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Solving diagnostic errors is difficult and progress on preventing those errors has been slow since the 2015 National Academy of Medicine report. There are several methods used to improve diagnostic and other errors including voluntary reporting; malpractice claims; patient complaints; physician surveys, random quality reviews and audits, and peer review data which usually evaluates single cases and not the systems that allowed the error. Additionally, manual review of charts is often labor intensive and reviewer dependent. In 2010 we developed an e-Autopsy/e-Biopsy (eA/eB) methodology to aggregate cases with quality/safety/diagnostic issues, focusing on a specific population of patients and conditions. By performing a hybrid review process (cases are first filtered using administrative data followed by standardized manual chart reviews) we can efficiently identify patterns of medical and diagnostic error leading to opportunities for system improvements that have improved care for future patients. We present a detailed methodology for eA/eB studies and describe results from three successful studies on different diagnoses (ectopic pregnancy, abdominal aortic aneurysms, and advanced colon cancer) that illustrate our eA/eB process and how it reveals insights into creating systems that reduce diagnostic and other errors. The eA/eB process is innovative and transferable to other healthcare organizations and settings to identify trends in diagnostic error and other quality issues resulting in improved systems of care.

Background: Functional constipation (FC) is a common major problem in children. This study compared Jujube paste and polyethylene glycol (PEG) as laxative drugs in children with FC. Ziziphus Jujuba Mill (Jujube) was selected according to traditional Iranian medicine because it is native to Iran and a large extent of Asia, is safe and easy to access, with acceptable taste to children. Methods: This randomized controlled clinical trial was performed on 128 children aged 2 to 12 with FC according to Rome IV criteria. Patients were randomly divided into two groups of Jujube paste and PEG and underwent four weeks of treatment. The efficacy, safety, and tolerability of the Jujube oral product were compared with PEG. Results: Following four weeks of therapy, all clinical symptoms of constipation according to Rome IV criteria were improved significantly in both groups (P < 0.05). In all the seven criteria of Rome IV, Jujube paste was as effective as PEG and even stronger in reducing stool stiffness (P < 0.0001). No hazardous side effect was reported in the two groups. Moreover, the medication acceptance rate was higher in the group receiving Jujube paste than in the group receiving PEG. Conclusions: Jujube paste is as effective as PEG in pediatric FC. This product has high nutritional value and antioxidant properties, so it can be a safe substitute for PEG in pediatric FC.

Decreased tissue blood flow causes pressure ulcers due to prolonged pressure on the area, which becomes problematic for immobile individuals. The medical community has often been involved in curing such a problem in individuals with disabilities and immobility. To alleviate this problem, therefore, plenty of investigations are always seeking novel methods. Furthermore, herbal plants are increasingly used owing to the accepted status of plant-derived drugs in recent years. Our female case aged 52 years that was referred to the wound clinic complaining sensory and motor weakness of the upper extremity and sudden paralysis of the lower extremity as of 1 year ago, which was diagnosed as myelitis. She complained of two wounds on both sides of the right and left buttocks with a size of 9 × 5 and another 6 × 4.5 cm from 3 months ago, and a wound with a size of 5 × 4.5 in the sacral area (sacrum) from 20 days prior to the admission. There was tissue necrosis without muscle engagement, osteomyelitis, or tunneling; besides, nasty odors and sludge were absent accounted for in class 3 in the group of wounds. She received starting therapy using Arnebia euchroma oil. As of the 2nd week onward, she was treated very successfully, and the complete wound healing occurred in 8 weeks. The use of A. euchroma for wound healing and reducing infection and inflammation can greatly contribute to the cure of pressure ulcers and can be properly suggested in healing these ulcers.

While medical education continues to evolve away from a two-stage model of preclinical basic science education followed by clinical rotations, medical schools have struggled with how best to integrate basic science education with clinical application in the early educational curriculum. As Course Directors for the entire first year of medical student education at a new medical school, we review three models for the clinical application of basic science education that we utilized in the first year, including clinical retrofitting, parallel session development, and session co-creation.

Pressure ulcers, caused by reduced tissue blood flow because of long pressure on the site, are of the problems of people with immobility. Treatment of this problem has always been one of the problems of medical community with disabled and immobile people. Thus, many studies are always conducted to seek new approaches to reduce this problem. Additionally, given the acceptance of herbal medicines in recent years, using medicinal plants is on the rise. The case was a 52-year-old woman admitted to the wound clinic with a complaint of sensory and motor weakness of the upper limb and sudden paralysis of the lower limb since one year ago, with a diagnosis of myelitis .Her complaints were two wounds on both sides of the right and left buttocks measuring 9 by 5 and another 6 by 4.5 cm from three months ago and a wound with dimensions of 5 by 4.5 in the sacral region (sacrum) from twenty days before the visit. It had necrotic tissue without muscle involvement, osteomyelitis, or tunneling, also there were not bad odor and sludge, considered in class 3 in the category of wounds. Treatment was started for her by Arnebia euchroma ointment. The treatment was very successful from the second week on, and the wounds healed completely in 8 weeks. Using Arnebia euchroma as a wound treatment and reduction of infection and inflammation could be of great help in the treatment of pressure ulcers and a good suggestion in treating these ulcers. Keywords:Pressure ulcer, Wound healing, Arnebia euchroma, Bed sore, Persian traditional medicine

Background: The outbreak of COVID-19 has spread quickly all over the world Apparently, the uncontrolled increases in the inflammatory and the immune processes are its major pathologies Therefore, the use of natural plants containing antioxidant factors for the regulation of the immune system can be useful for the inflicted patients Many epidemic diseases have occurred throughout human history Persian physicians such as Avicenna offered solutions to these epidemics that were helpful in controlling these diseases Objective: In this study, we introduce the herbs according to traditional Persian medicine's point of view that confirm their having antitussive, antipyretic, anti-viral, anti-inflammatory and antioxidant effects Methods: In this regard, a thorough search was done on the detoxifier and immuno-modulatory plants in the Persian medicine books such as Makhzan-ol Advieh” and “Tohfat ol momenin” and “Qanun fi al tib” Then, the herbs that were effective in fever and pulmonary diseases were browsed and arranged, and their pharmacological properties were also searched in the scientific databases Results: This study examined the antipyretic, antitussive and immune-enhancing properties of the plants cited in Persian medicine books and showed that plants such as orange, sweat lemon, citron, myrtle and lavender have antipyretic, antitussive, anti-inflammatory, antioxidant and antimicrobial properties Conclusion: It seems that the introduced plants could be potential candidates for animal studies and clinical trials However, more studies are needed to prove their specific effectiveness © 2020 Open access This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4 0 International License (https://creativecommons org/licenses/by-nc/4 0/)

Objectives: Although Acne vulgaris is a chronic skin disease, which its standard treatment causes therapeutic limitations and some common adverse effects, medicinal plants can be effective in treatment with low adverse effects as combination therapy. Myrtle (Myrtus Communis) has some beneficial properties, which has been administered topically and orally for some skin diseases in Persian medicine. This study aimed to compare the efficacy and safety of Myrtle formula and 1% clindamycin topical solution.Methods: This was a split-face clinical trial that was done on 55 patients with mild to moderate acne vulgaris for 16 weeks. The patients received topical Myrtle solution to the right side of the face (group 1) and clindamycin solution to the left side (group 2) twice daily for 12 weeks. All participants were examined for the acne severity index (ASI) and total acne lesions counting (TLC) at certain times during the study. Then, they stopped using them for four weeks. They also did not take the drug in the final four weeks of the study.Results: Forty-eight patients completed the study for 16 weeks; 40 (83.2%) patients were female and the rest of them were male. The mean age and standard deviation were 25.62 ± 7.62 years. After 12 weeks, the percentage changes of comedones, inflammatory lesions, ASI and TLC were significantly reduced in both groups (p < 0.001). The percentage change of inflammatory lesions and ASI decrease was significantly higher in the group 1 (p = 0.03). There was no significant difference in the incidence of side effects between the two groups. There was a more significant decrease in sebum percentage change in the group 1 (p = 0.003).Conclusion: Myrtle lotion was effective and safe for the treatment of mild to moderate acne vulgaris.

Background. Functional constipation (FC) is a health concern that is prevalent in the pediatric population. It lowers the quality of life and increases the probability of comorbidities. As a complementary modality, herbal medicine has been considered useful in a variety of conditions. Persian medicine (PM) resources mention the Viola flower as an effective herb in treating constipation. The purpose of the current trial was to evaluate the efficacy of Viola flower syrup (VFS) compared with polyethylene glycol (PEG) in children with functional constipation. Methods. This randomized, active-controlled, single-center trial was conducted on 140 children aged between 4 and 10 years with confirmed FC according to Rome III criteria. Participants were randomly assigned to receive either VFS or PEG for four weeks. Independent t-test and general linear model (GLM) repeated measures analysis of variance were used to determine the intergroup difference, and paired sample t-test was used to evaluate the intragroup difference. Results. After four weeks of intervention, 133 individuals (66 in VFS and 67 in the PEG group) were analyzed. Results of both groups demonstrated significant improvement in all measured criteria at the end of the study compared to baseline ( P < 0.001 ). No significant difference was observed between the two groups at baseline or at the end of the study ( P > 0.05 ), except for fecal retention at baseline ( P = 0.028 ). Participants in the PEG group experienced more side effects compared to the VFS group. Conclusion. The findings of this investigation indicated that VFS is an effective and relatively safe medication to be used in the treatment of pediatric FC.

Acne is the most prevalent skin disease in the world and antibiotics as its standard treatments have limited and also adverse effects. Cedar (Ziziphus spina-christi) has medicinal properties like a...

Introduction: Head louse infestation is one of the major public health problems among children worldwide. Several drugs have been developed to treat the infestation. Side effects and drug resistance associated with these drugs limit their applicability. Increasing attention of scientific committees to alternative drugs along with greater effects and lower complications and costs, increase the hope of success for alternative drugs. Materials and Methods: 93 participants (11 men and 82 women) with positively diagnosed with head lice infestation were allocated into two groups using the stratified randomization method. The intervention in one group comprised of Peganum harmala oil applied onto the patient’s hair and scalp and the hair and scalp being washed after 20 minutes once a day. The procedure was performed on the first three days of week one of intervention (phase 1) and reiterated on the subsequent week (phase 2) in a similar manner. The other group applied permethrin shampoo once in the first week of intervention and once in the second week. Results: Permethrin shampoo recovered 7 (29.2%) in day 1, 2 (15.4%) in day 2, 2 (25.0%) in day 3 and 28 (73.7%) in day 11 but Peganum harmala oil recovered 17 (70.8%) in day 1, 11 (84.6%) in day 2, 6 (75.0%) in day 3 and 10 (26.3%) in day 11 (P-value

Psoriasis is a chronic disease that has no definitive cure. In this review study, the main sources of Persian Medicine (PM) such as the Canon of Medicine (by Avicenna) and

BACKGROUND The objective of this study was to evaluate the effect of changing the laboratory-reported D-dimer reference intervals to age-adjusted reference intervals on the use of advanced chest imaging and 30-day adverse events among emergency department (ED) encounters. METHODS A retrospective interrupted time-series analysis of ED encounters for patients > 50 years evaluated for suspected pulmonary embolism (PE) from April 2014 to April 2016. The primary outcome was use of advanced diagnostic imaging, and the secondary outcome was 30-day mortality or PE diagnosis. Secondary analyses also quantified delayed PE diagnoses pre- and postintervention. A generalized estimating equation segmented logistic regression model, adjusting for patient and facility characteristics, was used to determine changes in odds of diagnostic imaging and 30-day mortality or PE diagnoses. RESULTS A total of 10,534 (5,153 pre- and 5,381 postimplementation) ED encounters were included. Advanced imaging was obtained in 35.9% of pre- versus 33% of postimplementation encounters. Age-adjusted D-dimer (AADD) showed a small and nonsignificant decrease in month-to-month trends of advanced chest imaging postimplementation (odds ratio [OR] = 0.98, 95% confidence interval [CI] = 0.96 to 1.00). Use of advanced imaging in patients with D-dimer values lower than 500 ng/mL fibrinogen-equivalent units (FEU) was similar in the preintervention (5.8%) and postintervention (6.8%) periods. However, imaging was obtained in 30% of patients postintervention with a D-dimer result less than AADD reference interval , but more than the historical 500 ng/mL FEU reference interval. Implementing an AADD threshold demonstrated no change in the rate of 30-day adverse events (missed PE or mortality). CONCLUSION Changing the laboratory-reported D-dimer reference intervals for evaluation of PE was not associated with reduction in advanced chest imaging and did not increase 30-day adverse events. However, there was substantial noncompliance with the age-adjusted reference intervals in the postintervention period likely blunting the impact of this intervention.

Dry eye disease is a relatively common eye disorder associated with decrease in quality of life. In this study, efficacy of an eye drop of Plantago ovata mucilage on symptoms of dry eye disease was evaluated. In a randomized, double-blind, placebo-controlled clinical trial, sixty dry eye patients with ocular symptoms and total Ocular Surface Disease Index (OSDI) score of ≥12 were randomly assigned to receive either a natural ophthalmic drop, made of Plantago ovata mucilage or placebo 4 times a day for 6 weeks. The patients were evaluated at pretreatment (baseline), weeks 4 and 6 post-treatment. The evaluation of the efficacy and safety were conducted based on the OSDI questionnaire, the noninvasive tear film break-up time (NI-BUT) with keratograph, the Schirmer test without anesthesia, and the osmolarity test, as well as by monitoring possible adverse events. After 6 weeks, within group analysis showed a significant improvement in total OSDI score (p < 0.001). In addition, between group comparison revealed a significant improvement in the OSDI score of the intervention group (p < 0.001). Although, NI-BUT was significantly improved in the Plantago ovata group (p = 0.004), however no statistically significant difference was observed in between group analysis. There were no significant differences between two groups, or significant changes within the groups in the Schirmer test without anesthesia and the osmolarity test. No serious adverse events were reported. In conclusion, P. ovata mucilage is a natural, inexpensiveness, and safe lubricant polymer that could have beneficial ocular effects on subjective symptoms of the patients with dry eye disease.

Current paper reviews the pharmacological activities, therapeutic indications and phytochemicals of M. longifolia. This herb has been consumed traditionally for the treatment of various diseases, including gastrointestinal disorders, respiratory disorders, infectious diseases, inflammatory diseases, as well as menstrual disorders. In the modern era, various pharmacological activities have been confirmed for M. longifolia, such as anti-parasitic, antimicrobial, anti-insect, antimutagenic, antinociceptive, anti-inflammatory, antioxidant, keratoprotective, hepatoprotective, anti-diarrhea, and spasmolytic effects. The plant showed therapeutic benefits in irritable bowel syndrome, amenorrhea and oligomenorrhea, and oxidative stress-associated diseases as well. A vast variety of natural components such as flavonoids, phenolic acids, cinnamates, ceramides, sesquiterpenes, terpenes, and terpenoids have been suggested to be responsible for the pharmacological action of M. longifolia. These natural products can be considered as novel medicinal sources for developing new drugs. Further investigations to explore therapeutic efficacy, tolerability, and pharmaceutical properties of M. longifolia phytochemical agents are recommended.

Introduction. Emblica officinalis (EO) has some cardiovascular effects, and there are some animal studies that show its antihypertensive effect. This study was conducted to determine the effect of combination of EO with standard therapy on the systolic blood pressure (SBP) and diastolic blood pressure (DBP) in patients with uncontrolled hypertension. Materials and Methods. This was a randomized, triple-blind, placebo-controlled, 8-week study. Ninety-two patients with uncontrolled hypertension despite taking hypotensive drugs were randomly assigned into two groups to take EO (500 mg/TDS after meal) or placebo in combination with standard antihypertensive drugs. After 2, 4, 6, and 8 weeks of intervention, SBP and DBP and heart rate (HR) were measured. Data were analyzed by SPSS software using repeated measures ANOVA. Results. Eighty-one patients (41 in the drug group and 40 in the placebo group) completed the study for 8 weeks and were analyzed. The mean ± standard deviation of age was 53.64 ± 10.01 years. SBP decreased as 15.6 ± 8.23% in the EO group and 6.3 ± 7.49% in the placebo group (P < 0.001). DBP decreased as 12.3 ± 7.87% and 3.88 ± 7.98%, respectively (P < 0.001). Time effect was not significant, but the group effect was significant (F = 13.875, P=0.001 for systolic BP and F = 18.948, P < 0.001 for diastolic BP). No side effects were reported during the study. Conclusion. Eight-week combination therapy of EO with standard antihypertensive drugs significantly reduced the SBP and DBP more than placebo in patients with uncontrolled hypertension.

Background: Acne Vulgaris is a common skin condition in 35%-90% of youth. Although traditional methods of treating acne in Iran seem to be common and high demand, a few studies about this issue have been accomplished. This study aimed to find out how much definitions and recommendations about this condition in Traditional Persian Medicine (TPM) are similar to contemporary medicine. Methods: Seven main reference books from TPM were selected. The equivalents of acne in TPM were found and comparison of the definitions and recommendations of TPM and CM were extracted. Two diseases called Namlah and Bosoor-Labanieh were most similar to acne. These keywords were searched in TPM Books by using “Noor software”. Results: In TPM references, two diseases of “Namlah” and “Bosoor-Labanieh” are very similar to acne. The cause of these diseases in TPM textbooks has been explained as the effort of the body for the disposal of wastes through the skin and accumulation of them below it. The treatments are lifestyle modification, drug therapy, and manual interventions. Conclusion: Interventions of TPM have been experienced by Iranian physicians of the Old Testament over hundreds of years. There are meaningful similarities among TPM texts in descriptions and advice. In addition, there are remarkable similarities in the disease characteristics and some of the recommendations for acne in TPM and CM. The effectiveness and cost-benefit of the recommended TPM therapeutics and methods can be considered and evaluated as hypotheses for the case and group studies and clinical trials.

Background & Aims: Given the importance of pain management in burn patients, the present study aimed to assess the effect of aromatherapy massage with aromatic oils of lavender and chamomile on the intensity of the background pain in burn patients. Materials & Methods: This quasi-experimental study was conducted on 105 patients with burn injuries admitted to Shaheed Motahari Hospital in Tehran, Iran during January-May 2018. The patients were selected via convenience sampling and allocated to three groups of control, placebo massage, and combined aromatic oil massage by drawing lots and blocks of four with cards. The interventions were performed 20 minutes before bedtime in three sessions for one week. The control group only received routine care. Data were collected using the visual analogue scale (VAS). Data analysis was performed in SPSS version 20 using descriptive statistics (frequency, frequency percentage, mean, and standard deviation), and inferential statistics (Chi-square, Fisher’s exact test, analysis of variance, and paired t-test) were applied to determine the significance. Results: Before the interventions, the three groups had no significant difference in terms of the pain score (P=0.746), while after the intervention, the results indicated a significant difference between the three groups in terms of the pain score, (P

The theme of "Angel" in Hafez thoughts, in comparison with other texts of Sufism, has undergone serious semantic transformations. Most of the well-known scholars are of the opinion that Hafez considers love as the divine deposit, which is reserved only for human beings, and of which angels are deprived. However, the comparison of the codes in Hafez poetry with other works of Sufism does not support the validity of this proposition. Hafez’s claim that angels are deprived of love is controversial because it contradicts Muslim mystics' general approach, which declares the general dominance of love in the created world. It seems that Hafez was chiefly affected by Attar Neyshaburi and believed in the general dominance of love in the whole created world, although he held that the perfection of love which is the pain of love belongs exclusively to human beings. Nevertheless, the scholars who study Hafez have largely interpreted this view of Hafez differently and through these interpretations many of the concepts found in Hafez poetry turn out to be beyond the comprehension of readers. This article attempts to explicate one of the fundamental metaphors in Sufi texts, "Dordi-e-Dard" (the remains of pain) and compare its related propositions in the poetry of Hafez and other Sufi writings, and then reviews the theme of "Angel" and its share of love in the thoughts of Hafez.

The effect of a combination of Malva sylvestris and Althaea digitata flower powder in prevention of acute radiation proctitis was assessed in patients undergoing radiation therapy (RT) for prostate cancer. This double-blind randomized controlled study was conducted at three centers in Iran. Before starting RT, patients (N = 65) received a 4 g packet of flower powder or placebo to use 3 times a day as an infusion from the first day of RT and for five consecutive weeks including the three weeks of RT. They were visited by a physician 3 times during this period. Acute morbidity was classified according to the Radiation Therapy Oncology Group (RTOG) criteria. Severity of proctitis symptoms was assessed by Visual Analog Scale (VAS) with 10 points. Non-statistical significant differences were observed between the groups in relation to RTOG grade criteria (grade 0: drug 22.8% (N = 8), placebo 10% (N = 3), difference 12.8%; grade 1: drug 65.8%, placebo 64.4%, difference 1.4%; grade 2: drug 11.4% (N = 8), placebo 26.6% (N = 4), difference 15.2%. (P = .059)) According to VAS, the most common complaint was anal burning and diarrhea in the flower powder group showing a significant decrease in these symptoms at the end of the study as compared to the placebo; flower powder (1.56 ± 1.07) vs placebo (3.82 ± 1.67) for burning (P

Purpose: Onopordon acanthium L. is known for its medicinal properties. Our recent study showed that its seed extract is a novel natura angiotensin-converting-enzyme inhibitor (ACEI). This study was carried out to investigate its possible antihypertensive effects in patients receiving losartan. Methods: This uncontrolled clinical trial was carried out among 20 patients (30-60y) with uncontrolled hypertension despite receiving 50 mg losartan (stage I & II) in two hospitals in Iran. After completing informed consent, patients were treated by 2 capsules [each 1g of Onopordon acanthium seed extract (OSE)] as add-on therapy, two times per day. Results: 18 patients completed the study (50.94 ±8.37y). Mean systolic blood pressure (SBP) at the baseline was 151.9 ± 13.74mmHg and at the end of the study, it was 134.6 ± 18.25 mmHg and mean diastolic blood pressure (DBP) was 97.41 ± 10.36 at the baseline and was 85.71 ± 7.481 after 8 weeks. OSE significantly reduced SBP and DBP at the end of 8 weeks (P=0.003, 95% CI: -19.7, -15.1; P=0.0006, 95% CI: -10.23, -13.15; respectively). No evidence of hepatic or renal toxicity was detected. Conclusion: Based on the results of this study OSE has antihypertensive property with no significant adverse effects. However, because of the low number of samples, this medication may be not safely administered. The results of this study could be the basis for further studies with larger sample size. IRCT registration number: IRCT2013020712391N.

Introduction. Emblica officinalis (EO) has some cardiovascular effects, and there are some animal studies that show its antihypertensive effect. This study was conducted to determine the effect of combination of EO with standard therapy on the systolic blood pressure (SBP) and diastolic blood pressure (DBP) in patients with uncontrolled hypertension. Materials and Methods. This was a randomized, triple-blind, placebo-controlled, 8-week study. Ninety-two patients with uncontrolled hypertension despite taking hypotensive drugs were randomly assigned into two groups to take EO (500 mg/TDS after meal) or placebo in combination with standard antihypertensive drugs. After 2, 4, 6, and 8 weeks of intervention, SBP and DBP and heart rate (HR) were measured. Data were analyzed by SPSS software using repeated measures ANOVA. Results. Eighty-one patients (41 in the drug group and 40 in the placebo group) completed the study for 8 weeks and were analyzed. The mean ± standard deviation of age was 53.64 ± 10.01 years. SBP decreased as 15.6 ± 8.23% in the EO group and 6.3 ± 7.49% in the placebo group ( P < 0.001 ). DBP decreased as 12.3 ± 7.87% and 3.88 ± 7.98%, respectively ( P < 0.001 ). Time effect was not significant, but the group effect was significant (F = 13.875, P = 0.001 for systolic BP and F = 18.948, P < 0.001 for diastolic BP). No side effects were reported during the study. Conclusion. Eight-week combination therapy of EO with standard antihypertensive drugs significantly reduced the SBP and DBP more than placebo in patients with uncontrolled hypertension.

Acne is the most prevalent skin disease in the world and antibiotics as its standard treatments have limited and also adverse effects. Cedar (Eighty patients aged between 15-45 years with mild to moderate acne vulgaris were conducted in this randomized, double blind trial. The participants were allocated to receive the topical cedar solution plus clindamycin 1% or topical placebo plus 1% clindamycin solution for six weeks. Patients were evaluated at the beginning of the study, second, sixth and eighth weeks after intervention for the acne severity index (ASI) and total acne lesions counting (TLC). Data was analyzed by SPSS software with Mann-WhitneyFrom 105 subjects 68 people completed the study (33 persons in cedar group and 35 persons in placebo group). The mean and standard deviation of the age was 26.1 ± 7.5 years and 22 subjects (32.4%) were male. TLC and ASI in the sixth and eighth weeks in cedar group were significantly less than in placebo group (The topical cedar solution plus clindamycin 1% was more effective and safe than placebo plus 1% clindamycin for the treatment of acne vulgaris.

Objective Evidence suggests that exposure to opioids in adolescence increases risk of future opioid use. We evaluate if exposure to high versus low intensity opioid prescribers in the Emergency Department (ED) influences the risk of future opioid use in adolescents. Methods Retrospective study of opioid-naive patients 10 to 17 years seen in one of 14 EDs between January 2013 and December 2014. We categorized ED providers into quartiles according to the proportion of encounters resulting in opioid prescriptions. Primary outcome was use of opioids in the subsequent 12 months. Analysis adjusted for patient characteristics and compared future use of opioids for patients seen by the lowest versus the highest prescribing quartiles. Results We included 9,688 patient encounters evaluated by the lowest opioid prescribing physician quartile versus 9,467 in the highest. The highest quartile gave opioid prescriptions to 14.9% of their patients compared to 2.8% for the lowest quartile. No association with future opioid use was found for patients evaluated by low versus high prescriber quartiles (OR 0.99, 95% CI 0.90-1.08). Patients with increasing age (OR 2.15, 95% CI 1.92-2.42) and white versus Hispanic ethnicity (OR 1.55, 95% CI 1.33-1.80) were associated with recurrent opioid use. Conclusion We found no association between high intensity opioid prescribers and recurrent 12 month use of opioids in opioid-naive adolescents seen in the ED. This likely reflects various factors that put adolescents at risk for recurrent opioid use and may indicate the importance of the second prescription from primary care after initial exposure to opioids.