Al-Rafidain Journal of Medical Sciences

The ability of disseminated cancer cells from primary tumors to persist in a quiescent state for extended periods of years or even decades is a phenomenon known as cancer dormancy. This non-proliferative state represents a critical clinical challenge and constitutes a major barrier to therapy. Dormancy is often followed by stochastic relapses, or "reawakening," leading to metastasis of the primary cancer after its successful treatment. This narrative review synthesizes our current understanding of the complex and dynamic molecular mechanisms that govern dormancy and the eventual outgrowth of dormant cancer cells. We explore both cell-intrinsic factors and the microenvironmental determinants of establishing and maintaining dormant cancer cells. Crucially, this review translates these mechanistic insights into therapeutic strategies, highlighting the latest advances in targeting dormant cancer cells, preventing their reawakening, and the challenges of developing useful predictive biomarkers. By integrating our knowledge of the molecular underpinnings of dormancy, we aim to provide a roadmap for therapeutic interventions that can lead to a permanent state of cancer suppression.

A broad ligament (broad band) hernia is a rare internal hernia caused by small bowel herniation through a defect of the broad ligament, often presenting as intestinal obstruction. Delayed diagnosis may progress to strangulation and generalized peritonitis. We report a case of strangulating closed-loop ileal obstruction caused by broad ligament hernia complicated by ileal perforation. A 51-year-old woman was initially treated conservatively for 10 days at Jepara District Hospital for colicky abdominal pain suspected to be adhesive small bowel obstruction, despite no prior abdominal surgery. Nasogastric decompression, intravenous fluids, and nutritional support resulted in temporary improvement, and she was discharged. Symptoms recurred one day later, and plain abdominal radiography suggested small bowel obstruction; conservative treatment was continued. The next day she developed diffuse abdominal pain worsening with movement. Repeat radiography revealed free air under the diaphragm, and she was referred to St. Elizabeth Hospital, Semarang, with generalized peritonitis due to intestinal perforation. Emergency laparotomy found gas, fibrin, pus, and fecal contamination, with a distended ileal segment trapped in the pelvic cavity on the left side of the uterus. Two constriction rings were identified, with a bowel perforation at one site. A ~2 cm defect in the left broad ligament was confirmed. The constriction ring was opened up, the bowel was freed, the defect was sewn up, and a loop ileostomy was done. The patient recovered well and was discharged on postoperative day seven. Internal hernia should be considered in small bowel obstruction without previous surgery, and early abdominal CT is recommended to improve diagnostic accuracy and prevent life-threatening complications.

Background: Cardiovascular endurance among young adults is declining due to low engagement in conventional training. Culture-based physical training offers a promising alternative. However, empirical evidence remains limited. Objective: This study aims to evaluate the effectiveness of a structured Nias culture-based physical training program incorporating Fate’u and Fasukhu activities in improving cardiovascular endurance among young adults. Methods: A 12-week pre–post quasi-experimental study was conducted with 120 students (18–22 years) selected through purposive sampling and allocated into two groups: the Nias Culture-Based Physical Training (NCBPT) group and a conventional group (CG) that maintained their usual daily physical activities. Participants performed (NCBPT) three times per week (30–60 minutes/session). Cardiovascular endurance was assessed using the 20-m shuttle run test. Between-group differences in pre-post changes were analyzed using an independent samples t-test. Results: Each group improved cardiovascular endurance, with the NCBPT group showing greater gains (Δ = 6.16, 21.6%, Cohen's d = 1.02) than the conventional group (Δ = 1.20, 4.2%, Cohen's d = 0.94). These results indicate that the NCBPT program was significantly more effective in enhancing aerobic capacity than conventional physical activities. Conclusions: The NCBPT program demonstrated superior effectiveness in enhancing cardiovascular endurance compared to the control condition. This approach offers a practical and culturally relevant training strategy for improving aerobic fitness in sports and educational contexts.

Background: Adherence to guideline-directed medical therapy (GDMT) remains suboptimal among heart failure (HF) patients despite proven benefits in reducing mortality and hospitalizations. Data on adherence patterns and their clinical impact in Middle Eastern settings remain limited. Objective: To evaluate adherence to GDMT among HF patients at Shar Teaching Hospital, Sulaimani; identify sociodemographic correlates; and assess associations with short-term clinical outcomes, including NYHA class, hospitalizations, and quality of life. Methods: This prospective observational study enrolled 140 adult patients with HFrEF (diagnosed >3 months) at Shar Teaching Hospital cardiology wards/outpatient clinics (April–December 2025). Adherence was assessed using the validated 8-item Morisky Medication Adherence Scale (MMAS-8), categorizing patients as low (<6), medium (6–<8), or high adherence. Sociodemographic/clinical data were collected via structured interviews and medical record review. Results: Low adherence predominated (81.43%, n=114), with medium (12.86%, n=18) and high adherence (5.71%, n=8) less common (p<0.001). Higher adherence correlated with older age (p=0.009) and being male (p=0.037). Key non-adherence barriers included lack of understanding (24.24%), cost (23.48%), and regimen complexity (21.21%). After GDMT optimization/adherence counseling, significant NYHA class improvement occurred (p<0.001), HF-related 3-month hospitalization was low (10.71%), and quality of life improved in 70.71%. Conclusions: Alarmingly high low-adherence rates exist among HF patients in this setting, though older age and being male predict better adherence. Higher adherence, supported by GDMT optimization and counseling, was associated with better NYHA class, fewer hospitalizations, and improved quality of life.

Background: Obesity is a major risk factor for postoperative complications and prolonged hospital stays, yet preoperative nutritional management remains insufficiently integrated, particularly in resource-limited settings. Objectives: To evaluate the impact of obesity on postoperative complications and to analyze nutritional management practices in hospitals. Methods: An ambispective analytical observational study was conducted in two public hospitals in Setif, Algeria. It included 2205 surgical patients in 2024 (retrospective phase) and 234 patients between August and November 2025 (prospective phase) to complement missing data on nutritional management; 62 healthcare professionals were also surveyed. Data were collected from medical records and structured questionnaires, including sociodemographic characteristics, body mass index (BMI), postoperative complications, length of hospital stay, and nutritional practices. Results: Obesity prevalence was 54.1%. Postoperative complications occurred in 33.97% of obese patients versus 23.79% of non-obese patients (RR=1.43; 95% CI: 1.25–1.64; OR=1.65; 95% CI: 1.37–1.99). Obese patients had a longer mean hospital stay (7.99±3.75 days) compared to non-obese patients (7.14±3.36 days). Only 1% of patients received preoperative nutritional support, 98% of surgical departments lacked dietitians, and 98% of healthcare professionals had no training in clinical nutrition, while all expressed a need for further training. Conclusions: Obesity is significantly associated with increased postoperative complications and prolonged hospitalization. These findings emphasize the need to integrate nutritional assessment into routine care, strengthen professional training, and recruit dietitians to improve surgical outcomes and quality of care.

Background: Long-term immunosuppression following renal transplantation has been linked to thyroid dysfunction and malignancy. However, data on thyroid nodule prevalence and characteristics in transplant recipients remain limited. Objective: To screen in RT recipients, stratifying nodule malignancy risk using the TI-RADS reporting system. Methods: A cross-sectional study evaluated thyroid nodules in 166 clinically euthyroid renal transplant recipients attending routine follow-up at the Transplant Center, Medical City, compared with 221 age- and sex-matched healthy controls. All participants underwent standardized ultrasound using the American College of Radiology Thyroid Imaging Reporting and Data System classification. Of 39 nodules biopsied, 14 were malignant and 25 benign. Results: The mean age of RT recipients was 42±12 years, with males comprising 77.7%. Incidental thyroid nodules were identified in 42.2% compared to 31.2% in the controls. Among transplant recipients, 51.4% of nodules were solitary and 48.6% were multiple. Following TIRADS classification, TIRADS-3 was reported in 9.6% of mildly suspicious nodules, while 11.4% of the nodules were moderately suspicious TIRADS-4, and 1.8% were highly suspicious TIRADS-5. Malignancy was confirmed in 10% of biopsied nodules. TIRADS stratification demonstrated a statistically significant association with malignancy, while other demographic and clinical variables, including immunosuppressive regimen, were not predictive. The ultrasound features of nodules in the transplant group were comparable to those observed in healthy controls. Conclusions: Thyroid nodule prevalence and malignancy risk in renal transplant recipients resemble the general population; immunosuppression may not be a key factor, but ACR-TIRADS surveillance supports early selective detection.

Background: The most frequent bone fracture, rib fractures, affects 10–20% of individuals with violent trauma and, in extreme circumstances, can also injure the internal organs. Objective: To share our experience in treating individuals who have isolated rib fractures due to trauma without concurrent trauma and evaluate the importance of patients’ follow-up. Methods: This was a retrospective study of 250 patients (aged approximately 10 or more). All patients were initially treated without surgery. After management, the following information was collected: sex, fracture characteristics, mechanism of injury, age, selective CT scan examinations, and median follow-up time. Results: 250 consecutive patients aged 10 or older were enrolled; 184 (73.6%) of these patients were men, and their ages ranged from 10 to 67 (mean: 61.4; median: 65). False ribs (VIII-XII) were more affected, and the most frequent mechanism of rib fracture was a household accident. Associated injuries occurred in only 13 (5.2%) patients, and pneumothorax was the most frequent complication, which was recorded in 10 (4%) patients. Conclusions: While dealing with patients who have sustained thoracic trauma, a trauma team needs to be more informed to offer them effective treatment options. Accurate diagnosis, sufficient analgesia, and efficient physical treatment are necessary to prevent complications. Estimating the number of broken ribs can help management decisions and is crucial for categorizing patients who are at a high risk of complications.

Background: Attention-deficit/hyperactivity disorder (ADHD) is a prevalent neurodevelopmental disorder of unknown etiology. In addition to genetic susceptibility, various exogenic risk factors have been linked to ADHD. Objective: The current study was conducted to identify and assess factors associated with an increased risk of ADHD in children. Methods: A case-control study included 185 ADHD children aged 6-15 years with age- and sex-matched controls recruited from the outpatient clinics of the same tertiary hospital, Baghdad, Iraq. Data were collected using a caregiver-administered structured questionnaire covering sociodemographic and clinical characteristics, perinatal factors, environmental exposure, and lifestyle factors. Variables showing significant univariate associations with ADHD were included in multivariate binary logistic regression to determine independent adjusted odds ratios. Results: The children included in the study had a mean age of 9 years, and males predominated. Four sociodemographic factors significantly relate to ADHD: first-born children, small household size, employed mothers, and young paternal age. Among perinatal factors, cesarean delivery, lower paternal age, maternal vaginal infections, and antibiotic use during pregnancy were significant in univariate analysis. However, multivariate analysis revealed four independent risk factors for ADHD, including antibiotic use during pregnancy, maternal employment, younger paternal age at time of delivery, and early exposure to screens. Conclusions: ADHD is influenced by a combination of sociodemographic and early life factors. Maternal employment, antibiotics use during pregnancy, younger paternal age, and early screen exposure were identified as independent risk factors for ADHD in children.

Background: Glioblastoma multiforme is a Grade IV, very aggressive malignancy and the most frequent primary cancer of the central nervous system. Despite its favorable alkylating agent property and use in the treatment of GBM, the low aqueous solubility and high dose-related systemic toxicity restrict the clinical use of lomustine. Objectives: The aim of the study was to design and optimize a high-performance liquid chromatography assay to measure lomustine and to assess the pharmacokinetic properties of a novel nano-vesicular delivery system, lomustine-loaded solusomes, to estimate nose-to-brain targeting. Methods: Solosomes of lomustine were developed by the thin-film hydration method. Their ability to target the brain was tested in vivo with 84 Wistar rats. The pharmacokinetic parameters were determined after intranasal administration of solusomal formulation and compared with intravenous administration of a lomustine solution for 72 hours. Results: When delivered intranasally, lomustine-loaded solusomes achieved greatly improved brain targeting with a 2.3-fold greater maximum brain concentration (Cmax) than with intravenous delivery and a shorter time to peak concentration (Tmax). The formulation showed high targeting efficiency, with drug targeting efficiency (DTE% 486.22) and direct transport percentage (DTP% 64.8). Histopathological analysis was used to establish the preservation of the integrity of nasal mucosa, and the formulation was found to be safe and non-irritating. Conclusions: Solusomes administered through the nasal route are effective in bypassing the blood-brain barrier through olfactory and trigeminal routes. The method has proven to be an effective way of increasing concentrations of therapeutic agents in the brain without worsening the safety profile.

Background: Type 2 diabetes mellitus (T2DM) is a major global cause of lower-extremity complications, including diabetic peripheral neuropathy (DPN), impaired foot perfusion, and diabetic foot ulcers (DFUs). Wearable vibration-based devices have emerged as non-pharmacological adjuncts to improve microcirculation, sensation, balance, and wound healing; however, evidence remains fragmented. Objective: To synthesize the effects, safety, and feasibility of wearable vibration-based therapies across perfusion, neuropathy, functional, and wound-healing outcomes in adults with T2DM. Methods: A systematic review was conducted following PRISMA 2020 and SWiM guidelines. Four databases (Scopus, PubMed, ScienceDirect, and SAGE Journals) were searched (2016–2026). Eligible studies included adults with T2DM receiving vibration-based interventions. Two reviewers independently screened and extracted data. Risk of bias was assessed using RoB 2, ROBINS-I, and CASP. Results: Thirteen studies (n ≈ 370) were included. Eleven reported favorable outcomes. Interventions improved vibration perception threshold, ankle–brachial index, skin blood flow, plantar sensation, balance, gait, and neuropathic pain. Adjunct vibration therapy accelerated DFU healing by approximately 8 days and increased nitric oxide levels. No serious adverse events were reported. Conclusions: Wearable vibration-based therapies appear to be safe and may provide short-term improvements in perfusion, sensory function, balance, and wound healing in adults with T2DM. However, larger well-designed studies are required to confirm long-term effectiveness.

Background: Migraine is a common neurovascular condition that is increasingly recognized to affect the auditory system, even in the presence of normal hearing thresholds. Subclinical cochlear dysfunction, particularly affecting outer hair cells, has been hypothesized but not well understood. Objective: To investigate cochlear function in migraine patients utilizing transient-evoked and distortion product otoacoustic emissions and to evaluate their relationship with migraine clinical characteristics and sex. Methods: This case-control study involved 120 participants (60 migraine patients and 60 age/sex-matched healthy controls) aged 18–45 years. All individuals had normal otoscopy, a type A tympanogram, and normal hearing thresholds on pure tone audiometry. Cochlear function is evaluated by transient-evoked and distortion product otoacoustic emissions (TEOAE, DPOAE). Migraine severity and disability were assessed using the Visual Analog Scale (VAS) and Migraine Disability Assessment (MIDAS). Results: Migraine patients had a significantly higher proportion of abnormal TEOAE responses (50.8%) than controls (0%) (p<0.05). DPOAE amplitudes were decreased significantly in migraine patients at all frequencies (2000-8000 Hz) while lower frequencies (1000-1500 Hz) remained unaffected. Signal-to-noise ratio values were significantly lower in migraine patients at most frequencies. Migraine patients with aura, longer illness duration, higher severity, and disability score had more cochlear damage. Conclusions: Migraine is associated with frequency-dependent subclinical cochlear impairment, primarily affecting higher frequencies. This dysfunction correlates with disease severity and clinical burden, suggesting that otoacoustic emissions are a sensitive technique for evaluating and monitoring migraine-induced auditory impairment.