Institutional Environment and Tourism: Moderating Role of Host Countries' Health System

Tourism has gradually emerged to become a significant factor for sustainable economic growth around the globe. Along with other variables, the institutional environment has a significant influence on the growth of the tourism industry. Consequently, there are two primary goals for this study: firstly, to improve the body of knowledge already available on the institution-tourism nexus;secondly, to investigate how the health systems of the host countries contribute to the said nexus. To analyze these relations, we collected data from 50 countries across 10 years (2009-2018). We apply multiple regression analysis to a balanced panel dataset of 500 observations. Furthermore, we also used an interactive variable in conjunction with the primary independent, dependent, and control variables of the study to determine the moderating effect of the host countries' health systems. The study's findings demonstrated the significance of an efficient institutional structure in boosting tourism. Additionally, the health systems of the host nations play a significant role in strengthening the connection between institutions and tourism, especially in the post-COVID-19 period. Through the creation of institutional frameworks and health infrastructure, the study's findings will assist policymakers in developing efficient tourism policies. All of the above strategies will eventually lead to a trustworthy, safe, and healthy environment for both locals and visitors.

Case Series: Post-COVID Small Fiber Neuropathy

Objective: To report a case series documenting biopsy-proven small fiber neuropathy (SFN) after COVID-19. Background: Patients recovering from COVID-19 who present with sensory as well as autonomic symptoms, including positional orthostatic tachycardia syndrome (POTS), frequently have negative electrodiagnostic testing. Skin biopsy may be required to reveal SFN. Design/Methods: This is a retrospective case series of patients seen in the Yale Neurology COVID-19 Clinic with positive SARS-CoV-2 PCR or antibody or a clinically consistent illness. After laboratory testing and a negative nerve conduction study, all patients underwent skin biopsy to test for intraepidermal SFN. Case 1: A 40F with pre-diabetes (HbA1c 6.2%) developed burning, numbness, and tingling in the hands and legs and POTS 6 weeks after acute COVID-19. Skin biopsy demonstrated non-length dependent SFN. Complete remission of neuropathy symptoms occurred within days of intravenous immunoglobulin (IVIG) therapy, which has been continued longitudinally. Case 2: A 65F with non-insulin dependent diabetes (HbA1c 8.0%) developed excruciating burning pain in her feet and orthostasis within weeks of acute COVID-19. Skin biopsy demonstrated non-length dependent SFN. She experienced partial relief of symptoms after IVIG and gabapentin. Case 3: A 43F with pre-diabetes (HbA1c 6.0%) developed orthostasis, numbness, paresthesias, and a “sunburned” feeling in her face, back, hands, and feet 2 weeks after acute COVID-19. Skin biopsy demonstrated length-dependent SFN. Symptoms improved over several months of pregabalin treatment, but have not resolved. The patient deferred immunotherapy. Case 4: A 40M developed POTS, numbness, and paresthesias in his face and left leg up to the knee within weeks of a clinical COVID-19 illness. Skin biopsy demonstrated non-length dependent SFN. IVIG therapy has resulted in significant improvement in symptoms. Conclusions: Sensory symptoms and POTS occur post-COVID, and SFN should be considered in the differential. Given the time of onset and response to immunotherapy, post-COVID SFN may have an underlying autoimmune etiology.

Impact of COVID-19 pandemic on head-neck cancer referral and treatment pathway in North East London.

INTRODUCTION: The COVID-19 pandemic has led to wide-ranging disruption of head-neck cancer (HNC) service provision in the UK. Early reports suggest delays in referral, diagnosis and initiation of treatment for new cancer cases compared with before the pandemic. METHODS: The HNC service was studied retrospectively for the time-periods between 1 January 2020 to 31 October 2020 (hereafter 'post-COVID') and 1 January 2019 to 31 October 2019 (hereafter 'pre-COVID'). We analysed: (1) the number of cases treated at our centre, (2) stage of disease at presentation and (3) treatment delivery times. RESULTS: In the post-COVID period, the total number of HNC cases treated decreased (48 vs 56 pre-COVID). There was increase in advanced stage at presentation (58% vs 42% pre-COVID) and a significant increase in the need for airway stabilisation (13 vs 5 pre-COVID; p=0.03). Average time from referral to treatment was significantly prolonged (72.5 days vs 49.23 days pre-COVID; p=0.03). Two-week wait referrals were seen in HNC clinics at median time of 11.9 days, compared with 7.1 days during the pre-COVID period (p=0.07). However, there was no delay in the initiation of first treatment after the decision to treat (29.2 days vs 24.7 days pre-COVID; p=0.58). CONCLUSION: The results of this study call for early referral at the primary care level and rapid radiopathological confirmation at the tertiary level to prevent delays in diagnosis of new HNC cases.

Head-neck dissection course during COVID-19 pandemic: challenges, adaptations and how we did it.

INTRODUCTION: Cadaveric dissection courses have come to a standstill since the onset of the COVID-19 pandemic. In addition to limited operative opportunities, cancellation of such courses has severely impacted surgical training, especially in a craft-based specialty such as head-neck surgery. The aim of this educational project was to: (1) study the feasibility of an in-person head-neck cadaveric dissection course during COVID-19 pandemic; and (2) validate the educational benefit of this teaching method to ear, nose and throat (ENT) trainees. METHODS: We developed a 2-day head-neck cadaveric dissection course for ENT trainees. The course programme covered essential head-neck open surgical procedures. Content validity (subjective feedback) was assessed using a 5-point Likert scale. Construct validity (objective usefulness) was evaluated via two pre- and post-course questionnaires, estimating knowledge of head-neck surgical anatomy and self-assessment of levels of confidence with head-neck procedures, respectively. RESULTS: A risk assessment was conducted and a protocol developed (risk was deemed to be low/tolerable). Content validity showed high satisfaction compared with a median Likert score of 3, 'average' (p=0.000002). For construct validity, the mean score per question improved significantly (p=0.001). Overall levels of confidence showed a trend towards improvement (p=0.08). There was significant improvement in laryngectomy (p=0.01) and level I dissection (p=0.01), with an indication of improvement in level II-V dissection (p=0.07). CONCLUSIONS: We demonstrated that a cadaveric dissection course, using thorough risk assessment and protocol, could be safely conducted with high content and construct validation during these unprecedented times. This is an invaluable learning environment that needs to be encouraged despite infection control restrictions.

The Viability of Blended Model in Undergraduate Medical Education in COVID-19 Pandemic

Introduction: With the new era of life threatening variants of Covid-19 the medical and dental education has been greatly compromised. Every school/college has to shift their educational setup to Blended model. Blended model can also be called as hybrid approach of learning or mixed mode of learning. It is an "insightful combination of Face to Face and Online opportunities for growth". Objective: The aim of this study is to measure the viability of Blended Model through series of assessments by measuring the retention of the content after the teaching session in online and in face to face settings in Knowledge acquisition and knowledge retention test. Material & Method Methodology: This was a Quantitative Experimental study which was conducted in the Fatima Memorial college of Medicine and Dentistry Lahore. The participants were 66 of final year BDS students who voluntarily participated in the research project. Results: A total of 96 students participated in the study and it was found a significant difference between the two intervention groups regarding the mean scores of Knowledge acquisition and knowledge retention test. The PowerPoint group showed lower grades in Knowledge acquisition and knowledge retention test in comparison with Prezi group. The learning performances was evaluated from immediate learning responses in Knowledge acquisition and in long term learning retention in knowledge retention test showed that both the presentation software can be used as a presentation medium and students do learn from both but Prezi presentation software students are superior in learning performances from immediate learning to long term memory retention as compared to PowerPoint presentation software in online and in face to face settings. Conclusion: Blended model can help the medical teachers to teach the theoretical aspects of the curriculum via online and make easy schedules of student's rotations for clinical clerkships. When it comes to clinical training, there is no shortcut or better way than face to face teaching strategy. Therefore blended learning is a viable method of teaching in this period of Covid-19.

Ischemic stroke, inflammation, and endotheliopathy in COVID-19 patients

Objective: Early reports suggest an increased risk of ischemic stroke during COVID-19 infection. We aimed to identify patients with COVID-19 and ischemic stroke and explore markers of endotheliopathy, inflammation, and hypercoagulability. Background: Novel coronavirus-19 disease (COVID-19) is associated with a diverse array of neurologic complications, including ischemic stroke. Suspected mechanisms include hypercoagulability and endothelial injury, although evidence is sparse in stroke patients. Design/Methods: This was a retrospective, observational cohort study of patients with acute ischemic stroke and COVID-19 (n=21) compared to non-COVID-19 acute ischemic stroke patients (n=11). Timing of stroke onset during COVID-19 course, acute phase reactant levels, cytokine levels, endothelial activation, and hypercoagulability were evaluated with respect to stroke onset and etiology. Results: Twenty-one ischemic stroke patients were diagnosed with COVID-19 during the study period. Both groups had a similar age and burden of vascular risk factors. COVID-19 patients had significantly higher levels of endothelial activation around the time of stroke when compared to controls. The mean Factor VIII level was 332% of normal in the COVID-19 group and 49% in the control group, while von Willebrand Factor antigen and activity were 330% and 285% in the COVID-19 group and 213% and 152% in the control group, respectively. Cytokine storming and a strong inflammatory responses are defining features of severe COVID-19. We demonstrated a temporal correlation between stroke onset and the peak of acute phase reactants. Elevated cytokine levels, IL-6 and soluble IL-2 receptor levels in particular, were significantly associated with embolic stroke of undetermined source (ESUS) in COVID-19 patients when compared with other etiologies. Conclusions: We provide emerging evidence that endotheliopathy and the systemic inflammatory response in patients with vascular risk factors and COVID-19 is associated with ischemic stroke. Further research is needed. Understanding the mechanism of stroke in COVID- 19 patients will be critical in providing primary stroke prevention and treatment.

Mycobacterium tuberculosis sepsis a fatal mistake

INTRODUCTION: Septic shock from Mycobacterium tuberculosis (MTB) is a rare entity that is typically reported in developing countries and amongst immunocompromised adults. We report a previously healthy patient who presented with MTB shock that rapidly progressed to shock, multiorgan failure, and death. METHODS: A 24-year-old female who presented to the ER with shortness of breath and productive cough of 3 months. She remained home despite symptoms due to the fear of COVID19. She also complained of night sweats, fevers, decreased appetite, and unintentional weight loss of 60 pounds. She did not report sick contacts, incarceration, intravenous drug use, smoking, or TB exposure. She had traveled to Guyana six months prior. She was afebrile, tachycardiac, and hypotensive with and was started on crystalloid for hypotension. The exam was notable for profound cachexia, auscultation of the chest revealed diffuse rale with hollow breath sounds. Lab data significant for Hemoglobin 6.6g/dL, BUN:Cr 10:0.47mg/dL, Albumin was 2.1g/dL, AST was elevated. HIV was non-reactive, and QuantiFERON was negative. CT chest revealed bilateral nodular interstitial opacities, large cystic changes and tree-in-bud nodularity in lower lobes. She was initiated on board spectrum antibiotics with piperacillin/tazobactam and vancomycin. Sputum was sent for Acid-fast bacilli (AFB). When tested positive for AFB, we initiated treatment with rifampin, isoniazid, pyrazinamide, and ethambutol. But within 24 hours, she progressed to acute hypoxemic respiratory failure requiring intubation and developed septic shock refractory to 4 vasopressors. She was also started on methylprednisolone for relative adrenal deficiency. Blood cultures remained negative. Despite maximum ventilatory and vasopressor support, she became progressively hypoxemic and passed after a Vfib arrest. RESULTS: MTB sepsis is believed to be secondary to tumor necrosis factor production. Antituberculosis therapy is typically not initiated microbiologic evidence of AFB but as per Kethireddy et al. Early recognition of active disease and initiation of appropriate therapy before or at the onset of hypotension can potentially limit the high mortality observed with MTB septic shock.

Emergent Ophthalmic Surgical Care at a Tertiary Referral Center During the COVID-19 Pandemic.

PURPOSE: This study characterized the delivery of emergent ophthalmic surgical care during April 2020 of the coronarvirus disease-19 (COVID-19) pandemic compared with the same interval the previous year. DESIGN: Retrospective observational before-and-after study. METHODS: This study reviewed and characterized each emergent and/or urgent procedure performed during April 2020 and April 2019 at a single tertiary ophthalmology referral center. Information collected included the details of patient presentation, diagnosis, surgical procedure, and preoperative COVID-19 testing. RESULTS: In total, 117 surgical procedures were performed on 114 patients during the month of April 2020 compared with 1,107 performed in April 2019 (P < .0001). Retinal detachment repair was the most common procedure (n = 37; 31.6%) in April 2020, whereas elective cataract surgery (n = 481; 47.3%) was the most common procedure in April 2019. The mean age of patients was 50.0 years in April 2020 compared with 59.0 years (P < .0001) the previous year. During April 2020, the mean age of surgeons performing procedures was 42.3 years compared with 48.4 years (P < .0001) during April 2019. In April 2020, all but 5 patients (96%) had reverse transcriptase polymerase chain reaction based COVID-19 testing before their procedure. One patient (0.88%) had a positive COVID-19 test. CONCLUSIONS: The COVID-19 pandemic decreased our institution's surgical volume in April 2020 to approximately 10% of the usual volume. The pandemic changed the type of cases performed and led to a statistically significant decrease in both the age of our surgeons and patients relative to the same interval in the previous year. Broad preoperative screening led to 1 positive COVID-19 test in an asymptomatic patient.