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OBJECTIVE: This study aimed to compare the quality-adjusted life years (QALYs) of patients with gastrointestinal (GI) cancer after receiving palliative and supportive care. MATERIALS AND METHODS: Conducted at Firoozgar Hospital in Tehran, Iran, this observational study included 500 end-stage gastrointestinal cancer patients. The study divided these patients into two groups: 250 utilized palliative medicine services, while the remaining 250 did not. The study compared the conditions of patients in both groups. Results: Among those receiving palliative care, only 21% underwent chemotherapy, significantly lower than the 55% in the non-palliative care group (P < 0.001). Hospital mortality rates were considerably reduced in the palliative care group, with 115 patients (46%) compared to 200 patients (80%) in the non-palliative group (P < 0.001). The average hospital stay for patients receiving palliative care was 25.11 ± 5.12 days, significantly shorter than the 96.42 ± 14.15 days in the non-palliative group (P < 0.001). The EuroQol 5-Dimensions 3-Levels (EQ-5D-3L) questionnaire scores showed that patients in the palliative care group experienced significantly better outcomes in pain and mood symptoms, but no significant difference was observed in physical function compared to the non-palliative group. Conclusion: Palliative medicine is recommended for gastrointestinal cancer patients as it can significantly reduce unnecessary hospital referrals and length of hospitalization.

Background and purpose: Acute ischemic stroke is one of the main causes of death and long-term disability worldwide. Prehospital emergency diagnosis and subsequent transfer of stroke patients to the nearest stroke center for starting an appropriate treatment are critical steps in stroke rescue chain. In Iran, emergency medical technicians implement the SAMA code, following the diagnosis of acute stroke using FAST protocol, to manage the patients. Materials and methods: This retrospective cross-sectional study was conducted on patients who were referred to the prehospital emergency department of Hazrat Rasool Akram Hospital with the announcement of the SAMA code in 2019. The aim of this study was to evaluate the positive predictive value of the prehospital emergency technicians in the announcement of the SAMA code. Results: Of the 95 patients referred with the SAMA code, 19 patients diagnosed with hemorrhagic stroke (based on brain CT-scan) were excluded from the study. In 17.1% of the remaining 76 patients, diagnoses other than acute ischemic stroke were proposed. Ultimately, diagnosis of acute ischemic stroke was confirmed in 63 patients, and 25% of them were eligible for intravenous thrombolytic therapy, however, merely 5.26% of the eligible patients received the treatment. The positive predictive value of prehospital emergency service in referring patients diagnosed with acute ischemic stroke was determined to be 86.3%. Additionally, the positive predictive value for identifying acute cerebral stroke patients eligible for intravenous thrombolytic therapy was calculated to be 25%. Conclusion: This study revealed that prehospital emergency's positive predictive value for acute ischemic stroke identification was adequate. However, activating the SAMA code with greater diagnostic accuracy can save time and costs.

Zika virus (ZIKV) was identified in 1947 in a rhesus monkey during an investigation of the yellow fever virus in the Zika Forest of Uganda; it was also isolated later from humans in Nigeria. The main distribution areas of ZIKV were the African mainland and South-East Asia in the 1980s, Micronesia in 2007, and more recently the Americas in 2014. ZIKV belongs to the Flaviviridae family and Flavivirus genus. ZIKV infection, which is transmitted by Aedes mosquitoes, is an emerging arbovirus disease. The clinical symptoms of ZIKV infection are fever, headache, rashes, arthralgia, and conjunctivitis, which clinically resemble dengue fever syndrome. Sometimes, ZIKV infection has been associated with Guillain-Barré syndrome and microcephaly. At the end of 2015, following an increase in cases of ZIKV infection associated with Guillain-Barré syndrome and microcephaly in newborns in Brazil, the World Health Organization declared a global emergency. Therefore, considering the global distribution and pathogenic nature of this virus, the current study aimed at reviewing the virologic features, transmission patterns, clinical manifestations, diagnosis, treatment, and prevention of ZIKV infection.

Background: Penetrating traumas to joints if not detected and properly treated, will be damaged, and causes intra-articular contamination and septic arthritis. At present, saline test is used to detect penetrating wound into the joint. Considering that it is invasive and painful, and is prone to infectious complications especially in busy emergency wards, the purpose of this study was to determine the consensus of computed tomography (CT) scan with saline test to increase the detection rate of penetrating knee trauma cases. Methods: This cross-sectional diagnostic study was done in the year 2017 in an emergency hospitals of the Iran University of Medical Sciences, Tehran, Iran. 62 patients with knee trauma were selected using convenience sampling method, and were evaluated using saline test and CT scan. Findings: Saline test was positive in 19 cases of 62 patients. Kappa agreement rate was 54.5% between the results of saline test with CT scan reported by radiologist and 43.9% with CT scan reported by emergency medicine specialist. Conclusion: According to the results of the study, there was no acceptable agreement between the results of saline test and CT scan, and CT scan could not be a good alternative to saline testing. However, concurrent testing and CT scan can be helpful; as there were negative results of saline test in cases of septic arthritis, which had positive CT scan results.

Dissection of neck arteries including carotid artery is among the vascular injuries following blunt neck trauma. Manifestations of this injury are usually delayed and present as neurological problems. This injury is accountable for about 2% of cerebral infarctions but causes 20% of brain strokes in patients less than 45 years old. Aiming to discuss and emphasize the importance of this injury, in this article a case of carotid dissection presenting to emergency department (ED) is presented. The patient was a 34 year-old woman that visited ED following left hemiparesis, dysartery and headache that had initiated a few hours back. She had a history of hospital admission 10 days before due to car accident and rollover, and had been discharged with good general health following required examinations. In brain computed tomography (CT) scan, there was evidence of sub-acute ischemic infarction around the middle cerebral artery. Considering the age of the patient, evidence of wide ischemia and history of recent trauma, neck artery dissection was suspected and angiography was performed, which confirmed the diagnosis of carotid artery dissection.

Professionalism is a core competency in the medical profession. In this paper, we aimed to confirm the validity, reliability and acceptability of the Professionalism Mini-Evaluation Exercise (P-MEX) instrument for the emergency medicine (EM) residency program. Twenty-two EM attending physicians completed 383 P-MEX forms (the Persian version) for 90 EM residents. Construct validity was assessed via structural equation modeling (SEM). The reliability coefficient was estimated by the generalizability theory, and acceptability was assessed using two researcher-made questionnaires to evaluate the perspectives of residents and assessors. There was a consensus among the participants regarding the content of P-MEX. According to the results of SEM, the first implementation of the original model was associated with a moderate fit and high item loadings. The model modified with correlated error variances for two pairs of items showed an appropriate fit. The reliability of P-MEX was 0.81 for 14 occasions. The perception survey indicated high acceptability for P-MEX from the viewpoint of the residents and increasing satisfaction with P-MEX among the assessors over time. According to the results of the research, P-MEX is a reliable, valid, and acceptable instrument for assessing professionalism in EM residents.

Introduction: N-methyl-D-aspartate receptor subunits antibody (NR2-ab) is a sensitive marker of ischemic brain damage in clinical circumstances, such as cerebrovascular accidents. We aimed to assess the value of serum NR2-ab in predicting the post-cardiopulmonary resuscitation (CPR) survival. Methods: In this cohort study, we examined serum NR2-ab levels 1 hour after the return of spontaneous circulation (ROSC) in 49 successfully resuscitated patients. Patients with traumatic or asphyxic arrests, prior neurological insults, or major medical illnesses were excluded. Participants were followed until death or hospital discharge. Demographic data, coronary artery disease risk factors, time before initiation of CPR, and CPR duration were documented. In addition, Glasgow coma scale (GCS), blood pressure, and survival status of patients were recorded at 1, 6, 24, and 72 hour(s) after ROSC. Descriptive analyses were performed, and the Cox proportional hazard model was applied to assess if NR2-ab level is an independent predictive factor of survival. Results: 49 successfully resuscitated patients were evaluated; 27 (55%) survived to hospital discharge, 4 (8.1%) were in vegetative state, 10 (20.4%) were physically disabled, and 13 (26.5%) were physically functional. Within 72 hours of ROSC all of the 12 NR2-ab positive patients died. In contrast, 31 (84%) of the NR2-ab negative patients survived. Sensitivity, specificity, positive and negative likelihood ratios of NR2-ab in prediction of survival were 54.5% (95%CI=32.7%-74.9%), 100% (95%CI=84.5%-100%), infinite, and 45.5% (95%CI=28.8%-71.8%), respectively. Subsequent analysis showed that both NR2-ab status and GCS were independent risk factors of death. Conclusions: A positive NR2-ab serum test 1 hour after ROSC correlated with lower 72-hour survival. Further studies are required to validate this finding and demonstrate the value of a quantitative NR2-ab assay and its optimal time of measurement.

Abdominal pain is one of the most common complaints during pregnancy, which is constantly debated due to its numerous differential diagnoses. Acute appendicitis is the most common problem requiring surgery during pregnancy and has a prevalence of 1 in 1500 pregnant women. Existing studies have declared that acute appendicitis during pregnancy is diagnosed with delay in 30 - 35% of cases. This can have severe side effects and may even lead to death of the mother or fetus. Strong clinical suspicion of the physician in addition to taking proper advanced paraclinical measures can reduce errors in this regard. To emphasize the importance of this subject, we have reported a case of appendicitis during pregnancy.

Abdominal aortic aneurysm is a condition with a high mortality rate among those presenting to the emergency department. Its common symptoms include abdominal, back, and flank pain and hypotension and syncope are among its other manifestations. However, sometimes these patients present with uncommon manifestations. Considering this important point, we have introduced a patient with atypical manifestations in the present report. Initial diagnosis of this condition is based on high clinical suspicion and performing bedside abdominal ultrasonography. Diagnostic standard is abdominal computed tomography (CT) scan in patients with stable vital signs. The treatment is performing endovascular or open surgery and delay in treatment is accompanied with a high rate of mortality.

پارگی آنوریسم آئورت شکمی عارضه ای با میزان مورتالیتی بالا در مراجعه کنندگان به بخش اورژانس می باشد. علائم شایع آن شامل درد شکم، پشت و پهلوها بوده و هیپوتانسیون و سنکوپ از سایر تظاهرات آن می باشد. ولی گاها این بیماران با تظاهرات نامعمول مراجعه می کنند که با توجه به این مهم، در این گزارش به معرفی بیماری با تظاهرات آتیپیک پرداختیم. تشخیص اولیه این عارضه بر مبنای ظن بالینی بالا و انجام سونوگرافی شکمی بر بالین است. استاندارد تشخیصی سی تی اسکن شکمی در بیماران پایدار از نظر علائم حیاتی است. درمان انجام جراحی باز یا اندوواسکولار است و تاخیر در درمان با مرگ و میر بسیار بالایی همراه خواهد بود.

مقدمه: قسمت عمده ای از زندگی روزانه هر فرد صرف اشتغال به کار می شود و فعالیت کاری از نظر سلامت روانی شخص، امری مهم به حساب می آید. همواره عوامل متعددی به عنوان منابع فشار های روانی (استرس) در محیط کار وجود دارند و با توجه به اهميت مشکل فرسودگي شغلي و عواقب آن مطالعه حاضر با هدف بررسی شيوع و علل فرسودگي شغلي در دستیاران طب اورژانس در بیمارستان های دانشگاه ایران انجام شد. روش کار: این مطالعه مقطعی در بیمارستان حضرت رسول وابسته به دانشگاه علوم پزشکی ایران در طی سالهای 1393 تا 1396 انجام گرفت. نمونه گیری به شیوه سرشماری انجام شد و تمامی دستیاران طب اورژانس دانشگاه علوم پزشکی ایران در طی مدت انجام این در صورت تمایل و داشتن حداقل ٦ ماه سابقه کار در بخش اورژانس وارد مطالعه شدند. خوانا نبودن و یا مخدوش بودن پرسشنامه تکمیل شده به عنوان معیار خروج از مطالعه لحاظ گردید. اطلاعات پس از جمع آوری توسط نرم افزار SPSS-16 تحت روش های آماری مورد تجزیه و تحلیل قرار گرفت. يافته ها: در کل 83 دستیار طب اورژانس با میانگین سنی 4/3 ± 0/33 سال در مطالعه شرکت کردند که 45 نفر (2/54 درصد) زن بودند. از این تعداد 60 نفر (3/72 درصد) به رشته خود ابراز علاقه نمودند. متوسط میزان فرسودگی شغلی دستیاران با میانگین 13/19 ± 32/90 (محدوده بین 124- 26) نمره بود.. نتيجه گيری: میانگین فرسودگی شغلی در بین دستیاران مورد مطالعه در محدوده مطلوب بدست آمد و افزایش سن مهمترین عامل بالا رفتن شاخص فرسودگی شغلی ایشان بود.

Introduction: N-methyl-D-aspartate receptor subunits antibody (NR2-ab) is a sensitive marker of ischemic brain damage in clinical circumstances, such as cerebrovascular accidents. We aimed to assess the value of serum NR2-ab in predicting the post-cardiopulmonary resuscitation (CPR) survival. Methods: In this cohort study, we examined serum NR2-ab levels 1 hour after the return of spontaneous circulation (ROSC) in 49 successfully resuscitated patients. Patients with traumatic or asphyxic arrests, prior neurological insults, or major medical illnesses were excluded. Participants were followed until death or hospital discharge. Demographic data, coronary artery disease risk factors, time before initiation of CPR, and CPR duration were documented. In addition, Glasgow coma scale (GCS), blood pressure, and survival status of patients were recorded at 1, 6, 24, and 72 hour(s) after ROSC. Descriptive analyses were performed, and the Cox proportional hazard model was applied to assess if NR2-ab level is an independent predictive factor of survival. Results: 49 successfully resuscitated patients were evaluated; 27 (55%) survived to hospital discharge, 4 (8.1%) were in vegetative state, 10 (20.4%) were physically disabled, and 13 (26.5%) were physically functional. Within 72 hours of ROSC all of the 12 NR2-ab positive patients died. In contrast, 31 (84%) of the NR2-ab negative patients survived. Sensitivity, specificity, positive and negative likelihood ratios of NR2-ab in prediction of survival were 54.5% (95%CI=32.7%-74.9%), 100% (95%CI=84.5%-100%), infinite, and 45.5% (95%CI=28.8%-71.8%), respectively. Subsequent analysis showed that both NR2-ab status and GCS were independent risk factors of death. Conclusions: A positive NR2-ab serum test 1 hour after ROSC correlated with lower 72-hour survival. Further studies are required to validate this finding and demonstrate the value of a quantitative NR2-ab assay and its optimal time of measurement.

The patient was a 41 year old woman that was brought to the emergency department (ED) by her husband following seizure. According to the relatives accompanying her, the seizure was of tonic-clonic type, had occurred one hour before presentation to ED, and had lasted 3 minutes. The patient had been drowsy for about 15 minutes after the end of the seizure. She had no history of head trauma and did not mention headache, nausea and vomiting, fever, vision problems or others. On presentation, amnesia regarding the things that happened was evident. In her history, she had a generalized tonic-clonic seizure 4 years back, regarding which she had not done proper follow up for taking necessary diagnostic measures and had not been treated with anti-epileptic medication. She had a history of surgery for removing cold thyroid nodule 20 years ago and was under calcium treatment for 15 years but she had decided to stop taking her medications since 5 year ago. She did not have a history of alcohol or drug abuse. The patient was conscious and awake on presentation and did not have any specific clinical complaints. Her vital signs on presentation were as follows: Blood Pressure = 120/70mmHg, Pulse Rate = 68/minute, Respiratory Rate = 16/minute, O2saturation= 98% at air room, Oral Temperature= 37°C, and bedside blood sugar in the normal range. In head and neck examination, the surgery scar was seen in the thyroid region. Examination of the thyroid also showed a nodular surface in palpation. Examination of the heart, lungs, abdomen and extremities did not have pathologic findings. Neurologic examinations including evaluation of cranial nerves, sense and power of the muscles, cerebellar examination and deep tendon reflexes were normal. Based on the opinion of the in-charge physician, anti-epileptic drugs were not prescribed at this stage. Laboratory tests including complete blood cell count, liver function tests (LFT), and level of blood sugar (BS), sodium, potassium, calcium, phosphorus, magnesium, urea and creatinine electrolytes were ordered. Considering the full consciousness of the patient and stability of vital signs and clinical examinations, by taking safety measures and accompanied by a nurse, the patient was referred to the radiology unit to undergo a brain computed tomography (CT) scan, the results of which are shown in figure 1.

دیسکسیون شریان های ناحیه گردن از جمله شریان کاروتید از جمله آسیب های عروقی متعاقب ترومای بلانت ناحیه گردن به شمار می روند. تظاهرات این عارضه معمولا تاخیری بوده و به شکل تظاهرات نورولوژیک خود را نشان می دهد. این عارضه در مجموع عامل حدود 2 درصد موارد انفارکت های مغزی است ولی 20 درصد علل استروک مغزی افراد زیر 45 سال می باشد. با هدف بحث و تاکید بر اهمیت این عارضه، در این مقاله به معرفی یک مورد از بروز دایسکسیون کاروتید مراجعه کننده به بخش اورژانس پرداخته ایم. بیمار خانم 34 ساله ای است که متعاقب همی پارزی چپ و دیزارتری و سردرد که از چند ساعت قبل شروع شده به بخش اورژانس آورده شد که 10 روز قبل سابقه بستری بدلیل تصادف و واژگونی ماشین داشت که بعد از انجام بررسی های لازم، با حال عمومی خوب ترخیص شده بود. در سی تی اسکن مغز شواهد انفارکت ایسکمیک تحت حاد در محدوده شریان مغزی میانی رویت شد. با توجه به سن بیمار و شواهد ایسکمی وسیع و شرح حال ترومای اخیر، با شک به دیسکسیون عروق گردنی جهت بیمار آنژیوگرافی انجام شد و تشخیص دیسکسیون شریان کاروتید مسجل گردید.

درد شکم یکی از شایعترین شکایت های دوران بارداری است و بدلیل تشخیص های افتراقی متعددی که به همراه دارد همواره مورد بحث می باشد. هرچند در برخورد با این بیماران تشخیص های مرتبط با شرایط بارداری و پاتولوژی های فضای رحم و اطراف آن در اولویت قرار دارند، ولی هرگز نباید از سایر تشخیص های غیرمرتبط با بارداری که در این دوران تظاهرات متفاوتی از خود نشان می دهند، غافل بود. آپاندیسیت حاد شایعترین عارضه نیازمند جراحی در دوران بارداری است و شیوع آن یک مورد در هر 1500 مورد زن باردار گزارش شده است. به گواه مطالعات موجود آپاندیسیت حاد در دوران بارداری در 35-30 درصد موارد دیر تشخیص داده می شود. این کم توجهی می تواند عوارض وخیمی در پی داشته و موجب مرگ و میر مادر و جنین گردد. ظن بالینی قوی پزشک در کنار استفاده از اقدامات پاراکلینیک مناسب و پیشرفته می تواند از میزان بروز خطا در این زمینه بکاهد. به جهت تاکید بر اهمیت این موضوع به گزارش یک مورد آپاندیست در بارداری پرداخته ایم.