Propofol-Ketamine vs. Propofol-Fentanyl Combinations in Patients Undergoing Closed Reduction: A Randomized, Double-blind, Clinical Trial

Introduction: Painful surgical procedures require adequate sedation and analgesia. A vast array of medications can be used for Procedural Sedation and Analgesia (PSA) in Emergency Departments (EDs). Objective: The present study was conducted to compare Propofol-Ketamine (PK) and Propofol-Fentanyl (PF) compounds in patients undergoing closed reduction in EDs. Methods: This randomized, double-blind, clinical trial was conducted on 110 consecutive patients who required sedation for closed reduction. The patients were randomly divided into two groups of equal sizes. The PK group received an intravenous bolus of 1 mg/kg of propofol plus 0.5 mg/kg of ketamine, and the PF group received an intravenous bolus of 1 mg/kg of propofol plus 1 µg/kg of fentanyl. The analgesic effect and success rate were the primary outcomes under study. Results: The PK group achieved more effective analgesia at the end of the experiment. The success rate was almost the same in both groups Shivering (p=0.005) and a drop in oxygen saturation to below 92% (p=0.048) were two side effects that were more prevalent in the FK group . The mean recovery time was significantly shorter in the PK group (p<0.001). The patients in the PK group were more satisfied. Conclusion: In comparison with the PF compound, the use of KP leads to better pain relief and greater patient satisfaction and shorter sedation time in PSA

The Involvement of Drug Efflux System in Amikacin Resistance of Multiple Drug Resistant Acintobacter baumannii Isolates in Isfahan, Iran

Background: Due to the extensive usage of antibiotics in recent decades, the emergence of multiple drug-resistant (MDR) strains has dramatically increased. In the present study, we studied the distribution and involvement of drug efflux system in conferring resistance to amikacin in MDR isolates of Acinetobacter baumannii isolated from hospitalized patients. Methods: In this cross-sectional study 80 MDR A. baumannii were isolates isolated from hospitalized patients in Alzahra hospital, Isfahan, Iran. A. baumannii isolates were identified by standard microbiologic procedure and were confirmed by specific PCR primers. Minimum inhibitory concentration (MIC) was determined by agar dilution method according to CLSI guidelines. Carbonyl cyanide 3-chlorophenylhy­drazon (CCCP) was used as an efflux pump inhibitor for amikacin susceptibility. The presence of efflux genes was detected by PCR method. Results: Antibiotic susceptibility results showed that 39 of isolates had MIC ≥32 µg/mL and were amikacin-resistant. Totally, 41 isolates which had an amikacin MIC ≥2 μg/mL were tested for reduction of MIC in presence of 25 μg/mL efflux pumps inhibitor. After the treatment, 25 (61%) isolates had ≥2 fold and 15 (36.6%) isolates had 4 fold reduction in amikacin MIC. The results of PCR-amplifications indicated that the presence rate of AdeA, AdeB, AdeC, AbeM and AdeS genes were 100%, 96.3%, 95%, 98.8%, and 95%, respectively. Conclusion: In summary, significant involvement of drug efflux system in conferring resistance to amikacin along with high distribution of efflux genes suggests an alternative therapy using antibiotics in combination with efflux inhibitors in the fight against MDR isolates of A. baumannii

Intravenous Acetaminophen vs. Ketorolac in Terms of Pain Management in Prehospital Emergency Services: A Randomized Clinical Trial

Introduction: Although pain management in EDs has been fully addressed in clinical trials, prehospital settings have rarely been investigated. Objective: The present study was conducted to compare the effectiveness of intravenous acetaminophen with that of ketorolac in pre-hospital pain control. Method: This randomized clinical trial (RCT) was performed at a prehospital setting during EMS missions in Tehran, Iran. The eligible candidates comprised all patients over the age of 7 years with a complaint of moderate to severe pain. The patients were randomly assigned to two groups, one receiving 30 mg of intravenous (IV) ketorolac and the other 1 g of IV acetaminophen. The pain intensity was measured using a visual analog scale (VAS) before administering the analgesic and upon admission to the ED. Results: The present study was conducted on 150 patients aged 8-81 years with a mean age of 40.4 ± 17.7, including 84 (56%) males. The mean reduction in the pain score was 14.9±8.6 in the acetaminophen group and 16.0±8.8 in the ketorolac group. Univariate analyses suggested no statistically significant differences between the two groups in terms of delta pain score (pain reduction) (P=0.429). Conclusion: Based on the obtained findings, both ketorolac and acetaminophen could be administered for pain management in prehospital settings in both traumatic and non-traumatic patients in case their contraindications are considered

Screening performance of Ultrasonographic B-lines in Detection of Lung Contusion following Blunt Trauma; a Diagnostic Accuracy Study

Introduction: Chest ultrasonography is routinely used in evaluation of chest trauma for diagnosis of pulmonary injury. This study aimed to evaluate the accuracy of B-Lines for diagnosing lung contusion in patients with blunt trauma of the chest. Methods: Trauma patients who met the inclusion criteria were enrolled in the study and underwent ultrasonography by trained emergency medicine residents. Ultrasound results were recorded in terms of number of B-lines and the existence of peripheral parenchymal lesion (PPL). After ultrasound, the patient underwent chest x-ray and chest CT scan (as reference test) and screening performance of B-lines and PPL were evaluated.Results: 147 patients underwent chest ultrasound. The mean age of the patients was 40.74 ± 18.6 (78.9% male). B-lines˃3 had 94.0% (95% CI: 83.45-98.75) sensitivity and 57.7% (95% CI: 47.3-67.7) specificity, B-lines˃6 had 90.0% (95% CI: 78.2-96.7) sensitivity and 93.81% (95% CI: 87.0-97.7) specificity, and PPL had 34.0% (95% CI: 21.2-48.8) sensitivity and 100% (95% CI: 96.3-100.0) specificity. Composite findings of B-lines˃6 + PPL had 92.0% (95% CI: 80.8-97. 8) sensitivity and 93.8% (95% CI: 87.0-97.7) specificity in the diagnosis of lung contusion.Conclusion: PPL and B-Lines˃6 had the highest accuracy in detecting lung contusion. B-Line˃6 had high sensitivity and specificity and was easy to perform; thus, it seems that B-Line˃6 could be considered as an alternative screening tool in detection of lung contusion

Demographics of Scorpion Sting in Iran; a Cross Sectional Study

Introduction: Scorpion sting is an important public health problem in some countries, including Iran. This study aimed to describe the demographics of a large number of these victims in some endemic areas of Iran.Methods: This cross-sectional study evaluated baseline characteristics, clinical findings, management, and disposition of scorpion stung cases in 26 cities of 4 provinces in the southwest quarter of Iran, during one year. Results: 3008 cases of scorpion sting with mean age of 27.07 ± 16.58 years were studied (51.3% female). The mean time from sting to hospital was 1.89 ± 1.04 hours. No first aid measures had been taken in 96.6% of cases. Lower (39.5%) and upper (35.7%) extremities were stung most frequently. Midnight to 6:00 am was the period of time most of stings occurred (34.2%). Local pain (77.2%) and erythema (63.5) were among the most common signs and symptoms. 2026 (67.3%) victims had been discharged; 326 (10.8%) were admitted or referred to other hospitals and 5 (0.2%) cases died.Conclusion: It seems that demographic characteristics of scorpion sting in Iran are not so different from those reported from other sites of the world, as signs and symptoms of local and systemic envenomations. Victims, companions, and healthcare providers perform many futile and maybe harmful measures and there is a need to educate all about all of these details

Comparing the Outcome of Immobilizing Lower Limb Injuries Using Standard-Sized and Half-Length Short Leg Splints

Background: Soft tissue injuries (STIs) of lower extremities are considered as a very common complaint in those patients that were admitted to the emergency department. One of the main purposes in these patients' treatment strategies is early returning to work and regular activities. This study purpose was to compare the results of two lower limb (leg) splinting methods: standard-sized short leg splinting, and also half-sized short leg splinting. Methods: In this randomized controlled clinical trial research, we enrolled those patients with STI of the lower limb and without bone fracture. The setting was Haftom Tir trauma center and all patients signed the written consent before the study starting. We categorized participants into two groups: standard-sized short leg splint and halfsized short leg splint. The data were entered into SPSS 18 software and also were analyzed using that. Results: 300 patients were included in this study totally. The splinting complications were similar in two groups, but the splint fracture and skin burn frequency were significantly lower in half-sized short leg splint (p value <0.005). The mean score of pain and swelling frequency had no significant differences in both groups (P>0.005). Conclusions: The results indicated that the performance of standardsized and half-sized short leg splinting was similar in lower limbs STIs. The difficulties were less in half-sized short leg splint. Therefore, this study recommend that emergency physicians could consider half-sized short leg splinting in STIs, but the recommendation may be considered as valuable when this study results reassess in other clinical trials with multicenter researches and more sample size

Comparing the Outcome of Immobilizing Lower Limb Injuries Using Standard-Sized and Half-Length Short Leg Splints

Background: Soft tissue injuries (STIs) of lower extremities are considered as a very common complaint in those patients that were admitted to the emergency department. One of the main purposes in these patients' treatment strategies is early returning to work and regular activities. This study purpose was to compare the results of two lower limb (leg) splinting methods: standard-sized short leg splinting, and also half-sized short leg splinting. Methods: In this randomized controlled clinical trial research, we enrolled those patients with STI of the lower limb and without bone fracture. The setting was Haftom Tir trauma center and all patients signed the written consent before the study starting. We categorized participants into two groups: standard-sized short leg splint and halfsized short leg splint. The data were entered into SPSS 18 software and also were analyzed using that. Results: 300 patients were included in this study totally. The splinting complications were similar in two groups, but the splint fracture and skin burn frequency were significantly lower in half-sized short leg splint (p value <0.005). The mean score of pain and swelling frequency had no significant differences in both groups (P>0.005). Conclusions: The results indicated that the performance of standardsized and half-sized short leg splinting was similar in lower limbs STIs. The difficulties were less in half-sized short leg splint. Therefore, this study recommend that emergency physicians could consider half-sized short leg splinting in STIs, but the recommendation may be considered as valuable when this study results reassess in other clinical trials with multicenter researches and more sample size

Detection of circulating tumor cells using manually performed immunocytochemistry (MICC) does not correlate with outcome in patients with early breast cancer – Results of the German SUCCESS-A- trial

Background: Recently, the prognostic significance of circulating tumor cells (CTCs) in primary breast cancer as assessed using the Food-and-Drug-Administration-approved CellSearch® system has been demonstrated. Here, we evaluated the prognostic relevance of CTCs, as determined using manually performed immunocytochemistry (MICC) in peripheral blood at primary diagnosis, in patients from the prospectively randomized multicenter SUCCESS-A trial (EudraCT2005000490-21). Methods: We analyzed 23 ml of blood from 1221 patients with node-positive or high risk node-negative breast cancer before adjuvant taxane-based chemotherapy. Cells were separated using a density gradient followed by epithelial cell labeling with the anti-cytokeratin-antibody A45-B/B3, immunohistochemical staining with new fuchsin, and cytospin preparation. All cytospins were screened for CTCs, and the cutoff for positivity was at least one CTC. The prognostic value of CTCs with regard to disease-free survival (DFS), distant disease-free survival (DDFS), breast-cancer-specific survival (BCSS), and overall survival (OS) was assessed using both univariate analyses applying the Kaplan–Meier method and log-rank tests, and using multivariate Cox regressions adjusted for other predictive factors. Results: In 20.6% of all patients (n = 251) a median of 1 (range, 1–256) CTC was detected, while 79.4% of the patients (n = 970) were negative for CTCs before adjuvant chemotherapy. A pT1 tumor was present in 40.% of patients, 4.8% had G1 grading and 34.6% were node-negative. There was no association between CTC positivity and tumor stage, nodal status, grading, histological type, hormone receptor status, Her2 status, menopausal status or treatment. Univariate survival analyses based on a median follow-up of 64 months revealed no significant differences between CTC-positive and CTC-negative patients with regard to DFS, DDFS, BCSS, or OS. This was confirmed by fully adjusted multivariate Cox regressions, showing that the presence of CTCs (yes/no) as assessed by MICC did not predict DFS, DDFS, BCSS or OS. Conclusions: We could not demonstrate prognostic relevance regarding CTCs that were quantified using the MICC method at the time of primary diagnosis in our cohort of early breast cancer patients. Further studies are necessary to evaluate if the presence of CTCs assessed using MICC has prognostic relevance, or can be used for risk stratification and treatment monitoring in adjuvant breast cancer. Trial registration The ClinicalTrial.gov registration ID of this prospectively randomized trial is NCT02181101; the (retrospective) registration date was June 2014 (study start date September 2005)

Development of central nervous system metastases as a first site of metastatic disease in breast cancer patients treated in the neoadjuvant trials GeparQuinto and GeparSixto

Background: The incidence of central nervous system (CNS) metastases in breast cancer patients is rising and has become a major clinical challenge. Only few data are published concerning risk factors for the development of CNS metastases as a first site of metastatic disease in breast cancer patients. Moreover, the incidence of CNS metastases after modern neoadjuvant treatment is not clear. Methods: We analyzed clinical factors associated with the occurrence of CNS metastases as the first site of metastatic disease in breast cancer patients after neoadjuvant treatment in the trials GeparQuinto and GeparSixto (n = 3160) where patients received targeted treatment in addition to taxane and anthracycline-based chemotherapy. Results: After a median follow-up of 61 months, 108 (3%) of a total of 3160 patients developed CNS metastases as the first site of recurrence and 411 (13%) patients had metastatic disease outside the CNS. Thirty-six patients (1%) developed both CNS metastases and other distant metastases as the first site of metastatic disease. Regarding subtypes of the primary tumor, 1% of luminal A-like (11/954), 2% of luminal B-like (7/381), 4% of HER2-positive (34/809), and 6% of triple-negative patients (56/1008) developed CNS metastases as the first site of metastatic disease. In multivariate analysis, risk factors for the development of CNS metastases were larger tumor size (cT3–4; HR 1.63, 95% CI 1.08–2.46, p = 0.021), node-positive disease (HR 2.57, 95% CI 1.64–4.04, p < 0.001), no pCR after neoadjuvant chemotherapy (HR 2.29, 95% CI 1.32–3.97, p = 0.003), and HER2-positive (HR 3.80, 95% CI 1.89–7.64, p < 0.001) or triple-negative subtype (HR 6.38, 95% CI 3.28–12.44, p < 0.001). Conclusions: Especially patients with HER2-positive and triple-negative tumors are at risk of developing CNS metastases despite effective systemic treatment. A better understanding of the underlying mechanisms is required in order to develop potential preventive strategies