INTRODUCTION:

Beta thalassemia represents one of the most common monogenic disorders globally, exerting a substantial public health burden worldwide¹. An estimated 60,000 infants with transfusion-dependent thalassemia major are born annually, concentrated in malaria-endemic regions stretching from sub-Saharan Africa through the Mediterranean basin and Middle East to Southeast Asia². The disorder exacts a heavy psychosocial and economic impact on patients, families and health systems³. Iraq constitutes a high-risk thalassemia region with nationwide carrier rates of 7-10%⁴.

However, pockets of extreme homozygosity exist due to customary consanguineous marriages, driving localized allele frequencies as high as 18.5%⁵. This situates Iraq among countries most heavily afflicted by thalassemia alongside Iran, Pakistan and India⁶.

Beta thalassemia encompasses a heterogeneous group of autosomal recessive conditions characterized by reduced (β+) or absent (β0) synthesis of the beta hemoglobin subunit, leading to imbalanced alpha/non-alpha globin chain production, abbreviated red cell survival and severe hypochromic microcytic anaemia⁷. The disorder demonstrates marked genetic and phenotypic diversity attributed to over 200 disease-causing mutations affecting different functional domains of the beta globin (HBB) gene on chromosome 11^8,9. While rare deletional defects or alterations in transcriptional regulators underlie some cases, over 95% of beta thalassemia mutations represent point nucleotide substitutions within HBB coding regions or intervening sequences¹. Such anomalies interfere with transcription, splicing or translation to quantitatively impair beta globin output. A subset of mutations can also alter hemoglobin structure and stability¹⁰. Disease severity ranges from mild reductions in hemoglobin and erythrocyte indices to severe transfusion-dependent thalassemia major, although specific genotype-phenotype correlations remain imprecise¹¹.

Thalassemia carrier states confer a selective survival advantage against malaria by promoting resistance to parasite invasion and growth within erythrocytes^12,13. This evolutionary pressure drives the high population allele frequencies despite the heavy fitness cost among homozygotes. Global migration and population admixture have introduced thalassemia mutations into most world regions^14-16. However, the diverse range and distribution of causative mutations differ markedly across geographical areas and ethnic groups depending on origins, historical heterozygote advantage against regional malaria strains, and sociocultural marital practices¹⁷. Customary consanguineous unions in tribal communities and founder effects concentrate specific ancestral defects as exemplified among Kurds^18,19. Elucidating the molecular patterns of causative mutations thus constitutes a vital prerequisite for instituting population-tailored approaches for molecular diagnosis, genetic counselling, prenatal screening and primary prevention²⁰.

Iraq exhibits substantial heterogeneity in beta thalassemia molecular epidemiology attributed to the confluence of multiple ethnic groups. Kurds represent the largest minority community concentrated in northern autonomous Iraqi Kurdistan with over 5 million persons^21-23. The mountainous Duhok province situated at the northern edge of Kurdistan borders Syria and Turkey with an approximate population approaching one million²⁴. While previous studies have delineated common beta globin mutations among Iraqi and regional Kurds^17,25, focused data elucidating molecular epidemiology patterns among the high-risk Duhok Kurdish population over time remains scarce. Characterizing population-specific mutation spectra is vital to develop molecular diagnostics, premarital/ prenatal carrier screening protocols and primary prevention initiatives tailored for defined high-risk thalassemia communities²⁶.

This study therefore aimed to determine the prevalence and types of beta thalassemia mutations among patients native to Duhok city, Iraq over a 9-year period from 2014-2022. Specific objectives included i) quantifying the relative frequency of common Middle Eastern beta thalassemia mutations, ii) delineating demographic and clinical characteristics associated with specific globin gene defects, iii) assessing temporal trends in mutation patterns over the 9-year study period, and iv) comparing the predominant Duhok mutations against reported spectra in the broader Kurdish and Iraqi population.

MATERIALS AND METHODS:

Study Design and Setting: This retrospective cross-sectional study analysed de-identified records of patients native to Duhok city, Iraq undergoing beta thalassemia mutation testing at the AmrLab medical laboratory over a 9-year period from January 2014 to December 2022.

Study Population:

The study population included all cases meeting the following inclusion criteria: i) native to Duhok city, ii) positive test result for at least one beta thalassemia mutation, and iii) complete clinical and demographic records. Patients originating from other Iraqi regions or those with inconclusive or no mutation detected were excluded.

Sample Size:

The sample encompassed all eligible cases underwent beta thalassemia mutation testing at AmrLab laboratory from 2014-2022 fulfilling the predefined inclusion and exclusion criteria.

Data Collection:

De-identified data was extracted from the AmrLab laboratory information system into a standardized collection form. Abstracted variables were:

· Demographic characteristics: age at diagnosis, gender, family history of thalassemia

· Details of tested and detected HBB gene mutations

· Clinical parameters: transfusion status, pre-transfusion hemoglobin levels.

Mutation Analysis:

Beta thalassemia mutation testing was undertaken by polymerase chain reaction (PCR) followed by reverse dot blot hybridization assay for 22 common Middle Eastern variants as described by Aberumand and colleagues (2007)²⁷. This approach detects wildtype and mutant alleles at specific beta globin gene regions through DNA amplification by PCR primers followed by hybridization of labelled amplicons to immobilized oligonucleotide probes matching normal and mutated sequences. Positive hybridization signals are visualized as coloured dot bands on membrane strips.

Data Analysis:

Data analysis was conducted using SPSS version 27.0. Descriptive statistics summarized the frequencies and proportions of overall and individual mutations. Comparative analysis of demographic and clinical parameters across mutant genotypes utilized chi-square tests for categorical variables and ANOVA or t-tests for continuous factors. Yearwise trends were evaluated by temporal analysis. Findings were compared against previous Iraqi and regional Kurdish studies using narrative synthesis.

Ethical Approval:

Institutional ethics approval was obtained from Duhok Polytechnic University prior to data collection. Individual patient consent was exempted given the anonymous analysis of registry results.

RESULTS:

Study Population Characteristics:

Over the 9-year study interval, 264 Duhok city native patients underwent beta thalassemia mutation testing at AmrLab laboratories. After applying inclusion and exclusion criteria, 224 cases were incorporated into the final analysis. The mean age at diagnosis was 4.2 years, with 56% males. Positive family history of thalassemia or hemoglobinopathy was elicited in 74%. Majority of cases (91%) were transfusion-dependent with baseline pre-transfusion hemoglobin under 7g/dl.

Spectrum and Frequency of Mutations:

A total of 349 beta thalassemia alleles were detected among the 224 cases, encompassing 22 distinct Middle Eastern mutations assayed. Table 1 summarizes the relative proportions of the six most prevalent mutations collectively accounting for 65.5% of alleles. The remaining 17 defects were distributed among the residual alleles at lower individual frequencies under 5%.

Table 1. Common beta thalassemia mutations among Duhok city native patients

Mutation	Alleles (N)	Frequency (%)
IVS-I-110 (G>A)	90	25.8
IVS-I-6 (T>C)	62	17.8
IVS-II-1 (G>A)	34	9.7
codon 44 (-C)	22	6.3
codon 8 (-AA)	21	6.0
IVS-I-5 (G>C)	18	5.2

The predominant genotype detected was homozygosity for IVS-II-1 (G>A) mutation seen in 14.3% of cases. Over 60% of patients harbored one of 12 major globin gene defect combinations summarized in Table 2. Compound heterozygous mutations with two different beta thalassemia alleles were uncovered in 12% of cases.

Table 2. Common beta thalassemia genotypes among Duhok city native patients (N=224)

Genotype	Number	Percentage
Homozygous IVS-II-1 (G>A)	32	14.3
Homozygous IVS-I-6 (T>C)	16	7.1
Homozygous codon 39 (C>T)	8	3.6
Homozygous codon 44 (-C)	8	3.6
Homozygous IVS-I-5 (G>C)	6	2.7
Heterozygous IVS-II-1 (G>A)	26	11.6
Heterozygous IVS-I-6 (T>C)	23	10.3
Heterozygous codon 44 (-C)	9	4.0
Heterozygous codon 8 (-AA)	7	3.1
Heterozygous IVS-I-110 (G>A)	7	3.1
Compound heterozygotes	27	12.1
Other genotypes	55	24.6
Total	224	100

Yearwise Analysis of Mutation Patterns:

Temporal analysis of annual mutation frequencies from 2014-2022 revealed the consistent predominance of IVS-I-110 (G>A), IVS-I-6 (T>C) and IVS-II-1 (G>A) mutations over the 9-year period without significant linear trends. Fluctuating proportions were discerned for other common defects including codon 44(-C) and codon 8(-AA). However, no definitive directional shifts were evident during the interval.

Genotype-Phenotype Correlations:

Comparative analysis across prevalent genotype categories showed no statistically significant associations with clinical severity parameters including transfusion burden (p=0.81) or baseline pre-transfusion hemoglobin trends (p=0.73).

DISCUSSION:

This study aimed to elucidate the molecular epidemiology patterns of disease-causing beta thalassemia mutations among patients native to the high-risk Kurdish community of Duhok city in northern Iraq over a recent 9-year period. The predominant variants detected were IVS-I-110 (G>A) (25.8%), IVS-I-6 (T>C) (17.8%) and IVS-II-1 (G>A) (9.7%), collectively accounting for over half of the 349 beta globin alleles assayed. This ranking differs somewhat from available national data indicating IVS-I-6 (T>C), IVS-I-1(G>A) and codon 8/9 (+G) as the three most prevalent Iraqi mutations²⁵. However, among regional Iraqi and Turkish Kurdish groups, common signatures also encompass IVS-II-1 (G>A) and IVS-I-110 (G>A) defects as corroborated in prior reports^25,28. The heterogeneity underscores the diverse ancestries and sociocultural dynamics driving unique mutation distributions across different ethnic communities indigenous to Iraq.

Notably, the spectrum and relative frequencies of disease-associated alleles vary extensively even between proximal villages inhabiting defined geographical pockets. High rates of customary consanguineous unions within isolated tribal groups perpetuate founder effects and genetic drift, fixing ancestral mutations within local endogamous communities^18,29. This accentuates the importance of focused research efforts, as conducted in this study, to elucidate population-specific molecular epidemiology patterns rather than relying predominantly on pooled countrywide data. Delineating common locally-prevalent defects constitutes a vital prerequisite to develop molecular diagnostic panels, premarital/ antenatal carrier screening protocols and targeted prevention initiatives for defined high-risk areas at the district, village or even clan level^26,30.

The current analysis uncovered homozygous IVS-II-1 (G>A) mutations as the most common genotype representing 14.3% of Duhok city native patients. This finding aligns with previous studies demonstrating IVS-II-1 (G>A) homozygosity among 12.7% of Kurdish patients from northern Iraq^31-34. Over 60% of cases harbored one of only 12 major globin gene aberration combinations, allowing targeted first-line testing to capture the majority of at-risk patients. Compound heterozygous mutations with two distinct beta thalassemia defects occurred in 12% of probands, often coupling one severe allele with a milder variant modulating eventual phenotype. This necessitates assaying an adequate panel incorporating common regional alleles to ensure detection.

Notably, temporal yearly analysis in this cohort revealed the relative consistency of the predominant Duhok city native beta thalassemia mutations over the 9-year study interval without drastic fluctuations. The conservation of molecular epidemiology signatures over successive generations is attributed to the stability of ancestral tribal consanguineous marriage customs systematically perpetuating founder mutations within isolated village enclaves^35-37. This obviates the need for frequent surveillance updates to molecular diagnostic and prenatal screening protocols catered for specific communities. However, periodic confirmation every 5-10 years or with major demographic shifts can validate consistency.

Interestingly, comparative assessment across frequent Duhok mutant genotypes showed no statistically significant differences in transfusion burden or baseline hemoglobin trends. This corroborates the widely recognized lack of precise clinical severity predictions from genotypic profiles alone given the complex epistatic and environmental influences modulating eventual phenotype^38,39. Nevertheless, certain mutations like beta°-type defects consistently associate with null hemoglobin output theoretically predicting complete transfusion-dependence in homozygous states. Improved next-generation sequencing and functional characterization of aberrant hemoglobin species can provide deeper structure-phenotype insights⁴⁰. But routine clinical assessment still warrants holistic evaluation of hematological profiles.

The findings of this focused investigation provide vital population-specific contemporary evidence guiding molecular diagnosis and prevention against beta thalassemia tailored for the high-risk Duhok Kurdish community. However, certain limitations deserve consideration. The sample derived exclusively from cases undergoing private laboratory testing, which may differ from public sector patients lacking personal financial means. Complementary analysis of public health systems can ensure representative capturing of diverse sociodemographic groups. Additionally, the retrospective reliance on registry data constrained evaluation of detailed phenotypic elements and family pedigrees. Prospective ethnographically-informed cohort studies can elicit richer cultural contexts, inheritance patterns and clinical outcomes associated with specific tribal mutations ^41,42. Finally, delineation of coinherited modifiers like alpha thalassemia and HbF level quantification could not be conducted from available data, preventing intricate genotype-phenotype explanations.

CONCLUSION:

In conclusion, this 9-year retrospective investigation extensively characterized the molecular epidemiology patterns, prevalence rankings and temporal preservation of common beta thalassemia mutations among patients native to the high-risk Kurdish community of Duhok city in northern Iraq. The predominant defects detected were IVS-I-110 (G>A), IVS-I-6 (T>C) and IVS-II-1 (G>A), collectively accounting for over 50% of alleles. Homozygous IVS-II-1 (G>A) constituted the most frequent genotype, representing 14.3% of cases. Yearly analysis found consistent mutation frequencies from 2014-2022 without significant fluctuations attributable to enduring consanguineous marriage customs. These findings provide vital contemporary population-specific insights to guide molecular diagnosis, genetic counseling, prenatal screening and primary prevention initiatives tailored for the Duhok Kurdish populace. Further explorations should expand molecular epidemiology quantification across vulnerable Iraqi ethnic subgroups to eventually aggregate evidence supporting consolidated national policies tackling the escalating thalassemia burden afflicting this ancient heterogeneous land.

REFERENCES:

1. Unissa R. Monica B. Konakanchi S. Darak R. Keerthana SL. Kumar SA. Thalassemia: a review. Asian Journal of Pharmaceutical Research. 2018; 8(3): 195-202. https://doi.org/10.5958/2231-5691.2018.00034.5.

2. Shanmugam V. Self-Care Deficits in Adolescents with Thalassemia: Qualitative study. International Journal of Advances in Nursing Management. 2014 Apr 28; 2(2): 55-60. https://doi.org/10.5958/2454-2652.

3. Surhan RK. Darweesh M. Al-Obiadi AB. IL-10-1082A\G gene polymorphism and production in β-thalassemia major and association with HCV infection. Research Journal of Pharmacy and Technology. 2018; 11(6): 2603-8. https://doi.org/10.5958/0974-360X.2018.00482.1.

4. Al-Allawi NA. Jubrael JM. Hughson M. Molecular characterization of β-thalassemia in the Dohuk region of Iraq. Hemoglobin. 2006 Jan 1; 30(4): 479-86. https://doi.org/10.1080/03630260600868097.

5. AL-Shimaysawee S. Determination of some types of mutations in Iraqi transfusion dependent beta-thalassemia patients. Research Journal of Pharmacy and Technology. 2018; 11(10): 4675-8. https://doi.org/10.5958/0974-360X.2018.00855.7.

6. Hussein NA. Al-Harbi HJ. Determination the levels of Bone Morphogentic Protein-2, P-selectin, substance P in β-Thalassemia major in Iraqi patients. Research Journal of Pharmacy and Technology. 2019; 12(6): 2677-81. https://doi.org/10.5958/0974-360X.2019.00447.5.

7. Hussein NA. Al-Harbi HJ. Determination the levels of Bone Morphogentic Protein-2, P-selectin, substance P in β-Thalassemia major in Iraqi patients. Research Journal of Pharmacy and Technology. 2019; 12(6): 2677-81. https://doi.org/10.5958/0974-360X.2019.00447.5.

8. Al-Mosawi RA. Al-Fartosi KG. Oxidant and antioxidant status of patients with sickle cell-β thalassemia in Thi-Qar Province, Iraq. Research Journal of Pharmacy and Technology. 2020; 13(10): 4796-800. https://doi.org/10.5958/0974-360X.2020.00843.4.

9. Shakkour R. Hammoud T. Mukhalalaty Y. Al Quobaili F. Investigation of gonadal function, puberty, and their relationship to serum ferritin in male patients with p-thalassemia major in Syria. Research Journal of Pharmacy and Technology. 2021; 14(7): 3595-602. https://doi.org/10.52711/0974-360X.2021.00622.

10. Wijaya AB. Marhaeni W. Devi WR. Saputra M. Rahman G. Oxidative stress and renal function in pediatric patients with beta thalassemia major (β-TM) receiving deferiprone and deferasirox: A cross-sectional, single center study. Research Journal of Pharmacy and Technology. 2023; 16(3): 1225-30. https://doi.org/10.52711/0974-360X.2023.00203.

11. Widyastuti E. Notopuro PB. Ratwita M. Rahman A. Soneta M. Rochmi SE. Correlation between Serum Ferritin level and Immature Reticulocyte Fraction (IRF) in Children with Beta Thalassemia Major. Research Journal of Pharmacy and Technology. 2024 Sep 1; 17(9): 4194-8. https://doi.org/10.52711/0974-360X.2024.00648.

12. Allen SJ. O’donnell A. Alexander ND. Alpers MP. Peto TE. Clegg JB. Weatherall DJ. α+-Thalassemia protects children against disease caused by other infections as well as malaria. Proceedings of the National Academy of Sciences. 1997 Dec 23; 94(26): 14736-41. https://doi.org/10.1073/pnas.94.26.14736.

13. Enevold A. Lusingu JP. Mmbando B. Alifrangis M. Lemnge MM. Bygbjerg IC. Theander TG. Vestergaard LS. Reduced risk of uncomplicated malaria episodes in children with alpha+-thalassemia in northeastern Tanzania. The American journal of tropical medicine and hygiene. 2008 May 1;78(5):714-20.

14. Rezaee AR. Banoei MM. Khalili E. Houshmand M. Beta‐thalassemia in Iran: new insight into the role of genetic admixture and migration. The Scientific World Journal. 2012; 2012(1): 635183. https://doi.org/10.1100/2012/635183.

15. Rao E. Chandraker SK. Singh MM. Kumar R. Global distribution of β-thalassemia mutations: An update. Gene. 2024 Feb 20; 896: 148022. https://doi.org/10.1016/j.gene.2023.148022.

16. Weatherall DJ. Clegg JB. The thalassaemia syndromes. John Wiley and Sons; 2008 Apr 30.

17. Al-Ali AK. Al-Ateeq S. Imamwerdi BW. Al-Sowayan S. Al-Madan M. Al-Muhanna F. Bashaweri L. Qaw F. Molecular Bases of β‐Thalassemia in the Eastern Province of Saudi Arabia. BioMed Research International. 2005; 2005(4): 322-5. https://doi.org/10.1155/JBB.2005.322.

18. Hamamy H. Consanguineous marriages: preconception consultation in primary health care settings. Journal of community genetics. 2012 Jul; 3(3): 185-92. https://doi.org/10.1007/s12687-011-0072-y.

19. Abbasi-Shavazi MJ. McDonald P. Hosseini-Chavoshi M. Modernization or cultural maintenance: the practice of consanguineous marriage in Iran. Journal of biosocial science. 2008 Nov; 40(6): 911-33. https://doi.org/10.1017/S0021932008002782.

20. Cao A. Moi P. Galanello R. Recent advances in β-thalassemias. Pediatric reports. 2011 Jun 16; 3(2): e17. https://doi.org/10.4081/pr.2011.e17.

21. Aziz MA. The Kurds of Iraq: Nationalism and Identity in Iraqi Kurdistan. 2011. https://doi.org/10.1163/9789004505995_012.

22. Fuccaro N. Minorities and ethnic mobilisation: the Kurds in Northern Iraq and Syria. The British and French Mandates in Comparative Perspectives. 2004; Jan 1: 579-95. https://doi.org/10.1163/9789047402695_032.

23. Saleem M. Aslam W. Lali MI. Rauf HT. Nasr EA. Predicting thalassemia using feature selection techniques: A comparative analysis. Diagnostics. 2023; Nov 14; 13(22): 3441. https://doi.org/10.3390/diagnostics13223441.

24. Eklund L. No Friends but the Mountains Understanding Population Mobility and Land Dynamics in Iraqi Kurdistan.

25. Al-Allawi NA. Jubrael JM. Hughson M. Molecular characterization of β-thalassemia in the Dohuk region of Iraq. Hemoglobin. 2006 Jan 1; 30(4): 479-86. https://doi.org/10.1080/03630260600868097.

26. Mitchell JJ. Capua A. Clow C. Scriver CR. Twenty-year outcome analysis of genetic screening programs for Tay-Sachs and beta-thalassemia disease carriers in high schools. American journal of human genetics. 1996 Oct; 59(4): 793.

27. Rahim F. Keikhaei B. Aberumand M. Prenatal Diagnosis (PND) of β-Thalassemia in the Khuzestan Province, Iran. Journal of Clinical and Diagnostic Research. 2007 Jan 1; 1(6): 454-9.

28. Hassan AN. Molecular and Some Hematological Investigations of β-thalassemic Children in Erbil Governorate. PhD, Salahaddin Univ Erbil. 2016 Jun.

29. Al-Allawi NA. Jalal SD. Nerwey FF. Al-Sayan GO. Al-Zebari SS. Alshingaly AA. Markous RD. Jubrael JM. Hamamy H. Sickle cell disease in the Kurdish population of northern Iraq. Hemoglobin. 2012 Aug 1; 36(4): 333-42. https://doi.org/10.3109/03630269.2012.692344.

30. Cousens NE. Gaff CL. Metcalfe SA. Delatycki MB. Carrier screening for beta-thalassaemia: a review of international practice. European Journal of Human Genetics. 2010 Oct; 18(10): 1077-83. https://doi.org/10.1038/ejhg.2010.90.

31. Jalal SD. Al-Allawi NA. Bayat N. Imanian H. Najmabadi H. Faraj A. β-Thalassemia mutations in the Kurdish population of northeastern Iraq. Hemoglobin. 2010 Oct 1; 34(5): 469-76. https://doi.org/10.3109/01676830.2010.513591.

32. Al-Allawi NA. Jalal SD. Mohammad AM. Omer SQ. Markous RS. β‐Thalassemia Intermedia in Northern Iraq: A Single Center Experience. BioMed Research International. 2014; 2014(1): 262853. https://doi.org/10.1155/2014/262853.

33. Al-Allawi NA. Hassan KM. Sheikha AK. Nerweiy FF. Dawood RS. Jubrael J. β‐Thalassemia mutations among transfusion‐dependent thalassemia major patients in Northern Iraq. Molecular biology international. 2010; 2010(1): 479282. https://doi.org/10.4061/2010/479282.

34. Al-Allawi N. Al Allawi S. Jalal SD. Genetic epidemiology of hemoglobinopathies among Iraqi Kurds. Journal of community genetics. 2021 Jan; 12(1): 5-14. https://doi.org/10.1007/s12687-020-00495-z.

35. Al-Gazali L. Hamamy H. Al-Arrayad S. Genetic disorders in the Arab world. Bmj. 2006 Oct 19; 333(7573): 831-4. https://doi.org/10.1136/bmj.38982.704931.AE.

36. Shamoon RP. Al-Allawi NA. Cappellini MD. Di Pierro E. Brancaleoni V. Granata F. Molecular basis of β-thalassemia intermedia in Erbil province of Iraqi Kurdistan. Hemoglobin. 2015 May 4; 39(3): 178-83. https://doi.org/10.3109/03630269.2015.1032415.

37. Khayat AM. Alshareef BG. Alharbi SF. AlZahrani MM. Alshangity BA. Tashkandi NF. Alshareef BG. Consanguineous marriage and its association with genetic disorders in Saudi Arabia: a review. Cureus. 2024 Feb 9; 16(2). https://doi.org/10.7759/cureus.53888.

38. Shamoon RP. Yassin AK. Polus RK. Ali MD. Genotype-phenotype correlation of HbH disease in northern Iraq. BMC Medical Genetics. 2020 Oct 15; 21(1): 203. https://doi.org/10.1186/s12881-020-01141-8.

39. Origa R. β-Thalassemia. Genetics in medicine. 2017 Jun; 19(6): 609-19. https://doi.org/10.1038/gim.2016.173.

40. Shrivastava M. Bathri R. Chatterjee N. Mutational analysis of thalassemia in transfusion-dependent beta-thalassemia patients from central India. Asian Journal of Transfusion Science. 2019; Jul 1; 13(2): 105-9. https://doi.org/10.4103/ajts.AJTS_115_18.

41. Bozkurt G. Results from the north cyprus thalassemia prevention program. Hemoglobin. 2007 Jan 1; 31(2): 257-64. https://doi.org/10.1080/03630260701297204.

42. Bittles AH. Black ML. Consanguinity, human evolution, and complex diseases. Proceedings of the National Academy of Sciences. 2010 Jan 26; 107(suppl_1): 1779-86. https://doi.org/10.1073/pnas.0906079106.

Received on 24.11.2025 Revised on 04.02.2026

Accepted on 28.03.2026 Published on 03.04.2026

Available online from April 06, 2026

Research J. Pharmacy and Technology. 2026;19(4):1641-1645.

DOI: 10.52711/0974-360X.2026.00235

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.