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BACKGROUND Irritable bowel syndrome (IBS) is one of the common gastrointestinal disorders with unknown etiology. In experimental models, it is proposed that soy isoflavones may suppress the clinical and psychological symptoms of IBS by alteration of gut barrier tight junctions. METHODS We conducted this study to evaluate the effects of soy isoflavones on IBS symptoms and patients' quality of life. In a randomized double blind placebo-controlled clinical trial, 67 patients with IBS were allocated to consume either soy isoflavones capsules or a placebo for 6 weeks. The primary outcome was a significant reduction in symptoms severity score and the secondary outcome was a significant improvement in quality of life. RESULTS 45 participants completed the study. There was no significant changes in mean differences of symptoms severity score between the two groups; however soy isoflavone supplementation could significantly improve the quality of life scores (p=0.009). CONCLUSION Soy isoflavones supplementation could improve the quality of life in patients with IBS; however it did not suppress the symptoms severity in 6 weeks. Further research with a longer duration is needed to determine the sustained clinical efficacy. This study was registered at clinicaltrials.gov as NCT02026518.

Background: There is a global interest for deploying faculty members' activities evaluation systems, however implementing a fair and reliable system is a challenging issue. In this study, the authors devised a model for evaluation of faculty members' activities with regard to their viewpoints and meta-evaluation standards., Materials and Methods: The reliability of the current faculty members' activities metrics system was investigated in Medical School of Tehran University of Medical Sciences in 2014. Then authors conducted semi-structured interviews regarding meta-evaluation standards and designed a questionnaire based on interviews' results which were delivered to faculty members. Finally, they extracted the components of the model regarding interviews' content analysis and questionnaire's factor analysis and finalized them in a focus group session with experts., Results: Reliability of the current system was 0.99 (P < 0.05). The final model had six dimensions (mission alignment, accuracy, explicit, satisfaction, appropriateness, and constructiveness) derived from factor analysis of the questionnaire and nine factors (consensus, self-reporting, web-based system, evaluation period, minimum expectancies, analysis intervals, verifiers, flexibility, and decision making) obtained via qualitative content analysis of the interviews., Conclusion: In this study, the authors presented a model for faculty members' activities evaluation based on meta-evaluation of the existing system. The model covered conceptual and executive aspects. Faculty members' viewpoints were the core component of this model, so it would be acceptable in a medical school to use the model for evaluating their activities.

Objectives: Alzheimer's disease (AD) is the most common age-related neurodegenerative disorder. One of the hallmarks of AD is an abnormal accumulation of fibril forms of tau protein which is known as a microtubule associated protein. In this regard, inhibition of tau aggregation has been documented to be a potent therapeutic approach in AD and tauopathies. Unfortunately, the available synthetic drugs have modest beneficial efficacy with several side effects. Therefore, pipeline drugs from natural sources with anti-aggregation properties can be useful in the prevention and treatment of AD. Among medicinal plants, saffron (Crocus sativus, L.), as a traditional herbal medicine has different pharmacological properties and can be used as treatment for several nervous system impairment including depression and dementia. Crocin as a major constituent of saffron is the glycosylated form of crocetin., Materials and Methods: In this study, we investigated the inhibitory effect of crocin on aggregation of recombinant human tau protein 1N/4R isoform using biochemical methods and cell culture., Results: Results revealed that tau protein under the fibrillation condition and in the presence of crocin had enough stability with low tendency for aggregation. Crocin inhibited tau aggregation with IC50 of 100 µg/ml. Furthermore, transmission electron microscopy images confirmed that crocin could suppress the formation of tau protein filaments., Conclusion: Inhibitory effect of crocin could be related to its interference with nucleation phase that led to increases in monomer species of tau protein. Based on our results, crocin is recommended as a proper candidate to be used in AD treatment.

Liver biopsy has been performed for many decades for classifying the patients with TM. Meanwhile, using non-invasive methods such as T2* MRI technique has been recently much more considered to determine the hepatic iron overload. Ninety-three pediatric HSCT candidates with TM who underwent liver biopsy were included in this study. Hepatic T2* MRI values and serum ferritin concentrations were assessed to investigate and determine the useful method in detection of patients with TM class III whom received different conditioning regimens, in comparison with class I and II. Twenty (21.5%) patients were categorized as class III. Hepatic T2* MRI could detect TM class III patients with 60% sensitivity and 87.67% specificity (LR+: 4.867, accuracy: 81.72%), while predictive feature of ferritin values for distinguishing patients with TM class III was not statistically significant (p-value >0.01). Combination of T2*MRI with age (T2*-age) could detect TM class III with 85% sensitivity and 72.6% specificity (LR+: 3.1, accuracy: 75.27%).T2*-age may be considered as an alternative and non-invasive method to liver biopsy for differentiation and classification of patients with TM before transplantation., (© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Massive ischemic stroke causes significant mortality and morbidity in stroke patients. The main treatments for massive ischemic stroke are recombinant tissue plasminogen activator (rtPA), craniotomy, and endovascular interventions. Due to destructive effects of bradykinin on the nervous system in ischemic stroke, it seems reasonable that using Noscapine as a Bradykinin antagonist may improve patients' outcome after ischemic stroke. The effect of Noscapine on massive ischemic stroke was shown by the previous pilot study by our group. This pseudo-randomized clinical trial study was designed to assess the result of the pilot study., Methods: Patients who had clinical symptoms or computed tomography scan indicative of massive stroke (in full middle cerebral artery territory) were entered to the study. The cases received the drugs according to their turns in emergency ward (pseudo-randomized). The patient group received Noscapine, and the control group received common supportive treatments. The patients and data analyzer were blinded about the data. At the end of the study, to adjust confounding variables we used logistic regression., Results: After 1-month follow-up, 16 patients in the control group and 11 patients in the case group expired (P = 0.193). Analyzing the data extracted from Rankin scale and Barthel index check lists, revealed no significant differences in the two groups., Conclusion: Despite the absence of significant statistical results in our study, the reduction rate of 16% for mortality rate in Noscapine recipients is clinically remarkable and motivates future studies with larger sample sizes.

Background: Several pain rating methods are used to quantify pain. Although these instruments have been extensively studied, their inter-agreement, especially in emergency department (ED) settings, has yet to be determined., Objective: This study was designed to assess the agreement between Visual Analog Scale (VAS), Color Analog Scale (CAS), and verbally administered Numeric Rating Scale (NRS) in the emergency setting., Methods: A sample of 150 adult patients presenting with acute pain to two EDs was recruited. Patients' pain severity at presentation, 30 and 60 min later was assessed using the three pain scales. The agreement between pain scales was assessed using Bland-Altman method and Spearman correlation. We described a composite measure to serve as the gold standard and to be compared with each score. Factor analysis was also performed to assess the underlying construct., Results: Spearman correlation coefficients between NRS and CAS, NRS and VAS, and CAS and VAS were 0.95, 0.94, and 0.94, respectively (p < 0.001). On a scale of 0 to 10, the 95% limits of agreement between the paired NRS and VAS, VAS and CAS, and CAS and NRS as measured by Bland-Altman method ranged from -2.0 to 2.6, from -2.7 to 2.0, and from -2.1 to 2.0, respectively. The Kaiser-Meyer-Oklin measure of sampling adequacy was 0.785 and Bartlett's test for sphericity was significant (p < 0.001)., Conclusions: The three pain scales were strongly correlated at all time periods. The findings suggest that NRS, CAS, and VAS can be interchangeably applied for acute pain measurement in adult patients., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Controlling networked structures has many applications in science and engineering. In this paper, we consider the problem of pinning control (pinning the dynamics into the reference state), and optimally placing the driver nodes, i.e., the nodes to which the control signal is fed. Considering the local controllability concept, a metric based on the eigenvalues of the Laplacian matrix is taken into account as a measure of controllability. We show that the proposed optimal placement strategy considerably outperforms heuristic methods including choosing hub nodes with high degree or betweenness centrality as drivers. We also study properties of optimal drivers in terms of various centrality measures including degree, betweenness, closeness, and clustering coefficient. The profile of these centrality values depends on the network structure. For homogeneous networks such as random small-world networks, the optimal driver nodes have almost the mean centrality value of the population (much lower than the centrality value of hub nodes), whereas the centrality value of optimal drivers in heterogeneous networks such as scale-free ones is much higher than the average and close to that of hub nodes. However, as the degree of heterogeneity decreases in such networks, the profile of centrality approaches the population mean.

Objective: The present study was performed to examine the effects of two speech therapy methods on six verbal behaviors of autistic children, including oral speech, listening, organizing, speaking, semantics, and syntax., Materials & Methods: IN THIS STUDY, THIRTY CHILDREN WITH AUTISM WERE ASSIGNED TO ONE OF TWO GROUPS: imitative and cognitive groups. Before starting the main procedures of the study, the children of both groups were homogenized concerning their autism level. In the first phase of the study, the speech development level of the two groups was measured in a pre-test, in which both groups showed similar results. Then, both groups of children received 6 months of speech therapy instruction, during which one group was taught using an imitative method, while the other group was being worked with cognitive method., Results: After 6-month treatment period, a post-test was done, and the t-tests based on the data of the two groups revealed a significant difference between the results., Conclusion: The statistics showed that after the teaching period, autistic that worked with cognitive method gained a better development in their speech abilities, comparing to those worked with the imitative method.

Electroencephalography (EEG)-based functional brain networks have been investigated frequently in health and disease. It has been shown that a number of graph theory metrics are disrupted in brain disorders. EEG-based brain networks are often studied in the whole-brain framework, where all the nodes are grouped into a single network. In this study, we studied the brain networks in two hemispheres and assessed whether there are any hemispheric-specific patterns in the properties of the networks. To this end, resting state closed-eyes EEGs from 44 healthy individuals were processed and the network structures were extracted separately for each hemisphere. We examined neurophysiologically meaningful graph theory metrics: global and local efficiency measures. The global efficiency did not show any hemispheric asymmetry, whereas the local connectivity showed rightward asymmetry for a range of intermediate density values for the constructed networks. Furthermore, the age of the participants showed significant direct correlations with the global efficiency of the left hemisphere, but only in the right hemisphere, with local connectivity. These results suggest that only local connectivity of EEG-based functional networks is associated with brain hemispheres.

A class of networks are those with both positive and negative links. In this manuscript, we studied the interplay between positive and negative ties on mesoscopic level of these networks, i.e., their community structure. A community is considered as a tightly interconnected group of actors; therefore, it does not borrow any assumption from balance theory and merely uses the well-known assumption in the community detection literature. We found that if one detects the communities based on only positive relations (by ignoring the negative ones), the majority of negative relations are already placed between the communities. In other words, negative ties do not have a major role in community formation of signed networks. Moreover, regarding the internal negative ties, we proved that most unbalanced communities are maximally balanced, and hence they cannot be partitioned into k nonempty sub-clusters with higher balancedness (k≥2). Furthermore, we showed that although the mediator triad ++- (hostile-mediator-hostile) is underrepresented, it constitutes a considerable portion of triadic relations among communities. Hence, mediator triads should not be ignored by community detection and clustering algorithms. As a result, if one uses a clustering algorithm that operates merely based on social balance, mesoscopic structure of signed networks significantly remains hidden.

Introduction: Interindividual variations in regional structural properties covary across the brain, thus forming networks that change as a result of aging and accompanying neurological conditions. The alterations of superficial white matter (SWM) in Alzheimer's disease (AD) are of special interest, since they follow the AD-specific pattern characterized by the strongest neurodegeneration of the medial temporal lobe and association cortices., Methods: Here, we present an SWM network analysis in comparison with SWM topography based on the myelin content quantified with magnetization transfer ratio (MTR) for 39 areas in each hemisphere in 15 AD patients and 15 controls. The networks are represented by graphs, in which nodes correspond to the areas, and edges denote statistical associations between them., Results: In both groups, the networks were characterized by asymmetrically distributed edges (predominantly in the left hemisphere). The AD-related differences were also leftward. The edges lost due to AD tended to connect nodes in the temporal lobe to other lobes or nodes within or between the latter lobes. The newly gained edges were mostly confined to the temporal and paralimbic regions, which manifest demyelination of SWM already in mild AD., Conclusion: This pattern suggests that the AD pathological process coordinates SWM demyelination in the temporal and paralimbic regions, but not elsewhere. A comparison of the MTR maps with MTR-based networks shows that although, in general, the changes in network architecture in AD recapitulate the topography of (de)myelination, some aspects of structural covariance (including the interhemispheric asymmetry of networks) have no immediate reflection in the myelination pattern.

Performance of compacted clay liners commonly used as landfill barrier systems can be subject to decline in terms of hydraulic conductivity if left exposed to atmospheric conditions for an extended period of time prior to placement of overlaying layers. The resulting desiccation cracking can lead to increased hydraulic conductivity. Desiccation crack intensity was studied for three clayey soils commonly used for construction of landfill barrier system in a relatively large scale test setup exposed to real time atmospheric conditions over a complete annual cycle. A white separator geotextile cover was presumed to be capable of reducing the intensity of desiccation cracking through absorbing and maintaining higher amounts of moisture and reducing the temperature of the soil surface in comparison to a directly exposed soil surface. Desiccation cracking was monitored using a digital imaging technique for three compacted clay liners in two sets, one open to air and the second covered with the white geotextile. Crack intensity factor approached a relatively stable phase after certain cycles corresponding to atmospheric dry wet cycles. The results indicated that the white separator geotextile was capable of reducing the crack intensity factor by 37.4-45.9% throughout the experiment including the cyclic phase of desiccation cracking. During the stable phase, the maximum reduction in crack intensity factor of 90.4% as a result of applying geotextile cover was observed for the soil with the lowest plastic index and clay content and therefore the lowest magnitude of crack intensity factor. The other two soils with similar clay content but different plastic index showed 23.6% and 52.2% reductions in crack intensity factor after cyclic phase when covered with geotextile., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: This study aims to investigate the effect of antioxidants supplement on clinical outcomes and antioxidant parameters in rheumatoid arthritis (RA)., Methods: The pre-post study was conducted on 40 female patients with RA in 12 weeks that taken daily one Selenplus capsule contained 50 μg selenium, 8 mg zinc, 400 μg vitamin A, 125 mg vitamin C, and 40 mg vitamin E. About 5 mL venous blood sample was taken from all participants and disease activity score (DAS) was determined by DAS-28 formula and high-sensitive C-reactive protein (hs-CRP). Glutathione peroxidase (GPX) and superoxide dismutase (SOD) were measured by spectrophotometric kit and catalase (CAT) was measured by Abei method. Total antioxidant capacity (TAC) was determined by spectrophotometric kit. Distribution of the variables was assessed using histogram with normal curve as well as Kolmogorov-Smirnov test and data were analyzed with paired t-test for differences between pre-post data using SPSS software version 13.5., Conclusions: Our findings showed that antioxidants may improve disease activity significantly, but it did not affect the number of painful and swollen joints and increased erythrocyte antioxidant levels. Antioxidants may be useful for controlling of clinical outcomes and oxidative stress in RA.

Objective: The objective structured examination is one of the most valid, reliable, and effective tools for assessing clinical and communication skills, often by use of standard patients (SPs). SPs can also be assessors of those skills. One of the crucial areas when utilizing SP-based assessment is the quality and consistency assurance of their portrayal of the case and their ability to fill in checklists in an adequate way. The aim of this study was to assess the validity and reliability of SPs' ability to assess students' communication skill via a Calgary-Cambridge checklist., Method: This cross-sectional and correlational study was conducted at the Tehran University of Medical Science. We first analyzed validity; the criterion validity of the SPs' filling in the checklists was assessed through determining the correlation between the SPs' completed checklists and the checklists filled in by three physician raters individually and then reproducibility: it was assessed by a test-retest approach inter-rater reliability., Result: The mean correlation for assessing the validity of SPs' completed checklists by individual SPs was 0.81. The inter-rater reliability was calculated by kappa coefficient, and the total correlation among the three raters was 0.85. The reliability of the test-retest approach showed no significant differences between the test and re-test results., Conclusion: The increased number of medical students and different faculties' responsibilities such as doing educational, research, and health services duties assessing medical student communication skills is a complex issue. The results of our study showed that trained SPs can be used as a valid tool to assess medical students' communication skills, which is also more cost effective and reduces work load of medical faculties.

Objective: Prevalence of allergies is different around the world. Allergic rhinitis is a common chronic disease in children. Intelligence quotient (IQ) is an indicator of efficacy and many factors including chronic diseases may affect it. This study compares the IQs of children diagnosed with persistent or perennial allergic rhinitis with healthy children., Material & Methods: This was a comparative study that was conducted from June 2011-May 2013 in an academic referral clinic. In this study, 90 patients aged 6- to 14-yearsold who were diagnosed with persistent or perennial allergic rhinitis and were compared to 90 age and gender match healthy patients from their respective families. The Wechsler Intelligence Scale for Children was used to divide and calculate overall IQ, verbal IQ, and practical IQ. The t-test and chi square were used to analyze quantitative variables and qualitative variables, respectively., Results: In this study, out of total 180 children, 90 (50%) in the case group and 90 children (50%), the control group participated for IQ comparison. One hundred (57%) were male and 80 (43%) were female. The overall IQ for allergic rhinitis patients and healthy patients was 109.2 and 107.5, respectively. This difference was not considered significant. Furthermore, there was no significant difference between the IQ scores of males and females., Conclusion: Although allergic rhinitis is a chronic disease and effects quality of life, there were no identifiable negative effects on IQ.

The process of determining the minimum pass level to separate the competent students from those who do not perform well enough is called standard setting. A large number of methods are widely used to set cut-scores for both written and clinical examinations. There are some challenging issues pertaining to any standard setting procedure. Ignoring these concerns would result in a large dispute regarding the credibility and defensibility of the method. The goal of this review is to provide a basic understanding of the key concepts and challenges in standard setting and to suggest some recommendations to overcome the challenging issues for educators and policymakers who are dealing with decision-making in this field.

Background: The quality of the educational environment is a key determinant in postgraduate training programs. In order to evaluate and understand this environment a valid and reliable instrument is required. The PHEEM (Postgraduate Hospital Educational Environment Measure) questionnaire is one of the most widely used tools for evaluating the perception of hospital-based residents. The aim of this study was to examine the psychometric quality of the PHEEM in the context of emergency medicine program., Methods: This study evaluated the reliability, construct validity and applicability of the Persian version of the PHEEM questionnaire using a sample of emergency medicine residents from 3 emergency medicine residency programs in Iran. Eighty-nine residents were asked to complete the questionnaire and indicate their agreement with each of the 37 statements using a 5-point Likert scale(strongly disagree: 0 to strongly agree: 4). Cronbach's alpha coefficient was calculated to determine internal consistency. Confirmatory and explanatory factor analyses were performed to assess the construct validity of the original 3 subscales of the questionnaire., Results: The mean score for the total questionnaire was 2.24 (SD: 0.06). The Cronbach's alpha value was found to be 0.86. Factor analysis did not confirm the original three subscales of the PHEEM questionnaire., Conclusion: The Persian version of PHEEM proved a reliable and practical tool for assessing clinical educational environment in emergency medicine departments.

Synchronization behavior of electroencephalographic (EEG) signals is important for decoding information processing in the human brain. Modern multichannel EEG allows a transition from traditional measurements of synchronization in pairs of EEG signals to whole-brain synchronization maps. The latter can be based on bivariate measures (BM) via averaging over pair-wise values or, alternatively, on multivariate measures (MM), which directly ascribe a single value to the synchronization in a group. In order to compare BM versus MM, we applied nine different estimators to simulated multivariate time series with known parameters and to real EEGs.We found widespread correlations between BM and MM, which were almost frequency-independent for all the measures except coherence. The analysis of the behavior of synchronization measures in simulated settings with variable coupling strength, connection probability, and parameter mismatch showed that some of them, including S-estimator, S-Renyi, omega, and coherence, aremore sensitive to linear interdependences,while others, like mutual information and phase locking value, are more responsive to nonlinear effects. Onemust consider these properties together with the fact thatMM are computationally less expensive and, therefore, more efficient for the large-scale data sets than BM while choosing a synchronization measure for EEG analysis.

Background: The aim of this study was to compare the efficacy and safety of sublingual buprenorphine with intravenous morphine sulfate for acute renal colic in the emergency department., Methods: In this double-dummy, randomized controlled trial, we enrolled patients aged 18 to 55 years who had a clinical diagnosis of acute renal colic. Patients received either 2 mg sublingual buprenorphine with an IV placebo, or 0.1 mg/kg IV morphine sulfate with a sublingual placebo. Subjects graded their pain with a standard 11-point numeric rating scale (NRS) before medication administration and 20 and 40 minutes after that. The need for rescue analgesia and occurrence of side effects were also recorded in the two groups., Results: Of 69 patients analyzed, 37 had received buprenorphine, and 32 had taken morphine. Baseline characteristics were similar in both groups. NRS pain scores were reduced across time by administration of both buprenorphine (from 9.8 to 5.22 and then 2.30) and morphine (from 9.78 to 4.25 and then 1.8), significantly (P <0.0001). The two regimens did not differ significantly for pain reduction (P?=?0.260). Dizziness was more frequently reported by the buprenorphine group (62.1% versus 37.5%, P <0.05) but other adverse effects observed within 40 minutes were similar in the two groups., Conclusions: Sublingual buprenorphine (2 mg) is as effective as morphine sulfate (0.1 mg/kg) in acute renal colic pain management.

To evaluate the effect of frequent feedback on residents' communication skills as measured by a standardized checklist. Five medical students were recruited in order to assess twelve emergency medicine residents' communication skills during a one-year period. Students employed a modified checklist based on Calgary-Cambridge observation guide. The checklist was designed by faculty members of Tehran University of Medical Science, used for assessment of students' communication skills. 24 items from 71 items of observational guide were selected, considering study setting and objects. Every two months an expert faculty, based on descriptive results of observation, gave structured feedback to each resident during a 15-minute private session. Total mean score for baseline observation standing at 20.58 was increased significantly to 28.75 after feedbacks. Results markedly improved on "gathering information" (T1=5.5, T6=8.33, P=0.001), "building relationship" (T1=1.5, T6=4.25, P<0.001) and "closing the session" (T1=0.75, T6=2.5, P=0.001) and it mildly dropped on "understanding patients view" (T1=3, T6=2.33, P=0.007) and "providing structure" (T1=4.17, T6=4.00, P=0.034). Changes in result of "initiating the session" and "explanation and planning" dimensions are not statically significant (P=0.159, P=0.415 respectively). Frequent feedback provided by faculty member can improve residents' communication skills. Feedback can affect communication skills educational programs, and it can be more effective if it is combined with other educational methods.

Objective: Intelligence quotient is an indicator of one's efficacy and many factors including chronic diseases may impact upon it. This study aims to compare the IQ of children diagnosed with moderate asthma to the IQ of healthy children., Methods: This comparative study was conducted between June 2011 and January 2012 in an Academic Referral Clinic. In this study, 114 patients aged 6 to 13 years who were diagnosed with moderate asthma were compared with 90 age and sex matched healthy patients from their families. Wechsler intelligence scale for children was used by split half method to calculate the overall IQ, verbal IQ and practical IQ. The t-test and Chi square test were used to analyze quantitative variables and qualitative variables, respectively., Results: In this study, 204 children, 114 (56%) in the case group and 90 children (44%) in the control group participated in comparing their IQs. One hundred and fifteen (56%) were males and 89 (44%) were females. The overall IQs of asthmatic patients and healthy patients were 109 and 108, respectively; the difference was not significant (p=0.905). Furthermore, there was no significant difference in the IQ scores between males and females., Conclusion: Although asthma is a chronic disease and causes many respiratory problems, it has no negative impact on IQ.

Despite the existence of a large variety of competency frameworks for medical graduates, there is no agreement on a single set of outcomes. Different countries have attempted to define their own set of competencies to respond to their local situations. This article reports the process of developing medical graduates' competency framework as the first step in the curriculum reform in Tehran University of Medical Sciences (TUMS). A participatory approach was applied to develop a competency framework in Tehran University of Medical Sciences (TUMS). Following literature review, nominal group meetings with students and faculty members were held to generate the initial list of expectations, and 9 domains was proposed. Then, domains were reviewed, and one of the domains was removed. The competency framework was sent to Curriculum Reform Committee for consideration and approval, where it was decided to distribute electronic and paper forms among all faculty members and ask them for their comments. Following incorporating some of the modifications, the document was approved by the committee. The TUMS competency framework consists of 8 domains: Clinical skills; Communication skills; Patient management; Health promotion and disease prevention; Personal development; Professionalism, medical ethics and law; Decision making, reasoning and problem-solving; and Health system and the corresponding role of physicians. Development of a competency framework through a participatory approach was the first step towards curriculum reform in TUMS, aligned with local needs and conditions. The lessons learned through the process may be useful for similar projects in the future.

Craniofacial clefts are extremely rare congenital anomalies, the importance of which lies in their great range of variety of anatomic forms and their complex management. Proboscis is one of the rare cases of this kind in which half of the nose is separated from the face and it is only pedicled on the right or left medial canthal regions by a nose-like, rudimentary tubular structure. This article reports the case of a 3-month-old infant with left-sided proboscis. Left lower eyelid coloboma was also present. The proboscis was treated with local flaps at the age of 3 months, and at the age of 10 months the coloboma was managed.

Purpose: This study was conducted to compare the efficacy and safety of naproxen 500 mg twice daily (BID) versus naproxen 500 mg as needed (PRN) for treatment of ankle sprain., Methods: In this seven-day, randomized, parallel group trial, 135 patients with ankle sprain occurring less than 48 hours prior to the first dose of study medication were randomized to receive naproxen 500 mg BID (67 patients) and naproxen 500 mg as needed (PRN) (68 patients). The ankle pain was assessed at rest and on full weight bearing using Numeric Rating Scale (NRS) from 0 (no pain) to 10 (the worst imaginable pain). Ankle swelling was assessed as a 4-point scale ranging from 0 (no swelling) to 3 (severe swelling) rated by the investigator. The primary efficacy end point was the patient's assessment of ankle pain via NRS and the degree of swelling on day seven., Results: Results showed a significant decrease in pain on weight bearing, pain at rest and the extent of swelling (P<0.001) in both groups, but there was no substantial difference between the two groups (P>0.05) after seven days. Assessing the safety profile of the two different dosing, 13.3% of the naproxen BID group and 6.7% of the as needed group had adverse events, showing that the as needed regimen was safer (P<0.001)., Conclusion: Results showed that naproxen as needed may reduce the pain and edema of the sprained ankle with no significant difference compared to the BID regimen, while it possesses better safety profile and lower total drug use.

Regarding to the high prevalence and comorbidities of chronic high blood glucose in diabetic patients and the limited efficacy and current painful treatments. It is necessary to improve new treatments that are non-invasive and long-term for controlling blood glucose. Recent studies have shown that the healthy microflora in different body organs can perform as the gene vectors for expressing different types of gene therapies in situ. We have proposed that by constructing a recombinant Escherichia coli Nissle 1917 that expresses CTB-IGF-1 hybrid gene under control of ompC glucose sensitive promoter, the intestinal glucose level can be regulated. This method in comparison with other methods is a non-invasive way to control the blood glucose orally and it can be used for all types of diabetes., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

In this paper, distributed electroencephalographic (EEG) sources in the brain have been mapped with the objective of early diagnosis of Alzheimer's disease (AD). To this end, records from a montage of a high-density EEG from 17 early AD patients and 17 matched healthy control subjects were considered. Subjects were in eyes-closed, resting-state condition. Cortical EEG sources were modeled by the standardized low-resolution brain electromagnetic tomography (sLORETA) method. Relative logarithmic power spectral density values were obtained in the four conventional frequency bands (alpha, beta, delta, and theta) and 12 cortical regions. Results show that in the left brain hemisphere, the theta band of AD subjects shows an increase in the power, whereas the alpha band shows a decreased activity (P-value <0.05). In the right brain hemisphere of AD subjects, a decreased activity is observed in all frequency bands. It was also noticed that the right temporal region shows a significant difference between the two groups in all frequency bands. Using a support vector machine, control and patient groups are discriminated with an accuracy of 84.4%, sensitivity 75.0%, and specificity of 93.7%.

A signaling pathway is a sequence of proteins and passenger molecules that transmits information from the cell surface to target molecules. Understanding signal transduction process requires detailed description of the involved pathways. Several methods and tools resolved this problem by incorporating genomic and proteomic data. However, the difficulty of obtaining prior knowledge of complex signaling networks limited the applicability of these tools. In this study, based on the simulation of signal flow in signaling network, we introduce a method for determining dominant pathways and signal response to stimulations. The model uses topology-weighted transit compartment approach and comprises four main steps which include weighting the edges, simulating signal transduction in the network (weighting the nodes), finding paths between initial and target nodes, and assigning a significance score to each path. We applied the proposed model to eighty-three signaling networks by using biologically derived source and sink molecules. The recovered dominant paths matched many known signaling pathways and suggesting a promising index to analyze the phenotype essentiality of molecule encoding paths. We also modeled the stimulus-response relations in long and short-term synaptic plasticity based on the dominant signaling pathway concept. We showed that the proposed method not only accurately determines dominant signaling pathways, but also identifies effective points of intervention in signal transduction., (© 2013 Elsevier Inc. All rights reserved.)

Background: One of the methods used for standard setting is the borderline regression method (BRM). This study aims to assess the reliability of BRM when the pass-fail standard in an objective structured clinical examination (OSCE) was calculated by averaging the BRM standards obtained for each station separately., Materials and Methods: In nine stations of the OSCE with direct observation the examiners gave each student a checklist score and a global score. Using a linear regression model for each station, we calculated the checklist score cut-off on the regression equation for the global scale cut-off set at 2. The OSCE pass-fail standard was defined as the average of all station's standard. To determine the reliability, the root mean square error (RMSE) was calculated. The R (2) coefficient and the inter-grade discrimination were calculated to assess the quality of OSCE., Results: The mean total test score was 60.78. The OSCE pass-fail standard and its RMSE were 47.37 and 0.55, respectively. The R (2) coefficients ranged from 0.44 to 0.79. The inter-grade discrimination score varied greatly among stations., Conclusion: The RMSE of the standard was very small indicating that BRM is a reliable method of setting standard for OSCE, which has the advantage of providing data for quality assurance.

Background: Emergency physicians are at risk of burnout, which can affect their mental health, as well as patient care. We assessed burnout level among Iranian emergency physicians and investigated demographic, work-related factors and stressors associated with higher burnout., Methods: In a cross-sectional study, we surveyed all 188 emergency medicine residents and practitioners in Iran. We measured burnout using 22-item Maslach Burnout Inventory assessing emotional exhaustion, depersonalization and personal accomplishment, also demographic factors, work related factors and sources of stress in emergency department using anonymous self-administered questionnaire. Descriptive analysis, univariate analysis to evaluate association with higher score of burnout, and multivariate logistic regression analysis to predict high burnout in 3 subscales was performed., Results: Totally, 165 questionnaires were filled (response rate: 88%; mean age: 33.6 years, 91% male). Mean burnout scores were 22.94 for emotional exhaustion (95% CI=20.78-25.01; moderate), 9.3 for depersonalization (95% CI=8.24-10.36; moderate to high), and 31.47 for personal accomplishment (95% CI=29.87-33.07; moderate to high). Frequent reported sources of stress were shortage of equipment, problem with work physical environment, and relationship with other services. All 19 sources of stress were associated with higher score of emotional exhaustion and depersonalization; while twelve out of 19 were significantly associated with lower level of personal accomplishment. In logistic regression model, the significant predictors for high emotional exhaustion were work overload, feeling of insecurity for future career and difficulties to balance professional and private life., Conclusion: Burnout is high among Iranian emergency medicine practitioners and some interventions can be proposed to reduce stress.

Sepsis constitutes an important cause of hospital admission with a high mortality rate. Appropriate antibiotic therapy is the cornerstone of therapy in patients with sepsis. Although numerous studies have recommended early antibiotic initiation in severe sepsis or septic shock stages of sepsis syndrome, its role in treatment of patients with sepsis who have not entered these stages remains to be investigated. The purpose of this study is to investigate the effect of door-to-antibiotic time in sepsis patients with various degrees of severity. This is a longitudinal prospective cohort study on adult patients admitted with sepsis to the emergency department. Sepsis was defined as presence of at least two criteria of systemic inflammatory response syndrome and procalcitonin levels ≥ 2μg/l. Severity of sepsis was determined using the APACHE II (Acute Physiology and Chronic Health Evaluation II) scoring system. Time to antibiotic administration was recorded and its relationship with mortality was assessed. A total of 145 patients were eligible for enrollment. The mean age was 60.4 years and the mean APACHE score was 13.7. The overall in-hospital mortality was 21.4%, and the mean length of stay in hospital was 211.9 hours. The mean door-to-antibiotic time for our patients was 104.4 minutes. Antibiotic administration time and mortality in patients with APACHE scores of 21 or higher (P=0.05) were significantly related; whereas such a relationship was not observed for patients with APACHE scores of 11- 20 (P=0.46). We observed early antibiotic initiation for patients in sepsis phase with higher severity scores was associated with significant improvement in survival rate.

Background: Hematopoietic stem cell transplantation (HSCT) has been established as a promising treatment in acute myeloid leukaemia (AML). Several studies have been performed to minimize the toxicity of HSCT in children without impairing the efficacy. We report our long-term results of HSCT in pediatric AML patients using non-total body irradiation conditioning regimen., Procedure: From May 1991 to June 2010, 133 pediatric patients with AML (age<15 y) who were referred to our institute underwent autologous (auto-) or allogeneic (allo-) HSCT. The conditioning regimen consisted of oral busulfan plus etoposide in auto-HSCT patients and oral busulfan plus cyclophosphamide in allo-HSCT patients., Results: Overall survival (OS), leukemia-free survival (LFS), probability of relapse, and transplantation-related mortality at 3 years were 67.6%, 62.2.5%, 27.3%, and 10.1%, respectively. There was no significant difference between allo-HSCT and auto-HSCT groups. In multivariable analysis using Cox proportional hazards regression model, male sex was associated with significantly improved OS (P<0.001) and LFS (P=0.022). An age ≤3 years was associated with higher relapse (P=0.034) and worse OS (P=0.001) and LFS (P=0.014)., Conclusions: The role of allo-HSCT in pediatric AML patients in first complete remission is uncertain. Further randomized studies are recommended to clarify the optimal postremission therapy in these patients.

In this paper, we review the literature on enhancing synchronizability of diffusively coupled dynamical networks with identical nodes. The last decade has witnessed intensive investigations on the collective behavior over complex networks and synchronization of dynamical systems is the most common form of collective behavior. For many applications, it is desired that the synchronizability-the ability of networks in synchronizing activity of their individual dynamical units-is enhanced. There are a number of methods for improving the synchronization properties of dynamical networks through structural perturbation. In this paper, we survey such methods including adding/removing nodes and/or edges, rewiring the links, and graph weighting. These methods often try to enhance the synchronizability through minimizing the eigenratio of the Laplacian matrix of the connection graph-a synchronizability measure based on the master-stability-function formalism. We also assess the performance of the methods by numerical simulations on a number of real-world networks as well as those generated through models such as preferential attachment, Watts-Strogatz, and Erdos-Rényi.

Cerebral venous thrombosis (CVT) is an uncommon but important cause of stroke. Since there are few number of studies about the factors associated with CVT, we aimed to perform a study on Iranian patients, during a 12-year period (1997-2010) and assessed the risk factors, mortality rate, symptoms and signs, imaging and seasonal distribution. This study was a retrospective cross sectional study conducted in Rasul-e-Akram Hospital of Tehran University of Medical Sciences. The hospital is a referral neurology center for west, south and east parts of the capital city. The patients' data were extracted from the documents and entered to a self-designed checklist including probable risk factors, sequels, involved venous and also demographic characteristics. From 62 patients, 85.5% of the patients were female. Most of the patients were between 25 and 35 years old. Superior sagittal sinus was involved in 35 patients. Generalized seizure in the expired group (7 patients) was significantly more than the alive group (P = 0.017). There was a significant relationship between intracranial hemorrhage and mortality rate and between the site of thrombosis and level of consciousness. There was also a significant relationship between fasting and pregnancy with seizure in these patients. Although most of the patients presented in spring and autumn, majority of the expired cases were reported in autumn. This study can help defining risk factors, symptoms, and predicting risk factors of seizure in patients with CVT. We suggest future studies based on gathering data for meta-analysis.

In this paper, we investigated phase synchronization in delayed dynamical networks. Non-identical spiking Hindmarsh-Rose neurons were considered as individual dynamical systems and coupled through a number of network structures such as scale-free, Erdős-Rényi, and modular. The individual neurons were coupled through excitatory chemical synapses with uniform or distributed time delays. The profile of spike phase synchrony was different when the delay was uniform across the edges as compared to the case when it was distributed, i.e., different delays for the edges. When an identical transmission delay was considered, a quasi-periodic pattern was observed in the spike phase synchrony. There were specific values of delay where the phase synchronization reached to its peaks. The behavior of the phase synchronization in the networks with non-uniform delays was different with the former case, where the phase synchrony decreased as distributed delays introduced to the networks.

Objectives: To estimate the number of emergency department (ED) visits due to nonurgent problems and to describe the characteristics of those patients, as well as their reasons for presenting to the ED., Study Design: Descriptive cross-sectional study., Methods: In this study, all adult (aged >15 years) patients presenting to the ED over a 2-week period were evaluated. Data regarding the age, sex, marital status, educational level, and insurance status of all patients were recorded. The time and date of the presentation were also noted. Those classified by the triage nurse as having nonurgent conditions were surveyed regarding their reasons for presenting to the ED., Results: Out of 1923 visits, 400 (20.8%) were classified as nonurgent. The prevalence of inappropriate ED visits was slightly greater in patients aged 15 to 49 years. Patients whose visits were paid for by health insurance accounted for the majority of inappropriate visits (82.75%). There were higher rates of inappropriate visits in the evening and night shifts compared with morning and afternoon shifts (17.39% vs 25.03%). The most common reason for presenting to the ED was "to obtain rapid treatment" (76.5%); only 10.75% presented because of a perceived urgent problem., Conclusions: The results of our study corroborate the previous findings that inappropriate use of the ED is common. The prevalence of presentation for nonurgent problems was substantive between 6 PM and 6 AM. Gender, marital status, education, insurance, and day of the week had no association with nonurgent presentation.

Abnormalities in the topology of brain networks may be an important feature and etiological factor for psychogenic non-epileptic seizures (PNES). To explore this possibility, we applied a graph theoretical approach to functional networks based on resting state EEGs from 13 PNES patients and 13 age- and gender-matched controls. The networks were extracted from Laplacian-transformed time-series by a cross-correlation method. PNES patients showed close to normal local and global connectivity and small-world structure, estimated with clustering coefficient, modularity, global efficiency, and small-worldness (SW) metrics, respectively. Yet the number of PNES attacks per month correlated with a weakness of local connectedness and a skewed balance between local and global connectedness quantified with SW, all in EEG alpha band. In beta band, patients demonstrated above-normal resiliency, measured with assortativity coefficient, which also correlated with the frequency of PNES attacks. This interictal EEG phenotype may help improve differentiation between PNES and epilepsy. The results also suggest that local connectivity could be a target for therapeutic interventions in PNES. Selective modulation (strengthening) of local connectivity might improve the skewed balance between local and global connectivity and so prevent PNES events.

Objective: Evaluation of the effect of Propolis as a bioactive material on quality of dentin and presence of dental pulp stem cells., Materials and Methods: For conducting this experimental split-mouth study,a total of 48 maxillary and mandibular incisors of male guinea pigs were randomly divided into an experimental Propolis group and a control calcium hydroxide group. Cutting the crowns and using Propolis or calcium hydroxide to cap the pulp, all of the cavities were sealed. Sections of the teeth were obtained after sacrificing 4 guinea pigs from each group on the 10(th), 15(th) and 30(th) day. After they had been stained by hematoxylin and eosin (H&E), specimens underwent a histological evaluation under a light microscope for identification of the presence of odontoblast-like cells, pulp vitality, congestion, inflammation of the pulp and the presence of remnants of the material used. The immunohistochemistry (IHC) method using CD29 and CD146 was performed to evaluate the presence of stem cells and the results were statistically evaluated by Kruskal-Wallis, Chi Square and Fisher tests., Results: In H&E stained specimens, there was no difference between the two groups in the presence of odontoblast-like cells, pulp vitality, congestion, inflammation of the pulp and the presence of remnants of used material(p>0.05). There was a significant difference between the quality of regenerative dentin on the 15(th) and 30(th) days (p<0.05): all of the Propolis cases presented tubular dentin while 14% of the calcium hydroxide cases produced porous dentin. There was no significant difference between Propolis and calcium hydroxide in stimulation of dental pulp stem cells (DPSCs)., Conclusion: This study which is the first one that documented the stimulation of stem cells by Propolis, provides evidence that this material has advantages over calcium hydroxide as a capping agent in vital pulp therapy. In addition to producing no pulpal inflammation, infection or necrosis this material induces the production of high quality tubular dentin.

Background: Laboratory turnaround time (TAT) is an important determinant of patient stay and quality of care. Our objective is to evaluate laboratory TAT in our emergency department (ED) and to generate a simple model for identifying the primary causes for delay., Methods: We measured TATs of hemoglobin, potassium, and prothrombin time tests requested in the ED of a tertiary-care, metropolitan hospital during a consecutive one-week period. The time of different steps (physician order, nurse registration, blood-draw, specimen dispatch from the ED, specimen arrival at the laboratory, and result availability) in the test turnaround process were recorded and the intervals between these steps (order processing, specimen collection, ED waiting, transit, and within-laboratory time) and total TAT were calculated. Median TATs for hemoglobin and potassium were compared with those of the 1990 Q-Probes Study (25 min for hemoglobin and 36 min for potassium) and its recommended goals (45 min for 90% of tests). Intervals were compared according to the proportion of TAT they comprised., Results: Median TATs (170 min for 132 hemoglobin tests, 225 min for 172 potassium tests, and 195.5 min for 128 prothrombin tests) were drastically longer than Q-Probes reported and recommended TATs. The longest intervals were ED waiting time and order processing. , Conclusions: Laboratory TAT varies among institutions, and data are sparse in developing countries. In our ED, actions to reduce ED waiting time and order processing are top priorities. We recommend utilization of this model by other institutions in settings with limited resources to identify their own priorities for reducing laboratory TAT.

Recently graph theory and complex networks have been widely used as a mean to model functionality of the brain. Among different neuroimaging techniques available for constructing the brain functional networks, electroencephalography (EEG) with its high temporal resolution is a useful instrument of the analysis of functional interdependencies between different brain regions. Alzheimer's disease (AD) is a neurodegenerative disease, which leads to substantial cognitive decline, and eventually, dementia in aged people. To achieve a deeper insight into the behavior of functional cerebral networks in AD, here we study their synchronizability in 17 newly diagnosed AD patients compared to 17 healthy control subjects at no-task, eyes-closed condition. The cross-correlation of artifact-free EEGs was used to construct brain functional networks. The extracted networks were then tested for their synchronization properties by calculating the eigenratio of the Laplacian matrix of the connection graph, i.e., the largest eigenvalue divided by the second smallest one. In AD patients, we found an increase in the eigenratio, i.e., a decrease in the synchronizability of brain networks across delta, alpha, beta, and gamma EEG frequencies within the wide range of network costs. The finding indicates the destruction of functional brain networks in early AD.

Daclizumab, a humanized MoAB to IL-2Ra, has been found to be safe and effective in adults with refractory GvHD; however, data in children are limited. The aim of this prospective study was to evaluate the long-term safety and efficacy of daclizumab in children with steroid-refractory GI aGvHD. This study included 13 children who developed steroid-refractory GI GvHD between 2007 and 2009. When first-line treatment failed, daclizumab was given in a regimen of 1 mg/kg intravenously and then repeated on a 10- to 14-day interval for maximum five doses if necessary. Daclizumab was well tolerated, but infections were common. Ten patients responded to daclizumab completely, one patient responded partially, and two patients failed to respond. With a median follow-up of 630 days, 10 patients were alive and free of severe infections, but among them, four patients were suffering from cGvHD. Of the three remaining patients, one died because of bacterial meningitis, and the other two patients died because of severe refractory GI GvHD. This long-term evaluation showed that daclizumab could be an effective and relatively safe treatment in most of the pediatric patients with severe steroid-refractory GI GvHD., (© 2012 John Wiley & Sons A/S.)

Compacted clay liners (CCLs) when feasible, are preferred to composite geosynthetic liners. The thickness of CCLs is typically prescribed by each country's environmental protection regulations. However, considering the fact that construction of CCLs represents a significant portion of overall landfill construction costs; a performance based design of liner thickness would be preferable to 'one size fits all' prescriptive standards. In this study researchers analyzed the hydraulic behaviour of a compacted clayey soil in three laboratory pilot scale columns exposed to high strength leachate under simulated landfill conditions. The temperature of the simulated CCL at the surface was maintained at 40 ± 2 °C and a vertical pressure of 250 kPa was applied to the soil through a gravel layer on top of the 50 cm thick CCL where high strength fresh leachate was circulated at heads of 15 and 30 cm simulating the flow over the CCL. Inverse modelling using HYDRUS-1D indicated that the hydraulic conductivity after 180 days was decreased about three orders of magnitude in comparison with the values measured prior to the experiment. A number of scenarios of different leachate heads and persistence time were considered and saturation depth of the CCL was predicted through modelling. Under a typical leachate head of 30 cm, the saturation depth was predicted to be less than 60 cm for a persistence time of 3 years. This approach can be generalized to estimate an effective thickness of a CCL instead of using prescribed values, which may be conservatively overdesigned and thus unduly costly.

Objectives: The objective was to validate the Vancouver Chest Pain Rule in an emergency department (ED) setting to identify very-low-risk patients with acute chest pain., Methods: A prospective cohort study was conducted on consecutive patients 25 years of age and older presenting to the ED with a chief complaint of acute chest pain during January 2009 to July 2009. According to the Vancouver Chest Pain Rule, cardiac history, chest pain characteristics, physical and electrocardiogram (ECG) findings, and cardiac biomarker measurement (creatine kinase-myocardial band isoenzyme [CK-MB]) were used to identify patients with very low risk for developing acute coronary syndrome (ACS) in 30 days. The primary outcome was defined as developing ACS (myocardial infarction or non-ST-elevation myocardial infarction [MI]/unstable angina) within 30 days of ED presentation, and all diagnoses were made using predefined explicit criteria. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated., Results: Of 593 patients who were eligible for evaluation, 39 (6.6%) developed MI and 43 (7.3%) developed unstable angina. Among all patients, 292 (49.2%) patients could have been assigned to the very-low-risk group and discharged after a brief ED assessment according to the Vancouver Chest Pain Rule. Among these patients, four (1.4%) developed ACS within 30 days. Sensitivity of the rule was 95.1% (95% confidence interval [CI]=88.0% to 98.7%), specificity was 56.3% (95% CI=52.0% to 60.7%), positive prediction value was 25.9% (95% CI=21.0% to 31.0%), and negative prediction value was 98.6% (95% CI=96.5% to 99.6%)., Conclusions: This study showed a lower sensitivity and higher specificity when applying the Vancouver Chest Pain Rule to this population as compared to the original study., (© 2012 by the Society for Academic Emergency Medicine.)

Purpose: To present a case of unilateral Aspergillus endophthalmitis after bilateral anterior chamber phakic intraocular lens (IOL) implantation in a 26-year-old myopic patient., Methods: Three days after bilateral phakic IOL implantation, the patient presented with complaints of pain and low vision in the left eye and was treated for uveitis. Four weeks later, the patient presented with complaints of pain and decreased vision., Results: Culture results of the anterior chamber and IOL specimens were positive for Aspergillus. Anterior chamber washing, membrane removal, anterior chamber phakic IOL removal, lensectomy, and anterior vitrectomy along with administration of topical, systemic, and antifungal drugs and intracameral tissue plasminogen activator improved the patient's corrected distance visual acuity to 20/40 with +6.00 -2.00 × 130°., Conclusions: Although ocular inflammation occurring after IOL implantation responds to corticosteroids, intraocular infections should always be taken into consideration to prevent severe ocular morbidity., (Copyright 2012, SLACK Incorporated.)

Pediatric patients with leukocyte adhesion deficiency type-I (LAD-I) experience severe and recurrent life-threatening bacterial infections with failure of pus formation and delayed wound healing. LAD-I is a rare inherited disease caused by mutation in the leukocyte CD18 integrin expression, resulting in defective adherence and migration of leukocytes, in particular neutrophilic granulocytes through the intravascular space. Hematopoietic SCT is the only curative treatment option available to patients with LAD-I. Since 2007, in a prospective trial, reduced-intensity conditioning regimen have been developed for 10 consecutive patients with LAD-I who were referred to our center. Based upon available data, it is the first time that such a number of patients affected by LAD-I have been treated with this regimen. This study attempts to show that reduced-intensity regimen leads to a favorable result in LAD-I patients even in those who have experienced comorbid complications. Following transplantation, some patients develop mixed chimerism, however, in our study mixed chimerism was not followed by transplant rejection.

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., (Copyright © 2011. Published by Mosby, Inc.)