Epidemiology, clinical characteristics, and associated cost of acute poisoning: a retrospective study.

Introduction: Poisoning is a major public health issue and a leading cause of admission to the emergency department (ED). There is a paucity of data describing the epidemiology and cost of acute poisoning. Therefore, this study investigated the epidemiology, patterns, and associated costs of acute poisoning in emergency department of the largest tertiary care healthcare centre in Qatar. Method: This study was a retrospective review of the health records of patients admitted to the ED due to poisoning between January 2015 and December 2019. Incidence, clinical characteristics, and costs associated with acute poisoning were assessed. Frequency and percentages were calculated for categorical variables and mean and SD for continuous variables. The relationship between sociodemographic characteristics and poisoning profile was assessed using the chi-square test. A micro-costing approach using the cost of each resource was applied for cost calculations. Result: The incidence of acute poisoning was 178 cases per 100,000 patients. Females (56%) and children below 14 years (44.3%) accounted for the largest proportion. Most of the exposures were accidental involving therapeutic agents (64.2%). The mean length of hospital stay was found to be 1.84 ± 0.81 days, and most patients (76.6%) were discharged within the first 8 h. A statistically significant difference was found between age groups and type of toxin (χ2 = 23.3, p < 0.001), cause and route of exposure (χ2 = 42.2, p < 0.001), and length of hospital stay (χ2 = 113.16, p < 0.001). Admission to intensive care units had the highest cost expenditure (USD 326,008), while general wards accounted for the least (USD 57,709). Conclusion: Unintentional poisoning by pharmacological agents is common in infants and children. This study will assist in the development of educational and preventive programmes to minimise exposure to toxic agents. Further studies are required to explore the impact of medical toxicology services, and post discharge monitoring of poisoning.

Septic pulmonary embolism arising from a small temporal boil in a patient with diabetes mellitus type 2: A rare case report.

Septic pulmonary embolism (SPE) can originate from unusual sources like small boils, warranting consideration of diverse etiologies in respiratory distress. Prompt diagnosis, tailored antibiotics, and vigilant complication management optimize outcomes. Early recognition and treatment of minor infections, especially in diabetes are crucial.

Epidemiological profile of stroke in Qatar: Insights from a seven-year observational study.

OBJECTIVES: Stroke prevalence is progressively increasing in developing countries due to increased vascular risk factors. This study aims to describe the epidemiology, prevalent risk factors, and outcomes of stroke in a multi-ethnic society of Qatar. MATERIALS AND METHODS: We conducted a retrospective analysis of all patients with suspected stroke admitted to stroke services between January 2014 and September 2020. RESULTS: A total of 11,892 patients were admitted during this period with suspected stroke. Of these, the diagnosis was ischemic stroke (48.8 %), transient ischemic attack (10.3 %), intracerebral hemorrhage (10.9 %), cerebral venous sinus thrombosis (1.3 %), and stroke mimics (28.6 %). The median age was 52 (43-62), with a male-female ratio of 3:1. The study population was predominantly Asian (56.8 %) and Arab (36 %). The majority of the patients were hypertensive (66.8 %), diabetic (47.9 %), and dyslipidemic (45.9 %). A history of prior stroke was observed in 11.7 %, while 0.9 % had prior transient ischemic attack. Among ischemic strokes, 31.7 % arrived within 4.5 h, 12.5 % received thrombolysis, and 4.6 % underwent thrombectomy. Median Door-to-Needle time was 51 (33-72) minutes. The average length of stay was 5.2 ± 9.0 days, with 71.5 % discharged home, 13.8 % transferred to rehabilitation, 9.3 % to other specialties, 3 % to long-term care, and 2.4 % suffered in-hospital mortality. CONCLUSION: Stroke in Qatar is characterized by a younger, expatriate-dominant cohort, with notable prevalence of ischemic and hemorrhagic stroke and a distinct risk factor profile. Further analysis of epidemiological differences among different population groups can inform targeted policies for prevention and management to reduce the burden of disease.

Incidence, clinical features, and outcomes of posterior circulation ischemic stroke: insights from a large multiethnic stroke database.

Background: Posterior cerebral circulation ischemic stroke (PCS) comprises up to 25% of all strokes. It is characterized by variable presentation, leading to misdiagnosis and morbidity and mortality. We aim to describe PCS in large multiethnic cohorts. Methods: A retrospective review of a large national stroke database from its inception on the 1st of January 2014 till 31 December 2020. Incidence per 100,000 adult population/year, demographics, clinical features, stroke location, and outcomes were retrieved. We divided the cohort into patients from MENA (Middle East and North Africa) and others. Results: In total, 1,571 patients were identified. The incidence of PCS was observed to be rising and ranged from 6.3 to 13.2/100,000 adult population over the study period. Men were 82.4% of the total. The mean age was 54.9 ± 12.7 years (median 54 years, IQR 46, 63). MENA patients comprised 616 (39.2%) while others were 954 (60.7%); of these, the majority (80.5%) were from South Asia. Vascular risk factors were prevalent with 1,230 (78.3%) having hypertension, 970 (61.7%) with diabetes, and 872 (55.5%) having dyslipidemia. Weakness (944, 58.8%), dizziness (801, 50.5%), and slurred speech (584, 36.2%) were the most commonly presenting symptoms. The mean National Institute of Health Stroke Score (NIHSS) score was 3.8 ± 4.6 (median 3, IQR 1, 5). The overall most frequent stroke location was the distal location (568, 36.2%). The non-MENA cohort was younger, less vascularly burdened, and had more frequent proximal stroke location (p < 0.05). Dependency or death at discharge was seen in 39.5% and was associated with increasing age, and proximal and multilocation involvement; while at 90 days it was 27.4% and was associated with age, male sex, and having a MENA nationality (p < 0.05). Conclusion: In a multiethnic cohort of posterior circulation stroke patients from the MENA region and South Asia, we noted a rising incidence over time, high prevalence of vascular risk factors, and poor outcomes in older men from the MENA region. We also uncovered considerable disparities between the MENA and non-MENA groups in stroke location and outcome. These disparities are crucial factors to consider when tailoring individualized patient care plans. Further research is needed to thoroughly investigate the underlying reasons for these variations.

Maximal Tizanidine withdrawal managed with dexmedetomidine: a vital intervention.

Tizanidine withdrawal is a rare and complex phenomenon characterized by a surge in adrenergic activity upon abrupt discontinuation of the drug. We present a unique case of a 41-year-old male with multiple comorbidities who self-administered an exceptionally high daily dose of Tizanidine, leading to severe withdrawal symptoms. This case report highlights the challenges in managing such cases. The patient, with a history of myofascial pain syndrome, hypertension, anxiety, and depression, experienced distressing symptoms, including tachycardia, rebound hypertension, neuropsychiatric manifestations, and involuntary muscle movements. Unlike previous cases, our patient required the addition of dexmedetomidine in conjunction with benzodiazepines for symptom management. Reintroduction of Tizanidine, carefully controlled and tapered, led to stabilization of hemodynamics and cessation of involuntary movements. This case underscores the importance of individualized treatment and vigilant monitoring when dealing with Tizanidine withdrawal, particularly at elevated daily doses.

Advancement in pleura effusion diagnosis: a systematic review and meta-analysis of point-of-care ultrasound versus radiographic thoracic imaging.

BACKGROUND: Pleural effusion is a fluid buildup in the pleural space that mostly result from congestive heart failure, bacterial pneumonia, malignancy, and pulmonary embolism. The diagnosis of this condition can be challenging as it presents symptoms that may overlap with other conditions; therefore, imaging diagnostic tools such as chest x-ray/radiograph (CXR), point-of-care ultrasound (POCUS), and computed tomography (CT) have been employed to make an accurate diagnosis. Although POCUS has high diagnostic accuracy, it is yet to be considered a first-line diagnostic tool as most physicians use radiography. Therefore, the current meta-analysis was designed to compare POCUS to chest radiography. METHODS: n extended search for studies related to our topic was done on five electronic databases, including PubMed, Medline, Embase, Scopus, and Google Scholar. A quality assessment using the Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2) was performed on all eligible articles obtained from the databases. Moreover, the diagnostic accuracy of POCUS and CXR was performed using STATA 16 software. RESULTS: Our search yielded 1642 articles, of which only 18 were eligible for inclusion and analysis. The pooled analysis showed that POCUS had a higher diagnostic accuracy compared to CXR (94.54% (95% CI 91.74-97.34) vs. 67.68% (95% CI 58.29-77.08) and 97.88% (95% CI 95.77-99.99) vs. 85.30% (95% CI 80.06-90.54) sensitivity and specificity, respectively). A subgroup analysis based on the position of patients during examinations showed that POCUS carried out in supine and upright positions had higher specificity than other POCUS positions (99%). In comparison, lateral decubitus CXR had higher sensitivity (96%) and specificity (99%) than the other CXR positions. Further subgroup analyses demonstrated that CXR had higher specificity in studies that included more than 100 patients (92.74% (95% CI 85.41-100). Moreover, CXR tends to have a higher diagnostic accuracy when other CXR positions are used as reference tests (93.38% (95% CI 86.30-100) and 98.51% (95% CI 94.65-100) sensitivity and specificity, respectively). CONCLUSION: POCUS as an imaging modality has higher diagnostic accuracy than CXR in detecting pleural effusion. Moreover, the accuracy is still high even when performed by physicians with less POCUS training. Therefore, we suggest it is considered a first-line imaging tool for diagnosing pleural effusion at the patients' bedside.

The role of point-of-care ultrasound (POCUS) imaging in clinical outcomes during cardiac arrest: a systematic review.

BACKGROUND: Cardiac arrest in hospital and out-of-hospital settings is associated with high mortality rates. Therefore, a bedside test that can predict resuscitation outcomes of cardiac arrest patients is of great value. Point-of-care ultrasound (POCUS) has the potential to be used as an effective diagnostic and prognostic tool during cardiac arrest, particularly in observing the presence or absence of cardiac activity. However, it is highly susceptible to "self-fulfilling prophecy" and is associated with prolonged cardiopulmonary resuscitation (CPR), which negatively impacts the survival rates of cardiac arrest patients. As a result, the current systematic review was created to assess the role of POCUS in predicting the clinical outcomes associated with out-of-hospital and in-hospital cardiac arrests. METHODS: The search for scientific articles related to our study was done either through an electronic database search (i.e., PubMed, Medline, ScienceDirect, Embase, and Google Scholar) or manually going through the reference list of the relevant articles. A quality appraisal was also carried out with the Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2), and the prognostic test performance (sensitivity and sensitivity) was tabulated. RESULTS: The search criteria yielded 3984 articles related to our topic, of which only 22 were eligible for inclusion. After reviewing the literature, we noticed a wide variation in the definition of cardiac activity, and the statistical heterogeneity was high; therefore, we could not carry out meta-analyses. The tabulated clinical outcomes based on initial cardiac rhythm and definitions of cardiac activity showed highly inconsistent results. CONCLUSION: POCUS has the potential to provide valuable information on the management of cardiac arrest patients; however, it should not be used as the sole predictor for the termination of resuscitation efforts.

Seroconversion and safety of Covid-19 vaccines in pa-tients with chronic liver disease and liver transplant: A systematic review.

BACKGROUND AND AIMS: As part of the COVID-19 control strategy, a growing number of vaccine portfolios evolved and got fast-tracked through regulatory agencies, with a limited examination of their efficacy and safety in vulnerable populations, such as patients with chronic conditions and immunocompromised states. Patients with chronic liver disease (CLD), and cohorts post liver transplant (LT) in particular, were underrepresented in the determinant trials of vaccine development, hence the paucity of data on their efficacy and safety in published literature. This systematic review aims to examine the available evidence and ascertain the effectiveness and safety of Covid-19 vaccination in patients with CLD and those with LT. METHODS: A systematic review of PubMed (Medline), Google Scholar, Cochrane Library, and ScienceDirect from inception until 1st March 2022 was conducted. We included observational studies and assessed vaccine efficacy regarding seroconversion or immunological rate, whereas serious or significant adverse effects have been considered safety outcomes when reported. RESULTS: Studies comprised 45275 patients, performed in 11 different countries. Seroconversion or immunological rate after Covid-19 vaccination was mostly the primary endpoint, whereas other endpoints like covid-19 related adverse effects were also reported. Twenty-four of the final analyzed studies are prospective cohort studies, while four are retrospective cohort studies. Twenty-one studies included patients who underwent LT and received the Covid vaccine; nine included patients who had CLD due to various etiologies. The median age range of all included patients varied from 43-69 years. All patients with LT who received at least two doses of Covid vaccine had a seroconversion rate of around 60%. Patients with CLD had a seroconversion rate of about 92% post two doses of Covid vaccination. The average seroconversion rate in post-transplant recipients was around 45% after two doses of the significant Covid vaccines: Pfizer, AstraZeneca, Moderna, and Jansen. Only two studies have reported a higher seroconversion rate of 75% and 73% after the third dose of Covid vaccine. No significant adverse effects were reported in all studies; the most commonly reported negative effect was local injection site pain. CONCLUSION: The present systematic review, comprising real-world observational data studies, concludes that Covid-19 vaccination was associated with 92% and 60% seroconversion rates in patients with CLD and LT, respectively. No significant side effects were reported in all studies. This finding helps to resolve the uncertainty associated with Covid-19 vaccination in this cohort of patients.

Behaviour and associated determinants of COVID-19 vaccine acceptance and advocacy: a nationwide survey of pharmacy professionals in Qatar.

BACKGROUND: Vaccine hesitancy poses a global challenge and is acknowledged to be a complex, multifactorial phenomenon. Of particular concern is hesitancy among health professionals, as this may also impact their advocacy roles. There is a lack of theory-based investigations of pharmacy professionals. AIM: The study aims to determine the behaviour and associated determinants influencing pharmacy professionals' attitude towards vaccine acceptance and advocacy. METHODS: A cross-sectional survey of 2400 pharmacists and pharmacy technicians at government, semi-government, and private community pharmacies in Qatar. Questionnaire items captured perspectives on COVID vaccine acceptance, advocacy and associated determinants based on the domains and constructs of the Theoretical Domains Framework (TDF). Data were analysed by descriptive and inferential statistics, with TDF items subjected to principal components analysis (PCA). FINDINGS: The response rate was 38.6% (927/2400). Almost all (n = 825, 89.0%) were willing to receive the vaccine, which was higher for males (p < 0.001) and those in polyclinics (p < 0.05). PCA of acceptance items gave five components, with response to 'emotions' being most negative, associated with acceptance (p < 0.001) and more negative in females (p < 0.001). The majority (n = 799, 86.2%) agreed that it was their professional duty to advocate vaccines. PCA for advocacy items gave two components, with the most negative responses for 'professional role and identity', which were more negative for those working in hospitals (p < 0.05). CONCLUSION: Respondents were least positive regarding emotion-related behavioral determinants for acceptance and professional role and identity for advocacy. Behavior change technique interventions that target these issues have the potential to influence the vaccine hesitancy of pharmacy professionals and other individuals.

Injuries related to pets, exotic animals, and falconry in Qatar.

INTRODUCTION: Pets and exotic animals are increasingly popular all over the world. Some of these animals may cause injuries to their owners or other people during interactions. Both injuries and systemic infections always present diagnosis and treatment challenges. Emergency physicians´ clinical experience in managing patients with injuries caused by pets and exotic animals, in particular, is limited; hence, we believe that it is a domain to explore in a Middle Eastern country to help raise awareness and provide reminders as to the best evidence-based medical practice. METHODS: Hamad Medical Corporation's hospital records of patients treated between 2015 and 2022 were analyzed retrospectively. Cases whose diagnosis was recorded as injuries caused by animals kept as pets were included in the study. Patients were evaluated in terms of demographic characteristics, type of injury, injury locations, injury severity, treatments applied, and complications. Descriptive statistics were carried out, and findings were expressed as percentages in a frequency table. RESULTS: Following a search of the electronic patient records during the period of interest, 43 patients were found to have sought treatment following an injury caused by a pet or domestic exotic animal. The mean age of the patients was 23.5 years; about three-quarters were male, and approximately half were children. All injuries were minor, and 74.4% were skin abrasions. The most commonly injured body parts were the hand, the leg, and facial injuries. It was observed that cats caused 53.5% of the injuries, whereas falcons were involved in 11.6% of the cases. All patients were prescribed prophylactic antibiotics, and 60.5% were administered a tetanus injection. CONCLUSION: Despite our study spanning over seven years, a relatively low number of patients reported to the government hospitals´ emergency departments. The injuries are most commonly caused by cats and often involve children and animal bites to hands. The key recommendations are for parents or childminders to always supervise children when interacting with animals, be particularly cautious, and wear some form of protection when handling pets and domestic, exotic animals. Whether it is a bite or a scratch, healthcare professionals should always anticipate the potential risk of infection, treat the patient accordingly, and prescribe prophylactic antibiotics.

Antihypertensive Interventions in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis Evaluating Clinical Outcomes Through an Emergency Medicine Paradigm.

High blood pressure (HBP) is usually prominent after the onset of acute ischemic stroke (AIS). Although previous studies have found that about half of patients with AIS have a background of hypertension, there is no clear etiology for HBP in AIS. The literature reveals discrepancies in the relationship between HBP and clinical outcomes of AIS, pointing toward the contested effect of blood pressure (BP) reduction clinical outcomes. Thus, the potential benefits and hazards of HBP treatment were explored in the context of clinical outcomes after AIS. An electronic database and a manual search were carried out to identify all the articles related to this topic and published between 2000 and January 2023. The Review Manager software was also used to perform the meta-analysis and quality appraisal. In analyses related to patients not treated with reperfusion therapies, mortality, and dependency outcomes were categorized as short-term (<3 months) or long-term (≥3 months). Our search strategy yielded 2459 articles, of which only 15 met the inclusion criteria. The results of our meta-analysis demonstrate that in patients not treated with reperfusion therapies, BP lowering had no significant impact on either short-term or long-term mortality (risk ratio (RR): 1.18; 95% confidence interval (CI): 0.81-1.73; p = 0.39, and RR: 1.04; 95% CI: 0.77-1.40; p = 0.81, respectively) and dependency (RR: 1.12; 95% CI: 0.97-1.30; p = 0.11, and RR: 0.98; 95% CI: 0.90-1.07; p = 0.61, respectively). Furthermore, BP lowering prior to reperfusion showed no significant effect on mortality (RR: 0.7; 95% CI: 0.23-2.26; p = 0.58), but it did significantly reduce the risk of dependency (RR: 0.89; 95% CI: 0.85-0.94; p < 0.00001). When the dataset was restricted to patients who had successful reperfusion, intensive BP lowering (target systolic BP <120 mmHg) was found to increase the risk of dependency (RR: 1.23; 95% CI: 1.09-1.39; p = 0.0009). In addition, BP reduction had an insignificant effect on the risk of recurrent strokes and combined vascular events (RR: 1.00; 95% CI: 0.54-1.84; p = 1.00, and RR: 0.99; 95% CI: 0.70-1.41; p = 0.95, respectively). Lowering BP in patients not treated with reperfusion therapies is not beneficial in reducing the risk of either short or long-term mortality and dependency. However, BPR before reperfusion reduces the risk of dependency, while aggressive BPR (target systolic blood pressure (SBP) <120 mmHg) after successful reperfusion increases the risk of dependency. Therefore, we recommend BPR as early as possible for patients undergoing reperfusion therapies but suggest against aggressive BPR in patients who have undergone successful reperfusion.

Patterns and outcomes of paracetamol poisoning management in Hamad Medical Corporation, Qatar: A retrospective cohort study.

We aimed to investigate the characteristics and clinical outcomes of paracetamol poisoning and paracetamol overdose in Qatar. This retrospective cohort study included patients admitted to the emergency department (ED). We included patients who presented with excessive paracetamol ingestion, between December 2018 and September 2019. The primary outcomes were describing the characteristics and outcomes of paracetamol overdose (from a suicidal overdose or accidental overdose, dose ≤ 150 mg/kg, when serum levels of <60 mmol/L) or dose ingested (≤75 mg/kg) with staggered ingestion poisoning due to suicidal attempt or accidental attempt, defined as the dose ingested (>150 mg/kg), acute ingestion, nomogram level more than the treatment line, or dose ingested (>75 mg/kg) with staggered ingestion, and assessing the management of excessive paracetamol ingestion. Secondary outcomes included evaluation of the time difference between ingestion and time of administration, hospitalization, and adverse drug events. Significant differences were detected between patients who presented with paracetamol overdose and those who presented with paracetamol toxicity. A total of 69 patients were analyzed, of whom 43 received paracetamol overdose (mean age 27.5 ± 11.1 years) and 26 had paracetamol poisoning (mean age 25 ± 6.22 years). Paracetamol poisoning was identified in 26% of the patients with a 24.3% history of psychiatric illness, compared to 18.6% with paracetamol overdose. More patients presented with paracetamol toxicity in the time between ingestion and obtaining serum levels compared to the overdose group. A significantly longer length of hospitalization was observed in the toxicity group. A significantly higher number of patients in the toxicity group received N-acetylcysteine (NAC). More hypotension and rashes were observed among those who received NAC in the toxicity group. Patients presenting to the ED due to paracetamol toxicity are not uncommon, and most cases occur in young adults, and few in patients with a history of psychiatric illness, suggesting that preventive approaches are highly required.

The Battle of the Pneumonia Predictors: A Comprehensive Meta-Analysis Comparing the Pneumonia Severity Index (PSI) and the CURB-65 Score in Predicting Mortality and the Need for ICU Support.

The CURB-65 (confusion, uremia, respiratory rate, blood pressure, age ≥ 65 years) score and the pneumonia severity index (PSI) are widely used and recommended in predicting 30-day mortality and the need for intensive care support in community-acquired pneumonia. This study aims to compare the performance of these two severity scores in both mortality prediction and the need for intensive care support. A systematic review and meta-analysis was carried out, following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) 2020 guidelines, and PubMed, Scopus, ScienceDirect, and Google Scholar were searched for articles published from 2012 to 2022. The reference lists of the included studies were also searched to retrieve possible additional studies. Twenty-five studies reporting prognostic information for CURB 65 and PSI were identified. ReviewManager (RevMan) 5.4.1 was used to produce risk ratios, and a random effects model was used to pool them. Both PSI and CURB-65 showed a high strength in identifying high-risk patients. However, CURB-65 was slightly better in early mortality prediction and had more sensitivity (96.7%) and specificity (89.3%) in predicting admission to intensive care support. Thus, CURB-65 seems to be the preferred tool in predicting mortality and the need for admission into intensive care support.

What adult patients prefer for reporting their pain levels, and frequency of reassessment when in the emergency department.

OBJECTIVES: This study interviewed adult patients presenting to the emergency department (ED) for various pain conditions enquiring about their preferred tool for reporting pain severity and preferred time interval between initial assessment and subsequent pain reassessments. METHODS: A prospective observational (cross-sectional) study was conducted in adult patients with acute pain in a tertiary care hospital ED setting. Patients' initial pain score was recorded using NRS (numerical rating scale) pain scale, and appropriate analgesia offered. Once the patient had been evaluated by an attending physician, a research team member interviewed the patient regarding the pain reassessment time and preferred pain assessment tool. The pain assessment tools evaluated in this study were NRS, PS (picture scale or face pain scale), VRS (verbal rating scale), and VAS (visual analogue scale). The patients were presented with the four pain assessment tools (in their primary language) through an audio-visual on an electronic tablet display. RESULTS: 200 (138 male, mean age 36.5 ± 11.17) patients participated in the study. With increasing age, pain reassessment interval increased by 0.19 min (95% CI 0.03-0.36 min). Males requested pain reassessment 6.7 min (95% CI 2.2-10.8) faster than females. In this study, the preferred interval for pain reassessment was reported as a mean of 22.8 (SD + -13.6) minutes. There was no relationship reported between time reassessment and pain severity (P = 0.22). Out of 200 subjects, irrespective of the initial pain scores, 100 preferred NRS. NRS was preferred by patients with mild to moderated pain due to the perception of being faster. However, patients with severe pain choose a non-NRS scale to prioritize accuracy. CONCLUSION: There was no influence found between the initial pain severity scores and the desired frequency of pain reassessment. However, associations were identified between the time for pain reassessment interval and age, sex, and geographical region. Patients with severe pain preferred PS or VRS while patients with mild/moderate pain preferred the NRS.

Clinical assessment and risk stratification for prehospital use of methoxyflurane versus standard analgesia in adult patients with trauma pain.

Oligoanalgesia, the undertreatment of trauma-related pain using standard analgesics in prehospital and emergency departments, has been extensively documented as one of the major challenges affecting the effective treatment of trauma-related pain. When administered in low doses, methoxyflurane has been highlighted by numerous medical works of literature to provide an effective, nonopioid, nonnarcotic treatment alternative to standard analgesics for prehospital and emergency department use. Low-dose methoxyflurane has been associated with fast-pain relief in adult patients manifesting moderate-to-severe pain symptoms. This systematic review and meta-analysis aimed to assess the clinical implication of low-dose methoxyflurane use in prehospital and emergency departments in adult patients with moderate-to-severe trauma-related pain. Moreover, the review aimed at assessing the risk stratification associated with using low-dose methoxyflurane in prehospital and emergency departments. The systematic review and meta-analysis performed a comprehensive search for pertinent literature assessing the implications and risks of using low-dose methoxyflurane in adult patients exhibiting moderate-to-severe trauma-related pain in prehospital settings. A comparison between the use of low-dose methoxyflurane and standard-of-care analgesics, placebo, in prehospital settings was reported in four clinically conducted randomized controlled trials (RCTs). These RCTs included the STOP! trial, InMEDIATE, MEDIATA, and the PenASAP trials. A meta-analysis comparing the time taken to achieve first pain relief on initial treatment of patients with moderate-to-severe trauma-related pain favored the use of low-dose methoxyflurane to the standard-of-care analgesics (mean difference = -6.63, 95% confidence interval = -7.37, -5.09) on time taken to establish effective pain relief. Low-dose methoxyflurane has been associated with superior and faster pain relief in prehospital and emergency departments in adult patients exhibiting moderate-to-severe trauma-related pain compared to other standard analgesics.

Comparison between transthoracic echocardiography and transoesophageal echocardiography in the diagnosis of acute aortic dissection from an emergency perspective. A systematic review and meta-analysis.

Background: Acute aortic dissection (AAD) is a life-threatening medical condition with high early fatality. Therefore, a prompt and precise diagnosis, which can be achieved through invasive and non-invasive techniques is vital. Echocardiography, unlike MRI and CT, is accessible in emergency units and bedside-compatible. The recommended echocardiographic techniques for AAD are transthoracic and transoesophageal echocardiography (TTE and TOE). Therefore, our review compares their diagnostic roles in AAD. Methods: Studies relevant to our topic were attained through a database search and manual scrutiny of references lists of articles obtained from the electronic databases. The Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2) has been used for quality assessment. All quantitative analyses were performed using either STATA 16 or Comprehensive Meta-Analyst software. Results: The search strategy yielded 1,798 articles, of which only 11 were eligible for inclusion. Our subgroup analysis showed that conventional TTE had a sensitivity and specificity of 85.35% and 84.51% for the diagnosis of Stanford type A AAD and was 45.89% sensitive and 87.05% specific for the diagnosis of type B AAD. However, the subgroup analysis shows that contrast-enhancement of TTE results in a sensitivity and specificity of 93.30% and 97.60% for diagnosis of type A AAD, and 83.60% and 94.50% for diagnosis of type B AAD, respectively. On the other hand, conventional TOE was 93.64% sensitive and 95.50% specific for the diagnosis of type A AAD, 99.80% sensitive and 99.87% specific for the diagnosis of type B AAD. Moreover, our analyses show that TTE has pooled false negative and positive rates of 28.6% and 18.6%, while TOE has shown false negative and positive rates of 2.4% and 4.3%, respectively. Conclusion: TOE is the more favorable diagnostic tool for AAD diagnosis than TTE. However, it cannot be used as a stand-alone diagnostic tool since misdiagnosis cases are being reported. Contrast-enhanced TTE can also diagnose AAD since it provides similar results to conventional TOE.

Systematic Review and Meta-Analysis of Randomized Controlled Trials (RCTs) Revealing the Future of Airway Management: Video Laryngoscopy vs. Macintosh Laryngoscopy for Enhanced Clinical Outcomes.

Since the 1940s, Macintosh laryngoscopy (Mac laryngoscopy) has been the gold standard for tracheal intubation, offering visualization of the glottis entrance. However, recent years have witnessed the emergence of various video laryngoscopy (VL) techniques. This systematic review and meta-analysis aims to assess the clinical outcomes of VL versus Mac laryngoscopy in an elective setting. We comprehensively searched five medical databases - PubMed, EMBASE, Medline, Cochrane Library, and Web of Science. All the databases were last searched in January 2023. We only included studies with full texts comparing VL to Mac laryngoscopy clinical outcomes. Studies were excluded if they were non-full text or non-randomized controlled trials (RCTs) and did not compare VL to Mac laryngoscopy. We extracted data comprising author names, publication year, key study outcomes (first-attempt intubation success rate, Cormack and Lehane grade, hypoxia incidence, and glottis view quality), video laryngoscope types, and sample sizes of both VL and Mac laryngoscopy groups. The Cochrane risk of bias tool was used to assess the risk of bias in the included studies. Statistical analysis was performed using Review Manager (RevMan, version 5.4; Cochrane Collaboration, London, UK), presenting results as odds ratio (OR) and risk ratios (RR) at a 95% confidence interval (CI). This facilitated the identification of relevant and appropriate studies of our analysis. The search produced 19 studies that were included in this review. The evaluated sample size ranges from 40 to 802, with 3,238 participants. The rate of success at the first attempt in the use of VL was 1,558/1,890 (82.43%), while the success rate for Mac laryngoscopy was 982/1,348 (72.85%; OR: 1.98 (1.25, 3.12)) at a 95% confidence interval. Pooled analysis indicated no significant difference for hypoxia concerning the type of device used RR (random effects: 1.02; 95% CI: 0.80-1.29). A video laryngoscope had a higher likelihood of visualizing the vocal cords categorized as category 1 in the Cormack-Lehane system of classification (RR: 2.45; 95% CI: 1.43-4.21). Additionally, considerably better glottis views were attained during VL than Mac laryngoscopy (OR: 1.77; 95% CI: 1.19-2.62). In elective tracheal intubation, VL demonstrates superior first-attempt success rates, offers improved glottis visualization, and reduces instances where the glottis cannot be viewed compared to Mac laryngoscopy.

An integrative comparative study between ultrasound-guided regional anesthesia versus parenteral opioids alone for analgesia in emergency department patients with hip fractures: A systematic review and meta-analysis.

Background: Emergency physicians play a major role in managing patients with hip fractures. The most commonly used pain management option is parenteral opioids. However, parenteral opioids are subjected to several adverse effects. New pain management techniques such as regional anesthesia are used as alternatives to parenteral opioids. Anatomical landmarks were used to administer regional anesthesia; however, ultrasound guidance has shown promising results with regional anesthesia. Objective: of the Review: The present study compares the efficacy of ultrasound-guided regional anesthesia (USGRA) to parenteral opioids in analgesia of hip fractures patients. Methods: A literature search for original and relevant articles carried out through six electronic databases, yielded 710 articles which were then assessed using the eligibility criteria resulting in 8 studies eligible for inclusion. Results: A Meta-analysis of the seven studies showed that ultrasound-guided femoral nerve block was more effective than parenteral opioids in relieving pain. Similarly, meta-analysis of data from two studies shows that US-guided FICB significantly reduced pain scores than parenteral opioids. A subgroup analysis of adverse events showed no significant difference in nausea/vomiting and respiratory complications. However, a subgroup analysis on hypotension showed that the incidence of hypotension was significantly lower in USGRA than parenteral opioids. The present study also revealed that patients in the USGRA group required less frequent rescue analgesia than the patients in the parenteral opioids group. Conclusion: Results of the present study show that USGRA is superior to parenteral opioids in reducing pain and the need for rescue analgesia in patients with hip fractures.

Acceptability and Feasibility of Mini Clinical Evaluation Exercise (Mini-CEX) in the Busy Emergency Department.

BACKGROUND: Mini Clinical Evaluation Exercise (Mini-CEX) has been adapted to different specialties in clinical practice but with very little evidence documented about its use for residency training in the emergency department (ED). This study aims to assess its acceptability and feasibility as a formative tool in the busy emergency department. MATERIALS AND METHODS: Both the faculty members and the emergency medicine residents were sent a validated questionnaire using Google forms, and the results were analyzed using simple statistical tools. RESULTS: Forty-nine residents and 58 faculty participated in the survey. The study was carried out over a period of 4 months. The resident's completion rate was 96% (49 out of 51), while faculty completion rate was 96% (58 out of 60). The time for Mini-CEX completion ranged from 10 to 20 minutes. Most of the residents were satisfied with Mini-CEX as an assessment tool. Twelve residents expressed their concern regarding available time during busy clinical shifts. Most of the faculty agreed with the benefits of using Mini-CEX as a formative assessment tool. Several of them commented that they need "protected time" and "more training" to use this tool to provide maximum benefit to the residents. CONCLUSION: Despite busy nature of ED, Mini-CEX has been identified as an acceptable learning tool for residents in emergency medicine. Based on the faculty's feedback and comments, several faculty development workshops were conducted to improve faculty skills in carrying assessments by using Mini-CEX, and protected time is provided to some faculty members to carry out these formative assessments for the benefit of the residents.