Effects of Telestroke on Thrombolysis Times and Outcomes: A Meta-analysis.

OBJECTIVE: Telestroke systems are tools, used to provide an advanced stroke care in regions without sufficient neurologic services. We performed this meta-analysis to assess the effects of telemedicine on treatment times and clinical outcomes of acute stroke care. METHODS: A literature search of PubMed, SCOPUS, and Cochrane CENTRAL was conducted for original studies investigating telemedicine applications in acute stroke care. Dichotomous data on treatment outcomes were pooled as odds ratios (ORs), while continuous data on thrombolysis times were pooled as mean differences (MDs) with 95% confidence interval (CI), using RevMan software (version 5.3). RESULTS: Pooling data from 26 studies (6605 thrombolysed patients) showed no significant differences between the telestroke and control groups in terms of in-hospital mortality (OR = 1.21, 95% CI [0.98, 1.49]), 90-day mortality (OR = 1.08, 95% CI [0.85, 1.37]), symptomatic intracranial hemorrhage (sICH) (OR = 1.10, 95% CI [0.79, 1.53]), and favorable clinical outcome at discharge (OR = 1.03, 95% CI [0.69, 1.53]) and 90 days later (OR = 0.99, 95% CI [0.82, 1.18]). The onset-to-door (OTD) duration (MD = -10.4 minutes, 95% CI [-14.79, -.01]) and length of hospital stay (MD = -0.55 days, 95% CI [-1.02, -0.07]) were significantly shorter in the telestroke group, compared to the control group. Although the overall effect estimate (under the fixed-effect model) showed a significant decrease in the onset-to-treatment (OTT) duration in the telestroke group (MD = -5.83 minutes, 95% CI [-8.57, -3.09]), employing the random-effects model for between-study heterogeneity abolished this significance (MD = -5.90 minutes, 95% CI [-13.23, 1.42]). CONCLUSION: Telestroke significantly reduced OTD and hospital stay durations in stroke patients without increasing the risk of mortality or sICH. Therefore, telemedicine can improve stroke care in regional areas with minor experience in thrombolysis. Further randomized controlled trials are needed to assess the benefits of telestroke systems, especially in terms of cost-effectiveness and quality of life outcomes.

Socioeconomic determinants and metabolic syndrome: Results from the Isfahan Healthy Heart Program.

Introduction: The prevalence of metabolic syndrome (MetS) is increasing in Iran. We assessed the relationship between socioeconomic status (SES) and Mets components in the Iranian population. MATERIALS AND METHODS: The sample for this study comprised a random cross-section of men and women from two province districts who participated in the Isfahan Healthy Heart Program (IHHP) in 2007. Each participant completed a questionnaire, underwent anthropometric testing and blood pressure measurements, and provided a blood sample. Mets was defined based on ATPIII criteria. Several SES dimensions, such as education, occupation, and number of children, as well as home, car, and personal computer ownership, were assessed to determine the participant's SES. RESULTS: A higher-than-average income, car ownership, owning or renting a private home, and having a computer are increasing towards increment in SES. All MetS components were more prevalent in participants defined as having a lower SES, while low HDL levels were more common in participants having an SES II (P>0.001). A multivariate analysis showed that having the lowest SES (I) increased the risk of MetS by 1.72 [1.44-2.07], whereas subjects having an SES III had a 1.23 [1.04-1.47] lower risk for MetS. CONCLUSIONS: The relationship between SES and Mets is due largely to behavioural factors, such as practicing unhealthy eating habits. Given the high prevalence of Mets in Iran, we propose that regular health check-ups may be useful in the early detection of the syndrome and, consequently, in the prevention of its effects. In addition, the early detection of MetS may result in the early diagnosis and prevention of cardiovascular diseases.

Efficacy of measuring procalcitonin levels in determination of prognosis and early diagnosis of bacterial resistance in sepsis.

BACKGROUND: Rapid and proper diagnosis of sepsis is one of the daily challenges of emergency department (ED) and intensive care units. The general aim of the present study was to determine the efficacy of measuring procalcitonin levels in the early diagnosis of bacterial resistance to antibiotics administered empirically in patients with sepsis. MATERIALS AND METHODS: The present cross-sectional study consisted of patients with clinical evidence of sepsis or systemic inflammatory response syndrome (SIRS), referring to the ED of a third-level hospital in Tehran, Iran in 2012. After collection of basic and clinical data of patients, venous blood samples were taken for routine laboratory tests and determination of procalcitonin serum levels at baseline and 6 and 24 hours after administration of the first dose of an empirical antibiotic. The subjects were divided into two groups of discharged and expired and then comparisons were made using t-test, Chi-squared test and Fisher's test. Specificity and sensitivity of procalcitonin were evaluated along with ROC curve. RESULTS: In the present study, 170 patients with sepsis were included. Evaluation of serum levels of procalcitonin 24 hours after administration of antibiotics exhibited the best sensitivity and specificity for each patient's response to antibiotics. Use of the cutoff point of 6.5 mg/mL for procalcitonin can predict the disease outcome with sensitivity and specificity of 67% and 80%, respectively. CONCLUSION: It is suggested that procalcitonin be used for the diagnosis of sepsis or SIRS resulting from an infectious disease, for follow-up of treatment and for evaluation of response to treatment.

Effects of pain relief on arterial blood o2 saturation.

BACKGROUND: Pain management with the use of sedatives and analgesics has several advantages and few complications or side effects. OBJECTIVES: In this study, we planned to evaluate the effects of pain control on oxygen saturation independent of other factors, such previous cardio-pulmonary conditions or respiratory rate. PATIENTS AND METHODS: Sixty-seven adult patients with direct trauma to extremities, who were referred to Imam Hossein Educational Hospital emergency room were enrolled in this study. Exclusion criteria were trauma to parts of the body other than extremities, and comorbidity with cardiovascular, pulmonary, or other disorders. Pain was evaluated using a numerical rating scale and scored between 0-10. Patients' respiratory rates (RR) were recorded by a physician and blood oxygen saturations were measured using a pulse oximeter. Then, fentanyl 1 µg/kg was administered under direct supervision of a physician. After five minutes, pain score, oxygen saturation, and RR were measured in the above-mentioned order. RESULTS: The data from 67 patients with a average age of 30 years were collected: 77% were male and 23% were female. The average pain score of these patients was 7.3 at the time of admission, which significantly decreased to 3.8 after fentanyl administration (P < 0.001). Upon arrival in emergency department the mean oxygen saturation and RR were 97.1% and 21.5/minute, respectively. After pain control, mean oxygen saturation and RR were 94.9% and 19.2 /minute, respectively, showing a significant decrease only for RR in comparison with that at the time of admission (P < 0.001). Regression analysis of pain score and O2 saturation differentiation showed no significant relation between these variables. There were no side effects or complications of fentanyl observed in these patients. CONCLUSIONS: The results of our study revealed no independent causative relationship between pain control and oxygen saturation.

Interpretation of Computed Tomography of the Head: Emergency Physicians versus Radiologists.

BACKGROUND: Many patients are brought to crowded emergency departments (ED) of hospitals every day for evaluation of head injuries, headaches, neurologic deficits etc. CT scan of the head is the most common diagnostic measure used to search for pathologies. In many EDs the initial interpretation of images are performed by emergency physicians (EP). Since most decisions are made based on the initial interpretation of the images by emergency physicians and not the radiologists, it is necessary to assess the accuracy of interpretations made by the former group. OBJECTIVES: The objective of this study was to compare the findings reported in the interpretation of head CTs by emergency physicians and compare to radiologists (the gold standard). MATERIALS AND METHODS: This was a prospective cross sectional study conducted from March to May 2009 in a teaching hospital in Tehran, Iran. All non-contrast head CTs obtained during the study period were copied on DVDs and sent separately to a radiologist, 6 emergency medicine (EM) attending physicians and 14 senior EM residents for interpretation. Clinical information pertaining to each patient was also sent with each CT. The radiologist's interpretation was considered as the gold standard and reference for comparison. Data from EM physicians and residents were compared with the reference as well as with each other and statistical analysis was performed using SPSS 18.5. RESULTS: Out of 544 CT scans, EM physicians had 35 false negatives and 53 false positives compared with radiologist's interpretations (P < 0.0001). EM residents had 74 false negatives and 12 false positives compared with radiologist's interpretations (P < 0.0001). CONCLUSIONS: Both EPs and ER residents either missed or falsely called a significant number of pathologies in their interpretations. The interpretations of EPs and ER residents were more sensitive and more specific, respectively. These findings revealed the need for increased training time in head CT reading for residents and the necessity of attending continuing medical education workshops for emergency physicians.

Matrix metalloproteinase enhances big-endothelin-1 constriction in mesenteric vessels of pregnant rats with reduced uterine blood flow.

Preeclampsia is a leading cause of maternal and fetal morbidity/mortality; however, the pathophysiological mechanisms are unclear. Vascular endothelial dysfunction in preeclampsia has been partially attributed to changes in endothelin-1 (ET-1). Several enzymes, including matrix metalloproteinases (MMPs; particularly MMP-2), cleave the inactive precursor big ET-1 (bET-1) to active ET-1. Notably, expression levels of MMP-2 have been shown to be on the increase in women who subsequently develop preeclampsia. We hypothesized that the increased MMP-2 expression leads to increased bET-1 conversion, thereby increasing vasoconstriction in preeclampsia. A reduced uteroplacental perfusion pressure (RUPP) model of preeclampsia in the rat was used to assess mesenteric artery vascular function. Responses to bET-1 (3-310 nmol/L) and ET-1 (1-200 nmol/L) were studied in the presence or absence of inhibitors of enzymes known to cleave bET-1. Vascular contractility in response to bET-1 was greater in RUPP than Sham (P<0.001), whereas neither responses to ET-1 nor maximal contractility to high potassium salt solution (123.70 mmol/L) were different. MMP inhibition with GM6001 (30 µmol/L) significantly decreased responses to bET-1 in RUPP (P<0.001) but not Sham-operated rats. Interestingly, combined treatment with GM6001 and L-NG-nitroarginine methyl ester (100 µmol/L) revealed a NO modulation of MMPs that was reduced in RUPP. In summary, we found increased vascular contractility to bET-1 in the RUPP model of preeclampsia that was likely attributable to upstream enzymatic pathways. These data are consistent with a greater contribution of MMP to cleavage of bET-1 to ET-1 ex vivo in RUPP, suggesting that this enzyme may be partially responsible for increased bET-1-induced contractility.

Status epilepticus after myelography with iohexol (Omnipaque).

Myelography has been of great use as a diagnostic modality, especially when other modalities were not conclusive.However, considering the invasive nature of myelography, it should receive the attention of medical personnel for them to be aware of its possible complications, especially when newer agents are applied as the contrast media. Myelography could lead to some common adverse effects and complications, but in this case report, we will present one of the most serious and uncommon complications accompanied with myelography using Omnipaque, a nonionic second-generation contrast agent. These complications include lower-extremity myoclonic spasms, tonic seizure leading to status epilepticus, rhabdomyolysis, disseminated intravascular coagulation and anaphylactic shock. Having the knowledge of possible complications and available solutions, particularly fatal ones, could prepare medical staff beforehand for primary and secondary preventions.

Lectin-like oxidized low-density lipoprotein 1 receptor in a reduced uteroplacental perfusion pressure rat model of preeclampsia.

Preeclampsia is a major cause of maternal and fetal morbidity and mortality that has been associated with endothelial dysfunction attributed, in part, to dyslipidemia, an imbalance in angiogenic factors and oxidative stress. One of the many factors that have been shown to be elevated in women with preeclampsia is low-density lipoprotein (LDL) and the more oxidizable, small dense LDL, which can lead to increased vascular oxidative stress and decreased bioavailability of NO. Lectin-like oxidized LDL-1 receptor (LOX-1) is a specific receptor for oxidized LDL. We hypothesized that a reduction of placental perfusion using a rat model of reduced uteroplacental perfusion pressure would result in enhanced LOX-1 expression in the maternal vasculature causing impaired vascular endothelial function through the actions of increased superoxide production and decreased NO-mediated vasodilation. We demonstrated a significant increase in the expression of the LOX-1 receptor (4.3-fold; P=0.002), endothelial NO synthase (2.7-fold; P=0.001), and superoxide (P=0.02) in thoracic aorta of the reduced uteroplacental perfusion pressure model, whereas maximal vasodilator function was modestly decreased (P<0.05). Endothelial-dependent vasodilator function was unaffected by either oxidized LDL or an LOX-1 receptor inhibitor in controls but was modestly increased in the presence of both oxidized LDL and the LOX-1 receptor inhibitor in reduced uteroplacental perfusion pressure (P=0.03). In summary, we have shown that, in a rat model of preeclampsia, there is a dramatic increase in the expression levels of both the LOX-1 receptor and the endothelial NO synthase enzyme, along with evidence of increased superoxide production and subsequent modestly decreased endothelial function.

Epidemiologic study of road traffic injuries by road user type characteristics and road environment in Iran: a community-based approach.

OBJECTIVE: Crash injuries in traffic accidents are affected by a variety of factors. In this study we analyzed road user type information based on different contributing factors. METHOD: Data from all of the road traffic victims on a road extending from the east of the city of Tehran to Mazandaran province were included prospectively over a one-year period (May 2008 to May 2009). Data collected included the crash time, patient's age and sex, road user category, helmet or seat belt use, anatomical site of injury, Injury Severity Score (ISS), and mortality. Prevalence and cross-tabulations were included in the analysis. RESULTS: There were 433 patients, of whom 345 were hospitalized and 33 died either before or after arriving at the hospital. Sixty-nine percent of injured patients were vehicle occupants. Mean and median of ISS were higher for pedestrians, who accounted for 49 percent of the deaths. Head injury was the most common injury and injury to upper and lower extremities was the most common cause of admission. A significant difference in lower extremity injuries between vehicle occupants and nonoccupants was found. Sex and age group did not have a significant effect on mortality. Mortality was significantly higher in pedestrians (P < .001) when data were analyzed based on road user type. CONCLUSION: Because pedestrians are the most vulnerable road users, stricter legislation and law enforcement should be used to protect them. Greater protection can also be reached by holding effective public awareness campaigns on how to use different roads safely. On the other hand, because rear seat passengers are at the same risk for road traffic injuries as front seat passengers, employment of newer laws and preventive measures targeting this group of occupants can prevent many road traffic injuries (RTIs).

Evaluation of the Acute Physiology and Chronic Health Evaluation III in predicting the prognosis of patients admitted to Emergency Department, in need of intensive care unit.

INTRODUCTION: Many of critically ill patients receive medical care for prolonged periods in emergency department (ED). This study is the evaluation of efficiency of Acute Physiology and Chronic Health Evaluation (APACHE) III scoring system in predicting mortality rate in these patients. METHODS: This study was conducted between 2008 and 2009 in Tehran, Iran. One hundred subjects were enrolled in the study. Cases were chosen from patients in need of intensive care unit (ICU) bed who were kept in the ED. The APACHE III scores and predicted and observed mortality rates were calculated using the information from patients' files, interviews with the patients' families, and performing required physical examinations and laboratory tests. RESULTS: The age of the patients and the ED length of stay were 66.07 (±19.92) years and 5.11 (±3.79) days, respectively. The mean (±SD) of APACHE III score of the patients was 58.89 (±18.24). The predicted mortality rate was calculated to be 32.73%, whereas the observed mortality rate was 55%. The mean (±SD) of APACHE III score of survivors and nonsurvivors was 48.63 (±16.35) and 67.63 (±14.84), respectively (P < .001). Furthermore, the ED length of stay was 3.20 (±1.34) and 6.57 (±4.4) days in survivors vs nonsurvivors, respectively (P < .001). CONCLUSION: The APACHE III score and ED lengths of stay were higher in this study compared with other studies. This could be ascribed to more critical patients presenting to the study center and also limited ICU bed availability. This study was indicative of applicability of APACHE III scoring system in evaluating the quality of care and prognosis of ED patients in need of ICU.

Necessity of an integrated road traffic injuries surveillance system: a community-based study.

OBJECTIVES: A prerequisite to improving the situation of traffic accidents and injury prevention is to set up a road traffic accident and victim information system (RTAVIS), which does not exist in Iran. The objective of this study was to compare the 3 major sources of information, including police, emergency medical services (EMS), and hospitals, to show the necessity of an integrated road traffic injury surveillance system. METHOD: This prospective cohort study was performed by pursuing all road traffic accident (RTA) cases during one year (May 2008 to May 2009) within 30 days of their occurrence by a draft questionnaire and data pooling from participating sources. RESULTS: After pooling the data from all organizations, it was revealed that during one year, 245 road traffic accidents occurred in Tehran-Abali route (with a 45-km radius) in which 434 people were either injured or deceased. Out of these crash injuries, police and EMS were unaware of 67 and 51 cases, respectively. In other words, police, pre-hospital emergency services and hospitals reported 56.2, 82.9, and 76.4 percent of the entire number of injuries or deaths, respectively. CONCLUSION: None of the organizations investigated, that is, police, EMS, and health care facilities, have complete records on injuries and deaths caused by traffic accidents. We recommend the formulation and implementation of an integrated and multidisciplinary data collection system of national traffic accidents with the collaboration of police, Ministry of Health and Medical Education (EMS and hospitals), forensic medicine, and the Iranian Red Crescent.

Troponin utilization in patients presenting with atrial fibrillation/flutter to the emergency department: retrospective chart review.

BACKGROUND: There are few recommendations about the use of cardiac markers in the investigation and management of atrial fibrillation/flutter. Currently, it is unknown how many patients with atrial fibrillation/flutter undergo troponin testing, and how positive troponin results are managed in the emergency department. We sought to look at the emergency department troponin utilization patterns. METHODS: We performed a retrospective chart review of patients with atrial fibrillation/flutter presenting to the emergency department at three centers. Outcome measures included the rates of troponins ordered by emergency doctors, number of positive troponins, and those with positive troponins treated as acute coronary syndrome (ACS) by consulting services. RESULTS: Four hundred fifty-one charts were reviewed. A total of 388 (86%) of the patients had troponins ordered, 13.7% had positive results, and 4.9% were treated for ACS. CONCLUSIONS: Troponin tests are ordered in a high percentage of patients with atrial fibrillation/flutter presenting to emergency departments. Five percent of our total patient cohort was diagnosed as having acute coronary syndrome by consulting services.

Tetanus Quick Stick as an applicable and cost-effective test in assessment of immunity status.

INTRODUCTION: Tetanus vaccine and immunoglobulin administration are challenging decisions mostly because of the fact that the current protocol for immunization against tetanus is based on 2 variables: the vaccination status of the patient and the nature of wound and its exposure. To solve this problem, Tetanus Quick Stick (TQS; Nephrotek Laboratory, Rungis, France), an immunochromatographic dipstick test, was developed to determine the tetanus immunity of the patients. The aim of this present study was to investigate the sensitivity, specificity, and the positive and negative predictive values and cost-effectiveness of TQS in the emergency department (ED) setting. METHODS: Blood samples were collected from 200 patients presenting to our ED. Information including demographic information, tetanus immunization status, wound description, and the preventive measures taken by the emergency physician were gathered by a preeducated nurse. Tetanus Quick Stick test and enzyme-linked immunosorbent assay were performed as the standard diagnostic test by an emergency physician and a laboratory technician, respectively; and results of the 2 techniques were compared. RESULT: Overall, tetanus vaccine was administered to 141(70.5%) patients and immunoglobulin to 105 (52.5%) patients. The analysis revealed 88.1% sensitivity and 97.6% specificity for the TQS test. The positive and negative predictive values of TQS test were 99.3% and 66.1%, respectively. Our analysis is also showed a significant decrease in cost when TQS was applied for patients with dirty, tetanus prone wounds or injuries and unknown or incomplete vaccination history (€ 9.48 versus € 12.1). CONCLUSION: This study revealed TQS test to be appropriate and cost-effective for ED use especially in evaluating patients who do not remember or cannot give their tetanus immunization history.

Gender differences in the prevalence of hypertension in a representative sample of Iranian population: the Isfahan Healthy Heart Program.

BACKGROUND: Management and control of hypertension is an important potential health challenge that may result in considerable cardiovascular adverse events especially for women. In this population-based survey, we sought to determine the epidemiology of hypertension among women compared with men in a community sample of Iranians in the 2008s. METHODS: Data were originated from the Isfahan healthy heart program (IHHP) that was designed and launched in 2000 in order to assess the efficacy of lifestyle interventions such as determining the cumulative prevalence of hypertension in a representative sample of Iranian women and to compare it to men. Blood pressure was measured in 12514 individuals (6123 men and 6391 women aged > or = 19 years) selected through multistage random cluster sampling in each sex and age groups. Baseline data were also collected using a special questionnaire and interviews by expert and trained nurses for this survey. RESULTS: It was revealed a significant increasing trend in the prevalence of hypertension in both urban and rural population in the two genders (p for trend <0.001). The prevalence of hypertension in women was estimated from 4.4 % in subjects aged < 30 years to 39.1% in the elderly aged > or = 60 years in urban population. Moreover, hypertension was also estimated from 8.6% in individuals aged < 30 years to 32.0% in the elderly aged > or = 60 years in rural population. Both systolic and diastolic blood pressures were frequently higher in women than in men aged 50-60 years. Women more than men are aware of their blood pressure changes and hypertension is more controlled and under pharmacological treatment in women. CONCLUSION: Our study supports the pivotal role of women-specific control and management of hypertension and emphasizes the global education programs about the importance of hypertension control and monitoring and also lifestyle modification for reducing the risk of hypertension in Iranian women. (www.actabiomedica.it).