The Coronavirus Disease-2019 (COVID-19) outbreak has become a global health emergency owing to its magnitude, attributed deaths, and its propensity to spread across the world. In-fact, owing to its quick spread across international boundaries and the resulting caseload, the disease has been declared as a Public Health Emergency of International Concern on 30 January 2020. It is worth noting that out of the 395 cases detected in other nations, 165 (41.8%) have a positive history of travel to China. As of now, the World Health Organization has not recommended for any restrictions on the travel or trade aspects, but has clearly specified that implementation of International Health Regulations should be strictly done at the airports and seaports. In conclusion, the COVID- 19 outbreak has created an alarm across the globe as the causative virus is novel in nature. However, strengthening of standard infection control practices and adoption of preventive measures for travelers can significantly minimize the threat of further transmission of the disease.

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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.

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Biomarkers have been used to diagnose, prognose, evaluate, and identify the severity and outcomes in traumatic brain injury (TBI) patients. This study explored if it is possible to predict the outcome of TBI patients by estimating the biomarkers in cerebrospinal fluid and serum. We searched data bases and literature about biomarkers, and found forty epidemiologic studies from 92 potentially relevant articles. However, limited data are available about postanoxic encephalopathy. It showed that presently, neurofilament, S100B, glial fibrillary acidic protein, and ubiquitin carboxyl terminal hydrolase-L1 seemed to have the best potential as diagnostic biomarkers for distinguishing focal and diffuse injury, whereas C-Tau, neuron-specific enolase, S100B, glial fibrillary acidic protein, and spectrin breakdown products appear to be candidates for reflective biomarkers of TBI. Point-of-care biomarkers are needed in TBI which is one of the most important additional risk factors in road traffic injuries. In a holistic approach, more researches about biomarkers of TBI are required. These biomarkers are very useful for treatment of patients with TBI.

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Objective: To investigate the frequency of integrase genes intI1, intI2 and intI3 of Escherichia coli strains, and their association with resistance to routinely used antibiotics. Methods: A total of 120 Escherichia coli strains were collected from patients with urinary tract infection in Ahvaz, Southwest of Iran. Antibiotic susceptibility testing was performed. The presence of intI1, intI2, and intI3 genes was determined by polymerase chain reaction. Results: Antibiotic susceptibility testing disclosed the highest resistance rate to ampicillin (91.7%) followed by trimethoprim/sulfamethoxazole (65.8%), and ceftazidime (56.7%). The imipenem susceptibility rate was 91.7%. IntIl and intI2 were identified in 74 (61.6%) and 8 (6.6%) of Escherichia coli strains, respectively, but intI3 was not found in any isolates. The presence of integrons was significantly associated with resistance to ampicillin, trimethoprim/ sulfamethoxazole, ceftazidime, and ciprofloxacin antibiotics (P<0.05). Conclusions: The high resistant Escherichia coli isolates harboring class 1 integrons (intI1) were detected in patients with urinary tract infection in our region. Therefore, preventive strategies are necessary to restrict further dissemination of resistant strains.

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Objective: To investigate the protective effects of Aristolochia longa (A. longa) and Aquilaria malaccensis (A. malaccensis) on acute hepatotoxicity induced by lead in female albino rats. Methods: Twenty five (25) apparently healthy female Wistar rats were randomly divided into five groups of five rats in each: control, Pb, Pb + A. longa (Ar), Pb+ A. malaccensis (Aq), and Pb+ A. longa (Ar) + A. malaccensis (Aq) lead (100 mg/kg b.w.) as Pb (C₂H₃O₂)₂ added in their drinking water for 75 days. A. longa (rhizome powder at a dose of 10 g/kg of diet) and A. malaccensis (heartwood powder at a dose 10 g/kg of diet) were added to the feed during the last 15 days of lead exposed in the animals. Results: Obtained results revealed that lead treatment caused a significant increase in serum GOT, GPT and ALP activities and in liver of MDA level and CAT activity. In contrast, it led to an decrease in the liver GOT, GPT and GST activities and in GSH level in rats. Also, the results clearly showed that lead causes alterations of hepatic tissue in comparison with controls. Our results showed that treatment with A. malaccensis and A. longa a partial correction of the previous parameters. The histological observations confirmed the hepatoprotection results by the biochemical parameters. Conclusions: Results demonstrated beneficial effects of A. longa and A. malaccensis treatment in Pb-induced oxidative stress and tissue damage in liver.

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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 management. In case of failure by conservative treatment, facial nerve decompression yields a favorable outcome.

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Acanthamoeba keratitis, a vision-threatening disease, is caused by a free-living amoeba of genus Acanthamoeba. Amoeba is widely distributed all around the world. Several cases of Acanthamoeba keratitis have been reported from the Middle East and Iran as well. The infection is mainly caused by inappropriate use of contact lens; therefore, it is more common among lens wearers. The number of reported cases worldwide is increasing annually due to the increasing number of contact lens wearers for medical or cosmetic reasons. It is known that early diagnosis and treatment can reduce consequent damages, while the delay in these processes will deteriorate the vision. Nowadays contact lens wearing, surgery and use of corticosteroids are known to predispose to Acanthamoeba keratitis, and it was also believed that trauma was the main cause. Increasing public knowledge about Acanthamoeba infection, inquiring the history of patients, clinical signs and laboratory findings can be helpful to early diagnosis and better treatment. Regardless of the increasing knowledge of diagnosis and treatment, this disease is still a challenge. Considering the long curative time, and insufficient efficacy of available treatments, it seems that the prevention is more important than the treatment. This review aimed to explain Acanthamoeba keratitis in the Middle East and Iran from the aspects of epidemiology, diagnosis, and therapeutic treatment.

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Levothyroxine intoxication is a rare clinical entity which is usually asymptomatic. However, severe symptoms such as respiratory failure, malignant hyperthermia, seizures, arrhythmia, and coma have been reported. In this case report, a patient who ingested high dose (15 mg) levothyroxine for suicide and admitted to intensive care unit was presented. There was a decrease in Glasgow coma score in the follow-up. The patient was intubated due to acute respiratory failure. Gastric lavage, activated charcoal, methylprednisolone, cholestyramine and therapeuthic plasma exchange were administered. Despite ingestion of high dose of levothyroxine, thyrotoxicosis symptoms resolved with appropriate treatment and the patient was discharged from the intensive care unit.

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Rationale: Strongyloides stercoralis (S. stercoralis) is an intestinal nematode with a complicated life cycle that can involve the gastrointestinal system. Infected patients are generally asymptomatic; but if symptomatic, the symptoms will include skin rash, respiratory and gastrointestinal symptoms like abdominal pain, diarrhea, nausea and vomiting. Patient concerns: A 77-year old man presented with edema of the lower extremities and insignificant tenderness in the epigastric region. Diagnosis: The histopathology of gastric tissue showed severe inflammation and multiple ulcers in the cardia, antrum and proximal duodenum. A large number of rhabditiform larvae of S. stercoralis along with tissue hyperemia and infiltration of lymphoplasma cells, eosinophils, and neutrophils were found. Intervention: Treatment with albendazole. Outcome: Despite the albendazole treatment, the patient’s condition deteriorated and eventually died because of a sepsis-like syndrome. Lesson: Physicians should remain alert to the urgency due to threadworm, especially among the elderly people and immunosuppressed cases; and should ensure accurate diagnosis, suitable treatment and careful follow-up of these cases.

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Objective: To investigate the improved antitrypanocidal activity and toxicity of diminazene aceturate modified Nano drug in experimental rats. Methods: Aqueous leaf extract of Hyptis suaveolens was used to reduce gold tetrachloride to its nanoparticle size and this was characterized and formulates with naturally synthesized polyhydroxybutyrateas a Nano carrier. A total of thirty ^[30] albino rats were group into 6 (A-F) of 5 rats each & infected intraperitoneally with 0.2 mL of the inoculum containing about 1x10³ Trypanosoma brucei brucei parasites per 0.2 mL of blood. Groups A and B were treated with 3 and 6 minutes released orange PHB, Groups C and D were treated with 15 and 30 minutes released mango PHB formulated tablet while Groups E and F were negative (untreated) and standard drug (Dininazene aceturare) respectively. Results: The free drug and modified orange synthesized polyhydroxy butyrate shows antitrypanocidal activities by reducing the replicating rate of the parasite as compared to infect untreated. While the modified- mango synthesized shows increasing order of replication. There were significant increases in all the haematological parameter evaluated in the infected treated groups compared to infect untreated. But no significant difference (P<0.05) observed in the Catalase activity in the serum and liver of all the groups whereas, the modified orange synthesized shows significant decrease in other enzymes activities evaluated when compared with the free drug, mango synthesized and the infected untreated groups. Conclusion: Orange synthesized modified diminazene aceturate show efficacy as free drug with limited toxicity that can enhance the therapeutic.

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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 biofilm- producing 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.

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Paraquat (PQ, methyl viologen) was widely used in agricultural production throughout the world in 1962 for its efficient herbicidal activity. PQ was also highly toxic drug. About 5 mL medicine including 20% paraquat was life-threatening that can cause poisoning. In 1966, some people died because of PQ poisoning. Most patients had acute respiratory distress syndrome after 2 wk, and 70% of them died due to the lack of effective detoxification drugs. Thus, it was particularly important to understand the pathogenesis of PQ poisoning and give some effective treatments. This article will review the toxicological mechanism and treatment on PQ poisoning of acute lung injury.

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The role of laparoscopy in the acute care surgery had significantly increased during the latest years, both as a diagnostic and treatment method of all the upper or lower gastrointestinal pathologies. The objective of the present research is to review the current indications for laparoscopy in bdominal emergencies and to detail the benefits and complications associated with this approach. We have reviewed the relevant literature about this topic published between January 2005 and December 2017, using the PubMed/Medline and Web of Science Core Collection databases. According to the current evidence, we may conclude that the laparoscopic approach is an integral part of the emergency surgery for all the abdominal pathologies. Although laparoscopy requires specialized training and curricula, it brings all the benefits of minimal access in acute care arena.

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Intracerebral hemorrhage secondary to thrombolysis in patients with acute myocardial infarction is a catastrophic condition. Several factors predispose to intracranial bleeding including low body weight, female sex, advanced age, use of oral anticoagulants prior to the administration of fibrinolytic therapy, diastolic blood pressure (greater than 110 mm Hg), among others. Optimal medical management involves multidisciplinary roles of hematology, neurosurgery and critical medicine. In this illustrative case, a classification and management algorithm were proposed for patients with complications hemorrhage associated with thrombolysis after myocardial infarction.

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Rationale: Necrotizing fasciitis is an aggressive infection of subcutaneous tissues, which tends to spread rapidly through the fascial planes. Colonic diverticulosis is a common disease in advanced age, although it rarely causes a lethal necrotizing soft-tissue infection. Patient concerns: A 58-year-old woman complained of left leg pain for 15 d without abdominal pain. Diagnosis: Diverticulitis perforation presented as necrotizing fasciitis of the left thigh. Interventions: Extensive debridement. Outcomes: The patient died due to sepsis-induced multiple organ failure and severe metabolic acidosis. Lessons: Clinicians should be aware of presentations of diverticulitis in patients who have a soft-tissue infection in lower extremity even though patients may not have had a history of diverticulosis or abdominal pain.

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Cytomegalovirus (CMV) can cause significant inflammation. Besides, it is an important cause of pancreatitis in organ transplantations. We report a case of CMV pancreatitis in a 48-year-old male kidney transplant recipient who was admitted with elevated amylase (3 337 U/L) and lipase (1 160 U/L) enzymes, and abdominal pain. CMV infection was tested by reverse transcription polymerase chain reaction and the result was positive. CMV viremia was successfully cleared with ganciclovir. Then the absence of some of more noticeable clinical symptoms of pancreatitis may not be a decisive reason not to rule out the disease in transplanted cases.

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Objective: To determine the survival rate of tuberculosis (TB) patients and to identify the important factors associated with the survival of these patients in southern Iran. Methods: The present retrospective cohort study extracted and reviewed available medical records of 134 TB patients undergoing TB treatment centre, during 2005 to 2016. The Survival rate of patients for the outcome of the interval from diagnosis until death was plotted using life table and Kaplan-Meier survival curve. Cox proportional hazard regression model was used to examine the simultaneous effect of variables on survival rate. The significance level was considered to be 0.05. Results: In this study, 64.2% of the participants were male, 73.1% had pulmonary TB and 5.22% had HIV. The survival rate of one, five and thirteen years after diagnosis were 93%, 78% and 69%, respectively. The risk of death in patients with extrapulmonary TB (95% CI=1.96-15.83, P=0.001) was 5.58 times higher than in patients with pulmonary TB. The risk of death in smokers with TB (95% CI=1.74-2.46, P<0.001) was 2.07 times higher than in non-smoker patients, and also the risk of death increased to 1.10 times more for a one-year increase in patient age (95% CI=1.06-1.14, P<0.001). Conclusions: The risk of death in patients with extrapulmonary TB and TB smokers was higher than other patients. Therefore, timely diagnosis and proper treatment of patients with extrapulmonary TB as well as the development and integration of smoking cessation programs are underlined and emphasized in the formulation and implementation of the National Tuberculosis Control Program.

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Objective: To study earthquake planning and crisis management with an emphasis on the facilities, utilities, and services of the health care centers of Tiran and Karvan County, Isfahan Province. Methods: This is a descriptive-analytical survey based on the quantitative and qualitative characteristics of Tiran and Karvan County Health Care Centers(HCCs). Twenty quantitative and qualitative indicators were derived from the studied HCCs and analyzed using the strengths, weaknesses, opportunities and threats analysis technique. The top crisis management strategies were identified and a number of strategies and solutions were proposed. Results: The HCC utilities such as water, electricity, gas, and heating and cooling systems were in average condition, whereas the facilities of the majority of HCCs were in vulnerable-to-average condition. In addition, they sustained relatively high degree of instability which calls for reassessment and effective policies to minimize weaknesses and eliminate threats using strengths and opportunities. Conclusions: It is recommended that the condition of Tiran and Karvan County HCCs be enhanced by distributing new HCCs based on the population density, expanding the road network and creating vast, wide-open spaces to enable field hospital construction in times of crisis.

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Objective: To explore the toxicological profile of methanol extract of Chlorophytum alismifolium (MECA) tubers in Wistar rats. Methods: MECA was subjected to acute and sub-acute studies which were conducted according to Organization for Economic Co-operation and Development (OECD 425 and 407 guidelines respectively). In the acute toxicity experiment, a limit test (5 000 mg/kg) was administered to five rats and monitored for 2 weeks. The sub-acute studies were conducted on 4 groups of rats. The first group served as control, while the 2^nd, 3^rd and 4^th groups received MECA (150, 300 and 600 mg/kg respectively). The treatments were given orally and daily for 4 weeks. At the end of the experiment (29^th day), the animals were euthanized to obtain blood samples and organs for haematological, biochemical and histological evaluations. Results: Acute toxicity study showed that the oral median lethal dose was >5 000 mg/kg. In the sub-acute studies, the results showed no significant (P>0.05) changes in the haematological, hepatic and renal indices compared to control animals. In the fourth week, a significant (P<0.01) increase in body weight of the rats was observed at 150 mg/kg and 600 mg/kg compared to week one. However, there were no major changes in the organ/ body weights of the rats. Histological examination of the kidney showed slight glomerular adhesion and tubular distortion. Moderate hepatic necrosis was observed at 150 mg/kg and 300 mg/kg. Conclusions: The results of this research revealed that the MECA tubers is virtually non-toxic after acute administration and it has low sub-acute toxicity potential in rats.

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Objective: To analyze the data of pre-hospital emergency treatment in zhengzhou from 2007 to 2016, and evaluate the current situation of pre-hospital trauma emergency treatment, in order to provide a scientific basis for effective use of first aid resources and enhance success rate of trauma emergency treatment. Methods: Retrospective analysis was conducted based on pre-hospital emergency resources of Zhengzhou Emergency Medical Rescue Center from 2007 to 2016. Results: The total number of pre-hospital emergency treatment cases was 9 305 687 from 2007 to 2016 in Zhengzhou, of which 418 882 were trauma cases. The top five causes of injury were traffic accident injury, cutting injury, beating injury, crushing injury and falling injury. The top five emergency treatments used were oxygen, hemostasis, dressing and fixation, fluid supplementation, analgesics and sputum aspiration. According to different directions of diagnosis, the pre-hospital emergency patients were divided into four groups: emergency treatment group, emergency observation group, admission to general ward group and admission to ICU group. There was no statistical difference in the ages among the four groups (P>0.05). There were significantly statistical differences in gender composition among the four groups, with more males than females (P<0.01). Significant statistical differences also showed in CRAMS scores among the four groups (P<0.01). Before and after the training of primary trauma care, there was no significant difference in the constituent ratio of the trauma (P>0.05), but the mortality of the trauma, the average arrival time, and the mean treatment time were significantly different (P<0.01). Conclusions: The number of pre-hospital emergency trauma patients increased year by year, but the constituent ratio changed little. CRAMS score is important for the patients triage. Through the training of primary trauma care, the constituent ratio of death was reduced, and the average treatment time was shortened.

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Acinetobacter baumannii is a major cause of nosocomial infections worldwide. By summarizing the epidemiology, molecular and drug resistance mechanisms, diagnosis and treatment strategies of Acinetobacter baumannii, the clinical outcome is finally improved.

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Pulmonary embolism (PE), with the incidence of about 60 per 100 000 annually, can be a life- threatening disease if it is not treated promptly. It has been estimated that some 10% of PE patients die within the first hour of the event. Untreated PE has a mortality of about 30%. PE is a condition that is treatable if suspected and diagnosed early. The chest radiograph is still the first investigation that is ordered in patients presenting with cardiorespiratory symptoms or symptoms suggestive of PE. The CXR is also helpful in identifying or excluding other conditions or diagnoses. Thus, knowing and understanding some of the more specific CXR signs can be useful. We suggest that physicians to be aware of and utilize CXR findings such as Palla's sign, Westermark sign and Hamptons hump to help with the diagnosis of PE and to exclude other conditions that can mimic venous thrombo-embolism. Even if these signs are not common, their presence, even in an unsuspected patient without a high pretest probability of PE, should prompt further investigations such as a D-dimer test, lung scintigraphy or computed tomography pulmonary angiography as required.

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The impact of a bullet by firearm is a mortal entity that in recent years has been on the rise due to the increase in crime, confrontations, among other acts of violence. Brain injuries by firearm account for 33.3% of all fatal injuries from this type of weapon. This resulted in a significant number of disabilities with its burden cost at a global level. The types of bullet injuries to the head include: penetrating (inlet without outlet), perforating (through and through), tangential (not enter the skull, causing coupe injury), ricochet (intracranial bouncing of bullet) and careening (rare, enter skull but not brain, runs in the subdural space). There are several situations that can occur once the bullet enters the body or into the intracranial cavity. Unmatched association of the bullet trajectory with the final position of the bullet within the body raise the suspicion for additional phenomena involvement, this can be explained by either internal bullet ricochet or internal bullet migration. The former usually represents an active movement and the latter is a passive movement. Intracranial ricocheting of bullets forms up to 25% of all penetrating bullet injuries to the skull. Such bullets types are commonly tumbling and have an unpredictable trajectory. The surgical management for intracranial bullet injury developed over decades from the time of Harvey Cushing and the World War I till the present. Now, the accepted intervention ranges from simple wound care to a proper surgery that includes hematoma evacuation, removal of only accessible bone fragments and foreign bodies, dural repair and wound debridement with or without decompressive craniectomy. Also, intracranial pressure monitoring is generally indicated. We reported a thirty-three years old male, victim of homicidal bullet injury to the head, presented with Glasgow Coma Scale score of 8 (best eye response: 2, best motor response: 4, best verbal response: 2), upon examination a right parietal (near vertex) inlet without outlet was found. The poor prognostic factors in this patient included bi-hemispheric involvement, associated acute subdural hematoma with interhemispheric extension, ricochet type of injury and effacement of sulci. Intracranial ricocheted-bullet injury is a special entity of bullet injury to the head with its particular ballistics and management that deserve highlighting by the trauma team to gain fluent treatment and better outcome.

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