سید مهدی نورایی

An increase in the number of intraepithelial lymphocytes (IEL) in the duodenal mucosa is an important criterion for the histological diagnosis of celiac disease (CD). We determined the normal range for intraepithelial lymphocytes (IEL) in the second part of duodenum in healthy Iranian population.

Four biopsy samples of the endoscopically normal appearing mucosa at the second part of duodenum were obtained from 50 individuals referred to Shariati hospitals (48 for epigastric pain, 2 for esophageal varices). They had no sign, symptoms and evidence for malabsorption or small intestinal disorders in history, physical examination, Laboratory tests and IgA anti tissue transglutaminase (t.T.G). Four-micrometer thick sections were stained with Hematoxillineosine (H&E) and immunohistochemistry (IHC) for leukocyte common antigen (LCA). At least 500-600 cells from the tip and body of villi were counted separately and the number of IEL was given as mean/ 100 epithelial cells.

The mean for IEL count in total villi in IHC method was 21/100 (23/100 in tip, 21/100 in body, p = 0.058) and 19/100 in H&E method (19/100 in tip, 18/100 in body, p =0.035) (p = 0.006). Considering total villi, the normal upper limit (Mean+2SD) was calculated to be 35/100 in IHC and 34/100 in H&E stained sections and normal upper limit of confidence interval (the 95 percentile) was 39/100 in IHC and 37/100 in H&E stained sections. The villus height to crypt depth ratio was 3/94 in average.

Respectively in IHC and H&E methods, the amounts equal or less than 35/100 and 34/100 are considered as normal. values between 35-39/100 and 34-37/100 as border line and counts more than 39/100 and 37/100 represent a pathology. Although the difference between two staining methods was statistically significant, considering cost effectiveness, we recommend H&E staining for routine clinical practice.

To investigate about knowledge, attitudes and practice among general practitioners m Tehran, Iran. Material &

Using a short questionnaire 339 physicians were entered into the study. The subjects were approached during the 13 compulsatory postgraduate courses.

The study findings indicate that 84.9% of general practitioners believe that the use of alternative therapies is mounting yearly and herbal medicine, cupping and acupuncture (respectively) are the most common methods being used. There were at least 9.9% of physicians using one or more methods of complementary medicine in practice and 24% of them had referred their patients to alternative therapist during the last 6 months. The knowledge of the majority of general practitioners about the most of the common procedures was very limited. Physicians besides having emphasis on supervision of such activities, disagree strongly with these methods being performed by non-physicians.

Overall physicians had positive attitudes toward usefulness of complementary methods. However, there is need to improve their knowledge on the topic.

Quality assessment based on client oriented approach is one of the most effective methods in improving efficacy of services. The "Self-assessment" consists of four monitoring tools including "service assessment, client flow analysis, client exit interview and plan of action"; and can be performed by staff group forming in Service Delivery Points (SDPs). The main objective of the present study was to compare "Self-assessment" with "Routine supervision". Material &

Eight urban SDPs have been allocated (by stratified random allocation) to the "Self-assessment" and "Routine supervision" groups, which had three and five SDPs, respectively. The following variables have been determined for comparison of two methods after one round of the Self-assessment: 1) monitoring performance by finding problems in SDP 2) job satisfaction of staff 3) staff attitudes towards their job 4) staff practice. Difference of pre and post intervention data of two groups have been compared by Man Whitney and t-test.

Most frequent problems which have been picked up by the Self-assessment were deficiencies in materials and instruments, problems in physical structure of SDPs and educational materials. In the other hand problems that raised by "Routine supervision" were usual administrational issue, deficiencies in materials and instruments, and finally roughly suggestions regarding service delivery, e.g. low quality of care. The Self-assessment had more in-depth approach in evaluation of technical aspects of services and client rights than routine supervision. In addition, although this was a short term evaluation, Self-assessment showed regarding staff attitudes towards relations with their colleagues (P=0.05) and their overall satisfaction (P=0.04). It seems that these effects were contributed by team forming in SDPs.

The Self-assessment affects staff participation, their attitudes towards client rights, innovation for problem solving and finally results in quality improvement. The important point is coordination and supportive role of central levels with this activity; otherwise its impact would be diminished after afew rounds.

Client-oriented approach has been recently introduced to health services as a basis for quality improvement. The main purpose of the study was to adapt a method for development of a monitoring tools called "Self - assessment". In addition, staff opinions regarding simplicity, feasibility and workload have been investigated as part of a comprehensive assessment of this monitoring tool. Material &

The first step for development of this monitoring tool was to consider quality elements in each health program based on client oriented and provider efficient approach. Then, preceding quality elements were used for developing a monitoring tool. This monitoring tool, i.e. Self- assessment, is focuses on assessment of activities by providers themselves. In addition, without any predetermined investigations; it can motivate staff for efficient service delivery by team building in health center. For assessment, four urban health centers were selected for intervention in Semnan. Three days workshop was hold for each center. The tutors in one center were authors and in the remaining centers were district staff. Data were obtained from 42 staff in health centers by open and ended questionnaires.

In three centers, which workshops were conducted by district staff, 87.5% (95% CI: 75.8 - 99.9) of staff agreed with "Self - assessment" model. The mean Point of weaknesses and strengths were 0.5 and 3.4, respectively. After a few rounds of "Self - assessment" comparing the results between centers having more versus less experties indicated that coordination with upper managerial level is crucial.

The "Self - assessment" monitoring method is highly focused on monitoring process and structural dimensions of quality. Looking for measuring outcomes must be considered as an essential part of a comprehensive assessment. Further evaluation of "Self - assessment" not only in comparison to other monitoring tools, e.g. "Routine supervision", but also long term effect is highly recommended before any wider implementation of this newly developed tool.