Effectiveness of educational intervention and cognitive rehearsal on perceived incivility among emergency nurses: a randomized controlled trial.

BACKGROUND: Witnessing or experiencing of incivility affected the nurses' perception of the ethical climate and quality of their work life. The aim of this study was to investigate the effectiveness of educational intervention and cognitive rehearsal on perceived incivility among emergency nurses. METHOD: This study was conducted as a randomized controlled parallel group clinical trial. Eighty emergency nurses participated in this study and were randomly assigned to intervention and control groups during December 2019-March 2020. Cognitive rehearsal program (include of definitions of incivility, ten common incivilities and appropriate practice methods for responding to each and role-plays) was delivered in five two-hour sessions over three weeks on different working days and shifts. The control group received only written information about what incivility is and how to deal with it before the implementation of intervention and one month after the completion of the training sessions, the demographic information form and the incivility scale were completed by the nurses. RESULTS: The results showed that there was a significant effect on overall incivility, general incivility, and supervisor incivility between the intervention and control groups. However, these significant reductions were seen in control group who received only written education. There were no significant differences in nurse's incivility towards other nurses, physician incivility, and patient/visitor incivility between the two groups. CONCLUSION: The cognitive rehearsal program did not decrease perceived incivility among emergency department nurses in the short term. TRIAL REGISTRATION: Our research was registered on clinicaltrials.gov. REGISTRATION NUMBER: IRCT20200714048104N1 , first registration 16/07/2020.

Impact of Education on Trauma Patients' Handover Quality; a Before-After Trial.

INTRODUCTION: Poor handover and inadequate transmission of clinical information between shifts cause a lot of problems in patient care and result in significant risks for physicians and patients. This study was designed to evaluate the impact of education and application of handover checklist on trauma patients' handover quality. METHODS: In this before-after trial, handover process of trauma patients in an educational hospital was evaluated before and after education and application of a handover checklist, abbreviated as "WHO MISSED IP?", using a questionnaire that consisted of 10 necessary items, which should be delivered during handover of trauma patients. A total score of 10 was considered for each patient handover, the score 10 out of 10 indicating that all 10 important pieces of patient information were correctly delivered. RESULTS: 52 pre and post-intervention handover sessions were evaluated (438 patients). Prior to intervention, 18% of patients were not delivered to the next shift, most of which were in the night shift handover (p < 0.001). From the pre-intervention to the post-intervention period, significant improvements were detected in all items except for diagnosis and consulting items. The mean duration of handover changed from 1.22 ± 0.24 minutes to 1.58 ± 0.23 minutes after intervention (p < 0.01). In the pre-intervention period, the score equal or greater than 9 was observed in 7.5% of patients, while after intervention, 63.6% of patients had score ≥ 9 regarding complete handover (p < 0.01). CONCLUSION: Based on the findings of the present study, teaching handover standards and application of handover checklist could be helpful in improving the quality of information delivery between emergency medicine residents and improve trauma patients' handover indices.

Full and Modified Glasgow-Blatchford Bleeding Score in Predicting the Outcome of Patients with Acute Upper Gastrointestinal Bleeding; a Diagnostic Accuracy Study.

INTRODUCTION: Screening of high risk patients and accelerating their treatment measures can reduce the burden of the disease caused by acute upper gastrointestinal (GI) bleeding. This study aimed to compare the full and modified Glasgow-Blatchford Bleeding Score (GBS and mGBS) in prediction of in-hospital outcomes of upper GI bleeding. METHODS: In the present retrospective cross-sectional study, the accuracy of GBS and mGBS models were compared in predicting the outcome of patients over 18 years of age with acute upper GI bleeding confirmed via endoscopy, presenting to the emergency departments of 3 teaching hospitals during 4 years. RESULTS: 330 cases with the mean age of 59.07 ± 19.00 years entered the study (63.60% male). Area under the curve of GBS and mGBS scoring systems were 0.691 and 0.703, respectively, in prediction of re-bleeding (p = 0.219), 0.562 and 0.563 regarding need for surgery (p = 0.978), 0.549 and 0.542 for endoscopic intervention (p = 0.505), and 0.767 and 0.770 regarding blood transfusion (p = 0.753). Area under the ROC curve of GBS scoring system regarding need for hospitalization in intensive care unit (0.589 vs. 0.563; p = 0.035) and mortality (0.597 vs. 0.564; p = 0.011) was better but the superiority was not clinically significant. CONCLUSION: GBS and mGBS scoring systems have similar accuracy in prediction of the probability of re-bleeding, need for blood transfusion, surgery and endoscopic intervention, hospitalization in intensive care unit, and mortality of patients with acute upper GI bleeding.

Imaging appropriateness in an academic emergency medicine program.

INTRODUCTION: As radiologic assessment is a key part in evaluating patients visited in emergency department, this survey was conducted to measure emergency medicine residents' competency in choosing appropriate diagnostic imaging in different clinical scenarios. METHODS: All emergency medicine residents enrolled in an academic emergency medicine discipline in the three medical universities of Tehran, Iran were recruited. A questionnaire was designed consisting of 10 clinically common scenarios selected from the American College of Radiology appropriateness criteria. Each resident completed the survey separately with answers only given after all residents participated. RESULTS: 196 residents completed the survey (95% of all residents). The results were stratified by post-graduate year and university. The average number of correct answers was 6.2. First, second and third year residents scored the average of 6.1, 5.8 and 6.5, respectively (P=0.04). The average score of residents from different universities did not differ significantly. CONCLUSION: According to the low average score, it is recommended that attentive educational perfections are needed to help residents order more appropriate diagnostic images, which may also be helpful for other healthcare providers. However, it seems that our emergency medicine academic curriculum is relatively efficient to enhance residents' skills in choosing proper imaging.

Self-Injury in Autism Spectrum Disorder and Intellectual Disability: Exploring the Role of Reactivity to Pain and Sensory Input.

This paper provides information about the prevalence and topography of self-injurious behavior in children and adults with autism spectrum disorder and intellectual disability. Dominant models regarding the etiology of self-injury in this population are reviewed, with a focus on the role of reactivity to pain and sensory input. Neuroimaging studies are presented and suggestions are offered for future research.

Diabetes in Iran: Prospective Analysis from First Nationwide Diabetes Report of National Program for Prevention and Control of Diabetes (NPPCD-2016).

We estimated proportions of different types of diabetes, comorbidities, treatment (the use of oral glucose-lowering agents and insulin), control (hyperglycemia, dyslipidemia and hypertension) and chronic microvascular and macrovascular complications among people with diabetes presenting to the tertiary-care academic diabetes outpatient clinics in Iran. This study is the prospective analysis of data (n = 30,202) from the registry of university-affiliated adult outpatient diabetes clinics in the country during 2015-2016. The proportions of type 1 diabetes, types 2 diabetes, and other types of diabetes were 11.4%, 85.5%, and 1.3%, respectively. The frequencies of drug-naivety, use of oral agents, insulin monotherapy and insulin combination therapy were 2.9%, 60.5%, 11.5%, and 25.1%, respectively. Around 13.2%, 11.9% and 43.3% of patients with diabetes had controlled hyperglycemia, hyperlipidemia and hypertension, respectively. The proportions of retinopathy, nephropathy, peripheral neuropathy, diabetic foot, and ischemic heart disease were 21.9%, 17.6%, 28.0%, 6.2%, and 23.9%, respectively. Despite the wide availability of medications and insulin coverage in Iran, the estimated national control of hyperglycemia, hyperlipidemia and hypertension (especially for young men and old women) remains subpar. The present study further suggests that the frequencies of chronic vascular complications among patients with diabetes are relatively high in Iran.

Clinical Information Transfer between EMS Staff and Emergency Medicine Assistants during Handover of Trauma Patients.

Introduction Clinical handover by Emergency Medical Services (EMS) staff, as the first people who have contact with trauma patients, in the emergency department (ED), is very important. Therefore, effective communication to transfer clinical information about patients in a concise, rational, clear, and time-bound manner is essential. In Iran, the transfer of necessary information in clinical handover in EDs was carried out orally and without following standard instructions. This study aimed to audit the current clinical handover according to the Identify, Situation, Background, Assessment, and Recommendation (ISBAR) tool and survey the effect of training the ISBAR tool to Emergency Medicine Assistants (EMAs) and EMS staff on improvement of the clinical handover of patients to the ED. METHODS: This is a clinical audit study in three phases in Imam Hossein Hospital (Tehran, Iran) during 2016. In the first phase, the clinical handover between EMS staff and EMAs for 178 trauma patients admitted to the ED using ISBAR was audited and information was recorded. In the second phase, the correct approach of clinical handover according to the ISBAR tool was taught to EMS staff and EMAs using pamphlets and lectures. In the third phase, again, the clinical handover between EMS staff and EMAs for 168 trauma patients admitted to the ED was audited using the ISBAR tool and information was recorded. At the end, clinical audit assessment indicators of handover were evaluated before and after training. RESULTS: Clinical audit of the current situation in the ED showed that the clinical handover process does not follow standard ISBAR (0.0%). However, after training, 65.3% of clinical handover processes were performed in accordance with ISBAR. In the current study, there was an increase in all parameters of the ISBAR tool after training, most of which increased significantly compared to the first phase of the study (before the intervention). CONCLUSIONS: Findings demonstrate that patient handover in the ED did not initially follow the ISBAR standard guideline. After providing education as pamphlets and lectures to EMS staff and EMAs, a high percentage of patient handovers were conducted in accordance with the ISBAR instructions. Fahim Yegane SA , Shahrami A , Hatamabadi HR , Hosseini-Zijoud SM . Clinical information transfer between EMS staff and Emergency Medicine Assistants during handover of trauma patients. Prehosp Disaster Med. 2017;32(5):541-547.

The Accuracy of Plain Radiography in Detection of Traumatic Intrathoracic Injuries.

INTRODUCTION: Rapid diagnosis of traumatic intrathoracic injuries leads to improvement in patient management. This study was designed to evaluate the diagnostic value of chest radiography (CXR) in comparison to chest computed tomography (CT) scan in diagnosis of traumatic intrathoracic injuries. METHODS: Participants of this prospective diagnostic accuracy study included multiple trauma patients over 15 years old with stable vital admitted to emergency department (ED) during one year. The correlation of CXR and CT scan findings in diagnosis of traumatic intrathoracic injuries was evaluated using SPSS 20. Screening characteristics of CXR were calculated with 95% CI. RESULTS: 353 patients with the mean age of 35.2 ± 15.8 were evaluated (78.8% male). Age 16-30 years with 121 (34.2%), motorcycle riders with 104 (29.5%) cases and ISS < 12 with 185 (52.4%) had the highest frequency among patients. Generally, screening performance characteristics of chest in diagnosis of chest traumatic injuries were as follows: sensitivity 50.3 (95% CI: 44.8 - 55.5), specificity 98.9 (95% CI: 99.5 - 99.8), PPV 97.8 (95% CI: 91.5 - 99.6), NPV 66.4 (95% CI: 60.2 - 72.03), PLR 44.5 (95% CI: 11.3 175.3), and NLR 0.5 (95% CI: 0.4 - 0.6). Accuracy of CXR in diagnosis of traumatic intrathoracic injuries was 74.5 (95% CI: 69.6 - 78.9) and its area under the ROC curve was 74.6 (95% CI: 69.3 - 79.8). CONCLUSION: The screening performance characteristics of CXR in diagnosis of traumatic intrathoracic injuries were higher than 90% in all pathologies except pneumothorax (50.3%). It seems that this matter has a great impact on the general screening characteristics of the test (74.3% accuracy and 50.3%sensitivity). It seems that, plain CXR should be used as an initial screening tool more carefully.

Diagnostic Value of Clinical Findings in Evaluation of Thoracolumbar Blunt Traumas.

INTRODUCTION: Necessity of imaging for symptom-free conscious patients presented to emergency department (ED) following traumatic thoracolumbar spine injuries has been a matter of debate. The present study was aimed to evaluate the diagnostic value of clinical findings in prediction of traumatic thoracolumbar injuries compared tocomputed tomography (CT) scan. METHODS: The present diagnostic value study was carried out using non-random convenience sampling during the time between October 2013 and March 2014. All trauma patients > 15 years old underwent thoracolumbar CT scan were included. Correlation between clinical and CT findings was measured using SPSS 21.0 and screening performance characteristics of clinical findings in prediction of thoracolumbar fracture were calculated. RESULTS: 169 patients with mean age of 37.8 ± 17.3 years (rage: 15-86) were evaluated (69.8% male). All fracture patients had at least 1 positive finding in history and physical examination. The fracture was confirmed in only 24.6% of the patients with positive findings in history or physical examination. In 37.5% of patients the location of fracture, matched the area of positive physical examinations. Sensitivity, specificity, PPV, NPV, PLR, and NLR of clinical findings in comparison to thoracolumbar CT scan were 100 (95% CI: 89 - 100), 1.5 (95% CI: 0.2-6), 24.5 (95% CI: 18.3-31.9), 100 (95% CI: 19.7-100), 32.5 (95% CI: 24.6-43.03), and infinite, respectively. CONCLUSION: The results of the present study, show the excellent screening performance characteristics of clinical findings in prediction of traumatic thoracolumbar fracture (100% sensitivity). It could be concluded that in conscious patients with stable hemodynamic, who have no distracting pain and are not intoxicated, probability of thoracolumbar fracture is very low and near to zero in case of no positive clinical finding.

Serum concentration of magnesium as an independent risk factor in migraine attacks: a matched case-control study and review of the literature.

There is controversy over the role of magnesium in the etiology of migraine headaches. We aimed to evaluate and compare serum levels of magnesium between healthy individuals and those with migraine headaches during migraine attacks and between attacks to evaluate the role of magnesium in the etiology of migraine headaches. Forty patients with migraine headaches and 40 healthy individuals were enrolled in this matched case-control study. Malnutrition, digestive system disorders, history of smoking, drug abuse, and history of medications use were recorded at baseline. The pain scores of patients were measured and recorded based on a 10 cm visual analog scale. Subsequently, blood samples were collected at 8-10 in the morning to determine serum levels of magnesium. Analysis of variance, χ-test, and conditional logistic regression were used for data analysis. There were no significant differences in demographic data between the two groups. There were significant differences in magnesium serum levels between the three groups (1.09±0.2 mg/dl during migraine headaches; 1.95±0.3 mg/dl between the attacks; and 1.3±0.4 mh/dl in the control group; P<0.0001). Odds of acute migraine headaches increased 35.3 times (odds ratio=35.3; 95% confidence interval: 12.4-95.2; P=0.001) when serum levels of magnesium reached below the normal level. The odds in patients who are not in the acute attack phase were 6.9 folds higher (odds ratio=6.9; 95% confidence interval: 1.3-2.1; P=0.02). The serum level of magnesium is an independent factor for migraine headaches and patients with migraine have lower serum levels of magnesium during the migraine attacks and between the attacks compared with healthy individuals.

True Vertigo Patients in Emergency Department; an Epidemiologic Study.

INTRODUCTION: Vertigo prevalence is estimated to be 1.8% among young adults and more than 30% in the elderly. 13-38% of the referrals of patients over 65 years old in America are due to vertigo. Vertigo does not increase the risk of mortality but it can affect the patient's quality of life. Therefore, this study was designed to evaluate the epidemiologic characteristics of vertigo patients referred to the emergency department (ED). METHODS: In this 6-month retrospective cross-sectional study, the profiles of all vertigo patients referred to the ED of Imam Hossein Hospital, Tehran, Iran, from October 2013 to March 2014 were evaluated. Demographic data and baseline characteristics of the patients were recorded and then patients were divided into central and peripheral vertigo. The correlation of history and clinical examination with vertigo type was evaluated and screening performance characteristics of history and clinical examination in differentiating central and peripheral vertigo were determined. RESULTS: 379 patients with the mean age of 50.69 ± 11.94 years (minimum 18 and maximum 86) were enrolled (58.13% female). There was no sex difference in vertigo incidence (p = 0.756). A significant correlation existed between older age and increase in frequency of central cases (p < 0.001). No significant difference was detected between the treatment protocols regarding ED length of stay (p = 0.72). There was a significant overlap between the initial diagnosis and the final decision based on imaging and neurologist's final opinion (p < 0.001). In the end, 361 (95.3%) patients were discharged from ED, while 18 were disposed to the neurology ward. No case of mortality was reported. CONCLUSION: Sensitivity and specificity of history and clinical examination in differentiating central and peripheral vertigo were 99 (95% CI: 57-99) and 99 (95% CI: 97-99), respectively.

Histamine Antagonists for Treatment of Peripheral Vertigo: A Meta-Analysis.

OBJECTIVE: Vertigo, the hallucination of movement of oneself or one's surroundings, can have substantial adverse effects on the quality of life of affected patients. It is essential to decrease the frequency, severity, and duration of vertigo attacks using effective medications with minimal debilitating adverse effects. We performed a meta-analysis of available clinical trials to evaluate the efficacy of histamine antagonists in the treatment of vertigo compared to the rate of resolution in untreated control groups. MATERIALS AND METHODS: A systematic search of articles in any language from January 1970 to March 2015 was performed through the following databases: the Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval System Online, the Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature, Latin American and Caribbean Health Sciences Literature, Allied and Complementary Medicine Database, Web of Science, ClinicalTrials.gov, and Google. Randomized controlled trials comparing each kind of antihistamine to untreated control participants in the treatment of vertigo (blinded/unblinded) were screened for inclusion. Three reviewers separately performed data extraction from the included trials using a standard data abstraction form. Three other researchers read the final list of all articles retained. Discrepancies were settled by mutual consensus between the authors. Random effects models were applied to estimate the pooled odds ratio (OR) and 95% confidence interval (CI) using the Review Manager software. The evaluation of publication bias was performed by Egger's test and Begg's funnel plot. RESULTS: We identified 13 eligible citations. The pooled OR was 5.370, 95% CI (3.263-8.839), and I2=56.0%, with no obvious evidence of publication bias. CONCLUSION: Our results provide clarification of the effectiveness of several categories of histamine antagonists compared with placebos in controlling peripheral vertigo.

Analgesic Effects of Inhalation of Nitric Oxide (Entonox) and Parenteral Morphine Sulfate in Patients with Renal Colic; A Randomized Clinical Trial.

OBJECTIVE: To compare the analgesiceffects of Nitrous oxide and morphine sulfate in patients with acute renal colic due to urolithiasis. METHODS: This was randomized clinical trial being performed in Imam Hossein hospital affiliated with Shahid Beheshti University of Medical Sciences during a 1-year period from May2013 to May2014.  A total of number of 100 patients, with an age range of 20-50 years, who presented with renal colic secondary to urolithiasis confirmed by ultrasonography were randomly assigned to receive morphine sulfate injection (0.1 mg/kg) with 100 mg diclofenac suppository (n=50) or Entonox exhalation (50% nitric oxide and 50% oxygen) for 30-minutes with 100 mg diclofenac suppository (n=50). Quantitative measurement was of pain was performed according to a visual analogue scale (VAS), before, 3, 5, 10 and 30-minute after the intervention. The pain severity and side effects were measured between two study groups. RESULTS: The baseline characteristics of the patients in two study groups were comparable. The frequencies of pain persistence (at least 50%) at 3-, 5-, 10- and 30-minute intervals in morphine sulfategroup were 96%, 80%, 50% and 8%, respectively; these frequencies in Entonex  were 82%, 42%, 12% and 2%, respectively (p<0.001). Cox regression modeling showed that use of Entonox was the only effective agent in the success of treatment, compared to the use of morphine, i.e. use of Entonox increased the success of treatment up to 2.1 folds compared to the use of morphine (HR=2.1; 95% CI: 1.2-3.6; p=0.006). CONCLUSION: The results of the present study demonstrate that inhalation of Entonox is an effective and safe analgesic regimen for acute renal colic. It acts more rapidly and is more potent in relieving renal colic when compared to morphine sulfate.Entonox can be regarded as an appropriate alternative to analgesics like opioids in this ground.

Comparison of therapeutic effects of magnesium sulfate vs. dexamethasone/metoclopramide on alleviating acute migraine headache.

BACKGROUND: There is controversy about the efficacy of currently used treatment modalities to alleviate migraine headaches. OBJECTIVE: We aimed to evaluate and compare the effects of magnesium sulfate and combined use of dexamethasone/metoclopramide on relieving acute migraine headache. METHODS: We randomly divided 70 patients who had been referred to an emergency department, into two equal treatment groups with the two treatment plans, and analyzed pain severity at baseline using a numeric rating scale (NRS). We gave dexamethasone/metoclopramide to one group and magnesium sulfate to the other group, and evaluated pain severity at 20 min and at 1- and 2-h intervals after infusion. Finally, we used repeated-measure and two-way analysis of variance for intra- and inter-group evaluations of pain severity and complications, respectively. RESULTS: We found no significant differences in demographic data and pain severity at baseline (8.2 vs. 8.0) between the two groups (p < 0.05). In the dexamethasone/metoclopramide group, pain severity (mean ± standard deviation) was 7.4 ± 1.4 (p = 0.36), 6.0 ± 2.4, and 2.5 ± 2.9 (p < 0.0001) at 20-min, 1-h, and 2-h intervals after treatment, respectively, with statistically significant differences between the baseline values and 1-h and 2-h interval values. Administration of magnesium sulfate was associated with decreased pain severity at the three intervals (5.2 ± 1.7, 2.3 ± 1.9, and 1.3 ± 0.66, respectively), exhibiting significant differences compared to baseline values and the corresponding time intervals in the dexamethasone/metoclopramide group (p < 0.0001). CONCLUSIONS: According to the results, magnesium sulfate was a more effective and fast-acting medication compared to a combination of dexamethasone/metoclopramide for the treatment of acute migraine headaches.

Intravenous promethazine versus lorazepam for the treatment of peripheral vertigo in the emergency department: A double blind, randomized clinical trial of efficacy and safety.

BACKGROUND: Vertigo imposes considerable health restrictions with significant impact on the patient's quality of life. The most effective antivertigo agent is undetermined thus far. OBJECTIVE: This study was performed to assess whether promethazine has superior vertigo reduction compared with lorazepam in ED patients. METHODS: In this randomized, double-blind, parallel group trial 184 patients were assigned (1:1 ratio) to receive either promethazine, 25 mg intravenously, or lorazepam, 2 mg intravenously. Primary endpoint was mean change in vertigo intensity at 2 hours measured using visual analog scale (VAS). Secondary endpoints were mean change in nausea score, need for second dose of study medications, and adverse events (AEs). RESULTS: Promethazine was associated with significantly more reduction (46.5 mm) in vertigo than lorazepam (25.7 mm, p< 0.001). Mean change in nausea score 2 hours after drug injection on the VAS was 28.7 mm for promethazine and 22.8 for lorazepam (p=0.002). The most frequently reported AEs were lethargy (14.1% in lorazepam group, 4.3% in promethazine group, p=0.013) and drowsiness (10.8% for promethazine, 2.1% for lorazepam, p=0.017). CONCLUSION: Our study demonstrated the evidence that promethazine is superior to lorazepam in management of peripheral vertigo and vertigo-related nausea in ED adults.

Cause of Emergency Department Mortality; a Case-control Study.

INTRODUCTION: Based on previous studies, cardiovascular diseases, traffic accidents, traumas and cancers are the most important etiology of mortalities in emergency departments (ED). However, contradictory findings have been reported in relation to mortality in emergency departments. Therefore, the present study was undertaken to evaluate the role of clinical factors in mortality among patients referring to an emergency department in a third-level hospital in Tehran, Iran. METHODS: In the present case-control study, all the patients over 18 years of age were evaluated, referring to the ED of Imam Hossein Hospital, Tehran, Iran, from the beginning of 2009 to the end of 2010. The patients died in the ED were placed in the case group and those discharged or hospitalized in other hospital wards in the control group. Demographic data, background diseases, and the final diagnoses were recorded. Chi-squared test, multivariate logistic regression, and Pearson's correlation coefficient were used to evaluate the relationship between the variables mentioned above and patient mortality. RESULTS: 2907 patients (969 (59.9% male) in the case and 1938 (62.2% male) in the control groups) were evaluated. Cardiovascular diseases (39.2%), severe traumas (18.5%), and cerebrovascular accidents (17.7%) were the most frequent etiology of patient mortality in ED. Multivariate regression analysis showed that presentation with cardiovascular complaints (OR=7.3; 95% CI: 3.5-16.1; p<0.001), a history of hypertension (OR=5.4; 95% CI: 1.2-12.3; p<0.001), severe trauma (OR=4.6; 95% CI: 2.0-13.2; p<0.001), age over 60 (OR=3.8; 95% CI: 1.8-7.8; p<0.01) and a final diagnosis of renal disease (OR=3.4; 95% CI: 2.1-6.4; p<0.001) were factors that increased the odds of mortality in patients referring to the ED. Multivariate regression analysis in patients over 60 years showed that sepsis was an independent factor increasing the risk of death (OR=2.9; 95% CI: 1.3-5.9; p=0.009). A patient's risk of death increases with an increase in the number of risk factors in that patient (r(2)=0.96; p=0.02). CONCLUSION: It appears the odds of mortality in patients referring to ED with cardiovascular complaints, a history of hypertensive, severe trauma, age over 60 and a final diagnosis of renal disease are higher versus other patients. In addition, the patients' odds of death increase with an increase in the number of risk factors. Such an increase is more noticeable at age over 60.

Quality of Life in Emergency Medicine Specialists of Teaching Hospitals.

INTRODUCTION: Quality of life (QOL) of emergency medicine specialists can be effective in providing services to patients. The aim of the present study was evaluating the lifestyle of emergency medicine practitioners, understanding their problems, and addressing the solutions to enhance and improve their lifestyles, in teaching hospitals in Iran. METHOD: This descriptive cross-sectional study was conducted on emergency medicine physicians in 10 teaching hospitals of Iran in 2011. Emergency physicians with at least three years of experience, who interested in the study, were enrolled in the project. All participants filled out the consent form and QOL questionnaires, and then underwent physical examinations and some medical laboratory tests. Categorical variables were reported as percentages, while continuous variables expressed as means and standard deviations. p <0.05 was considered statistically significant. RESULTS: Totally, 100 subjects participated in the study, of whom 48 were male. The mean and standard deviation of the physicians' age were 38.7±5.1 years. 43% of physicians had an average QOL, while 37% good. 96% of studied physicians had a good condition regarding habitual history, while 93% of them had a poor condition in performing screening tests. Exercise program and personal health in individuals with normal BMI were correlated with higher levels of QOL. BMI was higher in 40-50 years old subjects than youth. Hypertension was present in five cases (5%), hypercholesterolemia in six (6%), hypertriglyceridemia in six (6%), increased LDL in four (4%), low HDL in four (4%), and impaired FBS in 4 (4%). CONCLUSION: The findings showed that 63% of studied emergency physicians had an average level of QOL and other ones good. The majority of physicians had undesirable situation regarding the performance of screening tests.

Spontaneous Spinal Epidural Hematoma; a Case Report.

Spontaneous spinal epidural hematoma (SSHE) is a rare entity can have several reasons. Its prevalence in population is 0.1 per 100,000 with the male to female ratio of 1/4:1. For the first time Jackson in 1869 reported a case of SSHE and after that, it was declared as several hundred cases in literatures. Here, a case of SSHE was reported in a 52-year-old male referred to emergency department following severe low back pain.

Promethazine plus sumatriptan in the treatment of migraine: a randomized clinical trial.

OBJECTIVE: This study was performed to evaluate the efficacy and safety of the combination of sumatriptan (50 mg) plus promethazine (SPr) (25 mg) compared with sumatriptan (50 mg) plus placebo in patients with migraine attacks. BACKGROUND: Migraine is a chronic, disabling disorder with an estimated worldwide prevalence of 10% in adults imposing substantial social and economic impact. Efficient treatment of migraine attacks could benefit patients by reducing their disability and the need for health care resources, and improving economic productivity. DESIGN AND METHODS: This was a multicenter, randomized, double-blind trial conducted at 5 university-affiliated research centers in Iran. Between January 2013 and April 2013, 350 individuals with a history of migraine were evaluated. Patients were diagnosed with migraine, with or without aura, as defined by the International Headache Society diagnostic criteria. The 242 patients meeting the eligibility criteria were randomly assigned to SPr group (n = 121) or the sumatriptan plus placebo (SP) group (n = 121). The study medications were taken on an outpatient basis during the moderate to severe phase of migraine attack. Patients recorded details of the treated migraine on a diary card and rated pain severity immediately before dosing and 30 minutes, 1 hour, 2 hours, and 4 hours after dosing using a 4-point scale (0 = none to 3 = severe). RESULTS: Of 242 patients randomized, 216 were included in the intention-to-treat efficacy analysis. In the SPr group, 39.6% of subjects experienced 2-hour headache-free response (primary outcome), which was significantly more effective than SP treatment (26.3%, odds ratio: 1.83, 95% confidence interval: 1.03-3.26, P = .038). Significantly more patients receiving SPr treatment (62.2%) had headache improvement compared with SP treatment (37.2%) at 2 hours (odds ratio: 2.77, 95% confidence interval: 1.60-4.81, P < .001). A similar pattern of between-group differences was observed for 4-hour headache-free response (P = .006) and headache improvement response (P = .003). The incidence of headache recurrence within 2-48 hours after treatment was lowest in the SPr group (15.0%) compared with SP group (26.6%, P = .041). The only significant drug-related adverse events reported in ≥15% of patients in any treatment group were somnolence (32.2% and 7% in the SPr and SP groups, respectively, P < .001), extrapyramidal symptoms (4.3% and 0%, P = .05), and nausea (1% and 8%, P = .03). CONCLUSION: This is the first prospective clinical trial to demonstrate that multimechanism therapy for migraine, combining a triptan and an antiemetic agent, is well tolerated and offers improved clinical benefits compared with monotherapy.

Improving the prediction of stroke or death after transient ischemic attack (TIA) by adding diffusion-weighted imaging lesions and TIA etiology to the ABCD2 score.

The present study investigated the addition of transient ischemic attack (TIA) etiology and diffusion-weighted imaging (DWI) to the ABCD2 score, creating the ABCDE+ score, to improve the predictive ability of stroke risk or death at 6 months after TIA. We performed a cohort study of 150 consecutive patients with TIA. All patients underwent DWI and all had an etiologic workup and were followed up for 6 months. The area under the receiver operating characteristic curve (AUC) was used to compare the scores' ability to predict the outcome of stroke or death. Multivariate Cox regression analysis was performed to evaluate the association between the measured variables and subsequent stroke or death. Thirty patients (20%) experienced future stroke, and 12 patients (8%) died within the 6-month follow-up. A comparison of AUCs demonstrated the superiority of the ABCDE+ score over the ABCD2 score for predicting stroke (0.64 vs 0.60) and for predicting death (0.62 vs 0.56). ABCD2 score >4, ABCDE+ score >6, large-artery disease, and lesions detected on DWI were found to be independent predictors of future stroke, and ABCDE+ score >6, age, and heart disease were independent predictors of death. We conclude that incorporating DWI positivity and etiology of TIA into the ABCD2 score can improve the ability to predict stroke and death within 6 months after TIA.