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 transfusion as a rescue treatment was performed and led to an improvement in her general condition and delayed gradual recovery in respiratory function after two months. Conclusion: The promising role of early treatment with convalescent plasma transfusion in seriously ill pregnant women infected with SARS-CoV-2, needs to be elucidated by further randomized studies.  https://fem.tums.ac.ir/index.php/fem/article/view/726 https://fem.tums.ac.ir/index.php/fem/article/download/726/356

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 5 4 2021 06 01 e37 e37 Shaghayegh Rahmani Innovated Medical Research Center, Faculty of Medicine, Mashhad Branch, Islamic Azad University, Mashhad, Iran Shahram Keikha Department of Emergency Medicine, Mashhad Branch, Islamic Azad University, Mashhad, Iran 2021 05 17 2021 05 20 About 18 months has passed since the first case of coronavirus disease of 2019 (COVID-19) was reported., that caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). There has been some incoherence about various aspects of the disease. A concern has been raised regarding reinfection of patients who have recovered from COVID-19. There are rare reports of cases with suspected COVID-19 “recurrence” or “reactivation”. This could be horrible news for all countries over the world, because the novel virus has a great impact on economy, society, and health. “Retesting Positive for SARS‐CoV‐2” is very attractive and frightening for scientists and has triggered discussions. Retesting positive might be explained in two categories; first, test quality and second, discharge criteria. On the other hand, it has been suggested that there might be a lag in virus clearance in some cases, for example older ones. But the evidence is not sufficient. Here we report a case of virologically-confirmed COVID-19 patient having experienced a clinically- and virologically-confirmed reinfection of COVID-19. One of our nurses who was a 50-year-old man with history of ischemic heart disease and coronary artery bypass graft was referred to the emergency department with dyspnea and myalgia. He was hospitalized for three days because of his risk factors and positive Reverse transcription polymerase chain reaction (RT-PCR) test for COVID-19. He was discharged and advised to isolate and quarantine. After 6 months, he came back with uncontrolled fever and dyspnea. His O2 saturation was below 80%. He was admitted and hospitalized for 10 days. His RT-PCR test result was positive again for COVID-19. Figure 1 shows his first and second x-ray. It is important to distinguish reinfection and reactivation of COVID-19, because, in Iran, we permit patients to leave isolation or discharge them from hospital based on clinical recovery without retesting in many cases. While, for example in the Korean approach it has been suggested to label patients as negative after two negative test results in 24 hours. Re-positive RT-PCR test result for SARS-CoV-2 is an emerging global pandemic control challenge. Korea Centers for Disease Control and Prevention (KCDC) reported a high percentage of re-positive cases among asymptomatic patients, most reported cases had mild to moderate symptoms and most of them were asymptomatic. All in all, it is a fact that patients with COVID-19 history might experience re-activation or reinfection. We believe that the criteria for calling patients non-infectious should be reviewed. https://fem.tums.ac.ir/index.php/fem/article/view/755 https://fem.tums.ac.ir/index.php/fem/article/download/755/359

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 5 4 2021 03 28 e40 e40 Alireza Jalali Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran Ehsan Karimialavijeh Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran Parto Babaniamansour Department of Biomedical Engineering, University of Kentucky, Lexington, Kentucky, USA Ehsan Aliniagerdroudbari School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran Sepideh Babaniamansour School of Medicine, Islamic Azad University Tehran Faculty of Medicine, Tehran, Iran. 2021 02 03 2021 03 07 Introduction: Coronavirus Disease (COVID‐19) has become the most important global health issue, and chest computed tomography (CT) scan can help determine the severity of the infection. Objectives: This study aimed to provide an emergency scoring tool for predicting 30-day adverse outcomes in non-critical new-onset COVID-19 patients. Methods: This derivation study was conducted on new-onset COVID-19 patients presenting to the emergency department of an urban teaching hospital in Tehran, Iran, between 20 February and 20 March 2020. The total lobe severity score (TSS), age, history of comorbidities, and 30-day adverse outcomes (death, ICU admission or intubation) were taken into account to produce three prediction models. Results: Overall, 137 patients were included in the study. Their mean age was 59.9±16.8 years and 62% were male. The ground glass nodule, patch B/punctate ground-glass opacity, fibrous stripes, and air bronchogram sign with perihilar distribution, bilateral and ≥ 2 affected lobes were the most common findings. The mean TSS (model 1) was significantly higher in patients with an adverse outcome (9.4±3.2) compared to the discharged patients (7.2±3.3) (p<0.001, AUC: 0.703, sensitivity: 64.4% and specificity: 74.1%). The optimal cut-off point of model 2 (TSS and age) had the following parameters: AUC: 0.721, sensitivity: 71.2% and specificity: 67.2%. The optimal cut-off point of model 3 (TSS, age, comorbidities) had: AUC: 0.755, sensitivity: 79.7% and specificity: 65.5%. The discrimination achieved with model 3 based on Bonferroni’s test was significantly better than that achieved with TSS (p<0.001). Conclusion: TSS combined with age and history of at least one comorbidity had a better predictive value for adverse outcomes with a cut-off point above 8. https://fem.tums.ac.ir/index.php/fem/article/view/662 https://fem.tums.ac.ir/index.php/fem/article/download/662/351

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 5 4 2021 07 04 e41 e41 Alireza Fahimzad Pediatric Infectious Diseases Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran Iraj Sedighi Department of Pediatric, Faculty of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran Neda Pak Children Medical Centre of Excellence, Tehran University of Medical Sciences, Tehran, Iran Mitra Khalili Radiology Department, Mofid Children Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran Mohammad Farahmand Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Mohammad Reza Shokrollahi Pediatric Medicine Research Center, Qom University of Medical Sciences, Qom, Iran Hosein Heydari Pediatric Medicine Research Center, Qom University of Medical Sciences, Qom, Iran Zahra Movahedi Pediatric Medicine Research Center, Qom University of Medical Sciences, Qom, Iran Anahita Sanaei Dashti Alborzi Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran Fatemeh Cheraghali Department of Pediatric, Faculty of Medicine, Golestan University of Medical Sciences, Gorgan, Iran Ahmad Shamsizadeh Aboozar Children Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran Mohammadreza Mirkarimi Aboozar Children Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran Mohsen Alisamir Aboozar Children Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran Houman Hashemian Pediatric Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran Jafar Soltani Department of Pediatrics, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran Ali Hosseininasab Infectious and Tropical Research Center, Kerman University of Medical Sciences, Kerman, Iran Abdolkarim Hamedi Infection Control Hand & Hygiene Research Center, Mashhad University of Medical Sciences, Mashhad, Iran Mohammad Sadegh Rezai Pediatric Infectious Diseases Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran Shirin Sayyahfar Research Center of Pediatric Infectious Diseases, Institute of Immunology and Infectious Diseases, Iran University of Medical Sciences, Tehran, Iran Manijeh Kahbazi Infectious Diseases Research Center, Arak University of Medical Sciences, Arak, Iran Aliakbar Abedini Department of Pediatrics, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran Afsaneh Akhondzadeh Infectious Disease Research Center (IDRC), Arak University of Medical Sciences, Arak, Iran Hamid Reza Sherkatolabbasieh Department of Pediatrics, School of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran Ali Akbar Razlansari Department of Pediatrics, School of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran Mina Alibeik Pediatric Infections Research Center, Mofid Children Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran Soheil Omid Malayeri Health Clinical Sciences Research Center, Zahedan Branch, Islamic Azad University, Zahedan, Iran Zohreh Shalchi Department of Pediatric, Faculty of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran Ali Shahabinezhad Joint Reconstruction Research Center, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran Parinaz Khalkhali Asl Department of Microbiology, Faculty of Medicine, Golestsn University of Medical Sciences, Gorgan, Iran Yousef Erfani Department of Medical Laboratory Sciences, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran Mehdi Norouzi Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Fatemeh Nafe Monfared Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Shiva Maleki Department of Virology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran Rezvan Kakavand Department of Virology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran Babak Shahbaz Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Vahdat Poortahmasebi Research Center for Clinical Virology, Tehran University of Medical Sciences, Tehran, Iran Sara Akhavan Rezayat Department of Health Care Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Mohammad Reza Karimi Department of Laboratory Sciences, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran Ali Jafarpour Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Saber Soltani Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Azam Ghaziasadi Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Razieh Dowran Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Shohreh Azimi Research Center for Clinical Virology, Tehran University of Medical Sciences, Tehran, Iran Shima Sadeghipour Marvi Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Foad Abazari Research Center for Clinical Virology, Tehran University of Medical Sciences, Tehran, Iran Milad Zandi Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Seyed Mohammad Jazayeri Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Ahmad Tavakoli Research Center of Pediatric Infectious Diseases, Institute of Immunology and Infectious Diseases, Iran University of Medical Sciences, Tehran, Iran 2021 05 09 2021 06 22 Introduction: To date, little is known about the clinical features of pediatric COVID-19 patients admitted to intensive care units (ICUs). Objective: Herein, we aimed to describe the differences in demographic characteristics, laboratory findings, clinical presentations, and outcomes of Iranian pediatric COVID-19 patients admitted to ICU versus those in non-ICU settings. Methods: This multicenter investigation involved 15 general and pediatrics hospitals and included cases with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection based on positive real-time reverse transcription polymerase chain reaction (RT-PCR) admitted to these centers between March and May 2020, during the initial peak of the COVID-19 pandemic in Iran. Results: Overall, 166 patients were included, 61 (36.7%) of whom required ICU admission. The highest number of admitted cases to ICU were in the age group of 1–5 years old. Malignancy and heart diseases were the most frequent underlying conditions. Dyspnea was the major symptom for ICU-admitted patients. There were significant decreases in PH, HCO3 and base excess, as well as increases in creatinine, creatine phosphokinase (CPK), lactate dehydrogenase (LDH), and potassium levels between ICU-admitted and non-ICU patients. Acute respiratory distress syndrome (ARDS), shock, and acute cardiac injury were the most common features among ICU-admitted patients. The mortality rate in the ICU-admitted patients was substantially higher than non-ICU cases (45.9% vs. 1.9%, respectively; p<0.001). Conclusions: Underlying diseases were the major risk factors for the increased ICU admissions and mortality rates in pediatric COVID-19 patients. There were few paraclinical parameters that could differentiate between pediatrics in terms of prognosis and serious outcomes of COVID-19. Healthcare providers should consider children as a high-risk group, especially those with underlying medical conditions. https://fem.tums.ac.ir/index.php/fem/article/view/747 https://fem.tums.ac.ir/index.php/fem/article/download/747/362

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 5 4 2021 07 06 e42 e42 Özge Can Emergency Department, Ege University, Izmir, Turkey Sercan Yalcinli Emergency Department, Ege University, Izmir, Turkey Yusuf Altunci Emergency Department, Ege University, Izmir, Turkey 2021 05 16 2021 06 15 Introduction: Pre-hospital intubation is a challenging but essential intervention. During intubation, it is difficult to identify vocal cords when using a cervical collar and trauma board. Therefore, the success rate of intubation by paramedics decreases in trauma patients. Video laryngoscopy increases intubation success rate and has been recommended for difficult airways in studies. Objective: In this study, we compared the intubation success rates when using a video laryngoscope and a direct laryngoscope in a manikin with simulated cervical immobilization. Methods: In this cross-sectional study, the manikin’s neck collar and spine board created a complicated airway model with cervical immobilization. Inexperienced paramedic students tried intubation with both methods, and their trial periods were recorded. Students answered a question evaluating the convenience of the procedure for both methods after the trial. Results: In this study, 83 volunteers, who were first-year and second-year paramedics, participated; 32 (38.6%) of the volunteers were first-year students, while 51 (61.4%) were second-year students. All volunteers had previous intubation experience with direct laryngoscopy, but not with video laryngoscopy. There was a statistically significant difference in the first-attempt success rates of the procedure between the groups in favor of video laryngoscope (p=0.022). Note that there was no significant difference between the groups in terms of first attempt durations (p=0.337). Conclusion: Video laryngoscopy in airway management can increase the success rate of first-attempt intubation by inexperienced pre-hospital healthcare personnel. https://fem.tums.ac.ir/index.php/fem/article/view/753 https://fem.tums.ac.ir/index.php/fem/article/download/753/363

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 5 4 2021 04 22 e43 e43 Zohre Najafi School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran Abbas Abbaszadeh Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran Hassan Vaezi Hospital Emergency Management Center, Deputy Minister of Health, Ministry of Health and Medical Education, Tehran, Iran Maryam Rassouli Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran Amir Mirhaghi Evidence-Based Care Research Center, Mashhad University Medical Sciences, Mashhad, Iran Sima Zohari Anboohi School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2021 02 23 2021 03 06 Introduction: The lack of a fixed and clear protocol causes confusion for nurses resulting in care performance delay in the emergency room (ER). Given that the purpose of triage is to examine the patient upon arrival in ER for the rapid classification and prioritization of emergency patients in need of treatment, it seems that the development and implementation of hospital triage standards can greatly affect this purpose. Objective: The present study was conducted to review the experiences of experts in hospital triage in terms of determining the standards of hospital ER triage. Methods: This qualitative research was conducted through content analysis method based on Donabedian model. Participants include experts (Politician, Nurse Supervisor, Nurse, Midwife, Faculty of Nursing, Emergency Medicine Specialist) working in educational and private hospitals and single-specialized ERs. Data were collected through in-depth and semi-structured interviews lasting between 25-60 minutes. The main interview questions were: What are the structural standards of a good triage?  What are the process standards for a good triage?  What are the standards of a good triage? Data analyzed through Content Directed Analysis with Shannon and Hsieh approach. Results: Totally, 21 experts the mean age of 46.9±1.8 (ranged from 30 to 57) years and the mean work experience of 18.9± 8.21 years were participated, of whom 16 (76.2%) persons were male. From the analysis, we extracted 48 codes, 14 subcategories and 3 main categories of "structural standards", "process standards" and "outcome standards". Conclusions: Guidelines are needed so that the nurse in charge of triage can quickly and accurately undertake the important responsibility of patient triage. Additionally, having structure and process and outcome standards improves triage performance. https://fem.tums.ac.ir/index.php/fem/article/view/672 https://fem.tums.ac.ir/index.php/fem/article/download/672/355

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 5 4 2021 05 27 e44 e44 Shaghayegh Rahmani Innovated Medical Research Center, Mashhad Branch, Islamic Azad University, Mashhad, Iran Sonia Norkhomami Department of Obstetrics and Gynecology, Faculty of Medicine, North Khorasan University of Medical Sciences, Bojnourd, Iran Behzad Shahi Department of Emergency Medicine, Faculty of Medicine, Zahedan University of Medical Sciences, Zahedan, Iran Mahjoubeh Keykha Department of Emergency Medicine, Faculty of Medicine, Zahedan University of Medical Sciences, Zahedan, Iran 2021 03 26 2021 05 02 Introduction: In March 2020, the World Health Organization introduced the Coronavirus disease 2019 (COVID-19) pandemic as a global health concern and predicted that without any changes in the transmission process, the disease would reach its peak in April. Hence, it was not unreasonable to expect the referral of pregnant women in all trimesters. Since respiratory illnesses can increase the risk of infectious diseases and maternal mortality, it is justifiable to consider COVID-19-positive cases as high-risk pregnancies. Case presentation: The present study introduced six pregnant women with COVID-19 and discussed the points to consider in managing these patients. Conclusions: Pregnant women are at increased risk in all epidemics of infectious diseases due to their physiological and immunological changes. Moreover, the safety of the fetus is another important issue to consider. https://fem.tums.ac.ir/index.php/fem/article/view/713 https://fem.tums.ac.ir/index.php/fem/article/download/713/357