Archives of Iranian Medicine
Volume:6 Issue: 4, Oct 2003

The objective of this article is to review important changes which may occur during Islamic fasting in diabetic patients and the safety of fasting during the Islamic month of Ramadan for diabetics. Despite diverse findings regarding the physiological impact of Ramadan on diabetics, researchers have not yet found, in the diabetics who fast, any pathological changes in body weight, blood glucose, HbA1c, C-peptide, insulin, fructosamine, cholesterol, or triglycerides. In the guidelines section of the article, we recommend that diabetic patients continue their regular daily activity and diet regimen. It is also critical that diabetics adjust their drug regimen, particularly those diagnosed as type 1 diabetes mellitus. These three important factors, i.e. drug regimen adjustment, diet control, and daily activity constitute the “Ramadan 3D Triangle”. With 3D attention, proper education, and diabetes management, we conclude that most type 2 and some type 1 diabetic patients who insist on fasting can carefully observe Ramadan.

Background – Recently, the necessity of determining the boundaries of health system has been sensed by the World Health Organization. Accordingly, any set of activities whose “primary intention” is to improve or maintain health is defined as a health action. There remain various activities like “standardization of all industrial products” that are under debate to be determined as health actions. Considering the numerous concepts of “health” as the main source of controversy among health theorists, we designed a model to enable policy makers to delineate any given activity in a definite boundary of health system. We used a spectrum of health definitions for making the model.Methods and Results – All the definitions of health were classified in two major classes; a first class comprising of those parts of health concepts directly related to physical and mental health, and a second class containing those parts of health system pertaining to all types of health actions except physical and mental health including spiritual, sexual, societal, social, environmental, and emotional concepts. The organizations were theoretically divided into three layers: “primary organizations” are composed of core (the first layer) and satellite (the second layer) organizations and function in the first class of health definitions while the functions of the third layer (secondary organizations) fall within the second class. One can distinguish the core from satellite primary organizations by the extent of their contribution to mental and physical health activities.In the next step, we catalogued a list of organizations in the country with their official and published constitutions. Then, they were grouped into the three layers. Conclusion – Using this model, a policymaker can not only define the status of any set of activities within a definite health boundary, but she/he would also be able to allocate the available resources for a certain health problem to those organizations in each layer dealing with that problem

Background – Gastrointestinal anthrax is quite rare and often fatal. Here we report the clinical presentation and outcome of nine patients with this disease.Methods – The medical records of all patients with documented anthrax admitted to our university hospitals from 1975 to 2000 were reviewed. Nine patients were found to have gastrointestinal anthrax. Data regarding the clinical presentation, incubation period, site of involvement, history of animal contact and/or ingestion of contaminated meat, complications, and clinical outcome of the cases with gastrointestinal anthrax were looked for and recorded.Results – There were 7 males and 2 females with an age range of 3 to 70 years. The most important features included upper gastrointestinal bleeding, ascites, disseminated intravascular coagulation, and early mortality in 8 (88%) patients. The incubation period ranged from 2 to 7 days. Eight patients had history of contact with animals or infected animal products, 4 of whom had ingested raw, uncooked meat of dead sheep as well. One patient presented with acute abdomen mandating laparotomy. Only one patient survived and was discharged after 52 days of intensive care management.Conclusion – Gastrointestinal anthrax, although rare, continues to be a dreadful consequence of consumption of raw or undercooked meat of infected animals. Public education and proper animal vaccination, especially in areas where anthrax is prevalent may prevent a large number of such cases.

Background – Resistance to antituberculosis agents is an important obstacle in the treatment and control of tuberculosis in the world. The present study was undertaken to assess the pattern of resistance at a referral center in Tehran, Iran.Methods –The tests of pretreatment susceptibility to isoniazid (INH), rifampin (RIF), ethambutol (EMB), and streptomycin (STM) were performed by standard proportional method for the isolated bacilli from 273 smear- and culture-positive pulmonary tuberculosis patients (both old = 86/273 and new = 187/273) between September 1996 and March 2000, and the results were classified in three Groups: I) newly diagnosed without any history of treatment; II) patients with a history of treatment with one course; and III) patients with a history of treatment for two or more courses supposed to be MDR cases. The results were collected for each drug individually, and different combinations of two, three, and four medications.Results – Resistance was significantly higher in Group III compared with Groups II and I; the resistance in Group II was also significantly higher than that in Group I. We observed a high rate of primary resistance to INH and STM in Groups I (15%) and II (22.5%), respectively. A high rate of MDR (INH and RIF resistance) was found in Groups II (22.5%) and III (62%).Conclusion – The duration of bacilli exposure to antituberculosis agents in the past is a major factor in developing resistance. Due to high rates of primary resistance especially to STM in our area, we recommend a more conservative approach with six drugs for treatment of the patients whose initial four-drug regimens have failed (Group II).

Background – Because of the increasing incidence of tuberculosis, the growing number of extrapulmonary cases, and paucity of information about abdominal tuberculosis we performed this study on biopsy-proved abdominal tuberculosis cases in the past 15 years in Tabriz. Methods – The medical records of all tuberculosis patients admitted to Tabriz Tuberculosis Center between the years 1984 and 1999 were reviewed and biopsy-proved abdominal cases were selected for a descriptive cross-sectional study. Results – Among 4,693 new cases of tuberculosis in a 15-year period, abdominal tuberculosis was the 5th common type of TB in Tabriz and 77 biopsy-proved cases were selected for the study. Eighty-seven percent of the patients were females. The mean age of the patients was 34 ± 16 years (age range: 13 – 75 years). The peak incidence was seen in the second, third, and fourth decades of life (28%, 27%, and 23%, respectively). The most common complaints were abdominal pain (57%), abdominal swelling (16%), and infertility (9%). The sites of involvement were peritoneum (56%), peritoneum plus genitalia (6.5%), mesenteric lymph nodes (6.5%), peritoneum plus abdominal lymph nodes (2.6%), cecum (2.6%), esophagus (2.6%), gallbladder (2.6%) and a combination of intraabdominal or intra/extraabdominal organs. Before 1991, the majority of patients were treated with isoniazid (INH) + rifampicin (RMP) +ethambutol (ETB) or streptomycin (SM); since then, the treatment has changed to the standard 6-month regimen with 4 drugs. Overall, treatment regimens were INH + RMP + ETB (48%), INH + RMP + ETB + PZA (44%), and INH + RMP + SM (8%).Conclusion – In this study, abdominal tuberculosis was more common in females than males and 7% of our patients were referred due to infertility. Applying more stringent criteria for diagnosis of abdominal TB and availability of noninvasive or less-invasive diagnostic methods may change our results in the future.

Background – The current methods of treating muscle spasticity are not fully desirable. The present study was conducted to assess the effect of botulinum toxin type A (BTA) on spastic hemiplegia due to cerebrovascular accident as a therapeutic modality. Methods – Thirty-eight patients with a history of stroke who signed an informed consent were treated with BTA within a year (mid-2001 to mid-2002) in Azzahra Hospital, Isfahan, Iran. Five-hundred units of botulinum toxin type A was injected into the flexor carpi ulnaris, flexor carpi radialis, flexor digitorum profundus, and biceps brachii muscles. The injections were repeated 2 – 4 times for some patients at three-month intervals. The level of spasticity was assessed before injection, based on Ashworth scale. Response to treatment was evaluated according to the Global Assessment table. The range of motion of the wrist and elbow joints as well as patients'' satisfaction with the treatment were evaluated before and after the intervention. Wilcoxon test was used to compare the data before and after the intervention. SPSS 9 software (SPSS Co, Chicago, IL, USA) was used to analyze the data.Results – Mild to moderate reduction in spasticity was observed in the hands of 13 (34.2%) and arms of 14 (35.55%) patients following injections. This reduction in spasticity was temporary, lasting for two to three months. Patients with severe reduction of range of motion prior to treatment experienced more satisfactory improvement than those with mild to moderate reduction in range of motion. Improvement in the range of motion of the wrist joint corresponded to that of the elbow. Sixty percent of the patients reported “moderate” to “good” improvement in their conditions. Conclusion – Injection of botulinum toxin type A can temporarily reduce limb spasticity after stroke and improve the range of motion of involved joints, bringing about patients'' satisfaction. However, the effect of botulinum toxin type A on the underlying etiology of disability is open to question.

Background – HBV infection is preventable by effective vaccination in general population, but response to vaccine among the HIV-infected people seems to be low.Methods – In this study, 48 HIV-positive patients who did not have a history of HBV infection received the conventional three-dose HBV vaccine (each dose: 20 µg) in HIV/STI/IDU Counseling and Care Center of Kermanshah Province, Iran. Anti-HBs levels were measured two months after the last dose. The sample gathering method was a random sample size. All the patients gave informed consent before entering the study. For statistical analysis, Chi-square test was performed and p < 0.05 was considered significant.Results – Only 14 (29.1%) of the 48 vaccinated HIV-infected patients had positive anti-HBs titers. Among them, 11 (78.6%) were males and 3 (21.4%) females. The mean number of CD4+ T- lymphocytes per milliliter of blood was 351.5 in responders and 283.9 in nonresponders. There was a significant difference between the response to vaccine and immunologic stages of HIV infection. There was a significant statistical difference regarding sex, as 42.5% of the females responded to vaccine while this rate was 24.9% among the males. Conclusion – The HIV-infected patients have a lower response rate to the conventional three-dose HBV vaccine compared with the general population and we recommend higher and more booster doses in early immunologic stages of HIV infection.

Background – Several studies have shown that the null genotypes of glutathione S-transferase M1 (GSTM1) and T1 (GSTT1) predispose to the development of specific types of cancers. A case-control study was carried out to examine the relationship between genetic polymorphisms of GSTM1 and GSTT1, and breast cancer risk. Methods – Blood samples from 57 females with breast cancer and 57 age- and sex-matched healthy individuals were collected. The eligible cases were randomly-selected patients at the Chemotherapy Unit of Nemazi Hospital, Shiraz, South of Iran from October 1999 to August 2000. Both patient and control groups were unrelated Iranian Muslims. Using polymerase chain reaction (PCR) method, the GSTM1 and GSTT1 genotypes were determined. The association between GSTM1 and GSTT1 genotypes, and the development of breast cancer was examined using odds ratio (OR) and 95% confidence intervals (CIs) derived from logistic regression analysis using SPSS 10.0 software (SPSS Inc, Chicago, IL, USA). Results – Homozygote deletion of either GSTM1 (OR = 1.65, 95% CI: 0.77 – 3.53) or GSTT1 (OR = 2.07, 95% CI: 0.96 – 4.48) was not associated with a statistically significant increased risk of breast cancer, whereas deletion of both GSTM1 and GSTT1 genes gave rise to a statistically significant increased risk of this malignancy (OR = 4.50, 95% CI: 1.30 – 15.58). Our results revealed that the combined genotypes were highly associated with breast cancer in the less than 50-year-old patients (OR = 5.63, 95% CI: 1.32 – 24.05).Conclusion – Our findings suggest a novel additive effect of GSTM1 and GSTT1 polymorphisms which plays an important role in susceptibility to breast cancer.

Background – Discrimination of malignant cells from reactive mesothelium in body cavity effusions is a diagnostic problem in some cases. In an attempt to resolve this problem, several accessory techniques have been tried without general acceptance. Sialosyl-Tn (STn) is a mucin carbohydrate-associated antigen, which represents an aberrant glycosylation product of cellular mucin carcinomas. This antigen may sparsely be detected in normal epithelial cells such as goblet cells of small and large intestinal mucosa, gallbladder, urinary bladder, salivary glands, and basal cells in normal laryngeal stratified epithelium; besides, it is frequently expressed in dysplastic epithelium and epithelial carcinomas. We investigated the STn monoclonal antibody for its clinical utility as an isolated stain to distinguish metastatic carcinomatous cells from benign mesothelium.Methods – In this study, cell block materials from the serosal cavity fluids of 76 cases (48 with malignant and 28 with nonmalignant effusions) were immunostained for detecting STn. Specimens were retrieved from the archives of the pathology departments of the teaching hospitals of Shaheed Beheshti University of Medical Sciences, Tehran, Iran from March 2000 to February 2001.Results – Strong immunoreactivity was noted in 42 (95%) and negative staining was observed in 2 (4.5 %) of the 44 carcinoma cases. Benign effusions showed no strong staining but weak response was seen in 5 (18%) of the 28 benign cases. No immunoreactivity was noted in the 4 noncarcinomatous malignant effusions. The diagnostic value indexes of STn immunostaining test were as follows: specificity: 100%, sensitivity: 95%, positive predictive value: 100%, negative predictive value: 93%, and accuracy rate: 92%.Conclusion – This method is of great value in discriminating metastatic carcinomatous cells in body cavity effusions. STn immunostaining can also be used to differentiate carcinomatous from noncarcinomatous malignant effusions

Background – The lytic function of natural killer (NK) cells is markedly influenced by recognition of class I major histocompatibility complex molecules (MHC). The soluble form of human MHC molecules (sHLA) has been reported to be secreted by lymphocytes and is presented in the normal human serum. The aim of this study was to evaluate the possible immunomodulatory effect of sHLA on NK cell lytic function. Methods – HLA class I expression on three different tumor cell lines including M4, K562, and HSB-2 were determined using flowcytometry and then the susceptibility of the cells to the killing effect of NK- and CD56-positive lymphokine-activated killer (LAK) cells was measured using 51Cr-release assay. Different concentrations of an anti-HLA class I antibody (W6/32) were used to block class I antigens on the surface of target cells and cytotoxic assay was subsequently carried out. Recombinant sHLA-A2 and sHLA-B7 in monomeric and dimeric forms were used for treatment of NK and LAK cells. The killing activity of these effector cells against K562 and M4 cells was measured. Results – HLA class I molecules were abundantly presented on M4 cells followed by HSB-2. K562 cells expressed extremely low levels of HLA class I on the surface. In cytotoxicity assay, the most and the least susceptible cells to the lytic effect of NK cells were K562 (47.2% killing at 25/1 E/T [effector/target] ratio) and M4 cells (7.3% at 50/1 E/T ratio), respectively. Treatment of these cells with 1 and 10 μg/mL of W6/32 monoclonal antibody increased the susceptibility of M4 cells to lysis but had no effect on K562 cells. Treatment of effector cells with 0.7 to 11.2 μg/mL of sHLA molecules lead to a dose-dependent inhibition of LAK cell lysis in the presence of sHLA-B7 molecules. In addition, sHLA-A2 decreased the lytic activity of LAK cells. In contrast to the effect of sHLA-B7 on K562 cells, an increase in NK cell activity on M4 cells was observed.Conclusion – M4 cells expressing high amounts of HLA class I were more resistant than other cells to the lytic effect of NK cells; masking these molecules could change M4 susceptibility. Binding of sHLA molecules to NK/LAK cells can downregulate the killing activity against cells with low HLA expression (K562) and upregulate the activity against the ones with high HLA expression.

Seminal vesicle cysts are unusual but treatable causes of lower urinary tract symptoms. Transrectal ultrasonography is a good method for initial evaluation of seminal vesicle cysts; endorectal magnetic resonance imaging should be reserved for the cases whose ultrasonographic results are not conclusive. Treatment should be restricted to symptomatic patients. Transvesical approach and laparoscopy in the hands of an experienced urologist are the best methods for resection of seminal vesicle cysts. In this article, two cases of acquired and congenital seminal vesicle cysts are presented and the clinical symptoms, diagnosis, and management of are discussed.

Renal transplantation has been developed in human over the past 50 years. The major limit in this form of renal replacement therapy is the shortage of kidney donors. It has been suggested that spouses are important sources of living-donor kidney grafts. Mental and behavioral health issues have been recognized to have important influences on the outcome of renal transplantation. Generally, the motive for donating an organ to a spouse or loved one is not apathy or guilt, but it is born out of love and great concern. We are reporting an unusual case of a renal transplant from a man to his wife in which the husband abandons the wife after the transplantation. Our aim is to emphasize the importance of psychological assessment of donors prior to transplantation.

Spastic paraplegia is manifested by progressive spasticity and weakness of the legs and is one of the presenting signs of upper motor neuron disorders. Several diseases present solely with spastic gait disorders, but spastic paraplegia with severe polyneuropathy is an uncommon condition. We report three cases of spastic paraplegia from childhood with severe distal atrophy due to profound polyneuropathy; two of them had a hereditary and one sporadic (nonhereditary) background. In the present report, positive clinical and paraclinical findings with the possible differential diagnosis have been discussed.

A case of an unusual communication between the submandibular and sublingual salivary glands demonstrated incidentally during sialangiography is reported. In contrast to the routine occurrence of relation between the excretory ducts of these two glands, in this case, the drainage of the sublingual gland was totally accomplished by the submandibular gland itself or vice versa. To the author’s knowledge, this is the first and probably unique case of this type reported in this domain of specialty