Journal of the Faculty of Medicine Baghdad <h3>Journal of the Faculty of Medicine – University of Baghdad</h3> <h3>A peer-reviewed journal published Quarterly by the college of medicine –Baghdad University</h3> <h3>ISSN:&nbsp; &nbsp;0041-9419</h3> <h3>EISSN: 2410-8057</h3> <h3>The Journal interested in the publication of clinical and basic medical research.</h3> <h3>The first issue of this Journal was published under the name of (Journal of the Royal Iraqi Medical College) in April /1936, approved by the council of the College as a general journal dealing with the news of the college and few scientific articles to encourage the teaching staff for research publication. The journal was published randomly and ceased during World War II due to financial difficulties.</h3> <h3>In 1946 Prof. Dr. Hashim Al Witri, the college dean, assigned republication of the journal and urged the teaching staff to participate and publish their research in the journal. Despite his effort, the journal remained irregular in publication. In 1959&nbsp; Prof. Dr. Faisal Al-Sabih became the Editor in Chief of the journal when he returned from the United Kingdom and appointed on the teaching staff, restructured the journal and changed its name to (The Journal of the Faculty of Medicine) and used a new scientific system for publication of articles.</h3> <h3>The first issue of the new series started in June 1959. The journal continued to be published on a regular basis since then without interruption in (four issues during the year). The journal became registered the international number (ISSN) in 2000 and entered in many important international indexes.</h3> <h3>After 2003 the journal continued despite the difficulties involved in every aspect of the country and by the beginning of 2004, the journal progressed through a series of changes to reach a level that can be recognized internationally.</h3> <h3>After 2010 the journal became published electronically of the same edited issues.</h3> en-US <p>&nbsp;For all articles published in Journal of the Faculty of Medicine Baghdad, copyright is retained by the authors. Articles are licensed under an open access<a href="">&nbsp;Creative Commons CC BY NC 4.0 license</a>,&nbsp;meaning that anyone may download and read the paper for free. In addition, the article may be reused and quoted provided that the original published version is cited. These conditions allow for maximum use and exposure of the work, while ensuring that the authors receive proper rights.</p> <p>&nbsp;</p> (prof. Tharwat I. Sulaiman) (Assistant Lecturer Sara Mohammed) Sun, 21 Feb 2021 22:34:12 +0000 OJS 60 Mitral valve surgery: comparison between superior septal and left atrial approaches <p><strong>Background </strong>Mitral valve (MV) is one of the most complex structures in human heart with a challenging exposure. Traditionally, MV is approached via left atriotomy (LAA) while superior septal approach (SSA) is an alternative.<strong><br>Objective</strong>: &nbsp;is to highlight the merits and demerits of these two approaches in providing access to the MV in term of the aortic cross clamp time (ACCT), quality of exposure, and potential complications in view of the published literature.</p> <p><strong>Patients and Method: </strong>Over an 18-month period ending at June 30<sup>th</sup>, 2019, 56 patients with MV disease ± other cardiac diseases were enrolled in this study. Twenty patients had surgery via LAA (one surgeon) whereas 36 were operated upon via SSA (another surgeon). Standard surgery was done via median sternotomy, cardiopulmonary bypass and hypothermia of 32 <sup>0</sup>C. Perioperative events were recorded.</p> <p><strong>Results </strong>In SSA group (males=25; age ranged 23-74 years; mean=57.4), patients had chest pain and breathlessness for a mean of 3 months (&gt;LAA) besides low ejection fraction (EF) in 44%, atrial fibrillation (AF) in 38.9% and dilated LA in 19.4%. They underwent 25 MV replacements (MVR), 11 MV repairs (0 in LAA), 11 coronary artery bypass grafts (CABGs) (2.6 graft per patient vs. 1.3 in LAA; significant) and 2 aortic valve replacement. Mean ACCT was 81.6 minutes (˂LAA). Postoperatively, 32 patients (88.9%) had a normal or improved EF, 11 of 14 AF patients (78.6%) reverted to sinus rhythm and no hospital death was recorded. <strong>Conclusion </strong>Besides excellent exposure, the SSA enabled us to perform MVR or repair ± additional interventions within a short time and without a heart block. Hence, our results matched the international literature.</p> Abdulsalam Yaseen Taha, Shkar Raouf Haji Saed, Amanj Kamal Mohammed, Jivara Hama Nadr ##submission.copyrightStatement## Sun, 21 Feb 2021 20:38:43 +0000 Predictive Value of Alvarado Score and Ultrasound in the Diagnosis of Acute Appendicitis (A prospective study <p><strong>Background:&nbsp; </strong>Acute appendicitis is the commonest non traumatic cause of acute abdominal pain that needs surgical management .Alvarado score and ultrasonographies are the most cost effective, easy and available aids for diagnosis. The aim of the study was determining&nbsp;&nbsp; the reliability of Alvarado score and ultrasound in the diagnosis of acute appendicitis.</p> <p><strong><br>Results: </strong>The study was applied with 100 cases with different types of abdominal pain at presentation with 51 males and 49 females .The sensitivity was97.3% ,specificity 90%, and accuracy&nbsp; 89 of combined usage of Alvarado score and U/S findings preoperatively.</p> <p><strong>Patients and method:&nbsp; </strong>A prospective non-interventional study including patients admitted with suggestive history with signs and symptoms of acute appendicitis to the surgical emergency ward of Baghdad teaching hospital from July 1<sup>st</sup> 2017 to Feb 10<sup>th</sup> 2018, Alvarado score calculated and ultrasonography done for each patient enrolled in this study, then to be followed for intraoperative findings.</p> <p><strong>Conclusions: </strong>Combined application of Alvarado score and U/S has sensitivity 94.1% ,specificity 90% and accuracy 89% . In our medical facility and emergency ward, acute appendicitis remains as one of the top acute abdominal emergencies needing surgery in patients presenting with atypical clinical finding. So diagnosis becomes difficult. So Alvarado score along with ultrasound findings are useful for increasing the reliability in emergency department for&nbsp; accurate diagnosis of acute appendicitis therefore there should be training for the use of U/S by emergency physician and general surgeon in the diagnosis of acute appendicitis in order to decrease the rate of negative appendectomies .&nbsp;&nbsp;</p> Waleed Saadi Ahmed, Salah M. Tajer, Hend M. Sayaly ##submission.copyrightStatement## Sun, 21 Feb 2021 21:12:11 +0000 Artifacts in electrocardiogram interpreted as cardiac arrhythmias: Reports of clinical cases <p><strong>Background:</strong> Artifact waves in the ECG and Holter recording are not rare in clinical practice and can be mistaken for tachyarrhythmia.</p> <p><strong>Objective:</strong> To orient the practicing physicians to differentiate these artifacts from cardiac arrhythmias.</p> <p><strong>Patients and Methods:</strong> Thirteen patients with incorrectly diagnosed cardiac arrhythmias by ECG or Holter recording then distinguished to be ECG artifacts were included in this study. The patients were collected from the author’s private practice in the northern Iraqi governorate of Sulaimanya during the period from June 2015 to August 2020. The differentiation of the artifact waves from the arrhythmias were made by careful inspection of the ECG, identification of the R waves within the artifact waves and correlating the artifact waves with the patient’s symptoms.</p> <p><strong>Results:</strong> The artifacts were mistaken for ventricular fibrillation in two patients, ventricular tachycardia in four, atrial fibrillation in two, atrial flutter in four, and in one patient bradycardia of high grade atrio-ventricular block.</p> <p><strong>Conclusion:</strong> Distinguishing artifact in ECG and differentiating them from cardiac arrhythmia is important to avoid mismanagement.</p> AMAR Talib AL-HAMDI ##submission.copyrightStatement## Sun, 21 Feb 2021 21:26:07 +0000 Pediatric emergency department; resource exhaustion and burden of work in a resource-constrained region. <p><strong>Background:</strong> emergency care is well known as the care delivered in a hospital setting to any patient with unexpected, sudden, threatening reversible condition. In countries where health care is not optimum, this type of care represents the weakest element of the health system.</p> <p><strong>Aims of the study:</strong> to figure out the main causes behind the admission in Pediatric Emergency Department (PED) of Children Welfare Teaching Hospital (CWTH) and the urgency of visits.</p> <p><strong>Patients and methods:</strong> a cross sectional study retrospective analysis that was carried out in the PED of CWTH in Medical City, Baghdad. Five hundred visits for patients below the age of 14 years between August and November 2017 were enrolled in this study and their data were analyzed. Perceived urgency of the current visit was assessed and analyzed.</p> <p><strong>Results:</strong> the mean age for the patients was 3 years. Males represent 239 patients (47.8%). Of the whole group, 110 patients with a range of hours (22.0%). The most common complaint recorded was fever in 175 patients (21.0%). The most common comorbidities recorded were chronic respiratory diseases in 10 patients. Complete blood count was ordered for 460 patients (92.0%). Strikingly, blood culture was recorded in 5 patients only (1.0%). Reviewing the patients’ files has shown that 381 patients (76.2%) were prescribed antibiotics during stay in PED. The diagnosis of the patients visiting the PED was documented in 252 (50.4%) patients’ files only. Lower respiratory tract infections were the most frequently recorded diagnosis in 41 patients (8.2%). 266 patients (53.2%) were shown to be urgent visits, while 234 of them (46.8%) were non-urgent visits. Most of the patients who have comorbidities were labeled as urgent patients (89.4%), with a significant statistical difference (P value 0.001). Most of the patients who presented with a duration of complaint of within hours (89.1%) were stratified as urgent cases. Noteworthy, the majority of the patients who did not receive antibiotic therapy were stratified to be urgent (74.7%), the p value was 0.0001. Considering the disposition of the patients, majority of the patient who were discharged home (61.2%) were stratified as non-urgent, while (38.8%) were urgent.</p> <p><strong>Conclusions:</strong> The study identifies the critical pitfalls of improper documentation of the data in the PED. It also delineates the resource exhaustion from the non-urgent visits. This may call for the need of structured training of physicians in the PED to improve efficiency, and reduce the cost and expenses of each patients through reducing the investigations and this will improve the standards of service. Triage system should be implemented in CWTH PED.</p> Hasanein Habeeb Ghali, Mustafa A. Al-Shafiei, Hayder M. Al-Musawi ##submission.copyrightStatement## Sun, 21 Feb 2021 21:43:09 +0000 Surface Web Merits for SARS-CoV-2 Pandemic in Iraq <p><strong>Background:</strong> Data on SARS-CoV-2 from developing countries is not entirely accurate, demanding incorporating digital epidemiology data on the pandemic.</p> <p><strong>Objectives:</strong> To reconcile non-Bayesian models and artificial intelligence connected with digital and classical (non-digital) epidemiological data on SARS-CoV-2 pandemic in Iraq.</p> <p><strong><br>Results:</strong> Baghdad and Sulaymaniyah represented statistical outliers in connection with daily cases and recoveries, and daily deaths, respectively. Multivariate tests and neural networks detected a predictor effect of deaths, recoveries, and daily cases on web searches concerning two search terms, "كورونا" and "Coronavirus" (Pillai's Trace value=1, F=1106915.624, Hypothesis df=3, Error df=12, p-value&lt;0.001, Partial Eta Squared=1). Using hierarchical clustering, we identified distinctive aggregates involving the Iraqi capital, Kurdistan region, and the south of Iraq. Three search terms were most prevalent among Iraqi web users, including "كورونا", "كوفيد-19", and "Coronavirus". Significant bivariate correlations were all positive except for those involving the search term "لقاح كورونا". Al-Muthanna governorate residents were least interested in data on SARS-CoV-2 vaccines.<strong>Methods:</strong> Our study design is longitudinal, for the period from 24 February 2020 to 25 September 2020. We retrieved data from the Iraqi Ministry of Health on the daily cases, recoveries, and deaths from SARS-CoV-2, and incorporated collateral data from Google Trends using five search terms, "Coronavirus", "كورونا", "COVID-19", "كوفيد-19", and "لقاح كورونا". The search terms "كورونا", "كوفيد-19", and "لقاح كورونا" represent the Arabic translations for "Coronavirus", "COVID-19", and "COVID-19 Vaccine". We implemented multivariate tests and machine learning to scrutinize the spatio-temporal trends of the pandemic in Iraq and interpret the causality influencing Iraqis to seek digital knowledge, via the web, on SARS-CoV-2.</p> <p><strong>Conclusion:</strong> Our analyses were triumphant in syncretizing non-Bayesian and machine learning models, using two forms of epidemiology data on the pandemic in Iraq. We opine that the current study is exquisite and precious for decision-makers at the Iraqi Ministry of Health.</p> Ahmed Al-Imam, Marek A. Motyka, Hend J. Al-Doori ##submission.copyrightStatement## Sun, 21 Feb 2021 21:54:22 +0000 Early onset familial relapsing polyneuropathy, mimicking CIDP; A lesson from clinical genetics <p><strong>Background</strong>: In children, chronic immune-mediated neuropathies present with slowly progressive or relapsing episodes of gait difficulty, symmetric weakness and sometimes paraesthesia. Infancy and early childhood age of presentation and familial recurrence are believed to be atypical features.</p> <p><strong>Case presentation</strong>: Herein, we describe two brothers from a non- consanguineous Iraqi family, who presented with episodes of acute immune-mediated demyelinating peripheral neuropathy in early infancy that relapsed recurrently. Mild haemolytic anaemia was also reported. Inherited metabolic disorders were suspected and Whole Exome Sequencing of the youngest brother revealed homozygous frame shift mutation in CD59 gene, confirming the diagnosis of autosomal recessive hemolytic anemia, CD59-mediated, with or without immune-mediated polyneuropathy (HACD59).</p> <p><strong>Conclusion</strong>: The report highlights the advantage of genetic testing in such rare and inherited conditions. In the lack of necessary non-traditional diagnostic methods, it is substantial to maintain the accustomed medical practice and strategies, based on available clinical data.</p> nebal wael saadi ##submission.copyrightStatement## Sun, 21 Feb 2021 22:04:29 +0000 Misleading Presentation of Colorectal Cancer in an Otherwise Healthy Patient <p><strong>Background</strong>: Colorectal cancer (CRC) represents the second most common malignancy and the fourth most common cause of cancer deaths. CRC can manifest early with bright red bleeding per rectum, tenesmus, and altered bowel habits. These symptoms are often attributed to benign lesions, including anal fissure. Our objective is to highlight the alarming scenario of an anal fissure masking the clinical features of an underlying colorectal cancer in healthy middle-aged patients.</p> <p><strong>Case Report</strong></p> <p>Our case report aims to discuss how congruent clinical features of benign-looking anal fissure can delay the diagnosis of rectal cancer. In January 2019, a healthy forty-four years old Iraqi male with no family history of colorectal neoplasms presented to Baghdad Medical City. He suffered from a long-standing peri-anal pain and infrequent bowel motion that was initially diagnosed as an anal fissure. Subsequent clinical assessment, with endoscopy, confirmed the presence of colorectal adenocarcinoma. We also carried out analytics, using Google Trends, to assess the spatiotemporal mapping of web users interested in case scenarios similar to our patient.</p> <p><strong>Conclusion</strong></p> <p>Anal fissure could coexist with colorectal cancer, even in younger patients. Therefore, it is essential to consider anal fissure and colorectal cancer on clinical assessment. Follow-up visits are paramount to exclude underlying life-threatening aetiology at secondary care.</p> Mustafa Aljarshawi, Haitham Albadree, Hasan Bahar, Ahmed Al-Imam ##submission.copyrightStatement## Sun, 21 Feb 2021 22:20:57 +0000 Foreign bodies’ inhalation, 38-year-experience Past, present and future <div dir="auto">Four decades of personal experience in dealing with the inhaled foreign body (FB)</div> <div dir="auto">Ways of presentations.</div> <div dir="auto">Methods of diagnosis.</div> <div dir="auto">Methods used for the successful removal the FBs using the rigid paediatric bronchoscope will be elucidated.&nbsp;</div> <div dir="auto">The changing patterns of the types of FB during these years will be emphasized.</div> <div dir="auto">Majority of these incidents of inhaled FBs are preventable.</div> waleed M. hussen ##submission.copyrightStatement## Sun, 21 Feb 2021 22:26:43 +0000