Pharmacist prescriber smoking cessation intervention during the COVID-19 pandemic.

INTRODUCTION: During the pandemic, smokers who wished to access support to quit faced additional barriers. A smoking cessation service which utilized pharmacist independent prescribers working within community pharmacy was implemented. Clients received behavioral advice via a consultation with an advisor and then three consultations with a pharmacist, who prescribed varenicline, where appropriate. Consultations were by phone or video. This evaluation assessed the self-reported outcomes and experiences of clients and pharmacists. METHODS: A mixed-methods approach was used involving both on-line questionnaires to clients and interviews with a sample of questionnaire respondents and participating prescribing pharmacists. RESULTS: The questionnaire was completed by 85 clients with 59% reporting they had quit. Eleven clients and seven out of eight pharmacists were interviewed. Varenicline had been received by 96% of clients. The best aspects of the service reported by clients in the questionnaire and at interview were support received from the pharmacist and ease of access to varenicline. Clients regarded the service as being 'safe' to access during the pandemic. Nearly three-quarters of client respondents (72%) stated no service improvements were required. However, national supply challenges made collection of varenicline from the nominated pharmacy an issue. Some clients experienced a long wait-time before accessing the service. For pharmacists, the service offered flexibility including the opportunity to contact clients 'out of office' hours without distractions. However, not being physically in the pharmacy could result in them not being able to access the client's medicine history. Pharmacists identified that remote consultations were not ideal for all clients. CONCLUSIONS: Pharmacist prescribers can deliver effective smoking cessation services through remote consultations. Greater flexibility would allow the service to be tailored to the client's need.

Diphtheria case detection and carrier study of close contacts: A step towards diphtheria eradication.

INTRODUCTION: Diphtheria is an infectious disease caused by gram-positive bacilli C. diphtheriae involving nasal, pharyngeal, tonsillar, or laryngeal mucus membranes. The mortality rate is as high as 20%, with India contributing almost 78% of the world incidence. AIMS AND OBJECTIVES: We report a fatal case of nasopharyngeal diphtheria with carrier study in close contacts. MATERIALS AND METHODS: Seven years child presented with fever, throat pain, and earache for 3 days followed by neck swelling and noisy respiration. On examination, membrane was present in the throat, which was received for Albert and Gram staining and reported as positive for C. diphtheria like organisms followed by culture. The patient was treated with ADS and antibiotics, and intensively managed, but still succumbed to death. Follow-up was done for carriage of C. diphtheriae on the throat and nasopharyngeal swabs of siblings and close contacts. It was isolated in 3 of them. Samples were processed for Gram, Albert stain, and culture. Identification, antibiotic sensitivity, and toxigenicity were done. RESULTS AND DISCUSSION: Four samples, one from the patient and three from contacts showed the presence of gram-positive slender bacilli with cuneiform arrangement, less cellular infiltrate on the Gram stain, and the presence of few metachromatic granules in the Albert stain. C. diphtheriae was grown on Potassium Tellurite agar. Antibiogram of all isolates was similar with resistance to Erythromycin and sensitivity to Penicillin. Isolates were confirmed by PCR and ToxA gene was detected. Contacts were treated with Penicillin and repeat swabs were negative. CONCLUSION: Present health statistics and this study suggests, fight against diphtheria in India is far from being over. It still lurks in some remote areas. It is a need to remain vigilant, keep tracing, and treating contacts to curtail down the rate of infection. In view of the resurgence, Government has given directives to replace TT with Td in UIP. Still, a lot needs to be done.

COVID-19 and Progesterone: Part 1. SARS-CoV-2, Progesterone and its potential clinical use.

SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) infection is a global medical challenge. Experience based medicines and therapies are being attempted and vaccines are being developed. SARS-CoV-2 exhibits varied patterns of infection and clinical presentations with varied disease outcomes. These attributes are strongly suggestive of some variables that differ among individuals and that affect the course of SARS-CoV-2 infection and symptoms of COVID-19 (Corona Virus Disease of 2019). Sex hormones vary with ageing, between the sexes, among individuals and populations. Sex hormones are known to play a role in immunity and infections. Progesterone is a critical host factor to promote faster recovery following Influenza A virus infection. Anti-inflammatory effects of progesterone are noted. In part 1 of the current study the regulatory role of progesterone for SARS-CoV-2 infection and COVID-19 is analyzed. The role of progesterone at different stages of the SARS CoV-2 infection is investigated with respect to two types of immunity status: immune regulation and immune dysregulation. Progesterone could have various alleviating impacts from SARS-CoV-2 entry till recovery: reversing of hypoxia, stabilizing of blood pressure, controlling thrombosis, balancing electrolytes, reducing the viral load, regulation of immune responses, damage repair, and clearance of debris among others. The present research adds to the available evidence by providing a comprehensive and thorough evaluation of the regulatory role of progesterone in SARS COV-2 infection, COVID-19 pathogenesis, and immune dysregulation. The available evidence has implications for upcoming studies about pathophysiology of COVID-19, as well as the roles of progesterone and other hormones in other infectious diseases.

COVID-19 and Progesterone: Part 2. Unraveling High Severity, Immunity Patterns, Immunity grading, Progesterone and its potential clinical use.

Severely ill COVID-19 (Corona Virus Disease of 2019) patients have a hyperinflammatory condition with a high concentration of pro-inflammatory cytokines termed the cytokine storm. This milieu is reported to cause acute lung injury, oxygen deprivation, multiorgan damage, critical illness, and often death. Post SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) infection, the fight between the invading virus and the host's immune system would either terminate in recovery, with eradication of the infection and regulation of the immune system; or there would be a continuation of immune attacks even after the virus has been cleared, leading to immune dysregulation and disease. This outcome is chiefly dependent on two factors: (1) the patient's immune response, and (2) sufficiency plus efficiency of the regulator(s). Concerning the first, the present research introduces a framework based on different types of immune responses to SARS-CoV-2 along with known disease examples, and how this relates to varying clinical outcomes and treatment needs for COVID-19 patients. About the second factor of 'regulator(s)', part 1 of the manuscript described in depth the regulatory role of progesterone in COVID-19. The present study investigates five immunity patterns and the status of the regulatory hormone progesterone with respect to the two established demographic risk factors for COVID-19 high-severity: male sex, and old age. The study evaluates the status of progesterone as a credible determinant of immune regulation and dysregulation. It duly relates the immunity patterns to clinical outcomes and evinces indications for clinical use of progesterone in COVID-19. It proposes a clear answer to the question: "why are males and old patients most likely to have critical illness due to COVID-19?" The study highlights clinical domains for the use of progesterone in COVID-19. Part 2 of this research introduces the concept of immunity patterns and immunity grading. These concepts herewith provided for the clinical course of COVID-19 also apply to other hyperinflammatory conditions. Possible clinical applications of progesterone to treat critically ill COVID-19 patients will open an avenue for hormonal treatments of infections and other immune-related diseases.

Not what it seems.

A 5-month-old female patient presented to the general practitioner with a 2-week history of an unexplained linear lesion on her left lower limb extending from the medial part of her thigh to the medial aspect of her leg and onto the sole of her foot (figures 1 and 2). It was hyperpigmented, papular and non-blanching. There was no history of trauma, itching, pain, infective symptoms or social concerns. The baby was well kempt and parents were appropriately concerned.

Standardisation of management after Norwood operation has not improved 1-year outcomes.

INTRODUCTION: Treatment of hypoplastic left heart syndrome varies across institutions. This study examined the impact of introducing a standardised programme. METHODS: This retrospective cohort study evaluated the effects of a comprehensive strategy on 1-year transplant-free survival with preserved ventricular and atrioventricular valve (AVV) function following a Norwood operation. This strategy included standardised operative and perioperative management and dedicated interstage monitoring. The post-implementation cohort (C2) was compared to historic controls (C1). Outcomes were assessed using logistic regression and Kaplan-Meier analysis. RESULTS: The study included 105 patients, 76 in C1 and 29 in C2. Groups had similar baseline characteristics, including percentage with preserved ventricular (96% C1 versus 100% C2, p = 0.28) and AVV function (97% C1 versus 93% C2, p = 0.31). Perioperatively, C2 had higher indexed oxygen delivery (348 ± 67 ml/minute/m2 C1 versus 402 ± 102ml/minute/m2 C2, p = 0.015) and lower renal injury (47% C1 versus 3% C2, p = 0.004). The primary outcome was similar in both groups (49% C1 and 52% C2, p = 0.78), with comparable rates of death and transplantation (36% C1 versus 38% C2, p = 0.89) and ventricular (2% C1 versus 0% C2, p = 0.53) and AVV dysfunction (11% C1 versus 11% C2, p = 0.96) at 1-year. When accounting for cohort and 100-day freedom from hospitalisation, female gender (OR 3.7, p = 0.01) increased and ventricular dysfunction (OR 0.21, p = 0.02) and CPR (OR 0.11, p = 0.002) or ECMO use (OR 0.15, p = 001) decreased the likelihood of 1-year transplant-free survival. CONCLUSIONS: Standardised perioperative management was not associated with improved 1-year transplant-free survival. Post-operative ventricular or AVV dysfunction was the strongest predictor of 1-year mortality.

A Phase II randomized controlled trial for lung and diaphragm protective ventilation (Real-time Effort Driven VENTilator management).

Lung Protective Mechanical Ventilation (MV) of critically ill adults and children is lifesaving but it may decrease diaphragm contraction and promote Ventilator Induced Diaphragm Dysfunction (VIDD). An ideal MV strategy would balance lung and diaphragm protection. Building off a Phase I pilot study, we are conducting a Phase II controlled clinical trial that seeks to understand the evolution of VIDD in critically ill children and test whether a novel computer-based approach (Real-time Effort Driven ventilator management (REDvent)) can balance lung and diaphragm protective ventilation to reduce time on MV. REDvent systematically adjusts PEEP, FiO2, inspiratory pressure, tidal volume and rate, and uses real-time measures from esophageal manometry to target normal levels of patient effort of breathing. This trial targets 276 children with pulmonary parenchymal disease. Patients are randomized to REDvent vs. usual care for the acute phase of MV (intubation to first Spontaneous Breathing Trial (SBT)). Patients in either group who fail their first SBT will be randomized to REDvent vs usual care for weaning phase management (interval from first SBT to passing SBT). The primary clinical outcome is length of weaning, with several mechanistic outcomes. Upon completion, this study will provide important information on the pathogenesis and timing of VIDD during MV in children and whether this computerized protocol targeting lung and diaphragm protection can lead to improvement in intermediate clinical outcomes. This will form the basis for a larger, Phase III multi-center study, powered for key clinical outcomes such as 28-day ventilator free days. Clinical Trials Registration: NCT03266016.

Ssssh for Handover: protected medical handover; optimising quality and prioritising safety-a regional initiative.

Medical handover is one of the most commonly performed actions in the healthcare system today. While it is performed regularly, it is often not done as effectively as it could or should be. 1 Many organisations have implemented systems and structures to improve the quality and impact of their handover process. These include advocating senior presence, introducing validated handover tools and an emphasis on multidisciplinary involvement. 2 A protected handover prioritises safety, enhances communication and encourages improvement in handover effectiveness. Our local pilot and subsequent regional initiative has begun actively addressing this issue using a low-cost, interprofessional, multispeciality quality improvement initiative.

Pediatric Perioperative Pulmonary Arterial Hypertension: A Case-Based Primer.

The perioperative period is an extremely tenuous time for the pediatric patient with pulmonary arterial hypertension. This article will discuss a multidisciplinary approach to preoperative planning, the importance of early identification of pulmonary hypertensive crises, and practical strategies for postoperative management for this unique group of children.

Optimization of cellulase production by Penicillium oxalicum using banana agrowaste as a substrate.

The purpose of this study was to produce a higher amount of cellulase by using an alternative carbon source, such as banana agrowaste, and to optimize the fermentation parameters for a high yield. In the present study, cellulase-producing Penicillium was isolated from a decaying wood sample. Different nutritional and environmental factors were investigated to assess their effect on cellulase production. The highest crude enzyme production was observed at a pH 6.0 and a temperature of 28°C in a medium that was supplemented with banana agrowaste as the carbon source. Pretreatment with 2N NaOH, at 7% substrate (banana agrowaste) concentration yielded the highest cellulase activity. Further to this, the effect of other parameters such as inoculum age, inoculum size, static and agitated conditions were also studied. It is concluded that Penicillium oxalicum is a powerful cellulase-producer strain under our tested experimental conditions using banana agrowaste as the carbon source.

International rescue? Managing the dental tourist.

UNLABELLED: The concept of dental tourism can be considered two-fold. On one side it is a term used to describe non-UK residing patients who visit, requesting NHS dental care whilst here in the U.K. Alternatively, it also encompasses patients who travel to destinations outside their residing countries to receive care. The latter has become an ever-growing issue in the U.K.; one that warrants appropriate management and knowledge of current legislation amongst dental professionals. CLINICAL RELEVANCE: Clarity and guidance on who is eligible for care under the NHS when visiting the U.K. and who, if anyone, is ultimately responsible when treatment abroad fails.

Reducing HIV stigma among nursing students: a brief intervention.

HIV stigma can be devastating and is common among health care providers, particularly nurses. The objectives of this study were to (a) assess the acceptability and feasibility of a brief stigma-reduction curriculum among a convenience sample of Indian nursing students and (b) examine the preliminary effect of this curriculum on their knowledge, attitudes, and intent to discriminate. At baseline, 57% of students had at least one misconception about HIV transmission, 38% blamed people living with HIV for their infection, and 87% and 95% demonstrated intent to discriminate while dispensing medications and drawing blood, respectively. Following the curriculum, HIV-related knowledge increased while blame, endorsement of coercive policies, and intent to discriminate decreased significantly. In addition, more than 95% of participants described the curriculum as practice changing. This brief intervention resulted in decreased stigma levels and was also highly acceptable to the nursing students. Next steps include rigorous evaluation in a randomized controlled trial.