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   Table of Contents - Current issue
Coverpage
October-December 2017
Volume 6 | Issue 4
Page Nos. 55-105

Online since Tuesday, February 20, 2018

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REVIEW ARTICLE  

Challenges to Use Response Time Standard in Assessing Emergency Medical Services in Iran: A Systematic Review Highly accessed article p. 55
Seyyed Mohammad Reza Hosseini, Mohammadreza Maleki, Hasan Abolghasem Gorji, Davoud Khorasani-Zavareh, Masoud Roudbari
DOI:10.4103/atr.atr_29_17  
Response time (RT) accounts as a common tool for emergency medical services (EMS) assessment. While the national standard RT has been established in Iran since 2007, its application has hardly been put into scrutiny. This study aimed at investigating the use of RT standard in assessing EMS in Iran. This systematic review included papers focusing on prehospital EMS assessment published in Google Scholar, Scopus, Embase, PubMed, and the Persian databases of Magiran and SID. Selection criteria involved all English and Persian studies focusing on RT as an assessment of prehospital EMS in the context of Iran. Repetitious papers and those presented in conferences were omitted, which left 21 papers published from 2007 to mid-2016 for systematic review. A data collection form was designed. This provided both inclusive information about the papers and indicators used to report RT in each paper (i.e., mean and percentages of RT below 8 min) as well as the use of these indicators vis-a-vis that of the standard. From among the 21 papers focusing on RT, seven (33%) reported RT as percentages of operations performed in <8 min according to the national standard and compared the percentage with the national standard. A total of 18 (86%) reported the means of RT; nine studies compared mean and the national standard as expressed in percentage. Limited use of the national standard to report RT was identified as a challenge to EMS assessment. Further, the inconsistency that exists when comparing RT in terms of means and percentage is a challenge to the validity of judgments expressed in some previous studies. Employment of uniform methods to report and evaluate performance based on the national standard will lead to greater transparency in emergency operation performance.
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ORIGINAL ARTICLES Top

An Epidemiologic Study of Deceased Pedestrians in Road Traffic Accidents in Iran during 2012-2013 p. 63
Jalil Hasani, Noushin Sadat Ahanchi, Abdolhalim Rajabi, Mohammadreza Ghadirzadeh, Seyed Saeed Hashemi Nazari
DOI:10.4103/atr.atr_57_17  
Background and Objectives: Due to the high rate of pedestrian deaths in traffic accidents and given that describing demographic profiles of pedestrian deaths and features of accident locations is an important factor in the prevention, management, and analysis of road traffic accidents, this study aimed at describing the demographic and personal patterns as well as environmental factors affecting the occurrence of road traffic accidents among pedestrians in Iran. Materials and Methods: This cross-sectional study was conducted on all pedestrian deaths caused by traffic accidents referred to the Forensic Medicine Organization in Iran from March 20, 2012, to March 19, 2013. In this study, demographic information as well as the information related to the accidents and other information including trauma location, the final cause of death, date of accident, date of death, time of death, and time of accident were examined. The information received from the Forensic Medicine Organization was first controlled and then analyzed using the Stata 11 software. Results: From a total of 4371 pedestrians died in 2012 due to traffic accidents, 3201 cases (73.2%) were males with a mean age of 48.1 ± 0.46 years, and 1170 cases (23.8%) were females with the mean age of 46.1 ± 0.77 years. In terms of age, education, and marital status, the highest frequencies of pedestrian deaths were, respectively, observed in the age group 65 years old and above (33.4%), the illiterate group (44.5%), and married people (67.9%). The highest and the lowest incidence rates of death were seen in Gilan (11 per 1000 people) and South Khorasan Provinces (2.4 per 100,000), respectively. Conclusions: Pedestrians as the most vulnerable people in traffic accidents comprise a large proportion of deaths and disabilities caused by road traffic accidents. It seems necessary to take some measures including paying special attention to physiological characteristics of the age group above 65 years old, doing close monitoring by the traffic police in October and the rush hours, and providing facilities for pedestrians to cross in busy locations of suburban areas.
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Analysis of Direct Medical Expenses Resulting from Road Traffic Injuries in the City of Tabriz p. 69
Narges Shadkam, Alireza Mahboub-Ahari, Mohamad Asghari Jafarabadi, Ali Imani
DOI:10.4103/atr.atr_31_17  
Background: Road crashes as a major global public health problem cost 3% of most countries and 5% of low- and middle-income countries' gross domestic product (GDP). The World Health Organization has predicted that without sustained action, road traffic crashes will become the seventh leading cause of death by 2030. Objectives: The aim of this study was to analyze the death rate, severity of injuries, and direct medical costs caused by road traffic injuries (RTI) in the city of Tabriz in 2014. Methods: Trauma injury admissions due to RTI in Imam Reza Hospital in Tabriz City were investigated in terms of etiology and the direct medical costs during 2014–2015. Data were collected using a researcher-made checklist after being confirmed by relevant experts in terms of face validity. All information on direct medical costs are extracted from several sources including hospitals, database of the Ministry of Health and Medical Education, disaster and emergency medical management center, and public and private physiotherapy clinics across the city. Results: Review of the hospital records showed that the mean age of the patients (67.9% males and 32.1% females) was 34 ± 17.3 years. In addition, 79.2% of the patients were treated on an outpatient basis, and 20.8% were treated on a hospitalization basis (hospitalization or death). The mean times of inpatient and outpatient hospitalization for injuries were 3 h and 6.7 ± 5.3 days, respectively. Total direct medical costs were 11.631 dollars, of which 8% was for hospital costs, 9.7% for prehospital costs, and 2.3% for physiotherapy costs. Chest and lower part injuries had highest medical costs. From etiological standpoints, the greatest reason of being injured and hospitalization is multiple injuries and bruises, and the prominent cause of death was blow to the head and neck (70%). Conclusions: The results of the present study showed that direct medical costs in Tabriz during 2014–2015 were equal to 0.1% of GDP, which is a considerable amount. High economic and social costs of road accidents and their harmful physical and psychological effects on individuals and community require the attention of professionals and experts in the transportation industry and health-care system to determine appropriate strategies for interventions in reducing accidents' burden and injuries.
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The Epidemiology, Management, and Outcome of Field Hockey-related Fractures in a Standard Population p. 76
Greg A J. Robertson, Alexander M Wood, Stuart A Aitken, Charles M Court-Brown
DOI:10.4103/atr.atr_56_17  
Background: Field hockey is one of the most popular sports in the world, yet little is known about patient outcome following fracture injuries sustained during this sport. Objectives: The aim of this study is to describe the epidemiology, management, and outcome of field hockey-related fractures in a known UK population at all skill levels. Materials and Methods: All fractures sustained during field hockey from 2007 to 2008 within the adult Lothian population were prospectively recorded and confirmed by an orthopedic surgeon during treatment at the sole adult orthopedic center in the region. Nonresident individuals were not included in the study. Follow-up data were obtained in September 2010 to determine return rates and times to field hockey. Results: Nineteen fractures were recorded over the study period in 19 patients. Seventeen (89%) of the fractures were recorded in the upper limb, with 15 (79%) recorded in hand. Eighteen fractures (85%) in 18 patients (95%) were followed up at a mean interval of 31 months (range: 25-37 months; standard deviation [SD] 2.1 months). The mean time for return to field hockey from injury was 10.8 weeks (range: 3-26 weeks; SD 7.1 weeks). For patients with upper limb injuries, the mean time was 9.2 weeks (range: 3-20 weeks; SD 5.7 weeks), compared to 22 weeks (range: 18-26 weeks; SD 5.7 weeks) for patients with lower limb injuries. Eleven percent of the cohort did not return to field hockey. Seventy-eight percent of the cohort returned to field hockey at the same level or higher. Fifty percent had ongoing related problems, yet only 17% had impaired field hockey ability because of these problems. Fractures with the highest morbidity in not returning to field hockey were as follows: Metacarpal 14% and finger phalanx 13%. Conclusions: The significant majority of field hockey-related fractures are sustained in the upper limb, notably the hand. Around ninety percent of patients sustaining a fracture during field hockey will return to this sport at a similar level. While half of these will have persisting symptoms 2 years postinjury, only one-third of symptomatic patients will have impaired field hockey ability because of this.
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The Effects of Mindfulness-based Stress Reduction on Emotional Regulation and Psychological Well-being of Iranian Veteran's Homemakers with Secondary Posttraumatic Stress Disorder p. 82
Abdollah Omidi, Mahboobeh Shabanzadeh Fini, Hossein Akbari, Goodarz Akasheh
DOI:10.4103/atr.atr_4_18  
Background: Problems of emotional regulation and lack of social skills in veterans' families are very common and like psychological complications have unpleasant consequences for them. Therefore, effective and helpful interventions and therapies are highly important. Objectives: The current study aimed at evaluating the effect of mindfulness-based stress reduction (MBSR) on the improvement of emotional regulation and psychological well-being in veterans' homemakers with secondary posttraumatic stress disorder. Patients and Methods: In the current study, the permuted blocked randomization method was used. Participants were selected from veterans' homemakers referred to the counseling center of veterans in Kashan city (Iran) in 2015. They were randomly assigned into two groups (30 controls and 31 cases). The case group underwent the MBSR treatment. Results: Results showed no significant difference between the two groups at the baseline (P < 0.05). No significant difference was observed in the total score of MBSR on emotional regulation between the groups. However, the difference between pre- and post-test of rejection of emotional response subscale was significant. In addition, the total score in the psychological well-being at pre- and post-test was significant. Conclusions: It seems that MBSR significantly affects the psychological well-being, but it has no effect on the emotional regulation except the subscale of emotional response rejection.
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Explorative Analysis of Motorcyclists' Injury Severity Pattern at a National Level in Iran p. 87
Ali Tavakoli Kashani, Ahmad Mohammadian, Mohammad Mehdi Besharati
DOI:10.4103/atr.atr_38_17  
Objectives: This study aimed at examining the hidden patterns of motorcycle crashes and riders' injury severity at the national level in Iran. Methods: Hierarchical clustering (HC) and latent class clustering (LCC) techniques were used in combination to analyze riders' injury pattern in 6638 motorcycle crashes occurred in Iran during 2009–2012. First, the HC was performed to classify the provinces into homogeneous groups, based on the percentage of different crash factors in each province and a new variable called “province group” was added to the crash database as the output of the HC analysis. Next, the LCC was conducted to cluster the crash data and to investigate the riders' injury pattern across the country. Results: Among the six crash clusters identified by the LCC, Clusters 1 and 5, in which, respectively, 91% and 84%, of the riders were under 30 as well as Cluster 2, in which 65% of the riders were above 30 years had the highest percentages of injured motorcyclists (86%, 84%, and 88%, respectively). Cluster 5 had also the lowest percentage of helmet usage (about 5%) and licensed riders (5%). Moreover, Cluster 6 had the highest fatality rate among the six clusters. In this cluster, 73% of the crashes were occurred in nonresidential/agricultural land uses, and 94% were occurred in rural areas. Conclusions: Since a significant share of crashes in Cluster 5 was occurred in province Groups C and E; this might be regarded as an indication of weak law enforcement over helmet usage and licensure in these provinces. In addition, as the pattern of helmet usage was different among province clusters, future studies might be conducted regarding motorcyclists' helmet-wearing intentions among several provinces. Moreover, crashes occurred in rural roads, particularly in the vicinity of nonresidential or agricultural land uses were more severe and need special future attention.
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CASE REPORTS Top

A Very Rare Cause of Shoulder Weakness: Concurrent Traumatic Neuropathies of Accessory, Long Thoracicus, and Suprascapular Nerves p. 94
Halil Onder, F Gokcem Yildiz, Gulay Nurlu, Kubilay Varli
DOI:10.4103/atr.atr_61_17  
Accessory nerve is one of the most sensitive cranial nerves to injury, and its injuries are usually caused by iatrogenic interventions. As many other causes can mimic its clinical presentation, careful physical examination should be performed while evaluating a patient suspected of accessory neuropathy. In this report, we aimed to illustrate a very rare case with concurrent traumatic cranial neuropathies of accessory nerve, suprascapular nerve, and long thoracicus. A 16-year-old boy was admitted with complaints of shoulder weakness and pain following a trauma of strain injury. He had first taken the misdiagnosis of brachial plexopathy; however, after a detailed physical examination and electrophysiological study, the diagnosis of concurrent traumatic neuropathies of accessory, suprascapular, and long thoracicus nerves was made. In our opinion, during evaluation of these rare traumatic neuropathies, detailed clinical evaluations combined with detailed electromyography investigations may give crucial data for the proper diagnosis.
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A Unique Case of Gossypiboma following Treatment of the Orbitozygomatic Complex Fracture p. 98
Saeed Nezafati, Seyed Ahmad Arta, Masoomeh Amani, Farzin Ahmadpour
DOI:10.4103/atr.atr_37_17  
Transmaxillary approach to the orbital floor has been used successfully to treat the blowout fracture by antral packing to support the orbital floor. However, antral packs are associated with a high incidence of infection and persistent oroantral fistula. A 30-year-old man with a history of the orbitozygomatic complex fracture 8 years ago presented with a persistent facial wound on the right side of the cheek. The patient underwent an exploratory surgery under general anesthesia, and the maxillary sinus was approached through the Caldwell-Luc operation and a long 2-m nasal tampon was found in the sinus. Foreign bodies including gossypibomas are rare, hard to diagnose, and mostly asymptomatic and in chronic cases do not reveal specific radiological and clinical signs for differential diagnosis. Therefore, in the evaluation of the soft-tissue lesions in patients with a history of a prior operation, it is wise to consider foreign bodies in the differential diagnosis.
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Different Aspects of Penile Amputation; Surgery, Forensics, and Psychiatry (Case Report and Short Review) p. 101
Hamid Pakmanesh, Rayka Sharifian, Mahmoodreza Ashabyamin
DOI:10.4103/atr.atr_13_17  
Penile amputation (PA) is a rare genitourinary injury. Three main etiologies of PA consist of iatrogenic, accidental, and self-mutilation. Eighty-seven percent of the self-mutilated patients suffer from psychiatric disorders. Nowadays, microsurgical techniques with neurovascular anastomosis are the best approach for PA. This paper insists on psychiatric and legal consequences, which may involve health-care team. A 25-year-old male patient presented to our emergency department with self-inflicted PA. As he had a history of some psychiatric problems, psychiatric consultation was requested. The patient did not accept any surgical interventions. We informed his relatives completely; however, they did not agree with surgical intervention because they predicted that he might repeat amputation again. According to the forensic medicine specialist consultation, we took the coroner's warrant for emergency surgical intervention and transferred the patient to the operating room without any consent. Microsurgical penile replantation was performed. There was no leakage in retrograde pericatheter urethrography on the 3rd postoperative week, and the urethral catheter was removed. The patient was able to void normally, and cystostomy tube was removed at the same time. Consent for all medical procedures is an important part of national and international human right law and medical ethics. Physicians should inform patients about their problem and take a reliable consent. If the patient was unreliable for informed consent, relatives could do it. However, in an emergency, there is an exception in the law that let surgeons do the operation without consent for these cases.
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LETTER TO EDITOR Top

Tetanus after Trauma: Still Existed Problem in Tropical Country p. 105
Viroj Wiwanitkit
DOI:10.4103/atr.atr_59_17  
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