Journal of Practical Emergency Medicine

Background: The measurement of mid-regional pro-atrial natriuretic peptide (MR-proANP) as a clinical biomarker has become a potent diagnostic value for identifying patients with heart failure. This study aimed to determine the diagnostic value of MR-proANP in heart failure in comparison with brain natriuretic peptide (BNP).

Methods: This prospective diagnostic accuracy study evaluated two biomarkers in consecutive patients presenting to the emergency department (ED) with acute dyspnea. Blood samples were collected immediately from the participants. A diagnostic value of MR-proANP versus BNP for the diagnosis of acute heart failure was analyzed. All patients underwent transthoracic echocardiography to classify the diagnosis as dyspnea due to heart failure or due to other causes. Patients without a subsequent diagnosis of heart failure were compared as the controls. The diagnostic performance was evaluated by receiver operating characteristics (ROC) analysis.

Results: Overall, 100 patients with heart failure and 85 controls were included in the study. The plasma levels of BNP and MR-proANP were significantly higher in the heart failure patients than in the control patients (p<0.001). MR-proANP levels significantly correlated with BNP levels (r=0.745, p<0.001). The ROC analysis demonstrated an area under the curve (AUC) of 0.872 (95% CI: 0.815–0.917) for MR-proANP and an AUC of 0.814 (95% CI: 0.751–0.868) for BNP. The AUC of MR-proANP was significantly higher than BNP to detect heart failure in patients with dyspnea (p=0.008). The optimal cut-off point of plasma MR-proANP was 134 pmol/L (sensitivity: 88.1%; specificity: 84.5%; PPV: 87.3%; NPV: 85.5%).

Conclusion: MR-proANP may be a useful biomarker for the diagnosis of acute heart failure in patients with dyspnea presenting to ED. The diagnostic value of MR-proANP was superior to BNP for diagnosing heart failure.

Background: This study was conducted to investigate nursing student satisfaction and anxiety with an emergency and crisis management game-based training (GBT) course.

Methods: This quasi-experimental study included 60 third-year nursing students who had completed their clinical clerkships. The majority were single females, with no significant age differences, disaster experience, or crisis management training. The participants were randomly assigned to two equal group. The intervention group used disaster-themed games, while the control group received case-based training. The study comprised a four-week internship, and a self-reported anxiety levels was assessed before and after their first clinical experience. In addition, a self-report questionnaire was used to measure students' satisfaction with the Game-based Training program. The reliability of these questionnaires was assessed by a panel of ten faculty members and using Cronbach's alpha. The reliability of both the anxiety and satisfaction questionnaires was found to be 87%. The satisfaction questionnaire's alpha coefficients for realism, transferability, and value were 0.52, 0.79, and 0.74, respectively. Additionally, the face validity of these questionnaires was evaluated.

Results: Participants felt that the experiences recreated real-life situations, tested their clinical decision-making, prepared them for the "real-life" clinical setting, and increased their confidence while in the clinical setting. In comparison to students who did not take part in the preclinical GBT, students who engaged in disaster-themed games showed significantly lower self-reported anxiety scores.

Conclusion: Nursing students are increasingly utilizing game simulators for learning, practicing, and enhancing their skills. They experience positive satisfaction and reduced anxiety through GBT. These simulations offer realistic clinical scenarios, opportunities for decision-making, and confidence-building.

Background: This study aimed to investigate the incidence of rheumatoid arthritis (RA) flare-ups following immunization with the Sinopharm COVID-19 inactivated virus-based vaccine.

Methods: We conducted a retrospective observational study at the Rheumatology Clinic of Imam Hossein Hospital, incorporating 200 RA patients in remission undergoing non-biologic Disease-Modifying Antirheumatic Drugs (DMARDs) treatments. A rheumatologist confirmed a flare-up based on patients complain of arthralgia and joint stiffness and complete examination of joints over a three-month period following vaccination.

Results: Twelve percent of all included patients experienced symptom recurrence. The average age of patients with flare-ups was significantly higher, but no gender-based differences were observed (p<0.001 and p=0.071, respectively). The second vaccine dose resulted in a higher number of symptom flares compared to the first dose (9.30% vs. 3.0%, p < 0.001). No significant differences were observed between patients experiencing flare-ups after the first dose and the second dose in terms of the number of involved joints (p=0.321) and the time gap from vaccination to symptom recurrence (p=0.526). No patients required hospitalization, and prednisolone dosage adjustments effectively managed symptoms.

Conclusion: The occurrence of flare-ups was relatively low after the Sinopharm COVID-19 vaccination in RA patients undergoing treatment with DMARDs during remission. The majority of these flares were mild and no hospitalizations were required.

Background: Rapid antigen tests have gained importance during the COVID-19 pandemic due to low prices and availability. The present study investigated the performance of the SARS-CoV-2 rapid diagnostic test in diagnosing patients with COVID-19 referred to the emergency department.

Methods: In this diagnostic accuracy study, patients with suspected COVID-19 referred to Imam Hossein and Shohadaye Tajrish Hospitals, Tehran, Iran, were examined. All patients were subjected to a rapid corona test according to the manufacturer’s guide and a chest computed tomography (CT) scan as the standard test. The screening characteristics of the rapid test compared to CT scan were calculated and reported.

Results: 183 people with an average age of 46.83 ± 14.26 (range: 21-83) years entered the study. 141 suspected cases of COVID-19 (77%) had evidence of lung involvement in CT, and the rapid test was positive in 83 (45%) cases. Out of 83 patients who tested positive for COVID-19, all (100%) had positive chest CT findings. Out of the 100 patients who tested negative, 42 patients (42%) had negative chest CT findings, and 58 patients (58%) had positive CT scans. The sensitivity, specificity, and accuracy of the mentioned test were 58.86, 100.00, and 68.30 percent, respectively.

Conclusion: Due to the relatively low sensitivity, the Rapid SARS-CoV-2 antigen test fails to screen for SARS-CoV-2 infection. However, it can be used to confirm the presence of the disease in symptomatic individuals and reduce virus transmission during the COVID-19 pandemic.

Background: Even though the basic principles of cardiopulmonary resuscitation (CPR) are simple, the patients' outcome remains inconsistent. This study aimed to investigate the CPR outcomes and associated factors in the emergency department.

Method: This cross-sectional study was conducted on patients who underwent in-hospital CPR following a cardiac arrest in the emergency department for one year. The patient's baseline characteristics and CPR outcomes were recorded from patients' profiles, and the association of patient-related and CPR-related variables with the outcomes was assessed.

Results: 220 patients with a mean age of 71.5 ± 16.9 (range: 20-100) years were included (60.5% male). 193 cases of cardiac arrests had occurred in the hospital. Presenting cardiac rhythm in 198 cases (90.0 %) was asystole (not requiring defibrillation). The mean duration of conducted CPR was 43.2 ± 15.6 (5-120) minutes. Only 7 patients (3.2%) achieved the return of spontaneous circulation (ROSC) and were discharged from the hospital, with one suffering from neurological impairment due to CPR. There was a significant association between age (p = 0.047), consciousness status at admission (p = 0.003), presenting cardiac rhythm at CPR initiation (p = 0.0001), and establishment of ROSC under 45 minutes (p = 0.043) with patients' outcomes. Presenting cardiac rhythm at CPR initiation (p = 0.001), ROSC under 45 minutes (p = 0.012), and consciousness status at admission (p = 0.027) were independent predictive factors of survival. The area under the ROC curve for presenting cardiac rhythm and ROSC under 45 minutes was 0.817 (95% CI: 0.617-1.000) and 0.805 (95% CI: 0.606-1.000), respectively.

Conclusion: Based on the present study's findings, the survival rate of patients after CPR in ED was 3.2%. Presenting cardiac rhythm, ROSC under 45 minutes, and consciousness status at admission was among the independent predictors of mortality.

Background: Surgeons played a vital role in the Iraq-Iran War by healing injured soldiers and reducing the rate of death. The purpose of this study was to describe their lived experiences and social impact during the war.

Methods: This qualitative study was conducted from May2018-June2019 and surgeons who participated in the Iraq-Iran War were invited. Semi-structured in-depth interviews were used to collect the data from 28 participants.

Results: Four main themes emerged from the data: 1- Military role was important in providing essential facilities and safe zones for personnel and soldiers at the warfront. 2- It was critical to reinforce the infrastructure for immediate medical assistance. 3- Disaster training for medical personnel was vital for triage, treatment, education and research planning. 4- Spiritual and religious beliefs.

Conclusion: Disaster planning and training for physicians by drills is essential to meet the challenges of unexpected events and operative readiness requires drill training on a quarterly or semi-annual basis.

Background: Evidence indicates the protective role of Irisin on nervous tissue following ischemic events, by preventing the cascades of secondary damage. We conducted this scoping review to summarize what has been discovered so far on the neuroprotective effects of Irisin, with a focus on ischemic stroke.

Methods: Search strategies were designed based on the keywords related to ischemic stroke and Irisin. Next, an extensive search in Medline, Embase, Scopus, and Web of Science was conducted by the end of April 2022. Two researchers independently reviewed the articles and performed the screening of the selected papers according to the inclusion criteria. Finally, the required data were extracted to a checklist designed based on the PRISMA guideline. The “meta” package was used for the meta-analysis, and heterogeneity between studies was assessed using the I² test.

Results: Pooled data analysis showed that the Irisin administration significantly improved the neurological function following cerebral ischemia / reperfusion injuries (SMD = 3.08; 95% CI: 1.10, 5.06; p<0.0001). Additionally, meta-regression demonstrated that the improvement in neurological function was directly related to the dose of administered Irisin (meta-regression coefficient = 0.03; p = 0.02). Moreover, Irisin administration significantly reduced the volume of infarcted lesions (SMD= -3.14; 95% CI: -4.23, -2.04; p<0.0001), the amount of edema in the brain (SMD= -2.30; 95% CI: -4.07, -0.53; p<0.0001), and the extend of neuronal-cell apoptosis rate (SMD= -4.67; 95% CI: -8.15, -1.19; p<0.0001).

Conclusion: The present study demonstrates that the administration of Irisin in animal models of cerebral ischemia / reperfusion injuries is associated with a significant dose-dependent improvement in neurological function. Due to the limited number of articles, more research on the aim of finding the optimum Irisin dosage is in high demand.

Background: Los Angeles Motor Scale (LAMS) is a validated prehospital scoring tool to identify stroke patients with large vessel occlusions (LVOs). While some studies have reported conflicting data in regards to the diagnostic value of LAMS, this systematic review and meta-analysis aims to provide a more concrete evidence for the value of this clinical decision tool in the diagnosis of LVO in suspected stroke patients.

Method: Online databases of PubMed, Embase, Scopus, and Web of Science were searched until the end of October 2022, for studies evaluating the diagnostic performance of LAMS in the detection of LVOs in suspected stroke patients.

Results: The results of our analysis demonstrated an AUC of 0.83 (95% CI: 0.79, 0.86), sensitivity of 0.65 (95% CI: 0.54, 0.74), and specificity of 0.83 (95% CI: 0.79, 0.86) for the diagnostic value of LAMS score with a cut-off value of ≥ 4. The diagnostic odds ratio of LAMS score was 8.81 (95% CI: 6.24, 12.45). Sensitivity analyses reveled that diagnostic performance of LAMS improves when utilized for detection of occlusion in the more proximal segments of large vessels, with a sensitivity of 0.75 and specificity of 0.83.

Conclusion: A high level of evidence showed that LAMS scale does not have a promising diagnostic value in the identification of LVOs in suspected stroke patients. The sensitivity of 0.65 for this tool makes it obsolete as a proper triaging tool. As a suggestion, LAMS could be utilized in conjunction with other additional factors to increase its diagnostic performance.

Background: In recent years, various peptides have been introduced for the complementary treatment and management of post-reperfusion injuries. Nesfatin-1, a peptide secreted by the nervous system and peripheral tissues, modulates cardiac function, and plays an important role in the cardiovascular response to stress conditions. This systematic review and meta-analysis aims to investigate the preclinical evidence on the effect of Nesfatin-1 administration in the improvement of cardiac ischemia/reperfusion injury.

Method: Online databases of PubMed, Embase, Web of Science, and Scopus were searched until November 2^nd, 2022, for articles investigating the therapeutic effects of Nesfatin-1 administration on myocardial ischemia/reperfusion injury in preclinical models. Cardiac functions, infarct size, myocardial tissue fibrosis, inflammation, oxidative stress, apoptosis, necroptosis, and necrosis were chosen as outcomes. The results are reported as an overall standardized mean difference (SMD) and 95% confidence interval (CI).

Results: Our results demonstrate that the administration of Nesfatin-1 improves cardiac parameters such as ejection fraction (SMD = 3.94, 95% CI: 0.30 to 7.58), heart rate (SMD = 3.30, 95% CI: 0.41 to 6.18), and negative dp/dt (SMD = 2.05, 95% CI: 0.60 to 3.50) and positive dp/dt (SMD = 2.78, 95% CI: 0.56 to 4.99). Nesfatin-1 was shown to significantly reduce myocardial infarct size (SMD = -4.32, 95% CI: -5.95 to -2.69 and fibrosis (SMD = -3.91, 95% CI: -5.67 to -2.15). Apoptotic score (SMD = -2.07, 95% CI: -3.51 to -0.63) and oxidative stress were also reduced subsequent to Nesfatin-1 administration. Nesfatin-1 was not shown to decrease inflammation, necroptosis, and necrosis.

Conclusion: In conclusion, we demonstrated that Nesfatin-1 could serve as a potential therapeutic agent in ameliorating the secondary damages during myocardial I/R injury. Nesfatin-1 administration can preserve cardiac function by reducing oxidative stress, apoptosis, and myocardial necrosis. However, much more studies are required to endorse further clinical translation of Nesfatin-1 to be utilized in the management of myocardial I/R injury.

The situation, structure, and facilities of hospitals change in a crisis, which negatively affects the provision of care quality of health services. One of the current world crises is the Covid-19 pandemic. This study aimed to investigate the preparedness of hospitals to deal with the Covid-19 crisis. This narrative review searched the SID, PubMed, Scopus, and Google Scholar databases/search engines in published articles between 2019-2022. A search strategy was defined for PubMed and it was translated into other selected databases. Also, the reference list of the included articles was searched. The databases/search engines were searched by two authors independently, and any disagreement was resolved through discussion. Inclusion criteria included being an original paper, in Persian or English, and compliance with the purpose of the study. The exclusion criteria included not having access to the full text of the article. To find related articles, Iranian and International databases were searched using Persian keywords and their English equivalents (Covid-19, Hospital, Preparedness, epidemic, and Pandemic). A total of 311 articles were found, of which 15 were reviewed. The study showed that hospital preparedness against the Covid-19 pandemic in most countries and different regions in Iran is not optimal. Hospitals should be prepared in terms of personal protective equipment, staffing, and beds. Rapid response management and hospital equipment should be strengthened. Considering the desirability of patient preparation in coping with Covid-19, it is necessary to improve healthcare facilities by increasing the number of workforce and beds.

Cervical ectopic pregnancies (CEPs) are rare, comprising less than 1% of ectopic pregnancies. On one hand, the abundant blood supply of the cervix and its incompatibility to keep the pregnancy in progress increases the potential for bleeding following CEP, mortality, complications, and infertility in affected women. CEPs are more difficult to diagnose and get identified at later gestational ages. CEP is one of the rarest forms of ectopic pregnancies and most commonly are a consequence of assisted reproductive technology (ART); while definitive risk factors are not fully known. Possible risk factors include cervical and uterine anomalies, previous curettages or cesarean sections, smoking, tubal factor infertility, or in vitro fertilization (IVF) treatment. Our analysis of literature in 200 patient restricted to retrospective case series , showed that a history of previous C-section, uterine curettage or D&C procedures, and a history of using assisted reproductive technology might be some of the potential risk factors. The increasing application of Hegar dilators was hypothesized as the cause of the rise in CEPs. Dilation and curettage (D&C) might also make the subject vulnerable to CEP development in the future. Previous D&C history could be a potential predisposing factor that is common among CEP patients.  In this review, we critically reviewed these potential risk factors. In conclusion, the risk factors of CEP and their effect on fertility are also not studied properly. The rarity of these cases makes it difficult to predict as well if the risk of their recurrence is elevated.

Artificial Intelligence (AI) has emerged as a transformative force across various industries and healthcare. With the ever-expanding capabilities of AI, there is growing interest in the exploration of its potential applications in nursing practice to enhance patient care, improve workflow efficiency, and possibly revolutionize healthcare systems. The integration of AI in clinical decision support systems has shown immense promise. AI algorithms can rapidly analyze vast amounts of patient data, symptoms, medical history, and treatment options to provide evidence-based recommendations to healthcare professionals. By augmenting clinical decision-making, AI-powered systems can assist nurses in making well-informed decisions, leading to more accurate diagnoses, personalized treatment plans, and improved patient outcomes.

Moreover, AI technology has the potential to revolutionize patient monitoring and predictive analytics. Smart devices integrated with AI algorithms can continuously monitor patients' vital signs, detect abnormalities, and alert nurses in real-time, enabling early intervention and proactive care. Furthermore, predictive analytics can help identify high-risk patients, predict potential complications, and optimize resource allocation, leading to improvements in patient safety and resource management within healthcare facilities (3). Another thrilling application of AI in nursing is the utilization of virtual nursing assistants or chatbots. These AI-driven virtual assistants can provide patients with personalized health information, respond to their questions, and offer guidance on self-management of chronic conditions. By alleviating the burden of routine nursing duties, virtual nursing assistants would allow nurses to focus more on direct patient care and complex tasks.  Despite the unquestionable potential benefits of AI implementation in nursing practice, it's essential to acknowledge certain considerations and challenges. Maintaining patient privacy and data security, addressing ethical concerns, ensuring the human touch in care delivery, and providing adequate training and support for healthcare professionals in adopting AI technologies are crucial aspects that need careful attention as we move forward.

In conclusion, it is evident that the application of AI in nursing practice holds immense promise and has the potential to herald a new era of healthcare. From clinical decision support systems to predictive analytics and virtual nursing assistants, AI can augment nursing practice, enhance patient outcomes, and optimize healthcare processes. However, it is imperative to proceed prudently, ensuring a delicate balance between technological advancements and empathetic human-centered care.

Ischemic heart diseases (IHDs) are among the most important causes of death and disability worldwide. Every year, 10.6 million people are diagnosed with IHDs; in 2017, 8.9 million died due to this disease. The treatment of myocardial infarction is principally based on prompt blood supply restoration to salvage the ischemic tissue utilizing timely thrombolytic medications and coronary revascularization. However, the subsequent reperfusion provokes secondary cellular damage, broadly referred to as reperfusion injury. Although a compendium of therapeutic agents has been proposed to allay the detrimental consequences of reperfusion, they do not yet have desirable efficacies, and the research for discovering novel promising treatments is still ongoing.

Preclinical studies are integral to the translation of preliminary research into clinical practice. Conventionally, plausible treatments and innovative drugs are tested in animal experiments to ascertain their effectiveness and safety. Experimentations on cardiac Ischemia/reperfusion injuries comprise a significant body of literature among the preclinical studies, and one can find a myriad of evidence in online databases.

Through our systematic reviews, we have encountered various myocardial ischemia/reperfusion (I/R) models, including large vessel ligation, global ischemia by administrating Isoproterenol, and interrupted perfusion of isolated hearts mounted on the Langendorff apparatus. Moreover, the studies were inconsistent regarding the duration of ischemia and, the subsequent reperfusion phase. The secondary damages in the course of I/R injury are proportionate to the extent and duration of the ischemia. Moreover, Pathways leading to myocardial damage during I/R injury are considered a dynamic and evolving process. Therefore, the efficacy of interventions in mitigating I/R injury may be misestimated depending on the duration of the ischemic and reperfusion phases.

To surmount these concerns, we suggest an expert panel develop standardized guidelines for myocardial I/R injury induction in experimental studies to consolidate further the reliability and validity of the results obtained from preclinical studies, ultimately contributing to the better appraisal of the studies. In the meantime, tissue markers representative of the degree of infarction or tissue fibrosis can be used to compare the induced ischemia/reperfusion injuries in studies.

Cardiovascular diseases are one of the most important causes of death worldwide, resulting in a burden of 423 million DALYs and 21 million deaths in 2021. Extensive research is being conducted in numerous fields of cardiovascular disease, and observational studies have become a significant body of related literature.  One of the main purposes of observational studies is the evaluation of the diagnostic and prognostic capabilities of index tests, scoring tools, and other clinical and paraclinical factors.  

Quality Assessment of Prognostic Accuracy Studies (QUAPAS) guidelines have been recently introduced as an alternative to Quality Assessment of Diagnostic Accuracy Studies (QUADAS) guidelines for appraisal of the risk of bias in prognostic studies. QUAPAS guidelines propose treatment regimen differences between patients as a source of bias in the flow and timing domain.

According to these guidelines, “Clinical management should ideally be identical for all study participants during the follow-up period”; otherwise, the study results will likely contain bias. In our previous systematic reviews, most articles had not specified their patient treatment regimens. The differences in treatment strategies between patients and between studies can affect the study results and influence the calculated prognostic or diagnostic value of a possible index test. Thus, these studies are evaluated as having some concerns regarding their risk of bias. Observational studies, especially diagnostic and prognostic accuracy studies, should report the patient’s treatment regimens to address this issue.

Since it is often impossible to equate the treatments of cardiovascular patients due to their different assessed risks, the studies should utilize multivariate analysis models to adjust for the treatment regimen variations and report their results as adjusted odds ratio, adjusted relative risk, or adjusted hazard ratio. Prognostic studies are also subject to time-event outcomes and need to account for censoring. Therefore, we suggest these studies implement cox regression models in their analyses.

Cardiac tamponade is a leading cause of death in patients with aortic dissection. When aortic dissection is accompanied by cardiac tamponade, emergency surgery to repair the aorta is required. The treatment approach for this group of patients differs from other cases with pericardial effusions, and percutaneous pericardiocentesis is contraindicated. Attempting pericardiocentesis in this type of tamponade leads to increased leakage from the aorta into the pericardium, worsening the patient's condition. Here I present a 29-year-old woman with chest pain who called emergency medical service to her home. Cardiac arrest occurred during her transfer to the emergency department. During the cardiac resuscitation, this pericardiocentesis was performed, but drainage was unsuccessful due to the presence of a gelatinous fluid, despite the needle being visible within the pericardial space. Suspecting aortic dissection as the cause of cardiac tamponade, an on call cardiothoracic surgeon was immediately consulted. The surgeon ordered the patient to be transferred to the operating room, while cardiac resuscitation was continued.  Following the surgery, the surgeon reported that the patient has a cardiac tamponade caused by an aortic dissection, and that the gelatinous effusion resulted was a result of clotted blood around the heart. However, the patient did not survive after surgery.

Procedural sedation and anesthesia (PSA) is a common practice in the emergency department (ED). We report a case of seizure after ketamine and propofol administration for procedural sedation. Seizure is not a common side effect of ketamine nor propofol. A 60 years old man admitted to the emergency department with complaint of right shoulder pain caused by the blunt trauma. Simple X-Ray revealed anterior dislocation. After administration of 30 mg ketamine and propofol (1:1) intravenously, closed shoulder reduction was performed. After 2 minutes, the patient experienced a generalized tonic-clonic seizure with upward gaze and urinary incontinence. The clonic movements resolved after about 1 minute with supportive care and without anti epilepsy drugs, then the patient entered the post-ictal phase. 45 minutes later, the patient was completely awake and after 6 hours observation, he was sent home with discharge instructions. Seizure is not a common complication of any of the administered drugs. Nevertheless, rare possibilities may also occur, and thus emergency clinicians and others who perform procedural sedation, should be ready for any possible complications to treat them appropriately.

Coincident impalement trauma to the neck and chest is infrequent but life-threatening. Our case was a 35-year-old man, who presented with rebar penetration injury to the neck and mediastinal area. He was conscious and his vital signs were stable. After initial imaging, the patient was transferred to the operation room for explorative surgery; however, as the rebar was loos in its site, we simply pulled out the rod. The patient developed acute respiratory distress syndrome (ARDS) during their administration and was eventually discharged without further complications and comorbidities.

Sickle cell disease (SCD) is a known risk factor for the development of severe dengue, however, literature documenting dengue in SCD is scarce. Dengue fever further triggers the sickling process in a patient with SCD by augmenting endothelial dysfunction, the main identifiable cause behind organ dysfunction. Hepatic involvement in SCD due to enhanced sickling can be in the form of acute viral hepatitis, cholecystitis, acute sickle hepatic crisis, and more severe sickle cell intrahepatic cholestasis (SCIC). Initially starting as an acute sickle hepatic crisis, SCIC progresses to striking jaundice, enhanced bleeding tendency coupled with mostly renal failure. We report a rare case of a female, native of Chhattisgarh with SCD and dengue shock syndrome who had fatal hepatic complications resulting from accelerated severe endothelial dysfunction due to concurrent illnesses.

Renal infarction is rare and may be considered acute renal colic in presentation. In this report, we describe a case of renal infarction caused by thrombosis that extended from the aortoiliac to the infrapopliteal segment, along with thrombosis that occurred in the right popliteal artery and left atrium. A 48-year-old man was referred to the emergency department (ED) suffering left flank pain. The pain was significant with radiation to the left lower quadrant, and the pain did not significantly decrease despite intravenous ketorolac and morphine sulfate administration. We decided to perform a color Doppler ultrasound test of intraabdominal vessels that revealed low flow in the left iliac artery. By computed tomography angiography (CTA), it was confirmed that the left renal, iliac, and popliteal arteries were thrombosed. The patient underwent anticoagulation, thrombectomy, and Mitral valve replacement surgery during the hospitalization. After 14 days, his heart rhythm returned to normal sinus and he was discharged from the hospital with proper outpatient follow-up. Patients with severe flank pain and who do not respond to routine treatments, especially patients with significant risk factors, should be evaluated more carefully for red flag diagnosis.

Electrical cardioversion or intravenous ibutilide are currently recommended as the acute treatment for pre-excited atrial fibrillation. Recent guidelines for this circumstance forbid intravenous amiodarone despite its effectiveness in blocking the accessory pathway and atrioventricular node due to the possibility of ventricular fibrillation. But as our presented case, some physicians continued to favor intravenous amiodarone successfully in a suitable setting.

Blood product transfusion is a double-edged sword; it can be lifesaving in many circumstances, yet life-threatening serious complications may occur. Although transfusion-related reactions have decreased over the years as a result of hemovigilance networks all over the world, human errors still remain an important concern. In this case report, we describe a patient undergoing elective spinal surgery who received an incompatible blood product. Then we will describe measures to mitigate such errors.

Although Hymenoptera stings mostly present with benign local inflammation, they can also be fatal. The true incidence of fatal reactions is unknown as sudden deaths due to insect bites might be regarded as heart attacks or strokes. Hymenoptera stings remain an underrecognized and underdiagnosed entity with no relation between the early cutaneous manifestations and the uncommon deadly reactions that are seen days to weeks later. We report a case of a 69-year-old farmer referred to our hospital with both acute coronary syndrome and acute ischemic stroke approximately 5 hours after a bee sting without a history of any initial anaphylaxis.

Kawasaki disease is an acute febrile disease with the vasculitis of small and medium vessels that mainly affects children under the age of five, usually occurring after a viral respiratory diseases. During the coronavirus disease-19 (COVID-19) pandemic, a significant increase was reported in the number of children with symptoms similar to Kawasaki disease, which is known as a multi-system inflammatory syndrome in children (MIS-C). A Kawasaki-like disease is rare in adults, especially in the context of COVID-19. We hereby present the case of A 41 year old female patient presented with complaints of bleeding from the gums and red and watery eyes, high fever, sore throat, weakness, and lethargy. She mentioned a recent contact with a COVID-19 patient. Covid-19 was confirmed by a positive reverse transcription polymerase chain reaction (RT-PCR) test. Other lab tests and clinical manifestations revealed inflammatory phenomena that fully complied with multi-system inflammatory syndrome in adults (MIS-A) criteria. The patient was treated with a possible diagnosis of MIS-A in the context of COVID-19 and was discharged in good general condition. COVID-19 rarely presents in adults without clear respiratory symptoms and in the form of multisystem inflammatory syndrome (MIS-A). Due to the possibility of irreversible complications, MIS-A requires special attention and early diagnosis and treatment.

Today, clinicians use ultrasound, similar to the use of a stethoscope ten years ago. We will soon see ultrasound probes in the pockets of every medical student. Nowadays, ultrasound probes are used in the examination of patients, and ultrasound is no longer considered a para-clinical procedure, and during patient examinations, we also perform ultrasounds for our patients in order to limit differential diagnosis. As a result of these examinations and applying clinical and ultrasound findings, the desired treatment is determined.

In ultrasound, one challenge that always arises is the Doppler field and vascular flow. Recent articles have emphasized the importance of using ultrasound for clinicians. There is a general lack of enthusiasm among clinicians when the term Doppler is mentioned. Due to this, I considered it necessary to write an educational article in an easy-to-understand manner and at the same time practical in this field for the medical community, especially clinicians. It is my goal to provide the information in a simple and practical manner.

As a practicing orthopedic surgeon and educational deputy in the orthopedic ward, I have witnessed challenges teaching complex surgical procedures and managing orthopedic trauma patients to residents in real-time. However, the advancement of technology has dramatically accelerated the learning process. During Covid-19, we have benefited from online teaching and case discussions using WhatsApp and received many positive feedbacks from residents and faculties. Speaking of the new technological assets, one particular tool that has proven to be very effective for educational purposes is ChatGPT.