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Introduction: Educational programs and curriculums are developed using underlying concepts of value. The development of values-based curriculum and access to education based on values requires clarification of the concept of value. This article is an interpretive review of the large body of diverse and complex literature on the concept of value in medical education. Methods: This project used critical interpretive synthesis (CIS) to carry out qualitative analysis and synthesis of the literature in critical interpretive style. The main review question was the clarification of the concept of value in medical education, which produced over related 800 articles; 70 articles related to the research objective were studied by purposive sampling. After identifying the main categories and sub-categories, a well-reasoned synthesis of the contradictory findings in different studies was conducted. New concepts and relationships between concepts were created using CIS of documentation related to the concept of value and the philosophy and place of values in medical education.Results:To perceive the concept of value and its use in the design and development of medical curriculum, a loop of concepts related to the concept of value was created. A more useful means of understanding value is offered by the synthetic constructs of principle-, outcome-, and virtue-oriented values. This triad of value loops shelters institutional, programming, and curricular levels of the education system. Conclusion: This new theoretical conceptualization of value in the education system can be an appropriate guide for value-based educational programs and curricula in medical education in every context.

Morning report sessions are for sure the best known case- based educational meetings in the history of medical education. This study is aimed to evaluate the proper case presentation in such sessions. Seventy three morning report sessions in different wards of five main hospitals of a type-1 university were evaluated regarding the number of the cases, duration of each presentation, availability of 24-hour admission lists and seven quality indices of proper case presentation. The Mean number of the cases was 3 and the mean duration of case presentation was 4 minutes. The Total score of quality indices was 82%, while the Total score of the availability of admission list of cases was 50%. In the present study, the different aspects of proper case presentation were revealed in the studied university.

Social accountability has been increasingly discussed over the past three decades in various fields providing service to the community and has been expressed as a goal for various areas. In medical education system, like other social accountability areas, it is considered as one of the main objectives globally. The aim of this study was to seek a social accountability theory in the medical education system that is capable of identifying all the standards, norms, and conditions within the country related to the study subject and recognize their relationship. In this study, a total of eight experts in the field of social accountability in medical education system with executive or study experience were interviewedpersonally. After analysis of interviews, 379 codes, 59 secondary categories, 16 subcategories, and 9 main categories were obtained. The resulting data was collected and analyzed at three levels of open coding, axial coding, and selective coding in the form of grounded theory study of “Accountability model of medical education in Iran”, which can be used in education system’s policies and planning for social accountability, given that almost all effective components of social accountability in highereducation health system with causal and facilitator associations were determined.Keywords: SOCIAL ACCOUNTABILITY, COMMUNITY–ORIENTED MEDICINE, COMMUNITY MEDICINE, EDUCATION SYSTEM, GROUNDED THEORY

Background: The need for internalization of values for professional development in medicine and surgery, and sense of duty linked to the practice of the medical professionalism were recognized in Iran. With regard to the shortcomings currently existed in the curriculum of the medical education, in 2013, the design of an operational model for the curriculum based on values was placed on the agenda through the PhD thesis. Objectives: The aim of this study is to develop the operational model of the value-based curriculum for medicine and surgery education with respect to indigenous values in Shahid Beheshti University of Medical Sciences, Tehran, Iran. Methods: Our value-based curriculum model was developed through qualitative ontology foundations of Hugh McKenna concept analysis. Finally we developed our operational model by comparing our domestic extracted attributes with what is existed and experienced in other countries through systematized searching, determined the process of value curriculum, the sequence of process steps, menu and taxonomy for operationalization of each step, and recommended practices for each step for integration of values in medicine and surgery education in Iran. Results: Ten steps of curriculum model for integration of values in medicine and surgery education include: general need assessment of values, designing hierarchy system of values, need assessment of targeted learners’ values, developing value programme statement, determination of value outcomes and objectives, production of value rich content, value based teaching and learning methods, value based settings, value themes management, determination of values evaluation and assessment methods. Conclusions: This Indigenous operational model of value based curriculum proposes the process with exact sequence for the concrete implementation of values education in medicine and surgery, accordance with our country offers. The operational value based curriculum model was prepared in order to develop a practical guideline for value based experiments in medicine and surgery, helps to move from the information level and expressing factual knowledge, to the conceptual and judgment level, understanding the connections and interactions between facts and analysis them.

Higher education which has the main role in the training of skilled human resource can also be considered as the foundation of wealth creation in the country. The quantitative and qualitative expansion of higher education is inevitable. The facilities and the government budget are not responsive for the need, due to the increasing demand of young people for entering higher education in Iran. Therefore, developing and equipping universities and unpublicized and private higher education institutions have received considerable attention and have grown substantially. We aimed to evaluate educational experts regarding encouraging factors of the private sections for more participating in financing of higher education centers and institutions in Iran. Qualitative content analysis method has been used.The participants were selected using purposive sampling. The professors were in positions of policymaking and managing and had opinions on the challenges of universities financing. Data collection was conducted with semi-structured interview in 2016 and all ethical considerations associated with qualitative research were respected. The main concepts obtained from the interview were reported in the three main themes and their sub-classes. We have found that with the authorities given to universitiesby law, and preparing the transition from the based solely on government resources to the private section is provided by taking the appropriate decisions of managers to attract investors Universities can benefit from promoting different mechanisms to attract private financing in the higher education section. Solutions also were presented in this way. The idea of educational investment not only can promote the community investments towards higher education, but also has been the promotion of knowledge-based business in the community and promotes entrepreneurship and knowledge-based economy.Keywords: HIGHER EDUCATION, EDUCATIONAL INVESTMENT, KNOWLEDGE-BASED ECONOMY

Background: Among core competencies introduced by the Accreditation council for graduate medical education (ACGME), practice-based learning and improvement (PBLI) monitors the improvement and quality of physicians’ performance during their professional practice. Understanding and knowledge of the viewpoints of medical professionals, planners, and graduates about the concept of PBLI and investigating its current status are required for proposing appropriate policies and plans in this area. Methods: This qualitative study was performed through thematic content analysis. In-depth semi-structured interviews were conducted to gather data in Tehran, Iran from June 2016 to January 2017. Purposeful sampling was applied, and the participants included experts, planners, and medical graduates. While considering the trustworthiness criteria during the study, interviews were performed, transcribed, and coded. We used ATLAS.ti version 6 for coding and categorization. Results: The study sample consisted of 11 participants, including 4 executive officials, 4 experts of medical education, and 3 general practitioners (4 females and 7 males). The average age of the participants was 48 ± 8.47 years. The analyses introduced 9 categories, 56 subcategories, and 224 initial codes. The main categories included: PBLI attributes, components of PBLI, shortcomings of the academic educational system, shortcomings of the health system, strategies for academic education reform, strategies for health system reform, activators of PBLI, solutions for gaps in PBLI, and need for PBLI. Conclusions: PBLI is a professional necessity for all physicians. Feasibly, excellence in clinical care can be achieved with this competency. Implementation of PBLI requires a competency-based curriculum, academic education, and a proper infrastructure for its implementation in clinical service delivery environments. Health system stewardship plays a great role in overcoming the challenges and developing coordinated national systems.

Background and Purpose: The office of educational services at universities is a very important division and it is necessary for employees to strive towards providing suitable services to students. The quality of educational services has always been a major concern for higher education managers. Interviewing stakeholders and experts increases our understanding of different aspects of the subject in order to create a native model with high performance capability based on existing conditions and the cultural and political infrastructure of our country. Therefore, we aimed to define the perception and experiences of educational service stakeholders.Methods: In this qualitative thematic content analysis that adapted a deductive approach using Graneheim and Lundman’s method. Initially, purposeful sampling was done to identify and select the students (as first level stakeholders) studying paramedical majors at one of the medical science universities of the country during the educational year 2015-2016. Altogether, 20 people were interviewed consisting of 6 students, 4 faculty members, 2 student affairs employees, 1 counselor, 2 education officers, and 2 education office managers).Data were analyzed and coded using MAXQDA software.Results: Of the 400 initial codes extracted through data analysis, 336 abstract codes, 48 sub-categories, 20 categories, and 7 themes were obtained. The level of abstraction was different in the categories. The extracted themes were as follows: information gap before and after entering university, the difference between expected and perceived services and factors contributing to expectations, the university’s approach in enhancing service quality, the student and management of educational problems, the system-student interaction in educational planning, and the professors’ responsibilities and performance in enhancing quality, and the role on the university management system in enhancing the quality of services.Conclusions: In the current educational management system, there are several gaps affective the quality of service providing such as the gap between the students’ expectations and the management system, the gap between the perceptions of the university management and the designing and standardizing of services, the gap between standardization and presentable services, communicational gaps, and gaps between received services and expected services. Therefore, in a future study, we will define these gaps and present a model that could fill those gaps.Keywords: EXPERIENCES, PERCEPTION, EDUCATIONAL STAKEHOLDERS, EDUCATIONAL SERVICES, QUALITY

Background and Purpose: In education of medical science courses, there has been a growing orientation towards replacing traditional teaching in with E-learning education. Since the modern system of education is based on self-directed learning, e-learning requires special powers to deal with new-emerging challenges and professionally encounter the learning environment. The purpose of the present research is to explain and provide a conceptual model for professional competency in this system.Methods: In this review, different internet and library resources, indexed in Scirus, Pre Quest, Scopus, IEEE, SID, Magiran, Eric, Taylor and Francis, and Google Scholar from 1990 to 2015 were searched using the following keywords: function, manner, ethics, conduct disposition, netiquette, values, academic fraud, moral professionalism, and behavior ine-learning in combination and separately. The Critical Review methodology and Carnwell and Randolph structures were used. The most recent and richest resources that were more relevant to the issue were selected and their information was extracted.Results: Among review of 98 articles, documents of 34 relevant and valid articles were extracted. Based on the results, Digital Literacy, study skills, Cyber Ethics, and Netiquette were considered the main components of scientific and ethical competency in e-learning. 40 components were included in these dimensions.Conclusions: Although there is general interest in e-learning, the target population (learners) are not prepared to use such an environment and require strong support. In this paper, we provided a summarized scheme and conceptual pattern fore-learners to move towards promotion of learning.Keywords: PROFESSIONAL FUNCTION, E-LEARNER, E-LEARNING, CRITICAL REVIEW

Purpose: It is essential to adjust the responsibilities and function of medical education offices (MEOs) in regard to the current societal requirements. Therefore, it is a good idea to learn lessons from the experiences about the establishment and function of these offices around the world. The aim of the present study was to carry out a comparative study to investigate the function and structure of MEOs at some of the medical universities from America, Europe, and Asia. Subjects and Methods: This is a comparative, descriptive study that was conducted in 2015. Eleven offices around the world (in America, Europe, and Asia) were selected for the study. Expert group discussion and literature review were used in order to select research sample. The data were gathered using self-constructed checklists. Content and face validity of the checklist was assessed by gathering feedback from experts. The Kappa coefficient was used to determine the inter-rater reliability. Results: All the 11 offices in our study (100%) dealt with the issues of faculty development and research and scholarship activities. Only one out of the 11 offices (27%) dealt with the issues of society and patient education. Five out of the 11 offices (36%) dealt with the continuing medical education and continuing professional development. Consultation services are provided at seven of the 11 offices (64%). Conclusions: This study revealed both commonalities and differences in the function and structure of MEO among the 11 offices we examined. Based on this study, effective goals and strategies for MEO can be recommended.

Introduction: Over the past few decades, two revolutionary approaches have emerged as a new form of medical education: Electronic Medical Education and Web-based Medical Education. A number of well-known medical institutions, such as Harvard and Johns Hopkins used a wide range of cyberspace capabilities to increase their competitiveness. Researchers have expressed that cyberspace will change health system’s main objective of training physicians and medical education. We conducted this study to identify the health system critical considerations on core issues, involving the development of medical education on cyberspace. Methods: In order to conduct this study, we observed the steps of a critical literature review, combined with the ‘Four-phase method’ adopted by Carnwell and Daly. We focused on particular literature on health and cyber system functions; it was associated with systemic approach. Results: We developed a six-level taxonomy, Cyber level, Governance level, Ministerial level, Organizational level, Program level and Performance level, as a key solution that can be applied for the success of medical education on cyberspace. The results were summarized and appraised in more details. Conclusion: Medical education on cyberspace is a complex interdisciplinary system. It is important that all aspects of the health systems be involved as integral to the development of cyber based medical education; without this convergence, we will be confused by the decisions made by others within the system. Health system should also communicate with those external sectors that are critical to achieving better learning on cyberspace. Integrated planning, governance and management of medical education in cyberspace are pivotal elements for the promotion.

The aim of this qualitative study was to determine the most important medical errors made by gynecology residents. This study used a Delphi technique in three rounds. First, a list of common errors was prepared using a questionnaire, then the most important errors were prioritized and finally, the managerial and training procedures were determined for errors. In this study, 45 common errors were detected. The most common errors were inadequate surgical homeostasis, excessive use of magnesium sulfate, managerial error of post-operative infections; undiagnosed pulmonary embolism and incorrect prescription of heparin. Specialists and residents stated that designing an instructional guideline was the best method to manage all kinds of errors. Different regulatory and training procedures should be applied to prevent and control errors. An effective method for professional practitioners is designing instructional guidelines. In this study, an instructional manual was developed for the most frequent errors observed in obstetrics and gynecology.

Screening is a way of looking for patients who do not seem to have major medical problems. Screening tests usually include several phases. In double phase screening, one test is to find the potential patient, and then another test is to prove the disease in those patients. The combination of these two tests is important and can be either "in series", where running or not running the second test depends on the results of the first one, or "in parallel" where the second test is independently performed regardless of what the first test result is. In this article we compared the combined tests based on their final sensitivity and specificity using mathematical analysis to determine how the order of different tests with different sensitivity, and specificity can impact the final specificity and sensitivity of the combined tests.

This study designed a framework for assessing the stewardship function of the oral health system in Islamic Republic of Iran. The modified RAND Corporation/University of California Los Angeles (RAND-UCLA) Appropriateness Method was used in a 2-step process that combined literature evidence and the collective judgement of experts. After a comprehensive literature review, policy instruments related to stewardship components were extracted as candidate standards and categorized according to the 6 sub-functions of stewardship (accountability; defining strategic direction; alignment of policy objectives and organizational structure; regulation; intersectoral leadership; and generation of intelligence). Five key informants then rated the appropriateness of the 85 standards on a 5-point Likert scale. The 38 highest ranked standards, including at least 2 standards in each of the 6 sub-functions, formed a set of proposed standards for evaluating the current stewardship of oral health system. Piloting of the instrument will be reported separately.إطار لتقييم القوامة في نظام صحة الفم في جمهورية إيران الإسلاميةباهاره تهاني، شهرام يازداني، محمد خوشنيفيسان، بول دوغدالي، ثمين صديقي، أريزو ابن أحمديوضعت هذه الدراسة إطار عمل لتقييم وظيفة القوامة في نظام صحة الفم في جمهورية إيران الإسلامية. وتم استخدام الطريقة المعدلة لمؤسسة البحث والتقييم التابعة لجامعة كاليفورنيا في لوس أنجلوس على خطوتين للربط بين البيِّنات المنشورة والرأي الجماعي للخبراء. وبعد إجراء مراجعة شاملة للنّشريات، تم استخلاص النصوص الخاصة بالسياسات المتعلقة بعنصر القوامة كمقاييس مقترحة، وتم تصنيفها وفقاً للوظائف الفرعية الست للقوامة (المساءلة، والتوجهات الاستراتيجية المحددة؛ وترتيب أهداف السياسيات؛ والهيكل التنظيمي؛ والتنظيم، والقيادة المشتركة بين القطاعات، وإنتاج المعلومات). ثم قام خمسة مبلِّغين رئيسيين بتقييم مدى ملاءمة المعايير البالغ عددها 85 مقياساً وفقاً لمقياس ليكرت ذي النقاط الخمس. وقد شكلت المقاييس التي حصلت على أعلى ترتيب والبالغ عددها 38 مقياساً، بما فيها مقياسان على الأقل في كل من الوظائف الفرعية الست، مجموعة من المقاييس المقترحة لتقييم القوامة الحالية لنظام صحة الفم. وسيتم تقديم تقرير عن هذه الأداة بشكل منفصل.Cadre d’évaluation de la gouvernance du système de santé bucco-dentaire en République islamique d’Iran.La présente étude a conçu un cadre d’évaluation de la fonction de gouvernance du système de santé bucco-dentaire en République islamique d’Iran. La Méthode modifiée de détermination de la pertinence des indications de la Rand Corporation et de l’Université de Californie Los Angeles (Rand/UCIA) a été utilisée, dans un processus en deux étapes, combinant les données probantes de la littérature et le point de vue collectif d’experts. Après un examen exhaustif de la littérature, des instruments de politiques liés aux composantes de gouvernance ont été extraits en tant que normes candidates puis classés en catégories selon les six sous-fonctions de gouvernance (responsabilisation, définition d’une orientation stratégique, harmonisation des objectifs politiques et de la structure organisationnelle, réglementation, direction intersectorielle et production de données). Cinq informateurs clés ont ensuite attribué une note à la pertinence de 85 normes sur l’échelle de Likert en cinq points. Les 38 normes les mieux notées, dont au moins deux normes dans chacune des six sous-fonctions, ont formé un ensemble proposé pour l’évaluation de la gouvernance actuelle du système de santé bucco-dentaire. Le pilotage de l’instrument fera l’objet d’un rapport distinct.

Background: Morning report has long been regarded as a stressful session for students and lecturers. This study aims to evaluate the main indices regarding stress. Materials and Methods: In a university including 5 hospitals and 25 academic wards, three indices regarding stress were evaluated including talking interruption, serving snacks and systematic feedback. Results: In none of the wards, serving snacks during teaching sessions was observed. In 53 out of 73 (72%) talking interruption was demonstrated. The score of systematic feedback was 48%. Conclusion: Talking interruption in morning report sessions is high and systematic data gathering (feedback) from learners is low. Serving snacks is ignored at all.

Background and Purpose: ConsideringBackground and Purpose: Considering the importance and necessity of competency-based education at a global level and with respect to globalization and the requirement of minimum competencies in medical fields, medical education communities and organizations worldwide have tried to determine the competencies, present frameworks and education models to respond to be sure of the ability of all graduates. In the literature, we observed numerous competency development models that refer to the same issues with different terminologies. It seems that evaluation and synthesis of all these models can finally result in designing a comprehensive meta-model for competency development.Methods: Meta-ethnography is a useful method for synthesis of qualitative research that is used to develop models that interpret the results in several studies. Considering that the aim of this study is to ultimately provide a competency development meta-model, in the previous section of the study, the literature review was conducted to achieve competency development models. Models obtained through the search were studied in details, and the key concepts of the models and overarching concepts were extracted in this section, models’ concepts were reciprocally translated and the available competency development models were synthesized.Results: A presentation of the competency development meta-model and providing a redefinition of the Dreyfus brothers model.Conclusions: Given the importance of competency-based education at a global level and the need to review curricula and competency-based curriculum design, it is required to provide competency development as well as meta-model to be the basis for curriculum development. As there are a variety of competency development models available, in this study, it was tried to develop the curriculum using them.Keywords: Meta-ethnography, Competency development, Meta-model, Qualitative synthesis

CYP2C19 polymorphisms affect clopidogrel metabolism and clinical outcomes in patients undergoing percutaneous coronary intervention (PCI). The use of a point-of-care (POC) assay to routinely genotype patients immediately prior to PCI in a hospital cardiac catheterization lab has shown to be feasible

The recent increase of 'Health Technology Assessment' (HTA)-related activities in Iran has necessitated the clarification of policy-making process based on the HTA reports. This study aimed to develop a Decision Support System (DSS) in order to adopt evidence-informed policies regarding health technologies in Iran. The study can be classified as Health Policy and Systems Research. A core panel of seven experts conducted two separate reviews of relevant literature for: 1- Determining the potential technology-related policies. 2- Listing the criteria influencing those policy decisions. The policies and criteria were separately discussed and subsequently rated for appropriateness and necessity during two expert meetings in 2013. In the next step, The 'Discrete Choice Experiment' (DCE) method was employed to develop the DSS for the final technology-related policies. Accordingly, the core panel members independently rated the appropriateness of each policy for 30 virtual technologies based on the random values assigned to all the criteria for each technology. The obtained data for each policy were separately analysed using stepwise regression model, resulting in a minimal set of independent and statistically significant criteria contributing in the experts' judgments about the appropriateness of that policy. The obtained regression coefficients were used as the relative weights of the different levels of the final criteria of any policy statement, shaping the decision support scoring tool for each policy. The study has outlined 64 policy decisions under 7 macro policy areas concerning a health technology. Also, 34 criteria used for making those policy decisions have been organized within a portfolio. DCE, using stepwise regression, resulted in 64 scoring tools shaping the DSS for all HTA-related policies. Both the results and methodology of the study may serve as a guide for policy makers (researchers), particularly in low and middle income countries, in developing decision aids for their own context-specific HTA-related policies.

Context: Most of the studies proved that effective self-care of patients depends on continuing systematic support of patients to improve their knowledge, skills, and confidence of self-care. With regard to the importance of self-care support system, the design of a pattern for it in Iran was placed on the agenda through the ministry of health and medical education (MOHME) project. The aim of this article is to develop a pattern through two steps; the first is critically analyzing the literature on the structure and functions of self-care support system, and the second is to summarize potential factors which can be used as self-care support system components in health system to synthesize the pattern. Evidence Acquisition: Systematic literature searches of papers published between 2002 - 2014 were carried out using the electronic databases. Critical interpretive synthesis (CIS) was then undertaken to provide a comprehensive overview of the topic for developing the national pattern. Finally, scrutinizing the pattern was done through focus group discussion of experts in MOHME. Results: We found the steps of designing a system for self-care support. Then, we set the goals and strategies of self-care support program and factors affecting the choice of self-care support pattern. Then, series of interventions were selected as self-care program pattern by a team of health care providers from all levels of the health system. Components of self-care support system in the country based on their interactions with patients and place of the program in the health care system were categorized in a matrix. Conclusions: To empower the staff of self-care support system, an appropriate training design is needed beside a good self-care support program. Self-care team members must teach specific information or skills to patients and their families. These members must possess special knowledge and skills. Also, the evaluation of self-care support program is one of the main components of the national system of self-care.

Background and Purpose: The literature review over the past few decades is a reflection of a global specific move towards the competency and evaluation of outcomes based education and the importance of this type of education is to the extent that Harden introduced "competency-based education" through a focus on outcomes and competencies as the most important trend in the medical education in the past decade. Due to the particular importance of competency-based education and the need to review the competency -based curriculum to be based on the competencies, the need to review the design of the curriculum is completely evident. But a question arises here that "Is there a comprehensive model that can be drawn for the development of competency in order to design new curriculum based on it?"In this study, we have tried to develop models to assess and synthesize existing development models, achieve to design a comprehensive meta-model for competency development.Methods: Meta-ethnography is a useful method for the synthesis of qualitative researches which is used in order to develop models that interpret findings in several studies. Considering that the aim of this study was finally to provide a meta-model of competency development, in the first step of meta-ethnography, first three steps and also a criticism was conducted on the available competency development models, for this purpose, literature review was also done to achieve competency development models. The models obtained by search were studied precisely and the models were presented based on first hand description of the by the developer(s), then offering critiques were extracted from the literature and the critical of researcher was finally provided.Results: After determination of the research question and characterization of synthesis focus, inclusion criteria and quality assessment of search were conducted and eight competency development models were selected and a precise investigation has been done on each.Conclusions: Considering the importance of competency-based training at the global level and the urgent need to review the existing curriculum and competency-based curriculum design, the analyzed models can provide the basis for synthesis of a meta-model for competency development and curriculum. Keywords: meta-ethnography, competency development, meta-model, qualitative synthesis

Background and Purpose: "Office-based" course in General Medical Curriculum of Shahid Beheshti School of medicine (the reform program) is a four-month course that is presented in the last six months of the program for interns. Office is a major practice setting after graduation for general practitioner in Iran and for this purpose physicians' offices in health care centers have been selected. Purpose of the course is to prepare interns to work independently and they have passed all their courses and had adequate knowledge to practice but they had not enough experience of office-based practice in the community and outpatient settings. This study was designed and implemented aimed to determine the program’s weaknesses and strengths in the range of the course stakeholders ‘questions (5 major questions), and provide proposed solutions to policy-makers in order to improve and promote the program of "office- based education internship" of Shahid Beheshti School of Medicine.Methods: The assessment was conducted in 3 descriptive study and the population under study included 44 interns and 36 physician mentor in 36 health care centers which were all centers under office based education plan in Shahid Beheshti medical school from October till December of 2014.The instruments used for data collection were questionnaires (mentor physician and intern students) and a check list made by the researcher. Mentor physician questionnaire contained 23 items, student questionnaire contained 20 items and documentations review check list and evidence included contained 30 items. Twenty items were on a 4-point Likert-type (weak, less than expected, as expected as and higher than expected), 14 items on a 3-point Likert-type (none, partially, totally), 33 items on two-choice question (Yes/No) and 6 as an open question. All items had the same value. Face and content validity were checked by Scientific Committee and evaluations of Shahid Beheshti University of Medical Sciences.For checking educational achievement, a student self-assessment and mentor assessment were performed in 3status, at the beginning of the course, after 2 months and after 4 months.Results: The gap between design and implementation was at least 14.1%. More than 75% of mentors had desirable conditions in terms of scientific, educational and professional competencies from the perspective of students but mentor physicians' abilities in basic skills of practice was lower compared with educational and professional abilities. Students’ skills at the beginning of the first two months of office-based course internship was lower than expected in all areas and at the end of the 4-month course learning reached 95% to 100%. Per capita, variety and number of patients referring to teach students (90.6% of the centers) were sufficient. 66.7% of mentor physicians were interested in working as a general physician and 42.7% were interested in teaching students. 52.8% of mentor physicians did not receive any fee and 100% of the recipients were not satisfied with the amount of the fee. In 81.2% of health care centers, work and training space was appropriate and there were some difficulties about equipment.Conclusions: The results of this study showed that health centers are appropriate educational setting for general medical students' office-based course and effective on promoting their essential skills of practice. Although educational and professional competencies of about 75% of mentors was desirable but the necessity of considering mentors' training, becoming more familiar with the goals and standards of the program, as well as the promotion of knowledge at the same time with considering financial motives and job promotion can play an important role in presenting this program. The need to pay attention to provide basic facilities in the centers, as well as continuous and periodic evaluation are other recommendations of the study.Keywords: EVALUATION, OFFICE-BASED COURSE

Background and Purpose: Educational development center (EDC) at Shahid Beheshti University of Medical Sciences began general medical degree program reform from early 2000 and it was implemented since October 2004 with the admission of the first group of medical students. The study objective is to investigate faculty members and medical students' viewpoints on the achievement of the objectives of the reform of general medical degree program at the level of basic sciences.Methods: The study is cross-sectional and its field is "Medical Education". Studied population is all faculty members employed to teach and medical students in the fourth and fifth semesters in pre-clinical phase. Sampling method was census and data collection tools were two researcher-made questionnaires. Data analysis was performed using SPSS software.Results: The overall average response to the questionnaire questions was 2.98 for students (n=116, SD=0.646) and for faculty members was 3.36 (n=31; SD=0.551). 84 students (72.4%) and 21 faculty members (67.7%) announced the achievement of the objectives of the program. No correlation is observed between the response of faculty members and students (Spearman's Coefficient=0.1, P=0.873). In student-centered strategies (Spearman's Coefficient=0.975, P=0.005) and electives (Spearman's Coefficient=0.943, P=0.005) there is a correlation between students in the fourth and fifth semesters.Conclusions: Insufficient number of similar previous studies and lack of faculty members' willingness to participate in the study make it difficult to generalize the results to other departments. However, as the first study, the results of this study can be effective on future revisions of the program.Keywords: EDUCATIONAL PROGRAM, REFORMS, PHASE OF BASIC MEDICAL SCIENCES, FACULTY MEMBERS, MEDICAL STUDENTS

Background/Objectives: Professional ethics in teaching is an abstract and obscure concept. Analyzing this concept is key to reach a common sense, setting behavioral standards and preparation of measures of evaluation. Methods/Statistical Analysis: This study was a qualitative research and the concept of professional ethics in teaching analyzed using Walker and Avant method. Review of literature was done to carry out the eight stages of concept analysis. The sample was 38 studies and the saturation was reached by 21 of them. Findings: The results showed professional ethics in teaching is form in deference to professional obligations and has four constituting elements consist of professional etiquette, intrapersonal professional values and beliefs, professional-exclusive social behavior and, professional encountering with technical issues and problems. Forming this concept needs ethical competencies including ethical sensitivity, ethical knowledge, ethical reasoning and ethical self-regulation. Applications/Improvements: Identification of these elements and attributes contributes to optimization of teaching professional ethics as a necessity for high quality assurance of professional performance of teachers and designing its evaluation measures.

We assessed the effect of a transcatheter aortic valve replacement (TAVR) program and Heart Team concept on our approach to severe isolated symptomatic aortic stenosis (AS) with regard to surgical practice, patient selection, perioperative outcomes, 1-year survival, and AVR volume. TAVR program began in August 2011. Patients having isolated surgical AVR between January 2008 and August 2011, when the program began (n = 282, 42 months), were compared with those after the program began until February 2015 (n = 344, surgical AVR and n = 126, TAVR, 42 months). Isolated surgical AVR accounted for 21% of all valve procedures (isolated and concomitant) before and after the TAVR program. However, the volume of all isolated AVR (surgical and transcatheter) increased to 27% of all valve procedures (isolated and concomitant) after the TAVR program implementation. Mean Society Of Thoracic Surgeons (STS)-predicted mortality risk was similar among patients who had surgical AVR pre-TAVR and post-TAVR implementation (2.3% vs 2.1%, P = 0.227), but addition of patients who had TAVR (STS risk = 7.1%) increased STS-predicted risk for all isolated AVR (surgical and transcatheter) procedures (2.3% vs 3.4%, P < 0.001). A similar trend was found for age, including a slight decrease in octogenarians for surgical AVR post-TAVR (18% vs 13%, P = 0.084). Operative mortality for isolated surgical AVR was similar in pre-TAVR and post-TAVR (2.1% vs 1.8%, P = 0.798), as were observed/expected (O/E) ratios (0.91 vs 0.82). For all isolated AVR, O/E ratio was 0.91 pre-TAVR and 0.82 post-TAVR (n = 470), including O/E = 0.79 for patients who had TAVR. No changes were found in proportion of isolated surgical AVR cases or patient risk and outcomes after introduction of TAVR program and Heart Team. However, volume of patients with severe AS treated increased significantly post-TAVR. Our results reflect growing awareness of TAVR availability and accompanying increases in patients referred to our Heart Team for AS treatment.

Root canal therapy (RCT) and tooth extraction have been conventional treatment options for management of human mature teeth with irreversible pulpitis. Excellent short-term treatment outcomes of vital pulp therapy with calcium-enriched mixture cement (VPT/CEM), as a new treatment option, on postoperative pain relief was demonstrated; if intermediate- and long-term treatment outcomes of the new treatment are also non-inferior compared to RCT, then VPT/CEM may become a viable treatment option for management of mature teeth with irreversible pulpitis.In 23 healthcare centers, 407 9- to 65-year-old patients were randomly allocated into two study arms including one-visit RCT (reference treatment; n = 202) and VPT/CEM (alternative treatment; n = 205). Six- and twelve-month clinical and radiographic successes were assessed.Mean follow-up times at 6- and 12-month follow-ups were "6.70 ± 0.68 and 6.72 ± 0.71 months" and "12.96 ± 0.67 and 12.90 ± 0.66 months" in the available cases of RCT and VPT/CEM arms, respectively. Favorable clinical success rates in the two study arms did not show statistical difference; however, the radiographic success rate in the VPT/CEM was significantly greater than RCT arm at the two follow-ups (P0.001). The patients' age had no effect on the treatment outcomes (P = 0.231).Treatment outcomes of VPT/CEM may be superior to RCT in mature molars with irreversible pulpitis. The performance of biomaterials such CEM cement may assist in the shift towards more biologic treatments.VPT/CEM may be a realistic alternative treatment for human mature molar teeth with symptoms of irreversible pulpitis; the use of VPT/CEM is highly beneficial for patients as well as general dentists.

Background Despite the significant role “values” play in decision-making no definition or attributes regarding the concept have been provided in health policy-making. This study aimed to clarify the defining attributes of a concept of value and its irrelevant structures in health policy-making. We anticipate our findings will help reduce the semantic ambiguities associated with the use of “values” and other concepts such as principles, criteria, attitudes, and beliefs. Methods An extensive search of literature was carried out using electronic data base and library. The overall search strategy yielded about 1540 articles and 450 additional records. Based on traditional qualitative research, studies were purposefully selected and the coding of articles continued until data saturation was reached. Accordingly, 31 articles, 2 books, and 5 other documents were selected for the review. We applied Walker and Avant’s method of concept analysis in studying the phenomenon. Definitions, applications, attributes, antecedents, and consequences of the concept of “value in health policy-making” were extracted. We also identified similarities and differences that exist between and within them. Results We identified eight major attributes of “value in health policy-making”: ideological origin, affect one’s choices, more resistant to change over time, source of motivation, ability to sacrifice one’s interest, goal-oriented nature for community, trans-situational and subjectivity. Other features pinpointed include alternatives, antecedents, and consequences. Alternative, antecedents and consequences case may have more or fewer attributes or may lack one of these attributes and at the same time have other distinctive ones. Conclusion Despite the use of the value framework, ambiguities still persist in providing definition of the concept value in health policy-making. Understanding the concept of value in health policy-making may provide extra theoretical support to decision-makers in their policy-making process, to help avoid poor policy formulation and wastage of limited resources.

Objective: This study assessed the relative risk factors for osteoporosis in women referring to the Bone Densitometry Center during 2007, with the aim of designing a formula to estimate the severity of osteoporosis.Subjects andMethods: Data of outpatients (n = 1,047) who visited the Bone Densitometry Center of Chamran Hospital were gathered by administering a questionnaire to subjects before a dual-energy X-ray absorptiometry (DXA) densitometry test of the hip and vertebrae. Results: Of the 1,047 subjects, 764 (73%) were menopausal. The average (± SD) age and weight were 54.5 ± 10.3 and 69.5 ± 10.8, respectively. The average (± SD) T score of hip and lumbar spine were –1.88 ± 1.08 and –1.04 ± 1.05, respectively. After assessment, the precipitating factors of osteoporosis of the hip were age, menopause, duration of menopause, history of fracture, history and dosage of calcium supplementation, parity and duration of breastfeeding. Protective factors were weight, history of oral contraceptive pill consumption, and exercise, being significant (p < 0.05). Precipitating factors in osteoporosis of vertebrae were age, menopause and duration of menopause, diabetes, history of fracture, history and dosage of calcium supplementation, parity and duration of breastfeeding, with weight as a protective factor (p = Conclusion: Using the mathematical model, along with clinical findings and history, persons at risk of osteoporosis may be identified and early prevention and treatment made possible. Unnecessary expenses of diagnostic procedures for people without the risks of osteoporosis can also be prevented.

Although FDA recommended pharmacogenetic testing and alternative antiplatelet agents in CYP2C19 loss-of-function(LoF) allele carriers in patients treated with clopidogrel, implementation in practice has been minimal. Appropriate P2Y12 receptor antagonist therapy following PCI based on bedside

Objective:A longitudinal pediatric palliative care curriculum was introduced into the pediatric residency program at the University of California, Los Angeles. The present study explores the possible effects of this curriculum on the interns' self-assessed comfort levels regarding caring for children with life-threatening conditions.Methods:A newly created assessment tool was administered to interns in order to rate their comfort regarding pediatric palliative care at the beginning and conclusion of their intern year.Results:Twenty-two of the 29 interns completed this survey. Baseline data indicated 55% of the interns had some experience with taking care of a dying pediatric patient during their medical school training, and 79% indicated that they had taken care of a dying adult. Only 7% of the interns felt adequately prepared to deal with death and dying, but all interns indicated interest in further learning about pediatric palliative care. Comparison of the overall comfort levels of the 22 responding residents before and after the first year of training in 20 different related tasks demonstrated a significant self-assessed improvement of comfort in seven areas. There was no increase in self-reported comfort in communication related to palliative care.Significance of results:Residents indicated increased comfort in some areas of pediatric palliative care after the first year of their training. The underlying cause of this increased comfort is unclear at this time. The overall effect of longitudinal palliative care curriculums on residents' level of comfort in caring for this population deserves further assessment.

BACKGROUND: Few studies exist on the ability of standardized preprinted order forms to improve patient care. OBJECTIVE: To examine resident-perceived effects of introducing a pediatric admission order set (PAOS) on the quality of inpatient care. DESIGN: Cross-sectional study. SETTING: University of California, Los Angeles (UCLA) Children's Hospital, a nonprofit, tertiary-care teaching hospital and major referral center with approximately 3,000 admissions per year. PARTICIPANTS: A total of 97 pediatric residents (PL-1, n = 34; PL-2, n = 33; and PL-3, n = 30) who did the vast majority of the inpatient admissions. MEASUREMENTS: Residents were asked to rate the PAOS overall and with respect to 9 specific dimensions using a 5-point Likert scale. RESULTS: Overall, 89% of respondents approved of the PAOS, 58% reported using it ≥90% of the time, and all said that they would recommend it to their colleagues. Eighty-four percent thought that it improved inpatient care, and 75% thought that medical errors were reduced. Eighty-eight percent reported that the PAOS saved time; 93% said it was convenient; and most reported less need for clarification with secretaries (81%) and nurses (82%). In multivariate regression analyses, the only predictor of overall rating was whether the PAOS improved inpatient care (P = 0.04). Improved patient care, meanwhile, was predicted by whether the PAOS was comprehensive (P = 0.01), reduced medical errors (P = 0.01), and required less clarification with nurses (P = 0.01). CONCLUSIONS: A standardized admission order set is a simple, low-cost intervention that residents believe may benefit patients by reducing medical errors and expediting high-quality care. Journal of Hospital Medicine 2009;4:90–96. © 2009 Society of Hospital Medicine.

The aim of this study was to show the interaction between the society, applicants and medical schools in terms of medical student selection. In this study, the trends to implement social factors in the selection process were highlighted. These social factors were explored through functionalism and conflict theories, each focusing on different categories of social factors. While functionalist theorists pay attention to diversity in the selection process, conflict theorists highlight the importance of socio-economic class. Although both theories believe in sorting, their different views are reflected in their sorting strategies. Both theories emphasize the importance of the person-society relationship in motivation to enter university. Furthermore, the impacts of social goals on the selection policies are derived from both theories. Theories in the sociology of education offer an approach to student selection that acknowledges and supports complexity, plurality of approaches and innovative means of selection. Medical student selection does not solely focus on the individual assessment and qualification, but it focuses on a social and collective process, which includes all the influences and interactions between the medical schools and the society. Sociological perspective of medical student selection proposes a model that envelops the individual and the society. In this model, the selection methods should meet the criteria of merit at the individual level, while the selection policies should aim at the society goals at the institutional level.

Background and purpose: Considering that health care training centers’ teachers are one of the main elements of human-force training for rural health care system in the country, it is essential to improve knowledge and skills. The purpose of this study was to explain educational needs of teachers in our country in Behvarz training centers.Methods: This is a qualitative and a needs assessment study and experts’ opinion method, experts’ group discussion and Delphi was used for data extraction and the study was conducted during the years 2012-2013 by two methods: direct and indirect needs assessment. Needs related to learning were determined using experts’ opinion method after holding two sessions of experts’ group discussion (two groups of ten top country teachers and a group of five top experts responsible for health providing) and two rounds of Delphi (a group of 12 Behvarz experts) and a round of ranking. The first round of Delphi questionnaire was designed with 77 closed questions and 3 essay questions in 5 categories based on Behvarz educational textbooks and the results of experts' group discussion sessions and were sent to the participants. Based on the results of the first round, the second round of Delphi questionnaire consisted of 84 closed questions and 3 open-ended questions was designed and resent. In third stage, a questionnaire of 68 items was sent to the experts to determine the priorities of educational needs. Data were analyzed using SPSS-18 statistical software.Results: The findings indicate that each teacher needs general and special education issues (teaching, management, research method, personal development skills). Educational needs of first aid and relief efforts (of nursing) were determined for all teachers with different specialties and only English language skill was not determined necessary.Conclusions: The results indicate that the educational needs are common in some cases for all teachers and in some cases differ in terms of study field and teaching area and due to changes in the current health package; educational needs are changing and require needs assessment and teachers’ ongoing retraining.Keywords: EDUCATIONAL NEEDS ASSESSMENT, INSTRUCTOR, BEHVARZ EDUCATION CENTERS, HEALTH CARE SERVICE SYSTEM

Background and purpose: Today, according to busy doctors, one of the ways to keep their medical information up to date is the use of evidence-based medicine (EBM). The purpose of this study was to determine the educational needs of EBM in clinical faculty members working in Shahid Beheshti University Hospitals in Tehran and the prioritization of these needs.Methods: The study was descriptive, cross-sectional for 320 doctors working in four hospitals of Shahid Beheshti University in Tehran in 1390. A researcher-made questionnaire was used to collect data that its reliability was obtained 0.95 by calculating the Cronbach’s alpha coefficient. The data were analyzed using SPSS software.Results: From 140 distributed questionnaires, 133 questionnaires (93.3 %) were completed. The results showed that 65.4 % of the subjects were male and 34.6 % were female. The academic status of 55.6% of them was assistant professor and their average age was 47 years and their work experience average was 12.8 years. 41.6% of the target population was familiar with electronic information resources and 19.4 % were familiar with EBM concepts and terminology and 90.6% had a positive attitude towards EBM.Conclusions: The results showed that although the subjects had positive attitude towards EBM, but their knowledge and use of EBM is low, also the greatest barriers in effective implementation is the lack of evidence-based approach infrastructure and lack of time, therefore, it is recommended to develop a training package to enhance awareness and encourage the use of EBM by clinical faculty members. Keywords: education, clinical faculty members, needs assessment, prioritization and evidence-based medicine

Morning report sessions had long-standing history in medical education. Morning report management isan important aspect of professional medical education.To evaluate the contents of the morning report sessions, including management, staff training, deeplearning, attention to learners at different level of education, record keeping, feedback, and finalsummarizing, direct observation of 73 sessions was conducted in five teaching hospitals in a medicaluniversity in Tehran.The following scores were obtained: morning report management (91%), training faculty members(9%), residents' training (4%), direct learning by patient management instead of memorizing studymaterial (88%), paying attention to the different educational levels of learners (28%), record keeping(36%), systematic feedback (48%), and a final summarizing session (26%).Out of eight, five dimensions related to teaching in the morning report sessions need improvisation,specifically on the training of faculty members and residents, paying attention to different educationallevels of learners, brief summary of all sessions, and record keeping.Keywords: MEDICAL EDUCATION,MORNING REPORT, LEARNING, FEEDBACK

Background Overtreatment (or unnecessary treatment) is when medical or dental services are provided with a higher volume or cost than is appropriate. This study aimed to investigate how a group of dentists in Switzerland, a wealthy country known to have high standards of healthcare including dentistry, evaluated the meaning of unnecessary treatments from an ethical perspective and, assessed the expected frequency of different possible behaviors among their peers. Methods A vignette describing a situation that is susceptible for overtreatment of a patient was presented to a group of dentists. The vignette was followed by five options. A questionnaire including the vignette was posted to 2482 dentists in the German-speaking areas of Switzerland. The respondents were asked to rate each option according to their estimation about its prevalence and their judgment about the degree to which the behavior is ethically sound. Results 732 completed questionnaires were returned. According to the responses, the most ethical and the most unethical options are considered to be the most and the least prevalent behaviors among dentists practicing in Switzerland, respectively. Conclusions Suggesting unnecessary treatments to patients seems to be an ethically unacceptable conduct in the eyes of a sample of dentists in Switzerland. Although the respondents believed their colleagues were very likely to behave in an ethical way in response to a situation that is susceptible to overtreatment, they still seemed to be concerned about the prevalence of unethical behaviors in this regard.

Background and purpose: Partial knowledge is one of the main factors to be considered when dealing with the improvement of the administration of Multiple Choice Questions (MCQ) in testing. Various strategies have been proposed for this factor in the traditional testing environment. Therefore, this study proposed a Confidence Based Assessment (CBA) as a pertinent solution and aims at comparing the effect of the CBA Scoring system with that of the conventional scoring systems (with and without negative score estimation as penalty) on the students’ scores and estimating their partial knowledge on clinical studies.Methods: This comparative study was conducted using a standardized clinical knowledge exam for 117 clinical students. After two-step training, both the conventional MCQ and CBA examination was given in a single session simultaneously. The exam included 100 questions and the volunteers were requested to complete a questionnaire regarding their attitude and satisfaction on their first experience of the CBA after exam. A new confidence based marking system was selected for the scoring, which was a hybrid of the UCL and MUK2010 systems. The MCQ-Assistant, SPSS and Microsoft office Excel software were used for scoring and data analysis.Results: The mean age of the volunteers was 27.3±5.47, of whom 43.6% were men and 69.2% were senior medical students. Exam reliability was 0.977. The fit line of the MCQ scores without penalty estimation was R2=0.9816 and Intercept=18.125 or approximately.2 deviation in the low scores. The MCQ scoring with penalty had a fit line approximately parallel to the 45-degree line but on or above it and the CBA scoring fit line was nearer to the 45-degree line, parallel to it and a little below it. These two sets of scores had a significant p value0.037. The response percentage to the CBA is higher (p value=0.0001). The discrimination power of the MCQ and the CBA for the upper and lower 1/3 of the students was not significantly different (p value=0.34). The students’ satisfaction score was high and acceptable to the CBA system and expressed a positive perspective on this system for their examinations.Conclusions: The CBA method can increase the competencies of the MCQ exams. It was found to have a greater fairness assessment, was an effective examination, an authentic testing method, with precise estimation and higher constructs validity than the conventional MCQ exam. The CBA simulate the reflection for deeper learning among the students. Keywords: STUDENT ASSESSMENT, PARTIAL KNOWLEDGE, MCQ, CONFIDENCE-BASED ASSESSMENT, EXAM SCORING SYSTEM

BACKGROUND: Falls and related injuries are common health problems in the elderly. Fractures, brain and internal organ injuries and death are the common consequences of the falls, which result in dependence, decreased self-efficacy, fear of falling, depression, restricted daily activities, hospitalization and admission to the nursing home and impose costs on the individual and the society. OBJECTIVES: The purpose of this study was to determine the types of fall-related injuries and the related risk factors in the elderly population of Qom province, Iran. PATIENTS AND METHODS: This retrospective study was performed on 424 elderly people (65 years and over) referred to Shahid Beheshti Hospital, Qom, Iran, due to falls between 2010 and 2012. The ICD-10 codes of external causes of injury from w00 to w19 related to falls were selected from the health information system of the hospital and demographic variables of the patients and external causes of falls were extracted after accessing the files of the patients. Data were analyzed using SPSS version 18 (SPSS Inc., USA). The duration of hospital stay and its relationship with underlying variables were investigated using t test and ANOVA. The level of significance was considered P RESULTS: Among 424 elderly people, 180 cases (42.45%) were male and the mean age of the patients was 78.65 ± 7.70 years. Fall on the same level from slipping, tripping, and stumbling was the most common external cause with 291 victims (68.60%), and hip fracture in 121 patients (29.00%), intertrochanteric fracture in 112 patients (26.90%), and traumatic brain injury in 51 patients (12.20%) were the most common causes of hospital stay. The mean hospital stay was 7.33 ± 3.63 days. CONCLUSIONS: Lower limb fracture and traumatic brain injury were the most common causes of hospitalization, which resulted in the longest hospital stay and highest hospitalization costs in the elderly. Language: en

An 8-year-old white male was referred to our clinic for a 1-year history of decreased appetite and no weight gain. His entire workup failed to demonstrate cystic fibrosis, or any infectious or immune-related diseases. Chest imaging and clinical picture suggested parenchymal lung disease. Histopathology examination of the video-assisted thoracoscopic biopsy of his lungs showed a desquamative interstitial pneumonia (DIP)-like pattern that resembled that of adult smokers with the same disease. Genes for surfactant proteins B and C and the transporter ABCA3 were all negative. Furthermore, lack of any genetic disorder for surfactant proteins, along with his history of heavy exposure to 10 pack-years of indoor secondhand smoke suggests that this child's DIP is due to secondhand cigarette exposure. He had nearly complete resolution of his symptoms after a year of treatments with pulse steroid and hydroxycholoroquine. To the best of our knowledge this is the first case of cigarette smoke-related DIP reported in a child.

Clinical skill centers were designed in 1960, offers innovative, more effective clinical health care and treatment curriculum. Clinical skill center (CSC) can provide a special facility for clinical and communication skills practice in a setting outside hospital wards in order to train students with enough confidence of confronting real patients. Learning clinical skills in these centers are not patient-dependent and by practicing on manikins and simulated models errors in real patients can be prevented. Moreover, possible feedback of this method can be used for evaluation and can improve quality and quantity of the education. This review intends to determine the purpose, undertaking, and structure of CSC. The study emphasizes the importance of integrating the clinical skill centers into the teaching curriculum of medical universities. Apparently, organizing clinical skill centers can play an important role for improving the quality and quantity of the educational system and consequently post-graduate performance. The authors recommend this program can be a solution for having both the knowledge and skill of diagnosis and treatment seasonal and rare diseases. Key words clinical skill center, medical education, curriculum

SUMMARY Chronic pain in children is a poorly recognized entity that is challenging to treat and leaves many families frustrated. Often, lack of an identifiable etiology along with the complex biopsychosocial nature of this condition leads to a lengthy diagnostic odyssey and delayed treatment that exacerbates the existing problem. Effective treatment of chronic pain requires a team approach in order to deal with the various aspects of this condition. Combinations of medication along with nonpharmacologic treatments, such as physical therapy, psychological interventions and complementary therapies, are often the most effective ways of treating chronic pain rather than medication alone. Further research is needed to understand the complex biobehavioral processes involved in the development and maintenance of chronic pain. Development of targeted novel therapies as well as comparative studies of existing treatments will help to improve treatment for chronic pain in children.

The term 'authentic assessment' has recently gained widespread use in education. A five-dimensional questionnaire for authentic assessment was translated into Farsi. The questionnaire which comprises 29 items, divided into 5 subscales (task, physical context, social context, result/form and criteria) was developed in English by Dr. Gulikers and her colleagues in the Netherlands. The questionnaire was translated using a forward-backward method and was pilot tested in terms of translation clarity and applicability. The psychometric properties of the Persian version of the questionnaire were evaluated in terms of face, content, and construct validity in addition to test-retest reliability. A convenience sample of 230 dental students (70 males and 160 females) studying in four dental schools in Tehran city was recruited to evaluate the reliability and construct validity of the Persian version. The quality rating of the translations was favorable, suggesting a high quality of both forward and backward translations. The Content Validity Index (CVI) and Ratio (CVR) for the final Farsi version of the questionnaire were found to be acceptable. Cronbach alpha coefficients for all subscales ranged from 0.78-0.91. These preliminary results suggest that a five dimensional questionnaire in its Farsi version may be a valuable tool in dental education assessment and studies.

This study was designed in order to generate a priority list of dentistperceived important ethical issues in dental practice in Iran. A two-stage modified nominal group study was conducted. At first, the main ques tion of the study was presented to 24 dental specialists through direct interview (16) or e-mail (8, response rate was 75%). After analyzing the interview transcripts and email responses, a list of issues was extracted. The list was presented to a nominal group of 10 dental specialists to prioritize ethical issues according to their frequency and ethical signifi cance. Each participant selected and ranked the five most important is sues and then, the sum of ranks for each issue was calculated. The first stage of the study resulted in a list of 26 ethical issues. After grouping and combining related items, the list was condensed into 18 issues. The nominal group session resulted in a prioritised list. The first six issues of the list included: performing procedures without adequate competency, not taking responsibility for one’s errors, over-treatment (or unnecessary treatment), inappropriate manners towards patients, unprofessional discussion of a colleague’s work, and unprincipled behaviors towards disadvantaged patients. Conclusions: The results suggest that the problems occurring in the therapeutic relationship between dentists and their patients are the major ethical issues of dentistry in Iran. Issues such as respecting patient’s autonomy, confidentiality, taking informed consent, third-party issues, and dentists’ duties toward society don’t seem to be considered of high priority by dentists in Iran as a developing country.

Background: T-lymphocytes are present in significant numbers in the atherosclerotic plaque, but their role in the progression and pathogenesis of coronary syndromes remains poorly understood. Hypothesis: We sought to determine the relationship between T-lymphocyte activation and ischemic heart disease by measuring plasma levels of cytokines related to T-lymphocyte function in patients with stable and unstable angina. Methods: Plasma levels of interleukin-2 (IL-2) and soluble IL-2 receptor (sIL-2R) were measured in 105 patients: 66 with stable angina, 24 with unstable angina, and 15 healthy controls. Patients who presented to the cardiac catheterization laboratory with unstable or stable anginal syndromes for coronary angiography or percutaneous coronary intervention enrolled in the study. Results: Mean levels of IL-2 were significantly higher in patients with stable angina than in those with unstable angina. The differences between stable angina and control groups, or between unstable angina and control groups, were not statistically significant. Mean levels of sIL-2R were significantly higher in patients with stable angina than in either patients with unstable angina or control patients. Conclusions: Levels of IL-2 and sIL-2 receptor are significantly elevated in patients with stable angina, but not in patients with unstable angina. The contribution of T-lymphocytes to the development of both stable and unstable angina requires further investigation.

In this study, we assess the strengths, challenges and opportunities regarding the oral health system stewardship in Iran.A mixed methodology was used, comprised of a quantitative questionnaire using the functional standards, semi structured interviews with key stakeholders and document review. The level of current attainments of each standard was determined based on a Likert-type scale. Literature review was completed to find official documents of national organizations.The responsibility of policy development of oral health care at the national level mostly falls on the Oral Health Bureau. This office has formulated a strategic plan for its policy-making and has considered the required capacity to implement them. However, the Bureau has some problems in enforcing its regulatory framework, especially in the private sector. There are rigorous problems in managing information and using them for evidence-based decision making. Setting and allocation of operational budgets for implementing the policies is only partially attained, as is monitoring and evaluating the performance.While the Ministry of Health and Medical Education has achieved some stewardship measures, it still needs further improvements in the oral health system. It needs to strengthen its information system and its executive capacity to implement the proposed regulations. The Ministry must improve accountability in the oral health system, especially the provider accountability.

Background: Multiple studies support a role for inflammation in the pathogenesis of coronary atherosclerosis and unstable cardiac syndromes. However, of the known proinflammatory cytokines, only elevated plasma levels of interleukin-6 have been linked to unstable angina. We sought to examine the plasma levels of other major proinflammatory cytokines in similar clinical settings and to determine the extent of the relationship between inflammation and unstable coronary syndromes by measuring the levels of various proinflammatory cytokines in patients with stable and unstable angina.

Platelet-derived growth factor (PDGF) stimulates smooth muscle cell (SMC) migration owing to stimulation of SMC tissue plasminogen activator (t-PA) production. In this study we examined the effects of the T-cell lymphokine interleukin-4 (IL-4) on PDGF induction of human aortic SMC antigen levels of urokinase-type plasminogen activator (u-PA) and those of plasminogen activator inhibitor-1 (PAI-1), the endogenous inhibitor of t-PA and u-PA, measured by enzyme-linked immunosorbent assays (ELISAs). u-PA antigen levels from human aortic SMC incubated with PDGF 100 ng/mL and IL-4 500 U/mL were significantly greater than those incubated with PDGF 100 ng/mL alone. Coincubation of PDGF with IL-4 did not significantly increase SMC u-PA antigen levels in cellular lysates. Coincubation with PDGF 100 ng/mL and IL-4 500 U/mL did not significantly affect SMC PAI-1 antigen levels in conditioned media or cellular lysates. Therefore, interleukin-4 modulates vascular SMC u-PA production induced by PDGF.

Objectives. The objectives of this study were to define the hemostatic profiles of patients with unstable angina compared with patients with stable angina and to investigate the effect of percutaneous interventions on the follow-up hemostatic profiles of these patients. Background. Disturbances in hemostatic factors have been shown to be present in various clinical syndromes involving coronary artery disease. However, their role in stable angina versus unstable angina is less well defined. Methods. We studied 61 patients with either stable or unstable angina undergoing percutaneous coronary interventions. Blood samples were drawn immediately before the intervention and at 1-month follow-up. Plasma levels of tissue-type plasminogen activator (t-PA), plasminogen activator inhibitor-1 (PAI-1) and von Willebrand factor (vWF) were measured by enzyme-linked immunosorbent assays. Results. Patients with unstable angina had significantly higher t-PA levels (mean [±SE] 23.7 ± 3.4 vs. 14.3 ± 1.4 ng/ml, respectively, p = 0.02) and vWF antigen concentrations (2,231 ± 157 vs. 1,792 ± 108 mU/ml, respectively, p = 0.03) than patients with stable angina. No statistically significant differences were observed in the PAI-1 levels between the two groups (27.9 ± 5.5 vs. 21.4 ± 2.5 ng/ml, respectively, p = 0.25). At 1-month follow-up, there were no longer any significant differences in the t-PA or vWF levels between the two groups (15.7 ± 1.2 vs. 13.6 ± 0.6 ng/ml, p = 0.13; 1,962 ± 170 vs. 1,809 ± 88 mU/ml, p = 0.39, respectively). There were no significant differences between the hemostatic profiles of patients undergoing percutaneous transluminal coronary angioplasty or coronary stenting initially and at 1-month follow-up. Conclusions. These data suggest that elevated plasma levels of t-PA and vWF may correlate with instability of atheromatous plaques, and that their decrease after coronary interventions may reflect plaque reendothelialization and stabilization.