Al- Anbar Medical Journal

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Acute respiratory distress syndrome (ARDS) is a life-threatening condition with high mortality, often triggered by severe lung infections such as those caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). By disrupting immune regulation and inducing excessive cytokine release, SARS-CoV-2 plays a key role in the onset and progression of ARDS. Approximately 10.4% of intensive care unit (ICU) admissions are due to ARDS, with mortality rates ranging from 30% to 50% depending on severity. Viral entry occurs when the spike (S) protein binds to the angiotensin-converting enzyme 2 (ACE2) receptor and is primed by transmembrane protease serine 2 (TMPRSS2), enabling penetration into respiratory epithelial cells. Subsequent viral replication and immune hyperactivation trigger a “cytokine storm,” leading to alveolar and capillary membrane damage, increased pulmonary permeability, and alveolar edema, hallmark features of ARDS. This study reviews the SARS-CoV-2 life cycle, structural and functional characteristics, ARDS pathophysiology, diagnostic approaches including real-time polymerase chain reaction (RT-PCR) and inflammatory biomarkers, and emerging therapeutic strategies. Understanding the molecular pathways underlying viral invasion, immune dysregulation, and lung injury may facilitate the development of targeted therapies for affected patients.

Background: The rapid proliferation of antimicrobial resistant superbugs, particularly multi-drug resistant (MDR) and extensively drug-resistant (XDR) Escherichia (E. coli), is a significant global public health issue.
Objectives: To investigate the prevalence and clinical relevance of CRISPR systems in MDR and XDR E. coli isolates from urinary tract infections (UTIs) and their association with antimicrobial resistance patterns.
Materials and Methods: Eighty E. coli culture-positive clinical specimens from patients with UTIs were identified using the VITEK® 2 Compact System and submitted to antibacterial sensitivity surveillance using selected Gram-negative cards according to CLSI guidelines. E. coli ATCC 25922 was used as a quality control strain. CRISPR-2, -3, and -4 gene detection was performed using the polymerase chain reaction (PCR) method.
Results: Out of 120 clinical specimens, 80 yielded positive cultures, including 45 (56.25%) resistant E. coli isolates. Among these, 32 (71%) were MDR, 12 (26.7%) XDR, and one (2.2%) non-MDR. CRISPR-2, -3, and -4 were detected in 66.7%, 82.2%, and 22.2% of E. coli isolates, respectively. Co-occurrence of CRISPR-2 and -3 was found in 60%, CRISPR-3 and -4 in 22.2%, and CRISPR-2 and -4 in 15.6% of isolates. In MDR strains, CRISPR-2 and -3 were common, while CRISPR-4 was rare. In XDR isolates, the frequencies of CRISPR-2, -3, and -4 were 22.7%, 25%, and 20.5%, respectively.
Conclusion: CRISPR-2 and CRISPR-3 are strongly associated with MDR E. coli, while their reduced presence in XDR strains may indicate CRISPR loss or suppression during resistance evolution, suggesting a role in bacterial adaptation.

Background: Parkinson’s disease is a progressive neurological disorder that affects the substantia nigra, a brain region responsible for controlling body movement. In Parkinson's disease, the death of dopaminergic neurons is thought to result, at least in part, from a neuroinflammatory state that originates from the activation of toll-like receptor-4 (TLR4) and glycogen synthase kinase-3 beta (GSK3β), among other contributing mechanisms.
Objective: To assess the neuroprotective role of metformin, alone or in combination with levodopa/carbidopa, against rotenone-induced Parkinsonism in male albino mice.
Methods: Thirty healthy male albino mice weighing 25-30 grams were randomly assigned to six experimental groups (n = 5 per group). The total duration of the experiment was 47 days. The neuroprotective and therapeutic effects were evaluated by measuring serum levels of GSK3β, malondialdehyde (MDA), and superoxide dismutase (SOD) using enzyme-linked immunosorbent assay kits. Additionally, quantitative real-time polymerase chain reaction was performed to evaluate the messenger ribonucleic acid expression of TLR4 specifically in the substantia nigra region.
Results: Rotenone administration led to a significant elevation in GSK3β and MDA levels, a reduction in SOD activity, and upregulation of TLR4 expression in the substantia nigra, indicating its strong neurotoxic effect. Preventive administration of metformin effectively restored these molecular and oxidative stress markers to normal levels, demonstrating a clear protective role. Moreover, therapeutic intervention with metformin, whether administered alone or in combination with levodopa/carbidopa, significantly improved the biochemical and inflammatory profiles associated with rotenone exposure.
Conclusions: Metformin showed neuroprotective activity in the rotenone-induced model, potentially by modulating oxidative stress and inflammation.

Background: The mental health of university students, particularly those in the medical field, is a topic of growing concern due to the demanding nature of their education.
Objectives: To examine the prevalence of psychotropic drug use among university students in the health sector and explore the factors influencing their consumption.
Materials and methods: A cross-sectional study was conducted from February to June 2024 at the University of Basrah across four colleges: the College of Medicine, Al-Zahraa College of Medicine, the College of Dentistry, and the College of Pharmacy. An online self-administered questionnaire was emailed to 2,811 students aged ≥18 years, with 715 responding. The survey covered demographics, psychotropic drug use, and psychological and social factors.
Results: The present prevalence of psychotropic drug usage was 8.7% among the 715 participants. Out of 715 participants, 504 were students of the College of Medicine, of whom 48 students were utilized psychotropic medications (9.5%). Additionally, a strong association was observed between a history of psychological illness and drug use, as 90.6% (56) of students with psychotropic drug use reported a diagnosed psychological illness, compared to only 41.2% (6) who claimed the use of psychotropic drugs without clear or diagnosed psychological illness (P -value < 0.001). Among the commonly used drug classes, selective serotonin reuptake inhibitors were the most frequently used, reported by 32 students (4.4%), followed by antipsychotic medications (n = 18, 2.5%), tricyclic antidepressants (n = 15, 2.1%), and sedative anxiolytics (n = 32, 4.4%).
Conclusion: The study highlights a notable prevalence of psychotropic drug use among medical students, along with various associated factors. It offers insightful data and suggestions for institutional educational initiatives to enhance students' mental health.

Background: Chemotherapy is a modality for breast cancer (BC) treatment, particularly to reduce cancer size within the affected breast and lymph nodes before surgery. It employs anti-cancer (cytotoxic) medicines to kill cancer cells; however, it has significant adverse effects, including hematological disturbance, renal disorder, and hepatotoxicity. Laboratory evaluation is an important component for ensuring chemotherapeutic safety for BC patients.
Objectives: To assess the laboratory parameters features before and after chemotherapeutic treatment in type IIIB BC patients.
Materials and methods: This laboratory-based retrospective study included medical record data of 90 adult female BC stage IIIB patients who had chemotherapy at a tertiary-level hospital. Laboratory results were collected from each patient before and after the chemotherapy procedure, which included hematological and clinical chemistry parameters. From the hematological parameters, several inflammatory hematological ratios were calculated. Statistical analysis was performed to compare laboratory parameters before and after chemotherapy intervention using the Paired T-test or the Wilcoxon test based on data distribution.
Results: Following chemotherapy, there are significant drops in leukocytes (P-value = 0.002) and erythrocytes (P-value < 0.001), and hemoglobin (P-value < 0.001). In addition, the leukocyte differential count revealed a decrease in the percentage of eosinophils (P-value = 0.006) and an increase in the percentage of monocytes (P-value < 0.001). Upon an inflammatory hematological ratio investigation, we discovered monocyte-to-lymphocyte ratio and platelet-to-lymphocyte ratio elevation (P-value = 0.003 and 0.030, respectively) and neutrophil-to-monocyte ratio reduction (P-value = 0.002) following chemotherapy. Creatinine and aspartate transaminase were the blood chemistry parameters that differed significantly before and after chemotherapy (P-value = 0.028 and P-value = 0.038, respectively).
Conclusion: Following BC chemotherapy, several laboratory changes, including bicytopenia, shifted leukocyte differentials, hematological inflammatory ratio change, and altered renal and hepatic function indices, were observed.

Background: RAS gene mutations are found in a variety of malignancies throughout the body. NRAS mutations have been identified in several types of thyroid cancer. Although concurrent RAS mutations have recently been reported in papillary thyroid carcinoma (PTC), their impact on tumor progression and patient survival remains unclear.
Objective: To investigate the significance of NRAS mutations in PTC and their correlation with clinicopathological characteristics.
Materials and methods: Formalin-fixed paraffin-embedded tissue blocks were obtained from 60 histologically confirmed PTC cases, referred between June 2022 and June 2023 to the National Center for Education Laboratories, Medical City Campus, and AL-Kimma Private Hospital in Baghdad, Iraq. The study investigated the presence of the NRAS Q61R mutation in these samples and analyzed its association with various clinical and pathological parameters, including age, sex, PTC variants, tumor size, capsular invasion, multifocality, extrathyroidal extension, and lymph node metastasis.
Results: The NRAS Q61R mutation was detected in 11 out of 60 PTC specimens (18.3%), with no statistically significant difference between patients with and without the mutation (P-value = 0.073). However, the presence of the NRAS mutation was significantly associated with encapsulated tumors (63.6%, P-value = 0.007). No significant associations were found between NRAS mutation status and other clinicopathological variables, including age, sex, PTC subtype, tumor size, multiplicity, extrathyroidal extension, or lymph node metastasis (P-value > 0.05).
Conclusion: The NRAS Q61R mutation was detected at a low frequency in PTC and was significantly associated only with encapsulated tumors. No correlation was found with aggressive features, suggesting a limited role in tumor progression. Further studies with larger sample sizes are recommended to clarify its clinical significance.

Background: Sepsis is a significant health concern characterized by high mortality rates, further complicated by diagnostic challenges and the absence of reliable prognostic biomarkers. Objective: To investigate the clinical value of specific immunological parameters along with liver and kidney function tests in individuals with sepsis and their relationship to disease severity.
Materials and Methods: In this research, we included 300 participants (100 healthy individuals as the control group and 200 patients in the sepsis group, including 100 with non-severe sepsis and 100 with severe sepsis). Serum levels of interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), C-X-C motif chemokine ligand 9 (CXCL9), C-C motif chemokine ligand 12 (CCL12), soluble urokinase plasminogen activator receptor (suPARIII), and monocyte chemoattractant protein-1 (MCP-1), creatinine (S-Cr), High-sensitive C-reactive protein (hs-CRP), platelet counts (PLT), and the PaO2/FiO2 ratio were measured for each participant.
Results: Our results showed significantly increased (P-value < 0.05) levels of IL-6 and TNF-α in patients with non-severe sepsis and severe sepsis compared to the control group. The levels of CXCL9, CCL12, suPARIII, and MCP-1 were also significantly elevated in both non-severe sepsis and severe sepsis patients compared with the control group. Significantly higher levels of TSB, hs-CRP, and S-Cr were observed in the severe sepsis group compared to the control group. Conversely, platelet counts were markedly reduced in both non-severe and severe sepsis patients relative to controls.
Conclusion: The study identified several critical immunological and biochemical markers that demonstrated a significant positive correlation with sepsis severity. Elevated levels of these immune response markers were consistently associated with more severe clinical presentations, underscoring their potential utility as early diagnostic and prognostic indicators in sepsis management.

Background: Gestational diabetes mellitus (GDM), affecting up to 14% of pregnancies, is linked to obesity, sedentary lifestyle, and advanced maternal age. It is characterized by insulin resistance and adipose tissue inflammation. Zinc α-2-glycoprotein (ZAG) promotes lipid metabolism and glucose utilization, potentially linking it to GDM pathophysiology.
Objectives: To evaluate the association between serum ZAG levels and GDM.
Materials and methods: This case-control study was conducted at Al-Emamein Al-Kadhimein Medical City, Baghdad, Iraq, and included 100 pregnant women (24–28 weeks gestation), equally divided into GDM cases and healthy controls. Data collection included interviews, clinical exams, oral glucose tolerance tests, and serum ZAG level measurements.
Results: There were no statistically significant differences (P-value > 0.05) in age, body mass index, or parity between the GDM group and the control group. However, GDM was significantly associated with a family history of diabetes and a history of macrosomia (P-value < 0.05). Patients with GDM had significantly higher levels of fasting blood sugar, hemoglobin A1c, and two-hour postprandial glucose compared to the control group (P-value = 0.0001). Serum ZAG levels were significantly lower in the GDM group (40.49 ± 7.63 ng/mL) than in the control group (55.7 ± 10.96 ng/mL), with a statistically significant difference (P-value = 0.0001). A cutoff value of ≥ 50.5 ng/mL was identified for ZAG in distinguishing between the two groups.
Conclusion: This study suggests a potential role of ZAG in glucose metabolism during pregnancy and highlights its possible utility as a biomarker for metabolic alterations in GDM. However, as a single-center study with a relatively small sample size, further research is warranted to validate these findings and assess the clinical relevance of ZAG in GDM.

Background: In recent years, employee well-being has emerged as a critical factor influencing workplace efficiency and productivity. Physically and mentally healthy employees tend to be more productive and are better equipped to provide high-quality services.
Objective: To evaluate the impact of workplace burden on the health of nursing professionals working in intensive care units (ICUs).
Method: This research was conducted in four hospitals in Al-Nasiriyah city, southern Iraq, from October 2024 to January 2025 using a cross-sectional study design. The study population consisted of 127 ICU nurses currently employed at the selected hospitals. A purposive sampling technique was employed. Data were collected using the Symptom Checklist-90-Revised (SCL-90-R) questionnaire.
Results: Out of 127 nurses, 70 were male (55.1%), with the majority aged 39-49 years (33.9%). Approximately 33.1% reported experiencing frequent physical health impacts from their workplace, and 48% reported regular psychological effects. Factor analysis showed strong symptom loadings (extraction values > 0.600) across physical (e.g., fatigue, back pain) and psychological (e.g., panic, low self-worth) domains (P-value = 0.001). Age and education level significantly predicted physical burden (P-values = 0.001 and 0.018, respectively), while sex, experience, and patient loss were not (P-value > 0.05). Age was the only significant predictor of psychological burden (P-value = 0.001).
Conclusion: The findings underscore the significant challenges faced by ICU nurses, including physical strain, emotional exhaustion, and burnout, all of which can profoundly affect their overall health and well-being. Addressing these issues requires a comprehensive approach that integrates both individual-level and organizational-level interventions.

Background: Colorectal cancer (CRC) remains a significant global health burden with high mortality and rising resistance to chemotherapy. Angiotensin receptor blockers (ARBs), traditionally used to treat hypertension, have recently been shown to have anti-cancer effects by inhibiting the angiotensin II type 1 receptor (AT1).
Objectives: To assess the anti-proliferative effects of telmisartan and candesartan on CRC cells and their synergy with chemotherapy.
Materials and Methods: This in vitro study used CRC cell lines to assess viability (MTT assay), growth (soft agar), migration (wound healing), cell cycle and apoptosis (flow cytometry), and gene expression of B-cell lymphoma 2 (BCL2), vascular endothelial growth factor (VEGF), and AT1 by quantitative polymerase chain reaction.
Results: Telmisartan and candesartan inhibited CRC cell growth in a time- and dose-dependent fashion, with IC₅₀ values ranging from 63 to 274 µM. When combined with doxorubicin or 5-fluorouracil, they reduced chemotherapy IC₅₀ values by up to 11.6-fold, indicating synergistic cytotoxicity (CI < 1). Both ARBs suppressed wound closure by more than 60%, decreased colony formation by over 50%, induced G0/G1 cell cycle arrest (42% to 66%), and markedly increased apoptosis (54.4% with candesartan vs. 4.6% in controls). Additionally, gene expression analysis revealed more than a twofold downregulation of BCL2, VEGF, and AT1.
Conclusion: Telmisartan and candesartan show anti-cancer effects in CRC and synergise with chemotherapy, supporting their potential for repurposing.

Background: Despite its vital role in child health, breastfeeding is often hindered by social, cultural, and health system barriers.
Objectives: To assess mothers’ knowledge and practice of exclusive breastfeeding (EBF) in Dibis district, Kirkuk, and examine its association with selected demographic factors.
Materials and Methods: A household-based descriptive cross-sectional study was conducted in Dibis, Kirkuk Governorate, from June 2020 to January 2023, involving 1823 mothers of children aged ≤ two years. Data were collected using a structured questionnaire covering sociodemographic characteristics, knowledge of EBF, and actual breastfeeding practices. Descriptive and inferential statistics were used to analyze associations between sociodemographic factors and mothers' knowledge and performance.
Results: Mothers’ knowledge and performance regarding EBF were at a moderate level. Significant associations were observed between EBF and the mother's level of education (P-value = 0.046). The mother’s age at marriage (P-value = 0.090) and the number of family members (P-value = 0.074) were not statistically significant. Binary logistic regression analysis indicated that mothers who regularly visited primary health care centers were twice as likely to practice EBF (OR = 2.011; 95% CI: 1.263–3.203). Among all predictors, normal vaginal delivery emerged as the strongest factor, with mothers who delivered vaginally being over four times more likely to exclusively breastfeed (OR = 4.547; 95% CI: 3.181–6.496).
Conclusion: Mothers showed moderate knowledge and performance, with education, delivery type, and healthcare access identified as key factors. Further research should explore cultural and systemic barriers to breastfeeding in Iraq.

Plexiform neurofibroma (PN) is a pathognomonic feature of neurofibromatosis type 1 (NF1). When the clinical manifestations of NF1 are unrecognized and PN develops in deep anatomical locations, diagnosis may be delayed until the tumor is large enough to compress adjacent structures. We report a case of PN in which delayed recognition of NF1 led to years of misdiagnosis. A 27-year-old female with a history of poorly controlled asthma and a bizarre, lobulated opacity on chest X-ray had experienced respiratory symptoms since her early twenties, initially diagnosed with asthma at age 22. Despite multiple courses of antibiotics, bronchodilators, and steroids, her symptoms persisted. Computed tomography (CT) revealed a lobulated mass encasing the bronchial tree and pulmonary vessels, consistent with PN. The combination of a positive family history and a thorough physical examination is a cornerstone in the diagnostic process, ultimately establishing the diagnosis of NF1. This case underscores the crucial importance of a comprehensive clinical examination in the early recognition of PN and NF1.