Comparison of APACHE II and SAPS II Scoring Systems in Prediction of Critically ill Patients’ Outcome

Introduction: Using physiologic scoring systems for identifying high-risk patients for mortality has been considered recently. This study was designed to evaluate the values of Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiologic Score (SAPS II) models in prediction of 1-month mortality of critically ill patients.Methods: The present prospective cross sectional study was performed on critically ill patients presented to emergency department during 6 months. Data required for calculation of the scores were gathered and performance of the models in prediction of 1-month mortality were assessed using STATA software 11.0.Results: 82 critically ill patients with the mean age of 53.45 ± 20.37 years were included (65.9% male). Their mortality rate was 48%. Mean SAPS II (p < 0.0001) and APACHE II (p = 0.0007) scores were significantly higher in dead patients. Area under the ROC curve of SAPS II and APACHE II for prediction of mortality were 0.75 (95% CI: 0.64 - 0.86) and 0.72 (95% CI: 0.60 - 0.83), respectively (p = 0.24). The slope and intercept of SAPS II were 1.02 and 0.04, respectively. In addition, these values were 0.92 and 0.09 for APACHE II, respectively.Conclusion: The findings of the present study showed that APACHE II and SAPS II had similar value in predicting 1-month mortality of patients. Discriminatory powers of the mentioned models were acceptable but their calibration had some amount of lack of fit, which reveals that APACHE II and SAPS II are partially perfect

A sustainability approach to vehicle modular platform design: A mathematical model

Today, sustainability and its economic, social, and environmental pillars are the main elements of new product market development. Therefore, manufacturers, considering all stages of a product life-cycle, consider it necessary to have a framework for producing sustainable products. Moreover, new product design and development processes especially sub-process of product definition and detailed design processes can play a very critical role in developing product sustainability. This paper considers the role that the car platform can play in creating a family of products and with regard to various data related to the environmental, economic, and social pillars of each of the 15 modules of a car platform and also, using the best–worst method technique and multi-objective mathematical programming with the augmented epsilon constraint method, we were able to achieve a set of platforms with maximum sustainability. The present study explores the possibility of determining the most efficient combinations of modules for every one of the 23 cars’ platforms to produce a collection of products. Through these methods, the 54 efficient solutions in the Pareto front were achieved, and out of this number, after considering all the factors and weights of the objective functions, solution no. 51 was selected as the most efficient. Subsequently, all the 15 module variants of the 23 platforms were determined for solution no. 51. Finally, these variants were ranked on the basis of the SAW technique, and finally, sensitivity analysis is done

The effect of intravenous metoclopramide on pain, nausea, discomfort, and ease of insertion of nasogastric tube in emergency department: a double-blind randomized clinical trial

Background: Placement of nasogastric tube (NGT) is a routine procedure in the emergencydepartments, which can be uncomfortable, painful, and cause nausea. The aim of this study was to investigate the effect of intravenous metoclopramide on the ease of NGT insertion, as well as reduction of patients’ pain, nausea, and discomfort during NGT insertion in the emergency department.Methods: In this randomized, double-blind, placebo-controlled trial, 80 patients referred to Imam Khomeini Hospital, Mazandaran Province, Iran were enrolled. Data were collected from December 2015 to March 2016. Participants were selected via convenience sampling and randomly divided into two equal groups (placebo and intervention groups). In metoclopramide and placebo groups, 10 mg of metoclopramide and 10 mg of normal saline solution were administered, respectively. All of the NGT was inserted 15–20 mins after the intravenous infusion. Patient-reported pain, discomfort, and nausea were evaluated using visual analogue scale (VAS), at four time points including before (T0), immediately (T1), 30 min after (T2), and 1hr after the NGT placement (T3). The ease of NGT insertion was evaluated as easy, moderate, and difficult to pass.Results: None of the patients had pain, nausea, and discomfort in T0. Additionally, for those who received intravenous metoclopramide, pain intensity significantly decreased compared with the placebo group in T1 (37.7 vs 55.0), T2 (26.2 vs 41.7), and T3 (20.5 vs 33.7), respectively (P < 0.001). Nausea intensity decreased significantly over time among patients in the interventiongroup compared with the placebo group in T1 (32.7 vs 43.2), T2 (19.5 vs 31.2), and T3 (9.0 vs 21.7), respectively (P < 0.001). The intensity of patients’ discomfort decreased significantlyamong patients in the intervention group compared with the placebo group in T1 (39.5 vs 54.0), T2 (28.7 vs 40.2), and T3 (26.2 vs 39.6), respectively (P < 0.001). Patients in the intervention group had easier placement of NGT compared with the placebo group (Easy: 40.0% vs 0.0%, Moderate: 45.0% vs 62.5%, and Difficult: 15.0% vs 37.5%; P < 0.001).Conclusion: Based on the results of the present study, it seems that intravenous metoclopramide can be used as a promising modality for improving the ease of NGT placement and reducing patients’ pain, nausea, and discomfort during NGT insertion in the emergency department

The Effect of Intravenous Metoclopramide on Pain, Nausea, Discomfort, and Ease of Insertion of Nasogastric Tube in Emergency Department: A Double-blind Randomized Clinical Trial

Background: Placement of nasogastric tube (NGT) is a routine procedure in the emergency departments, which can be uncomfortable, painful, and cause nausea. The aim of this study was to investigate the effect of intravenous metoclopramide on the ease of NGT insertion, as well as reduction of patients’ pain, nausea, and discomfort during NGT insertion in the emergency department. Methods: In this randomized, double-blind, placebo-controlled trial, 80 patients referred to Imam Khomeini Hospital, Mazandaran Province, Iran were enrolled. Data were collected from December 2015 to March 2016. Participants were selected via convenience sampling and randomly divided into two equal groups (placebo and intervention groups). In metoclopramide and placebo groups, 10 mg of metoclopramide and 10 mg of normal saline solution were administered, respectively. All of the NGT was inserted 15–20 mins after the intravenous infusion. Patient-reported pain, discomfort, and nausea were evaluated using visual analogue scale (VAS), at four time points including before (T0), immediately (T1), 30 min after (T2), and 1 hr after the NGT placement (T3). The ease of NGT insertion was evaluated as easy, moderate, and difficult to pass. Results: None of the patients had pain, nausea, and discomfort in T0. Additionally, for those who received intravenous metoclopramide, pain intensity significantly decreased compared with the placebo group in T1 (37.7 vs 55.0), T2 (26.2 vs 41.7), and T3 (20.5 vs 33.7), respectively (P < 0.001). Nausea intensity decreased significantly over time among patients in the intervention group compared with the placebo group in T1 (32.7 vs 43.2), T2 (19.5 vs 31.2), and T3 (9.0 vs 21.7), respectively (P < 0.001). The intensity of patients’ discomfort decreased significantly among patients in the intervention group compared with the placebo group in T1 (39.5 vs 54.0), T2 (28.7 vs 40.2), and T3 (26.2 vs 39.6), respectively (P < 0.001). Patients in the intervention group had easier placement of NGT compared with the placebo group (Easy: 40.0% vs 0.0%, Moderate: 45.0% vs 62.5%, and Difficult: 15.0% vs 37.5%; P < 0.001). Conclusion: Based on the results of the present study, it seems that intravenous metoclopramide can be used as a promising modality for improving the ease of NGT placement and reducing patients’ pain, nausea, and discomfort during NGT insertion in the emergency department

Ability of Ultrasonography in Detection of Different Extremity Bone Fractures; a Case Series Study

Introduction: Despite radiography being the gold standard in evaluation of orthopedic injuries, using bedsideultrasonography has several potential supremacies such as avoiding exposure to ionizing radiation, availabilityin pre-hospital settings, being extensively accessible, and ability to be used on the bedside. The aim of thepresent study is to evaluate the diagnostic accuracy of ultrasonography in detection of extremity bone fractures.Methods: This study is a case series study, which was prospectively conducted on multiple blunt trauma patients,who were 18 years old or older, had stable hemodynamic, Glasgow coma scale 15, and signs or symptomsof a possible extremity bone fracture. After initial assessment, ultrasonography of suspected bones was performedby a trained emergency medicine resident and prevalence of true positive and false negative findingswere calculated compared to plain radiology. Results: 108 patients with the mean age of 44.6 § 20.4 years werestudied (67.6% male). Analysis was done on 158 sites of fracture, which were confirmed with plain radiography.91 (57.6%) cases were suspected to have upper extremity fracture(s) and 67 (42.4%) to have lower ones.The most frequent site of injuries were forearm (36.7%) in upper limbs and leg (27.8%) in lower limbs. Prevalenceof true positive and false negative cases for fractures detected by ultrasonography were 59 (64.8%) and 32(35.52%) for upper and 49 (73.1%) and 18 (26.9%) for lower extremities, respectively. In addition, prevalence oftrue positive and false negative detected cases for intra-articular fractures were 24 (48%) and 26 (52%), respectively.Conclusion: The present study shows the moderate sensitivity (68.3%) of ultrasonography in detectionof different extremity bone fractures. Ultrasonography showed the best sensitivity in detection of femur (100%)and humerus (76.2%) fractures, respectively. It had low sensitivity in detection of in intra-articular fractures

Diagnostic Accuracy of Ascites Fluid Gross Appearance in Detection of Spontaneous Bacterial Peritonitis

Introduction: Spontaneous bacterial peritonitis (SBP) as a monomicrobial infection of ascites fluid is one of the most important causes of morbidity and mortality in cirrhotic patients. This study was aimed to determine the diagnostic accuracy of ascites fluid color in detection of SBP in cirrhotic cases referred to the emergency department. Methods: Cirrhotic patients referred to the ED for the paracentesis of ascites fluid were enrolled. For all studied patients, the results of laboratory analysis and gross appearance of ascites fluid registered and reviewed by two emergency medicine specialists. The sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ration of the ascites fluid gross appearance in detection of SBP were measured with 95% confidence interval. Results: The present project was performed in 80 cirrhotic patients with ascites (52.5 female). The mean of the subjects’ age was 56.25±12.21 years (35-81). Laboratory findings revealed SBP in 23 (29%) cases. Fifty nine (73%) cases had transparent ascites fluid appearance of whom 17 (29%) ones suffered from SBP. From 21 (26%) cases with opaque ascites appearance, 15 (71%) had SBP. The sensitivity and specificity of the ascites fluid appearance in detection of SBP were 46.88% (Cl: 30.87-63.55) and 87.50% (95% Cl: 75.3-94.14), respectively. Conclusion: It seems that the gross appearance of ascites fluid had poor diagnostic accuracy in detection of SBP and considering its low sensitivity, it could not be used as a good screening tool for this propose

مقایسه مورفین و استامینوفن تزریقی در کنترل درد بیماران مشکوک به کله سیستیت حاد؛ یک کارآزمایی بالینی

Introduction: Acute cholecystitis is one of the most common surgical emergencies and a major cause of acute abdomen all over the world. One of the most important measures taken for these patients in emergency department (ED) is pain management. Therefore, the present study aimed to compare the effectiveness of intravenous acetaminophen and morphine for managing abdominal pain caused by acute cholecystitis. Methods: The present study is a single blind randomized clinical trial that evaluates and compares the effectiveness of morphine sulfate and intravenous acetaminophen in pain management of patients with suspected acute cholecystitis aged above 18 years with stable vital signs, who were admitted to ED. To gather data a pre-designed checklist, consisting of demographic data, pain severity on arrival and 30, 60, and 90 minutes after injection, vital signs on arrival, presence or absence of side effects, and clinical findings, was used. Finally, the 2 groups were compared regarding pain relief and side effects using SPSS 18. Results: 70 patients with the mean age of 55.2 ± 16.3 years were randomly allocated to 2 groups of 35 (61.4% female). 38 (54.3%) patients had only one ultrasonogrphic indication for acute cholecystitis, while 32 (45.7%) had 2 or more. Mean pain severity was significantly different between the 2 groups 30, 60, and 90 minutes after drug injection (p < 0.05). However, nausea (p = 0.617) and vomiting (p = 0.150) rates after injection were not significantly different between the groups. Fever was significantly lower in acetaminophen group (p < 0.001). Conclusion: Based on the results of the present study, morphine is more efficient than acetaminophen in pain relief during the initial 30 minutes after injection. However, although the difference in pain relief was statistically significant between the groups, 60 and 90 minutes after injection, it was not clinically important (less than 3 score). On the other hand, intravenous acetaminophen was simultaneously effective in controlling fever among the patients. مقدمه: کله سیستیت حاد یکی از شایعترین اورژانس های جراحی و از علل مهم شکم حاد در تمام دنیا می باشد. از مهمترین اقدامات لازم برای این بیماران در بخش اورژانس کنترل درد حاد شکم تا زمان رسیدن به تشخیص قطعی است. لذا، مطالعه حاضر با هدف مقایسه اثرات ضد دردی استامینوفن تزریقی و مورفین در کنترل درد ناشی از کله سیستیت حاد طراحی شده است. روش کار: مطالعه حاضر از نوع کارآزمایی بالینی تصادفی شده یک سوکور می باشد که به بررسی و مقایسه اثر دو داروی مورفین سولفات و استامینوفن تزریقی در کنترل درد بیماران مشکوک به کله سیستیت حاد بالای 18 سال و با علائم حیاتی پایدار پذیرش شده در بخش اورژانس پرداخته است. جهت جمع آوری اطلاعات از چک لیستی از پیش طراحی شده شامل اطلاعات دموگرافیک، شدت درد در بدو ورود و دقایق 30 و 60 و 90 بعد از تزریق، علایم حیاتی بدو ورود، وجود یا عدم وجود عوارض جانبی و یافته های بالینی استفاده شد. در نهایت دو گروه با استفاده از نرم افزار آماری SPSS 18 مورد مقایسه از جهت میزان کنترل درد و عوارض قرار گرفتند. يافته ها: در مجموع 70 بیمار با میانگین سنی 3/16 ± 2/55 سال به صورت راندوم به دو گروه 35 نفری وارد شدند (4/61 درصد زن). 38 (3/54 درصد) بیمار فقط یک معیار سونوگرافیک کله سیستیت حاد را داشتند حال آنکه 32 (7/45 درصد) بیمار دو معیار یا بیشتر را داشتند. میانگین شدت درد در دقایق 30، 60 و90 بعد از تزریق دارو در دو گروه تفاوت معنی دار آماری داشت (05/0 < p). میزان عوارض تهوع (617/0 = p) و استفراغ  (150/0 = p) بعد از تزریق در دو گروه مورد مطالعه تفاوت معنی داری نداشت . تب در گروه استامینوفن تزریقی به طور معنی داری کاهش پیدا کرده بود  (001/0 > p). نتيجه گيری: بر اساس یافته های مطالعه حاضر، داروی مورفین در مقایسه با استامینوفن کارایی بیشتری در کاهش شدت درد بیماران طی 30 دقیقه را دارد، بطوریکه نمره VAS  بیماران 30 دقیقه پس از تزریق مورفین کاهش معنی داری داشت. اما در دقایق 60 و 90 بعد از تزریق علی رغم تفاوت معنی دار آماری کنترل درد بین دریافت کنندگان دو داروی مورد مطالعه، این مقادیر از نظر کلینیکی معنی دار نبودند. با این وجود داروی استامینوفن تزریقی در کنترل تب بیماران نیز به طور همزمان تاثیر گذار بوده است

Intravenous acetaminophen versus morphine sulfate in pain management of acute renal colic: a randomized clinical trial

Objective: The main purpose in the treatment of renal colic patients in emergency department is pain management. This study aimed to compare the analgesic effects of intravenous (IV) acetaminophen and morphine sulfate in this regard. Methods: This double blind clinical trial was conducted on >18 years old renal colic patients in need of pain management in emergency department. Pain severity was recorded as 15, 30, and 60 minutes before injection, and 120 minutes after injection. In addition, side effects were compared between IV acetaminophen and morphine sulfate groups using SPSS version 16. Results: A total of 355 patients were randomly allocated to one of the treatment groups. There were no significant differences between the two groups regarding baseline characteristic of participants. There was no significant difference in the pain intensity of the groups; 15 (P = 0.13) and 30 (P = 0.15) minutes after treatment. Although, the difference in pain severity was statistically significant between the two groups; 60 (P = 0.02) and 120 (P = 0.003) minutes after the infusion. This was not clinically important. The prevalence of side effects in morphine group was higher than the acetaminophen group (RR: 2.14, 95% CI: 1.53-2.98, P< 0.0001). Conclusion: Based on the findings, IV morphine sulfate and acetaminophen had equal effectiveness regarding acute renal colic pain management, but considering the significantly higher frequency of side effects, IV acetaminophen seems to be a more reasonable choice in this regard