فهرست مطالب pooya payandemehr

Trauma severity indices are commonly used to describe the severity of sustained injuries in a quantitative manner perceivable by healthcare providers in different settings. In this study, we aimed to assess the predictive utility of the Glasgow Coma Scale (GCS) and the 2015 revision of the head Abbreviated Injury Scale (head AIS) as two of the most widely used severity indices for traumatic brain injury (TBI).

In this cross-sectional study, we used data from the National Trauma Registry of Iran. The area under the receiver operating characteristic curve (AUROC) was calculated to assess the utility of GCS and head AIS scores in predicting patients’ outcomes.

A total of 321 patients, predominantly males (81.9%) with an average age of 41.9 (±19.5) years were enrolled in the study. The most common cause of injury was road traffic accidents (73.5%) followed by falls (20.2%). The mean admission GCS and head AIS scores were 13.5 (±3.2) and 2.5 (±1.0), respectively. AUROC of the GCS was significantly higher than the head AIS for all outcome variables (P<0.05). AUROC of both severity scoring systems for predicting in-hospital mortality was significantly higher in the 15–44 age group than the 65 or older age group (P<0.05).

Based on our study results, GCS had better performance in predicting patients’ outcomes than the head AIS. Also, we found that age significantly affected the ability of these indices in predicting in-hospital mortality of TBI patients.

Since 1990, neonatal, infant, and child mortality has substantially decreased in Iran. However, estimates for mortality by cause at subnational scale are not available.

This study is part of the Global Burden of Diseases, Injuries, and Risk Factors study (GBD) 2019. Here we report the number and rates of neonate, infant, and child deaths by cause across provinces of Iran from 1990 to 2019.

Between 1990 and 2019, the neonatal mortality rate per 1000 live births decreased from 31.8 (95% UI: 28.1–35.5) to 6.8 (6.1–7.4). The child mortality rates decreased from 71.2 (63.6–79.1) to 11.1 (10.2–12.0) per 1000 live births. Mortality rates among neonates per 1000 live births ranged from 3.1 (2.6–3.7) to 10.0 (9.2–10.8) across provinces in 2019. Child mortality rate per 1000 live births ranged from 5.5 (4.6–6.5) to 17.9 (16.4–19.4) across provinces in 2019. Neonatal disorders, congenital birth defects, and lower respiratory infections were the three main causes of mortality in almost all provinces of Iran. The majority of neonatal disorders were due to neonatal preterm birth and neonatal asphyxia, trauma, and infections. The trends of mortality across provinces from 1990 to 2019 were converging and decreased along with increase in sociodemographic index (SDI).

All provinces achieved the Sustainable Development Goal 3.2 of neonatal mortality less than 12 and child mortality less than 25 per 1000 live births. However, disparities still exist across provinces, specifically in low-SDI provinces.

Environmental factors such as the lighting of the scene, time of the day, and physical surrounding of the patient and healthcare providers in the prehospital setting can affect difficult intravenous access (DIVA). The study aimed to evaluate the association of environment, patient, and emergency medical services (EMS) technicians on the DIVA in the prehospital setting.

Six-hundred adult patients (aged ≥18 years) who necessitated prehospital peripheral IV access and were transferred to the Sina and Shariati hospitals by EMS technicians from June 2018 to October 2018 were included. There were seven research nurses for interviewing the EMS technicians. Patients were examined using the prepared checklists.

Overall, there were 125 (20.83%) DIVA cases. There was a significant relationship between DIVA and the higher respiratory rate of the patients, lower the blood pressure of the patient, prior cannulation of the targeted limb, time since the last meal of EMS technician, and untidiness of the environment (Odds Ratio=1.75, 1.3, 9.4, 3.84 and 7.01, respectively).

The results showed fasting of EMS technicians affects DIVA and the study suggests it can be resolved by proper scheduling of the working hours of EMS technicians. Also, some risk factors of DIVA can help the paramedics to predict the DIVA and take the necessary measures.

Patients with multiple sclerosis (MS) visit Emergency Departments (ED) due to both neurological and non-neurological symptoms.

Our main aim was to study some epidemiologic features of the ED visits of MS cases in a referral hospital.

This cross-sectional study was conducted during 22 September 2018 - 21 September 2019 in Sina Hospital, Tehran, Iran. Admission causes were divided into two categories: patients admitted because of neurological complaints (MS true attacks and pseudo attacks) and patients admitted due to non-neurological reasons that may or may not be related to the disease. To compare the differences between the two categories, t and χ2 tests were used.

A total of 375 visits by 346 MS patients were reviewed. We observed that 239 (63.7%) visits were due to neurologic complaints, of which 213 (89.1%) were diagnosed with true MS relapses. Moreover, 136 visits were because of non-neurologic complaints, with urinary tract infection (UTI) being the most common complaint. The patients with MS visiting the ED were mostly female, though there was no significant difference between men and women diagnosed with true relapses (P = 0.154). Patients with neurologic symptoms were significantly younger than those with non-neurologic symptoms (P = 0.007). Our findings showed that 90% of patients with neurological symptoms underwent magnetic resonance imaging (MRI), and the yield of MRI was about 50%. Furthermore, the duration of admission was significantly higher in patients with neurological symptoms (P < 0.001).

MS relapse was the most frequent cause of ED visits by individuals with MS. There were also many ED visits by MS patients due to non-neurological causes, and the UTI was the most prevalent chief complaint.

 Since the outbreak of coronavirus 2019 (COVID-19), identifying risk factors associated with in-hospital mortality has been a global priority. In this study, the purpose was to evaluate the clinical, laboratory, and radiological characteristics of hospitalized patients with COVID-19 to develop a predictive model and scoring system for in-hospital mortality.

In this retrospective cohort study, 611 adult patients with COVID-19, admitted to Sina hospital were enrolled and followed up.

Out of the total number of 611 patients, 104 patients (17%) deceased during hospitalization, including 75 (12.2%) deaths in ICU and 29 (4.7%) deaths in the wards. After multivariate logistic regression analysis, several characteristics including age >55 years, previous history of malignancy, history of cerebrovascular accident, tachypnea on admission, CRP>54 on admission, D-dimer>1300, and bilateral pulmonary consolidation on chest Computed Tomography (CT) were shown to be the main determinants for stratifying the risk for in-hospital death. The factors were finally considered for introducing a new predictive scoring system for COVID-19 related death. 

In-hospital mortality rate in patients with COVID-19 is estimated to be 17%. A new scoring system for predicting in-hospital mortality in such patients was structured based on determinant factors of advanced age, history of malignancy, cerebrovascular accident, tachypnea, raised CRP, raised D-dimer on admission, and bilateral pulmonary consolidation on chest CT scan.

Since December 2019, an outbreak of Covid-19 has caused growing concern in multiple countries. Researchers around the world are working to find a treatment or a vaccine for Covid-19 and different treatment approaches have been tested in this regard. 

This study was designed and conducted to assess the possible efficacy of Interferon beta-1a as a safe and efficient candidate for Covid-19 treatment. 

This is an investigator-initiated, open-label, single-arm clinical trial. Twenty patients with suspected Covid-19, who were admitted to Sina hospital in Tehran, Iran, with moderate to severe symptoms, from 6 to 10 March, 2020, were enrolled. Patients were treated with antiviral and hydroxychloroquine combination therapy, along with subcutaneous Interferon beta-1a for 5 consecutive days. Baseline characteristics and findings during the course of admission and 5 days after discharge were recorded for all the patients. 

In total, 20 patients with suspected Covid-19 were included in this study, 12 (60%) of which were male. The median (Interquartile (IQ) range) of patients’ age was 55.5 (43-63.5). The most common symptom of the patients at onset of disease was fever. The median (IQ range) of duration of hospital stay was 5.0 (3-6) days. Only 2 cases were admitted to ICU. At the time of follow-up, 15 (94%) patients reported that they generally felt good and had oral tolerance, 1 patient had suffered from dyspnea, 5 patients had suffered from cough, none of them had experienced fever and no case of re-admission or death was reported after discharge. 

Results of the current study are in favor of using Interferon beta-1a in addition to recommended antiviral treatment in Covid-19 patients.

Monitoring the quality of cardiopulmonary resuscitation (CPR) could help in achieving favorable outcomes, decreasing mortality, and preventing post-CPR neurologic sequels. This study aimed to generate a user-friendly checklist for CPR quality control in emergency department (ED).

A qualitative study was performed between January and December 2018. In the first step, two emergency medicine specialists searched currently available databases and extracted the factors related to CPR quality. Afterward, two sessions of focus group discussions were held. The participants included four emergency medicine specialists, two ED managers, one anesthesiologist, and one cardiologist. Subsequently, 20 medical specialists, consisting of 10 emergency medicine specialists, six anesthesiologists, and four cardiologists, were invited to a Delphi panel in order to rate the extracted items from the prior group discussions.

During the two rounds of focus group discussions, 38 items related to the quality of CPR were identified. A Delphi panel evaluated the items; 31 items with at least 75% agreement were selected. These 31 items were included in the final checklist and after a pilot study and adjustment of its content they were sorted in 10 categories as follows: 1. chest compression, 2. airway, 3. bag-mask ventilation, 4. cardiac monitoring, 5. defibrillation, 6. intravenous (IV) drug delivery, 7. Medications, 8. Advanced airway, 9. CPR sequence, and 10. Reversible causes.

Our study provides a checklist for monitoring the quality of CPR in ED, but it is still necessary to include other factors related to the ED environment on this checklist.

Migraine is a frequent chief complaint of patients in the emergency department. A wide range of treatments are used for acute migraine. This study aimed to compare the therapeutic effects of a combination of metoclopramide + dexamethasone with those of ketorolac for treatment of acute migraine in the emergency department. This quasi-experimental study enrolled patients identified as migraine headache cases admitted to the emergency departments of Shohadaye Tajrish and Sina hospitals, Tehran, Iran. The patients were divided into two groups and treated with either 8 mg Dexamethasone + 10 mg Metoclopramide or 60 mg ketorolac, and then compared regarding the rate of pain control based on visual analogue scale (VAS) on arrival and 1 and 2 hours afterward. Overall, 86 patients were recruited, of whom 50 were male (58.1%). Their mean age was 37.6 ± 10.3 years. Thirty-five (40.7%) were in the ketorolac group and 51 (59.3%) were in the dexamethasone + metoclopramide group. Treatment success was defined as a reduction of at least 3 points in pain severity in comparison to the admission time. One hour after administration of medications, the reported pain intensity was 4.7 ± 2.0 and 6.2 ± 2.3 in ketorolac group and dexamethasone + metoclopramide group, respectively. By the second hour, pain intensity was 3.4 ± 1.2 and 2.9 ± 1.3 in ketorolac group and dexamethasone + metoclopramide group, respectively. The two groups did not show a significant difference in terms of the reported pain at this time (p= 0.04). Based on our findings, the pain reduction time was relatively shorter for ketorolac in acute migraine, but the final response was identical in the two groups.

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.

The patient was a 58-year-old woman with a history of mitral valvuloplasty, presenting to the emergency department (ED) due to weakness and shortness of breath. Her vital signs were stable. The patient’s electrocardiogram (ECG) is presented in figure 1. What is the correct interpretation of this ECG?
1.Sinus dysrhythmia
2.Paroxysmal atrial tachycardia with variable AV node block
3.Atrial flutter with variable AV node block
4.Sinoatrial block
5.Atrial fibrillation with normal ventricular rate
The baseline rhythm of this ECG shows an irregularity at the first glance that is repeated without any specific pattern. After considering this irregular abnormal pattern, in the next step, the heartbeat in this ECG should be calculated, taking into account the irregular base rhythm, about six seconds of the ECG should be considered, and the number of complete QRS complexes should be counted in this period. The resulting number should be multiplied by ten in order to estimate the heart rate in a minute. In this patient, the heart rate was about 90 beats per minute. So far, we have an irregular abnormal rhythm in the ECG. Differential diagnosis of this condition in the ECG varies based on the wide or narrow QRS complexes. A narrow QRS complex is a sign of the natural ventricular depolarization, and several rhythms with a natural rate (60-100 beats per minute) can have irregular QRS intervals. In the case of irregular abnormal rhythms, normal rates, and narrow QRS complexes, there are various differential diagnoses, some of which are mentioned in the multiple choice answer to this question. In the following, after mentioning the electrocardiographic characteristics of each of the rhythms mentioned in the question and their simultaneous assessment in this ECG, we will reach the correct answer.