A single-center audit of a novel tonsil long-waiter outpatient clinic.

BACKGROUND: Outpatient waiting list figures have substantially increased over the last 3 years due to the effects of a global pandemic and cyber-hacking crisis. Multidisciplinary initiatives are essential to try to reduce the burden on overwhelmed medical and surgical specialties. OBJECTIVE: The purpose of the study is as follows: (1) to demonstrate the potential for a problem-specific clinic to help ease the burden on an overwhelmed specialty and identify high-risk patients who may benefit from earlier surgical intervention and (2) to provide supervised clinical training to our clinical nurse specialist. METHODS: A retrospective audit of outpatient referrals awaiting an appointment was conducted, and a new outpatient clinic was formed for patients referred with tonsil issues with or without additional complaints. RESULTS: Two hundred ninety-five patients with an average waiting time of 14.4 months were offered an outpatient appointment over 5 months. Sixty-four percent (n = 189) attended their appointments, and 59.3% (n = 112) of these were listed for surgery. One hundred fifty-eight patients were able to be discharged back to the care of their general practitioners. DISCUSSION/CONCLUSION: This outpatient clinic identified a large number of patients waiting significant periods of time for an outpatient appointment and allowed a definitive clinical decision to be made with most patients being either discharged or listed for surgery. Initiatives such as this offer the possibility of reducing the burden of long waiting times on individual institutions.

Anti-COVID property of subcutaneous ivermectin in synergy with zinc among midlife moderately symptomatic patients: a structured summary of a study protocol for a randomised controlled trial.

OBJECTIVES: The study objective is to quantify the effectiveness of ivermectin (subcutaneous/oral IVM) in the presence or absence of zinc (Zn) for clinical and radiological improvement in coronavirus disease 2019 (COVID-19) patients with moderate severity. TRIAL DESIGN: This quadruple-blinded, placebo-controlled randomized clinical trial will be a multiarmed multi-centered study with superiority framework. PARTICIPANTS: Quinquagenarian and sexagenarian patients with moderate COVID-19 symptoms and positive severe respiratory syndrome coronavirus -2 (SARS-CoV-2) PCR will be included. Participants with co-morbidities and pregnant women will be excluded. Patient recruitment will be done in Shaikh Zayed Medical Complex, Doctors Lounge and Ali Clinic in Lahore (Pakistan). INTERVENTION AND COMPARATOR: The registered patients will be allocated in 6 groups (30 participants each). Patients will be taking subcutaneous IVM at 200 µg/kg/48 h (Arm A) or subcutaneous IVM at 200 µg/kg/48 h and oral Zn 20mg/8 h (Arm B) or oral IVM at 0.2 mg/kg/day (Arm C) or oral IVM at 0.2 mg/kg/day and oral Zn 20mg/8 h (Arm D) or alone oral Zn 20mg/8 h (Arm E) or placebo alone (Arm X). Patients in all arms will receive standard care and respective placebo (empty capsule 8 hourly and/or subcutaneous normal saline 2ml/48 h). MAIN OUTCOMES: Primary endpoints will be duration of symptomatic phase and SARS-CoV-2 clearance along with high resolution CT (HRCT) chest score and clinical grade scale (CGS) on day 6. 30-day mortality will be documented as a secondary endpoint. SARS-CoV-2 clearance will be calculated by second PCR on day 7. HRCT chest score will be measured by the percentage and lung lobes involvement on day 6 with a maximum score of 25. CGS will be recorded on a seven-point scale; grade 1 (not hospitalized, no evidence of infection and resumption of normal activities), grade 2 (not hospitalized, but unable to resume normal activities), grade 3 (hospitalized, not requiring supplemental oxygen), grade 4 (hospitalized, requiring supplemental oxygen), grade 5 (hospitalized, requiring nasal high-flow oxygen therapy and/or noninvasive mechanical ventilation), grade 6 (hospitalized, requiring ECMO and/or invasive mechanical ventilation) and grade 7 (death). RANDOMISATION: A simple lottery method will be used to randomly allocate scrutinized patients in 1:1:1:1:1:1 ratio in 6 groups. BLINDING (MASKING): Patients, primary care physicians, outcome assessors and the data collection team will be blinded. NUMBERS TO BE RANDOMISED (SAMPLE SIZE): 180 participants will be randomized into six arms with five investigational and one placebo group. TRIAL STATUS: Institutional Review Board Shaikh Zayed Post-Graduate Medical Complex, Lahore, Pakistan has approved the protocol (version 2.3) with ID SZMC/IRB/Internal0056/2020. The trial was approved on July 14, 2020, and enrolment started on July 30, 2020. The estimated completion date is October 30, 2021. TRIAL REGISTRATION: Clinical Trial has been retrospectively registered on www.clinicaltrials.gov with registration ID NCT04472585 dated July 16, 2020. FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). With the intention of expediting dissemination of this trial, the conventional formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. The study protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines.

Zoonotic and reverse zoonotic events of SARS-CoV-2 and their impact on global health.

Coronaviruses (CoVs) are enveloped, positive sense, single-stranded RNA viruses. The viruses have adapted to infect a large number of animal species, ranging from bats to camels. At present, seven CoVs infect humans, of which Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) is responsible for causing the Coronavirus Disease 2019 (COVID-19) in humans. Since its emergence in late 2019, SARS-CoV-2 has spread rapidly across the globe. Healthcare systems around the globe have been stretched beyond their limits posing new challenges to emergency healthcare services and critical care. The outbreak continues to jeopardize human health, social life and economy. All known human CoVs have zoonotic origins. Recent detection of SARS-CoV-2 in pet, zoo and certain farm animals has highlighted its potential for reverse zoonosis. This scenario is particularly alarming, since these animals could be potential reservoirs for secondary zoonotic infections. In this article, we highlight interspecies SARS-CoV-2 infections and focus on the reverse zoonotic potential of this virus. We also emphasize the importance of potential secondary zoonotic events and the One-Health and One-World approach to tackle such future pandemics.

Barriers and facilitators of medicines reconciliation at transitions of care in Ireland - a qualitative study.

BACKGROUND: Medication error at transitions of care is common. The implementation of medicines reconciliation processes to improve this issue has been recommended by many regulatory and safety organisations. The aim of this study was to gain insight from healthcare professionals on the barriers and facilitators to the medicines reconciliation implementation process. METHODS: Semi-structured interviews were conducted in Ireland with a wide range of healthcare professionals (HCPs) involved with medicines reconciliation at transitions of care. Thematic analysis was undertaken using an adaptation of a combined theoretical framework of Grol, Cabana and Sluisveld to classify the barriers and facilitators to implementation of medicines reconciliation. RESULTS: Thirty-five participants were interviewed, including eleven community pharmacists (CPs), eight hospital pharmacists (HPs), nine hospital consultants (HCs), five general practitioners (GPs), and two non-consultant hospital doctors (NCHDs). Themes were categorized into barriers and facilitators. Barriers included resistance from existing professional cultures, staff interest and training, poor communication and minimal information and communications technology (ICT) support. Solutions (facilitators) suggested included supporting effective multidisciplinary teams, greater involvement of pharmacists in medicines reconciliation, ICT solutions (linked prescribing databases, decision support systems) and increased funding to provide additional (e.g. admission and discharge reconciliation) and more advanced services (e.g. community pharmacist delivered medicines use review). CONCLUSIONS: Medicines reconciliation is advocated as a solution to the known problem of medication error at transitions of care. This study identifies the key challenges and potential solutions that policy makers, managers and HCPs should consider when reviewing the practices and processes of medicines reconciliation in their own organisations.

Idiopathic toe walking-A follow-up survey of gait analysis assessment.

BACKGROUND: Toe-walking is a normal variant in children up to 3 years of age but beyond this a diagnosis of idiopathic toe-walking (ITW) must be considered. ITW is an umbrella term that covers all cases of toe-walking without any diagnosed underlying medical condition and before assigning these diagnosis potential differential diagnoses such as cerebral palsy, peripheral neuropathy, spinal dysraphism and myopathy must be ruled out. Gait laboratory assessment (GLA) is thought to be useful in the evaluation of ITW, and kinematic, kinetic and electromyography features associated with ITW have been described. However, the longer term robustness of a diagnosis based on GLA has not been investigated. The primary aim of this study was to examine if a diagnosis of ITW based on GLA features persisted. METHODS: All patients referred to a national gait laboratory service over a ten year period with queried ITW were sent a postal survey to establish if a diagnosis of ITW which had been offered following GLA persisted over time. The gait and clinical parameters differentiating those reported as typical ITW and not-typical-ITW following GLA were examined in the survey respondents. RESULTS: Of 102 referrals to the laboratory with queried ITW, a response rate of 40.2% (n = 41) was achieved. Of the respondents, 78% (n = 32) were found to be typical of ITW following GLA and this diagnosis persisted in the entire group at an average of 7 years post GLA. The other nine subjects were reported as not typical of ITW following GLA and 44.4% (n = 4) received a subsequent differential diagnosis. The clinical examination and gait analysis features differentiating these groups were consistent with previous literature. CONCLUSION: GLA appears to be a useful objective tool in the assessment of ITW and a diagnosis based on described features persists in the long-term.

Median survival time of patients after transcatheter chemo-embolization for hepatocellular carcinoma.

OBJECTIVE: To determine the effect on survival after transarterial chemoembolization (TACE) in patients with unresectable hepatocellular carcinoma (HCC). DESIGN: Longitudinal cohort study. PLACE AND DURATION OF STUDY: Radiology Department, The Aga Khan University Hospital, Stadium Road, Karachi, from December 1997 to September 2005. PATIENTS AND METHODS: Patients undergoing TACE procedure for HCC were prospectively followed. Fortythree patients were enrolled from December 1997 to March 2003 in the study and subjected to chemoembolization therapy. Eight out of 43 patients were excluded from the study, who lost to follow-up. All the patients were followed till their death. Median and mean survival were calculated. RESULTS: The median survival of these 35 patients was 410 days (13.6 months), with 95% confidence interval (236 days lower bound and 536 days upper bound). Mean survival time was 603 days (20.1 months) with 95% confidence interval (394 days lower bound and 812 days upper bound). There was significant difference in mean survival time (in days) by Child s Pugh class (chi(2) = 12.384; df=2, p-value=0.002). CONCLUSION: The study showed that TACE is an effective palliative treatment. TACE increases the median survival time.

Characterization of Chinook head salmon embryo phenotypes of infectious salmon anemia virus by real-time RT-PCR.

We have previously described the development of a onetube SYBR Green real-time RT-PCR assay for the detection and quantitation of infectious salmon anemia virus (ISAV) in various biological samples. The twofold aim of the present study was to verify that the optimized SYBR Green real-time RT-PCR conditions could detect ISAV isolates of different geographic origins, and to analyze the growth patterns of the selected ISAV isolates in the Chinook head salmon embryo (CHSE) -214 cells by this assay to better characterize their CHSE-phenotypes. A total of 24 ISAV isolates were used in this study. The results indicated that the SYBR Green real-time RT-PCR could detect ISAV of different geographic origins or laboratory sources. The capacity of ISAV isolates to cause cytopathic effects (CPE) in the CHSE-214 cell line, viral titration of the infected CHSE-cell harvests, and analysis of viral RNA levels in CHSE-214 cells at post-infection day zero, 7 and 14 by SYBR Green real-time RT-PCR confirmed the existence of three CHSE-phenotypes of ISAV: replicating cytopathic, replicating non-cytopathic, and non-replicating non-cytopathic. The identification of these three CHSE- phenotypes of ISAV has important implications from diagnostic and biological points of view.

Constitutive expression of Atlantic salmon Mx1 protein in CHSE-214 cells confers resistance to infectious salmon anaemia virus.

Infectious salmon anaemia (ISA) is a highly fatal viral disease affecting marine-farmed Atlantic salmon which is caused by ISA virus (ISAV), a fish orthomyxovirus that has recently been assigned to the new genus Isavirus within the family Orthomyxoviridae. Mx proteins are among the interferon (IFN)-induced proteins responsible for the development of an antiviral state in vertebrate cells. We used real-time reverse transcription-polymerase chain reaction (RT-PCR) and Chinook salmon embryo (CHSE-214) cells constitutively expressing Atlantic salmon Mx1 protein (ASMx1) to examine the antiviral properties of ASMx1 against two ISAV strains, NBISA01 and HKS-36, having phenotypically different growth properties (cytopathic vs non-cytopathic) in the CHSE-214 cell line. We present evidence that ISAV is sensitive to ASMx1. CHSE-214 cells constitutively expressing ASMx1 showed increased resistance to infection with the cytopathic ISAV strain NBISA01, manifested as delayed development of cytopathic effects (CPE) and significant reduction in the severity of CPE, as well as a 10-fold reduction in virus yield. However, by real-time RT-PCR we observed no significant difference in the mean threshold cycle (Ct) values of ISAV RNA levels, suggesting that the ASMx1 activity on ISAV occurs at the post-transcription steps of virus replication, possibly in the cytoplasm.

Infectious salmon anemia virus: causative agent, pathogenesis and immunity.

Infectious salmon anemia (ISA) virus (ISAV), an economically important new pathogen in marine aquaculture, is classified in the family Orthomyxoviridae, genus Isavirus. The main structural properties of this genus include enveloped virions 90-140 nm in diameter with surface projections of a combined receptor-binding hemagglutinin and receptor-destroying enzyme activity demonstrated to be an esterase, hence recently designated HE, and a genome composed of eight segments of linear, single-stranded, negative sense RNA ranging in length from 1.0 to 2.4 kb, with a total size of approximately 14.3 kb. The viral genome encodes at least ten proteins, of which nine are structural and one is non-structural. Examination of more than 160 ISAV isolates has led to the identification of two hemagglutinin subtypes of ISAV, one North American and one European. The immune response against ISAV after infection or vaccination does not provide full protection against the infection. The recent discovery of antibody-mediated uptake and replication of ISAV in macrophage-like fish cell lines suggests that Fc receptor-mediated antibody-dependent enhancement of the ISA virus infection might also occur in vivo, as the virus in Atlantic salmon (Salmo salar) targets endothelial cells lining blood vessels and macrophage-like cells. Cumulative mortalities in Atlantic salmon during natural ISA outbreaks and experimental infections range from 0 to 100%. ISAV causes fatal systemic infections in marine-farmed Atlantic salmon and asymptomatic infections in feral fish. Experimentally induced fatal clinical disease in rainbow trout (Oncorhynchus mykiss) has identified a correlate of virulence of ISAV that may explain its emergence as a fish pathogen.

Endovascular-covered stent treatment of posttraumatic cervical carotid artery pseudoaneurysms.

Pseudoaneurysm involving the cervical portion of the carotid artery can result from prior trauma or dissection. Two patients are reported with posttraumatic carotid artery pseudoaneurysms. In both cases, endovascular-covered stents were placed across the diseased portion of the artery resulting in thrombosis of the aneurysm and preservation of the parent artery without any significant complication. It is therefore concluded that covered stent placement is an alternative approach in treating carotid artery pseudoaneurysms.

Detection of infectious salmon anaemia virus by real-time RT-PCR.

A one-tube real-time reverse transcription-polymerase chain reaction (RT-PCR) using LightCycler technology and SYBR Green chemistry that quantitatively detects infectious salmon anaemia virus (ISAV) in biological samples is described. The assay utilized primers targeting ISAV RNA segment 8, with ISAV isolate U5575-1 as template. The entire optimized assay, including one cycle of reverse transcription, 50 cycles of complementary DNA amplification, and data acquisition and analysis took only 80min. The melting curve and gel electrophoresis analyses of real-time RT-PCR showed harmony with each other as a virus-specific single melting peak and a product of the expected size of 211 bp were obtained. A regression line between the mean threshold cycle (Ct) values and viral template concentrations over a 1:10(5) dilution range with an r(2) value of 0.962 and a slope of -3.771 indicated that the assay was highly reproducible. This assay was 100 times more sensitive than the conventional one-tube RT-PCR assay when compared on the same sample. Analysis of different tissues from fish that survived an ISAV experimental infection further confirmed that real-time RT-PCR was more sensitive than regular RT-PCR for detection of ISAV nucleic acids. Temporal analysis of ISAV-infected TO cell cultures showed that the amount of the specific viral RNA increased more than 100-fold within 32 h post-inoculation (p.i.) and over 1200-fold by 144 h p.i. The melting curve analysis throughout the duration of the infection sampled had a single melting peak suggesting that the virus population was uniform in the targeted region. Quantitative analysis of CHSE-214 cell cultures infected with different ISAV isolates indicated that ISAV isolates, based on their ability to replicate and cause cytopathic effects in CHSE-214 cells, may be differentiated into three CHSE phenotypes: replicating cytopathic, replicating non-cytopathic, and non-replicating. Thus, the SYBR Green real-time RT-PCR is a sensitive, rapid, and highly reproducible assay that can be used to quantitate ISAV in biological samples.