فهرست مطالب مصطفی علوی مقدم

Multiple trauma may cause major bleeding will result in adverse clinical outcomes in the absence of proper and on time initial management in emergency department. In the present study, we aimed to synthesis the critical appraised evidences for initial management of patients with multiple trauma and major bleeding in emergency department.

This was a systematic review study. Following formulating of PICOs for clinical questions in the study, Search strategy selected to gather related evidences in Google scholar, Pubmed, Cochrane, and Trip database in English language from original articles, between 2008 to 2018.The key words were “Multiple trauma, hemorrhage, emergency treatment, therapy”. The Prisma flowchart was used to check the quality of evidences. The strength of evidences reported according to Oxford classification.

Out of 502 articles, 44 original articles were selected for final evaluation based on the search strategy criteria. Results indicated the favorable effects and safety of permissive hypotension resuscitation, using tourniquet, applying early blood transfusion, prescription of transamine, fibrinogen and factor VII on clinical outcomes of patients with multiple trauma and major bleeding in the emergency room.

Based on the study, applying permissive hypotension resuscitation, tourniquet, early blood transfusion, prescription of transamines fibrinogen and factor VII in special patients with multiple trauma and major bleeding in emergency department are recommended.

Drug interactions, as one of the most important subsets of medication errors, can lead to adverse reactions in patients. Considering the increase in drug interactions and their consequences, this study aimed to evaluate the frequency and pattern of drug interactions in patients admitted to the emergency department of a university affiliatedhospital.

This was a cross-sectional study. The study population consisted of patients referring to the Emergency Department of Imam Hossein Hospital from Aprilto the end of September 2018. 552 patients hospitalized in the emergency department of Imam Hossein Hospital were selected via random sampling and the rate of drug interactions reported in their medical profile was evaluated.

The mean age of these patients was 58.51 ± 20.05 years. Sex distribution evaluation showed that 54.4% were male. Based on the number of patients-days recorded, 34.2% had no drug interactions. The total number of interactions recorded was 1139, the highest number of which belonged to group C and the lowest number belonged to group X and A. 50% of people experienced two or less drug interactions and 75% of people experienced 4 or less drug interactions. Mean hospitalization days were 7.63 ± 6.15 days. Finally, 90.8% of patients recovered and 9.2% died.

Based on the findings of the present study, only 34.2% of the patients had no drug interactions. The total number of interactions recorded was 1139, the highest number of which belonged to group C and the lowest number belonged to group X and A. There was a significant correlation between the number of administered drugswith duration of hospitalization, final outcome and the probability of drug interactions. In addition, there was a significant correlation between type D and X drug interactions with mortality rate in patients.

Despite the considerable advances in medical diagnosis and treatment, treatment staff errors show an increasing trend, which can lead to decline in people’s trust and rise in stress and anxiety among patients. The present study was performed with the aim of assessing the causes of diagnostic errors leading to complaints from emergency medicine specialists from 2012 to 2017.

In the present cross-sectional study,100 files that were referred to the forensic medicine unit were evaluated. The data gathering tool was a researcher-made checklist, using which the demographic data of the patients and the type of error were extracted from the patients’ profiles. Data were coded and entered to SPSS software, version 20, after gathering and then reported using descriptive statistics.

In this study, the medical profiles of 100 patients who had filed complaints due to medical errors, in which a medical error was confirmed, were evaluated. In terms of sex distribution, 67% of the patients were male and 50% of the individuals were in the 30 –59 years age range. 32% of the errors were due to the physician not ordering laboratory tests, 37% were due to errors in examination, and 31 were due to errors in interpretation of the test results. In the level ofdiagnostic error and ordering diagnostic tests, the most important cause of error was that the physician did not believe testing was necessary for diagnosis. In the stage of examination and history taking also incomplete physical examination by the physician was the most important cause of error.Among the most important factors affecting medicalerror incidence in the studied files, judgment with 58%, changing shifts without providing information about the patients with 45%, workload with 38%, and the patient not cooperating with 29% were the most important cognitive, communicative, systemic, and patient-related factors, respectively.

Error in judgment regarding need for ordering diagnostic tests or further imaging, error in shift handover and not providing information regarding the patients for the next shift, overcrowding and heavy workload in the emergency department, and patients not cooperating were among the most important underlying factors in incidence of errors in the emergency department

Liver cirrhosis has grown significantly in Asian countries over the last few years. However, there is no tool for collecting liver cirrhosis data. The purpose of this study was to design a minimum data set for the self-care education of liver cirrhosis.

This descriptive study was conducted in the first half of 2018 in cooperation with 16 liver specialists of Rasool Akram Hospital and Firoozgar Hospital in Tehran. The research tool was a researcher-made questionnaire. The content validity method was used to validate the questionnaire and its reliability was confirmed through test-retest method (r = 0.84). Data were analyzed using SPSS21 software.

The minimum data set was organized in six categories: demographic, clinical, disease symptoms, dietary recommendations, general recommendations, medications and reminders. The demographic data collection consisted of 15 data elements, clinical data included 27 data elements, clinical symptoms included 9 data elements, food recommendations, consisted of 7 parts and 14 data elements, general recommendations consisted of 7 parts and 12 elements of data, and medications and reminders had two parts and 12 elements.

Considering the importance of data and information in the self-care of patients with liver cirrhosis and the role of software in collecting and sharing data with physicians, as well as reducing the number of visits to the hospital, attention should be paid to the minimum data set of self-care in patients with liver cirrhosis.

Based on the protocol of American Heart Association (AHA), target temperature of 32°C to 36°C for at least 24 hours should be provided, continuously, for all cases of spontaneous return of blood flow following successful cardiopulmonary resuscitation (CPR) in adult patients with evident altered level of consciousness. Therefore, the present study was done to evaluate the obstacles and assess the possibility of performing this protocol for patients in emergency department. This study was a qualitative research that consisted of 2 phases. In the first phase, by meeting the specialists involved with these patients, a standard questionnaire was filled regarding the obstacles to performing this protocol from their viewpoint. In the second phase, hypothermia protocol was done on a sample of eligible patients in emergency department. The aim of this phase was to find the problems of doing this protocol in real practice. The findings were reported using descriptive statistics. A total of 100 questionnaires were filled. Lack of experience or needing more information with 58%, limited facilities and equipment with 46% and lack of a national protocol with 24%, respectively, were the most important obstacles from the specialists’ point of view. In addition, losing golden time (57.14%), the in charge attend not giving permission (28.57%), and the relatives not giving consent (14.28%) were among the most important obstacles in the executive phase. Based on the findings of the present study, it seems that training the physicians involved with these patients regarding induction of hypothermia with the primary equipment present in emergency departments, writing inter-department protocols and preparing national protocols in this regard can help in spreading this treatment method.

Evaluation of cervical spine injuries makes up a major part of trauma patient assessments. Based on the existing sources, more than 98% of the cervical spine X-rays show no positive findings. Therefore, the present clinical audit aimed to evaluate the correlation of ordered cervical spine X-rays in multiple trauma patients with NEXUS and Canadian c-spine clinical decision rules.
The present clinical audit, evaluated the correlation of cervical spine imaging orders in multiple trauma patients presented to the emergency department, with NEXUS and Canadian c-spine rules. Initially, in a pilot study, the mentioned correlation was evaluated, and afterwards the results of this phase was analyzed. Since the correlation was low, an educational training was planned for all the physicians in charge. Finally, the calculated correlations for before and after training were compared using SPSS version 21.
Before and after training, cervical spine X-ray was ordered for 98 (62.82%) and 85 (54.48%) patients, respectively. Accuracy of cervical spine X-ray orders, based on the standard clinical decision rules, increased from 100 (64.1%) cases before training, to 143 (91.7%) cases after training (p Teaching NEXUS and Canadian c-spine clinical decision rules plays a significant role in improving the correlation of cervical spine X-ray orders in multiple trauma patients with the existing standards.

Nosocomial infections have increasingly resulted in unwanted side- effects and death and the patients should bear high treating costs. This research has been done to determine the knowledge, attitude, and practice of Hospital Administration and Chief medical officers about Nosocomial Infections Control and ha nd hyiegne in Imam Hossein Hospital of Tehran in 2013. This KAP study was conducted among 40 Hospital Admi nistration and Chief medical officers in Imam Hossein. Three world health organization questionnaires and checklist was used to collect the Knowledge, Attitu de, and Practice data from them. Data was entered and analyzed by using SPSS version 17.Of the 40 Hospital Administration and Chief medical officers, 25 (62.5%) were female and 15 (37.5%) were male. The mean age (±SD) of participants was 44.5 ± 7.3 years. The small number of participantes could identify correct answer of knowldege questions. More than 80% had positive attitude towards nosocomial infections control and hand hyegine. Overall, based on the questionare and check list their practice about Nosocomial Infections Control and hand hyiegne in hospital wasnot suitable. The limited knowledge and unsuitable practice of most Hospital Administration and Chief medical officers regarding Nosocomial Infecti ons Control and hand hyiegne was observed. So paying more attention by authorities to this spe cific topic is essential in order to apply the necessary actions and implementation of WHO protoco ls.

Since many years ago several problems have been felt in emergency departments (ED) of hospitals. In fact, none of physicians in the hospital have accepted the direct responsibility of patients’ management in the EDs and emergency wards of Uni versity centers have been managed by residents of various disciplines. Thus, the first line of therapy does not have guardian and several consultants with various specialists have been performed regarding patient’s management. The necessity of physician tr aining was noticed for the first time in 1950 and after 24 years in 1974, the academic emergency medicine was established in United States of America (USA) in response to people expectations for overnight accessibility to specialized and quality medical ca res. It was performed with foundation of the first period of resident’s training in emergency medicine discipline at University of Cincinnati, Ohio. At beginning, specialists of different fields such as internal medicine, surgery, anesthesia, orthopedics, and neurosurgery initiated the training of emergency medicine residents together which could be responsible to most of referees. Finally, with formal accepting the specialty board in 1978, this field has been officially identified as the 23 th discipline in USA. Today the EDs of most hospitals in European and American countries has been managing by emergency medicine specialists which leads to improve the quality of education and treatment, significantly. Also in Iran the request of establishin g this major has been presented in the secretariat of the council for graduate medical education for the first time in 1996. This request was approved and principles of its initiating recognized officially by the ministry of health. But, considering to lac k of an appropriate infrastructure, it postponed until 2000 that again this discipline was missioned for initiating to the council for graduate medical education by the minister and its outcome was directly declared to him. Lastly, in ministry time of Dr. Farhadi in 2001 this major was initiated for the first time in Iran University of Medical Sciences. The present report was addressed to the education guideline of emergency medicine at Shahid Beheshti University of Medical Sciences besides evaluating the f ormation history of emergency medicine discipline in Iran.

Stenotrphomonas maltophilia is an opportunistic nosocomial pathogen with high mortality in immunocompromised cases. The aim of this study was to isolate and identify Stenotrphomonas maltophilia in the hospitals’ environment and wards. In this cross-sectional study, a total of 1108 samples were collected from environment of two hospitals during 12 months. Identification of isolates was performed using biochemical, phenotypic (intrinsic resistance to carbapenems) and molecular methods (amplification of 23S rRNA gene). Of the studied samples, 186 (16.78%) nonfermentative gram negative bacilli (NFGNB) were identified. Amongst NFGNB, 18 (1.62%) isolates were identified as S. maltophiliaby using biochemical tests. Of 18 biochemically identified isolates, 15 (83.3%) were confirmed via PCR. Sinks (40%) and men surgery ward (33.3 %(were the most contaminated sites and wards of hospitals, respectively. S. maltophilia is repeatedly isolated from sink which shows that the moist hospital environments need to be considered as a source for dissemination of bacteria.

Venous Thromboembolism is one of the most serious conditions in ICU that might complicate patient’s general condition. This descriptive study was delivered to assess the cumulative incidence of VTE amongst ICU Patients in a general university hospital in Tehran in a one year period. We reviewed all the files from patients admitted to ICU for a one year period from May 2005 to May 2006. Patients who had an episode of venous thromboembolism were selected and their age, gender, preliminary disease, prophylaxis regimen for venous thromboembolism, treatment approach, and their outcome were recorded. There were 14 cases of venous thromboembolism among 339 patients admitted. Out of these 14 patients 5 had pulmonary thromboembolism and 3 patients expired (2 general surgery and 1 neurosurgery cases). 5 out of 14 patients had received prophylaxis for venous thromboembolism while none of the 3 expired patients had received it. Based on the underlying disease, there were 4 general surgery patients, 6 neurosurgery, 3 orthopedic surgeries, and 1 internal medicine patient. Treatment approach in all cases was heparin and enoxaparin administration while one case had IVC filter. ‍ It can be concluded that the incidence of VTE in ICU patients and the mortality rate is predictable; therefore correct and effective DVT/VTE prophylaxis can prevent massive PE and death amongst high risk patients.

Resistance in microorganisms is a serious problem in infectious medicine which the most reason is inappropriate antibiotic prescription by physicians. As there was not any information about the pattern of empiric antibiotic prescription in Iran, this study designed for recognition of antibiotic prescription pattern in one of emergency departments in a hospital affiliated to Shahid Beheshti medical university. This cross sectional study was performed during the years 2006-7 in the emergency department of the above mentioned hospital on 200 patients whom at least received one antibiotic. Physicians, after taking history and physical examination, completed the information form according to the patients chart in emergency department. Our references on appropriateness of empiric prescribed antibiotics were a) textbook of "Mandell's Principles and Practice of Infectious diseases, 6th Edition; 2005", and b) protocols from the "Infection Control Committee" of the same hospital. Among 200 patients to whom at least one antibiotic was prescribed, for 108 cases (54%), prescribed antibiotic was without indication and among 92 cases which antibiotic was indicated, in 55 cases (59.8%) the prescribed antibiotic was appropriate, i.e., the prescribed antibiotic was appropriate by type, dose and interval. according to the results, it is prudent that the prescription of antibiotics without clear indication and wrong selection of empiric antibiotics in this hospital's emergency department were disproportionately high. Thus it seems that using solutions like periodic education programs for physicians and supervision for prescribed antibiotics are mandatory.

The accuracy of the pre-hospital care has not been evaluated in Iran so that the purpose of the present study was to evaluate the efficacy of the pre-hospital care performed by Tehran Emergency Service in traumatic patients referred to “Sina Hospital”.

This prospective study was conducted on traumatic patients referred to emergency department of “Sina hospital” by Tehran Emergency Service from September 2003 to September 2004. The accuracy of the pre-hospital care performed by Tehran Emergency technicians, regarding the patients’ general condition was evaluated. The on-call physicians in emergency department of “Sina hospital” were responsible for gathering the data and filling the questionnaires based on their observation and the EMS forms.

994 patients were enrolled in the study. Wound bandage and homeostasis were done correctly in 80% of the cases. Splint was applied correctly in 50% of the patients, while other therapeutic procedures such as collar and spinal bed were not performed among 80% of the cases. IV-line was obtained in 91.2% of the patients, while serum infusion was initiated in only 20% of patients.

It is recommended to compile evidence-based protocols for the pre-hospital procedures and train the emergency technicians to follow the rules, in order to improve the efficacy and the accuracy of the pre-hospital care. According to the principal changes recently made in the quality and quantity of the care offered by Iran's Emergency Service, it is necessary to perform a new study to evaluate the present condition and compare the results of these qualitative and quantitative changes with the current study.

The accuracy of the pre-hospital care has not been evaluated in Iran so that the purpose of the present study was to evaluate the efficacy of the pre-hospital care performed by Tehran Emergency Service in traumatic patients referred to “Sina Hospital”. This prospective study was conducted on traumatic patients referred to emergency department of “Sina hospital” by Tehran Emergency Service from September 2003 to September 2004. The accuracy of the pre-hospital care performed by Tehran Emergency technicians, regarding the patients’ general condition was evaluated. The on-call physicians in emergency department of “Sina hospital” were responsible for gathering the data and filling the questionnaires based on their observation and the EMS forms. 994 patients were enrolled in the study. Wound bandage and homeostasis were done correctly in 80% of the cases. Splint was applied correctly in 50% of the patients, while other therapeutic procedures such as collar and spinal bed were not performed among 80% of the cases. IV-line was obtained in 91.2% of the patients, while serum infusion was initiated in only 20% of patients. It is recommended to compile evidence-based protocols for the pre-hospital procedures and train the emergency technicians to follow the rules, in order to improve the efficacy and the accuracy of the pre-hospital care. According to the principal changes recently made in the quality and quantity of the care offered by Iran's Emergency Service, it is necessary to perform a new study to evaluate the present condition and compare the results of these qualitative and quantitative changes with the current study

In spite of extended vaccination programs against measles, it is the most preventive contagious disease that leads to death. For adaptation of WHO policy for measles in Iran; we should determine susceptible age population whom at present lay out of current vaccination program. Methods and Materials: In this descriptive study which was performed in the public health School of the Tehran medical university; we obtained 131 documented measles cases among 650 suspected case of measles (as WHO discrimination) According to serum samples analysis (capture IgM EIA 71% and 29 % HI). In this study 63. 4 % of cases were male and 39.6 % were females. Between patients, the most prevalent age group was between 15 - 19 years old. Two peaks of the time of the disease were March and June. History of past vaccination against measles showed that 43 % had unknown history; 24. 4 % had two vaccination; 39. 3 % had one vaccination and 3.1 % had no vaccination history. It is suggested (by further investigations in future) the need for revaccination of measles for age group of 15-19 in Iran will be determined.