Infantile hypertrophic pyloric stenosis, the cause of non-bilious vomiting of a 3-day-old male infant with situs inversus totalis: A case report.

The synchronicity of situs inversus totalis (SIT) and infantile hypertrophic pyloric stenosis (IHPS) is rare. We have reported a case of this concurrency in a 3-day-old newborn with classic symptoms.

Comparison of Ketamine and Tramadol in Management of Acute Pain; a Systematic Review.

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 in management of acute pain were included. RESULT: 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.

Early pyeloplasty versus conservative management of severe ureteropelvic junction obstruction in asymptomatic infants.

BACKGROUND: Ureteric-pelvic junction obstruction (UPJO) is the most common cause of antenatal and neonatal hydronephrosis and its management remains controversial. While conservative management is advocated for all, this strategy puts a quarter of these patients at risk for possibly irreversible renal damage. AIM: In this study, we compare functional and anatomic outcomes in newborns and infants less than 1 year of age with high-grade unilateral UPJO, following early surgical pyeloplasty (ESP) versus conservative management (CM). MATERIALS AND METHODS: This was a single center prospective interventional study. Infants referred to our tertiary care pediatric surgery clinic between September 2016 and September 2018 with UPJO were considered. To be included patients must have been less than 1 year old, lack of clinical symptoms, suffer from severe hydronephrosis as defined by Society for Fetal Urology (SFU) grades 3 or 4, and have affected kidney Split Renal Function (SRF) above 40%. Patients with bilateral disease, structural anomalies, or an abnormal voiding cystourethrogram (VCUG) were excluded. Anatomical and functional outcomes were measured and compared at 6 and 12 months. RESULTS: Fifty-six patients were assigned to receive either ESP (n = 28) or CM (n = 28). At 6 months Cortical thickness, polar length, and SFU indices were significantly lower in the ESP group, while none of the outcomes were significantly different between the two groups at 12 months. Despite the two groups not being different at 12 months regarding differential renal function (DRF), there was a significant decrease of function in the CM group compared to baseline. CONCLUSION: When considering treatment options for infants with high-grade UPJO, it appears that ESP hastens improvement of anatomic and functional indices, while CM may lead to a significant deterioration in renal function.

Prevalence and Associated Factors of Acute Traumatic Coagulopathy; a Cross Sectional Study.

INTRODUCTION: Acute traumatic coagulopathy (ATC) is defined as having evidence of coagulopathy in patients with severe trauma. The aim of this preliminary study was to assess the prevalence and associated factors of ATC in severely traumatic patients presenting to emergency department (ED). METHODS: In this retrospective cross sectional study, all patients with severe traumatic injury and available coagulation profile, presenting to the EDs of two major trauma centers in Tehran, Iran, during one year, were studied. Rate of ATC was determined and the associations with various variables as well as outcome were analyzed using SPSS 21. RESULTS: 246 patients with the mean age of 36.57±17.11 years were included (88.2% male). The mean injury severity score (ISS) was 21.83 ± 7.37 (16 - 54). Patients were resuscitated with 676.83 ± 452.02 (0 - 1500) ml intravenous fluid before arriving at the ED. The maximum and minimum frequencies of ATC were 31.3% based on PTT > 36s and 2.4% based on PT > 18s, respectively. There was a significant association between the occurrence of ATC (PT ratio > 1.2) and ISS > 23 (p = 0.001), abdominal abbreviated injury score (AIS) > 3 (p = 0.003), base deficit > 4 (p = 0.019), pulse rate > 90/minute (p = 0.041), and pH < 7.30 (p = 0.043). CONCLUSION: The frequency of ATC in the present series varied from 2.4% to 31.3% based on different ATC definitions. Abdominal AIS > 3 and base deficit > 4 were among the significant independent factors related to ATC occurrence based on stepwise logistic regression analysis.

Serum concentration of magnesium as an independent risk factor in migraine attacks: a matched case-control study and review of the literature.

There is controversy over the role of magnesium in the etiology of migraine headaches. We aimed to evaluate and compare serum levels of magnesium between healthy individuals and those with migraine headaches during migraine attacks and between attacks to evaluate the role of magnesium in the etiology of migraine headaches. Forty patients with migraine headaches and 40 healthy individuals were enrolled in this matched case-control study. Malnutrition, digestive system disorders, history of smoking, drug abuse, and history of medications use were recorded at baseline. The pain scores of patients were measured and recorded based on a 10 cm visual analog scale. Subsequently, blood samples were collected at 8-10 in the morning to determine serum levels of magnesium. Analysis of variance, χ-test, and conditional logistic regression were used for data analysis. There were no significant differences in demographic data between the two groups. There were significant differences in magnesium serum levels between the three groups (1.09±0.2 mg/dl during migraine headaches; 1.95±0.3 mg/dl between the attacks; and 1.3±0.4 mh/dl in the control group; P<0.0001). Odds of acute migraine headaches increased 35.3 times (odds ratio=35.3; 95% confidence interval: 12.4-95.2; P=0.001) when serum levels of magnesium reached below the normal level. The odds in patients who are not in the acute attack phase were 6.9 folds higher (odds ratio=6.9; 95% confidence interval: 1.3-2.1; P=0.02). The serum level of magnesium is an independent factor for migraine headaches and patients with migraine have lower serum levels of magnesium during the migraine attacks and between the attacks compared with healthy individuals.

Emergency department management of falls in the elderly: A clinical audit and suggestions for improvement.

INTRODUCTION: Falls are a major source of injury in the elderly and their incomplete management is a cause for concern by health systems. The present study looks at the current state of managing fall victims in Iran and offers suggestions for improvement. METHODS: This was a clinical care audit comparing the state of current care with an institutionally approved optimum. Patients aged 60 years and over presenting with a fall were evaluated and deficiencies in their care were recorded and categorized. These were presented to an expert panel, where the Delphi method was used to come up with a list of actions to address the deficiencies. Furthermore an educational program was implemented based on these suggestions. Chi-squared and t-test were used to evaluate the efficacy of this program in improving treatment. Linear regression analysis was used to find factors affecting care. RESULTS: Overall 431 cases were reviewed. The most common errors during clinical examination were: not performing Romberg test (92.75%) and lack of physiotherapy consultation (82.75%). The educational program had a modest effect on improving the clinical audit processes (ß = 3.79; P < 0.001) and medical interventions (ß = 2.004; P = 0.002); however, performing the correct diagnostic tests was worse after the program (ß = -1.21; P = 0.008). CONCLUSION: There is a wide gap between the care services delivered in the management of falls and international standards. Therefore, measures should be adopted to close this gap. Education may have a modest positive effect in this regard.

Erythrocyte Sedimentation Rate Measurement Using as a Rapid Alternative to the Westergren Method.

INTRODUCTION: Erythrocyte sedimentation rate (ESR) remains as one of the most reliable tests in clinical practices. Yet its use is time consuming and requires a large blood sample. The aim of this study was assessing a faster and reliable method of ESR estimation. METHODS: An ESR estimation method was described and performed on 108 patients using capillary tube (micro ESR) and capillary peripheral blood. Micro ESR results at different intervals were measured and compared with Westergren ESR (conventional ESR) estimation by Pearson and Spearman's coefficients. A regression equation was derived to predict conventional ESR values based on micro ESR results. The agreement of two measurements was demonstrated using the Bland-Altman plot. RESULTS: Micro ESR results at 20 minutes showed the earliest close correlation with conventional ESR results at one hour (r = 0.987). The presented regression equation was able to closely predict ESR values (r(2) = 0.974) and the Bland-Altman plot showed an acceptable agreement between converted and conventional ESR measurements. CONCLUSION: Using capillary tube and capillary blood sample (micro ESR) appears to be a faster, cheaper, more reliable, and precise tool for ESR measurement in the ED. The results have acceptable correlation with conventional ESR, especially at 20 minutes of measurement.

Celox-coated gauze for the treatment of civilian penetrating trauma: a randomized clinical trial.

BACKGROUND: Uncontrolled hemorrhage is a well-recognized cause of mortality in trauma victims and the control of active hemorrhage is among the initial steps in resuscitation. OBJECTIVES: The purpose of this study was to assess the role of a hemostatic agent "celox" in the management of civilian stab-wound trauma. PATIENTS AND METHODS: In this clinical trial study, 160 patients with penetrating limb trauma were randomly allocated to either the control or intervention group (n = 80, each group). Controls were treated with the simple pressure dressing, while the celox-coated gauze was used in the intervention group. The time for achievement of hemostasis and the amount of bleeding were recorded. Data were analyzed using SPSS Version 21 and Stata 13. A P value of less than 0.05 was considered statistically significant. RESULTS: The mean age of participants was 30.5 and the majority of patients were male (90.6%). The forearm and distal leg were the most sites of injury. Hemostasis was achieved within 5 minutes in 32.5% of the control group and 51.3% of the intervention group. Using the celox-coated gauze significantly reduced the time to hemostasis (P = 0.01). Moreover, the blood loss was significantly lower in the celox group compared to the controls (P < 0.05). CONCLUSIONS: Using the celox-coated gauze is able to achieve hemostasis in penetrating limb trauma faster than the conventional pressure bandage. Further research is required to clarify the subset of patients who will benefit the most from this effect in the emergency department.

Comparison of morphine-midazolam versus morphine injection for pain relief in patients with limb fractures - a clinical trial.

BACKGROUND: Pain relief, using opiates as a primary choice, is an important part of treating limb fractures. Yet, in order to reduce opiate consumption, other combinations have been introduced. This study aimed to compare pain reduction by a combination of morphine-midazolam with morphine injection in patients with limb fractures. METHODS: A randomized double-blind study of patients with upper or lower extremity fractures was conducted. Patients' response to treatment with either morphine-midazolam solution or morphine at 15, 30, 45, 60, 120, and 180 minutes were assessed. The Kaplan-Meier curves and generalized estimating equations were examined to evaluate the success of treatment. RESULTS: A total of seventy-two patients aged 18-60 (80.6% male; mean age: 35±17.9 years) were included. At 15, 30, 45, and 60 minutes, successful pain control was seen in 8.83 22.2%, 33.3% and 63.9% of the patients in the morphine group, and 11.1%, 27.7%, 44.4% and 63.8% in the midazolam-morphine group. By the third hour, pain-control was achieved in all patients receiving morphine while pain persisted in one patient receiving morphine-midazolam. Log-rank test showed no significant difference between the two groups (p=0.55). CONCLUSION: Our findings revealed that adding midazolam to morphine did not improve its pain-relief profile.

Familial adenomatous polyposis: ileo-anal pouch versus ileo-rectal anastomosis.

AIM: In this study we describe the presentation, treatment, and complications of 27 FAP patients. BACKGROUND: Treatment of Familial adenomatous polyposis (FAP) is centered on early recognition and curative surgery with either restorative proctocolectomy with ileal-pouch-anal-anastomosis (IPAA) or colectomy with ileo-rectal anastomosis (IRA). PATIENTS AND METHODS: All patients diagnosed with FAP at our center from 2008 to 2012 were included in this case series. Either IPAA or IRA was used for treatment. Complications were recorded for 12 months after the procedure. RESULTS: Overall 27 patients were included, 12 (44.44%) index patients, and 15 (55.55%) relatives diagnosed by screening. Eight Index patients presented with rectal bleeding, two with occult fecal blood and two with abdominal masses found to be desmoid tumors. Nineteen patients were treated by IPAA, 6 with IRA, and 2 were inoperable due to diffuse desmoid tumors. Daytime stool frequency was the most common side effect (70.37%), followed by bowel discomfort episodes (55.56%), requiring dietary restrictions (37.4%), passive incontinence (25.93%), soiling (22.22%), nighttime stool frequency (18.52%), flatus incontinence (16.0%), and anastomosis leakage (3.70%). On average patients treated by IPAA experienced less complication than those treated by IRA. CONCLUSION: compared with previous reports, this series had older age of diagnosis, higher rate of adenocarcinoma at diagnosis, and fewer side effects after IPAA than IRA. The latter may reflect technique improvement with experience, and if supported by future studies, will cement IPAA as the treatment of choice in FAP.

Development of an Easy-to-Use Tool for the Assessment of Emergency Department Physical Design.

Physical design of the emergency department (ED) has an important effect on its role and function. To date, no guidelines have been introduced to set the standards for the construction of EDs in Iran. In this study, we aim to devise an easy-to-use tool based on the available literature and expert opinion for the quick and effective assessment of EDs in regards to their physical design. For this purpose, based on current literature on emergency design, a comprehensive checklist was developed. Then, this checklist was analyzed by a panel consisting of heads of three major EDs and contradicting items were decided. 178 crude items were derived from available literature. The Items were categorized in to three major domains of Physical space, Equipment, and Accessibility. The final checklist approved by the panel consisted of 163 items categorized into six domains. Each item was phrased as a "Yes or No" question for ease of analysis, meaning that the criterion is either met or not.

Endovenous laser ablation of the great saphenous vein versus high ligation: long-term results.

Endovenous laser therapy (EVLT) for greater saphenous vein (GSV) insufficiency is a relatively new method of treatment only recently made available in Iran. This is the first long-term randomized trial comparing EVLT with high ligation of saphenous vein (HLS) in the Iranian population. Sixty-five patients met the inclusion criteria and were divided into homogenous treatment groups of EVLT (n = 30) or HLS (n = 35). Clinical severity, etiology, anatomy, pathophysiology (CEAP) classification and Aberdeen Varicose Vein Symptom Severity Scores (AVSS) were used to determine disease severity and symptoms before and after the procedure in both groups. Outcome was measured by the rate of recurrence as shown in Doppler ultrasonography evaluation. Follow-up was conducted 1 week and 3, 6, 12, and 18 months after the intervention. The occlusion rate of GSV was similar in both groups (93.6% for EVLT, 88.3 for HLS) at 18 months of follow-up. The median CEAP score showed a dramatic decrease in both groups after 1 week which was sustained for the rest of the study. The Aberdeen Varicose Vein Symptom Severity score was significantly lower in the EVLT group at 12 and 18 months of follow-up. There was no significant difference in patient satisfaction in both groups. Our findings show that EVLT may offer a better long-term relief of symptoms. This, alongside its better cosmetic outcome, and less invasive anesthesia requirements may make it the favorable choice for treatment of GSV insufficiency.

Firecracker injuries during chaharshanbeh soori festival in iran: a case series study.

On the last Wednesday of every year Iranians celebrate the sanctity of fire in the annual festival of Chaharshanbeh Soori. Each year many cases of firecracker-related injuries (FRI) are reported during this festival. The aim of this study was to assess the pattern of injuries and the frequency of disabilities during this period. In 2011, a cross-sectional study was conducted at the emergency departments (EDs) of three educational hospitals in Tehran, to assess the extent and demographics of FRI. The age and sex of the patient, type of referral to the hospital, type of injury, its region and treatment process were recorded for each patient by the physicians. Data were analyzed by SPSS version 20. Thirty-five patients suffering from FRI were admitted to the hospitals during the festival. The majority of patients were under 30 years-old and most of them were male (83% male and 17% female). The injuries were mostly lacerations and cuts (n = 17, 49%) and scratches (n = 12, 34%). One patient suffered amputation. The most common site of the injuries were the hands (n = 13, 37%) followed by the face (n = 10, 29%). There were 10 patients (29%) with more than one site of injury. Twenty-one patients were hospitalized, 12 patients (34%) received outpatient treatment and two patients were referred to other hospitals. There are still many victims during Chaharshanbeh Soori festival despite efforts and legislations by the government. Education and raise of awareness among people especially for youth are the most important ways to prevent and reduce Red Wednesday injuries.

Posttraumatic endophthalmitis: report No. 2.

PURPOSE: To study predisposing factors of endophthalmitis in patients with open-globe injury. METHODS: All 2,340 patients with open-globe injury admitted to our center over 5 years were studied retrospectively, and patients with endophthalmitis were compared with other patients. RESULTS: The number of endophthalmitis cases among patients with open-globe injury was 117 eyes, accounting for an incidence of 5.1%. The risk of endophthalmitis was significantly higher among male patients with pure corneal injuries (6.8%), intraocular foreign bodies (9.3%), traumatic lens rupture (7.1%), trauma resulting from needles (22.2%), and shorter lacerations. The existence of hyphema or iris prolapse was associated with lower rates of endophthalmitis. The mean gap between injury time and operation time was longer in the endophthalmitis group (2.1 ± 1.8 vs. 1.1 ± 1.3 days). Patients with endophthalmitis had significantly lower ocular trauma scores compared with other patients. CONCLUSION: Posttraumatic endophthalmitis is more likely among patients with open-globe injury that are needle related and among those who have intraocular foreign bodies, traumatic lens rupture, smaller wounds, or wounds exclusively in the cornea. Lower ocular trauma scores in this group of patients with penetrating trauma indicated a greater risk of poor visual prognosis. Therefore, it is suggested that necessary measures and immediate treatment be undertaken in high-risk patients.

Epidemiology of open-globe injuries in Iran: analysis of 2,340 cases in 5 years (report no. 1).

PURPOSE: To review characteristics of open-globe injuries presented to Farabi Eye Hospital, a large referral center for serious ocular injury in the capital city of Iran. PATIENTS AND METHODS: A retrospective review of 2,340 open-globe injury patients during a 5-year period was performed. Data about any patient that was diagnosed as open-globe injury were collected from medical records. RESULTS: Of 2,340 patients, 1,904 (81.4%) were men. Mean age was 22.44 +/- 16.65 years (range, 4 months to 90 years). Seventy-five percent of cases were younger than 30 years, with a peak of 5 years. There were 561 patients who had an intraocular foreign body (24.7%). In patients younger than 16 years, a knife was the most prevalent cause (22%); in patients younger than 7 years, knives accounted for 33.6% of trauma etiology; and in patients more than 16 years, a projectile metallic foreign body was the most common cause, accounting for 27% of open-globe injuries. Endophthalmitis developed in 5.1% (117 cases). Factors that had a positive association with severity of ocular injury were visual acuity lower than 20/200 at admission, endophthalmitis, double perforation, and laceration length. According to Ocular Trauma Scoring, there was better visual prognosis in younger age groups, male sex, and intraocular foreign body groups. The rate of enucleation or evisceration was 5.3% (126 cases). We had a low sympathetic ophthalmia rate of 0.08%. CONCLUSION: The most prevalent trauma etiology is a projectile metallic foreign body in adults and a knife injury in children. Compared with other previous epidemiologic studies, we had younger patients, lower enucleations, and sympathetic ophthalmia.