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Table of Content

    15 March 2018, Volume 9 Issue 1
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    Original Articles
    Perceptions of emergency medicine residents on the quality of residency training in the United States and Saudi Arabia
    Ahmad Aalam, Mark Zocchi, Khalid Alyami, Abdullah Shalabi, Abdullah Bakhsh, Asaad Alsufyani, Abdulrahman Sabbagh, Mohammed Alshahrani, Jesse M. Pines
    2018, 9(1):  5-13.  doi:10.5847/wjem.j.1920-8642.2018.01.001
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    BACKGROUND: We compare educational environments (i.e. physical, emotional and intellectual experiences) of emergency medicine (EM) residents training in the United States of America (USA) and Saudi Arabia (SA).
    METHODS: A cross-sectional survey study was conducted using an adapted version of the validated Postgraduate Hospital Educational Environment Measure (PHEEM) survey instrument from April 2015 through June 2016 to compare educational environments in all emergency medicine residency programs in SA and three selected programs in the USA with a history of training Saudi physicians. Overall scores were compared across programs, and for subscales (autonomy, teaching, and social Support), using chi-squared, t-tests, and analysis of variance.
    RESULTS: A total of 219 surveys were returned for 260 residents across six programs (3 SA, 3 USA), with a response rate of 84%. Program-specific response rates varied from 79%-100%. All six residencies were qualitatively rated as “more positive than negative but room for improvement”. Quantitative PHEEM scores for the USA programs were significantly higher: 118.7 compared to 109.9 for SA, P=0.001. In subscales, perceptions of social support were not different between the two countries (P=0.243); however, role autonomy (P<0.001) and teaching (P=0.005) were better in USA programs. There were no significant differences by post-graduate training year.
    CONCLUSION: EM residents in all three emergency medicine residency programs in SA and the three USA programs studied perceive their training as high quality in general, but with room for improvements. USA residency programs scored higher in overall quality. This was driven by more favorable perceptions of role autonomy and teaching. Understanding how residents perceive their programs may help drive targeted quality improvement efforts.

    Intravenous fluid selection rationales in acute clinical management
    Wing Yan Shirley Cheung, Wai Kwan Cheung, Chun Ho Lam, Yeuk Wai Chan, Hau Ching Chow, Ka Lok Cheng, Yau Hang Wong, Chak Wah Kam
    2018, 9(1):  13-19.  doi:10.5847/wjem.j.1920-8642.2018.01.002
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    BACKGROUND: Intravenous fluid (IVF) is commonly used in acute clinical management. This study aimed to review the choice and primary considerations in IVF prescriptions and to evaluate the adequacy of guidelines and trainings on it in the New Territories West Cluster (NTWC) of Hong Kong.
    METHODS: This is a descriptive study based on data collected from an online survey. Data were processed by SPSS for statistical analysis. This study focused on a general description and doctor-nurse between group comparison. Participants were asked the choice of IVF for nine acute clinical scenarios and provide reason. A 1-10 scale was used to assess the sufficiency of guideline, training and information, and time for revision on IVF prescription.
    RESULTS: 0.9% sodium chloride was the most familiar IVF (36%), followed by 5% Dextrose solution (26%). In the nine scenarios, the most chosen IVF was 0.9% sodium chloride (37%-61%). There was significant difference in the choice of IVF between doctors and nurses in 7 cases. The second most chosen IVF for doctors was Plasma-Lyte A while that for nurses was Gelofusine. Departmental practice was the most chosen reason to account for the prescription. The adequacy of guideline, information and training, and time for revision was rated 5. Doctors had significantly more time at work than nurses to update knowledge in IVF prescription (5.41 versus 4.57).
    CONCLUSION: 0.9% sodium chloride was mostly chosen. The choice of IVF was mainly based on departmental practice. Adequacy of guideline, information and training, and time for revision on IVF prescription were average, indicating significant training deficit.

    Association between the elderly frequent attender to the emergency department and 30-day mortality: A retrospective study over 10 years
    Yuzeng Shen, Yee Chien Tay, Edward Wee Kwan Teo, Nan Liu, Shao Wei Lam, Marcus Eng Hock Ong
    2018, 9(1):  20-25.  doi:10.5847/wjem.j.1920-8642.2018.01.003
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    BACKGROUND: To determine if elderly frequent attenders are associated with increased 30-day mortality, assess resource utilization by the elderly frequent attenders and identify associated characteristics that contribute to mortality.
    METHODS: Retrospective observational study of electronic clinical records of all emergency department (ED) visits over a 10-year period to an urban tertiary general hospital in Singapore. Patients aged 65 years and older, with 3 or more visits within a calendar year were identified. Outcomes measured include 30-day mortality, admission rate, admission diagnosis and duration spent at ED. Chi-square-tests were used to assess categorical factors and Student t-test was used to assess continuous variables on their association with being a frequent attender. Univariate and multivariate logistic regressions were conducted on all significant independent factors on to the outcome variable (30-day mortality), to determine factor independent odds ratios of being a frequent attender.
    RESULTS: 1.381 million attendance records were analyzed. Elderly patients accounted for 25.5% of all attendances, of which 31.3% are frequent attenders. Their 30-day mortality rate increased from 4.0% in the first visit, to 8.8% in the third visit, peaking at 10.2% in the sixth visit. Factors associated with mortality include patients with neoplasms, ambulance utilization, male gender and having attended the ED the previous year.
    CONCLUSION: Elderly attenders have a higher 30-day mortality risk compared to the overall ED population, with mortality risk more marked for frequent attenders. This study illustrates the importance and need for interventions to address frequent ED visits by the elderly, especially in an aging society.

    Differential diagnoses of magnetic resonance imaging for suspected acute appendicitis in pregnant patients
    Ji Yong Jung, Ji Ung Na, Sang Kuk Han, Pil Cho Choi, Jang Hee LEE, Dong Hyuk Shin
    2018, 9(1):  26-32.  doi:10.5847/wjem.j.1920-8642.2018.01.004
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    BACKGROUND: Accurate and timely diagnosis of acute surgical disease in pregnant patient is challenging. Although magnetic resonance imaging (MRI) is the most accurate modality to diagnose acute appendicitis in pregnant patients, it is often used as a last resort because of high cost and long scan time. We performed this study to analyze differential diagnoses of appendix MRI and to investigate if there are any blood tests that can predict surgical condition in pregnant patients.
    METHODS: A retrospective, cross-sectional study was conducted on 46 pregnant patients who underwent non-enhanced appendix MRI in suspicion of acute appendicitis from 2010 to 2016. Differential diagnoses of appendix MRI were analyzed and blood tests were compared between those who had surgical and non-surgical disease.
    RESULTS: Appendix MRI differentiated two surgical disease; acute appendicitis and ovarian torsion; and various non-surgical conditions such as uterine myoma, hydronephrosis, ureterolithiasis and diverticulitis among clinically suspected acute appendicitis in pregnancy. The diagnostic accuracy of MRI for acute appendicitis in this study was 93.5%. Patients who had surgical disease showed significantly higher WBC count (≥11,000/mm3), proportion of neutrophils in the WBC (≥79.9%), neutrophil-to-lymphocyte ratio (NLR≥6.4), levels of C-reactive protein (CRP≥1.82 mg/dL) and bilirubin (≥0.66 mg/dL ) than those who had non-surgical disease.
    CONCLUSION: MRI can reliably differentiate surgical conditions and several blood tests (WBC, proportion of neutrophils in the WBC, NLR, CRP, bilirubin) can help anticipate acute surgical condition among pregnant patients suspected to have acute appendicitis.

    Ultrasound curriculum taught by first-year medical students: A four-year experience in Tanzania
    Sean P. Denny, William B. Minteer, Reece T.H. Fenning, Sahil Aggarwal, Debora H. Lee, Shella K. Raja, Kaavya R. Raman, Allison O. Farfel, Priya A. Patel, MarkLieber, Megan E. Bernstein, Shadi Lahham, John C. Fox
    2018, 9(1):  33-40.  doi:10.5847/wjem.j.1920-8642.2018.01.005
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    BACKGROUND: Diagnostic imaging is an integral aspect of care that is often insufficient, if not altogether absent, in rural and remote regions of low to middle income countries (LMICs) such as Tanzania. The introduction of ultrasound can significantly impact treatment in these countries due to its portability, low cost, safety, and usefulness in various medical assessments. This study reviews the implementation of a four-week ultrasound course administered annually from 2013-2016 in a healthcare professional school in Mwanza, Tanzania by first-year allopathic US medical students.
    METHODS: Participants (n=582, over 4 years) were recruited from the Tandabui Institute of Health Sciences and Technology to take the ultrasound course. Subjects were predominantly clinical officer students, but other participants included other healthcare professional students, practicing healthcare professionals, and school employees. Data collected includes pre-course examination scores, post-course examination scores, course quiz scores, demographic surveys, and post-course feedback surveys. Data was analyzed using two-tailed t-tests and the single factor analysis of variance (ANOVA).
    RESULTS: For all participants who completed both the pre- and post-course examinations (n=229, 39.1% of the total recruited), there was a significant mean improvement in their ultrasound knowledge of 42.5%, P<0.01.
    CONCLUSION: Our data suggests that trained first-year medical students can effectively teach a point of care ultrasound course to healthcare professional students within four weeks in Tanzania. Future investigation into the level of long-term knowledge retention, impact of ultrasound training on knowledge of human anatomy and diagnostic capabilities, and how expansion of an ultrasound curriculum has impacted access to care in rural Tanzania is warranted.

    Drug calculation ability of qualified paramedics: A pilot study
    Malcolm J. Boyle, Kathryn Eastwood
    2018, 9(1):  41-45.  doi:10.5847/wjem.j.1920-8642.2018.01.006
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    BACKGROUND: The inability of paramedics to perform accurate calculations may result in a compromise of patient safety which may result from under or over dosing of drugs, incorrect joules for defibrillation, or a major adverse event such as death. The objective of this study was to identify the drug calculation and mathematical ability of qualified operational paramedics.
    METHODS: The study used a cross-sectional design with a paper-based calculation questionnaire. Twenty paramedics enrolled in an intensive care paramedic course were eligible to participate in the study. The questionnaire consisted of demographic, drug calculation (seven questions), and mathematical (five) questions. Students were given no notice of the impending study and use of a calculator was not permitted.
    RESULTS: All eligible students participated in the study. The average time employed as a paramedic was 7.25 years, SD 2.5 years, range four years to twelve years. Four (20%) students got all 12 questions correct, and five (41.6%) got 50% or less. The average score was 8.6 (71.7%) correct, SD 2.8 correct, range 3 to 12 correct questions. There were eight (40%) conceptual errors, 12 (60%) arithmetical errors, and five (25%) computational errors.
    CONCLUSION: The results from this study supports similar international studies where paramedic’s ability to undertake mathematical and drug calculations without a calculator varies, with some results highlighting the paramedics mathematical skills as a potential risk to patient safety. These results highlight the need for regular continuing mathematical and drug calculation practice and education to ensure a lower error rate.

    Falls from height: A retrospective analysis
    Kasim Turgut, Mehmet Ediz Sarihan, Cemil Colak, Taner Güven, Ali Gür, Sükrü Gürbüz
    2018, 9(1):  46-50.  doi:10.5847/wjem.j.1920-8642.2018.01.007
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    BACKGROUND: Emergency services manage trauma patients frequently and falls from height comprise the main cause of emergency service admissions. In this study, we aimed to analyse the demographic characteristics of falls from height and their relationship to the mortality.
    METHODS: A total of 460 patients, who admitted to the Emergency Department of Inonu University between November 2011 and November 2014 with a history of fall from height, were examined retrospectively. Demographic parameters, fall characteristics and their effect to mortality were evaluated statistically.
    RESULTS: The study comprised of 292 (63.5%) men and 168 (36.5%) women patients. The mean age of all patients was 27±24.99 years. Twenty-six (5.6%) patients died and the majority of them were in ≥62 years old group. The highest percentage of falls was at 0-5 years age group (28.3%). People fell mainly from 1.1-4 metres(m) level (46.1%). The causes of falls were ordered as unintentional (92.2%), workplace (8.1%) and suicidal (1.7%). Skin and soft tissue injuries (37.4%) were the main traumatic lesions.
    CONCLUSION: Age, fall height, fall place, linear skull fracture, subarachnoidal hemorrhage, cervical fracture, thoracic vertebra fracture and trauma scores had statistically significant effect on mortality. The casualties died because of subarachnoid hemorrhage mostly.

    Prognostic value of cortisol and thyroid function tests in poisoned patients admitted to toxicology ICU
    Shahin Shadnia, Nasim Zaman, Hossein Hassanian-Moghaddam, Hamed Shafaroodi, Mina Padandar, Mohammad Hasan Rezaeizadeh
    2018, 9(1):  51-55.  doi:10.5847/wjem.j.1920-8642.2018.01.008
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    BACKGROUND: Prognostic value of cortisol and thyroid function tests (TFTs) has previously been evaluated in medical ICUs. We aimed to evaluate prognostic efficacy of cortisol and TFTs in critically ill poisoned patients admitted to toxicology intensive care unit (ICU).
    METHODS: In a prospective study of consecutively enrolled subjects admitted to the toxicology ICU, lab analyses included TFTs (total T3 and T4 as well as TSH) and cortisol levels drawn between 8 am-10 am during period of the first 24 hours post-ingestion/exposure. Simplified Acute Physiology Score II (SAPS II) and Acute Physiology and Chronic Health Evaluation II (APACHE II) were recorded. All scores were compared to detect the best prognostic factor. Type of poisoning was also included.
    RESULTS: In 200 patients evaluated, 129 were male and mean age was 31 years. In general, SAPS II, T4, and cortisol could prognosticate death. After regression analysis, only cortisol had such efficacy (P=0.04; OR=1.06; 95%CI=1.05-1.08; cut-off=42 μg/dL; sensitivity=70%; specificity=82%). Between aluminium phosphide (ALP)- and non ALP-poisoned patients, level of consciousness, mean arterial pressure, and cortisol level could prognosticate death in ALP poisoning (all Ps<0.001 in both uni and multivariate analyses). Median (interquartile range; IQR) GCS was 7 (6, 10) and 15 (8, 15) in non-ALP and ALP-poisoned patients (P<0.003). SAPS II and APACHE II could not prognosticate death at all.
    CONCLUSION: Cortisol best prognosticated outcomes for subjects admitted to the toxicology ICU. Its level is higher in ALP-poisoned patients probably due to the higher stress while they remain conscious till the final stages of toxicity and are aware of deterioration of their clinical condition or may be due to their significantly lower blood pressures.

    Dose-related effects of dexmedetomidine on immunomodulation and mortality to septic shock in rats
    Yan Ma, Xiang-you Yu, Yi Wang
    2018, 9(1):  56-63.  doi:10.5847/wjem.j.1920-8642.2018.01.009
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    BACKGROUND: Dexmedetomidine has already been used in septic patients as a new sedative agent, few studies have examined its effects on immunomodulation. Therefore, the authors have designed a controlled experimental study to characterize the immunomodulation effects of dexmedetomidine in the cecal ligation and puncture (CLP) model in rats.
    METHODS: After CLP, 48 Wistar rats were randomly allocated into four groups: (1) CLP group; (2) small-dose treatment group (2.5 μg·kg -1·h-1); (3) medium-dose treatment group (5.0 μg·kg -1· h-1); and (4) large-dose treatment group (10.0 μg·kg -1·h-1). HLA-DR and plasma cytokine (IL-4, IL-6, IL-10 and TNF-α) levels were measured, and the mean arterial blood pressure (MAP), heart rate (HR), arterial blood gases, lactate concentrations and mortality were also documented.
    RESULTS: The HLA-DR level, inflammatory mediator levels, MAP and HR had no obvious changes among Dexmedetomidine treatment groups (DEX groups). Compared with the CLP group, the DEX groups exhibited decreased HLA-DR levels (Pgroup=0.0202) and increased IL-6 production, which was increased at 3 h (P= 0.0113) and was then attenuated at 5 h; additionally, the DEX groups exhibited decreased HR (P<0.001) while maintaining MAP (Pgroup=0.1238), and remarkably improving lactate (P<0.0001). All of these factors led to a significant decrease in the mortality, with observed rates of 91.7%, 66.7%, 25% and 18% for the CLP, DEX2.5, DEX5.0, DEX10.0 groups, respectively.
    CONCLUSION: Dexmedetomidine treatment in the setting of a CLP sepsis rat model has partially induced immunomodulation that was initiated within 5 h, causing a decreased HR while maintaining MAP, remarkably improving metabolic acidosis and improving mortality dose-dependently.

    Brief Report
    First-in-man implantation of the retrievable and repositionable VenusA-Plus valve
    Xian-bao Liu, Yu-xin He, Chun-hui Liu, Li-han Wang, Feng Gao, Lei Yu, Ai-qiang Dong, Min-jian Kong, Ji-fang Chen, Yong Xu, Qi-jing Zhou, Min Yan, Jian-an Wang
    2018, 9(1):  64-66.  doi:10.5847/wjem.j.1920-8642.2018.01.010
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    BACKGROUND: No retrievable and repositionable second generation transcatheter aortic valve is available in China. Here, we report the first-in-man implantation of the retrievable and repositionable VenusA-Plus valve.
    METHODS: A 76-year-old patient with symptomatic severe aortic stenosis and high surgical risk (STS 13.8%) was recommended for transcatheter aortic valve replacement (TAVR) by heart valve team. Type 0 bicuspid aortic valve with asymmetric calcification was identified by dual source computed tomography, and the unfavorable anatomies increased the possibility of malposition and paravalvular leakage during TAVR. Therefore, we used the retrievable and repositionable VenusA-Plus valve for the patient.
    RESULTS: Transfemoral TAVR was performed under local anesthesia with sedation, and a 26-mm VenusA-Plus valve was successfully implanted. No transvalvular pressure gradient and trace paravalvular leakage were found.
    CONCLUSION: The successful first-in-man implantation indicates the retrievable and repositionable VenusA-Plus valve is feasible in complicated TAVR cases such as bicuspid aortic valve.

    Case Letters
    A Lazarus effect: A case report of Bupropion overdose mimicking brain death
    Douglas Stranges, Alan Lucerna, James Espinosa, Neveen Malik, Marc Mongeau, Kelly Schiers, Syed Omar Shah, Joan Wiley, Philip Willsie
    2018, 9(1):  67-69.  doi:10.5847/wjem.j.1920-8642.2018.01.011
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    Ischemic stroke due to carbon monoxide intoxication: Two case reports
    Atif Bayramoglu, Abdullah Osman Kocak, Esra Kadioglu
    2018, 9(1):  73-75.  doi:10.5847/wjem.j.1920-8642.2018.01.013
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    Letter to the Editor
    Instructions for Authors
    Instructions for Authors
    2018, 9(1):  77-80. 
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