RESUMEN

Objective: Cerebral Venous Sinus Thrombosis (CVST), a complex and infrequent cerebrovascular disorder characterized by the formation of clots within the cerebral venous sinuses, occurs as a result of multiple risk factors and casualties, and its epidemiological picture should be investigated. Methods: This descriptive study was conducted retrospectively on patients with a final diagnosis of cerebral vein thrombosis, who were referred to the emergency room of Ghaem Hospital (Mashhad, Iran) between 2009 and 2019. The study included all patients with cerebral vein thrombosis who were older than 18 years. Clinical symptoms and causes were documented and contrasted according to demographics. Results: During the 10 years of this study, 749 cases of cerebral vein thrombosis were observed, with women accounting for the majority (72.8%). The most prevalent symptom was headache (554 cases; 74.0%), followed by seizures (23.1%), blurred vision (16.0%), nausea (7.5%), vomiting (6.9%), double nose (4.9%), and dizziness (3.3%). There was no significant difference in the frequency of symptoms between the two genders (p<0.05). The most commonly identified risk factors were OCP (110 cases; 14.7%), followed by infection (103 cases; 13.8%), malignancies (78 cases; 10.4%), and fasting (15 cases; 2.0%). There was no significant difference in risk factors between the two genders, with the exception that all cases of fasting were in women, and the differences were significant (p=0.015). The most common site of involvement according to Magnetic Resonance Venography (MRV) was the upper sagittal sinus (427 cases; 57.0%). There was no significant difference in terms of the site of the conflict between the two genders (p<0.05). Conclusion: The findings of the present study showed that deep vein thrombosis occurred mainly in women and manifested itself mostly as a headache. Moreover, the upper sagittal sinus was the most common site of involvement.

RESUMEN

Introduction: The COVID-19 pandemic has been considered an international problem. This study aimed to survey the demographic and clinical characteristics of the deceased COVID-19 patients. Methods: The present cross-sectional study was performed on all deceased COVID-19 patients who died in Imam Reza Hospital, Mashhad, Iran, from March 20, 2020, to September 23, 2021. Their data, including age, gender, complaints, and clinical symptoms at the time of admission, as well as information at the time of death (hour, shift, holiday/non-holiday) were analyzed and reported. Results: 3364 deaths due to COVID-19 have been registered during the study period (60.46% male). The patients' mean age was 66.99±16.97 (range: 1-101) years (92.7% of them were Iranian). The mortality at night shifts was less than day shifts (1643 vs. 1721). The average amount of deaths/day on holidays and workdays was (5.63 vs. 6.24). The number of deaths varied during the various hours of the day and night. Diabetes and cardiovascular diseases were the most common confounding factors, which were observed in 22.44% and 15.36% of the cases, respectively. Conclusion: Based on the findings of this series, COVID-19 mortality was frequently observed in male patients, those with the mean age of 66.99 years, morning shifts, and workdays.

Asunto(s)

RESUMEN

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.

RESUMEN

INTRODUCTION: Nowadays according to competency based curriculum, selecting an appropriate assessment method is inevitable. This study aimed to investigate application of Direct Observation of Procedural Skills (DOPS) in undergraduate medical students. METHODS: This is a cross sectional study conducted during emergency ward rotation in last year medical students using consensus sampling method. Each student performed 2 procedures at least twice under the observation of 2 assessors using modified DOPS rating scales designed for each procedure simultaneously. Correlation between DOPS score and final routine exam was measured. Face and content validity was determined by the panel of experts. Moreover, through the test-retest and inter-rater reliability, the correlation of each score and total score was investigated. The spent time was calculated too. The statistical analysis was carried out using SPSS version 18. RESULTS: Totally 60 students did 240 procedures under DOPS. The face and content validity confirmed by an expert panel. The findings showed that there was a significant correlation between the scores of each test and the total DOPS score (r1=0.736**, r2=0.793**, r3=0.564**, r4=0.685**; p<0.001). There was a significant correlation between the first and second scores of doing the same procedure (Pearson Cor.=0.74, p<0.001) and also between the scores of the two individual examiners when observing the same procedure (Pearson Cor.=0.84-0.94 p<0.001). The results showed that there was no correlation (Pearson Correlation =0.018, p<0.89) between the scores of this test and the final routine ward exam scores. The average time for doing DOPS test and the average time for providing feedback were 11.17 Max and 9.2 4.5 Min, respectively. CONCLUSION: The use of novel performance assessment methods such as DOPS is highly beneficial in order to ensure the adequacy of learning in medical students and assess their readiness for accepting professional responsibilities. DOPS as a practical and reliable test with acceptable validation can be used to assess clinical skills of undergraduate medical students.

RESUMEN

OBJECTIVE: The challenging and stressful nature of emergency medicine place the practitioners of this young branch of medicine at risk of burnout. In Iran, the number of women choosing the specialty of emergency medicine has been increasing in recent years. No studies have focused on burnout among female emergency medicine physicians. We conducted this study to evaluate the level of burnout in female emergency medicine physicians in Iran. METHODS: In this cross-sectional study, all Iranian female emergency medicine physicians with more than 2 years of work experience as specialists, received a questionnaire containing 22-item Maslach Burnout Inventory scales and 7-item Cassidy social support scale, as well as questions about workload and career satisfaction. RESULTS: In total, 77 questionnaires were analysed (response rate: 75%; median age: 36 years, median for work experience = 3 years). A total of 34% of participants were academic faculties. The level of burnout in three subscales of emotional exhaustion, depersonalisation and perceived low personal accomplishment was moderate to high in 84.5, 48.1 and 80.5% of participants respectively. A total of 94.8% of female emergency medicine physicians perceived their workload to be moderate to high and only 1.3% of them had high job satisfaction. CONCLUSIONS: Alarming high rate of burnout and job dissatisfaction among female emergency medicine physicians in our study requires careful attention. Further investigations are suggested to identify the contributory factors to burnout and the probability of some gender disparities in this field.

Asunto(s)

Asunto(s)

RESUMEN

PURPOSE: Rib fractures are the most common skeletal thoracic injuries resulting from blunt chest trauma. Half of the rib fractures are not detected upon a precise physical evaluation and radiographs. Recently ultrasonography (USG) has been investigated to detect rib fractures. But based on literature the usefulness of USG varies widely. This study was conducted to investigate the role of USG in the detection of possible rib fractures in comparison with radiography. METHODS: In this cross-sectional study, consecutive patients with minor blunt chest trauma and suspected rib fractures presenting in Imam Reza Hospital located in Mashhad-Iran, between April 2013 and October 2013 were assessed by USG and radiography. The radiography was performed in a posteroanterior (PA) chest projection and oblique rib view centered over the area of trauma. The time duration spent in taking USG and radiography were recorded. The prevalence and location of fractures revealed by USG and radiography were compared. RESULTS: Sixty-one suspected patients were assessed. The male to female ratio was 2.4:1 (43 men and 18 women) with a mean ± SD age of (44.3 ± 19.7) years. There were totally 59 rib fractures in 38 (62.3%) patients based on radiography and USG, while 23 (37.7%) patients had no diagnostic evidence of rib lesions. USG revealed 58 rib fractures in 33 (54.1%) of 61 suspected patients and radiographs revealed 32 rib fractures in 20 (32.8%) of 61 patients. A total of 58 (98.3%) rib fractures were detected by USG, whereas oblique rib view and PA chest radiography showed 27 (45.8%) and 24 (40.7%) rib fractures, respectively. The average duration of USG was (12 ± 3) min (range 7-17 min), whereas the duration of radiography was (27 ± 6) min (range 15-37 min). The kappa coefficient showed a low level of agreement between both USG and PA chest radiography (kappa coefficient = 0.28), and between USG and oblique rib view (kappa coefficient = 0.32). CONCLUSION: USG discloses more fractures than radiography in most patients presenting with suspected rib fractures. Moreover USG requires significantly less time than radiography.

Asunto(s)

RESUMEN

PURPOSE: To accurately assess the mechanism, type and severity of injury in Iranian multiple trauma patients of a trauma center. METHODS: Patients with multiple traumas referring to the emergency department of Hasheminejad University Hospital in Mashhad, Iran, entered this cross sectional study from March 2013 to December 2013. All the patients with injury severity score (ISS) > 9 were included in this study. Data analysis was performed by SPSS software (Version 11.5) and P values less than 0.05 were considered as significant differences. RESULTS: Among the 6306 hospitalized trauma patients during this period, 148 had ISS>9. The male female ratio was 80%. The mean age of the patients was (33.5 ± 19.3) years. And 71% of the patients were younger than 44 years old. There were 19 (13%) deaths from which 68.5% were older than 44 years old. The mean transfer time from the injury scene to hospital was (55 ± 26) minutes. The most frequent mechanisms of injury were motorcycle crashes and falling from height, which together included 66.2% of all the injuries. A total of 84% of hospital deaths occurred after the first 24 h of hospitalization. Head and neck were the most common body injured areas with a prevalence of 111 cases (75%). CONCLUSION: Motorcycle crashes have high frequency in Iran. Since most victims are young males, injury prevention strategies should be considered to reduce the burden of injuries.

Asunto(s)

Asunto(s)

RESUMEN

INTRODUCTION: Spontaneous pneumocephalus without any pathological condition is very rare. We described a patient with spontaneous pneumocephalus probably arising from the relatively enlarged air-filling sphenoid sinus. CASE PRESENTATION: A 51-year-old woman admitted Imam Reza Hospital, Mashhad, Iran with a sudden onset of severe headache and nausea without any neurological deficit. Brain computed tomography (CT) scan was performed to role out any pathology in the brain. Brain CT revealed large ethmoidal and sphenoid sinuses and disseminated intracranial pneumocephalus. A Cerebrospinal Fluid (CSF) examination was performed to rule out meningitis. Further evaluation confirmed a small defect in the sphenoid sinus. She has no recurrent headache or other symptoms after about six-month follow-up. CONCLUSIONS: An extremely rare condition, a spontaneous intracranial pneumocephalus with skull base defect origin could be considered as a possible diagnosis in patients with sudden and severe headache. We can safely conclude that medical treatment and close follow-up is an effective mode of therapy in this patient.

RESUMEN

BACKGROUND: The analysis of arterial blood gas (ABG) is an invasive procedure that is used frequently in the emergency department (ED) to evaluate the acid-base status of critically-ill patients. However, capnometry is an alternative procedure that has been used in recent years to determine the metabolic status of patients' blood. Considering the correlation between end-tidal carbon dioxide (ETCO2) and arterial partial pressure of carbon dioxide (PaCO2) identified in the previous studies and the strong correlation between PaCO2 and bicarbonate (HCO3(-) ), we assumed that ETCO2 might be a useful parameter in predicting the presence of metabolic acidosis. The aim of this study was to determine the correlation between ETCO2 and the parameters of ABG in adult patients who were likely present metabolic acid-base disturbances in the Emergency Department of Imam Reza Hospital, the largest academic hospital in Mashhad in northeast Iran. METHODS: This was a cross-sectional study conducted during six months on 62 adult patients who presented with suspected metabolic acid-base disorders to the ED. The exclusion criteria were patients with chronic obstructive pulmonary diseases, loss of consciousness, intubated patients, and those who were unable to tolerate capnography. The patients' demographic information and vital signs were recorded. Also, ABG and ETCO2 results were recorded. The Pearson product moment correlation analysis and linear regression were used to determine the correlation between ETCO2 and ABG parameters. RESULTS: Sixty-four patients were enrolled, consisting of 37 men and 27 women with a mean age of 55.4 ± 22.7 years. The most common complaints presented were nausea and vomiting (n = 24). The average value for ETCO2 was 26.2 ± 6.1. There were significant linear correlations between ETCO2 level, pH (r = 0.368), HCO3(-) (r = 0.869), PaCO2 (r = 0.795), and Base Excess (B.E.) (r = 0.346). HCO3 and PaCO2 were the significant predictor values for ETCO2 (linear regression analysis). CONCLUSION: ETCO2 can be an appropriate indicator to estimate HCO3(-) and PaCO2 in critical emergency situations, but it cannot be used as an indicator to estimate all ABG variables.

RESUMEN

BACKGROUND: The aim of this study was to examine the association between the responses of headache to IV morphine and the findings of brain CT scan in minor head injury (MHI), and to propose a new risk indicator to identify patients requiring CT scanning. METHODS: A total of 1857 MHI patients ≥15 years of age, presenting with headache and a GCS score of 14 or 15 were included in the study. Intravenous morphine sulfate was administered, and thereafter, patients were assessed for the relief or persistence of headache. Subsequently, a brain CT scan was obtained from all patients. RESULTS: Patients were divided into two age groups: 15-60 and >60 years. There was a significant association between the response of headache to morphine and the result of brain CT in both age groups (p<0.001). In patients aged between 15 and 60, none whose headache had responded to morphine showed any abnormal findings in CT scan (sensitivity=100%). In the >60 group, sensitivity was 58.3% for abnormal CT and 71.4% for neurosurgical intervention. CONCLUSION: This study suggests that a headache not relieved by morphine is a risk indicator for intracranial injury. This protocol can be used in rural areas with limited access to CT scan as an adjunct to the existing criteria for selecting patients with MHI for CT scanning.

Asunto(s)

RESUMEN

OBJECTIVE: We evaluated a new hypothesis of acetaminophen therapy to reduce the necessity of imaging in patients with probable traumatic cervical spine injury. METHODS: Patients with acute blunt trauma to the neck and just posterior midline cervical tenderness received acetaminophen (15 mg/kg) intravenously after cervical spine immobilization. Then, all the patients underwent plain radiography and computerized tomography of the cervical spine. The outcome measure was the presence of traumatic cervical spine injury. Sixty minutes after acetaminophen infusion, posterior midline cervical tenderness was reassessed. RESULTS: Of 1 309 patients, 41 had traumatic cervical spine injuries based on imaging. Sixty minutes after infusion, posterior midline cervical tenderness was eliminated in 1 041 patients, none of whom had abnormal imaging. CONCLUSION: Patients with cervical spine trauma do not need imaging if posterior midline cervical tenderness is eliminated after acetaminophen infusion. This analgesia could be considered as a diagnostic and therapeutic intervention.

Asunto(s)

RESUMEN

Spontaneous pneumomediastinum is an unusual and benign condition in which air is present in mediastinum. A 20-year-old male patient presented to ED with complaint of hoarseness and odynophagia from the day before, after weightlifting. The patient was nonsmoker and denied history of other diseases. On physical examination he had no dyspnea with normal vital signs. Throat examination and pulmonary auscultation were normal and no crepitation was palpable. We could not find subcutaneous emphysema in neck and chest examination. In neck and chest X-ray we found that air is present around the trachea. There was no apparent pneumothorax in CXR. In cervical and chest CT free air was present around trachea and in mediastinum. Subcutaneous emphysema was also evident. But there was no pneumothorax. The patient was admitted and went under close observation, oxygen therapy, and analgesic. The pneumomediastinum and subcutaneous emphysema gradually resolved within a week by conservative therapy and he was discharged without any complication. Many different conditions could be trigged because of pneumomediastinum but it is rarely seen in intense physical exertion such as weightlifting and bodybuilding. Two most common symptoms are retrosternal chest pain and dyspnea. But the patient here complained of hoarseness and odynophagia.

RESUMEN

The troponin I serum level is widely used in acute coronary syndrome patients for their classification. The qualitative assay is faster and more available than the quantitative assay. The objective was to determine the operating characteristics of a qualitative troponin I assay compared with a quantitative method. This is a prospective observational study and patients suspected to have acute coronary syndrome were enrolled. A rapid troponin I test and a quantitative assay were carried out for each patient on arrival and 6 h after admission. A total of 262 patients were enrolled. The degree of agreement between the second rapid qualitative and quantitative troponin I was excellent (κ=0.946; 95% confidence interval, 0.903-0.989). The sensitivity, specificity, negative predictive value, and positive predictive value of the rapid qualitative troponin I test were 92.6, 100, 96.8, and 100%, respectively. In conclusion, this study reveals an excellent agreement between quantitative and qualitative bedside assays 6 h after admission in a sample of Iranian patients in the emergency department.

Asunto(s)

RESUMEN

INTRODUCTION: Second National Medical Sciences Olympiad was done in Shiraz in August 2010 with aim of indentifying scientifically talented individuals, motivating students and orienting extracurricular activities. This Olympiad was done in 3 areas, basic sciences, clinical sciences and management. In clinical sciences, we used TOSCE (Team Objective Structured Clinical Examination). In this article we report the details of this exam and participants' satisfaction. MATERIALS AND METHODS: This Olympiad in Clinical Medical Sciences was held in 2 levels: Individual and team. In the team stage, 9 teams from 9 universities participated. We used TOSCE for measuring clinical competency of teams. Each team consisted of 3 students. We designed 12 stations based on emergency medicine in medical and surgical fields. The time considered for each station was 15 min, after doing this exam the view of students was measured using a valid and reliable questionnaire. RESULTS: Most of the students believed that TOSCE was a useful examination for measuring competency. More than 50% of students reported that success in this exam needs clinical competency, team work and problem solving ability. Nearly, half (48.1%) of students believed that 15 min is not enough for each station and they need more time. CONCLUSION: The results of this study showed that this kind of exam is useful for measuring clinical competency from students' viewpoint.

RESUMEN

BACKGROUND: Clinical reasoning plays a major role in the ability of doctors to make a diagnosis and reach treatment decisions. This paper describes the use of four clinical reasoning tests in the second National Medical Science Olympiad in Iran: key features (KF), script concordance (SCT), clinical reasoning problems (CRP) and comprehensive integrative puzzles (CIP). The purpose of the study was to design a multi instrument for multiple roles approach in clinical reasoning field based on the theoretical framework, KF was used to measure data gathering, CRP was used to measure hypothesis formation, SCT and CIP were used to measure hypothesis evaluation and investigating the combined use of these tests in the Olympiad. A bank of clinical reasoning test items was developed for emergency medicine by a scientific expert committee representing all the medical schools in the country. These items were pretested by a reference group and the results were analyzed to select items that could be omitted. Then 135 top-ranked medical students from 45 medical universities in Iran participated in the clinical domain of the Olympiad. The reliability of each test was calculated by Cronbach's alpha. Item difficulty and the correlation between each item and the total score were measured. The correlation between the students' final grade and each of the clinical reasoning tests was calculated, as was the correlation between final grades and another measure of knowledge, i.e., the students' grade point average. RESULTS: The combined reliability for all four clinical reasoning tests was 0.91. Of the four clinical reasoning tests we compared, reliability was highest for CIP (0.91). The reliability was 0.83 for KF, 0.78 for SCT and 0.71 for CRP. Most of the tests had an acceptable item difficulty level between 0.2 and 0.8. The correlation between the score for each item and the total test score for each of the four tests was positive. The correlations between scores for each test and total score were highest for KF and CIP. The correlation between scores for each test and grade point average was low to intermediate for all four of the tests. CONCLUSION: The combination of these four clinical reasoning tests is a reliable evaluation tool that can be implemented to assess clinical reasoning skills in talented undergraduate medical students, however these data may not generalizable to whole medical students population. The CIP and KF tests showed the greatest potential to measure clinical reasoning skills. Grade point averages did not necessarily predict performance in the clinical domain of the national competitive examination for medical school students.