From Tehran to Dallas Jafar Forghani MD InternistRheumatologist

From Tehran to Dallas Jafar Forghani, MD Internist-Rheumatologist Iran University of Medical Sciences (IUMS) Tehran, Iran March 17, 2006

Jafar Forghani, MD • • Born in Abadan, Iran MD degree from Isfahan Medical school: Internship @ Malden Hosp. , Malden, MA: Medical residencies + Rheumatology fellowship @ Cleveland Clinic, Cleveland, OH: • Prof. of medicine , Dep. Internal Med Head, division of Rehumatology @ IUMS: • 1945 1963 -1970 1973 -1974 -1978 - present Member: Iranian Board of Internal Medicine Iranian Board of Rheumatology Iranian Rheumatology Association

From Tehran to Dallas • • Iran & Tehran Medical schools in Iran Internal medicine & rheumatology in Iran University of Medical Sciences (Tehran) • Examples of patients and quizzes for medical residents • Sabbatical study in Dallas

Iran-Persia Iran (Eran, Arynam, land of Aryans) The Aryans came about 2000 BC and split into two main groups, the Medes and the Persians. The Persian Empire founded (c. 550 BC) by Cyrus the Great. It was succeeded, after a period of Greek and Parthian rule, by the Sassanid in the early 3 d century (AD).

Achaemenid Empire(500 B. C. ) The Achaemenid Persians of central Iran ruled an empire which comprised Iran, Mesopotamia, Syria, Egypt, and parts of Asia Minor and India from the 6 th to the 4 th century B. C.

The Achaemenids ceremonial capital was Persepolis in southern Iran founded by King Darius the Great (522 -486 B. C. )

XPa Trilingual 1 Gate of Xerxes North Door Jamb, West Doorway | Elamite Inscription | Old Persian Inscription | Akkadian Inscription |

Cyrus II = Cyrus(Koresh) the great Length: 22. 86 cm Cyrus Cylinder This cylinder has sometimes been described as the 'first charter of human rights'

Text of the declaration(Cyrus Cylinder) I am Cyrus, King of Persia, great king, mighty king, King of Babylon, king of the land of Sumer and Akad, King of. . . , king of the four quarters of Earth, son of Cambysis (Kambujiye), great king, king of Anshan, grandson of Cyrus (Kurosh),

Text of the declaration(Cyrus Cylinder) As to the inhabitants of Babylon who against the will of the gods were enslaved, I abolished the corvee which was against their social standing, I freed all slaves. I brought relief to their dilapidated housing, putting thus an end to their misfortunes and slavery

Now that I put the crown of kingdom of Iran, Babylon, and the nations of the four directions on the head with the help of (Ahura) Mazda, I announce that I will respect the traditions, customs and religions of the nations of my empire and never let any of my governors and subordinates look down on or insult them until I am alive. I never let anyone oppress any others, and if it occurs , I will take his or her right back and penalize the oppressor. And until I am the monarch, I will never let anyone take possession of movable and landed properties of the others by force or without compensation. Until I am alive, I prevent unpaid, forced labor.

Text of the declaration(Cyrus Cylinder) To day, I announce that everyone is free to choose a religion. People are free to live in all regions and take up a job provided that they never violate other's rights. No one could be penalized for his or her relatives‘ faults. I prevent slavery and my governors and subordinates are obliged to prohibit exchanging men and women as slaves within their own ruling domains. Such a traditions should be exterminated the world over. . .

Persepolis was burned by Alexander the great in 331 B. C. Only the columns, stairways, and door jambs of its great palaces survived the fire. The stairways, adorned with reliefs representing the king, his court, and delegates of his empire bringing gifts, demonstrate the might of the Persian monarch.

Perspolis – 600 miles south of Tehran The Achaemenids ceremonial capital was Persepolis in southern Iran founded by King Darius the Great (522 -486 B. C. )

IRAN: Persepolis - Portico of the "Hundred-columned Hall" of Darius (ca. 520 B. C. ). The body of a colossal bull from the gateway can be seen at the lower left.

U. S. A. : Chicago - Colossal bull head from Persepolis, as restored and installed in the Iranian Hall of the Oriental Institute Museum

Area: 1. 648 million sq km Slightly larger than Alaska Land boundaries: total: 5, 440 km Border countries: Afghanistan 936 km, Armenia 35 km, Azerbaijan-proper 432 km Azerbaijan-Naxcivan exclave 179 km, Iraq 1, 458 km, Pakistan 909 km, Turkey 499 km, Turkmenistan 992 km Population: ~ 70 million

Azadi Square: Tehran Population: 10 to 12 millions Milad Tower : Tehran

Isfahan (Esfahan)= half the world Naghsh-e-Jahan (Shah) square

Sheikh Lotfollah mosque - Isfahan

Medical Schools in Iran Year 1979 Year 2005 Medical Schools 10 >50 Population of Iran Physicians 60, 000 40, 000 70, 000 12, 000 Internists (total) <1000 3000 (Subspeciali <1 sts) 00 00 Rheumatologists <10 120 ~10

Tehran University : 1934 Iran University of Medical Sciences: 1974

Internal Medicine in Iran • • • 4 year program > 3 y. program > 4 y. program Admission through national entrance exams Promotion by universities evaluations + national exam Board eligible internists get license to practice National Board of Internal Medicine Board certified internists may go to subspecialty programs or employed as medical staff in universities • Currently there are 7 approved subspecialty programs: Card. , Endo. , GI. , Hem-Onc. , Nephro. , Pulm. , and Rheum. (Infectious disease – straight from MD)

Morning Report Internal Medicine Hazrat Rasool Hospital

Medical staff – Internal Medicine, Hazrat Rasool Hospital

Rheumatology

Rheumatology in Iran • Fellowship programs started in 1983 • 2 years clinical programs in 5 centers ( 3 in Tehran, 1 in Shiraz, and 1 in Mashad) • Admission through national entrance exams (written and oral)- 11 positions each year • Subspecialty Board of Rheumatology exam after completion of 2 years fellowship

Hazrat Rasool Hospital- Rheumatology staff and fellows

Rheumatology fellows waiting for oral exam (Board)

• Common and uncommon rheumatic diseases in Iran • Interesting cases • Quizzes

A 25 year old female presented with problem with walking

Unilateral sacroiliitis(Brucellosis) Brucella spondylitis

Behcet’s Disease

A 32 year old female with 12 years history of SLE (malar rash, + ANA +Anti DNA, GN, arthritis) was admitted to hospital for treatment of sever thrombocytopenia. She had been on prednisolone 5 mg t. i. d, Chloroquine 150 mg/day and Azathioprine 50 mg b. i. d. for last 3 years. She was treated with 3 pulses of Methylprednisolone 1000 mg/day followed by daily plasmaphresis via a Jugular vein catheter for 2 weeks and then 3 time/week for next 3 weeks. She has had pain of right hip on walking since 5 years ago. The X-ray of pelvis on admission is shown.

X-ray on admission

She developed fever( up to 104 ) 6 weeks after admission. Jugular catheter was removed and IV antibiotics started. One week later, she complained of severe pain in right hip. She was not able to stand or walk. Right hip was in external rotation position and all movements were painful. The X-ray of pelvis at this time is shown.

X-ray 7 weeks after admission

Interpret X-rays. What is your diagnosis? X-ray on admission X-ray 7 weeks later

30 year old woman with chronic joint pain and swelling in hands and feet for 10 years.

A patient with jaundice

NEJM: Vol. 336, No 12, March 20, 1997 Medical Mystery

From an old book

Sabbatical study • 3 months @ Arthritis Consultation Center , Presbyterian Hospital of Dallas • To observe design, and process of clinical trials on biologic agents for treatment of rheumatoid arthritis and other rheumatic diseases. • To observe implementation of medical residency curriculum at PHD.

Painting by Mahmood Farshchian

Thank you for your attention