Frontiers in Emergency Medicine (E-Journal)
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Evaluating the diagnostic efficacy of 12-point lung ultrasound in detecting COVID-19 lung lesions: a comparative study with low-dose chest CT scan
Get PDFObjective: Chest computed tomography (CT) scans are the gold standard for identifying pulmonary involvement in pneumonia-like COVID-19 cases, albeit with certain drawbacks such as radiation exposure and high costs. This research aims to evaluate the diagnostic precision of a 12-point lung ultrasound (LUS) against a low-dose chest CT scan in identifying lung lesions associated with COVID-19. Methods: The study incorporated 100 consecutive patients, aged over 18 years, exhibiting suspected clinical symptoms of COVID-19 or inpatients requiring a low-dose chest CT scan for diagnosing asymptomatic COVID-19 lung lesions. All participants underwent a 12-point LUS, followed by a low-dose chest CT scan. Data analysis was conducted using STATA-16, with descriptive results presented as mean and standard deviation. Results: The study comprised 60 males and 40 females, with an average age of 43.0±16.9 years. The mean distribution of the patients' clinical features was calculated. The LUS demonstrated a sensitivity, specificity, and positive and negative predictive values of 97.5%, 86.4%, 83.3%, and 98%, respectively. Conclusion: The 12-point LUS exhibited high sensitivity and specificity in assessing pulmonary involvement in COVID-19 patients. Therefore, lung ultrasound results, combined with medical history and clinical examination, can serve as an effective triage tool for COVID-19 patients. The LUS, a swift, safe, and effective ionization tool, can potentially replace chest CT scans in scenarios such as CT scan unavailability, intensive care management, and patient follow-up
A rare case in emergency department: intracranial dermoid cyst rupture
Get PDFIntracranial dermoid cysts (IDC) are rare cystic lesions that are present from birth. After rupture of these cysts, patients may present to the hospital with ischemic cerebral symptoms, headaches, seizures, syncope, and meningitis. Brain magnetic resonance imaging (MRI) is the most sensitive radiologic method in the diagnosis of IDC rupture, which has a high mortality rate. Patients should be rapidly evaluated for surgery if a symptomatic and ruptured cyst is detected. In this presentation, we aimed to describe the diagnosis and treatment of IDC in a 23-year-old male patient brought to the emergency department after syncop
Causes and outcomes of hypotonia: a cross-sectional study of children admitted to a pediatric intensive care unit
Get PDFObjective: Hypotonia in children is an important and common clinical symptom that can manifest in various neurological disorders. It often poses a serious diagnostic challenge for physicians, frequently leading to inaccurate evaluations and unnecessary investigations. The purpose of this study was to investigate the causes of hypotonia, various diagnostic methods, and the final outcomes of these patients. Methods: Children with hypotonia who were hospitalized in the pediatric intensive care unit (PICU) of Bahrami Children's Hospital and Children's Medical Center during a two-year period (2017-2018) were enrolled. All relevant information, including key points from their medical history, clinical examinations, and paraclinical data that could lead to diagnosis, were recorded. The patients was followed up for two years after hospitalization through phone calls or visits to the neurology clinic. Results: Out of 65 children examined, 28 patients (43.07%) had peripheral nervous system involvement, 20 (30.76%) had central nervous system involvement, and 4 (6.17%) had both central and peripheral nervous system involvement. The most common causes for peripheral and central involvement were spinal muscular atrophy (SMA) and syndromic causes, respectively. In 20% of cases however an, specific underlying cause was found. The most common diagnoses were SMA (16.9%) and Guillain-Barre syndrome (13.8%). Finally, 15 children (23.1%) recovered, 31 (47.7%) had neurological sequelae, and 19 (29.2%) died. Conclusion: Understanding the underlying causes and outcomes of patients hospitalized with hypotonia in the PICU enhances physicians’ diagnostic skills. It is also useful for selecting effective treatment strategies and avoiding the complications associated with delayed diagnosis
Love protects us; we should take care of it
Get PDFFive years of work as emergency physician (EP) in some of the busiest hospitals in a developing country has never been an exhausting experience for me. In fact, my immense passion for this job has brought me happiness even amidst the most challenging shifts. There has been, however, instances of extraordinary difficulty, which have long stuck in my mind. One of those occasions was the time when, at the end of an already tough shift, my middle-aged patient died despite our team’s efforts. At that very moment, I assumed that it would not be possible for me to survive from my terrible feelings this time. Nevertheless, just in a couple of days, I was prepared for my next shift. I wondered what helped me recover so early. I knew that loving my job had rescued me. However, many questions engaged my mind. What was the origin of this passion?
I have had the privilege of working with passionate, responsible physicians whose primary goal in life was caring for patients. This experience encouraged me to take pleasure in my struggle to improve my clinical practice. I should also humbly admit that plenty of medical students have gained the same attitude and insight from working with me.
The reputation of the experience of “love transmission” augmented somewhat the hypothesis of its origin. But what will be the consequences of that? Will the resilience and hardiness remain in the future or cause dropping out of my job earlier than normal?
A rapid review of the medical literature revealed only a few papers dealing with the role of love in medicine, none specifically pertaining to the realm of emergency medicine. Some studies investigated love in terms of biology. Tobias et al. evaluated central nervous system activity in response to love. They showed that love could activate the limbic structure which could in turn result in reduction of stress and improving health, well-being and productivity. Dr. Marcum defined the concept of “prudent love” by a philosophical analysis method in 2011. He maintains that wisdom in combination with the emotion of love can work synergistically and result in a better outcome. In other words, a physician with prudent love tries constantly with pleasure to gain more and the best knowledge and skill for caring of patients (i.e., more wisdom). A positive cycle will exist among the experience in mind and the pleasure in heart. This pleasure could heal a tired healer. Such physicians with prudent love not only will treat more effectively their patients, but will also feel more long-term wellness in their career, and perhaps even more longevity.In summary, I believe EPs deserve a quality of life better than what is achieved through just struggling with difficulties and fighting against burnout. An EP who loves his job, has a different perception of inevitable occupational stresses, because love can create a mindset that views sad events and even failures as opportunities which motivates him instead of causing disappointment and tiredness. However, we are human beings and unwanted stress will inevitably occur. In these circumstances, such EPs will find out the best coping strategy to react to them properly in a way that would prevent from entrapment in the vicious cycle of burnout. I acknowledge that, at present, these remarks remain vague, poetic, and non-pragmatic. They need to be operationalized in the form of transferrable skills. Therefore, I think the topic of love in this context is an untouched area that merits further research, preferably in cooperation with psychologists and psychiatrists. I sincerely hope that in future we will see more powerful, self-healing physicians, who care for their patients with pleasure
Incidental findings in brain CT scans of patients with head trauma
Get PDFObjective: Incidental findings (IFs) are newly discovered abnormal findings unrelated to the primary purpose of imaging. Brain computed tomography (CT) scan is one of the most essential and initial imaging evaluations for head trauma patients, which may also have nontraumatic IFs. We aim to investigate the prevalence and nature of IFs in brain CT scans of head trauma patients. Methods: We conducted a cross-sectional study to evaluate brain CT scans of 1006 head trauma patients over one year (April 2021 to March 2022), to identify incidental findings by consensus agreement of two radiologists. We categorized the incidental findings into four categories based on appropriate follow-up recommendations. Results: We included 1006 head trauma patients who underwent brain CT scan, of which 126 incidental findings were discovered in brain CT scan of 107 patients. The prevalence of incidental findings was 10.6% (107/1006). The most common incidental finding was brain atrophy (n=15, 11.9%). The mean age of patients with IFs was significantly higher than those without IFs, but there was no difference between the two groups regarding gender. Conclusion: The discovery rate of incidental findings of brain CT scans in head trauma patients was considerable. Serious medical findings that need immediate evaluation were found in 5.6% of patients, mostly over the age of 40. Therefore, patients who have clinically significant incidental findings need improved documentation and follow-up to evaluate the long-term outcomes and reliability of imaging results
Comparative analysis of four upper gastrointestinal bleeding scoring systems for predicting multiple outcomes: an observational study in the emergency department
Get PDFObjective: Numerous scoring systems have been developed to assess the risk associated with upper gastrointestinal bleeding (UGIB), and several studies have investigated their comparative accuracy in predicting patient outcomes. This study was undertaken to compare four well-known scoring systems, namely the pre-endoscopy Rockall score, full Rockall score, Glasgow-Blatchford Bleeding score (GBS), and AIMS65, with the aim of predicting five distinct outcomes in cases of non-variceal UGIB. Methods: This prospective observational study was conducted focusing on adult patients with UGIB presenting to the emergency department (ED). The primary endpoints of this study included in-hospital mortality, the need for re-endoscopy, the requirements for packed red blood cell (PRBC) transfusion, massive transfusion, and one-month rebleeding. Results: A total number of 320 patients were enrolled, with 44 (13·75%) in-hospital deaths. Based on the area under the curves (AUC), while certain scores outperformed others in specific outcome prediction, the AIMS65 scoring system demonstrated superior predictive capability for both in-hospital mortality (0.91) and massive transfusion (0.71). Regarding PRBC transfusion requirements, both AIMS65 and GBS exhibited similar predictive capacities (AUC=0.67 and 0.68, respectively). In terms of re-endoscopy and one-month rebleeding, the GBS scoring system displayed slightly better performance compared to the other systems (AUC=0.61 and 0.63, respectively). In the composite outcome, all scores had significant associations, and among them, the AIMS-65 score had the highest AUC (0.76). Conclusion: The AIMS65 scoring system was the most reliable tool for predicting in-hospital mortality and, to a lesser extent, massive transfusion requirements, while GBS and AIMS65 could be moderately and cautiously relied on for preparations regarding the need for PRBC transfusion
Impact of cigarette smoking on the outcomes of ST-elevation myocardial infarction after primary percutaneous coronary intervention in metropolitan Tehran
Get PDFObjective: Although the adverse effects of smoking are well-established, evidence shows a longer survival rate following an acute myocardial infarction (MI) among smokers or the so-called “smoker's paradox”. This study aimed to determine the impact of smoking on the one-year clinical outcomes of ST-elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention (PPCI) in a large registry of the Iranian population. Methods: A total of 3087 patients diagnosed with acute STEMI who underwent PPCI between 2013 and 2018 were enrolled in the study. Patients' smoking status was determined based on self-reported history and categorized into two groups: current smokers and non-smokers. Clinical and angiographic data were collected from the Tehran heart center (THC) registry. The primary outcome was one-year of major adverse cardiac and cerebrovascular events (MACCE). The effect of smoking on MACCE was evaluated using a Cox model. Results: From the study population, 1967 (63.7%) were non-smokers, and 1120 (36.3%) were
current smokers. Non-smokers had higher rates of prior CABG (5.3%) as well as a higher history of co-morbidities, including a history of diabetes mellitus (46.0%), hypertension (52.7%) and hyperlipidemia (55.4%) than smokers (2.3%, 30.4%, 35.7%, and 49.8% respectively). Smokers had a higher reference vessel diameter than non-smokers (P=0.005). The unadjusted hazard ratios HRs) for MACCE within one year were significantly lower in smokers than non-smokers (0.73, 95% CI: [0.58,0.92; P=0.009); however, after adjustment for confounders, the HRs for MACCE in smokers were similar to non-smokers (HR: 1.00 95% CI: [0.73,1.38]). Conclusion: The study found that smoking had no significant impact on the one-year clinical outcomes of STEMI patients after PPCI in the Iranian population. This study is the first of its kind to assess the effect of smoking on STEMI patients in Iran and highlights the need for further research in this area
A 67-year-old man with cardiac air tamponade: a case report
Get PDFPneumopericardium is a rare entity, primarily described as a result of causes such as penetrating/blunt trauma and procedures, aspergillosis, and diaphragmatic hernia. Malignancy history has also emerged as a new cause. A 67-year-old man with a history of active cancer presented to the emergency department with the chief complaint of shortness of breath and hemoptysis. He had low blood pressure and tachycardia along with hypoxia. The thoracic computed tomography (CT) imaging revealed a right pulmonary mass, central necrosis, and anterior pneumopericardium and gas adjacent to the right pericardial border.Patients with small, stable, asymptomatic pneumopericardium may be treated conservatively with close monitoring to prevent escalation to cardiac tamponade. Prompt decompression is advised if there are progressive symptoms, a concurrent pneumothorax, or cardiac tamponade
The role of thiol/disulfide hemostasis in the diagnosis and severity prediction of acute pancreatitis
Get PDFObjective: Reactive oxygen radicals are generated in the early stages of acute pancreatitis (AP) and are responsible for its progression. Thiol/disulfide homeostasis (TDH) is an important antioxidative mechanism. This study aimed to evaluate the role of TDH in the differential diagnosis of AP and predict its clinical severity. Methods: Patients admitted to the emergency department due to upper abdominal pain were evaluated. The study consisted of two groups: the AP group and the non-AP group (patients with diagnoses other than AP). The AP group was divided into mild and severe according to Acute physiology and chronic health evaluation II (APACHE-II) scores. TDH was measured with an automated assay from Erel et al. Statistical analyses were done with SPSS 16.0. Results: The results from 128 cases—58 in the AP group and 70 in the non-AP group—were evaluated. There was no difference in TDH parameters between the AP and non-AP groups. Among the AP subgroups, native thiol (sh) and total thiol (tt) were significantly lower in the severe AP group (sh: 313.9 μmol/L, 239.1 μmol/L; tt: 351.5 μmol/L, 303 μmo/L, respectively, in the mild and severe AP groups, P-value=0.006, P-value=0.013). Conclusion: TDH parameters change because of inflammatory processes in AP. Since this change does not occur for any specific reason, using TDH parameters for differential diagnosis of AP in patients with upper abdominal pain is not appropriate. However, in patients already diagnosed with AP, native and total thiol levels might be helpful in the prediction of clinical severity with a limited role
A mortality indicator in acute pulmonary embolism: the inferior vena cava contrast reflux score feasibility
Get PDFObjective: Acute pulmonary embolism (APE) is frequently associated with high morbidity and mortality rates. Numerous studies have investigated the prognostic significance of cardiovascular computed tomography (CT) parameters. This study aimed to investigate potential CT scan predictors of 24-hour mortality in APE and to evaluate the value of the inferior vena cava (IVC) reflux score calculated on CT scan in predicting mortality. Methods: This study was a single-center, retrospective study. Approval from the local ethics committee (decision no. 2023/76) was obtained before patients’ data scanning. Patients who were admitted to the emergency department (ED) of a tertiary education and research hospital in Turkey between January 1, 2019, and December 31, 2021, who were diagnosed with APE at CT scan in the ED and whose treatment was started, and who did not meet the exclusion criteria were included in the study. The relationship between CT scan findings and early and late mortality was evaluated. Results: The study population comprised 226 patients, meeting the inclusion and exclusion criteria. Of the 226 patients, a total of 39 (17.3%) patients died, 16 (7.1%) within the first 24 hours. In evaluating CT scan parameters, the inferior vena cava (IVC) reflux score showed a statistically significant difference between the groups with and without mortality (24-hour P=0.001; 30-day P=0.001). Patients who died within the first 24-hour and 30-day after admission showed a reflux grade 3 into IVC more often than survivors (24-hour odds ratio (OR): 14.57, 95% confidence interval (CI): 3.64,58.1; P=0.001); 30-day (OR: 6.54, 95% CI: 2.51,16.98; P=0.001). However, other CT parameters were evaluated, and no statistical relationship was found between the groups with and without mortality. Conclusion: The cardiovascular CT scan findings may not be suitable for use as predictors of mortality. However, the IVC reflux score may be a good indicator of both early and late mortality