Utilising South Africa's underutilised international medical graduatesTo the Editor: The coronavirus disease 2019 (COVID-19) pandemic has wreaked havoc on global healthcare systems, with even well-resourced healthcare systems in Western Europe, the UK and the USA being significantly affected. [1]lthough official data are difficult to obtain, a UK media statement [2] suggests that 25% of the UK's doctors are absent due to COVID-19, with European figures [3] just as alarming.The concern is such that the UK recently provided temporary registration to 11 800 doctors, [4] while Harvard [5] is contemplating the early graduation of medical students to improve capacity in the USA.Numerous South African (SA) healthcare workers have already been quarantined. [6]Trying to expand SA's healthcare capacity while simultaneously contending with a loss of healthcare staff due to COVID-19 could pose a significant challenge to a system already under strain.SA international medical graduates (IMGs) could potentially assist.The integration of these doctors has long been problematic for the Health Professions Council of South Africa (HPCSA) [7] and the National Department of Health (NDoH), with the matter previously ending up in parliament. [8,9]A 2018 NDoH policy, [10] aimed at bridging their integration, has yet to be implemented.Regardless, SA has a significant pool of underutilised IMGs.A recent petition and survey in the UK [11,12] called for IMGs awaiting UK registration to be allowed to assist, while amended legislation [13] already allows specific unlicensed IMGs to serve during the COVID-19 crisis in New York.Analysis of IMG availability in SA was lacking, so we conducted an online survey. [14]he survey generated 644 responses within 48 hours (Fig. 1).Of these IMGs, 458 are currently in SA, and are either unemployed or working in non-medical roles.Almost all are willing to serve during the COVID-19 outbreak, but conditions such as brief orientation training or working near to home would ideally need to be considered.Although the demographics and registration statuses vary, many are registered with international councils or are awaiting HPCSA board examination results or registration.Currently, HPCSA IMG administration is on hold during the lockdown. [15] In contrast, other medical regulators, such as the Medical Board of
Abstract Background: The severe acute respiratory syndrome coronavirus-2 outbreak was identified in China in December 2019 and spread worldwide, reaching the pandemic levels. However, a specific, effective and proven therapy for the patients with coronavirus disease 2019 (COVID-19) remains elusive. We aim to compare the efficacy and the safety of three antiviral monotherapies (chloroquine phosphate, arbidol (Umifenovir) or lopinavir/ritonavir) in non-severe, hospitalised COVID-19 patients. Methods: We retrospectively analysed the hospitalised, laboratory-confirmed COVID-19 patients, treated with antiviral monotherapies at Huizhou Municipal Central Hospital between Jan 19 and Mar 16, 2020. Demographic and clinical data were extracted from electronic medical records. The primary outcome of the study was the viral shedding interval. Results: Twenty-seven patients with COVID-19 were included in the study with 10 receiving chloroquine phosphate, 11 receiving arbidol and 6 receiving lopinavir/ritonavir. Baseline demographics and clinical data were similar between groups. The median viral shedding interval in the lopinavir/ritonavir group was 13.0 days (95% CI: 12.2-23.8), while significantly shorter in the chloroquine group at 5.0 days (95% CI: 0.4-9.6) (p=0.003). A reduced median interval was also observed in the arbidol group, with 8.0 days (95%CI: 4.9-11.1) (p=0.008). Moreover, the hospitalisation duration was shorter in the chloroquine (9.3 ± 1.8 days, p<0.001) and arbidol groups (11.7 ± 3.7 days, p<0.001), and the hospitalisation costs were significantly reduced in the chloroquine (USD 1327 ± 566, p=0.001) and arbidol groups (USD 1167 ± 434, p<0.001), when compared with the lopinavir/ritonavir group (hospitalisation length and costs: 19.7 ± 4.4 days and USD 3806 ± 2262, respectively). Conclusions: Chloroquine and arbidol could not only shorten the viral shedding interval but also decreased the hospitalisation duration and hospitalisation expenses. Trial registration: The ethics committee of the Huizhou Municipal Central Hospital approved this study, and the trial was registered with www.chictr.org.cn (ChiCTR2000030931).
Proteins secreted by strains of Mycobacterium tuberculosis during short-term, zinc-sufficient batch culture were identified in order to define antigens likely to be relevant to the pathogenesis of human disease. [35S]Methionine-labelled proteins in supernatants of 4-7 d cultures were separated by PAGE under both denaturing and non-denaturing conditions, and the position of labelled material was determined. Secreted protein patterns of M. tuberculosis were quite similar to those of Bacillus Calmette-Guérin (BCG) but differed by the absence of the 46 kDa dimeric protein specific to BCG and by the presence in large amounts of a 23 kDa protein which, when denatured, gave 13 kDa subunits. This 13 kDa subunit protein constituted up to 20% of secreted proteins in classical strains of M. tuberculosis of phage type B but was not detected in phage type I strains from South India. This may be relevant to the different pathogenicity of these strains. Western blot analysis showed that antigens defined in supernatants of short-term (3 d) cultures of M. tuberculosis constituted a small subset of those seen in supernatants of organisms cultured for longer periods. One of the secreted proteins has the interesting property of binding to fibronectin. The available monoclonal antibodies and antisera have been used to identify lines on immunoblots corresponding to the secreted/released antigens of M. tuberculosis. The present findings suggest that there are major secreted antigens to which antibodies do not yet appear to have been produced experimentally.
HUMAN DISEASEin the latter part of the last century, the causative organisms of leprosy and tuberculosis were described, respectively, by Armauer Hansen in 1874 and Robert Koch in 1882.These bacteria were distinguished from all others known at that time by a characteristic acid-fast staining property by Paul Ehrlich in 1883.In 1898, when the generic name Mycobacterium was introduced, no other acid-fast bacillus had been formally described and named but from that time onwards many such organisms were isolated from environmental sources and from diseased mammals, birds and cold-blooded animals.A few were also isolated from patients, but their role as human pathogens was not seriously considered until the middle of this century when two new mycobacterial skin diseases, swimming pool granuloma I and M. ulcerans infection,2 later termed Buruli ulcer, were described and when Runyon published his classical description of the four groups of mycobacteria causing pulmonary disease.3Many unsatisfactory collective names including 'atypical', 'anonymous', 'tubercu loid' and 'MOTT (mycobacteria other than typical tubercle) bacilli' have been given to these mycobacteria but when it became apparent that these species were not primarily pathogenic but widely distributed in nature, the name 'environmental mycobacteria' (EM) was generally adopted.At present there are about 60 known mycobacterial species: 41 are included in the Approved Lists of Bacterial Names4 published in 1980 and the others have been described subsequently.5Cultivable mycobacteria are divisible into two main groups: the slow and rapid growers, which, by antigenic analysis and DNA homology, appear to belong to two quite distinct subgenera. The ecology of the environmental mycobacteriaIt is not generally appreciated just how common the EM are in nature.Sphagnum marshes contain very large numbers6 and they are also readily isolated from mud, compost, wet soil, surface water, rivers and estuaries.7Some species colonize piped water supplies and have been isolated from taps and showerheads.There is also evidence that mycobacteria are washed into estuaries, taken up into aerosols generated by breaking waves and wafted inland by sea breezes and thereby sensitize people who inhale them.8Some species or strains are more hydrophobic than others and thus more readily enter
Twenty-six leprosy patients (23 lepromatous, 2 borderline tuberculoid and I with indeterminate disease) were treated with recombinant gamma interferon (rIFN-y) intralesionally.Patients were divided into 3 groups.Group A received 10 Jig dose of rIFN-y for 3 consecutive days; Group B 20 Jig for 3 days and Group C 20 Jig for 5 days.Twenty-three pairs of skin biopsies and 25 pairs of radial cutaneous nerves were obtained prior to, and 2 days fo llowing, the last injections ofrIFN-y.Leprosin A skin tests were negative before and after rIFN-y.Injections of rIFN-y induced indurated swelling characteristic of delayed type hypersensitivity in all patients.Histologically, rIFN-y caused localized oedema, influx of mononuclear cells and eosinophils; epithelioid cell transformation and rapid reduction in the numbers of acid-fast bacilli in the majority of the patients.Immunocytochemical analysis revealed an increase in pan T cells, with equal numbers of Tg and T 4 phenotypes, and increased expression of HLA-c1ass II antigens of macro phages, epithelial cells and keratinocytes.These immunological changes indicate a shift in the immune spectrum of lepromatous leprosy.These results suggest that rIFN-y may be used in lepromatous leprosy as an adjunct to chemotherapy.Leprosy exhibits a wide range of cell-mediated immune responses resulting in a spectrum of disease ranging from paucibacillary tuberculoid to multi bacillary lepromatous fo rms.I Patients with lepromatous (LL) leprosy have defective cell-mediated immune responses to the causative organism which permit the extensive replications of My cobacterium /eprae in the dermal macrophages. 2The LL patients are anergic to skin testing reagents derived from M. /eprae and their lesions are deprived 0305-75 1 8/87/058389 + 12 so i .oo
BACKGROUND: Our group previously reported that right-sided vagus nerve stimulation (RVNS) signifi cantly improved outcomes after cardiopulmonary resuscitation (CPR) in a rat model of cardiac arrest (CA).However, whether left-sided vagus nerve stimulation (LVNS) could achieve the same eff ect as RVNS in CPR outcomes remains unknown.METHODS: A rat model of CA was established using modified percutaneous epicardial electrical stimulation to induce ventricular fi brillation (VF).Rats were treated with LVNS or RVNS for 30 minutes before the induction of VF.All animals were observed closely within 72 hours after return of spontaneous circulation (ROSC), and their health and behavior were evaluated every 24 hours. RESULTS:Compared with those in the RVNS group, the hemodynamic measurements in the LVNS group decreased more notably.Vagus nerve stimulation (VNS) decreased the serum levels of tumor necrosis factor-alpha (TNF-α) and the arrhythmia score, and attenuated inflammatory infiltration in myocardial tissue after ROSC, regardless of the side of stimulation, compared with fi ndings in the CPR group.Both LVNS and RVNS ameliorated myocardial function and increased the expression of α-7 nicotinic acetylcholine receptor in the myocardium after ROSC.Moreover, a clear improvement in 72-hour survival was shown with VNS pre-treatment, with no signifi cant diff erence in effi cacy when comparing the laterality of stimulation.CONCLUSIONS: LVNS may have similar eff ects as RVNS on improving outcomes after CPR.
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A cluster of pneumonia cases with an unknown etiology were identified in China in December 2019,1 and later confirmed to be caused by the severe acute respiratory syndrome coronavirus-2 and subsequently named coronavirus disease 2019 (COVID-19). So far, the vast majority of patients are presented as mild cases, with approximately 20% of patients categorized with severe or critical illness.2 Patients with severe or critical COVID-19 may develop hypoxemic respiratory failure and require respiratory support to improve hypoxia or relieve dyspnea. Mechanical ventilators are among the most significant medical devices in the treatment of severe or critical COVID-19 patients. About 960 000 patients in the United States will need mechanical ventilation, according to an estimation by the American Hospital Association,3 while a previous study estimated that there were only 62 188 mechanical ventilators with comprehensive functionalities and 98 738 mechanical ventilators with limited functionalities in the United States acute care hospitals.4 Currently, there is a growing global demand for ventilators in health care facilities. With the reduced availability of ventilators during the pandemic, manufacturers are working together to increase capacity and meet these clinical demands.5 However, simply increasing the number of ventilators is not enough, and there are other issues that need to be addressed. Not only is the number of patients requiring mechanical ventilation increasing, but there is also a shortage of respiratory therapists or well-trained pulmonary and critical care staff, skilled in the operation of mechanical ventilators.6 Additionally, medical staff from other departments, retired medical staff, or even medical students are involved in treating patients with severe or critical COVID-19. Under normal circumstances, ventilator operators receive years of training in order to use the ventilator correctly and optimize ventilation parameters. Colombo et al7 investigated the ability of Italian intensive care unit (ICU) physicians to detect patient-ventilator asynchrony using ventilator waveforms. It was suggested that experienced clinicians (working in the ICU for at least the last 3 years) had an increased sensitivity for detecting patient-ventilator asynchrony when compared to less experienced clinicians (first-year ICU residents).7 The experience and ability of medical staff have a significant impact on the effective monitoring of mechanical ventilation. If the improper use of ventilators, or problems arising during mechanical ventilation, cannot be detected and solved timeously, it may limit the efficacy of ventilatory support and lead to treatment failure. In addition, the incorrect operation could even increase the risk of infection among medical staff, thus further increasing the strain placed on healthcare systems. Therefore, personnel training remains crucial during the current crisis. In our hospitals, the basic operating standards should be maintained through relevant training courses or online training resources for inexperienced or unskilled ventilator operators, before treating severe or critical COVID-19 patients. This becomes an increasing challenge as more experienced ICU staff become infected and need to be replaced. Hospitals can potentially utilize telemedicine for improved convenience and thereby making it easier for well-trained and experienced ICU staff to obtain the respiratory parameters of ventilated patients.8 In this way, trained staff can also guide inexperienced staff in optimizing the use of ventilators, thereby save more lives. Due to the increasing number of different types of new ventilators, manufacturers need to ensure they supply a simple operating manual or video, available in different languages, so that all staff can rapidly comprehend the various functionalities of the individual machines. Moreover, given the current situation, when machine errors occur, ventilator technicians may not be able to debug the ventilators as quickly. Remote monitoring software and tools should be available to adjust or troubleshoot the ventilators, in order to ensure their continued and correct use, maximizing the efficient utilization of this scarce resource. Additionally, further exploration and use of different intelligence modes (e.g., neurally adjusted ventilatory assist), which automatically adjust the parameters according to the needs of the patient, may reduce the burden placed on medical staff operating ventilators. In conclusion, although collaboration between different countries can increase global ventilator availability and help improve the current situation, this is only the first step to solve the problem. There remain additional aspects around the use of mechanical ventilators that are affected, and that also need to be considered if we are to continue providing optimal therapy for patients requiring mechanical ventilation during this crisis. The study was supported by the Project supported by the Chinese National Natural Science Foundation (81700096), the foundation of the First Affiliated Hospital of Guangzhou Medical University (ZH201802) and Guangzhou Medical University (2017[160]). The authors declare no conflict of interest.
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