Evaluation of the performance of general practitioners in a collaborative care program by employing simulated patients.

OBJECTIVE: To compare the performance of the general practitioners (GPs) in a collaborative care (CC) program in Iran with a control group of GPs in the usual care by employing simulated patients. METHODS: Six trained simulated patients (SPs) made unannounced visits to 26 GP offices participating in the CC program and to 26 age and sex matched controls. The SPs role played five clinical scenarios of mental disorders and filled out checklists to evaluate the GPs' performance regarding interviewing, taking history, establishing rapport, showing empathy, and giving advice to patients. Additionally, the GPs' plan of care and prescriptions were evaluated later by a psychiatrist based on the documents provided by the SPs. RESULTS: There was a significant difference between collaborative care and control group physicians in their global performance; CC physicians built up better patient-physician relationship. They performed better in evaluating a psychotic patient, although not better in their management. CC physicians were marginally better in approach to patients with generalized anxiety disorder (GAD) and mild major depressive disorder. CONCLUSION: The overall performance of physicians in CC was better than the GPs in the control group in making an effective patient-physician relationship, and evaluating a psychotic patient. The main weakness of the GPs was in proper treatment of the minor and more common psychiatric disorders and in evaluation of patients with suicidal ideations who were in need for emergent referral. Evaluating performance of the practitioners is feasible employing SPs and the findings can be translated into improvements in the available services.

Minocycline combination therapy with fluvoxamine in moderate-to-severe obsessive-compulsive disorder: A placebo-controlled, double-blind, randomized trial.

AIM: Several lines of evidence implicate glutamatergic dysfunction in the pathophysiology of obsessive-compulsive disorder (OCD), presenting this neurotransmitter as a target for the development of novel pharmacotherapy. The objective of this study was to assess the efficacy of minocycline as an augmentative agent to fluvoxamine in the treatment of patients with OCD. METHODS: One hundred and two patients with the diagnosis of moderate-to-severe OCD were recruited to this study. A randomized double-blind trial was designed and patients received either L-carnosine or placebo as adjuvant to fluvoxamine for 10 weeks. The patients randomly received either minocycline 100 mg twice per day or placebo for 10 weeks. All patients received fluvoxamine (100 mg/day) for the first 4 weeks, followed by 200 mg/day for the rest of the trial, regardless of their treatment groups. Participants were evaluated using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). The main outcome measure was to assess the efficacy of minocycline in improving the OCD symptoms. RESULTS: General linear model repeated measures demonstrated significant effect for time × treatment interaction on the Y-BOCS total scores, F(1.49, 137.93) = 7.1, P = 0.003, and Y-BOCS Obsession subscale score, F(1.54, 141.94) = 9.72, P = 0.001, and near significant effect for the Y-BOCS Compulsion subscale score, F(1.27, 117.47) = 2.92, P = 0.08. A significantly greater rate of partial and complete response was observed in the minocycline group (P < 0.001). The frequency of side-effects was not significantly different between the treatment arms. CONCLUSION: The results of this study suggest that minocycline could be a tolerable and effective adjuvant in the management of patients with OCD.

Comparing effects of ketamine and thiopental administration during electroconvulsive therapy in patients with major depressive disorder: a randomized, double-blind study.

OBJECTIVES: Recently, ketamine has attracted attention for induction of anesthesia during electroconvulsive therapy (ECT). This study compared the effects of thiopental and ketamine in patients undergoing this procedure. METHOD: This randomized, double-blind clinical trial included inpatients, with major depressive disorder, undergoing ECT. Subjects were randomly allocated to receive either ketamine or thiopental. Mini-Mental State Examination and Hamilton Depression Rating Scale were used to assess memory and depression, respectively, before the first and second ECT sessions as well as a few days and 1 month after the sixth session. The electrical charge, seizure duration, blood pressure, and heart rate were also recorded. RESULTS: Of the 31 patients, 17 met the criteria for the ketamine group but 2 dropped out of the study. Therefore, 15 patients received ketamine and 14 received thiopental. Each patient underwent 6 ECT sessions. At the end of the study, depression improved significantly in both groups. However, a significant difference in depression improvement was noted only before the second ECT with ketamine compared with thiopental. Despite a significant decline in Mini-Mental State Examination scores in both groups after the first ECT, cognitive function improved afterward but was only significant in ketamine group. Seizure duration was found to be significantly longer with ketamine. Stimulus intensity used for each ECT increased gradually and linearly with a greater increase observed in thiopental group. CONCLUSIONS: Ketamine administration during ECT is well tolerated and patients may experience earlier improvement in depressive symptoms, longer seizure duration, and better cognitive performance when compared with thiopental.

Comparing the effects of fluoxetine and imipramine on total cholesterol, triglyceride, and weight in patients with major depression.

BACKGROUND: There are some reports on the effects of antidepressants on metabolic syndrome. However, our search in the previously published literature showed a lack of information on the comparison of the effects of different classes of antidepressants on lipid profile. Therefore, this study was aimed to compare the effects of fluoxetine and imipramine on serum total cholesterol (TC) and triglyceride (TG) as well as body weight (BW) in patients with major depressive disorder. METHODS: Fifty one patients, 18 to 70 years of age, with major depressive disorder complied with the criteria of this preliminary, open-label clinical trial. Subjects received either imipramine (75-200 mg/day) or fluoxetine (20-40 mg/day) for 8 weeks. Total cholesterol and TG levels, as well as BW were compared at baseline with those at weeks 4 and 8. Data was analyzed by SPSS software version 16.0. RESULTS: In the fluoxetine group, TC levels decreased from 165.71 mg/dL to 156.71 mg/dL at week 4 (P = 0.07), and to 143.94 mg/dL at week 8 (P = 0.16); TG levels decreased from 129.35 mg/dL to 115.88 mg/dL at week 4 (P <0.001), and to 110.41 mg/dL at week 8 (P = 0.56). In the imipramine group, TC levels increased from 169.10 mg/dL to 178.69 mg/dL at week 4 (P = 0.07), and to 208.69 mg/dL at week 8 (P < 0.001) while TG levels increased from 111.73 mg/dL to 128.83 mg/dL at week 4 (P = 0.005), and to 160.90 mg/dL at week 8 (P < 0.001). BW was significantly increased in the imipramine group at weeks 4 and 8. In the fluoxetine group, BW was non-significantly decreased from 75.69 ± 7.97 Kg (baseline) to 75.67 ± 8.01 Kg at week 4 (P = 0.88), and to 75.22 ± 8.67 Kg at week 8 (P = 0.20), while in the imipramine group, BW had significant increases from 72.53 ± 8.55 Kg (baseline) to 73.95 ± 8.61 mg/dL at week 4 (P < 0.001), and to 75.13 ± 8.34 mg/dL at week 8 (P < 0.001).Repeated measures ANOVA showed significant effects on both TC and TG levels as well as on BW in all patients receiving imipramine. However, in patients on fluoxetine, repeated measures ANOVA showed significant effects of this medication only on TC levels in males. CONCLUSIONS: Monitoring TC and TG and BW is recommended before starting imipramine in depressed patients with increased risk for cardiovascular disease. Fluoxetine may be the preferred agent in those with high or borderline high lipid levels.

Three dimensional patient-specific guides for guide pin positioning in reverse shoulder arthroplasty: An experimental study on different glenoid types.

INTRODUCTION: Incorrect positioning is one of the main factors for glenoid component loosening in reverse shoulder arthroplasty and component placement can be challenging. This study aimed to assess whether Patient-Specific Instrumentation (PSI) provides better guide pin positioning accuracy and is superior to standard guided and freehand instrumentation methods in cases of glenoid bone deformity. MATERIALS AND METHODS: Based on the Walch classification, five different scapula types were acquired by computed tomography (CT). For each type, two different surgeons placed a guide pin into the scapula using three different methods: freehand method, conventional non-patient-specific guide, and PSI guide. Each method was repeated five times by both surgeons. In these experiments, a total of 150 samples of scapula models were used (5 × 2 × 3 × 5 = 150). Post-operative CT scans of the samples with the guide pin were digitally assessed and the accuracy of the pin placement was determined by comparison to the preoperative planning on a three-dimensional (3D) model. RESULTS: The PSI method showed accuracies to the preoperative plan of 2.68 (SD 2.10) degrees for version angle (p < .05), 2.59 (SD 2.68) degrees for inclination angle (p < .05), and 1.55 (SD 1.26) mm for entry point offset (p < .05). The mean and standard deviation errors compared to planned values of version angle, inclination angle, and entry point offset were statistically significant for the PSI method for the type C defected glenoid and non-arthritic glenoid. CONCLUSION: Using the PSI guide created by an image processing software tool for guide pin positioning showed advantages in glenoid component positioning over other methods, for defected and intact glenoid types, but correlation with clinical outcomes should be examined.

Training and validation of standardized patients for unannounced assessment of physicians' management of depression.

OBJECTIVE: Standardized patients (SPs) have been developed to measure practitioner performance in actual practice settings, but results have not been fully validated for psychiatric disorders. This study describes the process of creating reliable and valid SPs for unannounced assessment of general-practitioners' management of depression disorders in Iran. METHOD: Ten psychology and nursing students (potential SPs) took part in a five-session course involving training in dialogue and body language. Five scenarios, along with corresponding checklists representing common presentations of mood disorders in primary-care settings, were developed by an expert group. The SPs' role-play performance of their respective scenario was videotaped and scored independently by three psychiatrists according to an observational rating scale to assess validity. The role-play was repeated after 1 week with the same scenario and the same doctor, to assess test-retest reliability. The reliability of each checklist to be used by the SPs was assessed by testing interrater reliability between groups of SPs. RESULTS: The cutoff score for the SPs' portrayal validity was 90% or above for all SPs. Mean interrater reliability for the checklists was acceptable for the SPs watching the same videos and filling in the checklists, while the mean kappa for assessing concurrent validity in filling in the checklists was lower. The test-retest performance for assessing reliability resulted in a mean kappa of 0.72. All SPs except one, who was not recruited, performed acceptably well. CONCLUSION: The authors have demonstrated a thorough validation of the technique of using standardized patients in the portrayal of depressive disorders in primary-care settings in Iran, which creates confidence in employing this technique to evaluate doctors' performance, for example, after an educational intervention. Similar methods of validation can be used for SPs' portrayal of other psychiatric disorders.

Image processing methodology for patient-specific instrument design.

BACKGROUND: Patient-specific instrumentation (PSI) improves accuracy of surgical operations. PSI needs software for preoperative planning and instrument design. In this study, we explain the methodology of developing a software tool for PSI guide design and preoperative planning in reverse shoulder arthroplasty (RSA). METHODS: Approaches used to prepare input data, transform them into meaningful features and use of those features to create special guide geometries are explained by describing different algorithms and libraries. RESULTS: The developed software is tested on three different patients' data. Preoperative planning is performed and guides designed by software and the patients' bones are manufactured and tested for RSA. The method of building a software is presented to do the preoperative planning and designing specific guides for each patient are shown to be properly functional. CONCLUSIONS: This study proves processes in the development of the PSI software and the design of a specific guide for RSA.

Effects on knowledge and attitudes of using stages of change to train general practitioners on management of depression: a randomized controlled study.

OBJECTIVE: To assess the impact on knowledge and attitudes of a tailored educational intervention on depression using a modified version of the Prochaska stages of change model, compared with standard continuing medical education, for general practitioners (GPs) in primary care in Iran. METHOD: Using a randomized controlled trial, a total of 192 GPs were evenly randomized to intervention or control arm. The topic for the educational intervention was depressive disorders. The participants were divided in to small and large groups, depending on their initial stage of change. The GPs' knowledge and skills regarding management of depressive disorders were assessed through a questionnaire with 7 multiple choice questions, 11 Likert statements, 3 case vignettes, and 1 essay question. Attitudes toward management of depressive disorders were also assessed. Both questionnaires were validated. RESULTS: There was a significant improvement in knowledge mean scores regarding multiple choice and Likert questions (intervention effect 6%; P = 0.002), as well as for the case vignettes and essay question (intervention effect 12%; P = 0.011) in the intervention arm, in comparison with the control arm. There were significant changes in mean attitude scores in both study arms, but no difference between them. CONCLUSIONS: A theoretical model of medical learning and behavioural change can be used to devise educational formats that suit different stages of learning. Such tailored educational formats can improve GPs' knowledge and skills regarding management of depressive disorders.

Applying a modified Prochaska's model of readiness to change for general practitioners on depressive disorders in CME programmes: validation of tool.

OBJECTIVE: To assess the validity and reliability of an 11-item questionnaire for stages of readiness to change according to a modified Prochaska model (including attitude, intention and action stage) in the context of continuing medical education (CME) on depressive disorders for general practitioners (GPs) in Tehran, Iran. METHODS: Three hundred and fifty GPs were recruited for filling in a questionnaire in order to assess content validity and modifying the questionnaire. Fifty-nine GPs were involved for testing reliability and 39 GPs for testing concurrent validity. Content validity of the questionnaire was assessed by expert consensus. Concurrent validity was assessed by correlating the results of a semi-structured interview with those of the self-assessment questionnaire. For testing reliability there was a test-retest approach with an interval of 3-7 days. RESULTS: A panel of experts was held at four times and the final version of modified Prochaska questionnaire (MPQ) was compiled by the panel. Total kappa coefficient for concurrent validity of the whole questionnaire was 0.80. Only two of the questions had a kappa coefficient lower than 0.70. In the test-retest, 96% of participants reassigned to the same stage and the total kappa coefficient of reliability was 0.89 for the whole questionnaire. CONCLUSION: The validity and reliability of the MPQ for assessing GPs' readiness to change in the field of depressive disorders were found to be high in the Iranian context. These findings support its application in tailoring and evaluating CME programmes for GPs in Iran.

Hartree-Fock, Møller-Plesset calculations and dynamic NMR study of 3,3-dimethoxy-1-(imidazolidin-2-ylidene)propan-2-one.

The experimental (1)H, (13)C NMR spectra of 3,3-dimethoxy-1-(imidazolidin-2-ylidene)propan-2-one were recorded in CDCl(3) at temperature range 213-323 K. The variable temperature spectra revealed a dynamic NMR effect which is attributed to restricted rotation around the C=C double bond. Fast exchange processes of deuterium atoms between CDCl(3) and 3,3-dimethoxy-1-(imidazolidin-2-ylidene)propan-2-one or fast exchange of proton between nitrogen and oxygen atoms of carbonyl group is also revealed by broadening of N-H (singlet) proton NMR signals. Proton and carbon theoretical chemical shifts of the title molecule were calculated by using RHF and MP2-GIAO levels and different basis sets in gas phase at 298 K. The calculated proton chemical shifts show that the experimental values have no agreement with theoretical values, but for carbon chemical shifts a good agreement achieved by using RHF with 6-31G basis set and MP2/3-21G, 6-31G basis sets. Discrepancies are attributed to either the limitations of calculating program, because the change of the structure while rotation are not considered. The results showed that to select of basis set has more important rule, because RHF-GIAO level calculation with 6-31G basis set in gas phase can excellently reproduce the (13)C NMR spectrum. Moreover, MP2/3-21G, 6-31G calculation has not significant influence on (13)C NMR chemical shifts with respect to RHF-6-31G.

Solvatochromic, spectroscopic and DFT studies of a novel synthesized dye: l-(4-Dimethylaminophenyl)-2-(5H-phenanthridine-6-ylidene)-ethanone (6-KMPT).

A novel solvatochromic l-(4-dimethylaminophenyl)-2-(5H-phenanthridine-6-ylidene)-ethanone (6-KMPT) dye was synthesized and characterized by means of NMR, IR, mass spectroscopies. Also, it was studied using UV-vis and fluorescence spectroscopic methods in a broad range of solvents. UV-vis results showed that increasing 6-KMPT concentration dose not cause molecular aggregation in chloroform. Varying the temperature in the range from 25 to 55 degrees C dose not have a significant effect on the characteristics bands of the molecule. However, in the presence of surfactant SDS the UV-vis spectrum undergoes drastic alteration. This phenomenon is related to the removal of hydrogen atom from nitrogen atom of phenanthridine moiety. Fluorescence spectroscopic results showed that 6-KMPT has an appreciable fluorescence quantum yield. The effect of excitation wavelength, concentration of 6-KMPT, concentration of oxygen and surfactants (SDS, C(16)TAB, CPC, Brij-35) were studied. Further results showed that the fluorescent behavior of 6-KMPT can be attributed to planarity induced by intramolecular hydrogen bonding which can in turn be destroyed by anionic surfactant SDS. Results showed that oxygen and SDS can be operate as fluorescence quencher compounds for 6-KMPT and Stern-Volmer plot showed a straight line. Fluorescence polarization and anisotropy of 6-KMPT in chloroform strongly depend on concentration. The 6-KMPT exhibits solvent-induced spectral band shifts. By using Lippert equation, the change of dipole moment of 6-KMPT molecule upon excitation was estimated as 6.39 D. Furthermore, absorption, fluorescence emission, Stokes shift values and fluorescence quantum yield (Phi(F)) of 6-KMPT in different solvents of polarity were determined. Maximum Phi(F) value of 0.372 for 6-KMPT molecule was found in ethanol solvent with a Stokes shift of 2446.8 cm(-1). The results of DFT calculations showed that tautomer 2c (enol) energetically is more stable than tautomer 2b (keto) in gas phase whereas it was vice versa in CHCl(3).

Psychological defense mechanisms among individuals with SCI with adjustment disorder.

OBJECTIVES: The used psychological defense styles among individuals with spinal cord injury (SCI) with adjustment disorders (AJD) have not yet been described. In the present investigation, the prevalence of AJD among people with SCI has been estimated and the pattern of used defense styles has been identified. DESIGN: Cross-sectional investigation. SETTING: A tertiary rehabilitation center in Iran. PARTICIPANTS: Individuals referred to Brain and Spinal Cord Injury Research Center were invited to participate in a screening interview. AJD was diagnosed based on DSM-V criteria. Those with AJD diagnosis were scheduled for another interview to assess defense mechanisms. OUTCOME MEASURES: Demographic and injury-related variables were recorded. Defense mechanisms were assessed by the 40-item version of the Defense-Style Questionnaire (DSQ-40). RESULTS: Among 114 participants, 32 (28%) were diagnosed with AJD among whom 23 subjects attended the second interview. Mean age and time since injury were 29.57 ± 9.29 years and 11.70 ± 6.34 months, respectively. The majority of patients were using idealization defense mechanism (91.3%). In the second and third place, passive aggression (87.0%) and somatization (82.6%) defense mechanisms were observed, respectively. Neurotic style was dominantly used (11.52 ± 2.26). Sex, marital status, educational level, cause of the injury and injury level were not related to defense style (P: 0.38, 0.69, 0.88, 0.73, and P: 0.32, respectively). CONCLUSION: Prevalence of AJD is estimated to be 28% among individuals with SCI. The most prevalent defense style was neurotic and the dominant used defense mechanism was "idealization." The role of demographic and injury-related variables in determining the used defense mechanisms was insignificant.

A tailored educational intervention improves doctor's performance in managing depression: a randomized controlled trial.

RATIONAL AND OBJECTIVES: To assess the effects of a tailored and activating educational intervention, based on a three-stage modified Prochaska model of readiness-to-change, on the performance of general physicians in primary care (GPs) regarding management of depressive disorders. METHODS: Parallel group, randomized control trial. Primary hypothesis was that performance would improve by 20 percentage units in the intervention arm. The setting was primary care in southern Tehran. The participants were 192 GPs stratified on stage of readiness-to-change, sex, age and work experience. The intervention was a 2-day interactive workshop for a small group of GPs' at a higher stage of readiness-to-change ('intention') and a 2-day interactive large group meeting for those with lower propensity to change ('attitude') at the pre-assessment. GPs in the control arm participated in a standard educational programme on the same topic. The main outcome measures were validated tools to assess GPs' performance by unannounced standardized patients, regarding diagnosis and treatment of depressive disorders. The assessments were made 2 months before and 2 months after the intervention. RESULTS: GPs in the intervention arm significantly improved their overall mean scores for performance regarding both diagnosis, with an intervention effect of 14 percentage units (P = 0.007), and treatment and referral, with an intervention effect of 20 percentage units (P < 0.0001). The largest improvement after the intervention appeared in the small group: 30 percentage units for diagnosis (P = 0.027) and 29 percentage units for treatment and referral (P < 0.0001). CONCLUSIONS: Activating learning methods, tailored according to the participants' readiness to change, improved clinical performance of GPs in continuing medical education and can be recommended for continuing professional development.

Comparison of two different curricula in psychiatry clerkship at tehran university of medical sciences.

OBJECTIVES: The aim of this study was to evaluate the efficacy of a new psychiatry clerkship curriculum which was designed to improve the knowledge and skills of medical students of Tehran University of Medical Sciences (TUMS), Iran. METHODS: This quasi-experimental study was conducted in two consecutive semesters from February 2009 to January 2010. In total, 167 medical students participated in the study. In the first semester, as the control group, the clerks' training was based on the traditional curriculum. In the next semester, we constructed and applied a new curriculum based on the SPICES model (student-centered, problem-based, integrated, community-based, elective and systematic).At the end of the clerkship, the students were given two exams: Multiple Choice Questions (MCQ) to assess their knowledge, and Objective Structured Clinical Examination (OSCE) to assess their skills. Baseline data and test performance for each student were analyzed. RESULTS: Compared to the control group, students in the intervention group showed significantly higher OSCE scores (P= 0.01). With respect to MCQ score, no significant difference was found between the two groups. CONCLUSIONS: The results suggest that the revised curriculum is more effective than the traditional one in improving the required clinical skills in medical students during their psychiatry clerkship.

Undiagnosed Bipolar Disorders in Patients with Major Depressive Episode: Iran's part of a Multicenter Cross-Sectional Study.

OBJECTIVE: Bipolar spectrum disorders may often go undiagnosed or unrecognized. The aim of this study was to determine the proportion of bipolar disorder symptoms in Iranian patients with a major depressive episode. METHODS: 313 patients with a current DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders 4th ed. Text rev.) diagnosed with a major depressive episode entered this cross-sectional study. Thirty two items revised Hypomania/ mania Symptoms Checklist (HCL-32) was used to determine the frequency of bipolar episodes. RESULTS: Considerable proportion of patients (53.9%) previously diagnosed as major depressive disorder fulfilled the criteria for bipolar disorder by Bipolarity Specifier. The Bipolarity Specifier additionally identified significant association for manic / hypomanic states during antidepressants therapy (p<0.0003) and current mixed mood symptoms (p<0.0001). CONCLUSION: Bipolar symptoms meeting the criteria for bipolar disorders in depressed patients who have not been previously diagnosed with bipolar disorder are frequent. Current DSM criteria may not be sufficient to diagnose more subtle or atypical forms of bipolar disorders.

Double-blind, randomized, placebo-controlled 6-week study on the efficacy and safety of the tamoxifen adjunctive to lithium in acute bipolar mania.

BACKGROUND: Considerable amount of biochemical data supports the potential involvement of protein kinase C in the pathophysiology and treatment of bipolar disorder. The aim of this double-blind, placebo-controlled study was to investigate the efficacy and tolerability of tamoxifen as an adjunct to lithium for the treatment of acute mania in hospitalized bipolar patients. METHODS: Eligible participants were 40 inpatients, between the ages of 19 and 49 years with current manic episode. Patients were randomly allocated to lithium (1-1.2 mEq/L) + tamoxifen 80 mg/day (group A) or lithium (1-1.2 mEq/L) + placebo (group B) for a 6-week, double-blind, placebo-controlled study. The principal measure of outcome was the Young Mania Rating Scale. The raters used standardized instructions for Young Mania Rating Scale. RESULTS: Young Mania Rating Scale scores improved with tamoxifen. The difference between the two protocols was significant as indicated by the effect of the group, the between-subjects factor (F=5.41, df=1, p=0.02). A significant difference was observed on the Positive and Negative Syndrome Scale total score at week 6 in the two groups. The difference between the two groups in the frequency of side effects was not significant except for fatigue that occurred more often in the tamoxifen group. LIMITATIONS: Tamoxifen is an antagonist of estrogen receptor as well. CONCLUSION: The results demonstrate that the combination of tamoxifen with lithium was superior to lithium alone for the rapid reduction of manic symptoms. The combined use of tamoxifen with lithium was well tolerated in these acutely manic patients.

Modeling the formation and reactions of benzene metabolites.

One or more of the muconaldehyde isomers is a putative product of benzene metabolism. As muconaldehydes are highly reactive dienals and potentially mutagenic they might be relevant to the carcinogenicity of benzene. Muconaldehydes may be derived through the action of a cytochrome P450 mono-oxygenase on benzene oxide-oxepin, which are established metabolites of benzene. Oxidation of benzene oxide-oxepin either by the one-electron oxidant cerium(IV) ammonium nitrate (CAN) or by iron(III) tris(1,10-phenanthroline) hexafluorophosphate in acetone at -78 degrees C or acetonitrile at -40 degrees C gave (E,Z)-muconaldehyde, which was a single diastereoisomer according to analysis by (1)H NMR spectroscopy. Reaction of toluene-1,2-oxide/2-methyloxepin with CAN gave (2E,4Z)-6-oxo-hepta-2,4-dienal. Similarly, the action of CAN on 1,6-dimethylbenzene oxide-2,7-dimethyloxepin gave (3Z,5E)-octa-3,5-diene-2,7-dione. In vivo, benzene oxide-oxepin could suffer one-electron oxidation by cytochrome P450 mono-oxygenase giving (E,Z)-muconaldehyde. The observations presented may be relevant to the toxicology of benzene oxide-oxepin and other arene oxide-oxepins as we have previously shown that (E,Z)-muconaldehyde, analogously to (Z,Z)-muconaldehyde, affords pyrrole adducts with the exocyclic amino groups of the DNA bases adenine and guanine. Independent of their possible toxicological significance, the experiments described provide preparatively useful routes to (E,Z)-muconaldehyde and its congeners. Methods are also described for the trapping and analysis of reactive benzene metabolites, e.g. using the Diels-Alder reaction with the dienophile 4-phenyl-1,2,4-triazoline-3,5-dione to trap arene oxides and with the diene 1,3-diphenylisobenzofuran to trap enals.

How do examiners and examinees think about role-playing of standardized patients in an OSCE setting?

OBJECTIVE: The use of standardized patients in Objective Structured Clinical Examinations in the assessment of psychiatric residents has increased in recent years. The aim of this study is to investigate the experience of psychiatry residents and examiners with standardized patients in Iran. METHOD: Final-year residents in psychiatry participated in this study. Experienced examiners were asked to complete a questionnaire concerning the ability of standardized patients to realistically portray psychiatric patients. RESULTS: Standardized patients can convincingly portray psychiatric disorders and act according to the requested complex scenarios. CONCLUSIONS: According to these findings, the authors recommend the use of standardized patients in OSCEs for psychiatric board certification exams.

Psychiatry in Iran.

The Islamic Republic of Iran is located in the Middle East between the Caspian Sea and the Persian Gulf. Iran's total land area is 1 648 000 km2. Its total population in 2003 was about 68 920 000 (UNICEF, 2003). The population growth rate is 1.41%. Of the total population, 60.4% live in urban and 39.6% in rural areas (Yasamy et al, 2001).

Comparing the effects of 8-week treatment with fluoxetine and imipramine on fasting blood glucose of patients with major depressive disorder.

This study was designed to compare the effects of fluoxetine and imipramine on fasting blood glucose (FBG) in patients with major depressive disorder. Sixty nondiabetic patients with major depressive disorder (based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria) entered this randomized, double-blind study. Patients did not receive any medication affecting serum FBG levels for at least 2 weeks before the initiation of the study. Patients were assigned to receive 20 to 40 mg/d of fluoxetine or 75 to 200 mg/d of imipramine for 8 weeks. Pregnant women and patients with diabetes mellitus and a history of any major heart disease were excluded from this study. Additionally, none of the patients should have received electroconvulsive therapy within 6 months before the initiation of the antidepressants. FBG levels were measured at the initiation, as well as 4 and 8 weeks after starting antidepressants. Nineteen patients in the fluoxetine and 24 patients in the imipramine groups completed the study. In the fluoxetine group, FBG level was decreased from 88.5 mg/dL (baseline) to 85.0 mg/dL at week 4 (P = 0.73), and to 79.8 mg/dL at week 8 (P < 0.001). On the other hand, in the imipramine group, FBG level was increased from 86.96 mg/dL (baseline) to 89.71 mg/dL at week 4 (P = 0.079), and to 96.90 mg/dL at week 8 (P < 0.001). This 8-week study showed that FBG levels may decrease in depressive patients receiving fluoxetine and may increase in those patients treated with imipramine. Therefore, it is suggested to measure and monitor FBG before initiation and during treatment with fluoxetine and imipramine.