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Background: Despite the widespread teaching of evidence-based medicine (EBM) to medical students, the relevant literature has not been synthesized appropriately as to its value and effectiveness. Aim: To systematically review the literature regarding the impact of teaching EBM to medical students on their EBM knowledge, attitudes, skills and behaviors. Methods: MEDLINE, SCOPUS, Web of science, ERIC, CINAHL and Current Controlled Trials up to May 2011 were searched; backward and forward reference checking of included and relevant studies was also carried out. Two investigators independently extracted data and assessed the quality of the studies. Results: 10,111 potential studies were initially found, of which 27 were included in the review. Six studies examined the effect of clinically integrated methods, of which five had a low quality and the other one used no validated assessment tool. Twelve studies evaluated the effects of seminars, workshops and short courses, of which 11 had a low quality and the other one lacked a validated assessment tool. Six studies examined e-learning, of which five having a high or acceptable quality reported e-learning to be as effective as traditional teaching in improving knowledge, attitudes and skills. One robust study found problem-based learning less effective compared to usual teaching. Two studies with high or moderate quality linked multicomponent interventions to improved knowledge and attitudes. No included study assessed the long-term effects of the teaching of EBM. Conclusions: Our findings indicated that some EBM teaching strategies have the potential to improve knowledge, attitudes and skills in undergraduate medical students, but the evidenced base does not demonstrate superiority of one method. There is no evidence demonstrating transfer to clinical practice. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

To evaluate the effect of frequent feedback on residents' communication skills as measured by a standardized checklist. Five medical students were recruited in order to assess twelve emergency medicine residents' communication skills during a one-year period. Students employed a modified checklist based on Calgary-Cambridge observation guide. The checklist was designed by faculty members of Tehran University of Medical Science, used for assessment of students' communication skills. 24 items from 71 items of observational guide were selected, considering study setting and objects. Every two months an expert faculty, based on descriptive results of observation, gave structured feedback to each resident during a 15-minute private session. Total mean score for baseline observation standing at 20.58 was increased significantly to 28.75 after feedbacks. Results markedly improved on "gathering information" (T1=5.5, T6=8.33, P=0.001), "building relationship" (T1=1.5, T6=4.25, P<0.001) and "closing the session" (T1=0.75, T6=2.5, P=0.001) and it mildly dropped on "understanding patients view" (T1=3, T6=2.33, P=0.007) and "providing structure" (T1=4.17, T6=4.00, P=0.034). Changes in result of "initiating the session" and "explanation and planning" dimensions are not statically significant (P=0.159, P=0.415 respectively). Frequent feedback provided by faculty member can improve residents' communication skills. Feedback can affect communication skills educational programs, and it can be more effective if it is combined with other educational methods. [ABSTRACT FROM AUTHOR]

Clinical assessment of distal symmetric polyneuropathy (DPN) involves the evaluation of symptoms and signs. Although there are numerous tools to evaluate DPN, there is still a need to determine the most sensitive, specific, and accurate tests to detect DPN in a busy outpatient clinical setting. A total of 107 patients with type 2 diabetes were examined using Michigan Neuropathy Screening Instrument (MNSI). Total score of the instrument was used as a standard to calculate sensitivity, specificity and diagnostic accuracy of every single item of MNSI to find the most accurate and applicable test for evaluation of DPN. In patients' history, the most sensitive (99.4%) and accurate (78%) symptoms were muscle cramp and weakness. Numbness and prickling had lower sensitivity (72.6% and 67.9%, respectively) but greater specificity (65.2% and 47.8%). In physical assessment, the most accurate signs were appearance of feet (81.3%), ankle reflexes (67.2%), and vibration perception (63.5%). Monofilament test had a sensitivity of 16.7%, accuracy of 31.7% with specificity of 87%. Findings show that symptoms such as a muscle cramp, weakness, numbness, and prickling, as well as signs such as ankle reflexes, appearance of feet, and vibration could be used as the most accurate tests for rapid diagnosis of DPN. In addition, the results suggest that monofilament examination may not be the optimum test to detect high risk patients. [ABSTRACT FROM AUTHOR]

Background: Patients with diabetes experience some level of emotional distress varying from disease-specific distress to general symptoms of anxiety and depression. Since empirical data about symptom distress in relation to diabetes are sparse in Iran, this study was designed to assess the diabetes-specific distress in Iranian population. Methods: Persian version of Diabetes Distress Scale (DDS) questionnaire was completed by volunteer outpatients on a consecutive basis between February 2009 and July 2010, in Endocrine Research Center (Firouzgar Hospital). Then, scheduled appointments were made with a psychiatrist in the same week following completion of the questionnaire. The psychiatrist was not aware about the results of this questionnaire and patients were interviewed based on DSM-IV criteria. Results: One hundred and eighty-five patients completed the questionnaire and were interviewed by a psychiatrist. Fifty-two percent of the patients were females. The mean age was 56.06 (SD=9.5) years and the mean of duration of diabetes was 9.7 (SD=7.3) years. Sixty-five (35%) had distress. Among the patients with distress, 55% were females and 64% had lower grade of education. Eighty patients were diagnosed as having Major Depressive Disorder. There was a relation between Emotional Burden subscale and age (P=0.004), employment status (P=0.03), and also diabetes duration (P=0.02). The physician-related distress subscale was also related to the type of medication (P=0.009) and marital status (P=0.01). It has been shown that the regimen-related distress subscale was also related to age (P=0.003) and duration of diabetes (P=0.005). Conclusions: High prevalence rate of distress in the study highlights the significance of the need for identifying distress and also other mental health conditions in patients with diabetes in order to take collaborative care approaches. [ABSTRACT FROM AUTHOR]

Background: The aims of this study were to analyze the trend of cesarean section (CS), determining possible risk factors and also comparing the rate of CS in mothers with gestational diabetes (GDM) and normal pregnant population. Materials and methods: A hospital-based midwives data collection including 37,997 pregnancies in Tehran was used for this study. The study population included all women giving birth between 1 January 1980 and 31 December 2009. Results: The global rate for CS was 37.8 and 85.9% in normal pregnant population and GDM subjects, respectively. An increase in the rate of CS was observed in normal population from 16.97% during 1980-1989 to 71.08% during 2000-2009. There was a similar upward trend for GDM subjects from 79.17 to 93.55%. The most frequent indications for CS in GDM subjects were unsuccessful induction (31%) and repeat CS (22.76%). Conclusion: The rate of CS is surprisingly very high in normal pregnant population as well as subjects with GDM. This should be an alarming issue for healthcare policy-makers and a trigger for monitoring situation in the country. [ABSTRACT FROM AUTHOR]

Diabetes Mellitus affects large numbers of people in a wide range of ethnic groups and at all social and economic levels worldwide. This is exemplified by the dramatic increases in diabetes prevalence in newly developed and developing countries. As type 2 diabetes is so heterogeneous, for preventive measures to be fully effective in a community, they must be based on knowledge of the risk determinants in that community. Uncontrolled diabetes is currently a topic of considerable debate. Uncontrolled diabetes often leads to biochemical imbalances that can cause acute life-threatening events. Iran with a heterogeneous population of almost 70 million at the end of 2006 is located in the Middle East now has been confronted with this important issue. In 2005. Iranian CDC conducted a national health survey in the country. This study was conducted to describe the socio-demographic and clinical features and the level of glycemic control of subjects with diagnosed type 2 diabetes based on this national database. The survey was conducted on 89404 individuals in all provinces, (rural and urban) areas in Iran. Of total 2923 people were recognized as having type 2 diabetes. Age, gender, living area, obesity, educational level and family history for diabetes were determined and analyzed by employing logistic regression model. Fifty seven percent of people with type 2 diabetes (57%) (95%CI: 55.1-58.8%) had FPG>130 mg/dl indicating that their diabetes were uncontrolled. There was no statistically significant difference between male and female; literate an illiterate individuals. People with type 2 diabetes in rural areas had better control on their diabetes than people living in urban areas. In addition, we found that the control of FPG were much better in younger diabetic cases. Surprisingly, those diabetic cases that had positive family history had greater uncontrolled FPG(63% vs 52%). In conclusion the results of this study implies that health policy makers in Iranian health system should pay much more attention to tackle this health predicament particularly for elderly people and people with diabetes living in urban areas. [ABSTRACT FROM AUTHOR]

Diabetes mellitus is a global health problem affecting 366 million people worldwide and its prevalence is growing rapidly. Diabetic eye disease is present in up to 25% of diabetic subjects. Diabetic retinopathy is a chronic complication of diabetes that can result in blindness. Generally, there are two stages of diabetic retinopathy, non-proliferative and proliferative. The longer a person has diabetes and the poorer metabolic control, the higher the chance of developing diabetic retinopathy. The majority of people with type 2 diabetes will ultimately develop diabetic retinopathy. Multifactorial therapy targeted to lifestyle modification and optional glycemic control reduces the risk. However, diabetic retinopathy develops or progresses with time. Primary (preventive) strategies include glycemic, lipid, and blood pressure control. Glycemic control effectively reduces the incidence of diabetic retinopathy. In additional, its effect on progression of diabetic retinopathy has been demonstrated in randomized clinical trials. Furthermore, tight control of blood pressure significantly reduces the progression of retinopathy and visual loss. However, the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Eye Study Group has shown that intensive blood pressure control has no beneficial effect on reducing the rate of diabetic retinopathy in subjects with type 2 diabetes. Elevated serum lipids and dyslipidemias are associated with a higher risk of diabetic retinopathy. The beneficial effects of lipid-lowering agents on the progression of retinopathy have been reported. Intensive combination therapy for dyslipidemia has been shown to effectively reduce the rate of progression of diabetic retinopathy in type 2 diabetes. Secondary strategies are focused on various pathophysiologic approaches such as blockade of the renin angiotensin system (RAS), anti-vascular endothelial growth factor agents, somatostatin analogues, protein kinase inhibitors, and anti-inflammatory agents. The purpose of the current overview is to look into the medical management of diabetic retinopathy, and to explore the primary (preventive) measures as well as secondary strategies proposed to be effective in its medical management. [ABSTRACT FROM AUTHOR]

Background: Migraine headache significantly impacts the health of individuals and of society. The application of simple physical nonpharmacological techniques could greatly reduce the therapeutic costs and side effects in acute onset of such headaches., Methods: Ten male patients (mean age was 32.0 ± 10.59 years) with acute onset of a migraine headache according to IHS-2004 diagnostic criteria were enrolled in the study. Neck and upper thoracic spine massage and manipulation technique was performed. Headache pain intensity was assessed before and after the intervention by means of a verbal analog scale., Results: Following treatment, headache pain intensity was significantly reduced compared to the pretreatment values (1.85 ± 1.11 vs. 5.80 ± 2.25, p = .005). As a percentage, this represents a mean pain reduction of 68.77% ± 18.56. No side effects were observed, and all of the patients reported satisfaction with the intervention., Conclusion: Our results show that the applied cervical and upper thoracic massage and manipulation technique could reduce the headache attack pain intensity in patients with migraine headaches, though further testing, including study designs that make use of control groups, is needed.

Background: We determined, in Iranian patients with diabetes mellitus, the prevalence of inadequate glycemic control and its predictors., Material/methods: The data from a national population-based survey that included a random sample of 89 404 Iranian individuals in 2005 were analyzed. In that sample, 2923 diabetic subjects (age range, 25-64 years) were identified. We linked the results of their fasting plasma glucose levels with demographic and behavioral variables to determine predictors of poor glycemic control., Results: About 57% of the subjects had a fasting plasma glucose level of > or =130 mg/dL. That percentage was comparable in male and female subjects and in literate and illiterate subjects. However, inhabitants in rural areas controlled their fasting plasma glucose level about 11% better than did subjects who lived in an urban area. We also found that control of the fasting plasma glucose level was much better in relatively younger diabetic patients. Diabetic subjects with a family history of type 2 diabetes mellitus exhibited a higher uncontrolled fasting plasma glucose level than those without positive family history of diabetes., Conclusions: The percentage of uncontrolled type 2 diabetes found in our study suggests that the Iranian healthcare system should devote more attention to that disorder, particularly in elderly individuals, who are more vulnerable to the complications of diabetes and control their disorder less well than do younger diabetic patients. The recent integration of diabetic care in primary healthcare systems in Iranian rural areas was found to have a promising effect on community health.