Severe acute hepatitis of unknown etiology in children in 2022: A Narrative Review.

Severe cases of acute hepatitis have been reported all around the world since 5 April 2022. Common viral hepatitis agents (HAV, HBV, HCV, HDV, and HEV) were ruled out by laboratory investigations, impelling the term "acute non-A-E hepatitis". Common manifestations consist of abdominal pain, jaundice, and vomiting. A highly elevated level of liver enzymes was a remarkable laboratory finding among the patients. Currently, there is no clear etiology and thus treatment for the condition. Adenovirus serotype 41 (ad-41) was detected in most of the patients even though there is no elucidated link between Adenovirus and acute hepatitis. Other viral agents such as SARS-CoV-2 tested positive in a few cases. Treatment strategies depend on the severity, complications, and sequela of acute hepatitis and can vary widely from supportive therapy to liver transplantation. As of 8 July 2022, 1010 probable cases were reported from 35 countries. More than half were from the European region and were mostly children under the age of 6 years. Among different hypotheses about the etiology of severe acute non-A-E hepatitis, adenovirus-41 is of great importance but further assessments are needed to prove any definite link between ad-41 and severe acute hepatitis.

Clinical Characteristics and Outcomes of 905 COVID-19 Patients Admitted to Imam Khomeini Hospital Complex in the Capital City of Tehran, Iran.

BACKGROUND: We studied the clinical characteristics and outcomes of 905 hospitalized coronavirus disease 2019 (COVID-19) patients admitted to Imam Khomeini Hospital Complex (IKHC), Tehran, Iran. METHODS: COVID-19 patients were recruited based on clinical symptoms and patterns of computed tomography (CT) imaging between February 20 and March 19. All patients were tested for the presence of COVID-19 RNA. The Poisson regression model estimated the incidence rate ratio (IRR) for different parameters. RESULTS: The average age (± standard deviation) was 56.9 (±15.7) years and 61.77% were male. The most common symptoms were fever (93.59%), dry cough (79.78%), and dyspnea (75.69%). Only 43.76% of patients were positive for the RT-PCR COVID-19 test. Prevalence of lymphopenia was 42.9% and more than 90% had elevated lactate dehydrogenase (LDH) or C-reactive protein (CRP). About 11% were severe cases, and 13.7% died in the hospital. The median length of stay (LOS) was 3 days. We found higher risks of mortality in patients who were older than 70 years (IRR = 11.77, 95% CI 3.63-38.18), underwent mechanical ventilation (IRR = 7.36, 95% CI 5.06-10.7), were admitted to the intensive care unit (ICU) (IRR = 5.47, 95% CI 4.00-8.38), tested positive on the COVID-19 test (IRR = 2.80, 95% CI 1.64-3.55), and reported a history of comorbidity (IRR = 1.76, 95% CI 1.07-2.89) compared to their corresponding reference groups. Hydroxychloroquine therapy was not associated with mortality in our study. CONCLUSION: Older age, experiencing a severe form of the disease, and having a comorbidity were the most important prognostic factors for COVID-19 infection. Larger studies are needed to perform further subgroup analyses and verify high-risk groups.

Validity of a Serological Diagnostic Kit for SARS-CoV-2 Available in Iran.

BACKGROUND: The Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) epidemic broke out in December 2019 and is now characterized as a pandemic. Effective control of this infectious disease requires access to diagnostic techniques, for both case finding and epidemic size estimation. The molecular technique is routinely used worldwide. Although it is the "standard" case detection and management method, it has its own shortcomings. Thus, some easy-to-use rapid serological tests have been developed. METHODS: One hundred and fourteen positive RT-PCR-diagnosed patients were tested by VivaDiag Kit, a brand of rapid serological kits available in hospitals affiliated to Tehran University of Medical Sciences (TUMS), Tehran, Iran. Frozen serum specimens taken from healthy people in summer and fall 2019 were also tested as negative controls. RESULTS: Test sensitivity was 47.9% (95% confidence interval [CI]: 38.8-56.9) for IgM and 47.0% (95% CI: 38.0-56.0) for IgG. There was no difference between IgG and IgM seropositivity except in one case. Specificity was calculated as 99.0% (95% CI: 96.4-99.9) for IgM and of 100.0% (95% CI: 0.98.2-100.0) for IgG. Sensitivity was higher in men and older participants. CONCLUSION: This test can be used for epidemiological investigations, especially for the estimation of the level of infection in the community, after it is properly corrected for sensitivity and specificity. The low sensitivity could be attributed to the technical limitations of the kit or low levels of antibodies after infection. The different sensitivity in age and sex groups supports the hypothesis that different people show different immune responses to this virus.

Twelve Lessons on Hospital Leadership during COVID-19 Pandemic.

Coronavirus pandemic has been announced by World Health Organization Director General on March 11th, 2020. Imam Khomeini Hospital Complex, affiliated to Tehran University of Medical Sciences, was one the first referral hospitals in the capital city of Tehran, I.R.Iran that entered the crisis and started a serious battle with the disease. The hospital had to change many routine operations to cope with the situation and during this journey, we used published leadership principles and reached to some new experiences. As this is probably the most severe health-related crisis in Iran in the past 100 years, we gathered our lessons learned in the first fifty days of epidemic from the leadership point of view to share those with all colleagues worldwide. We know that leadership is of pivotal role in such a massive crisis and focused leadership experiences can help health care providers to manage the crisis while we are in the middle of it.

EFFECTIVE DOSE FOR RADIOLOGICAL PROCEDURES IN AN EMERGENCY DEPARTMENT: A CROSS-SECTIONAL STUDY.

The extent of radiation exposure in emergency settings is not well documented; here, the corresponding effective dose (ED) is provided. In 500 patients admitted in row to the emergency department, ED was compared in patients according to complaints and their visiting physicians. Out of all, 220 patients aged 43.5 ± 22.2 years (admission: 2.0 ± 1.6 days) had at least an imaging. The main reasons for admission were trauma (10.5%) and then orthopedic problems (8.6%). EDs from CT and radiography were 1.66 ± 3.59 and 0.71 ± 1.67 mSv, respectively (from all 2.29 ± 4.12). Patients with abdominal (5.8 ± 5.2 mSv; p < 0.002) and pelvic (12.0 ± 6.3 mSv; p < 0.007) complaints received higher ED from CT and radiography and, also, patients visited by surgeons (7.94 ± 6.9 mSv). CT scan was the main source for ED to patients. Irrespective of the final diagnosis, patients with abdominopelvic complaints and those visited by surgeons are at higher exposure risk.

Clinical and Pathological Features of Ulcerative Colitis in Patients with and without Clostridium Difficile Infection; An Observational Study.

BACKGROUND A dramatic rise in the rate of clostridium difficile infection (CDI) in patients with inflammatory bowel disease (IBD) has been reported in recent years. METHODS In this observational case control study, 65 patients were included and were divided into two groups of IBD + CDI as case group and IBD without CDI as control group. RESULTS 35 patients who had positive test for clostridium difficile were assigned to the case group. The control group consisted of 30 patients with negative test for clostridium difficile. Pancolitis was seen in the cases more statistically significant than the controls and proctitis was seen more among the controls than the cases (p = 0.001). The cases were on immunosuppressive (p = 0.001) and antibiotic (p = 0.02) therapy more than the controls. Colonoscopic findings revealed more severe and extensive inflammation among the cases versus milder inflammation among the controls, but these differences were not statistically significant (p = 0.2). Colectomy was seen in 10% of controls and none of the cases and this difference was statistically significant (p value = 0.05). More fecal calprotectin were seen among the cases than the controls and this difference was statistically significant (p < 0.05) CONCLUSION This study showed more clostridium difficile infection among the patients on antibiotic or immunosuppressive therapy. Pathological investigation revealed more severe and extensive inflammation among the cases than the controls. Cases had clinically more severe signs and symptoms with higher mayo scores than the controls. ESR (Erythrocyte sedimentation rate) and fecal calprotectin were higher in patients with positive clostridium difficile infection and serum albumin was lower in such patients.

Case series of papillectomy by endoscopic retrograde cholangiopancreatography (ERCP).

Ampullary neoplasms are one of the causes of obstructive jaundice. Endoscopic retrograde cholangiopancreatography (ERCP) is useful procedure for diagnosing and tissue sampling of ampullary neoplasms. Ampullectomy by resecting entire ampulla provides whole lesion for pathologic evaluation and also is appropriate for real pathologic staging for further management decision but ampullectomy considered as a heroic endoscopic procedure. We share our experience in this field and explain our results.

Squamous cell carcinoma (SCC) arising in esophageal colon interposition.

The idea of using the colon to replace a resected esophagus has a long history. The colon has become a favored organ for esophageal reconstruction in adults with esophageal cancer when the stomach is not suitable or is unavailable. In this article, we introduce an 84-year-old woman that she had surgery 40 years ago and presented with an invasive well differentiated squamous cell carcinoma of colonic origin in reconstructed esophagus.

A Case Based-Shared Teaching Approach in Undergraduate Medical Curriculum: A Way for Integration in Basic and Clinical Sciences.

To present a multiple-instructor, active-learning strategy in the undergraduate medical curriculum. This educational research is a descriptive one. Shared teaching sessions, were designed for undergraduate medical students in six organ-system based courses. Sessions that involved in-class discussions of integrated clinical cases were designed implemented and moderated by at least 3 faculties (clinicians and basic scientists). The participants in this study include the basic sciences medical students of The Tehran University of Medical Sciences. Students' reactions were assessed using an immediate post-session evaluation form on a 5-point Likert scale. Six two-hour sessions for 2 cohorts of students, 2013 and 2014 medical students during their two first years of study were implemented from April 2014 to March 2015. 17 faculty members participated in the program, 21 cases were designed, and participation average was 60 % at 6 sessions. Students were highly appreciative of this strategy. The majority of students in each course strongly agreed that this learning practice positively contributed to their learning (78%) and provided better understanding and application of the material learned in an integrated classroom course (74%). They believed that the sessions affected their view about medicine (73%), and should be continued in future courses (80%). The percentage demonstrates the average of all courses. The program helped the students learn how to apply basic sciences concepts to clinical medicine. Evaluation of the program indicated that students found the sessions beneficial to their learning.

Medical students' attitudes towards early clinical exposure in Iran.

OBJECTIVE: This study was carried out to investigate the medical students' attitudes towards early clinical exposure at Tehran University of Medical Sciences. METHODS: A cross-sectional study was conducted during 2012-2015. A convenience sample of 298 first- and second-year students, enrolled in the undergraduate medical curriculum, participated in an early clinical exposure program. To collect data from medical students, a questionnaire consisting of open-ended questions and structured questions, rated on a five-point Likert scale, was used to investigate students' attitudes toward early clinical exposure. RESULTS: Of the 298 medical students, 216 (72%) completed the questionnaires. The results demonstrated that medical students had a positive attitude toward early clinical exposure. Most students (80.1%) stated that early clinical exposure could familiarize them with the role of basic sciences knowledge in medicine and how to apply this knowledge in clinical settings. Moreover, 84.5% of them believed that early clinical exposure increased their interest in medicine and encouraged them to read more. Furthermore, content analysis of the students' responses uncovered three main themes of early clinical exposure, were considered helpful to improve learning: "integration of theory and practice", "interaction with others and professional development" and "desire and motivation for learning medicine". CONCLUSIONS: Medical students found their first experience with clinical setting valuable. Providing clinical exposure in the initial years of medical curricula and teaching the application of basic sciences knowledge in clinical practice can enhance students' understanding of the role they will play in the future as a physician.

Subsegmental pulmonary embolism: A narrative review.

Through the introduction of computed tomography pulmonary angiography (CTPA) for diagnosis of the pulmonary embolism (PE), the high sensitivity of this diagnostic tool led to detecting peripheral filling defects as small as 2-3mm, termed as subsegmental pulmonary embolism (SSPE). However, despite these substantial increases in diagnosis of small pulmonary embolism, there are minimal changes in mortality. Moreover, SSPE patients generally are hemodynamically stable with mild clinical presentation, lower serum level of biomarkers, lower incidence of associated proximal DVTs and less frequent echocardiographic changes compared to the patients with emboli located in more central pulmonary arteries. However, the pros and cons of anticoagulant therapy versus non-treating, monitoring protocol and exact long term outcome of these patients are still unclear. In this article we review existing evidence and provide an overview of what is known about the diagnosis and management of subsegmental pulmonary embolism.