Effect of simulating training of the fundamentals of laparoscopic surgery on the attitude of operating room nurses students:an intervention study

Objective:Clinical education plays a key role in preparing students for patient care.Laparoscopy is one of the most important minimally invasive surgeries(MISs)wherein surgical technologists are responsible for camera navigation and assistant surgeons are responsible for peg transfer.Therefore,it is necessary to improve the attitude of the operating room students toward these skills during their study period.The present study was conducted to determine the effect of simulating training in the fundamentals of laparoscopic surgery(FLS)on the attitude of the operating room students.Methods:This interventional study was conducted on 28 operating room students of Iran University of Medical Sciences in 2019.The census sampling method was used.The data-collection tool included the“Intrinsic motivation inventory(IMI)questionnaire.”The educational intervention was carried out in theoretical(booklet design)and practical(simulation)sections.Data analysis was carried out using descriptive and inferential analyses including the paired t-test,Mann–Whitney U test,and independent t-test.The collected data were analyzed using R and SPSS software.P-value<0.05 was considered as the significant level.Results:The mean±SD of the participants'age was 22.93±2.14 years,and the majority of them were women(67.9%).There was a significant difference in the mean scores of students'attitudes toward the FLS before and after the educational intervention(P<0.001)in all dimensions(interest,perceived competence,perceived choice,and tension).There was also a significant correlation between gender and interest dimension(P=0.005).Conclusions:The results of the present study showed that simulating the training FLS curriculum positively affects students'attitudes.Therefore,the researchers suggest that for creating a positive attitude,increasing students'interest in laparoscopic surgery,and ensuring a more effective presence in the operating room,this training should be considered in the operating room curriculum.

Post-discharge follow-up of patients with spine trauma in the National Spinal Cord Injury Registry of Iran during the COVID-19 pandemic:Challenges and lessons learned

Purpose:The purpose of the National Spinal Cord Injury Registry of Iran(NSCIR-IR)is to create an infrastructure to assess the quality of care for spine trauma and in this study,we aim to investigate whether the NSCIR-IR successfully provides necessary post-discharge follow-up data for these patients.Methods:An observational prospective study was conducted from April 11,2021 to April 22,2022 in 8 centers enrolled in NSCIR-IR,respectively Arak,Rasht,Urmia,Shahroud,Yazd,Kashan,Tabriz,and Tehran.Patients were classified into 3 groups based on their need for care resources,respectively:(1)non-spinal cord injury(SCI)patients without surgery(group 1),(2)non-SCI patients with surgery(group 2),and(3)SCI patients(group 3).The assessment tool was a self-designed questionnaire to evaluate the care quality in 3 phases:pre-hospital,in-hospital,and post-hospital.The data from the first 2 phases were collected through the registry.The post-hospital data were collected by conducting follow-up assessments.Telephone follow-ups were conducted for groups 1 and 2(non-SCI patients),while group 3(SCI patients)had a face-to-face visit.This study took place during the COVID-19 pandemic.Data on age and time interval from injury to follow-up were expressed as mean±standard deviation(SD)and response rate and follow-up loss as a percentage.Results:Altogether 1538 telephone follow-up records related to 1292 patients were registered in the NSCIR-IR.Of the total calls,918(71.05%)were related to successful follow-ups,but 38 cases died and thus were excluded from data analysis.In the end,post-hospital data from 880 patients alive were gathered.The success rate of follow-ups by telephone for groups 1 and 2 was 73.38%and 67.05%respectively,compared to 66.67%by face-to-face visits for group 3,which was very hard during the COVID-19 pandemic.The data completion rate after discharge ranged from 48%-100%,22%-100%and 29%-100%for groups 1-3.Conclusions:To improve patient accessibility,NSCIR-IR should take measures during data gathering to increase the accuracy of registered contact information.Regarding the loss to follow-ups of SCI patients,NSCIR-IR should find strategies for remote assessment or motivate them to participate in follow-ups through,for example,providing transportation facilities or financial support.

Comparing epidemiologic features,outcomes,and diagnostic and therapeutic procedures of traumatic patients before and during COVID-19 pandemic:Data from the National Trauma Registry of Iran

Purpose:To prepare for future possible communicable disease epidemics/pandemics,health care providers should know how the COVID-19 pandemic influenced injured patients.This study aimed to compare epidemiologic features,outcomes,and diagnostic and therapeutic procedures of trauma patients admitted to a university-affiliated hospital before and during the pandemic.Methods:This retrospective study was performed on data from the National Trauma Registry of Iran.All injured patients admitted to the hospital from July 25,2016 to March 10,2021 were included in the study.The patients were excluded if they had hospital length of stay less than 24 h.The injury outcomes,trauma mechanisms,and therapeutic and diagnostic procedures of the 2 periods:before(from July 25,2016 to February 18,2020)and during(from February 19,2020 to March 10,2021)COVID-19 pandemic were compared.All analyses were performed using STATA version 14.0 software(Stata Corporation,College Station,TX).Results:Totally,5014 patients were included in the registry.Of them,773(15.4%)were registered after the beginning of the COVID-19 pandemic on February 19,2020,while 4241 were registered before that.Gender,education level,and cause of injury were significantly different among the patients before and after the beginning of the pandemic(p<0.001).In the≤15 years and≥65 years age groups,injuries decreased significantly during the COVID-19 pandemic(p<0.001).The frequency of intensive care unit(ICU)admission decreased from 694(16.4%)to 88(11.4%)(p<0.001).The mean length of stay at the hospital(days)and at the ICU(days)declined as follow:8.3(SD=17.2)vs.5.5(SD=6.1),p<0.001 and 7.5(SD=11.5)vs.4.5(SD=6.3),p<0.022.The frequency of diagnostic and therapeutic procedures before and during the pandemic was as follows,respectively:ultrasonography 905(21.3%)vs.417(53.9%)(p<0.001),echocardiography 313(7.4%)vs.107(13.8%)(p<0.001),angiography 1597(37.7%)vs.534(69.1%)(p<0.001),MRI 166(3.9%)vs.51(6.6%)(p<0.001),surgery 3407(80.3%)vs.654(84.6%)(p<0.001),and internal/external fixation 1215(28.6%)vs.336(43.5%)(p<0.001).Conclusion:The pandemic affected the epidemiology of traumatic patients in terms of gender,age,educational level,and trauma mechanism.It changed the outcomes of injured patients:ICU admission,length of stay at the hospital and ICU decreased.The patients received more diagnostic and therapeutic procedures during the pandemic.To be more precise,more research is needed on the details.

Assessment of mechanism, type and severity of injury in multiple trauma patients： A cross sectional study of a trauma center in Iran

Purpose： To accurately assess the mechanism, type and severity of injury in Iranian multiple trauma patients of a trauma center. Methods： Patients with multiple traumas referring to the emergency department of Hasheminejad University Hospital in Mashhad, lran, entered this cross sectional study from March 2013 to December 2013. All the patients with injury severity score （ISS） 〉 9 were included in this study. Data analysis was performed by SPSS software （Version 11.5） and P values less than 0.05 were considered as significant differences. Results： Among the 6306 hospitalized trauma patients during this period, 148 had ISS〉9. The male fe- male ratio was 80%. The mean age of the patients was （33.5 m 19.3） years. And 71% of the patients were younger than 44 years old. There were 19 （13%） deaths from which 68.5% were older than 44 years old. The mean transfer time from the injury scene to hospital was （55 e 26） minutes. The most frequent mechanisms of injury were motorcycle crashes and falling from height, which together included 66.2% of all the injuries. A total of 84% of hospital deaths occurred after the first 24 h of hospitalization. Head and neck were the most common body injured areas with a prevalence of 111 cases （75%）. Conclusion： Motorcycle crashes have high frequency in lran. Since most victims are young males, injury prevention strategies should be considered to reduce the burden of injuries.

Situation analysis of trauma based on Arizona trauma center standards in university hospitals of Tehran, Iran

Objective: Injuries are common and important problem in Tehran, capital of Iran. Although therapeutic centers are not essentially established following the constructional principles of developed countries, the present opportunities and equipments have to be used properly. We should recognize and reduce the deficits based on the global standards.This study deliberates the trauma resources and capacities in university hospitals of Tehran based on Arizona trauma center standards, which are suitable for the assessment of trauma centers.Methods: Forty-one university hospitals in Tehran were evaluated for their conformity with "Arizona trauma center standards" in 2008. A structured interview was arranged with the "Educational Supervisor" of all hospitals regarding their institutional organization, departments, clini-cal capabilities, clinical qualifications, facilities and resources, rehabilitation services, performance improvement, continuing education, prevention, research and additional requirements for pediatric trauma patients. Relative frequencies and percentages were calculated and Student's t test was used to compare the mean values.Results: Forty-one hospitals had the average of 77.7 (50.7%) standards from 153 Arizona trauma center standards and these standards were present in 97.5 out of 153 (63.7%) in 17 general hospitals. Based on the subgroups of the standards, 64.8% items of hospital resources and capabilities were considered as a subgroup with the maximum criteria, and 17.7% items of research section as another subgroup with the minimum standards.Conclusions: On the basis of our findings, no hospital meet all the Arizona trauma center standards completely. The hospitals as trauma centers at different levels must be promoted to manage trauma patients desirably.

The effect of tranexamic acid in traumatic brain injury： A randomized controlled trial

Purpose： Traumatic brain injury （TBI） is a leading cause of death and disability, lntracranial hemorrhage （ICH） secondary to TBI is associated with a high risk of coagulopathy which leads to increasing risk of hemorrhage growth and higher mortality rate. Therefore, antifibrinolytic agents such as tranexamic acid （TA） might reduce traumatic ICH. The aim of the present study was to investigate the extent of ICH growth after TA administration in TBI patients. Methods： This single-blind randomized controlled trial was conducted on patients with traumatic ICH （with less than 30 ml） referring to the emergency department of Vali-Asr Hospital, Arak, Iran in 2014. Patients, based on the inclusion and exclusion criteria, were divided into intervention and control groups （40 patients each）. All patients received a conservative treatment for ICH, as well as either intravenous TA or placebo. The extent of ICH growth as the primary outcome was measured by brain cr scan after 48 h. Results： Although brain CT scan showed a significant increase in hemorrhage volume in both groups after 48 h, it was significantly less in the TA group than in the control group （p = 0.04）. The mean total hemorrhage expansion was （1.7 ± 9.7） ml and （4.3 ± 12.9） ml in TA and placebo groups, respectively （p 〈 0.001）. Conclusion： It has been established that TA, as an effective hospital-based treatment for acute TBI, could reduce ICH growth. Larger studies are needed to compare the effectiveness of different doses.

Epidemiology and short-term mortality in traumatic patients admitted to Shariati Hospital in Iran between 2012 and 2013

Purpose： Trauma is an inevitable part of the health burden in every country. Both the preventive and rehabilitative aspects of traumatic injuries are expensive. Since most of the injuries happen in low- and middle-income developing countries, a judicious allocation of the limited resources to the most cost- efficient strategies is necessary. The present study was designed to report the causes of trauma, injured body regions, trauma severity scores and the one year survival rate of a randomly selected sample of trauma patients in a major referral hospital in Tehran, Iran. Methods： We chose and analyzed a random subgroup of traumatic patients admitted during the one- year period of May 2012 to May 2013 to Shariati Hospital, a major University Teaching Hospital in Tehran, Iran. Patients who stayed at the hospital for less than 24 h were excluded. In total, 73 traumatic patients were registered. The mean age was （40.19 ＋ 20.34） years and 6Z1% of them were male. Results： In general, the most common cause of injury was falls （47.9%）, followed by road traffic crashes （RTCs, 40.8%）. Assault and exposure to inanimate mechanical forces each were only associated with 5.6% of all injuries. The only cause of injury in ages of more than 65 years was fall. The most common cause of injury in ages between 15 and 45 years was RTCs. During the study, two deaths occurred： one was at ICU and the other was at home. The most commonly injured body region was the head （23.8%）, followed by the elbow and forearm （19%）, hip and thigh （15.9%）, and multiple body regions （14.3%）. The mean abbreviated injury score was 2.23 ± 1.02; injury severity index was 7.26 ± 7.06; and revised trauma score was 7.84, calculated for 38 patients. Conclusion： Prevention strategy of traumatic injury should focus on falls and RTCs, which are respec- tively the most common cause of trauma in older aged people and young males.

Effects of neurofeedback on the short-term memory and continuous attention of patients with moderate traumatic brain injury： A preliminary randomized controlled clinical trial

Purpose： There are some studies which showed neurofeedback therapy （NET） can be effective in clients with traumatic brain injury （TBI） history. However, randomized controlled clinical trials are still needed for evaluation of this treatment as a standard option. This preliminary study was aimed to evaluate the effect of NET on continuous attention （CA） and short-term memory （STM） of clients with moderate TBI using a randomized controlled clinical trial （RCT）. Methods： In this preliminary RCT, seventeen eligible patients with moderate TBl were randomly allo- cated in two intervention and control groups. All the patients were evaluated for CA and STM using the visual continuous attention test and Wechsler memory scale-4th edition （WMS-IV） test, respectively, both at the time of inclusion to the project and four weeks later. The intervention group participated in 20 sessions of NFT through the first four weeks. Conversely, the control group participated in the same NF sessions from the fifth week to eighth week of the project. Results： Eight subjects in the intervention group and five subjects in the control group completed the study. The mean and standard deviation of participants＇ age were （26.75 ~ 15.16） years and （2Z60 ＋_ 8.17） years in experiment and control groups, respectively. All of the subjects were male. No significant improvement was observed in any variables of the visual continuous attention test and WMS-IV test between two groups （p _~ 0.05）. Conclusion： Based on our literature review, it seems that our study is the only study performed on the effect of NET on TBl patients with control group. NET has no effect on CA and STM in patients with moderate TBI. More RCTs with large sample sizes, more sessions of treatment, longer time of follow-up and different orotocols are recommended.

Establishment of a regional multicenter traumatic spine fracture/dislocation registry

Objective：Trauma is one of the leading causes of mortality and morbidity in adults and a major contributor to health care expenditures.Although spine-related injuries constitute a small proportion of trauma cases,they need special consideration due to poor functional outcomes and substantial burden.Despite relatively extensive previous studies on traumatic spinal injuries,there is still obscurity in some aspects of the issue.The purpose of this study is to establish a regional multicenter traumatic spine fracture/dislocation registry.Methods：This is a prospective case series study,including all patients with acute traumatic spine lesions admitted to a regional multicenter since 2014.Data is extracted based upon a form developed by Sina Trauma and Surgery Research Center,Tehran University of Medical Sciences,Tehran,Iran.Novel electronic data entry software is initiated and data will be entered to the software.Information remains confidential and security considerations will be taken based on standards of data entry systems.Results：The results of this study will include age and gender distribution of the patients,causes of injury,location of pain and neurological deficit,the American Spinal Injury Association score and Frankel grade on admission,at discharge,after 6 and 12 months and at the latest annual follow-up,radiologic findings,details of operative procedures and methods of external fixation.Conclusion：This study will identify prognostic factors that influence the ultimate fate of spine fracture patients and determine short and long-term outcome of different treatment methods.It can lead to a considerable improvement in patient care and will have a great national and transnational impact.

Evaluating mechanism and severity of injuries among trauma patients admitted to Sina Hospital,the National Trauma Registry of Iran

Purpose:Injuries are one of the leading causes of death and lead to a high social and financial burden.Injury patterns can vary significantly among different age groups and body regions.This study aimed to evaluate the relationship between mechanism of injury,patient comorbidities and severity of injuries.Methods:The study included trauma patients from July 2016 to June 2018,who were admitted to Sina Hospital,Tehran,Iran.The inclusion criteria were all injured patients who had at least one of the following:hospital length of stay more than 24 h,death in hospital,and transfer from the intensive care unit of another hospital.Data collection was performed using the National Trauma Registry of Iran minimum dataset.Results:The most common injury mechanism was road traffic injuries(49.0%),followed by falls(25.5%).The mean age of those who fell was significantly higher in comparison with other mechanisms(p<0.001).Severe extremity injuries occurred more often in the fall group than in the vehicle collision group(69.0%vs.43.5%,p<0.001).Moreover,cases of severe multiple trauma were higher amongst vehicle collisions than injuries caused by falls(27.8%vs.12.9%,p=0.003).Conclusion:Comparing falls with motor vehicle collisions,patients who fell were older and sustained more extremity injuries.Patients injured by motor vehicle collision were more likely to have sustained multiple trauma than those presenting with falls.Recognition of the relationship between mechanisms and consequences of injuries may lead to more effective interventions.

Comparison of road traffic fatalities and injuries in Iran with other countries

Objective： To compare fatalities and injuries in road traffic crashes （RTC） in Iran with other countries. Methods： Data were obtained from national health sources of Iran. These data included population number, registered motor-vehicles number, number of RTCs and consequent fatalities and injuries from 1997 to 2006. Results： RTC fatality and injury rates increased from 1997 to 2005, but decreased in 2006. The overall men/women ratio in the RTC fatalities was 4.2：1. High RTC fatality rate of 39 per 100 000 population in Iran was almost the same as some other developing countries. In Iran, RTC fatalities in recent years were almost twice as much as the highest rate among the European countries. Conclusions： This investigation shows that in spite of reduction of RTC fatality in Iran in 2006, it is still one of the highest in the world. Moreover, this paper describes the state of RTC-related parameters in a developing country in comparison with the developed countries.

Spinal fractures resulting from traumatic injuries

Objective： To illustrate mechanisms of spine fractures and the pattern of spinal injuries characterized by the major mechanisms in urban population of Iran. Methods： Data regarding spinal injuries including demographics, mechanism and level of spinal injury, abbreviated injury score, associated injuries and final fate of the patients were extracted from the Iranian national trauma registry database from 1999 to 2004. Results： A total of 619 patients with traumatic spine fractures were identified, of whom 68.5% were males. The peak frequency of these injuries occurred in the 21-40 year age-group. Accidental falls and road traffic crashes （RTCs） were the most common mechanisms of spinal fractures （47.2% and 44.1%, respectively）. RTCs tended to occur in younger patients compared with accidental falls. The most common spinal region for spinal fracture was the lumbar spine （53.63%）. Cervical spine fractures were significantly more common in RTCs, while lumbar spine fractures were more common in accidental falls （P〈0.001）. A total of 171 （27.6%）patients had associated non-spinal injuries, of whom 127 had associated extremity injuries, and 55 had head injuries. Thirty-six （5.6%） patients had spinal cord injury （SCI）.The injury severity score of the RTC group was significantly higher than that of accidental falls （P=-0.002）. Fifteen （4%） patients died of traumatic injuries. The rate of death was significantly higher in RTCs compared with accidental falls （5.1% vs 2.1%, P=0.039）. Conclusions： The patterns of spinal fractures are similar to those reported from developed countries. RTCs tend to affect the younger age population and are associated with a higher degree of associated injuries and mortality than accidental falls. Therefore preventive strategies should be based on reduction of the number and severity of RTCs.

Modern concepts of transport in multiple trauma： a nar- rative review

Multiple variables can influence triage decision in multiple trauma. Recognition of priorities and selection of the destination can be successfully achieved by field triage and individualized clinical judgment. This narrative review summarizes the new options and protocols for transport of injured subjects. There are four levels of emergency medical providers including first responders and three levels of emergency medical technicians. Two distinct accepted protocols for transport are known as scoop and run and treat and then transfer. The former provides mini- mum lifesaving treatment at the scene of accident followed by transferring the patient（s） as soon as possible, and thelatter mainly emphasizes the need for complete stabilization as a prerequisite for safe transport. The destination and mode of transport are selected according to clinical capa- bilities of the receiving hospital, transfer time from the scene to the facility, patient＇s medical condition, accessibility of the scene, and weather. Two common methods of transfer are ground transport, including various type of ambulances, and air medical transport, i.e. helicopter and airplane.

Comparison of ultrasonography and radiography in diagnosis of rib fractures

Purpose： Rib fractures are the most common skeletal thoracic injuries resulting from blunt chest trauma. Half of the rib fractures are not detected upon a precise physical evaluation and radiographs. Recently ultrasonography （USG） has been investigated to detect rib fractures. But based on literature the usefulness of USG varies widely. This study was conducted to investigate the role of USG in the detection of possible rib fractures in comparison with radiography. Methods： In this cross-sectional study, consecutive patients with minor blunt chest trauma and suspected rib fractures presenting in Imam Reza Hospital located in Mashhad-Iran, between April 2013 and October 2013 were assessed by USG and radiography. The radiography was performed in a posteroanterior （PA） chest projection and oblique rib view centered over the area of trauma. The time duration spent in taking USG and radiography were recorded. The prevalence and location of fractures revealed by USG and radiography were compared. Results： Sixty-one suspected patients were assessed. The male to female ratio was 2.4：1 （43 men and 18 women） with a mean ± SD age of （44.3 ± 19.7） years. There were totally 59 rib fractures in 38 （62.3%） patients based on radiography and USG, while 23 （37.7%） patients had no diagnostic evidence of rib lesions. USG revealed 58 rib fractures in 33 （54.1%） of 61 suspected patients and radiographs revealed 32 rib fractures in 20 （32.8%） of 61 patients. A total of 58 （98.3%） rib fractures were detected by USG, whereas oblique rib view and PA chest radiography showed 27 （45.8%） and 24 （40.7%） rib fractures, respectively. The average duration of USG was （12 ± 3） min （range 7e17 min）, whereas the duration of radiography was （27 ± 6） min （range 15-37 min）. The kappa coefficient showed a low level of agreement between both USG and PA chest radiography （kappa coefficient=0.28）, and between USG and oblique rib view （kappa coefficient=0.32）. Conclusion： USG discloses more fractures than radiography in most patients presenting with suspected rib fractures. Moreover USG requires significantly less time than radiography.

Accuracy of chest radiography versus chest computed tomography in hemodynamically stable patients with blunt chest trauma

Objective：Thoracic injuries are responsible for 25% of deaths of blunt traumas.Chest X-ray （CXR） is the first diagnostic method in patients with blunt trauma.The aim of this study was to detect the accuracy of CXR versus chest computed tomograpgy （CT） in hemodynamically stable patients with blunt chest trauma.Methods：Study was conducted at the emergency department of S ina Hospital from March 2011 to March 2012.Hemodynamically stable patients with at least 16 years of age who had blunt chest trauma were included.All patients underwent the same diagnostic protocol which consisted of physical examination,CXR and CT scan respectively.Results：Two hundreds patients （84% male and 16% female） were included with a mean age of（37.9±13.7） years.Rib fracture was the most common finding of CXR （12.5%） and CT scan （25.5%）.The sensitivity of CXR for hemothorax,thoracolumbar vertebra fractures and rib fractures were 20%,49% and 49%,respectively.Pneumothorax,foreign body,emphysema,pulmonary contusion,liver hematoma and sternum fracture were not diagnosed with CXR alone.Conclusion：Applying CT scan as the first-line diagnostic modality in hemodynamically stable patients with blunt chest trauma can detect pathologies which may change management and outcome.

Evaluating clinical abdominal scoring system in predicting the necessity of laparotomy in blunt abdominal trauma

Objectives： Trauma is among the leading causes of death. Medical management of blunt abdominal trauma （BAT） relies on judging patients for whom laparotomy is mandatory. This study aimed to determine BAT patients＇ signs, as well as paraclinical data, and to clarify the accuracy, sensitivity, specificity, positive and negative predictive value of clinical abdominal scoring system （CASS）, a new scoring system based on clinical signs, in predicting whether a BAT patient needs laparotomy or not. Methods： Totally 400 patients suspected of BAT that arrived at the emergency department of two university hospitals in Tehran from March 20, 2007 to March 19, 2009 were included in this study. They were evaluated for age, sex, type of trauma, systolic blood pressure, Glasgow coma scale （GCS）, pulse rate, time of presentation after trauma, abdomial clinical findings, respiratory rate, temperature, hemoglobin （Hb） concentration, focused abdominal sonography in trauma （FAST） and CASS. Results： Our measurements showed that CASS had an accuracy of 94%, sensitivity of 100%, specificity of 88%, positive predictive value of 90% and negative predictive value of 100% in determining the necessity of laparotomy in BAT patients. Moreover, in our analysis, systolic blood pressure, GCS, pulse rate, Hb concentration, time of presentation after trauma, abdominal clinical findings and FAST were also shown to be helpful in confirming the need for laparotomy （P〈0.05）. Conclusion： CASS is a promising scoring system in rapid detection of the need for laparotomy as well as in minimizing auxiliary expense for further evaluation in BAT patients, thus to promote the cost-benefit ratio and accuracy of diagnosis.

Impact of intravenous acetaminophen therapy on the necessity of cervical spine imaging in patients with cervical spine trauma

Objective：We evaluated a new hypothesis of acetaminophen therapy to reduce the necessity of imaging in patients with probable traumatic cervical spine injury.Methods：Patients with acute blunt trauma to the neck and just posterior midline cervical tenderness received acetaminophen （15 mg/kg） intravenously after cervical spine immobilization.Then,all the patients underwent plain radiography and computerized tomography of the cervical spine.The outcome measure was the presence of traumatic cervical spine injury.Sixty minutes after acetaminophen infusion,posterior midline cervical tendemess was reassessed.Results：Of 1 309 patients,41 had traumatic cervical spine injuries based on imaging.Sixty minutes after infusion,posterior midline cervical tenderness was eliminated in 1 041 patients,none of whom had abnormal imaging.Conclusion：Patients with cervical spine trauma do not need imaging if posterior midline cervical tendemess is eliminated after acetaminophen infusion.This analgesia could be considered as a diagnostic and therapeutic intervention.

Effect of Advanced Trauma Life Support program on medical interns＇ performance in simulated trauma patient management

Objective： Since appropriate and time- table methods in trauma care have an important impact on patients＇ outcome, we evaluated the effect of Advanced Trauma Life Support （ATLS） program on medical interns＇ performance in simulated trauma patient management. Methods： A descriptive and analytical study before and after the training was conducted on 24 randomly se- lected undergraduate medical interns from Imam Reza Hospital in Mashhad, Iran. On the first day, we assessed in- terns＇ clinical knowledge and their practical skill performance in confronting simulated trauma patients. After 2 days of ATLS training, we performed the same study and evaluated their score again on the fourth day. The two findings, pre- and post- ATLS periods, were compared through SPSS version 15.0 software. P values less than 0.05 were considered statistically significant. Results： Our findings showed that interns＇ ability in all the three tasks improved after the training course. On the fourth day after training, there was a statistically significant increase in interns＇ clinical knowledge of ATLS procedures, the sequence of procedures and skill performance in trauma situations （P〈0.001, P=0.016 and P=0.01 respectively）. Conclusion： ATLS course has an important role in increasing clinical knowledge and practical skill performance of trauma care in medical interns.

Patterns of extremity traumas leading to amputation in Iran： results of Iranian National Trauma Project

Objective： To determine the patterns of traumatic extremity injuries leading to amputation in Iran. Methods： Data of Iranian National Trauma Project was used to identify patients with upper and lower extremity traumas undergoing amputation. This project was conducted in 8 major cities during 2000-2004. Results： Of 17 753 traumatic patients, 164 （0.92%） had injuries to the extremities that resulted in the limb amputation. Of these, 143 （87.2%） were men. The patient＇s mean age was 29.0 years ± 15.4 years and the highest incidence was seen in the age group of 21 to 30 years （34.1%）. One hundred and four cases were occupational accidents （63.4%）. Blunt trauma was in 54.9% of the cases. The most common reasons for amputation were respectively stabbings （37.8%） and crush injuries （31.7%）. Amputation of hand fingers was the most frequent type of amputation （125 cases, 76,2 %）. One patient died from severe associated iniuries. Conclusions： This study shows the patterns of traumatic limb amputation in Iran, a developing country. Results of this study may be used in preventive strategic planning.

National Spinal Cord Injury Registry of Iran(NSCIR-IR)-a critical appraisal of its strengths and weaknesses

The National Spinal Cord Injury Registry of Iran(NSCIR-IR)is a not-for-profit,hospital-based,and prospective observational registry that appraises the quality of care,long-term outcomes and the personal and psychological burden of traumatic spinal cord injury in Iran.Benchmarking validity in every registry includes rigorous attention to data quality.Data quality assurance is essential for any registry to make sure that correct patients are being enrolled and that the data being collected are valid.We reviewed strengths and weaknesses of the NSCIR-IR while considering the methodological guidelines and recommendations for efficient and rational governance of patient registries.In summary,the steering committee,funded and maintained by the Ministry of Health and Medical Education of Iran,the international collaborations,continued staff training,suitable data quality,and the ethical approval are considered to be the strengths of the registry,while limited human and financial resources,poor interoperability with other health systems,and time-consuming processes are among its main weaknesses.