ISSN: 1990-5483

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

Kerbala Journal of Medicine, Volume 11, Issue 2, Pages 3964-3977

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 Journal of Medicine, Volume 11, Issue 2, Pages 3978-3987

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 Journal of Medicine, Volume 11, Issue 2, Pages 3988-3992

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 Journal of Medicine, Volume 11, Issue 2, Pages 3993-4001

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 Journal of Medicine, Volume 11, Issue 2, Pages 4002-4010

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 Journal of Medicine, Volume 11, Issue 2, Pages 4011-4016

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 Journal of Medicine, Volume 11, Issue 2, Pages 4017-4024

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 Journal of Medicine, Volume 11, Issue 2, Pages 4025-4031

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 Journal of Medicine, Volume 11, Issue 2, Pages 4032-4038

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 Journal of Medicine, Volume 11, Issue 2, Pages 4039-4047

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 Journal of Medicine, Volume 11, Issue 2, Pages 4048-4058

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 Journal of Medicine, Volume 11, Issue 2, Pages 4059-4063

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 Journal of Medicine, Volume 11, Issue 2, Pages 4064-4067

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.

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

Kerbala Journal of Medicine, Volume 11, Issue 2, Pages 3964-3977

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 Journal of Medicine, Volume 11, Issue 2, Pages 3978-3987

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 Journal of Medicine, Volume 11, Issue 2, Pages 3988-3992

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 Journal of Medicine, Volume 11, Issue 2, Pages 3993-4001

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 Journal of Medicine, Volume 11, Issue 2, Pages 4002-4010

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.

Electrocardiography (Holter) study of patients with panic attacks

Abdulhamza Rajooj Hmood; Sami A. Al-Badri

Kerbala Journal of Medicine, Volume 7, Issue 2, Pages 1870-1877

background: many patients complaining of palpitations seem to have normal electrocardiography (ECG).
Aim: to study the 24-hours electrocardiography of patients with panic attacks.
Material and Methods: fifty patients with panic attacks were studied by Holter monitoring for 24 hours each.
Results: Holter monitoring showed ectopic beats in all 50 patients. No other arrhythmia was recorded.
Smoking was significantly associated with having more ectopic beats per day.
Discussion: panic attacks are not well understood. Some link it to autonomic instability. Some studies had found that some people diagnosed with panic disorder are having paroxysmal supraventricular tachycardia (PSVT). No one of the 50 patients we studied had PSVT. On the other hand, all of the 50 patients had several ectopic beats per day.
Conclusion: it seems that ectopic beats are very common among patients with panic attacks.
Keywords: panic, Holter, ectopic

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

Kerbala Journal of Medicine, Volume 11, Issue 2, Pages 3993-4001

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

Haemostatic parameters in acute promyelocytic leukemia patients treated with All Trans-Retinoic Acid (ATRA).

Mohammad Shnain Ali; Saad Sh. Mansoor; Ali Muslim Al- Amiry

Kerbala Journal of Medicine, Volume 1, Issue 0, Pages 63-68

Background: Acute Pormyelocytic Leukemia (APL) is commonly associated with
Disseminated Intravascular Coagulation (DIC)
1,2
.
Objective: The work was conducted to identify patients with APL who show
laboratory evidence of DIC (clinical or subclinical) with serial laboratory follow up.
Subjects and Methods: In this study 44 newly diagnosed APL patients were included. For
each patient, full hemostatic investigations were done at time of diagnosis and repeated on
day 3 and day 7 of therapy.
Results: Before starting therapy, all patients had elevated levels of D-dimer, indicating the
presence of DIC. On day 7 of treatment, plasma D-dimer levels were normal in ATRA-
treated group, but were high in the chemotherapy treated group, indicating that DIC was
essentially resolved in ATRA treated patients.
Conclusion: DIC is commonly encountered at presentation in patients with APL,
necessitating a rapid and full coagulation study in all patients. ATRA therapy in APL
patients is associated with rapid improvement of coagulopathy, hence it will aid those
patients to pass quickly the critical period of DIC. Therefore, ATRA therapy is justified to
be used from day one of treatment in APL patients.

Isovolumetric Relaxation Time “IVRT” as an Assessment of Left Ventricular Diastolic Function: M-Mode Derived Versus Doppler Derived

Akeel A. M. Hassan Zwain

Kerbala Journal of Medicine, Volume 2, Issue 3, Pages 345-351

Background: Isovolumetric Relaxation Time” IVRT” may be defined as: That part of the cardiac cycle
between the time of aortic valve closure and mitral opening, during which the ventricular muscle
decreases its tension without lengthening so that ventricular volume remains unaltered. During this period
there is a drastic decrease in ventricular pressure without a change in ventricular volume but prior to
mitral valve opening. IVRT can be estimated by M-Mode echocardiography with simultaneous
phonocardiography or simply by determining the time interval between the maximal systolic excursion of
the left ventricular posterior wall to the onset of mitral valve opening. More recently, Doppler technique
has been used to assess not only IVRT but also MPI “Myocardial Performing Index”; comparisons of
Doppler IVRT with catheterization measurement of this time period have shown reasonable correlations.
Objective: To compare M-Mode derived IVRT with Doppler derived IVRT.
Method: The study was performed on healthy individuals of age of 20-55y. Echo-Doppler Siemens
V.Plus equipment with phased array 2.5MHz probe and PW or CW facilities was used. A good M-mode
image of mitral valve excursion and left ventricular posterior wall systolic excursion was first obtained
and the time between the mitral valve opening and the maximal systolic excursion of LV posterior wall
was then calculated. Doppler IVRT was obtained by directing the Pulsed or continuous wave beam from
apical 5 chamber view across the region between the aortic out flow tract and the mitral inflow tract. The
spectral wave form obtained in this position should include aortic valve flow with valve closure and the
onset of mitral inflow with E/A configuration. In this spectrum the aortic closure- mitral opening interval
can be determined.
Results & conclusion: There was no significant difference between M-mode derived IVRT and Doppler
derived IVRT. Since the later has been validated on the ground of correlation with catheterization, thus it
seems feasible to use either techniques to assess LV diastolic function.

In-Hospital Mortality Of Acute Coronary Syndrome By Grace Score

Sabah M. H. Zangana

Kerbala Journal of Medicine, Volume 9, Issue 2, Pages 2575-2581

background: Patients with acute coronary syndrome (ACS) are liable to death during their hospitalization or thereafter. The Global Registry of Acute Coronary Events (GRACE) score is a simple tool that can predict mortality
Objective: To develop a risk prediction tool for estimating death in ACS. This may facilitate triage and management of patients with ACS
Design: Cross-sectional study
Setting: Azadi teaching hospital, Coronary Care Unit(CCU)
Patients and methods
400 patients with ACS admitted to CCU from Jan. 2012 to Jan. 2014 , were studied by applying GRACE score which uses readily identifiable clinical parameters like cardiac arrest on admission, age of the patient ,heart rate, systolic blood pressure and heart failure(according to Killip class), laboratory parameters like serum creatinine concentration, elevated cardiac markers, and lastly electrocardiogram(ECG) changes like ST segment elevation.
Results: According this score patients were grouped into low, medium and high risk groups .Out of 400 patients enrolled in the study, 34(8.5%) died during the period of admission, most of them in the medium and large groups
Conclusions This risk prediction tool is an easy method that can provide prediction of in-hospital mortality for ACS patients.

Isovolumetric Relaxation Time “IVRT” as an Assessment of Left Ventricular Diastolic Function: M-Mode Derived Versus Doppler Derived

Akeel A. M. Hassan Zwain

Kerbala Journal of Medicine, Volume 2, Issue 3, Pages 345-351

Background: Isovolumetric Relaxation Time” IVRT” may be defined as: That part of the cardiac cycle
between the time of aortic valve closure and mitral opening, during which the ventricular muscle
decreases its tension without lengthening so that ventricular volume remains unaltered. During this period
there is a drastic decrease in ventricular pressure without a change in ventricular volume but prior to
mitral valve opening. IVRT can be estimated by M-Mode echocardiography with simultaneous
phonocardiography or simply by determining the time interval between the maximal systolic excursion of
the left ventricular posterior wall to the onset of mitral valve opening. More recently, Doppler technique
has been used to assess not only IVRT but also MPI “Myocardial Performing Index”; comparisons of
Doppler IVRT with catheterization measurement of this time period have shown reasonable correlations.
Objective: To compare M-Mode derived IVRT with Doppler derived IVRT.
Method: The study was performed on healthy individuals of age of 20-55y. Echo-Doppler Siemens
V.Plus equipment with phased array 2.5MHz probe and PW or CW facilities was used. A good M-mode
image of mitral valve excursion and left ventricular posterior wall systolic excursion was first obtained
and the time between the mitral valve opening and the maximal systolic excursion of LV posterior wall
was then calculated. Doppler IVRT was obtained by directing the Pulsed or continuous wave beam from
apical 5 chamber view across the region between the aortic out flow tract and the mitral inflow tract. The
spectral wave form obtained in this position should include aortic valve flow with valve closure and the
onset of mitral inflow with E/A configuration. In this spectrum the aortic closure- mitral opening interval
can be determined.
Results & conclusion: There was no significant difference between M-mode derived IVRT and Doppler
derived IVRT. Since the later has been validated on the ground of correlation with catheterization, thus it
seems feasible to use either techniques to assess LV diastolic function.

Evaluation of The Response of Children with Short Stature to A Six Months Treatment with Recombinant Human Growth Hormone

Abdulabbas Abduon Hadi

Kerbala Journal of Medicine, Volume 9, Issue 2, Pages 2569-2574

background: Human Growth hormone (GH) is 191amino acids protein , gene located on long arm of chromosome 17. its secretion is under control of 2 hypothalamic hormones: growth hormone releasing hormone(GHRH) and somatostatin. Growth hormone is a major promoter of anabolism, its effects on growth are believed to be indirect ,being mediated through peptides called somatomedins or insulin-like growth factors (IGFs) that in turn mediate many of the growth promoting effects of Growth hormone . Recent advances have focused on biological actions of IGFs & their six well defined binding proteins (IGFBPs), the major one is IGF-BP3 which decreased in GH-deficient children. IGFs are GH-dependent serum peptide with potent metabolic & mitogenic activities believed to be responsible for growth effects of GH, they stimulate cellular replication & differentiation .
Objective: To evaluate the difference in the response of the children with short stature (of different causes) to a six months treatment with recombinant human GH .
Patients And Methods: this is a prospective study in which a total no. of 84 pt (with age ranging from 4-20 years) were included. They were presenting to the endocrine clinic in Al-Mansour teaching hospital for children in 2002 with short stature & growth delay. After the final diagnosis was made, all pt were treated by recombinant GH (in a dose of 0.1-0.2 unit/kg / day) by subcutaneous or intramuscular route at night time (7-8pm) , After completing 6 months of treatment with GH, the patients were evaluated again for height and height velocity, weight, bone age, height age, sexual maturity rate, testicles and phallus in male.
Results: There was no significant difference in response to the therapy between male and female ; the mean height velocity in male was 9.37 +/-3.99 cm / year (ranging from 1-19 cm) and the mean height velocity in female was 9.90 +/-4.39 cm / year ranging from 3-20 cm . Conclusion: Growth hormone therapy is effective in increasing the height velocity in most patients with short stature and it should be initiated as early as possible to improve height as much as possible.

Diabetic Mastopathy In Iraqi patients; Modalities Of Diagnosis And Management Options

Ali Khairi Toman

Kerbala Journal of Medicine, Volume 7, Issue 1, Pages 1797-1805

background: Diabetic fibrous mastopathy, also known as lymphocytic mastitis, is an un common lesion of the breast that occurs in women with long standing insulin dependent diabetes mellitus (IDDM)
It is a distinct clinicopathologic entity with specific histopathological characteristics, which include keloid fibrosis, epithelioid fibroblast, widespread periductal/lobular lymphocytic infiltration and widespread perivascular lymphocytic infiltration.
Objective: To confirm that: (a) Many diabetic patients can be spared from undergoing multiple, unwarranted surgical biopsies (b) Mastopathy can happen even in NIDDM, (c) Diabetic mastopathy can co-exist with malignant breast lesions.
Patients And Methods: A study for 48 patients with palpable breast masses. The patients are divided into 3 groups: Group A (10 patients): contain the patients with long standing IDDM. Group B (14 patients): contain the patients with NIDDM. Group C (24 patients): contain age matched control non-diabetic patients selected with clinical finding similar to that present in diabetic mastopathy. FNAC, ultrasound and mammographic examinations were done before proceeding for excisional biopsy.
Results & Discussion: We found that 7 out of 10 patients in Group A (70%) have features suggesting of diabetic mastopathy and only 4 out of 14 patients in group B (28.5%) and (0%) in group C, have the same features. So we demonstrate that, diabetic mastopathy could be the only cause of palpable breast mass in diabetic patients.
Diabetic mastopathy is a distinct clinicopathologic entity with specific histopathological features, which include keloid fibrosis, epithelioid fibroblast, widespread Periductal/lobular lymphocytic infiltration and widespread perivascular lymphocytic infiltration. Our work confirmed the presence of the histopathological characteristics of diabetic mastopathy in palpable breast masses in long standing IDDM (group A). We also observed the presence of the histopathological characteristics of diabetic mastopathy in breast tissue in mastectomy specimens away from intraductal and infiltrating ductal carcinoma in NIDDM (group B).
Conclusion: we should have awareness that this entity exists and a careful correlation of the patient history with physical, radiological and cytological examination should be applied.

Protein C Deficiency in Patients with Retinal Vein Thrombosis

Rahem M. Rahem

Kerbala Journal of Medicine, Volume 8, Issue 2, Pages 2202-2206

introduction: Retinal vein occlusions are the most common retinal vascular disorder after diabetic retinopathy with several ocular and systemic disorders associated with retinal veins thrombosis. Protein C deficiency as part of inherited thrombophilia due to deficiency of natural anticoagulant may associated with retinal vein thrombosis.
The aims of this study were to measure the Protein C concentrations in patients with retinal vein thrombosis and to evaluate its role in the etiology of those patients.
Patients, materials and methods: During a period of 6 months a total number of 42 patients who were diagnosed with retinal vein thrombosis while attending the out patient clinic in Karbala, Iraq. From each patient appropriate amount of venous blood was withdrawn and estimated for plasma protein C level, Complete blood count, blood film, ESR, Kaolin clotting time, anticardiolipin antibodies, antinuclear antibody, TSH, blood urea, serum creatinin, random blood sugar and serum cholesterol. For control group individual only protein C estimation was done.
Results: Forty-two patients with retinal vein thrombosis were investigated. There were 22 females and 20 males and a mean age of 48 ± 2 years with no significant statistical differences in mean age and sex between the patients and the control group. Decreased levels of PC were found in six (14%) of the patients, and a statistically significant difference was seen for PC concentration between the patients and the control groups.
Conclusions: Deficiency of natural anticoagulant proteins, especially protein C, may play a role in the etiology of retinal vein thrombosis and measurement of these parameters with proper prophylaxis especially in young patients may be useful in prevention of venous thrombosis.

Hypothyroidism in Adults Early Clinical Presentation in Relation to Age

Karim O. Al-Naffii; Hassan A. A. Nasseralah; Kadhum A. Al-Hillali; Akram F. M. Ali

Kerbala Journal of Medicine, Volume 2, Issue 3, Pages 352-356

Background: Hypothyroidism in adults is not a rare disease but has non –specific clinical
presentation which may delay its diagnosis.
Objective: the aim of the study is to identify the presenting symptoms of hypothyroidism,
their frequency & their relation to age.
Patients & Method : All adult patients > over 18 years of age who attended the consultation
clinic, in Al-Hussein Teaching Hospital / Karbala, from January 2002 to December 2007
showing clinical features suggestive of hypothyroidism were sent for T3, T4 & TSH.
Results: Sixty eight patients were found to have hypothyroidism, 52 females & 16 males
(F/M ratio 4.7:1). Seventy percent of the group are less than 55 yr of age, their mean age is
42.3 yr. Malaise & arthralgia were the main complaints especially in those aged 55year &
over (69% & 25%) respectively while skin changes were the main early physical signs in
those less than 55yr of age (26%).
Discussion: Hypothyroidism is a disease which may present in a nonspecific clinical picture
such as malaise or fatigability especially in elderly or skin changes in young age group or as
menstrual irregularities in young females.
Conclusion: High index of suspicion is the main initial tool for diagnosis of hypothyroidism
& should be considered in any elderly patient with unexplained malaise or fatigability or in
young females with unexplained menstrual irregularities. To look for other physical
symptoms & signs in those patients which may mandate sending them for thyroid function
test or at least only TSH level.

Journal Information

Publisher: College of Medicine - University of Kerbala

Email:  karbalamedj@uokerbala.edu.iq

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

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....
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