Background:Researchers have regarded moral distress as a major concern in the health care system. Symptoms associated with moral distress may manifest as frustration, dissatisfaction, and anxiety and may lead to burnout, job leaving, and finally, failure to provide safe and competent care to patients. Proper management of this phenomenon can be fulfilled through study of its causes at different levels of health services and taking necessary measures to solve them.Objectives:This study aimed to determine the status of moral distress in physicians practicing in hospitals affiliated to Medical Sciences Universities in Tehran.Materials and Methods:This cross-sectional study was carried out using the Standard Hamric Scale to collect data after modification and evaluation of its reliability and validity. A total of 399 physicians responded to the scale. Data analysis was performed using descriptive and correlation statistics with respect to the variables.Results:Results showed that the frequency of moral distress of physicians was 1.24 ± 0.63 and the intensity of moral distress and composite score of moral distress were 2.14 ± 0.80 and 2.94 ± 2.38, respectively. A significant negative correlation existed between age and frequency and composite score (r = -0.15, P < 0.01 and r = -0.16, P < 0.01, respectively) as well as years of experience and composite score (r = -0.11, P = 0.04). Moral distress composite score in adults specialists was higher than pediatricians (P = 0.002), but lower in physicians participated in medical ethics training courses compared to those not participated.Conclusions:Physicians may encounter moral distress during their practice; therefore, the common causes of distress should be identified in order to prevent its occurrence.

BackgroundEmergency Department (ED) overcrowding adversely affects patients’ health, accessibility, and quality of healthcare systems for communities. Several studies have addressed this issue. This study aimed to conduct a systematic review study concerning challenges, lessons and way outs of clinical emergencies at hospitals.MethodsOriginal research articles on crowding of emergencies at hospitals published from 1st January 2007, and 1st August 2018 were utilized. Relevant studies from the PubMed and EMBASE databases were assessed using suitable keywords. Two reviewers independently screened the titles, abstracts and the methodological validity of the records using data extraction format before their inclusion in the final review. Discussions with the senior faculty member were used to resolve any disagreements among the reviewers during the assessment phase.ResultsOut of the total 117 articles in the final record, we excluded 11 of them because of poor quality. Thus, this systematic review synthesized the reports of 106 original articles. Overall 14, 55 and 29 of the reviewed refer to causes, effects, and solutions of ED crowding, respectively. The review also included four articles on both causes and effects and another four on causes and solutions. Multiple individual patients and healthcare system related challenges, experiences and responses to crowding and its consequences are comprehensively synthesized.ConclusionED overcrowding is a multi-facet issue which affects by patient-related factors and emergency service delivery. Crowding of the EDs adversely affected individual patients, healthcare delivery systems and communities. The identified issues concern organizational managers, leadership, and operational level actions to reduce crowding and improve emergency healthcare outcomes efficiently.

Background and Objective:Selecting the appropriate technique for surgical incisions, and reconstruction of facial defects after skin tumour excision has always been one of the surgeon's biggest concerns. The aim of this study is to compare the results between the local flap and skin graft to reconstruct cheek defects after basal cell carcinoma excision.Patients and Methods:In this retrospective study, 40 patients with skin defects resulting from skin tumour (Basal cell carcinoma) excision in cheek zones (16 sub-orbital, 18 bucco-mandibular and six auricular) were treated using local flap (n = 20) and skin graft (n = 20) from October 2010 to April 2012. All patients were followed up for 12 months, postoperatively. In addition, general assessments including complications, patient satisfaction, tissue co-ordination, skin colour and hospitalisation days were obtained.Results:Five patients had postoperative hyper-pigmentation complication in the skin graft group and none occurred in the local flap (P = 0.046). In the early postoperative period (2 weeks), mean scores in patient satisfaction, tissue co-ordination and skin colour were statistically significant increase in the local flaps (P < 0.001, P < 0.001, P < 0.001, respectively) and in the later postoperative period (12 months) only mean scores in skin colour significantly increased in the local flaps (P < 0.001). The mean postoperative length of hospitalisation days was 1.7 ± 0.4 days in the local flap group, and 3.63 ± 1.16 days in the skin graft group (P = 0.001).Conclusion:In the local flap group: Patient satisfaction, tissue co-ordination and skin colour were improved after 2 weeks. Also in 12-months follow up visits, skin colour was improved significantly and the hyperpigmentation was reduced. Generally, in this study the local flaps had better results in clinical outcomes and patient satisfaction. However, for each cheek defect the surgeon must choose the appropriate reconstruction strategy to avoid undesirable outcomes.

Background:Rapid ultrasound in shock (RUSH) is the most recent emergency ultrasound protocol, designed to help clinicians better recognize distinctive shock etiologies in a shorter time frame.Objectives:In this study, we evaluated the accuracy of the RUSH protocol, performed by an emergency physician or radiologist, in predicting the type of shock in critical patients.Patients and Methods:An emergency physician or radiologist performed the RUSH protocol for all patients with shock status at the emergency department. All patients were closely followed to determine their final clinical diagnosis. The agreement between the initial impression provided by RUSH and the final diagnosis was investigated by calculating the Kappa index. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of RUSH for diagnosis of each case.Results:We performed RUSH on 77 patients. Kappa index was 0.71 (P Value = 0.000), reflecting acceptable general agreement between initial impression and final diagnosis. For hypovolemic, cardiogenic and obstructive shock, the protocol had an NPV above 97% yet it had a lower PPV. For shock with distributive or mixed etiology, RUSH showed a PPV of 100% but it had low sensitivity. Subgroup analysis showed a similar Kappa index for the emergency physician and radiologist (0.70 and 0.73, respectively) in performing rush.Conclusions:This study highlights the role of the RUSH exam performed by an emergency physician, to make a rapid and reliable diagnosis of shock etiology, especially in order to rule out obstructive, cardiogenic and hypovolemic shock types in initial exam of shock patients.

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