Special Issue, October (2026)

Background and objectives: Community pharmacists play a crucial role in providing counselling on self-medication using non-prescription analgesics (NPAs); ensuring pharmacy staff have adequate expertise is critical for safe and effective patient care. This study aimed to assess the knowledge of pharmacists and assistant pharmacists in Erbil City regarding NPAs.

Methods: A cross-sectional survey was conducted among 400 community pharmacy staff in Erbil. A structured questionnaire assessed demographic characteristics and knowledge of NPAs, including their uses, side effects, interactions, and appropriate populations. Chi-square tests were used to explore associations between knowledge level and participant characteristics.

Results: The majority of participants (90.3%, n = 361) demonstrated sufficient knowledge of NPAs, while a smaller percentage (9.8%, n = 39) had poor knowledge. Significant gaps were found in pediatric dosage, NSAID interactions, and use in high-risk populations. Gender (p = 0.006) and academic degree (p < 0.001) were significantly associated with knowledge level. Female participants had significantly higher knowledge than males (93.8% vs. 85.0% sufficient knowledge, respectively), and bachelor's degree holders also had significantly higher knowledge than diploma and postgraduate participants (93.8%, 86.8%, and 57.1% sufficient knowledge, respectively).

Conclusion: Community pharmacy professionals in Erbil demonstrated sufficient knowledge regarding NPAs overall, but gaps in safety-related knowledge remain that could put patient care at risk. To close these gaps, those in non-clinical roles and postgraduates should receive specialized training and participate in ongoing education.

Backgroundand objective: Helicobacter pylori infection is the most common and treatable cause of chronic gastritis; it is strongly linked to peptic ulcer, low-grade gastric lymphoma, and adenocarcinoma. Infection with this microorganism affects more than half the world's population.The research aimed to compare sensitivity, specificity, and positive predictive value between two histopathological methods, hematoxylin and eosin (H&E) and immunohistochemistry (IHC), in patients with chronic gastritis and gastric cancer.

Methods: A total of 90 gastric biopsies were included in the study — 44 with chronic gastritis and 46 diagnosed with gastric adenocarcinoma — collected from the archive of the Histopathology Department at Erbil International Private Hospital between January 2024 and January 2025. Slides were stained with H&E, and IHC staining was performed using a polyclonal anti-H. pylori antibody. Sensitivity, specificity, and positive predictive value were calculated.

Results: More than two-thirds of cancer patients (67.4%) were aged ≥ 60 years, compared to 38.6% of the gastritis group (p = 0.012). More than half (52.2%) of cancer patients were male, compared with 43.2% of patients with gastritis. The two diagnostic techniques revealed a statistically significant difference (p = 0.035); the H&E stain showed 50% sensitivity, 46.9% specificity, and 47.7% overall agreement with IHC.

Conclusion: IHC staining is more accurate for determining Helicobacter pylori infection than the traditional H&E stain, especially in equivocal samples with a low bacterial load and inactive gastritis. IHC showed the highest sensitivity, specificity, and inter-observer agreement compared with H&E stain.

Background and objective: Hyperlipidemia is a key risk factor for atherosclerotic cardiovascular disease (ASCVD). Bempedoic Acid (BA) is an ATP-citrate lyase inhibitor indicated for statin-intolerant patients, or patients at high risk of ASCVD with hyperlipidemia. However, BA may raise plasma uric acid levels, potentially causing hyperuricemia and gout. Coenzyme Q10 (CoQ10), a natural antioxidant, has anti-inflammatory and renal-protective properties. This study evaluates CoQ10's potential to mitigate BA-induced renal side effects in a hyperlipidemic rat model.

Methods: Forty male Sprague-Dawley rats were divided into five groups: a negative control (normal), a positive control (hyperlipidemic), a BA-treated group (hyperlipidemic rats on BA monotherapy),a BA + CoQ10 group (hyperlipidemic rats receiving BA and CoQ10 combination), and a BA + Allopurinol group (hyperlipidemic rats receiving BA and Allopurinol combination). The positive control and all treatment groups received a high-fat diet to induce and maintain hyperlipidemia throughout the experiment. After 8 weeks of inducing hyperlipidemia, therapeutic interventions were administered for a further 10 weeks. Renal biomarkers (uric acid, serum creatinine, and blood urea nitrogen) and the oxidative stress biomarker malondialdehyde (MDA) were measured.

Results: BA monotherapy significantly raised mean serum uric acid and creatinine compared with the negative control group. Co-administration of CoQ10 significantly lowered both parameters. Mean serum MDA was significantly reduced in all treatment groups compared with the positive control group.

Conclusion: These findings suggest that combining BA with CoQ10 could serve as a therapeutic strategy for hyperlipidemic patients on BA therapy who have compromised renal function.

Background and objective: Infection prevention and control (IPC) is essential for protecting patient and healthcare worker safety. IPC adherence within a resource-constrained environment, such as Erbil, Iraq, continues to be suboptimal due to multifactorial barriers. The objective of this study was to determine adherence to IPC among healthcare workers (HCWs) and the associated barriers in public hospitals in Erbil.

Methods: A descriptive cross-sectional study was conducted among healthcare workers between October 2024 and end of May 2025, in five public hospitals in Erbil city. A total of 415 HCWs were surveyed via proportionally allocated convenience sampling, using a validated, pilot-tested questionnaire adapted from a WHO tool. SPSS version 26 was used for data entry and analysis. A p-value ≤0.05 was considered statistically significant.

Results: Of the total study sample, 14.2% were in full compliance with IPC practices. Nurses carried the greatest burden of human and environmental barriers, including inadequate training, inadequate support from staff, and inadequate equipment availability. Occupation and qualification showed statistically significant associations with compliance (p=0.003 and p=0.013, respectively), with nurses — including infection control nurses — and Master's degree holders showing higher compliance. Lack of manpower, role conflict, lack of experience, lack of IPC training, lack of IPC staff contact, equipment shortage, quality of materials and equipment, and non-compliance of healthcare workers with IPC protocol were significantly reported as barriers.

Conclusion: IPC practice among HCWs in Erbil is low, especially among disproportionately exposed nurses. There is an urgent need for routine training, institutional support, better infrastructure, and objective monitoring to strengthen IPC compliance and enhance patient safety.

Background and objective: Endometrial cancer (EC) is considered the sixth most prevalent cancer among women worldwide, with over 400,000 new cases annually, and both its incidence and mortality rates are rising. This study attempted to examine the concentrations of interleukins (IL-2, IL-4, IL-10, IL-13, IL-17, IL-22), tumor necrosis factor alpha (TNF-α), and interferon gamma (IFN-γ) in Kurdish women diagnosed with endometrial cancer.

Methods: Seventy patients were included in the study, from which random samples were selected for testing by ELISA multiplex enzyme immunoassay. Serum was separated from the patients' peripheral blood.

Results: The findings revealed a significant (p <0.05) increase in mean concentration of IFN-γ (55±0.2 pg/mL), IL-2 (122±0.33 pg/mL), TNF-α (18.14±9.06 pg/mL), IL-17 (3.06±1.49 pg/mL), IL-22 (10.34±2.34 pg/mL), and IL-4 (9.75±11.35 pg/mL) in patients diagnosed with endometrial cancer compared with their respective healthy individuals, whereas no significant difference was found in the level of IL-10 (3.02±1 pg/mL) in endometrial cancer patients compared with healthy individuals (3.00±0.3 pg/mL). Finally, IL-13 levels showed a significant decrease in EC patients (0.99±0.11 pg/mL) compared with healthy individuals (2.1±0.2 pg/mL).

Conclusion: The study demonstrates a significant elevation of pro-inflammatory cytokines (IFN-γ, IL-2, TNF-α, IL-17, IL-22, and IL-4) and a marked reduction of IL-13 in endometrial cancer patients, suggesting their involvement in tumorigenesis and local immune dysregulation. IL-10 levels remained unchanged, indicating complex immune dynamics.

Background and objective: Diabetes mellitus is a widespread endocrine disease with a severe impact on health systems worldwide. Skin disorders can be found in about one-third of people with diabetes and frequently occur before diagnosis, playing an important role in the initial recognition of the underlying disease. This study aimed to identify the frequency of dermatological manifestations among diabetic patients and to examine the association between these manifestations and risk factors.

Methods: This descriptive cross-sectional study was carried out among 300 diabetic patients with type I or II diabetes mellitus, aged ≥10 years, recruited from Layla Qasim Specialized Diabetic Center in Erbil City, Iraq. Each patient was examined and asked about skin symptoms. Skin manifestations diagnosed by the researcher were recorded directly; for uncertain or intractable findings, photographs were taken and reviewed by a dermatologist to reach an accurate diagnosis. The study was carried out over four months, from the start of February to the end of May 2024.

Results: About two-thirds of patients reported associated skin manifestations. The most common cutaneous manifestations were acrochordons (24.73%), xerosis (22.53%), fungal infections (21.98%), bacterial infections (13.19%), insulin lipodystrophy (12.64%), and generalized pruritus (12.08%).

Conclusion: Skin manifestations are highly prevalent among patients with diabetes, and infectious skin diseases are among the most common. Routine skin screening in diabetes care may facilitate early intervention and improve patient outcomes.

Background and objective: Lifestyle modification counseling by pharmacists is essential in managing chronic diseases. Community pharmacists are well positioned to conduct health promotion initiatives due to enhanced accessibility and the absence of a need for earlier appointments. This study aimed to evaluate community pharmacists' knowledge, attitudes, and practice roles regarding lifestyle modification counseling.

Methods: A structured questionnaire was used to survey community pharmacists in a cross-sectional study conducted in Sulaymaniyah city from November 2024 to February 2025. A convenience sampling method was used to include a diverse group of pharmacists. The survey evaluated knowledge levels, attitudes toward lifestyle change, adequacy of practice counseling, and barriers. Descriptive statistics and chi-square tests were used to analyze the data and identify associations.

Results: This survey garnered 311 responses from a pool of 500 community pharmacy professionals, a 62.2% response rate; 136 were male and 175 were female. Among respondents, 40.8% showed good knowledge, 54% had moderate knowledge, and 5.1% had poor knowledge of lifestyle change. Additionally, 76% demonstrated adequate practice. A significant association was found between higher knowledge levels and positive attitudes. Knowledge scores showed no significant association with place of graduation (p = 0.13) or employment sector (p = 0.37). Notably, 56% of pharmacists reported not having enough time, and more than 60% cited a lack of patient motivation as the primary barrier.

Conclusion: Community pharmacists in Sulaymaniyah have positive attitudes toward lifestyle modification counseling, but knowledge gaps and systemic barriers impede effective implementation. Improving pharmacists' contribution to health promotion will depend on addressing these issues through focused educational initiatives and interprofessional collaboration.

Background and objective: Self-medication (SM) is an increasing global concern, particularly among pharmacy and medical students. This group often has early access to medical knowledge and prescription drugs, which may lead to inappropriate medication practices. Understanding their behavior is crucial to addressing potential risks associated with SM. The purpose of this study was to evaluate the prevalence, causes, and patterns of self-medication among pharmacy and medical students in the Kurdistan Region of Iraq.

Methods: A total of 106 pharmacy and medical students from different medical schools in the Kurdistan Region of Iraq participated in a cross-sectional survey. Data on demographics, self-medication habits, reasons for use, symptoms treated, and medication types were gathered using a structured questionnaire.

Results: Of the 106 participants, 68 (64.2%) were female and 90 (84.9%) were undergraduate students. Most students fell within the 18–27 age range. A total of 85 students (80.5%) reported using self-medication for acute pain, while only 21 (19.5%) used it for chronic conditions. The most common symptoms treated were headache, runny nose, and cough (38.7%). Menstrual issues were also frequently reported among female students (16%).

Conclusion: Kurdistan's medical students frequently use SM, mostly for minor acute ailments. Even though this practice is not as dangerous as when seen among licensed physicians, it nevertheless raises health concerns. Educational activities are required to encourage appropriate SM and increase awareness of its possible hazards.

Background and objective: Klebsiella pneumoniae, a Gram-negative encapsulated bacterium, is one of the most significant etiological agents of healthcare- or community-acquired infections worldwide. This study set out to explore the phylogenetic relationships and genetic diversity of multidrug-resistant K. pneumoniae using 16S rRNA sequencing and Multilocus Sequence Typing (MLST).

Methods: A total of 298 urine samples were analyzed from patients with symptoms of urinary tract infection. Standard biochemical tests were used for isolate identification. Resistant isolates were further analyzed by molecular diagnosis through 16S rRNA gene sequencing and Multilocus Sequence Typing (MLST), in accordance with international standards.

Results: Out of 298 urine specimens, 49 K. pneumoniae isolates were confirmed (isolation rate: 16.4%). Resistance was high: 49% to amoxicillin/clavulanic acid, 38.8% to cefazolin, 34.7% to ceftriaxone, and 12.2% to ertapenem and 16.3% to both imipenem and meropenem among the carbapenems. Multidrug resistance was detected in 65.3% of isolates (32/49), and 18.4% were extensively drug-resistant. MLST testing of 13 MDR strains identified 13 different sequence types, the most dominant (15%) being ST147, followed by ST405 and ST268 (10% each). Both the 16S rRNA sequence analysis and MLST typing showed genetic variation among the resistant isolates, with multiple alleles differing across the seven loci, indicating substantial genetic diversity in the studied isolates.

Conclusion: UTIs associated with antimicrobial-resistant K. pneumoniae pose a primary problem in this region. Genetic diversity was found within resistant isolates using molecular typing. Study limitations include the small sample size for MLST (n=13) and the absence of whole genome sequencing, which limit the epidemiological conclusions that can be drawn. Future studies with larger populations and more advanced sequencing methods (such as WGS) are needed for more comprehensive surveillance and a fuller understanding of resistance mechanisms and transmission patterns.

Background and objective: Diabetes mellitus (DM) is a leading cause of global morbidity and mortality, while vitamin D deficiency is a growing public health concern. Although vitamin D levels are linked to obesity and insulin resistance, limited research exists on the knowledge, attitudes, and practices (KAP) surrounding vitamin D deficiency in both diabetic and non-diabetic individuals.

Methods: A cross-sectional study was conducted in Erbil from September 2024 to July 2025, involving 394 participants — 195 diabetics and 199 non-diabetics — recruited from hospitals and clinics. Data were collected using a structured, validated KAP questionnaire. Convenience sampling was used to ensure representation from both groups. Participants gave verbal consent, and ethical approval was obtained.

Results: A total of 394 participants (195 diabetics, 199 non-diabetics) took part in the study. The mean age of diabetics was 48.9 years, while non-diabetics had a mean age of 40.6 years. Vitamin D deficiency was reported by 61% of diabetics and 59.3% of non-diabetics. Non-diabetics reported higher vitamin D supplement use (66.3%) than diabetics (60%). Both groups exhibited similar behaviors regarding sun exposure and physical activity, with the majority undergoing vitamin D screening every six months (72.3% diabetics, 71.4% non-diabetics). Women made more vitamin D knowledge and lifestyle adjustments than men (27.63 vs. 24.95, p=0.015). Higher socioeconomic status and education levels increased awareness and lifestyle adjustments; non-diabetics with high SES had a mean knowledge score of 31.13 compared with 21.87 for low SES, whereas diabetics had 32.55 compared with 25.00 (p=0.001).

Conclusion: Vitamin D deficiency is common among adults with and without diabetes in Erbil. Non-diabetics are more likely to use supplements, while gender, education, and socioeconomic status significantly influence awareness and health behaviors. Targeted educational interventions are recommended to address these disparities.

Background and objective: Primary hypothyroidism is a prevalent endocrine disorder marked by reduced production of thyroid hormones, which disrupts metabolic homeostasis and may influence glycosylation. Fucosylation, a type of glycosylation, is required for immune system function and cell communication. Serum levels of Total Fucose (TF), Protein-Bound Fucose (PBF), and Lipid-Associated Fucose (LAF) have been observed to change in various diseases, but their role in primary hypothyroidism is unclear. This study evaluated serum TF, PBF, and LAF levels in patients with primary hypothyroidism to determine whether they could support diagnosis.

Methods: This case-control study included individuals diagnosed with primary hypothyroidism and matched healthy controls. Serum levels of TF, PBF, and LAF were measured spectrophotometrically. Thyroid function tests (TSH, FT3, and FT4) were also evaluated. Statistical comparisons, Pearson correlation analyses, and Receiver Operating Characteristic (ROC) curve analyses were performed to assess diagnostic utility.

Results: Significantly elevated levels of TF (33.86 ± 2.82 vs. 17.90 ± 1.61 mg/dL), PBF (12.97 ± 1.47 vs. 8.50 ± 1.10 mg/dL), and LAF (4.11 ± 0.13 vs. 2.69 ± 0.37 mg/dL) were observed in the hypothyroid group compared with controls (p <0.0001 for all). TF, PBF, and LAF showed strong positive correlations with TSH and strong negative correlations with FT3 and FT4. ROC curve analysis revealed excellent diagnostic performance for all three parameters.

Conclusion: Serum TF, PBF, and LAF are significantly elevated in primary hypothyroidism patients (n=50) compared with healthy controls (n=50) and strongly correlate with thyroid hormone levels. These markers demonstrate excellent diagnostic accuracy and may serve as diagnostic markers in primary hypothyroidism.

Background and objective: Integration of artificial intelligence (AI) in healthcare and medical research represents significant potential; however, it also introduces practical and ethical challenges. This study analyzes physicians' perceptions of AI implementation in clinical and academic settings, exploring their awareness, perceptions, barriers, concerns, and insights into ethical and regulatory considerations.

Methods: A mixed-methods approach was used. The quantitative component involved standardized surveys completed by 390 physicians (241 clinical, 149 academic) in Erbil City from November 2024 to June 2025. Participants were selected using systematic sampling, and surveys were self-administered. The qualitative component included two focus group discussions, involving 6 clinical physicians and 8 academic physicians, to explore in-depth perceptions and concerns regarding AI in healthcare and research.

Results: Of 390 physicians, the majority of participants were male (69.2%). Mean age was 46.7±7 years. Familiarity with AI was higher among younger, male, and academic physicians, with age showing a negative association (p <0.001). Clinical physicians reported more concerns regarding privacy in healthcare (p=0.003) and research (p=0.041), as well as algorithmic bias (p=0.030). Despite these concerns, most physicians valued AI in healthcare and academic research and demonstrated strong interest in training and collaboration. Qualitative findings showed optimism and frequent use of AI tools such as ChatGPT and DeepSeek, often described as “Google replacements.” However, physicians also highlighted ethical issues and the need for local training and infrastructure improvement.

Conclusion: Physicians generally welcome the use of AI in healthcare and research but emphasize the necessity of ethical guidelines, peer collaboration, and formal education. To ensure responsible adoption, addressing infrastructural and trust barriers will be essential for guaranteeing that AI technologies improve rather than undermine patient care and research integrity.

Background and objective: Acne vulgaris is one of the most prevalent dermatological conditions worldwide. Reliable research on the effects of acne on teenagers and its impact on quality of life is needed; such research may help dermatologists become more aware of the psychological impact of acne and may encourage teenagers to seek treatment. This study aimed to identify the prevalence of acne vulgaris among high school students in Erbil City.

Methods: A cross-sectional study was conducted among 400 high school students aged 12-19 years in Erbil City, Iraq. The study was carried out over about one year, from October 2024 to October 2025, using a voluntary structured questionnaire and clinical examination.

Results: Among the study population, 59% of students had acne, with a greater frequency among females (65.9%) than males (54.1%). Regarding severity, mild cases made up the majority (66.1%), followed by moderate (28.8%) and severe cases (5.1%). Acne was most frequent (63.6%) among those aged 16-17 years, though the difference across age groups was not statistically significant (p = 0.066). There was no significant association between socioeconomic status and acne prevalence (p = 0.803).

Conclusion: A large proportion of high school students in Erbil suffer from acne vulgaris, with a greater frequency among females than males. Adolescent acne may be lessened through early education, lifestyle counseling, and dermatological care.

Background and objective: Pneumoperitoneum is essential to provide a good surgical view during laparoscopy. Carbon dioxide is the most commonly used gas for pneumoperitoneum, and it induces multiple changes in the mechanics of respiration and cardiovascular function, particularly under general anesthesia. This study aimed to identify the key physiological parameters most likely to deviate from normal during laparoscopic cholecystectomy. Respiratory variables assessed included end-tidal CO₂ (EtCO₂) and peak airway pressure, while cardiovascular parameters encompassed mean blood pressure (MBP), pulse rate, body temperature, and oxygen saturation.

Methods: This prospective observational cohort study evaluated physiological changes in patients classified as American Society of Anesthesiologists (ASA) grade I/II undergoing elective laparoscopic cholecystectomy at Rizgary Teaching Hospital, Iraq, over four months. A sample of 186 patients, aged 18–75 years, meeting inclusion and exclusion criteria were enrolled. Median-split methodology was used to divide patients into two groups based on the median duration of surgery (≤27 minutes vs. >27 minutes).

Results: CO₂ insufflation during laparoscopic surgery led to significant physiological changes. Mean blood pressure decreased from 95.7±13.5 mmHg to 87.4±14.3 mmHg (p <0.001), and heart rate dropped from 95.6±16.2 bpm to 89.3±13.8 bpm (p <0.001). Peak inspiratory pressure (PIP) increased markedly from 15.9±3.7 cmH₂O to 21.2±3.8 cmH₂O (p <0.001), while end-tidal CO₂ declined from 33.7±4.1 mmHg to 31.2±4.9 mmHg (p <0.001). Following CO₂ exsufflation, PIP decreased to 18.7±8.0 cmH₂O, and end-tidal CO₂ increased to 37.5±6.1 mmHg (both p <0.001), reflecting improved respiratory compliance. Intraoperative comparisons revealed higher end-tidal CO₂ levels in procedures lasting more than 27 minutes compared with shorter ones: 32.6±4.8 mmHg vs. 29.8±4.6 mmHg after insufflation, 37.6±5.7 mmHg vs. 33.0±5.4 mmHg after artery clamping, and 39.2±6.0 mmHg vs. 34.5±5.8 mmHg after gallbladder dissection (all p <0.001). These findings emphasize the need for vigilant monitoring and ventilatory adjustments to prevent potential complications associated with CO₂ insufflation.

Conclusion: CO₂ insufflation caused notable fluctuation in most monitored parameters (end-tidal CO₂, peak inspiratory pressure, heart rate, body temperature). Minimizing insufflation time is a key factor in reducing pneumoperitoneum effects.

Background and Objective: Endometrial cancer, originating in the uterus's inner epithelial lining, is treated with radiotherapy, including external beam radiotherapy and brachytherapy. However, radiotherapy may disrupt electrolyte balance and affect blood components. This study aimed to evaluate the effect of radiation on hematological and electrolyte parameters in patients with endometrial cancer.

Methods: The study was conducted at the Awat Center, Erbil, Iraq, between December 25, 2024, and February 22, 2025, involving 25 patients. Blood samples were collected before, during, and after therapy, and parameter analyses were performed. The Elekta Infinity machine was used for curative treatment, including Volumetric Modulated Arc Therapy (VMAT). The local Ethics Committee approved the study and protocol.

Results: Radiotherapy significantly reduced white blood cell counts (WBC) from 6.94±2.59×10⁹/L before treatment to 4.70±1.45×10⁹/L during treatment (p <0.001), with partial recovery post-treatment (5.18±1.84×10⁹/L, p=0.001). Platelet counts also declined from 234.84±63.34×10³/μL to 199.08±47.69×10³/μL after radiotherapy (p=0.008). Hemoglobin, red blood cells, and most electrolytes (sodium, potassium, chloride, magnesium, phosphate) showed no significant variation. However, serum calcium levels declined modestly but significantly after radiotherapy (from 9.69±0.54 to 9.36±0.58 mg/dL, p=0.034).

Conclusion: Adjuvant VMAT radiotherapy in endometrial cancer patients induces significant hematological suppression, particularly of WBCs and platelets, while maintaining stable electrolyte levels. These findings highlight the hematologic sensitivity of pelvic radiotherapy and the importance of regular monitoring to reduce cytopenic risks.

Background and objective: Warfarin is the primary anticoagulant used in patients undergoing heart valve replacement surgery. Genetic variations in the CYP2C9 and VKORC1 (Vitamin K Epoxide Reductase Complex Subunit 1) genes have a significant impact on warfarin metabolism and sensitivity. However, there are limited studies on these variants in the Iraqi population. The purpose of this study was to assess the impact of the single-nucleotide polymorphisms (SNPs) VKORC1 -1639 G>A, CYP2C9*2, and CYP2C9*3 on anticoagulation response, time to reach therapeutic International Normalised Ratio (INR), and warfarin dosage requirements in patients undergoing heart valve replacement surgery.

Methods: Fifty patients (34 Kurdish, 16 Arab) participated in a prospective observational study in Erbil, Iraq, from October 2024 to March 2025. Real-time PCR was used for genotyping. INR values, warfarin dosing, and the time in days from the first day of warfarin treatment after surgery until reaching the therapeutic INR (2–3) were recorded.

Results: CYP2C9 *1/*1 was the most common genotype. VKORC1 genotype frequencies differed significantly between Kurdish and Arab patients. Warfarin maintenance dose varied significantly by CYP2C9 (p=0.017) and VKORC1 (p=0.04) genotype. Patients with CYP2C9 *2/*3 required the lowest dose (7 mg/week). CYP2C9 genotype correlated with time to therapeutic INR (p=0.043), while VKORC1 genotype did not.

Conclusion: The CYP2C9 and VKORC1 polymorphisms found in the studied population require lower warfarin dosages in Iraqi patients who have undergone heart valve replacement. These results demonstrate the importance of genotype-guided warfarin dosing in enhancing safety and efficacy, especially in genetically diverse populations such as Iraq.

Background and Objective: Pharmacies in Erbil Province face numerous challenges, compromising their ability to provide patient-centered, safe, and effective care. This study aimed to identify these challenges in depth and propose evidence-based strategies from developed countries to overcome them.

Methods: In-depth, semi-structured interviews were conducted with 27 pharmacy managers operating in Erbil's urban, semi-urban, and rural areas, using a qualitative, phenomenological approach. Participants were selected through purposive sampling and included managers of both independent and chain pharmacies. Data were analyzed through thematic analysis using Braun and Clarke's six-phase framework, with six themes structured deductively and subthemes emerging inductively from the data.

Results: Six main themes (regulatory compliance, supply chain and inventory management, human resource management, patient service and care, financial viability, and technology adoption) were identified. Participants reported outdated (n=18) and inconsistent regulations (n=13), improper control of drug pricing (n=27) and drug storage (n=10), oversaturation of the pharmacy market (n=6), reliance on manual inventory systems (n=22), shortage of qualified professionals (n=25), high staff turnover (n=14), lack of structured training (n=20), limited patient consultation services (n=19), poor financial tracking (n=19), and low utilization and availability of digital tools (n=25). These challenges were experienced similarly across all pharmacy settings.

Conclusion: The findings highlight the need for comprehensive reform in the Erbil pharmacy sector. Although the challenges are significant, they align with recognized worldwide patterns, suggesting that effective strategies could be adapted to improve pharmacy operations, professional standards, and healthcare outcomes in the region.

Background and objective: Mammography is a common imaging method, utilizing low-dose X-rays to detect calcifications and other tissue abnormalities. The aim of this study was to determine the most effective techniques for enhancing mammogram images to ensure accurate and reliable breast cancer detection.

Methods: Mammogram images from the MIAS database were enhanced using various techniques to improve image quality for more accurate diagnostic identification. The methodology proceeded in two steps. First, artificial noise — Gaussian, quantum, salt-and-pepper, Poisson, and speckle — was purposefully added to create a controlled testing environment and replicate noisy settings; although mammogram images naturally contain some noise, this artificial addition allowed systematic evaluation of enhancement and denoising techniques. Second, contrast enhancement (histogram equalization and contrast-limited adaptive histogram equalization, CLAHE) and denoising (Gaussian, median, and Wiener filters) were applied to restore image clarity while preserving diagnostically significant information. Peak signal-to-noise ratio (PSNR) was used to evaluate effectiveness, and one-way ANOVA was used to determine the significance of each technique's effect on PSNR values.

Results: The Gaussian filter achieved the best performance, with PSNR values of 66.79 dB and 46.6 dB for salt-and-pepper and Poisson noise, respectively, while CLAHE performed best for Gaussian noise (PSNR=50 dB). PSNR values were significantly affected by the enhancement technique used, according to ANOVA (F=1.08×10⁴, p <0.001).

Conclusion: The Gaussian filter successfully lowers noise and greatly improves image contrast, making these techniques useful for the precise and early identification of breast cancer in mammograms.

Background and objective: Subconjunctival hemorrhage (SCH) is a common condition; one of its important causes is intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF), which is used to treat various ocular pathologies. In this study, we aimed to decrease subconjunctival hemorrhage with the use of a 5% phenylephrine hydrochloride topical drop.

Methods: Prospective, randomized, single-blind, multicenter study. One hundred patients (116 eyes) with different retinal pathologies were enrolled, divided into two groups: group 1, 50 patients (60 eyes), received one drop of phenylephrine, and group 2, 50 patients (56 eyes), received a drop of distilled water, fifteen minutes before intravitreal injection. Patients were examined by slit lamp for presence of subconjunctival hemorrhage 24 hours after the injection.

Results: The frequency of subconjunctival hemorrhage in the intervention group was 23.3% (14 of 60 eyes), notably less (p=0.041) than in the control group (41.1%, 23 of 56 eyes).

Conclusion: Administration of topical phenylephrine hydrochloride 5%, 15 minutes prior to intravitreal injection of anti-VEGF, appears to be an effective and straightforward approach for reducing or preventing subconjunctival hemorrhage (SCH) — a commonly reported complication following such injections. This strategy may contribute to improved patient comfort and compliance with ongoing intravitreal therapy.

Background and objective: Approximately one-third of health systematic reviews do not employ meta-analysis, and novice reviewers may report narrative syntheses with insufficient methodological detail. Established resources such as PRISMA 2020, PRISMA-P, SWiM, the Cochrane Handbook, and GRADE provide complementary guidance but are distributed across separate documents. This guideline provides a practical, step-by-step approach for conducting and reporting systematic reviews without meta-analysis for students at Hawler Medical University.

Methods: The 19-step guideline was developed by mapping complementary recommendations from PRISMA 2020, PRISMA-P, SWiM, the Cochrane Handbook, MMAT, Garrard's matrix method, GRADE, and JBI guidance across four sections: Methods (Steps 1–9), Results (Steps 10–13), Discussion (Step 14), and Conclusion and reporting elements (Steps 15–19). Reporting standards were distinguished from methodological guidance and institutional recommendations. Each step identifies its intended location, procedure, rationale, and corresponding reporting output. A draft was circulated to a panel for feedback and revised with an audit trail.

Results: The guideline links methodological decisions to reporting outputs, including protocol development and registration, topic scoping, reproducible search design, eligibility criteria, two-stage screening, design-appropriate critical appraisal, standardized data extraction, and structured synthesis. It emphasizes reviewer calibration, transparent documentation, and selection of synthesis methods according to the review question and evidence type. Worked examples, synthesis matrices, and conceptual models are presented as optional teaching tools where appropriate rather than universal requirements.

Conclusion: This practical 19-step guideline integrates established methodological and reporting resources into a single institutional framework for systematic reviews without meta-analysis. It is intended to support novice reviewers while allowing methodological choices to vary according to the review question, study designs, and evidence type. The framework also incorporates considerations relevant to Iraq and the Kurdistan Region and should be refined through future usability and implementation evaluation.