Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 5 4 2021 03 04 e38 e38 Roxana Sadeghi Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; 2. Department of Cardiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Amirmohammad Toloui Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran. Asma Pourhoseingholi Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran Niloufar Taherpour Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran Mohammad Sistanizad Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; 2. Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Fatemeh Omidi Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; 2. Department of Cardiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Mohammad Haji Aghajani Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; 2. Department of Cardiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2021 02 03 2021 02 09 Introduction: The correlation between echocardiographic findings and the outcome of COVID-19 patients is still under debate. Objective: In the present study it has been endeavored to evaluate the cardiovascular condition of COVID-19 patients using echocardiography and to assess the association of these findings with in-hospital mortality. Methods: In this retrospective cohort study, hospitalized COVID-19 patients from February to July 2020 with at least one echocardiogram were included. Data were extracted from patients’ medical records and the association between echocardiographic findings and in-hospital mortality was assessed using a multivariate model. The findings were reported as relative risk (RR) and 95% confidence interval (95% CI). Results: Data from 102 COVID-19 hospitalized patients were encompassed in the present study (63.7±15.7 mean age; 60.8% male). Thirty patients (29.4%) died during hospitalization. Tricuspid regurgitation (89.2%), mitral valve regurgitation (89.2%), left ventricular (LV) diastolic dysfunction (67.6%), pulmonary valve insufficiency (PI) (45.1%) and LV systolic dysfunction (41.2%) were the most common findings on patients’ echocardiogram. The analyses of data showed that LV systolic (p=0.242) and diastolic (p=0.085) dysfunction was not associated with in-hospital mortality of COVID-19 patients, while the presence of PI (RR=1.85; 95% CI: 1.02 to 3.33; p=0.042) and patients’ age (RR=1.03; 95% CI: 1.01 to 1.08; p=0.009) were the two independent prognostic factors of in-hospital mortality. Conclusions: It seems that LV systolic and diastolic dysfunction was not associated with in-hospital mortality of COVID-19 patients. However, presence and PI and old age are possible prognostic factors of COVID-19 in-hospital mortality. Therefore, using echocardiography might be useful in management of COVID-19. https://fem.tums.ac.ir/index.php/fem/article/view/663 https://fem.tums.ac.ir/index.php/fem/article/download/663/345

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 5 4 2021 03 16 e46 e46 Hossein Zabihi Mahmoudabadi Department of Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran Fatemeh Mohammadi School of Medicine, Tehran University of Medical Sciences, Tehran, Iran Maryam Bahreini Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran 2021 02 04 2021 03 07 Introduction: The possibility of foreign body ingestion should be considered in psychiatric patients. In some complicated cases, foreign bodies become problematic and require immediate surgical intervention. Case presentation: A 45-year-old man with schizophrenia swallowed razor blades and pieces of glass resulting in esophageal perforation, pneumothorax, pneumomediastinum and urgent need for surgery. He was presented in shock state but successfully passed post-operative period in the intensive care unit and surgical ward and was ultimately transferred to the psychiatric ward. Conclusion: Management of asymptomatic patients depends on the demographic factors of patients as well as the site affected in the gastrointestinal tract. https://fem.tums.ac.ir/index.php/fem/article/view/665 https://fem.tums.ac.ir/index.php/fem/article/download/665/348

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 5 4 2021 03 31 e36 e36 Kiumarth Amini Student Research Committee, Faculty of Pharmacy, Tehran 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 03 27 2021 03 28 In February 2020, the World Health Organization officially named the disease caused by the new corona virus as COVID-19 (Corona Virus Disease 2019). For COVID-19 patients, there are usually four phases of the disease. The first one is virus reproduction phase. The second phase is accompanied with mild symptoms and usually includes flu-like symptoms. The third phase is associated with the development of acute respiratory distress syndrome (ARDS) and is characterized by its symptoms. The fourth phase is associated with high fever, systemic inflammatory responses, especially in the lungs, and eventual respiratory failure. COVID-19 is associated with upregulations of inflammatory cytokines. In the acute phase of COVID-19, the function of TCD4+ cells are impaired and the production of interferon-gamma (IFN-γ) and Tumor Necrosis Factor-alpha (TNF-α) in these cells is reduced. With impaired immune function, virus replication continues, and damaged lung cells induce excessive inflammatory responses and overproduction of inflammatory cytokines such as TNF-α, IL-1β, and IL-6 from immune cells. This eventually induce cytokine storm with systemic inflammatory responses and end organ damage. The level of inflammatory cytokines such as IL-1β, IL-6 and IL-10 in COVID-19 patients has been reported to be higher in COVID-19 patients admitted in ICU. The lack of effective treatment for the severe infection caused by COVID-19 has led scientists and physicians to repurpose popular medications that are indicated for other similar conditions. No effective modality to successful management of this viral disease has yet been identified. Immunosuppressive and anti-inflammatory drugs have been suggested for acute patients with cytokine storms and severe lung involvement. Recently, due to the anti-inflammatory effects of selective serotonin reuptake inhibitors (SSRIs), their therapeutic effects have been proposed for COVID-19 patients. This group of drugs are usually prescribed to treat depressive disorders. SSRIs have been shown to reduce inflammation and the expression of inflammatory cytokines such as TNF⍺ and IL-1β. The decrease in inflammatory cytokines such as IL-1β and TNF-α in the cerebral tissue has been shown as a result of sertraline administration, indicating the anti-inflammatory effects of this drug. In another study, Fluvoxamine could lower IL-1β, IL-6, and TNFα expression in the striatum in depressed mice. Much attention is paid to sertraline due to its very low anticholinergic activity which is especially desirable for the elderly with coronary heart diseases. Moreover, the anti-inflammatory properties of this compound is attributed to prevention of the expression of pro-inflammatory cytokines. Recently, it was demonstrated that treatment of patients with major depression with SSRIs could reduce the expression of inflammatory cytokines, such as IL-10, TNF-α, and IL-6 in these patients. The expression of these inflammatory mediators increase in critically ill COVID-19 patients. Therefore, the use of this class of medications in the management of COVID-19 patients could be considered, especially for acute patients with cytokine storms. In a recently published study, the use of antidepressants SSRI and paroxetine and SNRI venlafaxine in hospitalized patients due to COVID-19 reduced the risk of intubation and death. This therapeutic effect on COVID-19 could be attributed to the inhibition of acid sphingomyelinase activity, which prevents epithelial cell from being infection by SARS-CoV2. It has also been suggested that S1A (σ-1- receptor) agonists can prevent cytokine storms in severe COVID-19. SSRIs, especially fluvoxamine and to a lesser extent sertraline have a moderate to high affinity for this receptor. Antidepressants are associated with decreased plasma levels of pro-inflammatory cytokines which elevate in COVID-19. Furthermore, the antiviral activity of some antidepressants such as fluoxetine has been reported in COVID-19 patients. In a randomized clinical trial on adult outpatients with COVID-19, administration of 100 mg of fluvoxamine reduced the likelihood of clinical deterioration over 15 days. This has been attributed to the high affinity of fluvoxamine for S1R, which reduces the inflammatory responses. It seems that SSRIs are potential candidates for COVID-19 due to their anti-inflammatory properties. Future clinical studies will determine the exact role of this class of medications in clinical outcomes of COVID-19 patients. https://fem.tums.ac.ir/index.php/fem/article/view/715 https://fem.tums.ac.ir/index.php/fem/article/download/715/353

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 5 4 2021 04 20 e45 e45 Dina Elkady Conservative Department, Faculty of Dentistry, Cairo University, Egypt Walid Abdella Faculty of Medicine, Al-Azhar University, Damietta, Egypt Muhamed Abdella Faculty of Medicine, Al-Azher University, Cairo, Egypt Abdelrahman Kopeya Department of Pediatric Surgery, Al-Azhar University, Assuit, Egypt Aboalmagd Hamdallah Faculty of Medicine, Al-Azhar University, Damietta, Egypt 2021 03 11 2021 03 31 Context: There is an unmet clinical need to develop simple, easy, rapid, and accessible testing for the detection of SARS-CoV-2. Recent reports suggested that saliva may be a host for the virus. The existence of SARS-CoV-2 in saliva can be associated with oral manifestations in infected patients. A systematic review was conducted as well as a meta-analysis to evaluate the diagnostic accuracy of detecting SARS-CoV-2 in saliva and investigate the association between positive saliva test and oral manifestations of COVID-19. Evidence acquisition: A literature search in MEDLINE via PubMed, Scopus, Web of Science, and Cochrane was done in June 2020 and updated in February 2021 using relevant keywords. We screened studies for eligibility. The extracted data were analyzed using Meta-Disc software. Results: Eighteen studies were included. Pooled data from eligible studies showed that the sensitivity of diagnosis of SARS-CoV-2 in saliva was 0.86 (95% CI, 0.83–0.89), and the specificity was 0.98 (95% CI, 0.96–0.98). COVID-19 was associated with oral diseases as amblygeustia, dry mouth, dryness, inflammation of the mouth, and enlargement of lymph nodes in the submandibular regions. Conclusions: Our results showed that the saliva has a high accuracy in the detection of SARS-CoV-2. https://fem.tums.ac.ir/index.php/fem/article/view/678 https://fem.tums.ac.ir/index.php/fem/article/download/678/354

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 5 4 2021 03 28 e39 e39 Hamid Kariman Emergency Department, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran Behnam Babadi Emergency Department, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran Masomeh Raofi Department of Radiology, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran Saeed Safari Department of Emergency Medicine, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 2021 03 28 2021 03 28 Introduction: Predicting the outcome is one of the most frequent and important issues when approaching patients with intracranial hemorrhage (ICH). Objective: This study aimed to evaluate the correlation of SUSPEKT score variables plus electrocardiogram (ECG) abnormalities with one-month mortality of patients with ICH presenting to emergency department (ED). Methods: In this cohort study, adult patients presenting to the EDs of three educational hospitals, during one year, were followed and their one-month mortality rate as well as independent predictors of outcome among the variables of SUSPEKT score plus electrocardiography findings were evaluated. Results: One hundred seventy-seven patients with the mean age of 63.07±14.89 years were studied (59.9%). The most common locations of intra-parenchymal hemorrhage were basal ganglia (53.7%) and cortex (36.2%). Ninety-two (52.0%) of cases had at least one ECG abnormality. The most frequent ECG abnormalities were ST segment depression (20.3%), T wave inversion (16.4%), and left ventricular hypertrophy (14.7%). Thirty (16.9%) cases died during the 30-day follow-up. Survived and non-survived cases were significantly different regarding the location of intra-parenchymal hemorrhage (p < 0.0001), presence of intraventricular hemorrhage (IVH) (p = 0.007), ST segment elevation (p < 0.0001), bradycardia (p < 0.0001), tachycardia (p < 0.0001), arterial fibrillation (p < 0.0001), blood sugar (p = 0.044), and serum level of potassium (p = 0.022). Conclusions: The location of hemorrhage (basal ganglia), higher blood sugar, and presence of ECG abnormalities (ST segment elevation, tachycardia, bradycardia, atrial fibrillation) were among the independent predictors of one-month mortality of ICH patients in this study. https://fem.tums.ac.ir/index.php/fem/article/view/716 https://fem.tums.ac.ir/index.php/fem/article/download/716/350

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 5 4 2021 05 16 e47 e47 Zahra Soleimani Nephrology and Urology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran Sedigheh Hantoushzadeh Valiasr Maternal Fetal Neonatal Research Center, Tehran University of Medical Sciences, Tehran, Iran Azam Soleimani Cardiac Rehabilitation Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran 2021 04 16 2021 05 02 Introduction: Management of seriously ill patients infected with new corona virus (SARS-CoV-2) is challenging especially in pregnancy and postpartum state. Case presentation: A 39- year-old primigravid critically ill woman with acute respiratory distress (ARDS) due to confirmed SARS-CoV-2 infection underwent urgent cesarean delivery (a healthy neonate) at 33 weeks and 5/7 of pregnancy. She received treatments including hydroxychloroquine, antivirals and broad-spectrum antibiotics while she was intubated for mechanical ventilation. In spite of all treatments, she developed a critical course after the mild primary clinical improvement. Convalescent plasma transfusio: The results from this review indicate that the chest CT scan should be used for symptomatic and hospitalized patients. Moreover, chest CT scan should not be used as a primary screening tool for diagnosing COVID-19. Application of RT-PCR as the first line diagnosis is still recommended. https://fem.tums.ac.ir/index.php/fem/article/view/459 https://fem.tums.ac.ir/index.php/fem/article/download/459/311

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 4 2s 2020 04 05 e37 e37 Mohammad Jalili Department of Emergency Medicine, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran. 2020 04 05 Emergency medical services (EMS) play a vital role in the management of public health emergencies such as epidemics of infectious diseases. Unique challenges, however, are expected under these circumstances beyond what occurs during normal conditions. EMS personnel often have limited information about their patients, work under uncontrolled conditions, and accompany their patients in enclosed spaces of the ambulance. They are at particular risk of contracting the infectious agent unless standard and transmission-based precautions are implemented. Appropriate use of personal protective equipment (PPE) by responding personnel is, therefore, of paramount importance. Since the report of the first cases of COVID-19 in late December 2019, the disease has spread beyond China. As of March 29th, a total of 634,835 confirmed cases have been reported globally and 29,975 people have died. The Center for Diseases Control (CDC) and other authorities and advisory agencies have prepared guidelines regarding safety precautions for EMS personnel, including appropriate selection and use of PPE . https://fem.tums.ac.ir/index.php/fem/article/view/376 https://fem.tums.ac.ir/index.php/fem/article/download/376/274

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 4 2s 2020 04 09 e40 e40 EN Zahid Hussain Khan Department of Anesthesiology and Critical Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran. Jalil Makarem Department of Anesthesiology and Critical Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran Mojgan Rahimi Department of Anesthesiology and Critical Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran 2020 04 04 2020 04 05 The novel coronavirus (COVID-19) emerged for the first time in China and then rapidly spread and swept the entire world like a tornado killing thousands of patients around the planet. People were advised to stay in-doors to prevent the spread of this deadly disease, and this slogan helped to a greater extent in containing the spread of the virus. Unfortunately, there is no treatment for the disease at present, but extensive research is going on to find a definitive treatment. Regarding endotracheal intubation (ETI) of COVID-19 patients, data are scarce and no randomized clinical trials are available to develop and formulate succinct and acceptable guidelines in tackling the problem of ETI in these highly risky and vulnerable patients. https://fem.tums.ac.ir/index.php/fem/article/view/374 https://fem.tums.ac.ir/index.php/fem/article/download/374/276

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 4 2s 2020 04 22 e59 e59 Debkumar Chowdhury Emergency Department, University Hospital Ayr, Ayr, Scotland, UK 2020 04 22 2020 04 22 Context: There is a significant burden on all emergency services in the management and prevention of the novel COVID-19 transmission. The effects are felt right across the World with certain geographical areas being most affected, it has affected all countries irrespective of their healthcare infrastructure. It has been suggested that certain parts of World that are prone to natural disasters are better prepared for pandemics. However, this is completely unfound as major economies are overwhelmed with the effects of the COVID-19 and it becomes completely irrelevant of any past experiences as these have been in never seen before scale. Evidence acquisition: The national fight against COVID-19 has been dubbed as the greatest fight for the National Health Service (NHS) with the entire United Kingdom under lockdown and the unfamiliar situation not seen before in peacetime. The general understanding of the disease process is that it has profound effects on the elderly and those with significant underlying health conditions such as cardiovascular, respiratory amongst others. However, it has surfaced from time to time that the very young are being affected and at times unfortunately been fatal. Results/Measures: The United Kingdom has been in a lockdown just like several nations across the globe in a desperate measure to limit the spread of the virus. There have been weeks of planning at every level for all possible eventualities with regards to the ongoing COVID-19 pandemic. All routine operations and procedures have been cancelled only procedures that emergency life and limb saving and cancer surgery continue to take place in hospitals all across the hospitals in the NHS. Widespread measures such as social distancing, calling a dedicated helpline for information and advice rather than attending the nearest Emergency Department have led to a significant number of presentations to the Emergency Department. Conclusions: The main concerns that remains for the NHS and other countries that have been affected is that once the lockdown restrictions are slowly eased will lead to a significant resurgence of cases that will overwhelm their respective healthcare infrastructures. From a clinician perspective, the main concern is the potential late presentations of the acutely unwell patients. This is the sentiment that is likely to be felt by many of my critical care colleagues working across NHS hospitals. https://fem.tums.ac.ir/index.php/fem/article/view/398 https://fem.tums.ac.ir/index.php/fem/article/download/398/283

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 4 2s 2020 05 10 e50 e50 Anitha Silvery Department of Emergency Medicine, Nizams Institute of Medical Sciences, Panjagutta, Hyderabad, India Mohammed Ismail Nizami Department of Emergency Medicine, Nizams Institute of Medical Sciences, Panjagutta, Hyderabad, India Ashima Sharma Department of Emergency Medicine, Nizams Institute of Medical Sciences, Panjagutta, Hyderabad, India Lakshmi Bhaskar Department of Hospital Administration, Nizams Institute of Medical Sciences, Panjagutta, Hyderabad, India 2020 04 30 2020 05 03 Introduction: Since the outbreak of Coronavirus on December 31, 2019 in Wuhan, Hubei Province, People’s Republic of China, the number of cases from China that have been imported into more than 180 countries and regions around the world.  Objective: The goal of this study is to flatten the curve of new infection, through nosocomial transmission by health care system along with early identification of asymptomatic COVID-19 cases.  Methods: A Survey was conducted over a period of 35 days. A total of 1709 individuals were screened (647 patients and 1062 patient attendees) coming to emergency Department. The waiting area of Emergency Care was divided into 3 screening zones and a separate second triage is established. The individuals entering are ensured that they are screened at all the 3 zones. Individuals were divided into two Groups after screening: Group A (suspected COVID-19) and Group B (unsuspected COVID-19). In Acute emergencies, the patient was directly treated at second triage.  Results: A total of 1709 individuals, 247 in Group A (Suspected COVID-19) and 1462 in Group B (Unsuspected COVID-19). Among 247 individuals, 141 were males and 106 were females. Age ranged from 14-72 years with a mean age of 46.7years. Among 247 individuals (Group A), 81 were patients, of which one case was found to be COVID-19 Positive. Two Health care workers (HCW’s) found to be positive.  Conclusion: Challenges from the widespread pandemic underscores the importance of early implementation of a second triage and vigorous screening for all the individuals to minimize the spread of infection, failing which pandemic infection may turn into an epidemic. https://fem.tums.ac.ir/index.php/fem/article/view/410 https://fem.tums.ac.ir/index.php/fem/article/download/410/295

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 4 2s 2020 05 11 e54 e54 Shervin Farahmand Department of Emergency Medicine, Tehran University of Medical Sciences, Tehran, Iran Shahram Bagheri-Hariri Department of Emergency Medicine, Tehran University of Medical Sciences, Tehran, Iran 2020 05 11 Introduction: It is likely that high rate of healthcare workers (HCWs) infection has occurred in Iran, but there is not any proof yet. Objective: This study was conducted to highlight the rate of Iranian HCWs infected by COVID-19 and some of its surrounding points. Methods: This cross-sectional study was conducted in Tehran, Iran. Using web-based applications including WhatsApp, Telegram, Instagram and Facebook, the link to the questionnaire was sent and exposed to the eligible ones. The target population of the study was HCWs who were diagnosed as approved cases of COVID-19. They were asked about their baseline characteristics and also possible source of infection, symptoms onset, hospitalization and etc. All findings presented by frequency and percent. Results: From March 29, 2020 to April 5, 2020, a total of 452 HCWs had completed the online questionnaire of whom 50.9% were women; mostly were in the age range of 25-29 years old. Among the participants, physicians had the largest population with 312 people (69.0%). The most frequent clinical symptoms were fatigue, fever and myalgia, respectively. The highest frequency with 85 cases (18.8%) was reported their symptoms onset within 20-24th February, 2020. The most commonly used piece of equipment was gloves, which was used in 57.3% of the cases, followed by simple surgical mask, which was used by 47.1% of the participants. In 21.9% cases no personal protective equipment was used. Totally, 348 cases (91.6%) were treated in an outpatient setting and only 36 cases (9.5%) needed to be hospitalized. In 160 cases (35.4%), at least one other person was infected with COVID-19 in their household. Conclusions: Considerable number of participants that declared their infection in this study, emphasizes on the considerable rate of Iranian HCWs infected by COVID-19. https://fem.tums.ac.ir/index.php/fem/article/view/425 https://fem.tums.ac.ir/index.php/fem/article/download/425/296

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 4 2s 2020 04 12 e41 e41 Davood Farsi Emergency Medicine Management Research Center, Iran University of Medical Sciences, Tehran, Iran Mani Mofidi Emergency Medicine Management Research Center, Iran University of Medical Sciences, Tehran, Iran Babak Mahshidfar Emergency Medicine Management Research Center, Iran University of Medical Sciences, Tehran, Iran Peyman Hafezimoghadam Emergency Medicine Management Research Center, Iran University of Medical Sciences, Tehran, Iran 2020 04 05 2020 04 06 Health care workers (HCWs) are heavily involved in the fight against COVID-19 in all over the world. They have the vital role of treating patients and searching for the proper treatment for the disease, while supporting and protecting their families. It is imperative that the systems should try hard to keep them safe and healthy. World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) have recently published guidelines for keeping HCWs safe and protected. The Personal Protective Equipment (PPE) is the cornerstone of recommendations and contains face mask (air purifying respirator), goggles or face shield, gown, and gloves. There is no doubt that a proper mask (e.g. N95) is the most important element of the protective gear when it comes to transmission of COVID-19. https://fem.tums.ac.ir/index.php/fem/article/view/378 https://fem.tums.ac.ir/index.php/fem/article/download/378/277

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 4 2s 2020 04 28 e60 e60 EN Fariba Asghari Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran Saeedeh Saeedi Tehrani Department of Medical Ethics, Iran University of Medical Sciences, Tehran, Iran 2020 04 18 2020 04 19 At present, the biggest challenge to health and economic systems around the world is the emergence of COVID-19 pandemic. Several ethical questions have been raised at the macro-, meso- and micro-levels with respect to proper management and control of this pandemic. The most important factor in creating fear and public anxiety and disturbances of social functions is the fatalities caused by the epidemic by an unknown pathogen in most countries. Decisions for epidemic control measures are made among many uncertainties, and prioritize public health over individual rights. People's trust and compliance with recommendations play a decisive role in public actions. Therefore, during an epidemic, necessities such as adherence to the values of honesty, respect, human dignity, solidarity, justice, reciprocity, transparency, and responsiveness in the response system need to be considered. The major ethical considerations in macro and micro levels of decision-making responding to the COVID-19 will be reviewed in this paper. Ethical dilemmas arise in different domains of a pandemic such as restriction on freedom of movement, individual’s refusal of preventive or therapeutic interventions, health care workers’ rights and duty to care, the allocation of scarce resources, off-label use of diagnostic and therapeutic measures and research. The purpose of this article is to pay attention to ethical principles in solving these challenges and does not necessarily respond to all ethical problems; however, it draws the reader's attention and moral sensitivity to the issues raised in this area. https://fem.tums.ac.ir/index.php/fem/article/view/390 https://fem.tums.ac.ir/index.php/fem/article/download/390/286

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 4 2s 2020 05 21 e55 e55 Samad Azari Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran Negar Omidi Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran Jalal Arabloo Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran Hamidreza Pourhosseini Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran Aziz Rezapour Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran 2020 05 01 2020 05 03 There is little data on direct medical costs and how to overcome the shock introduced by the novel Coronavirus (COVID-19) which emerged in Wuhan, China. The aim of this report is to present the methodology of an observational study for analyzing the resource utilization and direct medical costs of hospitalization. A multicenter retrospective observational study will be conducted on hospitalized patients with COVID-19 in selected hospitals of Tehran University Medical Sciences from February 2020 to June 2020. Cost calculations will be based on micro-costing approaches according to the health insurance perspective. Demographic, clinical, and cost data for the aforementioned patients will be collected through reviews of medical and financial records using a self-made questionnaire categorized in three parts (Form No. 1). The first part consists of demographic characteristics, the second part includes clinical information (e.g., symptoms, comorbidities, and complications), and the third part consists of resource utilization and cost data. Descriptive statistics (means, frequencies, percentages, and 95% confidence intervals) will be used to report data. With this report we sought to provide a valuable framework for estimating the direct medical costs of COVID-19 for hospitalized-patients basis on the severity of presentation. This will be the core for an assessment of the economic burden of COVID-19 in different presentations of the disease. https://fem.tums.ac.ir/index.php/fem/article/view/414 https://fem.tums.ac.ir/index.php/fem/article/download/414/301

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 4 2s 2020 05 26 e51 e51 Pooya Payandemehr Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran Morteza Azhdarzadeh Department of Pharmaceutical Nanotechnology, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran Hooman Bahrami-Motlagh Radiology Department, Loghman Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran Azar Hadadi Department of Infectious Diseases, Tehran University of Medical Sciences, Tehran, Iran Farhad Najmeddin Clinical Pharmacy Department, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran Shaghayegh Shahmirzaei Trauma and Surgery Research Center, Sina hospital, Tehran University of Medical sciences, Tehran, Iran Marzieh Pazoki Department of Pulmonary Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran Mehran Sotoodehnia Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran Reza Rahimian McGill Group for Suicide Studies, Douglas Mental Health University Institute, McGill University, Montreal, QC, Canada 2020 05 26 Introduction: Since December 2019, an outbreak of Covid-19 has caused growing concern in multiple countries. Researchers around the world are working to find a treatment or a vaccine for Covid-19 and different treatment approaches have been tested in this regard.  Objective: This study was designed and conducted to assess the possible efficacy of Interferon beta-1a as a safe and efficient candidate for Covid-19 treatment.  Methods: This is an investigator-initiated, open-label, single-arm clinical trial. Twenty patients with suspected Covid-19, who were admitted to Sina hospital in Tehran, Iran, with moderate to severe symptoms, from 6 to 10 March, 2020, were enrolled. Patients were treated with antiviral and hydroxychloroquine combination therapy, along with subcutaneous Interferon beta-1a for 5 consecutive days. Baseline characteristics and findings during the course of admission and 5 days after discharge were recorded for all the patients.  Results: In total, 20 patients with suspected Covid-19 were included in this study, 12 (60%) of which were male. The median (Interquartile (IQ) range) of patients’ age was 55.5 (43-63.5). The most common symptom of the patients at onset of disease was fever. The median (IQ range) of duration of hospital stay was 5.0 (3-6) days. Only 2 cases were admitted to ICU. At the time of follow-up, 15 (94%) patients reported that they generally felt good and had oral tolerance, 1 patient had suffered from dyspnea, 5 patients had suffered from cough, none of them had experienced fever and no case of re-admission or death was reported after discharge.  Conclusions: Results of the current study are in favor of using Interferon beta-1a in addition to recommended antiviral treatment in Covid-19 patients. https://fem.tums.ac.ir/index.php/fem/article/view/454 https://fem.tums.ac.ir/index.php/fem/article/download/454/307

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 4 2s 2020 05 28 e38 e38 Hooman Hossein-Nejad Department of Emergency Medicine, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran 2020 05 28 Overcrowding during pandemics, such as COVID-19 necessitates the separation of respiratory patients in different locations with special protective measures. Thus, we allocated space to such a purpose and named it "respiratory emergency” in our emergency department and started to triage the patients coming in with respiratory tract signs and symptoms apart from others. However, the most critical point for the triage of respiratory patients is differentiation between COVID-19 and non COVID-19 suspicious patients as well as decision-making in terms of self- quarantine and outpatient treatment or admission. Considering the lack of test kits and more importantly, the uncertainty revolving around the performance and efficacy of tests, we used computed tomography (CT) scan as a triage tool, yet our machines cannot scan all these patients because we had up to more than eight hundred patients per day. Meanwhile three of us - emergency attending physicians - were under the impression that lung ultrasound may help. Therefore, we started to use lung ultrasound in a limited fashion. Fortunately, typical cases had peripheral and sub-pleural lesions that could be seen by ultrasound. Parallel to these efforts, limited reports were published about the use of ultrasound for COVID-19 in other regions. Evidently, a screen test is expected to have high sensitivity rather than specificity and the ultrasound provides this opportunity. Also we know the findings are not specific and for example we had observed these patterns in other viral epidemics, such as severe acute respiratory syndrome (SARS) or middle East Respiratory Syndrome (MERS). To date, several triage systems have been developed. The Italian version used by Dr. Volpicelli first and developed further by others, like that of Liam Devonport can exemplify this case. Furthermore, a simple triage system has been developed by Dr. Mike Stone, based on the ultrasound of lungs plus oxygen need. This flowchart summarizes Dr. Stone’s idea with three elements for decision-making consisting of:  a) O2 requirement, b) B lines and c) consolidation. Three categories are enrolled. All patients with cough, fever and dyspnea or patients coming in from high-risk areas or those having close contact with covid-19 patients are enrolled. After bedsides sampling for polymerase chain reaction (PCR) test, the O2 saturation is measured and lung ultrasound is also done and then according to the data obtained, four categories are created as follows: • Inpatients for whom supplementary O2 is not required. If lung ultrasound shows A profile, patients can be discharged to home quarantine. If lung shows profile B, patients should undergo quarantine plus follow-up. This quarantine can be at home or institutes considering the facilities available. • Patients, depending on supplementary oxygen, should be admitted according to the findings of lung ultrasound. If they have only B lines, they are admitted in the ward but if they have profile B plus consolidation, we should consider intensive care unit (ICU) beds for them. In essence, all these systems use lung ultrasound for decision-making, which is efficient in a majority of occasions, yet