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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Objective: To investigate the prevalence of viral myocarditis worldwide. Methods: We conducted a systematic search for the prevalence of the most common viruses in myocarditis and 75 studies were included for statistical analysis of the prevalence of adenovirus, hepatitis C virus, cytomegalovirus, Ebola virus, human herpesvirus 6, influenza virus, parvovirus, and non-polio enteroviruses. Results: The highest prevalence was related to B19 (25.0%) and non-polio enteroviruses (18%). The prevalence of human herpesvirus 6, cytomegalovirus, and Ebola virus was12.8%, 5.5%, and 3.1%, respectively. Hepatitis C virus accounted for 6.1% of the disease, the adenoviruses contributed to 5.2% of viral myocarditis. The lowest incidence was related to the influenza virus with 2.0%. Conclusions: Treatment of myocarditis is still problematic and may depend on the etiologic diagnosis. So it is important to know the commonly occurring viral factors in myocarditis and timely diagnosis and treatment are also imperative.

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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 follow-^up. Lesson: Emerging antibiotic-resistant and hypervirulent strains of Klebsiella pneumoniae should drive further studies on novel antibiotic combinations for extensively drug-resistant Klebsiella pneumonia.

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Objectives: To identify the reasons for delayed reception of postexposure prophylaxis (PEP). Methods: In this cross-sectional study, a total of 1 407 individuals with animal bites who were referred to the Abadeh Rabies Treatment Center were investigated using the census method from January 2012 to December 2018. The patients were divided into two groups based on their delay times to referral and receive PEP: timely referral (less than 48 h after the bite) and delayed referral (equal to or longer than 48 h after the bite). Frequency, Chi-square, and logistic regression tests were used. Results:. The average delay time was (16.33±11.37) h. Low level of education (OR: 3.87; 95% CI: 1.19-12.54; P=0.02), active economic age (21-35 and 36-50 years-old, OR: 12.81; 95% CI: 3.16-51.97; P<0.001 and OR: 3.83, 95% CI: 3.83-58.61; P<0.001 respectively), occupation (OR: 9.16; 95% CI: 1.89-44.29; P=0.006), long distance from the rabies treatment center (OR: 3.41; 95% CI: 2.03-5.72; P<0.001), bites by household and domestic animals (OR: 12.22; 95% CI: 2.29-65.18, P=0.003), superficial injuries (OR: 4.51; 95% CI: 1.38-14.73; P=0.01), and residence in rural area (OR: 12.74; 95% CI: 6.58-24.66; P<0.001) had significant correlations with delayed referral of victims. Conclusions: To reduce the delay time, the high-risk groups should be informed about the importance of timely referral via educational measures. Furthermore, rabies treatment services should be rendered at the nearest possible center.

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Rationale: Diffusion-weighted imaging (DWI) is a cardinal tool for detecting acute brain ischemia; however, recent studies have shown that DWI may not show the ischemic lesion during the hyperacute period. Patient concerns: A 76-year old male patient was admitted due to an acute onset of dysarthria and right lower paresis which progressed on the second day of admission. Diagnosis: The preliminary diagnosis was an ischemic stroke and the final diagnosis was left medullary stroke. Interventions: Antiaggregant and anticoagulant therapies were initiated after excluding hemorrhagic stroke by cranial computed tomography. However, DWIs, which were recorded on the 6th hour and 19th hour after the symptom onset, were in normal ranges. Hence, the patient was referred to a senior hospital for further etiological investigations. Outcome: The patient was discharged after treatments with aspirin and atorvastatin, and the neurological examination showed mildmoderate dysarthria and moderate right-sided paralysis (3/5). Lessons: Clinicians should pay more attention to stroke patients with negative DWI and perform DWI several times when the diagnostic is unclear.

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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-out- of 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.

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Objective: To determine patterns of antimicrobial resistance, analyze the prevalence of oxacillinase and molecular typing of strains of Acinetobacter baumannii (A. baumannii). Methods: A total of 121 strains of A. baumannii were obtained from patients admitted to Imam Hossein and Imam Khomeini Hospitals, Tehran, Iran, from January 2016 to November 2018. Antimicrobial susceptibility testing was performed by Kirby- Bauer disc diffusion method according to the Clinical and Laboratory Standards Institute recommendations. The presence of oxacillinase genes was assessed by polymerase chain reaction (PCR). To determine clonal relatedness, all isolates were subjected to repetitive sequence-based PCR (REP-PCR). Results: The isolates were obtained from 56 (46.3%) males and 65 (53.7%) females with the mean age of 39.5 years. Colistin with 100.0% sensitivity rate had the highest effect, while ceftriaxone with 16.5% sensitivity rate had the least effect on A. baumannii isolates. In addition, 96 (79.3%) and 99 (81.8%) isolates were resistant to imipenem and meropenem, respectively. A total of 109 isolates (90.0%) exhibited multiple drug resistance with 10 different resistotypes. In total, 75 (75.7%) of carbapenem resistant isolates were positive for bla_OXA-23-like, and 14 (14.1%) for bla_OXA-24-like gene. The five main clones A, B, C, D, and E were detected in 25 (25.2%), 36 (36.4%), 10 (10.1%), 8 (8.0%), and 6 (6.1%) of isolates, respectively. Conclusions: Carbapenem-resistant A. baumannii strains are high in the current study. To control the spread of carbapenem-resistant A. baumannii strains, regular monitoring programs are needed.

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