Rationale: Cope’s sign is reflex bradycardia seen in the patient presenting with symptoms of acute cholecystitis. This bradycardia may be due to vagally mediated cardio-biliary reflex. Many of these reflexes due to acute cholecystitis have similar clinical features (some electrocardiographic changes like bradycardia, complete heart block, and asystole) mimicking that of acute coronary syndrome. Patient’s concern: A 60-year old male presented with symptoms of acute cholecystitis and referred to the emergency department with complete heart block and abdominal pain with hypotension requiring an emergency temporary pacemaker. Diagnosis: Cope’s sign and complete heart block. Intervention: Emergency temporary cardiac pacemaker insertion. Outcomes: The patient was discharged after three days with regular follow-up and advice for laparoscopic cholecystectomy. Lessons: Complete heart block or any symptomatic bradycardia associated with abdominal pain should be under consideration of cholecystitis that may be associated with either presence or absence of gall stones due to cardio biliary reflex.

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The five main arbovirus families that cause diseases in humans and other animals are Bunya viridae, Togaviridae, Flaviviridae, Reoviridae, and Rhab doviridae. Chikungunya arbovirus (Togaviridae: Alphavirus), an arbovirus transmitted by Aedes spp., is a well-known global health threat. It has been recognized in more than 60 countries in Asia, Africa, Europe, and the Americas. Pakistan, the eastern neighborhood of Iran, is one of the endemic foci of this disease. As the largest province of Iran, Sistan- Baluchestan has always been threatened by infectious diseases from abroad due to its geographical location and neighborhood with Afghanistan and Pakistan. Contagious diseases are more likely to occur in the eastern borders of Iran arising from (1) lack or limited jobs due to deprivation of the area, the harsh weather conditions, unbearable conditions, traditional society, and lack of industry development; (2) Lack or limited facilities due to the distance from the center of the country and high percentage of illiteracy or low literacy, and traffic to neighboring countries to trade goods and get a job. Therefore, health authorities should pay more attention to trafficking of illegal aliens, traveling of people to high-risk countries, smuggling of livestock, and strengthening of quarantine posts across borders, especially in the eastern borders of Iran. The first case of chikungunya disease was confirmed in Sistan-Baluchestan province in 2019, where most of the cases have been reported. The findings of the present study provide evidence of chikungunya virus in Iran and emphasize the urgency to increase the preventive standards and surveillance system.

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Objective: To investigate the prevalence of isolated organisms in patients with lower respiratory tract infections and the antibiotic susceptibilities at a tertiary care center. Methods: In this observational and cross-sectional analysis, 114 patients admitted in the intensive care unit were enrolled. The endotracheal aspirates and bronchoalveolar lavage were collected. The bacteria were isolated and identified, and finally, antimicrobial sensitive pattern of the isolated bacteria was examined. Results: The prevalence of infection was 72.72% in male patients and 27.28% in females. The predominant bacteria were Klebsiella pneumoniae (37.50%) followed by Acinetobacter spp. (36.36%), Pseudomonas aeruginosa (7.95%), Escherichia coli (6.81%), Proteus mirabilis (2.27%), atypical Escherichia coli (1.13%), Enterococcus spp. (1.13%), Elizabethkingia meningoseptica (1.13%), Staphylococcus aureus (1.13%), Proteus vulgaris (1.13%), Citrobacter freundii (1.13%), and Citrobacter koseri (1.13%). High resistance to cephalosporins (82.18%) was demonstrated in all Gram-negative bacteria. Bacteria showed susceptibility to colistin (88.75%) followed by tigecycline (83.11%), gentamycin (36.18%), and amikacin (49.23%). Conclusions: As the most frequent respiratory organisms, Klebsiella pneumoniae and Acinetobacter spp. have increased resistance to cephalosporins and susceptibility to colistin followed by tigecycline.

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The author has performed several rescues in both basic and advanced CPR failure. Such practice consists in stimulating an acupuncture point called KI-1 Yongquan, where terrestrial Yin energy enters into our bodies to nourish heart and lungs to maintain vital functions. Said stimulus follows the same ascending path of a lightning bolt. This integration between heart and kidneys makes up the deepest energetic level in acupuncture: the Shao Yin. Such level not only proceeds over cardiovascular physiology but also influences the central nervous system. This helps us to better understand the outstanding response when applied in cardiac arrest and stroke (84.51% survival rate in last 30 years). Such benefit in patients with bilateral amputation lead the discovery of a new energetic path called “reconciliation vessel”, presented before the Chinese National Academy of Medical Science in 2014 and 2016. The “resuscitator” can be used when physical barriers hamper the precordial massage: crashed or overturned vehicles, building collapses, landslides, and other catastrophes with a large number of victims. This prototype was developed under safety measures to avoid any collateral damage in patients or rescuers. By 2020, the global number of victims of cardiovascular diseases will involve 30 million people. Adding the 7% of brain-vascular victims will reach over 30% of all causes of death. Advanced technology may provide the “resuscitator” with global positioning systems to notify the emergency network to send the closest rescue unit to the victim. The present invention has been developed to assist resuscitation maneuvers in humans as well for veterinary use.

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Objective: To compare the effect of 8-week and 12-week of triple therapy (doxycycline, rifampicin, and gentamicin) on brucellosis. Methods: This parallel clinical trial was conducted on 339 brucellosis patients who were divided into 2 groups. The first group (175 patients) received doxycycline (100 mg/12 h) for 8 weeks, rifampicin (600 mg/d) for 8 weeks, and gentamicin (5 mg/kg/ d) for 7 d, while in the second group (164 patients), doxycycline and rifampicin treatment were prolonged to 12 weeks, along with gentamicin therapy for 7 d. The patients were followed-up for six months after the treatment. Baseline information, clinical manifestations of the patients were collected, and serological tests for brucellosis were performed after the treatment. Results: The mean age of the patients was (45.95 ± 18.65) years, and 56.9% of the patients were male. In total, 73.5% of the patients were residents in rural areas and the majority of them were farmers and ranchers (34.6%). The 3-month relapse rates of the two groups were 11.42% and 6.70%, respectively (P=0.132). Moreover, the 6-month relapse rate of the two groups was 6.3% and 2.4%, respectively (P=0.085). In the two groups, both treatments could reduce serological titers based on Wright and 2ME tests (P<0.05). Conclusions: The efficacy of 8-weeks and 12-weeks triple therapy (doxycycline, rifampicin, and gentamicin) is similar in terms of brucellosis relapse. The 8-week triple therapy including doxycycline, rifampicin, and gentamicin can be considered as an effective approach for the treatment of brucellosis.

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Objective: To evaluate the incidence of Enterobius vermicularis (E. vermicularis) in appendectomies in Iran from 1993 to 2018. Methods: Data were systematically collected on the electronic databases including PubMed, GoogleScholar, ScienceDirect, Scopus, Web of Science, Magiran, Irandoc (Bareket), IranMedex, and Scientific Information Database in English or Persian. Six articles including 29 694 cases of appendicitis with 258 positive cases of infection with E. vermicularis were eligible to enter into this systematic review and meta-analysis. Results: The overall prevalence of E. vermicularis in appendicitis in Iran was 1% (95%CI=0.00-0.02) with the highest rate of 3% (95%CI=0.02-0.03) and lowest rate of 0% (95%CI=0.00-0.01). Conclusions: Prevalence of E. vermicularis infectionin appendicitis in Iran is low and has no statistically significant correlation with age and gender.

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Objective: To evaluate the effect of open reduction and internal fixation on radial head fracture and assess the post-operative function. Methods: This prospective observational study was conducted from June 2016 to July 2017 at Liaquat National Hospital and Medical College, Karachi. Altogether, 28 patients with radial head and neck fractures were enrolled in our study. These patients were admitted to the hospital and their fractures were fixed with open reduction and internal fixation. Baseline information of the patients was collected, and patient-rated elbow evaluation scores were calculated. Results: Out of the 28 patients, 21 were male and 7 were female. Besides, 16 fractures were on the right side and 12 were on the left side and 17 involving the dominant hands. In addition, 8 patients had Mason type II fracture and 20 had Mason type III fracture. The mean age of patients was (31.0 ± 8.0) years, and the mean follow-up is (1.2 ± 0.5) years. The mean average patient-rated elbow evaluation scores were (27.64 ± 1.60) at 1-year follow-up. Conclusions: The majority of the patients who had radial head fractures and treated by open reduction and internal fixation have attained an excellent range of motion postoperatively.

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Objectives: To assess the outcomes of the intensive care of Syrian refugees under temporary protection (SRUTP). Methods: The sample of the study was composed of 110 SRUTP patients who were treated at a tertiary intensive care unit (ICU) between 2013 and 2019 in Istanbul, Turkey. Baseline information and clinical data of the patients were collected by scanning the hospital’s electronic database and clinical decision support system. Results: The mean length of ICU stay was 97.6 (36.3-187.8) h. Among the patients, 71 (64.5%) had comorbid diseases, and ICU mortality was 40%. The median cost of health care for each patient was 2 144 (1 060-4 471) USD, and the total health care cost of all patients was 534 012USD. Conclusions: Use of vasoactive drug, hemodialysis application, and low Glasgow Coma Scale scores are independent risk factors of the mortality. More researches are needed to clearly reveal the health and cost consequences of war.

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Rationale: Fever of unknown origin (FUO) is a frequently observed phenomenon in clinical practice. Definite diagnosis of FUO is a great challenge in clinical practice since potential causes for FUO involve more than 200 diseases. Adult-onset Still’s disease is a defined clinical entity and a known rare cause of FUO. Patient’s concern: A 19-year girl was referred to the clinic with the concern of intermittent fevers and shivering for almost a year despite multiple investigations and consultations. She had undergone intensive serologic, radiologic, laboratory investigations to exclude infectious diseases, connective tissue diseases, and malignancy, and all the investigation showed no conclusive diagnosis. Diagnosis: Adult-onset Stills disease. Intervention: Steroids and supportive treatment. Outcomes: The symptoms were relieved within three days, and the patient became asymptomatic. Lessons: Physicians need to be familiar with the diagnostic criteria of adult-onset Still’s disease, or it shall remain a diagnostic dilemma. Besides, all shivers are not infections.

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