Healthcare workers safety in the COVID-19 era: the impact of pre-pandemic personal protective equipment (PPE) training in Pakistan.

BACKGROUND: The COVID-19 pandemic has revealed vulnerabilities in healthcare systems worldwide, emphasizing the importance of healthcare worker safety through adequate utilization of personal protective equipment (PPE). This study aims to assess the impact of pre-pandemic PPE training on the practices and other associated factors among frontline healthcare workers during the COVID-19 pandemic in Pakistan and provide insights into the implications of such training programs for future initiatives. METHODS: A cross-sectional study from May 9th to June 5th, 2020 was conducted among the frontline healthcare workers against COVID-19 in Pakistan, utilizing an online structured questionnaire shared via WhatsApp and Facebook by using purposive sampling. Statistical analyses, including chi-square tests for proportion and logistic regression for the association while multi-logistic regression for potential confounders, were performed using SPSS version 22. RESULTS: A total of 453 healthcare staff participated, with 68.9% (n = 312) reporting no prior PPE training and 31.1% (n = 141) having received training. Significant associations were found between prior training and healthcare group distribution (p = 0.006), with doctors exhibiting the highest proportion of training 82 (37.61%), followed by nurses 50 (27.32%) and paramedics 9 (17.31%). Those who didn't receive any prior training in PPEs showed a higher perceived professional risk of 216 (69.23%) compared to those who received prior PPE training 96 (30.77%, p-value 0.005). Similarly, a higher frequency 137 (63.72%) of Perceived Personal risk was observed in those who didn't receive training, labeled as "high risk" compared to those who were trained 78 (36.28%, P value 0.02). Multi-logistic regression analysis identified paramedics as 0.26 times less likely to have received prior PPE training (Adjusted OR 0.26, 95% CI 0.10-0.65, p = 0.01) compared to medical doctors. Healthcare workers in tertiary care hospitals were 0.46 times less likely to undergo PPE training (Adjusted OR 0.46, 95% CI 0.25-0.87,p = 0.01) compared to those working at COVID-19 facilities/hospitals/quarantine centers. Likewise, individuals who doffed disposable gowns [Adjusted OR 3.86, (95% CI, 1.23-12.08, p = 0.02] were 3.86 times more interested in getting prior training in PPE compared to those who don't have skills to wear them. CONCLUSION: Our findings highlight that healthcare levels, type of healthcare, and doffing skills are important predictors of whether healthcare workers have taken prior training in PPE. These findings imply developing effective training programs for healthcare workers to ensure safety while providing care during pandemics like COVID-19.

Patient Satisfaction and Utilization of Ambulance Services in Prehospital Services at a Tertiary Care Hospital: A Cross-Sectional Study in Peshawar, Khyber Pakhtunkhwa, Pakistan.

OBJECTIVE: Patients reporting to emergency departments frequently use different ambulance services; therefore, the measurement of patient satisfaction is relevant to encouraging those services to meet patient expectations. The aim of this study was to determine the patients' satisfaction and utilization of different ambulance services at a tertiary health care hospital in Peshawar relating to prehospital services. METHODS: This cross-sectional study was conducted at Lady Reading Hospital, Peshawar, Khyber Pakhtunkhwa, Pakistan, from July 2019 to January 2020 using a consecutive sampling technique with a total sample size of 378. The patients reporting to the emergency department using any ambulance service were included in this study. Different types of ambulance services were used as an outcome variable. Proportions were compared for the categoric variables using the chi-square test, whereas the 1-way analysis of variance test was used to determine the mean response time and age. Results were considered significant at a P value ≤ .050. All analyses were completed using SPSS version 20 (IBM Corp, Armonk, NY). RESULTS: Of the total 378 study participants, approximately 166 (43.9%) used Rescue 1122 services, 99 (26.2%) used private ambulance services, and 44 (11.6%) used public ambulance services. Road traffic accidents were the most common complaint by 98 (25.9%, P < .003) participants. The mean response time for Rescue 1122 was 13.2 ± 18 minutes followed by the Chippa Foundation (private) at 17.8 ± 20 minutes (P < .005). Males (n = 254) were the predominant users of all services. Participants from the urban region (n = 112) used Rescue 1122, whereas the public ambulance service was used only by 31 patients (P < .005). Among all the ambulance services, 19 (61.3%) participants were not satisfied with the Chippa service regarding vehicle cleanliness, whereas participants were highly satisfied with Rescue 1122. CONCLUSION: Overall, the patients were more satisfied with the services provided by the Rescue 1122 ambulances compared with all other ambulance services.

A nonrandom association of breast implants and the formation of desmoid tumors.

BACKGROUND: Studies suggest that surgical breast augmentation with implants is a risk factor for breast desmoid tumors. The statistical strength of this correlation is unknown, as evidence is limited to anecdotal reports. METHODS: Patients with breast desmoid tumors and a history of breast implants seen at a single center between 2000 and 2021 were identified via radiology, breast, and sarcoma databases. The standardized incidence ratio (SIR) was calculated to assess the correlation between breast desmoid tumors and breast implants. The cases were pooled with published cases for analyses. Progression-free survival curves and hazard ratios were estimated using the Kaplan-Meier method and Cox proportional-hazards modeling. RESULTS: Fourteen patients from one institution and 66 cases in the literature were identified. All patients were female, and the mean age was 38 years old (range 20-66). 63 patients (82%) underwent resection, 9 (12%) received chemotherapy, 3 (4%) received sorafenib, 11 (14%) received hormonal therapy, and 3 (4%) underwent active surveillance. After resection, the 2-year recurrence-free survival rate was 77% (95% CI 65%-89%). The recurrence risk was lower for resection with no residual tumor (R0) compared to microscopic (R1) or macroscopic (R2) residual tumor (HR: 0.15; 95% CI 0.02-0.8; p < 0.05). The SIR was 482 (95% CI 259-775) to 823 (95% CI 442-1322), suggesting a 482-823 times higher risk of developing a breast desmoid tumor after breast augmentation than the general population. CONCLUSION: We present a nonrandom association between breast implants and desmoid tumors. Whether the tumors arise from the surgical trauma or the implant's biomaterial is unknown. When surgery is indicated, negative margins reduce the risk of recurrence.

Substance P induces plasticity and synaptic tagging/capture in rat hippocampal area CA2.

The hippocampal area Cornu Ammonis (CA) CA2 is important for social interaction and is innervated by Substance P (SP)-expressing supramammillary (SuM) nucleus neurons. SP exerts neuromodulatory effects on pain processing and central synaptic transmission. Here we provide evidence that SP can induce a slowly developing NMDA receptor- and protein synthesis-dependent potentiation of synaptic transmission that can be induced not only at entorhinal cortical (EC)-CA2 synapses but also at long-term potentiation (LTP)-resistant Schaffer collateral (SC)-CA2 synapses. In addition, SP-induced potentiation of SC-CA2 synapses transforms a short-term potentiation of EC-CA2 synaptic transmission into LTP, consistent with the synaptic tagging and capture hypothesis. Interestingly, this SP-induced potentiation and associative interaction between the EC and SC inputs of CA2 neurons is independent of the GABAergic system. In addition, CaMKIV and PKMζ play a critical role in the SP-induced effects on SC-CA2 and EC-CA2 synapses. Thus, afferents from SuM neurons are ideally situated to prime CA2 synapses for the formation of long-lasting plasticity and associativity.

Renal ultrastructural alterations induced by various preparations of mefenamic acid.

Mefenamic acid (MFA) treatment is associated with a number of cellular effects that potentiate the incidence of renal toxicity. The aim of this study is to investigate the potential ultrastructural alterations induced by various preparations of MFA (free MFA, MFA-Tween 80 liposomes, and MFA-DDC liposomes) on the renal tissues. Sprague-Dawley rats were subjected to a daily dose of MFA preparations for 28 days. Renal biopsies from all groups of rats under study were processed for transmission electron microscopic examination. The findings revealed that MFA preparations induced various ultrastructural alterations including mitochondrial injury, nuclear and lysosomal alterations, tubular cells steatosis, apoptotic activity, autophagy, and nucleophagy. These alterations were more clear in rats received free MFA, and MFA-Tween 80 liposomes than those received MFA-DDC liposomes. It is concluded that MFA-DDC liposomes are less potential to induce renal damage than free MFA and MFA-Tween 80 liposomes. Thus, MFA-DDC liposomes may offer an advantage of safe drug delivery.

Interferon-γ induces biphasic changes in caldesmon localization as well as adherens junction organization and expression in HUVECs.

Endothelial barrier dysfunction leads to increased endothelial permeability and is an early step in the development of vascular inflammatory diseases such as atherosclerosis. Interferon-γ (IFN-γ), a proinflammatory cytokine, is known to cause increased endothelial permeability. However, the mechanisms by which IFN-γ disrupts the endothelial barrier have not been clarified. This study aimed to investigate how IFN-γ impairs the endothelial barrier integrity by specifically examining the roles of caldesmon, adherens junctions (AJs) and p38 mitogen-activated protein (MAP) kinase in IFN-γ-induced endothelial barrier dysfunction. IFN-γ exhibited a biphasic effect on caldesmon localization and both the structural organization and protein expression of AJs. In the early phase (4-8 h), IFN-γ induced the formation of peripheral caldesmon bands and discontinuous AJs, while AJ protein expression was unchanged. Interestingly, IFN-γ also stimulated caldesmon phosphorylation, resulting in actin dissociation from caldesmon at 8 h. Conversely, changes seen in the late phase (16-24 h) included cytoplasmic caldesmon dispersal, AJ linearization and junctional area reduction, which were associated with reduced membrane, cytoskeletal and total AJ protein expression. In addition, IFN-γ enhanced myosin binding to caldesmon at 12 h and persisted up to 24 h. Furthermore, inhibition of p38 MAP kinase by SB203580 did not reverse either the early or late phase changes observed. These data suggest that IFN-γ may activate signaling molecules other than p38 MAP kinase. In conclusion, our findings enhance the current understanding of how IFN-γ disrupts endothelial barrier function and reveal potential therapeutic targets, such as caldesmon and AJs, for the treatment of IFN-γ-associated vascular inflammatory diseases.

Comparative ultrastructural hepatic alterations induced by free and liposome-encapsulated mefenamic acid.

Mefenamic acid (MFA) is used as an anti-inflammatory, antinociceptive, and antipyretic agent for treatment of a wide range of pathological disorders. While the uncertainty of its safety and the poor oral bioavailability constitute the major limiting factors of its medical use, considerable efforts including liposomal encapsulation are needed to achieve maximum therapeutic advantages. The current work was conducted to investigate the ultrastructural alterations in the liver induced by free MFA and its liposomal preparation. Female Sprague-Dawley rats were treated with daily oral doses of either free MFA or MFA entrapped in Tween 80 inoculated liposomes at the concentration of 80 mg/kg for 28 days. Ultrathin sections were prepared from biopsies taken from the liver of each member of all animals under study and subjected to examination by transmission electron microscopy. The liver of rats that were exposed to liposomal MFA showed more ultrastructural alterations than the rats treated with the free drug. While both groups of rats demonstrated sinusoidal dilatation, Kupffer cell hyperplasia, mitochondrial damage, and nuclear alterations, rats treated with liposome-encapsulated MFA induced an increase in the multiple lysosomes formation, hepatocytic steatosis, and apoptotic activity than free MFA-treated rats. The ultrastructural findings of the present study indicate that the use of liposomal MFA induces more hepatic damage than the use of free MFA.

Asiaticoside Inhibits TNF-α-Induced Endothelial Hyperpermeability of Human Aortic Endothelial Cells.

The increase in endothelial permeability often promotes edema formation in various pathological conditions. Tumor necrosis factor-alpha (TNF-α), a pro-atherogenic cytokine, impairs endothelial barrier function and causes endothelial dysfunction in early stage of atherosclerosis. Asiaticoside, one of the triterpenoids derived from Centella asiatica, is known to possess antiinflammatory activity. In order to examine the role of asiaticoside in preserving the endothelial barrier, we assessed its effects on endothelial hyperpermeability and disruption of actin filaments evoked by TNF-α in human aortic endothelial cells (HAEC). TNF-α caused an increase in endothelial permeability to fluorescein isothiocyanate (FITC)-dextran. Asiaticoside pretreatment significantly suppressed TNF-α-induced increased permeability. Asiaticoside also prevented TNF-α-induced actin redistribution by suppressing stress fiber formation. However, the increased F to G actin ratio stimulated by TNF-α was not changed by asiaticoside. Cytochalasin D, an actin depolymerizing agent, was used to correlate the anti-hyperpermeability effect of asiaticoside with actin cytoskeleton. Surprisingly, asiaticoside failed to prevent cytochalasin D-induced increased permeability. These results suggest that asiaticoside protects against the disruption of endothelial barrier and actin rearrangement triggered by TNF-α without a significant change in total actin pool. However, asiaticoside seems to work by other mechanisms to maintain the integrity of endothelial barrier rather than stabilizing the F-actin organization.

In vitro inhibition of histamine release behavior of cetirizine intercalated into Zn/Al- and Mg/Al-layered double hydroxides.

The intercalation of cetirizine into two types of layered double hydroxides, Zn/Al and Mg/Al, has been investigated by the ion exchange method to form CTZAN and CTMAN nanocomposites, respectively. The basal spacing of the nanocomposites were expanded to 31.9 Å for CTZAN and 31.2 Å for CTMAN, suggesting that cetirizine anion was intercalated into Layered double hydroxides (LDHs) and arranged in a tilted bilayer fashion. A Fourier transform infrared spectroscopy (FTIR) study supported the formation of both the nanocomposites, and the intercalated cetirizine is thermally more stable than its counterpart in free state. The loading of cetirizine in the nanocomposite was estimated to be about 57.2% for CTZAN and 60.7% CTMAN. The cetirizine release from the nanocomposites show sustained release manner and the release rate of cetirizine from CTZAN and CTMAN nanocomposites at pH 7.4 is remarkably lower than that at pH 4.8, presumably due to the different release mechanism. The inhibition of histamine release from RBL2H3 cells by the free cetirizine is higher than the intercalated cetirizine both in CTZAN and CTMAN nanocomposites. The viability in human Chang liver cells at 1000 µg/mL for CTZAN and CTMAN nanocomposites are 74.5 and 91.9%, respectively.

In vitro anti-diabetic activities and chemical analysis of polypeptide-k and oil isolated from seeds of Momordica charantia (bitter gourd).

The amino acid and fatty acid composition of polypeptide k and oil isolated from the seeds of Momordica charantia was analysed. The analysis revealed polypeptide k contained 9 out of 11 essential amino acids, among a total of 18 types of amino acids. Glutamic acid, aspartic acid, arginine and glycine were the most abundant (17.08%, 9.71%, 9.50% and 8.90% of total amino acids, respectively). Fatty acid analysis showed unusually high amounts of C18-0 (stearic acid, 62.31% of total fatty acid). C18-1 (oleic acid) and C18-2 (linoleic acid) were the other major fatty acid detected (12.53% and 10.40%, respectively). The oil was devoid of the short fatty acids (C4-0 to C8-0). Polypeptide k and oil were also subjected to in vitro α-glucosidase and α-amylase inhibition assays. Both polypeptide k and seed oil showed potent inhibition of α-glucosidase enzyme (79.18% and 53.55% inhibition, respectively). α-Amylase was inhibited by 35.58% and 38.02%, respectively. Collectively, the in vitro assay strongly suggests that both polypeptide k and seed oil from Momordica charantia are potent potential hypoglycemic agents.

Diabetic ketoacidosis amongst patients with COVID-19: A retrospective chart review of 220 patients in Pakistan.

OBJECTIVES: To determine the frequency of diabetes mellitus and diabetic ketoacidosis and associated factors in COVID-19-positive patients. BACKGROUND: High mortality amongst SARS-Cov2 patients may be attributed to diabetes and diabetic ketoacidosis. METHODS: A total of 220 COVID-19 positive patients, hospitalized in North West General Hospital & Research Center, Peshawar, KP, Pakistan, from April to September 2020, were analysed using STATA 14. Patients with positive PCR were labelled as COVID-19 positive and were included in the study. Patients with a clinical picture of COVID-19 and negative PCR were excluded from the study. Those having ketonemia >0.6 and random blood glucose level >250mg/dl, while HCO3 (bicarbonate) ≤18, were labelled as diabetic ketoacidosis. The statistical significance level was set at p < .05. RESULTS: A total of 220 COVID-19 patients were admitted; 166 (75.4%) were male and 54 (24.5%) were female. The mean age in years of the patients was 55.95 (SD13.9). About 57.7% of patients had diabetes mellitus, and 15 (6.8%) patients developed diabetic ketoacidosis. Amongst those with DKA, 5 patients died during hospital admission. The use of steroids was significantly higher (p < .001) in the DKA group compared with non-DKA patients. Hypertension (103,46.8%) and fever (170,77.3%) were the most reported comorbidity and symptom respectively. CONCLUSION: The proportion of diabetes mellitus is high in patients with COVID-19. Diabetic ketoacidosis is a frequent complication in this group associated with in-hospital mortality. Steroid administration for COVID-19 should be balanced with strict glycemic control to prevent diabetic ketoacidosis and increase hospital survival.

Radiation-Associated Sarcoma of the Breast in a Patient With a Germline Tumor Protein p53 Mutation.

Radiation-induced sarcoma of the breast is a rare complication that is primarily treated with surgical resection but in patients with advanced disease, a multimodality treatment approach is often required. This case report discusses a 37-year-old female with a history of a pT3N3M0, estrogen receptor (ER)+, progesterone receptor (PR)+, human epidermal growth factor receptor 2 (HER2)+, right breast cancer, and a germline tumor protein (TP) p53 mutation who underwent right modified radical mastectomy, adjuvant systemic therapy, and radiation therapy, and subsequently developed a radiation-induced sarcoma. The patient is a 37-year-old female who has a history of pT3N3M0, ER/PR+, HER2+, and right breast cancer diagnosed in 2014. At the time of diagnosis, she had locally advanced disease and underwent right modified radical mastectomy followed by adjuvant chemotherapy, radiation, delayed right breast implant-based reconstruction, and left breast augmentation with mastopexy. Upon completion of adjuvant chemotherapy, she was started on hormonal therapy. In February 2020, she underwent genetic testing given her early onset of breast cancer and was found to have a germline TP53 mutation. Routine MRI for breast implant evaluation showed two irregular enhancing masses with an additional satellite lesion in the right breast. Right breast ultrasound (US)-guided biopsy revealed two separate foci of high-grade pleomorphic fibroblastic/myofibroblastic sarcoma. Further staging workup with a whole-body MRI was negative for evidence of metastatic disease. Her case was discussed in multidisciplinary sarcoma tumor board and consensus was for surgical resection. She underwent radical resection of the right chest wall masses and subcutaneous tissue, removal of right breast implant and capsulectomy, and left breast mastectomy with left breast implant removal and capsulectomy. The final pathology revealed two separate foci of high-grade pleomorphic fibroblastic/myofibroblastic sarcoma, 1.2 cm and 1.1 cm in their greatest dimensions with negative margins. Her case was re-discussed in multidisciplinary sarcoma tumor board and due to T1 size of the tumors and the negative resection margins, close surveillance with annual whole-body MRI and quarterly chest MRI imaging was recommended. In patients with a germline TP53 mutation and breast cancer, the utilization of adjuvant radiotherapy should be considered cautiously given the increased risk of radiation-associated sarcoma.

Synthesis of Novel Esters of Mefenamic Acid with Pronounced Anti-nociceptive Effects and a Proposed Activity on GABA, Opioid and Glutamate Receptors.

BACKGROUND: Mefenamic acid (MFA), a commonly prescribed non-steroidal anti-inflammatory drug (NSAID), possesses a greater risk of dose-related central nervous system (CNS) toxicity than other NSAIDs. In this study, α-tocopherol and α-tocopherol acetate were selected as prodrug moieties for MFA in an attempt to reduce the CNS toxicity and enhance the therapeutic efficacy. METHOD: α-tocopherol monoester of MFA (TMMA) and α-tocopherol di-ester of MFA (TDMA) were synthesized by esterification reaction and were subjected to various in vivo characterizations. RESULTS: Masking of the carboxylate group of MFA with the proposed pro-moieties significantly (p<0.05) delayed the onset of tonic-clonic seizure in mice. Besides, the intraperitoneal administration of TMMA and TDMA in mice produced significantly (p<0.05) stronger anti-inflammatory effects in the carrageenan-induced paw edema test and greater anti-nociceptive effect in the acetic acid-induced writhing test than MFA at an equimolar dose of 20 mg/kg. Treatment with TMMA and TDMA caused a significant (p<0.05) inhibition of pain at 1st and 2nd phases of formalin-induced licking test in mice, whereas treatment with MFA inhibited the 2nd phase only. Pretreatment with naloxone and flumazenil significantly (p<0.05) reversed the anti-nociceptive effect of MFA, TMMA and TDMA in the acetic acid-induced writhing test. In addition, treatment with TMMA and TDMA caused significantly (p<0.05) a higher inhibition of pain in the glutamate-induced licking response in mice than MFA. CONCLUSION: Masking the carboxylate moiety of MFA by α-tocopherol and α-tocopherol acetate has a great potential for reducing CNS toxicity, enhancing the therapeutic efficacy and altering the mode of anti-nociceptive action.

Intramedullary Fixation With a Short Nail in a Young Patient Presenting With a Pathological Proximal Femur Fracture.

An 18-year-old man presented with a pathological fracture of the right proximal femur. Desmoplastic fibroma was diagnosed through histological studies. Surgical management involved extended intralesional curettage and fracture stabilization by open reduction with intramedullary nailing, using a short Gamma nail. At 42-month follow-up, the patient presented no limitations or recurrence. Internal fixation after prior intralesional curettage is a valid treatment strategy for pathological fractures in young patients. A short nail was chosen to prevent direct tumor cell seeding throughout the femur and future recurrence. Fracture consolidation was achieved because of the healing potential of a young patient.

Effects of 8 Weeks of Balance Training, Virtual Reality Training, and Combined Exercise on Lower Limb Muscle Strength, Balance, and Functional Mobility Among Older Men: A Randomized Controlled Trial.

BACKGROUND: Poor muscle strength, balance, and functional mobility have predicted falls in older adults. Fall prevention guidelines recommend highly challenging balance training modes to decrease falls; however, it is unclear whether certain modes are more effective. The purpose of this study was to determine whether traditional balance training (BT), virtual reality balance training (VR), or combined exercise (MIX) relative to a waitlist control group (CON) would provoke greater improvements in strength, balance, and functional mobility as falls risk factor proxies for falls in older men. HYPOTHESIS: We hypothesized that 8 weeks of MIX will provoke the greatest improvements in falls risk factors, followed by similar improvements after BT and VR, relative to the CON. STUDY DESIGN: Single-blinded randomized controlled trial NCT02778841 (ClinicalTrials.gov identifier). LEVEL OF EVIDENCE: Level 2. METHODS: In total, 64 community-dwelling older men (age 71.8 ± 6.09 years) were randomly assigned into BT, VR, MIX, and CON groups and tested at baseline and at the 8-week follow-up. The training groups exercised for 40 minutes, 3 times per week, for 8 weeks. Isokinetic quadriceps and hamstrings strength on the dominant and nondominant legs were primary outcomes measured by the Biodex Isokinetic Dynamometer. Secondary outcomes included 1-legged stance on firm and foam surfaces, tandem stance, the timed-up-and-go, and gait speed. Separate one-way analyses of covariance between groups were conducted for each outcome using baseline scores as covariates. RESULTS: (1) MIX elicited greater improvements in strength, balance, and functional mobility relative to BT, VR, and CON; (2) VR exhibited better balance and functional mobility relative to BT and CON; and (3) BT demonstrated better balance and functional mobility relative to CON. CONCLUSION: The moderate to large effect sizes in strength and large effect sizes for balance and functional mobility underline that MIX is an effective method to improve falls risk among older adults. CLINICAL RELEVANCE: This study forms the basis for a larger trial powered for falls.

Perceptions of COVID-19-related Risks and Deaths Among Health Care Professionals During COVID-19 Pandemic in Pakistan: A Cross-sectional Study.

COVID-19 is an established challenge to the health care professionals (HCPs) having physical, emotional, and psychological repercussions. We determine the perceptions of Pakistani HCPs regarding the risks and deaths related to COVID-19. A cross-sectional study was conducted among HCPs throughout Pakistan from 16th February 2021 to 6th March 2021 by disseminating an online Google questionnaire via all possible social media platforms including WhatsApp, Facebook, Twitter, and emails. Out of total of 462 HCPs, 33.55% tested COVID-19 positive and 49.43% had received their first dose of COVID-19 vaccine. The proportion of HCPs worried about contracting COVID-19 was 46.97%. A total of 69.48% mentioned that doctors are at a higher risk of dying from COVID-19 infection compared to the general population. In a dichotomous analysis done for risk perception, 72.06% of doctors reported a high-risk perception of contracting COVID-19 in hospital settings. The main reasons identified to be associated with higher mortality amongst the HCPs, specifically doctors, included comorbidities (47.26%), working in high-risk wards (24.02%) and lack of adequate personal protective equipment (PPE) (28.72%). Using univariate and multivariate regression the HCPs tested positive rated two-fold high risk while performing professional duty during COVID-19 pandemic [unadjusted odds ratio (OR) (95% confidence interval (CI)): 2.23 (1.24-4.02), P = .007; adjusted OR (95% CI) 2.27 (1.22-4.19), P = .009]. In conclusion, Pakistani HCPs have significant COVID-19-related concerns and anxieties. The doctors perceived to be at a higher risk of dying with COVID-19, due to a variety of personal and professional reasons.

Access and Use Experience of Personal Protective Equipment Among Frontline Healthcare Workers in Pakistan During the COVID-19 Emergency: A Cross-Sectional Study.

Healthcare workers are at the highest risk of contracting novel coronavirus disease 2019 (COVID-19) and, therefore, require constant protection. This study assesses access to personal protective equipment (PPE), availability of adequate information about PPE use, self-reported ability to correctly wear and remove (donning and doffing) PPE, and risk perceptions associated with COVID-19 among frontline healthcare workers in Pakistan. Using a structured and validated questionnaire, an online survey was conducted from May 9 to June 5, 2020. Responses were received from 453 healthcare workers. Of these, 218 (48.12%) were doctors, 183 (40.40%) were nurses, and 52 (11.48%) were paramedical staff. Only 129 (28.48%) healthcare workers reported having adequate access to PPE at all times, whereas 156 (34.44%) never had access to PPE and 168 (37.09%) had access to PPE occasionally. Lack of access to PPE led the majority (71.74%) of healthcare workers to use coping strategies such as reuse of N95 and surgical masks. A total of 312 (68.87%) respondents believed that the risk of contracting COVID-19 in the work environment was high and the majority (62.69%) adopted precautionary measures at home to keep their families safe. A significantly high (n = 233, 51.43%, P = .03) number of respondents reported self-medicating. Of all the respondents, only 136 (30.02%) were tested for COVID-19 at least once, of which 32 (23.53%) ever tested positive. These findings suggest that healthcare workers in Pakistan had limited access to PPE. Adequate provision and training is vital to protect the healthcare workforce during the COVID-19 pandemic.

Asiatic acid stabilizes cytoskeletal proteins and prevents TNF-α-induced disorganization of cell-cell junctions in human aortic endothelial cells.

Endothelial hyperpermeability represents an initiating step in early atherosclerosis and it often occurs as a result of endothelial barrier dysfunction. Asiatic acid, a major triterpene isolated from Centella asiatica (L.) Urban, has previously been demonstrated to protect against tumor necrosis factor (TNF)-α-induced endothelial barrier dysfunction. The present study aimed to investigate the mechanisms underlying the barrier protective effect of asiatic acid in human aortic endothelial cells (HAECs). The localization of F-actin, diphosphorylated myosin light chain (diphospho-MLC), adherens junctions (AJs) and tight junctions (TJs) was studied using immunocytochemistry techniques and confocal microscopy. Their total protein expressions were examined using western blot analysis. The endothelial permeability was assessed using In Vitro Vascular Permeability Assay kits. In addition, intracellular redistribution of the junctional proteins was evaluated using subcellular fractionation kits. We show that asiatic acid stabilized F-actin and diphospho-MLC at the cell periphery and prevented their rearrangement stimulated by TNF-α. However, asiatic acid failed to attenuate cytochalasin D-induced increased permeability. Besides, asiatic acid abrogated TNF-α-induced structural reorganization of vascular endothelial (VE)-cadherin and ß-catenin by preserving their reticulum structures at cell-cell contact areas. In addition, asiatic acid also inhibited TNF-α-induced redistribution of occludin and zona occludens (ZO)-1 in different subcellular fractions. In conclusion, the barrier-stabilizing effect of asiatic acid might be associated with preservation of AJs and prevention of TJ redistribution caused by TNF-α. This study provides evidence to support the potential use of asiatic acid in the prevention of early atherosclerosis, which is initiated by endothelial barrier dysfunction.

Surgical Skills Workshops Should Be a Part of the United Kingdom Undergraduate Medical Curriculum.

INTRODUCTION:  Medical students across the United Kingdom (UK) report poor satisfaction with surgical teaching. The Surgical Skills Day (SSD) begins to address this by exposing medical students to surgery through an easily accessible one-day practical workshop. This study shows how the SSD encourages undergraduate engagement in surgery. METHOD:  Feedback forms were emailed to attendees of the SSD and their anonymised responses were used to evaluate the SSD. RESULTS:  A total of 144 students attended the SSD across three years and the feedback response rate was 74% (n = 107). Key findings were that 100% of respondents (n = 107) would like the SSD to be an annual event, 79% (n = 83) were more inclined to pursue a surgical career following the event, and 97% (n = 103) would like to see practical surgical skills incorporated into the curriculum. The SSD was able to engage undergraduates with surgery through mentorship, practical skills, specialty exposure, and teaching of the General Medical Council (GMC) mandated skills. CONCLUSIONS:  Undergraduate surgical teaching in the UK is insufficient. The student-led annual SSD showed improved engagement in practical surgical skills and increased enthusiasm for a surgical career. In light of this, the authors feel the SSD or similar event should be integrated into the UK medical school curriculum.

Cosmos caudatus extract/fractions reduce smooth muscle cells migration and invasion in vitro : A potential benefit of suppressing atherosclerosis.

HIGHLIGHTS: Cosmos caudatus Ethanolic extract fractionation by n-butanol produced a phenolics-saponin rich fraction.Cosmos caudatus butanol fraction was the most potent in all antioxidant and MTT assays.High concentrations of all fractions increased cells migration and invasion in vitro.Butanol fraction intermediate concentration maximally inhibited VSMC migration and invasion.Mild concentrations of crude and butanol fractions showed the best invasion inhibition index. BACKGROUND: Cosmos caudatus Kunth is a medicinal herb used traditionally in Latin America and South East Asia to retard aging, rigidify bones and for several cardiovascular uses. OBJECTIVE: Is to assess C. caudatus extract/fractions' antioxidant and vascular smooth muscle cells (VSMC) migration and invasion inhibition capacity in vitro. METHODS: Cosmos caudatus shoots were extracted by cold maceration in 50% ethanol to produce crude (CEE), and then the extract was fractionated to butanol (Bu.F), and aqueous fractions (Aq.f). Phenolics and saponins were quantified in extract and fractions by colorimetric methods and their antioxidant capacity was assayed in four different tests. Cytotoxic effect and safety level concentrations were determined for the fractions by using MTT assay. Migration and invasion inhibitory potential were measured in vitro at three different concentrations equivalent to (IC10, IC25, and IC50). Finally, invasion inhibitory index was calculated to obtain the best fraction(s) that show(s) the highest ratio of cell invasion inhibition to the total cell migration inhibition. RESULTS: Butanol fraction yield was the lowest; nevertheless, its phytochemical contents, antioxidant activities as well as its potency were the highest. Unlike other fractions, Bu.F was strongly correlated with all antioxidant assays experimented. In addition, it has the highest inhibitory effect at IC25 against VSMCs migration and invasion that accounts for 53.93% and 59.94% respectively. Unexpectedly, Bu.F and CEE at IC10 displayed the highest invasion inhibitory index (approx. 68%). CONCLUSION: Butanol fraction of C. caudatus offers a potentiality for the discovery of new leads for preventing atherosclerosis.