Iraqi Peer review Journal

The New Iraqi Journal of Medicine
The official peer review medical journal of the Iraqi Ministry of Health
Executive Editor: Ali Hassan Al Shimari Minister of Health Editor in Chief: Aamir Jalal Al-Mosawi

Advisory Editorial Board
Nada Al Ward Hussam Abdul Kareem Hakam Abdul Muheimen Abdul Ridhah Al Rawaf

Hassan Ahmed Hassan

http://www.geocities.com/new_iraqijm Registered by Copernicus Index Journal Master List Copyright©Postspeciaty CME Center University Hospital in Al Kadhimiyia. Iraqi Ministry of Health 0

Content

Iraqi Peer Review Journal

The New Iraqi Journal of Medicine
The Official Peer Review Journal Of The Iraqi Ministry of Health August 2006 Volume 2 Number 2
Content
Instructions for Contributors Anatomy Double extensor pollicis longus muscle and its clinical significance 8- 11

1-2
3-7

Srijit Das, Rajesh Suri Vijay Kapu
Traumatology

The epidemiology of war-like injuries in children and adolescents during postwar violence wave: Experience of a teaching hospital in Baghdad. Dhia Talib Al Anbaky Psychiatry The Epidemiological Pattern of Psychosis in Military Patients Safaa Jawad, Ghazi Aboud Abstract from international conference Fourth International conference on pediatric continuous Renal Replacement Therapy February 23-25, 2006 | Campus of University Zurich-Irchel, Switzerland Pediatric Nephrology Nephropathic cystinosis in Iraqi children

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16-19

20-21

22-25

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The New Iraqi Journal of Medicine 2006 2(1): 3-7 http://www.webspawner.com/users/alkarkhjm/index.html

Instructions for Contributors
2006 © Postspecialty CME center in the University Hospital in Al-Kadhimiyia

Aamir Jalal Al Mosawi MD, PhD Editor in chief Head department of pediatrics University Hospital in Al Kadhymiyia Al Kadhymiyia Baghdad Iraq PO Box: 70025 E-mail: new_iraqijm@yahoo.com

The New Iraqi Journal of Medicine welcomes the submission of unsolicited articles for publication. Our reputation for author care, quality control through the publishing process and rapid, timely publication is unrivalled. Typically, from receipt of a first draft to publication takes only 8-12 weeks allowing 2 weeks each for peer-review and revision. If you would like to propose an article or have any queries about contributing to the journal, please contact the Editorial Office (new_iraqijm@yahoo.com). The New Iraqi J Med expects manuscripts to conform to the Uniform Requirements for Manuscripts Submitted to Biomedical Journals (the Vancouver style; N. Engl. J. Med. 336,309–315 [1997] www.icmje.org.The Journal will consider the publication of papers dealing with broad fields of medicine (Original aricles, case reports, and review articles).All articles must be submitted solely to The New Iraqi Journal of Medicine and must be written entirely in English.

This journal is a peer-reviewed scientific journal that publishes original articles in all fields of experimental and clinical medicine and related disciplines. The New Iraqi Journal of Medicine is currently issued 3 times per year. The new Iraqi J Med is listed by the ICMJE and Doctor Guide journal lists. The editor endorses the principles embodied in the Declaration of Helsinki RECOMMENDATION FOR CONDUCT OF CLINICAL RESEARCH and expects that all investigations involving humans will have been performed in accordance with these principles. Review process. Manuscripts are evaluated on the basis that they present new insights to the investigated topic, are likely to contribute to a research progress or change in clinical practice or in thinking about a disease. It is understood that all authors listed on manuscript have agreed to its submission. The signature of the corresponding author on the letter of

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submission signifies that these Received manuscripts are first examined by the editor. Manuscripts with insufficient priority for publication are rejected promptly. Incomplete packages or manuscripts not prepared in the advised style will be sent back to authors without scientific review. The authors are notified with the reference number upon manuscript registration at the editorial office. The registered manuscripts are sent to independent experts for scientific evaluation. The evaluation process usually takes 1–3 weeks. Submitted papers are accepted for publication after a positive opinion of the independent reviewers. Conflict of interests. Authors of research articles should disclose at the time of submission any financial arrangement they may have with a company whose product figures prominently in the submitted manuscript or with a company making a competing product. Such information will be held in confidence while the paper is under review and will not influence the editorial decision, but if the article is accepted for publication, the editors will usually discuss with the authors the manner in which such information is to be communicated to the reader. Permissions. Materials taken from other sources must be accompanied by a written statement from both author and publisher giving permission to the Journal for reproduction. Obtain permission in writing from at least one author of papers still in press, unpublished data, and personal communications. Patient's confidentiality. Changing the details of patients in order to disguise

conditions have been fulfilled them is a form of data alteration. However authors of clinical papers are obliged to ensure patients privacy rights. Only clinically or scientifically important data are permitted for publishing. Therefore, if it is possible to identify a patient from a case report, illustration or paper, a written consent of the patient or his/her guardian to publish their data, including photogram is necessary prior to publication. The description of race, ethnicity or culture of a study subject should occur only when it is believed to be of strong influence on the medical condition in the study. When categorizing by race, ethnicity or culture, the names should be as illustrative as possible and reflect how Theses groups were assigned. Copyright transfer. Upon acceptance, authors transfer copyright to The New Iraqi J Med. Once an article is accepted for publication, the information therein is embargoed from reporting by the media until the mail date of the issue in which the article appears. Upon acceptance all published manuscripts become the permanent property of The New Iraqi J Med, and may not be published elsewhere without written permission from the editor .Every effort is made by the editor to see that no inaccurate or misleading data, opinion or statement appears in the journal. However, they wish to make it clear that the data and opinions appearing in the articles and advertisements herein are the responsibility of the contributor, sponsor or advertiser concerned.

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CRITERIA FOR MANUSCRIPTS The journal takes under consideration for publication original articles in experimental and clinical medicine and related disciplines with the understanding that neither the manuscript nor any part of its essential substance, tables or figures has been published previously in print form or electronically and is not under consideration by any other publication or electronic medium. The Journal discourages the submission of more than one article dealing with related aspects of the same study. Each submission packet should include the statement signed by the first author that the work has not been published previously or submitted elsewhere for review and a copyright transfer. PREPARATION OF MANUSCRIPT Guidelines for submission are in accordance with: Uniform Requirements for Manuscripts Submitted to Biomedical Journals (N Eng J Med, 1997; 336: 309-15). Manuscripts should be up to 4000 words in length with a target of no more than 80 references. Article structure Original research articles, clinical studies, and case reports should be organized as follows: The manuscript should be typewritten on a white paper of the size ISO A4 (210x297 mm). The text should be processed on the laser or inkjet printer preferably, or on a type writer; in the last case, however, the authors are requested to take care about the quality of printing tape. Text should be one spaced with 12 points typeface.

Margins: 2.5 cm (1 inch) at top, bottom, right, and left. Illustrations are very helpful and for case reports are mandatory. In reviews it should be explained what information retrieval sources were used and what were the criteria in selecting the referred papers. The Editor reserves the privilege to adjust the format of the article.

The manuscript should include:
Title page should include the following Information: • Full names of all authors • Name of the department and institution in which the work was done • Affiliations of the authors • Manuscript full title • Full name, address, telephone and/or fax number of the author responsible for manuscript preparation. • E-mail address to speed up contacts with authors • Source(s) of support in the form of grants (quote the number of the grant) equipment, drugs etc. Abstract Page. Abstract in structured form not exceeding 300 words should consist of four paragraphs labeled: Background, Material (Patient) and Methods, Results, Conclusion. Each summary section should begin in a new line and briefly describe, respectively, the purpose of the study, how the investigation was performed, the most important results and the principal conclusion that authors draw from the results. KEY WORDS (3 to 6) or short phrases should be written at the bottom of the page.

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Text. The text of the article should be divided to seven paragraphs labeled: Introduction, Material (Patient) and Methods, Results, Discussion, Conclusions, Acknowledgements, References. Introduction should contain scientific rationale and the aim of the study or (in case of a review) purpose of the article Material (Patient) and methods should describe clearly the selection of observational or experimental subjects (patients or laboratory animals)including controls, such as age, gender, inclusion and exclusion criteria, (the circumstances for rejection from the study should be clearly defined),randomization and masking (blinding)method. The protocol of data acquisition, procedures, investigated parameters, methods of measurements and apparatus should be described in sufficient detail to allow other scientists to reproduce the results. Name and references to the established methods should be given. References and brief description should be provided for methods that have been published but are not well known, whereas new or substantially modified methods should be described in detail. The reasons for using them should be provided along with the evaluation of their limitations. The drugs and other chemicals should be precisely identified including generic name, dose and route of administration. The statistical methods should be described in detail to enable verification of the reported results. Results should concisely and reasonably summarize the findings. Restrict tables and figures to the number needed to explain the argument of the paper and assess its support. Do not duplicate data

in graphs and tables. Give numbers of observation and report exclusions or losses to observation such as dropouts from a clinical trial. Report treatment complications. The results should be presented in a logical sequence in the text, tables and illustrations. Do not repeat in the text all the data from the tables or graphs. Emphasize only important observations. Discussion should deal only with new and/or important aspects of the study. Do not repeat in detail data or other material from the Background or the Results section. Include in the Discussion the implications of the findings and their limitations, including implications for future research. The discussion should confront the results ofother investigations especially those quoted in the text. Conclusions should be linked with the goals of the study. State new hypotheses when warranted. Include recommendations when appropriate. Unqualified statements and conclusions not completely supported by the obtained data should be avoided. Acknowledgements. List all contributors who do not meet the criteria for authorship, such as technical assistants, writing assistants or head of department who provided only general support. Financial and other material support should be disclosed and acknowledged. References must be numbered consecutively as they are cited. References should be denoted numerically and in sequence in the text, using Arabic numerals placed in square brackets, i.e., [12]. List references in numerical order in the Reference list References selected for publication should be chosen for their importance,

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accessibility, and for the „further readings opportunities they provide. References first cited in tables or figure legends must be numbered so that they will be in sequence with references cited in the text. The style of references is that of Index Medicus. List all authors when there are six or fewer; when there are seven or more, list the first three, then„et al.³ The following is a sample reference: Standard journal article *Lahita R, Kluger J, Drayer DE, Koffler D, Reidenberg MM. Antibodiestonuclear antigens in patients treated with procainamide or acetylprocainamide. NEngl J Med 1979; 301:1382-5. Book, personal author(s) Ringsven MK, Bond D. Gerontology and leadership skills for nurses. 2nd ed. Albany (NY): Delmar Publishers; 1996. Book, editor(s) as author Norman IJ, Redfern SJ, editors. Mental health care for elderly people. New York: Churchill Livingstone; 1996. Tables. Type or print out each table on a separate sheet of paper. Do not submit tables as photographs. Number tables consecutively in the order of their first citation in the text, and supply a brief title for each. Give each column a shorter abbreviated heading. Place explanatory matter in footnotes, not in the heading. Explain in footnote. All non standard abbreviations that are used in each table. For footnotes use the following symbols, in this sequence: *, ý, §, ||, Â, **, ýý, etc.Identify statistical measures of variations such as standard deviation and standard error of the mean. Do not use internal horizontal and

vertical rules. Be sure that each table is cited in the text. Figures should be numbered consecutively according to the order in which they have been first cited in the text. Define in the legend all abbreviations that are used in the figure. Review articles Each review article should concentrate on the most recent developments in the field. These articles aim to summarize and highlight recent significant advances in and ongoing challenges in the field. Authors should strive for brevity and clarity. The final structure of the review will, of course, depend on the title/focus but wherever possible, the following sections should be included. Submission Manuscript should be sent on floppy disc. Submission by e-mail is also welcome. Editor in chief: Aamir J Al -Mosawi Main Editorial office: Expansion building, first floor University Hospital in Al Kadhimiyia Al Kadhimiyia Baghdad Iraq PO Box: 70025 E-mail: new_iraqijm@yahoo.com

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The New Iraqi Journal of Medicine 2006 2(2): 8-11

Anatomy

Anomalous Plantaris Tendon and its Clinical Implications
Srijit Das, Rajesh Suri, Vijay Kapur

Abstract
Background: The Plantaris muscle belongs to the superficial flexor group of muscles of the leg. In human beings, the muscle is attached well short of plantar aponeurosis and assists in the plantar flexion of the foot. It runs along the medial border of tendocalcaneus tendon to insert into the calcaneum. The plantaris muscle is considered to be vestigial in nature. It need not be reemphasized that the muscle assists in the plantar flexion of the foot. The anatomical knowledge of the anomalies pertaining to the insertion of the plantaris muscle may be clinically important for surgeons performing tendon transfer. Objective: The present study reports the aberrant insertion pattern of the plantaris muscle. Materials and Methods: We dissected the lower limbs of 20 cadavers (i.e. n= 40 limbs) to study the insertion pattern of the plantaris muscle. The insertion of the plantaris muscle was studied in detail and appropriate photograph was taken. Results: The average of the maximum length and the maximum width of the plantaris muscle measured 8.5 cm and 1.6 cm respectively. In twelve out of 20 cadavers (60%) the plantaris muscle inserted into the calcaneum, its normal site. In the other 8 cadavers (40%), the insertion was into the superficial fascia of the leg. Conclusion: In order to avoid any inadvertent injury during surgical operations, the possibility of such anomalous insertion of the plantaris tendon into the superficial fascia of the leg must be borne in mind. Awareness of the insertion pattern of the plantaris tendon is also important for clinicians in the diagnosis of muscle tears and for surgeons performing reconstructive procedures. Key Words: Plantaris tendon, anomaly, variation, superficial fascia, calcaneum.

Corresponding author: Srijit Das, Associate Professor Department of Anatomy, Maulana Azad Medical College, New Delhi, India. Add: 190, RPS Flats, Sheikh Sarai Phase-I, New Delhi-110017, India Tel: 91-11-23239271Ext125 E-mail: das_srijit23@rediffmail.com Rajesh Suri, Professor, Department of Anatomy, Vardhman Mahavir Medical College, New Delhi, India. Vijay Kapur , Former Director Professor & HOD, Department of Anatomy, Maulana Azad Medical College, New Delhi, India.

Introduction
Knowledge of the anatomical details of the plantaris and its variations is important for surgeons while carrying out tendon transplants and reconstructive procedures in the leg region.

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Injuries to the plantaris muscle and its tendon are not uncommon in clinical practice. As compared to hamstring muscles, the injuries to the quadriceps muscles are more common as they stretch and change length over two joints unlike the soleus muscle which spans only one joint [1]. Such injuries may cause severe calf pain and mimic other serious conditions like gastrocnemius tear or deep vein thrombosis of the leg [2]. Ultrasonography or MRI studies are the investigations of choice [3, 4]. The plantaris tendon is considered to be an excellent source of tendon graft [4]. Awareness of such variations in the morphological details of the plantaris muscle may be important in this context. The present study describes variations in the insertion pattern of the plantaris muscle.

oblique course over the heads of the gastrocnemius muscle and merged with the superficial fascia of the leg. The branch innervating the plantaris muscle was as usual found to be originating from the tibial nerve.

Material and Method
Forty legs were dissected to note the insertion pattern of the plantaris muscle. The superficial group of flexor muscles of the posterior compartment of the leg was dissected to expose the entire extent of the plantaris. Appropriate measurements were recorded and the pattern of insertion of the plantaris was studied.

Figure (1): Photograph of right leg showing: (A) Medial head of gastrocnemius (B) Lateral head of gastrocnemius (P) Plantaris muscle. The Plantaris tendon has been lifted with forceps and shown with arrow (↑).

Discussion Results
The mean maximum length and the maximum width of the plantaris muscle measured 8.5 cm and 1.6 cm respectively. In 12 cadavers (60%), the site of insertion was the usual insertion into the calcaneum, while in 8 (40%), the tendon was found to blend with the superficial fascia of the leg (Fig.1). In such anomalies, the tendon traversed an The plantaris muscle is vestigial in man. It is due to the evolution of erect posture that the plantaris muscle gradually lost its attachment into the plantar aponeurosis and thereby gained insertion into the calcaneum. Interestingly in some animals like American brown bear, the plantaris muscle resembles the gastrocnemius muscle and it crosses the calcaneum to join the plantar aponeurosis [5]. 9

The plantaris muscle arises from the lateral supracondylar line and the oblique popliteal ligament [6]. The plantaris muscle belongs to the superficial flexor group of muscles of the posterior compartment of the leg. The plantaris muscle is sometimes considered as the counterpart of the palmaris longus of the forearm. The fusiform belly of the muscle has a slender tendon which crosses the gastrocnemius obliquely to insert into the calcaneum and often the tendon inserts into the fascia of the leg [6]. Past reports suggest that with evolution, the tendon of the muscle has shifted its normal insertion from the plantar aponeurosis to the calcaneum. Occasionally the tendon is so long and thin that it is termed as ‘Fool’s Nerve’ because of its resemblance to a nerve. The anomalous position and attachment of the plantaris tendon into the superficial fascia of the leg, as seen in the present study, renders it vulnerable to injury Research studies have outlined the fact that the size of the muscle correlated with the overall degree of muscular development of the individual. [7] .The rupture of the muscle and its tendon occur in individuals who have larger than average muscle [7]. Rupture of the tendon of the plantaris muscle usually occurs at mid calf level [8]. These are usually detected by ultrasound or MRI scans. Sometimes fluid accumulation may be detected near the tendon bed. Tendinous injury is also associated with hemorrhage and edema [9]. The most significant point in the diagnosis of the plantaris tendon rupture is the presence of the tense mass between the gastrocnemius and the soleus muscle [7]. It is often stated that the plantaris muscle is really not known to any individual unless one has ruptured

it. The tendon of the plantaris muscle has been used as an excellent graft [4]. Thus awareness of the variations in the morphology of plantaris muscle and its tendon is relevant for surgeons. The present cadaver study aims to highlight the anomalous insertion of the slender tendon of the plantaris muscle which may be important for clinicians and surgeons in clinical practice.

References
1-Alexander RM, Ker R F. The architecture of the leg muscle. In: Multiple Muscle Systems: Biomechanics and Movement Organization edited by Winters JM, Woo S, New York City, Springer-Verlag, 1990, pp 568-577. 2- Kane D, Balint P V, Gibney. R, Bresnihan B and Sturrock R D. Differential diagnosis of calf pain with musculoskeletal ultrasound imaging. Annals of the Rheumatic Diseases2004; 63:11-14. 3-Saxena A, Bareither D. Magnetic resonance and cadaveric findings of the incidence of plantaris tendon. Foot Ankle Int. 2000 Jul; 21(7):570-2. 4-Simpson SL, Hertzog MS, Barja RH. The plantaris tendon graft: an ultrasound study. J Hand Surg [Am]. 1991; 16 : 708-11. 5- Daseler EH, Anson BJ. The Plantaris Muscle – An Anatomical Study of 750 specimens. The Journal of Bone and Joint Surgery 1943; 25: 822- 827. 6- Standring Susan. Gray’s Anatomy - The Anatomical Basis of Clinical Practice. Elsevier Churchill Livingstone, 39th edn, New York, 2005, pp-1499-1500. 7- Allard JC, Bancroft J, Porter G. Imaging of plantaris muscle rupture. Clin Imaging. 1992; 16: 55-8.

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8-Leekam RN, Agur AM, McKee NH. Using sonography to diagnose injury of plantaris muscles and tendons. AJR Am J Roentgenol. 1999; 172: 185-9. 9-Deutsch AL, Mink JH. Magnetic resonance imaging of musculoskeletal injuries. Radiol Clin North Am. 1989; 27: 983-1002. ____________________________________

*Editors note: Reviewers advised replacement of reference (5) by a newer reference ,but the authors commented that Reference(5) is unique in its kind that it was a comparative study in the year 1943 and there is no recent reference to quote in case once this old reference is deleted.

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The New Iraqi Journal of Medicine 2006 2(2):12-15

Traumatology

The epidemiology of war-like injuries in children and adolescents during postwar violence wave: Experience of a teaching hospital in Baghdad.
Dhia Talib Al Anbaky

Abstract
Background: In most developing countries communicable diseases continue to be a major cause of childhood morbidity and mortality. However in this geographic area of the world war-like injury involving civilians including children has become a massive health problem. These injuries produce a significant burden on medical facilities. The human and economic costs of the injuries are tremendous. Objective: The aim of this study is to repot the occurrence of war-like injuries in children and adolescents during postwar violence wave Materials and Method: The pattern of war-like injuries in 272 injured children and adolescents aged 15 years or less admitted to the casualty unit at the University Hospital in Al Kadhimiyia (UHK) over a 2 year period from March 2003 to March 2005 was studied. These injuries occurred during the postwar violence wave. Results: The injuries in the majority of casualties were caused by explosions in civilian areas, mortar bombardment of civilian’s buildings and housing and family assassinations.
Specialist surgeon. University hospital in Al Kadhimiyia.Baghdad Iraq.

Corresponding author: Dhia Talib Al Anbaky

The injuries were more common in males with a male to female ratio of (3.1/1),206 (75.7%) of the causalities were males and 66 (24.3%) were females. Of the 272 casualties studied,52 (19.1%) were 5 years old or less,95 (34.9%) were between 6 to 11 years, and 125(45.9%) were between 12 to 15 years. There were126 (46.3%) minor casualties, which were managed in the outpatient emergency unit, while 146(53.6%) casualties had serious and major injuries, 120 (44.1%) of whom were admitted to (UHK) and 6 were transferred to other hospitals. 20(7%) casualties died (12 on arrival and 9 during resuscitation) and two casualties were discharged by parent shortly after receiving them without adequate medical evaluation. Fragmentation weapons (blast injuries) caused 216 (79.4%) casualties and 54(19.8%) casualties sustained gunshot wounds and 2 (0.7%) substantiated burn. Injuries to the lower limbs and trunk were the most common injuries in this series accounting for 126(46.3%) of all injuries. Conclusion: Recognition of the potential for pediatric casualties in the violence wave in this geographic area is 12

necessary to facilitate appropriate planning, training and equipping of causality units.

Introduction
In most developing countries communicable diseases continue to be a major cause of childhood morbidity and mortality. However in Iraq, war- injuries involving civilians including children has become a massive health problem. These injuries produce a significant burden on medical facilities. The human and economic costs of the injuries are tremendous. Exposure of children and adolescents to injuries during war time has been increasingly reported in this geographic area [1, 2]. During the first two weeks of the 2003 gulf conflict, the sole British field hospital in the region received 482 casualties, eight of which (1.7%) were children. During the same conflict, the 202 Field Hospital reported that the first child casualty arrived two days later and over the next four weeks there were 24 admissions of patients aged 15 years or less, amounting to 2% of the total admissions. Although exposure of children and adolescents to injuries during war time has been increasingly reported in this geographic area, an epidemic of war-related wounds during postwar violence in children and adolescence has not been reported in the medical literature. The aim of this study is to repot the occurrence of war-like injuries in children and adolescents during two years of post-war violence wave.

admitted to the casualty unit at the University Hospital in Al Kadhimiyia (UHK) over a 2 years period March 2003 to March 2005 was studied. All data on war- related injuries in children and adolescents 15 years of age or younger were collected .These injuries occurred during post war violence wave. The precise numbers of the total admissions to the casualty unit were not available to the investigators because of the poor recording system during this period of crisis. The precise numbers of the total admissions to the casualty unit were not available to the investigators because of the less serious cases tend to be discharged without being recorded or registered.

Results
The injuries in the majority of casualties were caused by explosions in civilian areas, mortar bombardment of civilian’s buildings and housing and family assassinations. There were more males 206 (75.7%) than females 66 (24.3 %) among the casualties with a male to female ratio of (3.1/1). Those who were 5 years of age or less comprised 52 (19.1%) of the causalities, while 95 (34.9%) were between 6 - 11 years, and 125 (45.9%) were between 12 - 15 years. Figure (1) shows the age distribution of the causalities.

Materials and Methods
The pattern of war-related injuries in 272 injured children and adolescents 13

Of the 272 casualties received, 126 (46.3%) were considered minor and were managed in the outpatient emergency unit without hospitalization Two casualties were discharged on the responsibility of their parents shortly after receiving them without adequate medical evaluation to assess the seriousness of their injury., while 146(53.3%) casualties had serious and major injuries; 120 (44.1%) of whom were admitted to (UHK), and 6 transferred to other hospitals. 20 casualties (7%) died (12 on arrival and 9 during resuscitation). The injuries were generally classified as blast injuries with shells from fragmentation weapons and gunshot injuries with bullets. 216(79.4%) casualties suffered wounds from fragmentation weapons (blast injuries) and 54 (19.8%) casualties sustained gunshot wounds (Bullet injuries) and 2 (0.8%) burns. According to the anatomical location and extent of injury, the injuries fell into

6 categories Table (1). Injuries to the lower limbs and trunk were the most common injuries in this series account for 42% of all injuries. Of the 120 causalities admitted to this hospital 35 were admitted to the general surgery and wards and 30 to the neurosurgery wards. The remaining cases were admitted to other surgical wards, as shown in Table (2). Discussion Exposure of children and adolescents to injuries during war time has been increasingly reported in this geographic area [1, 2]. During the first two weeks of the 2003 gulf conflict, the sole British field hospital in the region received 482 casualties, eight of which (1.7%) were children During the same conflict, the 202 Field Hospital reported that the first child casualty arrived two days later and over the next four weeks there were 24 admissions of patients aged 15 years or less, amounting to 2% of the total admissions [3].

Type of injury according to the anatomical location & extent Head & Neck Upper limb & Shoulder Trunk - Thoracic - Abdomen and back - pelvis Lower Limb Reached dead Generalized

Blast injuries, (Shells from fragmentation weapons) Number (%) 47 (17.2%) 40 (14.7%) 29 (10.6%) 11 (4.3%) 16(5.6%) 2 (0.7%) 61 (22.8%) 8(3%) 31(11.3%)

Gunshot wounds (Bullet injuries) Number (%) 13 (4.8%) 3 (1.1%) 17 (6.5%) 5 (1.5%) 11 (4.3%) 1 (0.4%) 19 (6.5%) 2(0.7%) 0 54(19.8%)

burn

Total Casualties Number (%)

2(0.7%) 2(0.8%)

60 (22%) 43 (15.8%) 46 (17.1%) 16 (5.8%) 27 (9.9%) 3 (1.1%) 80 (29.4%) 12(4.4%) 31(11.3%) 272(100%)

216(79.4%) Total (%) *One or more injuries per case

Table (1): Categories of injuries according to the anatomical location and extent of injury 14

Hospital Wards

General surgery Neurosurgery Cardiothoracic surgery Orthopedic surgery Facio-maxillary surgery Intensive care unit Ophthalmology / Urology / Plastic surgery 120(44.1%) Total (100%) Table (2): Table (2): Distribution of the hospitalized patient to various hospital departments

Admitted Causalities 35(12.8%) 30(11%) 24(8%) 21(7.7%) 4(1.4%) 2(0.7%) 4(1.4%)

children required transfer to a specialist facility. The present paper is a unique one reporting an epidemic of war-related injuries among children and adolescents during the post-war wave of violence in Iraq that has not been reported in the medical literature. Conclusion: Recognition of the potential for pediatric casualties during the violence wave in Iraq is necessary to facilitate appropriate planning, training and equipping of causality units. References: 1- Hinsley DE, Rosell PA, Rowlands TK, and Clasper JC. Penetrating missile injuries during asymmetric warfare in the 2003 Gulf conflict. Br J Surg. 2005; 92 (5): 637 - 42. 2- Heller D. Child patients in a field hospital during the 2003 Gulf conflict. J R Army Med Corps. 2005; 151 (1): 41 3. 3- Gurney I. Paediatric casualties during OP TELIC. J R Army Med Corps. 2004 Dec; 150 (4): 270 - 2.

The Pattern of injuries in the present study was different from the pattern of injuries to children and adolescents during war time like that reported by Gurney [3]. from which country and in which war. In that retrospective analysis of Seventy eight children (All <16years-old) admitted to a British Army Field Hospital during war fighting, 44 (56%) children had burns as the principal injury; 7 (9%) had shrapnel injuries, 5 (6%) had blunt trauma from a road traffic accident (this is not warrelated). Only one child had Gun-shot wounds. 'Medical' complaints rather than trauma accounted for 17% of attendances and 78% of

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The New Iraqi Journal of Medicine 2006 2(2): 16-19

Psychiatry

The Epidemiological Pattern of Psychosis in Military Patients
Safaa Jawad, Ghazi Aboud

Abstract
Background: The schizophrenic breakdown rate of recruits to the US army was mush higher in their first month of military service taken at any time in the next two years suggesting that the transition from civilian life to recruiting barracks was contributing to the genesis of these illnesses. Objectives: The aim of this study is to explore, retrospectively, the epidemiological pattern of psychosis in military patients including family history, scholastic achievement, social status and precipitating factors. Patients and methods: The case records of 100 psychotic patients were reviewed. Most of the cases were clinically diagnosed in Al Rasheed military hospital during 2001 - 2002 as having schizophrenic. The case records included clinical notes of the general practitioner and specialist in addition to family, social and military records. Results: Out of the 100 cases, 32 were volunteer conscripts and 68 were compulsory recruits. Seventy six patients illness. The majority of psychotic patients were with low scholastic achievement, attributed mostly to early onset of the illness and social stigma. The precipitating factor of the impact of the demanding new military life is more evident than family history so the most important preventive measure to address is to improve handling of transference of societies from civilian life to military one. Conclusion: Military discipline could be considered as stressful factor that precipitates the illness. Key Words: Psychosis-Military patients-Pattern

Introduction
The variable course of psychotic disorders has been well documented in the literature. However, the understanding of different combinations of biological predisposition, clinical characteristics and psychosocial environment accounting for different illnesses remains illusive. It has been asserted that each dimension of psychotic outcome is best predicted by what has happened earlier [1]. The term “psychotic” denotes loss of reality testing which can occur as a result of delusional belief or hallucinatory perception, usually auditory or visual. The psychotic symptoms are the most

Safaa Jawad, Psychiatrist Al Kindy Hospital, Baghdad. Ghazi Aboud, Psychiatrist Al-Rashad Psychiatric Hospital Baghdad, Iraq

were single, 30 had a positive family history of psychiatric illness and 54 had a stressful factor prior to the onset of the 16

dramatic and potentially dangerous features of this illness, but other symptoms may be even more disabling [2]. Genetic factors are likely to be important in schizophrenia, but it can also be familial, because family members share the same disadvantaged environment [3]. Paul Meehl [4] in his integrative model that led to the development of the diathesis-stress model suggested that certain people possess a genetic predisposition to schizophrenia and other psychotic disorders, which are expressed behaviorally only if they are reared in a stressful environment. On other hand, if environmental stress remains below the person's stress threshold, schizophrenia may never develop even in persons at genetic risk. A role has been suggested for adverse life events and social adversity as operating factors on already predisposed individuals to trigger onset [5]. Schizophrenic patients experience a significantly higher frequency of such events during the 3-week period prior to the onset of their symptoms [6]. The schizophrenic breakdown rate of recruits to the US army was mush higher in their first month of military service taken at any time in the next two years suggesting that the transition from civilian life to recruiting barracks was contributing to the genesis of these illnesses [7]. It was reported that such pre-schizophrenic children showed lower I.Q. and poor scholastic performance [8]. It was suggested that life events serve to trigger the florid onset in those who are predisposed [9].

Patients and methods The case records of 100 psychotic patients were reviewed. Most of the cases were clinically diagnosed in Al Rasheed military hospital during 2001 2002 as having schizophrenic. The case records included clinical notes of the general practitioner and specialist in addition to family, social and military records. Results Out of the 100 cases, 32 were volunteer conscripts and 68 were compulsory recruits. Single men constituted 76 cases while the remaining 24 were married men. Figure (1) shows that 37 patients completed elementary school only, 38 completed intermediate school, 13 completed secondary school and 12 completed colleges.

40 35 30 25 20 15 10 5 0 Elementary Intermediate Secondary school school school Educational Level Achieved College

Figure (1): Scholastic Achievement of the Studied Cases

A positive family history of the illness was found in 30 patients, 13 of them had also a stressful factor prior to the onset of their illness illness, 21 patients were reared without their fathers and 9 patients were reared without their mothers.

17

Number of Patients

Just over one half of the cases (51) were admitted to the hospital more than 3 times, 35 patients had 3 admissions, and 14 patients had 2 previous admissions. A course of Electroconvulsive Therapy (ECT) was used for the treatment of 61 patients during their admission. Precipitating factors: 54 patients had a variety of stressors which are considered as precipitating factors preceding the onset of the illness. In addition to these factors, 13 patients also had a positive family history of the illness. These factors occurred during the first 3 weeks prior to the onset of the illness in 39 patients while in 15 patients they preceded the onset of the illness by at least 6 months. Discussion The majority of patients (68%) were recruited soldiers, which may indicate that military discipline could be considered as stressful factor that precipitates the illness according to Steinberg and Durnel study [7]. Low level of Scholastic achievement in the sample may be related to the early onset of the disease process which goes with the results of the study of Jones et al [8]. The majority of patients (76%) were single which may be related to the result of the disease process itself and the social stigma and label, which may be considered as an obstacle to marriage. A positive family history of psychiatric illness was found in 30 cases, 13 of whom also had a stressful factor prior to the onset of the illness which is consistent with the results of many other studies [3, 4, 5, 9]. Stressful events / factors were reported by 54 patients to have happened prior to the onset of illness. This event was the

only factor that determines or expresses the disease process in 41 patients, especially in the first three weeks prior to the onset of the illness which agrees with the results of many studies [4, 6, 7]. References
1. Beiser M, Iacono W: An update on the epidemiology of schizophrenia. Can .J. psychiatry 1990; 35: 657- 688. 2. Donald C.Goff (2002) , A 23- year Old Man with schizophrenia ( 12). JAMA Neurology & Psychiatry 2002; 287:32493257. 3. Johnston E: Schizophrenia, chapter 13 (381), Companion to psychiatric studies, Sixth ed., Churchill Livingstone by Johnstone, Freeman & Zeally (1998) 4. Meehl PE: A Critical Afterword. II , Gottesman & J. shields (Eds), schizophrenia and genetics. A twin study vantage point 1972; (367- 415). New York Academic Press. 5. Bebbington PE, Wilkins S, Jones P, etal: Life events & psychosis: Initial results from the Camberwell Collaborative Psychosis Study. Br. J. Psychiatry, 1993; 162, 72-9. 6. Brown GW & Birley JLT: Crises & Life changes & the onset of schizophrenia, J. Health Soc. Behav. 1968; 9: 203-214. 7. Steinberg HR, Durnell J: A stressful Social situation as a precipitant of schizophrenic symptoms: an epidemiological study: British Journal of Psychiatry; 1968; 114: 1097-1105. 8. Jones, P.B, Rodgers, B, Murray. R.M. & Marmot, M. (1994a): Child developmental risk factors for adult’s schizophrenia in the British 1996 birth cohort Lancet; 344, 1398402.

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9. Brown GW, Birley JLT & Wing JK: Influence of family life on the source of schizophrenic disorders: a replication. Br.J.Psychiatry; 1972; 121: 241-58.

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The New Iraqi Journal of Medicine 2006 2(2):20-21

International conference

Fourth International conference on pediatric continuous Renal Replacement Therapy
February 23-25, 2006 | Campus of University Zurich-Irchel, Switzer

Abstract
Continuous Renal Replacement Therapy (CRRT) in the Developing World: Is there any alternative?
AJ AL MOSAWI

Dialysis and transplantation (RRT) originally developed to forestall death in patients with ESRF, have become standard management practice in developed countries. However RRT requires an expert team consisting of at least a nephrologists, cardiovascular surgeon and urologist, in addition to a skilled nursing staff. Therefore, in many areas of the world RRT is considered extremely expensive both in manpower and cost of treatment, with a maintenance cost far beyond those observed in other areas of medical care. In areas where RRT has been introduced to some extent (e.g. hemodialysis and transplantation) despite the lack of effective and skilled teams, rehabilitation is commonly unsatisfactory and results are discouraging relative to costs. Patients undergoing RRT in these areas commonly experience a disproportionate amount of discomfort and suffering which cannot be balanced by the added length of life achieved. 17 years old boy with biopsy proven rapidly progressive (Endocapillary

crescentic) glomerulonephritis developed end-stage renal failure (ESRF) despite receiving steroids and cyclophosphamide.He developed symptomatic uremia (anorexia, fatigue, and tachypnea) about 6 months before referral. laboratory tests at that time showed serum creatinine 10 mg/l,blood urea 360 mg/dL.Since that time he was receiving regular hemodialysis (HD) 2 sessions /week. He received more than one blood transfusion during that period. Both of the parents and the patient considered this form of RRT is not convenient and have disrupted their life and all of them experienced a significant amount of discomfort and suffering. On referral 2 days after HD session the boy has symptomatomatic uremia (fatigability, and mild tachypnea).The boy was receiving erythropoietin,parentral iron ,one alphacalcidol,calcium carbonate ,and frusemide.The boy started a new form of RRTconsisting of acacia gum(AG) 1g/kg/day dissolved in fluids and given in divided doses in conjunction with low protein diet (LPD).After 2 weeks from the start of this form of RRT the boy reported improved well being and much

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more comfort has ever experienced since the onset of uremia. Table (1) shows the effect of this form of RRT on serum creatinine and blood urea. The values of serum calcium, and potassium are expected to be more by other therapies (one-alphacalcidol, eryrthropoeitin, diutertc, etc,) The family traveled outside the country and the boy stopped AG therapy ,but continued on LPD.After 2 weeks he presented again with symptomatic uremia. Both the parents and the decided to continue this form of RRT rather than returning to regular HD. This novel form of RRT has already been reported to provide children treated by intermittent peritoneal dialysis a long period of dialysis freedom and improved well being[1].This is first paper reporting HD freedom and improved well being with this form of RRT.

References
1-Al-Mosawi AJ. Acacia gum supplementation of a low- protein diet in children with end-stage renal disease. Pediatr Nephrol 19; 1156-1159 (2004). 2-Al-Mosawi AJ, Chesney RC, Patters A. Acacia gum therapeutic potential: Possible role in the management of uremia-A new potential medicine. Therapy [suppl] 3(2) (2006).

University Hospital in Al Kadhimiyia PO Box 70025 Baghdad Iraq E-mail: almosawiAJ@yahoo.com

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The New Iraqi Journal of Medicine 2006 2(2) :22-25

Pediatric Nephrology

Nephropathic cystinosis in Iraqi children
Aamir Jalal Al Mosawi M.D, Ph.D. Head of Department of Pediatrics. University Hospital in Al Kadhimiyia (Al-Kadhimiyia Teaching Hospital). Al-Kadhimiyia, Baghdad, Iraq. PO Box 70025 e-mail:almosawiAJ@yahoo.com Tel: 964 1 4431760

Abstract
Background: Nephropathy cystinosis is a

rare, autosomal recessive lysosomal storage disorder caused by mutations in the CTNS gene that codes for a cystine transporter in the lysosomal membrane. Affected patients store 50-100 times the normal amounts of cystine in their cells, and suffer renal tubular and glomerular disease, growth retardation, photophobia, and other systemic complications, including a myopathy and swallowing dysfunction. The aim of this study is to describe the pattern of cystinosis in Iraqi children.
Patients and Methods: From 1999 to 2005 eight patients with Cystinosis were observed at the university hospital in Al Kadhimiyia.There age ranged from 10 months to 14 years at the time of first referral. (Mean 5 years).The diagnosis of Cystinosis was confirmed by finding the pathognomic corneal cystine crystals on slit lamp examination. Results: Three patients have evidence of Fanconi syndrome and one patient has evidence of RTA on referral. The remaining 4 patients had chronic renal failure on referral with 2 of them have reached endstage renal failure and have undergone dialysis. Four of the patients with Cystinosis have at least one sibling died from the same

illness. The remaining three patients had no family history of similar illness. All the patients have significant growth retardation with all of their growth parameters below the third centile. Among the patients with Cystinosis only one patient was receiving cysteamine sent to him from a relative living in UK. During the follow-up period, two of the patients with Cystinosis died from uremia. Only two of the 7 observed patients had the correct diagnosis of Cystinosis before referral .The remaining 5 patients were diagnosed as having RTA before referral indicating delay in referring the patients to the appropriate consultant. Conclusion: The outcome of nephropathic cystiosis in Iraqi children is poor as most of them progressed to CRF because of the nonavailability of cysteamine Keywords: Fanconi Nephropathic -Cystinosis syndrome--

Introduction Cystinosis, clinically recognized since 1903, is a rare autosomal recessive lysosomal storage disease caused by mutations in CTNS. This gene codes for a lysosomal cystine transporter, whose absence leads to intracellular cystine crystals, widespread cellular destruction, renal Fanconi syndrome in infancy, renal glomerular failure in later childhood and 22

other systemic complications. Before the availability of kidney transplantation, patients affected with cystinosis uniformly died during childhood. After solid organ transplantations became successful in the 1960s, cystinosis patients survived, but eventually developed life-threatening consequences of the disease (e.g., swallowing disorders). Since the introduction of cysteamine into the pharmacological management of cystinosis, well-treated adolescent and young adult patients have experienced normal growth and maintenance of renal glomerular function. Cysteamine (and kidney transplantation) have commuted the death sentence of cystinosis into a nearly normal life with a chronic disease. Because treatment with oral cysteamine can prevent, or significantly delay, the complications of cystinosis, early and accurate diagnosis, as well as proper treatment, is critical [1, 2, 3, 4]. The aim of this study is to describe the pattern of cystinosis in Iraqi children.
Patients and Methods From 1999 to 2005 eight patients with Cystinosis were observed at the university hospital in Al Kadhimiyia.There age ranged from 10 months to 14 years at the time of first referral. (Mean 5 years).The diagnosis of Cystinosis was confirmed by finding the pathognomic corneal cystine crystals on slit lamp examination. Results Three patients have evidence of Fanconi syndrome and one has evidence of proximal RTA on referral. The remaining 4 patients had chronic renal failure on referral with 2 of them have reached end-stage renal failure and underwent dialysis. Four of the patients with Cystinosis have at least one sibling died from the same illness. The remaining 4

patients had no family history of similar illness. All the patients have significant growth retardation with all of their growth parameters below the third centile.One patient developed severe bowing deformities interfered with mobilization. Table (1) shows the characteristics of the 8 patients with cystinosis. Among 13 the patients with Cystinosis (8 referred to us and 5 of their siblings) only one patient was receiving cysteamine sent to him from a relative living in UK. During the follow-up period, two of the patients with Cystinosis died from uremia. Only 3 of the 8 observed patients had the correct diagnosis of Cystinosis before referral and the diagnosis in these 3 patients was suggested by the ophthalmologist after the development of photophobia rather by the treating physician. The remaining 5 patients were diagnosed as having RTA before referral indicating delay in referring the patients to the appropriate consultant.

A girl with Nephropathic cystinosis and cronic renal insufficiency.

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Table (1) shows the characteristics of the 8 patients with cystinosis.

Gender 1 2 3 4 female male female male

Age at Diagnosis referral before referral 4 years RTA 10 RTA months 2 year RTA 1 year Cystinosis

Presentation referral Proximal RTA Fanconi syndrome Renal insufficiency Fanconi syndrome ESRF

on Family history Negative Negative Negative Brother died 1 week before referral at the age of 1 year Brother died before the age of 10 Negative

Mortality A live –ESRF A live -------------------

5 6 7 8

male female female male

11 years 2 years 14 years 4

cystinosos cystinosos RTA RTA

Died uremia -----------Died uremia ------------

from

Fanconi syndrome CRF and skeletal 2 sisters died deformities before 7 years CRF Bother died

from

Discussion
Before the availability of kidney transplantation, patients affected with cystinosis uniformly died during childhood. After solid organ transplantations became successful in the 1960s, cystinosis patients survived, but eventually developed life-threatening consequences of the disease (e.g., swallowing disorders). Since the introduction of cysteamine into the pharmacological management of cystinosis, well-treated adolescent and young adult patients have experienced normal growth and maintenance of renal glomerular function. Oral cysteamine therapy is given at doses of 60 - 90 mg/kg/day q.i.d. every 6 h, and generally achieves approximately 90% depletion of cellular cystine, as 24

A boy with cystinosis and Fanconi syndrome

measured in circulating leucocytes. Cysteamine (and kidney transplantation) have commuted the death sentence of cystinosis into a nearly normal life with a chronic disease. Because treatment with oral cysteamine can prevent, or significantly delay, the complications of cystinosis, early and accurate diagnosis, as well as proper treatment, is critical. In this study most patients were not diagnosed before referral and was referred relatively late.Cysteamine is generally not available in Iraq. Renal replacement therapy is also not available for children with cystinosis when they eventually reach end-stage renal failure.
Among 13 the patients with Cystinosis (8 referred to us and 5 of their siblings) only one patient was receiving cysteamine

cysteamine therapy. Medicine (Baltimore). 2005 May;84(3):137-46. 4-Levtchenko EN, van Dael CM, de Graaf-Hess AC, Wilmer MJ, van den Heuvel LP, Monnens LA, Blom HJ. Strict cysteamine dose regimen is required to prevent nocturnal cystine accumulation in cystinosis. Pediatr Nephrol. 2006 21(1):110-3.

Conclusion: The outcome of Nephropathic cystinosis in Iraqi children is poor as most of them progressed to CRF because of the non-availability of cysteamine.

References
1- Kleta R, Gahl WA. Pharmacological treatment of nephropathic cystinosis Expert Opin with cysteamine. Pharmacother. 2004 Nov; 5(11):225562. 2- Kleta R, Bernardini I, Ueda M, Varade WS, Phornphutkul C, Krasnewich D, Gahl WA. Long-term follow-up of well-treated nephropathic cystinosis patients. J Pediatr. 2004 Oct; 145(4):555-60
3-Sonies BC, Almajid P, Kleta R, Bernardini I, Gahl WA. Swallowing dysfunction in 101 patients with nephropathic cystinosis: benefit of long-term

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