Remifentanil versus Fentanyl/Midazolam in Painless Reduction of Anterior Shoulder Dislocation; a Randomized Clinical Trial

Introduction: Performance of painful diagnostic and therapeutic procedures is common in emergency department(ED), and procedural sedation and analgesia (PSA) is a fundamental skill for every emergency physician.This studywas aim to compare the efficacy of remifentanil with fentanyl/midazolam in painless reduction of anteriorshoulder dislocation. Methods: In this randomized, double blind, clinical trial the procedural characteristics,patients satisfaction as well as adverse events were compared between fentanyl/midazolamand remifentanilfor PSA of 18–64 years old patients, which were presented to ED following anterior shoulder dislocation.Results: 96 cases were randomly allocated to two groups (86.5% male). There were no significant difference betweengroups regarding baseline characteristics. Remifentanil group had lower duration of procedure (2.5§1.6versus 4.6§1.8 minutes, p Ç 0.001), higher pain reduction (53.7§13.3 versus 33.5§19.6, p Ç 0.001), lower failurerate (1 (2.1%) versus 15 (31.3%), p Ç 0.001), higher satisfaction (p Æ 0.005). Adverse events were seen in 12 (25%)patients in midazolam/fentanyl and 8 (16.7%) cases in remifentanil group (p Æ 0.122). Conclusion: It seemsthat use of remifentanil resulted in lower procedural time, lower failure rate, and lower pain during procedureas well as higher patient satisfaction in comparison with midazolam/fentanyl combination in anterior shoulderdislocation

Prevalence of Mycoplasma Pneumoniae Infection in Patients with COPD Exacerbation; a Letter to the Editor

Dear editor;Currently, control and prevention of respiratory illnesses is considered a health priority in most developed countries and managing the risk factors is necessary for improving the population’s health. Chronic obstructive pulmonary disease (COPD) is the 5th cause of death around the world and estimations have indicated that due to an increase in environmental pollution, this disease will become the 3rd cause of death in the future.In previous studies, pulmonary infection with mycoplasma pneumoniae has been introduced as one of the causes for COPD exacerbation. Mycoplasma pneumoniae affects the upper and lower respiratory tract and its clinical manifestation is trachea-bronchitis accompanied by restlessness and dry coughs. The pathogenesis spectrum of this bacterium ranges from mild pharyngitis and trachea-bronchitis to acute pneumonia. Epidemiologic studies have shown that this bacterium is responsible for more than 20% of community acquired pneumonias.In a cross-sectional study by the authors of the present letter, 66 patients over the age of 18 years who had presented to the emergency department of Imam Reza Hospital, Mashhad, Iran, with diagnosis of COPD exacerbation were evaluated. Sputum sample of the patients was obtained and sent to the laboratory for performing polymerase chain reaction (PCR). Mean age of the patients participating in this study was 67.28 ± 13.68 years (60.6% male). The result of PCR was positive in 6 patients out of the total of 66 patients (9.1%). The results of the present study showed that there was no correlation between age (p=0.18), sex (p=0.25), duration of being affected with COPD (p=0.20), consumption of antibiotics (p=0.35), smoking (p=0.62), opioid abuse (p=0.44), corticosteroid use (p=0.57), underlying illness (p=0.94) and health care—associated pneumonia (HCAP) (p=0.46) with mycoplasma infection. However, prevalence of leukocytosis (p=0.01) and myalgia (p=0.02) was significantly higher in the mycoplasma group.Numerous studies have confirmed the presence of mycoplasma pneumoniae in exacerbation of COPD using serologic diagnosis. For instance, in a study by Lieberman et al. prevalence of mycoplasma pneumoniae in patients with COPD exacerbation was reported as 14.2% and in Meloni et al. study the prevalence of this infection was expressed to be 6.7%. These rates were reported between 5% and 14% in other studies.Thus, it seems that prevalence of mycoplasma is high in COPD exacerbation, but there is still no answer to the question if this infection results in exacerbation of COPD or not and there is controversy between the studies in this regard. Therefore, it is suggested to design case-control or cohort studies to find the answer to this question

Emergency Medicine Resident versus Radiologist in Detecting the Ultrasonographic Signs of Acute Cholecystitis; a Diagnostic Accuracy Study

Introduction: Dependence of ultrasonography on the operator’s skill plays a major role in the differences between various studies in reporting its diagnostic accuracy. Therefore, the present study was done with the aim of comparing the ultrasonography findings performed by emergency medicine resident and radiologist in evaluation of acute cholecystitis. Methods: The present diagnostic accuracy study has been carried out on patients presenting to the emergency department with complaint of pain in the right upper quadrant of abdomen suspected with acute cholecystitis. All the patients underwent gallbladder ultrasonography by a trained emergency medicine resident and a radiologist and their findings were compared with surgical and pathology findings regarding gallstone and increased gallbladder wall thickness. Results: 51 patients with the mean age of 42.3±15.8 (17-81) years were analyzed (82.4% female). The overall agreement between emergency medicine resident and radiologist in ultrasonographic diagnosis of cholecystitis was 0.421 (95% CI: 0.118-0.724). Based on the pathology and surgical findings, acute cholecystitis was confirmed for all 51 (100%) patients. Meanwhile, based on the ultrasonographic report of radiologist and emergency medicine resident only 45 (88.2%) and 34 (66.7%) patients, respectively, were diagnosed with cholecystitis. Screening performance characteristics of ultrasonography by radiologist for detection of gallbladder stone (p = 0.010) and gallbladder wall thickness (p < 0.0001) were significantly better than emergency medicine resident. Conclusion: The screening performance characteristics of ultrasonography by radiologist in detection of gallstones and increased wall thickness of gallbladder were significantly better

A Randomized Clinical Trial of Intravenous and Intramuscular Ketamine for Pediatric Procedural Sedation and Analgesia

Introduction: Ketamine is an agent used broadly for pediatric procedural sedation and analgesia in emergency departments. It has been found to be safe and with a low risk of complications. As choosing between intravenous (IV) and intramuscular (IM) injections is a matter of concern, we did comparison between two methods in terms of their efficacy and the rate of complications. Methods: This single-blind clinical trial study recruited 240 children (age: three months to 15 years, weight > 5 kg), who underwent short and painful procedures at the emergency departments. They were randomly allocated in to two groups of 120 patients to receive either IV or IM ketamine with doses of 1.5 and 4 mg/kg, respectively. Indications for use, dose, side effects, and efficacy of the medications as well as duration of the procedure and time to recovery were compared between two groups. Results: The mean age of the IV and IM groups were 6.5 ± 3.6 and 3.05 ± 2.6 years, respectively (p < 0.001). The onset of action of ketamine was 1.7 ± 1.1 minutes in the IV group and 8.6 ± 3.1 in the IM ones (p < 0.001). Patients of the IV and IM groups remained in optimal sedation for 20.6±12.0 and 37.2±11.8 minutes, respectively (P < 0.001). Time until emergency department discharge was 65.3 ± 36.9 minutes in the IV group and 72.2 ± 14.5 in the IM group (P = 0.40). Ketamine had excellent and moderate efficacy in 66.7% and 32.5% of the IV group and 70.0% and 25.0%  in the IM group, respectively (p = 0.02). Totally, 60.0% of IV group patients and 40.0% of IM group experienced drug side effects (p = 0.21). Need to rescue dose was significantly higher in IV group (26.7% vs. 10.0%; p < 0.001). Finally, recovery was tranquil and comfortable in 88 patients (73.3%) of the IV group and 108 patients (90.0%) of the IM group (p = 0.06). Conclusion: We found that although the sedative and analgesic effects of IM and IV ketamine are not significantly different, duration of effect and onset of action are more desirable in the IV group for suturing, fracture reduction, and foreign body removal. Meanwhile, the IM method can lead to lesser need of rescue doses

The Relation of Q Angle and Anthropometric Measures with Ankle Sprain; a Case-control study

Introduction: Since most studies on ankle sprain are medical and sports-related and not much epidemiologic and etiologic data from the general population exist in this field, the present study evaluates the relationship between Q angle and anthropometric measures with ankle sprain in the general population.Methods: In the present case-control study, all of the patients over 18 years age presenting to emergency departments (ED) of two educational Hospitals, complaining from ankle sprain, were evaluated during more than 1 year. A checklist consisting of demographic data, height, weight, body mass index (BMI), and history of ankle sprain, as well as degree of Q angle was filled for all participants. The correlation of mentioned variables with incidence of ankle sprain was calculated using SPSS 22.Results: 300 patients with ankle sprain were evaluated (53.5% male). Mean age of the patients was 37.03 ± 14.20 years. Mean weight, height, and BMI were 71.71 ± 11.26 (43 – 114), 168.74 ± 8.63 (143 – 190) and 25.14 ± 3.19 (18.41 – 38.95), respectively. Mean Q angle of the patients was 12.78 ± 3.19 degrees (5 – 23). There was a significant correlation between weight (p < 0.001), BMI (p = 0.001), history of sprain (r: 0.26, p < 0.001) and Q angle (p = 0.002) with incidence of ankle sprain. In addition, there was a significant statistical correlation between weight (p = 0.031), BMI (p = 0.020) and Q angle (p = 0.004) with history of ankle sprain. In patients with a history of ankle sprain, Q angle was wider by about 2 degrees.Conclusion: It seems that the prevalence of ankle sprain directly correlates with high weight, BMI, and Q angle and is more prevalent in those with a history of sprain. Although the findings of the present study show a statistically significant correlation between these factors and ankle sprain, the correlation is not clinically significant

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

Screening Characteristics of Bedside Ultrasonography in Confirming Endotracheal Tube Placement; a Diagnostic Accuracy Study

Introduction: Confirmation of proper endotracheal tube placement is one of the most important and lifesaving issues of tracheal intubation. The present study was aimed to evaluate the accuracy of tracheal ultrasonography by emergency residents in this regard.  Method: This was a prospective, cross sectional study for evaluating the diagnostic accuracy of ultrasonography in endotracheal tube placement confirmation compared to a combination of 4 clinical confirmation methods of chest and epigastric auscultation, direct laryngoscopy, aspiration of the tube, and pulse oximetry (as reference test).Results: 150 patients with the mean age of 58.52 ± 1.73 years were included (56.6% male). Sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratio of tracheal ultrasonography in endotracheal tube confirmation were 96 (95% CI: 92-99), 88 (95% CI: 62-97), 98 (95% CI: 94-99), 78 (95% CI: 53-93), 64 (95% CI: 16-255), and 0.2 (95% CI: 0.1-0.6), respectively.Conclusion: The present study showed that tracheal ultrasonography by trained emergency medicine residents had excellent sensitivity (>90%) and good specificity (80-90) for confirming endotracheal tube placement. Therefore, it seems that ultrasonography is a proper screening tool in determining endotracheal tube placement

Mapping 123 million neonatal, infant and child deaths between 2000 and 2017

Since 2000, many countries have achieved considerable success in improving child survival, but localized progress remains unclear. To inform efforts towards United Nations Sustainable Development Goal 3.2—to end preventable child deaths by 2030—we need consistently estimated data at the subnational level regarding child mortality rates and trends. Here we quantified, for the period 2000–2017, the subnational variation in mortality rates and number of deaths of neonates, infants and children under 5 years of age within 99 low- and middle-income countries using a geostatistical survival model. We estimated that 32% of children under 5 in these countries lived in districts that had attained rates of 25 or fewer child deaths per 1,000 live births by 2017, and that 58% of child deaths between 2000 and 2017 in these countries could have been averted in the absence of geographical inequality. This study enables the identification of high-mortality clusters, patterns of progress and geographical inequalities to inform appropriate investments and implementations that will help to improve the health of all populations

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

Global, regional, and national cancer incidence, mortality, years of life lost, years lived with disability, and disability-Adjusted life-years for 29 cancer groups, 1990 to 2017 : A systematic analysis for the global burden of disease study

Importance: Cancer and other noncommunicable diseases (NCDs) are now widely recognized as a threat to global development. The latest United Nations high-level meeting on NCDs reaffirmed this observation and also highlighted the slow progress in meeting the 2011 Political Declaration on the Prevention and Control of Noncommunicable Diseases and the third Sustainable Development Goal. Lack of situational analyses, priority setting, and budgeting have been identified as major obstacles in achieving these goals. All of these have in common that they require information on the local cancer epidemiology. The Global Burden of Disease (GBD) study is uniquely poised to provide these crucial data. Objective: To describe cancer burden for 29 cancer groups in 195 countries from 1990 through 2017 to provide data needed for cancer control planning. Evidence Review: We used the GBD study estimation methods to describe cancer incidence, mortality, years lived with disability, years of life lost, and disability-Adjusted life-years (DALYs). Results are presented at the national level as well as by Socio-demographic Index (SDI), a composite indicator of income, educational attainment, and total fertility rate. We also analyzed the influence of the epidemiological vs the demographic transition on cancer incidence. Findings: In 2017, there were 24.5 million incident cancer cases worldwide (16.8 million without nonmelanoma skin cancer [NMSC]) and 9.6 million cancer deaths. The majority of cancer DALYs came from years of life lost (97%), and only 3% came from years lived with disability. The odds of developing cancer were the lowest in the low SDI quintile (1 in 7) and the highest in the high SDI quintile (1 in 2) for both sexes. In 2017, the most common incident cancers in men were NMSC (4.3 million incident cases); tracheal, bronchus, and lung (TBL) cancer (1.5 million incident cases); and prostate cancer (1.3 million incident cases). The most common causes of cancer deaths and DALYs for men were TBL cancer (1.3 million deaths and 28.4 million DALYs), liver cancer (572000 deaths and 15.2 million DALYs), and stomach cancer (542000 deaths and 12.2 million DALYs). For women in 2017, the most common incident cancers were NMSC (3.3 million incident cases), breast cancer (1.9 million incident cases), and colorectal cancer (819000 incident cases). The leading causes of cancer deaths and DALYs for women were breast cancer (601000 deaths and 17.4 million DALYs), TBL cancer (596000 deaths and 12.6 million DALYs), and colorectal cancer (414000 deaths and 8.3 million DALYs). Conclusions and Relevance: The national epidemiological profiles of cancer burden in the GBD study show large heterogeneities, which are a reflection of different exposures to risk factors, economic settings, lifestyles, and access to care and screening. The GBD study can be used by policy makers and other stakeholders to develop and improve national and local cancer control in order to achieve the global targets and improve equity in cancer care. © 2019 American Medical Association. All rights reserved.Peer reviewe