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The confirmed and suspected cases of the 2019 novel coronavirus disease (COVID-19) have increased in the entire world. There is still no vaccine or definitive treatment for this virus due to its unknown pathogenesis and proliferation pathways. Optimized supportive care remains the main therapy, and the clinical efficacy for the subsequent agents is still under investigation. Enormous demand for handling the COVID-19 outbreak challenged both the health-care personnel and medical supply system. As outbreaks of COVID-19 develop, prehospital workers, emergency medical services personnel, and other emergency responders are potentially asked to follow specific practice guidelines to mitigate the effects of an escalating pandemic. In this article, we have summarized the current guidance on potential COVID-19 management options. The recent experience with COVID-19 provided lessons on strategy and policymaking that the government and ministry of health should be on the alert and concentrate more on capacity to manage an outbreak like COVID-19. It is important to consider the new data that emerge daily regarding clinical characteristics, treatment options, and outcomes for COVID-19. [ABSTRACT FROM AUTHOR]

Intensified process based on subcritical water conditions (120 °C and 1.5 atm, for 2 h) was utilized to prepare thyme oil in water (O/W) nanoemulsions. In this technique, water and xanthan gum, as green solvent and natural microbial emulsifier, were utilized. Results of gas chromatography revealed that Thymol and Carvacrol were two main bioactive compounds of the extracted thyme oil. Effects of amounts of xanthan gum (0.05–0.25 g) and thyme essential oil (0.2–0.8 mL) on size of oil nanodroplets and polydispersity index (PDI) of the resulted nanoemulsions were evaluated using response surface methodology. Results demonstrated that the produced thyme O/W nanoemulsion by 0.242 mL thyme oil and 0.140 g xanthan gum had smallest average nanodroplet size (150 nm) and PDI (0.088). Furthermore, monodispersed and spherical in shape thyme oil nanodroplets were provided in the nanoemulsion using these optimal conditions with zeta potential value of −10.1 mV and antioxidant activity of 17.4%. Results also indicated that this prepared nanoemulsion had high fungicidal and bactericidal activities toward Penicillium digitatum and Escherichia coli, respectively. [ABSTRACT FROM AUTHOR]

Background: This study was performed to determine the sensitivity and specificity of ultrasound in the diagnosis of traumatic ankle injury in comparison with magnetic resonance imaging (MRI). Materials and Methods: This cross-sectional study was performed on 31 patients with soft-tissue injury or fracture, referring to the MRI imaging center of Alzahra and Kashani Hospitals in Isfahan from October 2018 to March 2019. After an MRI, an ultrasound of the affected ankle was performed for all patients. Sonography and MRI were performed by two radiologists who were blinded to the results of each other's reports. The sensitivity, specificity, positive predictive value, and negative predictive value of sonography were determined. Results: In this study, 31 patients with ankle trauma were studied. The mean age of the patients was 30.73 ± 10.15 years; 32.3% were male and 67.7% were female. The sensitivity of ultrasound relative to MRI to detect damage to the anterior talofibular ligament (ATFL), posterior talofibular ligament (PTFL), and calcaneofibular ligament (CFL) was 66.67%, 50%, and 100%, respectively, and the corresponding specificity was 92.86%, 93.10%, and 93.10%, respectively. According to Kappa test, the agreement between ultrasound and MRI methods for detecting injury to ATFL (κ = 0.51), PTFL (κ = 0.35), and CFL (κ = 0.63) was statistically significant (P < 0.05). Conclusion: Ultrasound is an appropriate modality for the diagnosis of injuries to CFL and ATFL and has shown acceptable results for PTFL. It could be used as an alternative in cases where access to MRI is not available. [ABSTRACT FROM AUTHOR]

Aloe vera leaf extract has been obtained and utilized for silver nanoparticles (AgNPs) synthesis by autoclave at 121 °C and 1.5 bar (pressure) for 15 min. The results of GC-MS analysis of A. vera life extract indicated that there were several natural reducing agents such as acetic acid, hexanol and ethyl amine in the A. vera peel. Central composition design and response surface methodology have been used to design the experiment and to evaluate the effect of independent variables on dependent variables, respectively. After extraction of A. vera leaf extract with different concentrations (0.5–5.5% w/v), 0.1 mL of the prepared extract has been added into different amounts of 1 mM AgNO3 solution (9.5–20.5 mL) and placed into the autoclave. The obtained results indicated that the minimum particle size (53.9 nm) and maximum concentration (46.25 ppm) and color (0.851 IU) values for synthesized AgNPs were obtained using 4.69% w/v of A. vera leaf extract and 11.1 mL of AgNO3 solution (1 mM). The zeta potential value of the synthesized AgNPs at obtained optimum conditions was +15.5 mV which indicated the high stability of the synthesized AgNPs. The high antifungal activity of the synthesized AgNPs was evaluated against to Aspergillus flavus and Aspergillus terreus strains. [ABSTRACT FROM AUTHOR]

Silver nanoparticles (AgNPs) were synthesized using Aloe vera leaf extract as both reducing and stabilizing agents via microwave irradiation method. The effects of the microwave exposure time and the amount of AgNO3 solution on the mean particle size and concentration of the synthesized AgNPs solution were investigated using response surface methodology. The synthesized AgNPs were characterized by transmission electron microscopy, UV-Vis spectroscopy, and dynamic light scattering. Well-dispersed and spherically fabricated AgNPs with mean particle size (46 nm) and maximum concentration (64 ppm) and zeta potential (+15.5 mV), were obtained at optimal synthesis conditions, using 9 ml of AgNO3 (1 mm) and 0.1 ml of Aloe vera extract during microwave exposure time of 360 s. The antibacterial activity of the synthesized AgNPs was tested using Escherichia coli and Staphylococcus aureus bacteria and the obtained results indicated their significant inhibitory effects against these two Gram-negative and Gram-positive bacteria. [ABSTRACT FROM AUTHOR]

Background: Renal colic is a painful medical emergency, needs urgent intervention to reduce pain. Nonsteroidal anti-inflammatory drugs, opioids, and entonox are pain-relieving agents. This study was aimed to compare fentanyl + entonox (nitrous oxide + O2) versus fentanyl + oxygen. Materials and Methods: One hundred and twenty patients with acute renal colic presenting to the emergency department were enrolled. First, 50 μg fentanyl was infused for all patients. Then, patients divided into two groups receiving masks of entonox and oxygen, respectively. Quantitative measurement of pain was performed by visual analog scale, before the intervention, after 3, 5, 10, and 30 min of that. If the pain was not relieved after 30 min, 50 μg fentanyl was infused. If the pain was still continued, ketorolac and ketamine were used. Hospitalization duration and severity of pain at specified times were compared between patients in two groups. Results: The mean (standard deviation) time of hospitalization was 211 (59) and 236 (61) min in fentanyl + entonox and fentanyl + O2 groups, respectively (P = 0.024). The decrease in pain severity after 10 and 30 min in fentanyl + entonox group were significantly greater than fentanyl + O2 group (P = 0.002 and 0.001, respectively). Mean (standard error) of needed time for renal colic pain to get better was 11.27 (1.23) and 20.47 (1.71) min in fentanyl + entonox and fentanyl + O2 groups, respectively (P < 0.001). Proportion of patients relief from pain in fentanyl + entonox in the second, third, and fourth measurements were significantly more than fentanyl + O2 group (P = 0.036, P < 0.001, and P < 0.001, respectively). Conclusion: Entonox is more effective to decrease the duration of hospitalization and reduction of pain than O2 in renal colic patients. Key words: Fentanyl, nitrous oxide, oxygen, renal colic [ABSTRACT FROM AUTHOR]

The potential of magnetic nanoparticles (MNPs) in drug delivery systems (DDSs) is mainly related to its magnetic core and surface coating. These coatings can eliminate or minimize their aggregation under physiological conditions. Also, they can provide functional groups for bioconjugation to anticancer drugs and/or targeted ligands. Chitosan, as a derivative of chitin, is an attractive natural biopolymer from renewable resources with the presence of reactive amino and hydroxyl functional groups in its structure. Chitosan nanoparticles (NPs), due to their huge surface to volume ratio as compared to the chitosan in its bulk form, have outstanding physico-chemical, antimicrobial and biological properties. These unique properties make chitosan NPs a promising biopolymer for the application of DDSs. In this review, the current state and challenges for the application magnetic chitosan NPs in drug delivery systems were investigated. The present review also revisits the limitations and commercial impediments to provide insight for future works. [ABSTRACT FROM PUBLISHER]

Background: Restless and violent behaviors are common in Emergency Departments (EDs), which need therapeutic interventions in most of the times. The first-generation anti-psychotic drugs are one of the most applicable therapeutic agents in the management of such patients, but their use has some limitations. Some studies suggest midazolam as an alternative medicine. Therefore, this study was performed with the aim of comparison of the efficacy and safety of haloperidol and midazolam in the restless management of referring patients to EDs. Materials and Methods: The present double-blinded trial was done on patients needed sedation and referred to the ED of Alzahra Hospital, Isfahan, Iran, in 2014. The patients were categorized into two random groups of haloperidol (5 mg) and midazolam receivers (2.5 mg for those weighing <50 kg and 5 mg in >50 kg), as intramuscular administration. The time to achieve sedation, need for rescue dose, need to resedation within the first 60 min, and adverse effects of drugs were compared among the groups. Results: Forty-eight patients were entered to the study. The mean age in the haloperidol and midazolam groups was 44.8 ± 4.1 years and 45.5 ± 4.7 years, respectively ( P = 0.91). The mean time of sedation in the haloperidol and midazolam groups was 5.6 ± 0.3 min and 5.2 ± 0.1 min, respectively ( P = 0.31). The mean time of full consciousness after sedation was 36.2 ± 4.5 min and 38.2 ± 3.4 min in the haloperidol and midazolam groups, respectively ( P = 0.72). On average, time to arousal in the midazolam group was 10.33 min more than the haloperidol group, but it was not statistically significant. Conclusion: The results of the present study show that administration of midazolam and haloperidol have similar efficacy in the treatment of restless symptoms with the same recovery time from drug effects for referring patients to the ED. In addition, none of the adverse effects were observed in this study. [ABSTRACT FROM AUTHOR]

Background: We assessed the effects of low-dose IV ketamine-midazolam versus morphine on pain control in patients with closed limb fracture(s); and also compared the incidence of adverse events (cardio-pulmonary) between two groups. Materials and Methods: This prospective, single-blind, non-inferiority trial randomized consecutive emergency department (ED) patients aged 18-60 years to two groups: Receiving 300-500 mcg/kg ketamine plus 0.03 mg/kg midazolam, or 0.05-0.1 mg/kg morphine. Visual analogue score (VAS) and adverse events were verified during an interval of 30 minutes. Results: Two hundred and thirty -- six patients were selected, among whom 207 were males (87.3%). The average age was 29 ± 2, (range, 18-60 years). The VAS score at T30 (i.e., 30 minutes after initial analgesic dose) was significantly decreased compared with VAS score at T0, in both groups. No statistically significant difference, however, was observed between the two groups (-6.1 ± 1.1 versus -6.2 ± 1.0; P = 0.16). With regard to systolic blood pressure and respiratory rate, however, a meaningful difference was noted between the two groups (1.5 ± 6.4 versus -2.1 ± 6.6; P = 0.000 for SBP, and -0.2 ± 1.1 versus -1.1 ± 6.1; P = 0.048 for RR). Conclusion: "Low-dose" intravenous ketamine plus midazolam has the same analgesic effects as morphine on pain control in trauma patients with closed limb fracture(s), in addition to less respiratory adverse events. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to evaluate the frequency distribution and associated factors of burnout syndrome among nurses in Alzahra Hospital, Isfahan, Iran. Methods: This was a cross-sectional study conducted on 100 selected nurses in Alzahra Hospital in 2010, Iran. The subjects filled maslach burnout inventory (MBI). The data was analyzed by Student's t-test and analysis of variance (ANOVA) in SPSS18 software. Findings: The mean age of nurses was 37.35 ± 12.13 years. Our results showed significant differences in burnout scores between nurses in different departments, i.e. the scores of nurses in ICU and emergency departments were significantly higher than those in dialysis and orthopedic departments (P = 0.01). Student's t-test revealed the scores of women to be significantly higher than men (P = 0.0001). In addition, ANOVA showed a work experience lower than 10 years to be associated with lower burnout scores. Conclusion: Based on our results and previous studies, sex, work experience and site of working in the hospital are important factors affecting burnout syndrome in nurses. [ABSTRACT FROM AUTHOR]

An abstract of the article "Quality of Nursing Care and Documentation with Overcrowding in Emergency Department," by Omid Ahmadi and colleagues is presented.

Objective: Musculoskeletal ultrasound is increasingly used as the modality of choice in diagnosing many medical situations. The present study aimed to compare the accuracy of point-of-care ultrasonography (POCUS) and magnetic resonance imaging (MRI) to detect acute medial meniscus tears in knee., Methods: The prospective study was conducted on patients with suspected medial meniscus tears in knee. in the emergency department. In the absence of a knee fracture on x-ray, POCUS on the knee was performed. All patients underwent POCUS and MRI of the knee followed by arthroscopy. POCUS findings were then compared to MRI findings to diagnose medial meniscus tears., Results: A final total of 157 patients with a mean age of 25.04±7.41 years was included. Out of 157 patients, 94 (59.9%) were male. Medial meniscus tears were detected in 89 patients (56.7%) using arthroscopy as the gold standard. The sensitivity, specificity, positive and negative predictive values, and accuracy of POCUS to detect medial meniscus tears were 88.8% (95% confidence interval [CI], 80.3%-94.5%), 89.7% (95% CI, 79.9%-95.8%), 91.9% (95% CI, 84.8%-95.8%), 85.9% (95% CI, 77.2%-91.7%), and 89.2% (95% CI, 83.3%-93.6%), respectively. The diagnostic accuracy of MRI to detect medial meniscus injury was 93.0% (95% CI, 87.8%- 96.4%)., Conclusion: The present study demonstrated that POCUS is an accurate and reliable diagnostic tool alternative to MRI in detecting medial meniscal tears. POCUS had acceptable sensitivity, specificity, and accuracy in detecting meniscal injuries and could be performed as an effective immediate investigation to guide further modalities in patients with acute knee trauma.

Introduction: In recent years, several scoring systems have been developed to assess the severity of trauma and predict the outcome of trauma patients. This study aimed to compare Rapid Emergency Medicine Score (REMS), Modified Early Warning Score (MEWS), Injury Severity Score (ISS), and Glasgow Coma Scale (GCS) in predicting the in-hospital mortality of trauma patients., Methods: This diagnostic accuracy study was done on adult patients admitted to the emergency department (ED) between June 21, 2019, and September 21, 2020, following multiple trauma. Patients were followed as long as they were hospitalized. The REMS, MEWS, GCS, and ISS were calculated after data gathering and comprehensive assessment of injuries. Receiver operating characteristics (ROC) analysis was performed to examine the prognostic performance of the four different tools., Results: Of the 754 patients, 32 patients (4.2%) died and 722 (95.8%) survived after 24 hours of admission. The mean age of the patients was 38.54 ± 18.58 years (78.9% male). The area under the ROC curves (AUC) of REMS, MEWS, ISS, and GCS score for predicting in-hospital mortality were 0.942 (95% CI [0.923-0.958]), 0.886 (95% CI [0.861-0.908]), 0.866 (95% CI [0.839-0.889]), and 0.851 (95% CI [0.823-0.876]), respectively. The AUC of REMS was significantly higher than GCS (p=0.035). The sensitivities of GCS ≤ 11, ISS ≥ 13, REMS ≥ 4, and MEWS ≥ 3 scores for in-hospital mortality were 0.56, 0.97, 0.81, and 0.94, respectively. Also, the specificities of GCS, ISS, REMS, and MEWS scores for in-hospital mortality were 0.93, 0.82, 0.81, and 0.85, respectively., Conclusion: It seems that REMS is more accurate than GCS, ISS, and MEWS in predicting in-hospital mortality ≥ 24 hours of multiple trauma patients.

Background: The present study was designed to evaluate the effectiveness of magnesium sulfate (MgSO 4 ) in procedural sedation and analgesia (PSA) when combined with ketamine in patients with fractures in emergency departments and required short and painful emergency procedures., Materials and Methods: In this study, 100 patients with fractures and dislocations who were presented to the emergency departments and required PSA for short and painful emergency procedures were randomly allocated to groups of ketamine plus MgSO 4 or ketamine alone. Train of four (TOF) stimulation pattern was assessed using nerve stimulator machine and compared between groups., Results: The mean age of studied patients was 46.9 ± 9.3 years old. 48% were male and 52% were female. No significant differences were noted between groups in demographic variables. The status of TOF, 2 min after the injection of ketamine (1.5 mg/kg), in both groups was similar. After the injection of the second dose of ketamine (1 mg/kg) the status of TOF in four patients in ketamine plus MgSO 4 (0.45 mg/kg) group changed, it was three quarters but in ketamine group, the status of TOF in all patients was four quarters. The difference between groups was not statistically significant ( P = 0.12)., Conclusion: The findings revealed that for muscle relaxation during medical procedures in the emergency department, ketamine in combination with MgSO 4 with this dose was not effective for muscle relaxation during procedures., Competing Interests: There are no conflicts of interest.