Journal of the Faculty of Medicine Baghdad

Background Mitral valve (MV) is one of the most complex structures in human heartwith a challenging exposure.Traditionally, MVis approached via left atriotomy (LAA)while superior septal approach (SSA)is an alternative. Objective: 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.Patients and Method:Over an18-month period ending at June 30th, 2019, 56 patients with MV disease ± other cardiac diseaseswereenrolled in this study. Twenty patients had surgery via LAA(one surgeon) whereas 36were operated upon via SSA(another surgeon). Standard surgery was done via median sternotomy, cardiopulmonary bypass and hypothermia of 32 0C. Perioperative events were recorded.ResultsIn SSAgroup(males=25; age ranged 23-74 years; mean=57.4), patients had chest pain and breathlessnessfora mean of3 months(>LAA)besideslowejection fraction (EF)in 44%, atrial fibrillation (AF)in 38.9%and dilated LAin 19.4%. They underwent 25MVreplacements(MVR), 11 MV repairs(0 in LAA), 11 coronary artery bypass grafts (CABGs)(2.6 graft per patientvs. 1.3 in LAA; significant)and 2aortic valve replacement. Mean ACCTwas 81.6 minutes (˂LAA). Postoperatively, 32 patients (88.9%) had a normal or improved EF, 11of 14AF patients (78.6%) reverted to sinus rhythm and no hospitaldeath was recorded. Conclusion Besides excellent exposure, the SSAenabled us to perform MVRor repair ± additional interventionswithin a short time and without a heart block. Hence, our results matched theinternationalliterature

Background: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 the reliability of Alvarado score and ultrasound in the diagnosis of acute appendicitis.Patients and method: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 1st2017 to Feb 10th2018, Alvarado score calculated and ultrasonography done for each patient enrolled in this study, then to be followed for intraoperative findings.Results: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 89 of combined usage of Alvarado score and U/S findings preoperatively..Conclusions: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 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

Background:Artifact waves in the ECG and Holter recording are not rare in clinical practice and can be mistaken for tachyarrhythmia.Objective:To orient the practicing physicians to differentiate these artifacts from cardiac arrhythmias.Patients and Methods: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’sprivate practice in the northern Iraqi governorate of Sulaimanya duringthe period from June 2015toAugust 2020. The differentiation of the artifact waves from the arrhythmias were made by careful inspectionof the ECG, identification of the R waves within the artifact waves and correlating the artifact waves with the patient’s symptoms. Results:The artifactswere mistaken for ventricular fibrillationin two patients, ventricular tachycardiainfour, atrial fibrillation in two,atrial flutter infour, and in one patient bradycardia ofhigh grade atrio-ventricular block.Conclusion:Distinguishing artifact in ECG and differentiating them from cardiac arrhythmia is important to avoid mismanagement.

Background:Emergency care is the care delivered in a hospital setting to any patient with an unexpected, sudden, threatening reversible condition. In countries where health care is not optimum, this type of care can represent the weakest element of the health system. Objective:To explorethe main causes behind the admission in the Pediatric Emergency Department (PED) of the Children Welfare Teaching Hospital (CWTH) in Baghdad and the urgency of visits.Patients and methods:A cross-sectional study was carried out in the PED of CWTH in the Medical City, Baghdad.A convenient sample offive hundred visits on Sundays, Tuesdays and Thursdays of every week during the study period for patients below the age of 14 years between August and November 2017 were enrolled in this study and their data was analyzed. The perceived urgency of the visitswere assessed and analyzed. Results:The mean age for the patients was 3 years, with 239 males (47.8%). Of the whole group, 110 patientspresented with complaints ofhoursin duration(22%). The most common complaint recorded was fever in 175 patients (35%). The most common comorbidities recorded were chronic respiratory diseases in 10 patients. Complete blood count was ordered for 460 patients (92%). Strikingly, blood culture was recorded in five 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%). Two hundred sixty-six patients (53.2%) were justifiedas urgent visits, while the remaining(46.8%) were non-urgent. Most of those withcomorbidities were labeled as urgent (89.4%), with a statistically significant association(P < 0.001). Most of the patients who presented with ashort duration of complaint (within hours)(89.1%) were classified as urgent. The majority of the patients who did not receive antibiotic therapy were classified asurgent (74.7%), (p <0.0001). Themajority of the patientswho were discharged (61.2%) were classified as non-urgent, while (38.8%) were urgent.Conclusions: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 through reducing the investigations to those necessary only whichwill improve the standards of service. A triage system should be implemented in CWTH PED

Background: Data on SARS-CoV-2 from developing countries is not entirely accurate, demanding incorporating digital epidemiology data on the pandemic.
Objectives: To reconcile non-Bayesian models and artificial intelligence connected with digital and classical (non-digital) epidemiological data on SARS-CoV-2 pandemic in Iraq.
Methods: 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.
Results: 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<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.
Conclusion: 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.

Background: 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. Case presentation: Herein, we describe two brothersfrom 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 alsoreported. 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). Conclusion: Thereport 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.

Background: 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.

Foreign body inhalation is common in pediatric age and since 1897, when Gustav Killian succeeded in removing aspirated Porkbone, from the bronchus. It turned to be a daily practice in Thoracic surgical department to deal with these patients.Four decades of personal experience in dealing with the inhaled foreign bodies(FB),Ways of presentations. Methods of diagnosisand the successful removalofthe FBs using the rigid pediatric bronchoscope will be elucidated. The changing patterns of the types of FB during these years will be emphasized. Majority of these incidents of inhaled FBs are preventable.The detailsof findings ofall patients,who were subjected to bronchoscopy to remove inhaled foreign bodies, willbe presented. Different kinds and shapesof the inhaled FB s are dealt with during these decades, most of patients were belowthree years of age,with variable clinical presentation and differentradiological appearances. All were managed successfully with minimal complications using the rigid pediatric bronchoscopes.FBs inhalation is so common in our society and occursin both lay and professional segments,but commoner in lower socio economic class. Bronchoscopy is the procedure of choice in the removal of this FBs.