Anxiety and Stress Seem Temporary during the Pneumonia COVID-19 Pandemic: A Survey on the Mental Health Status of Healthcare Workers.

Objective: To evaluate the presence/severity of depression, anxiety, and stress among health care workers (HCWs) who work on the specially allocated COVID-19 ward (Group A) and HCWs on the other wards (Group B). Methods: This questionnaire-based study was conducted from January 25 to February 28, 2021. The mental status was assessed using the Persian version of the 42-item Depression, Anxiety, and Stress score (DASS-42). Gathered data was analyzed using SPSS version 25. The independent T-test and Chi-square tests were used to compare quantitative and qualitative variables. Results: Two-hundred and twenty two questionnaires were eligible for analysis. Group A consisted of 33 HCWs, and 189 (85.1%) individuals were working on the other wards. No statistically significant differences were seen regarding the Socio-demographic features except for the marital status (p=0.005). The depressions' mean score was comparable between group A and B (p=0.102). The mean scores of anxiety and stress were significantly lower in group A than group B (p=0.006), although the frequency of DASS-42 parameters did not differ between these two groups (p>0.05). Conclusion: Contrary to our assumptions, this study showed that the DASS-42 parameters were not higher in HCWs working on the COVID-19 wards. This might be justified by developing coping mechanisms, being on the honeymoon phase of the disaster, compassion satisfaction, promising vaccine news, and working on the less impacted hospital.

Impact of Peer-Assisted Learning in Chest Tube Insertion Education on Surgical Residents.

Objective: To investigate the impact of peer-assisted learning (PAL) in chest tube insertion education on surgical residents. Methods: This study is a quasi-experimental study conducted on thirty general surgeon residents enrolled in the PAL program. They were divided into two learner groups (A and B) based on the period of residency start. Group A and B had six and one months of general surgery residency experience, respectively. All participants received adequate training for chest tube insertion by a recently graduated general surgeon. Chest tubes insertion skill was assessed using the tool for assessing chest tube insertion competency (TACTIC) test. Results: Post-TACTIC test score was significantly higher (p=0.001) than Pre-TACTIC test score in both groups. However, a comparison of mean Pre-TACTIC test scores and mean Post-TACTIC test scores between group A and group B showed that PAL effectiveness in group A was significantly higher (p=0.001) than group B. Conclusion: There was a positive relationship between the PAL program and the improvement of chest tube insertion technical skills in surgical residents. Based on our findings and similar studies, it can be concluded that the PAL program can increase the chest tube insertion skill of surgical residents.

Comparison of chest CT scan findings between COVID-19 and pulmonary contusion in trauma patients based on RSNA criteria: Established novel criteria for trauma victims.

PROPOSE: In this study, we re-assessed the criteria defined by the radiological society of North America (RSNA) to determine novel radiological findings helping the physicians differentiating COVID-19 from pulmonary contusion. METHODS: All trauma patients with blunt chest wall trauma and subsequent pulmonary contusion, COVID-19-related signs and symptoms before the trauma were enrolled in this retrospective study from February to May 2020. Included patients (Group P) were then classified into two groups based on polymerase chain reaction tests (Group Pa for positive patients and Pb for negative ones). Moreover, 44 patients from the pre-pandemic period (Group PP) were enrolled. They were matched to Group P regarding age, sex, and trauma-related scores. Two radiologists blindly reviewed the CT images of all enrolled patients according to criteria defined by the RSNA criteria. The radiological findings were compared between Group P and Group PP; statistically significant ones were re-evaluated between Group Pa and Group Pb thereafter. Finally, the sensitivity and specificity of each significant findings were calculated. The Chi-square test was used to compare the radiological findings between Group P and Group PP. RESULTS: In the Group PP, 73.7% of all ground-glass opacities (GGOs) and 80% of all multiple bilateral GGOs were detected (p < 0.001 and p = 0.25, respectively). Single bilateral GGOs were only seen among the Group PP. The Chi-square tests showed that the prevalence of diffused GGOs, multiple unilateral GGOs, multiple consolidations, and multiple bilateral consolidations were significantly higher in the Group P (p = 0.001, 0.01, 0.003, and 0.003, respectively). However, GGOs with irregular borders and single consolidations were more significant among the Group PP (p = 0.01 and 0.003, respectively). Of note, reticular distortions and subpleural spares were exclusively detected in the Group PP. CONCLUSION: We concluded that the criteria set by RSNA for the diagnosis of COVID-19 are not appropriate in trauma patients. The clinical signs and symptoms are not always useful either. The presence of multiple unilateral GGOs, diffused GGOs, and multiple bilateral consolidations favor COVID-19 with 88%, 97.62%, and 77.7% diagnostic accuracy.

Evaluation of Chest CT Scan as a Screening and Diagnostic Tool in Trauma Patients with Coronavirus Disease 2019 (COVID-19): A Cross-Sectional Study.

BACKGROUND: The lack of enough medical evidence about COVID-19 regarding optimal prevention, diagnosis, and treatment contributes negatively to the rapid increase in the number of cases globally. A chest computerized tomography (CT) scan has been introduced as the most sensitive diagnostic method. Therefore, this research aimed to examine and evaluate the chest CT scan as a screening measure of COVID-19 in trauma patients. METHODS: This cross-sectional study was conducted in Rajaee Hospital in Shiraz from February to May 2020. All patients underwent unenhanced CT with a 16-slice CT scanner. The CT scans were evaluated in a blinded manner, and the main CT scan features were described and classified into four groups according to RSNA recommendation. Subsequently, the first two Radiological Society of North America (RSNA) categories with the highest probability of COVID-19 pneumonia (i.e., typical and indeterminate) were merged into the "positive CT scan group" and those with radiologic features with the least probability of COVID-19 pneumonia into "negative CT scan group." RESULTS: Chest CT scan had a sensitivity of 68%, specificity of 56%, positive predictive value of 34.8%, negative predictive value of 83.7%, and accuracy of 59.3% in detecting COVID-19 among trauma patients. Moreover, for the diagnosis of COVID-19 by CT scan in asymptomatic individuals, a sensitivity of 100%, specificity of 66.7%, and negative predictive value of 100% were obtained (p value: 0.05). CONCLUSION: Findings of the study indicated that the CT scan's sensitivity and specificity is less effective in diagnosing trauma patients with COVID-19 compared with nontraumatic people.

The Neutrophil-to-Lymphocyte Ratio at the Time of Admission: A New Prognostic Indicator for Hospital Mortality of Trauma Patients.

The elevated neutrophil-to-lymphocyte ratio (NLR) is associated with poor clinical outcomes, especially in pro-inflammatory states such as surgical injuries and severe hemorrhages. Therefore, it was hypothesized whether NLR value at the time of admission could be a prognostic indicator of hospital mortality in trauma patients. This retrospective cohort study was conducted on 865 trauma patients referred to Rajaee Hospital between April 2016 and July 2019. The NLR value was calculated at the time of admission, and receiver operating characteristics (ROC) curve analysis was used to determine the cut-off point value of admission NLR related to hospital mortality of trauma patients. Furthermore, Kaplan-Meier survival analysis and Cox regression models have been applied to determine the effectiveness and prognostic potential of the admission NLR in the hospital mortality of trauma patients. The median age of the trauma patients was 32 years with an interquartile range (IQR) of 23 to 48 years, and most of them were male (83.9%). Also, trauma patients had a median injury severity score (ISS) of 9 (IQR=4-16) and a median Glasgow coma scale (GCS) of 14 (IQR=9-15). The cut-off value for admission NLR was 5.27 (area under the curve: 0.642, 95%CI: 0.559-0.726, p=0.001). In Kaplan-Meier survival analysis, the admission NLR>5.27 was an indicator of hospital mortality in trauma patients (p=0.001). Multivariate Cox regression models demonstrated that trauma patients with an admission NLR>5.27 had a 2.33-fold risk of hospital mortality (hazard ratio=2.33, 95%CI: 1.02-5.38, p=0.041). Furthermore, the admission NLR>5.27 was associated with a higher risk of hospital mortality in trauma patients with age≥65 years, systolic blood pressure≤90 mmHg, blood potassium>4.5 mmol/L, blood sodium>144 mEq/L, blood potential hydrogen (pH)≤7.28, GCS≤8, ISS>24 and blood base excess≤-6.1 mEq/L. The NLR value greater than 5.27 at the time of admission was associated with poorer outcomes, and it can be considered an independent prognostic indicator of hospital mortality in trauma patients.

Should we change our approach to resuscitating victims of femoral fracture? A clinical experience in a busy trauma hospital in Shiraz, Iran.

PURPOSE: Traumatic hemorrhagic shock is a life-threatening event worldwide. Severe brain trauma accompanying femoral fractures can trigger inflammatory responses in the body and increase pre-inflammatory cytokines such as TNF-α, IL-1. The primary treatment in these cases is hydration with crystalloids, which has both benefits and complications. The purpose of this study was to investigate the effects of fluid therapy on the hemodynamics, coagulation profiles, and blood gases in such patients. METHODS: In this cross-sectional study, patients were divided into two groups: femoral fracture group and non-femoral group. The hemodynamic status, coagulation profile, and blood gases of patients in both groups were evaluated upon arrival at the hospital and again 2 h later. Data were analyzed by t-test and ANOVA with repeated data and paired samples t-test. RESULTS: A total of 681 trauma patients (605 men and 76 women) participated in this study, including 69 (86.3%) men and 11 (13.8%) women in femoral fracture group and 536 men (89.2%) and 65 women (10.8%) in non-femoral group. The laboratory parameters were evaluated in response to the equal amount of crystalloid fluid given upon arrival and 2 h later. Blood gases decreased in the fracture group despite fluid therapy (p < 0.003), and the coagulation profile worsened although the change was not statistically significant. CONCLUSION: The treatment of multiple-trauma patients with femoral bone fractures should be more concerned with the need for the infusion of vasopressors such as norepinephrine. If there is evidence of clinical shock, excessive crystalloid infusion (limited to 1 L) should be avoided, and blood and blood products should be started as soon as possible.

Effects of Topical Sesame Oil Extracted from Tahini (Ardeh) on Pain Severity in Trauma Patients: A Randomized Double-Blinded Placebo-Controlled Clinical Trial.

OBJECTIVE: To investigate the effects of sesame oil extracted from tahini (Ardeh) on pain severity in patients with upper or lower limbs trauma. METHODS: This double-blinded randomized clinical trial study was conducted on 120 patients with upper or lower trauma in Shahid Rajaee Hospital, Shiraz, Iran, from May the 1st through November 30th, 2016. The patients were randomly assigned to two groups using block randomization. The intervention group received topical sesame oil extracted from tahini (Ardeh) and the placebo group received cooking oil. Pain severity, pain sensitivity and heaviness of painful site were assessed. RESULTS: Overall, we included 90 patients with traumatic limb injuries in this study who were randomized to two study groups. The mean age of the patients was 28.3 ± 6.8 (ranging from 25 to 35) years and there were 63 (70%) men and 27 (30%) women among the patients. In the sesame oil group, the mean changes in the pain severity (-1.53 ± 0.57, P<0.001), pain sensitivity (-1.45 ± 0.64, P<0.001) and heaviness of painful site (-1.56 ± 0.68, P<0.001) were significantly lower when compared to the placebo group in the second day of the intervention. None of the patients experience adverse drug effects. CONCLUSION: Our findings suggest that the topical use of sesame oil extracted from Tahini has a pain reliever effect on the skin after bruising and it helps prevent skin discoloration in patients with traumatic injuries of limbs.

Our Experience of Trauma Management During Novel Coronovirus 2019 (COVID-19) Pandemic in a Busy Trauma Center in Southern Iran.

During the past few months, the novel coronavirus 2019 (COVID-19) pandemic has significantly affected medical service provision. In Iran, it has caused around 197,000 inflictions and 9200 deaths up to June 18, 2020. While many departments turned to telehealth in this era, the trauma service should provide non-stop in presence service to the trauma victims. Our trauma center is the largest in the southwest of Iran, with the mean annual admission of 18,500 polytrauma patients. In this center, we designed a safety protocol to mitigate the spread of disease and also have a more robust case finding system, especially among asymptomatic carriers who attend hospitals based on their trauma. In brief, all unstable patients were considered SARS-COV-2 positive and were directed toward the Specialized COVID-19 related ICU. For all stable patients, history, physical examination, CXR, and lab test (Complete Blood Count, Erythrocyte Sedimentation Rate, C-Reactive Protein) were ordered before entering the wards. If there was any suspicion of COVID-19, the stable patient was admitted to the COVID-19 specialized ward. Among all 1805 patients admitted during a ten weeks interval (from January 30, 2020, to April 14, 2020), 84 had a red flag and toward to COVID-19 related wards. Of those, 67 had positive PCR or evidence in CT in favor of the COOVID-19. Moreover, during regular workups, we found that 19 completely asymptomatic trauma victims had typical Chest CT scan findings of COVID-19.

Jejunostomy with Enteroenterostomy for Enteral Nutrition in Critically Ill Trauma Patients. A Novel Technique.

Purpose The aim of the current study was to report the surgical outcome and complications of jejunostomy with enteroenterostomy for enteral nutrition (EN) in critically ill trauma patients with prolonged nasogastric (NG) nutrition. Methods This cross-sectional study was carried out in a level I trauma center in Shiraz, southern Iran during a one-year period from 2016 to 2017. We included a total number of 30 patients with severe trauma admitted to the intensive care unit (ICU) with more than three months NG nutrition and bowel atrophy. We performed a novel jejunostomy with an enteroenterostomy procedure for providing a route for enteral nutrition in all 30 patients. The rate of complications, such as dislodgement, clogging, obstruction, leakage, mucosal bleeding, and infection, were recorded and reported. We also recorded the hospital and ICU length of stay (LOS). Results We included a total number of 30 patients with a mean age of 35.64 ± 8.91 years, and there were 23 (76.6%) men and seven (23.4%) women among the patients. Overall, 14 (46.6%) patients experienced complications related to the jejunostomy with enteroenterostomy. The most common complication was nausea and vomiting (33.3%) and distention (33.3%), followed by surgical site infection (30.0%). The mean ICU LOS and hospital LOS was found to be 16.8 ± 3.7 and 24.3 ± 4.1 days, respectively. The overall mortality rate was 17 (56.6%), which was secondary to the primary injury and was not related to the procedure. Conclusion Jejunostomy with enteroenterostomy is a safe and feasible method for providing a route for EN in critically ill trauma patients with prolonged NG nutrition and bowel atrophy.

Antimicrobial Survey of Local Herbal Drugs against Acinetobacter baumannii Isolated from Patients Admitted to a Level-I Trauma Center.

Objective: To determine the antimicrobial activity and entity of several local herbal plants against Acintobacters isolated from trauma patients admitted to a Level-I trauma center. Methods: The antibacterial activities of the Satureja bachtiarica oil and someselected Iranian medicinal plants (Artemisia sieberi and Tanacetum dumosum belonging to the Asteraceae/Compositae; Salvia mirzayanii and Mentha mozaffarianii belonging to the Lamiaceae/Labiatae) were assayed on A. baumannii by microdilution and agar disc diffusion methods. Having obtained the acceptable antibacterial data, the shade-dried aerial parts of the plants were extracted by hydrodistillation method using Clevenger apparatus according to European pharmacopeia for 3 h. The analysis of S. bachtiarica essential oil accompanied by other herbal drug oils were performed by using GC/FID and GC/MS methods. Results: Outcomes revealed that the S. bachtiarica essential oil exhibited the potent antibacterial capability against Acinetobacter strains in comparison with Colistin, as a positive control. For S. bachtiarica,the growth inhibition zone and minimum inhibitory concentration (MIC) values were 21 mm and 0.5 mg/ml, while, for Colistin, the data were in order: 8 mm and 0.016 mg/ml. Consequently, GC/MS outcomes demonstrated that the major components of the essence were carvacrol (48.6%), followed by p-Cymene (16.6%), γ-terpinene (6.9%) and linalool (5.3%). Conclusion: Based on the considerable inhibitory activity against nosocomial infections by essential oil of S. bachtiarica, it could be considered as the suitable candidate in the food industry and pharmaceutical uses.

Huge mesenteric low-grade fibromyxoid sarcoma: A case report and review of the literature.

Low-grade fibromyxoid sarcoma is a rare soft tissue tumor which has been mostly reported in lower extremities; however, it can also occur in other parts of the body such as head and neck and abdominal wall, but its occurrence in the abdominal cavity and mesentery of bowel is an extremely rare event and has very rarely been reported. Herein, we report our experience with a 24-year-old lady with a huge mesenteric mass, turned out to be low-grade fibromyxoid sarcoma. This case is the largest one reported in the English literature. We will also discuss about the previously reported cases of low-grade fibromyxoid sarcoma in the English literature.

Early Predictive Factors of Hypofibrinogenemia in Acute Trauma Patients.

BACKGROUND: Uncontrolled hemorrhage still remains a major cause of trauma-associated mortality. The events resulting in acute traumatic coagulopathy, particularly hypofibrinogenemia, make control of bleeding difficult. It is essential to timely predict, diagnose, and manage trauma-induced coagulopathy. AIMS: The aim of this study is to determine clinical and easily available laboratory variables that are predictive of hypofibrinogenemia in acute trauma patients. SETTINGS AND DESIGN: This 2-year retrospective work examined the data of major trauma patients that were referred to Shahid Rajaee Hospital's emergency room in hemorrhagic shock condition. MATERIALS AND METHODS: Fibrinogen level was assessed for these patients on their arrival at our facility. Along with clinical and routine paraclinical variables, we evaluated the predictive value of these variables for a fibrinogen level below 100 mg/ml. RESULTS: A total of 855 cases were included (females: 16.4%; and males: 83.6%) in the study. The mean ± SD age was 36 ± 17.9 years, and the mean ± SD injury severity score was 12.2 ± 9. Motor vehicle accident was the most common cause of injury. Three factors, including arterial pH (cut off point = 7.34; area under the curve [AUC]: 0.59), base excess (cutoff point = -4.3; AUC: 0.60), and patients' gender had a significant association with the fibrinogen level under 100 mg/ml. When three factors of pH, BE, and patients' gender are being assessed simultaneously, the AUC became 0.62 (the predictive ability improved). CONCLUSIONS: Variables, including arterial pH, BE level, and patients' gender have predictive value for fibrinogen transfusion in trauma.

Comparison of the impact of applications of Targeted Transfusion Protocol and Massive Transfusion Protocol in trauma patients.

BACKGROUND: The current study assessed a recently developed resuscitation protocol for bleeding trauma patients called the Targeted Transfusion Protocol (TTP) and compared its results with those of the standard Massive Transfusion Protocol (MTP). METHODS: Per capita utilization of blood products such as packed red blood cells (RBCs), fresh frozen plasma (FFP), and platelet concentrates was compared along with mortality rates during two 6-month periods, one in 2011 (when the standard MTP was followed) and another in 2014 (when the TTP was used). In the TTP, patients were categorized into three groups based on the presence of head injuries, long bone fractures, or penetrating injuries involving the trunk, extremities, or neck who were resuscitated according to separate algorithms. All cases had experienced motor vehicle accidents and had injury severity scores over 16. RESULTS: No statistically significant differences were observed between the study groups at hospital admission. Per capita utilization of RBC (4.76 ± 0.92 vs. 3.37 ± 0.55; P = 0.037), FFP (3.71 ± 1.00 vs. 2.40 ± 0.52; P = 0.025), and platelet concentrate (1.18 ± 0.30 vs. 0.55 ± 0.18; P = 0.006) blood products were significantly lower in the TTP epoch. Mortality rates were similar between the two study periods (P = 0.74). CONCLUSIONS: Introduction of the TTP reduced the requirements for RBCs, FFP, and platelet concentrates in severely injured trauma patients.

Injury patterns among various age and gender groups of trauma patients in southern Iran: A cross-sectional study.

Administrative data from trauma referral centers are useful sources while studying epidemiologic aspects of injuries. We aimed to provide a hospital-based view of injuries in Shiraz considering victims' age and gender, using administrative data from trauma research center.A cross-sectional registry-based study of adult trauma patients (age ≥15 years) sustaining injury through traffic accidents, violence, and unintentional incidents was conducted. Information was retrieved from 3 hospital administrative databases. Data on demographics, injury mechanisms, injured body regions, and injury descriptions; outcomes of hospitalization; and development of nosocomial infections were recorded. Injury Severity Score (ISS) was calculated by crosswalking from ICD-10 (International Classification of Diseases) injury diagnosis codes to AIS-98 (Abbreviated Injury Scale) severity codes. Patients were compared based on age groups and gender differences.A total of 47,295 trauma patients with a median age of 30 (interquartile range: 24-44 years) were studied, of whom 73.1% were male and the remaining 26.9% were female (M/F = 2.7:1.0). The most common injury mechanisms in the male group were car and motorcycle accidents whereas females were mostly victims of falls and pedestrian accidents (P < .01). As age increased, a shift from transportation-related to unintentionally caused injuries occurred. Overall, young men had their most severe injuries on head, whereas elderly women suffered more severe extremity injuries. Injury severity was similar between men and women; however, elderly had a significantly higher ISS. Although incidence of nosocomial infections was independent of victims' age and gender, elderly men had a significantly higher mortality rate.Based on administrative data from our trauma center, male gender and age >65 years are associated with increased risk of injury incidence, prolonged hospitalizations, and in-hospital death following trauma. Development of a regional trauma surveillance system may provide further opportunities for studying injuries and evaluating preventive actions.

Time distribution of injury-related in-hospital mortality in a trauma referral center in South of Iran (2010-2015).

In Iran, there are no studies addressing trauma death timing and factors affecting time of death after injuries. This study aimed to examine time distribution of trauma deaths in an urban major trauma referral center with respect to victims' injury characteristics during 2010 to 2015.This was a cross-sectional study of adult trauma-related in-hospital deaths resulting from traffic-related accidents, falls, and violence-related injuries. Information on injury characteristics and time interval between admission and death was extracted from 3 hospital databases. Mortality time distribution was analyzed separately in the context of each baseline variable.A total of 1117 in-hospital deaths (mean age 47.6 ±â€Š22.2 years, 80% male) were studied. Deaths timing followed an extremely positive skewed bimodal distribution with 1 peak during the first 24 hours of admission (41.6% of deaths) and another peak starting from the 7th day of hospitalization to the end of first month (27.7% of total). Subjects older than 65 years were more likely to die after 24 hours compared to younger deceased (P = .031). More than 70% of firearm-related deaths and 48% of assault-related mortalities occurred early, whereas 67% and 66% of deaths from falls and motorcycle accidents occurred late (P < .001). Over 57% of deaths from severe thoracic injuries occurred early, whereas this value was only 37% for central nervous system injuries (P < .001). From 2010 to 2015, percentage of late deaths decreased significantly from 68% to 54% (P < .001).Considering 1 prehospital peak of mortality and 2 in-hospital peaks, mortality time distribution follows the old trimodal pattern in Shiraz. This distribution is affected by victims' age, injury mechanism, and injured body area. Although such distribution reflects a relatively lower quality of care comparing to mature trauma systems, a change toward expected bimodal pattern has started.

Epidemiology of Cervical Spine Fractures.

BACKGROUND: Epidemiology of cervical spine fractures (CSfx) in trauma patients of general population is not yet exclusively known. OBJECTIVES: The purpose of this study was to evaluate the epidemiology of CSfx in trauma patients. PATIENTS AND METHODS: Data from trauma patients admitted in the emergency room (ER) of Shiraz Shahid Rajaei hospital during the 3.5 years period from September 22, 2009 to March 21, 2013, were gathered. All trauma patients with CSfx and/or spinal cord injuries were included in the study. The time of the trauma, mechanism of trauma, injury position, and incidence of cervical spine fractures in the patients were recorded. RESULTS: A total of 469 patients met the inclusion criteria. The mean age of the patients was 34.7 years old, with a minimum age of 16 years old and a maximum age of 89 years old. Young adults were most frequently affected. Out of 469 cases, 368 patients (78.47%) were male and 101 (21.53%) were female. We had a total of 17 SCI cases among our patients (3.62%), out of which 5 (29.41%) were deceased. The total number of deaths in our study was 29 (6.18%); 5 (17.24%) with SCI and 24 (82.76%) without SCI. CONCLUSIONS: This study demonstrated that most victims of CSfx in our region are 16 to 40 years of age. A male predominance was observed, and motor vehicle collisions were the most frequent trauma mechanism leading to cervical spine injury (mostly due to car rollover accidents), with falls as the second most frequent. The rate of SCI in our study was 3.62% of all cases and the mortality rate was 6.18%.