Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 3 2019 06 02 e21 e21 Ahmed Negida Faculty of Medicine, Zagazig University, Zagazig, El-Sharkia, Egypt Ahmed Raslan Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA 2019 06 02 2019 06 02 We invite worldwide neurosurgeons, trauma surgeons, emergency medicine physicians, anaesthesiologists, and trainees to join the GNS team. Any worldwide hospital the receives and manages TBI patients is eligible for participation in the study. Collaborators can register through the official GNS website available here: https://www.globalneurosurg.org/ There are several ways in which collaborators can participate in the GNS team, these roles can be found on the GNS website here: https://www.globalneurosurg.org/collaborator-roles/ https://fem.tums.ac.ir/index.php/fem/article/view/173 https://fem.tums.ac.ir/index.php/fem/article/download/173/182

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 3 2019 03 27 e22 e22 Donnel Don Bosco Department of Emergency Medicine, Kerala Institute of Medical Sciences, Trivandrum, India Gangalal G M Department of Emergency Medicine, Kerala Institute of Medical Sciences, Trivandrum, India Suhas Rao Department of Emergency Medicine, Kerala Institute of Medical Sciences, Trivandrum, India Anoop T Chakrapani Department of Emergency Medicine, Kerala Institute of Medical Sciences, Trivandrum, India 2019 03 07 2019 03 27 Introduction: Acute kidney injury (AKI) is a common and devastating clinical issue in the community associated with high rates of morbidity and mortality. Objective: We aimed at estimating the frequency and levels of severity of AKI in trauma patients requiring hospital admission using the RIFLE criteria and assess their outcome. Method: Our retrospective record based study enrolled data of 80 participants aged 18-59 years who presented to the emergency department of KIMS hospital following an acute traumatic event. Participants with pre-existing renal dysfunction, chronic heart failure and chronic liver disease were excluded. Tests of significance were Chi square and independent sample t test, a p<0.05 was considered statistically significant. Results: Participants with AKI had significantly lower age (p=0.02) and lower revised trauma score (RTS) (p=0.01). Significant association of AKI with hypotension (p=0.01) and Glasgow coma scale (GCS) (p=0.008) was observed. No association of AKI with gender was observed (p=0.6). None of the AKI patients required renal replacement therapy and all participants attained normal renal function at discharge. Significantly longer mean duration of hospital stay (14.4 days) was observed among AKI patients (p=0.02). Totally, 6.3 % mortality was observed among both participants with and without AKI. Conclusion: Forty percent of acute trauma patients had AKI (in risk and injury category); but none were in failure, loss or end stage renal disease. No association of AKI and mortality was observed. AKI was associated with age, RTS, hypotension and GCS. https://fem.tums.ac.ir/index.php/fem/article/view/141 https://fem.tums.ac.ir/index.php/fem/article/download/141/169

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 3 2019 04 30 e23 e23 Saeed Majidinejad Emergency Medicine Department, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran. Mahdi Ebrahimi Emergency Medicine Department, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran Farhad Heydari Emergency Medicine Department, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran Mahdi Ahmadpour Emergency Medicine Department, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran Mehrdad Esmailian Emergency Medicine Research Center, Department of Emergency Medicine, Al-Zahra Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran. 2019 02 06 2019 03 27 Introduction: Recent years have witnessed widespread reports on the effectiveness of nebulized morphine for dyspnea, yet there is no evidence for its effectiveness in analgesic therapy. Objective: This study aims to compare effectiveness and side effects of inhalation morphine with oral methadone and transdermal fentanyl in sequential days in end stage cancer patients. Method: This double-blind, randomized controlled study conducted between April and September 2017. Ninety eligible cancer patients presenting to Sayed al-Shohada Hospital were selected non-randomly according to inclusion criteria and then divided to 3 groups in random order. Pain severity was scored by Visual Analog Scale (VAS). Patients were followed up for 3 days and then data were analyzed by SPSS. The benchmark of success was set as marking 4 or below on VAS and a reduction ratio of 50 percent. Results: Pain severity was equal for 3 groups before the first administration (p>0.05), but it decreased significantly from 8.45 (range 6-10) at baseline to 2.46 (range 1-4) at the end of the 3rd day in the nebulized group. The decrease ratio was equal to 70.8% after three days (p<0.05). Pain severity reduced from 8.45 (range 7-10) to 1.8 (range 1-3) (p<0.05) in the methadone group, and reduced from 8.5 (range 6-10) to 2.13 (range 1-3) in the fentanyl group. Conclusion: Our study showed that nebulized morphine, just like oral methadone and transdermal fentanyl, is effective, safe, and well-tolerated for pain management in patients with cancer. https://fem.tums.ac.ir/index.php/fem/article/view/129 https://fem.tums.ac.ir/index.php/fem/article/download/129/174

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 3 2019 05 12 e24 e24 Zinat Nadia Hatmi Departmentof Preventive Medicine, Medical School, Tehran University of Medical Sciences, Tehran, Iran / Department of Epidemiology, Centre for Public Health, Medical University of Vienna, Vienna, Austria Nasrin Jalilian Department of Obstetrics and Gynecology, Kermanshah University of Medical Sciences, Kermanshah, Iran Ali Pakravan Institute of National Insurance, Tehran, Iran 2019 05 05 2019 05 11 Introduction: So far, there is no evidence available to demonstrate the relationship between five subgroups of total cholesterol/high density lipoprotein cholesterol (TC/HDL-C) ratio with premature myocardial infarction (MI). Objective: We conducted a case control study to probe more features of the relation between TC/HDL-C ratio and the five subgroups of the ratio with myocardial infarction under 55 years and above it. Method: A hospital based case control study with incident cases was designed. Cases and controls were comprised of 523 under 55-year and 699 above 55-year documented newly diagnosed MI cases, respectively. Standardized clinical and para clinical method were used to ascertain disease and risk factors. Independent sample t-test, Pearson chi square test, Odds ratios and Mantel-Haenszel test and logistic regression analysis conducted to evaluate relationships. Results: This study enrolled 1222 MI cases.  Patients with very low risk category of TC/HDL-C ratio estimated OR=0.18 with 95% confidence interval (CI) (0.04-0.72) for developing MI under 55 years. Patients who had low risk category of TC/HDL-C ratio having OR=0.26 95% CI (0.07-0.89). Low risk and very low risk categories of the TC/HDL-C ratio compare to high risk subgroup of the ratio demonstrate decreased risk of developing MI under 55 years p<0.05. Conclusion: Our study results can be translated as an aggressive treatment for lowering TC/HDL-C ratio in both general population and victims of coronary events. Mitigation of the level of TC/HDL-C ratio from low risk to very low risk category will attenuate the risk of MI under55 years about 8% which is the immediate clinical implication of our findings. https://fem.tums.ac.ir/index.php/fem/article/view/149 https://fem.tums.ac.ir/index.php/fem/article/download/149/176

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 3 2019 05 16 e25 e25 EN Atousa Akhgar Prehospital and hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran Shamim Bahrami Department of Emergency Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran Payam Mohammadinejad Department of Emergency Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran Zahra Khazaeipour Brain and Spinal Cord Injury Research Center, Tehran University of Medical Sciences, Tehran, Iran Hooman Hossein-Nejad Department of Emergency Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran 2019 05 16 2019 05 16 Background Endotracheal intubation is an important procedure in critical care and emergency medicine settings. Optimal depth of the tube placement has been a serious concern because of several complications associated with its malposition. Objective: The aim of the current study was to find a new formula to estimate the proper endotracheal tube depth when using ultrasonography or lighted stylet device in order to increase the accuracy of determining Endotracheal tube (ETT) depth and decrease the side effects of ETT misplacement. Method: Patients older than 18 years of age admitted to Imam emergency department who needed tracheal intubation were included. Tube’s length at the angle of the mouth while the tube passed the suprasternal notch, ETT depth after insertion and the distance from ETT’s tip to carina were recorded. Ultrasonography and portable chest x-ray were used as tools for measuring these lengths. Results: A total number of 91 patients including 55 men and 36 women were eligible for inclusion in the study. Not placing the tube at proper depth was considered as failure of intubation. This failure rate was 9.9% in the standard method which would have been 1.1% if our proposed formula was used. Conclusion: The findings of this study suggest that the use of this new formula may help in predicting the proper intubation tube placement. Further studies are warranted to confirm these findings. https://fem.tums.ac.ir/index.php/fem/article/view/154 https://fem.tums.ac.ir/index.php/fem/article/download/154/178

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 3 2019 06 06 e26 e26 Maryam Mirshahi Sports Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran Farzin Halabchi Sports Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran Mohammadreza Golbakhsh Department of Orthopedic Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran Soheil Saadat Trauma and Surgery Research Center, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran 2019 06 06 Introduction: The Cumberland Ankle Instability Tool (CAIT) is a valid instrument for determining the presence and severity of functional ankle instability. This questionnaire was recently cross-culturally adapted into Persian; however, the reliability of the Persian version has not been examined in athletes. CAIT has also been used with various independently-selected cut-off scores to determine instability. Objective: The present study was conducted to evaluate the psychometric properties of the Persian version of CAIT and to determine its optimal cut-off score in athletic populations. Method: One-hundred and sixteen athletes (volleyball, basketball and track and field players) over 18 years old both with and without ankle instability completed the Persian version of the CAIT. The internal consistency, test-retest reliability and discriminative ability of the tool were assessed. A receiver operating characteristic (ROC) curve was drawn to confirm the cut-off point of the Persian version of CAIT using the Youden index. Results: The average CAIT score was 25.14±4.98 for the right and 25.76±4.94 for the left ankle. The Persian version of CAIT had a good internal consistency (Cronbach's α of 0.78 for the right ankle and 0.79 for the left ankle) and substantial reliability (ICC2, 1 = 0.88; 95% CI: 0.86 – 0.90) in athletes. No ceiling or floor effects were observed. The optimal cut-off score for discriminating between athletes with and without FAI was 24. Conclusion: The Persian version of CAIT was shown to be a reliable tool for assessing functional ankle instability among Iranian athletes. https://fem.tums.ac.ir/index.php/fem/article/view/180 https://fem.tums.ac.ir/index.php/fem/article/download/180/185

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 3 2019 04 08 e27 e27 EN Payman Moharamzadeh Emergency Medicine Research Team, Tabriz University of Medical Sciences, Tabriz, Iran Farzad Rahmani Emergency Medicine Research Team, Tabriz University of Medical Sciences, Tabriz, Iran Shirin Foroughifar Emergency Medicine Research Team, Tabriz University of Medical Sciences, Tabriz, Iran Kavous Shahsavarinia Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran 2019 02 10 2019 03 27 Introduction: Early diagnosis of pulmonary thromboembolism (PTE) is crucial in clinical medicine. Many para-clinical measurements are used to diagnose PTE. Objective: The present study was conducted to evaluate platelet indices in terms of diagnosing PTE. Methods: The present case-control study was conducted between September 2015 and September 2016 with 173 patients suspected of PTE in the emergency wards of Shahid Madani Hospital and Imam Reza Hospital affiliated to Tabriz University of Medical Sciences, Iran. The patients’ platelet indices were checked upon admission and they were evaluated in terms of diagnosing PTE. Platelet indices included mean platelet volume (MPV), platelet distribution width (PDW) and plateletcrit (PL-CR). PTE was diagnosed in 125 out of the 173 patients. Platelet indices were also compared between two groups. Results: No statistically significant differences were observed between the two groups in term of demographic variables (P>0.05). MPV was found to be 10.38±8.59 in the case group and 9.46±1.11 in the controls (P˃0.05). PDW was also found to be 12.86±5.57 in the case group and 12.32±2.48 in the controls (P>0.05). Moreover, PL-CR was found to be 22.59±7.32 in the case group and 21.97±8.16 in the controls (P>0.05). Conclusion: According to the obtained results, platelet indices do not increase in PTE. They cannot be therefore used to diagnose PTE in suspected patients. https://fem.tums.ac.ir/index.php/fem/article/view/137 https://fem.tums.ac.ir/index.php/fem/article/download/137/172

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 3 2019 05 22 e28 e28 Nicholas Gallagher Department of Emergency Medicine, Arnot Ogden Medical Center, Elmira, New York, USA Frank Edwards Department of Emergency Medicine, Arnot Ogden Medical Center, Elmira, New York, USA 2019 05 15 2019 05 16 Context: This review discusses the range of clinical presentations seen with poisonings by the major toxic alcohols--methanol, ethylene glycol, and isopropyl alcohol. It outlines a straightforward diagnostic strategy and discusses in detail the current treatment recommendations. Evidence acquisition: The authors conducted a literature search of primary and secondary sources related to the topic. For treatment recommendations, search restrictions included articles published between 2008 and 2019. For background information, search restrictions included articles written from 1990 – present. Results: This review discusses in detail how the diagnosis can be made via clinical signs, symptoms, and laboratory values as well as the most recent treatment recommendations. This paper will also discuss the limitations of the emergency department workup and how the absence of particular laboratory findings does not necessarily rule out the diagnosis. Conclusion: Poisoning with methanol, ethylene glycol, and isopropanol present diagnostic and therapeutic challenges to emergency physicians. Toxic alcohol poisonings lead to an elevated osmolar gap and, with the exception of Isopropanol, a metabolic acidosis. In order for the timely initiation of life-saving treatment, emergency physicians need a solid understanding of the pathophysiology, clinical presentation, laboratory workup, and treatment. Laboratory assays for these compounds are send-out tests in most hospitals and are therefore of no value in the acute clinical setting. https://fem.tums.ac.ir/index.php/fem/article/view/153 https://fem.tums.ac.ir/index.php/fem/article/download/153/179

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 3 2019 04 06 e29 e29 Mohammad Reza Mashhadi Department of Health, Rescue and Treatment of IR Iran Police Force, Applied Research Center, Tehran, Iran Mostafa Shahabinejad Department of Health, Rescue and Treatment of IR Iran Police Force, Applied Research Center, Tehran, Iran 2019 02 20 2019 03 22 Introduction: Unintentionally retained foreign bodies (RFBs) can be accompanied with acute reactions such as inflammatory responses, infections and abscesses within a few days or weeks after surgery with adverse consequences for patients and surgeons. Case Report: An 84-year-old woman was admitted to hospital with weakness, lethargy and infectious secretions of the umbilicus. The patient had undergone hysterectomy 21 years before. Clinical examinations and accurate umbilicus explorations found a 0.5-mm fibrin and smelly umbilical secretions. Dragging found the fibrin to be a surgical gauze thread. The patient was therefore identified as a candidate for laparotomy, which revealed a long gauze attached to a band and a metal ring in the umbilicus and hypogastric regions as well as a large abscess containing 200 ml of infectious secretions, severe adhesions of the intestines to each other and to the abdominal wall, a 10×10 cm cavity and an approximately 1-cm fistula or laceration in the Ileum due to the foreign body (long gauze). The patient was discharged from the hospital in good health conditions after the final surgery. Conclusion: Given the possibility of leaving foreign bodies in the surgery site, surgical teams are required to precisely control surgical instruments after surgery. https://fem.tums.ac.ir/index.php/fem/article/view/139 https://fem.tums.ac.ir/index.php/fem/article/download/139/170

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 3 2019 06 09 e30 e30 Marco Nastasi Division of Cardiology, University of Catania, Catania, Italy 2019 05 17 2019 05 29 Introduction: We describe a patient without a history of cardiovascular diseases as an example of Wellens’ syndrome (WS). Case Report: A 65-year-old man presented to emergency department due to intermittent chest pain. Physical examination and chest x-ray were unremarkable. Electrocardiogram (ECG) showed biphasic T-wave in precordial leads V1-V4. Primary cardiac serum biomarkers including high-sensitive cardiac troponin T (hs-cTnT) and CK-MB were slightly elevated, that further assessment did not show any increases; while ECG recorded during a pain period revealed T-wave pseudo-normalization. The patient underwent coronary angiography that revealed a proximal left anterior descending artery lesion. Conclusion: WS is a diagnostic and management challenge and serial ECG evaluation is still essential for a possible acute coronary syndrome. Having knowledge of all subtle features of this syndrome, could avoid improper discharge of high-risk patients. Definitely, accurate risk stratification, and prompting these patients to an early coronary angiogram and treatment are mandatory to avoid development of a massive anterior myocardial infarction. https://fem.tums.ac.ir/index.php/fem/article/view/155 https://fem.tums.ac.ir/index.php/fem/article/download/155/187

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 3 2019 05 25 e31 e31 Somayeh Karimi Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran Sepideh Babaniamansour School of Medicine, Islamic Azad University of Medical Sciences, Tehran, Iran Ehsan Aliniagerdroudbari School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2019 05 22 2019 05 25 A 34-year-old pregnant woman was referred to our emergency ward, complaining of intensification of skin lesions which had started six days earlier. Initially, vesicular lesions had started from head and face accompanied by fever which turn to generalized pustular lesions expanded to the whole body within four days (figure 1). By investigating the patient's personal contact history, we found that same symptoms were detected in her 9-year-old child 19 days prior to admission which was diagnosed as chickenpox. The patient also had mentioned previous history of chicken pox infection at her age of seven. She was ill but not toxic and was conscious with a blood pressure of 98/59 mmHg, respiratory rate of 18 breaths per minute, heart rate of 100 beats per minute and oral temperature of 37.2 °C in physical examination. She didn't have respiratory distress, dyspnea, meningism symptoms (Kernig Sign, Brudzinksi, and Nuchal Rigidity), ataxia or sensory defect and her all other physical examinations were normal. Upon diagnosis of chickenpox, intravenous (IV) acyclovir 750 mg three times a day and also IV clindamycin 900 mg TDS in combination with IV fluid were administered and finally the patient was admitted in Infectious diseases ward. https://fem.tums.ac.ir/index.php/fem/article/view/163 https://fem.tums.ac.ir/index.php/fem/article/download/163/180

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 3 2019 04 27 e32 e32 Mehran Sotoodehnia Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran Atefeh Abdollahi Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran Maryam Khodayar Imam Hossein Center for Education, Research and Treatment, Shahroud University of Medical Sciences, Shahroud, Iran 2019 04 27 An 85-year-old female patient was brought to emergency department (ED) from a nursing home with altered mental status (GCS: 12/15) and hypotension (90/60 mmHg). Bilateral fine crackles in lungs and severe cachexia were obvious in her physical examination. The ECG showed only sinus tachycardia. Several attempts at peripheral vein cannulation failed due to poor visualization of severely atrophied and contracted subcutaneous veins. Therefore, on two attempts, a central venous catheter (CVC) was inserted into the right internal jugular vein (IJV) using the Seldinger technique. After securing and taping the central line, fluid infusion started with no difficulty and a portable chest x-ray was ordered. https://fem.tums.ac.ir/index.php/fem/article/view/144 https://fem.tums.ac.ir/index.php/fem/article/download/144/173

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 3 2019 05 19 e33 e33 Ahmed Negida Faculty of Medicine, Zagazig University, Zagazig, El-Sharkia, Egypt. Nadien Fahim Clinical Program, Faculty of Pharmacy, Zagazig University, Zagazig, Egypt Yasmin Negida Faculty of Medicine, Zagazig University, Zagazig, El-Sharkia, Egypt 2019 05 19 In the previous educational articles, we explained how to calculate the sample size for a rate or a single proportion (part 1), for an independent cohort study (part 2), and for an independent case-control study (part 3). In this article, we will explain how to calculate the sample size for a diagnostic test accuracy study based on sensitivity, specificity, or the area under the ROC curve. https://fem.tums.ac.ir/index.php/fem/article/view/158 https://fem.tums.ac.ir/index.php/fem/article/download/158/181