Karbala Journal of Medicine

b
choolbags used by students has become the most popular means of carrying belongings
to and from school all over the world. The aim of this study is to review the literature
and to ascertain the recommended average weight of schoolbags in comparison to child
Body Weight (BW), to describe the correct way of schoolbag carrying and to determine risk
factors related to carriage of schoolbags in an attempt to suggest the alternatives to avoid or at
least to reduce these drawbacks. The majority of reports indicated that schoolbag greater than
the recommended weight (10% of student BW) for long period of time might affect the
musculoskeletal alignment which will cause back pain, neck pain, and shoulder pain in
addition to deformities in the stature.
Recent literature focused on schoolbag weight, the manner and duration of carriage, the age
and gender of the student which could affect the shoulders, cervical and thoraco-lumber
spines of students. A general guideline of 10% BW was initially proposed by a Germans
(Voll and Klimt) in 1977. Many of studies later on continued to recommend and emphasize
that the schoolbag load should not exceed this limit. The best way to carry schoolbag is on
both shoulders with well-padded straps and hip belts for proper distribution of the load. The
duration of carriage is also an important factor influencing cervical and shoulder posture and
could contribute to and maintain musculoskeletal symptoms. Student age was found to be
significantly associated with developing musculoskeletal disorders, especially among
adolescent children (11-14 years). Gender was another significant predictor with girls
showing more symptoms than boys of similar age. Back pain is the most frequent
musculoskeletal problem and shoulder pain was the second most common symptom among
children.
Preventive measures such as limiting carrying load and correcting way of carrying are multi
faceted and need to be implemented in cooperation between different authorities including
the students and their parents, the Ministry of Education and media in order to achieve these
goals.

b
ackground: The pioneers of thyroid surgery, Theodor Kocher and Theodor Billroth,
developed an acceptable technique of standardized thyroid surgery in the nineteenth
century. It includes three basic principles: identification and ligation of the feeding
vessels, identification and preservation of the laryngeal nerves and identification and
preservation of the parathyroid glands. The basic surgical instruments have not significantly
changed, the main innovations are new methods of coagulation and vascular section.
Aim: to compare the outcomes of total thyroidectomy and lobectomy, utilizing the
conventional hemostatic technique (CH) and harmonic scalpel technique (HS).
Patients and Methods: This study was carried at Al-Hussein medical city. In one group the
tie and ligature technique was applied and the new harmonic scalpel technique was applied to
the other group.
The study variables are: operative time, post-operative drainage volume, recurrent laryngeal
nerve (RLN) status and total serum calcium level in total thyroidectomy group.
Student’s t test was used to compare quantitative variables, chi square test was to compare
qualitative variables.
Results: Seventy patients were included in this study, 40 patients had total thyroidectomy,
and 30 patients underwent lobectomy.
The mean operative time, in the total thyroidectomy group, was 83.4±13.2 minutes versus
60.3±5.3 minutes in the CH and HS respectively. And it was statistically significant. In the
lobectomy group, the mean operative Time was 47.8±7.3 minute versus 38.8±6.8 minute in
the CH and HS respectively. It was statistically significant.
Post-operative drainage, in the total thyroidectomy group, was 128.6 ± 11.1 ml versus 98.1±
10.3 ml in the CH and HS group respectively. In the lobectomy group, it was 116.4±21.1 ml
versus 62.8±8.6 ml in the CH and HS group respectively. And both are highly significant.
Regarding RLN palsy, in the total thyroidectomy group, 2 patients out of 20 with CH versus
3 out of 20 with HS, sustained RLN palsy but statistically was non-significant. In the
lobectomy group, 2 patients out of 14 with CH versus zero out of 16 patients with HS
sustained RLN palsy also was non-significant.
Regarding hypocalcaemia, in the total thyroidectomy group, 4 patients out of 20 with CH
versus 3 patients out of 20 in the HS group developed post-operative hypocalcaemia and was
statistically non-significant.
Conclusion: Harmonic scalpel is a relatively safe, effective hemostatic tool in thyroid
surgery. Complications are no more than that of conventional hemostatic technique.

b
ackground: General anaestheia is the most frequently used method For spinal
surgery. Neuraxial blocks have proved most useful in lower abdominal, inguinal,
urogenital, rectal, and lower extremity surgery. Lumbar spinal surgery may also be
performed under spinal anaestheia.
Aim: To assess the notion that spinal anaestheia can be both safe and effective in the
treatment of patients undergoing lumbar spinal surgeries.
Methods: The study was performed in Al-Imam Al-Hussein medical city, Karbala, Iraq from
April 2010 to April 2014, 60 patients in whom either spinal anaestheia SA or general
anaestheia GA was induced to perform a lumbar laminectomy. Patients were matched for
anaestheia-related class, age, gender and preoperative vital sign. Thirty patients in each group
both groups were well matched.
Results: The heart rate (HR) and blood pressure (NIBP) was higher in SA during induction, but
they were higher in GA during surgery and recovery time. Recovery time was longer in GA
group, patient and surgeon were more satisfy with GA p-value <0.05.
Conclusion: Spinal anaestheia is a suitable alternative to general anaestheia for lumbar disc
surgery, but need cooperative patient.
Recommendation: Spinal anaestheia for spinal surgery is good choice for cooperative patient it’s
better to avoid if surgical time might be prolonged or in risky patient

b
ackground: Myocardial bridge occurs when one of the coronary arteries tunnels
through the myocardium rather than its normal course at the epicardial fat, so it will
be compressed during systole. Myocardial bridging was first recognized at autopsy
more than 200 years ago, firstly reported in depth in 1951, and was recognized
angiographically in 1960. Computed Tomography Coronary Angiography ―CTCA‖ has been
accepted as a reliable noninvasive imaging modality for the diagnosis of MB
Aim of the study: studying the prevalence & characteristic of myocardial bridge among
patients Subjected to Computed Tomography Coronary Angiography ―CTCA‖ in Iraq
Subject & methods: The study was conducted on 154 patients examined by CTCA , 110
(72%) was male & 44(28%) was female , between January 2013 till December 2014.
distribution of MB patients among age, sex, were identified, types of MB, Bridging
characteristics ,Coarse of the bridging within the muscle , Length of the segment of the
bridging, Site of the bridging at the main coronary arteries LAD, LCX, RCA, The location of
myocardial bridges in the LAD was classified according to segmental involvement as
proximal, middle and distal , Associated atherosclerotic among MB patients was estimated.
Result: This study show that myocardial bridging is common congenital anomalies with
total prevalence “41.55% “ , more commonly seen in male “70% of patient with MB“ than
female “ 30% of patient with MB , with age distribution of 52+\-11.4 y, the most frequently
involved artery is the LAD (59 patient :92%) & the most frequently involved segment is the
mid segment of the LAD “84.37% “, with variable length of the involved segment “(42 +/
17.8 ) mm ,the superficial type is more frequent (56.25%) than the deep (43.75%) & there
is increase occurrence of atherosclerosis at the pre bridging segment (94.7%) & less at the
post bridging segment (5.26%), while is not observed at the bridging segment itself.
Conclusion: MB is common in Iraqi population; CTCA is useful for detection &
characterization of MB & associated atheroscerltic changes

b
ackground: Pneumatization is an activity that occur physiologically in all paranasal
sinuses during the growing period, causing them to increase in volume.
Pneumatization of the sinus after extractions can have various treatment-planning
implications, such as reduction of the alveolar bone height available for implants,
orthodontic miniscrew or complication in preprosthetic surgery.
Aim of the study: To find the correlation between rate of pneumatization of maxillary sinus
and time after extraction of the related teeth.
Subjects, material and methods: A total of 96 panoramic radiograph used to measure the
supero-inferior differences of the sinus floor position by using interorbital line and 2
zygomatic lines as a reference lines after one to more than 10 years of the unilateral
extraction of one of the maxillary second premolar, first molar or second molar tooth of 48
experimental subjects to make a comparison with the contralateral 48 control subjects with
bilateral present mentioned teeth.
Results: 48 control subjects show no statistically significant mean difference between the one
side and the adjusted contralateral side. There was statistically significant increase in the side
of the missing tooth compared to that of the contralateral side. The site of the missing tooth is
associated with an average increase in distance of 2.53mm from the comparable 0.22mm in
the control subjects, and this change was statistically significant. There is a moderate strong
positive linear correlation coefficient between time interval and maxillary sinus
pneumatization r=0.45 P<0.001.
Conclusion & discussion: The pneumatization of the maxillary sinus is related to the time
interval since extraction. The longer the time interval the more maxillary sinus
pneumatization.

b
ackground: Type 2 diabetes mellitus (T2DM) is an endocrinopathy that affects
people of different ages. It is among the components of metabolic syndrome which
has broad health implications. Obesity, insulin resistance and hyperandrogenism
coexist in T2DM, and could have independent and interactive effects on dyslipidemia
manifested mostly by elevated low-density lipoprotein cholesterol (LDLc), triglyceride (TG)
levels and decreased high-density lipoprotein cholesterol (HDLc).
Aim of the study was to confirm the relationship between non-fasting TG, testosterone (Ts)
and sex hormone binding globulin (SHBG) levels in reproductive age women with T2DM.
Materials and Methods: Serum non-fasting lipid profile and sex hormone levels were
measured in 40 female patients with T2DM and 35 normoglycemic women without a known
family history of diabetes mellitus as a control group.
Enzymatic colorimetric methods were used to measure the non-fasting lipids and blood
glucose, while Eliza technique was used to measure testosterone (Ts) and sex hormone
binding globulin (SHBG) by DRG-ELISA kit.
Results & Discussion: There are significant elevations in triglycerides (TG) and atherogenic
index (AI), with highly significant reduction in HDL-C, p˂ 0.001; in the patient group
(women with T2DM) as compared to their control group .There were no significant
differences in the mean total cholesterol (TC) and low density lipoprotein-cholesterol (LDL
C).
As concerning sex hormones, there was a significant reduction in SHBG concentrations (p˂
0.01) in T2DM women in relation to their normal glycemic control women. Serum total Ts
levels showed no marked difference between the two groups, however it showed a significant
correlation with the TG (p< 0.05) and AI (p <0.05) in the T2DM women. The free
androgenic index (FAI) was significantly higher in the T2DM group and showed a significant
correlation with serum TG.
Conclusion: These results confirm the association of low SHBG with elevation in androgenic
activity and non-fasting TG in the diabetic women with expectation of high risk of
cardiovascular disease.

b
ackground: Uropathogenic Escherichia coli (UPEC) is most important causative agent of
urinary tract infection (UTI). This disease is still big health problem among human population
in spite of scientific progress.
Aims: aims of this study were to investigate the isolates of UPEC in patients with UTI, characterize
the virulence factors and phylogenic groups among clinical isolates.
Materials and Methods: A total of 150 urine specimens were collected from patients with UTI after
establishing the diagnosis via investigation and clinical diagnosis in Al-Hussein Hospital, Gynecology
and Obstetrics Hospital, and Children Hospital in Karbala province during the period from November
2013 to April 2014. Thirteen stool samples from apparently healthy individuals as control group were
included. All E. coli isolates were identified by standard methods. Molecular diagnosis and
characterization for virulence and phylogenic genes were detected by Multiplex PCR technique in
medical researches laboratory of medical college at Karbala University.
Results and Discussion: This study showed that 56/150 patients (37.3%) had UTI due to UPEC. The
isolated UPEC were examined for the presence of the adhesion genes (Papc, Afa and Sfa) and the
phylogeny groups’ genes by Multiplex PCR assays. The primers encoding virulence genes were tested
against to all the 56 UPEC and 13 stool isolates. It was found that 27(48.21%) urine isolates carried
just one virulence factor, of them 16(28.57%) isolates carrying papc, 2(3.57%) isolates carrying afa
and 9(16.07%) isolates carrying sfa. No isolates out of 56 had carried all the three genes. However, no
virulence factor was found in 24 (42.85%) isolates. Pap gene was found mostly in 7 isolates among
patients aged (1-10 years) and (21-30 years); while, the prevalence of sfa gene was found in 7 isolates
(50%) among patients aged (31-40 years); however, two isolates have afa gene it was in one isolate
in each age group (1-10 years) and (41-50 years).
The percentage of phylogenic groups of UPEC isolates belonging to B2 followed by D, A and B1,
were 39.28%, 33.92%, 16.07% and 10.71% respectively; while in control group the results were A
(53.84%), B2 (23.07%), B1 (15.38%) and D (7.69%).
Conclusions: ts concluded that the genes of virulence factors of UPEC isolates in patients with UTI
were higher than in healthy persons. Significantly, E. coli strains responsible for UTI were far more
likely to be members of phylogenic groups B2 or D than A or B1

b
ackground: EBV has been classified as a group 1 carcinogen associated with a
variety of lymphoid and epithelial cancers. EBV was evidenced as a monogenic virus
from its ability to transform normal human B cells, resulting in immortalization of
the infected cells. A tumor suppressor protein, P16, is a cyclin-dependent kinase inhibitor
plays a critical molecular role in cell senescence, regulation of the apoptosis pathway and G1
cell cycle arrest.
Aim of the study: To analyze the concordant frequency and impact of P16 protein
expression and EBV infection on tissues from a group of patients with Non- Hodgkin's
Lymphoma (NHL).
Patients and methods: Forty-five (45) formalin-fixed, paraffin- embedded tissues from
lymph nodes biopsies were enrolled in this study; (30) lymph nodes biopsies were related to
patients with NHL and (15) lymph nodes autopsies have included as apparently normal
control group. Detection of EBV was done by ultra-sensitive version of in situ hybridization
(ISH) method whereas immunohistochemical (IHC) system was used to demonstrate the
protein expression of P16 tumor suppressor gene.
Results: Detection of EBV -ISH reactions in tissues with NHL was observed in 17 out of 30
(56.7%), while in the tissues from lymph nodes autopsies was detected in 6.7% (1 out of
15).Positive P16- IHC reactions were observed in 14 out of 30 NHL cases (47.1%). No P16
positive – IHC reaction was detected in healthy lymph node tissues in the control group. The
differences between the percentages of EBV and P16 detection in NHL tissues and control
tissues group were statistically highly significant (P value = < 0.0001).
Conclusions: The significant protein expression of P16 tumor suppressor gene as well as
EBV infection in NHL in our results could indicate that cell cycle dysregulation and EBV
related transformation are important events in the pathogenesis of subset of NHL

b
ackground: Mature B-cell neoplasms include a number of disease entities arising
from mature B lymphocytes which involve primarily the blood, bone marrow
(BM) and lymphoid organs such as the lymph nodes and spleen.
Although there are difficulties in separating CLL from some NHL, the distinction
is important because prognostic and therapeutic differences exist.
Immunophenotyping (IPT) has become an essential tool to confirm the diagnosis and to
separate CLL from other lymphoid malignancies.
Objectives: To express the difference between the IPT& morphology with morphology
alone to reach definite diagnosis in mature B- cell neoplasm.
Methods: BM biopsies of fifty five adult patients with CLL and leukemic phase of NHL
were collected from December 2010 to April 2011; fifty of them were retrospectively while
five of them were prospectively collected.
Results: In this study, Twenty six out of 29 CLL patients were confirmed as CLL by IPT
while the rest three cases diagnosed as NHL rather than CLL and 25 out of 26 NHL cases
were confirmed by IPT and only one case diagnosed as CLL.
Conclusions: This study revealed that the IPT has important diagnostic role in the
subclassification of mature B-cell neoplasms also revealed that the IPT technique in
conjunction with morphology have more precise role than morphology alone in the diagnosis
of mature B-cell neoplasms

b
ackground: Epistaxis is a common symptom of diverse conditions which may
present as mild recurrent bleeds or severe life threatening rhinological emergency.
Children and adolescent are more often afflicted with minor episodes of anterior
epistaxis, whereas the incidence of severe posterior epistaxis is greater in those who
are more than 50 years old. Hypertension has been considered to be a major cause of
spontaneous epistaxis for a long time. However, particularly in the recent medical literatures,
the relationship between hypertension and epistaxis appears to be more controversial.
Objectives: To evaluate the relationship between hypertension and epistaxis and to compare
the prevalence of the epistaxis in hypertensive patients with normotensive patients.
Methods: A prospective study was carried out on 101 hypertensive patients (group A) and
152 normotensive patients (group B) who served as a control group at Department of
Medicine and ENT, Al-Hussian Teaching Hospital, Karbala during the period January to
July 2015. Data from epistaxis patients for both groups were collected.
Results: Out of total 101 hypertensive patients, 61 (60%) were males and 40 (40%) were
females (M: F=1.5:1). The age range was 33 to 86 years with a mean age of 58 years.
Twenty-seven out of 101 hypertensive patients were found to have epistaxis. The control
group (group B) were 152 normotensive patients; 104 male and 48 female (M: F=2.2:1), and
only 28 participants have a history of epistaxis. The prevalence of epistaxis was not
significantly higher among patients with hypertension compared to those without
hypertension.
Conclusions: We demonstrated that epistaxis was unlikely associated with hypertension, and
that epistaxis was not initiated by high BP. However, epistaxis was more difficult to control
in hypertensive patients.

b
ackground: A variety of non-neoplastic and neoplastic conditions involving the
nasal cavity, paranasal sinuses, and nasopharynx. Most patients present with
complaints of nasal obstruction. Other symptoms include nasal discharge, epistaxis,
and disturbances of smell, oral symptoms, facial swelling, orbital symptoms, and
ear symptoms. The presence of unilateral symptoms or pathology is regarded with caution as
sinonasal neoplasms which may also present during their early stages with subtle symptoms
that mimic an inflammatory pathology.
Objectives: The aim of the study was to analyze the histopathologic diagnosis of patients
with unilateral nasal mass and identify their different clinical presentations.
Methods: A cross sectional prospective study was carried out on 34 consecutive patients
with unilateral sinonasal mass at Al-Hussein Teaching Hospital and Maythem Al-Tammar
Private Hospital, Karbala between April to August 2015 focusing on patient’s age, sex, and
complaints. . Clinical examinations and proper investigations were carried out for all patients.
Biopsy was taken from all cases for histopathologic examination to confirm diagnosis.
Results: Out of total 34 patients with unilateral sinonasal masses 25 (73.5%) were males and
9 (26.5%) were females (M: F=2.8:1). The age range was 7 to 60 years with a mean age of
29.2 years. Twenty two patients were found to have non-neoplastic unilateral conditions
(64.7%), while 12 patients had neoplastic unilateral conditions (35.3%). Inflammatory nasal
polyp was the most common condition in non-neoplastic group (59.9%). Inverted papilloma
was the commonest benign neoplastic condition (17.7%), 3 cases of non-Hodgkin’s
lymphomas (8.9%) represents the commonest malignant neoplasms among malignant
neoplastic group and single case of adenoid cystic carcinoma.
Conclusions: Sinonasal masses have various differential diagnoses that otolaryngologists
have to consider this variability in diagnosis and treatment. Nasal obstruction is the most
common symptom while epistaxis and extranasal symptoms like facial pain, dental and
orbital complaints were found to be higher in the neoplastic conditions. The clinician must
have a high index of suspicion to rule out a neoplastic etiology in all cases of unilateral nasal
mass.