Global burden of the COVID-19 associated patient-related delay in emergency healthcare: a panel of systematic review and meta-analyses.

BACKGROUND: Apart from infecting a large number of people around the world and causing the death of many people, the COVID-19 pandemic seems to have changed the healthcare processes of other diseases by changing the allocation of health resources and changing people's access or intention to healthcare systems. OBJECTIVE: To compare the incidence of endpoints marking delayed healthcare seeking in medical emergencies, before and during the pandemic. METHODS: Based on a PICO model, medical emergency conditions that need timely intervention was selected to be evaluated as separate panels. In a systematic literature review, PubMed was quarried for each panel for studies comparing the incidence of various medical emergencies before and during the COVID-19 pandemic. Markers of failure/disruption of treatment due to delayed referral were included in the meta-analysis for each panel. RESULT: There was a statistically significant increased pooled median time of symptom onset to admission of the acute coronary syndrome (ACS) patients; an increased rate of vasospasm of aneurismal subarachnoid hemorrhage; and perforation rate in acute appendicitis; diabetic ketoacidosis presentation rate among Type 1 Diabetes Mellitus patients; and rate of orchiectomy among testicular torsion patients in comparison of pre-COVID-19 with COVID-19 cohorts; while there were no significant changes in the event rate of ruptured ectopic pregnancy and median time of symptom onset to admission in the cerebrovascular accident (CVA) patients. CONCLUSIONS: COVID-19 has largely disrupted the referral of patients for emergency medical care and patient-related delayed care should be addressed as a major health threat.

Accuracy of CREST Guideline in Management of Cellulitis in Emergency Department; a Systematic Review and Meta-analysis.

INTRODUCTION: Skin and soft tissue infections are important causes of outpatient visits to medical clinics or hospitals. This study aimed to review the literature for the accuracy of Clinical Resource Efficiency Support Team (CREST) guideline in management of cellulitis in emergency department. METHOD: Studies that had evaluated cellulitis patients using the CREST guideline were quarried in Scopus, Web of Science, and PubMed database, from 2005 to the end of 2020. The quality of the studies was evaluated using Scottish Intercollegiate Guideline Network (SIGN) checklist for cohort studies. Pooled area under the receiver operating characteristic curve (AUROC) of CREST guideline regarding the rate of hospital stay more than 24 hours, rate of revisit, and appropriateness of antimicrobial treatment in management of cellulitis in emergency department was evaluated. RESULTS: Seven studies evaluating a total of 1640 adult cellulitis patients were finally entered to the study. In evaluation of the rate of the appropriate treatment versus over-treatment, the pooled AUROC was estimated to be 0.38 (95% confidence interval (CI): 0.06 - 0.82), indicating low accuracy (AUROC lower than 0.5) of guideline for antimicrobial choice. CREST II patients had a significantly lower odds ratio (OR) of revisiting the Emergency Department, OR=0.21 (95% CI: 0.009 - 0.47). Pooled AUROC value of 0.86 (CI95%: 0.84 - 0.89) showed accuracy of the CREST classification in prediction of being hospitalized more or less than 24 hours. CONCLUSION: CREST classification shows good accuracy in determining the duration of hospitalization or observation in ED but it could lead to inevitable over/under treatment with empirical antimicrobial agents.

Diagnostic Accuracy of Physical Examination and History Taking in Traumatic Rib Fracture; A Single Center Experience.

OBJECTIVE: To evaluate the diagnostic accuracy of history taking and physical examination in the patients with traumatic rib fractures. METHODS: In a cross-sectional study, all patients with multiple traumas who referred to the emergency department were evaluated for the mechanism of injury, chief complaints, vital signs and oxygen saturation. History taking and physical examination were performed according to Barbara Bates reference. Fracture was diagnosed based on chest x-ray results and CT scan, if needed. The results were analyzed by receiver operating characteristic (ROC) curves and area under the curve (AUC) analysis. RESULTS: Isolated rib fractures of thoracic bones were found in 8 out of 99 subjects with mean age of 33.4±19.43 years. In the sensitivity analysis of history taking and physical exam tests, the highest sensitivity was chest tenderness and deformity with 100% sensitivity for each one and the lowest was for the dyspnea with 28.10%; however, the highest sensitivity was for dyspnea with 62.50% sensitivity; and pulmonary hearing aid and chest deformity were not specific (0%). For heart rate, AUC analysis was significant. Heart rate above 80/min was associated with 87.5% sensitivity and 62.5% specificity for rib fractures. CONCLUSION: Proper and physical examination and history taking can help to detect rib fractures with high sensitivity and specificity denoting to the importance of the issue; while, radiographic or surgical approval is required to diagnose rib fractures.

Association of Clinical Signs and Symptoms with Abnormal Urinalysis Findings of Blunt Trauma Patients; a Cross-Sectional Study.

INTRODUCTION: Urinalysis (UA) is performed routinely as a diagnostic screening test for trauma patients in most centers. This study aimed to examine the relationship between patients' clinical signs and symptoms with UA findings. METHODS: This cross-sectional study was carried out on multiple trauma patients between 18 to 65 years old, who were referred to the Emergency Department. UA was performed for all patients and its association with clinical signs and symptoms (pain, tenderness, abrasion, ecchymosis, hematoma, etc.) in abdomen, back, flank, and inferior hemi-thorax was evaluated. RESULTS: 640 patients with the mean age of 39.8 ± 11.2 years were studied (65.0% males). 271 (42.4%) cases had associated injuries and 554 (86.6%) cases had at least one sign or symptom of trauma in abdomen, back, flank or inferior hemi-thorax. 146 (22.8%) patients had negative UA. Among cases with positive UA, 364 (56.9%) cases had microscopic hematuria with RBC < 25/HPF, 60 (9.4%) had microscopic hematuria with RBC ≥ 25/HPF and 70 (10.9%) had gross hematuria. None of the asymptomatic patients had microscopic hematuria with RBC ≥ 25/HPF and gross hematuria (p <0.001). Symptomatic patients who had signs in the abdomen, back or inferior hemi-thorax mainly had microscopic hematuria with RBC < 25/HPF, but those with signs in the flank, mainly had microscopic hematuria with RBC ≥ 25/HPF (p<0.001). Patients with pain, tenderness, abrasion, and ecchymosis in flank had a higher risk of positive UA findings (figure 2; p <0.001). CONCLUSION: Based on the findings of the present study, patients with any findings of pain, tenderness, abrasion, or ecchymosis in flank had higher risk of abnormal UA and perhaps urogenital injuries. None of the asymptomatic patients had microscopic hematuria with RBC ≥ 25/HPF and gross hematuria.

Diagnostic Accuracy of Ultrasonography in Diagnosis of Metatarsal Bone Fracture; a Cross Sectional Study.

INTRODUCTION: Metatarsus is one of the most common sites in the sole of foot bones fractures. The aim of this study was to determine the diagnostic accuracy of ultrasound in diagnosis of metatarsal bone fractures following foot trauma. METHODS: This cross-sectional study was carried out on patients with blunt foot trauma admitted to emergency department of a hospital in Mashhad, Iran from January to September 2016. All patients were evaluated with bedside ultrasound for the presence of first to fifth metatarsal fractures and screening performance characteristics of ultrasonography in detection of metatarsal fractures were calculated considering foot radiography as the reference test. RESULTS: The study was conducted on 102 patients with a mean age of 35.14±14.32 years (56.8% male). The most common signs of trauma in physical examination were pain and tenderness (100%), swelling (96.1%), ecchymosis (14.7%) and deformity (1.9%). Sensitivity, specificity, and positive and negative likelihood ratio of ultrasonography in detection of metatarsal bone fracture were 96.7% (95% CI: 0.83-0.99), 84.5% (95% CI: 0.73-0.92), 73.1% (95% CI: 0.57-0.85), and 98.3% (95% CI: 0.91-0.99), respectively. The overall accuracy of ultrasonography was 0.906 (95% CI: 0.844 - 0.969) based on area under the receiver operating characteristic (ROC) curve. CONCLUSION: Considering the excellent diagnostic accuracy, ultrasonography can be used as an alternative means in diagnosis of metatarsal bone fractures.

Quebec Decision Rule in Determining the Need for Radiography in Reduction of Shoulder Dislocation; a Diagnostic Accuracy Study.

INTRODUCTION: The Quebec Decision Rule (QDR) has been developed for deciding on the necessity of radiography for patients with shoulder dislocation. This study aimed to investigate the diagnostic value of QDR in this regard. METHOD: This diagnostic accuracy study was conducted on patients with shoulder dislocation visiting the emergency department. After filling out the QDR-based checklist for all patients, they underwent radiography and the obtained radiography results were compared to QDR-based clinical diagnostic findings. RESULTS: 143 patients with the mean age of 32.1±12 years were evaluated (88.8% males). Sensitivity, specificity, and positive and negative predictive values of QDR were 50%, 58.2%, 3.3%, and 97.6%, respectively. The sensitivity and specificity were 100% and 50% in patients >40 years old, and 33.3% and 59.8% in those <40 years old. These indices were 33.3% and 60.4%, respectively, in the male sex and 100% and 40% in the female sex. CONCLUSION: | Quebec decision rule holds promise to diagnose concomitant fractures in patients over the age of 40 with 100% sensitivity, thereby reducing the number of radiographies by 50% without causing diagnostic errors. In contrast, this criterion proved inefficient in patients younger than 40. |.