In ischemic stroke, EVT improved 90-d function more than usual care across admission SBP levels.

SOURCE CITATION: Samuels N, van de Graaf RA, Mulder MJHL, et al; HERMES Collaborators. Admission systolic blood pressure and effect of endovascular treatment in patients with ischaemic stroke: an individual patient data meta-analysis. Lancet Neurol. 2023;22:312-319. 36931806.

Adopting and adapting clinical practice guidelines for timing of decompressive surgery in acute spinal cord injury from a developed world context to a developing region.

PURPOSE: The proper application of high-quality clinical practice guidelines improves trauma patients' care and outcomes. This study aimed to adopt and adapt guidelines on the timing of decompressive surgery in acute spinal cord injury (SCI) in Iranian clinical settings. METHODS: This study followed a systematic search and review of the literature to enter them into the selection process. The source guidelines' clinical suggestions were converted into clinical scenarios for clinical questions on the timing of decompressive surgery. After summarizing the scenarios, we prepared an initial list of recommendations based on the status of the Iranian patients and the health system. The ultimate conclusion was reached with the help of a national interdisciplinary expert panel comprising 20 experts throughout the country. RESULTS: A total of 408 records were identified. After title and abstract screening, 401 records were excluded, and the full texts of the remaining seven records were reviewed. Based on our screening process, only one guideline included recommendations on the topic of interest. All of the recommendations were accepted by the expert panel with slight changes due to resource availability in Iran. The final two recommendations were the consideration of early surgery (≤24 h) as a treatment option in adult patients with traumatic central cord syndrome and in adult patients with acute SCI regardless of the level of injury. CONCLUSION: Considering early surgery for adult patients with acute traumatic SCI regardless of the level of injury was the final recommendation for Iran. Although most of the recommendations are adoptable in developing countries, issues with infrastructure and availability of resources are the limitations.

Methocarbamol versus diazepam in acute low back pain in the emergency department: a randomised double-blind clinical trial.

BACKGROUND: Acute low back pain (LBP) is a common complaint in the emergency department and achieving effective analgesia can be challenging. METHODS: In this multicentre randomised double-blind clinical trial conducted at three EDs in Iran from August to November 2020, we assessed the efficacy and adverse effects of two muscle relaxants in patients aged 18 years or older who suffered LBP in the last 6 weeks. Group 1 received intravenous methocarbamol and group 2 received intravenous diazepam followed by a weight-based dose of intravenous morphine in both groups. Exclusion criteria mainly included non-spine aetiologies, cord compression, acute gastrointestinal bleeding, renal/hepatic insufficiency, pregnancy, breast feeding and unstable vital signs. Pain scores and adverse events were measured by a Numeric Rating Scale (NRS) at baseline and after 30 and 60 min by one of the researchers who was not involved with patient visits and was blinded to the intervention. We used t-test to assess the mean difference of NRS at 30 and 60 min. RESULTS: Out of 101 enrolled patients, 50 participants received methocarbamol and 51 diazepam. The baseline mean pain scores and demographic characteristics were not different between the study groups. Pain scores were reduced by both agents after 60 min, with slightly greater pain reductions in the diazepam group in comparison with methocarbamol (mean difference -6.1, 95% CI -6.5 to -5.7 vs mean difference -5.2, 95% CI -5.7 to -4.7, respectively, p<0.001). ED length of stay of patients did not differ between the groups (methocarbamol 5.9 vs diazepam 4.8 hours, p=0.365). Patients receiving diazepam were more likely to report drowsiness (2 (4.0%) vs 15 (29.4%), p=0.001). CONCLUSIONS: In patients with LBP, the pain was relieved in the methocarbamol and diazepam groups after 60 min. Although diazepam was more effective, its use was associated with a slightly higher risk of drowsiness. TRIAL REGISTRATION NUMBER: The protocol of this clinical trial was prospectively registered in the irct.ir (IRCTID: IRCT20151113025025N4; https://irct.ir/trial/50148) .

Comparison of the efficacy of ketamine- propofol versus sodium thiopental-fentanyl in sedation: a randomised clinical trial.

BACKGROUND: Many sedative regimens have been studied with controversial efficiencies. This study tried to assess the desirable and adverse effects of sodium thiopental-fentanyl (TF) with ketamine-propofol (KP) for procedural sedation and analgesia in the emergency department. METHODS: After signing written consent, patients were enrolled in this randomised double-blind trial to receive either KP or TF to reach the desired sedation level. The respiratory and haemodynamic complications, nausea and vomiting, recovery agitation, patient recall and satisfaction, provider satisfaction and recovery time were compared. RESULTS: Of the participants, 47 in the KP group and 49 in the TF group were enrolled. The mean and SD scores were 6.91±1.93 and 8.34±1.25 for patients' satisfaction and 7.55±1.54 and 8.65±1.00 for satisfaction of physicians performing the procedures in TF and KP groups, respectively (p=0.000). Moreover, 39 (79.59%) and 18 (38.29%) of patients declared that they had recalled the procedures in the TF and KP groups, respectively (p=0.000). Transient hypoxia was reported in 2.1% and 8.1% in the KP and TF groups leading to perform 4.2% vs 8.1% airway manoeuvres, respectively, without the need for endotracheal intubation or further admission. CONCLUSIONS: KP and TF combinations were effectively comparable although KP resulted in higher patient and provider satisfaction. This study did not detect a difference regarding adverse respiratory or haemodynamic effects. It is estimated that the TF combination can be potent and efficacious with possible low adverse events in procedural sedation.

How much change in pain score does really matter to patients?

OBJECTIVE: The goal of this study was to determine the minimal change in pain score recognized by patients as meaningful known as minimal clinically important difference (MCID). METHODS: Pain was recordedupon admission, 30 and 60 min later and patients were asked todescribe the extent of pain change on a 5-point Likert scale ranging from "much better" to "much worse". Patients reported their pain by two common pain scales comprising numeric rating scale (NRS) and visual analog scale (VAS). We used receiver operating characteristiccurve to assess the accuracy of pain scales. We then calculated the mean change in pain scores among patients who reported their pain change as "a little better" or "a little worse" and also analyzed regression to evaluate the MCID. RESULTS: A total of 150 patients and 253 pain changes were recruited. The MCID ±â€¯SD (95% CI) was 1.65 ±â€¯1.58 (1.32-1.97) for NRS and 16.55 ±â€¯17.53 (12.96-20.15) for VAS. The area under the curve by NRS and VAS were 0.86 and 0.89. For linear regression, the line slope and the y-intercept were 17.56 and 1.88, for VAS; these values were 1.73 and 0.31 for NRS, respectively. CONCLUSIONS: Recognizing the extent of change in pain score that really matters to patients is crucial for the evaluation of treatment effect. Patients perceived a change of 1.65 points on NRS and 16.55 on VAS in their pain severity as meaningful. This value was not different whether the pain was perceived alleviated or aggravated.

Opium-Related Lead Toxicity: An Integrative Review and Case Series.

BACKGROUND: Restrictive regulations and the increased price of opioids have resulted in the addition of impurities to illicit opioids by drug dealers. Among the adulterants, lead salts are optimal agents to make packages heavier. Consequently, lead toxicity has emerged in the opioid-user population. OBJECTIVES: Our goal was to review the related literature and describe patients with common presentations of opioid-related lead poisoning to provide a basis to prepare optimal management. METHODS: A narrative review was performed aiming to study opioid lead poisoning. PubMed and Google Scholar databases were explored with two Medical Subject Heading terms, lead poisoning and substance-related disorders to find a broad but relevant spectrum of articles. Then, the reference lists within those articles were checked to upgrade our literature pool on this issue. RESULTS: Ultimately, among English-language articles, 16 were case series and case reports of patients with lead intoxication after opioid consumption. Data pertaining to disease characteristics, diagnosis, and treatment protocols were extracted. CONCLUSIONS: The clinical presentation of opioid lead intoxication can vary from rather asymptomatic to severely debilitating gastrointestinal or neurologic symptoms. The diagnosis is made by checking lead blood levels after obviating other critical diagnoses and should be considered in each drug user in endemic regions of opioid addiction, such as the Middle East. Management protocols are suggested to cover both features of opioid-related complications and lead toxicity.

Unilateral sixth nerve palsy.

BACKGROUND: The diagnosis of cerebral venous sinus thrombosis still remains a real challenge. Seizure, unusual headache with sudden onset, unexplained persistently unilateral vascular headache and neurologic deficit-which is difficult to be attributed to a vascular territory are some of the suggestive symptoms. CASE: An isolated sixth nerve palsy is discussed as a rare presentation for cerebral venous thrombosis. Following the extensive investigation to rule out other possible diagnoses, magnetic resonance venogram revealed the final etiology of sixth nerve palsy that was ipsilateral left transverse sinus thrombosis; therefore, anticoagulant treatment with low molecular weight heparin was administered. CONCLUSION: Rapid and accurate diagnosis and treatment cause to achieve excellent outcomes for most patients. Considering different clinical features, risk factors and high index of suspicion are helpful to reach the diagnosis.

Ketamine-propofol combination (ketofol) vs propofol for procedural sedation and analgesia: systematic review and meta-analysis.

OBJECTIVE: This meta-analysis of trials was conducted to evaluate the analgesic and side effects of ketamine-propofol combination (ketofol) in comparison to propofol in procedural sedation and analgesia (PSA). METHODS: Medline, EMBASE, Scopus, CINHAL, and Cochrane Central Register of Controlled Trials were searched for clinical trial. The administration complications were the key outcomes of interest. RESULT: Eighteen clinical trials that met our criteria were included in the analysis. Pooling of data showed that ketofol is significantly effective for reduction of respiratory complication and with relative risk (RR) of 0.31 in 14 trials (95% confidence interval [CI], 0.47-0.7; P = .001). Ketofol was also effective in reducing cardiovascular complications with hypotension RR of 0.11 in 9 trials (95% CI, 0.17-0.97; P = .04) and bradycardia RR of 0.47 in 8 trials (95% CI, 0.28-0.72; P = .008). The present study also showed that the summary of RR for psychomimetic complications was 1.95 in 13 trials were (95% CI, 0.79-4.81; P = .15) and for muscle rigidity was 0.52 for 2 trials (95% CI, 0.06-4.67; P = .56), and both were insignificant. In regard to nausea and vomiting, the RR was 1.23 in 12 trials (95% CI, 0.39-3.88; P = .72) and insignificant. CONCLUSION: This meta-analysis demonstrates good safety profile in cardiorespiratory problems and comparable rate of other complications with propofol in adult procedural sedation and analgesia.

Discrimination of healthy and carious teeth using laser-induced breakdown spectroscopy and partial least square discriminant analysis.

In the laser drilling of teeth, a microplasma is generated which may be utilized for elemental analysis of ablated tissue via a laser-induced breakdown spectroscopy (LIBS) technique. In this study, LIBS is used to investigate the possibility of discrimination of healthy and carious tooth tissues. This possibility is examined using multivariate statistical analysis called partial least square discriminant analysis (PLS-DA) based on atomic and ionic emission lines of teeth LIBS spectra belonging to P, Ca, Mg, Zn, K, Sr, C, Na, H, and O elements. Results show an excellent discrimination and prediction of unknown tooth tissues. It is shown that using the PLS-DA method, the spectroscopic analysis of plasma emission during the laser drilling, would be a promising technique for caries detection.

A comparison of three self-report pain scales in adults with acute pain.

BACKGROUND: Several pain rating methods are used to quantify pain. Although these instruments have been extensively studied, their inter-agreement, especially in emergency department (ED) settings, has yet to be determined. OBJECTIVE: This study was designed to assess the agreement between Visual Analog Scale (VAS), Color Analog Scale (CAS), and verbally administered Numeric Rating Scale (NRS) in the emergency setting. METHODS: A sample of 150 adult patients presenting with acute pain to two EDs was recruited. Patients' pain severity at presentation, 30 and 60 min later was assessed using the three pain scales. The agreement between pain scales was assessed using Bland-Altman method and Spearman correlation. We described a composite measure to serve as the gold standard and to be compared with each score. Factor analysis was also performed to assess the underlying construct. RESULTS: Spearman correlation coefficients between NRS and CAS, NRS and VAS, and CAS and VAS were 0.95, 0.94, and 0.94, respectively (p < 0.001). On a scale of 0 to 10, the 95% limits of agreement between the paired NRS and VAS, VAS and CAS, and CAS and NRS as measured by Bland-Altman method ranged from -2.0 to 2.6, from -2.7 to 2.0, and from -2.1 to 2.0, respectively. The Kaiser-Meyer-Oklin measure of sampling adequacy was 0.785 and Bartlett's test for sphericity was significant (p < 0.001). CONCLUSIONS: The three pain scales were strongly correlated at all time periods. The findings suggest that NRS, CAS, and VAS can be interchangeably applied for acute pain measurement in adult patients.

Blood Pressure Control Following Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers: Insights from a Triple-Blind, Randomized, Clinical Trial.

Data on substituting one antihypertensive medication with the proper dose of another antihypertensive medication, in certain medical conditions, are scarce. Herein, we present the results of replacing angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) with the calcium channel blocker (CCB) amlodipine, with or without the alpha- and beta-blocker carvedilol, to control high blood pressure in patients with coronavirus disease 2019 (COVID-19). Iranian hypertensive patients with COVID-19 and a history of taking ACEI or ARB were randomized to "continue" and "change" groups. The continue group comprised patients who continued using their previous antihypertensive medication regimen as normal, whereas patients in the change group had their antihypertensive drugs changed to the CCB amlodipine, with or without the alpha- and beta-blocker carvedilol, based on their response to amlodipine. Patients' blood pressures were measured for 8 days following their recruitment. A total of 31 and 33 patients were randomly allocated to the ACEI/ARB continue and ACEI/ARB change groups, respectively. No significant deviations were seen in patients' systolic blood pressure by substituting an ACEI/ARB agent with the CCB amlodipine, with or without the alpha- and beta-blocker carvedilol. Moreover, the change group had a more balanced systolic blood pressure (ie, 110-130 mmHg) compared with the continue group (ie, 111.5-140.0 mmHg) throughout their hospitalization period. During their hospitalization, the blood pressure of the change group was well controlled with the proposed equivalent doses. Further investigations of the proposed equivalent doses in larger randomized clinical trials, populations other than Iranian COVID-19 patients, and extended duration are encouraged (clinical trial registration ID: IRCT20151113025025N3).

Distant Metastasis as the First Presentation of Thyroid Carcinoma.

Introduction: Thyroid carcinoma is the most common endocrine cancer which may manifest with unusual presentations. We addressed distant metastases as the first presentations of thyroid carcinoma in several patients, though previously considered to occur rarely. Methods: In this case series, 10 patients are introduced with signs and symptoms of distant metastasis. Detailed history, physical examination, laboratory data, and histopathologic final report of thyroid cancer are presented. Conclusion: Although it seems unusual to discover a distant metastasis without abnormal thyroid examination, several reports of similar findings urge the need to improve screening process. It is prudent to bear in mind these presentations for early detection of thyroid carcinoma.

Development of a comprehensive assessment tool to measure the quality of care for individuals with traumatic spinal cord injuries.

OBJECTIVE: To develop a comprehensive assessment tool to evaluate the Quality of Care (QoC) in managing individuals with traumatic spinal cord injuries (TSCI). METHOD: At first, the concepts of QoC for TSCI were identified by conducting a qualitative interview along with re-evaluation of the results of a published scoping review (conceptualization). After operationalization of indicators, they were valued by using the expert panel method. Afterward, the content validity index (CVI) and content validity ratio (CVR) were calculated and served as cut-offs for indicator selection. Then specific questions were developed for each indicator and classified into three categories: pre-hospital, in-hospital, and post-hospital. Data availability of the National Spinal Cord Injury Registry of Iran (NSCIR-IR) was subsequently used to design questions that represent indicators in an assessment tool format. The comprehensiveness of the tool was evaluated using a 4-item Likert scale by the expert panel. RESULT: Twelve experts participated in conceptualization and 11 experts participated in operationalization phase. Overall, 94 concepts for QoC were identified from published scoping review (87 items) and qualitative interviews (7 items). The process of operationalization and indicator selection led to the development of 27 indicators with acceptable content validity. Finally, the assessment tool contained three pre-hospital, twelve in-hospital, nine post-hospital, and three mixed indicators. Ninety-one percent of experts evaluated the entire tool as comprehensive. CONCLUSION: Our study presents a health-related QoC tool that contains a comprehensive set of indicators to assess the QoC for individuals with TSCI. However, this tool should be used in various situations to establish construct validity further.

COVID-19 patients presenting with gangrenous acalculous cholecystitis: Report of two cases.

Introduction and importance: COVID-19 virus is thought to complicate underlying conditions, including acalculous cholecystitis. Two COVID-19 patients with gangrenous gallbladder are reported who were not involved with severe pneumonia. Case presentation: We present two non-critically ill patients with COVID-19 presenting with acalculous cholecystitis. Both patients had gangrenous gallbladder and had to undergo cholecystectomy. Upon surgery, one of the patients showed patchy gangrene on gallbladder and the other, a fully gangrenous gallbladder. Conclusion: There may be a possibility for COVID-19 patients with cholecystitis to develop ischemic gallbladder.

Intravenous morphine plus ibuprofen or ketorolac versus intravenous morphine alone in reducing renal colic pain intensity in emergency department: A randomized, double-blind clinical trial.

OBJECTIVES: This study aimed to compare the efficacy of intravenous (IV) morphine plus ibuprofen or ketorolac versus IV morphine alone in controlling renal colic pain in the emergency department. METHODS: This double-blind, randomized clinical trial was conducted during November 2018 and March 2019 in Iran. Patients aged 18-65 years with acute renal colic and numerical rating scale (NRS) score of higher than 6 of 10 were enrolled to the study. They were randomly assigned to I, K, and control groups receiving 5 mg morphine with 800 mg ibuprofen (n = 65), 5 mg morphine with 30 mg ketorolac (n = 65), or only 5 mg morphine (n = 65) intravenously, respectively. NRS was evaluated 0, 15, 30, 60, and 120 min after injection. RESULTS: A total of 195 participants took part in the study. The presence of stone in pelvis area was higher in I group (P = 0.027). The mean rescue analgesic dose was higher in the control group and lower in K group (P = 0.031). From the 15th min, the NRS reduction in I and K group was higher than the control group (P < 0.001), but the difference between I and K group was not statistically significant in total (P = 1.0) or in the all follow-up time intervals (15th P = 0.864, 30th P = 0.493, 60th P = 0.493, and 120th min P = 1.0). The largest difference in pain reduction was observed in 120th min and mean of NRS was 2.9 (95% confidence interval [CI]: 2.6-3.3), 2.9 (95% CI: 2.6-3.3) and 7.0 (95% CI: 6.7-7.4) in I, K and control group, respectively. The adverse effects showed in 18.5%, 20.0%, and 13.8% of I, K, and control group, respectively. CONCLUSION: IV ibuprofen plus morphine and IV ketorolac plus morphine had similar effects in reducing renal colic pain but were more effective than IV morphine alone.

Comparison of Emergency Echocardiographic Results between Cardiologists and an Emergency Medicine Resident in Acute Coronary Syndrome.

INTRODUCTION: Early detection of regional wall motion abnormality (RWMA) can be a reliable tool for rapid disposition of patients with acute coronary syndrome (ACS) in the emergency department. In this study, the diagnostic accuracy of point-of-care echocardiography performed by a trained emergency medicine resident was evaluated in comparison with board-certified cardiologists. METHODS: A prospective, cross-sectional study was implemented on adult patients with ACS. A trained emergency medicine (EM) PGY-3 resident performed point-of-care echocardiography under the supervision of two cardiologists and the reports were compared with cardiologists as a reference test. RESULTS: 100 patients with the mean age of 54.1 ± 11.5 years were recruited (65% male). Based on Thrombolysis in Myocardial Infarction (TIMI) and History, EKG, Age, Risk factors, and troponin (HEART) scores, 43.0% and 25.0% of patients were categorized as low-risk for ACS, respectively. The absolute measure of agreement between cardiologists to determine ejection fraction (EF) was 0.829 (95% CI: 0.74-0.89) based on intraclass correlation coefficient (ICC) estimation. The measurements of agreement between specialists and the EM resident based on the analysis of Kappa coefficient were 0.677 and 0.884 for RWMA and pericardial effusion, respectively. Moreover, 25 patients were in the-low risk group according to the HEART score with an agreement rate of 92% for the lack of RWMA between the EM resident and cardiologists. CONCLUSION: This study found acceptable agreement between the EM resident and cardiologists in assessing RWMA in different ACS risk groups. In addition, there was acceptable agreement between the EM resident and cardiologists in determining left ventricular ejection fraction (LVEF) and pericardial effusion.

The influence of shift work on the psychomotor capabilities of emergency medicine residents.

OBJECTIVE: Shift work affects health status of healthcare providers and patients. We assessed the effect of shift work on psychomotor activities of emergency medicine residents of 3 university hospitals. METHODS: The participants were enrolled to perform selected psychomotor tests via the Vienna test system (VTS) after written consent. They passed 4 episodes of test performance before and after 2 consecutive day and night clinical shifts of 12 hours. The status of general health, circadian rhythm, sleepiness, smoking habits, and the scores of the cognition test (COG), the determination test (DT), and the visual pursuit test of emergency medicine residents were compared before and after morning and night shifts. RESULTS: Overall, 23 residents (34.8% were male) performed tests. The mean (SD) age was 35.7 + 8.5 years. The mean general health and circadian scores before and after day/night shifts were not different. The Stanford sleepiness scale showed higher scores after night shifts. In the cognition test, the sum of correct rejections was higher after day shifts. Moreover, in the DT results, correct responses were more prevalent, the omitted responses were fewer accompanied by better median reaction time after day shifts. The sum of correct rejections of the COG test showed difference in terms of improved results in night tests compared to day-shift tests. The mean reaction time of the DT showed significant difference with shorter reaction time in night-shift tests. The visual pursuit test results were not different between day and night shifts. CONCLUSIONS: Sleepiness was higher after night shifts. The results of selected psychomotor tests showed that the psychomotor function of the residents was not delayed or worse after night shifts in comparison to the day shifts.

Developing and validating an instrument to measure: the medical professionalism climate in clinical settings.

This study was conducted to develop and validate an instrument to measure the medical professionalism climate in clinical settings. The item pool was developed based on the Tehran University of Medical Sciences Guideline for Professional Conduct. The items were distributed between two questionnaires, one for health-care providers and the other for patients. To assess the construct validity of the questionnaires, 350 health-care providers and 88 patients were enrolled in the study. The reliability of the questionnaires was evaluated by calculating Cronbach's alpha and ICC. At first a 74-item pool was generated. After assessing and confirming face and content validity, 41 items remained in the final version of the scale. Exploratory factor analysis revealed the three factors of "personal behavior", "collegiality" and "respect for patient autonomy" in a 25-item questionnaire for service providers and a single factor of "professional behavior" in a 6-item questionnaire for patients. The three factors explained 51.775% of the variance for service providers' questionnaire and the single factor explained 63.9% of the variance for patients' questionnaire. The findings demonstrated that from the viewpoints of patients and service providers, this instrument could be applied to assess the medical professionalism climate in hospital clinical settings.