Volume 4, Issue 9, Winter and Spring 2011, Page 933-1040


The variation of renal artery anatomy in the Iraqi population: An angiographic study of 358 middle Euphrates Iraqi patients attending the catheterization laboratory in Hilla province

Haider J.K.ALghizzi

Kerbala Journal of Medicine, Volume 4, Issue 9, Pages 933-938

Objective: the aim of this study is to determine the prevalence and the rate of renal artery variations in the middle Euphrates Iraqi population.
Materials and methods : Three hundred fifty eight (358) patients were referred to Shaheed Al Mihrab Cardiac Centre in Hilla province for a variety of indications for catheterization including ischemic heart disease , lower limb peripheral arterial disease , valvular heart disease , etc , detailed information about the angiographic procedure was given, an informed consent was obtained ,all patients renal arteries were visualized by either selective engagement using Judkins RT catheter or non selectively using a pig tail catheter .
Results : Anatomically the origin of the main renal artery was at the level of the first lumbar vertebra (L1) in 62% , L1-L2 disk in 13% ,L2(22%) of the cases , the remaining 3% was distributed over the T12 ,T12-L1 ,L2-L3 ,L3, L4 vertebral levels .
The renal artery bifurcates at the hilum into the segmental arteries in 56.7% of the cases , in the remaining 43.3% ,the renal artery bifurcates in to segmental arteries before it reaches the hilum and at variable distance from it aortic origin .Each kidney was supplied by a single renal artery on both side in the same patients in 79.8% of the cases while in the remaining 20.2% there was more than one renal artery in the following ratios :unilateral dual blood supply on the LT kidney (10%), RT kidney (6.5%) ,bilateral dual blood supply on both sides (2.5%) and in 1% of the cases there was more than two arteries on either side .we recorded one case four renal arteries on the left kidney , and there was triple renal arteries bilaterally in another one case .
Conclusion: Renal artery anatomical variation is common in the general population and this study confirms a nearly comparable frequency of variations in the Iraqi population with some diversion from the comparable studies that might be explained on racial bases.

Laparoscopic Surgical Anatomy of Calot`s Triangle…………………..………..….

Adnan Al Helli; Mohammad Al Taee; Majid Al Khafaji

Kerbala Journal of Medicine, Volume 4, Issue 9, Pages 957-963

introduction: Calot`s triangle is an anatomical space in the subhepatic region contains
the cystic duct and cystic artery. These structures are of normal arrangement and
configuration in about three quarters of people. Laparoscopic cholecystectomy now is
the gold standard surgical procedure for the treatment of cholecystolithiasis but is associated
with significant incidence of operative injuries. Recognition of the normal and variations of
the surgical anatomy in this space is essential in order to reduce the incidence of these events.
Aims: to start Iraqi data base, improve anatomy recognition and reduce laparoscopic
complication.
Method: Through a prospective observational study we identified the cystic artery and cystic
duct characters within Calot`s triangle during Laparoscopic Cholecystectomy operations.
Results: 200 cases, 96% females.
Cystic artery; total single artery; 179, 89%, double cystic arteries; 21, 10.5%, normal
configuration; 133, 66%, total artery anomalies; 67.33.5%.
Cystic duct; normal ducts; 125/62.5%, total anomalies; 75/37.5% and other details.
Discussion: the anatomy of Calot`s triangle is puzzling and surgeons should be aware of this
fact. The published studies are of variable ranges, arterial variations are more frequent than
ductal anomalies. Studies implementing Laparoscopic methodology sound the most accurate.
The current study denotes higher incidences of normal cystic arteries and lower incidence of
normal cystic duct compared to global ranges. Probably ethnic reasons play part in these
differences. It is the time to start national data base system and implement more accurate
diagnostic tools to improve diagnostic and therapeutic standards.
Key wards: Calot`s Triangle, cystic duct and cystic artery variations, laparoscopic
cholecystectomy.

Immunological Evaluation of Patients with Β-Thalassemia Major in Kerbala City Using Single Radial Immunodiffusion (SRID) Techniqu…………………..………….…

Zuhair Mohammed Ali Jeddoa; Sattar jabbar Rahi; Adel Ateia Abed Ali

Kerbala Journal of Medicine, Volume 4, Issue 9, Pages 939-943

background: Beta-thalassemia major is one of the major health problems in our country. Many studies have confirmed the fact that, these patients have an increased susceptibility to bacterial infections, assumed to be the result of immunological changes.
Objective: This study aimed to evaluate some of humoral immunological parameters of thalassemic patients by measuring their serum concentration of Immunoglobulin (IgG), IgM, IgA, and serum complement components C3 and C4.
Patients & Methods: A total of forty five beta-thalassemia major patients who were
attending to the thalassemia center in Kerbala teaching pediatrics hospital (24 males and 21
females) from January to August of 2009 and fifty of control children with matched age and
sex were randomly selected from apparently healthy individuals without any history of recent
or recurrent infections, were enrolled in the study. Serum IgG, IgM, IgA, C3 and C4 levels
were measured using Single Radial Immunodiffusion (SRID).
Results: The mean of serum IgG, IgM &IgA showed a significant increment (P<0.01) in thalassemic patients as compared with apparently healthy control group, while the serum levels of C3 and C4 were significantly decreased (P<0.01) in thalassemic patients as compared with control group.
Conclusion: The elevation of serum levels of studied immunoglobulins can be due to continuous exposure to antigens, repeated infections, and chronic liver disease, while the only probable cause of humoral immune deficiency were found in these patients were due to the decline of serum complement levels (C3 and C4).
Recommendations: The determination of serum levels of immunoglobulins and complement components have a beneficial value for evaluation of immunological status of thalassaemia major patients and further work need to be done to evaluate another immunological parameters for example the serum level of cytokines to manipulate the immunological aspects of thalassemic patients.
Key word: Beta-Thalassemia major, Immunoglobulin G, IgM, IgA, C3 and C4, (SRID).

Results of Antegrade Closed Static Femoral Interlocking Nailing for Closed Femoral Shaft Fractures………………………………………………….…………………….……

Ahmed Sabeeh Abid Ali Al-Zubaidi

Kerbala Journal of Medicine, Volume 4, Issue 9, Pages 944-949

objective: To evaluate the results of closed antegrade static femoral nailing for closed Winquist type III and IV fractures of shaft femur.
Methodology: A descriptive study conducted at department of Orthopedic surgery in Al Kadhimya hospital from March 2008 to July 2010. Twenty eight patients are included, twenty male patients and eight females , three were missed during follow –up period, admitted to the emergency department and operated on with closed reamed interlocking ante grade nailing under general or spinal anesthesia within 72 hours. Followed up for one year looking for union rate, malunion, infection, knee joint stiffness and trendelinburg gait.
Results: Union was achieved within twenty weeks in (twenty two 88%) patients, delayed union until thirty six weeks in (two 8%) patients and (one 4%) patient developed non union proved clinically and radiologically.
Infection developed in two patients (8%) at the site of distal screw insertion, both were superficial and resolved conservatively.
Knee joint stiffness developed in six patients (24%), from which five resolved completely within six weeks of physiotherapy and one with long term less than twenty degree knee joint stiffness.
Trendelenburg gait developed in four (16%) patients, three (12%) resolved completely within ten weeks and one patient (4%) continues with Trendelenburg gait after one year.
The mean operative time was 90 minutes.
Malunion as shortening less than one cm developed in two cases (8%) and angulations less than 10 degrees in one case (4%).
Key words: Closed, reamed, ante grade, static interlocking nails, femoral shaft fracture.

Breast Cancers: Young Age the Significant Predictor……………..…………….…..

Ali A.Al-Katib; Mohend.A.N.Al-Shalah; Ali H.AL-Timimi

Kerbala Journal of Medicine, Volume 4, Issue 9, Pages 950-956

Background: The incidence of breast cancer in young women (age < 35) is low. The biology of the disease in this age group is poorly understood, and there are conflicting data regarding, the prognosis for these women compared to older patients.
Patients and methods: We retrospectively analyzed consecutive primary invasive breast cancer patients who underwent surgical procedures at our institution between 1990 and 2002. The younger age group was defined as patients aged <35 years at the time of diagnosis, the clinicopathological characteristics and treatment outcomes were compared between younger and older age groups.
Result: A total of 51 (12.5%) patients were aged <35. There was a significantly higher incidence of nuclear grade 3 and medullary histological-type tumors in younger patients compared to older patients. Axillary lymph node status, T stage, histological grade, and estrogen receptor status did not differ significantly between the two age groups. Younger patients had a greater probability of recurrence and death at all time periods, although there was no significant difference in disease-free survival between the two age groups.
In lymph node-negative patients, the younger group showed worse prognosis among lymph node-positive patients (p<0.001).
Conclusion: In multivariate analysis, young age remained a significant predictor of recurrence (p=0.010). Young age (<35) is an independent risk factor for relapse in operable breast cancer patients.

Assessment of The Effect of Copper Coated IUCD on The Uterine Blood Flow Using The Transvaginal Colour and Pulsed Doppler Sonography

Asmaa Kadhum Al-Sarraji; Suhaila Fadhil Al-Shaikh; Huda Ali Al-Araji

Kerbala Journal of Medicine, Volume 4, Issue 9, Pages 964-971

background: Transvaginal colour Doppler (TVCD) Sonography is the gold
standard in investigating gynecological pathologies, in addition to its close
proximity to the pelvic organs that gives close view of the morphological
features of the organs, it also provides an opportunity to visualize and quantify pelvic
blood flow in uterine and adnexial masses. Another use of TVCD to quantify the
physiological changes of the uterine and ovarian blood flow in relation to hormonal
changes during the menstrual cycle. The intrauterine contraceptive device (IUCD) is a
widely used measure of contraception that is not devoid of complications, and the
most important one is the occurrence of menorrhagia in women using the copper
coated IUCD which may be predicted by measuring both pulsatility and resistance
index of uterine artery .
Aims of the study: The aim of this study was to evaluate the effect of copper- IUCD on uterine artery blood flow by using pulsed and colour Doppler ultrasonography.
Patients material and method: Sixty women were submitted to this study and after exclusion of two of them then 58 women (age range 16-45) were divided into two groups: the control group 30 women (51.72%) without IUCD and the 2nd group 28 women (48.28%) with copper coated IUCD.
The RI and PI of the uterine artery were measured by colour and pulsed Doppler TVUS, 44 women (75.86%) of them were in the proliferative and the other 14 (24.14%) were in the secretory phase of the menstrual cycle.
Results: the RI and the PI values of the uterine artery are changed by the phase of the menstrual cycle in both groups, the mean RI in the early proliferative phase 0.88, and in the secretory phase 0.87 of the control group, and in the IUCD group it was in the proliferative 0.85 while in the secretory was 0.86
The PI also showed differences between the two halves of the cycle in both groups:
In the 1st group were 2.37, 2.13 in the early 1st and the 2nd halves of the cycle respectively, and in the 2nd was 2.15 and 2.53 in the early 1st and the 2nd halves respectively. It was evident that in women with IUCD and menorhagia both the RI (0.81) and PI (1.78) were lower than the women with IUCD and normal menstrual flow
Conclusions: The IUCD does not alter the blood flow indices of the uterine arteries significantly as measured by Doppler TVUS except in susceptible women who are prone to develop menorrhagia after IUCD insertion. So it can be used to predict which women will develop menorrhagia after IUCD insertion.

Infectious Complications of Visceral Leishmaniasis in Basrah, Southern Iraq…..

Zainab Hameed Gani; Meaad Kadhum Hassan; Abdul-Mohsin Hameed Jassim

Kerbala Journal of Medicine, Volume 4, Issue 9, Pages 972-979

objectives: A prospective study was carried out to study the complications that may be associated with visceral leishmaniasis with special emphasis on any bacterial or parasitic complications.
Methods: The study included 132 in-patient children who were admitted to Basrah Maternity
and Children Hospital and Basrah General Hospital with visceral leishmaniasis
from November 2004 till November 2005.
Direct agglutination test (DAT) and bone marrow examination were used to confirm the
diagnosis. All patients were sent for blood culture, urine culture and stool culture, in addition
to general stool examination.
Results: Among 132 sero-positive cases, Diarrhea with or without vomiting, was found in
75 cases (56.8%), followed by urinary tract infection in 30 (23.4%) of the cases, and
bronchopneumonia in 10 cases (7.5%). The main non-infectious complications were
malnutrition in 86 (65.1%) of the cases, followed by bleeding tendency in 18 cases (13.6%).
Pathogenic bacteria were isolated in 41(31%) out of 132 sero-positive patients. The commonest type of bacteria isolated was Klebsiella (16 isolates) followed by Escherichia coli and Proteus (11 and 9 isolates), respectively. These three types of bacteria represented (78.2%) of total isolates.
Parasitic infections were detected in 44 (33.3%) patients. The commonest parasites
detected were Cryptosporidium parvum (18.9%) and Entamoeba histolytica (13.6%), Giardia
lamblia, Blastocystis hominis, Hymenolypis nana, and Enterobius vermicularis were also
detected but in lower frequency.
Conclusion: From this study we conclude that bacterial infections and pathogenic parasites were confirmed in about one third of VL cases for each; Klebsiella is the most common bacteria reported while Cryptosporidium parvum is the most common parasite.

Evaluation of (HPLC) Patterns of Sickle Cell Anaemia Patients in Comparison with Apparently Healthy Individuals

Zuhair Mohammad Ali Jeddoa

Kerbala Journal of Medicine, Volume 4, Issue 9, Pages 980-987

background: Sickle cell haemoglobin (HbS) results from an autosomal recessively inherited mutation in which the amino-acid glutamine is replaced by valine at position 6 in the beta globin chain of haemoglobin (Hb). Sickle cells have a reduced deformability and are easily destroyed, causing occlusion of the microcirculation and a chronic haemolytic anaemia with a median Hb concentration level of about 9 g/dl. Routine electrophoresis methods and High performance liquid chromatography (HPLC) were used to screen normal and variant Hb, and allowed the verification of the Hb observed with electrophoresis and precise quantification of their proportion.
Objectives: 1- This study aimed to evaluate the chromatographic pattern of Hb types (HbA, HbF, HbA2 and HbS) of sickle cell anemia patients in comparison with the apparently healthy individuals.
2- To study the Hb chromatographic patterns according to the gender, age and blood groups.
3- To evaluate the efficiency of variant Hb testing system in detection of HbS type of sickle cell anaemia patients.
Methods: A total of eighty four sickle cell anemia patients who were attending to the
Ibn Al-Baladi pediatrics hospital (in Baghdad) and Kerbala teaching pediatrics
hospital, the samples were (39) males and (45) females , from April of 2006 to
February of 2007 . And thirty seven of case controls with matched age and sex were
randomly selected from apparently healthy individuals. High performance liquid
chromatography (HPLC) was adopted to determine the different types of Hb for
patients and control groups using variant Hb testing system which depend upon the
separation and quantification of Hb types by high performance liquid chromatography
technique.
Results: The study of Hb chromatographic patterns of samples revealed that there were no significant differences (p ≥ 0.05) between the values of HbA2 for the patients and control groups and there were significant differences (P≤ 0.05) for HbF and highly significant differences (P≤ 0.01) for HbA and HbS percentages of patients in comparison with the control group. The results of Hb chromatographic patterns of samples according to the gender revealed that there were no significant differences at (p≥ 0.05) between males and females within patient and control groups. The results of Hb chromatographic patterns of Hb types for patients and control groups according to the age groups revealed heterogeneous results with highest HbF, HbA, and HbA2 percentages of patients were (10.83±3.32, 57.6±7.33, and 4.22 ±1.88) respectively in age group less than five years old, while it was (54.33±8.9) for HbS type in age group (6-10) years old. As for control group, the highest HbF percentages was (8.2±4.09) in age group less than five years old, for HbA was (87.22±5.86) in age group (6-10) years old, for HbA2 was (3.6±0.23) in age group (11-15) years old, and for HbS was (0.3±0.05) in age group less than five years old. Finally, the results also showed that there were no significant differences at (P ≥ 0.05) for Hb chromatographic patterns of different Hb types percentages according to the blood groups of studied samples within group (patients or controls).
Conclusion:
1- The study of Hb chromatographic patterns is useful for the diagnosis of sickle cell anaemia.
2- There are no significant effects of gender and blood groups on the chromatographic patterns of different Hb types of sickle cell anaemia patients in comparison to the apparently healthy individuals.
3- HPLC is an excellent, powerful diagnostic tool for the direct identification of HbS.

Cardiac Involvement in Patients with Systemic Lupus Erythematosus

Mahdi Saleh Alzaidi; Adil S. Abdul Ghafour

Kerbala Journal of Medicine, Volume 4, Issue 9, Pages 988-993

background: The aim this study was to analyze the patterns of involvement of the heart in our patients with SLE by means of clinical evaluation, electrocardiography, and echocardiography. Methods: Forty six consecutive patients (40 females and 6 males) with systemic lupus erythematosus (SLE) were studied for cardiac manifestations of the disease. Clinical history, physical examination, electrocardiography, chest X ray ,echocardiography study and standard laboratory tests were performed .Thirty three patients (72%) have evidence of cardiac involvement . Results: Thirty one patients (67%) were found to have abnormal echocardiography findings. Reduction in shortening fraction which reflects reduction in left ventricular function was the commonest abnormality. It was present in 15 patients (33%). Endocardial involvement in form of valvular dysfunction with or with out thickening was found in 10 patients (22%).
Conclusion: The heart is a common target for systemic lupus erythematosus. Therefore, echocardiography should be performed periodically in SLE patients.

Changes of Liver Enzymes in Coronary Heart Disease

Salman K. Ajlan; Yasin A. Baqir

Kerbala Journal of Medicine, Volume 4, Issue 9, Pages 994-1001

background : Coronary heart disease is one of the leading causes of morbidity and mortality elsewhere in the world . An association between liver enzymes and coronary heart disease is suggested.
Objective: To evaluate the changes in liver enzymes, Alanine aminotransferases and
aspartate aminotransferases in patients with coronary heart disease.
Methods: The study included 60 patients with coronary heart disease (41 males and 19 females), and 40 control subjects (25 males and 15 females) from Basrah, Iraq. Alanine aminotransferase, aspartate aminotransferase, lipid profile and fasting blood glucose levels were determined.
Results: alanine aminotransferase , aspartate aminotransferase, fasting blood glucose, total
cholesterol, triglycerides, and low density lipoprotein- cholesterol levels were significantly
higher among coronary heart disease patients compared to controls (P<0.001), while high
density lipoprotein- cholesterol level was significantly lower among patients with coronary
heart disease in comparison to controls (P<0.001). Alanine aminotransferases revealed a
significant positive correlation with triglycerides (P=0.006), and significant negative
correlation with high density lipoprotein- cholesterol (P= 0.031) and no significant
correlations with body mass index, blood pressure, and other biochemical parameters
(P>0.05). On the other hand, aspartate aminotransferases showed significant positive
correlations with total cholesterol (P=0.009), triglycerides (P=0.025) and low density
lipoprotein- cholesterol (P=0.042), and no significant correlations with other physiological
and biochemical parameters (P>0.05).
Conclusions: A strong association exists between changes in liver enzymes, alanine aminotransferase and aspartate aminotransferase and coronary heart disease. These enzymes could be included within the increasing list of coronary heart disease risk factors. Also, they might have prognostic significance and a predictive value in coronary heart disease complications.
Key words: Coronary heart disease, liver enzymes, lipid profile.

Mechanical Intestinal Obstruction Causes and Management

Ali A.Al-katib; Mohend A.N.Alshalah; Mohammed.A.L.Al-husseiny

Kerbala Journal of Medicine, Volume 4, Issue 9, Pages 1002-1010

aim:- Is to find out the possible cause or causes leading to intestinal obstruction and to encourage doctors to make use of their clinical abilities with few laboratory and radiological facilities available to diagnose and manage intestinal obstruction.
Patients and Methods: The study consists of 73 patients admitted to AL-Hilla teaching hospital with intestinal obstruction from October 2006 to December 2007. Full medical assessment was done for them with full investigations. Thirty three patients needed surgical intervention.
Results: The commonest etiology of intestinal obstruction was adhesions and bands 44 patients (60%), 5 patients (6.8%) incarcerated abdominal hernia, 3 patients (4.1%) Volvulus of sigmoid, 2 patients (2.7%) mesenteric thrombosis, 2 patients (2.7%) intuscessuption and 2 patients (2.7%) with pseudo obstruction. Small intestinal obstruction constitutes 61 cases (83.56%) and large bowel obstruction 12 patients (16.4%).
Discussion: The results of this study indicates that postoperative adhesions and bands are the 'main cause of intestinal obstruction and appendicectomy was the main operation leads to adhesional intestinal obstruction followed by gynecological operation .It also indicates that generalized abdominal tenderness and rebound tenderness are significant indicator of bowel strangulation.
Conclusion: Intestinal obstruction is a serious surgical condition and needs careful clinical history and examination which remains the corner stone by which we can differentiate between simple and ischemic obstruction, usually early intervention needed to prevent gangrene and decrease morbidity and mortality.

Effects of Type-2 Diabetes Mellitus on Serum Leptin, Insulin, Interlukin-8, and Lipid Profile

Fadhil J. Al-Tu; Ammar G. Yassin; Tariq H. Al-Kayatt

Kerbala Journal of Medicine, Volume 4, Issue 9, Pages 1011-1018

background: Diabetes mellitus emerge as a developing global problem , insulin resistant occur to be prominent feature of type-2 diabetes mellitus, leptin hormone (which is a 167 amino acid protein synthesized in white adipocyte and directly proportionate with obesity) have a relationship with diabetes mellitus Type-2.while interlukin-8 (which is a chemotactic factor ) may play a role in obesity or type-2 diabetes mellitus.
Objective: The aim of this study is to:
1-Determine the serum levels of Leptin, Insulin, Interleukin-8 (IL-8) and Lipid
profiles in Type-2 diabetic Iraqi patients.
2-Evaluate the correlation between leptin, insulin, IL-8 and Lipid profiles in sera of Type-2 diabetes mellitus (T2DM) in Iraqi patients.
Materials and Methods: A total number of 95 (70 Type 2diabetic patients and 25
apparently normal subjects), (46male and 49 female) obtained from Al-Hussain
Teaching Hospital/ Karbala - Iraq between Oct. , 2010 – April , 2011 with age ranged
between (20-75) years how were divided into three groups: ( obese type-2 diabetic
patients, Non-obese type-2 diabetic patients, and Non-obese non-diabetic subjects )
.Obese diabetic patients was specified by body mass index, BMI ≥30kg/m2. Fasting
serum leptin, insulin, IL-8 ,and lipid profile have been determined. A pre-tested
questionnaire was designed to obtain information about age, gender, height, weight,
and past-medical history. Body Mass Index (BMI) and (BF%) were the only
anthropometric parameter specified.
Results and Discussion: The levels of each of leptin and insulin hormones, Cholesterol, LDL-cholesterol, TG, BMI and BF% were elevated markedly in diabetic patients compared with non-diabetic thin. Leptin hormone level shows a significant positive correlation with insulin hormone, LDL-cholesterol, BMI and BF%. The level of IL-8 was fluctuated and there is a non-significant positive correlation with increasing BMI. Significant differences were found in leptin mean values between male and female in which its levels is markedly elevated in females.
Conclusion: The results obtained in this study reveals significant elevations in serum leptin, insulin, cholesterol, and LDL-cholesterol with a non-significant decline in HDL-cholesterol in Type2 diabetic patients in comparison with normal subjects. Also there was a significant elevation in serum leptin level in females in comparison with males in both diabetic and control groups. There was a non-significant positive correlation between IL-8 and obesity. The results show a strong correlation between insulin resistant and leptin resistant.

Antimicrobial Susceptibility Patterns Against Escherichia Coli and Prevalence of Extended–Spectrum β-Lactamases

Shrooq R. Kadhim; Afrah M. Hassan; Duaa S. Shoukat

Kerbala Journal of Medicine, Volume 4, Issue 9, Pages 1019-1023

sixty seven samples were collected from urine, stool, pus, wounds of the patients and operating theater from Baghdad Hospitals in 2010. Sixty two isolates of Escherichia coli were diagnosed by bacteriological and biochemical tests. These isolates were submitted to hemolysis test and antibiotic sensitivity to 10 kinds of antibiotic disks on Mueller Hinton agar by disk diffusion method. The detection of β-lactamase production was also done as well as extended-spectrum beta-lactamase (ESBL) for all the isolates. Hemolysis test was positive for two isolates. All the isolates of E.coli were resistant to ampicillin and cephalothin (100%) and high resistance was observed to cephalixin (95.1%), tobramycin (90.3%), doxycycline (82.2. %) and nalidixic acid (70.9%). Both ciprofloxacin and nitrofurantoin was (67.7%). Low resistance was noticed to amikacin (11.2%) and trimethoprime (8.1%). β-lactamase test was positive for 57 isolates (91.9%), while three isolates (4.8%) showed positive result for extended-spectrum β-lactamase.
Conclusion: Isolates of E.coli showed high resistance to ampicillin, cephalothin and cephalixin. Low resistance was revealed to amikacin and trimethoprime. Most of the isolates were positive for β-lactamase test (91.9%) and (4.8%) of the isolates were positive for extended-spectrum beta-lactamase.

Malignant Pericardial Effusion: Case Report and Review Article

Karim O A Al-Naffi

Kerbala Journal of Medicine, Volume 4, Issue 9, Pages 1024-1032

a sixty-five year old farmer presented with dry cough & mild exertional dyspnea for 10 days, he has no previous history of asthma or TB, he was not smoker, with no history of hypertension or diabetes, O/E he is well built not cyanosed, mild dyspoenic BP 130/80, PR96/min regular, respiratory rate 20/min.chest examination is clear, Heart examination is normal, abdominal examination also normal. Chest X-Ray done for him shows normal lung field with enlarge cardiac globular shadow .He was sent for ECHO study which reveals normal cardiac chamber size& contractility with normal AV& semilunar valve. There is pericardial effusion of 21 mm depth posteriorly with early signs of tamponade. The patient was admitted to the hospital, initial hematological & biochemical investigations were normal. emergency pericardiocentesis done under ECHO & ECG monitoring where 300 CC of deep yellowish fluid aspirated and sent for laboratory study the results are protein =3.1gm/dl.sugar =43mg/dl/.microscopical examination reveals a hemorrhagic background with scattered sheets of atypical epithelial cells highly suggestive of malignant tumor most likely is squamous cell carcinoma of the lung. CT scan of the chest showed 17x19 mm enhanced lung mass at left upper lobe near the aortic arch, no hilar LN with big pericardial effusion.
After three days the patient presented with severe dyspnea & the echo showed big pericardial effusion so surgery is planned. Percardiecctomy with segmental peumonectomy done, the surgery was smooth with normal convalescence. The histopathology of the pericardium did not recognize a malignant involvement and that of the lung revealed moderately differentiated adenocarcinoma, after the healing of the wound the patient reassessed with CX-Ray &ECHO which was normal &he started a course of chemotherapy. He did well for the last 7 months

Osteopetrosis Manifesting As a Femoral Fracture in Childhood: A Case Report

Mahdi Abdul Sahib

Kerbala Journal of Medicine, Volume 4, Issue 9, Pages 1033-1038

osteopetrosis is a genetically determined bone disease that develops as a result of malfunction of osteoclastic activity leading to excessive deposition of immature bone, thickening of cortical bones and narrowing of the medullary cavities. The condition is rare; the overall incidence is estimated to be 2-10 per million populations.
We report a 9-years old child with osteopetrosis presented as pathological femoral fracture.
The clinical characteristics together with the negative family history, radiological findings of generalized osteosclerosis and laboratory results (mild anemia) suggest that our patient probably fits in to the intermediate autosomal recessive group of osteopetrosis.
Management presents a unique technical challenge in these patients because it often resulted in complications including blunting or breakage of drill bits, intraoperative fractures, delayed healing, nonunion and postoperative infections.
This report highlights for technical difficulties during surgery and, hence, prolonged operative time; therefore, preoperative planning is mandatory in the management of fracture in osteopetrotic bone.