Al- Anbar Medical Journal

As one of the most common diseases in ophthalmology today, dry eye disease (DED) poses a great challenge for public health systems globally. This is a multifactorial condition involving the production/evaporation of tears and consequential damage to the ocular surface. Symptoms of DED like discomfort and visual disturbance alter a person’s quality of life and pose a significant economic burden to healthcare systems. Today’s lifestyle favors DED development, especially long-term exposure to screens, poor sleep quality, and a diet abundant in saturated fats and omega-6 fatty acids, and we can expect that its prevalence will extend far beyond the currently estimated 10%. The underlying inflammation and symptoms of DED, are treated with various anti-inflammatory agents and autologous and/or allogeneic serum drops. Considering the role of lifestyle in DED pathophysiology, lifestyle modifications, including diet, sleep, and physical activity are getting more attention. Among them, supplementation with omega-3 fatty acids shows the most promising results in alleviating subjective and objective measures of DED through a direct effect on the stability and production of the tear film, inflammation markers, and corneal nerve regeneration. We aimed to provide insights into currently available research findings supporting omega-3 fatty acids as a valuable adjuvant therapy in treating DED.

Angiotensin receptor blockers (ARBs) are crucial in the management of cardiovascular diseases, by targeting the renin-angiotensin system, which plays a vital role in cardiovascular health. These drugs control hypertension and fluid imbalance, as well as influence adipose-derived hormones such as visfatin and apelin. The renin-angiotensin system is affected by these adipokines, which are closely associated with cardiovascular health and, consequently, can influence the complications of cardiovascular diseases. Understanding the relationship between ARBs, apelin, and visfatin is essential to optimizing therapeutic approaches to controlling cardiovascular diseases. Apelin stimulates vasodilation through two mechanisms including either building a heterodimer with G-protein-coupled receptors (GPCRs) or increasing the release of nitric oxide (NO) through enhancing the expression of angiotensin-converting enzyme 2. Visfatin is an adipocytokine with several interesting characteristics. Initially identified as a pre-B cell colony-enhancing factor, it later revealed enzymatic roles in nicotinamide adenine dinucleotide (NAD) synthesis. Researchers correlated higher visfatin levels with the risk of developing severe hypertension. Studies have demonstrated that ARBs influence the serum levels of apelin and visfatin, potentially enhancing their cardioprotective effects. This review article aims to highlight the roles and mechanisms of apelin and visfatin in hypertension, as well as the effects of ARBs on these adipokines.

Background: Red cell distribution width (RDW) is an inflammatory biomarker and a component of complete blood count that gains increased attention. Pre-eclampsia (PE) is a unique pregnancy syndrome for which inflammation was proposed for pathogenesis.
Objective: We aimed to examine RDW's role in PE and explore confounders that limit its implication in practice.
Materials and Methods: A case-control study recruited 120 participants matched in body mass index (BMI) and gestational age into 3 subgroups; late-onset severe PE cases (30/120), late-onset non-severe PE cases (30/120), and healthy controls (60/120). Participants' demographics (age, BMI, systolic and diastolic blood pressure (SBP, and DBP), hematological and biochemical parameters were evaluated.
Results: RDW was significantly higher in PE cases (P-value < 0.01 ); In addition, RDW was positively correlated to SBP, DBP, and protein urea, r =0.5, r = 0.46, and r = 0.47 ; P-value < 0.0001, respectively. Liver enzymes, hemoglobin, and white blood cell count were all significantly linked to RDW (r = 0.27, P-value = 0.015), (r = 0.32, P-value = 0.005), (r = -0.27, P-value = 0.02) and (r = 0.39; P-value = 0.0004) respectively. Applying ROC Curve analysis showed that RDW cut-off value of > 14.4% discriminated PE cases from healthy controls (P-value < 0.001). At a cut-off value > 15.6% RDW distinguished severe from non-severe PE cases (P-value < 0.001).
Conclusion: RDW was significantly correlated to PE predictors and severity markers independent of gestational age and BMI. The ROC curve showed that RDW distinguished PE from healthy controls in addition to non-severe from severe PE cases with high sensitivity and specificity. Being an inexpensive, reliable test with good predictive and prognostic value warrants further studies for RDW's role in PE screening and follow-up.

Background: Growth differentiation factor (GDF-9) and bone morphogenic protein (BMP-15) (GDF-9 co-factor) are proteins that are released by oocytes and control key stages of follicular development and growth.
Objectives: To determine the ability of serum follicular fluid GDF-9 and BMP-15 in predicting ovarian reserve represented by their correlations with female age, traditional markers; antral follicle count (AFC) and anti-mullerian hormone (AMH).
Materials and Methods: In this prospective cohort study, 114 infertile females from the High Institute of Infertility Diagnosis and Assisted Reproductive Technologies, Baghdad, Iraq, were included. Their age is 18-43 years old and their body mass index (BMI) is 19-30 Kg/m2. All were assessed on the second day of the menstrual cycle. Serum was taken to measure GDF-9 and BMP-15 using a special Kit by ELIZA. Following oocyte retrieval, follicular fluid was collected for measuring GDF-9 and BMP-15.
Results: The study showed that both had significant negative correlations with female age and no significant correlations with AMH. Significant positive correlations were found between serum follicular fluid GDF-9 and AFC, while only follicular fluid GDF-9 exhibited a significant positive correlation with mature II (MII) oocytes number. Significant positive correlations were found between serum, follicular fluid BMP-15 and AFC, MII oocytes number, while significant positive correlations were found between follicular fluid BMP-15 and a total number of oocytes.
Conclusions: Serum follicular fluid GDF-9 and BMP-15 can be good predictors of ovarian reserve due to their significant negative correlations with age (oocyte quality) and significant positive correlations with AFC (quantity). Follicular fluid GDF-9, serum and follicular fluid BMP-15 can predict oocyte maturity.

Background: Sperm motility is an essential factor in ensuring the fertility of males. Sperm mitochondria play a significant role in the generation of energy as well as the metabolism of sperm. The mitochondria nucleolus is essential for several sperm activities, such as sperm capping, hyperactivation, acrosome reactions and oocyte fusion. Therefore, as the mitochondria are the basic regulators of sperm motility, mitochondrial membrane potential (MMP) is used to assess the mitochondrial activity and integrity of sperm. This is evaluated by examination of MMP, which may be achieved by using fluorescent dyes like the JC-1 probe.
Objectives: To examine the correlation between MMP and sperm motility.
Materials and methods: This study included semen samples of 60 males that were separated into two groups: 30 normomozoospermic and 30 asthenozoospermic. The samples were collected in the infertility clinic at the High Institute for Infertility Diagnosis and Assisted Reproductive Technologies, Al-Nahrain University and Um Al-Banin Center for management and in vitro fertilization. The collected samples were processed for seminal fluid analysis and evaluated according to the recommendations of WHO 2021 using an MMP-Assay kit with JC-1 dye and examined by fluorescent microscope for evaluation.
Results: A positive significant correlation between subjects’ sperms motility percentage and active red-fluorescence MMP intensity (Red MMP) (P-value < 0.05, r = 0.406; P-value = 0.008) The MMP or activity plays an essential role in sperm motility and male fertility. The red MMP values in subjects with normal sperm motility were 10.22 ± 1.54 and showed a relatively higher reading in comparison to those readings of subjects group with low sperms motility (4.70 ± 0.91). Subjects with normal sperm motility showed a high MMP intensity (P-value = 0.004).
Conclusions: Normal MMP is crucial for normal sperm motility. The sperm motility is proportionate to the MMP, or activity.

Background: The indications for emergency laparotomy are many, depending on different pathological causes, organs involved, and preoperative management. All these factors limit the time to optimize the comorbidities that may affect the outcome of surgery in terms of morbidity and mortality.
Objectives: We aimed to detect the different predicting factors for morbidity and mortality after emergency laparotomies.
Materials and methods: This prospective cohort study was conducted on 100 patients who were subjected to an emergency laparotomy. The demographic and clinical characteristics of the enrolled participants were registered. The study was carried out at Duhok Emergency Teaching Hospital from February 2022 to January 2023. Patients were followed for 30 days after surgery.
Results: The mean age of the patients was 39.26 years ± 19.53, and males constituted 2/3rd of the cases. The non-traumatic causes comprised the majority of cases. Patients with acute abdomen and intestinal obstruction comprised 74% of the cases. The commonest imaging finding was intra-abdominal collections (35%). The commonest operative finding was perforated gastric or duodenal ulcer (19%). Morbidity was reported in 69 patients. These included wound infection, anastomotic leakage, bleeding, deep venous thrombosis, and burst abdomen. There was a significant association (P-value < 0.05) between the morbidity and the age of the patient (OR: 1.5), body weight (OR: 1.9), associated comorbidities (OR: 1.2), operative time (OR: 1.76), performance of bowel anastomosis (OR: 5.5), and admission to the intensive care unit (ICU) (OR: 2.79). Mortality was reported in 9 patients, and there was a significant association (P-value < 0.05) with anastomotic leakage (OR: 4.27), need for anti-coagulation (OR: 23.65), and admission to the ICU (OR: 16.36).
Conclusion: Emergency laparotomy is associated with high incidences of morbidity and mortality. The patient's age, body weight, associated comorbidities, operative time, performance of bowel anastomosis, and admission to the ICU might be risk factors for morbidity. High mortality might be due to anastomotic leakage, the requirement of anticoagulation, and ICU admission.

Background: Enterococcus, a low virulent yet hardy organism, is a cause of many community acquired as well as nosocomial infections. Antibiotic resistance in Enterococcus spp. is rising worldwide owing to their intrinsic resistance to multiple drugs. The combination therapy of beta-lactam antibiotics with aminoglycosides is the choice of treatment for this type of infection. But this is often rendered ineffective on account of high-level aminoglycoside resistance. Vancomycin resistance further complicates the scenario.
Objectives: To note the predominant infections caused by Enterococcus spp. and to show their resistance pattern, with particular emphasis on vancomycin resistance.
Materials and Methods: This study was conducted retrospectively in our tertiary care teaching hospital in Odisha, Eastern India, where 200 consecutive, nonrepetitive Enterococcus spp obtained on culture were included. Their demographic profile was collected from the lab register, and analysis was done using MS Excel.
Results: The commonest sample from which Enterococcus spp was isolated was urine (n = 82, 41%), followed by blood (n = 49, 24.5%). E. faecalis (n = 120, 60 %) followed by E. faecium (n = 55, 27.5 %) were the most common species seen. Flouroquinolones, macrolides, and tetracycline were the most resistant antibiotics for all the Enterococcus species. E. faecalis had a much higher percentage of susceptibility to penicillin and higher level gentamicin (76.5% and 55.6%, respectively) compared to E. faecium (10.7% and 13.2%, respectively). Among the total, 43 (21.5%) isolates were vancomycin resistant, and only 3 (1.5%) showed moderate susceptibility. All the isolates 200 (100%) were tigecycline susceptible.
Conclusion: The present study highlights increased vancomycin resistance as noted in 21.5% Enterococcus isolates. Quinolones, macrolides, and tetracycline showed better sensitivity to VRE, probably owing to lesser use in clinical scenarios. Urinary tract infection is the predominant infection caused by Enterococcus spp. Nitrofurantoin is an effective drug, particularly for E. faecalis.

Background: Epistaxis is a common condition in daily clinical practice and is presented either in emergency units or outpatient otolaryngology clinic. There is no relevant local study regarding its prevalence and clinical profile.
Objectives: To estimate the prevalence and demographic and clinical profile of patients with epistaxis.
Materials and methods: We prospectively reviewed the patients with epistaxis during the year 2021. Detailed information regarding every subject's demographic and clinical aspects was registered and analyzed.
Results: Of the 6645 patients visiting the private clinic, 344 (5.2%) had epistaxis. The highest proportion of patients was registered in June (12.5%). There were 53.5% males, 48.3% from the age group 11-18 years, and 80.02% lived inside the city. Around 60% were presented within 1-2 days from the bleeding onset. Unilateral epistaxis was seen in 74.4% of the cases (143 from the right and 113 from the left side). The majority of bleeding was from the anterior part (97.1%) and with mild form (96.5%). About 80% of the subjects had recurrent attacks of epistaxis. Early presentation (1-2 days) was seen more in the age group > 50 years (9/12), bleeding from the posterior part (10/10), severe epistaxis (11/12), patients with the first attack of bleeding, and with idiopathic (19.77%) cause (P-value < 0.05). The majority of the cases (84.3%) were treated conservatively.
Conclusion: The prevalence of epistaxis was 5.2%. June registered the highest cases of bleeding. The age group of 11-18 years and males were mostly affected. The age, site, severity, cause, and patient with the first attack were significantly affected the presentation time. Conservative treatment was effective in the majority of cases.

Background: Acute myocardial infarction (AMI) and metabolic syndrome (MeS) are two major health problems worldwide. In recent years, MeS has been introduced as a significant risk factor for AMI.
Objective: To estimate the prevalence of MeS and its components among patients with AMI.
Materials and Methods: This was a cross-sectional study conducted at Al-Ramadi Teaching Hospital during a period from January to December 2022, Including a total of 100 patients with AMI. The definition of MeS was established based on the criteria of the modified National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III).
Results: The mean age of patients was 58.6 ± 7.1 (range: 41–81 years). Males represented 55% of the studied group. Clustering of MeS components among cases revealed that 57% had less than three components while 43% had 3 or more criteria for MeS diagnosis, giving a prevalence rate of 43% for MeS. Only 5 cases had none of these components. MeS was relatively more prevalent in younger age groups and females. The mean values of all components of MeS were significantly higher in the MeS group than in the non-MeS group (P-value < 0.05).
Conclusion: MeS was an important risk factor for AMI. The study revealed a high prevalence of MeS among individuals with AMI and it was higher among women than men.

Background: Hepatitis G virus (HGV) infection is widespread worldwide in high-risk groups such as healthcare workers, voluntary blood donors, and chronic liver disease patients. Also, haemophilia and thalassemia are diseases within the high-risk groups for HGV infection. Although it has no clinical significance or impact on liver disease and its future course is uncertain, highly mutated (as in other RNA viruses) might happen, resulting in a severe liver injury.
Objective: To evaluate the subclinical impact of hepatitis G virus infection on liver health in high-risk populations through liver function tests (LFTs) analysis.
Materials and Methods: Blood samples were taken from 221 people in high-risk groups and chronic liver patients infected with hepatitis B and C viruses. An enzyme-linked immunosorbent assay (ELISA) was used to find HGV anti-E2 antibodies, and a multiplex nested real-time polymerase chain reaction method was used to find HGV RNA. LFTs were performed for all participants, which included checking the levels of AST, ALT, total bilirubin, AP, and serum albumin. A self-controlled case study was used to look at differences in liver function tests between people with a high risk and people who have chronic hepatitis B and C with or without HGV infection. .
Results: HGV infection was more prevalent in high-risk groups like patients with chronic liver disease (15.8%), healthcare professionals (6.8%), haemophiliacs (6.8%), and thalassemia patients (9.5%) compared to volunteer blood donors (3.2%) and recipients of blood (3.6%). There was no statistically significant difference (P-value > 0.05) in the abnormal rates of ALT, AST, serum albumin, ALP, and total bilirubin between high-risk groups and chronic liver patients regardless of whether they had HGV infection or not.
Conclusions: Surveillance for HGV infection does not appear to cause significant liver dysfunction in high-risk and chronic liver patients.

Background: Obstructive adenoid enlargement is common in our environmentit manifests with nasal obstruction, persistent mouth breathing, snoring, sleep apnea, and daytime somnolence, which results in poor school performance. Fibreoptic nasopharyngoscopy has recently been recommended for the diagnosis of adenoid enlargement. It is, however, expensive and not readily available in a resource-constrained setting. Clinical symptomatology is invaluable to the physician, as it may be the only assessment tool available to a healthcare provider in a rural setting. However, some workers considered it unreliable and insufficient for the diagnosis of adenoid enlargement.
Objectives: The research's aim was to find out how reliable clinical symptoms are for diagnosing obstructive adenoid enlargement compared to fiberoptic nasopharyngoscopy
Materials and Methods: This was a cross-sectional study among children with obstructive adenoid enlargement. Ethical approval and informed consent were given. A structured questionnaire was utelized to assess clinical symptomatology. A fiberoptic nasopharyngoscopic examination was carried out, and the data were analyzed.
Results: This study recruited 79 (56.4%) men and 61 (43.6%) women within the age range of 2 - 10 years with a mean of 4.5 ± 2.5 years. The clinical symptomatology score correctly predicted 60% of endoscopic grade 1, 67.5% of endoscopic grade 2, and 78.9% of endoscopic grade 3 adenoid enlargement. There was a statistically significant association between clinical symptomatology score and fiberoptic endoscopic findings (χ2 = 96.9, P-value = 0.000).
Conclusion: This study found that the clinical symptomatology score is relatively reliable in diagnosing obstructive adenoid enlargement.

Background: The FMS-like tyrosine kinase 3 mutation is one of the most prevalent recurrent genetic aberrations in acute myeloid leukemia (AML). Two modules of mutation are subsumed under the term FLT3 mutation, including internal tandem duplication (ITD) within the juxtamembrane domain and point mutations in the tyrosine kinase domain (TKD).
Objectives: To determine the frequency of FLT3 mutations in adults with newly diagnosed AML and to find any correlation between the existence of FLT3 mutations and the clinical or laboratory findings of the disease.
Materials and methods: Fifty newly diagnosed AML patients were investigated prospectively in this study. A complete blood count, peripheral blood film, bone marrow aspirate, and flow cytometry study were conducted for each patient. The detection of FLT3 mutations was performed using next-generation sequencing technology.
Results: Out of 50 AML patients, FLT3 mutations were detected in 12 (24%). 8 (16%) of them expressed FLT3-ITD, whereas FLT3-TKD was expressed in 4 (8%). There was a non-significant rise in the medians of the total leucocyte count and the peripheral blood blast percentage in both FLT3-ITD and FLT3-TKD mutated patients compared to those without mutation (P-value = 0.15, 0.28, 0.74, and 0.66, respectively). Most cases of both FLT3-ITD and FLT3-TKD mutations were female (65.8% and 75%, respectively). The majority of FLT3-ITD mutations were found in the FAB classification M5 subtype (37.5%), followed by the M1 subtype (25%). FLT3-TKD mutations were mostly detected in the M3 subtype (50%), followed by M4 and M5 (25%).
Conclusion: The FLT3 mutations were frequently seen in patients with AML disease. They were associated with a higher white blood cell count and peripheral blood blast percentage; therefore, they are considered a predictive and prognostic marker in AML disease.

Background: Placenta accreta spectrum (PAS) disorder is a potentially near-miss life-threatening hemorrhagic obstetrical condition causing maternal complications and death. As there was no unique method recommended for the treatment of PAS all over the world until now, an analysis of the treatment of these cases in the study’s locality was needed.
Objectives: To analyze the management of cases with a diagnosis of PAS and study the maternal outcome.
Materials and Methods: A descriptive observational retrospective case series study included 78 consecutive pregnant women with a diagnosis of PAS who were managed at Al-Khanssa Teaching Hospital in Mosul/Iraq from June 1st , 2017 to May 31st , 2020. The grade of PAS, time of diagnosis, treatment modalities, and complications were studied and analyzed.
Results: In these 3 years, 78 patients met the diagnostic criteria of PAS. Overall, 21.8% of patients had an antenatal diagnosis and had a scheduled Caesarean section. About half of cases (48.72%) had placenta increta. In 33.33% of patients, preservation of the uterus after removal of the placenta with good hemostasis was successful. Hysterectomy was needed in 66.67% of cases. Maternal complications were reported in 16.67% of cases, and fortunately, no maternal death was reported.
Conclusion: In a limited resource clinical setting, hysterectomy and preservation of the uterus after removal of the placenta with a low threshold to hysterectomy were two methods appropriate to treat PAS cases. Both these methods were effective with low complications by an experienced obstetrician.

Background: The human microbiota, K. oxytoca, is resistant to multiple drugs, endangering the lives of patients. Hypervirulent strains evolved into multidrug-resistant strains due to the acquisition of mobile genetic elements.
Objectives: To detect the antibiotic-resistant profile and the related virulence genes in the hypervirulent and non-hypervirulent strains isolated from clinical specimens.
Materials and Methods: A total of 136 clinical samples were collected from patients at Baghdad City Hospitals, Iraq. The isolates were identified, and an antibiotics sensitivity test was carried out. The polymerase chain reaction typing method was used to detect the virulence genes.
Results: The most frequent source of K. oxytoca was urine samples (36.03%), then blood samples (15.44%), particularly inpatient samples. About 12.5% of isolates were positive for the hypervirulent test (the string test). Isolates showed variable levels of resistance towards antibiotic groups. The blaCTX-M and aac(6')-Ib-cr genes were revealed in 88% of isolates, and the blaOXA-48 gene was in 44%. All the tested isolates were negative for the rmpA gene.
Conclusion: K. oxytoca is recognized as one of the leading causes of hospital-acquired infections. The rapid identification of antibiotics-resistant, hypervirulent isolates that present a considerable threat to human health is highly recommended in the local hospitals.

Background: Micro RNA155 (miR-155) was identified as an essential determinant in immunological responses, and its genetic variants have increasing attention due to their ability to modulate its expression and potentially influence the susceptibility to autoimmune illnesses including rheumatoid arthritis, systemic sclerosis, systemic lupus erythematosus, etc.
Objectives: To examine the impact of miR-155 gene polymorphism (rs767649A>T) and miR-155 gene expression and their association with multiple sclerosis (MS) in a sample of Iraqi patients.
Materials and Methods: A total of 75 blood specimens were obtained from individuals diagnosed with MS. While an additional 75 blood specimens were collected from evidently healthy participants serving as a control group, with an age ranged 20-71 years. miR-155 gene polymorphism (rs767649 A>T) was determined utilizing Tetra-ARMS Polymerase Chain Reaction (Tetra-ARMS PCR) and miR-155 expression was evaluated using Real-time Polymerase Chain Reaction (RT-PCR).
Results: The females experienced MS at a higher rate (69.33%) compared to the males. Furthermore, the age group 30-39 years showed a greater susceptibility to the disease (54.67%). The analysis of miR-155 (rs767649 A>T) SNP in MS patients indicated that 7 (9.34%) had the wild genotype (AA(, 31 (41.33%) had the heterogeneous genotype )AT(, and 37 (49.33%) had the mutant genotype )TT(. These differences were statistically significant (P-value = 0.040). A allele frequency was 45 (0.3) (OR: 0.25; CI: 0.15-0.41) and T allele frequency was 105 (0.7) (OR: 3.91; CI: 2.42-6.33) in MS patients. While analysis of miR-155 gene expression demonstrated a significant increase in the patient group (1.82 ± 0.25 fold) compared to the healthy control group (0.33 ± 0.13 fold). The relationship between miR-155 gene expression and miR-155 genotypes in MS patients, revealed a notable elevation in miR-155 gene expression at the TT genotype (3.15 ± 0.73 fold), followed by TA genotype (1.29 ±0.65fold) and finally AA genotype (0.37 ± 0.19 fold) with highly statistically significant difference (P-value = 0.001).
Conclusion: There was a significant positive correlation between miR-155 (rs767649 A>T) genotypes and miR-155 expression and susceptibility to MS in Iraqi patients. These findings suggests that miR-155 may hold potential as a diagnostic and therapeutic marker for the disease.

Background: Antibiotic resistance arises due to the overuse of antibiotics, leading to bacterial strains becoming resistant to previously effective treatments. This can result in infections that are harder to treat and can lead to longer hospital stays, increased healthcare costs, and even mortality.
Objectives: To determine the most common bacterial uropathogens and their sensitivity to antibiotics among patients diagnosed with urinary tract infections (UTIs).
Materials and Methods: In Mosul, Iraq, researchers conducted a retrospective cross-sectional analysis to evaluate the effectiveness of antibiotics commonly used to treat UTIs.. In this study, researchers collected and analyzed urine samples from three centers that conducted culture and sensitivity tests over five years, from January 2018 to December 2022.
Results: Of the 1326 urine samples collected during the study period, 1265 (95.5%) showed significant bacteriuria caused by a variety of bacterial strains, with Escherichia coli being the most common. The study evaluated the effectiveness of 21 antibiotics frequently used to treat UTIs against the identified bacterial strains. The results indicated that only a limited number of antibiotics have shown effectiveness against particular strains of Escherichia coli, with a mere 10 out of the 21 drugs exhibiting significant antibacterial efficiency. The presence of bacterial resistance to all tested antibiotics was observed, indicating a significant prevalence of antibiotic resistance and a decline in the availability of effective antibiotics.
Conclusion: This study revealed a concerning rise in antibiotic resistance in bacterial strains responsible for UTIs, as well as multidrug resistance, especially among gram-negative bacteria.

Background: Restless leg syndrome (RLS) is a common neurological disorder, but its correlation with endometriosis remains unclear.
Objectives: To evaluate the correlation of RLS with endometriosis.
Methods: A cross-sectional study included 155 patients who were diagnosed with RLS at the Neurology Department, Azadi Teaching Hospital, Kirkuk, Iraq. The study started on 1st June 2020 and ended on 1st March 2023. RLS was diagnosed using the criteria established by the International Restless Leg Syndrome Study Group (IRLSSG). The researchers questioned the patients about their history of endometriosis. Then categorized into two groups. The first group consisted of 72 cases with surgically confirmed endometriosis, whose severity was determined by the Gynecologists following the guidelines of the revised American Society of Reproductive Medicine (rASRM). The remaining 83 cases formed a group comprising individuals with RLS without endometriosis. We collected data from each participant about their age, marital status, smoking habit, and body mass index (BMI).
Results: One hundered fifty five patients with a mean age of 29.19 ± 6.12 years were diagnosed with RLS. There was a statistically significant difference (P-value = 0.029) between the RLS and the age of the patients with endometriosis compared to those without endometriosis. However, there were no significant statistical differences (P-value > 0.05) in marital status, smoking habits, or BMI between the two groups. In terms of RLS severity ratings, patients with endometriosis tended to have more severe rating scales compared to those without this condition. Additionally, a Pearson's correlation test showed a strong positive correlation, between IRLSSG and rASRAM scores (P-value = 0.0001, r = 0.7).
Conclusion: RLS was strongly and positively correlated with endometriosis. However, the exact cause and nature of this correlation remained obscure.

Renal cell carcinoma (RCC) is the most common solid lesion within the kidney and accounts for most kidney malignancies. The primary tumor size primarily determines the risk of metastasis in RCC. Literature rarely describes metastasis in tumors less than 2 cm; in fact, around 1/3 of RCC reported cases had metastatic disease at the time of diagnosis. RCC tends to metastasize to the lung in half of the patients, to the bones or the liver in 1/3 of patients, and the brain in 5% of all cases. RCC can metastasize to almost every organ in the human body. However, their metastases to the ovaries are incredibly uncommon. In this report, we describe a female presented with the smallest RCC (1cm) that metastasized to the ovary in a patient with previously undiagnosed autosomal dominant polycystic kidney disease (ADPKD). This case report aimed to raise physicians' awareness of the possibility of metastasis in RCC regardless of tumor size and that metastatic RCC could be the first presentation of patients with ADPKD.