Saeed Safari

Use of the sonographic diameter of optic nerve sheath to estimate intracranial pressure

BACKGROUND AND AIMS An increase in the intracranial pressure (ICP) might aggravate patient outcomes by inducing neurologic injuries. In patients with increased ICP the optic nerve sheath diameter (ONSD) increases due to its close association with the flow of cerebrospinal fluid. The present study was an attempt to evaluate the efficacy of sonographic ONSD in estimating ICP of patients who are candidates for lumbar puncture (LP). MATERIALS AND METHODS In this descriptive prospective study, the ONSD was measured before LP using an ultrasonography in 50 nontraumatized patients who were candidates for LP due to varies diagnoses. Immediately after the sonography, the ICP of each patient was measured by LP. Correlation tests were used to evaluate the relationship between ICP and the sonographic diameter of the optic nerve sheath. Receiver operating characteristic curve was used to find the optimal cut-off point in order to diagnose ICP values higher than 20 cm H(2)O. RESULTS The means of the ONSD were 5.17 ± 1.01 and 5.19 ± 1.06 mm on the left and right sides, respectively (P = .552). The mean ONSD for the patients with increased ICP and normal individuals were 6.66 ± 0.58 and 4.60 ± 0.41 mm, respectively (P < .001). This mean was significantly correlated with ICP values (P < .05; r = 0.88). The ONSD of greater than 5.5 mm predicted an ICP of ≥20 cm H(2)O with sensitivity and specificity of 100% (95% CI, 100-100) (P < .001). CONCLUSION The sonographic diameter of the optic nerve sheath might be considered a strong and accurate predicting factor for increased intracranial pressure.

Clinical decision rule to prevent unnecessary chest X‐ray in patients with blunt multiple traumas

Since the diagnostic yield of chest X‐ray (CXR) is not high enough, when it is ordered for all the multiple trauma patients, this study was aimed to evaluate the relationship between clinical and CXR findings in order to formulate a clinical decision rule to prevent unnecessary CXR in these patients.

Accuracy of urine dipstick in the detection of patients at risk for crush-induced rhabdomyolysis and acute kidney injury.

Objectives To evaluate the utility of urine dipstick test (UDT) for detecting rhabdomyolysis and acute kidney injury (AKI) due to crush injury. Methods All the rescued victims of the Bam earthquake who had a documented urine analysis and serum creatine phosphokinase and creatinine levels during their hospitalization period were eligible to enter the study. The sensitivity and the specificity, along with the positive and negative likelihood ratios, of UDT in detecting at-risk patients for rhabdomyolysis and crush-related AKI were calculated. Results Urine red blood cell count of 5 or less in blood-positive UDT, as a surrogate marker for myoglobinuria, was reported in 210 (31.7%) of the total 1821 urine analyses. Blood-positive UDTs (without considering the urine red blood cell count) had a 92.5% (95% confidence interval: 79.6–98.4) sensitivity in creatine phosphokinase, with a cut-off of 15 000 (IU/l). Comparing the results of the serum creatinine level and the urine blood, analysis showed that UDT had a sensitivity and a specificity of as high as 83.3 and 56.6% in detecting high-risk patients for AKI, respectively. Conclusion UDT can be considered as an early screening tool for the detection and triage of patients at risk of developing AKI because of traumatic rhabdomyolysis after mass disasters.

The efficacy of Schwann cell transplantation on motor function recovery after spinal cord injuries in animal models: A systematic review and meta-analysis.

AIM This article aimed to assess the efficacy of Schwann cell transplantation on motor function recovery in animal model of spinal cord injuries via meta-analysis. METHODS An extended search was carried out in the electronic databases of Medline (via PubMed), EMBASE (via OvidSP), CENTRAL, SCOPUS, Web of Science (BIOSIS), and ProQuest. Finally, 41 eligible studies conducted on 1046 animals including 517 control animals and 529 transplanted animals were included in the meta-analysis. Pooled standardized mean difference (SMD) and odds ratio (OR) with 95% confidence interval (95% CI) were reported. RESULTS The findings showed that treatment with Schwann cells leads to a modest motor function recovery after spinal cord injury (SMD=0.85; 95% CI: 0.63-1.07; p<0.001). Transplantation of these cells in acute phase of the injury (immediately after the injury) (OR=4.30; 95% CI: 1.53-12.05; p=0.007), application of mesenchymal/skin-derived precursors (OR=2.34; 95% CI: 1.28-4.29; p=0.008), and cells with human sources are associated with an increase in efficacy of Schwann cells (OR=10.96; 95% CI: 1.49-80.77; p=0.02). Finally, it seems that the efficacy of Schwann cells in mice is significantly lower than rats (OR=0.03; 95% CI: 0.003-0.41; p=0.009). CONCLUSION Transplantation of Schwann cells can moderately improve motor function recovery. It seems that inter-species differences might exist regarding the efficacy of this cells. Therefore, this should be taken into account when using Schwann cells in clinical trials regarding spinal cord injuries.

The Role of Caffeine in Pain Management: A Brief Literature Review

Context: Caffeine is the most commonly used psychoactive legal drug in the world. Caffeine’s role in controlling pain has received less attention in the past, yet is being increasingly considered. This article briefly reviewed the literature to clarify the role of caffeine as a drug for pain control and attract investigators to this topic. Evidence Acquisition: The data on Caffeine as an adjuvant therapy or as a main component for pain modulation has been narratively reviewed. Results: Caffeine plays an important role in pain modulation through their action on adenosine receptors which are involved in nociception. The use of caffeine as adjuvant treatment was well-established in the literature and caffeine is currently available in some over the counter medications. Studies showed controversial results about the interaction between caffeine and morphine for pain relief in patients with terminal stage cancer. As a main component for pain modulation, Caffeine can be used for hypnic headache and postdural puncture headache. Conclusions: Caffeine has a potential role for pain modulation. Current evidence on caffeine use for migraine and terminal stage cancer is not well-established. Future studies should address the use of caffeine alone for different types of pain with dose escalation and standardization of outcome measurement.

Accuracy of SOFA score in prediction of 30-day outcome of critically ill patients

Objectives Researchers have attempted to design various scoring systems to determine the severity and predict the outcome of critically ill patients. The present study aimed to evaluate the accuracy of SOFA score in predicting 1-month outcome of these patients in emergency department. Methods The present study is a prospective cross-sectional study of >18 year old non-trauma critically ill patients presented to EDs of 3 hospitals, Tehran, Iran, during October 2014 to October 2015. Baseline characteristics, SOFA score variables, and 1-month outcome of patients were recorded and screening performance characteristics of the score were calculated using STATA 11 software. Results 140 patients with the mean age of 68.36 ± 18.62 years (18–95) were included (53.5% male). The most common complaints were decrease in level of consciousness (76.43%) and sepsis (60.0%), were the most frequent final diagnoses. Mean SOFA score of the patients was 7.13 ± 2.36 (minimum 2 and maximum 16). 72 (51.43%) patients died during the following 30 days and 16 (11.43%) patients were affected with multiple organ failure. Area under the ROC curve of SOFA score in predicting mortality of studied patients was 0.73 (95%CI: 0.65–0.81) (Fig. 2). Table 2 depicts screening performance characteristics of this scale in prediction of 1-month mortality in the best cut-off point of ≥7. At this cut-off point, sensitivity and specificity of SOFA in predicting 1-month mortality were 75% and 63.23%, respectively. Conclusion Findings of the present study showed that SOFA scoring system has fair accuracy in predicting 1-month mortality of critically ill patients. However, until a more reliable scoring system is developed, SOFA might be useful for narrative prediction of patient outcome considering its acceptable likelihood ratios.

Effects of Pain Relief on Arterial Blood O2 Saturation

Background: Pain management with the use of sedatives and analgesics has several advantages and few complications or side effects. Objectives: In this study, we planned to evaluate the effects of pain control on oxygen saturation independent of other factors, such previous cardio-pulmonary conditions or respiratory rate. Patients and Methods: Sixty-seven adult patients with direct trauma to extremities, who were referred to Imam Hossein Educational Hospital emergency room were enrolled in this study. Exclusion criteria were trauma to parts of the body other than extremities, and comorbidity with cardiovascular, pulmonary, or other disorders. Pain was evaluated using a numerical rating scale and scored between 0-10. Patients’ respiratory rates (RR) were recorded by a physician and blood oxygen saturations were measured using a pulse oximeter. Then, fentanyl 1 μg/kg was administered under direct supervision of a physician. After five minutes, pain score, oxygen saturation, and RR were measured in the above-mentioned order. Results: The data from 67 patients with a average age of 30 years were collected: 77% were male and 23% were female. The average pain score of these patients was 7.3 at the time of admission, which significantly decreased to 3.8 after fentanyl administration (P < 0.001). Upon arrival in emergency department the mean oxygen saturation and RR were 97.1% and 21.5/minute, respectively. After pain control, mean oxygen saturation and RR were 94.9% and 19.2 /minute, respectively, showing a significant decrease only for RR in comparison with that at the time of admission (P < 0.001). Regression analysis of pain score and O2 saturation differentiation showed no significant relation between these variables. There were no side effects or complications of fentanyl observed in these patients. Conclusions: The results of our study revealed no independent causative relationship between pain control and oxygen saturation.

Deep vein thrombosis following below knee immobilization: the need for chemoprophylaxis.

Background There is controversy regarding routine prophylaxis for deep vein thrombosis (DVT) in patients treated via a short leg cast or splint following lower extremity trauma. Objectives The main aim of this study is to evaluate the incidence of DVT and need for chemoprophylaxis in these patients. Materials and Methods Patients with ankle sprains or stable foot/ankle fractures were entered in this cross-sectional study. Serum D-dimer levels were measured 2 weeks following fixation. If the D-dimer levels were above 0.2 micrograms/ml the test was considered positive and the patient was referred for Doppler ultrasound examination (DUE) to confirm or rule out the diagnosis of DVT. Finally, the incidence of DVT was calculated and the role of predisposing factors was investigated. Results There were 95 patients with an average age of 38 ± 13.7 (77.9% males); 46 patients had at least one risk factor for DVT. The D-dimer test was positive in 21(22.1%) patients. DVT was confirmed by DUE in 3 patients (3.1%). The incidence of DVT significantly increased in the presence of 3 or more risk factors (P = 0.01). Conclusions It seems that DVT is not a common complication of below knee fixation and chemoprophylaxis is not necessary when the patient has less than 3 predisposing factors. With 3 or more risk factors chemoprophylaxis and periodic follow-ups must be considered.

THE STORY OF CONTINUOUS AMBULATORY PERITONEAL DIALYSIS IN IRAN

Iran, a developing country with a population of approximately 71000 000, is the most populous country in the Middle East and the 16th most populous in the world. Gross domestic product (GDP) per capita is US

Sonographic Detection of Abdominal Free Fluid: Emergency Residents vs Radiology Residents.

8900 and total health expenditure is approximately 6% of GDP. The total number of end-stage renal disease (ESRD) patients reported by the Management Center for Transplantation and Special Diseases (MCTSD) was 32686 in 2007, which denotes a prevalence of 466 per million population (pmp) in Iran. Considering the growth rate of 12%, the expected number of ESRD patients in 2010 is 40 000; incidence of ESRD is expected to be 63.8 pmp (1). These numbers are lower compared to developed countries, which may suggest poor referral and under-diagnosis of ESRD. In Iran at present, hemodialysis (HD) and renal transplantation are the most common renal replacement therapy (RRT) modalities, accounting for 47.7% and 48.8% of prevalent RRT patients respectively. Based on the Iran Dialysis Center report of 2001, approximately 1% of ESRD patients were being treated with continuous ambulatory peritoneal dialysis (CAPD); this number increased to approximately 3.5% (6.8% of total dialysis patients) in 2006 (1). In the present article, reasons for underutilization of peritoneal dialysis (PD) and improvements in PD within the past 5 years will be reviewed.