Archives of Academic Emergency Medicine
Year:2020 | Volume:8 | Issue:1|Papers Count:71

Coronavirus disease 2019 or COVID-19 has rapidly emerged as a global pandemic. This viral infection involves the upper respiratory tract and could lead to severe pneumonia with respiratory distress or even death. Certain studies have found higher initial plasma levels of most pro-inflammatory cytokines during the course of the infection. In this context, both in vitro and in vivo studies have revealed that metronidazole could decrease the levels of several cytokines, which are known to increase during the COVID-19 infection, including interleukin (IL)8, IL6, IL1B, tumor necrosis factor (TNF)® , IL12, IL1® , and interferon (IFN)° , as well as the levels of C-reactive protein (CRP) and neutrophil count. Furthermore, the drug could decrease neutrophil-generated reactive oxygen species during inflammation. Metronidazole could counteract majority of the immunopathological manifestations of the COVID-19 infection. Therefore, studies with a large sample size are required to determine the efficacy of metronidazole in the treatment of COVID-19 infection.

Introduction: Several studies have confirmed neurological involvements, such as acute cerebrovascular disease and impaired consciousness in COVID-19. In the present study, our aim is to investigate the current evidence regarding central nervous system (CNS) complications in patients with confirmed COVID-19. Methods: An extensive search was conducted in electronic databases including Medline (using PubMed), Embase, Scopus, and Web of Science, in addition to the manual search in Google and Google scholar search engines, for articles published from 2019 until April 21st, 2020. Inclusion criteria was articles that were reviewed and reported the incidence of neurological outcomes in patients with confirmed COVID-19 disease. Results: The initial search yielded 638 records, fromwhich 7 articleswere included. Overall, the incidence of CNS complications was calculated to be 6. 27%(95% CI: 3. 32 to 9. 98). The incidence of the most common CNS complications, encephalopathy and acute cerebrovascular disease, were 9. 14% (95%CI: 2. 20 to 19. 81) and 2. 59% (95% CI: 1. 31 to 4. 25), respectively. Conclusion: CNS complications do exist in COVID-19 patients, encephalopathy being the most concerning one. The heterogeneity in the existing literature causes an uncertainty in reporting the definite prevalence rate for each complication. Thus, further studies are needed for scientists to reach a more accurate estimate of the prevalence of these complications in COVID-19 patients. However, healthcare providers should consider the possibility of CNS involvements in patients with SARS-CoV-2 infection.

Introduction: Ticagrelor is the first reversibly binding oral P2Y12 receptor antagonist that can block ADPinduced platelet aggregation. This study aimed to describe one-month follow-up findings of cases undergoing ticagrelor therapy after percutaneous coronary intervention (PCI). Methods: This case series was performed on acute coronary syndrome (ACS) patients who were candidates for PCI and received aspirin plus ticagrelor after PCI. Patients were followed for one month and their outcomes were described. Results: 156 cases with the mean age of 59. 74 § 9. 24 years were studied (63% male). 45 (28. 8%) cases complained of dyspnea (39 cases with mild and 6 cases with severe dyspnea). Bleeding occurred in 4 (2. 5%) cases (intra-cranial hemorrhage (ICH) in one, hematuria in two, and skin hemorrhage in one case). There were no cases with bradycardia or thrombosis. One (0. 6%) patient developed drug hypersensitivity reaction, which manifested as skin rash. The use of drug was stopped in 10 (6. 4%) cases due to severe dyspnea (n= 6), ICH (n=1), skin rash (n=1), and concomitant left ventricular (LV) clot (n=2). Conclusion: The most important finding of one-month ticagrelor consumption were dyspnea, bleeding, and hypersensitivity reaction. No case of bradycardia and stent thrombosis was detected. In our study, iranian population has more susceptibility to dyspnea than PLATO result. The rate of drug discontinuation in this series of cases was 6. 4%.

Introduction: Colchicine is a medication with narrow therapeutic index, leading to both accidental and suicidal poisonings incidents. This study aimed to investigate the clinical and laboratory manifestations, as well as outcomes of colchicine poisoning patients referred to emergency department. Methods: In this retrospective cross sectional study, demographics, clinical features, laboratory parameters, and outcomes of colchicine poisoned patients who were admitted to an academic referral center, Tehran, Iran, during 7 years were extracted from the patients’ profiles and analyzed. Results: 21 patients with the mean age of 25. 48 § 12. 65 years were studied (61. 9% female; 85. 7% suicidal). The mean ingested colchicine dose was 30. 25 § 21. 09 mg. The most common symptoms were nausea and vomiting observed in 19 (90. 5%) cases, followed by abdominal pain in 10 (47. 6%) and diarrhea in 9 (42. 8%) cases. 3 (14. 3%) had died, the cause being disseminated intravascular coagulation (DIC) in two cases and severe metabolic acidosis in one. Prevalence of abdominal tenderness (p = 0. 001) and abdominal pain (p = 0. 049) was significantly different between survived and non-survived patients. There were significant correlations between systolic blood pressure (p = 0. 010), diastolic blood pressure (p = 0. 002), serum glucose (p = 0. 031), calcium (p = 0. 017), white blood cell (WBC) count (p = 0. 043), aspartate aminotransferase (AST) (p = 0. 001), alkaline phosphatase (ALP) (p = 0. 012), prothrombin time (PT) (p = 0. 006), partial thromboplastin time (PTT) (p = 0. 014), PaCO2 (p = 0. 011), DIC (p < 0. 001), and need for mechanical ventilation (p = 0. 024) with survival. Conclusion: Based on the findings of the present study, the mortality rate of colchicine poisoning was 14. 3% and there was significant correlation between lower blood pressure, lower serum glucose and calcium levels, lower PaCO2, higher WBC count, higher AST and ALP levels, higher PT and PTT, need for mechanical ventilation, presence of DIC, and also abdominal pain and tenderness with survival.

SARS-CoV-2 is a newly emerging human infectious coronavirus that causes COVID-19, which has been recognized as a pandemic by theWorldHealth Organization (WHO) onMarch 11t h. There is still no vaccine or definitive treatment for this virus because its pathogenesis and proliferation pathways are still unknown. Therefore, in this article, new potential COVID-19 therapies are briefly reviewed.

Introduction: In the aftermath of mass casualty incidents (MCIs), many decisions need to be made in a fast and influential manner in a high pressure environment to distribute the limited resources among the numerous demands. This study was planned to rank the criteria influencing distribution of casualties following traumarelated MCI. Methods: This study utilized a modified Delphi methodology, concentrating on extracted criteria attained from preceding systematic literature reviews. The 114 extracted criteria were classified into eight sections including space, staff, equipment, system and structures, triage, treatment, transport, and uncategorized criteria and were imported into an online survey tool. In the first round, experts were asked to rank each criterion on a five-point Likert scale. The second round incorporated feedbacks from the first round, stating percent and median scores from the panel as a whole. Experts were then called upon to reassess their initial opinions regarding uncertain remarks fromthe first round, and once again prioritize the presented criteria. Results: Fiftyseven criteria were regarded as relevant to the following sections: space: 70% (7/10); staff: 44% (4/9); system / structure: 80% (4/5); equipment: 39. 1% (9/23); treatment; 66. 7% (6/9); triage: 73. 7% (14/19); transport: 38. 7% (12/31) and other sections: 12. 5% (1/8). The ï nˇ A˛ rst round achieved nearly 98% (n=48) response rate. Of the 114 criteria given to the experts, 68 (almost 60%) were approved. The highest percentage of approval belonged to the system and structures sections (4/5=80%). The response rate for the second round was about 86% (n=42). A consensus could be reached about nearly 84% (57) of the 68 criteria presented to experts. Conclusion: "Casualty Level of Triage on the Scene" and "Number of Available Ambulances" were the two criteria that obtained the highest level of consensus. On the other hand, "gender of casualty", "Number of Non-Medical staff in each Hospital" and "Desire to transport family members together" got lowest level of consensus. This sorted list could be used as a catalogue for developing a decision support system or tool for distribution of victims following mass casualty incidents.

Introduction: There is a significant discrepancy between studies on diagnostic precision of neutrophil gelatinase-associated lipocalin (NGAL) in diagnosis of urinary tract infection (UTI). Therefore, the present systematic review and meta-analysis was designed to assess the diagnostic value of NGAL in diagnosis of UTI in children and adolescents. Methods: An extensive search was performed on Medline, Embase, Scopus and Web of Science databases by the end of 2019. Two independent researchers screened and summarized the data. Discriminatory precision of urinary and serum NGAL was assessed by reporting area under the curve, sensitivity, specificity and diagnostic odds ratio with 95% confidence interval (95% CI). Results: Data from 12 studies were included. The area under the curve of urinary and serum NGAL for diagnosis of UTI in children and adolescents at the best cut-off point (between 30-39. 9 ng/ml) was 0. 95 (95% CI: 0. 93 to 0. 97) and 0. 83 (95% CI: 0. 80 to 0. 86), respectively. Sensitivity, specificity and diagnostic odds ratio on urinary NGAL at these cut-off points were 0. 89 (95%CI: 0. 64 to 0. 97), 0. 89 (95% CI: 0. 71 to 0. 97) and 67 (95% CI: 5 to 891), respectively. Sensitivity, specificity and diagnostic odds ratio of serum NGAL in UTI detection were 0. 85 (95%CI: 0. 70 to 0. 90), 0. 81 (95%CI: 0. 69 to 0. 88) and 9. 53 (95% CI: 1. 52 to 59. 65), respectively. Conclusion: The present meta-analysis showed that urinary NGAL had a high diagnostic value in detection of UTI in children and adolescents with an optimum cut-off point in the range of 30-39. 9 ng/ml.

Introduction: Tramadol is an active analgesic drug that is commonly used to treat moderate to severe pain. The present study aimed to assess the arterial blood gas (ABG) analysis of patients with tramadol-induced seizure (TIS). Methods: This prospective cross-sectional study was performed on 50 TIS cases that were referred to emergency department within a maximum of one hour after their last episode of seizure. The results of ABG analysis on admission were collected and their association with dosage and time interval between ingestion and admission was assessed. Results: 50 cases with the mean age of 35. 10 § 9. 62 years were studied (80. 0% male). Themean dosage of ingestion was 1122. 00 § 613. 88 (400 to 3000) mg and the mean time interval between ingestion and admission was 7. 16 § 2. 18 hours. ABG analysis on admission showed that 49 (98. 0%) patients had pH < 7. 35 and PaCO2 > 45 mmHg (respiratory acidosis). There was a significant association between ingestion to admission time interval and both PaCO2 (r =-0. 330, p = 0. 019), and PaO2 (r = 0. 303, p = 0. 032). The dose of ingestion was negatively associated with respiratory rate (r =-0. 556, p = 0. 001), arterial pH (r =-0. 676, p = 0. 001), and PaO2 (r =-0. 514, p = 0. 001), but was positively associated with PaCO2 (r = 0. 461, p = 0. 001). Higher doses of tramadol led to more severe hypercapnia and need for intubation (OR = 1. 12, 95% CI: 0. 88 – 1. 26; p = 0. 045). 5 (10. 0%) cases needed mechanical ventilation. All patients improved after supportive care with no in-hospital death. Conclusion: Based on the findings, 98% of TIS cases had respiratory acidosis. Higher doses of ingested drug and longer time interval between ingestion and admission were associated with severity of ABG disturbances.

Introduction: Abdominal aortic aneurysm (AAA, triple A) is one of the less common but important causes of abdominal pain. This study aimed to evaluate the characteristics and outcome of patients presenting to emergency department with triple A. Methods: In this retrospective cross-sectional study, all cases with confirmed triple A, who were presented to the emergency department of Shohadaye Tajrish Hospital, Tehran, Iran from 2006 to 2017 (10 years) were enrolled using census sampling method. Results: 500 cases with the mean age of 68. 11 § 11. 98 (25-94) years were studied (84% male). The mean duration of symptoms was 2. 32 § 9. 58 months and mean aneurysmal size was 63. 91 § 20. 08 mm. In 4 (0. 8%) cases, atrial fibrillation (AF) was found during cardiac monitoring. Patients stayed in the hospital for an average of 7. 06 § 6. 32 days. Aneurysmal leak was seen in 130 (26%) cases based on abdominal computed tomography (CT) scan findings. 369 (73. 8%) cases underwent aneurysmorrhaphy, 126 (25. 2%) were treated with non-surgical approaches, and 5 (1%) underwent grafting. 104 (20. 8%) died and 396 (79. 2%) were treated successfully. Older age (p = 0. 017), shock state at the time of presentation (p < 0. 0001), leakage of aneurysm (p < 0. 001), larger size of aneurysm (p = 0. 024), and aneurysmorrhaphy (p < 0. 001) were among the factors significantly associated with mortality. Conclusion: Based on the findings, the most frequent presenting symptom of patients was abdominal pain. The mortality rate of this series was 21% and older age, shock state, leakage of aneurysm, larger size of aneurysm, and performing aneurysmorrhaphy were among the factors significantly associated with mortality.

Dear Editor Since December 2019, when the first case of COVID-19 was reported in China, the main strategy of health policy makers has been to quarantine and impose social restrictions, causing significant behavioral changes in people due to fear of infection (1, 2). Laws limiting traffic, reduced travel permits, paying attention to personal hygiene, and making efforts to clean up private and public environments are some of the changes that have been observed. We also noticed alterations in patients’ admission to trauma centers. In a retrospective cross-sectional study, demographic characteristics and type of fracture were analyzed in patients referring to the trauma center of TaleghaniHospital, Kermanshah, Iran, from 1s t March to 15t h April, in 3 consecutive years (2018 to 2020)...

COVID-19 pandemic is a challenge in the current era. The spread of this viral infection began in Wuhan City in China, and Iran was also one of the countries struggling with it. Considering the nature of this virus and the current pandemic, it is essential that the healthcare system authorities issue a clear and firm law on treating people infected with COVID-19 to prevent the consequences affecting the professional life of physicians and healthcare staff. The current study aimed at evaluating the legal consequences of COVID-19 cases in emergency department (ED). This case series reported 10 patients that filed complaints against medical staff for problems that occurred on arrival, during the hospital stay or discharge in Shohada-ye-Tajrish and ShahidModarres educational Hospitals, Tehran, Iran. Consultation with forensic medicine department was requested for all patients and the final decision for each case was reported under the title legal considerations.

Although previous articles and reviews suggest that ketamine might effectively manage pain in trauma patients, these articles have serious limitations. Accordingly, the current meta-analysis aims to investigate the efficacy of ketamine administration in prehospital pain management of trauma patients. Method: In the present meta-analysis, controlled human studies were included. An extensive search was conducted in electronic databases including Medline (via PubMed), Embase, Central, Scopus, Web of Science, and ProQuest, gathering data to the end of 2018. The efficacy and side effects of ketamine administration in pre-hospital pain management were compared with those of opioid analgesics based on standard mean difference (SMD) and odds ratio (OR) calculations with 95% confidence interval (95% CI). Results: Data from seven articles were included in the presentmeta-analysis. Ketamine administration was not more effective than administrating morphine or fentanyl in prehospital pain management of trauma patients (SMD =-0. 56, 95% CI:-1. 38 to 0. 26, p = 0. 117). However, co-administration of ketamine+morphine was considerably more effective than ketamine alone, in alleviating pain in prehospital settings (SMD =-0. 62, 95% CI:-1. 12 to-0. 12, p = 0. 010). Finally, it was concluded that ketamine alone had less side effects than morphine alone (OR = 0. 25, 95% CI: 0. 11 to 0. 56, p = 0. 001). However, co-administration of ketamine+morphine increases the risk of side effects to 3. 68 times compared to when morphine is prescribed solely (OR=3. 68, 95% CI: 1. 99 to 6. 82, p<0. 001). Conclusion: For the first time, findings of the current meta-analysis demonstrated that ketamine, being administered alone, is an effective and safe medication in prehospital pain management in trauma patients, and can be considered as an acceptable alternative to opioid analgesics.

Introduction: Adequate chest compression is crucial for cardiopulmonary resuscitation (CPR). There are several chest compression monitoring devices with different costs. This study aimed to evaluate the agreement rate of Improved Quality of Cardiopulmonary Resuscitation meter (IQ-CPR meter) and automated external defibrillator (AED) in chest compression quality monitoring. Methods: In this comparative study, participants were instructed to perform chest compression on the CPR manikins with the set rate of 110 times/minute for two minutes. The CPR manikins had two monitors: AED (R series® , Zoll company) and IQ-CPR meter. AED showed the depth and speed of chest compression on the screen, while IQ-CPRmeter showed the depth of each chest compression by color light for quality of chest compression depth. Video-based analysis was used to compare the chest compression quality monitoring between the 2 devices. Results: There were 27 participants in the study with a mean age and body mass index (standard deviation; SD) of 26. 00 (5. 65) years, and 22. 93 (3. 62) kg/m2 (70. 37% male). The median (1s t to 3r d quartile range) of chest compression experience was 3 (1. 00-6. 50) years. The mean (SD) of chest compression rate was 107 (5. 29) times/minute. Based on Cohen’ s Kappa correlation, agreement between the IQ-CPR meter and the AED was 66. 54%. Conclusion: The IQ-CPR meter had fair agreement with the computerized chest compression monitoring device with lower cost and simple, real time audiovisual feedback.

Introduction: Reperfusion and neuroprotection are 2 main treatment strategies exist for management of patients with ischemic stroke. This study aimed to assess the 3-month outcome of patientswho underwent thrombolytic therapy following ischemic stroke. Methods: In the present prospective cohort study, the 3-month outcome of patients (mortality, disability) with acute ischemic stroke admitted to neurology department an educational hospital, Kermanshah, Iran, from 2016 to 2019, who had received thrombolytic therapy was assessed. National Institute of Health Stroke Scale (NIHSS) and Modified Rankin Score (MRS) were used for measuring the degree of disability (on admission, at the time of discharge and 3 months after thrombolytic therapy). Results: 217 patients with the mean age of 66. 40 § 13. 37 (27 – 97) years were studied (55. 3% male). There was no significant correlation between decrease in NIHSS score and age (p = 0. 44), sex (p = 0. 082), time interval between initiation of symptoms (p = 0. 104), and blood pressure on admission (p = 0. 156). However, patients with blood sugar lower than 144 had better 3-month outcome (p = 0. 045). Additionally, there was no significant correlation between the rate of decrease in MRS score and age (p = 0. 813), sex (p = 0. 875), time interval between initiation of symptoms (p = 0. 495), and blood pressure on admission (p = 0. 264). However, patients with blood sugar lower than 144 had better 3-month outcome (p = 0. 022). 47 (21. 7%) patient died and 170 (78. 3%) were discharged. Mean age of the patients who died (73. 70 § 11. 85 versus 64. 39 § 13. 09 years; p < 0. 0001) and their NIHSS score on admission (13. 22 § 6. 01 versus 11. 28 § 5. 70; p = 0. 045) were significantly higher. In other words, the odds of mortality was 3. 19 times in patients over 60 years of age (95% confidence interval (CI): 1. 18 – 8. 62) and 1. 83 times in patients with NIHSS score over 12 (95% CI: 0. 92 – 3. 61). Conclusion: There was no significant correlation between 3-month disabilities of stroke patients underwent thrombolytic therapy and age, sex, time from initiation of symptoms, or vital signs on admission. Patients with a blood sugar lower than 144 had better 3-month outcome.

Dear editor: Coronavirus (COVID-19) is a new respiratory disease that is spreading widely throughout the world(1). There is no valid information available on pregnant women and their complications. But given previous epidemics (SARS and MERS), as well as mental and physical changes during pregnancy (2), pregnantwomen are more likely to be affected by the virus. On the other hand, the Coronavirus epidemic has created stress and anxiety for pregnant women in different parts of the world. Concern and stress in pregnancy are associated with side effects such as preeclampsia, depression, increased nausea and vomiting during pregnancy, pretermlabor, low birth weight, and low APGAR score (3-7)...

Background: The purpose of the current systematic review is to evaluate the efficacy of antiviral therapies in treatment of COVID-19. In addition, clinical trials on the efficacy of antiviral therapies in the management of Severe Acute Respiratory Syndrome coronavirus (SARS-Cov) or Middle East Respiratory Syndrome coronavirus (MERS-CoV) have also been reviewed, in order to identify potential treatment options for COVID-19. Method: An extensive search was performed in Medline, Embase, Scopus, Web of Science and CENTRAL databases until the end of March 15, 2020. Two independent researchers performed the screening, and finally the related studies were included. Results: Only one clinical trial on the efficacy of antiviral therapy in management of COVID-19 was found. The results depicted that adding Lopinavir-Ritonavir to the standard treatment regimen of patients with severe COVID-19 has no benefits. Moreover, 21 case-series and case-report studies reported the prescription of antiviral agents in COVID-19, none of which can be used to determine the efficacy of antiviral therapies in confronting COVID-19. In addition, no clinical trials were found to be performed on the efficacy of antiviral agents in the management of SARS-CoV and MERS-CoV. Conclusion: The current evidence impede researchers from proposing an appropriate antiviral therapy against COVID-19, making the current situation a serious concern for international organizations such as World Health Organization (WHO). In the time of the current pandemic and future epidemics, organizations such asWHO should pursuemore proactive actions and plan well-designed clinical trials so that their results can be used in managing future epidemics.

Introduction: The outbreak of the new Coronavirus in China in December 2019 and subsequently in various countries around the world has raised concerns about the possibility of vertical transmission of the virus from mother to fetus. The present study aimed to review published literature in this regard. Methods: In this narrative review, were searched for all articles published in various databases including PubMed, Scopus, Embase, Science Direct, andWeb of Science usingMeSH-compliant keywords including COVID-19, Pregnancy, Vertical transmission, Coronavirus 2019, SARS-CoV-2 and 2019-nCoV fromDecember 2019 toMarch 18, 2020 and reviewed them. All type of articles published about COVID-19 and vertical transmission in pregnancy were included. Results: A review of 13 final articles published in this area revealed that COVID-19 can cause fetal distress, miscarriage, respiratory distress and preterm delivery in pregnant women but does not infect newborns. There has been no report of vertical transmission in pregnancy, and it has been found that clinical symptoms of COVID-19 in pregnant women are not different from those of non-pregnant women. Conclusion: Overall, due to lack of appropriate data about the effect of COVID-19 on pregnancy, it is necessary to monitor suspected pregnant women before and after delivery. For confirmed cases both the mother and the newborn child should be followed up comprehensively.

Introduction: Immature granulocytes (IG) in peripheral blood indicate increased bone marrow activation and inflammation, and SYNTAX score (SS) is an anatomical scoring system based on coronary angiogram. This study, aimed to evaluate the relationship between IG and SS, as a new inflammatory marker in patients with acute coronary syndrome (ACS). Methods: Patients aged >18 years who were diagnosed with ACS in the emergency department were included in this study, which was planned as a cross-sectional study. Patients were divided into two groups of patients with high and low SSs according to coronary angiography results. Demographic and laboratory parameters were compared between the groups. Results: Our study consisted of 78 patients diagnosed with ACS, who met the inclusion criteria. The average age of the study group was 59 years, and 67. 9% of the patients were male. 21 patients (26. 9%) had high SSs and 57 patients (73. 1%) had low SSs. Mean IG% was significantly higher in high SS group compared to low SS group (0. 71§ 0. 25 vs 0. 44§ 0. 21 mg/dl, p<0. 001). IG% can present a high SS with 76. 2% sensitivity and 75. 4% specificity at a cut-off value of 0. 7. Conclusion: IG was significantly higher in ACS patients with high SSs. It seems that IG can be used as a parameter, which is quickly accessible and cheap, in order to predict high SS in ACS patients in daily clinical practice.

Introduction: Seizure is a common complication of tramadol poisoning and predicting it will help clinicians in preventing seizure and better management of patients. This study aimed to develop and validate a prediction model to assess the risk of seizure in acute tramadol poisoning. Methods: This retrospective observational study was conducted on 909 patients with acute tramadol poisoning in Baharloo Hospital, Tehran, Iran, (2015-2019). Several available demographic, clinical, and para-clinical characteristicswere considered as potential predictors of seizure and extracted from clinical records. The datawere split into derivation and validation sets (70/30 split) via random sampling. Derivation set was used to develop a multivariable logistic regression model. The model was tested on the validation set and its performance was assessed with receiver operating characteristic (ROC) curve. Results: The mean (standard deviation (SD)) of patients’ age was 23. 75 (7. 47) years and 683 (75. 1%) of them were male. Seizures occurred in 541 (60%) patients. Univariate analysis indicated that sex, pulse rate (PR), arterial blood Carbone dioxide pressure (PCO2), Glasgow Coma Scale (GCS), blood bicarbonate level, pH, and serum sodium level could predict the chance of seizure in acute tramadol poisoning. The final model in derivation set consisted of sex, PR, GCS, pH, and blood bicarbonate level. The model showed good accuracy on the validation set with an area under the ROC curve of 0. 77 (95% CI: 0. 67– 0. 87). Conclusion: Representation of this model as a decision tree could help clinicians to identify high-risk patients with tramadol poisoninginduced seizure and in decision-making at triage of emergency departments in hospitals.

Introduction: In the beginning of 2020, an unexpected outbreak due to a new corona virus made the headlines all over the world. Exponential growth in the number of those affected makes this virus such a threat. The current meta-analysis aimed to estimate the prevalence of underlying disorders in hospitalized COVID-19 patients. Methods: A comprehensive systematic search was performed on PubMed, Scopus, Web of science, and Google scholar, to find articles published until 15 February 2020. All relevant articles that reported clinical characteristics and epidemiological information of hospitalized COVID-19 patients were included in the analysis. Results: The data of 76993 patients presented in 10 articles were included in this study. According to the metaanalysis, the pooled prevalence of hypertension, cardiovascular disease, smoking history and diabetes in people infected with SARS-CoV-2 were estimated as 16. 37% (95%CI: 10. 15%-23. 65%), 12. 11% (95%CI 4. 40%-22. 75%), 7. 63% (95%CI 3. 83%-12. 43%) and 7. 87% (95%CI 6. 57%-9. 28%), respectively. Conclusion: According to the findings of the present study, hypertension, cardiovascular diseases, diabetes mellitus, smoking, chronic obstructive pulmonary disease (COPD), malignancy, and chronic kidney disease were among the most prevalent underlying diseases among hospitalized COVID-19 patients, respectively.

Introduction: Differentiating central vertigo from peripheral ones poses a challenge to specialists. The present study aimed to examine the potential screening value of S100B and neuron-specific enolase (NSE) in this regard. Methods: This prospective cross-sectional study recruited adult acute vertigo patients with suspected central causes visiting the emergency department (ED) in the first six hours since the onset of symptoms. The screening performance characteristics of S100B and NSE biomarkers in differentiating central vertigo caseswere measured considering brain magnetic resonance imaging (MRI) as the reference test. Results: 85 cases who met the criteria were enrolled to the study (82. 3% female). The MRI of 21 (24. 7%) cases had abnormal findings. The two groups were the same in terms of age, sex, and vital signs. Patients with abnormal brain MRI had significantly higher levels of S100B (p < 0. 001) and NSE (p < 0. 001). S100B and NSE had area under the receiver operating characteristic (ROC) curve of 90. 3 (95% CI: 80. 7 – 99. 8) and 96. 9 (95% CI: 93. 7 – 100. 0) in differentiating the central causes of acute vertigo, respectively. At the cut-off point of above 119. 68 pg/l, S100b had sensitivity of 90. 00% (95% CI: 78. 83 – 95. 86) and specificity of 92. 00% (95% CI: 72. 49 – 98. 60). The sensitivity and specificity of NSE at the cut-off point of above 18. 12 ng/ml were 100. 00% (95% CI: 93. 14 – 100. 00) and 89. 47% (95% CI: 65. 46 – 98. 15), respectively. Conclusion: The serum levels of S100B and NSE were significantly higher in patients with central vertigo, and could therefore be considered as accurate tools in screening acute vertigo cases with central causes in ED.

Although the findings of some studies have been indicative of the direct relationship between the severity of clinical findings and imaging, reports have been published regarding inconsistency of clinical findings with imaging and laboratory evidence. Physicians treating these patients frequently report cases in which patients, sometimes in the recovery phase and despite improvements in imaging indices, suddenly deteriorate and in some instances suddenly expire. This letter aimed to draw attention to the role of pulmonary thromboembolism as a potential and possible cause of clinical deterioration in covid-19 patients.

Introduction: There is considerable controversy on the accuracy of Kidney InjuryMolecule-1 (KIM-1) in prediction of acute kidney injury (AKI) in children. Therefore, the present study intends to provide a systematic review and meta-analysis of the value of this biomarker in predicting AKI in children. Methods: An extensive search was performed on the Medline, Embase, Scopus and Web of Science databases by the end of 2019. Cohort and case-control studies on children were included. Urinary KIM-1 levels were compared between AKI and non-AKI groups. Findings were reported as an overall standardized mean difference (SMD) with a 95% confidence interval (CI). Also, the overall area under the receiver operating characteristic (ROC) curve (AUC) of KIM-1 in predicting AKI in children was calculated. Results: Data from 13 articles were included. Urinary KIM-1 levels in children with stage 1 AKI were higher than the non-AKI group only when assessed within the first 12 hours after admission (SMD = 0. 95; 95% CI: 0. 07 to 1. 84; p = 0. 034). However, urinary KIM-1 levels in children with stage 2-3 AKI were significantly higher than non-AKI children (p <0. 01) at all times. The AUC of urinary KIM-1 in predicting AKI in children was 0. 69 (95% CI: 0. 62 to 0. 77). Conclusion: Based on the available evidence, KIM-1 seems to have moderate value in predicting AKI in children. Since previous meta-analyses have provided other urinary and serum biomarkers that have better discriminatory accuracy than KIM-1, so it had better not to use KIM-1 in predicting AKI in children.

Introduction: Multiple lines of evidence have attested that decreased numbers of platelets may serve as a surrogate marker for poor prognosis in a wide range of infectious diseases. Thus, to provide a well-conceptualized viewpoint demonstrating the prognostic value of thrombocytopenia in COVID-19, we performed a metaanalysis of pertinent literature. Method: The keywords "platelet" OR "thrombocytopenia" AND "COVID-19" OR "coronavirus 2019" OR "2019-nCoV" OR "SARS-CoV-2" were searched in National Library ofMedicineMedline/ PubMed and Scopus between December 30, 2019, and May 9, 2020 in English without any restriction. The initial search results were first screened by title and abstract, and then full texts of relevant articles representing information on the platelet count (main outcome) with a clinically validated deï nˇ A˛ nition of COVID-19 severity were ï nˇ A˛ nally selected. To assess the existence of bias in the included studies, the funnel plot and egger plot along with egger tests were used. Also, the heterogeneity among the included studies was tested using the Chisquare test. Results: The results of our meta-analysis of 19 studies, totaling 3383 COVID-19 patients with 744 (21. 9%) severe cases, revealed that non-severe cases have a significantly higher number of platelets and showed that the probability of the emergence of thrombocytopenia is significantly higher in the severe cases with the pooled mean difference of-21. 5 (%95 CI:-31. 57,-11. 43). Conclusion: Decreased number of platelets more commonly associates with severe COVID-19; however, whether the emergence of thrombocytopenia may result in diseases severity or the severity of the disease may decrease platelets, is open to debate.

Transient global amnesia (TGA) is characterized by the abrupt onset of global amnesia, particularly anterograde amnesia. The pathophysiology of TGA is poorly understood and it could be caused by various factors and be associated with various diseases. We report a 58-year-old man who presented to the local emergency room with TGA lasting for several hours. The patient had complete anterograde amnesia without a past medical history of migraine or neurological findings. His systolic blood pressure on presentation was 220 mmHg, which was immediately treated with intravenous calcium ion influx inhibitor. Other than global amnesia, there was no evidence of neurological disturbance. Computed tomography and magnetic resonance imaging results were unremarkable. After treatment of his hypertension, his amnesia resolved within 12 hours. Emergency department physicians may encounter TGA. Correct diagnosis of the condition depends on recognizing the disease.

The 2019 novel coronavirus (officially known as severe acute respiratory syndrome coronavirus 2, SARS-CoV2) was first found inWuhan, China. On February 11, 2020, theWorld Health Organization (WHO) has declared the outbreak of the disease caused by SARS-CoV2, named coronavirus disease 2019 (COVID-19), as an emergency of international concern. Based on the current epidemiological surveys, some COVID-19 patients with severe infection gradually develop impairment of the respiratory system, acute kidney injury (AKI), multiple organ failure, and ultimately, death. Currently, there is no established pharmacotherapy available for COVID-19. As seen in influenza, immune damage mediated by excessive production of inflammatory mediators contributes to high incidence of complications and poor prognosis. Thus, removal or blocking the overproduction of these mediators potentially aids in reducing the deleterious cytokine storm and improving critically ill patients’ outcomes. Based on previous experience of blood purification to treat cytokine storm syndrome (CSS) in severe acute respiratory syndrome (SARS) andMiddle East respiratory syndrome (MERS), here we aimed to review the current literature on extracorporeal hemoperfusion as a potential therapeutic option for CSS-associated conditions, with a focus on severe COVID-19.

Introduction: Gaining knowledge about underlying diseases and associated comorbidities in patients with COVID-19 can be beneficial in developing a proper understanding of the disease prognosis as well as comprehensive management, and treatment of the disease. The aim of this study was to determine the prevalence of underlying diseases and associated comorbidities in COVID-19 patients using a systematic review and metaanalysis. Methods: Major biomedical electronic databases, including Scopus, PubMed, Web of Science, CINAHL and EMBASE were searched for all relevant literature published in English from January to July 2020. Crosssectional and retrospective studies reporting the prevalence of comorbid conditions such as acute cardiac injury, acute myocardial infarction, acute kidney injury, acute liver injury, shock, acute respiratory disease, and acute respiratory distress syndrome in patients with COVID-19 were included in the study. After selecting eligible studies, two authors extracted data of each study, independently, and any inconsistency was resolved through discussion with the third reviewer until reaching a consensus. The risk of bias was assessed by two independent research experts using the Newcastle-Ottawa Scale (NOS). The variance in the meta-analyses on prevalence was stabilized by double arcsine transformations. Results: The pooled prevalence of acute respiratory injury in patients with COVID-19 was estimated as 34%(95%Cl: 10 – 57%). Also, the prevalence of acute kidney injury, acute liver injury, acute respiratory distress syndrome, and shock were estimated as 10% (95% Cl: 6-14%), 19% (95% Cl: 10-27%), 23 % (95% Cl: 19-27%), and 12 % (95% Cl: 5 – 19 %). Conclusion: According to this meta-analysis, comorbidities such as hypertension, acute liver and kidney injury, acute respiratory distress syndrome, shock, diabetes, and coronary heart disease seem to be a predisposing factor for symptomatic and severe COVID-19 infection.

Dear Editor, COVID-19 is a newly emerging human infectious disease of SARS-CoV-2 origin that has affected many countries around the world. COVID-19 is now rapidly spreading worldwide, and this letter is written as the World Health Organization (WHO) has declared a global emergency on January 31st amid concerns about a growing outbreak of SARS-CoV-2. Most of the published articles on COVID-19 have highlighted lungs as the main organ involved in the disease, while few articles have reported SARS-CoV-2 involvement in other organs, including liver and kidneys, which can impair the metabolism and excretion of the medications taken to treat the disease...

There are significant misconceptions and many obstacles in the way of illuminating the epidemiological and clinical aspects of COVID-19 as a new emerging epidemic. In addition, usefulness of some evidence published in the context of the recent epidemic for decision making in clinic as well as public health is questionable. However, misinterpreting or ignoring strong evidence in clinical practice and public health probably results in less effective and somehow more harmful decisions for individuals as well as subgroups in general populations of countries in the initial stages of this epidemic. Accordingly, our narrative review appraised epidemiological and clinical aspects of the disease including genetic diversity of coronavirus genus, mode of transmission, incubation period, infectivity, pathogenicity, virulence, immunogenicity, diagnosis, surveillance, clinical case management and also successful measures for preventing its spread in some communities.

Introduction: Identification of high-risk patients with poor prognosis is essential for quick diagnosis and treatment of methanol poisoning to prevent death and improve the outcome. The aim of this study was to evaluate the clinical and laboratory factors in patients with methanol poisoning to determine the prognosis and outcome. Methods: In this retrospective cross-sectional study, all patients with methanol poisoning, who had presented to the emergency department of Tohid Hospital, Sanandaj, Iran from 2011 to 2019 (8 years) were enrolled using census method. Multivariate logistic regression analysis was performed to find the independent predictive factors of poor outcome in the mentioned patients. Results: Methanol poisoning was diagnosed in 52 (11. 55%) of the 450 cases admitted to hospital for alcohol intoxication. Inmultivariate analysis, time interval from methanol intake to hospital admission (OR=1. 06; 95% CI= 1. 00-1. 11; p=0. 04), respiratory arrest (OR=25. 59; 95% CI= 1. 37-478. 13; p=0. 03), and higher concentration of blood glucose (OR=1. 03; 95% CI= 1. 00-1. 09; p=0. 03) had a significant correlation with Poor outcomes. Conclusion: Based on the findings of this study, delayed admission to hospital, respiratory arrest and hyperglycemia were identified as independent risk factors of poor outcome in methanol poisoning.

1. Introduction In late 2019 and early 2020, many people in different countries around the world became infected by the new Coronavirus. This created challenges for these countries in many aspects including economic, political, social, health and so on. Some of these challenges are directly or indirectly related to information discussion, because providing the right information, at the right time and to the right audience, can solve or reduce some of the challenges. However, there were problems in this process during this crisis, as various individuals and organizations began to produce and disseminate information that, given the special circumstances of this crisis (that most countries have rarely experienced), produced types of information that are worth consideration...

Introduction: Health and efforts to maintain and promote it have always been an essential priority in various countries. This study aims to evaluate the implementation of the health system reform plan in emergency departments in Iran. Methods: This qualitative study evaluated five dimensions (finance, social responsibility, growth and learning, service recipients, and internal processes) through examining 70 indicators in 400 healthcare service providers and 300 healthcare recipients after the implementation of reform plan in ten emergency departments affiliated to Shahid Beheshti University of Medical Sciences using the balanced scorecard based on comprehensive evaluation model for the health system reform plan in Iran (CEHSRP-IR), from 2018 to 2019. Results: From the perspective of 51% of service providers and 55% of service recipients, the health system reform plan has achieved its goals in hospital emergencies. Significant gap between the ideal effectiveness and the current situation in health services in hospital emergencies was observed, especially in the educational and financial dimension. Conclusion: According to the findings of this study, adaptation of activities and programs to the model proposed for emergency departments in Health Reform Plan is essential for improving its effectiveness.

Introduction: The emergence and fast spread of 2019 novel coronavirus (2019-nCoV) threatens the world as a new public health crisis. This study aimed to clarify the impact of novel coronavirus disease (COVID-19) on pregnant patients and maternal and neonatal outcomes. Methods: A comprehensive literature search was conducted in databases including PubMed, Scopus, Embase, ProQuest, and Science Direct. All studies including original data; case reports, case series, descriptive and observational studies, and randomized controlled trials were searched from December 2019 until 19 March 2020. Results: The search identified 1472 results and 939 abstracts were screened. 928 articles were excluded because studies did not include pregnant women. Full texts of eleven relevant studies were reviewed and finally nine studies were included in this study. The characteristics of 89 pregnant women and their neonates were studied. Results revealed that low-grade fever and cough were the principal symptoms in all patients. The main reported laboratory findings were lymphopenia, elevated C-Reactive Protein (CRP), Amino alanine transferase (ALT), and Aspartate amino transferase (AST). In all symptomatic cases, chest Computerized Tomography (CT) scans were abnormal. Fetal distress, premature rupture of membranes and preterm labor were the main prenatal complications. Two women needed intensive care unit admission and mechanical ventilation, one of whom developedmulti-organ dysfunction and was on Extracorporeal Membrane Oxygenation (ECMO). No case of maternal death was reported up to the time the studies were published. 79 mothers delivered their babies by cesarean section and five women had a vaginal delivery. No fetal infection through intrauterine vertical transmission was reported. Conclusions: Available data showed that pregnant patients in late pregnancy had clinical manifestations similar to non-pregnant adults. It appears that the risk of fetal distress, preterm delivery and prelabor rupture of membranes (PROM) rises with the onset of COVID-19 in the third trimester of pregnancy. There is also no evidence of intrauterine and transplacental transmission of COVID-19 to the fetus in the third trimester of pregnancies.

Introduction: World Health Organization has declared COVID-19 a pandemic and a global health emergency. Thus, it is necessary to clearly characterize clinical manifestations and management of COVID-19 infection in children to provide accurate information for healthcare workers. Accordingly, the present study was designed to review articles published on clinical manifestations and characteristics of children and infants with COVID-19. Methods: In this systematic review, medical databases including Cochrane Library, Web of Science, Embase, Scopus, SID, Medline, WHO and LitCovid were searched using English and Persian keywords including COVID-19, Pediatrics, Newborn, Coronavirus 2019, 2019-nCoV, SARS-CoV-2. Finally, data of 14 related articles were included in the study. Results: A total of 2228 children, newborns and infants were studied. Clinical manifestation in children may be mild (72%), moderate (22%) or severe (6%), and the most common symptoms include dry cough (91%) and fever (96%). According to the included articles, two children had died, one of which was a 14-year-old boy and his exposure history and underlying disease were unclear, and the other was a male newborn with gestational age of 35 weeks and 5 days, birth weight of 2200, Apgar score of 8, 8 (1 min and 5 min) and his first symptom was increased heart rate. No differences were found between male and female children regarding infection with COVID-19. Conclusion: Most pediatrics were infected with COVID-19 due to family cluster or history of close contact. Infected children have relatively milder clinical symptoms compared to infected adults. We should pay special attention to early diagnosis and early treatment in children infected with COVID-19.

Spontaneous retroperitoneal hematoma (SRH) is a rare finding which is usually accompanied with anticoagulant and/or antiplatelet aggregation therapy. We describe a patientwith a rare presentation of SRH andmembranous glomerulonephritis with diffuse visceral arterial micro aneurysms due to medium to small size vasculitis and weakly positive antinuclear antibody (ANA). To the authors’ knowledge, this is a unique report, which does not have any serologic confirmation of specific vasculitis.

Introduction: The role of laboratory parameters in screening of COVID-19 cases has not been definitely established. This study aimed to evaluate the accuracy of laboratory parameters in predicting cases with positive RT-PCR for COVID-19. Methods: This diagnostic accuracy study was conducted on suspected COVID-19 patients, who presented to Behpooyan ClinicMedical center in Tehran (Iran) from 22 February to 14March, 2020. Patients were divided into two groups based on the results of real time reverse transcriptase-polymerase chain reaction (RT-PCR) for COVID-19, and the accuracy of different laboratory parameters in predicting cases with positive RT-PCR was evaluated using area under the ROC curve (AUC). Results: Two hundred cases with the mean age of 41. 3§ 14. 6 (range: 19-78) years were studied (0. 53% male). The result of RT-PCR for COVID-19 was positive in 70 (35%) cases. Patients with positive RT-PCR had significantly higher neutrophil (NEU) count (p = 0. 0001), and C-reactive protein (CRP) (p = 0. 04), lactate dehydrogenase (LDH) (p = 0. 0001), aspartate aminotransferase (AST) (p = 0. 001), alanine aminotransferase (ALT) (p = 0. 0001), and Urea (p = 0. 001) levels in serum. In addition, patients with positive RT-PCR had lower white blood cell (WBC) count (p = 0. 0001) and serum albumin level (p = 0. 0001) compared to others. ALT (AUC = 0. 879), CRP (AUC = 0. 870), NEU (AUC = 0. 858), LDH (AUC = 0. 835), and Urea (AUC = 0. 835) had very good accuracy in predicting cases with positive RT-PCR for COVID-19, respectively. Conclusion: Our findings suggest that level of LDH, CRP, ALT and NEU can be used to predict the result of COVID-19 test. They can help in detection of COVID-19 patients.

Anaphylaxis is a life-threatening systemic allergic hypersensitivity reaction that may potentially be triggered after the administration of any drug. Our case was a 51-year-old man with the history of mild pain in his flanks since the night before he was admitted to our hospital. The patientwas diagnosedwith urolithiasis and admitted to the emergency department. He developed anaphylaxis after intravenous injection of 30 mg ketorolac. Allergic reactions to non-steroidal anti-inflammatory drugs (NSAIDs) such as ketorolac are rare; nonetheless, they can be life-threatening and should be carefully monitored.

COVID-19, in certain respects, can be viewed as a CBRN (chemical, biological, radiological, or nuclear) event due to being a consequence of SARS-CoV2 virus (the “ contaminant” ). We, thus, reorganized our emergency department (ED) into 3 distinct zones (red, yellow, and green) for the purpose of infection control. Patients with high or medium risk of COVID-19 infection are managed in the red zones. Low-risk patients are managed in the yellow zones. All patients are prohibited to enter the green zones. Green zones are used by healthcare providers (HCPs) for personal protective equipment (PPE) donning, inventory, planning, and dining. Only HCPswho work in the red zones are required to use full level PPE (aerosol precaution). HCPs working in the yellow zones require less PPE (contact and droplet precaution). No PPE is required in the green zones. Establishing red, yellow, and green zones in the ED can be helpful in reducing cross-infections and minimizing demand for PPE.

COVID-19 is a novel infectious disease, which has challenged people all around the world. As of today, healthcare practitioners and researchers have made great effort to understand the characteristics and clinical presentations of the disease; however, the existing literature is still incomplete in this regard. A growing body of evidence indicates that coagulopathies and thromboembolic events are of utmost importance in COVID-19 patients and are related to poor prognosis. Here, we report three ICU admitted cases of COVID-19, in which massive pulmonary thromboembolism (PTE) occurred a few days after disease onset. Unfortunately, one of the patients did not survive and two were treated; one with thrombectomy and other with antithrombotic agents. It seems that severe cases of COVID-19 are at risk for developing PTE and in-charge physicians should be prepared and plan for anticoagulant prophylaxis using low-molecular-weight heparin (LMWH).

Coronaviruses, members of Coronaviridae family, cause extensive epidemics of vast diseases like severe acute respiratory syndrome (SARS) and Coronavirus Disease-19 (COVID-19) in animals and humans. Super spread events (SSEs) potentiate early outbreak of the disease and its constant spread in later stages. Viral recombination events within species and across hosts lead to natural selection based on advanced infectivity and resistance. In this review, the importance of containment of SSEs was investigated with emphasis on stopping COVID-19 spread and its socio-economic consequences. A comprehensive search was conducted among literature available in multiple electronic sources to find articles that addressed the "potential role of SSEs on severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) pandemic" and were published before 20th of August 2020. Overall, ninety-eight articles were found eligible and reviewed. Specific screening strategies within potential super spreading host groups can also help to efficiently manage severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) epidemics, in contrast to the partially effective general restriction measures. The effect of SSEs on previous SARS epidemics has been documented in detail. However, the respective potential impact of SSEs on SARS-COV-2 outbreak is composed and presented in the current review, thereby implying the warranted effort required for effective SSE preventive strategies, which may lead to overt global community health benefits. This is crucial for SARS-COV-2 pandemic containment as the vaccine(s) development process will take considerable time to safely establish its potential usefulness for future clinical usage.

Introduction: Currently, the basis of acute coronary syndrome (ACS) therapy is dual antiplatelet therapy (DAPT) with Aspirin as a nonsteroidal anti-inflammatory drug and clopidogrel as adenosine diphosphate receptor antagonists. Therefore, the aim of the present systematic review is to answer that should DAPT with Aspirin and clopidogrel be continued until coronary artery bypass grafting (CABG) in patients who have ACS? Methods: The search for relevant studies in the present meta-analysis is based on three approaches: A) systematic searches in electronic databases, B) manual searches in Google and Google Scholar, and C) screening of bibliography of related original and review articles. The endpoints included mortality rate, myocardial infarction (MI), cerebrovascular accident (CVA), reoperation, re-exploration, other cardiac events, renal failure, length of ICU and hospital stay, chest tube drainage and blood product transfusion after CABG. Results: After the initial screening, 41 articles were studied in detail, and finally the data of 15 studies were included in the meta-analysis. DAPT before CABG in patients with ACS does not increase the rate of mortality, CVA, renal failure, MI, and other cardiac events, but increases reoperation, re-exploration, length of ICU, and hospital stay. Chest tube drainage and blood product transfusion rate significantly increased in the DAPT group compared to the control group (non-antiplatelet or Aspirin alone). Increase in chest tube drainage and blood product transfusion rate indicates an increase in bleeding, so increase in reoperation, re-exploration to control bleeding, and, subsequently, increase in the length of ICU and hospital stay are expected. Conclusion: DAPT with Aspirin and clopidogrel before CABG in patients with ACS does not increase the rate of mortality, CVA, renal failure, MI, and other cardiac events despite more bleedings, and it may be suggested before CABG for better graft patency.

Introduction: Endotracheal suctioning is a method commonly used to clean airway secretions in patients under mechanical ventilation (MV). This study aimed to compare the effects of open and closed suction methods on the occurrence of ventilator associated pneumonia (VAP). Methods: This comparative study was carried out on adult intensive care unit (ICU) patients in need of MV for more than 48 hours, from October 2018 to January 2019. Patients were randomly allocated to either closed tracheal suction system (CTSS) group or open tracheal suction system(OTSS) group. Patientswere monitored for developing VAP within 72 hours of intubation and the findings were compared between groups. Results: 120 cases with the mean age of 57. 91§ 19. 9 years were randomly divided into two groups (56. 7% male). The two groups were similar regarding age (p = 0. 492) and sex (p = 0. 713) distribution. 22 (18. 3%) cases developed VAP (12 (20%) in OSST group and 10 (16. 7%) in CSST; p = 0. 637). The most prevalent bacterial causes of VAP were Acinetobacter_Baumannii (72. 7%), Klebsiella pneumoniae (18. 2%), and Methicillin-Resistant Staphylococcus aureus (9. 1%), respectively. There was not any significant difference between groups regarding the mean duration of remaining under MV (p = 0. 623), mean duration of hospitalization (p = 0. 219), frequency of VAP (p = 0. 637), and mortality (p = 0. 99). Conclusion: It seems that type of endotracheal suction system (OSST vs. CSST) had no effect on occurrence of VAP and other outcomes such as duration of need forMV and ICU stay as well as mortality.

The novel coronavirus is rapidly spreading around the world. Since the public announcement of the COVID-19 outbreak, several concerns have been raised by dermatologists as well as pemphigus patients who take immunosuppressive drugs. In this paper, we review the literature about the common treatment of pemphigus with a focus on the lessons from similar epidemics to find a proper suggestion to manage pemphigus in the COVID-19 pandemic era. The effect of many of the drugs used for treatment of Pemphigus vulgaris (PV) on COVID-19 is not clear. We also do not have data on the impact of this autoimmune disease, which may involve the mucous membranes, on the acquisition or course of COVID-19. We are currently in the midst of a pandemic and evaluating the effect of COVID-19 on the population of susceptible patients suffering from auto-immune diseases like pemphigus is essential. The evidence on best ways to manage patients with underlying conditions, such as pemphigus, during the outbreak of COVID-19 is evolving and the data is updated every day.

Introduction: Osteomyelitis is one of the complications of diabetic foot infection. The present study aimed to evaluate the diagnostic value of erythrocyte sedimentation rate (ESR) and C reactive protein (CRP) in detection of osteomyelitis in patients with diabetic foot. Methods: In this cross-sectional study, serum levels of ESR and CRP were measured for patients with diabetic foot referring to emergency department or endocrinology clinic and the screening performance characteristics of these markers in detection of osteomyelitis were calculated. The diagnosis of osteomyelitis was based on clinical examination and positive probe-to-bone test, which was confirmed by plain x-rays or MRI. Results: 142 diabetic patients with an average age of 61. 2 § 11. 8 years were evaluated (66. 2% male). The area under the ROC curve of ESR in detection of osteomyelitis in diabetic foot cases was 0. 70 (95% CI: 0. 62-0. 79). The best ESR cut-off point in this regard was 49 mm/hour. Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios of ESR in 49 mm/Hour cut-point were 74. 6% (95% CI: 62. 9-83. 9), 57. 7% (95% CI: 45. 5-69. 2), 63. 9% (95% CI: 52. 5-73. 9), 69. 5% (95% CI: 56. 0-80. 0), 1. 8 (95% CI: 1. 3-2. 4) and 0. 4 (95% CI: 0. 3-0. 7), respectively. The area under the ROC curve of CRP in detection of osteomyelitis was 0. 67 (95% CI: 0. 58-0. 76). The best cut-off point for CRP in this regard was 35 mg/liter with sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios of 76% (95% CI: 64. 2-85), 54. 9% (95% CI: 42. 7-66. 6), 62. 8% (95% CI: 51. 6-72. 8), 69. 6% (95% CI: 51. 7-80. 8), 1. 7 (95% CI, 1. 3-2. 2), and 0. 4 (95% CI: 0. 3-0. 7), respectively. Conclusion: Based on the findings of ROC curve analysis, ESR and CRP had fair and poor accuracy, respectively, in detecting the diabetic foot cases with osteomyelitis.

COronaVIrus Disease 2019 (COVID-19) is an on-going pandemic attributed to a novel virus named SARS-CoV-2. Comparing the statistics of incidence and death rates between nations reveals that there is discrepancy amongst countries in these regards, even between countries that share borders. We herein present information from the literature indicating how cross-protection against COVID-19 conferred by the encephalitis vaccine could be the reason for lower fatality rate in the countrieswhere immunization against encephalitis is widespread or included in national programs. This may pave the way for arriving at efficient prevention strategies as well as vaccine development.

Penetrating orbital trauma (POT) consists of high and low velocity penetrating injuries that may lead to severe consequences such as visual impairment and globe tearing. It has been reported to make up 30% to 50% of all orbital injuries. POT requires a multidisciplinary approach due to complex orbital injury, which involves eye function, brain injury, and facial aesthetics. In this report, we presented a case of POT due to knife injury in which the knife blade was removed and bleeding was controlled, the patient’ s general condition after surgery was good, but the vision of the right eye was lost.

Introduction: Creatine phosphokinase (CPK) is an intracellular enzyme found in higher levels in the brain, myocardium, soft muscle and skeletal muscle, as well as the fallopian tube. This review was conducted to evaluate the role of serum CPK in early diagnosis of tubal ectopic pregnancy (EP). Methods: We performed an electronic literature search inWeb of Science, Scopus, Embase andMedline databases and manual search in Google scholar and evaluated papers fromthe beginning of 1990 to September 2018. The inclusion criteria consisted of cohort, case-control and diagnostic value studies in English or Persian. Two independent researchers used the inclusion and exclusion criteria. In cases where there was doubt about the eligibility of studies, this problem was resolved by consulting a third researcher. After a thorough search, finally, we found 27 papers. However, four of these articles did not have the inclusion criteria and we excluded them from the study. As a result, 24 studies were evaluated. Results: Most studies have approved the use of CPK measurements in EP diagnosis. The main variablemeasured in most studies was the mean total CPK level. However, there is limited knowledge about the efficacy of measuring CPK levels in EP diagnosis; this review of studies shows positive results regarding use of CPK in EP diagnosis. Conclusions: The results highlighted the potential benefits of CPK as a marker for early diagnosis of EP.

Introduction: Few studies have described their experience using esmolol, an ultra-short acting Î š-adrenergic antagonist, in the emergency department (ED) as a feasible adjuvant therapy for the treatment of refractory ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) out-of-hospital cardiac arrest. However, there is currently insufficient evidence to support the widespread implementation of this therapy. The aim of this scoping review was to summarize the current available evidence on the use of esmolol as an adjuvant therapy for refractory VF/pVT out-of-hospital cardiac arrest, as well as to identify gaps within the literature that may require further research. Methods: We conducted a comprehensive literature search of MEDLINE via PubMed, Embase, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) on July 5, 2019. The search was restricted to articles that were published from January 2000 to July 2019. Google Scholar was searched and reference lists of relevant papers were examined to identify additional studies. We included any controlled clinical study design (randomized controlled trials and non-randomized controlled trials) and observational studies (cohort studies and case-control studies) in adults providing information on the use of esmolol as an adjuvant therapy for refractory VF/pVT out-of-hospital cardiac arrest. Results: The search yielded 2817 unique records, out of which 2 peer-reviewed articles were found relating to the research purpose totaling 66 patients 33. 3% (n = 22) of which received esmolol. These studies found that sustained return of spontaneous circulation (ROSC) was significantly more common in the patients that received esmolol compared to the control group. However, no statistically significant outcomes were found regarding survival to discharge and favorable neurological outcome. No randomized controlled trials were identified. Conclusion: To date, it is difficult to conclude the real benefit of esmolol as an adjuvant therapy for refractory VF/pVT out-of-hospital cardiac arrest based on the available evidence. The findings of this scoping review suggest that there is a paucity of research and limited evidence to support this therapy.

Introduction: The value of thoracic injury rule out criteria (TIRC) as a tool for decreasing the number of unnecessary chest radiographs in children has not been evaluated yet. Therefore, the present study was designed as a multi-center study to assess the validity of TIRC model in detection of very low risk children for traumatic intrathoracic injuries. Methods: In this diagnostic accuracy study, clinical data and chest radiographs of 974 children less than 18 years of age (72. 0% boys) who had presented to 5 hospitals, in Iran in 2018 were assessed. Data gathering and interpretation of radiographs were done by two independent researchers in each hospital. In the end, discriminatory power and calibration of the model was assessed with a 95% confidence interval (95% Cl). Results: In the present study, age was not a predicting factor of abnormal findings in radiographs of children and adolescents (p=0. 75); therefore, it was omitted from TIRC model and pediatric TIRC (pTIRC) was designed. Area under the curve of pTIRC rule was 0. 97 (95% CI: 0. 96-0. 98) for prediction of abnormal chest XRay in children and adolescents. The sensitivity and specificity of pTIRC was 100% and 90. 1%, respectively. The calibration of this decision rule had great concordance with the perfect line with a slope of 0. 99 and intercept of 0. 001. There was a 90. 1%reduction in the number of unnecessary chest radiographs when using pTIRC decision rule. Conclusion: pTIRC decision rule was introduced in the present study. pTIRC has excellent performance in identification of traumatic intrathoracic injuries and decreasing the number of unnecessary chest radiographs.

Introduction: There is an increasing interest in the use of different biomarkers to help distinguish psychogenic non-epileptic seizure (PNES) fromepileptic seizures (ES). This study aimed to evaluate the patterns of differentially expressed serum proteins in ES and PNES cases. Methods: In this cross-sectional study, 4 patients with mesial temporal lobe epilepsy and 4 patients with PNES were selected from patients with history of recurrent seizures. Venous blood samples were obtained within 1 hour after seizure and serum proteomes as well as the extent of protein expression were analyzed. Results: 361 proteins were identified; of these, expression of 197 proteins had altered. 110 (55. 9%) proteins were down-regulated and 87 (44. 1%) were up-regulated in the PNES samples compared to ES samples. The mean pI for deregulated proteins with 1. 5 to 3 fold changes were 6. 69 § 1. 68 in proteins with increasing expression in ES group and 5. 88 § 1. 39 in proteins with increasing expression in PNES group (p = 0. 008). The median and interquartile range (IQR) of molecular weight changes in proteins with 1. 5 to 3 fold changes were 64 (22. 0-86. 0) in proteins whose expression had increased in ES group and 39. 5 (26. 0-61. 5) in proteins whose expression had increased in PNES cases (p = 0. 05). Conclusion: Several spots with differential expression were observed by comparing patients with ES against the PNES groups, which could be potential biomarkers of the disease. Damage to the blood-brain barrier is the most important difference between the two groups, thus identifying total protein changes offers a key to the future of differentiating ES and PNES patients.

Introduction: Predicting the outcomes of COVID-19 cases using different clinical, laboratory, and imaging parameters is one of themost 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. Therewas 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 lowermortality.

Introduction: Renal colic affects 12% of the U. S. population, accounting for nearly 1% of emergency department (ED) visits. Current recommendations advocate narcotic-limiting multimodal analgesia regimens. The objective of this review is to determine if in patients with renal colic (Population), intravenous (IV) amide anesthetics (Intervention) result in better pain control, lower requirements for rescue analgesia, or less adverse medication effects (outcome) compared to placebo, non-steroidal anti-inflammatory drugs (NSAIDs), or opiates (Comparisons). Methods: Scholarly databases and relevant bibliographies were searched using a pre-designed systematic review protocol and registered with PROSPERO. Inclusion criteria were: (1) randomized clinical trial (RCT), (2) age ¸ 18 years, (3) confirmed or presumed renal colic, (4) amide anesthetic administered IV. Eligible comparison groups included: placebo, conventional therapy, acetaminophen, NSAID, or opiate. The primary outcome was pain intensity at baseline, 30, 60, and 120 minutes. Trial quality was graded, and risk-of-bias was assessed. Results: Of the 3930 identified references, 4 RCTs (479 participants) were included. One trial (n=240) reported improved analgesia with IV lidocaine (LidoIV) plus metoclopramide, compared to morphine. All other trials reported unchanged or less analgesia compared to placebo, ketorolac, or fentanyl. Very severe heterogeneity (I2= 88%) precluded pooling data. Conclusion: Current evidence precludes drawing a firm conclusion on the efficacy or superiority of LidoIV over traditional therapies for ED patients with renal colic. Evidence suggests LidoIV may be an effective non-opiate analgesic alliterative; however, it’ s efficacy may not exceed that of NSAIDs or opiates. Further study is needed to validate the potential improved efficacy of LidoIV plus metoclopramide.

Dear Editor On 31 December 2019, Chinese authorities reported the increase in incidence of severe pneumonia in Wuhan city, Hubei province of China. One week later, on January 7th, they confirmed that they had identified a new coronavirus, which is a family of microRNA respiratory viruses including the common cold, and viruses such as Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS). This new virus was temporarily named "2019-nCoV". Wuhan city is a major international transport hub. This report toWorldHealth Organization (WHO), raised global public health concern because this is the third coronavirus â ˘ A¸ Sassociated acute respiratory illness outbreak...

Introduction: Management of pain is an important part of care in the emergency department (ED). Tramadol and Ketamine have both been introduced as alternatives to opioids in the ED and post-operative setting. In this study, we conducted a systematic review of available literature to compare the analgesic efficacy, and side effect profile of these two medications in management of severe acute pain. Methods: This is a systematic review based on the PRISMA protocol. In this study, peer-reviewed papers published by March 3, 2020, which compared analgesic effects of tramadol and ketamine inmanagement of acute pain were included. Results: The initial search of online databases identified 2826 non-duplicate records. Finally, three papers available in full text were analyzed for study quality. The results show that ketamine has consistently been shown to be superior to tramadol for pain control and causes fewer significant side effects. Conclusion: Results of this review show that low-dose ketamine is more effective than tramadol in pain control, while causing fewer side effects.

Introduction: Given the importance of evidence-based decision-making, this study aimed to evaluate epidemiological and clinical characteristics as well as associate factors of mortality among admitted COVID-19 cases. Methods: This multicenter, cross-sectional study was conducted on confirmed and suspected COVID-19 cases who were hospitalized in 19 public hospitals affiliated to Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran, between February 19 and May 12, 2020. Epidemiological and clinical characteristics of the infected cases were compared between the deceased and survivors after discharge. Case fatality rates (CFRs) were calculated across all study variables. Single and multiple logistic regressions were used to explore the risk factors associated with COIVD-19 mortality. Results: Out of the 16035 cases that referred to the hospitals affiliated to SBMU, 16016 patients (99. 93% of Confirmed and 99. 83% of suspected cases) were hospitalized. 1612 patients died with median hospitalization days of 5 (interquartile range (IQR): 2-9) and 3 (1-7) for confirmed and suspected COVID-19 cases, respectively. The highest death rate was observed among ages>65 (63. 4% of confirmed cases, 62. 3% of suspected cases) and intensive care unit (ICU)/critical care unit (CCU) patients (62. 7% of confirmed cases, 52. 2% of suspected cases). Total case fatality rate (CFR) was 10. 05% (13. 52% and 6. 37% among confirmed and suspected cases, respectively). The highest total CFR was observed in patients with age>65 years (25. 32%), underlying comorbidities (25. 55%), and ICU/CCU patients (41. 7%). The highest CFR was reported for patients who had diabetes and cardiovascular diseases (38. 46%) as underlying non-communicable diseases (NCDs), and patients with cancer (35. 79%). Conclusion: This study showed a high CFR among suspected and confirmed COVID-19 cases, and highlighted the main associated risk factors including age, sex, underlying NCDs, and ICU/CCU admission affecting survival of COVID-19 patients.

Introduction: Many scoring systems have been developed to assist in diagnosis of acute appendicitis (AA). This study aimed to compare the screening performance characteristics of Alvarado, Eskelinen, Ohmann, Raja Isteri Pengiran Anak Saleha (RIPASA), and Tzanakis scores in predicting the need for appendectomy in AA patients. Methods: Our study prospectively evaluated AA patients that were treated in a tertiary hospital’ s emergency department. The obtained data were used to calculate Alvarado, Tzanakis, RIPASA, Eskelinen and Ohmann scores. Patients were categorized into two groups according to their histopathological results: positive (PA) and negative appendectomy (NA). The accuracy of different scoring systems in diagnosing AA was investigated. Results: 74 patients suspected to AA with the mean age of 36. 68 § 11. 97 years were studied (56. 8% male). The diagnosis was histopathologically confirmed in 65 cases (87. 8%). Median Alvarado, Tzanakis, RIPASA, Eskelinen and Ohmann scores were significantly higher in patients with positive appendectomy. The area under the curve (AUC), sensitivity, and specificity of Tzanakis score in the cut-off value of 8 were 0. 965, 84. 4%, and 100%, respectively. For Ohmann and Alvarado scores, these measures were 0. 941; 71. 9%, 89. 9% and 0. 938, 60. 9%, 89. 9%, respectively. Tzanakis scoring system had the best screening performance in detection of cases with AA. Conclusion: Tzanakis score is more sensitive and specific than Alvarado, RIPASA, Eskelinen and Ohmann scores in identifying AA patients needing appendectomy.

Introduction: Studies have shown that naloxone can cause behavioral changes in naive normal volunteers. This study aimed to investigate the possible complications of naloxone in methadone-overdosed opioid-naive patients. Methods: In this pilot study, a total number of 20 opioid-naive methadone-poisoned patients underwent naloxone challenge test to receive naltrexone. 0. 2, 0. 6, and 1. 2 mg doses of naloxone were administered on minutes 0, 5, and 15-20. The patients were followed for 30 minutes after administration of naloxone and monitored for any upsetting signs and symptoms. Patients with clinical opiate withdrawal scale (COWS) lower than 5 were considered not addicted and the severity of patients’ symptoms was calculated using subjective opiate withdrawal syndrome (SOWS). Results: 20 patients with mean age of 25. 5§ 8. 09 years were evaluated (70% female). Median ingested dose of methadone was 25 mg [IQR; 10 to 50 mg] and mean time interval between ingestion of methadone and naloxone challenge test was 7. 1§ 4. 9 hours. Fourteen patients reported some discomfort after administration of a mean dose of 1. 7§ 0. 5 mg of naloxone lasting for a maximum of four hours. The most common patients’ complaints were headache (45%) followed by nausea (20%), agitation (20%), abdominal pain (20%), and flushing (20%). Two (10%) mentioned severe panic attack and sensation of near-coming death. SOWS significantly correlated with female gender (p = 0. 004) and time elapsed post methadone ingestion (p = 0. 001). Conclusion: It seems that naloxone is not a completely safe medication even in opioid-naive patients, and administrating adjusted doses of naloxone even in opioid-naive methadone intoxicated patientsmay be logical.

In wake of the current COVID-19 pandemic, which has taken the world by storm, it is imperative to protect the health and safety of physicians and staff involved in acute management of COVID-19 patients. Numerous studies have been published, establishing evidence and opinion-based guides for emergency physicians, who are at the front line. Although many have established pathways for dealing with patient screening, testing, prognosis and disposition, I would like to discuss the management of the crashing patients in need of ventilation who we ought to be prepared for the most...

We are currently involved in the novel coronavirus 2019 (COVID-19) pandemic. A considerable number of COVID-19 infected cases are asymptomatic but they can transmit the disease to others, especially healthcare workers. In this study, we reported 8 incidentally detected cases of COVID-19 pneumonia in chest computed tomography (CT) scan of patients referred to emergency department following multiple trauma without any respiratory symptoms.

Introduction: Much attention has been paid to the association between valproic acid treatment and bone health. The objective of this study is to compare the serum vitamin D3 level in the epileptic children under valproic acid treatment with the healthy control group. Methods: A case-control study has been carried out to compare vitamin D3 levels in 50 epileptic children who were treated with valproic acid with 50 healthy children selected from children visiting the hospital for routine checkup as control group. Results: 100 cases with themean age of 7. 57§ 3. 62 years (range: 2 – 15 years) were studied (44% boys). Among the 50 epileptic cases; 41 (82%) had generalized and 9 (18%) had partial seizure (56% well controlled and 44%poorly controlled). 15 (30%) of epileptic cases were using anti-epileptic drugs for 6-12 months, 36% for 12-24 months, and 34% for more than 24 months. The case and control groups were similar regarding gender (p =0. 99), age (p = 0. 24), and BMI (p = 0. 64). 49 (49%) patients had some grade of vitamin D3 deficiency. There was a significant difference between case and control groups regarding vitamin D3 levels (p = 0. 001). None of the controls had severe vitaminD3 deficiency, while 14% of cases did. 36 (72%) individuals in control group had sufficient or optimal vitamin D3 levels; while only 15 (30%) case patients had such levels. Generally, the control group had higher vitamin D3 levels in comparison to case group (p = 0. 001). Conclusion: The study revealed that there was a higher prevalence of vitamin D3 insufficiency in epileptic children receiving valproate monotherapy compared with healthy children. Vitamin D3 supplementation should be given to all epileptic children even before initiation of anti-epileptic drugs.

1. Introduction By the beginning of COVID-19 crisis in China in late 2019, and its spread throughout the world in early 2020, countries around the world experienced numerous problems (1). The outbreak of the new Coronavirus started in Wuhan, and this third epidemic of Coronaviruses expanded to the middle east promptly. . Therefore, theWorldHealth Organization (WHO) expressed its concerns about the Coronavirus crisis (2). This crisis caused production and publication of large amounts of valid and invalid information, eventually leading to information obesity phenomenon. Information obesity can have many negative consequences on the general population, causing major problems for governments, especially if the amount of invalid information is too large. It is worth to mention that however almost impossible, controlling and monitoring media is a massive challenge for different governments. Hence, individuals should protect themselves against unreliable information, and pursue an authentic "information diet". In the present study, authors have explained and interpreted the concept of the information diet, proposed by Johnson, based on scientific evidence, observation of media news and the social media environment, to help maintain the use of valid information in facing the new Coronavirus crisis...

SARS-CoV-2 virus causes a pneumonia that was identified through fever, dyspnea, and acute respiratory symptoms and named COVID-19. This disease exacerbates in a number of patients and causes pulmonary edema, multi-organ failure, and acute respiratory distress syndrome (ARDS). Prevalence of ARDS among COVID-19 patients has been reported to be up to 17%. Among the introduced treatment methods for management of ARDS patients, prone position can be used as an adjuvant therapy for improving ventilation in these patients. Here we reviewed the literature regarding the role of prone position inmanagement of COVID-19 patients.

Introduction: External hemorrhage is a leading cause of preventable death due to trauma and EmergencyMedical Services (EMS) staff members play a vital role in the frontline of trauma management. This study aimed to assess the knowledge, attitude and practice of EMS staff in bleeding control. Methods: This knowledge, attitude and practice (KAP) study was conducted to assess the educational needs of EMS staff of Hormozgan province, Iran, regarding the bleeding control of trauma patients, during 2019. The participants were randomly selected and then their knowledge, attitude, and practice in management of hemorrhage and hemorrhagic shock were assessed using two researcher-made scenario-based questionnaires and one checklist. Results: The scores for knowledge of the EMS staff regarding actions during complete amputation, status of injured patients, and medicalmeasures during transfer of injured patients were 3. 22 § 0. 68, 2. 28 § 0. 83, and 2. 29 § 0. 62, respectively. The average participants’ attitude scores regarding the fear of bleeding, the importance of bleeding control, and confidence in bleeding control were 2. 09§ 0. 56, 2. 4§ 0. 58, and 1. 76§ 0. 55, respectively. The findings indicated that mean practice score was 1. 72 § 0. 46 in capillary hemorrhage control, 1. 41 § 0. 25 in venous bleeding control, 1. 47 § 0. 25 in arterial bleeding control, and 1. 56§ 0. 27 in control of bleeding in the amputee limb. Conclusion: The knowledge, attitude, and practice of EMS staff regarding bleeding control were moderate, positive and appropriate, and incomplete, respectively. Since bleeding is a life threatening status and EMS staff skills are critical in this issue, it seems that we need to provide continuous education in this regard.

Introduction: It seems that magnesium (Mg) sulfate can be helpful in controlling the acute pain caused by the stone passing from the ureter by reducing ureter smooth muscle contractions. The present study has been designed with the aim of assessing the role ofMg sulfate in controlling the renal colic pain in emergency department (ED). Methods: This double blind randomized clinical trial was performed on 18 to 60 year-old patients with acute renal colic presenting to the ED of a teaching hospital during 1 year. Patients were allocated to one of the 2 groups receiving either IV morphine or IVMg sulfate using block randomizationmethod and were then compared regarding pain control characteristics and probable side effects. Results: 90 patients with the mean age of 37. 34 § 12. 10 (18 – 60) years were divided into 2 equal groups. The 2 groups were in a similar condition regarding mean age (p = 0. 168), sex distribution (p = 0. 267), underlying disease (p = 0. 414) and alcohol and drug abuse (p = 0. 524). Mean pain scores of the patients based on VAS were not significantly different between the 2 groups on admission and 20, 30, 60, 120, and 180 minutes after drug administration. Success rate in reducing the pain by at least 3 points on VAS was equal and 91. 1% for both groups on the 20t h minute and reached 100% on the 30t h minute for both groups. The number of cases that were pain-free on the 20t h minute was significantly higher in the morphine groups (31 versus 16 patients, p = 0. 004). However, on the 30t h minute both groups experienced a similar condition in this regard (39 versus 29, p = 0. 063). None of the patients in the 2 groups experienced the studied side effects. Conclusion: It seems that Mg sulfate, as a muscle relaxant agent, can be considered as a safe adjunct medication in controlling the pain of renal colic patients in the ED.

Introduction: Computed tomography (CT) imaging has quickly found its place as a beneficial tool in the detection of coronavirus disease 2019 (COVID-19). To date, only a few studies have reported the distribution of lung lesions by segment. This study aimed to evaluate the lobar and segmental distribution of COVID-19 pneumonia based on patients’ chest CT scan. Methods: This was a retrospective study performed on 63 Iranian adult patients with a final diagnosis of COVID-19. All patients had undergone chest CT scan on admission. Demographic data and imaging profile, including segmental distribution, were evaluated. Moreover, a scoring scale was designed to assess the severity of ground-glass opacification (GGO). The relationship of GGO score with age, sex, and symptoms at presentation was investigated. Results: Among included patients, mean age of patients was 54. 2 § 14. 9 (range: 26-81) years old and 60. 3% were male. Overall, the right lower lobe (87. 3%) and the left lower lobe (85. 7%) were more frequently involved. Specifically, predominant involvement was seen in the posterior segment of the left lower lobe (82. 5%). The most common findings were peripheral GGO and consolidation, which were observed in 92. 1% and 42. 9% of patients, respectively. According to the self-designed GGO scoring scale, about half of the patients presented with mild GGO on admission. GGO score was found to be equally distributed among different sex and age categories; however, the presence of dyspnea on admission was significantly associated with a higher GGO score (p= 0. 022). Cavitation, reticulation, calcification, bronchiectasis, tree-in-bud appearance and nodules were not identified in any of the cases. Conclusion: COVID-19 mainly affects the lower lobes of the lungs. GGO and consolidation in the lung periphery is the imaging hallmark in patients with COVID-19 infection. Absence of bronchiectasis, solitary nodules, cavitation, calcifications, treein-bud appearance, and reversed halo-sign indicates that these features are not common findings, at least in the earlier stages.

Introduction: Critically ill and injured patients are at a higher risk of developing clinical deterioration during inter-facility transfers. This study aimed to determine the incidence rate and risk factors of clinical deterioration among critically ill patients during inter-facility transfers in Thailand. Methods: The present cohort study was conducted in 22 referring hospitals and 7 receiving hospitals under the supervision ofMinistry of Public Health, Thailand, between March 15 and December 31, 2018. The subjects were comprised of 839 critically ill patients aged 18 and over, 63 coordinator nurses in referral centers, and 312 referral team leaders. Data collected included pre-transfer risk score, clinical data of patient during transfer, characteristics of referral team leader, ambulance type, preparation time, time to definitive care, transfer distance, andNational EarlyWarning Score (NEWS) (clinical deterioration). Multilevel mixed-effects regression analysis was performed. Results: The incidence rate of clinical deteriorationwas 28. 69%. Themost common types of clinical deteriorationwere hemodynamic instability, respiratory instability, and neurological alteration. Time between 31-45 minutes was significantly associated with clinical deterioration (¯ 0. 133, P value 0. 027). The following illnesses were associated with higher probability of clinical deterioration: body region injuries/head injury/burn/ingested poison (¯ 0. 670, P value 0. 030), respiratory distress/convulsion (¯ 0. 919, P value 0. 001), shock/ arrhythmias/chest pain/hemorrhage (¯ 1. 134, P value <0. 001), comatose/alteration of consciousness/syncope (¯ 1. 343, P value <0. 001), and post-cardiac arrest (¯ 2. 251, P value <0. 001). Patients with unstable conditions (¯ 1. 689, P value 0. 001) and pre-transfer risk score of 8 or higher (¯ 0. 625, P value 0. 001) had a higher rate of deterioration. Transfer by non-emergency room (ER) nurses (¯ 0. 495, P value 0. 008) and transportation in a mobile intensive care unit (ICU) were associated with a higher rate of deterioration (¯ 0. 848, P value 0. 001). Conclusion: The incidence of clinical deterioration during inter-facility transfer in Thailand was high. Illnesses involving circulatory, respiratory, and neurological systems, clinical instability, high pre-transfer risk score, transport time of 31-45 minutes, transportation by non-ER nurse, and mobile ICU were associated with a higher rate of clinical deterioration.

Dear Editor, The novel coronavirus disease (COVID-19) has rapidly spread across the world and caused a pandemic, and still continues to evolve. In Iran, the first cases of COVID-19 were officially announced between February 19 and 23, 2020 and it soon became clear that Iran is one of the countries that is worst-hit by COVID-19 outbreak (1, 2)...

Psychogenic non-epileptic seizures (PNES) are paroxysmal changes that mimic epileptic seizures, so oftenmisdiagnosed and treated for epilepsy. PNES are considered a psychiatric illness, personality pathology, and experiential and behavioral manifestation of depression. Despite studies over the past two decades, the pathological mechanisms of this disorder are unclear. In this paper, we critically review the current literature about the definition, epidemiology, diagnosis, treatment, related genes, and biomarkers of PNES and provide suggestions for future research. Further studies are needed for more information and knowledge on PNES to determine the appropriate psychotherapies and development of clear treatment guidelines.

Introduction: There is still controversy over the value of renal angina index (RAI) in predicting acute renal failure (AKI) in children. Therefore, the present study aims to provide evidence by conducting a systematic review and meta-analysis on the value of RAI in this regard. Methods: An extensive search of Medline, Embase, Scopus and Web of Science databases was conducted by the end of January 2020 using words related to RAI and AKI. Two independent reviewers screened and summarized the related studies. Data were analysed using STATA 14. 0 statistical program and discriminatory precision of RAI was assessed. Results: Data from 11 studies were included. These studies included data from 3701 children (60. 41% boys). There were 752 children with AKI and 2949 non-AKI children. Pooled analysis showed that the area under the ROC curve of RAI in prediction of AKI was 0. 88 [95% confidence interval (CI): 0. 85 to 0. 91]. Sensitivity and specificity of this tool in predicting AKI were 0. 85% (95% CI: 0. 74% to 0. 92%) and 0. 79% (95% CI: 0. 69% to 0. 89%), respectively. The diagnostic odds ratio of RAI was 20. 40 (95% CI: 9. 62 to 43. 25). Conclusion: The findings of the present meta-analysis showed that RAI is a reliable tool in predicting AKI in children.