ISSN: 1990-5483

About Journal

Karbala Journal of Medicine is a four monthly published journal issued by Karbala college of Medicine.The Journal accepts original articles, case reports, and letters to editors in all fields of medicine from all parts of the world. Review articles of high standards are also considered in this journal. All articles and manuscripts must be in english ,only the abstract must be in arabic and english.Papers are accepted, on understanding that the content has not been published in a whole or in part by other journals. The papers are subject to editorial revision, and the editor is responsible for the...
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Journal Information

Publisher: Kerbala University

Email:  dr.mohma.med.school@gmail.com

Editor-in-chief: Professor Dr. Mohanad Mohsin Ahmed

ISSN: 1990-5483

Volume 11, Issue 2, Autumn 2018, Page 3964-4067


Correlation between H Pylori Infection and Nonalcoholic Fatty Liver Disease in Karbala City

Kerbala Jorunal of Medicine, Volume 11, Issue 2, Pages 3964-3977
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background: NAFLD patients had higher anti IgG H pylori and might be a clue that H pylori infection had a strong link the pathogenesis of early stage NAFLD mostly had simple steatosis. H pylori infection had a role in pathogenesis of IR and NAFLD. H pylori is strong inducer of pro inflammatory cytokine (IL6, IL8, TNF- α).Serum triglyceride was higher in H pylori positive group and NASH. Recent study have investigated weather H pylori induce insulin resistance mediated through fetuin which decrease in patients with sero positive Hpylori IgG patients.
Patient and method: Fifty six patients were collecting randomly as a case of fatty liver by ultrasound In Imam AL- Hussain Medical City in Karbala .Obese, DM, alcoholic patients, renal and hepatic diseases were exclude from this study. Fasting blood sample was taken and sent for IgG antibody H pylori, lipid profile, liver function test including ALT and AST.
Result: The mean age of patients was 45+10 and majority (65%) was females.
(67)% of patients who were fatty liver had Hpylori sero positive IgG (p value<0.05).
(66)% of patients who were fatty liver had normal liver function ALT mean±SD(31±7) and only 34% had increased liver function, ALT mean SD±(110±13)with p value<0.01.
(71)% of patients who were fatty liver and H pylori sero positive IgG had normal liver function mostly ALT mean±SD (29±10) in comparism with 29% who had increase liver function mostly ALT mean ±SD(98±18) p value <0.01.
(83)% of fatty liver patients had hyperlipidaemia mean±SD (290±20), (395±22) respectively p value<0.01.
(75)% of fatty liver patients with H pylori sero positive IgG had hyperlipidaemia mean±SD (279±15),(320±20) respectively p value <0.01.
Conclusion This study shown significant correlation between chronic H pylori infection and NAFLD .The pathogenic mediator include fetuin-A, TNF-α and adiponectin and on long term IR.

Primary Percutaneous Coronary Intervention in Acute ST Elevation Myocardial Infarction: A Single Centre Experience

Kerbala Jorunal of Medicine, Volume 11, Issue 2, Pages 3978-3987
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background Early revascularization is critically important in the management of patients presenting with acute myocardial infarction.
Aim To assess the benefit of early primary percutaneous coronary intervention in patients with acute ST elevation myocardial infarction.
Methods This study include 51 patients with acute STEMI they were selected from those who were admitted to the coronary care unit of Karbala cardiac center in Karbala-Iraq during a period between January 2017 and February 2018. Detailed history and thorough physical examination was done. Investigations done for each patient in form of ECG, cardiac troponin, blood urea, serum creatinine, and complete blood picture.
Results & discussion percutaneous coronary intervention only, using one stent, two stent, three stent, aspiration catheter, CABG & medical treatment, 7 (13.7%),25(49%), 8(15.6%), none , 4(7.8%), 4(7.8%), 4(7.8%), 3(5.8%) respectively).
Infarct related artery, LAD, LCX, RCA & LMS (30(58.8%), 4(7.8%), 6(11.7%), 2(3,9%) respectively, and the number of diseased vessels , single vessel, two vessels, three vessels & LMS which was (20(39.2%), 13(25.4%), 14(27.4%) respectively.
Inhospital outcome, which include the following:- favorable outcome, period of hospitalization, access site bleeding, contrast induced nephropathy, death, respectively. Which were (96%, ˂ 1day 38(74.5%), ˃1day 13(25.5), 3.9%, 5.8%, 3.9% respectively)
Conclusion in case of ST elevation myocardial infarction, left anterior descending artery is most culprit vessel to be involved, one quarter of patient needs one stent & carry favorable out comes in form of less complications and also decrease the period of hospitalization.

Current Practice in Management of Acute Coronary Syndrome in Tertiary Iraqi Cardiac Centers

Kerbala Jorunal of Medicine, Volume 11, Issue 2, Pages 3988-3992
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background There is continued debate as to whether a routine, early invasive strategy is superior to a conservative strategy for the management of acute coronary syndromes.
Aim of the study: To verify current practice in the setting of management of acute coronary syndromes in tertiary cardiac centers in Iraq.
Patients and methods Four hundred (400) patients were included in this study from 1st of January 2012 to 1st of January 2013from two tertiary Iraqi cardiac centers. Three hundred (300) patients from Ibn Albitar hospital and One hundred (100) patients from Iraqi center for heart disease refered to them as group (A) and group (B) respectively.
Results & discussion Mean age for all patients was54.6±9.9 year. In group A there was 208 male patients (69.3%), 92 female patients (30.6%), in group B there was 65 male patients (65%), 25 female patients (25%).
Low score (using thrombolysis in myocardial infarction score) found in 166(41.6%), intermediate score in 221 (55.3%), high in 13 (3.3%), no patients with high score was found in group B, mean TIMI score in group A was 1.61±0.5, in group B was 1.60±0.5 (P value NS). In group A UA found in 249 (83%), STEMI in 23 (7.7%), NSTEMI in 28 (9.3%).In group B UA in 79 (79%), STEMI in16 (16%), NSTEMI in 5 (5%) (Pvalue0.02). Smoking is prevalent more in group A (186 patients (62%) versus 43 patients (34%) in group B), while diabetes mellitus and family history of premature coronary artery were more prevalent in group B (Pvalue0.03).
All patients in group A with low score were treated medically while in group B with low score treated invasively. Invasive approach was more in group B compared with group A in intermerdiate risk score.
Normal coronaries were found in (3.3%) in group A versus (6.8%) in group B. Percutaneous coronary intervention was applied in (66.6%) in group A versus (50%)in group B, surgery used in (23.3%)in group A versus (28.3%)in group B, medical treatment in (10%) in group A versus (21.6%) in group B.
There were no statistical difference between both groups regarding duration of admission to hospital and mortality.
Conclusion Management of acute coronary syndromes was the same between tertiary cardiac centers and it is progressing significantly in our country.

Prevalence of Intracerebral Hemorrhage and Its Risk Factors among Stroke Cases Admitted to Sulaimani General Teaching Hospital

Kerbala Jorunal of Medicine, Volume 11, Issue 2, Pages 3993-4001
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background: Although hypertension remains the most common cause of non-traumatic Intracerebral hemorrhage (ICH), several other conditions and lifestyle factors have been associated with ICH such as age, gender, race differences, cigarette smoking, alcohol, drug abuse, anticoagulant treatment, dyslipidemia, and others .
Aim: Our aims are to estimate a prevalence and incidence of ICH among stroke cases within Sulaimani’s people, in addition to investigate the main risk factors of patients with ICH among stroke cases admitted to General teaching hospital in Sulaimani city.
Patients and method: In this study, 108 patients with either ischemic stroke or non-traumatic ICH were enrolled; these patients were recorded in Sulaimani General Teaching Hospital with a special form of demographic data. All patients were thoroughly examined and investigated with brain CT scan for all and brain MRI for some of them.
Discussion: Out of 108 stroke patient admitted, 33 patients (30.6%) had ICH, while 75 patients (69.4%) had ischemic stroke, 19 cases (out of 33) (57.58%) of ICH patients were females, while 14 (42.42%) of them were males. Among the modifiable risk factors of ICH, hypertension remains the most common risk which was present in 25 patients out of 33 (75.8%), but dyslipidemia and diabetes mellitus were other less common risk factors which might have predisposed to the occurrence of ICH.
In conclusions: Spontaneous intracerebral hemorrhage, which is a common cause of mortality and morbidity, is relatively a common form of stroke in our locality which is more predominant in females. Hypertension is the main risk factor for spontaneous ICH

Role of Prophylactic Postoperative Calcium Supplementation Following Total Thyroidectomy in Preventing Hypocalcemia

Kerbala Jorunal of Medicine, Volume 11, Issue 2, Pages 4002-4010
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background:Hypocalcemia remains a major post-operative complication of total thyroidectomy causing potentially serious side effects and tension in influenced patients and expanding hospitalization time. Accurate prediction and appropriate management may help reduce morbidity and hospital stay.
Aim of study: To evaluate the effect of Ca supplementation following thyroidectomy in preventing hypocalcemia.
Patients and Methods: A randomized prospective study including 74 patients who underwent total thyroidectomyin the surgical unit, Department of Surgery, Al-Khidhir Hospital in Al-Muthanna provinceduring a period of two years and six months from Oct, 2015 – April, 2018. Group A - patients who didn’t receive any supplement (37 patients), group B - patients who received Ca therapy immediately after operation (37 patients). Laboratory tests for S.Ca were done preoperatively and postoperatively at day 0, day one, day two, day three, and then after 10 days and for patient who developed hypocalcaemia, another reading was done after 10 – 20 days and followed monthly.
Results: No significant differences (P ≥ 0.05) between study groups regarding age, BMI and duration of goiter. At day zero and day one postoperatively, no significant association between prevalence of hypocalcemia and receiving Ca postoperatively (P≥0.05) while at day two and three, this association was significant and hypocalcemia occurred more prevalent in patient of group A. Patients of group B were discharged earlier than patients of group A (58.9% versus 41.1%).
Conclusion: Routine Ca supplementation following total thyroidectomy is better than no supplement. Although they do not completely eliminate the occurrence of postoperative hypocalcemia.

Vitamin-D Status in Type 1 Diabetic Children and Teenagers in Karbala, Iraq

Kerbala Jorunal of Medicine, Volume 11, Issue 2, Pages 4011-4016
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background: Vitamin-D deficiency is a very important subject in clinical endocrinology. Low vitamin-D levels detected in many metabolic and immune disorders like Diabetes-Mellitus type 1 (T1DM).
Aim: Evaluate vitamin-D status of children & teenagers with T1DM in Karbala, Iraq.
Patients and Methods: (171) subjects were enrolled in a case-control study, consisted of two groups; diabetic patients (121) cases (48 male and 73 female), aged 5-16 years and the control non-diabetic (50) (26 female and 24 male) children with matched age and sex. 25 (OH) D3 measured for all subjects, glycosylated hemoglobin was measured for diabetic cases.
Results: The level of vitamin-D was significantly lower for diabetic cases (p=.003). Further analysis of vitamin-D using 10ng/ml as cutoff level to assess vitamin-D severe deficiency between diabetic patients and controls shows that percent of severity of vitamin-D deficiency within diabetic cases (42%) was more than control (12%) which was highly significant (p=0.0001).
Conclusion: diabetic children are more susceptible to deficiency of vitamin-D than non-diabetics are, with more prevalence of severe deficiency among them. We recommend Measuring of vitamin-D for all T1DM children

Role of Intravenous Extra Fluid Therapy in Icteric Term Neonates Receiving Intensive Phototherapy

Kerbala Jorunal of Medicine, Volume 11, Issue 2, Pages 4017-4024
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background: Jaundice is a common neonatal problem. This may be due to the limited ability of a neonate to metabolize indirect bilirubin, which predisposes to the risk of encephalopathy and long-term sequelae if not managed promptly. Sufficient hydration and good urine output improve the efficacy of intensive phototherapy
The aim of this study: was to evaluate the role of intravenous extra fluid supplementation in accelerating the reduction of serum bilirubin levels in neonates and to find out whether intravenous fluid supplementation decrease the total duration of phototherapy and the need for exchange transfusion
Methods: This is a prospective clinical trial study that was conducted at phototherapy ward at Karbala teaching hospital for children, Iraq from January 2017 to December 2017. Fifty-two term neonates with non-hemolytic hyperbilirubinemia [total serum bilirubin ≥18 mg/dl (308 μmol /L) and <25 mg/dl (428 μmol /L)] were randomly divided into 2 equal groups; (non-supplemented group) received breast milk and or formula, and (supplemented group) given intravenous fluid besides breast milk or formula. Both groups exposed to intensive phototherapy. The rate of bilirubin decrement, duration of phototherapy, and rate of exchange transfusion were compared
Results: Rate of bilirubin decrement at 4 hours, 8 hours, 24 hours of study were significantly higher in supplemented group as compared to non-supplemented group (p- value ≤0.001). Duration of phototherapy required in non-supplemented and supplemented groups was 56.54 vs. 41.54 hours respectively (p-value =0.0001). No statistically significant effect of intravenous extra fluid supplementation on exchange transfusion rate between these two groups.
Conclusions: Intravenous extra fluid supplementation in non-hemolytic jaundiced term neonates can accelerate decrement of serum bilirubin levels and decreases the duration of phototherapy

The Clinical and Pathological Characteristics of Colorectal Cancer in Young Age Group in Karbala Province/ Iraq

Kerbala Jorunal of Medicine, Volume 11, Issue 2, Pages 4025-4031
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background: Colorectal cancer (CRC) is a major health problem in Iraq.
Aim: to identify the clinicopathological characteristics of colorectal cancer in young Iraqi patients in Karbala.
Design of study: Retrospective study was conducted in a single center, Imam AL-Hussein general teaching hospital during the period from January 2009 to April 2017.
Patients and Methods: A sample size of 96cases of Colorectal Carcinoma was diagnosed during the study period. The clinic-pathological parameters were reported.
Results: The mean age of the patients was (51.68). There is a general increase in the incidence of colorectal cancer across the years with percentage of (41.7%) being younger than 45 years. There was slight male predominance. The predominant site of the tumor is colon in (75%) of cases followed by rectum (17.7%). The most common type was adenocarcinoma (82.1%) followed by mucinous type (27.3%), most patients presented with grade I (61.5%). In the majority of patients the malignancy reaching the pericolic fat (54.5%). About (43.6%) of patients presented with N1 and (50.9%) with stage III followed by stage II in (30.9%). For all cancer grades, the frequency of CRC was higher among patients > 45 years with the majority of patients with grade III being younger than 45 years and this make a significant difference between both categories, (P=0.043). With respect to the depth of invasion, those with advance disease (T3), 17 out of 30 cases were younger than 45 years, thus there was significant difference between 2 age groups.
Conclusion: the incidence of colorectal cancer is upgrading in those younger than 45 years

Correlation between Refractive Error and Corneal Thickness in a sample of Iraqi Population with a Wide Range of Ametropia

Kerbala Jorunal of Medicine, Volume 11, Issue 2, Pages 4032-4038
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background: The assessment of corneal thickness has gained importance in different fields of ophthalmology in recent years, and measurement of the central corneal thickness (CCT) has become an important part of a routine examination in refractive surgery.
Aim: To determine the Correlation between Refractive Error and Central Corneal Thickness in A NAJAF Population with a Wide Range of Ametropia.
Method: In a cross sectional observational study, Involved 399 eyes of 200 Patients for whom the cen-tral corneal thickness (CCT) was measured with Ultrasonic pachymetry (TOMEY PACHYME-TER SP-3000).
The refractive error, including sphere, cylinder, and spherical equivalent (SE), were measured with Topcon (KR.8900) autorefractometer And Manual refraction.
Examination of anterior segment using slit lamp and fundoscopy using volk + 90 D, were done to exclude any underlying pathology
Results: The mean age of the study subjects was 30.71(range, 17 to 61) years. The mean spherical equiva-lent (SE) of the right eye was -3,2475 Diopter (range,-11.25 to 5.75 Diop-ters) while SE of the left eye was-3,2035 Diopter (range,-14.5 to 8.5 Diopters). The mean cen-tral corneal thick-ness(CCT) of the right eye 533,1600 Micron (range,407.00 to 635.00 Mi-cron) while CCT of the left eye was 532,7638 Micron (range,394.00 to 630.00 Micron). No significant correlation were found between spherical equivalent (SE) and central corneal thickness (CCT) of right and left eye among the studied group.
Conclusion: No significant Relation found between Refractive errors and central corneal thickness (CCT).

Assessment of Metabolic Syndrome and Its Risk Factors among Patients with Type 2 diabetes mellitus at Merjan Teaching Hospital, Al-Hilla City

Kerbala Jorunal of Medicine, Volume 11, Issue 2, Pages 4039-4047
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background: Metabolic Syndrome (MS) has become prevalent medical problem globally and the main consequence of Diabetes Mellitus (DM) and Coronary Heart Diseases (CHD).
Aim of Study: To determine the proportion of metabolic syndrome among patients with type 2 diabetes mellitus and its association with metabolic syndrome risk factors.
Materials and Methods: A hospital-based cross sectional study design was carried out on (300) diabetic type 2 diabetes mellitus patients at diabetic outpatient clinic in Merjan Teaching Hospital. The study duration was from December 2011to December 2012. Categorical variables were presented as frequencies and percentages. Continuous variables were presented as means with their 95% confidence interval (CI) and standard deviation. The Pearson's chi-square test (x2) was used to determine the associations between categorical variables. Binary Logistic regression was done for multivariate analysis. A p-value of < 0.05 was considered as statistically significant.
Results: The results showed that, out of 300 diabetic patients, the proportion of metabolic syndrome was 226 (75.3%). The overall mean age of patients was 57.26± 7.07 years. (60.0%) patients were male and (45.7%) of the patients were from urban area. (60.0%) of patients had abdominal obesity and (61.0%) of patients adapt sedentary life style. (76.7%) of patients had high triglyceride, meanwhile, only (39.7%) had normal HDL. Hypertension was presented in (73.7%) of patients. Metabolic syndrome was statistically significant with male, urban area, abdominal obesity, sedentary lifestyle, high triglyceride and hypertension. Patients with high triglyceride were 71 times more likely to develop metabolic syndrome than patients with normal triglyceride.
Conclusion: High proportion of metabolic syndrome among diabetic type 2 patients in this study. High triglyceride, urban area and sedentary lifestyle were the strongest predictors of metabolic syndrome.

Compliance of Hypertensive Patients to Medication in AL-Imam AL-Hussein medical City- Kerbala- 2018

Kerbala Jorunal of Medicine, Volume 11, Issue 2, Pages 4048-4058
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background: High blood pressure (BP) is estimated to cause 7.5 million deaths worldwide, around 12.8% of the whole deaths . It is a major risk factor for coronary artery disease and its complications, heart failure, renal insufficiency, stroke and blindness in diabetic patients.
Aim: This study is designed to determine the compliance of hypertensive patients attending the consultation clinics of internal medicine in Al-Imam Al-Hussein medical city with treatment regimen and the causes of noncompliance.
Method: A descriptive cross- sectional study conducted in the outpatient clinics of Al- Imam Al-Hussein medical city in Kerbala during the period from March till June 2018.Total study sample was 335 hypertensive patients ,their ages over 25 years were selected by convenience sampling procedure according to the inclusion criteria . They were interviewed and assessed using special questionnaire format based on sociodemographic data, Morisky 8- item medication adherence scale (MMAS-8) ,and measuring of blood pressure.
Results: the mean age of the patients was 58.69 ± 11.87 years. Good compliance with treatment was present in only 28.36% of the sample, 25.67% with partial compliance and 45.97% had poor compliance. Good control of blood pressure was present only in 23.3% of the patients .The absence of symptoms was the first isolated cause of non-compliance to medication 21.9%, followed by forgetfulness 18.8%, the cost of medication 16.3%, then negligence and carelessness of patients 9.4%, while 23.1% of the patients had more than one specific reason to their poor compliance.
Conclusions: the study revealed a low rate of medication compliance and low level of blood pressure control with strong association between them. Compliance increased with age, male gender, higher level of education and income, longer duration of the disease, presence of complications, using healthy diet and having positive believe about hypertension treatment and its consequences.

A Misleading Presentation of Vogt – koyanaji – Harada Disease

Kerbala Jorunal of Medicine, Volume 11, Issue 2, Pages 4059-4063
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Purpose: To report an unusual clinical presentation of Vogt – koyanaji – Harada disease.
Design and methods: A 36 years-old Iraqi woman presented to Neurology department with chronic headache and bilateral disc edema, neuro-imaging was normal, a provisional diagnosis of idiopathic intracranial hypertension was made, aspiration of cerebrospinal fluid (CSF) was done. The CSF pressure was normal and the patient did not respond to conventional treatment. After 3 weeks, the patient developed drop of vision in the right eye, the patient referred to the Ophthalmology department for evaluation of the visual problem. On examination, vision was counting finger 3 meters right eye and 5 meters left eye. There is bilateral granulomatous uveitis both eyes, bilateral disc edema, and multifocal exudative retinal detachment in both eyes. Optical coherence tomography (OCT), and posterior fundus photography document the presence of multifocal retinal detachment.

Case Report of Chondrodysplasia Punctata: A Rare Complication of Hyperemesis Gravidarum

Kerbala Jorunal of Medicine, Volume 11, Issue 2, Pages 4064-4067
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Chondrodysplasia punctata is a very rare congenital disorder characterized by abnormal calcification within growing cartilage at the ends of the long bones affecting their growth. It has seen in inherited and acquired disorders. Acquired cases may be seen in infants of mothers with deranged vitamin K metabolism during pregnancy as in severe hyperemesis gravidarum. We report 2.5 years girl with features of chondrodysplasia punctata in whom maternal prenatal pregnancy history was remarkable of hyperemesis gravidarum. According to my information, this is the first recorded case in holy Karbala governorate.

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