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									                                                      ZJMS Volume 8
                                                            Dler             (2); 2004




                   JOURNAL OF MEDICAL SCIENCES
                             Published by
              College of Medicine-University of Salahaddin
                               Arbil-Iraq.




                                Chief Editor:
                             Hamanajm F. Jaff
                     FRCPI,FRCP(Lon.),FRCP(Glasg.),FCCP
                        Assistant Professor Of Medicine


                                 Secretary:
                          Salahaddin M. A. AL-Merani
                                     Ph.D
                        Assistant Professor Of Physiology


                           Assistant Secretary:
                              Dler Qader Gallaly
                                B.Sc.(Biology)



                                   Editors:
- Jamal Abdul Hameed Palani           M.B.Ch.B.,C.A.B.I.M.
                                      Assistant Professor of Medicine.
- Pishtewan Hashim Al-bazzaz          F.I.C.M.S.(Urology)
                                      Assistant Prof. of Surgery(Urology).
- Tayphor Jalil Mahmoud               Ph.D. [Bordeaux-France]
                                      Assistant Prof. of clinical Biochemistry.
- Fareed Hanna Abdul-Ahad             M.B.Ch.B., M.Sc.
                                      Assistant Professor of Anatomy
- Noor AL-ddin Ismail                 C.A.BS.
                                      Assistant Professor of Surgery.
- Abas Abdul-Kadir                    C.A.BS.
                                      Assistant Professor of Pediatrics.
- Atia M. Saeed                       FRCOG(U.K) Consultant
                                      Gynecologist & Obstetrician.
- Adnan Abdulwahab Shaker             M.Sc.( Psych. & Neurology).
                                      Assistant Professor in Psychiatry.
- Nadya Yassoub Ahmed                 F.I.C.M.S.( Histopathy ).
                                      Senior Lecturer of Histopathology.
                                                                                  DLER GALLALY
ZJMS Volume 8  Dler   (2); 2004




                         JOURNAL OF MEDICAL SCIENCES




                        ADVISORY BOARD

    -Dr. Najmaddin Kareem         American Board (USA), Neurosurgery Meryland.

    -Dr. Anwer Kadir Sheikhe      MRCPath, FRCPI, FACP
                                  Clinical haematology, Abha. Saudi Arabia.

    -Dr. Dlawer Alaaddin          MRCPath (Microbiology )
                                  Professor of clinical Microbiology
                                  Notttengham,(UK).

    -Dr. Ranj Nori Shaweiss       FRCS Lon. M.Sc., Med. Edn.
                                  Consultant Pediatric Sergeon, Sheifield (UK).

    -Dr. Mohammad S. Kareem FRCP Consultant Sergeon, Sheifield (UK).

    -Dr. Bahram M. Resul          Ph.D.(Pharmacy) Associate Professor,
                                  Dept. of Neuroscience, Pharmacology,
                                  The Biomedical Center,Uppsala University,
                                  Sweden.




DLER GALLALY
    Z.J.M.S
    VOLUME 8
       [2]                             INSTRUCTIONS TO AUTHORS
      2004



   1- The Aim :            The ZANCO JOURNAL FOR MEDICAL SCIENCES is presently issued twice a
                         year, and welcomes research papers with scientific merit and originality. These include
                         basic medical sciences and clinical researches as well, as case reports, review articles
                         short communications and bibliographics. Such disciplines should be of special interest
                         for medical practice in the region of Iraqi Kurdistan in particular, and in the other areas
                         of Iraq.
2- Requirements
                         1. The manuscript sent for consideration should be in four copies, type-written on A4
   For Publication
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                         3. Abstract: not more than 200 words in both English and Arabic or Kurdish languages,
                            describing briefly the objective of investigation and the most important findings.
                         4. Text: this should include the following sections in the order listed:
                          a- Introduction: stating purpose and rationales of the study with main pertinent
                             literatures. Numbers should be used for quotation to references.
                          b- Materials & Methods: include materials, subjects or patients, procedures, chemicals,
                             equipments and statistical analysis.
                          c- Results: setting out in logical sequence, tables and illustrations & principal findings.
                          d- Discussion: new aspects, interpretations, implications and their relations to other
                             relevant studies.
                          e- Acknowledgments, if any.
                          f- References: as in Index Medicus, numbers are sequenced as they are mentioned first
                             in the text. List all authors if less than six & add et al., if more.
                            A reference should be arranged as follows:
                            Name(s) of author(s):Title of the article. Publishing journal, year; volume ( ): pages.
                         5. Tables, figures and photographs:
                            Tables should be typed on separate sheets & numbered serially with self-explanatory
                          headings. Figures should be drawn in Indian pink on white paper or printed by laser
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4- Subscription fees 1. Personal annual subscription fee is (15000) I.D. and for Institutes and Libraries
                             is ( 30000 ) I.D or their equivalents in foreign currency.
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                         3. Submission of an article for publication requires one year’s subscription.

 - Correspondence         -The Secretary, Zanco Journal for Medical Sciences, College of Medicine,
                           Salahaddin University - Arbil, Iraq.
                           E.Mail: zjms_hawler@hotmail.com
                                   zjms_hawler@yahoo.com
                                                                                                                 Dler Gallaly

                                                         I
  2                8




                           .
                                                                                                                                                             :                                -1
               .
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                                                                                                                                                     :                                        -2
                                   .                     25                                   (A4)                                                                                   .1
                                                                                                  . ( C.D )                ( floppy disc )
                                                                     .                                                                                                               .2
                                                                                                                             .                                                       .3


                                       -:                                                                                                -           :                                    -3
                                                        .                                                                                                        :                   .1
                                                                                 .                                                                                                   .2
                                   .                                                                                             (200)                                       :       .3
                                                                                                              -:                                                     :                   .4
                                                         .                                                                                                                   :       -
                                            .                                                 (        )                                                     :                   -
                               .                                                                                                                                             :   -
                                                             .                                                                                                               :       -
                   :                                                                         Index Medicus                                                               :       -
                                                                                                                                     .
                                                                                                                                                 .
                                                                                                                             .
                                                                                                                                                         .
                                                                                                                                             .
                                                                                                                       .
                                                .                        (               )

                                            .                                                                                      :                                                     .5
                                                                             .
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                                                                                                                                                                                         -4
                       .                                ( 30000 )                                      .                    ( 15000)                                                     .1
                                       .                                                                                          ( 45000 )                                              .2
                                                                                                               .                                                                         .3


                                                    .        -                       -                                                   -
                                                zjms_hawler@hotmail.com                                            :             -
                                                zjms_hawler@yahoo.com

Dler Gallaly
                                                                                             II
                                                  ZJMS Volume 8
                                                        Dler           (2); 2004




            Title                        Authors                   Page        DD




-A  CLINICO-PATHOLOGICAL STUDY OF        Tayeb S. Kareem                  1
 WOMEN WITH BREAST LUMPS IN ERBIL        Nadya Y. Ahmad
 (KURDISTAN OF IRAQ).


-CURRENT STATUS OF BREAST CANCER IN      Nadya Y. Ahmad                  13
 KURDISH WOMEN IN ERBIL (KURDISTAN OF
 IRAQ).


-THE ROLE OF SALT AND ENDOGENOUS         Amad M. Saleh                   23
 NATRIURETIC    FACTORS    IN  THE       Salah Al-Din M.A. Al-Merani
 PATHOGENESIS OF HYPERTENSION.


-THE CHARACTERISTICS OF 110 ASTHMATIC    Ali S. Mohammad                 39
 PATIENTS  ADMITTED    IN   SULAIMANI    Aras A. Abdullah
 GENERAL HOSPITAL.                       Bakhtyar A. Hamachawash


-A COMPLICATION OF OGILVIES SYNDROME     Abdul-Kadir M. Zangana          47
 [COLONIC PSEUDO-OBSTRUCTION] CASE
 REVIEW.


-SONOGRAPHIC     EVALUATION  OF  THE     Abdul-kadir M. Zangana          51
 SCROTUM AND ASSOCIATED FINDINGS IN      Aram Latif Kaka-Hama
 DIFFERENT   AGE    GROUPS  IN  ERBIL
 PROVINCE –IRAQ.


-IRON STATUS IN PREGNANT VS NON-         Mohamad Salih Jaff              61
 PREGNANT WOMEN IN ERBIL REGION.


-PREVALENCE   OF  CRYPTOSPORIDIOSIS      Hadee M. A. Al-Sakee             71
 AMONG CHILDREN ATTENDING PEDIATRICS
 AND MATERNITY HOSPITAL IN ARBIL.


-EFFECT OF DIFFERENT ADHESIVE SYSTEMS    Dara Hama Saeed                 81
 ON MARGINAL ADAPTATION OF CLASS V       Ali H. Al – Khafaji
 COMPOSITE    RESIN  RESTORATION   (IN   Ali Sultan Al – Refai
 VITRO STUDY).


-EFFECT OF PRECLAMPTIC TOXAEMIA ON       Maysoon M. AL-Qzazz             91
 THE FETAL VESSELS.




                                                                               Dler gallaly

                                   III
Z.J.M.S.
 Vol. 8                       A CLINICO-PATHOLOGICAL STUDY OF
    (2)                      WOMEN WITH BREAST LUMPS IN ERBIL
 2004
                                     (KURDISTAN OF IRAQ)

                                Tayeb S. Kareem *         Nadya Y. Ahmad**



ABSTRACT:

In an attempt to delineate the spectrum of                 contrary the incidence of benign lumps
breast diseases presenting as breast                       were decreasing with age i.e. 100% in the
lumps      and to find the age-related                     2nd decade to 38.5% in the 7th decade.
frequency of benign and malignant                          Fibroadenoma was the most common
diseases in Kurdish female patients, we                    tumor encountered (25.3%), followed by
carried out     a prospective study of                     Fibrocystic changes (24.7%), carcinoma
females who present with breast lumps in                   (23.6%) and ductectasia (6.3%).
our private clinic and surgical outpatient                 Among malignant lumps, infilterative
department of Rizgary teaching hospital                    ductal carcinoma was the predominant
for a period of 5 years, from January                      histologic type, mean age was 50.3 years.
1999 to December 2003.                                     Pathological conditions associated with
A total of 368 female patients with breast                 lactation constituted (12.5%) of the cases
lumps were collected. After careful                        in our study.
clinical examination, all of them had                      In conclusion, nearly one in four female
undergone surgical excision biopsy for                     patients coming to a surgical clinic with
definitive    histopathlogic     diagnosis.                breast lumps may have malignancy with
Majority of them was in the 3rd, 4th and                   a greater frequency in younger age
5th decades of life. 76.4% of the lumps                    groups in our female population as
were benign lumps and 23.6% were                           compared with international data. This
malignant lumps.                                           should alert our clinician to be more
The incidence of malignancy increases                      cautious in managing breast lumps
with age (2.2%) in 3rd decade to 61.5% in                  especially in younger age group.
7th decade and 100% above 70 years. In

Key words:
Breast lumps ,cancer , Kurdish females , Erbil.




 * (M.B.Ch.B, F.I.C.M.S, F.I.C.S), Senior lecturer, Department of surgery, College of Medicine, Salahaddin
   University, Erbil, Kurdistan of Iraq. E-mail: tayebsk@yahoo.com
** ( M.B.Ch.B, F.I.C.M.S. Histopath.), Senior lecturer, Department of pathology, College of Medicine,
    Salahaddin University,Erbil, Kurdistan of Iraq.


                                                      1
INTRODUCTION:
 The breast is modified apocrine sweat                 The main presenting symptom for
gland (1), and functionally of great                 breast disease is a palpable lump (1) which
importance for the offspring as the                  is a thickening of breast tissue commonly
benefits of breast-feeding are many folds.           found in women of all ages and,
For the woman herself, breasts are                   regardless of its texture or size, a breast
symbol of womanhood and significant                  lump can be the result of a benign cyst or
component of famine beauty. However                  cancerous tumor. In spite of the fact that
one- fourth of women suffer from breast              over 80% of breast lumps are benign (9),
disease in their lifetime after puberty (2,3).       all lumps in the breast whatever the age
Worst of all it becomes a cause of death             of the patient, must be regarded clinically
among female population in the form of               as possibly malignant until proved
breast cancer which is the most common               otherwise (1,10).
malignant tumor and the leading cause of                    Early diagnosis is the key to
carcinoma death in women with more                   increased survival. Hence, it is important
than one million cases and nearly 600,00             for the surgeon to rule out malignancy
deaths occurring worldwide annually ( 4              with minimal invasive investigations and
– 6 ). In the western world breast cancer            thereby prevent the patient from
occurs commonly, accounting for 3-5 %                undergoing mutilating surgery while, on
of deaths and one out of twelve women                the other hand not missing the diagnosis
can expect to develop breast cancer in               of malignancy (5).
their lifetime, yet is a rare tumor in Japan                 A number of studies have been
and in developing countries it accounts              done on breast diseases in Iraq; but
for 1-3% of deaths (7).                              specific precise studies on the frequency
    A woman’s reaction to any actual or              of benign & malignant breast lumps in
suspected disease of the breast may                  Erbil (Kurdistan of Iraq) are lacking.
include fear of disfigurement, loss of               This study was basically designed to
attractiveness and death. Social &                   assess the incidence pattern of breast
religious          factors,        cosmetic          diseases presenting as breast lump and to
considerations, false vanity and fear of             find out the age-related incidence of
infertility have hindered early diagnosis            benign and malignant diseases in Kurdish
and treatment (8).                                   female patients.




                                                 2
PATIENTS AND METHODS:

A prospective study of females                               of the lump was carried in many patients.
presenting with breast lump in our                           Finally all of them have undergone
private clinic and surgical outpatient                       surgical excision of their lumps for
department of Rizgary teaching hospital                      definitive histopathological diagnosis.
was carried out for a period of 5 years,                     Patients, who do not undergo operation
from January 1999 to December 2003.                          for any reason, were excluded from our
     All female patients presenting with                     study. Patients with more than one
breast lumps were included in our study                      specimen for the same lesion were
and registered after thorough clinical                       counted once. Also patients with multiple
examination of the lump. FNA cytology                        or bilateral similar lesions, even if
excised at different times, were counted                     conditions affecting the skin overlying
once. Cutaneous tumors or inflammatory                       the breast were not included.

RESULTS:

At first, 406 patients were registered                       Patients’ age range between 14 an 80
during the study period. Thirty-eight                        years (mean 36.4). Majority of the
patients were lost and did not come back                     patients were in 3rd (25%), 4th (24%) and
with their results of histopathologic                        5th (21.2%) decades of life (Fig. 1) and
investigation, so they omitted from our                      the majority (53%) of the lumps were in
study. The remaining 368 patients with                       the upper outer quadrant followed by
breast lumps, who underwent surgical                         (20%) and ( 9%) in the upper inner and
biopsy with definitive histopathological                     lower outer quadrants respectively.
examination results of their lumps, were
included in our study.
                  30



                  25



                  20
              %




                  15



                  10



                   5



                   0
                       11--20   21--30   31--40     41--50      51--60   61--70   >71
                                                  Age (years)



                       Figure (1): Age distribution of females with breast lumps



                                                      3
Of the total 368 patients, 281 (76.4 %)                         The distribution of cases diagnosed as
were diagnosed as benign breast lumps by                        benign and malignant breast lumps, in
the histopathologic examination while 87                        assorted age groups is shown in Table (1)
(23.6%) were diagnosed as having                                and Figure (2)
malignant lumps.

                   120                                                             Benign lumps
                                                                                   Malignant lumps

                   100


                   80
               %




                   60


                   40


                   20


                     0
                            1      2      3        4        5       6     7        8
                                                   Age (years)

                         Figure (2): Frequency of benign and malignant lumps in
                                           different age groups.




      Table (1): Frequency of benign and malignant cases diagnosed in age groups.

                                                   Benign lumps                  Malignant lumps
          Age Groups            Number
                                                     %within age gp.                %within age gp.
             11-20                45          45          100%                 0           0%
             21-30                92          90          97.8%                2          2.2%
             31-40                88          71          80.7%               17         19.3%
             41-50                78          44          56.4%               34         43.6%
             51-60                50          26           52%                24          48%
             61-70                13          5           38.5%                8         61.5%
              >71                  2           0            0%                 2         100%
             Total               368       281             76.4%              87           23.6%



The frequency of malignancy in breast                           age, 100% in the 2nd decade to 38.5% in
lumps increases with age , ( 2.2 %) in 3rd                      the 7th decade.
decade to(48%), (61.5%) in 6th and 7th                          The histopathological findings in this
decade respectively and (100 %) above                           study with the corresponding number of
age 70 years. In contrary the frequency                         affected patients and the mean age are
of benign lumps was decreasing with the                         listed in table (2).



                                                       4
Table (2):Histopathological findings and mean age in ( 368 ) females with breast masses

                Types of lesions              of the patient    % of total   Mean age ( years)

           INFLAMMATORY CONDITIONS


   -Ducectasia                                     23              6.3             45.6
   -Acute mastitis & abscess                       15              4.1             25.6
   -Chronic non-specific mastitis                  10              2.7             28.9
   -Galactocele                                    9               2.4             26.2
   -Granulomatous mastitis                         4               1.1             38.2
   -Antibioma                                      3               0.8             26.4
   -Fat necrosis                                   2               0.5              30
   -Tuberculosis                                   1               0.3              27
   Subtotal                                        67            18.2%
    PROLIFERATIVE NON-NEOPLASTIC CONDITIONS


   -Fibrocystic changes                            91             24.7             40.6
   -Fibroadenosis                                  4              1.1              29.8
   -Sclerosing adenosis                            1              0.3               34
   Subtotal                                        96            26.1%
                 BENING TUMERS


   -Fibroadenoma                                   93             25.3             25.1
   -Lactational adenoma                            5              1.4              24.2
   -Ductal papilloma                               4              1.1              39.3
   -Tubular adenoma                                1              0.3              36.2
   -Lipoma                                         1              0.3              45.2
   Subtotal                                      104             28.3%
               MALIGNANT TUMERS


   Infilterative ductal carcinoma                  80             21.7             50.3
   Paget’s diseases                                4              1.1              53.1
   Papillary carcinoma                             2              0.5               51
   Medullary carcinoma                             1              0.3               47
   Subtotal                                        87            23.6%
           NO PATHOLOGICAL FINDINGS                14             3.8%             29.6
                    Total                        368             100%



Table (2) shows that benign tumors                      predominently ductectasia (6.3%), in that
(28.3%),      especially     fibroadenoma               order.
(25.3%),was the        leading pathologic               After careful histological examination ,
finding, followed by proliferative non-                 the lumps of 14 (3.8%) patients proved to
neoplastic diseases (26.1%) , mainly                    be normal or accessory breast tissues
fibrocystic change (mammary dysplasia)                  either    with    normal     pregnanacy/
(24.7%), then        carcinoma (23.6%),                 lactational changes or involuting
mostly infilterative ductal carcinoma                   unremarkable         breast        tissue.
(21.7%)      and     mastitis     (18.2%),

                                               5
                                            others

                                                                  Fibroadenoma
                                 No disease

                              Ductectasia



                                    Carcinoma                     Fibrocystic
                                                                   changes

     Figure (3) : Histopathologic Findings in a series of women seeking evaluation of
                  apparent breast lumps.


The frequencies and incidence of the commonest benign and malignant breast diseases, in
the total cases of breast lumps within different age groups is shown in table (3).

Table(3): Age distribution of the commonest breast lesions.
                                             Fibrocytic
                     Fibrodenoma                                  Ductal carcinoma           Ductectasia
     Age group                                changes
                       % of the total         % of the total           % of the total         % of the total
       11-20     36         38.7        7            7.7          0          0          0            0
       21-30     42         45.2        19           20.9         2         2.5         0            0

       31-40     12         12.9        40           44           11        13.8        2           8.7

       41-50     3          3.2         21           23.1         33        41.3        15         65.2
       51-60     0           0          3            3.3          24        30          6          26.1
       61-70     0           0          1            1.1          8         10          0           0
        >71      0           0          0             0           2         2.5         0           0
       Total     93        100%         91        100%            80       100%         23         100%



Fibroadenoma was the most common                               Fibrocystic change or mammary
lesion encoutered, which was more                              dysplasia was the second breast lesion in
common in the 2nd and 3rd decades of                           frequency, accounting for (24.7%) of all
life, average size was (2.4cm) and 13%                         cases. It was more common in the 4th
of them showed lactational changes                             decade of life.
within the fibroadenoma or the                                 Carcinoma of the breast ranked third in
surrounding breast tissues.                                    our study. The vast majority of the cases
                                                               (80 out of 87) were infiltrating ductal

                                                          6
carcinoma with peak incidence in the 5th        (Table 2), the mean age of this group was
decade of life and the mean age of our          45.6     years.    Other     inflammatory
patients was 50.3 years. If the mean age        conditions include acute mastitis and
of menopause in Kurdish females is              breast abscess (4.1%) which affected a
considered 50 years, then 57.5% of our          younger age population , mean age was
cases were premenopausal and 42.5%              25.6 and ( 83.3 %)of the patients were
were postmenopausal; 15.2% of the               less than 35 years of age, reflecting the
patients were less than 40 years of age.        association of this lesion with lactation
Average size of the mass was (4.3 cm).          and pregnancy.
Majority of them (79%) was stageII with         Generally the pathological conditions
involvement of the axillary lymph nodes.        associated with lactation such as acute
Inflammatory conditions of the breast,          mastitis, abscess, chronic non-specific
particulary ductectasia (6.3%), also            and granulomatous mastitis ,galactocele
known plasma cell mastitis ,constitute          and lactational adenoma constituted
the fourth major category in our study          ( 12.5 %) of the cases in our study .


DISCUSSION:

The high frequency and the diverse              is the commonest presentation (1). Almost
variety of breast lesions has prompted          77 to 78 % of the
many workers in various medical fields          patients diagnosed as breast cancer
to embark on numerous and exhaustive            present with breast lumps (18). Our study
studies of many aspects of these disease        involves
conditions. In addition, carcinoma of the       368 females with breast lumps. Certain
breast ranks first among malignant              social factors and demographic findings
tumors affecting females in many parts          contribute to the pattern of diseases of
of the world (4).                               breast encountered in this study. Kurdish
Wide variations in the spectrum of breast       females tend to marry at a young age,
diseases and the epidemiology of                according to the traditional conservative
mammary carcinoma in various countries          values of the society, with childbearing
or ethnic groups (9,11-17) have been            extending practically over the entire
reported. Few studies address themselves        reproductive period of life. These facts
to the whole spectrum of breast diseases        are reflected in our study by the
in Kurdish females particularly. In our         predominance of females in the 3rd, 4th
study we try to evaluate the pattern of         and 5th age groups (Fig. 1) and the
breast diseases in Kurdish females who          occurrence of many lactation related
present with breast                             conditions, including acute and chronic
lumps and comparing our results with            mastitis, granulomatous mastitis ,
other literatures.                              galactocele and lactational adenomas
Female patients with breast diseases            which account to 12.5% of all cases in
present in a surgical clinic with various       this study.
symptoms including breast lumps,                About half of the patients (53%), their
nodularity, pain, nipple discharge and          breast lumps were in the upper outer
others. Amongst these, a lump in breast         quadrant while 20% and 9% in the upper

                                            7
inner and lower outer quadrants                   ductal carcinoma. The incidence of
respectively. This marked differences in          malignancy in our work increases
breast lump frequency depending on the            gradually with the age, 0% in the 2nd
quadrant, is easily explainable by the fact       decade to 61.5% in the 7th decade and
that it matches closely the amount of             100% in 8th decade of life . On the other
breast parenchyma in each quadrant (5).           hand, the incidence of benign lesions is
The over all frequency of malignancy in           decreasing with advancing age, 100% in
all patients with breast lumps was 23.6%          the 2nd decade to 38.5 % in the 7th decade
and the remaining 76.4% cases were                & 0 % above 70 years (table 1, Figure 2).
having benign lumps. This frequency of            The incidence of malignancy in the 3rd
malignancy in the present work is some            decade of life in our study is 2.2% (table
what similar to that reported in the              1), which is somewhat close to Palmar
developing countries like India                   2.5% (22) and Donegan 2%(23)findings in
( 24.8% reported by Chaudhury etal) (19)          their studies .
and Pakistan ( 26% reported by Usmani             The peak incidence of malignancy in our
etal) (20) . However; our figures are             study was in the 5th decade of life
higher than those observed in the western         (43.6%)( Table 1) which is in between 4th
developed countries, Ellis and Cox                decade observed by Usmani (20) in his
observed 10% at UK (9) and Fleming etal           study and sixth decade in Western
observed 19.6% at Australia(21). This             countries as observed by Gaudette (24) in
higher incidence as compared to the               Canadian women. This indicate that
western world suggests a greater                  malignancy in breast lumps in our
incidence of breast cancer in Kurdish             females is more common at an early age
females like Arab females (15). A                 as compared to the Western population,
significant patient’s population is               so our surgeons and clinicians should be
illiterate or poorly educated and has a           more cautious in managing the breast
poor awareness of breast cancer;                  lump in early age.
moreover by virtue of Islamic beliefs,            The incidence of malignant lumps in 6th
modesty and due to the conservative               decade is (48%) (Table 1) which is again
nature of the society, many females with          higher than 44% as observed by Donegan
                                                  (23)
breast lumps will refrain from seeking                 . This augments our observation that
medical advice out of shyness until their         females in our city present to the surgeon
disease becomes far advanced i.e. when            with symptomatic malignant lumps and
it giving them significant symptoms such          ignore asymptomatic breast lumps until a
as pain, discomfort, skin changes or an           late     stage   when      they     become
increase in the size of lump(8). These            symptomatic and started causing
reasons could be the basis of higher              problems.
incidence of malignancy observed in our           After 6th decade, the incidence of
patients as compared to the west.                 malignancy is almost the same as
In our study, the youngest patient with a         reported in international literature (23).
breast lump was 14 years old with                 Benign tumors are the largest group
diagnosis of fibroadenoma and the                 (28.3%) in our series. Fibroadenoma are
youngest patient diagnosed to have a              the most frequent lesions encountered,
malignant breast lump was 29 years old            constituting 25.3% of all cases. This is
with a histopathology of infiltrating             higher than the reported frequency in
                                              8
England (7.7%) (9), USA (18.5%) (25) and           according to the presence or absence of
Jordan (21%) (26); but is slightly lower           various microscopic elements (31).
than American blacks (34.7%) (27) and              Malignant tumors are the 3rd frequent
Africans (28). In India, fibroadenoma is           histopathology diagnosis in breast lumps
the most frequent benign lesion of the             in our study. Infilterating ductal
breast (29). It is apparent that the high          carcinoma        was     the    predominant
frequency of fibroadenoma in our                   histologic type and found in 21.7 %of the
females is similar to what has been                total breast lumps. Data of our study are
observed in black American, African and            close to the data of other studies from
Indian females and contrasts with the              Egypt (15), Sudan (32), Jordan (26), Kuwait
                                                   (15)
lower frequency in Western white                        , Palestine (33) and Lebanon (34). The
females. The causes of this increased              similarities shared in these studies on
frequency are not clear. Racial                    Arab females with breast cancer and our
predisposition could be a factor.                  Kurdish females with malignant lumps
Demographic factors might play a role,             include their young age, which is on the
considering the relatively large number            average 10 years less than Western
of young females within the population             females (24,25) and the presence of several
of these groups. The rate of growth of             poor prognostic factors including large
fibroadenoma may increase during                   size of tumor and the higher frequency of
pregnancy (30) and this could alarm those          axillary lymph node metastasis. This
patients who will seek medical help with           probably       reflect    delays    in   the
subsequent excision of the mass, thus              presentation of the patient to the
adding a bias of selection . In the present        physician due to social & cultural
study , 12 patients (13%) with                     factors; however further work is needed
fibroadenoma        showed       lactational       to shed more light on the natural history
changes histologically.                            of breast carcinoma in Kurdish females.
Proliferative non-neoplastic conditions of         Inflammatory conditions are the 4th most
the breast are the second largest group in         frequent diagnosis accounting 18.2% of
our study, accounting for ( 26.1%) of              the total cases. Ductectasia was the
cases. Fibrocystic change is the most              predominant histologic type (accounting
frequent entity in this group. This lesion         6.3% of total cases); however it was
is the most common breast mass in the              observed in only 2% of cases in Western
studies done in UK (37%) (9) and in USA            population series (23).The lesion is more
(33.9%) (25). In the past, several terms           common in our population perhaps due
such as mammary dysplasia, cystic                  to multiparity and greater inclination
mastitis and fibrocystic disease were              towards breast- feeding as compared to
used to describe the pathologic spectrum           the western population.
of     apparently      related      clinical       Acute mastitis and breast abscesses in the
abnormalities of the breast. Now there is          present study is 4.1% of the total cases;
a consensus to use the term fibrocystic            however we believe the figures for the
condition or change as the preferred               breast abscess are underestimated
diagnostic term, the degree of                     because most of them are drained in
development of malignancy stated                   casualty hospital without taking biopsy.



                                               9
  CONCLUSION:

Benign tumors are the predominant                    malignancy is increased with age in each
histologic findings in our females with              subsequent age group, with a trend
breast lumps(28.3%); however frequency               towards a greater incidence in younger
of diagnosis of breast cancer in women               age group in our population as compared
with breast lumps is 23.6% of the total              with international data. This should alert
cases in our study i.e. nearly one in four           the clinician in our city to be more
female patients coming to a surgical                 cautious in managing breast lumps
clinic with breast lumps can have                    especially in younger age group.
malignancy.      The      frequency     of



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   The breast. Muir’s Textbook of                       M, Minhas S, Mahmood N, et al.
   Pathology.13th edn. ELBS: Edward                     Level of awareness about breast cancer
   Arnold. 1992:1038-55.                                among females presenting to a general
2. Siddiqi K, Imtiaz RM. Pattern of                     hospital in Pakistan. J Coll Physician
   breast diseases: preliminary report of               Surg Pak 2001;11:131-5.
   breast clinic. J Coll Physician Surg             9. Ellis H,Cox PJ. Breast proplems in
   Pak 2001;11: 497-500.                                1000 consecutive referrals to a surgical
3. Ghumro AA, Khaskhheli NM, Memon                      out-patients.     Postgrad     Med      J
   AA, Ansari AG, Awan MS. Clinical                     1984;60:653-6.
   profile of patients with breast cancer. J        10. Dunn JM, Lucarotti ME, Wood SJ,
   Coll Physician Surg Pak 2002; 12:28-                 Mumford A, Webb AJ. Exfoliative
   31.                                                  cytology in the diagnosis of brest
4. IARC, WHO. Breast cancer, in                         diseases. Br J Surg 1995;82:789-91.
   Stewart B, Kleihuses P (eds). World              11. Chaudary MA, Hayward JL, Bulbrook
   cancer report. Lyon: IARC Press                      RD. A comparison of epidemiological
   2003; 188-190.                                       characteristics in breast cancer patients
5. Rosai J. Breast. Ackerman’s Surgical                 and normal females in Great Britain
   Pathology. 18th edn. Mosby- Year                     and Japan: results of prospective study.
   Book, Inc.1996: 1590-626.                            Breast Cancer Res Tret 1991;18 (supp
6. Magrath       I(2004).     International             11): 19-22.
   network for cancer treatment and                 12. Ihekwaba FN. Breast cancer in
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   at:www.inctr.org/publications/2002_v                 1992;79:771-5.
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   ed. London:Arnold. 2000:749-72.                  14. Ghafoor A, Jemal A, Cokkinides V,
                                                        Ward E,Cokkinides V, Smith R ,et al.

                                               10
    Trends in breast cancer by race and           24. Gaudette LA, Sillberger C, Almayer
    ethinicity. Cancer J Clin 2003;53:342-            CA. Trends in breast cancer incidence
    355.                                              and     mortality.    Health    Report
15. Hoogstraten B, Gad-El-Mawla N,                    1996;8:29-37.
    Hamsa MR, Abdelaziz A,Omar Y.                 25. Leis HP. The diagnosis of breast
    Breast cancer in Arabic females.                 Wilkinson      S,      Forrest    APM.
    Oncology 1982; 39: 134-9.                        Fibroadenoma of the breast. Br J Surg
16. Dajani YF, Al-jitawi SA. A study of              1985;72:838-40.
    405 breast tumors in Jordians using           26.Consensus Meeting. Is “fibrocystic
    the revised WHO classification. Trop             disaease” of the breast precancerous?
    Geogr Med 1987;39:182-6.                         Arch Pthol Lab Med 1986:110:171-3.
17. Sengupta H, Al- Sulaimani SH , Alam           27.Hidaytallah A. Carcinoma of the breast
    MK, et al. Spectrum of breast disease            in the Sudan. I. Epidemiological
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                                             11
Z.J.M.S.
 Vol. 8          CURRENT STATUS OF BREAST CANCER IN KURDISH
    (2)              WOMEN IN ERBIL (KURDISTAN OF IRAQ)
 2004

                                            Nadya Y. Ahmad*



ABSTRACT:

In order to demonstrate the characteristics              About 63% were premenopause & 23.2%
of breast cancer in Kurdish females and                  were younger than 40 years. No in-situ
examine the extent of patient delay with                 carcinoma was recorded & only 3.2%
its impact on clinicopathologic features,                were stage I disease. A considerable
we carried out a prospective study of a                  proportion of our cases (96.8%) was
group of newly diagnosed breast cancer.                  stage II and higher. About 59% of
      A total of ninety-five patients were               patients delay medical seeking more than
interviewed. For each patient, age, type                 one month and nearly 73% of the cancers
of breast malignancy, clinical &                         were detected only after lymph node
pathologic staging , side & location of the              involvement.
tumor and the type of surgery were                           Lack of breast cancer awareness & its
recorded. In addition; we asked them                     symptoms was the predominant cause for
about the period from first onset of                     patients’ delay with statistical significant
symptoms to first medical consultation to                correlation between late presentation and
indicate patient delay with its main                     bigger tumor size & advanced stage of
underlying cause. Statistical analysis was               the disease ( P<0.05).
performed to study association between                      These results show advanced cases at
delay presentation and clinical variables.               presentation in Kurdish females which
     The mean age of women with breast                   further mandate a national cancer
cancer was 47.1 and the highest                          detection program involving more
frequency of breast carcinoma was                        effective     public    education       and
observed in the 40-49 age group (40%)                    encouragement of women for breast self-
which is at least one decade younger than                examination and participation in
their counterparts in developed countries.               screening campaigns.




* ( M.B.Ch.B F.I.C.M.S .Histopath) Senior lecturer, Department of pathology, College of Medicine,
  Salahaddin University,Erbil, Kurdistan of Iraq.




                                                    13
INTRODUCTION:
The breasts (modified apocrine sweat                  Moreover the late stage of disease and
glands) (1), are functionally of great                high mortality are seen with delay in
importance for the offspring as the                   diagnosis & treatment of breast cancer
                                                      (11)
benefits of breast-feeding are many folds.                 . There is evidence that small tumors
For the woman herself, breasts are                    are more likely to be treated successfully
symbol of womanhood and significant                   with limited breast surgery, and perhaps
component of famine beauty. However                   a better quality of life. In the United
one-fourth of women suffer from breast                States, there has been a sharp increase in
disease in their lifetime after puberty (2,3).        the       detection of breast carcinoma ,
Worst of all, it becomes a cause of death             largely due to the widespread use of
among female population in the form of                mamography(12). Most of these cases
breast cancer which is the most common                have been localized, measuring less than
malignant tumor and the leading cause of              2cm in diameter and/or insitu (13).
carcinoma death in women with more                          Delay and late stage at diagnosis of
than one million cases and nearly600,00               breast cancer are related to socio-
deaths occurring worldwide annually                   demographic factors such as age,
(4,5,6)
        . In the western world breast cancer          education, marital status, economic
occurs commonly, accounting for 3-5 %                 status, history of breast disease, Family
of deaths and one out of twelve women                 history of breast cancer, the nature of the
can expect to develop breast cancer in                first symptom and many other
their lifetime, yet is a rare tumor in Japan          factors(10,11).The aim of this work was to
and in developing countries it accounts               study the clinicopathologic features of
for 1-3% of deaths(7,8). However; the                 breast cancer among Kurdish women in
rates in women living in developing                   Erbil and to evaluate the extent of patient
regions are rising (9) and in the Middle              delay in seeking medical advice with
East,breast cancer is the most common                 clarification of the possible underlying
malignancy among women(8).                            reasons for delay & its impact on
      Delayed presentation of breast cancer           clinicopathological characteristics.
is associated with lower survival (10).



PATIENTS & METHODS:
A group of newly diagnosed breast                     demographic factors, modes of breast
cancer patients, who were admitted to                 cancer detection and the time between
Razgary teaching hospital or attending                initial patient perception of breast lesion
our private clinic, were interviewed                  and first medical consultation. Delay in
following their surgery or first course of            seeking medical advice was defined as
radiotherapy &/or chemotherapy between                time period of = or > 1 month between
January 1999 and December 2003.                       initial perception of the breast lesion &
A structured printed questionnaire was                first physician visit. Patients were
used as an interview guide. In addition to            excluded if their data were unreliable i.e.
the essential data, it included socio-                If patients were not sure of the date of

                                                 14
first symptom recognition or could not              staging, based on AJCC TNM
recall the date, data considered                    Classification (14),side & location of the
unreliable.                                         tumor and the type of surgery, were also
Clinical data including pathological                recorded.

RESULTS:
In all, there were (103) female patients            large size and was associated with
with     histologically   proven      breast        ulceration of skin with formation of a
carcinoma. Ninety-five patients were                fungating mass.
recruited into the study & the remaining 8          The vast majority of the cases (91 out of
patients were missed or refused to be               95) were infiltrating ductal carcinoma.
interviewed. The characteristics of breast          35.2% were grade III poorly differentiated
cancer females are demonstrated in table            ductal carcinoma. Six patients showed
(1).                                                clinical & histological features of
The mean age of women with breast                   involvement of the nipple by Paget’s
cancer was 47.1 year with a range of 29-            disease, all were associated with
80 years and higher frequency of                    underlying infiltrating ductal carcinoma.
malignancy was in 40-49 age group.                  The commonest surgical intervention for
Premenopausal women younger than 50                 malignant breast lesions was modified
years constituted 63.2% and 3.2%of                  radical mastectomy, which had been done
patients were less than 30 years old.               for 84 (88.4%) patients. Following
Both breasts were about equally affected            histological examination, 23 cases
by carcinoma. Involvement of the Rt.                (27.4%) had negative lymph nodes for
breast was 48.3% and the Lt. Breast was             metastatic deposits and 61 cases (72.6%)
51.7%. Upper outer quadrant was the                 had positive lymph nodes. Of the latter
most frequent site (31.4%) and 8(8.4%) of           group, 13 cases (21.3%) had metastasis in
cases, the lesion was large enough to               one to three lymph nodes & 48 cases
involve more than one anatomical region             (78.7%) in more than three lymph nodes.
of breast. Three cases (3.2%) showed                It should be stated that most of the
massive nipple involvement & ulceration             patients with advanced involvement of the
by direct extension from underlying                 breast, including the ones with ulceration
tumor.                                              or fungation, were among the remaining
Most of the patients (85.3%) presented              11(11.6%) patients who had conservative
with breast lumps that either discovered            surgery or simple mastectomy only.
accidentally by themselves or by the                In all, 96.8 % were diagnosed as having
physicians during clinical examination.             stage II disease and higher (AJCC on
Average size of the lump at the time of             cancer classification) while only 3.2% of
diagnosis was (3.7 +/ - 2.1) cm. Thirteen           patients were stage I disease. Actually no
(13.7%) their lumps were less than 2 cm             incidence of in situ carcinoma was
in maximum diameter while 82 (86.3%)                recorded. Twenty one(22.1%) patients
were more than 2 cm in diameter. Five               had locally advanced disease ( T4 ) and
patients (5.3%)had more than one focus or           five( 5.3%) patients had distant metastasis
nodule of tumor in the same breast. In 4            at      the     time      of      diagnosis.
cases (4.2%), the tumor attained quite a

                                               15
Table (1): Characteristics of women with breast cancer (n=95)

                                                    NUMBER      (%)
                   Age groups (years)
                            >20                           0       0
                           20-29                          3      3.2
                           30-39                          19     20
                           40-49                          38     40
                           50-59                          25    26.3
                            >60                           10    10.5
                           Mean                          47.1
                           Range                        29-80
                   First symptom seen
                           Lump                          81     85.3
                          Other*                         14     14.7
                    Education levels
                         Illiterate                      34     35.8
                          Primary                        39     41.1
               Secondary/higher education                22     23.1
                 Delayed presentations
                       < 1 month                         39     41.1
                       > 1 month                         56     58.9
                     Mean17.5 wks
                Range1 wks- 36 months
                 Type of breast cancer
               Invasive ductal carcinoma                 91     95.8
                  - Grade I 8(8.8%)
                  - Grade II 51(56%)
                  - Grade III 32(35.2%)
                   Papillary carcinoma                   2       2
                  Medullary carcinoma                    1      1.1
                   Lobular carcinoma                     1      1.1
                       Tumor size
                          < 2 cm                         13     13.7
                         2- 5 cm                         73     76.8
                          > 5 cm                         9       9.5
                Tumor local extension
                         T0 / Tis                        0        0
                            T1                           10     10.5
                            T2                           59     62.1
                            T3                           5       5.3
                            T4                           21     22.1
            Lymph node involvement ( n=84)
                            N0                           23     27.4
                           YES                           61     72.6
                    Stage of disease
                              I                          3       3.2
                             II                          65     68.4
                            III                          22     23.2
                            IV                           5       5.3

          *Including Nipple Discharge & Skin Problem.




                                          16
About 59 % of patients delay seeking medical advice for more than one month after initial
perception of breast lesion. On average patients took (17.5 ) weeks to the first physician
visit. Common reasons for delay medical advice are summarized in Table (2).
Table (2): Common reasons for delay medical advise*.
         lack of breast cancer awareness & Ignorance                                43.2 %
         Asymptomatic painless lump.                                                26.3 %
         Shying.                                                                     20 %
         Financial i.e. low socioeconomic state.                                    13.7 %
         Fear of surgery.                                                            10.5 %
         Fear of cancer.                                                             8.4 %
         Residence in rural area.                                                    5.3 %
         Others                                                                      3.2 %
      * N.B:- percentage do not total 100% because some patients had more than one reason for one delay.

About 64% of patients were educate(table1); however lack of breast cancer awareness &
ignorance was the leading cause for delay seeking medical advice.
In order to study more the level of cancer awareness & its symptoms among our females,
we asked our patients with breast cancer about their initial etiologic perceptions of their
breast lesions that probably result in a significant delay (Table 3). Unfortunatly, only 4%
thought of malignancy!!.
   Table (3): Patients’ etiologic perceptions of their breast lesion.

                               Benign growth                         35.8%
                               Milk Clot                             25.3%
                               Trauma                                19%
                               Infections                            13.7%
                               Malignant growth                       4.2 %
                               Unknown                               2.1%

Finally a cross tabulation analysis (Table 4) showed that delay of more than one month
was significantly associated with advanced disease (P = 0.01), and bigger tumor size (P =
0.003).    However,      nodal     status   did    not    show      significant   results.

Table (4): Association between delay presentation & clinical variables
                                                  < 1 month              > 1 month              P value
                                                    No.( % )               No.( % )
     Stage of disease (n=95)
              I & II                                  57                       11
             III & IV                                 16                       11
                                                  X2 = 6.6, df =1                                  0.01
     Tumor size (n= 95)
            <2 cm.                                     10                      3
            2- 5 cm.                                   61                      12
            > 5 cm.                                     3                      6
                                                  X2= 11.7, df = 2                                0.003
     Nodal involvement (n= 84)
             No                                         15                      8
            Yes                                         42                      19
                                                  X2= 0.10, df= 1                                  0.75



                                                       17
DISCUSSION:
                                                   (18)
Breast cancer is one of the most growing              , Saudi Arabia (19) and Bahrain(20). In
and important women’s health problems              Yemen, the age groups of women mostly
in our country, although its statistics is         affected have been 30-39 and then 40-49
very similar to that of the regional               years (21).
countries (15). It is estimated that the              The mean age of our patients was 47.1
crude incidence rate of the disease is             (table 1) which is about similar to that
about 20 new cases per 100,00 women                observed by Malik (22) in Pakistani
per year; many of them (70%) die within            women.
a short period of time because of                      So, in Erbil (Kurdustan of Iraq), like
advanced disease at presentation (16).             other developing countries of Asia &
   Our study showed the largest                    Africa(16-22), breast cancer affects women
proportion of cases (40% of breast                 at least one decade younger than their
cancer women) occurring in the 40-49               counterparts in developed countries(23,24)
years age group. This is similar to data of        that indicate our surgeons & clinicians
other studies from surrounding regional            should be more cautious in managing
countries as Iran (16), Jordan (17), Kuwait        breast lesions in early age.


 Similar studies from other developing countries (20,25), Our data indicates that, women
with breast cancer in Erbil visit the physician rather late in the course of the disease with
more advanced disease (Table1). All the features of advanced breast carcinoma are
summarized below:-
       86.3 % of cases were more than 2cm in diameter.
       72.6 % of cases with axillary lymphadenectomy had positive lymph nodes.
       78.7 % of cases with positive lymph nodes had more than 3 nodes involved.
       35.2 % of infilterative ductal carcinoma were grade III (poorly differentiated).
       22.1 % of cases showed locally advanced disease & 4.2% of all cases showed
       skin ulceration +/or fungation.
In term of staging, more than 68 % presented in stage II and about 23% in stage III.

 These results, which are seriously                carcinoma. In developed countries as the
alarming, are similar to other data from           United States, there has been sharp
some neighboring countries (16-22).                increase in the detection of breast
Considering this picture and the fact that         carcinoma, largely due to the widespread
more advanced cases of breast cancer are           use of
less amenable to tissue–sparing surgery            mamography(12). Most of these cases
(21)
     , it’s not surprising that modified           have been localized, measuring less than
radical mastectomy done frequently                 2cm in diameter and/or insitu(13).
(88.4%)& no female had the chance of                    About 59% of patients with breast
conservative mastectomy because no                 symptoms had a delay of more than one
women had presented with early stage               month before presenting to a health

                                              18
professional. This finding is comparable             examined by male attendants. Also in
with other studies (10,11). However, the             Islamic countries the social values and
extent of patient delay can be different in          moral considerations limit the use of
different places. One explanation for                mass media for publicizing breast cancer
such a difference might relate to the                study. However Montazari in his study
                                                     (30)
patient’s health related behaviors and the                  did not found evidence to suggest that
social context they live in. About 64% of            religious beliefs interfere with early
our patients considered educated, at least           detection behaviors and contribute to
they had primary school education; but               subsequent delayed presentation of breast
lack of knowledge about breast cancer &              cancer in Iranian women.
it’s related symptoms (Table 2) was the                    The influence of delay on tumor size
predominant underlying reason for                    and disease stage is well-documented
                                                     (10,31)
patients’ delay and this is proved by the                    . Like other studies, our findings
finding that the vast majority (95.8%) of            indicated that those who presented late
our patients (table4), initially did not             had significantly bigger tumor size and
think about malignancy as a probable                 presented with advanced stage of the
underlying cause for their breast                    disease (Table 4).
symptoms and consider them as benign                     Finally, it is worth noting that there
conditions that could disappear with                 were several limitations inherent in this
time. However; it is argued that an                  study and the findings cannot be
intention to seek evaluation of breast               generalized beyond the study sample.
symptoms is not merely a matter of                   The sample size was small and thus the
education & economics but it is                      predictive power of the study was
dependent on a complex picture of                    limited. Additionally, the questions used
personal and social factors with previous            to recall dates and times such as first
habit of health care utilization (26). On the        presentation of the disease and first
other hand, the role of education and                medical consultation might be biased,
knowledge in decreasing delay has been               especially in cases with longer delay.
confirmed in other studies (27,28) and                   Furthermore, it seems that in addition
experience from other countries show                 to patient delay, system delay (which is
that after introduction of breast cancer             the interval between first presentation to
screening programs with general public               a medical professional and initial
education, the stage at diagnosis has                treatment) is also an important issue that
decreased significantly (29)                         merits           further       investigation.
                                                     Unfortunately this was not investigated
    The situation leading to late                    in this study and as indicated in other
discovery of a potentially curative cancer           literature on delayed presentation of
in our country might be further affected             breast cancer, system delay appears to be
by scarcity of female surgeons and social            both under researched & underestimated
                                                     (32)
embarrassment of some women for being                     .




                                                19
CONCLUSION:

  Our patients with breast carcinoma presented at an advanced stage that adversely
influence the clinicopathological behavior and outcome of the disease. These results
recommend an urgent need for national cancer detection program involving more
effective public education and encouragement of women for breast self- examination and
also education of primary care physician for strengthening this strategy.



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                                               21
Z.J.M.S.
 Vol. 8         THE ROLE OF SALT AND ENDOGENOUS NATRIURETIC
    (2)                FACTORS IN THE PATHOGENESIS OF
 2004
                                HYPERTENSION*

                         Amad M. Saleh **            Salah Al-Din M.A.Al-Merani ***


 ABSTRACT :

   Substantial data indicate a significant                  renal function measurements. Whereas,
role of dietary salt in the development of                  similar infusion of plasma from
hypertension. The amount of salt in the                     hypertensive patients induced biphasic
body determines the volume of the                           actions. The plasma from patients with
extracellular      fluid     (ECF)      that                high diastolic blood pressure (DBP)
consequently triggers physiological                         caused marked and significant increases
mechanisms to regulate Na+ balance,                         in arterial BP, urine flow, Na+ & K+
volume homeostasis and arterial blood                       excretion rates and glomerular filtration
pressure (BP).Therefore, experiments                        rate (GFR). These effects were
were      designed        to     investigate                accompanied by a statistically significant
cardiovascular and renal responses of                       reduction in the percentage Na+
rabbits to salt loading and to intravenous                  reabsorption of the filtered load (%Na+
infusion of plasma taken from normal                        RFL). While the plasma from
subjects and patients with chronic                          hypertensives with an upper limit of
hypertension.                                               normal DBP, in contrast, significantly
    Salt loading produced highly                            decreased arterial BP and Na+ excretion
significant increases in arterial BP , urine                rate and produced small reductions in
flow and urinary Na+ and K+ excretion                       GFR and urine flow. It was suggested
rates. These effects are attributed mainly                  that the plasma of hypertensive patients
to the release of a natriuretic factor(s)                   with high DBP contained high levels of
with pressor activity.                                      ouabain-like compound (OLC). Whereas
    Intravenous infusion of plasma from                     the plasma of those hypertensives with
normotensive subjects into bioassay                         normal DBP contained higher levels of
rabbits (6 ml/hr./kg) produced no                           atrial natriuretic peptide (ANP) and
detectable changes in cardiovascular and                    much less OLC.




  * Part of a Ph.D. thesis .
 ** Ph.D , College of Agriculture , University of Dohuk , Iraq .
*** Ph.D , Dept. of Physiology & Biophysics, College of Medicine, University of Salahaddin , Erbil , Iraq .




                                                      23
INTRODUCTION:
Hypertension is the most prevalent                    cultures that ingest a very low salt intake,
cardiovascular disorder in the human                  even in cultures with high salt intake, not
community particularly over the age of                every one develops hypertension and
60. A great deal of research has been                 some remain normotensive (11). In healthy
centered on the mechanisms underlying                 normotensive subjects, an ordinary
essential hypertension (1) . Sodium intake            quantity of ingested salt will be excreted
is one of the important environmental                 in the urine without any discernible
factors influencing the development and               elevation in systemic blood pressure. By
maintenance of high blood pressure                    contrast, in hypertensive individuals, the
(2,3)
      .The role of dietary sodium in the              same quantity of salt can be excreted
pathogenesis of essential hypertension                only with elevated blood pressure, and
has stimulated a great deal of interest and           their blood pressure levels will steadily
investigation in recent years (4,5,6,7).              rise in response to increasing quantities
Although most workers in the field agree              of salt ingestion. In many conditions,
that salt causes hypertension, there is no            hemodynamic changes occur which raise
well-established mechanism explaining                 the blood pressure and so excrete the
how dietary sodium is related to the                  excess salt by pressure diuresis
                                                      (12)
pathogenesis of essential hypertension.                    .Almost all forms of experimental
Vast literature exists on abnormal sodium             hypertension are known to begin with
transport process in experimental                     some obvious malfunction of kidney that
hypertension from various cell systems.               alters renal hemodynamics and tubular
The multiple sites of defects and                     reabsorption. Although specific renal
sometimes conflicting reports on Na+                  defects are difficult to identify in most
transport in hypertension also led to                 patients with essential hypertension,
alternative        hypothesis       associated        there is one aspect of kidney function,
membrane              abnormalities       with        the relation between sodium excretion
                (8,9)
hypertension . Uncertainties are due to               and arterial pressure, that is abnormal in
the complex effects of salt on the                    all types of experimental and clinical
cardiovascular system and in blood                    hypertension (13).
pressure regulation (10).                                      Recent data indicate the existence
         Salt-induced hypertension has                of some relation of salt to hypertension
been produced in both man and                         through the release of endogenous
experimental animals. The primary                     natriuretic factors. It has been
defect in the pathogenesis of essential               demonstrated that an expansion of the
hypertension appears to be an inability of            ECF volume is associated with the
the kidneys to handle the salt load with              appearance in the plasma of an
which they are faced in the presence of a             endogenous substance that is suggested
normal blood pressure. Blood pressure                 to augment sodium and water excretion
therefore rises along the renal function              by the kidney via its ability to inhibit the
curve, until induced pressure natriuresis             Na – K pump (9,14) . This sodium pump
enables the kidney to balance salt                    inhibitor subsequently became associated
excretion with salt intake (5). Indeed,               with salt-sensitive forms of hypertension
                                                      (15)
hypertension is not seen in human                          .Recently , an endogenous Na pump

                                                 24
inhibitor (OLC ), was isolated from the          of endogenous OLC that slows down the
human circulation and found to be                sodium–potassium pump lining cell
structurally similar to the cardiac              membranes. This will give rise to an
glycoside ouabain ( 16,17). Subsequent           increase in intracellular sodium which, in
cross-sectional studies showed that the          turn ,reduces the extrusion of Ca2+ by the
plasma levels of OLC were elevated in            Na+ - Ca2+ exchanger mechanism that
about 50% of patients with essential             leads to a rise in intracellular Ca2+ and
hypertension (18).                               thereby an increase in peripheral
       When salt–sensitive subjects are          resistance (9) . Whether endogenous OLC
maintained on a high–salt diet, they tend        plays an important role in essential
to retain more sodium and thereby                hypertension is not known. Nevertheless,
stimulate compensatory mechanisms to             the overall concept does help to explain
get rid of extra sodium and water. These         how a high salt intake could cause high
compensatory       mechanisms       would        blood pressure (1).
include the ANP, which has been found                 The aim of this study was to
to be raised in many patients with               determine the cardiovascular and renal
essential hypertension and may involve           responses of rabbits to salt loading , to
other sodium excreting mechanisms                evaluate similar responses in normal
which in themselves could, in the long–          bioassay rabbits to intravenous infusion
term, cause a rise in arteriolar tone and        of plasma from chronic hypertensive
peripheral resistance. One potential             patients and to elucidate the role of
mechanism whereby this could occur is            circulating natriuretic factors in the
through an increase in the plasma levels         pathogenesis of hypertension .




                                            25
MATERIALS AND METHODS:
Local domestic rabbits ( Oryctolagus               tubes . In female rabbits urine was
cuniculus ) of both sexes were used.               collected by applying firm pressure to the
They were acclimatized to standard                 lower abdomen above the bladder using
conditions of the animal house for 2 – 3           the thumb and the index finger, that helps
weeks prior to experimentation. Some of            emptying the bladder. Urine samples
the animals were salt – loaded after being         were collected in appropriate measuring
maintained on normal saline as drinking            cylinders.
water for at least 12 days. The rabbits                 It has been reported that rabbits like
were anaesthetized by phenobarbitone               humans also have blood groups due to
and urethane. Phenobarbitone was first             the presence of certain antigens in their
injected intraperitoneally in a dose of 100        red blood cells (20). Therefore, the blood
mg/kg , followed after 10 – 20 minutes             of rabbits was examined for blood
by an intraperitoneal injection of 0.75            grouping by using conventional human
g/kg urethane. Surgical anaesthesia was            antisra. Their blood group turned out to
reached in about 15 min after urethane             be compatible to group B–Rh+. The
administration.        Thereafter         ,        determination of blood groups was
supplementary small doses of urethane              considered when human plasma was
were injected intravenously as required            infused into bioassay rabbits to ensure
to maintain deep and prolonged                     compatibility. Human plasma from
anaesthesia . Tracheostomy was not                 normal subjects and hypertensive
performed as pulmonary ventilation was             patients were bioassayed in normal
adequate throughout experiments.                   rabbits .
     Intravenous (IV) infusions of                       GFR was determined by measuring
physiological saline or human plasma               the renal clearance of endogenous
into rabbits were given at a rate of 6             creatinine . Urine and plasma samples
ml/hr/kg via one of the marginal ear               were analyzed for Na+ and K+ by flame
veins. The arterial BP of rabbits was              photometry. The urine specific gravity
recorded via cannulation of one of the             ( S.G.) was determined by using specific
carotid arteries .The heart rate was               gravity refractometer (Uricon N,
accurately determined from the BP trace            ATAGO Co. Ltd. ,Japan ). When GFR
using the method described by Dizaye.(19)          was known, it was possible to express
    Arterial blood samples ( 1 ml each )           the amount of Na reabsorbed as a
were withdrawn through the carotid                 percentage of the filtered load (%Na
artery cannula , at the midpoint of each           RFL) :
urine collection period , and replaced by          % Na reabsorption of filtered load
                                                                                        ( amount of Na reabsorbed )
                                                                                                                     100
                                                                                           ( amount of Na filtered )
an equal volume of normal saline to
avoid volume depletion .                           The results are expressed as mean ± SEM
     Urine samples were collected easily           .Differences between means were
from male rabbits via the urethra by               evaluated with student’s t – test . P <
perurethral catheterization of the urinary         0.05 was considered statistically
bladder by small size pediatric feeding            significant.



                                              26
RESULTS:
     Salt loading induced highly significant increases in arterial blood pressure, urine flow
rate and Na+ & K+ excretion rates (Table,1). These changes were accompanied by a
statistically significant reduction in the percentage Na+ reabsorption of the filtered load.
Heart rate and plasma electrolyte concentrations were almost unchanged. GFR was only
slightly increased.


      Table(1): The effects of salt loading on blood pressure, heart rate ,
                    Plasma electrolytes and kidney function in rabbits.

                                                                      Statistical
                                   Normal       Salt-loaded
                                                                     Evaluation
          Parameters               rabbits        rabbits
                                                                        t–test
                                   (n =27)        (n = 8)
                                                                for unpaired samples
         Arterial B.P
                                 73.0 ± 2.56    118.7 ± 7.79         P < 0.001
           (mm Hg)
          Heart rate
             (HR)               278.1 ± 22.62   289.8 ± 28.55           NS
          (beat/min.)
          Plasma Na+
                                138.6 ± 0.77    138.6 ± 2.195           NS
        conc. (mEq/L)
          Plasma K+
                                 3.56 ± 0.11    3.71 ± 0.417            NS
        Conc. (mEq/L)
          Urine flow
                                0.037 ±0.004    0.073 ± 0.011        P < 0.001
         (ml/min./kg)
        Na+ Excr. Rate
                                5.40 ± 0.503    14.53 ± 1.918        P < 0.001
        (µEq/min./kg)
        K+ Excr. Rate
                                2.35 ± 0.256    4.30 ± 0.409         P < 0.001
        (µEq/min./kg)
             GFR
                                2.49 ± 0.272    2.92 ± 0.463            NS
         (ml/min./kg)
        Urine specific
                                1.027 ±0.002    1.020 ± 0.003           NS
        gravity (S.G.)
            % Na+
                                97.9 ± 0.275    94.2 ± 0.235          P < 0.01
             RFL
       NS indicates not significant .




                                                  27
Intravenous infusion of fresh human plasma from normotensive donors into bioassay
rabbits at a rate of 6 ml/hr/kg induced no appreciable changes in all parameters measured
(table,2). The slight changes observed were statistically insignificant.

Table(2): The effects of IV infusion of human plasma from normotensive subjects
          into normal rabbits.Assessment of cardiovascular and renal responses (n = 9).

                                            IV infusion                Statistical
                                             of human                  Evaluation
                                                             %
           Parameters        Control       plasma from                   t–test
                                                           Changes
                                              normal                   for paired
                                              subjects                  samples
           Arterial B.P
                            75.9 ± 3.85     75.0 ± 4.25     - 1.2          NS
            (mm Hg)
         HR (beat/min.)    303.5 ± 26.38   300.7 ± 23.84    - 0.9          NS
           Plasma Na+
                           136.4 ± 1.425   137.4 ± 1.396    + 0.7          NS
         conc. (mEq/L)
           Plasma K+
                            3.34 ± 0.08    3.89 ± 0.290     + 16.5         NS
         Conc. (mEq/L)
           Urine flow
                           0.032 ± 0.003   0.034 ± 0.003    + 6.3          NS
          (ml/min./kg)
         Na+ Excr. Rate
                           3.58 ± 0.591    3.73 ± 0.689     + 4.2          NS
         (µEq/min./kg)
         K+ Excr. Rate
                           2.46 ± 0.343    2.95 ± 0.560     + 19.9         NS
         (µEq/min./kg)
              GFR
                           2.25 ± 0.398    2.57 ± 0.691     + 14.2         NS
          (ml/min./kg)
          Urine specific
                           1.031 ± 0.004   1.029 ± 0.004    - 0.2          NS
          gravity (S.G.)
             % Na+
                           98.2 ± 0.528    97.9 ± 0.655     - 0.3          NS
              RFL




                                           28
   Similar intravenous infusion of plasma from hypertensive patients into bioassay rabbits
induced biphasic actions particularly on blood pressure, GFR and Na+ excretion rate.
These results are tabulated in two tables, according to the diastolic blood pressure (DBP)
of hypertensive patients. Table (3) shows the cardiovascular and renal responses of
normal rabbits receiving plasma from hypertensive patients with high DBP. This plasma
caused marked and significant increases in arterial blood pressure, urine flow, Na+ and K+
excretion rates and GFR. Meanwhile, The %Na+ RFL was significantly decreased. These
effects were almost completely recovered in the second control period immediately
following the discontinuation of plasma infusion (Fig. 1).

Table(3): The effects of IV infusion of human plasma from hypertensive patients with
          high DBP into normal rabbits. Assessment of cardiovascular and renal
          responses (n = 12).

                                        IV infusion of
                                                                          Statistical
                                        human plasma
                                                           %             Evaluation
        Parameters         Control          from
                                                         Changes            t–test
                                         hypertensive
                                                                     for paired samples
                                           patients
     Arterial B.P (mm
                         67.4 ± 4.35     89.6 ± 4.288     + 32.9         P < 0.001
            Hg)
     Heart rate (HR)
                        251.0 ± 41.42   258.1 ± 33.96     + 2.8             NS
         (beat/min.)
     Plasma Na+ conc.
                         139.6 ± 1.12   136.6 ± 1.751     - 2.2             NS
          (mEq/L)
         Plasma K+
                         3.67 ± 0.20     4.45 ± 0.719     + 21.3            NS
      Conc. (mEq/L)
         Urine flow
                        0.036 ± 0.006   0.127 ± 0.030    + 252.8          P < 0.02
        (ml/min./kg)
      Na+ Excr. Rate
                         6.84 ± 0.774   34.74 ± 8.219    + 407.9          P < 0.02
      (µEq/min./kg)
      K+ Excr. Rate
                         2.00 ± 0.291    8.96 ± 2.467    + 348.0          P < 0.05
      (µEq/min./kg)
            GFR
                         2.59 ± 0.367    7.97 ± 1.795    + 207.7          P < 0.05
        (ml/min./kg)
       Urine specific
                        1.024 ± 0.002   1.023 ± 0.002     - 0.1             NS
       gravity (S.G.)
           % Na+
                        97.8= ± 0.301    96.6 ± 0.326     - 1.2           P < 0.05
            RFL




                                            29
   Table (4) shows the effect of plasma infusion from hypertensive patients with normal
DBP (upper physiological limit of the DBP). In this case the arterial BP and the urinary
Na+ excretion rate were decreased significantly accompanied by statistically insignificant
reductions in GFR and urine flow.


Table (4):Effects of IV infusion of plasma from hypertensive patients with normal DBP
          into bioassay rabbits on cardiovascular and kidney function parameters (n = 6).


                                        IV infusion of
                                                                        Statistical
                                         plasma from
                                                           %            Evaluation
       Parameters         Control       hypertensives
                                                         Changes     t–test for paired
                                         with normal
                                                                         samples
                                             DBP
       Arterial B.P
                        80.0 ± 3.179    58.8 ± 5.949      - 26.5         P < 0.01
         (mmHg)
     Heart rate (HR)
                        291.0 ± 48.74   273.6 ± 38.35     - 6.0            NS
        (beat/min.)
        Urine flow
                        0.044 ± 0.014   0.026 ± 0.003     - 40.9           NS
       (ml/min./kg)
     Na+ Excr. Rate
                        5.27 ± 0.798    3.50 ± 0.539      - 33.6         P < 0.01
      (µEq/min./kg)
      K+ Excr. Rate
                        2.87 ± 0.880    2.45 ± 0.633      - 14.6           NS
      (µEq/min./kg)
           GFR
                        2.65 ± 0.856    1.77 ± 0.408      - 33.2           NS
       (ml/min./kg)
          % Na+
                        97.7 ± 0.820    98.2 ± 0.331      + 0.5            NS
           RFL




                                            30
           100                   P<0.001
            90
      mmHg 80
            70
            60
            50
            40
            30
            20
            10
             0
                         1                 2          3         Time/hrs
                                 Arterial BP

   Eq/ min./ kg 35
               30
               25                 P<0.02

               20
               15
               10
                5
                0
                             1                 2          3         Time/hrs
                                 Na+ Excretion rate




  ml / min./ kg 12

                10
                                  P<0.05
                8

                6

                4

                2

                0         1                2              3       Time/hrs
                          (A)               (B)           (C)
                                               GFR

Fig.(1): Effects of plasma infusion from hypertensive patients with high
         DBP on arterial BP ,Na excretion rate and GFR in bioassay
         rabbits showing the time course and sequence of measurements.
         (A) and (C) represent control measurements immediately before
         and after infusion of plasma (B).


                                   31
DISCUSSION:
The control of Na+ balance normally                volume expansion, the blood volume is
depends on the amount of Na+ in the                increased leading to increased filling of
body and not on the concentration of               the heart. It has been shown that
Na+ in the ECF which is normally                   procedures distending the heart atria
maintained almost constant. The ECF                induce prompt natriuresis and diuresis,
volume is increased with high salt intake          and prevention of such an atrial
and decreased with salt depletion (21,22).         distension in volume expanded animals
There is evidence that the control of Na+          abolished these expected responses (26).
excretion by the kidney in response to             Salt loading and ECF volume expansion
changes in salt intake is a consequence of         have been considered to be effective
relatively small changes in ECF volume             stimuli for the release of ANP in man
(23)
    .                                              and experimental animals (27,28,29,30).
        Salt loading of rabbits raised the         Therefore, the salt–loaded rabbits used in
arterial BP associated with highly                 the present study were expected to have
significant increases in urine flow and            high plasma levels of ANP . However,
Na+ & K+ excretion rates . These effects           this natriuretic peptide is thought to
were accompanied by a statistically                exert its natriuretic and diuretic actions
significant reduction in the %Na+ RFL,             mainly by increasing GFR (31,32,33), and
which clearly indicates a depression of            since the GFR was only slightly
the overall tubular Na+ reabsorption.              increased in the salt–loaded rabbits, it
        The marked natriuresis observed in         seems likely that factors other than ANP
salt-loaded rabbits receiving a low rate           are also involved in the natriuresis of salt
of isotonic saline infusion could not              loading.
simply arise from adding small volumes                    More recent data indicate also the
of saline to the blood. The plasma Na+             release of endogenous Na+ - pump
concentration was essentially unchanged            inhibitors in response to salt loading and
in these conditions indicating very                ECF volume expansion. The most likely
precise regulation. In an attempt to               candidate being the OLC. It has been
explain isotonic volume expansion                  demonstrated that excessive dietary salt,
natriuresis in dogs, De Wardener et al.            or factors that promote salt and water
(24)
      have proved that the main increase in        retention, cause plasma OLC levels to
Na+ excretion did not appear to be the             rise in animals and humans (9,16,18,34,35,36).
result of dilutional changes. Instead, they        In contrast to ANP that exerts
proposed that the natriuresis was due to a         hypotensive effects, ouabain is a
difference in the concentration of a               cardiotonic and vasopressor agent, hence
circulating     substance     other    than        it is able to raise the arterial blood
aldosterone. This observation was later            pressure (9,37). The clear-cut pressor
confirmed by other investigators who               response to salt loading in rabbits along
presented further evidence for a humoral           with the definite direct inhibition of
mechanism in the natriuresis of salt               tubular Na+ reabsorption strongly suggest
loading (25).                                      the release of OLC in such conditions. It
        In conditions of salt loading and          is not known how excess salt intake or

                                              32
ECF      volume       expansion      trigger        plasma can be safely bioassayed in
mechanisms that cause the release of                rabbits without problems providing that
endogenous OLC (9). However, it seems               compatibility of the blood samples is
that excessive dietary salt is much more            considered.
effective in potentially stimulating the                 Infusion of plasma from hypertensive
secretion of endogenous OLC than                    patients into bioassay rabbits induced
inducing the release of ANP. In support             biphasic effects depending on the level of
of this view is the prominent rise in               DBP. One prominent feature in the
arterial BP indicating that the normally            findings was that the plasma of
expected hypotensive response, if any in            hypertensive patients with relatively high
such      conditions,    to     ANP       is        DBP produced marked and significant
counterbalanced and overridden by the               increases in arterial BP, urine flow, Na+
pressor action of the postulated OLC.               & K+ excretion rates and GFR. The
Therefore, the natriuretic and diuretic             results are compatible with the responses
responses to salt loading may be                    of rabbits to salt loading except that the
explained mainly by direct inhibition of            rise in GFR here was greater and
tubular Na+ reabsorption induced by the             statistically significant. In another group
postulated OLC, and partly by the rise in           of bioassay rabbits, the infusion of
arterial BP that is capable of enhancing            plasma from hypertensive patients with
urine output(38).                                   the upper limit of normal DBP (90 mm
       The natriuretic and diuretic                 Hg) failed to produce these effects.
responses to salt loading were also                 Therefore it is clear that the higher DBP
accompanied by statistically significant            is an important factor causing the plasma
increases in urinary K+excretion .                  to induce the previous cardiovascular and
Rreduced Na+ reabsorption in the                    renal responses.
proximal tubule and/or in the loop of                       It has been reported that plasma
Henle would be expected to enhance                  ouabain-like activity increased ( 30-
passive K+ secretion in the late distal             200%) in many patients with high DBP
                                                    (39)
tubule and cortical collecting ducts, and               . It seems likely that the main factor
hence its excretion(38). The enhanced               increasing the DBP of the hypertensive
urinary K+ excretion can, therefore, be             patients investigated is the release of
considered secondary to increased                   OLC into their plasma that enhances the
delivery of Na+ and fluid to the distal             total peripheral resistance (TPR). The
tubules.                                            highly significant pressor and natriuretic
    Intravenous infusion of fresh human             responses of the bioassay rabbits
plasma of normotensive subjects, with               accompanied by the significant reduction
blood group B-Rh+, into normal rabbits              of %Na+ RFL clearly indicate that the
produced no detectable changes in all               plasma of hypertensive patients with high
cardiovascular and renal function                   DBP did contain significant amounts of
parameters recorded . Obviously, the                OLC.
plasma from normotensive subjects did                     Considerable evidence has also
not contain any active ingredient with              demonstrated that patients with essential
appreciable biological activity that can be         hypertension have a heterogeneous
detected in the bioassay rabbit. The data           distribution in plasma ANP, and a
also clearly show that crude human                  substantial proportion of them have a

                                               33
high level of plasma ANP (1,39,40). The            parameters including the significant
plasma of the hypertensive patients                decrease in Na+ excretion rate. A
whose DBP was normal did not produce               significant decrease in arterial BP
pressor, natriuretic and diuretic responses        reduces renal blood flow and GFR
in bioassay rabbits. On the contrary, the          thereby reducing the urine output and salt
plasma of these patients induced                   excretion(38 ).
statistically significant depressor and                   The plasma of hypertensive
anti-natriuretic effects . It is therefore         patients probably contained high levels
likely that these patients had high plasma         of both OLC and ANP. Their effects on
levels of ANP that was able to decrease            arterial BP in the bioassay rabbits could
the blood pressure. When the cause of              be taken as an indicator to show which of
hypertension is an increase in TPR,                the     two     endogenously      released
which is expected in those patients who            substances was available in higher
have high levels of endogenous OLC, the            concentrations in the plasma of
venous return and central venous                   hypertensive patients. The plasma of
pressure (atrial pressure) will be high.           those patients with high DBP induced a
This is an effective stimulus for the              clear-cut pressor response in the bioassay
release of ANP (27,28). The release of ANP         animals and therefore could be
in such conditions may be considered as            considered to contain higher levels of
a physiological compensatory mechanism             OLC. Whereas, those hypertensives with
to minimize the rise in BP due to its              normal DBP whose plasma induced a
capability to reduce CO and antagonize             significant reduction in arterial BP
vasoconstriction (41). Therefore, the              probably contained higher levels of ANP
reduction in arterial BP observed in the           and much less OLC. The cardiovascular
bioassay rabbits can be attributed to the          and renal effects of these two
cardiovascular effects of ANP. The                 endogenously released natriuretic factors
decrease in arterial BP to the low level of        possibly form physiological homeostatic
58.8 mm Hg can reasonably explain the              mechanisms to regulate body Na+
overall reductions in kidney function              balance and arterial BP.




                                              34
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                                              37
Z.J.M.S.
 Vol. 8
                    THE CHARACTERISTICS OF 110 ASTHMATIC
    (2)            PATIENTS ADMITTED IN SULAIMANI GENERAL
 2004                             HOSPITAL
    ALI S. MOHAMMAD *          ARAS A. ABDULLAH **        BAKHTYAR A. HAMACHAWASH ***

ABSTRACT :
In a prospective study , from 7th                     including     chest     radiographs      ,
January through 7th July 2003 , one                   electrocardiogram, peak        expiratory
hundred and ten asthmatic patients (77                flow rate ( PEFR ) ,and blood tests
females and 33 males, aged 18-80                      were carried out in all patents .
years), were studied in Sulaimani                        Our study           showed         the
General Teaching Hospital. Different                  predominance of females , higher
aspects of the patient’s age , sex ,                  incidence     in urban people , un
occupation , residence, family history ,              acceptance to use         inhalers, high
smoking , response to and side effects                percent of noncompliance to drugs ,
of medications , along with types of                  positive family history and blood
asthma and frequency of admissions                    eosinophilia    in all       early onset
were studied. Basic investigations                    asthmatics.

Key words : bronchial asthma

INTRODUCTION :
   Asthma is a common disease                         also has a high association with
affecting 3% to 5% of the population(1)               subsequent development of asthma. (5)
. It is characterized          by airway              No single hypothesis yet explains the
inflammation           and        reversible          asthmatic diathesis (6) .
obstruction to airflow ( 2 ) .                           The diagnosis of asthma is based on
    The inflammation of asthma                        appropriate clinical history and
consists of eosinophils , neutrophils ,               evidence      of      reversible    airflow
                                                                   (7)
macrophages , and lymphocytes along                   obstruction       . This information can
with edema , vascular dilation ,                      easily     be       obtained     with     an
mucous gland proliferation and                        inexpensive yet reliable desktop
ultimately sub epithelial fibrosis (3).               spirometer , change of 20% in the
    The etiology of           asthma      is          forced expiratory volume in one
multifactorial      ;    hereditary     and           second (FEV1)            from the best
environmental            factors    include           baseline measurement is an accepted
allergies , irritants and viral infections            sign of the bronchial hyper –
. It may be‘outgrown’ but often recurs                reactivity of asthma(2) . History taking
later in life (4) . Infection with                    should           include     a    thorough
respiratory syncitial virus in infancy                environmental and allergic history(8) .
  * MRCP (UK) , FRCP (UK) , consultant physician , Senior Lecturer in Medicine ,Sulaimani medical
    college .
 ** FICMS, consultant physician , Senior Lecturer in Medicine , Sulaimani medical college .
   -Address correspondence and reprint request to : Dr. Aras A. Abdullah , Dept. of Medicine ,
    Sulaimani University , Medical college , Email : dr.aras62@mail.com
*** MB , CHB , physician , Sulaimani DOH .

                                                39
should           include    a    thorough         expiratory flow (12,13).In general , the
environmental and allergic history(8) .           management of asthma includes
Asthma is associated with eosinophilic            patient education , monitoring with a
airway inflammation (9) and an                    home peak flow meter, control of
increased proportion of eosinophils               environmental factors (allergens &
in the sputum(10) .The combination of             irritants), management of concomitant
the presence of sputum eosinophilia               disorders ( chronic sinusitis , nasal
and / or methacholine airway hyper                polyposis , allergic rhinitis ,GERD)
responsiveness have been found to be              ,effective pharmacotherapy ,and lastly
a sensitive and specific marker of                management of side effects(4).
asthma (11) .The diagnosis of asthma in               During a period of six months ,
a clinical setting usually relies on the          we studied different aspects of those
combination of airway liability,                  asthmatic patients         who     were
demonstrated         by     spontaneously         admitted in       Sulaimani     General
variable      or     reversible    airflow        Teaching       Hospital     and      the
obstruction with 15% or greater change            characteristics of our patients were
in flow rate, a bronchoconstrictor                compared with the results of other
response to histamine or methcholine,             works .
or daily or diurnal variability in peak

PATIENTS AND METHODS:
From 7th January 2003 through 7th July            X-Ray, ECG , and laboratory
2003 , one hundred and ten patients               investigations including: Packed Cell
with bronchial asthma were studied                Volume       (PCV)     ,    Erythrocyte
prospectively during their admission              Sedimentation Rate ( ESR ) , White
in Sulaimani General Teaching                     Blood Cell Count ( WBC)             and
Hospital. They were 77 females (70%)              differential count , and through using
and 33 males(30%) .The age range was              a simple peak flow meter the peak
18 - 80 years . Through using a special           expiratory flow rates (PEFR) of all
case sheet , full history was taken and           patients were evaluated both before and
full clinical examination was done in             after giving Salbutamol inhaler .
all patients .They were sent for Chest

RESULTS:
General Information : Table 1 shows               patient's residence showed that (55.5%)
general information of our patients ,             of them werefrom urban regions . The
among 110 adult patients with                     history of smoking was relevant in
bronchial asthma , studied over a period          only27.3%) of the cases , and more
of 6 months (from 7th January 2003                than three fourths did not report the
through 7th July 2003) ,there were 77             presence of other affected family
females (70%) and 33 males (30%) ,                members.
and their ages ranged 18-80 years with               Hematological Examination : Table 2
41% of them aged 41-60 years .                    shows results of hematological
Late onset asthma was the predominant             examinations including eosinophilia
type (94.5%) ,and more than half of the           (89%), normal PCV(67%) , along with
cases (50.9%) were housewives ,                   normal ESR (below 20mm/hr) in
followed by farmers ( 12 % ) . The                (76.3%) of patients.
                                             40
Electrocardiography and Radiology :              was (42.7%) . The peak expiratory
     Table     3    shows      normal            flow rates (PEFR) before and after
electrocardiograph traces in (81.8%)             bronchodilator    nebulizer     therapy
and evidence of ischemic heart disease           showed significant changes . The least
in only 15 ( 13.6%) of cases Chest               response was (16.6%) and the highest
radiographs revealed abnormalities in            response was (200%), while a response
30% of patients including evidence of            of (<15%) was present in 6 patients .
infection in 16 (14.5%) of cases .                   Regarding the frequency of
Types of Treatment and Responses:                admissions ( Table 5 ) , a high
   Table 4 shows that among 73 total             percentage of the patients(41.8%) had
inhaler users , 42 (57.5%) were                  had one admission monthly while both
improperly using them and 61 (55.45%)            once a year admission and first time
of them were Salbutamol inhaler users.           presentation were (5.45%) , (1.8%)
The overall un acceptance for inhalers           respectively.

                           SUBJECT CHARACTERISTICS
Table ( 1 ) : General Information :

       Characteristics
  1 . Total Asthma Patients   ( 110 patients )
  2. Age range ( years )      100 % ( 18 yr. – 80 yr. )       ,   41 % ( 41 yr. – 60 yr. )
  3 . Female No.              77 ( 70 % )
  4. Male No.                 33 ( 30 % )
  5. Residence:
  Urban (%)                   61 ( 55.5 % )
  Rural (%)                   49 ( 44.5 % )
  6. Occupations :
  Housewife                   51 %
  Farmer                      12 %
  Others                      37 %
  7. Type of Asthma :
  Late-onset (%)              104 ( 94.5 % )
  Early-onset (%)             6 ( 5.5 % )
  8. Current smokers (%)      33 ( 27.3 % )
  9. Family history (%)       27 ( 24.5 % )

                           SUBJECT CHARACTERISTICS

Table ( 2 ) : Hematological Findings :

  1. Packed Cell Volume :
         < 37 %                               74 ( 67 % )
         > 52%                                36 ( 43 % )
  2 . Erythrocyte Sed. Rate ( ESR ) :
         < 20mm / hr                          84 ( 67.3 % )
         > 30 mm / hr                         26 ( 23 .7 %)
  3. Blood Eosinophil Count :
         Normal < 2 %                         98 ( 89 %)
          High > 6 %                          12 ( 11 % )

                                          41
                          SUBJECT CHARACTERISTICS


Table ( 3 ) : Electrocardiography and Chest X- Ray :

  1. Electrocardiogram :
          Normal ( % )                     90 ( 81.8 % )
          Abnormal ( % )                   22 ( 18.2 % )
          Ischemic changes ( % )           15 ( 13.6 % )
          Others ( % )                     7 ( 4.6 % )

  2. Chest X- Ray Findings :
         Normal ( % )                      70 ( 63.6 % )
         Abnormal ( % )                    30 ( 36.4 % )




                          SUBJECT CHARACTERISTICS

Table ( 4 ) : Types of Treatment and Response :

  1. Inhalers :
        Total users ( % )                  73 ( 66.36 % )
        Misused ( % )                      42 ( 57.5 % )
        Not accepting ( % )                47 ( 42.7 % )
        Salbutamol ( % )                   61 ( 55.45 % )
        Steroids ( % )                     12 ( 10.9 % )
  2. Oral Steroids ( % )                   31 ( 28 % )
  3. Steroids side effects ( % )           7 ( 16.2 % )
  4. Peak Expiratory Flow Rate ( PEFR )    All the patients
         The least response                16.6 %
         The highest response              200 %
         A response of < 15 % ( % )        6 ( 5.45 % )
  5. Treatment non compliance              77 ( 70 % )




                          SUBJECT CHARACTERISTICS

Table ( 5 ) : Frequency of Admissions :

  Frequency of admissions :
       Once per month ( % )                46 ( 41.8 % )
       Once per year ( % )                 6 ( 5.45 % )
       First presentation ( % )            2 ( 1.8 % )




                                          42
DISSCUSION :

Asthma is a chronic disease with                   asthma control (24) . In his work, Gwynn
increasing prevalence ,mortality, and              has concluded that current and former
cost of care(14) ,                                 smokers were more liable than never
the increasing prevalence of asthma and            smokers to report current asthma (16) ,
recognition of the burden it imposes on            and in an extensive study in France,
patients and health series has led to              smoking has been found to be clearly
extensive research into its etiology ,             related to the clinical severity of asthma
pathophysiology, and management.(15)               (25)
                                                           . Moreover Chaudhuri and
     In this work we could study most              coworkers (26) have concluded that
epidemiological      aspects    of     our         active smoking impairs the efficacy of
asthmatic patients presented and                   short term Glucocorticoid therapy in
admitted in an acute status to the                 patients with asthma . Less than one
emergency department of Sulaimani                  quarter of our patients were found to
General hospital.                                  have a positive family history of asthma
     In all patients , the cause of                ( Table 1 , No. 9 ) , and this is
admission was their presentation in an             explained by the very low percent of
acute episode of asthma.                           early onset asthma type (5.5%) . A
We found that females were more                    positive family history of asthma is a
likely than males to report asthma and             relatively specific, but not a sensitive
this is in accord with other works(16,17) .        parameter .
    A more westernized lifestyle and                        The role of blood tests in
urban living are associated with an                differential diagnosis of asthma is
increased prevalence of asthma (18)                limited (28) .We didn’t find any
.Exposure to a farming environment                 laboratory significance of both
can lead to a decreased rate of allergic           hematocrit           and       erythrocyte
sensitization and, thus, to protection             sedimentation rate estimations ( Table 2
against development of asthma (19) , and           ) . In regard with blood eosinophilia
asthma exacerbations have been linked              count;11% of the patients had had
to urban pollutant concentrations. (20)            significant eosinophilia which was
This supports our lower figure of                  higher than that reported in other works
                                                   (11)
asthma in rural patients (44.5%) than                   ( Table 2 ) . The same workers have
the urban group. Other works had the               shown that the result of a sputum
same results (21,22) .Asthma caused by             eosinophilia test is a valid marker of
exposure to occupational sensitizers               asthma and is more sensitive than that
accounts for about 37% of adult                    of a blood eosinophilia test. Due to the
asthma (23) .The highest percent of                lack of special stains ,our laboratories
asthma was among housewives (51%))                 couldn’t       arrange     the      sputum
and this supports the indoor rather than           eosinophilia count.
outdoor exposure to allergens (15).                          Electrocardiography and Chest
Nearly one quarter of our patients were            X- ray :          Previous reports have
current smokers and they reported more             documented         the   occurrence      of
frequent admissions to emergency                   reversible electrocardiographic changes
department than non-smokers. Patients              in patients with acute attacks of asthma.
with asthma should be advised strongly             In our study ,the electrocardiographic
not to smoke since this should improve             traces of 22 patients were abnormal

                                              43
( Table 3 ) . The abnormalities were                were (5.45%) , (1.8%) respectively.
mostly T-wave inversions and ST-                    ( table 5 ) .
segment        depression        suggesting                The proportion of patients on
myocardial ischemia. These and many                 inhaled steroid in our study(10.9%)
other changes have been described by                seemed low in comparison to other
other workers (29 , 30 , 31 , 32 ) .The last        works (11 , 34 , 35 ). Users of inhaled short
work even has found an association                  acting Beta 2 agonist (Salbutamol) in
between the severity of an acute attack             our work was much higher (55.45%)
of asthma and the development of T                  than the inhaled steroid users, but still
wave inversion.                                     much lower than other works (34,36).
       The value of Chest X-Rays in                        This under use of both types of
differential diagnosis of chronic airflow           inhalers in our patients is explained by
obstruction, particularly during disease            the false belief of developing
exacerbation is limited (28) . However              habituations to such inhalers , and the
30% of our patients showed some                     misuse of these inhalers was a major
radiographic abnormalities in forms of              defect in our patients; almost 70% of
pneumonic changes, enlarged cardiac                 them were using them incorrectly. So
size and few mild pleural effusions. No             techniques must be taught or reinforced
single case of pneumothorax was found               constantly. Noncompliance with the
( Table 3 ) .                                       drugs is a frequent problem interfering
       Response to Treatment and Type               with effective asthma control. We
of Treatment : Inhaled corticosteroids              found that 70% of our asthmatic
are the corner stone of treatment for               patients were not taking their
asthma and they have been shown to                  medications regularly ( Table 4 ).
reduce readmissions (33) . Regarding the            Diette and coworkers have found a
frequency of admissions , we found that             nearly similar figure in their patients
                                                    (37)
(41.8%) of patients had had one                         . Repeated patient education has a
admission per month, but both once a                major role in increasing the level of
year admission and first presentation               compliance              with       prescribed
                                                                   (4,2 )
                                                    medications           .



CONCLUSION:


   We could find that most epidemiological aspects of asthmatic patients in this
study have the same characteristics of asthmatic patients studied elsewhere , and we
strongly encourage the avoidance of smoking, repeated education to increase the level
of drug compliance along with proper use of the inhaler devices.




                                               44
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   Service,1997;NIH           publication            femmes. In: Saurel - Cubizolles MJ ,
   No.97-4051                                        Blondell B,eds .La sante des fommes
8. Connolly MJ Crowley JJ, Nielson                   .paris: Flammanon, Medicine et
   CP, et al. Peripheral mononuclear                 sciences,1996:20933
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   1994;49(1):26-32                                  life and development of asthma and
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    June;32(3):328-32



                                             46
Z.J.M.S.
 Vol. 8              A COMPLICATION OF OGILVIES SYNDROME
    (2)                  [COLONIC PSEUDO-OBSTRUCTION]
 2004
                                  CASE REVIEW
                                      Abdul- Kadir M. Zangana*


 ABSTRACT :
A 17–year old female patient admitted                  obvious pathology seen, a full thickness
to the emergency hospital on December                  biopsy from the wall of intestine was
21, 1998 Erbil city with clinical                      taken, showed scanty ganglion cells and
features of large bowel obstruction .on                signs of atrophied nerve cells.
admission she was extremely ill                           After 9 months she had been
complaining from abdominal pain,                       readmitted to the hospital because of
nausea, vomiting and constipation of 12                acute abdomen with the diagnosis of
hours duration. At laparotomy the large                generalized peritonitis. At laparotomy a
bowel found to be hugely distended, the                large anterior perforation of the cecum
possible diagnosis of pseudo colonic-                  was found. Colectomy was done with
obstruction was made. No surgical                      ilio-rectal anastomosis, postoperative
intervention was performed at that time.               period was stormy but latter on
    At a second laparotomy, 6 months                   recovery was complete apart from
later because of the recurrent similar                 frequent loose motions.. The aim of
condition; surgical exploration of the                 reporting this case is that prolonged
abdomen was performed on the                           conservative management of this
assumption of fibrous adhesions of                     syndrome might be disastrous and may
previous laparotomy but again no                       endanger the life of the patient.

INTRODUCTION:

 Intestinal pseudo-obstruction [Ogilvies               any acute sever illness. Excess
syndrome] is a profound ileus with out                 sympathetic tone has been postulated as
evidence of mechanical obstruction,                    the common mechanisms. …………..…
was first described by Ingelfinger in                   This concept is supported by the
1943. The first description is though to               success with epidural anesthesia, which
be Sir Hereage Ogilvies 1948, report of                paralyses the sympathetic afferent and
two cases associated with malignant                    efferent nerve fibers to the colon, and
infiltration of the celiac plexus. Colonic             with neostigmine, which increases
pseudo-0bstyuction may be associated                   parasympathetic tone         by its anti-
                                                                             (3, 6)
with neuroleptic medications, opiates,                 cholinesterase effect.       .………….…..
malignancy; sever metabolic illness, or




*M.B.CH.B. , CABS. Consultant surgeon, Assistant Professor of surgery, College of Medicine, University
 of Salahaddin Erbil ,Iraq.



                                                 47
CASE REPORT:
    R.T.a 17–year old single girl with               At laparotomy the entire colon was
her third admission to the emergency             hugely      distended    and     severely
hospital, Erbil city on December 21,             discolored, with large anterior cecal
1998 with a history of sever generalized         perforation and generalized peritonitis.
abdominal pain, abdominal distention,            Other intra-abdominal structures were
vomiting and constipation of 6 hours             normal including the rest of the small
duration.                                        bowel. Because of the impaired
   On admission; patient was in great            vascular supply of the large bowel, and
pain, pale feverish, dehydrated with             sever discoloration colectomy was
diffuse tenderness of the abdomen and            performed with ileu-rectal anastomosis,
guarding, pulse rate was 108 beat/min.           cleaning of the peritoneal cavity
blood prsure85/50 mm.Hg. temperature             abdomen closed in layers and tube
was 39 ºC.                                       drain lifted for 3 days.
Resuscitation    had     been     started            Postoperative period was stormy
immediately with IV fluid, nasogastric           with high fever, and postoperative chest
suction parentral antibiotic, penicillin         infection for which she received
500mg 6 hourly, gentamicin 80 mg 8               intensive care treatment in intensive
hourly, and metronidazole 500mg 8                care unit [ICU], on the 8th postoperative
hourly. Inspite of intensive fluid               she developed severe mucous diarrhea,
replacement [about 1000ml/hour] she              ultrasonography of the abdomen
was passing to shock, electrolyte deficit        showed a large pelvic collection, trans-
replacement, and 2 units of blood were           rectal drainage performed. Discharged
given. After 4 hour she was stabilized.          on 14th postoperative day in a
Abdominal x-ray showed huge                      reasonable condition. Frequent follow
distention of the colon , chest x-ray            of the patient showed attacks of loose
revealed collection of air under the             frequent motions responding to medical
diaphragm; air was forming a sickle-             treatment and dietetic regimen.
shaped translucency between the
diaphragm above & the liver below .

DISCUSSION:
Acute pseudo-obstruction of the colon            symptoms mimic those of true
[Ogilvies syndrome] is massive colonic           obstruction. Plain x-ray of the abdomen
distention in the absence of a                   show marked gaseous distention of the
mechanically obstructing lesion(8, 9). It        colon. Although the entire colon may
is a sever form of ileus and arises in           contain gas, the distention is typically
bedridden patients who have serious              localized to the right colon, with cutoff
extra-intestinal illness [renal, cardiac,        at the hepatic or splenic flexure.
respiratory] or trauma [eg. Vertebral            Contrast enema proves the absence of
fracture]. Aerophagia and impairment             obstruction.
of colonic motility by drugs are                 Conservative        treatment       with
contributing      factors.   Abdominal           nasogastric suction and enemas
distention without pain or tenderness is         succeeds in resolving colonic pseudo-
the earliest manifestation, but later            obstruction in 86% of patients within 3-
                                            48
days.neostigmine is effective in treating         hypoalbomenemia, other tests include
colonic pseudo-obstruction(10, 12). If the        thyroid function testes. Biopsy of the
cecum is markedly dilated, the risk of            intestine may or may not reveal loss of
perforation is high, and direct                   myenteric plexus.
intervention must be prompt.………..                    The diagnosis of colonic pseudo-
Colonoscopic decompression is the                 obstruction is by exclusion, a water-
method of choice if an expert is                  soluble contrast enema or colonoscopy
available. Initial success is claimed in          should be performed to exclude
90% of patients, but recurrence is                mechanical obstruction.
common [25% or more]. Often it is                 Initial treatment maneuvers include
possible to place a tube into the                 naso-gastric decompression, rectal tube,
proximal colon during colonoscopy to              and correction of metabolic disorders
maintain decompression. Placement of              and discontinuation of the medications
a decomperessive tube per rectum                  that decrease colonic motility [e.g.
under fluoroscopic guidance has been              narcotics and anticholinergics].
described       recently(14).     Another             Evidence of rapid cecal dilation or a
alternative is cecostomy, performed               cecal diameter greater than 11 to12 cm
either in the standard open fashion or            on abdominal X-ray should call for a
by an endoscopic percutaneous method,             more aggressive intervention because
similar     to    the     technique    for        of the risk of cecal ischemia, necrosis
gastrostomy,        using      laproscopic        and perforation. Operation is reserved
assistance.                                       for patients with persistent colonic
    Cecal perforation, described above,           dilation       despite          colonoscopic
is a potentially lethal complication.             decompression and patients with
Partially obstructive lesions of the              peritonitis.
colon may be complicated by acute                    Cecostomy or loop colostomy is
colitis in the bowel proximal to the              effective in relieving distention,
obstruction; it is probably a form of             lapartomy should be performed in
ischemic colitis secondary to impaired            patients with peritonitis, and nonviable
mucosal blood flow in the distended               bowel should be resected.
segment(17).                                         Finally the most successful treatment
    No specific laboratory studies aid in         of idiopathic pseudo-obstruction is
the diagnosis one should rule out                 colectomy              with        ileo-rectal
                                                               (4, 6, 7, 12, 16)
hypokalemia, hypomagnesaemia and                  anastomosis                   .




                                             49
 REFERENCES:
1. Picklem a J, Lee RM. The management            Curr Treat Options Gastroenterol
    of patients with suspected early              1999;2,517.
    postoperative small bowel obstruction      11.Chapman AH; Mc Namara M, Porter
    Ann Surg 1989 210; 216,.                      G, The acute contrast enema in
2. Richards W.O , Williams LF.                    suspected large bowel obstruction;
    Obstruction of the large and small            Value and technique, Clin Radiol
    bowel. Surg Clinc North Am 1988, 68;          1992;46.,273.
    355.                                       12.Suri S; Comparative evaluation of
3. Riveron FA, Obeid. FN, The role of             plain films, ultrasound and CT in the
    contrast radiography in presumed              diagnosis of intestinal obstruction.
    bowel obstruction, Surg 1989. 106;            Acta Radiol 1999; 40,422.
    496,                                       13.Tanaka Tl; Endoscopic trns-anal
4. Sarr MG, Bulkley GB; Preoperative              decompression with a drainage tube
    recognition of intestinal strangulation       for acute colonic obstruction;
    obstruction Am Surg 1983, 145; 176.           Clinical aspects of preoperative
5. Wangenstern OH; understanding the              treatment; Dis Colon Rectum 2001;
    bowel obstruction problem Am J Surg           44,418.
    1978.135; 131,                             14.Baechrter KJ Surgical management
 6.    Livingston     EH,    Passaro    EP        of the acutely obstructed colon; A
    Postoperative ileus Dig Dis Sci 1990,         view of 127 cases Am J Surg 1988
    35; 121.                                      ; 156,163.
7. Smith J, Kelly, et al Patho-physiology      15.Gosche JR, Sharpe JN, Larson GM,
    of post operation Arch Surg 112; 203,         Colonoscopic decompression for
    1977.                                         pseudo-obstruction of the colon;Am
8. Ira J.Kodner, Robert DQ. Colon,                J Surg 1989; 55,111.
    rectum and Anus Principles of surgery      16.Salm Rl; Endoscopic percutaneous
    7th ed. 1999, 26; 1215-1382,                  cecostomy [EPC] Surg Endosc 1988;
9. Bender GN, Do- Dai DD, Briggi IM;              2, 92.
    Colonic             pseudo-obstruction;    17.Sloyer R; Ogilvies syndrome;
    decompression with a tricomponent             Successful management without
    coaxial system under fluoroscopic             colonoscopy Dig Dis Sci 1988; 33,
    guidance Radiology 1993; 188,395.             1391.
10.Bharuch AE; Acute, toxic,& chronic.




                                          50
 Z.J.M.S.
  Vol. 8          SONOGRAPHIC EVALUATION OF THE SCROTUM
     (2)          AND ASSOCIATED FINDINGS IN DIFFERENT AGE
  2004
                      GROUPS IN ERBIL PROVINCE –IRAQ
              A study of 1039 randomized patients seen between April and December 2002

                       Abdulkadir M. Zangana*          Aram Latif Kaka-Hama**


  ABSTRACT :
      This prospective study of age changes in testicular dimensions and associated
      findings in different age groups by ultrasound had been done.
 The aims of this study were;
 1. To estimate the growth of testes and epididymis with age and to compare it with
      other similar studies to know if there is any difference between our population and
      other populations, because there were no such similar studies were made in our
      locality.
 2. To know the frequency of associated findings and frequency of incidental disease
      and to compare it with standard figures.
 3. To know the incidence of testicular mass and weather such study is helpful in
       early detection of testicular mass.
 For each component of these organs, testes and epididymis, the length and width of the
 testes had been studied, with the width of the head of epididymis.


 INTRODUCTION:

  The testis is one of the normal organs of                 INDICATIONS OF SCROTAL
  the body and main part of the male                        SONOGRAPHY:
  reproductive system. They are the site
                                                       1.    Evaluation of a scrotal swelling.
  of sperm production and are also the
                                                       2.    Evaluation of scrotal pain.
  major producer of the male hormone,
                                                       3.    Assessment of scrotal trauma.
  testosterone.
                                                       4.    Investigation of infertility.
  In adult each testis is weight around 25-
                                                       5.    Investigation of ectopic testicle.
40 gm, when fully formed. Interestingly
the right one is often heavier than the left1




 * M.B.CH.B. –C.A.B.S. Assistant professor of surgery. Consultant surgeon. College of Medicine –Erbil –
   North of Iraq.
 **DMRD. Lecturer in radiology.



                                                  51
 ULTRASOUND IMAGING:

Since the pioneering work in 1974 by              subjected preoperatively to a 15 minute
Miskin and Bain, who described the                exposure to conventional ultrasound,
ultrasound appearance of testes with the          followed by studies of the specimens
static B-mode, the technology and                 under electron microscopy. No
applications of ultrasound have greatly           ultrastractural abnormalities and no
expanded. The incorporation of real-              detectable difference were found when
time, high frequently transducers, and            compared with healthy testes .(10)
pulsed and color Doppler has made                 During the past 10 years, sonography
ultrasound the most frequently used               has proved to be an accurate, rapid, and
imaging modality in evaluation of the             safe tool in the evaluation of scrotal
scrotum. Ultrasound has the advantages            masses. It is especially usefully used in
of general availability, portability, high        differentiating intratesticular masses
resolution,    functional     information         from those that are extratesticular (11)
(blood flow), and relatively low cost.            this is an important concept because
Limitation of the technique is its high           intratesticular masses are frequently
dependency on the quality of the                  malignant and patients are treated with
equipment and the expertise of the                radical orchidectomy. Benign lesions
operator. Nuclear medicine computed               can be simply excised. Scrotal
tomography,      magnetic       resonance         ultrasonography approaches near 100 %
imaging and to a lesser degree, venous            accuracy      rate    in      distinguishing
angiography plays complementary roles             intratesticular        lesions          from
                                                                           (11,12)
in the imaging of special situation.              extratesticular lesions.
Regarding the biologic effects of the             An extratesticular lesion is more likely
ultrasound on the direct examination of           the result of inflammation, trauma, or
the male gonads, Grunberger and                   benign neoplasm. (13) hydrocele is the
associates studied 10 men undergoes               most common extratesticular mass and
bilateral orchictomies for prostatic              typically anechoic on ultrasonography
carcinoma on whom the testes were                 .(11)



PATIENTS AND METHODS:

sonographically in ultrasound units of            special preparation needed for studied
radiology departments of Rizgary and              cases for each person the f    Between
Maternity and pediatric hospitals. The            April 2002 and December 2002,1039
age of the patients range from 1 day to           patients were examined ollowing
79 Years of age.                                  measures had been taken.
An ultrasound machine (Siemens                    1-Length of the testes.
primera) with linear probe was used.              2- Width of the testes.
With Gray scale real –time (7.5) MHz              3- Diameter of the head of epididymis.
transducer energy source was (220v) ae            All measurements were obtained in
current and an ultrasound room no                 millimeters.



                                             52
 METHODS & PROCEDURES OF EXAMINATION OF TESTS BY ULTRASOUND:

 The examination had been performed in             without changing the parameters. The
 a room that affords privacy. It was               site of the concern should be imaged. In
 warm to avoid a cremasteric reflex                the case of a nonapparent but suspected
 which is more pronounced in children.             varicocele or inguinal hernia, the
 Which pulls the tests upward outside              patient is scanned during a Valsalva
 the scrotal sac.                                  maneuver or while he is standing. if a
 With the patient in a supine position a           tumour of the testis is found and no
 sling is made with a small towel                  previous abdominal imaging has been
 between the proximal thighs to hold the           done periaortic and renal hilar regions
 scrotum anteriorly a second small towel           should be searched for possible
 holds the penis on the anterior aspect of         lymphadenopathy.
 the lower abdominal wall.                         Standard longitudinal and transverse
 Physical examination is used to find the          views of each testis and epididymis are
 position size and consistency of the              obtained. A transverse view with both
 testes and to locate a possible area of           testes on the same image permits direct
 disease.                                          comparison of subtle echo- texture
 High – frequency linear transducers in            changes.
 the range of 5-10 MHz with Doppler.               In cases in which marked scrotal
 Preferentially. Color Doppler capability          swelling is present, a high- frequency
 are necessary .The 7- 10 MHz linear               curved linear array transducer increases
 Array probe are preferred These do not            the field of view, allowing improved
 require a water bath and provide                  localization of the extratesticular
 excellent spatial resolution The                  findings, in patients had been referred
 transducer is applied directly to the             for palpable scrotal lesions, additional
 scrotum with aqueous coupling gel.                targeted images obtained during
 Scanning      parameters    had     been          palpation to correlate with physical
 optimized on the supposedly normal                findings.
 testis. , Which is imaged first. Then,


 PITFALL IN SONOGRAPHIC TECHNIQUE:

1) Near field Lesions: - Because the                  that diffusely affect the testis . such
   testis is a superficial structure. Every           as inflammation. Or infiltrative
   attempt should be made to optimize                 process. Such as leukemia the
   visualization of the near field. High              alteration of echotexture may be so
   frequency transducers in the range of              subtle that unless comparison is
   7.5 to 10MHz should be used                        made with the normal testis it may
   optimize the near – field focal zone.              be missed(10)
2) Testicular comparison in real time:             3) Intratesticular artery appearing as a
   Comparison of the ultrasound texture               focal hypoechoie region on gray
   of the presumed normal testis with                 scale imaging .This is an important
   the clinically suspicious testis is                pitfall . because this focal hypoecoic
   important. This comparison is                      region may be mistaken for an
   especially in certain circumstances.               intratesticular lesion.(14)
   For instance. in disease processes

                                              53
4) False-positive scrotal calcifications:-          b) Foreign bodies: Foreign bodies
a) Examiner fingers: when examining                     may also simulate calcifications
   the scrotum. Care must be taken lest                 within the scrotum. Historical
   the fingers of the operator s hand                   information is important in this
   holding the scrotum mimic scrotal                    regard.(10)
   wall calcifications.



 RESULTS:
   At birth the testis is about (15x10               that time it reaches 30 –50 mm in
 mm) , at 3rd months it reaches ( 20 x11             length and 20 – 30 mm in width, which
 mm ) , at 6 months it starts to declines            equals to adult size. The head of
 to ( 15 x 10 mm ) , then there is a slight          epididymis also shows same change
 increase till the time of puberty where             with puberty. Results were marked in
 significant increase was noted and at               (table-1) .


            Table –1- dimensions of testes according to different age groups

                                                 Width of
                         Length     Width                     Length                   Width of
                                                 head of                Width of
   Group       Age       of right   of right                  of left                 head of left
                                                  right                 left testis
                          testis     testis                    testis                 epididymis
                                                epdidymis

   1. 116     1dy-1m      14.85       9.91             2      14.87        9.99          2.01
   2. 37      1m-3m       19.96      11.1            3.04     19.91       11.07          2.96
   3. 35      4m- 6m      15.21      10.25           2.37     15.22       10.19          2.36
   4. 37      7m–12m      16.18      10.05           2.25     15.95       10.08          2.22
   5 .65      1y-6y       16.69      10.26            2.6      16.2       10.24          2.6
   6. 36     7y-10y       17.53      11.07            2.7     17.23       11.02          2.6
   7. 207    11y-16y      29.86      15.33           4.68     29.63       15.15          4.68
   8. 247    17y-50y      43.93      22.53           7.18     43.82       22.41          7.16
   9. 259    51y-79y      42.08      21.48           6.77     42.08       21.29          6.64




 About the associated findings of 1039,              had hernia. 42(4.04%) had testicular
 195(18.77%) had epididymal cyst.                    cyst.25 (2.4%) had undesended tests.
 142(13.67%)       had       hydrocele,              6(0.58%) had retractile tests and one
 102(9.82%) had varicocele, 58(5.58%)                case of testicular mass is reported.
                                                     Results are clarified in (table 2) .




                                               54
                         Table –2- Frequency of associated findings

                               Associated
        Groups                                           Cases               Percent
                                 findings
             1.              Epididymal cyst               195                18.77
             2.                 Hydrocele                  142                13.67
             3.                 Varicocele                 102                9.82
             4.                   Hernia                    58                 5.58
             5.               Testicular cyst              42                 4.04
             6.             Undesended testes               25                 2.4
                                Testicular
             7.                                            23                  2.21
                               calcification
          8.                 Retractile testes              6                   0.5
          9.                testicular atrophy              1                  0.09
          10.                Testicular mass                1                  0.09

One hundred ninety-five cases of                      bilateral. It was seen in 169 adult
epididymal cysts had been recorded in                 person (30.9%). While it was seen in 26
our study.102 (52.31%) were in right                  cases of the child and adolescent group
side. And 78 cases (40%) were on left                 (5.28%) Findings are seen in (table –
side and in 15 cases (7.69) it was                    3).

                          Table –3- Frequency of epididymal cyst

      Groups                Age            persons               Cases         Percents

        1.             Up to 17 years        492                  26             5.28
        2.                 Adult             547                  169            30.9




Of 1039 persons who had been                          significantly to (7.14%), while in adult
examined, 142 cases of hydrocele were                 only 5 cases seen which equals to
noted .133(93.66%) of the cases were                  (0.9%) of the cases. Findings seen in
less than 1 Year of age, between 1-2                  (table – 4)…………………………….
years the incidence is decreased

                  Table – 4- frequency of Hydrocele in different age groups

      Groups                 Age           Persons               Cases         Percent
        1.              Up to 1 year         223                  133           59.64
        2.                1-2 years          14                    1            7.14
        3.               2- 17 years         269                   3            1.12
        4.              17 –79 years         547                   5            0.91



                                                 55
Of 102 persons with varicocele,                  examined, 30. Persons have varicocele
90(88.24%) had left side varicocele,             (14.56%) while of 547 adult, 72
and 12(11.76%) had bilateral varicocele          persons (13.16%) have varicocele.
had been recorded in child below 11              Findings seen in (table 5).
years Of 206 adolescent had been


               Table –5- Frequency of varicocele in different age groups

       Group         Puberty state     Persons             Cases        Percentage
         1.            Puberty           206                30            14.45
         2.             Adult            547                72            13.16


Of the 58 persons with hernia, 34 (58.6          them (31.8 %) were premature in which
%) had right side hernia, 12 (20.6 %)            3 cases of hernia were seen (8 %).
had left side hernia and 12 (20.6 %) had         Of 131 primary schoolchildren aged, 3
bilateral hernia.                                (2.2 %) had hernia, while the incidence
Of 116 neonates, 4 (3.4 %) had hernia.           of hernia in adult male group was 49
Of these 116 neonates, 79 of them (68            cases (8.9 %). Findings seen in (table –
%) were fullterm in which 1 case of              6).
hernia was found (1.2 %), and 37 of

                Table –6- Frequency of hernia in different age groups.

       Group             Age           Persons             Cases          Percent
         1.            Newborn             116               4              3.45
         2.             6-12 y             131               3              2.29
         3.            12-17 y.             95               2               2.1
         4.            17-79 y.            547              49              8.96


Of 25 persons with undesended testes,            (0.73 %) .of 37 premature neonates 11
15 (60 %) had right undesended testis,           cases had been recorded (29.7 %),
5 (20%) left and 5 (20%) bilateral. Of           while of 79 fullterm neonates only 3
116 neonates 14 cases of undesednded             neonates have undesended testes (3.8
testes were reported (12 %), while of            %). Findings seen in (table 7 & 8).
547 adults only 4 cases had been noted

          Table- 7- Frequency of undesended testes in different age groups.

       Group             Age           Persons             Cases        Percentage
         1.         Up to 1 month          116              14               12
         2.         1 month –17 y.         376               7              1.86
         3.            17 –79 y.           547               4              0.73




                                           56
     Table –8- Frequency of undesended testes according to maturity of newborn.

       Groups             Maturity        Persons            Cases         Percentage
          1.              Premature           37              11              29.7
          2.              Fullterm            79               3               3.8

Of the 6 persons with retractile testis, it           One case of testicular mass has been
was on the right side in 1 child, on the           recorded, with 23 cases of isolated
left side in 1 child and bilateral in 4.           testicular calcification had been
 Forty-two cases of testicular cysts had           reported with no case of testicular
been recorded, all of them were                    micro- calcification…………………....
postpubertal (more at elder age group).

DISCUSSION:
In this randomized study all the cases             becomes smaller than in younger men.
had been seen by general surgeons and              The head of epididymis also enlarged
urologists in the out patient department           with age, it usually does not exceed 10
Rezgary teaching hospital, while cases             mm in diameter in adult.
which had been examined in maternity                 By comparing our results with other
hospital were referred to Erbil teaching           studies done on the same subject in
hospital to confirm the diagnosis . It is          other societies we noticed that our
observed that the dimensions of the                results is similar to their result about
testes at birth is about (15mm x 10mm),            the changes in testicular size with age
and there is a slight increase in the              as shown in table –9. The average of
dimensions of the testes at 3 rd month             testicular dimensions were also similar
because of the rise in testosterone                to other studies, but several cases with
levels, and then there is slight decrease          slightly larger dimensions reaching up
in the size from 6m then it remains                to 53 mm in length and 31 mm in width
approximately constant until age of 6              had been recorded. The diameter of
years. Then there is a slight increase till        head of epididymis not exceeds 10 mm
the time of puberty where significant              in our study. Following table and
increase was noted till the adult size             graphs show testicular size in different
(30- 50-mm length and 20 –30 mm                    age groups in other populations in
widths) has been reached. In elderly               comparison to our study.
men, the testis again regresses and

Table – 9- Normal size of the testicle as a function of age 17
               Age                     Width ( cm )                  Length ( cm )
             At birth                      1.0                           1.5
          1 –3 months                      1.2                           2.0
          4 –6 months                      1.0                           1.7
           1 – 10 years                    1.0                           1.6
          11 –12 years                  1.0 –1.3                       1.7 –2.1
          13 – 16 years                 1.5 –2.0                       2.3 –3.5
              Adult                       2 –3                           3 –5

                                              57
Epididymil cyst is said tobe present in           study 3.8 % of fullterm neonate had
up to 40 % of asymptotic adult males              undesended testes, while 29.7 % of
(19, 20 )
          . In our study 30.9 % of adult          premature neonate had undesended
male had Epididymil cyst (table –3 %              testes and the incidence in adult group
figure –8).                                       was 0.73 % (table 7 & 8).
    Hydrocele is very common in                   Malignant testicular tumors have a
newborn males. ( 20,21 ) the incidence of         incidence of approximately 3 per
Hydrocele in children older than 1 year           100,000, with peak incidence between
of age is probably less than 1 %(22) .            15 and 45 years of age (28,29 ) . In our
Some study shows incidence of up to               study only one case of testicular mass
80 % in newborn boys, and 1 % in adult            had been reported (table –2) in a young
man .(23 ) in our study the incidence of          man of 29 years age (which proved
Hydrocele is up to 1 year was 59.64 %             tobe testicular malignant tumour) and
and in adult it was 0.91 % ( table –4 ).          had history of undesended testis (right
   The incidence of varicocele in the             side) with history of orchidopexy when
general population ranges from 6 % to             he was at 9 years of age.
23 % , the average in most large series               Testicular cysts are found in up to
is 15 % to 16 % . (24) The incidence of           10 % of the population undergoing
varicocele in our study was 13.55 %               ultrasound examination (30 ) . in our
(table 5) comparing to 6.86 % reported            study it was recorded in 42 cases 7.68
in other study done in Jordan. (24 )              % ( table –2 ) .
     Varicocele is very rare under 10                 Atrophy of the testes may be
years (22,24,25 ) . in our study, no child        congenital or acquired. On ultrasound
under 11 years of age had varicocele,             when the length is less than 3 cm and
while in other studies a case had been            width less than 2 cm it considered to be
reported about 9 years age (23) .                 atrophied and the echogenicity of the
   The incidence of hernia in the general         testis is more than usual (31 ) ..in our
population is approximately 1 –5 %,               study we record one case of testicular
while in some studies 25 % of males               atrophy ( table 2 ) in a young aged
have been found to develop hernias in             patient who had atrophied left testis
their lifetimes (21 ) in our study 5.58 %         measuring 28 x18 mm and he had
of the cases had hernia ( table –6 ) . Its        history of varicocele for the last 5 years
incidence in fullterm newborns is                 without undergoing surgery .
estimated to be 0.5 –1 %, and in                      Isolated    testicular   calcification
premature newborns, 5 – 10 % (23,26 ) in          which may represent benign phleboliths
our study the incidence was 1.27% and             are of no clinical significance.(32 ) , had
8.1 % respectively .                              been seen in 23 cases of 547 adults
    Approximately 80 % of undesended              patients had been examined which
testes are found at or below the level of         equals to 4.2 % ( table-2 ) , but no case
the inguinal canal. Its incidence is 10           of testicular microcalcification had
times higher in premature infants than            been noticed in our study .
in fullterm newborns (22, 27 ) . In our




                                             58
CONCLUSIONS:

 1. The change in the size of                    noted between our study and
    testes with the age in our                   other studies.
    society is similar to other               4. Certain scrotal diseases are
    societies.                                   common in different age groups,
 2. The size of testes in our                    like hyrocele is more common in
    society is similar to others                 infancy, varicocele is seen in
    societies, but several cases                 adolescent and adult while
    had been recorded with                       hernia and epididymial cyst is
    maximum length of testis                     more in older patients.
    reaching up to 53 mm and                  5. Scrotal ultrasound examination
    width reaching up to 31 mm,                  of asymptomatic persons will
    but the number of such cases                 detects these diseases in addition
    was         not   significant                to detection of impalpable
    statistically.                               testicular mass so it help in early
 3. No difference in diameter of                 detection and treatment of these
    head of epididymis was                       disease.


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1-   Robert M.Berne and Matthew                   9- David Rickards and Simon Jones.
    N.Levy.Physiology –3 rd edition.                 The scrotum, testis and penis.
    1993; P.990                                      Textbook of radiology and imaging
2- G. M. H. Waites. Grays anatomy .35th              .6TH Ed.1999; O.1197.
    edition. 1975.; P.1343.                       10-Eugenio O.Gerscovich .Scrotum and
3- Kelalis, K.P; King, l.r.; and Belman.:            testes .Diagnostic ultrasound. 2000;
    Clinical Pediatric Urology , 3rd Ed              P.893- 930.
    Philadelphia , ,W.B.Saunders , 7Ed            11-Giyanani VL, Hennigan D, Fowler
    .1992; Sabiston.                                 M, and SandersTJ: Sonographic
4- Bailey and Loves. The testes and the              finding      in    leiomyoma       of
    scrotum. Short practice of surgery.              postorchieectomy scrotum. Urol.
    20th Ed. 1990; P.1352.                           1985; 25:204-206.
5- T.W.Sadler. Descent of the testes.             12-Yeager BA, Arger PH, Mintz MC,
    Langmans Medical Embryology.8th                  Grumbach K, Coleman BG, Arenson
    Ed.2000;P.339 .                                  RL, Riesch D: The impact of
6- Philip C.. Cryptorchidism. Principle              sonograghy on the management of
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7- Tumeh SS, Benson CB, Richie JP:                   scrotum. J.Clin Ultra. .1989; 17:573-
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    Ultrasound CT MR 1991; 11:135.                13-Rifkin MD: Scrotal ultrasound. Urol
8- Yamamoto, M.AND Turner,                           Rad 1987; 9:119-126,.
    T.T.Infertility in the male 2nd Ed .St        14-Dina Ragheb, MD. And Joseph
    Louis, Mosby – yearbook, 1991,                   L.Higgins,        Jr.MD,        PhD.
    P.103.                                           Ultrasonography of the scrotum.
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   //www. Ultrasound med .org/.                  24-Moshe Nussinovitch, MD.Et al
   J.Ultrasound Med 2002; 21:171-185                Prevalence of adolescent varicocele.
   0278-4279                                        Vo.I.No        7.155,July       2001.//
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   ultrasound. 1992; p.1133.                     25-Joy Nielsen, ND.Varicocele in
16-Lwerner RM, Mevorach RA, Hulbert                 adolescent. October 29.2001.Vol
   WC. Color Doppler ultrasound in                  .2,No.10.//auther.eMeddicine .com/.
   the evaluation of acute scrotal               26-Wiener ES, Touloukian RJ, Rogres
   disease. Radiology 1990; 176-355.                BM, Grosfeld, Smith EI, Ziegler
17-Siegel MJ, Pediatric Sonsgraphy,                 MM, et al. Hernia survey of the
   2nd Ed, 1995 Raven press http//                  Section on Surgery of the America
   www. Ohsu. Edu/.                                 Academy of Pediatrics .J Pediatr
18-Rundle     AT,      Sylvester      PE.           Surg 1996; 31: 1166-9.
   Measurement of Testicular Volume.             27-Ferrer FA, McKenna PH.Current
   BMJ.Publishing      Group       .1982;           approaches to the undesended
   37:514-517.                                      testicle. Contempt pediater 2000;
19-Bibbo M, Gill WB, Azizi F., et al                17:106-11.
   Follow up of male and female                  28-http;       ///www.         eMedicine
   offspring of DES –exposed mothers.               .comm/orchiectomy         –     radical
   Obstet Gynecol 1997; 49:1.                       .htm.2002.
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   ultrasound. Radiol Clin North Am                 M.D.Sonography of the tests. http :
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21-pillai SB, Besner GE.Pediatric                30-Gooding GA, Leonhaedt W, Stein
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22-K.AL-Abbadi       and     S.A.Smadi.          31-van Dijk R, Hige- Boetes C,
   Genital abnormalities and groin                  Debruyne FM, et al. Sonographic
   hernias in elementary- school in                 detection of a nonpalpabe regressed
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   3,2000,Page 296 – 298.//Eastern                  J Clin Ultrasound 1989; 17:594.
   Mediterranean Health Journal/.                32-Doherty FJ.Ultrasound of the
23-Sean Collins MD. Hydrocele and                   nonacute scrotum. Semin Ultrasound
   Hernia in children. Medicine                     CT MR 1991; 12:131
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                                            60
Z.J.M.S.
 Vol. 8          IRON STATUS IN PREGNANT VS NON-PREGNANT
    (2)                   WOMEN IN ERBIL REGION
 2004

                                      Mohamad Salih Jaff *


ABSTRACT:

  Anemia affects an estimated two billion          non-pregnant women respectively. Being
people worldwide, mostly due to iron               severe in only (3.3%) of the study
deficiency. The prevalence of iron                 population, (3.7 %) and (2.7 %), of the
deficiency anemia is disproportionately            pregnant and non-pregnant women
higher in developing countries, due to             respectively
poverty, inadequate diet, certain                      Using iron study measures (e.g serum
diseases, pregnancy and lactation, and             iron ,TIBC, and transferrin saturation %)
poor access are susceptible because of             indicate body iron status only but not
rapid growth and associated high iron              necessarily iron deficiency anemia, in the
requirements. This study was conducted             mean time Hb estimation alone though
on 80 pregnant women, and 74 non-                  more sensitive measure of anemia but not
pregnant married women from different              specific diagnostic tool of iron deficiency
residential      areas,      occupational,         anemia. This suggests that the use of
educational, and socioeconomic status in           multiple parameters (e.g. Hb, serum iron,
Erbil region.                                      TIBC and transferrin saturation %) will
    The study revealed normal iron                 more specifically and probably more
status in ( 40 % ) pregnant and ( 44.6%)           successfully estimate the true prevalence
non-pregnant      women.      The    total         of iron deficiency anemia than when
prevalence rate of iron depleted stores            using a single parameter only (e.g. Hb, or
(transferrin saturation <16%) was                  serum iron or TIBC or transferrin
(57.8%) in the study population, (60%)             saturation %.).
and (55.4%) in pregnant and non-                      This study also showed that the
pregnant women respectively. Iron                  prevalence and severity of iron depletion
deficiency anemia (i.e. Hb< 11.0g/dl +             and anemia increased with gestational
transferrin saturation < 16%) was                  age, and among women with unplanned
present in (38.3) of the study population,         pregnancy with        an inter-pregnancy
(41.3 %), and ( 35.1 %) in pregnant and            spacing, period of <12 months.




(M.B.,Ch.B.,D.C.Path.,D.T.M.,M.D.), Department of Pathology, College of Medicine, University of
 Salahaddin, Erbil, Kurdistan region, Iraq.




                                              61
INTRODUCTION:

Despite the concept of physiological              The percentage below this value
anemia of pregnancy, it should be                 identifies the anemic population,
remembered that true anemia is common             although no single value will separate all
in pregnancy. Global estimation suggests          anemic from all non-anemic women(4).
that 60% of pregnant women are anemic             Women have increased risk of ID due to
compared to 47% of non-pregnant. Iron             their higher iron demands. Physiologic
deficiency (ID) is by far the commonest           iron requirements are three times higher
cause of anemia in pregnancy although             in pregnancy than they are in
folate deficiency is still often seen when        menstruating       women. The         daily
prophylactic folic acid has not been taken        requirements for iron, as well as folate,
(1)
   .                                              are 6 times greater for a woman in the
                                                  last trimester of pregnancy than for a
     It is difficult to state the type or         non-pregnant woman. (5)
cause of anemia in pregnancy due to                   The daily requirements of iron may
concomitant ID and other causes of                be net 0.8 mg iron in the 1st trimester,
anemia (like deficiency of folate, vitamin        between 4 and 5 mg in the 2nd trimester,
B12 and other acquired causes of anemia           and more than 6 mg in the 3rd trimester.
like aplastic anemia), in addition to             Although      iron    requirements      and
changes in body fluid balance (2) There           absorption are both increased during
are    large       arrays of    laboratory        pregnancy, the absorption of iron from
measurements to identify and assess the           food could not be sufficiently increased
severity of iron deficiency anemia (IDA),         during pregnancy to meet net demand to
but yet no single measurement will                iron. The absorption of iron after delivery
diagnose IDA with confidence. All                 decreased to levels not significantly
measurements differ in their sensitivity          different from those found in early
and/or specificity in the diagnosis,              pregnancy(6). The reasons behind the
therefore a battery of measurements is            development of a negative iron balance
used to investigate these patients or a           in large percent of pregnant females
population(2) (3).                                especially in the developing countries
    There is difficulty in stating with           are; heavy menstruation., recent previous
confidence       the normal hemoglobin            pregnancy or lactation., recent previous
concentration in pregnancy.          WHO          post-partum hemorrhage. , malnutrition
defined anemia in pregnancy as                    or under-nourishment state., and
hemoglobin level <11.0 g/dL or                                               )
                                                  intestinal helminthiasis.(4)
hematocrit (PCV) level < 37%.




                                             62
 MATERIALS AND METHDOS:
STUDY POPULATION:                                    and       the       aliquot   was
    The study was conducted on 80                    separated immediately and used for
pregnant women and 74 non-pregnant                   measurements of SI & TIBC.
married women as controls in Erbil
Governorate from Jan.2003 to June 2004.            HEMATOLOGICAL TESTS:
These women were included in this study            a. Estimation of Hb concentration ,
after fulfilling the following criteria;              hematocrit (PCV),& MCHC.
no history of medical or surgical diseases         b. Reticulocyte count: was adjusted to
or chronic illnesses, no history of any               the degree of, anemia, i.e. corrected
surgical operation that have relation to              reticulocyte count was used =
iron absorption and metabolism, no                    Observed count (%) X (PCV / 0.45)
                                                      (7) (8)
history of recent blood donation, (at least                  .
in the previous 3-6 months), did not               c. Leishman Stained peripheral blood
receive iron containing tablets at least in           smears were examined using a light
the past 3 days before taking a blood                 microscope (Olympus, Japan) using
sample, no history of bleeding                        40X & 100X (oil immersion) powers.
tendencies, and no history of chronic
drug usage (esp. non-steroidal anti-               BIOCHEMICAL TESTS:
inflammatory drugs, anticoagulation                a)Serum iron (SI) &TIBC measurements:
drugs, or any other drugs) adversely                 SI and TIBC were measured using a
affecting blood haemostasis.                         commercial kit (Biomaghreb) and the
                                                     result was read by spectrophotometer.
BLOOD SAMPLING:                                    b)Transferrin saturation (%) has been
Five mLs of blood were taken and added               calculated as (SI ÷ TIBC) x 100.
into two separate tubes:
(a)2 mLs of blood into an EDTA tube,               STATISTICAL ANALYSIS:
   for      immediate       hematological          Statistical methods as: Mean, Standard
   measurements as Hb, PCV, blood                  deviation, Correlation coefficient, t-test,
   film, and reticulocyte count.                   and z-test, were used in this study. Level
(b)3 mLs of the blood into a plain tube,           of statistical significance was fixed at
   centrifuged (3000 r.p.m.) immediately           (p<0.01), and if required at (p<0.05) .


RESULTS:

Pregnant women:  (table:1)                         women (with a transferrin saturation
The age of pregnant women was ranged               equal and more than a depleted body iron
between (17 years to 50 years)                     stores (with a transferrin saturation less
Mean ± SD = (27.5 ± 8.7 yrs)                       than 16%).
The hemoglobin range was (6.0 -14.2                Forty seven pregnant women( 58.8%)
g/dl:; mean± SD:10.6 ± l.5 g/dl ).                 were not anemic (Hb.>11g/dl) While
Normal body iron stores were found in              thirty three women (41.2%) had definite
32 out of 80 cases (40%) of pregnant               IDA (i.e. anemia with depleted iron
                                              63
stores)..)The severity of anemia was as             Normal body iron stores was present in
follows; mild (Hb=10-11 g/dl) in 18                 33 out of 74 cases (44.6%) (with a
women (22.5%), moderate (Hb=7-10                    transferrin saturation equal and more
g/dl) in 12 women (15%), and severe                 than 16%). While 41 out of 74 (55.4%)
(Hb,7 g/dl) in 3 women (3.7%) (table:2).            of cases have been classified to have a
Non-pregnant married women (control)                depleted body iron stores (Transferrin
(table:1)                                           saturation less than 16%).
The age of non-pregnant control women               Hb level was normal (>11.0g/dl) in 48
was as; Age range =16 years to 50 years,            non-pregnant women (64.9%) and 26
Mean ± SD = (26.1± 9.4 yrs).                        (35.1%) have definite IDA .(i.e. anemia
The haemoglobin range was (8-14.6 g/dl,             with depleted iron stores) (table: 2).
mean ± SD :10.8±1.8 g/dl).

Table (1) : Clinical, hematological and biochemical parameters in 80 pregnant women
            and 74 non-pregnant women.

                                  Pregnant women                     non-pregnant women
        Parameter
                            Range         Mean           SD          Range     Mean     SD
       Age (years)          17-50         27.5           8.7         16-50     26.1     9.4
    Hemoglobin (g/dl)       6-14.2         10.6          1.5         8-14.5    10.8     1.8
        PCV(%)               18-43         33.6          4.3         18-47     34.8      5
         MCHC                23-43         31.5          2.7         19-39     30.6      2
     Retic count(%)         0.1-2.6        0.9           0.2          0.3-3     1.5     0.5
   Serum iron (ug/dl)        5-181        61.1           35          5-160     54.6    28.8
      TIBC (ug/dl)         250-1129       555.8          186        271-1110   487.8   153
    T .saturation(%)         6-40         12.3           8.5          1-50     12.4    8.2


Table(2): Hemoglobin levels & severity of anemia distribution in pregnant and non-
          pregnant women.
                           Hb          Pregnant            Non-Pregnant         Total Study
   Severity of anemia     range         women                women              population
                          (g/dl)      NO     %             NO       %           NO       %
       Non-anemic         > 11.0      47          58.8         48       64.9     95    61.7
      Mild anemia          10-11      18          22.5         13       17.5     31    20.1
    Moderate anemia        7-10       12          15           11       14.9     23    14.9
      Severe anemia        <7.0       3           3.7          2         2.7     5      3.3
          Total                       80          100          74       100     154     100



                                            64
The prevalence of anemia was higher in           levels (11.6±0.2 g/dl) were among
participants from rural than urban areas         pregnant women who had longest
in non-pregnant women only, although             spacing period (.> 24 months), although
the difference was not statistically             this difference didn’t reach a significant
significant.                                     level statistically (P>0.05) (table:4)
The highest mean Hb level (10.9 g/dl)            The relation of Hb levels in both groups
has been found among pregnant women              to serum iron, TIBC and Transferrin
in the first trimester and the lowest Hb         saturation were statistically significant
level (10.2 g/dl) has been found in those        (p< 0.05).
at 3rd trimester, but this difference was        Other factors like residency, educational
not significant statistically (p> 0.05)          level, economic status, social grade,
(table:3). .                                     number of gravida, and others, were
Lowest mean Hb levels (9.1±0.6 g/dl)             found to have either very little or no
were found among women who had                   significant effect on the anemia
shortest inter-pregnancy spacing period          prevalence rates.
(< 12 months) while highest mean Hb



Table (3): Distribution of mean hemoglobin level in different trimesters of pregnancy.

                                         Hemoglobin level (g/dl)
         Trimester
                                 Range          Mean                      ±SD
            First               13.6-8.7         10.9                     1.1
           Second               14.2-8.4         10.7                     1.2
            Third               13.1-4.5               10.2                1.9



Table (4) : Distribution of mean hemoglobin values in pregnant women
            grouped according to spacing from the last previous one.


                                                     Hemoglobin level (g/dl)
       Pregnancy spacing       Number
                                                    Range           Mean +SD
          < 12 months             21               10.3-4.3            9.1+ 0.6
          12-24 months            27               10.7-4.3            9.4+ 0.6
           >24 months             32              14.2-10.7           11.6+ 0.2




                                            65
DISCUSSION:

Our studied population represented a              prevalence rate of IDA in pregnant
mosaic picture of women, which allowed            women in two Governorates of Iraqi
us to have a general idea about the               Kurdistan Region and in the same period
incidence of body iron stores and IDA in          is most probably resulted from; (a) larger
two groups of women; pregnant and non-            sample size 797 cases, (b) the nature of
pregnant. The results of this study seem          sample collection in Sulaimaniya city
to approach those of other studies                and majority, most probably, were
conducted in different cities of Iraq e.g.        complying with antenatal care (ANC),
Alobeidi & Dawood (9). showed that 51%            while in our study pregnant women were
of reproductive females in Baghdad were           from both inside and outside Erbil City
iron deficient and Al-Kass (10). conducted        and majority not-complying with regular
a similar study in Baghdad and the rate           ANC visits, and (c) the most important
of IDA was 47.6% in non-pregnant                  reason was that only hematological test
women and 51.6 % in pregnant women.               used was Hb estimation which was done
 Our results although lower but                   by Hemo-Cue method, which is although
consistent with the prevalence rates in a         simple, quick but a rough method to
number of countries of eastern                    assess Hb values only, compared to this
Mediterranean region (EMR), including             study in which we used of a battery of
Sudan, Morocco, Jordan, and Palestine             measurements      (SI,TIBC,Tsat)      with
(11)
     .                                            spectrophotometric estimation of Hb
The prevalence rates of IDA were lower            which is considered by many authors to
in a number of Arabic Gulf countries;             be the more sensitive and the more
Hussain et al in a study Conducted in             accurate method to determine Hb level
                                                  (16)
United Arab of Emirates, showed that                   .
only 16% of non-pregnant women and                   The prevalence rates of IDA in
14% of pregnant women have IDA (12).              pregnant women; worldwide, Asia,
While Dawood et al . found that among             Africa, & Latin America (through global
1582 Kuwaiti pregnant women, 36.8%                estimations of the problem) were ;59% ,
have IDA, despite having one of the               60%, 51%, & 35% respectively, (17) (18). It
highest per capita incomes in the world,          appears that the prevalence rate of IDA
still anemia and probably ID remains an           among pregnant women (41.2%) in this
important public health problem in                study is lower than the above figures
Kuwait. (10–39.9%) (13).                          worldwide. Also our rates among non-
AL-Khalaf (14) studied 295 apparently             pregnant women (35.1%) were lower
healthy pregnant women in Baghdad, he             than the recorded rates worldwide & in
found that 42.4% of pregnant women                different continents, the most probable
have Hb level < 11.0 g/dL. which is               explanation for these differences may be;
similar to our finding. On the other              the sample size, socioeconomic status,
hand, Ali (15) showed that 30.2% of 797           dietary    habits    or     methods     of
randomly selected pregnant women in               investigations used for diagnosis of IDA
Sulaimaniya City have Hb level <11.0              alone but not anemia in general.
g/dL, This clear difference in the

                                             66
Our results of IDA in both pregnant and            presumably specific &/or sensitive
non-pregnant women are lower than                  measurement to determine IDA i.e.
those in developing countries e.g.                 serum ferritin assessment after the bone
Indonesia >50% (19), in India 88% (20), in         marrow examination (30) ( 31).
Nepal 75% (17) in Zaire 54% (21) for the               All teenagers included in both groups
same above reasons, but much higher                studied were anemic The inclusion of
than in developed countries e.g. in                young women (age less than 20 years) in
Denmark 2.6% (22) in Sweden 3.1% (23)              both studied groups gave results which
and in New Zealand 5.5% (24) in United             were comparable to other studies (32) (33),
States 2-5% (25) and Switzerland 3.4% (5).         who showed that teenage pregnancy will
These differences are more or less related         cause depletion of body iron stores, as
to the standards of living, personal health        the nutritional status of teenagers is not
motivation, and better medical care in             ready to cope with demands of rapid
both preventing and treating IDA in                body’s growth of the mother and the
developed countries (26).                          foetus, beside the demands required by
The low prevalence rate (3.7%) of severe           pregnancy itself.
anemia (Hb < 7.0 g/dL), in pregnant                Our results showed that the number of
women is supported by Rush (27), who               anemic cases increased toward the end of
proposed that in most of developing                pregnancy (i.e. 3rd trimester > 2nd
countries the rate of severe anemia have           trimester > 1st trimester). Although it did
been much lower than the rate of mild              not reached a statistically significant
and moderate anemia.                               level (p> 0.05), (table:4), this has been
Our study, showed that the use of Hb               supported by other studies, (9) (15) (34)
value alone will, overestimates anemia             showed that with the progress of the
prevalence rate in general, as concluded           gestational age, the prevalence rate of
by Schndall et al, (28) and Burns et al.,          anemia had increased and anemia was
(29)
     . But in our view it masks the                more pronounced in 3rd trimester than 2nd
diagnosis of IDA and underestimates the            and 1st trimesters, this is due to increased
iron depletion states. While estimation            requirement of the maturing foetus, the
of Hb level supported by SI,TIBC                   large placenta and the most probably by
measurement &/or transferrin saturation            the bulk of the uterus which limits the
%, will determine the prevalence of IDA            stomach expansion .during meal taking.
to be more realistic (specific) compared           The increase in Hb level with the longer
to the use of other parameters. The                inter-pregnancy spacing >24 months,
usefulness of TIBC and transferrin                 noticed in this study is comparable to the
saturation % in the assessment of IDA              study done in the United States by King
                                                   (35)
has been mentioned by a number of                       . Our explanation is that less time
literatures to be a good indicator in this         will be available for iron stores to be
respect beside that it will not be affected        replenished in those women with shorter
by      infectious    and    inflammatory          inter-pregnancy spacing time (<12
conditions compared to the other most              months) than those with >24 months. .




                                              67
CONCLUSION:

 The prevalence rate of depleted iron            deficiency anemia. This suggests that
stores and iron deficiency anemia in             the use of multiple parameters (e.g.
this region of Iraq is approaching the           Hb + Transferrin saturation %) will
worldwide in general,        Iraq and            more specifically and probably more
developing countries, in particular.             successfully    estimate    the   true
Using iron study measures (e.g serum             prevalence of iron deficiency anemia.
iron ,TIBC, and transferrin saturation               This study also showed that the
%) only indicate body iron status but            prevalence and severity of iron
not necessarily iron deficiency                  depletion and anemia increased with
anemia, in the mean time Hb                      gestational age, and among women
estimation alone though more                     with unplanned pregnancy with an
sensitive measure of anemia but not              inter-pregnancy spacing, period of
specific diagnostic tool of iron                 <12 months.




                                                                                  :
                          74                     80
    .

                                    .                 .%44.6                       %40
                               % .57.8.                (%16                         )
            )                  .                        %55.4                         %60
                %38.3                 (%16                          +    100/     11
                  )                           %35.1                     %41.3
% 2.7                    % 3.7           %3.3 :                               (   100/ 7
                                                                            .         .

                                             .                             12
                        (Hb)

        (                        TIBC                                                 )
                                                                .



                                          68
 REFERENCES:
1.   Royston E. The prevalence of                   10.AL-Kass S.Y: .M.Sc. Published thesis
   nutritional anemia in women in                      on: Body iron status in apparently
   developing countries. A critical review             healthy people and in pregnant females
   of available information. World health              in Baghdad submitted to the College of
   state Q;1982, 35:52-91.                             Medicine, University of Baghdad.
2. Hoffbrand A.V., Lewis S.M., &                       1990.
   Tuddenham E.G.D: Chapter (3): pp.                11.WHO eighth report on the world health
   33; Postgraduate Hematology, 4th                    situation; EMR (Eastern Mediterranean
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3,Cook J.D., Skikne B.S. & Baynes R.D.:                al :.The prevalence and correlates of
   Screening strategies for nutritional iron           anemia among young children and
   deficiency. In SJ Fomon and S Zlotkin,              women of childbearing age in Al Ain,
   eds. Nutritional Anemias. Nestle                    United Arab Emirates. Annals of
   Nutrition Workshop Series, Vol. 30,                 Tropical Pediatrician, 1995, 15(3):
   New York: Vevey/Raven Press, 2003                   227-35.
4 Young R: Tropical medicine, chapter               13. Dawood J.S., Prakash P., Shubber K.M
   92): Iron deficiency anemia in                         :Iron deficiency anemia among
   pregnant women, Blackwell Scientific                pregnant Arab women. Journal of
   Publication,1995.                                   Kuwaiti Medical Association; 1990,
5. Hess.S.Y., Zimmermann M.B., Brogli                  24:167-172.
   S. & Hurrell R.F :A national survey of           14. .AL-Khalaf A .:M.Sc. Published thesis
   iron and folate status in pregnant                  on: Hematinic supplementation during
   women in Switzerland. Int. J. Vitam.                pregnancy: a prospective comparative
   Nutr. Res., 2001; 71(5): 268-73. .                  study in Baghdad submitted to the
6. Milman N.et al: Iron status in Danish               College of Medicine, University of
   women,1984-1994:          a       cohort            Baghdad, 1989.
   comparison of changes in irone stores            15. Ali F.M.: Anemia during pregnancy in
   and the prevalence of iron deficiency               Sulaimaniya City; prevalence &
   and iron overload, 2003.,71:1,51.                   associated factors Published M.Sc.
7. Hoffman R., Benz E.J., Shattil S.J .et              thesis submitted to the College of
   al :Hematology Basic Principles and                 Medicine, University of Sulaimaniya,
   Practice, 3rd edition, Churchill                    2003.
   Livingstone, a Harcourt Health Science           16.Padle J.J. Evaluation of hemoglobin
   Company.2000 .                                      color scale and comparison to with the
8. Dacie J.V. & Lewis SM: Practical                    Hemocue hemoglobin assay. Bulletin of
   hematology, 8th edition, Churchill                  WHO, 2002, 80:813-816.
   Livingstone Press.1995 .                         17. United Nations. Second report of the
9. Alobeidi S. & Dawood A.N.: Anemia                   world nutrition situation : Global and
   and nutritional status of pregnant                  regional trends. Vol. (1): A report
   women attending MCH centers in                      compiled from information available to
   Baghdad City. Journal of Community                  the United Nations and the ACC/SCN.
   Medicine; Iraq, 1997, 10(1): 10-21.                 1992:

                                               69
18.Demaeyer E.M.,Adiels-Tegman M.The                   Am. J. Clin. Nutr, 2000, 72:1,212s-240.
    prevalence of anemia in the world.              28. Schndall S.F., Berliner N, Duffy T.P .
    World Health Stat.Q, 1985,.38:302-                 et al: An Approach to the adult and
    316.                                               child with anemia, chapter 23 from:
19.Kosen S., Herman S. & Schultink W.:                 Hematology basic principles and
    An overview of studies on iron                     practice, by Ronald Hoffman et al., 3rd
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    Research, 1998, 18: 1935-1941.                     Harcourt          Health         Science
20.WHO         UNICEF       &    UNU:Iron              Company.,2000.
    deficiency anemia in India .A survey            29. Burns E.R., et al: Clinical utility of
    of pregnant women in Bihar State,                  serum tests for iron deficiency in
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21. Kuvibidila S .Donovan U.M., Gibson              30.Worwood M. Laboratory determination
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22. Milman N.: Serum ferritinin Danes:                 London: WB Saunders Co Ltd,:449–76,
    Studies of iron status from infancy to             1994.
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    pregnancy. Int. J.Hematol, 1996,                   deficiency anemia. Semin. Hematol,
    63(2):103-35.                                      1982, 19:6.
23. Hallberg L., Hulthen L., Bengston C .           32.Dangour A.D., Hill H.L., & Ismail S.J.,
    et al : Iron balance in menstruating               Hemoglobin status of adult non-
    women. European Journal of Clinical                pregnant Kasakh women living in Kzyl-
    Nutrition; 1993 (49): 200-207 .                    Orda region, Kazakhstan. Nature
24. Ferguson E.L., Skikne BS, Simpson                  Publishing Group, 2001, Vol.55, No
    K.M .et al :.Serum transferrin receptor            (12), pp.1068-1075.
    distinguishes the anemia of chronic             33. Jolly M.C.& Sibre N., Obstetric risk of
    disease from iron deficiency anemia .              pregnancy in women less than18 years
    Journal of Lab. & Clinical Medicine;               old,    J.    Clin.     Invest,   2000.,
    2001, (119): 385-390.                              (1044);1110:1037.
25 Looker A.C., Dallman P.R., Carroll               34. Media N .et al :.Anemia during
    M.D .et al.:(1997). Prevalence of iron             pregnancy in Burkina Faso, West
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    1996, 277:973-976.                                 associated factors .Bulletin of WHO,
26.WHO: Report of World Health                         1999, 77(11) 916-22.
    Organization informal consultation on           35. King J.S.: The risk of maternal
    hookworm infestation and anemia in                 nutritional    depletion     and    poor
    girls      and     women        .Eastern           outcomes increases in early or closely
    Mediterranean Health Journal 1                     spaced pregnancies .Journal of
    64 1994,.79                                        Nutrition, 2003, 133: 1732S-1736S.
27. Rush M.C. Nutrition and maternal
    mortality in the developing world.


                                               70
Z.J.M.S.
 Vol. 8          PREVALENCE OF CRYPTOSPORIDIOSIS AMONG
    (2)            CHILDREN ATTENDING PEDIATRICS AND
 2004
                       MATERNITY HOSPITAL IN ARBIL
                                                       s e
                                         Hadee M. A. Al- ake*


ABSTRACT :
   The present study was undertaken to                  oocysts, 16 (14.8 %) were boys and 16
investigate       the     status     of                 ( 12.12 %) were girls, of whom 6 cases
Cryptosporidium infection and its role                  were associated with Entamoeba
in gastroenteritis in children in Arbil                 histolytica and 2 cases with Giardia
governorate . A total of 240 fecal                      lamblia . Statistical analysis by x²
samples were collected from children                    revealed no significant differences
(108 boys and 132 girls) aged less than                 between boys and girls at this period of
three years, they were admitted to the                  age and among the first three years of
Pediatrics and Maternity Hospital in                    age, at p<0.05 level of significance .
Arbil from 1 June to 1 October 2003,                    Direct saline preparation revealed that
for acute or persistent diarrhea. The                   Entamoeba histolytica (18.75 %) and
fecal samples were examined by both                     Girdia lamblia (11.25 %) were most
Modified Ziehl-Neelsen Technique for                    common intestinal parasites among
Cryptosporidium oocysts and direct                      children in Arbil. The study revealed
saline preparation for other intestinal                 that Cryptosporidium infection is
parasites .Modified Ziehl-Neelsen                       highly endemic in Arbil governorate
Technique revealed 32 (13.33 %)                         and children in this area are at high risk
positive cases for Cryptosporidium                      of infection…………………………….


INTRODUCTION:

   Cryptosporidium       parvum is a                    Human cryptosporidiosis has been
common protozoan pathogen with a                        described in six continents, with
worldwide distribution and it can cause                 children    constituting    the    most
severe and life-threatening diarrhea in                 susceptible portion of the population
an immunocompromised host (1).This                      .Recently it is also recognized as a
protozoan was first recognized in mice                  frequent cause of gastroenteritis in
by Tyzzer in 1907 and first reported in                 normal individuals (3,4). Over the past
an immunocompetent child and an                         decade , the role of Cryptosporidium as
immunosuppressed adult with diarrhea                    the agent of human diarrhea has been
in 1976 (1,2).



                                                                                                   I
* Msc. Parasitology , Microbiology Department ,College of Medicine ,Salahaddin University, Arbil , raq .




                                                   71
 redefined from that of a rare                   in Iraq available data on this parasite is
opportunistic pathogen to a possible             limited , Mahdi et al.(9) were first
causative organism for mass infection            pointed       to     the    status     of
by water-borne transmission route                cryptosporidiosis in children in Bazra .
(5)
   .Because of the wide spread nature of         In Arbil governorate , to our knowledge
this disease , its contribution to infant        there is no accurate data that explain
morbidity and mortality through acute            the true status of cryptosporidiosis .
and persistent diarrhea and its potential        This study is an attempt to shed light on
for severe diarrheal illness in HIV              the prevalence and epidemiology of
patients (6,7,8), there were intense             Cryptosporidium and its role in
interest in studying the epidemiology of         gastroenteritis in young children in
Cryptosporidium infection . However              Arbil governorate .


MATERIALS AND METHODS:

Fecal samples were collected from 240            examined       for       oocysts   of
children (132 girls and 108 boys ) aged          Cryptosporidium ( Figure-1 ). Oocysts
less than three years and they were              of 4-5 Mm in diameter , red in color
admitted to Pediatrics and Maternity             and containing sporozoites were
Hospital in Arbil for acute or chronic           considered           positive     for
diarrhea during a period of 1 June to 1          cryptosporidiosis (1).
October 2003. Fecal smears were                   Fecal samples were also examined
prepared from each sample , air dried            microscopically by the direct saline
,fixed with absolute methanol and then           smear for the presence of other
stained by modified Ziehl-Neelsen                protozoan and helminthes .
procedure(10). The stained smears




Figure (1): Cryptosporidium oocyst containing sporozoites. Stained by Modified
            Ziehl-Neelsen Technique . ( 1000 x )

                                            72
RESULTS:
Of the 240 fecal samples examined by                 and among the three age groups ( x² =
Modified Ziehl-Neelsen Technique , 32                4.957, p<0.05 ). The results of direct
( 13.3 %) were positive for                          smear examination for other protozoans
Cryptosporidium oocysts , 16 (14.8 %)                and helminthes are detailed in Table-3 ,
were boys and 16 (12.12 %) were girls ,              in 240 fecal samples examined ,
of whom six cases were associated with               Entamoeba histolytica (18,75 %) and
Entamoeba histolytica and two cases                  Giardia lamblia (11.25 %) seemed
with Giardia lamblia (Table-1,2). The                more common among children with
statistical analysis revealed that there is          gastroenteritis  due     to    parasitic
no significant differences in prevalence             infections .
rate between boys and girls ( x² = 0.374
, p<0.05 ),




Table (1): Sexand age distribution of cry ptosporidiosis by Modified
         Z e N
         iehl- elsen Technique

                        Female                          Male
   Age                                                                              Positive
                                                                          Total
  groups                      Positive                         Positive              (%)
                a
               exmined         (%)             a
                                              exmined           (%)
     1
    0-            56          8 (14.3)          46         10(21.74)      102      18(17.6)

     2
    1-            38          6 (15.8)          32          4 (12.5)       70      10(14.3)

     3
    2-            38          2 (5.3)           30             2 (6.7)     68       4 (5.9)

   Total          132         16(12.12)         108            16(14.8)    240     32(13.3)




                                               73
Table (2): Details of 32 cases of Cryptosporidium oocysts positive children .



                          Age /          Associated        Direct microscopic
               Sex
                          Month          parasites              findings
      1         F            24              -              Pus cells (+  )
                                                                          +
      2         F            12          G. lamblia                   -
      3         M             8              -                  easts
                                                                Y
      4         M            18              -                    -
      5         F            26              -              Pus cells (+ +
                                                                         )
      6         F            13          G.lamblia                    -
      7         M            10              -                    -
      8         M            28              -                    -
      9         M            18              -                  easts
                                                                Y
     10         M            5               -           N
                                                         eutral fat globules
     11         M            8               -           N
                                                         eutral fat globules
     12         F            18         E. histolytica       Pus (+ +
                                                                    ),RBCs(+    )
     13         M            15              -                    -
     14         M            8               -           N
                                                         eutral fat globules
     15         F            15         E. histolytica            +
                                                           Pus ( ),RBCs(+     +
                                                                              )
     16         M            8               -           N
                                                         eutral fat globules
     17         M             6         E. histolytica    Pus(+ RBCs(+
                                                               ),
                                                               +            +
                                                                            )
     18         M             8         E. histolytica            ),
                                                                  +
                                                             Pus(+ RBCs(+       )
     19         F            7               -                    -
     20         F            5               -                    -
     21         M            10         E. histolytica     Pus(+ RBCs(+
                                                                ),
                                                                +            +
                                                                             )
     22         F            9               -                  easts
                                                                Y
     23         F            7               -                    -
     24         M             8         E. histolytica    Pus(+ RBCs(+
                                                               ),
                                                               +            +
                                                                            )
     25         F            8               -                    -
     26         F            10              -                    -
     27         F            10              -                    -
     28         F            7               -                    -
     29         M            14              -                  easts
                                                                Y
     30         F            16              -                Pus (+  )
                                                                      +
     31         M            25              -                    -
     32         F            22              -                 Pus (+  )
                                                                       +
 M: Male , F: Female




                                         74
Table (3): Prevalence of parasitic infections other than cryptosporidiosis
            by direct saline preparation .


                                          Total                   Male                Female
         of fecal samples
                                            240                    108                   132
            a
           exmined
                                                                                         15
    Entamoeba histolytica                   45                      30
                                                                                       (11.36)
           (%)                            (18.75)                 (27.7)

        Giardia lamblia                     27                     12                    15
             (%)                          (11.25)                (11.11)               (11.36)

        Entamoeba coli                      11                      7                     4
            (%)                           (4.58)                  (6.5)                (3.03)

      Hymenolepis nana                       3                       3                    0
           (%)                            (1.25)                  (2.77)                (0.0)




DISCUSSION:

Cryptosporidium continues to be a                         ,in addition to fowls which may also
threat        not          only              among        serve as reservoir hosts (23, 24 ) , thus this
immunocompromised persons but also                        parasite can be zoonotic .Most residents
among young children in developed                         of Arbil city migrated from villages and
and developing countries (6) . The                        small towns surrounding the city , in
prevalence rate of this infection among                   addition to migrants from other
children in the world ranged from 1.9                     governorates , and raising domestic
% to 16.7 % (11, 12, 13, 14, 15, 16, 17, ) .              animals , especially poultry , sheep and
The present study revealed that the                       cattle are more common among them ,
incidence of cryptosporidiosis among                      plus their personal hygiene is not so
children ( less than three years ) and                    good. Other possible explanation for
who were with a primary diagnosis of                      such high incidence in Arbil city may
gastroenteritis , was 13.3 % ( Table-1)                   be associated with contaminated
.This figure is relatively look higher                    drinking      water    supplies.        Since
than that reported by Mahdi et al.(9)                     Cryptosporidium oocysts are resistant
among children in Bazra .                                 to routine chlorination of drinking
       Cryptosporidium spp. infect a                      water (25, 26) and the presence of a high
wide range of mammalian hosts , in                        incidence of other water-borne parasites
particular cattle (1, 18, 19) , household                 , Entamoeba histolytica (18.75 %) and
rodents (18, 20 ) , pigs (1, 21 ) , and dogs (22)         Giardia lamblia (11.25 %) which
                                                     75
observed in this study ( Table-3), make             epidemiological factors that increase
the second interpretation may be most               risk of infection in certain sex at this
accepted .                                          age stage .
           Although the statistical analysis
of the results revealed no significant                        In this study the incidence of
differences ( at p<0.05 level of                    cryptosporidiosis (13.3 %)was higher
significance ) among the three age                  than giardiasis (11.25 %)which known
groups selected in this study (Table-1)             to be responsible for a high percentages
,the infection was most common among                of diarrhea. This figure may lead to a
children under two years .This finding              suggestion that Cryptosporidium is
is similar to that reported by                      highly endemic in Arbil governorate
(11,13,14)
          .The     high      occurrence   of        and may be there are a high percentages
cryptosporidiosis          among       young        of asymptomatic carriers ,but the
children may be due to their                        absence of reports of cryptosporidiosis
immuonological immaturity, lack of                  in this area may be because a specific
protective immunity from prior                      diagnostic method is not being used
exposure , their general risk of infection          routinely during stool examination .
due to hygienic behavior and \or                              Such       high    incidence      of
contracting the infection from their                cryptosporidiosis         among         young
household (2,6,16,27) ,in addition to the           children in Arbil governorate is very
role of breast-feeding in human                     important from epidemiological and
cryptosporidiosis remains controversial             clinical point of view ,because
but did not prevent Cryptosporidium                 cryptosporidiosis is known to be a
infection in one primate model (27) .The            significant risk factor for malnutrition
results were not in agreement with the              and growth retardation in young
observations reported by (1,2,5) in rural           children, several studies have suggested
areas of Korea , the authors found that             that cryptosporidiosis is most common
adults aged 30-70 years revealed the                in children younger than two years and
highest positive rate among all age                 is      associated      with      malnutrition
                                                    (15,17,25,33,34)                 (33)
groups and they attributed their finding                             .Checkly et al.      observed
to one possible reason that the active              that children with symptomatic
working population who are ready to                 cryptosporidiosis were grew less during
Cryptosporidium infection in the rural              the first month of infection than
areas is mainly older age group .Other              children without diarrhea. The effect of
possible reason for this discrepancy                asymptomatic cryptosporidiosis was
may be the genus Cryptosporidium                    less severe ,but these children also
includes so complex species and strains             gained less weight than controls did .
(28,29,30,31,32)
                 and the strains which found        Since Cryptosporidium causes severe
in such area may be more infective to               life-threatening diarrheal illness in
aged people than younger children .                 immunocompromised hosts and the
                                                    infection in such hosts may extend from
       The results also revealed no                 causing gastroenteritis to severe
significant differences (p<0.05) in the             sclerosing cholangitis, cholecystitis and
prevalence rate by sex .Boys and girls              papillary stenosis (26) ,therefore
at this period of age possibly got the              identification        and    diagnosis      of
same     chance     of   exposure    to             cryptosporidiosis must be gained more
Cryptosporidium oocysts and there are               attention in order to arrive at the proper
no known sex related physiological and              treatment          and     avoidance        of

                                               76
hospitalizing cryptosporidiosis cases               Since there are no effective drug
with     patients    suffering   from            therapies for cryptosporidiosis (25, 34) the
immunological disorders, leukaemia,              control measures are most important
organ transplantation and persons are            way. For this purpose, the source of
under immunosuppressed drugs .                   infection should be investigated more
                                                 intensively. Prior to these the
       This study documented that                nationwide epidemiological survey is
cryptosporidiosis is endemic in Arbil            essential for the exact knowledge of
governorate and its most common                  cryptosporidiosis status in Kurdistan
among young children (< 2 years) with            region and in Iraq. Finally, emphasis on
diarrheal illness. No significant                personal hygiene and sanitary behaviors
differences in the prevalence rate were          like avoidance of direct contact with
observed between boys and girls .                domestic animals , washing the hands
                                                 after using the toilet and cleaning the
       Direct contact with domestic              infants and also before preparing food
animals and their feces ,and                     and feeding the infants .Treating
contaminated drinking water supplies             drinking water by boiling or iodine
are considered to be the most important          crystals ,all these are essential steps for
sources of intestinal parasitic outbreaks        prevention and reduction of parasitic
, particularly amoebic dysentery                 infections, including cryptosporidiosis
,cryptosporidiosis and giardiasis .




                                                                                 :


                                                   240            .

                                                                          2003
                                                                                     .
                                                 Cryptosporidium parvum
                                            .
                                                                                 (%13,33)32
                            6                    (%12,2)16                        (%14,8)16
                     Entamoeba histolytica
                                                                . Giardia lamblia

                                        . P<0.05

                                                       (%11,25)             (%18,75)
                                                                      .
                              .
                                            77
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   Parasitol. 39:201-203 (2001) .                    Cryptosporidium        infections      in
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   ;Tadesse , W. ;Aldo ,A.M. et al.                  nutritional,enteropathogenic         and
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   rts,M. and et al. Epidemiologic                   Cryptosporidium        from      various
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   Paniagua,M.;Menesos-                              kuyama,M. and et al. Sensitive
   Esquivel,R.;Novales,M. and et al.                 detection of Cryptosporidium oocysts
   Cryptosporidium parvum infection                  in environmental water samples by
   in wellnourished and malnourished                 reverse        transcription       PCR.
   children without diarrhea in a                    Jpn.J.Infec.Dis. 54:122-124 (2001).
   Mexican         rural       population.        25- Clark,D.P. New insights into human
   Rev.Invest.Clinic.          52:625-631            cryptosporidiosis.
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   Isolation and identification of                26- Harrison,T.R.;Reshick,W.R.;Wintro
   Cryptosporidium        from     various           be,M.M.;Thorn,G.W. and et al.
   animals:          prevalence         of           Cryptosporidiosis. In: Harrison,s,
   Cryptosporidium in various animals.               principles of internal medicine.
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19- Alves,M.;Xiao,L.;Sulaiman,I;Lal,A.            27- Ungar,B.L. Cryptosporidium. In:
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   humans,cattle and zoo ruminants in                Livingstone. pp. 2500-2510 (1995).
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   30:259-262 (1992) {Abstract}.                     patients           in           England.
21- Izumiyama,S.;Furukawa,I.Kuroki,T.                J.Med.Microbiol. 50:293-296 (2001).
   Yamai,S. and et al. Prevalence of              29- Limor,J.R.;Lal,A.       and     Xiao,L.
   Cryptosporidium parvum infections                 Detection and differentiation of
   in weaned piglets and fattening                   Cryptosporidium parasites that are
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   Japan. Jpn.J.Infec.Dis. 54:23-26                  PCR. J.Clinic.Microbiol. 40:2335-
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   heteroduplex mobility assay and                   having sporadic cryptosporidiosis.
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                                             80
 Z.J.M.S.
  Vol. 8         EFFECT OF DIFFERENT ADHESIVE SYSTEMS ON
     (2)
  2004          MARGINAL ADAPTATION OF CLASS V COMPOSITE
                            RESIN RESTORATION
                              (IN VITRO STUDY)

                Dara Hama Saeed*   Ali H. Al – Khafaji**   Ali Sultan Al – Refai***


  ABSTRACT:
This      research      assessed     the           adhesive was used. all teeth well stored
microleakage of composite resin                    in normal saline at 37º C for 7 days, in
restoring class V prepared with                    an incubator, Thermocycled then
different cavosurface margins with &               immersed in 0.5 % methylin blue in
without using different types of                   the incubator at 37º C for 24 hours.
bounding agents. Sixty four human                  The teeth blocked in a clearcold cure
upper premolars teeth were randomly                acrylic & sectioned longitudinally
divided into two groups, in the 1st                through the buccal & lingual cavities.
group, the cavosurface margins were                Each cavity was examined by
made at 90 degree angle to produce but             measuring microscope to evaluate dye
joint, while in the 2nd group, the                 penetration at both occlusal & gingival
cavosurface margins were beveled at                margins. Using the ANOVA test, the
angle. Each main group was                         results showed that beveling of the
subdivided into two subgroups, the 1st             cavosurface margin revealed a high
subgroup filled without etching & the              significant reduction of microleakage
2nd filled with etching. Then each                 at the tooth / restoration interface & on
subgroup was further divided into four             using a low-viscous bonding agent, a
groups with eight cavities in each. in             high reduction in microleakage
the 1st group teeth filled directly                occurred. There was no significant
without bonding agent. While in the 2nd            difference between the three types of
group Admira bond dental adhesive                  bounding agents used. The occlusal
was used. in the 3rd group, Scotch bond            margin exhibited a high significant
MultiPurpose dental adhesive was used              reduction in microleakage than the
& in the 4th group, Exite dental                   gingival margin.




 * B.D.S., M.Sc.
 ** B.D.S., M.Sc.
*** B.D.S., M.Sc., Ph.D.


                                              81
 INTRODUCTION:
Resin composite restorative materials,          happen due to many reasons such as
have gained a permanent position on             contraction of composite during
the dental market (1). It has many              polymerization &/or stresses that are
advantages like conservation of tooth           applied to unsupported margins (4) .
structure , strengthening the remaining         Dye penetraion method is one of the
tooth     structure,     low    thermal         oldest & commonest method for
conductivity, ease of manipulation,             studying microleakage around the
absence of mercury, tarnish, corrosion          restorations (5,6) . The use of dentin
& less wear of apposing teeth (2) .             bonding agent increases the bonding
Microleakage at the tooth /restorative          of resin to the walls of the cavity &
interface may be responsible for a              reduces the interfacial space ( 7) . The
number of          clinical   conditions        need for adhesive restorative dental
including; recurrent caries, post               material is self evident from the
operative pain, discoloration of teeth,         clinical requirements:. Cavity sealing ,
chronic hypersensitivity, & pathosis            restoration , retention & reinforcement
of the pulp (3) . The most common               of tooth tissue ( 8) .
cause of microleakage of composite
restorations are marginal gaps, which

 THE AIMS OF THIS STUDY WERE:
1- To evaluate the influence of different adhesive systems on marginal adaptation of
   composite resin material .
2- To determine the effect of two different marginal configurations on reduction of
   microleakage .
3- To notice any difference in microleakage between occlusal and gingival margins.


 MATERIALS AND METHODS:
    Sixty four human upper premolars            were in the dimensions of 3mm.
teeth human premolars teeth , freshly           Length mesiodistally, 2mm. width
extracted for orthodontic reasons were          occlusogingivally, 2mm. depth, & the
stripped of calculus & debris with a            gingival margins were 1.5mm. away
cavitron scaler, polished by pumice &           from the cementoenamel junction .
rubber cup with a contra angle hand                The teeth were randomly divided
piece at a low speed to remove stain &          into two groups. Each group consist of
debris completely.                              32 teeth.
    A standardized class V cavity               Group 1: The cavosurface margins
preparations (half round), were drown           were made at 90 degree angle (but
on the buccal & lingual surfaces of the         joint).
teeth, & cut by using carbide fissure           Group II : The cavosurface margins
bur No.56, in a turbine hand piece              were prepared as a continuous 0.5mm.
under a copious disilled water spray,           wide bevel at a 45 degree angle ,
by one dentist to ovoid operated                producing a 135 degree cavosurface
mediated errors. The preparations               angle . using a flame shaped , fine grit
                                           82
, cylindrical diamond bur using water          normal physiological saline in side a
spray.                                         container for 7 days, in an incubator at
     Each group intern was subdivided          37º C .
into four subgroups according to the               The thermocycling machine cycles
treatment :                                    the specimens manually , on bath
A=But-joint margin filled directly             maintained at 5º C & the other at
     with composite without etching.           55º C , the immersion time was 30
B=But-joint margin filled directly             second in each bath & the number of
    with composite with etching.               cycles employed was 600 cycles .The
C=Beveled-joint margin filled directly         dye used to demonstrate microleakage
     with composite without etching .          was 0.5 % methylin blue ,which was
D=Beveled-joint margin filled directly         placed in containers in an incubator.
     with etching.                             The teeth were stored in the dye for 24
Each subgroup was also subdivided              hours at 37º C .The teeth were
into four groups according to the type         embedded in blocks of acrylic resin &
of treatment :                                 sectioned (buccolingual longitudinal
Group 1: ( A1, B1, C1, D1) teeth               section ).
filled directly without bonding.                   A measuring microscope was used
Group 2: ( A2, B2, C2, D2) teeth               to measure linear dye penetration at
filled using Admira bond.                      tooth / restoration interface. Then a
Group 3: ( A3, B3, C3, D3) teeth               scoring system was used in this study
filled using Scotch bond MP.                   to determine the amount of linear dye
Group 4: ( A4, B4, C4, D4) teeth               penetration as shown in (Table 1).
filled using Exite .                           ANOVA test was used to evaluate the
   A Hawe cervical Matrix was placed           effect of cavity design, different
on the composite to hold it in place           bonding agents, cavity margins & the
under pressure, finishing & polishing          use of acid etching on reduction
discs, then all teeth were stored in           microleakage.


      Table 1: Scoring criteria for the amount of linear dye penetration.

                 Score                      Criteria

                   0             No dye penetration
                   1             Penetration up to 0.5 mm.
                   2             Penetration up to 1 mm
                   3             Penetration up to 1.5 mm
                   4             Dye reaching the floor




                                          83
 RESULTS:
The reading for dye penetration which            These tables also showed that
represented the microleakage where               although there were no significant
taken, then the value was converted              difference between the bonding
into scores as shown in tables 2,3 &             agents, yet the Scotch bond had the
figure 1. ANOVA test was performed               lowest mean microleakage followed
between the two different types of               by Admira bond & Exite. Statistical
cavity designs & there was a very                analysis also showed that there was a
high significant difference between              high     significant    difference     in
butt-joint & beveled joint in regard to          microleakage between the gingival
cavity designs (table 4 & figure 2 ).            margin & occlusal margin (table
The results showed that there is a high          7,8,& figure 3).
significant difference between cavities          The results also showed that a high
restored without using bonding agent             significant difference in microleakage
& restorations using bonding agent               was noticed when comparing the use
(p=0.000) as shown in tables 5,6.                of acid etching & restoration with out
                                                 etching as seen in table 9 & figure 4.


Table 2: Summary of statistics(mean, standard deviation) of microleakage of the
         different subgroups at gingival occlusal teeth/ restoration interfaces.
                                   Gingival                  Occlusal
                  Group
                              Mean(mm)         S.D.     Mean(mm)      S.D.
                    A1           2              0          2           0
                    A2          1.303          0.348      0.906       0.161
                    A3          1.778          0.258      1.065       0.325
                    A4          1.871          0.191      0.748        0.54
                    B1          1.7525         0.418      0.7725       0.58
                    B2          1.1037         0.52       0.557       0.396
                    B3          0.586          0.277      0.281       0.004
                    B4          0.695          0.544      0.197        0.23
                    C1            2             0           2           0
                    C2           1.46          0.481      0.563       0.252
                    C3          1.168          0.278      0.762        0.24
                    C4           1.73          0.35       0.971        0.66
                    D1          1.627          0.394      0.686       0.578
                    D2          0.585          0.197      0.246       0.107
                    D3          0.266          0.114      0.123       0.086
                    D4          0.445          0.277       0.14       0.112




                                          84
        Table 3: Mean score of microleakage of the different subgroups at
                gingival occlusal teeth/ restoration interfaces.

                       Group                Gingival              Occlusal

                           A1                   4                    4
                           A2                   3                    2
                           A3                   4                    3
                           A4                   4                    2
                           B1                   4                    2
                           B2                   3                    2
                           B3                   2                    1
                           B4                   2                    1
                           C1                   4                    4
                           C2                   3                    2
                           C3                   3                    2
                           C4                   4                    2
                           D1                   4                    2
                           D2                   2                    1
                           D3                   1                    1
                           D4                   1                    1




        Figure 1: Bar chart graph shows the mean of microleakage different
                  subgroups at gingival occlusal teeth/ restoration interfaces.




   Table 4: ANOVA-test for dye penetration measurement between butt-joint
            and beveled joint cavity designs.

     Source           df        Sum of Square          Mean Square             F      Significant
Butt_Beveled Joint    1             2.569                 2.569              22.520     0.000




                                             85
Figure 2: Bar chart graph shows the mean of microleakage at tooth / restoration
           interfaces in butt-joint and beveled joint cavity designs.




Table 5: ANOVA-test for dye penetration between the groups.

     Group                 G2                        G3                 G4
       G1              H S (p=.000)              H S (P=.000)       H S (p=.000)
       G2                                        N S (P=.247)       N S (P=.427)
       G3                                                           N S (P=.109)




Table 6: Mean of microleakage for the different subgroups.
                  Mean          S.E     95% Confidence interval
                                             Lower Bound          Upper Bound
        Group1    1.605       0.042             1.522                1.688
        Group2    0.808       0.042             0.725                0.891
        Group3    0.754       0.042             0.671                0.837
        Group4    0.850       0.042             0.767                0.933




Table 7: ANOVA-test for dye penetration between gingival and occlusal
         margins.

        Cavity margins          Mean      S.D             F       Significant
            Gingival            1.256     0.30       142.234        0.000
            occlusal            0.725     0.30




                                        86
 Table 8: ANOVA-test for dye penetration between gingival and occlusal
          margins within the gruops.

                        Sum of                 Mean of
                                      d.f                      F        Sig.
                        squares                 square
Group1    between    3.691           1      3.691            11.254     0.001
          groups
          Within     20.336          62     0.328
          groups
          Total      24.027          63
Group2    between    3.478           1      3.478            20.469     0.000
          groups
          Within     10.535          62     0.170
          groups
          Total      14.013          63
Group3    between    2.457           1      2.457            8.417      0.005
          groups
          Within     18.098          62     0.292
          groups
          Total      20.555          63
Group4    between    7.216           1      7.216            17.086     0.000
          groups
          Within     26.185          62     0.422
          groups
          Total      33.401          63




    Figure 3: Bar chart dye penetration between gingival and occlusal
              margins within the groups.




                                    87
Table 9: ANOVA-test for dye penetration between etched and un-etched
         restorations.

       Group           Mean           S.D                F       Significance

   Without etching     1.379          0.30             142.234      0.000
   With etching        0.629          0.30




               Figure 4: The effect of acid etching.




                                     88
 DISCUSSION:
    Microleakage is considered as one            Hember (16) , who stated that there
of the major problems in restoring               was no significant difference in
teeth with different kinds of                    microleakage observed in restorations
restorative material. The highly                 placed on butt-joint & beveled
significant difference in microleakage           preparations.
between the gingival & occlussal                     There was a highly significant
margins for all sub-groups may be due            difference in microleakage between
to frequent occurrence of rodless                teeth filled with composite & bonding
enamel at the gingival margins of                agent, & teeth filled with composite
class V cavity preparation in                    only. This could be attributed to that
permanent teeth. This agree with                 beveling increases the surface area of
Retief (9) , Akria etal ( 10 ) . But this        enamel margins, exposing more
comes in disagreement with Ben-                  enamel rods for etching allowing low-
Amar (11) & Al-Nassiry (12) . They               viscous bonding agents to enter the
found that there is no difference                core of enamel rods result in a good
between the occlussal & gingival                 micro mechanical bond. This study
margins. There was statically high               coincides with Ben-Amar (17) ,
significant difference in microleakage           Staninec (18) , Korale & Meiris (19) ,
in restorations placed on butt-joint &           Al-Abussi (20) .
beveled cavo-surface margins. This                   Non of the three bonding agents
could be explained that beveled                  was able to completely prevent
margin provides more surface for acid            microleakage due to the fact of
etching, for retentive purposes. This            coefficient of thermal expansion of
result comes in agreement with                   resin is higher than that of tooth
Munechika (13) & AL-Ghany (14) , but             structure & polymerization shrinkage
does not coincide with Retif (15) &              of the materials used in the study.



 CONCLUSION:
1-Beveled      cavo-surface   margins            3-There was a highly significant
  showed high significant reduction                difference in microleakage between
  in microleakage at the tooth /                   the gingival & occlussal margins,
  composite restoration interface than             occlussal margins showed less
  butt-joint cavo-surface margin.                  microleakage.

2-high significant reduction in                  4-No significant differences observed
  microleakage when acid etching &                 between the three bonding agents in
  bonding agent were used.                         reduction of microleakage.




                                            89
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 1.Dauviller B S, Aarnts M P, Feilzer A.               composite resin. M.Sc. Thesis,
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 4. Erake F : Dentin adhesion , J Dent              15.Retief DH: The effect of cavosurface
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      fillings as hermetic sealing agents .            Dent.(1982),47: 496-501.
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    Denys F R: Surface topography of                   (1988);59: 397- 402.
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                                               90
Z.J.M.S.
 Vol. 8            EFFECT OF PRECLAMPTIC TOXAEMIA ON THE
    (2)                         FETAL VESSELS
 2004


                                       Maysoon M. AL-Qzazz *



ABSTRACT :
   Twenty umbilical cords were taken                   Mosul city .
from two groups of pregnant women                         The study showed many histological
after labour. The first group are those                changes in the umbilical vessels of the
umbilical cords taken from women who                   first group , the changes included,
are    suffering    from    preclamptic                narrowing of the lumen, destruction of
toxaemia ( B.p 150/90- 160/110 with                    the internal elastic membrane ,and
oedema and proteinuria ) .                             largely were replaced by atheromatous
   The second group are those healthy                  like lesion in the smooth muscle of the
pregnant , women suffering from                        media , infarction and necrosis with
hypertension before pregnancy ,                        oedema of the wharton s jelly . These
diabetes mellitus or Rh- incompatibility               changes indicat sever vascular damage
and those with history of cigarette                    due to high maternal blood pressure
smoking were excluded from the study.                  which in turn affect fetal development.
   All the specimens were collected                    The second group showed no such
from AL- Batool Teaching Hospital in                   changes.


Key words :
Preclampsia – Fetal vessels – hypertension with pregnancy.


INTRODUCTION:

Preclampsia is a multisystem disorder                  considerable proportion of maternal and
of human pregnancy with genetic                        fetal death, it affect two patients, the
predisposition , it occures more                       mother and the fetus because delivary
commonly in the first pregnancy and                    of the fetus is the only cure of
primarly affects        maternal renal,                preclampsia, it is always the treatment
cerebral and hepatic systems .(Biagini                 of choice for the mother. ( Eyal Shiff et
et al., 1992 ).                                        al., 1994 ).
Preclampsia complicates 3-5% of all                    Ramzis et al. ( 1999 ) explained the
pregnancies     and      accounts    for               pathogenesis of toxeamia of pregnancy
phenotype of normal endothelial cells,                 inability      of      the      invading
this defect may further influence by the               cytotrophoblast     to     assume    the


* Department of anatomy and histology, College of medicine - Mousl


                                                 91
remodeling of uterine vasculature,                number of lesions : acute atherosis,
reducing blood flow and leading to                arteriosclerosis and alteration in the
placental ischemia which induces                  expected physiologic restructuring of
stimulation      of     vasoconstrictor           the spiral arteries during pregnancy (
substances and the inhibition of                  Sheppard and Bonnar ,1974 and 1981).
vasodilator substances.                           Robertson and Dixon ( 1969 ) found
Douglas and Baha ( 1989 ) reported                that the characteristic abnormality
that      extensive      ultrastructural          which is consistantly present in the
endothelial    injury    was      found           decidual arteriols in toxeamia is
consistently in both placental site and           fibriniod necrosis with secondary
uterine non placental site boundary               infiltration of the damaged vessel wall
myometrium in all specimens from                  by lipophages, lymphocytes, and
preclamptic pateints but not in                   histiocytes, lipophages are often a
normotensive women.                               prominent feature of acute atherosis.
European studies have identified a

MATERIALS AND METHODS:

20 pregnant women who suffered from               changes xylol with period of 1 hr each
preclampsia and other 20 healthy                  ,finally they were embeded in 3
pregnant women used as control group              changes of 60 c moulting point paraffin
.Pieces of 1-2 cm in length were taken            for 2 hrs each .2 blocks from each
from the umbilical cords of both groups           portion were done , from each block a
and prepared for ligth microscopical              thin section of 5 micron were cut using
study , each piece were cut in to slices          Reicheart Rotary microtom ( Mcmanus
with an average thickness of 3-4mm                and Moury , 1964 ). These sections
fixed in 10% fomalin solution for more            were then mounted on slides to be
than 24 hr , the tissue then dehydrated           stained by the following stains :
in ded alcohol using 70% , 2 changes of           1-Hematoxilin and eosin ( Mcmanus
90% respectively with period of 1 hr                 and Moury )
each . This followed by 2 changes of              2- Sudden black stain for fatty tissues
absolute alcohol second one left over                ( 1985,          .)
night , after that the tissue cleared by 2

RESULTS:
Morphological changes were detected               in addition to infarction and necrosis
in the arteries ,veins and wartons jelly          ( fig. 4 ) . No such changes were
of the umbilical cord taken from the              detectedin the umbilical cord of the
women suffering from preclamptic                  control group. ( fig. 1) . Using sudden
toxiemia, using hematoxilin and eosin             black stain , accumulation of the lipid
stain there was constriction in the               in the smooth muscle of the tunica
lumen of the arteries ,with the                   media of the umilical arteries and veins
destruction of the internal elastic               was observed ( fig. 5) , while the
membrane of the intima ( fig. 2) ,                vessels of the umilical cord taken from
fibrinoid materials were observed in the          the control group showed no reaction to
smooth muscle of the tunica media ( fig           sudden black stain ( fig. 6).
. 3 ) , with oedema in the whartons jelly

                                             92
DISCUSSION:
    Preclampsia has been studied by               vasoconstriction with destruction of
many authors and many explanations                internal elastic membrane, infarction
were put to explain the mechanism of              necrosis and oedema of wharton s jelly,
preclampsia, among these explanations             all these changes are a result of
( Biagini et al., 1992 ) reported that            placental ischemia which the basis of
there may be 1) a genetic predisposition          toxeamia of pregnancy, which lead to
for the occurrence fo preclampsia or 2)           placental infarction, retroplacental
preclampsia is caused by placenta as a            heamatoma, villous ischemia and
result of vasoconstriction, intravascular         fibrinoid necrosis with acute atherosis
coagulation and reduced maternal blood            of the uterine and fetal vessels ( Ramzis
volume        leading        to     organ         et al., 1999 )
hypoprofusion. Current hypothesis                        In an ultrastructural study of the
proposed that 3) preclampsia is due to            uteroplacental spiral arteries Sheppard
wide spread cytotoxic substance which             and Bonnar ( 1981) showed a similar
released by the placenta caused                   changes in the spiral arteries of
endothelial cell damage.Other cause               hypertensive women.
may be 4) the abnormal balance of                       Our finding of lipid accumulation
vasoactive factors in preclampsia like            in the smooth muscle layer gose with
angiotensin,         aldosteron       and         that found by Robertson and Dixon
prostacyclin activity, other explanation          ( 1969 ) they descried fibrinoid necrosis
was 5) volume heamostasis which                   of the decidual arterioles with
causes      increase      in     capillary        secondary infiltration by lipophages a
permeability and lead to inbalance                feature of acute atherosis, they
between hydrostatic and oncotic                   explained that by the endothelial
pressure.                                         damage due to placental ischemia.
     Preclampsia described by Roberts                    Lee-CN et al. ( 1997 ) postulated
and Redman ( 1993 ) as a disease of               that the preclamptic pateints have both
endovascular damage which leads to                a higher ratio of free fatty acid to
loss of vascular autoregulation,                  albumin and increase lipolytic activity
significant vascular spasm and vascular           compared with the control, the
leakage.                                          hyperlipidemia inhance the lipid
Vaillant- P. et al. ( 1995 ) reported that        accumulation in the endothelial cells of
placental ischemia in preclampsia may             the       umbilical      vessels      and
be due to endothelial dysfunction with            placenta.Joannel et al. ( 1994 ) was
inbalance between prostacyclin and                found that accumulation of the lipid and
thromboxin       A2      and     possibly         triglyceride in the endothelial cells of
dysfunction of nitrous oxide (NO).                the umbilical vessels and placenta will
      In this study many histological             damage the cells and promote
changes were detected in the section of           vasoconstriction, in addition the plasma
the umbilical vessels taken from                  lipid peroxidase level are significantly
preclamptic patients included the                 high in patients with preclampsia .




                                             93
Fig.(1): Photomicrograph of normal umbilical artery.(H. and E. X432).




Fig.(2):Photomicrograph of umbilical cord from preclamptic patient showing
        constriction of lumen with the destruction of internal elastic
        lamina(arrows) (H. and E. X432).




                                      94
Fig.(3):Photomicrograph of umbilical artery from preclamptic patient showing
        deposition of fibrinoid material(F) in the tunica media. (H. and E. X432).




Fig.(4): Light micrograph of the Wharton’s Jelly (WJ) from the umbilical cord of
 preclamptic patient showing Oedema (od) & necrosis (arrows) (H. and E. X432).




                                       95
Fig.(5):Light micrograph of umbilical artery from preclamptic patient showing
        deposition of lipids (arrows) (Suddan black X1730).




Fig.(6):Light micrograph of normal umbilical artery showing negative reaction to
        the Suddan black stain (arrows) (Suddan black X1730).




                                      96
                                         :

       .
116 \110- 150/90             )
                                 (
                         .

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                .



            .


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                    97
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   E, Cataldinic-C, Placental villi-         ( preclampsia and eclampsia ) : In
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   Ostet-Gyneacol(1992)34(1)9-15.            475-476.
2- Douglas, R., Shanklin, MD. and         8- Robertson W. B. and Dixon H. G. . In :
   Baha      M., Sibai, MD. ,        .       Foetus and Placenta ( eds-A. Klopper
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4- Joannel-Stone, MD. Charles J.             BR.Common W. (1974);81, 20-9.
   Lock Wood.MD. Gertrnd. S.,             11-Sheppard BL, Bonnar, J.: An
   Berkowit Z. : Risk factors for            ultrastructural study of uteroplacental
   sever preclampsia ,Obstet and             spiral arteries in hypertesive and
   Gyneacol (1994); 83 ,357-361.             normotensive pregnancy and fetal
5- Lee-CN, Chang-SW. Cho-NH,                 growth retardation. B. J. Obestet
    Cho-SH. Nitrous oxide synthesis          Gyneacol. (1981) 88, 695-705.
    expression in placenta of             12-Vaillant-P., Gondery-J., Fourneir A..
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6- Mcmanus, JF. A. and Moury ,R.W.
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7- Ramzis Cotran, Vinay Kumar and




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