Search

Background: Guillain-Barre Syndrome (GBS) is the most prevalent acute peripheral polyneuropathy disorder. The disparities between populations and variations in the major risk factors highlight the importance of country-specific studies. This study aimed to report clinical characteristics and outcomes of ICU-admitted patients with GBS in an academic medical center in Iran. Methods: The data were collected retrospectively from all patients with GBS admitted to Namazi Hospital, affiliated with Shiraz University of Medical Sciences, (Shiraz, Iran), between March 2016 to March 2021. Specialized neurological information and the Acute Physiology and Chronic Health Evaluation (APACHE II) score were recorded. The SPSS software was used to analyze the data. The analyzed data were reported as numbers and percentages, or mean±SD, or median(Interquartile) Results: The study included 132 GBS patients, with an average age of 47.87±15.4 years and a male-to-female ratio of 1.69:1. More than half of the patients (58.5%) were classified as having an axonal disease. In patients with axonal illness, 51.4% of patients had lower limb powers

BACKGROUND: Despite the beneficial effects, RBC transfusion can be associated with infectious and non-infectious complications in critically ill patients. OBJECTIVES: Investigate current RBC transfusion practices and their effect on the clinical outcomes of patients in intensive care units (ICUs). DESIGN: Retrospective observational study SETTING: Three mixed medical-surgical adult ICUs of a large academic tertiary hospital PATIENTS AND METHODS: From March 2018 to February 2020, all adult patients admitted to medical or surgical ICU. Patients who received one or more RBC transfusions during the first month of ICU admission were included in the “transfusion” group, while the remaining patients were assigned to the “non-transfusion” group. MAIN OUTCOME MEASURES: Mortality and length of ICU and hospital stay. SAMPLE SIZE: 2159 patients RESULTS: Of 594 patients who recieved transfusions, 27% of patients received red blood cell (RBC) products. The mean pre-transfusion hemoglobin (Hb) level was 8.05 (1.46) g/dL. There was a significant relationship between higher APACHE II scores and ICU mortality in patients with Hb levels of 7–9 g/dL (OR adjusted=1.05). Also, ICU mortality was associated with age (OR adjusted=1.03), APACHE II score (OR adjusted=1.08), and RBC transfusion (OR adjusted=2.01) in those whose Hb levels were >9 (g/dL). CONCLUSION: RBC transfusion was associated with an approximately doubled risk of ICU mortality in patients with Hb>9 g/dL. High APACHE II score and age increase the chance of death in the ICU by 8% and 3%, respectively. Hence, ICU physicians should consider a lower Hb threshold for RBC transfusion, and efforts must be made to optimize RBC transfusion practices. LIMITATIONS: Single-center and retrospective study.

Abstract Developing an anesthesia module in the operating room is one of the significant steps toward the implementation of electronic medical records (EMR) in health care centers. This study aimed to develop and evaluate the web based-anesthesia module of an electronic medical record Sciences, in the operating room of the Namazi Medical Training Center of Shiraz University of Medical Iran. This developmental and applied study was conducted in steps including determining the functional and non-functional requirements, designing and implementing the anesthesia module, and usability evaluation. 3 anesthesiologists, 3 anesthesiologist assistants, and 12 anesthetist nurses were included in the study as a research community. React.js, Node.js programming language to program this module, Mongo dB database, and Windows server for data management and USE standard questionnaire were used. In the anesthesia module, software quality features were determined as functional requirements and non-functional requirements included 286 data elements in 25 categories (demographic information, surgery information, laboratory results, patient graphs, consults, consent letter, physical examinations, medication history, family disease records, social record, past medical history, type of anesthesia, anesthesia induction method, airway management, monitoring, anesthesia chart, blood and fluids, blood gases, tourniquets and warmers, accessories, positions, neuromuscular reversal, transfer the patient from the operating room, complications of anesthesia and, seal/ signature). Also, after implementing the anesthesia module, results of the usability evaluation showed that 69.1% of the users agreed with the use of this module in the operating room and considered it user-friendly.

Abstract Background The prevalence of resistant hospital infections in the intensive care unit (ICU) increases mortality and antibiotic resistance. COVID-19 pandemic may have unintended impact on nosocomial infections (NI) and the prevalence of resistant microorganism. Methodology The present non-interventional study was performed by a pre and a post survey each lasting 8 months before (March–October 2019) and after (March–October 2020) the onset of COVID-19 pandemic in three ICU’s, not allocated to COVID-19 patients, in Nemazee Hospital, Shiraz, Iran. The rates of the following nosocomial infections were compared at pre- and post-pandemic period: ventilator associated pneumonia (VAP), central line associated blood stream infection (CLABSI), catheter-associated urinary tract infections (CAUTI) and incidence of multiple drug resistance (MDR) pathogens. Results Pre-pandemic and pandemic incidence of VAP was 23.5 and 17.2 cases per 1000 device-days, respectively; an absolute decrease of 27%. The main reason for the decrease in the rate of VAP during the pandemic was a significant decrease in the rate of VAP caused by Acinetobacter baumannii; from 39 to 17% in total VAP episodes. The rate of VAP associated with other microorganisms remained relatively unchanged from 14.2 cases in pre-pandemic period to 14.3 cases per 1000 MV-days during the pandemic (P = 0.801). Pre-pandemic incidence of CLABSI was 7.3 cases and, in pandemic period, was 6.5 cases per 1000 device-days (IRR = 0.88, 95% CI 0.43–1.73, P = 0.703). Pre-pandemic incidence of CAUTI was 2 and in pandemic period, was 1.4 cases per 1000 device-days (IRR = 0.70, 95% CI 0.22–1.98, P = 0.469). Conclusion The results of the present study showed a decrease in the incidence of VAP in critically ill non-COVID-19 patients during the pandemic compared to before the pandemic, especially regarding Acinetobacter baumannii.

Objective(s): The worldwide emergence of carbapenem-resistant Enterobacteriaceae (CRE) has become a major therapeutic concern to medical institutions. To date, no study has determined the frequency and risk factors of inpatients with CRE fecal carriage in Southern Iran. We studied the features of carbapenemase-producing Enterobacteriaceae (CPE) collected from the central ICU of a university hospital.Materials and Methods: Totally, 173 samples, including 124 stool samples from 46 ICU inpatients on admission and different follow-ups, 9 ICU staff, and 40 environmental samples were included. CRE was identified using microbiological methods. Antimicrobial susceptibility was investigated by using the disk diffusion method and E-test. Carbapenemase producers were detected using the mCIM method. Seven carbapenemase genes were characterized. The genetic relationship among 20 CPE was elucidated by PFGE. Results: The overall fecal carriage rate was 28.2%, while CRE acquisition was 6.1%. CRE were classified as Klebsiella pneumoniae (71.4%), Escherichia coli (23.8%), and Enterobacter aerogenes (4.8%). From 21 CRE, 20 (95.2%) produced carbapenemases, of which 10, 15, 10, 25, 5, and 65% were blaKPC, blaSME, blaIMP, blaVIM, blaNDM and blaOXA-48-positive, respectively. Out of 20 CPE, 14 different PFGE patterns were observed, categorized into six clusters, suggestive of non-clonal spread. No difference between the examined risk factors with CRE carriage was shown. Conclusion: The data indicate a high CRE fecal carriage rate among inpatients. Our findings implicate the widespread of OXA-48 carbapenemase together with heterogeneity among CRE with great concern for dissemination and therapeutic threat. Early diagnosis and monitoring of CRE among inpatients are urgent.

Objective: To compare clinical and paraclinical similarities between trauma patients with positive RT-PCRtests (PCR+ve) and the RT-PCR negative ones (PCR -ve).Methods: This a case-control study, where cases had a PCR+ve and controls had a negative result. Two groupswere compared regarding (para) clinical values. Multivariable binary logistic regression analysis investigatedthe variables predicting COVID-19 and the mortality rate.Results: Both groups were similar regarding the clinical findings and comorbidities (p>0.05). PCR+ve grouphad lower lymphocyte count (1.41 [1.45] vs. 1.66 [1.61], p=0.030), CPK level (411 [928.75] vs. 778 [1946.5].p=0.006) and CRP level (17 [42.5] vs. 24 [50.75], p=0.004). However, none of these findings were significant inthe multivariable analysis. Finally, PCR+ve group had increased odds of death (OR=2.88; 95% CI=1.22-7.41).Conclusion: Unlike our primary hypothesis, the study failed to mark any significant (para) clinical featuresguiding us to detect COVID-19 earlier in trauma patients. Moreover, the PCR+ve group is at increased mortalityrisk. A larger, multicentric prospective study should be designed to address this issue.

Background: The coronavirus disease 2019 (COVID-19) has become the leading source of pneumonia outbreaks in the world. The present study aimed to compare the condition of intensive care unit (ICU) and non-ICU COVID-19 patients in terms of epidemiological and clinical features, laboratory findings, and outcomes in three cities across Iran.Methods: In a cross-sectional study, 195 COVID-19 patients admitted to five hospitals across Iran during March-April 2020 were recruited. Collected information included demographic data, laboratory findings, symptoms, medical history, and outcomes. Data were analyzed using SPSS software with t test or Mann-Whitney U test (continuous data) and Chi square test or Fisher’s exact test (categorical variables). P40 years, body mass index

Abstract Background One of the challenging decision-making tasks in healthcare centers is the interpretation of blood gas tests. One of the most effective assisting approaches for the interpretation of blood gas analysis (BGA) can be artificial intelligence (AI)-based decision support systems. A primary step to develop intelligent systems is to determine information requirements and automated data input for the secondary analyses. Datasets can help the automated data input from dispersed information systems. Therefore, the current study aimed to identify the data elements required for supporting BGA as a dataset. Materials and methods This cross-sectional descriptive study was conducted in Nemazee Hospital, Shiraz, Iran. A combination of literature review, experts’ consensus, and the Delphi technique was used to develop the dataset. A review of the literature was performed on electronic databases to find the dataset for BGA. An expert panel was formed to discuss on, add, or remove the data elements extracted through searching the literature. Delphi technique was used to reach consensus and validate the draft dataset. Results The data elements of the BGA dataset were categorized into ten categories, namely personal information, admission details, present illnesses, past medical history, social status, physical examination, paraclinical investigation, blood gas parameter, sequential organ failure assessment (SOFA) score, and sampling technique errors. Overall, 313 data elements, including 172 mandatory and 141 optional data elements were confirmed by the experts for being included in the dataset. Conclusions We proposed a dataset as a base for registries and AI-based systems to assist BGA. It helps the storage of accurate and comprehensive data, as well as integrating them with other information systems. As a result, high-quality care is provided and clinical decision-making is improved.

Introduction: Drug abuse is a major concern, leading to inappropriate control of pain, agitation, and delirium. In the current study, we aimed to evaluate the effect of implementing Pain, Agitation, and Delirium (PAD) control protocol on the outcomes of critically ill patients with a history of drug abuse in the intensive care unit (ICU).Methods: In this experimental study, 44 opioid-dependent patients (18 years and older) were included. The pain was assessed by the Behavioral Pain Scale (BPS) per hour, the level of sedation was evaluated by the Richmond Agitation Sedation (RASS) per hour, and Delirium was measured every 8 hours by the Confusion Assessment Method (CAM-ICU). Based on the type and dose of the consumed drug and the way it was used, the dose of methadone was calculated. In addition, possible symptoms of withdrawal syndrome and excessive use were assessed every hour by the intensive care unit nurse.Results: The ICU stay length was 17 days in the control group and seven days in the intervention group. Patients in the intervention group received lower doses of Methadone and Propofol compared to the control group during 72 hours and lower doses of fentanyl after 48 and 72 hours (p

Abstract Background Administration of an optimal dose of anesthetic agent to ensure adequate depth of hypnosis with the lowest risk of adverse effects to the fetus is highly important in cesarean section. Sodium thiopental (STP) is still the first choice for induction of anesthesia in some countries for this obstetric surgery. We aimed to compare two doses of STP with regarding the depth of anesthesia and the condition of newborn infants. Methods In this clinical trial, parturient undergoing elective Caesarian section were randomized into two groups receiving either low-dose (5 mg/kg) or high-dose (7 mg/kg) STP. Muscle relaxation was provided with succinylcholine 2 mg/kg and anesthesia was maintained with O2/N2O and sevoflurane. The depth of anesthesia was evaluated using isolated forearm technique (IFT) and bispectral index (BIS) in various phases. Additionally, infants were assessed using Apgar score and neurobehavioral test. Results Forty parturient were evaluated in each group. BIS was significantly lower in high-dose group at skin incision to delivery and subcutaneous and skin closure. Also, significant differences were noticed in IFT over induction to incision and incision to delivery. Apgar score was significantly lower in high-dose group at 1 min after delivery. Newborn infants in low-dose group had significantly better outcomes in all three domains of the neurobehavioral test. Conclusion 7 mg/kg STP is superior to 5 mg/kg in creating deeper hypnosis for mothers. However, it negatively impacts Apgar score and neurobehavioral test of neonates. STP seems to has dropped behind as an acceptable anesthetic in Cesarean section. Trial registration IRCT No: 2016082819470 N45 , 13/03/2019.

Introduction: Therapeutic drug monitoring (TDM) and pharmacokinetic assessments of vancomycin would be essential to avoid vancomycin-associated nephrotoxicity and obtain optimal therapeutic and clinical responses. Different pharmacokinetic parameters, including trough concentration and area under the curve (AUC), have been proposed to assess the safety and efficacy of vancomycin administration.Methods: Critically ill patients receiving vancomycin at Nemazee Hospital were included in this prospective study. Four blood samples at various time intervals were taken from each participated patient. Vancomycin was extracted from plasma samples and analyzed using a validated HPLC method.Results: Fifty-three critically ill patients with a total of 212 blood samples from June 2019 to June 2021 were included in this study. There was a significant correlation between baseline GFR, baseline serum creatinine, trough and peak concentrations, AUCτ, AUC24h, Cl, and Vd values with vancomycin-induced AKI. Based on trough concentration values, 66% of patients were under-dosed (trough concentration 600 μg h/ml) that emphasizes on the superiority of AUC-based monitoring approach for TDM purposes to avoid nephrotoxicity occurrence.Conclusion: The AUC-based monitoring approach would be superior in terms of nephrotoxicity prediction. Also, to avoid vancomycin-induced AKI, trough concentration and AUCτ values should be maintained below the cut-off points.

Background: Short-term peripheral venous catheters-related bloodstream infections (PVCR-BSIs) rates have not been systematically studied, and data on their incidence by number of device-days is not available. Methods: Prospective, surveillance study on PVCR-BSI conducted from September 1st, 2013 to 31st Mays, 2019 in 246 intensive care units (ICUs), members of the International Nosocomial Infection Control Consortium (INICC), from 83 hospitals in 52 cities of 14 countries in the Middle East (Bahrain, Egypt, Iran, Jordan, Kingdom of Saudi Arabia, Kuwait, Lebanon, Morocco, Pakistan, Palestine, Sudan, Tunisia, Turkey, and United Arab Emirates). We applied U.S. Results: We followed 31,083 ICU patients for 189,834 bed-days and 202,375 short term peripheral venous catheter (PVC)-days. We identified 470 PVCR-BSIs, amounting to a rate of 2.32/1000 PVC-days. Mortality in patients with PVC but without PVCR-BSI was 10.38%, and 29.36% in patients with PVC and PVCR-BSI. The mean length of stay in patients with PVC but without PVCR-BSI was 5.94 days, and 16.84 days in patients with PVC and PVCR-BSI. The microorganism profile showed 55.2 % of gram-positive bacteria, with Coagulase-negative Staphylococci (31%) and Staphylococcus aureus (14%) being the predominant ones. Gram-negative bacteria accounted for 39% of cases, and included: Escherichia coli (7%), Klebsiella pneumoniae (8%), Pseudomonas aeruginosa (5%), Enterobacter spp. (3%), and others (29.9%), such as Serratia marcescens. Conclusions: PVCR-BSI rates found in our ICUs were much higher than rates published from USA, Australia, and Italy. Infection prevention programs must be implemented to reduce the incidence of PVCR-BSIs.

Background and purpose: Vancomycin is a glycopeptide antibiotic which is the drug of choice against methicillin-resistant Staphylococcus aureus. It has a narrow therapeutic index, and thus therapeutic drug monitoring (TDM), and clinical pharmacokinetic assessment are necessary in order to prevent adverse drug reactions such as nephrotoxicity. In this study, we aimed to develop a simple and validated HPLC method for vancomycin assay in order to establish a TDM center for patients admitted to the ICU of Nemazee Hospital in southern Iran. Experimental approach: In this study, a brief review of different parameters and variables which could affect the sensitivity, selectivity of the validated HPLC method for vancomycin determination were considered. According to the previous studies a simple, fast, and the relatively low-cost method was established for vancomycin determination in plasma samples. Findings/Results: The developed HPLC assay indicated a calibration curve with R-square of > 0.999, acceptable selectivity, the accuracy of 90-105%, CV% of less than 15%, the limit of quantification of 1 μg/mL, and limit of detection of 300 ng/mL. Vancomycin trough level, the area under the curve, renal clearance, the volume of distribution,, and elimination constant were measured in patients using this validated method. Conclusion and implications: Validated method for assay of vancomycin plasma levels was used to quantify vancomycin levels of four patients who were admitted to the ICU of Nemazee Hospital. According to the results, two of these patients showed lower levels than recommended therapeutic purposes while one of them showed a toxic level. According to the results, the TDM assessment of vancomycin is strongly recommended for patients who are hospitalized in ICU.

The world has come to its knees by COVID-19 during the last two years, and the end of the catastrophe is yet unknown. This disaster, although deeply tragic with more than six million casualties, has made different medical disciplines to reconsider outdated, time-consuming methods for reacting to a new problem in medicine. We have never been under such pressure to respond immediately to a destructive and fatal minatory. However, some branches of the health care system such as preventive medicine, emergency medicine, pulmonary disease, infectious disease, anesthesiology, pharmaceutical sciences, and in particular, the critical care, were on the front lines of this onrush.

Background: Extra corporeal membrane oxygenation (ECMO) has been considered as a crucial modality for the management of acute respiratory distress syndrome (ARDS). Since ECMO is considered to be an invasive modality and may be associated with some complications, there are strict indications for its use. Here we report successful treatment of a case of severe ARDS with Veno-Venous ECMO. Case presentation: A 30 years old male was admitted to Nemazee Hospital in Shiraz with decreased level of consciousness due to cerebral hemorrhage following fibrinolytic therapy for myocardial infarction with ST elevation (STEMI). After diagnosis of moderate to severe ARDS, VV-ECMO was used for the management of ARDS. In this case, 5 days after starting ECMO, PaCO2 improved and O2Sat was maintained at 97-98%, so weaning was considered. Ventilator mode was BIPAP with FiO2 40% and sweep flow was 1.7L/min. We clamped the sweep flow and observed whether the patient was able to maintain O2 Sat at 97% with ventilation alone. Then, we decided to disconnect the patient from ECMO. The patient remained stable afterwards. Conclusion: Our case was intubated and was on MV from 10 days prior to ECMO administration.Moreover, our patient had simultaneous multi-organ involvement (nephrotic syndrome and sepsis) which decreased the benefits of ECMO. Despite all these problems, ECMO was started and patient was discharged from ICU with an acceptable health condition.

Background: Extra corporeal membrane oxygenation (ECMO) has been considered as a crucial modality for the management of acute respiratory distress syndrome (ARDS). Since ECMO is considered to be an invasive modality and may be associated with some complications, there are strict indications for its use. Here we report successful treatment of a case of severe ARDS with Veno-Venous ECMO. Case presentation: A 30 years old male was admitted to Nemazee Hospital in Shiraz with decreased level of consciousness due to cerebral hemorrhage following fibrinolytic therapy for myocardial infarction with ST elevation (STEMI). After diagnosis of moderate to severe ARDS, VV-ECMO was used for the management of ARDS. In this case, 5 days after starting ECMO, PaCO2 improved and O2Sat was maintained at 97-98%, so weaning was considered. Ventilator mode was BIPAP with FiO2 40% and sweep flow was 1.7L/min. We clamped the sweep flow and observed whether the patient was able to maintain O2 Sat at 97% with ventilation alone. Then, we decided to disconnect the patient from ECMO. The patient remained stable afterwards. Conclusion: Our case was intubated and was on MV from 10 days prior to ECMO administration.Moreover, our patient had simultaneous multi-organ involvement (nephrotic syndrome and sepsis) which decreased the benefits of ECMO. Despite all these problems, ECMO was started and patient was discharged from ICU with an acceptable health condition.

Objectives: Many risk factors are associated with death in and discharge from the Intensive Care Unit (ICU). This study aimed to evaluate the risk factors associated with death and discharge among ICU patients. Methods: This historical cohort study was conducted on 712 patients admitted to the ICU of Namazi hospital in Shiraz between 2013 and 2015. The competing risks regression model was suitable for assessing the risk factors associated with death and discharge in ICU. Data analysis was performed using STATA 13.0 and R software. Results: The mean age of the participants was 53.3±20.7 years. Out of 712 patients, 436 (61.2%) were male and 121 (17.8%) died. In the competing risks model, death was considered as the event of interest, and age and total days of Central Venous Catheter (CVC) and mechanical ventilation use increased the risk of death (all Sub-distribution Hazard Ratios (SHRs) > 1). Conclusion: The findings indicated that increase in age, use of CVC and mechanical ventilation, and female sex caused an increase in death in ICU. However, the risk of death decreased or the chance of discharge increased when the patients were admitted due to surgical reasons.

Aim: Prophylaxis against stress ulcer in mechanically ventilated patients is one of the causes for ventilator-associated pneumonia (VAP). Our aim was evaluating the effect of intravenous pantoprazole and ranitidine in the incidence of VAP in critically ill patients. Materials and Methods: Patients with at least 48 h of expected mechanical ventilation were allocated randomly to receive either 50 mg ranitidine (R) every 8 h or 40 mg pantoprazole (P) every 12 h intravenously from admission. VAP diagnosis was according to the Clinical Pneumonia Infection Score and positive culture. Results: Eighty-six patients during a 15-month period were analyzed; the study showed a low difference between VAP incidence in the ranitidine and pantoprazole groups. No significant difference was observed in terms of gastrointestinal bleeding, intensive care unit, hospital length of stay, and mortality between the groups. Conclusion: VAP incidence is hardly related to the type of stress ulcer prophylaxis agent with a high rate of VAP and low utilization of VAP prophylaxis bundle.

Objective. To evaluate the effects of application of a manual on the improvement of alarms management in Intensive Care Units (ICU). Methods. This quasi-experimental study evaluated the effectiveness of the introduction into of a manual for alarm management and control in the ICU of a hospital in southeastern Iran. The intervention was a 4-hour workshop was on topics related to the adverse effects of alarms, standardization of ECG, oxygen saturation and blood pressure monitoring systems, and the use of ventilators and infusion pumps. Data were collected thorough 200 hours of observation of 60 ICU nurses (100 hours’ pre-intervention and 100 hours’ post-intervention). Response time, type of response, customization of alarm settings for each patient, the person responding to an alarm, and the cause of the alarm were analyzed. Alarms were classified into three types: false, true and technical. Results. The results showed a statistically significant difference between the pre- and post-intervention frequency of alarm types, frequency of monitoring parameters, customized monitoring settings for patients, and individuals who responded to alarms. The percentage of effective interventions was significantly higher for all parameters after the intervention (46.9%) than before the intervention (38.9%). Conclusion. The employment of a manual for management of alarms from electronic equipment in ICUs can increase the frequency of appropriate responses to alarms in these units.

Background: An important application in health care system is computerized physician order entry system (CPOE) which improves the quality of patient’s care. Given that the users’ satisfaction is necessary in predicting the success of a system, this study aimed to evaluate the satisfaction of CPOE users in Nemazi Hospital. Methods: This cross-sectional study was conducted as a descriptive-analytical research three months after CPOE implementation 2016 at Nemazi Hospital. The study population consisted of all physicians and nurses in General Intensive care Unit (ICU), which included 14 physicians and 26 nurses who had been working with CPOE system. A standard questionnaire was applied for data gathering; its validity and reliability was confirmed in the study (α=0.84). The data were processed by SPSS 21 software and appropriate statistical tests including T test, One-way Anova and Chi-square tests were used. Results: Overall, the satisfaction of physicians and nurses about the CPOE systems was moderate (4.83±1.99). Although the physician’s satisfaction score was 5.30±1.54, which was greater than that of nurses (4.56±2.19), this differences was not significant (P>0.05). Results also showed a significant relationship between the user satisfaction score and age and gender of the participants (P=0.001, P=0.006) respectively.A significant relationship was found between the CPOE user friendliness and age (P=0.05). Conclusion: Overall, there is a relative satisfaction among the physicians and nurses about CPOE in Nemazi hospital. Hospital managers could accelerate the use of CPOE in hospitals. It is suggested that the challenges of the system should be examined in future studies.

Background and aim: Accurate prediction of prognosis of patients admitted to intensive care units (ICUs) is very important for the clinical management of the patients. The present study aims to identify independent factors affecting death and discharge in ICUs using competing risk modeling. Methods: This retrospective cohort study was conducted on enrolling 880 patients admitted to emergency ICU in Namazi hospital, Shiraz University of Medical Sciences, Shiraz, Iran during 2013-2015. The data was collected from patients’ medical records using a researcher-made checklist by a trained nurse. Competing risk regression models were fitted for the factors affecting the occurrence of death and discharge in ICU. Data analysis was conducted using STATA 13 and R 3.3.3 software. Results: Among these patients, 682 (77.5%) were discharged and 157 (17.8%) died in the ICU. The patients’ mean ± SD age was 48.90±19.52 yr. Among the study patients, 45.57% were female and 54.43% were male. In the competing risk model, age (Sub-distribution Hazard Ratio (SHR)) =1.02, 95% CI: 1.007-1.032), maximum heart rate (SHR=1.009, 95% CI: 1.001-1.019), minimum sodium level (SHR=1.035, 95% CI: 1.007-1.064), PH (SHR=7.982, 95% CI: 1.259-50.61), and bilirubin (SHR=1.046, 95% CI: 1.015-1.078) increased the risk of death, while maximum sodium level (SHR=0.946, 95% CI: 0.908-0.986) and maximum HCT (SHR=0.938, 95% CI: 0.882-0.998) reduced the risk of death. Conclusion: In conclusion, the results of this study revealed several variables that were effective in ICU length of stay (LOS). The variables that independently influenced time-to-discharge were age, maximum systolic blood pressure, minimum HCT, maximum WBC, and urine output, maximum HCT and Glasgow coma score. The results also showed that age, maximum heart rate, maximum sodium level, PH, urine output, and bilirubin, minimum sodium level and maximum HCT were the predictors of death. Furthermore, our findings indicated that the competing risk model was more appropriate than the Cox model in evaluating the predictive factors associated with the occurrence of death and discharge in patients hospitalized in ICUs. Hence, this model could play an important role in managers’ and clinicians’ decision-making and improvement of the standard of care in ICUs.

Background: Malnutrition is an important factor in the survival of critically ill patients. The purpose of the present study was to assess the nutritional status of patients in the intensive care unit (ICU) on the days of admission and discharge via a detailed nutritional assessment. Methods: Totally, 125 patients were followed up from admission to discharge at 8ICUs in Shiraz, Iran. The patients’ nutritional status was assessed using subjective global assessment (SGA), anthropometric measurements, biochemical indices, and body composition indicators. Diet prescription and intake was also evaluated. Results: Malnutrition prevalence significantly increased on the day of discharge (58.62%) compared to the day of admission (28.8%) according to SGA (P

The purpose of this study was to investigate the relationship between game location (host advantage), match result (win, lose or tie) and the level of aggression in football teams of the Iranian Premier League. The study population consisted of Premier League Football teams (League XIII), and 60 matches (related to 4 teams) that were available for the researcher, were selected as the sample. The current study can be regarded as applied and descriptive, in terms of purpose and data collection, respectively. In order to collect data, the match videos of selected teams were studied, then the results of the observations were written and recorded using Roberts et al. (1999) aggression model. The results showed that no significant difference was found between teams' aggression in host and guest matches (p>0.05). Also, a significant difference was observed between aggression and match result and the behaviors were more in lost matches (p< 0.05). In fact, mental stress caused by the loss resulted to more aggression to win. Hence, a match result, physical aggression and players' position led to significant difference in players' aggression. Therefore, the control and management of aggressive behaviors, especially at the time of failure will result in improved performance and efficiency of football teams. Also, these behaviors can be minimized by providing necessary training on anger management and negative emotions control among players.

Background: Acute kidney injury (AKI) is a common problem in critically ill patients and is independently associated with increased morbidity and mortality. Recently, serum cystatin C has been shown to be superior to creatinine in early detection of renal function impairment. We compared estimated GFR based on serum cystatin C with estimated GFR based on serum creatinine for early detection of renal dysfunction according to the RIFLE criteria. Methods: During 9 months, three hundred post trauma patients that were referred to the intensive care unit of a referral trauma hospital were recruited. Serum creatinine and serum cystatin C were measured and the estimated GFR within 24 hours of ICU admission was calculated. The primary outcome was the incidence of AKI according to the RIFLE criteria within 2nd to 7th day of admission. Results: During the first week of ICU admission,21% of patients experienced AKI. After adjusting for major confounders, only the patients with first day's serum cystatin level higher than 0.78 mg/l were at higher risk of first week AKI (OR=6.14, 95% CI: 2.5-14.7, P

Background & Objective: Journal club is one of the classical methods of medical education dating back to 100 years ago This method can be used for teaching critical evaluation evidencebased medicine research design statistics and educational concepts to medical residents The purpose of this study was to investigate the anesthesiology residents attitude toward a new method of presenting journal club (with the presence of specialists in community medicine and/or statistics) Methods: This was a crosssectional interventional study performed in the adult intensive care unit of Namazi Hospital Shiraz Iran From among 50 faculty members and second year anesthesiology residents participating in the journal club through both the new and traditional methods 36 returned their viewpoints A questionnaire with 19 items was designed by the researcher with the collaboration of the Medical Education Development Office and the Anesthesiology Department of Shiraz University of Medical Sciences Iran The validity of the questionnaire was confirmed by educational experts and its reliability was reported as over 90% using Cronbachs alpha coefficient Results: The intervention group (journal club sessions with the presence of community medicine or statistics professionals) scored significantly higher than the control group on all items of the questionnaire The participants in the experimental group reported that the most important effects of the new approach was their better understanding of statistical terms and research methodology a positive attitude toward the usefulness of interdisciplinary communication article reviews and the application of results in clinical practice development of article assessment skills creating motivation for further research causing desire to participate in other journal clubs and recommending colleagues to participate in such clubs Moreover Spearmans rank correlation coefficient showed that with the increase in the number of journal club sessions participated in the rate of knowledge and desire to participate in more sessions also increased Conclusion: Participants admitted that they had improved academically and were generally satisfied with this new approach Regarding the generalizability and implementation in other training centers this new approach can be exploited in other departments of specialized medical fields In case of achieving valid and reliable results the approach can be proposed as a national model

Background: Clinical assessment of disease severity is an important part of medical practice for prediction of mortality and morbidity in Intensive Care Unit (ICU). A disease severity scoring system can be used as guidance for clinicians for objective assessment of disease outcomes and estimation of the chance of recovery. This study aimed to evaluate the hypothesis that the mortality and length of stay in emergency ICUs predicted by APACHE-IV is different to the real rates of mortality and length of stay observed in our emergency ICU in Iran. Methods: This was a retrospective cohort study conducted on the data of 839 consecutive patients admitted to the emergency ICU of Nemazi Hospital, Shiraz, Iran, during 2012-2015. The relevant variables were used to calculate APACHE-IV. Length of stay and death or discharge, Glasgow coma score, and acute physiology score were also evaluated. Moreover, the accuracy of APACHE-IV for mortality was assessed using area under the Receiver Operator Characteristic (ROC) curve. Results: Of the studied patients, 157 died and 682 were discharged (non-survivors and survivors, respectively). The length of stay in the ICU was 10.98±14.60, 10.22 ± 14.21 and 14.30±15.80 days for all patients, survivors, and non-survivors, respectively. The results showed that APACHE-IV model underestimated length of stay in our emergency ICU (p

Background: One of the complications of anesthesia induction with propofol is a substantial decrease in arterial blood pressure and heart rate (HR), which can be intensified by adding remifentanil. This study aimed to assess the prophylactic effects of two doses of ephedrine to control the hypotension and bradycardia caused by anesthesia induced with propofol and remifentanil. Materials and Methods: A total of 150 patients candidate for short-term minor elective orthopedic and ophthalmic surgery under general anesthesia were randomized to three groups receiving normal saline, low dose ephedrine (0.07 mg/kg) or high dose ephedrine (0.15 mg/kg). Anesthesia was induced in all groups with propofol 2.5 mg/kg and remifentanil 3 μg/kg. No neuromuscular blocking agent was used. Patients′ hemodynamic status was assessed in the following four steps: Immediately before, 2 min after induction of anesthesia, as well as 1 and 5 min after intubation. Results: A total of 143 patients consisting of 46 patients in the low dose ephedrine (0.07 mg/kg) group, 49 patients in the high dose ephedrine (0.15 mg/kg) group and 48 controls completed the trial. In all three groups, after induction of anesthesia, significant decreases occurred in the mean systolic, diastolic and mean arterial pressures, as well as in the mean HR. This decline was highest in the control group and lowest in the high dose ephedrine (0.15 mg/kg) group. Conclusion: Our findings suggest that the administration of high dose ephedrine (0.15 mg/kg) may have a significant effect in preventing hypotension and bradycardia after anesthesia induction with propofol and remifentanil.

Introduction:APACHE (Acute Physiologic and Chronic Health Evaluation) score is a medical tool designed to measure the severity of disease for adult patients admitted to Intensive Care Units (ICU). However, it is designed based on the American patients’ data and is not well suited to be used for Iranian people. In addition, Iranian hospitals are not equipped with High Dependency Units which is required for original APACHE. Method: We aimed to design an intelligent version of APACHE system for recognition of patients’ hospitalization period in ICUs. The new system can be designed based on Iranian local data and updated locally. Intelligence means that the system has the ability to learn from its previous results and doesn’t need manual update. Results: In this study, this new system is introduced and the technical specifications are presented. It is based on neural networks. It can be trained and is capable of auto-learning. The results obtained from final implemented software show better performance than those obtained from non-local version. Conclusion: Using this method, the efficiency of the prediction has increased from 80% to 90%. Such results were compared with the APACHE outputs to show the superiority of the proposed method.

BackgroundAn important concern of intra-operative infusion of remifentanil is the possible development of acute opioid tolerance, which manifests as an increased postoperative analgesia requirement. We have examined the effect of the timing of intra operative morphine administration on the need for morphine consumption for pain control during the first 24 hours after operation.MethodsSixty adult patients scheduled for elective open unilateral nephrolithotomy surgery were recruited for this prospective randomized double-blind study. Anesthesia was induced with 0.03 mg/kg midazolam, 1 µg/kg remifentanil, and 1.5-2 mg/kg propofol. Anesthesia was maintained with 100 µg/kg/min propofol, and 0.25 µg/kg/min remifentanil. Both groups received 0.1 mg/kg morphine intravenously at 2 different times; in the first group (group E) immediately after intubation and in the second group (group L) 20-30 min before the anticipated end of operation.ResultsThere was no difference in pain scores at awakening, the amount of morphine given to the 2 groups for pain control, or the time to discharge from PACU between the 2 groups. The pain scores at admission to ward and at every 4 hours thereafter, until 24 hours, were not significantly different between the 2 groups. The cumulative amount of the first 24 hours morphine consumption in the ward in E group was 28.2 ± 20.1 mg and 26.5 ± 15 mg in L group, respectively (P = 0.71).ConclusionsEarly intra-operative administration of morphine compared to that of morphine in the end of surgery did not affect postoperative morphine consumption and pain scores during the first 24 hours after surgery for open nephrolithotomy. Newer pharmacologic interventions for prevention of acute tolerance of opioids seems rational (Clinical trial registration No. ACTRN: 12609000570280).

Bladder cancer is one of the most common cancers of men between the ages of 60 to 70 years, but its occurrence in a young pregnant female is unusual. Until now less than 40 cases have been reported. Herein we report our experience in the diagnosis and management of a pregnant female with urothelial neoplasm of low malignant potential who has been treated with transurethral resection during pregnancy. She has had an uneventful pregnancy outcome. The patient also had an episode of recurrence, successfully treated with transurethral resection and intravesicalmitomycin.

JUSTIFICATIVA E OBJETIVOS: O tubo laríngeo com sucção (LTS-II) é uma versão recente dos dispositivos supraglóticos reutilizáveis que permitem a drenagem gástrica. Neste estudo prospectivo e aleatório comparam-se inserção e ventilação de LTS-II descartável (LTS-D) com a reutilizável (LTS-II) para manuseio das vias aéreas em condições associadas com pressão abdominal elevada induzida por pneumoperitônio. MÉTODO: Sessenta pacientes, ASA I e II, submetidos à colecistectomia laparoscópica eletiva foram aleatoriamente separados para receber LTS-D (n = 30) ou LTS-II (n = 30) para manutenção das vias aéreas. Após a indução da anestesia geral, os dispositivos foram inseridos, seu correto posicionamento foi verificado e a pressão de vazamento de ar foi medida. Facilidade de inserção, qualidade do selo das vias aéreas, visualização fibrobroncoscópica, risco de insuflação gástrica, inserção do tubo nasogástrico e morbidade faríngea pós-operatória foram avaliados. RESULTADOS: Os índices de sucesso da primeira e segunda tentativas foram comparados nos dois grupos (86% versus 93% e 96% versus 96% nos grupos LTS-D e LTS-II, respectivamente). Um paciente de cada grupo não pode ser intubado após três tentativas Após a insuflação, a ventilação falhou em um paciente no grupo LTS-D e em dois pacientes no LTS-II e os pacientes precisaram ser intubados com cânula traqueal. O tempo até o primeiro volume corrente ser fornecido pelo LTS-D e LTS-II foi de 20,8 ± 11,6 e 18,2 ± 4,8 segundos, respectivamente (p = 0,27), e o tempo de fixação e manipulação foi de 73,3 ± 18,5 e 65,5 ± 16,2 segundos, respectivamente (p = 0,096). Sonda nasogástrica foi inserida em todos os pacientes. Não foram observadas diferenças significativas nas queixas pós-operatórias. CONCLUSÕES: Foi possível obter vias aéreas seguras com os dois dispositivos em condições de pressão intra-abdominal elevada.JUSTIFICATIVA Y OBJETIVOS: El tubo laríngeo con succión (LTSII) es una versión reciente de los dispositivos supraglóticos reutilizables que permiten el drenaje gástrico. En este estudio prospectivo y aleatorio, comparamos la inserción y la ventilación de LTS-II desechable (LTS-D) con la reutilizable (LTS-II) para la administración de las vías aéreas en condiciones asociadas con la presión abdominal elevada inducida por el neumoperitoneo. MÉTODO: Sesenta pacientes ASA I y II sometidos a la colecistectomía laparoscópica electiva fueron aleatoriamente divididos para recibir el LTS-D (n = 30) o LTS-II (n = 30) para la administración de las vías aéreas. Después de la inducción de la anestesia general, los dispositivos se insertaron, y se verificó su correcta posición junto con la presión de salida de aire que también se midió. La facilidad de inserción, la calidad del sellado de las vías aéreas, la visualización fibrobroncoscópica, el riesgo de insuflación gástrica, la inserción del tubo nasogástrico y la morbilidad faríngea postoperatoria fueron evaluadas. RESULTADOS: Los índices de éxito del primer y segundo intento se compararon en los de los grupos (86% vs. 93% y 96% vs. 96% en los grupos LTS-D y LTS-II, respectivamente); un paciente en cada grupo no pudo ser intubado después de haberlo intentado tres veces. Después de la insuflación, la ventilación de uno y de dos de los pacientes en los grupos LTS-D y LTS-II, respectivamente, falló y los pacientes necesitaron ser intubados con un tubo endotraqueal. El tiempo hasta que se suministró el primer volumen corriente a través del LTS-D y LTSII fue de 20,8 ± 11,6 y 18,2 ± 4,8 segundos, respectivamente (p = 0,27), el tiempo de fijación y manipulación fue de 73,3 ± 18,5 y 65,5 ± 16,2 segundos, respectivamente (p = 0,096). El tubo nasogástrico fue insertado en todos los pacientes. No se observaron diferencias significativas en los quejidos del postoperatorio. CONCLUSIONES: Se pudieron obtener vías aéreas seguras en condiciones con presión intraabdominal elevada con los dos dispositivos.BACKGROUND AND OBJECTIVE: The laryngeal tube suction II (LTS-II) is a recent version of reusable supraglottic airway devices allowing gastric drainage. In this prospective, randomized study we compared insertion and ventilation of disposable LTS-II (LTS-D) with reusable type (LTS-II) for airway management under conditions with elevated intra abdominal pressure induced by capnoperitoneum. METHODS: 60 ASA I and II patients undergoing elective laparoscopic cholecystectomy were randomized to receive either a LTS-D (n=30) or LTS-II (n=30) for airway management. After induction of general anaesthesia the devices were inserted, their correct placement was verified and airway leak pressure was measured. Ease of insertion, quality of airway seal, fiberoptic view, risk of gastric insufflation, insertion of nasogastric tube and postoperative pharyngeal morbidity were examined. RESULTS: First time and second time success rates were comparable for both groups (86% vs. 93% and 96% vs. 96% in LTS-D and LTS-II groups, respectively). One patient in each group could not be intubated after three attempts. After gas insufflation, ventilation of one patient in LTS-D and 2 patients in LTS-II groups was faulty and the patients were intubated with endotracheal tube. Time until delivery of first tidal volume for LTS-D and LTS-II was 20.8 ± 11.6 s, and 18.2 ± 4.8 seconds respectively (p = 0.27), fixation and manipulation time was 73.3 ± 18.5 and 65.5 ± 16.2 seconds, respectively (p = 0.096). Nasogastric tube insertion was successful in all patients. There were no significant differences in postoperative complaints. CONCLUSIONS: Both devices provide a secure airway under conditions of elevated intra abdominal pressure.

Despite a lot of efforts and investigations worldwide, DNR is still a controversial issue in many countries. In Iran although significant achievements are reached in different fields; end of life care is hardly considered as a scientific necessity. Development and implementation of clear policies for DNR orders is required to prevent futile prolongation of death, psychological stress to the patients and their family, high financial costs and waste of limited resources.

Recent studies in animal models indicate that recombinant human erythropoietin (rhEPO) is very effective in enhancing neurological recovery after spinal cord injury (SCI). We aimed to evaluate the effect of rhEPO plus methylprednisolone sodium succinate (MPSS) compared to MPSS alone to improve neurological function of patients after SCI in a randomized clinical trial. During a 15-month period 30 patients presenting to emergency departments of two university affiliated hospitals within less than 6 hours after acute SCI were randomized to two groups. Both groups received MPSS 30 mg/kg initially and 5.4 mg/kg every hour till 23 hours if admitted within 3 hours and till 47 hours if recruited within 3-6 hours after injury. Group EPO also received 500 unit/kg rhEPO on admission and another 500 unit/kg 24 hours later instead of placebo in group MPSS. Neurologic evaluation was performed on admission, 24, 48, 72 hours and one and 6 months later. Range of patients' age was 18-65 years. There was no significant difference between patients receiving two types of treatment in neurological exam on admission (P=0.125), 24 hours after admission (P=0.108) and 48 hours after admission (P=0.085). However, one week (P=0.046), one month (P=0.021) and six months (P=0.018) after admission these differences were significant. MPSS plus rhEPO started within 6 hours after acute spinal injury may be more effective than MPSS plus placebo in improvement of neurologic dysfunction. More studies with larger sample sizes are warranted.

Right atrial dilation due to left heart disease is a common complication among adults. The present review aimed to describe a case of massively dilated right atrium in a female patient presenting with valvular heart disease and no atrial fibrillation. The results of chest X-ray revealed a large opacity filling the lower right hemithorax, falsely interpreted as a mediastinal mass. During the transesophageal echocardiography, severe enlargement of the right atrium was detected, and open mitral and tricuspid valve replacements were performed successfully.

Background: Most medical errors are preventable. The aim of this study was to compare the current execution of the 3 patient safety solutions with WHO suggested actions and standards. Methods: Data collection forms and direct observation were used to determine the status of implementation of existing protocols, resources, and tools. Results: In the field of patient hand-over, there was no standardized approach. In the field of the performance of correct procedure at the correct body site, there were no safety checklists, guideline, and educational content for informing the patients and their families about the procedure. In the field of hand hygiene (HH), although availability of necessary resources was acceptable, availability of promotional HH posters and reminders was substandard. Conclusions: There are some limitations of resources, protocols, and standard checklists in all three areas. We designed some tools that will help both wards to improve patient safety by the implementation of adapted WHO suggested actions.