Cope's sign and complete heart block secondary to acute cholecystitis: A case report

Rationale: Cope's sign is reflex bradycardia seen in the patient presenting with symptoms of acute cholecystitis. This bradycardia may be due to vagally mediated cardio-biliary reflex. Many of these reflexes due to acute cholecystitis have similar clinical features (some electrocardiographic changes like bradycardia, complete heart block, and asystole) mimicking that of acute coronary syndrome. Patient's concern: A 60-year old male presented with symptoms of acute cholecystitis and referred to the emergency department with complete heart block and abdominal pain with hypotension requiring an emergency temporary pacemaker. Diagnosis: Cope's sign and complete heart block. Intervention: Emergency temporary cardiac pacemaker insertion. Outcomes: The patient was discharged after three days with regular follow-up and advice for laparoscopic cholecystectomy. Lessons: Complete heart block or any symptomatic bradycardia associated with abdominal pain should be under consideration of cholecystitis that may be associated with either presence or absence of gall stones due to cardio biliary reflex.

COVID-19 presentation as acute pancreatitis:A case report

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.

An approach for selection of solid waste treatment and disposal methods based on fuzzy analytical hierarchy process

Solid waste management is a severe challenge in India due to massive and rapid growth in waste generation rates,environmental difficulties,and financial constraints for proper treatment.Poorly managed municipal solid waste(MSW)has substantial negative consequences for society,including financial and aesthetic harm,contamination of natural resources,environmental pollution,and severe health danger.Both qualitative and quantitative factors are required to select the appropriate solid waste treatment and disposal technologies.Multi-Criteria decision-making tools helped in analyzing solid waste in terms of qualitative and quantitative factors.In this paper,seven criteria and their sub-criteria are selected for ranking solid waste treatment and disposal technology using fuzzy-analytic hierarchy process.The results showed that composting is the most suitable option for solid waste treatment and disposal technology,followed by refuse-derived fuel.The incineration and sanitary landfills are the least preferred MSW management alternatives.The sensitivity analysis reveals a high consistency,robustness,and stability level.