Objective: Chest pain is a prevalent and potentially life-threatening presentation in emergency departments, necessitating prompt and precise risk stratification to identify patients at high risk, particularly those with acute coronary syndrome (ACS). This study evaluates the predictive accuracy of the HEART score in stratifying short-term major adverse cardiac events (MACE) risk among chest pain patients in Bandar Abbas, aiming to enhance clinical decision-making and resource utilization in emergency departments. Method: This prospective observational study was conducted on patients presenting with chest pain at Shahid Mohammadi Hospital’s emergency department. Patients aged ≥18 years with chest pain were included, while those with STEMI or incomplete records were excluded. The HEART score was used for risk stratification, and patients were classified into low, moderate, or high-risk groups. The primary outcome was MACE within six weeks, confirmed via follow-up calls. Data analysis included logistic regression and ROC curve analysis. Result: A total of 1,501 individuals participated in the study, with a mean age of 48.99±14.71 years. Among the participants, 28.6% were diagnosed with MACE. The most common risk factors for MACE included a history of coronary artery disease (79.1%) and hypertension (77.2%). Based on the HEART score, patients were categorized into low-risk (≤ 3), moderate-risk (4-6), and high-risk (≥ 7) groups. The majority of non-MACE patients were classified as low-risk (78.3%), while 65.6% of MACE patients fell into the moderate-risk category. The mean HEART score was significantly higher in the MACE group (5.73±1.68) compared to the non-MACE group (2.31± 1.54). The optimal HEART score cutoff for predicting MACE was determined to be 3.5, with the ROC curve demonstrating strong predictive performance (AUC=0.932). Conclusion: The HEART score is a reliable tool for risk stratification in chest pain patients in the emergency department. Our study shows that a score of ≤ 3.5 indicates low risk, while higher scores predict a greater likelihood of MACE. The HEART score effectively guides clinical decisions, highlighting its high sensitivity and specificity for identifying low- and high-risk patients, making it an essential tool for patient management in emergency settings.
Objective: Religious mass gatherings in Iraq attract millions of pilgrims and have significant public health challenges. The martyrdom anniversary of Imam Ali bin Abi Talib (peace be upon him) in Najaf involves high population density and potential health risks. However, limited data exists on the spectrum of patient presentations during this event. Methods: It was a cross-sectional study in 12 health facilities (10 temporary mobile clinics and 2 fixed centers) established in Najaf for the event. The study was conducted from March 29 to April 1, 2024 (18–21 Ramadan 1445H). Data was collected by convenience sampling, entered via KoboToolbox, and analyzed in SPSS version 26 using descriptive statistics and chi-squared tests. Results: A total of 8,959 patients were registered. Most were aged 31–60 years (58.2%) and Iraqi nationals (80.8%). The most common acute infectious presentation was pharyngitis (16.7%: 95% CI: 15.9,17.4), followed by acute diarrhea (3.2%: 95% CI: 2.9,3.6). Noncommunicable conditions included hypertension (11.5%; 95% CI: 10.9,12.2), and diabetes mellitus (7.9%; 95% CI: 7.3,8.4). Patient presentations varied significantly by age group and nationality (P< 0.001). Conclusion: Pharyngitis was the leading acute presentation, suggesting a risk of respiratory disease transmission. Chronic conditions, particularly hypertension and diabetes, especially among adults over 31 years. These findings highlight the need for preparedness of temporary clinics to manage both communicable and noncommunicable diseases during religious mass gatherings in Iraq.
Backgound: Approximately one-third of the spontaneous bacterial peritonitis (SBP) are missed due to the absence of paracentesis, and any delay in antibiotic initiation significantly increases mortality. Clinical decision tools may help to rule out or rule in the diagnosis without paracentesis. This study systematically reviewed the performance of available decision tools for diagnosing SBP in adult patients with cirrhosis. Methods: We included all original studies that evaluated clinical decision tools for SBP diagnosis. Search was conducted in MEDLINE, Embase, Scopus, and Web of Science Core Collection from inception to September 2024. Study quality was evaluated using Quality Assessment of Diagnostic Accuracy Studies version 2 (QUADAS 2). Results: From 2038 records, 44 articles were scrutinized in full text. Twenty-four studies ultimately met eligibility criteria. Most of the studies were at low risk of bias. Several tools relied on laboratory findings with clinical features. In meta-analysis the Mansoura scoring system (cut-off of 4) showed a pooled sensitivity of 70.96% (95% CI: 42.06%,99.86%) and a negative predictive value 92.27% (95% CI: 88.80%,95.74%). The Wehmeyer’s scoring system achieved pooled specificity and positive predictive value of 98.43% (95% CI: 95.29,101.58%) and 90.26% (95% CI: 70.28,110.23%). A MELD score >15 yielded had pooled sensitivity of 83.85% (95% CI: 78.50%,89.20%) and negative predictive value of 87.56% (95% CI: 81.29%,93.84%). Conclusion: Several decision tools, particularly laboratory-based (e.g. procalcitonin) tools, showed high sensitivity to potentially rule out SBP. Some other tools (e.g. Mansoura, Wehmeyer rules) can reliably rule in the diagnosis. However, tools all the tools need further validation before widespread adoption.
Objective: Assessing the risk levels of patients with acute ischemic stroke (AIS) can assist in making informed choices about their treatment and rehabilitation. To assess the prognostic value of serum insulin-like growth factor-1 (IGF-1) in neurological deficit (National Institutes of Health Stroke Scale [NIHSS]), functional independence (Modified Rankin Scale [mRS]), and mortality following AIS. Methods: The search encompassed Medline, Embase, Scopus, and Web of Science until June 2023. Two autonomous researchers incorporated articles by the established inclusion and exclusion criteria. The quality of the included studies were assessed using the quality assessment of prognostic accuracy studies (QUAPAS) tool. Results: Ten articles were included, with evidence suggesting that IGF-1 may have prognostic value in AIS outcomes. Several studies reported positive associations between IGF-1 levels, reduced neurological deficits, improved functional independence, and lower mortality. Additionally, intraindividual fluctuations in IGF-1 after AIS were identified as a potential predictor of recovery in functional independence, though significant inconsistencies exist in the findings. Conclusion: The available studies with a very low level of evidence are not sufficient to firmly endorse the applicability of IGF-1 as a prognostic factor for mortality, neurological disability, and functional independence.
Objective: The aim of this study was to evaluate whether verbal pressure from the team leader distracted students during a critical care simulation scenario. Particularly, examining the influence of unethical leadership on CPR quality was the objective of this work. Methods: Eighty students were randomized into study (n=40) and control group (n=40). They participated in a short cardiac arrest simulation scenario, each one separately. The scenario consisted of two tasks. Firstly, they were asked to bring to the team leader one ampule of a particular drug. A variety of drugs in their original packaging were placed on a shelf, but the handicap of this task was that the ampullae were mixed up between boxes. The second task was to perform 30 good-quality chest compressions. Study group participants were experiencing verbal pressure during the first part. Results: Study group participants fulfil the first task faster (require less time to bring the ampulla), but fewer of them find out that medications are mistaken (in comparison with the control group). Moreover, the study group reports higher stress levels (as assessed in 1-10 scores), and more participants perform too fast chest compressions (faster than 120 times per minute) in this group. Conclusion: Verbal pressure from a team leader increases participants' stress levels and decreases their effectiveness (chest compression quality and the ability to identify that ampullae are mistaken).
Objective: Identifying trauma care quality from the trauma victims' viewpoints is key to patient-centered care, identifying service gaps, developing effective protocols, and building trust in medicine. The current study aims to establish a new quality of trauma care questionnaire and to assess its psychometric characteristics within the hospital context in Iran. Methods: First, items were developed through a combination of literature review and interviews. Then, the validity of the items, including content, face, and internal consistency, was evaluated. Construct validity was assessed using exploratory factor analysis (EFA) on a sample of 220 patients, followed by confirmatory factor analysis (CFA) with a separate group of 253 patients from August to October 2022. Results: Content validity, as measured using modified Kappa, was 0.95. Cronbach's alpha for internal consistency was 0.91, and test-retest reliability over two weeks was 0.94. The EFA revealed four factors: interpersonal quality, technical quality, outcome quality, and non-medical quality, which collectively accounted for 67% of the total variance in measuring the quality of care in trauma victims. Using CFA, researchers validated the final version of the trauma quality scale from patients' perspective (TQS-PP), which includes 22 items across four dimensions. The CFA model of the TQS-PP demonstrated an acceptable fit, with 2/df = 2.064, RMSEA=0.058, CFI=0.912, and NNFI=0.920. Conclusion: Psychometric evaluations demonstrated sufficient validity and reliability for TQS-PP application in quality research involving trauma victims in Iran. The developed and evaluated TQS-PP serves as a reliable measure of health care quality from the perspective of trauma victims. The new tool could assist public health researchers in assessing the quality of care in emergency departments (EDs) and similar contexts.
Objective: Religious mass gatherings in Iraq attract millions of pilgrims and have significant public health challenges. The martyrdom anniversary of Imam Ali ibn Abi Talib (peace be upon him) in Najaf involves high population density and potential health risks. However, limited data exists on the spectrum of patient presentations during this event. Methods: It was a cross-sectional study in 12 health facilities (10 temporary mobile clinics and 2 fixed centers) established in Najaf for the event. The study was conducted from March 29 to April 1, 2024 (18-21 Ramadan 1445H). Data was collected by convenience sampling, entered via KoboToolbox, and analyzed in SPSS version 26 using descriptive statistics and chi-squared tests. Results: A total of 8,959 patients were registered. Most were aged 31-60 years (58.2%) and Iraqi nationals (80.8%). The most common acute infectious presentation was pharyngitis (16.7%: 95% CI: 15.9,17.4), followed by acute diarrhea (3.2%: 95% CI: 2.9,3.6). Noncommunicable conditions included hypertension (11.5%; 95% CI: 10.9,12.2), and diabetes mellitus (7.9%; 95% CI: 7.3,8.4). Patient presentations varied significantly by age group and nationality (P< 0.001). Conclusion: Pharyngitis was the leading acute presentation, suggesting a risk of respiratory disease transmission. Chronic conditions, particularly hypertension and diabetes, especially among adults over 31 years. These findings highlight the need for preparedness of temporary clinics to manage both communicable and noncommunicable diseases during religious mass gatherings in Iraq.
Objective: The aim of this randomized-controlled simulation study was to evaluate the impact of external verbal pressure on the effectiveness and safety of automatic external defibrillator (AED) use and hands-on cardiopulmonary resuscitation (CPR) performed by students. Methods: Sixty-two first-year nursing students were recruited. Participants were split into pairs (n=31), randomly assigned to the study (n=16 pairs) and control groups (n=15 pairs). Subsequently, each pair took part in a brief simulation scenario concerning out-of-hospital cardiac arrest. One student was responsible for performing chest compressions, whilst the second was responsible for using an AED. The researcher verbally pressed the participants responsible for AED use in the study group. Students performing chest compressions were not the addressee of any comments. Participants in the control group acted without the researcher's pressure. Results: Only 2 participants in the control group used AED incorrectly, compared with 8 participants in the study group who incorrectly performed defibrillation. The rate of hands-on CPR was significantly faster in the study group compared to the control group (124 +/- 29.7 versus 104 +/- 20.8; P=0.028). Conclusion: Verbal pressure in simulation settings significantly diminishes the quality of performance during AED use. The pressure affected not only the participants to whom it was directly addressed but also their teammates, who performed worse compared to those without additional stressors.
A 72-year-old woman presented to the emergency department with fatigue and epigastric pain. Imaging revealed pneumatosis intestinalis and portomesenteric venous gas (PMVG), ultimately diagnosed as mesenteric infarction. The case highlights PMVG as an urgent radiological sign requiring prompt recognition and surgical consultation in emergency settings.
Background: Road traffic injuries (RTIs) are a leading global health challenge, with Iran facing significant economic and social costs due to these incidents. This study investigates Iranian drivers' preferences for road safety and their willingness to pay (WTP) to reduce injury and mortality risks. It also examines the influence of demographic and driving-related factors on these preferences. Methods: A discrete choice experiment (DCE) was conducted among Shiraz residents to analyze route preferences. Participants evaluated hypothetical commuting scenarios characterized by variations in travel time, cost, injury risk, and fatality risk. Using a D-efficient fractional factorial design, 10 two-alternative choice scenarios were developed. Data were collected through interviews in five districts, achieving an 81% response rate. A mixed logit regression model was employed to assess how route attributes influenced participants' decisions. Results: Key factors driving route choices included the number of deaths, injury rates, travel time, and cost, with fatalities being the most influential. Participants were willing to pay $7.07 extra for routes with travel times under 30 minutes, $8.98 for routes with fewer than 10 annual injuries, and $11.83 for routes with fewer than 5 annual deaths. WTP varied significantly across demographic groups: men prioritized reduced travel time, while women emphasized safety. Personal-use drivers exhibited higher WTP compared to professional drivers like taxi operators. Larger family sizes correlated with lower WTP, whereas individuals in excellent health or with supplementary health insurance displayed higher WTP for safer and faster routes. Conclusion: This study underscores the utility of DCEs in capturing drivers' preferences for road safety and efficiency in Iran. By highlighting the trade-offs drivers are willing to make and identifying key factors, these findings offer actionable insights for policymakers to design transportation systems that align with public safety and mobility priorities.
Objective: Emergency department length of stay (EDLOS) is a critical measure of healthcare efficiency and quality, and prolonged stays are associated with worse outcomes, particularly for patients requiring intensive care unit (ICU) admission. This study evaluates the impact of a digital consultation management system implemented at Hiwot Fana Comprehensive University Hospital in Ethiopia between May 2020 and May 2024. Methods: A pre-post quasi-experimental design was utilized to compare EDLOS for ICU patients before and ter the implementation of the new consultation system. The traditional consultation process was characterized by multi-step verbal communication among healthcare providers. The new system employed a secure Telegram channel to facilitate real-time communication, whereby all physicians in the consulting service were simultaneously notified of the patient requiring ICU care. We determined the proportion of patients admitted to the ICU staying more than 24 hours in the emergency department (ED) between pre-and post-implementation of the Telegram system using chi-squared tests and mean difference in LOS using Mann Whitney U. Results: This study included 415 patients with 202 patients in the pre-implementation period (May 01, 2020, to May 31, 2022) and 213 in the post-implementation period (June 01, 2022, to May 31, 2024). The mean age was 43.3 years (SD: 18.75 years), and no significant demographic or clinical differences were observed between the pre-and post-intervention groups, except for payment method. Before implementation, 32.6% of patients stayed in the ED> 24 hours while after the implementation 28.8% stayed > 24 hours (P=0.03) The mean EDLOS decreased from 2.83 (SD: 2.5) days to 2.27(SD: 1.64) days following implementation (P=0.04), with a reduction approximately 13.2 hours in EDLOS. Overall ICU mortality decreased from 31.4% to 25.8%, though this was not statistically significant. Conclusion: A digital consultation system can reduce EDLOS in a limited-income country, consistent with findings from similar studies. Further research is needed to explore long-term impacts and scalability, especially low-resource settings.
Objective: Deep learning-based automatic segmentation provides significant advantages over traditional manual segmentation methods in medical imaging. Current approaches for segmenting regions of Coronavirus disease 2019 (COVID-19) infections mainly utilize convolutional neural networks (CNNs), which are limited by their restricted receptive fields (RFs) and consequently struggle to establish global context connections. This limitation negatively impacts their performance in accurately detecting complex details and boundary patterns within medical images. Methods: This study introduces a novel dual-path Swin Transformer-based network to address these limitations and enhance segmentation accuracy. Our proposed model extracts more informative 3D input patches to capture long-range dependencies and represents both large and small-scale features through a dual-branch encoder. Furthermore, it integrates features from the two paths via the new transformer interactive fusion (TIF) module. The architecture also incorporates an inductive bias by including a residual convolution (Res-conv) block within the encoder. Results: The proposed network has been evaluated using a 5-fold cross-validation technique, alongside data augmentation, on the publicly available COVID-19-CT-Seg and MosMed datasets. The model achieved Dice coefficients of 0.872 and 0.713 for the COVID-19-CT-Seg and MosMed datasets, respectively, demonstrating its effectiveness relative to prior methodologies. Conclusion: The significant improvements in segmentation accuracy, demonstrated by the achieved Dice coefficients on the COVID-19-CT-Seg and MosMed datasets, highlight the potential of our approach to enhance automated segmentation in medical imaging.
Spontaneous esophageal perforation, also known as Boerhaave syndrome, is a rare but potentially fatal condition that classically presents with chest pain, vomiting, and subcutaneous emphysema. Atypical presentations can lead to diagnostic delays and increased morbidity and mortality rates. A 51-year-old male presented to the emergency department with isolated left flank pain. Initial clinical assessment suggested renal pathology, which prompted physicians to order a non-contrast thoracoabdominopelvic computed tomography (CT) scan. The CT scan unexpectedly revealed bilateral diffuse subcutaneous emphysema and left pleural effusion. Following chest tube insertion, food particles were recovered from the pleural drainage, which established the diagnosis of esophageal perforation. Emergency surgical repair was performed successfully with a good clinical outcome. This case highlights the importance of maintaining high clinical suspicion for esophageal perforation even in patients presenting with atypical symptoms. The absence of classic triad symptoms should not exclude this diagnosis from consideration. CT imaging can provide crucial diagnostic information when the clinical presentation is unclear or atypical.
Objective: Emergency departments (EDs) are critical to healthcare systems, yet in Jordan, overcrowding and resource limitations challenge care quality. This study assessed how Jordanian patient satisfaction with nursing care at EDs related to their understanding of triage systems and wait times. Methods: A prospective cross-sectional design was used. Data were collected from largest two healthcare hospitals in Jordan which utilizing Canadian triage system. A convenience sampling method was utilized. All adult patients (>= 18 years) were included. However, patient's triaged at level 1 (resuscitation) or 2 (emergent) based on Canadian triage system, pediatric patients, and/or those with documented history of psychiatric illness were excluded. Valid and reliable tools were used. Results: The mean age of patients was 37.6 years (SD=11.4), with a mean satisfaction score of 15.79/20 (SD=3.22), reflecting high satisfaction. Most patients (61.3%) were unaware of triage processes; however, their satisfaction with nursing care was related with triage understanding (P<0.05). Younger patients (t=2.045, P<0.05), Jordanian nationals (t=1.817, P<0.05), unmarried individuals (F=3.32, P<0.05), and government-sector workers (F=3.42, P< 0.05) reported significantly higher satisfaction than others. Conclusion: Enhancing patient satisfaction in EDs relies on optimizing nursing care, particularly through staff training in triage systems and patient education about triage processes. Implementing standardized protocols, along with accessible educational materials for patients while they are in the waiting room, is critical to addressing care gaps and ensuring sustainable improvements.
Spontaneous coronary artery dissection (SCAD) is a rare but life-threatening cause of acute coronary syndrome, particularly in young women with few traditional risk factors for atherosclerosis. SCAD is often underrecognized due to its atypical presentation which can lead to misdiagnosis or delayed diagnosis in emergency settings. We present a case of a 40-year-old female who presented to the emergency department with acute chest pain and was found to have ST-elevation myocardial infarction (STEMI) due to SCAD. This case highlights the importance of considering SCAD in the differential diagnosis of acute coronary syndrome in young patients, especially females, and the need for increased awareness among emergency physicians to optimize patient outcomes and reduce recurrence risks. This case also emphasizes the importance of recognizing SCAD as a distinct entity from atherosclerotic ACS, as it requires a different management approach, particularly in the initial steps of care.
Objective: As emergency department (ED) visits for atrial fibrillation (AF) grow, comorbidities lead to challenging treatment scenarios. There are limited data evaluating the safety of diltiazem in the acute management of AF with rapid ventricular rate (RVR) in patients with heart failure with reduced ejection fraction (HFrEF). The objective of this study was to evaluate the safety of diltiazem vs metoprolol in patients presenting to the ED with AF with RVR with HFrEF. Methods: This multicenter, retrospective, cohort study evaluated patients with AF with RVR with HFrEF who received either intravenous (IV) diltiazem or metoprolol in the ED. The primary endpoint was worsening heart failure, defined as an increase in supplemental oxygen requirement, acute kidney injury (AKI), or inotrope administration. Secondary endpoints included bradycardia, systolic blood pressure (SBP) <90 mmHg, or atropine administration. Results: Of the 5,465 patients screened, 62 (1.1%) patients were included for analysis. Forty-nine (79%) patients received IV diltiazem and 13 (21%) received IV metoprolol. The primary endpoint of worsening heart failure occurred in 26.5% in the diltiazem cohort and 15.4% in the metoprolol cohort (P=0.493). There were no differences in increased need for supplemental oxygen, incidence of AKI, or inotropic support. There were no differences in the secondary safety endpoints. Conclusion: For ED management of patients with AF with RVR with HFrEF, treatment with IV diltiazem did not lead to an increase in worsening heart failure compared to IV metoprolol. Future prospective trials are needed to evaluate this treatment approach in this population.
Objective: Aspiration of a foreign body in the airways of children is one of the important emergencies in children, which is associated with high mortality and morbidity if not diagnosed promptly or managed effectively. The aim of this study was to investigate the clinical and radiographic findings in children with foreign body aspiration. Methods: In a large cross-sectional retrospective study at a tertiary hospital from 2009 to 2019, children with foreign body aspiration were evaluated. The required information (demographics, clinical examination findings, and results of radiological and bronchoscopy reports) was extracted from the medical records of the patients in the hospital archive. Results: In this study, 330 patients were enrolled, 61.2% of whom were male. The mean age of the patients was 2.65 +/- 2.68 years. The average time interval from the onset of symptoms to the final diagnosis was 11.54 days. The most common location and type of aspirated foreign body were the right main bronchus (60%) and seeds (39.1%), respectively. Cough and decreased unilateral lung sounds were the most common clinical symptoms (91.5%) and physical findings (50.6%), respectively. The most common finding on chest X-ray was local emphysema (43%). Conclusion: Foreign body aspiration can lead to irreparable injuries if it is not recognized and managed promptly. Aspiration of a foreign body can result in serious harm if not quickly diagnosed and properly managed. Clinical suspicion of aspiration and the management of these children are critical.
