Intravenous Paracetamol vs Intranasal Desmopressin for Renal Colic in the Emergency Department: A Randomized Clinical Trial.

OBJECTIVE: To evaluate the analgesic efficacy of intranasal desmopressin alone vs intravenous paracetamol in patients referred to the emergency department with renal colic. DESIGN: Randomized clinical trial. SETTING: This study was conducted in the emergency unit of a university hospital. SUBJECTS: Patients referred to the emergency room with renal colic. PRIMARY OUTCOME: Effect of intranasal desmopressin in pain relief in comparison with intravenous paracetamol. METHODS: In this trial, 240 patients diagnosed with renal colic were randomly divided into two groups to compare the analgesic effect of intravenous paracetamol (15 mg/kg) and intranasal desmopressin spray (40 µg). Pain scores were measured by a numeric rating scale at baseline and after 15, 30, and 60 minutes. Adverse effects and need for rescue analgesic (0.05 mg/kg max 3 mg morphine sulphate) were also recorded at the end of the study. RESULTS: Three hundred patients were eligible for the study; however, 240 were included in the final analysis. The patients in the two groups were similar in their baseline characteristics and baseline pain scores. The mean pain score after 15 minutes was more reduced and was clinically significant (>3) in the desmopressin group (P < 0.0001). There was no significant difference between mean pain scores in the two groups after 30 minutes (P = 0.350) or 60 minutes (P = 0.269), but the efficacy of the two drugs was significant in terms of pain reduction (>6). CONCLUSIONS: Our study showed that intranasal desmopressin is as effective as intravenous paracetamol for renal colic pain management; however, significant clinical reduction in pain score occurred faster with intranasal desmopressin.

Ketamine and atropine for pediatric sedation: a prospective double-blind randomized controlled trial.

INTRODUCTION: Sedation in children can be a challenge for emergency physicians, which demands for selecting an effective medication with few complications and good analgesic effects. This study has been performed to evaluate the adverse effects of ketamine while using either atropine or placebo in emergency departments. METHODS: This is a prospective randomized controlled trial involving 200 patients with age ranging between 2 and 15 years, who need a painful procedure. Participants randomly were divided into 2 groups both treated by ketamine (1 mg/kg intravenously administered); group 1 received excessive intravenous atropine (0.01 mg/kg), whereas distilled water was given to group 2 as placebo. Adverse effects and duration of the treatments were recorded. RESULTS: From March to September 2010, 200 of 218 eligible patients were enrolled. The mean (SD) age of patients in the intervention group was 7.0 (3.6) years that showed no statistical difference with the control group (age range, 2-15 years; mean, 7.1 [3.8] years). The mean procedure and sedation time between the intervention and placebo groups were not significantly different (P = 0.919 and 0.783, respectively). Several differences between the intervention and placebo groups were noted including nausea and vomiting, but only the difference in hypersalivation was statistically significant (12% vs 28%). Low oxygen saturation was reported only in 2% of the participants, whereas none of the children experienced apnea or laryngospasm during the sedation process. CONCLUSIONS: Atropine added to ketamine significantly reduces hypersalivation without producing any adverse effects on the procedure duration or success rate.

Delayed post-traumatic Tension Hydropneumocephalus; a Case Report of Conservative Treatment.

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

Prognosis of patients with tracheal intubation in the emergency department.

Background: Intubation of critically ill patients is one of the increasing emergency procedures. We designed this study to determine age and sex-related mortality rates after emergency intubation. Methods: This retrospective study collected and analyzed non-trauma intubated patients in a referral hospital from the years 2017-2019 and before the appearance of COVID-19. Patients who were intubated outside of emergency by EMS technicians were excluded. We recorded data of intubated patients, like sex, age, length of being intubated and final diagnosis. P values of less than 0.05 were significant. Results: Data of 520 non-trauma intubated patients were collected and analyzed. More than 64% of the patients were over 65 years old and had a higher mortality rate (86.7%; P < 0.001) than younger patients. The overall in-hospital mortality rate was 80%. More than three quarters of the decedents died within a week of intubation (P < 0.001). There was no significant relationship between sex and mortality rate (P = 0.535). Conclusion: Our data showed that with increased age there was a decrease in the chance of being extubated.

Chronic pain after spinal cord injury: results of a long-term study.

OBJECTIVE: Chronic pain after spinal cord injury (SCI) is a common and considerable complication and may continue for a long time. DESIGN: During a 2-year survey, 13.9 +/- 3.0 years after injury, a total of 1,295 war-related spinal cord injury survivors were thoroughly examined by physical and rehabilitation specialists and all relevant data, consisting of type and site of pain as well as exacerbating or palliative factors, were recorded. PATIENTS: The mean age of the survivors was 35.9 +/- 7.2; 98.5% were male and 1.5% were female. The level of injury was cervical in 9.3%, thoracic in 67%, and lumbosacral in 23.7%, with 8.1% tetraplegic and 89.1% paraplegic. About 89.8% had complete spinal cord injuries and 10.2% had incomplete spinal cord injuries, based on sensory and motor testing. RESULTS: Spinal cord related pain was reported in 64.9% of the subjects; 8.8% reported a history of pain but had no complaint at the time of examination, and 26.3% had never suffered from any pain. Patients suffering from lumbar spinal cord injury reported the highest percent of pain perception, with pain detected in 83.5% of these patients. Common sites of reported pain were the distal lower extremities (46.5%), proximal lower extremities (40.9%), pelvic girdle (24.5%), and upper limbs (5.7%). CONCLUSION: Spinal cord injury-related pain interferes with daily activities of patients and significantly influences their quality of life.

Mustard gas exposure and carcinogenesis of lung.

UNLABELLED: Sulfur mustard (SM), also known as mustard gas, is an alkylating compound used as a chemical weapon in World War I and by Iraqi forces against Iranians and indigenous Iraqi Kurds during the Iran-Iraq War of the 1980s. Although SM is a proven carcinogen there are conflicting views regarding the carcinogenicity of a single exposure. The present study characterizes lung cancers formed in mustard gas victims from the Iran-Iraq War. METHODS AND MATERIALS: Demographic information and tumor specimens were collected from 20 Iranian male lung cancer patients with single high-dose SM exposures during the Iran-Iraq War. Formalin-fixed, paraffin-embedded lung cancers were analyzed by immunohistochemistry for p53 protein. In addition, DNA was extracted from the tissues, PCR amplified and sequenced to identify mutations in the p53 and KRAS genes associated with SM exposure. RESULTS: A relatively early age of lung cancer onset (ranging from 28 to 73 with a mean of 48) in mustard gas victims, particularly those in the non-smoking population (mean age of 40.7), may be an indication of a unique etiology for these cancers. Seven of the 20 patients developed lung cancer before the age of 40. Five of 16 cancers from which DNA sequence data was obtainable provided information on eight p53 mutations (within exons 5-8). These mutations were predominately G to A transitions; a mutation consistent with the DNA lesion caused by SM. Two of the lung cancers had multiple p53 point mutations, similar to results obtained from factory workers chronically exposed to mustard agent. No mutations were detected in the KRAS gene. DISCUSSION: The distinguishing characteristics of lung carcinogenesis in these mustard gas victims suggest that a single exposure may increase the risk of lung cancer development in some individuals.

Mental health status following severe sulfur mustard exposure: a long-term study of Iranian war survivors.

INTRODUCTION: This study aimed to describe the mental health status of sulfur mustard-exposed survivors suffering from severe respiratory and ophthalmological problems. METHODS: Out of 450 invited Iran-Iraq War survivors of sulfur mustard exposure with severe symptoms, 350 participated in this cross-sectional study. Mental health status was assessed using the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, criteria. Fisher exact test, Pearson chi-square test, and chi-square test were used to assess any relationship, and the independent-sample t test was employed to compare differences between the veterans with ocular and pulmonary injuries. RESULTS: There were 60.9% (n = 213) survivors who suffered from mental disorders. Among them, 39.7% (n = 139) were previously untreated and required the initiation of psychiatric treatment. The prevalence of anxiety and mood disorders among all survivors was 40.6% (n = 142) and 32.0% (n = 112), respectively. The most common anxiety and mood disorders were posttraumatic stress disorder (32.9%, n = 115) and major depressive disorder (22.3%, n = 78), respectively. Psychiatric disorders were more prevalent in cases with severe pulmonary chemical injury than in subjects with severe ophthalmologic chemical injury. Significant relationships were found between the types of psychiatric disorders and age, education, and occupation (P < .05). CONCLUSION: The psychiatric morbidity in the chemically injured populations was remarkable and significantly different between the populations. The prevalence of mental illness in these groups highlights the need for the appropriate provision of mental health services.

Phantom Limb Sensation (PLS) and Phantom Limb Pain (PLP) among Young Landmine Amputees.

OBJECTIVE: To determine the frequency of phantom limb sensation (PLS) and phantom limb pain (PLP) in children and young adults suffering landmine-related amputation. MATERIALS & METHODS: All youths with amputation due to landmine explosions participated in this study. The proportions of patients with phantom limb sensation/pain, intensity and frequency of pain were reported. Chi square test was used to examine the relationship between variables. Comparison of PLP and PLS between upper and lower amputation was done by unpaired t-test. RESULTS: There were 38 male and 3 female with the mean age of 15.8±2.4yr. The mean interval between injury and follow-up was 90.7±39.6 months. Twelve (44.4%) upper limb amputees and 11 (26.8%) lower limb amputees had PLS. Nine (33.3%) upper limb amputees and 7 (17.1%) lower limb amputees experienced PLP. Of 27 upper limb amputees, 6 (14.6%) and among 15 lower limb amputees, 6 (14.6%) had both PLS and PLP. One case suffered amputation of upper and lower limbs and was experiencing PLS and PLP in both parts. PLS had a significant difference between the upper and lower amputated groups. Significant relationship was observed between age of casualty and duration of injury with PLP. CONCLUSION: Phantom limb sensation and pain in young survivors of landmine explosions appear to be common, even years after amputation.

The association between serum 25-hydroxyvitamin D level and recurrent falls in the elderly population: a cohort study.

INTRODUCTION: Serum vitamin D concentration is a major contributing factor for increasing the risk of fall and fall-related injuries in older adults. However, when prescribed and supplemented for these populations, the outcomes are controversial, and in several cases no improvement has been reported in reducing the risk of recurrent falls. This study aimed to examine the association between serum vitamin D concentration and recurrent falls in Iranian older adults. METHODS: This cohort study was conducted in the emergency departments of two university hospitals. A cohort of 82 elderly participants aged over 60 and suffered from an unintentional episode of falling was evaluated six months after their first ED visit. A structured, self-administered checklist was developed to obtain the participants' demographic and clinical information. Participants also were asked about any recurrent fall experience during follow-up. RESULTS: The mean (SD) age of the study population was 75 (8). Over half of the participants were male (57.3%). The mean (median) serum 25-hydroxyvitamin D (25 (OH)D) concentration was 38 (34) ng/ml. Mean serum 25(OH)D levels varied slightly between gender groups (p=0.450). An inverse but insignificant association was found between the age of participants and their serum 25(OH)D levels (r=-0.03, p=0.7). A small but insignificant association also was found between the mean serum 25(OH)D level and the number of recurrent falls in elderly patients irrespective of their age, gender, or physical activity groups (OR=1.008, p=0.992). CONCLUSION: In contrast to previous studies, no significant association of serum 25(OH)D concentration was found with recurrent falls in Iranian older adults.

Diagnostic accuracy of emergency-performed focused assessment with sonography for trauma (FAST) in blunt abdominal trauma.

INTRODUCTION: Intra-abdominal hemorrhage due to blunt abdominal trauma is a major cause of trauma-related mortality. Therefore, any action taken for facilitating the diagnosis of intra-abdominal hemorrhage could save the lives of patients more effectively. The aim of this study was to determine the accuracy of focused assessment with sonography for trauma (FAST) performed by emergency physicians. METHODS: In this cross-sectional study from February 2011 to January 2012 at 7th Tir Hospital in Tehran (Iran), 120 patients with abdominal blunt trauma were chosen and evaluated for abdominal fluid. FAST sonography was performed for all the subjects by emergency residents and radiologists while they were blind to the other tests. Abdominal CTs, which is the gold standard, were done for all of the cases. SPSS 20.0 was used to analyze the results. RESULTS: During the study, 120 patients with abdominal blunt trauma were evaluated; the mean age of the patients was 33.0 ± 16.6 and the gender ratio was 3/1 (M/F). The results of FAST sonography by emergency physicians showed free fluid in the abdomen or pelvic spaces in 33 patients (27.5%), but this was not observed by the results of CT scans of six patients; sensitivity and specificity were 93.1 and 93.4%, respectively. As for tests performed by radiology residents, sensitivity was a bit higher (96.5%) with lower specificity (92.3%). CONCLUSION: The results suggested that emergency physicians can use ultrasonography as a safe and reliable method in evaluating blunt abdominal trauma.

A comprehensive musculoskeletal and peripheral nervous system assessment of war-related bilateral upper extremity amputees.

BACKGROUND: Upper limb amputations are one of the unpleasant war injuries that armed forces are exposed to frequently. The present study aimed to assess the musculoskeletal and peripheral nervous systems in Iraq-Iran war veterans with bilateral upper extremity amputation. METHODS: The study consisted of taking a history and clinical examinations including demographic data, presence and location of pain, level of amputation, passive and active ranges of movement of the joints across the upper and lower extremities and spine, manual palpation, neurological examination, blood circulation pulses and issues related to a prosthetic limb. In this study, 103 Iranian bilateral upper extremity amputees (206 amputations) from the Iran-Iraq war were evaluated, and a detailed questionnaire was also administered. RESULTS: The most common level of amputation was the finger or wrist level (108, 52.4 %). Based on clinical examination, we found high frequencies of limited active and passive joint range of movement across the scapula, shoulder, elbow, wrist and metacarpophalangeal, interphalangeal and thumb joints. Based on muscle strength testing, we found varying degrees of weakness across the upper limbs. Musculoskeletal disorders included epicondylitis (65, 31.6 %), rotator cuff injury (24, 11.7 %), bicipital tendonitis (69, 33.5 %), shoulder drop (42, 20.4 %) and muscle atrophy (19, 9.2 %). Peripheral nerve disorders included carpal tunnel syndrome in 13 (6.3 %) and unilateral brachial plexus injury in 1 (1 %). Fifty-three (51.5 %) were diagnosed with facet joint syndrome at the level of the cervical spine (the most frequent site). Using a prosthesis was reported by 65 (63.1 %), both left and right sides. The back was the most common site of pain (71.8 %). CONCLUSION: The high prevalence of neuro-musculoskeletal disorders among bilateral upper extremity amputees indicates that they need regular rehabilitation care.

Mental health disorders in child and adolescent survivors of post-war landmine explosions.

BACKGROUND: To describe the mental health status of 78 child and adolescent survivors of post-war landmine explosions. METHODS: Child and adolescent survivors of landmine explosions who were younger than 18 years old at the time of the study were identified and enrolled in this study. The mental health status of the participants was assessed by general health assessment and psychiatric examinations. Psychiatric assessment and diagnosis were undertaken using the Diagnostic and Statistical Manual for mental disorders (DSM-IV) criteria. A psychiatrist visited and interviewed each survivor and identified psychiatric disorders. RESULTS: Seventy-eight child and adolescent survivors with a mean age of 16.11 ± 2 years old were identified and agreed to participate in the study. The mean age of the victims at the time of injury was 8.2 ± 3.12 years old (range 2-15). Thirty-seven (47.4 %) of the adolescent survivors suffered from at least one psychiatric disorder. Twenty-nine survivors (37.1 %) were newly diagnosed and needed to start medication and psychiatric treatment. The most common findings were anxiety disorders (34.6 %), including posttraumatic stress disorder (PTSD) in 20 (25.6 %), and generalized anxiety disorder (GAD) in 7 (9 %) subjects. Mild-Moderate depression was found in 5 (6.4 %) subjects. No personality disorders were observed, and two patients suffered from mental retardation. The study results revealed a significant association between age of casualty, duration of injury and limb amputation, and types of psychological disorders. CONCLUSION: Child and adolescent survivors of landmine explosions had a high prevalence of psychiatric disorders.

Epidemiological Study of Child Casualties of Landmines and Unexploded Ordnances: A National Study from Iran.

BACKGROUND: Despite landmine-risk education programs and extensive demining activities on the Western border of Iran, landmines and unexploded ordnance (UXOs) still cause civilian and child casualties three decades after the Iraq-Iran war (1980-1988). The objective of this study was to understand the epidemiological patterns and risk factors of injury in child casualties of landmines and UXOs in Western and Southwestern Iran. METHODS: Children who were 18 years old or younger at the time of study and who sustained injuries from landmines and UXOs were identified through a search at the Iranian National Veterans Registry. These children participated in a 5-day gathering. The information on socioeconomic status, health-related issues, quality of life, health care utilization, and clinical profiles concerning the landmine and UXO injuries were collected. The method of data collection consisted of three component surveys: health interview, social survey, and medical examinations. Social surveys and health interviews were conducted in a face-to-face method by utilizing a questionnaire consisting of 39 questions addressing household and individual components, including information on time and type of injuries, physical activity, mental health, and quality of life. A comprehensive team of physicians in different subspecialties evaluated and examined children to assess the current medical and psychiatric conditions and physical activity, and recommended and arranged further medical, rehabilitation, or surgical planning. RESULTS: Seventy-eight child casualties were identified and participated in the study. The mean age of the participants at the time of study was 16.11 years old (SD=2 years). The mean age of victims at the time of injury was 8.2 years (SD=3.12 years; ranged from 2 to 15 years old). Sixty-seven (85.9%) of the children were male. Provinces of Kurdistan and Kermanshah had the highest number of casualties, with a total number of 54 children (68.3%). Eighty percent of the injuries were caused by landmines, and UXO explosions were reported in 20% of the cases. Overall, 24 children (30%) had received some landmine-risk education before or after the events. Sixty percent of the explosions had happened in the morning between 9:00 am and 12:00 pm. Playing and grazing livestock were the most prevalent activities/reasons at the time of injury, which were reported in 77% of the subjects. Sixty-three percent of incidents had multiple casualties and in only 13 explosions were the children the only victims of the explosion. The most prevalent injuries were amputations in 41 subjects (52.56%), followed by hearing loss in 23 subjects (29.5%). Amputations were more common in upper extremities (62%) than in lower extremities (38%). CONCLUSION: Landmines and UXOs comprise a significant safety hazard to the children living in the Western border of Iran decades after the Iraq-Iran War. The large number of injuries and lack of risk training among victims suggest that landmine cleanings and landmine-risk education should be age-specifically targeted and expanded substantially.

Prophylactic Antibiotic Therapy in Contaminated Traumatic Wounds: Two Days versus Five Days Treatment.

INTRODUCTION: Emergency department manages several kinds of wounds including simple, non-bite traumatic wounds and lacerations. Prophylactic antibiotic therapy is one of pre-scribed treatment in these conditions. We aimed to compare the clinical efficacy of the two day regimen of prophylactic antimicrobial agents with the five day regimen in simple traumatic but highly contaminated wounds. METHODS: Between January 2010 and May 2010, patients presenting with simple traumatic wounds or lacerations in different parts of the body, highly contaminated with soil, debris or feces in emergency department of a referral educational hospital in Tehran (Rasul-Akram hospital), Iran, went for primary closure. All of the patients were provided prophylactic antibiotic, however, prescribed for one group (A) of patients for 2 days and other group (B) received for 5 days, according to the physician concerned. As these treatments were routine, we selected 70 patients from each group using table of random numbers. The patients were warned about the signs of infection including long-lasting erythema, purulent discharge and inflammation and were supposed to inform the concerned physician in any of such alarming situations. Oral Cephalexin 500 mg qid was prescribed for all patients enrolled for prophylaxis treatment. RESULTS: On follow-up 11 (8.2%) patients were found to develop sutured site infection (6 out of 70 (8.57%) in group A, and five out of 70 (7.14%) in group B (P=0.31)). There was no statistical difference between infection rates between men (8.6%) in comparison to women (6.25%) (P>0.05; CI=95%). CONCLUSION: Our study showed that 2-day prophylactic antibiotic therapy using Cephalexin is at least as effective as a 5-day regimen in relation to development of surgical site infection in patients with simple traumatic contaminated wounds or lacerations.

Phantom pain in bilateral upper limb amputation.

PURPOSE: To alert health professionals on presence and extent of phantom pain and sensation following bilateral upper limb amputation. METHODS: Of a total of 140 war-related bilateral upper limb amputees in Iran, 103 subjects were thoroughly examined in this cross-sectional study by a physical medicine specialist. The patients were questioned for the presence of phantom pain and sensations, and frequency and intensity of the feeling were recorded. RESULTS: At 17.1 +/- 6.1 years after injury, 82.0% of the 103 amputees suffered from phantom sensation, including varying degrees of phantom limb pain in 53.9% of stumps. Phantom phenomena had a higher frequency in the right extremities, but this was not statistically significant (p > 0.01). Of those amputees who had phantom pain or sensation, 51.2% reported that they 'always' had phantom limb sensation; and approximately one-fourth of the subjects (24.6%) 'always' had phantom pain. Among the stumps who reported phantom pain (N=112), the pain was excruciating (38.5%), distressing (34.9%) or discomforting (25.6%). A significant statistical relation between phantom limb sensation and level of amputation was observed (p < 0.01). CONCLUSION: At this time there is no healing for phantom pain; medical and surgical modalities only bring temporary relief, and less than 1% of the respondents achieve permanent relief through different treatment methods.

Neuroma in bilateral upper limb amputation.

To evaluate the prevalence of neuroma in bilateral upper limb amputees and investigate the effect of level of amputation on their pain, 86 patients with bilateral upper limb amputation were thoroughly examined by an orthopedic surgeon. Of 172 bilateral amputated upper limbs (86 victims of war) 17.1+/-6.1 years after injury, physical examination revealed that 26.2% had moderate to severe stump pain and clinical signs suggestive of neuroma. Statistical analysis showed no relation between level of amputation, prosthesis usage, and occurrence of neuroma. Although high occurrence of neuroma among traumatic bilateral upper limb amputation had no significant effects on wearing prosthesis, its treatment can deeply influence alleviation of their pain and subsequently their quality of life.

Spinal cord injury-induced osteoporosis in veterans.

In a cross-sectional study, 132 male veterans with spinal cord injury (average age 37.4 years; injuries sustained from 5 to 23 years ago), underwent dual-energy x-ray absorptiometry, by LUNAR, to define bone mineral density (BMD) in second to fourth lumbar vertebrae and the neck of the right femur (g/cm(2)). The results showed that bone minerals in the lumbar area are reserved better than in the femoral neck. The study on the femoral neck revealed that 81.5% of subjects had osteoporosis and 13.1% osteopenia. Evaluation of lumbar spines also showed that 16.7% of the veterans had osteoporosis and 18.2% osteopenia. A significant difference was observed between vertebral bone density (mean 1.23 g/cm(2)) and the neck of the right femur (mean 0.66 g/cm(2)). There was also a slight negative correlation between bone density and risk of bone fracture in vertebrae and femoral neck. No significant relation between bone density and age, level of injury, spasm, occupation, and postinjury period was reported. A slight negative correlation between weight and bone mineral density and a slight positive correlation between height and bone mineral density were found.