Frontiers in Emergency Medicine
Volume:3 Issue: 1, Winter 2019

Pace of medical research development heralded an escalation in recent years. Groundbreaking evidences have been provided for managing dyslipidemia in 2017. Beside statins, alternatives of Anti PCSK-9 monoclonal antibodies in human and AT04A anti PCSK-9 vaccine in mice have shown to significant decrease in total cholesterol level. Wonderful! Apart from this, dual pathway inhibition by using aspirin with very low dose Rivaroxaban has been shown to be more effective in mitigating ischemic event rate than aspirin alone in patients with stable coronary artery disease or peripheral artery disease. Furthermore, patients with atrial fibrillation undergo percutaneous coronary intervention will benefit more from double antithrombotic therapy than triple one. Besides, a novel risk score of PRECISE-DAPT has determine the optimal duration of antiplatelet therapy in patients implanting coronary stents; and many other medical research advances which grabs our attention on 2018. In order to translate recent advances in medical research into clinical practice we need to design, conduct and apply high quality research in different medical subspecialties. The emergency medicine (EM) environment defined as overburdened with inability to afford more than a few minutes per patients. Where, time for research might be considered as a potential risk of interruption in clinical practice. EM is a broad field involving multiple disciplines and crosscutting themes with the unique features in research including urgency and location of the treatment. Art of research in EM comprises hybridization of clinical research, basic science and health services research. Accordingly, research priority setting should be put forwarded based on these three areas, examining existing gaps in EM knowledge, system design issues, educational predicament and disparities between diagnostic skills and clinical decisions. Where the most appropriate research questions arise? Definitely, it comes from critical thinking in patient care setting, regular reading habit, teaching, journal clubs, collaborations and society. To alleviate the issue of immense question and limited time in EM field which tangles decision makers mind we recommend to prioritize questions in line with; patients well- being, learners need, feasibility to answer, inquiries that most likely to recur in your practice and most interesting foreground research query. A research need has been defined as a gap in existing knowledge on practice, learner‚s education, patient values and societal demands. To examine the gaps in EM research knowledge we can provide research time and facilities, training new investigators, develop multicenter research networks, improve research coordination and involving funding agencies to make practical attempts for filling pre specified gaps. In conclusion, since patient oriented outcome research will provide us with the most important endpoints for clinical policy making and patient care standard setting, I totally agree with the advocates of involving stakeholders including clinicians, society and patients in EM research process to mitigate the existence knowledge gaps for dedicating high quality EM care

Road traffic traumatic injuries are the leading cause of death especially among young men who are mostly vulnerable victims. This catastrophe is more complicated in low to middle income countries. This study assessed the financial costs of traffic casualties in Iran. One thousand trauma patients presenting to the emergency department of Shohaday-e-Tajrish Hospital were included in the study. The prehospital and hospital costs as well as the expenses of physiotherapy, rehabilitation, outpatient visits and further surgical interventions were considered as direct expenses. The costs of productivity loss were estimated as indirect expenses. The direct and indirect costs were assessed 27.4% and 72.6% of total, respectively. The mean age of permanent disability was 43 years old. The average expenses of temporary and permanent disabilities were 2934.4 million rials (nearly 4.2 million rials per patient) and 23.9 billion rials (1.1 billion rials per person), respectively. The national burden of traffic injuries in Iran is significantly destructive as it consists of 2.19 % of Gross Domestic Product annually. Besides, young men are involved in most of the traffic accidents representing the need to establish rigorous preventive instructions and reduce human, and financial costs.

The quality of medical services and attention paid to patients in medical centers have been concerning for healthcare providers. The present study was designed to identify factors affecting patient satisfaction with medical service in the emergency department (ED). This was a cross-sectional study conducted in spring 2016 in Imam Khomeini Hospital, Jiroft, Iran. Patients aged more than 18 years presenting to the ED with a minimum stay of 24 hours were included. Unwillingness to take part, incomplete questionnaires, or unavailability for an interview were considered the exclusion criteria. Data were collected using a 24-item researcher-made questionnaire based on Servqual quality measuring tool with five components of tangibles, reliability, responsiveness, assurance, and empathy. The present study recruited 373 patients with the mean age of 41.7±21.8 years (minimum 18 and maximum 79 years), of whom, 67.1% were men. Mean scores indicate the level of patient satisfaction with the hospital service ranging from relatively satisfied to totally satisfied. The components ranking in improving patient satisfaction were as follows: tangibles 4.59, assurance 2.77, reliability 2.74, responsiveness 2.57, and empathy 2.33. Of the components assessing the patient satisfaction, tangibles were the most effective component and empathy was the least effective one.

Asthma is one of acute respiratory diseases leading to emergency department (ED) referral. Management of acute attack plays an important role in its outcome. This trial was designed to evaluate the effectiveness of nebulized budesonide versus placebo in moderate to severe acute asthma attack in adults in the ED. In this clinical trial, we enrolled patients with acute exacerbation of asthma and standard treatment of acute asthma attack was administered to all of them. 41 patients in our study were randomly entered into 2 groups. In one group, we prescribed nebulized budesonide and in the other group nebulized placebo (normal saline) was administered. Patients’ demographic data, vital signs, symptoms’ acuity and the time of symptom relief, patient and physician satisfaction were all recorded and compared between the 2 groups. All cases were followed and disease outcome, readmission, mortality and morbidity rates were documented. In this study, 20 patients were entered the budesonide group and 19 patients were enrolled in the placebo group. The mean age ranges were 55.70±15.30 and 60.32±18.41 years old respectively. Heart rate, respiratory rate and O2 saturation in the first group were improved significantly after the treatment in comparison to the second group (p<0.05). The mean time of recovery and length of hospital stay were better in the first group than the second group but this difference was not significant (p>0.05). The addition of nebulized budesonide to standard asthma treatment might result in more improvement in O2 saturation and less patient’s distress.

Although rare, but it is very important to understand that intubation will be difficult for which of the patients. Some scoring systems are available in this regard that influenced by many factors such as body anthropometric factors. This study was conducted to investigate the relationship between Mallampati score, biting the upper lip as well as 2-3-3 maneuver with body anthropometric factors in different population of society. This cross-sectional study was conducted during the years 2014-2015 in Yazd, Iran. The subjects using simple randomized sampling method, and they were included in study after obtaining their informed consent. Demographic (age and gender) as well as anthropometric parameters of body, including weight, height, neck, waist circumference, hip circumference, body mass index (BMI) and waist-to-hip ratio (WHR) were collected in a pre-prepared checklist. Then, Mallampati score, biting the upper lip score, maneuver 2-3-3 were examined and calculated by researchers. The results of these examinations were recorded for each person in checklist. In this study, 498 people with mean age of 42.1 ± 16.1 were enrolled (51% female). Based on results of this study, although all three methods significantly correlated with age but none had any relation with gender. Significant relationship was found between upper lip biting and Mallampati score and all body anthropometric factors evaluated in this study (p < 0.05). By increasing the mean of these factors, Mallampati score increases, while this relationship is reverse in the case of height. In addition, significant correlation was found between maneuver 2-3-3 and weight, height, waist circumference, hip circumference and BMI, while it showed no correlation with neck circumference (p = 0.328) and WHR (p = 0.121). Based on findings of current study, it is likely that upper lip biting test and Mallampati score have significant relation with all body anthropometric factors evaluated in this study. But maneuver 2-3-3 has no correlation with neck circumference and WHR.

Many advances have been made in method, applied medications and the skill of the treatment staff for performing cardiopulmonary resuscitation (CPR), yet the rate of mortality following cardiac arrest is still high, which is affected by many factors. This study was designed and performed aiming to evaluate the effective factors in the success rate of CPR. This cross-sectional study was performed on patients who had undergone CPR in Dr. Shariati Hospital, Isfahan, Iran, from March 2017 to March 2018. A pre-designed checklist was used for data gathering, which included questions regarding demographic data and medical history of the patients, data related to CPR and the final outcome of resuscitation. A total of 190 patients with the mean age of 69.4±17.7 years were evaluated in the present study, 115 (60.5%) of which were male. Overall, 28.9% of CPRs were initially successful and 5.3% of the cases were finally discharged from the hospital. There was no significant correlation between CPR success and age, sex, hospitalization ward, time interval between hospitalization and cardiac arrest, the number of CPR attempts, or working shift (p > 0.05). On the other hand, CPR success significantly correlated with underlying illnesses and the first cardiac rhythm recorded before the initiation of resuscitation (p < 0.05). Based on the findings of the present study, it seems that underlying illness and the initial cardiac rhythm recorded correlate with the probability of CPR success.

The aim of this study is to reviewing various approaches for dealing with agitated patients in emergency department (ED) including of chemical and physical restraint methods. This review was conducted by searching “Violence,” “Aggression,” and “workplace violence” keywords in these databases: PubMed, Scopus, EmBase, ScienceDirect, Cochrane Database, and Google Scholar. In addition to using keywords for finding the papers, the related article capability was used to find more papers. From the found papers, published papers from 2005 to 2018 were chosen to enter the paper pool for further review. Ultimately, 200 papers were used in this paper to conduct a comprehensive review regarding violence management in ED. The results were categorized as prevention, verbal methods, pharmacological interventions and physical restraint. In this study various methods of chemical and physical restraint methods were reviewed so an emergency medicine physician be aware of various available choices in different clinical situations for agitated patients.

Some studies have shown that patients consuming alternate medicine can suffer from complications like acute kidney injury (AKI) due to heavy metal poisoning. The use of traditional ayurvedic herbal remedies may be difficult to identify as a source of toxicity, especially if the treating doctor is not aware of this habit, unless a detailed history is taken. In this report, we describe a patient who had consumed ayurvedic supplements for treating fever and abdominal pain and presented to our emergency department (ED) with AKI. A 24-year-old male presented to the ED with complaints of abdominal pain, fever and loose stools. His blood tests revealed AKI and he was started on emergency hemodialysis. His renal function improved after only one cycle of dialysis and he was discharged in a stable condition. Acute lead toxicity should be suspected in patients with abdominal and neurological dysfunction who have a history of chronic ayurvedic medicine intake and thus should be promptly treated. Physicians should rule out potential toxicity from these supplements and have a heightened level of suspicion for lead toxicity in patients presenting with abdominal pain and AKI without any obvious cause.

Ectopic adrenocorticotropic hormone (ACTH) syndrome is recognized by edema, proximal muscle weakness, hypertension, diabetes and skin hyperpigmentation. This syndrome is mainly associated with malignancies. A 43-year-old woman came to our hospital with a history of new-onset diabetes, hypertension, edema and facial hyperpigmentation from four months before. Upon admission, she had alkalosis, hypokalemia, mild hypertension and low-grade fever. Due to abdominal pain, an abdominal ultrasound was performed, which revealed common bile duct (CBD) and pancreatic duct dilation. The abdominopelvic computed tomography (CT) scan showed a poorly-enhancing mass in the periampullary region. The patient's facial hyperpigmentation and hypokalemia appear to have been due to ACTH ectopic syndrome as a result of periampullary cancer.

Hepatic hemangioma is the most common benign tumor in the liver. Although intra-abdominal bleeding associated with its rupture is rare, but life-threatening. Here we report a case of ruptured hepatic hemangioma and applied method for controlling its bleeding. The patient was a 45-year-old man who was referred after crashing his motorcycle into a car. The patient’s primary survey revealed intra-abdominal free fluid, but stable vital signs. Thirty minutes later, the patient’s systolic blood pressure dropped to 85 mmHg. Laparotomy was performed a large hemangioma was observed involving almost the entire left lobe of the liver. Using a liver needle and 2-0 chromic suture, we entered the hemangioma at the perforation site of the lower portion of the liver and exit from the upper part. Then, we entered the upper part of the liver and exited from the lower part, and then it was tied. According to this approach, hemangioma was packed from the lower segment of the liver. In this case, the patient’s abdomen was primarily closed without extra packing and embolization. The proposed method thus may be more effective compared to conventionally used methods.

A 73-year-old woman with no history of headache, seizure and trauma was admitted to the emergency department complaining about fever, vomiting and delirium for 3 days. She was lethargic upon admission and her blood pressure (BP) was recorded as 140/90 mm/Hg, her pulse rate (PR) as 75 beat/min and oral temperature as 38 °C. No localizing findings were observed in neurological examinations. Laboratory findings were as follows: White Blood Cell (WBC) count: 7,000/mm3, Hemoglobin: 13 g/dl, Platelet count: 300000. Lumbar CSF, blood and urine cultures were found to be negative for infections. Brain Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) were also performed. MRI showed filling defects in the left transverse sinus, the jugular bulb and the internal jugular vein. Moreover, hyper-intense signal was observed in the left temporal lobe (T1 sequence) suggesting hemorrhagic venous infarction (Figure1). The obtained results were confirmed by Magnetic Resonance Venography (MRV) of the brain (Figure2). The patient underwent anticoagulation therapy using LMWH and she was? hydrated using physiologic solution. The patient’s symptoms disappeared and she was then followed up regularly.

In the previous article, we explained how to calculate the sample size for a cross-sectional study based on a rate or a single proportion. In this article, we will explain how to calculate the sample size for an independent cohort study based on a comparison of two proportions representing the event rates in both the exposed and the non-exposed groups.