Al- Anbar Medical Journal

Tuberculosis (TB) has been a well-known infectious disease for many centuries. It carries a high rate of morbidity and mortality across the globe. Pregnant women are more susceptible to TB than other individuals owing to the certain physiological changes that accompany pregnancy. There is still doubt that pregnancy is a risk factor for the progression of a TB infection (TBI) to a TB illness. Latent TB infection (LTBI), a term used to describe the fact that mycobacterium tuberculosis is found in a dormant stage, can be isolated in pregnant women. As a rule of thumb, early diagnosis and prompt treatment prevent unwanted complications and even mortality in pregnant women and developing fetuses. As a consequence, knowing the various aspects of TB is of utmost importance when dealing with physicians and pregnant women. Many diagnostic tools, including history and physical examination, chest X-ray, tuberculin test, and interferon-gamma release assays, are useful in the early detection of TB. However, the risks and benefits of each test should be taken into consideration. Furthermore, close monitoring of the pregnant woman with TB is an essential step for early detection of its complications. Anti-tuberculosis therapy, including isoniazid, rifampin, ethambutol, and pyrazinamide, can be used with certain modifications of their doses to decrease the risk of the disease to both a pregnant woman and her fetus. This narrative review aims to summarize the different aspects (epidemiological distribution, risk factors, diagnostic tools, complications, and management) of TB during pregnancy.

The authors conducted an extensive literature search of the Science Direct, Scopus, PubMed, and Web of Science databases. Published studies and original articles published in reputed peer-reviewed journals reporting original research were considered. Different wound dressings show different properties and may have different applications depending on the types of wounds. Traditional wound dressings (like gauze), mainly used for clean and dry wounds with mild exudate, are cheap and affordable, however, they suffer from many limitations. including adherence to the skin, pain in removal, contamination with bacteria, and other obstacles. On the other hand, modern dressings have many advantages, such as the fact that they do not adhere to the wound, they are easily removed, and many other advantages. The introduction of nanotechnology in the field has accelerated the discovery and the applications, and many new pharmaceutical products for wound treatment will enter the market soon. Therefore, evaluating the advantages and limitations of different types of dressings and determining a suitable type of wound dressing to be applied is crucial. This article aims to explain the different types of wound healing agents or dressings available to treat acute or chronic wounds.

Background: Wilson disease (WD) is a genetic disorder (autosomal recessive) that affects copper metabolism. A favorable prognosis for WD can be achieved with early diagnosis and treatment. It is also strongly advised to conduct a family screening.
Objective: To find the relationship between genotype and phenotype to facilitate the diagnosis of the disease as well as using modern methods in diagnosing WD.
Methods: This study included nine WD patients and fifteen healthy participants. Members of patients with WD and healthy members provided whole blood. Blood DNA was extracted, and Exon 14 was amplified using specific primers using polymerase chain reaction (PCR). The results of the PCR products were aligned to the published human genome database using the BLAST tool.
Results: Three different variations have been recorded as a result of the experiment. All of the changes point to a deficiency in the ATP7B protein, which has been identified as a cause of WD.
Conclusions: The ATP7B gene mutation spectrum in Iraqi patients has been enhanced as a result of our research, and this information could be used to develop gene therapy and clinical/prenatal diagnosis to prevent WD in Iraq.

Background: Cancer patients are more susceptible to psychological issues such as nervousness, traumatic stress, and depression because their vulnerability to stress increases after a cancer diagnosis. Multiple harmful effects of psychological strain on health outcomes are possible. Those who have undergone surgery for cancer are more at risk of cancer-related fatigue and psychological distress. Studies in Western countries have shown a 40–80% reduction in cancer-related distress if the patients are subjected to appropriate psycho-oncological interventions.
Objectives: The aims of this study were to: 1) screen head and neck cancer patients for distress using a cancer-specific questionnaire; 2) test the association of cancer-related distress with socio-demographic and clinical characteristics of patients; and 3) evaluate the effect of cognitive behavioral therapy (CBT) on the distress level of head and neck cancer patients about to undergo surgery.
Materials and Methods: A pre-tested, semi-structured, self-administered 23-item Questionnaire on Stress in Cancer patients (QSC-R23) was used to measure the level of distress. Three sessions of CBT of one hour duration on every alternate day have been given to elicit the response. Categorical data were analyzed using the Chi-square test. Pre and post-scores were compared using a paired sample t-test. The correlation was done to compare continuous variables using Pearson's correlation test. To determine how other related factors will affect the results, linear regression analysis was used.
Results: The mean age of the 94 participants was 54.64  10.97 years. The mean pre-score was 60.06  20.42, and the post-score was 34.63  5.3. There was a significant improvement in the post score (P-value = 0.0001) implying a reduction in stress among the study participants after the 3 sessions of CBT. Participants with middle/high monthly family income (P-value = 0.013, 95% CI= 0.639-17.418), no past medical history (P-value = 0.0001, 95% CI= 0.639-17.418), and no past psychiatric history (P-value = 0.008, 95% CI= 3.621-20.162) were statistically significantly affected by the difference in distress score.
Conclusion: This study has successfully reported that CBT can reduce distress levels among cancer patients. However, there is still a need to explore this research and produce more relevant, evidence-based literature.

Background: The Nottingham prognostic index (NPI) combines lymph node status, tumor size, and histological grade, reflecting breast cancer's metastatic behavior, growth rate, and genetic instability. NPI is a commonly used, clinically relevant, and internationally validated system for classifying early and locally advanced breast cancer cases [TNM (tumor, lymph nodes, and metastasis) stages I, II, and III] into three or more prognostic groups. NPI is important for patients and clinicians to decide whether to undergo adjuvant chemotherapy following surgery.
Objectives: To determine the prevalence of various categories of NPI in breast cancer patients in Duhok, Iraqi Kurdistan and to establish a correlation between NPI and a variety of clinical, pathological, and immunohistochemical parameters.
Materials and Methods: This retrospective cross-sectional study was conducted in the Oncology Clinic at Azadi Teaching Hospital, Duhok, Iraq. The data included age, side of the breast involved, multi-centricity of cancer, histological type, NPI category, surgery type, and excision margins. The histopathological data included the type of carcinoma, lympho-vascular invasion (LVI), dermal invasion, and nipple involvement. IHC profile included ER, PR, Her2-neu and ki67 index. These data were expressed in frequencies and percentages, and the NPI was correlated with the previous parameters using appropriate statistical tests, and a P-value < 0.5% is considered a statistically significant difference.
Results: There was no statistically significant association between NPI and age, focality and ER status (P-value = 0.93, 0.55 and 0.64, respectively). Significant correlations exist with, dermal involvement, surgical margins involvement, and PR status (P-value = 0.03, 0.029, 0.046, and 0.011, respectively). The correlation is highly significant when the NPI is considered against the stage, Ki-67, and Her2-neu (P-value = 0.001 for all).
Conclusion: Most cases that were examined belonged to the moderate and poor numerical NPI categories, and these NPIs show significant associations with the stage, Ki-67, and Her2-neu.

Background: Hypercoagulable state is a major complication of the coronavirus disease-2019 (COVID-19), with a possible result of debility and/or mortality. Homocysteine and SCUBE-1 are plasma biomarkers; their abnormal levels are relatable to coagulation as a cause or an effect.
Objectives: To investigate the association of homocysteine and SCUBE-1 with COVID-19–associated hypercoagulability.
Materials and Methods: This is a cross-sectional study with ninety adult COVID-19 patients with variable severity. Patients were classified according to D-dimer level at the time of hospital admission into two groups: with and without hypercoagulability. Serum was extracted from centrifuged blood (collected in gel tubes) and stored at -20 ºC. Serum levels of homocysteine and SCUBE-1 were measured utilizing Chemiluminescense Immunoassay and Enzyme-Linked Immunosorbent Assay, respectively, using commercially available kits.
Results: Thirty-eight patients (42.22%) out of the ninety had a hypercoagulable state, and the vast majority of patients with hypercoagulability (89.47%) had severe disease. The median (IQR) levels of homocysteine and SCUBE-1 in patients with hypercoagulability were 9.56 (8.75) µmol/L and 0.19 (0.11) ng/ml, respectively, which were higher than that of normal coagulable patients (8.15 [5.85] µmol/L and 0.16 [0.06] ng/ml, respectively) with highly significant differences (P-value = 0.044 and 0.01, respectively).
Conclusion: Homocysteine and SCUBE-1 serum levels are significantly associated with COVID-19 hypercoagulability and disease severity, and may be utilized as adjunct biomarkers for prediction/diagnosis of hypercoagulability in COVID-19 patients.

Background: Female diffuse alopecia is a common dermatologic problem. Consequently, a simple, quick, and quantitative assessment is required to aid in diagnosis. A clinic-based modified hair fall count in 60 seconds is proposed as a new, simple, and quick method for evaluating hair loss.
Objectives: To assess bias and limit of agreement between the new Clinic-based modified hair fall count in 60 seconds (CBMHFC 60-S) and conventional home-based hair fall count in 60 seconds (HBHFC 60-S) determining hair fall in women with diffuse hair loss.
Materials and Methods: Seventy-five women with diffuse alopecia recruited from Al-Salam Teaching Hospital, Mosul, Iraq underwent assessment of hair fall count by using two instruments, new single reading (CBMHFC 60-S) and conventional three reading (HBHFC 60-S). A multistage statistical analysis of validity tests was used to assess the performance of CBMHFC 60-S in comparison to HBHFC 60-S. These included the estimation of the difference between both methods; correlation and prediction; and lastly estimating accuracy (amount of bias and limits of agreement) using Bland Altman blot. A P-value < 0.05 was considered a statistically significant difference.
Results: A non-statistically significant difference (P-value = 0.06) in average hair fall count was estimated by CBMHFC 60-S and HBFHFC 60-S (15.81 ± 7.16 vs 18.18 ± 8.56). A very highly significant linear relationship between both tests (r = 0.434, P-value <0.0001). A regression analysis yields the following prediction equation [CBMHFC 60-S = 9.21 + 0.36* (HBHFC 60-S)]. Bland-Altman blot revealed a high accuracy of the CBHFC 60-S. The count was less than HBHFC 60-S count by an average of 2.38 hairs. The 95% CI of CBMHFC 60-s in comparison to HBHFC 60-S will fall between -18.95 and 14.19.
Conclusion: The new single reading CBMHFC-60S estimation of hair fall count was a valid test reflected by its strong association with an average of three readings of conventional HBHFC-60 and high concordance (low bias and high precision).

Background: Oral mucosa refers to the mucous membrane that lines the tissues within the oral cavity. Wound healing is an essential physiological process that involves the collaboration of numerous cell strains and their products to restore damage caused by a local aggressor. This process begins very early in the inflammatory phase and finishes with tissue repair. Myrrh oil has an anti-inflammatory effect on wound contraction, re-epithelization, early neovascularization, and increased collagen density.
Objectives: To evaluate the effectiveness of myrrh oil in rats oral mucosal ulcer healing.
Materials and Methods: 36 adult male albino rats (Rattus norvegicus) of about 250-300 mg of weight and an age of about 2-3 months were used in this experimental study. The practical part of this study lasted two months (June–July 2022) in the private animals’ house of Al-Dhyaa in Baghdad City, Iraq. The traumatic ulcer, with an 8 mm diameter and 1 mm depth was made on the right cheek mucosa by using a round diamond bur. The ulcer was treated once daily with a single topical dosage of 10 L of sterile distilled water (control Group). While in the myrrh oil Group, the ulcer was managed once a day with a micropipette dose of 10 L of 1 g/ml of myrrh oil. Animals were sacrificed after ulceration with general anesthesia over healing periods 1, 3, and 7 days. Histological analysis was performed by calculating the average wound contraction size, inflammatory cells and epithelial cells, and blood vessels. On days 1, 3, and 7 of the healing process, Van Gieson stain and Periodic Acid-Schiff stain were used to organise collagen fibre deposition and extracellular matrix production in all of the groups that were looked at.
Results: Histological findings of an induced oral ulcer treated with daily application of myrrh oil showed more epithelization, reduced inflammation, increased angiogenesis, and decreased healing time in comparison to the control Group. The histochemical findings showed a significant difference in collagen fibers synthesis and extracellular matrix formation in myrrh oil in comparison to the control Group.
Conclusion: Myrrh oil is more effective in promoting the healing of ulcers.

Background: Maternal beta-thalassemia minor may increase the risk of adverse obstetrical outcomes like restricted fetal growth, reduced birth weight, and preterm delivery.
Objective: To determine maternal and neonatal outcomes in pregnant women with beta-thalassemia minor in Kirkuk province, Iraq.
Materials and Methods: A case-control study was conducted and enrolled 95 pregnant women with beta-thalassemia minor and 100 control pregnant women without beta-thalassemia minor. A comparison between the two groups was performed regarding the general characteristics of the pregnant women, obstetrical complications, and neonatal outcomes.
Results: The mean hemoglobin (Hb), gestational age, and birth weight were significantly lower in the cases compared to the control group, with a P-value < 0.001, 0.002, and 0.004, respectively. Blood transfusion, emergency caesarean section (CS), postpartum hemorrhage, preterm labor, small for gestational age (SGA), and admission to the neonatal care unit (NCU) in cases were significantly higher compared to the control group. Admission to NCU was higher with low maternal Hb, lower gestational age at the time of delivery, pregnancies complicated by diabetes mellitus, oligohydramnios, meconium-stained liquor, preterm labor, pregnant women who delivered by CS, neonates with SGA , and those with a low APGAR (A= appearance, P = pulse rate, G = grimace, A = activity, and R = respiration) score.
Conclusion: Beta-thalassemia minor may adversely affect pregnancy outcomes and increase the frequency of neonatal admission to NCU.

Background: Hypothyroidism is one of the mostimportant thyroid disorders, and chronic autoimmune (Hashimoto's) thyroiditis is the most common cause in iodine-replete areas. Anti-thyroglobulin antibodies (anti-Tg Ab) and anti-thyroid peroxidase antibodies (anti-TPO Ab) are commonly associated with the development of chronic autoimmune thyroiditis. However, the precise relationship between them has not been defined yet.
Objective: To study the relationship between anti-Tg Ab and anti-TPO Ab among patients with primary hypothyroidism.
Materials and Methods: In a cross-sectional study of 169 patients with primary hypothyroidism, their anti-TPO Ab and anti-Tg Ab were measured, analyzed, and correlated together.
Results: Positive anti-TPO Ab and anti-Tg Ab were observed in 52.1% of the patients, while 26% and 8.9% of them were only positive for anti-TPO Ab or anti-Tg Ab, respectively, and the remaining 13% showed no positivity for both of them. Anti-Tg Ab titer increased steadily with advancing age in contrast to anti-TPO Ab (P-value = 0.009). The best and highest positive predictive value for having a positive anti-TPO Ab was 91%, and this was obtained at an anti-Tg titer of > 691 IU/mL with a sensitivity of 31% and specificity of 89% at an odds ratio of 3.72 (P-value = 0.014). The best negative predictive value was seen at an anti-Tg Ab titer < 11 IU/mL with a sensitivity of 99% and a specificity of 24% (P-value < 0.001), while a maximum Youden’s value of 1.4 (i.e., maximum sensitivity at a maximum specificity) was obtained at a titer of 26 IU/mL with a positive predictive value of 86% and a negative predictive value of 59% with a sensitivity of 90% and a specificity of 51% (P-value < 0.001).
Conclusion: Both anti-Tg Ab and anti-TPO Ab had considerable information in patients with chronic autoimmune hypothyroidism. Anti-Tg Ab tends to be more informative in older people (> 50 years), where it is more prevalent than anti-TPO Ab. At an anti-Tg Ab titer > 691 IU/mL, we most likely will have positive anti-TPO Ab, while at an anti-Tg Ab titer < 11 IU/ml, we most likely have negative anti-TPO Ab.

Background: Doxorubicin-induced cardiotoxicity (DIC) is a major complication of cancer chemotherapy. Thus, developing effective myocardial protection strategies during doxorubicin (Dox) therapy is a medical necessity.
Objectives: To evaluate and compare the cardioprotective effectiveness of free berberine (Ber) and berberine loaded in micelles (mBer) against DIC.
Materials and Methods: The study, which was conducted in 2023, employed the H9c2 cell line, derived from embryonic cardiomyocytes, as a model. The study included a control group and six experimental groups: the Ber-treated group, the mBer-treated group, the Dox-treated group, the Ber-Dox combination-treated group, and the mBer-Dox combination-treated group, as well as the void micelles-treated group. The study evaluated the alterations in several cardiotoxicity markers with triplicate measurements: [lactate dehydrogenase (LDH), creatine kinase myocardial band (CK-MB), and cardiac troponin I (cTn-1)], lipid peroxidation indicator (malondialdehyde (MDA), oxidative stress markers [Reduced glutathione (GSH), catalase (CAT), and superoxide dismutase (SOD), inflammatory cytokines (interleukin-1β (IL-1β) and interleukin-6 (IL-6)], and the activity of the apoptosis proteins caspases 3/7.
Results: The DOX group demonstrated significant increases in cardiotoxicity enzyme indices, lipid peroxidation, generation of free radicals, inflammatory cytokines, and caspase 3/7 activity relative to the control group. When Ber, or mBer, was co-delivered with Dox, the levels of LDH, CK-MB, cTn-1, and MDA significantly decreased. Whereas the activities of SOD and CAT were significantly improved when Ber, or mBer, was co-delivered with Dox. They reduced the elevation in both IL- β and IL-6 levels as well as the activities of caspases 3 and 7 induced by Dox. Importantly, the utilization of the micellar formulation of Ber in conjunction with Dox significantly enhanced the cardioprotective efficacy of Ber against DIC in H9c2 cells.
Conclusion: Our results suggest that mBer offers a novel Ber delivery approach and prospective therapeutic strategy for the treatment of DIC.

Background: Secreted frizzled-related protein 5 (SFRP5) is an adipokine that inhibits the noncanonical Wingless Type (Wnt) signalling pathway. It may have anti-inflammatory and insulin-sensitizing effects, but the evidence is conflicting.
Objectives: This study examined the influence of serum and follicular fluid levels of SFRP5 and Wnt5a on intracytoplasmic sperm injection (ICSI) outcomes in infertile women, considering their relationship to insulin sensitivity.
Materials and Methods: Ninety infertile women aged 18 to 45 years undergoing ICSI for various reasons were enrolled in this prospective cross-sectional study at the infertility centre of the High Institute for Infertility Diagnosis and Assisted Reproductive Technologies, Al-Nahrain University, Baghdad, Iraq, from September 2021 to July 2023. They received antagonist ovarian hyperstimulation treatment and had their blood fasting sugar, serum fasting insulin, serum and follicular fluid SFRP5, and serum and follicular fluid Wnt5a measured on ovum pickup. The Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) was calculated.
Results: Serum and follicular fluid SFRP5 levels were higher in normal-weight women (P-value < 0.001), while serum and follicular fluid Wnt5a levels were insignificantly higher in obese women (P-value > 0.05). HOMA-IR was higher in the obese group (P-value < 0.001). Insulin resistance markers were lower in pregnant women (P-value < 0.05), while serum and follicular fluid SFRP5 levels were higher in pregnant women (P-value < 0.01). Serum and follicular fluid SFRP5 levels were negatively correlated with insulin resistance markers and positively correlated with oocyte quality, quantity, fertilization rate, and embryo grade (P-value < 0.05).
Conclusion: SFRP5 and Wnt5a were detected in infertile women's serum and follicular fluid. Serum and follicular fluid SFRP5 levels were associated with lower insulin resistance, a lower body mass index, and better ICSI outcomes.