Frontiers in Emergency Medicine
Year:2020 | Volume:4 | Issue:2|Papers Count:20

INTRODUCTION In the previous educational articles, we explained how to calculate the sample size for a rate or a single proportion, for an independent cohort study, for an independent case-control study, for a diagnostic test accuracy study, for a superiority clinical trial, and for a non-inferiority or equivalence clinical trial (1-6). In this article, we will explain how to calculate the sample size for a clinical study with the aim of detecting the correlation coefficient between two variables....

Introduction: Globally, stroke is one of the leading causes of death and disability-adjusted life-years (DALYs). The red cell distribution width (RDW) is a readily available and inexpensive test which is done routinely as a part of complete blood count in these patients. Objective: In this study, we tried to correlate the RDW with severity of acute ischemic stroke (AIS). Methods: Patients presenting to emergency department (ED) within 24 hours of the onset of clinical signs and symptoms suggestive of AIS were assessed for Glasgow Coma Scale (GCS) and National Institutes of Health Stroke Scale (NIHSS) score followed by non-contrast computed tomography (NCCT) scan. RDW value for all the patients who were included in the study were co-related with the severity of the stroke. Results: The median (IQR) RDW in the patients with minor stroke on the basis of GCS was 13. 5 (13. 3-13. 5), moderate stroke was 13. 8 (13. 5-14. 4) and with severe stroke was 15. 4 (15. 1-15. 6) (p < 0. 001). The median (IQR) RDW in the patients with minor stroke on the basis of NIHSS score was 13. 4 (13. 2 – 13. 6), moderate stroke was 13. 8 (13. 5-14. 3), and moderate to severe stroke was 14. 7 (14. 5-15. 3) and with severe stroke was 15. 5 (15. 1-15. 7) (p < 0. 001). The median RDW in patients who were alive was 13. 8 (13. 5-15. 1) and in patients who expired was 15. 5 (14. 5-15. 7) (p = 0. 048). Conclusion: Based on the findings of this study, RDW index has statistically significant correlation with the severity of AIS. So it can potentially be an important parameter to predict the prognosis of AIS patients.

Context: Pediatric traumatic spinal cord injury (SCI) is an uncommon presentation in the emergency department. Severe injuries are associated with devastating outcomes and complications, resulting in high costs to both the society and the economic system. Evidence acquisition: The data on pediatric traumatic spinal cord injuries has been narratively reviewed. Results: Pediatric SCI is a life-threatening emergency leading to serious outcomes and high mortality in children if not managed promptly. Pediatric SCI can impose many challenges to neurosurgeons and caregivers because of the lack of large studies with high evidence level and specific guidelines in terms of diagnosis, initial management and of in-hospital treatment options. Several novel potential treatment options for SCI have been developed and are currently under investigation. However, research studies into this field have been limited by the ethical and methodological challenges. Conclusion: Future research is needed to investigate the safety and efficacy of the recent uprising neurodegenerative techniques in SCI population. Owing to the current limitations, there is a need to develop novel trial methodologies that can overcome the current methodological and ethical limitations.

Introduction: Acute appendicitis is the most common cause of the abdominal pain in surgery. Despite its significant prevalence, the diagnosis is associated with many problems in some cases, which leads to false appendectomy. Objective: The aim of this study was to determine the validity of diagnostic tests of mean platelet volume (MPV) and red cell distribution width (RDW), as a new possible tool in the diagnosis of acute appendicitis. Methods: In this study, all patients who referred to the emergency department of Besat Hospital, Hamadan, Iran, in 2015, with abdominal pain and first impression of acute appendicitis, undergone appendectomy, were evaluated. The diagnostic markers of pre-operative and post-operative pathology and the validity of MPV and RDW were determined in diagnosis of acute appendicitis. Results: Laboratory and clinical data from 438 patients, presenting the signs and symptoms of acute appendicitis with the mean age of 26. 51± 13. 9 years, were examined (55. 6% men). The sensitivity, specificity, positive and negative predictive value of MPV in the diagnosis of acute appendicitis were 59. 77, 98. 66, 99. 5 and 34. 26 percent, and for the RDW were 57. 79, 56. 00, 86. 07 and 21. 98 percent, respectively. The area under the receiver operating characteristic (ROC) curve for RDW and MPV was 0. 61and 0. 90, respectively. The mean of MPV in patients with normal pathologic outcome was 9. 52± 1. 60 and in patients with acute appendicitis was 7. 51± 1. 22. There was a significant difference between the mean MPV in both groups (p<0. 001). The mean of RDW in patients with normal pathology were 13. 42± 1. 97 and 13. 05± 1. 09, in patients with acute appendicitis. There was a significant difference between the mean RDW of the two groups (p=0. 009). Conclusion: MPV and RDW indexes have the potential to be used by the surgeons in diagnosis of acute and perforated appendicitis, especially in adults, in order to reduce unnecessary appendectomy, but MPV is more valid in screening acute appendicitis, compared to the RDW.

Introduction: Pregnancy-associated plasma protein-A (PAPP-A) is a metalloproteinase that plays a role in atherosclerotic plaque destabilization. In recent studies, insulin-like growth factor-1 (IGF-1) has been introduced as a mediator of atherosclerosis. PAPP-A and IGF-1 level may be important diagnostic indicators of acute coronary syndrome (ACS). Objective: The present study tried to assess the diagnostic role of IGF-1 and PAPP-A biomarkers in ACS spectrum. Methods: The serum level of IGF-1, PAPP-A and troponin I was determined in 121 consecutive patients with ACS. Relationships were assessed by t-test, ANOVA and the non-parametric equivalent. Accuracy of biomarkers was measured by the area under the ROC curve (AUC) and optimal cut-off points to diagnose STEMI and NSTEMI using Youden index. Results: In patients with acute ST segment elevation myocardial infarction (STEMI), all of these three biomarkers were significantly higher than those in patients with unstable angina (P= 0. 028 for IGF-1, P<0. 001 for PAPP-A and Troponin-I). Mean level of IGF-1 in patients with renal failure was significantly higher than that in patients without renal failure (137. 9± 35. 1 vs 105. 1± 46. 9, P=0. 003), but PAPP-A and serum Troponin-I level had no significant difference in renal failure groups (P>0. 05). ROC curve analysis showed that after Troponin-I, PAPP-A was a good discriminator between patients with STEMI and patients with unstable angina (AUC=0. 79). Optimum cut-off value for PAPP-A was found to be 89. 2 ng/ml, with sensitivity and specificity of 66. 7% and 83. 8%, respectively. Conclusion: PAPP-A can be a novel biomarker for both identification of patients with STEMI and risk stratification in patients with ACS.

Context: Acute abdominal pain is one of the most common complaints of patients admitted to emergency units. This study aimed to propose a new approach to abdominal pain by designing a more structured diagnostic workup for physicians. Evidence acquisition: A comprehensive review of relevant articles and algorithms presented in books and websites was conducted. Approaches which were relevant to the study concept, were selected. Results: Seven algorithms were introduced with respect to the site of abdominal tenderness. The mainstay of these algorithms was differential diagnosis of the tenderness site. Conclusion: Based on the findings, the designed approach can prevent confusion among physicians and reduce requests for many unnecessary paraclinical tests, which delay the final diagnosis and impose unacceptable costs on patients and healthcare systems.

Introduction: In the background of the increased suicide rate in the second decade of life, analysis of the characteristics of poisoning-related attempted suicide in adolescents and evaluation of the differences from adults may form an important basis for establishing measures to prevent deaths from poisoning. Objective: We aimed to investigate the types of toxic substances ingested for attempted suicide by poisoning in adolescents admitted to the emergency department (ED). Method: This cross-sectional study retrospectively analyzed and investigated the medical records of patients aged 13 or older, admitted to the ED of a tertiary medical institute over a period of 3 years, for attempted suicide by poisoning. Results: The psychiatric diagnoses among patients in the adolescent group included depression (75. 8%), bipolar disorder (12. 5%), and panic disorder (12. 5%). In terms of the type of drug used for poisoning, antidepressants or anti-psychotics and sleeping pills were the most commonly used in the adolescent (43 subjects, 45. 2%) and adult (286 subjects, 37. 6%) groups, respectively. Conclusion: As there is a higher chance of poisoning by easily accessible drugs, the emergency physician needs to investigate any preceding diagnoses of psychiatric or medical illnesses in the adolescent patients attempting suicide with unknown drugs.

Introduction: Resilient schools can warranty students’ health and survival at disasters. It is obligatory that schools be prepared for natural challenges through local programs. Considering the great population of students, disaster-resilient schools can be a safe and suitable environment for students at the time of disaster. Objective: This study aims to identify certain operational strategies for establishing schools resilient to natural disasters. Method: This qualitative study was based on conventional content analysis. Using purposive sampling method, 24 experts in the fields of health in disasters, construction engineering, psychology, teaching, and administrative management participated in the study. Maximum variation sampling continued until data saturation was achieved. The data collected via unstructured interviews were analyzed with Graneheim and Lundmen’ s conventional content analysis. Results: Content analysis resulted in four main categories as operational strategies for establishing disasterresilient schools including: 1) “ construction and non-construction optimization” , with four subcategories of construct risk management, optimization of construct architecture and physical structure, correct construct localization, and promotion of non-construct safety, 2) “ promotion of organizational coordination and interactions” with two subcategories, namely improvement in intra-organizational communication and improvement in extra-organizational communication, 3) “ improvement in education” with three subcategories of holding educational courses for families and students, holding educational courses for managers and personnel, and holding simulated exercises, and 4) “ process promotion” with four subcategories of increased preparedness, correct planning, creation of organizational structure, and rehabilitation facilitation. Conclusion: Various factors affecting schools’ response to disasters form operational strategies to establish disaster-resilient schools. These strategies influence pre-and post-disaster preparedness. Awareness of these components followed by preparedness prior to disasters can save students’ lives, improve school performance after disasters, and aid in establishing disaster-resilient schools as safe lodgings.

Introduction: Repolarization abnormalities such as prolongation of QT interval and changes in ST segment and T wave are the most usual electrocardiogram (ECG) changes in patients with intracranial hemorrhage (ICH). It has recently been recommended that prolonged QTc interval raises the risk of death due to malignant ventricular arrhythmias or sudden cardiac death. Objective: The goal of this study was to evaluate the relationship between QT interval and death in patients with ICH. Method: This cross-sectional study was performed on patients with ICH who referred during 2015-2017 to Poursina Hospital, Rasht, Iran. The QT interval was manually measured based on the BAZETT formula. Max QT and Max QTc and QT dispersion were the variables evaluated by the ECG of the patients. The outcome under the study was the death or survival of patients during hospitalization. Results: Finally, 466 cases with the mean age of 69± 12 years were studied of whom 68. 7% were male. The average QT-Max interval was 350. 4± 56. 5 milliseconds, and the average QTc-Max was 583. 6± 57. 6 msec. Totally, 22. 7% of the patients died. There was a significant statistical relationship between QTc-MAX and death (p=0. 001). However, there was no statistically significant relationship between QT-MAX and the outcome (p=0. 593). Conclusion: It is likely that, prolonged QT interval is correlated with in-hospital mortality of patients with ICH. Therefore, it can be expected that assessing ECG abnormalities, especially prolonged QTc could be valuable in these patients.

Introduction: Ramadan, the ninth month of the Islamic lunar calendar, is, to Muslims, the holiest month of the year. During this month, young, able-bodied Muslims are commanded to abstain from food and drink from dawn to dusk. Objective: The objective of the study is to analyze emergency department (ED) patients flow during the holy month of Ramadan and compare it to non-Ramadan days. We hypothesized that Ramadan would affect ED attendance by altering peak hours, and expected a dip in attendance around evening time (after sunset). Methods: In Abu Dhabi, United Arab Emirates, a retrospective study was conducted at a tertiary hospital (2014-2016). The data was strategically separated and patient presence was analyzed year-wise, weekday basis and based on the hourly presence of the patients in the ED of the chosen hospital. Results: A total of 45, 116 ED’ s patient visits were analyzed over the mentioned study period. There was a difference in the total volume of Ramadan and non-Ramadan patient between the years 2014-2016. In all of the years, the highest percentage of visits was during the non-Ramadan days and this had a small fluctuation from 53% in 2014 to 52% in 2016 (p=0. 001). It was observed from the collected data that 53% of the patients were present in the hospital during the fasting hours whereas 47% were present during the nonfasting hours (p<0. 001). Conclusion: We were successfully able to derive a pattern from the data of 3 years in relation to the patient flow in the ED of the hospital. Moreover, we observed the difference in the patient arrival pattern between the Ramadan and non-Ramadan days in the hospital along with the predominant categorization of patient chief complaints. Our study identified a unique pattern of ED hourly visits during Ramadan.

Introduction: Mesenteric cysts are rare benign intra-abdominal vesicles with various clinical presentations. They almost located in the mesentery of the small intestine. The selective therapeutic method is complete surgical excision, however more than half need resection and bowel anastomosis. Case presentation: Here, we presented a 5-year-old girl with a huge mesenteric cyst (15×14cm2) mesenteric cyst that was excised surgically., which the diagnosis confirmed by computed tomography scan and managed through surgical excision. Conclusion: Acute abdominal pain may be due to the presence of mesenteric cysts, but it is not always possible to differentiate and diagnose it preoperatively, and this challenge especially exists in the case of bulky masses. it is recommended to choose primary radical, surgical treatment in case of intra-abdominal cystic mass in the pediatric age.

Introduction: Abdominal pain is one of the most common patient complaints in the emergency department (ED) and abdominopelvic computed tomography (ACT) scan plays an important role in evaluation of these patients. Objective: The aim of this study was to determine the differences between interpretations by generalist radiologists and abdominal subspecialist radiologists regarding the abdominopelvic computed tomography (ACT) of patients who were admitted to the Emergency Department (ED) and to investigate its effect on the patients’ therapeutic approach. Methods: The records of 16452 patients who were admitted to the emergency department with complaint of abdominal pain between January 2015 and April 2017 were reviewed, retrospectively. Out of these patients, 245 (1. 5%) underwent ACT for differential diagnosis and among them, 137 (0. 8%) patients had their ACT reports evaluated by generalist radiologists in 45 minutes and by abdominal subspecialist radiologist 8– 12 hours later and were included in the study. Patients were divided into three groups according to the effect of ACT reports on the performed treatment. Group 1: no effect on planned treatment, group 2: minor effect on planned treatment, which did not result in a change in the treatment process and group 3: major effect on planned treatment approach, which resulted in a change in the treatment process. These changes included at least one of the two criteria: changing the indication of surgery from emergency surgery to elective surgery and/or discharge of the patient from the ED, when actually hospitalization was required. Results: Out of the 137 patients, 87 (63. 5%) were male, 50 (36. 5%) were female and the patients’ mean age was 56 (27-93) years. There were 117 (85. 4%) patients in group 1, 15 (10. 9%) patients in group 2, and 5 (3. 7%) patients in group 3. We determined minor inconsistency between the reports in group 2 and major inconsistency in group 3. Patients in group 3 suffered from delayed surgical intervention due to inconsistency of the CT reports resulting in prolonged hospital stay and increased morbidity. In 17 patients (four patients in Group 1 and 13 patients in Group 2) treatment plan was changed due to CT results; and while surgical treatment was planned for them prior to CT scan, they were discharged with medical treatment after that and overtreatment was prevented. Conclusion: Contribution of abdominal radiologists to evaluation of ACT images in the ED would reduce the inconsistency in ACT reports and prevent the patients from receiving insufficient treatment or overtreatment.

Context: The present systematic review and meta-analysis aims to perform an extensive search in databases to compare the efficacy of the intranasal administration of naloxone with its intramuscular/intravenous administration in the pre-hospital management of opioid overdose. Evidence acquisition: This meta-analysis included controlled trials conducted on the efficacy of naloxone administration in the pre-hospital management of opioid overdose. A search was carried out in electronic databases on relevant articles published by the end of 2018. After data collection, analyses were performed in STATA 14. 0 software and the efficacy and side-effects of the two administration routes of naloxone, i. e. intranasal and intramuscular/intravenous, were compared. An overall effect size with 95% confidence interval (95% CI) was provided for each section. Results: Eventually, data from six studies were included in this meta-analysis. The success rate of the intranasal and intramuscular/intravenous administration of naloxone in the management of opioid overdose in prehospital settings was 82. 54% (95% CI: 57. 97 to 97. 89%) and 80. 39% (95% CI: 57. 38 to 96. 04%), respectively. There was no difference between injectable (intramuscular/intravenous) naloxone and intranasal naloxone in the pre-hospital management of opioid overdose (Odds Ratio=1. 01; 95% CI: 0. 42 to 2. 43; P=0. 98). The onset of action of intranasal naloxone, however, was slightly longer than injectable naloxone (Standardized Mean Difference=0. 63; 95% CI: 0. 07 to 1. 19; P=0. 03). Additionally, the odds of needing a rescue dose was 2. 17 times higher for intranasal naloxone than intramuscular/intravenous naloxone (OR=2. 17; 95% CI: 1. 53 to 3. 09; P<0. 0001). The prevalence of major side-effects was non-significant for both intranasal (0. 00%) and intramuscular/intravenous (0. 05%) routes of naloxone administration and there was no difference in the prevalence of major (OR=1. 18; 95% CI: 0. 38 to 3. 69; P=0. 777) and minor (OR=0. 64; 95% CI: 0. 17 to 2. 34; P=0. 497) side-effects between the two routes. Conclusion: The present meta-analysis demonstrated that intranasal naloxone is as effective as injectable naloxone in the pre-hospital management of opioid overdose complications. Consequently, intranasal naloxone may be an appropriate alternative to injectable naloxone.

Introduction: Chiari malformations are a group of congenital anomalies which involve the hindbrain and the cervical spinal canal. Case presentation: Here, we describe a patient who presented with acute diplopia and gait unsteadiness which was first deigned with Chiari malformation type-1. However due to progression of the ataxia the full neurologic evaluation was considered which established the diagnosis of spinocerebellar ataxia type 3 (Machado-Joseph-Disease). Conclusion: We aim to highlight the importance of careful examination in order to avoid misdiagnosis of even rare diseases.

On August 25, 2019, you published an article titled “ The Current Status of Genes and Genetic Testing in Emergency Medicine: A Narrative Review” (1). I recently read the article and want to both commend the authors for including information on Vascular Ehlers-Danlos Syndrome (vEDS) and expand upon the information provided. Thank you for publishing this article....

Introduction: The continuing-to-grow number of older adults with traumatic brain injury (TBI) presenting to emergency departments (EDs) and hospitals necessitates the investigation of TBI in these patients. Objective: The present study was conducted to investigate the epidemiology of TBI and the factors affecting intracranial lesions and patient outcomes in older adults. Method: The present retrospective cross-sectional study was performed between March 2016 and March 2018. The study population comprised all TBI patients with a minimum age of 60 years presenting to the ED. The eligible candidates consisted of patients presenting to the ED within 24 hours of the occurrence of traumas and requiring head CT scan as part of their examination. The patients’ baseline information was also recorded. Results: A total of 306 older adult patients with a mean age of 70. 61± 8. 63 years, of whom 67. 6% were male, underwent CT scan for TBI during the study period. Falls were the major cause of head injuries, and intracranial lesions were observed in 22. 9% (n=70) of the patients. Subdural hematoma (SDH) was observed as the most prevalent injury in 27. 6% of the patients, 22. 9% (n=16) were transferred to the operating room, and 7. 5% (n=23) died. Moreover, the severity of trauma was significantly different between the two genders (P=0. 029). Midline shift, SDH, subarachnoid hemorrhage (SAH) and moderate-to-severe head injuries were also significantly associated with poor outcomes (P<0. 05). Conclusion: Death from TBIs was more likely in the patients with SDH, SAH and midline shift or in those with an initial Glasgow coma scale (GCS) of below 13. These predictions are clinically relevant, and can help improve the management of older adults with TBI.

Having an extremely toxic compound for humans and most animals, paraquat (PQ) is known as one of the most frequently used herbicides. Accordingly, PQ poisoning has been recognized as a serious medical problem across the world, with a severe case fatality rate (CFR) (1, 2). In this respect; accidental or intentional ingestion of PQ, even in a small amount, can be significantly associated with poor clinical prognosis and increased mortality. Moreover; inherent toxicity of PQ, absence of specific antidotes, as well as lack of effective treatments have been principally attributed to high fatality of PQ poisoning. Once PQ is ingested, it can be absorbed through skin and the digestive and respiratory system and often progresses to multiorgan failure, particularly the lungs as the main target. In this respect, PQ accumulates predominantly in the lungs and can lead to lung fibrosis, pneumonitis, and consequently respiratory failure and death (2, 3). Given the nonexistence of specific and widely accepted guidelines for treatment of PQ poisoning, a range of conservative therapeutic modalities have been proposed and administered by clinicians to moderate PQ absorption and to prevent organ failure in these patients. In spite of this, PQ-induced mortality rate is high and disappointing (1, 3)...

Introduction: Fat embolism syndrome (FES) is most often associated with orthopedic trauma that typically presents 24– 72 hours after the trauma with a classic triad. Only few cases of fat embolism due to lower extremity venous system had been reported. Case presentation: The current case report presents a pregnant woman who was referred to our emergency department with bilateral femoral open fracture. After detecting fetal demise by abdominopelvic ultrasound, an area of fat density in right external iliac vein was detected in abdominopelvic contrast enhanced computed tomography (CT) scan which was considered as the probable diagnosis of fat embolism. While the patient did not show signs and symptoms of FES, the fat embolism was confirmed in further evaluations. Conclusion: In summary, although detection of fat embolus in CT scan in the emergency department is very rare, evaluation of lower extremity venous system in a posttraumatic patient seems to be crucial because early diagnosis of fat embolism can help the clinicians to prevent FES.

CASE PRESENTATION A 27-year-old woman was presented with a burning like lesion. The skin lesion was developed after a jellyfish stings (Rhizostomae) while she was swimming in Pattaya Sea in Thailand, five days prior to her presentation. Instantly after jellyfish stings, she was taken into the ship for rescue operations. The ship personnel applied lemon juice and baking soda to the injured area believing that this remedy is efficient in this situation....

Road traffic accidents stand as one of the leading causes of mortality and morbidity across the globe. The reasons for the high burden of road traffic injuries (RTIs) in developing countries are increasing in the number of motor vehicles, poor enforcement of traffic safety regulations, inadequacy of health infrastructure and poor transport facility. However, the systematic collection of road traffic data is not well developed in many developing countries including India and under-reporting of RTIs and deaths are common. Hence, surveillance of RTIs is recommended to assess the burden, to identify high-risk groups, to establish an association with probable risk factors and to plan interventions to control the RTIs. The broad objective of this study is to establish an electronic-based comprehensive and integrated RTI surveillance system, to assess the burden of RTIs, its risk factors and outcomes across rural and urban settings in India. This study with the support of the Indian Council of Medical Research (ICMR) is progressing in three cities (Chennai, Delhi and Jaipur) and two rural areas (Chittoor and Tehri-Garhwal). At each centre, major sources of data can be categorized under two categories including health facilities and community. In urban areas, one trauma centre, one private hospital and a community of 10000-population are included in the study. In rural areas, a district hospital, a private nursing home and two sub-centres areas of different primary health centres at each site are included for the surveillance. Passive surveillance is done at the trauma centres/district hospitals, while active surveillance is done in private hospitals/nursing homes, sub-centres and communities. Before establishing the surveillance system, situational analysis has been undertaken. Surveillance-related software was developed during the preparatory stage. This electronic surveillance platform allowed to gather data electronically across multiple sites. This internet-enabled surveillance platform has several modules to capture and analyse the data. The present study provides a model of surveillance including both passive and active surveillance to cover maximum number of RTIs. This study further provides the first comprehensive epidemiology of RTIs. The results of these studies will contribute to the setting of research and investment priorities to tackle the burden of RTIs.