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OBJECTIVES: Ultrasound (US) airway indexes were frequently compared with other scoring systems such as Mallampati score and Cormack - Lehane classification system, but to the best of our knowledge never with LEMON. Here, in this study, we evaluated the accuracy of some recommended airway US parameters in terms of screening difficult airway using the LEMON criteria as a reference. METHODS: This was a cross-sectional diagnostic accuracy study in which people with at least 18 years old coming to the emergency departments for any reason who had consent for participation, were enrolled with the simple random sampling method. Hyo-mental distance (HMD), skin to epiglottis distance (EP), and peri-epiglottic space to epiglottis to vocal cord ratio (PEP/E. VC) were the US indexes that were calculated in all participants. Using a preprepared checklist, measured US parameters were recorded. For each participant, the LEMON score variables were also assessed and recorded, and the cutoff point for considering as a difficult airway case, based on LEMON score, was 2. Demographic characteristics of the participants were also registered. RESULTS: A total of 299 cases with a mean age of 41.1 years (95% confidence interval [CI]: 39.3-42.9), were participated. Based on LEMON score =2, 20 participants (6.7%) were categorized in difficult airway group. Comparison of the PEP/E. VC (P = 0.007) and EP distance (P = 0.049) of the participants based on LEMON score showed a statistically significant difference; but comparison of the means of HMD in the two groups was not statistically significant (P = 0.144). The median of EP of the participants was 7.70 mm (interquartile range [IQR]: 6.70-9.40). The best cutoff point of EP distance for evaluating a difficult airway was 12.27 mm and more with the sensitivity of 35% and the specificity of 86.96% (accuracy = 0.614; 95% CI: 0.492-0.736). The median of PEP/E. VC was 1.01(IQR: 0.79-1.23). The best cutoff point of PEP/E. VC for evaluating a difficult airway was 0.88 and less with the sensitivity of 70% and the specificity of 67.38% (accuracy = 0.701; 95% CI: 0.583-0.818). CONCLUSION: As per our results, PEP/E. VC and EP distance measured with sonography can be used in distinguishing the difficult airway, using the LEMON criteria as the reference. However, further studies are needed to use PEP/E. VC and EP distance as a part of reliable indexes. [ABSTRACT FROM AUTHOR]

Introduction: Owing to the imposed burden of the coronavirus disease 2019 (COVID-19), the need for stratifying the prognosis of patients has never been timelier. Hence, we aimed to ascertain the value of CHADS2, CHA2DS2-VASc, and CHA2DS2-VASc-M (one point for male instead of female) scores to predict unfavorable outcomes in COVID-19 patients. Methods: We enrolled consecutive patients above 18 years of age with confirmed COVID-19, who were admitted between February 16 and November 1, 2020. The primary endpoint of this study was three-month all-cause mortality. The secondary endpoints were considered four major in-hospital clinical features, including acute respiratory distress syndrome, cardiac injury, acute kidney injury, and mechanical ventilation. Results: A total of 1,406 hospitalized COVID-19 patients were studied, among which 301 (21.40%) patients died during the follow-up period. Regarding the risk scores, CHADS2 ≥1, CHA2DS2-VASc ≥2, and CHA2DS2-VASc-M ≥2 were significantly associated with mortality. The performance of all risk scores for predicting mortality was satisfactory (area under the curve: 0.668, 0.668, and 0.681, respectively). Appraising secondary endpoints, we found that all three risk scores were associated with increased risk of acute respiratory distress syndrome, cardiac injury, acute kidney injury, and mechanical ventilation. Lastly, we revealed that all risk scores were significantly correlated with serum levels of laboratory biomarkers. Conclusion: Our analysis illustrated that the CHADS2, CHA2DS2-VASc, and CHA2DS2-VASc-M scores could aid prognostication of unfavorable outcomes in COVID-19 patients. Therefore, these easily calculable methods could be integrated into the overall therapeutic strategy to guide the COVID-19 management more accurately. [ABSTRACT FROM AUTHOR]

OBJECTIVES: This study aimed to compare the efficacy of intravenous (IV) morphine plus ibuprofen or ketorolac versus IV morphine alone in controlling renal colic pain in the emergency department. METHODS: This double‑blind, randomized clinical trial was conducted during November 2018 and March 2019 in Iran. Patients aged 18–65 years with acute renal colic and numerical rating scale (NRS) score of higher than 6 of 10 were enrolled to the study. They were randomly assigned to I, K, and control groups receiving 5 mg morphine with 800 mg ibuprofen (n = 65), 5 mg morphine with 30 mg ketorolac (n = 65), or only 5 mg morphine (n = 65) intravenously, respectively. NRS was evaluated 0, 15, 30, 60, and 120 min after injection. RESULTS: A total of 195 participants took part in the study. The presence of stone in pelvis area was higher in I group (P = 0.027). The mean rescue analgesic dose was higher in the control group and lower in K group (P = 0.031). From the 15th min, the NRS reduction in I and K group was higher than the control group (P < 0.001), but the difference between I and K group was not statistically significant in total (P = 1.0) or in the all follow‑up time intervals (15th P = 0.864, 30th P = 0.493, 60th P = 0.493, and 120th min P = 1.0). The largest difference in pain reduction was observed in 120th min and mean of NRS was 2.9 (95% confidence interval [CI]: 2.6–3.3), 2.9 (95% CI: 2.6–3.3) and 7.0 (95% CI: 6.7–7.4) in I, K and control group, respectively. The adverse effects showed in 18.5%, 20.0%, and 13.8% of I, K, and control group, respectively. CONCLUSION: IV ibuprofen plus morphine and IV ketorolac plus morphine had similar effects in reducing renal colic pain but were more effective than IV morphine alone. [ABSTRACT FROM AUTHOR]

Background: Since the outbreak of coronavirus 2019 (COVID-19), identifying risk factors associated with in-hospital mortality has been a global priority. In this study, the purpose was to evaluate the clinical, laboratory, and radiological characteristics of hospitalized patients with COVID-19 to develop a predictive model and scoring system for in-hospital mortality. Methods: In this retrospective cohort study, 611 adult patients with COVID-19, admitted to Sina hospital were enrolled and followed up. Results: Out of the total number of 611 patients, 104 patients (17%) deceased during hospitalization, including 75 (12.2%) deaths in ICU and 29 (4.7%) deaths in the wards. After multivariate logistic regression analysis, several characteristics including age >55 years, previous history of malignancy, history of cerebrovascular accident, tachypnea on admission, CRP>54 on admission, D-dimer>1300, and bilateral pulmonary consolidation on chest Computed Tomography (CT) were shown to be the main determinants for stratifying the risk for in-hospital death. The factors were finally considered for introducing a new predictive scoring system for COVID-19 related death. Conclusion: In-hospital mortality rate in patients with COVID-19 is estimated to be 17%. A new scoring system for predicting in-hospital mortality in such patients was structured based on determinant factors of advanced age, history of malignancy, cerebrovascular accident, tachypnea, raised CRP, raised D-dimer on admission, and bilateral pulmonary consolidation on chest CT scan. [ABSTRACT FROM AUTHOR]

Background: Many sedative regimens have been studied with controversial efficiencies. This study tried to assess the desirable and adverse effects of sodium thiopental-fentanyl (TF) with ketamine-propofol (KP) for procedural sedation and analgesia in the emergency department.Methods: After signing written consent, patients were enrolled in this randomised double-blind trial to receive either KP or TF to reach the desired sedation level. The respiratory and haemodynamic complications, nausea and vomiting, recovery agitation, patient recall and satisfaction, provider satisfaction and recovery time were compared.Results: Of the participants, 47 in the KP group and 49 in the TF group were enrolled. The mean and SD scores were 6.91±1.93 and 8.34±1.25 for patients' satisfaction and 7.55±1.54 and 8.65±1.00 for satisfaction of physicians performing the procedures in TF and KP groups, respectively (p=0.000). Moreover, 39 (79.59%) and 18 (38.29%) of patients declared that they had recalled the procedures in the TF and KP groups, respectively (p=0.000). Transient hypoxia was reported in 2.1% and 8.1% in the KP and TF groups leading to perform 4.2% vs 8.1% airway manoeuvres, respectively, without the need for endotracheal intubation or further admission.Conclusions: KP and TF combinations were effectively comparable although KP resulted in higher patient and provider satisfaction. This study did not detect a difference regarding adverse respiratory or haemodynamic effects. It is estimated that the TF combination can be potent and efficacious with possible low adverse events in procedural sedation. [ABSTRACT FROM AUTHOR]

OBJECTIVES: In this study, we aimed to investigate the accuracy of recognition of stroke in the Emergency Room (ROSIER) Scale in the diagnosis of patients with acute ischemic stroke (AIS) transferred to the emergency department (ED). METHODS: The present study was a multicenter study. Records from patients suspected of stroke, who referred to the ED were reviewed. Demographic, clinical, and diagnostic data were extracted and then entered in checklists. ROSIER Scale was used to evaluate the possible diagnosis in this study. The definitive diagnosis of a stroke was made based on neurologist's assessment and clinical and neuroimaging findings, mainly brain magnetic resonance imaging (MRI). Receiver operating characteristic (ROC) curve analysis was conducted for assessing the accuracy of ROSIER in discrimination of stroke. RESULTS: The data of 356 suspected stroke patients were analyzed. Of all, 186 patients (52.2%) were male, and the mean age was 65.2 (standard deviation = 14.0) years ranging from 26 to 95 years. One hundred and fifty-one patients (42.4%) had AIS based on the final diagnosis. The area under the ROC curve was 0.85. The best cutoff point for ROSIER scale was =1 with a sensitivity of 85.4% (95% confidence interval [CI]: 78.8, 90.6%) and specificity of 65.8% (95% CI: 58.9, 72.3%). CONCLUSION: Based on the findings, although the best cutoff point was the same as the original (derivation) study, its sensitivity (85.4% vs. 92%) and specificity (65.8% vs. 86%) were considerably lower. [ABSTRACT FROM AUTHOR]

BACKGROUND There is an ongoing controversy about harms and benefits of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) in hypertensive patients with coronavirus disease 2019 (COVID-19). Given the unresolved debate, we investigated the association of ARBs with in-hospital outcomes of these patients. METHODS In this retrospective observational study, we studied patients with COVID-19 who referred to Sina Hospital in Tehran, Iran, from 20 February to 29 May 2020. Patients with either positive real-time reverse-transcriptase polymerase-chain-reaction test of swab specimens, or high clinical suspicion according to the World Health Organization's interim guidance were included. We followed-up patients for incurring death, severe COVID-19, and in-hospital complications. RESULTS We evaluated 681 patients with COVID-19 of whom 37 patients were excluded due to incomplete medical records and 8 patients who used ACEIs which left 636 patients in the analysis. In this cohort, 108 (17.0%) patients expired and 407 (64.0%) patients incurred severe COVID-19. Of 254 (39.9%) patients with hypertension, 122 (48.0%) patients were receiving an ARB. After adjustment for possible confounders, we found no independent association between taking ARBs and in-hospital outcomes except for acute kidney injury (AKI), in patients with confirmed or clinically suspected COVID-19, either hypertensive or not-hypertensive. We found that discontinuation of ARBs during hospitalization was associated with a greater risk of mortality, invasive ventilation, and AKI (all P ˂ 0.002). CONCLUSIONS We found that taking ARBs by patients with hypertension and confirmed or clinically suspected COVID-19 is not associated with poorer in-hospital outcomes after adjustment for possible confounders. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Digital nerve block is a painful procedure. Several methods have been proposed to decrease the injection pain. Applying an ice pack is a pertinent choice due to its effectiveness on pain reduction, convenience, and low costs. In this study, the degree of injection pain reduction was assessed after applying an ice pack to the site of anesthetic injection. METHODS: One hundred participants with traumatic finger injury were assessed. Digital nerve block was performed in fifty patients in the intervention group after 6 min of ice application. In the control group, this procedure was done without ice. The primary outcome was the difference between the needle stick and infiltration pain scores with and without ice pack. The secondary outcome the patient satisfaction score. The protocol of this study was approved by the Institutional Review Board, and it is registered in the Iranian Registry of Clinical Trials. RESULTS: The pain score was assessed using a Numeric Rating Scale. Both the needle skin and infiltration pain scores were statistically significantly lower in the intervention group (P < 0.001). The mean and median needle stick pain scores were 1.5 and 1.0 in the intervention group and 6.8 and 7.0 in the control group, respectively. Moreover, the mean and median infiltration pain scores were 2.7 and 2.0 in the intervention group and 8.5 and 9.0 in the control group, respectively. Patient satisfaction score was significantly higher in the intervention group. CONCLUSIONS: Ice pack is inexpensive, readily available, and is easy to apply. We recommend this method to reduce the injection pain before digital nerve block in the emergency department. [ABSTRACT FROM AUTHOR]

Background: This study was conducted to compare the effectiveness of low-dose ketamine versus ketorolac in pain control in patients with acute renal colic presenting to the emergency department (ED). Methods: This is a double-blind randomized clinical trial. The initial pain severity was assessed using the numerical rating scale (NRS). Then, ketamine or ketorolac was administered intravenously at a dose of 0.6 mg/kg and 30 mg respectively. The pain severity and adverse drug reactions were recorded 5, 15, 30, 60, and 120 min thereafter. Results: The data of 62 subjects in the ketamine group and 64 patients in the ketorolac group were analyzed. The mean age of the patients was 34.2 ± 9.9 and 37.9 ± 10.6 years in the ketamine and ketorolac group, respectively. There was no significant difference in the mean NRS scores at each time point, except for the 5 min, between the two groups. Despite a marked decrease in pain severity in the ketamine group from drug administration at the 5 min, a slight increase in pain was observed from the 5 min to the 15 min. The rate of adverse drug reactions, including dizziness (P = 0.001), agitation (P = 0.002), increased systolic blood pressure (> 140 mmHg), and diastolic blood pressure (> 90 mmHg) was higher in the ketamine group. Conclusions: Low dose ketamine is as effective as ketorolac in pain management in patients with renal colic presenting to the ED. However, it is associated with a higher rate of adverse drug reactions. [ABSTRACT FROM AUTHOR]

Defects in medical records is a common problem in many hospitals of Iran, especially emergency departments. This study was conducted to evaluate and establish a continuous quality improvement (CQI) system for improving the quality of patient data recording in the emergency department. This clinical audit was performed on the medical records of the patients discharged from the emergency department of Jiroft, Imam Hospital in 2017. Evaluations were conducted before and one month after an intervention entitled "data recording quality improvement." Data registration rate by the medical staff was 73% before and 84% after the intervention. There was no marked difference in the quality of data recording in in-patients before and after the intervention. Regarding the establishment of a CQI system, the data registration rate by the medical staff of the emergency department improved significantly after the intervention. [ABSTRACT FROM AUTHOR]

Background: The diagnosis of cerebral venous sinus thrombosis still remains a real challenge. Seizure, unusual headache with sudden onset, unexplained persistently unilateral vascular headache and neurologic deficit-which is difficult to be attributed to a vascular territory are some of the suggestive symptoms.Case: An isolated sixth nerve palsy is discussed as a rare presentation for cerebral venous thrombosis. Following the extensive investigation to rule out other possible diagnoses, magnetic resonance venogram revealed the final etiology of sixth nerve palsy that was ipsilateral left transverse sinus thrombosis; therefore, anticoagulant treatment with low molecular weight heparin was administered.Conclusion: Rapid and accurate diagnosis and treatment cause to achieve excellent outcomes for most patients. Considering different clinical features, risk factors and high index of suspicion are helpful to reach the diagnosis. [ABSTRACT FROM AUTHOR]