Knowledge assessment and outcomes of otolaryngology practice amidst the COVID-19 pandemic in a busy ENT department.

INTRODUCTION: Otolaryngology health personnel are at high risk of acquiring COVID-19 disease and, hence, are likely to have high stress levels. This study was designed to evaluate the feedback of otolaryngology healthcare workers in ENT departments who are managing patients in the coronavirus pandemic. METHODS: A questionnaire focused on all aspects of healthcare delivery was completed by otolaryngology healthcare workers. RESULTS: The findings, based on statistical analyses, included high stress levels and inadequate disease-related information in these workers. CONCLUSIONS: Healthcare authorities need to take care of issues related to mental health in healthcare professionals in addition to spreading awareness about safe practices. Further studies are needed to continuously monitor feedback from personnel as the coronavirus pandemic unravels in the future.

A multicentre observational study on the epidemiology, risk factors, management and outcomes of mucormycosis in India.

OBJECTIVES: To describe the epidemiology, management and outcome of individuals with mucormycosis; and to evaluate the risk factors associated with mortality. METHODS: We conducted a prospective observational study involving consecutive individuals with proven mucormycosis across 12 centres from India. The demographic profile, microbiology, predisposing factors, management and 90-day mortality were recorded; risk factors for mortality were analysed. RESULTS: We included 465 patients. Rhino-orbital mucormycosis was the most common (315/465, 67.7%) presentation followed by pulmonary (62/465, 13.3%), cutaneous (49/465, 10.5%), and others. The predisposing factors included diabetes mellitus (342/465, 73.5%), malignancy (42/465, 9.0%), transplant (36/465, 7.7%), and others. Rhizopus species (231/290, 79.7%) were the most common followed by Apophysomyces variabilis (23/290, 7.9%), and several rare Mucorales. Surgical treatment was performed in 62.2% (289/465) of the participants. Amphotericin B was the primary therapy in 81.9% (381/465), and posaconazole was used as combination therapy in 53 (11.4%) individuals. Antifungal therapy was inappropriate in 7.6% (30/394) of the individuals. The 90-day mortality rate was 52% (242/465). On multivariate analysis, disseminated and rhino-orbital (with cerebral extension) mucormycosis, shorter duration of symptoms, shorter duration of antifungal therapy, and treatment with amphotericin B deoxycholate (versus liposomal) were independent risk factors of mortality. A combined medical and surgical management was associated with a better survival. CONCLUSIONS: Diabetes mellitus was the dominant predisposing factor in all forms of mucormycosis. Combined surgical and medical management was associated with better outcomes. Several gaps surfaced in the management of mucormycosis. The rarer Mucorales identified in the study warrant further evaluation.

Tuberculosis infection control measures at health care facilities offering HIV and tuberculosis services in India: A baseline assessment.

BACKGROUND: Tuberculosis (TB) is one of world's oldest infectious disease and ranks alongside HIV as leading infectious killer. Tuberculosis infection control especially in HIV and TB care facilities has warranted attention after the recent health care-associated outbreaks in South Africa. The aim of this study was to describe the tuberculosis infection control measures implemented by HIV and TB care facilities in five high HIV burden provinces in India. METHODS: Baseline assessment of 30 high burden Antiretroviral centers and TB facilities was conducted during Oct 2015-Dec 2015 by AIC trained staff using a structured format. RESULTS: Thirty HIV and TB care facilities in five high HIV burden provinces were enrolled. Facility infrastructure and airborne infection control practices were highly varied between facilities. TB screening and fast tracking at ART centers is happening at majority of centers however inadequate TB infection control training, poor compliance to administrative and personal protective measures and lack of mechanism for health care workers surveillance need attention. CONCLUSIONS: Local specific TB infection control interventions to be designed and implemented at HIV and TB care facilities including implementation of administrative, environmental and use of personal protective equipment's with the training of staff members. Health care workers surveillance needs to be prioritized considering the rising instances of tuberculosis among Health care workers.

Newer glycopeptide antibiotics for treatment of complicated skin and soft tissue infections: systematic review, network meta-analysis and cost analysis.

OBJECTIVES: Skin and soft tissue infections (SSTIs) carry significant economic burden, as well as morbidity and mortality, especially when caused by methicillin-resistant Staphylococcus aureus (MRSA). Several new MRSA-active antibiotics have been developed, including semisynthetic glycopeptides (telavancin, dalbavancin and oritavancin). Of these, dalbavancin and oritavancin offer extended dosing intervals. METHODS: We performed a systematic review, network meta-analysis and cost analysis to compare the newer glycopeptides to standard care and to each other for the treatment of complicated SSTIs (cSSTI). A search for randomized controlled trials (RCTs) was conducted in Medline, Embase and the Cochrane Central Register of Controlled Trials. We also developed a model to evaluate the costs associated with dalbavancin and oritavancin from the third-party payer perspective. RESULTS: Seven RCTs met the inclusion criteria. Network meta-analyses suggested that the clinical response to telavancin, dalbavancin and oritavancin was similar to standard care (odds ratio (OR) 1.09, 95% confidence interval (CI) 0.90-1.33; OR 0.78, 95% CI 0.52-1.18; and OR 1.06, 95% CI 0.85-1.33, respectively). Head-to-head comparisons showed no difference in clinical response between oritavancin and dalbavancin (OR 1.36; 95% CI 0.85-2.18), oritavancin and telavancin (OR 0.98; 95% CI 0.72-1.31) or dalbavancin and telavancin (OR 0.72; 95% CI 0.45-1.13). Telavancin had a higher incidence of overall adverse events compared to standard care (OR 1.33; 95% CI 1.10-1.61). Compared to telavancin, there were fewer overall adverse events with dalbavancin (OR 0.58; 95% CI 0.45-0.76) and oritavancin (OR 0.71; 95% CI 0.55-0.92). Studies were of high quality overall. Our cost analyses demonstrated that dalbavancin and oritavancin were less costly compared to standard care under baseline assumptions and many scenarios evaluated. The use of dalbavancin could save third-party payers $1442 to $4803 per cSSTI, while the use of oritavancin could save $3571 to $6932 per cSSTI. CONCLUSIONS: Dalbavancin and oritavancin demonstrate efficacy and safety comparable to standard care in well-designed RCTs and result in cost savings when standard care is treatment that covers MRSA.

Efficacy and safety of surfactant replacement therapy for preterm neonates with respiratory distress syndrome in low- and middle-income countries: a systematic review.

Surfactant replacement therapy (SRT) has been shown to reduce mortality and air leaks in preterm neonates from high-income countries (HICs). The safety and efficacy of SRT in low- and middle- income countries (LMICs) have not been systematically evaluated. The major objectives of this review were to assess the (1) efficacy and safety, and (2) feasibility and cost effectiveness of SRT in LMIC settings. We searched the following databases-MEDLINE, CENTRAL, CINAHL, EMBASE and WHOLIS using the search terms 'surfactant' OR 'pulmonary surfactant'. Both experimental and observational studies that enrolled preterm neonates with or at-risk of respiratory distress syndrome (RDS) and required surfactant (animal-derived or synthetic) were included. A total of 38 relevant studies were found; almost all were from level-3 neonatal units. Pooled analysis of two randomized controlled trials (RCTs) and 22 observational studies showed a significant reduction in mortality at the last available time point in neonates who received SRT (relative risk (RR) 0.67; 95% confidence interval (CI) 0.57 to 0.79). There was also a significant reduction in the risk of air leaks (five studies; RR 0.51; 0.29 to 0.90). One RCT and twelve observational studies reported the risk of bronchopulmonary dysplasia (BPD) with contrasting results; while the RCT and most before-after/cohort studies showed a significant reduction or no effect, the majority of the case-control studies demonstrated significantly higher odds of receiving SRT in neonates who developed BPD. Two studies-one RCT and one observational-found no difference in the proportion of neonates developing pulmonary hemorrhage, while another observational study reported a higher incidence in those receiving SRT. The failure rate of the intubate-surfactant-extubate (InSurE) technique requiring mechanical ventilation or referral varied from 34 to 45% in four case-series. No study reported on the cost effectiveness of SRT. Available evidence suggests that SRT is effective, safe and feasible in level-3 neonatal units and has the potential to reduce neonatal mortality and air leaks in low-resource settings as well. However, there is a need to generate more evidence on the cost effectiveness of SRT and its effect on BPD in LMIC settings.

Safety, cost-effectiveness and feasibility of daycase paracentesis in the management of malignant ascites with a focus on ovarian cancer.

BACKGROUND: Paracentesis for malignant ascites is usually performed as an in-patient procedure, with a median length of stay (LoS) of 3-5 days, with intermittent clamping of the drain due to a perceived risk of hypotension. In this study, we assessed the safety of free drainage and the feasibility and cost-effectiveness of daycase paracentesis. METHOD: Ovarian cancer admissions at Hammersmith Hospital between July and October 2009 were audited (Stage 1). A total of 21 patients (Stage 2) subsequently underwent paracentesis with free drainage of ascites without intermittent clamping (October 2010-January 2011). Finally, 13 patients (19 paracenteses, Stage 3), were drained as a daycase (May-December 2011). RESULTS: Of 67 patients (Stage 1), 22% of admissions and 18% of bed-days were for paracentesis, with a median LoS of 4 days. In all, 81% of patients (Stage 2) drained completely without hypotension. Of four patients with hypotension, none was tachycardic or symptomatic. Daycase paracentesis achieved complete ascites drainage without complications, or the need for in-patient admission in 94.7% of cases (Stage 3), and cost £954 compared with £1473 for in-patient drainage. CONCLUSIONS: Free drainage of malignant ascites is safe. Daycase paracentesis is feasible, cost-effective and reduces hospital admissions, and potentially represents the standard of care for patients with malignant ascites.

The practice and tradition of bonesetting.

CONTEXT: Traditional bonesetting is an art that in the face of urbanization, lack of public attention and lack of modern facilities has survived more than 3,000 years. This article explores the role of bonesetters in the developing world, their successes and failures and possible utilization of their services as part of the healthcare system of a country. METHODS: Articles depicting working or techniques of bonesetters or those related to training and education issues of traditional bonesetters, especially in developing countries, were reviewed. The current scenario of healthcare delivery and medical education along with existing socioeconomic conditions prevailing in India were analyzed with generalization of findings to the healthcare delivery systems of other developing countries. FINDINGS: Bonesetting has its strengths and weaknesses. With current socioeconomic conditions and the types of health needs prevailing in developing countries, it would be difficult to abolish traditional bonesetting. These providers have widespread community acceptance and support. Complications can be minimized and practice potentially improved with training and education. CONCLUSIONS: Pending infrastructure and socioeconomic development, it appears that traditional bonesetters will remain providers of healthcare. Their methodology utilizes regional resources and is commonly believed to be cheaper and effective. Although the deficiencies of traditional bonesetters have been shown, with adequate training in the basics of orthopaedic care, they can be utilized to provide useful health services at the primary care level.

Resting energy expenditure in chronic kidney disease: relationship with glomerular filtration rate.

BACKGROUND: The kidneys may account for up to 20% of resting energy expenditure (REE), but there is controversy regarding the relationship between severity of renal impairment and REE. Furthermore, reduction in protein intake is associated with declining glomerular filtration rate (GFR) that contributes to malnutrition. If a selective aversion to protein intake or a global reduction in food intake takes place is not known. METHODS: To define the relationship between REE and its relationship to GFR, we measured REE with indirect calorimetry, GFR with iothalamate clearance, and body composition with creatinine kinetics and skin-fold measurements in 16 patients with mild to moderate renal failure due to type 2 diabetes mellitus (n = 12) or glomerulonephritides (n = 4). RESULTS: In univariate analysis, age, weight, height, body mass index, lean body mass, urine urea nitrogen but not hemoglobin or albumin correlated with REE. In multivariate analysis, lean body mass emerged as the strongest predictor of REE followed by GFR. A lower GFR was associated with a lower REE. Also, we found reduced REE, but not a fall in GFR, was associated with a fall in dietary protein intake. This supports the hypothesis that patients with CKD have no selective aversion to protein; reduction in dietary protein intake with progressive CKD is due to global reduction in food intake. CONCLUSIONS: We conclude that REE falls with declining renal function in patients with CKD. This is likely secondary to combination of reduced energy expenditure of kidneys, adaptation to decreased energy intake or alteration in cellular energy metabolism.

Role of home blood pressure monitoring in hemodialysis patients.

To investigate the use of manual home blood pressure (BP) monitoring in chronic hemodialysis patients, daily home BPs in 20 patients undergoing chronic hemodialysis were compared with the 44-hour interdialytic ambulatory BPs (ABPs). Each patient recorded home BPs for 2 consecutive weeks with a digital BP monitor three times daily. Prehemodialysis and posthemodialysis BPs were recorded by an oscillometric device in the hemodialysis unit during the same 2 weeks. ABPs were recorded either after the first or second hemodialysis session of the second week during a 44-hour interdialytic period using a Spacelab 90207 ABP monitor. ABP monitoring showed that BP decreased progressively after dialysis, decreased during the first night, and rapidly reached predialysis levels by the next morning. There was no decrease in BP during the second night. There was an excellent correlation between average systolic and diastolic ABP and respective home BPs. Prehemodialysis diastolic BPs were a good reflection of diastolic ABP, but there was more variability in predialysis systolic BP. Posthemodialysis BPs did not correlate with ABP. In patients undergoing chronic hemodialysis, home BPs more reliably reflected the overall BP than incenter BP readings. Predialysis, but not postdialysis, BP should be used as a screening tool to detect hypertension in the hemodialysis unit. Home BP monitoring should be used as a cost-effective means to diagnose occult hypertension in chronic hemodialysis patients.

Povidone iodine plus neosporin in superficial burns--a continuing study.

A total of 1053 patients with superficial burn injury were treated with povidone iodine plus neosporin (PVP + N) and the results after treatment were compared with those obtained after treating 1089 patients with silver sulphadiazine (SSD). Qualitative analysis showed Staphylococcus aureus and Pseudomonas spp. to be the most common infecting organisms. Quantitatively, fewer patients showed infection on the 7th and 18th day post-treatment in the PVP + N group (P < 0.01 and P < 0.001, respectively). Similarly, healing times were also better with PVP + N, with a maximum number of patients having healed within 15 days (P < 0.001). However, the mortality rates were not much different between the two groups.

Ultraviolet B radiation-induced DNA lesions in mouse epidermis: an assessment using a novel 32P-postlabelling technique.

Ultraviolet B (UVB) component of the sunlight is the major cause of nonmelanoma skin cancer (NMSC) in humans. UVB is absorbed directly by cellular DNA and produces lesions that may cause mutation(s) in target gene(s) ultimately leading to cancer. Early detection of these lesions, therefore, may help to identify individuals at a high risk to develop NMSC, and devise approaches for the prevention of this common malignancy. Employing mouse skin as a model, we applied a 32P postlabelling method to detect UVB-induced DNA lesions in the epidermis in nanomole quantities. Autoradiography maps showed that epidermal DNA from UVB exposed mice at 24 h contain up to five DNA lesions; the quantitation of these lesions showed that their formation increased in a UVB dose-dependent manner. Treatment of DNA samples with the bacteriophage DNA repair enzyme T4 endonuclease V confirmed that four of these lesions are pyrimidine dimers. While, some of these lesions were repaired 18 h after UVB irradiation, 30% of them persisted even 48 h post-irradiation. Application of a sunscreen containing ethylhexyl-p-methoxycinnamate or chemopreventive agent green tea polyphenols or silymarin to the skin of the mice prior to UVB exposure was found to prevent the formation of pyrimidine dimers.

Noninvasive assessment of systolic and diastolic left ventricular function in patients with chronic severe anemia: a combined M-mode, two-dimensional, and Doppler echocardiographic study.

Thirty-one patients with chronic severe anemia of more than 3 months' duration (hemoglobin less than 7 gm/dl) and no underlying heart disease were studied by means of M-mode, two-dimensional, and Doppler echocardiography; an equal number of normal control subjects was also studied. There are conflicting reports regarding the influence of chronic severe anemia on systolic myocardial function, but diastolic function has not been systematically assessed. It is also uncertain whether anemia alone can cause heart failure in a structurally normal heart. We therefore performed a detailed study of echocardiographic indexes of systolic and diastolic left ventricular function in these patients. We found that patients with anemia have significantly faster heart rates and lower diastolic and mean blood pressures than normal subjects. They also have a significantly elevated cardiac output and stroke volume and larger left ventricles. Left ventricular contractility, assessed by the end-systolic stress-dimension relationship, was enhanced. There was no systematic evidence of diastolic dysfunction by Doppler assessment of mitral inflow. There was also no clinical evidence of congestive heart failure. We conclude that chronic severe anemia leads to a hyperdynamic state with systolic hyperfunction and no impairment of diastolic function. Anemia does not lead to congestive heart failure in the absence of underlying heart disease.

Assessment of cyclosporin A in whole blood and plasma in five patients with different hematocrits.

Measurement of whole blood and plasma levels of cyclosporin A (CsA) by radioimmunoassay in kidney transplant recipients receiving the drug showed that CsA concentrations in plasma increased nonlinearly when whole blood levels of the drug exceeded 1,000 ng/ml. At low plasma levels (less than 200 ng/ml), most of the CsA in the blood was in the nonplasma component, indicating that cellular elements have high affinity for CsA. Comparison of nonplasma CsA concentrations in two patients with hematocrit values of 32.5 and 35% showed that in the patient with a hematocrit of 35% the cellular associated drug was twice as great as that in the other patient, indicating that there may be significant differences in the cellular affinity of CsA in patients with similar hematocrits. Linear regression analysis of the cellular associated CsA versus plasma levels of the drug in a double-reciprocal plot showed a drug saturation capacity of 6,060 ng/ml in the nonplasma component of blood in the patient with a hematocrit of 35%. Similar analyses in the other patients indicated saturation capacities ranging from 4,750 to 10,400 ng/ml.