Mass food challenges in a vacant COVID-19 stepdown facility: Exceptional opportunity provides a model for the future.

BACKGROUND: Internationally, the COVID-19 pandemic severely curtailed access to hospital facilities for those awaiting elective/semi-elective procedures. For allergic children in Ireland, already waiting up to 4 years for an elective oral food challenge (OFC), the restrictions signified indefinite delay. At the time of the initiative, there were approx 900 children on the Children's Health Ireland (CHI) waiting list. In July 2020, a project was facilitated by short-term (6 weeks) access to an empty COVID stepdown facility built, in a hotel conference centre, commandeered by the Health Service Executive (HSE), Ireland. The aim of this study was to achieve the rapid roll-out of an offsite OFC service, delivering high throughput of long waiting patients, while aligning with existing hospital policies and quality standards, international allergy guidelines and national social distancing standards. METHODS: The working group engaged key stakeholders to rapidly develop an offsite OFC facility. Consultant paediatric allergists, consultant paediatricians, trainees and allergy clinical nurse specialists were seconded from other duties. The facility was already equipped with hospital beds, bedside monitors (BP, pulse and oxygen saturation) and bedside oxygen. All medication and supplies had to be brought from the base hospital. Daily onsite consultant anaesthetic cover was resourced and a resuscitation room equipped. Standardized food challenge protocols were created. Access to the onsite hotel chef facilitated food preparation. A risk register was established. RESULTS: After 6 weeks of planning, the remote centre became operational on 7/9/2020, with the capacity of 27 OFC/day. 474 challenges were commenced: 465 (98%) were completed and 9 (2%) were inconclusive. 135 (29%) OFCs were positive, with 25 (5%) causing anaphylaxis. No child required advanced airway intervention. 8 children were transferred to the base hospital. The CHI allergy waiting list was reduced by almost 60% in only 24 days. CONCLUSIONS: Oral food challenges remain a vital tool in the care of allergic children, with their cost saving and quality-of-life benefits negatively affected by a delay in their delivery. This project has shown it is possible to have huge impacts on a waiting list efficiently, effectively and safely with good planning and staff buy-in-even in a pandemic. Adoption of new, flexible and efficient models of service delivery will be important for healthcare delivery in the post-COVID-19 era.

Podiatric assessment in children and adults with epidermolysis bullosa: are foot and ankle patient-reported outcome measures (PROMs) able to measure the severity of podiatric involvement among EB patients?

Epidermolysis bullosa (EB) represents a group of rare genetic skin fragility disorders characterized by (muco) cutaneous blistering upon minimal mechanical trauma. Ninety percent of EB patients experience podiatric symptoms which may affect physical functioning and emotional well-being. To date, an EB-specific podiatric assessment has not been outlined to guide clinicians in the assessment of EB podiatric involvement. This review describes the podiatric involvement of patients with EB and assesses the relevance of validated foot and ankle patient-reported outcome measures (PROMs) in measuring podiatric severity among EB patients. A literature review was conducted to identify systematic reviews and clinical studies investigating foot health and podiatric manifestations using validated foot health PROMs across foot and ankle conditions. Limited studies have documented the significance of podiatric involvement among EB patients. Existing EB-specific PROMs are not region-specific for assessing podiatric involvement. Among the foot and ankle PROMs, the Foot Health Status Questionnaire, Foot Function Index, and Manchester Oxford Foot Questionnaire were identified as potentially appropriate for assessing podiatric severity among EB patients, each with its strengths and limitations in assessment. However, they have not been widely validated for assessing dermatology-related diseases. An evaluation of the relevance of each identified PROM to EB podiatric assessment would enable future development of an appropriate EB-specific podiatric assessment tool that would guide management.

Evaluation of Root Canal Configuration of Maxillary and Mandibular First Molar by CBCT: A Retrospective Cross-Sectional Study.

Adequate knowledge of root canal morphology along with its probable variations is imperative to acquire successful endodontic treatment. This retrospective cross-sectional study aimed to investigate the root canal configuration of maxillary and mandibular first molar using Cone-Beam Computed Tomography (CBCT) among patients in Al-Ahsa region, Saudi Arabia. A total of 377 samples were included, out of which 123 CBCT (I-CAT Vision QTM) scans with intact all first permanent molars were selected in this study and scanned in sagittal, axial, and coronal views by using BlueSkyPlan software. The number of canals in each root and their configuration according to the Vertucci classification system was evaluated. Statistical analysis was analyzed using SPSS version 21 (IBM). Chi-square test was applied to evaluate the association of root canal morphology and mandibular and maxillary first molars with respect to gender. Out of 123 CBCT scans, 59 (48.0%) were males and 64 (52.0%) were females; the mean age was 26.95 ± 10.65 years. The mesiobuccal root of bilateral maxillary first molar had Type-I (87.0%) of Vertucci classification followed by Type-IV (9.8%). Additionally, all mesiobuccal roots (100%) of the left mandibular first molar had Type-I of Vertucci's classification. A significant association has been observed between gender and a number of canals in bilateral maxillary first molars. Females showed a significantly higher prevalence of three-root canal configuration in maxillary first molars of both sides compared four canals found most commonly in males (p = 0.004). This study concluded that the majority of maxillary and mandibular permanent first molars had three roots and three canals with Type-I Vertucci's classification in patients belonging to the Al-Ahsa region of the Saudi Arabia. It was also proved that gender is significantly associated with the number of canals in a bilateral maxillary molar.

Use of Transversus Abdominis Plane (TAP) Blocks for Postoperative Pain Management in a Patient With an Open Abdomen: A Case Report and Review of Literature.

In light of the superior analgesia and opioid sparing effects provided by transversus abdominis plane (TAP) blocks, numerous new techniques and applications have evolved. However, TAP blocks are still underutilized in the critical care setting, and PubMed­listed reports on the relevance of TAP integrity for TAP block efficacy are lacking. Here, we report bilateral TAP blocks delivering quick, potent and durable pain relief to a patient with open abdomen (OA) after prior management with opioids and epidural anesthesia had failed. Extending TAP block application to OA patients even in the post­operative setting might hence reduce opioid consumption and quicken reconvalescence.

Parvovirus B19 infection in a patient of juvenile arthritis: A case report

Parvovirus B19 infection, or fifth disease or erythema infectiosum, is a self-limiting viral exanthem and can occur along with other connective tissue disorders. Occasionally, children may have preceding chronic joint complaints suggestive of juvenile idiopathic arthritis. A 7-year-old female patient presented to the outpatient department with a rash over her face, upper and lower limbs, and trunk, which was preceded by fever. The patient is a known case of juvenile arthritis. On examination, there were multiple erythematous and skin-colored plaques over cheeks; few pustules over lips; multiple erythematous papules over upper limbs, lower limbs, and trunk; multiple erythematous macules over palms; and swelling over interphalangeal joints of bilateral hands, elbow and knee joints with genu valgum deformity of limbs. The patient was given topical antibiotic and steroid combination cream and oral antihistaminic for her cutaneous complaints.

[Adrenal tuberculous pseudotumour]. / Pseudotumeur tuberculeuse surrénalienne.

Tuberculous pseudotumour of the adrenal gland with no other extra-adrenal sites of tuberculosis is a very rare entity. The authors describe the case of a 24-year-old patient in whom ultrasound and CT revealed a right adrenal mass. Adrenalectomy was performed by laparoscopy and the aetiological diagnosis was only established after histological examination of the operative specimen.

Liver biopsy for parenchymal liver disease - is routine real time image guidance unnecessary?

Liver biopsy even today remains the standard of care for grading and staging chronic hepatitis despite advances in noninvasive markers of liver fibrosis. Literature suggests an expanding role for real-time image guided liver biopsy and declining trend for blind liver biopsies. In our center, where we perform around 400 liver biopsies per year, we performed a prospective clinical audit of our practice of blind outpatient percutaneous liver biopsies. Patients requiring histological grading and staging of chronic hepatitis routinely undergo blind outpatient percutaneous liver biopsies in our endoscopy unit unless there is a definite indication for real-time image guidance. All procedures were assessed for safety, and all specimens were evaluated by a specimen quality grading score for adequacy for grading and staging of chronic hepatitis. Of the 446 patients referred for histological grading and staging of chronic hepatitis C by liver biopsy, only 42 patients (9.5 %) required real-time ultrasound for liver biopsy. The remaining 404 patients underwent blind outpatient percutaneous liver biopsies which were found to be extremely safe with no major complications, yielding adequate liver tissue with high specimen quality score allowing optimal grading and staging of chronic hepatitis.

Neuroprotective effects of HSP70 overexpression after cerebral ischaemia--an MRI study.

Heat shock proteins (HSPs) have been reported to increase cell survival in response to a wide range of cellular challenges. However, the role of HSP70 overexpression is still a matter of debate, with some reports showing protection and others not. In order to resolve these discrepancies and further investigate the action of these proteins in vivo, transgenic mice overexpressing HSP70 have been compared to wild-type mice in a middle cerebral artery occlusion model of permanent cerebral ischaemia. Previously, the effect of HSP70 was assessed histologically postmortem. In this report, magnetic resonance imaging (MRI) was used to assess the mice in vivo after the onset of stroke. The lesion volume, as measured at 24 h using T(2)-weighted MRI, was significantly smaller in HSP70 transgenic mice compared with wild-type mice. The smaller lesion size in HSP70 transgenic mice could not be attributed to differences in vascular anatomy or in cerebral blood flow during occlusion. Additionally, the apparent diffusion coefficient showed different spatial and temporal patterns between the groups, suggesting that the damage within the lesion may be less severe for HSP70 transgenic mice. Thus, we conclude that overexpression of HSP70 reduces the overall lesion size and may also limit the tissue damage within the lesion.

Therapeutic potential of silver in Unani system of medicine: an overview

Metals play important roles in human body, the deficiency of which may lead to various disorders. Earlier there was a perception that metals are not compatible with human body at all, but now it has been reported that number of metallic compounds are essential for body and some are in the category of essential elements. Metals are present in human body in different concentration and combination at various sites and help the respective body tissues to perform their required activities. Perfect health is attributed to the state of equilibrium of these metals in body tissues. Any imbalance in their concentration or inactive states disturbs the body metabolism. Silver is one of the metals known since antiquity. It was used for medicinal purpose since time immemorial. The first recorded use of silver for medicinal purposes dates back to 8th century A.D. where Ibn Sina used silver filings for palpitation of the heart. In Unani system of medicine it is used in the form of kushta [calcined-oxidized herbo-metallic form] and warq [thin foils]. It is highly recommended in fever, chest affections, impotency, seminal weakness, painful and irritable conditions of the stomach, heart burn, chronic diarrhoea and nervous affections. This review is an effort to summarize the detailed prospects of ancient literature on silver along with recent pharmacological studies

Management of ureteric calculus renal failure: a cost effective and decision making analysis with and without percutaneous nephrostomy

Background: Calculus acute renal failure is a urological emergency. Prompt treatment in the form of either temporary urinary diversion, or definite treatment can save the patients from developing chronic renal failure

Objectives: To compare the management of patients with obstructive uropathy with and without percutaneous nephrostomy

Patients and methods: A prospective interventional study conducted at SIMS/ SZMC, 2007-10. Twenty patients of ureteric calculus presenting with acute renal failure were included in our study. Patients were divided into two groups. Age, sex, duration of anuria and biochemical profile like serum creatinine and serum potassium levels were noted in both groups. In group A, a preliminary percutaneous nephrostomy tube was placed as a temporary diversion. On normalization of clinical and biochemical profile, definite treatment in the form of ureterorenoscopy/ lithoclast was performed. In group B, all the patients underwent definite treatment in the form of ureterorenoscopy/ lithoclast without preliminary temporary urinary diversion. The duration of normalization of renal function test, efficacy of URS lithoclast, hospital stay and cost effectiveness in both the groups were noted

Results: A total of 20 patients with 75% male and 25% female were included. Duration of anuria in group A was one day in 1 patients and 2-3 days in 6 patients. The duration of anuria in group B was 102 days in 8 patients. Mean normalization of serum creatinine level in group A was 5.9 days while it was 5.2 days in group B. The mean hospital stay was 10 days in group A while it was 4.7 days in group B. The mean cost of treatment in group A was Rs. 12300 and Rs. 4800 in group B

Conclusion: In patients with deranged renal functions but otherwise clinically normal can be offered definite treatment without temporary diversion in the form of PCN. This not only decreases the morbidity associated with PCN but also comforts the patients in term of shorter hospital stay and cost effectiveness

Causes of ureteric injures and outcome of different surgical procedures for the repair of ureter

Background: iatrogenic ureteric injuries have long been recognized as a potential complication of any abdominal or pelvic surgery. The present descriptive study was conducted at the Department of Urology Services Hospital, Lahore and Sheikh Zayed Medical College Rahim Yar Khan

Objectives: the specific objective of the study was to determine causes of ureteric injures and outcome of various treatment options

Patients and Methods: a total of 40 patients included in the study were presented either in the emergency ward or referred from other wards. Detailed History and thorough general and physical examination was done. Routine investigations were done in all cases while ultrasonography, intravenous urography, retrograde urography, ante grade urography and Computed Tomography [CT] scan were done in selected cases. Various procedures for ureteral repair were performed according to the site and extent of injury. Ureteral repair was done over a DJ stent

Results: in our study out of 40 patients 33 [82.5%] were female and 7 [17 .5%] males. Mean age of patients was 36 years. Maximum number of patients had lower ureteric injuries i.e 29 [72.5%] while 8 [17.5%] had upper ureteric injuries and 3 [7.5%] presented with mid ureteric injuries. 38 [95%] patients presented with iatrogenic injuries and 2 [ 5%] patients with firearm injury. Abdominal hysterectomy was the main cause in lower ureteric injuries. In case of upper and mid ureteric injures pyeloplasties and ureterouretrostomy was performed while in case of lower ureteric injuries 27 patients underwent extra vesical and intra vesical ureteroneocystostomy. Boari flap with psoas hitch was performed in two patients. Patients were followed at fourth week, three months and six months interval. Success rate in upper and mid ureteric injuries were 100% while in case of lower ureteric injuries it was [93 .1 % ]

Conclusion: ureteric injury causes a considerable morbidity for the patients. Detail understanding of anatomical relations of ureter and meticulous surgery will prevent iatrogenic injuries. The most common lower ureteric injuries can be best managed with Modified Liche [taguchi] technique

Case series of unusual intravesical foreign bodies and review of literature

Foreign bodies in urinary bladder are not uncommon. However, very little published series are available. Although, not being a fatal disease can lead to serious complications like acute or chronic cystitis, stone formation or fistula formation. We present 3 cases of different foreign bodies with different etiology which were removed successfully

Biochemical basis of secondary injury following neurotrauma

Primary trauma to the nervous tissue initiates a cascade of cellular and molecular events that promote continued tissue damage for an extended period following the initial injury. Oxidative stress mediated injury is an important component of secondary neuronal damage. In an attempt to explore the biochemical origin of oxidative stress associated with secondary injury we studied certain markers of oxidative stress and antioxidants in animal models of head, spinal cord and sciatic nerve injuries. Adult Wistar rats weighing 180-200g were subjected to concussive head injury, compression-induced spinal cord injury and crush injury to the sciatic nerve. Animals in the different groups were killed at various time intervals and the injured tissues [brain, spinal cord and sciatic nerve] were collected. Tissues were analyzed for markers of oxidative stress malondialdehyde, lipid hydroperoxides, conjugated dienes and myeloperoxidase] and level of antioxidants [glutathione and vitamin E]. Results of this study clearly showed a significant increase in the markers of oxidative stress and depletion of antioxidants following neurotrauma. In conclusion, this study clearly demonstrates a role of oxidative stress in the process of neurodegeneration following neurotrauma