A Population-Oriented Genetic Scoring System to Predict Phenotype: A Pathway to Personalized Medicine in Iraqis With β-Thalassemia

To assess the roles of genetic modifiers in Iraqi β-thalassemia patients, and determine whether a genotype-based scoring system could be used to predict phenotype, a total of 224 Iraqi patients with molecularly characterized homozygous or compound heterozygous β-thalassemia were further investigated for α-thalassemia deletions as well as five polymorphisms namely: rs7482144 C > T at HBG2, rs1427407 G > T and rs10189857 A > G at BCL11A, and rs28384513 A > C and rs9399137 T > C at HMIP. The enrolled patients had a median age of 14 years, with 96 males and 128 females. They included 144 thalassemia major, and 80 thalassemia intermedia patients. Multivariate logistic regression analysis revealed that a model including sex and four of these genetic modifiers, namely: β+ alleles, HBG2 rs7482144, α-thalassemia deletions, and BCL11A rs1427407 could significantly predict phenotype (major versus intermedia) with an overall accuracy of 83.9%. Furthermore, a log odds genetic score based on these significant predictors had a highly significant area under curve of 0.917 (95% CI 0.882-0.953). This study underscores the notion that genetic scoring systems should be tailored to populations in question, since genetic modifiers (and/or their relative weight) vary between populations. The population-oriented genetic scoring system created by the current study to predict β-thalassemia phenotype among Iraqis may pave the way to personalized medicine in this patient's group.

Evaluation of Olfactory Dysfunction Among COVID-19 Patients in Baghdad, Iraq

Background SARS‑CoV‑2 (COVID-19) causes olfactory dysfunction which is characterized by anosmia or hyposmia. Characterization of olfactory dysfunction has added value to the diagnosis and prognosis of the disease. Nevertheless, scarce information exists about COVID-19 patients suffering from olfactory dysfunction in Iraq. This study aimed to identify olfactory dysfunction (anosmia or hyposmia) in Iraqi COVID-19 patients and examine their response to smell exercise at Baghdad Medical City Complex, Baghdad, Iraq. Methodology This case series prospective study involving 300 patients (160 males and 140 females) with COVID-19 infection was conducted from June 1, 2020, to October 1, 2021. We recorded signs and symptoms of COVID-19 among patients by examining olfactory dysfunction, n-butanol olfaction test, and smell test exercise. Results Anosmia and hyposmia were found in 69.3% and 30.7% of the patients, respectively; of these, 65.7% were of sudden onset. The association between olfactory dysfunction and smoking was not significant. The most frequent signs and symptoms of COVID-19 were fatigue, fever, loss of taste, myalgia, headache, sore throat, cough, depressed appetite, dyspnea, nausea, abdominal pain, and diarrhea. The highest frequencies of occurrence of anosmia (30.7%) and hyposmia (13.3%) were in the age group of 31-40 years. The majority (47.7%) of patients with olfactory dysfunction recovered within one month of COVID-19 onset. The rest of the patients recovered within one month to 16 months. The most commonly encountered ear, nose, and throat symptoms were nasal obstruction, rhinorrhea, and facial/ear pain. The percentages of patients with anosmia and hyposmia recovering with smell exercise were significant at 64.7% and 25.3%, respectively. Conclusions The prognosis of olfactory dysfunction in COVID-19 patients was good as most cases recovered within a short period with concomitant smell exercise. Olfactory dysfunction in the majority of COVID-19 patients was self-limiting in young age groups, albeit in association with the non-severity of the disease. Being an important public health issue, examining olfactory dysfunction aspects should be considered in the diagnosis, prognosis, and treatment protocols of COVID-19 patients. In-depth exploration is needed to examine olfactory and gustatory dysfunction in patients suffering from severe COVID-19.

Risk Stratification of Differentiated Thyroid Cancer: A Single-Center Study in Basrah

Background Differentiated thyroid cancer is a common endocrine cancer; most of it has an indolent course and favorable outcomes, with a subset of patients having the risk of disease recurrence, which can be assessed using the fixed American Thyroid Association (ATA) risk stratification system or the dynamic response to therapy risk stratification that can be modified during patients follow-up. Aim The aim of this article is to assess the risk stratification of patients having differentiated thyroid cancer. Methods This is a retrospective cross-sectional study in which we evaluated medical records of 75 patients having differentiated thyroid cancer to assess the baseline ATA risk of recurrence and compared it to the results of dynamic risk stratification in response to therapy at 6-12 months post-surgery and at the last visit. Thyroglobulin level, anti-thyroglobulin antibody, thyroid ultrasound, and cytopathological examination were used to determine dynamic response to therapy and divided subjects into four groups: excellent response (ER), biochemical incomplete response (BIR), structural incomplete response (SIR), and indeterminate response (IR). Results At baseline, 55 patients had low risk, 14 patients had intermediate risk, and six patients had high risk. At 6-12 months post-surgery, in the low-risk group, ER, BIR, and IR responses were observed in 56.4%, 5.5%, and 38.2% of patients, respectively, and none of them exhibited SIR. In the intermediate-risk group, ER, BIR, and IR responses were observed in 57.1%, 21.4%, and 21.4% of patients, respectively, and none exhibited SIR. Among the high-risk group, two patients had ER, two patients had BIR, one patient had IR, and one patient had SIR. At the last visit, ER, BIR, and IR were observed in 65.5%, 9.1%, and 25.5% of low-risk patients, respectively, and no patient developed SIR. In the intermediate-risk group, ER, BIR, and IR were observed in 50%, 21.4%, and 28.6% of patients, respectively, and no patients developed SIR. Among the high-risk group, three patients achieved ER, one had BIR, one had IR, and one had SIR. Conclusion Most of the differentiated thyroid cancers in this study are low-risk. Dynamic risk stratification appears to be an effective tool in the follow-up of this population of patients having differentiated thyroid cancer.

Cut-Off Value of Thyrotropin-Receptor Antibodies in Grave's Disease in Basrah

BACKGROUND

The diagnosis of Grave's disease (GD) poses a challenge. Thyrotropin-receptor antibodies (TRAb) are the key diagnostic feature of GD, as the American and European Thyroid Associations suggested.

AIM OF THE STUDY

This study aims to find a cut-off level of TRAb in GD in Basrah.

METHODS

This is a retrospective study that included 617 patients with hyperthyroidism (530 GD and 87 non-Grave's disease (NGD) (thyroiditis or subclinical hyperthyroidism)). The candidates were patients presenting with hyperthyroidism who were referred for TRAb assay, while patients with thyroid carcinoma or nodular thyroid disease, pregnant ladies, and patients who were treated were excluded.

RESULTS

The manufacturer cut-off value of 1.75 IU/L had a sensitivity of 88.1%, specificity of 72.4%, positive predictive value (PPV) of 95.1%, and negative predictive value (NPV) of 50.0%. Our data analysis through receiver operating characteristic (ROC) statistics revealed that the optimum cut-off point with the highest total sensitivity and specificity was determined to be 3.95 IU/L, as it had a sensitivity of 76.9%, specificity of 98.8%, PPV of 99.7%, NPV of 41.3%.

CONCLUSION

For a more accurate diagnosis of GD, the findings of the present study support the implementation of a higher TRAb cut-off value (3.95 IU/L) than that predefined by the manufacturer (1.75 IU/L).

Gross Hematuria and Lower Urinary Tract Symptoms Associated With Military Burn Pits Exposures in US Veterans Deployed to Iraq and Afghanistan

OBJECTIVE

The aim of the study is to describe rates of hematuria and other lower urinary tract symptoms, including self-reported cancer rates, among veterans postburn pits emissions exposure during deployment to Iraq and Afghanistan.

METHODS

US post-9/11 veterans with burn pits emissions exposure confirmed via DD214 forms in the Burn Pits360.org Registry were sent a modified survey. Data were deidentified and anonymously coded.

RESULTS

Twenty-nine percent of the 155 respondents exposed to burn pits self-reported seeing blood in their urine. The average index score of our modified American Urological Association Symptom Index Survey was 12.25 (SD, 7.48). High rates of urinary frequency (84%) and urgency (76%) were self-reported. Bladder, kidney, or lung cancers were self-reported in 3.87%.

CONCLUSIONS

US veterans exposed to burn pits are self-reporting hematuria and other lower urinary tract symptoms.

Epidemiology of Migraines in Iraqi Females: Emphasis on Dietary Influence

Introduction  Migraine is a neurological condition that frequently results in a severe headache. The headache comes in episodes and is occasionally accompanied by nausea, vomiting, and sensitivity to light. Migraines can be caused by a variety of conditions and can last anywhere from three to four hours to several days, with females experiencing them three times more frequently than men. Studies have found some evidence that lifestyle variables, such as nutrition, may play an important role in the emergence of migraines. The purpose of this research is to determine the epidemiology of migraine among females with an emphasis on the relationship between headaches and the dietary habits of females who are enduring migraine attacks in Iraq. Methods This study is descriptive research employing a quantitative method, specifically a survey. The data collection process involved a three-section online survey disseminated to females through internet platforms, including WhatsApp, Viber, Facebook, and Instagram. In this research, 360 females from Sulaymaniyah, Iraq, aged 18 to 35, participated. The survey's primary questions centered on the characteristics of the female respondents, drawing from the International Headache Society (IHS) criteria for migraine diagnosis. Participants meeting the migraine diagnostic criteria were also asked a few questions about aura symptoms. The Migraine Disability Assessment (MIDAS) questionnaire was incorporated, accompanied by inquiries about headache treatment, headache-related signs and symptoms, headache triggers, factors that relieve headaches, sleep routines, dietary consumption, and the impact of each factor on migraines. Results Of the 360 females who participated in the study, 159 (44.2%) experienced migraines, while 201 (55.8%) did not. The dietary habits of females who experienced migraines showed a statistically significant relationship to the duration of their headaches, specifically those lasting from 4 to 72 hours. This relationship was particularly evident in relation to nuts (p-value= 0.000), hot/spicy foods (p-value= 0.000), tomatoes (p-value= 0.005), bananas (p-value=0.01), aspartame (p-value=0.012), beverages containing caffeine (p-value=0.000), and citrusy fruits (p-value=0.008). These findings are based on p-values less than the commonly accepted alpha of 0.05. To maintain good health, it's essential to adhere to healthy eating habits and proper nutritional guidelines. Further research is necessary to identify additional dietary triggers for migraines. Enhancing data collection methods, such as using face-to-face interviews, could improve the quality of future research. Conclusion This study determined the prevalence of migraines among a sample of females in Sulaymaniyah, Iraq, and identified various foods consumed in excess by females without considering their potential impact on migraines.

Age-Related Variations in Serum Zinc Levels Among Female Patients in Sulaymaniyah, Iraq: Implications for Addressing Zinc Deficiency

Background Zinc plays a crucial role in human nutrition and various biochemical processes, making it indispensable for all life forms. Therefore, it is important to address low zinc levels, particularly among women, to prevent potential health issues. Objective This study aimed to evaluate the serum zinc levels of female patients in Sulaymaniyah, Iraq. Methods This retrospective cross-sectional study included a total of 299 patients, ranging in age from 16 to 48 years, who sought medical care at Baxshin Hospital in Sulaymaniyah Governorate, Iraq, between October 2022 and April 2023. The biochemical test was conducted to screen the patient's blood samples for serum zinc levels. Results Among 299 patients, 99 individuals had low zinc levels, 11 had high zinc levels, and 189 exhibited normal zinc levels. The analysis revealed a significant difference between low, normal, and high serum zinc levels, as evidenced by a p-value of <0.05. In terms of age-related variations, individuals under 20 years old had an average serum zinc level of 121.4 µg/dL. However, those between 21 and 30 years old demonstrated the highest average serum zinc level of 153.6 µg/dL, followed by 135 µg/dL for individuals aged 31-40, and 119 µg/dL for those above 40 years old. Conclusion These findings indicate that serum zinc levels may vary based on the age group of individuals. Consequently, further research is needed to explore the implications of these variations and establish appropriate strategies to address zinc deficiency among women in Sulaymaniyah.

Rates of the Trans-radial Approach in Elective and Emergency Coronary Angiography in Iraq: A Cross-Sectional Study

Background and aims The trans-radial access is becoming the default approach in many cardiac centers worldwide. Data from the Middle East, including Iraq, on the trends and rates of the use of trans-radial access are scarce. The aim of this study is to determine the rates of trans-radial approach (TRA) versus transfemoral approach (TFA) in patients with coronary artery syndromes undergoing coronary angiography and/or percutaneous coronary intervention (PCI) in Iraq. Methods In this multicenter prospective study, we collected 885 cases of coronary artery disease undergoing coronary angiography/PCI from three main cities of the Kurdistan Region in Iraq from 2022 to 2023. Results Of the total sample, 57.2% were diagnostic coronary angiography and 42.8% were PCI, 57.1% of all cases were TFA and 42.9% were TRA, and 64.3% of PCI cases were performed through TFA. Eghty-two percent of total emergency PCI included (primary PCI) cases underwent the procedure through the TFA, and only 18% of such cases were through the TRA. The overall crossover rate between both approaches happened in 14 (3.6%) cases. Conclusions Despite its main benefits, the radial access use in the Cath lab is yet underused in our region. Further steps in training programs are indicated to popularize the use of radial access among interventional cardiologists in addition to transfemoral access.

Identification of SARS CoV‐2 Omicron BA.1 and a novel Delta lineage by rapid methods and partial spike protein sequences in Sulaymaniyah Province, Iraq

Background

Five variants of concern (VOCs) of severe acute respiratory syndrome coronavirus 2 (SARS CoV‐2) have been globally recorded including Alpha, Beta, Gamma, Delta, and Omicron. The Omicron variant has outcompeted the other variants including the Delta variant. Molecular screenings of VOCs are important for surveillance, treatment, and vaccination programs. This study aimed to identify VOCs by using rapid inexpensive methods and partial sequencing of the virus's spike gene.

Methods

Mutation‐specific rRT PCR probes were used for both D614G and K417N mutations to potentially discriminate between Delta and Omicron variants. These were followed by sequencing of a fragment of spike gene (748 nucleotides), which covers the most notable VOC mutations in the receptor binding domain of SARS CoV‐2.

Results

Rapid methods showed that out of 24 SARS CoV‐2 positive samples, 19 carried the N417 mutation, which is present in the Omicron variant. Furthermore, 3 samples carried K417 wildtype, which is present in the Delta variant. Additionally, 2 samples containing both K417 and N417 suggested mixed infections between the two variants. The D614G mutation was present in all samples. Among the 4 samples sequenced, 3 samples carried 13 mutations, which are present in Omicron BA.1. The fourth sample contained the two common mutations (T478K and L452R) present in Delta, in addition to two more rare mutations (F456L and F490S), which are not commonly seen in Delta. Our data suggested that both Omicron variant BA.1 and a novel Delta variant might have circulated in this region that needs further investigations.

Development of the First Health-Related Quality of Life Questionnaires in Arabic for Women With Polycystic Ovary Syndrome (Part III): Scoring System Interpretation

BACKGROUND

Our team developed the first highly reliable, validated, easily comprehensible, and self-administered polycystic ovary syndrome quality of life (PCOSQOL)-42 and PCOSQOL-47 questionnaires for unmarried and married women with polycystic ovary syndrome (PCOS), respectively. Using such scales needs a scoring system that covers the responses to each item per domain and overcomes the missing responses. we developed a scoring system for PCOSQOL-42 and PCOSQOL-47 to interpret the items' responses at any similar population.

METHODS

The scoring was inspired by the 5-point Likert scale that was used during the creation of PCOSQOL-42 and PCOSQOL-47, where each item represents the woman's experience in the last two weeks before seeking consultation, i.e., Never=5 or no effect, on the health-related quality of life (HRQOL), (Seldom=4), (Quite often=3), (Very often=2), and (Always=1 or the maximal effect on the QOL). The sum of the total points in each item per domain was evaluated. Then we divided the results by the number of the items that had been scored only to get the final domain score as a (mean ± SD). The ultimate or final score per the questionnaire was gained from the sum of individual domain scores divided by the number of domains that had been evaluated. Ultimately, the first interval values (from 1 to < 3 points) represent marked effects on HRQOL; second interval values (from 3 to < 4 points) represent the marginal effect on HRQOL; third interval values (from 4 to < 5 points) represent the minimal effect on HRQOL; fourth interval (5 points) represents no effect on HRQOL.

RESULTS

The lower the score, the greater the negative impact on HRQOL. Although all domains in both questionnaires showed a marked reduction in HRQOL, women in either cohort were more concerned with their body image dissatisfaction and psychological distress induced by PCOS than their reproductive concerns. The mean score calculated for the questionnaire had a greater negative impact than the emotions subscale and was similar to the subscale for infertility. All mean points per item and domain values indicate a marked effect (< 3 points) on QOL using PCOSQOL-42 and PCOSQOL-47. All values referred to a marked reduction in PCOSQOL-47 points, whether item or domain-wise.

CONCLUSIONS

The current scoring system provides an easy way to interpret the responses in both questionnaires and overcome the missing responses in any item per domain. There was a marked impact on all domains of HRQOL using both questionnaires, with a special impact on body image and psychological concerns. The responses of women in either cohort to the sexual and reproductive items were extremely high, reflecting the scope of this problem in the life of women with PCOS.

Pseudo-pheochromocytoma due to obstructive sleep apnea: a case report

SUMMARY

Obstructive sleep apnea (OSA) is a condition of intermittent nocturnal upper airway obstruction. OSA increases sympathetic drive which may result in clinical and biochemical features suggestive of pheochromocytoma. We present the case of a 65-year-old male with a 2.9-cm left adrenal incidentaloma on CT, hypertension, symptoms of headache, anxiety and diaphoresis, and persistently elevated 24-h urine norepinephrine (initially 818 nmol/day (89-470)) and normetanephrine (initially 11.2 µmol/day (0.6-2.7)). He was started on prazosin and underwent left adrenalectomy. Pathology revealed an adrenal corticoadenoma with no evidence of pheochromocytoma. Over the next 2 years, urine norepinephrine and normetanephrine remained significantly elevated with no MIBG avid disease. Years later, he was diagnosed with severe OSA and treated with continuous positive airway pressure. Urine testing done once OSA was well controlled revealed complete normalization of urine norepinephrine and normetanephrine with substantial symptom improvement. It was concluded that the patient never had a pheochromocytoma but rather an adrenal adenoma with biochemistry and symptoms suggestive of pheochromocytoma due to untreated severe OSA. Pseudo-pheochromocytoma is a rare presentation of OSA and should be considered on the differential of elevated urine catecholamines and metanephrines in the right clinical setting.

LEARNING POINTS

Obstructive sleep apnea (OSA) is a common condition among adults. OSA may rarely present as pseudo-pheochromocytoma with symptoms of pallor, palpitations, perspiration, headache, or anxiety. OSA should be considered on the differential of elevated urine catecholamines and metanephrines, especially in patients with negative metaiodobenzylguanidine (MIBG) scan results.

Gastrointestinal Endoscopic Outcome in Late Adolescent Women With Iron-Deficiency Anemia in Basrah-Iraq: A Multicenter Study

Background

Iron deficiency anemia (IDA) in late adolescent women has multiple pathophysiologies. Silent blood loss, celiac disease (CD), malignancies, and other gastrointestinal (GI) lesions receive much attention during IDA management. There is no consensus about endoscopic screening. Our study evaluates factors affecting GI endoscopic diagnosis for the etiology of IDA in late adolescent women.

Materials and Methods

We conducted an observational, multicenter retrospective analysis of 192 adolescent women with IDA admitted for GI endoscopic diagnosis from 2006 to 2016. Baseline measurements included hemoglobin, serum ferritin, mean corpuscular volume, serum iron, total iron-binding capacity, and transferrin saturation. We collected demographic characteristics, duration of hospital stay, the degree of severity of anemia, and endoscopic findings.

Results

The mean age was 19±1 years (range 17 to 21 years), with mildly to moderately severe IDA. Patients received esophagogastroduodenoscopy (EGD, n=178) or colonoscopy (n=14). The mean hospital stay was 2.0±1.0 days. We found negative endoscopies (n=74), CD (n=85), gastric ulcer (n=19), malignancy (n=2), inflammatory bowel disease (n=1), and other nonsignificant endoscopic findings (n=11). We found no correlation between the duration of the hospital stay with the severity of IDA, no significant association between GI symptoms of the patients with endoscopic findings, and a significant but weak association between GI symptoms and serum ferritin.

Conclusions

In late adolescent women with IDA who have significant GI endoscopic lesions, the GI symptoms are of limited value in guiding the endoscopic diagnostic approach for evaluation of IDA.

Basrah Preliminary Experience With COVID-19: A Report on 6404 Patients

Background: The first case of coronavirus disease 2019 (COVID-19) reported in Basrah was in early March 2020. This study aimed at assessing some of the characteristics of patients with COVID-19 in Basrah during the period from March 4th to September 8th, 2020.

Methods: Retrospective analysis of the University of Basrah database on COVID-19. All patients with positive COVID-19 reverse transcription polymerase chain reaction (RT-PCR) test during the study period were enrolled.

Results: Of 6404 patients included (males 54.8% and females 45.2%), healthcare workers constituted 11.4%. Physicians represented 16.1% of health care workers. The mean age was 39±16.7 years, those aged 61 years or more constituted 9.8%. The case fatality rate was 3% (males 55.2% and females 44.8%). No deaths were reported in adolescents or children. The highest death rate was among those aged 61 years or more.

Conclusion: The situation of COVID-19 infection in Basrah, Iraq is evolving similar to other countries. Studies are needed to assess the influence of associated comorbidities, results of treatment regimens used and variables associated with high mortality.

Clinical Descriptive Study of Masturbatory Behavior Among Infants and Preschool Children: A Recent Observation From Iraq

BACKGROUND

Pleasurable feelings are normal human behaviors experienced not only by adults but even in infancy and childhood. These feelings might become habitual behavior in form of masturbation.

OBJECTIVE

To evaluate the clinical criteria of infants and preschool children with masturbation habits who were described by parents as having unremitted genital pruritus.

PATIENTS AND METHODS

This is a case-series study describing cases of children with masturbation referred to the Department of Dermatology at Baghdad Medical City and Basra Teaching Hospital, central and southern Iraq, for four years (2014-2018). Children and their parents were carefully interrogated including detailed information about the problem. Local and general examinations were performed. Children with obvious genital lesions and those who proved to have urinary or gastrointestinal problems were not included.

RESULTS

Forty-four children with masturbation were enrolled in the study (22 females and 22 males). The only reason for referral was unremitted genital pruritus. The mean age was 3.6 years. The frequency of masturbation events was variable; the mean length of events was 5 minutes. In 80% of children, masturbation happened at any time. Behavior during the event was prone or supine posturing with rubbing of the genital area with either hands or furniture followed by facial congestion, sweating, and sleep. The majority of children (68%) belonged to low social class families.

CONCLUSION

 Masturbatory behavior is not uncommon in infants and preschool children and may mimic episodes of ongoing genital pruritus.

A multicentre point prevalence survey of hospital antibiotic prescribing and quality indices in the Kurdistan regional government of Northern Iraq: the need for urgent action

BACKGROUND

Rationale antibiotic use is crucial to address antimicrobial resistance (AMR) threats. No study has been undertaken in the Kurdistan Regional Government (KRG) to document current antibiotic use/areas for improvement given the high AMR rates.

RESEARCH DESIGN AND METHODS

Point prevalence survey (PPS), using the Global PPS methodology, was conducted among the three major public hospitals in KRG/northern Iraq from September-December 2019. Prevalence and quality of antibiotic use were assessed using agreed indicators.

RESULTS

Prevalence of antibiotic use was high (93.7%; n = 192/205); third-generation cephalosporins were the most commonly prescribed antibiotics (52.6%; n = 140/266). Reasons for treatment were recorded for only 61.7% (n = 164/266) of antibiotics and high use (89.9%) of parenteral therapy was observed. All therapy was empirical, no stop/review dates were recorded, and no treatment guidelines were available. The majority of the prescribed antibiotics (62%; n = 165/266) were from the WHO Watch list.

CONCLUSION

Prevalence of antibiotic use was high not only versus other hospitals in the region but globally, coupled with significant evidence of sub-optimal prescribing. Swift action is needed to improve future prescribing to reduce AMR. One or two areas should initially be targeted for quality improvement including development of local guidelines, documentation of antibiotic indications, and/or stop/review dates.

Rux largely restores lungs in Iraq PM-exposed mice, Up-regulating regulatory T-cells (Tregs)

Background Military personnel post-deployment to Iraq and Afghanistan have noted new-onset respiratory illness. This study's primary objective was to further develop an animal model of Iraq Afghanistan War Lung Injury (IAW-LI) and to test a novel class of anti-injury drug called RuX. Methods Particulate Matter (PM) samples were obtained in Iraq then characterized by spectromicroscopy. C57BL/6 mice underwent orotracheal instillation with PM, followed by drinkable treatment with RuX. Lung histology, inspiratory capacity (FlexiVent), thymic/splenic regulatory T cell (Treg) number, and whole-lung genomics were analyzed. Results Tracheal instillation of Iraq PM led to lung septate thickening and lymphocytic inflammation. PM-exposed mice had suppression of thymic/splenic regulatory T-cells (Tregs). Drinking RuX after PM exposure attenuated the histologic lung injury response, improved lung inspiratory capacity, and increased Tregs. Pooled whole lung genomics suggest differences among gene expression of IL-15 among control, PM, and PM + RuX groups. Conclusions RuX, a ruthenium and alpha-lipoic acid complex, attenuates lung injury by improving histology and inspiratory capacity via upregulation of Tregs in Iraq PM-exposed C57BL/6. Plausible genomic effects may involve IL-15 whole lung gene expression.

Descriptive analysis of the medical care performed in the Spanish military Role 1 Medical Treatment Facility deployed in Operation 'Inherent Resolve' (Iraq), 2015-2016

INTRODUCTION

Operation 'Inherent Resolve' was approved by the United Nations in August 2014 with the objective of suppressing the Islamic State in Iraq and the Levant and increasing the region's stability. The mission of the Spanish military forces within this was to direct training missions for the Iraqi Army. The aim of this study is to analyse the medical care provided in the Spanish Role 1 deployed medical treatment facility during Operation 'Apoyo a Irak'.

METHODS

A cross-sectional, descriptive and retrospective study was conducted between 15 December 2015 and 18 November 2016. The study population comprised all personnel treated at the Spanish Role 1 medical treatment facility of the 'Gran Capitan' base in Besmaya, Iraq.

RESULTS

During the study period, a total of 2208 consultations were performed, 1547 of which were first consultations. The predominant type of medical care was categorised as 'traumatology' (n=438; 19.8%), followed by 'healing of wounds and minor surgical processes' (n=332; 15%), 'acute upper respiratory tract infections' (n=267; 12%), 'dermatology' (n=214; 9.6%) and 'gastroenterology' (n=214; 9.6%). Twenty-eight patients (1.2%) required care in the upper medical echelon of care, three of whom were urgently evacuated. Oral diseases were the main reason for evacuation to the next medical echelon. Four patients were repatriated to the national territory for medical reasons. One death was recorded due to a vehicle accident.

CONCLUSIONS

The results of our study reinforce those found in similar recent international missions in which the Spanish Armed Forces and other allied armies have deployed a Role 1 medical treatment facility. Military physicians deploying on operations such as Iraq should have up-to-date training in emergency and primary care medicine, with special emphasis on basic trauma knowledge and performing minor surgical processes.

Serological and molecular detection of bovine leukemia virus in cattle in Iraq

Bovine leukemia virus (BLV) is highly endemic in many countries, including Iraq, and it impacts the beef and dairy industries. The current study sought to determine the percentage of BLV infection and persistent lymphocytosis (PL) in cattle in central Iraq. Hematological, serological, and molecular observations in cross breeds and local breeds of Iraqi cattle naturally infected with BLV were conducted in the peripheral blood mononuclear cells of 400 cattle (340 cross breed and 60 local breed) using enzyme-linked immunosorbent assay and polymerase chain reaction (PCR). On the basis of the absolute number of lymphocytes, five of the 31 positive PCR cases had PL. Among these leukemic cattle, one case exhibited overt neutrophilia. Serum samples were used to detect BLV antibodies, which were observed in 28 (7%) samples. PCR detected BLV provirus in 31 samples (7.75%). All 28 of the seropositive samples and the 3 seronegative samples were positive using PCR. Associations were observed between bovine leukosis and cattle breed, age and sex. Age-specific analysis showed that the BLV percentage increased with age in both breeds. Female cattle (29 animals; 7.34%) exhibited significantly higher infectivity than male cattle (two animals; 4.34%). In conclusion, comprehensive screening for all affected animals is needed in Iraq; programs that segregate cattle can be an effective and important method to control and/or eliminate the BLV.

Community-based mental health treatments for survivors of torture and militant attacks in Southern Iraq: a randomized control trial

BACKGROUND

Systematic violence is a long-standing problem in Iraq. Research indicates that survivors often experience multiple mental health problems, and that there is a need for more rigorous research that targets symptoms beyond post-traumatic stress (PTS). Our objective was to test the effectiveness of two counseling therapies in Southern Iraq in addressing multiple mental health problems among survivors of systematic violence: (1) a transdiagnostic intervention (Common Elements Treatment Approach or CETA); and (2) cognitive processing therapy (CPT). The therapies were provided by non-specialized health workers since few MH professionals are available to provide therapy in Iraq.

METHODS

This was a randomized, parallel, two site, two-arm (1:1 allocation), single-blinded, wait-list controlled (WLC) trial of CETA in one site (99 CETA, 50 WLC), and CPT in a second site (129 CPT, 64 WLC). Eligibility criteria were elevated trauma symptoms and experience of systematic violence. The primary and secondary outcomes were trauma symptoms and dysfunction, respectively, with additional assessment of depression and anxiety symptoms. Non-specialized health workers (community mental health worker, CMHW) provided the interventions in government-run primary health centers. Treatment effects were determined using longitudinal, multilevel models with CMHW and client as random effects, and a time by group interaction with robust variance estimation, to test for the net difference in mean score for each outcome between the baseline and follow up interview. Multiple imputation techniques were used to account for missingness at the item level and the participant level. All analyses were conducted using Stata 12.

RESULTS

The CETA intervention showed large effect sizes for all outcomes. The CPT intervention showed moderate effects sizes for trauma and depression, with small to no effect for anxiety or dysfunction, respectively.

CONCLUSIONS

Both CETA and CPT appear to benefit survivors of systematic violence in Southern Iraq by reducing multiple mental health symptoms, with CETA providing a very large benefit across a range of symptoms. Non-specialized health workers were able to treat comorbid symptoms of trauma, depression and anxiety, and dysfunction among survivors of systematic violence who have limited access to mental health professionals. The trial further supports the use of evidence-based therapies in lower-resource settings.

TRIAL REGISTRATION AND PROTOCOL

This trial was registered at ClinicalTrials.gov on 16 July 2010 with an identifier of NCT01177072 as the Study of Effectiveness of Mental Health Interventions among Torture Survivors in Southern Iraq. The study protocol can be downloaded from the following website: http://tinyurl.com/CETA-Iraq-Protocol . In the protocol, the CETA intervention is given a different name: components-based intervention or CBI.

A randomized controlled trial of mental health interventions for survivors of systematic violence in Kurdistan, Northern Iraq

BACKGROUND

Experiencing systematic violence and trauma increases the risk of poor mental health outcomes; few interventions for these types of exposures have been evaluated in low resource contexts. The objective of this randomized controlled trial was to assess the effectiveness of two psychotherapeutic interventions, Behavioral Activation Treatment for Depression (BATD) and Cognitive Processing Therapy (CPT), in reducing depression symptoms using a locally adapted and validated version of the Hopkins Symptom Checklist and dysfunction measured with a locally developed scale. Secondary outcomes included posttraumatic stress, anxiety, and traumatic grief symptoms.

METHODS

Twenty community mental health workers, working in rural health clinics, were randomly assigned to training in one of the two interventions. The community mental health workers conducted baseline assessments, enrolled survivors of systematic violence based on severity of depression symptoms, and randomly assigned them to treatment or waitlist-control. Blinded community mental health workers conducted post-intervention assessments on average five months later.

RESULTS

Adult survivors of systematic violence were screened (N = 732) with 281 enrolled in the trial; 215 randomized to an intervention (114 to BATD; 101 to CPT) and 66 to waitlist-control (33 to BATD; 33 to CPT). Nearly 70% (n = 149) of the intervention participants completed treatment and post-intervention assessments; 53 (80%) waitlist-controls completed post-intervention assessments. Estimated effect sizes for depression and dysfunction were 0.60 and 0.55 respectively, comparing BATD participants to all controls and 0.84 and 0.79 respectively, compared to BATD controls only. Estimated effect sizes for depression and dysfunction were 0.70 and 0.90 respectively comparing CPT participants to all controls and 0.44 and 0.63 respectively compared to CPT controls only. Using a permutation-based hypothesis test that is robust to the model assumptions implicit in regression models, BATD had significant effects on depression (p = .003) and dysfunction (p = .007), while CPT had a significant effect on dysfunction only (p = .004).

CONCLUSIONS

Both interventions showed moderate to strong effects on most outcomes. This study demonstrates effectiveness of these interventions in low resource environments by mental health workers with limited prior experience.

TRIAL REGISTRATION

ClinicalTrials.Gov NCT00925262 . Registered June 3, 2009.

Echocardiographic evaluation of thalassemia intermedia patients in Duhok, Iraq

BACKGROUND

Cardiac complications are among the most serious problems of thalassemia intermedia patients. The current study was initiated to address the latter issue through the study of the echocardiographic findings and correlate it with clinical characteristics of thalassemia intermedia patients in Duhok, Kurdistan region, Iraq.

METHODS

An echocardiographic assessment of 61 beta-thalassemia intermedia cases was performed. It included 30 males and 31 females, with a mean age 19.6 ± 7.5 years. The standard echostudy of two-dimension and M-mode measurements of cardiac chambers were done. The continuous doppler regurgitant jet of tricuspid and pulmonary valves were recorded. Left ventricle diastolic function was assessed by pulsed doppler of mitral valve inflow. To correlate the clinical with echocardiographic findings, patients were divided, according to tricuspid regurgitant velocity, into three groups (<2.5 m/sec, 2.5-2.9 m/sec and ≥3 m/sec).

RESULTS

Tricuspid regurgitant velocity <2.5 m/sec, 2.5-2.9 m/sec and ≥3 m/sec occurred in 42(69%), 11(18%) and 8(13%) respectively. Comparing to other groups patients with tricuspid regurgitant velocity ≥3 m/sec were older and included more males. They had lower hemoglobin levels, but higher ferritin levels. Their age at diagnosis and the age of the initiation of blood transfusion were later. Most of them had significant exertional dyspnea. They also had relatively lower left ventricle ejection fraction values. Right ventricular diameter and right atrial size were larger in the same group. Tricuspid regurgitant velocity as a continuous predictor was associated positively with age, cardiac volumes and pulmonary regurgitation though negatively associated with ejection fraction.

CONCLUSIONS

Echo-derived right and left side cardiac complications are not uncommon in thalassemia intermedia patients. Therapeutic trails targeting these complications are indicated, and echocardiographic assessment is necessary to be offered early for thalassemia intermedia.

Maternal obesity and its relation with the cesarean section: a hospital based cross sectional study in Iraq

BACKGROUND

Obesity during pregnancy is reported in approximately one in five pregnant women worldwide. It increases the risk of pregnancy complications many of which necessitate Cesarean section (CS). This study determines the association between obesity and type of delivery.

METHODS

A cross-sectional study involving 404 pregnant women was carried out at Al-Yarmouk Teaching Hospital, Baghdad, Iraq. Women with hypertension, diabetes, preterm labor, fetal presentation other than cephalic presentation and multiple gestations were excluded from the study. BMI and past obstetric history were recorded.

RESULTS

The overall rate of CS was 38%. The overall mean body mass index (BMI) was 25.0 ± 4.52 Kg/m2 and it was significantly higher among women who delivered by cesarean section. Significantly high rate of CS was found in primigravida and multigravida women with high BMI. Moreover, all obese multigravid women with history of previous CS were delivered by CS. The rate of CS was higher in women with primary level education when compared to women with secondary or tertiary education. CS was significantly lower in women with a previous history of abortion.

CONCLUSION

Obese women with or without a previous history of CS are at a higher risk of having a CS and should therefore be considered as high risk and managed appropriately during pregnancy. Weight management prior to or during pregnancy could help reduce the need for CS.

Iraq dust is respirable, sharp, and metal-laden and induces lung inflammation with fibrosis in mice via IL-2 upregulation and depletion of regulatory T cells

OBJECTIVES

Determine whether surface dust grab samples taken from a large military base in Iraq are toxic and respirable.

METHODS

X-ray diffraction for mineral content, x-ray fluorescence for elemental content, in vivo mouse dust challenges for assessment of histological changes, bronchoalveolar lavage for cytokines, polarizing light microscopy for crystals in lung tissue, and Fluorescence Activated Cell Sorting for cell surface and intracellular markers were utilized.

RESULTS

Camp Victory, Iraq dust taken during wartime contains respirable particles 2.5 microns in size, constituting particulate matter air pollution. Dust particles are angular and have sharp edges. Trace metals (including titanium) calcium and silicon are present. Mice with airway instillation of dust have polarizable crystals in lung and septate inflammation. Regulatory T cells (CD4⁺CD25⁺FOXP3⁺) are decreased in thymus and spleen. Interleukin-2 (IL-2) is upregulated in bronchoalveolar lavage.

CONCLUSIONS

Respirable Iraq dust leads to lung inflammation in mice similar to that seen in patients with polarizable crystals, which seem to be titanium.

Unusual trichobezoar of the stomach and the intestine: a case report

INTRODUCTION

Trichobezoars are an infrequent form of bezoar found in the stomach or intestine, created from ingested hair. This condition has been well described in the surgical literature, but less reported in psychiatry.

CASE PRESENTATION

We describe the case of an 18-year-old Middle Eastern Caucasian woman with trichotillomania who presented to our emergency department with a history of central abdominal pain associated with vomiting and constipation for five days. An examination showed a trichobezoar requiring emergent surgical intervention, and indicating the need for psychiatric treatment. The trichobezoar was treated successfully by laparotomy.

CONCLUSION

The medical and psychiatric sequelae of trichotillomania should not be underestimated, and early diagnosis and treatment is of utmost importance to save the patient's life and prevent recurrence. Although laparotomy is still considered an excellent option, pharmacotherapy and behavioral assessment play a useful role in patient management. Our case highlights the fundamental concept of a holistic approach rather than only treating the symptoms, by considering factors such as genetic influences to understand the disease.

Factors underlying inadequate parents' awareness regarding pediatrics immunization: findings of cross-sectional study in Mosul- Iraq

BACKGROUND

Since last 100 years, immunization rate is one of the best public health outcome and service indicators. However, the immunization system is still imperfect; there are many countries that still have unvaccinated children. Parental decisions regarding immunization are very important to improve immunization rate. The aim of this study is to evaluate the association between parental knowledge-practice (KP) regarding immunization with family and immunization providers' factors.

METHODS

This is a prospective cross-sectional study design. Immunization knowledge and practices among 528 Iraqi parents were evaluated through validated questionnaire. Familial data and immunization provider's characteristics were collected from parents through interview.

RESULTS

More than half of respondents/study population (66.1%) have adequate knowledge- practice scores. Significant associations were noted for knowledge-practice groups with father's education level, mother's education level, mother's age at delivery, number of preschool children, parents gender, family income, provider types, and birth place (p < 0.05).

CONCLUSION

Immunization campaigns and awareness are required to improve parents' knowledge and practice regarding immunization. The study results reinforce recommendations for use of educational programmes to improve the immunization knowledge and practice.

Are parents' knowledge and practice regarding immunization related to pediatrics' immunization compliance? a mixed method study

BACKGROUND

Immunization rate is one of the best public health outcome and service indicators of the last 100 years. Parental decisions regarding immunization are very important to improve immunization rate. The aim of this study was to evaluate the correlation between parental knowledge-practices (KP) and children's immunization completeness.

METHODS

A mixed method has been utilized in this study: a retrospective cohort study was used to evaluate immunization completeness; a prospective cross-sectional study was used to evaluate immunization KP of parents. 528 children born between 1 January 2003 and 31 June 2008 were randomly selected from five public health clinics in Mosul, Iraq. Immunization history of each child was collected retrospectively from their immunization record/card.

RESULTS

About half of studied children (n = 286, 56.3%) were immunized with all vaccination doses; these children were considered as having had complete immunization. 66.1% of the parents was found to have adequate KP scores. A significant association of immunization completeness with total KP groups (p < 0.05) was found.

CONCLUSIONS

Future efforts are required to improve immunization rate and parents' knowledge and practice. The study results reinforce recommendations for the periodic assessment of immunization rate and the use of educational programmes to improve the immunization rate, knowledge and practice.

Malnutrition among 3 to 5 years old children in Baghdad city, Iraq: a cross-sectional study

The unstable geopolitical situation in Iraq since 2003 still affects the health of people, especially children. Several factors may indirectly affect a child's nutritional status. The main aim of this study was to identify factors contributing to malnutrition among 3 to 5 years old children in Baghdad city, Iraq. Two hundred twenty children aged 3 to 5 years were chosen randomly from four kindergartens in Baghdad city according to the cross-sectional design. The nutritional status of the children was assessed using a weight-for-age z-score based on the World Health Organization 2007 cutoff points, in which any child with a z-score of <-2 is considered to be malnourished. The overall prevalence rate of underweight children was 18.2%. There was no significant difference in the prevalence rate between males and females (p=0.797). However, the percentage of underweight children was slightly higher among females (18.9%) compared to males (17.6%). There was no association between parents' educational level or employment status and childhood malnutrition. There was no association between a family's movement from their house and childhood malnutrition (p=0.322). Living in an unsafe neighbourhood and having a family member killed during the past five years were significantly associated with childhood malnutrition (p=0.016 and 0.018 respectively). Childhood malnutrition is still a public-health concern in Baghdad city, especially after the war of 2003. Malnutrition is significantly associated with living in unsafe neighbourhoods and at least one family member having been killed during the past five years.

Metal contamination and the epidemic of congenital birth defects in Iraqi cities

Between October 1994 and October 1995, the number of birth defects per 1,000 live births in Al Basrah Maternity Hospital was 1.37. In 2003, the number of birth defects in Al Basrah Maternity Hospital was 23 per 1,000 live births. Within less than a decade, the occurrence of congenital birth defects increased by an astonishing 17-fold in the same hospital. A yearly account of the occurrence and types of birth defects, between 2003 and 2011, in Al Basrah Maternity Hospital, was reported. Metal levels in hair, toenail, and tooth samples of residents of Al Basrah were also provided. The enamel portion of the deciduous tooth from a child with birth defects from Al Basrah (4.19 μg/g) had nearly three times higher lead than the whole teeth of children living in unimpacted areas. Lead was 1.4 times higher in the tooth enamel of parents of children with birth defects (2,497 ± 1,400 μg/g, mean ± SD) compared to parents of normal children (1,826 ± 1,819 μg/g). Our data suggested that birth defects in the Iraqi cities of Al Basrah (in the south of Iraq) and Fallujah (in central Iraq) are mainly folate-dependent. This knowledge offers possible treatment options and remediation plans for at-risk Iraqi populations.

The prevalence and correlates of intermittent explosive disorder in Iraq

OBJECTIVE

Intermittent explosive disorder is common, begins early in life, and is associated with considerable impairment in the United States. The epidemiology of IED outside the United States is unknown. We examined the prevalence and correlates of IED in Iraq, where exposure to violence has been widespread during the last three decades.

METHOD

Data were drawn from a national survey of the Iraq population, the Iraq Mental Health Survey (IMHS), conducted in 2006-2007. The WHO Composite International Diagnostic interview was used to assess DSM-IV disorders, including IED. The response rate was 95.2%.

RESULTS

Lifetime and 12-month prevalence estimates of IED were 1.7% and 1.5%. Mean age of onset was 18.5. The mean number of lifetime attacks was 141.6 attacks, and IED-related injuries occurred 61 times per 100 lifetime cases. IED was significantly comorbid with mood and anxiety, but not substance, disorders.

CONCLUSION

Although the prevalence of IED is lower in Iraq than in the United States, the disorder has an early age of onset, is highly persistent, and is associated with substantial comorbidity and functional impairment. Iraq lacks national policies or systematic programmes to reduce aggression, highlighting the importance of implementing violence prevention programmes to reduce the societal burden of violence in Iraq.

Post deployment care for returning combat veterans

Since September 11, 2001, 2.4 million military personnel have deployed to Iraq and Afghanistan. To date, roughly 1.44 million have separated from the military and approximately 772,000 of these veterans have used VA health care. Combat deployments impact the physical, psychological, and social health of veterans. Given that many veterans are receiving care from non-VA providers, it is important that all community health care workers be familiar with the unique health care needs of this patient population, which include injuries associated with blast exposures (including mild traumatic brain injury), as well as a variety of mental health conditions, such as post-traumatic stress disorder. Other important health concerns are chronic musculoskeletal pain, medically unexplained symptoms, sequelae of environmental exposures, depression, suicide, substance abuse, sleep disturbances, and impairments in family, occupational and social functioning. Elevated rates of hypertension and tobacco use remind us that deployment may result not only in immediate impacts on health, but also increase risk for chronic disease, contributing to a growing public health burden. This paper provides a comprehensive review of these health concerns and offers practical management guidelines for primary care providers. In light of relationships between physical, psychological and psychosocial concerns in this population, we recommend an interdisciplinary approach to care directed toward mitigating the long-term health impacts of combat.

Development and clinical evaluation of clotrimazole-β-cyclodextrin eyedrops for the treatment of fungal keratitis

Fungal keratitis is a serious corneal disease that may result in loss of vision. There are limited treatment options available in Iraqi eye hospitals which might be the main reason behind the poor prognosis of many cases. The purpose of this study was to prepare and pharmaceutically evaluate clotrimazole-β-cyclodextrin (CTZ-β-CD) eyedrops then clinically assess its therapeutic efficacy on fungal keratitis compared with extemporaneous amphotericin B eyedrops (0.5% w/v). A CTZ-β-CD ophthalmic solution was prepared and evaluated by various physicochemical, microbiological, and biological tests. The prepared formula was stable in 0.05 M phosphate buffer pH 7.0 at 40 ± 2°C and 75 ± 5% RH for a period of 6 months. Light has no significant effect on the formula's stability. The CTZ-β-CD eyedrops efficiently complied with the isotonicity, sterility, and antimicrobiological preservative effectiveness tests. Results of the clinical study revealed that 20 (80%) patients showed a favorable response to the CTZ-β-CD eyedrops, while 16 patients (64%) exhibited a favorable response to amphotericin B (P > 0.05). The mean course of treatment was significantly (P < 0.05) less in the CTZ treatment group than in the amphotericin group (21.5 ± 5.2 vs. 28.3 ± 6.4 days, respectively). The CTZ formulation was significantly (P < 0.05) more effective in the management of severe cases and also against Candida sp. than amphotericin B. There was no significant difference (P < 0.05) between both therapies against filamentous fungi. The CTZ-β-CD formulation can be used alternatively to other ophthalmic antimycotic treatment options in developing countries where stability, cost, or efficacy is a limiting factor.

Ten-year results from a time-cohort and trauma audit study in Iraq

BACKGROUND

Blunt implementation of Western trauma system models is not feasible in low-resource communities with long prehospital transit times. The aims of the study were to evaluate to which extent a low-cost prehospital trauma system reduces trauma deaths where prehospital transit times are long, and to identify specific life support interventions that contributed to survival.

METHODS

In the study period from 1997 to 2006, 2,788 patients injured by land mines, war, and traffic accidents were managed by a chain-of-survival trauma system where non-graduate paramedics were the key care providers. The study was conducted with a time-period cohort design.

RESULTS

37% of the study patients had serious injuries with Injury Severity Score ≥ 9. The mean prehospital transport time was 2.5 hours (95% CI 1.9 - 3.2). During the ten-year study period trauma mortality was reduced from 17% (95% CI 15 -19) to 4% (95% CI 3.5 - 5), survival especially improving in major trauma victims. In most patients with airway problems, in chest injured, and in patients with external hemorrhage, simple life support measures were sufficient to improve physiological severity indicators.

CONCLUSION

In case of long prehospital transit times simple life support measures by paramedics and lay first responders reduce trauma mortality in major injuries. Delegating life-saving skills to paramedics and lay people is a key factor for efficient prehospital trauma systems in low-resource communities.

Adolescent male with anorexia nervosa: a case report from Iraq

This is the first reported case of an adolescent male with anorexia nervosa in Iraq. This disorder is believed to be rare in males across cultures and uncommon for both genders in Arab countries. The patient met the DSM-IV diagnostic criteria for anorexia nervosa. He was hospitalized and received medical and psychiatric treatment at local facilities as discussed below and responded well to treatment.

Uranium and other contaminants in hair from the parents of children with congenital anomalies in Fallujah, Iraq

BACKGROUND

Recent reports have drawn attention to increases in congenital birth anomalies and cancer in Fallujah Iraq blamed on teratogenic, genetic and genomic stress thought to result from depleted Uranium contamination following the battles in the town in 2004. Contamination of the parents of the children and of the environment by Uranium and other elements was investigated using Inductively Coupled Plasma Mass Spectrometry. Hair samples from 25 fathers and mothers of children diagnosed with congenital anomalies were analysed for Uranium and 51 other elements. Mean ages of the parents was: fathers 29.6 (SD 6.2); mothers: 27.3 (SD 6.8). For a sub-group of 6 women, long locks of hair were analysed for Uranium along the length of the hair to obtain information about historic exposures. Samples of soil and water were also analysed and Uranium isotope ratios determined.

RESULTS

Levels of Ca, Mg, Co, Fe, Mn, V, Zn, Sr, Al, Ba, Bi, Ga, Pb, Hg, Pd and U (for mothers only) were significantly higher than published mean levels in an uncontaminated population in Sweden. In high excess were Ca, Mg, Sr, Al, Bi and Hg. Of these only Hg can be considered as a possible cause of congenital anomaly. Mean levels for Uranium were 0.16 ppm (SD: 0.11) range 0.02 to 0.4, higher in mothers (0.18 ppm SD 0.09) than fathers (0.11 ppm; SD 0.13). The highly unusual non-normal Fallujah distribution mean was significantly higher than literature results for a control population Southern Israel (0.062 ppm) and a non-parametric test (Mann Whitney-Wilcoxon) gave p = 0.016 for this comparison of the distribution. Mean levels in Fallujah were also much higher than the mean of measurements reported from Japan, Brazil, Sweden and Slovenia (0.04 ppm SD 0.02). Soil samples show low concentrations with a mean of 0.76 ppm (SD 0.42) and range 0.1-1.5 ppm; (N = 18). However it may be consistent with levels in drinking water (2.28 μgL-1) which had similar levels to water from wells (2.72 μgL-1) and the river Euphrates (2.24 μgL-1). In a separate study of a sub group of mothers with long hair to investigate historic Uranium excretion the results suggested that levels were much higher in the past. Uranium traces detected in the soil samples and the hair showed slightly enriched isotopic signatures for hair U238/U235 = (135.16 SD 1.45) compared with the natural ratio of 137.88. Soil sample Uranium isotope ratios were determined after extraction and concentration of the Uranium by ion exchange. Results showed statistically significant presence of enriched Uranium with a mean of 129 with SD5.9 (for this determination, the natural Uranium 95% CI was 132.1 < Ratio < 144.1).

CONCLUSIONS

Whilst caution must be exercised about ruling out other possibilities, because none of the elements found in excess are reported to cause congenital diseases and cancer except Uranium, these findings suggest the enriched Uranium exposure is either a primary cause or related to the cause of the congenital anomaly and cancer increases. Questions are thus raised about the characteristics and composition of weapons now being deployed in modern battlefields.

Does PTSD moderate the relationship between social support and suicide risk in Iraq and Afghanistan War Veterans seeking mental health treatment?

OBJECTIVE

This study examined posttraumatic stress disorder (PTSD) as a potential moderating variable in the relationship between social support and elevated suicide risk in a sample of treatment-seeking Iraq and Afghanistan War Veterans.

METHOD

As part of routine care, self-reported marital status, satisfaction with social networks, PTSD, and recent suicidality were assessed in Veterans (N=431) referred for mental health services at a large Veteran Affairs Medical Center. Logistic regression analyses were conducted using this cross-sectional data sample to test predictions of diminished influence of social support on suicide risk in Veterans reporting PTSD.

RESULTS

Thirteen percent of Veterans were classified as being at elevated risk for suicide. Married Veterans were less likely to be at elevated suicide risk relative to unmarried Veterans and Veterans reporting greater satisfaction with their social networks were less likely to be at elevated risk relative to Veterans reporting lower satisfaction. Satisfaction with social networks was protective for suicide risk in PTSD and non-PTSD cases, but was significantly less protective for veterans reporting PTSD.

CONCLUSIONS

Veterans who are married and Veterans who report greater satisfaction with social networks are less likely to endorse suicidal thoughts or behaviors suggestive of elevated suicide risk. However, the presence of PTSD may diminish the protective influence of social networks among treatment-seeking Veterans.

Health system reconstruction: Perspectives of Iraqi physicians

In conflict or post-conflict situations, health system reconstruction becomes a critical component of ensuring stability. The purpose of this study was to determine the priorities for health system reconstruction among Iraqi physicians residing in the northern region of the country. A convenience sample of practicing male and female physicians residing in the Kurdish region completed a 13-item survey about health system reconstruction. A total of 1001 practitioners completed the survey with gender breakdown of 29% female and 71% male, all working in different specialty areas. Significant differences between the providers based on gender (p=0.001), specialty (p=0.001) and geographic location (p=0.004) were found to affect the responses of the participants. This study demonstrates that input from healthcare professionals is important for health system reconstruction, but that gender, geography and medical specialty make the process complex.

Prevalence and predictors of health service use among Iraqi asylum seekers in the Netherlands

BACKGROUND

A long asylum procedure is associated with higher prevalence rates of psychiatric disorders, lower quality of life, higher disability and more physical health problems. Additional knowledge about health seeking behavior is necessary to guide governments and health professionals in their policies.

OBJECTIVE

To measure service use among one of the biggest asylum seekers population in the Netherlands and to assess its relationships with predisposing and need variables (including post-migration living problems).

METHOD

Two groups were randomly selected: Group 1 (n = 143), less than 6 months and Group 2 (n = 151), more than 2 years in the Netherlands. Respondents were interviewed with fully structured, culturally validated, translated questionnaires, which contained instruments to measure psychiatric disorders, quality of life, disability, physical health and post-migration living problems. Use of preventive and curative (physical and mental) health services was measured and the relationship with predisposing and need risk factors was estimated with univariate and multivariate logistic regression analyses.

RESULTS

A long asylum procedure is not associated with higher service use, except for mental health service use and drug use. Use of mental health services is, however, low compared to the prevalence of psychiatric disorders. Low quality of perceived general health and functional disability are the most important predictors of services use. Psychopathology predicts use of a medical specialist (non-psychiatrist), but does not predict mental health service use.

CONCLUSION

A high percentage of asylum seekers with a psychiatric disorder is not getting adequate treatment. There is a mismatch between the type of health problem and the type of health service use. The various health services should work together in education, detection, referral and care in order to provide help to this group of patients.

Effect of zinc supplement in the prognosis of burn patients in iraq

Many studies have reported that zinc plasma levels significantly decrease after a burn, leading to zinc deficiency, and that increased free radical generation and decreased natural antioxidant may negatively affect wound healing and burn outcome in general. Targeting of these changes is considered an important strategy in the treatment of burns in an attempt to improve burn outcome in the clinical setting. Zinc was given orally in a nutritional dose (15 mg elemental zinc) as a zinc sulphate capsule to burn patients in order to improve post-burn zinc deficiency and burn outcome. The study was carried out in 58 burn patients of different age groups, sex, and occupation with different burn size. The patients were allocated to two groups: group A patients (43 in number) were treated with topical povidone-iodine ointment for the first four days post-injury followed by topical silver sulphadiazine cream 1% until discharge in addition to other prescribed drugs according to our burn unit policy; group B patients (15) received the same treatment as group A plus a single daily oral dose of zinc sulphate in a 66 mg capsule, equivalent to 15 mg elemental zinc. In each group, using standard methods, we considered plasma zinc and copper levels, oxidative stress parameters, thyroid, liver, and renal function tests, microbiological factors, mortality rate, healing time, and cost effectiveness. The administration of zinc in dietary doses significantly increased the plasma zinc level in burn patients to around normal control levels and improved the antioxidant status, as represented by elevation of the natural antioxidant level (glutathione), in addition to improving healing time, the incidence of eschar formation, and the mortality rate, compared with the zinc-nonsupplemented group. We conclude that dietary zinc supplementation in zinc-deficient burn patients led to great improvements in their outcome and that zinc deficiency was as an important goal to target during treatment; also, that the use of a combination of topical and systemic antioxidants (povidoneiodine ointment and zinc sulphate, respectively) represented a good strategy for improving results in burn patient treatment.