Silymarin as a Promising Potential Therapeutic Agent for Treatment of Patients with Paraquat Poisoning: An Issue that Merits Further Research

Having an extremely toxic compound for humans and most animals, paraquat (PQ) is known as one of the most frequently used herbicides. Accordingly, PQ poisoning has been recognized as a serious medical problem across the world, with a severe case fatality rate (CFR). In this respect; accidental or intentional ingestion of PQ, even in a small amount, can be significantly associated with poor clinical prognosis and increased mortality. Moreover; inherent toxicity of PQ, absence of specific antidotes, as well as lack of effective treatments have been principally attributed to high fatality of PQ poisoning. Once PQ is ingested, it can be absorbed through skin and the digestive and respiratory system and often progresses to multi-organ failure, particularly the lungs as the main target. In this respect, PQ accumulates predominantly in the lungs and can lead to lung fibrosis, pneumonitis, and consequently respiratory failure and death. Given the nonexistence of specific and widely accepted guidelines for treatment of PQ poisoning, a range of conservative therapeutic modalities have been proposed and administered by clinicians to moderate PQ absorption and to prevent organ failure in these patients. In spite of this, PQ-induced mortality rate is high and disappointing

Future Direction of Emergency Medicine Research; Can We Overcome the Difficulties and Fill in Knowledge Gaps?

Pace of medical research development heralded an escalation in recent years. Groundbreaking evidences have been provided for managing dyslipidemia in 2017. Beside statins, alternatives of Anti PCSK-9 monoclonal antibodies in human and AT04A anti PCSK-9 vaccine in mice have shown to significant decrease in total cholesterol level. Wonderful! Apart from this, dual pathway inhibition by using aspirin with very low dose Rivaroxaban has been shown to be more effective in mitigating ischemic event rate than aspirin alone in patients with stable coronary artery disease or peripheral artery disease. Furthermore, patients with atrial fibrillation undergo percutaneous coronary intervention will benefit more from double antithrombotic therapy than triple one. Besides, a novel risk score of PRECISE-DAPT has determine the optimal duration of antiplatelet therapy in patients implanting coronary stents; and many other medical research advances which grabs our attention on 2018.  In order to translate recent advances in medical research into clinical practice we need to design, conduct and apply high quality research in different medical subspecialties. The emergency medicine (EM) environment defined as overburdened with inability to afford more than a few minutes per patients. Where, time for research might be considered as a potential risk of interruption in clinical practice. EM is a broad field involving multiple disciplines and crosscutting themes with the unique features in research including urgency and location of the treatment. Art of research in EM comprises hybridization of clinical research, basic science and health services research. Accordingly, research priority setting should be put forwarded based on these three areas, examining existing gaps in EM knowledge, system design issues, educational predicament and disparities between diagnostic skills and clinical decisions. Where the most appropriate research questions arise? Definitely, it comes from critical thinking in patient care setting, regular reading habit, teaching, journal clubs, collaborations and society. To alleviate the issue of immense question and limited time in EM field which tangles decision makers mind we recommend to prioritize questions in line with; patients well- being, learners need, feasibility to answer, inquiries that most likely to recur in your practice and most interesting foreground research query. A research need has been defined as a gap in existing knowledge on practice, learner‚s education, patient values and societal demands. To examine the gaps in EM research knowledge we can provide research time and facilities, training new investigators, develop multicenter research networks, improve research coordination and involving funding agencies to make practical attempts for filling pre specified gaps. In conclusion, since patient oriented outcome research will provide us with the most important endpoints for clinical policy making and patient care standard setting, I totally agree with the advocates of involving stakeholders including clinicians, society and patients in EM research process to mitigate the existence knowledge gaps for dedicating high quality EM car

The Current Status of Genes and Genetic Testing in Emergency Medicine: A Narrative Review

Context: An emergency is any medical problem that could cause death or permanent injury if not treated quickly. In some occasions, the kind of urgent intervention depends on patient’s exact genetic background. Unfortunately, the importance of genes in medical emergencies has been forgotten in recent decades. Evidence acquisition: In order to find relevant articles, we searched two databases of Pubmed and Embase. The exact words of “genes”, “genetics”, “epigenetics”, “DNA”, and “emergency” were used alone and in combination. All studies like randomized clinical trials (RCT), case/controls, case series, case reports, and review articles were studied to find the related data. No time limitation was considered for the studies. Results: Several aspects of genetic testing are newly considered in emergency departments including cell-free DNA (cfDNA) for disease diagnosis, pharmacogenetics for decreasing the adverse drug effects, and personalized medicine for exact emergency interventions in diseases like Vascular Ehlers-Danlos syndrome (vEDS). Data from genetic testing and genome wide association studies have yielded promising results to make medical emergency interventions more beneficial in the near future. Conclusion: Taking everything into consideration, several advanced genetic and epigenetic alteration technologies can change emergency medicine for the better. Personalized genetic data of patients can turn emergency medicine to personalized medicine

Bidirectional Ventricular Tachycardia in a Women with Dilated Cardiomyopathy: A Case Report

Introduction: Bidirectional ventricular tachycardia (BVT) is a rare arrhythmia characterized by QRS complexes with an axis in the frontal plane alternating polarity in the precordial leads and right bundle branch block (RBBB) morphology. To the best of our knowledge, there is no previous report in dilated cardiomyopathy or in the context of a probable peripartum cardiomyopathy. Case Presentation: A 26-year-old, 9-month female patient, with no significant past medical history (the patient denies medication intake, herbs like aconite, trouble during delivery, any heart issues or family history of sudden death or cardiomyopathies) who presents to the emergency room due to 11 days of dyspnea, exacerbated by daily activities, orthopnea, and paroxysmal nocturnal dyspnea. She presented with ventricular bigeminy and systolic dysfunction with left ventricular ejection fraction (LVEF) <20%. The patient later developed a stable ventricular tachycardia (VT) treated with amiodarone, which resulted in hemodynamic instability and BVT rhythm with VT paroxysms. Without the possibility of ablation, the use of high dose beta blockers and an implantable cardioverter defibrillator resulted in the same rhythm with a lower heart rate, better NYHA functional class, and less episodes of VTs. Conclusion: BVT is a rare type of tachycardia that can be present in dilated cardiomyopathy. In the absence of ablation capabilities, decreasing the heart rate with beta-blockers may reduce the rate of paroxysmal VTs

Prospective Evaluation of Safe Observation Period after Asymptomatic Penetrating Thoracic Injury: 1 Hour is Enough

Introduction: The observation period was recently challenged by some studies; and it has been suggested that a 1-hour observation period may be sufficient to allow safe discharge in asymptomatic patients with penetrating thoracic injury (PTI) and normal initial Chest X-Ray (CXR). Objective: The current study was performed to investigate if in asymptomatic and hemodynamically stable patients with PTIs who has an initial normal evaluation, 1-hour observation interval is safe to detect clinically significant injuries and is it possible to discharge these patients safely after a negative Extended – Focused Assessment with Sonography in Trauma (E-FAST) at hour1 instead of hour 3. Method: This cross-sectional study was performed on asymptomatic patients with penetrating thoracic injury, referred to emergency department (ED) and normal initial CXR and the Extended Focused Assessment with Sonography in Trauma (E-FAST). The second E-FAST was done 1 hour after the first one and the third repeat E-FAST and control CXR then performed 3 hours post-injury. 24 hours follow up by phone call was done for each patient after discharge. Results: Finally, 117 patients with the average ages of 25.9 ± 7.8 years were enrolled of whom 92.5% were male. Eight patients developed PTX or HTX during first hour of observation that were diagnosed by E-FAST or CT scan requested by the in-charge physician. One hundred-nine patient completed E-FAST and radiograph studies at times zero, 1 h, and 3 h. One patient had a normal initial evaluation but demonstrated a PTX on the 3-h managed without intervention. The rate of delayed abnormality after an initially normal study was 7.7 % (9/117). No discharged patients returned to our ED with delayed manifestations of either PTX or HTX. Conclusion: The results of our study have shown that asymptomatic patients with PTI with negative initial evaluation and no deterioration at intervals, about 1 hour may be sufficient for detection of clinically significant pathology, considered for safe and early discharge

An 85-year-old Woman with Altered Mental Status and Hypotension

An 85-year-old female patient was brought to emergency department (ED) from a nursing home with altered mental status (GCS: 12/15) and hypotension (90/60 mmHg). Bilateral fine crackles in lungs and severe cachexia were obvious in her physical examination. The ECG showed only sinus tachycardia. Several attempts at peripheral vein cannulation failed due to poor visualization of severely atrophied and contracted subcutaneous veins. Therefore, on two attempts, a central venous catheter (CVC) was inserted into the right internal jugular vein (IJV) using the Seldinger technique. After securing and taping the central line, fluid infusion started with no difficulty and a portable chest x-ray was ordered

Sample Size Calculation Guide - Part 4: How to Calculate the Sample Size for a Diagnostic Test Accuracy Study based on Sensitivity, Specificity, and the Area Under the ROC Curve

In the previous educational articles, we explained how to calculate the sample size for a rate or a single proportion (part 1), for an independent cohort study (part 2), and for an independent case-control study (part 3). In this article, we will explain how to calculate the sample size for a diagnostic test accuracy study based on sensitivity, specificity, or the area under the ROC curve