Radial Head Subluxation: Possible Effective Factors on Time to Re-use the Affected Limb

Introduction: Radial head subluxation (RHS) is a common disorder in children. Although it is not accompanied by any important short- or long-term sequel, it could make the parents worried about. Objective: The purpose of this study was to determine the possible effective factors that may influence time to use the affected limb. Methods: This cross-sectional study was conducted prospectively during the years 2014 to 2016. All children under the age of 6 years who visited the emergency department (ED) and were diagnosed as having RHS were eligible. The patients’ baseline information was recorded. After the reduction, the time until the affected arm use returned was recorded. The possible relationship between the baseline data and time to re-use the affected limb was assessed. Results: During the study period, 112 children with a mean age of 30.18 ± 18.18 months were evaluated (53% male). Among the children who visited the ED during the first 4 hours and thereafter, 84% and 60%, respectively, re-used their limb in less than 10 minutes after reduction (p = 0.004). Also, 55% of children less than or equal to 24 months and 89% over the age of 24 months re-used the arm in 10 minutes (p < 0.001). The success rate of the first reduction maneuver was significantly lower in children with a recurrent dislocation (p = 0.001). Conclusion: It is likely that age less than or equal to 24 months and ED visit after 4 hours of the event lead to a longer duration for re-using the affected arm following reduction

Prospective Evaluation of Safe Observation Period after Asymptomatic Penetrating Thoracic Injury: 1 Hour is Enough

Introduction: The observation period was recently challenged by some studies; and it has been suggested that a 1-hour observation period may be sufficient to allow safe discharge in asymptomatic patients with penetrating thoracic injury (PTI) and normal initial Chest X-Ray (CXR). Objective: The current study was performed to investigate if in asymptomatic and hemodynamically stable patients with PTIs who has an initial normal evaluation, 1-hour observation interval is safe to detect clinically significant injuries and is it possible to discharge these patients safely after a negative Extended – Focused Assessment with Sonography in Trauma (E-FAST) at hour1 instead of hour 3. Method: This cross-sectional study was performed on asymptomatic patients with penetrating thoracic injury, referred to emergency department (ED) and normal initial CXR and the Extended Focused Assessment with Sonography in Trauma (E-FAST). The second E-FAST was done 1 hour after the first one and the third repeat E-FAST and control CXR then performed 3 hours post-injury. 24 hours follow up by phone call was done for each patient after discharge. Results: Finally, 117 patients with the average ages of 25.9 ± 7.8 years were enrolled of whom 92.5% were male. Eight patients developed PTX or HTX during first hour of observation that were diagnosed by E-FAST or CT scan requested by the in-charge physician. One hundred-nine patient completed E-FAST and radiograph studies at times zero, 1 h, and 3 h. One patient had a normal initial evaluation but demonstrated a PTX on the 3-h managed without intervention. The rate of delayed abnormality after an initially normal study was 7.7 % (9/117). No discharged patients returned to our ED with delayed manifestations of either PTX or HTX. Conclusion: The results of our study have shown that asymptomatic patients with PTI with negative initial evaluation and no deterioration at intervals, about 1 hour may be sufficient for detection of clinically significant pathology, considered for safe and early discharge

Prospective Evaluation of Safe Observation Period after Asymptomatic Penetrating Thoracic Injury: 1 Hour is Enough

Introduction: The observation period was recently challenged by some studies; and it has been suggested that a 1-hour observation period may be sufficient to allow safe discharge in asymptomatic patients with penetrating thoracic injury (PTI) and normal initial Chest X-Ray (CXR). Objective: The current study was performed to investigate if in asymptomatic and hemodynamically stable patients with PTIs who has an initial normal evaluation, 1-hour observation interval is safe to detect clinically significant injuries and is it possible to discharge these patients safely after a negative Extended – Focused Assessment with Sonography in Trauma (E-FAST) at hour1 instead of hour 3. Method: This cross-sectional study was performed on asymptomatic patients with penetrating thoracic injury, referred to emergency department (ED) and normal initial CXR and the Extended Focused Assessment with Sonography in Trauma (E-FAST). The second E-FAST was done 1 hour after the first one and the third repeat E-FAST and control CXR then performed 3 hours post-injury. 24 hours follow up by phone call was done for each patient after discharge. Results: Finally, 117 patients with the average ages of 25.9 ± 7.8 years were enrolled of whom 92.5% were male. Eight patients developed PTX or HTX during first hour of observation that were diagnosed by E-FAST or CT scan requested by the in-charge physician. One hundred-nine patient completed E-FAST and radiograph studies at times zero, 1 h, and 3 h. One patient had a normal initial evaluation but demonstrated a PTX on the 3-h managed without intervention. The rate of delayed abnormality after an initially normal study was 7.7 % (9/117). No discharged patients returned to our ED with delayed manifestations of either PTX or HTX. Conclusion: The results of our study have shown that asymptomatic patients with PTI with negative initial evaluation and no deterioration at intervals, about 1 hour may be sufficient for detection of clinically significant pathology, considered for safe and early discharge

Accuracy of Ultrasonography in Confirmation of Adequate Reduction of Distal Radius Fractures

Introduction: Restoration of normal anatomic alignment is a key component of the treatment of distal radius fractures (DRF). This study aimed to evaluate the accuracy of ultrasonography (US) in determining the adequacy of closed reduction in these fractures. Methods: DRF patients admitted to the emergency department of Al-Zahra Hospital, Isfahan, Iran from September 2011 to 2012, were enrolled. After closed reduction, the adequacy was investigated through both US and control plain radiography. Then, sensitivity, specificity, positive and negative predicative values of US in confirmation of closed reduction was evaluated. Also inter-rater agreement between the two diagnostic tools was analyzed by calculating Cohen’s kappa coefficient. Results: Finally, 154 patients were evaluated (females: 53.9%) with mean age of 40.03±14.7 (range: 22-73). US had sensitivity, specificity, positive and negative predictive value of 99.3% (95%CI: 96.2-99.9), 100.0% (95%CI: 62.9-100.0), 100.0% (95%CI: 97.5-100.0), and 88.9% (95%CI: 51.7-98.1) in confirmation of the adequate reduction, respectively. In addition, inter-rater reliability was 0.94 (95%CI: 0.89-0.99; p<0.0001). Conclusion: It seems that US could be considered as a highly sensitive, accurate, easy to use, noninvasive and safe tool for guidance and confirming of closed reduction in DRF.

Oral Chloral Hydrate Compare with Rectal Thiopental in Pediatric Procedural Sedation and Analgesia; a Randomized Clinical Trial

Introduction: The increasing use of diagnostic imaging in pediatric medicine has resulted in growing need for procedural sedation and analgesia (PSA) to minimize motion artifacts during procedures. The drug of choice in pediatric PSA was not introduced till now. The aim of the present study was comparison of oral chloral hydrate (OCH) and rectal sodium thiopental (RST) in pediatric PSA.Methods: In the present randomized clinical trial, 2-6 years old pediatrics who referred for performing brain computed tomography scan was enrolled and were randomly divided in to two groups. OCH (50mg/kg) and RST (25mg/kg) were prescribed and a trained nurse recorded the time from drug prescription to receiving the conscious sedation (onset of action), the total time period which the patient has the Ramsay score≥4 (duration of action), and adverse effect of agents. Mann-Whitney U test and chi-squared test, and Non-parametric analysis of covariance (ANCOVA) were used for comparisons. Results: One hundred and forty children were entered to two groups of OCH and RST, randomly. The patients of two groups had similar age, sex, weight, and baseline vital signs except for diastolic blood pressure (p<0.001). The onset of action in OCH and RST groups were 24.5±6.1and 28.7±5.2 minutes, respectively (p<0.001). Duration of action in OCH and RST groups were 12.9±2.8 minutes and 13.7±2.6 minutes, respectively (p=0.085). Non parametric ANCOVA revealed that only diastolic blood pressure was affected by drug prescription (p=0.001). In 11(15.7%) patients in RST group, diarrhea was observed during 24 hours (p=0.001). Oxygen desaturation was observed only in two patients, both in OCH group. Conclusion: Each of the sedative has advantages and disadvantages that should be considered when selecting one for inducing short-term sedation. It seems that rectal sodium thiopental and oral chloral hydrate are equally effective in pediatric PSA and based on patient’s condition we can administrate one of these agents.

Predictive Value of Tracheal Rapid Ultrasound Exam Performed in the Emergency Department for Verification of Tracheal Intubation

BACKGROUND: Verification of the correct placement of the endotracheal tube (ETT) has been one of the most challenging issues of airway management in the field of emergency medicine. Early detection of oesophagal intubation through a reliable method is important for emergency physicians.AIM: The aim of this study was to assess the diagnostic accuracy of tracheal rapid ultrasound exam (TRUE) to assess endotracheal tube misplacement during emergency intubation.METHODS: This was an observational prospective study performed in the emergency department of the major tertiary referral hospital in the city. We included a consecutive selection of 100 patients. TRUE was performed for all these patients, and subsequently, quantitative waveform capnography was done. The later test is considered as the gold standard.RESULTS: From our total 100 eligible patients, 93 (93%) participants had positive TRUE results (tracheal intubation) and 7 (7%) patients have negative TRUE results (esophageal intubation). Quantitative waveform capnography report of all 93 (100%) patients who had positive TRUE was positive (appropriate tracheal placement). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of TRUE for detecting appropriate tracheal placement of ETT were 98.9% (95% CI, 93.3% to 99.8%), 100% (95% CI, 51.6% to 100%), 100% (95% CI, 95.1% to 100%) and 85.7% (95% CI, 42% to 99.2%) respectively.CONCLUSIONS: Performing TRUE is convenient and feasible in many emergency departments and pre-hospital settings. We would recommend emergency units explore the possibility of using TRUE as a method in the assessment of proper ETT placement

A Rare Presentation of Colorectal Cancer with Unusual Progressive Intramuscular and Subcutaneous Metastatic Spread

Colorectal carcinoma is one of the most common causes of cancer-related death, worldwide. Recently, due to the introduction of novel imaging and therapeutic techniques, five-year survival of patients has increased. However, distant metastasis is still expected in half of the patients. Colorectal cancer tends to target the abdominal cavity, liver, lungs, and bones as the common sites of metastasis. Nevertheless, rare cases of muscle metastasis have been reported. This report presents a 23-year-old male, who despite chemotherapy, demonstrated gradual progressive disease and metastases to the submandibular region, lungs, adrenal gland as well as muscles and subcutaneous tissues. He had developed multiple asymptomatic muscular metastases metachronously over two-year time period discovered on an 18FDGPET/CT, namely in the deltoid, external oblique abdominis, rectus abdominis, and quadriceps muscles, as well as one of the extrinsic muscles of the tongue. The presence of distant, especially extrahepatic metastasis, adversely affects the prognosis of colon carcinoma. Since limited cases of muscle metastasis have been reported in carcinoma of colon, the underlying pathophysiology, optimum treatment, and prognostic issues are yet to be substantiated

The Relationship between Risk Factors of Head Trauma with CT Scan Findings in Children with Minor Head Trauma Admitted to Hospital

BACKGROUND: In emergency medicine for determining the intracranial injury (ICI) in children with head trauma, usually brain CT scan is performed. Since brain CT scan, especially in children, has some disadvantages, it is better to find a procedure which could help to choose only the children with real head trauma injury for brain CT scan.AIMS: The aim of this study is to find such procedure. This study was descriptive, analytic and non-interventional.METHODS: We reviewed the archived files of children with head trauma injuries referred to the emergency department of Imam Hossein Hospital within two years. Patient’s CT scan findings and head trauma risk factors were evaluated in this study.RESULTS: Out of 368 patients, 326 patients had normal brain CT scan. 28 of them showed symptoms of ICI consisting intraventricular haemorrhage (IVH), contusion, subarachnoid haemorrhage (SAH), subdural haemorrhage (SDH), epidural hematoma (EDH), and pneumocephalus. Twenty-seven patients showed skull FX, which 14 of them had an Isolated fracture, and 13 of them also showed symptoms of ICI. Since patients with isolated FX usually discharge quickly from Emergency Department; their data did not include in results of the study. The patients have been divided into two groups: 1- ICI, 2- without ICI. RR (relative risk), CI (Confidence interval) and sensitivity, positive predictive value (PPV), negative predictive value (NPV) and association of these risk factors with ICI were assessed with the Chi-2 test. In the end to determine the indications of CT scan, the presence of one of these five risk factors is important including abnormal mental status, clinical symptoms of skull FX, history of vomiting, craniofacial soft tissue injury (including subgaleal hematomas or laceration) and headache.CONCLUSIONS: For all other patients without these risk factors, observation and Follow Up can be used which has more advantages and less cost

Estimating global injuries morbidity and mortality : methods and data used in the Global Burden of Disease 2017 study

Background: While there is a long history of measuring death and disability from injuries, modern research methods must account for the wide spectrum of disability that can occur in an injury, and must provide estimates with sufficient demographic, geographical and temporal detail to be useful for policy makers. The Global Burden of Disease (GBD) 2017 study used methods to provide highly detailed estimates of global injury burden that meet these criteria. Methods: In this study, we report and discuss the methods used in GBD 2017 for injury morbidity and mortality burden estimation. In summary, these methods included estimating cause-specific mortality for every cause of injury, and then estimating incidence for every cause of injury. Non-fatal disability for each cause is then calculated based on the probabilities of suffering from different types of bodily injury experienced. Results: GBD 2017 produced morbidity and mortality estimates for 38 causes of injury. Estimates were produced in terms of incidence, prevalence, years lived with disability, cause-specific mortality, years of life lost and disability-adjusted life-years for a 28-year period for 22 age groups, 195 countries and both sexes. Conclusions: GBD 2017 demonstrated a complex and sophisticated series of analytical steps using the largest known database of morbidity and mortality data on injuries. GBD 2017 results should be used to help inform injury prevention policy making and resource allocation. We also identify important avenues for improving injury burden estimation in the future

Global injury morbidity and mortality from 1990 to 2017 : results from the Global Burden of Disease Study 2017

Correction:Background Past research in population health trends has shown that injuries form a substantial burden of population health loss. Regular updates to injury burden assessments are critical. We report Global Burden of Disease (GBD) 2017 Study estimates on morbidity and mortality for all injuries. Methods We reviewed results for injuries from the GBD 2017 study. GBD 2017 measured injury-specific mortality and years of life lost (YLLs) using the Cause of Death Ensemble model. To measure non-fatal injuries, GBD 2017 modelled injury-specific incidence and converted this to prevalence and years lived with disability (YLDs). YLLs and YLDs were summed to calculate disability-adjusted life years (DALYs). Findings In 1990, there were 4 260 493 (4 085 700 to 4 396 138) injury deaths, which increased to 4 484 722 (4 332 010 to 4 585 554) deaths in 2017, while age-standardised mortality decreased from 1079 (1073 to 1086) to 738 (730 to 745) per 100 000. In 1990, there were 354 064 302 (95% uncertainty interval: 338 174 876 to 371 610 802) new cases of injury globally, which increased to 520 710 288 (493 430 247 to 547 988 635) new cases in 2017. During this time, age-standardised incidence decreased non-significantly from 6824 (6534 to 7147) to 6763 (6412 to 7118) per 100 000. Between 1990 and 2017, age-standardised DALYs decreased from 4947 (4655 to 5233) per 100 000 to 3267 (3058 to 3505). Interpretation Injuries are an important cause of health loss globally, though mortality has declined between 1990 and 2017. Future research in injury burden should focus on prevention in high-burden populations, improving data collection and ensuring access to medical care.Peer reviewe