Upper Gastrointestinal Bleeding as Delayed Presentation of Traumatic Diaphragmatic Hernia: a Case Report

Introduction: Traumatic diaphragmatic hernia (TDH) is one of the critical complications resulting from penetrating chest trauma. The rate of undiagnosed TDH equivocates 12-60%. The significant part of complications happens 1-4 years after the primary damage. Here, we report a case of delayed TDH presented with upper gastrointestinal bleeding (GIB) as an excuse to discuss this issue. Case presentation: The patient was a 35-year-old man, admitted with objection of abdominal pain. A nasogastric tube was inserted and fixed that resulted in drainage of about 500cc dark blood. He was candidate for emergent endoscopy due to upper GIB. During resuscitation measures, he suddenly developed respiratory distress that could not be justified by upper GIB alone. Therefore, bedside sonography discovered some soft tissue apart from lung tissue in the left hemithorax. After performing diagnostic measures, with diagnosis of diaphragmatic herniation and strangulation he underwent emergent surgery. Conclusion: Small diaphragmatic lesions, which usually result from stab wounds, may develop into larger injuries if left untreated and they might lead to a diaphragmatic hernia with a potential risk of early or late complications and mortality. One of the rare complications is GIB, which should be considered in a patient with past history of trauma and presentation of GIB

Using Visco-Plastic Lubrication For Suspension Transportation

This study focuses on a common problem in suspension plasma spraying called clogging. Different mechanisms causing that issue are described and a technique called visco-plastic lubrication is introduced as a solution to this problem. Numerical modelling has been done using mentioned technique and effect of viscosity ratio of the fluids on the flow are investigated

Lidocaine-Midazolam-Fentanyl Combination in Controlling Pain for Reduction of Anterior Shoulder Dislocation; a Randomized Clinical Trial

Introduction: Finding a fast-acting compound with minimal side-effects to induce a safe and efficient analgesia with short or medium duration of action is of great interest in the emergency department. The present study has been designed with the aim of comparing the effect of midazolam + fentanyl + lidocaine combination with midazolam + fentanyl + placebo in pain management of anterior shoulder dislocation reduction.Methods: The present two-arm parallel double-blind randomized controlled trial was performed on patients who presented to emergency department with anterior shoulder dislocation. Patients were randomly allocated to the 2 treatment groups of midazolam + fentanyl + placebo (double-drug group) and midazolam + fentanyl + intravenous (IV) lidocaine (triple-drug group). Then outcomes such as treatment success rate and side-effects following prescription of drugs were compared between the 2 groups.Results: 100 patients were included in the present study (50 patients in each group; mean age of the studied patients 27.3±8.9 years; 93.0% male). Using the double-drug regimen led to 35 (70%) cases of complete analgesia, while this rate in the triple-drug group was 41 (82%) cases (p=0.16). The calculated number needed to treat was 9 cases. This means that about one in every 9 patients in treatment arm will benefit from the treatment. The most important side-effects observed included dysrhythmia (1 patient in double drug and 1 patient in triple-drug group), apnea (2 patients in each group) and SPO2<90% (2 patients in triple-drug group) (p=0.78). Number needed to harm was 25 cases. In other words, for each 25 patients treated with the triple drug regimen, 1 case of SPO2<90% is observed.Conclusion: Findings of the present study showed that adding IV lidocaine to IV midazolam + fentanyl drug combination does not provide additional analgesia in sedation for anterior shoulder reduction

Upper Gastrointestinal Bleeding as Delayed Presentation of Traumatic Diaphragmatic Hernia: a Case Report

Introduction: Traumatic diaphragmatic hernia (TDH) is one of the critical complications resulting from penetrating chest trauma. The rate of undiagnosed TDH equivocates 12-60%. The significant part of complications happens 1-4 years after the primary damage. Here, we report a case of delayed TDH presented with upper gastrointestinal bleeding (GIB) as an excuse to discuss this issue. Case presentation: The patient was a 35-year-old man, admitted with objection of abdominal pain. A nasogastric tube was inserted and fixed that resulted in drainage of about 500cc dark blood. He was candidate for emergent endoscopy due to upper GIB. During resuscitation measures, he suddenly developed respiratory distress that could not be justified by upper GIB alone. Therefore, bedside sonography discovered some soft tissue apart from lung tissue in the left hemithorax. After performing diagnostic measures, with diagnosis of diaphragmatic herniation and strangulation he underwent emergent surgery. Conclusion: Small diaphragmatic lesions, which usually result from stab wounds, may develop into larger injuries if left untreated and they might lead to a diaphragmatic hernia with a potential risk of early or late complications and mortality. One of the rare complications is GIB, which should be considered in a patient with past history of trauma and presentation of GIB

True Vertigo Patients in Emergency Department; an Epidemiologic Study

Introduction: Vertigo prevalence is estimated to be 1.8% among young adults and more than 30% in the elderly. 13-38% of the referrals of patients over 65 years old in America are due to vertigo. Vertigo does not increase the risk of mortality but it can affect the patient’s quality of life. Therefore, this study was designed to evaluate the epidemiologic characteristics of vertigo patients referred to the emergency department (ED). Methods: In this 6-month retrospective cross-sectional study, the profiles of all vertigo patients referred to the ED of Imam Hossein Hospital, Tehran, Iran, from October 2013 to March 2014 were evaluated. Demographic data and baseline characteristics of the patients were recorded and then patients were divided into central and peripheral vertigo. The correlation of history and clinical examination with vertigo type was evaluated and screening performance characteristics of history and clinical examination in differentiating central and peripheral vertigo were determined. Results: 379 patients with the mean age of 50.69 ± 11.94 years (minimum 18 and maximum 86) were enrolled (58.13% female). There was no sex difference in vertigo incidence (p = 0.756). A significant correlation existed between older age and increase in frequency of central cases (p < 0.001). No significant difference was detected between the treatment protocols regarding ED length of stay (p = 0.72). There was a significant overlap between the initial diagnosis and the final decision based on imaging and neurologist’s final opinion (p < 0.001). In the end, 361 (95.3%) patients were discharged from ED, while 18 were disposed to the neurology ward. No case of mortality was reported. Conclusion: Sensitivity and specificity of history and clinical examination in differentiating central and peripheral vertigo were 99 (95% CI: 57-99) and 99 (95% CI: 97-99), respectively

Numerical investigation of air mediated droplet bouncing on flat surfaces

A liquid droplet can bounce off a flat substrate independent of surface wettability if the impact occurs at low velocities, i.e., We of less than seven. In this case, the droplet spreads on a sub-micrometer air layer and rebounds subsequently without any direct contact with the surface. We have numerically investigated the process of air layer formation beneath the droplet. The numerical simulations are validated using experimental results available in the literature based on morphology of the droplet interface and thickness of the air layer. Numerical results revealed that the formation of a high pressure zone at the center of impact deforms the droplet to a kink shape at the moment of impact. The deformation leads to displacement of high pressure zone from center to kink edge of the droplet interface. Further investigation of pressure and velocity of air beneath the droplet divulged that high pressure region at the kink edge suppresses air flow at the inner region while accelerating flow at the outer region. In addition, it is demonstrated that fluid flow at the kink edge where droplet interface has the minimum distance from the substrate resembles Couette flow. It is demonstrated that the deformation of droplet along with displacement of high pressure region from the center to kink edge are responsible for stabilizing the air layer beneath the droplet and consequently spreading and receding of droplet over a thin air cushion

Baseline Characteristics of Fall from Height Victims Presenting to Emergency Department; a Brief Report

Introduction: Trauma due to accidents or fall from height is a major cause of disability and mortality. The present study was designed aiming to evaluate the baseline characteristics of fall from height victims presenting to emergency department (ED).Methods: This prospective cross-sectional study evaluates the baseline characteristics of fall from height cases presenting to EDs of three educational Hospitals, Tehran, Iran, during one year. Data were analyzed using SPSS 21 and presented using descriptive statistics.Results: 460 patients with the mean age of 27.89 ± 20.95 years were evaluated (76.5% male). 191 (41.5%) falls occurred when working, 27 (5.9%) during play, and 242 (52.6%) in other times. Among construction workers, 166 (81.4%) had not used any safety equipment. Fracture and dislocation with 180 (39.1%) cases and soft tissue injury with 166 (36.1%) were the most common injuries inflicted. Mean height of falling was 3.41 ± 0.34 (range: 0.5 – 20) meters. Finally, 8 (1.7%) of the patients died (50% intentional) and 63% were discharged from ED. A significant correlation was detected between mortality and the falls being intentional (p < 0.0001) as well as greater height of fall (p < 0.0001).Conclusion: Based on the findings, most fall from height victims in the present study were young men, single, construction workers, with less than high school diploma education level. Intentional fall and greater height of falling significantly correlated with mortality

Consequences of “Infiltration” in Religious State (A Glance at the Formation of the Islamic State in Medina)

“Infiltration” terminologically means penetration and technically refers to creeping and silent penetration in the social and political elements of a state and a secret attempt to overthrow, control or change it. The phenomenon of infiltration is always considered as one of the threats against a religious state. The Islamic State, from the beginning of its formation in Medina until now, has been constantly confronted with such a political and cultural threat. In the verses of the Holy Qur’an, whether in the form of hypocrisy or otherwise, this danger and political-cultural threat has been mentioned. There are many motives behind infiltration, including: changing the foundations of power, impacting the government, power-seeking and espionage acting. Layers of infiltration also are diversity and multiplicity; A look at the early Islam era shows that different layers of belief, culture, politics and economics existed among the levels of infiltration of the enemies and opponents of the Islamic State. Depending on the layers of infiltration, its methods have been different: “Friendship plans”, “hypocrisy”, “espionage” and “horrific propaganda” are among the methods of infiltration. Infiltration, like any other threat, has unintended consequences. The present paper aims to examine and analyze the consequences of the enemies’ infiltration in the civil era of the Islamic State

Dexmedetomidine-Fentanyl versus Midazolam-Fentanyl in Pain Management of Distal Radius Fractures Reduction; a Randomized Clinical Trial

Introduction: Currently, using various combinations of narcotic and analgesic drugs has received attention for induction of sedation and analgesia due to their synergy in controlling pain and anxiety. The present study was designed with the aim of comparing dexmedetomidine-fentanyl combination with midazolam-fentanyl in this regard. Methods: In this randomized clinical trial, patients diagnosed with distal radius fracture who had visited the emergency department (ED) were allocated to either the group receiving the combination of fentanyl-midazolam or the one receiving dexmedetomidine-fentanyl for procedural sedation and analgesia (PSA) and were compared regarding analgesic characteristics, time to recovery and side effects. Results: 80 patients with the mean age of 42.08 ± 12.17 (18 - 60) years were randomly allocated to 2 groups of 40 (83.80% male). The 2 groups did not have a significant difference regarding baseline characteristics as well as pain severity.  Mean pain score at the time of procedure was 3.47 ± 1.37 in dexmedetomidine and 2.85 ± 1.05 in midazolam group (p = 0.025). In addition, time to recovery in dexmedetomidine and midazolam groups was 6.60 ± 1.86 minutes and 12.70 ± 1.70 minutes, respectively (p < 0.001). Out of the 9 patients who experienced treatment failure, 8 (88.90%) patients were in dexmedetomidine group and 1 (11.10%) was in midazolam group (p = 0.029). Absolute risk increase rate of treatment failure in case of using dexmedetomidine instead of midazolam was 17.50% (95%CI: 4.19 – 30.81) and number needed to harm was 6.00 (95% CI: 3.20 – 23.80). Conclusion: Although the combination of dexmedetomidine-fentanyl had a shorter time to recovery compared to midazolam-fentanyl for induction of sedation and analgesia, the treatment failure rate in case of using dexmedetomidine with 1 µg/kg increased 17.5% and about 1 out of each 6 patients needed a rescue dose

Iran's National Roles and Foreign Policy: A Quantitative Analysis of Martyr Beheshti's Interviews and Lectures

The main question of the present study is what kind of national roles did martyr Beheshti consider for Iranian foreign policy? The research hypothesis refers to roles such as Islamic world leadership, supporter of the oppressed, and the struggle against arrogance and colonialism. To answer this question, we used K.J Holsti's theoretical framework and the roles of foreign policy that Holsti identified in his book applied with the views of the martyr Beheshti. For this purpose, two methods of quantitative analysis (frequency counting of indexes related to national roles) and qualitative analysis (interpretation of findings with descriptive-analytical method) were used. The findings showed that among the 16 national roles mentioned by Holsti, the national roles of the anti-imperialist State (131 frequency), the defender of Islam (53 frequency), and the revolution and liberation stronghold (48 frequency) had the highest reflection in martyr Beheshti's interviews and lectures. However, there were no mention of the roles such as regional leader and regional protector; instead, three roles have been assigned by martyr Beheshti for Iran's foreign policy that there was not in the roles mentioned by Holsti. These roles include the anti-Zionist state, the justice-seeking state and the peace-loving state