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, men expose more viral load than women, also athletes receive more viral load than non-athletes. Viral load is a critical parameter in the severity and mortality of COVID-19 infection. The offered hypothesis may recognize a potential approach in future studies and investigations of COVID-19 infection. Confirmation of this theory in comer studies may update health advice and improve precaution recommendations between athletes and non-athletes as well as men and women based on the surface area of the respiratory system. https://fem.tums.ac.ir/index.php/fem/article/view/702 https://fem.tums.ac.ir/index.php/fem/article/download/702/352

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 5 3 2021 01 29 e30 e30 EN Haleh Ashraf Cardiac Primary Prevention Research Center (CPPRC), Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran Azadeh Sadatnaseri Department of Cardiology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran Arya Aminorroaya Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran Zahra Kuhi Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran Nadia Zandi Cardiac Primary Prevention Research Center (CPPRC), Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran Shahrokh Karbalai Saleh Department of Cardiology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran 2020 12 23 2020 12 29 Introduction: Pseudoaneurysm may occur as a rare complication of myocardial infarction (MI) when a hemorrhagic process is covered by adherence of the visceral or parietal pericardium or of both, preventing the formation of cardiac tamponade. Pseudoaneurysm is prone to rupture because they are not easy to diagnose. Case presentation: Here, we report three cases of left ventricular pseudo-aneurysm (LVP) that all were related to MI. Two patients were managed conservatively, one of them was lost to follow-up, and the other one expired one month later. One patient underwent surgery, but he expired during post-operation period. Conclusions: High mortality rate of LVP emphasizes the importance of looking for it in cardiac evaluation of patients with history of MI. Due to available non-invasive modalities, the ability to differentiate LVP from other cardiac pathologies is improving. Still, the most recommended management of LVP is early surgery. https://fem.tums.ac.ir/index.php/fem/article/view/617 https://fem.tums.ac.ir/index.php/fem/article/download/617/340

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 5 3 2021 02 09 e31 e31 Mohsen Ebrahimi Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical sciences, Mashhad, Iran. Samaneh Abiri Department of Emergency Medicine, Jahrom University of Medical sciences, Jahrom, Iran. Esmaeal Rayat Dost Department of Emergency Medicine, Jahrom University of Medical sciences, Jahrom, Iran. Fatemeh Rahmanian Department of Emergency Medicine, Jahrom University of Medical sciences, Jahrom, Iran. Mahdi Foroughian Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical sciences, Mashhad, Iran. Alireza Abbasi Department of Infectious Disease, Jahrom University of Medical Sciences, Jahrom, Iran. Mohammad Hashem Abdi Department of Nursing, Jahrom University of Medical Sciences, Jahrom, Iran. Poyan Keshavarz Student Research Committee, Jahrom University of Medical Sciences, Jahrom, Iran. Naser Hatami Student Research Committee, Jahrom University of Medical Sciences, Jahrom, Iran. Navid Kalani Research Center for Social Determinants of Health, Jahrom University of Medical Sciences, Jahrom, Iran Marzieh Haghbeen Women’s Health and Disease Research Center, Jahrom University of Medical Sciences, Jahrom, Iran. 2020 12 29 2020 12 29 Introduction: COVID-19 is currently a global pandemic, and coagulation-related mortality has been widely reported in patients suffering from it. Objective: this article aimed to investigate the coagulation profile of COVID-19 patients. Methods: This was a cross-sectional study conducted using a retrospective research design. We recruited patients with COVID-19 admitted to a hospital from June 15th to July 7th, 2020. Upon patients' entering a blood sample was drawn from each patient for assessing patient’s coagulation profile (PT, PTT, INR, Platelet count); and a chest high-resolution computed tomography (HRCT) scan was performed for each patient. The study patients were divided in to sever group (CO-RADS score 5) and non-sever group (CO-RADS score <5). Results: Thirty-six patients (20 males and 16 females) with a mean age of 54.7±17.5 years were studied. Of them, 11 cases (30.56%) had severe pulmonary involvement. Also, the coagulation profiles were longer in the severe group than non-sever group. As well, the means of platelet count that were 232.440 per microliter in the non-severe group and 289.180 per microliter in the severe and non-sever groups, respectively; but still not statistically significant (p>0.05). The Area under the ROC Curve (AUC) for PT and INR was 0.615 and 0.611, respectively. The AUC for platelet count was 0.680 (95% CI: 0.501 to 0.859) and had an acceptable discriminating power. Conclusions: In this study, we did not find any statistically significant relationship between the results of coagulation tests and the severity of pulmonary involvement according to HRCT scan findings in COVID-19 patients. But further analyses suggest that, except PTT, the other coagulation tests (PT, INR, and platelet count) may discriminate severe COVID-19 patients. https://fem.tums.ac.ir/index.php/fem/article/view/619 https://fem.tums.ac.ir/index.php/fem/article/download/619/341

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 5 3 2021 03 14 e32 e32 EN Majid Shohrati Department of Pharmacotherapy, Faculty of Pharmacy, Baqiyatallah University of Medical Sciences, Tehran, Iran Amir Mohammadi Student Research Committee, Faculty of Pharmacy, Shahid Sadoughi University of Medical Sciences, Yazd, Iran Atabak Najafi Department of Anesthesiology and Critical Care, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran Mohammad Sharifzadeh Department of Pharmacology and Toxicology, Tehran University of Medical Sciences, Tehran, Iran Hamidreza Sharifnia Department of Anesthesiology and Critical Care, Sina Hospital, Tehran University of Medical Sciences, Iran. Mohammad Abdollahi Toxicology and Diseases Group, The Institute of Pharmaceutical Sciences (TIPS) and Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran Mahmood Salesi Chemical Injuries Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran Adeleh Sahebnasagh Clinical Research Center, Department of Internal Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran Mojtaba Mojtahedzadeh Department of Clinical Pharmacy, Pharmaceutical Research Institute, Tehran University of Medical Sciences, Tehran, Iran 2021 02 19 2021 03 07 Introduction: Considering that hemorrhagic stroke patients are at higher risk for bleeding, administration of higher doses of melatonin with a controversial coagulation profile is a serious concern. Objective: This study aimed to investigate the possible effects of high doses of melatonin on bleeding parameters and blood hemostasis in hemorrhagic stroke patients. Methods: This study is a randomized, double-blind, prospective, controlled trial. Confirmed hemorrhagic stroke patients were divided into two groups. Participants were randomly assigned into the melatonin group (30 mg daily via gastric tube gavage for 5 consecutive days) or the control group. Each patient was monitored for 5 days, and 2 blood samples were taken and the effect of the intervention on coagulation factors and blood hemostasis were investigated. Result: In total, 30 patients were randomly assigned to melatonin (n=15) or control groups (n=15). there was no significant difference between the two groups in demographic and clinical characteristics. There was a significant decline in prothrombin time (PT) and fibrinogen levels in the melatonin group (p=0.011 & p<0.001, respectively). P-values for VII and VWB factors showed a significant increment in these two factors in the melatonin group after the intervention (p=0.035 & p=0.002, respectively). No significant changes in serum levels of D-dimer factor, APACHE II, and GCS scores were evident in the two groups after the intervention (p>0.05). Conclusion: Considering the favorable changes in coagulation parameters observed in this study, it could be concluded that melatonin can have both procoagulant and antithrombin properties. https://fem.tums.ac.ir/index.php/fem/article/view/671 https://fem.tums.ac.ir/index.php/fem/article/download/671/347

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 5 3 2021 12 31 e33 e33 Hosseinali Abdorrazzaghi Division of Reconstructive Surgery, Department of Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran Babak Hajibarati Division of Plastic and Reconstructive Surgery, Emam Khomeni Hospital, Tehran University of Medical Sciences, Tehran, Iran Fateme Mohammadi School of Medicine, Tehran University of Medical Sciences, Tehran, Iran 2021 03 17 Introduction: Soft tissue defects over the distal leg and/or heel are probable injuries that need a flap. Various coverage techniques have been described in this regard. It seems that applying Reverse Sural Fascio-Cutaneous Flap (RSFCF) for reconstructing soft tissue defects of lower limbs has superiorities over other techniques. Objective: We intend to present a case series with soft tissue defect over the distal third of lower limb, covered using RSFCF technique. Methods: This is a case series and longitudinal study in which patients with crush injuries who referred to the emergency department (Sina hospital, Tehran, Iran) from 2013 until 2020 and were treated with RSFCF technique were included. The data were collected using patients’ charts, by interviewing the patients, and from hospital records. The patients' wounds were prepared, examined, and the surgery was done. Tendon and bone defects were repaired, and wounds were closed using reverse sural Fascio-Cutaneous Flap. Results: A total of 13 patients were eligible during the 6-year study period. Men were more commonly affected with no conclusive gender trend. The posterolateral part of the foot of the right leg was the most frequently injured part (53.8%). Only 1 patient had mentioned complications after surgery including mild congestion and abnormal sensory and motor examination. Patients were followed by the surgeons until 3 months after the operation and all of them had been able to resume their daily life activities by then. Conclusion: According to our findings, almost all of the patients (except one) had received their flaps without any complications. All the patients had been able to resume their daily life activities three months after the surgery. This may show that RSFCF, which can be quickly performed and does not need microsurgical skills, could be a suitable option for the coverage of distal third of lower limb soft tissue defects caused mainly by trauma. https://fem.tums.ac.ir/index.php/fem/article/view/681 https://fem.tums.ac.ir/index.php/fem/article/download/681/349