The Diagnostic Evaluation of the SINEH Cardiopulmonary Triage Scale and the Emergency Severity Index in the Emergency Department: A Comparative Study.

Introduction: The diagnostic evaluation of the emergency severity index (ESI) in the triage of patients with cardiopulmonary complaints has a high sensitivity but a low specificity in the emergency department (ED). Therefore, triage scales with more accurate diagnostic evaluation are required. As a result, accuracy of the SINEH triage scale (SinTS) and the ESI was compared to compare mistriage of critically ill patients with cardiopulmonary complaints. Methods: This descriptive, analytical and cross-sectional study was conducted between December 2022 and April 2023. In this study, two nurses independently examined each patient using two triage scales. The admission unit and length of hospital stay were also recorded. The outcome was classified as high-risk admission (cardiac care unit and intensive care unit) and low-risk admission (internal unit or discharge from the ED). Undertriage and overtiage were defined as high-risk admission with triage level 3 and 4 and low-risk admission with triage level 1 or 2, respectively. A panel of experts evaluated content validity of SinTS and kappa designating agreement on relevance reported. The inter-rater reliability of two scales was also reported. Results: Finally, the study included 145 patients. The average age of the patients studied was 61.35 years. SinTS has a total mistriage of 29.63%, with 4.13% being undertriage and 25.5% being overtriage. In ESI, the total mistriage is 66.8%, with 1.3% being undertriage and 65.5% being overtriage. The undertriage of the two scales did not differ significantly by admission unit (p=0.26), but the overtriage of the two methods did (p=0.001). The sensitivity, specificity, and accuracy of SinTS were 86.3%, 63.37%, and 72.27%, respectively, while those of ESI were 95.4%, 5.94%, and 32.79%, respectively. Conclusion: SINEH triage scale has achieved the optimal accuracy in recognizing the acuity of the patients with chest pain and dyspnea by using SpO2, pressure of end-tidal carbon dioxide, troponin I, and peak expiratory flow. When triaging patients with chest pain and dyspnea, SinTS may exhibit a higher level of accuracy compared to ESI. More research is needed to improve accuracy of triage scales in patient with cardiopulmonary complaints.

Oral nano-curcumin formulation efficacy in the management of mild to moderate outpatient COVID-19: A randomized triple-blind placebo-controlled clinical trial.

BACKGROUND: Curcumin, a natural polyphenolic compound, is proposed as a potential treatment option for patients with coronavirus disease by inhibiting the entry of virus to the cell, encapsulation of the virus and viral protease, as well as modulating various cellular signaling pathways. In this study, the efficacy and safety of nanocurcumin oral formulation has been evaluated in patients with mild-moderate Coronavirus disease 2019 (COVID-19) in outpatient setting. METHODS: In this triple-blind randomized placebo-controlled clinical trial, sixty mild to moderate COVID-19 patients in outpatient setting who fulfilled the inclusion criteria were randomly allocated to treatment (n = 30) group to receive oral nanocurcumin formulation (Sinacurcumin soft gel which contains 40 mg curcuminoids as nanomicelles), two soft gels twice a day after food for 2 weeks or placebo (n = 30) group. Patients' symptoms and laboratory data were assessed at baseline and during follow-up period and compared between two groups. RESULTS: All symptoms except sore throat resolved faster in the treatment group and the difference was significant for chills, cough and smell and taste disturbances. The CRP serum level was lower in the treatment group at the end of two weeks and the lymphocyte count was significantly higher in treatment group. No significant adverse reaction reported in the treatment group. CONCLUSION: Oral nanoformulation of curcumin can significantly improve recovery time in patients with mild to moderate COVID-19 in outpatient setting. Further studies with larger sample size are recommended.

The Minocycline Ameliorated the Synaptic Plasticity Impairment in Vascular Dementia.

Chronic cerebral hypoperfusion (CCH) leads to vascular dementia with progressive hippocampal damage and cognitive impairments. In the present study, we compared early and late Minocycline (MINO) treatment on cognitive function, long and short-term synaptic-plasticity following CCH. We used bilateral common carotid arteries occlusion model (2VO) for induction of hypoperfusion. Male Sprague-Dawley rats were divided into 5 following groups (each having 2 subgroups): 2VO + V (vehicle), 2VO+MINO-E (early treatment of MINO on days 0 to 3 after 2VO), 2VO+MINO-L (late-treatment on days 21 to 32 after 2VO), control, and sham. Passive-avoidance (PA) and radial arm maze (RAM) tests were used to investigate learning and memory. Long term and short term synaptic plasticity were assessed by field potential recording, the brains were removed after recording and preserved for histological study to count pyramidal cells in CA1 region.Cerebral hypoperfusion could impair memory performance, synaptic plasticity, and basal synaptic transmission (BST) along with hippocampal cell loss. Thus, we found a significant reduction in step-through latency (STL) of PA test with a higher number of working and reference errors in RAM in CCH rats. However, only late treatment with MINO improved memory performance, synaptic plasticity, hippocampal cell loss, and increased neurotransmitter pool (NP) in CCH rats, but early treatment could not produce long-lasting beneficial effects 32 days after 2VO. MINO may improve synaptic plasticity and memory performance in hypo-perfused rats directly and indirectly by increasing NP and/or suppressing inflammatory factors, respectively.

Comparison between Emergency Severity Index and Heart Failure Triage Scale in heart failure patients: A randomized clinical trial.

BACKGROUND: It is not clear whether Emergency Severity Index (ESI) is valid to triage heart failure (HF) patients and if HF patients benefit more from a customized triage scale or not. The aim of study is to compare the effect of Heart Failure Triage Scale (HFTS) and ESI on mistriage among patients with HF who present to the emergency department (ED). METHODS: A randomized clinical trial was conducted from April to June 2017. HF patients with dyspnea were randomly assigned to HFTS or ESI groups. Triage level, used resources and time to electrocardiogram (ECG) were compared between both groups among HF patients who were admitted to coronary care unit (CCU), cardiac unit (CU) and discharged patients from the ED. Content validity was examined using Kappa designating agreement on relevance (K*). Reliability of both scale was evaluated using inter-observer agreement (Kappa). RESULTS: Seventy-three and 74 HF patients were assigned to HFTS and ESI groups respectively. Time to ECG in HFTS group was significantly shorter than that of ESI group (2.05 vs. 16.82 minutes). Triage level between HFTS and ESI groups was significantly different among patients admitted to CCU (1.0 vs. 2.8), cardiac unit (2.26 vs. 3.06) and discharged patients from the ED (3.53 vs. 2.86). Used resources in HFTS group was significantly different among triage levels (H=25.89; df=3; P<0.001). CONCLUSION: HFTS is associated with less mistriage than ESI for triaging HF patients. It is recommended to make use of HFTS to triage HF patients in the ED.

The Relationship between Clinical Findings of Shoulder Joint with Bone Damage of Shoulder Joint in Patients with Isolated Shoulder Blunt Trauma.

BACKGROUND: Due to the prevalence of shoulder injuries among athletes and other people and the prevalence of radiography for these injuries, there are still no valid criteria for indication of doing shoulder radiography. AIM: This study aimed to examine the relationship between some signs and clinical examinations of the shoulder with shoulder bone injuries and the need for radiography. METHODS: This is a cross-sectional study. All patients aged 18-70 years who referred to the emergency ward of Imam Reza and Hasheminejad Hospital in the year 2014 due to blunt trauma and had criteria for entering the study and lacking exclusion criteria were included in the study process. Data on clinical symptoms, radiographic results, and final diagnosis were extracted from the patients' records through a questionnaire and analysed statistically. RESULTS: There was a significant relationship between the clinical signs of patients Existence of ecchymosis in the shoulder fractures with glenoid and humerus fractures (p = 0.029, p = 0.004 respectively). There was also a significant relationship between clavicle fracture and limitation in shoulder rotation and abduction (p = 0.000 and p = 0.001 respectively). Other clinical symptoms did not show any significant relationship with radiographs indicative of the problem requiring specific treatment. CONCLUSION: Although it is possible to define critters based on clinical symptoms that reduce the need for unnecessary radiographs that the does not reliably help inpatient treatment, but finding these critters to indicate the performance of the graphs in shoulder injuries requires further studies with the higher population and more clinical variables.

Analysis of correlation between estradiol and fracture of femur neck.

Osteoporosis is a major public health challenge all over the world. Estrogen hormone was cited amongst other hormones to be an efficient hormone for the production and maintenance of bone density. This study was designed with the purpose of evaluating and analyzing the estradiol effect on fractures of femur neck in the Iranian society. This study evaluated men over 50 years of age suffering with mild trauma (falling off the same level height or lower) and with a fracture on their femur neck. Also, their serum level of estradiol was measured with an ELISA method. Using this procedure, the patients were assigned into groups with either normal estradiol serum level (10pg/ml and higher) or with lower than normal level (lower than 10 pg/ml). A control group including 50-year-old and older men without hip fracture, or its history, was chosen to access their estradiol serum level. Data collected from these two groups were statistically compared. A total of 120 patients were evaluated (60 in the control and 60 in the test group). The mean age of patients in the control and test groups were 67.9±10.22 and 69.5±8.84 years, respectively (p=0.376). Smoker patients' percentages in the control and test groups were 35% and 31.7%, respectively (p=0.699). On the basis of the serum estradiol level, patients' percentages with low estradiol level in control and test groups were 10% and 16.7%, respectively (p=0.283). The only significant factor in predicting serum estradiol level was smoking. In conclusion, in this study it was observed that fractures of the femoral neck following a mild trauma were not correlated to low level of serum estradiol.

Effects of intravenous administration of fentanyl and lidocaine on hemodynamic responses following endotracheal intubation.

OBJECTIVES: To compare the effects of intravenous fentanyl and lidocaine on hemodynamic changes following endotracheal intubation in patients requiring Rapid Sequence Intubation (RSI) in the emergency department (ED). METHODS: A single-centered, prospective, simple non-randomized, double-blind clinical trial was conducted on 96 patients who needed RSI in Edalatian ED. They were randomly divided into three groups (fentanyl group (F), lidocaine group (L), and fentanyl plus lidocaine (M) as our control group). M was administered with 3 µgr/kg intravenous fentanyl and 1.5 µgr/kg intravenous lidocaine, F was injected with 3g/kg intravenous fentanyl and L received 1.5mg/kg intravenous lidocaine prior to endotracheal intubation. Heart rate (HR) and mean arterial pressure (MAP) were assessed four times with the chi-square test: before, immediately after, 5 and 10 min after intubation. Intervention was discontinued for five people due to unsuccessful CPR. RESULTS: HR was notably different in F, L and M groups during four time courses (p<0.05). Comparison of MAP at measured points in all groups exhibited no significant difference (p>0.05). In fentanyl group both HR and MAP increased immediately after intubation, and significantly decreased 10 min after intubation (p<0.05). CONCLUSIONS: Overall, the result of this study shows that lidocaine effectively prevents MAP and HR fluctuations following the endotracheal intubation. According to our findings, lidocaine or the combination of fentanyl and lidocaine are able to diminish hemodynamic changes and maintain the baseline conditions of the patient, thus could act more effectively than fentanyl alone.

The Relation of Q Angle and Anthropometric Measures with Ankle Sprain; a Case-control study.

INTRODUCTION: Since most studies on ankle sprain are medical and sports-related and not much epidemiologic and etiologic data from the general population exist in this field, the present study evaluates the relationship between Q angle and anthropometric measures with ankle sprain in the general population. METHODS: In the present case-control study, all of the patients over 18 years age presenting to emergency departments (ED) of two educational Hospitals, complaining from ankle sprain, were evaluated during more than 1 year. A checklist consisting of demographic data, height, weight, body mass index (BMI), and history of ankle sprain, as well as degree of Q angle was filled for all participants. The correlation of mentioned variables with incidence of ankle sprain was calculated using SPSS 22. RESULTS: 300 patients with ankle sprain were evaluated (53.5% male). Mean age of the patients was 37.03 ± 14.20 years. Mean weight, height, and BMI were 71.71 ± 11.26 (43 - 114), 168.74 ± 8.63 (143 - 190) and 25.14 ± 3.19 (18.41 - 38.95), respectively. Mean Q angle of the patients was 12.78 ± 3.19 degrees (5 - 23). There was a significant correlation between weight (p < 0.001), BMI (p = 0.001), history of sprain (r: 0.26, p < 0.001) and Q angle (p = 0.002) with incidence of ankle sprain. In addition, there was a significant statistical correlation between weight (p = 0.031), BMI (p = 0.020) and Q angle (p = 0.004) with history of ankle sprain. In patients with a history of ankle sprain, Q angle was wider by about 2 degrees. CONCLUSION: It seems that the prevalence of ankle sprain directly correlates with high weight, BMI, and Q angle and is more prevalent in those with a history of sprain. Although the findings of the present study show a statistically significant correlation between these factors and ankle sprain, the correlation is not clinically significant.

Impact of morphine use in reducing the need for CT scan in patients with cervical spine trauma: a double blinded randomized clinical trial.

BACKGROUND: Cervical spine trauma occurs mostly among young males due to falls and car accidents. The CT scan technology is replacing radiography in many medical clinics as it is very capable in detecting subtle cervical spine injuries. However, the use of CT scan for routine screening in patients with cervical spine trauma remains controversial due to its radiation risks and relatively high cost. OBJECTIVE: The focus of this research was on using morphine in patients with cervical spine trauma. The objective was to determine the ability of morphine to reduce the number of patients in need of CT scans. METHODS: This double-blinded randomized clinical trial study was conducted from April 2014 to March 2015 in Hasheminejad Hospital in Mashhad, Iran. We enrolled 67 patients with cervical spine trauma and normal radiography in the study. They were divided randomly into two groups (groups A and B), where group A received intravenous morphine, and group B received a placebo. We measured the pain scores in both groups before giving the medication and 10 minutes afterwards using a visual analog scale (VAS). RESULTS: As a result of receiving morphine, the patients in group A had significantly lower pain than group B (p-value < 0.001). The average pain score in group A was reduced by 43% versus 23% in group B. However, the most pain reduction was in those in group A with a normal CT scan. The pain score of these patients dropped by 52%. CONCLUSIONS: The findings of this study suggest that patients with a normal radiography may be discharged with a cervical collar without a need for a CT scan if morphine reduces their pain. This is because the pain in these patients stem from the muscles and non-bony structures in the cervical spine area. CLINICAL TRIAL REGISTRATION: The trial was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the IRCT ID: IRCT2013100214872N1. FUNDING: The authors received no financial support for the research or for the publication of this article.

Diagnostic Value of Leukocyte Esterase Test Strip Reagents for Rapid Clinical Diagnosis of Spontaneous Bacterial Peritonitis in Patients Admitted to Hospital Emergency Departments in Iran.

BACKGROUND: Spontaneous bacterial peritonitis (SBP) is a common and important clinical problem and is life-threatening in decompensated liver disease. Ascites fluid test by leukocyte esterase test strip has been recently proposed as an effective and rapid method to diagnose SBP in patients with cirrhosis. OBJECTIVES: This study aimed to evaluate sensitivity and specificity of leukocyte esterase test strip in the diagnosis of SBP. PATIENTS AND METHODS: The population of this research was all patients with cirrhosis and ascites admitted to the emergency room at Imam Reza (AS) hospital, Mashhad. A written consent was taken for inclusion in the study. 50 mL ascites sample was taken from all patients for use in a urine test strip (LER) (Urine Test Strips Convergys®Urine Matrix 11). The patient's ascites samples were evaluated for cell counting. Positive dipstick test for LER in this study considered as grade 3 +. The values of WBC > 500 cell/mm(3) or PMN > 250 cell/mm(3) considered as positive result of the gold standard method for the diagnosis of SBP. RESULTS: In this study, 100 patients with ascites due to cirrhosis, with an average age of 38.9 ± 6.54 years were evaluated. Twenty cases had positive results, of whom 17 cases were also detected based on the standard diagnostic criteria and other three cases were healthy individuals. Thus, sensitivity, specificity, positive and negative predictive values, and accuracy of the method were 95%, 96.3%, 85%, 97.5% and 95%, respectively. CONCLUSIONS: The use of leukocyte esterase urine dipstick test can be a quick and easy method in early diagnosis of SBP to start the treatment until preparation of SBP-cell count results.

Enriched environment improves synaptic plasticity and cognitive deficiency in chronic cerebral hypoperfused rats.

Recent studies have indicated that environmental enrichment (EE) increases the sensorial and social stimulations and leads to strengthened plastic changes in the brain. In models of chronic cerebral hypoperfusion, the ability of an EE to restore the cognition depends on hippocampal synaptic plasticity. The mechanisms for this effect have not, however, been adequately studied. Thus, the aim of the present study was to evaluate the neuroprotective effects and underlying mechanism of environmental enrichment by assessment of spatial memory tasks as well as parameters of synaptic plasticity in rats subjected to occlusion of the bilateral common carotid arteries (2-VO) model. Male Sprague-Dawley rats were used in this study. The model group was established by occlusion of the bilateral common carotid arteries. The animals were tested for learning, memory performance and synaptic plasticity using Morris water maze (MWM), 8-arm Radial Maze (RM), and field potential recording, respectively. The rats subjected to 2-VO in EE exhibited a significantly lower number of working errors and reference errors in RM. Moreover, the enriched environment recovered the memory performance of hypoperfused rats and decreased the swimming time to reach the platform in MWM. In addition, conditions of the environment did not have any effect on baseline synaptic transmission and presynaptic plasticity, but housing the animals in EE rescued the impairment of LTP induction induced by 2-VO. These results suggest that EE ameliorates the LTP and spatial memory impairment induced by 2-VO. Our data indicated that the LTP recovery by EE in the rat models of 2-VO is probably mediated by post-synaptic mechanisms.

The correlation between end-tidal carbon dioxide and arterial blood gas parameters in patients evaluated for metabolic acid-base disorders.

BACKGROUND: The analysis of arterial blood gas (ABG) is an invasive procedure that is used frequently in the emergency department (ED) to evaluate the acid-base status of critically-ill patients. However, capnometry is an alternative procedure that has been used in recent years to determine the metabolic status of patients' blood. Considering the correlation between end-tidal carbon dioxide (ETCO2) and arterial partial pressure of carbon dioxide (PaCO2) identified in the previous studies and the strong correlation between PaCO2 and bicarbonate (HCO3(-) ), we assumed that ETCO2 might be a useful parameter in predicting the presence of metabolic acidosis. The aim of this study was to determine the correlation between ETCO2 and the parameters of ABG in adult patients who were likely present metabolic acid-base disturbances in the Emergency Department of Imam Reza Hospital, the largest academic hospital in Mashhad in northeast Iran. METHODS: This was a cross-sectional study conducted during six months on 62 adult patients who presented with suspected metabolic acid-base disorders to the ED. The exclusion criteria were patients with chronic obstructive pulmonary diseases, loss of consciousness, intubated patients, and those who were unable to tolerate capnography. The patients' demographic information and vital signs were recorded. Also, ABG and ETCO2 results were recorded. The Pearson product moment correlation analysis and linear regression were used to determine the correlation between ETCO2 and ABG parameters. RESULTS: Sixty-four patients were enrolled, consisting of 37 men and 27 women with a mean age of 55.4 ± 22.7 years. The most common complaints presented were nausea and vomiting (n = 24). The average value for ETCO2 was 26.2 ± 6.1. There were significant linear correlations between ETCO2 level, pH (r = 0.368), HCO3(-) (r = 0.869), PaCO2 (r = 0.795), and Base Excess (B.E.) (r = 0.346). HCO3 and PaCO2 were the significant predictor values for ETCO2 (linear regression analysis). CONCLUSION: ETCO2 can be an appropriate indicator to estimate HCO3(-) and PaCO2 in critical emergency situations, but it cannot be used as an indicator to estimate all ABG variables.

The Accuracy of Pain Measurement in Diagnosis of Scaphoid Bone Fractures in Patients with Magnetic Resonance Imaging: Report of 175 Cases.

INTRODUCTION: Scaphoid fracture is the most common fracture among the bones of the wrist. Plain radiography has a sensitivity of 59 to 79 percent for the diagnosis of scaphoid fracture after injury. Casting is done to avoid complications in patients with suspected fractures with normal radiography. Magnetic resonance imaging (MRI) has a sensitivity of 100% and a specificity of 99%. To avoid unnecessary casting and high costs, we decided to offer a way more efficient than radiography and less costly than MRI. MATERIAL AND METHODS: In the present study, 175 patients with suspected scaphoid fracture along with snuff box tenderness and normal radiography were enrolled in the study. On arrival, patients' pain score were determined using visual analog scale method with anatomical snuffbox tenderness and then MRI was performed on the patients' wrist and the results were recorded for patient in the check list. The data was then aggregated and analyzed. RESULTS: The result of MRI for fracture was negative for 90.9% and positive for 9.1%. The mean pain score was 7.3 in negative MRI group and 8.75 in positive MRI group, considering a significant difference. ROC curve graph showed that the sensitivity and specificity will be 87% and 57%, respectively for scores 7.5 and higher and 75% and 72%, respectively for scores 8.5 and higher. CONCLUSION: It seems that although this method, beside other criteria in the diagnosis of fractures, can be useful in future studies, it would not be helpful in fracture detection.

Cellular and biological evaluation and diagnostic immunohistochemistry of cytokeratin 15/19 expression in distinguishing cutaneous basal cell carcinoma.

Recent studies have investigated the expression of proliferative markers, but little is known about the expression of cytokeratin 15 and 19 in different histological subtypes of basal cell carcinoma (BCC). We conducted cellular, biological, clinicopathological and immunohistochemical analysis on the manifestations of 8 BCC by hematoxylin and eosin stain (H&E) staining and immunohistochemistry and reviewed relevant literature. Microscopically, the tumor cells were multiple remarkable foci of epidermolytic hyperkeratosis with large pleomorphic nuclei and scant cytoplasm together with peripheral palisading and forming solid nests. Furthermore, the most tumors were composed of highly cellular areas with a homogenous population of round, ovoid and spindle cells, hyperchromatic nuclei, high cellular pleomorphism, high mitotic index and various morphologic patterns. Moreover, the tumors displayed an invasive growth, with positive expression of Cytokeratin 19 (CK19) and negative expression of CK15. Our study revealed that the expression of CK19 was associated with progression and invasion in cases with BCC and immunohistochemistry is indispensable in distinguishing this tumor from other types of cutaneous carcinoma. To our best knowledge, it may be a considerable biomarker to assess invasiveness of cutaneous-surface BCC and to guide clinical management of such tumors.

Effectiveness of local anesthesia with lidocaine in chronic opium abusers.

CONTEXT: It had been demonstrated that chronic opium abusers have lower pain thresholds compared with than non-abusers. AIMS: This study aimed to compare the required dose of lidocaine, a common local anesthetic drug, with regard to the onset of anesthesia in opium abusers with that in non-abusers undergoing similar suturing of minor hand lacerations. MATERIALS AND METHODS: In this study, 109 opium abusers and 91 non-abusers underwent similar suturing for hand lacerations known as digital block. We explained the patients that their case records would remain confidential and admitting to any history of opioid abuse could assist in alleviating any pain associated with the procedure. RESULTS: There was no statistically significant difference between the two groups with regard to age, gender, and cause of injury (P > 0.05). We found a significantly longer duration of onset of analgesia in nonopioid abusers (5.42 ± 1.93 min) than that in abusers (10.30 ± 1.79 min) (P < 0.001). In addition, the lidocaine dose administered to abusers (6.67 ± 1.21 ml) was higher (4.07 ± 1.26) as well as statistically significant (P < 0.001) than that in non-abusers. CONCLUSION: The findings from this study suggest a longer duration of onset of anesthesia and requirement of a higher lidocaine dose in opium abusers compared with nonopioid abuser. Moreover, chronic opium abusers (4-5 years) experienced significantly higher time of onset of anesthesia compared with nonchronic abusers. This outcome may be useful in selecting a more suitable local anesthetic protocol in such patients.