin rash 13 (7%) 0 Nausea and vomiting 62 (35%) 11 (10%) dyspepsia 18 (10%) 2 (1.8%) Elevated Serum creatinine to upper limits 26 (15%) 0 Asthenia 54 (31%) 17 (15%) headache 38 (21%) 22 (20%) Allergic conjunctivitis 15 (8.6%) 0 *Subcutaneous
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Deferoxamine vs. Deferasirox in the treatment of thalassemia major with iron Jamal Qasim Weli overload: retrospective study in Thalassemia Center, Kirkuk, Iraq.
Table.3 Difference in the rate of main sides for Oral Deferasirox between our study and (13) Capellini et al study . Side effect Our study Capellini et al (13) Abdominal cramp 30% 13% Skin rash 7% 5% Nausea and vomiting 35% 22.5% Elevated serum creatinine 15% 38 %
Discussion: In this retrospective study we evaluate 1527 ng/ml while 926 ng/ml in the effect of iron chelating therapy Deferasirox group-Capellini study, (Deferoxamine or Deferasirox) on while in our study it was 840 ng/ml. serum ferritin in Thalassemia major This means nearly similar effects for patients as a primary end point. both irons chelating therapy on serum Deferasirox is an effective oral iron ferritin in our study to Capellini et al chelator with a long half-life, which study. could be used as monotherapy. As the oral Deferasirox become However, the efficacy on the high iron available just in the last decade in our overload is questionable; in addition to center and show less side effect profile that it could not achieve a negative iron and more compliance with the patients balance even with highest recommended in comparison to SC Deferoxamine dose, which might cause severe side (which require SC an electronic pump effects (9, 10, 11, 12). For those reasons for slow infusion over 8-12 hours, 5 to7 patients with high serum ferritin (above nights per week), so we can notice from 4000 ng/ ml) were preferred to be given the age sub categorization that most SC Deferoxamine. Thalassemia major patients treated with Capellini et al (13) were the pioneers for SC Deferoxamine were in the age using oral Deferasirox as a monotherapy group more than 10 years old age and in Thalassemia major patients and prove just (20%) in the age limit 5-10 years the non-inferiority to subcutaneous old and even non in the age group less l Deferoxamine in Thalassemia major than 5 years. This is because the oral patients. Although, in their study they Deferasirox becomes available in our use Liver Iron content (LIC) as a mean center and it shows more compliant by for the burden of iron and monitoring patients in comparison with response to therapy, still they consider subcutaneous Deferoxamine (14). changes in Liver Iron Content (LIC) Sex ratio analysis illustrates slight parallel to changes in serum ferritin. female predominance over male similar Comparing the mean decrease in serum to a study done at Italy (15). While in a ferritin level in our study (for both irons study done in a nearby Mosul province chelating group) with the results in between 2001and 2002 there was slight Capellini et al study (13); we can see that higher male to female proportion (mainly in patients with Liver Iron (54%:46%) (16). Concentration more than 14 mg Fe /g Crossover between the two therapies dry weight) the decrease in serum lines had been allowed as five patients ferritin level over one year study period in the Deferasirox group changed their was1003ng /ml in Deferoxamine group treatment to Deferoxamine at higher Capellini study, and in our study was levels of serum ferritin monotherapy, Journal of Kirkuk Medical College 34 Vol. 1, No. 2, 2013
Deferoxamine vs. Deferasirox in the treatment of thalassemia major with iron Jamal Qasim Weli overload: retrospective study in Thalassemia Center, Kirkuk, Iraq. while 21 patients on the subcutaneous [5]. Davis BA, Porter JB. Long-term therapy did not tolerate the infusion outcome of continuous 24-hour pump and change to oral Deferasirox. deferoxamine infusion via indwelling The cross over allowance based on intravenous catheters in high-risk beta- studies preferring either combination or thalassemia. Blood 2000; 95:1229-36. sequential Iron chelating therapy over [6]. Ali T. Taher, Khaled musallam, AV Hoffbrand. Currant strategies in the monotherapy for more compliance and assessment of Iron overload EJCMO 2011; optimal 24 hour chelator “coverage” (17, 18, 19, 20, 21) 3 (3). June 2011 . [7]. Olivieri NF, Brittenham GM. Iron- Regarding the side effect profile for oral chelating therapy and the treatment of Deferasirox in comparison with thalassemia. Blood 1997; 89:739-61. Capellini et al data (13) we can see that [8]. Gabutti V, Piga A. Results of long-term skin rashes take place in nearly similar iron-chelating therapy. Acta Haematol rates, while abdominal cramps, nausea 1996;95:26-36. and vomiting seems to be more [9]. Cabantchik ZI, Breuer W, Zanninelli G, profound in our study. Affecting the Cianciulli P. LPI-labile plasma iron in iron renal function and elevation of serum overload. Best Pract Res Clin Haematol creatinine to high levels during the 2005; 182:277–87. [10]. Nick H, Acklin P, Lattmann R, Deferasirox was less in comparison with Buehlmayer P, Hauffe S, Schupp J, et al. Capellini study (table 3). Development of tridentate iron chelators: from desferrithiocin to ICL670. Curr Med Conclusion: Chem 2003; 10:1065–76. In spite of less side effects and more [11]. Nick H, Wong A, Acklin P, Faller B, compliance of Thalassemia Major Jin Y, Lattmann R, et al. ICL670A: Patients treated with Deferasirox than preclinical profile. Adv Exp Med Biol Deferoxamine; Deferoxamine still is 2002; 509:185-203. more effective treatment modality than [12]. Cohen AR .New Advances in Iron Deferasirox in decreasing serum ferritin Chelation Therapy. Hematology 2006; 42- 47. level. [13]. Cappellini MD, Cohen A, Piga A, References: Bejaoui M, Perrotta S, Agaoglu L, et al. A Phase III study of deferasirox (ICL670), an [1]. Borgna-Pignatti C, Rugolotto S, De oncedaily oral iron chelator, in patients with Stefano P, Piga A, Di Gregorio F, B-thalassemia. Blood 2006; 107:3455-62. Gamberini MR, et al. Survival and disease [14]. Porter JB. Deferoxamine complications in thalassemia major. Ann pharmacokinetics. Semin Hematol. 2001; NY Acad Sci 1998; 850:227-31. 38:63–8. [2]. Olivier NF, Nathan DG, MacMillan JH, [15]. Differential effects of the type of iron Wayne AS, Liu PP, McGee, A, et al. chelator on the absolute number of Survival in medically treated patients with hematopoietic peripheral progenitors in homozygous B-thalassemia. N Engl J Med patients with b-thalassemia major Gian 1994; 331:574-8. Luca Forni, Marina Podestà, Marco Musso. [3]. Gary M. Brittenham, M.D Iron- haematologica | 2013; 98(4) Chelating Therapy for Transfusional Iron [16]. Certain hematological values of the ß- Overload; New England Journal of thalassaemia major among Mosul Medicine; January 13th, 2011 -364; 2. population Sharaf KhH, Moayad M.Y Al- [4]. Porter JB. Practical management of Anzy , Mustaffa NG . Tikrit Journal of Pure iron overload. Br J Haematol. 2001; Science Vol. 11 No. (1) 2006 115:239–52.
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Deferoxamine vs. Deferasirox in the treatment of thalassemia major with iron Jamal Qasim Weli overload: retrospective study in Thalassemia Center, Kirkuk, Iraq.
[17]. Nisbet-Brown E, Olivieri NF, in the Treatment of Thalassaemia Major Giardina PJ, Grady RW, Neufeld EJ, and Other Diseases. Catania, Italy: 2001; Séchaud R, et al. Effectiveness and safety 74-78. of ICL670 in iron-loaded patients with [20]. Breuer W, Empers MJJ, Pootrakul P. thalassaemia: a randomised, double-blind, Deferoxamine-chelatable iron, a component placebo-controlled, dose-escalation trial. of serum non- transfusion bound iron, used Launcet 2003; 361:1597–602 for assessing chelation therapy. Blood [18]. Hoffbrand AV, Cohen A, Hershako C. 2001; 97:792-798. Role of deferiprone in chelation therapy for [21]. Link G, Konijn AM, Breuer W, transfusional iron overload. Blood 2003; Cabantchik ZI, Hershko C. Exploring the 102:17-24. “iron shuttle” hypothesis in chelation [19]. Grady RW, Berdoukas V, therapy: effects of combined deferoxamine Rachmilewitz EA. Iron chelation and deferiprone treatment in hyper therapy:metabolic aspects of combining transfused rats with labeled iron stores and deferiprone and deferoxamine.11th in iron loaded rat heart cells in culture. J International Conference on Oral Chelation Lab Clin Med. 2001; 138:130-138.
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Maternal serum creatine kinase and single serum progesterone Aseel Ghazi Rifat measurement as predictors of ectopic pregnancy
Maternal Serum Creatine Kinase and Single Serum Progesterone Measurement as Predictors of Ectopic Pregnancy
Aseel Ghazi Rifat, Maha Mohammed Al-Bayati, Abdul Wahab Razooqi Hamad Department of Obstetrics and Gynecology/ College of Medicine/ Kirkuk University Department of Obstetrics and Gynecology/ College of Medicine/ Al-Nahrain University. Department of Biochemistry/ College of Medicine/ Al-Nahrain University.
Abstract: Objective: To evaluate the role of serum creatine kinase (CK) and progesterone (p) in the prediction of ectopic pregnancy (E.P). Patients and methods: A prospective study was carried out on 60 pregnant women of comparable gestational age and they were divided into 3 groups: Group A: 20 patients with confirmed E.P. Group B: 20 patients with missed or spontaneous miscarriage. Group C: 20 women with normal intrauterine pregnancy (IUP). The following laboratory measurements were performed for the studied groups: 1- Test for serum CK level for all groups. 2- Test for serum progesterone for all groups. 3- Histopathological study to determine the depth of invasion of the trophoblast to the muscular layer of fallopian tube for group A. Results: 1- The serum CK level was significantly higher in group A than in group B and C and was significantly higher in ruptured than in unruptured and in isthmic compared to ampullary EP. 2- The serum progesterone level was significantly lower in group A and B than in group C, but there was no significant difference between group A and B. 3- The serum progesterone level was significantly higher in ruptured than in unruptured EP. 4- There was significant positive correlation between serum CK and progesterone level in group A. Conclusion: 1- An increase in serum CK levels probably antedates tubal rupture and could help in discriminating ruptured from unruptured EP. 2- Serum progesterone discriminates EP from normal IUP but it does not differentiate it from miscarriage. 3- The combination of both serum CK and progesterone in suspected EP has a higher differential accuracy than either analysis alone. Keywords: Ectopic pregnancy, Creatine kinase, Progesterone.
Introduction: Ectopic pregnancy (EP) is an ovaries, broad ligament, and peritoneal unmitigated disaster of reproduction (1), cavity (4). where earlier diagnosis enhances both Seventy four percent of tubal maternal survival and conservation of pregnancies are situated in the ampulla, reproductive capacity (2) and it is defined (12%) occur in the isthmus, (12%) are as implantation of the conceptus in any fimbrial and approximately (2%) are site other than a normal intrauterine interstitial (1, 2). location (3). A dramatic increase in incidence over The commonest site is in the tubes about time has been reported in several (95%) the remainder may locate in the countries due to increased incidence of Journal of Kirkuk Medical College 37 Vol. 1, No. 2, 2013
Maternal serum creatine kinase and single serum progesterone Aseel Ghazi Rifat measurement as predictors of ectopic pregnancy salpingitis and increased use of epithelium, lying adjacent to the intrauterine contraceptive devices muscular layer and the trophoblast (IUCDs) and assisted reproductive invades the muscular layer of the techniques (1, 2, 3) . fallopian tube (13). It has been The clinical features of ectopic hypothesized that one of the serum pregnancy are not unique to the markers for tubal pregnancy could be an condition but the classic triad consists of increase in the muscle cell product of amenorrhea, vaginal bleeding and CK released into the maternal blood abdominal pain (5, 6). stream after the cell damage, and The conventional diagnostic means used maternal serum CK level can serve as an are: additional diagnostic tool in early A- HCG level: HCG production in diagnosis of ectopic pregnancy (14). ectopic pregnancy is generally lower than in intrauterine pregnancy (IUP) (4) Progesterone: but the interpretation of a single result It is the most important steroidal plasma of HCG is difficult and usually needs hormone in human pregnancy (15, 16). serial HCG determination with at least 48 hour delay in making diagnosis (7, 8, 9), Serum progesterone measurement women with ectopic pregnancy have and ectopic pregnancy: low HCG which may either decline Serum progesterone value can often be slowly have a slow rise or plateau in to use to establish that there is an comparison with normal intrauterine abnormal pregnancy, that is either a pregnancy (4). miscarriage or an ectopic pregnancy (1, 5) B- Ultrasound (US): The detection of a and the use of a single random level of normal IUP {at 4 weeks + 3 days by progesterone, rather than serial transvainal sonography (TVS)} virtually measurement is because of that most excludes the diagnosis of ectopic investigators have failed to pregnancy (4) although a demonstrated a statistically significant pseudogestational sac or decidual cast in increase of progesterone value over the ectopic pregnancy may be confused on first 10 weeks of pregnancy, a time US with an intrauterine sac (8). when most ectopic pregnancy The characteristic ultrasound features of manifest (17, 18). ectopic pregnancy are (4): Empty uterus + adnexal sac + fluid in Patients and methods: pauch of Dogllas (POD) (4) c- This study was conducted on 60 Laparoscopy (2, 10). d-Culdocentesis: to pregnant women age range between 18- exclude haemoperitonium (10). 40 years old in the University Hospital of Al-Nahrain College of Medicine/ Creatine Kinase (CK): Department of Gynecology and It is an intracellular metabolic enzyme Obstetrics over a period of 14 months with concentrations highest in the brain, starting from the first of March, 2001 to myocardium, skeletal and smooth the end of April 2002. muscle (11, 12). Women included in this study were Creatine kinase and ectopic pregnancy: divided into 3 groups: In the pathogenesis of ectopic Group A: 20 patients admitted to the pregnancy the zygot penetrates the tubal hospital with positive pregnancy test
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Maternal serum creatine kinase and single serum progesterone Aseel Ghazi Rifat measurement as predictors of ectopic pregnancy and symptoms or ultrasonographic tubal pregnancy, and were stratified by findings suspicious of ectopic pregnancy implantation site as isthmic or confirmed by–surgical procedures ampullary by visual examination intra (laproscopy and/ laprotomy) and operatively and subsequent histopathology. histopathological study of the specimens Group B: 20 patients admitted to the taken, which also determined the depth hospital with non-continuing pregnancy of invasion of the trophoblast into the (missed or spontaneous miscarriage) muscular layer of fallopian tube. diagnosed by ultrasound or after After that statistical analysis of the data curettage with comparable gestational was done to compare the level of serum age. CK and serum progesterone between the Group C: 20 women with normal three groups of ectopic pregnancy, intrauterine pregnancy of comparable miscarriage and normal pregnancy. gestational age as assessed by menstrual The levels of CK and serum dates and confirmed by ultrasound scan. progesterone were also compared Any women with history of recent between ruptured and unruptured and trauma, surgery or intramuscular between amplullay and isthmic ectopic injection were excluded from the study. pregnancy. Women with history of muscle, heart, The statistical analysis of the data was thyroid or liver disease, women with performed using the following tests: twin or multiple pregnancy and women Modified student t-test, Chi-square test, who had taken exogenous progesterone Sperman,s rank ordered correlation test. or conceived after ovarian stimulation and all types of ectopic pregnancy other Results: than tubal pregnancy were also After collection and categorization of excluded. the data from 60 women included in the In addition to the routine laboratory study, statistical analysis was done and tests, we performed the following revealed the following: laboratory measurements for them: (Table 1) show the characteristics of 1- Test for measurement of CK level in women with tubal pregnancy and the serum were performed to all groups control groups, the following results upon admission, before any invasive were noted: procedure or intra muscular injection, by 1- The age range of presentation reflects enzymatic calorimetric method using that although the most likely age of the creatine kinase enzymatic calorimetric presentation with ectopic pregnancy was method kit from (RANDOX laboratories in the last 20s, women at either end of Ltd). reproductive age spectrum are not 2- Test for the measurement of serum exempt from developing ectopic progesterone level for all groups by pregnancy. standard radio immunoassay technique 2- There was no statistically significant using radio immunoassay kit from (CIS difference in age between women in the bio international). three studied groups (P value=0.85) Women with suspected ectopic 3- There was no statistically significant pregnancy were followed during surgery difference in weight between women in and ectopic pregnancy confirmed and the three studied groups (P value=0.77) classified as ruptured or un ruptured
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Maternal serum creatine kinase and single serum progesterone Aseel Ghazi Rifat measurement as predictors of ectopic pregnancy
4- There was no statistically significant ampullary in location (85%), while only difference in gestational age between (15%) of the cases were isthmic. women in the three studied groups (Table 4) shows the number (%) of (P value=0.7) ruptured ectopic pregnancy in ampullary 5- The incidence of ectopic pregnancy and isthmic pregnancy in group A. Fifty was more in multiparous women (80%) three percent of ampullary pregnancies of the cases were multipara while (20%) found to be ruptured, while all isthmic were nulliparous) pregnancy were ruptured (100%). 6- There was no statistically significant (Table 5) shows the mean serum CK difference between women in the three level for the three compared groups. The studied groups regarding history of mean serum CK level in group A was previous preterm delivery or early found to be significantly higher than in spontaneous miscarriage.(P value=0.99) group B and C (P value <0.0001). A cut 7- Thirty- five percent of patient with off value for serum CK of 125 IU/L was ectopic pregnancy had history of using (100%) sensitive and specific for the contraception previously. (20%) used diagnosis of ectopic pregnancy. intrauterine contraceptive device, (10%) (Table 6) shows statistically significant used combined oral contraceptive pills difference in the mean serum CK level and (5%) used barrier method (only one between ruptured and unruptured patient had ectopic pregnancy while ectopic pregnancy being higher in the using oral contraceptive pills) ruptured group (P<0.000 3). A cut off 8- History of previous abdominal value for serum CK of 250 IU/L was surgery was identified in (30%) of cases (91.6%) sensitive and (78.5%) specific with EP (10%) of them with caesarian for the prediction of tubal rupture. section, (10%) with appendicectomy (Table 7) shows a statistically and (10%) with other abdominal significant difference in the mean serum surgery. CK level between ampullary and 9- (80%) of patients in group A had isthmic ectopic pregnancy being higher history of pelvic inflammatory disease, in the isthmic group (P<0.007). which appears to be an important risk (Table 8) shows the mean serum factor for development of ectopic progesterone level in the three compared pregnancy. groups. (Table 2) shows the number (%) and The mean serum progesterone level in mean gestational age of ruptured and group A and B was significantly lower unruptured tubal pregnancy in group A. than in group C (P<0.0001) and lower in Sixty percent of them were ruptured group B than in group A. but This while (40%) were unruptured, there was difference was not statistically no statistically significant difference in significant (P<0.18). the mean gestational age between (Table 9) shows statistically significant women with ruptured and unruptured difference in mean serum progesterone tubal pregnancy, although the mean level between ruptured and unruptured gestational age in the unruptured was ectopic pregnancy, being higher in the slightly lower. ruptured group (P<0.01). (Table 3) show the number (%) of (Table 10) shows the mean progesterone ampullary and isthmic pregnancy in level in ampullary and isthmic ectopic group A. Most of the cases were pregnancy. The mean serum
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Maternal serum creatine kinase and single serum progesterone Aseel Ghazi Rifat measurement as predictors of ectopic pregnancy progesterone level was higher isthmic (Figure 1) show a significant positive than the ampullary group, yet the correlation between serum CK level and difference was not statistically serum progesterone level in group A significant (P<0.45). (correlation coefficient r=0.679).
Table (1): The characteristics of women with tubal pregnancy and control groups. Characteristic Group A no (%) Group B no (%) Group C no (%) Age (Year) 10-24 5 (25%) 4 (20%) 4 (20%) 25-30 10 (50%) 9 (45%) 11 (55%) 31-35 3 (15%) 3 (15%) 4 (20%) >35 2 (10%) 4 (20%) 1 (5%) Not significant P value=0.858 Body weight (KG) 40-50 3 (15%) 4 (20%) 2 (10%) 51-60 5 (25%) 6 (30%) 5 (25%) >60 12 (6-%) 10 (50%) 13 (65%) Not significant P value=0.772 Gestational age
(W) <6 W 4 (20%) 2 (10%) 2 (10%) 6-8 W 14 (70%) 14 (70%) 13 (65%) >8 W 2 (10%) 4 (20%) 5 (25%) Not significant P value =0.700
Table (2): Number (%) and mean gestational age of ruptured and unruptured tubal pregnancies in group A. No.(%) Mean gestational age (W) Ruptured 12 (60%) 8 Unruptured 8 (40%) 6.5 Total 20 (100%)
Table (3): No. (%) of ampullary and isthmic pregnancies in group A. No. % Ampullary 17 85 Isthmic 3 15 Total 20 100
Table (4): No. (%) of ruptured ectopic pregnancy in ampullary and isthmic pregnancies in group A. Ruptured No. (%) Unruptured No. (%) Total Ampullary 9 (53%) 8 (47%) 17 Isthmic 3 (100%) 3 Total 12 8 20
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Maternal serum creatine kinase and single serum progesterone Aseel Ghazi Rifat measurement as predictors of ectopic pregnancy
Table (5): Mean serum CK level for all groups. Mean serum CK level IU/L ± standard error
A B C 302.37±23.6 80.56±5.3 96.38±5.0
Table (6): Mean serum CK level in ruptured and unruptured ectopic pregnancy. Mean serum CK level IU/L± standard error Ruptured Unruptured CK 359.90±90 203.59±14.28
Table (7): Mean serum CK level in ampullary and isthmic pregnancy. Mean serum CK level IU/L± standard error Ampullary Isthmic CK 278.36±22.88 438.42±28.78
Table (8): Mean serum progesterone level for all groups Mean serum progesterone level ng/ml± standard error A B C 5.11±0.5 4.19±0.4 31.39±1.2
Table (9): Mean serum progesterone level in ruptured and unruptured ectopic pregnancy. Mean serum progesterone level ng/ml± standard error Ruptured Unruptured progesterone 6.14±0.65 3.59±0.67
Table (10): Mean serum progesterone level in ampullary and isthmic ectopic pregnancy. Mean serum progesterone level ng/ml ± standard error Ampullary Isthmic progesterone 4.84±0.55 6.63±1.91
Figure (1): Regression curve estimation for correlation between serum CK level and serum progesterone level in group A.
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Maternal serum creatine kinase and single serum progesterone Aseel Ghazi Rifat measurement as predictors of ectopic pregnancy
Discussion: their studies were not statistically different from values obtained in control *Serum CK level in ectopic groups (25, 26, 27, 28, 29). pregnancy, abortion and normal However the mean levels of CK in the pregnancy control groups mentioned by Garcia- In this study it was found that the mean Velasco et al (25) were much higher than serum CK level in ectopic pregnancy the mean levels of CK in the control was significantly higher than in abortion groups of our study. What is striking and normal pregnancy (302.7 IU/L also is that the findings of these authors versus 80.56 and 96.38 IU/L could not be corroborated by the extent respectively). In a cut off level of 125 of tubal damage observed or by IU/L CK was (100%) sensitive and histologic evaluation of the involved specific for the diagnosis of ectopic tube which could influence the increase pregnancy. This is consistent with the in CK levels. results of Laive et al who found in two consecutive studies that CK levels in *Serum CK level in ruptured and ectopic pregnancy were raised above unruptured ectopic pregnancy levels observed in normal intrauterine In our study (60%) of tubal pregnancies pregnancy or missed miscarriage. They were ruptured. We found that CK level deduced that CK level above a cut off in ruptured ectopic pregnancy was value of 45 IU/L had a sensitivity & significantly higher than in unruptured specificity of (100%) and (86%) (359.9 IU/L versus 203.5 IU/L), respectively for the diagnosis of this however even in the unruptured group condition. They suggested that elevation the CK level was significantly higher in of CK in tubal pregnancy is due to comparison with abortion or normal trophoblastic invasion and ensuing pregnancy. damage to the muscularis layer of the WE found that a cut off value for CK of tube, known to lack submucosal layer (14, 250 IU/L was (91.6%) sensitive and 19). These findings was supported by the (87.5%) specific for the prediction of studies of other authors who found that tubal rupture. maternal serum CK can be an important In the study of Develiglue et al (53%) biochemical marker in suspected tubal of ectopic pregnancies were ruptured pregnancy (20, 21, 22, 23, 24). However the and they found that tubal rupture was difference in mean and cut off levels of associated with an increase in CK level CK measured in our study and these while in unruptured ectopic pregnancy studies may be due to the difference in CK level may not necessarily differ the method used for estimation of CK in from levels encountered in normal the serum , difference in selection pregnancy. They revealed that the criteria of patient and the use of optimal cut off value of CK to be used dissimilar control groups with different for the prediction of tubal rupture in nutritional and genetic factors. ectopic pregnancy was 120 IU/L which On the other hand the result of other resulted in a sensitivity of (65%) and studies doubt the described relationship specificity of (87%) (30). between serum CK and the existence of ectopic pregnancy because the CK values found in tubal pregnancies in
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Maternal serum creatine kinase and single serum progesterone Aseel Ghazi Rifat measurement as predictors of ectopic pregnancy
*CK level in ampullary and significantly lower than in normal isthmic EP intrauterine pregnancy (5.1 ng /ml 4.1 In our study (85%) of tubal pregnancies ng/ml versus 31.3 ng/ml). There was no were ampullary in location of which significance difference in progesterone (53%) were ruptured and (15%) of the level between ectopic pregnancy and cases were isthmic in location all of abortion .No intrauterine pregnancy which were ruptured. We found that the have progesterone level <20 ng/ml serum CK level in isthmic ectopic while no ectopic pregnancy have pregnancy is significantly higher than in progesterone > 10ng/ml. It may be ampullary EP (438.42 IU/L) versus suggested that in ectopic pregnancy the (278.36 IU/L). This is inconsistent with fetoplacental unit appears to be the findings of Develiglue et al (30) and dysfunctional presumably affected by has been confirmed in more recent the adverse condition at implantation studies done by Soundravally et al and site o of the fallopian tube and this is Abha et. al. (23, 31). reflected by the uniformly low serum The presence of tubal rupture alone progesterone level. cannot account for the higher CK level This is consistent with the finding of observed in isthmic compared with Mathews et al and other authors who ampullary ectopic pregnancy. Although described different discriminatory levels the frequency of tubal rupture is for serum progesterone to distinguish admittedly higher in the isthmic ectopic viable intrauterine pregnancy from pregnancy a significant difference in CK accidents of pregnancy (abortion and level between the two groups exist even ectopic pregnancy ) both individually when only ruptured cases of isthmic and and collectively but they could not ampullary ectopic pregnancy are efficiently discriminate abortion versus (8, 32, 33, 34, 35) considered, So the reason for the higher ectopic pregnancy . They CK levels in the ruptured isthmic speculated that an active inhibitor or ectopic pregnancy compared with metabolic block for progesterone ruptured ampullary ectopic pregnancy synthesis could be present in patient could be a more extensive muscular with ectopic pregnancy to cause decline damage at the time of invasion in the in progesterone synthesis by corpus (8) former. luteum . Senterman et al have reasoned that the Serum progesterone was also reported to greater surface area of mucosa in the be lower in ectopic pregnancy than in ampulla could favor intraluminal normal intrauterine pregnancy by other placental growth were as a relative lack studies but there was significant overlap (36, 37, 38) of mucosa and the small caliber of the between values in both groups . lumen could allow early invasion of the tubal wall in isthmic ectopic pregnancy *Serum progesterone in ruptured (13). and unruptured ectopic pregnancy It was found that serum progesterone in *Serum progesterone in ectopic ruptured ectopic pregnancy was pregnancy, abortion and normal significantly higher than in unruptured pregnancy ectopic pregnancy. In the study of In our study progesterone level in Hubinont et al (52%) of ectopic ectopic pregnancy and abortion was pregnancy were ruptured. A significant
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Maternal serum creatine kinase and single serum progesterone Aseel Ghazi Rifat measurement as predictors of ectopic pregnancy positive correlation was present between ectopic pregnancy, in addition it could B-HCG and serum progesterone. They help in discriminating ruptured from concluded that the vitality of ectopic unruptured ectopic pregnancy. pregnancy that eventually ruptures is 3-Serum progesterone efficiently probably better than that of those do not discriminate ectopic pregnancy from rupture. This explains both the higher normal intrauterine pregnancy but it hormone secretion and the trophoblastic does not differentiate it from proliferation leading to tubal rupture (39). miscarriage. Stovall et al findings in two different 4-The combined use of serum CK and studies were consistent with these serum progesterone measurement in findings (10). patients with suspected ectopic *Serum progesterone in ampullary pregnancy has a higher differential and isthmic ectopic pregnancy accuracy than either analysis alone. Our study revealed that serum progesterone in the isthmic ectopic Recommendation: pregnancy was higher than in ampullary 1- Serum CK and serum progesterone ectopic pregnancy, yet the difference levels vary between laboratories and was not statistically significant. There depend on the assay method used, so the was no available study comparing serum clinician should be aware of the normal progesterone level between ampullary levels from laboratory at his institution and isthmic pregnancy. before using the information clinically. *Correlation between serum CK 2- Serum CK and progesterone and serum progesterone in ectopic screening are advised to be widely employed in emergency department pregnancy. setting for patients at risk of ectopic Other finding in this study was the pregnancy regardless of symptoms, and presence of significant positive in any patient with risk factor if the correlation between serum CK and diagnosis of ectopic pregnancy is being serum progesterone in ectopic considered. pregnancy. The combined use of both 3- The combined use of serum CK and assays in patients with suspected ectopic serum progesterone in the evaluation of pregnancy may increase the proportion patient at risk of ectopic pregnancy of cases in which adequate diagnosis require further confirmation in a can be established early and in which prospective trial before wide spread less invasive therapeutic approaches will clinical implementation. be sufficient. Laive et al did not find such correlation in their studied (14) References: groups . [1]. Cunning F.G, Mac Donald P.C,.Grant N.F.etal : Reproductive success and failure Conclusion: .In : William Obstetrics , 20th edition , vol . 1-An increase in serum CK levels (1), 1997:607-634. accompanying muscular damage in [2]. Ash Monga and Stephen Dobbs: ectopic pregnancy antedates tubal problems in early pregnancy. In: th rupture, and may be related to Gynecology by ten teachers, 19 edition, trophoblastic growth patterns. 2011: 94-98. 2-Serum CK level is useful, rapid and [3]. Shamkoni M,Nelson NL, Gambone JC: easy test for early primary diagnosis of Ectopic pregnancy . In: Hacker N.F., Gambone JC, Hobel CJ. (Eds) Essentials of Journal of Kirkuk Medical College 45 Vol. 1, No. 2, 2013
Maternal serum creatine kinase and single serum progesterone Aseel Ghazi Rifat measurement as predictors of ectopic pregnancy obstetric and gynecology, 5rd edition. [15]. Gronowski A.M., Levine M.L., Philadelphia, W.B Saunder 2010:292-297. Reproductive endocrine function. In: Bartis [4]. Grudzinsksas J.G: Ectopic pregnancy. C.A., Ashwood E.R. (Eds). Tietz textbook In: Edmonds D.K (Eds). Dewhurst, of clinical chemistry, 3rd edition. textbook of obstetric and gynaecelogy for Philadelphia, WB saunders company, postgraduates, 6th edition, 1999:66-71. 1999:1610-1637. [5]. Rosavear S.: Bleeding in early [16]. Ganong W.F.: The Gonads pregnancy. In: James D.K., staer P.I. Development and function of the Weiner C.P. (Eds). High risk pregnancy, 2nd reproductive system In: Review of Medical edition 1999:72-81. physiology, 18th edition, USA, Appleton [6]. Rosai J.: Fallopian tube. In: Ackerman's and long company, 1997:415-416. surgical pathology, 8th ed., Philadelphia, [17]. Dart R., Dart L., Segal M., et al.The Mosby company, 1996: 1448-1459. ability of a sdingle serum progesterone to [7]. Halim M., Sjoblom P., Lindblom B. identify abnormal pregnancies in patient Combined use of progesterone and human with beta-HCG values less than 1000 chorionic gonadotropin determination for mIU/ml. Acad. Emerg. Med. 1998; 5 (4): differential diagnosis of very early 304-309. pregnancy. Fertil. Steril. 1991; 55 (3):492- [18]. Witt B.R., Wolf D.J., Wainwright 496. C.J., et al. Relaxin, Ca-125, progesterone, [8]. Saxena R: Ectopic Pregnancy in estradiol, Schwangerschaft protein and Bedside Obstetric and Gynecoilogy, 1st ed. HCG as predictor of outcome in threatened ,New delhi, JP brothers ,2010:486-501. and non threatened pregnancies. Fertil. Steril. 1990; 53(6):1029-1063. [9]. Banerjee S., Aslam N., Woelf B., et al. [19]. Laive O., Newman M., Beller U. Expectant management of early pregnancy Replay Am. J. Obstet. Gynaecol. 1996; of unknown location: a prospective 175(1):239-240(letters). evaluation of methods to predict [20]. Chandra L., Jain A. Maternal serum spontaneous resolution of pregnancy Br. J. creatine kinase as abiochemical marker of Ostet. Gynaecol. 2001; 108: 158-163. tubal pregnancy. Int. J. Gynaecol. Obstet. [10]. Stovall T. G., Ling F. W. Ectopic 1995; 49(1):21-23. pregnancy: Diagnosis and therapeutic [21]. Saha P.K., Guptal I., Ganguly N.K. algorithms minimizing surgical Evaluation of serum creatine kinase as intervention. J of Reprod. Med. 1993; diagnostic marker for tubal pregnancy. 38(10):807-812. Aust-N-Z-J- Obstet. Gynaecol.1999; [11]. Lott JA,Abott L. B. Creatine Kinase 39(3):366-367. (abst). isoenzymes. Clin. Lab. Med. 1986; 6:547- [22]. Cartwright J., Duncan W.C., Critchly 576. H.O. et al.Serum biomarkers of tubal [12]. Moss D.W., Headerson A.R.: Clinical ectopic pregnancy, Reproduction .2009; enzymology. In: Bartis C.A. Ashwood E.R. rd 138:9-22. (Eds). Textbook of clinical chemistry, 3 [23]. Abha S., Shweta B. Serum creatinine edition, Philasdelphia, WB Saunders kinase-an alternative diagnostic marker in company, 1999:617-721. ruptured tubal pregnancy.J Obstet Gynecol [13]. Senterman M., Jibdh R., Tulandi T. India. 2005; 55(5):451-453. Histopathologic study of ampullary and [24]. Katsikis I.,Rousso D., Farmakiotis D. isthmic tubal ectopic pregnancy. Am. J. et al.Creatine phosphokinase in ectopic Obstet. Gynaecol. 1988; 159(4):933-941. pregnancy revisited: significant diagnostic [14]. Laive O., Beiier V., Neuman M., et al. value of its MB and MM isoenzyme Maternal serum creatine kinase a possible fraction. Am J Obstet Gynecol. 2006; predictor of tubal pregnancy. Am. J. Obstet. 194:86-91. Gynaecol. 1993; 16995):1149-1150.
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Maternal serum creatine kinase and single serum progesterone Aseel Ghazi Rifat measurement as predictors of ectopic pregnancy
[25]. Garcia-Velasco. J.a., Requena A., ectopic pregnancy: exchange specificity and Santisteban J. Maternal serum creatine sensitivity to obtain optimal test kinase: a possible predictor of tubal performance Fertil. Steril. 1997; 67:980- pregnancy? Am. J. Obstet. Gynaecol.1996; 981. 175(1):238-239. [34]. Daponte A, Pournaras S, Zintzaras E, [26]. Korhonen J., Alfthan H., Stenman et al. The value of A single combined U.H., et al. Failure of creatine kinase to measurement of VEGF, glycodelin, predict ectopic pregnancy. Fert. Steril. progesterone, PAPP-A, HPL and LIF for 1996; 65(5):922-924. differentiating between ectopic and [27]. Qasim S.M., Trias A., Sachder R., et abnormal intrauterine pregnancy. Human al. Evaluation of serum creatine kinase Reprod .2005; 20:3163-3166. levels in ectopic pregnancy.Fert. Steril. [35]. Katsikis I, Rousso D, Farmakiotis D. 1996;65(2):443-445. et al. Receiver operator characteristics and [28]. Spitzer M, Pinto AB, Dasgupta R, et diagnostic value of progesterone and Ca- al. Early diagnosis of ectopic pregnancy: 125 in the prediction of ectopic and can we do it accurately using a biochemical abortive intrauterine gestation. European J profile? J Womens health Gend Based of Obstet Gynecol and Reproductive Med: 2000; 9:537-544. Biology. 2006; 125:226-232. [29]. Kurzel RB, Mazdisnian F , Paige S. et 36-Milwidsky A., Adoni A., Segal S. al. Serum creatine kinase is not a reliable Chorionic gonadotropin and progesterone indicator of ectopic pregnancy.Int J Fertil levels in ectopic pregnancy. Obstet. Womens Med. 2001;46:300-3. Gynaecol.1997; 50(2):145-147. [30]. Develioglue O.H., Askalli C., Uneu [37]. Condous G, Lu C, Van Huffel SV, G., et al. Evaluation creatine kinase in Timmerman D. et al .Human chorionic ectopic pregnancy with reference to tubal gonadotrophin and progesterone levels in status and histopathology . Br. J. Obstet. pregnancies of unknown location. Int J of Gynaecol. 2002; 109:121-128. Gynecol and Obstet .2004; 86:351-357. [31]. Soundravally R, Soundra RS and [38]. Muller MD, Raio L, Spoerri S, et al . Selvaraj N.Serum creatine kinase as a Novel placental and non placental serum predictor of tubal ectopic pregnancy. Int J markers in ectopic versus normal of Gynecol & Obstet . 2007; 98:253-254. intrauterine pregnancy.Fertil and Steril. [32]. Mol B.W, Lijmer J.G, Ankum W.M, 2004; 81:1106-1111. et al. The accuracy of single serum [39]. Hubinont C. J., Thomas C., Schwers, progesterone measurement in the diagnosis J.F. Luteal function in ectopic pregnancy. of ectopic pregnancy. Hum.Repord. 1998; Am. J. Obstet. Gynaeco. 1987; 15(3):669- 13(11):3220-3227. 674. [33]. Mc Cord ML, Muram D, Buster JE, et al. single serum progesterone as ascreen for
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Development of chronic conjunctival swelling in association Abdulhameed Abdulmajeed Hassan with congenital lymphedema
Development of Chronic Conjunctival Swelling in Association with Congenital Lymphedema
Brian Campolattaro, Abdulhameed Abdulmajeed Hassan, Francine Beli Department of Pediatric Ophthalmology/ New York Eye & Ear Infirmary/ USA Department of Surgery /College of Medicine/ Kirkuk University Department of Pediatrics/ River Valley Pediatrics Clinic/ USA
Abstract:
Although the association between the conjunctival swelling & lymphedema is rare, but this may occur, most of the cases described are part of the lymphedema distichiasis syndrome, this is the first case reported in North America where patient developed many years after birth (when the patient is 9 years old) an isolated chronic conjunctival swelling (not associated with any syndrome affecting the eyes) in association with congenital lymphedema of the feet. Key words: Conjunctival swelling, Lymphedema, Childhood diseases.
Introduction: Lymphedema describes a clinical progressive, the secondary form results condition characterized by the when an inflammatory or mechanical following: obstruction of the lymphatic's which 1- Painless edema of one or both lower occurs from trauma , regional lymph limbs usually involves the dorsum node resection or irradiation or of the foot & toes primarily in extensive involvement of the regional young women. lymph nodes by malignant disease or 2- Initially pitting edema, which filariasis , secondary dilation of becomes brawny & often non- lymphatic's that occur in both forms pitting with time. leads to incompetence of the valve 3- Ulceration, varicosities & stasis system , disrupting the orderly flow pigmentation do not occur, but there along the lymph vessels & result in may be episodes of lymphangitis progressive stasis of protein rich fluid and cellulitis. with secondary fibrosis , episodes of The underlying mechanism in acute & chronic inflammation may be lymphedema is impairment of the flow superimposed with further stasis & of the lymph from an extremity, when fibrosis , hypertrophy of the limb results due to congenital developmental with markedly thickened & fibrotic skin abnormalities consisting of hypo- or & subcutaneous tissue with decrease in (1) hyperplastic involvement of the fatty tissue . proximal or distal lymphatic's, it is Although the association between the referred to as the primary form. The conjunctival swelling & lymphedema is obstruction may be in the pelvic or rare, but this may occur, most of the lumber lymph channels and nodes when cases described are part of the (2) the disease is extensive and lymphedema distichiasis syndrome ,
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Development of chronic conjunctival swelling in association Abdulhameed Abdulmajeed Hassan with congenital lymphedema this is the first case reported in north improvement noticed in her strabismus America (as to our knowledge ) where and amblyopia with time, but on her patient developed after birth in her visit to the office at Jan. 18, 2011, the childhood a chronic conjunctival development of bilateral conjunctival swelling in association with congenital nasal side chemosis worse on the right lymphedema of the feet . eye noticed, this associated with her accommodative esotropia and high Case report: hyperopic astigmatism, fortunately her A young girl (DOB: March 19 , 2003 ) left amblyopic eye improved with best with a history of congenital chronic corrected visual acuity 20/20 OD, 20/40 lymphedema at her feet (figure 1) OS, her cycloplagic refraction was referred to our office from River valley +6.00 OD & +7.75 / -0.75 *180 OS, full Pediatrics Clinic complaining from time spectacles required, a small angle strabismus on September 10, 2007, a esotropia was noted at distance and near thorough examination performed & the vision which becomes better controlled following observed : the best corrected with spectacle correction, otherwise the visual acuity is 20/30 +2 OD & 20/60 slit lamp and fundus examination were +2 OS , the cycloplagic refraction was normal, Alrex eye drops were prescribed +8.00 / -0.75 *8 OD & +9.25/-1.00 *170 in her right eye three times daily for two OS (anisometropic hypermetropic weeks and part time occlusion therapy astigmatism), left accommodative of her more dominant right eye was esotropia for distance & near with left recommended during non-school hours, amblyopia, the reminder of her slit lamp follow up after one month suggested. examination revealed normal structures Later with subsequent visits there were & dilated fundus examination was no improvement of the conjunctival within normal limits. Atropine swelling (figure 2), although all allergic penalization as a form of occlusion and other causes were rolled out therapy was prescribed once daily in her (conjunctival biopsy was refused by the right eye for one month with a full time mother), this lead as to the conclusion spectacles were prescribed, a follow up that the development of this in 2 months were suggested. conjunctival chemosis in the patient The patient continued regular visits to may be associated with her the office with continuous checkup and lymphedema.
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Development of chronic conjunctival swelling in association Abdulhameed Abdulmajeed Hassan with congenital lymphedema
Figure (1-a): Bilateral foot & leg edema- Figure (1-b): Bilateral foot &leg edema- frontal view. frontal view.
Figure (1-c): Bilateral foot & leg edema Figure (2): Chronic conjunctival swelling from back. (name removed for patient privacy).
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Development of chronic conjunctival swelling in association Abdulhameed Abdulmajeed Hassan with congenital lymphedema
Discussion: of the feet who developed later in her The association between conjunctival childhood (when she became nearly 9 swelling in conjunction with chronic years old ) a chronic conjunctival lymphedema is rare, most of the cases swelling. reported are part from the so called (lymphedema distichiasis syndrome ) (2), Conclusion: few other cases reported to have such Isolated congenital chronic lymphedema association, one reported by Perry and may be associated with the development Cossary, they described a three and half of chronic conjunctival swelling later in year old female with Turners syndrome childhood many years after birth. and strabismus having bilateral References: conjunctival chemosis persistent for [1]. Lawrence M. Tierney, Stephen J. years in association with lymphedema (3) Mcphee, Maxine A. Papadakis: Current , another case reported by Bourcier, medical diagnosis & treatment. 39th ed. Baudrimont, Mayaud and Laroche , New York, McGraw-Hill ; 2000:494-495. they described a patient with a yellow [2]. Jack J.Kanski & Brad Bowling: nail syndrome ( a rare syndrome Clinical ophthalmology. Seventh ed characterized by slow growing yellow .London, Elsevier Saunders;2011:27. nails associated with peripheral [3]. Henry D. Perry, Alered J. Cossary. lymphedema) who developed a chronic Chronic lymphangiectasis in Turner“s conjunctival chemosis (4), there is only syndrome. British journal of ophthalmology one case which reported by Tabbara 1986; 70:396-399. [4]. Bourcier T, Baudrimont M , Mayaud and Baghdassarian, where they C & Laroche L . Conjunctival changes described a patient having isolated associated with yellow nail syndrome. congenital lymphedema of extremities British journal of ophthalmology 2002; 86: (not associated with any other 930. syndrome) in association with [5]. Tabbara KF, Baghdassarian SA. conjunctival edema ,but their case Chronic hereditary lymphedema of the legs developed conjunctival swelling earlier ( with congenital conjunctival lymphedema . when the patient was 7 years old ) (5), American journal of ophthalmology 1972; our case is the first case reported to have 73: 531-1. isolated congenital chronic lymphedema
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E valuation of the employment of four laboratory diagnostic methods Yahya Jirjees Salman in detecting of Giardia lamblia among children in Kirkuk City.
Evaluation of the Employment of Four Laboratory Diagnostic Methods in Detecting of Giardia lamblia among Children in Kirkuk City.
Yahya Jirjees Salman, Maha Ismaiel Mussttafa Department of Microbiology/ College of Medicine /Kirkuk University. Department of Biology/ College of Science /Kirkuk University.
Abstract: Background: Giardiasis is the most common cause of diarrhea among people in Iraq, caused by Giardia lamblia parasite. Laboratory diagnosis requires diversity usage of method to reveal the parasite with in different types of specimens. Aim: The aim of this study were to determine the prevalence of giardiasis in Kirkuk city, to assess the efficacy of four different methods employee in detecting Giardia parasite and an attempt to extract and amplify DNA of this parasite using mixed primers of Giardia assemblages A and B. Material and Methods Cross sectional study was carried on a total of 310 stool samples were collected and tested for giardiasis by using direct microscopy, ELISA-corpo-antigen, Lateral immune-chromatography assay (Triage panel) and PCR technique. Results: The overall rate of parasitic infection was (51.93%); Giardia lamblia rate was (20.32%). Giardiasis among males was higher than in females. Traige panel show high efficacy for detecting Giardia lamblia than detecting of Entamoeba histolytica and cryptosporidium. Statistically the differences among direct microscopy, ELISA and Triage panel were not significant. Application of PCR single step technique show high rate of sensitivity than other methods in detecting giardiasis. Amplified Giardia genome length extended from 280 to 750 bps with mean of 437.6 bps. Conclusions: Giardiasis among peoples in Kirkuk city was high especially among males. Triage panel and ELISA were simple and easy, but were less sensitive than conventional microscopy methods. PCR technique using k 725 gene (Mixed primers of assemblages A1, A2 and B) loci was performed for the first time in Kirkuk city with high sensitivity and specificity than other laboratory methods. Key words: Giardiasis, Cryptosporidium, ELISA, Triage panel, PCR, Sensitivity.
Introduction: Giardia intestinalis (also known as G. applied for the identification of this (3) lamblia, G. duodenalis) is the most parasite . Giardia genotypes A and B commonly diagnosed protozoan have been isolated in human samples worldwide causing non-bacterial and show biological and pathogenic (4) diarrhea (1). It is a complex species with differences . In the amplified fecal similar morphologic characteristics but samples of the isolates obtained, with phenotypic and genotypic zoonotic genotypes A II and B were heterogeneity (2). In recent years; detected, the latter being predominant. genotypic classification has been These results match the global
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E valuation of the employment of four laboratory diagnostic methods Yahya Jirjees Salman in detecting of Giardia lamblia among children in Kirkuk City. predominance of genotype B (5). The goals of this study, first is to Children with genotype-B infection evaluate the employee of direct were reported to release more cysts than microscopy, lateral immune- those infected with genotype A (6). chromatography assay, ELISA-corpo- Diagnosis of Giardia by conventional antigen with PCR usage for detecting microscopic methods following the Giardia lamblia in stool samples in application of fecal concentration Kirkuk city. The second aim is to extract techniques, especially zinc sulphate Giardia lamblia DNA from stool flotation and centrifugation remains a samples and to detect purity and relatively reliable indicator of genomic mass of the Giardia parasite. infection (7). The detection of Giardia by microscopy or fecal ELISA is of limited Materials and Methods: epidemiological value. The development In total, 310 fresh stool specimens were of the rapid lateral immune- tested at the Medical Research chromatography assay Triage panel laboratory – Kirkuk College of improved the sensitivity of detecting Medicine. The samples were obtained and quantitating the fecal Giardia cysts from patients attending the private and more accurate prevalence rate and clinics and medical labs in Kirkuk city cysts excretion intensities as compared who presented with abdominal to the conventional microscopy. There is symptoms, mainly diarrhea. Prior to need for a sensitive and specific processing complete information were diagnostic procedure for detecting the reported in a special questionnaire etiological agent of infectious disease, prepared for this purpose. One aliquot of with Giardia, molecular techniques each sample was immediately examined particularly PCR based procedures have using direct wet preparations of lugols greater sensitivity and specificity than iodine (1%) and (0.85%) of NaCl for the conventional diagnosis that are detecting motility of Giardia reliant on microscopy or immune- trophozoites and other intestinal diagnosis (8). One of major advantage of protozoan parasites. The residue of each PCR based techniques is the eases of specimen was preserved by adding interpretation which usually involves the sufficient amount of (2.5%) of visualization of small number of bands potassium dichromate for examination on a gel (9). The prevalence of Giardia by other laboratory methods (11). A duodenalis genotypes was determined in second aliquot of each stool specimen adult dairy cows. Specimens, cleaned of was immediately frozen and stored at - fecal debris and concentrated using 20 C. Subsequently, the frozen aliquots (CsCl) density gradient centrifugation, were thawed and mixed thoroughly were subjected to PCR and DNA before testing with immune- sequence analysis. G. duodenalis chromatographic dipstick tests (Triage infection, the prevalence was ranged Micro Parasite Panel) which is an from (3%) to (64%), with an average enzyme immunoassay for the detection prevalence of (27%). DNA sequence of G. lamblia, E.histolytica/dispar and analysis of the 16S rRNA gene revealed Cryptosporidium parvum in fresh or the presence of Assemblage A (2%) and fresh frozen, un-fixed human fecal Assemblage E (25%) in G. duodenalis specimens. The presence of the specific (10) infection . antigens is detected usually by the presence of a purple- black color bar
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E valuation of the employment of four laboratory diagnostic methods Yahya Jirjees Salman in detecting of Giardia lamblia among children in Kirkuk City. next to the name printed and the test amplification was done according to device. This procedure was done manufactured company instruction according to (12). The Giardia C-ELISA which included the following cycles: 15 (capture enzyme immunoassay) kit is a seconds at 95 C, 15 seconds at 60 C qualitative in vitro enzyme and 15 seconds at 72 C. Each immunoassay for the detection of temperature degrees were repeated 35 Giardia lamblia cyst antigen in fecal cycles. specimens was used. The procedure was Four: Gel Electrophoresis which applied according to instruction of involve the following procedure; Gel manufactured company and according to Agarose (2.0%) in TAE (1x) (13) that used by . Genomic mass of buffer(agarose powder 2.0 gm was Giardia lamblia were detected by using dissolved in 100 ml Tris –acid borate the four following steps: buffer which prepared by adding 10 ml First: DNA extraction from stool of TAE 1x to 100ml of distilled water. samples, for that, the E.Z.N.A. stool Heated gently avoiding boiling, 50µl of DNA Kit was purchased from Omega ethidium bromide stain solution bio kit company –German. (0.5μg/ml); was added to agarose Second: DNA purity assessments: Total solution then poured in to gel tang of 107 extracted DNA elutes in step one containing special chambers with were checked for purity using Thermo standard coombs. After 5 to 10minutes TM Scientific Nano-Drop 2000c and before the gel completely dry, the spectrophotometer manual protocol ,that combs were up stand hold to permit carried on by using a ratio of ~1.8 is pores in the gel).About 200ml of 1x generally accepted as “pure” for DNA; a TAE buffer was added to gel chamber, ratio of ~2.0 is generally accepted as 2μl of dye (tube F) was added to each (14) “pure” for RNA. . micro-tubes. Amount of 10μl of marker Third: the amplification of each (tube E: 100bp) were inserted in to the specimen that done by using first and the last lane of electrophoresis, conventional Gene-Amp PCR System while other lanes were inserted with 9700, Dual 384-Well Sample Block amplified samples. The gel Module .While amplification kit has electrophoresis instrument was set for been manufactured by 60 min. at 120 Volt. After finishing the GenekamBiotechnology AG, Germany electrophoresis, the visualizing of was used to detect Giardia lamblia (in Giardia DNA band was done with one step). It contains the following: wearing UV goggles. The length of Tube A forward primer, which consist giardia genome was measures by using of a mixture of assemblage A1, A2 and UV standard scale and confirmed with B). Tube B reverse primers for all the length of marker bands at the first assemblages. Positive control (tube D1), and last lanes to give out the length of negative Control (tube D2), DNA giardia genome /bps. Marker (tube E): (max 1000 bp): 100, 150, 200, 300, 400, 500, 600, 700, 800, Statistical analysis: 900,1000bp and Dye (tube F). Thermo- The following terms and equations were cycler (Gene Amp® PCR System used for detecting the efficacy of 9700Dual 384-Well Sample Block laboratory methods in detecting Giardia Module) was switch on for sample lamblia; TP=True positive, NP=True amplification process, and the negative, FP=false positive, FN=false
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E valuation of the employment of four laboratory diagnostic methods Yahya Jirjees Salman in detecting of Giardia lamblia among children in Kirkuk City. negative, PPV=positive predictive value Giardia+Iodamoeba+Balantidium coli, and NPV=negative predictive value. for each the rate was (0.32%) Sensitivity=TP/ (TP+FN). respectively, (table 2). (Table 3) Specificity=TN/ (TN+FP), Accuracy= showing the efficacy of three laboratory (TN+TP) (TN+TP+FN+FP), PPV=TP methods for demonstrating Giardia, (TP+FP) and NPV=TN/ (TN+FN) (15). E. histolytica and cryptosporidium, high All data in the present study were stored rate of Giardiasis (20.23%) and in Microsoft Excel program and (19.35%) were recorded by using direct arranged in tables. Some statistical microscopy(double preparation) and formulas such as: Chi-square, t-student ELISA, compare to (14.51%) by using test, Fisher test and sign test for medium Triage panel, P<0.05. Cryptosporidium were used to detect variances among and E. histolytica detecting rates were parameters in the study at probability (6.45%) and (2.6%) using direct 0.05 and.0.01. microscopy compare to (4.5%) and (3.5%) using Triage panel respectively, Results: P>0.05. Triage usage for three parasites From the examination of total 310 stool perform high efficacy for giardiasis samples, the all rate of parasitic (14.51%) followed by (4.5%) and infections was (51.93%), this rate (3.5%) for Cryptosporidium and consist of high rate of intestinal E. histolytica respectively, P<0.05.For protozoan infection (42.58%) that assessments the efficacy of four involved (20.32%) for Giardia lamblia employee methods in detecting Giardia and (22.25%) of other intestinal lamblia, the application of sensitivity, parasites. while intestinal helminthic specificity and accuracy of laboratory rate was (9.35%). Relationship between methods: High rate of giardiasis intestinal protozoan and helminthic (21.29%) was reported by using by PCR distribution was statistically significant, technique, followed (20.32%) and P <0.05. (Table1). According to gender, (19.35 and 14.51)% by using direct wet the rate of giardiasis was higher in preparation technique, ELISA and males (18.01%) than in females Triage panel respectively P<0.05 .. (9.04%), P< 0.05.Giardia co-exist Statistical analyses reveal low efficacy infection rate with other intestinal and sensitivity of Triage panel in protozoan parasite was (7.05%) detecting giardiasis. While specificity compare to (0.96%) for Giardia co- and accuracy of all methods were not existing helminthic parasitic infections. significant. Negative predictive values More common protozoan coexisted NPV in relation to type of laboratory were Giardia +Cryptosporidium methods were high, but statistically parvum (2.3%) and Giardia were not significant, controversy to +Blastocystis hominis (1.28%), while positive predictive values PPV that Common helminthic coexistence with showed significances, P<0.05. (Table Giardia were Hymenolepis nana, 4). The molecular study of Giardia Enterobius vermicularis and lamblia by using the extract of DNA Ancylostoma duodenali (0.32%) for all from 107 stool samples positive for helminthes equally. Triple protozoan giardia, reveal (1.7%) of genome purity infections were recorded with and 437.56 bps genomic mass or density Giardia + Cryptosporidium + Ent.coli, in 80 extract. While the extract of Giardia+Blastocysits+Ent.coli and Giardia positive with other protozoa;
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E valuation of the employment of four laboratory diagnostic methods Yahya Jirjees Salman in detecting of Giardia lamblia among children in Kirkuk City. purity and mean genomic mass were use of PCR kit, K725, the amplificated (1.56%) and 439.89 bps respectively. genomes reveal bands migration during Controversy to Giardia positive with electrophoresis process ranged from 280 intestinal helminthes that show (1.49%) bps to 715 bps, but the majority of of genome purity and 443.33 bps. giardia genomes were detected between Statistical analysis exerts no 350bps to 441bps. (Table 5) and significance among purity rates and (figure 1). genomic mass of giardia parasite. The
Table (1): Positive number and percentages of parasitic infections. Types of parasitic infection No. Positive % Positive Other intestinal protoza 69 22.25 Giardia lamblia 63 20.32 Total protozoan infections 132 42.58 * Helminthic infections 29 9.35 Total 161 51.93 Total No. exam=310 *P<0.05
Table (2): Giardia lamblia Co-infection rate with other intestinal parasites. Type of parasitic infection Male Female Total T- student Protozoan Mixed infections No.,(%)+ve No., (%) +ve No., (%) +ve and P values Giardia + cryptosporidium 4 3.6 * 3 1.5** 7 2.3 * p<0.05 Giardia + Blastocystis hominis 2 1.8 2 1.05 4 1.28 **P<0.05 Giardia + Iodamoeba butschlii 1 0.9 2 1.05 3 0.96 Giardia + Entamoeba coli 1 0.9 2 1.05 3 0.96 Giardia + Entamoeba. histolytica 1 0.9 0 0 1 0.32 Giardia + Crypto + E.histolytica 0 0 1 0.5 1 0.32 Giardia + Crypto + E.coli 1 0.9 0 0 1 0.32 Giardia + Blastocysits + E.coli 0 0 1 0.5 1 0.32 Giardia + Iodamoeba + Bal.coli 0 0 1 0.5 1 0.32 Total 10 9.0 12 6.03 22 7.09 Helminthic mixed infections Giardia+Ancylostoma dueodenale 1 0.9 0 0 1 0.32 Giardia+ Hymenolepis.nana 0 0 1 0.5 1 0.32 Giardia+Enterobius vermicularis 0 0 1 0.5 1 0.32 Total 1 0.9 2 1.0 3 0.96 Total mixed parasitic infections 11 9.99 14 7.03 25 8.065 Giardia lamblia (pure) 20 18.01 18 9.04 38 12.25 ***P<0.05 *** Total Giardia lamblia infection 31 10.00 32 10.32 63 20.32 Total number of male = 111 Total number of female= 199 Total No. exam=310
Table (3): Relationship between lab method and distribution of the intestinal parasites. Direct wet Preparation ELISA corpo antigen Triage Cassette parasites No, and % +ve No, and % +ve No, and % +ve Giardia lamblia 63 20.23 60 19.35 45 14.51 *a Cryptosporidium 18 6.45 Not applied 14 4.5 *b Entamoebahistolytica 8 2.6 Not applied 11 3.5 *c *a P<0.05, * b P>0.05, * c P>0.05 Journal of Kirkuk Medical College 56 Vol. 1, No. 2, 2013
E valuation of the employment of four laboratory diagnostic methods Yahya Jirjees Salman in detecting of Giardia lamblia among children in Kirkuk City.
Table (4): Distribution of Giardia lamblia according to laboratory methods. Lab No.of % Sensitivity Specificity Accuracy PDV NDV T-value methods +ve +ve %* % % and P 21.29 82.5 a*T=19.25 PCR 66 82.5 a* 93.75 b* 94.51 c* 98.36 a* d* P<0.05 Direct wet b*T=42.51 63 20.32 78.75 93.56 92.53 78.75 97.16 preparation P<0.05 C*t=110.48 ELISA 60 19.35 77.20 92.59 91.98 75 96.00 P<0.05 d*t=85.48 Triage 45 14.51 69.56 88.33 85.15 56.25 90.56 P<0.05 PDV=Positive predictive value NDV=Negative predictive value.
Table (5): Determination of parasites genome mass and genomes purity. Parameters Genome mass /bp Genome purity % Number Parasites * * Pure Giardia lamblia 437.56 1.705 80 In males 436.11 1.82 36 In females 443.99 1.59 44 Protozoa genomes mass Giardia+ Cryptosporidium pavrum 430.40 1.35 12 Giardia +Blastocystishominis 394.00 1.41 4 Giardia + Entamoeba coli 490.05 2.47 3 Giardia + Entamoebahistolytica 335.00 1.35 1 Giardia+Crptosporidum+Entamoeba 550.00 1.25 1 coli Total 439.89 1.56 23 Helminthes genome mass Giardia+ Hymenolepis nana 500.00 1.72 1 Giardia +Enterobiusvermicularis 480.00 1.41 1 Giardia+ Ancylostomaduedenali 350.00 1.35 1 Total 443.33 1.49 1 Total Giardia lamblia genomic mass 440.26 1.54 107 *P>0.05
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E valuation of the employment of four laboratory diagnostic methods Yahya Jirjees Salman in detecting of Giardia lamblia among children in Kirkuk City.
Discussion: The all rate of intestinal infection be due to socioeconomic status (24). For (51.93%) and Giardia lamblia rate diagnosis of Giardia infections; PCR (20.32%) in the present study were high single step and direct wet preparation when compared to those (0.90%, 9.3%, microscopy detection of Giardia parasite 13.13%, 13.7%, 14.41% and 15.8%) In provided the best results, with Kirkuk, Al-Kerbala, Kirkuk, Al-Najaf, sensitivities ranging from (82.5%) and Kirkuk and Babylon recorded by (16, 17, (78.75%). In contrast, the Giardia- 18, 19, 20, 21). Also it was not agreed with Triage panel that reveal low sensitivity those (11.4%) and (17.1%) recorded in (69.56%). Our finding was agree with Libya and Brazil respectively by (22, 23). that recorded by Sharpe, et.al.2001 (12) The rate of Giardia lamblia (20.32%) Lower sensitivity of triage panel might was lower than those (44.59%), be due that three types of antigens were (35.89%), and (62.2%) recorded in immobilized on chromatography paper Kirkuk, Erbil in Iraq and in Egypt by (24, holding three types of specific 25, 26). High prevalence of parasitic antibodies (30) or due to high rate of infection reflects: lower educational giardia co-infection in the present study. level to health hygiene among children, The sensitivity of ELISA test (77.20%) poor experience in toilet use, was close with (76.4 %) that recorded in overcrowded families, water Duhok province (31). Similar results contamination with Giardia parasite, and have been found in Egypt (32), the United lack of insecticides that had role in States (33) and Germany (34). The ELISA mechanical transmission of the infective copro-antigen and Triage panel assays stages of intestinal parasites. The were less time-consuming and easier to variance of Giardia rates from one perform, but were less sensitive than region to another might be due to nature conventional microscopy methods. of residence survey, level of personal While PCR technique remain high hygiene and sanitation, safety of water sensitive, specific and accurate than consumption from water supplies. In other methods, but it is not easy to addition to type of diagnostic performed and costly, it can be used in techniques, size of samples. The rate of researches or incase when giardia persist infection in males was higher than in in patient in spite of treatment, Thus, females. This might be due to that males these tests might be a useful addition to are mostly outside their houses and are stool examination for parasites including mostly exposed to feces transmitted Giardia lamblia, but not a substitute for parasites. This finding was not agreed microscopical methods in the diagnosis with those reported in two studies done of giardiasis. The giardia genome among different localities of Kirkuk extraction in current study was accurate governorate (19, 20) and with that recorded and precise, because the genomic purity by Kadir and al-Barzanji in Arbil (24, 27) (1.705%) was close to standardized and with that recorded by Al-Hanoon in mean (1.6 to 1.8)%. Also Giardia Mosul (28) whom they did not find lamblia mass mean 437.6bps was very significant difference in the rate of close to 432 bps fragment recorded in infection between males and females. Baghdad by Kader and baker, in2011(35) These differences were probably due to whom they use gdh gene locus the different in technique used, or could amplified in the PCR using primers
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E valuation of the employment of four laboratory diagnostic methods Yahya Jirjees Salman in detecting of Giardia lamblia among children in Kirkuk City.
GDHiF and GDHiR. Genomic mass by PCR. Vet. Parasitol., 2003; 110: 197- extension within study from 280 to 205. 750bps was not agree with that recorded [8]. Monis, P. T, R. H. Andrew, G. by (36) whom they were show Giardia Mayhofer and P. L. Ey. Molecular duodenalis genomic extract from systematic of the parasitic protozoan sewages ranged from 530 to 750 bps. Giardia duodenalis. Mol. Biol. Evol., 1999; 16: 113. 1144. Conclusion: [9]. Sultan A. Epidemiology, molecular Giardiais in Kirkuk province was high diagnosis and chemotherapy of giardiasis in bovine. Ph.D. thesis .Lahore Univ.2009. especially among males. PCR technique [10]. Trout, J. M., M. Santin., E. Greiner was highly sensitive for detecting and F. Fayer (2005). Prevalence and giardiasis in stool samples. ELISA and genotypes of Giardia duodenalis in post- triage panel were simple and easily weaned dairy calves. Vet. Parasitol., 130(3- performed, but microscopy diagnosis 4):177-183. remain high sensitive method. Mean [11]. Garcia L. Diagnostic medical genomic mass of Giardia lamblia pure parasitology, 1993; 2nd edit. Washington, was 437.6 bps with genome extension DC: American Society for Microbiology,. range from 280 to 750bps. [12]. Sharp SE, Suarez CA, Duran Y and References: Poppiti RJ Ealuation of the Triage Micro [1]. Adam RD Biology of Giardia lamblia. Parasite Panel for Detection of Giardia ClinMicrobiol Rev 2001; 14: 447-475. lamblia, Entamoeba histolytica/Entamoeba [2]. Thompson R and Monis P Variation in dispar, and Cryptosporidium parvum in Giardia: implications for taxonomy and Patient Stool S pecimens. J. Clin. epidemiology. AdvParasitol 2004; 58: 69- Microbiol.2001, 39 (1): 332-334. 137. [13]. Maraha B, Buiting AG. Evaluation of [3]. Mohammed Mahdy A, Surin J, Wan K, four enzyme immunoassays for the Mohd-Adnan A, Al-Mekhlafi M, Lim Y detection of Giardia lamblia antigen in stool Giardia intestinalis genotypes: Risk factors specimens.Eur J ClinMicrobiol Infect Dis. and correlation with clinical symptoms. 2000; 19(6):485-7. Acta Trop 2009; 112: 67-70. [14]. William W. Wilfinger, KM, and Piotr [4]. Cacciò S and Ryan U Molecular C. Effect of pH and Ionic Strength on the epidemiology of giardiasis. Spectrophotometric Assessment of Nucleic MolBiochemParasitol 2008; 160: 75-80. Acid Purity .Bio Techniques.1997; 22:474- [5]. Lebbad M, Ankarklev J, Tellez A, 481. Leiva B, Andersson J, Svard S Dominance [15]. Gardner MJ, Altman DG. Calculating of Giardia assemblage B in León, confidence intervals for proportions and Nicaragua. Acta Trop 2008; 106: 44-53. their differences. In: Gardner MJ, Altman [6]. Kohli A, Oluma Y, Bushen R, DG, eds. Statistics with confidence. Pinkerton E, Houpt R, Newman C, Sears A, London: BMJ Publishing Group, 1989; 28- Lima A, Guerrant R Giardia duodenal 33. isassemblage, clinical presentation and [16].Salman,YJ and Salih LA .Detection of markers of intestinal inflammation in some microbial infectious agents among brazilian children. Trans R Soc Trop Med children aging below two years in Kirkuk Hyg 2008; 102: 718-725. city.J.Kirkuk Med Coll.2013,1:53-63. [7]. McGlade, T. R., I. D. Robertson, A. D. [17]. Al-Mousawy,KA. Prevalence of Elliot and R. C. A. Thompson (). intestinal parasites among people in Highprevalence of Giardia detected in cats Kerbala. M.Sc.thesis Ibn-Alhaitham educ.Coll.2001.
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[18]. Juomaa E A. Effect of Giardia [28]. Al-Hanoon, Z.A. Study of Prevalence lamblia infection on some biochemical of Intestinal Parasitic Infection in Mosul changes of the human. 2006. M.Sc. thesis. .M.Sc. thesis, College of Science, Mosul Kirkuk Coll.Tech. University, Iraq, 1976. [19]. Al-Yasseri HFA. Isolation and [29]. 19.Haydar, A.A. Study of the identification of Entamoebahistolytica, Prevalence of Human Intestinal Parasites in Giardialamblia and Cryptosporidium Al-Tameem governorate and the Effect of parvum in Al-Najaf. M.Sc.thesis. Giardia lamblia in Some Blood Coll.Sci.Kufa Univ.2004. Components. M.Sc. thesis, College of [20]. Noori TK. Efficacy of some Medicine, Salahaddin University, Iraq laboratory methods in detecting some 1993. protozoan parasites in Kirkuk province. [30]. Pillai D. R., Kain K. C. M.Sc.thesis.Coo.SCI.kirkuk Univ.2013. Immunochromatographic strip-based [21]. Shenin, W TH. Epidemiological study detection of Entamoebahistolytica-E. dispar of some intestinal parasites among children and Giardia lambliacoproantigen. J. Clin. in Babylon city.M.Sc.thesis.Ibn- Microbiol.1999; 37:3017–3019. Alhaithameduc.Coll 2005. [31]. Al-saeed AT and Issa SH. Detection [22]. Dar F F, El-Kholey S I, El-Boulagi H of Giardia lamblia antigen in stool A, Munir R and El-MeghribiS.Intestinal specimens using enzyme-linked parasites in Benghzi school children. immunosorbent assay. EMHJ .2010; 16 Garyounis Med J.1979. (2):3-7. (4):362-364. [23]. Boia M N, Da-Motta L P,Salzar M D, [32]. Sanad M et al. 8. Giardia lambliaand Mutis M P,Conutinho R B and Coura J R. chronic gastritis.Journal of the Egyptian Cross sectional study of intestinal parasites Society of Parasitology, 1996, 26(2):481– and Chagas disease in the municipality of 95. Nova Airao-Amazons. Brazil Cad Soude [33]. Maraha B, Buting AGM. Evaluation Publca.2000; 15(3): 497- 504(Abstract in of four enzyme immune assays for the English). detection of Giardia lambliaantigen in stool [24]. Salman Y J, Al-Alousi T I and Hamad specimens.Eur j ClinMicrobiolInfect Dis. S Sh. Prevalence of intestinal parasites 2000, 19(6):485–7. among people in Kirkuk city using double [34]. Homan WL, Mank TG. Human wet preparations..Al-Mustanseryia J Sci; giardiasis: genotype linked dif10. ferences 2001; 1: 12-20. in clinical symptomatology. International [25]. Kadir M A, Kadir A A and faraj k K. journal for parasitology, 2001, 31:822–6. Survey study of intestinal parasites among [35]. Qader AM and Baker TY. Molecular different population of Erbil city .; JFac Identification of Giardia duodenalis Med Baghdad 1987; 29(4):455-459. Parasite Isolatesfrom Human by [26]. Yassin M M , Shubir M E, Al-Hindi A Polymerase Chain Reaction – L and JadAllah S Y. Prevalence of RestrictionFragment Length Polymorphism intestinal parasites among children in Geza Technique (PCR-RFLP) in Baghdad district. J Egy Sco.parasitol.2000; 2(29): Province.Diyala J Pure Sci.2011;7(4):54- 365-373. 60. [27]. Kadir, M.A. and Salman,Y.J. [36]. MAYER, CL and palmer CJ. "Prevalence of Intestinal Parasites Among Evaluation of PCR, nested PCR, and Primary School Children in Al-Tameem fluorescent antibodies fordetection of Province, Iraq". Ann. Coll. Med. Giardia and Cryptosporidium species in Mosul.2008; 25: 94-98. wastewater.Appl.EnvironMicrobiol.1996; 62(6):2081-2085.
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Management of the missile injuries of the knee Adnan Abdulmajeed Faraj
Management of Missile Injuries of the Knee
Adnan Abdulmajeed Faraj Department of Surgery/ College of Medicine/ Kirkuk University
Abstract:
Background and Objectives: Iraq continues to be a troublesome area, missile injuries around the large joints of the extremity remains to be a challenging injury to the under resourced and poorly equipped unsafe hospitals. The aim of this study is to report our experience in the management of such injuries. patients and methods: Thirteen patients (14 knees) with grade III Gustillo open fractures of the knee caused by war injury including bullets, shells of blast and missiles were treated by wound debridement, washout, repair of arterial injury after external or internal fixation of the fracture. Five patients (38%) required Dacron arterial graft for associated vascular injury, there was a case of permanent nerve damage (7%). Results: The outcome was satisfactory in 6 patients (46%), fair in five (38%) and poor in the remaining (16%). One limb remained was ischemic; one case of infection required amputation. These patients underwent wound debridement, skeletal fixation and vascular and or plastic reconstruction. Conclusion: There is high association of open war injuries of the knee with neurovascular
injuries. Awareness of the associated vascular injury and team approach, is vital in the management of these injuries. Skeletal stabilization using any method deem to be appropriate is associated with good outcome provided appropriate early wound debridement is performed. Key words: Open, Joint, Knee, Injuries, Bullets, Surgery, Shell.
Introduction: Proper management of bullet wounds Undoubtedly, these injuries poise a great requires a working knowledge of challenge to the surgeons. physical factors involved in the creation The high incidence and the management of such injuries and the way in which of these challenging injuries pose a they interact. American military threat to the inexperienced. surgeons repeatedly demonstrated that The aim of this study is to report our blood vessels. Remote from the bullet's experience in the management of such course were disrupted, with wide injuries. separation of fascial planes (1). Damage was most severe in tissues of greater Patients and methods: density, such as fluid-filled structures or Between 2003 and 2010, thirteen male bone (2). The extent of damage is patients with mean age of 38 years (16- attributed to the increased velocity, 47 years), were treated in the Azadi instability of the bullet in flight and in teaching hospital of Kirkuk for knee the tissues, and bone fragments as injury. The injury was caused by gun secondary missiles (3) . Contamination shot in five patients (velocity of more must always be suspected in gunshot than 1000m/sec) and by shaprnell of injuries and may occur in many ways. explosions in the remaining. The femur
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Management of the missile injuries of the knee Adnan Abdulmajeed Faraj
was affected in six patients (46%), the 4. Unidentified arterial injury (one) tibia was affected in four patients (7%). This settled down spontaneously, (30%), both femur and tibia was the injury was most probably affecting affected (through the knee) in the the geneicular artery. remaining (24%). All these patients had Internal fixation using plate and screws accordingly open fracture. Five of these for 4 cases (30%), external fixation was patients had Anderson-Gustillo Grade used for seven patients (55%); two ring III-C (38%), two patients had Grade III- fixators (15). In one case external A (15%) and the remaining patients had fixator was changed to internal fixation. grade III-B Gustillo open fractures Results: (47%). The injuries were bilateral in one At a mean follow-up of 19.4 months (6- case (7%). All these patients were 88 months), the following outcome young and fit; they had primary measures were studied: The outcome debridement and fixation within 12 was assessed following the following hours of injury, they were taken to criteria; we have designed our own operating theatre and underwent wound assessment of outcome measure: debridement and fixation, whenever Satisfactory (6 patients) (46%): required a vascular surgeon was Patient’s leg is viable, has functional consulted. Excluded from this survey, range of knee movement and the open fractures caused by injuries other fracture(s) has healed than bullet or shrapnel’s. Fair (4 patients, five knee) (38%): when The arterial repair was carried out by a the results are satisfactory (as above), vascular surgeon who explored the but the patient has pain of arthritis, femoral artery in the femoral triangle, to shortening of less than 3 cm and have a proximal control. The affected restrictive stiffness of the knee. part of the artery was excised to remove Poor (3) (16%): The presence of the torn intima and the artery was complications. repaired using Dacron graft. The arterial The following complications were surgery was as followed encountered: 1. Excision of the damaged segment and 1. Infection (one case) (7%), did not Dacron graft with fasciotomy (five) settle with repeated debridement, (38%) washout and antibiotics, had above knee 2. Direct repair of the popliteal artery amputation was carried out in one patient. 2. Malunion (1) (7%), requiring 3. Ligation of genicular artry (6 cases) derotation osteotomy and fixation. (46%) 3. Ischemic leg (one case) (7%) requiring below knee amputation.
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Management of the missile injuries of the knee Adnan Abdulmajeed Faraj
Table (1): Illustration of the cases, procedures and outcome
Age & Site injured Mechanism Procedure Outcome sex
left knee, penetrating left femur and Debridement, a flap of 25 M* upper tibia genicular artery injury, Gun infrapatellar fat pad was used to Satisfactory ligation seal-off the articular surface
Lt knee, upper tibia, genicular artery Shrapnel, 47 M Debridement, internal fixation Satisfactory injury, ligation explosion
Rt knee, lower femur, associated Debridement, repair of artery, 32M Gun Satisfactory femoral artery injury, Dacron graft external fixation of lower femur
Lt knee, lower femur, injury to a Ligation of artery, debridement, 46M Gun satisfactory branch of the popliteal artery, repair blade plate distal femur
Right upper tibia, segmental, 23M Explosion Debridement, external fixator Fair genicular artery injury, ligation
Lower femur, left, femoral arterial External, changed to internal 16M Explosion Poor injury, Dacron graft fixation
Rt knee, femoral artery injury, lower 45M Gun Arterial repair, External fixation Fair femoral fracture, Dacron graft
Rt lower femur, Lt articualr injury of 31M the knee with comminution, foot drop Explosion Ex fix across the knee Fair on the right side Dacron graft
Upper tibia left, genicular artery 24M Explosion Ring fixator Fair injury, ligated
Through the knee, popliteal artery, 26M Bullet Debridement, arterial repair Poor Dacron graft
Through the knee destruction/, 28M comminution, unidentified bleeder, Explosion External fixation, fusion Satisfactory ligated
Lt knee upper tibia, genicular artery, explosion Debridement, ring 29M Explosion Fair ligated fixator of upper tibia
Lt lower femur, femoral arterial 25 M Explosion Debridement, internal fixation Satisfactory injury, Dacron graft
*Male
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Management of the missile injuries of the knee Adnan Abdulmajeed Faraj
Figure (1): AP view of a bullet injury to the lower femur showing the comminution and the fixation.
Figure (2): Anteroposterior view of the left knee showing shrapnel and a comminuted open fracture of the tibia extending in to the articular surface.
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Management of the missile injuries of the knee Adnan Abdulmajeed Faraj
Figure (3): Hoffman fixator used to stabilize the comminuted fracture, articular fracture is fixed with partially threaded cancellous screws.
Figure (4): An image of the fixator.
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Management of the missile injuries of the knee Adnan Abdulmajeed Faraj
Discussion: Skeletal missile and shrapnel injuries achieve with external fixation when the are usually high energy injuries fracture is in and around the joints, ring associated with high incidence of fixator may be of use. External fixation complications. The complications are across a joint may provide stability, related to the fracture(s), sustained, however it is associated with high complications of implants used and the incidence of stiffness of the joint. debilitating effect on the nearby joint. Fracture stabilization around and in the Often there is loss of function. knee joint may necessitate internal There is a higher incidence of delayed fixation using screws and plates or union, non-union and malunion of intramedullary locked nail. The concern fractures sustained following high for the use of internal fixation in open energy injuries, compared to low energy fractures caused by shrapnel injuries injuries. The shrapnel and explosion (Gustilo III) is deep wound infection. injuries are often high energy (1, 7). In the The incidence of this was (7%) in our current series, there was one case of series. We adopt thorough early deep malunion; the detrimental effect of the wound debridement, down to bone with injuries is on the knee joint. Five of the copious irrigation of saline. patients in the current series had There is a high association of missile restrictive stiffness of the knee joint penetrating injuries with (38%). femoral/popliteal artery injury (6, 7). Low Regarding the method of fixation, the index of suspicion of vascular injury current concept is that of damage caused by penetrating shrapnel or bullet control surgery; this is to perform a and putting in place means to diagnose short and easy procedure(s) using and address them, is associated with temporizing external fixator. Damage relatively a good outcome. We had a control concept aims at reducing the case of amputation below the knee catabolic state in multiple injured performed for failed arterial surgery. patients external fixation is easy and quick to use. Definitive primary fixation Conclusion: and reconstructive procedures, is time There is high association of open war consuming, and has to be deferred until, injuries of the knee with neurovascular the patient is not in the catabolic state; injuries. Awareness of the associated hence the policy (damage control) (5). vascular injury and team approach is Definitive fixation is performed usually vital in the management of these in the first two weeks of the injury. It is injuries. Early deep wound debridement uncommon to use external fixation as a and washout, is vital. Internal fixation definitive method for fixation because may become the only implant to provide of the associated high complications stability and to reduce the incidence of compared to internal fixation (4). Internal stiffness of the joint; it is a safe practice. fixation was used in 4 of the current Long term use of external fixation series (30%). None of the patients had across the knee joint need to be avoided external fixation crossing the knee joint, because of the associated with joint the overall degree of disability in our stiffness. series was less than reported in literature (4, 5). A stable construct is difficult to
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Management of the missile injuries of the knee Adnan Abdulmajeed Faraj
References: [1]. Callender GR, French RW Wound Ballistics. Military Surgeon 1935; 77:177- 182. [2]. Hennessy MJ, Banks HH, Leach RB, and Quigley T.B Extremity gunshot wound and gunshot fracture in civilian practice. Clin Orthop Rel Res 1976; 114:296-300. [3]. Almskog. BA, Haljamäe, H, Hasselgren, PO, Nordstrom G, Seeman, T Local metabolic: Local metabolic changes in skeletal muscle following high energy missile injury. J. Trauma 1982; 22:382. [4]. Oberli H, Frick T The open femoral fracture in war--173 external fixators applied to the femur (Afghanistan war)] Helv Chir Acta. 1992; 58(5):687-92.
[5]. Vining NC, Pasque, CB External Fixation about the Knee in High-energy War Injuries Techniques in Knee Surgery. 2010; 9:1: pp 2-10 [6]. Woodward EB, Clouse WD, Eliason JL, Peck MA, Bowser AN, Cox MW, Jones WT, Rasmussen TE Penetrating femoropopliteal injury during modern warfare: experience of the Balad Vascular Registry. J Vasc Surg. 2008; 47(6):1259- 64. [7]. Starnes BW, Beekley AC, Sebesta JA, Andersen CA, Rush RM Jr Extremity vascular injuries on the battlefield: tips for surgeons deploying to war. J Trauma. 2006; 60(2):432-42.
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An epidemiological study of irritable bowel syndrome among Dilshad Sabir Mohammed students of medical and nursing colleges in Kirkuk University
An Epidemiological Study of Irritable Bowel Syndrome among Students of Medical and Nursing Colleges in Kirkuk University
*Dilshad Sabir Mohammed, **Amanj Mohammed Salih, ***Mohammed Mustafa Mohammed *Department of Medicine, ** Department of Surgery, *** Department of Community Medicine (College of Medicine/ Kirkuk University). Abstract:
Background: Irritable Bowel syndrome is a functional bowel disease characterized by abdominal pain associated with change in the frequency and consistency of stool, this study was carried out to study the prevalence and the clinical characteristics of irritable bowel syndrome among students of medical school of Kirkuk university. Subjects and Methods: This is a cross sectional study done among students in medical and nursing college of Kirkuk university from September 2012 to March 2013 according to a standardized questionnaire based on Rome II criteria for the diagnosis of IBS. Results: This study showed that symptoms of IBS is present in (35%) of students in nursing college and (31%) of students in medical college with overall frequency of (33%), also this study showed a frequency of IBS among (24.3%) of female and (11.2%) of male in nursing college while (18.6%) among female, (12.9%) of male in college of medicine. Regarding the type of IBS according to the bowel motion, diarrheal type was present in (41.6%), constipation type in (30.5%) and the mixed type in (27.7%). Conclusion: The present study showed that symptoms of IBS are frequent among students in medical and nursing college and it is commoner in females more than males. Key words: Irritable bowel syndrome, Epidemiology, Medical and Nursing College students.
Introduction: Irritable bowel syndrome (IBS) is a type hyperalgesia (decreased pain threshold), of functional gastrointestinal disorder abnormal intestinal motility and that affects a large number of people psychological factors are considered in worldwide especially in western the etiology of this disorder (8). It has countries (1). IBS is characterized by been shown that some factors especially changes in bowel motility and psychological factors (9), and dietary abdominal pain in the absence of habits (10) are associated with the onset unrecognizable physical disorder (2). and the course of IBS, and many The prevalence of IBS in western colleges and university students have countries has been variously reported as psychological problems such as anxiety (15-24%) (3,4), and in most Asian and depression which can be predictive communities is (5-10%) which is lower of IBS (11). than in the western countries (5), It is Around (10-56%) of adults with generally recognized that IBS occurs symptoms of IBS presents for medical more frequently in females than in evaluation (12) and this may be related to males (6,7). The definite cause of the cultural factors (13), the presence and the disease is not yet clear however degree of the pain and psychological
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An epidemiological study of irritable bowel syndrome among Dilshad Sabir Mohammed students of medical and nursing colleges in Kirkuk University disturbances and access to health changes in frequency of the stool. care (14). Patients with irritable bowel syndrome The aim of the present study is to find were divided into constipation out the prevalence and the clinical predominant type, diarrhea predominant characteristics of IBS among students of type and mixed type according to the medical and nursing college in Kirkuk proportion of lumpy and hard stool. University. Red flag items: according to the recent guidelines of IBS from published Patients and Methods: studies (16), there are 7 red flag items A cross-sectional study was done in the used to distinguish organic bowel medical and nursing college of Kirkuk disease from IBS and these are: weight university during the period from first of loss, history of organic bowel disease, September 2012 to the first of March history of bowel surgery, awakening due 2013, the study sample was chosen to abdominal pain during night, blood in randomly among students in the medical the stool, fever and arthralgia. rd th th college (3 , 4 , 5th and 6 class) and in Participants who had one or more of the th the nursing college (3rd and 4 7 items were excluded from the class).A total of 215 students responded diagnosis of IBS. to the questionnaire (unstructured questionnaire), 90(42%) were males and Results: 125(58%) were females with 108 This study shows that (31.5%) of students from the college of Medicine medical students (12.9%) males and and 107 from the college of Nursing (18.6%) females and (35.55%) of with the age range of 20-26years. nursing students (11.2%) males and A standardized questionnaire was (24.3%) females had irritable bowel designed for the study based on Rome II syndrome, with overall frequency of criteria for the diagnosis of irritable IBS among student to be (33.4%) (table bowel syndrome (15); the questionnaire 1and 2). evaluated demographic characteristics, This study shows the frequency general gastrointestinal symptoms distribution of the study sample by type comprising items from the Rome II of bowel motion and college. Regarding criteria. Data was collected and the type of IBS, according to the bowel Statistical methods such as Chi-square motion (41%) of the cases was of test were used and P value ≤ 0.05 was diarrheal D-type, (30%) of the considered significant. constipation C-type and (27%) of the Rome II criteria have been widely used mixed M-type (Table 3). in the diagnosis of irritable bowel This study Shows the frequency syndrome, the diagnosis of irritable distribution of the study sample by the bowel syndrome was based on the symptoms of IBS, type of college and presence of abdominal pain or sex, among students with IBS 37 (51%) discomfort for at least 3 months in the have straining, 30 (41%) have urgency, preceding 12 months with 2 or all of the 39 (54%) have feeling of incomplete following symptoms: pain improved emptying, 26 (36%) have mucous in the after defecation, symptoms associated stool and 37 (51%) have bloating with change in the consistency of the (Table 4). stool and symptoms associated with
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An epidemiological study of irritable bowel syndrome among Dilshad Sabir Mohammed students of medical and nursing colleges in Kirkuk University
Table (1): Percent distribution of the study sample by the type of college & existence of irritable bowel syndrome (IBS). Type of college IBS positive No. (%) IBS negative No. (%) Total No. (%) Medicine 34(31.5%) 74(68.5%) 108(100%) Nursing 38(35.5%0 69(64.5%) 107(100%) Total 72(33.5%) 143(66.5%) 215(100%) X2=0.39 d.f=1 p>0.05
Table (2): Percent distribution of the study sample by sex & existence of IBS Sex IBS positive No. (%) IBS negative No. (%) Total No. (%) Male 26(28.9%) 64(71.1%) 90(100%) Female 46(36.8%) 79(63.2%) 125(100%) Total 72(33.5%) 143(66.5%) 215(100%) X2=1.44 d.f=1 p>0.005
Table (3): Percent distribution of the study sample by the type of bowel motion, sex and college College Of medicine College Of Nursing Total Type of bowel motion Male Female Male Female Medicine Nursing No.* No. No. No. No. (%)** No. (%) Constipation Type 7 6 0 9 13 9 Diarrheal Type 4 7 6 13 11 19 Mixed Type 3 7 0 10 10 10 **The percentage is computed out of the total
Table (4): percent distribution of the study sample by the symptoms of IBS, type of college and sex. College of College of Total Symptoms of medicine nursing Total IBS Male Female Male Female College of College of No. % No. No. No. No. Medicine Nursing Straining 9 10 3 15 19 18 37 (51.1%) Urgency 6 7 4 13 13 17 30 (41.6%) Incomplete 10 11 4 14 21 18 39 (54.1%) emptying Mucous in 6 8 3 9 14 12 26 (36.1%) the stool Bloating 10 16 1 10 26 11 37 (51.1%)
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An epidemiological study of irritable bowel syndrome among students of medical and nursing colleges in Kirkuk University Dilshad Sabir Mohammed
Discussion: Conclusion: The present study suggest that This study showed a high frequency of symptoms of IBS are frequent among IBS among students in the medical and medical and nursing college students, nursing college with a female the prevalence of IBS was (35%) among predilection. students in the nursing college and (31%) among students in the medical References: college with overall frequency of (33%), [1]. Drossman DA, Camilleri M, Mayer this is similar to other studies done by EA, Whitehead We. AGA technical review Wasim et. al. and Okami Yukikoy et al on irritable bowel syndrome. (17,18) Whereas other studies done by Gastroenterology; 2002:123: 2108-2131. [2]. Fock KM, Chew CN, Try LK, Peh LH, Davitat D. et al. and Yang Yang Dong et (19,21) Chan S, Pang EP. Psychiatric illness, al in Thailand, Singapore and personality trait and irritable bowel China showed lower prevalence of IBS syndrome. Ann Acad Med Singapore; in these students; the reason for the 2001:30:611-614. discrepancy may be due to the use of [3]. Andrews EB, Eaton Sc, Hollis KA, et different populations from different al. Prevalence and demographics of irritable countries and the use of different bowel syndrome. Aliment Pharmacol Ther; clinical criteria for the diagnosis of IBS, 2005:22:935-942. the students in the medical and nursing [4]. Hungin AP, Chang L, Lock GR, Dennis college may be under more stress and EH, Barghout V. Irritable bowel syndrome because of their medical background in the united states: Prevalence, may be more aware of their somatic Symptoms,Pattern and Impact. Aliment Pharmacol Ther; 2005:21:1365-1375. symptoms. [5]. Chang FY, Lu CL. Irritable bowel The present study also showed a higher syndrome in the 21st century: Perspective frequency of IBS among female more from Asia or South East Asia. J than male and this is consistent with Gastroenterology Hepatol; 2007:22:4-12. (22,26) other studies done . [6]. Thompson WG, Longstreth GF, Regarding the type of IBS, this study DrossmanDA,et al. functional bowel showed that the diarrheal type is the disorder and functional abdominal pain. commonest type of IBS and this is Gut; 1999:45(2):1143-1147. similar to other studies done (27, [7]. Heaton KW, Odonnel LJD, Braddon 28).Whereas Thomson et al reported FEM, et al. Symptoms of irritable bowel almost equal prevalence of diarrheal or syndrome in a British urban community; constipation subtype in a Canadian Consulters and Non-Consulters. Gastroenterology; 1992:102:1962-1967. population (25). The reason for the higher [8]. FogelBs, Stoudemir A. personality prevalence of the diarrheal type in our disorder in the medical setting. In study may be due to different dietary Greenberg DB, Fogel BS editors. habits, irregular meal time and the Psychiatric care of medical patient. 2nd ed. stressful life situations of the students in Oxford university press: New York the medical schools. 2000:443-458. Regarding the other symptoms of IBS [9]. Faresjo A, Grodzinsky E, Johansson S, (bloating, straining, urgency, feeling of Wallander MA, Timpka T, Akerlind A. incomplete emptying and mucous in the Psychological factors at work and in stool), this study results was similar to everyday life are associatedwith irritable other studies (29, 30). bowel syndrome. Euro J Epidemiol; 2007:22:473-
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An epidemiological study of irritable bowel syndrome among students of medical and nursing colleges in Kirkuk University Dilshad Sabir Mohammed
[10]. Saito LA, Locke GR,Weaver AL, [20]. Ho KY, Kang JK, Seow A. Prevalence Zinsmeiste AR, Tally NJ. Diet and of gastrointestinal symptoms in a functional gastrointestinal disorders a multiracial Asian population with particular population based case-control study. Am J reference to reflux-type symptoms. Am J Gastroenterology; 2005: 100: 2743-2748. Gastroenterol; 1998: 93: 1816-1822. [11]. Hazlett-Stevens H, Craske MG, [21]. Yan-Yan Dong, Xiu-Li Zan,Chang- Mayer EA, Chang LA, Naliboff BD. Qing Li, Yan-Bo YU, Qiu-Jie Zhao, Yan- Prevalence of irritable bowel among Qing LI. Prevalence of irritable bowel university students: The role of worry, syndrome in Chinese college and university neuroticism, anxiety sensitivity and visceral students assessed using Rome III criteria. anxiety. J Psychosom Res;2003:55:501- World J Gastroenterol ; 2010:16(33): 4221- 505. 4226. [12]. Maxwel PR, Mandel MA, Kumar D. [22]. Agreus L, Svardsudd K, Nyren O, Irritable bowel syndrome. Lancet: 1997; Tibblin G. Irritable bowel syndrome and 350: 191-195. dyspepsia in the general population: [13]. Jain AP, Gupta OP, Jajoo UN, Sidhwa Overlap and lack of stability over time. HK. Clinical profile of irritable bowel Gastroenterol; 1995:109:671-680. syndrome at a rural based teaching hospital [23]. Frank L, Kleinman L, rentz A, Ciesla in Central India. J Associate Physics India; G, Kim J, Zacker C. Health related Quality 1999:39: 385-386. of life associated with IBS: Comparison [14]. Drossman DA, Mckee DC, Sandler with other chronic diseases. Clinic Ther ; RS, et al. Psychological factors in irritable 2002:24: 675-689. bowel syndrome. Gastroenterology; [24]. Longstreth GF, Wolde-Tsakik G. 1998:95: 701-708. Irritable bowel-type symptoms in HMO [15]. Drossman DA, Corazziari E, Talley examinees. Prevalence, dermographics and NJ Rome II.Thefunctional clinical correlates. Dig Dis Sci; gastrointestinaldisorders. Diagnosis, 1993:38:1581-1589. pathophysiology and treatment: a [25]. Thompson WG, Irvin EG, Pre P, multinational consensus, 2000 2nd edn. Ferrazi S, Rance L. Functional McLean, gastrointestinal disorders in Canada. First Virginia: 670-688. Population based survey using Rome II [16]. Whitehead W. E., PalssonO. S.,Feld criteria with suggestion for improving the A. D.,Levy R. L.,Von Korff M., Turner M. questionnaire. Dig Dis Sci; 2002:47:225- J.,Drossman D. A. Utility of Red Flag 235. Symptom Exclusions in the Diagnosis of [26]. Gulewitsh Marko D,Enack Paul Irritable Bowel Syndrome. Aliment P,Hautzinger Martin M,Schlarb Angelika PharmacolTher; 2006:24:137-146. A. Irritable bowel syndrome among [17]. WasimJafri, Jared Yakoob, German students: Prevalence, Nadimjafri, Mohammed Islam, characteristics and associations to somatic QaziMasroor Ali. Frequency of IBS in complaints. Eur J gastroenterolHepatol; college students. J AyubColl Abbottabad; 2011: 23(4): 311-316. 2005:17(4):9-11. [27]. Masud Ma, Hasan M, Khan AK. [18]. OkamiYukikoy, Kato Takako T, Nin Irritable bowel syndrome in rural Gyozen G, et al. life style and community in Bangladish: Prevalence, psychological factors related to IBS in symptom pattern and health seeking nursing and medical school students. J behavior. Am J gastroenterology; 2001:96: Gastroenterol; 2011:46(12): 1403-1410. 1547-1552. [19]. Danivat D, Tankeyoon M, Srirataban [28]. Xiong LS, Chen MH, Chen HX, Xu A. Prevalence of IBS in non-western AG, Wang WA, Hu PJ. A population based population. BMJ; 1988:296:1710-1714. epidemiological study of irritable bowel
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An epidemiological study of irritable bowel syndrome among students of medical and nursing colleges in Kirkuk University Dilshad Sabir Mohammed
syndrome in south China: stratified randomized study by cluster-sampling. Aliment PharmacolTher; :2004:19: 1714- 1724. [29]. IrinPerveen, Mahmud Hasan, Mohamed A. Masud, Mohamed M.R. Bhuiyan, Mohamed M. Rahman. Irritable bowel syndrome in Bangladish urban community. Prevalence and health seeking pattern. Saudi J Gastroenterol; 2009:15(4): 239-243. [30]. Alhazmi Ahmed Hamoud AH. Irritable bowel syndrome in secondary male students in Aljouf province, north of Saudi Arabia. J Pak MedAssoc; 2011: 61(11): 1111-1115.
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Correlation of handedness with high cerebral function Osama Hassan Othman
Correlation of Handedness with High Cerebral Function
Osama Hassan Othman, Mohammed Mustafa Mohammed, Summer Saad Abdulhussain *Department of Medicine, ** Department of Community Medicine (College of Medicine/ Kirkuk University). Abstract: Background: Handedness in human kind means a lot apart from social impact. It gives a hint to localization of dominant hemisphere. This study was done on Kirkuk University students & well concluded that activities other than only hand writing are well correlated to high cerebral function like learning & memory, speech & language. Family history is important in this aspect. Objective: To explore correlation of handedness to candidate performance & other daily activities which need high cerebral function. It's relation to family history is well addressed. The patterns of speech fluency were studied. Subjects and methods: Subjects included in this cross sectional study were selected randomly from students in different colleges in Kirkuk University from Jan. 2012 – Jan. 2013. Proposing sheets of information & asking candidates directly by researchers about wanted data & the result were fixed in appropriate boxes and then analyzed properly. Results: Among 242 students 148 (61.15%) were using right hand during writing while 94 (38.85%) using left hand during writing. Some of them were in forced by their parents to change handedness during early childhood. Handedness were different during other activates, correlated well with performance & got family history. Conclusion: Handedness correlated with many parameters other than hand writing. Important daily activities, performance at college, ability in mathematics, drawing, quality of hand writing were all observed. Key words: Handedness, Students, High cerebral function, Kirkuk.
Introduction: Handedness depends on cerebral which is facilitation of recognition by dominance. The concept of cerebral prior exposure to subject, then non dominance replaced by complimentary associative learning which is about specialization one for sequential- single stimulus and lastly associatitive analytic processes (categorical) learning correlates with relation of one hemisphere & concerned mainly with stimulus to another. These involve short language, the other for visuospatial term memory, amenable for disruption relations (Representational hemisphere) by trauma and drugs while long term (1). Handedness appears to be genetically memory stores information for years or determined (2). Learning is acquisition of life& resists to disruption (4). Working information and memory is retention & memory is a form of short term memory storage of this. Memory is divided into that keeps information available while explicit and implicit forms. It is further one bases on it (5). Use of MRI and PET subdivided into episodic memory for provided insight or at least glimpses into events and semantic memory for facts ways serial processing of cognition, (words, rules and languages) (3). Priming language, mathematics, drawing, and
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Correlation of handedness with high cerebral function Osama Hassan Othman writing occur in the brain (5). Language the inferior portion of the categorical is one of fundamental bases of human frontal lobe concerned with number intelligence and key part of human facts and exact calculation and culture. The primary brain areas mathematical ability. Men have larger concerned with language are arrayed brain than women and are said to have along & near the Sylvian fissure of superior spatial skills and ability to categorical hemisphere. Wernickes area navigate. Parietooccipital area process in the posterior end of superior temporal sequential information for drawing and gyrus concerned with comprehension of hand writing (7). The aim of this study information which projects via Arcuate was to assess frequency of handedness fasciculus to Broca's area in frontal lobe & its correlation to high cerebral immediately in front of the inferior end function among students in Kirkuk of the motor cortex. Broca's area University & to compare the available processes the information received from data with what was published from other Wernickes area into a detailed and universities& localities. coordinated pattern for vocalization then project pattern via a speech in Subjects and methods: articulation area in insular to motor This cross sectional study was done in cortex which initiate the appropriate university of Kirkuk during Jan. 2012- movement of lips, tongue larynx to Jan. 2013 & (250) students were produce speech. The Angular gyrus, enrolled from different colleges & behind Wernickes area, appears to different classes of both sexes. Special process information from words read in sheets were prepared by researchers such away than can be converted into including information about whether the auditory forms of words in the student using right Hand or the left Wernickes area (5). It is interesting that hand during writing and during five in individuals who learn second activities, eating, cleansing, using language in adult hood, MRI reveals microscope, when kicking or throwing a that the portion of Brocu's area concern ball and using a racket. The other with it is adjacent to but separate from information concerned with forcing the area concerned with native language, children to change handedness. The next however in children who learn two data concerned with five very valid languages early in life only single area functions of one's brain, performance is involved with both. It is a well-known (top rank, middle or low) during that children acquire fluency in a second previous years, and ability for language more easily than adult. memorization, mathematics, drawing & Fluency is related to categorical quality of hand writing. Family history hemisphere while stammering or was the next point searched for and stuttering has been found to be included sister &brothers asked for their associated with representational handedness. The last point in the sheet hemisphere & widespread over activity included speech &language assessed as in cerebral cortex & cerebellum, which fluency. Eight papers were dropped includes increased activity of from the study owe to uncoordinated, supplementary motor area (6). Brain non-conclusive data. Tables & statistical regions involved in arithmetic work performed by university staff in calculation has highlighted two areas: in community medicine and Chi square
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Correlation of handedness with high cerebral function Osama Hassan Othman method employed for concluding P top in their performance while 13 values if appropriate. Consent for (48.1%) left handers were low, not so performing the study was taken from different from 14 (51.9%) of right Deans. handers whose performance not so satisfactory. This is shown in (table 3). Results: Memorization and recall were very good From (250) students responded to in 92 (62%) of right handers while so in questionnaire, the data used was only 70 (74.5%) of left handers. Those with (242) sheets as others were not unsatisfactory memory were 9 (9.6%) conclusive. There were 148 (61.1%) left handed and 8 (5.4%) right handers. students using Right hand during While 96 (64.9%) of right handers writing and 94 (38.8%) Left handed. showed very good mathematics ability Inquiring for enforcement by either in distinction with 60(63.8%) of Left parent to change handedness during handed students. Drawing ability was early childhood revealed that 15 not good in 49 (33.1%) of right handers (34.9%) Right handed and 28 (65.1%) but only 18 (19.1%) left handed students of Lt. handed were subjected to such were bad drawers. Hand writing quality attitude, this is shown in (table 1). was poor in 3 (3.2%) Left handed During other activities like eating, right candidates while very good in74 (50%) hand was used by 137 (92.5%) of right right handed students. This is well hander’s while left hand used in 11 grouped in (table 4). Influence of family (7.4%) of them. Most of left hander’s 75 history was more to left handers as 59 (79.7%) also use Left hand during (62.8%) students admitted to have either eating while 19 (20.2%) students use a brother or sister who is left handed right hand. Handedness during other while 56 (37.8%) of right handers have activities like cleansing, using another member in their family who is microscope, when kicking or throwing a also Left handed (table 5). The last ball and using racket in both right and information demonstrates language left handers is demonstrated in (table 2). effect, 10 (71.4%) left handed students Comparing performance as being in top, were very fluent while this was seen in 4 middle or low rank during previous (28.6%) right handers; the others speak years showed that 44 (47.3%) Rt. not so fluent. This is shown in (table 6). Handed students ranked top superseded by 49 (52.7%) left handers who were
Table (1): Frequency distribution of study sample regarding forcing children by parents to change handedness during early childhood. Forced children Rt. handed (%) Lt. handed (%) Total Yes 15 (34.9%) 28 (65.1%) 43 (100%) No 133 (61.2%) 66 (38.8%) 199 (100%) Total 148 (61.2%) 94 (38.8%) 242 (100%) X2=15.2 d.f =1 P< 0.05
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Correlation of handedness with high cerebral function Osama Hassan Othman
Table (2): Frequency distribution of study sample by handedness during certain cognitive activities. Rt. handed Lt. handed Total Type of using Rt. using Lt. using Rt. using Lt. using Rt. using Lt. activity hand hand hand hand hand hand During eating 11 (7.4%) 137 (92.5%) 75 (79.7%) 19 (20.3%) 86 (35.5%) 156 (64.4%) During 20 128 (86.5%) 79 (84%) 15 (16.0%) 99 (40.9%) 143 (59.1%) cleansing (13.5%) Using 17 131 (88.5%) 73 (77.7%) 21 (22.3%) 90 (37.2%) 152 (62.8%) microscope (11.5%) Kicking or 29 119 (80.4%) 70 (74.5%) 24 (25.5%) 99 (40.9%) 143 (59%) throwing a ball (19.6%) Using racket 16 (0.8%) 132 (99.2%) 66 (70.2%) 28 (29.8%) 82 (33.9%) 160 (66.1%)
Table (3): Frequency distribution of study sample by academic performance during their previous years. Level of performance Rt. handed Lt. handed Total Top Rank 44 (47.3%) 49 (52.7%) 93 (100%) Middle Rank 90 (73.8%) 32 (26.2%) 122 (100%) Low Rank 14 (51.9%) 13 (48.1%) 27 (100 %) Total 148 94 242 X2= 16.7 d.f = 3 P<0.05
Table (4): Frequency distribution of the study sample by their ability & performance for cognitive activities. Type of ability Rt. Handed Lt. handed Total Very Not Very Not Very Not Fair Fair fair good good good good good good 92 48 8 70 15 9 162 63 17 Memorization (62.2%) (32.4%) (5.4%) (74.5%) (15.9%) (9.6%) (66.9%) (26.0%) (7.1%) 96 43 9 60 26 8 156 69 17 Mathematics (64.9% ) (29.1%) (6.0%) (63.8%) (27.7%) (8.5%) (64.5%) (28.5%) (7.0%) 56 43 49 55 21 18 111 64 67 Drawing (37.8 %) (29.1%) (33.1%) (58.5%) (22.3%) (19.1%) (45.9%) (26.4%) (27.7%) 74 52 22 65 26 3 139 78 25 Hand writing (50%) (35.1%) (14.9%) (69.1%) (27.7%) (3.2%) (57.5%) (32.2%) (10.3%)
Table (5): Frequency distribution of study sample by the significance of family history as regards Handedness. Type of handedness Yes No Total Right handed 56 (37.8%) 92 (62.2% 148 (100%) Left handed 59 (62.8%) 35 (37.2%) 94 (100%) Total 115 (47.5%) 127 (52.4%) 242 X2=14.2 d.f =1 P<0.05
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Correlation of handedness with high cerebral function Osama Hassan Othman
Discussion: Handedness depends on cerebral (13). In this study (131) right hand complementary specialization. (88.5%) of Rt. hander &17 (11.5%) of Handedness means more than laterality left handers were using right eye for as is associated with other high cerebral microscope. Similar to a study showing functions .It not only hand writing but that sighting dominance is a behavioral related to other tasks performance with preference for one eye over the other hand preference (8). To our knowledge during mono ocular viewing condition this is the first study conducted in Iraq. (14). During kicking and throwing a ball In this study 148 (61.1%) candidate out 191 (80.4%) of right handed students of (242) were right handed, while 94 were using right foot, while 29 (19.6%) (38.3%) where left handed, in right handed cross preference was comparison to Korean college student related to what was seen in Korean studying 866 candidates, (22%) of them college study (15), which was were left handed it was very clear that conducting to obtain normative data on their sample was too extensive foot preference in relation to hand compared to our sample (9). In our study preference. Footedness fact as for no one admitted to be bi manual unlike skilled unipedal actions and for a study done in USA showing (10%) of balance, stabilization and varied in population who are actually bimanual direction , strength , so well related to (10). In this study performance of other handedness in mixed footers and left activities rather than hand writing handers (15) . In this study 132 (89.2%) where different between right and left of right handers used right hand for hander but in a study done in United using racket, 16 (10.8%) used Lt. Hand. kingdom, it was shown that degree of In present study level of performance handedness and not only direction well correlated with handedness so 44 (consistence versus inconsistence) was (47.3%) where in top rank, 49 (52.7%) more powerful tool than traditional way of left handed were in the top, while in based only on direction ( right versus another study consistency of left) (11) . Inconsistant handedness was handedness regardless of direction associated with intrahemispheric predicts base line memory, accuracy interaction leading to increase in and potential for memory enhancement memory retrieval, believe updating and (16) . There is an observation in other cognitive flexibility (12). In a study done study than consistent handed in Edinburgh measurement of hand individuals are more authoritarian (17). performance was divided to three sub Two studies using MRI to demonstrate groups in right handers. relations of working memory well Inventory exclusive strong (Rs) documented that hemispheric right-handers (they always used right lateralization of verbal and spatial hand for more than 8 out of 10 daily memory is well organized during activities. adolescence (18, 19). In this study the Exclusive week (Rw) right handers same applies to memorization and used >3 out of 10. mathematics ability, for both students Predominant (Rp), who who were right handed using were very preferred right hand for most item but good in 92 (62.2%) & 96 (64.9%) used left hand for at least one activity respectively while drawing & hand
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Correlation of handedness with high cerebral function Osama Hassan Othman writing quality were better in left Recommendations: handed & seen in 55 (58.5%) and 65 1. Inform the students, teachers, (69.1%) respectively. This observation observers that left handedness can be was consistent with a study relating associated with good characters like handedness indices and success hand writing quality and drawing. published in Netherlands (19). The 2. Doctor awareness is to correlate relationship between handedness and handedness with pathological states & drawing was well validated in a study diseases like schizophrenia, dementia, from Greece (20, 21, 22). In our work personality disorders, stroke etc. family history in form of presence of Lt. handed brother or sister was seen in Acknowledgement: 56 (37.8%) while more frequently The authors are thankful to all encountered in left handed 59 (62.8%) participants in the study. this was strengthened by a study. The last important observation in our work References: is the fact that left handed students are [1]. Bareett, Barman, Boitano, Brooks more fluent than right handers as 10 Representative hemispheres versus dominance hemispheres. Ganong s Review (71.4%) left hander can speek fluently rd of Medical Physiology 23 ed. while (23) (28.6%) of right Handers International edition 2010:295-299 can do so, this is in accordance with a [2]. Colledge,Walker,Ralston presenting studies from United kingdom showing problems in neurological disorders. motor laterality as an indicator to Davidson s principles &practice of language & speech development medicine.21st ed .Edinburgh, Churchill (23,24,25). Livingstone Elsevier2010:116 [3]. Berberian B, et al Automatism & sense Conclusion: of control. Flight dynamics department Handedness is not just an observational journal 2012; 7:340 variability in human kinds, beside hand [4]. Mc Grew wc, et al Introduction to writing, it is well correlated to other evolution of human handedness. Ann N Y types of activities during person s life. Acad Sci. 2013; 1:200-202 It has localization importance. Right [5]. Korsnes MS, et al working memory, handed students are more frequent than an f MRI pilot study. Journal of Affect Disorders 2013; 149:383-92 Left handed students. In regards [6]. Nicholls ME, et al Flinders handedness hemispheric specialization, handedness survey (FLANDERS) .Cortex 2013; was well correlated with level of 13:1016 performance. Ours study demonstrated [7]. Marchant LF,et al Handedness is that memorization, mathematics, more than laterality. Ann.NYAcad. Sci. drawing and hand writing quality are so 2013; 1-8:10 different in different handed groups [8]. AsaiT, et al Relation between hand & .The importance of family history in foot preference. Psychiatry & behavioral left handed students is well shown . science journal 2011; 30:189 Language and speech which are the [9]. Kang Y., et al Handedness & most sophisticated and characterizing Footedness in Korean college students. features in human kind species also Brain Cognition 2000; 43:268-74 [10]. Nelson E.L., et al Unimanual to dependant on handedness and Bimanual Attitudes. Infant behavioral documented in our study. development 2013; 36:181-8
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Correlation of handedness with high cerebral function Osama Hassan Othman
[11]. LyleKB, et al Consistency of [18]. Founders Al, et al Hand preference & handedness regardless of direction predicts Magnetic Resonance Image, asymmetries baseline memory accuracy& potential for of the central sulcus. Cortex 2012; 8:200- memory enhancement. Exp. Psychology 212 learning, memory, cognition 2012; 1:187- [19]. Schufsma SM., et al Relation 93 between handedness Indices& [12]. CoreyDM, et al Multivariate Reproductive success in a Nonindustrial approach using hand preference& hand Society Behavioral biology journal performance. Neuropsychology behavioral 2013;8:63114 neurology 2001; 14:144-52 [20]. Valchos F, et al Handedness& [13]. Bishop DV.,et al The measurement of drawing. Percept motivated skills 2011; hand preference, a validation study 113:277-80 comparing 3 groups of Rt. Handers. British [21]. BrydenMP, et al Behavioral measure journal of psychology 1996; 87; 85 of hand preference as opposed to hand [14]. Carey D.P,et al Looking at eye skill. Neuropsychology 1994; 32:991-9 dominance from a different angle ,Is [22]. Picard D. Impact of manual sighting strength related to hand preference on children drawing. preference ?. Cortex 2012; 13:9452 Latrality2011; 5:24-34 [15]. Nagel BJ, et al Hemispheric [23]. Flowers KA,et al Motor laterality as lateralization of verbal & spatial working an indicator of speech laterality. memory during adolescence. Brain Neuropsychology 2013; 27:256-65 cognition 2013; 82:58-68 [24]. Groen MA,et al Association between [16]. Prichard E, et al Degree of handedness & cerebral lateralization for handedness but not direction as a systemic language. Behavioral Science institute predictor of cognitive performance. Front magazine 2013; 30:1371 psychology 2013; 4:9 [25]. Anett M, et al Handedness & cerebral [17]. Lyle KB, et al Consistent handed representation of speech. Ann. Human individual is more authoritarian. Laterality biology 1976; 3:317-328 2013:16:1958
Journal of Kirkuk Medical College 80 Vol. 1, No. 2, 2013
Knowledge of women attending two primary health care centers / Sulaimany city/Iraq regarding breast cancer Bushra Muhammed Ali
Knowledge of Women Attending Two Primary Health Care Centers / Sulaimany City/Iraq Regarding Breast Cancer
Bushra Muhammed Ali Department of Community and Family Medicine/ College of Medicine/ Sulaimany University Abstract: Background: Breast cancer in Iraq is the most dangerous disease which has the highest incidence that threats women lives in Iraq for the last twenty years. Objectives: To assess the knowledge level of women about breast cancer in relation to some socio-demographic and other relevant factors. Subjects and methods: A cross-sectional study included women attending Ibrahim Pasha and Ali Kamal Health Centers/Sulaimany City. Data were collected by self-administered and interviewing questionnaires from 1st October to 31th December 2012. Total number of the women was 802. The data were analyzed using SPSS version 19.0. Results: There was a significant association between the knowledge score of breast cancer risk factors and protective factors (P=0.001) with the age and level of education. There is a significant association between those with knowledge score of risk factors and protective factors of breast cancer and history of breast mass (P= 0.045, family history of breast mass (P= 0.042). There is a significant association between knowledge score of symptoms of breast cancer and age (P= 0.001) occupation (P= 0.0002), marital status (P= 0.041), those with use of hormonal replacement therapy (P= 0.016) and had history of breast infection (P= 0.031). Conclusion: Participants had an accepted knowledge about breast cancer. There was a significant association between the knowledge level of women about breast cancer in relation to some socio-demographic, and other relevant factors. Key words: Awareness, Breast cancer, Sulaimany.
Introduction: Breast cancer is one of the most decrease to (21%) when the disease common cancers among females diagnosed after spreading to other sites worldwide. Global statistics shows that (2). the annual incidence of breast cancer is In Kurdistan/Iraq, breast cancer is increasing and this is occurring more predominantly a disease of rapidly in countries with previous low premenopausal women having multiple incidence rates. Nearly 1 in 8 women pregnancies. For younger patients, will develop breast cancer (1, 2). breast cancer incidence was similar to Seventy percent of breast tumors is the west and possibly higher than many discovered by women themselves, so it middle eastern countries but unlike the is important to learn how to practice west the estimated rates decline breast self-examination regularly (3). markedly in the elderly (4). The etiology Early diagnosis is essential to breast of breast cancer is unknown; numerous cancer survival, when diagnoses at local risk factors may influence the state, (97%) of women are still alive 5 development of it including genetic, years later. The 5 years survival rate socio-biological, hormonal,
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Knowledge of women attending two primary health care centers / Sulaimany city/Iraq regarding breast cancer Bushra Muhammed Ali environmental toxins, and psychological Those who were very tired, mentally factors (5,6). The chance of an individual retarded patients, age less than 18 years developing cancer depends on both old are excluded from the study. genetic and non-genetic factors. A The questionnaire contained 4 questions genetic factor is an inherited, regarding socio-demographic unchangeable trait, while non-genetic characteristics including age (year), factors may include diet, exercise, or level of education, occupation and exposure environmental factors (7). marital status. Other part of the Primary prevention of breast cancer questionnaire included 4 questions includes educating women on its risk regarding medical background whether factors and influencing behavioral the patients had breast mass (benign or changes, such as healthy eating and malignant), use of hormonal exercise as well as secondary prevention replacement therapy (HRT combined in the form of breast screening has been one which contains estrogen and introduced in an attempt to decrease the progesterone ), had history of breast mortality from the disease (8). infection and had family history of Objectives: breast mass (benign or malignant) was (1) To assess the knowledge level of asked and the answers were categorized women about breast cancer in relation to to three groups including first degree some socio-demographic and other relative (mother, siblings or offspring), relevant factors. second degree relative ( aunt, niece, or (2) To identify the relation between grant mothers) and other members who knowledge of women about breast live/ lived in the family such as mother cancer and history of breast disease. in law, which could make the patient has more knowledge of risk factors, Subjects and methods: protective factors and the symptoms of This is a cross-sectional study which breast cancer. was approved by ethics committee of The last part of the questionnaire School of Medicine, University of included questions to assess the Sulaimany. Data were collected over the knowledge about factors increasing period from 1st October to 31th breast cancer (age, personal history, December 2012 by self-administered family history, alcohol consumption, and interviewing questionnaires from smoking, obesity, radiation, HRT 1000 women attending the two primary contains estrogen and progesterone). health care centers. After filtration of the Protective factors like monthly breast questionnaires; only 802 women self-examination is the best method for included in the study. Ibrahim Pasha and detecting breast mass early, breast Ali Kamal health centers are covering a feeding, eating fruits and vegetables wide area of different socio-economic which contained antioxidants, exercise, status population. Ibrahim Pasha health having children, and symptoms of breast center was established in 1965 while Ali cancer like (breast lamp, enlarged lymph Kamal health center in 1998. Both node in the axilla, change in the breast centers contain departments of antenatal size, shape, breast skin dimpling, nipple care, internal medicine, inversion, spontaneous single nipple ophthalmological care, dental care, discharge) were asked as close-ended dressing unit, etc. questions with answers of "No""Yes"
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Knowledge of women attending two primary health care centers / Sulaimany city/Iraq regarding breast cancer Bushra Muhammed Ali and "Don’t know". The correct answer frequency among the (9-17) score for coded as 1 the wrong as 0, and do not the age of 41-50 years (91.8%). Level of know as 2, for each participant education: college and institute and calculated the total score according to postgraduate (91.89%), Retired (100 %), the response answer, the scores for the and widow (92.6%). There is a answering the questions of factors significant association between the increasing and protective factors of age, level of education and the breast cancer between 0-26, those who knowledge score of risk factors were being under the score 0-8 regarded increasing and factors protective breast as wrong answers, those under the score cancer P= 0.001. There is no significant 9-17 regarded as right answers and those association between occupation and under the score 18-26 regarded as do not marital status with knowledge score of know the answers. The scores of risk factors increasing and factors answering the questions about the protective breast cancer. symptoms between 0-14, those under (Table 3) shows the patients distribution the score 0-4 regarded as wrong according to the socio-demographic in answers, those under the score 5-9 relation to the knowledge about regarded as right answers and those symptoms of breast cancer. The highest under the score 10-14 regarded as do not frequency among the (5-9) score for the know the answers. age of 41-50 years (69.9%), level of education: college, institute and Statistical analysis: postgraduate (95%), retired (69.2%), The data was entered to Microsoft Excel widow (62.96%). There is a significant sheet and was analyzed using SPSS association between the age P = 0.001, version 19.0 software program. level of education P = 0.001, occupation Frequencies were calculated for P = 0.0002, marital status P = 0.041 categorical variables. Chi square and with knowledge score of symptoms of Fisher exact tests were used to find breast cancer. association between knowledge scores (Table 4) shows patients distribution and other variables. P-value of < 0.05 according to the conditions in relation was regarded as statistically significant. to the knowledge about risk factors increase and factors protect breast Results: cancer. The highest frequencies among (Table 1) shows the knowledge score of the (9-17) score were for those had the women regarding factors increasing, history of breast mass (100%), use of protecting and symptoms of the breast HRT (90.6%), had history of breast cancer. The highest percentage of the infection (81.8%) and those with family factors increasing, protecting (76.1%) history of breast mass (first degree and symptoms of the breast cancer relative 89.4%). There is a significant (45.15%) under the correct knowledge association between those who had score (9-17) and (5-9) respectively. history of breast mass P = 0.045 and (Table 2) Shows the women distribution family history of breast mass P = 0.042 according to the socio-demographic in and knowledge score of risk factors relation to the knowledge score about increase and factors protect breast risk factors increasing and factors cancer. Regarding those who use of protective breast cancer. The highest hormonal replacement therapy and had
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Knowledge of women attending two primary health care centers / Sulaimany city/Iraq regarding breast cancer Bushra Muhammed Ali history of breast infection there is no history of breast mass (first degree significant association. relative 68.87%). There is a significant (Table 5) shows patients distribution association between those who use of according to conditions in relation to hormonal replacement therapy P = the knowledge score about symptoms of 0.016, had history of breast infection P breast cancer. The highest frequencies = 0.031and knowledge score of among the (5-9) score were for those symptoms of breast cancer .Regarding had history of breast mass (65.2%), use those who had history of breast mass of HRT (75%), had history of breast and family history of breast mass there infection (69.1%) and those with family is no significant association.
Table (1): Distribution of the women according to the knowledge score about factors increasing, protecting and symptoms of breast cancer. Breast Cancer Knowledge Score No. % Knowledge about factors increasing and protecting 0-8 ( wrong answer score) 37 4.6 9-17 (right answer score) 610 76.1 18-26 (do not know answer score) 155 19.3 Total 802 100 Knowledge about symptoms 0-4 ( wrong answer score) 107 13.35 5-9 (right answer score) 365 45.5 10-14 (do not know answer score) 330 41.15 Total 802 100
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Knowledge of women attending two primary health care centers / Sulaimany city/Iraq regarding breast cancer Bushra Muhammed Ali
Table (2): Patients distribution according to the socio-demographic in relation to the knowledge score about risk factors and factors protect breast cancer. Knowledge score about increased risk factors and protective factors Total P value 0-8 N (%) 9-17 N (%) 18-2 N (%) Age groups in years 20 and less 29( 7.97) 231(63.46) 104 (28.57) 364 21-30 6 (2.84) 178 (84.36) 27 (12.79) 211 0.001 31-40 2 (1.72) 101 (87) 13 (11.2) 116 41-50 0 (0.0) 67 (91.8) 6 (8.2) 73 51-≤60 0 (0.0) 33 (86.84) 5 (13.16) 38 Level of education Illiterate 30 (8.26) 233 (64.18) 100 (27.5) 363 Read and write 6 (2.8) 176 (82.6) 31 (14.55) 213 Primary 1(0.86) 101 (87) 14 (12) 116 0.001
Secondary 0 (0.0) 66 (90.4) 7 (9.6) 73 College, Institutes and 0 (0.0) 34 (91.89) 3 (8.11) 37 Post graduate Occupation Employed 12 (6.7) 146 (82.0) 20 (11.2) 178 0.067 Retired 0 (0) 13 (100.0) 0 (.0) 13
Self-employed 7 (3.2) 176 (80.7) 35 (16) 218 Housewife 9 (4.5) 129 (64) 63 (31.3) 201 Student 9 (4.7) 146 (76.0) 37 (19.3) 192 Marital status Single 19 (7.8) 159 (65.1) 66 (27) 244 0.311 Married 521 17 (3.3) 418 (80.2) 86 (16.5) Widow 0 (.0) 25 (92.6) 2 (7.4) 27 Divorced 1(10.0) 8 (80.0) 1 (10.0) 10 (0-8) wrong answers score (9-17) right answers score (18-26) do not know score
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Knowledge of women attending two primary health care centers / Sulaimany city/Iraq regarding breast cancer Bushra Muhammed Ali
Table (3): Patients Distribution according to the socio-demographic in relation to the knowledge score about symptoms of breast cancer. Knowledge score about clinical symptoms P value 0-4 N (%) 5-9 N (%) 10-14 N (%) Total Age in years 20 and less 69 (18.95) 106 (29.1) 189 (51.9) 364 21-30 21 (9.95) 108 (51.1) 82 (38.8) 211 0.001 31-40 10 (8.6) 76 (65.5) 30 (25.86) 116 41-50 4 (5.5) 51 (69.9) 18 (24.65) 73 51- ≤ 60 3 (8) 24 (63) 11 (29) 38 Level of education Illiterate 57 (15.7) 31 (8.53) 275(75.75) 363 Read & write 48 (2.5) 134 (62.9) 31(14.55) 213 Primary 1 (0.86) 99 (85.3) 16(13.8) 116 0.001 Secondary 1 (1.3) 67 (91.8) 5(6.84) 73 College, Institute, 0 (0.0) 35 (95) 2(5) 37 & post graduate Occupation Employed 29(16.3) 88 (49.4) 61 (34.26) 178 Retired 1(7.7) 9 (69.2) 3 (23.0) 13 0.0002 Self-employed 35(16.0) 111 (50.9) 72 (33.0) 218 Housewife 18(8.95) 73 (36.3) 110 (33.0) 201 Student 24(12.5) 84 (43.75) 84 (43.75) 192 Marital status Single 42 (17.2) 69 (28.27) 133 (54.5) 244 Married 61 (11.7) 276 (52.97) 184 (35.3) 521 0.041 Widow 2 (3.7) 17 (62.96) 8 (3.7) 27 Divorced 2 (20.0) 3 (30.0) 5 (50.0) 10 (0-8) wrong answers score (9-17) right answers score (18-26) do not know score
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Knowledge of women attending two primary health care centers / Sulaimany city/Iraq regarding breast cancer Bushra Muhammed Ali
Table (4): Patients distribution according to conditions in relation to the knowledge score about risk factors increasing and factors protective breast cancer. Knowledge score about risk factors and protective factors Total P value 0-8N (%) 9-17 N (%) 18-26 N (%) Had history of breast mass No 37 (4.7) 587 (75.63) 155 (19.89) 779 0.045 Yes 0 (.0) 23 (100.0) 0 (.0) 23 Use of HRT 0.277 No 770 37 (3.77) 581 (75.45) 152 (19.7) Yes 0 (0) 29 (90.6) 3 (9.4) 32 Had history of breast infection
No 37 (4.9) 565 (75.6) 145 (19.4) 747 0.292 Yes 0 (0) 45 (81.8) 10 (18.18) 55 Family history of breast mass No 32 (5.8) 395 (71.7) 124 (22.5) 551 1st degree relative 2 (1.3) 135 (89.4) 14 (9.3) 151 0.042 2nd degree relative 2 (2.6) 61 (79.2) 14(18.18) 77 Other family 1 (4.3) 19 (82.6) 3(13.0) 23 member. (0-8) wrong answers score (9-17) right answers score (18-26) do not know score
Table (5): Patients distribution according to conditions in relation to the knowledge score about symptoms of breast cancer. Knowledge score about clinical symptoms Total P value 0-4 N (%) 5-9 N (%) 10-14 N (%) History of breast mass
779 No 104 (13.3) 350 (45) 325 (41.7) 0.343 Yes 3 (13) 15 (65.2) 5 (21.8) 23 Use of HRT No 107 (13.9) 341 (44.3) 322 (41.8) 770 0.016 Yes 0 (.0) 24 (75) 8 (25) 32 Had history of breast infection No 104 (14) 327 (43.7) 316 (42.3) 747 0.031 Yes 3 (5.4) 38 (69.1) 14 (25.5) 55 Family history of breast mass No 88 (15.97) 199 (36.1) 264 (47.9) 155 1st degree relative 14 (9.27) 104 (68.87) 33 (21.85) 151 0.921 2nd degree relative 3 (3.9) 47 (61.0) 27 (35.0) 77 Other family 2 (8.7) 15 (65.2) 6 (26.08) 23 member (0-4) wrong answer score (5-9) right answer score (10-14) do not know score
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Knowledge of women attending two primary health care centers / Sulaimany city/Iraq regarding breast cancer Bushra Muhammed Ali
Discussion: In this study about (76.1%) within (9- occupation and knowledge score of risk 17) score (the correct answers) of risk factors increased and factors protect factors increased and factors protect breast cancer, although women working breast cancer. There was a significant outside their homes were more exposed association between the age, and the to information as employed, retired (was knowledge score of risk factors working outside) and self- worker, their increasing and factors protective breast percentage (82.0%), (100.0%) and cancer. It was found that the highest (80.7%) respectively. Madanat found percentage among those 41-50 years that profession of women significantly (91.8%), this is explained by that middle influenced breast cancer awareness, he aged women having led a disease they concluded that professionals were more were likely to get the disease now, and knowledgeable about breast cancer risk were therefore interested in acquiring factors and also more frequently than (11) information about breast cancer. This those who were housewives . This is could also be due to adequate perception explained by, since women who were in this group of women this goes with a housewives were pre-occupied with study done by Javandi in Iran found that their daily chores and hardly ever older women were more knowledgeable seemed to find time for themselves, it as opposed to younger women (9). On seems improbable that they would go the other hand this finding was not seen out of their way to specially have a in two Jordanian studies, one conducted clinical breast examination by a by Petro-Nustus at the Hashemite physician even if they know that breast University (10), and another by Madanat cancer is a life threatening disease. (11). Concerning the marital status, the Regarding level of education, there is a highest frequency among those who get significant association between the level married, married (80.2%) widow of education and the knowledge score of (92.6%) and divorced (80.0%). More risk factors increased and factors protect than the single women (65.1%) within breast cancer and it was found whenever the (9-17) score. This means that the level of education increased the women in general search for highest percentage of the sample had information about prevention of breast gotten the information, this goes in cancer during getting married because constant with a study done by Alam in they are liable for breast infection Saudi Arabia (12). Petro- Nustus (10) and during breast feeding, asking about the Haji Mahmoodi in Tahran/Iran (13) who side effects of contraceptive method found that with more qualified women especially ( hormones contraception ) being significantly more aware than and regularly visited a family physician women who were only primary school or a gynecologist during antenatal care educated and illiterate ones. This may or for the problems associated with be due to reading more books, pregnancy or infertility which included magazines and getting the information hormones treatment for that reasons by using the internet other social media they had a good knowledge about risk to get more information. factors increased and factors protect While for the occupation there is no breast cancer. But there is no significant significant association between association between marital status and
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Knowledge of women attending two primary health care centers / Sulaimany city/Iraq regarding breast cancer Bushra Muhammed Ali the knowledge score of risk factors are health seeking people and motivated increased and factors protect breast to get advice for better health. People cancer this is in constant with a study with family history of breast tumor done by Jaff in Sulaimany/Iraq (14) would be discussing the issues with their Several studies conducted in different close family and friends. countries that showed relatively low There was a significant association knowledge to warning signs and between those with use of hormonal symptoms of breast cancer. But in this replacement therapy and knowledge study there was a significant association about the symptoms of breast cancer. It between the ages, level of education, was shown that about (75%) of those occupation, marital status with who used hormonal replacement therapy knowledge score of symptoms of breast had good knowledge about the cancer this was an important element of symptoms of breast cancer this this study since recognition of explained by that they asked about any symptoms would decide whether a side effects of the hormones and the woman would seek timely medical help. physician explained to them if any of This goes in constant with a study done the symptom occurs to consult them, for by Yaren among women in Turkey (15). that reason they kept the symptoms of In this study a highest frequency of breast cancer in their mind. Also there correct answer about risk factors was a significant association between increase and factors protect breast those had history of breast infection and cancer among those who had history of knowledge score of symptoms of breast breast mass (100%) and those who had cancer and about (69.1 %) of those who family history of breast mass among had breast infection they had good first relative degree (89.4%),and there knowledge score this was because they was a significant association between exposed to a serious disease (but not those had history of breast mass and malignant) in their breast so this made family history of breast mass and them be more caution for the symptoms knowledge score of risk factors increase of breast cancer by searching about the and factors protect breast cancer, while these symptoms for visiting the doctors for those with use of hormonal early if they will see any of these replacement therapy the highest symptoms. frequency among those of correct Regarding those had history of breast answers (90.6%) and had history of mass and family history of breast mass breast infection (81.8%) although there although there was no significant is no significant association. This goes association among them but it was in constant with studies of Madanat and shown that the highest percentage of (5- Petro-Nustus and co wokers of Jordan as 9) score knowledge among those who well as Haji Mahmoodi of Tehran /Iran had personal history and family history all concluded that awareness about of the breast mass (65.2 %), (68.87%), breast cancer was significantly (61.0%) and (65.2%). This is explained associated with a personal history and/or by they always more worried about any a family history of breast tumors (10,11,13). returning back of any symptoms of the This could be explained by more breast mass and knowing more about exposure to healthcare providers' advice breast cancer symptoms. Overall and patients with positive medical status participants had good knowledge about
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Knowledge of women attending two primary health care centers / Sulaimany city/Iraq regarding breast cancer Bushra Muhammed Ali risk factors increasing and factors :incidence, clinical stage, and case control protecting breast cancer (76.1%) within analysis of parity and family risk. BMC the (9-17) score, this goes in constant Womens Health 2009, 9:33doi: with a study of Yaren, Ozkilinic; but 10.1186/1472-6874-9-33 .online at: their knowledge about breast cancer Htt://www.biomedcentral,com/1472- symptoms is a little bit not acceptable 6874/9/33.on December 2009. [5]. Norsadah B, Rusli B, Imran A, Naing I, (45.5%) within (5-9) score this was not Winn T. Risk factors of breast cancer in the same what was found in the study of (15) women in Kelantan, Malaysia. (Online) Yaren, Ozkilinic . 2005, 46(12).698.Available on 3/4/2008. While a study of Mc Donald, Thorne [6]. Martin F. Does Nulliparity influence and coworkers, knowledge about breast Estrogen Receptor status among Women cancer among African- American with Breast Cancer? A North Carolina Pilot women was poor (16). Study SCHS Study No.120. 2000. Online available from. www.schs.state.nc.us/ Conclusion: SCHS/pdf/SCHS120.pd. Overall participants had accepted [7]. Perkins L. Breast implants and cancer. knowledge about breast cancer. There Causation, delayed detection, and survival. was a significant association between Plast Reconsre surge, (on line).2001, the knowledge score of risk factors and 107(6):p.1393-407. Available from: factors protect breast cancer with the www.ncbi.nlm.nih.gov/pubmed/11335807. age, level of education those with breast Accessed on 3/1/2008. mass and family history of breast mass. [8]. Leinster S, Gibbs T, Downey H. Shared Also there was a significant association care for Breast Disease. Oxford: Isis between the knowledge score of Medical Media Ltd. 2000 [9]. Jarvandi S, Montazeri A, Harirchi I, symptoms of breast cancer with age, Kazemnejad A. Beliefs and behaviours of level of education, occupation, marital Iranian teachers towards early detection of status, those who use of hormonal breast cancer and breast self-examination. replacement therapy and had history of Public Health; 2002 July; 116(4). 245-9 breast infection. [10]. Petro- Nustus W, Mikhail BI; Factors associated with breast self-examination References: among Jordanian women. Public Health [1]. Agrawal G, Pradeep P, Agrawal V, Yip Nursing 2002 Jul-Aug. 19(4): 263-71 C, Cheung P. Spectrum of breast cancer in [11]. Madanat H, Merrill RM; Breast cancer Asian women. Department of Endocrine risk factors and screening awareness among and Breast Surgery, Sanjay Gandhi women nurses and teachers in Amman, postgraduate Institute of Medical Sciences, Jordan; Cancer Nursing; 2002 Aug; 25(4): Raebareli Road.World Journal Surgery. 276-82 2007 th [12]. Alam AA. Knowledge of breast [2]. Hahn D, Payne W, Focus on Health. 6 cancer and its risk and protective factors ed. McGraw-Hill Inc. New York. 2003. P among women in Riyadh. Annals of Saudi 257-258 Medicine. 2006 August; 26(4): 272-7 [3]. Oussama M. Guidelines for the early [13]. Haji Mahmoodi M, Montazeri A, detection and screening of breast cancer . Jarvandi S, Ebrahimi M, Haghighat S, EMRO technical publication series 30. Harirchi I. Breast self-examination: World Health Organization, regional office knowledge, attitudes, and practices among for the Eastern Mediterranean, Cairo; 2005. female health care workers in Tehran, Iran; [4]. Majid R, Mohammed H, Saeed H, Breast Journal; 2002 July August; 8(4): Safar B , Rashid R , Hughson M. Breast 222-5 cancer in Kurdish women of northen Iraq Journal of Kirkuk Medical College 90 Vol. 1, No. 2, 2013
Knowledge of women attending two primary health care centers / Sulaimany city/Iraq regarding breast cancer Bushra Muhammed Ali
[14]. Jaff .Ch .S. Knowledge of Female Journal of Cancer Care (Engl). 2008 May. Preparatory Students Regarding Breast 17(3): 278-84 Cancer and Breast Self-Examination [16]. McDonald PA, Thorne DD, Pearson /Sulaimani City P: 93 (2010) .Thesis of JC, Adams-Campbell LL; Perceptions and master/Sulaimani University knowledge of breast cancer among African- [15]. Yaren A, Ozklinic G, Guler A, Oztop American women residing in public I. Awareness of breast and cervical cancer housing; Ethnicity Disease; 1999 Winter; risk factors and screening behaviors among 9(1): 81-93 nurses in rural region of Turkey. Eurpopean
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JKMC
ﻣﺠﻠﺔ ﻛﻠﻴﺔ ﻃﺐ ﻛﺮﻛﻮﻙ ﺗﺼﺪﺭ ﻋﻦ ﻛﻠﻴﺔ ﺍﻟﻄﺐ، ﺟﺎﻣﻌﺔ ﻛﺮﻛﻮﻙ، ﻛﺮﻛﻮﻙ، ﺍﻟﻌﺮﺍﻕ
ﺍﻟﻤﺠﻠﺪ ﺍﻻﻭﻝ، ﺍﻟﻌﺪﺩ ﺍﻟﺜﺎﻧﻲ، ﻛﺎﻧﻮﻥ ﺍﻻﻭﻝ ISSN: 2308-6270 201 3
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ﻧﺎﺋﺐ ﺭﺋﻴﺲ ﺍﻟﺘﺤﺮﻳﺮ: ﺍﻻﺳﺘﺎﺫ ﺍﻟﻤﺴﺎﻋﺪ ﺯﻳﺎﺩ ﻣﺤﻤﺪ ﺻﺎﺩﻕ
ﺳﻜﺮﺗﻴﺮ ﺍﻟﺘﺤﺮﻳﺮ: ﺍﻟﻤﺪﺭﺱ ﺭﻋﺪ ﺣﺴﻦ ﻧﺠﻢ
ﻫﻴﺌﺔ ﺍﻟﺘﺤﺮﻳﺮ: ﺍﻻﺳﺘﺎﺫ ﻣﺤﻤﺪ ﻣﺼﻄﻔﻰ ﻣﺤﻤﺪ ﺍﻻﺳﺘﺎﺫ ﺍﻟﻤﺴﺎﻋﺪ ﻟﺆﻱ ﺷﻬﺎﺏ ﺃﺣﻤﺪ ﺍﻻﺳﺘﺎﺫ ﺍﻟﻤﺴﺎﻋﺪ ﺳﻌﺪﻭﻥ ﺩﺍﻭﺩ ﺃﺣﻤﺪ ﺍﻻﺳﺘﺎﺫ ﺍﻟﻤﺴﺎﻋﺪ ﻇﺎﻫﺮ ﺣﻤﻴﺪ ﺑﺮﺍ
ﺍﻟﻬﻴﺌﺔ ﺍﻷﺳﺘﺸﺎﺭﻳﺔ: ﺍﻻﺳﺘﺎﺫ ﺣﻜﻤﺖ ﻋﺒﺪﺍﻟﺮﺳﻮﻝ ﺣﺎﺗﻢ ﺍﻻﺳﺘﺎﺫ ﺣﻤﻪ ﻧﺠﻢ ﺍﻟﺠﺎﻑ ﺍﻻﺳﺘﺎﺫ ﻧﺠﻢ ﺍﻟﺪﻳﻦ ﻛﺮﻳﻢ ﺍﻻﺳﺘﺎﺫ ﻓﺎﺭﺱ ﺑﻜﺮ ﺍﻟﺼﻮﺍﻑ ﺍﻻﺳﺘﺎﺫ ﻋﻠﻲ ﻣﺤﻤﺪ ﺟﻮﺍﺩ ﺍﻻﺳﺘﺎﺫﺓ ﻧﻮﺭﻫﺎﻥ ﺷﺎﻛﺮ ﻣﺤﺎﻭ ﺍﻻﺳﺘﺎﺫ ﻣﻮﺳﻰ ﻣﺤﻤﻮﺩ ﻣﺮﺑﻂ ﺍﻻﺳﺘﺎﺫﺓ ﺑﺪﻭﺭ ﻋﺒﺪﺍﻟﻘﺎﺩﺭ ﺍﻟﺮﺣﻴﻢ ﺍﻻﺳﺘﺎﺫﻫﺮ ﻋﺒﺪﻪﻠﻟﺍ ﻫﻮﺭﺍﻣﻲ ﺍﻻﺳﺘﺎﺫ ﻣﺤﻤﺪ ﺷﺮﻳﻒﺪﻪﻠﻟﺍ ﺍﻻﺳﺘﺎﺫ ﻃﺎﺭﻕ ﺍﻟﺤﺪﻳﺜﻲ
ﺳﻜﺮﺗﺎﺭﻳﺔ ﺍﻟﻤﺠﻠﺔ: ﺣﺴﻴﻦ ﻓﺎﺭﻭﻕ ﺷﺮﻳﻒ
ﺭﻗﻢ ﺍﻹﻳﺪﺍﻉ ﺑﺪﺍﺭ ﺍﻟﻜﺘﺐ ﻭﺍﻟﻮﺛﺎﺋﻖ ﺑﺒﻐﺪﺍﺩ (1919) ﻟﺴﻨﺔ 2013