Evaluating anemia on non-contrast thoracic computed tomography.

Anemia is a major global disease burden factor linked to an adverse impact on overall prognosis and negatively affects the quality of life. There are some suggested findings for anemia on non-contrast chest CT, like relatively dense interventricular septum (septal sign) or fairly dense aortic wall (aortic ring sign). The measured attenuation value is a reproducible physical density measurement, readily obtainable from a standard CT examination. There is no reliable cut-off for blood attenuation to suggest anemia on the non-contrast chest CT. In the current study, we evaluated subjective and objective criteria' diagnostic accuracy for diagnosing anemia on unenhanced thoracic CT. This study is approved by Mashhad University of Medical Sciences. The patients admitted in the internal medicine ward of our hospital from June 2019 to March 2020 for whom a non-contrast chest CT was acquired for any non-traumatic medical indication, were enrolled in this retrospective study. For the subjective assessment, the radiologists were asked to record the presence or absence of the "aortic ring sign" and "interventricular septum sign". For the objective evaluations, blood density was measured at various anatomic locations. A total of 325 patients were included in this study. There was a significant correlation between blood attenuation in all measured segments and Hb level (0.78 (R2: 0.61), p = 0.000). Findings revealed that considering the aortic arch threshold value as 20 HU is the best diagnostic performance for detecting severe anemia. Subjective analysis revealed that the aortic ring sign was more sensitive (82.5%) than the interventricular septum sign (32%) in detecting anemia, whereas the latter character was more specific (87% and 99.2%, respectively). The results suggest that it is possible to detect anemia from an unenhanced chest CT scan. Both objective and subjective criteria show promising sensitivity and specificity.

Global burden of the COVID-19 associated patient-related delay in emergency healthcare: a panel of systematic review and meta-analyses.

BACKGROUND: Apart from infecting a large number of people around the world and causing the death of many people, the COVID-19 pandemic seems to have changed the healthcare processes of other diseases by changing the allocation of health resources and changing people's access or intention to healthcare systems. OBJECTIVE: To compare the incidence of endpoints marking delayed healthcare seeking in medical emergencies, before and during the pandemic. METHODS: Based on a PICO model, medical emergency conditions that need timely intervention was selected to be evaluated as separate panels. In a systematic literature review, PubMed was quarried for each panel for studies comparing the incidence of various medical emergencies before and during the COVID-19 pandemic. Markers of failure/disruption of treatment due to delayed referral were included in the meta-analysis for each panel. RESULT: There was a statistically significant increased pooled median time of symptom onset to admission of the acute coronary syndrome (ACS) patients; an increased rate of vasospasm of aneurismal subarachnoid hemorrhage; and perforation rate in acute appendicitis; diabetic ketoacidosis presentation rate among Type 1 Diabetes Mellitus patients; and rate of orchiectomy among testicular torsion patients in comparison of pre-COVID-19 with COVID-19 cohorts; while there were no significant changes in the event rate of ruptured ectopic pregnancy and median time of symptom onset to admission in the cerebrovascular accident (CVA) patients. CONCLUSIONS: COVID-19 has largely disrupted the referral of patients for emergency medical care and patient-related delayed care should be addressed as a major health threat.

Accuracy of the Emergency Department Triage System using the Emergency Severity Index for Predicting Patient Outcome; A Single Center Experience.

OBJECTIVE: To evaluate the accuracy of the five-level triage system using the emergency severity index (ESI) and to determine the compliance of the triage level with patient outcomes. METHODS: This was a cross-sectional study which was performed in the emergency department of Imam Reza Hospital of Mashhad during 2017. We included all the adult patients (≥15 years of age) referring to the emergency department. The data were recorded in a questionnaire containing three sections including demographic information, results of triage by ESI and final outcome of the patient. Patients referred to the triage unit were simultaneously triaged by triage nurse and some emergency medicine physicians. The triage was performed by a nurse with an emergency medicine physician (EMP) was considered as a gold standard and the outcome was compared in 24 hours later. RESULTS: Overall, we included 400 patients with a mean age of 46.40 ± 18.52 years among whom there were 211 (52.8%) men and 189 (47.3%) women. Finally, 123 patients were hospitalized, 12 died, 256 were discharged by a physician, and 9 people left the hospital with their own consent. The calculated weight kappa was used to determine the agreement between the observers (nurse triage and physician) at 0.701 so that the agreement between the triage performed by a nurse and an EMP was in an excellent level (p<0.001). There was a significant relationship between the triage levels (determined by physicians) and the outcome of the patient (p<0.001), and the five-level system had a high overlap and significant relation with patient's outcome. CONCLUSION: The results of the current study revealed that the five-level triage system using the ESI has a high accuracy in triage and estimates the patient outcomes effectively and thus, could be used as an effective system in hospital triage.

Quebec Decision Rule in Determining the Need for Radiography in Reduction of Shoulder Dislocation; a Diagnostic Accuracy Study.

INTRODUCTION: The Quebec Decision Rule (QDR) has been developed for deciding on the necessity of radiography for patients with shoulder dislocation. This study aimed to investigate the diagnostic value of QDR in this regard. METHOD: This diagnostic accuracy study was conducted on patients with shoulder dislocation visiting the emergency department. After filling out the QDR-based checklist for all patients, they underwent radiography and the obtained radiography results were compared to QDR-based clinical diagnostic findings. RESULTS: 143 patients with the mean age of 32.1±12 years were evaluated (88.8% males). Sensitivity, specificity, and positive and negative predictive values of QDR were 50%, 58.2%, 3.3%, and 97.6%, respectively. The sensitivity and specificity were 100% and 50% in patients >40 years old, and 33.3% and 59.8% in those <40 years old. These indices were 33.3% and 60.4%, respectively, in the male sex and 100% and 40% in the female sex. CONCLUSION: | Quebec decision rule holds promise to diagnose concomitant fractures in patients over the age of 40 with 100% sensitivity, thereby reducing the number of radiographies by 50% without causing diagnostic errors. In contrast, this criterion proved inefficient in patients younger than 40. |.

Surgical outcome and clinicopathological characteristics of emergency presentation elective cases of colorectal cancer.

INTRODUCTION: The aim of this study was to evaluate the significance of clinicopathological characteristics of colorectal cancer patients undergoing emergency and elective surgery. MATERIAL AND METHODS: In total, 116 tumors from patients treated surgically for colorectal cancer at four hospitals in Tehran between 2008 and 2013 were analyzed in the current study. RESULTS: Our findings revealed that the emergency cases were significantly more likely to have an advanced TNM stage (p = 0.027) and histologic grade (p = 0.01) compared with the elective patients. Furthermore, the nature of surgery was significantly associated with vascular and perineural invasion (p = 0.021; p = 0.001). We also evaluated the association of gender, age, and tumor location with the nature of surgical presentation. However, no association was found between these parameters and the nature of surgery. Emergency was also correlated with greater length of hospital stay and higher rate of admission to the intensive care unit. The mortality rate was 20% in emergency cases, while patients with elective surgery had 5.63% perioperative mortality (p = 0.001). The emergency patients had a higher rate of mortality. CONCLUSIONS: Our data indicated that colorectal cancer patients undergoing emergency surgery showed an advanced stage. The emergency patients had a higher rate of mortality than elective cases.

Investigation of clinicopathological parameters in emergency colorectal cancer surgery: a study of 67 patients.

INTRODUCTION: The aim of the present study was to establish, having adjusted for case mix, the size of the differences in postoperative mortality and 5-year survival between patients presenting as an emergency with evidence of obstruction and perforation and the association of clinicopathological factors with mortality (bivariate analyses). MATERIAL AND METHODS: The study included 67 patients who presented with colorectal cancer (CRC) between 2009 and 2013 in Iran. The mean age of the patients was 59.7 years. Of the 67 patients, 37 (55.22%) were male and 30 (44.77%) were female. Certain parameters that correlated with CRC and surgical treatment were investigated. RESULTS: Our results showed that 46 (68.65%) patients had obstruction, while perforation was observed in 21 (31.34%) cases. Among the patients with obstruction, obstruction of the right colon was observed in 29 (43.28%) cases. There was no significant difference in mortality rate between right and left colonic obstruction. Based on the bivariate analyses, our findings showed that death of patients was significantly related to tumor grade (p = 0.02) and TNM staging (p = 0.026), but no association was found between other parameters and death, including age, sex, and tumor site. CONCLUSIONS: Compared with patients who undergo elective surgery for colon cancer, those who present as an emergency with evidence of obstruction or perforation have higher postoperative mortality rates and poorer cancer-specific survival. Also, colorectal cancer patients with emergency surgery showed aggressive histopathology and an advanced stage.

Assessment of mechanism, type and severity of injury in multiple trauma patients: A cross sectional study of a trauma center in Iran.

PURPOSE: To accurately assess the mechanism, type and severity of injury in Iranian multiple trauma patients of a trauma center. METHODS: Patients with multiple traumas referring to the emergency department of Hasheminejad University Hospital in Mashhad, Iran, entered this cross sectional study from March 2013 to December 2013. All the patients with injury severity score (ISS) > 9 were included in this study. Data analysis was performed by SPSS software (Version 11.5) and P values less than 0.05 were considered as significant differences. RESULTS: Among the 6306 hospitalized trauma patients during this period, 148 had ISS>9. The male female ratio was 80%. The mean age of the patients was (33.5 ± 19.3) years. And 71% of the patients were younger than 44 years old. There were 19 (13%) deaths from which 68.5% were older than 44 years old. The mean transfer time from the injury scene to hospital was (55 ± 26) minutes. The most frequent mechanisms of injury were motorcycle crashes and falling from height, which together included 66.2% of all the injuries. A total of 84% of hospital deaths occurred after the first 24 h of hospitalization. Head and neck were the most common body injured areas with a prevalence of 111 cases (75%). CONCLUSION: Motorcycle crashes have high frequency in Iran. Since most victims are young males, injury prevention strategies should be considered to reduce the burden of injuries.

The Prognostic Value of Using Ultrasonography in Cardiac Resuscitation of Patients with Cardiac Arrest.

Cardiopulmonary arrest is the final result of many diseases and therefore, need for a careful implementation of cardiopulmonary resuscitation (CPR) protocols in these cases is undeniably important. The introduction of ultrasound into the emergency department has potentially allowed the addition of an extra data point in the decision about when to cease cardiopulmonary resuscitation (CPR). The aim of this study is to evaluate the ability of cardiac ultrasonography performed by emergency physicians to predict resuscitation outcome in adult cardiac arrest patients. Ultrasonographic examination of the subxiphoid cardiac area was made immediately after admission to the emergency department with pulseless cardiac arrest. Sonographic cardiac activity was defined as any detectable motion within the heart including the atria, ventricles or valves. Successful resuscitation was defined as: return of spontaneous circulation for ≥ 20 min; return of breathing; palpable pulse; measurable blood pressure. The present study includes 159 patients. The presence of sonographic cardiac activity at the beginning of resuscitation was significantly associated with a successful outcome (41/49 [83.7%] versus 15/110 [13.6%] patients without cardiac activity at the beginning of resuscitation). Ultrasonographic detection of cardiac activity may be useful in determining prognosis during cardiac arrest. Further studies are needed to elucidate the predictive value of ultrasonography in cardiac arrest patients.

Antibiotic Resistance Properties of Pseudomonas aeruginosa Isolated From Cases of Superficial Infections at the Emergency Unit.

BACKGROUND: Pseudomonas aeruginosa, a ubiquitous opportunistic pathogen, is one of the main causative agents of human superficial infections. Infections due to these bacteria are difficult to heal and cause serious economic issues. OBJECTIVES: The present study was carried out to investigate the antibiotic resistance pattern of P. aeruginosa isolated from cases of superficial infections referred to the emergency health care units of Iranian Hospitals. MATERIALS AND METHODS: Three hundred swab samples were collected from patients with superficial infections. Samples were cultured and those that were P. aeruginosa positive were analyzed by the disk diffusion method. RESULTS: One hundred and seventy-two out of 300 swab samples (57.3%) were positive for P. aeruginosa. The results of the culture technique were also confirmed using the polymerase chain reaction (PCR). Females had a higher prevalence of P. aeruginosa than males, patients older than 70 years were the most infected age group and finally burn infections had the highest prevalence of bacteria. P. aeruginosa strains had the highest levels of resistance against ampicillin (93%), gentamycin (89.5%), ciprofloxacin (82.5%) and amikacin (77.3%). The most effective drugs were meropenem (2.3%, imipenem (2.9%), polymyxin B (21.5%) and cotrimoxazole (31.9%). CONCLUSIONS: It is logical to primarily prescribe meropenem, imipenem, polymyxin B and cotrimoxazole in the cases of superficial infections caused by P. aeruginosa. Medical practitioners should be aware of the presence of such levels of antibiotic resistance in cases of superficial infections in Iran.

The Diagnostic Value of MRI in Brucella Spondylitis With Comparison to Clinical and Laboratory Findings.

BACKGROUND: Brucellosis is an endemic zoonotic disease, especially in the Middle East and Mediterranean regions and can involve many organs and tissue. Osteoarticular involvement is the most common complication. Spondylitis is its most prevalent clinical form in adults, and there may be difficult in diagnosis and treatment. In present study, we aimed to assess these diagnostic value of MRI, in patients with spondylitis due to brucella, comparing with clinical and laboratory findings. METHOD: Patients with low back pain who were admitted to Sheikhol-raees MRI center were included in this study. None of these patients had any documented infectious disease. Diagnosis of brucellosis was made, based on MRI findings, which would be approved by serology. After confirmation with serology, the group with positive serology were compared with the negative group, in sex, age, MRI findings level of vertebral involvements, signal intensity in T1 weighted and T2 weighted. RESULTS: Among 53 patients with diagnosis of brucella spondylitis, 33 underwent serology study, 20 were positive and 13 were negative and the others consider out of study. From these 20, 3 had tuberculosis spondylitis, whose mean age was 56 and the 67% of them were male. Mean age in the positive brucella spondylitis were 46 and 67% of them were male. In negative group mean age was 55, and of whom 57% were male. There was no statistically significant difference in MRI findings such as changes in signal intensity, disk space narrowing, Intracanalicular mass, Abscess formation. Level of invlovment in vertebrae. CONCLUSION: The results of this study shows that although MRI is Modality of choice in diagnosis of spondylitis, it is not enough specific to diagnosis the reasons of spondylitis.

THE ROLE OF LACTATE CLEARANCE AS A PREDICTOR OF ORGAN DYSFUNCTION AND MORTALITY IN PATIENTS WITH SEVERE SEPSIS.

BACKGROUND: Little is known about biomarkers which are used to classification of patients in order to diagnosis severity of sepsis among clients of emergency units. It seems that Lactate's clearance can be used in this regard. This study aimed to determine the relationship between Lactate's clearance, mortality and organ's dysfunction with severe sepsis. MATERIALS AND METHODS: In this study 90 patients with severe sepsis, were visited and examined exactly. Para clinical tests, serum venous lactate, organ's dysfunction scores, Acute Physiology and Chronic Health Evaluation II (APACHE-II) and Sequential Organ Failure Assessment (SOFA) were applied upon admission and 6 hours after it. According to clinical and laboratory criteria, dysfunction in main organs were examined and Lactate's Clearance was accounted. All the patients were cured according to early goal-directed therapy protocol. RESULTS: Among the participants 49 and 41 were male and female respectively. The mean age of the group was 49.37±1.41. The patients were classified to groups, less or more than 10% lactate's clearance. Mortality rate of the patients was 18.9% (17 people). Mean age of the dead group was 49.71±13.33. The mean of dysfunctional organs which is assessed in terms of clinical, laboratory and SOFA criteria was significantly higher among the dead group than other. The Lactate's clearance in the dead group was significantly lower than the other group (p<.05). CONCLUSION: It was concluded that patients with severe sepsis is a marker which is related to tissue hypoxia, also lactate's clearance increasing is related to drastic reduction in biomarkers, mortality, and incidence of organ's dysfunction. Overall, patients with lower lactate's clearance are counted a high risk group for mortality and organs' dysfunction.

Vancomycin-Resistant Pseudomonas Aeroginosa in the Cases of Trauma.

BACKGROUND: One of the main problems in the treatment of cases of P. aeruginosa especially in the orthopedic infections is the occurrence of high antibiotic resistance. The present study was carried out in order to investigate the prevalence of vancomycin-resistant P. aeruginosa in the cases of trauma in Iran. METHODS: Two hundred and fifty swab samples were collected from the site of trauma from the patients who referred to the orthopedic wards of the Iranian health centers. Samples were cultured immediately and those that were P. aeruginosa-positive were analyzed by the disk diffusion method. RESULTS: Of 250 swab samples collected, 43 were positive for P. aeruginosa (17.2%). The results of the culture technique were also confirmed by the PCR reaction. Of 43 P. aeruginosa isolates, 32 strains (74.41%) were resistant to vancomycin. Total prevalence of bacteria in Tehran and Mashhad hospitals were 18.46% and 15.83%, respectively. Statistically significant difference was seen for the prevalence of vancomycin-resistant P. aeruginosa between the samples collected from Tehran and Mashhad (P =0.027). More than 55 years old and less than 10 years old patients had the highest prevalence of P. aeruginosa. P. aeruginosa strains of male and more than 55 years old patients harbored the highest levels of resistance against vancomycin. CONCLUSIONS: It is logical to primary identification of type of bacteria causing infection in the site of trauma and then using from the disk diffusion method to choose the best antimicrobial agent. Highest levels of health care should be performed for the patients less than 10 years and more than 55 years old patients.

Spontaneous pneumomediastinum with a rare presentation.

Spontaneous pneumomediastinum is an unusual and benign condition in which air is present in mediastinum. A 20-year-old male patient presented to ED with complaint of hoarseness and odynophagia from the day before, after weightlifting. The patient was nonsmoker and denied history of other diseases. On physical examination he had no dyspnea with normal vital signs. Throat examination and pulmonary auscultation were normal and no crepitation was palpable. We could not find subcutaneous emphysema in neck and chest examination. In neck and chest X-ray we found that air is present around the trachea. There was no apparent pneumothorax in CXR. In cervical and chest CT free air was present around trachea and in mediastinum. Subcutaneous emphysema was also evident. But there was no pneumothorax. The patient was admitted and went under close observation, oxygen therapy, and analgesic. The pneumomediastinum and subcutaneous emphysema gradually resolved within a week by conservative therapy and he was discharged without any complication. Many different conditions could be trigged because of pneumomediastinum but it is rarely seen in intense physical exertion such as weightlifting and bodybuilding. Two most common symptoms are retrosternal chest pain and dyspnea. But the patient here complained of hoarseness and odynophagia.

Scapular manipulation for reduction of anterior shoulder dislocation without analgesia: results of a prospective study.

OBJECTIVES: To the best of knowledge, this was the first study of scapular manipulation technique (SMT) in Asia. We conducted this prospective study to report our experiences of reducing anterior shoulder dislocation by SMT without analgesia in a large study group in Iran. METHODS: Scapular manipulation technique was applied to 111 patients presenting with anterior shoulder dislocation to the ED of the largest teaching hospital in north-east of Iran between January 2009 and January 2010. Reduction was performed without medication and if unsuccessful, the second attempt was carried out with i.v. injection of midazolam. We also evaluated the pain experienced by the patients immediately after reduction attempt. RESULTS: The study consisted of 112 dislocations (one patient had bilateral dislocation). We achieved a success rate of 87.5% without medication at the first attempt and 97.3% overall. In total, 98.2% of dislocations were reduced in less than 1 min. The success rate was significantly lower in the presence of greater tuberosity fractures and also in late presentations (>6 h after trauma). We showed a success rate of 100% in recurrent dislocations. Some 81.1% of the patients reported no pain or mild pain. No complications were observed. CONCLUSION: The results of our study showed that SMT even without medication is a safe, rapid and relatively painless technique in reducing anterior shoulder dislocation in the ED that might reduce medical resource utilization and can be cost-effective.