C-Reactive Protein and D-dimer as Prognostic Markers for Clinical Outcomes in Patients with Mild Traumatic Brain Injury: A Cross-Sectional Study.

Objective: To investigate the use of prognostic markers such as C-reactive protein (CRP) and D-dimer for clinical outcomes in patients with mild traumatic brain injury (TBI). Methods: This cross-sectional study was conducted on patients with mild head trauma who were admitted to the Emergency Department of Imam Khomeini Hospital (Sari, Iran). Data were collected from 2018 to 2019. Age, sex, the time of injury hospitalization, length of hospitalization, length of unconsciousness, blood pressure, heart rate, respiratory rate, and concomitant symptoms were all recorded using a pre-designed checklist. The patient's Glasgow Coma Scale (GCS), CRP, and D-dimer were also measured. Moreover, all patients underwent CT scan. Results: This study included 74 patients with TBI. The mean age of the participants was 36.92±3.54. The mean CRP and D-dimer values were 5.69±0.77 and 0.58±0.11 in these patients, respectively. At the cut-off point of 11.50 for CRP, the sensitivity and specificity to detect the pathological lesions in CT scan were 75% and 95.50%, respectively (p<0.001). Additionally, with a D-dimer cut-off point of 0.90, the sensitivity and specificity for diagnosing pathological lesions in CT scan were 100% and 98.50%, respectively (p<0.001). Conclusion: In general, the CRP and D-dimer levels of patients with mild TBI (GCS≥13) can be assessed to protect against CT-induced radiation exposure and subsequent disorders; if they do not exhibit clinical signs to increase the risk of adverse brain damage, such as reduced level of consciousness, drowsiness, and prolonged periods of unconsciousness.

Comparison of the diagnostic accuracy of CT scan with oral and intravenous contrast versus CT scan with intravenous contrast alone in the diagnosis of blunt abdominal trauma.

PURPOSE: Abdominal CT scan using oral and intravenous (IV) contrast is helpful in the diagnosis of intra-abdominal injuries. However, the use of oral and IV contrast delays the process of diagnosis and increases the risk of aspiration. It has also been shown that CT scan with IV contrast alone is as helpful as CT scan with oral and IV contrast and rectal CT scan in detecting abdominal injuries. Therefore, the present study aims to prospectively compare the diagnostic value of CT scan with oral and IV contrast versus CT scan with IV contrast alone in the diagnosis of blunt abdominal trauma (BAT). METHODS: Altogether 123 BAT patients, 60 (48.8%) women and 63 (51.2%) men with the mean age of (40.4 ± 18.7) years who referred to the emergency department of Imam Khomeini Educational and Medical Center in Sari, Iran (a tertiary trauma center in north of Iran) from November 2014 to March 2017 and underwent abdominal CT scans + laparotomy were investigated. Those with penetrating trauma or hemodynamically unstable patients were excluded. The participants were randomly allocated to two groups: abdominal CT scan with oral and IV contrast (n = 63) and CT scan with IV contrast alone (n = 60). No statistically significant difference was found between two groups regarding the hemodynamic parameters, age, gender, injury mechanisms (all p > 0.05). The results of CT scan were compared with that of laparotomy results. The collected data were recorded in SPSS version 22.0 for Windows. Quantitative data were presented as mean and SD. RESULTS: The sensitivity and specificity of CT scan using oral and IV contrast in the diagnosis of BAT were estimated at 96.48 (95% CI: 90.73 - 99.92) and 92.67 (95% CI: 89.65 - 94.88), respectively; while CT scan with IV contrast alone achieved a comparable sensitivity and specificity of 96.6 (95% CI: 87.45 - 99,42 and 92.84 (95% CI: 89.88 - 95.00), respectively. CONCLUSION: CT scan with IV contrast alone can be used to assess visceral injuries in BAT patients with normal hemodynamics to avoid diagnostic delay.

Clinical Predictors of Testicular Torsion in Patients with Acute Scrotum; a Cross-Sectional Study.

INTRODUCTION: Testicular torsion is an important and critical issue in patients with acute scrotum referring to emergency department (ED). Early detection is very important to save the testicles. This study aimed to determine the diagnostic accuracy of clinical variables in predicting the presence of testicular torsion. METHODS: This prospective cross-sectional study was done using the information of patients hospitalized from September 2015 to September 2020, with complaint of acute scrotum (ICD 10 code: N50.8), referring to ED for evaluation of the clinical predictors of testicular torsions, which were confirmed by surgery. RESULTS: 81 patients with the mean age of 20.07 ± 9.64 (3- 45) years were studied. After surgical exploration, 70 patients (86.4%) had testicular torsion. Patients with torsion had lower age (p < 0.0001), lower time from symptom to ED visit (p < 0.0001), sudden onset pain (p = 0.003), left side pain (p < 0.0001), and lower white blood cell (WBC) count (p = 0.001). The frequency of dysuria (p = 0.032), diarrhea/vomiting (p = 0.005), and fever (p = 0.002) was significantly lower in patients with torsion. The cremasteric reflex was absent in 57 (81.4%) cases who suffered from testicular torsion (p = 0.001). Based on the results of binary logistic regression analysis, age (B = -0.175, SE = 0.45; p < 0.0001) was the sole independent predictor of testicular torsion. The highest area under the receiver operating characteristics (ROC) curve in predicting the presence of torsion belonged to lower age [91.0 (95%CI: 83.2 - 98.7)], pain in left testis [0.931 (95%CI: 0.828-0.987)], and lower WBC count [0.805 (95%CI: 0.684-0.926)], respectively. CONCLUSION: It seems that clinical variables are not accurate enough to be considered as the sole predictor of testicular torsion and they should be used with caution and in combination with other available screening tools like Doppler ultrasonography in this regard.

The Effect of Intravenous Magnesium Sulphate as an Adjuvant in the Treatment of Acute Exacerbations of COPD in the Emergency Department: A Double-Blind Randomized Clinical Trial.

BACKGROUND: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are serious complications that often require immediate intervention in an emergency department (ED). The aim of this study was to investigate the effect of intravenous magnesium sulphate as an adjuvant in the treatment of AECOPD in the ED. METHODS: In a double-blind, randomized clinical trial, a total of 60 patients with AECOPD presenting to the ED of Imam Khomeini Hospital in Sari, Iran, were included. The study was conducted between September 2016 and February 2018. Eligible patients were randomly allocated into two groups of intervention and control. Patients in the intervention and control groups received intravenous infusion of magnesium sulfate (2 gr) or normal saline over 30 minutes, respectively. For all patients, Borgdyspnea score, forced expiratory volume in one second (FEV1) result and clinical variables of interest were evaluated before the beginning of the intervention, and also 45 minutes and 6 hours after the commencement of intervention. RESULTS: Regardless of time of evaluation, pulse rate (PR), respiratory rate (RR) and Borg score in intervention group was lower than control group. Also, FEV1 and SPO2 were greater in intervention group compared to control group. However, these differences were not statistically significant (between-subject differences or group effect) (p<0.001). The trends of FEV1, SPO2, PR, RR and Borg score were similar between two groups of study (no interaction effect; P>0.05). CONCLUSION: According to the results of this study, it seems that using intravenous magnesium sulfate has no significant effect on SPO2, FEV1, RR, and PR of patients with AECOPD who presented to ED.

The predictive role of amylase and lipase levels on pancreas injury diagnosis in patients with blunt abdominal trauma.

Objectives Despite the low incidence of pancreatic injury in the abdominal blunt trauma (BTA), its early diagnosis is very important; since pancreatic injury is associated with high rates of morbidity and mortality. However, due to the high association of pancreatic injury with injury of other abdominal organs, its diagnosis may be delayed and complicated. The use of imaging modalities is also subject to limitations for reasons such as cost, unavailability, and harmfulness. Consequently, the present study aimed to investigate the predictive role of amylase and lipase enzyme levels in the final diagnosis of pancreatic injury in patients with BTA. Methods In a prospective diagnostic study, 384 patients with BTA referring to Imam Khomeini hospital of Sari (north of Iran) were enrolled according to the inclusion and exclusion criteria. Initial patient data including age and sex were recorded. Blood samples were analyzed in the laboratory to measure complete blood count (CBC), amylase and lipase enzyme levels. Patients were followed up during hospitalization and focal ultrasound for abdominal trauma (FAST), CT-Scan and laparotomy results were recorded. Finally, the data was analyzed using SPSS version 22. Results The level of amylase enzyme was significantly higher in males (p = 0.04), but the level of lipase enzyme was not significantly different between two genders (p > 0.05). The most common symptoms and signs in patients were pain, tenderness, and hematoma, respectively. The frequency of pancreatic injury in all patients with blunt abdominal trauma was 7.5% based of FAST, 7% based on CT-Scan and 12.4% based on laparotomy. Comparison of laboratory findings based on FAST, CT-Scan and laparotomy results showed that the level of amylase and lipase enzymes in patients with internal organ and pancreatic damage were higher than in patients without internal organ injury (p < 0.05). But based on FAST results; patients with pancreatic injury and injury of other organs had no significant difference (p > 0.05). However, comparison of laboratory findings based on CT-Scan and laparotomy results showed a significant increase in the level of amylase and lipase enzymes in patients with pancreatic trauma compared to patients with injury of other organs (p < 0.001). Conclusions The results of this study showed that pancreatic injury in blunt trauma is associated with a significant increase in levels of amylase and lipase enzymes. In addition, an increase in levels of amylase and lipase enzymes is associated with internal organ damage. Serum amylase and lipase levels can be used as useful biomarkers to decide whether to perform CT-Scan or laparotomy.

Demographic and epidemiologic evaluation of mushroompoisoning: a retrospective study in 4-year admissions of Razi Hospital (Qaemshahr, Mazandaran, Iran).

Aim Wild mushroom intoxication is a public health problem, which causes a wide range of symptoms: from mild gastrointestinal symptoms to multiple organ failure and death. The present study aims to evaluate the epidemiology of mushroom intoxication in 4-year admissions of Razi Hospital, Qaemshahr, Mazandaran, Iran. Methods Medical records of all identified cases of mushroom poisoning admitted during the period between 2015 and 2018 were extracted and patients' demographic data including age, sex, latency period, season of poisoning, clinical presentations, laboratory findings, prognosis, duration of hospitalization and therapeutic interventions were recorded. Results A total of 65 mushroom poisoning cases were identified (mean age of 35.68 years), of which 32 (49.2%) were females. Latency of ≤ 6 hours was seen in 63 (96.4%) cases. The most prevalent season of intoxication was spring (60.7%). The most frequent symptoms were nausea and vomiting (86.5%) and abdominal pain (51.2%). No case required intensive care unit (ICU) care or mechanical ventilation. Mean hospital stay was 1.89 days without any mortality. Mean aspartate aminotransferase (AST) level was 21.89 (±9.55), but the disturbance of liver function tests (LFTs), coagulopathy, elevated level of bilirubin and/or platelet was not noted. In 93% of patients ranitidine, in 7% Penicillin G, and in 3.6% cefaclor and ceftriaxone was administrated. Conclusion People and health care providers must be educated about mushroom poisoning. Prompt transfer of suspicious cases with history of wild mushroom ingestion to the emergency department is crucial since patients showing toxicity symptoms after 6 hours might have worse and mortal prognosis despite treatment.

Minor Head Trauma and its Short-term Outcomes Among Elderly Patients: a Prospective Epidemiological Study in North of Iran.

INTRODUCTION: Traumatic brain injury (TBI) is of the most challenging public health problems. AIM: The aim of this study was to investigate the epidemiology of mild TBI, frequency of clinically important head injuries identifiable on computed tomography (CT) scans and also short-time outcomes of mild TBI in elderly population in north of Iran. PATIENTS AND METHODS: A prospective epidemiological study was conducted at the Emergency department of Imam Khomeini general hospital, Mazandaran, Iran. Inclusion criteria were age older than 60, Glasgow coma scale (GCS) score of 13-15, and a single head trauma. Data were collected by retrospective chart review, interview with patients or their caregivers and contact with them after a week from time of discharge or transferring to another wards. RESULTS: Response rate was estimated at 67.8% (n: 122/180). Mean age of patients was 65.54±6.42 years. 82% of patients were younger than 70. Mean time from head trauma to hospital admission was 270 minutes. In majority of patients, mechanism of trauma was fall (28%) and then interpersonal violence (25%). 6.6% (95% CI: 2.87 to 12.5%) of patients suffered from important radiologically head injuries and 2.5% (95% CI: 0.5-7.00) were readmitted to hospital within a week. CONCLUSION: Time to admission for minor TBI in elderly patients was too long and could be of clinical concern. Considering the lower prevalence of important radiologically head injury among elderly population, using any clinical guideline for indication of CT scan may be more cost-effective than routine use of CT scan. Although short term outcomes of minor TBI were less threatening and not lethal but these patients need follow-up.

One-Month Follow-Up of Patients with Unspecified Abdominal Pain Referring to the Emergency Department; a Cohort Study.

INTRODUCTION: About one third of patients referring to emergency department (ED) with abdominal pain, are discharged without a definite diagnosis. This study aimed to investigate the one-month outcome of patients with unspecified abdominal pain. METHODS: This cohort study was conducted on subjects who were evaluated in ED with unspecified abdominal pain and were referred to the gastroenterology clinic and followed for one month. Finally, they were divided into two groups of cases with clear cause of abdominal pain and unclear cause of abdominal pain and patients' characteristics were compared between the groups. RESULTS: 150 cases with the mean age of 40.68 ± 18.34 years were studied (53.3% female). After one month, 67 (44.7%) patients still complained of abdominal pain. A definitive cause of abdominal pain was established in 88 (58.7%) cases. There was not any significant difference between groups regarding, sex distribution (p = 012), duration of pain (p = 0.11), history of previous similar pain (p = 0.136), pain radiation (p = 0.737), length of hospital stay (p = 0.51), and presence of anorexia (p = 0.09), nausea and vomiting (p= 0.50), fever (p = 1.0), diarrhea (p = 0.23), and constipation (p = 0.07). There was a significant difference between the groups regarding location of pain (p = 0.017), age (p = 0.001) and history of comorbid diseases (p = 0.046). The predictive factors of finding a clear cause for abdominal pain in one-month follow-up, were leukocytosis (OR: 5.92 (95% CI: 2.62 - 13.39); p < 0.001), age (OR: 2.78 (95% CI: 1.15 - 6.71); p = 0.023), and outpatient follow-up (OR: 1.04 (95% CI: 1.02 - 1.07); p < 0.001). CONCLUSION: Approximately, 40% of patients who were discharged with unspecified abdominal pain did not receive a clear diagnosis after one month of follow-up. Older age, leucocytosis in initial evaluations, and outpatient follow-up increased the probability of finding a clear cause for abdominal pain in the mentioned cases.

Diagnostic Accuracy of a Three-point Compression Ultrasonography Performed by Emergency Medicine Resident for the Diagnosis of Deep Vein Thrombosis: a Prospective Diagnostic Study.

INTRODUCTION: Deep vein thrombosis (DVT) is a common cause of admission to the emergency departments (ED). Doppler ultrasonography of the entire lower limb is the first-line imaging modality. But most EDs do not access to full-time radiologists which can lead to delayed diagnosis. AIM: The aim of this study was to evaluate the diagnostic accuracy of three-point compression ultrasonography performed by emergency medicine resident for diagnosis of DVT. METHODS: This prospective diagnostic study was carried out at Imam Khomeini Hospital in Sari from March 2018 to November 2018. For all patients with suspected lower extremity DVT, first bedside 3-point compression ultrasound were performed by a third year emergency medicine resident at ED. Then Doppler ultrasonography were performed by a radiologist in the radiology department, as a reference test. Sensitivity, specificity, and positive predictive value of the three-point compression ultrasound performed by emergency medicine resident was calculated. RESULTS: Of the 72 patients enrolled in our study, 50% of the patients were male, with an average age of 36±19 years. The mean of patient admission time to perform ultrasonography by an emergency medicine resident and radiologist were 14.05±19 and 216±140.1 minutes, respectively. The two groups had a statistically significant difference (P<0.0001). In ultrasonography performed by emergency medicine resident and doper ultrasonography by radiologist, 91.67% and 36.1% of patients were diagnosed with DVT, respectively. Although the ultrasonography performed by emergency medicine resident has a relatively low sensitivity (53.8%), it has a good specificity (85.7%). The positive and negative predictive value was 70 and 75%, respectively. CONCLUSION: Although the results of this study indicate insufficient sensitivity of bedside three-point compression ultrasound performed by emergency medicine resident in diagnosis of lower limb DVT, the specificity, positive and negative predictive values and positive likelihood ratio were almost appropriate.

The prevalence of post-traumatic stress disorder among emergency nurses: a cross sectional study in northern Iran.

BACKGROUND AND OBJECTIVE: Posttraumatic stress disorder (PTSD) is one of the anxiety disorders which occurs in response to facing events and accidents accompanied by fear, frustration, and terror. Nurses who worked in the emergency departments witness unpleasant accidents and are exposed to stress and violence more than others. The aim of this study was to investigate the prevalence of PTSD among Iranian nurses working in the emergency department. MATERIALS AND METHODS: In this cross-sectional study, all nurses working in the emergency department of educational hospitals affiliated with Mazandaran University of Medical Sciences were included through census method (n = 131). Each of the participants in this study responded to the questionnaires individually. The first part of the questionnaire captured demographics, while the second part was the Civilian Mississippi Scale for PTSD, which was used to investigate the extent of PTSD in this study. Data were analyzed using SPSS version 22. RESULTS: In this study, 131 respondents were included. In the classification of age, nurses with 20-30-year- old had the maximum frequency (41.2 %,). Most nurses in the study (93.1%, n = 122) had a bachelor's degree in nursing and 84 were married. The prevalence of PTSD in emergency nurses was 82.96%, which was higher in nurses with shorter working background and nurses with lower levels of education. Further, the average score of PTSD was higher in married nurses. CONCLUSION: The results of this study revealed the high prevalence of PTSD among nurses who worked in emergency department. Therefore, it seems that designing and providing supportive and educational services to emergency nurses can be effective for preventing and managing this disorder, which probably can improve their performance.

Prognostic Value of Cardiac Troponin I and T on Admission in Mortality of Multiple Trauma Patients Admitted to the Emergency Department: a Prospective Follow-up Study.

INTRODUCTION: The relationship between increased levels of cardiac troponins and morbidity and mortality of traumatic patients is not still well recognized. AIM: The aim of this study was to investigate the prognostic value of cardiac troponin I and T on admission in mortality of multiple trauma patients admitted to the emergency department. METHODS: In this prospective follow-up study, the cardiac troponin I and T levels were measured in patients with multiple trauma referring to the emergency department (ED) between March 2014 and February 2015 at Imam Khomeini Hospital, Sari, Iran. Patients were followed prospectively until discharge from hospital or death. RESULTS: The levels of cardiac troponins I and T in patients with multiple trauma were significantly associated with their mortality, especially at the level of 0.5 and 1.2 µg/dl (p<0.05). Multivariate regression analysis showed association of level of cardiac troponin I and T with patients' mortality, after controlling for patients' age, vital signs and GCS on admission. The sensitivity and specificity of troponin I at levels greater than 0.4 µg/dl in predict mortality in this study were as 65.5% and 55.3%, while the values for troponin T were 65.1% and 54.9%, respectively. CONCLUSION: Elevated cardiac troponin I and T levels provide excellent prognostic information regarding mortality in patients with multiple-trauma, independent of age, hemodynamic variables and GCS score.

Investigation of Frequency of the Lethal Triad and Its 24 Hours Prognostic Value among Patients with Multiple Traumas.

BACKGROUND: Death in multiple trauma (MT) patients is one of the serious concerns of the medical service provider. Any prediction of the likelihood of death on the assessment of the patient's condition is performed using different variables, one of the tools in the triage of patients to determine their condition. AIM: We aimed to investigate the frequency and the predictive value of death in 24 hours triad of death in patients qualified with multiple traumas admitted to Imam Khomeini hospital. METHODS: This was a prospective cross-sectional study to determine the prevalence and predictive value of 24-hour triad of death among patients with MT referred to an emergency department. Three factors including acidosis, hypothermia and coagulopathy and predictive value of 24-hour death were evaluated. Arterial blood gas, oral temperature and blood samples for coagulation factors were analysed. Data were analysed using SPSS version 19. Multivariate analysis (logistic regression) was used to determine the predictive value of the triad of death. RESULTS: A group of 199 MT patients referring to Imam Khomeini hospital during the first 6 months of 2015 were evaluated for the first 24 hours of admission. Logistic regression analysis showed that using the following formula based on the triad of death can predict death in 96% of cases can be based on the triad of a death foretold death upon admission to the emergency room. It should be noted that this prediction tool as 173 people left alive after 24 hours as live predicts (100% correct). CONCLUSION: The triad of death is one of the tools in the triage of patients to determine their condition and care plan to be used, provided valuable information to predict the prognosis of patients with a medical team.

The Efficacy and Safety of Prochlorperazine in Patients With Acute Migraine: A Systematic Review and Meta-Analysis.

OBJECTIVE: The aim of this review was to evaluate the efficacy and safety of prochlorperazine (PCP) in patients with acute migraine headache in the emergency department (ED). METHODS: Electronic databases (Medline, Scopus, Web of Science, and Cochrane) were searched for randomized clinical trials that investigated the effect of PCP on headache relief. The outcomes were the number of patients without headache or with reduced headache severity, the number of adverse events, and the need for rescue analgesia. RESULTS: From 450 citations, 11 studies (n = 771) with 15 comparison arms met the inclusion criteria. Overall, PCP was more effective than placebo (OR = 7.23; 95% CI = 3.82-3.68), metoclopramide (OR = 2.89; 95% CI = 1.42-5.86), and other active comparators (OR = 3.70; 95% CI = 2.41-5.67) for headache relief. The odds ratio of experiencing adverse events with PCP compared with placebo was 5.79 (95% CI = 2.43-13.79). When PCP compared with other active comparators, no statistical difference was found regarding the overall number of adverse events (OR = 1.88; 95% CI = 0.99-3.59). However, PCP significantly increased the odds of akathisia/dystonia (OR = 2.55; 95% CI = 1.03-6.31). The request for rescue analgesia was significantly lower in the PCP group compared with other groups (16% vs 84%; OR = 0.16; 95% CI = 0.09-27). CONCLUSIONS: For adult patients with acute migraine, PCP could effectively abort the acute attack and reduce the request for rescue analgesia in the ED. However, compared with placebo, PCP could increase the risk of adverse events.

Comparing the analgesic efficacy of morphine plus ketamine versus morphine plus placebo in patients with acute renal colic: A double-blinded randomized controlled trial.

OBJECTIVES: Renal colic (RC) is a common cause for emergency department visits. This study was conducted to compare the analgesic efficacy of morphine plus ketamine (MK) versus morphine plus placebo (MP) in patients with acute renal colic. METHOD: Using a single center, double-blind, two-arm, parallel-group, randomized controlled trial, 200 patients were equally and randomly divided to receive 0.1 mg/kg morphine plus normal saline and 0.1 mg/kg morphine plus 0.2 mg/kg ketamine. The severity of renal colic was assessed by VAS at baseline, 20 and 40 min after drug injection. The number of adverse events also was recorded. RESULTS: Totally, 200 patients completed the study. Mean age of the patients was 35.60 ±â€¯8.17 years. The patients were mostly men (68.5%). The severity of pain between the groups was not significantly different at baseline. Both groups showing a significant reduction in VAS scores across the three time points. The main effect comparing the two types of intervention was significant (F = 12.95, p = 0.000), suggesting a significant reduction in pain severity of patients in the MK group. The number of patients who suffered from vomiting was significantly higher in MP group than that of MK group (13 and 3, respectively (P = 0.009)). However, the risk of dizziness in the MK group was >2 times higher than MP group (relative risk: 2.282, 95% CI: 1.030-5.003, P = 0.039). The number of patients who needed rescue analgesia was significantly lower in the MK group (OR, 0.43 (0.22-0.83)). CONCLUSION: Adding 0.2 mg/kg ketamine to 0.1 mg/kg morphine can reduce the renal colic pain, nausea and vomiting more than morphine alone; however, it was associated with higher number of patients with dizziness.

Efficacy and Safety of Morphine and Low Dose Ketamine for Pain Control of Patients with Long Bone Fractures: A Randomized, Double-Blind, Clinical Trial.

OBJECTIVE: To compare the effects of intravenous morphine and a low dose of ketamine on pain intensity of patients with traumatic fractures of the long bones. METHODS: This randomized, controlled, double-blinded, clinical trial was conducted in the adult emergency department (ED) of Emam Khomeini hospital, a tertiary general hospital affiliated with Mazandaran University of Medical Sciences, in Northern Iran, during a 6-month period. Patients were randomly assigned to receive intravenous morphine (0.1 mg/kg) or low dose ketamine (0.5 mg/kg) for control of the pain in the emergency room. The pain intensity was checked by a nurse using the visual analogue scale (VAS) at 30, 60, 90, 120, 180 and 240, minutes after the intervention. RESULTS: Overall we included a total number of 156 patients with mean age of 35.87±3.38 years. There were 111 (71.2%) men and 4 (28.8%) women among the patients. Patients were randomly assigned to receive intravenous morphine (n=78) or low dose ketamine (n=78). The pain intensity decreased significantly in both study groups after 240 minutes of intervention. However, there was no significant difference between the two study groups regarding the pain intensity at 30 (p=0.378), 60 (p=0.927), 90 (p=0.434), 120 (p=0.557), 180 (p=0.991) and 240 (p=0.829) minutes. The side effects were comparable while low dose ketamine was associated with higher need for rescue analgesic (p=0.036). CONCLUSION: The results of the current study demonstrates that the intravenous low dose ketamine leads to successful pain control in patients with long bone fractures and the effects are comparable with intravenous morphine.

Diagnostic Accuracy of Quick Stick for Identifying Traumatic Patients in Need of Tetanus Prophylaxis; a Cross-sectional Study.

INTRODUCTION: Based on the existing studies, measuring serum level of immunoglobulin for making decisions regarding prescription of tetanus prophylaxis seems logical and cost effective. Therefore, the present study was done with the aim of evaluating the diagnostic accuracy of tetanus quick stick (TQS) in comparison with ELISA method in this regard. METHODS: The present diagnostic accuracy study was carried out on trauma patients presenting to emergency department, who were in need of receiving tetanus prophylaxis due to dirty wounds or injuries. Patients' blood was evaluated regarding presence of anti-tetanus antibody via TQS and ELISA methods and screening performance characteristics of TQS in identifying the cases in need of receiving prophylaxis was calculated compared to ELISA as the reference test. RESULTS: 148 patients with the mean age of 34.58 ± 15.86 years (4-86) were studied (87.8% male). Agreement rate between the results of TQS and ELISA was 0.78 based on calculation of kappa coefficient. Sensitivity, specificity and area under the ROC curve of TQS were estimated to be 100 (95% CI: 96.50 - 100), 66.66 (95% CI: 38.68 - 86.01), and 0.83 (95% CI: 0.68 - 0.98), respectively. If TQS was used, the cost of treatment regarding use of tetabulin could have a 91.7% reduction. CONCLUSION: Based on the findings of the present study, TQS has good diagnostic accuracy in comparison with ELISA and considering its 100% sensitivity and negative predictive value in cases with dirty wound, it can be considered as a reliable tool for screening patients that do not need to receive anti-tetanus prophylaxis.

Efficacy and Safety of Combination Therapy with Ketorolac and Morphine in Patient with Acute Renal Colic; A Triple-Blind Randomized Controlled Clinical Trial.

OBJECTIVE: To compare the efficacy of combination therapy with ketorolac and morphine with monotherapy with each in patients with acute renal colic. METHODS: This triple-blind, randomized clinical trial was conducted during a 6-month period from March to September 2014 in Northern Iran. We included 300 patients with clinical diagnosis of acute renal colic and pain score greater than 4 on 10 cm visual analogue scale (VAS) score. Patients were randomly assigned to three study groups to receive 0.1 mg/kg morphine in combination with 30 mg ketorolac (n=100), or only 0.1 mg/kg morphine (n=100) or only 30mg ketorolac (n=100). All the patients were evaluated at 0, 20 minute,40 minute later. Our outcomes were pain reduction and need for additive morphine in 20 and 40 minutes. We also recorded and compared the adverse effects between the study groups. RESULTS: There was no significant difference between the study groups. The pain intensity was comparable between three study groups after 20-min of intervention. However, we found that the pain intensity was significantly lower in balanced analgesia group when compared to morphine (3.01±0.98 vs. 3.66±1.02; p=0.012) or ketorolac alone (3.01±0.98 vs. 3.68±0.88; p=0.018). However, those receiving the balanced analgesia, required significantly less rescue analgesia when compared to morphine (16% vs. 20%; p=0.041) or ketorolac (16% vs. 24%; p=0.012) alone. CONCLUSION: Balanced analgesia with morphine and ketorolac is more effective compared to morphine or ketorolac alone determine by lower pain scores after 40-min of injection and lower need for rescue analgesia.

Theoretical study of electron transfer process between fullerenes and neurotransmitters; acetylcholine, dopamine, serotonin and epinephrine in nanostructures [neurotransmitters].C n complexes.

Neurotransmitters are the compounds which allow the transmission of signals from one neuron to the next across synapses. They are the brain chemicals that communicate information throughout brain and body. Fullerenes are a family of carbonallotropes, molecules composed entirely of carbon, that take the forms of spheres, ellipsoids, and cylinders. Various empty carbon fullerenes (Cn) with different carbon atoms have been obtained and investigated. Topological indices have been successfully used to construct effective and useful mathematical methods to establish clear relationships between structural data and the physical properties of these materials. In this study, the number of carbon atoms in the fullerenes was used as an index to establish a relationship between the structures of neurotransmitters (NTs) acetylcholine (AC) 1, dopamine (DP) 2, serotonin (SE) 3, and epinephrine (EP) 4 as the well-known redox systems and fullerenes C n (n = 60, 70, 76, 82, and 86) which create [NT].Cn; A-1 to A-5 up to D-1 to D-5. The relationship between the number of carbon atoms and the free energy of electron transfer (ΔG et(n); n = 1-4) is assessed using the Rehm-Weller equation for A-1 to A-5 up to D-1 to D-5 supramolecular [NT].Cn complexes. The calculations are presented for the four reduction potentials ( (Red.) E 1 to (Red.) E 4 ) of fullerenes C n . The results were used to calculate the four free energy values of electron transfer (ΔG et(1) to ΔG et(4)) of the supramolecular complexes A-1 to A-8 up to D-1 to D-8 for fullerenes C60 to C120. The first to fourth free activation energy values of electron transfer and the maximum wavelength of the electron transfers, ΔG (#) et(n) and λ et (n = 1-4), respectively, were also calculated in this study for A-1 to A-8 up to D-1 to D-8 in accordance with the Marcus theory.

Oral verapamil in paroxysmal supraventricular tachycardia recurrence control: a randomized clinical trial.

BACKGROUND: Adenosine is the first-line medication in patients with paroxysmal supraventricular tachycardia. Because it is cleared so rapidly from the circulation, recurrence of paroxysmal supraventricular tachycardia after initial successful conversion may occur. OBJECTIVE: This study was conducted to evaluate the role of oral verapamil administration to control early recurrences of paroxysmal supraventricular tachycardia after adenosine infusion. METHODS: Patients with acute paroxysmal supraventricular tachycardia and no contraindications for adenosine or verapamil treatment were included in study. All patients received an adenosine protocol (6 mg rapid bolus intravenous injection followed by two repeated doses of 12 mg if necessary). Patients in the adenosine-only group did not received any other medications but patients in the adenosine/verapamil group received 40 mg verapamil orally immediately after converting the rhythm to sinus rhythm. All patients were followed up for 6 h in the acute care area of the emergency department under continuous cardiac monitoring. RESULTS: A total of 113 patients were assessed for eligibility and 92 patients were randomized into two groups (adenosine only versus adenosine/verapamil). There was no statistically significant difference in paroxysmal supraventricular tachycardia recurrence rate between the two groups in the first 30 min after treatment. Recurrence rate was statistically significantly lower in the adenosine/verapamil group than in the adenosine-only group between 30 and 120 min after treatment and thereafter. Two patients in the adenosine-only group experienced flushing and one patient in the adenosine/verapamil group experienced decreased systolic blood pressure. CONCLUSION: Oral verapamil can decrease paroxysmal supraventricular tachycardia recurrence after successful control with intravenous adenosine.