Role of point-of-care ultrasound study in early disposition of patients with undifferentiated acute dyspnea in emergency department: a multi-center prospective study.

INTRODUCTION: Sonography is a safe and simple diagnostic modality which can help emergency physicians in their clinical decision makings and improve the patient disposition process in emergency departments. OBJECTIVE: This prospective multi-center study evaluates the role of bedside ultrasound performed by emergency physicians in accelerating the patient disposition process in cases with acute undifferentiated dyspnea. METHODS: 103 patients were randomized to "early ultrasound" and "routine assessment" groups. In early ultrasound group, emergency physicians performed bedside ultrasound scans on heart and lungs as soon as possible after triage and randomization. In routine assessment group, ultrasound was used whenever the emergency physician or other consultant services ordered or performed it. Mean randomization-to-diagnosis time was compared in two studied groups. RESULTS: Mean randomization-to-diagnosis time was 79.33 (± 38.90) min in routine assessment and 42.61 (± 19.20) min in early ultrasound groups, showing a statistically significant difference (p value < 0.01). CONCLUSION: Using early sonography in assessing the patients with undifferentiated acute dyspnea in emergency department decreases the patient turnover time while increasing the diagnostic accuracy.

Therapeutic role of enoxaparin in intra-uterine growth restriction: A randomized clinical trial.

OBJECTIVE: Intrauterine growth restriction is a leading cause of perinatal mortality and morbidity. Using enoxaparin may enhance the placental circulation and improve the intrauterine growth. This study was conducted to assess the efficacy and safety of enoxaparin in treatment of intra-uterine growth restriction. STUDY DESIGN: 125 women with intrauterine growth restriction were randomized to control group and intervention group (receiving routine high risk pregnancy prenatal care plus daily subcutaneous injection of 40 mg enoxaparin). Prolongation of pregnancy, fetal birth weight, fetal outcome and enoxaparin side effects were compared in 2 groups. RESULTS: Baseline characteristics were similar in 2 groups. Mean gestational age at delivery was 36.73(±2.71) in enoxaparin group and 36.85(±2.17) in control group which showed no statistically significant difference. Mean fetal birth weight had also no statistically significant difference in enoxaparin and control group (2370.16 ± 580.72 g versus 2456.07 ± 543.06 g). Rate of betamethasone administration, intubation, NICU admission, sepsis, necrotizing enterocolitis, intra-ventricular hemorrhage, hypoglycemia and low apgar score were similar in two groups. No major adverse effect was seen. CONCLUSION: Enoxaparin did not prolong the pregnancy and fetal birth weight and did not improve the fetal outcome even in patients with impaired baseline Doppler findings.

Evaluation of Awareness, Adherence, and Barriers of Pelvic Floor Muscle Training in Pregnant Women: A Cross-sectional Study.

INTRODUCTION: Adherence to pelvic floor muscle training (PFMT) may be enhanced when the women become aware of its preventive/therapeutic role in pelvic floor disorders. OBJECTIVE: This study is conducted to evaluate the PFMT awareness, adherence, and barriers in pregnant women. METHOD: We studied the awareness, adherence, and barriers of PFMT in 200 pregnant women attended in prenatal care clinic in their third trimester of pregnancy using semistructured interviews with open and closed questions derived from recent literature review on PFMT. RESULT: Fifty-four (27%) of studied women were familiar with PFMT, 175 (87.5%) of patients thought that the UI is normal during pregnancy, and 25 (32.05%) had experienced UI episodes and had consulted with their obstetrician. Twenty-one (10.5%) of patients did the PFMT exercises before their pregnancy, 14 (66.6%) of them continued their PFMT exercises during their pregnancy, and 7 (33.4%) stopped it. Concerns about miscarriage were the main reason of discontinuing the exercises during pregnancy. Routes of knowledge acquisition were the Internet in 24 cases (44.4%), health system in 13 cases (24.07%), family and friends in 11 cases (20.3%), and books/magazines in 6 cases (11.1%). Main means of mass communication (including TV, radio, and newspapers) had no role in knowledge distribution in this filed. CONCLUSIONS: Pregnant women require more health education regarding PFMT. Health care professionals should be more involved in patient education process. Internet resources are used widely by women and need more academic/scientific supervision.

Prophylactic use of tranexamic acid for decreasing the blood loss in elective cesarean section: A placebo-controlled randomized clinical trial.

INTRODUCTION: Tranexamic acid is used as a known treatment of post-partum hemorrhage both in natural vaginal deliveries and cesarean sections, but its use in elective cesarean as a prophylactic measure to decrease the blood loss is not so common. OBJECTIVE: This clinical trial evaluates the efficacy and safety of tranexamic acid in decreasing the bleeding in women undergoing elective cesarean section. METHOD: 200 term singleton pregnant women who were scheduled for elective cesarean section were randomized to 2 groups and received a bolus of 1 gm tranexamic acid if body weight was <90 kg and 1.5 g if body weight was >90 kg diluted in 15 ml of 5% dextrose intravenously, or 5 ml of distilled water in 15 ml of 5% dextrose as placebo (before skin incision). Intra-operative and post-operative blood loss and hemoglobin levels were compared. RESULTS: Tranexamic acid decreased the mean blood loss by 25.3 % in our studied women. Mean volume of intra-operative blood loss was 391.1 (±67.4) ml in tranexamic acid group and 523.8 (±153.4) ml in control group which was statistically significant lesser with a 132.7 ml difference. Rate of >1000 ml and >500 ml bleeding and need to blood transfusion were also statistically significant lower in tranexamic acid group., mean hemoglobin level was statistically significant lower in placebo group than tranexamic acid group (11.77 ± 0.50 versus 11.31 ± 0.56) 6 h after cesarean section. No adverse reaction was documented. CONCLUSION: Prophylactic use of intravenous tranexamic acid decreases the blood loss safely in women undergoing elective cesarean section.

PLA-PCL-PEG-PCL-PLA based micelles for improving the ocular permeability of dexamethasone: development, characterization, and in vitro evaluation.

The aim of the present research was to investigate the feasibility of developing polylactide-polycaprolactone-polyethylene glycol-polycaprolactone-polylactide (PLA-PCL-PEG-PCL-PLA) based micelles to improve ocular permeability of dexamethasone (DEX). PLA-PCL-PEG-PCL-PLA copolymers were synthesized by a ring-opening polymerization method. DEX was loaded into the developed copolymers. The DEX-loaded micelles were characterized using transmission electron microscopy (TEM) and dynamic light scattering (DLS) methods. Cytotoxicity of the micelles obtained was investigated on L929 cell line. Cellular uptake was followed by fluorescence microscopy and flow cytometry analyses. The release behavior of DEX from the micelles as well as the drug release kinetics was studied. Corneal permeability was also evaluated using an ex vivo bovine model. The pentablock copolymers were successfully synthesized. The TEM results verified the formation of spherical micelles, the sizes of which was approximately 65 nm. The micelles exhibited suitable compatibility on L929 cells. The release profile showed an initial burst release phase followed by a sustained release phase, the kinetic of which was close to the Weibull's distribution model. The micelles showed higher corneal permeability in comparison to a marketed DEX eye drop. Taken together, the results indicated that the PLA-PCL-PEG-PCL-PLA micelles could be appropriate candidates for the ocular delivery of DEX, and probably other hydrophobic drugs.

Long-term outcome of endometrial ablation therapy with Cavaterm Thermal Balloon in patients with abnormal uterine bleeding

Objective: The purpose of this study was to evaluate the long-term outcome of endometrial ablation (EA) therapy with Cavaterm Thermal Balloon in patients with abnormal uterine bleeding (AUB). Material and Methods: The retrospective cross-sectional study was performed on 209 patients who referred to Shahid Sadoughi Hospital in Yazd, Iran between March 2010 and September 2017 with AUB undergoing EA therapy. The data was collected by a questionnaire from the medical records of patients and phone call. The primary and secondary outcomes post EA therapy (from six months to seven years post-operatively) were assessed in patients. Results: The mean age of participants was 45.9±5.9 years and the mean follow-up duration was 21.2±13.2 months. The rate of treatment response was 95% in the first six months and 92.1% thereafter. The prevalence of amenorrhea was 41.2%. The patient satisfaction rate at the end of follow-up duration was 81.3%. Dysmenorrhea completely resolved in 32.6%. Moreover, 1.4% of patients became pregnant during follow-up. By the end of follow-up, four (1.9%) patients had a hysterectomy due directly to treatment failure. Conclusion: This study showed that EA surgery with Cavaterm Thermal Balloon was an effective treatment for AUB. The procedure was safe and was associated with a very low rate of postoperative adverse events. The patient satisfaction rate was favorable.

Protocol Adherence in Prehospital Medical Care Provided for Patients with Chest Pain and Loss of Consciousness; a Brief Report.

INTRODUCTION: Although many protocols are available in the field of the prehospital medical care (PMC), there is still a notable gap between protocol based directions and applied clinical practice. This study measures the rate of protocol adherence in PMC provided for patients with chest pain and loss of consciousness (LOC). METHOD: In this cross-sectional study, 10 educated research assistants audited the situation of provided PMC for non-traumatic chest pain and LOC patients, presenting to the emergency department of a tertiary level teaching hospital, compare to national recommendations in these regards. RESULTS: 101 cases with the mean age of 56.7 ± 12.3 years (30-78) were audited (55.4% male). 61 (60.3%) patients had chest pain and 40 (39.7%) cases had LOC. Protocol adherence rates for cardiac monitoring (62.3%), O2 therapy (32.8%), nitroglycerin administration (60.7%), and aspirin administration (52.5%) in prehospital care of patients with chest pain were fair to poor. Protocol adherence rates for correct patient positioning (25%), O2 therapy (75%), cardiac monitoring (25%), pupils examination (25%), bedside glucometery (50%), and assessing for naloxone administration (55%) in prehospital care of patients with LOC were fair to poor. CONCLUSION: There were more than 20% protocol violation regarding prehospital care of chest pain patients regarding cardiac monitoring, O2 therapy, and nitroglycerin and aspirin administration. There were same situation regarding O2 therapy, positioning, cardiac monitoring, pupils examination, bedside glucometery, and assessing for naloxone administration of LOC patients in prehospital setting.

Comparison of oral oxycodone and naproxen in soft tissue injury pain control: a double-blind randomized clinical trial.

OBJECTIVES: This randomized clinical trial compares the efficacy and safety of oral oxycodone (an oral opioid) with naproxen (a nonsteroidal anti-inflammatory drug) in acute pain control in patients with soft tissue injury. It also evaluates the need for additional doses of analgesics in the first 24 hours of discharge from emergency department (ED). METHODS: Adult (>18 years old) patients with soft tissue injuries were enrolled in a teaching urban ED. Subjects were randomly allocated to receive a single dose of oral oxycodone (5 mg) or oral naproxen (250 mg). Pain scores and drugs' adverse effects were assessed before, 30 minutes, and 60 minutes after medication. OUTCOME: efficacy in pain control (reduction in pain scale >2 points) and safety (rate of side effects). The need for additional pain medication after discharge was assessed by follow-up phone call 24 hours after discharge. RESULTS: A total of 150 patients were enrolled. Pain scores were similar in oxycodone vs naproxen groups before (6.21 ± 0.9 in vs 6.0 ± 1.0), 30 minutes (4.5 ± 1.4 vs 4.4 ± 1.2), and 60 minutes (2.5 ± 1.3 in vs 2.6 ± 1.3) after medication, respectively. Twelve (16.0%) patients in oral oxycodone group and 5 (6.6%) patients in naproxen group needed more analgesics in first 24 hours after ED discharge. Adverse effects were more common in oxycodone group (statistically significant difference). The most common adverse effects in oxycodone group were nausea, (13.3%); vomiting, (8.0%); dizziness, (5.3%); drowsiness, 3 (4.0%); and pruritis, (2.7%). CONCLUSION: Oral oxycodone is as effective as naproxen in soft tissue injury pain control but has a less favorable safety profile.

Diagnostic accuracy of emergency physician performed graded compression ultrasound study in acute appendicitis: a prospective study.

PURPOSE: Accurate early diagnosis of appendicitis can decrease its complications and minimize the mortality, morbidity and costs. This prospective study evaluates the accuracy of bedside emergency physician performed ultrasound study diagnosis in acute appendicitis. METHODS: Patients who were suspicious to have appendicitis based on their clinical findings were included and underwent emergency physician performed ultrasound study. Then they were followed up until the recognition of final diagnosis based on pathology report or identification of an alternative diagnosis. Ultrasound studies were done by post-graduate year three emergency medicine residents or emergency medicine attending physicians who were attended in a 4 h didactic and practical course and with 7.5 MHz linear probe both in longitudinal and axial axes. RESULTS: Ninety-seven patients were included and analyzed. 27 (27.8 %) of patients had appendicitis according to the results of emergency physicians performed ultrasound studies. 19 (70.37 %) of them had appendicitis according to their pathologic reports too. Forty-three (44.3 %) of patients had appendicitis according to pathology reports. Only 19 (44.18 %) of them were diagnosed by emergency physicians. Emergency physician performed ultrasound study had a sensitivity of 44.18 %, specificity of 85.18 %, positive predictive value of 70.37 %, negative predictive value of 65.71 % and overall accuracy of 67.01 % in diagnosing appendicitis in patients clinically suspicious to have acute appendicitis. CONCLUSION: Emergency physician performed bedside ultrasound has an acceptable overall accuracy but its sensitivity is low thus it can help emergency physicians to diagnose the acute appendicitis when used in conjunction with other clinical and para-clinical evaluations but not per se.

Accuracy of bedside emergency physician performed ultrasound in diagnosing different causes of acute abdominal pain: a prospective study.

OBJECTIVE: Abdominal pain is a common complaint in the emergency department and accurate diagnosis of its etiology may affect the patient's outcome. METHOD: Patients with abdominal pain underwent ultrasound study first by trained emergency physicians and then by radiologists blinded to emergency physician's results. RESULT: Emergency physician who performed bedside ultrasound had 78% diagnostic accuracy. Emergency physicians showed better results in diagnosing some entities (abdominal aortic aneurysm and renal stones) than the others (acute appendicitis, cholelithiasis, and cholecystitis). CONCLUSION: Bedside ultrasound can accurately identify the etiology of acute nontraumatic abdominal pain in the hands of emergency physicians.

Risk factors of delayed pre-hospital treatment seeking in patients with acute coronary syndrome: A prospective study.

OBJECTIVES: Despite enormous efforts in public education, treatment seeking time still remains more than optimal in patients with acute coronary syndrome. This prospective study tries to determine the risk factors of pre-hospital delay in patients with acute coronary syndrome. METHODS: Descriptive data of 190 patients with diagnosis of acute coronary syndrome attending in 2 tertiary level teaching hospital emergency departments were analyzed to determine risk factors of delayed pre-hospital treatment seeking. Demographic, social and clinical characteristics of patients were obtained and they were asked to fully describe their symptoms and the actions they had done after their symptoms onset. RESULTS: Thirty nine (20.52%) of patients were arrived in emergency department in <1 h of their symptoms onset, 73 (38.43%) were arrived between 1 and 6 h and 78 (41.05%) were arrived in >6 h. Sex, route of transport, scene-to-hospital distance, attributing the symptoms to non-cardiac causes and outpatient physician consultation and cigarette smoking were the risk factors of delayed treatment seeking in our studied patients with acute coronary syndrome. Patients with previous history of ischemic heart disease and Coronary Care Unit admission and patients with underlying diseases like diabetes mellitus, hypertension and hyperlipidemia showed a trend to have more delayed treatment seeking behavior but not with a statistically significant difference. Patients with positive family history of acute coronary syndrome arrived in emergency department earlier than other patients but again with not a statistically significant difference. CONCLUSION: Most patients with acute coronary syndrome arrived in emergency department in >6 h of their symptoms onset. Sex, route of transport, scene-to-hospital distance, attributing the symptoms to non-cardiac origins, outpatient physician consultation and cigarette smoking were risk factors of delayed treatment seeking in studied patients.

Hydrogels for ocular drug delivery and tissue engineering.

Hydrogels, as crosslinked polymeric three dimensional networks, possess unique structure and behavior in response to the internal and/or external stimuli. As a result, they offer great prospective applications in drug delivery, cell therapy and human tissue engineering. Here, we highlight the potential of hydrogels in prolonged intraocular drug delivery and ocular surface therapy using stem cells incorporated hydrogels.

Ultrasound-guided hematoma block in distal radial fracture reduction: a randomised clinical trial.

OBJECTIVE: We compared the efficacy and safety of ultrasound-guided haematoma block with that of procedural sedation and analgesia in patients with acute distal radial fracture reduction pain control. METHODS: This was a randomised clinical trial on adult patients conducted in two teaching hospitals. Patients received intravenous midazolam plus fentanyl in the procedural sedation and analgesia group, and fracture site injection of lidocaine 10% in the ultrasound guided haematoma block group. We measured pain scores before reduction, during reduction and 5, 10 and 15 min after reduction by a numeric rating scale, and patient and physician satisfaction by a four-level Likert scale. Time to discharge, early adverse effects and late complications were also compared. RESULTS: We enrolled 160 patients with distal radial fracture and randomised 143 patients into two groups (after excluding 17 patients). Pain was effectively controlled in both groups. Pain scores had no statistically significant difference before and during reduction and 5 and 15 min after reduction in the procedural sedation and analgesia and ultrasound guided haematoma block groups. Patient and physician overall satisfaction were similar in the two groups. Time to discharge was significantly lower in the ultrasound guided haematoma block group. Four patients (5.5%) in the procedural sedation and analgesia group showed early adverse effects. No patient in either group showed any late complications. CONCLUSIONS: Ultrasound guided haematoma block may be a safe and effective alternative to procedural sedation and analgesia. TRIAL REGISTRATION NUMBER: 201112308104N5.

Oral verapamil in paroxysmal supraventricular tachycardia recurrence control: a randomized clinical trial.

BACKGROUND: Adenosine is the first-line medication in patients with paroxysmal supraventricular tachycardia. Because it is cleared so rapidly from the circulation, recurrence of paroxysmal supraventricular tachycardia after initial successful conversion may occur. OBJECTIVE: This study was conducted to evaluate the role of oral verapamil administration to control early recurrences of paroxysmal supraventricular tachycardia after adenosine infusion. METHODS: Patients with acute paroxysmal supraventricular tachycardia and no contraindications for adenosine or verapamil treatment were included in study. All patients received an adenosine protocol (6 mg rapid bolus intravenous injection followed by two repeated doses of 12 mg if necessary). Patients in the adenosine-only group did not received any other medications but patients in the adenosine/verapamil group received 40 mg verapamil orally immediately after converting the rhythm to sinus rhythm. All patients were followed up for 6 h in the acute care area of the emergency department under continuous cardiac monitoring. RESULTS: A total of 113 patients were assessed for eligibility and 92 patients were randomized into two groups (adenosine only versus adenosine/verapamil). There was no statistically significant difference in paroxysmal supraventricular tachycardia recurrence rate between the two groups in the first 30 min after treatment. Recurrence rate was statistically significantly lower in the adenosine/verapamil group than in the adenosine-only group between 30 and 120 min after treatment and thereafter. Two patients in the adenosine-only group experienced flushing and one patient in the adenosine/verapamil group experienced decreased systolic blood pressure. CONCLUSION: Oral verapamil can decrease paroxysmal supraventricular tachycardia recurrence after successful control with intravenous adenosine.

Oral oxycodone plus intravenous acetaminophen versus intravenous morphine sulfate in acute bone fracture pain control: a double-blind placebo-controlled randomized clinical trial.

OBJECTIVES: Bone fracture is a common cause of acute pain in emergency and orthopedics departments. Targeting the multifaceted mechanisms of pain with combinations of multiple analgesics (multimodal analgesia) can increase the pain control efforts efficacy and decrease the adverse effects of each medication. METHODS: One hundred and fifty-three patients with acute bone fracture were randomly allocated to two groups receiving intravenous morphine sulfate (74 patients) or oral oxycodone plus intravenous acetaminophen (79 patients). Pain scores and drugs' adverse effects were assessed 10, 30 and 60 min after treatment. RESULTS: Pain scores were similar between groups before, 30 and 60 min after medication but patients in morphine sulfate group experienced less pain 10 min after medication. Eight (10.8%) patients in morphine sulfate group and 26 (32.9%) patients in acetaminophen/oxycodone group experienced nausea that was statistically significant higher (P value = 0.001). Itching was seen in 12 (15.1%) patients of acetaminophen/oxycodone group and three (4.0%) patients of patients in morphine sulfate group (P value = 0.02). CONCLUSION: Intravenous acetaminophen plus oral oxycodone is as effective as intravenous morphine sulfate in acute pain control in emergency department but with a less desirable safety profile.

Serum S100B Protein as an Outcome Prediction Tool in Emergency Department Patients with Traumatic Brain Injury.

OBJECTIVES: Traumatic brain injury is a common cause of death and disability worldwide. Early recognition of patients with brain cellular damage allows for early rehabilitation and patient outcome improvement. METHODS: In this prospective study, the clinical conditions of patients with mild to moderate traumatic brain injury (TBI) were assessed, and patient serum S100B levels were measured. Patients were followed up one month later and evaluated for level of consciousness, presence or absence of post-traumatic headache, and daily activity performance (using the Barthel scale). Student's t-test and the chi-square test were used for data analysis, which was performed using SPSS software. RESULTS: The mean serum S100B value was significantly lower for patients with minor TBI than for patients with moderate TBI (23.1±14.2 ng/dl and 134.0±245.0 ng/dl, respectively). Patients with normal CT scans also had statistically significantly lower serum S100B levels than patients with abnormal CT findings. The mean S100B value was statistically significantly higher for patients with suspected diffused axonal injury (632.18±516.1 ng/dl) than for patients with other abnormal CT findings (p=0.000): 24.97±22.9 ng/dl in patients with normal CT results; 41.56±25.7 ng/dl in patients with skull bone fracture; 57.38 ±28.9 ng/dl in patients with intracranial hemorrhage; and 76.23±38.3 ng/dl in patients with fracture plus intracranial hemorrhage). CONCLUSIONS: Serum S100B levels increase in patients with minor to moderate TBIs, especially in those with diffused axonal injury. However, serum S100B values cannot accurately predict one-month neuropsychological outcomes and performance.

Operating characteristics of a qualitative troponin assay for the diagnosis of acute coronary syndrome.

The troponin I serum level is widely used in acute coronary syndrome patients for their classification. The qualitative assay is faster and more available than the quantitative assay. The objective was to determine the operating characteristics of a qualitative troponin I assay compared with a quantitative method. This is a prospective observational study and patients suspected to have acute coronary syndrome were enrolled. A rapid troponin I test and a quantitative assay were carried out for each patient on arrival and 6 h after admission. A total of 262 patients were enrolled. The degree of agreement between the second rapid qualitative and quantitative troponin I was excellent (κ=0.946; 95% confidence interval, 0.903-0.989). The sensitivity, specificity, negative predictive value, and positive predictive value of the rapid qualitative troponin I test were 92.6, 100, 96.8, and 100%, respectively. In conclusion, this study reveals an excellent agreement between quantitative and qualitative bedside assays 6 h after admission in a sample of Iranian patients in the emergency department.

Accuracy of emergency physician-performed ultrasound in detecting traumatic pneumothorax after a 2-h training course.

BACKGROUND: Pneumothorax is one of the leading causes of preventable death in trauma patients. Chest radiograph has a lower sensitivity than a computed tomography (CT) scan for the diagnosis of pneumothorax. OBJECTIVES: The objective of this study is to assess the accuracy of ultrasound (US) in diagnosing post-traumatic pneumothorax using a simplified diagnostic algorithm. METHODS: This prospective study was carried out in two academic emergency departments with a combined annual emergency department census of 70 000 visits per year by convenient sampling. Emergency physicians underwent a 2-h training course using a two-step diagnostic algorithm. The trauma patients included suspected of having post-traumatic pneumothorax were evaluated by thoracic US and chest CT scan. The accuracy of US in identifying pneumothorax was measured by calculating the sensitivity, specificity, positive predictor value, and negative predictor value using CT scan as the gold standard. The performance of US was compared with chest radiograph, which was also done as a part of standard trauma care for all patients. RESULTS: From June 2009 until July 2009, a total of 153 patients were included. US had a sensitivity of 86.4%, a specificity of 100%, a positive predictor value of 100%, and a negative predictor value of 95.6%. Chest radiograph showed a sensitivity of 48.6%, a specificity of 100%, a positive predictor value of 100%, and a negative predictor value of 85.1%. The mean time to perform chest radiograph was 12 min, which was significantly higher than US, with a mean time of 2 min. All missed pneumothoraces in US evaluation were small in size. CONCLUSION: After just a 2-h training course, emergency physicians showed a good success rate in finding pneumothoraces. Thoracic US can be an easy to learn and an accurate diagnostic modality for the detection of traumatic pneumothorax in emergency departments.

Comparison of diagnostic value of conventional ultrasonography by emergency physicians with Doppler ultrasonography by radiology physicians for diagnosis of deep vein thrombosis.

OBJECTIVES: To determine sensitivity, specificity and other operating characteristics of bedside three-point compression ultrasonography performed in emergency department by emergency physicians in comparison with duplex ultrasonography. METHODS: The cross-sectional study at Rasoul-e-Akram Hospital in Tehran, Iran, prospectively evaluated 81 suspected patients of lower extremity deep vein thrombosis between March 2006 and March 2007. A trained second-year resident and one attending physician of emergency medicine evaluated the veins of all the patients with through compression ultrasonography. Then, a second-year resident of radiology assessed the patients with duplex ultrasonography. Finally, data were compared and quantitative and categorical variables were worked out along with other statistical analysis through SPSS version 16. RESULTS: The mean age of the patients was 47.2 +/- 18.6 years. When cases who lost the compressibility of at least one of their femoral or popliteal veins were considered to be positive, there were 80.2% diagnosed by compression ultrasonography and 79% by the duplex variety. Sensitivity, specificity and accuracy of the former in comparison with the latter were 85.9%, 41.2% and 84.6% respectively. CONCLUSION: Compression ultrasonography has relatively an acceptable sensitivity and accuracy level, but has low specificity in the diagnosis of deep vein thrombosis in the hands of Iranian emergency physicians. It is better to implement duplex ultrasonography whenever accessible. Otherwise, compression ultrasonography results should be compared with the results of duplex ultrasonography as soon as possible.

Sublingual buprenorphine in acute pain management: a double-blind randomized clinical trial.

STUDY OBJECTIVE: We compare the efficacy and safety of sublingual buprenorphine versus intravenous morphine sulfate in emergency department adults with acute bone fracture. METHODS: Enrolled patients received buprenorphine 0.4 mg sublingually or morphine 5 mg intravenously in this double-blind, double-dummy, randomized controlled trial. Patients graded their pain with a standard 11-point numeric rating scale before medication administration and 30 and 60 minutes after, and we recorded adverse reactions. RESULTS: We analyzed 44 and 45 patients in the buprenorphine and morphine groups, respectively. Mean pain scores were similar at 30 minutes (5.0 versus 5.0; difference 0; 95% confidence interval -0.6 to 0.8) and at 60 minutes (2.2 versus 2.2; difference 0; 95% confidence interval -0.3 to 0.3). Adverse effects observed within 30 minutes were nausea (14% versus 12%), dizziness (14% versus 22%), and hypotension (4% versus 18%). CONCLUSION: For adults with acute fractures, buprenorphine 0.4 mg sublingually is as effective and safe as morphine 5 mg intravenously.