The Impact of JAK2 V617F, CALR, and MPL Mutations as Molecular Diagnostic Markers of Myeloproliferative Neoplasms in Kurdish Patients. A Single-center Experience.

Myeloproliferative neoplasms have a high prevalence and genetic mutations play a role in their occurrence. Determination of these mutations can be valuable in the screening, diagnosis, and treatment of patients. Therefore, this study was conducted to investigate the mutation of JAK2, CALR, and MPL genes as diagnostic and prognostic biomarkers in patients with myeloproliferative neoplasms in the Kurdistan region of Iraq. This case-control study was conducted in 2021 on 223 patients with myeloproliferative neoplasm referred to Hiwa Sulaymaniyah Cancer Hospital. The data were collected from three groups of Polycythemia Vera (PV) patients (70 people), Essential Thrombocythemia (ET) (50 people), and Primary Myelofibrosis (PMF) (103 people) by sampling for JAK2, CALR, and MPL gene mutation tests and demographic and clinical information have been collected through examination. The data were analyzed by SPSS v. 23 software and descriptive and chi-square statistical tests. The study included 223myeloproliferative neoplasms (MPN) patients. JAK2 V617F mutation was detected mostly in PV patients and CALR and MPL mutations in ET and PMF patients and this mutation difference was significant in prognosis and disease diagnosis. An association between JAK 2 mutation and splenomegaly was also demonstrated. Considering the lack of a definitive diagnostic method in myeloproliferative disease, the results of this study showed that molecular studies, including JAK2 V617F, CALR, and MPL mutations and other hematological tests can be useful and effective in the diagnosis of MPN. In addition, it is necessary to pay attention to new diagnostic methods.

The Outcome of Acute Lymphoblastic Leukemia in 109 Adult Iraqi Patients.

While many studies addressed the outcome of adult ALL in developed Western countries, there is paucity of such prospective studies from developing Mediterranean ones. This is a prospective cohort study conducted at Hiwa Cancer Hospital in Sulaimani city and Nanakali Hospital in Erbil city-Kurdistan Iraq from March 2012 to August 2017. The main characteristics of adult ALL patients, type of therapy and risk factors were analyzed to assess their impact on treatment outcome and survival status. A total of 109 adult ALL patients were included with a median age of 24 years and male to female ratio of 1.7:1. B-ALL accounted for 76.1% of the cases, while the rest were T-ALL. BCR-ABL rearrangement was encountered in 12% of B-ALL. Complete remission (CR) rate was 81.7%, the overall 5 year survival (OS) was 38%, Relapse Free 5 year Survival (RFS) was 49%. Younger adults (< 35 years) had significantly higher CR rates and OS compared to the older group (P < 0.001 each). On the other hand, gender, high leucocyte count ≥ 50×109/L, immunophenotype (including B and T ALL subtypes), and clinical risk status did not predict a poor outcome. Multivariate analysis revealed that only age < 35 years and BCR-ABL rearrangement were significantly associated with better OS. Despite some limitations, the outcomes of Iraqi adult ALL is comparable to those reported in Western developed countries, with particularly favorable outcomes in younger patients. The need to improve outcome in adult ALL remains an important priority in our country as it is throughout the world.

The contribution of CD200 to the diagnostic accuracy of Matutes score in the diagnosis of chronic lymphocytic leukemia in limited resources laboratories.

Flow cytometry immunophenotyping has an essential role in distinguishing chronic lymphocytic leukemia from other B-chronic lymphoproliferative disorders. Recently, CD200 is considered as a relatively consistent marker in chronic lymphocytic leukemia. We retrospectively assessed CD200 expression in 252 patients with B chronic lymphoproliferative disorders with four-color flow cytometry. CD200 expression estimation included the proportion of positive cells (≥30%) and the mean fluorescence intensity ratio. Additionally, we have incorporated CD200 into Matutes score, also replaced FMC7 and CD79b in an attempt to improve the score discriminative power. Of 252 patients enrolled, 199(79%) patients were classified as chronic lymphocytic leukemia and 53 (21%) as other B-chronic lymphoproliferative disorders. All chronic lymphocytic leukemia cases and 20 of 53 (37.7%) of other B-chronic lymphoproliferative disorders demonstrated high CD200 expression (≥30%). Further, CD200 (≥30%) revealed a higher accuracy in comparison to other markers in Matutes score (range: 51%-92.5%). Also, CD200 addition to the Matutes score has correctly recognized all 199 chronic lymphocytic leukemia cases including 10 atypical chronic lymphocytic leukemia cases. As for non-CLL cases, 20 of 53 attained a higher score, yet keeping the original diagnosis. Moreover, CD200 enhanced the diagnostic accuracy of Matutes score to 100%, and when included in a simplified 4-markers score, showed an accuracy of 99.8% compared to 99.4% of Matutes score. In conclusion, CD200 is an accurate diagnostic marker for chronic lymphocytic leukemia, and can refine the modified Matutes score accuracy when added with other markers.

Genetic epidemiology of hemoglobinopathies among Iraqi Kurds.

Hemoglobinopathies are major health problems among Iraqi Kurds, who are a distinct ethnic group inhabiting North and Northeastern Iraq. We reviewed published literature on these disorders in this part of the world, and it was revealed that the most prevalent is ß-thalassemia with carrier rates of 3.7-6.9%. Alpha thalassemia is less prevalent with carrier rates of 0.03-1.22%, while the sickle cell gene is variably distributed with carrier rates of 0.06-1.2%. Other structural hemoglobinopathies and δß-thalassemia are sporadic. Twenty-seven different ß-thalassemia mutations were identified, with seven constituting 82% of 1039 chromosomes characterized, namely: IVS-II-1 (G>A), IVS-I-6 (T>C), IVS-I-I (G>A), codon 8 (-AA), codon 8/9 (+G), IVS-I-110 (G>A), and codon 5 (-CT). There were notable regional variations in the distribution of ß-thalassemia mutations, with Cd44 being mainly prevalent in the North, while IVS-I-110 is mainly prevalent in the East. In relevance to α-thalassemia, ten different mutations were detected, with the four most frequent constituting 92.4% of 262 alleles characterized being: -α3.7, --MED, α-5ntα, and αPolyA1α. In relevance to sickle cell gene, it is seen in the northern part of the region bordering Turkey, with comparable prevalence rates, and is associated, similar to Turkey, mainly with the Benin haplotype, unlike that in Southern Iraq where it is associated with the Arab-Indian haplotype, similar to Eastern Arabian Peninsula. Given the high prevalence of hemoglobinopathies in the region, and the high rates of consanguineous marriages, a preventive program was initiated in 2008, and results of its first 5 years were promising, though there are still many outstanding challenges that require addressing.

Molecular Characterization and Disease-Related Morbidities of ß-Thalassemia Patients from the Northeastern Part of Iraq.

BACKGROUND: ß-thalassemia is a significant problem in the northeastern part of Iraq, and has imposed a huge burden on the health authorities. OBJECTIVE: To identify the molecular characterization and morbidity prevalence in transfusion-dependent thalassemia (TDT) and non-transfusion dependent thalassemia (NTDT) phenotypes in northeastern Iraq. PATIENTS AND METHODS: This is a cross-sectional study conducted on 242 ß-thalassemia patients from 162 families. Reverse hybridization technique and direct gene sequencing were used to characterize ß-thalassemia mutations, and medical records of the patients were reviewed with a well-designed questionnaire. RESULTS: A total of 22 ß-globin mutations arranged in 53 different genotypes were identified: IVS-II-1 (G> A) (35.7%), followed by IVS-I-6 (T> C) (18.0%), and codon 8/9 (+G) (8.5%) were the most frequent. Among disease-related morbidities, bone disease amounted to (66.9%), followed by endocrinopathies (32.2%), hepatobiliary complications (28.9%), and pulmonary hypertension (9.9%), whereas thrombosis, extramedullary hemopoiesis, and leg ulcers were less frequent. CONCLUSION: The overall complications rate was 78.9%, with a growing probability of complications with advanced age, with evidently higher rates in patients with ß0ß0 and ß0ß+ genotypes that explain the role of underlying genetic defects in the pathophysiology of disease complications.

Corrigendum to "Beta-Thalassemia Intermedia: A Single Thalassemia Center Experience from Northeastern Iraq".

[This corrects the article DOI: 10.1155/2020/2807120.].

ABO Blood Groups and Thrombophilia Markers in Patients With Unstimulated Thrombosis in Kurdistan Region of Iraq.

Thromboembolism (TE) is a complex disease caused by various acquired and inherited factors. The common mutations; factor V Leiden G1691A (FVL G1691A), prothrombin G20210A (PTG20210A), and methylene tetrahydrofolate reductase C677T (MTHFR C677T) are important inherited causes in both venous and arterial thrombosis. The association between ABO blood groups and thrombophilia has been noted by researchers. We aimed to determine the frequency and association of ABO blood groups as a risk factor along with 3 thrombophilia mutations and another 3 thrombophilia markers in a group of patients with unstimulated thrombosis. In a prospective case-control study, we focused on 100 samples, 50 patients with documented thrombosis as well as 50 healthy age-matched controls. Multiplex polymerase chain reaction and reverse hybridization to oligonucleotide particular probes were employed to detect FVL G1691A, PT G20210A, and MTHFR C677T mutations. Analysis of other thrombophilia markers including protein C (PC), protein S (PS), and antithrombin (AT) assays was also performed. ABO blood group typing was done according to standard methods. Non-O blood group was significantly more frequent among cases than controls (76% vs 54%) with high odds of TE (odds ratio [OR] = 2.69). Positivity for at least 1 thrombophilia marker was more in cases (60%) than controls (34%; OR = 2.9). The combined effect of non-O blood group and thrombophilia markers raised the risk of TE (OR = 4.16, P = .001), particularly FVL (OR = 6.76). This study illustrates that harboring the non-O blood group poses an additive effect with other thrombophilia markers in the causation of TE.

The Effects of Smoking on IgE, Oxidative Stress and Haemoglobin Concentration.

BACKGROUND: Smoking is a well-known related factor for many health problems in a human being through different ways of exposure. OBJECTIVES: Thie aim of the study was to examine the effects of different types of cigarette smoking on hemoglobin level, high sensitive C-Reactive Protein (hsCRP), Malondialdehyde (MDA), and IgE levels in healthy adult subjects. METHODS: One hundred seventy-one healthy adult females and males were included in this study. They divided into four groups: cigarette, shisha, passive smokers, and non-smokers groups. Serum samples from all groups analyzed for hemoglobin, hsCRP, IgE, and malondialdehyde level. RESULTS: The mean MDA, IgE, and hemoglobin levels significantly increased in both smokers (cigarette and Shisha groups) and passive smokers than in non-smokers group (p<0.05). The hsCRP levels were significantly increased (p<0.05) in cigarette and Shisha smokers compared to non-smokers. At the same time, there was a non-significant relationship between passive smoker in comparison to non-smokers (p>0.05). CONCLUSION: This study concluded that smoking, including cigarette and shisha, even passive smoking harmed health through increasing Malondialdehyde, serum IgE and hs-CRP levels in the body.

Beta-Thalassemia Intermedia: A Single Thalassemia Center Experience from Northeastern Iraq.

OBJECTIVE: To determine the molecular characterization and disease-associated complications of beta-thalassemia intermedia (ß-TI) patients in Sulaymaniyah province, northeastern Iraq. METHODS: A total of 159 ß-TI) patients in Sulaymaniyah province, northeastern Iraq. ß-TI) patients in Sulaymaniyah province, northeastern Iraq. RESULTS: Nineteen different ß-globin gene mutations arranged in 37 various genotypes were determined. The most frequent were IVS-II-I (G>A) (47.2%), followed by IVS-I-6 (T>C) (23.3%) and IVS-I-110 (G>A) (5%). Among disease-related morbidities documented, bone disease amounted to 53% (facial deformity and osteoporosis), followed by endocrinopathies 17.6% (growth retardation and subclinical hypothyroidism), cholelithiasis 13.8%, pulmonary hypertension 11.3%, and abnormal liver function test 7.5%, whereas venous thrombosis, extramedullary hemopoiesis, and leg ulcer were less frequently observed. Age ≥ 35 and female sex were risk factors for cholelithiasis, while age was an independent risk for hypothyroidism and female sex was associated with increased risk for osteoporosis. Mean serum ferritin of ≥1000 µg/L was associated with an increased risk of osteoporosis, whereas chelation therapy was protective for a multitude of other complications. Transfusion, on the other hand, increased the risk of osteoporosis, yet it was protective for cholelithiasis and hypothyroidism. Moreover, splenectomy was protective for cholelithiasis, although it was an independent risk for hypothyroidism. Finally, hydroxyurea was associated with an increased risk of osteoporosis, while it was protective for cholelithiasis. Discussion and Conclusion. ß +-thalassemia mutation had contributed to 41.25 of families with a less severe ß-thalassemia phenotype in the northeastern part of Iraq, justifying the need to investigate the contribution of genetic modifiers in ameliorating disease severity. In addition, the substantial number of ß-TI patients developed disease-related morbidities, which necessitates the need for more appropriate clinical management with earlier intervention.ß-TI) patients in Sulaymaniyah province, northeastern Iraq. µg/L was associated with an increased risk of osteoporosis, whereas chelation therapy was protective for a multitude of other complications. Transfusion, on the other hand, increased the risk of osteoporosis, yet it was protective for cholelithiasis and hypothyroidism. Moreover, splenectomy was protective for cholelithiasis, although it was an independent risk for hypothyroidism. Finally, hydroxyurea was associated with an increased risk of osteoporosis, while it was protective for cholelithiasis. Discussion and Conclusion. ß +-thalassemia mutation had contributed to 41.25 of families with a less severe ß-thalassemia phenotype in the northeastern part of Iraq, justifying the need to investigate the contribution of genetic modifiers in ameliorating disease severity. In addition, the substantial number of ß-TI patients developed disease-related morbidities, which necessitates the need for more appropriate clinical management with earlier intervention.Discussion and Conclusion. ß +-thalassemia mutation had contributed to 41.25 of families with a less severe ß-thalassemia phenotype in the northeastern part of Iraq, justifying the need to investigate the contribution of genetic modifiers in ameliorating disease severity. In addition, the substantial number of ß-TI patients developed disease-related morbidities, which necessitates the need for more appropriate clinical management with earlier intervention.ß-TI) patients in Sulaymaniyah province, northeastern Iraq. ß-TI) patients in Sulaymaniyah province, northeastern Iraq.

Non-Hodgkin Lymphoma in the Middle East Is Characterized by Low Incidence Rates With Advancing Age.

PURPOSE: In the Middle East, incidence rate ratios (IRRs) of non-Hodgkin lymphoma (NHL) to Hodgkin lymphoma (HL) are more than 50% lower than the United States. MATERIALS AND METHODS: Age-specific incidence rates (ASIRs), age-adjusted incidence rates (AAIRs), and IRRs of NHL:HL were compared using the cancer registries of Iraq, Jordan, Saudi Arabia, and US SEER. RESULTS: The NHL AAIR (95% CI) per 100,000 population was 4.4 (4.1 to 4.7) for Iraq, 5.4 (4.6 to 6.2) for Jordan, 4.7 (4.4 to 5.1) for Saudi Arabia, and 13.2 (13.0 to 13.4) for the United States. The HL AAIR was 1.8 (1.6 to 2.0) for Iraq, 1.8 (1.4 to 2.2) for Jordan, 2.1 (1.9 to 2.2) for Saudi Arabia, and 2.3 (2.2 to 2.4) for the United States, with respective NHL:HL IRR of 2.4 (2.2 to 2.7), 3.0 (2.4 to 3.8), 2.2 (2.0 to 2.5), and 5.7 (5.5 to 6.0). NHL ASIRs for the Middle East and the United States were similar until 30 to 39 years of age. Thereafter, ASIR of NHL peaked at 20 to 33 per 100,000 at age 70 years in the Middle East regions, all much lower than the US age 70 years rate of greater than 100 per 100,000. Diffuse large B-cell lymphoma (DLBCL) represented 52% of NHL in Sulaimaniyah Province of Iraq and 51% of NHL in Saudi Arabia. Both regions had AAIR for DLBCL less than 42% of DLBCL in US SEER. Pediatric Epstein-Barr virus-related Burkitt's lymphoma at 8% was the second most frequent NHL in Sulaimaniyah but made little contribution to overall NHL rates. CONCLUSION: The incidence of HL was slightly lower than in the United States, but it was the markedly lower rates of adult NHL with advancing age, including the predominant DLBCL, that accounted for the low NHL:HL IRR in these Middle Eastern countries.

ß -thalassemia intermedia in Northern Iraq: a single center experience.

To investigate the molecular basis of ß -thalassemia intermedia in Northern Iraq and evaluate its management practices, a total of 74 patients from 51 families were enrolled. The patients were clinically and hematologically reevaluated, and had their ß-thalassemia mutations characterized, as well as the number of α-globin genes and Xmn I (G)γ-158 (C>T) polymorphism studied. Out of 14 ß-thalassemia mutations identified, the four most common were IVS-I-6 (T>C) [33.3%], IVS-II-I (G>A) [21.1%], codon 82/83(-G)[10.1%], and codon 8 (-AA) [8.1%]. The most common contributing factors to the less severe phenotype of thalassemia intermedia were found to be the inheritance of mild ß-thalassemia alleles and the Xmn I polymorphism, while concomitant α-thalassemia had a limited role. Several complications were documented including: pulmonary hypertension in 20.4%, diabetes mellitus in 1.4%, hypothyroidism in 2.9%, and heart failure in 2.7%, while no documented cases of venous thrombosis were found. Compared to their counterparts in several Mediterranean countries, it appears that our patients were much less frequently transfused and had a lower proportion of patients who were splenectomized, on iron chelation, or hydroxycarbamide therapy. Such practices require further scrutiny to ensure that a better level of care is provided and that growth retardation, skeletal changes, and other complications are prevented or reduced.

The first five years of a preventive programme for haemoglobinopathies in Northeastern Iraq.

OBJECTIVE: To evaluate the feasibility and effectiveness of a preventive programme for haemoglobinopathies in a single centre in Northeastern Iraq. METHODS: Premarital screening, genetic counselling and prenatal diagnosis (PND) were implemented over a 5 year period. RESULTS: Among a total of 108,264 screened individuals (54,132 couples), ß-thalassaemia trait, δß-thalassaemia trait, and sickle cell trait were diagnosed in 3.98%, 0.11% and 0.07%, respectively. Of 130 at risk couples (2.4/1000), 107 (82%) were available for follow up, with 105 couples (98.1%) proceeding with their marriage after counselling. In the 125 registered pregnancies in the latter couples, PND was performed in 85 (in 80 couples, uptake 76%). Selective termination was chosen in 10 of the 11 pregnancies with an affected fetus. Six affected babies were born among couples who declined PND. At the same time 30 already married couples with at least one thalassaemic child underwent PND, revealing three affected fetuses; all three pregnancies were terminated. CONCLUSION: The programme revealed that most at risk couples diagnosed by premarital screening chose to proceed with their marriage, with 76% seeking PND followed by selective termination of an affected fetus. A 65% reduction in number of affected births was reported over the 5 year period. This regional programme could serve as a prototype for a national haemoglobinopathy prevention programme.

The spectrum of ß-thalassemia mutations in Baghdad, Central Iraq.

While previous studies from Iraq have focused on ß-thalassemia (ß-thal) mutations in the northern part of the country, inhabited mainly by Kurds, no study of significance has looked at these mutations in central or southern Iraq, which is inhabited by the Arab majority. For the latter purpose this study was initiated and 103 ß-thal carriers from Baghdad at the center of the country were investigated using multiplex polymerase chain reaction (PCR) and reverse hybridization followed by sequencing. The results revealed that a total of 17 mutations were implicated, six of which, IVS-I-110 (G>A), IVS-II-1 (G>A), IVS-I-5 (G>C), codons 8/9 (+G), IVS-I-I (G>A) and codon 44 (-C), constituted 78.0% of the mutations characterized. Among the 17 mutations identified, six are reported for the first time from Iraq and include: IVS-I, 25 bp deletion, IVS-II-848 (C>A), -28 (A>C), IVS-I-130 (G>C), IVS-I-128 (T>G) and codons 41/42 (-TTCT). The findings of the current study clearly illustrate the genetic heterogeneity of the population of central Iraq, as demonstrated by the presence of a combination of Mediterranean, Asian Indian, Kurdish, Iranian, Egyptian, Saudi Arabian and Turkish mutations that is reflective of the historical background of this part of the country.

The spectrum of α-thalassemia mutations in the Kurdish population of Northeastern Iraq.

In an attempt to determine the spectrum of α-thalassemia (α-thal) mutations in the Kurdish population of Northeastern (NE) Iraq, a total of 101 unrelated adults with unexplained hypochromia and/or microcytosis were enrolled. α-Thalasssemia mutations were characterized by gap polymerase chain reaction (gap-PCR), multiplex PCR (m-PCR) and reverse hybridization and sequencing for both α genes. A total of nine α-thal mutations were characterized including four deletional ones: -α(3.7) (rightward), - -(MED-I), -(α)(20.5), -α(4.2) (leftward) and five nondeletional ones: α(polyA1)α, αα(Adana), α(-5 nt)α, α(CS)α and α(polyA2)α. These determinants were arranged in 12 different genotypes, the most frequent of which were: -α(3.7)/αα, - -(MED-I)/αα, -α(3.7)/-α(3.7), α(polyA1)α/αα, αα(Adana)/αα and -(α)(20.5)/αα. This pattern is similar to that reported in Turkey, western (W) Iran, Cyprus and Greece, and to some extent, different from the pattern observed in the Arabian Peninsula.

Sickle cell disease in the Kurdish population of northern Iraq.

Epidemiological studies have revealed that sickle cell disease patients are clustered in two geographical areas in Iraq, one among the Arabs in the extreme south, another among the Kurdish population in the extreme north, where they constitute major health problems. However, no studies have focused on the genotypes responsible for sickle cell disease or the ß-globin gene haplotypes associated with it. For the latter purpose, a total of 103 unrelated Kurdish sickle cell disease patients were evaluated by restriction fragment length polymorphism (RFLP) for the sickle cell mutation, followed by multiplex polymerase chain reaction (PCR) and reverse hybridization for ß- and α-thalassemia (ß- and α-thal) mutations, whenever indicated. Results showed that the most common genotype was sickle cell anemia (68.0%) followed by Hb S/ß(0)-thal and Hb S/ß(+)-thal at frequencies of 24.2 and 7.8%, respectively. Eight ß-thal mutations were associated with the latter two genotypes including: IVS-II-1 (G>A), IVS-I-110 (G>A), codon 8 (-AA), codon 44 (-C), codon 22 (-7 bp), IVS-I-1 (G>A), codon 30 (G>C) and IVS-I-6 (T>C). In Hb SS patients, the -α(3.7) deletion was documented in 10.0% and was the only α-thal mutation detected. Furthermore, 5' ß-globin gene cluster haplotyping of 128 ß(S) chromosomes revealed that the most common haplotype seen in 69.5% was the Benin haplotype, followed by the Arab-Indian haplotype in 12.5%. These latter findings closely resemble reports from neighboring Turkey, Syria, Jordan, Lebanon and Mediterranean countries, suggesting a possible common origin, but are in contrast to findings from the Eastern Arabian Peninsula and Iran.

ß-Thalassemia mutations in the Kurdish population of northeastern Iraq.

A random 123 carriers of ß-thalassemia (ß-thal), identified by the Sulaimaniyah Provincial Premarital Screening Program in northeastern Iraq, were screened for ß-thal mutations using multiplex polymerase chain reaction followed by reverse hybridization StripAssay and direct sequencing. A total of 11 different ß-thal mutations was identified in the studied samples, of which eight represented 96% of the mutated ß-globin genes. These were IVS-II-1 (G>A), IVS-I-110 (G>A), codon 8 (-AA), codons 8/9 (+G), IVS-I-5 (G>C), codon 5 (-CT), IVS-I-6 (T>C) and IVS-I-1 (G>A). Other mutations were less common or sporadic. There were some notable differences in frequencies of various mutations in comparison to other eastern Mediterranean populations, as well as with previous studies of Iraqi Kurds. The latter illustrate the relative heterogeneity of the mutations distributed in Iraq, and the need to screen other areas of the country, to ensure the establishment of an effective prenatal diagnosis program.