Advanced Journal of Emergency medicine
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Interferon beta-1a as a Candidate for COVID-19 Treatment; An Open-Label Single-Arm Clinical Trial
Get PDFIntroduction: Since December 2019, an outbreak of Covid-19 has caused growing concern in multiple countries. Researchers around the world are working to find a treatment or a vaccine for Covid-19 and different treatment approaches have been tested in this regard. Objective: This study was designed and conducted to assess the possible efficacy of Interferon beta-1a as a safe and efficient candidate for Covid-19 treatment. Methods: This is an investigator-initiated, open-label, single-arm clinical trial. Twenty patients with suspected Covid-19, who were admitted to Sina hospital in Tehran, Iran, with moderate to severe symptoms, from 6 to 10 March, 2020, were enrolled. Patients were treated with antiviral and hydroxychloroquine combination therapy, along with subcutaneous Interferon beta-1a for 5 consecutive days. Baseline characteristics and findings during the course of admission and 5 days after discharge were recorded for all the patients. Results: In total, 20 patients with suspected Covid-19 were included in this study, 12 (60%) of which were male. The median (Interquartile (IQ) range) of patients’ age was 55.5 (43-63.5). The most common symptom of the patients at onset of disease was fever. The median (IQ range) of duration of hospital stay was 5.0 (3-6) days. Only 2 cases were admitted to ICU. At the time of follow-up, 15 (94%) patients reported that they generally felt good and had oral tolerance, 1 patient had suffered from dyspnea, 5 patients had suffered from cough, none of them had experienced fever and no case of re-admission or death was reported after discharge. Conclusions: Results of the current study are in favor of using Interferon beta-1a in addition to recommended antiviral treatment in Covid-19 patients
Professional Resilience among Trauma Emergency Department Nurses in Iran: A Qualitative Study
Get PDFIntroduction: Nursing staff’s professional resilience plays an important role in overcoming the stressful and adverse situations common to the trauma emergency department and helps to achieve positive outcomes. Objective: This study intended to explore the concept of resiliency among Iranian trauma emergency department nurses. Methods: Data were collected using semi-structured interviews with 21 trauma emergency department nurses and analysed through a deductive content analysis based on the general conceptual model of resilience derived from King and Rothstein’s study. Results: All codes were nested into the four main categories of the above-mentioned model including: 1) Personal characteristics; 2) Opportunities, supports and resources; 3) Self-regulatory processes; 4) Positive outcomes. Some new sub-categories including Professional abilities (sub-category of Personal characteristics) and Cooperation with colleagues and Volunteers’ declaration of readiness (sub-categories of opportunities, supports and resources) were developed in this study. In the positive outcomes category, three sub-categories including Improved professional abilities, Personal growth, and Job retention were developed. Conclusion: Our results demonstrated that Iranian trauma emergency department nurses could achieve positive outcomes using specific affective, cognitive, and behavioural personality traits, professional abilities and effective external supports from different resources during self-regulatory processes. It is suggested that nurses should be selected for work in the emergency department based on appropriate characteristics and skills
Endotracheal Intubation of COVID-19 Patients
Get PDFThe novel coronavirus (COVID-19) emerged for the first time in China and then rapidly spread and swept the entire world like a tornado killing thousands of patients around the planet. People were advised to stay in-doors to prevent the spread of this deadly disease, and this slogan helped to a greater extent in containing the spread of the virus. Unfortunately, there is no treatment for the disease at present, but extensive research is going on to find a definitive treatment. Regarding endotracheal intubation (ETI) of COVID-19 patients, data are scarce and no randomized clinical trials are available to develop and formulate succinct and acceptable guidelines in tackling the problem of ETI in these highly risky and vulnerable patients
Three Tier Screening Tool and Second Triage to Minimize the Spread of COVID-19 in Emergency Department of a Tertiary Hospital in India
Get PDFIntroduction: Since the outbreak of Coronavirus on December 31, 2019 in Wuhan, Hubei Province, People’s Republic of China, the number of cases from China that have been imported into more than 180 countries and regions around the world. Objective: The goal of this study is to flatten the curve of new infection, through nosocomial transmission by health care system along with early identification of asymptomatic COVID-19 cases. Methods: A Survey was conducted over a period of 35 days. A total of 1709 individuals were screened (647 patients and 1062 patient attendees) coming to emergency Department. The waiting area of Emergency Care was divided into 3 screening zones and a separate second triage is established. The individuals entering are ensured that they are screened at all the 3 zones. Individuals were divided into two Groups after screening: Group A (suspected COVID-19) and Group B (unsuspected COVID-19). In Acute emergencies, the patient was directly treated at second triage. Results: A total of 1709 individuals, 247 in Group A (Suspected COVID-19) and 1462 in Group B (Unsuspected COVID-19). Among 247 individuals, 141 were males and 106 were females. Age ranged from 14-72 years with a mean age of 46.7years. Among 247 individuals (Group A), 81 were patients, of which one case was found to be COVID-19 Positive. Two Health care workers (HCW’s) found to be positive. Conclusion: Challenges from the widespread pandemic underscores the importance of early implementation of a second triage and vigorous screening for all the individuals to minimize the spread of infection, failing which pandemic infection may turn into an epidemic
Evaluation of Mother and Fetus after a Traumatic Event: An Overview
Get PDFTrauma due to accidents or violence is a common complication during pregnancies. Every woman in reproductive age who has been admitted due to trauma should be considered pregnant until proven otherwise. A multidisciplinary approach is usually warranted to optimize the outcome for both the mother and her fetus and some headlines should always be taken into consideration when dealing with a pregnant trauma patient. In major trauma, obstetrician consultation should be done as soon as possible. You should not delay indicated radiographic studies due to concerns regarding fetal exposure to radiation. It is preferable to perform one computed tomography (CT) scan with iodinated contrast rather than multiple suboptimal imaging procedures without contrast. Physiologic changes during pregnancy put injured pregnant woman at increased risk, necessitates special attention. In this paper we try to overview on some important aspects of a pregnant trauma patient management
Factors Contributing to the Containment of the COVID-19 in Kurdistan Region of Iraq
Get PDFA highly contagious coronavirus disease 2019 (COVID-19) is caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), which was first identified in Wuhan, China in December 2019. The virus primarily affects the respiratory system of human beings and results in the symptoms of headache, fever, dry cough, sore throat, shortness of breath and fatigue with abnormal chest computed tomography (CT) scan. In some cases, nasal sputum discharge and diarrhea have been also reported. Up to the 26th of April 2020, more than three million laboratory confirmed cases of COVID-19 have been recorded worldwide with more than 220,000 confirmed deaths. In the Kurdistan region of Iraq, the first case of laboratory confirmed COVID-19 was recorded in March 1st, 2020 in Sulaymaniyah province. 
The Prognostic Accuracy of Neutrophil-Lymphocyte Ratio in COVID-19 Patients
Get PDFIntroduction: COVID-19 is a newly emerging pandemic viral disease. Multiple management guidelines were introduced; nevertheless, their efficacy is still under debate. Thus, the presences of prognostic factors are essential for predicting which patients will need more invasive treatments. Objective: The study aims to investigate the prognostic accuracy of neutrophil-lymphocyte ratio in COVID-19 infection. Methods: This is a prospective study done in Al-Ain Hospital in the United Arab Emirates. All the Covid-19 patients presenting to the hospital were enrolled over 1 month from 20/3 to 20/4/2020. We gathered information about their age, sex, mode of transmission, and calculated their Neutrophils/Lymphocytes ratio (NLR) from the first complete blood picture on admission. We divided the patients into two groups: those whose age was 50 years and above and the those aged less than 50 years. We chose the best NLR cut-off value based on the Youden index and receiver operating characteristic (ROC) curve analysis and the target endpoint was presence or absence of intensive care unit (ICU) admission. Results: The study revealed that 48 patients (14%) needed ICU admission, while 296 patients (86%) were admitted to a ward or quarantine facilities. When the patient's age was > 50, and NLR was ≥ 3.10, it showed a sensitivity of 95.24% and a specificity of 92.86% for predicting the need for ICU admission. When NLR was ≥ 4.21, and the patient's age was < 50, the sensitivity and specificity were 70.3% and 93.7%, respectively. Conclusions: NLR proved to be highly specific and sensitive in helping to identify patients who need more invasive care among people over 50 years of age with COVID-19
Analgesic Effects of Ketamine Nebulizer vs. Intravenous Morphine in Limb Trauma Patients in Pre-Hospital Emergency Setting; A Randomized Double-Blinded Clinical Trial
Get PDFBackground: Limb trauma is one the main causes of emergency room (ER) referrals and patients often complain of pain from the very moment of arrival. Objective: We decided to compare the analgesic effect of ketamine nebulizer with intravenous (IV) morphine in trauma patients referred to ER. Methods: In this clinical trial study trauma patients referred to ER of Alzahra and Kashani hospitals in Isfahan, Iran were selected. All trauma patients older than 18 years with limb pain who had a pain score ≥ 7 based on visual analogue scale (VAS) criteria were included. During pre-hospital management, patients were divided into two groups of receiving ketamine nebulizer with a dose of 1.6 mg/kg and receiving IV morphine with a dose of 0.1 mg/kg. Pain score, vital signs and complications were recorded 5 and 15 minutes after receiving the first dose of drug and also at the time of arrival to ER. Results: Finally, the records of 391 patients were analysed. There was no significant difference between the two groups in terms of pain intensity, vital signs before intervention, the first 5 and 15 minutes after and the time of arrival in ER (P>0.05). But the changing of VAS scores in different times was significant in both groups (P<0.001). There was a significant difference between the two groups in complications including nausea and vomiting (P<0.001), and also delirium (P=0.010). Conclusion: Using ketamine nebulizer can produce similar analgesic effects as IV morphine in trauma patients referred to ER
Sample Size Calculation Guide - Part 7: How to Calculate the Sample Size Based on a Correlation
Get PDFIn the previous educational articles, we explained how to calculate the sample size for a rate or a single proportion, for an independent cohort study, for an independent case-control study, for a diagnostic test accuracy study, for a superiority clinical trial, and for a non-inferiority or equivalence clinical trial. In this article, we will explain how to calculate the sample size for a clinical study with the aim of detecting the correlation coefficient between two variables
Prophylactic Recommendation for Healthcare Workers in COVID-19 Pandemic
No full textDuring COVID-19 pandemic, it seems that healthcare workers (HWs) are more prone to the infection than general population. Indeed, a high viral load atmosphere and infected medical equipment are sources for spreading the disease. Many HWs should care for patients in the intensive care units (ICUs) which are one of the most contaminated areas. However, despite the adequate protections, HWs are still exposed to the coronavirus. Moreover, some procedures such as tracheal intubation increase the risk of infection. Overall, the probability of contamination in HWs is three times more than that of other people. According to Keshavan et al., about 3300 Chinese HWs have been infected by COVID-19, with a mortality rate of 0.4%. In Iran, we have a large number of affected HWs, with 69 registered deaths until late March 2020. Most of them were young with no previous medical history. So we have to improve protection and plan additional arrangements against COVID-19.
There are several mechanisms for the antiviral activity of hydroxychloroquine. This drug is a weak base that concentrates on the intracellular sections including endosome and lysosome; so, viral replication in the phase of fusion and uncoating will be stopped. Also, hydroxychloroquine can change the ACE2 glycosylation and inhibits both S-protein binding and phagocytosis. The last mechanism would be the suppressing effect on cytokine production and the immunomodulatory effect of the drug. Based on in-vitro studies of chloroquine on SARS-CoV-1, its effective role as a prophylactic agent and a post-infection treatment has been raised. According to another cell-culture study, the preventive effect of the drug is estimated to be 24 hours before and 5 hours after the contamination. The weekly dose of 500 mg chloroquine, which is used for malaria prophylaxis, will result in a concentration below the EC50, which is not enough for inhibition of the novel coronavirus. But the minimum dosage, which is used for rheumatoid arthritis treatment (250mg daily) will result in plasma concentrations higher than EC50, which may be sufficient in this regard. Regarding this pharmacokinetics and in-vitro investigations a double-blind, randomized, placebo-controlled trial using chloroquine as a prophylactic agent for SARS-CoV-2 infection is ongoing. The recommended dose is a loading dose of 10 mg/kg from base drug followed by 150 mg daily (250 mg chloroquine phosphate salt). Subsequently, the number of infected patients will be assessed after 3 months. Another running clinical trial is a phase III triple blinded one employing hydroxychloroquine with 200mg daily dose for 60 days and the outcome as well as the rate of symptomatic infected patients will be evaluated. There is also another ongoing study on hydroxychloroquine as a COVID-19 post-exposure prophylactic agent prescribed within 3 days of either a HWs or household contact. The recommended dose is 800mg once, followed by 600 mg during 6 to 8 hours, then 600mg once a day for 4 consecutive days. Finally, the rate and severity of COVID-19 infections are compared. The study could probably show that 200-400mg of hydroxychloroquine per day is a reasonable prophylactic regimen for the exposed HWs.
To be more precise, our experience on the rheumatologic patients who tool 200 mg per day hydroxychloroquine, as well as the medical workers who received the same dose for prophylaxis against the novel coronavirus showed that hydroxychloroquine with a 200 mg/day dose can have a relative prophylactic effect on COVID-19. According to our data, the few cases who received 200mg of hydroxychloroquine per day, showed mild to moderate symptoms with no severe manifestations. However, the prophylactic dose of 400mg per day may be accompanied by some drug interactions and adverse effects in the long term; so 200mg of hydroxychloroquine is a rational prophylactic dose for practitioners who are exposed to the high viral load environment