The Iraqi National Journal of Medicine (IqNJM) is a peer-reviewed, biannual publication, dedicated to advancing the field of medical research. Published by the Iraqi Association for Medical Research and Studies (IAMRS), the journal aims to support the research community by promoting high-standard scientific research in Iraq and the surrounding region. IqNJM is committed to facilitating the growth of medical research, education, and health services. By adopting an open access policy, the journal provides authors with the opportunity to share their work with a global audience, ensuring that their research is widely disseminated and accessible.
Iraqi Association for Medical Research and Studies (IAMRS)
Corrigendum: Prevalence of high tricuspid regurgitation jet velocity in patients with sickle cell disease
Post-publication Author Correction Following publication of the above article, the Editorial Office of the Iraqi National Journal of Medicine (IqNJM) received a formal request on 7 July 2025 from Dr. Assad Faisal Al-Kuheli requesting a correction to the authorship of the article, including removal of one author and rearrangement of the author sequence. Upon receipt of this request, the Editor-in-Chief initiated a formal investigation in accordance with the journal’s bylaws and authorship correction policy. As part of this process, Dr. Weal Al-Shehaby and the Editor-in-Chief contacted all originally listed authors as well as the newly proposed author, both directly by telephone and officially via email. The communications and documentation provided to the Editorial Board demonstrated clear evidence that Dr. Saifali Jabbar Al-Jabran does not fulfill the authorship requirements as defined by the International Committee of Medical Journal Editors (ICMJE) criteria. In contrast, the investigation confirmed that Dr. Jawad K. Atiya fulfills all ICMJE authorship criteria and should be included as an author of the article. All authors involved submitted a signed covering letter confirming their agreement with the proposed authorship changes and revised author sequence. Based on the findings of the investigation and following discussion during the regular meeting of the Editorial Board held on 11 January 2026, the Board approved a formal correction to the authorship of the article. Accordingly, a Corrigendum is issued to reflect the corrected authorship information and will be published in Volume 8, Issue 1 of the Iraqi National Journal of Medicine. The authorship correction does not affect the scientific content, results, or conclusions of the article. Link to the article https://www.iqnjm.com/index.php/homepage/article/view/189Top of FormBottom of Form
Corrections, Retractions, and Article Removal
Copyright (c) 2026 Amer Al Mansory https://creativecommons.org/licenses/by-nd/4.0
Levels of 8-isoprostane and advanced oxidation protein products in relation to sperm count and motility
Background: Oxidative stress is implicated in male infertility, with reactive oxygen species contributing to sperm dysfunction. Among oxidative stress markers, 8-isoprostanes (8-isoP) and advanced oxidation protein products (AOPP) serve as indicators of lipid peroxidation and protein oxidation, respectively. However, their relationship with specific sperm abnormalities remains unclear. Aim: This study investigates the oxidative stress markers 8-isoprostane (8-isoP) and advanced oxidation protein products (AOPP) across different semen profiles and explores their correlation with sperm count and motility to evaluate their potential as diagnostic biomarkers in male infertility. Methods: A cross-sectional study was conducted on male partners of infertile couples between May 2024 and February 2025. Subjects were categorized into four groups based on semen analysis: normozoospermia (control), oligozoospermia, asthenozoospermia, and azoospermia. Seminal plasma levels of 8-isoP and AOPP were measured using sandwich ELISA kits, and results were compared among the groups. Results: Levels of 8-isoprostanes (8-isoP) and advanced oxidation protein products (AOPP) were significantly elevated in the asthenozoospermia group. In the azoospermia group, AOPP levels showed a significant increase, while 8-isoP exhibited a near-significant rise compared to the control. In contrast, the oligozoospermia group showed no significant increase in either marker. Conclusions: Although both markers increased in asthenozoospermia and azoospermia, AOPP showed greater sensitivity, highlighting protein oxidation’s role in severe sperm dysfunction. The oligospermic group showed no increase in both markers, indicating that isolated reduction in sperm count is unlikely to be caused by oxidative stress.
Copyright (c) 2026 Ahmed Abdulghafoor Sulaiman, Sherwan Ferman Salih https://creativecommons.org/licenses/by-nd/4.0
The Pattern of Immunoglobulin Production in Secretory Myeloma and the Relationship Between Relevant Hematological and Clinical Parameters in Basrah
Background: Plasma cell disorders encompass a spectrum of diseases ranging from benign to malignant. Among malignant plasma cell disorders, multiple myeloma is the most common and well-recognized entity. Aim: To identify the pattern of immunoglobulin production in secretory myeloma in Basra and correlate findings with hematological and clinical data. Methods: A retrospective study of 143 patients with plasma cell disorders was conducted at the Department of Pathology, Basrah Oncology Center, Iraq. Clinical data, relevant laboratory parameters (erythrocyte sedimentation rate, renal function tests, and serum calcium), bone marrow examination findings, radiological findings of bony lesions, and results from serum/urine protein electrophoresis and immunofixation or flow cytometric immunophenotyping were analyzed in conjunction with medical records. Results: Abnormal urine protein electrophoresis was found in 93.4% of patients, with most M bands located in the gamma region. The most prevalent subtype was IgG kappa, accounting for 68% of cases. This was followed by IgG lambda (17%), IgM lambda (6.5%), IgM kappa (3.2%), IgA kappa (1.3%), and free light chains (1.3%). Laboratory parameters showed wide variability, with a median hemoglobin of 9.1 g/dL, serum calcium of 9.9 mg/dL, and erythrocyte sedimentation rate of 80 mm/hr. Significant associations were found between immunofixation electrophoresis subtypes and erythrocyte sedimentation rate, serum calcium, and urea. Notably, the IgA kappa group had higher serum calcium (mean 12.45 mg/dL, p = 0.020). Radiological findings revealed multiple bony lesions in the majority of patients. Conclusions: Serum protein electrophoresis is a useful initial screening tool for detecting paraproteinemia, but it lacks sensitivity for accurately characterizing monoclonal proteins. Immunofixation, by contrast, provides higher sensitivity and allows precise identification of monoclonal immunoglobulin subtypes. In our cohort, IgG kappa was the predominant subtype, aligning with global trends, whereas patients with the IgA isotype exhibited more severe laboratory abnormalities.
Copyright (c) 2026 Mays Ahmed Yousif , Sadiq Khalaf Ali https://creativecommons.org/licenses/by-nd/4.0
Association of Matricellular Protein, Growth Factor, and Transcription Factor with Molecular Subtypes of Breast Cancer: A Case Control Study
Background: Breast cancer is a heterogeneous disease comprising molecular subtypes such as Luminal A, Luminal B, Human Epidermal Growth Factor 2 (HER-2)-Enriched, and Triple Negative, each with distinct clinical, molecular, and immunological features. Immunological markers play a critical role in modulating tumor behavior, angiogenesis, and immune evasion. Aim: This study aimed to identify key immunological markers that correlate with the molecular (intrinsic) subtypes of breast cancer and to explore their potential as prognostic factors. Methods: Serum samples from 180 breast cancer patients (56 untreated and 74 treated) were analyzed using Enzyme-Linked Immunosorbent Assay (ELISA) to determine the levels of four immunological biomarkers, including Cellular Communication Network Factor 6/WNT 1 Inducible Signaling Pathway Protein (CCN6/WISP3), Vascular Endothelial Growth Factor A (VEGF-A), Nuclear Factor Kappa B (NF-κB p65), and Cancer Antigen CA15-3. Demographic data and clinical parameters were collected using questionnaires. Results: Compared to the controls, patients with breast cancer exhibited significantly elevated levels of VEGF-A, NF-κB p65, and CA15-3, alongside decreased CCN6 levels (P < 0.05). At the molecular subtype level, HER2-enriched tumors showed the highest concentrations of CCN6 and VEGF-A, while elevated NF-κB p65 and CA15-3 levels were noted in Luminal B tumors, indicating the lowest CCN6 concentration in triple-negative tumors. Conclusions: This study demonstrates the roles of CCN6, VEGF, NF-κB p65, and CA15-3 as reliable biomarkers for distinguishing between molecular subtypes and suggests their potential as prognostic indicators.
Copyright (c) 2026 Marwa Munther Homman , Eman Tariq Ali, Maitham Ali Alrikabi https://creativecommons.org/licenses/by-nd/4.0
Measles Outbreak in Anbar Province During 2023-2024. Demographic Distribution and Vaccination Status
Background: This is the first public study covering all cities in Anbar Province regarding the measles outbreaks occurred in 2023 and 2024. Aim: To estimate the demographic distribution of measles among infected children (age, gender, residence) in Anbar Province and to study the effectiveness of the measles vaccine for each patient on infection. Methods: A retrospective analytic cross-sectional study was conducted across all sectors of Anbar Province. The patients included those who were admitted, diagnosed, and treated in various hospitals during the measles outbreak in 2023, and 2024 years. The data was recorded in files of the Anbar Public Health Directorate, which included information on age, gender, residence, clinical manifestations, and vaccination status for each patient. Results: A total of 1,663 cases was 1663 patients with a male-to-female ratio of 1.2:1. Among the patients, 203 (12.2%) were less than one year old, 595 (35.8%) were between one to two years old, and 865 (52%)were more than two years. Of the cases, 259 (15.6%) were unvaccinated, 944 (56.8%) had received single dose of the measles vaccine, and 460 (27.6%) had received two or more doses. The most commonly reported clinical features were fever, skin rash, conjunctivitis, coryza, and cough, while lymphadenopathy was the least reported. Conclusions: A high percentage of cases were diagnosed with measles in Anbar Province, and a significant number of patients contracted the infection despite being vaccinated.
Copyright (c) 2026 Rafi Khaleel Al-Ani, Mohammed Sabah Dawood https://creativecommons.org/licenses/by-nd/4.0
Serum Iron Profile in Sudanese Patients Infected by Helicobacter Pylori
Background: Helicobacter pylori is a Gram-negative, spiral-shaped, motile bacterium that represents one of the most widespread chronic infections in humans, affecting nearly half of the global population. Iron is a vital micronutrient required for almost all living organisms, including H. pylori, which relies on iron to establish colonization. Although several studies have indicated an association between iron deficiency (ID) or iron deficiency anemia (IDA) and H. pylori infection, the precise mechanisms remain incompletely understood. Aim: To assess the serum iron profile among Sudanese patients with H. pylori infection. Methods: Analytical case‑control hospital-based study was conducted at Bahri Hospital, Khartoum state during the period from December 2018 to April 2019. Eighty subjects were involved; forty patients with H. pylori and forty healthy individuals as a control group. Serum total iron and Total Iron Binding Capacity (TIBC) concentrations were estimated using the colorimetric method with a Mindray Analyzer. Serum total ferritin concentrations were estimated using an ELISA kit method with a TOSOH Analyzer. Results: The mean ± SD of serum iron, TIBC, and ferritin in the case groups were 92.80±34.38, 304.65±50.19, and 159.73±80.58, respectively. In the controls, the corresponding values were 109.00±22.51, 323.75±32.14, and 200.95±45.09, respectively. These parameters were significantly lower in cases compared with controls (p<0.05). Conclusions: Sudanese patients with H. pylori infection exhibited significantly lower serum iron, TIBC, and ferritin levels compared with controls. No significant association was detected between iron profile parameters and patient age.
Copyright (c) 2026 Rimaz Gurashi, Abuagla M. Dafalla, Suhair A. Ahmed, Shereen Faisal, AbdElkarim A. Abdrabo, Amira S. Khalafalla, GadAllah Modawe https://creativecommons.org/licenses/by-nd/4.0
Acute Isolated Unilateral Palatal Palsy in an Adolescent Girl: Case Report
Although reported in children, acquired and acute-onset isolated unilateral palatal palsy is a clinically rare condition. It is typically caused by involvement of the pharyngeal branch of the vagus nerve, with presenting symptoms primarily including acute-onset hypernasal speech and ipsilateral nasal regurgitation of fluids. While the etiology is often considered idiopathic, several pathologies, such as infections, trauma, tumors, and brainstem lesions, must be excluded, as direct associations have been established in literatures. We report a case of a 13-year-old girl who developed acute-onset left sided isolated palatal palsy following mild rhinitis with non-conclusive neuroimaging and negative routine serology. Complete recovery was achieved within two weeks with a tapering course of oral corticosteroids. The patient was closely monitored for three months to exclude recurrence and the possibility of other underlying pathologies.
Copyright (c) 2026 Mueen Jawad ALabdullah, Sana Barwari https://creativecommons.org/licenses/by-nd/4.0
Clinical Evaluation of Intraoperative Indocyanine Green (ICG) Fluorescent Cholangiography During Laparoscopic Cholecystectomy: A Comparative Study
Background: Laparoscopic cholecystectomy (LC) is one of the most common surgical procedures performed globally. While it is generally considered safe, there remains a risk of serious biliary injuries occurring during the procedure. Indocyanine green (ICG) is a water-soluble, non-toxic dye that allows real-time intraoperative visualization of the extrahepatic biliary tree. Aim: This study aims to compare the bile duct injury rate, duration of surgery, conversion rate, length of hospitalization, and overall outcomes between laparoscopic cholecystectomy with and without indocyanine green (ICG). Methods: Ninety-two patients who underwent LC from October 2023 to October 2024 were included in the study; 42 of them underwent LC with ICG (group 1), and 50 did not receive it (group 2). Both groups were compared regarding intraoperative complications, duration of surgery, conversion rates, length of hospitalization, and overall outcomes. Results: The mean total operative time in minutes for group 1 was 44.6 minutes, compared to 51.1 minutes for group 2 (p-value = 0.001). No CBD or cystic duct injuries occurred in any patient in either group. Two patients were converted to open cholecystectomy in group 2, while none were converted in group 1; however, there was no statistically significant difference between the two groups (p-value = 0.174). There was no significant statistical difference in the length of hospital stay between both groups (p-value = 0.08). Conclusions: Indocyanine green (ICG) in LC allows for better visualization of the extrahepatic biliary system, leading to a significant reduction in operative time, gallbladder perforation, and bile spillage; however, there is no significant difference in bile duct injury rates, conversion rates to open surgery, or length of hospitalization in the ICG group.
Copyright (c) 2026 Mariam Akeel, Issam Merdan, Ali Dawood https://creativecommons.org/licenses/by-nd/4.0
Psychiatric Disorders among Divorced People in Basrah
Background: Divorce has been linked to increased psychiatric morbidity; however, studies in regions such as Iraq remain sparse. Despite the known mental health challenges that often follow divorce, the impact within the Iraqi context—shaped by unique cultural changes—demands focused exploration. Aim: This study aimed to estimate the prevalence of psychiatric morbidity among divorced individuals, identify psychiatric disorders post-divorce, and assess the impact of various sociodemographic variables on psychiatric morbidity in this population. Methods: Employing a case-control design, this study was conducted in collaboration with local courts and psychiatric clinics in Basrah. A total of 154 participants, divided equally between divorced individuals (cases) and married controls, were selected. Data were collected using the General Health Questionnaire (GHQ) and semi-structured interviews, followed by statistical analysis to evaluate the association between divorce and psychiatric disorders. Results: The study revealed a significant prevalence of psychiatric disorders among divorced individuals compared to controls. A notable increase in depressive symptoms was observed in 68% of cases versus 55% of controls. Generalized Anxiety Disorder (GAD) was present in 42% of cases, compared to 22.2% of controls. Substance abuse was reported at 8% in cases but was not present in controls. A history of psychiatric illness before divorce was significantly associated with post-divorce psychiatric morbidity (P<0.05). The analysis highlighted a marked difference in the psychological impact of divorce, underscoring the intensified risk of psychiatric disorders among the divorced population. Conclusions: The findings underscore the heightened vulnerability of divorced individuals to psychiatric disorders, emphasizing the need for targeted mental health support and interventions. This study contributes to the growing body of evidence on the mental health repercussions of divorce and underscores the importance of comprehensive support systems for this population.
Copyright (c) 2026 Jamal Abdulzahra Muzil, Rafal W. Khalid, Aqeel Ibraheem Al-Sabbagh https://creativecommons.org/licenses/by-nd/4.0
Copyright (c) 2026 Vitorino dos Santos, Kin Modesto Sugai , Vitor R. D. A. Modesto https://creativecommons.org/licenses/by-nd/4.0
Research Integrity Risk Index (RI²) and Iraqi Universities
Copyright (c) 2025 Dhurgham A. Abdulwahid https://creativecommons.org/licenses/by-nd/4.0
Post-Induction Minimal Residual Disease Study by Flow Cytometry in Pediatric B ALL and Its Correlation with Initial Clinical and Laboratory Parameters
Background: Acute lymphoblastic leukemia (ALL) is a cancer characterized by the rapid and uncontrolled growth of immature lymphoid cells. Among its subtypes, B-lineage ALL in children represents the most frequently diagnosed malignancy in the pediatric population. Despite high survival rates, relapsed or refractory cases remain challenging. Minimal Residual Disease (MRD), detected by flow cytometry, is a strong prognostic marker that guides the intensity of post-induction therapy. Aim: This study aims to evaluate the correlation between post-induction MRD, measured by multicolor flow cytometry, and the initial clinical and laboratory parameters in pediatric patients with B-ALL. Methods: A retrospective cross-sectional study was conducted at the Children’s Specialty Hospital in Basrah, including 51 pediatric B-ALL patients (aged 1–14 years) treated between April 2023 and August 2024. All patients successfully completed the induction phase of chemotherapy, and their MRD status was subsequently evaluated. Results: MRD was negative in 60.78% and positive in 39.22% of patients. The majority of patients in both MRD groups were under 10 years old, with no significant age-related difference (P = 0.732). Patients with positive MRD had significantly higher mean white blood cell (WBC) counts (58.62 ± 86.9 vs. 11.44 ± 13.04) and blast cell percentages (87.1% ± 7.6% vs. 76.6% ± 16%) compared to those with negative MRD (P = 0.004 and 0.008, respectively). No significant associations were found between MRD and hemoglobin levels, platelet counts, or National Cancer Institute (NCI) risk classification. Conclusions: Flow cytometric MRD detection is a valuable prognostic tool in pediatric B-ALL. Higher WBC counts and blast percentages at presentation are associated with positive MRD, while MRD was not significantly linked to age, hemoglobin, platelet count, or risk stratification
Copyright (c) 2026 Huda Ali Alnaseri, Yassmin Ali Alaamiri , Hussam Mahmood Salih https://creativecommons.org/licenses/by-nd/4.0
A New Vitamin D Deficiency Cut-Off Value in Basrah, Iraq
Background: Vitamin D deficiency is a common health issue worldwide. Clinical observations have shown that most healthy individuals living in Iraq and the Middle East are vitamin D deficient. This study aimed to establish the true cut-off value for vitamin D deficiency (25(OH)D) in Basrah, Iraq, by analyzing the value at which parathyroid hormone (PTH) begins to rise above its reference range. Aim: This study sought to determine the true cut-off value for vitamin D deficiency (25(OH)D) in Basrah, Iraq by analyzing the value at which PTH starts to exceed its reference range. Methods: A cross-sectional study was conducted involving 874 apparently healthy subjects from Basrah, Iraq. Serum calcium, creatinine, vitamin D and PTH levels were measured for each participant. Individuals with impaired renal function and primary hyperparathyroidism were excluded from the study. The association between serum 25(OH)D and PTH was examined using multiple logistic regression analysis. The best cut-off value of serum 25(OH)D to predict elevated PTH was determined using receiver operating characteristic (ROC) analysis. Results: The mean values of 25(OH)D and PTH were 16.9 ± 14.9 ng/ml and 129.1 ± 110.5 pg/ml, respectively. If the universal cut-off values were applied, 25-hydroxyvitamin D deficiency was identified in 599 subjects (68.5%) and was inversely related to PTH. Only 139 subjects (15.9%) had optimal 25(OH)D levels. Secondary hyperparathyroidism was found in 487 subjects (45.7%). Using ROC analysis, a serum 25(OH)D value of 12.5 ng/ml was identified as the best cut-off point to predict secondary hyperparathyroidism in the population (sensitivity: 88.2%, specificity: 53.6%). The number of subjects classified as vitamin D deficient decreased to 461 (52.7%) when the new cut-off value was applied. Conclusions: The cut-off value for vitamin D deficiency needs to be redefined in areas where the disease is unexpectedly prevalent. A single cut-off value cannot be universally applied worldwide due to genetic and environmental variations. The new cut-off value is lower than that used globally. Further studies are required to establish new cut-off values.
Copyright (c) 2026 Majid Alabbood, , Haider Alrubaye https://creativecommons.org/licenses/by-nd/4.0
Platelet Count Pitfalls Between Routine and Advanced Techniques
Background: Precise quantification of platelet counts is a fundamental aspect of clinical hematology, pivotal in diagnosing and managing conditions such as thrombocytopenia and thrombocytosis. However, inconsistencies in platelet measurements across various automated hematology analyzers present significant challenges, potentially compromising the reliability of results. This variability is especially critical when platelet counts inform urgent clinical interventions, including the administration of platelet transfusions. Aim: The present study evaluated the accuracy of Sysmex XN-350 and Mindray in comparison to flow cytometry, the gold standard for platelet counting. Methods: 120 blood samples were categorized into thrombocytopenic, thrombocytosis, and normal groups. Platelet counts were measured using Sysmex XN-350, Mindray BC-720, and flow cytometry. Statistical analyses, including correlation coefficients, Bland-Altman plots, and repeated measures ANOVA, were employed to assess agreement and differences among the methods. Results: The study revealed significant discrepancies in platelet counts among the devices. Sysmex XN-350 consistently overestimated platelet counts compared to flow cytometry, particularly at higher counts, with a mean difference of 176.76 ± 358.51. Mindray BC-720 demonstrated greater agreement with flow cytometry, with a mean difference of 60.062 ± 119.67 and a stronger correlation (r = 0.972). Bland-Altman analysis showed that Sysmex exhibited substantial overestimation at higher platelet counts, while Mindray maintained consistency within clinically relevant ranges. Conclusions: Mindray BC-720 outperformed Sysmex XN-350 in terms of agreement with flow cytometry, especially in the thrombocytopenic and normal ranges. These findings highlight the importance of validating automated hematology analyzers against advanced techniques like flow cytometry to ensure precision in platelet enumeration.
Copyright (c) 2026 Dhuha Ali, Sadiq Khalaf Ali https://creativecommons.org/licenses/by-nd/4.0
Central cervical cleft: A very rare case of cervical congenital malformation
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.
Copyright (c) 2025 Wael j. Alshihaby https://creativecommons.org/licenses/by-nd/4.0
Clinicopathological Features of Colorectal Cancer in Young Patients in Comparison with Older Patients
Background: Colorectal cancer (CRC) has traditionally been considered a disease of older adults; however, recent evidence shows an increasing incidence among younger patients. Understanding the differences in clinicopathological features between young and older individuals is essential for improving early diagnosis, treatment strategies, and outcomes. Aim: The primary objective of this study is to compare the demographic profiles and clinicopathological characteristics of younger patients (aged <40 years) with those of older patients (aged ≥40 years) diagnosed with colorectal cancer. Methods: Eighty-five consecutive patients admitted to our hospital were prospectively followed for their entire hospital stay or up to 7 days, whichever came first. Each patient's blood glucose measurement was recorded according to ward protocol. Indices included total blood glucose per ward, per patient-day, or patient stay, and percentage blood glucose levels per predefined cut points to assess the incidence of hypo-, eu-, and hyperglycemia. The trial registration number at Clinicaltrials.org is NCT04800861. Results: Total data consisted of 645 blood glucose tests from 85 patients and 284 patient-day results, with an average of 2.27 tests per patient-day and 7.59 measurements per patient stay. The percentage of blood glucose in the range (80–180 mg/dL) varied by model, with patient-day showing the highest results at 48.24%, while the percentage of patients with hypoglycemia (blood glucose <60 mg/dL) was highest per patient stay at 1.18%. Conclusions: Younger colorectal cancer patients in this study presented more frequently with rectal tumors, poor differentiation, and advanced disease stages. Despite similar symptom profiles, delayed diagnosis may contribute to worse pathological features. These findings support the need for greater awareness and consideration of earlier screening in younger populations.
Copyright (c) 2026 Bahaa K. Al-Neama, Wasam A. Al-Asadi https://creativecommons.org/licenses/by-nd/4.0
Clinical Characteristics and Outcomes of Acute Coronary Syndrome in a Group of patients in Slemani Cardiac Hospital
Background: Acute coronary syndrome (ACS) is a subcategory of coronary artery disease (CAD) that encompasses a range of thrombotic cardiovascular events and remains a significant cause of morbidity and mortality worldwide. The clinical characteristics and outcomes of ACS patients can vary significantly based on geographical location, healthcare facilities, and population demographics. These variations highlight the importance of region-specific studies to better understand the presentation, management, and outcomes of ACS in diverse populations. Aim: This study aimed to evaluate the demographic profile, cardiovascular risk factors, seasonal variations, clinical presentations, and in-hospital outcomes of ACS patients admitted to Slemani Cardiac Hospital. Methods: A retrospective cross-sectional study was conducted on 375 ACS patients admitted between June 2021 and January 2022. Data on demographics, comorbidities, lifestyle risk factors, past cardiovascular history, ACS subtype, seasonal variation, management, and complications were collected from medical records and analyzed using SPSS. Results: The mean age was 63.3 ± 6.7 years, with a 60% male predominance. Hypertension (57.3%) was the most common risk factor, followed by diabetes mellitus (43.2%), smoking (31.7%), and prior coronary artery disease (29.9%). Unstable angina was the most frequent presentation (51.2%), followed by STEMI (27.7%) and NSTEMI (21.1%). Younger patients (48–57 years) were more likely to present with STEMI, while NSTEMI predominated in older groups (70–78 years). ACS admissions were significantly higher in winter than in summer (p = 0.030), with notable seasonal differences in risk factor distribution. Coronary angiography was performed in 24.8% of cases, PCI in 16%, and CABG in 2.9%. The most common complication was heart failure (20%), with STEMI associated with higher rates of arrhythmia, cardiogenic shock, stroke, and in-hospital mortality (25% within the STEMI group). Conclusions: ACS in this region predominantly affects older males, with hypertension and diabetes as the leading modifiable risk factors. Seasonal variation influences ACS incidence, with higher rates in winter. Tailored prevention strategies—particularly targeting blood pressure control, diabetes management, and smoking cessation—are essential to reduce the ACS burden.
Copyright (c) 2026 khakan Radha Rostem, Amanj Kamal Muhammad, Hamza Hakim Abdullah , Renas Othman Hamad https://creativecommons.org/licenses/by-nd/4.0
Reviewing of radical radiotherapy to the mediastinum in patients with lymphoma
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.
Copyright (c) 2025 Zeina Abd-Aljabbar Mahdi Jaber, Manwar Al-Naqqash https://creativecommons.org/licenses/by-nd/4.0
Evaluation of anatomic and dosimetric changes during simultaneously integrated boost volumetric modulated arc therapy for head and neck cancer
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.
Copyright (c) 2025 Farah Dirar Yousif, Raad Hefdhi Abedtwfeq https://creativecommons.org/licenses/by-nd/4.0
Patients Journey to hemodialysis centers: Multi-center study
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.
Copyright (c) 2025 Ali Jasim Alsaedi , Dalia Ali, Anas Saad Kalaf Aljboori , Anas Nouri Mansour, Zahraa Haider Mahdi , Dalya Sameer Faeq, Riyam Khailed Mahsoob https://creativecommons.org/licenses/by-nd/4.0
Prevalence of Depression among Doctors in General Hospitals of Basrah City Center During the COVID-19 Pandemic
Background: Depression is the most common mental disorder in community settings and a major cause of disability worldwide. In 1999, it was the fourth most common cause of disability globally, and by 2020, it is projected to become the second most common cause. Doctors, as the primary workforce in hospitals, endure significant emotional and physical stress, which may have been exacerbated by the COVID-19 pandemic. Aim: This study aimed to estimate the prevalence of depression among doctors during the COVID-19 pandemic and its risk factors. Methods: This descriptive cross-sectional study was conducted from February 1 to June 1, 2021. The study population comprised 327 doctors working in seven general hospitals in Basra city center. An online questionnaire was utilized, and the responses were analyzed using SPSS program version 26. Results: The study included 48.9% males and 51.1% females, with participants aged between 24 and 67 years. Most participants were married (70.6%), and nearly half had children, with years of service being less than five. A total of 73% of doctors exhibited depressive symptoms, with mild depressive episode was the most common (36.4%), occurring more frequently in females (75.4%) than in males (70.6%). The most significant risk factors identified were exposure to violence and the presence of comorbid physical conditions. Conclusions: The high prevalence of depression was particularly noted among doctors who work in AL-Basra Teaching Hospital for Maternity and Children, with pediatricians being the most affected specialty.
Copyright (c) 2026 Riham Sabri Saleh, Amaleed Abduljalil Abdulmajed, Raya Habeeb Abdulimam https://creativecommons.org/licenses/by-nd/4.0
A comparative analysis of multidrug-resistant Escherichia coli in urinary tract infections among males and females (2022–2023)
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.
Copyright (c) 2025 Hussein Abd Ali Mohammed Sadeq Al Her, Ekhlas Abdulameer Hameed Alazzawi , Yehia Ali Hadi Al-Qhadi https://creativecommons.org/licenses/by-nd/4.0
Mean Platelet Volume (MPV), Mean Platelet Count, and Red Blood Cell Distribution Width (RDW) in Acute Coronary Syndrome (ACS)
Background: Red blood cell distribution width (RDW) reflects anisocytosis, which is the variability in erythrocyte size. This parameter is commonly used in the differential diagnosis of various types of anemia Mean platelet volume (MPV) demonstrates platelet size and serves as an indirect marker of platelet activation. Both RDW and MPV have been proposed as potential markers for cardiovascular disease severity and prognosis. Aim: To evaluate the role of RDW, MPV, and the MPV/PLT ratio as supporting indicators in the diagnosis and severity assessment of acute coronary syndrome (ACS). Methods: This cross-sectional hospital-based study included 104 patients diagnosed with ACS (ST-elevation myocardial infarction, non-ST elevation myocardial infarction, unstable angina) admitted to the coronary care unit between October and December 2023. A control group of 181 healthy individuals was used to establish reference values. Data analysis was conducted using IBM SPSS. Results: Platelet count, MPV, and the MPV/PLT ratio were significantly associated with ACS. However, RDW showed no association with ACS in this study. Conclusions: This study evaluated the role of hematological parameters in acute coronary syndrome. To the best of our knowledge, this is the first study in Basrah demonstrating that the PLT count, MPV, and MPV /PLT ratio are significantly associated with ACS. In this study, RDW was not related to ACS. Given that a complete blood count (CBC) is a simple, cost-effective, and widely available test, we propose that these hematological indices may serve as supportive tools in the risk assessment of ACS patients.
Copyright (c) 2026 Jenan Yaseen Al-Ansary, Amani Hameed Abdulsahib, Ruqia Hameed Abdulsahib, Iman Abdulrasool Bachay https://creativecommons.org/licenses/by-nd/4.0
Does Valsartan Affect the Cytotoxicity of Doxorubicin When Used as a Cardioprotective Drug Against Doxorubicin-Induced Cardiotoxicity ?
Background: Doxorubicin is widely used as a chemotherapeutic drug. It has several serious side effects, including cardiotoxicity. Valsartan is an angiotensin II receptor blocker that plays a cardioprotective role against doxorubicin-induced cardiotoxicity. Aim: The aim of our study is to evaluate whether the combination of valsartan and doxorubicin affects the therapeutic efficacy of doxorubicin in treating cancer using an in vitro breast cancer cell line (MCF-7). Methods: Different concentrations of doxorubicin, valsartan, and their combination were tested to detect their cytotoxic effects on the cell line using MTT colorimetric assay method. Three duplicates of each concentration and control were made. Results: Valsartan had a mild cytotoxic effect only at higher concentrations, with an estimated IC50 value of 125.8 μg/ml, while doxorubicin, had more potent cytotoxicity, with an estimated IC50 value of 87.43 μg/ml. The IC50 of the doxorubicin-valsartan combination was lower than the IC50 of both drugs when used alone, with a DRI more than 1 (3.56) and an IAI less than 1 (0.94). Conclusions: There is synergism between doxorubicin and valsartan on MCF-7 breast cancer cells, suggesting a potential role for the combination in cancer treatment. The combination induces cytotoxicity in lower doses than when doxorubicin used alone.
Copyright (c) 2026 Shaymaa Fadhil Abbas , Ahmed Bader Abdulwahid, Duha Emad Omran , Nehaya Mnahi Al-Aubody , Mohammad Fawzi Albadran https://creativecommons.org/licenses/by-nd/4.0
Evaluation of D-dimer Level in COVID-19 Patients
Background: The COVID-19 pandemic is associated with prothrombotic complications, leading to increased morbidity and mortality. D-dimer, a fibrin degradation product, serves as a biomarker for coagulation abnormalities. This study evaluates the role of D-dimer in predicting disease severity and hospitalization in COVID-19 patients. Aim: To assess correlations between D-dimer levels and age, gender, comorbidities, disease severity, and hospitalization needs in COVID-19 patients. Methods: A retrospective analysis of 78 COVID-19-positive patients admitted to an outpatient clinic was conducted. Data on demographics, comorbidities, vaccination status, disease severity, and admission D-dimer levels were analyzed using statistical tests (t-tests, chi-square, Mann-Whitney U). Results: The mean age of participants was 49 years, with 56.4% males and 43.6% females. Approximately 52% of patients had a comorbid disease, primarily hypertension and diabetes. Older patients and those with coexisting diseases had significantly higher D-dimer levels (p-values 0.017 and 0.045, respectively), with non-significant differences between males and females (p-value 0.648). Older patients had a significantly higher need for hospitalization during acute COVID-19 infection (p-value 0.002). Additionally, patients with elevated admission D-dimer levels showed a greater prevalence of severe disease (p-value 0.01) and a higher need for hospitalization (p-value 0.028). Conclusions: Elevated admission D-dimer levels are strongly linked to severe COVID-19 outcomes and hospitalization, highlighting their utility as an early prognostic marker. Clinical management of COVID-19 patients may be guided by D-dimer assessment, which may help predict disease severity.
Copyright (c) 2026 Amal Malik Hassan, Noor Kadhim Mohamed-Jawad, Hiba Dawood, Ali Adnan Mohsin https://creativecommons.org/licenses/by-nd/4.0
Alternate day oral iron replacement versus daily intake in women with iron-deficiency anemia in Basrah
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.
Copyright (c) 2025 Muntadar Jafar Mawla, Mohammed A. Al-Anssari, Qutaiba M. Dawood, Murtadha A. Jeber, Asaad A. Khalaf https://creativecommons.org/licenses/by-nd/4.0
Electronic Smoking Prevalence and Awareness among Al-Nahrain Undergraduate Medical Students: A Cross-Sectional Study
Background: Smoking is a significant global cause of preventable morbidity and mortality, resulting in six million deaths worldwide each year. Electronic cigarettes are becoming increasingly popular among adolescents and young adults globally. Aim: This study aims to determine the prevalence of electronic smoking and awareness among Al-Nahrain undergraduate medical students. Methods: A cross-sectional study was conducted at the College of Medicine, Al-Nahrain University, Baghdad, Iraq. Data were collected during March and April, 2022. A total of 474 undergraduate students completed a modified standard questionnaire. Statistical analysis was performed using SPSS-26. Results: The prevalence of electronic smoking was found to be 12% of the total sample. Of the students surveyed, 350 (73.8%) were aware of electronic cigarettes. A significant association was observed (P-Value < 0.05) between smoking and being male, having history of smoking among friends or relatives, and a lack of awareness that electronic cigarettes are similar traditional cigarette smoking. Conclusions: More than one-tenth of the sample reported history of electronic smoking, and they were generally aware of most information regarding it. The usage is a significant public health issue; therefore, it is crucial to implement strict laws and policies to minimize the sale of these products to the younger population. Health promotion strategies should be developed to reduce the usage of electronic cigarettes.
Copyright (c) 2026 Nibras Alaa Hussain, Tamara Ala’a Hussein https://creativecommons.org/licenses/by-nd/4.0
Infants and Young Children Feeding Practices Among Mothers Attending Primary Health Care Centers in Basrah
Background: Malnutrition accounts for sixty percent of annual deaths among children under five years in developing countries, attributed to inappropriate feeding practices, including non-diverse and insufficient feeding. Improving the nutrition of children under five is a top priority for human development in these regions. Caregivers’ knowledge, attitudes, and practice of young child feeding are essential factors for child health and growth. Aim: The primary aim of this study was to assess infants and young children feeding practice among mothers attending primary health care centers in Basrah. Methods: A cross-sectional study was conducted involving 250 mothers attending five primary health care centers in Basrah. Data were collected through face-to-face interviews with participants by the investigators, using a specially prepared questionnaire. Results: The study included 250 children under the age of two years, with 76% of the children being less than one year old. Only 100 (40%) of the mothers breastfed their last child at the time of the study. Among the 250 mother-child pairs who participated, 101 (63.9%) mothers exclusively breastfed. Among 86 mothers with children aged 12-24 months, 63 (73.3%) of them continued breastfeeding. The initiation of complementary feeding (CF) was ideal in only 32.5% of the respondents, with the majority initiating CF before six months. Conclusions: Infant and young child feeding practices were poor in this study. There is a need to promote optimal feeding practices during postnatal care and to utilize mass media to emphasize the importance of complementary feeding practices, especially for mothers with lower educational status.
Copyright (c) 2026 Jhood Molan, Russell Abdul Hussain, Naba Jawad kazem, Alaa Kazem lefta, Heba Abdul Razzaq Hassan, Hussein Salem Thamer https://creativecommons.org/licenses/by-nd/4.0
Self-reported post-COVID-19 vaccine signs, symptoms among vaccinated medical staff: Types, severity, and associated factors
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.
Copyright (c) 2025 Ali Khalid Saeed, Yousif Abdul Raheem https://creativecommons.org/licenses/by-nd/4.0
Role of surgical excision in the treatment of large macrocystic lymphatic malformations in children
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.
Copyright (c) 2025 Hiba Mahmood Yousuf, Moaied A. Hassan https://creativecommons.org/licenses/by-nd/4.0