Screening Characteristics of TIMI Score in Predicting Acute Coronary Syndrome Outcome; a Diagnostic Accuracy Study

Introduction: In cases with potential diagnosis of ischemic chest pain, screening high risk patients for adverse outcomes would be very helpful. The present study was designed aiming to determine the diagnostic accuracy of thrombolysis in myocardial infarction (TIMI) score in Patients with potential diagnosis of ischemic chest pain.Method: This diagnostic accuracy study was designed to evaluate the screening performance characteristics of TIMI score in predicting 30-day outcomes of mortality, myocardial infarction (MI), and need for revascularization in patients presenting to ED with complaint of typical chest pain and diagnosis of unstable angina or Non-ST elevation MI.Results: 901 patients with the mean age of 58.17 ± 15.00 years (19-90) were studied (52.9% male). Mean TIMI score of the studied patients was 0.97 ± 0.93 (0-5) and the highest frequency of the score belonged to 0 to 2 with 37.2%, 35.3%, and 21.4%, respectively. In total, 170 (18.8%) patients experienced the outcomes evaluated in this study. Total sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratio of TIMI score were 20 (95% CI: 17 – 24), 99 (95% CI: 97 – 100), 98 (95% CI: 93 – 100), 42 (95% CI: 39 – 46), 58 (95% CI: 14 – 229), and 1.3 (95% CI: 1.2 – 1.4), respectively. Area under the ROC curve of this system for prediction of 30-day mortality, MI, and need for revascularization were 0.51 (95% CI: 0.47 – 0.55), 0.58 (95% CI: 0.54 – 0.62) and 0.56 (95% CI: 0.52 – 0.60), respectively.Conclusion: Based on the findings of the present study, it seems that TIMI score has a high specificity in predicting 30-day adverse outcomes of mortality, MI, and need for revascularization following acute coronary syndrome. However, since its sensitivity, negative predictive value, and negative likelihood ratio are low, it cannot be used as a proper screening tool for ruling out low risk patients in ED

A 55-Year Old Man with Acute Painful Flank Mass, a Case Report

Lumbar hernias (LH) accounts for less than 1.5% of total hernia incidence. It can occur in two separate triangular areas of the flank. About 300 cases have been reported in the literature. Here, we report a 55-year old man with acute painful left side flank mass and final diagnosis of LH. The mass was appeared about three hours before admission and his pain was slight at first but became more severe gradually. He had stable vital sign and the only positive finding on his physical examination was the sphere shape, firm, mobile, and mild tender mass at his left flank

Protocol Adherence for Severe Sepsis and Septic Shock Management in the Emergency Department; a Clinical Audit

Introduction: Although significant development in the field of medicine is achieved, sepsis is still a major issue threatening humans’ lives. This study was aimed to audit the management of severe sepsis and septic shock patients in emergency department (ED) according to the present standard guidelines.Method: This is a prospective audit on approaching adult septic patients who were admitted to ED. The audit checklist was created based on the protocols of Surviving Sepsis Campaign and British Royal College recommendations. The mean knowledge score and the compliance rate of studied measures regarding standard protocols were calculated using SPSS version 21.Results: 30 emergency medicine residents were audited (63.3% male). The mean knowledge score of studied residents regarding standard guidelines were 5.07 ± 1.78 (IQR = 2) in pre education and 8.17 ± 1.31 (IQR = 85) in post education phase (p < 0.001). There was excellent compliance with standard in 4 (22%) studied measures, good in 2 (11%), fair in 1 (6%), weak in 2 (11%), and poor in 9 (50%). 64% of poor compliance measures correlated to therapeutic factors. After training, score of 5 measures including checking vital signs in < 20 minute, central vein pressure measurement in < 1 hour, blood culture request, administration of vasopressor agents, and high flow O2 therapy were improved clinically, but not statistically.Conclusion: The protocol adherence in management of severe sepsis and septic shock for urine output measurement, central venous pressure monitoring, administration of inotrope agents, blood transfusion, intravenous antibiotic and hydration therapy, and high flow O2 delivery were disappointingly low. It seems training workshops and implementation of Clinical audit can improve residents’ adherence to current standard guidelines regarding severe sepsis and septic shock

Role of Feedback during Evaluation in Improving Emergency Medicine Residents’ Skills; an Experimental Study

Introduction: Evaluation of students’ learning in clinical education system is one of the most important and challenging issues that facilities in this field have been facing. The present study aimed to evaluate the role of feedback during evaluation in increasing emergency medicine residents’ clinical skills.Method: The present experimental study was performed on all second year emergency medicine residents of two educational hospitals, Tehran, Iran, with switching replications design and before-after method. They were randomly allocated to two groups (with or without feedback) and evaluated three times regarding chest ultrasonography for trauma patients, using direct observation of procedural skills (DOPS) and valid and reliable checklist. Data were analyzed using SPSS 20.Results: 30 emergency medicine residents with the mean age of 36.63 ± 30.30 years were allocated to two equal groups (56.7% male). Studied groups were similar regarding the baseline characteristics. In both groups, obtained scores showed a significant increase from the first to the third evaluation (p < 0.001). Mean scores of first and second evaluations were 10.24 ± 0.77, 17.73 ± 0.46 in feedback receivers and 9.73 ± 0.77 and 12.13 ± 0.47 in others (p < 0.001). Mean third score after switching groups were 18.53 ± 0.22 in feedback receivers and 18.99 ± 0.22 in others (p = 0.213).Conclusion: Based on the findings of the present study, giving feedback after evaluating the second year emergency medicine residents regarding chest ultrasonography for trauma patients, led to a significant improvement in their scores in future evaluations and consequently their skill

A 16-Year-Old Girl with Acute Onset Respiratory Distress

A 16-year-old girl with an intellectual disability (known case of Down syndrome) arrived in the emergency eepartment with complaints of severe breathlessness, bloody salivation (bright red blood or clots), and difficulty in speaking and swallowing of liquids and solids. The patient gradually developed progressive bloody salivation and hoarseness, never had any history of trauma to the head and neck and respiratory problems, and was symptomatic from the previous 48 h. Furthermore, the patient had a positive history of peptic ulcer, chronic consumption of non-steroidal anti-inflammatory drugs, and traveled out of town and drank water from a well in the mentioned period. On admission, the patient had a respiratory rate of 17 per min, pulse rate of 89 per min, blood pressure of 120/80 mmHg, 90% O2 saturation in room air, and 38°C axillary temperature. The only positive finding on physical examination was inspiratory stridor. The auscultation of lung and heart sounds was normal. Digital rectal examination revealed brown feces. Throat examination was not possible owing to lack of patient cooperation. After initial assessment and essential consideration, electrocardiography (ECG) and imaging was performed. The ECG showed normal sinus rhythm, and analysis of arterial blood gas revealed the following: pH = 7. 35, Pa-CO2 = 39 mmHg, HCO3 = 24 mEq/L, PaO2 = 89 mmHg, and O2 saturation = 92%. All other laboratory data, including complete blood counts (CBC), urine analysis, hepatic and renal function tests, and coagulation profile were in the normal range.  What is your diagnosis

Efficacy and safety of sofosbuvir in the treatment of SARS-CoV-2: an open label phase II trial

Objective: Despite the worldwide spread of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), an effective specific antiviral treatment for coronavirus disease of 2019 (COVID-19) is yet to be identified .We did this study to investigate the safety and efficacy of sofosbuvir as antiviral therapy among hospitalized adult patients with SARS-CoV-2. Methods: Patients were randomized into intervention arm receiving sofosbuvir or comparison arm receiving usual antiviral agents in addition to standard of care. The primary end point of the study was clinical recovery as defined by normal body temperature and normal oxygen saturation. The main secondary outcome was all-cause mortality during the admission in hospital or within 14 days after discharge if applicable. Reports of severe adverse events were observed in the intervention arm. Results: Fifty-seven patients enrolled into either the clinical trial arm (n=27) or the comparison arm (n=30). Primary outcome was achieved by 24 (88.9%) and 10 (33.3%) in the intervention and comparison arms, respectively. Median hospital length of stay was significantly shorter in the intervention arm (10 days [IQR: 5-12] vs. 11.5 days [IQR: 8.5-17.75], P = 0.016). All-cause mortality was two and thirteen in intervention and comparison groups, respectively. No serious adverse events were reported by the patients receiving sofosbuvir during the study. Conclusion: Among patients hospitalized with SARS-CoV-2, those who received sofosbuvir had more clinical recovery rate and had a shorter hospital length of stay than those who received usual antiviral agents in the study and these differences were statistically significant

Disseminated Aspergillosis as the Herald Manifestation of Chronic Granulomatous Disease in an Adult Patient

Chronic granulomatous disease is an inherited defect in intracellular killing of ingested microorganisms characterized by recurrent life threatening bacterial and fungal infections including invasive aspergillosis in early childhood. We report  a  disseminated aspergillosis as  the  representative  of  adult  onset  chronic granulomatous disease without previous infection, with dramatic response to combination of antifungal and interferon therapy

Pro-BNP versus MEDS Score in Determining the Prognosis of Sepsis Patients; a Diagnostic Accuracy Study

Introduction: Pro-brain natriuretic peptide (Pro-BNP) can act as an independent predictor of mortality in septic patients. This study aimed to compare the diagnostic accuracy of pro-BNP and Mortality in Emergency Department Sepsis (MEDS) score in this regard.Method: This cross-sectional study was conducted on > 14 years old sepsis patients of an emergency department (ED), during 2 years. The level of Pro-BNP and MEDS score were measured for all eligible patients and considering one-month mortality as reference, screening performance characteristics of the two tests were compared using SPSS 21 and STATS 11.Results: 121 patients with the mean age of 75.87±11.82 years were studied (55.4% male). 85 (70.25%) patients had moderate to high probability of mortality according to MEDS score. The mean Pro-BNP levels of survivor and non-survivor patients were 489.69 ± 327.47 and 3954.98 ± 2717.85 pg/ml, respectively (p < 0.0001). Sensitivity and specificity of Pro-BNP (in 1000 pg/ml cut off) and MEDS score (in level 3) in prediction of 1-month mortality were 93.6 (83.7-97.9), 94.8 (84.7-98.6), 65.0 (51.9-76.3), and 98.2 (89.5-99.9), respectively. Area under the ROC curve of the two tests were 97.36 (95% CI: 92.92-94.48) and 92.31 (95% CI: 86.35-96.53), respectively (p = 0.0543).Conclusion: Pro-BNP and MEDS score both have excellent diagnostic accuracy in predicting 1-month mortality of sepsis patients. However, considering the higher sensitivity as well as availability and ease of calculation, it seems that Pro-BNP can be considered an appropriate tool for screening patients with high risk of mortality following sepsis in ED.

Multi-drug resistant Staphylococcus aureus isolated from emergency ward of an Iranian hospital

Purpose: To study the prevalence of resistant strains of S. aureus isolated from surfaces, beds and various equipment of an Iranian hospital emergency ward.Methods: Two hundred swab samples were collected from the surfaces, beds, trolleys, surgical equipment and diagnostic medical devices in emergency ward. Samples were cultured and those that were S. aureus-positive were confirmed using polymerase chain reaction (PCR). Antimicrobial resistance pattern was analyzed using disk diffusion method.Results: Nine of 200 samples (4.5 %) collected were positive for S. aureus. Surfaces (8.8 %), beds (5 %) and trolleys (5 %) were the most commonly contaminated. S. aureus isolates exhibited varying levels of resistance against antibiotics with the following being the highest: tetracycline (88.8 %), penicillin (88.8 %) and ampicillin (77.7 %). The prevalence of resistance against methicillin, oxacillin and azithromycin were 44.4, 33.3 and 33.3 %, respectively. There was no pattern of resistance against imipenem.Conclusion: Efficient disinfection of surfaces, beds, trolleys and surgical instruments should be performed periodically to reduce colonization of resistant strains of S. aureus in various areas of emergency health care centers.Keywords: Staphylococcus aureus, Nocosomial infection, Antibiotic resistance, Hospital equipment, Emergency war