Development of the first Iranian clinical practice guidelines for the diagnosis, treatment, and secondary prevention of acute coronary syndrome.

Background: This article introduces the first national guidelines for the management including diagnosis, treatment, and secondary prevention of acute coronary syndrome (ACS) in Iran. Materials and Methods: The members of the guideline development group (GDG) were specialists and experts in fields related to ACS and were affiliated with universities of medical sciences or scientific associations in the country. They carefully examined the evidence and clinical concerns related to ACS management and formulated 13 clinical questions that were sent to systematic review group who developed related evidence using Grade method. Finally the GDG developed the recommendations and suggestions of the guideline. Results: The first three questions in the guideline focus on providing recommendations for handling a patient who experience chest pain at home, in a health house or center, during ambulance transportation, and upon arrival at the emergency department (ED) as well as the initial diagnostic measures in the ED. Subsequently, the recommendations related to the criteria for categorizing patients into low, intermediate and high-risk groups are presented. The guideline addressed primary treatment measures for ACS patients in hospitals with and without code 247 or having primary percutaneous coronary intervention (PCI) facilities, and the appropriate timing for PCI based on the risk assessment. In addition, the most efficacious antiplatelet medications for ACS patients in the ED as well as its optimal duration of treatment are presented. The guideline details the recommendations for therapeutic interventions in patients with ACS and acute heart failure, cardiogenic shock, myocardial infarction with nonobstructive coronary arteries (MINOCA), multivessel occlusion, as well as the indication for prescribing a combined use of anticoagulants and antiplatelet during hospitalization and upon discharge. Regarding secondary prevention, while emphasizing the referral of these patients to rehabilitation centers, other interventions that include pharmaceutical and nonpharmacological ones are addressed, In addition, necessary recommendations for enhancing lifestyle and posthospital discharge pharmaceutical treatments, including their duration, are provided. There are specific recommendations and suggestions for subgroups, such as patients aged over 75 years and individuals with heart failure, diabetes, and chronic kidney disease. Conclusion: Developing guidelines for ACS diagnosis, treatment and secondary prevention according to the local context in Iran can improve the adherence of our health care providers, patients health, and policy makers plans.

The Profile of Self-Harm and Suicide in Iran Considering Gender Differences: A Multicenter Study Affiliated with the National Trauma Registry of Iran.

Objective: The main objective of this study was to determine various characteristics and outcomes of self-harm and suicide in men and women with data obtained from the National Trauma Registry of Iran (NTRI). Method : This retrospective multicenter study using data from the NTRI included all patients who went to the emergency department (ED) due to self-harm and suicide, considering the NTRI's specific inclusion criteria, from September 2016 to January 2023. We evaluated patients regarding demographics and clinical characteristics, various outcomes, and factors influencing in-hospital death. Statistical analyses were conducted using the STATA software version 15.0. The chi-square test was used to compare the distribution of variables between men and women. Also, the logistic regression models were applied to assess the predictors of in-hospital death. Results: Self-harm and suicide cases were gathered from eleven geographically diverse hospitals across the country, and our study included 511 men and 347 women out of 50,661 registered trauma cases. Among them, 443 men (86.7%) and 267 women (76.9%) were between 18 and 49 years old (P < 0.001). Single women constituted 130 (37.3%) of the female cases, while single men were 313 (61.6%) of the male cases (P < 0.001). The three most common methods among our patients were poisoning with 234 (45.8%) of men and 245 (70.6%) of women cases, stab/cut with 208 (40.7%) of men and 54 (15.6%) of women cases, and fall with 16 (3.1%) of men and 26 (7.5%) of women cases (P < 0.001). The risk of death in patients with a Glasgow Coma Scale (GCS) score of 3 to 8 was 46.22 (95% CI = 18.66 to 114.45) times more than patients with a GCS score of 13 to 15. Conclusion: Data on self-harm and suicide traumatology were gathered from eleven hospitals in Iran. Our findings indicated differences in the distribution of age and marital status between genders. Moreover, both genders used similar methods for self-harm and suicide, and gender did not affect the outcome.

Patterns and outcomes of patients with abdominal injury: a multicenter study from Iran.

BACKGROUND: Injury is one of the leading causes of death worldwide, and the abdomen is the most common area of trauma after the head and extremities. Abdominal injury is often divided into two categories: blunt and penetrating injuries. This study aims to determine the epidemiological and clinical characteristics of these two types of abdominal injuries in patients registered with the National Trauma Registry of Iran (NTRI). METHODS: This multicenter cross-sectional study was conducted with data from the NTRI from July 24, 2016, to May 21, 2023. All abdominal trauma patients defined by the International Classification of Diseases; 10th Revision (ICD-10) codes were enrolled in this study. The inclusion criteria were one of the following: hospital length of stay (LOS) of more than 24 h, fatal injuries, and trauma patients transferred from the ICU of other hospitals. RESULTS: Among 532 patients with abdominal injuries, 420 (78.9%) had a blunt injury, and 435 (81.7%) of the victims were men. The most injured organs in blunt trauma were the spleen, with 200 (47.6%) and the liver, with 171 (40.7%) cases, respectively. Also, the colon and small intestine, with 42 (37.5%) cases, had the highest number of injuries in penetrating injuries. Blood was transfused in 103 (23.5%) of blunt injured victims and 17 (15.2%) of penetrating traumas (p = 0.03). ICU admission was significantly varied between the two groups, with 266 (63.6%) patients in the blunt group and 47 (42%) in penetrating (p < 0.001). Negative laparotomies were 21 (28%) in penetrating trauma and only 11 (7.7%) in blunt group (p < 0.001). In the multiple logistic regression model after adjusting, ISS ≥ 16 increased the chance of ICU admission 3.13 times relative to the ISS 1-8 [OR: 3.13, 95% CI (1.56 to 6.28), P = 0.001]. Another predictor was NOM, which increased ICU chance 1.75 times more than OM [OR: 1.75, 95% CI (1.17 to 2.61), p = 0.006]. Additionally, GCS 3-8 had 5.43 times more ICU admission odds than the GCS 13-15 [OR:5.43, 95%CI (1.81 to 16.25), P = 0.002] respectively. CONCLUSION: This study found that the liver and spleen are mostly damaged in blunt injuries. Also, in most cases of penetrating injuries, the colon and small intestine had the highest frequency of injuries compared to other organs. Blunt abdominal injuries caused more blood transfusions and ICU admissions. Higher ISS, lower GCS, and NOM were predictors of ICU admission in abdominal injury victims.

Mini-dose Bier's block vs systemic analgesia in distal radius fractures: a promising reduction in emergency department throughput time.

Aim: This study compared the effect of the conventional technique of procedural sedation and the mini-dose intravenous regional anesthesia (IVRA). Patients & methods: 45 patients received IVRA, and 47 received iv. ketamine. The pain score, emergency department (ED) length of stay and patients' satisfaction were compared. Results: The study revealed that not only the levels of hemodynamic parameters but also their stability, and the patient's satisfaction in the IVRA group were significantly better. The patients' pain score and ED length of stay were also significantly decreased in those who received IVRA. Conclusion: Mini-dose IVRA technique contributes to better hemodynamic stability, without prominent adverse events, and leads to significant pain control and improved ED throughput time. Clinical Trial Registration: NCT03349216 (ClinicalTrials.gov).

The salivary alpha-amylase concentration in patients with rheumatoid arthritis: A case-control study.

Background: Rheumatoid arthritis (RA) is one of the most common chronic inflammatory diseases. Previous studies have reported an association between stress and salivary alpha-amylase. The aim of this study was to investigate the concentration of salivary alpha-amylase in patients with RA (by elimination of stress factor). Materials and Methods: In this case-control study, we enrolled 50 patients with RA and 48 healthy patients as the control group. The perceived stress scale questionnaire was used to evaluate scores of stress in both case and control groups, and then the participants with high scores of stress were excluded from the study. Moreover, the alpha-amylase activity kit was used for the assessment of the levels of salivary alpha-amylase. In all analyses, the significance level was considered to be < 0.05. Finally, the obtained data were analyzed by SPSS22. Results: Our results indicated a high score of stress in the case group (19.42 ± 5.83 units) compared with the control group (18.02 ± 6.07 units) which was not statistically significant (P < 0.248). Moreover, we demonstrated a high salivary alpha-amylase concentration in the case group (340.65 ± 38.04 units) compared to the control group (302.62 ± 58.72 units), which was statistically significant (P < 0.001). The sensitivity and specificity of this method, at >312 alpha-amylase concentrations, were 80% and 46%, respectively. Conclusion: In general, we indicated that the alpha-amylase concentration in patients with RA is higher than the healthy controls, and can be used as a codiagnostic factor.

Extracting the Factors Affecting the Survival Rate of Trauma Patients Using Data Mining Techniques on a National Trauma Registry.

Introduction: Thousands of people die due to trauma all over the world every day, which leaves adverse effects on families and the society. The main objective of this study was to identify the factors affecting the mortality of trauma patients using data mining techniques. Methods: The present study includes six parts: data gathering, data preparation, target attributes specification, data balancing, evaluation criteria, and applied techniques. The techniques used in this research are all from the decision tree family. The output of these techniques are patterns extracted from the trauma patients dataset (National Trauma Registry of Iran). The dataset includes information on 25,986 trauma patients from all over the country. The techniques that were used include random forest, CHAID, and ID3. Results: Random forest performs better than the other two techniques in terms of accuracy. The ID3 technique performs better than the other two techniques in terms of the dead class. The random forest technique has performed better than other techniques in the living class. The rules with the most support, state that if the Injury Severity Score (ISS) is minor and vital signs are normal, 98% of people will survive. The second rule, in terms of support, states that if ISS is minor and vital signs are abnormal, 93% will survive. Also, by increasing the threshold of the patient's arrival time from 10 to 15 minutes, no noticeable difference was observed in the death rate of patients. Conclusion: Transfer time of less than ten minutes in patietns whose ISS is minor, can increase the chance of survival. Impaired vital signs can decrease the chance of survival in traffic accidents. Also, if the ISS is minor in non-penetrating trauma, regardless of vital signs and if the victim is transported in less than ten minutes, the patient will survive with 99% certainty.

Assessment of ambulance services performance by queuing theory, at the Center for Disaster and Emergency Management: A descriptive-analytical study.

BACKGROUND: The emergency departments of the hospitals and emergency medical services (EMSs) centers have a critical role for providing urgent medical care for patients. The statistical data of the present study were provided by the EMS headquarters of the city of Isfahan, from August to November 2017. RESULTS: The findings showed that on average, 210 missions were accomplished each day by the emergency call center, with an average duration of about 53 minutes, for each mission. In addition, the average time for response time (the time between a call and dispatch of the ambulance) was less than 3 minutes, and the average time for arrival time (the time between request of ambulance and the arrival to the scene) was 8.1 minutes. Adequacy of current number of ambulances and staff is evaluated. CONCLUSION: Considering an average of 8.1 minutes for arrival time, we conclude that the EMS of Isfahan is within an acceptable range, compared to the international standards. In fact, it is shown that the infrastructures of EMS system including ambulance fleets, staff, and equipment are sufficient, and as an effective step for reducing the total time of the mission, the EMS has to operate seamlessly with the patient's admission process in hospitals. Information such as workload hours, availability of resources and staff, etc. ought to be shared between the EMS and the hospital.

Relationship between oral cancer stage and elapsed time from the onset of signs and symptoms to diagnosis and treatment.

BACKGROUND: Oral cancer includes a variety of diagnoses of malignancies that manifest in the oral tissues. Prognosis and treatment depend on the site of involvement, the time of diagnosis, and the stage of the tumor. Early diagnosis of oral mucosal lesions facilitates the early detection of cancer, which is a key step for treatment. The purpose of this study was to investigate the relationship between delayed referral of patients with oral cancer and disease progression at the time of diagnosis. MATERIALS AND METHODS: In this cross-sectional study, data were collected from 108 patients with a definitive diagnosis of oral cancer by a standardized questionnaire. Data were analyzed by descriptive statistics, including mean, standard deviation, frequency, frequency percentage, and inferential statistics, including logistic regression analysis. P<0.05 was considered to be statistically significant. RESULTS: The mean time of referral to a therapist was 17.73 ± 22.80 weeks, with 53 (49.1%) patients having a delay of more than 10 weeks. Age, education level, smoking, disease stage, N class, M class, and type of cancer were not significantly associated with the incidence of delay (P>0.05). Patients whose first signs were significant bleeding and/or unrecovered ulceration showed a significant reduction in the delay time (OR = 0.024 and P = 0.038). CONCLUSION: There was no significant relationship between the disease progression in oral cancer and the time elapsed from the onset of symptoms to diagnosis and treatment. Hence, it seems necessary to take appropriate measures to enhance public awareness of oral cancer and its symptoms.

Comparative Study of the Effect of Licorice Muco-adhesive Film on Radiotherapy Induced Oral Mucositis, A Randomized Controlled Clinical Trial.

BACKGROUND: Oral mucositis is a common complication induced by radiation in head and neck cancer patients. OM can cause pain, dysphagia, dehydration and impaired quality of life. The main objective of this study was to assess the effectiveness of licorice mucoadhesive film on symptoms of head and neck radiotherapy-induced mucositis. METHODS: sixty head and neck cancer patients who have been scheduled to undergo radiotherapy were randomly assigned to receive radiotherapy plus licorice mucoadhesive film (30) or radiotherapy plus placebo mucoadhesive film. In this double blinded randomized clinical trial, oral mucositis was estimated by world health organization scales, a quantitative scale, and symptoms were evaluated by visual analog scale. RESULTS: The results showed a meaningful difference in pain score between two groups in third and fourth weeks (P-value <0.05). Also, there was a significant difference in scale of mucositis between the two groups in weeks 3 and 4 (P-value <0.05). However, there were no meaningful differences with regard to pain and scale of mucositis in weeks 0, 1, 2. (P-value>0.05). CONCLUSION: This study showed that licorice mucoadhesive film can be effective in decreasing pain and level of radiation-induced mucositis and it could be administered as an alternative agent in OM management. Key words: Oral mucositis, Radiotherapy, Licorice, Mucoadhesive film, Placebo.

A mathematical model for efficient ambulance location based on DSM-MALP integration.

Optimal location of medical facilities and vehicles is one of the most crucial aspects of emergency services such that even slight improvements in this regard can save the lives of many people. In the large cities suffering from fluctuating population distribution and traffic congestion, finding the optimal location of ambulance stations can significantly reduce patient mortality due to delay of medical service and thus increase the efficiency of the healthcare sector. This study investigated the current status of ambulance service provided in four districts of Isfahan city (Iran) and assessed the potential for improvement in availability by increasing the number of ambulances and relocating the stations. The main objective of this work is to integrate two ambulance location methods, ie, double standard model (DSM) and maximum availability location problem (MALP), to develop a static probabilistic model, which allows covering radius of stations to be increased according to ambulance availability factor. The efficiency of the developed method was assessed by sensitivity analysis through four different approaches, all indicating an increase in the efficiency compared to the default model.

A novel formulation for radiotherapy-induced oral mucositis: Triamcinolone acetonide mucoadhesive film.

BACKGROUND: The main purpose of this study was to evaluate the effectiveness of triamcinolone acetonide (TA) mucoadhesive films versus placebo as a preventive and therapeutic intervention of oral mucositis (OM) induced by radiotherapy for head-and-neck cancer (HNC) patients. MATERIALS AND METHODS: In this double-blind, randomized case-controlled clinical trial, 60 HNC patients were randomized to receive TA mucoadhesive films (n = 30) or placebo mucoadhesive films (n = 30) taken four times daily. Mucositis severity was assessed during the course of radiation therapy using the World Health Organization scales, and pain scores were assessed using visual analog scale. Repeated measures ANOVA was used for data analysis. RESULTS: Mean ± standard deviation age of the TA group was 58.53 ± 8.89 years and 60% were male, whereas in the placebo group, it was 56.46 ± 9.36 years and 56.7% were male (P > 0.05). The mean value of pain score was significantly reduced in the TA group (5.36 ± 1.29 vs. 2.20 ± 2.02) compared with the placebo group (5.34 ± 0.78 vs. 4.69 ± 0.77) during 4 weeks (P < 0.001); repeated measures ANOVA analysis showed that the mean value of grade mucositis was significantly reduced in the TA group (2.40 ± 0.49 vs. 0.96 ± 0.81) compared with the placebo group (2.36 ± 0.80 vs. 1.86 ± 0.93) during 4 weeks (P < 0.001). CONCLUSION: TA film could be considered as an effective approach for reducing the mucositis grading and pain score in the patients with OM.

Comparing low-dose intravenous ketamine-midazolam with intravenous morphine with respect to pain control in patients with closed limb fracture.

BACKGROUND: We assessed the effects of low-dose IV ketamine-midazolam versus morphine on pain control in patients with closed limb fracture(s); and also compared the incidence of adverse events (cardio-pulmonary) between two groups. MATERIALS AND METHODS: This prospective, single-blind, non-inferiority trial randomized consecutive emergency department (ED) patients aged 18-60 years to two groups: Receiving 300-500 mcg/kg ketamine plus 0.03 mg/kg midazolam, or 0.05-0.1 mg/kg morphine. Visual analogue score (VAS) and adverse events were verified during an interval of 30 minutes. RESULTS: Two hundred and thirty - six patients were selected, among whom 207 were males (87.3%). The average age was 29 ± 2, (range, 18-60 years). The VAS score at T30 (i.e., 30 minutes after initial analgesic dose) was significantly decreased compared with VAS score at T0, in both groups. No statistically significant difference, however, was observed between the two groups (-6.1 ± 1.1 versus -6.2 ± 1.0; P = 0.16). With regard to systolic blood pressure and respiratory rate, however, a meaningful difference was noted between the two groups (1.5 ± 6.4 versus -2.1 ± 6.6; P = 0.000 for SBP, and -0.2 ± 1.1 versus -1.1 ± 6.1; P = 0.048 for RR). CONCLUSION: Low-dose intravenous ketamine plus midazolam has the same analgesic effects as morphine on pain control in trauma patients with closed limb fracture(s), in addition to less respiratory adverse events.

Folie à deux and delusional disorder by proxy in a family.

This report presents a 52-year-old woman who was admitted to nephrology ward with hypernatremia. She shared a persecutory delusion of poisoning with her 22-year-old daughter and did not feed her 8-year-old son due to her delusion.