IRAQI JOURNAL OF COMMUNITY MEDICINE

Background: The Sapropterin dihydrochloride enzyme cofactor, a synthetic analog form of 6R‑BH4, was offered as an oral treatment for
hyperphenylalaninemia. The sapropterin dihydrochloride role in patients with phenylketonuria (PKU) is to activate the endogenous phenylalanine
hydroxylase (PAH) and to restore partially the oxidative metabolism of phenylalanine (Phe), when patients have insufficiency or lack of
tetrahydrobiopterin. The sapropterin dihydrochloride anticipated to restore PAH activity through providing an exogenous source of the lost or
deficient cofactor. Aim of Study: This study aims to evaluate the effects and clinical significance of tetrahydrobiopterin supplementation in
hyperphenylalaninemia. Patients and Methods: This study describes the use of tetrahydrobiopterin in 58 patients with hyperphenylalaninemia
treated before the age of 15 years with the use of tetrahydrobiopterin loading test. More than 30% decrement in Phe consider positive.
Results: Fifty‑eight patient been enrolled in this prospective study as follows; seven patient non PKU hyperphenylalaninemia (Phe level <600 μM),
13 patients mild to moderate PKU (Phe level between 600 and 1200 μM) and 38 with classic PKU (Phe level equal or above 1200 μM). The mean
of Phe at the diagnosis was 377.00 ± 150.240 μM, 843.00 ± 133.899 μM and 1513.736 ± 274.372 μM sequentially. The response to treatment
with tetrahydrobiopterin was inversely related to the level of Phe where its 100% in non PKU hyperphenylalaninemia, 70% in mild‑to‑moderate
PKU and 16% in classic PKU. Tetrahydrobiopterin therapy significantly enhanced dietary Phe tolerance and permitted a Phe‑free medical
formula to be discontinued in a significant number of patients in whom phenylalaninemia within therapeutic target (120–300 μM) were
achieved. Tetrahydrobiopterin displays the safety and usefulness of this treatment for patients mild PKU. Conclusions: Tetrahydrobiopterin
therapy should be tried in all patients with hyperphenylalaninemia and/or PKU as it may significantly decrease the Phe level and improvement
his milestone moreover safe in mild PKU.

Background: Child abuse includes a wide range of abusive activities and procrastination in performing parental tasks and responsibilities,
leading to physical or mental harm, sexual abuse, neglecting the child, and even child death. Too many children are brought to primary
health care (PHC) centers on numerous occasions before they are recognized as victims of child abuse. For this reason, assessing physician’s
knowledge and taking suggestions for child abuse prevention is likely to have a significant impact on child health. Objective: The objective
is to assess the knowledge of PHC physicians in Baghdad city concerning child abuse. Methods: Cross‑sectional study with some analysis
carried out from first April to June 2018, on a sample of 200 PHC physicians working in 41 randomly selected PHC centers in Baghdad city/
Al‑Resafa and Al‑Karkh. Results: Nearly 40% of physicians had good overall knowledge about child abuse. PHC physicians reported the
lowest good knowledge for physical abuse (16%), and highest good knowledge rate (77%) about prevention of child abuse. Conclusion: Less
than half of the PHC physicians studied had good overall child abuse knowledge. Sexual and emotional child abuse knowledge was far better
than physical abuse. Management guidelines and child abuse training courses are recommended.

Background: Numerous markers of inflammation like C‑reactive protein (CRP) are raised considerably in the diabetic population. The levels
of these markers also associate with the severity of diabetes and presence of various complications. Objective: The objective was to study
the correlation between CRP and glycemic control in type 2 diabetic patients who were newly diagnosed renal impairment and to evaluate if
good glycemic control reduces the CRP values. Patients and Methods: This work was performed from June 2018 to January 2019. Forty‑five
type 2 diabetic patients who were newly diagnosed renal impairment are included after proper screening, between 48 and 60 years of age at
the National Diabetic Center/Al‑Mustansiriyah University. They were equated with 45 healthy subjects as control group. Then, relevant tests
were done which are involved: fasting serum glucose, glycated hemoglobin (HbA1c), urea, creatinine, serum lipid profile, and serum high
sensitivity CRP (hs‑CRP). Results: A significant increase in serum urea and creatinine was found in diabetic patients as paralleled to the
controls. Furthermore, there was a significant difference in hs‑CRP in diabetics as compared to the controls (13.95 ± 5.42 mg/l vs. 2.0 ± 1.16
mg/l, P = 0.01, odds ratio = 1.157). Well glycemic control is foremost to the decline in HbA1c moreover caused a reduction in CRP levels
when HbA1c was ≤7. Conclusions: It has been concluded that higher levels of CRP can be a prognostic element for the progress of type 2
diabetes, Also, it has a positive correlation with HbA1c, reflecting the glycemic status of the patient.

Background: Hepatitis B virus (HBV) vaccination was one of the success stories of the 20th century. It is highly effective and safe and
was incorporated into national immunization programs of countries worldwide. Objectives: The objective of the study as to explore the
response rate and titers of anti‑HBs antibodies among children 1–14 years old immunized with HB vaccine in Baquba city Diyala province.
Vaccinees and Methods: This cross‑sectional study was conducted in Baquba City, the center of Diyala province, Iraq for the period July 20,
2016–March 20, 2017. A total of 452 children were enrolled, 247 (54.6%) were males and 205 (45.4%) were females, with an age range of
1–14 years. All were previously immunized with genetically engineered HBV vaccine (Euvax B, Korea), with a dose of 10 g of HBsAg/0.5
ml intramuscularly. Venous blood samples were collected aseptically; sera were separated and subjected for the detection of HBsAg, anti‑HBs
antibody titer, HBe Ag, and total antibody and anti‑HBc total antibody using Enzyme‑Linked Immunosorbant assays(ACON, Foresight‑USA).
A preconstructed questionnaire form was prepared including information of sociodemographic, health, and vaccination status. Statistical
analysis was done using the Statistical Package for the Social Science (SPSS), Version 23. P < 0.05 was considered statistically significant.
Results: The overall anti‑HBs Ab positivity rate was 75.66% (95% confidence interval was 71.5%–79.6%), with a mean anti‑HBs Ab titers
range (10.1–673.4 mIU/ml). However, the titer was failed to reach the protective level in 110 (24.34%) vaccinees. The highest anti‑HBs Ab
positivity rate among children received 1 or 2 vaccine dose is significantly higher among those after <1‑year duration (80.0%, P = 0.043),
while the mean anti‑HBs Ab titer is insignificantly highest among the same group of children (43.7 mIU/ml, P = 0.24). The highest anti‑HBs
Ab positivity rate among children received three vaccine doses is significantly higher among those after <1‑year duration (91.3%, P = 0.003),
and similarly the highest mean of anti‑HBs Ab titer is insignificant higher among the same children group (81.3 IU/ml, P = 0.2). Regarding
those children received four vaccine doses, the anti‑HBs Ab positivity rate and the mean anti‑HBs Ab titer are significantly higher among
children after <1 year (89.9%, P = 0.004 and 97.7 IU/ml, P < 0.001), respectively. Finally, the anti‑HBs Ab positivity rate after five vaccine
doses was insignificantly higher after 1–3‑year duration (72.4%, P = 0.15), while the highest mean anti‑HBs Ab titer was significantly higher
among those with <1‑year duration (55.0 IU/ml, P < 0.041). Conclusion: Universal hepatitis B vaccination is generally produce high rate of
protection among children and the highest anti‑HBs antibody titer was achieved through 3 or 4 doses after <1‑year postvaccination.

Background: Thyroid hormones control most of the body’s metabolic processes; T3 and T4 from the thyroid gland and thyroid‑stimulating
hormone (TSH) from the pituitary gland. Any defect in these hormones may have a serious clinical impact on different body organs.
Objective: This study focus on the prevalence of thyroid diseases (subclinical and overt) in the Iraqi population and the possibility of linking
their incidence and progression to specific factors. Patients and Methods: Cross‑sectional study was conducted in the National Diabetes
Center for Treatment and Research/Mustansiriyah University in Al‑Karkh side from Baghdad/Iraq. Thousand and eight hundred patients,
both gender (males and females) from different age groups (12–62 years), have been involved for 6 months. This study was measured serum
TSH, thyroxin hormone (T4), and triiodothyroxin hormone (T3). Patients were categorized according to their thyroid status at the time of
testing based on both the traditional definitions of thyroid dysfunction and using TSH and T4 levels of subclinical hyper‑ and hypothyroidism,
overt hyper‑ and hypothyroidism. Results: Of 1800 cases collected over 6 months, 3.2% were overt hypothyroid (22.4% males and 77.6%
females) (P < 0.0001). Moreover, 14.1% were subclinical hypothyroid cases(19.7% males and 80.3% females) (P < 0.0001). Overt hyperthyroid
cases represent 3% (27.8% in male and 72.2% in females) (P < 0.0001). Subclinical hyperthyroid cases were 4% (18.3% in male and 81.7%
in females) (P < 0.0001). Distribution of thyroid status (euthyroid, subclinical, and overt thyroid) in females significantly higher than in
males (75.7%, 6.2%, and 18.1% respectively, P < 0.0001). Subclinical hypo‑ and hyperthyroid appeared in the age group (32–51 years) was
significantly higher than other studied ages (P < 0.05), and overt hyperthyroid appeared in the age group (42–51 years) higher than other
age of studied groups (P < 0.05), while overt hypothyroid was distributed equally in all age groups (P > 0.05). Less than ten percent of total
patients were taking thyroid medication for hypo‑ and hyperthyroidism. Subclinical and overt thyroid cases received treatments were (47.4%
and 42.9%, respectively). Treated old subjects >52 years represent about (17.6%) from the total patients. Conclusion: The majority of thyroid
problems occur in adult age (32–50) and in females. Understanding the prevalence and risk factors of subclinical thyroid disease could be a
help to identify the patients for screening and follow‑up. Treatment recommendations must base on measuring thyroid‑stimulating hormone
concentrations and underlying comorbidities.

Background: Referral system is one of the key elements in the primary health care (PHC), currently the Ministry of health is working on
establishment and development of an effective referral system with incentives to the population to use PHC centers(PHCC) instead of secondary
care, this includes monetary incentives and improvement of quality and quantity of services provided at PHC level. Objective: The aim is to
assess the knowledge and practice of PHC physicians about the referral system. Methodology: A cross‑sectional study with analytic elements
was conducted from February 1, 2019 to June 30, 2019, in Baghdad, from both sides AlKarkh and AlRusafa, a convenient sample of 15 PHCC
selected., data collection was carried out using a self‑administered questionnaire which included questions about demographic characteristics
of PHC physicians, qualification, and questions concerning their knowledge and practice about the referral system. Results: Total study group
included 150 physicians. Overall knowledge of physicians about the referral system was good, Nearly all physicians (98%) knew its benefit,
the results showed that all respondents used referral form (100%), and 94.7% wrote down the required information and followed the classical
measures. The referral feedback was poor (36%). Conclusion: Most of the physicians had good knowledge and practice about the referral
system. There was strong deficit in the training courses about referral system.

Background: The health‑care providers must exhibit consistent and correct utilization of growth charts and be able to correctly interpret
and comprehend its data. Objectives: The objectives were to assess the knowledge and use of growth chart by health care providers and
to investigate factors affecting the knowledge and use, including relation to reproductive Maternal, Newborn, Child, and Adolescent health
programs. Methodology: A descriptive cross‑sectional study was carried out in 20 primary health‑care centers in Baghdad: 8 in Al‑Rusafa
district and 12 in Al‑Karkh district, during the period from the first of February to the end of May 2019. Results: The total number of study
participants was 200, their mean age was 38.3 ± 8.3 years, and 150 (75%) were physicians including 85 (42.5%) family physicians. Most of
the respondents (82.5%) had acceptable knowledge, while 9% had good knowledge and 8.5% had poor knowledge. Regarding use, 158 (79%)
participants showed an acceptable level of use, 39 (19.5%) a good level of use, and only 3 (1.5%) had a poor level of use. Conclusions: Most
of the health‑care providers had an acceptable level of knowledge and use of growth charts, better knowledge, and use level were related to
the number of patients seen per day, while growth chart use was affected by participants’ age and being physician.

Background: Epstein–Barr virus(EBV) is a small double‑stranded linear DNA human herpes virus that is transmitted primarily through saliva.
Majority of primary EBV infections in infants and young children are clinically silent. Clinically, primary infections by EBV are presented
as infectious mononucleosis (IMN) syndrome, which is characterized by pharyngitis, cervical lymphadenopathy, fever, and lymphocytosis.
Objectives: This study was designed to explore the rate of EBV anti‑viral capsid antigen (VCA) immunoglobulin M (IgM) among children
who were clinically suspected as having IMN in Diyala province. Subjects and Methods: A total of 248 subjects were included; 190 were
clinically suspected as having IMN and 58 apparently healthy subjects were included as a control group. The age range of the patients was
9–168 months; 88 of them were males, while 102 were females. Similarly, the age range of the apparently healthy subjects was 9–168
months; 29 of them were males while 29 were females. The anti‑VCA IgM antibodies were detected in the serum samples using the VCA IgM
enzyme‑linked immunosorbent assay technique (DiaPro Diagnostic Bioprobes Srl, Italy). Human privacy was respected by taking the parents’
verbal consent. Statistical analysis of the data was carried out using Statistical Packages for the Social Sciences (SPSS), Version 25. Statistical
significance was considered whenever the P ≤ 0.05. Results: The results showed that the anti‑VCA IgM positivity rate among clinically
suspected children with IMN was 24/190 (12.6%), while only 2/58 (3.4%) of the apparently healthy subjects were positive, with a statistically
significant difference (P = 0.046). Age and gender distribution had no statistically significant effect on the IgM positivity rate (P = 0.432 and
P = 0.960, respectively). Furthermore, most IgM‑positive patients had at least three of the main clinical features; however, no statistically
significant association was found between the IgM positivity rate and the main clinical features (P = 0.157 for headache and P = 0.692 for
malaise). Conclusion: The rate of IMN among clinically suspected patients in Diyala province was 12.6%, the peak age of primary infection
was 1–4 years, the male‑to‑female ratio was 1:1.2, and the main presenting complaints were fever and sore throat.

Background: Pregnancy, childbirth, and puerperium are associated with profound physiological endocrine upheavals. The physiological events
of pregnancy and its resolution can also modify a number of concomitant dermatoses, and there are also some pathological skin conditions that
are virtually pregnancy specific. Objective: This study was an attempt to find the most common dermatological problems that are faced by
the Iraqi women during pregnancy. Patients and Methods: A convenient sample of 300 pregnant women was included in this cross‑sectional
study which was conducted in the consultation clinic of dermatology and the consultation clinic of obstetrics and gynecology of Al‑Kadhymia
Teaching Hospital between February 1, 2012, and the end of June 2012. Clinical diagnosis was based on history and clinical examination, and
appropriate investigation including biopsy was done accordingly. Results: Atotal of 300 pregnant women with ages ranged from 14 to 44 years,
with a mean age of 29 ± 15 years. Primi/multigravida ratio was 2:3 with gestational age between 2nd and 9th month. Various skin problems were
seen among these cases, those with specific dermatosis account for 22.4% of the total, while those with nonspecific diseases constitute 77.6%
of the cases. The major ones were infections and infestations(27.3%) followed by eczema and dermatitis(19.3%). Most common physiological
skin changes were striae gravidarum which was seen in 78% of cases, followed by melasma in 49% of cases. Conclusions: The study showed
that the most common skin changes and diseases during pregnancy include (1) pruritus gravidarum (more common started in primigravida
and in the third trimester); (2) scabies (may be due to endemic of this disease) and superficial fungal infection; (3) striae gravidarum (more
common in multigravida in the third trimester); followed by melasma (more common multigravida in the second trimester).

Background: There is increasing incidence of diabetes around the world. Moreover, diabetic retinopathy (DR) is one of the complications of
diabetes mellitus and the leading cause of blindness among working age adults. This study aimed to evaluate the prevalence of DR in type 2
diabetic patients and to estimate the risk factors and their relationship to the development of DR. Patients and Methods: A case–control
study was done on 262 type 2 diabetic patients with DR compared to 262 diabetic patients without DR. Further, retrospective cross‑sectional
study was done on cases with DR in Sulaimani/Iraq. Data were collected from January 1, 2017, to December 31, 2017. Association between
variables was tested by Chi‑square test; P ≤ 0.05 was regarded as significant. Results: The prevalence of DR was 8.6%. The mean age of the
patients with DR was 59.65 ± 7.55 years, with female being 31%. Age, gender, body mass index, and serum triglycerides were not associated
with increasing risk for the development of DR (P = 0.147, 0.536, 0.573, 0.111, respectively), while cases with poor glycemic control,
longer duration of diabetes mellitus, history of hypertension with elevated systolic and diastolic blood pressure (P ˂ 0.001), and high serum
cholesterol (P = 0.005) associated with increasing risk of DR. Conclusions: Poor glycemic control, history of hypertension, duration of diabetes
˃10 years, and high serum cholesterol are regarded as risk factors for the development of DR in diabetic patients.