Frontiers in Emergency Medicine
Volume:5 Issue: 2, Spring 2021

We enthusiastically read Payandemehr et al.’s study, which examined the effect of interferon β-1a (ReciGen, CinnaGen Co., Iran) on the severity of the disease in patients with COVID-19 and revealed that taking interferon β-1a (INF) significantly reduced the duration of hospitalization and the rate of mortality of hospitalized COVID-19 patients. INF is one of the main drugs in patients with relapsing-remitting multiple sclerosis (RRMS), and these patients mainly use this drug for a long time. We decided to examine whether the drug has an effect on the incidence rate of COVID-19 in MS patients and whether it affects the course of COVID-19 in case of infection. In November 2020, 75 RRMS patients treated with INF (ReciGen, CinnaGen Co., Iran) were evaluated for COVID-19. Fifty-seven and eighteen cases were female and male, respectively. Patients had a mean age of 36.9±7.2 years, disease duration of 7.0±4.4 years, and the INF use duration of 3.5±1.7 years. Of these 75 patients, only one patient (1.33%) tested positive for COVID-19. The patient was a 29-year-old female nurse working in the pediatric intensive care unit (ICU) and had been receiving INF for six years since the diagnosis of MS. She developed symptoms of cough, shortness of breath, lethargy, anorexia, constipation, and diarrhea in June 2020. The lung computed tomography (CT) scan indicated mild lung involvement, and the reverse transcription polymerase chain reaction (RT-PCR) test was positive for COVID-19. The patient continued her INF treatment, and the symptoms completely disappeared after five days. The patient did not require to be hospitalized during her COVID-19 infection. Therefore, the hospitalization rate due to COVID-19, hospitalization in the ICU, and mortality rate were zero in INF users. In a study by Sahraian et al. addressing 4647 MS patients revealed that the incidence of COVID-19 was 1.46%, which was similar to our findings concerning patients receiving INF. However, the hospitalization rate in the mentioned study was 25%, which was very different from that of our study. It should be noted that patients were taking a wide range of drugs in the mentioned study, and most of them were taking rituximab. Nevertheless, there was no relationship between the type of the administered drug and the chance of hospitalization in the mentioned study. Our findings suggest that there might be a link between the use of INF and non-hospitalization and lack of mortality in patients with MS infected by COVID-19. The obtained findings are in line with the results provided by Payandemehr et al.’s study. Although our study was observational and did not have a control group, it revealed that the INF administration might reduce the severity of the infection. However, the use of INF did not prevent COVID-19 infection. The positive effect of interferons on reducing the severity of COVID-19 has been indicated in other studies, as well. Considering its positive effect on COVID-19 and the fact that interferons have been used in the treatment of MS disease for many years, more attention should be devoted to administering this drug in patients with MS during COVID-19 as it can significantly reduce the risk of COVID-19 related complications.

Being infected with COVID-19 is associated with direct and indirect effects on the cardiopulmonary system and electrocardiography can aid in management of patients through rapid and early identification of these adversities. 

The present study was designed aiming to evaluate electrocardiographic changes and their correlation with the outcome of COVID-19 patients. 

This Prospective cohort study was carried out on COVID-19 cases admitted to the emergency department of an educational hospital, during late February and March 2020. Electrocardiographic characteristics of patients and their association with in-hospital mortality were investigated. 

One hundred and nineteen cases with the mean age of 60.52±13.45 (range: 29-89) years were studied (65.5% male). Dysrhythmia was detected in 22 (18.4%) cases. T-wave inversion (28.6%), pulmonale P-wave (19.3%), left axis deviation (19.3%), and ST-segment depression (16.8%) were among the most frequently detected electrocardiographic abnormalities, respectively. Twelve (10.1%) cases died. There was a significant correlation between in-hospital mortality and history of diabetes mellitus (p=0.007), quick SOFA score > 2 (p<0.0001), premature ventricular contraction (PVC) (p=0.003), left axis deviation (LAD) (p=0.039), pulmonale P-wave (p<0.001), biphasic P-wave (p<0.001), inverted T-wave (p=0.002), ST-depression (p=0.027), and atrioventricular (AV) node block (p=0.002). Multivariate cox regression showed that history of diabetes mellitus, and presence of PVC and pulmonale P-wave were independent prognostic factors of mortality. 

Based on the findings of the present study, 18.4% of COVID-19 patients had presented with some kind of dysrhythmia and in addition to history of diabetes, presence of PVC and pulmonale P-wave were among the independent prognostic factors of mortality in COVID-19 patients.

Acute urinary retention due to benign prostatic enlargement is one of the clinical complaints that patients refer to the emergency department. Selective α-blockers are used after urinary catheterization. Recently, the use of nitrate compounds has been shown to relieve bladder neck and to treat acute urinary retention. 

The aim of this study was to survey the addition of Isosorbide di nitrate to tamsulosin in the treatment of acute urinary retention in patients with benign prostatic hyperplasia. 

This is a randomized, double-blind placebo-controlled clinical trial. In all, 78 patients with benign prostatic hyperplasia-related acute urinary retention referred to the emergency department were divided into two groups and randomly assigned to receive either 0.4 mg tamsulosin plus placebo or 0.4 mg tamsulosin plus isosorbide dinitrate 40 mg extended-release tablets daily for 3 days. At the same first visit, the catheter was removed and the ability to void in same time and 1 month later was assessed in each group. 

After catheter removal, 27 (67.5%) patients in the tamsulosin plus placebo group and 31 (81.6%) in the tamsulosin plus isosorbide dinitrate group voided successfully after 3 days (p = 0.155). After 1 month, 20 (50.0%) patients taking tamsulosin plus placebo and 23 (60.5%) taking tamsulosin plus isosorbide dinitrate could void, yet indicating no significant difference (p = 0.350). 

Addition of isosorbide dinitrate to α-blockers has advantage in improving benign prostatic hyperplasia-related acute urinary retention versus tamsulosin alone, although was not statistically significant.

Lung US has been reported to be as useful as a chest CT scan and much better than a chest x-ray for the evaluation of pneumonia. 

This study aimed to compare the findings of lung ultrasound (US) and chest CT scan of patients with COVID-19-associated pneumonia in the Emergency Department (ED). 

This retrospective observational pilot study was carried out on confirmed COVID-19 patients in the isolation corona ward of the Imam Hussein Hospital ED from March 15 to March 22, 2020. After obtaining demographic data, the patients underwent a pulmonary bedside US examination, with the patients in the sitting position, turning their back to the examiner. A 10-point lung US was performed. Each lung was divided into two areas: posterior (three zones) and lateral (two zones). The patients’ lung ultrasound and chest CT scan as the standard imaging were blindly reviewed and recorded. The clinical value of ultrasound was evaluated with different severity of lung involvement according to CT severity score. 

Nineteen patients (38 zones), including 13 males, were evaluated with a mean age of 62.5±16.8 years. B2 lines and consolidation observed in the US examinations were significantly correlated with ground-glass opacity and consolidation observed in CT scan examinations, respectively (p <0.0001). US sensitivity and specificity of finding B2 lines were 90% and 100%, respectively. Also, the sensitivity and specificity of US in identifying consolidation were 82% and 100%, respectively. In the lungs with moderate and severe lobar involvement, US findings were significantly correlated (p <0.05) with CT scan findings. 

Ultrasound evaluation is a safe, fast, and rapid technique for the evaluation of patients with moderate to severe COVID-19-associated pneumonia. It is a reproducible procedure and can be implemented by the operator after a short course of training.

Since the start of COVID-19 pandemic in December 2019, until mid-April 2020 the total number of cases worldwide exceeded two millions and the death toll exceeded 130000 cases. 

The current study conducted to explore the clinical and epidemiological characteristics of COVID-19 patients, fatality of this disease and its mortality risk factors in major hospitals affiliated with Tehran University of Medical Sciences (TUMS). 

The data were collected in four major teaching hospitals affiliated with TUMS for all the patients that were admitted between Feb 19th and Apr 15th 2020 and were diagnosed as COVID-19 using reverse transcription polymerase chain reaction (RT-PCR), clinical diagnosis and/or lung computed tomography (CT) scan. The case fatality rate of the disease was estimated by age, sex, symptoms, comorbidities, and type of diagnosis. Logistic regression model was used to examine the associations between different factors and in-hospital deaths. 

By Apr 15th 2020, a total of 4377 patients were admitted with COVID-19 diagnosis in four selected hospitals and 496 (11.3%) of these patients died in hospital. The case fatality rate of this disease was 28.8% in the ≥80-year age group, which was the highest compared to the other age groups. The case fatality rates were 12.5% and 9.8% among men and women, respectively. The results of multiple logistic regression on the outcome of death indicated that age, sex, cough, myalgia, reduced consciousness at arrival and past history of cancer were significantly associated with in-hospital death. Adjusting the effect of other variables, for each 10-year increase in age, the odds of death due to COVID-19 was 1.61 times greater (adjusted OR 1.61, 95% CI: 1.51 to 1.72, p<0.001). 

Older age, the male gender, past history of comorbidities (particularly cancer) and reduced consciousness at arrival are among the factors that can significantly increase the odds of in-hospital death in COVID 19 patients. These factors might be helpful in detecting and managing patients with poorer prognosis.

Quality and safety is an important challenge in healthcare systems all over the world particularly in developing parts. 

This survey aimed to assess patient safety culture (PSC) in emergency departments (EDs) in Yemen and identify its associated factors. 

A questionnaire containing the Hospital Survey on Patient Safety Culture (HSOPSC) was distributed to ED physicians, nurses, and clinical, and non-clinical staff at three public teaching general hospitals. The percentages of positive responses on the 12 patient safety dimensions and the summation of PSC and two outcomes (overall patient safety grade and adverse events reported in the past year) were assessed. Factors associated with PSC aggregate score were analyzed. 

finally, out of 400 questionnaires, 250 (64%) were analyzed. In total, 207 (82.3%) participants were nurses and physicians; 140 (56.0%) were male; 134 (53.6%) were less than 30 years old; and 134 (53.6%) had a university degree. Participants provided the highest ratings for the “teamwork within units” PSC composite (67%). The lowest rating was for “non-punitive response to error” (21.3%). A total of 120 (48.1%) participants did not report any events in the past year and 99 (39.7%) gave their hospital an “excellent/very good” overall patient safety grade. There were significant differences between the hospitals’ EDs in the rating of “handoffs and transitions” (p=0.016), “teamwork within units” (p=0.018), and “frequency of adverse events reported” (p=0.016). Staff working in intensive care units (8.4%, n=21) had lower patient safety aggregate scores. 

PSC ratings appear to be low in Yemen. This study emphasizes the need to create and maintain a PSC in EDs through the implementation of quality improvement strategies and environment of transparency, open communications, and continuous learning.

Limb swelling is among the frequent complaints of patients referring to the emergency room (ER).

We decided to take a step towards facilitating the diagnostic process of patients who refer to ER with such complaint, and find out whether emergency medicine physicians (EMPs) can play an effective role in this regard. 

This was a diagnostic accuracy study in which all patients who referred to the ER with a complaint of unilateral leg swelling were studied. The patients underwent bedside sonography by the researchers, who were emergency medicine physicians (EMPs), and also underwent a second sonography by the in-charge radiologist using the same device and probe. The accuracy of the diagnoses made by researchers was evaluated using the radiologists’ opinion as the gold standard. 

In this study, the data of 52 patients were analyzed. In general, the agreement rate between the EMPs and radiologists was 0.863, which indicates a proper agreement. Based on the findings, Kappa agreement for the four differential diagnoses ranged from 0.639 to 0.919 and the AUC was between 0.750 and 0.976. 

In this study, the overall agreement between the EMPs and radiologists was appropriate.

The COVID-19 pandemic is now an international concern. COVID-19 is first reported in Wuhan, China on 31 December 2019 and affects different people in different ways. Evidence suggests that people with underlying disease are at higher risk for more severe disease. People with diabetes are not only more likely than the general population to have COVID-19 but also they are among those high-risk categories that can have serious illness if they get the virus.

While our knowledge is limited about COVID-19 immunity, recent cases of reinfection have raised concerns. 

Here, we report a case of COVID-19 reinfection after three months from recovery in a healthcare worker with negative IgM and IgG at the second infection and positive nasopharyngeal swab Reverse transcription polymerase chain reaction (RT-PCR) test despite being discharged with two negative RT-PCR tests at the first admission. Symptoms at first admission were fever, headache, sore throat, diarrhea, and vomiting and got changed to myalgia and anosmia. 

The strength of this case report is the long period (three months) between the infection and reinfection while other cases reported in literature were reinfected less than one month after their first infection.

Allergic angina is not a rare disease, but it should be recognized at the earliest. We are reporting two cases of anaphylaxis, one with a history of unknown insect bite and the other due to intravenous (IV) contrast, leading to reversible myocardial ischemia, which we managed in our Emergency Department. These two patients clinically improved, and their ST-segment elevation on electrocardiogram (ECG) disappeared after intramuscular adrenaline. Allergic angina is an acute presentation in which anaphylaxis, or allergic insult, causes coronary spasm, which leads to angina. Early diagnosis and management initiation can minimize mortality and morbidity.