Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 5 3 2020 12 20 e28 e28 EN Nahid Salehi Cardiovascular Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran Reza Heidari Moghadam Cardiovascular Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran Alireza Rai Cardiovascular Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran Nafiseh Montazeri Cardiovascular Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran Javad Azimivghar Cardiovascular Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran Parisa Janjani Cardiovascular Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran Mohammed Rouzbahani Cardiovascular Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran 2020 09 06 2020 10 19 Introduction: Acute myocardial infarction (AMI) is a leading cause of death and disability worldwide. Determining seasonal pattern of AMI may contribute to disease prevention and better treatment. Objective: The present study was conducted to investigate daily, monthly, and seasonal pattern for symptoms҆ onset in the patients with ST-segment elevation myocardial infarction (STEMI), and also other possible associated factors. Methods: This cross-sectional study was conducted on 777 patients diagnosed with STEMI admitted at the Imam Ali Cardiovascular Hospital affiliated with Kermanshah University of Medical Sciences (KUMS), Kermanshah province, Iran from March 2018 to February 2019. Data were collected using a checklist developed based on the study's objectives. Differences between subgroups were assessed using one-way analysis of variance (ANOVA) followed by Tukeys҆ post‐hoc test and Chi-Square test (or Fishers҆ exact test). Results: Out of 777 patients, 616 (79.3%) of them were male. Mean age of the patients was (mean±SD) equal to 60.93±12.86 years old. Occurrence of STEMI was most common in winter (38.4%), followed by autumn (27.8%), spring (22.9%), and summer (10.9%), respectively. Monthly occurrence of AMI was at the highest level in January (10.8%) and December (9.9%), and it was at the lowest level in July (4.9 %). Most patients were admitted on Fridays (15.8%) and Wednesdays (15.6%). Hypercholesterolemia, prior congestive heart failure (CHF), prior MI, prior stroke, prior atrial fibrillation (AF), low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglycerides, total cholesterol, creatine phosphokinase (CPK), and creatine kinase myocardial band (CK-MB) were significantly associated with seasonal pattern of STEMI (p-value<0.05). Conclusions: Results of the present study on Iranian patients with STEMI revealed that AMI occurred more frequently on Wednesdays and Fridays and during winter from December to January compared to the other days of the week, months, and seasons. https://fem.tums.ac.ir/index.php/fem/article/view/549 https://fem.tums.ac.ir/index.php/fem/article/download/549/330

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 5 3 2021 02 09 e26 e26 Abdorreza Naser Moghadasi Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran Nassim Anjidani Medical Department, Orchid Pharmed Company, Tehran, Iran Fereshteh Rashvand Orchid Life Patient Support Service, Orchid Pharmed, Tehran, Iran. 2021 01 24 2021 01 29 Since the onset of COVID-19 in December 2019, millions of people have been infected with SARS-CoV-2 across the world and many have died of the disease. Therefore, the search for any drug with a positive effect on the course of this disease is of great value. Fampridine is a drug widely used to improve gait disorders in patients with multiple sclerosis. The mentioned drug is a potassium channel blocker that increases the conduction of action potentials in damaged axons. However, it is not evident whether this drug can affect potassium channels on the surface of other cells. Some studies have revealed that potassium-blocking drugs can play a role in reducing the incidence or severity of infectious diseases. Hence, the question of whether fampridine could also have a protective effect on patients with MS in the face of COVID-19 should be attended to. The incidence and severity of COVID-19 in patients with MS receiving fampridine (Dalfyra®, Arvand Pharmed) were evaluated to address the mentioned question. In the present study conducted in November 2020, 117 MS patients receiving fampridine were tested for COVID-19. The majority of these patients (55.6%) were receiving rituximab. Of these 117 patients, nine were infected by the COVID-19 virus. Of these nine patients, five and four were female and male, respectively. Eight of the infected patients took rituximab, and one did not take any disease modulatory drug (DMD). One of these nine patients required to be hospitalized. She was a 40-year-old woman with MS disease duration of 3.5 years and was treated with rituximab. Her symptoms were manifested by fever, shortness of breath, and dry cough. The mentioned patient was hospitalized for three days due to the conditions associated with COVID-19. She did not need to be admitted to the intensive care unit (ICU) and was discharged with a good medical condition after three days. The incidence of COVID-19 in these patients was 7%, and the hospitalization rate was 11% in patients receiving fampridine. None of the patients with COVID-19 required hospitalization in the ICU, and no fatalities were reported. In a previous study conducted on 4,647 patients with MS in Iran, the incidence rate was reported to be 1.46% during the first wave of COVID-19 (May 2020). The incidence rate in our study was 7%, which was significantly higher than the percentage of the previous report. It should be noted that our study was conducted at the height of the second wave of COVID-19 in Iran, during which a much larger number of people were infected with COVID-19, according to official statistics. In the previous study, the hospitalization rate was 25%. However, fampridine users, despite being more infected, had a lower hospitalization rate (11%), which indicated a lower severity of the disease in these patients. The mentioned finding could be due to the possible protective effect of fampridine on the exacerbation of COVID-19 in these patients. This hypothesis requires further examination in more detail. https://fem.tums.ac.ir/index.php/fem/article/view/647 https://fem.tums.ac.ir/index.php/fem/article/download/647/342

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 5 3 2021 03 04 e35 e35 Zahra Tavoli Department of Obstetrics and Gynecology, Ziaeian Hospital, Tehran University of Medical Science, Tehran Iran Ali Montazeri Population Health Research Group, Health Metrics Research Centre, Iranian Institute for Health Sciences Research, Tehran, Iran 2020 12 21 2020 12 29 Introduction: Uterus didelphys with obstructed hemivagina associated with ipsilateral renal agenesis (OHVIRA syndrome) is a rare female urogenital malformation and delay in its diagnosis could lead to several complications. Case presentation: A 21-year-old virgin woman was admitted to the emergency department (ED) with severe abdominal pain, without fever and vaginal discharge. She reported a history of cyclic abdominopelvic pain and dysmenorrhea for 5 years. The primary diagnosis (OHVIRA syndrome) was made using ultrasonography, spiral computed tomography (CT) and magnetic resonance imaging (MRI). In addition, laparoscopy was performed to confirm diagnosis and drain hematosalpinx. Then, hysteroscopy was carried out for septum resection and catheter insertion. At one-month follow-up the ultrasonography showed normal left hemicavity of uterus associated with significant decrease in dysmenorrhea. Conclusion: Being aware of OHVIRA syndrome and clinical suspicion of this rare anomaly are essential for making a timely diagnosis, preventing complications, relieving symptoms, and preserving future fertility. https://fem.tums.ac.ir/index.php/fem/article/view/615 https://fem.tums.ac.ir/index.php/fem/article/download/615/344

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 5 3 2021 03 11 e34 e34 Javad Salimi Department of Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran. Ehsan Rahimpour Department of Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran. Hossein Zabihi Mahmoudabadi Department of Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran. Pezhman Farshidmehr Department of Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran. 2020 11 17 2020 12 08 Introduction: Acute limb ischemia is a critical medical condition that can quickly become a life threat. Therapeutic modalities such as catheter-directed thrombolysis (CDT) have demonstrated various levels of efficacy in previous studies. Objective: This study presents the descriptive findings of a series of cases who presented with acute arterial thrombotic limb ischemia and underwent CDT. Methods: This was a cross-sectional single-hospital-based case series, in which all patients who were diagnosed with acute arterial thrombotic limb ischemia, and consequently underwent CDT during the one-year study period were included.  Detailed baseline characteristics and clinical findings of the studied patients on presentation, after intervention and at one-year follow-up are presented. Results: A total of 21 patients with a mean age of 60.7±15.2 years, including 16 males (76.2%) were included. The initial technical and treatment success rates were 20 (95.2%) and 14 (66.7%), respectively. The amputation-free and the overall survival rates after the one-year follow-up were 15 (71.4%) and 17 (81%), respectively. Four patients (19%) developed complications, two (9.5%) of which were significant (pulmonary hemorrhage and intraventricular hemorrhage). Amputation was performed in 6 (28.6%) cases. Conclusion: In this study, the treatment success rate and the technical success rate were satisfactory. https://fem.tums.ac.ir/index.php/fem/article/view/598 https://fem.tums.ac.ir/index.php/fem/article/download/598/346

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 5 3 2021 01 19 e29 e29 Peyman Saberian Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran Nader Tavakoli Trauma and Injury Research Center, Iran University of Medical Sciences, Tehran, Iran Parisa Hasani-Sharamin Tehran Emergency Medical Service Center, Tehran, Iran Leila Kheyrati National Emergency Medical Organization, Ministry of Health and Medical Education, Tehran, Iran Somaye Younesian Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran Hosein Rafiemanesh Department of Epidemiology, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2021 01 19 Introduction: COVID-19 pandemic led to various consequences in medical care that had been long provided for the patients referred to the hospitals. Objective: We conducted this study to derive and validate a new scoring system that can accurately differentiate COVID-19 patients who may have a worse outcome from others at the prehospital stage. Methods: This study was performed on probable/confirmed COVID-19 patients, who were transferred to the hospitals by Tehran emergency medical services (EMS). Occurrence of one of the items including: in-hospital death, intensive care unit (ICU) admission, or hospitalization for more than 20 days was considered to indicate a “severe disease”. Univariate and multivariate logistic regression were used for assessment of the relationship between all independent variables and the outcome. In the validity assessment step, area under the receiver operating characteristic (ROC) curve was calculated for a data set independent from the data based on which the model was designed. The sensitivity and specificity were also presented based on the best suggested cut-off point. Results: In this study, the data of 557 cases were analyzed in the derivation step and 356 cases were assessed in the validation step. The univariate logistic regression showed that age, weakness and fatigue, disease history, systolic blood pressure, SpO2, respiratory rate, and Glasgow coma scale (GCS) were statistically significant in severe disease group. The area under the ROC curve (AUC-ROC) of the tool was 0.808 (95% CI: 0.779, 0.834). The best cut-off point for screening was the score of ≥4, in which the sensitivity and specificity of the tool for the best cut-off point were 71.87% and 78.06%, respectively. In the validation step, the AUC-ROC of the tool was 0.723. Conclusions: Seven criteria of severe COVID-19 (SCSC) tool could properly differentiate probable/confirmed COVID-19 patients with severe outcomes in the pre-hospital stage. https://fem.tums.ac.ir/index.php/fem/article/view/631 https://fem.tums.ac.ir/index.php/fem/article/download/631/338

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 5 3 2021 03 28 e27 e27 Sepideh Tahsini Tekantapeh Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran Haleh Mikaeili Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran Hassan Soleimanpour Emergency Medicine Research Team, Tabriz University of Medical, Tabriz, Iran 2021 03 24 2021 03 28 According to epidemiologic and analytic studies of different countries during coronavirus disease 2019 (COVID-19) pandemic, high prevalence of the disease, more hospitalization, getting a more severe form of the disease, diffused peripheral distribution of opacities, more need to receiving ICU care, poor prognosis, and high mortality rate in men compared with women were obtained. The causes of the above gender differences in subsequent studies were attributed to several factors including behavioral use of masks or handwashing, as well as genetic, hormonal, and immunological factors. Also in the past epidemiologic studies, a higher prevalence of severe acute respiratory syndrome (SARS) and the Middle East respiratory syndrome (MERS) among men was shown than women. Despite the lack of accurate statistical studies, some evidence shows high severe COVID-19 incidence and mortality rate in athlete’s society compared with non-athletes. Respiratory sex-related differences in women include smaller lung volumes, smaller-diameter conducting airways, smaller radial rib cage dimensions, shorter diaphragm, and fewer lung function parameters such as ventilation volume. Originally and typically, athletes have high lung volumes and capacities such as forced expiratory volume in 1 second (FEV1), especially high ventilation volume. It is well-known that in COVID-19 infection, the main route of transmission is respiratory droplets and direct contact with infected people. Hence, this hypothesis is raised that higher lung ventilation volume ratio of men than women and athletes than non-athletes may be the major reason for the difference of COVID-19 infection based on sex. In other words, in the same condition, y invite other experts in this regard. https://fem.tums.ac.ir/index.php/fem/article/view/1152 https://fem.tums.ac.ir/index.php/fem/article/download/1152/433

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 7 1 2022 07 07 e4 e4 Ali Vafaye Department of Emergency Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran Kamran Heydari Department of Emergency Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran Hossein Mardanparvar Department of nursing, Faculty of nursing & midwifery, Hormozgan University of Medical Sciences, Bandar Abbas, Iran Ali Alizadeh Kaseb Department of Emergency Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran Saeed Safari Men’s Health and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2022 07 03 2022 07 07 Introduction: Emergency medicine (EM) is a relatively new medical specialty, which concerns patients who need vital and urgent medical care. This study aimed to evaluate the general medicine interns’ attitude in continuing their education in EM residency programs. Methods: This study is a prospective cross-sectional study, which was performed on 180 medical students during their internship using convenience sampling. Data were collected using a valid and reliable researcher-made questionnaire and analyzed using SPSS 26 software. Results: One hundred and eighty medical students in the internship period with the mean of 25.65 ± 2.72 (23 – 46) years were studied (53.3% male; 76.7% single). Only 33 (18.3%) interns indicated their interest in continuing their education in EM residency programs. 30 (16.66) cases were not interested in continuing their education in any residency program (61.1% of whom cited migration as the reason, 13% cited not working as a specialist, 14.8% indicated lack of economic justification, and 11.1% cited other reasons for not wanting to enter residency programs). The mean overall interest score to EM residency program was 59.61 ± 12.66 % (20 – 96.41%). The lowest and highest interest scores obtained in the economic status (47.91 ± 21.13%) and education status (70.59 ± 15.77%) of EM specialty, respectively. The mean overall interest score was not statistically different between male and female students (p = 0.366). There was a significant statistical correlation between gender and type of discipline chosen, and female mostly chose non-surgical disciplines (p = 0.001). Conclusion: The interest of general medicine interns in continuing their education in EM residency program was average. The economic field of EM has been one of the best factors in attracting students to continue their studies in this field. https://fem.tums.ac.ir/index.php/fem/article/view/1034 https://fem.tums.ac.ir/index.php/fem/article/download/1034/414

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 7 1 2023 01 04 e11 e11 Sakher Awadalla Emergency Department, King’s College Hospital London, Dubai, UAE Ahmed Kamal Mohamed Emergency Department, NMC Royal Hospital Khalifa City, Abu Dhabi, UAE 2022 12 01 2022 12 06 An 8-month-old, male child was brought to the emergency department (ED) by his parents with difficulty of breathing. The child developed shortness of breath for one day with cough, but he had no fever. According to the parents, they did not notice the abdominal distension. The child was born prematurely at 25 weeks of gestation and stayed in the neonatal intensive care unit (NICU) for 2 months. Otherwise, he was healthy with minor repeated chest infections and bronchiolitis. In triage, his vital signs were as follows: heart rate: 180 beats/min; respiratory rate: 35 breaths/min; temperature: 35± C; oxygen saturation: 70%; and his blood pressure was undetected. The child was immediately transferred to the resuscitation room. The primary survey showed that the patient was comatose with a Glasgow coma scale of 3/15, the pupils were brisk with an unstable airway, and there was bilateral diminished air entry. The oxygen saturation did not improve despite assisted ventilation using an Ambu bag. The central and peripheral pulsation was weak with a delayed capillary refill, and the blood glucose level was 9 mmol/L. The abdomen was hugely distended and rigid with minimal rectal bleeding. The patient was immediately intubated and connected to mechanical ventilation with subsequent rising of his oxygen saturation to 100%. A plain chest X-ray examination followed the patient’s intubation. Intravenous access was obtained followed by administration of normal saline (20 ml/kg) with subsequent elevation of the blood pressure (82/50mmHg) and decrease in heart rate (160 beats/minute). Initial arterial blood gases (ABG) analysis after intubation showed pH: 6.6; PaCO2 >150 mmHg; PaO2: 100 mmHg; HCO3: 10mEq/L; and lactic acid: 9 mg/dL. Therefore, a bolus of sodium bicarbonate was given, intravenously. Ventilator parameters were set at the maximum limits to wash out carbon dioxide. Repeated ABG analysis showed pH: 6.7; PaCO2: 135 mmHg; PaO2: 150 mmHg; HCO3: 17 mEq/L; and lactic acid: 6.5 mg/dL. Immediate bedside abdominal X-ray and ultrasonography were carried out to rule out intussusception. The child remained critically ill and unstable with fluctuating vital signs. Despite high ventilator parameters and gasgastric tube suction, the child showed no improvement in the respiratory parameters. The child was then transferred to the operation theatre for decompression laparotomy, which showed small bowel (ileum) ischemia. After surgical decompression, the respiratory parameters improved, and the ventilator parameters were set back to normal settings for the patient’s age and weight. Unfortunately, the child remained critically ill. Then, he developed sepsis and multiple systems organ failure and died after 2 days. https://fem.tums.ac.ir/index.php/fem/article/view/1120 https://fem.tums.ac.ir/index.php/fem/article/download/1120/426

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 7 1 2022 12 26 e5 e5 Seyedmohammadmehdi Samimiardestani Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran Meisam Sharifi Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran Mehri Farhange Ranjbar Research Center for Trauma in Police Operations, Directorate of Health, Rescue & Treatment, Police Headquarter, Tehran, Iran 2022 12 26 Objective: Due to the important role of police during COVID-19 pandemics and lack of previous studies on the impact of personal protective equipment (PPE) in reduction of COVID-19 infection among police officers, we aimed to investigate the role of using PPE in prevention of COVID-19 infection among Iranian police personnel. Methods: This cross-sectional survey was conducted in Tehran, Iran during January 2021 to November 2022. The study sample consisted of police personnel who were active in field operations. Demographics (age, height, weight, gender, marital status, number of children and underlying diseases) and job characteristics such as frequency and type of operations, involvement of colleagues with COVID-19, and COVID-19 infection history, using PPE, types of used PPE (mask, face shield, gloves, etc), protective strategies (such as social distancing) and COVID-19 vaccination were recorded. Statistical analysis was performed with IBM SPSS Statistics for Windows, version 25. Results: Totally, 340 participants were analyzed (33.54±9.74 years old, 91.2% males), of whom, 150 participants (44.1%) reported at least one episode of confirmed COVID-19 infection. The most common component of PPE used both during operations and daily life was face mask (44.7% and 75%, respectively). The most popular measure with higher adherence compared to others was social distancing with 70% popularity and an adherence score of 5.85±3.74. Three hundred subjects (88.2%) had received at least one dose of COVID-19 vaccine. Among PPE items, using face mask, washing hands with soap, social distancing and vaccination were significantly different between patients with and without prior COVID-19 infection (p>0.05). Conclusion: The findings showed that use of PPE is significantly efficacious in reduction of COVID-19 infection among police officers. Therefore, despite difficulties of using PPE among police forces, it is strongly recommended for virus spread control in this population. https://fem.tums.ac.ir/index.php/fem/article/view/1144 https://fem.tums.ac.ir/index.php/fem/article/download/1144/423

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 7 1 2023 01 04 e6 e6 Mohmmad Reza Khajavi Department of Anesthesiology, Tehran University of Medical Sciences, Tehran, Iran Sanaz Kharazmi School of Medicine, Tehran University of Medical Sciences, Tehran, Iran Hossein Dialameh Urology Research Center, Tehran University of Medical Sciences, Tehran, Iran Azam Biderafsh Epidemiology and Biostatistics Department, Health Faculty, Tehran University of Medical Sciences, Tehran, Iran 2022 11 06 2022 12 15 Objective: In this randomized clinical trial study, the impact of prophylactic administration of methadone during surgery on postoperative pain and analgesic requirement following cadaveric renal transplantation was assessed. Methods: Ninety patients were randomized to receive either methadone 0.15 mg/kg or 0.15mg/kg morphine after tracheal intubation. Both groups were treated with acetaminophen 1 gr before extubation. Protocol of anesthesia was the same in both groups and the anesthetist was blinded to the study groups. The primary outcome was defined as total opioid consumption during recovery and first day after surgery. Secondary outcomes were pain scores and level of patients’ sedation during the recovery period and first postoperative day as well as opioid-related complications. Results: Data of eighty-five eligible patients were analyzed. The mean pain and sedation scores were lower in the methadone group compared to the morphine group during recovery and the first 24 hours after surgery. The time of first rescue analgesic requirement was later in the methadone group (10.4 vs 6.3 hours). Also, postoperative morphine consumption was significantly less in the methadone group compared to patients receiving morphine (3.5 vs. 6.9 mg; P < 0.001). Conclusion: Intraoperative administration of methadone decreased postoperative pain scores, reduced opioid consumption after surgery and improved level of sedation during the first 24 hours after surgery. https://fem.tums.ac.ir/index.php/fem/article/view/1106 https://fem.tums.ac.ir/index.php/fem/article/download/1106/427

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 7 1 2023 01 14 e7 e7 Mostafa Alavi-Moghaddam Emergency Medicine Department, Imam Hossein Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran Mohammad Sistanizad Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran Mehrdad Haghighi Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran Tahereh Sabaghian Nephrology Department, Shahid Beheshti University of Medical Sciences, Tehran, Iran Bahare Gholami Chaboki Biostatistics Department, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran Zahra Soroureddin Prevention of Cardiovascular Disease Research Centre, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2022 08 13 2022 11 29 Objective: Despite the worldwide spread of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), an effective specific antiviral treatment for coronavirus disease of 2019 (COVID-19) is yet t