Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 6 4 2022 05 24 e45 e45 Akram Fekry Elgazzar Department of Ophthalmology, Damietta Faculty of Medicine, Al-Azhar University, Egypt Walid Shaban Abdella Faculty of Medicine Al-Azhar University, Damietta, Egypt Ramadan Abdelmoez Farahat Faculty of Medicine, Kafrelsheikh University, Kafrelsheikh, Egypt 2022 05 09 2022 05 19 War is an organized and prolonged armed dispute between states or nations. It is characterized by high mortality, violence, and social or economic costs. There are multiple causes of war and conflict, including extreme poverty, high unemployment, and social, political, or economic disparities. The incidence of wars has increased since 1950, especially between states. Small Arms Survey reports that warfare kills nearly 133,750 persons, yearly. The rates of disability and death caused by war are more than many major diseases globally. It destroys the healthcare systems and public health services of the included states or societies, which results in more diseases and deaths. https://fem.tums.ac.ir/index.php/fem/article/view/1010 https://fem.tums.ac.ir/index.php/fem/article/download/1010/406

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 6 4 2022 07 21 e46 e46 Somayeh Mehrpour Department of Anesthesiology and Critical Car, Qom University of Medical Sciences, Qom, Iran Narges Kalhor Student Research Committee, Qom University of Medical Sciences, Qom, Iran Sarah Afshari Student Research Committee, Qom University of Medical Sciences, Qom, Iran Reihane Tabaraii Clinical Research Development Center, Shahid Beheshti Hospital, Qom University of Medical Sciences, Qom, Iran 2022 07 06 2022 07 07 To the Editor-in-Chief In viral pandemics, the possibility of accompanied bacterial infections is always a serious challenge for health care providers. In the recent pandemic with COVID-19, studies showed an increase in bacterial infections in patients with COVID-19, especially those requiring intensive care unit (ICU) admission. Various meta-analyses have shown that the prevalence of some secondary bacterial infections, especially infection with Mycoplasma pneumoniae, Gram-negative germs like extended-spectrum beta-lactamase, and Klebsiella pneumoniae, has increased significantly. Recent studies have also shown that the pathogens that cause bloodstream infections have changed during the COVID-19 pandemic for a variety of reasons, including the widespread use of antibiotics, the effects of COVID-19 on the immune system, and so on. Increased prevalence of bloodstream infections with Gram-negative bacteria that are resistant to third generation of cephalosporins and carbapenems in patients with COVID-19 has been reported in several studies. Studies have also shown increased isolation of pathogens such as members of the Enterobacteriaceae family, including Klebsiella and Escherichia specimens, from blood cultures of patients hospitalized due to COVID-19. https://fem.tums.ac.ir/index.php/fem/article/view/1038 https://fem.tums.ac.ir/index.php/fem/article/download/1038/416

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 6 4 2022 03 22 e47 e47 Farhad Heydari Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran Mehdi Nasr Isfahani Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran Azita Azimi Meibody Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran Fleuria Flechon-Meibody Department of Nephrology, French Center for Nephrology and Hemodialysis, Metz, France. Javad Shahabi Department of Cardiology, Cardiovascular Research Institute, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran Seyyed Taghi Hashemi Department of Anesthesiology, Anesthesiology and Critical Care Research Center, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran Omid Ahmadi Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran Neda Al Sadat Fatemi Trauma Registry Center, Isfahan University of Medical Sciences, Isfahan, Iran Khatere Ghaznavi Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran 2021 12 23 2022 03 02 Objectives: Acute kidney injury (AKI) is an independent risk factor in critically ill patients. This study aimed to evaluate the prevalence of AKI in resuscitated cardiac arrest (CA) patients, its potential risk factors, and outcomes of AKI in cardiac arrest survivors. Methods: A hundred and forty-nine cases of post-CA that survived for at least 24 hours, were admitted to three hospitals between 2016 and 2020, were studied. AKI was defined by the RIFLE (Risk, Injury, Failure, Loss, and End-stage) criteria. Baseline demographic data, resuscitation variables, the prevalence of AKI, in-hospital and six-month mortality were collected. Logistic regression evaluated the factors associated with AKI occurrence and mortality. Results: AKI occurred in 59 (39.6%) of the patients. Of these, nine patients (15.3%) required renal replacement therapy (RRT) during their hospital stay. There were 47 (52.2%) in-hospital mortality in patients without AKI and 41 (69.5%) in patients with AKI (P=0.036). Post-CA AKI was significantly associated with six-month mortality (OR 1.65 [1.39-2.88]; p = 0.029). Older age, the higher cumulative dosage of epinephrine during cardiopulmonary resuscitation, post-CA shock, in-hospital CA, PEA/asystole rhythm, longer duration of cardiac arrest, as well as higher admission creatinine and lactate levels were independently associated with AKI, in contrast, higher admission Base Excess level was negatively associated with AKI. Conclusion: AKI occurred in nearly 40% of CA patients. AKI was associated with a higher in-hospital and six-month mortality rates. https://fem.tums.ac.ir/index.php/fem/article/view/920 https://fem.tums.ac.ir/index.php/fem/article/download/920/407

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 6 4 2022 05 12 e48 e48 Utsav Anand Mani Department of Emergency Medicine, King George’s Medical University, Lucknow, India Mukesh Kumar Department of Emergency Medicine, King George’s Medical University, Lucknow, India Haider Abbas Department of Emergency Medicine, King George’s Medical University, Lucknow, India Pranay Gupta Department of Emergency Medicine, King George’s Medical University, Lucknow, India 2022 03 28 2022 05 03 Objective: Through the reporting of this case series, we aim to establish whether a conservative approach, through managing arrhythmias and vital signs, can be reliably used as a treatment modality for oleander poisoning in developing countries. Methods: This study is a case series of 11 patients who presented with oleander poisoning and were conservatively managed in the absence of standard antidote. Results: All 11 patients treated with conservative approach survived. Conservative approach included use of atropine for management of symptomatic bradycardia followed by Dopamine infusion, correction of serum potassium and magnesium levels, standby defibrillation, and transvenous pacing. Conclusion: The absence of reliable dosage of poison ingested, the lack of facilities for serum digoxin estimation, and the unavailability of digoxin fab antibodies pose challenges for the management of patients with oleander poisoning. Patients can, however, be managed conservatively following the Advanced Cardiac Life Support (ACLS) algorithm in a setting that lacks the standard treatment of this poison. https://fem.tums.ac.ir/index.php/fem/article/view/990 https://fem.tums.ac.ir/index.php/fem/article/download/990/405

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 6 4 2022 05 15 e49 e49 Ahmad Abbasian Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran Leyla Farshidpour UC Davis School of Medicine, Davis, California, USA Mehdi Chegin Emergency Medicine Department, Imam Khomaini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran Talayeh Mirkarimi Emergency Medicine Department, Qazvin University of Medical Sciences, Qazvin, Iran Amin Doosti-Irani Department of Epidemiology, School of Public Health and Modeling of Noncommunicable Diseases Research Center, Hamadan University of Medical Sciences, Hamadan, Iran Hadi Mirfazaelian Emergency Medicine Department, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran 2022 05 15 2022 05 15 Objective: About one out of every 10 patients with chest pain in the emergency department (ED) are finally diagnosed with acute coronary syndrome (ACS). A HEART score of ≤ 3 has been shown to rule out ACS with a low risk of major adverse cardiac events (MACE) occurrence. It has been proposed that a negative CARE rule (≤1), which stands for the first four elements of the HEART score and excludes the troponin assay requirement, may have similar rule-out reliability. This study aimed to externally validate the CARE rule. Methods: In this multicenter, observational study a convenience sample consisting of patients over the age of 15 who had at least one troponin study were included. The performance of the CARE rule at the cut-off ≤1 for MACE prediction was assessed and compared to a HEART score of ≤3 and physicians’ gestalt. MACE was defined as myocardial infarction, coronary angioplasty, coronary artery bypass graft, and all-cause mortality in 6 weeks. Results: The data of 154 patients was analyzed. Of these, 121 patients had a negative CARE score of ≤1 and 33 individuals had a positive CARE score. Of those with a negative CARE score, only 1 (3%) experienced an adverse cardiac event while in those with a positive CARE score, 26 individuals (16.88 %) experienced MACE. The sensitivity of the CARE rule was 96.15% and the specificity was 25% with a negative likelihood ratio (LR-) of 0.15. The indices for HEART score were 88%, 59.69%, and 0.2, respectively. In comparison, physicians' gestalt had a sensitivity of 96%, specificity of 49.22%, and a LR- of 0.08. Of note, utilizing the CARE rule with a cut-off of <3 showed sensitivity of 96%, specificity of 41.86%, and a LR- of 0.1. Conclusion: The CARE rule miss rate in MACE was more than 2% and while its performance was better than the HEART score, physicians’ gestalt outperformed both rules for ruling out MACE. https://fem.tums.ac.ir/index.php/fem/article/view/1014 https://fem.tums.ac.ir/index.php/fem/article/download/1014/418

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 6 4 2022 06 18 e50 e50 Abdulbary Alhalimi College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia Khalid Almulhim Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia 2022 04 30 2022 06 18 Objective: Emergency medicine (EM) is considered a competitive specialty worldwide with an acceptance rate of 57% in Canada but more competitive in Saudi Arabia with 18.7%. Factors that influenced the applicant’s acceptance include letters of recommendation, interview performance, research experience, and gender. This study aims to determine the factors playing a role in applicants matching to EM residency programs in Saudi Arabia from the view of program directors. Methods: A pilot study was done using a self-administered-questionnaire distributed to EM residency program directors (PDs) in Saudi Arabia in the period of 16-21 November 2021. The data were analyzed using SPSS, and all ethical considerations were ensured. Results: Twenty-seven PDs participated in the study, 19 (70.4%) were males, and most were former PDs (59.3%). The most crucial aspect in the applicant’s acceptance was the excellent impression in the interview (4.00 ± 1.00). The most crucial aspect of recommendation letters was a recommendation from a program director (29.6%), total duration of electives (40.7%) was superior; quality in EM research (29.6%) played a more critical role, and professionalism (29.6%) was the sought factor during the interview. There was no significant influence of the gender or the status of the PD and region of the program on the preference of the applicant’s gender. Conclusion: For those considering EM residency programs in Saudi Arabia, the chance of acceptance can be increased by getting a recommendation from a program director, increasing the duration of electives in EM, focusing on the research quality, and showing professionalism during the interview. https://fem.tums.ac.ir/index.php/fem/article/view/1003 https://fem.tums.ac.ir/index.php/fem/article/download/1003/411

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 6 4 2022 06 19 e51 e51 Behrooz Hashemi Research Center for Trauma in Police Operation, Directorate of Health, Rescue and Treatment, Police Headquarter, Tehran, Iran Zahra Eshghi Emergency Medicine Department, School of Medicine, Shohadaye Tajrish Hospital, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran Amir Ghabousian Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran Saeed Safari Men's Health and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2022 01 25 2022 06 19 Objective: Determining the exact underlying etiology of loss of consciousness (LOC) can become a real challenge for physicians due to the broadness of differential diagnoses. The current study aimed to assess the accuracscharge. https://fem.tums.ac.ir/index.php/fem/article/view/148 https://fem.tums.ac.ir/index.php/fem/article/download/148/190

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 4 2019 06 25 e40 e40 Peyman Saberian Department of Anesthesiology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran. Amir-Reza Farhoud Joint Reconstruction Research Center, Department of Orthopedic Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran Parisa Hasani-Sharamin Tehran Emergency Medical Service Center, Tehran, Iran Maryam Moghaddami Tehran Emergency Medical Service Center, Tehran, Iran Fatemeh Keshvari National Emergency Medical Service Organization, Tehran, Iran 2019 06 22 2019 06 23 Introduction: Knowledge of epidemiological aspects can be a useful guide in determining the resources for better prevention and management of injuries. There are some performed studies on this topic in Iran, based on the limited hospital database. However, to the best of our knowledge, there is not any survey based on the pre-hospital database. Objective: The purpose of this study was to assess baseline characteristics of the traumatic patients according to the records of Tehran Emergency Medical Service (EMS) Center to present descriptive statistics of their epidemiological features. Method: This cross-sectional study was conducted retrospectively, using Tehran EMS center data registry. All traumatic patients examined by EMS in Tehran, Iran following call to emergency medical dispatcher were included. By reviewing the EMS technicians’ mission forms, required data were extracted. The mission form contains information such as age, sex, injured location, damage mechanism, accident location (home, workplace, street), time of call, the outcome of the patient's ambulance mission and the results of the assessment of the technician, etc. Results: Totally, 56612 injured cases with the mean age of 33.1±15.6 years were examined by EMS during one-year study period of whom 80.4% were male. Crude Incidence Rate was 10.5 and 2.5 per 1000 in male and female, respectively. Traffic accident and then fall were the two most prevalent mechanism of injuries. All types of  injuries were significantly more prevalent in males (P<0.001). Most injuries were in winter season with 15570 cases (27.5%). Car accident was prevalent in winter and other injuries were significantly prevalent in spring (P<0.001). The most frequent places of injuries occurred on main roads and streets (55.7%). All of the road-related injuries was prevalent in winter, whereas injuries in other places were prevalent in spring (P<0.001). Most of the cases (78.3%) were transferred to the health centers, but 20.7% did not consent to treatment and transmission. Only 222 cases (0.4%) died, that 95% was due to traffic accident. there was a significant relationship between the number of injured organs and the death; So that the highest death rate occurred for those with more than 5 injured organs (P <0.001). Conclusion: Based on the findings, traffic accident was the most frequent cause of trauma that led to visiting a traumatic patient by an EMS technician in Tehran, Iran. Injuries in all age groups were more prevalent in males, and the involvement of 5 or more injured organ had a significant relationship with mortality. https://fem.tums.ac.ir/index.php/fem/article/view/198 https://fem.tums.ac.ir/index.php/fem/article/download/198/191

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 4 2019 07 01 e41 e41 EN Hani Najeh Al Yousef Al-Ghad International College for Applied Medical Science, Riyadh, Saudi Arabia Wael Awada Department of Anesthesiology and Intensive Care and Pain Management, Cairo University, Cairo, Egypt Evangelia Michailidou Department of Disaster Medicine and Health Crisis Management, University of Athens Medical School, Athens, Greece 2019 06 18 2019 06 18 Introduction: Emergency medical technicians (EMTs) should be always prepared to deal with the stressful condition of treating patients with serious physical and emotional injuries. Given that EMTs consider safety the first priority, they must pay adequate attention to their own physical well-being and fitness to practice. Objective: The present study was conducted to analyze the fitness of Jordanian EMTs. Method: The present prospective study was conducted to evaluate the well-being of Jordanian paramedics. The survey was designed using Google forms, which were completed by the participants. The data collection tools comprised an already-designed checklist, including items such as age, gender as well as height and weight, which are used for calculating body mass index (BMI). In addition, the presence of chronic diseases such as hypertension, diabetes mellitus, renal failure and cardiorespiratory diseases as well as the history of surgeries and disabilities were investigated. The participants were also asked about their smoking status and other health-related habits. Results: Out of 115 surveys conducted, 7 were discarded owing to loss of information or making completion mistakes. Out of the remaining 108 respondents, 82 (75.9%) were male and below 10% were over the age of 30 years. BMI was over 25 in 40.7% of the respondents, and only 4 (3.7%) had chronic diseases. Moreover, 46 (42.6%) respondents were smokers, and only 30 (27.8%) performed regular exercise. Conclusion: The present findings suggest health problems in a small percentage of the EMTs, potentially due to the appropriate support provided by the employers or university authorities in this regard. The major health problem was overweight and unhealthy lifestyle, including smoking and not doing regular exercise. https://fem.tums.ac.ir/index.php/fem/article/view/160 https://fem.tums.ac.ir/index.php/fem/article/download/160/192

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 4 2019 07 24 e42 e42 Kosar Yousefi Ilam University of Medical Sciences, Ilam, Iran Haleh Adibi-Larijani Iranian Red Crescent Society, Tehran, Iran Mohammad Golitaleb Department of Nursing, School of Nursing and Midwifery, Arak University of Medical Sciences, Arak, Iran. Ali Sahebi Department of Health in Disasters and Emergencies, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2019 06 27 2019 07 09 Context: Nurses are the largest group of health service providers with a vital role in assisting victims during disasters. They must be therefore appropriately prepared to respond to health requirements in these situations. Evidence acquisition: Three articles were ultimately extracted from a comprehensive search conducted in the present systematic review and meta-analysis in Google Scholar, SID, Magiran, Scopus, PubMed and Web of Science using English keywords and their Persian equivalents. The I2 index was used to evaluate the heterogeneity between the studies, and the analyses were performed in STATA 14. Results: This review was conducted on 586 nurses working in hospitals. The final meta-analysis included three articles. The matched mean scores of knowledge, attitude and performance concerning disaster preparedness were respectively found to be 43.49 (95% CI: 37.67-49.31, P=0.581, I2=0.0%), 68.81 (95% CI: 63.04-70.58, p=0.913, I2=0.0%) and 56.19 (95% CI: 53.95-58.42, P=0.001, I2=86.2%). Conclusion: The present findings suggested moderate levels of knowledge and performance and good attitudes associated with preparedness in disasters in the Iranian nurses. These parameters can be therefore improved to desirable levels and the overall preparedness for coping with disasters boosted in nurses by training nurses and performing hospital drills. https://fem.tums.ac.ir/index.php/fem/article/view/204 https://fem.tums.ac.ir/index.php/fem/article/download/204/197

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 4 2019 05 16 e43 e43 Ali Abdolrazaghnejad Department of Emergency Medicine, Khatam-Al-Anbia Hospital, Zahedan University of Medical Sciences, Zahedan, Iran Ali Rajabpour-Sanati Faculty of Medicine, Birjand University of Medical Sciences, Birjand, Iran Hojjat Rastegari-Najafabadi Department of Emergency Medicine, Khatam-Al-Anbia Hospital, Zahedan University of Medical Sciences, Zahedan, Iran Maryam Ziaei Department of Emergency Medicine, Khatam-Al-Anbia Hospital, Zahedan University of Medical Sciences, Zahedan, Iran AbdolGhader Pakniyat Department of Emergency Medicine, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran 2019 05 10 2019 05 12 Context: Acute abdominal pain is a common clinical problem in emergency and non-emergency cases accounting for 5 to 10% of all referrals to the emergency department. Studies have indicated that these widely differentiated diagnoses are common to these complaints. Considering the high prevalence of this complaint in the patients and the wide range of its differential diagnosis, this review study was designed and evaluated aiming at investigating the causes of acute abdominal pain with a focus on assessing the position of ultrasound as a diagnostic tool in the emergency department. Evidence acquisition: This article was conducted as a narrative review of 106 articles from 2005 through 2019. By comparing them, a comprehensive review of ultrasonographic status was conducted in patients with acute abdominal pain referring to the emergency department. Results: In this review study, we attempted to use the articles of the clinical approach, the required laboratory tests, the disadvantages and advantages of each imaging technique, the differential diagnosis for acute abdominal pain according to the location of the pain, and the position of ultrasound as a diagnostic aid tool. Eventually, the proposed protrusion will be considered in dealing with a patient with acute abdominal pain. Conclusion: Regarding the wide range of causes providing multiple differential diagnosis, as well as the limited time of the health team in the emergency department for diagnostic and therapeutic measures, particularly in time-sensitive clinical conditions, ultrasound offered by emergency medicine specialists as a diagnostic aid is considered to improve the overall diagnosis and treatment of patients, thereby reducing complications. https://fem.tums.ac.ir/index.php/fem/article/view/152 https://fem.tums.ac.ir/index.php/fem/article/download/152/177

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 4 2019 06 18 e44 e44 Zhila Farzinpoor Department of Infectious Diseases, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran 2019 05 01 2019 05 11 Introduction: Recently, the use of metal and plastic containers instead of clay containers in producing this type of cheese has provided the anaerobic condition for growing the bacterium and producing the botulinum toxin. In this case report was to introduce "clay cheese dug in the ground" as a source of botulinum toxin for the first time. Case Report: A 34-year-old man with dizziness, asthma, and inability to swallow for four days referred to the hospital emergency department. He had diplopia and ptosis for two days. During admission to the emergency, the patient was conscious without fever, but with dysarthria and bilateral ptosis, an impaired gag reflex, slow right papillary reaction to light, a decreased eye movement, and a decreased power of facial muscles and limbs. The patient reported the use of clay cheese in a week before referring to the emergency. Hematological, biochemical, electrocardiogram, magnetic resonance imaging, and chest X-ray assays were normal. According to the Centers for Disease Control and Prevention classification, these symptoms were related to botulism. The evaluation of serum samples, emission, and gastric juice confirmed botulism by type A toxin. Conclusion: Considering the clinical results of this case study, clay cheese, which is produced in the west of Iran, can be introduced as a new source of the botulinum toxin. https://fem.tums.ac.ir/index.php/fem/article/view/145 https://fem.tums.ac.ir/index.php/fem/article/download/145/189

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 4 2019 07 28 e45 e45 Ahmad Rezaee-Azandaryani Department of Radiology, Hamadan University of Medical Sciences, Besat Hospital, Hamadan, Iran Mohamadmehdi Eftekharian Department of Radiology, Hamadan University of Medical Sciences, Besat Hospital, Hamadan, Iran Mehrdad Taghipour Department of General Surgery, Hamadan University of Medical Sciences, Besat Hospital, Hamadan, Iran 2019 06 16 2019 06 26 Introduction: Lipomas are the most common benign neoplasms, occurring in any part of the body where fat is present. Their occurrence in the head and neck is not common. Here, we report a large laryngeal lipoma with extra laryngeal component, mimicking mixed form of laryngocele. Case presentation: A 47-year-old man presented with a 3-year history of hoarseness, intermittent dyspnea and mass sensation in the neck. The patient was submitted to indirect laryngoscopy; a large submucosal mass obliterating the left side of the supraglottic larynx and partially obstructing the airway was found. Enhanced computed tomography (CT) scan demonstrated non-enhancing homogeneous hypodense fat density mass lesion measured 55*45*32 mm, extending through the thyroid membrane to parapharyngeal space and showing extra laryngeal component with an intact laryngeal mucosa lesion. Open surgery of the submucosal mass was performed. Pathology examination confirmed the diagnosis of lipoma. Conclusion: Neck lipomas are also typically asymptomatic, but can compress nearby structures, causing symptoms such as hoarseness, dyspnea and dysphagia. When symptomatic, they should be removed via surgery. https://fem.tums.ac.ir/index.php/fem/article/view/196 https://fem.tums.ac.ir/index.php/fem/article/download/196/200

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 4 2019 07 12 e46 e46 Mohaddeseh Azadvari Physical Medicine & Rehabilitation Department, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran Sarvenaz Rahimi Physical Medicine & Rehabilitation Department, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran Seyede-Zahra Emami-Razavi Physical Medicine & Rehabilitation Department, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran 2019 07 12 Introduction: Diagnosing an osteoid osteoma as a benign tumor can be challenging owing to its different presentation patterns, ambiguous radiological findings and unusual sites of involvement. The present case report involves a 30-year-old female patient with a large osteoid osteoma of the thoracic vertebrae as an uncommon site of its presentation. Case Presentation: The patient presented with a one-year history of progressive right-sided upper back and interscapular pains. She was identified as a candidate for surgery using the whole body bone scan and a multiple detector computed tomography (MDCT) scan. A large 25-mm osteoid osteoma of the lamina of the third thoracic vertebra (T3) was also diagnosed through histopathology. Conclusion: As a potential cause of persistent back pain in young adults, an osteoid osteoma may be easily missed by routine radiographs. The CT scan is an effective tool in the investigation of the size and location of this tumor. Surgical excision can also be used for treating spinal lesions. https://fem.tums.ac.ir/index.php/fem/article/view/213 https://fem.tums.ac.ir/index.php/fem/article/download/213/195

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 4 2019 08 17 e47 e47 Utsav Mani Department of Emergency Medicine, Bharati Hospital, Maharashtra, India Danish Ansari Department of Emergency Medicine, Bharati Hospital, Maharashtra, India Firdaus Bhot Department of Emergency Medicine, Bharati Hospital, Maharashtra, India Elizabeth Sada Department of Emergency Medicine, Bharati Hospital, Maharashtra, India Rajesh Ursekar Department of Emergency Medicine, Bharati Hospital, Maharashtra, India 2019 08 11 2019 08 13 A 62-year-old male came to emergency department (ED) with a complaint of “separation of foot” during sleep at night. He noticed he lost his foot while getting up from bed to go to toilet at midnight. Upon arrival in ED, his blood pressure was 218/96 mmHg and random blood sugar 556mg/dl. The patient had large ketone bodies in urine. He was a known case of diabetes and hypertension for many years. He was on homeopathic medications for his diabetes, hypertension and diabetic foot. He refused any form of invasive treatment and hospitalization. The patient was adamant on not getting admitted and wanted to continue his homeopathic medications as before. He only wanted