Description of a Working Day as a Senior Emergency Medicine Resident; Burning Candle at Both Ends!

This text is a real-time description of an emergency medicine resident’s shift in an overcrowded emergency department (ED), Tehran, Iran

Worsened Dysrhythmia after Chemical Cardioversion with Digoxin; a Case of Malpractice

The patient was a 23-year-old man referred to the emergency department (ED) with the chief complaint of palpitation. The patient experienced dizziness, cold sweating, and lightheadedness after getting up which started spontaneously. He had four episodes of the same problems in seven months ago that felt better after taking 10 mg propranolol. But, in the current episode his problem was not solved by the same medication. He had no history of smoking, substance abuse, medication use, congenital heart disease, syncope, previous surgery, chest trauma, or any other known medical problems. As well, he had no any positive history of the same problems in his family. The patients’ on-arrival vital signs were as follow: systolic blood pressure (SBP): 90 mmHg, pulse rate (PR): 150/minute, respiratory rate (RR): 14/minute, oral temperature: 37◦C, oxygen saturation 96% with nasal cannula and 100% oxygen, Glasgow coma scale (GCS) 15/15. He was not experienced any other concomitant problems such as ischemic chest discomfort, shortness of breathing, or sign of circulatory shock such as paleness, mottling, etc. On general physical examination the patients’ lung and heart sounds, four limbs pulses, and capillary refile were normal. As well, focused neurological and abdominal examinations did not have any positive finding. The patient underwent close cardiac, vital sign monitoring and electrocardiography (ECG). Figure 1 shows the on-arrival patients’ ECG. Atrial fibrillation (AF) was diagnosed by the corresponding physician and digoxin (!?) prescribed that led to severe lethargy, weakness, sweating, and bradycardia. Figure 2 shows the post mediation ECG of patient

Religious Tourism Development Strategies in Qom Province: Using and Comparing QSPM and Best Worst Methods

After Mashhad county, Qom province has the most valuable religious, cultural, historical and natural potential as the second Iranian pilgrimage centre. This study was conducted to formulate strategies for the development of religious tourism in Qom province using the most influential view of the strategy-formation process named design school. This school normally uses External Factor Evaluation (EFE) Matrix, Internal Factor Evaluation (IFE) Matrix, SWOT Matrix, QSPM matrix, and some other tools. The strengths, weaknesses, opportunities, and threats were determined using IFE and EFE matrices. The SWOT matrix was prepared and then the proper strategies for the development of religious tourism in Qom province (hold and maintain strategies or ST strategies) were determined using the Internal-External (IE) Matrix in the next step. Extracted ST strategies were prioritised using the QSPM and five strategies were proposed respectively. This study used the Best-Worst Method (BWM) to prioritise the created strategies in addition to QSPM this aims at developing strategic planning methodology. The results of the BWM were compared to the QSPM and the priority of the second and third strategies were modified. The priority of the first, fourth and fifth strategies is the same in the two methods. Moreover, the correlation coefficient between the results of the two methods was calculated. This shows a similarity of approximately 95 percent. So, it seems using the BWM method is more cost-effective than QSPM, due to saving time and cost

Evaluation of Non-emergency Cases Using Emergency Department Services

مقدمه: بخش اورژانس به منظور ارایه خدمت به بیمارانی طراحی شده که از نظر شرایط فیزیولوژیک ناپایدار بوده و نیاز به بررسی و درمان مداوم براساس سیر بیماری دارند. از این رو بخش عمده ای از مراقبتهای بحرانی برای بیماران نیز در این بخش انجام می گیرد. با این حال تعدادی از بیماران مراجعه کننده به این بخش نیازی به اینگونه خدمات ندارند. مطالعه حاضر با هدف بررسي علل استفاده موارد غیر اورژانس از خدمات بخش اورژانس طراحی و اجرا شد. روش کار: این مطالعه مقطعی در بخش اورژانس بیمارستان امام حسین، تهران، ایران، از مردادماه سال 1393 تا مرداد ماه سال 1394 انجام گرفت. نمونه گیری به روش سرشماری انجام شد و کلیه بیمارانی که در بخش اورژانس پذیرش گردیدند بر اساس الگوریتم دپارتمان اورژانس دانشگاه نیویورک به موارد نیازمند خدمات اورژانس و سایر موارد تقسیم شدند. مواردی که بر اساس نتایج بررسی ها علت مراجعه نوعی بیماری بوده که نیازمند اقدامات اورژانس درمانی نبوده و از نظر سطح تریاژ در سطح چهارم و پنجم قرار داشتند پس از تایید پزشک وارد مطالعه شدند. جمع آوری اطلاعات توسط یک پرستار آموزش دیده و از طریق یک چک لیست انجام گرفت. يافته ها: در مطالعه حاضر 1500 بیمار با میانگین سنی 34/17±0/40 سال وارد مطالعه شدند (47/54 درصد زن). در نهایت 601 (1/40 درصد) مورد مراجعه غیراورژانسی بر اساس تعاریف مطالعه حاضر شناخته شد. تجدید نسخه به دلیل مخدوش بودن (7/16 درصد) و در دسترس نبودن پزشک معالج (07/14 درصد) شایعترین علل مراجعات غیر اورژانس به بخش اورژانس بودند. نتيجه گيری: بر اساس یافته های مطالعه حاضر به نظر می رسد که حدود 40 درصد موارد مراجعه کننده به بخش اورژانس مرکز مورد مطالعه را موارد غیراورژانس تشکیل دادند. تجدید نسخه بدلیل مخدوش بودن و در دسترس نبودن پزشک معالج شایعترین علل مراجعات غیر اورژانس بودند. جنسیت، زمان و ساعت مراجعه و همچنین داشتن سابقه بیماری به عنوان متغیرهای موثر بر مراجعات غیراورژانس مشخص شدند (001/0>p).Introduction: Emergency department (ED) has been designed to provide services for patients that are physiologically unstable and need continuous evaluation and treatment according to the process of their illness. Therefore, a major part of critical care is provided for patients in this department. However, a number of patients visiting ED do not need these kinds of services. The present study was done aiming to evaluate the causes of non-emergency cases using ED services. Methods: This cross-sectional study was carried out in ED of Imam Hossein Hospital, Teran, Iran, from August 2014 to August 2015. Convenience sampling was used and all the patients admitted to ED were divided into groups of in need of emergency services and other, based on the algorithm of New York University ED. Cases that visited due to an illness that did not need emergency services based on the evaluations and were in levels 4 and 5 of triage were included in the study after approval of a physician. Data gathering was done by a trained nurse using a pre-designed checklist. Results: In the present study, 1500 patients with the mean age of 40.0 ± 17.34 years were evaluated (54.47% female). Finally, 601 (40.1%) cases were non-emergency visits based on the definitions of this study. Rewriting the prescriptions due to distortion (16.7%) and unavailability of their physician (14.07%) were the most common causes of non-emergency visits to ED. Sex, time of visit and positive past medical history were identified as variables influencing non-emergency referrals. Conclusion: Based on the findings of the present study, it seems that about 40% of visits to the studied ED were non-emergency cases. Rewriting the prescriptions due to distortion and unavailability of their physician were the most common causes of non-emergency visits. Sex and history of illness were found to be effective variables of non-emergency visits.

The potential prognostic and therapeutic application of tissue and circulating microRNAs in cervical cancer

Cervical cancer (CC) is a common malignancy in women and a major cause of cancer- related mortality globally. Some novel biomarkers may enable the early diagnosis and monitoring of CC. MicroRNAs are small noncoding RNAs that control gene translation at a post transcriptional level. Hence the deregulation of these molecules can cause many diseases. There appears to be an association between aberrant miRNA expression and CC, but the molecular mechanisms involved in the development of CC remain unknown. The upregulation of some circulating miRNAs, e.g. miRNA-20a, miRNA-203, miRNA-21, miRNA-205, miRNA-218, and miR-485-5, as well as tissue specific-miRNAs, e.g. miR-7, miR-10a, miR-17-5p, miR-135b, miR-149 and miR-203 has been found in patients with CC. There is also growing evidence for the importance of miRNAs in the development of drug-resistance. This review therefore highlights recently published preclinical and clinical investigation performed on tissue-specific and circulating miRNAs, as potential biomarkers for the detection of patients at early stages of CC, in the prediction of prognosis, and monitoring of their response to therapy. Key word: cervical cancer, CIN, MiRNA, circulating biomarker, tissue-specific biomarker, HP

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, 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