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, ial worker considering the clinical features of the case. The social service experts and providing physicians were reassured there was no concerns for child abuse, sexual abuse, neglect, behavioral or psychiatric disorders. The patient was discharged with Bactrim and analgesics for one week after he was able to void independently. One month follow up at the urology clinic revealed that the patient had good skin preservation, wound healing, and micturition. The patient had no difficulties with anxiety, depression, or post-traumatic stress at his follow up appointments with a behavioral health therapist. https://fem.tums.ac.ir/index.php/fem/article/view/1157 https://fem.tums.ac.ir/index.php/fem/article/download/1157/436

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 7 2 2023 03 10 e20 e20 Wajeeha Musharraf Star Hospitals, Banjara Hills, Hyderabad, Telangana, India Sudhir Mane SVS Medical College and Hospital, Mahabubnagar, Telangana, India Habeeba Musharraf Shadan Institute of Medical Sciences, Peeramcheru, Hyderabad, Telangana, India 2023 02 08 2023 03 09 Workplace violence in hospitals, specifically in emergency departments (ED), has become a growing concern in recent years. This violence can come from patients, their families, or visitors and can take the form of verbal or physical attacks. Preventing violence in EDs can be achieved through design modifications with minimal personnel and infrastructure requirements. Infrastructure design plays a crucial role in reducing the risk of violence. Private lockers should be available at the ED entrance to limit dangerous objects being brought into the department. Furnishings should be fixed to prevent them from being used as weapons, and evacuation should be facilitated through open rows of seating. Positive distractions, such as gardens or natural areas visible through windows, can reduce stress in patients and lower aggression. Ligature points should be eliminated and tamper-resistant items should be provided to reduce dangers in the built environment. The triage desk should be positioned in a secure area with access control and panic buttons available for staff. Hidden exits should be provided in case of violence and emergency exits should open outward and be lockable only from the outside. It seems that preventing violence in EDs requires a combination of management, technology, planning, and physical design. Proper infrastructure design can play a crucial role in reducing the risk of violence, and healthcare professionals, administrators, and architects should be aware of best practices in ED design. https://fem.tums.ac.ir/index.php/fem/article/view/1164 https://fem.tums.ac.ir/index.php/fem/article/download/1164/437

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 7 2 2023 12 31 e14 e14 Shirin Madadian School of Medicine, Tehran University of Medical Sciences, Tehran, Iran Mojgan Rahimi Department of Anesthesiology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran Peyman Saberian Department of Anesthesiology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran Parisa Hasani-Sharamin Tehran Emergency Medical Service Center, Tehran, Iran Amirhossein Orandi Department of Anesthesiology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran Alireza Jalali Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran Seyed Khalil Pestechi Department of Anesthesiology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran Sepideh Aarabi Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran Mahshid Faghani Department of Internal Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran 2023 04 19 Objective: There are several methods for teaching emergency medical technicians (EMTs) cardiopulmonary resuscitation (CPR); but choosing the most effective option depends on several factors. This study was designed to compare the effectiveness of three different CPR training methods, including traditional, peer, and virtual methods, for EMTs. Methods: This study was a pretest-posttest study, which was performed from March to September 2020 in Tehran, Iran. Participants were EMTs working in the operations department of the EMS center. In the first step, for the pretest evaluation, an Objective Structured Clinical Evaluation (OSCE) exam was held for all participants. Thereafter, the subjects were divided into 3 groups including master-centered traditional collective education, peer training, and virtual courses. Then the participants underwent educational intervention and after that, another OSCE exam was held about 1 week after the sessions to evaluate the effect of interventions. Results: At first, 156 volunteers entered the study and participated in the pretest OSCE exam, of which 125 volunteers participated in the posttest OSCE exam. Of these, 51 volunteers participated in the peer education group, 35 volunteers were in the virtual education group, and 39 volunteers in the classic education group. The mean score of the participants in all 4 assessed skills, including endotracheal intubation, laryngeal mask airway insertion, basic life support, and advanced life support, increased significantly after educational intervention in all 3 groups (p<0.05); and this increase was higher in the virtual group compared to the other two groups (p<0.05). Conclusion: We found that virtual training was more effective than classic and peer training for CPR training of EMTs. https://fem.tums.ac.ir/index.php/fem/article/view/1201 https://fem.tums.ac.ir/index.php/fem/article/download/1201/441

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 7 2 2023 04 22 e15 e15 Khalid Almulhim Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia Ali Mobarki College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia Abdulelah Aljasir College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia. Abdullah Almulhim College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia. Ibrahim Almulhim College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia. 2022 12 25 2023 04 20 Objective: This study aims to understand students' skills based on their self-assessment and their perceptions regarding emergency medicine (EM) physicians, EM patients, and choosing EM as a future career. Methods: This study employed prospective observational design. It was conducted from 2 October to 2 November 2022 in Saudi Arabia. The study participants were senior medical students at King Faisal University. Senior students who finished a four-week EM rotation were involved as post-cases, and senior students who had not finished their EM rotation were involved as pre-cases. An online survey was administrated to all students who met out criteria. Results: A total of 161 students were included in the study; 65.2% had not yet done their EM clerkship, while 34.8% had completed their EM clerkship. Among them, 48.4% were male, and 51.6% were female. On average, post-EM clerkship students showed greater confidence in their skills of conducting an initial assessment of a patient (p=0.027), developing a management plan (p=0.007), explaining the principles of EM to others (p<0.001), presenting patient cases formally (p=0.049), interpreting electrocardiogram (p=0.006), and applying medical resuscitation (p=0.041). No significant differences were found between the average confidence in the skills and abilities of male and female students. Post-EM clerkship and male students were more likely to choose EM as a career when compared with pre-EM clerkship (p<0.001) and female students (p=0.006). Conclusion: It seems that, after completing a four-week rotation, students exhibited significant advances in knowledge, illness management, and procedural skills. It is likely that the EM clerkship significantly improved students' perceptions of the EM specialty. https://fem.tums.ac.ir/index.php/fem/article/view/1142 https://fem.tums.ac.ir/index.php/fem/article/download/1142/443

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 7 2 2023 04 26 e16 e16 Kiumarth Amini Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran Mojtaba Mojtahedzadeh Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran Atabak Najafi Department of Anaesthesiology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran Hamidreza Sharifnia Department of Anaesthesiology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran Aliasghar Tabatabaei Mohammadi Urmia University of Medical Sciences, Urmia, Iran 2022 12 13 2023 01 16 Objective: Sepsis is one of the leading causes of mortality in intensive care unit. Despite advances in its management, its mortality rate remains high. Recently, high dose of vitamin C in sepsis treatment has attracted the attention of researchers. In the current study, the impacts of 25 mg/kg of vitamin C every 6 hours as a bolus for 3 days were assessed in septic patients in intensive care unit (ICU). Methods: This was a prospective cohort study that was performed on adult patients with diagnosis of sepsis. Patients were assigned to control group (administration of placebo) or intervention group, i.e., those receiving a 25 mg/kg dose of vitamin C every 6 hours as a bolus for 3 days. Clinical data were recorded before and after the experiment. Also, plasma levels of antithrombin III, syndecan-1, fibrin degradation product (FDP), D-dimer, and C-reactive protein (CRP) were measured at 0, 24, 48, and 72 hours. Results: In septic patients receiving vitamin C, a significant upregulation of antithrombin III and significant decreases in the levels of syndecan-1 (at 48 hours; P-value=0.046 and at 72 hours; P-value=0.007), D-dimer and CRP were observed compared to the control. Reductions in sequential organ failure assessment (SOFA) score, in-hospital mortality, and ICU length of stay were seen in septic patients receiving vitamin C. Conclusion: Prescribing high dose of intravenous vitamin C can reduce the mortality of sepsis patients and reduce the length of stay in the ICU. https://fem.tums.ac.ir/index.php/fem/article/view/1131 https://fem.tums.ac.ir/index.php/fem/article/download/1131/442

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 7 2 2023 04 27 e17 e17 Alireza Zemestani Department of Epidemiology, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran. Iran Amir Kavousi Department of Epidemiology, School of Public Health and Safety, Safety Promotion and Injury Prevention Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran Homayoun Sadeghi-Bazargani Road Traffic Injury Prevention Research Center, Tabriz University of Medical Sciences, Tabriz, Iran Hamid Soori Department of Epidemiology, School of Public Health and Safety, Safety Promotion and Injury Prevention Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2023 01 03 2023 01 22