Al-Rafidain Journal of Medical Sciences

Background: Abuse-deterrent formulations (ADFs) are dosage forms designed to prevent or discourage the misuse of prescription drugs, particularly opioids. They achieve this aim by either minimizing the benefit of tampering with the dosage form or making it challenging to change this dosage form. Therefore, one of the priorities for public health is to develop dosage forms that have abuse-deterrent formulations. The escalation in the prescription of opioids has led to a surge in their abuse or misuse, resulting in a high mortality rate. Objectives: This review article explores drug abuse methods among addicted individuals and lists the most frequently abused drug classes. Furthermore, this review concentrates on understanding the most prevalent technologies used to deter abuse of prescribed opioid drugs. Methods: The search included online published databases from PubMed, Google Scholar, Research Gate, Science Direct, Elsevier, and others. The objective was to collect as much information as possible from articles using the keywords “abuse deterrent formulations and abuse deterrent technology." Conclusions: Physical-chemical barriers and agonist-antagonist formulations are available as marketed drugs as well as aversive agents’ formulations. Each of these types can inhibit or reduce specific cases of opioid misuse. Although the success of these products mostly relies on robust formulation strategies, it also requires a thorough understanding of their benefits and broad adoption in the market.

Objectives: This study aimed to evaluate the possible synergistic effect of bezafibrate and ginkgo biloba (GKB) extract on cardiotoxicity induced by doxorubicin. Methods: Thirty rats were allocated into 5 groups: The negative control group was treated daily with 1 ml of distilled water orally by gavage tube; the positive control received doxorubicin 3.7 mg/kg on day 11 for 3 days intraperitoneally; the bezafibrate group received 100mg/kg orally by gavage tube; the GKB group received 60mg/kg orally by gavage tube; and the combination of bezafibrate and GKB group. All the groups received the doxorubicin protocol, with an exception for the negative control. The treatment continued for 14 days. On day 14, blood samples were taken for the measurement of serum levels of troponin, natriuretic peptide, creatine phosphokinase (CPK), IL-6, and total lipid profile. The atherogenic index, cardiac risk, and LDL/HDL ratios were calculated. Cardiac tissues were sent for histopathological analysis. Results: Both bezafibrate and GKB exhibited attenuation of troponin, natriuretic peptides, CPK, IL-6, TG, cardiac risk ratio, and atherogenic index, as well as an increase in HDL levels. However, the combination group showed the greatest effect compared to the positive control group. The histopathological findings supported the biochemical outcomes. Conclusions: Combining GKB extract and bezafibrate protects against cardiac injury by restoring injury markers and IL-6, as well as improving the lipid profile, cardiac risk ratio, and atherogenic index.

Background: Descemet's membrane detachment (DMD) is a common complication following phacoemulsification surgery that can have a significant impact on the visual prognosis of patients undergoing surgery. Objective: Determine the incidence of DMD following phacoemulsification cataract surgery and identify potential risk factors for detaching. Methods: A prospective study was undertaken at Ibn Al-Haitham Eye Teaching Hospital between October 1st, 2022, and September 1st, 2023. Patients who underwent cataract surgery were clinically evaluated for DMD. Cataract density is ranked from 1 to 4 based on density and hardness. The conventional phacoemulsification surgery was performed without the use of systemic acetazolamide prior to the procedure. Results: The study included 253 participants, ranging in age from 10 to 89 years. One case indicated central detachment, while seven showed peripheral detachment. The stability of the Descemet membrane was found to be significantly associated with patients under the age of 65. Non-diabetics demonstrated a significant association with the lack of DMD. We discovered a statistically significant link between surgical operations lasting less than 30 minutes and a lack of separation. The single usage of a keratome was strongly related to the lack of detachment. Conclusions: DMD incidence is significantly associated with elderly people (≥65 years). We discovered a strong relationship between the lack of DMD and non-diabetic people who had a single keratome treatment lasting less than 30 minutes.

Background: Anti-glaucoma eye drops are mainly used to lower intraocular pressure (IOP) and manage glaucoma. Many studies found that achievement of the IOP target is poor. Objective: This study aimed to assess the achievement of the IOP target and factors affecting it among a sample of Iraqi patients with glaucoma. Methods: A single-center, cross-sectional study was conducted on patients with glaucoma from December 2023 to April 2024 at Ibn Al-Haytham Hospital, Baghdad, Iraq. All patients who received medical therapy for at least one month were eligible to participate in this study. Intraocular pressure values at the time of initial diagnosis and at the time of enrolment in the study were documented for all included patients. Medication adherence was measured by the Arabic version of the Morisky medication adherence scale-4. Eye drop administration technique was assessed through direct observation by the researcher using a newly developed and validated checklist. Results: Most participants in the current study were males with primary education. The average disease duration was 14 months. The target IOP was achieved among 36% of participants. The adherence to eye drops was good in 55% of participants. Only 9% of participants administered eye drops with a good technique. Achievement of the IOP target was significantly influenced by good adherence and technique for administration of eye drops (p<0.05). Conclusions: IOP-target achievement is poor among Iraqi patients. Adherence to and administration technique of eye drops are significant factors that could affect IOP-target achievement.

Cancer progression heavily relies on the tumor microenvironment (TME), and therapeutic targeting of its components could aid in cancer management. This narrative review highlights the different parts of TME and charts potential targets for cancer therapy. Overall, the influence of the various components of the microenvironment is that of tumor support through immunosuppression, particularly as cancer progresses beyond initiation. Targeting the supporting elements of the TME for therapeutic benefit is possible after a detailed evaluation of the cancer type and stage. Several therapeutic modalities are already well established, and more preclinical and clinical studies are underway.

Background: Periodontal disease is initially associated with a bacterial infection, such as dental plaque. With aging, the prevalence of periodontal diseases increases, and periodontal destruction in older individuals is due to cumulative damage rather than cumulative rates of devastation. Objective: To assess the effect of gender and age on periodontal health in selected Iraqi populations. Methods: The cross-sectional retrospective study analyzed the periodontal records of patients from October 2021 to June 2023. The study was conducted at the Dentistry Department, Al-Rafidain University College, Baghdad, Iraq. The sample was taken from patients who visited the periodontal department. A total of 508 subjects, with an age range of 10-69 years (35.23±10.25), participated in this study, including 287 males and 221 females. The sample was classified based on age and sex into 5 groups. The clinical evaluation includes plaque index (PLI), gingival index (GI), probing pocket depth (PPD), and clinical attachment loss (CAL). Results: The overall percentage of chronic gingivitis was 53.94%, while the percentage of chronic periodontitis was 46.06%. The 60–69-year-old group reported the highest rate of patients with chronic periodontitis. Additionally, the 10–19-year group showed the highest percentage of patients with chronic gingivitis. Conclusions: The prevalence of chronic periodontitis increases with age, and it is higher among females than males. Clinical periodontal parameters such as plaque index, probing pocket depth, and clinical attachment level are higher in older age groups than in younger age groups.

Background: HCMV is a prevalent virus that affects a significant section of the human population, causes severe disease, and affects the fetus in pregnant women. hcmv-miRNAs are important regulatory molecules in miscarriages in women CMV-infected. Objective: To evaluate the association of hcmv-miR-UL36-5P gene expression with miscarriages in women with HCMV. Methods: A case-control study was designed to include 140 women who had miscarriages at random, and 50 of them who had miscarriages with a high CMV viral load were categorized as miscarriage groups. Additionally, 50 healthy pregnant women who had not previously experienced miscarriages were included as a control group. After diagnosis of HCMV IgM and IgG via the VIDAS assay and CMV viral load detected by qPCR, RNA was extracted from blood samples to measure the hcmv-miR-UL36-5P gene expression by qPCR technique. Results: The results revealed that out of 140 women with miscarriages, 50(35.7%) were seropositive for CMV, while 90(64.3%) were seronegative for CMV, and show that only 3(6.0%) samples were seropositive to CMV IgM, 8(16.0%) seropositive for both CMV IgM and IgG, and 39(78.0%) were seropositive for CMV IgG. The expression of hcmv-miR-UL36-5P in miscarriage women was 3.11-fold higher than the control group. Conclusions: Up-regulated expression of the hcmv-miR-UL36-5P gene in women with miscarriage confirms its role in miscarriage. These miRNAs may contribute to the pathogenesis of HCMV infection and its involvement in pregnancy complications.

Background: War-induced. Compound fractures cause considerable damage to the limbs, affecting mobility and quality of life; surgeons consider managing compound fractures to be a difficulty. Although multi-stage conversion from external to internal fixation is still common, multiple studies worldwide are promoting single-stage conversion. Objective: To assess the efficacy and safety of a single-stage conversion from external to internal fixation using the functional results of many Iraqi war-wounded patients who were initially treated with external fixation. Methods: A retrospective cohort study analyzed the data of 40 war-wounded patients (39 males and 1 female) ranging in age from 18 to 50 years. All patients came with war-related complex fractures, which were stabilized and referred for external fixation. Following a single-stage conversion to internal fixation, the patients were followed up to assess the functional outcomes of this approach using Ketenjian's functional criteria. Results: A study of 40 patients (45 limbs), mostly male (97.8%), demonstrated a statistically significant link between non-union and time to convert from external to internal fixation. However, fracture type, Gustilo categorization, fixation method, and complication rates had no significant impact on Ketenjian's score results. Conclusions: The single-staged external to internal fixation conversion is regarded as a safe and reliable procedure with good overall functional outcomes; it could be performed by experienced surgeons instead of two-staged conversions, taking into account the patient's general health and the state of the local soft tissue.

Background: Keratoconus (KC) is a chronic, bilateral, non-inflammatory degenerative condition with severe consequences. Objective: To assess the prevalence of KC and Keratoconus Suspect (KCS) in a pediatric population with astigmatic error ≥1 diopter (D) and non-axial myopia. Methods: Between March and October 2022, a cross-sectional study was done with a group of 6–18-year-old kids with an astigmatic error of ≥1 D or non-axial myopia who went to the pediatric ophthalmology clinic at Ibn Al-Haitham Teaching Eye Hospital in Baghdad, Iraq, for regular checkups. All patients got a thorough eye examination and corneal imaging using the Corneal Tomography System (CSO) Sirius equipment and Scheimpflug technology. Results: The majority of patients were females aged 110–14 years (55%). The frequencies of KC and SKC were 13.5 and 119.6%, respectively. The proportion of KC was substantially higher for those above the age of 14. Patients with KC exhibited considerably larger cylinder and axis measurements. Participants with inferior cones and an asymmetric Bow Tie exhibited greater rates of KC (51.2% and 29.4%, respectively). Except for Pachy-Thin and corneal volume mean values, all other metrics were considerably greater in KC and KCS patients than in control patients. Conclusions: The high prevalence of KC and KCS emphasizes the importance of this issue and the necessity for a systematic strategy for screening in pediatric age groups with refractive error.

Background: One important clinical indicator that shows how the muscle affects the patellofemoral joint is the quadriceps angle. This angle is formed between the quadriceps femoris and the patellar ligament. It is also thought to be a key factor in maintaining good posture and patellar movement. The angle is often used as a clinical sign to check on people who have problems with their knee joints. Objective: The study is planned to measure the mean Q angle in Iraqi adult individuals with the goal of referring data to help improve the clinical diagnosis and evaluation of patients with knee joint malalignments. Methods: The right and left Q angles of 200 participants were measured using a universal goniometer. The relationship between Q angles and different anthropometric parameters was tested using appropriate statistical tests. Results: The mean right Q angles for males’ measure 15.63° and for the females 17.58°. The mean left Q angles for males measured 14.18° and for the females were 16.14°. Both Q angles (right and left) were greater in females. The study revealed a strong negative correlation between height and QA, a moderate negative correlation between weight and QA, and a slight negative correlation between BMI and QA. Conclusions: The study improves understanding of the usual range of the Q angle in a study group of seemingly healthy adults and attempts to establish a reference value for orthopedic surgeons, biomedical engineers, forensic specialists, and anthropologists.

Background: Urinary tract infections (UTIs) are primarily caused by Escherichia coli. Various genes in UPEC isolates are considered virulence factors that cause illness in humans. Objective: To identify the adhesive genes sfa and afa in UPEC strains isolated from UTI patients that form biofilm and to investigate the impact of probiotics (Lactobacillus acidophilus) on their expression. Methods: Between October and December 2023, 140 samples were obtained from Urinary Tract Infection (UTI) patients and urinary catheter specimens at Al-Yarmouk Hospital and Ghazi Al-Hariri Hospital for Surgical Specialties locations in Baghdad, Iraq. All bacterial isolates were identified using the VITEK-2 system and standard biochemical testing. The isolates were subsequently subjected to PCR to detect adhesive genes sfa and afa using primers that were specifically designed. The MRS broth was centrifuged, and Lactobacillus acidophilus extract was obtained as a result. Then, isolates that contained two genes were subjected to a Lactobacillus acidophilus extract test. Results: The formation of biofilm of UPEC isolates was (33.33%) a strong biofilm-former, (61.90%) a moderate biofilm, and (4.76%) a weak biofilm. The sfa and afa genes were present at a frequency of 80.95% and 14.28%, respectively. At least one adhesive gene was present in most isolates. Conclusions: Most of the isolates showed a decrease in the expression of sfa and afa genes because of the effect of L. acidophilus on gene expression.

Background: The extensive use of cross-sectional abdominal imaging (CT and MRI) has led to an increase in the occurrence of pancreatic cysts (PCs). Objectives: Identifying different forms of PC lesions, discriminating between malignant and benign cysts, and determining the prevalence of neoplastic and non-neoplastic PC. Methods: A retrospective cross-sectional analysis of 120 individuals with pancreatic cystic lesions was conducted between February 2023 and February 2024. There are 45 men and 75 women. The lesions were detected by EUS, MRI, CT, and TAUS. All patients underwent an EUS-guided FNA. Cytology and tumor markers (CA19-9 and CA-125) were used to evaluate the aspirated specimens. Results: PCs were substantially more common in females (62.5%). Benign SCN was the most common kind (40%). Malignant cysts were detected in 35 patients (29.2%) (IPMN 62.9%), with men accounting for a statistically significant majority (71.4%). Malignant cysts significantly correlated with vomiting and weight loss (34.3% and 91.4%, respectively). CA-19-9 and CA-125 showed considerably larger elevations in malignant cysts than benign cysts (68.6% and 56.5%, respectively). EUS was the most effective imaging tool for cyst detection, with a sensitivity of 94.3% and a specificity of 91.8%, followed by MRI, CT scan, and TAUS. Conclusions: Females were more likely to have PCs, whereas males had more malignant cysts. The most common and benign kind of PC was SCN. The most common form of malignant PC was IPMN, and EUS was the most effective way to diagnose PCs.

Background: The overuse and inappropriate use of antibiotics cause antimicrobial resistance (AMR). The antibiotic stewardship program (ASP) plays a crucial role in improving prescribing antibiotics. Although the Iraqi Ministry of Health has issued ASP legislation, its full implementation in clinical practice remains incomplete. Objectives: To explore physicians' perspectives regarding the current and potential implementation of ASP in Al-Nasiriya hospitals. Methods: A qualitative study was conducted in Al-Nasiriyah public hospitals from December 17, 2023, to January 21, 2024, using face-to-face interviews. Physicians who prescribe antibiotics, work in Al-Nasiriyah public hospitals, and consent to participate in the study were recruited using purposive and snowball sampling, and the size of the sample was specified by saturation. The interviews' audio was transcribed verbatim and analyzed thematically. Results: Nine public hospitals in Al-Nasiriyah were included in the study. One hospital was excluded because the ASP was activated after data collection began. Sixteen physicians in different specialties were recruited, 15 males and one female. Thematic analysis revealed two major themes: challenges in antibiotic prescribing practices (3 subthemes: antibiotic selection, review, and practice, antibiotic mismanagement, and antibiotic resistance) and antibiotic stewardship implementation (4 subthemes: ASP knowledge and components, perceived benefits and importance, implementation challenges and barriers, and ASP enablers). Conclusions: There were many challenges in antibiotic prescribing practice, including antibiotic mismanagement and AMR. The participants acknowledged the importance of the ASP, but they mentioned many barriers to its application.

Background: Back pain is one of the reasons for the patient's refusal of spinal anesthesia. Objective: To evaluate the efficacy of bupivacaine infiltration at the site of a spinal needle injection in reducing post-spinal back pain and using analgesics for post-spinal back pain. Methods: From July to August 2021, a prospective study was conducted on 60 patients getting spinal anesthesia for elective cesarean sections at Erbil Maternity Teaching Hospital. Group A (got bupivacaine) at the spinal needle track; group B (did not receive bupivacaine). We use a visual analog scale to assess pain severity. Results: In the first and third postoperative days, group A experienced significantly less post-spinal back discomfort (1.87 and 0.33) than group B (3.90 and 1.77). Furthermore, group A used much fewer analgesics on the first postoperative day (0.20); on the third postoperative day, they used none, in contrast to group B's 1.07 and 0.30. Conclusions: Bupivacaine infiltration along the spinal needle track is an excellent approach for reducing post-spinal back pain and the usage of analgesics.

Background: Endometrial carcinoma (EC) is a common genital tumor that frequently causes abnormal uterine bleeding (AUB). All gynecologists aimed to differentiate between malignant and benign causes of AUB using a noninvasive approach. Tumor markers like human epididymis protein-4 (HE4) and carbohydrate antigen-125 (CA125) were employed and assessed in this investigation. Objectives: To quantify HE4 and CA125 levels in AUB patients and assess their significance in distinguishing between benign and malignant endometrial tumors. Methods: This prospective observational case series analysis included 88 patients with AUB who were admitted for surgical surgery in Mosul hospitals between January 1st and September 30th, 2022. Preoperative blood samples were collected to assess HE4 and CA125 levels. After collecting histopathological results, the patients were separated into two groups: malignant (24) and benign (64) that were further divided into pre- and postmenopausal subgroups. The biomarker level was determined and statistically evaluated. Results: All 24 malignant cases, reported among postmenopausal patients, showed statistically significant differences. The mean HE4 level was higher in the postmenopausal than premenopausal benign group. The mean CA125 level was substantially greater in the malignant than in the postmenopausal benign groups. CA125 showed greater validity markers than HE4. There was no significant relationship between HE4 and CA125 concentrations. Conclusions: Measuring CA125 levels in postmenopausal patients with AUB may help differentiate EC in those with endometrial thickness greater than the threshold value.

Background: Ardisia crenata (A. crenata) and Peliosanthes teta Andrew (P. teta) are popular medicinal plants in Malaysia that are claimed to have several biological effects. Objective: To assess the anticancer and radical-scavenging properties of A. crenata and P. teta methanolic extracts. Methods: TPC was quantified using the Folin-Ciocalteu test; free radical scavenging was evaluated using the 2,2'-azino-bis3-ethylbenzothiazoline-6-sulfonic acid (ABTS) and 2,2-diphenyl-1-picrylhydrazyl (DPPH) assays; and cytotoxic activity was assessed using the MTT assay. Results: In both ABTS and DPPH systems, A. crenata exhibits much higher radical scavenging activity than ascorbic acid. P. teta showed less significant antioxidant activity. Furthermore, A. crenata methanolic extracts demonstrated free radical scavenging properties in a concentration-dependent manner, quenching ABTS and DPPH radicals with no lag phase observed in the experiments. Furthermore, A. crenata had a strong cytotoxic effect on the breast cancer 4T1 cell line but had no suppression of cell viability in the 3T3 normal fibroblast cell line. Interestingly, the TPC of A. crenata was significantly higher than that of P. teta methanolic extracts. Conclusions: A. crenata showed antioxidant and anticancer action against breast cancer 4T1 cells, indicating that it could be a valuable source for future pharmacological and medical research.

Background: Due to the limited ocular bioavailability, local ocular injections and systemic delivery were used instead of topical application. These alternative approaches were accompanied by numerous disadvantages. Objectives: Create and test mixed polymeric nanomicelles coated with hyaluronic acid as a topical drug carrier for targeted delivery to the vitreous fluid and retina, overcoming the limitations of eye drops. Methods: The thin-film hydration process was utilized to create nanomicelles, and their physical properties were studied. Colored, pigmented, healthy albino rabbits were employed in vivo experiment. Following anesthesia, 35µl of brimonidine nanomicelles and Alphagan® were administered topically. Samples from the vitreous and retina were collected for RP-HPLC analysis. Results: The nanomicelles' physical qualities made them appropriate as a carrier system for the vitreous fluid. They were spherical with a clear appearance and a pharmacological concentration of 97.11%. The particle size range was 134.2nm, with a PDI of 0.2824. The drug entrapment effectiveness was 62.69%, whereas the surface tension was 39.18 mN/m. Their vitreous pharmacokinetics Cmax, Tmax, and AUC0-t were 28.1ng/µl, 2.0min, and 1268.6ng/µl*min, respectively, compared to 5.0ng/µl, 8.0min, and 129.32ng/µl*min for Alphagan eye drops. The retinal pharmacokinetics were 64.9ng/µl, 17.0min, and 18688.04ng/µl*min, respectively, compared to 31.6ng/µl, 30min, and 6377.67ng/µl*min with Alphagan eye drops. Conclusions: Brimonidine nanomicelles coated with hyaluronic acid could be an effective topical drug-carrier method for delivering medications to the vitreous and retina, with higher bioavailability than eye drops.

Background: Most individuals with inflammatory arthritis are diagnosed with rheumatoid arthritis (RA), an immunological disorder characterized by autoantibodies, particularly anti-cyclic citrullinated peptide antibodies (ACCP), which initiate inflammatory responses. Recent studies have shown that cytokines contribute to the progression and dissemination of RA, with elevated levels of serum IL-27 and IL-30. Objective: To assess the utility of serum IL-27 and IL-30 levels as predictors of disease activity in RA patients and their correlation with response to treatment. Methods: One hundred patients and fifty healthy controls made up the total number of participants in this case-control research. Baghdad Teaching Hospital conducted the study from November 2023 to February 2024. The American College of Rheumatology 2010 criteria were used for patient recruitment. An ELISA technique was used to evaluate the amounts of the biomarkers. Results: The levels of IL-27 and IL-30 are significantly higher in rheumatoid arthritis patients compared to healthy controls. The mean serum IL-27 and IL-30 concentrations were highest in the severe, followed by moderate and low disease activity. Patients taking methotrexate had higher serum IL-27 and IL-30 concentrations, which were significantly higher than those on both etanercept and etanercept + methotrexate groups. Conclusions: Elevated serum levels of IL-27 and IL-30 may serve as diagnostic markers for RA and as indicators of disease activity and response to treatment.

Background: Cocrystals are stoichiometric, multicomponent crystalline materials composed of an active pharmaceutical ingredient (API) and a coformer arranged in a crystalline structure. Apixaban (APX) is an oral blood thinner that has a low aqueous solubility of 0.028mg/mL at 24 °C and a weak oral bioavailability of about 50% for doses below 10 mg, decreasing as doses above 25 mg are taken. Objectives: To develop and assess APX cocrystal to improve its solubility. Methods: Cocrystals of APX with diverse coformers were synthesized using the solvent evaporation technique in varying molar ratios. The structure of the synthesized cocrystals was validated by DSC, PXRD, and FTIR analyses. Saturation solubility of APX and cocrystals in water was also investigated. Results: APX cocrystals with diverse coformers exhibited distinct physicochemical features. The co-crystal of APX with oxalic acid at a 1:1 ratio exhibited a 2.54-fold enhancement in solubility relative to that of pure APX in water. Each coformer enhanced the solubility of the APX co-crystals. The FTIR spectra of the cocrystals indicated no interaction between the APX and the coformers. The DSC analysis revealed distinct endothermic peaks corresponding to its melting point, indicating the development of cocrystals. The PXRD diffractogram demonstrated fluctuation of 2 theta values of peaks and confirmed cocrystallization of APX. Conclusions: Cocrystallization may serve as a potential method to improve the solubility of APX.

Background: Wilms' tumor gene 1 (WT1), a tumor-associated antigen (TAA), is expressed in many types of cancer. Most acute leukemia patients have a quantitatively detectable and strong expression of it. Objectives: To analyze WT1 expression levels as a predictor of clinical outcomes at the time of diagnosis of de novo leukemia and to monitor tumor progression during treatment. Methods: A total of 71 patients with acute myeloid leukemia (AML) were separated into two groups: twenty-nine de novo AML patients upon presentation and 25 with AML at the time of initial induction. The second induction included 17 AML patients and ten healthy volunteers who served as controls in this study. The WT1 gene was tested using a real-time PCR with the Cyber Green assay. Results: Patients with acute myeloid leukemia had considerably greater levels of WT1 gene expression than controls (27.3 vs. 5.5). In terms of clinical outcomes, WT1 gene overexpression was substantially related to non-responsive AML patients compared to complete response at diagnosis (27.3 vs. 22.15). However, there is no substantial difference between instances following induction. Conclusions: The WT1 tumor antigen may serve as an early diagnostic for acute leukemia prognosis. Improved clinical outcomes have been linked to reduced WT1 levels. A high amount, on the other hand, was linked to a poor prognosis for people with AML, although more research is needed.

Background: Normal pressure hydrocephalus (NPH) is a complex neurological disorder characterized by enlarged ventricles in the brain. While the ventriculoperitoneal shunt is the preferred procedure, lumbar-peritoneal shunts also serve as an alternative. Lumbo-peritoneal shunts are an alternative for diverting cerebrospinal fluid without intracranial surgery. Objectives: To assess the efficacy of programmable LP shunts in managing idiopathic normal-pressure hydrocephalus (iNPH), focusing on postoperative outcomes and complications. Methods: This is a multicenter cohort study, including retrospective and prospective data. It involves 20 iNPH hospitalized patients from January 1st, 2019, to January 1st, 2022. The patients underwent programmable lumboperitoneal shunt surgery and had a six-month follow-up period. Patients with confirmed diagnosis of iNPH were included in this study. Other possible causes of symptoms were ruled out, and there were no reasons why the LP shunt should not be placed. Results: This cohort study involved 20 iNPH patients treated with programmable LP shunts; 19 patients (95%) experienced gait improvement, 16(80%) showed improvement in urinary symptoms, and 16 patients (80%) showed improvement in dementia. The most common post-operative complications included over-shunting (15%), subdural hygroma, CSF collection, and infection (10%). Most patients presented between 2–4 months. When evaluating predictors of operative time, the regression analysis revealed no significant factor that could predict operative time accurately. Conclusions: Lumbar-peritoneal shunts showed significant effectiveness rates with a moderate complication rate. It is minimally invasive without life-threatening complications and can be recommended for iNPH treatment.

Persistent pulmonary hypertension is a life-threatening illness that can be fatal if not diagnosed early. Some medications, notably selective serotonin reuptake inhibitors (SSRIs), can cause severe persistent pulmonary hypertension in newborns if administered antenatally, especially after 20 weeks of gestation. We present a case in which the use of selective serotonin uptake inhibitors during pregnancy resulted in severe chronic pulmonary hypertension in a newborn. A 2.5-kilogram male newborn was delivered via caesarean section and was asymptomatic for one day. On day 2 of life, the baby suffered cyanosis and difficulties breathing, necessitating intubation. In retrospect, the mother was taking sertraline for the treatment of depression. Based on the clinical characteristics and presentation, an echocardiogram was performed, which revealed severe chronic pulmonary hypertension. The baby was successfully treated with pulmonary vasodilators and high flow oscillating ventilation.

An inflammatory skin condition called lichen planus, characterized by pruritic, purplish papules and plaques, has many clinical variants; one uncommon clinical variant is eruptive lichen planus. There are many available treatment modalities for lichen planus, but none are particularly promising. Therefore, we still need a drug that can provide long-term relief without any recurrence. In this report, we share our experience treating a 56-year-old female patient, diagnosed with acute eruptive lichen planus, with cyclosporine.

Background: Urinary tract injuries (UIn) are commonly reported after obstetrical and gynecological operations. They contribute to higher morbidity rates, longer hospital stays, and lower patient life quality. Objective: To identify risk factors and predictors of UIn, as well as the best therapeutic techniques for preventing further harm and improving patient outcomes. Methods: A retrospective analysis examined UIn cases from obstetrical and gynecological procedures conducted at Yarmouk Hospital during 2021-2023. The records included information about the patients' demographics, operative data (surgery type, after diagnosis of UIn, and injury type, size, and confirmation), repair data (suture used, how many layers, and the use of suprapubic catheter), and post-operative complications (admission to intensive care, sepsis, renal failure, and maternal death). Results: 51.6% of the cases were between 30 and 40 years old. Cesarean hysterectomy was performed in 54.84% of instances, with 66.13% being diagnosed intraoperatively without the requirement for IVU, which was employed in just 30.65%. Bladder injuries account for 80.65% of all cases, with 48% of them measuring 3–5 cm. Injuries were healed in 77.4% of cases using two two-layer methods and Vicryle sutures. Most patients (69.35%) had a suprapubic catheter. 93.5% of cases had no serious problems. Conclusions: Early diagnosis during surgery, as well as a two-layer repair using Vicryle sutures and a suprapubic catheterization, are critical for reducing morbidity, enhancing recovery, and improving healthcare in high-risk settings.

Background: The anterior cruciate ligament (ACL) tear is one of the most common injuries among young athletes. Posterior displacement of the posterior horn of the lateral meniscus caused by anterior translation of the tibia has been recorded as a secondary finding of the anterior cruciate ligament (ACL) injury. Objective: to discriminate the association between the overhang of the posterior horn of the lateral meniscus and the anterior cruciate ligament tear. Methods: A specialist radiologist performed a comparative cross-sectional study at Al Ramadi Teaching Hospital, diagnosing 60 patients with ACL tears based on MRI findings, measuring the lateral meniscus overhang value, percentage meniscus diameter, and lateral tibial plateau diameter. Results: A significant difference between studied groups regarding the presence of LMO was higher in group 1 than in group 2, with a mean value of 1.85±0.74 mm for group 1 and 0.80±0.16 mm for group 2, which are also significantly different. The meniscal overhang percentage and the lateral meniscus diameter were higher in the ACL tears group than in other subjects; however, the lateral tibial plateau was significantly higher in the latter group. Conclusions: A significant association has been reported between the overhang of the posterior horn of the lateral meniscus and the anterior cruciate ligament tear; we recommend further studies to display the clinical value of this finding.

Background: Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) has had a global impact on millions of people's lives. Deteriorations in cellular activities induced by this lethal virus are not yet completely understood, and so its long-term consequences are unknown. There is increasing evidence that SARS-CoV-2 and its vaccinations may have a deleterious influence on DNA damage response (DDR)-associated proteins. Objective: To investigate the status of DNA integrity in COVID-19-recovered patients and post-recovered vaccinated individuals. Methods: Blood samples were taken from 88 participants who completed questionnaires and conducted face-to-face interviews. The samples were classified into four categories based on the subjects' PCR and vaccination status: PCR negative/not vaccinated, PCR positive/not vaccinated, PCR negative/vaccinated, and PCR positive/vaccinated. ELISA kits were used to determine the expression levels of TP53BP1, Chk1, and SARS-CoV-2 IgG proteins. Results: SARS-CoV-2 did not significantly reduce Chk1 expression, but it did have a significant negative influence on TP53BP1 expression when compared to the first group. Infection with SARS-CoV-2 and its vaccination resulted in increased Chk1 and IgG levels, as well as a significant increase in TP53BP1 expression compared to the second group. Conclusions: Both SARS-CoV-2 infection and the anti-SARS-CoV-2 vaccine may have a deleterious influence on DDR-associated proteins in vitro. Post-infection immunization may boost viral protection. While some studies imply that DDR effects are reversible, more research is needed to corroborate these assertions.

Background: Congenital heart defects (CHDs) are the most prevalent type of congenital defect. Early identification of CHDS increases postnatal treatment options and outcomes. Objective: To compare the rate of CHDS in the general pregnant population to those at high risk. It also assesses the efficacy of using periodic fetal echocardiography throughout pregnancy to test for CHDs. Methods: A prospective cross-sectional study was undertaken at the Medical City complex between September 1st, 2023, and May 1st, 2024. The fetal heart was screened antenatally during the mid-trimester. Data were gathered from 250 pregnant women, with half of them classified as high-risk due to fetal or maternal risk factors associated with congenital heart abnormalities. These parameters were compared to those seen in low-risk pregnancies to establish the need for fetal echocardiography. Results: The study comprised 250 pregnant women, with 125 in each of the low-risk and high-risk categories. The prenatal incidence of fetal cardiac disease was discovered to be 18%. Pregnancies with ultrasonography abnormalities had the highest prevalence, accounting for 37% of the overall high-risk category. In addition, 34 instances (14%) featured babies with minor cardiac abnormalities, while 6 cases (2%) involved fetuses with complicated cardiac disorders. Conclusions: The study found that CHDS is more common in high-risk pregnancies than in low-risk ones. All pregnant women, regardless of additional maternal concerns, should undergo prenatal screening, including CHDS detection.

Background: Psoriatic arthritis is an inflammatory arthritis associated with psoriasis. Patient education limits disability in rheumatic diseases and improves quality of life. Objective: To assess the patients’ knowledge about their disease in a sample of Iraqi patients with psoriatic arthritis and determine the relationship between sociodemographic, clinical characteristics and knowledge score. Methods: A sample of 100 adult Iraqi patients who met CASPAR criteria agreed to participate in this study over the period December 2021–July 2022. We reported the sociodemographic and clinical data, and after the participants completed the knowledge questionnaire, we ranked them into three categories: good, average, and bad. Results: There were 88 patients with good knowledge (88%), 12 (12%) with average knowledge, and no patient had bad knowledge. There were no significant statistical relationships between the mean total knowledge score and gender, age, marital status, smoking, occupation, educational level, and family history of psoriasis or psoriatic arthritis. There was a significant negative statistical relationship between the mean total knowledge score and the age at onset of arthritis. The mean total knowledge score did not exhibit any statistical relationships with the age at onset of skin disease, the duration of arthritis, the duration between skin disease and arthritis, or BMI. Conclusions: Iraqi patients with psoriatic arthritis have a good level of knowledge about their disease, despite inadequate awareness about specific aspects related to their disease. There was a significant negative relationship between the Iraqi PsA patients` knowledge and the age at onset of arthritis.

Background: Diabetes mellitus (DM) is a common illness that requires appropriate self-management for the best health outcomes. Mobile health (mHealth) apps, such as DiaCare, can improve management of DM. However, usability issues must be solved to ensure long-term user involvement and effectiveness. Objective: To assess the usability of the DiaCare app for DM management using quantitative and qualitative approaches. Methods: A total of 100 participants took part, including fifty Type 2 diabetes (T2DM) patients and fifty healthy subjects. Data were gathered using the uMARS tool, which evaluated six domains: interaction, performance, visual appeal, information quality, perceived impact, and subjective evaluation. Results: Healthy subjects demonstrated superior ratings in all domains except perceived impact. The qualitative analysis showed the importance of a personalized, interactive app for DM control. Conclusions: While DiaCare provides benefits, more customization is required to suit the demands of T2DM patients, particularly in terms of personalization and navigation. Future research should focus on social interaction aspects to improve user assistance.

Background: Phenytoin is used commonly as an anticonvulsant agent with potential wound-healing properties. Objective: To formulate and characterize topical creams of phenytoin and investigate the wound-healing effect in the animal model. Methods: Three oil-in-water emulsion-based cream formulas were prepared using white soft paraffin, cetyl alcohol, lanolin, and olive oil blends as an oil phase. The stability was enhanced by the addition of cetostearyl alcohol, Tween 80, and methylparaben. After in vitro characterization, creams were loaded with phenytoin. Full-thickness wounds were created on rabbits that were divided into three groups (six animals each). The test group received 10% phenytoin creams, the positive control received a placebo, and the negative control received no treatment. The wound-healing activity of phenytoin was evaluated by the wound closure rate. Results: All formulations exhibited desirable physicochemical properties, including appearance, texture, and spreadability. The in vitro release results demonstrated that formula 3 sustained the phenytoin release profile, followed by 2 and 1, respectively. Based on physicochemical properties, pH values, and release profiles, formula 2 was selected for animal studies. The wound closure rate in animals treated with phenytoin was 10%, which was significantly higher than that of other groups. These results reveal that the phenytoin promotes faster wound closure and increased reepithelialization. Conclusions: Phenytoin 10% cream could be used as a safe and effective topical wound-healing agent.

Background: Acute kidney injury (AKI) is a major problem in critically ill elderly patients in intensive care units (ICUs). It increases their morbidity, mortality, and length of ICU stay. Objective: This study aims to determine the prevalence of AKI, the factors associated with increased mortality of AKI patients, and the impact of AKI on ICU outcomes. Methods: This was a multistage cross-sectional study followed by a cohort study. Included 210 patients who were admitted to the geriatric ICU. We included the elderly aged 60 and more, and we excluded patients on regular dialysis, renal transplantation, and patients who died within the first 24 hours of admission. Results: 210 elderly patients were included in the study. The prevalence of AKI was 53.8%. Overall, in-hospital mortality was 46.2%. Mortality was higher in the AKI group compared to the non-AKI group (61.9% vs. 27.8%, p=0.001). 22.1% of patients needed renal replacement therapy. Mortality for this RRT group was 84%. In multivariable analysis, chronic kidney disease (CKD), KDIGO staging III, Acute Physiology and Chronic Health Evaluation (APACHE) II, septic shock, and diabetes (DM) were independent predictors of mortality. Conclusions: AKI is common in ICU patients. Most patients were having community-acquired AKI. Chronic kidney disease (CKD), serum creatinine at AKI diagnosis, KDIGO staging III, acute physiology and chronic health evaluation (APACHE) II, septic shock, and diabetes (DM) were independent predictors of mortality.

Background: Scientific research is a fundamental element for practicing evidence-based medicine and improving the quality of healthcare services. Exposure to training programs and workshops in research is critical in the medical curriculum. Objective: To evaluate knowledge, attitudes, practices, and barriers toward research and assess research participation experience among medical students. Methods: A descriptive cross-sectional study was conducted on students at Wasit University, College of Medicine. A simple random sampling procedure was used to recruit students from 3rd-year students onwards. A self-administered questionnaire comprising 33 questions, categorized into five parts (personal data, knowledge, attitudes, practice, and possible barriers), was used for data collection. Results: 360 participants completed the forms. The knowledge score was on the lower margin (3.86 on 10 questions); adequate knowledge was reported in 37.8%. Most of the students (89.7%) had a highly positive attitude towards scientific research. Approximately 55.6% of students had experience in research activities, while 9.7% of students had published articles. The students declared many perceived barriers, including a lack of time (70.3%) and a lack of knowledge and appropriate skills (56.9%). Conclusions: Even though the students have a good attitude towards research, they had an inadequate knowledge score. The integration of research workshops and training programs into the undergraduate curriculum may help to improve the student’s knowledge and practices.

Background: Scientific research is a fundamental element for practicing evidence-based medicine and improving the quality of healthcare services. Exposure to training programs and workshops in research is critical in the medical curriculum. Objective: To evaluate knowledge, attitudes, practices, and barriers toward research and assess research participation experience among medical students. Methods: A descriptive cross-sectional study was conducted on students at Wasit University, College of Medicine. A simple random sampling procedure was used to recruit students from 3rd-year students onwards. A self-administered questionnaire comprising 33 questions, categorized into five parts (personal data, knowledge, attitudes, practice, and possible barriers), was used for data collection. Results: 360 participants completed the forms. The knowledge score was on the lower margin (3.86 on 10 questions); adequate knowledge was reported in 37.8%. Most of the students (89.7%) had a highly positive attitude towards scientific research. Approximately 55.6% of students had experience in research activities, while 9.7% of students had published articles. The students declared many perceived barriers, including a lack of time (70.3%) and a lack of knowledge and appropriate skills (56.9%). Conclusions: Even though the students have a good attitude towards research, they had an inadequate knowledge score. The integration of research workshops and training programs into the undergraduate curriculum may help to improve the student’s knowledge and practices.

Background: Controlled hypotensive anesthesia is commonly utilized to reduce blood loss and provide a desirable surgical field during perioperative procedures, particularly in facial plastic operations. Objective: To assess the hypotensive effects of nitroglycerine and remifentanil for controlled hypotension anesthesia in primary open rhinoplasty. Methods: A prospective, comparative, randomized, double-blind study was carried out from June to October 2021 at Rizgary Teaching Hospital in Erbil, Iraq. Eighty patients were randomly divided into two groups and given either nitroglycerin or remifentanil to keep their mean arterial blood pressure between 50 and 60 mmHg. Heart rate, systolic and diastolic blood pressure, intraoperative blood loss, surgical field quality, and surgery duration are all measured and compared. Results: Patients in the nitroglycerin and remifentanil groups met the systolic, diastolic, and mean arterial pressure objectives with similar results. However, there is a statistically significant difference in operation duration between the remifentanil and nitroglycerin groups (135.3 and 145.3 minutes, respectively). The heart rate differed significantly between the two groups. The remifentanil group had decreased intraoperative blood loss, a higher surgical field quality, and significantly greater surgeon satisfaction. Conclusions: Continuous infusion of nitroglycerine and remifentanil is a dependable and effective method for achieving controlled hypotension by reaching the target mean arterial pressure. Remifentanil outperforms nitroglycerin in terms of limiting blood loss, reducing surgical time, and maintaining superior hemodynamics (particularly heart rate).

Background: Substance use disorders (USD) continue to be the primary cause of disability and early death, affecting the global criminal justice, social care, health, and welfare systems. Objectives: To identify the factors influencing the acceptance of patients with USD to complete the institutional detoxification period. Methods: This retrospective cohort study reviewed the medical records of the Al-Qanat Center for Social Rehabilitation, Baghdad, Iraq. The extraction chart was conducted from July 18 to August 26, 2024. It included patients who received mental services from SUD treatment programs during 2023. Results: The study included 470 patients with SUD. Most patients (95.5%) were male, with an average age of 26.85 years, 52.7% of them were single, 60.1% had low-income jobs, 61.1% had primary school degrees, and >73.8% completed the treatment during the hospitalization period. Addicted women were significantly less likely to complete the detoxification period compared to men. The addicted patients who were more likely to complete the hospitalization period included those with younger age, longer hospitalization periods, and shorter duration of addiction. Methamphetamine (Crystal) was the most used substance (77.7%) by the admitted patients. Conclusion: The gender disparities in treatment completion of SUD highlight the need for gender-sensitive detoxification centers that account for societal factors and encourage family and community support to improve treatment engagement and outcomes. Developing new centers across the country’s provinces is pivotal to being more accessible for such patients.