Family Medicine vs Community Medicine in Iran

In the early 1970s 15% of all Iranian Medical Graduates (IMG) left Iran and migrated to the United States(1, 2), while 50.000 villages in Iran had no health coverage(3). The initiation of the Department of Community Medicine in Shiraz Medical School was based on the gross misdistribution of health care facilities in Iran, when at the time 70% of population was residing in rural communities and almost 90% of all health facilities were concentrated in Tehran and larger cities (3). The main reason why Shiraz was among the institutions in Iran that initiated this endeavor was the fact that at the time, up to 90% of its medical graduates was deployed in Western countries, particularly the United States (2, 3).

The Limits to Health Care Planning

SUMMARY Health care is not a ‘thing’ to be ‘delivered’ to other people. Current approaches to health care planning in many countries are criticized. The lessons that could be derived from the Chinese model are reviewed and their broader socio?political context identified. RESUME Les Limites de la Planification dans la Protection de la Santé La Protection de la Santé pas un ‘produit’ que l'on peut ‘livrer’ à autrui. On critique ici les méthodes courantes d'approche de cette planification dans plusieurs pays. Les lecons que l'on pourrait tirer de l'exemple Chinois sont passées en revue, et leur contexte élargi, aussi bien politique que social est identifié. RESUMEN Los Límites de la Planificación de la Atencío? de la Salud La atención de la salud no es una ‘cosa’ que pueda ser ‘entregada’ a la demás gente. El articulo critica los enfoques sobre planificación de la atención de la salud que prevalecen en varios países. Se revisan las lecciones que pueden extraerse del modelo chino y se identifica su contexto socio?político más amplio

Effect of Supplementation with Zinc and Other Micronutrients on Malaria in Tanzanian Children: A Randomised Trial

Hans Verhoef and colleagues report findings from a randomized trial conducted among Tanzanian children at high risk for malaria. Children in the trial received either daily oral supplementation with either zinc alone, multi-nutrients without zinc, multi-nutrients with zinc, or placebo. The investigators did not find evidence from this study that zinc or multi-nutrients protected against malaria episodes

Modulation of T Cell Function by Combination of Epitope Specific and Low Dose Anticytokine Therapy Controls Autoimmune Arthritis

Innate and adaptive immunity contribute to the pathogenesis of autoimmune arthritis by generating and maintaining inflammation, which leads to tissue damage. Current biological therapies target innate immunity, eminently by interfering with single pro-inflammatory cytokine pathways. This approach has shown excellent efficacy in a good proportion of patients with Rheumatoid Arthritis (RA), but is limited by cost and side effects. Adaptive immunity, particularly T cells with a regulatory function, plays a fundamental role in controlling inflammation in physiologic conditions. A growing body of evidence suggests that modulation of T cell function is impaired in autoimmunity. Restoration of such function could be of significant therapeutic value. We have recently demonstrated that epitope-specific therapy can restore modulation of T cell function in RA patients. Here, we tested the hypothesis that a combination of anti-cytokine and epitope-specific immunotherapy may facilitate the control of autoimmune inflammation by generating active T cell regulation. This novel combination of mucosal tolerization to a pathogenic T cell epitope and single low dose anti-TNFα was as therapeutically effective as full dose anti-TNFα treatment. Analysis of the underlying immunological mechanisms showed induction of T cell immune deviation

ISS immune modulation, vaccination and the regulation of arthritis

Bacterial DNA contains unique unmethylated CpG motifs. The cytosine-phosphate-guanisine (CpG) sequence of this motif has an unmethylated cytosine which is suppressed or methylated in mammalian DNA. Synthetic oligodeoxynucleotides containing these CpG (CpG-ODN) motifs are called Immunostimulatory DNA Sequences (ISS). Our goal is to gain a better understanding of how ISS, a TLR9 agonist, modulates the immune response and how this response may influence chronic inflammation in those with Juvenile idiopathic arthritis (JIA). JIA is the most common rheumatic disease in children with an incidence of 1 in 1,000. It is defined as chronic arthritic conditions lasting for a minimum of three months affecting children under the age of 16 years. JIA is often characterized by a waxing and waning course, with flares separated by periods of time during which no symptoms of active synovitis are noted (remission). This is especially the case in the Oligoarticular subtype (OA-JIA) that is characterized by prolonged periods of medication-free remission of the disease. However, the polyarticular subtype (PA-JIA) is more severe and has a worse prognosis. The first part of this thesis demonstrates the potential candidacy of ISS as a future vaccine adjuvant with its Th1 promoting properties when administered systemically as well as at mucosal sites. Furthermore, ISS was shown to be arthritogenic in an experimental arthritis model such as adjuvant arthritis (AA). This led us to explore the safety and efficacy of a human vaccine with a bacterial component such as the MenC vaccine in the JIA population addressing the issue of whether an immune response to a bacterial antigen may harbor the risk of exacerbating autoimmunity in susceptible individuals. The MenC vaccine proved to be safe and effective in the JIA population, despite administration of immune suppressive medication. Moreover, we also investigated the quality and quantity of the immune response elicited by the OA-JIA as well as PA-JIA after vaccination towards vaccine and arthritis associated antigens including their regulatory mechanisms. When compared to the OA-JIA group or healthy individuals, the poly-articular subgroup’s greater T cell proliferation to an environmental trigger (the MenC vaccine) corresponds to a dysfunction of their CD4+CD25+ Tregs (despite their greater numbers), the suppressors of the immune response. This suggests that the hyperproliferation seen in the PA-JIA may be the result of the lack of function of the CD4+CD25+ Tregs potentially due to their higher levels of TNF-alpha. In summary, vaccinations and, by extension, infections may break tolerance in those predisposed to autoimmunity potentially leading to aggravation or even induction of the disease. It is conceivable that subunit vaccinations do not evoke a pro-inflammatory response that is strong enough to induce or exacerbate chronic inflammation. However, the risk may still exist, especially for live-attenuated vaccines known to induce more vigorous immune response. Therefore, it is important to evaluate the effects of every new vaccine in those predisposed to chronic inflammatory diseases both clinically as well as immunologically