Iraqi National journal of Medicine

Background: Post-transplant dyslipidemia is common and presents unique management challenges for nephrologists. The most important outcomes of post-transplant dyslipidemia treatment include preserving or improving allograft function and reducing cardiovascular morbidity and mortality. Aim: This study aims to assess the impact of immunosuppressive therapy on lipid profiles in kidney transplant patients Methods: This cross-sectional study was conducted at the Renal Transplant and Nephrology Center, Baghdad Medical City, over 15 months. A total of 51 kidney transplant recipients were enrolled, including 34 males (66.7%) and 17 females (33.3%), with an age range of 20 to 60 years and a male-to-female ratio of 2:1. Patient data, including age, gender, medical history (including drug history and pre-transplant dyslipidemia), date of kidney transplantation, donor type (related or unrelated), immunosuppressive regimen, renal function tests, fasting blood sugar, fasting lipid profile, urinalysis, body weight, body mass index (to exclude obese patients), and blood pressure, were recorded using pre-prepared data sheets. Dyslipidemia in kidney transplant recipients was diagnosed based on a fasting lipid profile obtained after 8–12 hours of fasting. Results: Among the 51 kidney transplant recipients, 25 patients were on cyclosporine A, 21 on tacrolimus, and five on sirolimus, in addition to mycophenolate mofetil and prednisolone. There were statistically significant differences in serum cholesterol, low-density lipoprotein (LDL), and triglyceride levels among kidney transplant recipients based on their immunosuppressive medication. However, no statistically significant differences were observed in serum high-density lipoprotein (HDL) and very low-density lipoprotein (VLDL) levels. The highest cholesterol, triglyceride, and LDL levels were observed in patients receiving sirolimus, followed by those on cyclosporine A. In contrast, the lowest levels of cholesterol, LDL, and triglycerides were found in patients on tacrolimus therapy. No statistically significant differences in serum lipid levels were observed between males and females, between patients older than 40 years and those younger than 40 years, or between individuals with and without diabetes mellitus. Patients were categorized based on the time since transplantation (one, two, three, four, or five or more years post-transplant), but no statistically significant differences in serum lipid levels were found based on the duration since transplantation. Conclusion: Cyclosporine and sirolimus may contribute to dyslipidemia. Among the immunosuppressive therapies studied, sirolimus was associated with the worst lipid profile, while tacrolimus was linked to a more favorable lipid profile compared to both sirolimus and cyclosporine.

Background: Historically and clinically, lymphomas are categorized into two major groups: Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL). Over the years, radiotherapy techniques have advanced from extended-field to involved-field and more recently to involved-site/involved node radiation therapy (RT) (ISRT/INRT). Aim: This study aimed to evaluate the efficacy of mediastinal radiotherapy in lymphoma patients in Iraq. Methods: A prospective study was conducted to assess clinical and dosimetric changes in various radiotherapy planes and dosimetry between January 2023 and December 2023. The data collected included The data collected included patient demographics, medical history, treatment details, lymphoma characteristics, staging, radiotherapy plans, dose/fraction, and organ doses. Results: The study included 30 lymphoma patients (19 HL and 11 NHL cases) with a mean age of 31.3 ± 9.11 years. The non-coplanar group demonstrated superior mean PTV coverage compared to the coplanar volumetric modulated arc therapy (VMAT) group (P = 0.005). Additionally, the mean heart dose in the coplanar plans was greater than that in the non-coplanar arm (p < 0.0001). The coplanar plans also showed higher mean doses to the left lung at V20 in comparison to the non-coplanar plans (p = 0.007). Furthermore, the mean dose to the spinal cord in the coplanar VMAT group was greater than that in the non-coplanar group (p = 0.003). The median survival times were 11 months for HL and 12 months for NHL. Patients treated with coplanar plans had a median survival of 10.36 months, while those treated with non-coplanar plans had a median survival of 8.13 months. The recurrence rate was 23.3%, with a 3.3% risk of cardiac toxicity. Conclusions: The mean PTV coverage in the non-coplanar group surpassed that of the coplanar VMAT group. The median survival for HL patients was less than that for NHL patients within the same follow-up period. The survival rate of patients under coplanar plans exceeded that of patients under non-coplanar plans.

Background: Mothers play a critical role in safeguarding the health and well-being of their children—a vulnerable population—particularly during outbreaks of infectious diseases. Aim: This study investigated the strategies employed by mothers to protect their children from COVID-19 and other viral illnesses. Methods: A cross-sectional study was conducted at the outpatient pediatric clinics of Basra Maternity and Children Hospital and Almawani Teaching Hospital, 118 mothers were enrolled from diverse backgrounds. Data was collected through structured interviews and a standardized questionnaire designed to assess maternal practices, attitudes, and experiences concerning the protection of their children. The key areas explored included hygiene practices, adherence to public health guidelines, and access to healthcare services. Results: Most participating mothers were between 20 and 40 years of age (79.66%), had attained a college education or higher (54.23%), and were primarily housewives (56.77%). Among the reported protective behaviors, 91.5% of mothers used hand sanitizers containing at least 60% alcohol, 75.4% cleaned and disinfected household objects and surfaces, and 60.16% frequently washed their hands with soap and water. Additionally, 94.91% communicated with family and friends solely through social media rather than in-person visits. A total of 66.94% avoided contact with individuals exhibiting flu-like symptoms, while 81.35% provided their children with information and health instructions regarding viruses. Furthermore, 71.4% reported preparing a sufficient supply of prescription medications for chronically ill children during the lockdown period. Conclusion: A positive association was found between the mothers’ level of education and certain preventive behaviors, such as disinfecting household surfaces, educating their children about viruses, and adhering to quarantine practices during the pandemic. However, no significant relationship was observed between education level and behaviors such as hand washing, sterilizing, avoiding sick individuals, or preparing a list of hospitals. This study’s findings provide valuable insights for developing evidence-based recommendations targeted at mothers, healthcare professionals, and policymakers. These results support the need for tailored educational programs and resources to enhance caregiver preparedness and protect children’s health during future infectious disease outbreaks.

Background: Cancer is the second leading cause of death globally, with an estimated 9.6 million fatalities reported in 2018. Thus, understanding the impact of cancer rates and examining how cancer deaths are distributed by age and have changed over the years is crucial. Aim: This descriptive statistical study aimed to identify the most prevalent cancer types responsible for deaths in the Basra Governorate from 2018 to 2022, along with their distribution across various age groups and geographical areas. Methods: The study utilized a descriptive statistical approach based on death certificate data from Basra Governorate, encompassing all cancer-related deaths from 2018 through the end of 2022. The data were processed using Excel and Statistical Package for the Social Sciences (SPSS) software, and the outcomes were presented in tables and charts. Results: The findings revealed an increase in cancer-related fatalities from 2018 to 2022, although the proportion of cancer deaths relative to total deaths experienced a slight decline. The incidence of cancer deaths rose with age, with lung cancer accounting for the highest percentage, followed by breast cancer, brain cancer, and hematological malignancies, which were most prevalent among children. Among the younger demographic, cancers of the breast, brain, and digestive system were the most common. For individuals aged 40 to 60, breast, lung, and digestive system cancers were predominant, while lung, bladder, and breast cancers were most frequently observed in those aged 60 and older. The central region of the governorate recorded the highest percentage of cancer deaths, followed by Al-Zubair and Abi Al-Khaseeb districts, with no significant difference in cancer death rates between genders. Conclusion: Over the past five years, the cancer-specific mortality rate experienced a slight reduction, with lung, breast, and brain cancers presenting the highest frequencies and cancer death rates increasing with advancing age.

Background: The global trend of self-medication is rising, making it a priority to investigate associated risks that could lead to life-threatening complications. Aim: To assess self-medication practices among undergraduate medical students and evaluate their knowledge and the factors influencing their use of self-medication Methods: A cross-sectional questionnaire-based study was conducted among 234 medical students from various medical colleges in Baghdad between November 2023 and March 2024. Participants were selected randomly. Data were collected and analyzed using SPSS version 23. The chi-square significance test was performed, and P-values ≤ 0.05 were considered statistically significant. Results: The study found that 72% of participants reported using self-medication at least twice a week in the past six months. Painkillers and cold medications were the most commonly used drugs without prior consultation. More than half of the participants (53%) relied on their previous knowledge as a source of information for obtaining medications, and they trusted social media more than physicians for medical advice. Conclusion: Self-medication practices were highly prevalent among undergraduate medical students in Baghdad, with many relying on their own experience for medical knowledge. Academics and pharmacists should educate students about the risks of improper self-medication and enforce stricter regulations on prescription-only medications.

Background: Uropathogenic Escherichia coli (UPEC) is a primary cause of urinary tract infections (UTIs) globally. The increasing antibiotic resistance of UPEC strains poses a significant challenge for treatment in countries like Iraq. Aim: The study aims to evaluate antimicrobial resistance patterns of Escherichia coli (E. coli) among UTI patients, considering age and sex, and to compare these findings with data from other geographical locations. Methods: Our study investigated antibiotic resistance patterns among E. coli strains responsible for UTIs in patients at Karbala Teaching Hospital for Children, Iraq. We specifically examined age and sex differences. Data on 144 E. coli isolates were collected and analyzed for their susceptibility to six antibiotics from January 1, 2022, to December 31, 2023. Results: There were no statistically significant sex-based differences in antibiotic resistance. Ceftriaxone (76%) and nalidixic acid (67%) demonstrated the highest resistance rates among the tested antibiotics in both sexes. In contrast, amikacin (91%) and gentamicin (60%) exhibited higher sensitivity rates compared to other antibiotics. A general trend of increasing antibiotic resistance with age was evident, particularly pronounced for nalidixic acid and ceftriaxone. Conclusion: Amikacin consistently demonstrated relatively low resistance rates across all age groups. Infants under one year of age displayed heightened susceptibility to certain antibiotics, as reflected in lower resistance rates. Conversely, nalidixic acid and ceftriaxone exhibited notably elevated resistance rates across all age groups.

Background: Volumetric modulated arc therapy (VMAT) is the most commonly used radiotherapy (RT) technique for locally advanced head and neck cancers (HNC), concurrent with chemotherapy. Aim: This study aims to evaluate the anatomical changes that may arise in patients undergoing VMAT treatment. Methods: The study involved 20 patients with locally advanced HNC who received VMAT treatment concurrently with chemotherapy. Prior to the initiation of radiotherapy treatment, computed tomography (CT) simulation was conducted for all patients. The prescribed doses for the primary target (PTVP), high-risk lymph nodes (PTV60), and low-risk lymph nodes (PTV54) were 69.96 Gy, 60 Gy, and 54 Gy, respectively, administered in 33 treatment fractions using the simultaneous integrated boost (SIB) technique. Anatomical comparisons were made between CT1, CT2, and CT3, while dosimetric evaluations were performed between iplan, Rplan1, and Rplan2. Results: The analysis revealed a significant weight decrement in terms of anatomical changes in all patients. The gross tumor volume (GTV) decreased notably at CT2 in comparison to CT1. The GTV volume decreased significantly again at CT3. Additionally, there was a substantial reduction in the volume of the parotid glands. For dosimetric evaluation, most organs at risk experienced a noteworthy increase in the received dose. For target coverage, the D95% of the PTVP in the (iplan) was 97%, which significantly increased in Rplan1. Conclusion: Patients with HNC must undergo a new CT simulation during the RT course owing to significant anatomic changes that impact the plan quality. New plans (adaptive plans) should be implemented for a specific number of fractions to ensure the maintenance of initial plan quality.

Background: Septoplasty is a common surgical procedure performed in otorhinolaryngology departments to correct nasal septum deviation. Traditionally, nasal packing or splints used to stabilize the septal mucosal flaps and promote adhesion. However, these can cause complications such as nasal obstruction until removal, dry mouth, watering of eyes, severe pain during pack removal, headache, difficulty swallowing, and hypoxia. Methods: This prospective longitudinal observational study conducted on 50 patients undergoing septoplasty for nasal obstruction without the use of nasal packing or splints. This study included 50 patients who presented to the ENT department with nasal obstruction over one year (October 2021 to October 2022). The septal mucosa was sutured using 4-0 poly glycolic with an initial few quilting sutures, followed by continuous sutures to approximate the flaps and prevent septal hematoma. Patients monitored on the day of surgery and during follow-ups for bleeding or hematoma. The severity of nasal obstruction assessed using the NOSE score preoperatively, then reassessed at one week and one month postoperatively. Follow-up examinations evaluated the nasal cavities for synechiae, hematoma, septal perforation, or residual deviation. Results: Among the 50 patients, 36 were male and 14 were female. The youngest patient was 15 years old, and the oldest was 57 years old. Minor bleeding occurred in two patients within a few hours postoperatively in the recovery room. These patients treated with intravenous tranexamic acid (500 mg) without requiring nasal packing. No complications occurred in the remaining patients, and no long-term complications were observed in any case. Conclusion: Septoplasty was performed using multiple continuous trans-septal sutures after initial quilting sutures for stabilizing the corrected septum with absorbable 4-0 Vicryl suturing material, without nasal packing or splints, is an effective method for preventing hematoma and synechiae. This technique also avoids the discomfort and complications associated with foreign material inside the nasal cavity. Thus, septoplasty can be safely performed as a daycare procedure.

Background: Type 2 diabetes mellitus (T2DM) is growing health concern globally, particularly in the Middle East. To encourage individuals to adopt a healthy lifestyle essential for managing diabetes, it is imperative to thoroughly understand the barriers, especially those that can be modified, encountered by patients following nutritional and exercise medical advice. Aim: The primary objective of this study was to investigate the barriers related to nutrition and exercise among patients with T2DM in hospitals located in Basrah. Methods: This cross-sectional study included 194 adults with history of T2DM who were visiting the outpatient departments of internal medicine in four selected hospitals in Basrah. Data was collected using a specially prepared questionnaire administered through direct interviews with the diabetic patients by the investigators. The questionnaire encompassed general information about the participant and barriers to diet and exercise among patients with T2DM. Results: Most of the participants were aged 40 years and older (82.5%). Approximately 46.9% of the participants adhered to their doctor’s dietary recommendations. Only 20.6% of the diabetic patients engaged in physical exercise. Among non-adherent patients with T2DM, the most frequently reported barriers to nutrition included a lack of preference for the recommended diet (86.4%), lack of motivation (57.2%), and lack of knowledge (52.4%). The most commonly cited barriers to exercise were lack of energy (87.0%), lack of willpower (81.8%), lack of skill (77.9%), and fear of injury (73.3%). Conclusion: The study revealed that the compliance of diabetic patients to dietary and exercise recommendations was low. Therefore, it is crucial for health professionals to proactively address the mentioned barriers, and policymakers should design active nutritional practice guidelines for patients with T2DM.

Background: Anemia is a global health problem that affects adolescents, adults, and children in both developed and developing countries. Anemia in adolescent girls (10–19 years of age) is defined as a hemoglobin level in the blood of <12 g/dL. In Indonesia, the prevalence of iron deficiency anemia in adolescent girls reaches 48.9%. Iron supplementation can be enhanced with vitamin C as a companion supplement. Vitamin C increases iron absorption in the body by reducing Fe3+ to Fe2+, which requires an acidic environment for optimal dissolution and absorption. Aim: This study aims to assess the comparative effectiveness of iron supplementation with or without vitamin C in increasing hemoglobin levels. Methodology: An experimental design with consecutive sampling was conducted in September 2023 at Junior High School 1 Prambon, Nganjuk, East Java. The total sample consisted of 52 girls aged 12–13 years with anemia. The first group received iron and vitamin C, while the second group received iron only. Hemoglobin levels were by the fingerstick method. Results: There were 32 samples (53.33%) aged 13 years. The average change in hemoglobin levels before and after intervention in group 1 was 2.238 g/dL with < 0.05, while in group 2 it was 0.661 g/dL with <0.05. The average difference in changes in hemoglobin levels between groups 1 and 2 after intervention was 1.303 g/dL with <0.05. Conclusion: Iron supplementation with vitamin C results in more significant increases in hemoglobin levels.

Background: The International Classification of Diseases, Tenth Revision (ICD-10), is a critical tool for standardizing health information globally. Despite its widespread adoption, gaps in understanding and application among healthcare providers persist, potentially affecting patient care and health system efficiency. Aim: To examine the knowledge, attitudes, and practices of physicians regarding the implementation of the ICD-10 system Methods: This descriptive, cross-sectional study assessed the knowledge and attitudes of 67 healthcare professionals (27 specialists, 25 senior residents, eight general practitioners, and seven junior residents) from various medical settings in Basra, southern Iraq, including hospitals and clinics. Participants completed a questionnaire evaluating their familiarity with and application of ICD-10, particularly in tasks such as death certification. Data were analyzed using SPSS version 26, with the Chi-Square Test employed to explore relationships between knowledge levels and demographic as well as professional variables. Results: While 61% of respondents reported familiarity with ICD-10, only 8% demonstrated “Good” proficiency in its application. A notable 60% exhibited “Poor” proficiency, particularly in death certification procedures. Statistical analysis found no significant correlation between professional role or years of practice and ICD-10 knowledge levels (Chi-Square values = 14 and 5.5, P-values = 0.1 and 0.9, respectively). The primary source of ICD-10 knowledge was self-education (54%), with formal training programs contributing minimally (15%). Despite recognizing the importance of ICD-10, only 14.9% of doctors regularly applied these standards in their practice, and 68.7% had never participated in any formal ICD-10 training. Conclusion: This study highlights a significant gap in the effective application of ICD-10 among medical professionals in Basra, pointing to systemic deficiencies in training and education. There is a critical need for comprehensive training programs and policy interventions to enhance ICD-10 understanding and usage. Strengthening these efforts could improve clinical documentation, patient care, and overall health system management, bridging the gap between the perceived importance of ICD-10 and its practical implementation

Background: Vaccines against severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection vary in mechanisms, side effects, and effectiveness. Health care professionals have shown high vaccine coverage rates. Aim: This study aims to assess the prevalence of self-reported clinical signs and symptoms of COVID-19 infection among health care professionals in Iraq and determine the type and severity of COVID-19 vaccine-related symptoms. Methods: A cross-sectional survey was conducted from January 1st to July 1st, 2023, using an online questionnaire disseminated through social media platforms. Results: Among 770 participants, common symptoms included body aches (36.9%), malaise (34%), headache (22%), and fever (20%), with chest pain (4.2%) and vomiting (3.4%) being less common. Most symptoms lasted for a short duration, with 45.9% lasting one day, 36.3% lasting two days, and 17.7% lasting three days. Only 1.6% needed hospitalization, while 72.7% treated the symptoms at home and 25.7% did not require any treatment. Mixed vaccine recipients were more likely to experience multiple symptoms and deoxyribonucleic acid (DNA) vaccines were linked with fever and headache symptoms. Symptoms were more pronounced in individuals with a history of COVID-19 infection but not influenced by vaccine dosage. Conclusion: Symptoms such as body aches, headache, fever, vomiting, and malaise were significantly associated with prior COVID-19 infection and receiving DNA and messenger ribonucleic acid (mRNA) vaccines. Most vaccinated participants managed symptoms at home.

Background: Lymphatic malformations are rare benign congenital cystic lesions that can develop anywhere in the body. Therapeutic options for these lesions include intralesional sclerotherapy, surgical excision, and other modalities. Aim: This study aims to assess the safety and efficacy of complete surgical excision as a therapeutic option in the treatment of large macrocystic lymphatic malformations in children, as well as to introduce a novel modification to the surgical procedure. Methods: A prospective study was conducted on 14 patients with large macrocystic lymphatic malformations in different body locations, treated between October 2018 and October 2021 at our institution. Complete surgical excision using a continuous traction technique was the principle therapeutic approach, with no alternative modalities applied. Patients were followed up to assess postoperative cosmetic and functional outcomes, as well as recurrence. Results: Most enrolled patients, comprising 12 (85.7%), presented before the age of 2 years, with eight (57.1%) having lesions in the neck. Clinical diagnosis was possible in 11 (78.6%) cases. Complete surgical excision was successfully achieved in 12 (85.7%) patients, with no significant injury to vital structures. No postoperative functional problems were reported, and esthetic results were satisfactory in the vast majority (92.8%) of patients. Recurrence was not reported in any of the patients enrolled. Conclusion: Complete surgical excision proves to be a safe and effective initial therapeutic modality in the management of large macrocystic lymphatic malformations in children, yielding excellent postoperative results in terms of functional outcomes and recurrence. Utilizing a continuous traction technique during surgical excision has been instrumental in achieving these favorable outcomes.

Background: Toxoplasmosis is a parasitic disease caused by Toxoplasma gondii. Humans acquire toxoplasmosis by consuming infected meat containing cysts of T. gondii or through contact with cat feces. Toxoplasmosis is known to cause miscarriage, also referred to as spontaneous abortion or pregnancy loss, which pertains to an unviable intrauterine pregnancy occurring during the first trimester and is the most common type of miscarriage. Aim: The aim of this study is to assess the level of knowledge of nursing students about toxoplasmosis. Methods: A questionnaire was administered to 90 nursing students. The self-completed questionnaire consisted of 17 questions covering the parasite, its diagnosis, clinical symptoms, and prevention of toxoplasmosis. Results: There was no significant relationship between participants’ knowledge and any of the demographic variables. Regarding participants’ knowledge, 28.9% demonstrated poor knowledge, 70% showed moderate knowledge, and only 1.1% exhibited good knowledge. Conclusion: The knowledge of nursing students regarding toxoplasmosis was found to be unsatisfactory

Background: Iron-deficiency anemia (IDA) remains a major global health concern, disproportionately affecting women of reproductive age. Conventional daily iron supplementation, though effective, is often associated with poor adherence due to gastrointestinal side effects. Emerging evidence suggests that alternate-day dosing may enhance iron absorption and tolerability, but comparative efficacy data in clinical settings remain limited. Aim: This study aimed to compare the hematological and iron store responses of women with IDA in Basrah, Iraq, between alternate-day and daily oral iron supplementation regimens. Methods: A total of 97 women with confirmed IDA (hemoglobin [Hb] < 12 g/dL, serum ferritin < 15 ng/mL) were enrolled in a prospective follow-up cohort study. The participants were divided into two groups: Group B (n = 48) received 100 mg of elemental iron daily, while Group A (n = 49) received the same dose every other day. Serum ferritin and hematological parameters (Hb, red blood cell [RBC] count, hematocrit) were assessed at baseline, three weeks, six weeks, and three months. ANOVA and paired t-tests were used for statistical analysis, with a significance level of P < 0.05. Results: Compared to the daily group, the alternate-day group exhibited a significantly higher mean increase in serum ferritin (28.6 ± 4.2 ng/mL vs. 22.3 ± 3.8 ng/mL, P = 0.001) and hemoglobin (2.8 ± 0.5 g/dL vs. 2.1 ± 0.4 g/dL, P = 0.001) at three months. The alternate-day group demonstrated earlier and more sustained improvements in iron reserves (P < 0.01 at all follow-ups), but both regimens increased RBC counts. Conclusion: In women with IDA, alternate-day iron supplementation is more effective in restoring hemoglobin and iron stores than daily dosing, possibly due to improved absorption and reduced hepcidin inhibition. These findings suggest potential benefits for patient adherence and clinical outcomes, supporting the use of alternate-day regimens as a superior therapeutic approach. To validate these results, further randomized controlled trials are necessary.

Background: Al-hijamah is a traditional therapy used to clear blood and interstitial fluids, thereby helping maintain optimal levels of various blood solutes. Smoking is known to increase packed cell volume percentage (PCV%), leading to increased blood viscosity and associated complications. Aim: This study aimed to examine the impact of Al-hijamah therapy on reducing elevated PCV levels in healthy adult smokers Methods: A pre-post study was conducted on 25 healthy male adults aged 30–55 years who underwent Al-hijamah therapy in Fallujah, Iraq. All the participants were smokers who were medication-free and had PCV% values near the upper limit. Al-Hijamah was performed at five specific points of the posterior neck, bilateral paraspinal areas of the neck, and the thoracic spine. Venous blood samples were collected to measure PCV% three and seven days before and after the treatment. The result was statistically analyzed using t-test and p-value by SPSS version 25. Results: The pre-treatment PCV% values were equal to nearly the upper limit of the normal range (mean = 46.12%). A statistically significant reduction was observed after three days of treatment (mean = 43.20%, p-value = 0.000), which decreased slightly after four more days (43.16%). There was no significant change between day 3 and 7 (p-value = 0.942). Conclusion: Al-hijamah therapy can rapidly and significantly reduce elevated PCV% in healthy adult smokers within three days of treatment, with effects persisting for at least a week.

Background: Hemodialysis is used to restore electrolyte balance (sodium levels, potassium in the body, bicarbonate, chloride, as well as magnesium, calcium, and phosphate) and filters the waste products and excess fluid. Unfortunately, developing nations continue to have a severe shortage of resources, which makes it difficult to provide highly technical and costly care like dialysis. Aim: The study's objective is to reveal and trace the journey of patients with end stage kidney disease who are on regular hemodialysis program and how they reach to dialysis centers. Methods: the study was to be conducted in many dialysis centers in different regions in Iraq to trace the patients journey to dialysis centers and how they reach the place. Results: The study population consisted of 400 participants, 60.2% of them were males and 39.8% were females. The majority were between 50-69 years old. Baghdad constituted the greater part of the participant’s province (88.3%). 56.00% of the patients went to dialysis sessions three times per week, 42.25% of them went twice times. (24.75%) of patient get to dialysis center by private car, (68.00%) by Taxi and (6.25%) by bus. 42.75% spent 30 mins-1hr to get to dialysis center, 41.75% spent 10 mins-30 mins .54.61% spend 10,000IQD to 20,000IQD to get to dialysis center. Conclusion: transportation-related issues seem to have an impact on the provision of in-center hemodialysis. This could have an impact on the dialysis provider as well as the particular patient.

Central cervical cleft is an rare congenital midline anomaly of the neck, typically presenting as a vertically oriented skin defect accompanied by a subcutaneous fibrous band and, in many cases, an associated skin tag. This case report presents a case involving a five-year-old female who exhibited a midline cervical lesion with intermittent clear discharge but no associated pain or functional impairment. Clinical examination identified a characteristic cutaneous defect with a prominent skin tag in the midline of the anterior neck. Radiological evaluation, including ultrasound and CT scan, confirmed the localized nature of the anomaly and excluded deeper structural involvement. After appropriate counseling and reassurance of the benign nature of the lesion, surgical management was undertaken under general anesthesia. The excision was followed by multilayered wound closure incorporating multiple Z-plasty incisions to optimize healing and minimize scar formation. The postoperative course was uneventful, and the cosmetic outcome was further enhanced through regular follow-up and scar management using silicone gel. This case highlights the importance of early recognition and surgical correction of central cervical cleft to prevent potential functional limitations and achieve superior aesthetic results. Z-plasty remains a valuable reconstructive technique in such congenital neck anomalies, particularly in pediatric patients.

A 24-year-old male with refractory cytopenia with multilineage dysplasia and ring sideroblasts (MDS/RCMD-RS) who developed severe dermatological manifestations concurrent with COVID-19 infection. The patient exhibited complex vasculitic and purpuric skin lesions, which were hypothesized to result from COVID-19-induced endothelitis and vasculitis, exacerbated by underlying immune dysfunction from MDS. Despite treatment with EPO therapy, cyclosporin, and supportive care, the patient's condition deteriorated rapidly, leading to fatal respiratory failure. The report underscores the interplay between hematologic malignancies, immune dysregulation, and COVID-19, highlighting the potential for exacerbated dermatological and systemic complications in such patients. This case emphasizes the need for heightened vigilance and tailored management strategies for MDS patients infected with COVID-19.