Medical Journal of The Islamic Republic of Iran (MJIRI)

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Serum levels of glucose, bilirubin, calcium, phosphorus, protein and albumin were measured in a group of nine healthy men before, and on the first, 10th, 20th and 29th day of Ramadan, and four weeks after Islamic fasting was terminated. There was a significant reduction in body weight, a significant increase in serum bilirubin and a slight decrease in calcium during Ramadan. Serum glucose decreased on the first and 10th days of Ramadan, but increased thereafter and reached pre-Ramadan values on the 29th day. The lowest serum glucose recorded was 63 mg/dl. All changes returned to basal values four weeks after Ramadan. There was no significant change in the levels of serum phosphorus, protein or albumin. Physicians caring for Muslims during this month should be aware of these changes.

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The response to methimazole [1-methyl-2-mercapto-imidazole (MMI)] therapy, 10 mg twice daily in 15 patients and propylthiouracil (P TU) therapy, 100mg twice daily in 10 patients with diffuse toxic goiter was evaluated in an area of iodine deficiency (Tehran). The mean free T4 index (FT4I) decreased from 22.7± 6.8 (± SD) to 10.8± 2.8 In MMI-treated, and from 25.1± 6.8 to 13.2± 2.1 in PTU-treated patients, two weeks after treatment. The FT4I further decreased to 6.8± 4.3 and 8.5± 2.1 after four weeks of MMI and PTU administration, respectively. The mean free T3 index (FT3I) was 415± 90, 162± 44 and 117± 46 in MMI treated and 430± 80, 210± 45 and 140± 53 in PTU treated patients before and two and four weeks after treatment, respectively. The mean FT4I and FT 31 had decreased more in the MMI treated groups as compared to the PTU treated patients, two weeks after treatment. In patients treated with MMI or PTU, 11 of 25 (44 %) had subnormal FT 41 after four weeks of treatment, of whom one had increased serum TSH. These results indicate that treatment with less than the recommended doses of thionamide compounds causes a rapid decline of thyroid hormone indices in patients residing iI). Tehran. The dosage of thionamide compounds as well as the duration of therapy with the initial doses necessary to induce euthyroidism, should be evaluated in various parts of the world.

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In order to investigate goiter prevalence in Boyer-Ahmad, an Iranian tribal province, 87 families were randomly selected in Yasuj township and Doruhan county. Clinical examination of the subjects disclosed 95% of females and 87% of males over 6 years of age to be goitrous. Grade 2 goiter had the highest prevalence among females. In males grade 1 b was the most prevalent. Hormonal studies on a subsample did not show major abnormalities but free T 3 index was increased significantly in subjects with grade 3 goiter compared to the goitrous and grade 2 groups (p < 0.01). Mean urinary iodine excretion was33.9 ± 30.1 fLg/gcreatinine in Yasuj and23.95 ± 16.6 1 in Ddruhan, indicating moderate to severe iodine deficiency. This study documents goiter hyperendemicity in a Southern province not previously acknowledged by national or international authorities.

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Serum concentration of FSH, LH, testosterone, prolactin, ACTH, cortisol, TSH, T4, T3 and resin T3 uptake were measured in 146 men who were exposed to vesicants used by the Iraqi regime a few days t04 weeks prior to testing. Clinical and laboratory findings had confirmed the use of mustard gas. Mean serum concentrations of FSH, LH, TSH and prolactin were not significantly different from normal values. Free T4 index (FT41) was subnormal in 6 men, and its mean was somewhat decreased (7.4 ± 0.8 vs normal 8.7 ± 1.2 P < 0.05). Free T3 index (FT31) was subnormal in 14 men, and its mean was significantly lower than normal (92 ± 20 vs 130 ± 11 P < 0.001). Serum testosterone concentration was subnormal in 42 men, and its mean was significantly lower than normal (361 ± 254 vs 676 ± 273 ngldl P < 0.001). Serum cortisol was subnormal in 11 and above normal in 8 men, its mean was not significantly different from normal values. There was an increase in serum ACTH concentration. We conclude that exposure to chemical weapons containing mustards may cause severe alterations in serum concentrations of various hormones.

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A prospective, randomized trial on 416 consecutive cases of appendicectomies was carried out in which half of the cases had simple ligation of the stump and the rest had invagination of the stump in addition. The two groups were matched for age, sex, state of personal hygiene and nutrition. The incidence of wound infection, and early and late post-operative complications remained comparable between the two groups. However, the mean operating time was significantly less in case of simple ligation. Barium enema in suspected cases of caecal neoplasm in post-operative cases did not reveal any ceacal deformity in the group of simple ligation thus avoiding confusion of mistaking deformed caecum due to the invaginated stumps as neoplasm. Simple ligation of the appendiceal stump is therefore advocated during appendicectomy.

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Clinical manifestations of sixteen children and teenagers exposed to chemical warfare in Halabje are presented. 15 patients complained of burning of skin. Dry coughing was present in 13 subjects. The most frequent signs were conjunctivitis, skin erythema, edema of the eyelids, hyperpigmentation, ulceration, erosion, dyspnea, closure ofthe eyes, blisters, edema of the skin, and crepitation in both lungs, in decreasing order of frequency. Two subjects had severe fatal leukopenia and anemia and three showed a transient leukopenia. Four of six teen died of bone marrow hypoplasia, sepsis and respiratory distress. This report again reminds need for an urgent international agreement to effectively ban the use of chemical weapons.

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The effects of exposure to chemical weapons containing sulfur mustards on the serum levels of total and free testosterone. gonadotropins and prolactin was investigated in young Iranian men. In the first five weeks after injury both serum total and free testosterone were significantly decreased as compared to control values. Three of 13 men had total testosterone below 300 ng/dL and two of six had subnormal serum free testosterone concentra• tions. By the fifth week after exposure serum free testosterone did not change however there was further fall in mean serum total testosterone ancI 70% of men had subnormal values. Both serum total and free testosterone concentrations returned to normal values by the 12th week after injury. There was a significant rise in serum FSH and prolactin by the fifth week ancI in serum LH by the fourth week after exposure. These data suggest that injury by the chemical warfare containing sulfur mustard may cause acute inhibition of testosterone secretion from the testis leading to a significant decline in serum total and free testosterone and some increase in gonadotropin concentrations. The inhibition seems to be transient ancI hormone levels return to normal by 12th week after injury.

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During the Islamic lunar month of Ramadan millions of Muslims abstain from drinking and eating from dawn to sunset. The objective of this study was to investigate the effect of intermittent Islamic fasting on reproductive function, hypothalamic-pituitary-thyroid axis and the peripheral metabolism of thyroid hormones in men. We measured serum levels of FSH, LH, testosterone, prolactin, TSH, T4, T3 and T3 uptake, and prolactin and TSH responses to TRH, before, at 10th, 20th and 29th days of Ramadan and four weeks after fasting month was terminated. Subj ects were nine healthy men who fasted 17 hours a day for 29 days. There were no significant changes in serum levels of any of measured hormones during Ramadan. Prolactin and TSH responses to TRH were also unaltered. The only positive finding 'Yas increased serum T4 of 1.5 to 2.8 Ilg/dl and increased free T4 index (FT4I) in five of nine subjects in the last days of Ramadan. We conclude that 1) Intermittent abstinence from food and drink for 17 hr a day, as is observed in Islamic fasting, does not alter male reproductive function, hypothalamic-pituitary-thyroid axis, or peripheral metabolism of thyroid hormones. 2) In some subjects slight increase in serum T4 may occur in the last days of Ramadan.

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Serum levels of glucose, bilirubin, calcium, phosphorus, protein and albumin were measured in a group of nine healthy men before, and on the first, 10th, 20th and 29th day of Rarnadan, and four weeks after Islamic fasting was terminated. There was a significant reduction in body weight, a significant increase in serum bilirubin and a slight decrease in calcium during Ramadan. Serum glucose decreased on the first and 10th days of Ramadan, but increased thereafter and reached pre-Ramadan values of the 29th day. The lowest serum glucose recorded was 63 mg/dl. All changes returned to basal values four weeks after Ramadan. There was no significant change in the levels of serum phosphorus, protein or albumin. Physicians caring for Muslims during this month should be aware of these changes.

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During the Islamic lunar month of Ramadan millions of Muslims abstain from drinking and eating from dawn to sunset. The objective of this study was to investigate the effect of intermittent Islamic fasting on reproductive function, hypothalamic-pituitary-thyroid axis and the peripheral metabolism of thyroid hormones in men. We measured serum levels of FSH. LH, testosterone, prolactin, FSH, T4 and T3 uptake, and prolactin and TSH responses to TRH, before, at 10th, 20th and 29th days of Ramadan and four weeks after fasting month was terminated. Subjects were nine healthy men who fasted 17 hours a day for 29 days. There were no significant changes in serum levels of any of measured hormones during Ramadan. Prolactin and TSH responses to TR H were also unaltered. The only positive finding was increased serum T4 of 1.5 to 2.8 pg/dI and increased free T4 index (Ff41) in five of nine subjects in the last days of Ramadan. We conclude that 1) intermittent abstinence from food and drink for 17 hr a day, as is observed in Islamic fasting, does not alter male reproductive function, hypothalamic-pituitary-thyroid axis, or peripheral metabolism of thyroid hormones. 2)1 some subjects slight increase in serum T4 may occur in the last days of Ramadan.

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Invasive gastric mucormycosis is a rare and fatal disease. We report a rare case with longstanding SLE who presented with fever. Autopsy showed multiple small shallow-based ulcers in the antrum. Histologic examination showed invasive mucormycosis. This is a rare case of invasive gastric mucormycosis localized exelusively in the stomach.

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Previous studies have shown that injection of iodized oil in pregnant women can be used as a prophylactic strategy for iodine deficiency disorders and may improve the growth indices of their offspring. Since administration of pharmacological doses of iodine may lead occasionally to large goiter and rarely to hypothyroidism, in the present study the thyroid function tests of neonates and infants born to women who had received 480 mg iodized oil intramuscularly during pregnancy were assessed and compared to those of a control group. Of 277 cord blood samples obtained from Mazandaran and Khohkiluyeh-Boyerahmad provinces, 125 made up the case (injected) and 152 the control (noninjected) group. Of 1026 blood samples of the neonates and infants from Mazandaran province, 544 made up the case and 482 the control group. Serum T4, T3 and TSH concentrations were measured with RIA kits. In the cord blood samples, mean serum T4 in cases who had received iodized oil was lower than that of the control group: 140±32 vs. 149±33 nmol/L, respectively p<0.03. T3 and TSH were not however different. In the neonates and infants, T4 and T3 concentrations were significantly higher in the case than control group: 178±40 vs. 168±39 and 3.5±0.02 vs. 3.0±0.02 nmol/L, respecti vely, both p<0.001 1. In contrast, TSH concentrations were lower in the experimental group in comparison to control: 2.6±2.2 vs. 3.1±2.9 mU/L, respectively p<0.001. Increased T3 and decreased TSH were seen in infants of mothers who were injected in the second and third trimesters of pregnancy. Injection of iodized oil in pregnant women does not cause hypothyroidism in the offspings, however it does cause a transient increase in serum thyroid hormones and a decrease in TSH concentrations

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The aim of this study was to evaluate the role of fine needle aspiration cytology in the diagnosis of abdominal and retroperitoneal masses in children on this study. In 53 cases of childhood abdominal and retroperitoneal masses within a 4 year period (1998- 2001) preoperative fine needle aspiration was done under the guide of CT scan. 2 pathologists reviewed fine needle aspiration smears. In all of the cases the gold standard for diagnosis was the tissue specimen, which showed 37 malignant, 2 benign neoplastic and 12 nonneoplastic diseases. This study showed that the sensitivity and specificity of fme needle aspiration cytology for the diagnosis of malignancy and benignity (positive or negative for malignancy) is 97.2% and 81.2% respectively. It was 100% accurate for the diagnosis of cell type in neuroblastoma-ganglioneuroblastoma, hepatoblastoma and Wilm's tumor, 77% accurate for lymphoma and 57% for germ cell tumors. There was no complication in any of the cases after fine needle aspiration. So fine needle aspiration is a reliable and sensitive method for the preoperative diagnosis of malignant pediatric abdominal and retroperitoneal masses and we recommend doing FNA cytology as a routine method for the diagnosis of such cases.

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MeduIIary thyroid carcinoma (MTC) occurs both sporadically and in the autosomal dominantly inherited multiple endocrine neoplasia (MEN) type 2 syndromes. The distinction between true sporadic MTC and a new mutation familial case is important for future clinical management of both the patient and family. The susceptibility gene for hereditary MTC is the RET proto-oncogene. DNA analysis for germline mutations of the RET proto-oncogene was performed in a series of 24 patients with MTC [apparently sporadic MTC (20 cases), familial MTC (2 cases), MEN 2A (one case) and MEN 2B (one case)] to determine whether they were true sporadic cases or hereditary forms. Genomic DNA was amplified using polymerase chain reaction (PCR) and oligonucleotide primers for exons 10 & I 1. The PCR products were examined by restriction enzymes analysis to detect the mutations. One of the 20 patients with apparent sporadic MTC had exon 10 mutation (Cys-620 Arg) and exon I I mutation (Cys- 634 Trp) was also found in the index case with MEN 2A. No mutation was detected in the other patients. Three of six evaluated members of the MEN 2A patient had the same mutation. We conclude that routine application of RET proto-oncogene testing should be included in all cases of apparent sporadic MTC.

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 Abstract

 Background: Misdiagnosis of the acute appendicitis may increase the rate of negative

 appendectomies, which involve a huge waste of resources and are sometimes

 associated with severe complications. Furthermore, false negative result of ultrasonography

 (US) could lead to perforation of appendix. Since ultrasonography is still

 the most common imaging technique used in Iranian appendicitis patients, the study focused

 on evaluate the accuracy of ultrasonograghy in an educational hospital in Iran.

 Methods: We retrospectively reviewed the results of ultrasonograghy in 270 patients

 who referred to Rasoul-e-Akram hospital in Tehran, Iran, between April 2002

 and October 2004 with acute abdominal symptoms suggestive of appendicitis. The

 results of ultrasonography were compared with the histopathologic reports of biopsies

 as a gold standard. In data analysis Chi-square, independent t-test and Mann-

 Whitney U-test were performed.

 Results: The accuracy of ultrasonograghy in acute appendicitis was 60.4% and

 the rate of negative appendectomy was 17.4%. Diagnostic values of US were calculated

 as the sensitivity of 55.4% [95% confidence interval (CI)=48.6-62], specificity

 of 72.3% (95%CI=57.1-83.9), positive predictable value (PPV) of 90.4% (95%CI=

 83.9-94.6) and negative predictable value (NPV) 25.6% (95%CI=18.6-34).

 Conclusion: Although the results of our study implied that the diagnostic values

 of ultrasonography were not considerable, but it is still the only imaging techniques

 available for patients in Iran. In reference to the low NPV, using an alternative technique

 such as abdominal CT scan is recommended. More attention must be paid on

 the signs and symptoms related to acute appendicitis in such patients especially in

 teaching hospitals.

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  Background: Dyssynergic defecation is a major cause of chronic functional constipation as a common digestive complaint. We clinically evaluated the effects of biofeedback therapy on the pelvic floor motion indices through magnetic resonance (MR) defecography, quality of life and depression in patients with dyssynergic defecation.

  Methods : In this clinical trial study, among patients referring to the Colorectal Clinic of HazratRasoul Hospital, 22 subjects were randomly assigned into two equal groups (n=11) to receive either standard only or biofeedback and standard therapy. Dynamic changes of the pelvic floor were measured by MR defecography. During the simulated defecation, two MR defecography dynamic indices including abnormal anorectal angle change and perineal descent were measured before and after treatment. The effects of biofeedback therapy on patients’ symptoms, quality of life and severity of depression were assessed and compared with the standard therapy. Statistical analysis was carried out using independent _t-test and Mann-Whitney test.

  Results : Paradox index (p< 0.001), perineal descent index (p< 0.001), depression (p< 0.1), physical function (p<0.001), vitality (p< 0.001) and role emotion (p< 0.001) significantly improved in the biofeedback therapy group in contrast to the standard therapySDT group.

  Conclusion : Biofeedback therapy appears to be effective in improving symptoms of functional constipation and dysfunction of pelvic floor motion as well as patient’s quality of life and depression state. MR defecography is able to show the changes in dynamic indices of the pelvic floor through biofeedback therapy.

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Background: World Health Organization (WHO) defines three goals to assess the performance of a health system: the state of health, fairness in financial contribution and responsiveness. We assessed the responsiveness of health system for patients with diabetes in a defined population cohort in Tehran, Iran.

Methods: Total responsiveness and eight domains (prompt attention, dignity, communication, autonomy, confidentiality, choice, basic amenities and discrimination) were assessed in 150 patients with diabetes as a representative sample from the Tehran Glucose and Lipid Study (TLGS) population cohort. We used the WHO questionnaire and methods for analysis of responsiveness.

Results: With respect to outpatient services, 67% (n=100) were classified as Good for total responsiveness. The best and the worse performing results were related to information confidentiality (84% good responsiveness) and autonomy (51% good responsiveness), respectively. About 61% chose “communication” as the most important domain of responsiveness it was on the 4th rank of performance. The proportions of poor responsiveness were higher in women, individuals with lower income, lower level of education, and longer history of diabetes. “Discrimination” was considered discrimination as the cause of inappropriate services by 15%, and 29% had limited access to services because of financial unaffordability. 

Conclusion: Health system responsiveness is not appropriate for diabetic patients. Improvement of responsiveness needs comprehensive planning to improve attitudes of healthcare providers and system behavior. Activities should be prioritized through considering weaker domains of performance and more important domains from the patients’ perspective.

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Background: World Health Organization (WHO) defines three goals to assess the performance of a health system: the state of health, fairness in financial contribution and responsiveness. We assessed the responsiveness of health system for patients with diabetes in a defined population cohort in Tehran, Iran.

Methods: Total responsiveness and eight domains (prompt attention, dignity, communication, autonomy, confidentiality, choice, basic amenities and discrimination) were assessed in 150 patients with diabetes as a representative sample from the Tehran Glucose and Lipid Study (TLGS) population cohort. We used the WHO questionnaire and methods for analysis of responsiveness.

Results: With respect to outpatient services, 67% (n=100) were classified as Good for total responsiveness. The best and the worse performing results were related to information confidentiality (84% good responsiveness) and autonomy (51% good responsiveness), respectively. About 61% chose “communication” as the most important domain of responsiveness it was on the 4th rank of performance. The proportions of poor responsiveness were higher in women, individuals with lower income, lower level of education, and longer history of diabetes. “Discrimination” was considered discrimination as the cause of inappropriate services by 15%, and 29% had limited access to services because of financial unaffordability. 

Conclusion: Health system responsiveness is not appropriate for diabetic patients. Improvement of responsiveness needs comprehensive planning to improve attitudes of healthcare providers and system behavior. Activities should be prioritized through considering weaker domains of performance and more important domains from the patients’ perspective. 

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Background: The paced auditory serial addition test (PASAT) was primarily developed to assess the effects of traumatic brain injury on cognitive functioning. Working memory (WM) is one of the most important aspects of cognitive function, and WM impairment is one of the clinically remarkable signs of aphasia. To develop the Persian version of PASAT, an initial version was used in individuals with aphasia (IWA).
   Methods: In this study, 25 individuals with aphasia (29-60 years) and 85 controls (18-60 years) were included. PASAT was presented in the form of recorded 61 single-digit numbers (1 to 9). The participants repeatedly added the 2 recent digits. The psychometric properties of PASAT including convergent validity (using the digit memory span tasks), divergent validity (using results in the control group and IWA group), and face validity were investigated. Test-retest reliability was considered as well.
   Results: The relationship between the PASAT and digit memory span tests was moderate to strong in the control group (forward digit memory span test: r= 0.52, p< 0.0001; backward digit memory span test: r = 0.48, p< 0.0001). A strong relationship was found in IWA (forward digit memory span test: r= 0.72, p< 0.0001; backward digit memory span test: r= 0.53, p= 0.006). Also, strong test-retest reliability (intraclass correlation= 0.95, p< 0.0001) was observed.
   Conclusion: According to our results, the PASAT is a valid and reliable test to assess working memory, particularly in IWA. It could be used as a feasible tool for clinical and research applications.