Context: Caffeine is the most commonly used psychoactive legal drug in the world. Caffeine’s role in controlling pain has received less attention in the past, yet is being increasingly considered. This article briefly reviewed the literature to clarify the role of caffeine as a drug for pain control and attract investigators to this topic. Evidence Acquisition: The data on Caffeine as an adjuvant therapy or as a main component for pain modulation has been narratively reviewed. Results: Caffeine plays an important role in pain modulation through their action on adenosine receptors which are involved in nociception. The use of caffeine as adjuvant treatment was well-established in the literature and caffeine is currently available in some over the counter medications. Studies showed controversial results about the interaction between caffeine and morphine for pain relief in patients with terminal stage cancer. As a main component for pain modulation, Caffeine can be used for hypnic headache and postdural puncture headache. Conclusions: Caffeine has a potential role for pain modulation. Current evidence on caffeine use for migraine and terminal stage cancer is not well-established. Future studies should address the use of caffeine alone for different types of pain with dose escalation and standardization of outcome measurement. Keywords: Caffeine; Adenosine; Role; Pain Management

Telestroke systems are tools, used to provide an advanced stroke care in regions without sufficient neurologic services. We performed this meta-analysis to assess the effects of telemedicine on treatment times and clinical outcomes of acute stroke care. A literature search of PubMed, SCOPUS, and Cochrane CENTRAL was conducted for original studies investigating telemedicine applications in acute stroke care. Dichotomous data on treatment outcomes were pooled as odds ratios (ORs), while continuous data on thrombolysis times were pooled as mean differences (MDs) with 95% confidence interval (CI), using RevMan software (version 5.3). Pooling data from 26 studies (6605 thrombolysed patients) showed no significant differences between the telestroke and control groups in terms of in-hospital mortality (OR = 1.21, 95% CI [0.98, 1.49]), 90-day mortality (OR = 1.08, 95% CI [0.85, 1.37]), symptomatic intracranial hemorrhage (sICH) (OR = 1.10, 95% CI [0.79, 1.53]), and favorable clinical outcome at discharge (OR = 1.03, 95% CI [0.69, 1.53]) and 90 days later (OR = 0.99, 95% CI [0.82, 1.18]). The onset-to-door (OTD) duration (MD = -10.4 minutes, 95% CI [-14.79, -.01]) and length of hospital stay (MD = -0.55 days, 95% CI [-1.02, -0.07]) were significantly shorter in the telestroke group, compared to the control group. Although the overall effect estimate (under the fixed-effect model) showed a significant decrease in the onset-to-treatment (OTT) duration in the telestroke group (MD = -5.83 minutes, 95% CI [-8.57, -3.09]), employing the random-effects model for between-study heterogeneity abolished this significance (MD = -5.90 minutes, 95% CI [-13.23, 1.42]). Telestroke significantly reduced OTD and hospital stay durations in stroke patients without increasing the risk of mortality or sICH. Therefore, telemedicine can improve stroke care in regional areas with minor experience in thrombolysis. Further randomized controlled trials are needed to assess the benefits of telestroke systems, especially in terms of cost-effectiveness and quality of life outcomes.

Background: Ultrasonography (US) is recently used frequently as a tool for airway assessment prior to intubation (endotracheal tube (ETT) placement), and several indicators have been proposed in studies with different reported performances in this regard. This systematic review and meta-analysis reviewed the performance of US in difficult airway assessment. Methods: This systematic review and meta-analysis was conducted according to the guideline of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Cochrane book. All the studies that had carried out difficult airway assessments using US, had compared the indicators in difficult and easy groups, and had published the results in English by the time we conducted our search in April 28, 2020, were included. Results: In the initial search, 17,156 articles were retrieved. After deleting the duplicate articles retrieved from multiple databases, 7578 articles remained for screening based on the abstracts and titles. Finally, the full text of 371 articles were assessed and the data from 26 articles were extracted, which had examined a total of 45 US indicators for predicting difficult intubation. The most common US index was the “thickness of anterior neck soft tissue at the vocal cords level”. Also, “skin to epiglottis” and “anterior neck soft tissue at the hyoid bone level” were among the most common indicators examined in this area. Conclusion: This systematic review showed that US can be used for predicting difficult airway. Of note, “skin thickness at the epiglottis and hyoid levels”, “the hyomental distance”, and “the hyomental distance ratio” were correlated with difficult laryngoscopy in the meta-analysis. Many other indicators, including some ratios, have also been proposed for accurately predicting difficult intubation, although there have been no external validation studies on them.

Background: Many patients are brought to crowded emergency departments (ED) of hospitals every day for evaluation of head injuries, headaches, neurologic deficits etc. CT scan of the head is the most common diagnostic measure used to search for pathologies. In many EDs the initial interpretation of images are performed by emergency physicians (EP). Since most decisions are made based on the initial interpretation of the images by emergency physicians and not the radiologists, it is necessary to assess the accuracy of interpretations made by the former group. Objectives: The objective of this study was to compare the findings reported in the interpretation of head CTs by emergency physicians and compare to radiologists (the gold standard). Materials and Methods: This was a prospective cross sectional study conducted from March to May 2009 in a teaching hospital in Tehran, Iran. All non-contrast head CTs obtained during the study period were copied on DVDs and sent separately to a radiologist, 6 emergency medicine (EM) attending physicians and 14 senior EM residents for interpretation. Clinical information pertaining to each patient was also sent with each CT. The radiologist’s interpretation was considered as the gold standard and reference for comparison. Data from EM physicians and residents were compared with the reference as well as with each other and statistical analysis was performed using SPSS 18.5. Results: Out of 544 CT scans, EM physicians had 35 false negatives and 53 false positives compared with radiologist’s interpretations (P < 0.0001). EM residents had 74 false negatives and 12 false positives compared with radiologist’s interpretations (P < 0.0001). Conclusions: Both EPs and ER residents either missed or falsely called a significant number of pathologies in their interpretations. The interpretations of EPs and ER residents were more sensitive and more specific, respectively. These findings revealed the need for increased training time in head CT reading for residents and the necessity of attending continuing medical education workshops for emergency physicians. Keywords: Tomography, X-Ray Computed; Brain; Emergencies; Radiologist; Interpretation