Objective: To investigate the effects of propofol and ketamine on seizure duration, hemodynamics, and recovery of electroconvulsive therapy (ECT). Methods: This prospective randomized trial included patients who had undergone ECT under anesthesia. Patients received injection of propofol 1.5 mg/kg i.v. (the propofol group) or ketamine 0.8-1.2 mg/kg i.v. (the ketamine group) during ECT. Seizure duration, hemodynamics, and recovery were recorded and compared between the two groups. Results: This trial included 44 patinets with 22 patients receiving propofol and 22 patients receiving ketamine. The total dose of propofol and ketamine was (105.68±25.27) mg and (81.36±24.55) mg, respectively. The motor seizure and electroencephalogram seizure duration were prolonged in the ketamine group (P<0.001). The hemodynamics at the admission of the two groups were comparable (P>0.05); however, the mean systolic blood pressure during the procedure was significantly higher in the ketamine group (P=0.04). Besides, spontaneous eye-opening in the ketamine group took longer than that of the propofol group (P=0.001). Conclusion: Both propofol and ketamine are safe as anesthetic agents for modified ECT, and ketamine provides a longer seizure duration without hemodynamic instability or any significant complication.

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Objective: To assess the efficacy of gabapentin in the treatment of low back pain patients. Methods: This prospective observational study was conducted over 6 months to assess the efficacy of gabapentin in patients suffering from low back pain. Past medical history, pain severity by Visual Analogue scale (VAS) and sleep quality by Pittsburgh Sleep Quality Index (PQSI) were collected. VAS scores and PQSI scores before and after gabapentin treatment were compared, and gabapentin satisfaction post treatment were recorded. Results: This study included 100 low back pain patients with 65 males and 35 females, and the mean age was (39.0±10.5) years. The commonest presentation was non-radiating low back pain (40%). The mean VAS score and the mean PQSI score in the study before treatment were 7.70±1.91 and 10.95±5.02, respectively. After treatment with gabapentin, the mean VAS score and the mean PQSI score decreased to 2.75±1.79 and 4.90±2.20, respectively, and the differences before and after the treatment were significantly different (both P=0.001). Overall, 62% of the patients were extremely satisfied with gabapentin because they reported no adverse drug reaction. Besides, 31% of the patients were satisfied and 7%were strongly dissatisfied with the therapy. Conclusion: Gabapentin can improve sleep quality and reduce lower back pain as measured by the VAS and PQSI. The efficacy of this drug is relatively good, but further improvement is required.

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Objective: To compare the efficacy of midazolam, fentanyl, and magnesium sulfate as adjuvants to intrathecal bupivacaine on both block characteristics and postoperative analgesia in knee arthroplasty. Methods: This randomized double-blind clinical trial recruited spinal anesthesia patients of the American Society of Anesthesiologists class I or II, who needed knee arthroplasty. Patients were stratified into three intervention groups, including the midazolam group, the fentanyl group, and the magnesium sulfate group, and the patients were administered with midazolam, fentanyl, and magnesium sulfate, respectively. Hemodynamic parameters, sensory and motor block, and pain score (Visual Analogue Scale) were measured and compared among the three groups. Results: A total of 105 patients were included in this study with 35 patients in each group. There was no statistically significant difference in terms of oxygen saturation, mean blood pressure, duration of surgery, and postoperative complications, including nausea, vomiting, bradycardia, dizziness, and hypotension, as well as the time of opioid administration among the three groups (P>0.05). Statistically significant differences were found in terms of heart rate at 15, 30, 45, 60, 75, and 105 min after beginning of operation among the three groups, which was lower in the midazolam group (P<0.05). The midazolam group showed a shorter time to achieve sensory block after spinal anesthesia, sensory block to T8 or higher and sensory block to T12 and L1 (P<0.05). Besides, the three groups showed significantly differences in terms of onset of motor block after spinal anesthesia and time to achieve motor block to T8 or higher or Bromage score 3 (P=0.001). No significant difference was noted in pain scores among the three groups (P>0.05). Conclusion: Midazolam resulted in a shorter time to achieve sensory and motor block to T8 or higher, the onset of motor block and sensory block after spinal anesthesia, and time to achieve sensory block to T12 and L1, and the pain scores were not significantly different among the groups. Thus, midazolam can be highly underlined, if a shorter onset of sensory and motor blocks is targeted. [Funded by the research deputy of Arak University of Medical Sciences (No.99258); fa.irct.ir number, IRCT20141209020258N164].

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Objectives: To assess the knowledge, attitude, and practice (KAP) towards COVID-19 and its associated factors among house officers. Methods: A multicentered crosssectional study on house officers was carried out using an online self-administered questionnaire. Sociodemographic data and data related to KAP towards COVID-19 were collected. Besides, KAP level of the house offices was recorded and factors associated with good KAP were determined. Results: This study included 555 house officers from 10 different hospitals with 128 males and 427 females. Almost half of the house officers had good knowledge and a favorable attitude (46.1% and 51%, respectively) on COVID-19. Still, 82.5% of them were committed to good practice of preventive measures. Besides, percentages of good knowledge and practice among those with chronic diseases or those who knew someone infected with SARS-CoV-2 were higher, but the differences were not statistically significant (P>0.05). In addition, the percentages of females with good practice were higher than those of males, with no statistical difference (P>0.05). Conclusion: House officers showed a good KAP towards COVID-19. Being aware of gaps in KAP can help to effectively contain the current pandemic.

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Objectives: To determine the correlation between lymphocyte count and A-DROP score in COVID-19 patients and their role in predicting poor outcomes. Methods: This retrospective observational single-center study was conducted in a tertiary care hospital in Vidisha district, India. COVID-19 patients were included in this study, who were admitted to ICU and the COVID Care Centre from August 2020 to October 2020. Demographic profile, clinical characteristics, medical history, A-DROP score, complete blood counts including lymphocyte counts (on admission), the severity of the disease course, and duration of hospitalization were collected. The correlation between lymphopenia and A-DROP score was determined, and their role in predicting poor outcomes was investigated. Results: This study included 220 patients, among which 134 were male, and 86 were female [mean age (48.98±16.98) years, 95% CI: 46.72-51.23]. Lymphocyte count in COVID-19 patients negatively correlated with the A-DROP score (r=−0.67, P<0.001). The area under the ROC curve was 0.892 (95% CI: 0.80-0.98, P<0.001) for the lymphocyte count, and the area under the ROC curve was 0.93 (95% CI: 0.84-1.00, P<0.001) for lymphocyte count-A-DROP. Conclusion: Lymphocyte count along with the A-DROP score on admission could be used to predict the severity of COVID-19 pneumonia and unfavorable outcome.

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Rationale: COVID-19 usually presents with flu-like symptoms and signs, but some rare presentations like leukemoid symptoms cannot be ignored. Patient’s concerns: A 37-year-old female presented to the outpatient department with flu-like symptoms. Diagnosis: The RT-PCR test for SARS-CoV-2 infection was positive, while complete blood cell and peripheral blood smear showed leukemoid reaction. Intervention: Paracetamol and fexofenadine for flu-like symptoms and leukemoid presentation. Outcomes: On the 10th day, the patient was asymptomatic and RT-PCR was negative. So the patient was discharged and leukemoid presentation subsided after clearance of viral disease. Lessons: COVID-19 has a myriad of presentations, and unusual symptoms/signs especially in this pandemic could be induced by COVID-19 infection.

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Rationale: The mechanism of sudden cardiac death in COVID-19 can be multifactorial. Cardiac hypersensitivity to 5-ASA therapy leading to myocarditis has been reported in some cases. Cytokine storm syndrome and idiosyncratic reaction with mesalazine use may lead to sudden cardiac death in COVID-19. Use of immunosuppressants in hospitalized COVID-19 patients should be continued with caution, especially in patients with inflammatory bowel disease. Patient’s concern: A 75-year-old man who was tested positive for SARS-CoV-2 was admitted with a history of shortness of breath for the last two days. He was a known case of Crohn’s disease treated with mesalazine. Diagnosis: COVID-19 pneumonia with underlying Crohn’s disease leading to sudden cardiac death. Intervention: Remdesivir, antibiotics, steroids, low molecular weight heparin, tablet zinc, tab vitamin C, and other supportive treatment were started. Because of increased inflammatory markers, itolizumab was given to the patient on the 2nd day. Outcome: On the 5th day of the intensive care unit, the patient complained of sudden chest pain with respiratory distress leading to bradycardia and asystole and could not be resuscitated. Lessons: Causes for sudden cardiac death in COVID-19 pneumonia patients with Crohn’s disease is multifactorial. Although mesalazine may be a safe and effective drug in the management of inflammatory bowel disease, it can induce sytokine strom syndrome and idiosyncratic reactions that could be one of the reasons of sudden cardic death. Therefore, we should be aware of its serious and potentially life-threatening complications, especially in COVID-19 infected patients.

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