Atorvastatin Effect on COVID-19 Outcomes: A Propensity Score Matched Study on Hospitalized Patients

BACKGROUND

This study investigated the association of atorvastatin use on survival, need for intensive care unit (ICU) admission, and length of hospital stay (LOS) among COVID-19 inpatients.

MATERIALS AND METHODS

A retrospective study was conducted between March 20th, 2020, and March 18th, 2021, on patients with confirmed COVID-19 admitted to three hospitals in Tehran, Iran. The unadjusted and adjusted effects of atorvastatin on COVID-19 prognosis were investigated. Propensity score matching (PSM) was used to achieve a 1:1 balanced dataset with a caliper distance less than 0.1 and the nearest neighbor method without replacement.

RESULTS

Of 4322 COVID-19 patients, 2136 (49.42%) were treated with atorvastatin. After PSM, 1245 atorvastatin inpatients and 1245 controls were included with a median age of 62.0 (interquartile range [IQR]: 51.0, 76.0) and 63.0 (IQR: 51.0, 75.0) years, respectively. The standardized mean differences were less than 0.1 for all confounders, suggesting a good covariate balance. The use of atorvastatin was associated with decreased COVID-19 mortality (HR: 0.80; 95% CI: 0.68-0.95), whereas no relationship was found between atorvastatin and the need for ICU admission (HR: 1.21; 95% CI: 0.99-1.47). LOS was significantly higher in the atorvastatin cohort than controls (Atorvastatin vs. others: 7 [5, 11] vs. 6 [4, 10] days; p = 0.003). The survival rate was higher in combination therapy of atorvastatin plus enoxaparin than in those who received atorvastatin alone (p-value=0.001).

CONCLUSION

Atorvastatin may reduce the risk of COVID-19 in-hospital mortality and could be a beneficial option for an add-on therapy. Randomized trials are warranted to confirm the results of the current observational studies.

On-admission and dynamic trend of laboratory profiles as prognostic biomarkers in COVID-19 inpatients

This large-scale study aimed to investigate the trend of laboratory tests of patients with COVID-19. Hospitalized confirmed and probable COVID-19 patients in three general hospitals were examined from March 20, 2020, to June 18, 2021. The confirmed and probable COVID-19 patients with known outcomes and valid laboratory results were included. The least absolute shrinkage and selection operator (LASSO) and Cox regression were used to select admittance prognostic features. Parallel Pairwise Comparison of mortality versus survival was used to examine the trend of markers. In the final cohort, 11,944 patients were enrolled, with an in-hospital mortality rate of 21.8%, mean age of 59.4 ± 18.0, and a male-to-female ratio of 1.3. Abnormal admittance level of white blood cells, neutrophils, lymphocytes, mean cellular volume, urea, creatinine, bilirubin, creatine kinase-myoglobin binding, lactate dehydrogenase (LDH), Troponin, c-reactive protein (CRP), potassium, and creatinine phosphokinase reduced the survival of COVID-19 inpatients. Moreover, the trend analysis showed lymphocytes, platelet, urea, CRP, alanine transaminase (ALT), and LDH have a dissimilar trend in non-survivors compared to survived patients. This study proposed a novel approach to find serial laboratory markers. Serial examination of platelet count, creatinine, CRP, LDH, and ALT can guide healthcare professionals in finding patients at risk of deterioration.

Generalizable machine learning approach for COVID-19 mortality risk prediction using on-admission clinical and laboratory features

We aimed to propose a mortality risk prediction model using on-admission clinical and laboratory predictors. We used a dataset of confirmed COVID-19 patients admitted to three general hospitals in Tehran. Clinical and laboratory values were gathered on admission. Six different machine learning models and two feature selection methods were used to assess the risk of in-hospital mortality. The proposed model was selected using the area under the receiver operator curve (AUC). Furthermore, a dataset from an additional hospital was used for external validation. 5320 hospitalized COVID-19 patients were enrolled in the study, with a mortality rate of 17.24% (N = 917). Among 82 features, ten laboratories and 27 clinical features were selected by LASSO. All methods showed acceptable performance (AUC > 80%), except for K-nearest neighbor. Our proposed deep neural network on features selected by LASSO showed AUC scores of 83.4% and 82.8% in internal and external validation, respectively. Furthermore, our imputer worked efficiently when two out of ten laboratory parameters were missing (AUC = 81.8%). We worked intimately with healthcare professionals to provide a tool that can solve real-world needs. Our model confirmed the potential of machine learning methods for use in clinical practice as a decision-support system.

Evaluating the Ability of PRISM4 and PIM3 to Predict Mortality in Patients Admitted to Pediatric Intensive Care Unit; a Diagnostic Accuracy Study

Introduction

Limited resources and the large number of children in need of services in the pediatric intensive care unit (PICU) emphasize the need for effective allocation of resources for improving the outcome of at-risk patients. This study aimed to evaluate and compare the accuracy of PRISM4 and PIM3 systems in prediction of in-hospital mortality of patients admitted to PICU.

Methods

The present retrospective cross-sectional study was a diagnostic accuracy study performed on patients admitted to PICU of Qods Hospital, Qazvin, Iran, during one year. Scores of PRISM4 and PIM3 scales were calculated for each patient using the available calculators, and the outcome of patients regarding in-hospital mortality was recorded. Finally, screening performance characteristics of the mentioned scales in prediction of patients' mortality were calculated and reported.

Results

218 patients with the mean age of 40.68 ± 37.92 (2-160) months were studied (57.8% female). There was a significant direct correlation between PIM3 score and duration of stay in PICU (p < 0.0001; r = 0.259), need for inotropic drug administration (p = 0.001), and mortality rate (p = 0.001). In addition, area under the receiver operating characteristic (ROC) curve of PIM3 and PRISM4 in prediction of mortality among patients admitted to the PICU was 0.939 (95%CI: 0.880 - 0.998) and 0.660 (95%CI: 0.371 - 0.950), respectively (p = 0.001). Based on the findings, the best cut-off point for PIM3 scale in prediction of mortality was the score of 4 and it was estimated to be the core of 8 for PRISM4 scale. Sensitivity and specificity of PIM3 scale in prediction of mortality in the cut-off of 4 points were 100.00 (95% CI: 56.09- 100.00) and 81.51 (95% CI: 75.47- 86.38), respectively. These measures were 42.85 (95%CI: 11.80- 79.76) and 98.10 (95%CI: 94.89- 99.39) for PRISM4 model, which indicates the higher sensitivity of PIM3 system in this regard.

Conclusion

based on the results of the present study, the accuracy of PIM3 is significantly higher than PRISM4 in prediction of in-hospital mortality among patients admitted to the PICU. It seems that considering the 100% sensitivity of PIM3 in prediction of outcome, this model is a better tool for screening patients who are at risk for in-hospital mortality in order to pay more attention and allocate more resources to improve their outcome.

Effect of Electrolyte Imbalance on Mortality and Late Acute Kidney Injury in Hospitalized COVID-19 Patients

INTRODUCTION

As a multisystem illness, Coronavirus disease 2019 (COVID-19) can damage different organs. This study investigated the effect of electrolyte imbalance (EI), with or without concomitant renal dysfunction, on the prognosis of COVID-19 in hospitalized patients.

METHODS

We evaluated 499 hospitalized patients with confirmed COVID-19, without a history of chronic kidney disease. The patients' demographic data, laboratory values, and outcomes were retrospectively collected from the hospital information system. Serumelectrolytes including sodium, potassium, magnesium, calcium, and phosphorus abnormalities were analyzed on admission and during the hospitalization period. The outcomes of this study were the occurrence of acute kidney injury (AKI) after the first week of hospitalization and in-hospital mortality rate. Multivariate analyses were carried out to obtain the independent risk of each EI on mortality, by adjusting for age, gender, and AKI occurrence.

RESULTS

Among the 499 COVID-19 patients (60.9% male), AKI occurred in 168 (33.7%) and mortality in 92 (18.4%) cases. Hypocalcemia (38%) and hyponatremia (22.6%) were the most prevalent EIs, and all EIs were more common in the AKI group than in the non-AKI group. Hyponatremia (Adjusted Odds ratio [AOR] = 2.34, 95% CI: 1.30 to 4.18), hypernatremia (AOR = 8.52, 95% CI: 1.95 to 37.32), and hyperkalemia (AOR = 4.63, 95% CI: 1.65 to 13) on admission were associated with poor prognosis. Moreover, hyponatremia (AOR = 3.02, 95% CI: 1.28 to 7.15) and hyperphosphatemia (AOR = 5.12, 95% CI: 1.24 to 21.09) on admission were associated with late AKI occurrence.

CONCLUSION

This study highlights the role of hyponatremia, hypernatremia, hyperkalemia, and hyperphosphatemia in poor prognosis of COVID-19. According to the independent effect of EI on late AKI and mortality, we recommend physicians to raise awareness to closely monitor and correct EI during hospitalization.  DOI: 10.52547/ijkd.6904.

Three patients with acute appendicitis diagnosis following blunt abdominal trauma

Objective: One of the most prevalent surgical emergencies is appendicitis, caused by different factors. However, its relation to trauma has not been well-known yet. Here we have described three cases with blunt abdominal trauma and a secondary diagnosis of appendicitis that were transferred to the operation room. Case Presentation: Three patients suffering from blunt trauma and abdominal pain were referred to the emergency department (ED). Of these patients, one of them was transferred to the operation room (OR) with a peritonitis diagnosis and the other two patients had appendicitis signs and symptoms. The abdominal pain and related signs and symptoms of these three patients were due to appendicitis. All three patients were discharged from the hospital with normal vital signs. Conclusion: Traumatic appendicitis might be regarded as one of the differential diagnoses of the patients referred to the ED with blunt abdominal trauma and abdominal pain; hence, appendicitis and blunt abdominal trauma have some unknown relations.

Medical treatment for paradoxical and saddle pulmonary embolism in a young man with patent foramen ovale and coronavirus disease 2019

Here, we reported a 32-year-old male presenting to the emergency department with respiratory symptoms and coronavirus disease 2019 (COVID-19) diagnosis. Multiple thrombi were detected in his heart and inferior vena cava, probably due to former deep-vein thrombosis. The presence of patent foramen ovale and high pressure of the right heart caused the clots to enter the heart's left side. He received fibrinolytics, and his condition improved with no need for surgery. Hence, patients with impending paradoxical embolism may take advantage of medical treatment, such as fibrinolytics. Moreover, COVID-19 appears to be associated with a strong thrombotic tendency, and anticoagulants might be helpful.

The effect of a short ultrasound training course on the performance of emergency medical technicians in terms of using extended-focused assessment with sonography in trauma (E-FAST) in the pre-hospital setting

Objective: The aim of this study was to determine the effect of an ultrasound training course on the performance of emergency medical technicians (EMTs) in terms of using extended-focused assessment with sonography in trauma (E-FAST) in the pre-hospital setting. Methods: In this quasi-experimental study, 107 EMTs affiliated to Shahid Beheshti and Kashan Universities of Medical Sciences, were randomly selected. At first, the EMTs were given a pre-test of five images concerning normal and abnormal ultrasound views of thoracic and abdominal cavities. Then, 6 hours of theoretical and practical sessions were done by emergency medicine specialists to teach the EMTs to use ultrasound for the detection of pneumothorax and free fluid. The EMTs were tested again in the form of 18 images post-test as well as a 13-item survey to evaluate their skills in taking correct 10 E-FAST. Results: A total of 107 EMTs with the mean age of 27±15.21 and average of 3.5 years work experience participated in this study. The mean of test score increased from 0.57± 0.19 to 0.81±0.08 (with P < 0.001) out of the total score of 100. In the 4-graded survey, 98% of EMTs obtained good to excellent grades in working with ultrasound machine. Also, 50.5% of EMTs were good in taking Morison’s view and 46.6% and 45.6% had medium grades in pericardial and splenorenal views, respectively. In addition, 22.3% had weak grades in taking pericardial views. Conclusion: The results of the present study showed that the implementation of the training course significantly improved the accuracy of free fluid detection in thoracic and abdominal cavities by EMTs.

Correlation between Chest Computed Tomography Scan Findings and Mortality of COVID-19 Cases; a Cross sectional Study

INTRODUCTION

Predicting the outcomes of COVID-19 cases using different clinical, laboratory, and imaging parameters is one of the most interesting fields of research in this regard. This study aimed to evaluate the correlation between chest computed tomography (CT) scan findings and outcomes of COVID-19 cases.

METHODS

This cross sectional study was carried out on confirmed COVID-19 cases with clinical manifestations and chest CT scan findings based on Iran's National Guidelines for defining COVID-19. Baseline and chest CT scan characteristics of patients were investigated and their correlation with mortality was analyzed and reported using SPSS 21.0.

RESULTS

380 patients with the mean age of 53.62 ± 16.66 years were evaluated (66.1% male). The most frequent chest CT scan abnormalities were in peripheral (86.6%) and peribronchovascular interstitium (34.6%), with ground glass pattern (54.1%), and round (53.6%) or linear (46.7%) shape. There was a significant correlation between shape of abnormalities (p = 0.003), CT scan Severity Score (CTSS) (p <0.0001), and pulmonary artery CT diameter (p = 0. 01) with mortality. The mean CTSS of non-survived cases was significantly higher (13.68 ± 4.59 versus 8.72 ± 4.42; <0.0001). The area under the receiver operating characteristic (ROC) curve of CTSS in predicting the patients' mortality was 0.800 (95% CI: 0.716-0.884). The best cut off point of chest CTSS in this regard was 12 with 75.82% (95% CI: 56.07%-88.98%) sensitivity and 75.78% (95% CI: 70.88%-80.10%) specificity. The mean main pulmonary artery diameter in patients with CTSS ≥ 12 was higher than cases with CTSS < 12 (27.89 ± 3.73 vs 26.24 ± 3.14 mm; p < 0.0001).

CONCLUSION

Based on the results of the present study it seems that there is a significant correlation between chest CT scan characteristics and mortality of COVID-19 cases. Patients with lower CTSS, lower pulmonary artery CT diameter, and round shape opacity had lower mortality.

Validation of SUSPEKT Score in Predicting One-month Mortality of Patients with Hemorrhagic Stroke; a Diagnostic Accuracy Study

INTRODUCTION

Predicting the outcome of patients with intracranial hemorrhage (ICH) is the area of interest for in charge physicians as well as patients and their associates. This study aimed to evaluate the accuracy of SUSPEKT score in predicting one-month outcome of patients with hemorrhagic stroke.

METHODS

This prospective cross sectional study was conducted on > 18 years old patients with non-traumatic supra-tentorial ICH admitted to emergency department, from February 2017 to January 2018. SUSPEKT score was measured for each patient and its screening performance characteristics in prediction of one-month mortality were calculated.

RESULTS

169 cases with the mean age of 63.09± 15.45 (21 - 96) years were studied (56.8% male). After one month follow up 47 (27.8%) cases had died, 30 (17.7%) cases were bed ridden, and 72 (42.6%) could walk without help or with a cane. Non-survived patients had significantly larger intra-ventricular hemorrhage (IVH) (p < 0.001) and hematoma (p < 0.001) volume, higher serum glucose (p < 0.001) and blood pressure (p = 0.028), higher frequency of IVH (p < 0.001), and higher WBC count (p = 0.037). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of SUSPEKT score at the 65 cut point were 82.97% (95% CI: 68.65% - 91.86%), 74.59% (95% CI: 65.76% - 81.84%), 55.71% (95% CI: 43.38% - 67.40%), and 91.91% (95% CI: 84.23% - 96.16%), respectively.

CONCLUSION

Total accuracy of SUSPEKT score in predicting one-month mortality of non- traumatic ICH patients is in good range and it has 82% sensitivity and 92% NPV in this regard. It seems that we need further studies before applying the score in routine practice.

The Impact of Resveratrol Supplementation on Inflammation Induced by Acute Exercise in Rats: Il6 Responses to Exercise

Severe physical activity leads to a sharp increase in free radicals, an oxidative stress, inflammation, and tissue damage. Resveratrol as one of the antioxidants can be effective in preventing the effects of oxidative stress. Therefore, the present study was aimed to evaluate the effect of trans-resveratrol supplementation and training exercise on inflammation-related factors. Sixty-four male Wistar rats were divided into six groups, each group consisting of 16 animals: 1) excursive + trans-resveratrol, 2) exercise group, 3) trans-resveratrol group, and 4) control group. Following the familiarization sessions, a more consistent protocol with an intensity of 65% vo2 max was performed for 12 weeks. Afterward, half of the mice in each group received acute exercise training with an intensity of 70-75% of vo2 max at the age of 20 weeks, until reaching the disability level. Finally, the levels of inflammatory markers were measured using special kits. Our findings depicted that inflammatory factors such as CPR, TNF-α, IL-6, and IL-7 were not affected by endurance protocol (P > 0.05), whereas, they were significantly increased by acute exercise training (P > 0.05). Additionally, we found that RES supplements led to a decrease in CPR and IL-6 levels, while not affecting TNF-α and IL-17 levels. According to available evidence, RES appears to have anti-inflammatory and protective effects during exercise by reducing inflammatory factors. Further studies are required to clarify the role of trans-resveratrol supplementation after exercise training.

Clinical Characteristics and Associated Factors of Mortality in Febrile Neutropenia Patients; a Cross Sectional Study

INTRODUCTION

The duration and severity of neutropenia directly correlate with the incidence of life-threatening infections. This study aimed to evaluate the clinical characteristics and associated factors of mortality in febrile neutropenia patients.

METHOD

This retrospective cross sectional study was conducted on all febrile neutropenia patients who were admitted to oncology department of two educational hospitals, Tehran, Iran, from 2011 to 2016. Available patients' data regarding baseline characteristics, treatment, and outcome were collected and analyzed using SPSS 21.

RESULTS

357 patients with the mean age of 50.9±17.7 years were studied (59.7% female). Mean white blood cell count of the studied patients was 715.1 ± 270.4 (100 - 1400) cells/mm³. The absolute neutrophil count (ANC) of all patients was <500 cells/mm3. The most frequent sources of malignancy in studied patients were gastrointestinal (35.9%), breast (22.4%), and sarcoma (15.7%), respectively. The mean time interval between initiation of treatment in ED and increase of ANC to > 500 cells/mm³ was 2.45 ± 2.1 (1 - 16) days. 186 (52.1%) subjects reached ANC>500 cells/ mm³ after 2-5 days of hospitalization. The rate of hospital mortality was 5.3% (338 (94.7%) survived). The correlation between gender (p = 0.11), temperature (p = 0.123), number of ED visits (p = 0.765), presenting clinical manifestation (p = 0.201), source of malignancy (p= 0.328), presence of metastasis (p = 0.69), positive urine culture (p = 0.45), positive blood culture (p = 0.62), time from last chemotherapy (p = 0.677), and time to reach ANC>500 cells/mm3 (p = 0.739) with mortality was not significant.

CONCLUSION

Based on the findings of the present study, the rate of hospital mortality in patients with febrile neutropenia was 5.3%. Older age and lower white blood cell count were among the significant associated factors of mortality in this series.

Residents' Experiences of Abuse and Harassment in Emergency Departments

The widespread epidemic of emerging abuse in Emergency Departments (ED) toward residents generates negative effects on the residents' health and welfare. The purpose of this study was to determine and highlight the high prevalence of abuse and harassment toward Emergency residents. In 2011, a multi-institutional, cross-sectional study was conducted at seven Emergency Residencies of central hospitals in Iran. Residents were asked about their age, marital status, postgraduate year (PGY) levels, and work experiences before residency. Prevalence of abuse in four categories was evaluated: verbal abuse; verbal and physical threat; physical assault and sexual harassment; and by whom. The data were analyzed by SPSS version 17.0 (SPSS, Inc., Chicago, IL, USA). Two hundred fifteen of the 296 residents (73%) completed the survey. The prevalence of any type of abuse experienced was 89%; 43% of residents experienced verbal and physical threats, 10% physical assault, and 31% sexual harassment. Verbal abuse and verbal and physical threats without the use of weapons were higher in men in comparison with women ( p< .04). Women were more likely than men to encounter sexual harassment (31% vs. 7%, p< .01). Among the sexual harassment categories, sexual jokes (51%) were the most prevalent between residents. Junior residents (PGY-1) were more likely to experience abuse than senior residents (PGY-2 and PGY-3; p< .01). Patients and their companions were the main agents of abusive behaviors. Abuse and harassment during residency in ED are highly prevalent. Educational programs and effective preventive measures against this mistreatment are urgently required.

Impact of Education on Trauma Patients' Handover Quality; a Before-After Trial

INTRODUCTION

Poor handover and inadequate transmission of clinical information between shifts cause a lot of problems in patient care and result in significant risks for physicians and patients. This study was designed to evaluate the impact of education and application of handover checklist on trauma patients' handover quality.

METHODS

In this before-after trial, handover process of trauma patients in an educational hospital was evaluated before and after education and application of a handover checklist, abbreviated as "WHO MISSED IP?", using a questionnaire that consisted of 10 necessary items, which should be delivered during handover of trauma patients. A total score of 10 was considered for each patient handover, the score 10 out of 10 indicating that all 10 important pieces of patient information were correctly delivered.

RESULTS

52 pre and post-intervention handover sessions were evaluated (438 patients). Prior to intervention, 18% of patients were not delivered to the next shift, most of which were in the night shift handover (p < 0.001). From the pre-intervention to the post-intervention period, significant improvements were detected in all items except for diagnosis and consulting items. The mean duration of handover changed from 1.22 ± 0.24 minutes to 1.58 ± 0.23 minutes after intervention (p < 0.01). In the pre-intervention period, the score equal or greater than 9 was observed in 7.5% of patients, while after intervention, 63.6% of patients had score ≥ 9 regarding complete handover (p < 0.01).

CONCLUSION

Based on the findings of the present study, teaching handover standards and application of handover checklist could be helpful in improving the quality of information delivery between emergency medicine residents and improve trauma patients' handover indices.

Frequency and Causes of Complaints against Emergency Medicine Specialists in Forensic Medicine Files; a Cross-Sectional Study

INTRODUCTION

Complaints against physicians have increased in recent years and one of the specialties facing a relatively high rate of complaints is emergency medicine. Therefore, the present study was designed with the aim of evaluating the frequency and causes of complaints against emergency medicine specialists in forensic medicine cases.

METHODS

In the present cross-sectional study, all the existing files in two forensic medicine centers, Tehran, Iran, from 2012 to 2015, in which complaints were filed against emergency medicine specialists, either alone or along with other physicians, were evaluated via census sampling method and their required data were extracted and recorded via a pre-designed checklist.

RESULTS

151 cases of medical complaints were filed against emergency medicine specialists during the study period. 85 (53.6%) complaints were filed following death of the patients and 66 (43.7%) were filed following an injury or disability. Multiple trauma, stomach ache, and altered level of consciousness were the most common chief complaints among young and old patients upon their ED visit. In 104 (68.9%) cases, the emergency medicine specialists were finally proved innocent. No significant correlation was found between the probability of proving innocent and the physician's experience (p = 0.92), physician's sex (p = 0.27), age range of the patient (p = 0.193), or the shift in which the patient had visited the ED (p = 0.32). The rate of proving innocent was significantly higher in complaints against governmental hospitals compared to non-governmental ones (73.6% vs. 61.9%; p= 0.004) and teaching hospitals compared to non-teaching ones (75.8% vs. 54.9%; p = 0.26).

CONCLUSION

In about 70% of medical complaint cases against emergency medicine specialists, the in charge physician was proved innocent. No significant correlation was found between the probability of proving innocent and physician's experience, the physician's sex, the patient's age range, or the shift in which the patient had presented to the ED.

Effects of resveratrol supplementation in male Wistar rats undergoing an endurance exercise and acute exercise training

OBJECTIVE

The present study was aimed to assess the effect of Resveratrol supplementation, endurance exercise and acute exercise training on oxidative stress and tissue damage markers.

METHODS

Sixty-four male Wistar rats were categorized into four groups including resveratrol group, exercise group, exercise + resveratrol group (n= 16) and control group (n= 16). RES was orally administered to male rats for 28 day at a dose of 10 mg per kg body during exercise. Following the familiarization sessions, rats were acclimated to a calibrated motor driven rodent treadmill for endurance exercise and acute exercise implementation. Changes in oxidative stress and tissue damage markers including 8-hydroxy-2'-deoxyguanosine (8-OhdG), Lactate dehydrogenase (LDH), Creatine Phosphokinase (CPK), protein carbonyl were biochemically measured using commercial ELISA kits based on the manufacturer's instructions.

RESULTS

The endurance and acute exercise training led to an increase in the levels of CPK and LDH, However, following the endurance and acute exercise training, a reduction in the level of carbonyl and 8-OHdG was observed. RES supplementation did not have any effect on the levels of CPK and LDH; nevertheless, reduced significantly carbonyl, and 8-OHdG levels. Based on this evidence, RES may have protective effects against exercise-induced oxidative stress.

CONCLUSION

This study provides further evidence of the antioxidant effects of RES after exercise. However, several factors such as type and duration of exercise, the type of model, the amount of RES supplementation and the time-course consideration can affect the quality of the results. For this reason, further studies in this field are required.

Low-Dose Fentanyl, Propofol, Midazolam, Ketamine and Lidocaine Combination vs. Regular Dose Propofol and Fentanyl Combination for Deep Sedation Induction; a Randomized Clinical Trial

INTRODUCTION

Need for procedural sedation and analgesia (PSA) is felt in emergency department (ED) more and more each day. This study aimed to compare the effectiveness of low-dose fentanyl, propofol, midazolam, ketamine and lidocaine combination with regular dose of propofol and fentanyl combination for induction of deep sedation.

METHODS

In this single-blind clinical trial, candidate patients for sedation and analgesia aged more than 15 and less than 60 years old, with pain score ≥6 were allocated to one of the groups using block randomization and were compared regarding onset of action, recovery time, and probable side effects.

RESULTS

125 patients with the mean age of 37.8 ± 14.3 years were randomly allocated to each group. 100% of the patients in group 1 (5 drugs) and 56.5% of the patients in group 2 (2 drugs) were deeply sedated in the 3^rd minute after injection. The 2 groups were significantly different regarding onset of action (p = 0.440), recovery time (p = 0.018), and treatment failure (p < 0.001).

CONCLUSION

Low-dose fentanyl, propofol, midazolam, ketamine and lidocaine combination was more successful in induction of deep sedation compared to regular dose of propofol and fentanyl combination. Recovery time was a little longer in this group and both groups were similar regarding drug side effects and effect on vital signs.

Workplace Violence against Residents in Emergency Department and Reasons for not Reporting Them; a Cross Sectional Study

INTRODUCTION

Due to the stressful nature of emergency Department (ED), residents in ED are at risk of violence from patients or their associates. This study aimed to determine the prevalence of workplace violence against ED residents and the reasons for not reporting them.

METHODS

This cross-sectional study was conducted on ED residents of three educational hospitals, Tehran, Iran, during 2015. The national questionnaire about workplace violence was used for data gathering. In addition, prevalence of reporting the violence and the reasons for not reporting them were determined.

RESULTS

280 questionnaires were analyzed. The mean age of residents was 32.2 ± 4.6 years (58.4% female). 224 (80%) residents stated that they had not passed any educational courses on violence management. The most prevalent type of violence was verbal (90.7%) and patients' associates (85.4%) were the most common source of aggression. The frequency of physical violence was higher in male aggressors (p = 0.001), resident age > 30 years (p = 0.044), aggressor age > 30 years (p = 0.001), and night shift (p = 0.001). The same trend was observed regarding verbal and racial-ethnic violence. There was no significant relationship between residents' sex, resident's specialty, and presence of security and police with frequency of violence. 214 (76.4%) residents did not report the violence, and the main reasons for not reporting from their viewpoint were uselessness of reporting (37.4%) and insignificance of the violence (36.9%).

CONCLUSION

Based on the findings of the present study more than 90% of ED residents had experienced at least one type of verbal, physical, or racial-ethnic violence during their shifts. It is necessary for residents in EDs to be trained about violence control and also report and follow these issues through legal channels.

The Relationship between Risk Factors of Head Trauma with CT Scan Findings in Children with Minor Head Trauma Admitted to Hospital

BACKGROUND:

In emergency medicine for determining the intracranial injury (ICI) in children with head trauma, usually brain CT scan is performed. Since brain CT scan, especially in children, has some disadvantages, it is better to find a procedure which could help to choose only the children with real head trauma injury for brain CT scan.

AIMS:

The aim of this study is to find such procedure. This study was descriptive, analytic and non-interventional.

METHODS:

We reviewed the archived files of children with head trauma injuries referred to the emergency department of Imam Hossein Hospital within two years. Patient’s CT scan findings and head trauma risk factors were evaluated in this study.

RESULTS:

Out of 368 patients, 326 patients had normal brain CT scan. 28 of them showed symptoms of ICI consisting intraventricular haemorrhage (IVH), contusion, subarachnoid haemorrhage (SAH), subdural haemorrhage (SDH), epidural hematoma (EDH), and pneumocephalus. Twenty-seven patients showed skull FX, which 14 of them had an Isolated fracture, and 13 of them also showed symptoms of ICI. Since patients with isolated FX usually discharge quickly from Emergency Department; their data did not include in results of the study. The patients have been divided into two groups: 1- ICI, 2- without ICI. RR (relative risk), CI (Confidence interval) and sensitivity, positive predictive value (PPV), negative predictive value (NPV) and association of these risk factors with ICI were assessed with the Chi-2 test. In the end to determine the indications of CT scan, the presence of one of these five risk factors is important including abnormal mental status, clinical symptoms of skull FX, history of vomiting, craniofacial soft tissue injury (including subgaleal hematomas or laceration) and headache.

CONCLUSIONS:

For all other patients without these risk factors, observation and Follow Up can be used which has more advantages and less cost.

Baseline Characteristics of fall from Height Victims Presenting to Emergency Department; a Brief Report

INTRODUCTION

Trauma due to accidents or fall from height is a major cause of disability and mortality. The present study was designed aiming to evaluate the baseline characteristics of fall from height victims presenting to emergency department (ED).

METHODS

This prospective cross-sectional study evaluates the baseline characteristics of fall from height cases presenting to EDs of three educational Hospitals, Tehran, Iran, during one year. Data were analyzed using SPSS 21 and presented using descriptive statistics.

RESULTS

460 patients with the mean age of 27.89 ± 20.95 years were evaluated (76.5% male). 191 (41.5%) falls occurred when working, 27 (5.9%) during play, and 242 (52.6%) in other times. Among construction workers, 166 (81.4%) had not used any safety equipment. Fracture and dislocation with 180 (39.1%) cases and soft tissue injury with 166 (36.1%) were the most common injuries inflicted. Mean height of falling was 3.41 ± 0.34 (range: 0.5 - 20) meters. Finally, 8 (1.7%) of the patients died (50% intentional) and 63% were discharged from ED. A significant correlation was detected between mortality and the falls being intentional (p < 0.0001) as well as greater height of fall (p < 0.0001).

CONCLUSION

Based on the findings, most fall from height victims in the present study were young men, single, construction workers, with less than high school diploma education level. Intentional fall and greater height of falling significantly correlated with mortality.

Characteristics of Methadone Intoxicated Children Presenting to Emergency Department; a Cross Sectional Study

Introduction:

Each year a large number of patients present to emergency departments (EDs) following accidental or intentional poisoning with methadone. This study was designed with the aim of demographic evaluation of methadone poisoning in children presenting to ED and proposing preventive measures to parents and the healthcare system.

Methods:

This cross sectional study was carried out on children under the age of 12 years presenting to ED of a poisoning referral center. Demographic characteristics of the child and parents, cause of poisoning, form of drug consumed, dose consumed, the symptoms of the child on admission, clinical examination, laboratory findings, and final outcome were recorded and reported using descriptive statistics.

Results:

179 cases were studied (59.2% boys). Cause of consumption was accidental in 175 (97.8%) cases and consumed drug dose was unknown in 53 (53.6%) cases. On admission 6 cases were in deep coma, 133 (74.3%) had miotic pupils, and 52 (29.1%) were affected with respiratory apnea and cyanosis. In 132 (73.8%) cases drugs were obtained from unapproved stores and form of drug consumed was syrup in 146 (81.6%) cases. 177 (98.9%) cases were discharged after 2 or3 days and 2 (1.1%) cases died.

Conclusion:

Based on the results of the present study, most cases of methadone poisoning were accidental, in children residing in poor and middle-class areas, with parents who had a low level of education and had obtained the drug from unapproved stores and stored it in improper containers or at improper places. Only 64.8% of the parents were educated regarding drug storage.

Evaluation of the Alvarado score in acute abdominal pain

BACKGROUND

The Alvarado score is utilized to determine the likelihood of appendicitis based on clinical signs, symptoms, and laboratory results. The goal of this study was to determine whether Alvarado scores can be used to aid in the accurate diagnosis of appendicitis.

METHODS

Alvarado score evaluations were performed on 300 patients that were referred to or presented to the emergency room with acute abdominal pain.

RESULTS

Out of the 300 patients, 85.66% had Alvarado scores of 7 or less and 14.33% had Alvarado scores greater than 7. For patients that had confirmed appendicitis, 25.7% had Alvarado scores of 7 or less, whereas 93% had Alvarado scores greater than 7. The Alvarado scoring system had poor sensitivity at 37%, and the specificity of this scoring system was high at 95%.

CONCLUSION

Our findings suggest that patients presenting with abdominal pain and Alvarado scores greater than 7 are more likely to have appendicitis. As such, the Alvarado scoring system may be utilized to better predict whether a patient has appendicitis. An Alvarado score that is positive for appendicitis would consist of a score greater than 7, which suggests that the patient has a 93% chance of having appendicitis. A negative Alvarado score is 7 or lower, suggesting a 26% probability of having appendicitis. In all, the Alvarado scoring system is a good rule-in test, but it does not adequately rule-out appendicitis.

Comparison of the accuracy and reproducibility of focused abdominal sonography for trauma performed by emergency medicine and radiology residents

We compared the diagnostic accuracy of emergency medicine residents (EMRs) and radiology residents (RRs) in performing focused abdominal sonography for trauma (FAST). The cohort in this prospective study comprised 200 unstable patients (163 males and 37 females; mean ± standard deviation of age, 34.3 ± 16.4 y) who presented with trauma. These patients were evaluated using FAST, first by EMRs and subsequently by RRs. Patients with positive FAST results underwent further diagnostic procedures such as computed tomography, diagnostic peritoneal lavage and laparotomy. Those with negative FAST results underwent clinical follow-up for 72 h until their condition deteriorated or they were discharged. Sensitivity, specificity, positive and negative predictive values and accuracy in evaluating free intraperitoneal fluid were 80%, 95%, 57%, 98% and 94% when FAST was performed by EMRs and 86%, 95%, 59%, 98% and 94% when FAST was performed by RRs. The level of agreement between EMRs and RRs was moderate (κ = 0.525). FAST is a useful screening tool for initial assessment of free abdominal fluid in patients with trauma. Our results indicate that EMRs can perform sonography on trauma patients as successfully as RRs.

Prevalence of undiagnosed hypertension in the emergency department

Background:

Hypertension (HTN) is a serious health problem that threatens one fourth of the adult population in some countries.

Objectives:

This study aimed to assess the prevalence and outcome of undiagnosed hypertensive patients admitted to the emergency department.

Materials and Methods:

This cross-sectional study was conducted from March 2009 to March 2010 at Imam Hossein Medical and Educational Center, Teheran, Iran. A total of 2070 patients aged 18 years and older were admitted to the emergency department without previous HTN history. Blood pressure was taken and repeated 10 minutes later if initial systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg. Those who matched the inclusion criteria entered the study for further follow-up. A numerical pain score was also used for pain intensity assessment. Chi-Square and Mann Whitney U tests were performed to compare differences between sex, age and education of the participants.

Results:

Based on the inclusion criteria, 346 patients entered the study, out of which 168 qualified for further evaluation and follow-up. Forty eight patients (28.6%) were finally diagnosed with high blood pressure. Our study showed that the prevalence of undiagnosed HTN was 4.8%. Significant differences between blood pressure, age, pain score and education level (P < 0.001) were found. This implies that old age, poor education and low pain score are positively associated with hypertension.

Conclusions:

Blood pressure readings in emergency departments should not be readily attributed to pain or anxiety. Diagnosis must be based on meticulous follow-up and precise examinations.

Interpretation of Computed Tomography of the Head: Emergency Physicians versus Radiologists

BACKGROUND

Many patients are brought to crowded emergency departments (ED) of hospitals every day for evaluation of head injuries, headaches, neurologic deficits etc. CT scan of the head is the most common diagnostic measure used to search for pathologies. In many EDs the initial interpretation of images are performed by emergency physicians (EP). Since most decisions are made based on the initial interpretation of the images by emergency physicians and not the radiologists, it is necessary to assess the accuracy of interpretations made by the former group.

OBJECTIVES

The objective of this study was to compare the findings reported in the interpretation of head CTs by emergency physicians and compare to radiologists (the gold standard).

MATERIALS AND METHODS

This was a prospective cross sectional study conducted from March to May 2009 in a teaching hospital in Tehran, Iran. All non-contrast head CTs obtained during the study period were copied on DVDs and sent separately to a radiologist, 6 emergency medicine (EM) attending physicians and 14 senior EM residents for interpretation. Clinical information pertaining to each patient was also sent with each CT. The radiologist's interpretation was considered as the gold standard and reference for comparison. Data from EM physicians and residents were compared with the reference as well as with each other and statistical analysis was performed using SPSS 18.5.

RESULTS

Out of 544 CT scans, EM physicians had 35 false negatives and 53 false positives compared with radiologist's interpretations (P < 0.0001). EM residents had 74 false negatives and 12 false positives compared with radiologist's interpretations (P < 0.0001).

CONCLUSIONS

Both EPs and ER residents either missed or falsely called a significant number of pathologies in their interpretations. The interpretations of EPs and ER residents were more sensitive and more specific, respectively. These findings revealed the need for increased training time in head CT reading for residents and the necessity of attending continuing medical education workshops for emergency physicians.

Minding the Prevention Protocol for Blood-Borne Diseases via EM Residents

Background

The emergency department (ED) is one of the high-risk places for blood-borne disease (BBD) transmission.

Objectives

This study aimed to assess the rate of adherence to preventive measures (PM) against the blood-borne diseases via emergency medicine (EM) residents.

Materials and Methods

In this descriptive cross-sectional study, 80 emergency residents of an educational public hospital were observed with regard to abiding by the preventive measures from March to May 2010.

Results

Cleaning blood tainted skin before phlebotomy or IV line preparation and hand washing before donning latex gloves achieved the maximum (88/150) and minimum (0/150) scores. The most observed barriers of PM were frequent attendance of patients (85%), work load (80%), and need to work rapidly (68%).

Conclusions

It seems that, the preventive instructions are not optimally respected by ERs possibly due to the crowded wards, high work load and the need to work rapidly.

Improving the prediction of stroke or death after transient ischemic attack (TIA) by adding diffusion-weighted imaging lesions and TIA etiology to the ABCD2 score

The present study investigated the addition of transient ischemic attack (TIA) etiology and diffusion-weighted imaging (DWI) to the ABCD2 score, creating the ABCDE+ score, to improve the predictive ability of stroke risk or death at 6 months after TIA. We performed a cohort study of 150 consecutive patients with TIA. All patients underwent DWI and all had an etiologic workup and were followed up for 6 months. The area under the receiver operating characteristic curve (AUC) was used to compare the scores' ability to predict the outcome of stroke or death. Multivariate Cox regression analysis was performed to evaluate the association between the measured variables and subsequent stroke or death. Thirty patients (20%) experienced future stroke, and 12 patients (8%) died within the 6-month follow-up. A comparison of AUCs demonstrated the superiority of the ABCDE+ score over the ABCD2 score for predicting stroke (0.64 vs 0.60) and for predicting death (0.62 vs 0.56). ABCD2 score >4, ABCDE+ score >6, large-artery disease, and lesions detected on DWI were found to be independent predictors of future stroke, and ABCDE+ score >6, age, and heart disease were independent predictors of death. We conclude that incorporating DWI positivity and etiology of TIA into the ABCD2 score can improve the ability to predict stroke and death within 6 months after TIA.

Epidemiologic study of road traffic injuries by road user type characteristics and road environment in Iran: a community-based approach

OBJECTIVE

Crash injuries in traffic accidents are affected by a variety of factors. In this study we analyzed road user type information based on different contributing factors.

METHOD

Data from all of the road traffic victims on a road extending from the east of the city of Tehran to Mazandaran province were included prospectively over a one-year period (May 2008 to May 2009). Data collected included the crash time, patient's age and sex, road user category, helmet or seat belt use, anatomical site of injury, Injury Severity Score (ISS), and mortality. Prevalence and cross-tabulations were included in the analysis.

RESULTS

There were 433 patients, of whom 345 were hospitalized and 33 died either before or after arriving at the hospital. Sixty-nine percent of injured patients were vehicle occupants. Mean and median of ISS were higher for pedestrians, who accounted for 49 percent of the deaths. Head injury was the most common injury and injury to upper and lower extremities was the most common cause of admission. A significant difference in lower extremity injuries between vehicle occupants and nonoccupants was found. Sex and age group did not have a significant effect on mortality. Mortality was significantly higher in pedestrians (P < .001) when data were analyzed based on road user type.

CONCLUSION

Because pedestrians are the most vulnerable road users, stricter legislation and law enforcement should be used to protect them. Greater protection can also be reached by holding effective public awareness campaigns on how to use different roads safely. On the other hand, because rear seat passengers are at the same risk for road traffic injuries as front seat passengers, employment of newer laws and preventive measures targeting this group of occupants can prevent many road traffic injuries (RTIs).

Troponin utilization in patients presenting with atrial fibrillation/flutter to the emergency department: retrospective chart review

Background

There are few recommendations about the use of cardiac markers in the investigation and management of atrial fibrillation/flutter. Currently, it is unknown how many patients with atrial fibrillation/flutter undergo troponin testing, and how positive troponin results are managed in the emergency department. We sought to look at the emergency department troponin utilization patterns.

Methods

We performed a retrospective chart review of patients with atrial fibrillation/flutter presenting to the emergency department at three centers. Outcome measures included the rates of troponins ordered by emergency doctors, number of positive troponins, and those with positive troponins treated as acute coronary syndrome (ACS) by consulting services.

Results

Four hundred fifty-one charts were reviewed. A total of 388 (86%) of the patients had troponins ordered, 13.7% had positive results, and 4.9% were treated for ACS.

Conclusions

Troponin tests are ordered in a high percentage of patients with atrial fibrillation/flutter presenting to emergency departments. Five percent of our total patient cohort was diagnosed as having acute coronary syndrome by consulting services.