Volume 9, Issue 2, Summer and Autumn 2016, Page 2417-2606

Upper & Lower Limbs Early Deep Burn Wound Excisions and Grafting Aided by Methylene Blue

Qutaiba A . Yassin; Aasem M. Al- byati; Mohammed M. Wais

Kerbala Journal of Medicine, Volume 9, Issue 2, Pages 2417-2424

background: Deep burn involve upper and lower limbs may lead to functional problems, interfere with patients life style, increase burn morbidity and mortality which also correlate to burn wound infection and septicemia, early burn excision and autografting minimize this risk, excision of burn wound need precise demarcation of non viable eschar tissue from underlying viable tissue. Methylene Blue using aid in staining of non viable burn eschar by blue color and not staining underling viable tissue this will provide precise demarcation of nonviable tissue and facilitating wound excision and grafting thus will increase graft take and dramatically decrease risk of burn wound infection and improve patients survival
Objectives: To evaluate early surgical excision of upper & lower limbs deep burn (deep second degree & third degree) & autograft aided by Methylene Blue with short term follow up.
Patients and Methods: In this study 28 patients included, 16 males and 12 females, age range from 10 years to 40 years, were treated by early surgical excision of burn wound aided by Methylene Blue staining between April 2014 to October 2015 in Azadi teaching hospital in Kirkuk city.
Results: All patients have single stage of early surgical excision of burn wound aided by Methylene Blue staining and autograft ; family and patients satisfaction were taken in consideration and almost all showed satisfaction, assessment of the results by the surgeon was also accepted in all of the cases, 71.4% of the graft patients have more than 80% graft take .Only 4 patients (14.2%) in this study had minimal postoperative complications.
Conclusion: early surgical excision of deep upper & lower limbs burn wound aided by Methylene Blue staining and autograft is a reasonable treatment option for deep burn of upper and lower limbs, this type of deep burn lead to functional and aesthetic problem and also interfere with patients life style, using this technique improve graft take and decrease hospitalization and risk of morbidity and mortality of burn trauma.
Keywords: Methylene Blue, eschar and autograft.

Evaluation of Cardiovascular Autonomic Dysfunction in Chronic Viral Hepatitis in untreated patients

Mahdy H. AbuRagheif

Kerbala Journal of Medicine, Volume 9, Issue 2, Pages 2425-2431

background: The autonomic nervous system plays a major role in the regulation of the cardiovascular system under both physiological and pathological conditions, Subclinical autonomic dysfunction can, however, occur within a year of diagnosis, and impaired autonomic function has been described in patients with chronic liver diseases from different etiologies, the chronic viral hepatitis (CVH) is the principal cause of chronic liver disease. Patients with CVH have many extrahepatic manifestations, and even with no clear evidence of autonomic nervous system dysfunction. Consequently, the purpose of this study/ to evaluate the cardiovascular autonomic dysfunction in such patients.
Method: Sixty two CVH patients include in this study, (36 patients have CVH B and 26 patients have CVHC), compared with thirty normal, healthy control group in analysis of heart rate, including heart rate in postural change, in deep breathing and valsalva maneuver, and the parameter of blood pressure in the supine position, response to postural change, isometric handgrip.
Result: The results point out to both parasympathetic and sympathetic efferent fibers modulates cardiovascular function is affected, it has been found cardiac autonomic dysfunction in analysis of results recorded in 55.56% of CVHB patients from these percentage 50% patients had subclinical cardiac autonomic dysfunction and 50% had mild clinical cardiovascular autonomic dysfunction, while the CVHC patients 69.23% had cardiovascular autonomic dysfunction, from these percentage 44.44% patients had subclinical cardiac autonomic dysfunction, and 55,56% had mild clinical cardiovascular autonomic dysfunction.
Conclusion: The cardiovascular autonomic neuropathy recorded in patients with CVH, remains mild clinical or subclinical and explained by autonomic function tests.
Keywords: ANS; autonomic nervous system, CVAFT; cardiovascular cardiac autonomic function test, CVH; chronic viral hepatitis, CVHB; chronic viral hepatitis B, CVHC; chronic viral hepatitis C.

Marsupialization after Undermining Excision and Flap-Like Margin Creation vs. (Marsupialization Only) or (Excision and Laying Open) Treatments for Pilonidal Sinus (PNS)

Hadi Awad Hmoud

Kerbala Journal of Medicine, Volume 9, Issue 2, Pages 2432-2335

bAckground: Pilonidal disease treatment should be minimal, minimal pain, short hospitalization, low recurrence rate, minimal wound care, and allow rapid return to normal activity. Unfortunately, no treatment meets all these ideal goals.
Aim: This study is conducted to find out a modality treatment for PNS that can achieve the above goals.
Methodology: It is a retro and prospective study of 51 patients presented with PNS.
All were divided randomly into 3 groups; First group treated by excision of the sinuses and laid the wound open. Second group treated by excision and marsupialization and third group treated by excision of skin containing sinuses’ openings only and further undermined (beneath the skin) resection of the infected tissues with flap forming with marsupialization of flap margins to the sacral fascia .
Results: Healing time; Third group healed earlier.
Post-operative painkillers; Third group needed less painkillers for shorter time.
Return to daily activities; Third group return to their jobs and life activities earlier.
Infection: Third group had only one case of cellulitis.
Recurrent PNS; zero patient from third group had recurrent cellulitis.
Discussion: Third group modality will reduce the tension on sutures and reduce the postoperative pain, and loosening sutures, also further reduces the recurrence rate.
Conclusion: Third group modality yields a promising results in term of reducing the healing time, post-operative pain, recurrence of PNS and infection rates.
It could be widely adopted, and would be largely cost-effective modality, as it will reduce the expenses of caring for wound, antibiotics use, painkiller use and the early return to the job.

Incidence And Risk Factors Of Hypocalcemia After Thyroid Surgery

Haydar Almousawi

Kerbala Journal of Medicine, Volume 9, Issue 2, Pages 2436-2442

background: Hypocalcemia is a major post- operative complication of total thyroidectomy, causing severe symptoms and increasing hospitalization time. The primary cause is secondary hypo-parathyroidism following damage to, or devascularisation of, one or more parathyroid glands during surgery.
Aim: Is to determine the incidence of hypocalcemia after thyroid surgery and find out the risk factors involved leading to hypocalcemia regarding gender and body habitus ,clinical diagnosis, extent of surgery, ligation of the inferior thyroid artery ,pathology report and the experience of the surgeon.
Material and method: Prospective study of 100 patients in Al-Immamian Al-Kadhymian Medical City in peroid between November 2012-November 2013 included in subtotal, near total, total thyroidectomies. Serum calcium is estimated at day 1,2,3 postoperatively.
Results and discussion: Thirty patients developed hypocalcemia postoperatively ,in 24 patients it was transient and in six patients was permanent (three of those six patients had underwent total thyroidectomy ,the other two had underwent near total thyroidectomy and the last patient had underwent subtotal thyroidectomy).
Conclusion: Post-thyroidectomy hypocalcemia is relatively common phenomenon especially after extensive thyroid surgery.

Antibiotics Use in Patients Underwent Appendecectomy at North Middlesex Hospital/ London: A Retrospective Analysis

Emad Geddoa

Kerbala Journal of Medicine, Volume 9, Issue 2, Pages 2443-2450

background: Appendicitis is a common condition that affects patients of all ages. Appendecectomy has been the mainstay for the treatment of acute appendicitis since first reported by McBurney in 1889.
Aim: To describe the effect and outcome of using antibiotics before appendecectomy, and assess whether antibiotic is being used appropriately in patients who have had appendecectomies. The study has also draw conclusions around the impact of inappropriate antibiotic use.
Method: This is a retrospective study at North Middlesex University Hospital „NMUH‟ in London over the period of one year .100 patient notes, those had appendecetomies, were collected on this study between April 2012 and March 2013. The following systems were approached: Admission clerking, Histopathology system, Patient Admission System, Radiology system (PACS), Anesthetic chart, Operation note, Drug chart, and Discharge summary.
Results: 22% of patients had histologically normal appendix and 13% of patients had histologically inflamed appendix were received no prophylactic antibiotics (Augmentin or Clarithromycin if allergic to penicillin + Flagyl). Also 13% of those had histologically proved gangrenous / perforated appendix received no course of antibiotics postoperatively. On the other hand, 11% of those had histologically normal appendix and 30% of patients who had histologically proven mild appendicitis were received unnecessary course of antibiotics after surgery.
Conclusion: 10% of patients had appendecectomies received no prophylactic antibiotic at all. Patients who developed postoperative complications (such as ileus, pelvic collection and surgical site infection) were mainly those who had no antibiotics before surgery. An agreed protocol for antibiotic use is needed to avoid erratic prescription of antibiotic. Also Patients should be followed up after discharge to assess for complication and review histology.

Diagnostic Indications for Upper GIT Endoscopy Prospective Study

Riyadh Zair Alrubaie; Haydar Talib Almousawi

Kerbala Journal of Medicine, Volume 9, Issue 2, Pages 2451-2454

background: Upper GIT endoscopy is considered a safe procedure performed by a doctor, a well-trained subspecialist who uses the endoscope to diagnose and, in some cases, treat problems of the upper digestive system.
Aim: to set a guideline for indications for upper GIT endoscopy in AKadhymiah Teaching Hospital.
Materials And Methods: Prospective study of 600 patients presented with upper GIT symptoms and referred for upper GIT endoscopy.
Results & Discussion: The results suggest the importance of symptoms indicating upper GIT endoscopy are in the following orders, dysphagia, acidity, melaena, vomiting, haematemesis, heartburn, nausea, epigastric pain and dyspepsia.
The highest age incidence with positive endoscopic findings is between 30-40years ,male more than female, (male/female ratio 2/1).
Conclusion: The duration of symptoms over 1 month found to be significant indication.
There is no relation between smoking, alcohol or drug intake with endoscopic findings in our study

The Success Rate of Expectant Management in The Treatment of 1st Trimester Missed Miscarriage

Maysaloon Adnan Abd-Alrazzaq

Kerbala Journal of Medicine, Volume 9, Issue 2, Pages 2455-2461

background: the expectant management has been considered possible alternative to surgical treatment (dilatation & curettage) of 1st trimester pregnancy missed miscarriage.
Aim of study: to determine the successfulness & safety of 2 weeks expectant management for 1st trimester pregnancy missed miscarriage.
Patients & methods: in this study was selected early pregnancy missed miscarriage, pregnant women ≤8weeks & pregnant women from 8-12 weeks.
150 cases of missed miscarriage were collected but only 128 women agreed for expectant management after counseling. Which they are randomly selected managed expectantly over 7-14 days periods.
Results: The results were found that the expectant management being successful in 65.6% (84/128) cases while being unsuccessful in 34.4% (44/128). 128 patients of this study attended follow-up to the karballa maternity hospital and were triaged by assessments of symptoms.
80 0f the patients ≤8 weeks the success rate was 100%,which is statistically highly significant =0.001
while 48 of patients 8-12 weeks success rate only 8.3% (4/48) while not success 91.7%(40/44)
Discussion: Expectant management of 1st trimester missed miscarriage has been found now days to be a good alternative to other methods for treatment of missed miscarriage.
It is safe, effective with good success rate which is 65.6% which is statistically highly significant. P=0.001
Conclusion: Expectant management appears to be sufficiently successful, safe and effective to be offered as an option for women with 1st trimester missed miscarriage.

Comparison between The Efficacy of Combined Metformin – Letrazole with Metformin – Clomiphene Citrate in Polycystic Ovarian Syndrome

Shiemaa; Mohsen Mohammad Al-Khafaje

Kerbala Journal of Medicine, Volume 9, Issue 2, Pages 2462-2469

background: Adding Metformin to clomiphene citrate in clomiphene –resistant PCOS patients increases ovulatory response. However because of anti-estrogenic effects of clomiphene it may be associated with lower pregnancy rate. Offsetting the ovulation rate benefit, Letrazole is an aromatase inhibitor which induce ovulation without antiestogenic effects.
Aim of Study: is to induce ovulation& increase the pregnancy rate and live birth rate in patient with PCOS using a new era of therapy with less side effects, less complications and better patient compliance.
Materials and Methods: The study is a single – blind randomized clinical trial , 120 ovarian cycle were studied in 60 clomiphene – resistant patients with PCOS , who were chosen among 115 PCOS patients attending infertility clinic in Samawa city – Iraq during the years 2011 – 2012 Infertile women with PCOS were randomly divided into Metformin –Letrazole (29 patients) and Metformin – clomiphene groups (30 patients) after an initial 6 – 8 weeks of metformin.They received either Letrazole (5mg) from2nd to 7th day orclomiphene citrate (100mg)daily from 5th to 9th day of menstrualcycle . Estradiol (E2) level , number of follicles and endometrial thickness were measured on the day of HCG administration .The pregnancy rate of both groups also estimated.
Results: Mean total E2 and E2per mature follicle were significantly higher in clomiphene group without a difference in mean number of follicles ≥ 18mm and ovulation rate .
Endometrialthickness was significantly higher in Letrazole group .Thepregnancy rate in Letrazole group (10 patients, 34.50%) as compared with clomiphene group (5 patients 16.6%) did not show significant difference, whereas full – termpregnancies were higher in Letrazole group (10 patients 34.5%) versus 3 patients (10%).
Conclusion: In clomiphene resistant PCOS, the combination of Letrazole and Metformin leads to higher full term pregnanciesas compared with clomiphene and Metformin .

Injectable Bulking Agents in the Treatment of Female Stress Urinary Incontinence due to Intrinsic Sphincter Deficiency

Ahmed H. Al-Shareef; Yasamin Hamza Sharif Al-Shibany; Alaq Saeed Abdulhussain

Kerbala Journal of Medicine, Volume 9, Issue 2, Pages 2470-2478

ackground and objectives: Stress urinary incontinence(SUI) has a significant impact on the quality of life for many women and it is caused by weakening of pelvic floor muscle that support the bladder and urethra. It affects (1 of 3 women) and it is often associated with childbearing and can be defined as a brief involuntary loss of urine due to increase abdominal pressure in the absence of detrusor activity.
Injectable agents have been used to manage SUI for more than a decade but their application has been limited by placement, durability, antigenicity and other compatibility issues. Therefore, there is a continuous development of techniques and materials for newer bulking agents. Our study was to evaluate the efficacy and safety of the urethral injectable agent DEXELL SUI in women with stress urinary incontinence after 12 months follow up.
Materials and Methods: A prospective, cohort study conducted in Iraq from January 2014 – January 2016 and data for the study was including 25 female patients (20 -52) years old with SUI due to intrinsic sphincter deficiency attending the department of Obstetrics and Gynecology, Urological department, out patients and privet clinic in Al-Diwaniya and AL-Najaf cities. All patients were treated with DEXELL SUI periurethral injection under local anesthesia. Patients were evaluated for efficacy and safety parameters at 6 weeks visit, 3 months and 12 months visit after injection.
Results: The mean stamey incontinence grade significantly decreased from 1.92 at baseline visit to 0.28 at 12 months visit(P<0.001).None of the patients were dry at baseline,64% were dry at 6 week visit, 80% at 3 months visit and 72% at 12 months visit. There was significant reduction in number of pads used per 6 hours per day from 2.44 to 0.40 after 12 months visit(P<0.001). Eight patients (32%)developed minor complications related to injection procedure and all were treated successfully.
Conclusion: DEXELL SUI is effective urethral bulking agents with moderate adverse effects used in the treatment of female SUI due to intrinsic sphincter deficiency with less invasive technique.

Diagnostic accuracy of panoramic maxillary sinus projection in patients with maxillary bone fractures according to CT scan findings

Ali S. Al-Haddad

Kerbala Journal of Medicine, Volume 9, Issue 2, Pages 2479-2482

background: Diagnostic imaging has been of recent and unique importance in substantiating the clinically suspected existence of the midface fracture and it is essential to be aware of the various procedures available to help initially in establishing an accurate diagnosis. The aim of the study is to evaluate the diagnostic accuracy of panoramic maxillary sinus projection according to computed tomographical findings in patients with maxillary bone fractures to be used as an emergency radiographic diagnostic aid.
Subjects, material and methods: Thirty patients with a midfacial trauma and twenty patients suspected to having midfacial fractures. All subjects were examined radiographically using panoramic maxillary sinus imaging system to evaluate the maxillary bone and recorded as either “positive” or “negative” according to the positive computed tomographical maxillary bone fracture findings.
Results: Panoramic maxillary sinus projection was 87.5% sensitive in detecting maxillary bone fractures line with 96% accuracy and it can establish the diagnosis of any maxillary bone fracture with 100% confidence in any clinical setting.
Conclusion: If panoramic maxillary sinus imaging is performed as the first imaging modality in case of suspected midfacial fractures by an experienced investigator, the visualization of fracture line can avoid conventional imaging, so that only an indicated computed tomography scan can be added.

Assessment Of Her-2/Neu Gene Amplification Status by Chromogenic in Situ Hybridization in Breast Cancer Patients with Equivocal 2+ Her-2/Neu Immunostaining and Its Relation to The Clinic Pathological Parameters

Rasha Abdul Raouf ALSafi; Sahira A. Ali; Ali Hausin Al-Khafaj; Manal Adnan Habib

Kerbala Journal of Medicine, Volume 9, Issue 2, Pages 2483-2490

background: human epidermal growth factor receptor-2 (her2/neu) is related to growth factor receptors with alkaline kinase activity and it is regarded as important prognostic and therapeutic factor that can depended on in breast cancer therapy. HER2/neu expression by immunohistochemistry (IHC) is submitted to a great in terob server inconsistency. Subsequently additional confirmatory tests for assessment of gene alterations and amplification status are needed for patients with early or metastatic breast cancer. In situ hybridization techniques and specifically Chromogenic in situ hybridization (CISH) was arise as a practical, cost-effective, and alternative to fluorescent in situ hybridization in testing for gene alteration
Aims of the study: was to determinate her2/neu gene amplification in (27) breast cancer cases with equivocal her2/neu (2+) detected by IHC by using dual-color chromogenic in situ hybridization (CISH) method and to compare the results with clinic-pathological parameters of those patients like age, stage, grade, ER, PR and ki-67.
Methods: twenty seven breast-cancer cases with equivocal HER2-IHC(2+) test results were prospectively collected and reanalyzedusing dual-color CISH (Zyto- Vision) detection kit for further identification of her2/neu gene amplification.
Results: Cases with equivocal staining for her2/neu were about 27 cases; these cases were involved in chromogenic in situ hybridization technique to determine the status of her2/neu gene. After CISH study 12(44.4%)cases show her2/neu gene amplification (her2/neu/CEN17 ratio > 2.2).In15 (55.5%) cases out of 27 cases, no amplification of the HER2 gene was shown (her2/neu/CEN17 ratio <1.8).
Conclusions: A significant proportion of patients with equivocal IHC(2+) test results show amplification of the HER2 gene by ISH.CISH method has the advantage of diagnosis of gene amplification and revealing tissue histopathology under light microscope.

Measurement of Zinc Concentration in Human Blood Serum Byspectophotometric Methods

Hussain Hasan Kharnoob

Kerbala Journal of Medicine, Volume 9, Issue 2, Pages 2491-2497

background: speciation of zinc means the determination of the concentration of chemical formula of zinc species which is more indicated than total concentration of zinc for clinical diagnosis. It was shown that atomic absortion spectrometry is good technique for measuring of total concentration of zinc after digestion of the serum with concentrated nitric acid and concentrated perchloricacid, while ionic concentration of zinc was determined by visible spectrometry.
Study design and objective :this study was conducted control healthy people from the workers in Tikrit teaching hospital,gendar (10male + 10 female) and their ages are between (35-70(years. This study aimes to find relation between the concentration of bound zinc in human blood serum and ischemaic heart disease.
Methods: bloods samples were collected from clincilay suspected patients who attend teaching hospital in salah-aldingovernate with sign and symtoms of ischemic heart disease (proven by specialist physician). Blood samples were centrifugated and serum was separated to examine for speciation of zinc concentration
Results: the zinc was determined by two analytical methods. The first method is visible spectrophotometry, the absorbance was measured at wavelength 578 nm and the zinc label as ionic zinc. The second method is atomic absorption spectrophotometrymetry, the absorbance was measurd at wavelength 213 nm and the zinc label as total zinc. The bound zinc was mathmetical calculated, which is higher in patients than control groups
Conclusion:according to the study data, it was concluded that the level of total zinc higher than ionic zinc in control and patient, and the levels of ionic and total zinc in patient groups are lower than their levels in control groups
List of abbreviation:
FAAS: Flame Atomic Absorption Spectrometry
GFAAS: Graphite Furnace Atomic Absorption Spectrometry

Perceived Severity and Susceptibility of Type II Diabetes Among Youth

Mohammed Abdulridha Merzah

Kerbala Journal of Medicine, Volume 9, Issue 2, Pages 2498-2504

background: In 2012, the prevalence rate of Type II diabetes among American population was 29.1 million, or 9.3% of population. As many as 1 in 3 American adults will have diabetes (Type I or Type II) in 2050 if present trends continue. Higher perceived severity and susceptibility of its risky factors may cause a higher level of attitudes toward practicing healthy behaviors among these subjects.
Objective: The aim of this study was to determine the constructs’ status, knowledge about Type II diabetes, and their related factors among college students.
Methods: This cross-sectional study was carried out on 223 undergraduate students who enrolled in Southern Illinois University at Carbondale (SIUC) in a non- random convenience way. A questionnaire was used for data collection which measured the perceived severity and susceptibility and knowledge regarding Type II diabetes. Subjects’ demographic variables such as age, sex, race/ethnicity, family history of diabetes, exercise level, and BMI were also recorded.
Results: 1.85 and 2.10 out of 4 were revealed as grand means of perceived susceptibility and perceived severity, respectively. Participants’ chances of suffering from Type II Diabetes in the next few years as great was perceived at the highest level of susceptibility and concerning about the likelihood of having Type II diabetes in the future was at the lowest level. Whole life would be change due to having Type II diabetes was at the highest level of perceived severity while dyeing within 10 years due to having Type II diabetes was at the lowest level. Family history was the best predictor of perceived susceptibility to Type II diabetes.
Conclusion: Despite the fact that belief in the seriousness of the disease among subjects was at favorable level, their perceived susceptibility was low. Increasing perceived susceptibility and severity may induce an increase in practicing healthy behaviors among college students.

Effect of Zinc Sulfate on Kidney Function in Cisplatin-Treated Cancer Patients

Ihsan Salah Rabeea; Amina Abdul Baqi Al Dujeli; Fadhil Abdul Jabbar Rizij; Ayad Ali Hussein

Kerbala Journal of Medicine, Volume 9, Issue 2, Pages 2505-2512

background: cisplatin is a potent chemotherapeutic agent that is currently used in management of many and various types of tumors. Cisplatin causes dose-related nephrotoxicity that significantly affects kidney function and limits cisplatin use with maximum required dose and usefulness. This study was to assess the protective and ameliorativen effect of zinc sulfate on kidney function and nephrotoxicity caused by cisplatin in cancer patients.
Patients and methods: 41 patients were enrolled in the study and were randomized into two groups. Patients in group I (N=20) received cisplatin based regimen every 21 days for six consecutive cycles. Patients in group II (N=21) received zinc sulfate plus cisplatin based regimen during the six consecutive cycles of treatment. Serum urea, creatinine and magnesium levels were measured at base line and 21 days after 1, 2, 4 and 6 cycles of cisplatin based regimen. The glomerular filtration rate of patients was calculated according to updated version of the Modification of Diet in renal Diseases formula.
Results: In group I, cisplatin based regimen after 6 cycles of treatment caused significant (P<0.05) increment in serum urea and creatinine and significant (P<0.05) decline in The glomerular filtration rate and magnesium in comparison to base line levels. Serum urea and creatinine levels of group II were significantly (P<0.05) lower than that of group I while glomerular filtration rate and magnesium were significantly (P<0.05) higher than that of group I.
Conclusion: zinc sulfate significantly ameliorated nephrotoxicity and improving kidney function in cisplatin-treated patients.

Study of Immune Adjuvant Activity of Propolis against MRSA in Laboratory Animals

Salim H. H. AL-Greti; Mohammad A. K. Al-Saadi

Kerbala Journal of Medicine, Volume 9, Issue 2, Pages 2513-2522

background: Propolis is a natural resinous product that honeybees collect from several plants and mix it with bees wax and salivary enzymes that is also called bee glue. Propolis has many properties that make it is chief in the medicine including antibacterial, antiviral, antifungal, antitumor and immunodulatory properties.
Aim: The aim of this study was to evaluate immune adjuvant activity of propolis against Methicillin Resistant Staphylococcus aureus MRSA in vivo.
Materials and Methods: Twenty male white New Zealand rabbits included in this study, that divided into tow groups (10 rabbits at each one), group I received orally one milliliter of Ethanolic Exract Propolis (EEP) at 20% concentration per day for lasting 20 days, while group II have no received any thing as control group. After 10 days from last dose of adminstration of EEP, all animals injected in intraperitonial (IP) with six doses of 108 cfu/ ml of killed somatic antigen of Staphylococcus aureus. Blood samples were taken by heart puncture from all animals to detect the immunological parameters by ELISA technique.
Results: Results revealed to significantly increased the mean value of total leukocytes counts (TLCs) in group I (5705 cells/mm3) as comparing with group II (4600 cells/mm 3), at level p ˂ 0.05, as well as the results pointed to increased significantly the percentage of neutrophil cells in group I (42%) as compared with group II (34%), in contrast to lymphocytes results that show significantly decrease in group I ( 54% ) as compared with group II ( 61%), in addition, monocytes, eosinophil and basophil were have no differences among the testing groups. Phagocytic activity result shows increased significantly in group I (55.47%) as compared with group II (43.94%). The results of complement component C3 revealed increased significantly in group I (69.76 pg/mL) as compared with group II (18.61 pg/mL), while the results of C4 concentration pointed to increase significantly in group I (4.20 pg/ml) as compared with group II (2.38 pg. /ml). IFN-γ concentration results revealed increased significantly in group I (22.18 pg/mL) as compared with group II (18.05 pg/mL. IL-2 results referred to increased significantly in group I (32.42 pg/mL) as compared with group II (24.27 pg/mL). On the other hand, the level of perforin was increased significantly in group I (0.23 ng/ mL) as compared with group II (0.12 ng/ mL).
Conclusion: It was concluded that propolis improve immune responses as adjuvant against MRSA antigen via increase the levels of cellular immunity elements.

Morphological Study of the mice’s Islets of Langerhans and β-cells mass assessment during Pregnancy and lactation conditions

May F. Al-Habib; Hayder H. Abdulameer; Ahmad H Abood

Kerbala Journal of Medicine, Volume 9, Issue 2, Pages 2523-2533

ackground: Islets of langerhans adapts to changing insulin demands in the body. One of the most amazing reversible islets of langerhansadaptations occurs during pregnancy and postpartum conditions. During pregnancy,β-cells mass expand by increasing their number and size . and they are rapidly reversed at end of pregnancy by β- cell apoptosis and retained to normal level .
Objectives: This study attempt to demonstrate the changes of the islets of langerhans that happen during pregnancy and lactation including changes in the general morphological and histological features, changes in the certain islets’ parameters e.g. number ,diameter and mean areas, and changes in the β – cells mass.
Material and Methods: We were used thirty female mice which divided into (3) groups ten for each group. Group(A): served as a control. Group(B) was pregnant group (at day 15 of gestation). Group(C) was lactating group (at day 4 of Postpartum). Tissues were processed for both paraffin block and semithin plastic sections . Tissue sections were stained with H&E stain, Gomoritri chrome stain and NDS. Two digital image analysing soft wares were used in this study: Image J program and Image Scope program
Results: It was demonstrated that the formation of new islets, enlargement of islets by union of adjacent small islets and by increased their cellularity were common features of pregnant group. also it was showed that in postpartum group, apoptosis of beta -cells started to restore the beta- cell number to normal level. The morphometric analysis of the islets parameters in this study showed a highly significant differences among the studied groups with P value ≤ 0.001. The mean number , mean diameter and mean area of islets were significantly higher in pregnant group, intermediate in lactating group and lowest in control group. In this study, the result also showed that the β-cell mass rose near the doubled during pregnancy as compared with control group, then decreased by 25% at 4th day of postpartum. This study conclude that islets of langerhans subjected to natural compensatory changes during pregnancy then they retain to normal state when pregnancy ended

Antihypertensive Drugs patterns in Diabetes Mellitus and Their Impact on Glycemic Control

Amir Omran

Kerbala Journal of Medicine, Volume 9, Issue 2, Pages 2534-2542

background: Hypertension management is paramount important in diabetic patients for cardiovascular events reduction. The utilization patterns of antihypertensive agents in diabetic patients must be consistent with recommended guidelines practice to produce a positive metabolic effect on glycemic control with proper control blood pressure and good compliance.
Objectives: The study aims to evaluate utilization prescribing pattern of five groups of antihypertensive agents among Type2 diabetic hypertensive patients and to explore the adherence to prescribing existing guidelines and their impacts on glycemic control.
Design: retrospective descriptive ,cross sectional study
Patients and Methods: A total of 230 Hypertensive Type2 diabetes patients on diet , Metformin and sulphonylureas drugs were enrolled in the study in diabetic clinic at Imam Al-Hussien medical city . The study was done between Jan 2009 And Jan 2014. The attendants' patients used five groups of the Anti-Hypertensive agents in single or in combinations patterns Angiotensin Converting enzymes inhibitor(ACEI), Angiotensin Receptor Blocker(ARB), Calcium Channels Antagonist(CCA), Beta Blocker(BB), Diuretics(Thiazide)). The study followed five groups of antihypertensive drugs for three months to evaluate prescribing patterns accordance to the evidence base guidelines and compare their impact on glycemic control. The study include gender, Age, age distribution, Glycemic control. The study excluded endocrine, liver, and renal diseases, and patients using steroids.
Results: The majority of the patients on Antihypertensive drugs 191 patients (83%) were receiving monotherapy including ACEI 77 ( 33.5%) patient, ARB 46( 20%)patient, BB 60(26.1%) patint, CCB 6 patients (2.6%),Thiazide 2 (0.9%) patients, while two or three drugs combined patterns formed 39 ( 16.95%) patient.
The proper and adequate glycemic control of both genders are 25.2% . The proper glycemic control of males 40.9% and in females16,7%( P˂0.05) , There were no significant differences of the impact on glycemic control compared between five groups, ACE or ARB compared with single BB (Atenolol, Metaprolol) or CCB, Diuretics, as monotherapy or polytherapy combination patterns.
Conclusion; The utilization patterns of Antihypertensive agents (ACEI,ARBS,BBS) were more commonly prescribed followed by CCB, Thiazide Diuretics ,irrespective of mono or polytherapy. The majority of the patients were on monotherapy pattern.
There was no significant difference among the five groups of Antihypertensive drugs regarding the impact on glycemic control.

Low Maternal Serum Vitamin D Level at Early Pregnancy and Subsequent Risk of Gestational Diabetes in Women with History of Previous Gestational Diabetes

Tareq Althuwaini; Saba M. Swadi AL-Thweeni

Kerbala Journal of Medicine, Volume 9, Issue 2, Pages 2543-2549

background and Objective: GDM is a common condition during pregnancy which is associated with negative short-term and long-term outcomes both for mothers and offspring. Accumulating evidence links vitamin D deficiency with abnormal glucose metabolism. We performed this survey to investigate the predictive value of vitamin D deficiency as risk factor of GDM and, to evaluate the role of its replacement and incidence of development of GDM.
Methods : Cohort study design was conducted in AL -Qadisia City .It included 60 pregnant women with previous history of GDM, and low level of vitamin D at this pregnancy which measured using enzyme immunoassay with cut- off point less than 20 ngml . FBS measured by photometric method .Then we divided the study population into : group1 include 30 women that given vitamin D from 16 weeks gestation till delivery. group2 include also 30 women who did not received vitamin .

Result: In our study , low level of vitamin D (MS vitamin D was 11.65+3.23 ng/ml) and normal FBS at 14-16 weeks gestation, the mean age of women was(28.83 +6.03 years). After follow up: group 2 had significantly higher level of FBS than in group 1, 155.77+41.30 versus 110.10+36.86 (P<0.001), and the number and percentage of diabetic patients was also significantly greater in group2 than in group 1, n=22 ,73.33% versus n=6 ,20% (P<0.001).Conclusion: There is a statistically significant positive correlation between vitamin D deficiency and subsequent risk of GDM and in addition, vitamin D replacement significantly reduced the incidence of development of GDM in study population.

Various Modalities in the Management of Large Bowel Volvulus

Amir Kareem Sultan; Sabah Kerim Al-husseiny; Jaber Mohsin Al-Goraby

Kerbala Journal of Medicine, Volume 9, Issue 2, Pages 2550-2556

ackground: Volvulus is twisting or axial rotation of a portion of bowel about its mesentery, colonic volvulus accounts for 10% to 30% of all large-bowel obstructions and occurs most commonly in the sigmoid colon.
Aim of study: To clarify factors contribute to the problem (large intestinal volvulus) and how can we manage these factors in various modalities of surgical treatment.
Patients and methods: A prospective study included (22) patients with large intestinal volvulus who were admitted to the emergency department and managed in the department of General Surgery, Baghdad Teaching Hospital Medical city, Iraq, during the period Oct. 2007 to Dec. 2009. In addition to demographic data, types of volvulus, and predisposing factors were identified. The diagnosis made according to the history, clinical features, and investigations; plain abdominal X-ray, hematological investigations and colonoscopy.
Results: The mean age of the patients was 60.7± 23.4 (range 28-95) years. Males were 15/22 and females were 7/22. Sigmoid volvulus was the most common reported type in (91%) of the patients while cecum volvulus in the remaining (9%). The main presenting symptoms and signs were absolute constipation in 20 (91%) patients, generalized abdominal distension in 20 (91%), and abdominal pain and tenderness in 19 (86%) patients. Emergency surgery performed in (63.6%) of patients and the other (37.4%) were subjected to elective surgery. During surgery viable bowel was found in (19) patients (86%), while non-viable bowel was found in (3) patients (14%). Post-operative complications were detected in 4 patients (18%) and unfortunately one patient (4.5%) died.
Conclusion: Volvulus of the colon is more frequent in males. Old age individuals seems to be the most affected group by sigmoid colon volvulus, Most cases can be treated conservatively, at first; by lower GIT endoscopy or by insert rectal tube to do reduction of colon then treated as elective definitive surgery after good preparation so can reduce the postoperative complications, in emergency surgery, if have viable bowel and stable patient we can do resection and primary anastomosis.

Risk Factors of Chronic Non-Communicable Diseases in Urban and Rural areas in Kerbala Governorate

Hassan Ali Abood Nassrullah

Kerbala Journal of Medicine, Volume 9, Issue 2, Pages 2557-2564

ackground: Urban and rural population have different life style, including diet, physical activity, habits, and this can have an influence on the prevalence of chronic none communicable diseases.
Objectives: To compare the prevalence of risk factors for chronic non-communicable diseases between urban and rural population sin Kerbala governorate in Iraq.
Methods: A cross-sectional survey was conducted from 16th Jan throughout Feb 2006 on the prevalence of none communicable diseases risk factors using the world health organization STEPS instrument. Data collected by direct interview with the 150 individuals adults (25-65 years old) from different parts of Kerbala governorate, 100 living in urban areas and 50 living in rural areas with nearly equal age and gender distribution. Data collected include demographic characteristics, lifestyle and risk factors (tobacco use, dietary habits regarding fruits and vegetables and oil or fat consumption, physical activity, and history of hypertension or diabetes mellitus). Physical examinations performed to measure blood, height, weight, body mass index, and waist circumference. Biochemical analysis tested the levels of glucose, high-density-lipoprotein cholesterol, low-density lipoprotein cholesterol, total cholesterol, and triglycerides.
Results: Income was lower in rural respondents. Smoking was more prevalent in rural respondents (35.4% vs. 19.4%). Fruits and vegetables consumption was higher in rural respondents. Participants consuming ≥ 5servings /day 27% in rural areas vs. 22.4% in urban areas. Low physical activity was high in both urban and rural participants 37.8% in urban and 43.8% in rural areas. Obesity and overweight was more prevalent in urban participants 70.8% vs 43.8% in rural participants. Hypertension was more prevalent in urban respondents 40% vs. 34% in rural. Fasting blood glucose showed impaired blood glucose and diabetes mellitus in urban respondents respectively 32.6% and 9.5% vs. 25% and 4.5% in rural. Hypercholesterolemia was more prevalent in urban participants 54% vs. 29.4% in rural while high-density lipoprotein cholesterol was lower in rural than urban participants (51.3% vs. 38%). Serum triglyceride was nearly the same in both urban and rural participants.
Conclusion: Risk factors in urban participants that were higher than those in rural participants were, low consumption of fruits and vegetables, high prevalence of overweight and obesity, HT, impaired blood glucose and DM, and hypercholesterolemia.
Smoking and low HDL cholesterol in rural participants were higher than those in urban participants.

Antinociceptive Effect of Peppermint in Mice

Rasheed Muhsin; Haifa

Kerbala Journal of Medicine, Volume 9, Issue 2, Pages 2565-2568

background: Menthol the primary component of the essential oil of peppermint is thought to be responsible for most. of its properties. It is thought to provide. a local anesthetic action and be of use in musculoskeletal pain, but with no. experimental evidence for analgesic activity with respect to the. leaves of this plant.
Methods: Forty Swiss mice of either. sex (weighing 20-25grams) was used in this study, divided into five. groups each with eight animals. Group 1: receiving distilled water. Groups 2, 3&4: pre-treated. with aqueous extract of peppermint in doses 50, 75 and 100 mg/kg, orally. Respectively, and Group 5: pre-treated with .standard drug (Ibuprofen 100 mg/kg), orally. The analgesic activity. was determined by radiant heat Tail-flick method in mice and converted (using special equation) to maximum. possible effect. The results are reported as mean ± S.E.M and analyzed with ANOVA followed by Dunetts multiple comparison test. The results. were significant at p<0.05.
Results: The Maximal. Possible Effect (%MPE) was significant when peppermint was. used in a dose of 100mg/kg, and not significant when was used in doses of 50mg/kg &75mg/kg as compared. to % MPE of Ibuprofen.
Conclusion: Peppermint has. analgesic effect when given orally as aqueous extract of dried leaves. in a dose of 100mg/kg in mice.

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.

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.

Rhinoscleroma in Karbala -- Case Report --

Ahmed Abdullah Alwan; Nadhim Omran Khadhim; Haider Jebur Kehiosh

Kerbala Journal of Medicine, Volume 9, Issue 2, Pages 2582-2587

a 14 year old boy presented with a history of progressive nasal obstruction with frequent bleeding episodes, for the last three months. The otolaryngological examination revealed slight dilated and flattened nose with grey red lobulated mass filling only the right side of the nose with no extension to the postnasal space. The mass excised completely and send for histopathology and the result was highly suggestive of chronic granulomatous inflammation of sinonasal cavity. The condition recurs six months later and the patient presented with the same lesion filling both sides of the nose. The patient underwent complete excision of the mass. The pathological report consistent with rhinoscleroma. The patient received ciprofloxacin with good improvement. He has remained asymptomatic up to the last visit six months following treatment and has shown no evidence of recurrence. This case report to raise awareness of this condition among physicians and aid in early diagnosis so as to reduce morbidity.

Correlation and frequency of HER-2/neu Status With Estrogen and Progesterone Receptors in Breast Carcinomas

Nazar J. Metib; Haider Jebur Kehiosh; Sabah K. Hamzah

Kerbala Journal of Medicine, Volume 9, Issue 2, Pages 2588-2599

background: Breast cancer is the most common malignant tumor in Iraqi females accounting for a third of registered female cancers. Prognosis and management are influenced by the classic variables such as histologic type and grade, in addition to tumor size, lymph node status, status of hormone receptors of the tumor and HER-2/neu status. HER-2/ neu, also known as c-erb B-2 (HER-2), a proto-oncogene located on chromosome 17, is amplified and/or the protein (HER-2) overexpressed in 15% to 25% of invasive breast carcinomas and is associated with a worse clinical outcome. The interrelationship of ER(estrogen receptor), PR (progesterone receptor), and HER-2 expression in invasive breast cancer has come to have an important role in the management of breast cancer. It has been shown that patients with breast carcinoma overexpressing HER-2 do not respond to tamoxifen therapy.
Objectives: To evaluate HER-2/neu overexpression in breast cancer by immunohistochemical study and to study the correlation between HER-2/neu status and expression of ER and PR receptors and other clinicopathological features in invasive breast carcinoma.
Patients and methods: Immunohistochemical analyses were performed successfully for ER, PR, HER-2/neu by streptavidin biotin indirect immunohistochemical methods using monoclonal antibodies for 41 specimens of formalin-fixed, paraffin embedded breast cancer tissue.
Results:. There was a significant difference in HER-2/neu overexpression between invasive ductal carcinoma of NOS (Not Otherwise Specified) type from other histopathologic types (lobular, and specified type ductal carcinoma). No significant correlation was observed between HER-2/neu overexpression and higher histological grades of invasive ductal carcinoma. The expression of ER or PR was decreased significantly in HER-2/neu positive tumors in comparison with HER-2 negative tumors .Only 7.3 % of all cases (3/41) were negative for estrogen , progesterone receptors (ER/PR) and HER2/neu oncoprotein (Triple negative breast cancers).The two cases of lobular carcinoma and the three cases of the special-type carcinomas were negative for HER-2/neu.
Conclusions: HER-2/neu protein was expressed more in ductal carcinoma ( NOS type ) than in lobular or in carcinoma of special type and frequently detected in higher-grade invasive ductal carcinoma tumors.The expression of ER or PR was decreased significantly in HER-2/neu positive tumors. HER-2/neu positivity was not correlated with other clinico-pathological parameters like age of the patient, menopausal state, primary tumor size and axillary lymph nodes status.

Clinical Significance of High First Trimester C- reactive Protein in Prediction for Development of Gestational Diabetes Mellitus

Saba M. Swadi AL-Thweeni

Kerbala Journal of Medicine, Volume 9, Issue 2, Pages 2599-2606

ackground: GDM is glucose intolerance with onset or first recognition during pregnancy, it has been associated with not only acute increased risk for complications of pregnancy but also long-term disease risks for both mother and baby due to inflammation that plays a key role in the pathogenesis of GDM. The need of a reliable early test to diagnose and predict GDM earlier is important for development of useful intervention therapies that may impact not only on the acute but long-term health outcomes.
Objective: We performed this survey to investigate the predictive value of the of first-trimester serum CRP as screening test of gestational diabetes mellitus and, to evaluate the correlation between high CRP and body mass index (BMI).
Patients and Methods: A prospective cohort study design was conducted in AL -Qadisia City in Iraq from January 2012 to January 2015. Data for the study was collected from patients attending the department of Obstetrics and Gynaecology ,outpatient and private clinic. It included 110 low risk pregnant women at first trimester(8-13 weeks). Study was included after meeting inclusion and exclusion criteria. Venous blood was screened for plasmatic C reactive protein by CLIA system to measure C reactive protein in values with cut- off point of high level more than 3mg/L , fasting blood sugar by photometric method and in addition to routine antenatal tests. They were followed up to delivery by continue to measure fasting blood sugar between 24-28 week and after 28 week of gestation . Also for assessing of complications (10 women were lost to follow ,so only 100 women were finally available).
Results: In total, 100 low risk pregnant women at first trimester with high CRP(>3mgL), (mean+SD 5.33+1.61), 88% of them developed GDM, 53women developed between 24-28week(early GDM, group1),35women developed >28 week(late GDM ,group2),while 12 of them remain normal(group3). CRP was significantly high in group1 comparing to group2 and group3 ( mean+SD 6.383+ 1.439 , p< 0.001). BMI was also significantly high in group1 comparing to group2 and group3 (100% versus14.8%). Maternal and fetal complications were significantly less frequent in women with group1 than group2 (1.88%, 11.32% and 17.14%, 28.57%) (p=0.010, 0.040) respectively.
Conclusions: We did find a significant correlation between high maternal serum CRP level at first trimester and subsequent development of gestational diabetes and also, our study showed a significant correlation between pre-pregnancy BMI and CRP in early gestational diabetic women