Multi-faceted CRISPR/Cas technological innovation aspects in the framework of 3P medicine.

Since 2009, the European Association for Predictive, Preventive and Personalised Medicine (EPMA, Brussels) promotes the paradigm change from reactive approach to predictive, preventive, and personalized medicine (PPPM/3PM) to protect individuals in sub-optimal health conditions from the health-to-disease transition, to increase life-quality of the affected patient cohorts improving, therefore, ethical standards and cost-efficacy of healthcare to great benefits of the society at large. The gene-editing technology utilizing CRISPR/Cas gene-editing approach has demonstrated its enormous value as a powerful tool in a broad spectrum of bio/medical research areas. Further, CRISPR/Cas gene-editing system is considered applicable to primary and secondary healthcare, in order to prevent disease spread and to treat clinically manifested disorders, involving diagnostics of SARS-Cov-2 infection and experimental treatment of COVID-19. Although the principle of the proposed gene editing is simple and elegant, there are a lot of technological challenges and ethical considerations to be solved prior to its broadly scaled clinical implementation. This article highlights technological innovation beyond the state of the art, exemplifies current achievements, discusses unsolved technological and ethical problems, and provides clinically relevant outlook in the framework of 3PM.

Changes in Healthcare During the Past 30 Years: Can the National Health Service in the United Kingdom Survive?

At the turn of the century, the National Health Service (NHS) in the United Kingdom (UK) was considered one of the top public healthcare systems in the world. Not only was it comprehensive and inclusive, but it was also free at the point of delivery for the entire UK population. It was also largely available to visitors and the families of residents that lived outside the UK. During the past 30 years, the NHS has received more and more funding both in cash terms and as a percentage of the gross national product. Despite this, the general consensus is that the NHS is delivering a poor service. The current government is facing unprecedented strike action from all areas of the workforce including doctors and nurses. This editorial asks the following questions: Where has the money gone? What has caused the current crisis? Can the current NHS model survive in today's highly technological healthcare environment?

RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS AND CLINICAL OUTCOMES IN COVID-19 PATIENTS WITH HYPERTENSION:A REPORT OF THREE PEAK WAVE PERIODS IN SEMARANG, INDONESIA

Objective: We aimed to assess the association between RAAS inhibitors (ACEi or ARB) and the clinical outcomes of COVID-19 patients with hypertension in the First Wave, Second Wave and Third Wave at Secondary Referral Hospital, Indonesia Methods: This cross sectional study was based on an electronic medical record in the Dr Adhyatma MPH Tugurejo General Hospital, Semarang, Indonesia. All patients more than 18 years old who confirmed COVID-19 case in the first wave (November 2020 to January 2021), second wave (May 2021 to July 2021) and third wave (January 2022 to February 2022) were included in this study. Data about demographic, comorbidities, features of antihypertensive drugs and clinical outcomes were collected. The clinical outcomes included mortality and prolonged hospitalization (length of stay (LOS) > 10 days). The statistical measures calculated were Chi square test and Fischer's exact test. Results: From three periods of peak wave, data from 1560 COVID-19 patients was collected in the first wave (304;19.5%), the second wave (1038;66.5%), and the third wave (218;14.0%). Subjects were dominated by males (50.4%) and a median of age 50 (19 -91) years old. The common comorbidities in studies were diabetes mellitus with 318 (20.4%) and hypertension with 254 (16.3%). In the main analysis, 99 (39%) patients with hypertension receiving RAAS inhibitors were compared with 155 (61%) patients receiving other antihypertensive drugs. Our results showed that RAAS inhibitors was not associated with a higher risk of COVID-19 mortality (RR:1.01;95% CI: 0.61-1.67;p:0.969) or prolonged LOS (RR:0.86;95%CI: 0.60-1.26;p:0.408). Conclusions: In COVID-19 patients with hypertension, the use of RAAS inhibitors showed no increased mortality or prolonged LOS compared to patients without RAAS inhibitors. COVID-19 patients and patients exposed to the COVID-19 pandemic should not discontinue ACEi or ARBs.

The Incidence of Large Vessel Vasculitis in Norfolk

Background/Aims There are no data on the collective incidence of the large vessel vasculitides. The incidence of GCA and Takayasu arteritis in the UK has been based on clinical coding in routine administrative datasets. There are no data on the incidence of these diseases based on clinically verfied diagnoses. We studied the incidence of the large vessel vasculitides in a stable population with a predominant Northern European ancestry. Methods Individuals attending a secondary care hospital with a clinically verified diagnosis of primary systemic vasculitis made between 2011-2020, who lived within the NR postcode districts of Norfolk county were included if they met classification criteria for GCA or Takayasu arteritis, or had definite tissue or imaging evidence of large vessel vasculitis. Population above the age of 18 as in the 2011 census, available from the office of national statistics, was accepted as the denominator. If classification criteria for both GCA and TAK were met, physician judgement was accepted as final diagnosis. Results 272 adults were diagnosed with large vessel vasculitis out of a population of 454,316. The annual incidence of large vessel vasculitis in Norfolk is 59.9/million in the adult population. The annual incidence of GCA is 9.9/100,000 over the age of 50 using the ACR 1990 criteria and 10.6/100,000 using the ACR/EULAR 2022 criteria. The rise in the incidence from 2017 onwards coincides with the establishment of a fast-track pathway (Table 1). The dip in the incidence in 2020 coincides with suspension of services during the SARS-CoV-2 pandemic. The annual incidence peaks at 168.5/100,000 in the 9th decade and is commoner in females (12.3/100,000 vs 7.3/100,000). The annual incidence of Takayasu arteritis is 3.3/million in the adult population using the ACR 1990 criteria and 1.1/million using the ACR/EULAR 2022 criteria. Conclusion This is the first study that reports the incidence of all objectively diagnosed large vessel vasculitis in a stable population in Norfolk county. The incidence of GCA rose with the establishment of a fasttrack pathway and its peak may have been affected by the SARS-CoV- 2 pandemic. GCA is commoner in females and peaks in the 8th and 9th decades. (Table Presented).

Health Resource Utilisation and Disparities: an Ecological Study of Admission Patterns Across Ethnicity in England Between 2017 and 2020.

BACKGROUND AND AIM: The COVID-19 pandemic highlighted adverse outcomes in Asian, Black, and ethnic minority groups. More research is required to explore underlying ethnic health inequalities. In this study, we aim to examine pre-COVID ethnic inequalities more generally through healthcare utilisation to contextualise underlying inequalities that were present before the pandemic. DESIGN: This was an ecological study exploring all admissions to NHS hospitals in England from 2017 to 2020. METHODS: The primary outcomes were admission rates within ethnic groups. Secondary outcomes included age-specific and age-standardised admission rates. Sub-analysis of admission rates across an index of multiple deprivation (IMD) deciles was also performed to contextualise the impact of socioeconomic differences amongst ethnic categories. Results were presented as a relative ratio (RR) with 95% confidence intervals. RESULTS: Age-standardised admission rates were higher in Asian (RR 1.40 [1.38-1.41] in 2019) and Black (RR 1.37 [1.37-1.38]) and lower in Mixed groups (RR 0.91 [0.90-0.91]) relative to White. There was significant missingness or misassignment of ethnicity in NHS admissions: with 11.7% of admissions having an unknown/not-stated ethnicity assignment and 'other' ethnicity being significantly over-represented. Admission rates did not mirror the degree of deprivation across all ethnic categories. CONCLUSIONS: This study shows Black and Asian ethnic groups have higher admission rates compared to White across all age groups and when standardised for age. There is evidence of incomplete and misidentification of ethnicity assignment in NHS admission records, which may introduce bias to work on these datasets. Differences in admission rates across individual ethnic categories cannot solely be explained by socioeconomic status. Further work is needed to identify ethnicity-specific factors of these inequalities to allow targeted interventions at the local level.

Recovering from COVID-19: lessons learnt from an intensive secondary care follow-up service.

In response to the first COVID-19 surge in 2020, secondary care outpatient services were rapidly reconfigured to provide specialist review for disease sequelae. At our institution, comprising hospitals across three sites in London, we initially implemented a COVID-19 follow-up pathway that was in line with expert opinion at the time but more intensive than initial clinical guidelines suggested. We retrospectively evaluated the resource requirements for this service, which supported 526 patients from April 2020 to October 2020. At the 6-week review, 193/403 (47.9%) patients reported persistent breathlessness, 46/336 (13.7%) desaturated on exercise testing, 167/403 (41.4%) were discharged from COVID-19-related secondary care services and 190/403 (47.1%) needed 12-week follow-up. At the 12-week review, 113/309 (36.6%) patients reported persistent breathlessness, 30/266 (11.3%) desaturated on exercise testing and 150/309 (48.5%) were discharged from COVID-19-related secondary care services. Referrals were generated to multiple medical specialties, particularly respiratory subspecialties. Our analysis allowed us to justify rationalising and streamlining provisions for subsequent COVID-19 waves while reassured that opportunities for early intervention were not being missed.

Continuous Positive Airway Pressure (CPAP)-Can this be a boon to tide over ICU crisis in pandemic? A case series.

Introduction: Coronavirus Disease 19 (COVID-19) disease has caused unusual overload of health care systems all over the world. We describe four severe COVID cases managed by non-intensivist. Cases and Outcome: We had four unvaccinated cases with acute onset influenza like illness with signs of respiratory failure. Apart from general and COVID-specific measures, we started Continuous Positive Airway Pressure (CPAP) trial for these patients. All these patients were weaned off CPAP and were discharged once they recovered. Discussion: Limitation of bed numbers in ICU has caused unforeseen stress upon the system to manage sudden increase of severe acute respiratory distress syndrome during COVID pandemics. Studies have shown non-invasive ventilation (NIV) and high frequency nasal cannula (HFNC) have improved patient outcomes. But managing NIV and HFNC is resource intensive in terms of manpower and equipment. We have found that patients with severe COVID disease can be managed safely using CPAP in secondary care with minimal training of non-intensivist healthcare workers in a cost-effective and efficient way of treating severe COVID who are unlikely to worsen. Conclusion: With the imminent third COVID wave looming, it is high time to strengthen our existing primary and secondary health care system by these novel methods to reduce the burden of our tertiary care.

An exploratory assessment of the impact of a novel risk assessment test on breast cancer clinic waiting times and workflow: a discrete event simulation model.

BACKGROUND: Breast cancer clinics across the UK have long been struggling to cope with high demand. Novel risk prediction tools - such as the PinPoint test - could help to reduce unnecessary clinic referrals. Using early data on the expected accuracy of the test, we explore the potential impact of PinPoint on: (a) the percentage of patients meeting the two-week referral target, and (b) the number of clinic 'overspill' appointments generated (i.e. patients having to return to the clinic to complete their required investigations). METHODS: A simulation model was built to reflect the annual flow of patients through a single UK clinic. Due to current uncertainty around the exact impact of PinPoint testing on standard care, two primary scenarios were assessed. Scenario 1 assumed complete GP adherence to testing, with only non-referred cancerous cases returning for delayed referral. Scenario 2 assumed GPs would overrule 20% of low-risk results, and that 10% of non-referred non-cancerous cases would also return for delayed referral. A range of sensitivity analyses were conducted to explore the impact of key uncertainties on the model results. Service reconfiguration scenarios, removing individual weekly clinics from the clinic schedule, were also explored. RESULTS: Under standard care, 66.3% (95% CI: 66.0 to 66.5) of patients met the referral target, with 1,685 (1,648 to 1,722) overspill appointments. Under both PinPoint scenarios, > 98% of patients met the referral target, with overspill appointments reduced to between 727 (707 to 746) [Scenario 1] and 886 (861 to 911) [Scenario 2]. The reduced clinic demand was sufficient to allow removal of one weekly low-capacity clinic [N = 10], and the results were robust to sensitivity analyses. CONCLUSION: The findings from this early analysis indicate that risk prediction tools could have the potential to alleviate pressure on cancer clinics, and are expected to have increased utility in the wake of heightened pressures resulting from the COVID-19 pandemic. Further research is required to validate these findings with real world evidence; evaluate the broader clinical and economic impact of the test; and to determine outcomes and risks for patients deemed to be low-risk on the PinPoint test and therefore not initially referred.

Did the March 2020 lockdown cause an increase in patients presenting to the emergency department with odontogenic pain and infection? A single centre, retrospective analysis.

On the 25 March 2020 the Chief Dental Officer (CDO) published guidance to restrict the provision of routine dental care in England due to the rapid spread of the severe acute respiratory syndrome Coronavirus 2 (COVID-19). We analysed the impact of the pandemic on the number of patients presenting with odontogenic pain and infection to the emergency department (ED) of an urban-based teaching hospital, the Bristol Royal Infirmary (BRI). Furthermore, we investigated the severity of infection at first presentation to the ED. The study period encompassed three phases that represented the stages of pandemic restrictions: phase 1 prior to lockdown measures, with no restrictions to dental practice; phase 2 during the government lockdown, with the severest restrictions on dental practices; and phase 3 following the ease of lockdown measures, with return to limited dental services. Data were collected retrospectively from electronic patient records (EPR) regarding adult patients presenting to the ED with dental pain. The rate of presentations (per week) was calculated for each timepoint and compared. A severity score was assigned to each patient using a grading system based on signs of clinical infection and treatment modality. Patients' presentations were analysed at each phase of the pandemic. There was a 42.8% increase in attendance with oral facial pain and infection to ED from phases 1 to 3. The COVID-19 pandemic resulted in restrictions to routine primary dental care services, which were deemed necessary to reduce the spread of the virus. However, this increased demand on secondary care services, as patients increasingly struggled to access primary dental care to manage dental pain.

Systematic voiding programme in adults with urinary incontinence following acute stroke: the ICONS-II RCT.

BACKGROUND: Urinary incontinence affects around half of stroke survivors in the acute phase, and it often presents as a new problem after stroke or, if pre-existing, worsens significantly, adding to the disability and helplessness caused by neurological deficits. New management programmes after stroke are needed to address urinary incontinence early and effectively. OBJECTIVE: The Identifying Continence OptioNs after Stroke (ICONS)-II trial aimed to evaluate the clinical effectiveness and cost-effectiveness of a systematic voiding programme for urinary incontinence after stroke in hospital. DESIGN: This was a pragmatic, multicentre, individual-patient-randomised (1 : 1), parallel-group trial with an internal pilot. SETTING: Eighteen NHS stroke services with stroke units took part. PARTICIPANTS: Participants were adult men and women with acute stroke and urinary incontinence, including those with cognitive impairment. INTERVENTION: Participants were randomised to the intervention, a systematic voiding programme, or to usual care. The systematic voiding programme comprised assessment, behavioural interventions (bladder training or prompted voiding) and review. The assessment included evaluation of the need for and possible removal of an indwelling urinary catheter. The intervention began within 24 hours of recruitment and continued until discharge from the stroke unit. MAIN OUTCOME MEASURES: The primary outcome measure was severity of urinary incontinence (measured using the International Consultation on Incontinence Questionnaire) at 3 months post randomisation. Secondary outcome measures were taken at 3 and 6 months after randomisation and on discharge from the stroke unit. They included severity of urinary incontinence (at discharge and at 6 months), urinary symptoms, number of urinary tract infections, number of days indwelling urinary catheter was in situ, functional independence, quality of life, falls, mortality rate and costs. The trial statistician remained blinded until clinical effectiveness analysis was complete. RESULTS: The planned sample size was 1024 participants, with 512 allocated to each of the intervention and the usual-care groups. The internal pilot did not meet the target for recruitment and was extended to March 2020, with changes made to address low recruitment. The trial was paused in March 2020 because of COVID-19, and was later stopped, at which point 157 participants had been randomised (intervention, n = 79; usual care, n = 78). There were major issues with attrition, with 45% of the primary outcome data missing: 56% of the intervention group data and 35% of the usual-care group data. In terms of the primary outcome, patients allocated to the intervention group had a lower score for severity of urinary incontinence (higher scores indicate greater severity in urinary incontinence) than those allocated to the usual-care group, with means (standard deviations) of 8.1 (7.4) and 9.1 (7.8), respectively. LIMITATIONS: The trial was unable to recruit sufficient participants and had very high attrition, which resulted in seriously underpowered results. CONCLUSIONS: The internal pilot did not meet its target for recruitment and, despite recruitment subsequently being more promising, it was concluded that the trial was not feasible owing to the combined problems of poor recruitment, poor retention and COVID-19. The intervention group had a slightly lower score for severity of urinary incontinence at 3 months post randomisation, but this result should be interpreted with caution. FUTURE WORK: Further studies to assess the effectiveness of an intervention starting in or continuing into the community are required. TRIAL REGISTRATION: This trial is registered as ISRCTN14005026. FUNDING: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 31. See the NIHR Journals Library website for further project information.

Urinary incontinence affects around half of stroke survivors. It causes embarrassment and distress, affecting patients' ability to take part in rehabilitation. It also has a major impact on families and may determine whether or not patients are able to return home. Finding the underlying cause and addressing it can prevent, cure or reduce problems. Doing this in a systematic way for everyone with incontinence problems as early as possible after the stroke, while they are still in hospital, may work best. We also wanted to avoid using catheters in the bladder to drain the urine away, as these are often unnecessary and can cause urinary tract infections. This study aimed to test whether or not continence problems and the use of urinary catheters could be reduced if everyone with incontinence was fully assessed and given the right management and support early after hospital admission. We also wanted to find out if the benefits outweighed the costs. We planned to involve 1024 men and women with incontinence from 18 stroke units in the study, with 512 people receiving the intervention and 512 receiving usual care. However, the trial was paused because of COVID-19, at which time only 157 participants had been recruited. When we were thinking about restarting the study and looked at its progress, we found that not enough people had agreed to take part and, of those who had agreed, many had not returned their outcome questionnaires. This indicated that the trial was not feasible and should not restart. We could not make any firm conclusions about whether or not the intervention worked, as not enough people were involved. We found that stays in hospital after stroke are shorter than they were in the past. This suggests that future studies investigating ways of treating incontinence should consider interventions with management and support for incontinence that continue after patients leave the hospital.

Virtual clinics versus face-to-face review: Is the benefit the same for new orthopaedic patients?

BACKGROUND: COVID-19 shocked global healthcare systems, particularly the surgical services, resulting in a significant backlog of patients with waiting times not expected to return to pre-pandemic levels until 2025. The Royal College of Surgeons has recommended a wider use of virtual clinics to meet the increased demand. The efficacy of virtual follow up is well documented in the literature; however, there is very little evidence of the role of virtual clinics in the assessment of new elective patients. METHODS: Observational study comparing clinical outcomes of new patients electively referred to orthopaedic virtual clinics between January and February 2021 with face-to-face clinics in January and February 2020. RESULTS: Over the equivalent time frame, more patients were reviewed in virtual clinics compared to traditional face-to-face (821 vs 499). However, virtual clinics lead to significantly more patients being brought back for follow up (78.3% vs 37.3%) and fewer patients received outcomes that progressed their journey towards a definitive intervention or discharge. CONCLUSION: The overall benefit of virtual clinic appointments in the context of reviewing new patients remains to be proven. Despite increasing use of virtual clinics in the National Health Service, we have shown a potential delay to patients' clinical progression, ultimately delaying healthcare delivery. Potential methods to improve the benefit of virtual clinics are proposed.

Learning from minor injury care restructure during the COVID-19 pandemic: a phenomenological study of orthopaedic clinical leaders.

BACKGROUND: During peaks of the COVID-19 pandemic, trauma and orthopaedic departments in England have been asked to support emergency departments by providing first contact care for minor injuries. The subsequent requirement for departmental restructure has resulted in a variety of service pathways across the country. This study aimed to explore the experiences of different clinical teams and identify any consistent themes or reflections, which could be applied to continuous improvement of minor injury care. METHODS: Using a phenomenological approach, nine semistructured interviews were conducted with trauma and orthopaedic clinical leads across England whose departments provided support to minor injuries service. Detailed transcripts were then analysed to identify themes for discussion. Interviews were conducted via video conferencing in November 2020 at the end of England's second national lockdown. RESULTS: Each of the nine orthopaedic departments provided support for minor injuries, six of which involved creating a new unit. Themes included the value of collaborative working between the emergency department and orthopaedic staff across multiple professions and the benefit to patients of early definitive decision making. A common theme was reduced barriers to change during the pandemic. Examples of long-term service improvements triggered by the pandemic focus on pathways to enable consultant to provide early opinions for injured patients. CONCLUSIONS: A range of experiences have demonstrated themes in reflection from service leaders. Departments across the country should be encouraged to consider what improvements to their own service may be applied long term. Resource limitations, staff well-being and education must all be considered.

Serosurvey for Middle East respiratory syndrome coronavirus antibody in dromedary camels and human patients at a secondary care hospital, Illela, Northwest Nigeria.

Middle East respiratory syndrome (MERS) is a serious emerging zoonosis. It is characterized by severe infection of the respiratory tract in humans. Dromedary camels are considered to be the most probable origin of the pathogenic Middle East respiratory syndrome coronavirus (MERS-CoV). This cross-sectional survey was carried out to ascertain the seroprevalence of MERS-CoV in dromedary camels at Illela border and human patients in a secondary care hospital in Illela, Sokoto State, Nigeria from November 2016 to January 2017. Serum samples from 74 camels and 39 human patients were collected while a data form was administered to the camel handlers (40) and human patients to obtain information on zoographic characteristics of dromedary camels, demographic characteristics of camel handlers and human patients and some practices of both groups which are likely to predispose to MERS-CoV infection. The serum samples were analyzed for antibodies against MERS-CoV using the indirect Enzyme-Linked Immuno-Sorbent Assay (ELISA). All the camels sampled were seropositive against MERS-CoV and 74% of the human patients had antibodies against MERS. All handlers treated their camels without consulting veterinarians and there was little or no biosecurity measures undertaken. Age, sex, and occupation were not significant determinants for the presence of MERS-CoV antibody in human patients sampled. This study serves as a baseline for similar researches and due to the high seroprevalence obtained in this study for both camels and humans, there is need for trained personnel, surveillance and diagnostic tools at our border posts and animal markets. Supplementary information: The online version contains supplementary material available at 10.1007/s00580-022-03351-3.

Hepatitis B immunity status and COVID-19 vaccination coverage among nurse aides working in the emergency department in a secondary hospital in Portugal

Introduction: Emergency healthcare workers (HCW) are the first point of contact for patients with traumatic injuries and acute illnesses. These professionals are at increased risk for respiratory and blood borne infections, as is the case of hepatitis B virus (HBV) infection and coronavirus disease 2019 (COVID-19). Vaccination is a major tool for preventing HBV infections. The protection provided by the COVID-19 vaccines are yet under evaluation. The objective of this study is to evaluate the HBV and COVID-19 vaccination coverage and the serological hepatitis B immunity among nurse aides working in the emergency department (EM) in a secondary hospital in Portugal. Material and Methods: A descriptive cross-sectional study was conducted by analyzing the Occupational Health Service database of Centro Hospitalar do Baixo Vouga in Aveiro, considering active nurse aides working in the EM in August 2021. Results and Conclusions: Of the total 71 workers included in the study, 61 (85.9%) had completed the vaccination against HBV. From these fully vaccinated HCW, 45 (73.7%) had confirmation of protective Hepatitis B surface antibody (HBsAb) levels (>10 mIU/mL) and 11 (18.3%) had unknown HBsAb levels. Regarding COVID-19 vaccination, 68 (95.7%) of the 71 total workers, had complete vaccination. From these, 43 (63.2%) had the last shot more than 6 months ago. Overall, there is a good adherence of nurse aides working in the EM to HBV and COVID-19 vaccination. In what concerns to HBV vaccination, it is important to implement a more robust system to diminish cases of workers only partially vaccinated or with unknown immunity status.

If virtual gynecology clinics are here to stay, we need to include everyone.

Before the COVID-19 pandemic virtual clinics in gynecology were not commonplace in the United Kingdom or most other countries. Owing to the need to reconfigure health provision to caring for COVID-19 patients, reducing footfall in hospitals and restricted movement, telemedicine was rapidly introduced at scale in hospitals thought the United Kingdom. This happened without much consultation with service users and healthcare professionals. It is anticipated that after the pandemic, telemedicine will remain to some extent. The authors report how their hospital how their place of work, a large London teaching hospital, adopted virtual phone consultations in gynecology, along with a countrywide survey of 200 service users and healthcare professionals. Now it is important carry out a robust evaluation of outcomes (both clinician and patient experience) and also to take care that service users from disadvantaged backgrounds do not lose out.

[Work engagement and burnout syndrome in a secondary care level during the COVID pandemic in Mexico, 2021]

Background: The coronavirus disease 2019 (COVID-19) was declared a pandemic on March 11, 2020. The health personnel were the first line of action, so detecting the presence of burnout and work engagement allows us to have an overview of the perspective on the work environment of these workers. Objective: To identify the presence of high levels of work engagement and burnout in COVID-19 response teams (RT) during the COVID-19 pandemic in a secondary care level. Material and methods: Cross-sectional, descriptive, and observational, discretionary study. Data from 156 workers belonging to the COVID-19 RT were collected. It was administered a survey-type instrument, which collected sociodemographic data, as well as the UWES-9 and the MBI-HSS scales. Data analysis was performed with measures of central tendency and inferential statistics. Results: High levels of work engagement were identified in 55.1% of the COVID-19 RT members, while the high levels of burnout were 3.2%. Conclusions: The prevalence of work engagement was higher than burnout, but this did not imply protection against exhaustion.

Comparing the clinical effectiveness of an online versus face-to-face ‘compassionate mind' group for adults in a secondary care setting

The following paper outlines a service evaluation project for a Compassionate Mind Group (CMG) in a UK adult Psychology service for people with severe and enduring mental health difficulties within secondary care. Due to the impact of Covid-19, the CMG was moved online in April 2020. The aim of this project was to compare outcomes between the face-to-face CMG and the online CMG in order to check for any changes in group participants' clinical symptoms and processes based on mode of delivery. This was done by analysing pre-existing data from three different questionnaires. Statistical tests revealed that mode of delivery for the CMG did not have a significant effect on outcome measure results. However, there was a significant difference between pre- and post-CMG scores on some of the measures, depending on mode of group delivery. Participant age and gender did not appear to affect group differences. Implications from the project findings as well as possible areas for future research are discussed. [ FROM AUTHOR]

Nine Maternal Mortalities in 2 Weeks of Second COVID-19 Surge in Indonesia: A Case Series from One Large Tertiary Center

BACKGROUND: The fluctuating COVID-19 cases among the pregnant women’s population encountered increased of cases and maternal mortality. AIM: This research aimed to describe the case of maternal deaths caused by COVID-19. CASE REPORT: We present nine serial cases of maternal death caused by COVID-19 who were admitted to Dr. Soetomo General Academic Hospital for 14 days in June. We found 32 positive COVID-19 obstetric cases and reported nine maternal deaths with a fatality rate of up to 28%. Seven of nine patients had reverse transcription-polymerase chain reaction–confirmed SARS-CoV-2 infection, while two had a positive antigen swab. Half of the patients ≥35 years old, and five of nine patients had Class I obesity as preexisting comorbidity. This study reported the death of pregnant woman at their 2nd trimester and 3rd trimester presenting infected by severe COVID-19. The usual symptoms are dyspnea, cough, fever, and decreased consciousness. The result of chest X-ray examination among eight patients showed bilateral pneumonia. Most of cases were referrals from a secondary hospital due to overload hospital capacity. Three patients were directly transferred to the tertiary hospital without receiving initial treatment. Eight of 9 patients (88.9%) were transferred to intensive care unit and intubated due to low oxygen saturation. CONCLUSION: In conclusion, the limited hospital facility and lack of intensive care capacity for obstetric cases during the second wave of the COVID-19 pandemic may enhance the probability of mortality and morbidity in pregnant women infected by COVID-19.

Asymptomatic SARS-CoV-2 Infection in Children's Tonsils

Introduction: The SARS-CoV-2 pandemic killed over 6 million people worldwide. Children were described to have predominantly mild or asymptomatic infections and to be less exposed to the virus, at least for the initial variants. In the present study, we describe how SARS-CoV-2 can silently infect tonsils and adenoids in children undergoing adenotonsillectomy. Method(s): In this cross-sectional study we assessed children who underwent adenotonsillectomy between October 2020 and September 2021 in a secondary hospital in Brazil. All the caregivers denied any symptom of acute viral upper airway infection in the month prior to surgery. Briefly, nasal cytobrush (NC), nasal wash (NW) and tonsillar tissue fragments posttonsillectomy were tested by RT-PCR, immunohistochemistry (IHC), in situ immunofluorescence (IF), and flow cytometry. Result(s): A total of 48 children (18 females, median age 5.5 years) were enrolled. None of them had been vaccinated against COVID-19 at the time of surgery. Only 2 had a history of previous COVID-19 diagnosis, 3 and 5 months, respectively, before surgery. SARS-CoV-2 RNA was detected in 25% (12) of patients-20% in palatine tonsils, 16.27% in the adenoids, 10.41% in NC, and 6.25% in NW. IHC labeling showed viral nucleoprotein presence in both adenoids and palatine tonsils, in epithelial surface and lymphoid cells from extrafollicular and follicular regions. In 5 out of 7 patients, in situ IF showed the expression of ACE2 and TMPRSS2 and viral spike protein in the tonsillar tissue. Flow cytometry revealed that SARS-CoV-2 is predominantly observed in CD123+ dendritic cells (10.57% of all tested sites), followed by CD14+ monocytes (6.32%). Conclusion(s): According to these results, the prevalence of SARS-CoV-2 infection seems to be higher than expected and underdiagnosed in children at this age group. Palatine tonsils and adenoids are important sites of infection and may be a reservoir for the virus. Nevertheless, it is still unclear the impact of these results on virus transmission.

Incidence of Ocular Herpetic pathologies in a hospital setting, United Kingdom

Purpose : The incidence of ocular herpetic pathologies, in particular Herpes Zoster Ophthalmicus (HZO), has seemingly been on a rise over the past years, especially among the elderly and immunocompromised. The nature of this rise is likely multifactorial ranging from access to Shingles vaccination programmes, potential increase in immunocompromised individuals, social factors and most recently, Covid-19 infection. The relationship between Covid-19 and ocular herpetic pathologies has anecdotal basis. Certain studies have hypothesized T-cell dysfunction as a mechanism of Varicella Zoster virus reactivation in patients affected by Covid-19. This retrospective, observational study analyses the pattern of incidence of ocular herpetic pathologies in a secondary care centre, United Kingdom (UK). Methods : This study was set in an eye casualty clinic in Queens Hospital, Burton-on-Trent (University Hospitals Derby & Burton NHS, UK). Diagnoses of each patient was recorded in the Eye Casualty Patient Register. Data was extracted from three time periods-i. Precovid pandemic (July -December 2019), ii. Pandemic (July-December 2021) and iii. Post coronavirus vaccine introduction, UK (April and May 2021). Extracted data was pooled into the following groups-Herpes Simplex Keratits (HSK)/ HZO/ Shingles/Herpetic Kertatouveitis/ Herpes Zoster/Herpes Simplex/Herpes simplex endothelitis. Results : The data between pre-pandemic and post-pandemic periods highlighted an increasing incidence of certain ocular herpetic conditions. Highest number of diagnoses were recorded as HSK and HZO. HSK accounted for the highest incidence across all time periods-41% (pandemic), 34% (pre-pandemic) and 37.5% (after vaccine introduction). On the other hand, similar incidence is noted with HZO diagnoses-32.9% (pandemic), 32.7% (pre-pandemic) and 37.5% (after vaccine introduction). Conclusions : Overall, a gradual increase in incidence of ocular herpetic pathologies was observed from 2019-2021 at this centre. Multiple factors could be responsible for this rise, with Covid-19 infection as a potential factor. However, there is insufficient data to draw up a definitive association between the increasing incidence of such conditions and Covid-19, especially as the immune response to the infection and vaccinations are poorly understood. Larger, multi-centre studies would be required to assess the burden of incidence in the UK.