EXPOSURES AND RISK FACTORS OF CORONA VIRUS AMONG HEALTH CARE WORKERS AND NEED FOR PREVENTIVE MEASURES IN COMBINED MILITARY HOSPITAL RAWALPINDI

Objective: Prospective To determine the various risk factors and exposures for spread of Corona Virus Disease 2019 (COVID19) among health care workers working at Combined Military Hospital Rawalpindi. Study Design: Cross sectional study. Place and Duration of Study: Combined Military Hospital, Rawalpindi, from Apr to Jul 2020. Methodology: A total of 134 health care workers who were infected with COVID-19, were included in study. A structured questionnaire was attained after informed consent and approval from hospital ethical committee. Data was analyzed using SPSS-19 statistical software. Results: Overall, 134 of 2591 Health care workers (Health care workers) in Combined Military Hospital Rawalpindi tested positive for COVID-19 during the study period. The infection rate was 5.17%. Among them 25 (18.7%) were women and 109 (81.3%) were men. There was not statistical difference in infection rate between male and female health care workers p=0.156). The infection rate in clinical category was significantly higher than non-clinical category (p<0.001. The infection rate in nursing assistants was significantly higher than the doctors (p=0.021). Personal protective equipment was optimally provided to health care workers except for goggles and face shields whose provision and use were both lacking. Conclusion: Health care workers are at high risk of developing COVID-19. There is need for extensive training, easy availability of personal protective equipment and strict compliance to infection control policies.

NGS and phenotypic ontology-based approaches increase the diagnostic yield in syndromic retinal diseases

Syndromic retinal diseases (SRDs) are a group of complex inherited systemic disorders, with challenging molecular underpinnings and clinical management. Our main goal is to improve clinical and molecular SRDs diagnosis, by applying a structured phenotypic ontology and next-generation sequencing (NGS)-based pipelines. A prospective and retrospective cohort study was performed on 100 probands with an a priori diagnosis of non-Usher SRDs, using available clinical data, including Human Phenotype Ontology annotation, and further classification into seven clinical categories (ciliopathies, specific syndromes and five others). Retrospective molecular diagnosis was assessed using different molecular and bioinformatic methods depending on availability. Subsequently, uncharacterized probands were prospectively screened using other NGS approaches to extend the number of analyzed genes. After phenotypic classification, ciliopathies were the most common SRD (35%). A global characterization rate of 52% was obtained, with six cases incompletely characterized for a gene that partially explained the phenotype. An improved characterization rate was achieved addressing prospective cases (83%) and well-recognizable syndrome (62%) subgroups. The 27% of the fully characterized cases were reclassified into a different clinical category after identification of the disease-causing gene. Clinical-exome sequencing is the most appropriate first-tier approach for prospective cases, whereas whole-exome sequencing and bioinformatic reanalysis increases the diagnosis of uncharacterized retrospective cases to 45%, mostly those with unspecific symptoms. Our study describes a comprehensive approach to SRDs in daily clinical practice and the importance of thorough clinical assessment and selection of the most appropriate molecular test to be used to solve these complex cases and elucidate novel associations.

Retinoblastoma seeds: impact on American Joint Committee on Cancer clinical staging

AimTo investigate whether the American Joint Committee on Cancer (AJCC) clinical category cT2b needs to be subclassified by the type and distribution of retinoblastoma (RB) seeding.MethodsMulticentre, international registry-based data were collected from RB centres enrolled between January 2001 and December 2013. 1054 RB eyes with vitreous or subretinal seeds from 18 ophthalmic oncology centres, in 13 countries within six continents were analysed. Local treatment failure was defined as the use of secondary enucleation or external beam radiation therapy (EBRT) and was estimated with the Kaplan-Meier method.ResultsClinical category cT2b included 1054 eyes. Median age at presentation was 16.0 months. Of these, 428 (40.6%) eyes were salvaged, and 430 (40.8%) were treated with primary and 196 (18.6%) with secondary enucleation. Of the 592 eyes that had complete data for globe salvage analysis, the distribution of seeds was focal in 143 (24.2%) and diffuse in 449 (75.8%). The 5-year Kaplan-Meier cumulative globe-salvage (without EBRT) was 78% and 49% for eyes with focal and diffuse RB seeding, respectively. Cox proportional hazards regression analysis confirmed a higher local treatment failure risk with diffuse seeds as compared with focal seeds (hazard rate: 2.8; p<0.001). There was insufficient evidence to prove or disprove an association between vitreous seed type and local treatment failure risk(p=0.06).ConclusionThis international, multicentre, registry-based analysis of RB eyes affirmed that eyes with diffuse intraocular distribution of RB seeds at diagnosis had a higher risk of local treatment failure when compared with focal seeds. Subclassification of AJCC RB category cT2b into focal vs diffuse seeds will improve prognostication for eye salvage.

Reporting antimicrobial susceptibilities and resistance phenotypes in Staphylococcus spp.: a nationwide proficiency study

Objectives To evaluate the proficiency of microbiology laboratories in Spain in antimicrobial susceptibility testing (AST) of Staphylococcus spp. Materials and methods Eight Staphylococcus spp. with different resistance mechanisms were selected: six Staphylococcus aureus (CC-01/mecA, CC-02/mecC, CC-03/BORSA, CC-04/MLSBi, CC-06/blaZ and CC-07/linezolid resistant, cfr); one Staphylococcus epidermidis (CC-05/linezolid resistant, 23S rRNA mutation); and one Staphylococcus capitis (CC-08/daptomycin non-susceptible). Fifty-one laboratories were asked to report: (i) AST system used; (ii) antimicrobial MICs; (iii) breakpoints used (CLSI or EUCAST); and (iv) clinical category. Minor, major and very major errors (mEs, MEs and VMEs, respectively) were determined. Results The greatest MIC discrepancies found were: (i) by AST method: 19.4% (gradient diffusion); (ii) by antimicrobial agent: daptomycin (21.3%) and oxacillin (20.6%); and (iii) by isolate: CC-07/cfr (48.0%). The greatest error rates were: (i) by AST method: gradient diffusion (4.3% and 5.1% VMEs, using EUCAST and CLSI, respectively); (ii) by breakpoint: 3.8% EUCAST and 2.3% CLSI; (iii) by error type: mEs (0.8% EUCAST and 1.0% CLSI), MEs (1.8% EUCAST and 0.7% CLSI) and VMEs (1.2% EUCAST and 0.6% CLSI); (iii) by antimicrobial agent: VMEs (4.7% linezolid and 4.3% oxacillin using EUCAST); MEs (14.3% fosfomycin, 9.1% tobramycin and 5.7% gentamicin using EUCAST); and mEs (22.6% amikacin using EUCAST). Conclusions Clinical microbiology laboratories should improve their ability to determine the susceptibility of Staphylococcus spp. to some antimicrobial agents to avoid reporting false-susceptible or false-resistant results. The greatest discrepancies and errors were associated with gradient diffusion, EUCAST breakpoints and some antimicrobials (mEs for aminoglycosides; MEs for fosfomycin, aminoglycosides and oxacillin; and VMEs for linezolid and oxacillin).

On the possible beneficial role for the regular use of potent mouthwash solutions as a preventive measure for COVID19 transmission; invoking the Evolutionary biology and Game Theory

1.AbstractMore in vitro studies recently demonstrated a bactericidal and virucidal role for some of the over-the-counter mouthwash solutions. Meanwhile, Game theory and Evolutionary Biology suggests that inhibiting cooperation -reciprocal altruism-between two organisms can negatively affect their survival. Based on a set of relevant publications, it is proposed here that 2019-nCoV may be relying on a “complicit”; be it a particular organism (e.g., bacterial species) or a state of dysbiosis in general. On this premise, the regular use of potent disinfectant (Hydrogen peroxide 2% and chlorhexidine gluconate mixed solution) for oral rinsing and gargling three times daily, through the repeated reduction in microbial load, was tested to determine whether it can induce a strain sufficient to inhibit reciprocal altruism, and hence halt the progression of the disease.The outcome tested in terms of the change COVID19 PCR and its average Cycle threshold (CT) value for nasopharyngeal-oropharyngeal swabs from the baseline (at diagnosis), changes in the clinical category (improvement Vs. deterioration), and the final disposition (discharge Vs. Death) in different disease categories.Our findings showed, upon the regular use of mouthwash, more symptoms improvement after two days of treatment, a higher conversion rate to “COVID19-negative PCR” by five days of treatment, and less intubation and mortality, with all P-value < 0.05.There was also a trend of improvement in other outcome variables, though with no significant statistical difference; namely “shorter hospital stay,” “less progression in Oxygen requirements,” “less rate of plasma transfusion,” and “extent of improvement” in terms of disposition relative to the clinical category on admission.These findings can be justified by the complicit hypothesis, predicting a rather preventive than a therapeutic advantage for the regular use of potent mouthwash as an additional control measure at the community level.

Complicated grief: A systematic review of the last 20 years

Background: Grief is a common reaction to the feeling of loss and it is considered a physiological and instinctive response. The ‘normal’ grief evolves into an ‘integrated’ phase within 1 year from death, and it is a non-pathological condition, that do not require specific therapeutic interventions. When this ‘integrated phase’ does not occur, the subject could reach pathological manifestations related to the grief. The Persistent Complex Bereavement Disorder (PCBD) is a new DSM5 clinical category characterized by symptoms related to the detachment and to the post-traumatic distress and it differs from normal and uncomplicated grief, for the disability caused by these reactions and their persistence and pervasiveness. Aim: The purpose of this work is the analysis of the pathways that led to this new definition, through a review of the main studies published in the last 20 years, with the aim to clarify the clinical utility of this new diagnostic category. Method: Relevant publications done in the last 20 years were identified via electronic searches of Pubmed, Embase, and Elsevier databases using the terms ‘complicated grief’ AND ‘persistent’, according to PRISMA guideline and PICO study design. Results: PCBD results a new important clinical category showing specific symptoms, diagnostic criteria, and treatment. It presents many differences with other pathologies, that goes into differential diagnosis with PCBD, and it and can be treated with targeted therapeutic approaches. Diagnostic criteria for PCBD could allow an early diagnosis and a correct treatment avoiding underdiagnosis and misdiagnosis. Conclusion: Further researches could focus on the evaluation of more neurobiological aspects, new psychometric tools, for assessing susceptibility to this pathology, and on the cultural aspects that may influence mourning reactions, in an ethno-psychiatric perspective.

Evaluation of Ocular Versions in Graves’ Orbitopathy: Correlation between the Qualitative Clinical Method and the Quantitative Photographic Method

Purpose. To assess the agreement between the qualitative clinical method and the quantitative photographic method of evaluating normal and abnormal ocular versions in patients with inactive Graves’ orbitopathy (GO). Methods. Forty-two patients with inactive GO had their ocular versions evaluated clinically according to three categories: normal, moderate alterations (−1 or −2 hypofunction), and severe alterations (−3 or −4 hypofunction). The subjects were photographed in the 9 positions of gaze, and the extent (mm) of eye movement in each position was estimated using Photoshop® and ImageJ and converted into degrees with a well-established method. The agreement between the two methods (qualitative vs. quantitative) for classifying ocular versions as normal or abnormal was assessed. Results. The mean quantitative measurements of versions were significantly different for each clinical category (normal, moderate alterations, and severe alterations) in the following five positions: abduction, adduction, elevation in abduction, elevation, and elevation in adduction (p<0.001). No such pattern was observed for the three infraversion positions (depression in abduction, p=0.573; depression, p=0.468; depression in adduction, p=0.268). Conclusion. The agreement was strong between the quantitative photographic method and the qualitative clinical method of classifying ocular versions, especially in lateral and supraversions, which are typically affected in GO. Digital photography is recommended for the assessment of ocular versions due to its practicality, suitability for telemedicine applications, and ease of monitoring during follow-up. This trial is registered with NCT03278964.

PREVALENCE OF COGNITIVE DISTORTIONS AMONG ADOLESCENTS IN PUNJAB, PAKISTAN

This study investigated the prevalence of cognitive distortions among adolescents in Pakistan. 1258 participants recruited through purposive sampling, falling in the age range of 16-22 years and studying in different Public sector collegesof Rawalpindi Division were administered the How I Think Questionnaire. The participants were placed into the following three categories; non-clinical, borderline and clinical range based on their responses on the „HIT-Q. This Questionnaire measures four types of cognitive distortions namely minimizing / mislabeling, self-centered, assuming the worst and blaming others. Results of the study revealed that of 17.17% (216/1258) of the participants were identified in in the clinical category on self-centered subscale whereas 13.83 % (174/1258) were in the clinical category of Blaming others subscale..48 % (148/1258) responses were in the clinical category on the “assuming the worst” subscale and 14.1% in the minimizing/ mislabeling subscale. 3.00-4.89 was the clinical range for the subscale of minimizing/mislabeling and Clinical range for “assuming the worst” subscale according to manual of the HIT-Q was 3.00-4.92. Meanwhile responses also indicated that 31.8% of adolescents scored high on oppositional defiance. 37.1% in physical aggression and 60% in stealing. Results suggest that adolescents in Pakistan has severe problem of thinking in distorted way and there is dire need for counselling centers to be established in every college in Punjab Pakistan.