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A new domain of "personal and professional development" was introduced as a core competency of health-care providers. This study aimed to explore the experiences of learners and faculty members about what competencies or skills were essential for the professional development and success of health-care providers.This is a qualitative study using an inductive content analysis approach in 2019-2020. In the present study, 58 academic faculty members participated by purposeful sampling including ten associate professors (17.24%) and 24 assistance professors (41.37%), in addition to 23-year medical residents (20.65%) and 4The qualitative data were classified in 953 open codes and eight categories, which were further divided into four main categories: "socio-emotional skills," "life-long learning skills," "coping skills," and "well-being strategies."The present results showed socioemotional and coping skills affect interpersonal and professional interactions that contributed to their improved health-care providers' capabilities. Participants also considered lifelong learning as influential in developing professional capabilities and keeping their knowledge and skills up-to-date for accountability to duties. Moreover, using well-being strategies protects the mental and physical health of health-care providers. These skills are synergistic, and their combination can have a significant role in improving the personal and professional capabilities.

This study aimed to compare the diagnostic accuracy of heart, lung and inferior vena cava (IVC) ultrasonography modalities, alone and combined, for possible added accuracy in diagnosing acute decompensated heart failure (ADHF), in a group of patients with the final diagnosis of ADHF based on plasma level of B-type natriuretic peptide (BNP) as the standard. The present study is a diagnostic accuracy study, which was carried out in the emergency department of Imam Khomeini hospital, affiliated to Tehran University of Medical Sciences, in 2014–2015. All patients over 18 years old, who were referred to emergency department with complaint of acute dyspnea were regarded as eligible and no exclusion criteria were considered. All ultrasounds were performed by a trained emergency medicine resident and then saved and classified for each patient, separately, and reviewed by the attending emergency medicine physician. In this study, patients with BNP levels higher than 500 pg/ml were considered positive for dyspnea caused by heart failure. A total of 120 patients with an average age of 60.83 ± 16.528 years were studied, 64 (53%) of which were male. In total, 47.5% of patients had a BNP level over 500 pg/ml. Among patients with positive ultrasound, 94.7% were true positive and among those with a negative ultrasound, 61.4% were true negative. Based on the findings, B-line ≥ 10 has the highest specificity and left ventricular ejection fraction (LVEF)

Introduction: It is likely that high rate of healthcare workers (HCWs) infection has occurred in Iran, but there is not any proof yet. Objective: This study was conducted to highlight the rate of Iranian HCWs infected by COVID-19 and some of its surrounding points. Methods: This cross-sectional study was conducted in Tehran, Iran. Using web-based applications including WhatsApp, Telegram, Instagram and Facebook, the link to the questionnaire was sent and exposed to the eligible ones. The target population of the study was HCWs who were diagnosed as approved cases of COVID-19. They were asked about their baseline characteristics and also possible source of infection, symptoms onset, hospitalization and etc. All findings presented by frequency and percent. Results: From March 29, 2020 to April 5, 2020, a total of 452 HCWs had completed the online questionnaire of whom 50.9% were women; mostly were in the age range of 25-29 years old. Among the participants, physicians had the largest population with 312 people (69.0%). The most frequent clinical symptoms were fatigue, fever and myalgia, respectively. The highest frequency with 85 cases (18.8%) was reported their symptoms onset within 20-24th February, 2020. The most commonly used piece of equipment was gloves, which was used in 57.3% of the cases, followed by simple surgical mask, which was used by 47.1% of the participants. In 21.9% cases no personal protective equipment was used. Totally, 348 cases (91.6%) were treated in an outpatient setting and only 36 cases (9.5%) needed to be hospitalized. In 160 cases (35.4%), at least one other person was infected with COVID-19 in their household. Conclusions: Considerable number of participants that declared their infection in this study, emphasizes on the considerable rate of Iranian HCWs infected by COVID-19.

Background This study performed to assess the efficacy of ultrasound in screening upper and lower extremities fractures in comparison with standard X-ray in pediatric trauma patients. Materials and Methods This was a prospective diagnostic study conducted at the emergency department of Imam Khomeini Complex Hospital, Tehran, Iran. All patients with the age under 18-year-old admitted with limb trauma were first evaluated by attending emergency medicine physician using ultrasound and then underwent necessary X-rays. Thereafter, the ultrasound reports were compared with X-ray reports regarding measurement of its accuracy. Results Forty patients with the mean age of 9.47 ± 5.26 years (minimum of 2 and a maximum of 17 years) entered the study (75% were male). The average time of performing ultrasound in pediatric population is 3.99± 0.83 minutes which is statistically significant compared to X-ray, 16.12 ± 4.15 minutes (P

In this study, the impact of contrast-enhanced abdominopelvic CT scan interpretations by emergency medicine team on patients’ morbidity and mortality was evaluated and their interpretations were compared to radiologists’ reports. During a 3-month period, all patients who had undergone a contrast-enhanced abdominopelvic CT scan at the emergency department enrolled in this study. All CT scans were interpreted blindly by the emergency medicine (ED) attending physicians and the patients were treated accordingly. Radiologists reported all the CT scans within 12 h. Radiologists’ reports were put into the agreement or disagreement group retrospectively. A panel of experts further evaluated the disagreement groups’ medical charts and placed them in clinically significant or insignificant group based on the follow-up for 28 days. In this study, 170 CT scans were interpreted. The agreement rate was 68.2%. In the clinically significant disagreement group, eight patients did not receive the required treatment and three patients were over treated. Although the overall mortality rate was 5, none could have been prevented by a prompt radiologist’s report. The disagreement group had longer hospital stay (p = 0.006) and transfer to other wards (p = 0.035). The inter-rater reliability between emergency medicine attending physicians and attending radiologists was substantial (kappa = 0.77) and statistically significant (p

Background Ultrasound can be used to facilitate lumbar puncture, especially in obese patients. Methods In this study, midline and paramedian approaches with curved and linear transducers were compared in patients with Body Mass Index (BMI) above 25 kg/m2 for the identification of spinal landmarks. In each view, six major landmarks, including spinous process, ligamentum flavum, laminae, epidural space, subarachnoid space and posterior longitudinal ligament, were detected by emergency medicine residents and were then reviewed by radiologists. Results Sixty patients with a mean BMI of 29.18 enrolled in the study. This study showed that a curved transducer detected major landmarks more accurately compared to a linear transducer. There was also a poor kappa correlation between these transducers in the midline and paramedian approaches. Conclusion This study showed that ultrasound can detect lumbar landmarks in overweight and obese patients, with the paramedian approach and a curved transducer being superior to the midline approach and a linear transducer in detecting these landmarks.

Background There were numerous studies using acupuncture for pain relief and in most, the effect of this technique on preventing migraine attacks has been investigated. In those several studies that surveyed the effect of acupuncture on treatment of migraine headaches, the conclusion was not completely persuaded and they suggested further researches on this topic. Objectives The purpose of this study is to examine the effect of acupuncture on controlling acute migraine attacks. Methods This study was a single blinded randomized clinical trial that was conducted on patients with a diagnosis of acute migraine attacks. At the time of reference, the patient’s pain intensity was measured and recorded in a written checklist. Acupuncture was done in the intervention group with thin metallic needles, which enter certain points in the ear’s skin; including shen men, autonomic, thalamus, frontal, and temple. In the placebo group, similar needles were used, however, they were inserted into unusual points. Thereafter, in 30 minutes, one, two, and four hours after the treatment, the pain intensity was also asked and compared with the reference time’s score. Results A total of 60 patients with the mean age of 31.4 ± 7.6 years were enrolled and 83.3% of them were women. There was no significant difference between two groups in terms of the baseline characteristics of participants including age, sex and pain duration before admission (P > 0.05). According to the results, there was a significant difference between the two groups on the checkpoints of 15, 30, 45, and 60 minutes after acupuncture (P < 0.05); however, the pain scores were not statistically different between the two groups on two, three, and four hours after intervention (P > 0.05). Conclusions Based on the findings of our study, although the pain score was lower in the intervention group than the control group during first hour after the acupuncture, there was no significant change in pain score thereafter. Comparison of the two groups showed no differences between acupuncture and placebo acupuncture on decreasing the mean pain score.

Background: This study aimed to assess satisfaction of emergency medicine residents and specialists. Methods: This was a cross-sectional survey conducted in Tehran, Iran. All emergency medicine specialists and residents in Iran at the time of study were eligible and included. A modified questionnaire, originally developed by Lloyd et al. was used. The final statistical analysis was done on the questionnaires. Results: A total of, 210 questionnaires from 143 residents and 67 emergency medicine specialists were collected. The overall satisfaction in specialists and residents was 50% and 42%, respectively (P < 0.05). The status of specialists’ recruitment, managerial aspects, available facilities, current lifestyle, and challenges related to the job, showed significant differences. Conclusions: Based on the findings of this study, although both residents and specialist satisfaction rates were at a moderate level, however, specialists were more satisfied with their job in comparison to residents.

A healthy 24-year-old female presented at the emergency department (ED) after a car accident with ambulance while injured severely after the bus got run over her lower limb. As the trauma team was activated, her primary survey was started: Ac (Airway and cervical collar): She was awake and could talk. Cervical collar was fixed, oxygenation with face mask was started. B (Breathing): Her chest rising was symmetrical without any laceration or abrasion. Chest auscultation was clear and there was no tenderness or crepitation on palpation. No tracheal shift was found. She had normal respiratory rate and O2 saturation of 94% at ambient air. C (Circulation): Two large bore IV lines were inserted and blood samples were obtained. Her vital signs were BP = 60/40 mmHg, PR = 130/min, RR = 12. E-FAST was performed which was negative for free fluid in abdomen, pelvis and thorax, tamponade, and hemopneumothorax. Her pelvis was unstable on examination and pelvic wrapping was performed with sheath. IV fluid therapy with normal saline was started followed by 3 units of packed RBC transfusion. More pack cells and FFP were also requested. D (Disability): She had Glasgow coma scale of 15/15 with normal size and reactive pupil. No neurologic deficit was found except disability of lower extremities due to crush injury. E (Exposure): She had no midline spinal tenderness with normal sphincter anal tone, but there was a laceration in the perineum which extended to the vagina. Portable chest and pelvic x-ray as an adjutant to primary survey were performed which showed type C pelvic fracture. On her secondary survey, she had abrasion on her scalp, 1.5 cm laceration on her right tibia, deformity of her right thigh, and laceration in her genitalia with some vaginal bleeding. Direct pressure was applied and all lacerations were packed. According to negative e-FAST and pelvic fracture and shock, since the angiography was not available, it was decided to fix the pelvis with external fixator in the operation room. After the fixation, and because shock persisted, operative pelvic packing was undertaken. Unfortunately, she suffered cardiorespiratory arrest in the operating room and died.

Clinical assessment and classification of shock is extremely difficult to conduct on critically ill patients especially upon arrival at the emergency department. Resuscitative point-of-care ultrasound could be used for rapid initial diagnosis and better management. In this study, the results of using the RUSH (Rapid Ultrasound in Shock) exam to determine the type of shock in the emergency department are compared to the final diagnosis of patients. This was a single-center prospective study in which all patients with an unknown type of shock and no prior treatment were included. Parallel to the standard resuscitative management and diagnosis of the emergency team, the RUSH exam was performed blindly on the patient by an emergency medicine staff who was not part of the patient's caregiving team. The results of the RUSH exam were then compared to the final diagnosis of the patients and the 48-h outcome. Twenty-five patients were enrolled in this study. The overall kappa correlation of the RUSH exam compared with the final diagnosis was 0.84 which is an almost perfect agreement. The overall sensitivity of the RUSH exam was 88 % and the specificity was 96 %. Although the mortality rate was 64 %, there was not a significant relationship between mortality and the protocol used for diagnosis. The RUSH exam could be used in emergency wards to detect types of shock.

Introduction: Artificial intelligence (AI) is the development of computer systems which are capable of doing human intelligence tasks such as decision making and problem solving. AI-based tools have been used for predicting various factors in medicine including risk stratification, diagnosis and choice of treatment. AI can also be of considerable help in emergency departments, especially patients’ triage. Objective: This study was undertaken to evaluate the application of AI in patients presenting with acute abdominal pain to estimate emergency severity index version 4 (ESI-4) score without the estimate of the required resources. Methods: A mixed-model approach was used for predicting the ESI-4 score. Seventy percent of the patient cases were used for training the models and the remaining 30% for testing the accuracy of the models. During the training phase, patients were randomly selected and were given to systems for analysis. The output, which was the level of triage, was compared with the gold standard (emergency medicine physician). During the test phase of the study, another group of randomly selected patients were evaluated by the systems and the results were then compared with the gold standard. Results: Totally, 215 patients who were triaged by the emergency medicine specialist were enrolled in the study. Triage Levels 1 and 5 were omitted due to low number of cases. In triage Level 2, all systems showed fair level of prediction with Neural Network being the highest. In Level 3, all systems again showed fair level of prediction. However, in triage Level 4, decision tree was the only system with fair prediction. Conclusion: The application of AI in triage of patients with acute abdominal pain resulted in a model with acceptable level of accuracy. The model works with optimized number of input variables for quick assessment.

Introduction This study was designed to assess the possible superiority of intravenous lidocaine to morphine for pain management. Methods This was a randomized double blind controlled superiority trial, carried on in the emergency department (ED). Traumatic patients older than 18-year-old with the complaint of acute pain greater than 4 on a numeric rating scale (NRS) from 0 to 10 on their extremities were eligible. One group received IV lidocaine (1.5 mg/kg), and the other received IV morphine (0.1 mg/kg). Pain scores and adverse effects were assessed at 15, 30, 45 and 60 minutes and patients' satisfaction was evaluated two hours later. A minimum pain score reduction of 1.3 from baseline was considered clinically significant. Results Fifty patients with the mean age of 31.28 ± 8.7 were enrolled (78% male). The demographic characteristics and pain scores of the two groups was similar. The on-arrival mean pain scores in two groups were, lidocaine: 7.9 ± 1.4 and morphine: 8.0 ± 1.4 (p = 0.57) and after 1 hour were, lidocaine: 2.28 ± 1.2 and morphine: 3.2 ± 1.7. Although the pain score decreased significantly in both group (p = 0.027), there were not any clinically and statistically significant difference between the two groups (p = 0.77). Patients' satisfaction with pain management in both groups were almost similar (p = 0.49). Conclusion The reduction in pain score using IV lidocaine is not superior to IV morphine in adult ED patients with traumatic limb pain.

Requesting non-enhanced brain CT scans for trauma and non-trauma patients in ER is very common. In this study, the impact of incorrect brain CT scan interpretations by emergency medicine team on patients’ primary and secondary outcome was evaluated in the setting where neuroradiologist reports are not always available. During a 3-month period, 450 patients were enrolled and followed for 28 days. All CT scans were interpreted by the emergency medicine team, and the patients were managed accordingly. Neuroradiologists’ reports were considered as gold standard, and the patients were then grouped into the agreement or disagreement group. A panel of experts further evaluated the disagreement group and placed them in clinically significant and insignificant. The agreement rate between emergency medicine team and neuroradiologists was 86.4 %. The inter-rater reliability between emergency team and neuroradiologists was substantial (kappa = 0.68) and statistically significant (p < 0.0001). Only five patients did not receive the necessary management, and among them, only one patient died, and 12 patients received unnecessary management including repeated CT scan, brain MRI, and lumbar puncture. Forty-one patients were managed clinically appropriate in spite of misinterpretation. A 28-day follow-up showed a mortality rate of 0.2 %; however, expert panel believed the death of this patient was not related to the CT scan misinterpretation. We conclude that although the disagreement rate in this study was 13.6 %, primary and secondary outcomes were not clinically jeopardized according to the expert panel idea and 28-day follow-up results.

Objective Intravenous morphine has been used as a common method of pain control in emergency care. Nebulized fentanyl is also an effective temporary substitute. This study was designed to compare the effectiveness of nebulized fentanyl with intravenous (IV) morphine on management of acute limb pain. Methods This was a placebo-controlled, double-blind randomized clinical trial. Ninety emergency department patients with moderate to severe pain aged 15 to 50 years were blocked randomized and enrolled in this study. Forty-seven patients in the experimental group received nebulized fentanyl (4 μ g/kg) and IV normal saline as placebo, and the remaining 43 patients in the control group received IV morphine (0.1 mg/kg) and nebulized normal saline as placebo. All participants' pain scores were assessed by Numerical Rating Scale before and after intervention at 5-, 10-, 15-, 30-, 45-, and 60-minute intervals. Patients' vital sign and possible adverse effects were recorded respectively. Finally, all participants were assessed for their satisfaction. Results The mean initial pain score in the experimental group was 8.7 and 8.4 in the control group ( P = .1). Pain relief in both groups after 5 and 10 minutes were similar ( P = .72). Although the pain relief was significantly greater with fentanyl at 15 minutes, this difference is not clinically significant. Pain management in both groups was successful and was more than 3 scores reduction in Numerical Rating Scale. Patient satisfaction in both groups was similar. No adverse effects were reported in the experimental group. Conclusion This study suggests that nebulized fentanyl is a rapid, safe, and effective method for temporary control of acute limb pain in emergency department patients.

Using ultrasound for detecting soft tissue foreign bodies seems to be the preferred choice with minimum invasion and easy availability at the bedside in emergency departments. In this study, a workshop (1 hour of lecture presentation and 3 hours of interactive hands-on) was designed to evaluate the efficacy of a short course of simple interactive training to improve the ability of emergency medicine residents to detect foreign bodies with ultrasound. Eight pieces of fresh full thickness (10 × 10 × 10 cm) lamb leg muscle were used in this study. Five different types of foreign bodies, including: a piece of glass (5 × 5 × 4 mm), wood (5 × 5 × 4 mm), gravel (5 mm diameter), plastic (5 × 5 × 2 mm) and a nail (25 mm in length) were placed deep inside each lamb leg. An ultrasound machine with a 7.5 MHz linear probe was used in this study. 35 emergency medicine residents (12 PGY1, 11 PGY2 and 12 PGY3) were enrolled in this study. Pretest and post-test results were compared and analyzed. Among all 35 participants in the training session, foreign body detection was significantly improved after the workshop ( p

Background The purpose of this study was to report interaction patterns among Iranian authors of emergency medicine using social network analysis methodology, focusing on coauthorship network. Methods The bibliographic data of Iranian authors on the ‘emergency medicine’ field during the years 2001–2011 were retrieved from the Science Citation Index Expanded database. Co-occurrence matrices were made by BibExcel and were imported to Ucinet and NetDraw to delineate coauthorship network. To detect structural patterns among authors, we considered some measures of social network analysis, such as density, centralisation indices, component analysis and cut-points. Lastly, subject experts separately analysed the content of papers. Results Of 116 papers published, the network was composed of 10 components, with the largest component having 25 authors. Using social network analysis measures, we identified science bottlenecks in knowledge sharing, hub authors and accelerators of information flow. Topic analysis showed ‘Wounds and Injuries’ as the most recent theme in all components because of existence of national registry for trauma, high burden of road traffic injuries and research priority of injuries in Iran. Conclusions because of Iranian low productivity in the emergency medicine field, social network analysis seems to be a proper option for bibliometrics to identify central authors and detect knowledge structure in this field.

Background Deep vein thrombosis (DVT) is prevalent in the emergency departments. Nearly 60% of them may lead to pulmonary embolism. A complete color-flow duplex ultrasound (CFDU), performed by the radiologists, is the most common diagnostic method used to detect DVT. A limited B-mode compression technique (BMCT) can also be useful for the emergency specialists visiting suspicious cases. Objectives The purpose of this study was to compare the sensitivity, specificity, and accuracy of a BMCT done by emergency medicine residents with that of a CFDU in diagnosing the proximal DVT of lower extremities. Methods This prospective study was conducted on 74 patients (41 men and 33 women) presenting with painful and swollen lower limbs in the emergency department of Imam Khomeini Hospital. First, the affected lower extremity was examined by a BMCT carried out by one of the 2 emergency medicine residents. Then, the CFDU was performed by a radiologist blinded to the results of the BMCT. The sensitivity, specificity, and accuracy of the BMCT were compared with that of the CFDU as a gold standard. Results The mean age of the patients was 55.16 ± 17.4 years. Positive results were reported in 35 patients (47.3%) using the 2 tests. Compared with CFDU, BMCT had a sensitivity, specificity, accuracy, positive predictive values, and negative predictive values of 100%. Conclusion These findings suggest that BMCT performed by the emergency medicine specialists to diagnose proximal DVT of lower extremities is not only an acceptable method but also less time-consuming when compared with CFDU.

In Iran, few studies have evaluated emergency medicine as a career option. In the present study, we aimed to find out how Iranian emergency-medicine specialists view their specialty as a career.Following a qualitative study, a Likert-scale questionnaire was developed. Iranian emergency physician specialists who had at least two years' job experience were contacted via email. A uniform link to a Web-based survey and a cover letter that explained the survey were sent to the recipients. We used the Kruskal-Wallis test and post hoc analysis to determine the differences between demographic subgroups.A total of 109 eligible responses were received, a response rate of 72.63%. Of the responders, 57.8% were 30-40 years of age, 86.2% were male, 86.2% were single, 84.4% were faculty members and 90.8% had fewer than 10 years' job experience. The main problems occurring during the career of Iranian emergency physicians were: insufficient income, inadequate recognition of the specialty by the community, inadequate union support, insecurity in the emergency wards, overcrowding, job stresses and night shifts. Despite insufficiency of income, Iranian emergency physicians (EPs) did not care about the financial benefits of patient care. Academic activity had positive effects on the perspectives of Iranian emergency physicians regarding their careers.Iranian emergency physicians and leaders in emergency medicine should struggle to improve the present situation, aiming at an ideal state.

Background Sleep deprivation resulting from night shifts, is a major cause of burnout among physicians. Exogenous melatonin may improve sleep quality in night-shift workers. The study aims to compare the effectiveness of melatonin versus placebo on sleep efficiency in emergency medicine (EM) residents. Methods A randomized, double-blind, replicated crossover trial was performed on EM residents. This study consisted of 4 phases within a month with intervention periods of 2 nights and washouts of 6 days. In our study, EM residents had nine-hour shifts on 6 consecutive days, 2 mornings, 2 evenings and 2 nights and then 2 days off. At the end of shifts' cycle, 24 EM residents were given 3 mg melatonin or placebo (12 in each arm of the study) for 2 consecutive nights after the second night shift with crossover to the other arm after a six-day off drug. This crossover intervention was repeated for two more another time. Finally, we created 48 cases and comparisons in each arm. Different items related to sleep quality were assessed and compared both within the same group and between the two groups. Results In the melatonin group, daytime sleepiness (calculated by Karolinska Sleep Scale) had a significant reduction after taking the second dose of drug (P=0.003) but the same result was not observed when comparing the 2 groups. Mood status (calculated by Profile of Mood States) showed no remarkable difference between the 2 groups. Conclusion Melatonin might have a limited benefit on sleep quality in EM residents working night shifts.

The aim of this study was to compare pain levels from arterial blood gas (ABG) sampling performed with or without application of lidocaine via jet injector.Pain is still a primary concern in the emergency department. Arterial blood gas sampling is a very painful procedure. No better technique for decreasing the pain of the ABG procedure has been presented. An ideal local anesthesia procedure for ABG sampling should be rapid, easily learned, inexpensive, and free of needlestick risk.We evaluated the effectiveness of a lidocaine jet injection technique in achieving satisfactory pain control in patients undergoing ABG sampling. Forty-two patients were randomized to 2 groups: group A, which received lidocaine by jet injection (0.2 mL of lidocaine 2%), and group B, a control group that received a topical application of 1 mL of lidocaine gel 2% 2 minutes before the ABG sampling. Pain was assessed on a 10-cm visual analog scale (0, absence of pain; 10, greatest imaginable pain).The pain visual analog scale score during ABG sampling was considerably lower in group A compared with group B (1.29 ± 0.90 vs 4.19 ± 1.43; P.001). The number of attempts required for ABG sampling was significantly lower in group A compared with group B (1.29 ± 0.46 vs 2.1 ± 0.12; P = .009). All residents reported ease of use with the lidocaine jet injection procedure (P.05).Lidocaine jet injection provides beneficial and rapid anesthesia, resulting in less pain and a greater rate of successful ABG sampling. Therefore, it is recommended for use before ABG sampling to decrease the patient's pain and the number of unsuccessful attempts and to enhance the patient's satisfaction.

Objective The present study aims to assess the influence of ultra-low doses of opioid antagonists on the analgesic properties of opioids and their side effects. Methods In the present randomized, double-blind controlled trial, the influence of the combination of ultra-low-dose naltrexone and morphine on the total opioid requirement and the frequency of the subsequent side effects was compared with that of morphine alone (added with placebo) in patients with trauma in the upper or lower extremities. Results Although the morphine and naltrexone group required 0.04 mg more opioids during the study period, there was no significant difference between the opioid requirements of the 2 groups. Nausea was less frequently reported in patients receiving morphine and naltrexone. Conclusion The combination of ultra-low-dose naltrexone and morphine in extremity trauma does not affect the opioid requirements; it, however, lowers the risk of nausea.

Background The efficacy and safety of enoxaparin in outpatient treatment of deep vein thrombosis have been well studied. The present study aimed to compare the efficacy of a 10-mg loading dose of warfarin with 5 mg of the drug and enoxaparin in achieving the international normalized ratio (INR) range. Methods This randomized clinical trial was performed in the emergency department (ED) of our study. International normalized ratio was checked daily for 7 days and on the 14th day. Based on the patient's INR on the third day, the doses were adjusted. Patients received enoxaparin (1.5 mg/kg per day) simultaneously until the therapeutic range of INR was achieved for 2 consecutive days. Result The side effects were compatible in both groups. There was a significant difference in the INR rates of the 2 groups recorded on the third, fourth, and seventh days. Conclusion The 10-mg loading dose of warfarin induces the therapeutic range of INR earlier than the 5-mg dose without causing any significant difference in the side effects. More cases in the 10-mg group had INR levels higher than 3; the very dose, therefore, is recommended as the loading dose in cases of outpatients with deep vein thrombosis referring to the ED. Tight control of INR, after the third day of treatment, is also recommended in these cases.

Ultralow-dose opioid antagonists can enhance opioid analgesia and prevent tolerance in rodent nociceptive pain assays.