Karbala Journal of Medicine

bThe current standard method for diagnosis of celiac disease (CD) is an
adequate small-bowel biopsy (usually obtained through upper gastrointestinal tract
endoscopy) showing characteristic histopathological changes, followed by a
therapeutic response to a gluten free diet. Commercially available IgA tissue trassglutaminase
antibody (TTG) screening tests have been developed with variable sensitivities and
specificities. The use of high titer cutoff values than currently recommended should improve
the specificity of the test and its positive predictive value.
Objectives. To evaluate the significance of high TTG titers in the diagnosis of CD.
Methods. One hundred sixteen patients with signs and symptoms suggestive of CD had
undergone TTG testings (IgA &IgG class) and small-bowel biopsies while 50 healthy
volunteers without family history of CD, were sent for TTG testings only. Ten patients
excluded from the study because their TTG values and small-bowel biopsies were negative.
Results. Ninety eight of 106 zpatients demonstrated positive biopsy results. Seventy two of
106 patients had IgA TTG levels of >100U/ml, with 70 of 72 exhibiting positive biopsy
Results. Twenty two of 28 patients with IgA TTG values >18-100U/ml exhibited positive
biopsy results. Six patients with negative IgA TTG levels of ≤18 U/ml had positive biopsies
and positive IgG TTG levels (>18 U/ml).Two volunteers had positive IgA TTG levels
(>18U/ml).The sensitivity and specificity of IgA TTG were 94.3% and 96% respectively
while the sensitivity of duodenal biopsy was 92.6%(8 symptomatic patients had negative
small-bowel biopsy while their IgA TTG values were positive).
Conclusions. Symptomatic patients with high titer TTG levels >100 U/ml can be treated as
CD without small-bowel biopsy and a negative biopsy does not exclude CD

bNeonates G6PD deficiency screening has been recognized as an essential
component of public health care in most developed and some Mediterranean
countries. However, such screening is yet to be widely embraced in Iraq. More than
442 variants of G6PD have been identified by various molecular methods. The aim of the
present study was to determine the normal values of G6PD and deficiency prevalence of this
enzyme in male neonates and then determination of the type molecular variant of G6PD
prevalence in Middle Euphrates Province of Iraq.
Objective: The objective of this study was to investigate the molecular basis of glucose-6
phosphate dehydrogenase (G6PD) deficiency in hyperbilirubinemic neonates in Middle
Euphrates province of Iraq. Molecular methods (genomic DNA extraction, polymerase chain
reaction and restriction fragment length polymorphism analysis) and then investigate the type
of G6PD variant predominantly present have been performed.
Methods: The study included a total of 917 full-term male neonates which were divided into
two groups:
The first group which include 704 neonates (76.8%) associated with severe
hyperbilirubinemia were admitted in Middle Euphrates Province Teaching Hospitals of
Maternity and Pediatrics during 1st Oct., 2007 to 12th July, 2008 with age ranged between 1 – 28 days, their total serum protein , TSB levels ≥ 15 mg/dl.
The second group which include 213 neonates (23.2%) with the same age ranged were
used as control group, their TSB levels ˂ 1 mg/dl. The blood sample taken from each neonate
was divided into two aliquots: the first aliquot was used for the determination of total and
serum conjugated bilirubin (TSB and SCB), and G6PD activity. The second aliquot was used
for molecular analyses including genomic DNA extraction and then application of
polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP)
protocols.
Results and Discussion: Severe hyperbilirubinemic neonates were screened for erythrocyte
G6PD enzyme activity, severe G6PD deficiency was detected in 75 of 704
hyperbilirubinemic neonates included and their activity levels was significantly decreased (P
< 0.05) to less than 10% of that found in control group. Therefore, the incidence of severe
G6PD deficiency identified in Middle Euphrates Province of Iraq was 10.65%. TSB levels
were markedly elevated to ( ≥ 15 mg/dl), whereas the mean ± SD values of SCB were
significantly lower than that found in controls (P < 0.05) , SCB was undetectable in 32 of 75
(42.67%) of hyperbilirubinemic neonates with severe G6PD deficiency which imply a partial
defect of bilirubin conjugation. The molecular part of the study involved the extraction of
genomic DNA from hyperbilirubinemic neonates with severe G6PD deficiency which was
detected by agarose gel electrophoresis and then amplified by PCR and finally was subjected
to digestion by endonuclease restriction enzymes to create RFLP and to enable the detection
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Karbala J. Med. Vol.3, No.3,4, Dec, 2010

Molecular Basis of G6PD Deficiency in Hyperbilirubinemic…. Fadhil Jawad Al-Tu'ma
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Karbala J. Med. Vol.3, No.3,4, Dec, 2010
of mutation that caused G6PD deficiency. The majority of affected severe G6PD deficient
neonates with hyperbilirubinemia in Middle Euphrates province – Iraq, were due to G6PD
Med variant (C563T, Ser 188 Phe) , of such 67 of 75 neonates (89.3%) have this type of
mutation, and 5 of 75 (6.67%) have G6PD A- variant (G202A ; A376G mutations), whereas
only 3 of 75 (5.3%) remain unknown G6PD variants which require future molecular studies.
Conclusion: The predominant G6PD gene detected in hyperbilirubinemic neonate with
severe G6PD deficiency in Middle Euphrates province was G6PD Med.variant.

bThe objective of this study was to evaluate the effectiveness of screening
laryngoscopic examination in evaluating vocal fold (VF) mobility before and after thyroid
surgery.
Patients and methods: A prospective study of 112 patients underwent thyroid surgery at the
Hilla teaching general Hospital and Al-Shafaa private hospital were undertaken in order to
study the patterns of pre-operative and postoperative voice changes and Indirect laryngoscope
(IDL) findings. Patients with pathologic findings at postoperative laryngoscopy underwent
reassessment of voice and (VF) mobility for 6 months duration.
Results: A total of (9.8 %) of patients had pre-operative suspicion of VF Palsy, only (27.3
%) of this group had abnormalities detected on pre-operative IDL .Of 101 documented IDL,
no vocal cord pathology in asymptomatic patients were detected.
Post operatively
Conclusions: Preoperative laryngoscopy is necessary in symptomatic patients and those who
undergo re operation or in patients when malignancy is suspected. The necessity of a
preoperative laryngoscopy in all other patients must be questioned. Postoperative
laryngoscopy and additional diagnostic testing better to be reserved for symptomatic patients.

b The main causes of menstrual cycle disturbances are
classified as hormonal abnormalities, structural abnormalities, bleeding diatheses,
anovulation, polycystic ovary (PCO), obesity and miscellaneous. In this work, the
prevalence of endocrine disorders in Iraqi women with menstrual disturbances was estimated.
Patients and Methods: One hundred Eighteen females with menstrual disturbances
(delay>10 days occasionally) were included in this study in addition to thirty seven control
women. They were attending to the gynecological clinics for regulation of menstruation
cycle. The study excluded any women taking steroid hormones, neuroleptics, anticoagulants
and cytotoxic agents that frequently lead to menstrual disturbances. Luteinizing hormone
(LH), follicle stimulating hormone (FSH), thyroid stimulating hormone (TSH), prolactine,
total testosterone, estradiol (E2) and progesterone were estimated in the second day of the
menstrual cycle using ELISA technique using a ready for use kits.
Results: The endocrine disorders in menstrual disturbances in the Iraqi women under study
were: 16.1% hypothyroidism, 3.4% hyperthyroidism, 3.4% type 1 diabetes mellitus, and
pituitary tumor was observed in 1.6 % of patients. Additionally, there is a high prevalence of
patients with POCS cases and a high significant increase in the mean of BMI in the patients
when compared with the control women.
Conclusion: Surprisingly, the most common endocrine disorder in the women with menstrual
disturbances group was hypothyroidism. Additionally the PCO is common in these women.
The prevalence of endocrine disorders in irregular women in Iraq was lower than the other
countries and the type of prevalent endocrine disorders is different

bMorphological changes of megakariocytes are common and they are
different according to the cause of thrombocytopenia.
Aim: To differentiate the morphological changes of megakariocytes according to the
cause of thrombocytopenia.
Materials and methods: A total number of 88 cases of symptomatic thrombocytopenia (in
which bone marrow examination was indicated) were included. The study was done in a legal
private laboratory for hematological investigations (Zaid Bin Ali private laboratory) in
karbala city. Patients with thrombocytopenia were referred from different specialists. Blood
samples were taken for complete blood picture and platelet count. Thrombocytopenia was
defined as platelet number below 100 X109/L. Bone marrow aspirate samples were taken,
bone marrow smear slides were made, fixed and stained by Leishman stain, dried and
examined under the light microscope for various abnormal morphological changes of
megakariocytes. Normal megakariocytes were defined as the largest marrow cells which
retain lobulated nuclei (4-16 lobes) while abnormal morphological changes include large
magakariocytes with dispersed nuclear lobes, dwarf micromegakario- cytes, juvenile
megakariocytes, emperipolesis, megakariocytes with bare nuclei, presence of cytoplasmic
vacuoles, hyperpolyploidy (defined as nuclear lobes more than 16) and hypopolyploidy
(defined as nuclear lobes less than 4). Using Fisher’s exact test, P value of less than 0.05 was
considered to be significant.
Results: Large magakariocytes with dispersed nuclear lobes, dwarf micromegakariocytes,
juvenile megakariocytes and emperipolesis were 31% (9 out of 29), 34.48% (10 out of 29),
96.55% (28 out of 29) and 72.41% (21 out of 29), respectively in cases of thrombocytopenia
which are caused by ITP.
Large magakariocytes with dispersed nuclear lobes, dwarf micromegakariocytes, juvenile
megakariocytes and emperipolesis were 71.42% (5 out of 7), 85.71% (6 out of 7), 57.14% (4
out of 7) and 57.14% (4 out of 7), respectively in cases of thrombocytopenia which are
caused by MDS. In MDS, the presence of large magakariocytes with dispersed nuclear lobes
and dwarf micromegakariocytes was statistically significant when compared with other
diseases that cause thrombocytopenia (P<0.05).
The other abnormal morphological changes of megakariocytes in cases of thrombocytopenia
are shown in table 1. While the presence of one or more megakaryocytic changes or absence
of such changes in various hematological cases of thrombocytopenia are shown in table 2.
Conclusion: There are great interactions and similarities in morphological changes of
magakariocytes among different hematological diseases; however, the diagnostic approach
will vary when detailed knowledge about morphological changes of megakariocytes is
available.

bDiabetes can affect the health of the teeth and the surrounding
structures that are increased the risk of developing periodontal disease that resulting
destruction of the bone and the periodontal tissues that lead to greater teeth loss than
those without diabetes.
Objectives: The aim of this study to compare the teeth loss of the diabetic and non
diabetic patients considering the age, sex , duration of the disease and oral health
behaviors.
Methods: Teeth loss of 67 adult diabetics and 67 non-diabetic patients of age 45-74
years old were examined also diabetic group was compared according to the duration
of the disease. The oral health behavior including the frequency of the tooth brush per
day, cleaning method, and tobacco use were compared among the diabetic and non
diabetic groups.
Results: There is highest significant difference in mean number of the teeth loss
between the diabetics and non diabetics with non significant difference between the
patients of more than 10 years and less than 10 years of the duration. The diabetics
showed significantly higher frequency of the tooth brush and tobacco use than non
diabetic group and the teeth loss decreased with increased the frequency of the tooth
brush.
Conclusions: The teeth loss was greater in diabetics than non-diabetics, when the
duration of the disease was increased there was increased in teeth loss. The study
indicated that diabetic subjects should improve their oral hygiene practices

bSchistosomial infestation is commonly infested the appendix. However it
is not known if this- is a predisposing, factor for appendicitis, or a mere coincidental
histological finding.
Patients and methods: In the present study a total of 48 cases (40 males and 8 females)
underwent appendectomy for schistosomal appendicitis over a 10-year period at Basrah and
Hilla Teaching hospitals were studied. Their histological slides were reviewed carefully.
Results: showed that the highest incidence of schistosomal appendicitis was recorded in the
21-40-year age group. Ova were seen in the submucosal layers of all the excised appendices.
The most common tissue responses were submucosal fibrosis (93.8%) and eosinophilia
(89.6%), followed by the presence of suppurative inflammation (75%). Granulomatous
reaction was evident in 32 cases (66.6%),and commonly found in the serosa and submucosa.
A feature of atrophy of submucosal lymphoid follicles was noted in 48% of the cases and
hyperplasia in 44%. most.. Similar tissue responses were histologically seen in three normal
appendices examined.
Conclusion: Appendiceal infestation may predispose to appendicitis in the majority of
affected cases, but in others, it may well be a mere coincidental histological finding.
However, preoperative knowledge bears no Clinical significance and does not alter
management.

bUric acid (UA) can stimulate the biosynthesis of c-reactive protein (CRP), and
that might be one of the mechanisms underlying the endothelial dysfunction. Several studies
showed an independent link between UA and CRP suggest that chronic exposure to mild
hyperuricemia may be a factor that contributes to micro inflammation and raised CRP in
individuals with essential hypertension.
Aim: The aim of this study is to investigate the relationship between the serum uric acid,
CRP , total cholesterol and endothelial dysfunction in patient with essential hypertension .
Patients and methods: Twenty patients with essential hypertension and fifteen apparently
subjects matched for age and weight have been included in this study, Uric acid and total
cholesterol were determined by enzymatic methods. High sensitivity C-reactive protein
(HsCRP) enzyme immunoassay for the quantitative determination in human serum was used.
Results: The data obtained showed that the serum levels of uric acid, CRP and total
cholesterol were significantly higher in patients with hypertension than in healthy controls.
Conclusion:
The conclusion was that hyperuricemia in individuals with essential
hypertension is associated with endothelial dysfunction. This association, which is
independent of classical risk factors like total cholesterol, CRP, supports the hypothesis that
UA plays a significant role in this alteration in humans.

bThere are two main medical teaching systems; the older traditional and the newer
of block courses methodology. Sequential feedback evaluation of the medical graduates is
mandatory in the accredited medical colleges.
Most of Iraqi medical colleges apply the traditional UK teaching system.
Aims: To evaluate the clinical skills experiences of Iraqi medical college's outcomes and to remind
health authority on the resident competency level in order to achieve effective internship training and
safe health service.
Subjects and methods: During December 2010 a feed back self evaluation was performed for 38
new resident doctors (♀/♂; 26/12), (26) were from University of Karbala, while the rest from other
universities. The checklist consisted of 52 randomly closed basic medical skills.
Results: Responding rate were (100%).In (16) skills group (34) 94%-(20), 52% respondents claimed
having proper performance (median73). In the other 2/, (32) skills3group, (12), 32%-(0), 0%
respondents claimed having the skills (median; 22.5). All were untrained to perform 3 life supporting
skills. (1♂&8♀) of graduates had the experience to examine the similar sex genitalia. (35; 92%) of
graduates were unconfident about their clinical skills.
Conclusion: The medical college graduates are under the supposed level of the faculties` objectives.
Faculties should implement sequential outcome evaluations, depend the more contemporary
integrated teaching methodology aided by the clinical skill labs, and concern the emergency and
inpatient training under supervision of expert staff.

bThe aim of this study is to know the opinion of the patients whom had been
diagnosed as acute appendicitis and their operations were deferred to the next
morning instead of being done at the same night of their admission.
Patients and Methods: 102 consecutive patients admitted to the AL Hilla teaching general
hospital from the period of Oct/31/2008 to Feb/28/2009 diagnosed as acute appendicitis were
admitted from the causality department .Their operations were deferred to the next day for
different reasons. Observations overnight were done and then postoperatively a Questionnaire
were given to the patients to know their opinion regarding the deferred operation and their
overnight complaining.
Results: 102 patients were studded, their median age 23 years (10 -58 years); 48 males, 54
females. The majority of these patients (48) were presented between10-12pm.
70(68.6 %) patients remembered a reason for deferred operation and the remaining not
remembering being given an explanation.
66 (64.7 %) of the patients poorly slept preoperatively, mainly due to the pain and ward
noise. Operation on the same night as their admission was the preferred option in 82(80.4%)
patients. 67(65.6) patients would have preferred the admitting surgeon to perform their
operation; 18(17.6%) expressed no preference and 17(16.6%) patients preferred a 'new'
surgeon the following day. Of the 102 patients, 13(12.7%) patients did not know who had
performed their operation.
Conclusion: Most patients would prefer not to have their procedure delayed, In spite of
being told why their operation was delayed. Major determinant of patient opinion were lack
of sleep pre-operatively. Few patients asked for a 'new' surgeon to perform their operation.
There is no system arranges the work in our country for cases of acute appendicitis which
presented late at night so we need to improve our surgical practice by" Implementation of a
guideline to avoid out-of-hours operation done by a junior doctors'