Publications by authors named "Amirhossein Mirafzal"

13 Publications

  • Page 1 of 1

Persistence of post-concussion symptoms in patients with mild traumatic brain injury and no psychiatric history in the emergency department.

Brain Inj 2020 08 10;34(10):1350-1357. Epub 2020 Aug 10.

Department of Emergency Medicine, Kerman University of Medical Sciences , Kerman, Iran.

Purpose: To elucidate the predictive factors for persistent post-concussion symptoms at 1 and 3 months following minor traumatic brain injuries (mTBIs) in patients with no psychiatric history.

Methods: This was an observational study in an academic trauma centre including adult patients with a history of mTBI and no psychiatric history. Exclusion criteria were missing the follow-up phone calls, radiologic abnormalities, simultaneous injuries and refusal to participate. Outcomes were post-concussion syndrome according to the international classification of diseases (ICD)-10 (ICD-PCS) and persistence of more than one mTBI related symptoms at 1 and 3 months post-injury.

Results: From 364 enrolled patients, 16 (4.4%) developed ICD-PCS, whereas 28 (7.6%) and 8(2.1%) reported more than one symptom at one and three months, respectively. Multivariable analysis showed associations between ICD-PCS with more than one initial symptom in the emergency department (ED) and the non-motor vehicle collision (non-MVC) impact mechanism with area under curve of 0.77. The former variable was associated with the persistence of more than one post-concussion symptom at one and three months.

Conclusion: More than one symptom in the ED and the mechanism of injury not related to MVCs (sports, violence or fall injuries) may predict symptom persistence. Early treatment and follow-up strategies may be beneficial for vulnerable patients.
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http://dx.doi.org/10.1080/02699052.2020.1802659DOI Listing
August 2020

Consensus statements on the approach to patients in a methanol poisoning outbreak.

Clin Toxicol (Phila) 2019 12 22;57(12):1129-1136. Epub 2019 Jul 22.

The Norwegian CBRNE Centre of Medicine, Department of Acute Medicine, Oslo University Hospital, Oslo, Norway.

Methanol poisoning is an important cause of mortality and morbidity worldwide. Although it often occurs as smaller sporadic events, epidemic outbreaks are not uncommon due to the illicit manufacture and sale of alcoholic beverages. We aimed to define methanol poisoning outbreak (MPO), outline an approach to triaging an MPO, and define criteria for prioritizing antidotes, extracorporeal elimination treatments (i.e., dialysis), and indications for transferring patients in the context of an MPO. We convened a group of experts from across the world to explore geographical, socio-cultural and clinical considerations in the management of an MPO. The experts answered specific open-ended questions based on themes aligned to the goals of this project. This project used a modified Delphi process. The discussion continued until there was condensation of themes. We defined MPO as a sudden increase in the number of cases of methanol poisoning during a short period of time above what is normally expected in the population in that specific geographic area. Prompt initiation of an antidote is necessary in MPOs. Scarce hemodialysis resources require triage to identify patients most likely to benefit from this treatment. The sickest patients should not be transferred unless the time for transfer is very short. Transporting extracorporeal treatment equipment and antidotes may be more efficient. We have developed consensus statements on the response to a methanol poisoning outbreak. These can be used in any country and will be most effective when they are discussed by health authorities and clinicians prior to an outbreak.
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http://dx.doi.org/10.1080/15563650.2019.1636992DOI Listing
December 2019

Measuring serum albumin levels at 0 and 24h: Effect on the accuracy of clinical evaluations in the prediction of burn-related mortality.

Burns 2018 05 1;44(3):709-717. Epub 2018 Feb 1.

Department of Emergency Medicine, Kerman University of Medical Sciences, Kerman, Iran. Electronic address:

Objectives: To evaluate whether measuring serum albumin levels in clinical assessments affects the accuracy of mortality predictions in large burns and to compare patients' serum albumin levels at hour 0(Alb0h) and hour 24(Alb24h) following their admission.

Methods: This prospective observational study was performed at an academic burn unit. Aged between 16 and 65, patients who presented with burns on more than 20% of total body surface area (%TBSA) were included. Patients with severe comorbidities, concomitant trauma or referred from other centres were excluded from the study. The main variables in the study were Alb0h, Alb24h and Abbreviated Burn Severity Index (ABSI) scores. The primary outcome was in-hospital mortality.

Results: In a population of 105 patients, %TBSA, being female, inhalational injury, Alb0h, Alb24h and ABSI score (p<0.001) and the presence of a full thickness injury (p=0.008) were associated with mortality. In the multivariable analysis, ABSI scores and Alb24h remained in the model (OR, 2.32 and 0.06, respectively). The area under curves (AUCs) were 0.94, 0.97 and 0.97 for ABSI, ABSI+Alb0h and ABSI+Alb24h, respectively. No significant difference among the AUCs was seen, but adding Alb0h and Alb24h improved the mortality predictions of ABSI by 5 (4.7%) and 4 (3.8%) patients, respectively. Alb0h (at 3.5g/dL) and Alb24h (at 2.4g/dL) showed 84-85% and 88-85% sensitivity-specificity for mortality, respectively.

Conclusion: Measuring serum albumin levels in clinical assessments slightly increases the accuracy of mortality predictions; however, different cut-off points for Alb0h and Alb24h needs to be considered to avoid interpretation errors.
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http://dx.doi.org/10.1016/j.burns.2017.10.020DOI Listing
May 2018

Physician expertise and cultural issues may play role in the results of ultrasound guided inter-scalene brachial plexus block.

Am J Emerg Med 2018 04 4;36(4):718-719. Epub 2018 Jan 4.

Department of emergency medicine, Kerman University of Medical Sciences, Kerman, Iran; Bahonar Hospital, Gharani St, Kerman, Iran. Electronic address:

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http://dx.doi.org/10.1016/j.ajem.2018.01.012DOI Listing
April 2018

Ultrasound-guided interscalene nerve block vs procedural sedation by propofol and fentanyl for anterior shoulder dislocations.

Am J Emerg Med 2017 Oct 14;35(10):1435-1439. Epub 2017 Apr 14.

Department of Emergency Medicine, Kerman University of Medical Sciences, Kerman, Iran. Electronic address:

Background: Few studies were performed to compare ultrasound guided brachial plexus block with procedural sedation for reduction of shoulder dislocations in the Emergency Department (ED). This study was done to provide further evidence regarding this comparison.

Methods: This was a randomized clinical trial performed on patients presenting with anterior shoulder dislocations to the emergency department of an academic level 2 trauma center. Exclusion criteria were any contraindications to the drugs used, any patient which may not be potentially assigned into both groups because of an underlying medical condition, presence of neurovascular compromise related to the dislocation, presence of concomitant fractures, and patient refusal to participate in the study. Patients were randomly assigned into the Procedural Sedation and Analgesia (PSA) group with propofol and fentanyl or ultrasound guided Inter-Scalene Brachial Plexus Block (ISBPB) with lidocaine and epinephrine.

Results: A total of 60 patients (30 in each group) were included in the study. The emergency room length of stay was significantly lower in the ISBPB group, with mean (SD) values of 108.6 (42.1) vs. 80.2 (25.2) minutes (p=0.005). However, pain scores in the PSA group during reduction showed advantage over ISBPB [0.38 vs. 3.43 (p<0.001)]. Moreover, patient satisfaction was higher with PSA (p<0.001).

Conclusion: Using ISBPB for reduction of anterior shoulder dislocations takes less time to discharge and may make it more feasible in conditions mandating faster discharge of the patient. However, since pain scores may be lower using PSA, this method may be preferred by many physicians in some other situations.
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http://dx.doi.org/10.1016/j.ajem.2017.04.032DOI Listing
October 2017

Eleven years of children methadone poisoning in a referral center: A review of 453 cases.

J Opioid Manag 2017 Jan/Feb;13(1):27-36

Department of Epidemiology, School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Center for Educational Research in Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran.

Objectives: Methadone can be fatal due to respiratory failure even in little doses. This study aimed to evaluate the possible risk factors of death and/or intubation in methadone-poisoned children of 12 years or younger.

Design: Retrospective routine database study.

Setting: The only tertiary hospital for children poisoning in Tehran.

Patients: Four hundred fifty-three methadone-poisoned patients aged 12 or younger were studied between 2001 and 2012.

Main Outcome Measures: In-hospital mortality and intubation/mechanical ventilation.

Results: Of a total of 475 children included, 22 were excluded due to coingestion of other drugs. Three (0.66 percent) expired and 12 (2.65 percent) were intubated during the course of hospital stay. Intubation (p < 0.001), fever (T axillary ≥ 37.5°C, p = 0.01), being unresponsive at presentation (p = 0.02), tachycardia (p = 0.01), acidosis (p = 0.03), leukocytosis (p = 0.02), and longer hospital stay (p = 0.01) associated with death. Mortality (p < 0.001), fever (p = 0.004), aspartate aminotransferase (AST; p = 0.006), alanine transaminase (p = 0.04), creatinine (p = 0.005), corrected QT (QTc) interval in triage electrocardiogram (p = 0.02), and longer hospital stay (p = 0.005) associated with intubation in univariate analysis. However, after running regression analysis, only fever, QTc ≥ 480 ms, tachycardia, and AST independently associated with intubation and death. Axillary T ≥ 37.45 °C with an accuracy of 91.9 (95% confidence interval [CI] 88.8-94.2) and odds ratio of 9.3 (95% CI 2.5-34.9) predicted intubation, and T ≥ 37.75 with an accuracy of 96.0 (95% CI 93.5-97.5) and odds ratio of 47.4 (95% CI 4.1-550.1) predicted death.

Conclusion: A methadone-poisoned child presenting with tachycardia, fever, abnormal AST, or an initial prolonged QTc interval should be managed with great caution.
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http://dx.doi.org/10.5055/jom.2017.0365DOI Listing
May 2018

The authors respond: methodological issues in studying shock indices.

Am J Emerg Med 2017 02 13;35(2):342-343. Epub 2016 Nov 13.

Department of Emergency Medicine, Kerman University of Medical Sciences, Kerman, Iran. Electronic address:

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http://dx.doi.org/10.1016/j.ajem.2016.11.026DOI Listing
February 2017

Shock index, modified shock index, and age shock index for prediction of mortality in Emergency Severity Index level 3.

Am J Emerg Med 2016 Nov 14;34(11):2079-2083. Epub 2016 Jul 14.

Clinical Research Center, Afzalipoor Hospital, Kerman, Iran.

Objectives: To elucidate the predictive capability of shock index (SI), modified SI (MSI), and age SI for mortality in patients assigned to Emergency Severity Index (ESI) level 3 patients.

Methods: This was a retrospective medical record review performed in an academic internal medicine emergency department in Kerman, Iran. All patients older than 14 years triaged to ESI level 3 were enrolled in the study. Triage time vital signs were used to calculate SI, MSI, and age SI. The primary outcome was in-hospital mortality.

Results: A total number of 3375 patients were enrolled in the study, in which 84 (2.5%) died during hospital stay. In the adjusted multivariate analysis, age SI, systolic blood pressure (SBP), and sex were independently associated with mortality, with P values (odds ratio [95% confidence interval]) of <.001 (1.03 [1.01-1.04]), .003 (0.97 [0.96-0.99]), and .04 (1.61 [1.01-2.59]), respectively. Receiver operating characteristic curve showed an area under curve of 0.717 for the 3-variable final model and an area under curve of 0.678 for age SI in mortality prediction.

Conclusions: In ESI level 3 patients, age SI and SBP showed to be better than SI or MSI in predicting mortality. However, because their predictive capability was modest, age SI or SBP should be considered adjuncts to sort actions in favor of patients with higher risk for mortality.
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http://dx.doi.org/10.1016/j.ajem.2016.07.017DOI Listing
November 2016

Association of triage time Shock Index, Modified Shock Index, and Age Shock Index with mortality in Emergency Severity Index level 2 patients.

Am J Emerg Med 2016 Jan 21;34(1):63-8. Epub 2015 Sep 21.

Clinical Research Center, Afzalipoor Hospital, Kerman, Iran.

Background: Shock Index (SI) is considered to be a predictor of mortality in many medical and trauma settings. Many studies have shown its superiority to conventional vital sign measurements in mortality prediction.

Objectives: The objectives were to compare mortality and intensive care unit admission prediction of triage time SI, Modified SI (MSI), and Age SI with each other and with triage time blood pressure in Emergency Severity Index (ESI) level 2 patients.

Methods: A retrospective medical record review was performed in the internal medicine emergency department of a general hospital in Kerman, Iran. Triage time vital signs were used to calculate the indices. Multivarible regression analysis was used to create the final model.

Results: A total of 1285 patients triaged to ESI level 2 were enrolled in the study. In the multivariate analysis, SI, MSI, and Age SI were found to be the only variables independently associated with mortality, whereas none of them were associated with intensive care unit admission. Sensitivity, specificity, and area under curve in the receiver operating characteristic curve for the model including SI, MSI, and Age SI were 60.8%, 65.4%, and 0.675, respectively. Sensitivity, specificity, and area under curve did not change significantly by excluding SI, MSI, or Age SI from the final model.

Conclusion: In nontrauma adult patients, triage time SI, MSI, and Age SI are superior to blood pressure for mortality prediction in ESI level 2. They can be used alone or in combination with similar results, but their low sensitivity and specificity make them usable only as an adjunct for this purpose.
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http://dx.doi.org/10.1016/j.ajem.2015.09.014DOI Listing
January 2016

Risk Factors for Mortality and Endotracheal Intubation after Methadone Intoxication.

Basic Clin Pharmacol Toxicol 2016 Mar 24;118(3):231-7. Epub 2015 Sep 24.

Department of Emergency Medicine, Kerman University of Medical Sciences, Kerman, Iran.

This was a retrospective chart review to evaluate various risk factors associated with in-hospital mortality and intubation risk in acute methadone overdose. All patients admitted to an academic hospital in Tehran, Iran, during a 10-year period (2000-2009) constituted the study sample. Exclusion criteria were significant comorbidities and age under 18 years. Outcome variables were in-hospital mortality and being intubated during admission. A total of 802 patients were enrolled in the study. There were 15 (1.8%) deaths due to methadone overdose or its complications. The number of yearly admissions was 15 patients in 2000, 16 in 2001, 16 in 2002, 18 in 2003, 23 in 2004, 38 in 2005, 59 in 2006, 110 in 2007, 206 in 2008 and 301 in 2009. Based on logistic regression analysis, the most important independent variable predicting mortality was length of admission in toxicology ward [OR (95% CI): 1.6 (1.1-2.3)]. For the prediction of intubation, independent variables were Glasgow Coma Scale (GCS) score of 5-9 [OR (95% CI): 356.5 (9.8-12907.4)] in the emergency department (ED), miosis in the ED [356.9 (1.4-87872.5)] and respiratory rate in the ED [1.5 (1.1-2.1)]. Linear regression model for length of hospitalization showed patient age as the most important variable for prediction of this outcome. Despite a relatively low mortality rate, the increasing number of methadone-poisoned patients requires special attention to this common intoxication. Careful disposition of patients from ED to ordinary wards or intensive care units and also from higher to lower levels of care should be considered in methadone overdose.
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http://dx.doi.org/10.1111/bcpt.12476DOI Listing
March 2016

Methanol mass poisoning in Iran: role of case finding in outbreak management.

J Public Health (Oxf) 2015 Jun 18;37(2):354-9. Epub 2014 Jun 18.

Ministry of Health, Mental and Social Health and Substance Abuse office, Tehran, Iran.

Background: There are no guidelines addressing the public health aspects of methanol poisoning during larger outbreaks. The current study was done to discuss the role of active case finding and a national guideline that organizes all available resources according to a triage strategy in the successful management of a methanol mass poisoning in Rafsanjan, Iran, in May 2013.

Methods: A retrospective cross-sectional study was performed reviewing the outbreak Emergency Operation Center files. The objectives were to describe the characteristics, management and outcome of a methanol outbreak using Active Case Finding to trace the victims.

Results: A total of 694 patients presented to emergency departments in Rafsanjan after public announcement of the outbreak between 29th May and 3rd June 2013. The announcement was mainly performed via short message service (SMS) and local radio broadcasting. A total of 361 cases were observed and managed in Rafsanjan and 333 were transferred to other cities. Seventy-five and 100 patients underwent hemodialysis (HD), retrospectively. The main indication for HD was refractory metabolic acidosis. Eight patients expired due to the intoxication. Except for the deceased cases, no serum methanol level was available.

Conclusion: In developing countries, where diagnostic resources are limited, use of active case finding and developing national guidelines can help in the management of large outbreaks of methanol poisonings.
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http://dx.doi.org/10.1093/pubmed/fdu038DOI Listing
June 2015

The correlation between prolonged corrected QT interval with the frequency of respiratory arrest, endotracheal intubation, and mortality in acute methadone overdose.

Cardiovasc Toxicol 2014 Dec;14(4):358-67

Department of Emergency Medicine, Iran University of Medical Sciences, Tehran, Iran.

Corrected QT interval (QTc) prolongation is long considered as a predisposing factor for the occurrence of torsade de pointes (TdP) and sudden cardiac arrest in methadone maintenance treatment. We aimed to elucidate the correlation between QTc prolongation and in-hospital death, respiratory arrest, and endotracheal intubation in acute methadone-intoxicated patients presenting to the emergency department and to assess the value of QTc in predicting these outcomes. A prospective cross-sectional study with a convenience sample of patients with acute methadone overdose was done. Participants were 152 patients aged 15-65 with negative urinary dipstick test for cyclic antidepressants, no history of other QTc-prolonging conditions and co-ingestions, no severe comorbidities affecting the outcomes, and positive urinary dipstick results for methadone. QTc intervals were measured and calculated in triage-time electrocardiogram (ECG). Death was correlated with QTc (P = 0.014) and length of ICU admission (P < 0.001). In multivariable analysis, death was independently associated only with length of ICU admission [odds ratio (OR) 95 % confidence intervals (95 % CI) 1.36 (1.14-1.61)]. Intubation and respiratory arrest were independently associated with QTc interval [OR (95 % CI) 1.03 (1.02-1.04) and 1.02 (1.01-1.03), respectively]. The receiver operating characteristics curves drawn to show the ability of QTc to predict death, intubation, and respiratory arrest showed thresholds of 470, 447.5, and 450 ms with sensitivity (95 % CI) and specificity (95 % CI) of 87.5 (47.3-99.7), 86.8 (74.7-94.5), and 77.3 (62.2-88.5), respectively. Our study showed that QTc is a potential predictor for adverse outcomes related to acute methadone intoxication. The correlations shown in this study between triage-time QTc and in-hospital respiratory arrest or intubation in methadone overdose may be of clinical value, whether these outcomes are hypothesized to be a reflection of background TdP or intoxication severity.
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http://dx.doi.org/10.1007/s12012-014-9259-xDOI Listing
December 2014