Case report: Dysphagia aortica.

Dysphagia, characterized by abnormal swallowing, presents as oropharyngeal or esophageal dysphagia. Dysphagia aortica, a rare manifestation, results from external aortic compression, leading to swallowing difficulties. Limited literature exists on this condition. We report a 22-year-old male with a complex surgical history, including aortic repairs, who presented with dysphagia and chest pain. Extensive evaluations ruled out other causes. Imaging revealed esophageal compression by an aortic graft. Endoscopy confirmed extrinsic compression. A barium swallow study was unremarkable. A diagnosis of dysphagia aortica was made, and conservative treatment was initiated. Dysphagia aortica remains a rare but noteworthy cause of dysphagia with this case highlighting the importance of considering vascular compression in patients with previous history of aortic surgery. Increased clinical awareness is essential for timely diagnosis and tailored treatment strategies. Further research is needed to establish guidelines for managing this condition, given its diverse causes.

Comparative Clinical Assessment and Risk Stratification of COVID-19 and Influenza Infections in Adults and Children: A Comprehensive Systematic Review and Meta-Analysis.

Objective: This study aimed to compare the clinical risks and outcomes of COVID-19 and influenza. Methods: The search for relevant articles was conducted using both a database search method and a manual search, which involved searching through the reference lists of articles related to the topic for additional studies. The Quality assessment was carried out using the Newcastle Ottawa tool, and the data analysis was conducted using the Review Manager Software (RevMan 5.4.1). Results: The meta-analysis results indicated that COVID-19 patients had similar lengths of hospital stays (SMD: -0.25; 95% CI: -0.60-0.11; p=0.17). However, COVID-19 patients had significantly higher mortality rates (RR: 0.28; 95% CI: 0.21-0.37; p<0.0001), in-hospital complications (RR: 0.57; 95% CI: 0.50-0.65; p<0.00001), intensive care unit (ICU) admissions (OR: 0.48; 95% CI: 0.37-0.61; p<0.00001), length of ICU stay (SMD: -0.45; 95% CI: -0.83-0.06; p=0.02), and mechanical ventilation use (OR: 0.36; 95% CI: 0.28-0.46; p<0.00001). Conclusion: The findings suggested that COVID-19 was more severe than influenza. Therefore, "flu-like" symptoms should not be dismissed without a clear diagnosis, especially during the winter when influenza is more prevalent.

Atypical Presentation and Diagnostic Challenges of Appendicitis in an 85-Year-Old Male: A Case Report.

Acute appendicitis in elderly individuals is uncommon and poses a significant challenge due to atypical symptomatology. An 85-year-old male presented to the emergency department (ED) with abdominal pain associated with nausea and reduced oral intake. Physical examination revealed diffuse abdominal tenderness. He was initially treated for constipation with an enema and discharged. Two days later, the patient returned with worsened pain and a new onset of fever. Examination revealed guarding. Lab results showed significant elevation in C-reactive protein (CRP) and white blood count (WBC). A contrast-enhanced computed tomography (CT) scan showed evidence of a perforated appendix. He was admitted into the surgical ward and improved on conservative treatment. This case describes an atypical presentation of acute appendicitis in an elderly patient, emphasizing the importance of recognizing unusual presentations in this population. Early use of contrast-enhanced CT scans is crucial for accurate diagnosis and improving patients outcomes.

Deep venous thrombosis (DVT) diagnostics: gleaning insights from point-of-care ultrasound (PoCUS) techniques in emergencies: a systematic review and meta-analysis.

BACKGROUND: The assessment of deep venous thrombosis (DVT) is clinically difficult diagnosis. The "gold standard test" for DVT diagnosis is venography; however, various point-of-care ultrasound (POCUS) protocols have been suggested for DVT evaluation in the emergency department. AIMS: This review evaluated the role of different POCUS protocols in diagnosing DVT in the emergency department. METHODS: A systematic review and meta-analysis was conducted based of PRISMA guideline and registered on PROSEPRO (CRD42023398871). An electronic database search in Embase, PubMed, ScienceDirect, and Google scholar and a manual search were performed to identify eligible studies till February 2023. Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2) was used to assess the risk of bias in included studies. Quantitative analysis was carried out using STATA 16 and Review Manager software (RevMan 5.4.1). Sensitivity, specificity of POCUS protocols for DVT diagnosis compared to reference standard test was calculated. RESULTS: Heterogeneity was identified between 26 included studies for review. The pooled sensitivity, specificity, PPV, and NPV for the 2-point POCUS protocol were 92.32% (95% CI: 87.58-97.06), 96.86% (95% CI: 95.09-98.64), 88.41% (95% CI: 82.24-94.58) and 97.25% (95% CI: 95.51-98.99), respectively. Similarly, the pooled sensitivity, specificity, PPV, and NPV for 3-point POCUS were 89.15% (95% CI: 83.24-95.07), 92.71% (95% CI: 89.59-95.83), 81.27% (95% CI: 73.79-88.75), and 95.47% (95% CI: 92.93-98). The data pooled for complete compression ultrasound, and whole-leg duplex ultrasound also resulted in a sensitivity and specificity of 100% (95% CI: 98.21-100) and 97.05% (95% CI: 92.25-100), respectively. On the other hand, the time from triage to DVT diagnosis was significantly shorter for emergency physician-performed POCUS than diagnostic tests performed by radiologists. CONCLUSION: The diagnostic performance of POCUS protocols performed by emergency physicians was excellent. Combined with the significant reduction in time to diagnosis. POCUS can be used as the first-line imaging tool for DVT diagnosis in the emergency department. We also recommended that attending emergency physicians with POCUS training are present during DVT diagnosis to improve diagnostic performance even though high diagnostic performance is observed even with the minimum training.

A Case of Necrotizing Pneumonia Complicated by Hydropneumothorax.

We present a case of a 58-year-old man who had asthma and developed necrotizing pneumonia (NP). The Computed Tomography (CT) scan of his chest showed cavitating consolidation with hydropneumothorax. Despite chest tube insertion and antibiotics, the patient did not improve. Therefore, surgical intervention was considered, and he underwent a right posterior-lateral thoracotomy, with middle lobe lobectomy, and decortication. As a result, the patient's condition started to improve, and he was discharged in good health.

Lhermitte-Duclos disease in a 51-year old patient.

Lhermitte-Duclos disease (LDD) is a rare, slow-growing neoplasm that develops in the brain's posterior fossa. It can appear as a single lesion or as part of Cowden's syndrome. We report the case of a 51-year-old female with a history of diabetes, hypertension, and a previously treated neuroendocrine tumor, who presented to the hospital after experiencing a generalized tonic-clonic seizure. Except for a tongue laceration, the neurological examination was unremarkable. Brain magnetic resonance imaging (MRI) showed a T2 left cerebellar hemisphere pseudomass lesion with iso-hyperintense signals suggestive of Lhermitte-Duclos disease. This case describes a unique presentation of LDD and its various radiological manifestations, emphasizing the importance of neuroimaging in its diagnosis. Additionally, it contributes to the expanding literature on the varied manifestations of LDD.

Advancement in pleura effusion diagnosis: a systematic review and meta-analysis of point-of-care ultrasound versus radiographic thoracic imaging.

BACKGROUND: Pleural effusion is a fluid buildup in the pleural space that mostly result from congestive heart failure, bacterial pneumonia, malignancy, and pulmonary embolism. The diagnosis of this condition can be challenging as it presents symptoms that may overlap with other conditions; therefore, imaging diagnostic tools such as chest x-ray/radiograph (CXR), point-of-care ultrasound (POCUS), and computed tomography (CT) have been employed to make an accurate diagnosis. Although POCUS has high diagnostic accuracy, it is yet to be considered a first-line diagnostic tool as most physicians use radiography. Therefore, the current meta-analysis was designed to compare POCUS to chest radiography. METHODS: n extended search for studies related to our topic was done on five electronic databases, including PubMed, Medline, Embase, Scopus, and Google Scholar. A quality assessment using the Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2) was performed on all eligible articles obtained from the databases. Moreover, the diagnostic accuracy of POCUS and CXR was performed using STATA 16 software. RESULTS: Our search yielded 1642 articles, of which only 18 were eligible for inclusion and analysis. The pooled analysis showed that POCUS had a higher diagnostic accuracy compared to CXR (94.54% (95% CI 91.74-97.34) vs. 67.68% (95% CI 58.29-77.08) and 97.88% (95% CI 95.77-99.99) vs. 85.30% (95% CI 80.06-90.54) sensitivity and specificity, respectively). A subgroup analysis based on the position of patients during examinations showed that POCUS carried out in supine and upright positions had higher specificity than other POCUS positions (99%). In comparison, lateral decubitus CXR had higher sensitivity (96%) and specificity (99%) than the other CXR positions. Further subgroup analyses demonstrated that CXR had higher specificity in studies that included more than 100 patients (92.74% (95% CI 85.41-100). Moreover, CXR tends to have a higher diagnostic accuracy when other CXR positions are used as reference tests (93.38% (95% CI 86.30-100) and 98.51% (95% CI 94.65-100) sensitivity and specificity, respectively). CONCLUSION: POCUS as an imaging modality has higher diagnostic accuracy than CXR in detecting pleural effusion. Moreover, the accuracy is still high even when performed by physicians with less POCUS training. Therefore, we suggest it is considered a first-line imaging tool for diagnosing pleural effusion at the patients' bedside.

Broken Heart: A Clear Case of Takotsubo Cardiomyopathy.

Takotsubo cardiomyopathy (TC) is a recognized clinical syndrome characterized by reversible cardiomyopathy with a distinctive left ventricular apical ballooning appearance. TC is associated with risk factors such as estrogen deficiency, emotional and physical stress, and genetic factors. The clinical presentation of TC can be like that of a myocardial infarction. While catecholamine-induced myocardial stunning is suggested by current evidence, the exact pathophysiological mechanisms remain uncertain. Diagnostic criteria, including the InterTAK Diagnostic Criteria, have been established by the Takotsubo International Registry. Supportive and symptomatic medication constitutes the mainstay of treatment, with a focus on improving left ventricle (LV) function over several days, leading to full recovery within three to four weeks. Given its resemblance to myocardial infarction, cautious diagnosis and management are essential for optimal outcomes. We present the case of a previously healthy 35-year-old female who presented with chest pain and dyspnea after discovering her father's death. On examination, she exhibited hypotension, bradycardia, and a new-onset left bundle branch block (LBBB) in her electrocardiogram. Her left ventricular ejection fraction (LVEF) on presentation was 22%, and troponin T (TnT) levels were notably elevated at 430 (normal ranges < 14). After two days of treatment and monitoring at the cardiac intensive care unit (CICU), she improved clinically, and her LVEF improved to 52%.

Unmasking the Underlying Causes: A Cross-Sectional Analysis of Mortality From Intentional and Unintentional Injuries in the United Arab Emirates.

The United Arab Emirates (UAE) has experienced substantial development in infrastructure and transportation in the last few decades. Although available evidence suggests that the incidence of injuries has considerably increased in the previous few years, there is a scarcity of literature that comprehensively analyzed the mortality due to different types of injuries in the UAE. Therefore, the current study was designed to report mortality due to various intentional and unintentional injuries in the UAE. Secondary data was obtained from the World Health Organization (WHO) mortality database. We targeted injuries-specific mortality datasets. We applied a filter (UAE) to retrieve mortality data from unintentional and intentional injuries in the UAE. The latest data in the WHO mortality database was for 2020-21. A total of 10,357 death records from the UAE were present in the WHO mortality database. The percentage of injury-specific deaths out of total deaths was 8.69% (n=900). Injury-specific mortality rate per 100,000 population was 9.09. The percentage of injury-specific deaths was higher for males (87.3%, n=786) and the age group 25-34 years (n=323, 35.9%). Of the 900 injury-specific deaths, 449 (49.9%) were due to unintentional injuries, 216 (24.0%) were due to unintentional injuries, while the remaining (26.1%, n=235) deaths occurred due to Ill-defined injuries. More than half (53.7%, n=241) of unintentional injuries were because of road traffic injuries (RTIs) followed by fall (14.7%, n=66), exposure to mechanical forces (6.5%, n=29), drowning (6.0%, n=27) fire (1.1%, n=5), poisonings (1.1%, n=5), natural disasters (n=1, 0.2%) and other unintentional injuries (16.7%, n=75). More than three-quarters (83.3%, n=180) of intentional injuries were because of self-inflicted injuries while the remaining (16.7%, n=36) intentional injuries-specific deaths occurred due to violence. Many deaths in the UAE occur due to unintentional and intentional injuries. RTIs and falls are the leading causes of unintentional injury-specific deaths, while self-inflicted injuries and violence are the leading causes of intentional injury-specific deaths.

Heparin-induced Anaphylaxis shock.

Introduction: Anaphylaxis is a fatal condition that can be easily managed if discovered early. Only a few examples of anaphylaxis-like reactions caused by heparin have been documented, and immediate-type hypersensitivity reactions to heparin are extremely uncommon. Case Presentation: We report a case of a 53-yearold gentleman known to have an End Stage Renal Disease (ESRD) on Hemodialysis for two years, who went to the dialysis facility in his usual state of health. After two hours of dialysis, a new lock of taurolidine/heparin was installed; one minute later, the patient started to vomit and became restless, blood pressure dropped to 60/47 mmHg, and urticarial hives and a reddish rash developed on his skin, covering his trunk and limbs. He was immediately given three doses of epinephrine intramuscularly, which he did not respond to. Therefore, an epinephrine infusion was started. IV hydrocortisone and diphenhydramine were given for symptomatic relief. The patient was shifted to the emergency department, where he became vitally stable and returned to baseline. Heparininduced anaphylaxis was assumed based on the quick response to the above medications. Conclusion: This case can be added to the growing literature regarding this rare reaction, and more studies should be done to understand the nature of the reaction better. We recommend that the healthcare team becomes vigilant of heparin as a possible cause of anaphylaxis.

Spontaneous Cerebrospinal Fluid Rhinorrhea Secondary to Idiopathic Intracranial Hypertension.

The cerebrospinal fluid (CSF) is a physiological fluid that functions to protect the brain tissue and maintain intracranial pressure. Defects between the subarachnoid spaces and other spaces can cause CSF leaks. We report the case of a 37-year-old female with no known past medical history who presented to the emergency department with a history of headaches for two months, nasal drip for 1.5 months, and recurrent fevers. Idiopathic intracranial hypertension was confirmed by cranial magnetic resonance imaging (MRI) and transnasal endoscopic repair of a CSF leak defect, and an abdomen fat graft was performed followed by an Axium navigation-guided right ventriculoperitoneal shunt (VPS).

Plasma exchange (PE) versus intravenous immunoglobulin (IVIG) for the treatment of Guillain-Barré syndrome (GBS) in patients with severe symptoms: A systematic review and meta-analysis.

Background and purpose: Guillain- Barré syndrome (GBS) is a neuropathic condition that leads to the rapid development of impairments and is characterized by weakness and numbness or tingling sensation in the legs and arms and sometimes loss of movement and feeling in the legs, arms, upper body, and face. Currently, the cure for the disease is yet to be developed. However, treatment options such as intravenous immunoglobulin (IVIG) and plasma exchange (PE) have been used to minimize the symptoms and duration of the disease. Therefore, this systematic review and meta-analysis compared the efficacy of IVIG and PE in treating GBS patients with severe symptoms. Methodology: Six electronic databases, including PubMed, Embase, Scopus, ScienceDirect, Medline, and Google scholar, were scoured for articles related and relevant to our research. Additionally, more studies were obtained through the reference lists of the studies retrieved from these electronic databases. Quality assessment and statistical data analysis were conducted using Review Manager software (RevMan 5.4.1). Results: The search for relevant articles resulted in 3253 articles, of which only 20 were included for review in the current study. A sub-group analysis indicated no significant difference in the curative effect (Hughes score reduces by at least one score 4 weeks after GBS treatment; OR: 1.00; 95% CI: 0.66-1.52; p = 1.00 and Achieving grade 0 or 1 on Hughes scale; OR: 1.03; 95% CI: 0.27-3.94; p = 0.97). Similarly, the statistical showed that the difference in length of hospitalization and duration of mechanical ventilation was insignificant between the IVIG and PE group (Standard Mean Difference (SMD): -0.45; 95% CI: -0.92, 0.02; I2 = 91%; p = 0.06 and SMD: -0.54; 95% CI: -1.67, 0.59; I2 = 93%; p = 0.35, respectively). Moreover, the meta-analysis did not find any significant difference in the risk of GBS relapse (RR: 0.47; 95% CI: 0.20-1.14; p = 0.10) and risk of complications related to the treatment regimens (RR: 1.03; 95% CI: 0.71-1.48; p = 0.89). However, the statistical analysis of outcomes from 3 studies showed that the risk of discontinuation was significantly lower in the IVIG group than in the PE group (RR: 0.22; 95% CI: 0.06-0.88; p = 0.03). Conclusion: Our study suggests that IVIG and PE have similar curative effects. Similarly, IVIG seems easier to use and thus can be preferred for treating GBS.

Arachnoid Cyst: A Sudden Deterioration.

Arachnoid cysts are relatively rare and usually asymptomatic. It can only be diagnosed through radiological imaging modalities. Some patients may develop symptoms such as seizures, headache, dizziness, or psychiatric symptoms. We present a case of a 25-year-old male, previously healthy, who presented with sudden, repetitive episodes of seizure without regaining his consciousness. Computed tomography (CT) head scan showed a large cystic lesion that showed a rightward midline shift. Treatment was done surgically via endoscopic fenestration, and the patient remained symptom-free for one year. Most arachnoid cysts tend to remain asymptomatic throughout a patient's life span, allowing them to lead everyday normal lives; however, when these symptoms surface, they tend to be of a sudden nature requiring urgent surgical intervention. Our report follows the case of a young patient whose symptoms appear suddenly with triggers that led to status epilepticus. Our patient continued to suffer from multiple seizure attacks despite being on multiple anti-convulsive medications, and his symptoms eventually subsided via surgical intervention.

Intracranial hemorrhage with concurrent aortic dissection.

Aortic dissection is a rare yet lethal condition that is often missed. Presenting symptoms often include chest pain, abdominal pain, or loss of consciousness. Rarely is it asymptomatic, and the concurring symptoms may draw attention away from the dissection. We present a case of a 51-year-old male who presented to the emergency department with sudden onset of slurred speech and right-sided weakness. The CT scan showed a basal ganglia hemorrhage. However, during the scan, the radiologist incidentally found some aortic changes and recommended an ECG-gated CT scan of the thorax, which revealed a Stanford type B aortic dissection. We aim to shed light on patients presenting with neurological findings and conclude to have aortic dissection to increase awareness and facilitate rapid diagnosis and treatment.

Case Report: Disseminated hydatid cyst: Unusual presentation and therapeutic challenges.

Introduction: Cystic echinococcosis (CE), caused by Echinococcus granulosus sensu lato, is a parasitic disease prevalent in endemic regions. CE frequently leads to the formation of hydatid cysts in various organs, with the liver being the most commonly affected site. Involvement of the spleen has been rarely reported in the literature. Managing disseminated hydatid cyst disease presents significant diagnostic and therapeutic challenges. Case presentation: A 40-year-old female with a past medical history of hypothyroidism presented with sudden onset shortness of breath, dry cough, and chest pain for 3 days. She had a recent travel history to Egypt. Physical examination revealed mild right upper quadrant tenderness. Laboratory findings showed elevated white blood cell count with eosinophilia and increased inflammatory markers. Chest X-ray and pan-computed tomography (Pan-CT) scans identified multiple cystic lesions in the lung, liver and spleen. Serological tests confirmed the presence of anti-Echinococcus antibodies, leading to a diagnosis of disseminated hydatid cyst disease. The patient was managed medically and surgically by a multidisciplinary team. Conclusion: Disseminated hydatid cyst disease, though rare, presents complex diagnostic and management challenges. Timely recognition, supported by clinical, radiological, and serological assessments, is essential. Surgical intervention should be considered in a patient when multiple extrahepatic cysts are present, and rupture is evident, as this approach can significantly reduce patient morbidity and mitigate life-threatening complications.

Systematic Review and Meta-Analysis of Randomized Controlled Trials (RCTs) Revealing the Future of Airway Management: Video Laryngoscopy vs. Macintosh Laryngoscopy for Enhanced Clinical Outcomes.

Since the 1940s, Macintosh laryngoscopy (Mac laryngoscopy) has been the gold standard for tracheal intubation, offering visualization of the glottis entrance. However, recent years have witnessed the emergence of various video laryngoscopy (VL) techniques. This systematic review and meta-analysis aims to assess the clinical outcomes of VL versus Mac laryngoscopy in an elective setting. We comprehensively searched five medical databases - PubMed, EMBASE, Medline, Cochrane Library, and Web of Science. All the databases were last searched in January 2023. We only included studies with full texts comparing VL to Mac laryngoscopy clinical outcomes. Studies were excluded if they were non-full text or non-randomized controlled trials (RCTs) and did not compare VL to Mac laryngoscopy. We extracted data comprising author names, publication year, key study outcomes (first-attempt intubation success rate, Cormack and Lehane grade, hypoxia incidence, and glottis view quality), video laryngoscope types, and sample sizes of both VL and Mac laryngoscopy groups. The Cochrane risk of bias tool was used to assess the risk of bias in the included studies. Statistical analysis was performed using Review Manager (RevMan, version 5.4; Cochrane Collaboration, London, UK), presenting results as odds ratio (OR) and risk ratios (RR) at a 95% confidence interval (CI). This facilitated the identification of relevant and appropriate studies of our analysis. The search produced 19 studies that were included in this review. The evaluated sample size ranges from 40 to 802, with 3,238 participants. The rate of success at the first attempt in the use of VL was 1,558/1,890 (82.43%), while the success rate for Mac laryngoscopy was 982/1,348 (72.85%; OR: 1.98 (1.25, 3.12)) at a 95% confidence interval. Pooled analysis indicated no significant difference for hypoxia concerning the type of device used RR (random effects: 1.02; 95% CI: 0.80-1.29). A video laryngoscope had a higher likelihood of visualizing the vocal cords categorized as category 1 in the Cormack-Lehane system of classification (RR: 2.45; 95% CI: 1.43-4.21). Additionally, considerably better glottis views were attained during VL than Mac laryngoscopy (OR: 1.77; 95% CI: 1.19-2.62). In elective tracheal intubation, VL demonstrates superior first-attempt success rates, offers improved glottis visualization, and reduces instances where the glottis cannot be viewed compared to Mac laryngoscopy.

Clinical Assessment of Intermittent Fasting With Ketogenic Diet in Glycemic Control and Weight Reduction in Patients With Type II Diabetes Mellitus: A Systematic Review and Meta-Analysis.

Diabetes mellitus (DM) is a global epidemic causing significant morbidity and mortality. The most occurring DM is type 2 diabetes mellitus (T2DM) which has similar symptoms as type 1 diabetes mellitus (T1DM). However, it is less marked, making it difficult to diagnose during the early stages. The management of T2DM is usually based on weight and glycemic control, which can be achieved through dietary interventions such as intermittent fasting (IF) and the ketogenic diet (KD). Therefore, this systematic review and meta-analysis aim to demonstrate the role of IF and KD in glycemic and weight control among patients with T2DM. Two methods, including an electronic database search through ScienceDirect, Google Scholar, PubMed, Scopus, Embase, and Web of Science, and a manual search were used to identify relevant studies published between 2000 and 2022. The search yielded 1299 articles, of which only 12 met the inclusion criteria. In addition, study quality appraisal was performed using Review Manager software (RevMan 5.4.1). The pooled results have shown that IF had a similar effect on HBA1c reduction as control interventions (standardized mean differences [SMD]: 0.36%; 95% CI; -0.37, 1.10; P = 0.33, I2 = 87%). Similarly, an insignificant difference in weight reduction between IF and control interventions was recorded (SMD: -1.05%; 95% CI; -2.29, 0.19; P = 0.10, I2 = 96%). On the other hand, KD significantly reduced body weight compared with control diets (SMD: -1.91 kg; 95% CI; -2.96 kg, -0.85 kg; P = 0.0004, I2 = 96%). Similarly, KD had a better effect on the HBA1c percentage reduction than control diets (SMD: -2.00%; 95% CI; -3.76, -0.25; P = 0.03, I2 = 97%). IF and KD have shown reductions in HBA1c and body weight among patients with T2DM. However, the interventions are subject to side effects and should be used with caution and under the supervision of a health professional.

Efficacy of Emla (Eutectic Mixture of Local Anaesthetics) and Let (Lidocaine, Epinephrine, Tetracaine) for Topical Use in Wound Management for Children: A Systematic Review and Meta-Analysis.

Lacerations are common injuries managed by emergency department practitioners and are mostly witnessed in children. These lacerations usually require wound closure, which may result in one of the most unpleasant and painful childhood experiences. The pain can be minimized through topical anesthesia, such as a combination of lidocaine, epinephrine, and tetracaine (LET) and a eutectic mixture of local anesthetics (EMLA). The current study was carried out to demonstrate the efficacy of EMLA and LET in pediatric wound management. A thorough literature search was carried out without any time limitation on five electronic databases, including PubMed, Medline, Web of Science, Embase, and Google Scholar. Relevant studies from these databases and their references were scoured for additional studies. Study quality appraisal and data analysis were conducted using Review Manager software (RevMan 5.4.1). The literature search yielded 1651 articles of which only eight were eligible for inclusion in the present study. A meta-analysis of results from 3 studies showed that LET had a significant pain reduction than the control interventions (SMD: -0.46; 95% CI: -0.69, -0.23: p<0.0001). However, the pooled effect size of data from 3 studies showed EMLA had an insignificant difference with the control interventions (SMD: -0.79; 95% CI: -1.82, -0.24: p = 0.13). Similarly, no significant difference in the number of adverse reactions was reported in either EMLA (OR: 2.31; 95% CI: 0.67, 7.93; p = 0.18) or LET (OR: 0.99; 95% CI: 0.15, 6.50; p = 0.99) Our study suggests that the topical application of EMLA and LET effectively offers pain-free wound management among pediatric patients. However, the interventions are subject to adverse reactions that should be considered when managing the wounds.

Rare triad of fractures in the upper limb. Simultaneous fractures of the distal radius, with the radial head and the ulna styloid.

We're reporting a 35-year-old gentleman that presented with a rare combination of ipsilateral fracture of both proximal and distal ends of the radius associated with ulna styloid fracture due to a fall with outstretched hands. Thorough clinical examination of 2 adjacent joints (elbow and wrist) is critical in identifying such an unusual or rare combination of injuries. Appropriate management for such cases depends on the characteristics of the injury, such as fracture patterns, job, hand dominance, and age of the patient. The treatment should aim to preserve the radial head to avoid the possibility of proximal radial migration, particularly in young patients. Such a combination of injury implies complex injury and needs special consideration in deciding management plan. In this case, the proximal end of the radius and the ulna styloid fractures were treated conservatively. In contrast, the distal end of the radius was treated with open reduction internal fixation.

A Rare Case of Metronidazole Overdose Causing Ventricular Fibrillation.

Ventricular fibrillation is not known as a complication of metronidazole poisoning. Although some arrhythmias have been reported as a complication of metronidazole intake while taking antiarrhythmic medications, most such arrhythmias are possibly related to co-ingestion of drugs with metronidazole as it affects the metabolism of these drugs. In this case, ventricular fibrillation occurred in a young patient without preexisting medical conditions or any other known drug ingestion, which was never been reported before. We present a case of an 18-year-old male brought in by the ambulance service after attempting to end his life by overdosing on metronidazole. While being transported he developed ventricular fibrillation and received an electric shock, which reverted the episode. Laboratory investigations did not show any clear cause that might have precipitated his arrhythmia.