Journal of Practical Emergency Medicine

Background: Functional neurological disorder (FND), formerly known as conversion disorder, is common in emergency departments (ED). Its treatment with short-acting drugs for quick symptom relief is unclear. This study compared intramuscular Trifluoperazine (TFP) to intravenous normal saline (NS) for rapid symptom resolution in acute FND.

Methods: We conducted a prospective cohort study at Khatam Al-Anbia Hospital, Zahedan, Iran, from January to December 2023 (ethics IR.ZAUMS.REC.1401.338). Adults diagnosed with FND per DSM-5, with supporting clinical signs, were assigned to receive either 1 mg intramuscular TFP or 500 mL IV NS. All received explanations and de-escalation. Symptoms were recorded at baseline and 15-60 minutes later. The primary outcome was symptom resolution within 60 minutes. Analysis used Cochran’s Q test for within-group changes and χ² or Fisher’s exact tests for between-group differences, significance set at 0.05.

Results: Of 80 enrolled patients, 79 were analyzed (39 TFP, 40 NS). Baseline characteristics were similar; non-communication was common. Both groups showed rapid symptom relief. By 60 minutes, 94.9% in the TFP group and 100% in the NS group had symptom resolution (p = 0.241). Symptoms like crying, weakness, and PNES resolved quickly in both groups, with no significant differences at any 15-minute checkpoint. Mild adverse events included transient sleepiness in 3 TFP patients (7.7%) and 1 NS patient (2.5%), and a headache in one patient. No extrapyramidal symptoms or arrhythmias were observed.

Conclusions: In cases of acute FND presenting in the emergency department, treatment with Trifluoperazine and normal saline appeared to provide similar relief of symptoms, with few adverse effects observed. These results indicate that factors beyond specific medications may significantly contribute to early symptom improvement. Implementing structured emergency department protocols that emphasize positive-sign diagnosis, de-escalation techniques, and simple supportive measures could be effective in improving patient outcomes.

Background: Medical emergencies may occur before, during, or after dental treatment and range from relatively benign events to life‑threatening conditions. This study used an Objective Structured Clinical Examination (OSCE) to assess senior dental students’ competence in managing medical emergencies.

Methods: In this cross-sectional study, sixty senior dental students at Zahedan University of Medical Sciences were assessed during the 2023–2024 academic year. Data were collected at OSCE stations using a two-part questionnaire and the required equipment. Part 1 recorded demographic characteristics (age, gender, grade point average [GPA], place of residence, and prior attendance at cardiopulmonary resuscitation [CPR] or basic life support [BLS] courses). Part 2 comprised author-developed items to evaluate competence in managing medical emergencies. Data were analyzed using SPSS version 26.0.

Results: Based on their performance, students were categorized into three groups: good (scores above nine), fair (scores between five and nine), and poor (scores below five). Overall, 27 students (45%) were rated as poor, 18 (30%) as fair, and 15 (25%) as good. Performance was significantly associated with academic standing (p = 0.039) and prior attendance at CPR/BLS courses (p = 0.043).

Conclusion: Senior dental students demonstrated limited knowledge and skills in managing medical emergencies. Additional basic life support training may improve preparedness among dental students and practicing dentists for life-threatening events in dental settings.

Background: Stroke is a time-critical neurological emergency in which pre-hospital actions strongly influence eligibility for reperfusion therapies and functional recovery. Many health systems employ structured pre-hospital stroke notification pathways to accelerate triage and treatment. This study examined the association between pre-hospital stroke notification indicators and short-term clinical outcomes in patients admitted to a 24/7 stroke center.

Methods: In this cross-sectional study, we analyzed 566 consecutive patients with confirmed stroke admitted to Namazi Hospital, Shiraz, during the second half of 2022. Hospital and pre-hospital emergency service (PHES) records provided data on mode of transport, application of FAST criteria, time from symptom onset to emergency department (ED) arrival, pre-hospital contact to ED admission, and time from ED admission to initiation of intravenous thrombolytic therapy. Outcomes were administration of intravenous thrombolysis, National Institutes of Health Stroke Scale (NIHSS) and Modified Rankin Scale (MRS) scores at discharge, and in-hospital survival. Associations were assessed using standard parametric tests with a significance threshold of p < 0.05.

Results: Of the 566 stroke patients, 331 (58.5%) were transported via PHES. Diagnostic concordance between PHES technicians using the FAST criteria and emergency physicians was 59%, while concordance with CT-scan findings was 76%. Patients who received thrombolytic therapy demonstrated significantly shorter prehospital contact-to-admission interval (p = 0.002). Conversely, prolonged pre-hospital contact times were significantly associated with poorer functional outcomes, indicated by higher mRS scores at discharge (p = 0.003). Notably, patients transported by PHES were significantly more likely to receive thrombolytic therapy (73.8%) but also exhibited higher mortality rates compared to those transported by companions or transferred from other facilities (p = 0.021 and p = 0.001, respectively).

Conclusion: The findings demonstrate that timely identification and rapid transfer by pre-hospital emergency technicians are critical determinants of short-term clinical outcomes in stroke patients. Pre-hospital indicators within the stroke activation code framework, particularly transport times and mode of transfer, are significantly correlated with the administration of thrombolytic therapy and functional recovery as measured by the mRS. These results demonstrate the vital role of optimized pre-hospital services in stroke care pathways.

Background: Acute appendicitis is a common cause of acute abdominal pain requiring prompt surgical intervention. Accurate diagnosis remains challenging, particularly in populations with atypical presentations. This study aims to compare the diagnostic accuracy of the Alvarado and RIPASA scoring systems in an Iranian cohort.

Methods: A prospective observational study was conducted in the emergency departments of two hospitals in Tehran, involving 340 patients suspected of having acute appendicitis. Both Alvarado and RIPASA scores were calculated, and their diagnostic performance was compared using post-operative histopathological findings as the gold standard.

Results: Acute appendicitis was confirmed in 312/340 (91.8%) participants. The RIPASA score demonstrated superior diagnostic accuracy compared to the Alvarado score, with a sensitivity of 85% versus 57% and an overall diagnostic accuracy of 85% versus 60%. The specificity was comparable between the two scores, with the Alvarado at 89% and the RIPASA at 86%. The RIPASA score also had a higher negative predictive value (34% vs. 18%) and positive likelihood ratio (6.07 vs. 5.18).

Conclusions: In this high-prevalence cohort of ED patients evaluated for suspected appendicitis, the RIPASA score showed higher sensitivity and overall diagnostic accuracy than the Alvarado score. However, given the selected study population and the verification strategy, external validity to unselected ED populations may be limited; multicenter studies using a uniform reference standard for both operated and non-operated patients are warranted.

Background: Diabetic foot is one of the long-term microvascular complications of diabetes mellitus (DM). The prevention of foot ulcers is the most effective way to reduce severe morbidity and mortality in patients with diabetes. Appropriate glycemic control is one of the most important preventive measures for diabetic foot ulcers. Glycosylated hemoglobin (HbA1C) is representative of long-term blood glucose levels over the prior three months. The present study evaluated the relationship between HbA1C levels and the development of diabetic foot ulcers.

Methods:The present study was an analytical case-control study conducted in Ali-ibn-Abitaleb Hospital in Zahedan, Iran, in 2022. 130 patients comprising 65 DM patients with diabetic foot ulcers and 65 DM patients without foot ulcers were included in this study. Demographic and laboratory information was collected by the researcher using a checklist. The data were analyzed using SPSS software.

Results: The average age of the control and case groups was 64.1 and 62.6 years, respectively. The results showed a significant relationship between the age of 60-70 years and the onset of diabetic foot ulcers. There was also a significant relationship between the female gender and the occurrence of diabetic foot. No significant relationship was observed between the duration of DM and the onset of diabetic foot. The results showed that 87.7% of the people in the control group had no previous history of diabetic foot. However, 76.9% of the people in the case group had a prior history of diabetic foot. There was a significant relationship between the previous history of the diabetic foot and its recurrence in diabetic patients. Regarding the serum level of HbA1C, 78.5% and 12.3% of patients in the case group had moderate (7-10%) and poor control (10-13%), respectively. 43.1%, 50.7%, and 6.2% of people in the control group had good, moderate, and poor control and in the multivariable model, only the previous history remained in the model, which showed that the probability of infection in people with a previous history is almost 24 times higher than in people without a previous history.

Conclusion: The results indicate that age, female gender, history of diabetic foot, and high serum level of HbA1c had a significant relationship with diabetic foot. Since the serum level of HbA1c is an important indicator of long-term blood sugar control, it can possibly be used as a reliable factor to predict diabetic foot complications

Background: Smoking is one of the most important risk factors for cardiovascular diseases. Although numerous studies have evaluated the long-term consequences of smoking, few studies have assessed the short-term effects of smoking, especially on the electrical activity of the heart. The aim of this study was the evaluation of the acute effect of smoking on cardiac electrical function and hemodynamic indices in smokers.

Materials: In this single-arm pretest-posttest study, 130 healthy smokers participated if they had smoked at least 100 cigarettes in their lifetime and were smoking daily. After considering the exclusion criteria, participants were monitored before and 10 minutes after smoking by electrocardiography (ECG) to measure QT dispersion (QTD) and P-wave dispersion (PWD), systolic blood pressure (SBP) and diastolic blood pressure (DBP), heart rate (HR), and respiration rate (RR). Finally, the data obtained before and after smoking were compared.

Results: The mean age of the participants was 40.3 ± 10.6 years (range 19 to 71 years). 55 (42.3%) participants smoked between 10-15 years and 67 (51.5%) smoked 10 to 20 pack-years. After smoking, SBP (127.3 ± 10.4 vs. 138.4 ± 12.8 mmHg), QTD (33.5 ± 9.6 vs. 43.9 ± 10.7 ms) and PWD (28.9 ± 6.6 vs. 34.5 ± 7.4 ms), HR (80.1±9.8 vs 87.6±9.9) increased significantly (P value <0.001). In other parameters, no significant differences were observed.

Conclusions: Smoking is associated with an acute increase in QTD and PWD, and thus an increased risk of ventricular arrhythmias (e.g. Torsade’s de pointes), atrial fibrillation, sudden death, and other heart problems.

Background: Emergency neurosurgery plays a critical role in the management of life-threatening neurological disorders. Previous studies have shown that the initial clinical status and prolonged time interval to surgery affect patient mortality and morbidity. This study aimed to describe the association of the baseline and clinical characteristics of patients and the timing of intervention with the emergency neurosurgical intervention outcomes.

Methods: A retrospective cross-sectional study was conducted involving all patients who received emergency surgery in the theatre of Udayana University Hospital from June 2021 until 2023. Age, gender, type of surgical procedures, severity of trauma, Glasgow coma scale (GCS) at emergency room arrival, time to theatre (TTT), the duration of the operation, and length of stay (LOS) were collected. Mortality was defined as the primary outcome.

Results: 43 emergency surgeries were included. The mean age was 42.35 (±21.85) years and the majority of patients were male (69.8%). 65.1% of patients were trauma cases and 51.2% underwent craniotomy. The median GCS at the time of admission was 9, the median TTT was 3 hours, the median duration of surgery was 2.41 hours, and the median LOS was 7 days. After the procedures, the survival rate was 67.4%. The GCS upon admission (p=0.003) and TTT (p=0.044) were significantly associated with the patient's mortality.

Conclusion: GCS at emergency room arrival and TTT in emergency surgery were associated with the mortality of emergency neurosurgery patients.

Background: Clinical, radiological, and laboratory findings characteristic of the coronavirus disease 2019 (COVID-19) infection have already been investigated and identified; however, data on pregnant women infected with COVID-19 are limited. This study aims to examine the clinical, radiological, and laboratory characteristics of pregnant women compared to non-pregnant women with COVID-19 disease.

Method: This hospital-based retrospective age-matched case-control study included two groups, pregnant and non-pregnant women, each consisting of 51 patients hospitalized with COVID-19 in Bushehr, Iran.  Demographic, clinical, and laboratory information was extracted from medical records using a predefined checklist.

Results: Except for cough, there were no statistically significant differences in clinical signs and symptoms between pregnant and non-pregnant women. Although hemoglobin oxygen saturations are statistically significant among the two groups, this difference is not clinically significant (95% vs 93%). There were no statistically significant differences between pregnant and non-pregnant women in the pattern of pulmonary involvement in chest CT findings. Laboratory factors such as serum hemoglobin, red blood cell count, absolute lymphocyte count, prothrombin time and partial thromboplastin time, serum creatinine, serum potassium, and lactate dehydrogenase had statistically significant differences between the two groups. However, these differences were not clinically significant.

Conclusion: In a few aspects, the clinical characteristics and laboratory test results of COVID-19 in pregnant patients seem to be distinctive from their nonpregnant controls. We believe our findings can guide the prenatal and postnatal considerations for COVID-19 pregnant patients.

Background: The purpose of this study was to examine the outcomes of cardiopulmonary resuscitation (CPR) including return of spontaneous circulation (ROSC), survival to hospital discharge and neurological outcome in the emergency department (ED).

Methods: This prospective observational study included 233 patients with 51 cases of Out-Of-Hospital Cardiac arrests (OHCA) and 182 cases of In-Hospital cardiac arrests (IHCA). The study was performed in the ED of a tertiary health care center in North India from July 2018 to June 2021.

Results: The majority of the study subjects (67.8%) were males, and the median age of patients was 47 years. 35.6% of cases (N=83) had a sustained ROSC after the first attempt of CPR. Survival to inpatient admission was seen in 20.2% of cases (N=47), and survival to hospital discharge was observed in 3.9% of cases (N=9). Out of 9 cases who survived, 7 cases (3%) were discharged with good neurological outcomes (Modified Rankin Scale of 0-2). For OHCA, the predictors of survival were witnessed arrest (Odds Ratio [OR]=4.58, 95% CI: 1.08-19.38), bystander CPR (OR=3.78, 95% CI: 1.78-18.13), and time to reach the hospital (OR=0.70, 95% CI: 0.55-0.89). Whereas in IHCA, patients with initial shockable rhythm had increased odds of survival (OR=1.49, 95% CI: 1.35-1.74).

Conclusion: In our study, in contrast to the developed countries, the survival to hospital discharge in cardiac arrest patients presenting to ED was very low. Therefore, this study proposes the development of a robust cardiac arrest registry in India, to address the gaps in the existing knowledge and facilitate future research.

Background: Stroke is considered as one of the most important causes of emergency medical services (EMS) dispatch worldwide. Stroke is a time-sensitive condition and rapid transport of the patients improves the prognosis. In this study, we described prehospital emergency response times for stroke patients in Isfahan, Iran.

Methods: In the current cross-sectional descriptive study, suspected stroke patients who were transported by EMS in Isfahan, Iran, from June 2022 to June 2023 were included. The data was extracted from patients’ files. The time interval between the receipt of a call and the EMS arrival at the scene (arrival time), the time interval between on-scene EMS arrival and the ambulance departure to the medical center (stroke scene time), and the time it takes to reach the medical center (transport time) were collected.

Results:  Overall, 79 patients with a mean age of 71.56 ± 12.03 were included. EMS diagnosed 63 (79.75%) of the patients with a definite diagnosis and 14 (17.72%) with probable stroke. Two false negative results were found. The average arrival time, was 11.56 ± 6.60 minutes, on-scene stroke time was 13.85 ± 7.23 minutes and the average transport time was 11.90 ± 6.08 minutes. The mean total EMS response time was 37.90 ±11.29 minutes.

Conclusion: Overall, our study showed that while the EMS transport time is longer than ideal, the total time to transport to the hospital is short enough not to affect the outcome. EMS was also found to be adept at spotting the signs of stroke and rapidly starting the process of treatment.

Background: Visceral fat has been associated with severe COVID-19 outcomes due to its pro-inflammatory effects. While computed tomography (CT) is the standard for measuring visceral fat, ultrasound (US) offers a non-invasive and accessible alternative. This study aimed to evaluate whether abdominal fat thickness measured via US predicts clinical outcomes in COVID-19 pneumonia.

Method: This prospective cohort study included 83 hospitalized COVID-19 patients. Visceral fat thickness (VFT), subcutaneous fat thickness (SFT), and preperitoneal fat thickness (PFT) were measured with US. The primary outcome of interest was mortality. Multivariable logistic regression was used to analyze associations, adjusting for confounders such as age, sex, and comorbidities.

Results: 83 patients with a median age of 62 (IQR: 49–73) years were included (53% male). Mortality was significantly higher in male (61.4% vs. 38.6%, p = 0.018); older age (73.5 vs. 59.5; p = 0.003); patients with lower median blood oxygen saturation (80% vs. 88%, p < 0.001), higher median levels of AST (66 vs. 39.5, p = 0.002), BUN (67 vs. 36.5, p < 0.001), and creatinine (1.6 vs. 1.2, p < 0.001); and patients under mechanical ventilation (p < 0.01). Based on multivariate logistic regression analysis the independent predictors of mortality were VFT (aOR: 1.025, 95% CI: 1.001–1.051, p = 0.047), old age (aOR: 1.064, 95% CI: 1.016–1.115, p = 0.008), and male sex (aOR: 4.430, 95% CI: 1.169–16.769, p = 0.029). In contrast, SFT had an aOR of 1.059 (95% CI: 0.966–1.161, p = 0.223), and PFT had an aOR of 1.016 (95% CI: 0.880–1.172, p = 0.830), neither of which was statistically significant. The area under the ROC curve of VFT in predicting mortality was 0.643. The optimal cutoff value for VFT, determined using the Youden Index, was 80.4. At this cutoff point, the sensitivity was 52.2% while the specificity was 75.0%.

Conclusion: It seems that ultrasound-measured VFT is a potential predictor of mortality in hospitalized COVID-19 patients, offering a cost-effective and accessible tool for risk assessment. Further research is needed to confirm its broader applicability.

Background: Mechanical ventilation in emergency departments (ED) is crucial to airway management. Various factors significantly influence patient outcomes. Objectives: This study aimed to evaluate the prognostic factors of mortality in patients undergoing mechanical ventilation in the ED.

Methods: This retrospective cross-sectional study examined patients over 18 who underwent mechanical ventilation in the ED of a referral hospital in Tehran, Iran, between August 2022 and September 2023. The association between patients’ characteristic and intubation-related parameters with in-hospital mortality was measured using univariate and multivariate logistic regression, as well as Kaplan-Meier survival curve analyses.

Results: We examined 430 patients with a mean age of 61.4 ± 22.0 (range: 18-103) years were studied (60.7% male). There was significant correlation between in-hospital mortality and age (P < 0.01); cancer (P = 0.002) and hypothyroidism (P = 0.009) as the underlying diseases; failure to protect airway (P = 0.27) and oxygenation failure (P = 0.04) as the causes of intubation; vasopressors usage (P < 0.001); medications which were used for rapid sequence intubation (P < 0.001); systolic blood pressure (P < 0.01) and diastolic blood pressure (P < 0.01); time to intubation (P = 0.006); platelet count (P < 0.001) and hemoglobin level (P= 0.003); and finally HCO3 (P = 0.05) and PCO2 levels (P = 0.013). Multivariate logistic regression analysis identified cancer (P = 0.019, OR = 0.13), oxygenation failure (P = 0.03, OR = 0.32), vasopressor medication (P < 0.001, OR = 0.07), systolic blood pressure (P = 0.035, OR = 1.03), platelet count (P = 0.042, OR = 0.99), and PCO2 (P = 0.013, OR = 0.95) as independent predictive factors of mortality rate.

Conclusion: This study identified several predictive factors of mortality in patients undergoing mechanical ventilation in the ED, including cancer, oxygenation failure, use of vasopressors, lower systolic blood pressure, lower platelet count, and lower PCO2.

Background: Sedatives and analgesics facilitate smooth mechanical ventilation for critically ill patients. This study compared the sedative effects of gabapentin, clonidine, and midazolam in intensive care unit (ICU) patients undergoing mechanical ventilation.

Methods: 90 patients were randomly assigned to one of three groups. The first group received clonidine at a dosage of 0.1 mg every 6 hours. The second group was administered 300 mg of gabapentin tablets every 8 hours. The third group received a continuous midazolam infusion at 0.07 mg/kg/hour. All groups began with an initial infusion rate of fentanyl set at 1-2 µg/kg/hour, with adjustments made every 10 minutes to achieve a Ramsay sedation score of 3-4. Fentanyl daily dose (µg/kg/hr), duration of ventilation (day), and length of ICU stay (hours) were compared among study groups.

Results:  Patients in the midazolam and clonidine groups required higher doses of fentanyl compared to those in the gabapentin group. The mean daily dose of fentanyl was 3.5 ± 0.1 mg (µg/kg/hour) in the clonidine group, 2.4 ± 0.04 mg in the midazolam group, and 1.9 ± 0.3 mg in the gabapentin group (p=0.003). The duration of ventilation (p=0.010) and the length of ICU stay (p=0.041) were significantly reduced in the gabapentin group when compared to the midazolam and clonidine groups. Importantly, there were no reports of severe adverse effects associated with the intervention.

Conclusion: The results indicate that all treatment modalities were successful in attaining the desired levels of sedation and analgesia. Notably, gabapentin exhibited superior efficacy in achieving these targets while concurrently requiring reduced doses of fentanyl. Furthermore, patients receiving gabapentin experienced shorter durations of ICU stay and mechanical ventilation.

Background: While specialized trauma care in the triage unit can greatly enhance the chances of survival for injured patients, obstacles to rapid triage remain a significant challenge. Identifying these barriers is crucial for effective clinical decision-making and for improving positive outcomes. This study aims to share the experiences of physicians and nurses concerning the challenges they face in achieving rapid triage.

Methods: A qualitative study was carried out with twenty physicians and nurses working in the triage unit of Poursina Hospital in northern Iran in 2021, using semi-structured interviews. The experiences were analyzed through content analysis. Credibility, reliability, and validity were applied to ensure data accuracy and trustworthiness. Sampling continued until data saturation.

Results: Analysis of interviews with 20 healthcare professionals revealed five main barriers to rapid triage in the emergency department: challenges related to triage staff (including inadequate training, experience, and staffing), limitations in physical space and equipment, workflow disruptions (such as software inefficiencies and administrative burdens), lack of coordination and oversight (including weak communication with prehospital services), and patient-related factors (such as aggression and incomplete histories). These findings highlight the complex interplay of human, structural, and systemic issues that hinder timely and accurate triage and suggest the need for comprehensive organizational and educational interventions.

Conclusion: The results of this study highlight the systemic barriers to rapid triage. To address these challenges, a coordinated effort is necessary, which includes structural investments, workforce development, improved interdepartmental communication, and policy reform. It is essential to resolve any deficiencies and monitoring problems and to take appropriate actions.

Background: The ideal diagnostic model for estimating trauma severity should be clinically sensitive, well-calibrated, and able to include a wide range of patients. This study investigates the predictive value of the Injury Severity Score (ISS), Revised GAP (GCS, Age, and Pressure) score, GAP and new trauma score (NTS) in predicting mortality in multi-trauma patients.

Methods: This cross-sectional descriptive study included 170 multi-trauma patients referred to Imam Reza Trauma Center in Tabriz during September 2022-2023. Data related to demographic variables, clinical status, and ISS index were collected. In-hospital and overall mortality (30-day mortality) were recorded as outcomes.

Results: Average age of patients was 39.29±21.14 years, and 71.2% were male. The mean ISS score in deceased and surviving patients was 38.61±17.12 and 9.73±1.46, respectively (P˂0.001). 24-hour mortality (early mortality) was 8.2% and the frequency of overall mortality was 21.1%. Regarding overall mortality, the ISS cut-off point was 19, with a sensitivity of 86% and a specificity of 83%. The R-GAP cut-off point was 16.5, with a sensitivity of 84% and a specificity of 86% for predicting the early survival of patients. GAP showed an AUC of 0.874, 82% sensitivity and 85% specificity, and NTS showed an AUC of 0.866, 87% sensitivity and 77% specificity. For overall mortality, R-GAP showed an AUC of 0.948, with 94% sensitivity and 81% specificity compared to GAP with an AUC of 0.938, 92% sensitivity and 83% specificity, and NTS with an AUC of 0.922, 90% sensitivity and 81% specificity.

Conclusion: According to the results obtained in this study, it can be concluded that in patients referred to the emergency department with traumatic injuries, the ISS and R-GAP tools could be reliable measures to estimate the risk of early mortality/survival rate within 24 hours after injury.

Background: Accurate assessment of trauma severity and prediction of intensive care needs are crucial for improving outcomes in polytrauma patients. This study compared the predictive accuracy of four widely used trauma scoring systems: Glasgow Coma Scale (GCS), Injury Severity Score (ISS), Revised Trauma Score (RTS), and Trauma and Injury Severity Score (TRISS).

Methods: A prospective observational study was conducted at Shahid Rahnamoon University Hospital, Yazd, Iran, from August to November 2018. Consecutive multiple trauma patients admitted to surgical wards or the intensive care unit (ICU) were included, while those discharged directly from the emergency department were excluded. Demographic and clinical data were collected on admission, and all four trauma scores were calculated according to standard guidelines. Patients were followed during hospitalization and 30 days after admission. Prognostic accuracy was evaluated using sensitivity, specificity, and area under the curve of receiver operating characteristic curve (AUC) analysis.

Results: A total of 769 patients were included (mean age 32.3 ± 21.7 years; 76.1% male). The overall mortality rate was 10.8%. All scoring systems demonstrated significant predictive value. GCS showed the highest prognostic accuracy for mortality (AUC = 0.912, 95% CI: 0.86–0.95) and ICU admission (AUC = 0.947, 95% CI: 0.91–0.97). In comparison, RTS yielded AUC = 0.861 (95% CI: 0.80–0.91) for mortality and 0.832 (95% CI: 0.78–0.87) for ICU admission; TRISS had AUC = 0.906 (95% CI: 0.86–0.94) and 0.884 (95% CI: 0.85–0.91), respectively; ISS performed with AUC = 0.858 (95% CI: 0.80–0.91) for mortality and 0.894 (95% CI: 0.86–0.92) for ICU admission.

Conclusion: GCS remains the most accurate and clinically feasible scoring tool for predicting mortality and ICU admission in multiple trauma patients. Although ISS and TRISS provide additional insights, particularly for benchmarking, their complexity limits real-time application in emergency settings.

Background: Fluid resuscitation is a common practice in emergency departments. Both Normal Saline (NS) and balanced fluids have been proposed for fluid resuscitation. Most patients need fluid resuscitation before the definitive diagnosis is made. To compare the immediate outcomes of early resuscitation with NS (0.9% sodium chloride) versus Lactated Ringer’s solution (LR) in patients admitted to an emergency department.

Methods: This was a parallel cluster-randomized, triple-blind, controlled trial. Eligibility criteria included a need for fluid resuscitation, no contraindication for NS or RL resuscitation, and agreement to sign the written consent form. Patients in the emergency department were allocated using a parallel-cluster design, with consecutive three-day clusters assigned to either NS or LR using a random table. Blinding was maintained by using identical labeled intravenous fluids, with only the drug provider aware of the codes. Data on IV fluid type, dose, initiation time, and patients’ demographics were recorded. Baseline and follow-up measurements of serum creatinine, urea, potassium, and serum pH were taken at 6 hours post-admission. The primary outcomes were in-hospital death and the duration of emergency department and hospital stays. Secondary outcomes included the occurrence of acute kidney injury (based on creatinine clearance) and hyperkalemia.

Results: During the study period, 1114 patients were included in the final analysis. Women constituted 271 (49.01%) individuals in the LR group and 270 (48.12%) individuals in the NS group. The average ages in the two groups were 53.35 and 53.52 years, respectively. Hospital and emergency department stays were significantly lower in the LR group compared with the NS group (p=0.001). There is no significant difference between the two groups about death (p=0.390), hyperkalemia (p=0.960), and acute kidney injury (p=0.652).

Conclusion: It appears that LR is superior to NS for initial resuscitation in the emergency department, as its administration is associated with shorter hospital and emergency department stays, without significant adverse events, compared to NS.

Background: Cerebrovascular diseases had been devastatingly crushing health care system, with no efficient treatment for them. The present study aims to systematically review and analyze existing preclinical evidence regarding one of the treatment candidates, apigenin, that could possibly serve the purpose. Methods: Databases of Medline, Scopus, Web of Science and Embase were systematically searched for records relevant to administrating apigenin in animal models of stroke. Meanwhile, studies that used derivatives or compounds of apigenin, review studies, uncontrolled and in vitro studies were excluded. Afterwards, two independent reviewers gathered data, and analyses were performed using STATA 17.0 and its random effects model. Results are presented as pooled standardized mean differences (SMD) with a 95% confidence interval (CI). Risk of bias and level of evidence were assessed using SYRCLE’s tool and GRADE framework, respectively. Results: The systematic search yielded 581 articles, of which 10 articles were included. Analyses depicted a significant effect of apigenin administration as a treatment in decreasing infarct volume (SMD = -2.32; 95%CI: -3.00, -1.65; p<0.001) and neurological deficit (SMD = -1.21; 95%CI: -1.59, -0.84; p<0.001). No publication bias regarding the two outcomes was identified. Conclusion: Moderate level of evidence emphasized on apigenin being a suitable candidate of further stroke treatment research. However, current evidence is scarce, specifically regarding the underlying mechanisms of apigenin protecting brain tissue after ischemic/reperfusion injury. Nonetheless, apigenin seems to modulate blood brain barrier, inflammation, apoptosis and brain edema. More studies are encouraged to further enlighten the effects of apigenin administration in animal stroke models.

Background: Epilepsy is one of the most prevalent neurological disorders, affecting approximately 50 million individuals globally. Cannabidiol (CBD) has demonstrated efficacy in reducing seizure frequency among patients with drug-resistant epilepsy. However, the precise mechanisms of action and their interactions with the endocannabinoid system remain inadequately understood.

Method: The study conducted a systematic review of the literature on the effects of CBD on epilepsy. A systematic literature review was conducted to identify preclinical and cohort studies involving both pediatric and adult patients. The search was performed across Medline (via PubMed), Scopus, Embase, Web of Science, and CINAHL, with the search period ending in August 2024. Data extraction and synthesis were performed, including study design, sample size, participants, treatment used, mechanisms, and findings.

Result: Several studies have shown that CBD has antipsychotic, antidepressant, and anxiolytic properties due to its inhibition of Fatty Acid Amide Hydrolase (FAAH), 5-Hydroxytryptamine (serotonin) receptor 1A (5-HT1A), and Transient Receptor Potential Vanilloid 1 (TRPV1) receptors. CBD has been studied for its effect on epilepsy-related receptors and channels and is an effective treatment for drug-resistant seizures in patients with Lennox-Gastaut Syndrome (LGS) and Dravet Syndrome (DS). Gamma-Aminobutyric Acid Type A Receptor (GABAAR) dysfunction leads to neurological and psychiatric disorders and different drug effects. CBD and 2-Arachidonoylglycerol (2-AG) are positive allosteric modulators of GABAARs. CBD and Cannabidivarin (CBDV) have been shown to activate and desensitize TRPV1 both in vitro and in vivo, which may explain why CBD is such an effective antiepileptic drug. CBD is rapidly absorbed and reaches maximum plasma concentrations in children and adults 0.5-6 hours after ingestion. The oral bioavailability of CBD is low (6-10%) and increases when administered with a high-fat, high-calorie meal. CBD inhibits Cytochrome P450 (CYP)2C19 and CYP3A4, increasing N-desmethylclobazam (N-CLB) and drowsiness in patients with epileptic encephalopathy. CBD has been used in the treatment of refractory epilepsy in recent years.

Conclusion: Epilepsy is a chronic hyperexcitability disorder caused by various defects in the brain's neuronal networks. CBD may be able to treat epilepsy by modulating the endocannabinoid system, thereby counteracting some of the functional effects of CB1 receptor activation in the central nervous system.

Dear Editor;

*Corresponding Author: Ameneh Marzban; Department of Health in Disasters and Emergencies, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran,  Email: amenemarzban@yahoo.com

Disasters, including floods, pose significant risks and challenges for all individuals. However, disabled individuals, due to physical, sensory, cognitive, or emotional impairments, often experience heightened vulnerability during such events (1). According to a report by the World Health Organization in 2011, the global prevalence of disability was reported to be an average of 15.4%. With this in mind, it is estimated that over one billion people worldwide live with some form of disability. Floods are the most common natural disasters globally, causing more fatalities than other natural disasters. They account for approximately one third of all natural disasters in both developed and developing countries, and their impact surpasses that of other natural disasters, contributing to more than half of the total losses and one-third of economic losses (2). The effects of floods can be categorized into two types: direct and indirect impacts, which occur at various stages such as flood exposure, evacuation, sheltering, secondary risks, and population displacement. Direct effects encompass risks associated with physical contact with floods, such as drowning, injuries from debris, chemical contamination, burns, bites, and hypothermia (2, 3). Indirect effects involve infrastructure damage and subsequent consequences such as water source contamination, the spread of infectious diseases like cholera, diarrhea, hepatitis A and E, shigellosis, typhoid fever, and leptospirosis, as well as malnutrition, disabilities, mental health issues, and diseases resulting from population displacement (2, 4). During large, unexpected floods, the elderly requiring assistance for evacuation and access to medical services, as well as those individuals who refuse to leave their homes, are at a higher risk of injury and mortality (5). As individuals with disabilities are up to four times more vulnerable to fatalities in disasters (6).

Giving due attention to disabled groups in all stages of disaster management, alongside conducting relevant studies, is of utmost importance. Such efforts not only aid in minimizing their injuries but also prevent many adverse and irreversible consequences that this group may face as a result of disasters. Here we review some of the most important stages to prevent or mitigating the effects of disasters on disabled groups:

1. Mitigation

Efforts to mitigate the impact of disasters are typically approached through two main methods: structural and non-structural measures. Structural measures may include constructing accessible infrastructure and facilities, ensuring safe evacuation routes, and incorporating inclusive design principles including creating spaces that are accessible to all, such as implementing ramps, tactile ground surface indicators, and clear signage in braille, which enhance mobility for individuals with disabilities. Non-structural measures encompass raising awareness among disabled individuals and their families about flood risks, providing them with necessary information and resources, and promoting community resilience through education and training programs (7, 8).

1. Preparation

In the preparation stage, accurately identifying disabled individuals within society is of utmost importance. Collecting and maintaining detailed information about their place of residence and living conditions should be undertaken by relevant organizations. Educational initiatives pertaining to floods as natural disasters should be provided to disabled individuals based on their comprehension level and abilities. Additionally, all managers, disaster experts, and first responders involved in flood situations should receive training to familiarize themselves with the needs and requirements of disabled individuals during such events. Given the high dependence of disabled individuals on medications, medical equipment, and aids, preparing emergency kits for those at risk of flooding should be conducted as part of the preparation efforts. It is essential to address the challenges faced by disabled individuals in receiving warning and evacuation messages during floods due to functional limitations. Emergency evacuation management should thus be considered a crucial component of flood disaster preparedness programs for the disabled (2, 8).

1. Response

In the response stage, it is crucial to prioritize the immediate needs of disabled individuals, such as access to healthcare, accessible shelters, specialized equipment, medications, and personal support. Coordination with disability organizations and stakeholders is paramount to ensure specific accommodations are in place, addressing medical, sensory, mobility, and communication requirements effectively. This can be achieved through established communication channels that foster collaboration between local government agencies, non-profit organizations, and disability advocacy groups. In this stage, engaging a team of rehabilitation specialists is advisable to address the needs of flood victims who have endured multiple traumas. Furthermore, emergency provisions for food and shelter are among the key activities during the response phase (9).

1. Recovery

The goal of the recovery stage is to restore and resume disrupted societal activities following a disaster. Reconstruction and rehabilitation are essential components of this phase. Since weather-related disasters, including floods, often contribute to an increased prevalence of mental health disorders such as post-traumatic stress disorder (PTSD), anxiety, depression, and property loss, the recovery phase must encompass the long-term needs of disabled individuals. This includes rehabilitation services, psychological support, access to assistive devices, enabling infrastructure reconstruction with universal design standards, and opportunities for inclusive participation in decision-making processes regarding post-disaster reconstruction and development. For example, after Hurricane Sandy in New York, recovery efforts emphasized inclusive community engagement, resulting in the development of accessible shelters and public spaces, as well as comprehensive mental health resources for affected individuals. Mental health support services for disabled individuals after disasters include counseling and therapy focused on trauma recovery, peer-led support groups, and 24/7 crisis intervention (2, 9).

Conclusion

Addressing the unique needs and challenges of disabled individuals in all phases of flood disaster management is essential to promote equity, reduce vulnerability, and enhance resilience. Inclusive strategies that integrate accessibility, tailored preparedness, coordinated response, and comprehensive recovery efforts can significantly mitigate the adverse effects of floods on this vulnerable population. Policymakers, disaster management authorities, and health professionals must prioritize disability-inclusive approaches to ensure no one is left behind in disaster preparedness and response frameworks.

Pre-hospital emergency care constitutes the initial response and intervention for patients experiencing emergency conditions outside hospital settings. The absence of female personnel within Iran's pre-hospital Emergency Medical Services (EMS) represents a notable deficiency in the organizational structure of these services (1, 2). Women have traditionally been underrepresented in pre-hospital EMS roles (3). While the gender disparity in pre-hospital EMS is gradually decreasing globally, the participation of women in Iran has received limited attention (1). Notably, during 2018, specialized ambulances were introduced in Tehran, Shiraz, and Behbahan to address women's emergency healthcare needs; these vehicles were staffed by a male driver and two female nurses (4). Given these developments, it is essential to undertake further research to understand women's presence and effectiveness within pre-hospital EMS. Such investigations could focus on recruitment strategies and training programs for female emergency medical technicians (EMTs), as well as examine the impact of gender diversity on patient outcomes (3).

Integrating female personnel into EMS in Iran presents multiple complex challenges that necessitate thorough careful consideration and action (4). The following infrastructure is required to ensure a safe, supportive, and gender-sensitive working environment for female staff

in Iranian EMS.

1- Adequate facilities and equipment: To promote the safety and well-being of female personnel, it is imperative to allocate resources toward the provision of appropriate facilities. These should include, but are not limited to, designated changing rooms, restrooms, and sleeping quarters to ensure a supportive and secure environment. (5).

2- Providing gender-specific training programs: A fundamental infrastructural element for the integration of female personnel within the Iranian EMS involves the formulation and implementation of comprehensive training programs (6, 7).

3- Developing gender-sensitive standard operating procedures: Develop and implement comprehensive Standard Operating Procedures (SOPs) that delineate the roles and responsibilities of female personnel within EMS. These procedures should systematically address key issues such as dress code protocols, working hours, and interactions with patients to ensure professionalism, clarity, and consistency.(8).

4- Ethical considerations: Implementing female personnel within the Iranian EMS requires meticulous ethical deliberation. This process involves identifying and mitigating potential biases or prejudicial attitudes inherent within the EMS community, while also ensuring equitable access to career advancement and promotion opportunities for female staff (5).

5- Work-life balance: To promote work-life balance, organizations should adopt flexible working hours and policies that accommodate personal and family commitments, thereby enabling female employees to manage their professional and personal responsibilities (9) effectively.

The involvement of female personnel in Iranian EMS presents a multifaceted issue. On one hand, there are several potential advantages, including enhanced diversity, improved patient comfort, and increased accessibility to services (9). Conversely, it is imperative to address challenges such as prevailing cultural and social norms, workplace safety issues, transportation barriers, and the complexities of maintaining a work-life balance. Regular review and systematic monitoring of the EMS framework are crucial to ensure the realization of its objectives. Furthermore, it is essential to actively solicit feedback and input from all stakeholders to facilitate the effective functioning of the system and to foster an inclusive environment.

Erythema multiforme (EM) and staphylococcal toxic shock syndrome (TSS) are acute, potentially life-threatening conditions that may present with overlapping clinical manifestations. EM typically features targetoid skin lesions, whereas TSS is characterized by fever, hypotension, and diffuse erythroderma with systemic involvement. We report the case of a 34-year-old man with end-stage renal disease (ESRD) undergoing routine hemodialysis, who developed generalized erythematous and pruritic lesions, fever, nausea, vomiting, and abdominal pain after receiving antibiotic therapy for pilonidal cyst surgery. His presentation suggested a possible overlap between EM and TSS. Prompt empiric treatment with corticosteroids, antihistamines, intravenous fluids, and antibiotic adjustment led to clinical improvement. This case highlights the diagnostic challenges of differentiating between EM and TSS in patients with complex comorbidities and underscores the importance of early recognition, supportive care, and vigilance regarding adverse drug reactions.