Original/Research Article


4-methylumbilliferon (4-MU) as a Potential Treatment Against Cerebral ischemia and Reperfusion Injury in Rats; An Experimental Study

Hamzeh Mirshekari Jahangiri, Alireza Moradi, Donya Nazarinia, Nahid Aboutaleb (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e8
https://doi.org/10.22037/aaem.v13i1.2456

Introduction: Ischemic stroke (IS) is one of the three main fatal disorders and is a major health challenge. 4-methylumbelliferone (4-MU) is one of the coumarin derivatives (7–hydroxy‐4–methylcoumarin) with antioxidant and anti-inflammatory impact. This study was conducted to elucidate the neuroprotective effects and anti-inflammatory impact of 4-MU in a rodent model of IS.

Methods: The IS model was induced by middle cerebral artery occlusion (MCAO) for 1 hour and reperfusion was established for 24 hours. 44 Male Wistar rats were assigned into four groups: (1) Sham, (2) MCAO (3) MCAO + Vehicle, and (4) MCAO + 4-MU (25 mg/kg). Evaluation of neurological deficit was performed using Garcia's score. 2,3,5-triphenoyl-2H-tetrazolium chloride (TTC) staining was employed to measure infarct size.  Nissl staining was applied to determine neuronal loss. Moreover, western blotting was utilized to detect the expression of the proteins relevant to the TLR4/NF-κB/NLRP3 axis (p–NF–κB p65, TLR4, NLRP3, IL-1β, IL-10, IL-18, ASC, and Caspase-1).

Results: It was observed that MCAO caused neurological deficit (P<0.0001), infarct (P<0.0001), and neuronal loss (P<0.002); up-regulated NLRP3 (P<0.0001), TLR4 (P<0.0001), p–NF–κB p65 (P<0.0005), IL-1β (P<0.0014), IL-18 (P<0.0001), ASC (P<0.0027), and Caspase-1 (P<0.0052); and reduced IL-10 concentrations (P<0.0024). Administration of 4-MU (25 mg/kg) quickly after reperfusion reduced neurological deficit (P<0.0001), infarct size (P<0.0001), neuronal loss (P<0.0058), and down-regulated NLRP3 (P<0.0257), TLR4 (P<0.0001), p–NF–κB p65 (P<0.0075), IL-1β (P<0.0106), IL-18 (P<0.0005), ASC (P<0.0072), and Caspase-1 (P<0.0315), and increased IL-10 concentrations (P<0.0215).

Conclusion: These results indicate that 4-MU can attenuate injury after MCAO by suppressing the TLR4/NF-κB/NLRP3 axis. Our findings show that 4-MU can be considered a novel therapeutic compound to cure IS.

TERMINAL-24 Score in Predicting Early and In-hospital Mortality of Trauma Patients; a Cross-sectional

Sadegh Ashrafian Fard, Sajjad Ahmadi, Haniyeh Ebrahimi Bakhtavar, Homayoun Sadeghi Bazargani, Farzad Rahmani (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e25
https://doi.org/10.22037/aaemj.v13i1.2526

Introduction: Determining the trauma patients’ prognosis is crucial for patients’ safety, triage, and appropriate management. This study aimed to evaluate the screening performance of Traumatic Emergency Room Major Injury Death At Least 24 hours (TERMINAL-24) score in predicting the mortality of trauma patients.

Methods: This cross-sectional study was conducted in the emergency department (ED) of a referral trauma center, between October 2023 and September 2024. The main goals of the project were determining the value of TERMINAL-24 score in predicting early (within 8 hours of admission to ED) and in-hospital mortality of multi-trauma patients as well as comparing the accuracy of TERMINAL-24 with other trauma severity scores (GAP, RGAP, NTS) in this regard.

Results: 963 multi-trauma patients were included in this study. The mean age of the patients was 37.75±17.10 years (73.2% male). 55 patients died in the emergency department and 46 patients died during hospitalization in other departments. Male gender (p = 0.009), older age (p =0.011), traffic accidents (p = 0.005), more critical vital signs (p = <0.001), admitting in neurosurgery ward (p < 0.001), and higher trauma severity (P < 0.001) were significantly associated with higher mortality rate. The area under the curve (AUC) of TERMINAL-24 score in predicting early and in-hospital mortality of trauma patients were 0.964 (95%CI: 0.937-0.991) and 0.954 (95%CI: 0.925-0.983), respectively. The specificity and sensitivity of TERMINAL-24 score for predicting early mortality at its best cut-off point (cut-off = 2.5) were 95.04% (95%CI: 93.43-96.28) and 96.36% (95%CI: 87.63-99.35), respectively. For predicting in-hospital mortality, these measures were 98.84% (95%CI: 97.88–99.37) and 87.13% (95%CI: 79.22-92.32), respectively (best cut-off = 2.5).

Conclusions: It seems that, TERMINAL-24 score has the same accuracy in predicting both early and in-hospital outcomes of trauma patients. Considering the calculation formula of this score and its simplicity, it can be used in pre-hospital and in-hospital settings to predict the outcome of trauma patients.

The Best ECG Lead for Predicting the Risk of Drug-Induced Torsade De Pointes Using Corrected QT Interval: A Comparative Prognostic Study

Tharathorn Raicharoen, Suphaphorn Vassasunthorn, Rittirak Othong (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e5
https://doi.org/10.22037/aaem.v13i1.2323

Introduction: Torsade de pointes (TdP) is a deadly complication from drug-induced QT prolongation. Each of the 12 lead of an electrocardiogram (ECG) has a different length of QT interval, and thus might have a different performance in TdP prediction. This study aimed to determine the best ECG lead or set of leads in this regard.  

Methods: This is a comparative prognostic accuracy study using a two-gate data gathering design. The population in this study was from two sources, a case group (Patients who had drug-induced TdP, which were identified through a systematic Medline search) and a control group (those who overdosed on QT-prolonging drugs, which included patients who were under the consultation of Medical Toxicology Services). The areas under the receiver operating characteristic curve (AUROC) of heart rate-corrected QT (QTc) in each single ECG lead and of a mean/median QTc from a set of ECG leads (17 index test) in predicting the risk of TdP were calculated and compared with each other, trying to find the best lead for this propose. QTc Interval measurements were done by four investigators (Interrater reliabilities 0.95).

Results: Finally, we included 136 and 148 ECGs from TdP cases and controls, respectively. V3 lead had the highest frequency of longest QTc interval, among the leads. The lead having the longest QTc yielded the greatest AUROC in predicting TdP regardless of QT correction formulas (QTcFRA=0.9915, QTcRTH=0.9893, QTcBZT=0.9904). The mean QTc of 3 leads (lead II, plus any two of leads V2-V4), and a median QTc of 6 leads (I, II, aVF, V2, V4, V6) provided  similar overall performance for TdP prediction (regardless of the type of QTc formula).

Conclusion: The longest QTc provided the greatest AUROC in predicting drug-induced TdP, however, the longest QTc is not located in a fixed individual lead in any patient. A less time-consuming method with comparable performance to that of the longest QTc was to use a mean QTc from 3 leads (lead II, plus any two of leads V2-V4). The potential clinical impact of this finding needs to be verified in a prospective cohort study.

Point-of-Care Testing (POCT) for Blood Gas and Electrolyte Analysis in Out-of-Hospital Cardiac Arrests’ Management; a Cross-sectional Study

Welawat Tienpratarn, Chaiyaporn Yuksen, Lunlita Chukaew, Chetsadakon Jenpanitpong, Chavin Triganjananun, Suteenun Seesuklom (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e32
https://doi.org/10.22037/aaemj.v13i1.2590

Introduction: Hypokalemia, hyperkalemia, and acidosis are among the reversible causes of out-of-hospital cardiac arrest (OHCA) that can be promptly identified using point-of-care testing (POCT) for blood gas and electrolyte analysis. This study aimed to evaluate the efficacy of POCT in the prehospital setting for OHCA management.

Methods: In this cross-sectional study the management and outcomes of OHCA patients were compared before and after implementing the POCT for blood gas and electrolyte analysis by EMS in the prehospital setting of Ramathibodi Hospital, Thailand.

Results: 217 OHCA patients with a mean age of 61 ± 17.07 (range: 58.72-63.28) years were studied (64.06 % male). 148 (68.2%) patients received POCT in the prehospital setting. Patients in the POCT group received higher administration of sodium bicarbonate (p < 0.001) and calcium gluconate (p < 0.001) compared to those without POCT. Sustained ROSC was achieved in 25% of the POCT group, compared to 11.59% in the no POCT group (p = 0.030). POCT blood gas analysis was identified as an independent predictor of sustained ROSC based on multivariable analysis (adjusted Odds: 4.60, 95% CI: 1.35-15.69; p = 0.015).

Conclusions: It seems that POCT for blood gas and electrolyte analysis in the prehospital setting could improve sustained ROSC in OHCA patients by enabling rapid and targeted management of cardiac arrest’s reversible causes.

Geriatric Nutritional Risk Index in Predicting the Mortality of Fournier's Gangrene: Analysis of 14-Year Statistics of Referral Center

Amir Alinejad Khorram, Seyyed Ali Hojjati, Fatemeh Sodeifian, Roya Kolahchi, Mohammad Farjami, Hossein Rahnama, Farzad Allameh (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e10
https://doi.org/10.22037/aaem.v13i1.2408

Introduction: Fournier’s gangrene (FG) is a type of necrotizing fasciitis affecting the external genitalia or perineum. The Geriatric Nutritional Risk Index (GNRI) has been reported as a prognostic factor to evaluate the outcomes of various diseases. This study aimed to investigate the utility of GNRI in predicting the mortality of FG patients.

Methods: This retrospective cross-sectional study evaluated the patients admitted to a referral hospital, during 14 years, with diagnosis of FG. The role of GNRI in predicting the mortality of these patients was studied. To further investigate the relationship of the GNRI score with patients’ prognosis, we controlled for the scores of Fournier's Gangrene Severity Index (FGSI) and Charlson Comorbidity Index (CCI).

Result: 78 patients with the mean age of 60.79 ± 13.76 (range: 24 -85) years were included in the study (89.74% male). The mortality rate in this series was 23 (29.5%) cases. The survived cases had significantly higher GNRI score (p < 0.001), higher Albumin level (p < 0.001), higher weight (p = 0.04), and lower mortality risk based on FGSI score (p < 0.001). In patients with low mortality risk according to FGSI score (p = 0.036) and mild comorbidities based on CCI score (p = 0.030), the association between GNRI and final prognosis was significant. In contrast, in patients with high mortality risk according to FGSI score (p =0.074) and moderate (p = 0.118) and severe (p = 0.215) comorbidities by CCI score this association was not significant.

The independent predictors of mortality in FG patients were GNRI score (OR: 1.242, 95%CI: 1.08, 1.41; p =0.001) and FGSI score (OR: 54.614, 95%CI: 6.89, 432.31; p < 0.001). The area under the receiver operating characteristic (ROC) curve of GNRI score in predicting the mortality of FG patients was 0.84 (95%CI: 0.75 - 0.93). The sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio of GNRI score at the optimal cut-off point (78.5) were, 80%, 77.9%, 60.6%, 90.4%, 3.69, and 0.255 respectively.

Conclusions: Our findings indicate that among patients with mild FG, as assessed by FGSI score, and those with low comorbidities based on CCI score, the GNRI score in survivors was significantly higher than that in non-survived. Additionally, multivariate regression analysis demonstrated that the GNRI score serves as an independent predictor of patient outcomes.

Comparison of Video Laryngoscope (VL) and Intubating Laryngeal Mask Airway (I-LMA) for Endotracheal Intubation in a Manikin with Restricted Neck Motion

Welawat Tienpratarn , Methapat Boonyingsatit , Chaiyaporn Yuksen, Sittichok Leela-amornsin, Parunchaya Jamkrajang , Thammanunt Chrunarm , Sumate Rienrakwong (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e1
https://doi.org/10.22037/aaem.v13i1.2421

Introduction: Intubating patients undergoing manual in-line stabilization (MILS) can make airway management more challenging. This study aimed to compare the outcomes of intubation with video-laryngoscope (VL) and Intubating Laryngeal Mask Airway (I-LMA) in manikin with restricted neck motion using MILS.

Methods: In this comparative study, emergency medicine residents and paramedics were randomly allocated to two crossover sets. Then the intubation outcomes (success rate, time to successful intubation, and cervical spine movement) were compared between intubation with VL and I-LMA in a manikin model with restricted cervical spine mobility, achieved through MILS.

Results: 64 participants with a mean age of 28.86 ± 4.03 (range: 24-47) years and a mean duration of intubation experience of 3.63 ± 1.35 years were studied (43.75% male, 81.3% emergency medicine resident). The intubation success rate was 62 out of 64 (96.88%) in the VL method and 52 out of 64 (81.25%) in the I-LMA method (p = 0.008). The mean time to successful intubation was 33.03±16.94 seconds in the VL method and 55.03±17.34 seconds in the I-LMA method (p < 0.001). The mean cervical range of motion (CROM) in flexion-extension was 4.38±1.82 degrees in the VL method and 4.13±3.20 degrees in the I-LMA method (p = 0.158). The mean CROM in rotation was 4.27±2.62 degrees in the VL method and 4.65±2.47 degrees in the I-LMA method (p= 0.258) and the mean CROM in lateral bending was 5.35±4.45 degrees in the VL method and 7.71±6.14 degrees in the I-LMA method (p = 0.010).

Conclusion: In a manikin model with restricted cervical spine mobility, the utilization of VL significantly improved intubation success rates, reduced time to successful intubation, and limited CROM.

Awareness of Emergency Department Workforce about the Operational Metrics: A Cross-sectional Study

Khalid Nabeel Almulhim (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e14
https://doi.org/10.22037/aaem.v13i1.2451

Introduction: The awareness of the Emergency Department (ED) workforce about the department's operational guidelines and metrics is essential to optimize the workflow and reduce workload and patient revisits to the ED. Therefore, this study aimed to evaluate the knowledge of the ED workforce regarding operational metrics.

Methods: We conducted a national cross-sectional study using an online survey in the Kingdom of Saudi Arabia between September and December 2020. ED personnel were studied regarding the ED operational metrics like laboratory/imaging turnaround times, ED length of stay, and patient revisits, linking them to quality care. Data was summarized and analyzed using the Jamovi statistical package.

Results: One hundred sixty-six participants responded to our online survey. Ministry of Health hospitals represented the largest section (n=90, 54.2%), followed by academic hospitals (n=40, 24.1%). The frequencies of an exit block in the ED were reported as 2-3 days per week (29.5%), most days (24.7%), or daily (18.1%). 41% of the respondents did not know the metrics of lab and imaging turnaround time, while 21.7% did not know about the length of stay. Most respondents agreed that the principles of ED operation should be implemented in the training programs (88.6%) and reported their satisfaction with the productivity of their department in practicing effective operations (70.9%).

Conclusion: About one-third of the ED workers were unaware of the key operational metrics of the ED. However, the respondents believe that implementing operational metrics for ED increases the quality of medical care and should be part of the training programs.

Drug Therapy-related Problems Detected by Clinical Pharmacists in a Closed Loop Medication Management; A Cross-sectional Study in UAE

Farah Selim, Mirza Baig, Mohamed Magoury, Waqar Ahmed, Mansour A. Mahmoud (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e16
https://doi.org/10.22037/aaem.v13i1.2470

Introduction: Drug therapy-related problems (DTRP) can lead to avoidable negative health consequences, particularly during hospital admissions. This study aimed to assess the frequency, causes, and associated factors of DTRPs, which are detected by clinical pharmacists’ interventions.

Methods: This is a prospective cross-sectional study of patients admitted to the medical wards of Fakeeh University Hospital, UAE, over a three-month period from September 2022 to December 2022. The data of patients who were assessed by clinical pharmacists regarding the pretense and causes of DTRPs were collected and analyzed using SPSS version 27.0.

Results: 310 patients with the mean age of 33.43 ± 19.98 years were studied (53.9% male). The highest percentage of patients were Asian (31.0%) and Arabs (30.6%). 79 (25.4%) cases had no DTRPs, while 231 (74.6) had DTRPs. The surgical ward had the highest frequency of DTRPs (41.0%). Improper drug selection with 79 cases, drug use without indication with 73 cases, and sub-therapeutic dosage with 26 cases were among the most common causes of DTRPs. Alcohol intake (p= 0.03), food allergy (p = 0.02), age group 31-40 years (p = 0.04), presence of co-morbidities (p = 0.01), family history of diseases (p = 0.02), and admission to the intensive care unit (ICU) (p = 0.01) were amongst the significantly associated factors of DTRPs. The acceptance status for clinical pharmacists’ interventions were complete in 90.0% of cases, partial in 4.1 %, and rejection in 5.9%.

Conclusion: The study findings show a high prevalence of DTRPs due to drug/dose selection and drug use without indication. It seems that the participation of clinical pharmacists in multidisciplinary teams together with the presence of closed loop medication management facilitates the detection and correction of DTRPs.

Care Complexity Factors and Discharge Destination in an Emergency Department: A Retrospective Cohort Study

Andrea Urbina, Jordi Adamuz, Maria-Eulàlia Juvé-Udina, Judith Peñafiel-Muñoz, Virginia Munoa-Urruticoechea, Maribel González-Samartino, Pilar Delgado-Hito, Javier Jacob, Marta Romero-García (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e27
https://doi.org/10.22037/aaemj.v13i1.2517

Introduction: Emergency department discharge destination is an important topic in both clinical practice and management. This study aimed to analyze the association of Care Complexity Individual Factors (CCIFs) with discharge destinations in patients who visit the emergency department (ED).

Methods: This is a retrospective cohort study with consecutive sampling, including all patients who visited the ED of a tertiary hospital during 2021-2022. Data were collected from electronic health records. The main study outcomes were discharge destinations (mortality, intensive care unit admission, hospitalization, left without being seen/discharge against medical advice, and home discharge) and 26 CCIFs. Independent multinomial logistic regression was used for assessing the association of each factor and the discharge destinations, adjusted for age, sex, and triage level. All analyses were performed with R, version 4.3.2.

Results: A total of 35,383 patients were included. Of these, 60.8% were home discharged, 34.1% were hospitalized, 2.6% were transferred to the intensive care unit, 2.1% were left without being seen, and 0.4% died. The presence of CCIFs was a risk factor of ED mortality (odds ratio (OR): 13.49 [95% confidence interval (CI): 4.99;36.46]), intensive care unit admission (OR:1.26 [95%CI:1.08;1.47]), and hospitalization (OR: 1.62 [95%CI:1.53;1.71]), whilst the presence of care complexity factors was a protective factor of discharge against medical advice (OR:0.64 [95%CI:0.55;0.74]).

Conclusion: The discharge destinations from the ED showed strong associations with the patient’s complexity factors. Health professionals should consider these relationships for the design of early detection strategies and as an aid in decision-making, to ensure equity and quality of care.

Associated Factors of Trauma Severity and Mortality in Pediatric Patients Admitted to Intensive Care Unit; a 10-Year Retrospective Study

Yiyao Bao, Jing Ye, Lei Hu, Lijun Guan, Caina Gao, Linhua Tan (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e7
https://doi.org/10.22037/aaem.v13i1.2413

Introduction: Trauma is a significant global public health concern and the leading cause of morbidity and mortality in children. This study aimed to assess the independent predictors of trauma severity as well as mortality in pediatric patients admitted to the intensive care unit (ICU).

Methods: In this cross-sectional study, following the STROBE checklist, we retrospectively analyzed the clinical and baseline characteristics of pediatric patients with trauma injuries admitted to the ICU of Children’s Hospital of Zhejiang University School of Medicine, China, over a decade.

Results: 951 pediatric patients with a mean age of 4.79 ± 3.24 years (60.78% Boys) were studied (mortality rate 8.41%). Significant associations were observed between ISS and place of residence (p = 0.021), location of the injury (p = 0.010), year of injury (p <0.001), and injury mechanism (p <0.001). The two independent factors of trauma severity were the year of injury (β  = 0.47; 95%CI: 0.28 – 0.65) and injury mechanism (β = -0.60; 95%CI: -0.88 - -0.31).

Significant differences were observed between survived and non-survived regarding age (p <0.001), ISS score (p <0.001), time elapsed from injury to ICU (p <0.001), duration of mechanical ventilation (p <0.001), GCS score (p <0.001), and the proportion of patients requiring mechanical ventilation (p <0.001 ). The results of multivariate analysis indicated that age (OR = 0.805; 95%CI: 0.70 - 0.914; p = 0.001) and GCS score at ICU admission (OR = 0.629; 95%CI: 0.53 - 0.735; p < 0.001) acted as protective factors, whereas mechanical ventilation in the ICU (OR = 7.834; 95%CI: 1.766 - 34.757; p = 0.007)  and ISS score at ICU admission (OR = 1.088; 95%CI: 1.047 - 1.130; p < 0.001) served as risk factors for mortality.

Conclusion: Automobile-related injuries represent the leading cause of trauma in children, with escalating severity scores year over year among pediatric patients admitted to the ICU with trauma injuries. Based on the findings the independent predictors of mortality of pediatric trauma patients admitted to the ICU were age, GCS score at ICU admission; mechanical ventilation in the ICU, and ISS score at ICU admission. Also, the year of injury and injury mechanism were independent predictors of trauma severity.

Pre-hospital Associated Factors of Survival in Traumatic Out-of-hospital Cardiac Arrests: An 11-Year Retrospective Cohort Study

Thanakorn Laksanamapune, Chaiyaporn Yuksen, Natthaphong Thiamdao (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e15
https://doi.org/10.22037/aaem.v13i1.2458

Introduction: Traumatic out-of-hospital cardiac arrest (TOHCA) presents significant public health challenges. The high accident rates and variability in prehospital management in Thailand further complicate TOHCA treatment. This study aimed to analyze prehospital prognostic factors of survival in TOHCA cases.

Methods: This study is a retrospective cohort study utilizing data from the Information Technology of Emergency Medicine System (ITEMS) from January 2012 to December 2022. It included TOHCA patients who received prehospital care and were transported to the emergency department (ED). We used an exploratory approach, incorporating all prognostic variables into a multivariable logistic regression model. Results are presented as odds ratios (OR) with 95% confidence intervals (CIs) and p-values.

Results: Over an 11-year period, 35,724 patients with the mean age of 39.69±20.53 (range: 1-99) years were included in the final analysis (78.69% male). Of these, 6,590 (18.45%) survived to hospital admission, while 29,134 (81.55%) died in the ED. Prehospital management factors significantly increasing the likelihood of survival to hospital admission included stopping bleeding (OR=1.38, 95% CI=1.24-1.54, P<0.001), endotracheal intubation (ETT) (OR=2.09, 95% CI=1.74-2.50, P<0.001), intravenous fluid administration (OR=1.66, 95% CI=1.35-2.05, P<0.001), defibrillation (OR = 2.35, 95% CI=1.96-2.81, P<0.001), age (aOR = 0.99, 95% CI = 0.98-0.99, P < 0.001), closed fracture (aOR = 0.59, 95% CI = 0.53-0.66, P < 0.001), open fracture (aOR = 0.54, 95% CI = 0.48-0.61, P < 0.001), dislocation (aOR = 0.60, 95% CI = 0.45-0.81, P = 0.001), and on scene time <10 min (aOR = 0.63, 95% CI = 0.54-0.75, P < 0.001).

Conclusions: To improve survival to hospital admission in TOHCA, several factors should be prioritized. These include administering intravenous fluid boluses, controlling external bleeding, delivering defibrillation when indicated, and performing ETT.

Associated Factors of the Need for Mechanical Ventilation Following Traumatic Injuries; a Registry-Based Study on 2,708 Cases in Iran

Zahra Ramezani, Vali Baigi, Mohammadreza Zafarghandi, Vafa Rahimi-Movaghar, Reza Farahmand-Rad, Akram Zolfaghari Sadrabad, Seyed-Mohammad Piri, Mahgol Sadat Hassan Zadeh Tabatabaei, Khatereh Naghdi, Payman Salamati (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e34
https://doi.org/10.22037/aaemj.v13i1.2511

Introduction: Traumatic injuries can affect respiration both directly and indirectly. This study aimed to evaluate the predictive factors of need for mechanical ventilation (MV) following traumatic injuries.

Methods: This Retrospective registry-based cross-sectional study comprised trauma patients admitted to a major referral trauma center in Iran, from March 28, 2019, to January 31, 2023, identified within the National Trauma Registry of Iran (NTRI). Logistic regression analysis was used to assess the association between demographic and clinical variables with the need for MV.

Results: A total of 2708 trauma patients with a mean age of 41.79 ± 21.84 (range:1-98) years were included (73.4% male). A total of 251 (9.3%) patients were admitted to the Intensive Care Unit (ICU); 113 (4.2%) experienced MV. The significant associated factors of need for MV based on the univariable analysis were age ≥ 65 years (p <0.001); penetrating trauma (p < 0.001) and falling (p = 0.01); private mode of transportation to ED (p < 0.001); site of injury (p < 0.001); heart rate ≥ 100/ minutes (p = 0.04); O2 saturation < 90 % on room air (p < 0.01); Glasgow Coma Scale (GCS) < 13 (p< 0.001); and injury Severity Score (ISS) ≥ 9 (p< 0.001). Based on the multivariate logistic regression analysis, the independent predictors of the need for MV in trauma patients were the site of injury (p < 0.001), GCS < 13 (p < 0.001), and ISS ≥ 9 (p < 0.001).

Conclusion: Based on the findings, ISS ≥ 9, GCS < 13, and site of injury were among the independent predictors of the need for MV following trauma.

The Impact of Intoxication on the Prognosis of High-Speed Motor Vehicle Accidents: A Tertiary Care Center Experience

Muhannad Q. Alqirnas, Rafeef M. Aljarwan, Moustafa S. Alhamadh, Sadeem A. Khallaf, Faisal A. Alsomali, Faris M. Albaqami, Najd R. AlMudaiheem, Munira A. AlKhashan, Mohammad Al Deeb (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e13
https://doi.org/10.22037/aaem.v13i1.2427

Introduction: Several studies suggest a causal link between psychoactive agents and motor vehicle accidents (MVA). This study aimed to evaluate the impact of substance abuse and alcohol intoxication on the prognosis of high-speed MVA victims.

Methods: This is a single-center retrospective cross-sectional study involving adult multiple trauma cases who were admitted to the emergency department for high-speed MVA and underwent toxicological screening. The cohort was conducted based on two main outcomes; the survival status and the neurological outcomes.

Results: 894 patients with the mean age of 27.8 ± 9.24 (range:18-37) years were studied (97.9% male). The most common indicators of severity were car rollover and ejection from the car. 296 of the patients had severe traumatic brain injury (TBI). 622 of the patients had a positive toxicological screening, with benzodiazepines (51.2%) and alcohol (26.6%) being the most commonly abused substances. The mortality rate was 5.8% and 12.1% of the patients had unfavorable neurological outcomes upon discharge. On multivariate logistic regression, predictors of mortality among high-speed MVA victims were report of a death at the scene (adjusted odds ratio (aOR): 2.529; 95% confidence interval (CI): 1.026-6.232; p = 0.044), severe TBI, the presence of dilated pupils (aOR: 11.074; 95% CI: 1.293-94.812; p = 0.028), hypotension (aOR: 0.456; 95% CI: 0.227-0.916; p = 0.027), and hypoxia (aOR: 2.95; 95% CI: 1.46-5.95; p = 0.003). Predictors of unfavorable neurological outcomes were report of a death at the scene (aOR: 3.133; 95% CI: 1.445-6.791; p = 0.004),  positive toxicology screening (aOR: 3.30; 95% CI:1.68-10.204; p = 0.038), severe TBI,  the presence of hypoxia (aOR: 2.96; 95% CI:1.645-5.319; p = 0.000), hypotension (aOR: 0.437; 95% CI: 0.252-0.758; p = 0.003), and bleeding (aOR: 0.287; 95% CI: 0.164-0.501; p < 0.001).

Conclusion: A concerning proportion of high-speed MVA victims had a positive toxicology screening. Although intoxication did not increase mortality of high-speed MVAs, it was a significant predictor of unfavorable neurological outcomes of survivors.

Detection of Body Packs in Abdominal CT scans Through Artificial Intelligence; Developing a Machine Learning-based Model

Sayed Masoud Hosseini, Seyed Ali Mohtarami, Shahin Shadnia, Mitra Rahimi, Peyman Erfan Talab Evini, Babak Mostafazadeh, Azadeh Memarian, Elmira Heidarli (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e23
https://doi.org/10.22037/aaemj.v13i1.2479

Introduction: Identifying the people who try to hide illegal substances in the body for smuggling is of considerable importance in forensic medicine and poisoning. This study aimed to develop a new diagnostic method using artificial intelligence to detect body packs in real-time Abdominal computed tomography (CT) scans.

Methods: In this cross-sectional study, abdominal CT scan images were employed to create a machine learning-based model for detecting body packs. A single-step object detection called RetinaNet using a modified neck (Proposed Model) was performed to achieve the best results. Also, an angled Bbox (oriented bounding box) in the training dataset played an important role in improving the results.

Results: A total of 888 abdominal CT scan images were studied. Our proposed Body Packs Detection (BPD) model achieved a mean average precision (mAP) value of 86.6% when the intersection over union (IoU) was 0.5, and a mAP value of 45.6% at different IoU thresholds (from 0.5 to 0.95 in steps of 0.05). It also obtained a Recall value of 58.5%, which was the best result among the standard object detection methods such as the standard RetinaNet.

Conclusion: This study employed a deep learning network to identify body packs in abdominal CT scans, highlighting the importance of incorporating object shape and variability when leveraging artificial intelligence in healthcare to aid medical practitioners. Nonetheless, the development of a tailored dataset for object detection, like body packs, requires careful curation by subject matter specialists to ensure successful training.

The Urinary Liver-Type Fatty Acid Binding Protein (L-FABP) in Early Detection and Outcome Prediction of Sepsis-Associated Acute Kidney Injury

Ghi Nguyen Hai, Binh Nguyen Gia, Hoa Do Thanh, Cuong Nguyen Thai, Duc Vu Anh, Anh Duong Duc, Duong Le Xuan Xuan (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e26
https://doi.org/10.22037/aaemj.v13i1.2525

Introduction: Acute kidney injury (AKI) is one of the most frequent complications in septic shock cases, and has a high mortality rate. The aim of this study was to determine the value of urinary liver-type fatty acid binding protein (L-FABP) in early detection and outcome prediction of AKI in patients with sepsis and septic shock.

Methods: This prospective cohort study was conducted on patients who presented to the emergency department (ED) with sepsis or septic shock. Urinary L-FABP levels were measured at the time of admission and patients were classified into AKI and non-AKI groups within 7 days according to the KIDGO Criteria. The screening performance characteristics of urinary L-FABP in early detection of AKI within seven days of admission and need for renal replacement therapy (RRT) were calculated and reported.

Results: 212 patients with the mean age of 66.5 ± 16.2 (range 18-99) years were included (60.4% male). 54 (25.5%) patients had sepsis, and septic shock was developed in 158 (74.53%) cases. 143 (67.5%) patients were complicated with AKI. The area under the receiver operating characteristic (ROC) curve (AUC) of urinary L-FABP in early detection of sepsis-associated AKI was 0.94 (95% confidence interval (CI): 0.90 - 0.97), compared to the AUC of 0.64 (95% CI: 0.54-0.74) for serum creatinine. The sensitivity and specificity of urinary L_FABP at its best cutoff point (13.90 μg L-FABP/g Cr) were 89.9% and 86.3%, respectively. The area under the ROC curve of urinary L-FABP in predicting the need for RRT in sepsis-associated AKI patients was 0.74 (95% CI: 0.64-0.85), compared to the AUC of 0.53 (95% CI: 0.41-0.64) for serum creatinine. The sensitivity and specificity of urinary L-FABP at its best cutoff point (22.05 μg L-FABP/g Cr) were 63.6% and 71.4%, respectively.

­Conclusions:  It seems that, L-FABP could be considered as a valuable biomarker for early detection and predicting the severity of AKI in septic patients.

Modified National Early Warning Scores (MNEWS) for Predicting the Outcomes of Suspected Sepsis Patients; A Prospective Cohort Study

Nipon Diskumpon, Busabong Ularnkul, Winchana Srivilaithon, Pariwat Phungoen, Kiattichai Daorattanachai (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e24
https://doi.org/10.22037/aaemj.v13i1.2407

Introduction: The National Early Warning Score (NEWS) is commonly used to identify patients at high mortality risk. However, it has notable limitations. In this study, to enhance the accuracy, we revised it and evaluated the performance of modified NEWS (MNEWS) in predicting the outcomes of suspected sepsis patients.

Methods: This single-center, prospective cohort study was conducted on patients with suspected sepsis to evaluate the accuracy of MNEWS in predicting mortality, survival to discharge, vasopressor requirements, and the need for mechanical ventilation. The MNEWS comprises the NEWS variables plus age, chronic major organ dysfunction, malignancy, functional status, and specific infected organ involvement. Sensitivity, specificity, likelihood ratio (LR), and area under the receiver operating characteristic curve (AUROC) were used to evaluate the performance of the MNEWS in predicting the studied outcomes.

Results: Of the 1,393 patients included in this study, 209 died. Mean MNEWS was significantly higher in non-survivors than survivors (19.8 vs. 14.9, p<0.001). The AUROC of MNEWS in predicting 30-day mortality was 0.82 (95% CI: 0.79–0.85). MNEWS ≥ 18 had the highest accuracy for 30-day mortality prediction with 76.1% sensitivity, 75% specificity, positive LR of 3.13, and AUROC of 0.76 (95% CI: 0.73–0.79). The AUROC of MNEWS ≥18 for predicting survival until discharge, need for vasopressors, and need for mechanical ventilation were 0.75 (95% CI: 0.72–0.78), 0.72 (95% CI: 0.69–0.75), and 0.76 (95% CI: 0.73–0.79), respectively. Additionally, MNEWS ≥18 demonstrated superior predictive performance, compared with NEWS ≥7 and qSOFA ≥2 for various clinical outcomes.

Conclusions: The MNEWS was similar to the NEWS in overall predictive accuracy for 30-day mortality but exhibited a higher predictive accuracy than did the qSOFA score. Notably, MNEWS ≥18 was a significant indicator of 30-day mortality risk, as well as the likelihood of requiring vasopressors, survival to discharge, and 7-day mortality.

Research Trends in the Field of Emergency Medicine; A Comparative Bibliometric Analysis on Publications Across Journal Quartiles

Mehrdad Farrokhi, Mohammad Mehdi Forouzanfar, Behrooz Hashemi, Seyed Saeed Hashemi Nazari (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e22
https://doi.org/10.22037/aaemj.v13i1.2461

Introduction: Quantitative and qualitative evaluations of the publication trends and architecture can be useful for guiding future research agendas of both researchers and journals.  This study aimed to investigate the bibliometric characteristics of emergency medicine (EM) researches across different journal quartiles.

Methods: A systematic search was conducted in the Scopus database to retrieve published documents from journals in Q1 to Q4 categories (based on Scimago Journal Ranking) from inception to April 2024. The bibliometric analyses were carried out using the Visualization of Similarities viewer (VOSviewer) software.

Results: Based on author keywords analysis, we identified 7 (96 nodes), 7 (110 nodes), 6 (89 nodes), and 7 (110 nodes) clusters for Q1 to Q4 categories, respectively. The most frequent author keywords in Q1 to Q4 categories were resuscitation, trauma, COVID-19, and pediatric, respectively. Among the top 10 author keywords in Q1 to Q4 categories, cardiac arrest, disaster, burn, and trauma with average of 19.58, 9.56, 4.92, and 1.61 citations were the most cited topics.

Conclusion: This bibliometric analysis highlights that main focus of research in EM researches varies across different journal quartiles. The most commonly studied topics in EM journal categories are resuscitation, trauma, COVID-19, and pediatric.

Identifying COVID-19-Infected Segments in Lung CT Scan Through Two Innovative Artificial Intelligence-Based Transformer Models

Zeinab Momeni pour, Ali Asghar Beheshti Shirazi (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e21
https://doi.org/10.22037/aaemj.v13i1.2515

Introduction: Automatic systems based on Artificial intelligence (AI) algorithms have made significant advancements across various domains, most notably in the field of medicine. This study introduces a novel approach for identifying COVID-19-infected regions in lung computed tomography (CT) scan through the development of two innovative models.

Methods: In this study we used the Squeeze and Excitation based UNet TRansformers (SE-UNETR) and the Squeeze and Excitation based High-Quality Resolution Swin Transformer Network (SE-HQRSTNet), to develop two three-dimensional segmentation networks for identifying COVID-19-infected regions in lung CT scan. The SE-UNETR model is structured as a 3D UNet architecture with an encoder component built on Vision Transformers (ViTs). This model processes 3D patches directly as input and learns sequential representations of the volumetric data. The encoder connects to the decoder using skip connections, ultimately producing the final semantic segmentation output. Conversely, the SE-HQRSTNet model incorporates High-Resolution Networks (HRNet), Swin Transformer modules, and Squeeze and Excitation (SE) blocks. This architecture is designed to generate features at multiple resolutions, utilizing Multi-Resolution Feature Fusion (MRFF) blocks to effectively integrate semantic features across various scales. The proposed networks were evaluated using a 5-fold cross-validation methodology, along with data augmentation techniques, applied to the COVID-19-CT-Seg and MosMed datasets.

Results: Our experimental results demonstrate that the Dice value for the infection masks within the COVID-19-CT-Seg dataset improved by 3.81% and 4.84% with the SE-UNETR and SE-HQRSTNet models, respectively, compared to previously reported work. Furthermore, the Dice value for the MosMed dataset increased from 66.8% to 69.35% and 70.89% for the SE-UNETR and SE-HQRSTNet models, respectively.

Conclusion: These improvements indicate that the proposed models exhibit superior efficiency and performance relative to existing methodologies.

The Burden of Head Injuries in Iran from 1990 to 2019: Findings from The Global Burden of Disease Study 2019

Tahereh Maleki, Vali Baigi, Negin Safari, Mahdi Sharif-Alhoseini (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e12
https://doi.org/10.22037/aaem.v13i1.2391

Introduction: Head injuries (HI) pose a significant public health concern globally, impacting morbidity, mortality, and economic burden. This study aimed to evaluate the epidemiology and trends associated with head injuries in Iran from 1990 to 2019.

Methods: Our study, based on data from the Global Burden of Diseases (GBD) Study 2019, undertook a comprehensive comparison of the burden of HI in Iran with the Middle East and North Africa (MENA) and global benchmarks. We assessed the incidence, prevalence, and years lived with disability (YLD) through various metrics, including absolute numbers, age-standardized rates (ASR), percentage changes, and estimated annual percentage changes (EAPC) from 1990 to 2019.

Results: The incidence of HI in Iran decreased significantly from 1990 to 2019, with a notable reduction compared to MENA and global trends (EAPC: -1.44, 0.71, and -0.11, respectively). Prevalence showed a declining trend (EAPC: -1.00), with a slight increase in YLDs (EAPC: 0.12). Notable peaks in HI incidence coincided with natural disasters, notably the 1990 Manjil-Rudbar earthquake and the 2003 Bam earthquake.

Conclusion: Our study reveals a decline in the overall burden of HI in Iran over the study period. To sustain this positive trend and minimize the impact of HI on public health and socioeconomic well-being, policy efforts should be directed toward ongoing prevention, early detection, and preparedness for natural disasters.

Review Article


Near Infrared Spectroscopy as a Diagnostic Tool for Screening of Intracranial Hematomas; A Systematic Review and Meta-Analysis

Hamed Zarei, Amirali Zarrin, Mahrokh Janmohamadi, Narges Saadatipour, Mobina Yarahmadi, Mohammadmobin Moeini, Shireen Shams Ardekani, Ali Safdarian, Mohammadhossein Vazirizadeh-Mahabadi , Mohammadhossein Babaei, Negin Bagheri, Amirhossein Gholipour, Mohammadreza Azadi, Soraya Parvari, Amir Azimi (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e9
https://doi.org/10.22037/aaem.v13i1.2411

Introduction: Evidence supports the clinical applicability of near-infrared spectroscopy (NIRS) in intracranial hematoma detection in prehospital settings. This systematic review and meta-analysis aimed to determine the diagnostic yield of NIRS for detecting intracranial hematoma in traumatic brain injury (TBI) patients.

Methods: A systematic search was performed in July 2024 in Medline, Embase, Scopus, and Web of Science databases. We included studies that evaluated the diagnostic performance of NIRS in detecting intracranial hematoma in both adult and pediatric patients suspected of TBI in prehospital or emergency settings, using brain computed tomography (CT) scan or magnetic resonance imaging as the gold standard.

Results: Eighteen studies enrolling 2979 patients were included. NIRS exhibited an Area Under the Curve (AUC) of 0.91 (95% confidence interval [CI]: 0.88, 0.93), with a sensitivity of 0.86 (95% CI: 0.78, 0.91), and specificity of 0.82 (95% CI: 0.72, 0.89) across all age groups. In children, the results demonstrated an AUC of 0.92 (95% CI: 0.89, 0.94), sensitivity of 0.95 (95% CI: 0.21, 1.00), and specificity of 0.81 (95% CI: 0.65, 0.91). Among adults, the AUC was 0.91 (95% CI: 0.88, 0.93), with sensitivity and specificity of 0.86 (95% CI: 0.78, 0.92) and 0.83 (95% CI: 0.70, 0.91), respectively. Performance improved when NIRS was operated by non-physicians (AUC = 0.94 [95% CI: 0.91, 0.96], sensitivity = 0.90 [95% CI: 0.79, 0.95], specificity = 0.85 [95% CI: 0.71, 0.93]) compared to physicians (AUC = 0.90 [95% CI: 0.87, 0.92], sensitivity = 0.88 [95% CI: 0.77, 0.94], specificity = 0.75 [95% CI: 0.59, 0.76]). Patients' age group and operator type were identified as potential sources of heterogeneity. Sensitivity analyses confirmed the robustness of the findings, particularly in mild TBI cases and studies implementing a ΔOD > 0.2 as the threshold for a positive NIRS result.

Conclusion: NIRS proves to be an effective diagnostic tool for detecting traumatic intracranial hematoma in both pediatric and adult groups, with high sensitivity and specificity. Its utility in prehospital triage, operated by physicians or paramedics, underscores its potential for broader clinical application.

Diagnostic Value of Chest Computed Tomography Scan for Identification of Foreign Body Aspiration in Children: A Systematic Review and Meta-analysis

Babak Goodarzy, Erfan Rahmani, Mehrdad Farrokhi, Reza Tavakoli, Atousa Moghadam Fard, Mohadese Ranjbaran Ghaleh, Yeganeh Ghalichebaf Yazdi, Reza Amani Beni, Erfan Ghadirzadeh, Fatemeh Afrazeh, Yalda Alipour Khabir, Sevda Alipour khabir, Paria Bakhtiyari, Javaneh Atighi, Mohammad Mahjoubi, Zahra Momeni, Hediyeh Jalayeri, Mohammad Hossein Hosseini, Behnam Hoorshad, Mehdi Tavakoli, Sepideh Seifi, Hamidreza Momeni, Amirhossein Mirbolook, Alireza Esmaili Jobani, Mozhdeh Mohammadi Visroudi, Aboulfazl Najafi, Zahrasadat Hosseini, Sobhan Aboulhassanzadeh, Negar Ajami, Sahel Ramezani, Mahdokht Sadat Manavi, Sina Safdari, Amirali Fallahian, Habib Azimi, Reza Zahedpasha, Ehsan Ranjbar, Mohammad Saeed Kahrizi, Lida Zare Lahijan (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e3
https://doi.org/10.22037/aaem.v13i1.2431

Introduction: Foreign body aspiration (FBA) is a common, life-threatening pediatric emergency and was shown to be associated with high risk of morbidity and mortality. This systematic review and meta-analysis aimed to investigate the diagnostic value of chest computed tomography (CT) scan for identification of FBA in children.

Methods: From inception to May 2024, a systematic search was carried out across multiple databases including Medline, Scopus, and Web of Science, considering published papers in English language. Quality assessment of the included studies was performed using seven domains of Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2).

Results: The systematic literature search yielded 7203 articles. The pooled sensitivity and specificity of chest CT scan for identification of FBA were 0.99 (95% CI: 0.98-0.99) and 0.97 (95% CI: 0.96-0.98), respectively. The pooled positive likelihood ratio was 10.12 (95% CI: 4.59-22.20), and pooled negative likelihood ratio was 0.05 (95% CI: 0.02-0.1). Furthermore, the area under the summarized receiver operating characteristic (SROC) curve was 0.98.

Conclusion: Our meta-analysis revealed that despite high heterogeneity, in the diagnostic characteristics of chest CT scan among studies, it has high diagnostic value in identifying FBA in suspected pediatric cases.

Optic Nerve Sheath Diameter in Predicting the Neurological Outcomes of Cardiac Arrest Survivors: A Systematic Review and Meta-analysis

Parisa Jafari Khouzani, Erfan Rahmani, Mehdi Rezaei, Sasan Pohrbagher Benam, Atousa Moghadam Fard, Reza Amani-Beni, Maziar Daneshvar, Faezeh Jalayer Sarnaghy, Naghme Masoomi Goodarzi, Ramila Abedi Azar, Amirhossein Mirbolook, Peyman Bashghareh, Elham Bibak, Babak Goodarzi, Zahra Salarinezhad, Reza Zahedpasha, Marzieh Hajizaman, Negar Pourhossein Rahmani, Azam Darvishi, Alireza Hadizadeh, Fatemeh Zandi, Ashkan Azizi, Armin Naderi, Sepideh Shah Hosseini, Asie Sanjary, Mozhdeh Mohammadi Virsoudi, Habibollah Afshang, Seyedsaber Mirabdali, Navid Fathalian, Pouria Momeni, Mahsan Valizade, Fateme Nozari, Hamed Ghorbani, Sanam Mohammadzadeh, Seyed Kiavash Sajadi, Azam Abdollahi, Mehrdad Farrokhi (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e29
https://doi.org/10.22037/aaemj.v13i1.2486

Introduction: Previous studies have investigated different methods for estimating neurological outcomes after cardiac arrest. However, there is still much uncertainty about using optic nerve sheath diameter (ONSD) measurement as an indirect method for predicting neurological outcomes following cardiac arrest. In this meta-analysis, we aimed to investigate the value of ONSD for predicting the neurological outcomes of cardiac arrest survivors.

Methods: We comprehensively performed a systematic search in three main electronic databases, including Scopus, Medline, and Web of Science Cochrane, from inception to August 2024. Based on the heterogeneity evaluation results, fixed or random effects models were used to estimate the pooled diagnostic parameters. Meta-regressions were performed for subgroup analysis.

Results: The pooled sensitivity and specificity of ONSD for predicting the neurological outcomes were 0.56 (95% CI, 0.35–0.74) and 0.92 (95% CI, 0.85–0.96), respectively. Meta-regression revealed that as the cutoff level of ONSD increases, the sensitivity significantly decreases (P < 0.01), while the specificity significantly increases (P = 0.01). Furthermore, meta-regression analysis revealed that ONSD measurement using CT scans is significantly associated with lower sensitivity and higher specificity compared to ultrasound (P = 0.009 and P = 0.01).

Conclusion: Our meta-analysis showed that ONSD has low sensitivity and high specificity for predicting neurological outcomes in survivors of cardiac arrest. However, since the cut-off values and methods of ONSD measurement affect its predictive performance, further studies will be required to standardize these factors to achieve optimal predictive parameters.

Ethical Decision-Making Regarding Life Sustaining Treatment in End-Of-Life Care: A Scoping Review of the Similarities and Differences Between Two Viewpoints

Bagher Larijani, Mina Mobasher, Farzaneh Zahedi, Mamak Tahmasebi (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e17
https://doi.org/10.22037/aaemj.v13i1.2402

Decisions on life-sustaining treatment depend on evaluating fundamental ethical principles regarding taking human life. This study aimed to compare the Islamic standpoint with secular views on ethical decision-making in end-of-life care. We conducted a scoping review to analyze and compare articles published in 2000-2022, regarding ethical criteria for withdrawing life-prolonging treatments in dying patients, and the final decision-maker in such cases. The main difference between the two viewpoints, however, lies in the perspective that in Islam to save human life is of utmost importance, and therefore the criteria for treatment benefits, indications, and goals should all be evaluated in the light of this profound Islamic concept. The most significant similarity discovered between the two standpoints was that a terminal patient’s wish not to prolong the process of dying should be respected, and the physician’s opinion in determining the benefit or futility of treatment is of utmost importance. Comparison of Islamic and Secular perspectives about ethical decision-making in end-of-life care regarding life sustaining treatment indicates that benefits of treatments for patients, and healthcare goals are among the major factors in decision-making according to both viewpoints, and patients, their families, physicians, and the medical team are all involved in making the final decision.

Traumatic Dental Injuries’ Prevalence across Diverse Healthcare Settings: A Systematic Review and Meta-Analysis

Monika Tysiąc-Miśta, Marta Tanasiewicz, Shayan Amini, Shaghayegh Najary, Mohammad Taghi Baghani, Reza Eftekhar Ashtiani, Shireen Shidfar, Mohammad Javad Nasiri (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e11
https://doi.org/10.22037/aaem.v13i1.2432

Introduction: Traumatic dental injuries (TDI) are a global public health concern, impacting individuals of various age groups. This systematic review aimed to consolidate current evidence on TDI prevalence, providing insights for improved management and prevention strategies.

Methods: A comprehensive search was conducted across PubMed/MEDLINE, Embase, and Scopus databases for studies published between January 1, 2000, and July 1, 2024. Studies reporting on the prevalence of TDI in various populations were included. We followed PRISMA guidelines in the review process. Descriptive statistics were used to summarize study characteristics, and a random-effects model was applied in the meta-analysis using STATA version 14 to pool prevalence rates, while accounting for inter-study variability. Begg’s and Egger’s tests were conducted to assess publication bias.

Results: The review included data of 151,205 patients from 30 studies across diverse healthcare settings. The prevalence rates varied significantly across studies, ranging from as low as 1.88% to as high as 86.98%. The overall pooled prevalence of TDI, calculated using a random effects model, was 19.48% (95% CI: 11.21% to 27.74%), indicating substantial heterogeneity among the studies (I-squared = 100.0%, p < 0.001). The prevalence varied significantly across different healthcare settings and demographic groups. No evidence of publication bias was found (p > 0.05).

Conclusions: This systematic review underscores the high prevalence of TDI and highlights the need for targeted preventive strategies and evidence-based interventions in dental trauma care.

Incidence and Risk Factors of Surgical Site Infection After Knee Arthroplasty; a Systematic Review and Meta-Analysis

Ayub Bagheri , Alireza Sharifi Niknafs, Bahar Farhadi, Seyed Amirhossein Mazhari, Parnia Karimian, Nafiseh Hekmati Pour, Hamid Hojjati, Iman Nosratabadi, Azadeh Emami , Reza Salehi (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e28
https://doi.org/10.22037/aaemj.v13i1.2543

Introduction: Surgical site infection (SSI) constitutes a substantial complication after knee arthroplasty, contributing to notable morbidity. This study aimed to review the existing literature on the incidence and risk factors of SSI following knee arthroplasty.

Methods: A systematic search was undertaken across various international electronic databases, including Scopus, PubMed, Web of Science, and Persian electronic databases such as Iranmedex and the Scientific Information Database. The search strategy involved the use of keywords derived from Medical Subject Headings, such as “incidence”, “Surgical wound infection”, “Surgical site infection”, and “Arthroplasty”, covering records from the earliest available up to March 17, 2024.

Results: The study incorporated a collective participant group of 1,366,494 knee arthroplasty procedures from twenty-three chosen studies. The pooled incidence rate of SSI after knee arthroplasty was 1.7% (95% confidence interval (CI): 1.1% to 2.6%; I²=99.687%; P<0.001). The Odds Ratio (OR) for the incidence of SSI in males was observed to be significantly higher than that in females (OR: 1.617; 95% CI: 1.380 to 1.894; Z=5.951; P<0.001). The pooled incidence of SSI among diabetic patients was 1.3% (95% CI: 0.6% to 2.8%; I²=99.126%; P<0.001).

Conclusion: Based on the main findings, SSIs continue to be a significant complication of knee arthroplasty, with an incidence of 1.1% to 2.6%. Male gender and diabetes mellitus were associated with an augmented probability of SSIs following knee arthroplasty.

Feasibility and Effectiveness of Vaccines for COVID-19: An Umbrella Review

SeyedAhmad SeyedAlinaghi, Amirreza Pashapouryeganeh, Soheil Dehghani, Pegah Mirzapour, Faeze Abbaspour, Fatemeh Afroughi, Payman Rahimzadeh, Morvarid Najafi, Hoomaan Ghasemi, Navid Mozafari, Zahra Soltanali, Esmaeil Mehraeen (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e6
https://doi.org/10.22037/aaem.v13i1.2357

Introduction: In January 2020, WHO declared the 2019 Coronavirus Disease (COVID-19) a pandemic. Though COVID-19 vaccines are recommended, ongoing surveillance is crucial due to potential unforeseen events. Evaluation of long-term effectiveness and safety and addressing emerging variants are vital. This study integrates systematic reviews to assess COVID-19 vaccine efficacy, immunogenicity, and safety comprehensively.

Methods: This study was an umbrella review study on the feasibility and effectiveness of vaccines for COVID-19. We conducted a comprehensive search in PubMed, Web of Sciences, and Scopus, using MeSH terms and keywords related to COVID-19 vaccines. Inclusion criteria comprised peer-reviewed systematic reviews and meta-analyses in English, focusing on feasibility and effectiveness. Exclusion criteria targeted non-systematic reviews exclusively on vaccine safety and duplicates. Two independent reviewers screened and resolved discrepancies. Data extraction included key details.  Methodological quality was assessed using the ROBIS tool. Data synthesis involves narrative and, if applicable, quantitative synthesis (meta-analysis). Reporting followed PRISMA guidelines.

Results: A total of 32 systematic reviews were included in the study, of which 20 also conducted a meta-analysis. The studies investigated in the included reviews ranged from 7 to 74. The included articles were conducted in various countries around the globe. The findings indicated that COVID-19 vaccines are generally safe and effective for individuals with various medical conditions. The overall risk of bias for the included studies was assessed as low risk.

Conclusion: The study outcomes indicated that mRNA vaccines exhibit a higher incidence of adverse events but demonstrate greater efficacy.  Conversely, inactivated and protein subunit vaccines are safer but exhibit lower efficiency.  Moreover, the vaccine is considered safe for individuals with specific conditions such as inflammatory bowel disease, solid organ transplant recipients, children, pregnant individuals, and those with hematologic problems. Ultimately, the acceptance of the COVID-19 vaccine among individuals is influenced by various factors, including geographic, socioeconomic, and pandemic-related considerations.

The Management of Traumatic Optic Neuropathy: A Systematic Review and Meta-Analysis

Mohammad Fallahzadeh, Amirreza Veisi, Faezeh Tajari, Zahra Khorrami, Mehri Farhang Ranjbar, Roozbeh Tavanaei, Navid Ghassembaglou, Seyed Hadi Aghili (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e19
https://doi.org/10.22037/aaemj.v13i1.2453

Introduction: Traumatic optic neuropathy (TON) is a serious condition resulting from optic nerve injury, often due to head trauma. This study systematically reviews the existing literature to evaluate the effectiveness of various treatments in improving visual outcomes in TON patients.

Methods: A comprehensive literature search was conducted across databases including Medline (via PubMed), Web of Science, Cochrane Library, and EMBASE from January 1992 to October 2024. Studies were selected based on inclusion criteria that focused on TON patients treated with corticosteroids, conservative therapy, erythropoietin therapy, or surgical interventions. Quality assessment of the included studies was performed using the Joanna Briggs Institute (JBI) Risk of Bias Tool for each design. Data extraction and quality assessment were performed by two independent reviewers, with a meta-analysis conducted to evaluate the pooled visual acuity (VA) improvement rates.

Results: A total of 23 studies were included, encompassing 1,851 patients with TON. The meta-analysis revealed a pooled VA improvement rate of 50.6% across all treatment modalities. Specifically, corticosteroid-only treatment resulted in a 56.2% improvement rate, while combined corticosteroid and surgical decompression showed a 42.9% improvement rate. Conservative therapy had a 47.8% improvement rate. The heterogeneity among studies was significant (I2= 89.9%), and no significant publication bias was detected. Subgroup analyses indicated varied outcomes, with some studies reporting better results with early intervention.

Conclusion: The treatment of TON remains challenging, with no single modality showing clear superiority. The corticosteroids and surgical interventions provide potential benefits; however, conservative therapy might be appropriate for certain cases. Future research should focus on optimizing treatment protocols and exploring new therapeutic options, such as erythropoietin to improve visual outcomes in TON patients.

Stem Cell-Derived Exosomes as a Therapeutic Option for Spinal Cord Injuries; a Systematic Review and Meta-Analysis

Sajjad Jabermoradi, Parsa Paridari, Hamzah Adel Ramawad, Pantea Gharin, Shayan Roshdi, Amirmohammad Toloui, Mahmoud Yousefifard (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e2
https://doi.org/10.22037/aaem.v13i1.2261

Introduction: Exosomes function as cell signaling carriers and have drawn much attention to the cell-free treatments of regenerative medicine. This meta-analysis aimed to investigate the efficacy of mesenchymal stem cell-derived (MSC-derived) exosomes in animal models of spinal cord injuries (SCI).

Method: A comprehensive search was conducted in Medline, Embase, Scopus, and Web of Science to attain related articles published by January 31, 2023. The eligible keywords were correlated with the spinal cord injury and MSC-derived exosomes. The evaluated outcomes were locomotion, cavity size, cell apoptosis, inflammation, neuro-regeneration, and microglia activation. A standardized mean difference was calculated for each sample and a pooled effect size was reported.

Results: 65 papers fully met the inclusion criteria. Treatment with MSC-derived exosomes ultimately improved locomotion and shrunk cavity size (p<0.0001). The administration of MSC-derived exosomes enhanced the expression of beta-tubulin III, NF200, and GAP-43, and increased the number of NeuN-positive and Nissl-positive cells, while reducing the expression of glial fibrillary acidic protein (p<0.0001). The number of apoptotic cells in the treatment group decreased significantly (p<0.0001). Regarding the markers of microglia activation, MSC-derived exosomes increased the number of CD206- and CD68-positive cells (p=0.032 and p<0.0001, respectively). Additionally, MSC-derived exosome administration significantly increased the expression of the anti-inflammatory interleukin (IL)-10 and IL-4 (p<0.001 and p=0.001, respectively) and decreased the expression of the inflammatory IL-1b, IL-6, and TNF-a (p<0.0001).

Conclusion: MSC-derived exosome treatment resulted in a significantly improved locomotion of SCI animals through ameliorating neuroinflammation, reducing apoptosis, and inducing neuronal regrowth by facilitating a desirable microenvironment.

Early Administration of Apelin Could Prevent Heart Failure Following Myocardial Injury; A Systematic Review and Meta-Analysis

Mohammad-Mehdi Hasheminezhad, Mina Mirzad, Saeed Sepehry Vafa, Amir-Reza Moradi, Nastaran Sadat Mahdavi, Yaser Azizi, Mahmoud Yousefifard (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e4
https://doi.org/10.22037/aaem.v13i1.2414

Introduction: Heart failure (HF) is a prevalent and advancing cardiovascular disorder that impacts 1-2% of the worldwide population, particularly the elderly. Studies indicate that the intravenous administration of apelin may yield advantageous effects in preventing heart failure subsequent to myocardial injury. This meta-analysis aimed to assess the effects of exogenous apelin administration on heart failure in animal models, in light of the lack of a definitive consensus on the matter.

Method: An extensive search was performed in the Medline (via PubMed), Web of Science, Embase, and Scopus databases till the end of January 2024. Two independent reviewers screened and summarized the relevant articles. Outcomes related to cardiac function, including ejection fraction (EF), maximum and minimum rate of left ventricle systolic pressure (+dp/dt and –dp/dt, respectively), heart rate, left ventricular end-diastolic pressure (LVEDP), and left ventricular systolic pressure (LVSP) were assessed. Findings were reported as a pooled standardized mean difference (SMD) with a 95% confidence interval (95% CI).

Results: 12 studies were included. Pooled analysis demonstrated that early treatment with apelin following myocardial injury significantly increases +dp/dt (SMD = 2.36; 95% CI: 1.58 to 3.15; p < 0.001) and decreases -dp/dt (SMD = -3.31; 95% CI: -4.46 to -2.17; p < 0.001). Furthermore, the administration of apelin resulted in a significant increase in EF (SMD = 0.79; 95% CI: 0.15 to 1.44; p = 0.02) and LVSP (SMD = 2.09; 95% CI: 0.82 to 3.36; p < 0.001), while it led to a decrease in LVEDP in the animals (SMD = -1.85; 95% CI: -2.81 to -0.88; p < 0.001). Noteworthy, apelin treatment was shown to have no significant influence on the heart rate of the animals (SMD = -0.12; 95% CI: -0.82 to -0.58; p = 0.73).

Conclusion: The current study demonstrated that the early administration of apelin has the potential to improve cardiac function and mitigate the onset of heart failure subsequent to myocardial injury. Further, in vivo research is essential to lay the groundwork for the integration of apelin into clinical practice.

Accuracy of Lung Ultrasonography for Diagnosis of Heart Failure; a Systematic Review and Meta-analysis

Erfan Rahmani, Masoud Farrokhi, Mehrdad Farrokhi, Shadi Nouri, Atousa Moghadam Fard, Behnam Hoorshad, Ramin Atighi, Erfan Ghadirzadeh, Michael Tajik, Habibollah Afshang, Aida Naseri, Mohadeseh Asoudehfard, Shiva Samami Kojidi, Arsham Ebnemehdi, Mehdi Rezaei, Maziar Daneshvar, Amirali Makhmalbaf, Sepideh Hassanpour Khodaei, Shirin Farsi, Saber Barazandeh Rad, Fateme Nozari, Pouya Rezaei, Negar Babapour, Salman Delavar, Babak Goodarzy, Lida Zare Lahijan, Sanam Mohammadzadeh, Helena Mehran, Fatemeh Gheibi, Ramtin Shemshadigolafzani, Behnaz Dalvandi, Amir Abderam (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e33
https://doi.org/10.22037/aaemj.v13i1.2555

Introduction: Despite the evident impact of ultrasonography on diagnosis in acute care settings, there is still a great deal of uncertainty regarding its accuracy. This study aimed to assess the diagnostic performance of lung ultrasonography (LUS) for the identification of acute heart failure in patients with suggestive manifestations.

Methods: Medline, Scopus, and Web of Science were comprehensively searched from their inception to November 2024 to identify original studies investigating accuracy of LUS for diagnosis of heart failure. Data extraction and quality assessment were performed by two independent reviewers. The statistical analysis for pooling the results of diagnostic performance parameters was conducted using Stata and Meta-DiSc softwares.

Results: Thirty-eight included studies in this meta-analysis were published between 2006 and 2024, encompassing a total of 6,783 patients. There was significant heterogeneity between included studies with respect to sensitivity (I2=92.51 and P<0.01) and specificity (I2=93.79 and P<0.01). The pooled sensitivity, specificity, and accuracy of LUS for detection of heart failure were 0.92 (95% CI, 0.87-0.95), 0.90 (95% CI, 0.86-0.93), and 0.96 (95% CI, 0.94-0.98), respectively. In addition, pooled positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) were 7.87 (95% CI, 5.60-11.07), 0.14 (95% CI, 0.10-0.19), and 70.74 (95% CI, 41.98-119.21), respectively.

Conclusion: Our meta-analysis demonstrates that LUS is a highly practical imaging for diagnosing acute heart failure, with excellent sensitivity, specificity, and accuracy. It is particularly valuable for excluding the heart failure when the result is negative. However, the influence of outlier and influential studies warrants caution, and future studies should aim to further validate these findings in diverse clinical contexts.

Case Report


Neurological Crisis Following Intravenous Ozone Therapy; a Case Report

Chloe Y Y Wong, Komal Saxena, John Meneer , Koshy George, Gerben Keijzers (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e31
https://doi.org/10.22037/aaemj.v13i1.2592

Ozone therapy, often marketed as an immune-boosting alternative treatment, lacks robust evidence of efficacy and poses significant safety risks. Despite claims of therapeutic benefits, Regulatory agencies, such as the U.S. Food and Drug Administration (FDA), warn against its use due to its toxic properties and lack of proven benefits at tolerable exposure levels. This case report highlights severe neurological complications, including ischemic infarcts and persistent cognitive deficits, following intravenous ozone (O3) therapy in a previously healthy patient. A 36-year-old woman presented to the emergency department with chest pain, syncope, and generalized seizure shortly after receiving intravenous ozone therapy. Diagnostic imaging revealed multiple ischemic infarcts in the thalamus and cerebellum, consistent with an embolic event. The patient required intensive care unit (ICU) admission, and despite improved neurological function experienced lasting cognitive impairments necessitating long-term rehabilitation.

Stanford Type A Aortic Dissection Masquerading as Acute Ischemic Stroke: A Case Report

Chao Liu, Jiangrong Ma, Bo Zhang, Ji Xie, Liyu Lu, Shinan Nie (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e18
https://doi.org/10.22037/aaemj.v13i1.2409

Aortic dissection (AD), a life-threatening cardiovascular emergency, is characterized by the separation of the aorta’s inner and middle layers due to a tear in the intima. It is classified as Stanford type A or B based on the tear’s location and extent. Symptoms vary but commonly include severe pain in the chest, back, or abdomen, along with atypical presentations such as shock, heart failure, or syncope. End-organ ischemia, including stroke and limb necrosis, may occur. Timely diagnosis and intervention are crucial for survival. Here, we report a 31-year-old male patient who presented with acute neurological symptoms, initially suspected of having a stroke, but was ultimately diagnosed with Stanford type A AD upon computed tomography (CT) angiography. This case underscores the importance of considering AD in the differential diagnosis of patients with neurological symptoms for accurate and prompt management.

Cardiopulmonary resuscitation (CPR) remains controversial with dismal outcomes for cardiac arrest (CA) victims. Inadequate organ perfusion and frequent CPR-related trauma most likely occur due to inappropriate adaptation to hemostatic conditions, electrophysiology, cardiotorsal anatomy, and thoracic biomechanics. Alternatively, we propose a new technique compromising chest compressions through the 5th intercostal space while placing the victim in the left lateral decubitus position with wrapped abdomen and raised legs, allowing to: bypass the sternal barrier, refill the heart, and then recoil-rebound the chest (3R /CPR), within the axis of the cylindrical ribcage. Our goal is to evaluate the technique following its necessary application on two drowning victims. It seems that, 3R/CPR adapts the pathophysiological conditions of CA victims promoting a less traumatic return of spontaneous circulation (ROSC), making it worthy of further investigation and study.

Editorial


A Glance at Archives of Academic Emergency Medicine Journal in 2024

Mehrnoosh Yazdanbakhsh (Author); Somayeh Saghaei Dehkordi

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e0
https://doi.org/10.22037/aaemj.v13i1.2571

There were 70 articles published in the 2024 volume of Archives of Academic Emergency Medicine. Around 350 authors contributed to the published works, who were affiliated to centers located in countries such as USA, Canada, Germany, Finland, China, Poland, Italy, Australia, UAE, Malaysia, India, Egypt, Bangladesh, Turkey, Thailand, Nigeria, Jordon, Yemen, Saudi Arabia, Azerbaijan, Vietnam, Pakistan. We would like to thank the authors for trusting us with their valuable works and publishing their articles with us.

Letter


Importance and Obstacles of First Aid in Burn Injuries; A Letter to The Editor

Farzan Madadizadeh, Golnaz Afzal (Author)

Archives of Academic Emergency Medicine, Vol. 13 No. 1 (2025), 3 September 2024, Page e20
https://doi.org/10.22037/aaemj.v13i1.2578

After a burn injury, pre-hospital care, which includes first aid measures before transfer to a burns center, is considered to be a significantly important step in the process of burn treatment. Individuals who receive medical care at a hospital following initial first aid administered at home experience a better outcome. This letter aimed to discuss about the importance and obstacles of prehospital management of burn injuries.