The role of point-of-care ultrasound in the assessment of pelvic urine leakage and diagnosis of urinoma.

BACKGROUND: Urinoma, a rare condition resulting from urine leakage due to trauma to the kidney, bladder, or urethra, is typically diagnosed using enhanced computed tomography urogram with delayed imaging. This report presents two cases of urinoma likely caused by overdistention of the renal pelvis following excessive fluid intake and the presence of a ureteral stone. CASE PRESENTATION: We present two cases of 36-year-old and 38-year-old patients who presented with flank pain. point-of-care ultrasound (POCUS) played a pivotal role in identifying perinephric fluid in Morrison's space and the splenorenal space, respectively. These ultrasound findings guided further investigations, leading to definitive diagnoses via abdominal pelvic CT scans. Treatment involved prophylactic antibiotics and the successful placement of a double J stent into the renal pelvis over the wire under fluoroscopic guidance, which resulted in significant clinical improvement for both patients. CONCLUSIONS: This study demonstrates the rare occurrence of urinoma from urolithiasis, the use of POCUS in expediting diagnosis and treatment, and the importance of interpreting sonographic images in the correct clinical setting.

Advance Without Cut and Retrograde Removal of Embedded Fishhook; Introducing a Novel Technique.

Removing embedded fishhook without causing further tissue damage from the barbed nature of the hook is a challenge in emergency department (ED). The four most commonly used techniques include advance and cut, string-yank, needle cover, and retrograde removal. This study aims to describe a modified push- through technique without cutting the barb, namely advance without cut and retrograde removal, as an effective technique of successful removal of fishhooks. There is no risk of additional injury to patients and healthcare staff, and the technique does not need tools that are not generally readily available in EDs.

A case report of pneumomediastinum and subcutaneous emphysema associated with pandemic COVID-19 in a 43-year-old man.

COVID-19 is a newly emerging disease with high mortality among the elderly and patients with underlying medical conditions. We report the case of confirmed COVID-19 infection complicated with pneumomediastinum.

Road Crashes in Adults with Attention Deficit Hyperactivity Disorder and Risky Driving Behavior.

Objective: Attention deficit hyperactivity disorder (ADHD) is one of the most common problems in adolescents. Risky behaviors in patients with ADHD are due to impaired impulse control resulting from problems with inhibition of proponent responses, controlling interference, and stopping ongoing responses after feedback on errors. The present study investigated the relationship between ADHD and risky driving behavior and the likelihood of car accident in Arak, Iran, in 2015-16. Method : This case-control study was conducted in the Emergency Department of Vali-Asr hospital in Arak (Iran) on drivers who met the inclusion criteria. The data gathering tools included the Demographic Questionnaire, Manchester Driving Behavior Questionnaire (MDBQ), and Wender Utah Rating Scale (WURS). Statistical analyses were performed using SPSS version 20 software. Results: The mean of ADHD (±SD) was higher among cases (81.64 [26.78]) than in controls (64 [24.28], P = 0.000). The mean of risky driving behaviors (±SD) was higher among cases (66.41[26.78]) than in controls (36.79 [25.42]). There was a significant relationship between ADHD, risky behavior, lapse errors, slips, deliberate violation, and unintentional violation and car accident (P = 0.000). Conclusion: This study showed that ADHD increases the risk of road crashes and motor vehicle injuries. These drivers tend to drive at unauthorized speed, have less control over the vehicle, drive more carelessly, and are more likely to have an accident.

The Role of Ultrasonography in Patients Referring to the Emergency Department with Acute Abdominal Pain.

CONTEXT: Acute abdominal pain is a common clinical problem in emergency and non-emergency cases accounting for 5 to 10% of all referrals to the emergency department. Studies have indicated that these widely differentiated diagnoses are common to these complaints. Considering the high prevalence of this complaint in the patients and the wide range of its differential diagnosis, this review study was designed and evaluated aiming at investigating the causes of acute abdominal pain with a focus on assessing the position of ultrasound as a diagnostic tool in the emergency department. EVIDENCE ACQUISITION: This article was conducted as a narrative review of selected articles from 2005 through 2019. By comparing them, a comprehensive review of ultrasound role was conducted in patients with acute abdominal pain referring to the emergency department. RESULTS: In this review study, we attempted to use the articles of the clinical approach, the required laboratory tests, the disadvantages and advantages of each imaging technique, the differential diagnosis for acute abdominal pain according to the location of the pain, and the position of ultrasound as a diagnostic aid tool. Eventually, the proposed protrusion will be considered in dealing with a patient with acute abdominal pain. CONCLUSION: Regarding the wide range of causes providing multiple differential diagnosis, as well as the limited time of the health team in the emergency department for diagnostic and therapeutic measures, particularly in time-sensitive clinical conditions, ultrasound offered by emergency medicine specialists as a diagnostic aid is considered to improve the overall diagnosis and treatment of patients, thereby reducing complications.

Comparing the Effect of Echinacea and Chlorhexidine Mouthwash on the Microbial Flora of Intubated Patients Admitted to the Intensive Care Unit.

BACKGROUND: Providing intubated patients admitted to the intensive care units with oral healthcare is one of the main tasks of nurses in order to prevent Ventilator-Associated Pneumonia (VAP). This study aimed at comparing the effects of two mouthwash solutions (echinacea and chlorhexidine) on the oral microbial flora of patients hospitalized in the intensive care units. MATERIALS AND METHODS: In this clinical trial, 70 patients aged between18 and 65 years undergoing tracheal intubation through the mouth in three hospitals in Arak, were selected using simple random sampling and were randomly divided into two groups: the intervention group and the control group. The oral health checklist was used to collect the data (before and after the intervention). The samples were obtained from the orally intubated patients and were then cultured in selective media. Afterwards, the aerobic microbial growth was investigated in all culture media. The data were analyzed using SPSS software. RESULTS: The microbial flora in the echinacea group significantly decreased after the intervention (p < 0.0001) and it was also the case withmicrobial flora of the patients in the chlorhexidine group (p < 0.001). After 4 days, the oral microbial flora of the patients in the intervention group was lower than that of the patients in the control group (p < 0.001). CONCLUSIONS: The results showed that the echinacea solution was more effective in decreasing the oral microbial flora of patients in the intensive care unit. Given the benefits of the components of the herb Echinacea, it can be suggested as a viable alternative to chlorhexidine.

Comparing the analgesic effect of intranasal with intravenous ketamine in isolated orthopedic trauma: A randomized clinical trial.

OBJECTIVES: Ketamine is commonly used in anesthetic and sedation before surgical procedures and acts as an analgesic in smaller doses. The aim of this study was to assess the effects of intranasal (IN) ketamine in patients with moderate to severe limb trauma (visual analog scale (VAS) > 60 mm). METHODS: In a triple-blind randomized controlled clinical trial; 154 patients with isolated orthopedic trauma and visual analog scale (VAS) ≥60 mm were included on the basis of inclusion and exclusion criteria. Patients were divided into two groups of ketamine-IN (0.4 mg/kg IN ketamine and an equal volume of placebo saline intravenously (IV)) and ketamine-IV (0.2 mg/kg ketamine IV with 0.5 ml saline IN) on the basis of balanced block randomization method. At 5, 10, 20, and 30 min, patients were assessed for VAS measurement and adverse events. Repeated measure ANOVA, independent t-test and chi square test were employed. The level of statistical significance was considered to be less than 0.05. RESULTS: Mean VAS in IN ketamine and IV group at minute 30 was 31.50 ± 13.40 and 29.35 ± 11.73, respectively. At minute 30, 31 patients (20.39%) required a low-dose of morphine as rescue analgesia (P = 0.427). The results showed that mean change score of VAS (difference of time 0 and time 30) in IN ketamine and IV ketamine VAS were 43.8 (95% confidence interval: 41.1-46.5) and 46.4 (95% confidence interval: 42.8-50.1) and there is no difference between two groups in case of score change of VAS (P = 0.245). Adverse events in nasal and intravenous ketamine in both groups were mild and transient. CONCLUSION: IN ketamine is associated with few side effects and appropriate analgesic effects in isolated orthopedic trauma patients, and it may be used in cases where there is no need for venipuncture of peripheral vessels, especially in crowded EDs.

A 24-Week Treatment of Pediatric Hemangioma with Oral Propranolol.

Hemangioma is a benign vascular tumor that shouldbe treated in problematic situations.Propranolol efficacy, target dose, range of age, duration of treatment and complications arenot conclusive for treatment of pediatric hemangioma. Our goal was to study efficacy and safety of propranolol for hemangioma treating in children. A randomized, open label crossover trial with two twenty four-week treatment phases separated by a one-week washout period, was conducted in Amir-Kabir Hospital, Arak, Iran. Thirty two patients with age of 1 month to 15 years were randomized to receive either oral propranolol 2 mg/Kg/day or receivedno treatment. The primary outcome measure changed in hemangioma size assessed at baseline, day 3, day 7, and every month. At baseline, the mean surface area was 36.9 ± 36.3 cm2. After 1 week of treatment, a decrease was seen in size of hemangiomas. After one month, a significant reduction was seen in size of lesionsin treatment group compared to observation group (30 cm2vs 16 cm2, P < 0.01). Significant reductions were present at other intervals (P < 0.05). In the second phase of the study, a significant reduction was observed only after one month of treatment (P < 0.05). The trial suggested that 24 week treatment with oral propranolol was effective for treatment of pediatric hemangiomas with acceptable safety profile.

Comparing between results and complications of doing voiding cystourethrogram in the first week following urinary tract infection and in 2-6 weeks after urinary tract infection in children referring to a teaching hospital.

INTRODUCTION: Urinary tract infection is the most common genitourinary disease in children so about 40% of the children with urinary tract infection suffering from reflux that caused some consequences such as pyelonephritis and kidney parenchymal injury. OBJECTIVES: This research was conducted to compare the timing of voiding cystourethrogram (VCUG) in children with urinary tract infection in first week and after the first week of urinary tract infection. PATIENTS AND METHODS: This research is a case-control study that both case and control groups include 208 children from 1 month to 12 years old with the complain of urinary tract infection. In case group, the VCUG was performed at the first week of infection and in control group, the VCUG was performed after the first week of infection. RESULTS: complication such as dysuria was observed in two-thirds of children who VCUG was performed during first week after urinary tract infection. Parents stress in case group was more than the other (P=0.015). For overall, the incidence of reflux in case and control groups was 49.5% and 50%, respectively. The mean of reflux grading in right kidney in case group was lower than control group resulting in significant differences between two groups. CONCLUSION: According to higher grade of stress in parents and complications due to VCUG at the first week of urinary tract infection, it is suggested that VCUG be conducted on selective patients in the hospital at the first week of urinary tract infection and during hospitalization.

The effect of short-term workshop on improving clinical reasoning skill of medical students.

BACKGROUND: Clinical reasoning process leads clinician to get purposeful steps from signs and symptoms toward diagnosis and treatment. This research intends to investigate the effect of teaching clinical reasoning on problem-solving skills of medical students. METHODS: This research is a semi-experimental study. Nineteen Medical student of the pediatric ward as case group participated in a two-day workshop for training clinical reasoning. Before the workshop, they filled out Diagnostic Thinking Inventory (DTI) questionnaires. Fifteen days after the workshop the DTI questionnaire completed and "key feature" (KF) test and "clinical reasoning problem" (CRP) test was held. 23 Medical student as the control group, without passing the clinical reasoning workshop DTI questionnaire completed, and KF test and CRP test was held. RESULTS: The average score of the DTI questionnaire in the control group was 162.04 and in the case group before the workshop was 153.26 and after the workshop was 181.68. Compare the average score of the DTI questionnaire before and after the workshop there is a significant difference. The difference between average KF test scores in the control and the case group was not significant but between average CRP test scores was significant. CONCLUSION: Clinical reasoning workshop is effectiveness in promoting problem-solving skills of students.

The prevalence of hypercalciuria in girl kids with over active bladder.

INTRODUCTION: Hypercalciuria may be a sign of over active bladder, these symptoms may be treated if we get rid of hypercalciuria. OBJECTIVES: This paper is intended to get to the prevalence of hypercalciuria in girl kids with over active bladder. PATIENTS AND METHODS: All patients with index of over active urinary bladder who admitted to Amir-Kabir hospital of Arak and children who have admitted without any particular disease just for a laboratory check were studied simultaneously. Urine sample was taken from both groups. RESULTS: The prevalence of hypercalciuria in the group with normal urinary bladder was 22.6% and in the case group was 42.9%. Hypercalciuria was reported in 30 (22.6%) children of control group and 57 (42.9%) children of case group. Based on chi-square test, hypercalciuria distribution between the two groups is not homogeneous (P = 0.001). Mean calcium to creatinine ratios were 2.384330 ± 0.55694 (mg/mg) and 2.186552 ± 0.56714 (mg/mg) for control and case groups respectively and no significant difference is observed between the two groups (P = 0.976). Based on logistic regression test, there is a significant relationship between both case and control groups and the occurrence of hypercalciuria with 2.58 times more than control group observed in case group. CONCLUSION: Based on the high prevalence of hypercalciuria in case group, examination and treatment of hypercalciuria in patients with over active bladder may be effective.

Relationship between progesterone level on the day of human chorionic gonadotropin administration with outcomes of intra-cytoplasmic sperm injection in infertile couples.

BACKGROUND: Gonadotropin-releasing hormone agonists or antagonists are used in assisted reproductive technique cycles as premature luteinizing hormone secretion inhibition. Studies have been reported different and contradictory results on the serum progesterone effect on intra-cytoplasmic sperm injection. OBJECTIVE: The purpose of this study was to evaluate the effect of serum progesterone level on the day of Human chorionic gonadotropin (HCG) administration on the intra-cytoplasmic sperm injection (ICSI) outcome in infertile women. MATERIALS AND METHODS: 249 infertile couples candidated for ICSI were enrolled in the study. Their serum progesterone level on the day of HCG administration was measured and according to serum level, patients were divided into four groups of less than 0.9, 0.9-1.4, 1.5-1.9, and ≥2 ng/mL. The four groups were compared with each other regarding fertility outcomes. RESULTS: Pregnancy rate was not significantly different among the four groups (p>0.05). Also, there was no significant difference among the groups regarding frequency of abortion and ectopic pregnancy. CONCLUSION: Serum progesterone level on the day of HCG administration does not have any significant effect on pregnancy outcomes, including abortion, ectopic pregnancy, and pregnancy rate in patients undergoing ICSI treatment.

Effect of movement and developmental factors in growth and evolution in children with vesicoureteral reflux.

INTRODUCTION: Vesicoureteral reflux (VUR) is a backward flow of urine from bladder to ureter or kidney. Potential reflux is harmful because of kidney being faced with the hemodynamic high-pressure during urination. This project was carried out for high prevalence of VUR and delay in growth of children with chronic diseases. In case of growth disorder in children with this disease and its difference with healthy person, treatment can be tried by treating the growth disorder. OBJECTIVES: The purpose of this study is survey of children with VUR about growth and developmental impairment. PATIENTS AND METHODS: All patients who performed voiding cystourethrogram (VCUG)because of UTI, divided into 2 groups, healthy and sick. History and checklist filled, patients' height and weight measured in a standard way and ASQ questionnaires adjusted to age, used for the studying development effect. The height and weight of children measured by standard meter and scale and used the curves adjusted to age and sex. Control group entered the study with the same characteristics of case group without VUR, however, their height and weight were recorded. The way of evolution studied according to Nelsons evolution table and ASQ questionnaire. RESULTS: The both groups (total of 150 studied children) in the area of development of fine motor, gross motor and indicators of mean and percentile of height and weight and parents' literacy, had a significant difference (P< 0.05). It is can be due to better assessment and follow, higher education levels and better socioeconomic situation. CONCLUSION: Children with VUR, in terms of height and weight growth and index of gross and fine movements and communicate were better than normal children.

Hypovolemic shock following induced abortion and spontaneous heterotopic pregnancy.

Spontaneous heterotopic pregnancy is a rare clinical condition in which intrauterine and extrauterine pregnancies occur at the same time. It is rare, estimated to occur in 1 in 30,000 pregnancies. The case was a 38-year-old woman with spontaneously conceived heterotopic pregnancy. She was admitted to our center with hypovolemic shock. Focused assessment sonography for trauma examination in emergency department showed large amount of free fluid in peritoneal cavity. She was managed surgical laparotomy. Considering spontaneous pregnancies, physician should be aware of the possibility of heterotopic pregnancy in all reproductive age women, especially those with history of recent abortion. It can occur without any predisposing risk factors. Patients should be informed about possible side effects of nonprescription medicines, and also the health care centers must be safe peaceful environment for them without severe legal consequences.