Pain Management via Ultrasound-guided Nerve Block in Emergency Department; a Case Series Study

Introduction: Pain is the most common complaint of patients referring to emergency department (ED). Consideringthe importance of pain management in ED, this study aimed to investigate the efficacy and feasibility ofultrasound-guided nerve blocks in this setting. Methods: 46 patients who came to the ED with injured extremitieswere enrolled in the study and received either femoral, axillary or sciatic nerve block depending on theirsite of injury (1.5 mg Bupivacaine per kg of patient’s weight). Patients were asked about their level of pain beforeand after receiving the nerve block based on numerical rating scale. The difference between pre and post blockpain severity was measured. Both patients and physicians were asked about their satisfaction with the nerveblock in 5 tiered Likert scale. Results: 46 patients with the mean age of 37.5 § 12.5 years (8-82 years) receivedultrasound-guided nerve block (84.8% male). 6 Sciatic, 25 axillary, and 15 femoral nerve blocks were performed.Mean pain severity on NRS score at the time of admission was 8.1 § 1.4, which reduced to 2.04 § 2.06 after block.25 (54.3%) patients were highly satisfied (Likert scale 5), 15 (32.6%) were satisfied (Likert scale 4), 3 (6.5%) wereneutral and had no opinion (Likert scale 3), 1 (2.1%) was not satisfied (Likert scale 2), and 2 (4.3%) were highlyunsatisfied (Likert scale 1). There was no significant difference among the satisfaction scores within the threeblock locations (p = 0.8). There was no significant difference in physicians level of satisfaction between the threeblock locations either (p = 0.9). 1 (2.1%) case of agitation and tachycardia and 1 (2.1%) case of vomiting wereobserved after the procedure. Conclusion: Ultrasound-guided nerve block of extremities is a safe and effectivemethod that can be used for pain management in the ED. It results in high levels of satisfaction among bothpatients and physicians

Clinical Recommendation for Emergency Physicians to Approach to Signs and Symptoms Related to COVID-19; a Preliminary Study

Introduction: There is not enough and comprehensive evidence on signs and symptoms of COVID-19; therefore, it seems too early to provide an appropriate clinical decision-making rule for this newly emerged pandemic viral disease. Objective: We tried to categorize patients’ signs and symptoms from very highly suspected to non-suspected, regarding having COVID-19. Methods: Most recently published English-language articles on COVID-19, were reviewed by the researchers. We considered each complaint, separately, and gathered available data, such as percentage of involved patients and their crude number. Then we considered the pooled and collected results as the final percentage of the occurrence of every specific symptom. We categorized patients’ complaints into six types, based on the data obtained. All extracted complaints were categorized and scored. Results: Twenty-seven articles were reviewed, of which, 12 considered for analysis. The selected papers had reported various numbers of patients, ranging from 16 to 1,099 patients (mean=229 patients per study). In total, nineteen different complaints, with an average of nine complaints per article, had been reported (IQR= 8-11). In terms of overall prevalence, based on the total number of patients, fever and dry cough were reported in more than half of the referred patients. The complaints were categorized in six types with and scored. Conclusions: The patients with score ≥17 are very highly suspected to COVID-19; However, patients with score <5 could be considered as non-suspected to COVID-19

Specialist Physicians’ Attitude towards Emergency Medicine; a Semi-Structured Qualitative Study

Introduction: The present study is a survey to assess the pros and cons of emergency medicine (EM) from the viewpoint of the scholars from other medicine disciplines to improve the efficiency of EM in the healthcare system. Methods: This is a semi-structured qualitative study. Face-to-face interviews with various physicians with different specialties were performed to gather information on their viewpoints. Study population was selected mainly based on their history of collaboration with emergency medicine specialists in several educational hospitals in Tehran, Iran. All interviews were recorded and then transcribed to paper. Data were mainly categorized and reported into four themes: 1) general aspects of emergency medicine, goals and policies 2) Management of emergency department 3) Educational aspects 4) therapeutic aspects. Results: 22 specialist physicians with the mean age of 47.3±7.6 years were studied (77.3% male). The average of their work experience as a specialist was 13.6±7.5 years. From the viewpoint of other experts, the establishment of EM and training of EM specialists is accompanied with relative disadvantages and advantages regarding goals and policies, patient management, therapeutic interventions and student education in the emergency department. Initiating resuscitation and maintaining hemodynamic stability and appropriate triage of the patients can add to the benefits of EM by preventing unreasonable hospitalization, and reducing the workload and difficulty of the work of other professionals working in the hospital. Conclusions: Based on the results of the current study, it seems that most Iranian specialist physicians have a positive attitude towards emergency medicine and think that emergency medicine could have beneficial effects for the health system and hospital management system

Two Different Endotracheal Tube Securing Techniques: Fixing Bandage vs. Adhesive Tape

Introduction: Emergency physicians should secure Endotracheal tubes (ETT) properly in order to prevent unplanned extubation (UE) and its complications. Despite various available endotracheal tube holders, using bandages or tape are still the most common methods used in this regards. Objective: This study aimed to compare adhesive tape (AT) versus fixing bandage (FB) method in terms of properly securing ETT. Methods: This was an observational longitudinal trial. All patients older than 15-years-old admitted to the ED who had indication for ETT insertion were eligible. Patients were randomly assigned to one of the two groups in which AT or FB was applied. All patients were observed thoroughly in the first 24 hours after intubation. Using a pre-prepared checklist, encountered UE rate and other data were recorded. Results: Seventy-two patients with the mean age of 55.98 ± 18.39 years were finally evaluated of which 38 cases (52.8%) were male. In total, 12% of patients in our study experienced unplanned extubation. Less than 12% of the patients experienced complete UE; there was no statistically significant difference between the two groups (p = 0.24). Comparison of UE with age showed no significant difference (p = 0.89). Male patients experienced more UE, but this was not statistically significant (p = 0.44). Conclusion: It is likely that whether the AT method or FB was applied for securing the ETT in emergency departments, there was no significant difference in rates of unplanned extubation

Mainstreaming road safety in the regional integration of the East African Community to reduce road traffic injuries

The East African Community (EAC) comprising of five states: Burundi, Kenya, Rwanda, Tanzania and Uganda bear a disproportionate burden of the global public health burden for road traffic injuries (RTIs). In response to this, each state has devised its own road safety measures, but not at the EAC level. This paper aims to explore how differing road safety policies could be aligned as part of EAC regional integration so that they become one mainstream policy in the EAC. This is done after exploring the rate of RTIs; the existing road safety initiatives; and the impact of RTIs on the EAC integration in the four EAC states excluding Burundi. A desk-based review of data and information from different sources between 2009 and 2015 for Kenya, Rwanda, Tanzania and Uganda was conducted. This revealed that the rate of RTIs in the four EAC states significantly exceeds the African and global average rates. This is associated with large numbers of fatalities, debilitating injuries and economic costs which hamper the EAC integration–especially its main pillar of a common market. All the four states have independently adopted different road safety laws and policies in line with the United Nations Decade of Action for Road Safety initiative. A unified road safety policy and road safety lead agency for the EAC as a whole is urgently needed. This should be based on cooperation and commitment, and take into account the region’sgeopolitical dynamics.Keywords: Road safety, road traffic injuries, regional integration, East African Communit

Prioritized Criteria for Casualty Distribution following Trauma-related Mass Incidents; a Modified Delphi Study

Introduction: In the aftermath of mass casualty incidents (MCIs), many decisions need to be made in a fast and influential manner in a high pressure environment to distribute the limited resources among the numerous demands. This study was planned to rank the criteria influencing distribution of casualties following trauma-related MCI. Methods: This study utilized a modified Delphi methodology, concentrating on extracted criteria attained from preceding systematic literature reviews. The 114 extracted criteria were classified into eight sections including space, staff, equipment, system and structures, triage, treatment, transport, and uncategorized criteria and were imported into an online survey tool. In the first round, experts were asked to rank each criterion on a five-point Likert scale. The second round incorporated feedbacks from the first round, stating percent and median scores from the panel as a whole. Experts were then called upon to reassess their initial opinions regarding uncertain remarks from the first round, and once again prioritize the presented criteria. Results: Fifty-seven criteria were regarded as relevant to the following sections: space: 70% (7/10); staff: 44% (4/9); system / structure: 80% (4/5); equipment: 39.1% (9/23); treatment; 66.7% (6/9); triage: 73.7% (14/19); transport: 38.7% (12/31) and other sections: 12.5% (1/8). The first round achieved nearly 98% (n=48) response rate. Of the 114 criteria given to the experts, 68 (almost 60%) were approved. The highest percentage of approval belonged to the system and structures sections (4/5=80%). The response rate for the second round was about 86% (n=42). A consensus could be reached about nearly 84% (57) of the 68 criteria presented to experts. Conclusion: "Casualty Level of Triage on the Scene" and "Number of Available Ambulances" were the two criteria that obtained the highest level of consensus. On the other hand, "gender of casualty", "Number of Non-Medical staff in each Hospital" and "Desire to transport family members together" got lowest level of consensus. This sorted list could be used as a catalogue for developing a decision support system or tool for distribution of victims following mass casualty incidents. KEYWORDS:Mass casualty incidents; decision making; supply and distribution; wounds and injurie

Outcome-Based Validity and Reliability Assessment of Raters Regarding the Admission Triage Level in the Emergency Department: a Cross-Sectional Study

Introduction: Emergency department (ED) is usually the first line of healthcare supply to patients in non-urgent to critical situations and, if necessary, provides hospital admission. A dynamic system to evaluate patients and allocate priorities is necessary. Such a structure that facilitates patients’ flow in the ED is termed triage. Objective: This study was conducted to investigate the validity and reliability of implementation of Emergency Severity Index (ESI) system version 4 by triage nurses in an overcrowded referral hospital with more than 80000 patient admissions per year and an average emergency department occupancy rate of more than 80%. Method: This prospective cross-sectional study was conducted in a tertiary care teaching hospital and trauma center with an emergency medicine residency program. Seven participating expert nurses were asked to assess the ESI level of patients in 30 written scenarios twice within a three-week interval to evaluate the inter-rater and intra-rater reliability. Patients were randomly selected to participate in the study, and the triage level assigned by the nurses was compared with that by the emergency physicians. Finally, based on the patients’ charts, an expert panel evaluated the validity of the triage level. Results: During the study period, 527 patients with mean age of 54 ± 7 years, including 253 (48%) women and 274 (52%) men, were assessed by seven trained triage nurses. The degree of retrograde agreement between the collaborated expert panel’s evaluation and the actual triage scales by the nurses and physicians for all 5 levels was excellent, with the Cohen’s weighted kappa being 0.966 (CI 0.985–0.946, p < 0.001) and 0.813 (CI 0.856–0.769, p<0.001), respectively. The intra-rater reliability was 0.94 (p < 0.0001), and the inter-rater reliability for all the nurses was in perfect agreement with the test result (Cohen’s weighted kappa were as follows: 0.919, 0.956, 0.911, 0.955, 0.860, 0.956, and 0.868; p < 0.001). Conclusion: The study findings showed that there was perfect reliability and, overall, almost perfect validity for the triage performed by the studied nurses

Outcome-Based Validity and Reliability Assessment of Raters Regarding the Admission Triage Level in the Emergency Department: a Cross-Sectional Study

Introduction: Emergency department (ED) is usually the first line of healthcare supply to patients in non-urgent to critical situations and, if necessary, provides hospital admission. A dynamic system to evaluate patients and allocate priorities is necessary. Such a structure that facilitates patients’ flow in the ED is termed triage. Objective: This study was conducted to investigate the validity and reliability of implementation of Emergency Severity Index (ESI) system version 4 by triage nurses in an overcrowded referral hospital with more than 80000 patient admissions per year and an average emergency department occupancy rate of more than 80%. Method: This prospective cross-sectional study was conducted in a tertiary care teaching hospital and trauma center with an emergency medicine residency program. Seven participating expert nurses were asked to assess the ESI level of patients in 30 written scenarios twice within a three-week interval to evaluate the inter-rater and intra-rater reliability. Patients were randomly selected to participate in the study, and the triage level assigned by the nurses was compared with that by the emergency physicians. Finally, based on the patients’ charts, an expert panel evaluated the validity of the triage level. Results: During the study period, 527 patients with mean age of 54 ± 7 years, including 253 (48%) women and 274 (52%) men, were assessed by seven trained triage nurses. The degree of retrograde agreement between the collaborated expert panel’s evaluation and the actual triage scales by the nurses and physicians for all 5 levels was excellent, with the Cohen’s weighted kappa being 0.966 (CI 0.985–0.946, p < 0.001) and 0.813 (CI 0.856–0.769, p<0.001), respectively. The intra-rater reliability was 0.94 (p < 0.0001), and the inter-rater reliability for all the nurses was in perfect agreement with the test result (Cohen’s weighted kappa were as follows: 0.919, 0.956, 0.911, 0.955, 0.860, 0.956, and 0.868; p < 0.001). Conclusion: The study findings showed that there was perfect reliability and, overall, almost perfect validity for the triage performed by the studied nurses

Transcranial Direct Current Stimulation Improves Executive Dysfunctions in ADHD: Implications for Inhibitory Control, Interference Control, Working Memory, and Cognitive Flexibility

Objective: This study examined effects of transcranial direct current stimulation (tDCS) over the DLPFC and OFC on major executive functions (EFs) including response inhibition, executive control, working memory, and cognitive flexibility/task switching in ADHD. Methods: ADHD children received (a) left anodal / right cathodal DLPFC tDCS and (b) sham stimulation in experiment one and (a) left anodal DLPFC / right cathodal OFC tDCS (b) left cathodal DLPFC / right anodal OFC tDCS and (c) sham stimulation in experiment two. The current intensity was 1 mA for 15 min with a 72-hr interval between sessions. Subjects underwent Go/No-Go task, Nback test, WCST and Stroop task after tDCS. Results: anodal lDLPFC tDCS most clearly affected executive control functions (e.g., WM, interference inhibition), while cathodal lDLPFC tDCS improved inhibitory control. Cognitive flexibility/task switching benefited from combined DLPFC-OFC, but not DLPFC stimulation alone. Conclusion: Task specific stimulation protocols can improve EFs in ADHD

A variant in CYP2R1 predicts circulating vitamin D levels after supplementation with high-dose of vitamin D in healthy adolescent girls

Aim The determinants of serum vitamin D seems to be the environmental factors (dietary and supplementary intake and exposure to ultraviolet light) and genetic factors. We aimed to study the relationship between a vitamin D‐associated genetic polymorphism and serum 25(OH)D concentrations in healthy adolescent girls in Iran, and its effects on a high‐dose supplement of vitamin D. Material and method A total of 616 healthy adolescent girls with mean age 15 received 50,000 IU of vitamin D3 weekly over 9 weeks. Serum vitamin D levels and other metabolic factors were measured at baseline and after the intervention. The genotyping of the CYP2R1 variant (rs10741657) was performed by TaqMan genotyping assays. Results Regardless of the genetic background, at baseline, 87% of adolescent girls were vitamin D deficient (serum 25(OH)D level < 50 nmol/l). High‐dose supplementation with VitD reduced the proportion of girls who were deficient substantially to about 24%. The genetic analysis revealed that although at baseline there was not a gene‐vitamin D association ( p trend = 0.1), the response to supplementation appeared to be modulated by this variant ( p trend < 0.001). However, other anthropometric and biochemical measures were not affected by this intervention, over this short period. Serum 25(OH)D was increased in all participants although the carriers of the minor A allele seemed to be better responders so that the percentages of the change serum vitamin D in the holder of AA and AG genotypes were 539.4 ± 443.1 and 443.7 ± 384.6, respectively, compared with those with common GG genotype (363.3 ± 354.0). Our regression analysis revealed that the probability of an increase in serum 25(OH)D in a participant with AA genotype was 2.5‐fold greater than those with a GG genotype (OR = 2.5 (1.4–4.4); p value = 0.002). Conclusion Based on our findings, it appears that the rs10741657 variant of the CYP2R1 gene modulates the response to high‐dose of vitamin D supplementation