Journal of the Faculty of Medicine Baghdad

Abstract:
Background: Tetralogy of Fallot TOF is the most common cause of congenital cyanotic heart disease.
It is the most common congenital lesion that is likely to result in survival to adulthood and encountered
in adult after repair. Tetralogy of Fallot comprises around 7.5 % of all congenital heart diseases in Iraq.
Objective: The aim of this study is to analyse the transatrial strategy for total correction of tetralogy of
Fallot TOF.
Methods: Cross-sectional study was done during the period between 2012-2014 for twenty-four
patients that admitted to Ibn Al-Bitar hospital in Baghdad with amenable TOF pathology for transatrial
repair.
Results: Twenty-four patients, 16 were males and 8 were females. Ages ranged from 2-31 years. There
was no early or late postoperative mortality in this review for follow-up period ranged from 6 – 24
months. The early and late postoperative echocardiography data in regard to pulmonary and tricuspid
regurgitation and right ventricle RV function were delineated. Normal pulmonary valve (62.5%,
58.3%), mild pulmonary regurgitation (29.2%, 37.5%), moderate pulmonary regurgitation (8.3%,
4.2%). Normal tricuspid valve (75%, 70.8%), mild tricuspid regurgitation (20.8%, 20.8%), moderate
tricuspid regurgitation (4.2%, 8.3%) respectively. No severe pulmonary or tricuspid regurgitation was
reported. Postoperative RV function was normal in (87.5%, 83.3%), mild RV dysfunction in (8.3%,
12.5%), moderate RV dysfunction in (4.2%, 4.2%) respectively. No severe RV dysfunction was
reported. The mean RVOT pressure gradient was 36.8 mmHg. This gradient decreased on follow-up
echocardiography, mean 24.5 mmHg. P values were less than 0.05%.
Conclusion: The transatrial approach is a feasible technique for total repair of TOF in adequate
pulmonary annulus size with satisfactory late postoperative echocardiography performance.
Keywords: Tetralogy of Fallot. Total correction. Transatrial repair.

Background: The SYNTAX score (SS) II is an objective tool for predicting 4-year mortality and guiding treatment decisions for percutaneous coronary intervention (PCI) and/or coronary artery bypass graft (CABG) in patients with complex coronary artery disease (CAD) and/or unprotected left main stem disease (ULMSD).
Objectives: To assess the agreement between the clinical decisions of the cardiologist and the SS II recommendation regarding the revascularization strategies in patients with complex CAD and/or ULMSD.
Patients and Methods: Prospective data from patients who presented to Baghdad Medical City Catheterization Labs for coronary angiography and were followed up between January 2014 and November 2015 were analyzed. For these patients, SS II was assessed by the two anatomical variables (SS and presence of ULMSD) and six clinical variables (age, creatinine clearance, left ventricular ejection fraction, sex, chronic obstructive pulmonary disease, and peripheral vascular disease) to predict 4-year mortality after revascularization with PCI and/or CABG. These scores were then compared with the clinical decisions of cardiologists. After 1 year of data collection, we followed up the patients by phone to assess their mortality status. Patients were categorized into three groups according the interventional procedures: Group 1 (for PCI), Group 2 (for CABG), and Group 3 (for PCI vs. CABG).
Results: Two hundred patients were enrolled. Their mean age was 60.23 ± 9.836 years, and 157 (78.5%) were men. Depending on the clinical judgment of the cardiologist, 71 (35.5%) patients were referred for PCI (Group 1), 119 (59.5%) patients for CABG (Group 2), and the remaining 10 (5%) patients for PCI vs. CABG (Group 3). Based on an assessment of 4-year mortality by the SS II, CABG would have been the treatment of choice in 67 (33.5%) patients, PCI in 30 (15%) patients, and both the treatments in 103 (51.5%) patients. There was a concordance between the clinical decision of the cardiologist and SS II in 67 (33.5%) patients and discordance in 133 (66.5%) patients. Six patients died within 1 year, most of whom were from the discordant group.
Conclusion: There was a statistically significant discordance between the SS II recommendation and clinical judgment of the interventional cardiologist. SS II proved to be a useful objective tool to assist experienced clinical judgment in determining appropriate revascularization strategy for CAD patients.
Keywords: SYNTAX score, complex coronary artery disease, coronary revascularization

Background: The spine is rarely affected by Hydatid cyst with incidence of (1%) of all cases. Despite advances in imaging as well as surgical and medical treatment, spine Hydatid cyst (H.C) is associated with high degree of morbidity, disability, and mortality.
Objective: To assess the clinical presentation, imaging of spine H.C. & the outcome of surgical management regarding neurological recovery, recurrence and mortality.
Patients and Methods: This is a retrospective study of the 25 patients of spine Hydatid cyst during five years period (Jan.2010 to Jan.2015), where diagnosed and treated at medical city. All patients after proper clinical assessment, imaging and laboratory tests had underwent posterior decompression laminactomy and removal of all Hydatid cyst without spine instrumentation. They received Elbendazol drugs (antihelmantic drugs) for three months with follow up six months to two years.
Results: They presented with paraplegia in (48%), paraparesis of lower limbs in (32%), local pain and radiculopathy in (12%) and asymptomatic in (8%). The spinal level was affected by hydatid cyst lumbar (64%), dorsal (24%), cervical (8%) and sacral (4%). 23 patients posterior decompression laminectomies were done, 8 patients re-do surgery and 2 patients had evacuation of subcutaneous multiple Hydatid cyst.Complete neurological recovery was achieved in (100%) of cases after primary surgery, but recurrence rate was in (21) patients (84%) and worsening of neurological status in two patients (8%).
Conclusions: Management of Hydatid cyst spine disease is challenging because of high recurrence rate, requiring aggressive and repeated surgeries with high rate of surgical complications and significant long term morbidity.Results are not satisfactory and prognosis is poor.
Keywords: Hydatid cyst, spine, recurrence, paraplegia, Elbendazole.

Background: Breast cancer account for 29% of all newly diagnosed cancer in female and is responsible for 14% of cancer related deaths in women. Breast cancer is basically detected either during a screening tests, before symptoms have appeared, or after a woman notices a mass. Overall risk doubles each decade until the menopause, when the increase slows down or remains stable.
Objective: to find the correlation between the tumor size and grade and involvement of axillary lymph node.
Patients and methods: a continuous prospective study of 50 patients from 1st January 2016 to 1st January 2017 in Baghdad teaching hospital at 1st surgical floor, where almost all patients with breast cancer operated on by modified radical mastectomy and axillary clearance included in the study.
Results: the commonest age group was 5th decade with 32% of patients followed by 6th decade with 28% of patients. The most common histological type was IDC with 78% and 22% of patients were ILC. The most common stage at presentation was stage II A with 32% of patients followed by stage III A with 28% of patients. Tumor size between (2-5)cm (T2) was the most common with 68% of patients. Grade II was the commonest histological grade in this study with 68% of patients. Axillary lymph nodes (ALN) involvement increase as tumor size increase, it was 50% in T1, 55.8% in T2, 88.8% in T3 and 100% in T4. Grade I associate with 25% +ve ALN, grade II 55.8% and 100% in grade III.
Conclusion: The majority of patients in this study were in fifth and sixth decades. There is delay in presentation of patients as evidenced by the most common tumor size being T2 and the most common stage being stage II A& stage III A.IDC was the most common histological type. The most common grade was grade II. The larger the tumor the more incidence of ALN involvement, also the higher grade of the tumor associate with more ALN involvement.
Keywords: Breast cancer, staging, axillary lymph node, histopathological grade.

Background: Induction of labour is a commonly practiced obstetric intervention designed to artificially initiate the process of cervical effacement to achieve vaginal delivery.
Objective: examine the hypothesis that corticosteroids, when administered extra-amniotically, can enhance labor process and reduce the induction--delivery interval in comparison with folly's and extra-amniotic saline infusion.
Patients and methods: This, randomized case- control study was conducted on99 women, who were referred to the AL-Batool teaching Hospital in Diyala, Iraq, for induction of labor with a Bishop score of less than or equal to 5 from January 2014-March 2016, and divided into 2 groups, 1st group consist of 58 pregnant, a 26F catheter & and 20 mg of dexamethasone mixed with 20 ml of sterile saline solution infused extraamniotically. 2nd group consist of 41 pregnant, with the same size catheter attached to 500 ml of saline solution infused into the extra-amniotic space.
Results: Administration of dexamethasone extraamnioticlly improve the Bishop score, reduce the time needed for expulsion of the catheter, shortening of 1st&2nd stage of labour without increasing the caesarean section rate.
Conclusion: Extraamniotic administration of dexamethasone is effective & safe method for induction of labour.
Keywords: labor, induction, corticosteroid, cervical ripening.

Background: Breast cancer ranks the first among the Iraqi population since three decades and is currently forming a major public health problem being the second cause of death women. Novel management of breast cancer depends upon precise evaluation of their molecular subtypes; identified by Hormone (Estrogen and Progesterone) receptors and HER2 contents of the primary tumor.
Objective: To assess the rates of the different molecular breast cancer subtypes in the examined tissue specimens belonging to females diagnosed with breast cancer in Iraq; correlating the findings with those reported in the literature at the regional and global levels.
Patients and Methods: This retrospective study documented the findings of tissue biopsy examination belonging to 686 female patients diagnosed with breast cancer. Formalin fixed paraffin-embedded blocks were utilized to assess the availability of Estrogen receptors (ER), Progesterone receptors (PR) and HER2 expressions through semi quantitative immuno-histochemical staining technique. Breast carcinomas were classified into four main molecular subtypes: Luminal A: ER/PR(+) / HER2(-), Luminal B/Triple Positive: ER/PR(+) / HER2(+), Non-Luminal HER-2 enriched: ER/PR(-) / HER2(+) and Non-Luminal/Triple Negative: ER/PR(-) and HER2(-). Other phenotypes included: ER(+)/PR(-) / HER2(+), ER(-)/PR(+) / HER2 (+), ER (+)/PR (-) / HER2 (-) and ER (-)/PR (+) / HER2 (-).
Results: Out of the exanimated cases of breast carcinomas, the registered rates of positive ER, PR and HER2 tumor contents in this study were 67.8%, 65.3% and 29.4% respectively. The main identified phenotype was the Luminal A in 309 cases (45%). That was followed by the Triple Negative in 107 cases (15.6%) and Triple Positive/Luminal B (96 cases, 14%), while 71 cases (10.3%) were HER2 enriched. The corresponding rates of the (E+/P-/H+), (E-/P+/H+), (E+/P-/H-) and (E-/P+/H-) subtypes were 3.1%, 2.0%., 5.7% and 4.2% respectively. Differences in in the expressions of these IHC molecular markers are illustrated among different countries.
Conclusions: Due to the displayed variations in the socio-demographic characteristics and biological risk factors among patients in different populations, it is mandatory to identify the molecular marker subtypes of breast cancer expressions in order to assess the impact of management and response to therapy. The routine documentation of their patterns in the cancer registry reports and published research ensures the validity and reliability of the presented clinical data.
Keywords: Breast, Cancer, Subtypes, ER, PR, HER2, Iraqi Patients.

Background: Cisplatin is a potent anti-cancer agent used successfully in treatment of cancers of solid organs, but it has a high rate of nephrotoxicity.
Objective: The present study was designed to study Cisplatin-induced nephrotoxicity and the nephroprotective property of pomegranate juice.
Materials and Methods: The experiment was performed on 36 Iraqi white male domestic rabbits. Rabbits were divided into three groups; control group (received neither pomegranate juice, no Cisplatin), Cisplatin group (received Cisplatin only), and pomegranate group (received pomegranate juice and Cisplatin).
Results: Cisplatin group showed marked reduction of renal function manifested by high levels of blood urea, serum creatinine, and low level of serum albumin.Raised levels of oxidative stress markers and severe renal parenchymal damage by histopathology.While, pomegranate group showed almost normal renal function tests and normal levels of oxidative stress markers, and normal renal parenchymal histopathology.
Conclusion: Cisplatin in a highly nephrotoxic drug, and Pomegranate juice has a nephroprotective activity against Cisplatin-induced nephrotoxicity.
Keywords: Cisplatin, nephrotoxicity, Pomegranate.

Back ground: The association between tumors necrosis factor-alpha (TNF-α)308 polymorphism and type 2 diabetes mellitus (T2DM) remains controversial. The variation in ethnicity and life style play important role in these conflicting results.
Objective: To investigate association of TNF-α 308 polymorphism with T2DM, TNF level and body mass index in these patients.
Patients and methods: The current case control study included fifty patients with T2DM in addition to twenty-five healthy controls. The fasting blood sugar (FBS)and fasting blood (cholesterol, triglyceride) were done by colorimetric methods. The body mass index (BMI) was calculated for each patients and healthy controls. The level TNF-α in serum was measured by ELISA method (Ray biotechnology/ USA, 46078). The TNF-α 308 polymorphism was done by restriction enzyme digestion after polymerase chain reaction (PCR).
Result: The age range for T2DM patients was (43.54±4.590) year while for control was (45.04±4.394) year. The T2DM patients whom carry AA alleles for TNF-α 308 polymorphism showed highly significant association with study parameter F.B. S, BMI, cholesterol, triglyceride and TNF-α level with (P˂0.01). The T2DM patients with normal allele GG genotyping and GA genotyping of TNF-α 308 polymorphism also showed highly significant association with study parameter F.B.S,BMI,Cholesterol,Triglyecride and TNF- α with (P˂0.01). The TNF- α level in serum of T2DM patients showed highly significant association with F.B.S, cholesterol and triglyceride with (P P˂0.01), however the TNF- α level was nonsignificant with BMI in T2DM patients.
Conclusion: In the present study TNF-α 308 polymorphism allele (AA, GA) showed a statistically significant association with TNF-α level in serum of T2DM patients and BMI. The AA and GA alleles showed a statistically significant association with high fasting glucose level. The TNF- α level didn't show a statistically significant association with BMI.

Background: Colonic cancer is a very common disease world-wide being fourth most common cancer characterized by abnormal proliferation of the inner wall of colon then taking full colon wall thickness then spreading to surrounding lymph nodes and tissues and finally distant metastasis. It is one of most complicated diseases with debilitating symptoms which becomes more sever , prominent and specific with advancing stage with high percent of fatality and relatively short survival if diagnosed late or if left untreated.
Objective: To evaluate the efficacy of serum CEA & sAPRIL levels in the diagnosis and screening of colon cancer and their validity for this.
Patients and methods: This study was applied on 35 patients with colonic cancer, 35 patients with benign polyps and 15 negative controls. All individuals were subjected to blood sampling for measuring their serum CEA & sAPRIL using ELISA technique.
Results: In this study, majority of patients with colon cancer were presented at ages between 53-82 years of age (mean 68.5±6.4 years). Serum levels of sAPRIL & CEA were significantly elevated in those patients with advancing stages (C & D) compared with stages (A & B) and lower levels were found in patients who had surgical removal of tumor or received chemotherapy. Also a positive relation was found between sAPRIL & CEA with alcohol intake and smoking
Conclusion: according to this study sample it was found that sAPRIL and CEA together are strong indicators for colon cancer screening & diagnosis, and by this will reduce the need for more invasive screening & diagnostic tools.
Keywords: colon cancer, tumor marker, CEA, sAPRIL.

Back ground: Vaginal candidiasis is the second common infection among child bearing women. The disease is caused by yeast organism especially Candida albican. Pregnancy is one of the risk factors of the disease. It has been revealed that more than 75 % of women may experience an attach of the disease during their life time.
Objectives: To study the epidemiological factors of vaginal candidiasis among pregnant women attending Tikrit teaching hospital out-patient clinic.
Patients and methods: The study was conducted on a sample of (120) pregnant women. The demographic and epidemiologic information was obtained according to special designed questionnaire. The study was done over a period from 1/3/2017 to 16/4/2017. Vaginal swabs were taken from patients and sent to the lab for direct microscopically examination and cultured in special nutrient media.
Results: About (29%) of study sample had vaginal candidiasis. There was a significant relation between a history of taking antibiotic, oral contraceptive drugs, diabetes mellitus and occurrence of the disease. The most frequent cases of vaginal candidiasis were from age group (25-35 years) (57.1%).
Conclusions: About (29%) of pregnant women sample was affected by vaginal candidiasis. There was a significant relation between history of using oral contraceptive pills, broad spectrum antibiotics taking, diabetes mellitus and occurrence of the disease.
Key words: pregnant women, epidemiology, vaginal candidiasis.

Background: Bladder cancer (BC) one of the most common urologic cancer characterized by the highest recurrence rate, many types belong to BC, but most common of them worldwide are transitional cell carcinoma(TCC) which constitute about 90-95% cases, squamous cell carcinoma (SCC) and adenocarcinomas
Objective: This study was designed to evaluate parameters of humoral immunity in Non-muscle invasive (superficial or early) bladder cancer patients in Iraq that may provide a new insight into the future of immunotherapies development and BC management.
Materials and methods: Fifty-nine volunteer's patients ranged from 24 to 83years old, and 30 control individuals ranged from 51-80 years old, who attended and admitted to Hospital of Gazi AL-Harery in medical city of Baghdad, and Al-Emamain Al-Khadhemain Teaching hospital was recruited in this investigation. The sera of study groups were subjected to serological test to estimate the levels of (IgA, IgG, IgM and C3) by Single radial immunodiffusion (sRID) assay and Enzyme-Linked immunosorbent assay (ELISA) was used to estimate the serum levels of IL-10.
Results: The ages ranged from 24 to 83years (females: 26 to 72years, males: 38 to 83years) with male to female ratio 4.9:1 and ages of controls ranged from 51 to 80years (females: 54 to 70years, males: 51 to 80years) with male to female ratio 2.75:1, the mean ages of cases and controls groups were (61.65±11.04) , current study showed significance dropping in C3 levels in patients control and Mitomycin C groups compared with apparently healthy, levels of IgM showed significant elevation in BCG group compared with apparently healthy group while patients control and mitomycin C groups showed insignificant elevation of IgM. Levels of IgG showed significant elevation in patients control and mitomycin C groups compared with apparently healthy group while in BCG group showed no differences. Serum levels of IL-10 showed no differences between apparently healthy group and each of patient's groups, also showed no differences within patient's groups
Conclusions: Bladder cancer is a common urologic malignancy in male than female patients enrolled in this study. Intravesical BCG or Mitomycin C leading to effective anti-bladder cancer immunity in the majority of Patients
Keywords: Keywords: humoral immunity, BC, MMC, BCG, IL-10, C3, IgA, IgM, IgG.

Background: Many studies have linked the prevalence of violence and conflicts to the increasing number of neonatal mortality rate (NMR). This study was conducted to clarify the relationship between conflict and neonatal mortality in Baghdad, Iraq.
Objective: Throw a light on the impact of conflicts on neonatal mortality in Iraq.
Methods: This cross-sectional study was carried out in two hospitals in Baghdad that were chosen randomly. All deceased newborns in neonatal intensive care units from January 2012 to December 2016 in the mentioned hospitals were included in this study.
Results: The admissions were increased during the period of the study by 1.3 times. There was a decrease in admission by 0.9 in 2016 than 2015. There was an increase in NMR during the period of the study by 1.4 times, from 60/1000 in 2012 to 85/1000 in 2016.
Conclusions: There has been an observed increase in neonatal mortality in Iraq due to the impact of conflicts that have led to deterioration in the neonatal health status.
Keywords: neonatal mortality, Baghdad, Iraq, conflicts.

Background: Assessment is an important part of the learning cascade in education. Students realize it as an influential motivator to direct and guide their learning. The method of assessment determines the way the students reach high levels of learning. It has been documented that one of factor affecting students’ choice of learning approach is the way how assessment is being performed. Many methods of assessment namely multiple choice questions, essay questions and others are mainly used to assess basic science knowledge in undergraduate education. Objectives: The aim of this study is to compare multiple choice questions (MCQ) and essay questions (EQ) (record the success and failure rate of multiple choice questions (MCQ) and essay questions (EQ)) in regards to the Physiology questions.
Methods: A retrospective study was done in which the results of the physiology exams -held in the medical college in Baghdad University -in 2010 are recorded. The number of students underwent the exam was 255. A total of 100 essay questions (EQs) and 100 multiple choice questions (MCQs) were evaluated from the written examinations delivered to second year medical students questions belonged to final examination.
Results: Regarding essay questions that have been answered, 33.5% of the questions were not answered as a total. 188 students out of 255 had succeeded which represent 73.7% of the students. Out of 78 marks for MCQ, 46.33 had been achieved, and out of 22 marks for essay 12.9 have been achieved. the success in MCQ questions was 82.9% while in the Essay questions was 67.7% and the failure in both types was 12.5%. Out of 100 questions for both MCQ and Essay questions 55.1±7.9 questions were answered for the MCQ and 51.1±15.3 Essay questions were answered. In general the percentage of the succeeded students was 73. 7% and that of failed students was 26.3%.
Conclusion: There is no significant difference in the success rate between MCQs and EQs.
Keywords: assessment, multiple choice questions, essay questions.