bahram einollahi

To evaluate and compare clinical outcomes after femtosecond laser-assisted implantation of 325-degree versus 340-degree arc length intracorneal ring segments (ICRS) in eyes with keratoconus (KCN).

In this prospective non-randomized interventional case series, 23 eyes of 21 patients diagnosed with KCN, underwent femtosecond laser-assisted implantation of two types of ICRS, which included a 325-degree ICRS (Group 325) and a 340-degree ICRS (Group 340). The primary outcome measures were uncorrected distance visual acuity (UDVA), and the secondary outcome measures included corrected distance visual acuity (CDVA), sphere, cylinder, mean refractive spherical equivalent (MRSE), keratometry, vectorial change in corneal astigmatism, and the location of maximum keratometry relative to the corneal apex. The study groups were compared using the primary and secondary outcome measures obtained at postoperative months six and 12.

Groups 325 and 340 consisted of 10 and 13 eyes, respectively. The two groups were comparable in terms of parameters measured preoperatively. On comparison to the baseline values, both study groups exhibited a significant increase in UDVA and CDVA measured at postoperative month six (Ps < 0.05) and a significant decrease in the sphere, cylinder, spherical equivalent refraction, and keratometry readings measured at postoperative months six and 12 (Ps < 0.05). No significant differences were observed between the two groups in terms of visual, refractive, and keratometric outcomes at any time point. No intraoperative or postoperative complications were observed in any of the study groups.

Both the 325-degree ICRS and the 340-degree ICRS effectively and equally improved visual, refractive, and keratometric outcomes in keratoconic eyes.

To investigate the effect of static accommodative tasks on intraocular pressure (IOP) of glaucomatous and normal eyes.

Four groups of subjects categorized as primary open-angle glaucoma (POAG), primary angle-closure suspects (PACS), normal age-matched controls, and normal young adults (NYA; age <40 years) were enrolled. The baseline IOPs were measured after the subjects were looking at a distant target for 15 min. Static accommodation was obtained by execution of near vision tasks (reading at 33 cm in daylight [300 lux] for 60 min). IOPs were measured at 15, 30, 45, and 60 min intervals while accommodating and then measured again after 15 min of relaxing accommodation while looking at a distant target.

One-hundred and eighteen eyes of 98 subjects were recruited. The study groups consisted of the following categories: 25 POAG (46 eyes), 24 PACS (47 eyes), 25 matched controls (50 eyes), and 24 NYA (48 eyes). Within all groups, the mean IOP decreased throughout the accommodation period at all time points. Maximum IOP reduction after accommodation was detected at the 30-min time among the POAG subjects, at the 45-min time in the PACS and matched control groups, and at 15 min after the relaxation of accommodation in the NYA group. IOP reduction levels showed no statistically significant difference among POAG, PACS, and the normal matched groups in their response to accommodation. However, NYA had significantly lower IOP and greater IOP reduction after the resting period (relaxation of accommodation).

Static accommodative tasks can significantly reduce IOP in normal, POAG, and PACS individuals. Encouraging glaucoma patients to practice periodical near vision tasks could be viewed as an adjunctive measure for glaucoma management.

Sacrifice is very valuable for Islamic and revolutionary ideals;if this is not a universal characteristic and the scope is not expanded, public security and peace will be threaten.We are all indebted to the sacrifice of a dynamic and dedicated generation.The generation that has defended the country throughout history and has made many sacrifices to defend the homeland.In this article, we will refer to the issue of self-sacrifice of the health community in the Corona era as well as the self-sacrifice of the holy war.

This article is a review of documents;  related documents have been extracted from reliable databases and analyzed.

The white-clad angels in the field of health, wholike in the holywar era sacrificed their comforts and stood at the forefront of the unequal battle, are examples of a selfless altruistic generation.

Comparison of the holy defense era and the fight against Corona shows the many similarities between them and the efforts of the medical staff and nurses. The study of these two periods can be a roadmap for the future of the country in both human and scientific capital.

The outstanding spiritual persons with spiritual health have prominent and excellent characteristics in the Holy Quran and Islamic teachings. Verse 29 of Raad Sura from the Holy Quran, introduces these instances, beautifully.  “Those who believe in God and work righteousness, is [every] blessedness, and beautiful place of [final] return. The exemplary aspects and religious models of Islamic spiritual health are summarized.

This article prepared from panel of the sixth Islamic Spiritual Health Conference which was held in March 2019 and completed by using library studies.

Throughout the history of Islam from the first to the contemporary, we find many prominent personalities, inspirational scientists, physicians and spiritual persons in the Islam and Iran culture and civilization. These examples of Islamic spiritual health are objective and effective models in different aspects of life including ethical, educational, scientific and professional behavior and lifestyle.

Human needs a practical model for moving to future. Therefore, the most natural, most effective and fastest method of training is the model method, which presents examples and the practical education. The role of models is the most sensitive of educational role which competent models lead people to excellence and corrupt models lead them to corruption. Recognition of the obvious and hidden characteristics of models life and introducing them to community is needed to promote Islamic spiritual health and is more effective than other promotional methods.

Randall Schweller is a leading neoclassical realist who has paved the way for the revival of realism through criticizing the structuralist approach of neo-realism. Waltz, Walt, and Mearsheimer have been the major targets of his attacks. This article argues that his main added value to realism is to find a way to respond to internal divisions among realists and weak historical support for many of neo-realist propositions. Within this framework he enters into internal debates among realists about status quo versus revisionist states; explains non-formation of balancing behavior and balance of power in the course of history; pays attention to change in international system ignored by many realists; and rejects the objections against realists for not accounting for international institutions. By including domestic factors in his analysis, his work accounts for the emergence of revisionist states, dynamics of international system, and the significance (or insignificance) of international institutions within a theory of states’ interest and the resulting balance of interests in the international system. This theory can clarify the historical conditions in which realists’ claims can prove to be true. In order to give an account of Schweller’s theoretical endeavors to modify and revive realism, this article analyses his major works and shows that although he could account for inconsistences within realism, his own work with its own problems can add to internal divisions within realist camp.

Today, theory of control provides a rich methodology and a set of supporting principles and tools for analysis of regional orders and its strategies and actors. Today, anti- systemic groups is a key concept in modern management of regional orders and interconnection between control system and new actors. Despite significant changes in international relations in recent decades the study of regional orders and their control are not at core of theories of international relation. Anti-systemic groups, as one of control variables in the regional orders, particularly in West Asia regional order, as an important strategic region, has been highlighted. Therefore, the core object of current research is to make a response to this question that what is the role and function of anti-systemic groups in order control system of West Asia region? In reply to this question, it can be said that anti-systemic groups will help to operation of control systems, including balance of power, deterrence and compellence, in asymmetrical condition of power and complexity of regional order. So, explaining the problem of offensive and resistant anti-systemic groups, as a mechanism for balancing, deterring and compelling, in West Asia region, is the main aim of this article. This survey concludes by considering the functions of these new actors for attempts to explain the management of new regional order.

To evaluate corneal changes after collagen crosslinking (CXL) therapy for keratoconus (KCN) using the Galilei dual Scheimpflug analyzer.
This prospective, nonrandomized clinical study included 35 eyes of 32 keratoconus patients who had undergone CXL. The eyes were saturated with riboflavin solution and were subjected for 30 minutes to ultraviolet-A (UV-A) light with irradiance of 3 mW/cm2. Effectiveness of the treatment was assessed by measuring uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), manifest cylinder/sphere, keratometry, pachymetry, posterior and anterior elevations by the Galilei dual Scheimpflug analyzer. Prior to treatment and 8 months after therapy, Scheimpflug analysis was performed using the Galilei system. The four sets of data including keratometry values, pachymetry, elevation parameters and surface indices were statistically analyzed and compared.
Mean patient age was 22.3 ± 3.8 years and mean postoperative follow-up was 8.1 ± 3.2 months. There was a significant increase in UCVA (0.54 ± 0.35 Log MAR preoperatively to 0.49 ± 0.34 LogMAR postoperatively, P = 0.01) and BCVA (0.21 ± 0.19 Log MAR preoperatively to 0.16 ± 0.17 LogMAR postoperatively, P = 0.01). Mean cycloplegic spherical equivalent refractive error was −4.13 ± 2.65 Diopter (D) preoperatively and − 4.67 ± 2.96 D postoperatively (P Corneal stabilization could be achieved by collagen crosslinking therapy for keratoconus in terms of corneal thickness, keratometry values, elevation parameters and surface indices.

To compare distant and near visual function after cataract surgery with implantation of Crystalens HD or Tek-Clear as accommodating intraocular lenses (IOLs), versus SA60AT as a standard IOL.
The study included 62 eyes of 58 patients divided into three groups using three different IOLs: Crystalens HD (Bausch and Lomb, NY, USA), Tek-Clear (Tekia, CA, USA) and SA60AT (Alcon, TX, USA) were implanted in 23, 14 and 25 eyes, respectively. Corrected distant visual acuity (CDVA), uncorrected and distance corrected near visual acuities (UCNVA and DCNVA), near point of accommodation (NPA), spectacle freedom and patient satisfaction were assessed six months postoperatively and compared between the three groups.
After 6 months, all patients showed significant improvement in CDVA with no significant difference among the study groups. However, UCNVA and DCNVA were significantly better in patients implanted with accommodating IOLs. NPA was closest in the Crystalens HD group, followed by Tek Clear and monofocal SA60AT (P Accommodating IOLs (Crystalens HD and Tek-Clear) effectively reduce the necessity for spectacles after cataract surgery.

To compare ultrasound pachymetry and Orbscan II for measurement of central corneal thickness (CCT) in normal eyes. The current study was performed at Labbafinejad Medical Center (LMC), Tehran, Iran. Three hundred eyes from 150 healthy individuals referred for keratorefractive surgery were assessed first by Orbscan II and then by ultrasound pachymetry, and CCT values were recorded and compared. Overall, Orbscan II overestimated CCT as compared to ultrasound pachymetry by about 2.4% (mean values 547.6 ± 34.7 versus 534.8 ± 34.7, respectively, P < 0.001). The difference was more significant when CCT was less than 500 microns (mean values 493.2 ± 16.9 versus 479.9 ± 15.6, mean overestimation: 2.6%, P < 0.001). There was good linear correlation between the two methods (Pearson's correlation r = 0.968, P < 0.0001). Orbscan II has good correlation with ultrasound pachymetry for measurement of CCT in normal eyes; however Orbscan II should not be used to evaluate corneal thickness before keratorefractive surgeries, as it tends to overestimate corneal thickness and may result in undesirable, low residual stromal thickness.

Ramadan fasting may alter a variety of physiological parameters which by themselves influence ocular system. Here, we review the effects of Ramadan fasting on the health and function of the eye. Literature records in PubMed/MEDLINE, Web of Science, EMBASE, Google Scholar, and Iran Medex databases as well as proceedings of related meetings from January 1986 to March 2014 were systematically reviewed. The search key words was based on the terms “Ramadan Fasting,”“Ramadan,” “Islamic Fasting,” “Fasting in Ramadan” accompanied with one of the eye, tear drop, myopia, intraocular pressure (IOP),tear break up time, basal tear secretion, refractive error, and visual acuity. Predawn water loading and dehydration in the evening are shown to increase and decrease IOP and tear secretion, respectively. Ocular blood flow is changed in Ramadan fasting, and patients with ocular vein occlusion may experience more frequent attacks. There are no or minimal fluctuations in visual acuity and refractive errors, but most of them are decompensated after Ramadan. Although the influence of fasting in different eye parameters is evaluated in several studies, there are no or only limited studies conducted on patients suffering from glaucoma,damage to ophthalmic vasculature, tear dysfunction, and minimal visual acuity. Such studies are required to make a definite decision before fasting is declared harmless to these patients.

To compare corneal higher-order aberrations (HOAs) between normal and keratoconic eyes, and to investigate the association between elevation-based corneal topographic indices and corneal wavefront data in the latter group. In this cross-sectional comparative study, 77 normal right eyes of 77 control subjects and 66 eyes of 36 keratoconic patients were included. In each eye, elevation-based corneal topographic indices including mean keratometry readings, best-fit sphere, maximum elevation, and 3-mm and 5-mm zone irregularity indices were measured using Orbscan II. The Galilei Scheimpflug analyzer was used to measure HOAs of the corneal surface. The independent student t-test was used to compare HOAs between the study groups. Spearman correlation was used to investigate possible associations between Orbscan and Galilei data in the keratoconus group. All Zernike coefficients up to the 4th order except for horizontal trefoil, and vertical and horizontal tetrafoil were significantly greater in the keratoconus group than normal eyes (P)

Background and comparison of the academic situation in various national and international universities may be done as ranking. Improving the quality of university education is an integral part of higher education management. Accurate measurement of specific indicators is an essential precondition of access to education systems quality. Current ranking indicators have not been adequately about teaching and the review on the world ranking systems is needed. The current study has been designed and implemented with the aim of explanation and identification of the teaching ranking Criteria in Iran and world universities. Systematic review of the literature for information on the latest events in the world rankings and teaching criteria via systematic searching of the databases, Academic journals and published books, national and international official reports, papers presented at national and international conferences and journals, research and evaluation projects and academic theses, reports and news related to the ranking were done. European University Association has published a report in 2013 that in addition to analysis of the current status of ranking systems, discuss on the new tool and new project of teaching ranking. Teaching Indicators in this project include: expenditure on teaching as a proportion of total expenditure, graduation rate, interdisciplinary of programs, relative graduate unemployment rate, time to degree, investment in laboratories, the proportion of staff with doctorates, the inclusion of issues relevant to employability in the curriculum, computer facilities comprising hardware, internet access, field-specific software and access to computer support, and student gender balance. Assessment of higher education learning outcomes and students satisfactory indicators are mentioned in this project, too. Due to the globalization of education and development of academic institutions, the necessity of academic performance evaluation is shown. Teaching ranking indicators as a mechanism for analyzing the performance of universities and judges about them are important. Collection and delivery of the indicators for promotion of higher education, and achieve a good position in the world rankings, is a small step that can be taken as a prelude to the development of native teaching ranking standards.

To investigate the outcomes of keratolimbal allograft (KLAL) for treatment of total limbal stem cell deficiency (LSCD). Patients with total LSCD and adequate tear production were included. A total of 27 KLAL procedures were performed in 21 eyes of 20 patients with LSCD. Immunosuppression was achived using mycophenolate and cyclosporine. Main outcome measure was improvement in vision; in addition, KLAL survival and post operative complications were studied. Mean follow up period was 22.14±11.83 months (range 6-39). Mean visual acuity improved from 2.53± 0.21 to 1.49±0.77 LogMAR (P<0.0001). Six KLALs never re-epithelialized and were considered as primary failures. Mean KLAL survival was 14.23±1.5 months. Graft survival rate was 61.9% at 1 year and 31% at 20 months. Complications included corneal ulcers in 6, glaucoma in 2 and scleral thining in 1 case. Keratolimbal allograft surgery is successful in the short term for visual rehabilitation of patients with total limbal stem cell deficiency.

To report the indications and techniques of corneal transplantation at a tertiary referral center in Tehran over a 3-year period. Records of patients who had undergone any kind of corneal transplantation at Labbafinejad Medical Center, Tehran, Iran from March 2004 to March 2007 were reviewed to determine the indications and types of corneal transplantation. During this period, 776 eyes of 756 patients (including 504 male subjects) with mean age of 41.3±21.3 years underwent corneal transplantation. The most common indication was keratoconus (n=317, 40.8%) followed by bullous keratopathy (n=90, 11.6%), non-herpetic corneal scars (n=62, 8.0%), infectious corneal ulcers (n=61, 7.9%) previously failed grafts (n=61, 7.9%), endothelial and stromal corneal dystrophies (n=28, 3.6%), and trachoma keratopathy (n=26, 3.3%). Other indications including Terrien''s marginal degeneration, post-LASIK keratectasia, trauma, chemical burns, and peripheral ulcerative keratitis constituted the rest of cases. Techniques of corneal transplantation included penetrating keratoplasty (n=607, 78.2%), deep anterior lamellar keratoplasty (n=108, 13.9%), conventional lamellar keratoplasty (n=44, 5.7%), automated lamellar therapeutic keratoplasty (n=8, 1.0%), and Descemet stripping endothelial keratoplasty (n=6, 0.8%) in descending order. The remaining cases were endothelial keratoplasty and sclerokeratoplasty. In this study, keratoconus was the most common indication for penetrating keratoplasty which was the most prevalent technique of corneal transplantation. However, deep anterior lamellar keratoplasty is emerging as a growing alternative for corneal pathologies not involving the endothelium.

To determine the rate and risk factors of vitreous loss during phacoemulsification in patients with cataracts operated by ophthalmology residents and fellows at Labbafinejad Medical Center. This prospective descriptive study included consecutive patients with cataracts undergoing phacoemulsification over a one year period. All patients were operated under local or general anesthesia using the divide and conquer technique. Preoperatively, all patients underwent a complete ocular examination including measurement of visual acuity, slitlamp biomicroscopy, intraocular pressure measurement, and dilated funduscopy. Main outcome measures included the rate of posterior capsular rupture and vitreous loss as well as associated risk factors such as surgical experience, ocular and systemic conditions, and type and severity of the cataract. Overall, 767 eyes of 767 patients with mean age of 63.7±10.3 (range, 25-91) years were operated. The overall rate of vitreous loss was 7.9% which was 5-fold greater in the hands of residents as compared to fellows. Among different factors, older age, female sex, small pupil, small capsulorrhexis, presence of pseudoexfoliation, and high myopia were significantly associated with vitreous loss. The highest rate of vitreous loss occurred in patients with dense nuclear cataracts. Considering the higher rate of vitreous loss in patients operated by ophthalmology residents; patients with known risk factors for vitreous loss should better be operated by more experienced surgeons.

To evaluate the effect of vacuum and flow rate on endothelial cell loss after high versus low vacuum phacoemulsification. This randomized clinical trial was performed on 60 eyes of 60 patients with moderate lens opacity (nuclear sclerosis 3+). All surgeries were performed by one experienced surgeon using stop and chop technique with Sovereign white star machine (AMO). Patients were randomly assigned to high and low vacuum techniques in equal numbers. The machine was set on 400 mmHg vacuum and 40 ml/min flow rate in the high vacuum group and on 200 mmHg vacuum and 20 ml/min flow rate in the low vacuum group during the chop stage. All other parameters were similar in both groups. Phacotime multiplied by average ultrasound power was defined as total ultrasound energy. Specular microscopy was performed before and 1, 6 and 12 weeks after the operation. After 12 weeks, mean endothelial cell loss was 9.0±4.0% versus 9.6±4.6% in the low and high vacuum groups, respectively (P=0.6). Mean ultrasound power was 9.2±4.3% and 13.1±4.6% in the low and high vacuum groups, respectively (P=0.001). Mean phacotime was 1.28±1.0 minutes in the low vacuum group versus 0.88±0.6 minutes in the high vacuum group (P=0.04). Total ultrasound energy and total fluid volume used (turbulence) during phacoemulsification was similar between the two study groups. Total ultrasound energy was the most powerful predictor of endothelial cell loss (R2=0936, P=0.001), but turbulence was not a significant predictor (R2=0.924, P=0.1). No significant difference in endothelial cell loss was found between low and high vacuum techniques. This study supports advice to junior surgeons to choose lower hydrodynamic phaco machine parameters; experienced surgeons can choose higher parameters to reduce phacotime

To report the rate of vitreous loss during phacoemulsification and its contributing risk factors in patients operated on at Labbafinejad Medical Center. This prospective comparative descriptive study included patients with cataract undergoing phacoemulsification by ophthalmology residents or cornea fellows from November 2006 to November 2007. All patients underwent a complete ocular examination including visual acuity, slitlamp examination, and dilated funduscopy, preoperatively. Phacoemulsification was performed under local or general anesthesia using Divide & Conquer technique. Main outcome measures included posterior capsular tear and vitreous loss and predisposing factors such as surgeon’s experience, ocular and systemic conditions, and type and severity of the cataract. Overall 767 patients including 393 male and 374 female subjects with mean age of 62.7±12.0 (range 6-96) years were studied. The overall rate of vitreous loss was 7.3% which was 5-fold higher in the hands of residents than fellows. Patients’ age and female sex, small capsulorrhexis, small pupil, pseudoexfoliation, and high myopia were other significant risk factors. The highest rate of vitreous loss occurred in patients with dense nuclear cataracts. Since ophthalmology residents had a higher rate of vitreous loss, patients with risk factors such as pseudoexfoliation, high myopia, and dense nuclear cataracts are better operated by more experienced surgeons.

To report the outcomes of penetrating keratoplasty (PKP) in patients with macular corneal dystrophy (MCD). This retrospective case series includes consecutive patients with MCD who underwent PKP from 1986 to 2006 with at least 6 months'' follow-up. Main outcome measures included best spectacle-corrected visual acuity (BSCVA), postoperative astigmatism and graft survival. Sixty-two eyes of 39 patients with mean age of 34.0±10.5 (range 13-58) years at the time of keratoplasty were included for analysis. After a mean follow-up period of 52.0±47.3 (range 6-190) months, BSCVA improved from 1.4±0.4 logMAR (4/100) preoperatively to 0.2±0.3 logMAR (20/32) at final follow-up (P < 0.001). Mean postoperative BSCVA was 0.15±0.40 logMAR in patients (36 eyes) aged less than 35 years at the time of surgery as compared to 0.26±0.25 logMAR in subjects (26 eyes) older than 35 years (P=0.005). Final astigmatism was comparable with different suturing techniques including separate, continuous, and combined sutures (P=0.9). All grafts were clear at final follow-up except a single case of MCD with visually insignificant recurrence. Episodes of immunologic graft rejection occurred in 12 eyes (19.4%) but none led to graft failure. PKP for MCD entails favorable outcomes in terms of graft survival and visual improvement. Final visual acuity seems to be better when transplantation is performed before the age of 35 years.

To evaluate anterior chamber aspirates at the conclusion of phacoemulsification and intraocular lens implantation (PE+IOL) for bacterial and fungal contamination. We prospectively evaluated 80 eyes of 80 patients undergoing routine PE+IOL by performing bacterial and fungal culture on aspirates obtained from the anterior chamber at the end of the surgery. Anterior chamber fluid aspirates were positive for bacteria in 5 eyes (6.33%) with coagulase-negative staphylococcus being the most common organism (three eyes). No instance of positive fungus culture was observed. One of the culture-positive eyes developed postoperative uveitis which resolved during a week of treatment with topical corticosteroids and antibiotics. None of the eyes developed endophthalmitis. In the current series, the rate of anterior chamber contamination by bacteria at the end of phacoemulsification was in the lower range reported by previous studies

To report the early results of transplantation of autologous limbal stem cells cultivated on amniotic membrane (AM) in patients with total unilateral limbal stem cell deficiency (LSCD). Four eyes of 4 patients with total unilateral LSCD confirmed with impression cytology underwent transplantation of autologous limbal stem cell cultivated on AM. At each follow up visit, a complete eye examination with special attention to recurrence or regression of vascularization, corneal opacification, and epithelial defect healing was performed. Digital imaging was performed at each follow up visit. Impression cytology was repeated in all cases after surgery. The patients were followed for 5-13 months. Visual acuity improved in all cases. Decrease in corneal opacification and vascularization was obvious in 3 cases with coverage of the cornea with corneal epithelium. Sectoral conjunctivalization was evident in these 3 cases, however the corneas were ready for transplantation. The procedure failed in one case with total corneal conjunctivalization. Transplantation of autologous stem cells cultivated on AM seems to be an effective way for total LSCD. More definite judgment needs longer follow up together with long-term results of corneal transplantation in these patients.

Internal evaluation has started in I 995 in various educational groups of different medical universities. Currently. more than 120 groups are involved in this project. The faculty members have a key role in the process as the main elements of internal evaluation.Internal evaluation was not only helpfill in identifying different practical aspects of education, but also had a prominent role in raising several questions about methodology, objectives, effectiveness and other dimensions of evaluation.Is the so-called internal evaluation consistent with the scientific criteria of evaluation? Could any better alternative method be found to perform this evaluation in the universities? Does the result of the internal evaluarion help the promotion of the education quality?Many of these questions could be answered by comparing the current evaluations with program evaluation standards.In this article, the program evaluation standards are considered and the current situation of internal evaluation in medical education units is compared with those standards. The defects of the current evaluations are assessed and necessary recommendations are presented.

Today, through out the world, medical education has two critical needs: need for structural reform and innovative plans and then need for social accountability in terms of educational program quality and its effectiveness. Educational assessment and accreditation could be considered as operational (executive) strategy to meet both needs. Of outmost important as the first toward educational assessment and accreditation is the task of specifying standards for medical education both in terms of the institution and the educational program of the institution. Since these standards constitute a new framework against which the medical institutes can measure themselves.Here, in this article we have briefly reviewed the process of developing these standards by AMFEM (in Mexico) and by WFME at an international level. We have tried to underlie two critical features common in both processes. First, the importance levels to defining the physicians' role in terms of what the society or better say, the health care system (as the representative of social health requirement) expects from a good physician. Second, the thoughtful attempt to involve as many experts as possible in the process of developing the standards and providing opportunities to discuss the result of each stage of the specifying standard process.