Al-Kindy College Medical Journal

An anal fissure which does not heal with conservative measures as sits baths and laxatives is a chronic anal fissure. Physiologically, it is the high resting tone of the internal anal sphincter that chiefly interferes with the healing process of these fissures. Until now, the gold standard treatment modality is surgery, either digital anal dilatation or lateral sphincterotomy. However, concerns have been raised about the incidence of faecal incontinence after surgery. Therefore, pharmacological means to treat chronic anal fissures have been explored.A Medline and pub med database search from 1986-2012 was conducted to perform a literature search for articles relating to the non-surgical treatment of chronic anal fissure.Pharmacological sphincterotomy using Glyceryl trinitrate , Isosorbide dinitrate or calcium channel blockers are exciting alternative treatment , that relaxes the anal sphincter and, therefore, promote healing, the drawback of such medications are headache and poor compliance. With the introduction of Botulinum toxin as mean of chemical sphincterotom, topical injection of Botulinum toxin reduces the anal hypertonia which lasts for few months, allows the fissure to heal, thus eliminating the need for surgery without incidence of incontinence. Cure rates are over 60%, and the procedure can be repeated safely. Therefore, Botulinum toxin is a reasonable first-line management of chronic anal fissure and the relapses can be managed by surgeryKeywords: Non-surgical treatment of anal fissure, fissure in ano, sphicterotomy,botulinum toxin in anal fissures, glyceryl trinitrate. Chemical sphincteratomy, pharmacological sphincteratomy.

Background: Mycoplasma pneumoniae (M. pneumoniae) is an important respiratory bacterial pathogen, especially among children. It causes acute upper and lower respiratory infections.Objective: This study was aimed to measure anti- M. pneumoniae antibodies among hospitalized children who were admitted to hospital diagnosed with acute respiratory tract infections.Method: Automated ELISA technique was performed to detect anti- M. pneumoniae antibodies (IgM and IgG antibodies) in serum from 108 children less than 5 years old. The children were admitted to the Pediatric Teaching Hospital in Suleimani city/Kurdistan Region/Iraq because of acute respiratory tract infections. A questionnaire was designed to collect demographic and clinical data from those children.Results: IgM anti- M. pneumoniae antibodies were positive in 15 (13.9%) out of 108 children. The highest seroprevalence was found in the age group 25-36 months while the lowest is in the age group 1-12 months. M. pneumoniae infections were more common among males than females though results were statistically not significant, and attendance of kindergarten or nursery, residency, history of chronic diseases, history of contact with similar conditions, and family history of chronic diseases, they were all statistically not significant. The IgMseropositive children were suffering from bronchitis, croup, pneumonia, or other respiratory infections, in frequencies of 7 (46.6%), 4 (26.7%), 3 (20%), and 1 (6.7%) respectively. Increased erythrocyte sedimentation rate, diagnosis of croup, and diagnosis of bronchitis were more frequent in M. pneumoniae infected group and the results were statistically significant. The IgG anti- M. pneumoniae antibodies were positive in 31 (28.8%) out of the 108 children, and the greatest IgG seroprevalence was highest in age group 49-60 months.Conclusion: M. pneumoniae is an important respiratorypathogen among hospitalized children in Sulaimanigovernorate/Kurdistan/Iraq, and nearly one third of childrenhad experienced M. pneumoniae infection by the age of fiveyears

The inflammatory bowel disease (IBD), Crohn’s disease (CD) and ulcerative colitis (UC) are heterogenous chronic inflammatory disorders of the gastrointestinal tract. The most widely accepted etiopathogenic hypothesis for these disorders suggests an immune mediated process.
Objective: This study was performed to evaluate the role of interleukine-33 in pathogenesis of inflammatory bowel disease and to correlate their levels with the disease activity and/or severity.
Methods: Fifty five subjects with inflammatory bowel disease (41 ulcerative colitis patients and 14 Crohn’s disease patients) their ages range from 16-65 years and 25 apparently healthy volunteers their ages and sexes were matched with the patients were participated in this study. Blood samples were collected from all patients and controls to assess serum concentrations of interleukine-33 by enzyme-linked immune-sorbent assay.
Results: The present data revealed that there was significant elevation (P<0.05) in serum levels of interleukine-33 in ulcerative colitis and Crohn’s disease patients as compared with control group. Concerning the correlation between serum levels of interleukine-33 with clinical parameters, the current study revealed a positive correlation between serum interleukine -33 with the disease activity in ulcerative colitis (P=0.41). As regards to disease location, interleukine-33 was significantly higher (P<0.001) in ulcerative colitis patients with pan-colitis (E3) as compared to those patients with proctitis disease (E1) and CD of the colon (E2).
Conclusion: This study indicated that interleukine-33 might be a crucial mediator in the pathogenesis of inflammatory bowel disease.

Infection at the site of vascular anastomosis is a serious complication of vascular surgery and is associated with a high limb loss and mortality rate. The classical method of management is ligation of the injured artery, adequate wound debridement and restoration of circulation. The latter is achieved by either in situ or extra-anatomic bypass. If the distal circulation is not maintained, subsequent amputation is most likely.
Objectives: In this study we tried to assess the efficacy of extra-anatomic synthetic bypass grafts in the treatment of vascular infection in the groin to save the limb and avoid the inevitable amputation.
Methods: Between January 2006 and December 2007, ten male patients aged twenty to thirty five years (mean=27.3years), with previous vascular surgery (reversed saphenous vein grafting) for sub-inguinal penetrating injuries complicated with infection and bleeding were admitted and managed surgically in the Department of Thoracic and Vascular Surgery, Surgical Specialties Hospital, Medical City Teaching Complex, Baghdad. These patients were studied retrospectively regarding their demographic and clinical features as well as details of the operative procedures and surgical outcome.
All patients received emergency wound debridement, arterial ligation and extra-anatomic synthetic (PTFE) bypass grafts (External iliac or common femoral to distal superficial femoral or popliteal artery, six routed laterally and four routed medially in the thigh away from the original surgical field).
Results: Excellent results were obtained in nine patients who saved amputation while one patient ended with above knee amputation. No mortality recorded.
Conclusion: Extra-anatomic bypass is a useful approach in dealing with infected and disrupted vascular anastomosis and can be used in emergency as well as elective situations as mentioned in most literatures.

Background: Tobacco smoking and tuberculosis (TB) are two major public health problems; Associations between smoking and tuberculosis including death from tuberculosis have been reported , A reduction in smoking could be expected to have a significant impact on TB incidence and prevalence .
Objectives: to assess the effect of smoking on tuberculosis.
Methods: This study was conducted from June 2011 to June 2012 in 200 patients, adult ( aged 17 years and more), newly diagnosed patients of pulmonary tuberculosis, at the chest and Respiratory Disease Specialized Center in Baghdad. Demographic data, presenting symptoms, data on smoking, and recurrence of disease were compared. Information on smoking status, tobacco smoking was collected from patients using a specialized questionnaire.
Smoking categories were grouped into ever for current / past smokers) and never.
Results: A total of 200 patients with pulmonary tuberculosis, including 116 smokers and 84 non-smokers, were evaluated. The smokers were higher than non-smokers. Smokers were mostly male (p=0.001) there was statistically difference (P value = 0.05) for the duration of smoking, and for the number of cigarettes per day (p < 0.001). Regarding the symptoms of TB, there was statistically difference in occurrence of hemoptysis (P value 0.034) but there was no statistically difference between smokers and non-smokers in relapse rate.
Conclusion: We conclude that smoking may increase the risk of pulmonary TB in men. The risk increase with increasing the duration of smoking and the number of cigarettes smoked. Hemoptysis significantly different with regard to the patients’ smoking status.

Background: Very low birth weight (VLBW) neonates constitute approximately 4–7 percent of all live births and their mortality is very high.
Objective: to find out if there is a relationship between Very Low Birth Weight Neonates and increased neonatal mortality for age 0 to 7 days.
Methods: A retrospective study of VLBW neonates admitted to NICU at Ibn Al- Baladi Pediatrics and Maternity hospital over one year (2012)were studied, The study period was from April till August 2013. Exclusion criteria were: (1) neonates weighing less than 700 g and with gestational age less than 24 weeks (abortion) (2) death in the delivery room (3) neonates weighing more than 1500 g. (4) Postnatal age more than 7 days. The outcome measure was in-hospital death. Medical records were reviewed and data were analyzed. Results being considered as statistically significant when the P value was≤0.05.
Result: A total of 150 cases of very low birth weight (VLBW) neonates were enrolled, of which a total of 69 (46 %) babies died. The survival rate was found to increase with the increase in birth weight and gestational age (P value was highly significant). There is no relation between gender, postnatal age, mode of delivery and social class
with number of death. Respiratory distress, gestational age, neonatal septicemia are the factors directly responsible for neonatal mortality. Premature rupture of membranes (PROM), multiple pregnancy and Young mothers were the most common maternal risk factors associated with death in VLBW.
Conclusions: Mortality rate in VLBW neonates was found to increase with the decrease in birth weight and gestational age. Prematurity, RDS and infection are major causes of perinatal deaths. Advanced medical care must be available in each neonatal care unit, including, Artificial ventilation, pulse oximetry and Surfactant. Obstetricians must be advised for Intense and regular follow up of at risk mothers (multiple pregnancies, PROM, IUGR, APH)

Background: Deep vein thrombosis is a multi causal disease and its one of most common venous disorder, but only one quarter of the patients who have signs and symptoms of a clot in the vein actually have thrombosis and need treatment .The disease can be difficult to diagnose. Venous ultrasound in combination with clinical finding is accurate for venous thromboembolism, its costly because a large number of patients with suspicious signs and symptoms. Venography still the gold standard for venous thromboembolism but it is invasive. The D-dimer increasingly is being seen as valuable tool rolling out venous thromboembolism and sparing low risk patients for further workup.Objectives: this study has designed the role of D-dimer to confirm diagnosis of deep vein thrombosis for patients with positive Doppler and those show no features of thrombosis in Doppler using more accurate and sensitive instrument measuring the concentration of D- dimer.Methods: Thirty patients with deep vein thrombosis diagnosed by Doppler and clinical signs and symptoms (for those with negative Doppler) assessed for D- dimer by automachine cormy accent 200 based on immunoassay which more sensitive than the ordinary methods.Results: Twenty-eight patients out of thirty shows a significant elevation of D-dimer compared to control group which show no elevation in D- dimer level. On other side higher level of D- dimer found in those with negative Doppler as same as level to the patients with positive Doppler.Conclusion: Patients with clinical sign and symptoms of deep vein thrombosis and negative Doppler should be assessed for D- dimer using more sensitive technique based on immunological assay.Key words: deep vein thrombosis (DVT) pulmonary embolism (PE), Doppler

ABSTRACTBackground: cochlear implants are electronic devices that convert sound energy into electrical signals to stimulate ganglion cells and cochlear nerve fibers. These devices are indicated for patients with severe to profound sensorineural hearing losses who receive little or no benefit from hearing aids. The implant basically takes over the function of the cochlear hair cells. The implant consists of external components (microphone, speech processor and transmitting coil) and internal components (receiver stimulator and electrode array). The implant is inserted via a trans mastoid facial recess approach to the round window and scala tympani.Objectives: to determine the effectiveness and safety of non fixation method in cochlear implantation.Methods: a prospective study carried out from September 2009 to September 2012 in Gazi Hariri Hospital. Eighty patients with congenital severe –profound sensorineural hearing loss prepared for cochlear implantation involved in the study and divided into 2 groups. Group A includes 40 patients in whom the internal device was fixed to the skull by nylon suture materials through small burr holes on both sides of the well. Group B includes 40 patients in whom the internal device placed in a tight sub pericranial pocket without nylon fixation to the skull. All patients followed postoperatively for 6 months observing wound healing and local complications (hematoma, infection, wound dehiscence, device extrusion and migration).Results: mean age 4.2 years and male-female ratio was 1.3:1.Group A: 1 patient (2.5%) developed minor wound infection treated conservatively. Three patients (7.5%) developedsevere wound infection with wound breakdown and device extrusion despite the use of antibiotics and local rotational flaps, the device was explanted in those 3 patients. Two patients (5%) developed hematoma without history of trauma and treated conservatively. One patient (2.5%) had device migration without affection of its function.Group B: 2 patients developed minor wound infection treated conservatively. One patient (2.5%) had severe wound infection ends up with wound dehiscence and device extrusion despite the use of antibiotics and local rotational flaps. Explantation of the device was done for this patient. Hematoma occurred in one patient (2.5%) without history of trauma and treated conservatively. Another one patient (2.5%) developed device migration without impairment of its function.Conclusion: creation of sub pericranial pocket without internal device fixation by nylon materials is an effective and reliable method in cochlear implantation without compromising the patient safety or device performance.Key words: cochlear implantation, non- fixation, sub pericranial pocket

Background: Insulin resistance (IR) is the primary metabolic disorder associated with obesity. Obesity is a growing worldwide health problem affecting both adults and children. Objectives: To determine the association between leptin and IR, and to identify the ratio of fasting glucose/leptin (G/L) and insulin/leptin (I/L) as a new simple method for the detection of IR in obese children.Methods: This study was done in the National DiabeticCenter/ AL-Mustansiriya University during the period fromMay 2013 until the end of October 2013. Fasting bloodglucose (FBG), serum insulin, leptin, and lipid profile weremeasured in 52 obese children (24 children with IR and 28without IR); their age range was (5-15) years, they werecompared with 38 healthy children as a control group.Results: Means of FBG, insulin, leptin, total cholesterol(TC), triacylglycerol (TAG), low density lipoproteincholesterol (LDL-C), and non high density lipoproteincholesterol (non HDL-C) were significantly increased inobese children with IR as compared in children without IR,(P<0.05), while there was a significant decrease in serumlevel of high density lipoprotein cholesterol (HDL-C) inobese children with IR when compared with obese childrenwithout IR, (P=0.001). There was a decrease in the ratio ofG/L and an increase in the ratio of I/L in obese children withIR, but it was not significant. A significant positivecorrelation was found between serum leptin verse bodymass index (BMI), FBG, insulin, homeostasis modelassessment for insulin resistance (HOMA-IR), I/L ratio, TC,TAG, LDL-C, and non HDL-C, while a significant negativecorrelation was found between serum leptin and HDL-C inobese children with IR.Conclusions: The present results showed that serum leptinis correlated with BMI, FBG, insulin, HOMA-IR, I/L ratio, TC,TAG, LDL-C, and non HDL-C in obese children with IR. TheG/L ratio can be used in addition to me /L ratio, and HOMAto accurately assess IR in obese children

Background: Laparoscopic cholecystectomy (LC) has become the treatment of choice for elective cholecystectomy.Objectives: To evaluate the safety and feasibility of early LC for AC and to compare the results with delayed LC.Methods: A prospective study done from April 2011 to October 2013, 88 patients with diagnosis of AC were divided randomly into two groups according to the mode of treatment; (early group n=40) treated by early LC within first 72 hours or (delayed group, n=48) initial conservative treatment for 4-6 weeks, followed by delayed LC.Results: There was no difference between the two groups (early & delayed LC), operating time (early 80min, delayed70min), conversion rate (early 7.5%, delayed 6.25%),postoperative complications (early 20%, delayed 14.58%),However, the early group had shorter mean hospital stay(early 2.5 days, delay 5 days).Conclusion: early laparoscopic cholecystectomy appears to be reliable, safe, and cost effective treatment modality for acute cholecystitis, offering the additional benefits of a shorter hospital stay.Keywords: Acute cholecystitis, early LC, delayed LC

Background: Acute coronary syndrome (ACS) is a common disease, and a major determinant of morbidity and mortality in all races. The pleiotropic effects of the receptor activator of nuclear factor-kappa B ligand (RANKL) such as modulation of cell survival, mineralization and inflammation, make it an interesting candidate mediator in the progression and destabilization of atherosclerotic lesions.Objectives: This study was performed to investigate the role of RANKL in the pathogenesis of ACS.Methods: The levels of RANKL were measured by ELISA method in sera of 60 ACS patients, 31 patients with unstable angina (UA) and 29 patients with myocardial infarction (MI) in comparison with 20 apparently healthy controls.Results: Current data indicated that there was a decrease in the median serum level of RANKL but statistically not significant (p>0.05)in ACS patients as compared with a healthy control group.Conclusion: Current study revealed a low RANKL serum level but statistically not significant in ACS patients in addition there were no significant differences in median serum levels of RANKL in ACS patients according to gender type, family history, smoking habit and troponin enzyme

Background: The treatment of an ovarian cyst relies on its nature, the discrimination of benign and malignant cysts is, therefore of crucial importance, and in spite of the continuous improvement of diagnostic means, it remains sometimes impossible to differentiate functional from organic (malignant or not) ovarian cysts. The therapeutic decision will search for the main midway between cancer’s negligence and the fear of performing an unnecessary surgical operation for an ovarian cyst.Objective: To review of 116 cases of ovarian cystic diseases aiming in identify proper management and reducing unnecessary surgical intervention.Methods: A retrospective study was conducted at Al-Elwiya maternity teaching hospital/ Baghdad/ Iraq. One hundred sixteen women underwent surgery for ovarian cystic diseases between January 2010 and December 2011. Age, menopausal status, referral history, clinical features, diagnostic methods, treatments and histopathological results were recorded and the collected data was arranged in tables for analysis.Results: From One hundred sixteen women, One hundred five (90.5%) were premenopausal and eleven (9.5%) were postmenopausal. Thirty two women (27.6%) underwent laparoscopic evaluation for Ovarian cystic diseases, while eighty four (72.4%) were candidates for laparotomy. Benign pathological conditions were found in thirty six (31%) pre-menopausal women and three (2.6%) post-menopause. The functional cysts presented in sixty of the cases (51.7%), Fifty five (47.4%) were premenopausal and five (4.3%) postmenopausal.Conclusion: There is difficulty in accurate discrimination between types of ovarian cysts In Iraq and we recommend to use risk of malignancy index (RMI) as a simple diagnostic tool that provide to discriminate between malignant and benign ovarian cysts.Keywords: Ovarian cystic diseases, risk of malignancy index (RMI)

Background: Spleen is a hemopoietic organ which is capable of supporting elements of different systems. It is affected by several groups of diseases; inflammatory, hematopoietic, reticuloendothelial proliferation, portal hypertension and storage diseases. Ultrasound (US) may detect mild splenomegaly before it is clinically palpable. Knowledge of the normal range of spleen size in the population being examined is a prerequisite. Racial differences in splenic length could result in incorrect interpretation of splenic measurements and such differences would make it difficult to standardize expected splenic length and to determine non- palpable splenic enlargement.Objectives: To measure the normal values of splenic lengthin Iraqi subjects and compare the results with western,Chinese and Jordanian data; to determine whether there is aconstant ratio of the length of the spleen to the left kidney,which could be used to diagnose splenomegaly withoutreference to a nomogram.Methods: This is a cross-sectional study conducted among a total of 280 subjects ranging in age from birth to 20 years (159 males and 121 females). US was used to measure maximum splenic and left kidney lengths to obtain normal values for splenic length and to determine spleen to left kidney ratio. The subjects were divided into the same age groups as those used by other similar international studies in order that comparisons with their results could be made.Results: Splenic lengths in Iraqi subjects are similar to those in American, Chinese and Jordanian subjects up to the age of 15 years. The spleen to left kidney ratio is strikingly constant with a mean value of 1. Using 2 SD above the mean as a guide, the upper limit of normal for spleen to left kidney ratio is 1.25.Conclusion: Splenomegaly should be suspected in children if the spleen is more than 1.25 times longer than the adjacent kidney.Key words: Spleen, subjects, ultrasound

ABSTRACTBackground: dyslipidemia plays a crucial rule in the development of cardiovascular disease, which has become the leading cause of death in most developed countries as well as in developing countries (1). The effects of reducing low density lipoprotein – C (LDL-C) concentrations on the prevention of cardiovascular events and stroke have been well reported in many clinical trials.Objectives: Evidence supports the use of statins for lipid modifications in the primary prevention of coronary artery disease, morbidity and mortality. This study aims to determine the effectiveness of atorvastatin in treating dyslipidemia in Iraqi obese patients.Methods: 200 overweight and obese patients with hypercholesterolemia, according to NCEP ATP III criteria, were included. They were randomized into 3 groups according to atorvastatin dose, 10, 20, 40 mg/ day, and treated for 8 weeks. Blood lipid profile, liver enzymes ALT and AST, urea, creatinine, uric acid, calcium and glucose were measured before and after therapy.Results: There was a significant reduction of total cholesterol (TC), Triglycerides (TG), low density lipoprotein (LDL), very low density lipoprotein (VLDL), but a non-significant reduction of high density lipoprotein (HDL) with all atorvastatin doses. The high doses of the drug caused a significant elevation of serum levels of ALT and AST and a significant decrease of blood calcium; but there was nosignificant change in blood levels ofurea, creatinine, uric acid or glucose with any dose.Conclusion: Short-term atorvastatin therapy in dyslipidemic obese patients caused a reduction of TC, TG, LDL, and VLDL, but had no significant effect on HDL, non-significant changes in blood urea, serum creatinine, serum uric acid or blood glucose, while there was a dose dependent elevation of ALT and AST

Background The traditional management of appendicular mass is an initial conservative treatment followed by interval appendectomy. Recently interval appendicectomy has been questioned.
Objective: The purpose of this study was to clarify the need and the role of interval appendicectomy after successful initial conservative treatment.
Method: This is a prospective study conducted in a major hospital in Basra from April 2006 to Septemper2010, included 65 patients with appendicular mass which subsequently proved postinflammmatory (phlegmonous) changes of the appendix were treated conservatively.
Results: Routine interval appendicectomy was not performed and needed after successful treatment in the majority of the patients (84.6%). Four patients (6.1%) developed abscess formation and operation
was necessary to drain the abscess. Four patients were readmitted with recurrent appendicitis after 2 months. During the 2 years follow up period another 2 patients presented with recurrent symptoms of acute appendicitis and appendectomy were arranged. The recurrence rate after successful conservative treatment was 10%.
Conclusion routine interval appendectomy after initial
successful conservative treatment is of questionable
benefit and needs further assessment.

Background: Atrophic postoperative and traumatic scarring are common cosmetic problems for patients. Combining CO2 laser ablation with a fractional photothermolysis system in a treatment known as ablative fractional resurfacing fulfilling the new demands for a lesser risk of side effects and minimal or no downtime.Objective: To assess the safety and efficacy of ablation fractional CO2 laser treatments for surgical scarring .methods: Twenty one patient ( 14 women, and 7 men ) with various skin types , I to IV , aged 3 to 48 years , presents with 24 scars between June and December 2012 , four patients excluded from study because they are not continued in follow up , the remaining 17 patient completed all 3 treatments & 6 months follow up.Results: Adverse effects of treatment were mild to moderate , and no scarring or delayed onset hypopigmentation was observed, For all patients demonstrated improvements in skin texture and reduction of pain and discomfort and improvement of tenderness and hardness of the scar which become more soft and mature .Conclusions: The ablation CO2 laser treatment represent safe , effective treatment modality for improving scar quality , texture, maturation and appearance.Keywords: Ablative fractional lasers, CO2 lasers, traumatic scars, atrophic scars

Background: Appreciation of the crucial role of risk factors in the development of coronary artery disease (CAD) is one of the most significant advances in the understanding of this important disease. Extensive epidemiological research has established cigarette smoking, diabetes, hyperlipidemia, and hypertension as independent risk factors for CADObjective: To determine the prevalence of the 4 conventional risk factors(cigarette smoking, diabetes, hyperlipidemia, and hypertension) among patients with CAD and to determine the correlation of Thrombolysis in Myocardial Infarction (TIMI) risk score with the extent of coronary artery disease (CAD) in patients with unstable angina /non ST elevation myocardial infarction (UA/NSTEMI).Methods: We conducted a descriptive study among 100 patients admitted with UA/NSTEMI to three major cardiac centers in Iraq: Iraqi Centre for Heart Disease ,Ibn- Al-Bitar Hospital for cardiac surgery and Al -Nasyria Cardiac Centre from January 2010 to January 2o11.Frequency of each conventional risk factors and number of conventional risk factors present among patients with CAD, compared between men and women and by age are estimated at study entry. The TIMI risk score was stratified on seven standard variables. The extent of CAD was evaluated on angiography and significant CAD was defined as ≥ 70% stenosis in any one of the three major epicardial vessels and ≥50% in LMS.Results : Among 100 patients with UA/NSTEMI , 82% of patients have one or more risk factors and only 18%of patients lacked any of 4 conventional risk factors.Smoking is the most common risk factor in male patients while diabetes mellitus and dyslipidemia are common among female patients, and all these results are statistically significant.There were 64 % patients with TIMI score < 4 (low and intermediate TIMI risk score) and 36% patients with TIMI score >4 (high TIMI risk score). Patients with TIMI score > 4 were more likely to have significant three vessel CAD and LMS versus those with TIMI risk score < 4 who have less severe disease (single and two vessel disease).Conclusion: Antecedent major CAD risk factor exposures were very common among those who developed CAD emphasizing the importance of considering all major riskfactors in determining CAD risk estimation . Patients with a high TIMI risk score were more likely to have severe multivessel CAD compared with those with low or intermediate TIMI risk score. Hence, patients with TIMI score >4 should be referred for early invasive coronary evaluation to derive clinical benefit.Key words: unstable angina , Thrombolysis in Myocardial Infarction score, risk factors

ABSTRACTBackground: In Medical ethics education, improving medical student’s attitudes toward respecting the right of patients is an essential task. The medical students’ attitude has been affected by social, educational and personality background factors.Objective: To investigate medical student’s attitudes regarding medical ethics courses.Method: The study was conducted in Al-Kindy College of Medicine on academic year (2013 -2014) for the period from January to September. A cross- sectional study design was adopted with a self- administered questionnaire form distributed to medical students in the 5th-6th under graduate grades. The questionnaire consisted of 31 items relevant to student’s opinion about attitudes concerning ethics courses.Result: Out of overall 113 students 90(78.1%) responded, the majority 88.9% considered medical ethics teaching for medical students an important issue, and 85.5% had general interest in learning more about medical ethics. However, about 84.4% agreed that medical ethics teaching would influence the attitudes and behaviors of doctors, and improvepatient doctor relationship, but about 65.6% of students were confident with their ability to recognize significant ethical problems in clinical practice. Only 46.7% knew how to proceed when a patient is mentally incompetent.Conclusion: Medical students have positive knowledge andattitude about the medical ethics teaching, but they may notbe adequately prepared to meet the challenges of clinicalpractice. There should be incorporation of creative andintegrated ethics curriculum to start in the first medical grade,with emphasis on ethical aspect of daily medical practice.

Background: Phosphodiesterase-5 (PDE-5) inhibitorsrestore nitric oxide (NO) signaling and may reducecirculating inflammatory markers, and improve metabolicparameters through a number of mechanisms. Dailyadministration of the PDE-5 inhibitor, tadalafil (TAD) mayattenuate inflammation; improve fasting plasma glucose andtriglyceride levels and body weight. This study aims toevaluate the efficacy of low dose PDE-5 inhibitor, tadalafil(TAD) in controlling dysglycemia and body weight in obesediabetic men.Methods: Forty obese men with type 2 diabetes aged 30-50years incorporated in this study, all with A1c of 7-8.5%,attending obesity unit in AL-Kindy college of medicine.Weight, height, BMI, FPG, A1c, cholesterol, TG, HDL andLDL measured for all and advised for low calories diet andincreasing exercise and randomized into 2 groups , first(control) without and the second (therapy) with addition oftadalafil 2.5mg/day for 8 weeks, then remeasure all theparameters after. Results blotted in tables and statisticalanalysis done using SPSS program and t-test.Results: There was significant reduction in weight, BMI,FPG, cholesterol, TG and LDL, while no significant change in A1c , and although there was elevation in HDL but was insignificant in control group. In therapy group both weight, BMI, FPG, A1c, cholesterol, TG, and LDL show significant reduction, with mild insignificant elevation in HD. When compare the results of both groups significant results appear in percentage of change of FPG and A1c in therapy group.Conclusion: Low calories diet and exercise are effective inreducing obesity parameters in type 2 diabetes, in addition,improve dysglycemia and dyslipidemia , adding tadalafil2.5mg/day can add beneficial effect specifically for FPG andA1c significantly.

Background: The antimicrobial resistance is one of the most serious and expanding health problems world -wide in the last decades. The esbl escherichia coli. (extended – spectrum beta-lactamase e.coli) represents an important aspect of it .Objectives: To get an overview on the esbl e.coli prevalence profile in general. Also to assess the antibiotic sensitivity of esbl e. coli trying to specify the most effective antibiotics in combating this micro-organism.Methods: this study tries to focus on this problem in Iraq which through a prospective study approach by taking 35 clinical samples from various sources (urine, blood, abscess, eye ,vagina ,stool and others),and after confirming the presence of e.coli, the presence of esbl e.coli and antibiotic sensitivity are confirmed by the use of Kirby - bauer method.Results: results showed that esbl e.coli constitutes 80% of the cases, while the results of antibiotic sensitivity were as follows: ampicillin 3.3% , ampicillin/sulbactam 20% , amoxi/clav 0%pipracillin/tazobactam 89.7% meropenem 96.7% ,imipenem 96.9% ,cefotaxime 0% ,ceftriaxone 11.8%,ceftazidime 16.1%,cefipime 14.3% ,cefazolin 16.1% cefoxitin 64.7%, aztreonam 14.3%,gentamycin 50% ,tobramycin 64.3%, amikacin 94.3%,ciprofloxacin 58.8% ,levofloxacin,64.5%nitrofurantoin,79.2%,trimethprimesulphamethoxazole 29.6% .Conclusion: the problem of esbl e.coli is expanding and there is a continuous demand for frequent monitoring of the new trends on antimicrobial resistance in different parts of the world in addition to trying to develop new antimicrobials to combat the new highly resistant strains .moreover there is a continuous need to educate the medical and the paramedical staff abot the risk of unjustified and improper prescription and use of antimicrobials.Key words: escherichia coli, extended-spectrum beta-lactamase, kirby-bauer method, muller hinton agar

Background: Osteoid osteoma(OO) is a relatively common benign skeletal neoplasm of unknown etiology that is composed of osteoid and woven bone, usually seen in adolescent and young males Although, the clinical, radiological and scintigraphic features of OO have been well described, these features may be misleading or altered in the cases of lesser trochanter of the femur which is relatively uncommon location for OO with a few number of cases reported up to date.Case Presentation: We report a case of a 20-year-old man who presented with painful limpThe pain had begun six months earlier and was made worse by walking and by exercise., with normal initial X-rays .The diagnosis was made after six months when typical Computed tomography, magnetic resonance imaging findings appeared , showing the nidus.Treatment: Acompleteen block resection accomplished successfully and the whole tumor with lesser trochanter of the femur in one mass was removed.Outcome and Follow-up: the post-operative period was uneventful. The pathological examination is consistent withosteoid osteoma. The patient was asymptomatic at one year follow up.Conclusions: lesser trochanter OO can mimic lots of pathologic entities related to the affected area, and presents a diagnostic challenge and cause a delay in the diagnosis. The delays in the diagnosis and treatment can be avoided with a high index of suspicion. Treatment should be individualized according to the surgeon’s preference and the characteristics of the case.Key words: Osteoid osteoma OO, lesser trochanter, enblock excision