Bedside ultrasonography (BUS) has been widely used in many emergency evaluations, but the technique was not thoroughly evaluated for use in adult fractures. The water bath technique (WBT) is a modality which overcomes some important limitations of using BUS in extremity fractures. The study aims to evaluate and compare diagnostic values of BUS and WBT. The sensitivity, specificity, positive and negative predictive values (PPV and NPV), positive and negative likelihood ratios (LR+ and LR-), and accuracy of BUS and WBT were calculated and compared by the McNemar chi-square test. BUS had the highest sensitivity, specificity, PPV, and LR+ in the distal forearm. The highest NPV and LR- of BUS were seen in phalangeal and wrist injuries, respectively. The WBT examination had the highest sensitivity in phalangeal injuries and the highest specificity, PPV, and LR+ in the distal forearm. The highest NPV and LR- of the WBT examination were seen in phalangeal and wrist injuries, respectively. The McNemar χ (2) values for the comparison of BUS and WBT indicate that the two techniques provide statistically different results. The ultrasound revealed excellent diagnostic values which make it a favorable alternative in evaluating upper extremity fractures in adults. The WBT provides even better results.

Introduction. Citrullus colocynthis Schrad. is a commonly used medicinal plant especially as a hypoglycemic agent. Case Presentation. Four patients with colocynth intoxication are presented. The main clinical feature was acute rectorrhagia preceeded by mucosal diarrhea with tenesmus, which gradually progressed to bloody diarrhea and overt rectorrhagia within 3 to 4 hours. The only colonoscopic observation was mucosal erosion which was completely resolved in follow-up colonoscopy after 14 days. Conclusion. The membranolytic activity of some C. colocynthis ingredients is responsible for the intestinal damage. Patients and herbalists should be acquainted with the proper use and side effects of the herb. Clinicians should also be aware of C. colocynthis as a probable cause of lower GI bleeding in patients with no other suggestive history, especially diabetics.

BackgroundClinical reasoning plays a major role in the ability of doctors to make a diagnosis and reach treatment decisions. This paper describes the use of four clinical reasoning tests in the second National Medical Science Olympiad in Iran: key features (KF), script concordance (SCT), clinical reasoning problems (CRP) and comprehensive integrative puzzles (CIP). The purpose of the study was to design a multi instrument for multiple roles approach in clinical reasoning field based on the theoretical framework, KF was used to measure data gathering, CRP was used to measure hypothesis formation, SCT and CIP were used to measure hypothesis evaluation and investigating the combined use of these tests in the Olympiad. A bank of clinical reasoning test items was developed for emergency medicine by a scientific expert committee representing all the medical schools in the country. These items were pretested by a reference group and the results were analyzed to select items that could be omitted. Then 135 top-ranked medical students from 45 medical universities in Iran participated in the clinical domain of the Olympiad. The reliability of each test was calculated by Cronbach's alpha. Item difficulty and the correlation between each item and the total score were measured. The correlation between the students' final grade and each of the clinical reasoning tests was calculated, as was the correlation between final grades and another measure of knowledge, i.e., the students' grade point average.ResultsThe combined reliability for all four clinical reasoning tests was 0.91. Of the four clinical reasoning tests we compared, reliability was highest for CIP (0.91). The reliability was 0.83 for KF, 0.78 for SCT and 0.71 for CRP. Most of the tests had an acceptable item difficulty level between 0.2 and 0.8. The correlation between the score for each item and the total test score for each of the four tests was positive. The correlations between scores for each test and total score were highest for KF and CIP. The correlation between scores for each test and grade point average was low to intermediate for all four of the tests.ConclusionThe combination of these four clinical reasoning tests is a reliable evaluation tool that can be implemented to assess clinical reasoning skills in talented undergraduate medical students, however these data may not generalizable to whole medical students population. The CIP and KF tests showed the greatest potential to measure clinical reasoning skills. Grade point averages did not necessarily predict performance in the clinical domain of the national competitive examination for medical school students.

BackgroundPicture archiving and communication system (PACS) has allowed the medical images to be transmitted, stored, retrieved, and displayed in different locations of a hospital or health system. Using PACS in the emergency department will eventually result in improved efficiency and patient care. In spite of the abundant benefits of employing PACS, there are some challenges in implementing this technology like users’ resistance to accept the technology, which has a critical role in PACS success.ObjectivesIn this study, we will assess and compare user acceptance of PACS in the emergency departments of three different hospitals and investigate the effect of socio-demographic factors on this acceptance.Materials and MethodsA variant of technology acceptance model (TAM) has been used in order to measure the acceptance level of PACS in the emergency department of three educational hospitals in Iran. A previously used questionnaire was validated and utilized to collect the study data. A stepwise multiple regression model was used to predict factors influencing acceptance score as the dependent variable.ResultsMean age of participants was 32.9 years (standard deviation [SD] = 6.08). Participants with the specialty degree got a higher acceptance score than the three other groups (Mean ± SD = 4.17 ± 0.20). Age, gender, degree of PACS usage and participant’s occupation (profession) did not influence the acceptance score. In our multiple regression model, all three variables of perceived usefulness (PU), perceived ease of use (PEU) and the effect of PACS (change) had a significant effect in the prediction of acceptance. The most influencing factor was change with the beta of 0.22 (P value < 0.001).ConclusionPACS is highly accepted in all three emergency departments especially among specialists. PU, PEU and change are factors influencing PACS acceptance. Our study can be used as an evidence of PACS acceptance in emergency wards.

BackgroundNephrolithiasis is a relatively common problem and a frequent Emergency Department (ED) diagnosis in patients who present with acute flank/abdominal pain. The pain management in these patients is often challenging.ObjectivesTo investigate the most effective dose of morphine with the least side effects in emergency renal colic patients.Materials and Methods150 renal colic patients who experienced a pain level of 4 or greater, based on visual analog scale (VAS) at admission time were included. Pain was scored on a 100 mm VAS (0 = no pain, 100 = the worst pain imagined). When patients arrived at ED, a physician would examine the patients and assessed initial pain score, then filled a questionnaire according to the patient information. Patients were assigned to receive 2.5 mg morphine sulfate intravenously. We monitored patients’ visual analog scale (VAS), and adverse events at different time points (every 15 minutes) for 90 minutes. Additional doses of intravenous morphine (2.5 mg) were administered if the patient still had pain. (Max dose: 10 mg). The cumulative dose of morphine, defined as the total amount of morphine prescribed to each patient during the 90 minutes of the study, was recorded. Patients were not permitted to use any nonsteroidal anti-inflammatory drugs as coadjuvant analgesics during the study period. Subjects with inadequate pain relief at 90 minutes received rescue morphine and were excluded from the study. The primary end point in this study was pain relief at 90 minutes, defined as either VAS<40 or decrease of 50% or more as compared to the initial VAS. The secondary objective was to detect the occurrence of adverse effects at any time points in ED.ResultsThe studied patients consisted of 104 men and 46 women with the mean age of 43 ±14 years (range, 18 to 75 years). There was no statistically significant difference between the mean age and gender differences in pain response. Rescue analgesia at 30 minutes were given in 54.5% receiving morphine. The average time to painless was 35 minutes. But there were no statistically significant differences between the mean age and gender differences in pain response (P > 0.05). Older patients responded sooner to morphine than the young. Most of the patients had a pain score of 90 -100 (77.3 %) at the beginning that was reduced to 29.4% during the 30 minutes follow up. During the first hour, we found that 94.7% of the patients had no pain or significant pain reduction and only 2.1% of the patients still had pain.ConclusionsWe conclude that there were no significant differences among the gender, time of admission and side - effects in renal colic patients in response to morphine.