Archives of Academic Emergency Medicine
Volume:11 Issue: 1, 2023

Thousands of people die due to trauma all over the world every day, which leaves adverse effects on families and the society. The main objective of this study was to identify the factors affecting the mortality of trauma patients using data mining techniques.

The present study includes six parts: data gathering, data preparation, target attributes specification, data balancing, evaluation criteria, and applied techniques. The techniques used in this research are all from the decision tree family. The output of these techniques are patterns extracted from the trauma patients dataset (National Trauma Registry of Iran). The dataset includes information on 25,986 trauma patients from all over the country. The techniques that were used include random forest, CHAID, and ID3.

Random forest performs better than the other two techniques in terms of accuracy. The ID3 technique performs better than the other two techniques in terms of the dead class. The random forest technique has performed better than other techniques in the living class. The rules with the most support, state that if the Injury Severity Score (ISS) is minor and vital signs are normal, 98% of people will survive. The second rule, in terms of support, states that if ISS is minor and vital signs are abnormal, 93% will survive. Also, by increasing the threshold of the patient's arrival time from 10 to 15 minutes, no noticeable difference was observed in the death rate of patients.

Transfer time of less than ten minutes in patietns whose ISS is minor, can increase the chance of survival. Impaired vital signs can decrease the chance of survival in traffic accidents. Also, if the ISS is minor in non-penetrating trauma, regardless of vital signs and if the victim is transported in less than ten minutes, the patient will survive with 99% certainty.

Identifying prognostic variables associated with the probability of recurrent paroxysmalsupraventricular tachycardia (PSVT) would aid decision-making regarding disposition of the patients. Thisstudy aims to develop a clinical scoring system to predict PSVT recurrence after adenosine administration inthe emergency department (ED).

This retrospective cross-sectional study was conducted on patientswho were referred to the emergency department of Ramathibodi Hospital, a university-affiliated super-tertiarycare hospital in Bangkok, Thailand, with diagnosis of PSVT during a 10-year period from 01 January 2010 un-til 31 December 2020. The cases were divided into recurrent and non-recurrent PSVT based on the responseto standard treatment and the independent predictors of recurrence were studied using multivariable logisticregression analysis.

264 patients were diagnosed with PSVT and successfully converted by adenosine.24 (9.1%) had recurrent PSVT, and 240 (90.9%) had no recurrent PSVT in the same ED visit. The risk of PSVTrecurrence in ED corresponded with the history of hypertension (p = 0.059), valvular heart disease (p = 0.052),heart rate≥100 (p = 0.012), and systolic blood pressure < 100 after electrocardiogram (ECG) converted to sinusrhythm (p = 0.022) and total dose of adenosine (p = 0.002). We developed a clinical prediction score of PSVT re-currence with an accuracy of 79.5%. A score of 0 (low risk), 1–2 (moderate risk), and > 2 (high risk) had a positivelikelihood ratio (LR+) of 0.31, 0.56 and 2.33, respectively.

It seems that, using the PSVT recurrencescore we could screen the high-risk patients for PSVT recurrence (score>2) who need to be observed for at least6-12 hours and receive cardiologist consultation in ED. In addition, the moderate and low-risk group (score 0-2)need to be observed for 1 hour and can be discharged from ED.

Provision of pre-hospital care by emergency medical services (EMS) requires paying attention toself-care and patient care against possible infections. The present study was conducted with the aim of deter-mining the level of self-care and patient care against COVID-19.

The present correlational, descrip-tive, analytical study was carried out on 301 EMS personnel in Iran. Data were collected using a demographicinformation form and questionnaires made by the researcher on the level of self-care and patient care againstCOVID-19.

The results showed that more than half of the participants (55%) were aged 27 to 34 years.The majority of the participants had an experience of participating in self-care (88.7%) and patient care (83.7%)training courses against COVID-19. The overall score of self-care was 55.96 ± 6.97 out of 72 and that of patientcare was 26.86± 3.39 out of 32, both of which revealed a favorable level. However, in some questions, the meanscore was lower than the optimal level. The lowest mean score among items related to self-care against COVID-19 was allocated to wearing protective clothing (1.77±1.19). Among items related to patient care against COVID-19, the lowest mean score was related to training the patient about hand hygine after touching contaminatedequipment (2.83±1.08 out of 4). There was a positive (r=0.491) and significant correlation between self-care andpatient care against COVID-19 (p=0.001) based on our findings.

Although the general level of self-care and patient care against COVID-19 was favorable, due to the undesired level of some domains, it seemsnecessary to implement corrective planning through periodical training and monitoring the performance of thepersonnel.

The Canadian C-spine Rule (CCR) and the National Emergency X-Radiography Utilization Study(NEXUS) are two criteria designed to rule-out clinically important traumatic cervical Spinal Cord Injury (SCI).In this systematic review and meta-analysis, we reviewed the articles comparing the performance of these twomodels.

Search was done in Medline, Embase, Scopus and Web of Science until June 2022. Observa-tional studies with direct comparison of CCR and NEXUS criteria in detection of clinically important cervical SCIwere included. Two independent reviewers screened the relevant articles and summarized the data. Certaintyof evidence was assessed based on QUADAS-2. Data were recorded as true positive, true negative, false posi-tive, and false negative. Then, using “diagma” package and applying weighted random effect model, area underthe receiver operating characteristic (ROC) curve (AUC), sensitivity, specificity, negative likelihood ratio, positivelikelihood ratio, and diagnostic odds ratio (DOR) were calculated with 95% confidence interval (95% CI).

We included 5 studies with direct comparison. Area under the ROC curve of NEXUS in screening of patients withclinically important cervical SCI was 0.708 (95% CI: 0.647 to 0.762). Pooled sensitivity and specificity of NEXUScriteria in screening of patients with clinically important cervical SCI were 0.899 (95% CI: 0.845 to 0.936) and0.398 (95% CI: 0.315 to 0.488). The positive and negative likelihood ratios of NEXUS were 1.494 (95% CI: 1.146 to1.949) and 0.254 (95% CI: 1.155 to 1.414), respectively. Diagnostic odds ratio of NEXUS was 5.894 (95% CI: 3.372to 10.305). Furthermore, area under the ROC curve of CCR in screening of clinically important cervical SCI was0.793 (95% CI: 0.657 to 0.884). Meta-analysis results showed that pooled sensitivity of CCR criteria in screeningof patients with clinically important cervical SCI was 0.987 (95% CI: 0.957 to 0.996) and specificity was 0.167 (95%CI: 0.073 to 0.336). The positive and negative likelihood ratios of CCR were 1.184 (95% CI: 0.837 to 1.675) and0.081 (95% CI: 0.021 to 0.308), respectively. Diagnostic odds ratio of CCR was 14.647 (95% CI: 3.678 to 58.336).

Based on studies, both CCR and NEXUS were sensitive rules that have the potential to reduce un-necessary imaging in cervical spine trauma patients. However, the low specificity and false-positive results ofboth of these tools indicate that many people will continue to undergo unnecessary imaging after screening ofcervical SCI using these tools. In this meta-analysis, CCR appeared to have better screening accuracy.

Induction of anesthesia for emergency procedures, without prior gastric preparation and incom-plete fasting, is associated with the risk of reflux of stomach contents and aspiration. This study aimed to eval-uate the effect of intravenous (IV ) metoclopramide administration on gastric emptying in opium users, candi-date for procedural sedation and analgesia (PSA).

In the present case-control study, opium-dependent(case) and non-dependent (control) patients in need of PSA were administered with 10 mg IV metoclopramideafter undergoing gastric ultrasonography for determination of its area and contents. Then, 30 minutes after theadministration of metoclopramide, the area and contents of the stomach were measured again and comparedwith the measures obtained before the intervention.

135 patients were evaluated in three groups of 45,including the case, control, and placebo groups. The three groups were similar regarding mean age (p = 0.068),sex (p = 0.067), weight (p = 0.596), height (p = 0.671), body mass index (BMI) (p = 0.877), duration of fasting (p =0.596), and type of gastric contents (p = 0.124). Mean antral cross-sectional area (CSA) of the study participantsin the case, control, and placebo groups before the administration of the drug was 8.49 ± 1.40, 8.31 ± 2.56, and6.56 ± 1.72 cm2, respectively. Mean gastric area in the case (p < 0.001) and control (p < 0.001) groups had signifi-cantly decreased after the intervention. Mean antral gastric grade of gastric contents in the case (p < 0.001) andcontrol (p < 0.001) groups had significantly decreased after the intervention.

It seems that meto-clopramide administration in opium users in need of PSA leads to a significant decrease in mean gastric areaand increases gastric emptying.

Introduction:

A comprehensive conclusion has yet to be made about the predictive value of serum N-terminalpro-brain natriuretic peptide (NT-proBNP) for stroke/systemic embolic events (SEE) in patients with atrial fib-rillation (AF). This study aims to review the evidence for evaluating the value of NT-proBNP in predicting the riskof stroke/SEE in patients with AF through a systematic review and meta-analysis.

Two independentreviewers screened all relevant studies that were retrieved from the database of Medline, Embase, Scopus, andWeb of Science until December 7th, 2021. The predictive value of NT-proBNP in the prediction of stroke/SEEwas recorded as hazard ratio (HR) and 95% confidence interval (95% CI).

Nine articles (38,093 patients,3.10% stroke/SEE) were included in our analysis. There was no publication bias in these studies (P=0.320). Ouranalysis showed that NT-proBNP can be a good predictor of stroke/SEE risk in AF patients, even at differentcut-off values (HR=1.76; 95% CI: 1.51, 2.02; P < 0.001). Subgroup analysis showed that diabetes could have apossible effect on the predictive value of NT-proBNP (meta-regression coefficient = 0.042; P = 0.037).Conclu-sion:Measurement of NT-proBNP during the first admission could be used to assess the short- or long-termrisk of stroke/SEE in patients with AF. Further studies are needed to evaluate the possible applicability of serumNT-proBNP measurement in the settings in which stroke is the sole outcome of the investigation.

Developing novel diagnostic and screening tools for exploring intracranial injuries following mi-nor head trauma is a necessity. This study aimed to evaluate the diagnostic value of serum glial fibrillary acidicprotein (GFAP) in detecting intracranial injuries following minor head trauma.

An extensive searchwas performed in Medline, Embase, Scopus, and Web of Science databases up to the end of April 2022. Hu-man observational studies were chosen, regardless of sex and ethnicity of their participants. Pediatrics studies,report of diagnostic value of GFAP combined with other biomarkers (without reporting the GFAP alone), arti-cles including patients with all trauma severity, defining minor head trauma without intracranial lesions as theoutcome of the study, not reporting sensitivity/specificity or any other values essential for computation of truepositive, true negative, false positive and false-negative, being performed in the prehospital setting, assessingthe prognostic value of GFAP, duplicated reports, preclinical studies, retracted articles, and review papers wereexcluded. The result was provided as pooled sensitivity, specificity, diagnostic score and diagnostic odds ratio,and area under the summary receiver operating characteristic (SROC) curve with a 95% confidence interval (95%CI).

Eventually, 11 related articles were introduced into the meta-analysis. The pooled analysis impliesthat the area under the SROC curve for serum GFAP level in minor traumatic brain injuries (TBI) was 0.75 (95%CI: 0.71 to 0.78). Sensitivity and specificity of this biomarker in below 100 pg/ml cut-off were 0.83 (95% CI: 0.78to 0.89) and 0.39 (95% CI: 0.24 to 0.53), respectively. The diagnostic score and diagnostic odds ratio of GFAP indetection of minor TBI were 1.13 (95% CI: 0.53 to 1.74) and 3.11 (95% CI: 1.69 to 5.72), respectively. The level ofevidence for the presented results were moderate.

The present study’s findings demonstrate thatserum GFAP can detect intracranial lesions in mild TBI patients. The optimum cut-off of GFAP in detection ofTBI was below 100 pg/ml. As a result, implementing serum GFAP may be beneficial in mild TBI diagnosis forpreventing unnecessary computed tomography (CT) scans and their related side effects.

ntroduction:Effective parenteral and enteral amino acid replacement is crucial for critically ill patients with alteredamino acid metabolism. This study aimed to assess the effects of l-citrulline supplementation on the clinical and labo-ratory outcomes in critically patients.

This was a double-blind placebo-controlled randomized clinical trial.82 critically ill patients who were expected to receive mechanical ventilation for more than 72 hours were selected. Thepatients were assigned to either a placebo or an intervention group. The patients in the placebo group received 10 gr ofmicrocrystalline cellulose and the ones in the intervention group were given l-citrulline daily for 7 days. Serum levelsof fasting blood sugar (FBS), lipid profile, hepatic enzymes, serum electrolytes, urea nitrogen, creatinine, and C-reactiveprotein (CRP) were evaluated before and after the intervention. Duration of invasive ventilation, intensive care unit(ICU) length of stay, ventilator-free days, and 28-day mortality rate were recorded and compared between groups.Re-sults:Eighty-two patients completed the trial. No statistically significant differences were observed between the twogroups in terms of age (p = 0.46), sex (p = 0.49), body mass index (BMI) (p = 0.41), Sequential Organ Failure Assessment(SOFA) Score (p = 0.08), Clinical Pulmonary Infection Score (CPIS) score (p = 0.76), Acute Physiology and Chronic HealthEvaluation (APACHE II) score (p = 0.58), risk factors (p = 0.13), ICU stay before randomization (p = 0.32), and reason ofadmission (p = 0.50) before the intervention. Citrulline group had a notable reduction in FBS (p = 0.04), total choles-terol (TC) (p = 0.02), low density lipoprotein (LDL-C) (p <0.001) and high-sensitivity CRP (hs-CRP) (p <0.001). Also, asignificant increase in lactate dehydrogenase (LDH) concentration (p <0.001) was observed in the intervention group atthe end of the trial. Total duration of invasive ventilation and the mean SOFA score on 7th day were significantly lowerin the citrulline group compared to the control group. Moreover, a significant increase in days alive and ventilator-freedays within 28 days after admission was found in the citrulline group at the end of the trial. Also, there were no signifi-cant differences between the groups in terms of mortality rate during intervention, serious adverse events, endotrachealintubation, the use of tracheotomy or non-invasive ventilation after extubation, length of ICU stay, ICU-free days at 28days, and CPIS and APACHE II scores. For mortality, in the citrulline group, there was two deaths compared to eightdeaths in the control group. This resulted in an absolute risk reduction (ARR) of 14.05% (95% CI: 0.39–27.71%) and anumber needed to treat (NNT) of 7.1 (95% CI: 3.6–29.5), regarding mortality.

The results of the presentstudy demonstrated the probable positive effects of citrulline supplementation on lipid profile, hs-CRP levels, durationof invasive ventilation, and SOFA score. Also, l-citrulline consumption may increase the probability of survival withoutmechanical ventilation.

Dizziness is a common scenario in the Emergency Departments (EDs). Among dizziness un-derlying causes, the posterior circulation stroke is especially relevant due to its mobimortality and concerningmisdiagnosis rates. Therefore, we conducted this study to assess dizziness evaluation and baseline characteris-tics of patients with PS in the ED.

We conducted a 3-year retrospective observational study on PS casesconfirmed by magnetic resonance imaging (MRI). Concretely, we analysed the demographic profile of these pa-tients, the initial PS clinical presentation, and diagnostic workup (with emphasis on dizziness evaluation) per-formed at the ED.

During the study period, 85 cases were registered. Risk factors for cardiovasculardisease were present in 85.5% and previous visits to the ED due to dizziness were recorded in 16.5%. The mainclinical presentation was dizziness, concretely as an acute vestibular syndrome (38.8%) with additional neuro-logical signs or symptoms (80%). Evaluation by the otolaryngologist on call was requested in less than 10% ofthe cases and included the HINTS protocol use with a sensitivity of 100% for central nervous system underlyingcausality. A brain CT study was always performed with a sensitivity of 27%. However, 96.47% of patients wereprimarily admitted to the Neurology hospitalization ward and MRI was always performed in a mean time of3.21 days confirming the diagnosis.

Dizziness is the most frequent symptom of PS. Patients usuallypresent an AVS (associated with additional N-SS or not) and HINTS bedside examination is the most adequateprotocol to differentiate a PS from other AVS causes until the diagnostic confirmation via MRI. Interestingly,mainly otolaryngologists seem to use HINTS. However, the use of CT is widespread despite its poor value.

To identify the strengths and weaknesses of emergency medicine residency curriculum in Iran,and to benefit from the experiences of successful universities, comparative studies are crucial. This study com-pared the components of the national curriculum of emergency medicine in the United States, Canada, the Eu-ropean Union, Australia, and Saudi Arabia with Iran.

Data for this research was collected by searchingthe websites of different universities and also contacting them for requesting curriculums. The leading countriesin emergency medicine and one of the countries in the Middle East region (Saudi Arabia) along with the WorldFederation of Emergency Medicine were selected as the sample. The model used in this field is a range modelthat identifies four stages of description, interpretation, proximity, and comparison in comparative studies.

In the curriculum of the United States, Canada, the European Union, Australia, and Saudi Arabia, therewere lots of similarities in expressing the general characteristics of the curriculum, mission elements, vision, val-ues, and beliefs of the discipline, educational strategy, techniques, expected competencies, rotation programs,and evaluation method, which were also similar to the Iranian curriculum. However, the duration of residencyfor emergency medicine in Iran is three years, which is shorter than other countries. As expected, the numberand duration of rotations are less than other countries. Also, the process of entering into this field is differentin Iran and is based on an exam for entrance, while most other countries use self-requested residency program.

Considering the results of comparing the Iranian curriculum with the curriculums of the UnitedStates, Canada, the European Union, Australia, and Saudi Arabia, it seems that Iran’s program is comprehen-sive and complete; but, a reappraisal of the course duration and entering options are necessary to eliminate orimprove the inadequacies.

Acute COVID-19 infection is associated with increased adverse clinical outcomes in patients with acutecoronary syndromes (ACS). Given that some studies suggested improved pulmonary function with Ticagrelor, this clin-ical trial aimed to compare the effects of Ticagrelor versus Clopidogrel on the short-term outcomes of these patients.

In this multicenter clinical trial, 180 COVID-19 patients with ACS who underwent urgent percutaneous coro-nary intervention (PCI) were randomized to receive Ticagrelor (180mg loading dose followed by 90mg twice daily, n=90)or Clopidogrel (600mg loading dose with 75mg daily, n=90), and then followed for one month after their procedure. Theprimary composite endpoint was a combination of all-cause mortality, myocardial infarction, and early stent throm-bosis within the first month after stent implantation.

After thirty days of follow-up, the primary compositeendpoint was non-significantly lower in the Ticagrelor compared to the Clopidogrel group (18.5% vs 23.5% respectively,p = 0.254). Based on the time-to-event analysis, the mean survival rate was 26.8 ±7.7 and 24.7 ±9.9 days, respectively, forthe Ticagrelor and the Clopidogrel arms (Log-rank p = 0.275). Secondary endpoints were similar in the two trial arms,except for the mean oxygen saturation, which was higher in the Ticagrelor group (95.28 ±2.68 % vs. 94.15 ± 3.55 %, re-spectively; p = 0.021).

Among COVID-19 patients with concomitant ACS, who were treated with urgent PCI,the composite outcome of death, myocardial infarction, and early stent thrombosis was not different between Ticagrelorand Clopidogrel groups. However, administration of Ticagrelor was associated with a slight but statistically significantincrease in oxygen saturation compared to Clopidogrel, but this difference wasn’t clinically important.

It could be beneficial to accelerate the hospitalization of patients with the identified clinical risk factorsof intensive care unit (ICU) admission, in order to control and reduce COVID-19-related mortality. This study aimedto determine the clinical risk factors associated with ICU hospitalization of COVID-19 patients.

The currentresearch was a cross-sectional study. The study recruited 7182 patients who had positive PCR tests between February 23,2020, and September 7, 2021 and were admitted to Afzalipour Hospital in Kerman, Iran, for at least 24 hours. Their demo-graphic characteristics, underlying diseases, and clinical parameters were collected. In order to analyze the relationshipbetween the studied variables and ICU admission, multiple logistic regression model, classification tree, and supportvector machine were used.

It was found that 14.7 percent (1056 patients) of the study participants were admit-ted to ICU. The patients’ average age was 51.25±21 years, and 52.8% of them were male. In the study, some factors suchas decreasing oxygen saturation level (OR=0.954, 95%CI: 0.944-0.964), age (OR=1.007, 95%CI: 1.004-1.011), respiratorydistress (OR=1.658, 95%CI: 1.410-1.951), reduced level of consciousness (OR=2.487, 95%CI: 1.721-3.596), hypertension(OR=1.249, 95%CI: 1.042-1.496), chronic pulmonary disease (OR=1.250, 95%CI: 1.006-1.554), heart diseases (OR=1.250,95%CI: 1.009-1.548), chronic kidney disease (OR=1.515, 95%CI: 1.111-2.066), cancer (OR=1.682, 95%CI: 1.130-2.505),seizures (OR=3.428, 95%CI: 1.615-7.274), and gender (OR=1.179, 95%CI: 1.028-1.352) were found to significantly affectICU admissions.

As evidenced by the obtained results, blood oxygen saturation level, the patient’s age, andtheir level of consciousness are crucial for ICU admission.

A decision-making guideline on when to intubate an older person based on predictors of intubationoutcome would be extremely beneficial. This study aimed to identify the associated factors that could predict the out-comes of endotracheal intubation among older adults in the Emergency Department (ED).

In this retrospec-tive cross-sectional study, patients aged≥65 years intubated at the ED of University of Malaya Medical Centre, KualaLumpur, Malaysia, from 2015 to 2019 were studied. The association between age, gender, place of inhabitation, Identifi-cation of Seniors at Risk (ISAR) score for frailty, Charlson Comorbidity Index (CCI), Acute Physiology and Chronic HealthEvaluation-II (APACHE-II) score, indication for intubation, and diagnosis on admission with in-hospital mortality (pri-mary outcome) and duration of ventilation, and length of stay (secondary outcomes) were evaluated using univariateanalysis and Cox’s regression survival analysis.

889 cases aged 65 years and above were studied (61.5% male).The rate of in-hospital mortality was 71.4%. There was a significant association between age (p < 0.001), nursing homeresidency (p = 0.008), CCI≥5 (p = 0.001), APACHE-II (p < 0.001), pre-intubation Glasgow Coma Scale (GCS) (p < 0.001),cardiac arrest as indication of intubation (p < 0.001), diagnosis on admission (p < 0.001), length of stay (p < 0.001), andlength of ventilation (p = 0.003) and in-hospital mortality. Age≥85 years (HR= 1.270; 95%CI=1.074 to 1.502) and 75 to84 years (HR=1.642; 95%CI=1.167 to 2.076), cardiac arrest as indication of intubation (HR: 1.882; 95% CI: 1.554 – 2.279),and APACHE-II scores 25 – 34 (HR: 1.423; 95% CI: 1.171 - 1.730) and≥35 (HR: 1.789; 95%CI: 1.418 - 2.256) were amongstthe independent predictive factors of in-hospital mortality.

Nearly three out of four individuals aged≥65years intubated at the ED died during the same admission. Older age, cardiac arrest as indication of intubation, andAPACHE-II score were independent predictors of in-hospital mortality.

Introduction:

Although the lungs are the main target of coronavirus disease (COVID-19), infection is also associatedwith a high rate of extra-pulmonary complications. This study aimed to evaluate the one-year incidence of long-termCOVID-19 complications among the nursing staff.

This study is a retrospective longitudinal study. All nursingstaff working in public hospitals affiliated with Shahid Beheshti University of Medical Sciences who had been affectedwith COVID-19 were included in the study via convenience sampling method. The patients were recruited from 20thFebruary 2020 to 20th March 2021.

1762 nursing staff with a mean age of 35.08 ± 8.02 (Range: 22-66) years werestudied (73.5% female). The results showed that among those who reported at least one type of complication, the dura-tion of complications was significantly longer than 1 week and the median was 8 weeks. The findings demonstrated thatcomplications occurred in 65% of infected females. For men, this rate was 62.3%. Generalized pain, anxiety disorders,and skin complications were among the complications that were significantly more common in women than in men.Additionally, the incidence of anosmia, ageusia, anxiety disorders, and skin complications was significantly higher inyounger people than in older people. The comparison of complications revealed that nurses were significantly morelikely than other occupations to experience respiratory complications, anosmia and ageusia, generalized pain, and skincomplications and that outpatients experienced significantly more complications than hospitalized patients.

Conclusion:

The one-year cumulative incidence of long-term complications in nursing staff with COVID-19 was 64.3%. Themost common complications were respiratory complications, generalized pain, anosmia, and ageusia, respectively.

The lingual abscess is rare due to several protective mechanisms against infection in this location. Concretely, the ab-scess in the base of the tongue (posterior lingual abscess) is even more exceptional. Its prompt detection is crucial toavoid potentially fatal airway complications. To familiarize physicians with this condition, we report 2 cases of posteriorlingual abscess. Both were referred to our emergency department due to minor oropharyngeal complaints. Finally, bothwere diagnosed and required surgical drainage. The clinical evolution was successful: both were discharged in less than72 hours and follow-up one week later confirmed clinical recovery.

Monkeypox is a zoonotic disease caused by a double-stranded DNA virus belonging to the genusOrthopoxvirus. Despitebeing endemic in Central and West Africa, the disease has received relatively little research attention until recent times.As the Coronavirus disease 2019 (COVID-19) pandemic continues to affect the world, the rising number of monkey-pox cases in non-endemic countries has further stoked global public health concerns about another pandemic. Unlikeprevious outbreaks outside Africa, most patients in the present outbreak had no history of travel to the endemic re-gions. The overwhelming majority of patients were initially identified amongst homosexual men, who had attendedlarge gatherings. Mutations in the coding regions of the viral genome may have resulted in fitness adaptation, enhance-ment of immune evasion mechanisms, and more efficient transmissibility of the 2022 monkeypox virus. Multiple factorssuch as diminished cross-protective herd immunity (cessation of smallpox vaccination), deforestation, civil war, refugeedisplacement, farming, enhanced global interconnectedness, and even climate change may facilitate the unexpectedemergence of the disease. In light of the increasing number of cases reported in the present outbreak, healthcare pro-fessionals should update their knowledge about monkeypox disease, including its diagnosis, prevention, and clinicalmanagement. Herein, we provide an overview of monkeypox, with a focus on the 2022 outbreak, to serve as a primer forclinical practitioners who may encounter the disease in their practice.

Neurologic disorders are common reasons for emergency consultations. Most neurologic disorders seenin the emergency department (ED) are life-threatening and require urgent treatment. The goal of this study is to investi-gate the pattern of neurological disorders among patients evaluated in the ED.

This is a cross-sectional studyconducted in the ED of Mogadishu Somali Turkish Training and Research Hospital, from July 2021 to February 2022. Theclinical and epidemiological characteristics of adult patients with neurologic manifestations in the ED were evaluated.Age, gender, distribution of neurological disease manifestations, neurological examination findings, and neurologicaldiagnoses made by consultant neurologists were assessed.

During the study period, 321 patients were assessed(3.7% of all ED admissions). The majority of the patients in the study were above 50 years of age (62.6% male). Hyper-tension was the most common comorbidity among these patients with 122 (38%) cases, followed by diabetes mellituswith 65 (20.2%), and heart diseases with 26 (8.1%) cases. The main reasons for neurology consultations were alteredmental status with 141 (44%) cases, motor weakness with 102 (31.8%), seizures with 33 (10%), headache with 17 (5.3%),and vertigo with 9 (2.8%) cases. 196 (61%) had hemiplegia, 60 (18.7%) had consciousness impairment, and 38 (11.8%)had normal neurological examination. The most frequent neurological diagnoses were ischemic strokes with 125 (39%)cases, hemorrhagic strokes with 65 (20.2%), epileptic seizures with 28 (8.7%), and metabolic encephalopathies with 13(4%) cases. The median duration of the neurology consultations was 20 minutes. 251 (78%) of the patients were ad-mitted to the hospital, while 70 (22%) were discharged from the emergency department. After neurology consultation,the neurology department made the most admissions with 226 (90%) cases, while 25 (10%) were admitted by other de-partments. Of those admitted, 186 (74.2%) were admitted to the neurology ward, and 65 (25.8%) were admitted to theintensive care unit.

In our study, neurologic emergencies accounted for 3.7% of all emergency admissions.Stroke, epileptic seizures, cerebral venous thrombosis, encephalopathies, and acute spinal cord diseases were the mostcommon neurological disorders. The admission rate was very high following neurologic assessment by neurologists.

Sepsis is a life-threatening and common cause of Emergency department (ED) referrals. Out-of-hourstaffing is limited in ED, which may potentially affect fluid administration. This study aimed to investigate fluid volumevariation in out-of-hour vs. routine-hour admissions.

The present study is a post-hoc analysis of a multicen-tre, prospective, observational study investigating fluid administration in ED patients with suspected infection, fromJan 20th - March 2nd, 2020. Patient groups were “routine-hours” (RH): weekdays 07:00-18:59 or “out-of-hours” (OOH):weekdays 19:00-06:59 or Friday 19:00-Monday 06:59. Primary outcome was 24-hour total fluid volumes (oral + intra-venous (IV )). Secondary outcomes were total fluids 0-6 hours, oral fluids 0-6 and 0-24 hours, and IV fluids 0-6 and 0-24hours. Linear regression adjusted for site and illness severity was used.

734 patients had suspected infection;449 were admitted during RH and 287 during OOH. Mean (95% CI) total 24-hour fluid volumes were equal in simple in-fection and sepsis regardless of admission time: Simple infection RH: 3640 (3410 - 3871) ml and OOH: 3681 (3451 - 3913)ml. Sepsis RH: 3671 (3443;3898) ml and OOH: 3896 (3542;4250) ml. Oral fluids 0-6h were reduced in simple infectionand sepsis among OOH vs. RH. Sepsis patients received more 0-6-hour IV fluid when admitted OOH vs. RH. There wereno associations between admission time and 0-24-hour oral or IV volumes in simple infection or sepsis.

Admission time did not have an association with 24-hour total fluid volumes. Sepsis patients admitted during OOHreceived more 0-6-hour IV fluids than RH patients, and simple infection and sepsis patients received less oral fluid in0-6 hours if admitted during OOH vs. RH.

One type of the developed COVID-19 vaccines that received emergency permission and was approved bythe food and drug administration (FDA) is the mRNA-based vaccine. The aim of this study is to gather information on theJordanian population’s experience with the vaccine’s side effects.

The study objectives were addressed througha cross-sectional study, which collected information regarding the short-term side effects experienced by the vaccinatedindividuals within one month following the injection of an mRNA-based COVID-19 vaccine. Data collection was carriedout in August 2021. Participants were invited to take part in a self-administered web-based survey created using GoogleForms.

Among the study’s participants (n= 533), about 56% experienced side effects after the first dose of themRNA-based COVID-19 vaccine. The most commonly reported side effects after the first dose were sore arm at theinjection site (91.6%), and fatigue (83.06%). The female gender was significantly associated with experiencing fatigue,discomfort, chills, and hair loss. Being over 30 years old was significantly associated with experiencing cough. Being asmoker was significantly associated with experiencing shortness of breath and gastrointestinal symptoms.

The mRNA-based COVID-19 vaccine side effects were common, yet, mild, local, and self-limited. The local pain at theinjection site was the most commonly reported side effect. Hopefully, the study’s findings will aid in lowering resistanceto vaccination.

Just as failure to diagnose an acute ischemic stroke (AIS) in a timely manner affects the patient’s out-come; an inaccurate and misplaced impression of the AIS diagnosis is not without its drawbacks. Here, we introduce atwo-stage clinical tool to aid in the screening of AIS cases in need of imaging in the emergency department (ED).Meth-ods:This was a multicenter cross-sectional study, in which suspected AIS patients who underwent a brain magneticresonance imaging (MRI) were included. The 18 variables from nine existing AIS screening tools were extracted anda two-stage screening tool was developed based on expert opinion (stage-one or rule in stage) and multivariate logis-tic regression analysis (stage-two or rule out stage). Then, the screening performance characteristics of the two-stagemode was evaluated.

Data from 803 patients with suspected AIS were analyzed. Among them, 57.4% were male,and their overall mean age was 66.9 ± 13.9 years. There were 561 (69.9%) cases with a final confirmed diagnosis of AIS.The total sensitivity and specificity of the two-stage screening model were 99.11% (95% CI: 98.33 to 99.89) and 35.95%(95% CI: 29.90 to 42.0), respectively. Also, the positive and negative predictive values of two-stage screening model were78.20% (95% CI: 75.17 to 81.24) and 94.57% (95% CI: 89.93 to 81.24), respectively. The area under the receiver operatingcharacteristic (ROC) curve of the two-stage screening model for AIS was 67.53% (95% CI: 64.48 to 70.58). Overall, usingthe two-stage screening model presented in this study, more than 11% of suspected AIS patients were not referred forMRI, and the error of this model is about 5%.

Here, we proposed a 2-step model for approaching suspectedAIS patients in ED for an attempt to safely exclude patients with the least probability of having an AIS as a diagnosis.However, further surveys are required to assess its accuracy and it may even need some modifications.

The diagnosis of intussusception can be challenging in children due to the fact that the findings of clinicalevaluations are nonspecific and most of the patients present with unclear history. Therefore, in this systematic reviewand meta-analysis, we aimed to investigate the diagnostic accuracy of ultrasonography for detection of intussusceptionand also compare the efficacy of point-of-care ultrasound (POCUS) with radiologist-performed ultrasound (RADUS).

Two independent reviewers systematically searched different online electronic databases including MED-LINE, Scopus, Web of Science, Google Scholar, Embase, and Cochrane from inception to December 1, 2022 to identifypublished papers reporting accuracy of ultrasonography for diagnosis of intussusception. The quality assessment ofthe included studies was investigated using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 tool.

A total of 1446 records were retrieved in the initial search of databases. After screening the titles, a total of344 studies were retrieved for the detailed assessment of full-text. Finally, 37 studies were included in qualitative andquantitative analysis. The pooled sensitivity and specificity of ultrasonography for diagnosis of intussusception were0.96 (95% CI: 0.95-0.97) and 0.97 (95% CI: 0.97-0.98), respectively. The pooled positive likelihood ratio (PLR) and nega-tive likelihood ratio (NLR) were 24.57 (95% CI: 8.26-73.03) and 0.05 (95% CI: 0.04-0.08), respectively. The area under thehierarchical summary receiver operating characteristic (HSROC) curve was 0.989. Mete-regression showed that there isno significant difference between diagnostic performance of POCUS and RADUS (p = 0.06 and rDOR (diagnostic oddsratio) = 4.38 (95% CI: 0.92-20.89)).

This meta-analysis shows that ultrasonography has excellent sensitiv-ity, specificity, and accuracy for diagnosis of intussusception in pediatric patients. Moreover, we found that diagnosticperformance of POCUS is similar to that of RADUS for diagnosis of intussusception.

In recent years, studies have provided evidence on the prognostic value of the leuko-glycemic index (LGI)in acute myocardial infarction (MI), but there is a lack of consensus. In addition, various reported cut-offs for LGI haveraised concern regarding its clinical applicability. So, to conclude, through this systematic review and meta-analysis,we aimed to investigate all available evidence on the prognostic value of LGI in acute MI.

Two independentresearchers summarized records available in the four main databases of Medline (Via PubMed), Embase, Scopus, andWeb of Science until 15 Sep 2022. Articles studying the prognostic value of the LGI in acute MI were included. Finally,sensitivity, specificity, prognostic odds ratio, and the area under the curve (AUC) for LGI were analyzed and reported.

Eleven articles were included (3701 patients, 72.1% male). Based on the analyses, AUC, sensitivity, and speci-ficity for LGI in prediction of mortality following acute MI were 0.77 (95% CI: 0.73 to 0.80), 0.75 (95% CI: 0.62 to 0.84),and 0.66 (95% CI: 0.51 to 0.78), respectively. Positive and negative post-test probability of LGI in prediction of mortalitywere 21% and 5%, respectively. AUC, sensitivity, and specificity for LGI in prediction of major cardiac complicationsafter acute MI were 0.81 (95% CI: 0.77 to 0.84), 0.84 (95% CI: 0.70 to 0.92), and 0.64 (95% CI: 0.49 to 0.84), respectively.Also, the Positive and negative post-test probability of LGI in this regard were 59% and 13%, respectively.

Although the results demonstrated that the LGI could predict mortality and acute cardiac complication after MI, the lowpost-test probability of LGI in risk stratification of patients raises questions regarding its applicability. Nevertheless, asmost of the available studies have been conducted in the Latino/Hispanic population, further evidence is warranted togeneralize the validity of this tool to other racial populations

Vertebral artery dissection (VAD) is a rare, but life-threatening condition. Compared to the general popu-lation, pregnant and postpartum women are more likely to develop VAD. Spontaneous arterial dissections have an am-biguous pathophysiology and may be difficult to manage. This study aimed to pool and analyze the data of publishedcases in this regard.

We conducted a literature search on February 24, 2022, using MeSH terms of interestin PubMed, Google Scholar, Ovid, Web of Science, and Scopus databases to find studies on VAD following childbirth.

A total of 28 studies were included in this review based on a database search. In the studies, 44 postpartumVAD (PPVAD) patients with a mean age of 34.26 ± 3.5 years were included. It took an average of 24.37± 13.7 days fromdelivery to dissection. 64% of the patients had developed unilateral dissection and 36% had developed bilateral dissec-tion; 70% reported full recovery, and 9% did not achieve full recovery. The most common symptoms were headaches(89%), neck pain (64%), and hypertension (52%). The most common methods of diagnosis were magnetic resonanceimaging (MRI) (64%) and computed tomography (CT) angiography (CTA) scan (66%). Only 8 (18%) cases reported theuse of electrocardiography (ECG). The recorded outcomes of the patients with unilateral and bilateral postpartum VADshowed no statistical difference. Most of the included studies recommend early suspension and management for a bet-ter prognosis and prevention of complications.

PPVAD is a severe medical condition but most cases werefully recovered after an early and proper antithrombotic plan for each case scenario.

The Corticosteroid Randomization After Significant Head injury (CRASH) and the International Missionfor Prognosis and Analysis of Clinical Trials (IMPACT) are two prognostic models frequently used in predicting the out-come of patients with traumatic brain injury. There are ongoing debates about which of the two models has a betterprognostic value. This study aims to compare the CRASH and IMPACT in predicting mortality and unfavorable outcomeof patients with traumatic brain injury.

We performed a literature search using Medline (via PubMed), Embase,Scopus, and Web of Science databases until August 17, 2022. After two independent researchers screened the articles,we included all the original articles comparing the prognostic value of IMPACT and CRASH models in patients with trau-matic brain injury. The outcomes evaluated were mortality and unfavorable outcome. The data of the included articleswere analyzed using STATA 17.0 statistical program, and we reported an odds ratio (OR) with a 95% confidence interval(95% CI) for comparison.

We included the data from 16 studies. The analysis showed that the areas under thecurve of the IMPACT core model and CRASH basic model do not differ in predicting the mortality of patients (OR=0.99;p=0.905) and their six-month unfavorable outcome (OR=1.01; p=0.719). Additionally, the CRASH CT model showed nodifference from the IMPACT extended (OR=0.98; p=0.507) and IMPACT Lab (OR=1.00; p=0.298) models in predicting themortality of patients with traumatic brain injury. We also observed similar findings in the six-month unfavorable out-come, showing that the CRASH CT model does not differ from the IMPACT extended (OR=1.00; p=0.990) and IMPACTLab (OR=1.00; p=0.570) in predicting the unfavorable outcome in head trauma patients.

Low to very lowlevel of evidence shows that IMPACT and CRASH models have similar values in predicting mortality and unfavorableoutcome in patients with traumatic brain injury. Since the discriminative power of the IMPACT Core and CRASH basicmodels is not different from the IMPACT extended, IMPACT Lab, and CRASH CT models, it may be possible to only usethe core and basic models in examining the prognosis of patients with traumatic injuries to the brain.

Introduction:

Several clinical manifestations have been discovered for COVID-19 since the emergence of SARS-CoV-2,which can be classified into early, medium, and long-term complications. However, late complications can be presentafter recovery from acute COVID-19 illness. The present study aims to comprehensively review the available evidenceof late complications related to COVID-19.

A search was conducted, using keywords, through electronicdatabases, which included Scopus, Web of Science, PubMed, and Embase up to August 29, 2022. Study selection wasperformed according to a strict inclusion and exclusion criteria. The Preferred Reporting Items for Systematic reviewsand Meta-Analyses (PRISMA) checklist was followed, and studies were appraised using the National Institute of Health(NIH) quality assessment and risk of bias tool.

In total, 50 studies were included, and nine distinct COVID-19late complication categories were identified. A review of these studies revealed that neurologic and psychiatric (n=41),respiratory (n=27), musculoskeletal and rheumatologic (n=22), cardiovascular (n=9), and hepatic and gastrointestinal(n=6) complications were the most prevalent complications of long COVID-19.

Almost all human bodysystems are affected by late complications of COVID-19 with different severity and prevalence. Fatigue and some otherneuropsychiatric symptoms are the most common late complications among long COVID-19 patients. Respiratorysymptoms including dyspnea (during exercise), cough, and chest tightness were the next most prevalent long-termcomplications of COVID-19. Since these complications are persistent and late, being aware of the signs and symptomsis essential for the healthcare providers and patients.

Altered immune responses, in particular neutrophil changes, are perceived to play a key role in immuneresponses to trauma. This study aimed to evaluate the association of neutrophil changes with patients’ survival in severetrauma cases.

The current retrospective cohort study was conducted using data from patients admitted in theintensive care unit (ICU) of a trauma center in Shiraz, Iran, between 2016 and 2021. Patients were divided into threegroups (i.e., normal, neutropenia, and neutrophilia) based on neutrophil count at the time of ICU admission, and theassociation of neutrophil count with in-hospital mortality was analyzed.

2176 patients with the mean age of37.90 ± 18.57 years were evaluated (84.04% male). The median trauma severity based on injury severity score (ISS) in thisseries was 9 (4 -17). Patients were divided in to three groups of neutrophilia (n = 1805), normal (n = 357), and neutropenia(n = 14). There were not any significant differences between groups regarding age distribution (p = 0.634), gender (p =0.544), and trauma severity (p = 0.197). The median survival times for the normal, neutropenia, and neutrophilia groupswere 49 (IQR: 33 -47) days, 51 (IQR: 8- 51) days, and 38 (IQR: 26 - 52) days, respectively (p = 0.346). The log-rank testshowed a statistically significant difference between the three groups adjustment for ISS (p≤0.001). For each unitincrease in ISS, the hazard ratio increased by 2%. In ISS 9-17, the hazard ratio increased by 11% compared to ISS<4. Also,in ISS>17, the hazard ratio increased by 76% compared to ISS<4 in ICU-hospitalized patients.

In general,the findings of the present study showed that the survival rate of patients in the normal group after ISS adjustment washigher than the other two groups. Also, the Cox model showed that the mortality risk ratio in the neutropenia group was15 times higher than the normal group.

In order to improve the efficacy of requesting knee radiography and reduce unnecessary radiation expo-sure, some clinical decision rules have been proposed for the assessment of knee injuries. Among them, the Ottawa KneeRule (OKR) was considered as one of the best guidelines with several validation studies. Therefore, in this meta-analysis,we aimed to investigate the accuracy of OKR for diagnosis of fracture in patients presenting with knee trauma.

A systematic search was conducted in PubMed, Web of Science, Scopus, Google Scholar, and EBSCO from inception toSeptember 2022. Quality assessment of the included studies was performed using QUADAS-2 tool. Diagnostic accuracyparameters were analyzed using random-effects model. Statistical analysis was performed using Meta-Disc and Statasoftwares.

The meta-analysis of the 18 included studies (6702 patients) showed that the pooled sensitivity andspecificity of OKR for diagnosis of fractures were 0.98 (95% CI: 0.96-0.99) and 0.43 (95% CI: 0.42-0.45), respectively. Thepooled positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 1.56 (95% CI: 1.39-1.75) and 0.12 (95%CI: 0.05-0.26), respectively. The area under curve (AUC) of the hierarchical summary receiver operating characteristic(HSROC) curve was 0.54.

This meta-analysis indicates that OKR has a high diagnostic performance fordiagnosis of fracture, with a pooled sensitivity of 98% and a pooled specificity of 43%. These results propose potentialeffects of OKR on reduction of unnecessary radiography, time spent in emergency departments, and direct and indirectcosts, which should be confirmed using high-quality studies in the future.

Ventilator-associated pneumonia (VAP) is one of the most common nosocomial infections affecting one-third of patients with mechanical ventilation. This study aimed to synthesize available evidence regarding the effect oftreatment with povidone-iodine (PI) among adult patients admitted to intensive care units (ICUs) for the prevention ofVAP.

An extensive search was conducted in online databases, including PubMed, Web of Science and Scopus,from the earliest records until January 1, 2023. STATA software v14 was used for statistical analysis. Publication biaswas assessed via funnel plot, Begg’s and Egger’s tests. A P-value less than 0.1 was considered statistically significant forpublication bias value.

Four studies were included in the meta-analysis. Three studies showed rhat PI decreasedVAP compared to the placebo group, but it was not statistically significant (RR: 0.61, 95%CI: 0.25 to 1.47, Z=1.10, P=0.27,I2:71.5%). One study compared the effect of PI with chlorhexidine on the rate of VAP, the difference between whichwas not statistically significant (RR: 1.50, 95%CI: 0.46 to 4.87, Z=0.67, P=0.50, I2:0). Two studies demonstrated that theuse of PI intervention compared to placebo decreased the average length of stay in ICU; however, it was not statisticallysignificant (WMD: -0.35, 95%CI:-3.90 to 3.20, Z=0.19, P=0.85, I2:0). Also, three studies showed that using PI had almost noeffect on mortality rate compared to placebo (RR: 1.05, 95%CI: 0.66 to 1.53, Z=0.8, P=0.27, I2:29.0%).

Morerigorously designed randomized clinical trials and further evidence are required to make a better decision/comparisonabout using PI as a suitable choice for preventing VAP among adult patients admitted to the ICU.

The disposition decision is a great challenge for clinicians in managing patients with chronic obstructivepulmonary disease (COPD) exacerbation. This study aimed to evaluate the accuracy of Ottawa COPD Risk Scale (OCRS)in predicting the short-term adverse events in the mentioned patients.

This prospective diagnostic accuracystudy was conducted on COPD exacerbation cases who were referred to the emergency department (ED). Patients werefollowed up for 30 consecutive days for adverse events including the need for intubation, non-invasive ventilation, my-ocardial infarction, readmission, and death from any cause, and finally the accuracy of OCRS in predicting the outcomewas evaluated.

362 patients with the mean age of 65.55 ± 10.65 (6- 95) years were evaluated (58.0% male).Among the patients, 164 (45.3%) cases were discharged from ED, and 198 (54.7%) were admitted to the hospital. 136(37.6%) cases experienced at least one of the studied short-term adverse events. The mean OCSD score of this series was1.96 ± 2.39 (0 – 10). The area under the curve of OCRS in predicting the outcome of COPD patients was 0.814 (95%CI:0.766 – 0.862). The best cut-off point of the scale in predicting the outcome was 1.5. The sensitivity and specificity ofthe scale were 75.75% (95%CI: 69.6% – 81.42%) and 89.63% (95%CI: 83.67% – 93.66%), respectively. By employing thisthreshold, 48 (13.25%) cases would have unnecessary hospitalization, and 17 (0.04%) would be discharged incorrectly.

The OCRS has acceptable level of prediction accuracy in predicting the short-term adverse event of COPDpatients. The use of this scoring in the routine practice of ED clinicians can lead to a reduction in unnecessary admis-sions and unsafe discharge for these patients.

Identifying the predictive factors of sustained return of spontaneous circulation (ROSC) following out-of-hospital cardiac arrest (OHCA) will be helpful in management of these patients. This study aimed to develop a predictivemodel in this regard.

In a retrospective observational study, data of adult patients with OHCA, were collectedfrom Vajira emergency medical services patient care report. Multiple logistic regression analysis with a regression co-efficient was used to develop a predictive score for a sustained ROSC at the scene. Area under the receiver operatingcharacteristic (ROC) curve (AUC) was used to validate the accuracy of the predictive score for a sustained ROSC.Re-sults:Independent factors associated with a sustained ROSC included cardiopulmonary resuscitation (CPR) duration <30 min (adjusted odds ratio (AOR)= 5.05, 95% confidence interval (CI): 3.34–7.65; p < 0.001); advanced airway manage-ment with an endotracheal tube (AOR= 3.06, 95% CI: 1.77–5.31; p < 0.001); advanced airway management with laryngealmask airway (AOR= 3.42, 95% CI: 1.02–11.46; p = 0.046); defibrillation (AOR = 2.05, 95% CI: 1.31–3.2; p = 0.002); Capillaryblood glucose (CBG) level < 150 mg% (AOR= 1.95, 95% CI: 1.05–3.65; p = 0.035); CBG at least 150 mg% (AOR= 2.87, 95%CI: 1.56–5.29; p = 0.001); pupil reflex (AOR = 2.96, 95% CI: 1.1–7.96; p = 0.032); and response time at most 8 min (AOR=1.66, 95% CI: 1.07–2.57; p = 0.023). These were developed into the pupil reflex, response time, advanced airway manage-ment, defibrillation, CBG, and CPR duration (PRAD-CCPR) score. The most accurate cutoff point of score using Youden’sindex was≥6 with AUC of 0.759 (95% CI: 0.715–0.802; p < 0.001), sensitivity of 62.0% (95% CI: 51.2–71.9%), specificityof 75.7% (95% CI: 69.4–81.2%), positive predictive value of 51.8% (95% CI: 40.9–62.3%), and negative predictive value of79.5% (95% CI: 73.5–84.6%).

An optimal PRAD-CCPR score of≥6 provides an acceptable accuracy of 0.759with sensitivity of 62.0% and specificity of 75.7% in prediction of sustained ROSC following OHCA. This predictive scoremight help CPR commanders to prognosticate the outcome of patients with OHCA at the scene.

The modified shock index (MSI) is the ratio of heart rate to mean arterial pressure. It is used as a pre-dictive and prognostic marker in a variety of disease states. This study aimed to derive the optimal MSI cut-off that isassociated with increased likelihood (likelihood ratio, LR) of admission and in-hospital mortality in patients present-ing to emergency department (ED).

We retrospectively reviewed data from the National Hospital AmbulatoryMedical Care Survey between 2005 and 2010. Adults>18 years of age were included regardless of chief complaint. Basicpatient demographics, initial vital signs, and outcomes were recorded for each patient. Then the optimal MSI cut-offfor prediction of admission and in-hospital mortality in ED was calculated. LR≥5 was considered clinically significant.

567,994,402 distinct weighted adult ED patient visits were included in the analysis. 15.7% and 2.4% resulted inadmissions and in-hospital mortality, respectively. MSI > 1.7 was associated with a moderate increase in the likelihoodof both admission (Positive LR (+LR) = 6.29) and in-hospital mortality (+LR = 5.12). +LR for hospital admission at MSI>1.7 was higher for men (7.13; 95% CI 7.11-7.15) compared to women (5.49; 95% CI 5.47-5.50) and for non-white (7.92;95% CI 7.88-7.95) compared to white patients (5.85; 95% CI 5.84-5.86). For MSI <0.7, the +LRs were not clinically signif-icant for admission (+LR = 1.07) or in-hospital mortality (LR = 0.75).

In this largest retrospective study, todate, on MSI in the undifferentiated ED population, we demonstrated that an MSI >1.7 on presentation is predictive ofadmission and in-hospital mortality. The use of MSI could help guide accurate acuity designation, resource allocation,and disposition.

In this study, a patient who developed acute hepatitis due to drinking Pistacia vera L. bud tea is presented. A twenty-eight-year-old woman who had just come out of the postpartum period applied to our clinic with complaints of nausea,vomiting, loss of appetite and weakness. Blood serum alanine aminotransferase and aspartate aminotransferase levelswere increased. All serological tests were negative for viral hepatitis and autoimmune diseases. She had been drinkingan herbal tea containing Pistacia vera L. bud every day for four weeks to increase milk production. Three weeks afterdiscontinuation of herbal tea, liver enzymes returned to normal. Based on our knowledge, this is probably the firsthepatitis report due to the use of an herbal tea containing Pistacia vera L. bud.

Artificial Inteligence (AI) application in emergency medicine is subject to ethical and legal inconsisten-cies. The purposes of this study were to map the extent of AI applications in emergency medicine, to identify ethicalissues related to the use of AI, and to propose an ethical framework for its use.

A comprehensive literature col-lection was compiled through electronic databases/internet search engines (PubMed, Web of Science Platform, MED-LINE, Scopus, Google Scholar/Academia, and ERIC) and reference lists. We considered studies published between 1January 2014 and 6 October 2022. Articles that did not self-classify as studies of an AI intervention, those that were notrelevant to Emergency Departments (EDs), and articles that did not report outcomes or evaluations were excluded. De-scriptive and thematic analyses of data extracted from the included articles were conducted.

A total of 137 outof the 2175 citations in the original database were eligible for full-text evaluation. Of these articles, 47 were included inthe scoping review and considered for theme extraction. This review covers seven main areas of AI techniques in emer-gency medicine: Machine Learning (ML) Algorithms (10.64%), prehospital emergency management (12.76%), triage,patient acuity and disposition of patients (19.15%), disease and condition prediction (23.40%), emergency departmentmanagement (17.03%), the future impact of AI on Emergency Medical Services (EMS) (8.51%), and ethical issues (8.51%).

There has been a rapid increase in AI research in emergency medicine in recent years. Several studies havedemonstrated the potential of AI in diverse contexts, particularly when improving patient outcomes through predic-tive modelling. According to the synthesis of studies in our review, AI-based decision-making lacks transparency. Thisfeature makes AI decision-making opaque.

This systematic review and meta-analysis aimed to summarize the evidence regarding the impact of nee-dle direction and distance of arteriovenous fistula (AVF) cannulation on KT/V (where k is the dialyzer urea clearance, t,the duration of dialysis, and V, the volume of distribution of urea) and access recirculation (AR) as hemodialysis (HD) ad-equacy criteria.

A comprehensive systematic search was performed on international and domestic electronicdatabases from the earliest to June 4, 2022 using keywords. Analysis was performed in STATA software v.14.

Three randomized control trials (RCTs) and four non-RCT articles were included in the final review. Six studies reportedthe effects of direction, while four mentioned the effects of distances of AVF cannulation on outcomes of HD adequacybased on KT/V or AR. Results of three non-RCT studies showed that retrograde direction decreased KT/V more than an-tegrade direction (ES: 0.44, 95% CI: -0.38 to 1.27). Two non-RCT studies showed that antegrade decreased AR comparedto the retrograde direction (ES: -0.64, 95%CI: -1.94 to 0.67). However, the results of two RCTs indicated uncertainty aboutthis issue. Two of the four studies suggested that a distance of 5 cm or more in arterial and venous needles had greateradequacy than a distance of less than 5 cm. However, other studies did not confirm this finding.

Overallcomparison of the results qualitatively and quantitatively indicated uncertainty about the effects of direction and dis-tance of AVF cannulation on HD adequacy outcomes. More studies with high-quality designs, such as RCTs, are requiredto better understand and adjudicate the effects of needle direction and distance of AVF cannulation on HD adequacyoutcomes.

During the COVID-19 outbreak, dental professionals have demonstrated their importance in combatingmass casualty incidents. This study aimed to understand dental students’ perceptions of their potential roles in a bioter-rorism attack.

This cross-sectional study used a self-administered anonymous questionnaire, which was sentto all dental students and interns at King Abdulaziz University, Saudi Arabia. Bivariate and multiple linear regressionanalyses were conducted to assess dental students’ willingness to provide care during a bioterrorism attack, knowledgeregarding bioterrorism and total number of roles a dentist should play during an attack.

This study included472 dental students and interns. The mean knowledge score regarding bioterrorism was 3.3 ± 1.9 out of 5. A large ma-jority of the respondents (83.8%) were willing to provide care during a bioterrorism attack. Students with a cumulativegrade point average (GPA) of 4.5–5 were more likely to indicate that a dental professional should take on more roles dur-ing a bioterrorism attack than those with a GPA of 2.5–2.99. Fourth- and fifth-year dental students had lower knowledgescores regarding bioterrorism than dental interns (B: -0.71; SE: 0.30; 95% CI: -1.3—0.1 and B: -0.68; SE: 0.30; 95% CI: -1.3–-0.1, respectively).

Despite the fact that dental curricula do not cover topics related to bioterrorism, moststudents would be willing to provide care under bioterrorism conditions. There is wide agreement among the studentsregarding the need to add bioterrorism-related educations to dental curricula.

Although the 2020 American Heart Association (AHA) guidelines recommend that sodium bicarbonate(SB) be avoided during routine cardiopulmonary resuscitation (CPR) a limited number of studies have examined theeffects of SB injection during prolonged CPR (>15 min) in prehospital setting. The present study aimed to examinethe effects of prehospital SB use during prolonged CPR on patients’ outcome.

In this retrospective cross-sectional study adult patients aged >18 years who experienced a non-traumatic, out-of-hospital cardiac arrest (OHCA)were compared regarding three outcomes, namely return of spontaneous circulation (ROSC), ROSC > 20 minute, andsurvival to discharge, based on receiving or not-receiving SB during CPR.

330 patients were divided into twoequal groups of 165. The two groups had similar conditions regarding gender distribution (p = 0.729); mean age (p =0.741); underlying diseases (p = 0.027); etiology of arrest (p = 0.135); the initial rhythm (p = 0.324); receiving normalsaline solution (p = 1.000), epinephrine (p = 0.848), and atropine during CPR (p = 0.054); and using defibrillation (p =0.324). Those who received SB had 0.80 times greater likelihood for sustained ROSC (adjusted odds ratio (OR) = 0.80,95% CI: 0.47–1.37, p = 0.415), 0.93 times greater likelihood for ROSC at the scene (adjusted OR = 0.93, 95% CI: 0.55–1.59,p = 0.798), and 0.34 times greater likelihood for survival to discharge (adjusted OR = 0.34, 95% CI: 0.10–1.17, p = 0.087).

The present study demonstrated that prehospital SB use by EMS during prolonged CPR did not improveROSC rate at the scene, sustained ROSC, and survival to discharge.

Low accuracy of clinical variables can result in delayed diagnosis and increase the incidence of com-plicated appendicitis in some cases. This study aimed to determine the value of simple complete blood count (CBC)biomarkers in predicting complicated appendicitis.

This is a single-center retrospective cross-sectional study,which was conducted on cases referred to emergency department following acute appendicitis who underwent appen-dectomy, to evaluate the accuracy of some cell blood count variables (white blood cell count (WBC), neutrophil percent,neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), mean platelet volume (MPV )) in predictingcomplicated cases (gangrenous and ruptured appendicitis).

There were 252 (68.3%) patients in the uncompli-cated appendicitis group and 117 (31.7%) patients in the complicated appendicitis group. The mean age of patients was34.1 ± 1.09 (Range: 18 -79) years (55.3% male). There were no differences between groups regarding the mean age (p =0.053), gender distribution (p=0.07), Alvarado score (p = 0.055), platelet count (p =0.204), PLR (p = 0.115), and MPV (p= 0.205). The complicated appendicitis cases had longer onset of symptoms (p <0.001), higher WBC count (p = 0.011),higher neutrophil count (p < 0.001), and higher NLR (p < 0.001). Neutrophil count (area under the curve (AUC) = 0.61,95% confidence interval (CI) = 0.56-0.66; p = 0.001) and NLR (AUC = 0.65, 95% CI = 0.60-0.69; p = 0.001) had higher levelof accuracy in this regard. In contrast, the area under the curve of WBC count (AUC = 0.57, 95% CI = 0.52-0.63; p = 0.22),platelet count (AUC = 0.44, 95% CI = 0.38-0.49; p = 0.049), PLR (AUC = 0.57, 95% CI = 0.52-0.62; p = 0.026), and MPV (AUC= 0.54, 95% CI = 0.49-0.60; p = 0.193) showed low accuracy in predicting complicated acute appendicitis.

Based on the findings of present study it seems that WBC, neutrophil percent, NLR, PLR, and MPV have failed to pooraccuracy in predicting cases with complicated appendicitis in emergency department.

Introduction:

Statins are known to have anticoagulation and anti-inflammatory effects. This study aimed to investi-gate the effect of Rosuvastatin in reduction of post thrombotic syndrome (PTS) following deep vein thrombosis (DVT).

In this randomized clinical trial, patients who were diagnosed with DVT of lower extremity were randomlyassigned to 4 treatment groups: group 1: Warfarin, group 2: Warfarin + Rosuvastatin, group 3: Rivaroxaban, and group 4:Rivaroxaban + Rosuvastatin. The treatments were followed for 3 months and prevalence of PTS (as primary outcome),as well as the changes in serum levels of D-dimer and C reactive protein (CRP), and the extent of thrombosis before andafter the intervention (as secondary outcomes) were compared between groups.

182 patients with the meanage of 55.22 ± 4.1 years finished the trial period (51.64% male). There was no significant difference between the groupsregarding the baseline characteristics. Based on the Brandjes score, 31 (17.03%) patients had PTS at the end of the study.The occurrence of PTS was significantly lower in the groups taking statins (p<0.0001). Although the change in the meandifference of legs circumference before and after intervention, were significant in all groups (p < 0.05), the differenceswas more prominent in groups 2 and 4 (p < 0.0001). After 3 months of taking medication, decrease of CRP was moreprominent in the statin groups (p = 0.001), and most cases with normal CRP were in statin groups. Among the patientswith the serum D-dimer level above 10000 ng/mL, patients in the statin groups experienced significantly more reduc-tion in D-dimer levels than the other groups (p<0.001).

Rosuvastatin administration in combination withrivaroxaban or warfarin significantly reduces the level of inflammatory factors including CRP and D-dimer, comparedto patients receiving anticoagulants alone. Rosuvastatin administration can significantly reduce the incidence of PTSand cause a difference in the size of the lower limbs within 3 months.

Inadequate spinal motion restriction in patients suffering from spinal injuries could lead to further neuro-logical damage, ultimately worsening their prognosis. This study aimed to investigate the efficacy of long spinal boards(LSB), ske stretcher, and vacuum mattress for cervical spine immobilization during transportation of patients by mea-suring the angular motion of the cervical spine following lifting, transferring, and tilting.

We conducted anexperimental study using a box of three randomizations and crossover designs without a washout period effect for thelong spinal board, sked stretcher, and vacuum mattress. We concealed the randomization with sequentially numbered,opaque, sealed envelopes (SNOSE). Kinematic data were collected using eight optoelectronic cameras at 200 Hz (BTSBioengineering, Milan, Italy) in triangular planes (lateral bending, flexion-extension, and axial rotation) while perform-ing all three motions (static lift-hold, transfer, and 90° tilt).

12 cases (7 males and 5 females) with the mean age of20 ± 3.03 (range: 18-28) years were studied. The three highest angular motions were observed in the axial rotation planeduring patient’s tilting under immobilization on all devices (Vacuum mattress having the highest value of 99.01±8.93,followed by the LSB at 89.89±34.35 and the sked stretcher at 86.30±7.73 degrees). During patient lifting, a higher angularmotion was observed with vacuum mattress immobilization in flexion extension (Coefficient = 4.45; 95%CI: 0.46 – 8.45;p =0.029) and axial rotation (Coefficient = 3.70; 95%CI: 0.58 – 6.81; p =0.020) planes. During patient transfer, a higher an-gular motion was observed with sked stretcher in the flexion-extension plane (Coefficient = 2.98; 95%CI: 0.11 – 5.84; p =0.042). During patient tilting to 90 degrees, a higher angular motion was observed with vacuum mattress immobilizationin lateral bending (Coefficient = -4.08; 95%CI: -7.68 - -0.48; p = 0.026) for the vacuum mattress.

Based onthe finding of the present study, patients on the vacuum mattress experience significantly higher angular motion in flex-ion extension and axial rotation during lifting, as well as lateral bending during 90-degree tilting. In addition, patientson the Sked stretcher showed significantly higher angular motion in flexion-extension during the transferring. However,the predictive margins for immobilization across all devices did not demonstrate clinically significant differences amongthe three immobilization devices.

Coronary computed tomographic angiography (CCTA) reporting has traditionally been operator-dependent, and no precise classification is broadly used for reporting Coronary Artery Disease (CAD) severity. TheCoronary Artery Disease Reporting and Data Systems (CAD-RADS) was introduced to address the inconsistent CCTA re-ports. This systematic review with meta-analysis aimed to comprehensively appraise all available studies and draw con-clusions on the prognostic value of the CAD-RADS classification system in CAD patients.

Online databasesof PubMed, Embase, Scopus, and Web of Science were searched until September 19th, 2022, for studies on the value ofCAD-RADS categorization for outcome prediction of CAD patients.

16 articles were included in this system-atic review, 14 of which had assessed the value of CAD-RADS in the prediction of major adverse cardiovascular events(MACE) and 3 articles investigated the outcome of all-cause mortality. Our analysis demonstrated that all original CAD-RADS categories can be a predictor of MACE [Hazard ratios (HR) ranged from 3.39 to 8.63] and all categories, exceptCAD-RADS 1, can be a predictor of all-cause mortality (HRs ranged from 1.50 to 3.09). Moreover, higher CAD-RADScategories were associated with an increased hazard ratio for unfavorable outcomes among CAD patients (p for MACE= 0.007 and p for all-cause mortality = 0.018).

The evidence demonstrated that the CAD-RADS classifica-tion system can be used to predict incidence of MACE and all-cause mortality. This indicates that the implementationof CAD-RADS into clinical practice, besides enhancing the communication between physicians and improving patientcare, can also guide physicians in risk assessment of the patients and predicting their prognosis.

Even though naloxone is the main treatment for methadone poisoning treatment there are controversiesabout the proper method of its tapering. This study aimed to compare two methods in this regard.

Thisstudy was a prospective, single-blind pilot quasi-experimental study on non-addicted adult patients poisoned withmethadone. Patients were randomly divided into 2 groups. In one group, after stabilization of respiratory conditionsand consciousness, naloxone was tapered using the half-life of methadone and in the other group, naloxone was taperedusing the half-life of naloxone. Recurrence of symptoms and changes in venous blood gas parameters were comparedbetween groups as outcome.

52 patients were included (51.92% female). 31 cases entered Group A (taperingbased on methadone’s half-life) and 21 cases entered Group B (tapering based on naloxone’s half-life). The two groupswere similar regarding mean age (p = 0.575), gender distribution (p = 0.535), the cause of methadone use (p = 0.599),previous medical history (p = 0.529), previous methadone use (p = 0.654), drug use history (p = 0.444), and vital signson arrival to emergency department (p = 0.054). The cases of re-decreasing consciousness during tapering (52.38% vs.25.81%; p = 0.049) and after discontinuation of naloxone (72.73% vs. 37.50%; p = 0.050) were higher in the tapering basedon naloxone half-life group. The relative risk reduction (RRR) for naloxone half-life group was -1.03 and for methadonehalf-life group was 0.51. The absolute risk reduction (ARR) was 0.27 (95% confidence interval (CI) = 0.01-0.53) and thenumber needed to treat (NNT) was 3.7 (95% CI= 1.87- 150.53). There was not any statistically significant difference be-tween groups regarding pH, HCO3, and PCO2changes during tapering and after naloxone discontinuation (P > 0.05).However, repeated measures analysis of variance (ANOVA), showed that in the tapering based on methadone’s half-lifegroup, the number of changes and stability in the normal range were better (p < 0.001).

It seems that, bytapering naloxone based on methadone’s half-life, not only blood acid-base disorders are treated, but they also remainstable after discontinuation and the possibility of symptom recurrence is reduced.