Archives of Academic Emergency Medicine
Volume:9 Issue: 1, 2021

Emergency department (ED) revisits increase overcrowding and predicting which patients mayneed to revisit could increase patient safety. This study aimed to identify clinical variables that could be usedto predict the probability of revisiting ED within 48 hours of discharge.

A retrospective case-controlstudy was conducted between July 2018 and January 2019 at the Emergency Medicine Department in Ramathi-bodi Hospital, Bangkok, Thailand. Patients who revisited the ED within 48 hours of discharge (case group) andpatients who did not (control group) participated. The predictive factors for ED revisit were identified throughmultivariate logistic regression analysis.

The case group consisted of 372 patients, who revisited the EDwithin 48 hours, and the control group consisted of 1488 patients. The most common reason for revisiting theED was recurring gastrointestinal illness, in 107 patients (28.76%). According to the multivariate data analysis ,five factors influenced the probability of revisiting the ED: age of more than 60 years (p < 0.001, OR = 2.04, 95%CI:1.51-2.77), initial Emergency Severity Index (ESI) triage level of 2 (p = 0.007, OR = 1.20, 95%CI: 0.93-1.56), ED stayduration of 4 hours or longer (p = 0.013, OR = 1.12, 95%CI: 0.87-1.44), body temperature of≥37.5◦C on discharge(p = 0.034, OR = 1.34, 95%CI: 1.00-1.80), and pulse rate of less than 60 (OR = 1.55, 95%CI: 0.87-2.77) or more than100 beats/minute (OR = 1.53, 95%CI: 1.10-2.11) (p = 0.011).

According to the findings, the mostimportant and independent predictive factor of ED revisit within 48 hours of discharge were, age≥60 years, ESItriage level 2, ED length of stay≥4 hours, temperature≥37.5 C, and 60 > pulse rate≥100 beats/minute.

Like other infectious diseases, it is expected that COVID-19 will mostly end with the developmentof neutralizing antibody immunity. This study aimed to evaluate the value of COVID-19 antibody rapid test as-sessment in emergency medical services (EMS) personnel.

This cross-sectional study was conductedin Tehran, Iran from 20th March until 20th May 2020. The results of chest computed tomography (CT) scan,and antibody rapid test were compared in EMS personnel with confirmed COVID-19, as well as symptomaticand asymptomatic ones who had exposure to a probable/confirmed COVID-19 teammate. In symptomatic orasymptomatic individuals who were only IgM-positive, chest CT scan or RT-PCR was recommended.

Atotal of 243 EMS personnel with the mean age of 36.14±8.70 (range 21 to 59) years took part in this study (87.7%were males). Most of the participants (73.3%) had history of exposure. One hundred sixty-three EMS personnelwere tested using either RT-PCR test or chest CT-scan or both, and 78 (47.9%) of them had at least one positiveresult. Among the participants who had undergone chest CT-scan and/or RT-PCR test (n=163), 78 had positivechest CT-scan and/or RT-PCR test; of these, 18 individuals had negative results for IgM and IgG. The rate of pos-itive IgM and IgG in participants with positive chest CT-scan was 1.6 or 1.3 times more than those with negativechest CT-scan, respectively (p < 0.05). The percentage of positive results for both IgM and IgG in participantshaving positive RT-PCR test was 1.7 times more than those having negative RT-PCR test (p < 0.05).

Rapid antibody test could help in diagnosis of COVID-19 in asymptomatic or symptomatic EMS personnel whodid not undergo RT-PCR test or the test was reported as negative. However, its sensitivity could be enhancedthrough use along with other diagnostic methods.

Spinal immobilization is the most important measure the Emergency Medical Service (EMS) hasto take when facing the victims of traumatic events, especially those with confirmed or suspected traumaticspinal cord injury (TSCI). The aim of this study was to investigate the clinical skills of EMS personnel regardingthe spinal immobilization of trauma victims.

This cross-sectional study was conducted to examinethe clinical skills of EMS personnel, regarding spinal immobilization of trauma victims during a 1-year periodin 2019. EMS personnel were selected via convenience sampling method. Data collection tools were a demo-graphic questionnaire and a researcher-made checklist to assess clinical skills. The face and content validityof the tool was reviewed and approved by 10 experts. Also, the overall reliability coefficient for the skills was0.98. Data were collected by the researcher through observing the skills performed, and filling out the clinicalskills checklist accordingly.

The mean overall score of the clinical skills of the 120 participants regardingspinal immobilization of trauma victims in supine, prone, and sitting positions were 0.60±1.44, 0.58±1.42and 0.65±1.62, respectively. Most of the studied personnel had moderate clinical skills in spinal immobiliza-tion, and they had poor clinical skills required to correctly pull the trauma victims in the longitudinal axis of thebody to put them on a long backboard and immobilize their torso, legs, and head using the Kendrick ExtricationDevice (KED).

The studied EMS personnel had moderate clinical skills regarding the spinal immo-bilization of trauma victims. It is recommended that the EMS training programs focus more on the practicalaspects of clinical skills in addition to theoretical aspects.

When cardiac arrest occurs in a confined space, such as in an aircraft or ambulance, kneeling bythe patient’s side may be difficult. Straddle chest compression is an alternative technique that can be used ina confined space. This study was performed to compare the quality of chest compressions in straddle versusconventional CPR on a manikin model.

The participants were randomized into two groups using thesequential numbered, opaque, sealed envelope method chosen through block-of-four randomization: strad-dle and conventional chest compression technique. Each participant performed a maximum of 4 minutes ofhands-only chest compressions, and quality parameters (compression rate and depth) were recorded from thedefibrillator’s monitor.

124 participants with mean age of 26.67 ± 6.90 years (27.58% male) were studied.There was no difference in the mean compression rate between the conventional and straddle chest compres-sion techniques (126.18 ± 17.11 and 127.01 ± 21.01 compressions/min, respectively; p = 0.811) or their meancompression depth (43.8 ± 9.60 and 43.4 ± 9.10 mm, respectively; p = 0.830). The participants’ comfort and fa-tigue were assessed through changes in their vital signs. In both methods, statistically significant differenceswere observed in vital signs before and after performing chest compression, but the differences were not clin-ically significant. In addition, there was no difference between the 2 groups in this regard.

Thequality of CPR using the straddle chest compression was as good as conventional chest compression technique.No significant differences were found in the quality of chest compressions or the participants’ comfort and fa-tigue levels.

Vertical transmission of the novel coronavirus 2019 (COVID-19), has been reported in case reports and series,while the data regarding its transmission is still not enough. Thus, presenting different experiences form variousregions could help better understand the virus behavior in pregnancy. We herein report a possible vertical trans-mission of COVID-19 from a mother to the neonate. A 41-year-old mother with signs and symptoms of acuterespiratory illness presented with labor pain and vaginal leak at 37 weeks of gestation. She tested positive forCOVID-19 using RT-PCR and underwent emergency cesarean section delivery and gave birth to a girl neonate.The baby tested positive for the COVID-19. Although vertical transmission of COVID-19 has not been provedyet, but there are several lines of evidences suggesting it. Paying close attention to the mother and newborn withCOVID-19 and long-term follow-up are needed for better understanding of the virus in pregnancy.

Epistaxis is one of the most prevalent complaints in the emergency department (ED), especiallyin patients who take antiplatelet agents. This study aimed to compare the effect of topical use of tranexamicacid (TXA) with phenylephrine-lidocaine anterior nasal packing (PANP) in controlling epistaxis of patients whotake aspirin or clopidogrel.

This prospective, double-blind, parallel-group, randomized clinical trialwas conducted to compare the effect of topical use of intravenous (IV ) TXA compared with PANP on controllinganterior epistaxis in patients who take aspirin or clopidogrel.

One hundred patients with the mean ageof 59.24±7.75 (45 – 75) years were studied (52% male). Two groups were similar in terms of age (p=0.81) and sex(p=0.23) distribution, diabetes mellitus (p=0.54), and hypertension (p = 0.037). The mean time to stop bleed-ing was 6.70±2.35 minutes in the TXA group and 11.50±3.64 minutes in the PANP group (p=0.002). Bleedingrecurrence occurred in 3 (6%) cases of the TXA group and 10 (20%) cases of the PANP group (p =0.03). Timeto discharge from ED in the TXA group was significantly lower than the PANP group (p<0.001). The absoluterisk reduction (ARR), relative risk reduction, and number needed to harm of treatment with TXA for anteriornasal bleeding were 14.00% (95%CI: 1.11 – 26.89), 17.50% (95%CI: 0.60 - 37.27), and 7.14 (95%CI: 3.71 -90.43),respectively.

Topical TXA is an appropriate treatment option in bleeding cessation, and reducingre-bleeding and duration of hospital stay in patients with epistaxis who take antiplatelet agents.

In the current systematic review, we intended to systematically review the epidemiology ofburnout and the strategies and recommendations to prevent or reduce it among healthcare providers (HCPs)of COVID-19 wards, so that policymakers can make more appropriate decisions.

MEDLINE (accessedfrom PubMed), Science Direct, and Scopus electronic databases were systematically searched in English fromDecember 01, 2019 to August 15, 2020, using MESH terms and related keywords. After reading the title andthe abstract, unrelated studies were excluded. The full texts of the studies were evaluated by authors, indepen-dently, and the quality of the studies was determined. Then, the data were extracted and reported.

12studies were included. Five studies investigated the risks factors associated with burnout; none could establisha causal relationship because of their methodology. No study examined any intervention to prevent or reduceburnout, and the provided recommendations were based on the authors’ experiences and opinions. None of thestudies followed up the participants, and all assessments were done according to the participants’ self-reportingand declaration. Assessing burnout in the HCPs working in the frontline wards was performed in four studies;others evaluated burnout among all HCPs working in the regular and frontline wards.

Paying at-tention to the mental health issues, reducing the workload of HCPs through adjusting their work shifts, reducingjob-related stressors, and creating a healthy work environment may prevent or reduce the burnout.

Despite recent progress in treatment of burn injuries, head and neck burn and its complications isstill considered a challenge. This study aimed to evaluate the baseline characteristics and outcomes of patientswith head and neck burn.

In this retrospective cross-sectional study, the medical profiles of patientswith head and neck burn referring to a burn care center during 2 years were reviewed and analyzed regarding thebaseline characteristics and outcomes of participants.

392 (17.97%) cases suffered from head and neckburns. The mean burn percentage of participants was 29.31 ± 24.78, and 126 (32.14%) cases required trachealintubation. There was a direct correlation between length of hospital stay and the degree of burn (p < 0.001). Thelength of hospitalization for patients burned by electricity was longer than those burned by other mechanisms(p = 0.003). There was a significant correlation between degree of burn and abnormal laryngoscopy findings (p= 0.036), developing acute respiratory distress syndrome (ARDS) (p < 0.001) and pneumonia (p < 0.001), needfor mechanical ventilation (p < 0.001), and mortality rate (p < 0.001).

Based on the findings of thepresent study, the prevalence of head and neck burn injuries was about 18% and 32.14% of these cases requiredairway management. 19 (4.85%) cases developed ARDS, 41 (10.46%) developed pneumonia, and 50 (12.76%)cases died. There was a significant correlation between degree of burn and abnormal laryngoscopy findings,developing ARDS and pneumonia, need for mechanical ventilation, and mortality rate.

Many reports have stated that patients admitted for COVID-19 may also suffer from cardiovas-cular diseases, suggesting cardiovascular involvement in COVID-19. Since there is direct association betweenelectrocardiography (ECG) data and the prognosis of cardiovascular disease, a systematic literature review wasperformed in the present study to address this association and make a conclusive agreement on the early di-agnostic and prognostic values of ECG in patients with COVID-19.

Electronic databases includingPubMed, Scopus, Web of Science, Science Direct, Ovid, Embase, and Google Scholar were searched for “COVID-19” and “ECG” using all their equivalents and similar terms as search words. Afterwards, the records were limitedto English articles and irrelevant documents, as well as articles that reported drug-induced cardiac dysfunctionor patients with previous history of cardiovascular complications were excluded.

Overall, 31 articleswith 2379 patients were found and used for qualitative data extraction. Findings showed that there is a signifi-cant association between COVID-19 infection and ECG findings. Also, ST-segment changes, T wave inversions,QT prolongation, and atrial fibrillation were found to be early indicators of cardiac involvement of COVID-19,which were associated with worse outcomes.

It is recommended to use ECG as a valuable diagnos-tic and prognostic tool for cardiac evaluation of patients with COVID-19.

COVID-19 is a new rapidly spreading epidemic. The symptoms of this disease could be diverseas the virus can affect any organ in the body of an infected person. This study aimed to investigate the availableevidence for long-term complications of COVID-19.

This study was a systematic review of currentevidence conducted in November 2020 to investigate probable late and long-term complications of COVID-19.We performed a systematic search, using the keywords, in online databases including PubMed, Scopus, ScienceDirect, Up to Date, and Web of Science, to find papers published from December 2019 to October 2020. Peer-reviewed original papers published in English, which met the eligibility criteria were included in the final report.Addressing non-human studies, unavailability of the full-text document, and duplicated results in databases,were characteristics that led to exclusion of the papers from review.

The full-texts of 65 articles havebeen reviewed. We identified 10 potential late complications of COVID-19. A review of studies showed thatlung injuries (n=31), venous/arterial thrombosis (n=28), heart injuries (n=26), cardiac/brain stroke (n=23), andneurological injuries (n=20) are the most frequent late complications of COVID-19.

Since we arestill at the early stages of the COVID-19 epidemic, it is too soon to predict what long-term complications arelikely to appear in the survivors of the disease in years after recovery. Furthermore, the complexity of COVID-19behaviors and targets in the human body creates uncertainty in anticipating long-term complications.

The use of computed tomography (CT) scan is essential for making diagnoses for trauma pa-tients in emergency medicine. Numerous studies have been conducted on guiding medical examinations inlight of advances in machine learning, leading to more accurate and rapid diagnoses. The present study aims topropose a machine learning-based method to help emergency physicians prevent performance of unnecessaryCT scans for chest trauma patients.

A dataset of 1000 samples collected in nearly two years was used.Classification methods used for modeling included the support vector machine (SVM), logistic regression, NaïveBayes, decision tree, multilayer perceptron (four hidden layers), random forest, and K nearest neighbor (KNN).The present work employs the decision tree approach (the most interpretable machine learning approach) asthe final method.

The accuracy of 7 machine learning algorithms was investigated. The decision treealgorithm was of higher accuracy than other algorithms. The optimal tree depth of 7 was chosen using the train-ing data. The accuracy, sensitivity and specificity of the final model was calculated to be 99.91% (95%CI: 99.10%– 100%), 100% (95%CI: 99.89% – 100%), and 99.33% (95%CI: 99.10% – 99.56%), respectively.

Con-sidering its high sensitivity, the proposed model seems to be sufficiently reliable for determining the need forperforming a CT scan.

Plastic bronchitis is an uncommon disorder marked by the production of bronchial casts and acute respiratoryfailure development. In pediatric cases, influenza infection sometimes results in the obstruction of bronchiand leads to this potentially life-threatening condition. We report the case of a five-year-old boy with plasticbronchitis related to influenza A infection, which could only be recovered by the use of extracorporeal mem-brane oxygenation (ECMO). ECMO could effectively provide sufficient oxygenation for patients suffering fromsevere reversible acute respiratory failure. If patients infected with the influenza virus present acute respira-tory distress with total lung atelectasis, clinicians should consider the diagnosis of plastic bronchitis and thesubsequent treatment interventions with ECMO in a severe cases.

Venous thromboembolic disease (VTD) is a very common and severe pathological condition in which there aremany predisposing factors. Olanzapine is a drug frequently used in psychiatric practises; it is thought to increasethe risk of VTD. Here, we report two cases, a young man and a woman, with a medical history of schizophreniatreated by olanzapine who developed pulmonary embolism and we did not find any aetiologies of VTD in them.Due to the link between olanzapine and pulmonary embolism, which has been previously described, olanzapineis considered responsible for this problem. Two mechanisms have been reported in the literature in this regard;significant weight gain and lethargy, which are very common side effects of olanzapine. So far, no direct effectof olanzapine on platelet aggregation or coagulation has been found. In patients developing VTD while beingtreated with olanzapine, discontinuation of olanzapine as a treatment option must be done with an adjustmentof antipsychotic treatment and regular monitoring of psychic symptoms. Since the diagnosis of pulmonaryembolism is not easy to make in a schizophrenic patient, clinicians should take that in consideration whenprescribing these drugs and when facing clinical situations where VTD is suspected.

Raising knowledge over cardiac complications and managing them can play a key role in theirrecovery. In this study, we aim to investigate the evidence regarding the prevalence of cardiac complicationsand the resulting mortality rate in COVID-19 patients.

Search was conducted in electronic databasesof Medline (using PubMed), Embase, Scopus, and Web of Science, in addition to the manual search in preprintdatabases, and Google and Google scholar search engines, for articles published from 2019 until April 30th,2020. Inclusion criterion was reviewing and reporting cardiac complications in patients with confirmed COVID-19.

The initial search resulted in 853 records, out of which 40 articles were included. Overall analysisshowed that the prevalence of acute cardiac injury, heart failure and cardiac arrest were 19.46% (95% CI: 18.23-20.72), 19.07% (95% CI: 15.38-23.04) and 3.44% (95% CI: 3.08-3.82), respectively. Moreover, abnormal serumtroponin level was observed in 22.86% (95% CI: 21.19-24.56) of the COVID-19 patients. Further analysis revealedthat the overall odds of mortality is 14.24 (95% CI: 8.67-23.38) times higher when patients develop acute car-diac injury. The pooled odds ratio of mortality when the analysis was limited to abnormal serum troponin levelwas 19.03 (95% CI: 11.85-30.56).

Acute cardiac injury and abnormal serum troponin level were themost prevalent cardiac complications/abnormalities in COVID-19 patients. The importance of cardiac compli-cations is emphasized due to the higher mortality rate among patients with these complications. Thus, troponinscreenings and cardiac evaluations are recommended to be performed in routine patient assessments.

Thyrotoxic periodic paralysis is a rare endocrine emergency that manifests as acute onset muscle weaknessand hypokalaemia secondary to thyrotoxicosis. It mainly occurs due to rapid and dramatic intracellular shift ofpotassium resulting in hypokalaemia and acute flaccid paralysis. This condition predominantly affects males ofAsian descent, and presentation can range from mild generalized weakness to complete quadriplegia, as seen inour case. We herein report a case of a 40-year-old female, who presented to us with acute onset flaccid quadriple-gia and thyroid storm, which is the first ever manifestation of previously undiagnosed Grave’s disease. Liverabscess was found to be the underlying trigger for thyrotoxic paralysis and thyroid storm.

Introduction:

There are numerous studies on the efficacy of intralipid emulsion (ILE) in various xenobiotictoxicities. This study aimed to evaluate the potential role of ILE as an antidote in tramadol-induced seizure.

A single-blind clinical trial was undertaken to establish the efficacy and safety of ILE in patients withacute tramadol intoxication, who referred to Booali Hospital in Qazvin. Patients were randomly assigned to 2groups. The Control group received standard care while the intervention group received intralipid emulsion(ILE) 20% in addition to the standard care. The occurrence of in-hospital seizure was compared between thegroups.

80 patients who abused tramadol and met the study criteria were randomly assigned to eitherthe intervention (40 cases) or the control (40 cases) group. Seizure occurred in 44 (56%) patients before admis-sion to the emergency department. There were not any statistical differences between the groups regarding sexdistribution (p=0.513) and mean age (p=0.19), presenting vital signs (p < 0.05), laboratory findings (p < 0.05),and mean abused dose of tramadol (p = 0.472) as well as occurrence of prehospital seizure (p = 0.7). In-hospitalseizure occurred in 15 (18.75%) cases (all in the control group; p < 0.001). The mean duration of admission was2.01±1.13 days in the control group and 2.15±1.04 days in the intervention group (p = 0.6). The number neededto treat for ILE to prevent tramadol-induced seizure was 2.7 (37.5% absolute risk reduction).

Thefindings of this study supported ILE administration, as an adjunct to standard antidote protocols, in tramadolintoxication to prevent tramadol-induced seizures.

Direct and indirect sequels of COVID-19 in the cardiovascular system are unclear. The presentstudy aims to investigate the echocardiography findings in COVID-19 patients and possible correlations be-tween the findings and the disease outcome.

In this cross-sectional study, baseline characteristics andechocardiographic findings of hospitalized COVID-19 cases, and their correlation with mortality were evaluated.Furthermore, computed tomography (CT) angiography was performed to assess possible pulmonary embolism.In-hospital mortality was considered as the main outcome of the present study.

680 confirmed COVID-19 cases with the mean age of 55.15 ± 10.92 (range: 28 – 79) years were studied (63.09% male). Analysis showedthat history of ischemic heart disease (RR=1.14; 95% CI: 1.08-1.19), history of hypertension (RR=1.04; 95% CI:1.00-1.08), presence of embolism in main pulmonary artery (RR=1.53; 95% CI: 1.35-1.74), CT involvement morethan 70% (RR=1.08; 95% CI: 1.1.01-1.16), left ventricular ejection fraction < 30 (RR=1.19; 95% CI: 1.07-1.32), pleu-ral effusion (RR=1.08; 95% CI: 1.00-1.16), pulmonary artery systolic blood pressure 35 to 50 mmHg (RR=1.11;95% CI: 1.03-1.18), right ventricular dysfunction (RR=1.54; 95% CI: 1.40-1.08), and collapsed inferior vena-cava(RR=1.05; 95% CI: 1.01-1.08) were independent prognostic factors of in-hospital mortality.

Ourstudy showed that cardiac involvement is a prevalent complication in COVID-19 patients. Echocardiographyfindings have independent prognostic value for prediction of in-hospital mortality. Since echocardiography isan easy and accessible method, echocardiography monitoring of COVID-19 patients can be used as a screeningtool for identification of high-risk patients.

Pneumocephalus refers to the presence of air in the cranial cavity. Trauma is the most common cause of acquiredpneumocephalus. Tension pneumocephalus occurs when intracranial accumulation of air causes high pressureon the brain as compared to extracranial pressure. Tension pneumocephalus is usually acute, and causes neu-rological symptoms, and its delayed form rarely occurs. A 12-year-old girl presented with a headache, lethargy,mild fever, and nausea from two days before admission to emergency department of Shahid Rajaei Hospital,Qazvin, Iran. The patient had a history of head trauma in a driving accident six weeks before and had under-gone brain computed tomography (CT) scan in another centre, which had revealed no sign of pneumocephalus.The patient had been treated for one week and had been discharged in good general condition. Consideringher reduced consciousness, the patient underwent brain CT scan again in our centre. CT scan revealed tensionhydropneumocephalus. The patient was transferred to the intensive care unit (ICU) for treatment. Consideringthe trend of her recovery, the patient was a candidate for conservative non-surgical therapy based on the in-charge neurosurgery specialist’s decision. The patient reported no complications during the six-month follow-up. Delayed tension pneumocephalus is among neurosurgery emergencies usually treated with early surgicalintervention and dura defect restoration, but this patient received non-surgical treatment without any seriousproblem during the six-month follow-up.

The recommended position for measuring Intra-Abdominal Pressure (IAP) is the supine position.However, patients put in this position are prone to Ventilator-associated pneumonia. This study was done toevaluate the relationship between bed head angle and IAP measurements of intubated patients in the intensivecare unit.

In this clinical trial, seventy-six critically ill patients under mechanical ventilation were en-rolled. IAP measurement was performed every 8 hours for 24 hours using the KORN method in three differentdegrees of the head of bed (HOB) elevation (0◦, 15◦, and 30◦). Bland-Altman analysis was performed to identifythe bias and limits of agreement among the three HOBs. According to World Society of the Abdominal Com-partment Syndrome (WSACS), we can consider two IAP techniques equivalent if a bias of <1 mmHg and limitsof agreement of - 4 to +4 were found between them. Data were analyzed using SPSS statistical software (v. 19),and the significance level was considered as 0.05.

The prevalence of intra-abdominal hypertension was18.42%. Mean ± standard deviation (SD) of IAP were 8.44 ± 4.02 mmHg for HOB angle 0◦, 9.58 ± 4.52 for HOBangle 15◦, and 11.10 ± 4.73 for HOB angle 30o (p = 0.0001). The IAP measurement bias between HOB angle 0◦andHOB angle 15◦was 1.13 mmHg. This bias was 2.66 mmHg between HOB angle 0◦and HOB angle 30◦.

Conclusion:

 Elevation of HOB angle from 0 to 30 degree significantly increases IAP. It seems that the measurement ofIAP at HOB angle 15◦was more reliable than 30◦.

Determining the diagnostic value of available biomarkers in predicting rhabdomyolysis-inducedacute kidney injury (AKI) is a priority. This study aimed to review the current evidence about the value of lactatedehydrogenase (LDH) in this regard.

In this narrative review, the papers in PubMed, Embase, and webof science were studied. The keywords prognosis, prognoses, prognostic, LDH, rhabdomyolysis, emergency pa-tients, and acute kidney failure or AKI had been selected from MeSH medical dictionary. Related papers writtenin English and published from November 2007 to December 2020 were selected.

Finally, 14 articleswere accepted for analysis. Among the selected articles, four were randomized clinical trials, seven were cross-sectional, and three were case-control studies. The results of the present review showed that abuse of illegaldrugs is the most common cause of rhabdomyolysis. AKI is the most serious complication of rhabdomyolysisreported in the studies. These studies have shown a three-fold increase in AKI following drug-induced rhab-domyolysis. The review of the included articles shows that high LDH can predicts AKI, especially in critical andemergency situations such as rhabdomyolysis where there is a risk of death if diagnosed late. These studiesshow that LDH increases in the presence of renal failure and tissue damage.

Serum LDH is an ap-propriate and cost-effective prognostic indicator that can be used for risk classification of patients at risk forrhabdomyolysis-induced AKI.

Mapping of COVID-19 infection in the city can help us know more about how the disease is dis-tributed and spread. This study was conducted to investigate the geographical distribution of probable COVID-19 patients who were transferred to destination hospitals by emergency medical services (EMS) in the first waveof the epidemic, in Tehran, Iran.

This cross-sectional study was performed based on recorded mis-sions during the first 3-month period of the pandemic in Tehran, Iran. All probable cases of COVID-19 who weretransferred to the hospitals following contact with Tehran EMS during the study period were enrolled. Arc-GISsoftware was utilized to draw the distribution map of the contact places of the cases.

In this study, thedata of 4018 patients were analyzed (60.9% male). The mean age of the patients was 54.1 ± 20.7 years; and themean age of the patients had increased with time during the studied 3 months (p = 0.003). The average inci-dence rate of this disease in Tehran during the study period was 4.6 per 10,000 population. Generally, the lowestand highest raw frequencies of Tehran COVID-19 contamination were seen in municipal districts 21 and 4, re-spectively. The raw frequency of cases during the 3-month study period also showed that the highest numberof cases in Tehran occurred in municipal districts 5 and 4, respectively.

In the present study, usinggeographic information systems (GIS), geographical distribution map of COVID-19 in Tehran, Iran, during thefirst 3 months of the pandemic was drawn.

Molecular pathophysiology of COVID-19 is not completely known. Expression changes in pa-tients’ plasma proteins have revealed new information about the disease. Introducing the key targeted plasmaprotein in fatal conditions of COVID-19 infection is the aim of this study.

Significant differentiallyexpressed proteins (DEPs) in the plasma of cases with a fatal condition of COVID-19 were extracted from anoriginal article. These proteins were included in a network via STRING database along with 100 first neighborproteins to determine central nodes of the network for analyzing.

Queried and added proteins wereincluded in a scale free network. Three hub nodes were identified as critical target proteins. The top queriedhub proteins were chains of fibrinogen; Fibrinogen Alpha chain (FGA), Fibrinogen gamma chain (FGG), andFibrinogen beta chain (FGB), which are related to the coagulation process.

It seems that fibrinogendysregulation has a deep impact on the fatality of COVID-19 infection.

Many proteomics-based and bioinformatics-based efforts are made to detect the molecularmechanism of COVID-19 infection. Identification of the main protein targets and pathways of severe cases ofCOVID-19 infection is the aim of this study.

Published differentially expressed proteins were screenedand the significant proteins were investigated via protein-protein interaction network using Cytoscape softwareV. 3.7.2 and STRING database. The studied proteins were assessed via action map analysis to determine therelationship between individual proteins using CluePedia. The related biological terms were investigated usingClueGO and the terms were clustered and discussed.

Among the 35 queried proteins, six of them (FGA,FGB, FGG, and FGl1 plus TLN1 and THBS1) were identified as critical proteins. A total of 38 biological terms,clustered in 4 groups, were introduced as the affected terms. “Platelet degranulation” and “hereditary factor Ideficiency disease” were introduced as the main class of the terms disturbed by COVID-19 virus.

Itcan be concluded that platelet damage and disturbed haemostasis could be the main targets in severe cases ofcoronavirus infection. It is vital to follow patients’ condition by examining the introduced critical differentiallyexpressed proteins (DEPs).

Rhabdomyolysis-induced acute kidney injury (AKI) is one of the most common complications ofcatastrophic incidents, especially earthquakes. Early detection of AKI can reduce the burden of the disease. Inthis paper, data collected from the Bam earthquake was used to find a suitable model that can be used in predic-tion of AKI in the early stages of the disaster.

Models used in this paper utilized many inputs, whichwere extracted from the previously published dataset, but depending on the employed method, other inputshave also been considered. This work has been done in two parts. In the first part, the models were constructedfrom a smaller set of records, which included all of the required fields and in the second part; the main purposewas to find a way to replace the missing data, as data are mostly incomplete in catastrophic events. The dataused belonged to the victims of the Bam earthquake, who were admitted to different hospitals. These data werecollected on the first day of the incident via questionnaires that were provided by the Iranian Society of Nephrol-ogy, in collaboration with the International Society of Nephrology (ISN).

overall, neural networks havemore robust results and given that they can be trained on more data to gain better accuracy, and gain more gen-eralization, they show promising results. overall, the best specificity that was achieved on testing almost all ofthe records was 99.24% and the best sensitivity that was achieved in testing almost all of the records was 94.44%.

We introduced several machine learning-based methods for predicting rhabdomyolysis-inducedAKI on the third day after a catastrophic incident. The introduced models show higher accuracy compared toprevious works performed on the Bam earthquake dataset.

Violence against healthcare workers mostly occurs in emergency departments and is a seriousglobal public health issue. This study aimed to evaluate the prevalence of violence directed towards emergencydepartment healthcare personnel and to ascertain the factors that might be correlated with it.

In thiscross-sectional study, an anonymous questionnaire was used to gather data from healthcare personnel workingin the emergency departments under the direction of the Bangkok Metropolitan Administration between 1 Au-gust 2019 and 30 November 2019, regarding the experience of violence during the previous year.

A totalof 258 (87.5%) responses were received from 295 personnel. The results showed that 88.4% (228 personnel) hadexperienced violence during the past year, of these, 37.6% involved physical abuse that caused minor injuries.Employees with shorter tenures, nurses, and those working in tertiary academic emergency departments in thecentral business district were found to have increased likelihood of confronting violence. Measures taken toprevent violence had a limited impact on the occurrence rate. The most common impact on employees after ex-periencing violence was discouragement in their jobs (75.1 %). The key factors that promoted cases of violencewere the consumption of alcohol or drugs (81.3%) and long waiting times (73.6%). Most violence tended tooccur during non-office hours (95.4%). One-third of emergency healthcare personnel reported facing violenceduring their work.

Emergency healthcare personnel in metropolitan of Thailand had a high rate ofexperiencing violence in the previous year. Younger age, lower work experience, being a nurse, and working inthe urban academic or tertiary emergency department increased the likelihood of being a victim of workplaceviolence

Screening of high-risk patients and accelerating their therapeutic procedures can reduce the bur-den of acute coronary syndrome (ACS). This study aimed to evaluate the accuracy of HEART score in predictingthe risk of one-month major adverse cardiac events (MACE) in these patients.

In this prospectivecross-sectional study, the accuracy of HEART score in patients over 18 years old who presented to emergencydepartment following acute chest pain, was evaluated during a 21-month period. Each patient was followed upregarding the incidence of MACE for one month via phone call and the hospital’s integrated health informationsystem.

240 cases with the mean age of 60.50 ± 16.07 years were studied (56.3% male). MACE wasobserved in 77 (32.1%) cases. The most common MACE was percutaneous coronary artery revascularization(PCAR) (12.9%). The mean HEART score of studied cases was 4.74 ± 2.12. The mean score of cases with MACEwas significantly higher than others (6.25 ± 1.97 versus 4.03 ± 1.79; p < 0.0001). Based on this score, the risk ofMACE was high in 34 (14.2%), moderate in 118 (49.2%), and low in 88 (36.7%) cases. The incidence of one-monthMACE was 85.3% in high-risk cases, 35.6% in moderate one, and 6.8% in low-risk cases based on HEART score.The area under the ROC curve of HEART score in predicting the risk of MACE was 0.796 (95% CI: 0.736 – 0.856).The best cut off point of HEART score in this regard was calculated as 4.5. The sensitivity and specificity of thisscore in 4.5 cut off were 83.11% (95% CI: 72.49 – 90.35) and 66.25% (95% CI: 58.38 – 73.35), respectively.

Conclusion:

Based on the findings of the present study the mean HEART score of ACS patients with one-month MACEwas significantly higher than others and the incidence of MACE in high-risk patients was significantly higher.But the overall accuracy of score in predicting one-month MACE in ACS patients was in moderate range

Myocarditis in patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seems to be associated with a higher mortality rate. This study aims to summarize the latest evidence onwhether the use of corticosteroids in patients with myocarditis associated with COVID-19 is necessary.

Methods:

We performed an extensive search using a combination of search terms in PubMed, Europe PMC, ProQuest,EBSCOhost, and Google Scholar up to January 2021. Full-text articles that met the predefined inclusion criteriawere included in the present study.

The full-texts of 18 articles have been reviewed. Thirteen out of theeighteen (72%) patients who got corticosteroid administration experienced major clinical improvements duringfollow-up while the other five (28%) were experiencing uneventful events. The mean age of the reported patientswas 47.8±13.2 years. There was no gender predominance. Most of the reported cases were from USA (39%) fol-lowed by Spain, China, and UK (11% each), while Brazil, Colombia, France, Belgium, and Italy contributed onecase each. Various corticosteroids were used but the most commonly applied were methylprednisolone (89%),hydrocortisone (5.5%), and prednisolone (5.5%). The most common route of administration among the studieswas intravenous administration and the duration of treatment varied between one and fourteen days.

Conclusion:

A review of the currently available literature shows that with the use of corticosteroid agents in treatingmyocarditis associated with COVID-19, favorable outcomes are attainable. Well-established randomized clini-cal trials are needed to evaluate the efficacy and safety of using corticosteroids in this condition

Fournier’s gangrene (FG) is a life-threatening disease, even with early diagnosis and administra-tion of vigorous treatment, its mortality rate is high. This study aimed to evaluate the factors relate to mortalityin patients with FG or necrotising fasciitis managed in a referral center.

This retrospective cross-sectional study was conducted on patients managed in a tertiary referral center, Tehran, Iran, from March 2009to March 2019, with diagnosis of FG or necrotising fasciitis. The correlation between different demographic andclinical parameters with mortality was analysed and reported.

73 cases with the mean age of 59.1 ± 15.8(range: 25 – 88) years were studied (87.7% male). 21 (28.8%) patients died. Escherichia coli (26 cases, 35.6%)was the most frequent microorganism in cultures. Non-survived cases had higher mean age (p = 0.01), higherfrequency of hyperlipidaemia (p = 0.02), immunosuppression (p < 0.001), longer hospital stay (p=0.02), lowerblood pressure (p=0.01), and lower platelet count (p=<0.001). Based on multivariate analysis, age (p = 0.015;Odds: 0.88 (0.79-0.97)), haematocrit level (p = 0.01; Odds: 1.27 (1.04-1.55)), platelet count (p = 0.03; Odds: 10.11(1.14-89.35)), and immunosuppression (p = 0.01; Odds: 0.01 (0.0-0.54)) were independent related factors of mor-tality.

The rate of mortality due to FG and necrotizing fasciitis was 28.8%. Based on multivariateanalysis, the independent related factors of mortality were older age, lower haematocrit level and platelet count,and presence of immunosuppression.

COVID-19 might present with other seemingly unrelated manifestations; for instance, neuro-logical symptoms. This study aimed to evaluate the neurologic manifestations and their correlated factors inCOVID-19 patients.

This retrospective observational study was conducted from March 17, 2020 toJune 20, 2020 in a tertiary hospital in Iran. The study population consisted of adult patients with a positive resultfor COVID-19 real-time reverse transcriptase polymerase chain reaction (RT-PCR) using nasopharyngeal swabs.Both written and electronic data regarding baseline characteristic, laboratory findings, and neurological mani-festations were evaluated and reported.

727 COVID-19 patients with the mean age of 49.94 ± 17.49 yearswere studied (56.9% male). At least one neurological symptom was observed in 403 (55.4%) cases. Headache(29.0%), and smell (22.3%) and taste (22.0%) impairment were the most prevalent neurological symptoms, whileseizure (1.1%) and stroke (2.3%) were the least common ones. Patients with neurological manifestations weresignificantly older (p = 0.04), had greater body mass index (BMI) (p = 0.02), longer first symptom to admissionduration (p < 0.001) and were more frequently opium users (p = 0.03) compared to COVID-19 patients withoutneurological symptoms. O2 saturation was significantly lower in patients with neurological manifestations (p =0.04). In addition, medians of neutrophil count (p = 0.006), neutrophil-lymphocyte ratio (NLR) (p = 0.02) andc-reactive protein (CRP) (p = 0.001) were significantly higher and the median of lymphocyte count (p = 0.03) wassignificantly lower in patients with neurological manifestations.

The prevalence of neurologicalmanifestations in the studied cases was high (55.4%). This prevalence was significantly higher in older age,grated BMI, longer lasting disease, and opium usage.

Ongoing exposure to a variety of Pre-hospital Emergencies (PE) has placed Emergency Medi-cal Technicians (EMTs) at serious psychiatric compromise such as Post-Traumatic Stress Disorder (PTSD). Thepresent study aimed to evaluate the prevalence and associated factors of PTSD among EMTs.

Thisprospective cross-sectional study was conducted on EMTs in the Emergency Medical Services (EMS) in west ofIran. A baseline information questionnaire including personal work-related characteristics and the PTSD check-list of DSM-5 (PCL-5) were used for data collection. Non-parametric tests and multivariate linear regression wereused to evaluate the associated factors of PTSD in these participants.

Among the participants, 22% oftechnicians had PTSD-diagnostic criteria. The mean total PCL-5 score was 21.60 ± 11.45, while the scores were38.02 ± 6.08 and 17.47 ± 8.36 in the PTSD-diagnosed and undiagnosed groups, respectively. The most commonsymptom of the clusters was negative alterations in cognition with a mean score of 7.42 ± 4.63. After adjustingconfounders, the number of missions (t= 2.50, P= 0.013), work experience (t= -3.24, P= 0.001) and number ofshifts (t: 26.38, P < 0.001) were significantly corelated with PCL-5 score.

The results indicated thatthe prevalence of PTSD among EMTs personnel of hamadan province is high. EMTs with the age of≤30 years,work experience of≤10 years, married status, informal employment, emergency medical technician’s degree,and more than 8 shifts per month, as well as no previous training history had a higher total PCL-5 score.

As a result of destruction and lack of access to vital infrastructures and mental stress, disastersintensify cardiovascular diseases (CVDs) and hence management of CVDs becomes more challenging. The aimof this study is investigating incidence and prevalence of CVDs, morbidity and mortality of CVDs, treatmentand management of CVDs at the time of natural disasters.

In the present systematic review, the arti-cles published in English language until 28. 11. 2020, which studied CVDs in natural disasters were included.The inclusion criteria were CVDs such as myocardial infarction (MI), acute coronary syndrome (ACS), hyper-tension (HTN), pulmonary edema, and heart failure (HF) in natural disasters such as earthquake, flood, storm,hurricane, cyclone, typhoon, and tornado.

The search led to accessing 4426 non-duplicate records.Finally, the data of 104 articles were included in quality appraisal. We managed to find 4, 21 and 79 full textarticles, which considered cardiovascular diseases at the time of flood, storm, and earthquake, respectively.

Prevalence of CVD increases after disasters. Lack of access to medication or lack of medicationadjustment, losing home blood pressure monitor as a result of destruction and physical and mental stress afterdisasters are of the most significant challenges of controlling and managing CVDs. By means of quick establish-ment of health clinics, quick access to appropriate diagnosis and treatment, providing and access to medication,self-management, and self-care incentives along with appropriate medication and non-medication measures tocontrol stress, we can better manage and control cardiovascular diseases, particularly hypertension.

Alvarado Scoring System (ASS) and Ohmann Scoring System (OSS) are two scoring systems for di-agnosing acute appendicitis (AA). This study was designed to compare the diagnostic accuracy of the two men-tioned scores in detection of acute abdominal cases at risk for AA.

In this prospective cross-sectionalstudy, patients admitted to the emergency departments of two academic hospitals in Qom, Iran, with right lowerquadrant (RLQ) abdominal pain suspected to AA were evaluated. All cases were scored using ASS and OSS, andscreening performance characteristics of the two scores were calculated and reported considering the patho-logic findings as a gold standard.

174 patients with a preliminary AA diagnosis and the mean age of38.1 ± 10.63 years (11- 73) were included in this study (62.07% male). At the optimal cutoff point of≥7 for theASS, the sensitivity and the specificity were 46.43% (95% CI: 37.97%-55.07%), 97.05% (95% CI: 84.67%-92.93%),respectively. At the optimal cutoff point of≥11 for the OSS, the sensitivity and the specificity were 74.29% (95%CI: 66.22%-81.29%), and 55.88% (95% CI: 37.89% - 72.82%), respectively.

Based on the finding ofthis study, the ASS≥7 was more accurate than the OSS≥11 for detection of AA. But it should be considered thatthe overall accuracy of Alvarado and Ohmann scores in this regard were fair (0.83) and poor (0.67), respectively.

Introduction:

An effective triage needs to consider many factors, such as good triage protocol, experiencedtriage nurses, and patient factors. This study aimed to evaluate the validity of Songklanagarind Pediatric Triage(SPT) for triage of pediatric patients in the emergency department (ED) and identify the factors associatedwith triage appropriateness.

This study was done in two phases. In the first phase, a team of emer-gency physicians, a pediatric emergency physician, and a pediatric critical care physician developed SPT modelby considering and combining Emergency Severity Index (ESI), Pediatric Assessment Triangle (PAT), PediatricCanadian Triage and Acuity Scale (PaedCTAS), and Pediatric Septic Shock early warning signs protocol of thehospital as the core concept. In the second phase, a prospective observational study was conducted in the ED ofSongklanagarind Hospital, which is a tertiary university hospital in southern Thailand, from September to Oc-tober 2019 to evaluate the accuracy of the developed triage model.

A total of 520 pediatric patients metthe inclusion criteria. The pediatric triage model had sensitivity and specificity values of 98.28% and 26.24%,respectively, and positive and negative predictive values of 27.67% and 98.15%, respectively, in prediction ofdeath, hospitalization, and resource utilization. The rates of appropriate triage, over-triage, and under-triagewere 68.8%, 28.5%, and 2.7%, respectively. Significant factors associated with appropriateness of triage wereunderlying disease of the respiratory system (OR = 4.16, 95%CI: 1.75–9.23), fever (OR = 0.60, 95%CI: 0.41–0.88),dyspnea (OR: 6.38, 95%CI: 2.51–16.22), diarrhea (OR = 0.26, 95%CI: 0.09–0.73), oxygen saturation <95% (OR =3.18, 95%CI: 1.09–9.27), accessory muscle use during breathing (OR = 3.67, 95%CI: 1.09–12.41), and wheezing orrhonchi (OR = 6.96, 95%CI: 3.14–15.43).

SPT showed good correlation of hospital admission ratesand resource utilization with pediatric triage level of urgency. However, further efforts are needed to decreasethe rates of over- and under-triage.

Augmentation of the number of trained basic life support (BLS) providers can remarkably reducethe number of cardiac arrest victims. The aim of this study was to evaluate the level of BLS awareness amongstudents of medical sciences in Iran.

This multicenter cross-sectional study was performed on medi-cal students at the 4 major medical schools in Tehran, the capital of Iran, between Jan 2018 and Feb 2019, usingconvenience sampling method. The level of medical sciences students’ awareness of BLS was measured usingan international questionnaire.

Finally, 1210 students with the mean age of 21.2 ± 2.3 years completedthe survey (79% female). 133 (10.9%) students had CPR experience and none had received any formal train-ing. None of the responders could answer all questions correctly. The mean awareness score of participantswas 11.93 ± 2.87 (range: 10.13 -17.25). The awareness score of participants was high in 49 (4.04 %) participants,moderate in 218 (18.01%), and low in 943 (77.93%) of studied cases.

Based on the findings of thisstudy, more than 70% of the studied medical sciences students obtained a low score on BLS awareness.

The social distancing plan is one of the ways that was implemented for management of COVID-19 pandemic. This study aimed to evaluate the effect of the social distancing on reducing the daily new casesand deaths from COVID-19.

In this cross-sectional study, the data of daily new cases and daily deathswere collected from 15/02/2020 to 19/04/2020. Changes in the level and trend of daily new cases and dailydeaths before and after the implementation of social distancing plan were evaluated using interrupted timeseries (ITS) analysis in STATA software.

The post-intervention trend had a decrease of 102 new casesper day and 7 new deaths per day compared to the pre-intervention trend (p < 0.001). Moreover, in the post-intervention period, the daily new cases had a decrease of 58 new cases per day and 2 new deaths per day (p <0.001).

It Could be concluded that social distancing plan directly affects the new daily cases andnew daily deaths.

The popularity of motorcycle riding in Iran is increasing. However, there is a lack of informa-tion about the safety of different motorcycle types. This study aimed to compare the severity of injury andtrauma pattern between scooter (vespa) and street (standard) motorcycle riders.

In a prospective co-hort study, a comparison of demographics, injury severity, trauma pattern, and clinical characteristics between324 riders (162 Vespa and 162 standard motorcycles) admitted to emergency departments was undertaken. Therisk factors associated with severe injuries in the two groups were also determined. An emergency medicine spe-cialist determined the severity of trauma based on the abbreviated injury scale (AIS).

The Odds Ratio(OR) of severe injuries was significantly higher in the standard motorcycle riders’ group (OR: 3.09; 95% CI: 1.9-4.21; p: 0.013). The frequency of lower extremity fractures was significantly lower in the Vespa group (OR: 4.11;95% CI: 2.01-6.25; p = 0.012). The frequency of admission to the intensive care unit was significantly higher inthe standard motorbike riders’ group (OR: 1.64; 95% CI: 1.11-2.51; p = 0.033). The multivariate analysis indicatedthat motorcycle type, the speed at the time of the accident, use of helmet, and age of riders are the most impor-tant predictors of trauma severity in riders (p<0.05).

The pattern of injury varies between standardand Vespa motorcycles. The standard motorcycle riders were prone to a higher risk of adverse outcomes such assevere injuries. Due to the particular structure of scooters, the rate of lower limb injuries was significantly lowerthan standard motorcycles.

Introduction:

The current international sepsis guideline recommends that administration of intravenousbroad-spectrum antibiotics should be initiated within 1 hour of emergency department (ED) arrival for sepsispatients. This study aimed to evaluate the association between door-to-antibiotic time and in-hospital mor-tality of these patients.

In this retrospective cross-sectional study, elderly patients (age≥65 years)diagnosed with sepsis in the ED of a tertiary referral and academic hospital from January to December 2019were enrolled. Door-to-antibiotic time was defined as the time from ED arrival to antibiotic initiation. The as-sociations of door-to-antibiotic time and each hour delay in first antibiotic initiation with in-hospital mortalitywere assessed.

Six hundred patients with the median age of 78.0 (IQR: 72.0-86.0) were studied (50.8%female). The median door-to-antibiotic time was 51.0 (36.0–89.0) minutes and in-hospital mortality rate was12.5%. There was no significant difference in the in-hospital mortality rate between door-to-antibiotic time≤1hour and >1 hour (13.1% vs. 11.6%, p = 0.726). When considering hour-upon-hour of door-to-antibiotic time,no significant difference in in-hospital mortality was observed (p = 0.866). Factors that led to a delay in door-to-antibiotic time were presenting body temperature <38°C (odds ratio [OR] 3.34; 95% CI, 2.12-5.29; p < 0.001)and age <75 years (OR 1.7; 95% CI, 1.09-2.64; p= 0.019).

Door-to-antibiotic time was not associ-ated with in-hospital mortality in elderly sepsis patients in this study. Significant factors that led to a delay indoor-to-antibiotic time were no fever, age <75 years, doctor time, and blood sample taking time.

Although current evidence points to the possible prognostic value of electrocardiographic (ECG)findings for in-hospital mortality of COVID-19 patients, most of these studies have been performed on a smallsample size. In this study, our aim was to investigate the ECG changes as prognostic indicators of in-hospitalmortality.

In a retrospective cohort study, the findings of the first and the second ECGs of COVID-19patients were extracted and changes in the ECGs were examined. Any abnormal finding in the second ECG thatwasn’t present in the initial ECG at the time of admission was defined as an ECG change. ECGs were interpretedby a cardiologist and the prognostic value of abnormal ECG findings for in-hospital mortality of COVID-19 pa-tients was evaluated using multivariate analysis and the report of the relative risk (RR).

Data of the ECGsrecorded at the time of admission were extracted from the files of 893 patients; likewise, the second ECGs couldbe extracted from the records of 328 patients who had an initial ECG. The presence of sinus tachycardia (RR =2.342; p <0.001), supraventricular arrhythmia (RR = 1.688; p = 0.001), ventricular arrhythmia (RR = 1.854; p =0.011), interventricular conduction delays (RR = 1.608; p = 0.009), and abnormal R wave progression (RR = 1.766;p = 0.001) at the time of admission were independent prognostic factors for in-hospital mortality. In the secondECG, sinus tachycardia (RR = 2.222; p <0.001), supraventricular arrhythmia (RR = 1.632; p <0.001), abnormal Rwave progression (RR = 2.151; p = 0.009), and abnormal T wave (RR = 1.590; p = 0.001) were also independentprognostic factors of in-hospital mortality. Moreover, by comparing the first and the second ECGs, it was foundthat the incidence of supraventricular arrhythmia (RR = 1.973; p = 0.005) and ST segment elevation/depression(RR = 2.296; p <0.001) during hospitalization (ECG novel changes) are two independent prognostic factors ofin-hospital mortality in COVID-19 patients.

Due to the fact that using electrocardiographic data iseasy and accessible and it is easy to continuously monitor patients with this tool, ECGs can be useful in identi-fying high-risk COVID-19 patients for mortality.

Due to illegal manufacturing and sales of alcoholic beverages, epidemic outbreaks of methanolpoisoning may occur. The aim of this study was to determine if there were differences in the severity, courseof poisoning, and outcomes between methanol-poisoned patients admitted during an outbreak versus thosewho were admitted following episodic exposures.

The present retrospective study was performed ina single referral poisoning center between March 2018 and March 2019 in patients with confirmed methanolpoisoning. During this time, in addition to episodic cases of methanol intoxication, there were three methanolpoisoning outbreaks. Outbreaks were characterized by an unexpected increase in the number of methanol-poisoned patients in a short period of time, which impacted resources and decision-making. The two groupswere compared regarding their severity of poisoning, sessions of hemodialysis, and clinical outcomes.

Outbreak cases had a higher level of methanol than episodic cases. Odds of being dialyzed more than once was5.4 times higher in the cases presenting during an outbreak (95% CI 2.1-14.0; p=0.001). Mean hospital stay, intu-bation/mechanical ventilation, and death were similar between the two groups. An evaluation of the alcoholicbeverage samples available in the Iranian black market during the outbreak showed a 7-percent methanol con-centration with no ethanol content.

Poisoning risk may be higher during methanol outbreaks dueto the higher methanol concentrations, requiring more hemodialysis sessions for persistent metabolic acidosis.In addition to alcohol dehydrogenase blockade, careful risk assessment of all methanol poisonings can assistwith stratifying the priority for, and duration of, hemodialysis to optimize outcomes.

Effective information management in the emergency department (ED) can improve the controland management of ED processes. Dashboards, known as data management tools, efficiently provide informa-tion and contribute greatly to control and management of ED. This study aimed to identify performance indica-tors quality dashboard functionalities, and analyze the challenges associated with dashboard implementationin the ED.

This systematic review began with a search in four databases (Web of Science, PubMed,Embase, and Scopus) from 2000 to May 30, 2020, when the final search for papers was conducted. The datawere collected using a data extraction form and the contents of the extracted papers were analyzed throughED performance indicators, dashboard functionalities, and implementation challenges.

Performanceindicators reported in the reviewed papers were classified as the quality of care, patient flow, timeliness, costs,and resources. The main dashboard functionalities noted in the papers included reporting, customization, alertcreation, resource management, and real-time information display. The dashboard implementation challengesincluded data sources, data quality, integration with other systems, adaptability of dashboard functionalitiesto user needs, and selection of appropriate performance indicators.

Quality dashboards facilitateprocesses, communication, and situation awareness in the ED; hence, they can improve care provision in thisdepartment. To enhance the effectiveness and efficiency of ED dashboards, officials should set performanceindicators and consider the conformity of dashboard functionalities with user needs. They should also integratedashboards with other relevant systems at the departmental and hospital levels.

Ultrasonography (US) has been suggested as an integral part of resuscitation to identify poten-tially reversible causes of cardiac arrest (CA). This study aimed to evaluate the association between cardiac ac-tivity on ultrasonography during resuscitation and outcome of patients with non-shockable rhythms.

We conducted a prospective, observational study on adult patients presenting with CA or experiencing CA inthe emergency department (ED), and initial non-shockable rhythm. US examination of the sub-xiphoid regionwas performed during the 10-second interval of rhythm and pulse check and the association of US findings andpatients’ outcomes was evaluated.

151 patients with the mean age of 65.32 ± 11.68 years were evaluated(76.2% male). 43 patients (28.5%) demonstrated cardiac activity on the initial US. The rate of asystole in initialrhythm was 58.9% (n=89). Return of spontaneous circulation (ROSC) was achieved in 36 (23.8%) patients, twenty(13.2%) survived to hospital admission and seven (4.6%) survived to hospital discharge. When the cardiac stand-still duration increased to six minutes, no patient survived hospital discharge. Potentially reversible causes weredetected in 15 cases (9.9%), and four of them survived to hospital discharge. Cardiac activity on first scan wasassociated with ROSC (OR: 6.86, 95%CI: 2.92-16.09; p < 0.001), survival to hospital admission (OR: 17.80, 95%CI:3.95–80.17; p < 0.001), and survival to hospital discharge (OR: 17.35, 95%CI: 2.02–148.92; p = 0.001).

Conclusion:

In non-traumatic cardiac arrest patients with non-shockable rhythms, bedside US is of great importancein predicting ROSC. The presence of pulseless electrical activity (PEA) rhythm and cardiac activity on initial USwere associated with ROSC, survival to hospital admission, and hospital discharge. When the cardiac standstillduration increased to six minutes, no patient survived hospital discharge.

Any surgical or preoperative treatment and diagnostic procedure may be associated with complications andrisks. Therefore, introduction of complicated cases plays an important role in educating those involved in thediagnosis of patients. Generally, if a physician or a nurse is informed that an item is inadvertently left behind ina patient’s body during surgery, he/she is obliged to take action by notifying the healthcare system authoritiesand informing the patient as soon as possible; otherwise, he/she has committed a disciplinary violation. Herewe present a 27-year-old female patient with a history of renal failure with prolonged fever following a retainedShaldon catheter in a patient’s chest

Collagen and omega-3 fatty acids (FAs) are suggested to have anti-inflammatory, anti-oxidant,and insulin-sensitizing properties. The aim of this study was to investigate the effect of collagen hydrolysate andomega-3 FAs on inflammation and insulin resistance in patients with major burns.

In this double-blind randomized clinical trial, 66 patients with 20-45% burns were assigned to either of the three groups ofcollagen (40 gr/d), collagen (40 gr/d) plus fish oil (10 ml/d), or control. High-sensitivity C-reactive protein (hs-CRP), fasting blood glucose (FBG) and insulin concentrations, and homeostatic model assessment for insulinresistance (HOMA-IR) were assessed at baseline, as well as end of weeks two and three.

Based on post-hoc analyses, hs-CRP levels were significantly lower in the collagen (p=0.026) and collagen+omega-3 (p=0.044)groups compared to the control group, at week three. However, pre- to post- (week three) changes of hs-CRPwere significantly higher only in the collagen+omega-3 group compared to the control group (173.2 vs. 103.7mg/l, p=0.024). After three weeks of the intervention, insulin (11.3 and 11.9 vs. 22.8μIU/ml) and HOMA-IR (2.9and 2.8 vs. 7.9) values seemed to be clinically, but not statistically, lower in both intervention groups comparedto the control group. Pre- to post- (week three) values of FBG decreased significantly in the collagen (p=0.002)and collagen+omega-3 (p=0.036) groups. Insulin (p=0.008) and HOMA-IR (p=0.001) decreased significantly onlyin the collagen+omega-3 group at week three compared to the baseline.

Supplementation withcollagen hydrolysate and omega-3 FAs can improve hs-CRP concentration and probably insulin resistance inpatients with severe burns. Omega-3 FAs had additional effects on modulating inflammation. Larger clinicaltrials are needed to confirm the current findings especially in terms of glucose homeostasis.

Many aspects of Covid-19 infection, especially its complications and long-term health consequences are stillunknown. Several reports concerning concomitant covid-19 infection and hematological disorders have beenpublished recently. We aim to present a unique case of acute myeloid leukemia in a 61-year-old man with aprevious history of covid-19 infection 40 days ago, with near complete resolution of signs and symptoms at-tributable to covid-19 infection. After 3 weeks, the patient presented again with progressive weakness, nausea,vomiting, and epigastric pain. No evidence of active covid-19 infection was observed. Instead, remarkable dropof hemoglobin and platelets relative to the values recorded in the discharge notes of the patient was observed.Further workup of the patient revealed evidence of acute leukemia and severe bone marrow involvement. Wedecided to present the current case as a concerning probable association.

The outcomes of acute ischemic stroke (AIS) are highly affected by time-to-treatment. Thepresent study aimed to determine the factors affecting in-hospital and pre-hospital delays in treatmentof AIS.

This prospective study was carried out on 204 AIS patients referring to the stroke care unit in Zanjan(Iran) in 2019. The required data were collected by interviewing the patients and families and using patients’records and observations.

The maximum delay was related to onset-to-arrival time (288.19 ± 339.02minutes). The logistic regression analysis indicated a statistically significant decline in the treatment delay viaconsultation after the initiation of symptoms (p< 0.001), transferring the patient through emergency medicalservice to the hospital (p<0.001), and patients’ perception regarding AIS symptoms (P< 0.001).

It isessential to inform people regarding AIS symptoms and referring to AIS treatment units to reduce the treatmenttime.

Early detection of regional wall motion abnormality (RWMA) can be a reliable tool for rapid dis-position of patients with acute coronary syndrome (ACS) in the emergency department. In this study, the di-agnostic accuracy of point-of-care echocardiography performed by a trained emergency medicine resident wasevaluated in comparison with board-certified cardiologists.

A prospective, cross-sectional study wasimplemented on adult patients with ACS. A trained emergency medicine (EM) PGY-3 resident performed point-of-care echocardiography under the supervision of two cardiologists and the reports were compared with car-diologists as a reference test.

100 patients with the mean age of 54.1 ± 11.5 years were recruited (65%male). Based on Thrombolysis in Myocardial Infarction (TIMI) and History, EKG, Age, Risk factors, and troponin(HEART) scores, 43.0% and 25.0% of patients were categorized as low-risk for ACS, respectively. The absolutemeasure of agreement between cardiologists to determine ejection fraction (EF) was 0.829 (95% CI: 0.74-0.89)based on intraclass correlation coefficient (ICC) estimation. The measurements of agreement between special-ists and the EM resident based on the analysis of Kappa coefficient were 0.677 and 0.884 for RWMA and peri-cardial effusion, respectively. Moreover, 25 patients were in the-low risk group according to the HEART scorewith an agreement rate of 92% for the lack of RWMA between the EM resident and cardiologists.

This study found acceptable agreement between the EM resident and cardiologists in assessing RWMA in differ-ent ACS risk groups. In addition, there was acceptable agreement between the EM resident and cardiologists indetermining left ventricular ejection fraction (LVEF) and pericardial effusion.

Mucormycosis is an expeditious invasion of a fungus of angioinvasive nature, predominant in immunocompro-mised individuals, often leading to organ malfunction and loss. Facial nerve involvement and total ophthalmo-plegia are its rare presentations. Early detection and treatment can alter natural disease course and prevent po-tential catastrophic outcomes in diabetic patients. Facial nerve palsy is mostly attributed to peripheral neuropa-thy in patients with advanced diabetes mellitus. It rarely raises alarm about an invasive fungal infection. Here,we report the case of a 38-year-old male with type 2 diabetes mellitus, who presented to us with left lower motorneuron type facial palsy and left-sided total ophthalmoplegia due to invasive rhino-orbito-cerebral mucormyco-sis (ROCM). Despite aggressive measures, including antifungal therapy and repeated endoscopic debridement,he subsequently developed central retinal artery occlusion (CRAO) and underwent left eye exenteration.

Performing Nasogastric Tube (NGT) insertion is very challenging in anesthetized and intubatedpatients. The current study aimed at comparing Digital (two-finger) and Video Laryngoscopy methods for NGTinsertion in the mentioned patients.

The present single-blind clinical trial was performed on 76 in-tubated patients, who were randomly divided into two groups. Groups A and B underwent Video Laryngoscopyand Digital (two-finger) methods, respectively. Then, the success rate, the number of attempts to insert NGT,duration of insertion, hemodynamic parameters, and patients’ satisfaction level were recorded and comparedbetween groups.

The mean duration of NGT insertion in group A was significantly higher than that ofgroup B (19.07 ± 2.07 vs 11.53 ± 2.16 seconds; P value=0.001). The success rate was higher in group B (94.7%vs. 78.9%; P value=0.042). Considering the interfering factors such as patients’ body mass index (BMI), the oddsof success in group B was reported to be 8.49 times higher than that of group A (P value =0.028).

Digital method can be considered as a safe and appropriate method of NGT insertion for intubated cases withhigh success rate and speed of performance.

Respiratory viruses spread fast, and some manners have been recommended for reducing thespread of these viruses, including the use of a facemask or respirator, maintaining hand hygiene, and perfomingsocial distancing. This systematic review aimed to assess the impact of facemasks and respirators on reducingthe spread of respiratory viruses.

We conducted a systematic review using MeSH terms, and reportedfindings according to PRISMA. PubMed, Embase, Cochrane Library, Scopus, ProQuest, Web of Science(WoS),and Google Scholar were searched for articles published between 2009 and 2020. Two independent reviewersdetermined whether the studies met inclusion criteria. The risk of bias of studies was assessed using Newcastle-Ottawa (NOS) and Consolidated Standards of Reporting Trials (CONSORT).

A total of 1505 articles wereinitially retrieved and 10 were finally included in our analysis (sample size: 3065). 96.8% of non-infected par-ticipants used facemask or respirator in contact with people infected with a respiratory virus, facemask andrespirator have a significant effect on reducing the spread of respiratory viruses.

Evidence supportthat using a facemask or respirator can reduce the spread of all types of respiratory viruses; therefore, this resultcan be generalized to the present pandemic of a respiratory virus (SARS-COV-2) and it is recommended to use afacemask or respirator for reducing the spread of this respiratory virus.

Traumatic spinal cord injury (SCI), as a dangerous central nervous system damage, continues tothreaten communities by imposing various disabilities and costs. Early adjustment of the immune system re-sponse using Myelin Basic Protein (MBP) immunization may prevent the SCI-related secondary damages. As aresult, the current study is designed to review and analyse the evidence on active and passive immunization withMBP for treatment of traumatic SCI.

Medline, Embase, Scopus, and Web of Science databases weresystematically searched until the end of 2020. Criteria for inclusion in the current study included pre-clinicalstudies, which performed passive (injection of MBP-activated T cells) or active (administration of MBP or MBP-modified peptides) immunization with MBP after traumatic SCI. Exclusion criteria was defined as lack of a non-treated SCI group, lack of evaluation of locomotion, review studies, and combination therapy. Finally, analyseswere conducted using STATA software, and a standardized mean difference (SMD) with a 95% confidence in-terval (CI) were reported.

Data from 17 papers were included in the present study. Finally, analysisof these data showed that passive immunization (SMD=0.87; 95%CI: 0.19-1.55; p=0.012) and active immuniza-tion (SMD=2.08, 95%CI: 1.42-2.73; p<0.001) for/with MBP both have good efficacy in improving locomotionfollowing traumatic SCI. However, significant heterogeneity was observed in both of them. The most impor-tant sources of heterogeneity in active immunization were differences in SCI models, route of administration,time interval between SCI and transplantation, and type of vaccine used. In passive immunization, however,these sources were the model of SCI and the time interval between SCI and transplantation. Although, there wassubstantial heterogeneity among studies, subgroup analysis showed that active immunization improved loco-motion after traumatic SCI in all tested conditions (with differences in injury model, severity of injury, method ofadministration, different time interval between SCI to vaccination, etc.).

The results of the presentstudy demonstrated that immunization with MBP, especially in its active form, could significantly improve mo-tor function following SCI in rats and mice. Therefore, it could be considered as a potential treatment in acutesettings such as emergency departments. However, the safety of this method is still under debate. Therefore,it is recommended for future research to focus on the investigation of safety of MBP immunization in animalstudies, before conducting human clinical trials.

The rates of unscheduled emergency department (ED) visits and readmissions after dischargefrom the ED in acute heart failure (AHF) patients are high. This study aimed to identify the predictive factorsof 30-day adverse events after discharge from the ED.

A retrospective study was conducted from 2017to 2019 in patients diagnosed with AHF and discharged from the ED at a tertiary university hospital. Thirty-dayadverse events were defined as (i) unscheduled revisit to the ED with AHF, (ii) hospital admission from AHF, and,(iii) death after discharge from the ED. The predictive factors of 30-day adverse events were examined usingmultivariate analyses by logistic regression.

421 patients with the median age of 73 (IQR: 63-81) yearswere studied (52.3% male). 81 (19.2%) patients had 30-day adverse events. Significant predictive factors of30-day adverse events consisted of underlying valvular heart disease (OR = 2.46; 95%CI: 1.27-4.78; p = 0.008),chronic obstructive pulmonary disease (COPD) (OR = 0.08; 95%CI: 0.01-0.64; p=0.001), malignancy (OR=3.63;95%CI: 1.17-11.24; p = 0.031), New York Heart Association functional class III (OR = 4.88; 95%CI: 0.93-25.59) andIV (OR = 7.23; 95% CI: 1.37-38.08) at the ED (p = 0.035), and serum sodium <135 mmol/L (OR = 2.20; 95%CI: 1.17-4.14; p = 0.014). Precipitating factors were anemia (OR = 2.42; 95%CI: 1.16-5.02; p = 0.021), progressive valvularheart disease (OR = 3.52; 95%CI: 1.35-7.85; p = 0.009), acute kidney injury (OR = 6.98; 95%CI: 2.32-20.96; p <0.001), time to diuretic administration >60 minutes after ED arrival (OR = 3.89; 95%CI: 2.16-7.00; p < 0.001), andno discharge advice for follow-up (OR = 2.30; 95%CI: 1.10-4.77; p = 0.028).

AHF patients who hadgood response to intravenous diuretics and were discharged from the ED were at high risk for 30-day adverseevents. Ten factors predicted 30-day adverse events after discharge from the ED.

Patients’ experience in hospitals affects their satisfaction. The purpose of the present study wasto assess the effect of applying a queue management system on patient satisfaction in emergency departmentwaiting rooms.

The present prospective randomized single-blinded interventional study was per-formed from July to August 2020 and involved 236 patients that were divided into one intervention group andone control group, each consisting of 118 patients. The mentioned patients’ perception of the waiting timeand satisfaction before being visited by an emergency medicine doctor was evaluated with and without apply-ing the queue management system.

The mean actual waiting time (15.5 ± 7.5 minutes) as well as themean perceived waiting time (11.9 ± 7.4 minutes) for the intervention group were significantly lower than thoseof the control group with the values of 27.03 ± 8.5 and 32.8 ± 8.7 minutes, respectively (p < 0.001). The meanperceived waiting time was significantly less than the mean actual waiting time (11.9 min vs 15.5 minutes) forthe intervention group (p <0.001); however, the mean perceived waiting time was significantly higher than themean actual waiting time (32.8 vs 27.03 minutes) for the control group (p < 0.001). The level of satisfaction inthe intervention group was significantly higher than that of the control group (p <0.001). There was an inverserelationship between the actual waiting time (Intervention group: r=-0.463; Control group: r= -0.567) and theperceived waiting time (Intervention group: r= -0.439; Control group: r= -0.568) with the satisfaction level inboth groups (p < 0.001).

It can be proposed that the application of a queue management system inthe emergency department waiting rooms can reduce the actual and perceived waiting times and increase thepatient satisfaction.

There is no comprehensive meta-analysis on the value of physiological scoring systems in pre-dicting the mortality of critically ill patients. Therefore, the present study intended to conduct a systematicreview and meta-analysis to collect the available clinical evidence on the value of physiological scoring systemsin predicting the in-hospital mortality of acute patients.

An extensive search was performed on Med-line, Embase, Scopus, and Web of Science databases until the end of year 2020. Physiological models includedRapid Acute Physiology Score (RAPS), Rapid Emergency Medicine Score (REMS), modified REMS (mREMS), andWorthing Physiological Score (WPS). Finally, the data were summarized and the findings were presented as sum-mary receiver operating characteristics (SROC), sensitivity, specificity and diagnostic odds ratio (DOR).

Data from 25 articles were included. The overall analysis showed that the area under the SROC curve of REMS,RAPS, mREMS, and WPS criteria were 0.83 (95% CI: 0.79-0.86), 0.89 (95% CI: 0.86-0.92), 0.64 (95% CI: 0.60-0.68)and 0.86 (95% CI: 0.83-0.89), respectively. DOR for REMS, RAPS, mREMS and WPS models were 11 (95% CI: 8-16), 13 (95% CI: 4-41), 2 (95% CI: 2-4) and 17 (95% CI: 5-59) respectively. When analyses were limited to traumapatients, the DOR of the REMS and RAPS models were 112 and 431, respectively. Due to the lack of sufficientstudies, it was not possible to limit the analyses for mREMS and WPS.

The findings of the presentstudy showed that three models of RAPS, REMS and WPS have a high predictive value for in-hospital mortality.In addition, the value of these models in trauma patients is much higher than other patient settings.

Gathering information regarding the risk factors of mortality and disability due to road traffic in-juries can provide evidence for adopting effective interventions to reduce the burden of the injury. Therefore,the present study intends to identify the most important risk factors of road accident-related mortality in Iranby conducting a systematic review and meta-analysis.

Search was done in English and Persian elec-tronic databases, for articles published until the end of 2020. Cross-sectional, cohort and case-control studieswere included. Risk factors were divided into age and sex, road related factors, exceeding speed limit, road userbehaviors, vehicle related factors, weather condition, and light condition. Data were reported as adjusted oddsratio (OR) of death with 95% confidence interval (95% CI).

20 studies were included (2,682,434 trafficaccident victims and 23,272 deaths; mortality rate=1.28%). The risk of death in road traffic injuries in men was1.66 times higher than women (OR = 1.66; 95% CI: 1.03, 2.68) and with each year increase in age, the risk in-creased by 1% (OR = 0.01; 95% CI: 1.00, 1.01). In addition, accident in urban streets (OR = 1.76; 95% CI: 1.08,2.88), roadway defects (OR = 2.15, 95% CI: 1.59, 2.91), and not driving on a flat and straight road (OR = 1.60; 95%CI: 1.14, 2.24) were the most important road-related risk factors for mortality. Exceeding the speed limit wasanother risk factor of death (OR = 3.16; 95% CI: 2.83, 3.54). However, regarding exceeding safe speed, only threestudies have been included, which greatly reduces the power of analysis. Not maintaining focus on the road (OR= 2.99; 95% CI: 1.49, 6.04), not fastening seatbelt (OR = 3.11; 95% CI: 1.08, 8.91), and reckless overtaking (OR =4.04; 95% CI: 3.34, 4.89) were independent road user-related risk factors for mortality. Risk of pedestrian mor-tality in comparison with drivers and passengers is 2.07 times higher (OR = 2.07; 95% CI: 1.53, 2.58). In addition,risk of death in accidents occurring during daylight hours (OR = 0.26; 95% CI: 0.18, 0.37) is lower than that ofother hours. No significant relationship was present between mortality and vehicle types (four-wheeled vehicle:OR = 0.99; 95% CI: 0.050, 1.97; two-wheeled vehicle: OR = 0.75; 95% CI: 0.48, 1.16). In the case of vehicle-relatedfactors, only 2 studies were included, which also dealt only with the type of vehicle (two-wheeled/four-wheeled).Vehicle-related factors such as the car model, its safety rating, and safety standards were not mentioned in anystudy.

Low to very low-level evidence shows that there is a significant relationship between factorsrelated to age, sex, road, road user, exceeding the speed limit, and light condition with the mortality of trafficaccident victims. However, all studies included in the present study were retrospectively designed and the anal-yses were not adjusted for most of the key potential confounders. Therefore, it seems that despite years of effortby researchers in the field of traffic accidents in Iran, there is still no comprehensive and reliable picture of themost important risk factors for road accident mortalities in Iran.

The most effective treatment for withdrawal syndrome in Opioid-dependent patients admitted tointensive care units (ICUs) remains unknown. This study aimed to compare fentanyl and methadone in this re-gard.

This prospective, single-blinded, controlled pilot study was conducted on opioid-dependent in-tubated patients admitted to the toxicology ICU of Loghman Hakim Hospital, Tehran, Iran, between August 2019and August 2020. Patients were alternately assigned to either fentanyl or methadone group after the initiation oftheir withdrawal syndrome. Duration and alleviation of the withdrawal signs and symptoms, ICU and hospitalstay, development of complications, development of later signs/symptoms of withdrawal syndrome, and needfor further administration of sedatives to treat agitation were then compared between these two groups.

Median age of the patients was 42 [interquartile range (IQR): 26, 56]. The two groups were similar in terms ofthe patients’ age (p = 0.92), sex (p = 0.632), primary Simplified Acute Physiology Score (SAPS) II (p = 0.861), andClinical Opiate Withdrawal Score (COWS) before (p = 0.537) and 120 minutes after treatment (p = 0.136) witheither methadone or fentanyl. The duration of intubation (p = 0.120), and ICU stay (p = 0.572), were also similarbetween the two groups. The only factor that was significantly different between the two groups was the timeneeded for alleviation of the withdrawal signs and symptoms after the administration of the medication, whichwas significantly shorter in the methadone group (30 vs. 120 minutes, p = 0.007).

It seems thatmethadone treats the withdrawal signs and symptoms faster in dependent patients. However, these drugs aresimilarly powerful in controlling the withdrawal signs in these patients.

Various methods of analgesia can be used to reduce or prevent procedural pain in emergencydepartment (ED). This study aimed to evaluate the effectiveness of topical lidocaine-diclofenac combinationcompared to lidocaine-prilocaine combination (Xyla-P) in reduction of the pain during central venous catheter(CVC) insertion.

In this randomized clinical trial, 100 adult patients requiring CVC insertion in the EDwere enrolled. These patients were randomly divided into two groups. The site of CVC insertion was coveredwith 2 g of topical Xyla-P cream in the first group, and 2 g of topical lidocaine-diclofenac cream in the secondgroup. The primary outcome was the pain during CVC implantation. The secondary outcomes were physiciansatisfaction and the incidence of side effects.

On the visual analog scale (VAS), the pain score duringCVC insertion was significantly lower in the second group (p = 0.027). However, there was no difference in painscores during lidocaine injection between the two groups (p = 0.386). Also, there was no significant differencein the rate of side effects between the two groups (p = 1.0). The physician’s satisfaction with the first groupwas significantly lower than the second group (p = 0.042).

Although the CVC insertion pain wassignificantly lower in patients who received the topical combination of Lidocaine plus Diclofenac, there wasno clinically important difference between the two groups and both topical anesthetics were effective and safein reducing pain intensity. Also, lidocaine-diclofenac combination cream was more cost-effective than Xyla-Pcream.

In recent years, several scoring systems have been developed to assess the severity of traumaand predict the outcome of trauma patients. This study aimed to compare Rapid Emergency Medicine Score(REMS), Modified Early Warning Score (MEWS), Injury Severity Score (ISS), and Glasgow Coma Scale (GCS) inpredicting the in-hospital mortality of trauma patients.

This diagnostic accuracy study was done onadult patients admitted to the emergency department (ED) between June 21, 2019, and September 21, 2020,following multiple trauma. Patients were followed as long as they were hospitalized. The REMS, MEWS, GCS,and ISS were calculated after data gathering and comprehensive assessment of injuries. Receiver operatingcharacteristics (ROC) analysis was performed to examine the prognostic performance of the four different tools.

Of the 754 patients, 32 patients (4.2%) died and 722 (95.8%) survived after 24 hours of admission. Themean age of the patients was 38.54 ± 18.58 years (78.9% male). The area under the ROC curves (AUC) of REMS,MEWS, ISS, and GCS score for predicting in-hospital mortality were 0.942 (95% CI [0.923-0.958]), 0.886 (95% CI[0.861-0.908]), 0.866 (95% CI [0.839-0.889]), and 0.851 (95% CI [0.823-0.876]), respectively. The AUC of REMSwas significantly higher than GCS (p=0.035). The sensitivities of GCS≤11, ISS≥13, REMS≥4, and MEWS≥3 scores for in-hospital mortality were 0.56, 0.97, 0.81, and 0.94, respectively. Also, the specificities of GCS, ISS,REMS, and MEWS scores for in-hospital mortality were 0.93, 0.82, 0.81, and 0.85, respectively.

Itseems that REMS is more accurate than GCS, ISS, and MEWS in predicting in-hospital mortality≥24 hours ofmultiple trauma patients.

Adults with underlying medical disorders are at increased risk for severe illness from the virusthat causes COVID-19. This study aimed to compare the effect of underlying diseases on the mortality of maleand female patients as a primary objective. We also evaluated the effect of drugs previously used by COVID-19patients on their outcome.

This retrospective cohort study was carried out on confirmed cases ofCOVID-19 who were admitted to a teaching hospital in Tehran, Iran. Data was gathered from patients’ files. Logbinomial model was used for investigating the association of underlying diseases and in-hospital mortality ofthese patients.

A total of 991 patients (mean age 61.62±17.02; 54.9% male) were recruited. Hyperten-sion (41.1%), diabetes mellitus (30.6%), and coronary artery disease (19.6%) were the most common underlyingdiseases. The multivariable model showed that hypertension (RR = 1.62; 95% CI: 1.22-2.14, p = 0.001) in malepatients over 55 years old and coronary artery disease (RR = 2.40; 95% CI: 1.24-4.46, p = 0.009) in female patientsunder 65 years old were risk factors of mortality. In females over 65 years old, the history of taking AngiotensinConverting Enzyme inhibitors (ACEi) and Angiotensin Receptor Blockers (ARB) (RR = 0.272; 95% CI: 0.17-0.41,p = 0.001) was a significant protective factor for death.

COVID-19 patients with a history of car-diovascular diseases such as hypertension and coronary artery disease, especially those in specific age and sexgroups, are high-risk patients for in-hospital mortality. Additionally, a previous history of taking ACEi and ARBmedications in females over 65 tears old was a protective factor against in-hospital mortality of COVID-19 pa-tients.

According to statistics provided by the forensic medicine facility of Iran, there are a high num-ber of Aluminum phosphide (ALP) poisoning-related deaths in the country; while the mortality rate varies indifferent studies. This study aimed to determine a pooled estimate of ALP poisoning mortality rate in Iran.

The present study was a systematic review and meta-analysis of the mortality rate of ALP poisoningin Iran. Through the quarry of Persian and English databases, using “aluminum phosphide”, “phosphine”, “ricepills”, “poisoning”, and “Iran” as keywords, and no time restrictions, studies reporting mortality rate in ALP poi-soning cases were collected. The random-effects model was used to pool the proportions of mortality and ageof survivors versus non-survivors.

21 studies with 3432 cases of ALP poisoning were included in thismeta-analysis. The pooled mortality rate of ALP poisoning in Iran was 39.6%, (95% CI: 31.5%-47.9%; I2 = 95%).Since there was significant publication bias, the trim-and-fill correction was conducted and the corrected pooledmortality rate was estimated to be 27.3% (95% CI: 18.9%- 36.5%), which is the rate that should be considered forclinical guidance. Morality rate in male and female patients was 62.3% (95% CI: 53.5%-70.8%) and 37.7% (95%CI: 29.2%-46.5%), respectively (p < 0.01). Survivors had significantly lower mean age than non-survivors (SMD:-0.26 (95% CI: -0.37 to -0.15); p < 0.01; I2=0%).

According to this report, the Mortality rate of ALPpoisoning in Iranian population is about 27%, with men having a higher fatality rate than women. Poisoning ata younger age is associated with better results.

Red blood cell distribution width (RDW ) has been introduced as a predictive factor for mortalityin several critical illnesses and infectious diseases. This study aimed to assess the possible relationship betweenRDW on admission and COVID-19 in-hospital mortality.

This cross-sectional study was performedusing the Isfahan COVID-19 registry. Adult confirmed cases of COVID-19 admitted to four hospitals affiliatedwith Isfahan University of Medical Sciences in Iran were included. Age, sex, O2 saturation, RDW on admission,Intensive Care Unit admission, laboratory data, history of comorbidities, and hospital outcome were extractedfrom the registry. Cox proportional hazard regression was used to study the independent association of RDWwith mortality.

4152 patients with the mean age of 61.1 ± 16.97 years were included (56.2% male).597 (14.4%) cases were admitted to intensive care unit (ICU) and 477 (11.5%) cases died. The mortality rate ofpatients with normal and elevated RDW was 7.8% and 21.2%, respectively (OR= 3.1, 95%CI: 2.6-3.8), which re-mained statistically significant after adjusting for age, O2 saturation, comorbidities, and ICU admission (2.03,95% CI: 1.68-2.44). Moreover, elevated RDW mortality Hazard Ratio in patients who were not admitted to ICUwas higher than ICU-admitted patients (3.10, 95% CI: 2.35-4.09 vs. 1.47, 95% CI: 1.15-1.88, respectively).

The results support the presence of an association between elevated RDW and mortality in patientswith COVID-19, especially those who were not admitted to ICU. It seems that elevated RDW can be used as apredictor of mortality in COVID-19 cases.

Recent studies have suggested that point-of-care ultrasonography can be used for confirming theplacement of endotracheal tube. This systematic review and meta-analysis aimed to investigate the sensitivityand specificity of ultrasonography for confirming endotracheal tube placement.

In this meta-analysis,systematic search of the previous published papers investigating the diagnostic accuracy of ultrasonography forconfirmation of endotracheal tube placement was performed. Seven electronic databases, including PubMed,Scopus, Google Scholar, EBSCO, EMBASE, Web of Science, and Cochrane Database were searched up to July2021, for all relevant articles published in English on this topic. Meta-DiSc version 1.4 software was used for sta-tistical analysis.

The estimated pooled sensitivity and specificity of ultrasonography for confirmation ofendotracheal tube location were 0.98 (95% CI: 0.98–0.99) and 0.94 (95% CI 0.91–0.96), respectively. The pooledpositive likelihood ratio and negative likelihood ratio were 5.94 (95% CI 4.41–7.98) and 0.03 (95% CI: 0.02-0.04),respectively. The diagnostic odds ratio of ultrasonography was 281.47 and the area under hierarchical summaryreceiver operating characteristic (HSROC) revealed an appropriate accuracy of 0.98.

Ultrasonog-raphy has high diagnostic accuracy and can be used as a promising tool for confirmation of endotracheal tubeplacement, especially in critically ill patients or when capnography is not available, or its result is equivocal.

Skin and soft tissue infections are important causes of outpatient visits to medical clinics or hos-pitals. This study aimed to review the literature for the accuracy of Clinical Resource Efficiency Support Team(CREST) guideline in management of cellulitis in emergency department.

Studies that had evaluatedcellulitis patients using the CREST guideline were quarried in Scopus, Web of Science, and PubMed database,from 2005 to the end of 2020. The quality of the studies was evaluated using Scottish Intercollegiate GuidelineNetwork (SIGN) checklist for cohort studies. Pooled area under the receiver operating characteristic curve (AU-ROC) of CREST guideline regarding the rate of hospital stay more than 24 hours, rate of revisit, and appropriate-ness of antimicrobial treatment in management of cellulitis in emergency department was evaluated.

Seven studies evaluating a total of 1640 adult cellulitis patients were finally entered to the study. In evaluation ofthe rate of the appropriate treatment versus over-treatment, the pooled AUROC was estimated to be 0.38 (95%confidence interval (CI): 0.06 – 0.82), indicating low accuracy (AUROC lower than 0.5) of guideline for antimicro-bial choice. CREST II patients had a significantly lower odds ratio (OR) of revisiting the Emergency Department,OR=0.21 (95% CI: 0.009 – 0.47). Pooled AUROC value of 0.86 (CI95%: 0.84 – 0.89) showed accuracy of the CRESTclassification in prediction of being hospitalized more or less than 24 hours.

CREST classificationshows good accuracy in determining the duration of hospitalization or observation in ED but it could lead toinevitable over/under treatment with empirical antimicrobial agents.

Assessing cardiopulmonary resuscitation (CPR) outcomes of patients with COVID-19 and em-ploying effective strategies for their improvement are essential. This study is designed in this regard.

This cross-sectional study was conducted between January 20, 2020 and January 20, 2021 in the emergency de-partments of two hospitals in Hamadan and Kermanshah, Iran. Participants were 487 patients with confirmedCOVID-19 and cardiac arrest (CA) who had undergone CPR during the study period. Data were collected us-ing the available CPR documentation forms developed based on the Utstein Style and analyses were performedusing Chi-square, Fisher’s exact, and Mann-Whitney U tests and the logistic regression analysis.

Par-ticipants’ mean age was 69.31±14.73 years and most of them were male (61.8%) and suffered from at least oneunderlying disease (58.1%). The rate of total and in-hospital CA was 9.67% and 9.39%, respectively. The mostprevalent first documented rhythm was asystole (67.9%) and the highest responsivity to CPR was for shockablerhythms. The rate of the return of spontaneous circulation (ROSC) was 9% and the rate of survival to hospitaldischarge was 2%. The significant predictors of CPR success were age (p = 0.035), epinephrine administrationtime interval (p = 0.00), CPR duration (p = 0.00), and First documented rhythm (p = 0.009).

The rateof in-hospital CA among studied COVID-19 cases was 9.39% with 9% ROSC and 2% survival to hospital dischargerates after CPR. Primary CPR success among patients with COVID-19 was poor, particularly among those withasystole and bradycardia. It seems that old age and improper doses of epinephrine can reduce CPR success.