Journal of the Faculty of Medicine Baghdad

Background: Trace elements are essential micronutrients that exist in very low concentrations in the body. They play an important role in various physiological processes and are crucial for proper functioning of the immune system. Many studies have shown that some micronutrients may have a role in febrile seizure such as selenium, zinc and copper.
Aim: To determine the level of serum zinc and copper in children with febrile seizures and explore their relation to selected patients\\' variables.
Methods: The study included 66 infants and children with simple febrile seizures with two control groups; a febrile control group which includes (62) children with febrile illnesses who were admitted to emergency department at Basrah Maternity and Children Hospital and Basrah General Hospital from the 1st of March to the end of October 2013, and a healthy control group which includes (58) children. Serum zinc and copper were measured for all infants and children enrolled in the study.
Results: Patients with febrile seizure had a significantly lower mean serum zinc level (8.85 ±3.26) in comparison to febrile patients and healthy children (14.98 ±2.20), (13.33 ±1.99) respectively. There is no significant association between the level of serum zinc and selected variables. Serum copper level did not show a significant difference between patients with febrile seizures and control groups.
Conclusion: Zinc supplementation may be considered in children who are at risk of recurrent febrile seizure.

biliary atresia within two months from birth, or effective dietary management in metabolic disorders like galactosemia.
Objective: To determine the causes of early childhood cholestasis in children attending the Children Welfare Teaching Hospital in Baghdad and to study some of associated factors in infancy and early childhood cholestasis.
Patients and method: This is a cross sectional descriptive study conducted on 48 patients attending the Children Welfare Teaching Hospital in Baghdad for the period of 1 November 2015 to 15 January 2016. These cases were evaluated by thorough history, examination and investigations.
Results: Of the 48 patients enrolled in this study, 30 (62.5%) lived in Baghdad, and the remaining 37.5% were referred from other governorates. The mean age of the patients was 11.1 ± 12.4 months, with 20 females (41.7%) and 28 males (58.3%). The results revealed that 11 (22.9%) were the result of congenital infections, 9 (18.8%) were idiopathic in origin, 8 (16.7%) were caused by biliary atresia, 8 (16.7%) of unknown origin, 5 (10.4%) were caused by sepsis (mainly staphylococcus, streptococcus species, E.coli, staphylococcus aureus), 2 (4.2%) were caused by progressive familial intrahepatic cholestasis and 1 (2.1%) case was caused by each of the following causes: Alagille syndrome, Choledochal cyst, Galactosemia, hypothyroidism and Tyrosinemia.
Conclusion: Congenital infections were the most common cause in this study, of which the most common is cytomegalovirus (CMV). Clay color stool and high alkaline phosphatase levels were found mostly in biliary atresia. No method by itself is sufficient to diagnose the cause of neonatal cholestasis. Diagnosis can only be established using all available methods.

Background: Viral Hepatitis C infection is global public health problem throughout the world. Different treatment regimens are used which produce different rates of response affected by many factors.
Objectives: To assess the efficacy of three different treatment regimens in 295 Iraqi patients infected with chronic HCV.
Patients and methods: This is an observational cohort study; in which 295 (133 male and 162 female) patients with chronic HCV infection were enrolled during the period between August 2015 to January 2017 from Gastroenterology Clinic of Baghdad Teaching Hospital and Gastroenterology and Hepatology Teaching Hospital. Baseline HCV viral load measurements and genotyping were done for each patient. Patients were followed up by viral load measurement at end of the treatment period and three months after the end of the treatment.
Results: The majority of patients infected with chronic HCV achieved sustained virological response(SVR) (defined as undetectable HCV RNA 12 to 24 weeks after the end of the treatment); were of the generic( sofosbuvir/ledipasvir) treatment group (51 out of 72 (70.8% ) followed by generic Sofosbuvir with( peg interferon/ribavirin)treatment group (68 out of 111 (61.3%) followed by (peg interferon/ribavirin) treatment group (42 out of 86 (48.8%).
Conclusions: The best treatment efficacy was obtained with generic sofosbuvir/ledipasvir followed by sofosbuvir with peg interferon and ribavirin then peg interferon and ribavirin. The most responder genotype in Iraqi patients was genotype 4 and the least responder genotype was genotype 1b.

Background: Multidisciplinary team meetings (MDTs) are designed to optimize patient outcomes. It appears intuitive that MDTs are essential to clinical decision-making and patient management; however, it is unclear whether that belief is supported by evidence. With regard to cancer patients, studies demonstrated that treatment plans made by interacting health care professionals are more effective than those made by individual practitioners.
Objectives: To assess the impact of multidisciplinary teams (MDTs) on clinical decision-making and patient outcomes.
Methods: We follow a descriptive questionnaire survey study design and created a (10) sections surveymonkey that was distributed via email to (150) experts in surgical oncology, general surgery, oncology, radiation oncology, pathologists, and administrative staff. Fourty (40) completed responses were collected to ensure a statistical basis on which to draw sound conclusions. The remaining 110 staff have submitted incomplete answers. Answers were discussed in a separate MDT meeting with most of the participants.The survey was followed by an interpretation of the respondents’ results and comparison with literatures.
Results: 75% of the participants chose ”Agree and strongly agree”, supporting the hypothesis that MDT meetings ensure an effective and up-to-date management guidelines. This means that the risk of not discussing a cancer patient cannot be neglected any longer. So the hypothesis statement (H0) is rejected and the alternative statement (Ha) is accepted.
Conclusions: The majority of participants saw the value in the MDT process and expressed support for its implementation locally and nationally; however, feedback about the most appropriate format is yet to be established. The clinicians identified the need for agreed standards in MDT performance

Background: Breast cancer is the most common cancer reported in women worldwide. In Iraq, it is the most common registered malignancy. Mammography plays a major role in the early detection of breast cancers. Dense breast parenchyma has been reported to be the most important inherent factor that limits depiction of breast cancer on mammogram, and often needs supplementary breast ultrasound for complete assessment.
Objectives: To evaluate and compare the diagnostic performance of mammography and ultrasound in the detection of breast cancer in dense breast tissue.
Patients and methods: A record review study was performed in the Oncology Teaching Hospital/ Medical City from April 2018 to December 2018. The study included forty five females, who attended the Main Referral Center for Early Detection of Breast Tumors during 2017 and 2018 were diagnosed with breast cancer histopathologically. They had dense breast tissues on mammography (either heterogeneously dense breast tissue i.e. category C or extremely dense breast tissue i.e. category D). All patients underwent subsequent breast ultrasound .Their information including the mammogram findings, breast ultrasound, fine needle aspiration (FNA) and biopsy results were reviewed analyzed and compared.
Results: Twenty four patients (53.3%) had heterogeneously dense breast tissue (ACR category C) and 21 patients (46.6%) had extremely dense breast tissue (ACR category D). The mammogram detected 36 from 45 breast cancers (80%) while 9 (20%) were not detected by mammogram, so the mammogram had a detection rate of breast cancer of 80% in mammographically dense breast, while breast ultrasound had higher detection rate of about 97.7%. The sensitivity of mammography in extremely dense breast tissue was about 71% and in heterogeneously dense breast was about 87% while ultrasound had shown a higher sensitivity with increasing tissue density (98% vs. 100%).
Conclusion: Breast cancer can be easily obscured and missed in mammographically dense breast tissue due to overlapping surrounding fibroglandular tissue and additional complementary breast ultrasound is highly recommended for a thorough evaluation and to depict mammographically occult breast carcinoma.
Key words: mammography, ultrasound, dense breast tissue, obscured breast cancer

Background: Global longitudinal strain (GLS) echocardiography is a new technique that can be used to detect an early left ventricular dysfunction in various heart diseases. Systemic hypertension is a major risk factor for cardiovascular accidents. The early managementof its complication on the heart plays an important role in the outcome of the disease. Hypertension is associated with changes in several aspects of left ventricular structure, function, and systolic strains. Various echocardiographic techniques are used to evaluate left ventricular function in hypertensive patients.
Objectives: To evaluate the effectiveness of speckle tracking global left ventricular strain percentage (GLVS%)in the assessments of left ventricular systolic function in comparison to conventional echocardiography in middle-aged hypertensive patients.
Patients and Methods: The study was conducted from December 2017 till November 2018 at the Department of Echocardiography and Catheterization / Baghdad Teaching Hospital – Medical City, Baghdad, Iraq. One hundred and four hypertensive patients classified as; group I that involved patients with reversed E/A ratio on PW Doppler with reversed Pulsed Wave (PW) tissue Doppler study and group II with patients having normal E/A ratio on PW Doppler and reversed E prime/A prime on PW tissue Doppler study. The control (group III) recruited from the relative of the patients included 104 sex and age-matched healthy individuals. A detailed history with the recommended investigations and blood pressure measurements was performed for all participants. Additionally, echocardiography examination was implemented using standard methods, considering left ventricle (LV) internal dimension, LV ejection fraction percentage (LV EF%), LV diastolic function using PW Doppler and lateral mitral annular tissue Doppler, S prime, Mitral annular plane systolic excursion (MAPSE) and global LV speckle tracking strain percentage (GLVS%).
Results: Group I included 76 patients with a mean age of (48 ± 6.6 years) and group II included 28 patients with a mean age of (48 ± 6.6 years). All the participants had normal EF%(> 60%), MAPSE (> 13 mm), and S prime (>9 cm /sec) while there were a significantly decreased GLVS% in the diseased groups in comparison to the control one (P < 0.005) being less in group II (-14 ± 1%) than in Group I (-16 ± 1%). In addition to a significant negative linear correlation between GLVS% with that of pulse pressure and IVST respectively (p=0.04) and with that of E/A ratio and E/E prime ratio (p=0.001).
Conclusions: GLVS% is a better method in the assessment of LV systolic function in in middle-aged hypertensive patients than conventional echo methods since it could detect an early impairment in LV systolic function despite preserved LV systolic function measured by the conventional echo methods.
Keywords: Systemic hypertension; Tissue Doppler Imaging; Speckle tracking echocardiography.

Background:Breast problems including breast cancer have been increasing in Iraq during the recent years. Yet, early detection and screening programs using mammography mainly with complementary ultrasound had dramatically decreased the mortality rates from this emerging disease.Objective:To assess the dense breast detected by mammography for the presence of any hidden suspicious lesion by using ultrasound. Patients and methods:this is a cross-sectional study on 53 female patients who came for breast cancer screening or attended the Breast Clinic in the Oncology Teaching Hospital of the Medical City Complex in Baghdad –Iraq. The study was conducted from January to October 2018.Two-view mammography was done for each breast, and those with dense breasts underwent further ultrasound assessment done by a board-certified radiologist.Results:The mean age for the 53 patients included in the study was 48 years. Mammographic findings showed that heterogeneous fibroglandular tissue density was present in (89%) of the study population. Suspicious or clearly defined mass(es) by mammograph were seen in 16 (30%) of the patients, while no mass was identified in (22%). Ultrasound findings were as follows: Suspicious mass in (75%) of the cases and benign lesions such as simple cysts or fibroadenoma in (9%). The results showed that ultrasound has upgraded 12 cases that were diagnosed as BI-RADS I/II to BI-RADS IV/V and this represented (23%) ofthe cases. On the other hand, the mammogram and the ultrasound were in concordance for BI-RADS IV/V in 28 cases (54%). The positive predictive value of the ultrasound and the mammogram for BI-RADS IV and V breast lesions is 72% for BI-RADS IV and 95% for BI-RADS V for ultrasound and that of mammograph is 83% for BI-RADS IV 80% for BI-RADS V, while the negative predictive value of mammograph is 55% for BI-RADS I/II 25% for BI-RADS III.Conclusion:Dense breast is still an important problematic issue in mammographic screening as it may obscure small lesions, for which, ultrasound is proved to be a complementary and essential targeting tool in the assessment process.Keywords:Dense breasts, mammography, breast cancer screening, breast ultrasound

Background:Increased exposure to risk factors of hearing loss leads to a high susceptibility to deafness among neonates admitted to neonatal care units in developing countries. Objective:This article aims tostudy the prevalence of risk factors for neonatal hearing defect and determine their effect on the result of transient evoked otoacoustic emissions hearing test (TEOAE).Methods: A longitudinal study was carried out for a period of one year from 1stOctober, 2016 to 30thSeptember, 2017 in the CWTH, Medical city, Baghdad, Iraq.Demographic characteristics and certain risk factors were recorded for screened neonates. TEOAEtest was done and if they failed to pass two steps, they were referred to automated auditory brainstem-response (AABR). Results:Out of 400 neonates, 342 (85.5%) passed from step 1 TEOAE,while 58 (14.5%) were referred to step 2. From 58, 26 (44.8%) have passed step 2 and 32 (55.2%) not pass step 2 and were referred to AABR.From those 32 neonates with suspected hearing defect, NICU stay >7 days, ototoxic drugs >7 days, use of ventilator >7 days, birth weight <1500gm, and craniofacial malformations were the main risk factors for hearing defects occurring in (90.6%), (90.6%), (59.4%), (40.6%), and (21.9%) respectively.Conclusions:Low birth weight, long intensive care stay, mechanical ventilation, drugs ototoxicity and craniofacial malformation of neonates are the main risk factors for failed TEOAEtest.