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   Table of Contents - Current issue
Coverpage
April-June 2022
Volume 11 | Issue 2
Page Nos. 51-103

Online since Friday, September 30, 2022

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REVIEW ARTICLE  

A systematic review of road traffic injury studies in Iran: Methodology and prevention levels p. 51
Mojtaba Sehat, Esmaeil Fakharian, Sajjad Lotfi, Somayyeh Nadi-Ravandi, Mehrdad Mahdian, Masoumeh Abedzadeh, Mohammad Reza Fazel, Fahimeh Sarbandi, Leili Abedi Gheshlaghi
DOI:10.4103/atr.atr_25_22  
Background and Objectives: Road traffic injuries (RTIs) are the most frequent public health problem in Iran. The present study reviewed the methodology of the RTI articles using the Haddon matrix evidence. Materials and Methods: PubMed, Scopus, Web of Science, ProQuest, and Persian national databases, including SID, Magiran, and IranDoc, were searched for the articles published from March 21, 2009, to October 21, 2020. The search process was done by two independent reviewers. The quality of the articles was assessed based on the Scopus index of journals. Results: Nine-hundred and fourteen articles were included in this review study, which mostly focused on RTIs in Iran and precrash and postcrash prevention approaches. The methodological approach was cross-sectional in 487 (53.2%) articles and merely 5 (0.54%) articles were randomized clinical trial (RCT) papers. RCT studies focused on the human factor in the precrash phase. Research center evidence indicated that the Safety Promotion and Injury Prevention Research Centers mainly focused on human and environmental factors. However, the Trauma Research Center of Kashan and Sina Trauma and Surgery Research Center of Tehran often addressed vehicles. Conclusion: The RTIs studies in Iran often followed a cross-sectional methodology and used a precrash prevention approach.
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ORIGINAL ARTICLES Top

Bone density loss following ankle fusion persists at long-term follow-up p. 59
Ulrich Wiebking, Ines Gaedke, F Padraigh O'Loughlin, Ralph Gaulke
DOI:10.4103/atr.atr_3_22  
Introduction: The aim of ankle fusion is to create a stable and pain-free hind foot. A decrease in bone density secondary to postoperative immobilization is well established. It is commonly accepted that bone density is restored toward normal values when normal weight bearing is permitted. To the current authors' knowledge, this restoration of bone density has not been definitively established via clinical studies. Subjects and Methods: Patients who underwent an isolated ankle fusion between January 1998 and March 2015, to address advanced degenerative or posttraumatic osteoarthrosis or rheumatoid arthritis were included. Clinical and radiological examination, Foot Function Index (FFI), and American Orthopedic Foot and Ankle Society-Score (AOFAS) scoring systems were utilized. Pain intensity was calculated using the Visual analogue scale (VAS). We use semiquantitative ultrasound osteodensitometry to measure bone density. Results: Bone density was determined in 60 patients, at an average follow-up of 9 years following ankle fusion. The mean T-score for bone density of the calcaneus was significantly lower in the treated foot compared to the contralateral side (−1.4 vs.−0.4; P = 0.001). With the numbers available, a reduction in bone density was found without a significant difference in the AOFAS score (P = 0.875), FFI (P = 0.655), VAS (P = 0.804), and body mass index (P = 0.272). Seven (12%) developed a nonunion. Conclusions: These results demonstrate that a reduction in bone density as a consequence of immobilization while bone union was achieved did not completely return to baseline values even at 10 years postoperative. This persistent reduction in bone density does not correlate in a statistically significant way with higher pain scores, inferior AOFAS scores or nonunion rates. Postoperative partial weight bearing should be instigated as soon as possible to minimize bone loss.
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Reliability, sensitivity, and specificity of the morse fall scale: A hospitalized population in Iran p. 65
Sayedeh-Somayyeh Mousavipour, Abbas Ebadi, Mahnaz Saremi, Mousa Jabbari, Davoud Khorasani-Zavareh
DOI:10.4103/atr.atr_7_22  
Background and Objectives: One of the important indicators of patient safety and quality of hospital care is the patient's fall. Patient falls are among the most crucial issues in the field of Never Events that will affect the health-care systems, and it is necessary to be considered to improve the safety of hospitalized patients. The present study was conducted to investigate the reliability, sensitivity, and specificity of the Morse Fall Scale (MFS) in Iran. Methods: In this prospective observational study, the reliability of the MFS was investigated through the inter-rater reliability. The researcher as the first evaluator and an experienced nurse as the second evaluator screened 180 patients in two educational hospitals in Tehran, Iran, between March and May 2021, using the access method with a MFS. The percentage of agreement of the evaluators was assessed using the Cohen's kappa coefficient, and sensitivity and specificity were assessed using the receiver operating characteristic curve. Results: The results showed that the percentages of agreement between the two assessors in the patient fall history index, in the index of secondary diagnoses, in the index of assistive devices, in the index of IV therapy and heparin lock, in the index of gait/transferring, and in the index of mental status were 0.869, 0.916, 0.871, 1.00, 0.898, and 0.815, respectively. The MFS reliability was obtained by an interclass correlation coefficient of 0.825, sensitivity of 66.7, and specificity of 81.6. Conclusion: The reliability, sensitivity, and specificity of the Morse scale are relatively favorable. Therefore, it is suggested that a patient fall screening scale be designed to measure all dimensions related to the correct assessment of the patient in terms of clinical conditions and nonclinical factors related to patient fall.
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Accuracy of the new injury severity score in the evaluation of patients with blunt trauma p. 71
Alireza Ala, Samad Shams Vahdati, Afsaneh Asghari, Mahsa Makouei, Masoumeh Poureskandari
DOI:10.4103/atr.atr_52_21  
Background and Objectives: Trauma is a worldwide problem that affects healthy people. Several scales such as Injury Severity Score (ISS) and New ISS (NISS) are used to evaluate trauma patients. This study aimed at evaluating the predictive values of ISS and NISS in predicting the possible mortality rate of trauma patients referred to the emergency department. Methods: This historical cohort study was conducted on multiple trauma patients admitted to the Emergency Department of Imam Reza Hospital in Tabriz, Iran, from January to March 2021. Pearson's regression, Spearman's correlation, and the receiver operating characteristic curve were used to analyze the data. ISS and NISS values were also calculated. Results: In NISS evaluation with the cutoff point of 24, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 93.65%, 82.33%, 51.3%, and 98.49%, respectively. Furthermore, positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 3.5 and 0.08, respectively. In ISS evaluation with the cutoff point of 21, the sensitivity, specificity, PPV, and NPV were 88.89%, 82.02%, 49.56%, and 97.38%, respectively. In addition, PLR and NLR were 4.94 and 0.14, respectively. Conclusions: Both ISS and NISS are useful in predicting outcomes in trauma patients, but NISS is more useful and better than ISS and has a higher sensitivity. Due to high sensitivity and a high NPV of NISS, using the high Abbreviated Injury Scale without considering the area of injury can be better and more effective. Therefore, the NISS value works better for patient evaluation and outcome prediction in the emergency department.
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The effect of dangerous driving behaviors on the risk of traffic accidents using structural equation modeling p. 74
Hossein Akbari, Masoud Motalebi Kashani, Sedighe Dehghani Bidgoli, Masoumeh Koochaki Nasrabadi, Mitra Hannani, Fahimeh Karamali
DOI:10.4103/atr.atr_21_22  
Background and Objectives: Professional drivers are mostly exposed to heavy workload, like night shifts, long working hours and irregular schedules, leading to high prevalence of psychiatric disorder, including fatigue, memory loss, and insomnia leading to road traffic accidents and injury. The present paper evaluates the relationship between unsafe behaviors and accident risk in heavy vehicle drivers. Methods: This cross-sectional study was carried out among 303 professional drivers in Kashan. Unsafe behavior was measured using the Driving Behavior Questionnaire. In addition, a questionnaire was developed to assess the number of accidents and sociodemographic factors. Structural equation modeling (SEM) approaches were employed in the evaluated research hypothesis. Results: The results revealed that the average age of participants was 43.15, consisting of passenger vehicle drivers (20.1%) and commercial vehicle drivers (79.9%). The majority were married (94%). Participants drove for an average 11.3 years (standard deviation [SD] = 9.2) with the average speed 85.9 km/h (SD = 13.2). The DB questionnaire had validity and reliability (the factor loading, alpha Cronbach, composite reliability, and average variance extracted were more than 0.5, 0.7, 0.7, and 0.5, respectively). The SEM's results showed proper fit indices for the tested model (x2/df = 2.37; confirmatory fit index = 0.83; root mean square error of approximation = 0.06). Conclusions: The main factors of the driver to get involved in a traffic accident and dangerous driving behavior are followed: (a) driver's education level, (b) driver's experience, (c) hours of driving, (d) driver's drug use habit, and (f) risky and slip. It was noted that the level of road safety awareness is low. It can be decided that additional exertions should be made for arranging and imposing road safety and active traffic law legislation to encourage traffic safety responsiveness of the public.
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Predicting factors associated with in-hospital mortality in severe multiple-trauma patients p. 80
Nazanin Noori Roodsari, Farhad Heydari, Ehsan Kazemnezhad Leyli, Atena Mosafer Masouleh, Ali Hassani Bousari, Payman Asadi
DOI:10.4103/atr.atr_28_22  
Background and Objectives: Traumatic injuries have become a health problem worldwide, especially in low- to middle-income countries. Therefore, this study was conducted to identify predicting factors of death in adult severe multiple trauma patients. Methods: This retrospective cross-sectional study was performed on 1397 adult multiple trauma patients referred to the emergency department (ED) of Poursina Hospital between June 2019 and August 2021. The demographic characteristics, on admission clinical parameters, laboratory tests, the need for packed red blood cell transfusion, and the need for endotracheal intubation were recorded. The revised trauma score (RTS) was calculated according to the physiological variables collected on admission to ED. The primary outcome was 1-day mortality after admission. Results: The mean age of subjects was 37.12 ± 13.61 (18–60) years, and 1250 (89.5%) subjects were male. The 1-day mortality was 339 patients (24.3%). Initial RTS score and the mean Glasgow coma scale (GCS) scores were significantly higher in the survived group than in the nonsurvived group (6.6 ± 1.2 vs. 4.9 ± 1.0, 10.2 ± 3.7 vs. 4.9 ± 2.4, P < 0.001). The multivariate analysis resulted in low GCS (odds ratio [OR] = 1.527, 95%CI 1.434–1625, P < 0.001), low O2 saturation (OR = 1.023, 95%CI 1.003–1.043, P = 0.022), and need for intubation in the ED (OR = 0.696, 95%CI 0.488–0.993, P = 0.046) as predictors of 1-day mortality. The area under the curves receiver operating characteristics of RTS and GCS scores to predict mortality were 0.853 (95% CI: 0.831–0.874) and 0.866 (95% CI: 0.846–0.887), respectively. Conclusion: Multiple factors associated with 1-day mortality were reduced GCS score, decreased oxygen saturation, and need for intubation in the ED. The RTS and GCS scores are good predictors of mortality survival in multiple trauma patients.
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Accuracy of Pediatric Emergency Care Applied Research Network Rules in Predicting Brain Injuries p. 86
Fereshteh Jamali, Sepideh Gholizadeh, Mahsa Kangari, Amir Ghaffarzad, Haniyeh Ebrahimi Bakhtavar, Farzad Rahmani
DOI:10.4103/atr.atr_5_22  
Background and Objectives: Head trauma is one of the most important causes of emergency department (ED) visits and the leading cause of disability and mortality in children. The aim of this study was to evaluate the Pediatric Emergency Care Applied Research Network (PECARN) rules to predict brain injuries in pediatrics with head trauma. Materials and Methods: This descriptive–analytic study was performed on 250 pediatric patients with head trauma referred to Imam Reza Hospital in Tabriz City from August to September 2020. All patients were evaluated in the ED for the existing of any rules of the PECARN, then the results of the PECARN rules and brain computed tomography (CT) scan findings were compared in these patients. According to the PECARN rules, patients were classified into three categories, namely low, moderate, and high risk. For all three groups, if there is an indication of brain CT scan, it was performed and reported by an emergency medicine specialist. Results: The mean age of the patients was 88 months. In this study, 162 (64.8%), 42 (16.8%), and 46 (18.4%) patients were in the low-risk, moderate-risk, and high-risk groups, respectively. Death was occurred in 18 (12.8%) patients. Results showed a statistically significant association between positive CT findings and some variables, such as behavioral change, vomiting, severe headache, LOC over 5 s, confusion, palpable skull fracture, skull base fracture, and the severe mechanism of injury (P < 0.05). Furthermore, a statistically significant association was found between PECARN rules and CT findings (P < 0.001). Conclusions: According to the results of the present study, PECARN rules have a significant association with brain CT scan findings. Therefore, using these rules is recommended to reduce the number of brain CT scan requests for pediatric patients.
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Acceptance and commitment: An intervention for improving family function and emotional problems in informal caregivers of people with severe traumatic brain injury: A randomized clinical trial p. 90
Mahtab Hadavand, Zahra Zanjani, Abdollah Omidi, Fatemeh Atoof, Esmaeil Fakharian
DOI:10.4103/atr.atr_4_22  
Background and Objectives: Traumatic brain injury (TBI) is one of the main causes of disability. Since individuals with TBI experience many problems in their daily life, they must be highly supported. Regarding the nature of their problems, their caregivers suffer from many psychological problems. The current study aimed to investigate the effect of group acceptance and commitment therapy (ACT) on the family function, experiential avoidance, and anxiety of the TBI patients' caregivers. Methods: The current study was a randomized clinical trial with waiting list and intervention groups. Forty caregivers of TBI patients who referred to Kashan's Shahid Beheshti Hospital, Iran, since 2017 until 2019 were randomly assigned to the experimental (n = 20) and the waiting list control (n = 20) groups. Both the groups completed a demographic information questionnaire, the Family Assessment Device, the Experiential Avoidance in Caregiving Questionnaire, and the anxiety subscale of the Depression, Anxiety, and Stress Scale in pretest, posttest, 3-month follow-up, and 6-month follow-up. Results: The results of repeated measures analysis of variance showed that ACT program can significantly decrease the anxiety, experiential avoidance, and most of the dimensions of the family functions (P < 0.005). Conclusion: ACT could be utilized to improve the family functions and reduce the experiential avoidance and the anxiety of the TBI patients' caregivers. This trial is registered with the Registry of Clinical Trials: “IRCT20190704044100N1.”
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CASE REPORTS Top

Slipped capital femoral epiphysis following a delbet type 3 intertrochanteric fracture fixation p. 97
Babak Mirzashahi, Mohammad Moshirfar, Alireza Moharrami
DOI:10.4103/atr.atr_11_21  
Slipped capital femoral epiphysis (SCFE) is the most common hip disorder affecting the adolescent population, usually between 10 and 15 years old, with some multifactorial etiologies may include obesity, trauma, and some endocrinal causes. We reported a 10-year-old boy who presented with unilateral SCFE following intertrochanteric fracture, which was fixed by dynamic compression plate 1 year before the SCFE. The SCFE fixed by a 6.5 mm cannulated screw. In the 1-year postoperative follow-up, the patient achieved the union and the physis did not displace. The patient had not any pain and his gait and function were normal in both sides.
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Bipartite nail deformity due to seymour's fracture in a pediatric patient p. 101
Ahmadreza Afshar, Ali Tabrizi, Hassan Taleb
DOI:10.4103/atr.atr_9_22  
Seymour fractures occur in the form of juxta-epiphyseal fractures in the distal phalanx bone of children, which are often accompanied by nail bed injuries. These fractures are also associated with complications such as nail deformity, infection, and growth disturbance. This report introduces a 6-year-old boy whose Seymour fracture occurred with the interposition of the nail bed on the fracture site, resulting in nonunion and nail deformity in the form of bipartite growth. Nail bed injuries could be accompanied by Seymour fractures and their treatment is independent of the fracture treatment. Nail bed repair can prevent subsequent deformities.
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