Caspian Journal of Internal Medicine
Volume:11 Issue: 2, Spring 2020

Cardiovascular disease (CVD) is the first cause of mortality worldwide, with all the healthcare systems facing this very challenging issue. Aspirin continues to be the major gold-standard treatment worldwide in the prevention of thrombotic disease in patients with CVD, even though not all individuals respond to antiplatelet therapy in a similar way, being resistant to aspirin. The aim of this study was to determine the prevalence of laboratory defined aspirin resistance in CVD patients worldwide.

Relevant articles were identified through searching EMBASE, PubMed/ MEDLINE, ISI /Web of Science, Scopus, and the Cochrane Library, from January 2000 to February 2018. The methodological quality of the included studies was critically appraised using the Newcastle-Ottawa scale. The pooled prevalence of laboratory defined aspirin resistance was computed using the Der Simonian-Laird random-effect model.

We included 65 studies, with a total of 10,729 patients. The overall prevalence of laboratory defined aspirin resistance in CVD patients was 24.7% ([95%CI 21.4-28.4]. Women were found to be at increased risk of laboratory defined aspirin resistance compared to men, with an odds ratio of 1.16 [95%CI 0.87-1.54]. 

Doctors and healthcare providers should pay special attention to aspirin resistance since lack of awareness could cause problems and increase mortality in these patients, if not properly treated with higher aspirin doses.

The present study aimed to investigate and compare the effect of starved
fibroblast culture supernatant (SFS), DMEM and normal saline alone or along with LA7 on dexamethasone-treated immunosuppressed Wistar rats.

After the isolation of fibroblasts from the fresh foreskin of children, it was cultured in serum-free DMEM, and the supernatant collected after 16 hours (16h-SFS). This solution and the other treatments were injected subcutaneously into the rats from each group once daily for 14 days. The liver, intestine and lung histology along with blood cellular and biochemical characteristics were studied.

The results showed that dexamethasone as immunosuppressant reduced the body weight. The histological change in the liver was mild fibrosis induced by LA7+16h-SFS. Also, among the different blood cellular and biochemical indices measured,  the eosinophil percentage in the 16h-SFS treated rats ,  glucose levels in the 16h-SFS+LA7 group and triglyceride concentrations  in the 16h-SFS group were changed (p<0.05).

This study showed that the secretions of starved fibroblasts especially that combined with LA7 cancer stem cells could induce some minor histological and biochemical changes in immunosuppressed rats, and also it opened a new window for subsequent investigations on unknown mechanisms related to this work.

To investigate the possibility that the eradication of H pylori infection is associated with a reduction in the risk of glaucoma.

Sixty-five successive patients with elevated intraocular pressure (IOP) or glaucoma were included in the study. Serum samples from all subjects were analyzed for the presence of H pylori- antibodies using ELISA. Forty patients with positive serologic test were included. Half of the patients enrolled into intervention group and the other half registered as control. Intervention arm was referred to the Gastroenterology Clinic for eradication of H pylori and evaluated for the effect of H pylori regimen eradication on IOP and glaucoma over 2 months of follow-up. The age-matched controls did not receive treatment. Urea breath test was applied to confirm eradication.

There was a significant (p=0.005) reduction in IOP after complete eradication in the intervention group.  This value was not significant in control patients (p=0.08). The mean IOP before treatment of glaucoma in the control group was 23.60±2.37 mmHg and after treatment with anti-glaucoma drugs was 14.25±1.48 mmHg on the onset of study, and 13.55±2.01 mmHg after follow up. The mean IOP before treatment of glaucoma in the intervention group was 24.55±3.6 mmHg and after treatment with anti-glaucoma drugs was 15.15±1.8 mmHg, and 14.3±1.6 mmHg after the eradication of H pylori with a drug regimen. However, after the treatment of glaucoma in all patients, the overall comparison of mean IOP differences showed no statistical difference (P=0.65).

H pylori eradication therapy may have a positive effect on the management of glaucoma.

Functional dyspepsia (FD) is the most common gastrointestinal disorder with several symptoms such as stomach pain and abdominal bloating. The aim of this study was to investigate and compare CD4+ and CD8+ in the Helicobacter pylori-negative functional dyspepsia and control groups.

Sixty one patients (35 patients with stomach pain and 26 with abdominal bloating), and 30 controls were reviewed based on the quantity of CD4+ and CD8+ T-cells isolated from gastric mucosa biopsy samples. The comparison between variables was analyzed with a chi-square or Fisher’s exact test and logistic regression analyses. P<0.05 and odds ratio (OR) with a 95% confidence interval demonstrated statistical significance.

A significant difference was observed between two-group patients and control group based on CD4+ and CD8+ presence, respectively (P=0.003, P=0.008). Furthermore, there was a significant difference between stomach pain-patients and control group with regard to CD4 count (P=0.01) and between abdominal bloating-patients and control group with regard to CD8 count (P=0.002). There was a decrease in both CD4+ and CD8+ T-cells in gastric mucosa in patients with FD with a significant reduction in the stomach pain-patients and abdominal bloating-patients in the number of CD4+ and CD8+ T-cells, respectively.

These results indicated that the role of immunology in the absence of the CD4+ and CD8+ T-cells in the gastric mucosa may have a protective role against FD.

Rituximab has been used successfully in the recent years for treatment of neuromyelitis optica spectrum disorders (NMOSD). However, a uniform treatment protocol for maintenance therapy and the best interval for evaluation and retreatment have not been postulated. We evaluated the efficacy and safety of rituximab treatment as second line therapy, in Iranian patients with refractory NMOSD, based on annualized relapse rate (ARR) and expanded disability status scale (EDSS).

In this prospective before-after study, a total of 18 patients were treated with a loading dose of rituximab (375 mg/m2 weekly in 4 consecutive weeks). Flow cytometric determination of CD19+ B cell in peripheral blood sample was carried every 6 weeks and patients were re-treated based on B cell repopulation with a single dose of 375 mg/m2. Wilcoxon signed rank test was used to evaluate the ARR and EDSS before and after treatment. A p-value of <0.05 was considered statistically significant.

Of the 18 patients, 10 (55.5%) were relapse-free during the period of follow up. The EDSS scores were reduced in nine (50%) patients and stable in the remaining nine (50%). The mean EDSS score before and after treatment were 4.1±0.4 and 3.7±0.3, respectively, which was statistically significant. There was also a statistically significant reduction in median ARR after treatment (1.48 (range 0.47-5) vs. 0 (range 0-2)). Rituximab administration did not have significant adverse effect in 94% of patients.

Repeated treatment with Rituximab is an effective and well-tolerated treatment in refractory NMOSD.

Manual therapy techniques are part of physiotherapy treatment of carpal tunnel syndrome (CTS) which are classified into two groups including nerve mobilization and mechanical interface mobilization. The aim of the study was to find which manual therapy method-technique directed to mechanical interface and nerve mobilization–has superior beneficial effects on clinical and electrophysiological findings in conservative management of patients with CTS.

Thirty patients with CTS participated into two groups namely: mechanical interface and nerve mobilization in this randomized clinical trial. The intervention was performed three times weekly for 4 weeks. Mechanical interface mobilization was directed to structures around the median nerve at the forearm and wrist. Techniques of median nerve gliding and tension were used in the nerve mobilization group. The outcome measures included visual analogue scale (VAS), symptom severity scale (SSS), hand functional status scale (FSS) and motor and sensory distal latencies of median nerve. Paired t-test and ANCOVA were used for statistical analysis.

At the end of the 4th week of the treatment, the mean of VAS, SSS and FSS significantly improved in both groups (p<0.05), but the difference was not significant between the two groups (P>0.05). Although the mean of motor and sensory distal latencies of median nerve at the end of the treatment period only improved in the nerve mobilization group (p<0.05), the difference was not significant between the two groups (P>0.05).

Mechanical interface mobilization and nerve mobilization techniques are not superior to each other in reducing pain and improving hand symptoms and functional status.

Carbapenem resistance in Acinetobacter baumannii has become a major concern for treating physicians. The aim of this study was to investigate the prevalence of metallo β-lactamase (MBL) genes (bla VIM , and blaIMP) among isolated multidrug-resistant A. baumannii .

Fifty non-repetitive carbapenem-resistant A. baumannii isolates were collected. Antibiotic susceptibility was performed by disk diffusion method. MICs were determined by E test method. The resistant strains were tested for the production of carbapenemases by the Modified Hodge Test (MHT) followed by EDTA-disk synergy test was performed for metallo-β-lactamases (MBL) phenotypic detection. Detection of bla VIM , and blaIMP was performed by PCR followed by sequencing.

All isolates had a multidrug resistant profile, and were all resistant to all antibiotics including the carbapenems but remained susceptible to colistin. Among these isolates, Carbapenemase production was confirmed by the Modified Hodge test for 42 (84%) isolates. Phenotypic method showed the production of MBL in 15 (30%) isolates. PCR techniques revealed that out of 50 isolates, 13 (26%) were positive for blaVIM and all were negative for blaIMP.

Our study concludes that the high prevalence of carbapenem resistant Acinetobacter species with MBL production is one of the main concerns in our country and this situation needs strict infection control measures.

Chronic microvascular complications consist of diabetic nephropathy (DN), diabetic retinopathy (DR), and diabetic neuropathy. Diabetic nephropathy is assessed through albuminuria, and diabetic retinopathy is assessed through fundoscopy. Several studies have assessed the albuminuria in diabetic retinopathy but have found inconclusive results. This study aims to investigate the albumin excretion rate in patients with diabetic retinopathy.

A cross sectional design was applied in this study. The diagnosis of type 2 diabetes mellitus was determined based on the anamnesis and laboratory examinations. The study was conducted at Dr. Wahidin Sudirohusodo Hospital and Hasanuddin University Hospital in Makassar during November 2018 until April 2019. The stages of diabetic retinopathy were based on funduscopic examinations. In addition, the blood pressure, BMI, albumin excretion rate, lipid profile, and HbA1C were also examined. Chi Square and Kappa tests were performed in the statistical analysis.

120 subjects with type 2 diabetes mellitus were observed. Of the total subjects, the number of females within the age of 36-79 years made up the biggest fraction. There was a significant relation between hypertension comorbidity with the albumin excretion rate and grading diabetic retinopathy where the A3 and proliferative diabetic retinopathy (PDR) percentages were higher in the hypertension group at 68.8% and 54.5%. There was also a significant correlation between incidence of albuminuria with diabetic retinopathy.  Particularly, proliferative diabetic retinopathy (PDR) remained associated with albuminuria, while non-proliferative diabetic retinopathy (NPDR) was related to non-albuminuria.

Albuminuria incidence confirms association with diabetic retinopathy grading.

Nowadays, obesity and overweight are projected to become main risk factors for coronary artery disease (CAD). We aimed to determine the association of anthropometric measures with presence of significant (sig.) CAD as evaluated by coronary angiography, among an adult Iranian population.

The present study included 441 patients (men=275) aged > 30 years with suspected CAD, who had undergone coronary angiography between January 2019 and November 2019. All demographic data and patients’ medical history as well as clinical examinations were recorded by a trained physician. Coronary angiography was performed using standard techniques to determine the presence of sig. coronary artery lesions. Logistic regression analyses were conducted to assess the odds ratio (OR) of each anthropometric measure for the presence of sig. CAD.

The mean age of participants was 51.2±8.7 years and sig. CAD was detected in 185 patients. Univariate analyses showed that body mass index (BMI), waist circumference (WC), and waist to hip ratio (WHR) were significantly associated with increased risk of CAD. On multivariable logistic regression model, BMI and WHR correlated independently with increased risk of CAD; while higher WC and wrist circumference (WrC) could not predict the CAD risk. The corresponding ORs (95% confidence interval) were 1.36 (1.04-1.74), 1.17 (0.95-1.63), 1.29 (1.12-1.41), and 1.24 (0.76-1.92) for BMI, WC, WHR, and WrC, respectively. Considering the receiver operating characteristic analysis, no superiority was observed for each of the measures for discriminating sig. CAD from non-sig. CAD status.

BMI and WHR are independently associated with the presence of CAD among Iranian population. These results emphasize the value of anthropometric assessment among those with suspected CAD.

Propolis as a natural product has shown beneficial effects on human health. This study was aimed to investigate the chemical compositions and biological activity of three different extracts of propolis from two distinct geographic areas in Iran.

The chemical composition of Iranian propolis extracts that were collected in the Spring of 2016 from two provinces in northern Iran: Ardabil and Polur in Mazandaran Province were measured through gas chromatography-mass spectrometry (GC-MS) methods. In addition, antimicrobial activity and cytotoxicity effect on HN5 and LNCaP cell lines were evaluated. The data were analyzed using one-way ANOVA and p<0.05 was considered as significant.

The GC-MS analysis identified the presence of compounds that belonged to the different groups such as aromatics acids and their related esters, flavonoid and flavonoid derivatives and terpenes. Flavanone was the most dominant compound of flavonoids. The maximum growth inhibition was observed against S. aureus of ethanolic extract of propolis (p<0.05). Moreover, cytotoxicity showed that ethanolic and dichloromethane extracts had more inhibitory effects on cell lines than the water extract.

The results determined that extracts had the highest percentage of flavonoids. Therefore, it is expected that the synergistic effect of the main components of propolis is related to the increase of biological activity of propolis.

Torque teno virus (TTV) is a non-enveloped DNA virus that its role as a helper or causative agent in hepatitis is still unclear. TTV prevalence varies in different regions of the world. This study aimed to determine the prevalence of TTV in healthy individuals and those infected with hepatitis C virus (HCV) living in Yazd city, Iran.

In this case-control study, 50 healthy subjects and 68 HCV-positive individuals who referred to Yazd hospitals participated in this study. TTV DNA in serum samples were detected by nested polymerase chain reaction (PCR) using specific primers of 5΄-UTR and N22 regions. The genotypes of HCV and TTV were determined by sequencing method.

TTV-DNA was detected in 2 out of 50 (4℅) healthy individuals and in 4 out of 68 (5.8℅) HCV-positive persons. There was not a significant correlation between the prevalence of TTV and HCV infection. The most common TTV genotypes among HCV-positive individuals were 3, 17 and 13, respectively. There was not a significant association obtained between HCV genotypes and TTV genotypes.

The prevalence of TTV in Yazd province was low compared with the other areas of Iran. The prevalence of TTV in HCV infected people was not significantly higher than its rate in uninfected individuals.

Hepatitis B Surface antigen (HBsAg) seroclearance and seroconversion (development of antibodies against HBsAg) can increases the survival of Chronic hepatitis B (CHB) patients. The aim of this study was to determine the percentage and timing of HBsAg seroclearance and seroconversion in patients with chronic hepatitis B infection.

1026 patients with CHB infection who referred to a private clinic were included. These patients had been followed-up for an average of 15 years. The patients whose HBs Ag was cleared from the blood and remained negative until the end of follow-up were designated as HBs Ag serocleared and the patients whose HBs Ab was positive during follow-upwas designated as HBs Ag seroconverted. The time of seroclearance and seroconversion of patients was recorded. Liver function tests, alpha-fetoprotein (AFP) and Hepatitis B early antigen (HBe Ag) status were extracted from the patients’ medical records. Data were analysis with SPSS 17.

The duration of follow-up was from 2 to 410 months and most patients were males (58.2%).
The survival rate of HBs Ag positivity after 5, 10 and 15 years were 95.6, 89.4 and 80.7%, and 98, 93.5 and 84.9% of patients had not yet developed anti-HBs antibodies after 5, 10 and 15 years, respectively. Age, gender and taking medication had no effect on HBs Ag clearance from the blood or anti-HBs production

The HBs Ag seroconversion is a rare occurrence, but the incidence of this may increase with time, age and drug consumption. Though there was no relationship in our patients

Psychiatric disorders are associated with poor pregnancy outcomes both for mother and child. This study aimed to determine the prevalence and related demographic risk factors of psychiatric symptoms among the pregnant women in Babol City.

This cross-sectional study was conducted in five private and public obstetrics clinics of Babol city. During routine appointments of prenatal care, 176 pregnant women filled in three questionnaires including; sociodemographic questionnaire, Edinburg Prenatal Depression Scale (EPDS), and Symptom Checklist-25 (SCL-25). Wilcoxon test, Spearman correlation, and multivariate logistic regression tests were used to interpret the data.

The prevalence of depressive disorders was 15.4%% for Edinburg scores ≥13.  The overall rate of maternal psychiatric symptoms (global severity index or GSI scores ≥ 1.75) was 48.5%. The prevalence of psychiatric symptoms was high; for 25% somatization, 258% anxiety, obsession-compulsion disorders or OCD 6.4%, 8.8% interpersonal sensitivity, 5.3% phobia, 7.6% paranoid ideation, and 1.2% psychoticism. Multivariate logistic regression revealed that pregnant women with history of abortion in previous pregnancy were at risk of depressive symptoms more (β=3.18, CI 1.28-7.93, p=0.01) than those without history of abortion. Also, the only demographic factor related to psychiatric symptoms was the age of pregnant women; younger age was associated with higher symptom levels for GSI ((r=-0.17).

The high prevalence of psychiatric symptoms, especially depressive symptoms, in pregnant women highlights the need for continued research on screening, identifying the risk factors, and developing effective treatments for mental disorders in pregnant women.

Epilepsy is one of the most common neurological disorder. This study aimed to investigating the relationship of family history pattern and prognosis of idiopathic epilepsy.

In this study, 377 patients with epilepsy referring to Imam clinic were investigated. Data were collected by means of a checklist that contained demographic data, age of first seizure attack, response rate to treatment, parental relationship, seizure history, family history and recurrence of seizure. And then the data were analyzed by SPSS Version 23.

Among the 337 patients, 199 (52.8 %) individuals were males and 178 (47.2%) individuals were females. The mean age of patients was 28.3±14 years. Approximately 50% of patients had a history of seizure and epilepsy in one of the close first relatives or relatives who had adequate knowledge of their disease. The mean incidence age of epilepsy was lower in patients with a positive family history of disease than those who did not have a family history of epilepsy (p<0.05). Among the 33 patients who did not respond well to treatment, there was a 75% family history of epilepsy (p<0.05). The average age of epilepsy was lower in those with family marriage, but was not statistically significant.

According to the findings of the present study, the patients diagnosed with idiopathic epilepsy, the family history of epilepsy and seizure, especially in their first degree relatives is fairly high, that may indicate genetic causes in the etiology of the disease.

Multiple sclerosis (MS) is an autoimmune disorder of the central nervous system which damages the myelin and axon. Primary biliary cholangitis (PBC) is a slow progressive liver disease with autoimmune feature in which non-purulent destructive cholangitis and interlobular bile duct destruction occur. Involvement of each of PBC and MS is thought to be related to environmental exposure in genetically susceptible persons.

Here, we aim to report 3 women 52, 27 and 51 years old with MS and PBC.

Although MS seems to have an association with some autoimmune gastrointestinal disorders such as ulcerative colitis, the concurrence of MS and PBC has been rarely reported

 Mucormycosis is an uncommon fungal infection caused by the members of the order Mucorales. In susceptible patients, mucormycosis can infect any tissue or organ, and without suitable treatment (i.e., debridement and antifungal therapy), this infection can be fatal. Our patient was a woman with lymphoma and cerebral mucormycosis who was treated with antifungals and without any neurosurgical debridement.

Herein, we present the case of a 35-year-old woman with diagnosis of B-cell lymphoma and rhino-orbito-cerebral mucormycosis (ROCM). She was a candidate for enucleation of the left eye, orbital decompression, and sinocerebral debridement. Nevertheless, the patient refused eye enucleation and craniotomy. Finally, she was treated with a combination of antifungals and sinus debridement without eye enucleation and craniotomy.

Endoscopic debridement, along with a combination of liposomal amphotericin B (LAMB) and posaconazole, may be a suitable therapeutic option for patients with ROCM, who are not eligible candidates for extensive surgery or craniotomy.

Thyrotoxicosis, though commonly encountered in endocrinology practice in Nigeria, seldom presents solely as thyroxine (T4) toxicosis. Thyroid storm, a known life-threatening complication of thyrotoxicosis, can be precipitated by myriad factors. Fine need aspiration for cytology is not known, and has not been previously reported (to the best of our knowledge) to precipitate thyroid storm.

The case described is that of a 55 year old woman who presented with a neck swelling and features of hyperthyroidism, with biochemical parameters in keeping with T4 toxicosis. Investigating the patient necessitated a fine needle aspiration of the thyroid swelling. The patient thereafter developed hyper-metabolic features, and subsequently progressed to confusion and loss of consciousness few hours following the procedure. Close monitoring and medical management with anti-thyroid and other supportive therapies, resulted in an improved clinical condition.

T4 toxicosis is a distinct biochemical entity of clinical significance. Physicians should bear in mind that micro-trauma from an investigation such as fine needle aspiration of the thyroid gland can tilt a thyrotoxic patient into thyroid storm, and this risk should be considered and prepared for by physicians and patients.