Journal of Emergency Medicine, Trauma and Acute Care - Current Issue

Early, aggressive, and minimally invasive approach is an advanced surgical approach for chronic empyema management. The traditional video-assisted technique is considered superior over open thoracotomy for empyema management; however, with further modification, the uniportal video-assisted thoracoscopic surgery (UVATS) has greater advantage for surgeons, providing better anatomical view of target tissues, allowing bimanual instrumentation similar to open approach, and nullifying the creation of dihedral angle by instruments that are not favorable in traditional VATS. The present case series describes different clinical scenarios including chronic empyema secondary to traumatic hemothorax, recurrent tubercular empyema following postoperative open decortication, and methicillin-resistant staphylococcus aureus chronic empyema in pediatric patient, which are effectively managed with UVATS approach.

Health authorities are focused on swiftly alleviating the spread of COVID-19 infections to support the overburdened healthcare system and reduce the mortality rates associated with the ongoing pandemic. Across Oman, there are 243 primary healthcare (PHC) clinics that act as the first point of contact for providing a comprehensive range of healthcare services. Further, they provide access to more than 30 programs that are delivered by well-trained primary care staff from different categories. PHCs adopted the strategy of providing healthcare services directly related to positive COVID-19 cases, preventing the likely spread of COVID-19 infection among healthcare workers, and reducing the spread of COVID-19 in the community. This review outlines four major challenges that were observed and informally reported by the healthcare workers at PHCs in Oman from January to December 2020. Understanding the nature of these challenges can help health authorities in preparing effectively for any future viral outbreaks and mitigating them in a timely and efficient manner. One of the major challenges faced by PHCs was the reduction in outpatient services from January to December 2020 in comparison with the same time period in the last year. PHCs addressed the main health problems in the community through health promotion, as well as preventive, curative, and rehabilitative services under unusual circumstances. However, there is a need for a modified approach during circumstances such as the COVID-19 pandemic. This will help us cope with possible future viral outbreaks in a better manner.

Background: The time to initial physician contact or time for medical doctor (tMD) is one of the crucial key performance indicators for the emergency department (ED). The “tMD” helps in improving medical care, administrative benefits, and operational changes. The main aim of this study was to assess the effects of different operational changes on tMD. Methods: The study was a prospectively designed analysis for one year. Data were collected via the study center's electronic records. The study was divided into three operational events (increase in number of consultants, change of shift timings, and increase in consultants covering a shift) in comparison with the baseline (prestudy) period. Data were then downloaded and imported into the statistical software package Stata for a detailed analysis. Results: The study commenced on July 1, 2016, with a 52-week period and 418,899 patient encounters. The coefficient for tMD slope improvement as compared with baseline with confidence interval (CI) and p value was: Phase 1: −2.5 [CI: −4.1 to −0.97 (p = 0.002)]; Phase 2: −1.6 [CI: −2.8 to −0.37 (p = 0.031)]; and Phase 3: −2.4 [CI: −3.4 to −1.4 (p < 0.001)]. The study phases showed a significant improvement over the baseline study period. Conclusion: The study results indicate that different types of interventions (e.g.,., changing shift times, increasing total hours of MD coverage throughout the day) had demonstrated different apparent effects in this study's ED. Further work in this study's ED should aim to continue to reduce absolute tMD and decrease variation by homogenizing dispersion as much as possible across the 24 hours of a day. ED has no control over the concentration or spread of visitors over the period of the day. The data were useful for guiding operations planning both during the study period and thereafter, as operations continue to focus on optimizing tMD.

Background: The emergency department usually takes a supine posteroanterior (PA) chest X-ray imaging in trauma patients. In some cases, pneumothorax is not seen in the chest X-ray because of the patient's position. These cases are called occult pneumothorax. Misdiagnosis of occult pneumothorax in the emergency department may lead to complications such as tension pneumothorax. This study aimed to update patients’ features with occult pneumothorax due to blunt or penetrating trauma.

Methods: In this study, data of 615 thoracic trauma patients admitted to the emergency department between January 2008 and December 2010 were evaluated. In total, 157 patients had undergone both chest X-ray and chest computed tomography and were diagnosed with pneumothorax. Of the 157 patients, 52 were excluded due to some criteria. Data of 105 patient, including their characteristics, trauma types, accompanying traumas, etiology of the chest trauma, chest X-ray findings, and computed chest tomography results were recorded. Data obtained were compared with the results of similar studies conducted in the last 10 years. Chest computed tomography was considered the gold standard for the diagnosis of pneumothorax.

Results: The mean patient age was 36.19 ± 14.74 years. Occult pneumothorax was detected in 8 of 105 patients, giving a 7.6% overall incidence of occult pneumothorax. A traffic accident was the most common cause of etiology. All occult pneumothorax cases were caused by blunt trauma, and tube thoracostomy was performed in all of them. No significant differences were found between pneumothorax and occult pneumothorax cases concerning the etiology, accompanied trauma, intervention types, and trauma reasons (p < 0.05).

Conclusions: This study supports the incidence of occult pneumothorax reported in the literature. When a patient is admitted with thoracic trauma, a physician should carefully evaluate the patient through supine chest X-ray examination. Only one misdiagnosis in trauma patients can be lead to many unintentional clinical and forensic results.

Background: To determine if neutrophil-to-lymphocyte ratio (NLR) can be used to diagnose appendicitis and distinguish complicated from uncomplicated appendicitis. The secondary aim was to determine if the appendix cut-off size on ultrasound matches that of existing literature. Methods: We retrospectively analyzed all cases that underwent appendectomy in Father Muller medical college and hospital from 2014 to 2019. The NLR, histopathology, and ultrasound reports for all patients were reviewed. Recommended cut-off values for NLR and appendicular size on ultrasound were determined using receiver operating characteristic analysis (ROC). Data was analyzed using SPSS version 25. Ethical approval was obtained for this study. Results: We included 1623 patients in this study. The patients’ median age was 24 years, with appendicitis being more common in males than females. NLR>2.4 was statistically associated with appendicitis with sensitivity of 70.1% and specificity of 43.2%. NLR>4.3 was statistically associated with complicated appendicitis with sensitivity of 72.25% and specificity of 54.09%. An appendicular diameter >6.1 mm was suggestive of appendicitis on abdominal ultrasound based on our analysis. Conclusions: NLR is a simple adjunct that can be used to diagnose appendicitis and identify complicated appendicitis.

Background: Lumbosacral spinal stenosis (LSS) is one of the most common causes of back pain and disability. Its treatment varies from surgical to conservative, and the indications for optimal management are not obviously defined. This study aimed to compare the efficacy of caudal epidural injection (CEI) of steroid with and without calcitonin in patients with LSS. Method: This is a randomized, double-blind clinical trial of 31 LSS patients diagnosed between January 1, 2017, to December 30, 2017, who were randomly allocated into two groups. Group A consisted of 17 patients who received C-arm (mobile fluoroscopy)- guided CEI of local anesthetic and steroid, and group B included 14 patients who received C-arm-guided CEI of 100 international unit calcitonin added to local anesthetic and steroid. Outcome measures included the visual analog scale (VAS) for pain during movement and walking distance, Oswestry disability index (ODI), and Quebec back pain disability scale (QBPDS) score, which were obtained from patients before the CEI as a baseline and after the second, fourth, and eighth weeks. Result: Before CEI, no significant differences were found between the two groups, neither in demographic characteristics nor in VAS, ODI, and QBPDS parameters. After CEI, VAS, ODI, and QBPDS improved from baseline through the second, fourth, and eighth weeks in both groups (p < 0.001) without any superiority between the two groups (p = 0.012, 0.078, and 0.019). Conclusion: CEI of steroid with and without adding calcitonin appears effective in the management of LSS. However, CEI of calcitonin does not appear to have any superiority when compared with steroid injection alone.

Background: The coronavirus disease 2019 (COVID-19) pandemic has had a massive impact worldwide. Clinical symptoms vary in different countries. In addition, a wide range of symptoms involve most of the body systems including the respiratory system. However, COVID-19 has no classical presenting signs. Objective: This study aimed to describe the sociodemographic and clinical characteristics of hospitalized and nonhospitalized COVID-19 patients in Anbar Governorate, Iraq. Patients and Methods: This retrospective study was conducted in Anbar Governorate, Iraq. The study covered the period from May 1 to June 30, 2020. All cases were confirmed by real-time polymerase chain reaction. Data concerning the age, gender, residence, occupation, clinical symptoms, smoking, history of systemic diseases, and disease fate were collected from patients’ records. Results: Of 481 patients, 259 (53.8%) were male. The patient age ranged from 12 to 104 years with a mean age of 45.7 ± 16.11. Majority of the patients aged 36–58 years (n = 204, 42.4%) and were urban dwellers (n = 318, 66.1%), non-healthcare workers (n = 447, 92.9%), and nonsmokers (n = 440, 91.5%). The chief complaint was fever (n = 300, 64.2%). The mortality rate was 5.6% (n = 27). The increasing age, male gender, and a history of systemic illnesses showed an increased effect on the mortality rate (p < 0.05). Residence, occupation, and smoking status did not show significant difference (p>0.05). Conclusion: The mortality rate was 5.6%. Fever was the main feature of COVID-19. Male, older individuals with systemic diseases showed higher mortality rate.

Background: BRCA2 genes are not only found in humans, but in other animal species. BRCA2 gene plays a vital role in maintaining the stability of a cell's genetic information. BRCA2 is considered as a gatekeeper gene; however, if mutated or abnormally expressed, it causes the destruction of normal cell structure and promotes the growth of cancer cells. Objective: This study aimed to assess the differences and similarities of BRCA2 gene from different animal species in Africa through In silico genomics analysis providing further insight on its comparative genomics features. Materials and Methods: Fifteen nucleotide sequences of BRCA2 gene of different mammals and bird species were retrieved from National Centre for Biotechnology Information (NCBI). Multiple sequence alignment was done with MEGA 7.0 software, while identity and similarities were determined by constructing a pairwise comparison. Conserved domains on the sequences were identified with NCB1-CDD. Results: BRCA2 gene was found to be present not only in humans, but other lower animals and birds across African countries. The phylogenetic tree for Homo sapiens BRCA2 gene in Tunisia belongs to the same ecological niche with the Theropithecus gelada BRCA2 gene in Ethiopia and BRCA2 from the same African region has high bootstrap, implying that they share the same homology. Conserved regions identified in the all the sequences were absent in Miniopterus natalensis and most present in Chrysochloris asiatica, Theropithecus gelada, Apaloderma vittatum, Pterocles gutturalis, Rousettus aegyptiacus, Homo sapiens, Echinops telfairi, and Cavia porcellus. Conclusion: Based on the findings obtained from this study, BRCA2 gene in humans and other lower animals, particularly from same region, share the same homology and similarities.