Prevalence and Predictive Factors of Rhabdomyolysis in COVID-19 Patients: A Cross-sectional Study.

Introduction: The aim of the present prospective observational study was to demonstrate the prevalence and predictive factors of rhabdomyolysis in coronavirus disease 2019 (COVID-19) patients. Methods: The study was performed on reverse transcriptase-polymerase chain reaction (RT-PCR)-confirmed COVID-19 patients admitted to the emergency department between March 2020 and March 2021. Peak creatinine phosphokinase (CPK) levels were used to define rhabdomyolysis. A CPK level equal to or more than 1000 IU/L was defined as the presence of moderate to severe rhabdomyolysis. We developed a COVID-19-related Rhabdomyolysis Prognostic rule (CORP rule) using the independent predictors of rhabdomyolysis in COVID-19 patients. Results: Five hundred and six confirmed COVID-19 patients (mean age 58.36 ± 17.83 years, 56.32% male) were studied. Rhabdomyolysis occurred in 44 (8.69%) cases throughout their hospitalization. Male gender (odds ratio [OR] = 2.78, 95% confidence interval [CI]: 1.28, 6.00), hyponatremia (OR = 2.46, 95% CI: 1.08, 5.59), myalgia (OR = 3.04, 95% CI: 1.41, 6.61), D-dimer >1000 (OR = 2.84, 95% CI: 1.27, 6.37), and elevated aspartate aminotransferase level (three times higher than normal range) (OR = 3.14, 95% CI: 1.52, 6.47) were the significant preliminary predictors of rhabdomyolysis. The area under the curve of the CORP rule was 0.75 (95% CI: 0.69, 0.81), indicating the fair performance of it in the prognosis of rhabdomyolysis following COVID-19 infection. The best cutoff of the CORP rule was 3, which had a sensitivity of 72.9% and a specificity of 72.7%. Conclusion: This prospective study showed that 8.69% of patients developed rhabdomyolysis following COVID-19 infection. The CORP rule with optimal cutoff can correctly classify 72.8% of COVID-19 patients at risk of developing rhabdomyolysis.

NEXUS vs. Canadian C-Spine Rule (CCR) in Predicting Cervical Spine Injuries; a Systematic Review and Meta-analysis.

Introduction: Clinical decision tools have been shown to reduce imaging rates for clearance of suspected cervical spine injury (CSI). This review provides more comprehensive evidence on the diagnostic capabilities of National Emergency X-Radiography Utilization Study (NEXUS) and Canadian C-spine rule (CCR) in this regard. Method: A systematic review of the current literature was performed on studies published until Jan 26th, 2023, in databases of Medline, Scopus, Web of Science, and Embase, investigating the performance of NEXUS and CCR in blunt trauma patients. QUADAS-2 and GRADE guidelines were used to assess the quality and certainty of evidence. All analyses were performed using the STATA 14.0 statistical analysis software. Results: 35 articles comprising 70000 patients for NEXUS and 33000 patients for CCR were included in this review. NEXUS and CCR were evaluated to have a sensitivity of 0.94 (95% confidence interval (CI): 0.88 to 0.98) and 1.00 (95% CI: 0.98 to 1.00) in the detection of any CSI and 0.95 (95% CI: 0.89 to 0.98) and 1.00 (95% CI: 0.95 to 1.00) in the detection of clinically important CSI. The area under the curve (AUC) of NEXUS and CCR was 0.85 and 0.97 for any CSI and 0.78 (95% CI: 0.74 to 0.81) and 0.94 (95% CI: 0.91 to 0.96) for clinically important CSI. Conclusion: Our study demonstrates that both NEXUS and CCR can be used in ruling out patients with low risk of CSI, and CCR was shown to have superior performance. Even though these tools have low specificity, their application can still greatly reduce the number of radiographic imaging performed in emergency departments.

Ultra-early Spinal Decompression Surgery Can Improve Neurological Outcome of Complete Cervical Spinal Cord Injury; a Systematic Review and Meta-analysis.

Introduction: Early decompression within the first 24 hours after spinal cord injury (SCI) is proposed in current guidelines. However, the possible benefits of earlier decompression are unclear. Thus, the present meta-analysis aims to investigate the existing evidence regarding the efficacy of ultra-early decompression surgery (within 12 hours after SCI) in improving patients' neurological status. Methods: A search was performed in Medline, Embase, Scopus and Web of Science electronic databases, until the end of August 2021. Cohort studies and clinical trials were included in the present study. Exclusion criteria were absence of an early or late surgery group, failure to report neurological status based on the American spinal injury association impairment scale (AIS) grade, failure to perform the surgery within the first 12 hours after SCI, and duplicate reports and review articles. Two independent reviewers performed data collection, and risk of bias and certainty of evidence assessments. The outcome was reported as odds ratio (OR) and 95% confidence interval (CI). Results: Data from 16 articles, which studied 868 patients, were included. Compared to early or late decompression surgery, ultra-early decompression surgery significantly improves patients' neurological status (OR = 2.25; 95% CI: 1.41 to 3.58). However, ultra-early surgery in thoracolumbar injuries is not significantly more effective than early to late surgery. Moreover, ultra-early surgery in patients with a baseline AIS A increases the chance of neurologic resolvent up to 3.86 folds (OR=3.86; 95% CI: 1.50 to 9.91). Contrastingly, ultra-early surgery does not result in significant improvement compared to early to late surgery in patients with AIS B (OR = 1.32; 95% CI: 0.51 to 3.45), AIS C (OR = 1.83; 95% CI: 0.72 to 4.64), and AIS D (OR = 0.99; 95% CI: 0.31 to 3.17). Conclusion: Current guidelines emphasize that spinal decompression should be performed within 24 hours after SCI, regardless of injury severity and location. However, results of the present study demonstrated that certain considerations may be taken into account when performing decompression surgery: 1) in patients with AIS A injury, decompression surgery should be performed as soon as possible, since its efficacy in neurological improvement is 3.86 folds higher in the first 12 hours after injury. 2) ultra-early decompression surgery in patients with cervical injury is more effective than in patients with thoracic or lumbar injuries. 3) postponing decompression surgery to 24 hours in SCI patients with AIS B to D does not significantly affect the neurological outcome.

The Value of Lactate Dehydrogenase in Predicting Rhabdomyolysis-Induced Acute Renal Failure; a Narrative Review.

INTRODUCTION: Determining the diagnostic value of available biomarkers in predicting rhabdomyolysis-induced acute kidney injury (AKI) is a priority. This study aimed to review the current evidence about the value of lactate dehydrogenase (LDH) in this regard. METHODS: In this narrative review, the papers in PubMed, Embase, and web of science were studied. The keywords prognosis, prognoses, prognostic, LDH, rhabdomyolysis, emergency patients, and acute kidney failure or AKI had been selected from MeSH medical dictionary. Related papers written in English and published from November 2007 to December 2020 were selected. RESULTS: Finally, 14 articles were accepted for analysis. Among the selected articles, four were randomized clinical trials, seven were cross-sectional, and three were case-control studies. The results of the present review showed that abuse of illegal drugs is the most common cause of rhabdomyolysis. AKI is the most serious complication of rhabdomyolysis reported in the studies. These studies have shown a three-fold increase in AKI following drug-induced rhabdomyolysis. The review of the included articles shows that high LDH can predicts AKI, especially in critical and emergency situations such as rhabdomyolysis where there is a risk of death if diagnosed late. These studies show that LDH increases in the presence of renal failure and tissue damage. CONCLUSION: Serum LDH is an appropriate and cost-effective prognostic indicator that can be used for risk classification of patients at risk for rhabdomyolysis-induced AKI.

Corticosteroids on the Management of Coronavirus Disease 2019 (COVID-19): A Systemic Review and Meta-Analysis.

BACKGROUND: We aimed to examine the available evidence regarding the efficacy and safety of corticosteroids on the management of coronavirus disease 2019 (COVID-19), severe acute respiratory syndrome (SARS-CoV) and Middle East respiratory syndrome (MERS-CoV). METHOD: An extensive search was conducted in Medline, Embase, and Central databases until the end of March 2020, using keywords related to corticosteroids, COVID-19, SARS-CoV and MERS-CoV. The main outcome was considered to be the mortality rate, length of stay, virus clearance time, symptom improvement, and lung function improvement. The findings are presented as odds ratio (OR) with 95% confidence interval (95% CI). RESULTS: Fifteen paper compromising 5 studies on COVID-19, 8 studies on SARS-CoV and 2 studies on MERS-CoV were included. One study was clinical trial and the rest were cohort. The analyses showed that corticosteroids were not reduce the mortality rate of COVID-19 (OR=1.08; 95% CI: 0.34 to 3.50) and SARS-CoV (OR=0.77; 95% CI: 0.34 to 1.3) patients, while they were associated with higher mortality rate of patients with MERS-CoV (OR = 2.52; 95% CI: 1.41 to 4.50). Moreover, it appears that corticosteroids administration would not be effective in shortening viral clearance time, length of hospitalization, and duration of relief symptoms following viral severe acute respiratory infections. CONCLUSION: There is no evidences that corticosteroids are safe and effective on the treatment of severe acute respiratory infection when COVID-19 disease is suspected. Therefore, corticosteroids prescription in COVID-19 patients should be avoided.

Characteristics and Outcome of Abdominal Aortic Aneurysm in Emregncy Department; a 10-year Cross-sectional Study.

INTRODUCTION: Abdominal aortic aneurysm (AAA, triple A) is one of the less common but important causes of abdominal pain. This study aimed to evaluate the characteristics and outcome of patients presenting to emergency department with triple A. METHODS: In this retrospective cross-sectional study, all cases with confirmed triple A, who were presented to the emergency department of Shohadaye Tajrish Hospital, Tehran, Iran from 2006 to 2017 (10 years) were enrolled using census sampling method. RESULTS: 500 cases with the mean age of 68.11 ± 11.98 (25 - 94) years were studied (84% male). The mean duration of symptoms was 2.32 ± 9.58 months and mean aneurysmal size was 63.91 ± 20.08 mm. In 4 (0.8 %) cases, atrial fibrillation (AF) was found during cardiac monitoring. Patients stayed in the hospital for an average of 7.06 ± 6.32 days. Aneurysmal leak was seen in 130 (26%) cases based on abdominal computed tomography (CT) scan findings. 369 (73.8%) cases underwent aneurysmorrhaphy, 126 (25.2%) were treated with non-surgical approaches, and 5 (1%) underwent grafting. 104 (20.8%) died and 396 (79.2%) were treated successfully. Older age (p = 0.017), shock state at the time of presentation (p < 0.0001), leakage of aneurysm (p < 0.001), larger size of aneurysm (p = 0.024), and aneurysmorrhaphy (p < 0.001) were among the factors significantly associated with mortality. CONCLUSION: Based on the findings, the most frequent presenting symptom of patients was abdominal pain. The mortality rate of this series was 21% and older age, shock state, leakage of aneurysm, larger size of aneurysm, and performing aneurysmorrhaphy were among the factors significantly associated with mortality.

Prevalence of Depression and Personality Disorders in the Beginning and End of Emergency Medicine Residency Program; a Prospective Cross Sectional Study.

INTRODUCTION: Emergency medicine physicians are constantly under psychological trauma due to encountering critically ill patients, mortality, and violence, which can negatively affect their mental and physical health. The present study was performed with the aim of determining the rate of depression and personality disorders in first-year emergency medicine residents and comparing it with the time they reach the 3rd year. METHODS: In the present prospective cross-sectional study, emergency medicine residents working in multiple teaching hospitals were included via census method and evaluated regarding the rate of depression and personality disorders using the standard MMPI-2 questionnaire upon admission to the program and graduation and their status regarding the evaluated disorders were compared between the 2 phases of evaluation. RESULTS: 99 residents with the mean age of 33.93 ± 5.92 years were evaluated. 85 (85.85%) rated their interest in their discipline as moderate to high. The rates of stress (p = 0.020), anxiety (p < 0.001), and hypomania (p = 0.015) had significantly increased during the 3 years and psychasthenia rate had decreased significantly during this time (p = 0.002). Changes in the prevalence of other disorders on the third year compared to the year of admission to emergency medicine program were not significant. CONCLUSION: Considering the results of the present study, it seems that paying more attention to mental problems and decreasing environmental stressors of medical residents, especially emergency medicine residents, should be among the priorities of managers and policymakers of this discipline.

Trends of Serum Electrolyte Changes in Crush syndrome patients of Bam Earthquake; a Cross sectional Study.

INTRODUCTION: Electrolyte imbalances are very common among crushed earthquake victims but there is not enough data regarding their trend of changes. The present study was designed to evaluate the trend of changes in sodium, calcium, and phosphorus ions among crush syndrome patients. METHODS: In this retrospective cross-sectional study, using the database of Bam earthquake victims, which was developed by Iranian Society of Nephrology following Bam earthquake, Iran, 2003, the 10-day trend of sodium, calcium, and phosphorus ions changes in > 15 years old crush syndrome patients was evaluated. RESULTS: 118 patients with the mean age of 25.6 ± 6.9 years were studied (57.3 male). On the first day of admission, 52.5% (95% CI: 42.7 - 62.3) of the patients had hyponatremia, which reached 43.9% (95% CI: 28.5 - 59.3) on day 10. 100.0% of patients were hypocalcemic on admission and serum calcium level did not change dramatically during the 10 days of hospitalization. The prevalence of hyperphosphatemia on the first day was 90.5% (95% CI: 81.5 - 99.5) and on the 10th day of hospitalization 66.7% (95% CI: 48.5 - 84.8) of the patients were still affected. CONCLUSION: The results of the present study shows the 52.5% prevalence of hyponatremia, 100% hypocalcemia, and 90.5% hyperphosphatemia among crush syndrome patients of Bam earthquake victims on the first day of admission. Evaluation of 10-day trend shows a slow decreasing pattern of these imbalances as after 10 days, 43.9% still remain hyponatremic, 92.3% hypocalcemic, and 66.7% hypophosphatemic.

Trend of blood lactate level in acute aluminum phosphide poisoning / 世界急诊医学杂志（英文）

BACKGROUND:Aluminum phosphide (AlP) poisoning is common in the developing countries. There is no specific antidote for the treatment of acute AlP poisoning. Early diagnosis of poisoning and outcome predictors may facilitate treatment decisions. The objective of this study was to determine the trend of blood lactate level in acute AlP poisoning to evaluate its role as a prognostic factor. METHODS:This was a prospective study on acute AlP intoxicated patients during one year. Demographic data, clinical and laboratory data on admission, and outcome were recorded in a self-made questionnaire. Blood lactate levels were analyzed every two hours for 24 hours. RESULTS:Thirty-nine (27 male, 12 female) patients were included in the study. The mortality rate was 38.5％. The mean blood pressure, pulse rate, blood pH and serum bicarbonate level were significantly different between the survivors and non-survivors groups. Blood lactate level was significantly higher in the non-survivors group during 8 to 16 hours post ingestion. CONCLUSION:Blood lactate level could be used as an index of severity of acute AlP poisoning.

Comparison of different risk stratification systems in predicting short-term serious outcome of syncope patients.

BACKGROUND: Determining etiologic causes and prognosis can significantly improve management of syncope patients. The present study aimed to compare the values of San Francisco, Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL), Boston, and Risk Stratification of Syncope in the Emergency Department (ROSE) score clinical decision rules in predicting the short-term serious outcome of syncope patients. MATERIALS AND METHODS: The present diagnostic accuracy study with 1-week follow-up was designed to evaluate the predictive values of the four mentioned clinical decision rules. Screening performance characteristics of each model in predicting mortality, myocardial infarction (MI), and cerebrovascular accidents (CVAs) were calculated and compared. To evaluate the value of each aforementioned model in predicting the outcome, sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were calculated and receiver-operating curve (ROC) curve analysis was done. RESULTS: A total of 187 patients (mean age: 64.2 ± 17.2 years) were enrolled in the study. Mortality, MI, and CVA were seen in 19 (10.2%), 12 (6.4%), and 36 (19.2%) patients, respectively. Area under the ROC curve for OESIL, San Francisco, Boston, and ROSE models in prediction the risk of 1-week mortality, MI, and CVA was in the 30-70% range, with no significant difference among models (P > 0.05). The pooled model did not show higher accuracy in prediction of mortality, MI, and CVA compared to others (P > 0.05). CONCLUSION: This study revealed the weakness of all four evaluated models in predicting short-term serious outcome of syncope patients referred to the emergency department without any significant advantage for one among others.

Validation of CRASH Model in Prediction of 14-day Mortality and 6-month Unfavorable Outcome of Head Trauma Patients.

INTRODUCTION: To date, many prognostic models have been proposed to predict the outcome of patients with traumatic brain injuries. External validation of these models in different populations is of great importance for their generalization. The present study was designed, aiming to determine the value of CRASH prognostic model in prediction of 14-day mortality (14-DM) and 6-month unfavorable outcome (6-MUO) of patients with traumatic brain injury. METHODS: In the present prospective diagnostic test study, calibration and discrimination of CRASH model were evaluated in head trauma patients referred to the emergency department. Variables required for calculating CRASH expected risks (ER), and observed 14-DM and 6-MUO were gathered. Then ER of 14-DM and 6-MUO were calculated. The patients were followed for 6 months and their 14-DM and 6-MUO were recorded. Finally, the correlation of CRASH ER and the observed outcome of the patients was evaluated. The data were analyzed using STATA version 11.0. RESULTS: In this study, 323 patients with the mean age of 34.0 ± 19.4 years were evaluated (87.3% male). Calibration of the basic and CT models in prediction of 14-day and 6-month outcome were in the desirable range (P < 0.05). Area under the curve in the basic model for prediction of 14-DM and 6-MUO were 0.92 (95% CI: 0.89-0.96) and 0.92 (95% CI: 0.90-0.95), respectively. In addition, area under the curve in the CT model for prediction of 14-DM and 6-MUO were 0.93 (95% CI: 0.91-0.97) and 0.93 (95% CI: 0.91-0.96), respectively. There was no significant difference between the discriminations of the two models in prediction of 14-DM (p = 0.11) and 6-MUO (p = 0.1). CONCLUSION: The results of the present study showed that CRASH prediction model has proper discrimination and calibration in predicting 14-DM and 6-MUO of head trauma patients. Since there was no difference between the values of the basic and CT models, using the basic model is recommended to simplify the risk calculations.

A Systematic Review of Iranian Experiences in Seismo-Nephrology.

CONTEXT: Crush syndrome and its potentially life-threatening complications, such as acute kidney injury (AKI), are one of the most important medical problems of disaster victims. However, today, many unanswered questions abound about the potential risk factors of crush syndrome, predictive factors of AKI, proper amount of prophylactic hydration therapy, type of fluid, time of continuing fluid, intravenous versus oral hydration, etc. Therefore, this study was designed to review the findings on Iranian nephrologist experiences in diagnosis and management of traumatic rhabdomyolysis following the last two strong earthquakes of Bam (2003) and Manjil-Rudbar (1990). EVIDENCE ACQUISITION: The study was conducted according to the MOOSE reporting guideline. A literature review was conducted on the nephrologic aspects of earthquakes in Iran. Relevant articles were identified through a comprehensive search of online databases until 2014. The search was limited to articles studying the Iranian population published in English and Persian languages. The validated combination of MeSH terms and key words was used. In addition, a manual search was run among the references of all articles that met the entrance criteria and previous reviews. Only cohort, case-control, and cross-sectional studies were enrolled. Two reviewers independently reviewed the eligible studies, and another reviewer contributed in case of a disagreement. Basic information from each study was evaluated from the aspects of purpose and design, year of publication, methodology, main population, and source of data. The quality of the included studies was assessed using methods guide for effectiveness and comparative effectiveness reviews. Two reviewers independently rated each paper as "good", "fair", or "poor". RESULTS: A total of 1256 non-duplicate articles were identified, but only 35 potentially relevant papers were screened. Finally, 21 articles were found eligible and studied in details. In addition, one unpublished report was included. In the quality assessment, two articles had poor quality, and thus only 20 were finally included in the systematic review. No publication bias (coefficient = -2.28; 95% Confidence interval: -6.17 - 1.78; P = 0.26) was observed among the included studies. CONCLUSIONS: A few eligible articles on seismo-nephrology were found in Iran, and a limited number of current articles had poor or fair quality. As expected, the chaotic situation after mass disasters and the lack of documentation led to the loss of much important data on the diagnosis and management of victims. Lessons learned from the current researches can be used as a valuable guide for future studies.

The Role of Scoring Systems and Urine Dipstick in Prediction of Rhabdomyolysis-induced Acute Kidney Injury: a Systematic Review.

INTRODUCTION: During the past decade, using serum biomarkers and clinical decision rules for early prediction of rhabdomyolysis-induced acute kidney injury (AKI) has received much attention from researchers. This study aimed to broadly review the value of scoring systems and urine dipstick in prediction of rhabdomyolysis-induced AKI. MATERIALS AND METHODS: The study was designed based on the guidelines of the Meta-analysis of Observational Studies in Epidemiology statement. Search was done in electronic databases of MEDLINE, EMBASE, Cochrane Library, Scopus, and Google Scholar by 2 independent reviewers. Studies evaluating AKI risk factors in rhabdomyolysis patients with the aim of developing a scoring model as well as those assessing the role of urine dipstick in these patients were included. RESULTS: Of the 5997 articles found, 143 were potentially relevant studies. After studying their full texts, 6 articles were entered into the systematic review. Two studies had developed or validated scoring systems of the "rule of thumb," and the AKI index, and the Mangled Extremity Severity Score. Four studies were on the predictive value of urine dipstick in risk prediction of rhabdomyolysis-induced AKI, with favorable results. CONCLUSIONS: The findings of this systematic review showed that based on the available resources, using the prediction rules and urine dipstick could be considered as valuable screening tools for detection of patients at risk for AKI following rhabdomyolysis. Yet, the external validity of the mentioned tools should be assessed before their general application in routine practice.

The value of serum creatine kinase in predicting the risk of rhabdomyolysis-induced acute kidney injury: a systematic review and meta-analysis.

INTRODUCTION: Identifying the potential effective factors of rhabdomyolysis-induced acute kidney injury (AKI) is of major importance for both treatment and logistic concerns. The present study aimed to evaluate the value of creatine kinase (CK) in predicting the risk of rhabdomyolysis-induced AKI through meta-analysis. METHODS: Two reviewers searched the electronic databases of Medline, EMBASE, Cochrane library, Scopus, and Google Scholar. Data regarding study design, patient characteristics, number of cases, mean and screening characteristics of CK, and final patient outcome were extracted from relevant studies. Pooled measures of standardized mean difference, OR, and diagnostic accuracy were calculated using STATA version 11.0. RESULT: 5997 non-redundant studies were found (143 potentially relevant). 27 articles met the inclusion criteria but 9 were excluded due to lack of data. The correlation between serum CK and AKI occurrence was stronger in traumatic cases (SMD = 1.34, 95 % CI = 1.25-1.42, I(2) = 94 %; p < 0.001). This correlation was more prominent in crush-induced AKI (adjusted OR = 14.7, 95 % CI = 7.63-28.52, I(2) = 0.0 %; p = 0.001). Area under the ROC curve of CK in predicting AKI occurrence was 0.75 (95 % CI = 0.71-0.79). CONCLUSION: The results of this meta-analysis declared the significant role of rhabdomyolysis etiology (traumatic/non-traumatic) in predictive performance of CK. There was a significant correlation between mean CK level and risk of crush-induced AKI. The pooled OR of CK was considerable, but its screening performance characteristics were not desirable.

Clinical decision rule to prevent unnecessary chest X-ray in patients with blunt multiple traumas.

BACKGROUND: Since the diagnostic yield of chest X-ray (CXR) is not high enough, when it is ordered for all the multiple trauma patients, this study was aimed to evaluate the relationship between clinical and CXR findings in order to formulate a clinical decision rule to prevent unnecessary CXR in these patients. METHODS: Stable multiple blunt trauma patients referring to the ED were included. The clinical and radiographic findings of all the patients were collected and the relationships between these variables analysed. Finally, based on the regression coefficients (ß) of the variables, the Thoracic Injury Rule-out Criteria (TIRC) were designed. RESULTS: A total of 2607 patients were included (males: 78.9%, mean age: 34.1 ± 15.0 years). Age over 60 (ß = 0.8; 95% CI: 0.27-1.34; P = 0.003), crepitation (ß = 4.33; 95% CI: 1.65-7.0; P < 0.001), loss of consciousness (ß = 3.16; 95% CI: 2.44-3.88; P < 0.001), decrease in pulmonary sounds (ß = 2.67; 95% CI: 1.73-3.6; P < 0.001), chest wall pain (ß = 2.12; 95% CI: 1.63-2.61; P < 0.001) and tenderness (ß = 1.78; 95% CI: 1.26-2.27; P < 0.001), dyspnea (ß = 1.3; 95% CI: 0.41-2.18; P = 0.004) and abrasion (ß = 0.5; 95% CI: 0.22-0.83; P = 0.03) were independent factors predicting thoracic injury. CXR in stable conscious multiple blunt trauma patients under 60 years, without chest wall pain and tenderness, decrease in pulmonary sounds, crepitation, skin abrasion, and dyspnea did not provide any additional findings. CONCLUSIONS: Based on TIRC, it seems that CXR in stable multiple blunt trauma patients who are conscious and under 60 and have no decrease in pulmonary sounds, no dyspnea, no thoracic skin abrasion, and no crepitation can be ignored.

The Risk of Venous Thromboembolism with Different Generation of Oral Contraceptives; a Systematic Review and Meta-Analysis.

INTRODUCTION: Oral contraceptives (OCs) are considered as one of the most common risk factor of venous thromboembolism (VTE) in childbearing age. Some of the recent researches indicate that the odds of VTE may be even higher with newer generations of OCs. The present meta-analysis was designed to evaluate the effect of different generation of OCs on the occurrence of VTE. METHODS: Two researchers independently ran a thorough search in Pubmed, ISI Web of Science, EMBASE, CINAHL and Scopus databases regarding study keywords including thromboembolic event, thromboembolism, embolism, thromboembolic, thrombotic and thrombosis, combined with oral contraceptive. The outcomes were the incidence of diagnosed thromboembolism, such as deep vein thrombosis, pulmonary embolism and cerebral venous thrombosis. Based on the heterogeneity of the studies, random effect model was used and pooled odds ratio was reported. RESULTS: Three cohort and 17 case-control studies with 13,265,228 subjects were entered into meta-analysis. Analysis showed that the odds of VTE in women taking OCs are more than three-fold (OR=3.13; 95% CI: 2.61-3.65). The risk of VTE in women taking first-, second- and third-generation OCs are 3.5 fold (OR=3.48; 95% CI: 2.01-4.94), 3 fold (OR=3.08; 95% CI: 2.43-3.74) and 4.3 fold (OR=4.35; CI: 3.69‒5.01), respectively. CONCLUSION: It seems that the risk of VTE is not same between different generations of OCs, so that third-generation has highest risk. Taking second and third-generation OCs increases the risk of VTE up to 3 and 4.3 fold, respectively. The researchers of the present study suggest that more trials be designed in relation to the effect of newer generations of OCs in different communities.

Knowledge of Emergency Medicine Residents in Relation to Prevention of Tetanus.

INTRODUCTION: Knowledge of emergency medicine residents about the management of patients suspected of having tetanus-favoring wounds is very important due to their responsibility for the treatment of such patients. The aim of the present study was to evaluate this knowledge and making sure of the adequacy of instructions they have received in relation to prevention of tetanus. METHODS: A reliable and reproducible questionnaire was used to evaluate knowledge of all the emergency medicine residents in Imam Hussein Hospital in Tehran, Iran, about conditions favoring tetanus (9 questions) and proper interventions in such conditions (12 questions). The questionnaires were completed and scored as poor and good. The Mann-Whitney U test was used to analyze data. Statistical significance was set at P<0.05. RESULTS: In the present study, 73 emergency medicine residents were evaluated (45.2% male). Knowledge of 31 (42.5%) residents in relation to conditions favoring tetanus and 41 (56.2%) residents in correct therapeutic interventions was in good level. The most frequent incorrect answer was related to diabetic ulcers and wounds in patients with sepsis. There was an increase in scores of conditions favoring tetanus (P<0.001) and correct therapeutic interventions (P=0.001) with an increase in educational years. However, age (P=0.64), gender (P=0.31), job experience (P=0.38) and participation in educational courses (P=0.67) had no effect on the knowledge level of emergency medicine residents. CONCLUSION: According to the findings of the present study, the knowledge of emergency medicine residents about correct management of patients suspected of tetanus was low, which emphasizes the necessity of providing further instructions on prevention of tetanus in wound management.

An Audit of Emergency Department Accreditation Based on Joint Commission International Standards (JCI).

INTRODUCTION: Despite thousands of years from creation of medical knowledge, it not much passes from founding the health care systems. Accreditation is an effective mechanism for performance evaluation, quality enhancement, and the safety of health care systems. This study was conducted to assess the results of emergency department (ED) accreditation in Shohadaye Tajrish Hospital, Tehran, Iran, 2013 in terms of domesticated standards of joint commission international (JCI) standards. METHODS: This cohort study with a four-month follow up was conducted in the ED of Shohadaye Tajrish Hospital in 2013. The standard evaluation checklist of Iran hospitals (based on JCI standards) included 24 heading and 337 subheading was used for this purpose. The effective possible causes of weak spots were found and their solutions considered. After correction, assessment of accreditation were repeated again. Finally, the achieved results of two periods were analyzed using SPSS version 20. RESULTS: Quality improvement, admission in department and patient assessment, competency and capability test for staffs, collection and analysis of data, training of patients, and facilities had the score of below 50%. The mean of total score for accreditation in ED in the first period was 60.4±30.15 percent and in the second period 68.9±22.9 (p=0.005). Strategic plans, head of department, head nurse, resident physician, responsible nurse for the shift, and personnel file achieved the score of 100%. Of total headings below 50% in the first period just in two cases, collection and analysis of data with growth of 40% as well as competency and capability test for staffs with growth of 17%, were reached to more than 50%. CONCLUSION: Based on findings of the present study, the ED of Shohadaye Tajrish hospital reached the score of below 50% in six heading of quality improvement, admission in department and patient assessment, competency and capability test for staffs, collection and analysis of data, training of patients, and facilities. While, the given score in strategic plans, head of department, head nurse, resident physician, responsible nurse for the shifts, and personnel file was 100%.

Posterior reversible encephalopathy syndrome as the first presentation of chronic kidney disease.

Posterior reversible encephalopathy syndrome is a clinicoradiologic syndrome characterized by seizure, headache, nausea, vomiting, altered mental status, visual disturbance, or visual loss, together with radiologic findings. Herein we reported a patient who was a 27-year-old foreign workman brought to the emergency ward with blurred vision in both eyes, neck pain, somnolence, and altered mental status. He had no known medical or family history. On his physical examination, his blood pressure was 190/100 mmHg and visual acuity of both eyes was decreased (visual acuity = 20/40 for both eyes). Although blood pressure was controlled by intravenous labetalol bolus, his symptoms did not improve. The result of his brain computed tomographic scan was normal, but in the brain magnetic resonance imaging, there were hyperintensities in the occipital lobe and right cerebellar hemisphere, suggesting posterior reversible encephalopathy syndrome. The findings from a complete blood count, biochemical testing, and renal, pelvic and abdominal ultrasound and also the calculated glomerular filtration rate values revealed that all were in favor of chronic kidney disease (hemoglobin level, 10.3 mg/dL; blood urea nitrogen, 90 mg/dL; Cr, 6.8 mg/dL; potassium, 5 mEq/L; sodium, 140 mEq/L; Cockcroft-Gault glomerular filtration rate, 15; weight, 65 kg). The hemodialysis was performed by which the sign and symptoms and radiologic findings resolved within 24 hours. Although PRES is described to be in association with many medical conditions, as mentioned in many available articles, we came to a conclusion that PRES could be the first presentation of a condition such as chronic kidney disease in our case.