The N Iraqi JM Aug 06

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Iraqi Peer review Journal

The New Iraqi Journal of Medicine The official peer review medical journal of the

Iraqi Ministry of Health

Executive Editor: Ali Hassan Al ShimariMinister of Health

Editor in Chief: Aamir Jalal Al-Mosawi

Advisory Editorial Board

Nada Al Ward Hussam Abdul Kareem Abdul Ridhah Al Rawaf

Hakam Abdul Muheimen Hassan Ahmed Hassan

http://www.geocities.com/new_iraqijmRegistered by Copernicus Index Journal Master ListCopyrightPostspeciaty CME Center University Hospital in Al Kadhimiyia. Iraqi

Ministry of Health

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Content

I raq i Peer Rev iew Journa l

The New I raq i J ournal o fMedic ine

The Of f ic ia l Peer Review J ournal OfThe

I raq i Minis t ry o f Heal t hAugust 2006 Volume 2 Number 2

Content 1-2

Instructions for Contributors 3-7

Anatomy

Double extensor pollicis longus muscle and its clinical significance 8- 11

Srijit Das,

Rajesh Suri

Vijay KapuTraumatology

The epidemiology of war-like injuries in children and 12-15

adolescents during postwar violence wave:Experience of a teaching hospital in Baghdad.

Dhia Talib Al Anbaky

PsychiatryThe Epidemiological Pattern of Psychosis in Military 16-19

Patients

Safaa Jawad, Ghazi Aboud

Abstract from international conference 20-21

Fourth International conference on pediatric continuousRenal Replacement TherapyFebruary 23-25, 2006 | Campus of University Zurich-Irchel,

Switzerland

Pediatric Nephrology

Nephropathic cystinosis in Iraqi children 22-25

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The New Iraqi Journal of Medicine 2006 2(1): 3-7

http://www.webspawner.com/users/alkarkhjm/index.html

Instructions for Contributors

2006 Postspecialty CME center in theUniversity Hospital in Al-Kadhimiyia

Aamir Jalal Al Mosawi MD, PhDEditor in chiefHead department of pediatricsUniversity Hospital in Al KadhymiyiaAl Kadhymiyia Baghdad IraqPO Box: 70025E-mail: [email protected]

The New Iraqi Journal of Medicinewelcomes the submission of unsolicitedarticles for publication. Our reputationfor author care, quality control throughthe publishing process and rapid, timelypublication is unrivalled. Typically, fromreceipt of a first draft to publicationtakes only 8-12 weeks allowing 2 weekseach for peer-review and revision. If you

would like to propose an article or haveany queries about contributing to thejournal, please contact the EditorialOffice ([email protected]).

The New Iraqi J Med expectsmanuscripts to conform to the UniformRequirements for ManuscriptsSubmitted to Biomedical Journals (theVancouver style; N. Engl. J. Med.336,309315 [1997] www.icmje.org.TheJournal will consider the publication ofpapers dealing with broad fields ofmedicine (Original aricles, case reports,and review articles).All articles must besubmitted solely to The New IraqiJournal of Medicine and must be writtenentirely in English.

This journal is a peer-reviewed scientificjournal that publishes original articles inall fields of experimental and clinicalmedicine and related disciplines. TheNew Iraqi Journal of Medicine iscurrently issued 3 times per year. Thenew Iraqi J Med is listed by the ICMJEand Doctor Guide journal lists.

The editor endorses the principlesembodied in the Declaration ofHelsinki RECOMMENDATION FORCONDUCT OF CLINICALRESEARCH and expects that allinvestigations involving humans willhave been performed in accordance withthese principles.

Review process. Manuscripts areevaluated on the basis that they presentnew insights to the investigated topic,are likely to contribute to a researchprogress or change in clinical practice orin thinking about a disease. It isunderstood that all authors listed onmanuscript have agreed to itssubmission. The signature of thecorresponding author on the letter of

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submission signifies that these conditions have been fulfilledReceived manuscripts are first examinedby the editor. Manuscripts withinsufficient priority for publication arerejected promptly. Incomplete packages

or manuscripts not prepared in theadvised style will be sent back to authorswithout scientific review. The authorsare notified with the reference numberupon manuscript registration at theeditorial office. The registeredmanuscripts are sent to independentexperts for scientific evaluation. Theevaluation process usually takes 13weeks. Submitted papers are acceptedfor publication after a positive opinion of

the independent reviewers.Conflict of interests. Authors ofresearch articles should disclose at thetime of submission any financialarrangement they may have with acompany whose product figuresprominently in the submitted manuscriptor with a company making a competingproduct. Such information will be heldin confidence while the paper is underreview and will not influence theeditorial decision, but if the article isaccepted for publication, the editors willusually discuss with the authors themanner in which such information is tobe communicated to the reader.

Permissions. Materials taken from othersources must be accompanied by awritten statement from both author andpublisher giving permission to theJournal for reproduction. Obtainpermission in writing from at least oneauthor of papers still in press,unpublished data, and personalcommunications.

Patient's confidentiality. Changing thedetails of patients in order to disguise

them is a form of data alteration.However authors of clinical papers areobliged to ensure patients privacy rights.Only clinically or scientifically

important data are permitted forpublishing. Therefore, if it is possible toidentify a patient from a case report,illustration or paper, a written consent ofthe patient or his/her guardian to publishtheir data, including photogram isnecessary prior to publication. Thedescription of race, ethnicity or cultureof a study subject should occur onlywhen it is believed to be of stronginfluence on the medical condition in the

study. When categorizing by race,ethnicity or culture, the names should beas illustrative as possible and reflect howTheses groups were assigned.

Copyright transfer. Upon acceptance,authors transfer copyright to The NewIraqi J Med. Once an article is acceptedfor publication, the information thereinis embargoed from reporting by themedia until the mail date of the issue inwhich the article appears. Uponacceptance all published manuscriptsbecome the permanent property of TheNew Iraqi J Med, and may not bepublished elsewhere without writtenpermission from the editor .Every effortis made by the editor to see that noinaccurate or misleading data, opinion orstatement appears in the journal.However, they wish to make it clear thatthe data and opinions appearing in thearticles and advertisements herein are theresponsibility of the contributor, sponsoror advertiser concerned.

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CRITERIA FOR MANUSCRIPTS

The journal takes under considerationfor publication original articles inexperimental and clinical medicine and

related disciplines with theunderstanding that neither themanuscript nor any part of its essentialsubstance, tables or figures has beenpublished previously in print form orelectronically and is not underconsideration by any other publication orelectronic medium. The Journaldiscourages the submission of more thanone article dealing with related aspectsof the same study. Each submission

packet should include the statementsigned by the first author that the workhas not been published previously orsubmitted elsewhere for review and acopyright transfer.

PREPARATION OF MANUSCRIPT

Guidelines for submission are inaccordance with: Uniform Requirementsfor Manuscripts Submitted toBiomedical Journals (N Eng J Med,1997; 336: 309-15). Manuscripts shouldbe up to 4000 words in length with atarget of no more than 80 references.

Article structure

Original research articles, clinicalstudies, and case reports should beorganized as follows: The manuscriptshould be typewritten on a white paperof the size ISO A4 (210x297 mm). Thetext should be processed on the laser orinkjet printer preferably, or on a typewriter; in the last case, however, theauthors are requested to take care aboutthe quality of printing tape. Text shouldbe one spaced with 12 points typeface.

Margins: 2.5 cm (1 inch) at top, bottom,right, and left.

Illustrations are very helpful and for casereports are mandatory. In reviews it

should be explained what informationretrieval sources were used and whatwere the criteria in selecting the referredpapers. The Editor reserves the privilegeto adjust the format of the article.

The manuscript should include:

Title page should include the followingInformation: Full names of all authors

Name of the department and institutionin which the work was done Affiliations of the authors Manuscript full title Full name, address, telephone and/orfax number of the author responsible formanuscript preparation. E-mail address to speed upcontacts with authors

Source(s) of support in the form ofgrants (quote the number of the grant)

equipment, drugs etc.

Abstract Page. Abstract in structuredform not exceeding 300 words shouldconsist of four paragraphs labeled:Background, Material (Patient) andMethods, Results, Conclusion. Eachsummary section should begin in a newline and briefly describe, respectively,the purpose of the study, how theinvestigation was performed, the most

important results and the principalconclusion that authors draw from theresults. KEY WORDS (3 to 6) or shortphrases should be written at the bottomof the page.

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Text. The text of the article should bedivided to seven paragraphs labeled:Introduction, Material (Patient) andMethods, Results, Discussion,Conclusions, Acknowledgements,

References.Introduction should contain scientificrationale and the aim of the study or (incase of a review) purpose of the articleMaterial (Patient) and methods shoulddescribe clearly the selection ofobservational or experimental subjects(patients or laboratory animals)includingcontrols, such as age, gender, inclusionand exclusion criteria, (the

circumstances for rejection from thestudy should be clearlydefined),randomization and masking(blinding)method. The protocol of dataacquisition, procedures, investigatedparameters, methods of measurementsand apparatus should be described insufficient detail to allow other scientiststo reproduce the results. Name andreferences to the established methodsshould be given. References and briefdescription should be provided formethods that have been published butare not well known, whereas new orsubstantially modified methods shouldbe described in detail. The reasons forusing them should be provided alongwith the evaluation of their limitations.The drugs and other chemicals should beprecisely identified including genericname, dose and route of administration.The statistical methods should bedescribed in detail to enable verificationof the reported results.

Results should concisely and reasonablysummarize the findings. Restrict tablesand figures to the number needed toexplain the argument of the paper andassess its support. Do not duplicate data

in graphs and tables. Give numbers ofobservation and report exclusions orlosses to observation such as dropoutsfrom a clinical trial. Report treatmentcomplications. The results should be

presented in a logical sequence in thetext, tables and illustrations. Do notrepeat in the text all the data from thetables or graphs. Emphasize onlyimportant observations.Discussion should deal only with newand/or important aspects of the study.Do not repeat in detail data or othermaterial from the Background or theResults section. Include in theDiscussion the implications of the

findings and their limitations, includingimplications for future research. Thediscussion should confront the resultsofother investigations especially thosequoted in the text.Conclusions should be linked with thegoals of the study. State new hypotheseswhen warranted. Includerecommendations when appropriate.Unqualified statements and conclusionsnot completely supported by theobtained data should be avoided.Acknowledgements. List allcontributors who do not meet the criteriafor authorship, such as technicalassistants, writing assistants or head ofdepartment who provided only generalsupport. Financial and other materialsupport should be disclosed andacknowledged.

References must be numberedconsecutively as they are cited.References should be denotednumerically and in sequence in the text,using Arabic numerals placed in squarebrackets, i.e., [12]. List references innumerical order in the Reference listReferences selected for publicationshould be chosen for their importance,

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accessibility, and for the furtherreadings opportunities they provide.References first cited in tables or figurelegends must be numbered so that theywill be in sequence with references cited

in the text. The style of references is thatof Index Medicus. List all authors whenthere are six or fewer; when there areseven or more, list the first three, thenetal. The following is a sample reference:

Standard journal article

*Lahita R, Kluger J, Drayer DE, KofflerD, Reidenberg MM. Antibodiestonuclearantigens in patients treated with

procainamide or acetylprocainamide.NEngl J Med 1979; 301:1382-5.

Book, personal author(s)

Ringsven MK, Bond D. Gerontologyand leadership skills for nurses. 2nd ed.Albany (NY): Delmar Publishers; 1996.

Book, editor(s) as authorNorman IJ, Redfern SJ, editors. Mentalhealth care for elderly people. NewYork: Churchill Livingstone; 1996.

Tables. Type or print out each table on aseparate sheet of paper. Do not submittables as photographs. Number tablesconsecutively in the order of their firstcitation in the text, and supply a brieftitle for each. Give each column ashorter abbreviated heading. Placeexplanatory matter in footnotes, not inthe heading. Explain in footnote. All nonstandard abbreviations that are used ineach table. For footnotes use thefollowing symbols, in this sequence: *,, , ||, , **, , etc.Identify statisticalmeasures of variations such as standarddeviation and standard error of the mean.Do not use internal horizontal and

vertical rules. Be sure that each table iscited in the text.Figures should be numberedconsecutively according to the order inwhich they have been first cited in the

text. Define in the legend allabbreviations that are used in the figure.

Review articles

Each review article should concentrateon the most recent developments in thefield. These articles aim to summarizeand highlight recent significant advancesin and ongoing challenges in the field.Authors should strive for brevity and

clarity. The final structure of the reviewwill, of course, depend on the title/focusbut wherever possible, the followingsections should be included.

Submission

Manuscript should be sent on floppydisc. Submission by e-mail is alsowelcome.

Editor in chief: Aamir J Al -MosawiMain Editorial office:Expansion building, first floorUniversity Hospital in Al KadhimiyiaAl Kadhimiyia Baghdad IraqPO Box: 70025E-mail: [email protected]

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The New Iraqi Journal of Medicine 2006 2(2): 8-11 Anatomy

Anomalous Plantaris Tendon and its Clinical Implications

Srijit Das, Rajesh Suri, Vijay Kapur

Abstract

Background: The Plantaris musclebelongs to the superficial flexor group ofmuscles of the leg. In human beings, themuscle is attached well short of plantaraponeurosis and assists in the plantarflexion of the foot. It runs along the

medial border of tendocalcaneus tendonto insert into the calcaneum. Theplantaris muscle is considered to bevestigial in nature. It need not be re-emphasized that the muscle assists in theplantar flexion of the foot. Theanatomical knowledge of the anomaliespertaining to the insertion of theplantaris muscle may be clinicallyimportant for surgeons performingtendon transfer.

Objective: The present study reports theaberrant insertion pattern of the plantarismuscle.

Corresponding author: Srijit Das, AssociateProfessor Department of Anatomy, MaulanaAzad Medical College, New Delhi, India. Add:190, RPS Flats, Sheikh Sarai Phase-I, NewDelhi-110017, IndiaTel: 91-11-23239271Ext125E-mail: [email protected] Suri, Professor, Department of Anatomy,Vardhman Mahavir Medical College, NewDelhi, India.

Vijay Kapur , Former Director Professor &HOD, Department of Anatomy, Maulana AzadMedical College, New Delhi, India.

Materials and Methods: We dissectedthe lower limbs of 20 cadavers (i.e. n=40 limbs) to study the insertion patternof the plantaris muscle. The insertion ofthe plantaris muscle was studied in detailand appropriate photograph was taken.

Results: The average of the maximumlength and the maximum width of theplantaris muscle measured 8.5 cm and1.6 cm respectively. In twelve out of 20cadavers (60%) the plantaris muscleinserted into the calcaneum, its normalsite. In the other 8 cadavers (40%), theinsertion was into the superficial fasciaof the leg.Conclusion: In order to avoid anyinadvertent injury during surgical

operations, the possibility of suchanomalous insertion of the plantaristendon into the superficial fascia of theleg must be borne in mind. Awareness ofthe insertion pattern of the plantaristendon is also important for clinicians inthe diagnosis of muscle tears and forsurgeons performing reconstructiveprocedures.Key Words: Plantaris tendon, anomaly,variation, superficial fascia, calcaneum.

Introduction

Knowledge of the anatomical details ofthe plantaris and its variations isimportant for surgeons while carryingout tendon transplants and reconstructiveprocedures in the leg region.

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Injuries to the plantaris muscle and itstendon are not uncommon in clinicalpractice. As compared to hamstringmuscles, the injuries to the quadricepsmuscles are more common as they

stretch and change length over two jointsunlike the soleus muscle which spansonly one joint [1]. Such injuries maycause severe calf pain and mimic otherserious conditions like gastrocnemiustear or deep vein thrombosis of the leg[2]. Ultrasonography or MRI studies arethe investigations of choice [3, 4]. Theplantaris tendon is considered to be anexcellent source of tendon graft [4].Awareness of such variations in the

morphological details of the plantarismuscle may be important in this context.The present study describes variations inthe insertion pattern of the plantarismuscle.

Material and Method

Forty legs were dissected to note theinsertion pattern of the plantaris muscle.The superficial group of flexor muscles

of the posterior compartment of the legwas dissected to expose the entire extentof the plantaris. Appropriatemeasurements were recorded and thepattern of insertion of the plantaris wasstudied.

Results

The mean maximum length and themaximum width of the plantaris muscle

measured 8.5 cm and 1.6 cmrespectively. In 12 cadavers (60%), thesite of insertion was the usual insertioninto the calcaneum, while in 8 (40%),the tendon was found to blend with thesuperficial fascia of the leg (Fig.1). Insuch anomalies, the tendon traversed an

oblique course over the heads of thegastrocnemius muscle and merged withthe superficial fascia of the leg. Thebranch innervating the plantaris musclewas as usual found to be originating

from the tibial nerve.

Figure (1): Photograph of right leg

showing: (A) Medial head of gastrocnemius(B) Lateral head of gastrocnemius (P)Plantaris muscle. The Plantaris tendon hasbeen lifted with forceps and shown witharrow ().

Discussion

The plantaris muscle is vestigial in man.It is due to the evolution of erect posturethat the plantaris muscle gradually lost

its attachment into the plantaraponeurosis and thereby gained insertioninto the calcaneum. Interestingly in someanimals like American brown bear, theplantaris muscle resembles thegastrocnemius muscle and it crosses thecalcaneum to join the plantaraponeurosis [5].

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The plantaris muscle arises from thelateral supracondylar line and theoblique popliteal ligament [6]. Theplantaris muscle belongs to thesuperficial flexor group of muscles of

the posterior compartment of the leg.The plantaris muscle is sometimesconsidered as the counterpart of thepalmaris longus of the forearm. Thefusiform belly of the muscle has aslender tendon which crosses thegastrocnemius obliquely to insert intothe calcaneum and often the tendoninserts into the fascia of the leg [6].Past reports suggest that with evolution,the tendon of the muscle has shifted its

normal insertion from the plantaraponeurosis to the calcaneum.Occasionally the tendon is so long andthin that it is termed as Fools Nervebecause of its resemblance to a nerve.The anomalous position and attachmentof the plantaris tendon into thesuperficial fascia of the leg, as seen inthe present study, renders it vulnerableto injury Research studies have outlinedthe fact that the size of the musclecorrelated with the overall degree ofmuscular development of the individual.[7] .The rupture of the muscle and itstendon occur in individuals who havelarger than average muscle [7]. Ruptureof the tendon of the plantaris muscleusually occurs at mid calf level [8].These are usually detected by ultrasoundor MRI scans. Sometimes fluidaccumulation may be detected near thetendon bed. Tendinous injury is alsoassociated with hemorrhage and edema[9]. The most significant point in thediagnosis of the plantaris tendon ruptureis the presence of the tense massbetween the gastrocnemius and thesoleus muscle [7]. It is often stated thatthe plantaris muscle is really not knownto any individual unless one has ruptured

it. The tendon of the plantaris muscle hasbeen used as an excellent graft [4].Thus awareness of the variations in themorphology of plantaris muscle and itstendon is relevant for surgeons. The

present cadaver study aims to highlightthe anomalous insertion of the slendertendon of the plantaris muscle whichmay be important for clinicians andsurgeons in clinicalpractice.

References

1-Alexander RM, Ker R F. The architectureof the leg muscle. In: Multiple MuscleSystems: Biomechanics and Movement

Organization edited by Winters JM, Woo S,New York City, Springer-Verlag, 1990, pp568-577.

2- Kane D, Balint P V, Gibney. R,Bresnihan B and Sturrock R D. Differentialdiagnosis of calf pain with musculoskeletalultrasound imaging. Annals of theRheumatic Diseases2004; 63:11-14.

3-Saxena A, Bareither D. Magneticresonance and cadaveric findings of theincidence of plantaris tendon. Foot AnkleInt. 2000 Jul; 21(7):570-2.

4-Simpson SL, Hertzog MS, Barja RH. Theplantaris tendon graft: an ultrasound study. JHand Surg [Am]. 1991; 16 : 708-11.

5- Daseler EH, Anson BJ. The PlantarisMuscle An Anatomical Study of 750specimens. The Journal of Bone and JointSurgery 1943; 25: 822- 827.

6- Standring Susan. Grays Anatomy - TheAnatomical Basis of Clinical Practice.Elsevier Churchill Livingstone, 39th edn,New York, 2005, pp-1499-1500.

7- Allard JC, Bancroft J, Porter G.Imagingof plantaris muscle rupture. Clin Imaging.1992; 16: 55-8.

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http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10919622&query_hl=4&itool=pubmed_docsumhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Simpson+SL%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Hertzog+MS%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Barja+RH%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Barja+RH%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Hertzog+MS%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term=%22Simpson+SL%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10919622&query_hl=4&itool=pubmed_docsum


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8-Leekam RN, Agur AM, McKee NH.Using sonography to diagnose injury ofplantaris muscles and tendons. AJR Am JRoentgenol. 1999; 172: 185-9.

9-Deutsch AL, Mink JH. Magnetic

resonance imaging of musculoskeletalinjuries. Radiol Clin North Am. 1989; 27:983-1002.

____________________________________

*Editors note:Reviewers advised replacementof reference (5) by a newer reference ,but theauthors commented that Reference(5) is uniquein its kind that it was a comparative study in theyear 1943 and there is no recent reference toquote in case once this old reference is deleted.

____________________________________

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The New Iraqi Journal of Medicine 2006 2(2):12-15 Traumatology

The epidemiology of war-like injuries in children and

adolescents during postwar violence wave: Experience of a

teaching hospital in Baghdad.

Dhia Talib Al Anbaky

Abstract

Background: In most developingcountries communicable diseases

continue to be a major cause ofchildhood morbidity and mortality.However in this geographic area of theworld war-like injury involving civiliansincluding children has become a massivehealth problem. These injuries produce asignificant burden on medical facilities.The human and economic costs of theinjuries are tremendous.Objective: The aim of this study is torepot the occurrence of war-like injuries

in children and adolescents duringpostwar violence waveMaterials and Method: The pattern ofwar-like injuries in 272 injured childrenand adolescents aged 15 years or lessadmitted to the casualty unit at theUniversity Hospital in Al Kadhimiyia(UHK)over a 2 year period from March2003 to March 2005 was studied.These injuries occurred during the post-war violence wave. Results: The injuries

in the majority of casualties were causedby explosions in civilian areas, mortarbombardment of civilians buildings andhousing and family assassinations.

Corresponding author: Dhia Talib Al Anbaky

Specialist surgeon. University hospital in AlKadhimiyia.Baghdad Iraq.

The injuries were more common inmales with a male to female ratio of(3.1/1),206 (75.7%) of the causalitieswere males and 66 (24.3%) werefemales. Of the 272 casualties studied,52(19.1%) were 5 years old or less,95(34.9%) were between 6 to 11 years, and125(45.9%) were between 12 to 15years. There were126 (46.3%) minorcasualties, which were managed in theoutpatient emergency unit, while146(53.6%) casualties had serious andmajor injuries, 120 (44.1%) of whomwere admitted to (UHK) and 6 weretransferred to other hospitals. 20(7%)casualties died (12 on arrival and 9during resuscitation) and two casualtieswere discharged by parent shortly afterreceiving them without adequate medicalevaluation. Fragmentation weapons(blast injuries) caused 216 (79.4%)casualties and 54(19.8%) casualtiessustained gunshot wounds and 2 (0.7%)substantiated burn. Injuries to the lowerlimbs and trunk were the most commoninjuries in this series accounting for126(46.3%) of all injuries.Conclusion: Recognition of thepotential for pediatric casualties in theviolence wave in this geographic area is

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necessary to facilitate appropriateplanning, training and equipping ofcausality units.

Introduction

In most developing countriescommunicable diseases continue to be amajor cause of childhood morbidity andmortality. However in Iraq, war- injuriesinvolving civilians including childrenhas become a massive health problem.These injuries produce a significantburden on medical facilities. The humanand economic costs of the injuries aretremendous.

Exposure of children and adolescents toinjuries during war time has beenincreasingly reported in this geographicarea [1, 2]. During the first two weeks ofthe 2003 gulf conflict, the sole Britishfield hospital in the region received 482casualties, eight of which (1.7%) werechildren. During the same conflict, the202 Field Hospital reported that the firstchild casualty arrived two days later andover the next four weeks there were 24

admissions of patients aged 15 years orless, amounting to 2% of the totaladmissions. Although exposure ofchildren and adolescents to injuriesduring war time has been increasinglyreported in this geographic area, anepidemic of war-related wounds duringpostwar violence in children andadolescence has not been reported in themedical literature. The aim of this studyis to repot the occurrence of war-like

injuries in children and adolescentsduring two years of post-war violencewave.

Materials and Methods

The pattern of war-related injuries in 272injured children and adolescents

admitted to the casualty unit at theUniversity Hospital in Al Kadhimiyia(UHK) over a 2 years period March2003 to March 2005 was studied. Alldata on war- related injuries in children

and adolescents 15 years of age oryounger were collected .These injuriesoccurred during post war violence wave.The precise numbers of the totaladmissions to the casualty unit were notavailable to the investigators because ofthe poor recording system during thisperiod of crisis. The precise numbers ofthe total admissions to the casualty unitwere not available to the investigatorsbecause of the less serious cases tend to

be discharged without being recorded orregistered.

ResultsThe injuries in the majority of casualtieswere caused by explosions in civilianareas, mortar bombardment of civiliansbuildings and housing and familyassassinations. There were more males206 (75.7%) than females 66 (24.3 %)among the casualties with a male to

female ratio of (3.1/1). Those who were5 years of age or less comprised 52(19.1%) of the causalities, while 95(34.9%) were between 6 - 11 years, and125 (45.9%) were between 12 - 15 years.

Figure (1) shows the age distribution

of the causalities.

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Of the 272 casualties received, 126(46.3%) were considered minor andwere managed in the outpatientemergency unit without hospitalizationTwo casualties were discharged on the

responsibility of their parents shortlyafter receiving them without adequatemedical evaluation to assess theseriousness of their injury., while146(53.3%) casualties had serious andmajor injuries; 120 (44.1%) of whomwere admitted to (UHK), and 6transferred to other hospitals. 20casualties (7%) died (12 on arrival and 9during resuscitation).

The injuries were generally classified asblast injuries with shells fromfragmentation weapons and gunshotinjuries with bullets. 216(79.4%)casualties suffered wounds fromfragmentation weapons (blast injuries)and 54 (19.8%) casualties sustainedgunshot wounds (Bullet injuries) and 2(0.8%) burns.According to the anatomical locationand extent of injury, the injuries fell into

6 categories Table (1). Injuries to thelower limbs and trunk were the mostcommon injuries in this series accountfor 42% of all injuries. Of the 120causalities admitted to this hospital 35

were admitted to the general surgery andwards and 30 to the neurosurgery wards.The remaining cases were admitted toother surgical wards, as shown in Table(2).

Discussion

Exposure of children and adolescents toinjuries during war time has beenincreasingly reported in this geographicarea [1, 2]. During the first two weeks of

the 2003 gulf conflict, the sole Britishfield hospital in the region received 482casualties, eight of which (1.7%) werechildren During the same conflict, the202 Field Hospital reported that the firstchild casualty arrived two days later andover the next four weeks there were 24admissions of patients aged 15 years orless, amounting to 2% of the totaladmissions [3].

Type of injury

according to the

anatomical location &

extent

Blast injuries, (Shells

from fragmentation

weapons)

Number (%)

Gunshot

wounds (Bullet

injuries)

Number (%)

burn Total Casualties

Number (%)

Head & Neck 47 (17.2%) 13 (4.8%) 60 (22%)Upper limb & Shoulder 40 (14.7%) 3 (1.1%) 43 (15.8%)Trunk- Thoracic- Abdomen and back- pelvis

29 (10.6%)11 (4.3%)16(5.6%)2 (0.7%)

17 (6.5%)5 (1.5%)

11 (4.3%)1 (0.4%)

46 (17.1%)16 (5.8%)27 (9.9%)3 (1.1%)

Lower Limb 61 (22.8%) 19 (6.5%) 80 (29.4%)Reached dead 8(3%) 2(0.7%) 2(0.7%) 12(4.4%)Generalized 31(11.3%) 0 31(11.3%)

Total (%) 216(79.4%) 54(19.8%) 2(0.8%) 272(100%)*One or more injuries per case

Table (1): Categories of injuries according to the anatomical location and extent of

injury

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Hospital Wards Admitted

Causalities

General surgery 35(12.8%)Neurosurgery 30(11%)Cardiothoracic surgery 24(8%)Orthopedic surgery 21(7.7%)Facio-maxillary surgery 4(1.4%)Intensive care unit 2(0.7%)Ophthalmology / Urology/ Plastic surgery

4(1.4%)

Total (100%) 120(44.1%)Table (2): Table (2): Distribution of the

hospitalized patient to various hospitaldepartments

The Pattern of injuries in the presentstudy was different from the pattern ofinjuries to children and adolescentsduring war time like that reported byGurney [3]. from which country and inwhich war. In that retrospective analysisof Seventy eight children (All


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The New Iraqi Journal of Medicine 2006 2(2): 16-19 Psychiatry

The Epidemiological Pattern of Psychosis in Military Patients

Safaa Jawad, Ghazi Aboud

Abstract

Background: The schizophrenicbreakdown rate of recruits to the USarmy was mush higher in their firstmonth of military service taken at anytime in the next two years suggestingthat the transition from civilian life to

recruiting barracks was contributing tothe genesis of these illnesses.Objectives: The aim of this study is toexplore, retrospectively, theepidemiological pattern of psychosis inmilitary patients including familyhistory, scholastic achievement, socialstatus and precipitating factors.Patients and methods: The case recordsof 100 psychotic patients were reviewed.Most of the cases were clinically

diagnosed in Al Rasheed militaryhospital during 2001 - 2002 as havingschizophrenic. The case records includedclinical notes of the general practitionerand specialist in addition to family,social and military records.Results: Out of the 100 cases,32 werevolunteer conscripts and 68 werecompulsory recruits. Seventy six patients

Safaa Jawad, Psychiatrist Al Kindy Hospital,Baghdad.

Ghazi Aboud, PsychiatristAl-Rashad Psychiatric HospitalBaghdad, Iraq

were single, 30 had a positive familyhistory of psychiatric illness and 54 hada stressful factor prior to the onset of the

illness. The majority of psychoticpatients were with low scholasticachievement, attributed mostly to earlyonset of the illness and social stigma.The precipitating factor of the impact ofthe demanding new military life is more

evident than family history so the mostimportant preventive measure to addressis to improve handling of transference ofsocieties from civilian life to militaryone.Conclusion: Military discipline could beconsidered as stressful factor thatprecipitates the illness.Key Words: Psychosis-Militarypatients-Pattern

Introduction

The variable course of psychoticdisorders has been well documented inthe literature. However, theunderstanding of different combinationsof biological predisposition, clinicalcharacteristics and psychosocialenvironment accounting for differentillnesses remains illusive. It has been

asserted that each dimension ofpsychotic outcome is best predicted bywhat has happened earlier [1]. The termpsychotic denotes loss of realitytesting which can occur as a result ofdelusional belief or hallucinatoryperception, usually auditory or visual.The psychotic symptoms are the most

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dramatic and potentially dangerousfeatures of this illness, but othersymptoms may be even more disabling[2]. Genetic factors are likely to beimportant in schizophrenia, but it can

also be familial, because familymembers share the same disadvantagedenvironment [3]. Paul Meehl [4] in hisintegrative model that led to thedevelopment of the diathesis-stressmodel suggested that certain peoplepossess a genetic predisposition toschizophrenia and other psychoticdisorders, which are expressedbehaviorally only if they are reared in astressful environment. On other hand, if

environmental stress remains below theperson's stress threshold, schizophreniamay never develop even in persons atgenetic risk.

A role has been suggested for adverselife events and social adversity asoperating factors on already predisposedindividuals to trigger onset [5].Schizophrenic patients experience asignificantly higher frequency of suchevents during the 3-week period prior tothe onset of their symptoms [6]. Theschizophrenic breakdown rate of recruitsto the US army was mush higher in theirfirst month of military service taken atany time in the next two yearssuggesting that the transition fromcivilian life to recruiting barracks wascontributing to the genesis of theseillnesses [7]. It was reported that suchpre-schizophrenic children showedlower I.Q. and poor scholasticperformance [8]. It was suggested thatlife events serve to trigger the floridonset in those who are predisposed [9].

Patients and methods

The case records of 100 psychoticpatients were reviewed. Most of thecases were clinically diagnosed in Al

Rasheed military hospital during 2001 -2002 as having schizophrenic. The caserecords included clinical notes of thegeneral practitioner and specialist inaddition to family, social and militaryrecords.

Results

Out of the 100 cases,32 were volunteerconscripts and 68 were compulsory

recruits. Single men constituted 76 caseswhile the remaining 24 were marriedmen. Figure (1) shows that 37 patientscompleted elementary school only, 38completed intermediate school, 13completed secondary school and 12completed colleges.

0510

152025

303540

Elementaryschool

Intermediateschool

Secondaryschool

College

Educational Level Achieved

NumberofP

atients

Figure (1): Scholastic Achievement of theStudied Cases

A positive family history of the illnesswas found in 30 patients, 13 of themhad also a stressful factor prior to theonset of their illness illness, 21 patientswere reared without their fathers and 9patients were reared without theirmothers.

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Just over one half of the cases (51) wereadmitted to the hospital more than 3times, 35 patients had 3 admissions, and14 patients had 2 previous admissions.

A course of Electroconvulsive Therapy(ECT) was used for the treatment of 61patients during their admission.Precipitating factors: 54 patients had avariety of stressors which are consideredas precipitating factors preceding theonset of the illness. In addition to thesefactors, 13 patients also had a positivefamily history of the illness. Thesefactors occurred during the first 3 weeksprior to the onset of the illness in 39

patients while in 15 patients theypreceded the onset of the illness by atleast 6 months.

Discussion

The majority of patients (68%) wererecruited soldiers, which may indicatethat military discipline could beconsidered as stressful factor thatprecipitates the illness according toSteinberg and Durnel study [7]. Lowlevel of Scholastic achievement in thesample may be related to the early onsetof the disease process which goes withthe results of the study of Jones et al [8].The majority of patients (76%) weresingle which may be related to the resultof the disease process itself and thesocial stigma and label, which may beconsidered as an obstacle to marriage. Apositive family history of psychiatricillness was found in 30 cases, 13 ofwhom also had a stressful factor prior tothe onset of the illness which isconsistent with the results of many otherstudies [3, 4, 5, 9].Stressful events / factors were reportedby 54 patients to have happened prior tothe onset of illness. This event was the

only factor that determines or expressesthe disease process in 41 patients,especially in the first three weeks priorto the onset of the illness which agrees

with the results of many studies [4, 6, 7].References

1. Beiser M, Iacono W: An update on theepidemiology of schizophrenia. Can .J.psychiatry 1990; 35: 657- 688.

2. Donald C.Goff (2002) , A 23- year OldMan with schizophrenia ( 12). JAMANeurology & Psychiatry 2002; 287:3249-3257.

3. Johnston E: Schizophrenia, chapter 13(381), Companion to psychiatric studies,Sixth ed., Churchill Livingstone byJohnstone, Freeman & Zeally (1998)

4. Meehl PE: A Critical Afterword. II ,Gottesman & J. shields (Eds), schizophreniaand genetics. A twin study vantage point1972; (367- 415). New York AcademicPress.

5. Bebbington PE, Wilkins S, Jones P, etal:Life events & psychosis: Initial results fromthe Camberwell Collaborative PsychosisStudy. Br. J. Psychiatry, 1993; 162, 72-9.

6. Brown GW & Birley JLT: Crises & Lifechanges & the onset of schizophrenia, J.Health Soc. Behav. 1968; 9: 203-214.

7. Steinberg HR, Durnell J: A stressfulSocial situation as a precipitant ofschizophrenic symptoms: anepidemiological study: British Journal ofPsychiatry; 1968; 114: 1097-1105.

8. Jones, P.B, Rodgers, B, Murray. R.M. &Marmot, M. (1994a): Child developmentalrisk factors for adults schizophrenia in theBritish 1996 birth cohort Lancet; 344, 1398-402.

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9. Brown GW, Birley JLT & Wing JK:Influence of family life on the source ofschizophrenic disorders: a replication.Br.J.Psychiatry; 1972; 121: 241-58.

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The New Iraqi Journal of Medicine 2006 2(2):20-21 International conference

Fourth International conference on pediatric continuous RenalReplacement Therapy

February 23-25, 2006 | Campus of University Zurich-Irchel, Switzer

Abstract

Continuous Renal Replacement

Therapy (CRRT) in the Developing

World: Is there any alternative?AJ AL MOSAWI

Dialysis and transplantation (RRT)originally developed to forestall death inpatients with ESRF, have becomestandard management practice indeveloped countries. However RRTrequires an expert team consisting of atleast a nephrologists, cardiovascularsurgeon and urologist, in addition to askilled nursing staff. Therefore, in manyareas of the world RRT is consideredextremely expensive both in manpower

and cost of treatment, with amaintenance cost far beyond thoseobserved in other areas of medical care.In areas where RRT has been introducedto some extent (e.g. hemodialysis andtransplantation) despite the lack ofeffective and skilled teams,rehabilitation is commonlyunsatisfactory and results arediscouraging relative to costs. Patientsundergoing RRT in these areas

commonly experience a disproportionateamount of discomfort and sufferingwhich cannot be balanced by the addedlength of life achieved.17 years old boy with biopsy provenrapidly progressive (Endocapillary

crescentic) glomerulonephritisdeveloped end-stage renal failure(ESRF) despite receiving steroids andcyclophosphamide.He developedsymptomatic uremia (anorexia, fatigue,and tachypnea) about 6 months beforereferral. laboratory tests at that timeshowed serum creatinine 10 mg/l,bloodurea 360 mg/dL.Since that time he wasreceiving regular hemodialysis (HD) 2sessions /week. He received more than

one blood transfusion during that period.Both of the parents and the patientconsidered this form of RRT is notconvenient and have disrupted their lifeand all of them experienced asignificant amount of discomfort andsuffering. On referral 2 days after HDsession the boy has symptomatomaticuremia (fatigability, and mildtachypnea).The boy was receivingerythropoietin,parentral iron ,one

alphacalcidol,calcium carbonate ,andfrusemide.The boy started a new form ofRRTconsisting of acacia gum(AG)1g/kg/day dissolved in fluids and givenin divided doses in conjunction with lowprotein diet (LPD).After 2 weeks fromthe start of this form of RRT the boyreported improved well being and much

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more comfort has ever experienced sincethe onset of uremia. Table (1) shows theeffect of this form of RRTon serum creatinine and blood urea. Thevalues of serum calcium, and potassium

are expected to be more by othertherapies (one-alphacalcidol,eryrthropoeitin, diutertc, etc,) The familytraveled outside the country and the boystopped AG therapy ,but continued onLPD.After 2 weeks he presented againwith symptomatic uremia. Both theparents and the decided to continue thisform of RRT rather than returning toregular HD.This novel form of RRT has already

been reported to provide children treatedby intermittent peritoneal dialysis a longperiod of dialysis freedom and improvedwell being[1].This is first paperreporting HD freedom and improvedwell being with this form of RRT.

References

1-Al-Mosawi AJ. Acacia gumsupplementation of a lowprotein diet inchildren with end-stage renal disease.

Pediatr Nephrol 19; 1156-1159 (2004).2-Al-Mosawi AJ, Chesney RC, Patters A.Acacia gum therapeutic potential: Possiblerole in the management of uremia-A newpotential medicine. Therapy [suppl] 3(2)(2006).

University Hospital in AlKadhimiyiaPO Box 70025 Baghdad IraqE-mail: [email protected]

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The New Iraqi Journal of Medicine 2006 2(2) :22-25 Pediatric Nephrology

Nephropathic cystinosis in Iraqi children

Aamir Jalal Al Mosawi M.D, Ph.D.Head of Department of Pediatrics.University Hospital in Al Kadhimiyia(Al-Kadhimiyia Teaching Hospital).Al-Kadhimiyia, Baghdad, Iraq.PO Box 70025e-mail:[email protected]: 964 1 4431760

Abstract

Background:Nephropathy cystinosis is a

rare, autosomal recessive lysosomalstorage disorder caused by mutations inthe CTNS gene that codes for a cystinetransporter in the lysosomal membrane.Affected patients store 50-100 times thenormal amounts of cystine in their cells,and suffer renal tubular and glomerulardisease, growth retardation,photophobia, and other systemiccomplications, including a myopathyand swallowing dysfunction. The aim of

this study is to describe the pattern ofcystinosis in Iraqi children.Patients and Methods: From 1999 to 2005eight patients with Cystinosis were observedat the university hospital in AlKadhimiyia.There age ranged from 10months to 14 years at the time of firstreferral. (Mean 5 years).The diagnosis ofCystinosis was confirmed by finding thepathognomic corneal cystine crystals on slitlamp examination.Results: Three patients have evidence of

Fanconi syndrome and one patient hasevidence of RTA on referral. The remaining4 patients had chronic renal failure onreferral with 2 of them have reached end-

stage renal failure and have undergonedialysis. Four of the patients with Cystinosishave at least one sibling died from the same

illness. The remaining three patients had nofamily history of similar illness. All thepatients have significant growth retardationwith all of their growth parameters belowthe third centile. Among the patients withCystinosis only one patient was receivingcysteamine sent to him from a relative livingin UK. During the follow-up period, two ofthe patients with Cystinosis died fromuremia. Only two of the 7 observed patientshad the correct diagnosis of Cystinosisbefore referral .The remaining 5 patientswere diagnosed as having RTA beforereferral indicating delay in referring the

patients to the appropriate consultant.Conclusion: The outcome of nephropathiccystiosis in Iraqi children is poor as most ofthem progressed to CRF because of the non-availability of cysteamine

Keywords: Fanconi syndrome--Nephropathic -Cystinosis

Introduction

Cystinosis, clinically recognized since1903, is a rare autosomal recessivelysosomal storage disease caused bymutations in CTNS. This gene codes fora lysosomal cystine transporter, whoseabsence leads to intracellular cystinecrystals, widespread cellular destruction,renal Fanconi syndrome in infancy, renalglomerular failure in later childhood and

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other systemic complications. Before theavailability of kidney transplantation,patients affected with cystinosisuniformly died during childhood. Aftersolid organ transplantations became

successful in the 1960s, cystinosispatients survived, but eventuallydeveloped life-threatening consequencesof the disease (e.g., swallowingdisorders). Since the introduction ofcysteamine into the pharmacological

management of cystinosis, well-treated

adolescent and young adult patients

have experienced normal growth and

maintenance of renal glomerular

function. Cysteamine (and kidney

transplantation) have commuted thedeath sentence of cystinosis into a nearlynormal life with a chronic disease.Because treatment with oral cysteaminecan prevent, or significantly delay, thecomplications of cystinosis, early andaccurate diagnosis, as well as propertreatment, is critical [1, 2, 3, 4]. The aimof this study is to describe the pattern ofcystinosis in Iraqi children.

Patients and Methods

From 1999 to 2005 eight patients withCystinosis were observed at the universityhospital in Al Kadhimiyia.There age rangedfrom 10 months to 14 years at the time offirst referral. (Mean 5 years).The diagnosisof Cystinosis was confirmed by finding thepathognomic corneal cystine crystals on slitlamp examination.

Results

Three patients have evidence of Fanconisyndrome and one has evidence of proximalRTA on referral. The remaining 4 patientshad chronic renal failure on referral with 2of them have reached end-stage renal failureand underwent dialysis. Four of the patientswith Cystinosis have at least one siblingdied from the same illness. The remaining 4

patients had no family history of similarillness. All the patients have significantgrowth retardation with all of their growthparameters below the third centile.Onepatient developed severe bowing deformitiesinterfered with mobilization. Table (1)

shows the characteristics of the 8 patientswith cystinosis.Among 13 the patients with Cystinosis (8referred to us and 5 of their siblings) onlyone patient was receiving cysteamine sent tohim from a relative living in UK. Duringthe follow-up period, two of the patientswith Cystinosis died from uremia. Only 3 ofthe 8 observed patients had the correctdiagnosis of Cystinosis before referral andthe diagnosis in these 3 patients wassuggested by the ophthalmologist after the

development of photophobia rather by thetreating physician. The remaining 5 patientswere diagnosed as having RTA beforereferral indicating delay in referring thepatients to the appropriate consultant.

A girl with Nephropathic cystinosis andcronic renal insufficiency.

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measured in circulating leucocytes.Cysteamine (and kidney transplantation)have commuted the death sentence ofcystinosis into a nearly normal life witha chronic disease. Because treatment

with oral cysteamine can prevent, orsignificantly delay, the complications ofcystinosis, early and accurate diagnosis,as well as proper treatment, is critical.

In this study most patients were notdiagnosed before referral and wasreferred relatively late.Cysteamine isgenerally not available in Iraq. Renalreplacement therapy is also not availablefor children with cystinosis when they

eventually reach end-stage renal failure.Among 13 the patients with Cystinosis (8referred to us and 5 of their siblings) onlyone patient was receiving cysteamine

Conclusion: The outcome ofNephropathic cystinosis in Iraqi childrenis poor as most of them progressed toCRF because of the non-availability ofcysteamine.

References

1- Kleta R, Gahl WA. Pharmacologicaltreatment of nephropathic cystinosiswith cysteamine. Expert OpinPharmacother. 2004 Nov; 5(11):2255-62.

2- Kleta R, Bernardini I, Ueda M,Varade WS, Phornphutkul C,Krasnewich D, Gahl WA. Long-termfollow-up of well-treated nephropathiccystinosis patients. J Pediatr. 2004 Oct;145(4):555-60

3-Sonies BC, Almajid P, Kleta R,Bernardini I, Gahl WA. Swallowingdysfunction in 101 patients withnephropathic cystinosis: benefit of long-term

cysteamine therapy. Medicine (Baltimore).2005 May;84(3):137-46.

4-Levtchenko EN, van Dael CM, deGraaf-Hess AC, Wilmer MJ, van denHeuvel LP, Monnens LA, Blom HJ.Strict cysteamine dose regimen isrequired to prevent nocturnal cystineaccumulation in cystinosis. PediatrNephrol. 2006 21(1):110-3.
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