West Nile virus (WNV) is found in 26 provinces of Iran in humans, horses, and birds. Due to lack of vaccines, the only method to reduce the risk of the disease in communities is to increase people’s awareness. Lack of killing and overhunting of animals does not alter the infected-blood transmission from animals to humans by mosquito bites, but can reduce disease transmission risks including the transmission of West Nile fever (WNF) to humans. WNV is an enveloped Flavivirus that in nature has an enzootic cycle between mosquitoes and birds. The virus has occasional epizootic spillover causing disease in humans and horses. WNV-transmitting mosquitoes are widespread around the world, and the geographical range of transmission and the disease has increased over the past seven decades. Most human infections with WNV are asymptomatic, but severe neurological disease may develop resulting in long-term complications or death. Given the increasing trend of reported human WNF cases, it is necessary to implement surveillance programs and increase awareness of people and health staff about the function of biological factors including carnivores in the hunting of infected animals and collecting their carcass from nature. Hunting and killing of birds and dogs living near humans increase both the risk of deviation of blood-feeding of the zoophilic mosquitoes to humans and the outbreak of the disease.

Objective: To assess knowledge, attitude, and practice of medical students towards coronavirus disease 2019 (COVID-19). Methods: A self-designed questionnaire was developed and given to the students of a government medical college in Uttarakhand. The demographics, mean knowledge, attitude, and practice of the participants were investigated, and the scores were calculated. t-test and ANOVA were used for statistical analysis. Results: Out of the total participants (n=354), 50.3% were male and 54.5% were 21-23 years. Almost all the participants (96.6%) increase the frequency of washing hands under the influence of COVID-19. Although no significant relationship was found between different religions, age-categories in terms of knowledge, the participants who were aged 21-23 years had higher knowledge. In addition, gender had a significant impact on practice scores (P<0.05) while no demographic variable was found to have a significant relation with attitude score (P>0.05). Conclusions: The majority of the participants had good knowledge, positive attitude, and sufficient practice. Females and males have significantly different practices. Although the results are very positive, it is suggested that people should continue to strengthen knowledge, attitude, and practice towards COVID-19, so that India can win the battle against the disease.

Objective: To evaluate the factors resulting in the poor outcomes in patients with extradural hematoma (EDH). Methods: The study was conducted at the Neurosurgery Teaching Hospital in Baghdad with a group of 100 surgically treated EDH patients and was carried prospectively from February 1st, 2015 to May 1st, 2017. The baseline information (gender, age, cause of injury, time interval between injury and reception, Glasgow coma scale, etc.) of the patients was recorded, and the variables affecting the outcomes were analyzed. Results: In the study, 80% of patients were male; 54% were between 10-29 years old; the commonest cause of injury was fall accounting for 51%; 78% of the patients got good functional recovery, and 10% had a residual disability; 12% died. Better functional recovery was found among patients with a shorter time interval (≤3 h) (P=0.001), while the longer time interval (>3 h) increased the residual disability (P=0.005). In addition, functional recovery increased six times with higher Glasgow coma scale (P=0.001), and inversely related to mortality (P=0.005). Conclusions: Age between 10 and 29 years, male gender, and depth of hematoma more than 5 cm are at higher risks of poor outcomes of patients with surgically treated EDH. Neurological conditions on admission and time interval between injury and reception are also important factors.

Objective: To evaluate the clinical profiles, diagnosis, and treatment of patients with acute epiglottitis at a tertiary care teaching hospital of eastern India. Methods: This is a retrospective study in which 28 patients of acute epiglottitis participated. This study was conducted between January 2016 and October 2019. The diagnosis of acute epiglottitis was based on the clinical presentations and fiberoptic laryngoscopic examinations of the larynx and hypopharynx. Details of age, gender, personal history, clinical symptoms, treatment, and hospital stay were evaluated. Results: Out of the 28 patients with acute epiglottitis, 17 (60.71%) were male and 11 (39.29%) were female with age ranged from 4 years to 62 years and a mean age of 23.45 years. The median duration from the onset to resorting to physicians is 3 d. Among the 28 patients, 4 patients (14.29%) were under the treatment for diabetes mellitus. Four cases (14.29%) required airway management with intubation and tracheostomy. Conclusions: Acute epiglottitis is an acute infectious condition of the supraglottis and may lead to airway obstruction. Clinical presentations alone are insufficient for the diagnosis of acute epiglottitis. Fiberoptic nasopharyngolaryngoscopic examination should be performed as soon as possible for confirmation of the disease.

Objective: To define the level of alarm threshold for pertussis aberrations and to detect the aberrations of the reported suspected cases of pertussis from the Mazandaran province in the north of Iran. Methods: The included cases were composed of the suspected pertussis patients who came from Mazandaran province and registered in the Center for Disease Control and Prevention from 20 March 2012 to 20 March 2018. A discrete wavelet transform- based method was used to detect the aberrations. All analyses were performed using MATLAB Software version 2018a and Excel 2010. Results: A total of 1 162 cases were recruited in the study, including 545 (46.90%) males and 617 (53.10%) females, with median age of 1.47 (0.22-9.56) years. The median age of males was 1.18 (0.21-8.24) years, while that of females was 1.82 (0.21-10.75) years. Concerning the level of the alarm threshold, it was 1.28 case/d when k=2, while it was 1.34 case/d when k=3. The total detected aberration days were 123 d and 57 d by considering k=2 and 3, respectively. The most defined alarm threshold was related to spring (>2 cases/d) and summer (>1 case/d), respectively. Conclusions: The sensitivity of the surveillance system is subjected to a different time. Thus, determining the level of alarm threshold periodically using different methods is recommended.

Objective: To identify the pathogenic gene of Panton-Valentine leukocidin in methicillin-resistant Staphylococcus aureus strain isolated from clinical specimens of burn patients in Shaheed Zare Burn Hospital. Methods: A total of 104 samples of Staphylococcus were collected and 78 aureus samples were isolated from Zare Hospital patients from November 2016 to July 2017. All isolates were identified using a standard biochemical and laboratory methodology in accordance with CLSI principles, and disk agar diffusion antibiogram were performed to identify methicillin resistant colonies. Then the presence of the Panton-Valentine leukocidin gene was tested by PCR. Results: Of the methicillin-resistant Staphylococcus aureus samples, 80% were negative for the Panton-Valentine leukocidin gene, and only 20% of the samples had Panton-Valentine leukocidin gene. Male and female patients showed no significant difference in the positivity rate of Panton-Valentine leukocidin gene (16.12% vs. 33.33%) (P=0.25). Besides, there was no significant difference in bacterial resistance or susceptibility to antibiotics between samples with or without the Panton-Valentine leukocidin gene. Conclusions: In recent years, increased resistance has been a serious threat. The resistance or susceptibility of Staphylococcus aureus strains to different antibiotics is different in different geographical locations.

Rationale: Acute complications of cirrhosis can be life- threatening. One of the less common acute complications is hepatic hydrothorax whose medical management is rarely successful and is still controversial. Patient concerns: A 51-year-old patient presenting to the emergency room for a massive pleural effusion. Diagnosis: A hepatic hydrothorax with a placed chest tube whose removal was not possible. Interventions: Increased doses of diuretics with a strict salt-free diet. Outcomes: An improvement of the clinical state, with no recurrent pleural effusion up to one month. Lessons: Medical management of hepatic hydrothorax is possible.

Rationale: Levothyroxine is the most commonly used agent in thyroid hormone replacement therapy. Although there are many hypothyroid patients who use levothyroxine as a treatment, high level of thyroid stimulating hormone is found in a limited number of levothyroxine overdose cases worldwide. Patient concern: A 34-year-old male patient taking 4.5 mg levothyroxine for suicide. Diagnosis: Overdose of levothyroxine. Interventions: The patient was admitted to the intensive care unit for follow-up treatment. Cardiac rithym and vital parameters of patient were closely monitored. Outcomes: The patient discharged without any life-threatening complications. Lessons: Patient with initial high thyroid stimulating hormone levels may not be in hyperthyroidism crisis by levothyroxine poisoning.

Rationale: Symptoms of floaters and signs of retinal hemorrhages are common acute visual complaints and diagnoses. Diabetic or hypertensive retinopathy is prevalent, yet their differential of Valsalva retinopathy is rare. Patient concerns: A 32-year-old lady presented with floaters was found to have bilateral multi-layered retinal hemorrhages one day after laparoscopic surgery under general anesthesia. Diagnosis: Bilateral Valsalva retinopathy after general anesthesia. Interventions: The patient was offered observational conservative treatment. Outcomes: Multi-layered retinal hemorrhages resolved, but with residual left eye metamorphopsia from epiretinal membrane formation. Lessons: Valsalva retinopathy can be differentiated from common diabetic or hypertensive retinopathy by its characteristics of multi- layered hemorrhage. Valsalva retinopathy after general anesthesia is a rare disease. General anesthesia can cause Valsalva retinopathy in a few ways: intubation, positioning, iatrogenic Valsalva maneuver intra-operatively, post-operative coughing or vomiting, etc. In addition, permanent visual impairment could sometimes occur.