Journal of Acute Disease

49-50

Authors: Saurabh R Shrivastava1 , Prateek S Shrivastava2

56-60

Authors: Halil Onder

Objective: To reveal the factors leading to delay in the evaluation processes of patients with suspected acute ischemic stroke at Yozgat City Hospital in Turkey and suggest potential solutions. Methods: Patients who visited the emergency service of Yozgat City Hospital between 1 April 2017 and 1 July 2017 and those hospitalized with a diagnosis of ischemic stroke, were included in this retrospective study. The clinical information of the patients was collected via hospital files and telephone interviews. In addition, the potential association between arrival time and the clinical parameters was investigated. Results: A total of 87 patients were included. The median arrival time to emergency service was 5 (IQR=9) h. Forty-four percent of patients arrived within the first 4.5 h from symptom onset. However, intravenous thrombolytic treatment was performed in only 7% of the patients. The median time from arrival to neuroimaging performing was 20.0 (IQR=34) min. Fifty-one percent of patients were screened within the first 20 min from arrival to emergency service. There was no association between arrival time and transfer method of the patients. Conclusions: The main problem regarding acute stroke care in our region may be inefficient use of emergency ambulance. This study provides basis for measures to shorten the arrival time.

67-72

Authors: Ekong Raymond Eworo1 , Edmund Richard Egbe2 , Zibril A. Okhormhe1 , Bassey K. Offor1 , Bassey Ikoedem Uduak1 , Andeshongkwe Dauda3

Objectives: To determine the anthropometric indices, lipopolysaccharide-binding proteins (LBP), and lipid profile in patients with metabolic endotoxemia. Methods: The study comprised of 47 patients with metabolic endotoxemia (the metabolic endotoxemia group) and 43 controls (the control group). Patients in the metabolic endotoxemia group were categorized further into three subgroups including the normal weight group (n=8), the overweight group (n=12) and the obese group (n=27). Height, weight, waist, and hip circumference were measured, and waist-hip ratio (WHR) and body mass index (BMI) were calculated. LBP was determined by ELISA and total cholesterol, triglycerides, high density lipoprotein by the respective enzymatic colorimetric methods. In addition, low density lipoprotein and very low density lipoprotein were determined by Friedewald’s formula. Results: The mean waist circumference (WC), hip circumference (HC), BMI, total cholesterol, low density lipoprotein, and LBP of the metabolic endotoxemia group were significantly higher (P<0.05) than those of the control group. WHR, TG, high density lipoprotein and very low density lipoprotein of the metabolic endotoxemia group were not significantly different (P>0.05) from those of the control group. The mean WC, HC, WHR, and BMI of the obese group with metabolic endotoxemia were significantly higher (P<0.05) than those of the overweight group and the normal weight group with metabolic endotoxemia. Significant positive correlations were obtained between BMI and LBP (r=0.610, P=0.001), total cholesterol and LBP (r=0.385, P=0.007), TG and LBP (r=0.356, P=0.014) in patients with metabolic endotoxemia. Conclusions: Metabolic endotoxemia arising from increased circulating level of bacterial derive particles consequent to perturbation in the gut microbial community and the elevated serum level of LBP may precede the development of obesity, characterized by dyslipidemia, dysregulation of gut energy harvest, and metabolic energy imbalance.

78-82

Authors: Sana H. Mohamed1 , Rasha R. Binni2 , Bashir A. Yousef2,3

Objective: To evaluate the management of early-onset sepsis at Saad Abul-Ella Teaching Hospital, Sudan. Methods: A descriptive retrospective hospital-based study was carried out at the Nursery Department of Saad Abul-Ella Teaching Hospital. All medical records of neonates with suspected or confirmed sepsis during the year 2017 were reviewed to evaluate the management of antibiotics for sepsis using a data collection form. Results: Out of the 205 cases, 82 neonates (40%) were diagnosed as early-onset sepsis, among which the majority was male (68%). All neonates were given cefotaxime plus vancomycin as empirical therapy which was changed to other antibiotics in 23% of the cases. The common risk factors associated with early-onset sepsis wereprolonged rupture of membrane (41.8%), preterm delivery (26.3%) and low birth weight (15.1%). Blood cultures were performed in 168 cases, and 19% had bacterial growth of Staphylococcus aureus which is the most common isolated pathogen. Conclusions: Cefotaxime plus vancomycin are the main empirical antibiotic for sepsis, and Staphylococcus aureus is the most common pathogen associated with early-onset sepsis.

89-92

Authors: Chang Chee Yik

Rationale: Burkholderia pseudomallei is a Gram-negative bacterium and the causative pathogen of melioidosis, which manifests with a broad spectrum of clinical syndromes. Melioidosis is associated with high mortality and is endemic across tropical areas, especially in Southeast Asia and northern Australia. Patient concern: A 24-year-old diabetic male complained of fever and left upper quadrant abdominal pain for one-week duration. Diagnosis: Melioidosis with ruptured splenic abscess and splenic vein thrombosis. Interventions: Antimicrobial therapy (intensive therapy: intravenous ceftazidime, eradication therapy: oral trimethoprimsulfamethoxazole), and anti-coagulation (enoxaparin, then warfarin). Outcomes: Resolution of splenic abscess and splenic vein thrombosis. Lessons: Both splenic abscess and splenic vein thrombosis are uncommon but severe complications associated with melioidosis. Ultrasound is useful for diagnosis and monitoring response to treatment in such cases.

14-19

Authors: Mehmet Süleyman Sabaz1 , Nagihan Sabaz2 , Gökhan Sertçakacılar3 , Sinan Aşar 1

Objective: To investigate the code blue application at a training and research hospital in Turkey. Methods: The code blue declaration forms and the hospital database with 238 complete records between January 2016 and July 2017 were collected. The form involved individual characteristics, the reason for issuing the code blue call, the unit and block where the code was given, time and location related properties such as working time and arrival duration, properties regarding the intervention process such as its type, duration or result. The 24-hour and 30-day long survival data of the patients to whom cardiopulmonary resuscitation was implemented were obtained from the hospital database, or from their relatives. The influencing factors of arrival duration were analyzed. Results: The median duration of arrival was 2.14 (2.00-3.02) min. Code blue applications were performed more frequently in Departments of General Surgery, Internal Medicine, Orthopaedics, and Cardiology Clinics. Half of the code blue calls were due to cardiac arrest; the other half was due to shortness of breath or respiratory distress, syncope, and respiratory arrest. Three-outof four code blue calls were treated with orotracheal intubation and cardiopulmonary resuscitation, or only orotracheal intubation or only medical treatment; one-fourth of the calls were not intervened. Altogether, 72.36% of the code blue calls patients were intervened; 69.35% of them were made both orotracheal intubation and cardiopulmonary resuscitation, and 20.5% of them were made only orotracheal intubation and 10.55% of them made only medical treatment. It was found that giving the code blue day or night had no effect on the time to reach the area where the code was given. Similarly, it was found that giving the code blue within daytime or night shift had no effect on the time to reach the area where the code was given. (P>0.05). The survival rates were 39.1% within the first 24 h and 18.1% within the first 30 d. Conclusions: Applications of code blue should be analyzed at regular intervals as clinical quality indicators. Reasons for wrong calls should be determined. The duration of reaching locations where calls are made should also be decreased.

27-32

Authors: Fatemeh Shahi1,2,3, Hajar Hamidi2 , Saeed Khoshnood4 , Golshan Mehdipour2 , Aram Asarezadegan Dezfouli2 , Ahmad Farajzadeh Sheikh2,3

Objective: To evaluate the relationship between biofilm formation and incidence of virulence determinants in clinical isolates of Enterococcus. Methods: In this cross-sectional study, the clinical isolates of Enterococcus strains were collected from the university teaching hospitals in Ahvaz, Iran from June 2017 to June 2018. Then, the prevalence of Enterococcus species, antibiotic resistance, virulence factors, and biofilm-producing ability were determined. Results: Of the 119 tested isolates, 17 (14.3%) were Enterococcus faecalis, 72 (60.5%) were Enterococcus faecium and 30 (25.2%) were other Enterococcus spp. Gelatinase was detected in 97 (81.5%) isolates, enterococcal surface protein in 41 (34.5%) isolates, serine protease in 39 (32.8%) cases, accessory colonization factor in 111 (93.3%) cases and pathogenicity islands in 17 (14.3%) cases. The biofilm formation ability was observed in 75 (63.0%) of all isolates and the association between the presence of enterococcal surface protein gene and biofilm formation was statistically significant. Higher resistance to vancomycin, gentamycin, and teicoplanin was indicated in Enterococcus faecium with 81.8%, 58.4%, and 85.7% resistance rate, respectively. All Enterococcus faecalis isolates were sensitive to teicoplanin and vancomycin. Conclusions: The presence of antibiotic-resistance with several virulence factors in Enterococcus spp has become a concern. High prevalence of enterococcal surface protein gene among biofilmproducing isolates suggests a potential relation between biofilm formation and the enterococcal surface protein gene, and further studies are needed to identify the mechanism of biofilm inhibition.

40-42

Authors: Saurabh Karmakar1 , Somnath Bhattacharya1 , Shilpi Karmakar2 , Deependra Kumar Rai1

Rationale: Extensively drug resistant Klebsiella pneumoniae is defined as resistant to least one antimicrobial agent in all but two or lesser antimicrobial categories. Patient concerns: A 58-year-old diabetic male was admitted with bilateral pneumonia. Sputum culture grew Klebsiella pneumoniae which was sensitive to only colistin on culture. Diagnosis: Acute hypoxemic respiratory failure causes bilateral pneumonia (community acquired). Intervention: The combination therapy of oral faropenem and intravenous colistin for treatment. Outcome: The patient recovered fully and is doing well on followup. Lesson: Emerging antibiotic-resistant and hypervirulent strains of Klebsiella pneumoniae should drive further studies on novel antibiotic combinations for extensively drug-resistant Klebsiella pneumonia.

233-238

Authors: Sheyda Atabaki , Mansoureh Ashghali Farahani, Shima Haghani

Objective: To determine the effect of rehabilitation education on pain, knee stiffness and performance difficulty in patients undergoing knee replacement surgery. Methods: This randomized clinical trial study was performed on 96 patients undergoing knee replacement surgery, who were randomly divided into two groups: the control group and the intervention group, with 48 patients in each group. In the intervention group, the patients received educational intervention in four stages (one day before surgery, 24 h and 48 h later, upon discharge from the hospital. In the control group, only the routine of the hospital was performed. Questionnaires were completed before and 6 weeks after the intervention. Results: The mean scores of pain, knee stiffness and performance difficulty were significantly decreased in the intervention group (P=0.01). Compared to the control group, the intervention group had a better outcome of the illness, including pain, knee stiffness and performance difficulty (P=0.001). Conclusion: Rehabilitation education could be a suitable way to improve the surgical outcomes of patients undergoing total knee replacement.

245-249

Authors: Shahram Rafie, Hosein Kaveyani, Parastoo Moradi Choghakabodi

Objective: To determine the prevalence of the recurrent stroke and its risk factors in the city of Ahvaz, Iran. Methods: The present study investigated the medical records of 389 ischemic stroke patients admitted to the Department of Neurology, Ahvaz Hospitals from March 2015 to January 2016. Patients’ information was collected. Patients who suffered recurrent stroke but survived were followed up for at least 12 months after the first attack, and their medical records were collected. Results: The incidence rate of recurrent stroke was 14.91% (n=58). There was a significant relationship between the incidence rate of recurrent ischemic stroke with atrial fibrillation (OR=2.012, P<0.05) and ischemic heart disease (OR=1.695, P<0.05). However, there was no significant relationship between recurrent stroke and age, sex, dyslipidemia, diabetes, hypertension, and cigarette smoking (P>0.05). Conclusions: Patients with a history of atrial fibrillation and ischemic heart disease were at a higher risk of recurrent ischemic stroke. The incidence can be reduced by better treatment of atrial fibrillation and active follow-up

255-259

Authors: Ali Javadi, Mohamad Reza Pourmand, Javad Hamedi, Seyyed Saeed Eshraghi

Objective: To identify the biodiversity of Nocardia species isolated from the environments of Tehran hospitals via phenotypic and PCR molecular methods. Methods: A total of 236 samples were collected from the transplantation and cancer centers of five Tehran hospitals, and the presence of Nocardia was identified by using standard protocols. Conventional tests were used for preliminary identification, and PCR amplification of the 598 bp amplicon of the 16S rRNA and sequence analysis of 16S rRNA were performed for genus and species identification. Results: From the 236 soil samples, 16 samples were identified as positive based on the culture tests, while 8 samples showed positive results based on the molecular method. The phylogenetic tree showed that the most frequent genus of Nocardia was related to Nocardia cyriacigeorgica. Conclusion: The hospital environment is a potential reservoir of a diverse range of Nocardia species. Due to the strong capability of survival, these bacteria bring a threat to the health of patients. Its identification can help physicians to implement treatments and is important for healthcare centers.

265-268

Authors: Ahmad Karimi, Behnam Karimi, Ahmad Karimifard, Nabiollah Taherimotlagh, Amin Kasraei, Mohammad Yandarani, Fatemeh Safikhani, Fatemeh Majidpour

Objectives: To investigate the epidemiology of animal bites and associated factors in Abadeh district (central Iran) from 2012 to 2018. Methods: In this cross-sectional study, 1 407 individuals with animal bites who were referred to the Abadeh Rabies Treatment Center were investigated by using the census method from 2012 to 2018. The variables included the victim’s demographic information (age, gender, occupation), the type of biting animals (dog, cat, and other animals), the domesticated and wild animals, the time of biting based on year and month, the residence location (urban or rural), the treatment status, and the anatomical location of the wounds. Results: The annual incidence rate of animal bites was 189.62 per 100 000 population. Totally 83.4% of the victims were male. The average age was (33.66±18.97) years and individuals in the age range of 36-50 years were greater at risk. Most of the animal bites were from dogs (77.8%). About two thirds (62.1%) of the bites were from household animals. A total of 57.1% of individuals lived in urban areas. Most victims were engaged in farming and animal husbandry. The highest prevalence of animal bites (37.4%) happened in the summer. None of the patients had any clinical signs of rabies. Conclusions: To reduce the incidence of animal bites, high-risk groups including farmers and ranchers should be educated about bite prevention, and it should be ensured that they are managed correctly

185-190

Authors: Surendar Ravipragasam, Deepika Chandar, Vinay R Pandit, Anusha Cheriyan

Objectives: To study the rate of survival to discharge after in-hospital cardiac arrest and its associated factors in an emergency department of a tertiary care hospital, South India. Methods: This prospective observational study was conducted between December 2016 and May 2017 among all patients above 12 years old, who suffered witnessed cardiac arrest, after arrival in the emergency department. A semi-structured questionnaire was used to collect data (socio demographic details, chief complaints, comorbidities). Initial documented rhythm, duration of CPR, use of defibrillator, and presumed cause of cardiac arrest and others were collected from the case records. Results: The study cohort contained 252 participants. The age was (50.0+17.2) years and male patients accounted for 54.4%. The most common complaint was breathlessness (29%), followed by chest pain (20.2%) and trauma (17.5%). The proportion of non-shockable rhythm (77.4 %) was higher than shockable rhythm (22.6%). Pulseless electrical activity (53.9%) was the most common initially documented rhythm. The predominant presumed cause of arrest was cardiac origin (29.7%). The overall rate of survival to discharge was 17.5%. Logistic regression analysis showed age >60 years [odds ratio (OR): 3.4, 95% confidence interval (CI): 1.03-11.22, P=0.04], males (OR: 3.45, 95% CI: 1.00-11.44; P=0.04), presumed respiratory cause (OR: 11.8, 95% CI: 1.0-160.0, P=0.05), initial rhythm ventricular fibrillation (OR: 9.1, 95% CI: 1.0-92.0, P=0.05) as individual predictors of survival rate to discharge after in-hospital cardiac arrest. Conclusions: Our study shows that less than one-fifth of patients survive to discharge after inhospital cardiac arrest. This signifies the need to identify and to make the necessary changes at all levels of organization, service delivery and patient care, so as to improve the overall survival rate following cardiac arrest.

195-199

Authors: Ali Dehghani1, Seyed Ali Pourmostafavi Ardakani2, Sara Jambarsang2, Fatemeh Majidpour2, Ahmad Karimi3, Ali Akbar Tajfirouzeh4, Seyed Mohammad Hoseini4

Objective: To investigate the epidemiological pattern of animal bites in Yazd Province, central Iran. Methods: In this cross-sectional study, 8 545 individuals with animal bites who were referred to the Yazd Province Rabies Treatment Center were investigated using the census method from April 2013 to March 2017. The variables included: demographic information, household living condition, the type of biting animals, the domesticated and wild animals, the time of biting based on year, the residence location (urban or rural), and the treatment status. Data were analyzed by descriptive statistics using Excel 2013, SPSS version 25 and Arc GIS 14.1 Software. Results: A total of 8 545 cases of animal bites were reported in Yazd province from 2013 to 2017. The most animal bites (with 4 253 case of bites) and the lowest animal bites (with 121 case of bites) occurred in Yazd and Bahabad district, respectively. The incidence of animal bites was 168.4 per 100 000 people during the five-year period. Most of cases (73.9%) occurred in urban areas. Dog and cat bites accounted for 47.6% and 47.4% of all cases, respectively. Most of animal bites were reported in the summer (29.4%). Sixty percent of the cases received incomplete treatments, while 40% of them received complete treatments. During this study, three positive cases of fatal rabies from dog bites were reported. Conclusions: The incidence of animal bites is high in Yazd province, and more patients are bitten by dog and cat. Hence, educational, preventive, and informative programs are required to reduce the incidence of animal bites.

204-207

Authors: Santosh Kumar Swain1, Alok Das1, Jatindra Nath Mohanty2

Objective: To assess acute otitis media with facial nerve paralysis, its prognosis, and treatment. Methods: It is a retrospective study. Thriteen patients of acute otitis media associated with facial nerve paralysis attended the outpatient department of otorhinolaryngology between May 2017 and April 2019. All patients were clinically assessed with appropriate investigations, prognosis, and treatment. Results: Out of 13 patients, 2 were identified with complete facial paralysis and the remaining 11 patients presented with incomplete paralysis. Medical treatment including antibiotics and corticosteroids failed, while myringotomy and facial nerve decompression were done with a favorable outcome. Eleven patients recovered to grade-I (House-Brackmann) and 2 cases to grade-II (House-Brackmann). Conclusion: Peripheral facial nerve paralysis in acute otitis media is rare. Antibiotics and steroids yield good outcome as conservative

215-220

Authors: Yasser Mohammed Hassanain Elsayed

Rationale: Acute myocardial infarction in the presence of right bundle branch block. Patient concerns: A 70-year-old, male heavy smoker presented with angina and hypertension. Interventions: Electrocardiography, intravenous nitroglycerin infusion, intravenous streptokinase infusion. Diagnosis: Acute myocardial infarction in the presence of with changeable trifascicular heart block. Outcomes: Dramatic clinical improvement with electrocardiographic ST-segment (whether elevation or reciprocal ST-depression) resolution. Lessons: Acute myocardial infarction may be associated right bundle branch block. Accompanied trifascicular heart block had pre-streptokinase left anterior fascicular block with left axis deviation and post-streptokinase left posterior fascicular block with right axis deviation.

142-145

Authors: Abdullah Keyfo Kama1, Hakan Oguzturk2, Burak Mete3, Bulent Gungorer2, Miray Ozlem2, Afsin Emre Kayipmaz2, Ishak San4

Objective: To analyze the epidemiological and clinical data of patients who were admitted to Inönü University Turgut Özal Medical Center Emergency Department with bites and stings between 2013 and 2015. Methods: Patients with bites and stingings who were admitted to Inönü University Turgut Özal Medical Center during 2013-2015 were selected for this retrospective evaluation. We retrived the following information including age, gender, anatomic localization of the sting or bite, admission time, complaints, vital signs, length of stay, laboratory findings and hospitalization department. Pearson’s chi-square test, Fisher’s exact test, One-way ANOVA test and the Bonferroni correction as post hoc were used for statistical analysis. Results: The mean age of the patients was (43.51±16.90) years, and 55% were male. The most common admission reason was pain (34.7%), followed by rash (19.1%) and panic (11.6%). A total of 16.8% of the admissions occurred in July, 16.8% in August and 16.5% in June while the occurrence was the lowest in November with 1.5%. The most prevalent bites or stinging animals were scorpions (34.6%), followed by ticks (19.7%) and bees (12.9%). Antihistaminic-steroid-tetanus and analgesic-antihistaminic-steroid combinations were administered, respectively to 59.6% and 25% of the patients. The longest length of stay was (48.56±26.92) h due to snake bites. Conclusions: The community should be educated about the living areas of these animals, the seasons and hours in which they are active. Since individuals living and working in rural areas are at risk, more education should be given to them.

153-159

Authors: Seyed Hamid Madani1, Mitra Tarlan1, Hadi Mozafari2, Sedigheh Khazaei3, Farhad Shaveisi-Zadeh1, Shahab Mozafari2

Objective: To investigate the diagnostic value of platelet parameters in acute appendicitis. Methods: This retrospective case-controlled study was performed among 200 healthy people and 200 patients with a primary diagnosis of acute appendicitis between October 2017 and June 2018. The patients were classified into three groups: the acute complicated appendicitis (suppurative and gangrenous) group, acute non-complicated appendicitis group and the control group. Red blood cell, white blood cell, lymphocyte, monocyte and platelets count, red blood cell distribution width, hemoglobin, hematocrit, mean platelet volume, platelet distribution width, and C-reactive protein were compared between the groups. Results: Thirty-nine (19.5%) patients with acute appendicitis had no complication and 161 (80.5%) developed a complication. The white blood cell count, neutrophil count and C-reactive protein serum levels were significantly higher, whereas the mean age, lymphocyte count, monocyte count, red blood cell distribution width and platelet count were significantly lower in acute appendicitis patients with and without complications compared with the control group. Moreover, combined analysis of best diagnostic parameters (white blood cell, neutrophil and lymphocyte counts) showed that combined parallel sensitivity and specificity were 98.7% and 42.7%, respectively. Conclusions: White blood cell, lymphocyte counts and neutrophil count could be used for diagnosis of acute appendicitis. More over the utility of mean platelet volume for differential diagnosis might be overestimated.

165-169

Authors: Shivali Panwar, Aashish Dang

Objective: To evaluate the epidemiology, clinical profile and treatment for patients with snake bite in the intensive care unit of our hospital. Methods: A retrospective analysis of patients with snake bite admitted to the intensive care unit of a tertiary care hospital, North Delhi, was conducted between January 2013 and October 2018. Their demographic profile, time and site of bite, clinical manifestations and time interval between the bite and anti-snake venom administration were recorded. Results: A total number of 102 patients with snake bite were studied, of which 54.9% were males and 45.1% were females. Most patients were presented in the monsoon season and snake bites occurred mainly in the night and early morning. A total of 56.3% of the patients with clinical manifestations received anti-snake venom within 3 h after the snake bite. Most patients presented with painless bites and neuroparalytic features with ptosis that was the most common clinical manifestation (50.9%). Anti-snake venom was administered to 55 patients (53.9%) with an average dose of 42 vials per patient and the mortality was 11.7%. Conclusions: Neuroparalytic krait envenomation accounted for the highest incidence of venomous bites in our study. Early medical treatment with judicious anti snake venom administration and related education is crucial.

173-175

Authors: Mehdi Zolfagharkhani1, Alireza Sanei Motlagh2, Sahar Oladzade1, Arefeh Babazadeh3, Soheil Ebrahimpour3

Rationale: Gastropericardial fistula is a rare condition in which the patient presented with chest pain, dyspnea, tachycardia, pneumo/hydropericardium, or pericarditis. Alcohol intake or previous history of gastroesophageal surgery made the patient susceptible to fistula formation. Patient concerns: An 80-year-old male complained of sudden onset of dyspnea and respiratory distress. Nausea, hematemesis, and constipation were noted on clinical examination. Diagnosis: Herniation of the gastric fundus and massive pneumopericardium due to formation of fistula in the lesser curvature. Interventions: Urgent surgery was performed. Outcomes: The patient was discharged without any complication. Lessons: Although the lethal form of this condition is rare, gastroepicardial fistula should be included in the differential diagnosis workup of cases with stomach cardia and fundus ulceration.