Tehran University Medical Journal

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The diabetes is an autoimmune disease, in which the role of autoantibodies is of a specific importance. The appearance of these autoantibodies can be the first symptom in the serum of type I diabetic patients, which may appear ten years before onset of the disease. The most important autoantibodies include Glutamic acid decarboxylase autoantibodies (GAD65-Ab). This can be used as a good tool for prediction in screening tests in type I diabetic patients. In the present study with prosedure RIA, we investigated the level of GAD65-Ab in patients with diabetes type I and their close relatives, and compared them with healthy persons. From the type I diabetic patients who have been suffering from the disease for periods of one week to twenty years, 63.3% of them had positive Anti-GAD65. This ratio was 8% in their close trelatives, and 0% in healthy persons. The difference in Anti-GAD65 between the healthy persons and close relative of patients was significant. This test may be employed in diabetes type I, as a screening test, and confirms the results of studies which have been conducted so far outside this country.

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Introduction: Clinical manifestations of primary hyper-para-thyroidism (pHPT) had been dramatically changed during last 25 years. Evaluation of changes in clinical findings was the aim of this study.

Materials and methods: In a retrospective, descriptive case series, patients' records of all 47 pHPT (44 females, 3 males) from 1988 till 1998 were studied. Patients’ clinical presentations, signs and symptoms, laboratory and radiologic findings were reviewed and the results were compared with 34 patients' studied during 1978-1987. Serum Ca>10.5 mg/dl with increased or high normal PTH were the diagnostic criteria of pHPT.

Results: Patients’ age range was 11-70 and mean ±SD was 38±16 years, with a female to male ratio of 14:1. 57 percent of the patients had bone pain and muscle weakness, 12 percent were asymptomatic, 10 percent had pathologic fractures, 8 percent had renal stones, 8 percent had symptoms of hypercalcemia, and 2 percent had giant cell lesion. The mean±SD of serum calcium was 11.48±1.16 mg/dl, phosphorus was 2.4±0.6 mg/dl and 24-h urinary Ca was 294±197 mg. Serum PTH was increased from 1.5 to 500 folds. The frequency of single adenoma in right inferior, left inferior, and left superior gland were 43 percent, 30 percent, and 13 percent respectively.

Conclusion: In the study 12 percent of patients were asymptomatic whereas there was no asymptomatic case in the previous study. Prevalence of severe bone disease and the interval between onset of symptoms and diagnosis was also reduced. According to this study detection of pHPT in asymptomatic phase remarkably increased.

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Background: Patients with type 2 diabetes are often obese and require large dose of insulin to achieve glycemic control. Insulin therapy often cause weight gain and results in increasing insulin requirements. This study was conducted to evaluate the efficacy of metformin in combination with insulin in patients with type 2 diabetes poorly controlled with insulin therapy alone.

Materials and Methods: In a randomized clinical trial in outpatient diabetes clinic at university medical center, 39 patients with poorly controlled type 2 diabetes who were receiving insulin therapy were randomly assigned to receive metformin in combination with inslin or insulin alone for six months.

Results: Hemoglobin A1C levels decreased by 1.56 percentage (95% cl, 0.77 to 2.34 percentage point) in metformin group, a significantly greater change (P=0.008) than the increase of 0.03 percentage points in the insulin alone group. Average final hemoglobin A1C levels were 7.96% in the metformin group and 10.32% in the insulin alone group (difference 17%). For patients who did not received metformin, the insulin dose increased 9.37 units (95% cl 6 to 12 units) or 37% more than did the dose for patients who received metformin. (P<0.0005): for these patients, the insulin dose decreased 6.6 units (95% cl-1.24 to –11.96) Patients in insulin alone group gained an average of 3.08 kg of body weight (95% cl 1.56 to 4.58 kg) patient in the metformin group gained an average of 1.8 kg (95% cl 0.21 to 3.36 kg) Difference (1.9%) was not meaningful. Change of total cholesterol, low density lipoprotein cholestrol and triglyceride levels was not significant.

Conclusion: The addition of metformin to insulin therapy resulted in hemoglobin A1C concentrations that were 17.8% lower than those achieved by insulin therapy alone. This improvement occurred with use of 37% less insulin. Metformin is an effective adjunct to insulin therapy in patients with type 2 diabetes.

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Background: Definite diagnosis and treatment of Cushing's syndrome is still a dilemma. The aim of this study was to evaluate the accuracy of diagnostic tests and follow-up of patients with Cushing's syndrome.
Methods: Two hundred and fifty three consecutive cases with Cushing's syndrome during 1370-78 were studied. The screening tests were performed in all patients. High dose dexamethasone suppression test (HDDST) and ACTH measurement were carried out. MRI/CT Scan were performed and compared with laboratory data and pathologic specimens as a gold standard test.
Results: The age range was 32±11 yrs. The most frequent symptoms were weakness hypertension, typical striae, and depression .The frequency of hypertension in ACTH-dependent case were 77% vs. 36% in adrenal tumors (P< 0.001). HDDST was positive in 99% of micro and 71% of macroadenomas. Adrenal tumors showed 3.6% suppression but none in ectopic cases. HDDST had a sensitivity of 98%, specificity of 97% and accuracy equals to 98%. The frequency of different etiologies was as following: Cushing's disease in 64.8%, adrenal tumors in 32.8% and ectopic ACTH in 2.4% of patients. Trans-sphenoidal surgery (TSS) was performed in 120 patients .The patients were followed for 53±25 months whose remission periods were 46.7±23.8 months (range 4-114 months). Survival analysis showed 93% remission rate in 12mo, 82% in 2yr and only 33% after 5yr.This recurrence didn't have any platue level.
Conclusion: In our study, hypertension was more prevalent in ACTH-dependent Cushing's syndrome. HDDST had acceptable sensitivity, specificity and accuracy. Lifelong follow up of pituitary adenomas is inevitable in the case of progressive and gradual nature of recurrence in these tumors.

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Background: Myeloperoxidase (MPO), an iron-containing protein, is found in the azurophilic granules of neutrophils (PMNs), and catalyzes the conversion of hydrogen peroxide and chloride ions (Cl) into hypochlorous acid, which plays an important role in oxygen-dependent bacterial killing. The enzyme was first isolated in 1941, and deficiency of MPO was first described in 1954. Fewer than 5% of patients with MPO deficiency contract severe infections, which are usually fungal infections in diabetes mellitus (DM) patients. Besides the disorder in antifungal activity, diminished rate of bacterial (S. aureus) killing, and carcinogenesis, it seems that MPO deficiency is also related to atherosclerosis, degenerative neurologic diseases, as well as other disorders. In this study, we compared the levels of the MPO enzyme in the peripheral neutrophils of infected and non-infected DM patients at Imam Khomeini Hospital during 2005-2006. We compared these two groups the prevalence of MPO deficiency in each group, in order to then determine any correlations this may have with infection.

Methods: In this case-control study, 50 patients were in the infected group (case group) and 50 were in the control group. Patients were chosen using simple sampling methods. Data was gathered from blood samples, using a qualitative test to determine MPO deficiency (Kaplow stain), laboratory results (BUN, Cr, PMN, HbA1c), interviews and completion of a questionnaires, as well as hospital records. Data were analyzed with SPSS software using T test and chi-square test, with a confidence index of 0.05.

Results: In spite of differences seen in stained slides, the MPO enzyme was positive in all of the patients, and no differences were seen between the two groups.

The average patient age and the duration of DM in the case group were more than those of the control group. No statistical differences in the type of DM and glycosylated hemoglobin (HbA1c) levels were found between the two groups. Body mass indexes (BMI) and PMN counts were higher in the case group. The most prevalent infections were in the skin and soft tissue, bones and joints, as well as chronic respiratory infections (TB), pneumonia, urinary infections, CNS infections, gastrointestinal and intra-abdominal infections, mucormycosis, and sepsis.

Conclusions: We found no correlation between MPO enzyme deficiency and age, sex, type or duration of DM, HbA1c levels and BMI.