Issue 5

Presentation of Kerosene Pneumonia and the Role of Corticosteroids in Its Management

Abdul Kareem Sallal

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 527-533

Objective: Accidental kerosene pneumonia is common form of acute childhood poisoning. Corticosteroid is used for treatment of kerosene pneumonia. This study has been conducted to clarify the presentation of kerosene pneumonia and the role of corticosteroid in its management. Methods: One hundred twenty two children with kerosene poisoning admitted to kerbala teaching hospital for children from January 2006 to January 2008. (Two patients were excluded from the study because they died within few hours after arrival, one due to deep coma and the other due to severe abdominal distention and bleeding per rectum). Sixty patients were chosen for corticosteroid therapy and 60 patients were taken as a control group. Symptoms and signs were recorded; chest x-ray, leukocyte counts and erythrocyte sedimentation rate also obtained at first, third, fifth, eighth and twelfth days of admissionResults: Of the 120 admitted children, 71(59.2%) were boys and 49(40.8%) were girls, with ages ranging from 6 months to 6 years .The largest group, (48.4%,) were admitted during the summer months .The most commonly observed symptoms were tachypnea (66.6%), fever (58.3%), cough (54.1%) ,vomiting (45.9%), 18% of the patients showed signs of central nervous system (CNS) impairment, including drowsiness, restlessness, and stupor. There was no difference between the two groups who were treated with corticosteroid and those without corticosteroid regarding the clinical course, duration of illness, fever, respiratory rate, heart rate, leukocyte counts, Erythrocyte Sedimentation Rate, and changes in x-ray findingsConclusions: There is a higher risk of hydrocarbon poisoning during the hot months of the year; the respiratory system is the main target organ affected, vomiting after hydrocarbon ingestion is related to the rate of development of pneumonia; symptoms of central nervous system impairment were correlated with pneumonia, and fever. Corticosteroids are ineffective in altering the acute course of hydrocarbon pneumonia, shortening the duration of the disease, alleviation of symptoms and signs or prevention of complications.

Value of Quantifying the Intratumoral Microvessel Density Based on Immunohistochemical Detection of PECAM-1 and vWF in Colorectal Carcinoma from Iraqi Patients

Mohanad M. Ahmed; Suhad H. Mohammed

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 534-548

Counting of newly formed microvessel may prove to be a useful tool in the early detection of metastatic potential and selection of patients for whom antiangiogenesis drugs might be beneficial. Aim of the study: We designed this study to assess the significance of microvessel quantification in colorectal cancer with respect to different clinicopathological variables. Subjects and Methods: forty archived paraffin embedded colorectal adenocarcinoma samples and their resection margins were enrolled in our study. Thin paraffin embedded sections (3-5μm thick) of both tumor and resection margins were prepared for each respective biopsy and were used to detect endothelial cell surface expression of PECAM-1 and vWF, by and immunohistochemistry technique. Results: Based on the current outcome, there were significant differences in microvessel density based on PECAM-1 or vWF immunostaining when each tumor sample were compared to its respective resection margin (p<0.001and p<0.001, respectively). In addition, tumors ≥3mm3 in size demonstrated a significant increase in their microvessel density compared to their counterparts whether PECAM-1 or vWF immunostaining was applied (p<0.001 and p<0.001, respectively). Moreover, when tumor samples were analyzed based on their depth of invasion, for intratumoral microvessel count, exclusively, vWF immunostaining analysis demonstrated significant differences among the three groups SMP, SE, and OR since the latter came up with the highest microvessel count (p<0.05). When tumor lymph node metastases was questioned, exclusively, vWF immunostaining were significantly differentiated among N0, N1, and N2 groups (p<0.05). Concerning the possible correlations between the two investigated parameters in respect to various histopathological variables; both PECAM-1 and vWF immunostaining demonstrated significant positive correlations in tumor samples (r=0.37), whereas in resection margins, these correlations were absent. Although PECAM-1 and vWF immunostaining revealed significant and positive correlations within tumor differentiation (WD: r=0.56, MD: r=0.57, and PD: r=0.89) as well as with tumor stage (A-B: r=0.39 and C-D: r=0.31), still, they seem to correlate significantly and exclusively within SE group (r=0.74), tumors <3mm3 in size (r=0.66), N0 (r=0.36), and N1 (r=0.85) groups. However, PECAM-1 and vWF immunostaining revealed significant but negative correlation exclusively within N2 group (r= -0.38). Conclusions: In conclusion, microvessel count could be useful as a predictor for tumor metastases in patients with colorectal adenocarcinoma. Possible interpretations of the current outcome are explained thoroughly in the text.

Efficacy of Subcutaneous Epinephrine versus Nebulized Salbutamol in the Emergency Department Treatment of Bronchiolitis………………………………………………………………….………

Jasim M. Al-Marzoki

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 548-562

background: By age 2 years, 50% of children will have been infected with
bronchiolitis, with severe disease more common among infants aged 1–3
months. Despite wide spread use of nebulized B2-agonists in infants with
bronchiolitis since the late 1950s, the efficacy of these drugs remains unproven.
Statistical improvement in clinical scoring systems seen with the use of beta agonists
is not always clinically significant, and desaturations have been reported after
salbutamol nebulization. Epinephrine hydrochloride is being used with increasing
frequency in bronchiolitis. Subcutaneous administration of it may produce its effects
within 10 minutes and maximal effects in about 30 minutes.
Aim of the study: To determine the efficacy of S.C Epi. versus Neb. salbutamol in
the Emergency Department treatment of patients (age 2 years or less) with
Patients and method: Two hundreds patients less than 2 years of age with a clinical
diagnosis of bronchiolitis were enrolled in a prospective, randomized and controlled
study to receive either subcutaneous epinephrine (n=100) or nebulized 0.5%
salbutamol sulfate (n=100). This study was done in the Emergency Department of
Babylon maternity and children teaching hospital. Study enrollment occurred in
sequential winter season from the first of September 2007 to the first of March 2008.
Results: There is high significant improvement in O2 saturation at 30 and 60 min., in
respiratory rate at 60 and 90 min., heart rate improvement at 60 min. and better
improvement in the wheeze, chest retraction, nasal flaring, and reduced rate of
admission to the wards in patient who were treated with subcutaneous epinephrine
than those who were treated with nebulized salbutamol.
Conclusions: The response to subcutaneous epinephrine in patients younger than 12
months was better than older patients. Subcutaneous epinephrine improves the
clinical manifestation and parameters of respiratory distress with maximum
effectiveness at 30-60 min. Subcutaneous epinephrine decreases the load of patients
on E.D and reduces the rate of admission to the wards in comparison with nebulized

An In-vitro Study to Predict the Activity of Clotrimazole against Lishmania Donovani Promastigotes

Ali Mansour Jasim

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 563-567

AbstractStudy design and objective: this in vitro experiment was done in Kufa Medical College during March through July 2008 to predict the effect of clotrimazole on Leishmania donovani promastigotes (LDP) in term of growth inhibition and this effect was compared with that of meglumine antimoniate and placebo (control).Method: Leishmania donovani promastigotes were isolated and cultured in Rosewell Park Memorial Institute (RPMI) medium supplemented with 10% fetal calf serum (FCS). Promastigotes were then transferred in two 96-well plates with equal cell count (1 milion LDP/ml). Clotrimazole in final concentrations 5 and 10 µg/ml was added to the two test groups (30 wells each), and meglomine antimoniate (20 µg/ml) was added in other 30-well group, and a forth group was kept as a control.Results: After 3 days of incubation, LDP in the tests and control groups were counted to predict the growth inhibition effect of the clotrimazole (5 and 10 µg/ml) which were about 79% and 95% respectively, compared to that of meglumine antimoniate which eliminated about 89% of LDP at 20 µg/ml.Conclusion: clotrimazole was shown to have a reliable antileishmanial activity in vitro and it is recommended to be used as systemic (oral) treatment for visceral leishmaniasis in future.

Thyroid Role in Threatened Abortion

Thura jaafar kadhum

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 568-575

Background: Mild impairment of thyroid function may contribute to disturbed reproductive function. Objective: To evaluate the role of thyroid hormones in maintaining early pregnancy and their association with the outcome of the threatened abortion.Materials and methods: The study was carried out in Maternity and pediatric Teaching Hospital in Al-Najaf during period between 1st April to 1st September 2008. The study included 80 pregnant women divided into two groups 50 women with threatened abortion and 30 women with normal pregnancy of comparable age, parity, gestational age and body mass index (BMI). Both groups were subjected to clinical examination, obstetric ultrasound examination and were investigated for hemoglobin, total thyroxine (TT4), total tri-iodothyronine (TT3) and thyroid stimulating hormone (TSH). The group of threatened abortion women divided into two groups where 31 women had a positive outcome (continuation of pregnancy to the third trimester) and 19 women had a negative outcome (pregnancy ended with spontaneous abortion). Results: There was a significant difference in the level of TT3 and TSH between the control group and the women with threatened abortion (lower TT3 and higher TSH in threatened abortion women) with no significant difference in TT4 between the two groups while TT3and TT4 levels were significantly reduced in the women with negative outcome as compared with the women with a positive outcome while the TSH level was significantly increased in the women with negative outcome. Conclusion: reduced levels of thyroid hormones in early pregnancy may contribute to some cases of spontaneous abortion.Key words: thyroid hormones, pregnancy, abortion.

Assessment of Nurse – Midwives Practices concerning perinatal care throughout stages of labor

Rabe; a Muhsen Ali; Ahrar Muhssan Rasheid

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 576-588

Objective: To assess the Nurse – Midwives practices concerning the management during stages of labor. To find out the association between the Nurse – Midwives practices and certain variables. Methodology: A questionnaire was prepared for the purpose of this study which was consisted of (2) parts, including: sociodemograghic characteristic concerning Nurse – Midwives, second part consists of (60) items show practices of Nurse – Midwives throughout 1st, 2nd, and 3rd stage of labor. The sample of the study consisted of (75) Nurse – Midwives who they working at delivery room in Baghdad hospitals. A suitable statistically means were used to analyze the findings of the study. Results: The results revealed that there was statistical significant between nurse – midwives practices concerning first stage of labor and working shifts & birth / average, and significant between nurse – midwives practices concerning second stage of labor and educational level, birth / average, and significant between nurse – midwives practices concerning third stage of labor and age of nurse – midwives. Recommendation: The investigators recommend that installing inservice educational program for Nurse – Midwives to upgrade the techniques necessary to assess, evaluate and improve the quality of care rendered to laboring women, and conduct training course for the Nurse – Midwives periodicly in order to change their malpractices to good practices. Keyword: Assessment of Nurse- Midwives practices perinatal care.

The Effect of Maternal Anaemia on Cord Blood Haemoglobin and Newborn Birth Weight

Nadia Mudher Al-Hilli

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 589-593

Background: Maternal anaemia is a common problem in pregnancy, particularly in developing countries. Iron requirements increase during pregnancy, and a failure to maintain sufficient levels of iron may result in adverse maternal-fetal consequences.Aim of study: To determine the effect of maternal anaemia on fetal cord blood haemoglobin & its birth weight.Patients & Methods: The study was conducted in Babylon Teaching Hospital for Gynaecology & Paediatrics from February 2008 to February 2009. The study included ninety pregnant women at term who attended the labour room & they were in labour. Fifty women were anaemic with a haemoglobin level less than 11 g/dL, while the other fourty had normal haemoglobin. Women under study were assessed & followed up through out labour. After delivery of the baby, the cord clamped & divided then blood sample taken from the cord & sent for PCV assessment. The newborn weighed and the results compared between the two groups.Results: cord blood haemoglobin & newborns weights were lower in anaemic women compared to non-anaemic women at the same gestation.Conclusion: Maternal anaemia has a lot of consequences including neonatal complications like neonatal anaemia. In addition, there is a positive relation between maternal haemoglobin fetal cord blood haemoglobin.Recommendations: Optimization of maternal haemoglobin with good nutrition, iron supplementation & good spacing between pregnancies will avoid a lot of complication of maternal anaemia.

Congenital Anomalies Admitted to Intensive Neonatal Care Unit in Babylon Maternity and Pediatric Teaching Hospital……………………………………………………...……………………………

Bushra J. AL- Rubaii; Yahya A. AL-Tufaily; Abdul kareem A. Jasim Abushrayda; Mohammad Fakhri

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 594-598

background: The number of recognizable patterns of malformations have
more than tripled during the last 25 years. The potential prenatal effect of
various drugs, chemicals and environmental agents is better appreciated and
the number of genetic and non genetic defects has increased.
Aim of the study: to study the prevalence of the structural defects in the live
newborns in Babylon city.
Materials and Methods: Our study provides the structural defects that have been
detected in live newborns referred from the labor room and operative theater to the
Neonatal Intensive Care Unit (NICU) within one year. Information were taken from
the caregivers in a uniform list, examination of the newborn by pediatrician and
analysis of the data using chi square.
Results: During one year, 70 live newborns with birth defects admitted to NICU.
Thirty- four of them with neural tube defects (49%), cleft lip and / or cleft palate nine
cases (12.8%), achondroplasia six cases(8.5%), Down Syndrome five cases(7.1%),
ambiguous genitalia three cases( 4.3%), arythrogryposis multiplex three cases( 4.3%)
,imperforated anus two cases(2.9%), Prunbelly Syndrome two case(2.9%),
phacomelia, genovalgum, congenital heart disease, icthyosis each one case (1.4%).
Conclusion: Most patients with congenital anomalies had neural tube defects,
necessitating stress on preconception folate supplementation

The Possible Role of Peripheral Blood Lymphocytes in the Pathogenesis of Diabetes Mellitus…..

Haider Sabah Kadhim

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 599-603

background: Diabetes mellitus (DM) is disorder with world wide distribution
with severe complications and high mortality rate.
Aim: Our study shed light on the possible role of peripheral blood
lymphocytes (PBL) B-cells and T-cells and subsets (T-helper (CD4) and T-cytotoxic
(CD8)) in the pathogenesis of DM.
Patients and Methods: In this study, 40 patients with type-1 DM, and 40 patients
with type-2 DM, with 22 age matched control group were included.
Immunocytochemistry for PBL for each group were done to detect the level of B-cell
(CD19), T-cell (CD3), T-cell subsets CD4 and CD8.
Results: The results showed a significant difference between control group and DM-1
in CD8, while DM-2 showed a significant differences in CD3, CD8 and CD19. A
significant difference also seen between type-1 and type-2 DM in CD3 and CD19
markers, while CD4 and CD8 were not significant.
Conclusion: This study may explore the role of the immune cells, T-cells (CD3, CD4
and CD8) and B-cells in the pathogenesis of DM especially type -1 DM as it is the
prototype of autoimmune disease.

A Study of Cerebral Vasoreactivity: Middle Cerebral Artery (MCA) Versus Ophthalmic Artery (OPA)

Akeel A Zwain

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 604-615

background: Cerebral vaso reactivity describes the ability of the cerebral circulation
to respond to vasomotor stimuli which would reflect preserved auto regulatory
mechanism. Recently, cerebral autoregulatory capacity in humans can be studied
noninvasively by TCD. The degree of cerebral vasodilatation can be measured by the
increased middle cerebral artery (MCA) blood flow in response to hypercapnea induced by
either administration of 5% CO2 or I.V acetazolamide; few studies available on breath hold
induced cerebral vasodilatation. Cerebral vasoconstriction can be measured by the decreased
MCA blood flow in response to hypocapnea induced by hyperventilation. However,
conflicting reports exist on the modulatory effect of hypercapnea (induced by breath holding)
or hypocapnea (Induced by hyperventilation) on the ophthalmic artery (OPA) blood flow.
Objective: To demonstrate changes in MCA & OPA blood flow using physiological stimuli.
Secondly, to investigate whether or not OPA would respond in a similar fashion to MCA, to
the fore mentioned stimuli.
Methods: 30 healthy individuals were enrolled, using a TCCD sonography; the MCA and
OPA were insonated utilizing transtemporal and transorbital windows respectively. A mean of
10 cardiac cycles were used to estimate the base line control of Doppler derived spectral wave
forms regarding mean flow velocities (MFV) and resistant indices (RI). The response of
change of MCA flow or OPA flow to hypercapnea induced by breath hold (BH) was
measured during the last 5 seconds and that to hypocapnea induced by hyperventilation (HV)
was measured during 1.5min.
Results: In 30 Middle cerebral arteries examined, during breath hold, the MFV(mca) was
significantly increased (p<0.001) from a mean of 41.15±2.00cm/sto a mean of 55.22±2.66
cm/s. No significant increase of RI obtained (P>0.05); the breath hold index was of a mean of
0.38±0.077. When performing hyperventilation, The MFV(mca) significantly decreased
(p<0.001) from a mean of 41.15±2.00cm/s to a mean of 26.72 ±1.72cm/s; there was
significant increase in RI (p<0.001) from a mean of 0.54±0.011to a mean of 0.63±0.015. The
calculated MCA full range of vasodilatation was of a mean of 60℅±3.51. In 30 ophthalmic
arteries examined, during breath hold, The MFV(opa) significantly decreased (p<0.001) from a
mean of 18.49±1.12cm/s to a mean of 14.55± 1.20cm/s; no statistical significant decrease of
RI during breath hold obtained. When performing hyperventilation, the MFV(opa) significantly
increased (p<0.001) from a mean of 18.49±1.12cm/s to a mean of 24.09±1.27cm/s; there
was no statistical increase of RI (P: 0.05). The calculated OPA full range of vasodilatation
was of a mean of 57.03%±4.53.
Conclusion: Ophthalmic artery flow behaves in a different and opposite manner to that of
MCA in response to Hypercapnea and hypocapnea

Pancytopenia in adult Iraqi patients in Medical City of Baghdad (A prospective and retrospective study)

Raheem Mahdy Raheem

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 616-622

background: Pancytopenia is a term used to describe the simultaneous
presence of anemia, leucopenia and thrombocytopenia. Different
hematological and non hematological disorders may present with
pancytopenia e.g. aplastic anemia, acute leukemia, megaloblastic anemia, etc...
Aim of the study: The aim of this study is to identify the causes and presenting
symptoms of pancytopenia in Iraqi patients.
Patients and Methods: This study evaluated 173 patients admitted to Baghdad
Teaching Hospital between January 2004 and August 2006. Criteria for inclusion
were; anemia (PCV < 0.30 L/L), plus leucopenia (WBC count < 4 × 10 9 /L) and
thrombocytopenia (platelet count < 100 × 10 9/L). Cases of pancytopenia induced by
chemotherapy or radiotherapy were excluded. The adult patients were randomly
selected regarding age and sex. This study included 94 male and 79 female patients,
with age range from 15 to 79 years. Peripheral blood examination and bone marrow
aspiration were done in all patients, while bone marrow biopsy done in 98 patients.
Results: The major causes were acute leukemia in 66 (38.2 %) patients, aplastic
anemia in 31 (17.9 %) patients, megaloblastic anemia in 29 (16.8 %) patients and
myelodysplastic syndrome, non-Hodgkin lymphoma , systemic lupus erythematosus,
hypersplenism, hairy cell leukemia, kala-azar, paroxysmal nocturnal haemoglobinuria
and multiple myeloma constituted the remainder causes. The maximum age group of
patients presented with pancytopenia ranging in 21-30 years with male to female ratio
1.2:1. The major presenting symptoms were bleeding tendency found in 69 (39.9 %)
patients followed by easy fatigability found in 56 (32.4 %) patients and fever in 48
(27.7 %) patients , while common presenting signs were pallor, petechiae,
splenomegaly, hepatomegaly and lymphadenopathy. The most common peripheral
blood findings were anisopokoilocytosis, circulated immature cells and blasts cells.
Conclusions: Acute leukemia, aplastic anemia and megaloblastic anemia are the
major causes of pancytopenia, however, uncommon and rare causes like
myelodysplastic syndrome, non-Hodgkin lymphoma, systemic lupus erythematosus,
hypersplenism, hairy cell leukemia, kala-azar, paroxysmal nocturnal haemoglobinuria
and multiple myeloma could be presented with pancytopenia. Major presenting
symptoms were bleeding tendency, easy fatigability and fever, while common
presenting signs were pallor, petechiae, splenomegaly, hepatomegaly and
lymphadenopathy. Careful physical examination and peripheral blood smear
examination play an important role in planning investigations of pancytopenia.

The Influence of Body Weight on the Serum Sialic Acid Levels in Lymphoma Patients

Dafer A. Faysel; suaad L. Ibraheem

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 623-629

the a prospective study of the effect of body weight of 70 patients with
lymphoma on the levels of serum sialic acid forms, total sialic acid, bound
sialic acid, free sialic acid and lipid sialic acid were measured. The results
were compared with those obtained from control groups which consisted of 50 person
of matched age and sex.
Objective: To determine the influence of body weight on the serum sialic acid forms.
Methods: The patients were categorized into four groups according to the certain
statistical methods. The first group comprised 24 patients who have weight 5-20Kg
range. The second group comprised 13 patients who have weight 21-40Kg range. The
third group comprised 12 patients who have weight 41-60Kg range. The fourth group
comprised 21 patients who have weight >60Kg.
Results: Significant elevations (P<0.005) of total sialic acid, bound sialic acid, free
sialic acid, and lipid associated sialic acid (TSA, BSA, FSA, and LSA respectively)
levels were seen in all groups of lymphoma patients when compared with those of the
healthy subjects. Total serum protein was decreased significantly (P<0.005) and
TSA/TP, BSA/TP, FSA/TP, and LSA/TP ratios raised significantly (P<0.005) in the
cancer patients in comparison with those of the healthy individuals.
Conclusion: Sialic acid is not specific marker for detecting lymphoma patients.
Keywords: Body weight, lymphoma patients, serum sialic acid

Treatment Failure of Tuberculosis in Diabetic Patients

Mosa Ismail Al-Karawi; Sadiq Al-Muhana

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 630-634

background: despite the availability of effective treatment , tuberculosis continues to
infect a large number of patients . Treatment failure is one of the major problems in the
TB control programs.
Objective: To evaluate the treatment failure in tuberculosis patients with diabetes
Patient & Method: In this retrospective study that extended from August 2007 to
August 2008, 69 patients with tuberculosis and diabetes mellitus and 105 patients
with T.B. only, were included .All patients were from Al-Najaf and treated by ( Direct
Observe Therapy programs)D.O.T.s .The patients are evaluated by the following data
:- demographic data, site of disease by CXR, date of initial diagnosis of TB., purified
protein derivative (tuberculin test ) results , smoking history. The data were analyzed
by using the statistical package social system (SPSS) and P. value <0.05 was regarded
as statistically significant.
Results: Patients with tuberculosis and diabetes mellitus were 69 (58 male and 11
female) equal to(40%) of the total patients were treated with direct observe therapy
(D.O.T.s) program, the treatment failure were 18 patients (12 male and 6 female)
equal to (26%) of patients in this group. Patients with tuberculosis only were 105 (89
male and 16 female) and equal to (60%) of the total patients were also treated with(
D.O.T.s ),and the treatment failure were 10 patients ( 7 male and 3 female) that equal
to (1o%) of patients in this group. The age group(30-50) years had a higher failure
rate in both groups . The failure was more in males, smokers, with tuberculin test
negative, and in upper lobe lesions.
Conclusion: There was a significant association between diabetes and failure in TB.
treatment, which is more in male, smoker , in those have negative tuberculin test , and
in TB of upper lobe of the lung .

A Study of Immunological and Clinical Effects of Alslergen Immunotherapy on Asthmatic Patients in Babylon Province

Amjed H. A. Al-Mansoury

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 635-644

background: Allergen immunotherapy has important benefits on asthmatic
patients by reducing symptoms and medication use and it can be used as an
alternative treatment.
Objectives: This study aimed to assess the effects of allergen immunotherapy (AI) on
asthmatic patients of Babylon Province.
Materials and methods: The study was performed on 35 asthmatic patients as
immunotherapy group who received allergen immunotherapy and 15 asthmatic
patients as control group who remained on pharmacotherapy, the patients were
assessed by measurement of peak expiratory flow rate (PEFR), total immunoglobulin
E (IgE) and immunoglobulin G (IgG) symptoms and medication use score at 0 time, 3
months, and 6 months.
Results: The study showed that 30-40 years age group population were more affected
with asthma (44%) and then the incidence decreased with increasing age. Females
might be more affected than males (60% compared to 40%).There were significant
increase in the mean levels of PEFR and total IgG and significant increase in the
mean levels of total IgE. In addition, the study revealed larger reduction in symptoms
and medications use score in immunotherapy group in comparison to control group.
Conclusion: AI should be used in allergic asthma as one of the modalities of
treatment because it can reduce the symptoms and medications use by changing the
basic mechanism of asthma.

Molecular Characterization of Severe G6PD Deficiency in Hyperbilirubinemic Neonates in Karbala : Iraq……

Fadhil J. Al-Touma; William M. Frankool

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 663-680

Objective: The objective of this study was to investigate the molecular basis of
glucose-6-phosphate dehydrogenase (G6PD) genes in hyperbilirubinemic neonates in
Karbala province of Iraq by using molecular methods (genomic DNA extraction, PCR
and RFLP analysis) and then to investigate the type of G6PD variant predominantly
Methods: The study included a total of 253 full-term male neonates, 197 of them
associated with severe hyperbilirubinemia which were admitted in Karbala Teaching
Hospital of Pediatrics during the period from 1st October 2007 to 14th July 2008 with
age ranged between 1 – 28 days, their TSB levels ≥ 15 mg/dl, and another 53 neonates
were used as control group. The blood sample taken from each neonate was divided
into two aliquots: the first aliquot was used for total and conjugated serum bilirubin
(TSB and SCB), G6PD activity. The second aliquot was used for molecular analysis
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 measurements, severe G6PD deficiency was
detected in 18 of the total 197 hyperbilirubinemic neonates included and their activity
levels was significantly decreased (P < 0.05) to 0.56 ± 0.32 U/g Hb. The incidence of
severe G6PD deficiency identified was found 9.14%. TSB levels were markedly
elevated to (20.26 ± 4.96 mg/dl), whereas the mean ± SD values of SCB were
significantly lower than that found in controls (P < 0.05) and reached to 0.053 ± 0.046
mg/dl , and it was undetectable in 5 of 18 neonates (27.78%) 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 detected by agarose electrophoresis and then
amplified by PCR and finally was subjected to digestion by endonuclease restriction
enzymes to create RFLP to enable the detection of mutation that caused G6PD
deficiency. The overall majority of affected severe G6PD neonates with
hyperbilirubinemia in Kerbala province : Iraq were due to G6PD Med variant
(C563T, Ser 188 Phe) in which 17 out of 18 (94.4%) have this type of mutation, and
only one G6PD A- variant (5.56%) (G202A ; A376G mutations) was diagnosed.
Conclusion: The predominant G6PD gene detected in hyperbilirubinemic neonate
with severe G6PD deficiency in Kerbala province was G6PD Med.

Early Evaluation of Serum Albumin Level in Pediatric Burned Patients

Kadhum J. A. Shaba; Hasan Th. Ghanem; Suhad R. Majeed

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 681-686

background: Burn patients are unique in that not only do they reduce albumin
synthesis in response to trauma, but also they experience accelerated albumin
losses into their wound dressings and soft tissue.
Methods: Serum albumin has been determined in 26 children with age ranged
between (l-14) years and with total body surface area of burn (11-60%) during their
initial few weeks of care. Their serum albumin levels were estimated at second day,
seventh day and fourteenth day after burn. Intravenous albumin was administered by
infusion of 1-2 g/kg/d when plasma Albumin fell bellow 2 g/100ml. or bellows 2.5
g/100ml in the presence of enteral feeding intolerance or pulmonary dysfunction,
their further results were excluded.
Results: The mean plasma Albumin was 3.062 g/100ml) at day 2 , 2.952 g/100ml
at day 7 and 2.45 g/100ml at day 14 . The relationship between the surface area of
burn and albumin concentration was not significant, (r = - 0.1111406). The value
of albumin was found to be 0.752 g/dl under the normal average value (p< 0.005).
Conclusion: Hypoalbuminemia is usual in pediatric burned patients especially
after 7 -14 day of the accident, the period of high risk of septic complications.
Keywords: Serum albumin, Hypoalbuminemia, Burn

Laparoscopic cholecystectomy: clinical analysis……………………………………………...

Ali Aziz Ali

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 687-691

Background: laparoscopic cholecystectomy has revolutionized the surgery for
symptomatic cholelithiasis since its introduction in 1987, it became the gold standard
procedure for gall bladder disease, this clinical analysis study was carried in Al-
Husain general hospital- Karbala.
Objective: our study aims to evaluate the results of laparoscopic cholecystectomy in
symptomatic cholelithiasis in our setting.
Patients and Methods: a total of 145 patients with symptomatic gall stones were
subjected to laparoscopic cholecystectomy during the period June2005-
November2009, cases with common bile duct stone, obstructive jaundice, abnormal
liver function tests, high risk cardiovascular cases were excluded from the study.
All cases were analyzed & compared with the results in the international literatures
Results: out of 145 cases operated on 137(94%) were females, 8(6%) were male,
age range was 20year-65year,cases with past history of jaundice were 23(16%),cases
with history of previous abdominal surgery were 46(32%),cases with iatrogenic
perforation of the gall bladder were 23(16%),cases who needed conversion were
5(3%),hospital stay was 1-2 days in 70% of the cases.
Conclusion: laparoscopic cholecystectomy is the gold standard procedure for
symptomatic cholelithiasis provided the surgeon performance started through a
standard learning curve principles.

The Outcome of Retained Metallic Foreign Bodies in Upper and Lower Limbs…………...

Ali Khairi Toman

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 692-696

background: Retained metallic fragments represent a common problem that
can be encountered in surgical practice.
They could be bullets, part of bullets or other fragments and shells from
bombs or mines or in rare occasion, different foreign particles from the environment.
They are always the cause of patients complain to whom they refer their pain or
disabilities and sometime they insist for their removal.
Operations for removal of deep retained foreign bodies are not beneficial, take long
time and consume a lot of materials and sometime could be very risky, cause more
damage and in some cases, ended without finding the foreign body.
There are only few indications for removal of retained metallic fragments.
Objectives: We want to assess the problem of retained metallic foreign bodies and
find the indications of their removal.
Patients and Methods: This is a prospective study of 300 patients with retained
metallic foreign bodies presented to the out-patient department of Alhindiya general
hospital between July 2006 and July 2008 with different complains.
Results: Three hundred patients were included in this study, 264 patients(82%) were
males and 36 patients (18%)were females, 270 patients about (90%) presented within
the first week after injury, 243 patients(81%) have foreign bodies in the upper and
lower limbs, 45 patients(15%) in the trunk and 12 patients(4%) in the head & neck.
Conclusion: Palpable foreign body can be removed safely and successfully in most of
the cases while deep foreign body should not be removed unless there are indications.

Toxoplasmosis in Iraqi Women: a Retrospective Study

Hayder A. L. Mossa

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 697-701

background: Toxoplasmsosis is a relatively widespread parasitic infection,
caused by the protozoan toxoplasma gondii, which can affect pregnancy
Objectives: To identify the cases of toxoplasmosis among pregnant women and to
identify its relation to the outcome of pregnancy.
Materials and Methods: The present descriptive study of 54 female patients with
toxoplasmosis, their age ranged between 16-45 years old in the period between 2006-
2007 in AL-Kadhimia Teaching hospital & IVF Institute of Embryo Researches &
Infertility Treatment-AL-Nahrain University –Baghdad.
Results: Pregnant woman with positive IgG and/or IgM anti-toxoplasma was
considered as a seropositive case. IgG have done to all women in the study, 51(94%)
were positive and only 3(6%) were negative. IgM was performed to 27(50%) women,
9(33%) were positive, 18(67%) were negative. Only (18%) of the positive IgG had
history of animal contact. IgG test was positive in 82% of women with a history of
abortion. IgG test was positive in 18% of women with a history of stillbirth.
Conclusions: in conclusion the presence of IgG in the blood of women in this study is
not associated with abortion or stillbirth.

Types of dehydration from diarrhoea in children in Karbala

Ghusoon Ghanem

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 702-709

Background: Dehydration as a result of diarrhoea continues to be a leading cause of
death in children, especially in developing countries and in these countries, diarrhea
outbreaks are more often linked to contaminated water supplies, person to –person
contact in places such as child – care centres, or food poisoning. This study has
focused on children under 3 years of age who have been admitted to Karbala pediatric
hospital with diarrhoea and dehydration from January to July 2008 and the types of
dehydration from diarrhoea for these children were studied with relation between
these types and different ages and types of feeding with the level of serum sodium
Objective: To evaluate which types of dehydration is common between children with
diarrhoea in Karbala.
Materials and Methods : We present the results to retrospective analysis of the types
of diarrhoea dehydration in 150 cases admitted to Karbala paediatric hospital in 6
months period in summer 2008 in Karbala in relation to age and nutritional state of
children, of 150 children 27(18.1 %) were hypernatremia ; 122(81.9 %) were
isonatramia .and we divided the children into three groups age the first age group
from ( 1-12), the second age group (13-24) and the third age group ( 25-36)
Results: There are a significant in the level of serum sodium concentration among the
children with breast , artificial and mixed feeding ; while there are no significant
between the artificial and mixed feeding. However There are a significant in the level
of serum sodium concentration among the children in the three age groups; and there
are a significant in the two types of dehydration status moderate and severe.
Conclusion: It has been deduced that there are two kinds of dehydration from
diarrhoea in this study in Karbala, hypernatramic and isonatramic from total sample,
while no signs lead to existence hyponatramic type.

Anorectal Abscesses Bacteriology and the Antibiotics Susceptibility Testing

Maha K. Ali; Hussein A. Al- Aljasmawy

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 710-715

background: Anorectal abscesses are a common surgical problem, and the
most common disease of the anorectum.
Objectives: to identify the microorganisms commonly causing the anorectal
abscess and the drugs of chioce for treating these infections.
Materials and Methods: the patients who were admitted in Hilla Teaching General
Hospital during a period of one year from December 2001 to December 2002 were
prospectively studied. The aspirated pus was cultivated aerobically and the isolated
microorganisms were tested for their sensitivity to commonly prescribed antibiotics.
Results: fifty two patients 42 males and 10 females were studied. The most frequently
isolated micro-organisms were Proteus vulgaris (30.76%), Esch.Coli (13.46%) and
Klbesiella spp. (9.61%). The sensitivity pattern was that the cephalosporin's and
aminoglycosides (Gentamycin) were the most potent antibacterial against Proteus and
Staph aureus.
Conclusion: Anorectal abscesses are most commonly caused by Proteus vulgaris and
Staph aureus which mainly respond to cephalexin and gentamycin.

Evaluation of Thyroid function Status in Hemodialysis Patients

Mohammed F Abdul Mehdi Gamber

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 716-724

background The interactions between kidney and thyroid functions are known
for years. Thyroid hormones (TH) are necessary for growth and development
of the kidney and for the maintenance of water and electrolytes homeostasis.
On the other hand, kidney is involved in the metabolism and elimination of TH.
Chronic renal failure (CRF) affects thyroid function in many ways, including low
circulating thyroid hormone levels, altered peripheral hormone metabolism,
insufficient binding to carrier proteins, possible reduction in tissue hormone content
and altered iodide storage in the thyroid gland. Thus, patients with renal failure may
have various abnormalities of thyroid function; nevertheless, they are typically
clinically euthyroid.
Objectives: the aim of the present study is to evaluate thyroid function status in
patients with hemodialysis in Karbala province, and to determine the benefit of
thyroid function test as a routine test requested in hemodialysed patients.
Methods: Forty-two hemodialysed patients who attend hemodialysis unit in
Al_Hussien teaching hospital in Karbala province with mean age of (44.4±15.9),
another 32 apparently healthy subjects with mean age (41.4±12.5) took part in the
current study as a control group. An early morning fasting sample of venous blood
from each, total trioiodothyronine (TT3), total thyroxine (TT4) and thyroid
stimulating hormone TSH were estimated by Enzyme Linked ImmuoSorbent Assay(
Result: The (TT3) level in haemodialysed patients was significantly lower than the
level TT3 in control group (P< 0.001).T-student test reveals no significant difference
in the total thyroxine (TT4) level between haemodialysed patients and control group.
Also There was no significant difference in the mean level of TSH between
hemodialysis and control group. About 41% of haemodialysed patients have TT3
level in the lower tertile of the reference range another 26% have TT3 level below the
reference value. There was no correlation between TT3 level in hemodialysis group
and duration of hemodialysis (in months).
Conclusion: Abnormalities in thyroid function test in hemodialysis patient are more
common than that in general population, and low T3 syndrome is considered the main
disorder that affect the thyroid function test in hemodialysis patients. So this disorder
should be investigated in those patients routinely as, its presence in hemodialysis
patients indicates a bad prognosis for them

Co-Expression of Intestinal Lymphocyte Subpopulations in Ulcerative Colitis: An Analysis by Dual- Immunofluorescence Technique

Haider F. Ghazi

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 725-731

background: Fluoresceins labelled monoclonal antibodies against cell surface
antigens are able directly to examine the expression of multiple antigens on the
surface of lymphoid cells in Ulcerative colitis lesions.
Materials and methods: Using dual-immunofluorescence for investigated the
coexpression of (CD3-CD19 and CD4-CD8) antigens on infiltrated lymphocytes of 47
patients with ulcerative colitis and 10 subjects from control group. Total and
differential T cells as well as plasma cell counts were recorded in all tissue samples.
Non parametric Kruskal-Wallis test was used to compare the median cell counts
among different study groups.
Results: T lymphocyte, T-cell subtype and plasma cell in UC were high with highly
statistical significant difference when compared with those in normal control subjects
T cell UC (301.39) Controls (35.48), T-helper 2 UC (228.41) Controls (24.75), Thelper
1 UC (54.21) Controls (13.45) and plasma cell UC (45.46) Controls (12.94).
Recorded values of were different and increased according to modified Geboes
histological grades of disease activity T lymphocytes (r=0.944) followed by T helper
2 subtype (r=0.821), T helper 1 (r=0.653) and B lymphocyte (r=0.237).
Conclusions: The increased number of lymphocyte subsets was found in the UC
lesions and correlated with different histological grades of disease activity.

Immune response to heat shock protein 60 and its relations t enteric reactive arthritis

Razak H. Ahmed; Abdal; Mohammed hadi; Jabbar Salman Hussan

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 732-736

background: according to the molecular mimicry hypothesis, heat shock
protein 60 (hsp60) is among the most conserved proteins that have been
implicated as triggering agents in the pathogenesis of enteric reactive arthritis
Objective: In the present work, we aimed to determine the prevalence of anti-hsp60
antibodies in sera of patient with enteric reactive arthritis.
Methods: Forty-five patients with Reactive arthritis were enrolled in this study. They
were 22(48.89%) males and 23(51.11%) females, the age rang was 20 - 40 year with
mean (33.6 ± 10.6). All patients were outpatient visitor or hospitalized in the medical
City hospital in Baghdad. They were diagnosed clinically by consultant rheumatologist
with the aid of some laboratory tests such as RF, CRP, E.S.R.
The patients should be sero-negative (RF-negative) and fulfill Amor and
European Criteria to be included in this study. Patients were classified according to
disease activity into three groups: sever moderat and mild by using (DAREA score).
Thirty age and sex matched apparently healthy individual, were considered in this
study as a control group. ELISA was used to detect immune response against hsp60 in
the sera of each patients and controls. Wells of the micro titter plates were coated with
hsp60 in coating buffer and anti hsp60 antibodies were assayed.
Results: the mean age of patients was (33.6± 10.6) years and they were 23 females
and 22 males with females to male ratio 1.05:1, the majority of patients 19(42.22%)
present with high disease activity (sever) and 15(33.33%) patients were moderate and
the remainder 11 (24.44%) were mild disease group.
The result of anti-hsp60 Abs detection showed that there was highly significant
difference between ReA patients and control groups. Also there was significant
difference between sever, moderate and mild among ReA patients.
Conclusion: we concluded that bacterial hsp60 seems to be a major target of T-cell
response in enteric ReA. and cross reactivity against autologous hsp60 has been
documented as a triggering of enteric ReA.

Total body irradiation when the source of radiation is horizontal on the patient (phantom)…….…

Fatihiya F. Hasan

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 737-744

background: Medically administered total-body irradiation, (also known as
whole- body radiation), involves the use of external radiation sources that
produce penetrating rays of energy to deliver a relatively uniform amount of
radiation to the entire body. TBI can be done any for to suppress the patient’s immune
system and prevent rejection of donor-bone marrow after a bone marrow transplant
using donor marrow (from some one other than the patient).
Objective: using new technique for body irradiation to serve total body irradiation
(TBI) (the radiation will be covered the whole body) and detect time and dose of
required exposure by using a phantom (it is a material like a human tissue), When The
source of radiation was used in horizontal position on the phantom.
Materials & Methods: The source of radiation, obtained from 60Co available in
Hospital of Radiotherapy and Nuclear Medicine in Baghdad. Thimble Chamber: It is
an instrument employed in measurement of the ionizing radiation. Phantom: Data on
dose distribution are almost entirely derived from measurements in phantoms (tissue
equivalent materials)
Results: This technique is easily applied with less expenditure and the radiation will
be covered the whole body, but here because of large distance between the patient and
source of radiation, the dose rate is small so we need more time to give the prescribed
dose. The max. Field size of radiation that we get is (150cm x 150 cm) and because
the average length of Iraqi adult is 170 cm, therefore the patient should bend his knee
in order to be totally within the field size.
Conclusion: Recommend for future study on (Gamma – Ray in horizontal position)
which might be more effective than vertical position in case, they use (acceleration
device) that device will increase dose rate which result to reduce time of exposure to

The role of Matrix Metalloproteinase-2 and -9 with their Tissue Inhibitors in Oral Lichen Planus………………………………………………………………………………………...……..

er Kassim Al-Kassam; Tha; Ahlam H. Majeed; Haider S. Kadhim

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 745-750

Background: Oral Lichen Planus (OLP) is a chronic inflammatory mucosal disease,
presenting various clinical forms. Both antigen- specific and non- specific mechanisms
involved in the pathogenesis of OLP.Matrix Metallo Proteinases (MMPs) and their
inhibitors are one of the mechanisms that would be activated in this disease.
Objective: to explore the expression of Matrix MetalloProteinases (2&9) and their
inhibitors and correlation between them in oral lichen planus.
Method: Twenty five paraffin embedded blocks of OLP and six of sequamous cell
carcinoma were collected from the records of Oral Diagnosis Department. Six negative
control cases were freshly obtained from Maxillofacial Center in the Specialized
Surgeries Hospital in Baghdad. All samples were investigated for the expression of
MMPs & Tissue Inhibitors of Matrix MetalloProteinases (TIMP) by
Immunohistochemistry (IHC).
Results: Expression of MMP-2,-9, TIMP-1 and TIMP-2 were detected at higher
significant level in keratinocytes and lymphocytes of OLP cases as compared to control
healthy group (p<0.0001). There was no significant difference between the expression of
MMP-2, TIMP-1 and TIMP-2 in lymphocytes and keratinocytes. However MMP-9
expression showed significant difference with MMP-2& TIMP-1&-2 in lymphocytes.
There was non significant correlation between the expression of MMP-2, MMP-9, TIMP-
1 and TIMP-2; and the morphological types of OLP.
Conclusion: High expressions of MMPs and TIMPs in OLP may indicate their role in
pathogenesis of the disease as there is no expression of these enzymes in the control
healthy; so they could be a diagnostic of aid in OLP.

Vitamin D Level In Patients With Multiple Sclerosis In Comparison With Healthy Controls….....

Sana Abdul-Razak Ibraheem

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 751-757

background: Multiple sclerosis is a chronic, immune – mediated
inflammatory and neurodegenerative disease of the central nervous system
(CNS). The prevalence of multiple sclerosis is highest where environmental
supplies of vitamin D are lowest.
Vitamin D is a steroid aid to maintain the normal level of calcium in the circulation,
enhancing immune function, and may protect people from multiple sclerosis.
Objective: To evaluated the effectiveness of vitamin D and calcium level in patients
with multiple sclerosis.
Design: Two groups, healthy and patients based in hospital.
Setting: Both healthy and patients of the Iraqi population in Al-Hakeem hospital in
AL-Najaf city.
Population: 36 patients (11 male, 25 female), and 36 healthy (15 male, 21 female).
Methods: Study was carried out in the department of biochemistry, Collage of
Medicine, Kufa University in period from February to August 2005.
The samples was measured by the high performance liquid chromatography (HPLC)
technique. This technique was of choice in measuring the low levels of vitamin D in
Results: The normal values of vitamin D levels were in 19.21 ng/ ml ±5.51, and
calcium levels were 10.79 mg / dl ± 1.19 in both sexes (males and females).
The result were taken from also showed that a first group a high significant
decrement (P< 0.01).
In serum of thirty-six patients affected with multiple sclerosis, the vitamin D level
average in this group were 6.46 ± 0.91 ng / ml, and calcium level were 8.69 ± 1.85
mg / dl.

Prevalence of Current Smoking among Students in University of Kerbala

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 645-662

Background: Tobacco use is the leading preventable cause of death and it is prevalent
among college students.
Objective: To determine the prevalence and to study the determinants of smoking
habit and its associated factors among college students together with their level of
knowledge about the health effects of smoking and attitudes towards cessation.
Design: A cross-sectional study.
Setting: University of Kerbala, Kerbala, Iٌraq.
Subjects and Methods: During December 2008 and January 2009, a sample of 1132
students (603 male and 529 female), between17 and 28 years of age, selected
randomly from 8 colleges, was taken. Each subject was questioned about his/her past
and present experience and attitude towards smoking, according to a modified
Arabian version of the World Health Organization (WHO) standard questionnaire,
and the data was analyzed using the Statistical Package for the Social Sciences
(SPSS) 16.0, P-value greater than 0.05 was considered as statistically insignificant.
Results: Two hundred twenty students were smokers and 912 were nonsmokers. Of
the smokers 201 smokers were males and 19 were females, fifty percent were light
smokers, 37.7% were moderate smokers, and 12.3% percent were heavy smokers, and
the mean number of cigarettes smoked daily among the regular smokers was 14
Conclusions: The prevalence of cigarette smoking was 19.4%, and half of the
smokers were “light smokers”. The majority of the smokers were aware of the bad
effects of smoking and two thirds had a favorable attitude towards cessation.

Familial Heart Disease with Skeletal Malformations- Holt – Oram Syndrome (case report)

Karim Al-naffi

Kerbala Journal of Medicine, 2009, Volume 2, Issue 5, Pages 758-763

it is well known that congenital heart disease and skeletal deformities occur
together in several clinical syndromes such as 13-15 or DI trisomy,16-18 or EI
triosomy, mongolism, XO syndrome, XXXXX, XXXY, Ellis Van Crevald
syndrome and Marfan syndrome yet there are a lot of skeletal deformities which is
associated with congenital heart disease ,so if found such deformities we should
examine the heart of these patients for congenital anomalies..
Below is a case repot of a family having one of these condition namely Holt Oram
Syndrome, with review of this hereditary disease, and a list of her diseases which
have skeletal anomalies and congenital heart disease