Objective: To compare the benefits of enhanced recovery after surgery (ERAS) pathways with traditional pathways for adult patients undergoing laparoscopic appendectomy. Methods: We looked for publications using the keywords “Enhanced Recovery After Surgery,” “Fast-track Surgery,” “Laparoscopic Appendectomy,” and “Laparoscopic Appendicectomy” in PubMed/Medline, Embase, and the Cochrane library. Operative time, lesser length of stay, oral intake timing, readmission rate, pain/satisfaction levels, readmission rate, and surgical site infections were recorded and analyzed. Results: A total of 95 articles from registers and 161 articles from databases were identified. Three eligible studies were included. The ERAS pathways had a lesser length of stay [Z=2.06, MD= -1.05, 95% CI=(-2.04, -0.05), P=0.04] and an earlier start to postoperative feeds [Z=6.22, MD= -267.49, 95% CI=(-351.80, -183.19), P<001]. Conclusions: ERAS pathways have a shorter length of stay and earlier postoperative feed initiation for adult patients undergoing laparoscopic appendectomy compared with standard care. Both approaches have similar operative time, surgical site infection incidence, and readmission rate. Clinical registration: This review is registered with INPLASY202280005.

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Objective: To compare the effect of ketamine, lidocaine, acetaminophen, and dexmedetomidine combined with morphine patient-controlled analgesia for opium addicts after tibial fracture surgery. Methods: This double-blind clinical trial included opium-addicted patients undergoing tibia fracture surgery. Patients were recruited and randomized to four different groups including the ketamine group, the lidocaine group, the acetaminophen group, and the dexmedetomidine group. The hemodynamic parameters such as heart rate (HR), mean arterial pressure, and arterial SaO₂, alongside visual analog scale pain scores, sedation assessed by Ramsay score, nausea and vomiting, and opioid use were recorded and compared among the four groups. Results: This study included 140 patients, aged 37 (32, 41) years, with 92 males and 48 females, and each group had 35 patients. Dexmedetomidine-sedated subjects had the lowest blood pressure from 1 to 24 h after surgery, decreased HR at 12 and 24 h after surgery, and more satisfactory sedation (P<0.05). Notwithstanding no significant difference was noted in the pain scores, or nausea and vomiting among the groups (P>0.05). Conclusions: Dexmedetomidine has a better sedation effect compared to ketamine, lidocaine, and acetaminophen for pain control, but the final choice hinges on the patients’ physical condition and the anesthesiologist's preference. Clinical registarion: It is registered in Iranian Registry Clinical Trial by code IRCT20141209020258N146.

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Objective: To determine the real-world effectiveness of the ChAdOx1 nCoV-19 coronavirus vaccine in preventing severe disease and mortality due to COVID-19. Methods: A case-case design was used to estimate the effect of the ChAdOx1 nCoV-19 coronavirus vaccine on severe SARS-CoV-2 outcomes in individuals aged 40 years and above. Cases (n=200) were COVID-19 patients admitted to intensive care unit (ICU) or who died. Controls (n=223) were those with mild COVID-19, fit for home isolation. The logistic regression model was used to estimate adjusted vaccine effectiveness for full vaccination (two doses ≥14 d) and partial vaccination status (one dose ≥14 d or two doses <14 d). Results: The proportion of fully vaccinated individuals was significantly lower among cases (12, 6.0%) compared to controls (30, 13.5%). The adjusted effectiveness of a full dose of ChAdOx1 nCoV-19 coronavirus vaccine in preventing ICU admission or death was 81.9% (95% CI: 61.3%-91.6%, P=0.001). Subgroup analysis restricted to age group, sex, and comorbidities found that ChAdOx1 nCoV-19 coronavirus vaccine had a significant positive effect in all subgroups and categories. Conclusion: COVID-19 vaccination reduces ICU admissions or death. Therefore, increased vaccine uptake may reduce the severity of the pandemic, more so in the elderly and those with comorbidities.

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The ongoing COVID-19 pandemic due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has resulted in a significant public health care system crisis. This disease has resulted in devastating damage to human lives and significant disruption in economies. Use of “machine-learning” algorithms as tools of artificial intelligence may help identify a suspected or infected individual with an estimation of chances of survival. These algorithms make use of recorded observational data including medical histories, patient demographics as well as any related data on COVID-19.

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Objective: To investigate the effect of the variability of Na_s, Cl_s, K_s, lactate values and sodium effect (Na_Effect), chloride effect (Cl_Effect), non-lactate strong ion difference (SID_nl) values calculated according to Stewart’s approach on predicting intensive care unit (ICU) mortality. Methods: The study was conducted on 1539 patients, retrospectively. Serum Na (Na_s), serum Cl (Cl_s), serum K (K_s), serum Ca (Ca_s), serum Mg (Mg_s), lactate, pH values and SID_nl, Na_Effect, Cl_Effect, APACHE II (first, last), and SOFA (first, last) scores were recorded. Radiometer ABL 800 (Denmark) was used for blood gas analysis. The variability of each parameter was calculated. The effect of variability of each parameter on 30-day ICU mortality was analyzed. Results: The variability of lactate (P<0.001, OR=0.580, 95% CI=0.505-0.652), pH (P=0.001, OR=0.004, 95% CI=0.000-0.104), Na_Effect (P<0.001, OR=0.550, 95% CI=0.378-0.592), K_s (P<0.001, OR=0.385, 95% CI=0.244-0.565) values were protective factors of ICU mortality and Cl_s value was a risk factor (P=0.004, OR=1.095, 95% CI=1.024-1.164). Variability of Cl_Effect, SID_nl values did not affect ICU mortality. Conclusions: The variability of electrolytes is important. Electrolyte, effects, and lactate variability can guide treatment and fluid applications in ICU.

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Rationale: As an uncommon manifestation of congestive heart failure, congestive hepatopathy requires an early diagnosis in order to render appropriate care. Misdiagnosis as intraabdominal sepsis may lead to erroneous initial intervention, such as fluid boluses, that can potentially tip an already sick patient with poor reserves over into an extreme state. Patient’s Concern: A 65-year-old man was brought to the emergency department for excruciating abdominal pain, vomiting and jaundice. He also had lower limb pitting edema and was hypotensive en route. Diagnosis: Congestive hepatopathy. Interventions: Intravenous furosemide and fluid restriction. Outcomes: The patient declined admission to the cardiology ward and discharged himself against medical advice after his condition was improved in the emergency department. Lessons: It is important to pay attention to acute abdominal pain induced by extraabdominal pathologies. In this case of acute decompensated congestive heart failure, early recognition of the cause makes a difference to the management.

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Rationale: The gastrointestinal manifestations of COVID-19 include anorexia, nausea, vomiting, abdominal pain, and diarrhea. However, pancreatitis as the presentation of COVID-19 is rarely reported. Patient’s Concern: A 63-year-old COVID-19 patient presented with complaints of abdominal pain and difficulty breathing for 5 d. Diagnosis: Contrast-enhanced computed tomography of the abdomen suggested acute interstitial pancreatitis without any biliary tract obstruction. Interventions: The patient was resuscitated with intravenous fluids based on dynamic parameters of fluid responsiveness. The patient was started on enteral feeding, analgesics, antibiotics, dexamethasone, low molecular weight heparin, and supportive therapy. Outcomes: The patient developed severe acute respiratory distress syndrome and died 6 days after admission. Lessons: Management of COVID-19 in the presence of pancreatitis is challenging. Adequate early fluid resuscitation is an important aspect of medical management for COVID-19 patients with pancreatitis and restrictive strategies must be followed. Increased liver enzymes and renal dysfunction in acute pancreatitis can also limit the use of specific therapies like remdesivir. Dexamethasone, even though it has shown a beneficial effect in treating COVID-19, can have an additive effect in causing hyperglycemia in these cases. Clinicians should be aware of this atypical presentation of COVID-19 with pancreatitis and adjust their management strategies, keeping in mind the considerations for both diseases.

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Rationale: There are many cases of daily reported dog bite injuries around the world. However, craniofacial fractures owing to dog bites are quite rare. They are frequently seen in the pediatric age group. Here, we report the successful management of a pediatric patient with depression skull fracture due to a dog bite injury. Patient’s concerns: A 3-year-old boy was admitted to the emergency department with a complicated skull fracture due to a dog bite injury. In physical examination, the patient was neurologically intact. He had hemorrhagic scalp wounds. Cerebrospinal fluid was leaking on the right temporal and frontal sides. Diagnosis: Cranial computed tomography revealed pneumocephalus, brain edema, and compound fracture associated with right frontal concussion. Intervention: After decompressive craniectomy, duraplasty was performed by placing a galea graft. Depressed fractures were removed and subdural bleeding control was provided. Outcomes: Perioperative and postoperative periods were uneventful. Lessons: Emergency medicine physicians should control possible underlying fracture lines in pediatric head trauma caused by dog bites.

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Rationale: Symmetrical peripheral gangrene is a rare acute condition triggered by several medical conditions. It needs to be recognized early and treated as an emergency. Patient’s Concern: A 40-year-old patient without any comorbidities presented with sudden onset of pain, swelling, blistering and bluish discoloration of the fingers and toes associated with fever and constitutional symptoms. Later the fingers and toes turned dark and they were cold to touch. Diagnosis: Diagnosis of symmetrical peripheral gangrene was made and investigated. Blood culture isolated Escherichia coli indicating a possible role in the causation of symmetrical peripheral gangrene. Interventions: Patient was managed with antibiotics and anticoagulants along with supportive care. Outcomes: There was improvement in patient’s general condition along with development of gangrene demarcation line of the fingers and toes. Lessons: Awareness of this condition is needed and an early management is recommended including recognizing the cause and supportive therapy to prevent complications.

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