Journal of Acute Disease

222-227

Authors: Mansoreh Kokhaei, Hesameddin Modir, Esmail Moshiri, Mehran Azami

Objective: To compare effect of intrathecal meperidine, tramadol, magnesium sulfate, and dexmedetomidine on the prevention of postspinal anesthesia shivering and adverse events in hip fracture repair patients. Methods: In a randomized, double-blind trial, 132 patients with American Society of Anesthesiology (ASA) I and II spinal anesthesia who needed hip fracture surgery were enrolled. Patients were stratified into 4 intervention groups based on a randomized block pattern: meperidine, tramadol, magnesium sulfate, and dexmedetomidine. Hemodynamic parameters including blood pressure, heart rate, and oxygen saturation, as well as the severity of shivering, core body temperature, Ramsay sedation score, adverse events, meperidine consumption were recorded and compared. Results: There was no statistically significant difference in the normal hemodynamic parameters, temperature, duration of surgery, meperidine consumption, and adverse events such as dizziness, hypotension, nausea, and bradycardia among groups (P>0.05). Compared to other groups, severity of shivering was the lower in the dexmedetomidine group 6 and 8 h after surgery. The Ramsay sedation scores were higher in the dexmedetomidine and meperidine groups 4 h after surgery (P=0.020). Conclusion: Dexmedetomidine acts better than the other three adjuvants in reducing complications such as shivering. Overall, these four adjuvants are helpful to prevent postoperative shivering and could be put forward as promising local anesthetics in spinal anesthesia, based on anesthesiologists’ discretion and patients’ general conditions. Clinical registration: The study was approved by the Research and Ethics Committee at the Valiasr Hospital (Arak, Iran) with the clinical trial code of IRCT20141209020258N153.

236-242

Authors: Zeynep Ergenc, Hasan Ergenc, Ahmet Öztürk, Gülsüm Kaya, Özlem Karaca Ocak, Özgür İnce

Objective: To investigate the clinical symptoms of coronavirus disease 2019 (COVID-19) patients with and without B.1.1.7 mutation. Methods: This retrospective observational study included COVID-19 patients who were divided into two groups, the mutation and the non-mutation group. Demographics characteristics, clinical characteristics, laboratory parameters, and mortality rates were recorded and compared between the two groups. Results: A total of 196 patients were included in the study. The relationship between the mutant virus status and sex, age, comorbidity, survival status, and disease severity was not significant (P>0.05). No significant differences were found in duration of hospitalization between the mutation and the non-mutation group (P>0.05). However, there was a statistically significant difference between patients with and without mutant viruses in hemoglobin, mean platelet volume, procalcitonin, low density lipoprotein, ironbinding capacity, potassium, calcium, C-reactive protein, folate, creatine kinase myocardial band, D-dimer, and international normalized ratio (P<0.05). Conclusions: No significant difference is found in mortality rate, disease severity or duration of hospitalization between the patients with and without variant B.1.1.7. Careful monitoring of COVID-19 patients is required for all variants.

247-250

Authors: Wasim S Shaikh, Ayesha Shaikh, Sachin Sasane, Zeyad Al Rais, Mohammed Ali Baqer

Rationale: Acute iron poisoning is commonly seen in a pediatric population caused by accidental ingestion of iron syrups. We describe a case of iron poisoning who presented to the hospital following intentional near-fatal ingestion of ferrous sulfate. Patient’s Concern: A 14-years-old previously healthy female patient presented to the emergency department with a history of an intentional overdose of 80 ferrous sulfate tablets. Diagnosis: Ferrous sulfate poisoning. Interventions: The patient developed acute fulminant liver failure 24 h after of the overdose. She was managed conservatively, mainly with deferoxamine and N-acetylcysteine while awaiting transfer to a liver transplant facility. Outcomes: The patient responded well to medical therapy and was discharged on the 9th day of intensive care unit admission. Lessons: This case highlights the patient’s successful recovery with prompt conservative therapy. Severe iron toxicity can be treated with early use of deferoxamine and N-acetylcysteine where a liver transplant facility is not available.

254-255

Authors: Rajeev Ranjan, Soumya Jagannath Mahapatra, Tushar Sehgal

NA

173-180

Authors: Abhijit Nair, Hamed Humayid Mohammed Al-Aamri, Osama Azmy Ishaq, Parwez Waseemul Haque

Objective: To compare the benefits of enhanced recovery after surgery (ERAS) pathways with traditional pathways for adult patients undergoing laparoscopic appendectomy. Methods: We looked for publications using the keywords “Enhanced Recovery After Surgery,” “Fast-track Surgery,” “Laparoscopic Appendectomy,” and “Laparoscopic Appendicectomy” in PubMed/Medline, Embase, and the Cochrane library. Operative time, lesser length of stay, oral intake timing, readmission rate, pain/satisfaction levels, readmission rate, and surgical site infections were recorded and analyzed. Results: A total of 95 articles from registers and 161 articles from databases were identified. Three eligible studies were included. The ERAS pathways had a lesser length of stay [Z=2.06, MD= -1.05, 95% CI=(-2.04, -0.05), P=0.04] and an earlier start to postoperative feeds [Z=6.22, MD= -267.49, 95% CI=(-351.80, -183.19), P<001]. Conclusions: ERAS pathways have a shorter length of stay and earlier postoperative feed initiation for adult patients undergoing laparoscopic appendectomy compared with standard care. Both approaches have similar operative time, surgical site infection incidence, and readmission rate. Clinical registration: This review is registered with INPLASY202280005.

188-193

Authors: Priyanka Rajmohan, Unnikrishnan Uttumadathil Gopinathan, Nada Parvin Ashraf Saudha, Maria Jose, Lucy Raphael, Joe Thomas

Objective: To determine the real-world effectiveness of the ChAdOx1 nCoV-19 coronavirus vaccine in preventing severe disease and mortality due to COVID-19. Methods: A case-case design was used to estimate the effect of the ChAdOx1 nCoV-19 coronavirus vaccine on severe SARS-CoV-2 outcomes in individuals aged 40 years and above.Cases (n=200) were COVID-19 patients admitted to intensive care unit (ICU) or who died. Controls (n=223) were those with mild COVID-19, fit for home isolation. The logistic regression model was used to estimate adjusted vaccine effectiveness for full vaccination (two doses ≥14 d) and partial vaccination status (one dose ≥14 d or two doses <14 d). Results: The proportion of fully vaccinated individuals was significantly lower among cases (12, 6.0%) compared to controls (30, 13.5%). The adjusted effectiveness of a full dose of ChAdOx1 nCoV-19 coronavirus vaccine in preventing ICU admission or death was 81.9% (95% CI: 61.3%-91.6%, P=0.001). Subgroup analysis restricted to age group, sex, and comorbidities found that ChAdOx1 nCoV-19 coronavirus vaccine had a significant positive effect in all subgroups and categories. Conclusion: COVID-19 vaccination reduces ICU admissions or death. Therefore, increased vaccine uptake may reduce the severity of the pandemic, more so in the elderly and those with comorbidities.

199-201

Authors: Abhyuday Kumar, A. Valiyaparambath, Neeraj Kumar, Amarjeet Kumar, Ajeet Kumar

Rationale: The gastrointestinal manifestations of COVID-19 include anorexia, nausea, vomiting, abdominal pain, and diarrhea. However, pancreatitis as the presentation of COVID-19 is rarely reported. Patient’s Concern: A 63-year-old COVID-19 patient presented with complaints of abdominal pain and difficulty breathing for 5 d. Diagnosis: Contrast-enhanced computed tomography of the abdomen suggested acute interstitial pancreatitis without any biliary tract obstruction. Interventions: The patient was resuscitated with intravenous fluids based on dynamic parameters of fluid responsiveness. The patient was started on enteral feeding, analgesics, antibiotics, dexamethasone, low molecular weight heparin, and supportive therapy. Outcomes: The patient developed severe acute respiratory distress syndrome and died 6 days after admission. Lessons: Management of COVID-19 in the presence of pancreatitis is challenging. Adequate early fluid resuscitation is an important aspect of medical management for COVID-19 patients with pancreatitis and restrictive strategies must be followed. Increased liver enzymes and renal dysfunction in acute pancreatitis can also limit the use of specific therapies like remdesivir. Dexamethasone, even though it has shown a beneficial effect in treating COVID-19, can have an additive effect in causing hyperglycemia in these cases. Clinicians should be aware of this atypical presentation of COVID-19 with pancreatitis and adjust their management strategies, keeping in mind the considerations for both diseases.

206-208

Authors: Shenoy Manjunath Mala, Bendigeri Mukhthar Ahmed

Rationale: Symmetrical peripheral gangrene is a rare acute condition triggered by several medical conditions. It needs to be recognized early and treated as an emergency. Patient’s Concern: A 40-year-old patient without any comorbidities presented with sudden onset of pain, swelling, blistering and bluish discoloration of the fingers and toes associated with fever and constitutional symptoms. Later the fingers and toes turned dark and they were cold to touch. Diagnosis: Diagnosis of symmetrical peripheral gangrene was made and investigated. Blood culture isolated Escherichia coli indicating a possible role in the causation of symmetrical peripheral gangrene. Interventions: Patient was managed with antibiotics and anticoagulants along with supportive care. Outcomes: There was improvement in patient’s general condition along with development of gangrene demarcation line of the fingers and toes. Lessons: Awareness of this condition is needed and an early management is recommended including recognizing the cause and supportive therapy to prevent complications.

127-132

Authors: Abdel-Hady El-Gilany, Eman Sameh, Hala S Abou-ElWafa

This narrative review aims to highlight some of the factors contributing to challenges faced by many countries in controlling the spread of COVID-19 pandemic that continues to rage around the world, especially after stoppage of official prevention and control activities. A literature search was conducted on PubMed, and Google using search terms “COVID-19”, “challenges”, “prevention”, and “control” in different combinations. COVID-19 prevention and control challenges are related to health-system, vaccines, administration, and society culture. Controlling the spread of COVID-19 necessitates cooperation between community leaders, healthcare professionals, religious leaders, and the public.

140-149

Authors: Imene Adouani, Tassaadit Bendaoud, Hadjer Belaaliat, Wahiba Teniou, Faiza Keriou, Farida Djabi

Objective: To identify helpful laboratory paprameters for the diagnosis and prognosis of COVID-19. Methods: An observational retrospective study was conducted to analyze the biological profile of COVID-19 patients hospitalized in the Unit of Pulmonology at Setif hospital between January and December 2021. Patients were divided into two groups: the infection group and the control group with patients admitted for other pathologies. The infected group was further divided according to the course of the disease into non-severe and severe subgroups. Clinical and laboratory parameters and outcomes of admitted patients were collected. Results: The infection group included 293 patients, of whom 237 were in the non-severe subgroup and 56 in the severe subgroup. The control group included 88 patients. The results showed higher white blood cells, neutrophils, blood glucose, urea, creatinine, transaminases, triglycerides, C-reactive protein, lactate dehydrogenase, and lower levels of lymphocyte, monocyte and platelet counts, serum sodium concentration, and albumin. According to ROC curves, urea, alanine aminotransferase, C-reactive protein, and albumin were effective diagnosis indices on admission while neutrophil, lymphocyte, monocyte, glycemia, aspartate aminotransferase, and lactate dehydrogenase were effective during follow-up. Conclusions: Some biological parameters such as neutrophil, lymphocyte, monocyte, glycemia, aspartate aminotransferase, and lactate dehydrogenase are useful for the diagnosis of COVID-19.

156-160

Authors: Praphull Deepankar, Govind Kumar, Jyoti Kr Dinkar, Rishav Mittal

Objective: To explore risk factors of mucormycosis in COVID-19 recovered patients. Methods: A total of 101 patients, who were diagnosed with mucormycosis after recovery from COVID-19 and admitted to the Indira Gandhi Institute of Medical Sciences, Patna, a tertiary care hospital in India, were included in the study. The presenting clinical features and associated risk factors were assessed and analyzed subsequently. Results: Of 101, 68 (67.3%) were males, and 33 (32.7%) were females. A total of 89 (88.1%) patients were between 46 and 65 years old. The most common subtypes were rhino-ocular (61.4%), followed by paranasal sinuses (16.8%), rhino-ocular cerebral (16.8%), ocular (3.0%), and pulmonary (2.0%). Diabetes mellitus was present in 71% of cases of mucormycosis as co-morbidities. A total of 76.2% of patients were given systemic corticosteroids in oral or intravenous form during COVID-19 treatment. Severe COVID-19 was present in 45.5% of patients with mucormycosis, while the moderate infection was present in 35.6% of mucormycosis. Most patients had gap between the onset of mucormycosis and COVID-19 <15 d. Conclusions: A lethal confluence of uncontrolled diabetes mellitus, corticosteroid usage, and COVID-19 could cause a dramatic rise in mucormycosis. So, clinicians must be aware of these risk factors in patients suffering as well as recovering from COVID-19 to prevent mucormycosis.

165-167

Authors: Arshi Syal, Samiksha Gupta, Monica Gupta, Gautam Jesrani, Yajur Arya

Rationale: Delayed post-hypoxic leukoencephalopathy (DPHL) is usually an overlooked condition, which arises as a result of a multitude of reversible and irreversible conditions. Patient’s Concern: A 50-year-old female with a history of epilepsy, who developed DPHL 12 days after respiratory failure secondary to barbiturate toxicity. Diagnosis: DPHL on magnetic resonance imaging of the brain. Interventions: Mechanical ventilation was initiated for respiratory failure and hemodialysis for barbiturate toxicity. Outcomes: The patient developed akinetic mutism due to infirmity and had a residual disability, which led to permanent dependency. Lessons: The diagnosis of DPHL is often delayed or missed, given the rarity of this condition and its inconsistent clinical symptomatology. Diagnostic delay can be avoided by early recognition of the classical “delayed onset” symptoms.

94-100

Authors: Hesameddin Modir, Esmail Moshiri, Mehran Azami, Tayebe Sadat Sayafi-Sharifi

Objective: To compare the efficacy of midazolam, fentanyl, and magnesium sulfate as adjuvants to intrathecal bupivacaine on both block characteristics and postoperative analgesia in knee arthroplasty. Methods: This randomized double-blind clinical trial recruited spinal anesthesia patients of the American Society of Anesthesiologists class I or II, who needed knee arthroplasty. Patients were stratified into three intervention groups, including the midazolam group, the fentanyl group, and the magnesium sulfate group, and the patients were administered with midazolam, fentanyl, and magnesium sulfate, respectively. Hemodynamic parameters, sensory and motor block, and pain score (Visual Analogue Scale) were measured and compared among the three groups. Results: A total of 105 patients were included in this study with 35 patients in each group. There was no statistically significant difference in terms of oxygen saturation, mean blood pressure, duration of surgery, and postoperative complications, including nausea, vomiting, bradycardia, dizziness, and hypotension, as well as the time of opioid administration among the three groups (P>0.05). Statistically significant differences were found in terms of heart rate at 15, 30, 45, 60, 75, and 105 min after beginning of operation among the three groups, which was lower in the midazolam group (P<0.05). The midazolam group showed a shorter time to achieve sensory block after spinal anesthesia, sensory block to T8 or higher and sensory block to T12 and L1 (P<0.05). Besides, the three groups showed significantly differences in terms of onset of motor block after spinal anesthesia and time to achieve motor block to T8 or higher or Bromage score 3 (P=0.001). No significant difference was noted in pain scores among the three groups (P>0.05). Conclusion: Midazolam resulted in a shorter time to achieve sensory and motor block to T8 or higher, the onset of motor block and sensory block after spinal anesthesia, and time to achieve sensory block to T12 and L1, and the pain scores were not significantly different among the groups. Thus, midazolam can be highly underlined, if a shorter onset of sensory and motor blocks is targeted. [Funded by the research deputy of Arak University of Medical Sciences (No.99258); fa.irct.ir number, IRCT20141209020258N164].

107-114

Authors: Mariam M Alwerdani, Emtenan A Said, Wesam A Dosoky, Radwa Sehsah, Abdel-Hady El-Gilany

Objectives: To assess the knowledge, attitude, and practice (KAP) towards COVID-19 and its associated factors among house officers. Methods: A multicentered crosssectional study on house officers was carried out using an online self-administered questionnaire. Sociodemographic data and data related to KAP towards COVID-19 were collected. Besides, KAP level of the house offices was recorded and factors associated with good KAP were determined. Results: This study included 555 house officers from 10 different hospitals with 128 males and 427 females. Almost half of the house officers had good knowledge and a favorable attitude (46.1% and 51%, respectively) on COVID-19. Still, 82.5% of them were committed to good practice of preventive measures. Besides, percentages of good knowledge and practice among those with chronic diseases or those who knew someone infected with SARS-CoV-2 were higher, but the differences were not statistically significant (P>0.05). In addition, the percentages of females with good practice were higher than those of males, with no statistical difference (P>0.05). Conclusion: House officers showed a good KAP towards COVID-19. Being aware of gaps in KAP can help to effectively contain the current pandemic.

120-122

Authors: Prabhat Agrawal, Ashish Gautam, Anjana Pandey, Harendra Kumar, Nikhil Pursnani

Rationale: COVID-19 usually presents with flu-like symptoms and signs, but some rare presentations like leukemoid symptoms cannot be ignored. Patient’s concerns: A 37-year-old female presented to the outpatient department with flu-like symptoms. Diagnosis: The RT-PCR test for SARS-CoV-2 infection was positive, while complete blood cell and peripheral blood smear showed leukemoid reaction. Intervention: Paracetamol and fexofenadine for flu-like symptoms and leukemoid presentation. Outcomes: On the 10th day, the patient was asymptomatic and RT-PCR was negative. So the patient was discharged and leukemoid presentation subsided after clearance of viral disease. Lessons: COVID-19 has a myriad of presentations, and unusual symptoms/signs especially in this pandemic could be induced by COVID-19 infection.

127-128

Authors: Marianne Shahsuvaryan

NA

52-58

Authors: Duygu Akyol1 , Zafer Cukurova2 , Evrim Kucur Tulubas2 , Güneş Özlem Yıldız 2 , Mehmet Süleyman Sabaz

Objective: To investigate the effects of perioperative goal-directed fluid therapy (GDFT) on intraoperative fluid balance, postoperative morbidity, and mortality. Methods: This is a prospective randomized study, and 90 patients who underwent elective open gastrointestinal cancer surgery between April 2017 and May 2018 were included. Patients were randomized into 2 groups that received liberal fluid therapy (the LFT group, n=45) and goal-directed fluid therapy (the GDFT group, n=45). Patients’ Colorectal Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity (CR-POSSUM) physiological score, Charlson Comorbidity Index (CCI), perioperative vasopressor and inotrope use, postoperative AKIN classification, postoperative intensive care unit (ICU) hospitalization, hospital stay, and 30-day mortality were recorded. Results: The volume of crystalloid used perioperatively and the total volume of fluid were significantly lower in the GDFT group compared to the LFT group (P<0.05). CR-POSSUM physiological score and CCI were significantly higher in the GDFT group (P<0.05). Although perioperative vasopressor and inotrope use was significantly higher in the GDFT group (P<0.05), postoperative acute kidney injury development was not affected. Postoperative mortality was determined to be similar in both groups (P>0.05). Conclusion: Although GDFT was demonstrated to be a good alternative method to LFT in open gastrointestinal cancer surgery, and it can prevent perioperative fluid overload, and the postoperative results are comparable in the two groups.

65-70

Authors: Hamissou Moussa Maman Roufai, Jun Yang, Guang-Fu Song , Fu-Yi Yang

Objective: To investigate the effect of cold weather on carotid artery stenosis and occlusion. Methods: We conducted a retrospective observational study, in which 145 patients with carotid artery stenosis and occlusion were enrolled [115 men and 30 women; the mean age was 61.08 years (95% CI 59.27-62.88)]. Patients were divided into the lowtemperature group (n=98) (≤12曟) and the non-low temperature group (n=47) (>12曟). Clinical characteristics, blood pressure, National Institutes of Health Stroke Scale (NIHSS), blood fat, and blood viscositys were compared between the two groups. Correlation between NIHSS and mean daily temperature was analyzed. Results: There was no significant difference in the systolic and diastolic blood pressure between the two groups (P>0.05). The NIHSS score was slightly higher in the non-low temperature group compared to that of the low-temperature group (U=2 984, P<0.01). Glycemia, cholesterol level, prothrombin time, fibrinogen, and International Normalized Ratio did not show any significant difference (P>0.05). Correlation analysis showed a very low positive and statistically significant correlation between ambient temperature and NIHSS score (r=0.18, P=0.029). Conclusion: Cold weather does not impact blood pressure, blood cholesterol, and coagulation factors of patients with carotid artery stenosis and occlusion. The neurological deficit is more severe in the non-low ambient temperature group. A potential relationship exists between ambient temperature and the level of neurological impairment.

71-76

Authors: Nalini Ramesh Humaney, Shilpa Sachin Kuthe, Shamim Akhtar, Vivek K Pande

Objective: To determine the association between body weight and COVID-19 outcomes. Methods: This is a retrospective cohort study of COVID-19 patients admitted in a dedicated COVID-19 hospital, a tertiary health care center, between May and June 2021. Demographic data and baseline variables, including age, sex, body mass index (BMI), and comorbidities were collected. Outcomes (death or mechanical ventilation) of the patients with different BMI, age, comorbidities, and qSOFA scores were compared. Besides, the risk factors for death or mechanical ventilation were determined. Results: The mean age of the subjects was (51.8±14.7) years old, and 233 (74.2%) were male. There were 103 (32.8%) patients with normal weight, 143 (45.5%) patients were overweight, and 68 (21.7%) patients were obese. In-hospital deaths and need of mechanical ventilations were significantly higher in the obese and the overweight group compared to the normal weight group, in age group ≥65 years compared to <65 years, in patients with ≥1 comorbidities compared to patients without comorbidities, in patients with qSOFA scores≥2 compared to patients with qSOFA scores<2. There was a significantly increased risk of death (RR: 4.1, 95% CI 1.0-17.4, P=0.04) and significantly increased need of mechanical ventilation (RR: 5.2, 95% CI 1.8-15.2, P=0.002) in the obese patients compared with those with normal weight after controlling other covariates. Conclusion: Obesity is one of the significant risk factors for adverse outcomes in COVID-19 patients and should be considered during management

88

Authors: Godpower Chinedu Michael

Non