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History and Objectives: Due to the prevalence of breast cancer and its complications and the necessity of cancer screening by health workers including midwives and lack of accurate data on the knowledge, attitude and practice of midwives, the present study was carried out on midwives working in the health clinics of Tehran in 1994.

Materials and Methods: A descriptive study was performed on 100 midwives working in the health treatment centers in Tehran. Data were collected by multi-stage cluster and then by simple randomized sampling method. Information regarding age, educational level, marital status, work history, family history for breast cancer, breast self-examination, breast examination of patient and questions regarding midwives attitude and knowledge via separate questionnaire were collected. The performance of midwives was evaluated with a corresponding checklist.

Results: Most midwives have a fair knowledge (41%), strong positive attitude (58%) and moderate practical skills (50%) on breast examination. A direct statistical correlation was found between knowledge and type of attitude and between knowledge and practical skills of midwives on breast examination. In addition, a close relationship was found between educational level and family history of breast cancer with midwives knowledge. A statistically significant correlation was found between breast examinations of patients with midwives attitude. However, there were no relationship between other characteristics and midwives knowledge, attitude and practical skills.

Conclusion: Since midwives have fairly moderate knowledge and practical skills on breast examination and due to the importance of breast examination in early detection of cancer further studies are needed to determine the effect of continuing education on the level of midwives knowledge and practical skills and their performance of breast examination.

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History and Objectives: Due to the prevalence and complications associated with pregnancy in adolescents, the present research was carried out on the quality of concentrations among adolescent women referred to Gholabchi Medical Clinic.

Materials and Methods: A descriptive study was performed on adolescent women referred to the Gholabchi Medical Clinic for prenatal educational courses. Personal records concerning age, educational level of women and her husband, duration of marriage, type of contraceptive methods and factor associated with the contraceptive methods were collected. If a combination of different pills is used, it is considered low risk contraction and other methods are considered high-risk contraceptive method.

Results: From total of 191 of adolescent women, 176 were qualified with mean age of 16.9±1.6 years with a minimum of 11 years and a maximum of 19 years of age. Mean length of marriage was 11±3.7 months with a minimum of 5 months and a maximum of 18 months. 42.6% of individuals did not use any contraceptive method, 40.3% used high-risk method and 17.1% used low risk method. Owing to husband’s inclination for pregnancy, 44% of women did not choose contraception. Desire for pregnancy was the most prevalent cause of discontinuation of contraception. 50.6% of contraceptive users had previous pregnancy. 46.6% and 2.8% of cases had one and two successful pregnancies respectively.

Conclusion: Due to complications associated with pregnancy and delivery among adolescent women, further research is recommended to detect factors involved in the pregnancy and to reduce possible complications.

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Background: Maternal and fetal complications following the macrosomia are of utmost importance. The present study was carried out with the aim of determining the prevalence of fetal macrosomia and post-term delivery and multiparity as its risk factors in Kashan in 1999-2000.

Materials and Methods: It was an analytical study. During the first phase the prevalence of macrosomia was determined during a two-year period (1999-2001), then, the second phase was conducted on 110 infants with macrosomia (Case group) and 110 without macrosomia (Control). Groups were matched according to the sex, BMI, level of education, prenatal care, mother’s nationality and age. A questionnaire was used for data collection, then the role of post-term delivery (>40 weeks) and multiparity was determined.

Results: Macrosomia was found in 3.04% of the infants. Post-term delivery was reported in 45.5% and 61.8% of the control and case group, respectively (P<0.02). The mean parity was 2.39±1.34 and 2.54±1.37 in the control and case group, respectively (NS).

Conclusion: The prevalence of macrosomia is not high in Kashan. Post-term delivery has increased the rate of macrosomia, however, multiparity has no statistically significant association. Further studies are highly recommended.

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Background: With respect to the prevalence of short-interval pregnancy in our country and also lack of information data in Kashan, the present study was conducted in Kashan to determine the prevalence of short-interval pregnancy and also its association with birth height and weight.

Materials and Methods: A descriptive study was carried out to determine the prevalence of short-interval pregnancy whereas a historical cohort study was performed of determine its association with birth height and weight. Our case group consisted of two groups: 150 mothers with interval of less than 15 months and 90 mothers with interval of less than 12 months, between their pregnancies. 150 mothers with adequate interval between pregnancies were Surveyed in cone and control groups and analyzed by t-test. Relative and absolute risks of short-interval pregnancies were determined for birth weight of less 3000gr and birth height of less 49cm.

Results: Of 2300 mothers, 216 (94%) had short-interval pregnancy. Results have revealed that there is no association between interval of less than 15 mothers and birth height and weight, however of less than 12 months and birth height and weight. The mean (±SD) of birth weight was 3356±443 and 3237±430 gr in the control and case group (Interval <12 months), respectively (P<0.05). Meanwhile, their birth height was 50.4±2 and 49.7±1.8 cm, respectively. The RR of weight <3000gr was 105 and for height <49 was 2.1. The AR for these values were 0.5% and 16.5%, respectively (P<0.05%).

Conclusion: Pregnancy with interval of less than 12 months is associated with lower birth and weight. Further studies are highly suggested.

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Background : Breast cancer has been increased rapidly during the recent decades, however, self examination and clinical evaluation have been revealed to be effective for early diagnosis. The present study was conducted to determine knowledge, attitude, and performance of women referring health care centers in Kashan towards breast cancer and its screening tests.

Materials and methods : For this descriptive study 400 women were selected through a cluster sampling. Then, initial data such as age, marital status, educational level, occupation, familial history of breast cancer, self examination training, and other breast related diseases were recorded meanwhile knowledge and attitude were considered and performance was surveyed by direct observation.

Results : The mean ( ± SD) age of women was 29.7 ±7.9. The vast majority of participants were housewives, married and had under diploma education. Poor knowledge of breast cancer was revealed in 43%.,however, negative attitude and poor performance were observed in 5.5% and 65.3% of women, respectively. Better performance is achieved by increment in knowledge.

Conclusion : Most of the women had poor knowledge and performance regarding the breast cancer and its screening test. With respect to the importance and efficacy of self-examination in early diagnosis we highly suggest educational programs to promote knowledge, attitude, and performance towards the breast cancer.

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Background : Cholesterol and lipoprotein level of pleural fluid and their correlation with serum level is of utmost importance in differentiating exudative form transudative pleural fluid. The present study was conducted in patients with pleural fluid referring to Shaheed Beheshti hospital in Kashan during a two-year period.

Materials and methods : It was a cross sectional study. Light's criteria were used to differentiate exudative and transudative pleural fluid. Cholesterol and lipoprotein levels of pleural fluid and serum were determined using the standard techniques and their correlation was calculated by Pearson method. T-test and Mann-Whitney were used for data analysis.

Results : The study population included 52 males and 67 females with the mean age of 63.5±15 years. Pleural effusion was exudative in 70 (58.8%) patients and transudative in 49 (41.2%). Pleural fluid cholesterol level were 29±16 and 65±25 in transudative and exudative group, respectively (p<0.001). Pleural fluid cholesterol level (transudative and exudative) depends on their serum level as well as the ratio of pleural fluid to serum protein (for exudative r=0.61, p<0.001, and for transudative r=0.62, p<0.001). Correlation coefficient of LDL, HDL, VLDL, and triglyceride of exudative pleural fluid with the ratio of pleural fluid to serum protein were 0.53 (p<0.001), 0.40 (p=0.01), 0.29 (p=0.01), and 0.29 (p=0.02), respectively. These figures were 0.48 (p<0.001), 0.24 (p=0.09), 0.09 (p=0.52) and 0.04 (p=0.79) respectively for transudative pleural fluid. The percentage of cholesterol associated with LDL and HDL in exudative and transudative pleural fluid were 90 and 89, whereas their serum percentage were 83 and 86.

Conclusion : Pleural fluid cholesterol level (transudative and exudative) depends on their serum level as well as the ratio of pleural fluid to serum protein. With respect to the unchanged level of pleural fluid lipoproteins, determination of pleural fluid cholesterol level may help us to differentiate exudative from transudative pleural fluid. In exudative pleural effusion the pleural fluid lipoprotein level depends mainly on the ratio of pleural fluid to serum protein, however, in transudative state LDL level depends on this ratio.

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Background : Due to controversies in etiology of malnutrition, mother’s BMI and child’s sex, the present study was conducted in order to determine the role of mother’s BMI and child’s sex on malnutrition of children younger than 5 years old that referred to health care centers in Kashan in 2002-2003.

Materials and Methods : In a case-control study using cluster and random sampling,125 children with malnutrition based on weight for age using -2 standard deviations criteria NCHS (case group) and 125 children without malnutrition (control group), from 10 health centers in Kashan were enrolled during the study period. Mother’s BMI and child’s sex was compared in two groups. Case and control groups were matched in confounding variables.�Information was obtained from medical records through interview . Results were judged with Chi- square, t-test and mantel haenszel. Also Odd's ratio and confidence interval were determined.

Results : Results showed that matched factors such as maternal age, maternal employment, parity, birth weight and height, duration of breastfeeding and child age were similar in two groups. Mean mother’s BMI was significantly different in two groups (P<0.002). Also results demonstrated child’s sex was related to malnutrition, (P<0.02). Odd's ratio and confidence interval for effect of BMI<22 and female sex on malnutrition were ) OR=2.1 CI=3.74-1.16 P<0.05, OR=1.81 CI=3.05 -1.07 P<0.05) respectively. Although malnutrition was showed to be related to each variable separately, mantel haenszel test demonstrated that two factors were not concurrently related to malnutrition.

Conclusion : Low mother’s BMI and female sex, increased risk of malnutrition alone but not related with malnutrition together. Further studies are recommended to determine other risk factors.

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Background: Considering the adverse effects and difficulties due to formula feeding or early commencement of supplemental diet and also different reports from their status, this study was conducted to investigate the nutritional status and related factors in 4/5 month-old infants referred to health care centers in kashan in 2002.

Materials and methods: This cross - sectional study was performed on 350 mothers who had children aged 4/5 months. The sampling was done randomly in several phases. The information about kinds of diet, maternal age, maternal education, occupational status, infant sex, order of infant’s birth, the commencement time of first feeding, exclusive breast feeding period and the commencement time of supplemental diet were collected . Also the weight and height of infants were measured. Then the collected data was analyzed.

Findings:  Non exclusive breast feeding was observed in 17.7% of infants and in 3.7% of them, supplemental diet had begun earlier than their 4-month age. Breast feeding period in 82.3% of infants was more than 4 months. There was a statistically significant correlation between kinds of diet and maternal age (P<0.002), occupational status (p<0.001) and the commencement time of first feeding (p<0.0005). Infant weight in exclusive breastfeeding group (N1= 288) was 7243 ±792.1 gr and in non exclusive breast feeding group (N2=62) was 6891 ±1059 gr (P<0.002). Their height was respectively 62.63± 2.9 cm and 62.25± 3.1 cm (P<0.1)

Conclusion: Early beginning of breast feeding in postpartum period, paying further attention to old mothers and employed mothers have an important role in exclusive breastfeeding development and prevention of infant mortality.

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Background : Peroxide is the first compound that is produced after fats and oils are oxidated. Whenever peroxide concentration reaches to a certain amount, different changes occur and volatile essences are created which make unfavoured odour and flavour in oils and fats. The present article is a report of evaluation of peroxide concentration in Zoolbia and Bamieh which was planned and applied in kashan city in 2003-2004.

Materials and methods : The research was accomplished by a descriptive study on 57 samples of Bamieh and 36 samples of Zoolbia during 2 years. In this study, firstly, certain amount of sample oil was extracted by Suxeleh method, and then the amount of available peroxide in the oil was measured by titration (Sodium thiosulfate 0.02 Normal). To determine the amount of peroxide, the sodium thiosulfate consumption was measured and calculated by related formula. Statistical analyses were accomplished by use of test.

Results : From total 57 samples of Bamieh, 42 samples (73.7 %) were consumable and 15 samples (26.3 %) were inconsumable. Also 19 samples of total 36 samples Zoolbia samples (52.8 %) were consumable and 17samples (47.2 %) were inconsumable. The maximum peroxide level in Zoolbia and Bamieh samples were 65 and 38.3, respectively.

Conclusions : The results of this study show that most of Zoolbia and Bamieh samples had been inconsumable . According to high amount of peroxide in the most samples and also to dangerous effects that peroxide have on the health it seems that the presentation of continuos planning and practical approaches will be necessary by regional health professional.

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Background: Preeclampsia is one of the most important risk factors for maternal mortality in the world. The immune maladaptation theory suggests that the tolerance to paternal antigens, resulting from prolonged exposure to sperm, protects against the development of preeclampsia. Due to controversies in this regard the present study was conducted with main objective to determine the relationship between the extent of exposure to sperm, before pregnancy, and the risk of preeclampsia in pregnant women referring to Shabih-Khani maternity Hospital of Kashan during 2005-2006.

Materials and Methods: A case-control study was carried out on 150 mothers with preeclampsia (case group) and 150 mothers without preeclampsia (control group). Preeclampsia was determined by blood pressure≥ and proteinuria≥+1 by dipstick testing. The duration of sperm exposure prior to pregnancy, and the frequency and duration of the use of barrier method contraception before pregnancy were compared in the two groups. All results were analyzed using c ² , t-test , and Mann-Whitney U statistical test.

Results: There was no significant difference between the two groups in confounding variables. The mean duration of sperm exposure prior to pregnancy in the case and control groups was 11.4 ± 14 and 12.4 ± 13.8 months, respectively. Mann-Whitney U test showed that this difference was not significant. c ² statistical test appeared no significant difference between the two groups in barrier methods contraception (80 and 88 women in the case and control groups, respectively). Also Mann-Whitney U test showed that regarding duration of using barrier method contraception no important variation is evident between the case and control groups (25.8 ± 21.9 and 28.7 ± 23.7 months, respectively).

Conclusion: We concluded that pre exposure to sperm, frequency and duration of using barrier contraception are not effective in the etiology of preeclampsia.

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Background: Hypoxia following electroconvulsive therapy(ECT) causes hemodynamic instability and increases the threshold of convulsion. In this study we evaluated the effects of  laryngeal and face masks ventilation on oxygen saturation, hemodynamic changes and duration of convulsion after ECT.

Materials and Methods: Sixty-six patients with chronic depression aged 20-60 scheduled for ECT were randomly divided into two groups of 33. In both groups anesthesia was induced with intravenous sodium thiopental 2 mg/kg and succinylcholine 0.5 mg/kg. Ventilation with %100 oxygen was carried out by laryngeal mask in group I and face mask in group II. Systolic and diastolic blood pressures, heart rate, oxygen saturation and convulsion duration before and after ECT in all patients were measured and recorded.

Results: Oxygen saturation after ECT was higher in group I compared with group II (p<0.05). In both groups systolic and diastolic blood pressures 3 and 5 min after ECT were higher than those before ECT. Increased diastolic blood pressures 3 and 5 min after ECT, and systolic blood pressure 3 min after ECT were higher in group I (p<0.05). The duration of convulsion in group II (38.8 ± 11 seconds) was longer than that in group I (30.2 ± 11 seconds) (p<0.05).

Conclusion: the results of the current study revealed that laryngeal mask decreases convulsion duration and increases oxygen saturation during ECT so it is recommended that ventilation to be performed by laryngeal mask rather than the face mask.

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Background: Considering high complications of labor induction with drugs, finding an easy, inexpensive, confident method for induction of labor is important. This study was performed to evaluate the effect of castor oil on initiation of labor in pregnancies after 40 weeks in Shabihkhani Hospital in Kashan during 2004-2006.
Materials and Methods: This randomized clinical trial study was performed on 200 women after their 40 weeks of pregnancy. Women were divided to two groups (100 women in case group and 100 women in control group). The case group took 60 ml castor oil while control group didn’t take any treatment. The two groups were compared for onset of labor in 24 hours, time of onset of labor, delivery time and method and Apgar score of their newborns by X2, CI, OR and t-tests.
Results: Labor was induced in 70% of women in the case group versus 12% in the control group during 24 hours (p<0.001, OR=17.11, CI=8.17-35.84) and vaginal delivery happened in 28% of women in the case and 1% of women in the control group (p<0.001. OR=29.5. CI=5.86-226.4). There was no significant difference between the two groups in the method of delivery and newborns Apgar score.
Conclusion: The use of castor oil can induce labor in pregnant women after 40 weeks without any increase in the complications of pregnancy including caesarean section, and drop in Apgar score. To confirm findings, it is recommended to perform further clinical randomized studies.

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Background: The third stage of labor has been described as the most dangerous stage. Concerning importance of the third stage, this study was performed to determine the length of this stage and its related factors.

Material s and Methods: This cross-sectional study was carried out on 1000 deliveries in shabihkhani Hospital, in Kashan, during 2005-2006. Gestational age >20 weeks, singleton pregnancy, and vaginal delivery without any instrument were the including criteria. Data were analyzed using c ² , OR and CI .

Results: Mean and median of the third stage of labor were 6.03 and 5 minutes, respectively. There was significant association between the number of parturitions (p= 0.04), induction with oxytocin (p=0.002), analgesia during labor (pethedin) (p=0.008), and umbilical cord drainage for the third stage management (p<0.001). There was no significant association between history of abortion, gestational age, third stage management (oxytocin), fetal sex, and weight.

Conclusion: Use of induction, and analgesics during labor and umbilical cord drainage increased the length of the third stage but multiparty decreased it. It is recommended to consider these factors for prediction and prevention of dangers of prolonged third stage of labor.

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Background: As the population ages, a greater demand for long-term care is expected. Admitting older people to care unit and residential home has been identified as the most significant relocation. Studying risk factors resulting in entrance to the elderly home and developing programs to delay or prevent of them are important.

Materials and Methods: This is a qualitative phenomenological study using purposive sampling of elderly residents of private and state nursing homes in Isfahan continuing until data saturation encountered, e.g when sample size became 10 participants. They were between 66-85 years old (3 men, 7 women). Data were collected by interviewer, and through field notes. Colaizzi's method was used for data analysis. The rigor of present study was based on transferability and credibility.

Results: Two themes of voluntary and compulsory entry were found. Voluntary entry sub themes were entered with previous agreement, due to financial and family problems, compulsory entry sub themes were entered with cheating, and in unconscious condition, each with specific sub concepts.

Conclusion: Several elders have resided voluntarily for taking care or getting ride of family problems and the rest have resided compulsorily with family care giver agreement. The ability of families, friends, neighbors and other community- based caregivers to provide support should be strengthened.

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Background: Addiction to opioid drugs is considered as a problem throughout the world. Addiction can be studied concerning: social, medical and psychological aspects. The social aspect of addiction is quite important. For example, the negative result of addiction test is a requirement for marriage and job by law. On the other hand, frauds in addiction tests have been reported (such as displacement of urine from bladder, alkalization or acidification of urine and taking of diuretics or oral contraceptives).

Materials and Methods: In the present study, two different chronic morphine administration protocols (tolerance and dependency models) were applied. Estrogen and progesterone were given prior and simultaneously with morphine. After the last injection of morphine, urine samples were taken every 6 h for 24 h. Then morphine was quantitatively detected by High Performance Liquid Chromatography (HPLC). Data analysis was performed using two-way ANOVA and repeated measures ANOVA test followed by Student-Newman-Keuls test. Conjugated morphine was measured by the subtraction of free part of morphine from the total one in the urine samples.

Results: Our results indicated that prior administration of estrogen and progesterone increased the metabolism of morphine 6 and 12 h after the last injection, while no significant change was detected after 18 and 24 h.

Conclusion: In summary, it can be concluded that estrogen and progesterone transiently affect the metabolism of morphine. Thus, the effect of the sex hormones on morphine metabolism is not clinically important.

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Background: Asthma is the most common chronic disease in childhood. Several factors have been considered as the disease risk factors. The neonatal phototherapy has recently been recognized as the main childhood risk factor. The aim of this study was to evaluate the relationship between the neonatal phototherapy and childhood asthma.

Materials and Methods: This analytical case-control study was conducted on the asthmatic children with a history of neonatal icterus as the case group and those with no history of neonatal icterus as the control group with similar characteristics (age, gender, type of delivery and birth weight). Twenty-eight out of 200 subjects in the case and 34 in the control group had the inclusion criteria. Phototherapy and its duration were compared in the case and control groups. Data were analyzed using chi-square and t-test.

Results: Twenty-six (92.8%) subjects in the case group and 20 (58.8%) subjects in the control group had a past history of phototherapy (P=0.002). The mean number of days for neonatal phototherapy in the case and control groups was 4.9 and 3.2, respectively (P=0.001).

Conclusion: This study shows that neonatal phototherapy, as well as its duration, is an effective factor affecting childhood asthma. So, the phototherapy must be avoided except in rare situations with the least duration.

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Background: Prevention of preeclampsia is very important in reducing maternal and neonatal mortality and morbidity. The purpose of this study was to determine the effectiveness of aspirin in the prevention of preeclampsia in high-risk pregnancies with abnormal findings at uterine artery in doppler ultrasound among women referred to Shabih-Khani hospital in Kashan.

Materials and Methods: In this clinical trial study, women predisposed to preeclampsia at 12-16 weeks of gestation were evaluated by uterine artery doppler ultrasound and in the case of abnormal findings, they were randomly divided into two groups, experimental (n=40) and control (n=40) groups. The experimental group was received aspirin 80 mg/day. Groups were followed up until delivery and pregnancy outcomes (e.g. incidence of preeclampsia, IUGR, preterm labour, 1st and 5th min APGAR less than 5, delivery type and birth weight) were analyzed.

Results: The incidence of preeclampsia in experimental (aspirin) group and control group were 2.5%, 22.5%, respectively. In addition, the risk of preeclampsia was 9 folds more than that of control group (P=0.007). No significant difference was seen between the two groups in the type of delivery, birth weight and gestational age.

Conclusion: Aspirin administration during 12-16 weeks of pregnancy can decrease the incidence of preeclampsia in high-risk pregnancy with abnormal findings of uterine artery as a preventive measure.

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Background: Echinococcus granulosus is a cestode parasite that causes cystic hydatid disease in humans worldwide. The gene encoding EG95 protein may be a good candidate to design a DNA vaccine to prevent the disease. Considering the importance of EG95 gene and the scarceness of research on it in Iran, this study was carried out to determine and clone the gene encoding EG95 from Iranian isolate of E. granulosus.

Materials and Methods: At the first stage, protoscoleces was isolated from hydatid cyst fluid and then RNA was extracted from protoscoleces and after performing RT-PCR, the amplified cDNA samples were detected by gel electrophoresis. In next stage, the obtained gene was cloned in pTZ57R/T vector. Two methods were used for conformation of cloning: colony PCR amplification and digestion with the EcoRI and XhoI restriction enzymes. Finally, the cloned EG95 gene in pTZ57R/T vector was sequenced.

Results: Homological comparison of sequences showed that cDNA of EG95 in Iranian isolate of E. granulosus had 492 bp and was different from the standard strain of EG95 reported from New Zealand and Australia (X90928.1). Moreover, cloning of EG95 gene in pTZ57R/T plasmid was confirmed by digestion of this plasmid with the restriction enzymes.

Conclusion: The EG95 gene was cloned in pTZ57R/T plasmid successfully and this plasmid can be used to design a DNA vaccine in further studies.

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Background: Nausea, vomiting and retching, commonly experienced by women in early pregnancy, have considerable physical and psychological effects on pregnants. This study aimed to examine the effect of acupressure on nausea and vomiting during pregnancy.

Materials and Methods: This single-blind clinical trial was performed on 150 pregnant women (<16 weeks of gestation) referred to Naghavi prenatal clinic for seven days and at two research stages during 2010-11. They were randomly divided into three groups: the acupressure, placebo acupressure and control groups. At first stage, women received no treatment during the first 3 days and on next 4 days a continuous pressure was applied on the P6 point at both wrists using a sea-band in the acupressure and placebo groups. The control group did not receive any intervention. Data were collected by the self-trained women themselves using Rhodes index which then were analyzed statistically.

Results: There was no statistically significant difference among three groups in age, marriage age, gestational age, occupation and satisfaction with spouse. Although the mean change in Rhodes index was not significantly different between the acupressure and placebo groups, the difference was significant between the control and the other two groups.

Conclusion: Acupressure using sea-band is considered as a noninvasive, inexpensive, safe, and effective treatment for the nausea and vomiting during pregnancy.

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Background: This study aimed to evaluate the effectiveness of an acceptance and commitment-based therapy (ACT) for three patients with treatment-resistant obsessive compulsive disorder (OCD).

Materials and Methods: A single case-design was carried out on three patients with treatment-resistant OCD. Data were collected using a Yale Brown obsessive compulsive scale, Beck depression inventory-II, Beck anxiety inventory and a processing measure.

Results: Results showed a significant alleviation in obsessive symptoms, scores of anxiety and depression, believability and distress of obsessions and need to response to them in post-test among three patients and the alleviation continued for 1-month follow-up.

Conclusion: Results of this study show that the acceptance and commitment-based therapy can be an effective treatment for patients with treatment-resistant OCD.