Emergency medicine physicians face major ethical challenges in their practices. Furthermore, they need to be aware of the principles of ethical analysis and clinical decision-making in order to provide quality care. This study aimed to propose professional ethics codes in the emergency medicine department.

 This is a qualitative study, which was performed using narrative review and expert panel, and was conducted in three steps, including: literature review and preparation of the initial draft of the ethical concepts, obtaining expert opinions on this initial draft and its validation, and finalizing main ethical components in emergency medicine. In this study, we received the opinions of an expert panel including 10 medical ethicists and 12 emergency medicine specialists using a survey form.

 The ethical guide to emergency medicine can be formulated in 34 key ethical concepts, 6 sub-components, and 5 main components including emergency physician-patient relationship, and emergency physicians’ relationships with other professionals, students, researchers, and community.

 Emergency care providers need to be familiar with ethical guidelines in order to improve quality of care in emergency departments. The findings of this study suggest that a guideline on patient-physician relationship as well as the emergency physicians’ ethical obligations for other professionals, students, researchers, and community should be developed in line with ethical norms.

Removing embedded fishhook without causing further tissue damage from the barbed nature of the hook is achallenge in emergency department (ED). The four most commonly used techniques include advance and cut,string-yank, needle cover, and retrograde removal. This study aims to describe a modified push- through tech-nique without cutting the barb, namely advance without cut and retrograde removal, as an effective techniqueof successful removal of fishhooks. There is no risk of additional injury to patients and healthcare staff, and thetechnique does not need tools that are not generally readily available in EDs.

COVID-19 has affected the pattern of referral to medical centers and quarantine against COVID-19 might delay referral and management of surgical emergencies. This study aimed to compare the pooledevent rate of pediatric perforated appendicitis before and during the COVID-19 pandemic.

This wasa systematic review and meta-analysis study based on the PRISMA guidelines. Scopus, Web of Sciences, andPubMed databases were searched for studies reporting the rate of perforated appendicitis based on the post-appendectomy observations or imaging methods. The Egger bias test and funnel plot were used to detect anddepict publication bias. Statistical analysis was performed in Comprehensive Meta-analysis package version 3.

Twelve studies were eligible for inclusion in our study. The pooled prevalence of pediatric perforatedappendicitis in the pre-COVID era was 28.5% (CI95%: 28.3 to 28.7%) with a heterogeneity of 99%. In the COVIDera, the event rate proportion was 39.4% (CI95%: 36.6 to 42.3%) with a heterogeneity of 99%. There was a sig-nificant difference in the subgroup analysis within the pre-COVID and COVID era (P<0.001), showing a higherperforation rate in the COVID era.

Our study showed that during the COVID-19 pandemic, the rateof perforated appendicitis has significantly increased in comparison to before the COVID-19 pandemic.

A coin cell lithium battery is a common foreign body that can become lodged in the pediatric pharyngoe-sophageal junction. Because the voltage of such batteries is relatively high, their rapid removal is necessaryto avoid mucosal necrosis. Despite being the initial choice for removal, flexible endoscopy cannot remove suchforeign bodies from the esophagus. Various removal methods, including rigid esophagoscopy, should be con-sidered for removing lithium coin cell batteries. The transcervical approach is feasible for removing esophagealforeign bodies, but it carries the risk of complications such as esophageal stenosis. Here we report a case oflithium coin battery ingestion that was successfully removed using a rigid esophagoscope. A 2-year-old girl wasreferred to a local doctor with cough and general fatigue. Chest X-ray and flexible endoscopy revealed a coin celllithium battery stuck in the pharyngoesophageal junction, but it could not be removed. The foreign body wasremoved using Nishihata forceps through a rigid esophagoscope under general anesthesia.

One of the trends in the development of medical technologies is considered to be telemedicine. This study aimed to evaluate the accuracy of a remote electrocardiogram (ECG) analysis and transmission system in prehospital setting.

In this cross-sectional study, the data of 19,265 ECGs was gathered from emergency medical service (EMS) database of Almaty city, Kazakhstan, from 2015 to 2019. All ECGs were recorded in the prehospital setting by a paramedic, using "Poly-Spectrum" ECG recording device. Subsequently, all ECGs were sent to the cardiologist for interpretation and the findings were compared between software and cardiologist.

19,265 ECGs were registered. The average time from taking ECGs to receiving an expert’s conclusion was 9.2 ± 2.5 minutes. The medical teams were called in 17.9% of cases after paramedic ECG recording; however, in the rest of the cases there was no need to call those teams. Using the device reduced the number of visits of specialist teams. The overall sensitivity, specificity, and accuracy of ECG analysis device in diagnosis of ECG abnormalities were 83.8% (95%CI: 82.6 – 84.9), 95.5% (95%CI: 95.1 – 95.8), and 93.3% (95%CI: 92.9 – 93.7), respectively.

The findings of this study showed the 93.3% accuracy of automatic ECG analysis device in interpretation of ECG abnormalities in prehospital setting compared with the cardiologist interpretations. Using the device causes a decrease in the number of cardiologist visits needed as well as reduction in cost and elapsed time.

It is still unclear that which anti-arrhythmics are adequate for treating refractory dysrhythmia.This study aimed to compare amiodarone and nifekalant in management of out-of-hospital cardiac arrest caseswith refractory shockable rhythm.

This was a post hoc analysis of cases registered in a nationwide,multicentre, prospective registry that includes 288 critical care medical centres in Japan. From June 2014 toDecember 2017, we included all out-of-hospital cardiac arrest patients aged≥18 years who presented with re-fractory arrhythmia (sustained ventricular fibrillation or ventricular tachycardia following delivery of at leasttwo defibrillator shocks) and treated with nifekalant or amiodarone after arrival to hospital. Overlap weight wasperformed to address potential confounding factors.

1,317 out-of-hospital cardiac arrest patients withrefractory arrhythmia were enrolled and categorized into amiodarone (n = 1,275) and nifekalant (n = 42) groups.After overlap weight was performed, there were no significant intergroup differences in increased the rate ofadmission after return of spontaneous circulation [–5.9% (95%CI: –7.1 to 22.4); p = 0.57], 30-day favourable neu-rological outcome [0.1% (95%CI: –14 to 13.9); p = 0.99], and 30-day survival [–3.9% (95% CI: –19.8 to 12.0); p =0.63].

This nationwide study showed that nifekalant was not associated with improved outcomesregarding admission after return of spontaneous circulation, 30-day survival, and 30-day favourable neurologi-cal outcome compared with amiodarone.

Rupture of renal angiomyolipoma (AML) is an emergency and life-threatening complication. Thisstudy aimed to evaluate the association of computed tomography (CT) scan parameters with the risk of rupturein renal AMLs.

In this retrospective cross-sectional study, patients who were referred to a referraluniversity hospital with diagnosis of AML, between 2007 and 2019, were included. Patients were divided intoruptured and non-ruptured cases based on surgery and CT scan findings and the baseline characteristics as wellas CT scan parameters were compared between the two groups.

20 AML patients with the mean ageof 39.6 ± 12.5 years were included (75% female). The lesion was ruptured in 8 (40%) patients. The mean sizeof the lesion was 97.0 ± 15.9 mm in the ruptured and 72.0 ± 29.4 in the non-ruptured AML (p = 0.045). Themean fat density based on non-contrast enhanced CT (NCCT) scan (-56.1 ± 16.3 vs -74.9±24.1; p = 0.018) andcontrast enhanced CT (CECT) scan (-20.8 ± 16.9 vs -50.5 ± 31.7; p = 0.016) was significantly higher in the rupturedcases. Total tumor density based on NCCT scan was significantly greater in the ruptured AMLs (19.6 ± 25.9 vs-22.7±41.6, p=0.033).

It seems that some CT scan parameters such as mean fat density and totaltumor density could be used for differentiation between ruptured and non-ruptured AMLs.

Pulmonary thromboembolism (PTE) is one of the most prevalent medical disorders, with a no-table annual fatality rate. This study aimed to evaluated the accuracy of serum pro-BNP and troponin I levels inPTE diagnosis.

This cross-sectional study was implemented on 267 patients with suspected PTE (sud-den chest pain or sudden dyspnea) in Imam Reza Hospital in Mashhad, Iran. All patients underwent pulmonarycomputed tomography (CT) angiography (as the gold standard test) and their serum levels of troponin I andpro-BNP were measured. The screening performance characteristics of pro-BNP in detection of PTE cases weremeasured and reported using receiver operating characteristic (ROC) curve analysis.

Two-hundred-sixty-seven patients with a mean age of 67.7 ±11.5 years were evaluated (60.1% male). PTE was confirmed via CTangiography in 121 patients. The area under the ROC curve of troponin I and pro-BNP in detection of PTE was0.501 ng/mL and 0.972 pg/mL, respectively. The sensitivity and specificity of proBNP at the best cut-off point(100 pg/ml) were 85.4% and 80.2%, respectively. The sensitivity and specificity of troponin I at the best cut-offpoint (0.005 ng/ml) were 65.5% and 42%, respectively.

Due to the comparatively good sensitiv-ity and specificity of proBNP in diagnosis of pulmonary thromboembolism, it can be employed as a diagnosticdeterminant in patients with suspected pulmonary thromboembolism along with other laboratory tests.

Testicular torsion is an important and critical issue in patients with acute scrotum referring toemergency department (ED). Early detection is very important to save the testicles. This study aimed to de-termine the diagnostic accuracy of clinical variables in predicting the presence of testicular torsion.

This prospective cross-sectional study was done using the information of patients hospitalized from September2015 to September 2020, with complaint of acute scrotum (ICD 10 code: N50.8), referring to ED for evaluationof the clinical predictors of testicular torsions, which were confirmed by surgery.

81 patients with themean age of 20.07 ± 9.64 (3- 45) years were studied. After surgical exploration, 70 patients (86.4%) had testiculartorsion. Patients with torsion had lower age (p < 0.0001), lower time from symptom to ED visit (p < 0.0001), sud-den onset pain (p = 0.003), left side pain (p < 0.0001), and lower white blood cell (WBC) count (p = 0.001). Thefrequency of dysuria (p = 0.032), diarrhea/vomiting (p = 0.005), and fever (p = 0.002) was significantly lower inpatients with torsion. The cremasteric reflex was absent in 57 (81.4%) cases who suffered from testicular torsion(p = 0.001). Based on the results of binary logistic regression analysis, age (B = -0.175, SE = 0.45; p < 0.0001)was the sole independent predictor of testicular torsion. The highest area under the receiver operating char-acteristics (ROC) curve in predicting the presence of torsion belonged to lower age [91.0 (95%CI: 83.2 – 98.7)],pain in left testis [0.931 (95%CI: 0.828-0.987)], and lower WBC count [0.805 (95%CI: 0.684-0.926)], respectively.

It seems that clinical variables are not accurate enough to be considered as the sole predictor oftesticular torsion and they should be used with caution and in combination with other available screening toolslike Doppler ultrasonography in this regard.

Although neurologic involvement and neuroimaging abnormalities have been frequently identified in COVID-19 patients, the underlying factors remain unclear. In this study, we assessed the association of the neurological manifestations and neuroimaging features of hospitalized COVID-19 patients with their clinical, laboratory, and imaging characteristics.

This multicenter cross-sectional study was conducted between September 2020 and March 2021 at two large academic hospitals in Tehran, Iran. We used census sampling from medical records to enroll hospitalized patients with a positive COVID-19 Polymerase chain reaction (PCR) test who underwent brain imaging due to presenting any acute neurologic symptom during hospital stay.

Of the 4372 hospitalized patients with COVID-19, only 211 met the inclusion criteria (35.5% with severe infection). Central nervous system and psychiatric manifestations were significantly more common in severe cases (p ≤ 0.044). Approximately, 30% had a new abnormality on their neuroimaging, with ischemic (38/63) and hemorrhagic (16/63) insults being the most common. The most frequent reasons that provoked cranial imaging were headache (27%), altered consciousness (25.6%), focal neurologic signs (19.9%), and delirium (18%). Analysis revealed a positive correlation for age, neutrophilia, lymphopenia, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) with the emergence of neuroimaging abnormalities (p ≤ 0.018). In addition, patients with new neuroimaging abnormalities had a significantly higher lung CT score than those without any pathologic findings (11.1 ± 4.8 vs. 5.9 ± 4.8, p < 0.001).

Approximately 30% of the study population had various acute neuroimaging findings. The lung CT score, neutrophil count, and age were strong predictors of acute neuroimaging abnormalities in hospitalized COVID-19 patients.

Early decompression within the first 24 hours after spinal cord injury (SCI) is proposed in currentguidelines. However, the possible benefits of earlier decompression are unclear. Thus, the present meta-analysisaims to investigate the existing evidence regarding the efficacy of ultra-early decompression surgery (within 12hours after SCI) in improving patients’ neurological status.

A search was performed in Medline, Em-base, Scopus and Web of Science electronic databases, until the end of August 2021. Cohort studies and clinicaltrials were included in the present study. Exclusion criteria were absence of an early or late surgery group, fail-ure to report neurological status based on the American spinal injury association impairment scale (AIS) grade,failure to perform the surgery within the first 12 hours after SCI, and duplicate reports and review articles. Twoindependent reviewers performed data collection, and risk of bias and certainty of evidence assessments. Theoutcome was reported as odds ratio (OR) and 95% confidence interval (CI).

Data from 16 articles, whichstudied 868 patients, were included. Compared to early or late decompression surgery, ultra-early decompres-sion surgery significantly improves patients’ neurological status (OR = 2.25; 95% CI: 1.41 to 3.58). However,ultra-early surgery in thoracolumbar injuries is not significantly more effective than early to late surgery. More-over, ultra-early surgery in patients with a baseline AIS A increases the chance of neurologic resolvent up to 3.86folds (OR=3.86; 95% CI: 1.50 to 9.91). Contrastingly, ultra-early surgery does not result in significant improve-ment compared to early to late surgery in patients with AIS B (OR = 1.32; 95% CI: 0.51 to 3.45), AIS C (OR = 1.83;95% CI: 0.72 to 4.64), and AIS D (OR = 0.99; 95% CI: 0.31 to 3.17).

Current guidelines emphasizethat spinal decompression should be performed within 24 hours after SCI, regardless of injury severity and loca-tion. However, results of the present study demonstrated that certain considerations may be taken into accountwhen performing decompression surgery: 1) in patients with AIS A injury, decompression surgery should beperformed as soon as possible, since its efficacy in neurological improvement is 3.86 folds higher in the first 12hours after injury. 2) ultra-early decompression surgery in patients with cervical injury is more effective than inpatients with thoracic or lumbar injuries. 3) postponing decompression surgery to 24 hours in SCI patients withAIS B to D does not significantly affect the neurological outcome.

Ketamine is mainly used for short-acting general anesthesia, chronic pain, sedation, depression, and bipolardisorder. Long-term ketamine use may cause lower urinary tract symptoms and voiding dysfunction. Smallcapacity and fibrotic bladder can be associated with chronic ketamine use. Here, we present a 25-year-old malewith a history of chronic ketamine use complicated with contracted heart-shape bladder.

Complex metacarpophalangeal (MCP) joint dislocation is an uncommon entity, which occurs following a hy-perextension injury. Closed reduction is not feasible due to entrapped volar plate and/or coexisting fractures.Various approaches and techniques have been proposed for treatment of complex MCP dislocation; however,controversies exist over which one is superior. This study describes a right-handed 14-year-old boy who fellon the outstretched hand and sustained a dorsal dislocation of the left index MCP joint. The dislocation wascomplicated by an epiphyseal metacarpal head fracture with dorsal-ulnar displacement of the osteochondralfragment. The patient underwent open reduction through the dorsal approach, and the metacarpal head wasfixed via the two-screw technique. The patient resumed left-hand function after six weeks. At the two-yearfollow-up, the range of motion and grip strength were normal, the patient was pain-free, and no sign of growthdisturbance or joint stiffness was detected. Dorsal surgical approach with screw fixation is a feasible techniquefor the treatment of complex MCP dislocation, especially when it is complicated by a large epiphyseal headfracture.

On March 6th,2020, chlorine gas leak was reported at Engro Polymer & Chemicals Plant in KarachiCity, Pakistan. This study aimed to evaluate the clinical features and outcomes of patients who presented toemergency department (ED) following this event.

This retrospective cross-sectional study, evaluatedthe clinical features and outcomes (length of hospital stay, complications, and mechanical ventilation require-ment) of patients presenting to ED of Aga Khan University Hospital, Karachi, Pakistan, with history of chlorinegas exposure at the Engro Plant from 6th March to 14th March 2020.

38 patients with mean age of 33.1± 8.1 years presented to ED with history of chlorine gas exposure (100% male). 4 (10.5%) cases had comorbiddiseases. Most common presenting symptom was dyspnea, observed in 33 (86.8%) cases, followed by cough,seen in 27 (71.1%) subjects. 13.2% (5/38) patients had infiltration on chest x-ray and 33 (86.8 %) required hos-pitalization. 6 (15.8%) patients had repeat presentation requiring hospitalization or ED visit. 18 (47.4%) weremanaged with high flow oxygen therapy, 9 (23.7%) required non-invasive ventilation and one patient was intu-bated due to development of pneumo-mediastinum. Mean length of stay was 1.55 ± 1.58 days and no patientsdied. Presence of tachycardia was the only finding significantly associated with need for oxygen (p = 0.033) andnon-invasive ventilation (p = 0.012).

The majority of patients presenting with acute chlorine gasexposure showed good clinical outcomes and rapid recovery, however, a high index of suspicion and vigilanceshould be maintained for complications such as pneumomediastinum and acute respiratory distress syndromein these patients.

TIMI (Thrombolysis in Myocardial Infarction) score is a model for predicting the severity of vascular diseases. This study aimed to evaluate the correlation between this score and the number of vessels involved in patients with Unstable Angina (UA) or Non-ST Elevation Myocardial Infarction (NSTEMI).

This prospective cross-sectional study was designed to evaluate the correlation between TIMI score, and the number of vessels involved in the angiographic study of NSTEMI and UA patients presenting to emergency department.

297 patients with the mean age of 62.16±36.59 years were entered (58.2% male; 193 (65%) UA and 104 (35%) NSTEMI). The Mean TIMI score among patients was 3.21±1.55. Based on the TIMI score, patients were categorized into 3 groups. 105 (35.35%) patients had a TIMI score of 0 to 2, 120 (40.40%) had a score of 3 to 4, and 72 (24.24%) had a score of 5 to 7. Patients with a TIMI score of 5 to 7 had a greater likelihood of three-vessel coronary artery disease compared to patients with a TIMI score of 3 to 4 (OR: 5.34, 95% CI: 2.64 to 10.80; p < 0.0001) or those with a TIMI score of 0 to 2. (OR: 29.45, 95% CI: 12.87 to 67.37; p < 0.0001). Two-vessel coronary artery disease was more likely to be found in patients with a TIMI score of 3 to 4 or those with a score of 5 to 7 compared to patients with a TIMI score of 0 to 2 (OR: 3.69, 95% CI: 1.60 to 8.51; p <0.0001 and OR: 2.67, 95% CI: 1.04 to 6.82; p = 0.04, respectively).

There is a direct and significant correlation between TIMI score and the number of coronary vessels involved in patients presenting to emergency department following UA or NSTEMI.

Inferior hip dislocation or luxatio erecta femoris is among the rarest hip dislocations, which has been describedin limited studies. The patients usually present with their hip in flexion, abduction, and external rotation. Hipdislocation is an orthopedic emergency, and a reduction needs to be performed promptly to avoid devastatingcomplications such as avascular necrosis. Here, we present a rare case of inferior hip dislocation in a 60-year-old man following a car-motorcycle collision. The patient presented to the emergency department with left hipflexion, abduction, external rotation, and inability to move his leg due to pain. Closed reduction under procedu-ral sedation was attempted in the emergency department once, which was unsuccessful. The patient was thentaken to the operating room for another attempt of closed reduction under general anesthesia. The patient wasdischarged after two days with pin traction and double crutches. After two weeks, the pin was removed, andfull weight-bearing was permitted. After 12 weeks, the patient had mild pain with unusual activity and slightlimping; however, imaging revealed no signs of any complications.

Acute headache is one of the most common reasons for emergency department (ED) visits. Thisstudy aimed to compare the combination of propofol and granisetron with propofol and metoclopramide insymptom management of acute migraine headache.

In this double-blind randomized clinical trial,60 adult patients with acute migraine headache who referred to ED were randomly divided into two groups ofpropofol + metoclopramide and propofol + granisetron. Pain and nausea/vomiting severity as well as bloodpressure were compared between groups 30, 45, and 60 minutes after treatment.

The two groups hadsimilar situation regarding mean age (p = 0.606), sex distribution (p = 0.793), baseline severity of pain (p = 0.642),frequency of nausea/vomiting (p = 0.488), and vital signs (p > 0.05). The severity of pain was similar in the twogroups 30 (p = 0.731), 45 (p = 0.460), and 60 (p = 0.712) minutes after treatment. The number of patients withresistant nausea and vomiting 60 minutes after treatment was significantly higher in metoclopramide group(30.0% versus 10.0%; p = 0.033). Diastolic pressure 60 minutes after treatment (81.43 ±8.94 vs. 74.97 ± 4.8; p= 0.001) and heart rate 30 minutes after treatment (68.87 ±6.52 vs. 73.57± 7.62; p = 0.013) had statistically sig-nificant differences between the groups.

The combination of propofol and granisetron was supe-rior to propofol and metoclopramide in case of controlling nausea and vomiting of cases with acute migraineheadache; meanwhile, no differences were observed in case of pain relief and hemodynamic status between thetwo groups.

Different methods have been proposed for the reduction of the pain caused by the injection of local anesthetics. This study aimed to evaluate the effect of skin cooling on reduction of pain associated with local injection of lidocaine buffered with sodium bicarbonate.

This randomized controlled trial included 108 adult patients with arm/forearm wounds who referred to the emergency departments. Participants were randomly allocated to two equal groups. Patients in both groups received subcutaneous injection of buffered lidocaine. In the intervention group, an ice cube measuring 2 × 2 × 2 cm (at 0 ° C) in sterile gloves were placed on the wound for 2 minutes before the injection of buffered lidocaine. The primary outcome was severity of pain during lidocaine injection using a visual analog scale (VAS).

One hundred and eight patients were enrolled in the study, 54 in each group. There was no statistically significant difference in age (p = 0.777), sex (p = 0.466), and length of laceration (p = 0.410) between the two groups. The pain scores during lidocaine injection were significantly lower in the intervention group compared to control group (2.39 ± 1.14 vs 4.26 ± 0.94, p < 0.001).

Skin cooling prior to the injection of local anesthetics can significantly reduce the pain caused by local anesthetic infiltration

Endoscopic retrograde cholangiopancreatography (ERCP) is a standard for diagnosing and treating hepato-pancreatico-biliary (HPB) diseases in clinical settings. ERCP-related complications are relatively common, rang-ing from 4 to 30%. The most common one is acute pancreatitis. ERCP-related necrotizing pancreatitis accountsfor 7.7% of ERCP-related pancreatitis cases. This complication may still be misdiagnosed, which might lead toinappropriate treatment with a worse prognosis. Here, we report a 34-year-old case with ERCP-related necrotiz-ing pancreatitis who was successfully managed, but initially misdiagnosed with biliary peritonitis.

Emergency medicine has evolved as a speciality but airway management is still a challenge. Traditionally, direct laryngoscopy (DL) is used for intubation with maneuvers to directly visualize the vocal cords. Most tracheal intubations in the emergency department (ED) are done on an emergent basis and enhancing the technicalities of intubation can be life-saving. Video laryngoscopy (VL) is available in the emrgenyc department and can help reduce the intubation failure rate; hence, it has been recommended for maintaining airways in obese patients.

Considering the population's socioeconomic status and clinical features is essential in planning and performing interventions related to disease control. The main purpose of this study was to investigate the relationship between income level and hospitalization rate of COVID-19 patients.

A cross-sectional study was performed on 198,944 hospitalized COVID-19 patients in Tehran province between March 2020 and March 2021. Data of hospitalized COVID-19 patients was obtained from the Hospital Intelligent Management System (HIM). The income data of patients were obtained from the Iranian Database on Targeted Subsidies belonging to the Ministry of Cooperatives, Labor, and Social Welfare. Data analyses were performed using SPSS software.

About 2.5% of the inpatients were from the first decile, while 20.6% were from the tenth. The share of the lower three deciles of total hospitalization was about 11%, while the share of the upper three deciles was 50%. There was a big difference between the upper- and lower-income deciles regarding death rates. In the first decile, 30% of inpatients died, while the proportion was 10% in the tenth decile. There was a significant and positive relationship between income decline and hospitalization (r = 0.75; p = 0.02). Also, there was a significant and negative relationship between income decline and death rate (r = -0.90; p = 0.01).

Low-income groups use fewer inpatient services, are more prone to severe illness and death from COVID-19, and treatment in this group has a lower chance of success. Using a systemic approach to address socioeconomic factors in healthcare planning is crucial.

There is no consensus on the performance of decision rules in predicting the prognosis of traumapatients. Therefore, the present study aimed to compare the value of Glasgow coma scale (GCS) and physiologicscoring systems in predicting mortality and poor outcome of trauma patients.

This diagnostic accu-racy study was conducted on multiple trauma patients admitted to the intensive care units of two hospitals inTehran, Iran, from 21 November 2020 to 22 May 2021. The patients’ demographic characteristics, length of stayin the intensive care unit (ICU), the vital signs, and the GCS on admission were recorded. Finally, the mortal-ity, disability, and complete recovery of patients at the time of discharge were evaluated and receiver operatingcharacteristics (ROC) curve analysis was used to compare the performance of physiologic scoring systems withGCS.

200 trauma patients with the mean age of 43.53±19.84 years were evaluated (74% male). The areaunder the ROC curve for New Trauma Score (NTS), Revised Trauma Score (RTS), Worthing Physiological Scor-ing System (WPSS), Rapid Acute Physiology Score (RAPS), Rapid Emergency Medicine Score (REMS), ModifiedEarly Warning Score (MEWS), National Early Warning Score (NEWS), Glasgow Coma Scale, Age, and SystolicBlood Pressure score (GAPS) ,Glasgow coma scale (GCS) in prediction of mortality were 0.95, 0.95, 0.83, 0.89,0.91, 0.84, 0.77, 0.97, and 0.98 respectively. The performance of GCS was statistically superior to RTS (P=0.005),WPSS (P=0.0001), RAPS (P=0.0002), REMS (P=0.002), MEWS (P<0.0001), and NEWS (P<0.0001). However, theperformance of GCS, NTS (P=0.146), and GAPS (P=0.513) were not significantly different. Also, in predictionof poor outcomes, the AUC of GCS (0.98) was significantly higher than RTS (0.95), RAPS (0.85), REMS (0.85),MEWS (0.84), NEWS (0.77), and WPSS (0.75).

The GCS score seems to be a better instrument topredict mortality and poor outcome in trauma patients compared to other tools due to its high accuracy, wideapplication, and easy calculation.

Tramadol is a synthetic analgesic with weak mu-opioid receptor agonist activity. Tramadol over-dose is associated with adverse cardiac effects due to inhibiting cardiac Na+and K+channels. This study aimedto investigate the potential ameliorative role of 3% hypertonic saline on the electrocardiogram (ECG) changesin patients presenting with tramadol poisoning.

This was a single-center, controlled, randomized,single-blind clinical trial. Patients were randomized into the case (received hypertonic saline) and control (re-ceived placebo) groups. ECG was obtained twice in each group (upon arrival and following the intervention).Response to therapeutic interventions was evaluated using Wilcoxon Signed Ranks Test.

A total of76 patients were included. The mean age of patients was 24.88 ± 4.29 years, and 62 (81.6%) were male. Themean ingested dose of tramadol was 1673.68 ± 608.85 (range: 550-2750) mg. The number needed to treat andthe absolute risk reduction of 3% hypertonic saline in the treatment of wide QRS were 1 (95% CI: 1.00 – 1.00)and 100%, respectively. In the treatment of long QTc, these measures were 1.9 (95%CI: 1.2 – 4.5) and 53.85%(95%CI: 22.00 – 85.69), respectively.

Given that hypertonic saline infusion can significantly amelio-rate tramadol-mediated ECG changes, including QRS prolongation and QT lengthening, it can be regarded as apotential therapeutic strategy to prevent the development of life-threatening ventricular arrhythmias caused bytramadol toxicity.

Migraine headaches can cause severe pain for patients and lead them to multiple visits to theemergency department (ED). This study aimed to evaluate the efficacy of propofol + sumatriptan combinationin comparison with sumatriptan alone in the management of acute migraine headaches.

This triple-blind clinical trial involved patients who referred to two emergency departments with acute migraine headaches.Patients were randomly assigned to control (sumatriptan and placebo) or intervention (propofol and sumatrip-tan) groups for comparison of the efficacy and side effects of treatment.

In this study, 60 patients wereincluded whose mean age was 31±8.8 years, and headaches were more common among women. After 30 and60 minutes from the beginning of treatment, the mean pain score reduction in the intervention group was sig-nificantly greater than that in the control group (p=0.012, p=0.024). In addition, the rate of chest tightness inthe control group was significantly higher than the intervention group. The absolute risk reduction of adverseevents (Chest tightness, Bradycardia, hypotension, and etc.), in patients with acute migraine headache takingpropofol and sumatriptan treatment, was 32.18% (95% CI: 8.02 – 56.35).

This study supports theuse of propofol for treatment of acute migraine headaches and shows that combining sumatriptan with propofolis more effective in relieving migraine headaches and the associated symptoms than using sumatriptan alone.However, more studies with longer follow-ups are still needed.

Alveolar arterial (A-a) oxygen gradient and respiratory index can be of immense help for the crit-ical care physician in clinical decision making. This study aimed to evaluate the potential application of A-aoxygen gradient and respiratory index in predicting the survival of COVID-19 patients in intensive care unit(ICU).

This is a retrospective cross-sectional study involving 215 adult patients with COVID-19 dis-ease, admitted to the ICU between 1st April 2020 and 30 June 2021. Details regarding demographic variables,comorbidities, laboratory and arterial blood gas (ABG) findings were recorded. Alveolar-arterial gradient andrespiratory index were calculated and tested as predictors of survival.

The mean age of the patients was51.92 years (65.6 % male). Hypertension was the most common comorbidity and oxygen via non-rebreathingmask was the most common modality used at the time of ICU admission. Mortality was 28.37% and averagelength of stay was 12.84 days. Patients who died were older (p=0.02), mostly male (p=0.017), had at least onecomorbidity (p<0.001), and higher heart rate and respiratory rate (<0.001 and p=0.03, respectively), lower pHon arterial blood gas (ABG) (p=0.002), higher FiO2 requirement (p<0.001), and increased A-a oxygen gradienton admission compared to survivors. According to receiver operating characteristic (ROC) curve analysis, A-aoxygen gradient and respiratory index were not sensitive or specific in predicting mortality in the studied pa-tient subset.

A-a oxygen gradient and respiratory index calculated at time of admission to ICU inpatients with COVID-19 were poor predictors of survival

Pre-hospital and in-hospital emergency management play an important role in quality of carefor emergency patients. This prospective cohort study aimed to determine factors associated with the 24-hourclinical outcome of emergency patients.

The sample included 1,630 patients, randomly selectedthrough multi-stage stratified sampling from 13 hospitals in 13 provinces of Thailand. Data were collected dur-ing January-November 2018. Clinical outcome was determined using pre-arrest sign score. Data were analyzedvia ordinal multivariate regression analysis.

Factors influencing 24-hour clinical outcome of emer-gency patients were age (OR: 0.965; 95% CI: 0.96-0.97), having coronary vascular disease (CAD) (OR: 1.41; 95%CI: 1.05-1.88), and severity of illness based on Rapid Emergency Medical Score (REMS) (OR:1.09; 95% CI: 1.05-1.15). Self-transportation and being transported by emergency medical service ambulance with non-advancedlife support (EMS-Non-ALS) did not influence clinical outcome when compared to EMS-ALS transport. Beingtransported from a community hospital increased pre-arrest sign score 1.78 times when compared to EMS-ALS(OR: 1.78; 95% CI: 1.17-2.72). Increased transportation distance increased the risk of poor clinical outcome (OR:1.01; 95% CI: 1.002-1.011). Length of stay in emergency department (ED-LOS) more than 4 hours (OR: 0.21; 95%CI: 0.15-0.29) and between 2-4 hours (OR: 0.60; 95% CI: 0.47-0.75) decreased the risk of poor clinical outcomewhen compared to ED-LOS less than 2 hours.

Having CAD, severity of illness, increased transportdistance, and ED-LOS less than 2 hours were found to negatively influence 24-hour clinical outcome of emer-gency patients.

The mortality of burn injury is a serious health problem among older people. The presentstudy aimed to determine the epidemiological characteristics of burn mortality and Years of Life Lost (YLLs)among people aged≥60.

The National and Subnational Burden of Disease (NASBOD) study includespopulation-based cross-sectional data from the death registration system of Iran and those recorded by thecemeteries of Tehran and Esfahan were used in this study. Spatio-temporal and Gaussian process regressionmodels were applied to estimate rates and trends of mortality and cause-specific mortality fractions. YLLs werecalculated using Iranian life expectancy and the number of deaths.

The mortality rate for 1990 and 2015was 17.4 and 4.5 per 100,000, respectively. From 1990 through 2015, the annual percentage of change in burnmortality rate was -6.1% in females and -4.4% in males. During 2015, there were 326 deaths following burns inpeople aged 60+ with 4586 person YLLs, and in 1990 there were 523 deaths with 4862 person-YLLs. The male-female ratio for 1990 and 2015 were 0.80 and 0.88, respectively. The age-standardized mortality rate was higherthan 8.5 per 100,000 in border provinces in 2015. The provinces with better socioeconomic situations, such asTehran, had a lower mortality rate than poor provinces, such as Sistan va Baluchistan.

Althoughburn mortality in old people decreased in those 26 years, it is still high compared to high-income countries.Continued efforts to increase preventive measures and adequate access to quality care, especially in borderprovinces, is suggested.

Introduction:

To prioritize patients to provide them with proper services and also manage the scarce resourcesin emergencies, the use of triage systems seems to be essential. The aim of this study was to evaluate the ac-curacy of the existing triage systems in disasters and mass casualty incidents.

The present study is asystematic review of the accuracy of all triage systems worldwide. The results of this study were based on thearticles published in English language journals. In this research, all papers published from the beginning of 2000to the end of 2021 were sought through different databases. Finally, a total of 13 articles was ultimately selectedfrom 89 articles.

13 studies on the accuracy of triage systems were reviewed. The START, mSTART, SALT,Smart, Care Flight, ASAV, MPTT, Sieve and ESI triage systems, had an accuracy, sensitivity, and specificity of lessthan 90%. Only the Smart triage system had an overall accuracy of more than 90%.

According tothe findings of the current systematic review, the performance of the existing triage systems in terms of accu-racy of prioritizing the injured people and other performance indexes is not desirable. Therefore, to improvethe performance and increase the precision of triage systems, the world nations are recommended to change orrevise the indexes used in triage models and also identify other influential factors affecting the accuracy of triagesystems.

The clinical diversity of patients presenting to the emergency department (ED) allows emergencymedicine (EM) and non-EM residents to sharpen their clinical skills. In most EDs, residents self-assign pa-tients at their discretion. Our institution transitioned from a self-assignment-system to an automated-system,after which we sought to determine the productivity of our non-EM residents compared to the previous system.

In this retrospective cross-sectional study, resident productivity was measured as number of patientvisits per hour and per 8.5-hour shift before and after the implementation of an automated patient assignmentsystem in emergency department. The automated-system assigns one patient at the start of the shift, another30 minutes later, and one patient every hour thereafter, throughout the shift.

28 residents performed406 total shifts prior to implementation and 14 residents performed 252 total shifts post-implementation. Theaverage number of patient visits per hour significantly increased from 0.52 ± 0.18 (95% CI 0.45-0.59, IQR 0.43-0.60) to 0.82 ± 0.11 (95% CI 0.75-0.88, IQR 0.74-0.89) after implementation of our assignment system (p<0.00001;figure 1). Additionally, the average number of patient visits per 8.5-hour shift significantly increased from 4.46± 1.53 (CI 3.86-5.05, IQR 3.66-5.08) to 6.52 ± 0.86 (CI 6.02-7.02, IQR 5.90-7.09) after the implementation of oursystem (p<0.00001; figure 1).

These findings warrant further evaluation of the impact of patientassignment systems on trainee education.

Opioids have been the leading cause of death from poisoning in Iran for several years. This studyaimed to evaluate the clinical and para-clinical presentations of naltrexone intoxication, its toxic dose, andits epidemiological properties.

This retrospective cross-sectional study was conducted on medicalrecords of patients presenting to Toxicology Department of Loghman Hakim Hospital, Tehran, Iran, followingnaltrexone intoxication, from 2002 to 2016. Patients’ demographic and laboratory data, clinical signs, supposedingested dose, and intent of naltrexone consumption were collected, analyzed, and then interpreted.

907 patients with the mean age of 36.6 ±11.7 years were evaluated (94.3% male). The mean amount of naltrex-one consumed by the intoxicated patients reported in the medical records was 105.8 ± 267.8 mg. One hundredthirty patients (14.3%) used naltrexone to treat substance use disorder. Two hundred eighty-seven poisoned pa-tients (31.6%) were current opium users who intentionally or unintentionally used naltrexone concomitantly.The most common symptoms observed in these patients were agitation (41.8%), vomiting (16.4%), and nau-sea (14.8%). Among patients with naltrexone poisoning, 25 patients were intubated (2.8%), and three passedaway. Aspartate aminotransferase (AST) levels were significantly higher in patients intoxicated with naltrexonewho needed intubation (p = 0.02).

The probability of intubation of cases with naltrexone intoxica-tion was associated with AST elevation. It seems that, the number of intensive care unit (ICU) admissions andmortality rates are not high among these patients.

One of the most important concerns in responding to disasters is providing Basic Life Support(BLS) services. Considering the key role of Emergency Medical Services (EMS) in providing BLS, the purpose ofthis study is to investigate the experience of provincial EMS during their response to the Arasbaran twin earth-quakes and its challenges in Iran.

This study was conducted using a qualitative approach and theconventional content analysis method. Data were collected through Focused Group Discussions (FGD) andsemi-structured in-depth interviews with purposively-selected EMS paramedics and officials in East AzerbaijanProvince, Iran. To form the main categories, the interviews were encoded in three stages and the similar codeswere placed under the same subcategories and merged.

A total of 26 EMS paramedics participated inthe study. The codes extracted from the interviews, after three stages of reduction, were placed in the top tencategories, including the lack of preparedness and coordination, dead bodies’ management challenges, respon-ders’ psychosocial support, deficiencies in supplies and ambulances, difficulty of access to rural areas, volunteermanagement, non-documentation of the experiences, communication challenges, recalling, and deploying ofEMS responders.

Timely response of the EMS and paramedics’ sense of responsibility for provid-ing services were positive and successful points about the emergency response operations. The weaknesses ofEMS should, therefore, be addressed through transferring of experiences and by planning and arranging trainingcourses.

ntroduction:Outcome prediction of intensive care unit (ICU)-admitted patients is one of the important is-sues for physicians. This study aimed to compare the accuracy of Quick Sequential Organ Failure Assessment(qSOFA), Confusion, Urea, Respiratory Rate, Blood Pressure and Age Above or Below 65 Years (CURB-65), andSystemic Inflammatory Response Syndrome (SIRS) scores in predicting the in-hospital mortality of COVID-19patients.

This prognostic accuracy study was performed on 225 ICU-admitted patients with a defini-tive diagnosis of COVID-19 from July to December 2021 in Tehran, Iran. The patients’ clinical characteristicswere evaluated at the time of ICU admission, and they were followed up until discharge from ICU. The screeningperformance characteristics of CURB-65, qSOFA, and SIRS in predicting their mortality was compared.

225 patients with the mean age of 63.27±14.89 years were studied (56.89% male). The in-hospital mortality rateof this series of patients was 39.10%. The area under the curve (AUC) of SIRS, CURB-65, and qSOFA were 0.62(95% CI: 0.55 - 0.69), 0.66 (95% CI: 0.59 - 0.73), and 0.61(95% CI: 0.54 - 0.67), respectively (p = 0.508). In cut-off≥1, the estimated sensitivity values of SIRS, CURB-65, and qSOFA were 85.23%, 96.59%, and 78.41%, respectively.The estimated specificity of scores were 34.31%, 6.57%, and 38.69%, respectively. In cut-off≥2, the sensitivityvalues of SIRS, CURB-65, and qSOFA were evaluated as 39.77%, 87.50%, and 15.91%, respectively. Meanwhile,the specificity of scores were 72.99%, 34.31%, and 92.70%.

It seems that the performance of SIRS,CURB-65, and qSOFA is similar in predicting the ICU mortality of COVID-19 patients. However, the sensitivityof CURB-65 is higher than qSOFA and SIRS.

Medical and surgical priorities were dramatically changed during the COVID-19 pandemic. Thisstudy aimed to evaluate the impact of this pandemic on presentation to emergency department (ED) with uro-logic complaint.

This cross-sectional study was conducted at a tertiary urology referral center inTehran, Iran. The data of all ED admissions were collected and the frequency of admissions with urologic com-plain and their outcomes were compared between two 90-day periods (before and during COVID-19 era).Re-sults:480 ED admissions were studied. The number of patients visiting the ED with urologic complaint duringCOVID-19 era was significantly lower than the same period in the pre-COVID-19 period (125 vs. 355 admissions;p = 0.01). The mean hospitalization days for patients in the pre-COVID-19 period were significantly higher (5.6± 4.4 vs. 3.2 ± 4.2 days; p <0.001). The most common patient complaints before and during COVID-19 periodwere flank pain (32.7%) and gross hematuria (32.8%), respectively. The number of patients discharged againstmedical advice in the COVID-19 period was significantly higher than before (22 (17.6%) vs. 10(2.8%); p < 0.001).The number of patients who developed severe complications was significantly higher in the COVID-19 periodthan in the pre-COVID-19 period (p = 0.001).

During the COVID-19 pandemic we were faced withdecreasing frequency of admission with urologic complaint, change in the pattern of referrals, decrease in theduration of hospitalization, increase in the number of patients discharged against medical advice, and increasein the number of cases with irreversible urologic complications or complications requiring surgery due to de-ferred treatment.

ntroduction:Oxygen therapy, if done correctly, can save patients’ life promptly. However, improper use will bejust as dangerous. The present study aimed to investigate the level of nurses’ knowledge on properly using oxy-gen.

This was a cross-sectional study with a minimum sample size of 72 nurses who were randomlyselected from various wards of Masih Daneshvari Hospital, Tehran, Iran. To determine the level of knowledgeabout oxygen therapy, a questionnaire was used to collect data. This questionnaire consists of seven items, eachof which is designed to determine the level of the individual’s knowledge about the various details of oxygentherapy.

Seventy-eight nurses with the mean age of 35.80±7.42 years participated in the study (87%female). The mean knowledge score of nurses regarding oxygen therapy was 8.89 ± 2.79 out of 16 points. 84.6%of the nurses were able to differentiate various types of oxygen masks. Accordingly, 94.9% of nurses had goodknowledge on oxygen humidification. Also, 50% of the nurses had sufficient knowledge about the amount ofoxygen flow produced by different masks. 10.3% of the nurses could choose the most appropriate mask for dif-ferent clinical conditions. 6.4% of the nurses had knowledge of working with flowmeters, and 15.4% of the nurseshad sufficient information about the maximum level of oxygen required for the patient. 17.9% of the nurses werefamiliar with measuring the appropriate amount of oxygen for patients. There was no statistically significant re-lationship between age (p = 0.57), gender (p = 0.09), employment status (p = 0.38), workplace (p = 0.86), currentposition (p = 0.11), degree (p = 0.27), and graduation time (p = 0.58) of nurses with good knowledge of usingoxygen. However, a statistically significant relationship was reported between nurses’ related work experienceand their knowledge of the proper use of oxygen (p = 0.03).

In general, the nurses’ knowledge atMasih Daneshvari Hospital on how to properly use oxygen is at a moderate level. Nurses’ knowledge in someareas, such as working with the flowmeter, choosing the suitable mask for specific clinical conditions, and themaximum oxygen required for patients, is meager and requires training intervention.

Blunt traumas, like road accidents and falls, are common causes of injuries to pregnant women,and the major risk factors are young age and low socioeconomic level. Due to physiological and anatomicalchanges specific to pregnancy, such as changes in blood pressure and hemoglobin drop, trauma managementinvolves certain complexities. Physical trauma is estimated to cause at least 1 complication in every 12 pregnan-cies. This study aims to evaluate orthopedic trauma during pregnancy and appreciate the different approachesto circumvent the resultant challenges.

We reviewed 55 articles, published on orthopedic traumaduring pregnancy between 2011 and 2021. The articles were identified by searching PubMed, google-scholar,Scopus, and Science-Direct. We utilized the search terms: fall in pregnancy, traumas in pregnancy, motor vehi-cle accident/crash in pregnancy, blunt trauma in pregnancy, pregnant trauma patient, penetrating injury dur-ing pregnancy, assault, interpersonal violence in pregnancy, and mortality and pregnancy.

Accordingto available reports, after stabilizing the pregnant patient, diagnostic procedures, including radiography, andeven gadolinium-based techniques when needed, can be performed to examine extensive trauma. In contrastto elective orthopedic surgery, emergency orthopedic surgeries, including reduction of open fractures, shouldbe performed promptly.

Based on our investigation, pregnant women with orthopedic injuriesthat are severe, or even seemingly less severe, experience significantly increased adverse pregnancy outcomes,which include preterm birth, placental abruption, poor infant condition at birth, infant death, and even mater-nal death.

Although American Heart Association Guidelines (AHA) are practical and standardized in many aspects of car-diopulmonary resuscitation (CPR) performance, recommendations on when to terminate resuscitation are notfully understood and clear. There is not enough evidence about how long we can continue CPR in shockablerhythms and how many shocks can be delivered to patients, and if there is an end point for it or not. This is-sue is more challenging when we read papers published on survival rates and good functional and neurologicaloutcomes after prolonged CPRs. Here, we demonstrate a case of cardiac arrest receiving CPR in the emergencyroom, for whom it was hard and challenging to make a decision on when to terminate the resuscitation attempts.

Knowledge of vaccine-related adverse events is crucial as they are among the most important fac-tors that cause hesitation in receiving vaccines. Therefore, we aimed to systematically review the adverse eventsrelated to the mRNA vaccines reported in the literature.

A systematic literature search was carried outin the databases of Scopus, PubMed, Cochrane, and Web of Science. We selected original studies that exploredthe side effects of mRNA COVID-19 vaccines using a two-phase (title/abstract and full-text) screening process.

Cardiac complications were the most commonly reported severe adverse events. It appeared that sys-temic adverse reactions are more common after the second dose of vaccines. The number of adverse effectsreported after the Pfizer vaccine was higher than other vaccines, mostly due to its earlier approval and morewidespread use throughout the world. Cardiac adverse events had a higher prevalence but no significant associ-ation has been found between COVID-19 mRNA vaccines and cardiac adverse events except for myopericarditis.

Vaccines play a crucial role in controlling the COVID-19 pandemic and decreasing mortalities andthe results of the present review acknowledge the fact that the benefits outweigh the adverse events of thesevaccines

ntroduction:The COVID-19 pandemic has been considered an international problem. This study aimed tosurvey the demographic and clinical characteristics of the deceased COVID-19 patients.

The presentcross-sectional study was performed on all deceased COVID-19 patients who died in Imam Reza Hospital, Mash-had, Iran, from March 20, 2020, to September 23, 2021. Their data, including age, gender, complaints, andclinical symptoms at the time of admission, as well as information at the time of death (hour, shift, holiday/non-holiday) were analyzed and reported.

3364 deaths due to COVID-19 have been registered during thestudy period (60.46% male). The patients’ mean age was 66.99±16.97 (range: 1-101) years (92.7% of them wereIranian). The mortality at night shifts was less than day shifts (1643 vs. 1721). The average amount of deaths/dayon holidays and workdays was (5.63 vs. 6.24). The number of deaths varied during the various hours of the dayand night. Diabetes and cardiovascular diseases were the most common confounding factors, which were ob-served in 22.44% and 15.36% of the cases, respectively.

Based on the findings of this series, COVID-19 mortality was frequently observed in male patients, those with the mean age of 66.99 years, morning shifts,and workdays.

Burn injuries are under-appreciated trauma, associated with substantial morbidity and mortality.It is necessary to refer patients in need of specialized care to more specialized centers for treatment and rehabili-tation of burn injuries. This systematic review aimed to assess the adherence to referral criteria for burn patients.

An extensive search was conducted on Scopus, PubMed, and Web of Science online databases usingthe relevant keywords from the earliest to October 7, 2021. The quality of the included studies was assessedusing the appraisal tool for cross-sectional studies (AXIS tool).

Among a total of 7,455 burn patientsincluded in the nine studies, 60.95% were male. The most frequently burned areas were the hands (n=3) andthe face (n=2). The most and least common burn mechanisms were scalds (62.76%) and electrical or chemical(2.88%), respectively. 51.88% of burn patients had met≥1 referral criteria. The overall adherence to the referralcriteria for burn patients was 58.28% (17.37 to 93.39%). The highest and lowest adherence rates were related toWestern Cape Provincial (WCP) (26.70%) and National Burn Care Review (NBCR) (4.97%) criteria, respectively.

The overall adherence to the referral criteria for burn patients was relatively desirable. Therefore,well-designed future studies are suggested in order to uncover approaches to improve adherence to referral cri-teria for burn patients.

Emergency departments are operating with limited resources and high levels of unexpected re-quests. This study aimed to minimize patients’ waiting time and the percentage of units’ engagement to improvethe emergency department (ED) efficiency.

A comprehensive combination method involving DiscreteEvent Simulation (DES), Artificial Neural Network (ANN) algorithm, and finally solving the model by use of Ge-netic Algorithm (GA) was used in this study. After simulating the case and making sure about the validity of themodel, experiments were designed to study the effects of change in individuals and equipment on the averagetime that patients wait, as well as units’ engagement in ED. Objective functions determined using Artificial Neu-ral Network algorithm and MATLAB software were used to train it. Finally, after estimating objective functionsand adding related constraints to the problem, a fractional Genetic Algorithm was used to solve the model.Re-sults:According to the model optimization result, it was determined that the hospitalization unit, as well asthe hospitalization units’ doctors, were in an optimized condition, but the triage unit, as well as the fast trackunits’ doctors, should be optimized. After experiments in which the average waiting time in the triage sectionreached near zero, the average waiting time in the screening section was reduced to 158.97 minutes and also thecoefficient of units’ engagement in both sections were 69% and 84%, respectively.

Using the ser-vice optimization method creates a significant improvement in patient’s waiting time and stream at emergencydepartments, which is made possible through appropriate allocation of the human and material resources.

The coronavirus disease 2019 (COVID-19) is associated with a variety of physical and emotionaldisorders, and subsequently lower Quality of Life (QOL). This study aimed to investigate the effect of a 2-weekexercise-based pulmonary rehabilitation on clinical characteristics and QOL of severe COVID-19 patients afterdischarge from intensive care unit (ICU).

In this quasi-experimental study, eligible severe COVID-19cases, who had survived and were discharged from ICU were selected using convenience sampling method.Oxygen Saturation ( SpO2), pulse rate, dyspnea, and QOL were evaluated and compared before and after twoweeks of exercise-based pulmonary rehabilitation (PR).

35 cases with the mean age of 57.86 ± 11.73(18-75) years were studied (51.4% female). The mean SpO2 increased from 90.41 ± 3.97 to 95.11 ± 1.96% aftertwo weeks of pulmonary rehabilitation (p<0.0001). In addition, the mean pulse rate (98.97±16.23 to 88.91±14.03pulse/minute; p<0.001) and the mean dyspnea severity (5.6±1.97 to 3.45±1.97; p<0.0001) decreased after twoweeks of intervention. Besides, the mean total QOL and its dimensions, including general health (p<0.0001),physical status (p<0.0001), emotional status (p = 0.036), and social function (p<0.0001) of patients, had signif-icantly increased after intervention.

Based on the findings of this study, it seems that two-weekexercise-based pulmonary rehabilitation could be effective in increasing the SpO2, decreasing dyspnea andpulse rate, and improving the QOL of patients with severe COVID-19 after discharge from ICU.

Efforts to control the COVID-19 pandemic are still on. This study aimed to evaluate the effect ofsofosbuvir on length of hospital stay and complications in COVID-19 cases with moderate severity.

This randomized clinical trial was done on moderate COVID-19 cases, who were admitted to Shohadaye TajrishHospital, Tehran, Iran, from 4/2021 to 9/2021. Eligible patients were randomly allocated into two groups ofintervention (sofosbuvir) and control, and their outcomes were compared regarding the length of hospital stayand complications.

100 COVID-19 cases were randomly divided into two groups of 50 patients, asthe intervention and control groups. The mean age of patients was 50.56 ± 12.23 and 57.1±14.1 years in theintervention and control groups, respectively (p = 0.02). The two groups were similar regarding distribution ofgender (p = 0.15), underlying diseases (p = 0.08), the severity of COVID-19 (p = 0.80) at the time of admission,signs and symptoms (p > 0.05), and essential laboratory profile (p > 0.05). The length of hospital stay in thecontrol and intervention groups was 7.7 ± 4.09 days and 4.7±1.6 days, respectively (p = 0.02). None of our patientsneeded ICU or mechanical ventilation.

Sofosbuvir may decrease the length of hospital stay ofCOVID-19 cases with moderate severity, without a significant effect on the rate of intensive care unit (ICU) needand mortality.

The use of point-of-care ultrasonography (POCUS) for identifying medial collateral ligament(MCL) tears has increased in recent years. This study aimed to evaluate the diagnostic accuracy of POCUS inthe diagnosis of acute MCL tears of the knee.

This prospective cross-sectional study was performedon patients with suspected MCL tear of the knee in the emergency department (ED). After history taking andprimary physical examination, radiographic imaging of the knee was done. If there was no fracture in the kneeX-ray, the POCUS examination was done. All of the patients were asked to refer to an orthopedic clinic, 7-10 daysafter discharge from ED, for Magnetic Resonance Imaging (MRI) evaluation. The second POCUS was done in theorthopedic clinic. Finally, the findings of POCUS and MRI were compared in diagnosing MCL injury.

Two hundred and fifty patients with a mean age of 25.05 ± 9.12 years were analyzed (86.8% male). Accordingto the MRI findings, as the gold standard, 55(22.0%) patients had MCL injury. The sensitivity, specificity, pos-itive and negative predictive values (PPV and NPV ), and accuracy of ultrasound in detection of MCL injury, incomparison with MRI were 83.64 (95% CI, 71.20 to 92.23), 94.36% (95% CI, 90.13 to 97.15), 80.70% (95% CI, 69.95to 88.25), 95.34% (95% CI, 91.83 to 97.38), and 92.00% (95% CI, 87.92 to 95.05), respectively. The area under thereceiver operating characteristic (ROC) curve of POCUS was 0.890 (95% CI, 0.844 to 0.926).

It seemsthat POCUS can be applied in screening patients with MCL tears following blunt knee trauma.

The available literature regarding the rate of readmission of COVID-19 patients after discharge is rather scarce. Thus, the aim in the current study was to evaluate the readmission rate of COVID-19 patients and the components affecting it, including clinical symptoms and relevant laboratory findings.

In this retrospective cohort study, COVID-19 patients who were discharged from Imam Hossein hospital, Tehran, Iran, were followed for six months. Data regarding their readmission status were collected through phone calls with COVID-19 patients or their relatives, as well as hospital registry systems. Eventually, the relationship between demographic and clinical characteristics and readmission rate was assessed.

614 patients were entered to the present study (mean age 58.7±27.2 years; 51.5% male). 53 patients were readmitted (8.6%), of which 47 patients (7.6%) had a readmission during the first 30 days after discharge. The reasons for readmission were relapse of COVID-19 symptoms and its pulmonary complications in 40 patients (6.5%), COVID-19 related cardiovascular complications in eight patients (1.3%), and non-COVID-19 related causes in five patients (0.8%). Older age (OR=1.04; 95% CI: 1.01, 1.06; p=0.002) and increased mean arterial pressure during the first admission (OR=1.04; 95% CI: 1.01, 1.08; p=0.022) were found to be independent prognostic factors for the readmission of COVID-19 patients.

Readmission is relatively frequent in COVID-19 patients. Lack of adequate hospital space may be the reason behind the early discharge of COVID-19 patients. Hence, to reduce readmission rate, extra care should be directed towards the discharge of older or hypertensive patients.

Identifying patients at risk for mortality and using appropriate treatment for each patient based on their situation could be an effective strategy in improving their outcome. This study aimed to evaluated the predictors of COVID-19 in-hospital mortality.

This descriptive cross-sectional study was conducted on all adult COVID-19 patients who were managed in Imam-Reza and Sina Hospitals, Tabriz, Iran, from November 2020 until December 2021. The demographic, clinical, and laboratory characteristics of patients were evaluated and predictors of in-hospital mortality were identified using logistic regression model.

1000 patients with the mean age of 56.34 ± 18.00 years were studied (65.7% male). There were significant associations between COVID-19 in-hospital mortality and hospitalization above five days (p = 0.001), white blood cell count (WBC) > 4000 Cells*103/mL (p < 0.01), aspartate aminotransferase (AST) above 40 IU/L (p = 0.001), alanine transaminase (ALT) above 40 IU/L (p = 0.001), creatinine above 1.4 mg/dL (p = 0.007), urea above 100 mg/dL (p = 0.024), and SaO2 below 80% (p = 0.001). Hospital stay above five days (OR: 3.473; 95%CI: 1.272 - 9.479; p = 0.15), AST above 40 IU/L (OR: 0.269, 95%CI: 0.179 - 0.402; p = 0.001), creatinine above 1.4 mg/dL (OR: 0.529; 95%CI: 0.344 - 0.813; p = 0.004), urea above 100 mg/dL (OR: 0.327, 95%CI: 0.189 - 0.567; p = 0.001), and SaO2 below 80% (OR: 8.754, 95%CI: 5.413 - 14.156; p = 0.001) were among the independent predictors of COVID-19 in-hospital mortality.

The mortality rate of patients with COVID-19 in our study was 29.9%. Hospitalization of more than five days, AST above 40 IU/L, creatinine above 1.4 mg/dL, urea above 100 mg/dL and SaO2 < 80% were independent risk factors of in-hospital mortality among patients with COVID-19.

There are many ambiguities regarding the application of ultrasound in detection of intestinal obstruction. This study aimed to evaluate the diagnostic accuracy of ultrasound in diagnosis of intestinal obstruction.

This cross-sectional study was performed on patients with symptoms and signs of bowel obstruction between November19 and July 2020 in Shohadaye-Tajrish and Imam Hossein General Hospitals, Tehran, Iran. After a brief explanation and getting verbal consent, the patients underwent ultrasound examination in the emergency department by the emergency medicine resident. The results of ultrasound were compared with the surgical findings as the gold standard.

24 patients with the mean age of 57.50±18.26 (range: 28 – 81) years were studied (58.3% male). Ultrasonography findings revealed the lumen diameter ≥ 2.5 cm in 21 (87.5%) cases, wall thickness ≥ 3 mm in 3 (12.5%) cases and inter-loop free fluid in 3 (12.5%) cases. Sensitivity, positive predictive value, and accuracy of ultrasound in detection of intestinal obstruction were found to be 85.00% (95%CI: 61.13 – 96.03), 80.95% (95%CI: 57.42 – 93.71), and 70.83% (95%CI: 48.91 – 87.38), respectively.

It seems that point-of-care ultrasound has good sensitivity and accuracy in detection of intestinal obstruction when performed in the emergency department by a trained emergency medicine resident.

Interleukins (ILs) can act as a predictive indicator of Premature Coronary Artery Disease (pCAD) and may be useful in screening of high-risk patients. However, there is no consensus on the relationship of serum levels of ILs and pCAD, yet. As a result, this study has been conducted in order to review the literature on the relationship between serum levels of different ILs and pCAD.

Medline, Scopus, Embase, and Web of Science databases were searched until December 7th 2020. Two reviewers independently screened and summarized eligible articles. A meta-analysis was performed to assess the relationship of ILs and pCAD.

12 case-control articles were included. IL-6 plasma changes do happen in pCAD patients with a standardized mean difference (SMD) of 0.51 (95% CI: 0.12-0.90; p=0.010) compared with the control group. This difference was also observed when evaluating the plasma levels of IL-1 and IL-17, with an SMD of 1.42 (95% CI: 1.11-1.73; p<0.001) and 0.59 (95% CI: 0.14-1.04; p=0.011), respectively. Meanwhile, no significant difference existed in plasma levels of IL-10 (SMD=0.26; 95% CI: -0.17-0.70; p=0.236), and IL-18 (SMD=1.44; 95% CI: -0.19-3.07; p=0.083) between pCAD patients and those in the control group.

Low level of evidence showed that there may be a significant relationship between increased plasma levels of ILs and the occurrence of pCAD. As a result, prospective cohort studies with serial assessments of serum ILs during follow up period, focusing on controlling classical risk factors of pCAD and increase in level of ILs, should be conducted.

Various scoring systems have been designed for calculating the mortality risk of patients. This study evaluated the accuracy of Rapid Emergency Medicine Score (REMS) and Rapid Acute Physiology Score (RAPS) in predicting the 28-day mortality of non-trauma patients.

This prospective cross-sectional study was conducted on 1003 adult non-trauma patients, who referred to the emergency department of Imam Khomeini Hospital, Urmia, Iran, in the second half of 2018, using the census sampling. We determined the screening performance characteristics of REMS and RAPS in predicting the 28-day mortality of patients.

This study examined 1003 non-trauma patients with a mean age of 61.5±18.05 years (60.6% male). The mean REMS (8.7 ± 3.2 vs. 6.0 ± 3.6; p < 0.001) and RAPS (3.7 ± 2.8 vs. 2.7 ± 2.0; p < 0.001) scores were significantly higher in deceased cases. Sensitivity and specificity of REMS in predicting the risk of non-trauma patients’ mortality were 85.19% (95%CI: 78.05% - 90.71%) and 78.34% (95%CI: 75.45% - 81.04%), respectively. While, the Sensitivity and specificity of RAPS in this regard were 61.39% (95%CI: 53.33% - 69.02%) and 71.12% (95%CI: 67.94% - 74.16%), respectively. The area under the receiver operating characteristic (ROC) curve of REMS and RAPS were 0.72 (95% CI: 0.68 -0.75) and 0.62 (95% CI: 0.56 - 0.65) in predicting the patients’ 28-day mortality, respectively (p = 0.001).

The total accuracies of REMS and RAPS in predicting the 28-day mortality of non-trauma patients were in good and poor range, respectively. The screening performance characteristics of REMS were a little better in this regard.

Controversies existed regarding the duration of COVID-19 vaccines’ protection and whether receiving the usual vaccine doses would be sufficient for long-term immunity. Therefore, we aimed to systematically review the studies regarding the COVID-19 vaccines’ protection three months after getting fully vaccinated and assess the need for vaccine booster doses.

The relevant literature was searched using a combination of keywords on the online databases of PubMed, Scopus, Web of Science, and Cochrane on September 17th, 2021. The records were downloaded and the duplicates were removed. Then, the records were evaluated in a two-step process, consisting of title/abstract and full-text screening processes, and the eligible records were selected for the qualitative synthesis. We only included original studies that evaluated the efficacy and immunity of COVID-19 vaccines three months after full vaccination. This review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement to ensure the reliability of results.

Out of the 797 retrieved records, 12 studies were included, 10 on mRNA-based vaccines and two on inactivated vaccines. The majority of included studies observed acceptable antibody titers in most of the participants even after 6 months; however,it appeared that the titers could also decrease in a considerable portion of people. Due to the reduction in antibody titers and vaccine protection, several studies suggested administering the booster dose, especially for older patients and those with underlying conditions, such as patients with immunodeficiencies.

Studies indicated that vaccine immunity decreases over time, making people more susceptible to contracting the disease. Besides, new variants are emerging, and the omicron variant is continuing to spread and escape from the immune system, indicating the importance of a booster dose.

Knowledge of the safety of vaccines is crucial, both to prevent and cure them and to decrease the public hesitation in receiving vaccines. Therefore, this study aimed to systematically review the adverse events reported for inactivated vaccines and Novavax.

In this systematic review, the databases of PubMed, Scopus, Cochrane, and Web of Science were searched on September 15, 2021. Then we identified the eligible studies using a two-step title/abstract and full-text screening process. Data on the subjects, studies, and types of adverse events were extracted and entered in a word table, including serious, mild, local, and systemic adverse events as well as the timing of side effects’ appearance.

Adverse effects of inactivated coronavirus vaccines side effects were reported from phases 1, 2, and 3 of the vaccine trials. The most common local side effects included injection site pain and swelling, redness, and pruritus. Meanwhile, fatigue, headache, muscle pain, fever, and gastrointestinal symptoms including abdominal pain and diarrhea were among the most common systemic adverse effects.

This systematic review indicates that inactivated COVID-19 vaccines, including Sinovac, Sinopharm, and Bharat Biotech, as well as the protein subunit vaccines (Novavax) can be considered as safe choices due to having milder side effects and fewer severe life-threatening adverse events.

A variety of therapeutic modalities are available in management of ovarian endometrioma. This study aimed to compare the effects of ethanol sclerotherapy and laparoscopic surgery on disease recurrence and ovarian factors of these patients.

70 women with ovarian endometrioma and chronic pelvic pain were randomly divided into two groups. The first group underwent sclerotherapy with a puncture needle (cook) and the second group underwent laparoscopic surgery. Both groups were followed up every three months to investigate the recurrence rate. In this regard, ultrasonography was performed 3 months and 12 months after treatment, and serum anti-Müllerian hormone (AMH) levels were also reassessed 12 weeks after the intervention.

70 women with the mean age of 31.46 ± 4.71 years, and the mean body mass index (BMI) of 23.12 ± 1.01 were studied. The two groups were similar regarding age (p = 0.770), BMI (p = 0.371), history of gastrointestinal signs (p = 0.794), history of urinary diseases (p = 0.324), dysmenorrhea (p = 0.403), pelvic pain (p = 0.454), dyspareunia (p = 0.448), location of cyst (p = 0.448), and diameter of cyst (p = 0.250). In the laparoscopic group, a significant decrease in anti-Müllerian hormone (AMH) levels was observed after 12 weeks (p < 0.0001), while in the sclerotherapy group, no significant changes were found between pre-and post-operative AMH levels (p = 0.120). Cyst size decreased significantly in both groups three months (p < 0.001) and twelve months (p < 0.0001) after treatment. In the third month, 8 patients in the sclerotherapy group and 13 patients in the laparoscopic group had recurrences, and in the twelfth month, 17 patients in the sclerotherapy group and 15 patients in the laparoscopic group had recurrence of symptoms (p > 0.05).

Although AMH level and mean cyst diameter were significantly lower one year after laparoscopy, recurrence rate of ovarian endometrioma was similar between ethanol sclerotherapy and laparoscopy methods.

Mucormycosis as a rare but life-threatening disease with 46-96% mortality, which challenged the healthcare system during the COVID-19 pandemic. This study aimed to compare the characteristics of mucormycosis between cases with and without COVID-19.

This cross-sectional study was done in two referral hospitals, Imam Hossein and Labbafinezhad Hospitals, Tehran, Iran, between 21 March to 21 December 2021. Data related to all hospitalized adults subject with the diagnosis of mucormycosis during the study period was collected from patients’ profiles and they were divided into two groups of with and without COVID-19 based on the results of real time PCR. Then demographic, clinical, and laboratory findings as well as outcomes were compared between the two groups.

64 patients with the mean age of 53.40±10.32 (range: 33-74) years were studied (53.1% male). Forty-three (67.2%) out of the 64 subjects had a positive COVID-19 PCR test. The two groups had significant differences regarding some symptoms (cough (p < 0.001), shortness of breath (p = 0.006)), acute presentation (p = 0.027), using immunosuppressive (p = 0.013), using corticosteroid (p < 0.001), and outcomes (mortality (p = 0.018), need for intubation (p < 0.001)). 22 (34.3%) patients expired during hospital admission. Univariate analysis showed the association of in-hospital mortality with need for ventilation (p < 0.001), sinus involvement (p = 0.040), recent use of dexamethasone (p = 0.011), confirmed COVID-19 disease (p = 0.025), mean body mass index (BMI) (p =0.035), hemoglobin A1c (HbA1c) (p = 0.022), and median of blood urea nitrogen (BUN) (p =0.034). Based on the multivariate model, confirmed COVID-19 disease (OR = 5.01; 95% CI: 1.14-22.00; p = 0.033) and recent use of dexamethasone (OR= 4.08, 95% CI: 1.05-15.84, p = 0.042) were independent predictors of mortality in this series.

The mucormycosis cases with concomitant COVID-19 disease had higher frequency of cough and shortness of breath, higher frequency of acute presentation, higher need for immunosuppressive, corticosteroid, and ventilator support, and higher mortality rate. The two groups were the same regarding age, gender, BMI, risk factors, underlying diseases, symptoms, and sites of involvement.

Standard cardiopulmonary resuscitation (STD-CPR) is successful in only 10-15% of cases in emergency department (ED). This study aimed to determine the effect of interposed abdominal compression (IAC) during resuscitation on outcomes of ED cardiac arrests.

In this randomized clinical trial study, non-trauma patients aged 18-85 years, patients with in-hospital cardiac arrest hospitalized in the ED were randomly assigned into two either STD-CPR or IAC-CPR group on a 1:1 basis and using computer-generated random numbers. Participants in the intervention group, received abdominal compression during the diastole phase of STD-CPR. The rate of return of spontaneous circulation (ROSC), heart rate (HR), respiratory rate (RR), arterial blood gas (ABG) indicators, and survival rate were compared between the two groups.

Ninety patients were enrolled (45 in each group). There were no differences between the two groups regarding age (p = 0.76), sex (p = 0.39), employment status (p = 0.62) and Charlson comorbidity scale (p = 0.46). Abdominal compression had a positive effect on heart rate (p < 0.001), mean arterial pressure (p = 0.003), arterial blood oxygen pressure (p = 0.001), and arterial blood carbon dioxide pressure (p = 0.001) as well as a negative effect on arterial blood oxygen saturation (p = 0.029) 30 minutes after resuscitation. Out of the 90 CPR cases, 8 (17.7%) cases in intervention group and 8 (17.7%) cases in control group were successful, among which all of the 8 patients in the intervention group and 5 of the patients in the control group had been discharged from hospital without any complications.

The results showed that abdominal compression during CPR can improve resuscitation outcomes in patients with cardiac arrest. Therefore, in order to use this technique, further research is recommended.

Limited resources and the large number of children in need of services in the pediatric intensive care unit (PICU) emphasize the need for effective allocation of resources for improving the outcome of at-risk patients. This study aimed to evaluate and compare the accuracy of PRISM4 and PIM3 systems in prediction of in-hospital mortality of patients admitted to PICU.

The present retrospective cross-sectional study was a diagnostic accuracy study performed on patients admitted to PICU of Qods Hospital, Qazvin, Iran, during one year. Scores of PRISM4 and PIM3 scales were calculated for each patient using the available calculators, and the outcome of patients regarding in-hospital mortality was recorded. Finally, screening performance characteristics of the mentioned scales in prediction of patients’ mortality were calculated and reported.

218 patients with the mean age of 40.68 ± 37.92 (2-160) months were studied (57.8% female). There was a significant direct correlation between PIM3 score and duration of stay in PICU (p < 0.0001; r = 0.259), need for inotropic drug administration (p = 0.001), and mortality rate (p = 0.001). In addition, area under the receiver operating characteristic (ROC) curve of PIM3 and PRISM4 in prediction of mortality among patients admitted to the PICU was 0.939 (95%CI: 0.880 – 0.998) and 0.660 (95%CI: 0.371 – 0.950), respectively (p = 0.001). Based on the findings, the best cut-off point for PIM3 scale in prediction of mortality was the score of 4 and it was estimated to be the core of 8 for PRISM4 scale. Sensitivity and specificity of PIM3 scale in prediction of mortality in the cut-off of 4 points were 100.00 (95% CI: 56.09- 100.00) and 81.51 (95% CI: 75.47- 86.38), respectively. These measures were 42.85 (95%CI: 11.80- 79.76) and 98.10 (95%CI: 94.89- 99.39) for PRISM4 model, which indicates the higher sensitivity of PIM3 system in this regard.

based on the results of the present study, the accuracy of PIM3 is significantly higher than PRISM4 in prediction of in-hospital mortality among patients admitted to the PICU. It seems that considering the 100% sensitivity of PIM3 in prediction of outcome, this model is a better tool for screening patients who are at risk for in-hospital mortality in order to pay more attention and allocate more resources to improve their outcome.

Vascular system injuries (VSIs) are one of the main causes of preventable mortality and morbidity of trauma patients. This study aimed to evaluate baseline characteristics, presenting signs, managements, and outcomes of patients presenting to emergency department (ED) with traumatic VSIs.

This retrospective cross-sectional study was conducted on patients with traumatic VSIs admitted to the ED of a referral tertiary trauma center, during one year. Using a pre-prepared checklist, demographics, pre-hospital care, type of VSIs, injury severity score (ISS), anatomical location of trauma, associated injuries, method of surgery, complications, and outcome were collected from patients’ profiles and reported.

One hundred and twelve patients with the mean age of 33.5 ± 14.7 (range = 8 - 80) years were studied (90.2% male). Most of the patients were categorized as mild or moderate in terms of their ISS. 90 (80.4%) patients had at least one soft sign and 99 (88.4%) patients had at least one hard sign. Isolated arterial injury was diagnosed in 90 (80.4%) patients, isolated venous injuries in 12 (10.7%) cases, and combined arteriovenous injuries in 10 (8.7%) patients. The most common associated injury was tendon rupture (63.4%) and nerve injuries were present in 60.7% of patients. 1 (0.9%) patient died, 6 (5.4%) patients went through amputation, and 3 (2.7%) patients were discharged against medical advice. The rest of the patients were discharged in perfect health. There was a significant correlation between trauma type (p = 0.001), upper and lower extremity trauma (p < 0.001), presence of distal ischemia and lack of pulse (p = 0.041), penetrating injury close to a major vessel (p = 0.006), type of injured vessels and arteries (p<0.001), injury to nerve (p = 0.011) and tendon (p = 0.007), presence of open fracture (p = 0.005), multiple trauma (p < 0.001), method of surgery (p < 0.001), and number of postoperative complications (p< 0.001) with poor outcome.

The findings showed that the majority of the studied patients were young males, most of whom were discharged in perfect situation. Those who presented with higher ISS, or were affected by blunt trauma or injury to lower limb arteries had worse outcome than the others.

Jejunal Dieulafoy’s lesion is difficult to diagnose due to its rarity, intermittent hemorrhage, and lesion site, which is largely inaccessible to conventional endoscopes. A 39-year-old man, who had no underlying disease, pre- sented to the emergency department (ED) with weakness, dizziness, and dry cough with a history of several rec- tal bleeding episodes in the last few years. Endoscopy was normal, and the colon was full of clots on colonoscopy, and no gross pathology was found. On computed tomography (CT) angiography, a hyperdensity was seen in the middle of the jejunum, possibly suggesting contrast extravasation. Due to decreased hemoglobin of the patient, and hemodynamic instability, the patient became a candidate for surgery. A palpable lesion in the Jejunum was touched that opened longitudinally, which revealed active arterial bleeding from the nipple-like lesion. This seg- ment was resected, and an anastomosis was performed. Histopathological examination of the small intestine confirmed a Dieulafoy’s lesion. It seems that, when upper endoscopy and colonoscopy fail to identify the cause of gastrointestinal bleeding, a Dieulafoy’s lesion should be included in the differential diagnoses.

Distal radius fractures (DRFs) are the most common orthopedic injuries in emergency depart- ment. This study aimed to compare the outcomes of conservative and surgical managements of DRFs in the aged population.

In this retrospective cohort study, ninety patients with unilateral DRFs were treated using either surgical or conservative (casting) approach and the management outcomes as well as complica- tions were compared between the two groups at 3 and 6-month follow-ups.

A total of 90 patients over 70 years old were included (45 treated with cast immobilization, and 45 using the surgical method). The mean age (p = 0.56) and gender (p = 0.85) was similar in the two groups. Except for quality of life in both follow-up times, patients treated with surgical methods showed better outcomes in other aspects, including 3-month (p = 0.042) and 6-month (p = 0.022) mean Disability of the Arm Shoulder Hand (DASH) score, 3-month (p = 0.013) and 6-month (p = 0.006) mean range of motion (ROM), and 3-month (p = 0.003) and 6-month (p = 0.033) pain in- tensity based on Visual Analogue Scale (VAS). A total of 70 (77.77%) adverse events were registered (33 (36.6%) in the casting group and 37 (41.1%) in the surgical group; p = 0.05). The rate of mal-union (p = 0.021) and superficial radial nerve injury (p = 0.026) were significantly lower in the surgical group.

The findings suggest that surgical approach for management of DRFs in elder cases has better clinical and functional outcomes than cast immobilization.

Despite the increasing vaccination coverage, COVID-19 is still a concern. With the limited health care capacity, early risk stratification is crucial to identify patients who should be prioritized for optimal man- agement. The present study investigates whether on-admission lactate dehydrogenase to albumin ratio (LAR) can be used to predict COVID-19 outcomes.

This retrospective cross-sectional study evaluated hos- pitalized COVID-19 patients in an academic referral center in Iran from May 2020 to October 2020. The area under the receiver operating characteristic (ROC) curve (AUC) was used to evaluate the value of LAR in the pre- diction of mortality. The Yuden index was used to find the optimal cut-off of LAR to distinguish severity. Patients were classified into three groups (LAR tertiles), first: LAR<101.46, second: 101.46 ≤ LAR< 148.78, and third group: LAR ≥ 148.78. Logistic regression analysis was used to identify the association between tertiles of LAR, as well as the relationship between each one-unit increase in LAR with mortality and ICU admission in three models, based on potential confounding variables.

A total of 477 patients were included. Among all patients, 100 patients (21%) died, and 121 patients (25.4%) were admitted to intensive care unit (ICU). In the third group, the risk of mortality and ICU admission increased 7.78 times (OR=7.78, CI: 3.95-15.26; p <0.0001) and 4.49 times (OR=4.49, CI: 2.01-9.04; p <0.0001), respectively, compared to the first group. The AUC of LAR for prediction of mortality was 0.768 (95% CI 0.69- 0.81). LAR ≥ 136, with the sensitivity and specificity of 72% (95%CI: 62.1-80.5) and 70% (95%CI: 64.9-74.4), respectively, was the optimal cut-off value for predicting mortality.

High LAR was associated with higher odds of COVID-19 mortality, ICU admission, and length of hospitalization. On-admission LAR levels might help health care workers identify critical patients early on.

Traffic accident injury is one of the global leading causes of death and an important public health problem. This study aimed to evaluate the predictive factors of return of spontaneous circulation (ROSC) at the scene in out-of-hospital cardiac arrest (OHCA) due to traffic accidents.

This retrospective cross- sectional study was conducted on cases of OHCA due to traffic accident, who were resuscitated at the scene by emergency medical services (EMS) in Bankok, Thiland, from January 1, 2020, to December 31, 2020 (1 year). Patients were divided into two groups of with and without ROSC and independent predictive factors of outcome were evaluated.

2400 OHCA cases met the inclusion criteria, among them, 1728 (72.0%) achieved ROSC at the scene. Facial injury (adjusted OR = 2.17, 95%CI: 1.37–3.44, p = 0.001); prehospital airway management using bag valve mask (adjusted OR = 1.69, 95%CI: 1.21–2.34, p = 0.002), and endotracheal tube (adjusted OR = 3.88, 95%CI: 1.84–8.18, p <0.001); and prehospital fluid therapy using normal saline (adjusted OR = 4.24, 95%CI: 3.12–5.77, p <0.001), ringer lactate (adjusted OR = 5.13, 95%CI: 3.47–7.61, p <0.001), and other solutions (adjusted OR = 5.25, 95%CI: 2.16–12.8, p <0.001) were independent predictive factors of ROSC at the scene in OHCA due to traffic accidents.

Based on the findings, the rate of ROSC at the scene for cases with OHCA due to traffic accidents, serviced by EMS was high, i.e., 72%, and three independent predictive factors of ROSC at the scene were facial injury, prehospital airway management, and prehospital fluid management.

 Coronavirus disease 2019 (COVID-19) has directly affected global healthcare, especially the front- line of healthcare provision, including emergency medical services (EMS). The present study aimed to compare EMS processing times and the number of acute stroke patients serviced by EMS before and during COVID-19 pandemic.

This is a retrospective observational review of Bangkok Surgico Medical Ambulance and Rescue Team (S.M.A.R.T.) EMS data from 2018 to 2021. The EMS processing times and the number of acute strokes were compared between pre-COVID-19 era ( January 1st, 2018, and December 31st, 2019) and during COVID-19 pandemic ( January 1st, 2020, and December 31st, 2021).

The number of stroke patients transported by EMS in one year, before and during COVID-19 pandemic was 128 and 150 cases, respectively (Change difference = 17.2%, 95% CI: 11.1–24.9). However, the average number of acute stroke patients per week was not significantly different (p = 0.386). The mean total EMS processing times before and during COVID-19 era were 25.59 ± 11.12 and 45.47 ± 14.61 minutes, respectively (mean difference of 19.88 (95% CI: 16.77–22.99) minutes; p < 0.001). The mean time from symptom onset to EMS arrival (p < 0.001), the mean call time (p < 0.001), the mean response time (p < 0.001), and the mean scene time (p < 0.001) were significantly higher during COVID-19 period. The mean transportation times for stroke patients was similar before and during COVID-19 pandemic (10.14 ± 6.28 and 9.41 ± 6.31 minutes, respectively; p = 0.338).

During COVID-19 pan- demic, the number of acute stroke patients serviced by EMS increased substantially, but there was no difference in the average number of patients per week. During the pandemic, EMS processing times markedly increased.

Since the emergence of COVID-19 pandemic, several articles have reported the co-existence of mucormycosis and COVID-19. This study aimed to distinguish the characteristics of COVID-19-associated rhinocerebral mucormycosis.

In this case series, 18 patients with COVID-19-associated rhinocerebral mucormycosis and unique clinical manifestations and outcomes, who were referred to Amiralam Hospital, a tertiary otorhinolaryngology center, Tehran, Iran, during the COVID-19 era, were reported.

Eighteen patients with the mean age of 62.0 ± 11.6 (range: 42 – 83) years were studied (50% males). The mean time in- terval between diagnosis of COVID-19 and first manifestation of mucormycosis was 15.5 ± 9.7 days. The most common presenting symptom was facial paresthesia (72.2%). Fifty percent of patients developed frozen eye. Palatal necrosis was seen in 7 cases (38.8%). Remarkably, facial paralysis was observed in 5 (27.7%) patients. Another notable clinical picture was cavernous sinus thrombosis, seen in 7 patients. We also had two cases of carotid artery occlusion. Three patients, unfortunately, passed away.

Rhinocerebral mucormycosis is one of the most important complications of COVID-19 patients, especially those with underlying diseases. It seems that the key to proper management of mucormycosis is early diagnosis and timely intervention, which could give a patient a chance to live more.

Hamman’s syndrome is an uncommon clinical entity characterized by an idiopathic spontaneous pneumome- diastinum as a result of a sudden increase in intra-alveolar pressure. It can be triggered by repeated vomiting or Kussmaul breathing associated with diabetic ketoacidosis (DKA). Careful attention to this particular condition is needed to avoid under-diagnosis and to provide optimal management. Herein, we report a case of an 18-year- old man complaining of chest discomfort and progressive weight loss, ultimately diagnosed with Hamman’s syndrome secondary to DKA. The patient’s symptoms disappeared after intravenous fluid and insulin admin- istration, while his pneumomediastinum resolved following conservative treatment. Our report highlights the importance of recognition of the links between pneumomediastinum as a cause of chest pain in patients with DKA.

Anal abscess is considered as a relatively common compilation in type 2 diabetes mellitus (T2DM) patients. This study aimed to determine the risk factors of recurrent anal abscess in T2DM patients.

In this 4-year retrospective cross-sectional study, T2DM patients hospitalized due to anal abscess in Shahid Modar- res Hospital, Tehran, Iran from December 2016 to December 2020 were studied. The independent risk factors of disease recurrence were determined among demographic factors, underlying diseases, diabetes-related factors, clinical factors, laboratory parameters, abscess type, and culture using multivariate stepwise logistic regression analysis.

203 patients were enrolled in the study. 58 (28.6%) patients had at least one re-occurrence of anal abscess during four years. The recurrent episodes had occurred more frequently in the first year after the initial treatment (55.2%). The prevalence of comorbidities such as metabolic syndrome, coronary artery dis- ease, chronic kidney disease, end stage renal disease, and peripheral vascular disease was significantly higher amongst patients with abscess recurrence. The patients with recurrent anal abscess had statically significant poor glycemic control (HbA1C > 7.5), decreased levels of Estimated Glomerular Filtration Rate (e-GFR), and higher C-reactive Protein (CRP) upon the first admission. Presence of metabolic syndrome, HbA1c > 7.5%, WBC > 11.0 ×109/L, and CRP > 5 mg/l were amongst the independent risk factors of recurrence. HbA1c > 7.5% was the greatest independent risk factor of anal abscess recurrence (OR=2.68, 95% CI: 1.37-5.25; p < 0.001). The area under the receiver operating characteristic (ROC) curve (AUC) of HbA1C, CRP, and WBC in predicting the risk of abscess recurrence was 0.81, 0.71, and 0.64, respectively.

Th recurrence rate of anal abscess in this series was 28.6 %. It seems that in T2DM patients with uncontrolled diabetes who have metabolic syndrome and increased CRP and WBC in their routine tests, the probability of anal abscess reoccurrence is high